Full opinion text
ORDER CRAJBB, District Judge. Plaintiff Brenda Mombourquette attempted to commit suicide by hanging herself with a bed sheet while she was detained in the Monroe County jail. Although two previous attempts of self harm several days earlier did not cause long lasting injury, plaintiff was left seriously brain damaged after she made a third attempt. Plaintiff brought this suit under 42 U.S.C. § 1983 through her sister and children against various jail staff members, who plaintiffs believe violated Brenda Mombourquette’s constitutional rights when they failed to protect her from harming herself. (For the remainder of the opinion, I will refer to plaintiff Brenda Mombourquette simply as “plaintiff’ because most facts relevant to summary judgment relate to her solely.) Each of the defendants moved for summary judgment in three different groups: (1) defendants Charles Amundson, Candace Warner, Sandi Wegner, Anna Janusheske, Mike Wildes, Janita Leis, Sue Wieman and Patricia Fish; (2) defendant Jeanne Reinart and (3) defendant David Schal-dach, who adopted the briefs and proposed findings of fact submitted by the other parties. As an initial matter, it is important to understand the scope of plaintiffs claims. Although plaintiff does not say explicitly, it is clear from a review of her complaint, her brief opposing defendants’ motions for summary judgment and her proposed findings of fact that her claim is directed at defendant’s failure to prevent her attempted suicide on November 22, 2002. I do not understand plaintiff to be asserting a separate claim for the failure to prevent her from cutting her wrists on November 13. Rather, I understand her to be relying on facts surrounding that incident as evidence of defendants’ deliberate indifference to her suicide attempt on November 22. In addition to defendants’ motions for summary judgment, two other motions are before the court: (1) plaintiffs motion to supplement her summary judgment materials with a document she obtained after filing her opposition brief; and (2) defendant Schaldach’s “motion in limine” to exclude evidence that he engaged in sexual activity with another female inmate while plaintiff was detained at the Monroe County jail. Both motions will be denied. With respect to the motion to supplement the record, plaintiff seeks to add a 2004 resignation letter from the jail administrator to defendant Charles Amundson. However, the document adds no new evidence to the record, so it is unnecessary to consider its admissibility. For reasons discussed further below, defendant Schaldach’s motion in limine must be denied because plaintiffs complaint about Schaldach’s misconduct may be relevant to show that both defendants Schaldach and Amundson were deliberately indifferent to plaintiffs health and safety. Cases involving an unfortunate event like a jail suicide attempt are difficult for all parties involved. They are difficult as well for a judge or juror, who must resolve disputed issues on the basis of the law and not on feelings of sympathy either for plaintiffs, who have suffered greatly, or for defendants, who have a difficult and often thankless job. As is usually the case, the facts are not one-sided. However, I conclude that summary judgment is not appropriate with respect to any of the defendants because a reasonable jury could find that each of them was deliberately indifferent to a substantial risk that plaintiff would attempt to harm herself. From the parties’ proposed findings of fact and the record, I find that the following facts are undisputed. UNDISPUTED FACTS A. Sheriff Amundson and the Monroe County Jail Defendant Charles Amundson became sheriff of Monroe County in 2000. As sheriff, defendant Amundson has the obligation to “take the charge and custody of the jail maintained by the county and the persons in the jail.” After Amundson was elected, he met with Wisconsin Department of Corrections jail inspector Scott Morris, who told Amundson that the jail was “very poorly run” and “poorly supervised.” In particular, Morris believed that the jail lacked effective supervision and training of first line supervisors such as defendant David Schaldach, who was a lieutenant at the jail. Mark Pressler became the jail administrator in February 2002. One problem he identified was a practice called “paper whipping,” or a failure to perform cell checks. Pressler found that there were five to six hour gaps between cell checks, despite log entries indicating that checks were being performed regularly. Pressler reported numerous problems to Amundson regarding staff misconduct in 2002, including threats, vandalism and sexual misconduct with inmates. Amundson did not investigate any of these complaints. In Pressler’s view, there was no supervision of the jail by Amundson and no accountability of the jail staff. In October 2002, state jail inspector Morris issued a report to Amundson following an annual inspection of the jail that included the following criticisms: • Classification and housing of suicidal inmates: “Proper segregation is of special concern in regards to housing high-risk inmates including those with mental health issues; those considered suicide risk, violent and combative inmates, and those with significant medical issues.” Morris noted that it was the seventh consecutive year that the jail was in violation of a state law relating to segregation of inmates. (Defendant Amund-son admits this was a “real problem” in 2002.) ■ Crisis intervention: “At the present time, documented communication by crisis intervention personnel is not taking place. This communication is essential to insure proper continuity of care for the inmate, proper classification, and in addition to insure the proper supervision of inmates experiencing emotional or mental health crises.” (Defendant Amundson did not know what the crisis intervention program was because, as he testified, he left “those type of things up to the jail administrator.”) • Mental health screening reports: “It is recommended that first line jail supervisors take a more active role in reviewing and approving reports for accuracy, completenéss and legibility.... [M]edical and mental health screening reports ... continue to be an area in need of measurable improvement.” Morris concluded that staff needed training on “policies and procedures related to mental health access and treatment within the jail.” Although Morris did conclude that there were “significant and measurable improvement ... in the overall operation of the jail,” he credited these improvements to Pressler rather than defendant Amundson. B. Defendants’ Training Defendants Mike Wildes, Janita Leis, Patricia Fish, Sandi Wegner and Anna Janusheske were correctional officers at the Monroe County jail in 2002. They were trained by the state of Wisconsin in accordance with the standards developed and maintained by the Law Enforcement Standards Board of the Wisconsin Department of Justice. That training program includes the following information about preventing suicides of incarcerated individuals: • Suicides and suicide attempts are a significant problem in jails; the rate of suicide attempts of jail inmates may be nine times higher than society in general; pretrial detainees are at greater risk than sentenced inmates. • Officers have a duty to make reasonable efforts to prevents inmates from killing themselves by (1) taking steps to determine possible suicide risk among inmates; and (2) taking steps to prevent inmates who may be or are suicide risks from attempting to commit suicide. • Proper classification is the primary method for keeping inmates safe. • Suicide watch is a common form of classification in jails. Aspects of suicide watch include placing the inmate in a certain housing area, removing certain items from the inmate’s possession and checking on the inmate more frequently. • Inmates who have exhibited suicidal tendencies during intake screening or after being confined are at the highest risk. • Because most people considering suicide are ashamed of how they feel, they usually do not say, “I feel like killing myself. Please help me!” • Only a small percentage (around 10%) of people who feel suicidal really want to die. • People who have a history of suicide attempts are at higher risk for future attempts. • The more attempts a person has made, the greater the likelihood that the person will eventually die from suicide. This is true even of inmates who made several attempts that seem to be attempts at manipulation of jail staff. • Inmates who have harmed themselves on purpose should be considered higher suicide risks, even if their injuries are not potentially life threatening. This includes behavior such as wrist cutting. Defendant Jeanne Reinart is a registered nurse. She has received training in mental health, including suicide assessments, and she has made mental health assessments in the course of her employment at the Monroe County jail, where she began working in August 2000. With respect to making mental health assessments, Reinart was taught to document the facts she observes without offering her own opinion. In October 2002 or early November 2002, all Monroe County jail staff members received in-house training materials on mental illness and suicide prevention. (Neither side proposed facts about the content of these materials.) The jail’s policies and procedures in effect in 2002 included a section on suicide prevention. The policy includes the following provisions: •Whenever available, suicidal inmates will be housed in the observation cell. If the observation cell is not available, a holding cell will be utilized with only a mattress, a pillow and uniform, in critical cases. •An inmate who is classified suicidal who had medical/alcohol problems should be monitored in five (5) to fifteen (15) minute intervals, depending on the individual’s condition. • Jail staff must be aware of any information from health care providers and must exchange information we are aware of with said providers. This exchange of information is in reference to suicidal indications from inmates. Any officer has the authority to commence a suicide watch, at least if he notifies the nurse first. C.Previous Suicide Attempt at the Monroe County Jail In 2001, an inmate at the jail attempted suicide and was hospitalized. When the inmate returned several days letter, he was placed in the observation cell under 24-hour supervision. Defendant Schal-dach was employed at the jail during this time asa lieutenant and was informed of this problem. D.Plaintiffs Background In 2002, plaintiff was a 42-year-old divorced mother of two daughters, ages 8 and 12. She was self-employed, cleaning homes and commercial establishments. Plaintiff and her daughters lived with plaintiffs fiancé, Kevin Wall. Plaintiff was suffering from a great deal of stress. Her ex-husband was seeking a court order to obtain custody of her children. Both she and her fiancé suffered from health problems: he had a serious heart condition and she had degenerative bone disease in her right knee, which caused her pain daily. To combat her physical pain, plaintiff began taking medication and became addicted. In addition to these physical problems, plaintiff suffered from depression, for which she was taking medication. E.Plaintiffs First Detention On September 18, 2002, plaintiff was taken to the Monroe County jail after her probation officer, Stan Roellich, placed her on probation hold. An unidentified staff member filled out a medical screening report after booking plaintiff, noting that she was taking Zoloft, a medication for depression. However, numerous questions that were supposed to be answered by staff were left unanswered on the report, including: “Does the inmate seem depressed or express helplessness or depression?” “Does the inmate appear agitated, anxious or upset?” Defendant Candace Warner, a nurse employed at the jail, reviewed the medical screening report without noting any deficiencies. On September 20, plaintiff complained to defendant Reinart that she was experiencing withdrawal symptoms as a result of being deprived of Oxycontin, which she had been taking for her knee pain. On September 21, plaintiff made a request for anxiety medication. On September 26, 2002, plaintiff was seen by defendant Reinart. In her notes, Reinart reported that plaintiff was “upset” and “tearful” as a result of being separated from her children. Plaintiff requested medication for anxiety attacks that made it difficult for her to sleep. A physician’s assistant later prescribed Lorazepam. During the same meeting with defendant Reinart, plaintiff complained to her that defendant Schaldach was taking another female inmate, Sherry Calhoun, to the conference room at night to have sex with her. Defendant Reinart reported plaintiffs accusation to both Mark Pressler (the jail administrator) and defendant Sheriff Amundsen, who told Reinart he would speak with plaintiff the next morning. Pressler independently informed Amundson of plaintiffs allegations on the same day. Amundson told Pressler, “This is what we have insurance for.” Amund-son did not speak to plaintiff or otherwise initiate an investigation. (I consider these facts to be undisputed even though defendant Amundson says in his deposition that he “does not recall” whether these conversations took place). Tinder v. Pinkerton Security, 305 F.3d 728, 735-36 (7th Cir.2002) (fact not genuinely disputed when party opposing it says only that she “does not recall” whether event happened). On September 27, plaintiff prepared an inmate medical request in which she complained that the anxiety medication was not working. She wrote, “I can’t deal with this anxiety another day.” Defendant Fish received the request, which was forwarded to defendant Reinart. Reinart told plaintiff that she could not increase the dosage on her medication without approval of the physician assistant. On September 30, 2002, plaintiff was released from the jail. F. Plaintiff’s Second Detention 1. First attempt at self harm Plaintiff was detained again in the Monroe County jail on November 10, 2002, after she was arrested and charged with several crimes, including possession of drugs for which she did not have a prescription. Jail staff were aware of the problems plaintiff experienced during the previous detention, which included taking antidepressants, having anxiety attacks and experiencing distress over the separation from her children. The medical screening report, which was reviewed by defendant Reinart, again indicates that plaintiff was taking Zoloft. When plaintiff first arrived, she was placed in the observation cell, which can be viewed from the “control center” through large glass windows or by closed-circuit video. The cell is connected to the control center by one of the main hallways in the jail. Anyone walking in that hallway can see through the metal bars of the door into the cell. On November 11, plaintiff was removed from this cell and placed in general population after returning from a court appearance. (Neither side proposed any facts explaining why plaintiff was placed in the observation cell or why she was removed the following day.) Plaintiff was assigned to the south cell block, which houses a total of six female inmates. She was placed in a cell by herself, as are all inmates in that area of the jail. When doing cell checks, officers can see inside cells from a catwalk that the runs alongside the south block. On November 12, plaintiff fell on the floor while she was in her cell, hitting her head. After other inmates notified staff, including defendants Reinart and Warner, plaintiff was taken to the hospital. She told hospital staff that her knee had “given out.” She returned later the same day, with discharge instructions to be awakened every two hours and to be given an ice pack three times a day. Defendant Rei-nart communicated these instructions to other jail staff through the “pass on” log. (“Pass on” forms are used at the jail to communicate information from one shift to the next. Staff members are required to review these forms during their shift. The following defendants read them during every shift: Wildes, Wieman, Wegner, Jan-usheske, Fish and Schaldach.) Upon her return, plaintiff requested a visit with Roellich, who gave his impression of the visit to officer Marilyn Stuart. In the shift log report, Stuart wrote the following: “PO Reilick [sic] stating that Mombourquette was sad and stating if she can not have her kids back what is the use of going on. Advised nurse [defendant Reinart] of her attitude and feeling sorry for herself. Will keep an eye on her.” After speaking to the detective investigating her criminal case, plaintiff told defendant Schaldach that she had nothing to live for and could not make it in jail another night without killing herself. He recorded this exchange in the shift log report. He took plaintiff to the conference room, sat next to her so that their knees were touching and asked her to squeeze his hands. When plaintiff asked him “what the hell was going on,” he said, “This is better than hitting the wall.” Defendant Reinart spoke to plaintiff, after which plaintiff was placed in the observation cell. In the “staff to nurses” section of the November 12 “medical pass on” form, Reinart wrote of plaintiff: “in holding cell' — -very distraught — observe closely.” However, plaintiff was not placed on a formal suicide watch at this time. Plaintiff remained in the observation cell the following day. During the time plaintiff was in the cell, checks were conducted once or twice an hour, as often as every four minutes and as infrequently as every hour and thirty-six minutes. On the morning of November 13, defendant Reinart told defendant Janusheske, “We should keep an eye on” plaintiff. However, Rei-nart did not explain what this meant. Nine hours later, in the late afternoon, plaintiff asked defendant Janita Leis, a corrections officer, to see a nurse. After Leis instructed her to fill out a nurse slip, plaintiff handed Leis a note that said simply “cut wrist.” Plaintiff had used one of the lenses in her eyeglasses to (in the words of Leis) “slash” both of her wrists. Leis took the lens from plaintiff and sought help from defendants Wildes and Warner. Warner noticed that plaintiff had red marks and multiple abrasions on her neck, in addition to the three lacerations on each of her wrists, which had been bleeding. Warner documented her observations on the medical request form; Leis prepared an incident report, in which she classified the incident as a “suicide attempt.” Wildes took plaintiffs comb and food tray from her. As she cried, plaintiff told defendant Warner that she was afraid of losing her house, her children and a large contract for her cleaning business. During the same conversation, plaintiff said that defendant Schaldach had been taking another female inmate out of the cell at night to engage in sexual activity. She asked Warner whether “the other nurse” had reported anything. Warner responded, “If it doesn’t directly involve me, I don’t want to know about it.” Plaintiff also told Warner about her interaction with Schaldach in the conference room the night before. Plaintiff told defendant Warner that Schaldach “is a pig.” Plaintiff was placed in “emergency detention” status under Chapter 51 of the Wisconsin Statutes. Defendant Leis prepared a statement, witnessed and signed by defendant Warner, that plaintiff “evidences behavior which constitutes a substantial probability of physical harm to self or to others.” Defendant Wieman, a corrections officer, transported plaintiff to Gunderson Lutheran hospital. During the ride, plaintiff repeated her complaint to Wieman that defendant Schaldach was engaging in sexual activity with Calhoun. When Wieman returned, she told Schal-dach about plaintiffs accusation. On November 15, defendant Warner spoke with defendant Amundson about plaintiffs allegations about Schaldach. At the time, Amundson knew that Calhoun, the inmate with whom defendant Schal-dach was having sexual contact, was under psychiatric care. Warner expressed her concerns that plaintiff would use the allegation as a “trump card ... to get what she wants” and that the allegations would “come out in [Calhoun’s] therapy.” Defendant Amundson never spoke to defendant Schaldach about plaintiffs allegations or otherwise initiated an investigation while plaintiff was detained at the jail. 2. Second attempt of self harm At the hospital, a psychiatrist examined plaintiff. In his report, the psychiatrist summarizes plaintiffs complaint as “I slit my wrists and started on my throat and started banging my head against a brick wall.” She repeated her fear of losing her children, her home and her business. The psychiatrist noted a number of concerns: drug addiction, claustrophobia, family members who are alcoholics, anxiety because of her detention, paranoia related to her ex-husband and feelings of depression for the previous six to eight months. Plaintiff remained at the hospital for several days. On November 14, she attempted to hang herself with a bed sheet. She knotted the sheet around her neck, tied the other end to a door knob and slumped down on the floor. Staff discovered her and intervened before there were “significant consequences.” On November 18, the psychiatrist at the hospital released plaintiff from emergency detention status and discharged her from the hospital. Plaintiffs records from the hospital include the following observations from the psychiatrist: (1) a diagnosis of opioid dependence, depressive disorder not otherwise specified, claustrophobia and antisocial personality disorder; (2) a conclusion that “the main problem seems to be her suicidal ideation associated with the consequences of her sentence”; (3) a recommendation that plaintiff be kept on a suicide watch; (4) a list of “discharge medications,” including Zoloft (for depression, once in the morning); Ativan (for anxiety, every four hours if needed) and Ultram (for pain, four times a day). The discharge instructions from the hospital state “suicide watch” multiple times. The psychiatrist’s name is written at the top of these instructions. 3. Third attempt of self ham a. November 18 When plaintiff returned to the jail from the hospital on November 18 at 2:21 p.m., she was placed in the south block in general population. No one conducted a mental health evaluation of her. Plaintiff met with her probation officer, who told officer Marilyn Stuart that plaintiff had tried to hang herself at that hospital, that he was concerned for plaintiffs safety and that staff should take away a pencil that plaintiff had. Stuart recorded in the first shift “pass on” log that plaintiff was “suicidal” and had tried to hang herself at the hospital. A similar note was repeated in the second shift “pass on” log. At 3:30 p.m., plaintiff submitted a medical request to see a nurse about her medications. At 4:15 p.m., defendants Reinart and Wildes responded. Reinart called in plaintiffs prescriptions and noted that the lacerations on plaintiffs wrists were scabbed over. During the meeting, plaintiff told Reinart and Wildes what had happened at the hospital: “I hung myself in the bathroom with a sheet. I didn’t really want to kill myself. The staff didn’t check on me every 15 minutes.” Reinart asked plaintiff to promise that she would not harm herself and plaintiff agreed. Plaintiff asked Reinart to tell her lawyer in a letter that she was concerned about her children, but Reinart told her she could not honor the request “due to legal issues.” Defendant Reinart reviewed the discharge instructions but she did not place plaintiff on suicide watch and she did not inform other jail staff that the discharge instructions included a suicide watch. It was standard procedure in the jail for the nurse to provide discharge instructions to other jail staff. Reinart did not place plaintiff in the observation cell, give specific instructions to staff relating to plaintiff or document the “contract” she had made with plaintiff. Generally, the determination whether to place an inmate at the jail in an observation cell after a hospitalization depends on the recommendation made in the discharge instructions. Reinart wrote in the pass on log: “denies ideas of self harm or suicidal thoughts — continue to observe closely.” Reinart did not explain what “observe closely” meant. She believed it was up to “the lead officer” to determine how to implement that instruction. Janusheske recalls seeing a note stating, “watch Brenda,” which she interpreted to mean a suicide watch. Dawn Cole, another inmate, thought plaintiff seemed upset. Cole observed that plaintiff was crying frequently. Plaintiff told Cole multiple times that she was going to commit suicide. Cole and other inmates began “beating on the door,” telling staff that plaintiff belonged in the observation cell rather than general population. Cole told an officer named “Pat” that plaintiff should be put in the “birdcage,” or the observation cell, which can be viewed by staff at all times. Plaintiff told other inmates in the south block that she was sad and worried about being in prison and losing her children. After plaintiff returned, staff recorded cell checks of the south block (where plaintiff was housed) at 3:25 p.m., 3:53 p.m., 4:55 p.m., 4:57 p.m., 5:48 p.m., 6:25 p.m., 8:16 p.m., 8:47 p.m., 9:23 p.m., 9:26 p.m. and 11:29 p.m. Staff members performing these checks do not recall plaintiff exhibiting any behavior that would suggest she was a threat to harm herself. Defendants Wegner, Wildes, Schaldach and Leis were on duty November 18. b. November 19 Plaintiff requested an extra blanket from defendants Warner and Wegner, who denied the request. On the inmate medical request form, Warner wrote, “extra blanket [not] approved d/t suicide gestures.” Warner called the hospital to confirm plaintiffs statement to defendant Rei-nart that plaintiff had tried to hang herself while in the hospital. In her notes for the call, Reinart wrote that hospital staff stated that they were “well aware of the incident.” The first shift daily pass on sheet states: “ALSO WE LEARNED MOMBOUR-QUETTE TRIED TO HANG HERSELF WHILE AT LAX. LUTHER?” Defendants Fish, Janusheske, Wieman, Wegner, Warner, Leis, and Wildes were on duty November 19, 2002. Each was aware that plaintiff had been placed in emergency detention for cutting her wrists, that plaintiff had tried to hang herself while she was in the hospital and that Warner had refused to give plaintiff an extra blanket because of “suicide gestures.” Janusheske knew that plaintiff was taking medication for depression. Plaintiff was not placed on suicide watch on November 19 and no special checks were performed. She remained in general population. Staff recorded 30 cell checks that included the south block, ranging from once every four minutes to once every hour and forty-seven minutes. Staff members performing these checks do not recall plaintiff exhibiting any behavior that would suggest she was a threat to harm herself. c. November 20 Plaintiff met with her probation officer, who discussed with her a placement in a 130 day in-patient drug treatment program at Taycheedah Correctional Institution. The daily pass on log repeats the notation from November 19 that plaintiff tried to hang herself while at the hospital. Because of plaintiffs history of drug abuse, defendant Warner added a note to the medical pass on that jail staff should perform hand and mouth checks after dispensing medication to plaintiff to insure that she was not stockpiling it. Defendants Wieman, Janusheske, Weg-ner, Fish and Warner were on duty November 20. Plaintiff was not placed on suicide watch on November 20 and no special checks were performed. She remained in general population. Staff recorded 23 cell checks that included the south block, ranging from every minute to every three hours and five minutes. Staff members performing these checks do not recall plaintiff exhibiting any behavior that would suggest she was a threat to harm herself. d. November 21 At Roellich’s request, defendant Reinart prepared a form called “Health Transfer Summary” relating to plaintiff. (Plaintiffs probation officer had asked Reinart to prepare the form in the hope that plaintiff could be transferred to another institution with drug treatment programs. The transfer request was unrelated to plaintiffs past attempts of harming herself.) Under “Precautions/Behavioral Information,” Reinart marked the box for “Suicide Attempts/Threats.” Reinart wrote that plaintiff had been hospitalized on November 13 for a “suicide attempt.” Reinart met with plaintiff to discuss the transfer. During the evening, defendant Schal-dach approved a decision to place plaintiff in the conference room with colored pencils. Another inmate observed that plaintiff was “exhausted” and did not want to talk anymore. The daily pass on log repeats the notation from November 19 that plaintiff tried to hang herself while at the hospital. Defendants Leis, Janusheske, Reinart, Fish and Schaldach were on duty. Plaintiff was not placed on suicide watch on November 21 and no special checks were performed. She remained in general population. Staff recorded 30 cheeks that included the south block, ranging from once every minute to once every hour and fifty-three minutes. Staff members performing these checks do not recall plaintiff exhibiting any behavior that would suggest she was a threat to harm herself. e. November 22 The daily pass on log repeats the notation from November 19 that plaintiff tried to hang herself while at the hospital. Plaintiff remained in general population on November 22. She was not placed on suicide watch and no special checks were performed. Plaintiff met with her counselor, Kim Buchanan, around 1:30 p.m. Jail staff did not inform Buchanan about plaintiffs recent suicide attempts. Plaintiff voiced concerns to Buchanan about her children. She asked Buchanan whether she would be able to retain primary custody of them. In her notes, Buchanan stated that plaintiff “reports continued depression” and “responds impulsively.” Defendants Fish, Janusheske and Wildes were on duty at the time Buchanan had her meeting with plaintiff. None of them asked Buchanan about the meeting after it was over. Buchanan does not remember how long the meeting lasted, but her notes indicate that it finished at 2:30 p.m. Defendant Janusheske returned plaintiff to her cell after the meeting was over. Staff recorded twenty three cell checks before 2:58 p.m.: 12:41 a.m., 1:22 a.m., 2:02 a.m., 2:33 a.m., 3:03 a.m., 3:36 a.m., 4:17 a.m., 4:59 a.m., 5:31 a.m., 5:59 a.m., 6:29 a.m., 6:31 a.m., 6:55 a.m., 8:21 a.m., 9:07 a.m., 9:08 a.m., 9:58 a.m., 11:20 a.m., 11:35 a.m., 11:55 a.m., 1:13 p.m., 1:17 p.m. and 2:36 p.m. Defendant Fish conducted the cell check of the south block that was documented in the log at 2:36 p.m. Fish does not remember whether plaintiff was in her cell during the cell check. Defendant Janusheske recorded the following log entry at 2:57:57p.m.: Cell check in E/1, E/2, W/3, W/4, N/B. When I was walking in to [the south block], I saw [plaintiff] standing by the bars with a towel wrapped around her neck, called jail office, asked # 80 and # 8 to come back to [south block]. Nurse Jean assisting. After defendant Janusheske discovered plaintiff hanging from the bars, defendants Wildes, Fish and Reinart responded to Janusheske’s call for assistance. When Wildes arrived, he did not see defendant Janusheske. Instead, he saw another inmate trying to lift plaintiff to take the pressure off her neck. Reinart cut the bed sheet from around plaintiff’s neck and lowered her on to the bunk. (Although defendant Janusheske’s notes refer to the material as a “towel,” it appears to be undisputed that it was actually a bed sheet.) Defendant Reinart checked plaintiffs vital signs, finding no respiration and a very weak pulse. An ambulance was called while defendant Reinart began rescue breathing. Plaintiff was transported to the hospital at approximately 3:00 p.m. As a result of the suicide attempt, plaintiff suffered from anoxic encephalopathy secondary to a lack of oxygen to the brain. OPINION I. MOTION IN LIMINE Because it affects plaintiffs claims against multiple defendants, I consider first defendant Schaldach’s motion to exclude evidence of his sexual activity with other inmates. Before permitting this evidence to be introduced, I must find that it is relevant, admissible and not unfairly prejudicial. In her brief opposing defendant Schaldach’s motion in limine, plaintiff identifies three purposes of the evidence: (1) to show defendant Schaldach’s motivation for failing to protect her; (2) to show that defendant Amundson was deliberately indifferent in failing to supervise defendant Schaldach; (3) to show that defendant Schaldach was sexually harassing plaintiff. With respect to the third purpose, evidence that defendant Schaldach was sexually harassing plaintiff would certainly be highly relevant to the question whether he was deliberately indifferent to her health and safety. However, plaintiff does not explain how evidence that Schaldach was engaging in sexual activity with someone else is admissible to show he was sexually harassing plaintiff, particularly when there is little to no other evidence that Schaldach was harassing plaintiff. Using the evidence for that purpose would be marginally relevant at best and would certainly be unfairly prejudicial. Nevertheless, defendant Schal-dach’s motion in limine must be denied with respect to evidence that plaintiff reported Schaldach’s misconduct because such evidence shows that Schaldach had a strong motive to withhold protection from plaintiff and is thus relevant to show that he intentionally disregarded a risk to plaintiffs safety. Although there is no evidence that Schaldach ever spoke to plaintiff about her complaint, the facts show that defendant Wieman told him about it. This is sufficient to establish Schaldach’s intent. Although none of the defendants in this case acted to protect plaintiff, it is particularly puzzling why Schaldach, as the lead officer on November 18, failed to take any action once he learned that plaintiff tried to hang herself while she was at the hospital. Because plaintiffs accusation provides a possible motive for Schaldach’s indifference, her reporting of it is relevant. Although I agree with defendant Schaldach that the evidence is likely to be prejudicial, I cannot conclude that it is unfairly so. In addition, evidence that defendant Amundson refused to investigate plaintiffs allegations of sexual misconduct is relevant to show his state of mind. In Woodward v. Correctional Medical Services, 368 F.3d 917, 930 (7th Cir.2004), the court held in a jail suicide case that the defendants’ refusal to correct or investigate staff misconduct that could affect the health and safety of inmates was relevant and admissible to show deliberate indifference, even when that misconduct was not related to suicide prevention directly. The court rejected arguments that such evidence was unfairly prejudicial or barred under Fed.R.Evid. 404. Id. Similarly, in this case, Amundson’s dismissive attitude of a very serious complaint that could have a profound impact on the physical and psychological well-being of multiple inmates exhibits an attitude of deliberate indifference, both toward plaintiffs health and safety in particular and generally toward the health and safety of all the inmates at the jail. Although the relevance of this evidence is somewhat limited (this is not a case about sexual harassment after all), defendant Schaldach has not shown that any unfair prejudice to him or defendant Amundson substantially outweighs the probative value of the evidence. Fed. R.Civ.P. 403. The motion in limine will be denied. II. MOTIONS FOR SUMMARY JUDGMENT The Constitution guarantees persons in state or local custody a limited right to be protected from harm. Farmer v. Brennan, 511 U.S. 825, 114 S.Ct. 1970, 128 L.Ed.2d 811 (1994). In determining whether this right has been violated, the standard is the same, regardless whether the pérson is a convicted prisoner or detainee, a victim of violence at her own hand or the hands of others. The question is whether the defendants were deliberately indifferent to a substantial risk of serious harm. Cavalieri v. Shepard, 321 F.3d 616 (7th Cir.2003). (The Supreme Court has noted, and the court of appeals has repeated on several occasions, that pretrial detainees are entitled to “at least” the same protection under the Fourteenth Amendment’s due process clause as convicted prisoners are under the Eighth Amendment, suggesting that the standard of review could be different for pretrial detainees like plaintiff. See, e.g., City of Revere v. Massachusetts General Hospital, 463 U.S. 239, 244, 103 S.Ct. 2979, 77 L.Ed.2d 605 (1983); Henderson v. Sheahan, 196 F.3d 839, 854 (7th Cir.1999); Payne v. Churchich, 161 F.3d 1030, 1040 (7th Cir.1998). Despite this observation, I am unaware of any case in which the Supreme Court or the court of appeals has applied a different standard of review in detainee cases. In any event, both sides assume that a “deliberate indifference” standard applies, so I will do the same.) Not surprisingly, defendants do not argue that plaintiffs harm was insufficiently serious to trigger constitutional protections. Rather, as in other cases involving suicide or attempted suicide, the question is whether plaintiff has adduced sufficient evidence to allow a reasonable jury to find that each of the defendants was deliberately indifferent to plaintiffs health and safety. As is often repeated, the deliberate indifference standard requires more than a finding of negligence but less than a showing of intentional harm. Gil v. Reed, 381 F.3d 649, 664 (7th Cir.2004). The standard has two main parts. First, was the defendant subjectively aware of a substantial risk of serious harm to the plaintiff? Farmer, 511 U.S. at 828, 114 S.Ct. 1970. Second, if the defendant was aware of the risk, did he respond reasonably to the risk, even if the harm was not ultimately averted? Id. at 844, 114 S.Ct. 1970. Of course, this test does not resolve all questions regarding the meaning of “deliberate indifference.” For example, how great must a risk be before it is deemed “substantial” for the purpose of constitutional protections? The court of appeals has said only that it is more than “a mere possibility,” Pinkston v. Madry, 440 F.3d 879, 889 (7th Cir.2006), but less than a certainty, Collignon v. Milwaukee County, 163 F.3d 982, 990 (7th Cir.1998). The Supreme Court has provided little guidance on this question and in fact expressly declined to consider it in Farmer, 511 U.S. at 834 n. 3, 114 S.Ct. 1970. In another Eighth Amendment case, the Court defined an “unreasonable risk” in part as one that society would not tolerate. Helling v. McKinney, 509 U.S. 25, 26, 113 S.Ct. 2475, 125 L.Ed.2d 22 (1993). This suggests a meaning that is neither static nor rigid, but instead depends on the nature of the potential harm. In other words, the more serious a possible injury, the lower the threshold for showing that the risk is substantial. Cf. In re Forty-Eight Insulations, Inc., 115 F.3d 1294, 1300 (7th Cir.1997) (adopting “sliding scale” approach to granting preliminary injunctions, in which requisite likelihood of success is contingent on balance of harms). For example, it is reasonable to expect officials to be more sensitive to a risk of death than to a risk of unsanitary conditions. “[W]e cannot equate death with dirty cells.” Wever v. Lincoln County, Nebraska, 388 F.3d 601, 607-08 (8th Cir.2004) (holding that what constitutes adequate notice under deliberate indifference standard “must change depending on the seriousness of the incident”). With respect to the second part of the test, defendants suggest that they were not required to respond “reasonably” to known risks. They cite Cavalieri, 321 F.3d at 622, which includes the statement that, in a suicide case, the defendant “was not required to take perfect action or even reasonable action.” But this statement is best interpreted as simply rejecting the proposition that the Constitution adopts a negligence standard, which imposes liability whenever a defendant fails to recognize a risk that a “reasonable” person would recognize. Restatement (Second) of Torts § 283 (1965). Any other reading would conflict with Farmer, in which the Court held explicitly that an official is deliberately indifferent “if he knows that inmates face a substantial risk of serious harm and disregards that risk by failing to take reasonable measures to abate it.” 511 U.S. at 847, 114 S.Ct. 1970 (emphasis added). Generally, the court of appeals has reiterated the standard from Farmer that officials must take reasonable steps when they are aware of a substantial risk of harm. Borello v. Allison, 446 F.3d 742, 747 (7th Cir.2006); Woodtuard, 368 F.3d at 928; Peale v. McCann, 294 F.3d 879, 882 (7th Cir.2002); Sanville v. McCaughtry, 266 F.3d 724, 737 (7th Cir.2001); Estate of Novack v. County of Wood, 226 F.3d 525, 529 (7th Cir.2000); Estate of Cole by Pardue v. Fromm, 94 F.3d 254, 258 (7th Cir.1996). Accordingly, I conclude that the Constitution imposes a duty on government officials to respond reasonably to known risks of harm. A. Defendant Reinart I begin with defendant Jeanne Rei-nart, who was the only defendant to review plaintiffs discharge instructions from the hospital and the first person plaintiff identifies who made a choice not to place plaintiff on suicide watch after she returned to the jail on November 18. (Although someone made the initial decision to place plaintiff in general population when she returned to the jail on November 18, neither side identifies who that was.) Defendants argue both that Reinart was not aware of a substantial risk of serious harm and that, even if she were aware of the risk, she responded adequately. (I refer to defendants collectively rather than to defendant Reinart alone because although Reinart filed her own brief in support of her motion for summary judgment, the other defendants make arguments in her defense and most of the arguments overlap Rei-nart’s.) 1. Awareness of risk Under Farmer, 511 U.S. at 837, 114 S.Ct. 1970, a plaintiff must prove not only that the defendant knew facts that would allow the drawing of inference that the plaintiff was at a substantial risk of harm, but also that the defendant actually “dr[e]w the inference.” Thus, no matter how apparent the risk would be to a reasonable person, a defendant may avoid liability if she was in fact ignorant. However, a defendant does not immunize herself from trial simply by averring that she was unaware of a risk. A plaintiff may use circumstantial evidence to persuade the finder of fact that the defendant was aware of the risk, despite her protestations to the contrary. Further, although a defendant is not liable for obvious risks of which she remained unaware, the obviousness of a risk may be used as evidence that the defendant was aware that danger was present. Id. at 842, 114 S.Ct. 1970. (“a factfinder may conclude that a prison official knew of a substantial risk from the very fact that the risk was obvious”). Viewing the evidence in the light most favorable to plaintiff, Lopez v. City of Chicago, 464 F.3d 711, 715 (7th Cir.2006), I conclude that a reasonable jury could find that defendant Reinart was aware of the risk that plaintiff would attempt to harm herself again. In reaching this conclusion, I find two facts to be the most striking: (1) plaintiffs two previous attempts to harm herself within the previous ten days; and (2) plaintiffs hospital discharge instructions that she should be placed on a suicide watch. By themselves, plaintiffs two previous attempts of self harm would be sufficient to create a jury question. In all of the published appellate cases I have reviewed, the court found that, when the defendants were aware of recent suicide attempts, it would be improper to grant summary judgment or judgment as a matter of law on the question whether defendants were aware of a substantial risk of serious harm. Woodward, 368 F.3d at 924, 928; Cavalieri, 321 F.3d at 621-22; Hall v. Ryan, 957 F.2d 402, 405 (7th Cir.1992); Perez v. Oakland County, 466 F.3d 416 (6th Cir.2006) (Cudahy, J.) (suicide attempt one month earlier); Snow ex rel. Snow v. City of Citronelle, AL, 420 F.3d 1262, 1270 (11th Cir.2005) (inmate attempted to cut wrist one month earlier); Turney v. Waterbury, 375 F.3d 756, 760 (8th Cir.2004) (previous suicide attempt at another facility); Colburn v. Upper Darby Township, 838 F.2d 663, 669 (3d Cir.1988); Cabrales v. County of Los Angeles, 864 F.2d 1454 (9th Cir. 1988); Partridge v. Two Unknown Police Officers, 791 F.2d 1182 (5th Cir.1986) (suicide attempt in previous confinement). See also Bradich ex rel. Estate of Bradich v. City of Chicago, 413 F.3d 688 (7th Cir.2005) (concluding that defendants were not deliberately indifferent in failing to prevent suicide while noting that inmate had not tried to injure himself before); Brown v. Harris, 240 F.3d 383, 390 (4th Cir.2001) (defendant knew of suicide attempt week earlier; court assumed that defendant was aware of substantial risk but held that he acted reasonably by placing inmate on constant video monitoring); Robey v. Chester County, 946 F.Supp. 333, 337-38 (E.D.Pa.1996). Although the court concluded that summary judgment was appropriate in Matos ex rel. Matos v. O’Sullivan, 335 F.3d 553, 554 (7th Cir.2003), the inmate in that case had attempted suicide three years before his incarceration and, more important, the defendants were unaware of it. The only specific sign that he was currently at risk was his saying that he was depressed over the recent death of his father. When knowledge of plaintiffs suicide attempts is combined with instructions from the hospital to place plaintiff on suicide watch, it is clear that summary judgment is not appropriate with respect to this element. Although it is unnecessary to consider them, other facts suggest defendant Reinart was aware of a risk: (1) plaintiff was on medication for both depression and anxiety; (2) plaintiff had made multiple statements just days earlier that she was thinking of killing herself; (3) plaintiff had just returned from an emergency detention; (4) plaintiff had been upset since September about the prospect of losing her children, to the point that she could not sleep and anti-anxiety medications were not effective; and (5) plaintiff continued to face all of the stressors that led to her previous acts of self harm: continued incarceration and possible loss of her children and business. Despite defendant Reinart’s awareness of these facts, defendants advance several arguments why they believe Reinart is entitled to summary judgment. a. Medical judgment Perhaps defendants’ most vigorously asserted argument is that, despite defendant Reinart’s knowledge of plaintiffs past acts of self harm, the discharge instructions and the other information Reinart knew about plaintiff, Reinart made a medical judgment that plaintiff would not attempt suicide. In other words, defendants argue that despite Reinart’s awareness of these facts, she concluded that plaintiff did not have a “serious medical need” triggering a constitutional duty to act. State Bank of St. Charles v. Camic, 712 F.2d 1140, 1145 (1983) (analyzing failure to properly diagnose suicidal tendencies as question whether defendants were deliberately indifferent to serious medical need). Defendants seek to take advantage of the court of appeals’ holding that when “professionals such as physicians, psychiatrists, and nurses” make a decision “within their area of professional expertise,” there can be no liability under the Constitution for failing to recognize a risk of suicide unless “the professional’s subjective response was so inadequate that it demonstrated an absence of professional judgment.” Collignon v. Milwaukee County, 163 F.3d 982, 989 (7th Cir.1998) (citing Youngberg v. Romeo, 457 U.S. 307, 323, 102 S.Ct. 2452, 73 L.Ed.2d 28 (1982)). In other words, the court of appeals has held that unless there is evidence that the defendant did not use professional judgment, it would be unreasonable for a jury to find that the defendant was aware of the risk. Initially, there is a question whether defendant Reinart was qualified to make a determination that plaintiff was no longer at risk for harming herself. The cases on which defendants rely, Collignon, Fromm and Sanville involved decisions of psychiatrists, each of whom had conducted mental health examinations of the inmate. In fact, in Fromm, 94 F.3d at 263, the court concluded that a “risk classification is most appropriately made by a licensed psychiatrist” and that “it would have been inappropriate for any of the nurses to change [the psychiatrist’s] classification for anything other than a temporary basis without consulting a physician.” (Emphasis added). See also Perez, 466 F.3d at 425 (reasonable jury could find that caseworker was deliberately indifferent when she took inmate off suicide watch without consulting psychiatrist). Further, to the extent that some nurses might be qualified to make assessments about suicide risks, defendant Reinart has not shown that she is one of them. She avers vaguely in her affidavit that she received instruction on this issue in nursing school, but she does not provide any evidence about what the instruction was or how she used it to assess plaintiff. Lujan v. National Wildlife Federation, 497 U.S. 871, 888, 110 S.Ct. 3177, 111 L.Ed.2d 695 (1990) (“The object of [summary judgment] is not to replace conclusory allegations of the complaint or answer with con-clusory allegations of an affidavit.”); Drake v. Minnesota Mining & Manufacturing Co., 134 F.3d 878, 887 (7th Cir.1998). (“Rule 56 demands something more specific than the bald assertion of the general truth of a particular matter[;] rather it requires affidavits that cite specific concrete facts establishing the existence of the truth of the matter asserted.”). Reinart avers that she had experience making mental health assessments while working for the Monroe County jail, but again she provides no specifics. In any event, Reinart was not hired at the jail until 2000 and the parties have proposed facts about only one other suicide attempt between 2000 and 2002. Reinart does not allege that she was involved in assessing that inmate. Thus, defendant Reinart points to no evidence from which I could conclude that she was qualified to make a determination that an instruction for a suicide watch should be disregarded. In fact, as far as I can tell from this record, it appears that the officers received more training about suicide prevention than did defendant Rei-nart. Even if I could conclude that Reinart was qualified, there is a genuine dispute whether defendant Reinart was actually using medical judgment. Unlike the doctors in Collignon, Fromm and Sanville, Reinart did not prepare a written report or otherwise document the medical basis for her decision to keep plaintiff in general population. Even more important, Reinart did not explain at the time why she chose to disregard the discharge instructions. The only documentation of her thought process was one line in the staff log stating: “[plaintiff] denies ideas of self harm or suicidal thoughts — continue to observe closely.” I disagree with defendants that Rei-nart’s refusal to follow the discharge instructions is like the situation in Fromm, 94 F.3d at 261, in which the court held that no genuine dispute was created by an opposing opinion of the plaintiffs expex-t. This is not a case about a mere difference of opinion between two doctors. Snipes v. DeTella, 95 F.3d 586, 592 (7th Cir.1996). Rather, in this case, defendants had already “expressly noted” that plaintiff was at risk for harming herself when they hospitalized her. Farmer, 511 U.S. at 842, 114 S.Ct. 1970 (knowledge of risk may be inferred if risk was “longstanding, pervasive, well-documented, or expressly noted by prison officials in the past”). Defendant Reinart disregarded instructions from the very psychiatrist to whom plaintiff was sent in order to make a mental health assessment after she threatened to kill herself. That is not sound medical judgment. Accordingly, I conclude that a reasonable jury could find that Reinart was aware that plaintiff was a suicide risk, either because the risk would be obvious, even to a layperson, Collignon, 163 F.3d at 989 (“a trier of fact can conclude that the professional knew of the need from evidence that the serious medical need was obvious”), or because any medical judgment she says she made was a substantial departure from professional judgment. Cole, 94 F.3d at 261-62 (“[Djeliberate indifference may be inferred based upon a medical professional’s erroneous treatment decision only when the medical professional’s decision is such a substantial departure from accepted professional judgment, practice, or standards as to demonstrate that the person responsible did not base the decision on such a judgment.”) b. Discharge instructions Defendants make two sets of arguments related to the discharge instructions. First, defendants say that the discharge instructions did not provide notice of a risk of harm because they were not signed by the psychiatrist and they did not provide details for implementing the suicide watch. (Defendants also point to statements made by the psychiatrist in other medical records, but none of the defendants can rely on these because they did not see the records before November 22, 2002.) Defendant Reinart is free to make this argument to the jury, but it does not entitle her to summary judgment. Again, the instructions came from the hospital that had been charged with assessing plaintiffs mental health. Although the psychiatrist did not sign the instructions, his name was listed at the top of sheet as the attending physician. It is undisputed that the general practice at the jail was to follow discharge instructions. Further, Reinart cannot argue plausibly that the words “suicide watch” have no meaning to her or that they do not connote an assessment that there is a substantial risk that plaintiff would attempt to harm herself. The jail’s own policy outlines appropriate procedures for a suicide watch. Although it is certainly true that the instructions could be more detailed, a reasonable jury could find that defendant Rei-nart had at least enough notice to trigger a duty to investigate further by contacting the psychiatrist rather than simply failing to follow the instructions. Second, defendants suggest that instructions for a suicide watch, no matter how clear, are never sufficient to provide a notice of a risk. Defendants cite Collignon v. Milwaukee County, 163 F.3d 982, 990 (7th Cir.1998) and Taylor v. Wausau Underwriters Insurance Co., 423 F.Supp.2d 882 (E.D.Wis.2006), for the proposition that “even if an inmate is on actual suicide watch, this does not demonstrate a substantial awareness of a substantial risk of imminent suicide.” Defendants’ reliance on these eases is misplaced. First, with respect to Collignon, its facts are so inapposite that its instructiveness for this case is extremely limited. In Col-lignon, the decedent had killed himself after he was released from county custody; his family’s claim was that the county was liable for releasing him without an adequate treatment plan. In that context, the court considered the question whether .the defendants’ decision to place the decedent on suicide watch demonstrated that they were aware their treatment plan was inadequate to prevent the post-release suicide attempt. The court held only: “Placing him on a high level of suicide watch does not automatically impose on those responsible for the precaution a constitutional obligation to devise a treatment plan premised on the probability that Jonathan was on the verge of suicide.” Id. at 990. The facts of this case bear almost no relation to Collignon. Aside from the vastly disparate obligations the government owes to those in custody versus those out of custody, compare DeShaney v. Winnebago County Dept, of Social Services, 489 U.S. 189, 109 S.Ct. 998, 103 L.Ed.2d 249 (1989) with Estelle v. Gamble, 429 U.S. 97, 97 S.Ct. 285, 50 L.Ed.2d 251 (1976), the most notable difference in this case is that, unlike the defendants in Collignon, defendant Reinart is not being called to task because she erred on the side of caution and placed plaintiff on suicide watch despite the lack of a clear need to do so. It is not Reinart’s decision to place plaintiff in a particular status that shows her awareness of a risk, but her knowledge that the hospital from which plaintiff was just discharged believed that plaintiff should be placed on a suicide watch. If an official decides to place someone on closer observation as a matter of extreme caution or as a matter of routine (as defendants apparently did when plaintiff was initially detained), this does not necessarily communicate how great a risk the official perceived. See also Taylor, 423 F.Supp.2d at 893 (placement on suicide watch without more does not show awareness of risk when inmate was placed in that status primarily as matter of routine rather than because of risks specific to inmate). But knowledge of a recommendation for a suicide watch issued by those to whom the inmate was sent to have a mental health assessment is certainly strong evidence that the official is subjectively aware of a risk of harm. Neither Collignon nor Taylor suggests otherwise. Further, as noted above, the discharge instructions were not the only red flag for Reinart. They were simply a confirmation that the risk demonstrated by plaintiffs previous acts of self harm had not abated. Not surprisingly, defendants challenge the importance of those events as well. c. Past acts of self harm It is undisputed that defendant Reinart was aware that plaintiff cut her wrists on November 13, requiring her to be hospitalized, and that she attempted to hang herself with a bed sheet on November 14. Defendants make two related arguments in attempt to undermine the effect of the notice provided by these acts of self harm: (1) Reinart believed they were not “serious” suicide attempts; and (2) Reinart believed plaintiff was being “manipulative.” Throughout their proposed findings of fact and briefs, defendants object vigorously to any characterization of plaintiffs attempt to cut her wrists and neck on November 13 and to hang her herself on November 14 as “suicide attempts.” This seems to be an implied concession that if defendants had perceived plaintiffs first two attempts of self harm as “suicide attempts,” they would be unable to say they lacked awareness of a substantial risk of serious harm. These objections are disingenuous, however, because defendants, including defendant Reinart, consistently referred to the November 13 incident as a “suicide attempt” in their own records. In any event, defendants’ game of semantics is unavailing. Regardless of the degree to which plaintiff was physically harmed after her first two attempts, it is difficult to deny that cutting three lacerations on both wrists and hanging oneself with a bed sheet are distressing behaviors that signal the likelihood of another attempt, particularly when both attempts occurred within the previous few days. A similar conclusion follows from defendants’ “manipulation” objection. Defendants cite Riccardo v. Rausch, 375 F.3d 521, 525 (7th Cir.2004), for the proposition that a prison offici