"You Break It, You Own It": Eleventh Circuit Clarifies County Monell Liability for Privatized Jail Healthcare in Smothers v. Childers

I. Introduction

In Pamela Smothers v. Roger Childers, et al. (No. 24‑13131, decided Nov. 20, 2025), the Eleventh Circuit, in a published opinion authored by Judge Rosenbaum, reversed summary judgment in favor of Walker County, Alabama, in a § 1983 action arising from the death of a jail inmate, Mitchell Wayne Smothers, Jr.

The case sits at the intersection of three highly consequential doctrinal streams:

• Municipal liability under Monell for constitutional violations;
• The Eighth Amendment right to adequate medical care for incarcerated persons;
• The increasingly common practice of counties outsourcing jail healthcare to private contractors.

The central question was whether Walker County could be held liable under § 1983 for an alleged policy of contracting with – and then repeatedly reaffirming – an incompetent private medical provider to serve as the exclusive source of medical care in the jail, even though Alabama statutes formally place “medical attention” responsibilities on the sheriff, not the county commission. The district court had held that state law limited the county’s role to “funding” medical care and therefore barred county liability.

The Eleventh Circuit disagreed. It held that:

• A county may incur Monell liability where, by its own policy choices, it knowingly maintains an exclusive contract with an incompetent jail medical provider and constrains the sheriff’s ability to fix the problem; and
• Alabama’s statutory allocation of formal medical responsibilities to sheriffs does not insulate a county from federal § 1983 liability when the county’s own policies are a moving force behind an Eighth Amendment violation.

Invoking the popularized “Pottery Barn rule” (“you break it, you own it”), the court essentially held that once Walker County “broke” jail healthcare by its policy decisions and “doubled down” on that policy with full knowledge of the consequences, it could “own” § 1983 liability, notwithstanding the sheriff-centric language of Alabama law.

II. Overview of the Case

A. Parties and Procedural Posture

• Plaintiff–Appellant: Pamela Smothers, as administrator and personal representative of the Estate of her deceased son, Mitchell Wayne Smothers, Jr.
• Defendants:
  • Roger Childers – a registered nurse, Ph.D. in Business Administration, president/owner of Preemptive Forensic Health Solutions (“Preemptive”).
  • Preemptive Forensic Health Solutions – private contractor providing “comprehensive onsite medical services” at Walker County Jail.
  • Walker County – the county commission and county governing body responsible for funding and, by contract, overseeing jail medical services.

Smothers sued under 42 U.S.C. § 1983, alleging deliberate indifference to Mitchell’s serious medical needs in violation of the Eighth Amendment. She settled with Childers and Preemptive. The appeal concerns only the summary judgment granted in favor of Walker County by the U.S. District Court for the Northern District of Alabama.

B. Factual Context

The key factual elements, taken in the light most favorable to Smothers as required at summary judgment, include:

• Since 2009, Walker County had an exclusive contract with Preemptive to provide all onsite jail medical care. Preemptive had no physicians on staff; its owner, Childers, a nurse with a business Ph.D., signed correspondence as “Dr. Childers.”
• The contract was repeatedly renewed (2012, 2016, and then continued month‑to‑month) despite worsening indicators:
  • Medication expenditures fell from about $13,000 per month to about $2,200 per month – roughly an 85% reduction.
  • Offsite medical referrals dropped from 33 detainees in a single pre‑contract month to fewer than 12 over six years – a nearly 200‑fold decrease in referral rate.
  • Eleven inmates died while in jail custody after the contract was in place.
• There were numerous complaints that deaths and serious harms were tied to lack of adequate medical care, and these concerns became a public campaign issue in the sheriff’s race.
• Newly elected Sheriff Nick Smith campaigned explicitly on improving medical care and, after taking office, repeatedly urged the County Commission not to renew Preemptive’s contract, citing inadequate care and virtual absence of physicians.
• Contract language defined “County” to include both the Commission and the Sheriff collectively and gave “the County” the sole discretion to issue notices of noncompliance and to terminate or cure the contract, effectively preventing the sheriff from unilaterally ending the Preemptive relationship.
• When Sheriff Smith, frustrated, ordered jail staff to send detainees to the hospital at the slightest complaint, costs doubled; the County questioned the expenses but did not cut them and nonetheless continued the Preemptive contract on a month‑to‑month basis, even increasing the monthly fee.

Against this backdrop, Mitchell – a probation violator with severe chronic medical conditions and a recent MRSA‑infected leg wound – entered the jail in February 2019. The evidence viewed favorably to the plaintiff shows:

• Preemptive’s nurse recognized he needed to see a physician and allegedly put him on the doctor list; a physician never saw him.
• Wound care was minimal and discontinued after only a couple of bandage changes.
• Mitchell reported severe pain, bleeding, and inability to stand; he received only ibuprofen in jail.
• Preemptive nurses administered Lasix, a prescription diuretic, without a valid physician order; the ostensible supervising doctor never saw Mitchell or approved his medications.
• The plaintiff’s expert, Dr. McMunn, opined that the care fell well below nursing standards, that Childers’s conduct was “particularly egregious,” and that these deficiencies directly contributed to Mitchell’s septic shock and death.
• Despite worsening symptoms, a transfer request to the state prison system, framed as necessary because Mitchell posed “high medical risks” for the jail, languished for more than a month before transfer; no physician assessment occurred in that interval.
• Mitchell was finally sent to a hospital on August 2, 2019, diagnosed with acute metabolic encephalopathy, septic shock secondary to cellulitis, UTI, and hepatorenal syndrome, and died on August 12 from multisystem organ failure and septic shock.

C. Central Legal Issues

1. Monell Liability and Policy: Did Walker County have a “policy or custom” of providing inadequate jail medical care by knowingly contracting exclusively with an incompetent private provider and blocking remedial efforts, such that the County could be considered the “moving force” behind the Eighth Amendment violation?
2. Role of Alabama Statutes: Do Alabama Code §§ 14‑6‑19 (assigning sheriffs responsibility for “necessary medicines and medical attention”) and 14‑6‑20 (allowing counties to elect physicians for jail inmates) insulate the County from § 1983 liability by restricting its duty to funding alone?
3. Summary Judgment Appropriateness: Was the evidence so one‑sided that no reasonable jury could find the County deliberately indifferent to Mitchell’s right to adequate medical care?

III. Summary of the Opinion

The Eleventh Circuit reversed and remanded, holding that:

1. Policy/Custom Identified: Smothers presented sufficient evidence for a reasonable jury to find that Walker County had a policy of contracting with Preemptive as the exclusive provider of jail medical care despite knowing Preemptive was incompetent and providing inadequate care, and of preventing the sheriff from remedying the problem.
2. Deliberate Indifference: The County’s repeated renewal and continuation of the Preemptive contract – in the face of inmate deaths, severe cost‑cutting on medications and referrals, public controversy, and the sheriff’s documented complaints – could be found to constitute deliberate indifference to the known or obvious risk of serious harm to inmates.
3. Causation: Viewing the evidence most favorably to Smothers, a jury could find a direct causal link between the County’s policy of maintaining this contract and Mitchell’s death from septic shock, making the County’s policy a “moving force” behind the constitutional violation.
4. No State‑Law Bar: Alabama’s allocation of formal medical responsibilities to sheriffs, and district court precedent reading the County’s role as limited to funding, do not bar federal § 1983 liability where the County’s own policy causes a constitutional deprivation. State statutes cannot override Monell’s command that municipalities are liable for the constitutional harms caused by their policies or customs.
5. Summary Judgment Improper: There are genuine disputes of material fact about whether the County “voluntarily undertook” responsibility for jail medical care by electing and controlling the provider and whether its policy was deliberately indifferent and causally linked to Mitchell’s death; thus, summary judgment was inappropriate.

IV. Detailed Analysis of the Opinion

A. The Governing Legal Framework

1. Section 1983 and Monell

Section 1983 imposes liability on “every person” who, under color of state law, “subjects, or causes to be subjected” any person to a deprivation of constitutional rights. In Monell v. Department of Social Services, 436 U.S. 658 (1978), the Supreme Court held that:

• Municipalities are “persons” under § 1983; but
• They cannot be held liable on a respondeat superior (vicarious liability) theory for the acts of their employees.

Instead, a plaintiff must show that:

1. A constitutional right was violated;
2. The municipality had a policy, custom, or decision by a final policymaker that constituted deliberate indifference to that right; and
3. The policy/custom was the moving force behind the violation – that is, there was a direct causal link between the municipal action and the injury.

The Eleventh Circuit uses this three‑element framework, as articulated in McDowell v. Brown, 392 F.3d 1283, 1289 (11th Cir. 2004).

2. Eighth Amendment Deliberate Indifference to Medical Needs

For convicted prisoners, inadequate medical care implicates the Eighth Amendment’s prohibition of cruel and unusual punishment. In Estelle v. Gamble, 429 U.S. 97 (1976), the Supreme Court held that “deliberate indifference to serious medical needs of prisoners constitutes the ‘unnecessary and wanton infliction of pain’” forbidden by the Eighth Amendment.

Although some earlier Eleventh Circuit cases (e.g., Ancata) involved pretrial detainees under the Fourteenth Amendment’s Due Process Clause, the court here notes that, for medical‑care purposes, the protections are at least coextensive; the doctrinal standards for “deliberate indifference” are essentially the same.

3. Municipal Culpability and Causation

Subsequent Supreme Court decisions refined Monell:

• Culpability (“deliberate indifference”): A municipal policy must be adopted with “deliberate indifference to its known or obvious consequences.” Board of County Commissioners of Bryan County v. Brown, 520 U.S. 397, 407 (1997); McDowell, 392 F.3d at 1291.
• Causation (“moving force”): There must be a “direct causal link” between the municipal policy/custom and the constitutional deprivation. City of Canton v. Harris, 489 U.S. 378, 385 (1989). The policy must be the “moving force” behind the injury, not merely a background condition. Brown, 520 U.S. at 404.

The opinion systematically walks through these elements, using Ancata v. Prison Health Services, Inc., 769 F.2d 700 (11th Cir. 1985), as a close analogue.

B. Precedents Cited and Their Influence

1. Monell v. Department of Social Services (1978)

Monell establishes the fundamental rule: municipalities are liable only for constitutional deprivations caused by their own policies or customs, not for isolated aberrations by employees. The Smothers court invokes Monell to anchor the three core requirements:

• Identifiable policy/custom/final policymaker decision;
• Deliberate indifference (culpability);
• Causation (moving force).

The central issue in Smothers is not whether Monell applies but whether the County’s relationship with Preemptive and its contractual choices amount to a qualifying policy or custom.

2. Estelle v. Gamble (1976)

Estelle is cited for the basic Eighth Amendment principle that deliberate indifference to serious medical needs constitutes cruel and unusual punishment. It frames Mitchell’s death – allegedly from septic shock after months of inadequate treatment – as a textbook deliberate‑indifference scenario, if the facts alleged are proven.

3. Ancata v. Prison Health Services, Inc. (11th Cir. 1985)

Ancata is the opinion’s conceptual keystone. There, Broward County, Florida, contracted with a private provider (Prison Health Services) to provide jail medical care. The provider told an indigent detainee he would not be referred to an outside specialist without a court order and unless he paid for his own care. The detainee ultimately died.

The Eleventh Circuit held that:

• Broward County was responsible for ensuring adequate funds were provided to meet inmates’ medical needs; and
• If the County either:
  • “established or utilized a policy or custom requiring that inmates needing medical assistance obtain court orders,” or
  • “permitted the sheriff and/or prison health officials that it contracted with to establish such a policy or custom,”
  and that policy played a role in delaying treatment, then the County could be liable under Monell.

The Smothers panel characterizes the present case as “not materially different” from Ancata:

• In Ancata: The policy was requiring court orders and payment before outside referrals, despite indigency.
• In Smothers: The effective policy was contracting exclusively with an incompetent provider (lacking physicians, slashing medications and referrals, racking up inmate deaths) and then refusing to allow the sheriff to change providers.

In both instances, the County’s institutional choices about how medical care would be delivered to inmates – and on what terms – allegedly produced a systemic denial or delay of necessary treatment, satisfying Monell’s “policy or custom” requirement.

4. McDowell v. Brown (11th Cir. 2004)

McDowell articulates the three‑part Monell test the court applies here and reinforces that deliberate indifference is shown where a municipality acts with knowledge that its policy is likely to cause constitutional injury. The Smothers court quotes McDowell for the proposition that the municipality’s action must be “the moving force” behind the injury and that deliberate indifference involves awareness of “known or obvious consequences.”

5. Brown v. Board of County Commissioners of Bryan County (U.S. 1997)

Brown is cited for:

• The need for a “direct causal link” between municipal action and the deprivation;
• The caution that § 1983 municipal liability must not collapse into respondeat superior; the causal and culpability requirements are meant to preserve that distinction.

The Smothers opinion uses Brown to frame its causation analysis and to justify close scrutiny of whether the County’s contracting decisions themselves – not simply Preemptive’s misconduct – might form the “moving force.”

6. City of Canton v. Harris (U.S. 1989)

Canton supplies the “direct causal link” language and reinforces that where a city’s deliberate choices regarding training or policies foreseeably result in constitutional violations, § 1983 liability may attach. Smothers applies that logic to contracting choices instead of training choices.

7. Turquitt v. Jefferson County (11th Cir. 1998, en banc)

Turquitt held that under Alabama law, sheriffs operate county jails as state, not county, officers, so counties are generally not responsible under § 1983 for “conditions of confinement” policies they do not control. However, Turquitt also acknowledged liability where a county possesses and exercises “authority to control” the relevant aspect of jail operations.

Smothers invokes Turquitt precisely for this “authority to control” point. Through § 14‑6‑20 and the contracts with Preemptive, Walker County claimed authority over the selection, retention, and oversight of the jail’s exclusive medical provider and over the mechanisms for addressing noncompliance. This contractual control moves the County’s role beyond mere funding into operational policy, aligning the case with Ancata rather than with Turquitt’s funding‑only scenarios.

8. Other Eleventh Circuit and Alabama Authorities

• Denno v. School Board of Volusia County, 218 F.3d 1267 (11th Cir. 2000), and Depew v. City of St. Marys, 787 F.2d 1496 (11th Cir. 1986) are cited for the proposition that a custom or practice must be “persistent and widespread,” “well‑settled,” and not simply an isolated incident.
• Brown v. City of Fort Lauderdale, 923 F.2d 1474 (11th Cir. 1991) explains that a longstanding practice may be deemed authorized because policymakers must have known of it yet failed to stop it.
• Dailey v. City of Birmingham, 378 So. 2d 728 (Ala. 1979) is cited for the proposition that where there is a factual dispute about whether a governmental entity “voluntarily undertook” a duty, summary judgment is improper – directly echoing the County’s arguable voluntary assumption of responsibility for jail medical care via § 14‑6‑20.

The district court relied on Shaw v. Coosa County Commission, 330 F. Supp. 2d 1285 (M.D. Ala. 2004), and Cole v. Walker County, 2015 WL 1733810 (N.D. Ala. 2015), for the proposition that counties merely fund, but do not operate, medical services. Smothers effectively relegates those district court cases to irrelevance in the face of binding circuit precedent (Ancata) and the specific facts here showing that Walker County’s role far exceeded passive funding.

C. Application of Monell to Walker County’s Conduct

1. Policy or Custom

The first question is whether Smothers identified an actionable “policy or custom” attributable to Walker County. The court concludes that she has, pointing to:

• Exclusive contracting with Preemptive. From 2009 onward, the County repeatedly renewed a contract that made Preemptive the exclusive provider of onsite jail medical services, knowing it had no physicians on staff and was drastically cutting medications and referrals.
• Knowledge of deaths and complaints. Eleven inmates died after the contract took effect. Complaints linked those deaths to inadequate care. The issue became sufficiently public that it formed part of Sheriff Smith’s election campaign.
• Non‑isolated pattern. The court is explicit that these were not “random acts or isolated incidents.” The evidence suggested a persistent, systemic pattern:
  • Drastic, sustained reduction in prescription spending;
  • Near elimination of offsite referrals;
  • Repeated inmate deaths over a multi‑year period.
• Contractual structure centralizing control. The 2016 contract:
  • Expanded Preemptive’s obligations to provide “basic and adequate” care with “properly licensed and credentialed” staff – indicating awareness of quality issues;
  • Defined “County” as the Commission plus the Sheriff “collectively” for purposes of notice and cure;
  • Conferred “sole discretion” on the “County” to address noncompliance.
  Evidence suggested this structure effectively prevented the sheriff from unilaterally terminating or replacing Preemptive.
• Refusal to act despite sheriff’s objections. After taking office, Sheriff Smith:
  • Explicitly asked the County not to renew Preemptive’s contract;
  • Reported that he had not “laid eyes on any doctor” at the jail;
  • Complained that Preemptive was providing only CNAs and not adequate care.
  Despite this, the County continued the contract and even increased payments as medical hours expanded.

Together, these facts permit a jury to find not just that the County had a contract with Preemptive, but that it had a policy of knowingly continuing to rely on an incompetent exclusive provider, in the face of mounting evidence that this policy was endangering inmates.

2. Deliberate Indifference (Culpability)

The second element examines whether the County adopted or maintained its policy with deliberate indifference to the known or obvious risk of constitutional violations. The court points to several telling indicators:

• Awareness of quality problems. Deaths in custody, public controversies during the sheriff’s race, and sheriff’s direct complaints to the Commission about the absence of doctors and inadequacy of care are strong evidence of actual notice.
• Internal red flags from the contractor itself. Childers’s 2015 letter trumpeted:
  • Reduction of medication spending by about five‑sixths;
  • Reduction of outside referrals from 33 per month to fewer than 12 in six years.
  The court suggests such extreme “savings” should have prompted concern about under‑treatment, not celebration.
• Contractual oversight authority. Under Ala. Code § 14‑6‑20, the County elected Preemptive to “attend the inmates of the jails” and retained authority to remove the provider “at the will of the county commission.” The 2016 contract further centralized oversight in the “County.” Having taken on this authority, the County’s choice to not act, despite clear warning signs, supports a finding of deliberate indifference.
• Rejection of proposed corrective measures. The sheriff’s policy change of sending inmates directly to the hospital doubled costs but apparently improved access to care. The County, while questioning costs, neither cut off that practice nor used it as an occasion to restructure the Preemptive arrangement. Instead, it continued the contract month‑to‑month.

Against this record, the court concludes that a reasonable jury could find the County acted with deliberate indifference to “known or obvious consequences” of maintaining Preemptive as the sole jail healthcare provider.

3. Causation (“Moving Force”)

The final step is to link the County’s policy to Mitchell’s specific death. The key features are:

• Obvious need for medical care. Mitchell arrived with:
  • Severe chronic conditions (cirrhosis secondary to hepatitis C, COPD, recurrent cellulitis, nonhealing pressure wounds);
  • A recent MRSA‑infected leg wound and ongoing antibiotics prescribed only a month earlier.
  Preemptive’s nurse recognized he “needed to be seen by the physician” and allegedly placed him on a doctor list. No physician ever saw him.
• Clearly deficient care. According to the plaintiff’s expert:
  • Wound care was inadequate and discontinued;
  • Prescription medications (such as Lasix) were given without proper physician orders;
  • The standard of care for nurses was violated in “particularly egregious” fashion.
• Link to County policy. The court reasons that a jury could find that these inadequate practices were part of a “significant, recurring problem” under Preemptive’s regime – the same regime the County knowingly maintained as exclusive provider. Thus, the County’s policy was not a remote background condition: it structured the medical environment that predictably led to Mitchell’s untreated infection progressing to septic shock.
• Expert causal testimony. Dr. McMunn opined that had a licensed physician overseen Mitchell’s care, the problems with his nonhealing wound and other conditions would likely have been recognized and properly treated, avoiding or mitigating the septic shock that killed him.

Based on this record, the court holds that a reasonable jury could find “a direct causal link” between the County’s policy (continuing its contract with Preemptive despite known deficiencies) and the constitutional deprivation (deliberate indifference to Mitchell’s serious medical needs culminating in his death).

D. Rejection of Alabama’s Statutory “Bar” to County Liability

1. The District Court’s View

The district court relied heavily on Ala. Code § 14‑6‑19, which states that sheriffs must provide “necessary medicines and medical attention to those prisoners who are sick or injured,” to conclude that:

• Under Alabama law, only the sheriff has the duty to ensure provision of medical care; and
• The County’s role is limited to funding such care, which it fulfilled by contracting with Preemptive.

The court also cited district court opinions (Shaw, Cole) reading Alabama law to limit counties to “funding” responsibilities, concluding that this statutory scheme barred county liability under § 1983.

2. The Eleventh Circuit’s Response

The Eleventh Circuit firmly rejects that reasoning on two levels:

1. State statute cannot negate federal constitutional liability. Citing Monell and Ancata, the court emphasizes that:
   • A municipality is liable under § 1983 when its own policy or custom causes a constitutional violation;
   • That liability cannot be evaded by pointing to a state statute that formally allocates duties to a different actor (here, the sheriff).
   In Ancata, Broward County’s duty arose not from explicit statutory language but from the obligation, recognized in Estelle and City of Revere, to ensure inmates receive adequate medical care. The same underlying constitutional principle applies here.
2. Alabama law in fact enables county assumption of responsibility. The court notes Ala. Code § 14‑6‑20, which allows a county to “elect a physician” (or multiple physicians) to attend jail inmates and to remove them “at the will of the county commission.” Walker County invoked this statute when it contracted with Preemptive.
   • By doing so, the County did more than merely fund care; it affirmatively chose the exclusive provider and reserved to itself contractual “authority to control” compliance;
   • Having voluntarily undertaken this role, it may incur liability for policies that foreseeably produce constitutional violations.

The panel concludes that “the precise role that a state statute assigns to county officials in administering healthcare in a jail makes no difference” to the federal question. What matters is whether the County “establish[ed] a policy that directly causes inmates to receive inadequate healthcare.” On the facts presented, a jury could so find.

E. Privatized Jail Healthcare and Municipal Responsibility

A significant subtext of the opinion is the proliferation of privatized jail healthcare. Smothers underscores several important points about how § 1983 interacts with privatization:

• Contracting out does not contract away constitutional responsibility. Echoing Ancata, the court reiterates that when a county contracts with a private entity to discharge constitutionally rooted obligations (here, medical care for inmates), the county “remains liable for any constitutional deprivations caused by the policies or customs” of the contracted provider to the extent those policies are attributable to the county’s own policy decisions.
• Financial incentives can be evidence of deliberate indifference. The court does not condemn cost‑consciousness per se. But extreme cost cutting – medication budgets slashed by five‑sixths, outside referrals virtually eliminated – combined with mounting deaths and complaints, can demonstrate that the municipality prioritized savings over basic adequacy of care in a way that amounts to deliberate indifference.
• Exclusive contracts plus ineffective oversight raise stakes. When a local government:
  • Grants an exclusive franchise to a single medical provider;
  • Reserves to itself the sole authority to monitor and cure noncompliance; and
  • Then ignores clear red flags about care quality;
  it cannot credibly disclaim responsibility for the systemic deficiencies that follow.

The opinion therefore sends a clear message to counties in the Eleventh Circuit: privatization is not a liability shield. If anything, it may sharpen the focus on the county’s policy‑level decisions regarding whom to hire, how to structure incentives and oversight, and whether to respond to warning signs.

V. Complex Concepts Simplified

A. Section 1983 and “Under Color of State Law”

Section 1983 is a federal statute that lets individuals sue state and local officials (and municipalities) for violations of federal constitutional rights, when those violations are done “under color of” state law – meaning through the authority or power given by state law (e.g., jail operations, law enforcement).

B. Monell Liability vs. Respondeat Superior

• Respondeat superior: A common tort principle where an employer is automatically liable for its employee’s acts within the scope of employment, regardless of employer fault.
• Monell standard: Municipalities are liable only if the violation resulted from:
  • An official policy (such as an ordinance or formally adopted rule);
  • A widespread custom or practice that is so regular it has the force of law; or
  • A decision by a person with final policymaking authority in that area.

In Smothers, the County is not being sued simply because jail medical staff mistreated Mitchell. It is being sued for its own high‑level policy choice: maintaining an exclusive contract with a known‑deficient provider and constraining the sheriff’s efforts to change that arrangement.

C. “Deliberate Indifference” in the Medical Context

“Deliberate indifference” occupies a middle ground between simple negligence and intentional harm:

• It is more than carelessness or a mistake;
• But it does not require that officials wanted the inmate to be harmed.

Instead, deliberate indifference means:

• Officials knew of (or were aware of facts strongly indicating) a substantial risk of serious harm; and
• They consciously disregarded that risk by failing to take reasonable measures to address it.

Applied to a county, it means that policymakers knew their policy (e.g., keeping a dangerously inadequate medical contractor in place) was likely to cause serious harm to inmates but chose not to change course.

D. “Policy or Custom” and “Moving Force”

• Policy: A rule, practice, or decision officially adopted or endorsed by the government’s lawmakers or final decision‑makers (e.g., contracts, written directives).
• Custom: A long‑standing, widespread practice that is so well settled that it effectively represents official policy, even if not formally written.
• Moving force: The policy or custom must be closely connected to the harm – it must be a significant factor that directly leads to the violation, not a distant or trivial background condition.

In Smothers, the “policy” is the County’s repeated decision to contract exclusively with Preemptive and retain that contract despite clear evidence of dangerously deficient care.

E. Summary Judgment

Summary judgment is a procedural device used to resolve a case without trial when there is no “genuine dispute as to any material fact” and the moving party is entitled to judgment as a matter of law. Courts must:

• View all evidence in the light most favorable to the non‑moving party (here, Smothers);
• Draw all reasonable inferences in that party’s favor;
• Grant summary judgment only when a reasonable jury could not possibly find for the non‑movant.

The Eleventh Circuit found that significant factual disputes exist about:

• What the County knew;
• How it responded;
• Whether its policy caused Mitchell’s death.

These issues must be decided by a jury, not by a judge on summary judgment.

F. The “Pottery Barn Rule” Analogy

The opinion playfully invokes the so‑called “Pottery Barn rule” – “you break it, you own it” – to illustrate a legal point:

• If a county’s policy decisions “break” a critical system (here, jail healthcare) by installing and maintaining a dangerously inadequate provider,
• Then the county “owns” the consequences under federal law – i.e., it may be held liable when that broken system leads to constitutional violations, regardless of how state law allocates formal duties between the county and the sheriff.

VI. Impact and Future Implications

A. For Alabama Counties and Sheriffs

Smothers significantly clarifies and sharpens the contours of municipal liability for jail healthcare in Alabama:

• Counties cannot hide behind sheriff‑centric statutes. While sheriffs remain formally responsible for medical “attention” under § 14‑6‑19, a county that invokes § 14‑6‑20 to select and control a jail medical provider cannot use that statute as a liability shield.
• “Funding only” is no longer a safe characterization when the county goes further. When a county:
  • Chooses the exclusive provider;
  • Controls contract terms and enforcement;
  • Retains removal power;
  it has moved beyond mere funding. If it keeps a problematic provider despite clear warning signs, it risks Monell liability.
• Sheriff–County dynamics matter. By structuring contracts so that the sheriff cannot unilaterally terminate an incompetent provider, counties may create precisely the kind of “policy or custom” that courts attribute to the municipality. Sheriffs may wish to insist on contractual authority commensurate with their statutory responsibility.

B. For Privatized Jail and Prison Healthcare Nationwide

Although focused on Alabama, Smothers has broader resonance within the Eleventh Circuit (Alabama, Georgia, Florida) and potentially persuasive value elsewhere:

• Contracting is a policy choice. Counties and cities are on notice that decisions about who delivers medical care to inmates, and under what contractual terms, are policy decisions scrutinizable under Monell.
• Evidence of cost‑driven under‑treatment is legally significant. Extreme reductions in medications and referrals, combined with worsening medical outcomes, are not just moral or political concerns – they may be evidence of deliberate indifference.
• Patterns of deaths and serious harms matter. A string of inmate deaths or near‑fatal incidents under a contractor’s watch, if ignored, can establish a “persistent and widespread” custom sufficient to trigger municipal liability.

C. Litigation Strategy and Proof Considerations

For plaintiffs’ counsel in jail medical cases:

• Smothers underscores the importance of developing evidence of:
  • Contract terms (especially exclusivity, oversight, and termination powers);
  • Budget and cost‑cutting data; and
  • Complaint history, death and injury statistics, and political/public controversies surrounding jail healthcare.
• Ancata and Smothers together provide a robust template for pleading and proving county liability in privatized healthcare arrangements.

For defense counsel and local governments:

• There is a strong incentive to:
  • Ensure contracts require adequate staffing and physician involvement;
  • Create meaningful, documented oversight and quality‑assurance mechanisms;
  • Respond promptly and transparently to patterns of complaints, adverse outcomes, or red flags raised by sheriffs or jail staff.
• Structure and practice must align with the idea that counties remain ultimately responsible for not maintaining policies that foreseeably yield systemic constitutional violations.

VII. Conclusion

Smothers v. Childers is a significant Eleventh Circuit precedent that:

• Affirms that counties may be held liable under Monell when they knowingly maintain jail medical arrangements that are constitutionally deficient, even if state statutes formally place medical responsibilities on sheriffs;
• Clarifies that the act of contracting with and overseeing a private healthcare provider is itself a municipal policy choice subject to constitutional scrutiny;
• Rejects the notion that “funding only” duties insulate counties where, in practice, they exercise control over the selection, retention, and management of jail healthcare providers;
• Emphasizes that repeated warnings – in the form of deaths, complaints, election‑cycle controversies, and internal red flags – can transform inaction into deliberate indifference.

The opinion does not decide that Walker County is ultimately liable; it holds only that, on the record presented, a reasonable jury could find that the County’s policy of contracting with Preemptive – and clinging to that contract despite obvious dangers – was the moving force behind a violation of Mitchell Smothers’s Eighth Amendment right to adequate medical care. The case is remanded for trial or further proceedings, but the legal message is already clear: when a county “breaks” jail healthcare by its policy choices and then “doubles down,” federal law may hold it to “own” the constitutional consequences.