Jennifer Byrum v. Knox County, Tenn.

RECOMMENDED FOR PUBLICATION Pursuant to Sixth Circuit I.O.P. 32.1(b) File Name: 26a0279p.06 UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT ┐ JENNIFER BYRUM, as the personal representative and │ next of kin of Ricky Lynn Lewis, deceased, │ Plaintiff-Appellant, > No. 25-5830 │ │ v. │ │ KNOX COUNTY, TENNESSEE, │ Defendant-Appellee. │ ┘ Appeal from the United States District Court for the Eastern District of Tennessee at Knoxville. No. 3:24-cv-00239—Thomas A. Varlan, District Judge. Argued: April 29, 2026 Decided and Filed: October 8, 2026 Before: STRANCH, BLOOMEKATZ, and HERMANDORFER, Circuit Judges. _________________ COUNSEL ARGUED: Richard E. Collins, COLLINS LAW, Knoxville, Tennessee, for Appellant. Federico A. Flores, KNOX COUNTY LAW DIRECTOR’S OFFICE, Knoxville, Tennessee, for Appellee. ON BRIEF: Richard E. Collins, COLLINS LAW, Knoxville, Tennessee, Dan Channing Stanley, Knoxville, Tennessee, for Appellant. Federico A. Flores, David S. Wigler, KNOX COUNTY LAW DIRECTOR’S OFFICE, Knoxville, Tennessee, for Appellee. BLOOMEKATZ, J., delivered the opinion of the court in which STRANCH, J., concurred, and HERMANDORFER, J., concurred in part. HERMANDORFER, J. (pp. 23–31), delivered a separate opinion concurring in part and dissenting in part.  No. 25-5830 Byrum v. Knox County Page 2 _________________ OPINION _________________ BLOOMEKATZ, Circuit Judge. Jennifer Byrum sued Knox County on behalf of her father, Ricky Lynn Lewis, after he died of a drug overdose while in pretrial detention. Byrum asserts that during the approximately seventeen hours Lewis was in the County’s detention facility, it was obvious that he was experiencing a drug-related medical emergency and should have been provided medical care. Yet jail staff placed Lewis in a holding cell for over nine hours and left him virtually unmonitored and untreated—writhing in pain and lying barely conscious on the floor covered in his own feces. Byrum asserted several theories of liability against the County, all of which the district court rejected at the pleading stage. On appeal, Byrum challenges the district court’s dismissal of her municipal liability claims, arguing that her allegations plausibly establish that the County was deliberately indifferent to her father’s right to adequate medical care in jail and is at fault for her father’s death. We agree with Byrum, but only in part. Byrum’s allegations, along with the jail’s surveillance video, give rise to a reasonable inference that the County did not adequately train jail staff to recognize and respond to drug-related medical emergencies, such as Lewis’s overdose. Because we hold that Byrum stated a plausible claim for failure to train, we reverse as to that claim. But we affirm the district court’s dismissal of Byrum’s other municipal liability claims. BACKGROUND I. Factual History This case arises on a motion to dismiss, so we recite the facts as alleged in Byrum’s complaint and construe all reasonable inferences in her favor. England v. DENSO Int’l Am. Inc., 136 F.4th 632, 634, 636 (6th Cir. 2025).  No. 25-5830 Byrum v. Knox County Page 3 Early in the morning on May 25, 2023, Lewis called 911 to report a crime. He asked dispatch to help him retrieve his vehicle, which had just been stolen. When dispatch arrived, they observed that Lewis was intoxicated and behaving erratically, wandering in the street and muttering. He admitted to having used methamphetamine. According to the police report documenting the encounter, Lewis “posed a direct potential danger to himself and others.” First Am. Compl., R. 10, ¶ 15 (quoting police report). The officers searched Lewis’s vehicle and found “drug paraphernalia and a powdery substance ‘consistent with Heroin.’” Id. (quoting police report). The officers arrested Lewis for drug possession and took him to the Roger D. Wilson Detention Facility, a jail operated by the Knox County Sheriff’s Office. He arrived at the jail around 5:02 a.m. Surveillance footage shows Lewis “unstable on his feet and hunched over with his arms across his stomach” as Sheriff’s deputies, correctional officers, and other jail staff processed him into the jail. Id. ¶ 16. The Tennessee Corrections Institute establishes “minimum standards for local jails,” including “medical screening” during booking, and the jail’s written policies reaffirm the minimum standards. Id. ¶ 17. But “no initial medical screen was performed to determine whether Lewis could safely be admitted into the Jail.” Id. ¶ 19. As depicted by the surveillance footage, Lewis was moved “in a wheelchair” because he was unable to walk on his own and, at various points, he was “lying on a bench unconscious.” Id. ¶ 20. About two hours after Lewis arrived at the jail, footage shows at least four individuals— whom the complaint identifies as John Doe 1, John Doe 2, Jane Doe 1, and Jane Doe 2— surrounding Lewis. Jane Doe 1, an “apparent[]” member of the jail’s medical staff, performed a sternum rub on Lewis to wake him, but “he continued to drift in and out of consciousness” and “his breathing was labored, slow, and shallow.” Id. ¶¶ 22–23. According to the complaint, “Lewis’s medical distress was obvious; he was clearly in the throes of an overdose or acute drug withdrawal.” Id. ¶ 23. But instead of administering naloxone—a drug commonly used to reverse opioid overdose—Jane Doe 1 and Jane Doe 2 placed “‘smelling salt’ capsules under Lewis’s nose to keep him awake as they attempted to take vital signs.” Id. ¶ 25. And John Doe 1 joked that Lewis must be “dying of bone cancer.” Id. ¶ 26.  No. 25-5830 Byrum v. Knox County Page 4 Then, jail staff locked Lewis in a holding cell for approximately nine hours and did not monitor him. Tennessee Corrections Institute’s “minimum standards for adult correctional facilities” establish that “[a]ll inmates shall be personally observed by a facility employee at least once every hour on an irregular schedule. More frequent observation shall be provided for inmates who are intoxicated.” Id. ¶ 82 (quoting Tenn. Comp. R. & Regs. § 1400-01-.16). The jail’s written policies establish that pretrial detainees in holding cells “who have a medical condition, such as withdrawals from drugs or alcohol,” should be observed “every 15-30 minutes.” Id. ¶ 83. None of the staff followed either policy. Byrum alleges that, despite putting Lewis in an observation cell, jail staff “were not adequately trained on the requirements of the minimum standards or their own written policy and procedures.” Id. ¶ 85. Rather than monitor Lewis, John Doe 1, John Doe 2, Jane Doe 1, Jane Doe 2, and “all other correctional officers and medical personnel interacting with Lewis failed to take any reasonable measure to abate the risks” of his apparent overdose. Id. ¶ 29. About four hours after Lewis was taken to the holding cell, an officer dropped off a bag of food, but Lewis was otherwise left completely unmonitored. The surveillance footage shows him “writhing in pain” for several hours. Id. ¶ 30. About five hours in, Lewis “defecate[d] uncontrollably” on himself, and then spent three and a half more hours “convulsing on the ground in his own feces.” Id. ¶¶ 31–32. Finally, officers entered the cell, put Lewis in a wheelchair, and took him to the shower to clean him off. At that point, John Doe 3 asked Lewis “what he [was] on,” and Lewis responded, “meth.” Id. ¶ 33. After the shower, the officers placed him in another holding cell without providing medical attention. At around 6:06 p.m., the surveillance footage shows Lewis “forcefully hitting his head on the thick glass of the cell door.” Id. ¶ 35. As a result, John Doe 4, John Doe 5, and John Doe 6 took Lewis to a “padded room” and placed him in a restraint chair. Id. ¶ 36. While restrained, he continued to “thrash about,” “once again soil[ing] himself.” Id. ¶¶ 36–37. Around 8:30 p.m., officers took Lewis to the bathroom to clean him off and change his clothes, and then returned him to the cell without providing any medical care.  No. 25-5830 Byrum v. Knox County Page 5 Around 10:00 p.m., Jane Doe 3 and Jane Doe 4 came to the cell and discovered that Lewis was not breathing. They started chest compressions but did not call 911 until approximately 40 minutes later. Lewis was transported to a medical center where he was placed on life support, and he died early the next morning. According to the autopsy report, Lewis died of “acute methamphetamine, fentanyl, xylazine, and morphine intoxication.” Id. ¶ 42. II. Procedural History Byrum brought this lawsuit against Knox County, various County officials, and eight Jane and John Doe jail staff, raising civil rights claims under 42 U.S.C. § 1983 and state tort claims.1 As most relevant here, Byrum claimed that by failing to train jail staff and acquiescing to various unconstitutional customs, the County was deliberately indifferent to Lewis’s Fourteenth Amendment right to adequate medical care while in pretrial detention. The district court granted the County’s motion to dismiss the municipal liability claims and then declined to exercise supplemental jurisdiction over Byrum’s state law claims. Byrum timely filed a notice of appeal, challenging the dismissal of her municipal liability claims. ANALYSIS We review the district court’s decision to dismiss Byrum’s case for failure to state a claim de novo. Nugent v. Spectrum Juv. Just. Servs., 72 F.4th 135, 138 (6th Cir. 2023). In that review, we take all well-pleaded allegations contained in the complaint as true and construe the facts in the light most favorable to Byrum. Id. Reading the complaint in that light, Byrum’s claims need only be plausible to survive the motion to dismiss. Martinez v. Wayne County, 142 F.4th 828, 835 (6th Cir. 2025). To state a plausible claim, Byrum must plead “factual content that allows the court to draw the reasonable inference that the [County] is liable for the misconduct alleged.” Ashcroft v. Iqbal, 556 U.S. 662, 678 (2009). While Byrum’s “burden is not high in this posture, it does not disappear either,” Martinez, 142 F.4th at 836, and where a 1Byrum sued the individual defendants in their official and individual capacities. For somewhat confusing reasons not before us, Byrum’s individual capacity claims were dismissed without prejudice after she failed to properly serve the individual defendants. D. Ct. Op., R. 46, PageID 311. Byrum limited her appeal to challenging the dismissal of her claims against the County.  No. 25-5830 Byrum v. Knox County Page 6 complaint pleads conclusory factual allegations that are “merely consistent with a defendant’s liability, it stops short of the line between possibility and plausibility of entitlement to relief,” Crawford v. Tilley, 15 F.4th 752, 762 (6th Cir. 2021) (quoting Iqbal, 556 U.S. at 678). In this appeal, Byrum asks us to review the district court’s dismissal of her § 1983 claims that the County violated her father’s Fourteenth Amendment right to adequate medical care. Section 1983 imposes liability against “person[s]” who deprive others of federal rights under the color of state law. 42 U.S.C. § 1983. In Monell v. Department of Social Services, the Supreme Court held that municipalities are recognized as “persons” for purposes of § 1983. 436 U.S. 658, 701 (1978). But our review over these Monell claims proceeds differently than that over claims against individual officers. We use a “two-pronged inquiry” to evaluate Monell claims. Cash v. Hamilton Cnty. Dep’t of Adult Prob., 388 F.3d 539, 542 (6th Cir. 2004). First, we ask whether a plaintiff “asserted the deprivation of a constitutional right.” Id. Here, Byrum points to the County’s deliberate indifference to Lewis’s serious drug-related medical needs, which we have recognized as a deprivation of a constitutional right. See, e.g., Shadrick v. Hopkins County, 805 F.3d 724, 736–37 (6th Cir. 2015); Griffith v. Franklin County, 975 F.3d 554, 566 (6th Cir. 2020); Helphenstine v. Lewis County, 60 F.4th 305, 322–26 (6th Cir. 2023). Second, if the plaintiff has identified a constitutional violation, we must consider whether the municipality was “responsible for that deprivation” of rights. Cash, 388 F.3d at 542. The County did not challenge whether Lewis suffered a deprivation of a constitutional right in its motion to dismiss. It limited its challenge to the second inquiry—its responsibility for the deprivation. So we confine our analysis to that question as well. In evaluating whether the County was responsible for Lewis’s constitutional deprivation, we do not follow a theory of respondeat superior, meaning that a municipality may not be held liable under § 1983 simply because it “employ[ed] a tortfeasor.” Monell, 436 U.S. at 691. Instead, the County is responsible “only for ‘[its] own illegal acts.’” Connick v. Thompson, 563 U.S. 51, 60 (2011) (quoting Pembaur v. City of Cincinnati, 475 U.S. 469, 479 (1986)). Therefore, to survive the motion to dismiss her Monell claims, Byrum must identify a specific County policy or custom that caused the violation of Lewis’s constitutional rights. Wright v.  No. 25-5830 Byrum v. Knox County Page 7 Louisville Metro Gov’t, 144 F.4th 817, 827 (6th Cir. 2025). Our court has recognized four independent methods of establishing a municipality’s illegal policy or custom: a plaintiff may prove “(1) the existence of an illegal official policy or legislative enactment; (2) that an official with final decision making authority ratified illegal actions; (3) the existence of a policy of inadequate training or supervision; or (4) the existence of a custom of tolerance or acquiescence of federal rights violations.” Burgess v. Fischer, 735 F.3d 462, 478 (6th Cir. 2013) (citing Thomas v. City of Chattanooga, 398 F.3d 426, 429 (6th Cir. 2005)). Byrum presses several distinct theories of Monell liability in her complaint. We first consider Byrum’s failure-to-train theory, holding that she sufficiently pled this claim. Next, we address Byrum’s remaining theories of liability—which claim that the County maintained policies of inadequate medical screenings, underfunding, and overcrowding—and hold that Byrum failed to plausibly state these claims. I. Failure to Train We begin with Byrum’s failure-to-train claim. Byrum argues that the County inadequately trained jail staff to address drug-related medical emergencies, such as acute withdrawal and overdoses. Specifically, Byrum pleads that jail staff “lacked the training . . . to adequately screen arrestees for serious medical conditions requiring immediate medical attention” or otherwise treat or seek care for detainees with medical needs stemming from drug use. First Am. Compl., R. 10, ¶ 47. She further alleges that the jail staff were not trained on the jail’s own policies regarding screening and monitoring. At the outset, we emphasize that a “municipality’s culpability for a deprivation of rights is at its most tenuous where a claim turns on a failure to train.” Connick, 563 U.S. at 61. In this context, the court applies “rigorous requirements of culpability and causation.” Arrington-Bey v. City of Bedford Heights, 858 F.3d 988, 995 (6th Cir. 2017) (quoting Bd. of Cnty. Comm’rs of Bryan Cnty. v. Brown, 520 U.S. 397, 415 (1997)). To survive dismissal on her failure-to-train claim, Byrum must plausibly allege that (1) the County’s “training program was inadequate for the tasks that [officials] must perform,” (2) the “inadequacy was the result of the [County’s] deliberate indifference,” and (3) the “inadequacy was closely related to or actually caused the  No. 25-5830 Byrum v. Knox County Page 8 injury.” Jackson v. City of Cleveland, 925 F.3d 793, 834 (6th Cir. 2019); see also Helphenstine, 60 F.4th at 323. We examine each of these elements in turn. A. Adequacy of the Training Program Turning to the first element of a failure-to-train claim, Byrum’s complaint plausibly establishes that the County’s training program did not adequately teach jail staff how to recognize and respond to medical emergencies relating to drug overdoses. Screening and Initial Care. As alleged in the complaint, jail staff did not medically screen Lewis when he arrived at the jail, in contravention of the jail’s policy requiring medical screening during the intake process for all pretrial detainees. Nor did the jail staff provide or call for any medical care upon Lewis’s arrival, despite surveillance footage depicting him “unstable on his feet and hunched over,” Lewis’s previous admission that he had taken drugs, and the officers’ discovery of drug paraphernalia and a powdery substance in his vehicle. First Am. Compl., R. 10, ¶ 16. Immediately upon entry, Byrum alleges, Lewis’s medical needs were clear, as he had to be transported in a wheelchair because he was so impaired that he could not walk on his own. About two hours after Lewis first arrived at the facility, an “apparent[]” member of the jail’s medical staff performed a sternum rub on Lewis, to wake him from unconsciousness, while three other individuals surrounded Lewis. Even after the sternum rub, Lewis continued to go in and out of consciousness and his breathing was “labored, slow, and shallow.” Id. ¶ 23. A member of the jail staff also used smelling salts to revive Lewis long enough to take his vitals, but no one administered naloxone—a medication commonly used to reverse opioid overdose—or otherwise provided medical care. During this initial period, Byrum alleges that at least four individuals (John Doe 1, John Doe 2, Jane Doe 1, and Jane Doe 2) interacted with Lewis enough to observe the severity of his medical needs. But none provided care beyond briefly bringing him to consciousness, only for him to fall back out of it. Nor did these members of the jail staff screen Lewis for a serious medical need, provide instructions to jail staff for Lewis’s care and monitoring, or return to check on him over the next hours when he was locked in the holding cell.  No. 25-5830 Byrum v. Knox County Page 9 These allegations pertaining to Lewis’s initial intake and screening process give rise to a reasonable inference that, despite the jail’s screening policy, jail staff lacked adequate training on medical screening protocols. Byrum pleads that even within the first couple of hours, it was “obvious” that Lewis was in “medical distress,” but jail personnel did not provide proper care. Id. ¶ 23. Given that not one of the multiple individuals who interacted with Lewis during this initial period recognized the medical emergency, let alone responded to it by providing appropriate treatment, we can reasonably infer at this pleading stage that the staff were not trained on the jail’s screening policy, nor were they trained on how to identify the medical signs of overdose or administer care when a detainee was experiencing that type of medical emergency. See Helphenstine, 60 F.4th at 324–25. Monitoring and Seeking Medical Assistance. Beyond screening, Byrum pleads that during the nine hours jail staff locked Lewis in the holding cell, all Jane and John Does, as well as “all other correctional officers and medical personnel interacting with Lewis[,] failed to take any reasonable measures” to provide or seek medical care and failed to regularly monitor him. First Am. Compl., R. 10, ¶ 29. According to jail policy, staff are required to monitor and observe detainees in holding cells who have a medical condition every 15–30 minutes. The complaint alleges, however, that while Lewis was in the holding cell, no one monitored or observed him for hours at a time, in violation of even the minimum policy that requires jail staff to observe all detainees, on average, every hour. No one observed Lewis until four hours in, when an officer dropped off a bag of food at the door. During this period, Lewis was “writhing in pain” for several hours. Id. ¶ 30. An hour later, Lewis “defecate[d] uncontrollably” on himself. Id. ¶ 31. He spent three and a half more hours “convulsing on the ground in his own feces,” as depicted below. Id. ¶ 32.  No. 25-5830 Byrum v. Knox County Page 10 Even after finding him in that state, jail staff did not call for outside medical care or otherwise provide treatment. See Hehrer v. County of Clinton, 161 F.4th 955, 965 (6th Cir. 2025). Nor did they commit to frequent monitoring. Instead, jail staff simply put Lewis in a wheelchair, showered him off, and placed him back in the holding cell. These allegations give rise to the inference that jail staff were not adequately trained on the observation policies or how to otherwise identify and handle drug-related medical emergencies in the jail. Jail staff in this case did not even have to guess the cause of Lewis’s condition: he admitted to using drugs when the police arrested him for heroin possession and repeated that he was on “meth” to a staff member who evidently knew he was intoxicated and asked what he was “on.” Still, not one of the staff members who interacted with Lewis earlier in the day regularly monitored Lewis while he was locked in the holding cell or otherwise provided medical care for the acute drug reaction he was obviously experiencing. Further, Byrum alleges that later in the evening, at least three new individuals moved Lewis to a restraint chair after he was found “forcefully hitting his head” on the holding cell door, a behavior that is consistent with the symptoms of overdose. First Am. Compl., R. 10, ¶¶ 35–36. In the padded room he was taken to, Lewis defecated on himself again. Jail staff took him to the bathroom to clean him off, but—again—no one provided or called for any medical care.  No. 25-5830 Byrum v. Knox County Page 11 Several hours later, jail staff discovered Lewis was not breathing. Jail staff administered chest compressions, but no one called 911 for another 40 minutes. Multiple staff members knew he was not breathing; it was not as if there was only one employee who had to choose between chest compressions and calling 911, which delayed making the call. Instead, even in this dire scenario, no one immediately called for medical care. In Helphenstine v. Lewis County, we viewed the total failure to respond to a medical emergency, by multiple individuals, as creating a material question of fact as to whether those individuals were adequately trained—even where the “record [was] mixed on whether the jailers ever received any training or instruction regarding withdrawal or medical emergencies.” 60 F.4th at 324. Reviewing the summary judgment record, we recognized that at least one individual testified that she had “received training on what constituted an alcohol-withdrawal- related medical emergency” and most employees “agreed that an inmate experiencing a medical emergency should be sent to the hospital.” Id. But, we explained, the record also contained testimony from deputy jailers that they “had not received any training regarding withdrawal or how to identify medical emergencies,” and at least one individual testified that there was no specific training on how to determine whether an inmate’s symptoms “indicated that their withdrawal was about to be fatal.” Id. Other county defendants also testified that they “had never seen” the jail’s written policies recognizing withdrawal as a medical emergency. Id. On that record, we held, the staff had not been adequately trained by the jail. Critically, in Helphenstine we relied on the jail employees’ failure to respond to the emergency to support an inference of inadequate training. We acknowledged that employees might have received some training on how to identify withdrawal-related medical emergencies “in the abstract.” Id. But we concluded that the employees’ inability “to do so when one presented itself” would allow “a reasonable jury [to] conclude that their training, to the extent they were trained, was insufficient.” Id. So too here. Based on Byrum’s allegations that not one individual screened or monitored Lewis despite his obvious symptoms and the jail’s own policies, we can plausibly infer that to the extent the jail staff were trained on the jail’s policies, that training was “insufficient.” See id.  No. 25-5830 Byrum v. Knox County Page 12 The dissent suggests that Helphenstine is “far afield” from this case because the “affirmative evidence” (i.e., “employee testimony”) about the training program created the material question of fact. Dissent at 28. And it further says that Byrum’s failure to plead these types of specific facts regarding the content and extent of the training program is fatal to all three prongs of her failure-to-train claim. But, as the dissent also recognizes, Helphenstine was at summary judgment, while this case is at the pleading stage, subject to the motion to dismiss standard. At this juncture, our task is to consider whether Byrum alleged sufficient facts to permit a reasonable inference that the training was inadequate. And while our substantive reasoning in Helphenstine is instructive as to what factual allegations can suffice to state a plausible Monell claim, the type of evidence produced at summary judgment should not confuse what a plaintiff is required to allege at the pleading stage. See Dissent at 25 (citing City of Canton v. Harris, 489 U.S. 378, 390–91 (1989) (post-trial) and Jackson, 925 F.3d at 834 (summary judgment)). Byrum’s specific factual allegations regarding the total failure of the jail staff to identify and respond to Lewis’s obvious drug-related medical emergency and to follow the jail’s own policies permit the reasonable inference that the County’s training was inadequate. This is not a situation where the failure to recognize and respond to Lewis’s needs was consistent with “an otherwise sound program” that was “negligently administered,” nor a scenario where “adequately trained officers” made the “occasional[] . . . mistake[].” Dissent at 29 (quoting City of Canton, 489 U.S. at 391). As alleged, this was a comprehensive failure to provide medical treatment and follow clear jail policies to screen and monitor detainees with medical needs by every single member of the jail staff. The combined force of the factual allegations contained in the complaint plausibly establish that the staff was not adequately trained on how to identify and respond to drug-related medical emergencies, and to follow the jail’s own screening and monitoring protocols. This reasoning is not novel—it is rooted in the ordinary standards for assessing the sufficiency of a complaint on a Rule 12(b)(6) motion to dismiss. To be sure, discovery might reveal additional details of the County’s training policies, like the evidence available at summary judgment in Helphenstine. That discovery could support or harm Byrum’s claim. But here, the mere fact that Byrum has not yet had the opportunity to  No. 25-5830 Byrum v. Knox County Page 13 access that information, which is likely within the County’s sole possession, does not stand as an obstacle that defeats her claim at the pleading stage. Nor does it undermine the specific facts Byrum pled from which we can reasonably infer that her failure-to-train theory is plausible. See New Albany Tractor, Inc. v. Louisville Tractor, Inc., 650 F.3d 1046, 1051 (6th Cir. 2011) (explaining “plaintiff must allege specific facts” to state a claim “even if those facts are only within the head or hands of the defendants”). If, to establish a failure-to-train claim, Byrum were required to plead the specific details of what was contained in the County’s training manual, or what the County specifically told employees during each training session—as the dissent seems to suggest she might—it is hard to imagine how any such claim could survive. Such a rule would be at odds with the distinctions between the standard at the pleading stage and that at the post-discovery summary judgment stage. If that were indeed the rule, it would seem to incentivize plaintiffs to plead that no training was provided at all, as to escape the requirement of pleading specific details of the training program before that information was known. And it would also seem to make failure-to-train claims greatly dependent on the transparency of correctional institutions and local governments—and in turn to incentivize those entities to be less transparent. If we do not require specific details of training sessions in the complaint, the dissent suggests that our analysis “risks converting allegations about individuals’ bad acts or negligence into failsafe failure-to-train claims against municipalities.” Dissent at 24. But our holding is not so broad. It is based on the totality of the factual allegations here; not just that a few employees failed to respond to Lewis’s emergency. As the dissent itself points out, we recently affirmed the dismissals of failure-to-train claims where a few individuals allegedly failed to adequately respond or otherwise carry out their constitutional responsibilities. But in those cases, there was a dearth of surrounding allegations that plausibly pointed to a failure to train, rather than just the mistakes of a few individuals. Our holding today does not conflict with those prior results. In Linden v. City of Southfield, which the dissent emphasizes, first responders inaccurately ceased resuscitative efforts on a woman before obtaining permission to stop their attempts and then pronounced her dead even though “numerous medical indicators” showed signs of life. 75 F.4th 597, 600 (6th Cir. 2023). There, we explained that the plaintiff  No. 25-5830 Byrum v. Knox County Page 14 “marshal[ed] no facts to support th[e] bare conclusion” that a municipality had failed to provide its first responders with training on when to “take patients to the hospital in emergencies and obtain permission before ceasing resuscitative efforts.” Id. at 605–06. Unlike here, however, that was a scenario where the first responders—individuals with specialized education and expertise—were performing duties consistent with the education and expertise they would be expected to have. Considering that the first responders would be presumed to have this preparation, the simple fact that they made an inaccurate call, without more, did not indicate that it was the municipality’s failure to provide specialized training, rather than their negligence, that caused the error. Here, by contrast, one would not necessarily expect that jail staff would have the same education and expertise. So that the jail staff were inadequately trained is a much more reasonable inference to draw. What’s more, in Linden, “numerous laypersons recognized signs that [the decedent] was still alive,” which the court emphasized “suggest[ed] that . . . special training” would not have saved her life. Id. at 606. If training would not have saved the decedent’s life, then her death did nothing to imply a lack of training. But here, as explained above, that at least ten jail staff did nothing as Lewis suffered a medical emergency does suggest that those staff were inadequately trained. In Wright v. Louisville Metro Government, the other case cited by the dissent, the plaintiffs similarly pled conclusory allegations that the municipality “failed to adequately train their officers regarding the process to obtain a Search Warrant and its subsequent execution,” after the execution of a warrant allegedly violated their Fourth Amendment rights. 144 F.4th at 827. Unlike here, the plaintiffs in Wright identified no specific policy that the officers were insufficiently trained on, nor pled specific facts from which it could be inferred that it was the training program that caused the claimed constitutional error. In other words, the plaintiffs offered no reason to think the alleged constitutional defects resulted from anything other than isolated misconduct or negligence. By contrast, in this case, Byrum alleges that the jail had policies in place that required staff to screen for potential medical issues and observe detainees experiencing medical emergencies, yet no one—across seventeen hours and despite Lewis’s obvious medical needs—complied with those protocols, suggesting that jail staff were inadequately trained on them. So neither Linden nor Wright involved facts as extreme as those here, where at least ten people failed to respond to an obvious emergent situation for which they  No. 25-5830 Byrum v. Knox County Page 15 should have been prepared. The variation in the outcomes of our cases therefore underscores the essential point: the plausibility of the inference regarding inadequate training depends heavily on the facts, as alleged, in each specific case. The specific facts Byrum alleges here, starting with the moment Lewis entered the jail through to the 911 call, plausibly demonstrate that the County failed to adequately train its staff on how to handle drug-related medical emergencies. Indeed, throughout the approximately seventeen hours that Lewis was at the facility, at least ten individuals interacted with Lewis. Despite having policies in place, not even one individual properly medically screened Lewis, regularly monitored him, or otherwise sought or provided medical care—even as he defecated uncontrollably on himself, laid in his own feces, and banged his head into his cell door. This is not a case where a single employee (or even a few) failed to follow protocol or best practices. Instead, there is “enough factual matter” alleged in the complaint to give rise to a reasonable inference that jail staff were not adequately trained to recognize and respond when detainees were in the throes of a drug-related medical emergency. See Bell Atl. Corp. v. Twombly, 550 U.S. 544, 556 (2007). B. Deliberate Indifference Byrum has also sufficiently pled the deliberate indifference element of her failure-to-train claim. Deliberate indifference is “a stringent standard of fault,” Bryan Cnty., 520 U.S. at 410, requiring a plaintiff to prove that the municipality “disregarded a known or obvious consequence” of its actions, Connick, 563 U.S. at 61.2 There are two ways to satisfy the deliberate indifference standard for Monell claims. Under the first, Byrum must show a “pattern of similar constitutional violations by untrained employees.” Id. at 62. From a pattern of violations, we could infer that the County was on notice of the need for training to protect 2We note that our en banc court recently revised the standard for deliberate indifference claims for pretrial detainees under the Fourteenth Amendment. Poynter ex rel. Fernandez v. Shirley, __ F.4th __, 2026 WL 2641092 (6th Cir. Sep. 8, 2026). This case was briefed and argued before our en banc court decided Poynter. While we previously required “recklessness” for the subjective component of deliberate indifference claims for pretrial detainees under the Fourteenth Amendment, Brawner v. Scott County, 14 F.4th 585, 596 (6th Cir. 2021), we now require knowledge for the subjective prong of deliberate indifference, see Poynter, 2026 WL 2641092, at *2, *6. Here, we apply the more stringent standard, as articulated in Poynter. Under that standard, Byrum’s claim survives the pleading stage, so Poynter does not affect the outcome in this case.  No. 25-5830 Byrum v. Knox County Page 16 incarcerated persons’ constitutional rights but shirked its responsibility to provide that training. Id. Byrum has not identified prior instances of unconstitutional conduct, so we do not consider this theory.3 Even absent a pattern of violations, in limited circumstances, a single violation of federal rights can create a plausible inference of deliberate indifference. See Bryan Cnty., 520 U.S. at 409. Byrum pursues this single-violation path. But to sustain a claim under this theory, Byrum must show that the County “‘failed to train its employees to handle recurring situations presenting an obvious potential’ for a constitutional violation.” Shadrick, 805 F.3d at 739 (quoting Bryan Cnty., 520 U.S. at 407). In this context, obviousness has two components: it “must be obvious that the failure to train will lead to certain conduct, and it must be obvious (i.e., clearly established) that the conduct will violate constitutional rights.” Arrington-Bey, 858 F.3d at 995. Only if the need for training “is so obvious” and the training’s inadequacy is “so likely to result in the violation of constitutional rights” can we reasonably say the County was “deliberately indifferent to the need.” City of Canton, 489 U.S. at 390. As alleged, we can infer that the County was aware of, but disregarded, the “substantial risk of serious harm” that would result from inadequately training jail staff on how to identify and respond to drug-related medical emergencies. Farmer v. Brennan, 511 U.S. 825, 837, 839 (1994). This case, therefore, presents one of the “narrow” circumstances from which we may infer deliberate indifference based on a single incident. Bryan Cnty., 520 U.S. at 409. Consider the first component of “obviousness”—the need for training. The need to train jail staff on how to screen and handle drug-related medical overdoses is “patently obvious.” Connick, 563 U.S. at 64. Given the opioid epidemic and the prevalence of drug addiction, drug- related medical emergencies are not a hidden danger. And, as detailed in the complaint, drug- related emergencies i