Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca7-15-01419/USCOURTS-ca7-15-01419-1/pdf.json

Nature of Suit Code: 440
Nature of Suit: Other Civil Rights
Cause of Action: 

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In the 

United States Court of Appeals 

For the Seventh Circuit ____________________ 

No. 15-1419 

ALMA GLISSON, Personal Representative 

of the Estate of NICHOLAS L. GLISSON, 

Plaintiff-Appellant, 

v.

INDIANA DEPARTMENT OF CORRECTIONS, et al., 

Defendants-Appellees. 

____________________ 

Appeal from the United States District Court for the 

Southern District of Indiana, Indianapolis Division. 

No. 1:12-cv-1418-SEB-MJD — Sarah Evans Barker, Judge. 

____________________ 

ARGUED SEPTEMBER 7, 2016 — DECIDED FEBRUARY 21, 2017 

____________________ 

Before WOOD, Chief Judge, and BAUER, POSNER, FLAUM,

EASTERBROOK, KANNE, ROVNER, WILLIAMS, SYKES, and 

HAMILTON, Circuit Judges. 

WOOD, Chief Judge. Nicholas Glisson entered the custody 

of the Indiana Department of Corrections on September 3, 

2010, upon being sentenced for dealing in a controlled substance (selling one prescription pill to a friend who turned out 

to be a confidential informant). Thirty-seven days later, he 

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2 No. 15-1419 

was dead from starvation, acute renal failure, and associated 

conditions. His mother, Alma Glisson, brought this lawsuit 

under 42 U.S.C. § 1983. She asserts that the medical care Glisson received at the hands of the Department’s chosen provider, Correctional Medical Services, Inc. (known as Corizon) 

violated his rights under the Eighth Amendment to the U.S. 

Constitution (made applicable to the states by the Fourteenth 

Amendment). A panel of this court concluded that Corizon 

was entitled to summary judgment in its favor. See Glisson v. 

Indiana Dep’t of Corr., 813 F.3d 662 (7th Cir. 2016). The court 

decided to rehear the case en banc in order to examine the 

standards for corporate liability in such a case. We conclude 

that Glisson presented enough evidence of disputed, material 

issues of fact to proceed to trial, and we therefore reverse the 

district court’s judgment. 

I

There is no doubt that Glisson had long suffered from serious health problems. He had been diagnosed with laryngeal 

cancer in 2003. In October of that year, he had radical surgery 

in which his larynx and part of his pharynx were removed, 

along with portions of his mandible (jawbone) and 13 teeth. 

He was left with a permanent stoma (that is, an opening in his 

throat), into which a tracheostomy tube was normally inserted. He needed a voice prosthesis to speak. 

And that was not all. Glisson’s 2003 surgery and follow-up 

radiation left his neck too weak to support his head; this in 

turn made his head slump forward in a way that impeded his 

breathing. Because physical therapy and medication for this 

condition were ineffective, he wore a neck brace. He also developed cervical spine damage. In 2008 doctors placed a gastrojejunostomy tube (“G-tube”) in his upper abdomen for 

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No. 15-1419 3

supplemental feeding. In addition to the problems attributable to the cancer, Glisson suffered from hypothyroidism, depression, and impairments resulting from his smoking and 

excessive alcohol use. Finally, there was some evidence of cognitive decline. 

Despite all this, Glisson was able to live independently. He 

learned to clean and suction his stoma. With occasional help 

from his mother, he was able to use his feeding tube when 

necessary. He was able to swallow well enough to take his 

food and other supplements by mouth most of the time. His 

hygiene was fine, and he helped with household chores such 

as mowing the lawn, cleaning, and cooking. He also provided 

care to his grandmother and his dying brother. 

The events leading up to Glisson’s death began when a 

friend, acting as a confidential informant for the police, convinced Glisson to give the friend a prescription painkiller.1

Glisson was charged and convicted for this infraction, and on 

August 31, 2010, he was sentenced to a period of incarceration 

and transferred to the Wayne County Jail. (All relevant dates 

from this point onward were in 2010.) Before sentencing, Dr. 

Richard Borrowdale, one of his physicians, wrote a letter to 

the court expressing serious concern about Glisson’s ability to 

survive in a prison setting. Dr. Borrowdale noted Glisson’s se-

 

1 It is not entirely clear from the record on appeal when this offense 

took place. Glisson’s arrest record indicates that he was arrested for dealing in a controlled substance on July 31, 2007, and was released the same 

day on a $25,000 bond. The next entry is on August 31, 2010—the day he 

was sentenced and entered custody. The sentencing information sheet 

gives him one day’s credit for jail time. It thus appears that the incarceration at issue in this case was based on this three-year-old arrest. 

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vere disabilities from cancer and alcohol dependence, his difficulty speaking because of the laryngectomy, his trouble 

swallowing, his severe curvature of the spine (kyphosis), and 

his problems walking. The conclusion of the letter was, unfortunately, prophetic: “This patient is severely disabled, and I 

do not feel that he would survive if he was incarcerated.” Dr. 

William Fisher, another of Glisson’s physicians, also warned 

that Glisson “would not do well if incarcerated.” 

Many of Glisson’s disabilities were apparent at a glance, 

and his family tried to prepare him (and his custodians) for 

his incarceration. They brought his essential supplies, including his neck brace and the suction machine, mirror, and light 

that he used for his tracheostomy, to the Jail. When he was 

transferred on September 3 to the Reception Diagnostic Center of the Indiana Department of Corrections (“INDOC”), the 

Jail sent along his mirror, light, and neck brace. It is unclear 

what happened next to these items, but Glisson never received the neck brace, nor was he given a replacement. 

At INDOC’s Diagnostic Center, Glisson first came under 

Corizon’s care, when upon his arrival Nurse Tim Sanford assessed his condition. Sanford recorded Glisson’s account of 

his medication regimen and noted that Glisson appeared to 

be alert and able to communicate. Sanford noted that Glisson 

had a tracheostomy that had to be suctioned six times a day, 

and that Glisson had a feeding tube but that he took food 

through it only when he had difficulty swallowing. While 

Glisson was at the Diagnostic Center, medical personnel 

noted occasional problems with his blood pressure, pulse, 

and oxygen saturation level, as well as some signs of confusion and anger. 

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No. 15-1419 5

Several different medical providers saw Glisson while he 

was at the Diagnostic Center: Drs. Jill Gallien and Steven Conant (a psychiatrist); Nurses Rachel Johnson, Carla DeWalt, 

and Victoria Crawford; and mental health counselor Mary 

Serna. In addition, Health Services Administrator Kelly Kurtz 

contacted Glisson’s mother to ask about his medical history 

and his behavior at home. Her inquiry was the only one that 

occurred throughout Glisson’s incarceration, and there is no 

evidence that Mrs. Glisson’s response (that Glisson did not behave oddly at home) was communicated to anyone else. 

Ultimately the Diagnostic Center decided to place Glisson 

in INDOC’s Plainfield Correctional Facility. Glisson was 

transferred there on September 17; an intake examination performed by Licensed Practical Nurse (LPN) Nikki Robinson revealed that he weighed 119 pounds and had normal vital 

signs. On September 21, Dr. James Mozillo ordered Glisson to 

be placed in the general population with a bottom-bunk pass. 

Upon reaching Plainfield, Glisson’s medical care—again 

furnished by Corizon—began to resemble the blind men’s description of the elephant. A host of Corizon providers at Plainfield had a hand in Glisson’s treatment. As far as we can glean 

from the record, they include the following: Drs. Malak Hermina (the lead physician at Plainfield), Mozillo, and Conant 

(again); Director of Nursing Rhonda Kessler; Registered 

Nurses (RNs) Mary Combs, Carol A. Griffin, Melissa Pearson, 

and Jennifer Hoffmeyer; LPNs Robinson, Allison M. Ortiz, 

and Paula J. Kuria; and mental health professional Catherine 

Keefer. Andy Dunnigan, Plainfield’s Health Services Administrator, also played some part. We assume for the sake of argument here that none of these people, and none of the indiCase: 15-1419 Document: 55 Filed: 02/21/2017 Pages: 36
6 No. 15-1419 

vidual providers at the Diagnostic Center, personally did anything that would qualify as “deliberate indifference” for 

Eighth Amendment purposes. Most of them had so little to do 

with Glisson that such a conclusion is quite unlikely. The 

question before us is instead whether, because of a deliberate 

policy choice pursuant to which no one was responsible for 

coordinating his overall care, Corizon itself violated Glisson’s 

Eighth Amendment rights. 

Predictably, given the number of actors, Glisson’s care over 

the first few weeks of his residence at Plainfield was disjointed: no provider developed a medical treatment plan, and 

thus no one was able to check Glisson’s progress against any 

such plan. In fact, for his first 24 days in INDOC custody (including the time at the Diagnostic Center), no Corizon provider even reviewed his medical history. Granted, before Glisson arrived at Plainfield, Dr. Gallien had requested his medical history on September 10. But there is no evidence that anyone responded to this request. Indeed, no one at the Center 

followed up, nor did anyone at Plainfield do anything until 

September 27, when Dr. Hermina saw Glisson and asked for 

the records; he received them within several hours. 

At that visit, Dr. Hermina made an alarming observation 

about Glisson’s weight. As we noted, when Glisson arrived at 

Plainfield he weighed only 119 pounds. On September 27, Dr. 

Hermina noted that Glisson appeared cachectic, which means 

undernourished to the point that the person has physical 

wasting and loss of weight and muscle mass—in a word, he 

is starving. See MedicineNet, Definition of Cachectic, http://www.medicinenet.com/script/main/art.asp?articlekey=40464 (last visited on February 21, as were all websites 

cited in this opinion). Although the medical personnel at the 

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Diagnostic Center had ordered the nutritional supplement 

Ensure for Glisson, and apparently that order carried over to 

Plainfield, Dr. Hermina ordered a second nutritional supplement, Jevity. Remarkably, it appears that he did not weigh 

Glisson—at least, there is no record of a September 27 weight. 

He did, however, review Glisson’s earlier lab work, which 

showed anemia and high creatinine (a sign of impaired kidney function). Later that day, Dr. Hermina reviewed the medical records he had just received and learned that Glisson suffered from (among other things) kyphosis and back pain (for 

which he was treated with the opioids OxyContin and Oxycodone), gastroparesis (partial paralysis of the stomach), neck 

pain, and several mental conditions (depression, poor 

memory, mild cognitive decline). 

As time went on, along with the physical problems of cachexia, renal decline, and neck weakness (in part attributable 

to the fact that no one ever gave him his neck brace), Glisson’s 

mental status was deteriorating. Dr. Hermina wondered if 

Glisson belonged in the psychiatric unit at a different prison, 

but he displayed no awareness of the fact that Dr. Conant had 

just conducted a mental-health evaluation on Glisson on September 23. Dr. Conant’s findings were worrying, but no one 

connected them with any of the physical data on file, such as 

Glisson’s tendency to have inadequate oxygen profusion and 

his cachexia. Dr. Conant found that Glisson was restless, paranoid, delusional, hallucinating, and insomniac. He placed 

Glisson under close observation and settled on a diagnosis of 

unspecified psychosis; he saw no need for medication. (This 

too is odd: Glisson was actually already on psychotropic medications; while at Plainfield he was abruptly switched from 

Effexor to Prozac without any evaluation, weaning, or monitoring. The two drugs work quite differently, and Dr. Diane 

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Sommer, the expert retained by Glisson’s estate, concluded 

that “[t]his abrupt change in medication contributed to [Glisson’s] acute decline in function.”) 

Had Dr. Conant looked at something resembling a complete chart, he would have seen that Glisson had no history 

of psychosis, and he might have considered, as the post-mortem experts did, the more obvious possibility that lack of oxygen and food was affecting Glisson’s mental performance. 

Dr. Conant noted that Glisson had been experiencing hallucinations, which the doctor thought were caused by morphine. 

This observation was reached in an information vacuum. In 

fact, as the medical records Dr. Hermina reviewed just days 

later show, Glisson had been on narcotic medication without 

adverse effects for quite a while prior to his incarceration. 

Had Dr. Conant known of Glisson’s medical history, he would 

have known that morphine was an unlikely cause for the hallucinations and he would have looked further. 

The Corizon providers never took any steps to integrate 

the growing body of evidence of Glisson’s malnutrition with 

his overall mental and physical health. The physical signs 

were clear even before he arrived at Plainfield. On September 

4, Glisson’s urinalysis results showed the presence of ketones 

and leukocytes. Dr. Sommer’s report notes that 

“[k]etones suggest the presence of other medical conditions 

such as anorexia, starvation, acute or severe illness and hyperthyroidism to name a few.” The Corizon staff at the Diagnostic Center did nothing to address either potential problem, 

even though a second urine sample taken on September 5 

showed an increase in ketones and leukocytes. No physician 

reviewed either of those lab results, despite the fact that a note 

dated September 5 says that Glisson was not eating and 

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No. 15-1419 9

seemed confused. Rather than probing the signs of infection, 

starvation, and dehydration further, the staff opted to put 

Glisson in the psychiatric unit under suicide watch. 

The blood work at the Center continued to raise red flags. 

On September 9, it came back with signs of abnormal renal 

function. Although Glisson met with Dr. Gallien the next day, 

no one looked at the bloodwork until ten days after Glisson’s 

transfer to Plainfield, at his September 27 visit with Dr. Hermina. At that point, Dr. Hermina ordered fasting labs for September 28. When the results were returned on September 29, 

they showed acute renal failure—information that prompted 

Dr. Hermina to send Glisson immediately to Wishard Hospital. Taking the facts favorably to Glisson, the record indicates 

that he was already slipping into renal distress as early as September 4 or 9, and that the uncoordinated care Corizon furnished was a central cause for the increasing acuteness of his 

condition. 

Glisson was discharged from Wishard and returned to 

Plainfield shortly after midnight on October 7. The discharge 

summary included the following diagnoses: 

x Acute renal failure/acidosis/hyperkalemia on top of 

chronic kidney disease 

x Acute respiratory insufficiency/pneumonia 

x Tracheoesophageal voice prosthesis replacement 

x Hypothyroidism 

x Malnutrition 

x Squamous cell carcinoma of left lateral tongue 

x Hypertension 

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x Chronic pain 

x Dementia/psychological disorder/depression 

x Pressure wound on the sacrum 

The morning after Glisson’s return, Dr. Hermina saw him and 

reviewed the Wishard summary. He ordered the continuation 

of the medications prescribed at Wishard. RN Griffin saw him 

later that day, and the next day both Dr. Hermina and several 

nurses saw him. LPN Ortiz noted that he did not eat any of 

his breakfast. In fact, Dr. Hermina had ordered G-tube feeding only (which does not seem to have happened), and so it is 

not clear why he had a tray. 

On October 10, around 6:00 a.m., RN Combs was told that 

Glisson had been wandering about in a disoriented way. She 

tried to talk to him, but he apparently did not understand her. 

At 8:30 a.m., the staff notified RN Combs that Glisson was not 

moving and that there seemed to be blood in his bed. She 

found him unresponsive and called 911. The emergency team 

responded, and he was pronounced dead at 8:35 a.m. 

The county coroner, Joseph Neuman, concluded that the 

cause of Glisson’s death was complications from laryngeal 

cancer, with contributory chronic renal disease. He also observed that Glisson had extreme emaciation and cachexia. He 

then asked Dr. Steven Radentz, a forensic pathologist, to render a more detailed opinion. Dr. Radentz agreed with Neuman’s overall assessment and added that Glisson’s rapid-onset altered mental state could have resulted from hypoxia (insufficient oxygen saturation) and acute renal failure. Complications from laryngeal cancer include, Dr. Radentz said, aspiration pneumonia, acute renal failure, and hyperkalemia (elevated blood potassium, which can lead to cardiac arrest, see 

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MedicineNet, Definition of Hyperkalemia, http://www.medicinenet.com/hyperkalemia/article.htm). 

II

Alma Glisson filed this suit in state court in her capacity 

as Personal Representative of Glisson’s Estate. She raised 

claims under both state law and 42 U.S.C. § 1983 against several of the doctors and nurses who were involved in Glisson’s 

care, against INDOC, and against Corizon. The district court 

granted summary judgment in favor of the defendants on all 

of her federal claims, and it remanded the state-law claims to 

the state court. See Glisson v. Indiana Dep’t of Corr., No. 1:12-

cv-1418-SEB-MJD, 2014 WL 2511579 (S.D. Ind. June 4, 2014). 

On appeal, Mrs. Glisson has limited her arguments to her 

claim against Corizon. As noted earlier, a panel of this court 

ruled that Mrs. Glisson failed to present enough evidence to 

defeat summary judgment in Corizon’s favor. That conclusion 

rested on both a legal conclusion about what it takes to find 

an entity such as Corizon liable, as well as the characterization 

of the facts in the summary judgment record. 

It is somewhat unusual to see an Eighth Amendment case 

relating to medical care in a prison in which the plaintiff does 

not argue that the individual medical provider was deliberately indifferent to a serious medical need. See Estelle v. Gamble, 429 U.S. 97 (1976); Farmer v. Brennan, 511 U.S. 825 (1994). 

But unusual does not mean impossible, and this case well illustrates why an organization might be liable even if its individual agents are not. Without the full picture, each person 

might think that her decisions were an appropriate response 

to a problem; her failure to situate the care within a broader 

context could be at worst negligent, or even grossly negligent, 

but not deliberately indifferent. But if institutional policies are 

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themselves deliberately indifferent to the quality of care provided, institutional liability is possible. 

Ever since the Supreme Court decided Monell v. New York 

City Dep’t of Soc. Servs., 436 U.S. 658 (1978), the availability of 

entity liability under section 1983 has been established. This 

rule is not limited to municipal corporations, although that 

was the type of entity involved in Monell itself. As we and our 

sister circuits recognize, a private corporation that has contracted to provide essential government services is subject to 

at least the same rules that apply to public entities. See, e.g., 

Shields v. Illinois Dep’t of Corr., 746 F.3d 782, 789–90 (7th Cir. 

2014); Iskander v. Vill. of Forest Park, 690 F.2d 126, 128 (7th Cir. 

1982); Rojas v. Alexander’s Dep’t Store, Inc., 924 F.2d 406, 408–

09 (2d Cir. 1990); Harvey v. Harvey, 949 F.2d 1127, 1129–30 (11th 

Cir. 1992) (citing cases); Street v. Corr. Corp. of Am., 102 F.3d 

810, 818 (6th Cir. 1996). (We questioned in Shields whether private corporations might also be subject to respondeat superior 

liability, unlike their public counterparts, see 746 F.3d at 790–

92, but we have no need in the present case to address that 

question and we thus leave it for another day.) 

The critical question under Monell, reaffirmed in Los Angeles Cnty. v. Humphries, 562 U.S. 29 (2010), is whether a municipal (or corporate) policy or custom gave rise to the harm (that 

is, caused it), or if instead the harm resulted from the acts of 

the entity’s agents. There are several ways in which a plaintiff 

might prove this essential element. First, she might show that 

“the action that is alleged to be unconstitutional implements 

or executes a policy statement, ordinance, regulation, or decision officially adopted and promulgated by that body’s officers.” Humphries, 562 U.S. at 35 (quoting Monell, 436 U.S. at 

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No. 15-1419 13

690). Second, she might prove that the “constitutional deprivation[] [was] visited pursuant to governmental ‘custom’ 

even though such a custom has not received formal approval 

through the body’s official decisionmaking channels.” Monell, 

436 U.S. at 690–91. Third, the plaintiff might be able to show 

that a government’s policy or custom is “made ... by those 

whose edicts or acts may fairly be said to represent official 

policy.” Id. at 694. As we put the point in one case, “[a] person 

who wants to impose liability on a municipality for a constitutional tort must show that the tort was committed (that is, 

authorized or directed) at the policymaking level of government ... .” Vodak v. City of Chicago, 639 F.3d 738, 747 (7th Cir. 

2011). Either the content of an official policy, a decision by a 

final decisionmaker, or evidence of custom will suffice. 

The central question is always whether an official policy, 

however expressed (and we have no reason to think that the 

list in Monell is exclusive), caused the constitutional deprivation. It does not matter if the policy was duly enacted or written down, nor does it matter if the policy counsels aggressive 

intervention into a particular matter or a hands-off approach. 

One could easily imagine either kind of strategy for a police 

department: one department might follow a policy of zerotolerance for low-level drug activity in a particular area, arresting every small-time seller; while another department 

might follow a policy of by-passing the lower-level actors in 

favor of a focus on the kingpins. The hands-off policy is just 

as much a “policy” as the 100% enforcement policy is. 

Mrs. Glisson asserts that Corizon had a deliberate policy 

not to require any kind of formal coordination of medical care 

either within an institution (such as the Diagnostic Center or 

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14 No. 15-1419 

Plainfield) or across institutions for prisoners who are transferred. This is not the same as an allegation that Corizon was 

oblivious to the entire issue of care coordination. Read fairly, 

she is saying that Corizon consciously decided not to include 

this service, not that it had never thought about the issue and 

thus had nothing that could be called a policy. 

In some cases, it may be difficult to tell the difference between inadvertence and a policy to omit something, but on 

the facts presented by Mrs. Glisson, this is not one of them. 

INDOC has Chronic Disease Intervention Guidelines, which 

explain what policies its health-care providers are required to 

implement. Healthcare Directive HCSD-2.06 states that each 

facility must adopt instructions for proper management of 

chronic diseases, and it spells out what those instructions 

should address. Among other things, it calls for “planned care 

in a continuous fashion” and care that is “organized and ... 

consistent across facility lines.” It specifically mandates a 

treatment plan for chronic cases—both an initial plan and one 

that is updated as care needs change. In the face of this directive, which appeared seven years before Glisson showed up 

in prison, Corizon consciously chose not to adopt the recommended policies—not for Glisson, not for anyone. As relevant 

to Glisson’s case, it admitted that his care at INDOC was 

based only on general standards of medical and nursing care, 

not on any “written policies, procedures, or protocols.” It relied on none of the Health Care Service Directives in the 

course of his treatment. 

That in itself, of course, does not describe an Eighth 

Amendment violation. Nothing in the U.S. Constitution required Corizon to follow INDOC’s policies. The point is a 

more subtle one: the existence of the INDOC Guidelines, with 

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No. 15-1419 15

which Corizon was admittedly familiar, is evidence that could 

persuade a trier of fact that Corizon consciously chose the approach that it took. That approach itself may or may not have 

led to a constitutional violation. Suppose, for instance, that 

the state guidelines call for a primary-care physician to coordinate all care, both basic and specialized, and a company 

such as Corizon decides to ignore the guidelines and instead 

to hire hospitalists to coordinate care. This would represent a 

conscious policy choice, but in all likelihood one that does not 

violate any inmate’s constitutional rights. Moving closer to 

the facts of this case, it is also possible that a health-care provider’s deliberate policy choice not to implement the state’s 

guidelines does not lead to dire results. Some guidelines may 

be foolish or ineffective. A decision not to implement them 

would be a deliberate policy choice, but in such a case not one 

that gave rise to an Eighth Amendment violation. 

Other courts have endorsed the distinction we are drawing in their decisions. For example, in Long v. Cnty. of Los Angeles, 442 F.3d 1178 (9th Cir. 2006), an elderly man reported to 

the county jail to begin serving a 120-day sentence. At that 

time, as his attorney informed the Director of the Jail Medical 

Services Division, he weighed more than 350 pounds and was 

suffering from congestive heart failure (among other ailments). He had been under the care of a doctor affiliated with 

the Department of Veterans Affairs. During the ensuing 18 

days, he received uncoordinated and inadequate care, was ultimately transferred to a hospital by ambulance, but died 14 

hours later. The district court granted summary judgment for 

the county, but the Ninth Circuit reversed. It began by acknowledging that “[a] policy can be one of action or inaction.” 

Id. at 1185. The plaintiff (the decedent’s widow) attacked the 

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county’s “policies of inaction in the following areas: (1) its failure adequately to train MSB medical staff, and (2) an absence 

of adequate general policies to guide the medical staff’s exercise of its professionally-informed discretion.” Id. at 1190. 

With respect to the second ground, the court held that there 

was a triable issue on whether the county’s failure to implement several policies amounted to deliberate indifference. Id. 

The Third Circuit also encountered a similar case and resolved it in favor of the plaintiff: Natale v. Camden Cnty. Corr. 

Facility, 318 F.3d 575 (3d Cir. 2003). In that case a diabetic inmate brought a Monell suit in which he asserted that he suffered a stroke because New Jersey’s Prison Health Service 

failed to provide him with insulin. Addressing Natale’s claim 

against the Health Service itself, the court began with the 

common observation that “the Natales must provide evidence that there was a relevant PHS policy or custom, and 

that the policy caused the constitutional violation they allege.” Id. at 583–84. It then recalled this point from City of Canton, Ohio v. Harris, 489 U.S. 378 (1989): 

But it may happen that in light of the duties assigned to specific officers or employees the need 

for more or different training is so obvious, and 

the inadequacy so likely to result in the violation of constitutional rights, that the policymakers of the city can reasonably be said to have 

been deliberately indifferent to the need. In that 

event, the failure to provide proper training 

may fairly be said to represent a policy for 

which the city is responsible, and for which the 

city may be held liable if it actually causes injury. 

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Id. at 390. The Third Circuit applied that principle to the facts 

before it and concluded that “[a] reasonable jury could conclude that the failure to establish a policy to address the immediate medication needs of inmates with serious medical 

conditions creates a risk that is sufficiently obvious as to constitute deliberate indifference to those inmates’ medical 

needs.” Natale, 318 F.3d at 585; see also Warren v. District of 

Columbia, 353 F.3d 36, 39 (D.C. Cir. 2004) (ex-prisoner stated 

claim in Monell suit alleging that the District’s policy or custom caused constitutional violations in prison conditions and 

medical care; “faced with actual or constructive knowledge 

that its agents will probably violate constitutional rights, the 

city may not adopt a policy of inaction”). 

We are not breaking new ground in this area; to the contrary, this court has recognized these principles for years. In 

Sims v. Mulcahy, 902 F.2d 524 (7th Cir. 1990), we observed that 

“in situations that call for procedures, rules or regulations, the 

failure to make policy itself may be actionable.” Id. at 543 (citing Avery v. Cnty. of Burke, 660 F.2d 111, 114 (4th Cir. 1981); 

Murray v. City of Chicago, 634 F.2d 365, 366–67 (7th Cir. 1980)). 

In the same vein, we said in Thomas v. Cook Cnty. Sheriff’s Dep’t, 

604 F.3d 293 (7th Cir. 2010), that “in situations where rules or 

regulations are required to remedy a potentially dangerous 

practice, the County’s failure to make a policy is also actionable.” Id. at 303; see also King v. Kramer, 680 F.3d 1013, 1021 (7th 

Cir. 2012) (where municipality has “actual or constructive 

knowledge that its agents will probably violate constitutional 

rights, it may not adopt a policy of inaction”). 

Notably, neither the Supreme Court in Harris, nor the 

Ninth Circuit, nor the Third Circuit, said that institutional liCase: 15-1419 Document: 55 Filed: 02/21/2017 Pages: 36
18 No. 15-1419 

ability was possible only if the record reflected numerous examples of the constitutional violation in question. The key is 

whether there is a conscious decision not to take action. That 

can be proven in a number of ways, including but not limited 

to repeated actions. A single memo or decision showing that 

the choice not to act is deliberate could also be enough. The 

critical question under Monell remains this: is the action about 

which the plaintiff is complaining one of the institution itself, 

or is it merely one undertaken by a subordinate actor? 

We reiterate that the question whether Corizon had a policy to eschew any way of coordinating care is not the only 

hurdle plaintiff faces: she must also prove that the approach 

Corizon took violated her son’s constitutional rights. At trial, 

there is no reason why Corizon would not be entitled to introduce evidence of its track record, if it believes that this evidence will vindicate its decision not to follow the INDOC 

guidelines. (If it does so, it presumably would also have to 

face less flattering news about its record. See, e.g., David 

Royse, “Medical battle behind bars: Big prison healthcare firm 

Corizon struggles to win contracts,” Modern Healthcare, 

April 11, 2015, at http://www.modernhealthcare.com/article/20150411/MAGAZINE/304119981; Matt Stroud, “Why 

Are Prisoners Dying in County Jail?” Bloomberg, June 2, 2015, 

at https://www.bloomberg.com/news/articles/2015-06-

02/why-are-prisoners-dying-in-county-jail-. That issue, like 

the others we have identified, must await development at a 

trial.) 

One does not need to be an expert to know that complex, 

chronic illness requires comprehensive and coordinated care. 

In Harris, the Court recognized that because it is a “moral certainty” that police officers “will be required to arrest fleeing 

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No. 15-1419 19

felons,” “the need to train officers in the constitutional limitations on the use of deadly force ... can be said to be ‘so obvious,’ that failure to do so could properly be characterized as 

‘deliberate indifference’ to constitutional rights.” 489 U.S. at 

390 n. 10. A jury could find that it was just as certain that Corizon providers would be confronted with patients 

with chronic illnesses, and that the need to establish protocols 

for the coordinated care of chronic illnesses is obvious. And 

in the final analysis, if a jury reasonably could find that Corizon’s “policymakers ... [were] deliberately indifferent to the 

need” for such protocols, and that the absence of protocols 

caused Glisson’s death. Id. at 390. 

A jury could further conclude that Corizon had actual 

knowledge that, without protocols for coordinated, comprehensive treatment, the constitutional rights of chronically ill 

inmates would sometimes be violated, and in the face of that 

knowledge it nonetheless “adopt[ed] a policy of inaction.” Kramer, 680 F.3d at 1021. Finally, that jury could conclude that Corizon, indifferent to the serious risk such a 

course posed to chronically ill inmates, made “a deliberate 

choice to follow a course of action ... from among various alternatives” to do nothing. Harris, 489 U.S. at 389. Monell requires no more. 

In closing, we reiterate that we are not holding that the 

Constitution or any other source of federal law required Corizon to adopt the Directives or any other particular document. 

But the Constitution does require it to ensure that a well-recognized risk for a defined class of prisoners not be deliberately left to happenstance. Corizon had notice of the problems 

posed by a total lack of coordination. Yet despite that 

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20 No. 15-1419 

knowledge, it did nothing for more than seven years to address that risk. There is no magic number of injuries that must 

occur before its failure to act can be considered deliberately 

indifferent. See Woodward v. Corr. Med. Servs., 368 F.3d 917, 929 

(7th Cir. 2004) (“CMS does not get a ‘one free suicide’ pass.”). 

Nicholas Glisson may not have been destined to live a long 

life, but he was managing his difficult medical situation successfully until he fell into the hands of the Indiana prison system and its medical-care provider, Corizon. Thirty-seven days 

after he entered custody and came under Corizon’s care, he 

was dead. On this record, a jury could find that Corizon’s decision not to enact centralized treatment protocols for chronically ill inmates led directly to his death. The judgment of the 

district court is REVERSED and the case is REMANDED for further proceedings consistent with this opinion. 

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No. 15-1419 21

SYKES, Circuit Judge, with whom BAUER, FLAUM, and 

KANNE, Circuit Judges, join, dissenting. Today the court 

endorses Monell liability without evidence of corporate fault 

or causation. That contradicts long-settled principles of 

municipal liability under § 1983. The doctrinal shift is subtle 

but significant. The court rests its decision on the conceptual 

idea that a gap in official policy can sometimes be treated as 

an actual policy for purposes of municipal liability under 

Monell v. Department of Social Services, 436 U.S. 658 (1978). I 

have no quarrel with that as a theoretical matter. A municipality’s failure to have a formal policy in place on a particular subject may represent its intentional decision not to have 

such a policy—that is, a policy not to have a policy—and that 

institutional choice may in appropriate circumstances form 

the basis of a Monell claim. The Supreme Court’s cases, and 

ours, leave room for this theory of institutional liability 

under § 1983. 

But identifying an official policy is just the first step in 

Monell analysis; it is not the whole ballgame. Evidence of an 

official policy or custom is a necessary but not sufficient 

condition to advance a Monell claim to trial. The plaintiff also 

must adduce evidence on two additional elements: 

(1) institutional fault, which in this context means the municipality’s deliberate indifference to a known or obvious risk 

that its policy will likely lead to constitutional violations; 

and (2) causation. Because Monell doctrine applies to private 

corporations that contract to provide essential governmental 

services, see Shields v. Ill. Dep’t of Corr., 746 F.3d 782, 789–90 

(7th Cir. 2014); Iskander v. Village of Forest Park, 690 F.2d 126, 

128 (7th Cir. 1982), these requirements apply in full to 

Mrs. Glisson’s claim against Corizon, Indiana’s prison 

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22 No. 15-1419 

healthcare provider, for the death of her son while in state 

custody. 

But Mrs. Glisson produced no evidence to support the 

fault and causation elements of her claim. My colleagues 

identify none, yet they hold that a reasonable jury could find 

in her favor. I do not see how, without evidence on two of 

the three elements of the claim. The court’s decision thus 

materially alters Monell doctrine in this circuit. With respect, 

I cannot join it. 

To understand how the court’s decision works a change 

in the law, it’s helpful to begin with Monell itself. The familiar

holding of the case is that § 1983 provides a remedy against 

a municipality for its own constitutional torts but not those of 

its employees or agents; the statute doesn’t authorize vicarious liability under the common-law doctrine of respondeat 

superior. Monell, 436 U.S. at 691–92. 

To separate direct-liability claims from vicarious-liability 

claims, the Supreme Court announced the now-canonical 

“policy or custom” requirement: 

 Local governing bodies ... can be sued directly 

under § 1983 for monetary, declaratory, or injunctive relief where, as here, the action that is 

alleged to be unconstitutional implements or 

executes a policy statement, ordinance, regulation, or decision officially adopted and promulgated by that body’s officers. Moreover, although the touchstone of the § 1983 action 

against a government body is an allegation that 

official policy is responsible for a deprivation 

of rights protected by the Constitution, local 

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No. 15-1419 23

governments, like every other § 1983 “person,” 

by the very terms of the statute, may be sued 

for constitutional deprivations visited pursuant 

to governmental “custom” even though such a 

custom has not received formal approval 

through the body’s official decisionmaking 

channels. 

Id. at 690–91 (footnote omitted). Put more succinctly, Monell 

holds that when a plaintiff seeks to impose liability on a 

municipality under § 1983, he must have evidence that a 

municipal policy or custom—or the act of an authorized 

final policymaker, which amounts to the same thing—

actually caused his constitutional injury. 

But Monell sketched only the outlines of the doctrine; it 

took later decisions to fill in the details. Most pertinent here 

is Board of County Commissioners of Bryan County v. Brown, 

520 U.S. 397 (1997). There the Court provided a primer for 

how to apply Monell doctrine in actual practice. But first the 

Court elaborated on the rationale for the policy-or-custom 

requirement: 

Locating a “policy” ensures that a municipality 

is held liable only for those deprivations resulting from the decisions of its duly constituted 

legislative body or of those officials whose acts 

may fairly be said to be those of the municipality. Similarly, an act performed pursuant to a 

“custom” that has not been formally approved 

by an appropriate decisionmaker may fairly 

subject a municipality to liability on the theory 

that the relevant practice is so widespread as to have 

the force of law. 

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24 No. 15-1419 

Id. at 403–04 (emphasis added) (citation omitted). 

The Court made it clear, however, that identifying an official policy or widespread custom is not sufficient to support a finding of liability: 

[I]t is not enough for a § 1983 plaintiff merely 

to identify conduct properly attributable to the 

municipality. The plaintiff must also demonstrate that, through its deliberate conduct, the 

municipality was the “moving force” behind 

the injury alleged. That is, a plaintiff must show 

that the municipal action was taken with the requisite degree of culpability and must demonstrate a 

direct causal link between the municipal action and 

the deprivation of federal rights. 

Id. at 404 (second emphasis added). The culpability requirement—what I’ve referred to as “corporate fault” or “institutional fault”—must be tied to the specific alleged constitutional violation. Id. at 405. The causation element requires 

evidence that the municipality’s own action directly caused 

the constitutional injury. 

Brown involved a Monell claim by a plaintiff who was injured when a sheriff’s deputy pulled her from a car and 

forced her to the ground during an arrest after a high-speed 

chase. Id. at 400–01. The deputy had amassed a criminal 

record before joining the sheriff’s department—

misdemeanor convictions for battery, resisting arrest, and 

public drunkenness—but the sheriff hadn’t reviewed it 

closely before hiring him. Id. at 401. The injured plaintiff 

sued the county under Monell, attributing her injury to the 

sheriff’s lax hiring practices. Id.

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No. 15-1419 25

The Court rejected the claim, holding that a single instance of excessive force—the plaintiff’s own injury—wasn’t 

enough to trigger municipal liability. Id. at 415. The Court 

began by tracing Monell’s basic requirements—an express 

policy or widespread custom, municipal fault, and causation—and then explained how these elements apply in 

different types of cases. First up were the obvious cases. The 

Court explained that when a Monell claimant alleges that “a 

particular municipal action itself violates federal law, ... 

resolving ... issues of fault and causation is straightforward.” Id. at 404. “[P]roof that a municipality’s legislative 

body or authorized decisionmaker has intentionally deprived a plaintiff of a federally protected right necessarily

establishes that the municipality acted culpably.” Id. at 405 

(emphasis added). In the same way, when a legislative 

decision or an act of a final policymaker itself violates federal 

law, causation is clear and nothing more is needed; in that 

situation the act is necessarily the “moving force” behind the 

plaintiff’s injury. Id.

Most Monell claims are more complicated, however, and 

Mrs. Glisson’s claim is not in this straightforward category. 

She does not contend that Corizon’s failure to promulgate 

formal protocols for chronically ill inmates itself violated the 

Constitution. My colleagues concede the point, acknowledging that Corizon’s failure to adopt protocols for chronically 

ill inmates “does not [in itself] describe an Eighth Amendment violation.” Majority Op. at p. 15. Where, as here, the 

challenged policy or custom is not itself unlawful, something 

more is required to establish corporate culpability and 

causation. 

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26 No. 15-1419 

Helpfully, Brown contains further instructions for Monell 

claims like this one that do not rest on allegations that a 

municipal policy on its face violates federal law. This part of 

Brown begins with a warning that’s worth repeating here. 

The Court cautioned that Monell claims “not involving an 

allegation that the municipal action itself violated federal 

law ... present much more difficult problems of proof.” 

Brown, 520 U.S. at 406. Difficulties arise because claims of 

this type necessarily rest on the theory that a municipal 

policy or custom, though not itself unconstitutional, nonetheless led to constitutional torts by municipal employees 

acting in accordance with it. Monell claims in this category 

blur the line between municipal liability and respondeat 

superior liability; the Court worried that the line would 

collapse in actual practice. Id. at 407–08. To guard against 

that risk, the Court instructed the judiciary to “adhere to 

rigorous requirements of culpability and causation” when 

evaluating Monell claims of this kind. Id. at 415 (“Where a 

court fails to adhere to rigorous requirements of culpability 

and causation, municipal liability collapses into respondeat 

superior liability.”). 

More specifically, the Court held that 

a plaintiff seeking to establish municipal liability on the theory that a facially lawful municipal action has led an employee to violate a 

plaintiff’s rights must demonstrate that the municipal action was taken with deliberate indifference 

as to its known or obvious consequences. A showing of simple or even heightened negligence 

will not suffice. 

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No. 15-1419 27

Id. at 407 (emphasis added) (citation omitted) (internal 

quotation marks omitted). For this holding the Court drew 

on principles announced in its earlier decision in City of 

Canton v. Harris, 489 U.S. 378 (1989), which involved a claim 

that shift supervisors at a city jail were inadequately trained 

to recognize an inmate’s need for psychiatric intervention. 

Brown described Harris’s holding this way: 

We concluded [in Harris] that an “inadequate 

training” claim could be the basis for § 1983 liability in “limited circumstances.” [489 U.S.] at 

387. We spoke, however, of a deficient training 

“program,” necessarily intended to apply over 

time to municipal employees. Id. at 390. Existence of a “program” makes proof of fault and 

causation at least possible in an inadequate 

training case. If a program does not prevent constitutional violations, municipal decisionmakers may 

eventually be put on notice that a new program is 

called for. Their continued adherence to an approach that they know or should know has 

failed to prevent tortious conduct by employees may establish the conscious disregard for 

the consequences of their action—the “deliberate indifference”—necessary to trigger municipal liability. ... In addition, the existence of a 

pattern of tortious conduct by inadequately 

trained employees may tend to show that the 

lack of proper training, rather than a one-time 

negligent administration of the program or factors peculiar to the officer involved in a particular incident, is the “moving force” behind the 

plaintiff’s injury. 

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28 No. 15-1419 

Brown, 520 U.S. at 407–08 (emphasis added). 

Harris, in turn, drew on City of Oklahoma City v. Tuttle, 

471 U.S. 808 (1985). There a plurality of the Court observed 

that “where the policy relied upon is not itself unconstitutional, considerably more proof than the single incident will 

be necessary in every case to establish both the requisite 

fault on the part of the municipality, and the causal connection between the ‘policy’ and the constitutional deprivation.” 

Id. at 824 (opinion of Rehnquist, J.) (footnotes omitted). 

Together these decisions stand for the proposition that a 

Monell plaintiff’s own injury, without more, is insufficient to 

establish municipal fault and causation. The plaintiff must 

instead present evidence of a pattern of constitutional injuries traceable to the challenged policy or custom—or at least 

more than one. Only then is the record sufficient to permit 

an inference that the municipality was on notice that its 

policy or custom, though lawful on its face, had failed to 

prevent constitutional torts. Put slightly differently, the 

plaintiff’s own injury, standing alone, does not permit an 

inference of institutional deliberate indifference to a known

risk of constitutional violations. “Nor will it be readily 

apparent that the municipality’s action caused the injury in 

question, because the plaintiff can point to no other incident 

tending to make it more likely that the plaintiff’s own injury 

flows from the municipality’s action, rather than from some 

other intervening cause.” Brown, 520 U.S. at 408–09. 

In short, except in the unusual case in which an express 

policy (or an act of an authorized policymaker) is itself

unconstitutional, a Monell plaintiff must produce evidence of 

a series of constitutional injuries traceable to the challenged 

municipal policy or custom; the failure to do so means a 

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No. 15-1419 29

failure of proof on the fault and causation elements of the 

claim. Brown is unequivocal on this point: If the plaintiff can 

point only to his own injury, “the danger that a municipality 

will be held liable without fault is high” and the claim 

ordinarily fails. Id. at 408. 

It’s true that Brown and Harris do not foreclose the possibility that the requirement of pattern evidence might be 

relaxed in a narrow set of circumstances where the likelihood of recurring constitutional violations is an obvious or 

“highly predictable consequence” of the municipality’s 

policy choice. Id. at 409–10. Addressing the inadequatetraining context in particular, Brown acknowledged the 

“possibility” that “evidence of a single violation of federal 

rights, accompanied by a showing that a municipality has 

failed to train its employees to handle recurring situations 

presenting an obvious potential for such violation, could 

trigger municipal liability.” Id. at 409. But the Court took 

great pains to emphasize the narrowness of this “hypothesized” exception: 

In leaving open [in Harris] the possibility that a 

plaintiff might succeed in carrying a failure-totrain claim without showing a pattern of constitutional violations, we simply hypothesized 

that, in a narrow range of circumstances, a violation of federal rights may be a highly predictable 

consequence of a failure to equip law enforcement 

officers with specific tools to handle recurring situations. The likelihood that the situation will recur and the predictability that an officer lacking specific tools to handle that situation will 

violate citizens’ rights could justify a finding 

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30 No. 15-1419 

that [the] policymakers’ decision not to train 

the officer reflected “deliberate indifference” to 

the obvious consequence of the policymakers’ 

choice—namely, a violation of a specific constitutional or statutory right. The high degree of 

predictability may also support an inference of 

causation—that the municipality’s indifference 

led directly to the very consequence that was 

so predictable. 

Id. at 409–10. 

Despite the contextual language, I see no reason to think 

that this hypothetical path to liability in the absence of 

pattern evidence is open only in failure-to-train cases. So I 

agree with my colleagues that evidence of repeated constitutional violations is not always required to advance a Monell 

claim to trial. But it’s clear that this path to corporate liability 

is quite narrow. If the plaintiff lacks evidence of a pattern of 

constitutional injuries traceable to the challenged policy or 

custom, Monell liability is not possible unless the evidence 

shows that the plaintiff’s situation was a recurring one (i.e., 

not unusual, random, or isolated) and the likelihood of 

constitutional injury was an obvious or highly predictable 

consequence of the municipality’s policy choice. The Court’s 

use of the terms “obvious” and “highly predictable” is 

plainly meant to limit the scope of this exception to those 

truly rare cases in which the policy or custom in question is 

so certain to produce constitutional harm that inferences of 

corporate deliberate indifference and causation are reasonable even in the absence of any prior injuries—that is, in the 

absence of the kind of evidence normally required to establish constructive notice. 

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No. 15-1419 31

Our cases have always followed this understanding of 

Monell doctrine. We have held that a gap in municipal policy 

can sometimes support a Monell claim. See, e.g., Dixon v. 

County of Cook, 819 F.3d 343, 348 (7th Cir. 2016); Thomas v. 

Cook Cty. Sheriff’s Dep’t, 604 F.3d 293, 303 (7th Cir. 2009); 

Calhoun v. Ramsey, 408 F.3d 375, 380 (7th Cir. 2005). But we 

have also recognized that claims grounded on the failure to 

have a policy must be scrutinized with great care. Calhoun, 

408 F.3d at 380 (“At times, the absence of a policy might 

reflect a decision to act unconstitutionally, but the Supreme 

Court has repeatedly told us to be cautious about drawing 

that inference.” (citing Brown, 520 U.S. at 409; Harris, 489 U.S. 

at 388)). 

And in all cases we have consistently required Monell 

plaintiffs to produce evidence of more than one constitutional injury traceable to the challenged policy or custom 

(unless, of course, the policy or custom is itself unconstitutional, in which case the singular wrong to the plaintiffs is 

clearly attributable to the municipality rather than its employees). See, e.g., Chatham v. Davis, 839 F.3d 679, 685 (7th Cir. 

2016) (explaining that Monell claims “normally require 

evidence that the identified practice or custom caused 

multiple injuries”); Daniel v. Cook County, 833 F.3d 728, 734 

(7th Cir. 2016) (explaining that a Monell plaintiff “must show 

more than the deficiencies specific to his own experience” 

and allowing the claim to proceed based on a Department of 

Justice report documenting multiple instances of inadequate 

medical care in the jail); Dixon, 819 F.3d at 348–49 (same); 

Calhoun, 408 F.3d at 380 (explaining that a Monell claim 

ordinarily “requires more evidence than a single incident to 

establish liability”); Palmer v. Marion County, 327 F.3d 588, 

596 (7th Cir. 2003) (same); Gable v. City of Chicago, 296 F.3d 

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32 No. 15-1419 

531, 538 (7th Cir. 2002) (same); Estate of Novack ex rel. Turbin v. 

County of Wood, 226 F.3d 525, 531 (7th Cir. 2000) (A Monell 

plaintiff must show that “the policy itself is unconstitutional” or produce evidence of “a series of constitutional violations from which [institutional] deliberate indifference can 

be inferred.”). 

Finally, following the Supreme Court’s lead in Brown and 

Harris, we have left open the possibility that a Monell claim 

might proceed to trial based on the plaintiff’s injury alone, 

but only in rare cases where constitutional injury is a manifest and highly predictable consequence of the municipality’s 

policy choice. See Chatham, 839 F.3d at 685–86; Calhoun, 

408 F.3d at 381. So far, we’ve allowed recovery under this 

exception only once, in a case involving a jail healthcare 

provider’s failure to ensure that its suicide-prevention 

protocols were scrupulously followed. See Woodward v. Corr. 

Med. Servs. of Ill., Inc., 368 F.3d 917 (7th Cir. 2004). 

To be more specific, in Woodward a jail’s private 

healthcare provider had guidelines in place for inmate 

suicide risk identification and prevention. Id. at 921. An 

inmate committed suicide 16 days after he was booked into 

the jail; his estate sued the corporate healthcare provider 

alleging a systemic failure to enforce compliance with the 

guidelines. Id. at 919–20. The evidence at trial established 

that the provider neither trained its employees on how to 

use the guidelines nor monitored their compliance with 

them, and in fact had long condoned widespread violations 

of the nominally mandatory procedures. Id. at 925–29. A jury 

returned a verdict for the estate and we affirmed. Although 

there was no evidence of prior suicides at the jail, we held 

that Monell liability was appropriate because inmate suicide 

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No. 15-1419 33

is an obvious and highly predictable consequence of a jail 

healthcare provider’s thoroughgoing failure to enforce its 

suicide-prevention program. Id. at 929. 

This case is not at all like Woodward. While it’s patently 

obvious that a systemic failure to enforce a jail suicideprevention program will eventually result in inmate suicide, 

inmate death is not an obvious or highly predictable consequence of the alleged policy lapse at the center of this case. 

Mrs. Glisson claims that Corizon’s failure to promulgate 

formal guidelines for the care of chronically ill inmates as 

required by INDOC Directive HCSD-2.06 caused her son’s 

death. Everyone agrees that nothing in “the Constitution or 

any other source of federal law required Corizon to adopt 

the Directive[] or any other particular document.” Majority 

Op. at p. 19. So evidence is needed to prove corporate culpability and causation; in the usual case, this means evidence 

of a series of prior similar injuries. But Mrs. Glisson presented no evidence that other inmates were harmed by the 

failure to have protocols in place as required by the 

Directive. 

In the absence of prior injuries, Corizon was not on notice 

that protocols were needed to prevent constitutional torts. So 

Mrs. Glisson cannot prevail unless she can show that inmate 

death was an obvious or highly predictable consequence of 

the failure to promulgate formal protocols of the type specified in HCSD-2.06. 

She has not done so. Her expert witness, Dr. Dianne 

Sommer, did not offer an opinion on the subject; the doctor’s 

declaration states only that certain aspects of Nicholas 

Glisson’s treatment fell below the standard of care. My 

colleagues insist that “[o]ne does not need to be an expert to 

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34 No. 15-1419 

know that complex, chronic illness requires comprehensive 

and coordinated care.” Majority Op. at p. 18. Perhaps not, 

but it’s conceptually improper to frame the issue at that level 

of generality. 

This is a complicated medical-indifference case. It’s far 

from obvious that formal protocols of the sort required by 

Directive HCSD-2.06 were needed to prevent constitutional 

torts of the kind allegedly suffered by Nicholas Glisson. The 

Directive itself is entirely nonspecific. It contains only the 

following instructions: (1) “[o]ffenders with serious chronic 

health conditions need to receive planned care in a continuous fashion”; (2) chronic conditions must be identified and 

“a treatment plan must be established”; and (3) the treatment plan “should be maintained current” and “[a]s care 

needs change, the treatment plan should be updated.” In 

other words: Have a treatment plan and update it as needed. 

During discovery Mrs. Glisson asked Corizon to produce 

“all policies, procedures, and/or protocols relied on in 

developing the course of treatment for Nicholas Glisson.” 

Corizon objected based on overbreadth and asked for a more 

targeted document request. Subject to the objection, Corizon 

gave this response: “Mr. Glisson’s medical care and treatment at IDOC were based on standards of medical and 

nursing care, and generally were not dictated by written 

policies, procedures or protocols.” 

My colleagues do not explain how Corizon’s adherence 

to professional standards of medical and nursing care 

amounts to deliberate indifference to a known or obvious 

risk of harm. More to the point, they do not explain how 

inmate death was an obvious or highly predictable consequence of Corizon’s failure to promulgate protocols in 

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No. 15-1419 35

compliance with the very loose and highly generalized 

instructions contained in Directive HCSD-2.06. Unlike the 

jail-suicide case, it is neither self-evident nor predictable—let 

alone highly predictable—that Corizon’s reliance on professional standards of medical and nursing care (instead of 

HCSD-2.06-compliant protocols) would lead to constitutional injuries of the sort suffered by Nicholas Glisson. 

My colleagues say that the absence of formal protocols 

for chronically ill inmates created “a well-recognized risk” 

and “Corizon had notice of the problems posed by a total 

lack of coordination.” Majority Op. at p. 19. No evidence 

supports these assertions. No expert testified that the standard of care requires a corporate healthcare provider to 

promulgate formal protocols on this subject, so the record 

doesn’t even clear the bar for simple negligence. Monell 

liability requires proof of culpability significantly greater

than simple negligence. It also requires evidence that Corizon’s action—not the actions of its doctors and nurses—

directly caused the injury. There is no such evidence here. 

Without the necessary evidentiary support, a jury cannot 

possibly draw the requisite inferences of corporate fault and 

causation. On this record, a verdict for Mrs. Glisson is not 

possible. 

More broadly, by eliding the normal requirement of pattern evidence and relying instead on sweeping and unsubstantiated generalizations about the obviousness of the risk, 

my colleagues have significantly expanded a previously 

narrow exception to the general rule that a valid Monell 

claim requires evidence of prior injuries in order to establish 

corporate deliberate indifference and causation. The 

Supreme Court has instructed us to rigorously enforce the 

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36 No. 15-1419 

requirements of corporate culpability and causation to 

ensure that municipal liability does not collapse into vicarious liability. Today’s decision does not heed that instruction. 

Nicholas Glisson arrived in Indiana’s custody suffering 

from complicated and serious medical conditions. Some of 

Corizon’s medical professionals may have been negligent in 

his care, as Dr. Sommer maintains, and their negligence may 

have hastened his death. That’s a tragic outcome, to be sure; 

if substantiated, the wrong can be compensated in a state 

medical-malpractice suit. Under traditional principles of 

Monell liability, however, there is no basis for a jury to find 

that Corizon was deliberately indifferent to a known or 

obvious risk that its failure to adopt formal protocols in 

compliance with HCSD-2.06 would likely lead to constitutional violations. Nor is there a factual basis to find that this 

alleged gap in corporate policy caused Glisson’s death. 

Accordingly, I would affirm the summary judgment for 

Corizon. 

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