to repeated violations of those policies it can be held liable for deliberately indifferent costs and that is this case reasonable jury could conclude that wexford voluntarily assumed ultimate responsibility for mr hope its health health and medication contracting with the ideas that adopted to formal medication refill and renewal policies designed to protect inmates from medication gaps that it knows about mr hildreth's parkinson's disease his mirapex prescription its efficacy and the consequences of a stablished way for inmates to communicate problems with medications and health beats if you look at dr mannix testimony at age sixty five the record he specifically says that works for his in charge of managing the chronic care for this type of to essentially willful disregard pattern and we have at most three random delays in getting the prescription refilled yes sure enough a couple of days at most one was a little bit longer i'm guessing that we don't think that it's three st of all we cited to eight specifically in the rd well there were evidentiary decisions that were made in the district court but i would just like to describe the pattern that repeats itself over and over in the record here and i think you're limited to the three that the district court focused on those were the ones that were aggrieved the other ones r admissible evidence unless you've got a good case that the district court used its discretion and that's an uphill climb on an evidentiary ruling you're limited to the three we agree that it's  climb but it's it's clear that the two instances cited in the count affidavit were not hearsay under the party of opponent rule they were employees of blacks furred and they were acting within the scope of their ploy meant how do we know you would you suggest to somebody who's currently representing in the district court in a case like this representing a prisoner that they seek discovery works for its personnel records or the private care providers personal records to establish such agency yes your honor of course and would would nurses for the idea to see fall within the agency given  responsibility for delivery of health care yes yes i think that's important but i just want to emphasize that those records were sought in this case or were not they were dr maddox specifically testified we asked him specifically if he knew of any employees who were involved in this children's care and he couldn't identify a single nurse who can identify a single doctor who had cared for mr holder at since two thousand and twelve so it's not like there was no effort to specifically identify those again we we believe that there are eight instances and there are in the record minimum that should be considered here were how long a period of time did that stretch so so the st instance occurred in november of two thousand and nine and if it extends all the way to november two thousand and fift n but i would emphasize that repeatedly mr hildreth states that there were other instances he said that this happened again in his rd grievance so we think it's critical to consider the st and nd instances because they should explain that test as to saying this happened again and also suggests that it could have happened more so why is it not reasonable include just say look this is we've got a system here it's not perfect how do we infer or how would a jury reasonably infer even if you have always in front of a jury infer deliberate indifference spread out over it these are monthly renewals through your refills and spread out over about six twenty years doesn't seem like that's big a deal so your honor we we want to emphasize that there are violations of the refill and removal policy there so it's not just the refills that are issued that occur every thirty days it's also the buying your chronic medications are automatically reviewed despite the six month rule and then we've pointed to three gaps where it clearly shows that that his medication was not renewed in time specifically the rd the th and th gaps so we just want to emphasize that that there are those two avenues it's the refill policy and the renewal and then in terms of deliberate indifference we would just argue that the very act of adopting these formal policies that were designed specifically to counter medication gaps shows an awareness of the risk and then at the same time have these instances in the record that suggests that policy are sorry that medical staff are departing from those and then rd mr hildreth was doing everything in his power each time it's undisputed each time to  where expert about these delays tell the person in charge of his medication about these things didn't dr medics say that one of the three instances would have been as a result of mr hildreth not going to the chronic  chronic yes the chronic clinics clinics yes but he also admitted that he had not reviewed any of mr rogers medication records and looked at any of his refill records he didn't know anything about that it wasn't based on personal knowledge but more important his testimony he said that he didn't go for some reason he didn't explain why so his testimony is perfectly consistent with our theory that wexford simply failed to deliver the past for him to go to his chronic clinic so we don't think that there's that his testimony undercuts that anyway and so so i explain that mr holt is doing everything his power the th is that works for doesn't do anything after that to prevent any future delays or obstruction to parkinson's obviously a serious a could have exempted him from the refill sticker policy on the could have made sure that at least gets his passes he could have made his prescriptions last longer than the year on the bottom line is that it should have made sure that he got his medications i would just point the court to  with a disability that he communicates through writing i'm sorry that communication through writing is a prison activity that's covered by the idea that the failure to provide reasonable policy modifications is an independent basis for a liability and that reasonableness is a highly fact reasonable jury could find all three of those current modifications so for standard library access it's not even really a modification he gets the same time that all other inmates gets it's undisputed in the record despite the ideas he's contentions otherwise that he to one dollar and a half hours a month to use the typewriters there he says with respect to the nd one officer health he said that he's asked officers in the past and that they haven't helped him again we think that modifications are there any provable damages here there are your honor we've we've submitted a motion attaching it's a illinois supreme court letter and if you look at the top right of that letter he writes thirty eight dollars forty cents wasted so he is incurring compensatory damages i'm sorry monetary damages there are things like filing fees obviously it's not a one million dollars case but this is a person who had a monthly payment plan for three hundred and fifty dollars to get twelve dollars may please the court to sansa on a behalf of wexford i'm here with my colleague for it's a counsel table i think this is a good case to look at the big picture we have three delays as judge rosen single found that were properly before the district court over a period of seventy two months two of those instances involve situations in which there's no evidence that hildreth submitted his refill sticker that's at the required short appendix page twenty five  cell it's not that's right handed out and med rounds that's right your honor he's allowed to keep up to ninety pills at one time with this particular medication mirapex and then has to submit seven days  no evidence regarding wendy's submitted its rightful sticker so every three months this is supposed to i mean the prescription lasts for a year is good for a year but when he needs a refill every three months he gets three months at a time that's right your honor and then one week before he's to turn the refill sticker three months at a time ninety pills these three a day oh i'm sorry you're on a one month one month at a time and he turns in one week for ok i'll just make that correction there is it is a clear from the prescription whether he is supposed to take it every eight hours or is he take it as needed my understanding is he has to take three per day that it's not is needed that he takes three per day over a period of a month or so with respect to the episodes  involving nurses kirk and walters yet you can did you come forward with any evidence that they did not work for a wexford of the relevant times i would think that something you could show pretty easily has or it could be the personnel records would show i personally don't know the dates for a nurse kirk and the only evidence in the record from dr maddox was do you know whether she has been employed by wexford answer to my understand she was allegedly was on rounds and allegedly said that she didn't like the conduct excuse me didn't like the demeanor of the inmate but even if that's true if we soon for sake of argument that that's all true that would be personal misconduct perhaps and under the griefs and decision from the th circuit that's attributable to her not to wexford that doesn't show a policy when you look at the other nurse nurse walters there is no evidence in the record she ever worked for wexford what she said under its contract with the state have overall responsibility for health care at the facility it shares that responsibility with the illinois department of corrections sharers there's i mean you each get to point to the other in this kind of a situation it's common for nurses to come back and forth between state employment and lex for employment and to employment at the illinois department of corrections as well yes that's true your honor at the end of the day the plaintiff and looking at the big picture again where i started t plaintiff has to show a widespread practice that directly caused or was the moving force behind the constitutional violation so should the should the plaintiffs have sought broader discovery and other prisoners health records that would have helped your honor now it's true that ended and should have sought personal records yes that when you guys really want to turn that sort of stuff over to prisoner plaintiffs well if we had received a discovery quest i guess we had to look at those individually and determine whether we had a answer could have been given about the implied yes your honor so i've got to say the the arguments that you all are making here about what's not in this record seem to be an open invitation to much  discovery much more intrusive discovery in order to establish conduct that would qualify under men all potentially could be around and yes ok even in the glisten case the court made clear that the institutional policy itself must be deliberately indifferent to the quality of care provided and going back to the gastown decision from april rd again we just don't really have the who in the why even if you say we that we're having to speculate to get to the point of what would be the medical reason for the medical judgment involved in interrupting mr hildreth's supply of the drug he needs to treat his parkinson's i don't know your honor i can't imagine i don't know when doctor for him did not immediately renew the prescription for the mirapex i don't know why he didn't it's not in the record either way as to why he did  establish an th amendment violation and based on the record that's before the court and that was before judge rosen stingel there wasn't a basis to find an overall widespread policy who are the relevant policymakers for to establish the processes for prescription renewal and refills and then also for ensuring that those policies are complied with particularly with respect to prescriptions critical to care that would be the experts medical director at which level state national regional this would be at the regional level your honor and i don't know the name of that person at the time of these events but that would be the position works for its medical direct establishing the policies about for compliance there would be oversight responsibility on the medical director for compliance about the facility medical director the facility not a medical director would also be in the mix your honor ok in the mix is what worries me particularly because we've got this institutional structure here which defuses responsibility so clearly under doctrines adopted under section eight hundred and eighty three diffused responsibility can wind up meaning nobody's response that we can why shields said what it said no yes your honor but i think that guest on said we have to have do with respect to the causation issues that you've raised is there any evidence in this record that boswell pharmacy was slow in refill requests there's no evidence one way or the other your honor any evidence that affirmative were part of the process yes but they weren't solar responsible for delivery of medications tuesday there would be the illinois department of corrections would also be involved in that it was all under works responsibility correct none of our current share in the responsibilit responsible ok thank you would ask the court to affirm and i'll turn it over to the state thank you for your time your honour's thank concluded that the modification effect hildreth receive satisfied title to remedial aims because those modifications allowed him to access the courts and communicate otherwise by writing in the  modifications work he chooses not to the thought the concern was between from july of two thousand and fifteen until you change policy and decided to let him have a typewriter again i don't know when it was that he was but also was there to be his scribe to take dictation from him so he could draft court documents whatever communications wanted to draft for some period of time he had increased library access that's right he when he didn't have the writing this is really the extra law library access was a three days a week proximately six hours a day accommodation and then that switched when he was assigned the attendant who lived with him to help  with various matters including writing and that's that's the time period that's i guess now been narrowed by people tell him that it's we're looking at july two thousand and fifteen present really and there's just no evidence that this writing attendant was so deficient that his court filings were inadequate somehow or that he couldn't use the writing systems so bad he the worst thing that happened hildreth is that he didn't like the writing system but that doesn't mean that the writing system was not a reasonable modification for him to be able to write like any other inmate in his cell separately there are several obstacles to obtaining any someone know of a likely harm or in this case inadequate modification or deficient modification and then ignore that deficient modification or not help fix it and there's no evidence that either butler or oakley ever were put on notice that he had these complaints about the writing system does does the a p a provide for individual liability in this kind of a situation for capacity that's right so which raises potential th amendment issues which have not been raised before until the school they were raised in the answer and you know i bet we didn't include it in the motion for summary judgment but that is not a  relief it is moot because we now have the typewriter and these two other modifications he can choose between if you were moved to back to a maximum security prison he would lose them he would lose the typewriter likely  that from the get thank you thank you thank you your honor and just a few points about the claim against wexford st of all they cited grievous and we just wanted to stinkers that case or for instances over a much shorter time there was november december two thousand january two thousand and one december of two thousand the only complaint about  once there was no evidence that dispensing the full bottle there violated any formal policy so there was no inference that the person was aware of any risk of theft in that case and thus the instances where josh hamilton you asked about whether x resulted authority i'd direct the court to and sixty five or the record to sixty six or dr matic says that wexford manages the care for this type of patient with medications and evaluations in terms of pointing to other prisoners i point the court to the daniel decision that was signed the reply the davis decision as well records would have clarified anything their own thirty six disease and then in terms of identifying specific policy makers as we cite in the brief it's undisputed there was a revolving door of medical directors here moving in and out of travel and medical directors and then with respect to the ideas he claims we just want to point out that for confidentially you're right mr holder this is not a serial way to go and he has only found two civil cases that we know of he had two options here either handwrite illegible documents or