he died of starvation failure and other complications carried when he was on the outside taking care of himself whereas it was on the director of a specific client treatment plant the record in this case tell us that tells us that horizon when asked about adopting the medical service care directives indicated they did not adopt any of them and that they chose to do  so because they were going to be why and best medical practices what we know is that they didn't come up with any alternative and when i have to assess the corded math i went back through every medical directives the very first one one point zero one it says compliance with the health care service director spears mandatory so contrary to their position they are the health care directives were mandatory they had to adopt them there was a goes on to say if there's a problem on this council i'm puzzled by the emphasis on this you do you can't use the constitution to enforce state administrative directives the might opposite i assume given the nature of this litigation they are saying that the constitution does not require a particular policy it's i don't see how the fact that the state requires something means that the and they decided not to have any treatment plan any specific specified treatment plan then that indicates it may be my question isn't clear i can understand an argument that the constitution only its own for require such a plan i understood that to be the argument chief judge wood was making in dissent i just don't understand how it counts for or against that argument that the state has made such a requirement as a matter of state procedure theory that i discussed before because they are you say that c m s maintained an express policy of fractured care specifically that there was an intentional gap in the policies and then a little further down you say they intend it's a directive is of relevance only to the extent that you're wondering did they know about something it's not because it's indiana law or anything is judge a stripper says that isn't the constitution states can do all sorts of things but you said they adopted a policy of diffusing responsibility for medical needs in the question is  policy of if maybe it's an unfortunate word fractured care something that leads to deliberately and different outcomes meaning with with policy cases like mono cases it's not quite the same as a doctor saying i don't care what happens to you why don't you just die on the floor the policy itself has to lead to deliberately and different outcomes and i thought that hard on page forty seven is where you were articulating the constitutional of it's a way of sameness individualized encounters with health care providers without any kind of captain of the team you know making sure they get coordinated with an acceptable way to run their medical services so we can call that an acceptable policy if that's the policy you're going after then i would say peers from the briefs that maybe there are disputed issues of fact  state seems to say that in the electronic records chronic conditions are recorded you're saying nobody's getting them make maybe that is the disputed issues the fact that i think from own now somehow or another you've got to show that the entity in this instance it's corazon has a way of doing that a deliberate way of doing business which we can call a policy that leads to deliberate indifference well knew you have to show for part of a deliberate indifference claimed that they know so i can see all sorts of things being perhaps evidence of knowledge but that's the most i think you can get out of the medical directives or they could be some kind of bureaucratic when i personally because i'm some self so the department of corrections department has an unqualified obligation to take care of that person no matter how it presents himself put it no i think you're not getting just procedures question and you may not know the answer to who's seven years ago in the department of corrections created this typical find a physician to write them and if you don't know that's ok you can just say you don't know i think that was the question if you could step back to the microphone that would help to say step back i go all right maybe i'll let you think about that for a minute because i want to go back to a point that was i mean it's really critical point for mon el cases there are a couple of different ways  is a decision maker a final decision maker does something one of them is custom and certainly if it's custom then you can't prove custom by one incident only you have to prove custom by a number of incidents which one do you think you are trying to prove and how can you do you think you need numerous incidents if it's if you're actually trying to show that there's an unconstitutional policy now we have not a parish that that anybody who fails to have a treatment plan and place that takes contact into the elements that mr grayson had he had a stand i'll see as you say here in your brief of defeating responsibility and you're saying that's an unconstitutional you have conceded at least is the case now as before and none of the individual medical providers whether they were doctors or nurses or whatever they were in and of themselves were being deliberately indifferent you're saying that coordination you're not going to have any success rate with somebody with medical problems like mr gleason but when he was on the outside he took care of himself and not the gratitude they deploy he was starvation the renal failure and the lack of oxygen profusion with the mental problems that they're sending them off to the psych ward for the good they were sensible reasons for his mental compares with the medical norm out of prison when did it become normal for say a a good teaching hospital to have one central administrator in charge of each patient care know out of hospitals when did this become the norm in the top echelons of american care here's what i understand from medical practice with you may not know the answer i'm not asking you to make anything up i don't know the know when i suspect this is a recent invention it isn't well then i'd like to know when and then what i would like to know is whether there is any research on the question whether this improves health outcome for patients do we know that it does there are many articles i read which we have not included in the record which says suggests that the prison population which is look i'm not asking about prisons i'm trying to get a focus to the department of correction when it issued a directive in question here correct that was based upon their best medical judgment of the day several years before mr gleason shows up at the indiana department of corrections thought that was best practice hamilton's point is a good one it was subtle and it seems to me that the state's directive here strengthens your case but i'm not sure your case depends upon it i had understood you to be arguing not only that we went when we look at all of these methods of proof of multiple incidents that are similar with a failure to respond to them an explicit policy the failure to respond to the directive here we also have it seems to me the supreme court has told us for example in canton against terror so far we're against brennan that a danger can be so obvious and so serious that the state actor going to his case horizon just has an obligation to deal with it and i doubt i  understood you to be saying that even without the state department of corrections directive for medical care particularly with aging prison populations the problem of cot chronic as a policy or other policy which was not in writing anywhere and the policy they were talking about would have ben if they'd follow that mr gleason would probably be alright so my belief is that that's one reason the other one isn't that there's a that he got that you didn't see evidence of that if the qur'an didn't have their own individual treatment plan or they had demonstrated an individual treatment plan or dated plan even if it wasn't writing then we wouldn't be here but they did not do any of that so you meant  say you know when somebody is giving him one medication not knowing you know what the other treatment has been leading up to that that you were necessarily accusing bad doctor but then with nobody able to  back and look at the full picture i thought that was all you were saying that none of the doctors in another itself did anything wrong but that's what i was saying that if you go so the entire thirty nine days each of those doctors was doing something of their discipline suggested they needed to do a get the history so you know how to come up with a treatment plan i'd suggest that's right for one difference or at least that's an argument we can make to to a jury but we have to go by summary judgment in the burden under somebody's judgment is just to show that there are material at issue is a fact which ok well let's see if we need to worry about that now i think this case really presents a question of whether medical care that's provided in the present context that the start with i suspect a lot of common ground about what the law now said it's not a case that was decided yesterday so the question is whether you know whether one can speak sensibly of a policy when somebody has decided to take what i was calling kind of a less a fair point of view and not all policies would be vulnerable to a charge of  indifference but whether there is if that step could be taken whether in the medical setting of our c not to have one coordinating physician is something at least for the chronically ill and i gather this case is limited to that set of people is something that could be branded deliberately in different approach i'd like to try to answer that question in two ways pro choice to take a question as you phrased it as  s i mean i guess maybe there's a disputed issue of fact about you added some information in your response to that titian for rehearing that i had not seen in the record before that but why isn't it if you if you go seven years and you say we're you know we just don't think it's necessary we don't want to have a policy on coordination of care why isn't that a conscious decision is it was an accident could stand fast just sort of never read the chose to do things i guess like the b b c you are into the race because i believe the way that you were couch in the question is itself not supported by the record i don't think that the record supports the conclusion that there was a failure to following through on what you just said at a trial and we don't know what the outcome of a trial would be but why isn't there evidence in this record starting with the answer to the iraq retore which that an admission that a particular directive such as you know here's how you need to manage the chronically ill you said you're not following it maybe because you didn't think you needed to i mean again i'm worried an early stage of this chronically ill have one person responsible for a plan and directive actually seems quite sensible to me even though it's not not really what we're discussing here more interestingly the directive itself doesn't make a single person be responsible all the time i mean sometimes bedell deterioration is purely a mental illness sometimes it's physical his what shows up in this record is that he's got some really serious problems people not enough  seem to involve the kind of however it gets done through electronic mechanisms through a single person through through an administrator and through however it gets done there was no sure every person here is but it is so we need to see though is the way this company see a mask arise and whatever them to call them running their delivery of medical services the chronically ill something that is consciously indifferent to the outcomes for these chronically ill people uncoordinated not the kind of carried would suggests that there was a conscious decision not to bother to have any coordination now let me ask you the same question i ask for your to your adversary forget prisons for a moment look at america's top teaching hospitals do we know when they adopted a principle that there would be a central coordinator of care for patients i did answer that question from a serious perspective you is do we know what the consequence of this policy is and let me make it clear the significance of this for you supposed hospitals have adopted such policies and suppose they adopted them in the nineteen eighties and then studied them and then suppose you discover that when there's a cycle coordinator of care patients we have twice as long as they do when there is not a central coordinator when your client then says we're not having central coordinators well one could draw a logical  really wish is that these people would die as quickly as possible the other possibility is that they were adopted and there been studies and they don't have big benefits that your client has decided well you know there are these studies  don't look like there are benefits we're not adopting and then it would be extraordinarily difficult to infer that this was done to punish them to punish the patients compared to people outside so it would really help i think to know the answers to these questions and the fact that the lawyers for both sides don't have any information on them as well disappointing i agree with you it's a record is devoid of that sort of information  cases because there just a lot of people in prison in our society and that counts for indiana and illinois and wisconsin as well so coming to some clear understanding of where the provider totally lost why would it matter that there were or not others and your client has to make a decision we either will or won't have a perp a shrink coordinator for medical care in prison now the decision to have one is a policy decision not to have one is a policy and then we can argue about whether that policy which ever really is violates the at the moment but it's very hard to see how you can argue that it's not a policy to i think  complain about something and internist says well for this particular ailment you have to go or see x without without being able to get information like that from your principal you know treatment physician you would wander lost right you would know what to do then you would have a real risk of negative interactions of treatment you know something whether they were drugs or whether they were other therapy so actually on the outside i couldn't you know in any authoritative way answered register brock's question in which hamilton said about the fact that at least in indiana department of corrections that for at least seven years it's been thought that some sort of i don't personally know that they gather i don't know what it is to put it in a radical way if we were to go to the website of the indiana department of corrections and look at the personnel could we discover the name of somebody who actually has an m is it one of the people in the leadership or somewhere in the department i believe the answer is yes but there was at least one possibly milor again not providing care to the status and the difference between a policy person and since we're asking about personnel  multiple elements and that's determined there are listed now the question is how does he decide when he whom he goes kill when he has particular symptoms so he is and when he's responded to just voters question once you get past the nurses you go to a contract arrangement and you're talk about retail things and and so forth that's all on and under a taking this was a fair approach we're just going to let the individual doctors deal with patients as they confront them that that would certainly looks like a choice to take that approach seems to be a pretty effective wa prison context fail to provide adequate medical and nursing care then that concern will not be interfered with that this court upholds summary judgment on the mono claim because you want to rely upon state malpractise remedies i understand that but states have great flexibility in the way they frame medical malpractise law dinner are different it is was said earlier there are different remedies available different types of damages there caps on damages under indiana law you know that have been historically pretty low down on in so that's not really an answer to the constitutional question about whether part of the posse also include those people in county jails we're talking about i think the question was here in this case as i understand it is a heat up directed a seven year gap and then there's probably nothing in between i think i was addressing judge  there is no direct evidence of this there are other cases spread we're saying that it is compared to the training cases where it's foreseeable that this is an obvious medical problem and it is an obvious medical problem according to our expert dr summers i mean if you if you look at the thomas case or the davis case they had experts talking about why you need policies why you need to address  systematic way and failure to do that can lead to serious harm or even bath so and this case there was no effort made to coordinate the care and to answer your question judge there are eighty