West v. DeKalb County: Excited Delirium, Emergency Medical Response, and the Limits of ADA Title II and § 1983 Liability

I. Introduction

This unpublished Eleventh Circuit decision, Yvonne M. West v. DeKalb County, Georgia, No. 24‑13197 (11th Cir. Dec. 1, 2025) (per curiam), arises from a tragic death following an episode of “excited delirium.” The case sits at the intersection of disability law, municipal liability, qualified immunity, and emergency medical response practices.

Yvonne West, individually and as administrator of the estate of her son, Jamon West, sued DeKalb County, Georgia, its firefighters, and its police officers. She alleged violations under:

• Title II of the Americans with Disabilities Act (ADA), 42 U.S.C. § 12132; and
• 42 U.S.C. § 1983, invoking the Fourth and Fourteenth Amendments.

Her core theory: first responders knew Jamon suffered from a seizure disorder and was experiencing excited delirium, yet restrained him prone, handcuffed him behind his back, and administered maximum doses of sedatives (Haldol and Versed). After he was restrained and sedated, his respiratory rate dropped and he went into cardiac arrest, later dying. An autopsy attributed his death to delayed complications of cardiorespiratory arrest due to probable excited delirium and physical restraint, classifying the death as a homicide.

Ms. West alleged:

1. DeKalb County failed to modify its policies under the ADA.
2. The County failed to reasonably accommodate her son’s disability under the ADA.
3. The County failed to train its employees under § 1983 (Monell/failure-to-train theory).
4. Individual firefighters and officers used excessive force in violation of the Fourth Amendment.
5. Two individual firefighters were deliberately indifferent to Jamon’s medical needs in violation of the Fourteenth Amendment.

The district court dismissed all claims under Rule 12(b)(6). The Eleventh Circuit affirmed in full. Although “not for publication” and thus non-precedential, the opinion is a dense application of existing doctrine. It clarifies, in the specific context of excited delirium and emergency medical response, several important points:

• Title II of the ADA does not extend to disputes over the substance of medical treatment decisions.
• A Title II “failure to accommodate” claim seeking damages generally requires a specific request for accommodation; “constructive” or generalized notice is insufficient.
• For ADA damages, a public entity is not vicariously liable; deliberate indifference must be attributable to an official with authority to correct the problem.
• Municipal failure-to-train liability under § 1983 requires a pattern or “obvious” need for training; policies about excited delirium and prone restraint, without more, do not make the need “obvious.”
• In the excited‑delirium/prone‑restraint context, prior Eleventh Circuit cases (e.g., Lewis and Garrett) mean qualified immunity continues to shield officials absent materially different facts or controlling precedent.
• Internal departmental policies and guidance do not themselves create “clearly established law” for purposes of qualified immunity and deliberate indifference claims.

II. Factual Background and Procedural Posture

A. The Incident

Jamon West, who had a seizure disorder, lived with his mother. On August 16, 2019, he experienced what the complaint describes as an “episode of behavioral crisis” or “excited delirium”—a phenomenon associated with certain substance abuse or psychiatric/neurological conditions, characterized by extreme agitation, hyperactivity, confusion, hyperthermia, and insensitivity to pain.

Unable to control his symptoms, Jamon pleaded with his mother for help. She called 911, reporting that her son was having a seizure and she could not control him. Firefighters Winkler and Lakatos responded first, finding Jamon “highly agitated, hyperactive, confused, and not in control of his behavior.”

They restrained him in a prone position—face down on the ground. As additional fire personnel arrived (Captain Ditmore, and firefighters Kelly, Van Wie, and Fleming), four or five firefighters applied force to all four extremities and his back. Ms. West cried out that her son could not breathe with his face in the grass. One firefighter threatened to arrest her if she did not back away.

Captain Ditmore then took command and directed firefighter Payne to administer a “chemical restraint.” Payne injected Jamon with the maximum dosages allowed under county policy of the sedatives Haldol and Versed.

After the sedatives were given, police officers arrived. At Captain Ditmore’s request, Officers Lattimore and Williams handcuffed Jamon’s hands behind his back with Ditmore’s assistance, leaving him still prone. Ditmore walked away to report by radio. While he was gone, Jamon remained prone and handcuffed long enough for the sedatives to take effect.

When Ditmore returned and saw that Jamon was “calm,” he ordered the handcuffs removed and replaced with soft restraints. As they began transporting Jamon across the yard, his respiratory rate dropped, and he went into cardiac arrest. He was transported to a hospital, went into a coma, and died a few days later.

The county medical examiner concluded that Jamon died of “[d]elayed complications of cardiorespiratory arrest due [to] probable excited delirium and physical restraint,” and labeled the manner of death a homicide.

B. Departmental Policies

The DeKalb County Fire Department’s policy manual:

• Explicitly notes that side effects of Haldol and Versed include “respiratory depression and the inability to maintain an airway.”
• States that patients with excited delirium “should never be oriented in a prone position.”
• Requires that excited-delirium patients be restrained only with “soft medical restraints.”

By contrast, the Police Department’s policies did not prohibit prone restraint or behind-the-back handcuffing of persons with excited delirium.

Following an internal investigation, County officials concluded that all first responders complied with county policy.

C. Claims and District Court Dismissal

On behalf of Jamon’s estate, Ms. West sued:

• DeKalb County (for ADA and § 1983 municipal-liability claims); and
• Individual fire and police defendants (for § 1983 personal-capacity claims).

The five counts at issue on appeal were:

1. ADA – Failure to Modify Policies (Title II) against the County.
2. ADA – Failure to Accommodate (Title II) against the County.
3. § 1983 – Failure to Train against the County under Monell.
4. § 1983 – Excessive Force (Fourth Amendment) against the firefighters and police officers who restrained and handcuffed Jamon.
5. § 1983 – Deliberate Indifference to Medical Needs (Fourteenth Amendment) against Captain Ditmore and firefighter Payne.

Defendants moved to dismiss under Rule 12(b)(6), arguing:

• The ADA claims failed as a matter of law.
• The complaint did not plausibly allege Monell municipal liability.
• All individual defendants were entitled to qualified immunity.

The district court agreed and dismissed all claims. A separate failure-to-intervene claim was not pursued on appeal and was deemed abandoned.

III. Summary of the Eleventh Circuit’s Decision

Reviewing de novo, and accepting the complaint’s allegations as true, the Eleventh Circuit:

• Affirmed dismissal of the ADA failure-to-modify claim, holding that:
  • The Fire Department already had appropriate excited-delirium policies; and
  • As to Police Department policies, the complaint did not identify an “official” with actual knowledge and authority to correct policy defects, as required for Title II damages liability.
• Affirmed dismissal of the ADA failure-to-accommodate claim, holding that:
  • Title II does not apply to the substance of medical treatment decisions; and
  • The duty to reasonably accommodate is not triggered absent a specific request for accommodation.
• Affirmed dismissal of the § 1983 failure-to-train claim, finding that:
  • No pattern of similar incidents was alleged; and
  • The need for additional excited‑delirium/prone‑restraint training was not “so obvious” that a single incident sufficed to show deliberate indifference.
• Affirmed qualified immunity for all individual defendants on the excessive-force claim, because:
  • Existing Eleventh Circuit cases involving prone restraints and excited delirium (Lewis, Garrett) had not held such force to be clearly unconstitutional; and
  • The “deadly force cannot be used in non-deadly situations” principle, while real, did not clearly govern this more complex medical-restraint scenario.
• Affirmed qualified immunity for Captain Ditmore and firefighter Payne on the deliberate-indifference claim, because:
  • Ms. West cited no authority applying Fourteenth Amendment deliberate-indifference standards to first responders providing requested emergency medical aid, and
  • She cited no case, broad principle, or egregious-conduct precedent clearly establishing that their actions violated the Constitution; and
  • Internal policies cannot themselves create clearly established law.

The judgment of the district court was therefore affirmed in its entirety.

IV. Analysis of the Court’s Reasoning

A. ADA Title II Claims

1. Title II Framework and the “Official with Authority” Requirement

Title II of the ADA provides that:

no qualified individual with a disability shall, by reason of such disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by any such entity. (42 U.S.C. § 12132)

To state a Title II claim, the plaintiff must show:

1. A qualified individual with a disability;
2. Exclusion from, denial of benefits of, or discrimination in public services, programs, or activities; and
3. That such exclusion/denial/discrimination occurred by reason of the disability.

Where (as here) a plaintiff seeks compensatory damages, the Eleventh Circuit (via Ingram v. Kubik and Silberman v. Miami-Dade Transit) requires a further showing of intentional discrimination in the form of deliberate indifference. Under Liese v. Indian River County Hospital District and Gebser v. Lago Vista Independent School District, deliberate indifference by a public entity is established only if:

• An official of the entity
  • has “authority to address the alleged discrimination and to institute corrective measures” on the entity’s behalf; and
  • has actual knowledge that discrimination is substantially likely; and
  • fails to respond adequately.

Crucially, there is no vicarious liability under Title II for money damages: the intentional or deliberately indifferent conduct of rank-and-file employees cannot be imputed to the public entity absent the involvement of such an “official with authority.”

2. Failure-to-Modify Claim (Count One)

Ms. West alleged that DeKalb County failed to modify policies so as to prevent prone restraint and behind-the-back handcuffing of excited-delirium patients. The Eleventh Circuit’s analysis proceeds in two steps.

a. Fire Department Policies Were Already Protective

As to the Fire Department, the court notes:

• Policy already warns that Haldol and Versed carry risks of respiratory depression and airway compromise.
• Policy already mandates that excited-delirium patients “should never be oriented in a prone position.”
• Policy requires use of “only soft medical restraints” for such patients.

Given these existing written safeguards, the panel finds it “unclear what further modification” Ms. West seeks. Put differently, in terms of formal policy, the Fire Department was already aligned with the modifications she implicitly wanted. Her complaint instead targets alleged noncompliance with policy—something ADA Title II does not treat as a failure to modify policy.

b. No Qualifying Official Alleged for Police Department Policies

For the Police Department, policies did not prohibit prone restraint or behind-the-back handcuffing of persons with excited delirium. Still, the claim fails because Ms. West:

• Does not identify any official with authority to change Police Department policy who had actual knowledge that those policies were discriminatory; and
• Does not allege such an official failed to act despite that knowledge.

The first responders themselves (firefighters and officers on scene) are not alleged to have authority over county-level policy decisions. Under Silberman, the relevant question is not whether they had discretion in field-level decisions, but whether they had discretion at a “key decision point in the administrative process” such that their decisions constitute “an official decision by the entity itself not to remedy the misconduct.”

Because no such policymaker is plausibly alleged, the County cannot be held liable for a Title II failure-to-modify claim seeking damages. This reinforces an important principle: Title II damages claims hinge on higher-level officials’ knowledge and inaction, not just frontline misconduct.

3. Failure-to-Accommodate Claim (Count Two)

Ms. West’s second ADA theory was that the County failed to accommodate Jamon’s disability by, in substance, using unsafe restraints and sedatives. She argued that Captain Ditmore’s “substantial supervisory authority” made him an official whose conduct could be imputed to the County.

The Eleventh Circuit does not squarely resolve whether Ditmore qualifies as an “official” under Liese, because it finds two more fundamental defects:

a. ADA Does Not Apply to Medical Treatment Decisions

Relying on Schiavo ex rel. Schindler v. Schiavo, and earlier cases (e.g., University Hospital and Johnson v. Thompson), the court holds that:

The ADA “was never intended to apply to decisions involving medical treatment.”

Here, responders were called to provide emergency medical aid, not to perform a traditional law-enforcement function (e.g., arrest). The core of the failure-to-accommodate claim is that they chose the wrong clinical interventions—prone restraint, behind-the-back handcuffing, and maximum sedation—given what they knew about Jamon’s disability and excited delirium.

The court explicitly characterizes these as medical treatment decisions and holds that such decisions fall outside the scope of Title II. Thus, a plaintiff cannot repackage alleged medical malpractice or substandard clinical judgment as ADA discrimination.

b. No Specific Request for Accommodation

Even assuming the ADA could reach this context, the claim would still fail. Under Eleventh Circuit precedent (Gaston v. Bellingrath Gardens & Home, Inc.), the duty to provide a reasonable accommodation arises only after a specific request for accommodation. The duty is not triggered by:

• generalized notice of disability, or
• a belief that an accommodation would be helpful.

Ms. West conceded no explicit request was made for a particular accommodation (e.g., “do not handcuff him”; “do not use a prone position”; “use only soft restraints”). She argued that such a request was unnecessary because the need for accommodations for excited delirium is “widely recognized in the law enforcement community.”

The Eleventh Circuit rejects this constructive-notice theory. Citing Cordoba v. Dillard’s, Inc., it reiterates that:

Discrimination cannot be based on what decisionmakers “should have known.” Constructive knowledge is not enough for ADA liability.

In other words, even if law enforcement culture or general practices had evolved to recognize certain best practices for excited delirium, Title II still demands a concrete request or some equivalent clear communication of an accommodation need.

B. § 1983 Municipal Liability – Failure to Train (Count Three)

1. Monell, Canton, and Connick Framework

Under 42 U.S.C. § 1983, municipalities are not vicariously liable for the constitutional torts of their employees (Monell v. Department of Social Services). They may be liable only when the municipality itself “causes” the violation via:

• an official policy or decision by final policymakers;
• a widespread custom or practice; or
• a failure to train or supervise amounting to deliberate indifference to constitutional rights (City of Canton v. Harris).

The Supreme Court has repeatedly emphasized that failure-to-train claims are especially difficult to prove. In Connick v. Thompson, the Court described municipal culpability in this area as “at its most tenuous.”

A plaintiff must show:

1. The municipality had notice of a need to train in a particular respect; and
2. The municipality made a deliberate choice not to provide that training (Gold v. City of Miami).

“Notice” is generally shown in one of two ways:

• Pattern theory: A pattern of similar constitutional violations by inadequately trained employees (Bryan County v. Brown; Connick); or
• “Obviousness” theory: In a “narrow range of circumstances,” the need for training is so obvious that the failure to provide it is deliberately indifferent even absent a prior pattern. The canonical example: training in use of deadly force when the city arms its officers with firearms (Canton n.10).

2. Application to DeKalb County’s Alleged Failure to Train

Ms. West alleged that DeKalb County failed to train its personnel on the dangers of using prone restraints and behind-the-back handcuffing with excited-delirium patients, despite policies addressing excited delirium and sedation risks.

a. No Pattern of Similar Incidents

Ms. West did not allege any prior similar incidents in DeKalb County where lack of training on excited delirium or prone restraint produced constitutional violations. She thus could not rely on a pattern of violations to establish notice.

b. No “Obvious” Need for Training on Excited Delirium/Prone Restraint

She argued instead that:

• Because the County (and many other jurisdictions) had adopted policies recognizing the risks of prone restraint and sedation in excited delirium, policymakers had actual knowledge that improper restraint “may lead to respiratory depression and cardiac arrest.”
• Thus, the need to train officers and firefighters on those policies was obvious, making their failure to do so deliberate indifference.

The Eleventh Circuit rejects this argument as too broad. Several key points emerge:

• The mere existence of a policy on a topic does not show the municipality believed that non-compliance was likely to lead to constitutional violations.
• Accepting Ms. West’s theory would effectively make municipalities liable any time:
  • a written policy exists; and
  • a single-incident violation of that policy occurs; and
  • the plaintiff asserts some training should have occurred.
  That is precisely the concern Canton and Connick warned against—turning “failure to train” into a default municipal-liability route in almost every case.
• Prior Eleventh Circuit decisions (e.g., Weiland v. Palm Beach County Sheriff’s Office, Gold, and Lewis) have refused to find an “obvious” need for special training even in contexts involving mental illness, handcuffing complaints, or use of hobble ties on excited-delirium subjects—often where death occurred.

The panel thus holds that training on the use of restraints for excited-delirium patients, while perhaps sound policy and medically advisable, “falls far short” of the kind of obvious need that would justify imposing municipal liability in a single-incident case.

Result: The failure-to-train claim against DeKalb County fails as a matter of law.

C. § 1983 Excessive Force and Qualified Immunity (Count Four)

1. Excessive Force and Qualified Immunity Framework

The Fourth Amendment protects individuals from unreasonable seizures, including seizures accomplished through excessive force. The classic test, under Graham v. Connor, evaluates reasonableness from the perspective of a reasonable officer on the scene, considering the severity of the crime, immediate threat, and resistance or flight.

Here, all parties agree that the individual defendants (firefighters and officers) acted within their discretionary authority. Thus, the burden shifts to Ms. West to show that:

1. They violated a federal right; and
2. The right was “clearly established” at the time (District of Columbia v. Wesby; Sebastian v. Ortiz).

The panel elects to resolve the case on the clearly established prong without definitively deciding whether a constitutional violation occurred, as permitted by Pearson v. Callahan.

A right is “clearly established” when every reasonable official would understand that the conduct at issue violated that right (Ashcroft v. al‑Kidd). This can be shown by:

• Materially similar case law;
• A broad constitutional principle that clearly applies; or
• Conduct so egregious that it obviously violates the Constitution even without prior case law (Lewis; Corbitt v. Vickers).

2. Plaintiff’s “Deadly Force” Argument

Ms. West argued that the combination of:

• Prone restraint,
• Behind-the-back handcuffing,
• Known excited delirium, and
• Maximal sedation

constituted deadly force under the circumstances, deployed in a non-deadly situation, violating the “broad principle” that deadly force cannot be employed where less-than-lethal force will suffice (Tennessee v. Garner; Mercado v. City of Orlando; Bradley v. Benton).

The Eleventh Circuit acknowledges this general principle but concludes it does not clearly establish the specific rule Ms. West needs. The past “deadly force” cases she relies on involved:

• Shooting an unarmed, non-dangerous fleeing suspect (Garner);
• Firing a Taser at a suspect precariously perched on a high wall (Bradley);
• Firing a blunt-impact projectile launcher at a person’s head from short range (Mercado).

In each, the use of force was overtly and immediately lethal or life-threatening in a way that any reasonable officer would recognize as unnecessary.

3. Existing Eleventh Circuit Precedent on Excited Delirium and Prone Restraint

The panel instead finds Lewis v. City of West Palm Beach and Garrett v. Athens‑Clarke County controlling. In both:

• Police used prone restraints with hands and feet bound (or “hogtied”),
• The suspect exhibited violent, erratic, or excited‑delirium-like behavior,
• An officer applied body weight to the subject’s back or neck, and
• The subject died from asphyxia or positional asphyxia.

In Lewis, the Eleventh Circuit held that such force did not violate clearly established law. Likewise in Garrett, the court found the officers’ conduct, although tragic in outcome, not so clearly excessive that every reasonable officer would have understood it to be unconstitutional.

The present case, viewed in the light most favorable to Ms. West, involves:

• Prone restraint and handcuffing during a violent, confused excited-delirium episode;
• Use of sedatives recognized as potentially dangerous for respiration;
• Subsequent replacement of handcuffs with soft restraints once Jamon appeared calm; and
• Deterioration and cardiac arrest during transport, after he had been removed from the prone position.

Given Lewis and Garrett, the panel holds that the defendants’ actions were not “so far beyond the hazy border between excessive and acceptable force” that they had to know they were violating the Constitution even without specific case law on point (Smith v. Mattox).

Result: Even assuming arguendo that a constitutional violation occurred, the right allegedly violated was not clearly established, and the individual defendants are entitled to qualified immunity.

D. § 1983 Deliberate Indifference to Medical Needs and Qualified Immunity (Count Five)

1. Deliberate Indifference Standard

Under the Fourteenth Amendment Due Process Clause (for arrestees and pretrial detainees), and the Eighth Amendment (for convicted prisoners), the government must not be deliberately indifferent to serious medical needs (City of Revere v. Massachusetts General Hospital; Cottrell v. Caldwell).

Following Farmer v. Brennan and the Eleventh Circuit’s en banc decision in Wade v. McDade, a deliberate-indifference claim requires:

1. Objective seriousness: A serious medical need—either diagnosed as requiring treatment or so obvious that a lay person would recognize the necessity for medical attention (Mann v. Taser International; Hill v. DeKalb Regional Youth Detention Center).
2. Subjective recklessness: The defendant actually knew his conduct posed a substantial risk of serious harm and consciously disregarded that risk. Mere negligence or a mistake in judgment does not suffice.

Moreover, even with knowledge of a substantial risk, the official is not liable if he responds reasonably to that risk.

2. Application to Emergency Responders Ditmore and Payne

Ms. West argued that Captain Ditmore and firefighter Payne were deliberately indifferent when:

• Ditmore ordered a “chemical restraint” knowing Jamon was in excited delirium and prone; and
• Payne administered maximum doses of sedatives known to risk respiratory depression.

The Eleventh Circuit does not resolve in detail whether these allegations meet the objective or subjective prongs. Instead, it again turns to the clearly established prong of qualified immunity.

Two key gaps in Ms. West’s position are identified:

1. Scope of the deliberate-indifference standard: She cites no authority clearly extending Fourteenth Amendment deliberate-indifference standards to:
   • First responders who are not arresting or detaining a suspect as such, but
   • Are instead rendering emergency medical aid, requested by a family member, in a non-custodial setting.
   While Revere and Cottrell strongly apply the standard to arrestees and detainees, the application to purely medical-emergency responses is not clearly established.
2. No clearly established rule on facts like these: Ms. West identifies no case law, broad principle, or egregious-conduct analogy establishing that:
   • Ordering and administering sedatives in the field, in the presence of excited delirium and prone restraint, is clearly unconstitutional medical indifference; or
   • Failing to perfectly implement departmental policies in this emergency context equates to deliberate indifference.

She argued instead that Ditmore and Payne “should have known” what proper restraint and sedation practices were by reading their own policy manuals or receiving adequate training—not by reading case law.

The court emphasizes that:

• Policies are not law; they may inform reasonableness, but they do not themselves define constitutional baselines.
• Neither the Supreme Court nor the Eleventh Circuit has held that an entity’s internal policies can, by themselves, create “clearly established” constitutional law.

The court addresses Lombardo v. City of St. Louis, which Ms. West invoked. In Lombardo, the Supreme Court vacated and remanded a decision concerning possible excessive force in a prone-restraint situation, noting that “well-known police guidance” may inform whether force was reasonable. But the Eleventh Circuit underscores that Lombardo addressed:

• whether a constitutional violation occurred (prong one); not
• whether the right was clearly established for qualified immunity purposes (prong two).

Thus, Lombardo does not transform internal policy manuals into sources of clearly established law that automatically overcome qualified immunity for deliberate-indifference claims.

Result: Because Ms. West did not show that Ditmore and Payne violated clearly established law regarding deliberate indifference to medical needs, they are entitled to qualified immunity, and count five was properly dismissed.

V. Precedents and Doctrines Simplified

A. Key ADA Precedents

• Ingram v. Kubik, Silberman v. Miami-Dade Transit, Liese v. Indian River County Hospital District, Gebser v. Lago Vista ISD:
  • Set the standard for ADA damages: need deliberate indifference by an official who can correct the problem and has actual knowledge.
• Schiavo ex rel. Schindler v. Schiavo:
  • Recognizes that the ADA does not regulate medical treatment decisions as such.
• Gaston v. Bellingrath Gardens & Home, Inc.:
  • Holds that the duty to accommodate generally arises only after a specific request for accommodation.
• Cordoba v. Dillard’s, Inc.:
  • Rejects ADA liability based on what a decisionmaker “should have known”; constructive knowledge is insufficient.

B. Municipal Liability and Failure to Train

• Monell v. Department of Social Services:
  • No respondeat superior under § 1983; municipalities liable only for their own policies or customs.
• City of Canton v. Harris:
  • Establishes the failure-to-train theory and the “deliberate indifference” standard.
  • Introduces the “obvious need” idea with the firearms hypothetical.
• Board of County Commissioners of Bryan County v. Brown, Connick v. Thompson:
  • Reinforce that failure-to-train liability is a “high bar” and typically requires a pattern of prior violations.
• Gold v. City of Miami, Weiland v. Palm Beach County Sheriff’s Office, Lewis v. City of West Palm Beach:
  • Apply that bar in specific contexts (handcuff complaints, mentally ill citizens, hobble ties in excited delirium), rejecting single-incident “obvious” need theories.

C. Qualified Immunity and Excessive Force

• Graham v. Connor, Lee v. Ferraro:
  • Set the basic excessive-force standard: objective reasonableness under the Fourth Amendment.
• Tennessee v. Garner, Mercado v. City of Orlando, Bradley v. Benton:
  • Stand for the principle that deadly force cannot be used when the situation does not warrant it.
• Garrett v. Athens-Clarke County, Lewis v. City of West Palm Beach:
  • Hold that even where prone restraint of an excited-delirium subject leads to death, the law was not clearly established that such force was excessive.
• Ashcroft v. al‑Kidd, Anderson v. Creighton, District of Columbia v. Wesby, Pearson v. Callahan, Smith v. Mattox:
  • Shape the contours of qualified immunity and the “clearly established” requirement.

D. Deliberate Indifference to Medical Needs

• City of Revere v. Massachusetts General Hospital, Cottrell v. Caldwell:
  • Extend duty to provide medical care to arrestees and pretrial detainees under the Fourteenth Amendment.
• Farmer v. Brennan, Wade v. McDade:
  • Define the subjective “deliberate indifference” standard as akin to criminal recklessness.
• Mann v. Taser International, Hill v. DeKalb Regional Youth Detention Center, Hope v. Pelzer:
  • Clarify what constitutes a “serious medical need” and emphasize that negligence is not enough.
• Lombardo v. City of St. Louis:
  • Emphasizes that departmental guidance may inform the reasonableness analysis for use-of-force, but does not itself create constitutional law for qualified-immunity purposes.

VI. Complex Concepts Explained in Plain Terms

A. What Is “Excited Delirium” in Legal Context?

“Excited delirium,” as described in the complaint and the opinion, refers to an acute behavioral crisis associated with agitation, confusion, hyperactivity, sometimes hyperthermia, and a lack of pain awareness. In litigation, it often appears when:

• A person is behaving erratically and often violently;
• Police or EMS restrain them, sometimes with force or medical sedation; and
• The person subsequently dies, sometimes from positional asphyxia or cardiac arrest.

Legally, the term matters because:

• Departments often have specific protocols for managing such episodes;
• Plaintiffs argue that those protocols make the attendant risks “known” or “obvious”; and
• Courts must decide whether the use of force or failure to train in this context violates clearly established rights.

B. Deliberate Indifference vs. Negligence

In both ADA damages claims and § 1983 medical-needs claims, “deliberate indifference” is a demanding standard:

• Negligence: Mistake, carelessness, or poor judgment—without conscious disregard of a known serious risk.
• Deliberate indifference: The official actually knows of a substantial risk of serious harm and consciously ignores it or fails to take reasonable steps to address it.

The Eleventh Circuit repeatedly stresses that even very bad outcomes—even deaths—do not automatically convert negligence into constitutional wrongs.

C. Qualified Immunity and “Clearly Established Law”

Qualified immunity shields officials unless both:

1. Their conduct violated a constitutional right; and
2. The contours of that right were so clear at the time that every reasonable official would have understood he was violating it.

“Clearly established” typically requires:

• Prior binding appellate decisions with very similar facts; or
• A very clear constitutional principle whose application to the new facts is obvious; or
• Truly egregious conduct.

Internal manuals, training bulletins, or national practice guidelines do not automatically count as “law” for this purpose, even if they are probative of what good practice looks like.

D. Monell and the High Bar for Failure-to-Train

Under Monell and Canton:

• Municipalities are not insurers of their employees’ conduct.
• “Failure to train” is not a fallback theory whenever an officer makes a poor decision.
• Liability attaches only where the city’s own choices—e.g., a deliberate decision not to provide needed training in the face of clear risk—cause the violation.

The “obviousness” exception (where no pattern is needed) is exceedingly narrow. Courts rarely find it satisfied outside the firearms/deadly-force training hypothetical.

VII. Likely Impact and Broader Significance

A. Practical Limits on ADA Claims in Emergency-Response Settings

The decision reinforces that:

• Title II does not cover disagreements over emergency medical judgments, even where disability is involved.
• A specific request for accommodation remains the general trigger for a reasonable-accommodation duty, even in urgent or crisis situations.
• Attempts to characterize poor medical decisions as ADA discrimination will face strong doctrinal headwinds in the Eleventh Circuit.

For plaintiffs, this means that federal ADA litigation is a difficult vehicle for challenging field medical decisions by EMS or medically trained first responders. State-law medical negligence and wrongful-death claims may be more promising, though they have different requirements and immunities.

B. Excited Delirium, Restraint Practices, and Municipal Liability

The opinion continues a line of Eleventh Circuit authority (e.g., Lewis, Garrett) that:

• Recognizes the grave dangers associated with prone restraint of agitated subjects but
• Stops short of declaring such practices clearly unconstitutional as a matter of federal law.

For municipalities, it signals that:

• Having written policies on excited delirium and prone restraint is prudent from a risk-management and clinical perspective.
• But the existence of such policies, without a pattern of prior violations, does not equate to municipal liability for failure to train if a single tragedy occurs.

For civil-rights plaintiffs, it underscores that success on a federal failure-to-train claim in this context will almost certainly require:

• Evidence of multiple prior similar incidents; or
• Very strong facts making the need for training equivalent in obviousness to the firearm/deadly-force hypothetical (a very high bar).

C. Internal Policies vs. Constitutional Baselines

The court is explicit: internal policies do not themselves define constitutional minimums. They can:

• Guide officers and firefighters toward best practices.
• Be relevant in evaluating reasonableness (especially for prong-one/violation analysis).

But they do not, without more, make conduct that violates internal rules equivalent to conduct that violates clearly established constitutional rights. This distinction will remain important as more agencies adopt detailed use-of-force and medical-response protocols.

D. Non-Precedential but Persuasive

Because the panel designated the decision “not for publication,” it is not binding precedent in the Eleventh Circuit. Nonetheless, it:

• Synthesizes several key strands of Eleventh Circuit doctrine (ADA, Monell, qualified immunity, deliberate indifference).
• Applies them to a fact pattern—excited delirium, prone restraint, sedation—likely to recur in future cases.
• Will likely be cited in district courts as persuasive authority, especially within the Eleventh Circuit, in similar disputes involving emergency medical responses and excited-delirium-type scenarios.

VIII. Conclusion

West v. DeKalb County is a comprehensive reaffirmation of several established but demanding doctrines:

• ADA Title II:
  • Does not regulate the substance of medical treatment decisions.
  • Requires a specific request for accommodation to trigger the duty to accommodate.
  • Requires deliberate indifference from an official with authority; no vicarious liability for rank-and-file misjudgments.
• § 1983 Municipal Liability:
  • Failure-to-train claims remain “at their most tenuous” and rarely succeed without a pattern of prior violations.
  • Training on excited-delirium/prone-restraint practices does not present the sort of “obvious” need that permits single-incident liability.
• Qualified Immunity:
  • Even deadly outcomes from prone restraints in excited-delirium contexts do not, under existing Eleventh Circuit precedent, automatically refute qualified immunity.
  • Internal policies and general professional awareness cannot by themselves create clearly established constitutional law.
• Deliberate Indifference to Medical Needs:
  • The standard is exacting and has not clearly been extended to emergency responders in purely medical-assistance calls.
  • Policies may inform best practice but do not, by themselves, fix constitutional baselines.

For practitioners, the decision is a cautionary roadmap: claims arising from catastrophic outcomes in excited-delirium incidents face steep doctrinal hurdles under both the ADA and § 1983. For policymakers and agencies, it underscores the importance of robust training and protocols—not because federal law mandates them in this sense, but because the civil-rights backstop is limited and much of the risk must be managed through professional standards, supervision, and state-law accountability.