Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-ca7-15-01419/USCOURTS-ca7-15-01419-0/pdf.json

Parties Involved:
Mary Combs
Appellee
Correctional Medical Services, Inc.
Appellee
Alma Glisson
Appellant
Malaka G. Hermina
Appellee
Indiana Department of Corrections
Appellee

Document Text:

In the

United States Court of Appeals

For the Seventh Circuit

No. 15-1419

ALMA GLISSON, as 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-01418-SEB-MJD — Sarah Evans Barker, Judge.

ARGUED OCTOBER 26, 2015 — DECIDED FEBRUARY 17, 2016

Before WOOD, Chief Judge, and BAUER and SYKES, Circuit

Judges.

BAUER, Circuit Judge. Plaintiff-appellant, Alma Glisson

(“Appellant”), sued Correctional Medical Services, Inc., also

known as Corizon, Inc. (“CMS”), its employees Dr. Malaka G.

Hermina (“Dr. Hermina”), Mary Combs, R.N. (“Nurse

Combs”), andthe IndianaDepartment ofCorrections (“IDOC”)

(collectively “Appellees”), on behalf of her deceased son,

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Nicholas Glisson (“Glisson”). Glisson died while incarcerated

at Plainfield Correctional Facility (“Plainfield”) in Plainfield,

Indiana. The lawsuit’s federal claims arise under 42 U.S.C.

§ 1983 (“§ 1983”), specifically alleging that Appellees did not

offer Glisson constitutionally adequate medical care, and that

this failure violated his Eighth Amendment rights against cruel

and unusual punishment. The district court granted summary

judgment in favor of Appellees on all federal claims, and

remanded the remaining state law claims. Appellant now only

appeals the grant of summary judgment in favor of CMS,

arguing that CMS’s failure to implement a particular IDOC

Health Care Service Directive (the “Directive”) violated

Glisson’s Eighth Amendment rights. However, because

Appellant has not produced legally sufficient evidence to

demonstrate a genuine issue of material fact on this matter, we

affirm summary judgment for CMS.

I. BACKGROUND

Glisson’s medical history is tragic. Diagnosed with laryngeal cancer in 2003, he underwent surgery that removed his

larynx and part of his pharynx. The surgery also removed

portions of Glisson’s mandible and thirteen teeth. The surgery

left him with a permanent stoma, or opening in his throat,

accompanied by a tracheostomy tube. He was later fitted

with a voice prosthesis, and received postoperative radiation

treatment. Afterthe surgery, he suffered from painful swallowing (dysphagia) and neck pain, both resulting from progressive

neck instability. In 2008, doctors inserted a gastrojejunostomy

tube (“G-tube”) through his stomach to help with nutrition. In

March 2010, a cancerous lesion was found on his tongue, but

was successfully excised. 

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No. 15-1419 3

Exacerbating the effects of Glisson’s cancer and surgery

were ongoing memory issues, hypothyroidism, depression,

smoking, and alcohol abuse. Despite these many health issues,

Glisson lived independently and cared for himself; he even

cared for his grandmother when she was sick and his brother

when he was dying. 

On August 31, 2010, Glisson was sentenced to incarceration

for dealing in a controlled substance. He came into the custody

of IDOC on September 3, 2010. IDOC housed him in its

Reception Diagnostic Center from September 3 through

September 17. During this time, CMS medical personnel noted

spikes in Glisson’s blood pressure, an occasional low pulse,

and low oxygen saturation level. He also demonstrated signs

of confusion and anger, and was at one point deemed a suicide

risk. As a result, IDOC placed him in segregation and had him

undergo a psychiatric evaluation. 

IDOC transferred him from the Reception Diagnostic

Center to Plainfield on September 17. At Plainfield, Glisson’s

condition further deteriorated. At Plainfield, he came under

the medical care of Dr. Hermina and Nurse Combs. Plainfield

personnel quickly determined that Glisson’s medical issues

were worsening. On September 29, he presented with symptoms suggesting acute renal failure. In response, IDOC

personnel transferred him to a local hospital, where he

remained until October 7.

Upon returning to Plainfield, Glisson appeared stable.

However, on the morning of October 10, Nurse Combs

witnessed Glisson exhibiting strange behavior and transferred

him to a medical isolation room. While isolated, Glisson was

restless, moving from one side of the bed to the other. At

8:20 a.m., IDOC staff reported that Glisson was sitting upright

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in his bed, unresponsive. Emergency personnel arrived at

8:30 a.m., and pronounced Glisson dead at 8:35 a.m. The

coroner concluded that Glisson died of natural causes, resulting from complications of laryngeal cancer with contributory

renal failure. A pathologist agreed with these findings, and

added that Glisson’s various medical issues—diminished

mental state, oxygen deficiency, and acute renal failure—were

directly attributable to his throat cancer and laryngectomy.

After Glisson’s death, Appellant sued Appellees in Indiana

state court. She alleged that Dr. Hermina and Nurse Combs

were deliberately indifferent to Glisson’s medical needs. She

also alleged, under Monell v. Department of Social Services of City

of New York, 436 U.S. 658 (1978), and its progeny, that CMS’s

failure to implement the Directive led to this deliberate

indifference. The Directive reads:

Each facility must develop a site[-]specific directive

that guides the management of the chronic disease

management and clinics. Each site must have easily

available a compilation of instructions for proper

management [of] chronic diseases in the chronic

disease clinic setting.

Related IDOC guidelines further note that the Directive is

necessary because “[o]ffenders with serious chronic health

conditions need to receive planned care in a continuous

fashion” and that care provided to such inmates “should be

organized and planned and should be consistent across [IDOC]

facility lines.”

CMS has argued throughout the litigation that it is not

obligated to implement IDOC directives. It also admitted that

it did not implement the Directive, stating instead that

Glisson’s care was “based on standards of medical and nursing

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No. 15-1419 5

care.” CMS acknowledged that while IDOC “implement[s]

Health Care Service Directives ... generally none of those

directives were relied on in rendering medical care and

treatment to Mr. Glisson.”

Appellant claims that because CMS did not adopt the

Directive and did not create a centralized treatment plan for

Glisson, his care was fractured and disorganized. She argues

that CMS’s lack of a policy of centralized care for inmates like

Glisson led to the deliberate indifference of Dr. Hermina,

Nurse Combs, and other CMS personnel. She specifically

argues that CMS’s failure to adopt any policy mandating

coordinated care “prevent[ed] [CMS] medical personnel from

communicating properly and ensuring appropriate continuity

of care for inmates with serious medical problems,” such as

Glisson.

After Appellant filed the suit in Indiana court, Appellees

removed the case to federal court, and then moved for summary judgment on the federal law claims. The district court

granted summary judgment for Appellees, and remanded the

remaining state law claims. In granting summary judgment,

the district court found that Dr. Hermina’s and Nurse Combs’s

actions did not constitute deliberate indifference, and that as a

result Glisson did not suffer any constitutional injury. Having

determined that Glisson suffered no constitutional injury, the

district court then held that Appellant could not prove a Monell

claim against CMS as a matter of law.

Appellant appealed the district court’s order.

II. DISCUSSION

Appellant only appeals the dismissal of her Monell claim

against CMS. But this claim fails for want of necessary evidence. Specifically, Appellant has not presented evidence that

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CMS’s failure to implement the Directive led to a widespread

practice of deliberate indifference against not only Glisson, but

other inmates as well.

We review the grant of summary judgment de novo,

construing the facts in the light most favorable to the nonmoving party—here, Appellant. Rahn v. Bd. of Trustees of N. Ill.

Univ., 803 F.3d 285, 287 (7th Cir. 2015) (citation omitted).

Summary judgment is appropriate when there is no dispute of

material fact and the moving party is entitled to judgment as

a matter of law. Fed. R. Civ. P. 56(a); Lalowski v. City of Des

Plaines, 789 F.3d 784, 787 (7th Cir. 2015). That is, at this stage,

Appellant must have produced evidence that indicates a

genuine issue of material fact. See Armato v. Grounds, 766 F.3d

713, 719 (7th Cir. 2014) (quotations and citations omitted). See

also Celotex Corp. v. Catrett, 477 U.S. 317, 324 (1986) (quoting

Fed. R. Civ. P. 56(e) in holding that non-moving party must

“designate ‘specific facts showing that there is a genuine issue

for trial’”).

Here, Appellant must produce evidence that CMS’s failure

to adopt the Directive led to deliberately indifferent medical

care by CMS personnel. Government entities “have an

1

affirmative duty to provide medical care to their inmates.”

Duckworth v. Ahmad, 532 F.3d 675, 678–79 (7th Cir. 2008) (citing

Estelle v. Gamble, 429 U.S. 97, 103 (1976)). Deliberate indifference to a prisoner’s “serious medical needs ... constitutes the

‘unnecessary and wanton infliction of pain’ and violates the

Eighth Amendment’s prohibition against cruel and unusual

 Though a private corporation, CMS concedes that because it performs a 1

government function—providing medical care to state prisoners—it may

be liable as a government entity under § 1983. E.g., Iskander v. Vill. of Forest

Park, 690 F.2d 126, 128 (7th Cir. 1982).

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No. 15-1419 7

punishments.” Duckworth, 532 F.3d at 679 (quoting Estelle, 429

U.S. at 104 (internal quotation and citation omitted)). 

Here, Appellant has not produced the necessary evidence

for a Monell claim against CMS. Private corporations like CMS

cannot be liable in a § 1983 suit under respondeat superior. E.g., 2

Iskander, 690 F.2d at 128; Gayton v. McCoy, 593 F.3d 610, 622 (7th

Cir. 2010); Maniscalco v. Simon, 712 F.3d 1139, 1145 (7th Cir.

2013). Thus, even if Dr. Hermina and Nurse Combs were

deliberately indifferent to Glisson’s medical needs, a court

cannot impute this liability to their employer, CMS. Rather, to

survive summary judgment, Appellant must produce evidence

of “the existence of an ‘official policy’ or other governmental

custom that not only causes but is the ‘moving force’ behind

the deprivation of constitutional rights.” Teesdale v. City of Chi.,

690 F.3d 829, 833–34 (7th Cir. 2012) (quoting City of Canton,

Ohio v. Harris, 489 U.S. 378, 388–89 (1989)). See also Monell, 436

U.S. at 694.

Further, where a plaintiff alleges that a lack of a policy

caused a constitutional violation, she must produce “more

evidence than a single incident to establish liability.” Calhoun

v. Ramsey, 408 F.3d 375, 380 (7th Cir. 2005) (citing City of Okla.

City v. Tuttle, 471 U.S. 808, 822–23 (1985)). She must produce

Additionally, though CMS did not argue waiver on appeal, Appellant 2

has nevertheless waived her right to recovery on a theory of respondeat

superior. In the district court, she stated in her response to Defendants’

Motion for Summary Judgment, “Plaintiff does not seek to impose liability

on CMS under § 1983 based on respondeat superior.” Yet Appellant now asks

this Court to apply respondeat superior to private corporations like CMS.

This is a new argument on appeal, and is thus waived. See Brown v.

Automotive Components Holdings, LLC, 622 F.3d 685, 691 (7th Cir. 2010)

(“[a]rguments not raised in the district court are considered waived on

appeal”). 

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evidence of a “series of incidents” (Hahn v. Walsh, 762 F.3d 617,

638 (7th Cir. 2013), cert. denied, 135 S. Ct. 1419 (2015)), or a

“widespread practice constituting custom and usage.” Phelan

v. Cook Cnty., 463 F.3d 773, 789 (7th Cir. 2008) (a “widespread

practice” argument “would focus on the application of the

policy to many different individuals”). Evidence of a series of

incidents permits the inference that “there is a true municipal

policy at issue,” and allows the factfinder “to understand what

the omission means.” Calhoun, 408 F.3d at 380. By presenting

a series of incidents where “the same problem has arisen many

times and the [government entity] has acquiesced in the

outcome,” a plaintiff has produced sufficient evidence that the

lack of policy is in fact a de facto policy choice, not a discrete

omission. Id. However, “[w]ithout evidence that a series of

incidents brought the risk at issue to the attention of the

policymaker, we cannot infer that the lack of a policy is the

result of deliberate indifference.” Hahn, 762 F.3d at 637–38

(citing Calhoun, 408 F.3d at 380).

Such is the case here. Appellant alleges that CMS failed to

implement the Directive mandating a centralized care plan for

inmates such as Glisson. Appellant therefore argues that

CMS’s lack of a policy was the “moving force” behind any

deliberate indifference to Glisson’s medical needs. Thus, to

show that CMS’s failure to implement the Directive amounted

to a de facto policy, Appellant must have produced evidence

that CMS staff had been deliberately indifferent to other

inmates, and that a widespread practice of deliberate indifference flowed from the failure to implement the Directive. But

Appellant has not done so. Instead, she has only produced

evidence of alleged deliberate indifference towards Glisson,

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No. 15-1419 9

and admitted as much at oral argument. This evidence alone 3

is insufficient to maintain a Monell claim against CMS. Absent

evidence of a series of incidents or a widespread practice

against other inmates, we cannot infer that CMS’s failure to

implement the Directive was the result of deliberate indifference. See Hahn, 762 F.3d at 637. Therefore, Appellant’s claim

fails as a matter of law, and summary judgment for CMS was

appropriate.

III. CONCLUSION

Forthe foregoing reasons, we AFFIRM the judgment of the

district court.

Appellant waived use of evidence of other incidents because she did not 3

present such evidence before the district court. Her “Separate Appendix”

includes a 2013 Miami Herald news article discussing various lawsuits

brought by Florida prisoners against CMS (as Corizon), a 2012 expert report

relating to a lawsuit against Corizon brought in federal court in Idaho, and

a 2015 settlement order related to a lawsuit against Corizon in the Northern

District of California. She argues in her appellate brief that this is evidence

of a “pattern of constitutionally inadequate care.” But she presented none

of these three documents as evidence before the district court. Of course,

she could not have presented the 2015 settlement order to the district court

in this case, because the district court in this case ruled on summary

judgment on June 4, 2014. However, the district court presiding over the

Northern District of California settlement had denied summary judgment

to Corizon on April 14, 2014, before the district court in this case ruled. See

M.H. v. Cnty. of Alameda, 62 F. Supp. 3d 1049, 1087–88 (N.D. Cal. 2014).

Thus, Appellant could have offered the denial of summary judgment in

M.H. as supplemental authority for her argument before the district court.

But she failed to do so, and has thus waived any argument relating to these

three documents. See Brown, 622 F.3d at 691.

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WOOD, Chief Judge, dissenting. Most cases in which a 

prisoner raises a claim about constitutionally inadequate 

medical care in the prison are brought against the doctor or 

other professional who actually delivered the services. In 

those cases, as Estelle v. Gamble, 429 U.S. 97 (1976), and 

Farmer v. Brennan, 511 U.S. 825 (1994), illustrate, the prisoner 

may prevail only if the providers exhibited deliberate indifference to a substantial risk of serious harm. The Eighth 

Amendment, after all, is about unconstitutional punishment, 

not about medical competence. But there is another theory 

that has been cognizable under 42 U.S.C. § 1983 ever since 

the Supreme Court decided Monell v. Dep’t of Social Servs., 

436 U.S. 658 (1978). Overruling Monroe v. Pape, 365 U.S. 167 

(1961), insofar as that case held that municipalities are immune from suit under section 1983, Monell drew a line between respondeat superior liability and direct liability for the 

municipal organization’s own policies. It rejected the former, 

but it held that the latter was actionable. That latter theory is 

the one under which plaintiff Alma Glisson, acting as the 

personal representative of her deceased son, Nicholas L. 

Glisson, is seeking to recover damages against Correctional 

Medical Services, Inc. (Corizon), the company that was responsible for the deplorable medical care Glisson received in 

Indiana’s Plainfield Correctional Facility. (Unless the context 

requires otherwise, my references to “Glisson” mean Nicholas, not Alma.)

In Minix v. Canarecci, 597 F.3d 824, 835 (7th Cir. 2010), this 

circuit confirmed that private corporations that contract with 

jails or prisons to provide medical services are treated the 

same as municipalities for purposes of liability under section 

1983. That rule applies to defendant Corizon. Alma Glisson 

asserts that Corizon maintained a policy that led directly to 

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No. 15-1419 11

her son’s death. My colleagues have concluded that she cannot prevail—indeed, that the paper record is so one-sided 

that it was proper for the district court to grant summary 

judgment in Corizon’s favor. That conclusion can stand only 

if they have correctly depicted what it takes to prove that 

Corizon’s policies violated the Eighth Amendment. They 

characterize this case as a complaint about the lack of a policy, and they assert that the plaintiff must therefore show a 

series of incidents or a widespread practice. Alma Glisson 

did not submit such evidence (at least not in a timely fashion), and so, they conclude, she fails. This syllogism assumes 

that policies are always affirmatively stated and that a decision not to regulate cannot also be a policy. Nothing in Monell or later cases, however, so holds. The relevant questions 

in all instances are (a) what is the policy at issue, and (b) 

whether that policy reflects deliberate indifference to a serious medical need. Taking the facts in the light most favorable to the plaintiff, a rational jury could find that Corizon deliberately structured the delivery of medical care in a way 

that lacked critical oversight. That policy in Glisson’s case

predictably had fatal results. I would reverse and send this 

case to trial.

I

Before turning to the legal analysis, it is helpful to review 

the facts in some detail. Although Glisson had suffered from 

bad health for many years, he was able to function on his 

own until he was taken into custody by the Indiana Department of Corrections (INDOC) on September 3, 2010 (following his conviction for giving one prescription painkiller pill 

to a friend).

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12 No. 15-1419

Indeed, he not only lived independently, but he also provided care to his grandmother and his dying brother. After 41 

days in custody, 37 of which were in INDOC’s care, prison 

staff found him dead in his cell. The coroner concluded that 

Glisson died of “complications of laryngeal cancer.” But that 

was not all he said. He also noted Glisson’s “malnutrition,” 

“extreme emaciation and cachexia [wasting away of tissue].” 

Consultant Dr. Stephen Radentz, a forensic pathologist, 

agreed with those conclusions, and added that Glisson suffered from acute renal failure with hyperkalemia (i.e. too 

much potassium in the blood), dehydration and volume depletion, acute respiratory insufficiency or pneumonia, and 

altered mental status. Finally, for purposes of this litigation, 

Glisson’s estate retained Diane Sommer, M.D., who prepared 

a report finding “[w]ithin a high degree of medical certainty 

... that the health care [Glisson] received through out [sic] 

his brief incarceration lead [sic] to his early death.” 

No one disputes that Glisson’s health was poor before he 

went to prison. 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 several 

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. Over 

the years, Glisson had additional treatments. Importantly for 

our case, the 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.

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No. 15-1419 13

In 2008 doctors placed a gastrojejunostomy tube in his upper 

abdomen for supplemental feeding. Finally, there was some 

evidence of cognitive decline. 

Despite all this, Glisson was able to care for himself in the 

home. He learned to clean and suction his stoma independently. With occasional help from his mother, he was 

able to use his feeding tube when necessary. He was still 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, cooking, and caring for his 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. 

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. Before 

sentencing, Dr. Borrowdale, one of his physicians, wrote a 

letter to the court expressing serious concern about Glisson’s 

ability to manage in a prison setting. Dr. Borrowdale noted 

Glisson’s severe disabilities from cancer and from 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 prophetic: “This patient is severely disabled, 

and I do not feel that he would survive if he was incarcerated.” Dr. Fisher, another of Glisson’s physicians, also 

warned that Glisson “would not do well if incarcerated.” 

Glisson’s family brought his essential supplies to the 

Wayne County Jail, including his neck brace and the suction 

machine, mirror, and light that he used for his tracheostomy. 

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14 No. 15-1419

When he was transferred on September 3 to INDOC’s Reception Diagnostic Center, the Jail sent along his mirror, light, 

and neck brace, but it is unclear what happened to these 

items. Glisson never received the neck brace while he was at 

Plainfield, nor was he given a replacement. 

At the Diagnostic Center, Nurse Tim Sanford assessed 

Glisson’s condition, accurately as far as one can tell. 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. After that evaluation, 

Glisson was placed in the general population.

From this point on, Glisson’s care began to resemble the 

blind men’s description of the elephant. Different people 

took steps that were never coordinated or supervised by a 

single responsible medical provider. No provider furnished 

a comprehensive investigation of his medical condition. On 

September 5, staff reported that Glisson was angry and 

throwing candy out of his cell. (Glisson disputes this, and so 

this fact cannot be taken as established for summary judgment purposes.) Nurse Rachel Johnson tried to take his 

blood pressure, but could not. She recorded a pulse of 60 

and an oxygen saturation level of 84%, which was low. (The 

record includes evidence indicating that normal oxygen saturation ranges between 95 and 100%; saturation below 90% 

is a sign of respiratory distress.) Some staff thought that 

Glisson seemed confused, but Johnson found him to be alert 

and oriented. The staff told her that Glisson had consumed 

only milk in the past two days and that he was not cooperatCase: 15-1419 Document: 39 Filed: 02/17/2016 Pages: 28
No. 15-1419 15

ing with their efforts to handcuff him for a clinic visit. They 

tested his oxygen saturation again and found it to be fluctuating between 84% and 94%. At that point, they took him to 

the clinic and allowed him to use his suction machine. Also, 

for reasons that are largely unclear, they identified him as a 

suicide risk and transferred him to segregation. 

Glisson’s care over the next couple of weeks 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, no 

Corizon provider even reviewed his medical history. Dr. Gallien requested his medical history on September 10. But 

there is no evidence that anyone responded to his request, 

and no one followed up on that request until September 27, 

when Dr. Malaka G. Hermina asked for the records and received them within several hours. Except for one instance on 

September 10, no Corizon provider ever tried to contact 

Glisson’s mother or any other relative for information. During this time, Glisson’s oxygen saturation rate bounced up 

and down, occasionally reaching troubling lows: On September 5 it fluctuated between 84% and 94%; it rose to 96% 

when he was allowed to use his suction machine; it sank 

back to 86% on September 6 before suctioning restored it to 

94%; it was back down at 84% on September 8, and so on. 

Glisson’s weight, never high, was also deteriorating. On September 9 a psychiatrist, Dr. Conant, recorded that he had lost

weight; later that day a nurse practitioner ordered that Glisson be given the nutritional supplement Ensure. No one kept 

any daily account of how much—if any—Ensure Glisson 

consumed.

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16 No. 15-1419

When Glisson was transferred from the holding facility 

to Plainfield on September 17, 2010, he weighed 119 pounds. 

There is no record of anyone’s monitoring his weight, although 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. See MedicineNet.com, Definition of Cachectic, 

http://www.medicinenet.com/script/main/art.asp?articlekey=

40464. Dr. Hermina ordered a second nutritional supplement, Jevity, but he did not make any recording of Glisson’s 

weight. As noted above, the coroner also noted Glisson’s 

emaciation.

During this time, Glisson’s mental status was also deteriorating. Dr. Sommer’s report charts that process and notes at 

various points how the deterioration could have been halted 

if a qualified medical professional had been evaluating the 

full picture. Such an evaluation would have shown, Dr. 

Sommer said, a clear correlation between Glisson’s underlying medical problems and his mental state. Her report comments on the drugs Glisson was taking. He was switched 

from Effexor to Prozac without any evaluation; worse, he 

was not monitored or weaned off Effexor while the Prozac 

was started. The two drugs work quite differently, the report 

notes, and it concludes that “[t]his abrupt change in medication contributed to [Glisson’s] decline in function.”

While Glisson was in custody, he had numerous episodes 

of altered mental status. Despite this fact, Dr. Gallien (again 

operating on the basis of incomplete information) noted on 

September 10 that Glisson had “no real mental health issues.” Yet at roughly the same time, Health Services Administrator Kelly Kurtz called Glisson’s mother to ask whether 

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No. 15-1419 17

he had any abnormal behavioral issues, such as spitting on 

the floor. Alma Glisson said no. There is no record that Kurtz 

told anyone about this, or that any Corizon provider could 

or did take this information into account in structuring Glisson’s treatment.

Dr. Conant did conduct a mental health evaluation on 

Glisson on September 23. His 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. Had he looked, he would have seen that Glisson had 

no history of psychosis, and he might have considered (as 

the post-mortem experts did) the possibility that lack of oxygen and food was affecting Glisson’s mental performance. 

Dr. Conant noted that he thought that Glisson’s hallucinations were caused by morphine. This observation, too, was 

reached in an information vacuum. In fact, Glisson had been 

on narcotic medication for some time prior to his incarceration. Had Dr. Conant known of Glisson’s medical history, he 

would have known that morphine was an unlikely cause 

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. On September 4, 

Glisson’s urinalysis results showed the presence of ketones 

and leukocytes. Dr. Sommer’s report notes, without contradiction in the record, that “[k]etones suggest the presence of 

other medical conditions such as anorexia, starvation, acute 

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or severe illness and hyperthyroidism to name a few.” “Leukocytes,” it said, “are a sign of possible infection.” The medical staff did nothing to address either potential problem, 

even though a second urine sample taken on September 5 

showed an increase in ketones and leukocytes. There is no 

evidence in the record that a physician reviewed either of 

those lab results. That is so even though the record includes 

a note saying that on September 5 Glisson “had not been eating and seemed confused.” Rather than probing the signs of 

infection and dehydration further, the staff opted to put 

Glisson in the psychiatric unit under suicide watch. 

The blood work 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 September 27. 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. A jury 

could easily conclude that Glisson was already slipping into 

renal distress as early as September 4 or 9, but that the uncoordinated care Corizon furnished allowed his condition to 

become acute. Recall that Dr. Radentz listed acute renal failure as a cause of his death. 

Last, anyone with a good overall knowledge of Glisson’s 

health problems would have realized that he was at high risk 

for aspiration pneumonia because he had undergone major 

surgery that had disrupted his swallowing mechanism, he 

had a stoma and feeding tube, and he had a cervical-spine 

problem that caused laxity in his neck. Whether or not his 

neck brace was transferred from the jail to the prison is beCase: 15-1419 Document: 39 Filed: 02/17/2016 Pages: 28
No. 15-1419 19

side the point: the record shows that he never received it, 

and it was not replaced. The only care he received for his

neck and throat was suctioning, and then only after he was 

already hypoxic. Someone lost his voice prosthesis too. It 

was not replaced, despite the fact that there is evidence in 

the record to support a finding that its absence greatly increased the potential of aspiration and pneumonia, and that 

those were listed as contributing causes of death. 

II

It was not Alma Glisson’s burden ultimately to convince 

the district court that Corizon’s policy violates the Constitution; she needed only to show that there are genuine issues 

of material fact and that a rational jury could so conclude. In 

my view, the more complete account of the facts provided 

above leaves room for no other outcome. Two questions are 

critical: first, whether Corizon is automatically entitled to 

judgment if its staff committed no constitutional violation; 

and if the answer is no, then second, whether a jury could 

find that Corizon’s failure to formulate protocols to guide 

care for chronically ill inmates violates the Eighth Amendment.

A

There are two points on which I agree with my colleagues in the majority. We all accept that under the law as it 

presently exists, there is no respondeat superior liability in a 

case under section 1983 even for a private corporation such 

as Corizon. This court noted in Shields v. Illinois Dep’t of Corrections, 746 F.3d 782, 789−96 (7th Cir. 2014), that there may 

be some question about that proposition, but we went no 

further, and so for now the applicability of Monell’s rule to 

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20 No. 15-1419

private entities such as Corizon remains established. In addition, we all understand that Glisson did not need to prove 

that the individual providers’ care was deliberately indifferent in order to prevail. We squarely held in Thomas v. Cook 

Cnty. Sheriff’s Dep’t, 604 F.3d 293 (7th Cir. 2010), that “we find 

unpersuasive the County’s argument that it cannot be held 

liable under Monell because none of its employees were 

found to have violated [plaintiff’s] constitutional rights.” Id.

at 304. Sometimes the nature of the constitutional violation, 

the theory of municipal liability, and the defenses will cause 

a Monell claim to fail because of the lack of any underlying 

violation, but sometimes it will not. Our case falls in the latter category. Individual medical providers may act within 

constitutional boundaries, both objectively and subjectively, 

but if there is an unconstitutional policy at the corporate level, the corporation must answer for it.

B

This takes me to the essence of my disagreement with the 

majority. My colleagues read Glisson’s complaint as alleging 

only that it was Corizon’s failure to implement INDOC’s 

Health Care Service Directive that violated the Eighth 

Amendment, rather than as presenting a broader argument 

attacking Corizon’s decision not to require centralized monitoring of inmates with complex medical conditions. Certainly if Corizon had implemented the state’s Directive, quoted 

ante at 5, no policy would have stood in the way of adequate 

care for prisoners (such as Glisson) with chronic diseases. 

INDOC guidelines recognize the need for “planned care in a 

continuous fashion,” and it is obvious that Glisson received 

nothing of the kind. My colleagues see this as a complaint 

about the lack of a policy, ante at 9, and they then conclude 

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No. 15-1419 21

that in this situation a plaintiff must present evidence of a 

series of incidents or a widespread practice constituting custom and usage. That is not Glisson’s claim. Even if it were, I 

see no support for the final step of the majority’s line of reasoning.

The Supreme Court’s decision in Los Angeles Cnty. v. 

Humphries, 562 U.S. 29 (2010), unanimously reaffirms that 

the key holding of Monell is that a municipal policy or custom must be at stake, no matter what type of relief is sought. 

562 U.S. at 31. Monell’s requirement of a policy or custom is 

meant to ensure that a municipality is held liable only in situations where its “deliberate conduct” is the “moving force” 

causing the injury—that is, the deprivation results “from the 

decisions of ... those officials whose acts may fairly be said 

to be those of the municipality.” Board of County Commissioners of Bryan County v. Brown, 520 U.S. 397, 403–04 (1997) (emphasis in original). 

The Court has enumerated several ways to demonstrate 

that the municipality’s own conduct is at stake, not that of its 

employees or agents. First, it has held that “[l]ocal governing 

bodies ... can be sued directly under § 1983 ... where ... 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 36 (quoting Monell, 436 U.S. at 

690-91). A municipality can also be sued for “deprivations 

visited pursuant to governmental ‘custom’ even though such 

a custom has not received formal approval through the body’s 

official decisionmaking channels.” Id. (emphasis added). 

In other words, either the content of an official policy, a 

decision by an official decisionmaker, or evidence of custom 

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will suffice. It is true that a plaintiff must show multiple incidents to prove a custom or practice that has not been “officially adopted and promulgated.” Id. But if she seeks to establish municipal liability by either of the other two methods—proving that the unconstitutional action resulted from 

a policy or a decision by the entity’s “authorized decisionmakers”—she need not show multiple incidents. Pembaur v. City of Cincinnati, 475 U.S. 469, 481 (1986). In such cases, “the municipality is equally responsible whether that action is to be taken only once or to be taken repeatedly.” Id.

The choice the majority has framed—written policy versus lack of written policy—is therefore a false one. The majority assumes that because Glisson attacks Corizon’s failure 

to enact certain protocols, he is alleging the absence of a policy. Not at all. Glisson alleges that Corizon had a deliberate 

policy that eschewed coordinated care: in essence, a policy 

not to have a policy and instead to rely on each provider’s 

isolated decisions. And even if Glisson were alleging only the 

absence of a written policy, it does not follow that he must 

prove a custom. Glisson’s allegations—and his evidence—fit 

comfortably within the “authorized decisionmaker” route, 

which does not require proof of multiple incidents. Id. Nowhere does Glisson allege that Corizon has an informal custom of not creating a protocol for centralized treatment 

plans. He alleges instead that it made an affirmative, official 

decision not to do so. Policymakers make decisions to act and 

not to act; there is no reason why an official decision not to

act should be any less culpable—or any less official—under 

section 1983 than one to act. Corizon was well aware of the 

INDOC Directive. After seven years, it is reasonable to infer 

that Corizon’s decision not to enact the required protocols 

was deliberate and was made by persons within Corizon 

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No. 15-1419 23

with decisionmaking authority. (Indeed, it is hard to infer 

anything else.)

Even if Glisson’s claim fits awkwardly into the methods 

mentioned in Monell, that is not a problem unless one reads 

Monell as providing an exhaustive, not an illustrative, list. 

But nothing in Monell or later cases supports such a mechanistic approach. Monell’s methods of proof are not ends; they 

are means. They suggest three paths to the same place: proof 

that “the municipal action was taken with the requisite degree of culpability.” Brown, 520 U.S. at 404. Monell was about 

the conditions necessary to attribute conduct to the municipal “person” under section 1983: that is, whether the action 

in question can properly be considered the municipality’s 

“deliberate conduct.” Id. The harm itself—or the number of 

harms—is irrelevant for this purpose. Where there is strong 

evidence of official culpability—as there is in this case—a 

court need not worry about which path the plaintiff takes to 

proving that the municipality is culpable. What matters is 

that the proof point to the municipality’s own act. 

The essential prerequisite to deliberateness—and thereby 

culpability—is knowledge of the risk at issue. In policyomission cases, it is the plaintiff’s burden is to present “evidence that there is a true municipal policy at issue, not a 

random event.” Calhoun v. Ramsey, 408 F.3d 375, 380 (7th Cir. 

2005). Such evidence is “necessary to understand what the 

omission means:" it could reflect nothing more than the municipality’s ignorance of the problem’s existence or gravity 

or its preference for another permissible course. Id. (“No

government has, or could have, policies about virtually everything that might happen.”). To be attributed to the municipality as a “policy,” a course of action must be “consciously 

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chosen from among various alternatives;” therefore, evidence must “be adduced which proves that the inadequacies 

resulted from conscious choice—that is, proof that the policymakers deliberately chose a ... program which would 

prove inadequate.” Id. (quoting City of Oklahoma City v. Tuttle, 471 U.S. 808, 823 (1985)). When they lack evidence from 

which a conscious choice can be inferred, plaintiffs may

prove that the municipality had a custom or practice of dealing with incidents in a certain way; in other words, they may 

use circumstantial evidence to show an unspoken policy. 

Common sense says that one incident cannot constitute a 

custom. But where a plaintiff does present evidence from 

which the municipality’s knowledge and choice can be inferred, there is no reason why proving multiple incidents 

should be necessary.

That is why we have stated that, where a municipal entity has “actual or constructive knowledge that its agents will 

probably violate constitutional rights, it may not adopt a 

policy of inaction.” King v. Kramer, 680 F.3d 1013, 1021 (7th 

Cir. 2012) (alteration omitted) (quoting Warren v. District of 

Columbia, 353 F.3d 36, 39 (D.C. Cir. 2004)). It is why we have

noted that a policymaker may be directly liable where he has 

actual knowledge of a risk but nonetheless ignores it. See 

Steidl v. Gramley, 151 F.3d 739, 741 (7th Cir. 1998) (“If the 

warden were aware of ‘a systematic lapse in enforcement’ of 

a policy critical to ensuring inmate safety, his ‘failure to enforce the policy’ could violate the Eighth Amendment.”) 

(quoting Goka v. Bobbitt, 862 F.2d 646, 652 (7th Cir. 1988)). It 

is why we have held that where a situation calls for procedures, rules or regulations, the “failure to make a policy is 

also actionable.” Thomas, 604 F.3d at 303 (citing Sims v. Mulcahy, 902 F.2d 524, 543 (7th Cir. 1990)).

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No. 15-1419 25

For the same reason, the Supreme Court has noted that

even where there is no evidence of actual notice, deliberateness may be inferred where a risk is sufficiently obvious. For 

example, in its failure-to-train cases, the Court has said that 

where, “in light of the duties assigned to specific ... employees the need for more or different training is so obvious, and 

the inadequacy so likely to result in the violation of constitutional rights, ... the policymakers of the city can reasonably 

be said to have been deliberately indifferent to the need.”

City of Canton, Ohio v. Harris, 489 U.S. 378, 390 (1989). 

Here, Glisson has presented evidence that supports a 

reasonable inference that Corizon made “a deliberate choice 

to follow a course of action ... from among various alternatives,” and therefore may be held liable as a municipality 

under section 1983. Harris, 489 U.S. at 389 (quoting Pembaur, 

475 U.S. at 483–84 (plurality opinion)). The Indiana Department of Corrections saw fit to promulgate Health Care Services Directive 2.06 on “Chronic Disease Intervention Guidelines.” The Guidelines say that “[e]ach facility must establish 

a site specific directive that guides the management of 

chronic disease management and clinics.” They instruct that 

this directive should ensure that “[c]are provided to [inmates with chronic illnesses] should be organized and 

planned and should be consistent across facility lines.” They 

add other essential criteria for the care of the chronically ill, 

including the need for an individualized treatment plan that 

includes objectives for care and is kept current. 

This Directive squelches any possible argument Corizon 

might have about a lack of awareness of the risk of not having protocols for the care of inmates with chronic illnesses. 

Timing is not on Corizon’s side either. Seven years after the 

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Directive appeared, Corizon had yet to make any policy 

change with regard to the comprehensive treatment of 

chronically ill inmates. In its responses to Glisson’s interrogatories, Corizon admitted that it was aware of the Directive’s 

existence and that it had done nothing to comply with its 

dictates. The most plausible inference—if not the only one—

is that Corizon consciously chose, without medical justification, simply not to enact protocols for managing the care of 

these vulnerable inmates. 

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 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. It was just as certain that Corizon providers would be confronted with patients with chronic illnesses. The need to establish protocols for the coordinated 

care of chronic illnesses is obvious, just as is the recklessness 

exhibited by failing to do so. On the record here, a jury could 

reasonably 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. 

Indeed, it is not necessary to rely on the obviousness of 

these risks, because the Directive provided all the information Corizon needed. Through it, Corizon was “aware of 

‘a systematic lapse in enforcement” of the directive, a policy 

critical to ensuring inmate safety.’” Steidl, 151 F.3d at 741.

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No. 15-1419 27

It had actual knowledge that, without protocols for coordinated, comprehensive treatment, the constitutional rights of 

chronically ill inmates would sometimes be violated, and 

nonetheless it “adopt[ed] a policy of inaction.” Kramer, 680 

F.3d at 1021. A 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, it is important to stress that I am not arguing 

that the Constitution or any other source of federal law required Corizon to adopt the Directive or any other particular 

document. But the Constitution does require it to ensure that 

a well-recognized risk for a defined class of prisoners be 

competently addressed and not deliberately left to happenstance. Corizon had notice of the problems posed by a total 

lack of coordination. Yet despite that 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. Correctional Medical Services, 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. Forty-one 

days after he entered custody, he was dead. On this record, a 

jury could find that Corizon’s obdurate failure to enact centralized treatment protocols for chronically ill inmates led 

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28 No. 15-1419

directly to his death. I would reverse the judgment below 

and remand for a trial.

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