Court Opinion

ID: 6317012
Source: CourtListenerOpinion
Date Created: 2022-02-23 23:00:25.771128+00
Date Added: 2024-06-11T09:00:33.025674
License: Public Domain

In the

    United States Court of Appeals
                For the Seventh Circuit
                    ____________________
No. 19-2440
MICHAEL RECK,
                                                Plaintiff-Appellant,
                                 v.

WEXFORD HEALTH SOURCES,
INC., et al.,
                                             Defendants-Appellees.
                    ____________________

        Appeal from the United States District Court for the
                    Southern District of Illinois.
      No. 3:16-cv-01141-RJD — Reona J. Daly, Magistrate Judge.
                    ____________________

  ARGUED OCTOBER 28, 2021 — DECIDED FEBRUARY 23, 2022
               ____________________

   Before RIPPLE, HAMILTON, and SCUDDER, Circuit Judges.
   RIPPLE, Circuit Judge. Michael Reck, a prisoner at Menard
Correctional Center (“Menard”), an institution in the Illinois
Department of Corrections (“the Department”), filed this
Section 1983 action against a prison physician (“Dr. Trost”),
the Health Care Unit Administrator (“Administrator
Walls”), a prison nurse (“Nurse Smith”), and Wexford
Health Sources, Inc. (“Wexford”), the entity that provides
2                                                          No. 19-2440

medical services to inmates under a contract with the De-
partment. In his complaint, Mr. Reck alleged that the de-
fendants had violated the Eighth Amendment through their
deliberate indifference to his serious medical condition. In
due course, the defendants moved for summary judgment.
The district court granted the motion and then entered
            1                                  2
judgment. Mr. Reck timely appealed. For the reasons set
forth in this opinion, we affirm the judgment of the district
court.
                                    I
                          BACKGROUND
                                   A.
                                   1.
    We begin with an examination of the general medical
care arrangement at Menard during the relevant time peri-
od. With respect to the administration of medical care, this
institution identifies as a “blended site” because both Wex-
ford and Illinois Department of Corrections employees serve
on the medical staff. Wexford employs the physicians and
nurse practitioners; both Wexford and the Illinois Depart-
ment of Corrections employ nurses. A prisoner may seek
medical attention by making his need known to any staff

1 The district court had jurisdiction under 28 U.S.C. § 1331 and 28 U.S.C.
§ 1343. All parties consented to proceed before a magistrate judge. See
28 U.S.C. § 636(c)(1).
2 See 28 U.S.C. § 1291. Mr. Reck initially appeared pro se, and his appeal
was set for decision without oral argument under Rule 34. The panel lat-
er decided to appoint counsel and to set the case for oral argument.
No. 19-2440                                                          3

          3
member. However, because Menard is a maximum security
prison, the inmates’ freedom of movement within the insti-
tution is limited. Consequently, in seeking medical care, in-
mates also may submit written requests for medical care;
these requests are known as “sick calls” or “kites.” There are
several acceptable ways for an inmate to submit a kite. He
may drop it into a locked box in each cell house, leave them
in the cell bars for prison employees to collect, or give it to
medical staff.
    A nurse collects the kites from the locked boxes daily,
logs them, and then reviews them. Menard’s policy requires
that kites be reviewed daily and that a health care profes-
sional evaluate an inmate within seventy-two hours of a re-
quest for medical assistance. This timeframe was not always
achieved. According to the record, there were several rea-
sons for this lapse: understaffing in the Health Care Unit;
loss of sick call requests; failure to pick up requests; and
nurses’ ignoring sick call requests.
    During the relevant period, Menard’s Health Care Unit
was understaffed. There were days when a physician was
not available. Inmates were frequently unable to see medical
staff promptly.
   Dr. Trost’s personal attendance record reveals excessive
absences. There were days when Dr. Trost did not report to
work or left early. Dr. Trost himself agreed and testified that

3 Administrator Walls testified that inmates may contact “any employee,
doesn’t even have to be a nurse, [and] tell them they have an issue,
they’ll call over to health care, and they could see them.” R.151-9 at
103:23–25.
4                                                            No. 19-2440

he “can see where [his unscheduled departures] would po-
tentially contribute to” “creat[ing] additional backlog and
                                                     4
delay[ing] treatments provided to patients.” He was placed
on a corrective action plan. Shortly before Mr. Reck’s medi-
cal troubles began, Dr. Trost became the only physician at
Menard. The other physician left, and the sole nurse practi-
tioner took an extended medical leave, not returning until
after April 2016.
                                   2.
    We now turn to a rendition of Mr. Reck’s medical diffi-
culties and his interaction with the medical program at Wex-
ford.
   In 2015, Mr. Reck developed a “painful perianal abscess
with recurrent bloody discharge” because of his Crohn’s dis-
                                                         5
ease, which previously had been in remission. His condition
caused him considerable pain throughout 2015.
    He submitted sick call kites by leaving them in his cell
bars for prison employees to pick up when collecting the
mail. He submitted kites on July 10, July 14, July 19, August
10, August 18, September 14, September 20, October 16, Oc-
tober 25, October 31, November 14, 2015, and January 14,
      6
2016. Medical personnel did not see Mr. Reck in response to

4 R.151-3 at 75:13–75:21.

5 R.151-13 at 2.

6 Details of these sick call requests are set forth in the following text
when necessary to our analysis. Suffice it to say that Mr. Reck’s fistula
caused him considerable pain throughout 2015.
No. 19-2440                                                             5

those sick call requests. There is, however, no evidence that
the medical staff received these kites; the record contains on-
ly the contemporaneous copies that Mr. Reck made.
Mr. Reck also documented these requests in his journal. He
testified that he also made numerous oral requests to
Menard staff members.
    The record shows evidence that medical personnel re-
ceived a sick call request from Mr. Reck on July 26, 2015, and
that medical personnel saw Mr. Reck on the following day.
Specifically, on July 27, 2015, a nurse saw him and noted in
the log that Mr. Reck would be referred to a physician.
Mr. Reck did not see a physician, however, until September
1, 2015. The parties dispute whether this encounter was be-
                                                                   7
cause of the July 26 referral or because of an emergency.
   On September 1, Mr. Reck’s abscess burst. The dis-
charged blood soaked through his undergarments and his
shorts to his bed sheets. A prison employee took Mr. Reck to
the Health Care Unit where Dr. Trost examined him. During
that examination, Dr. Trost noted that Mr. Reck had an ab-

7 Administrator Walls blamed the delay on a “computer glitch.” R.153-2
at 5. Several other medical encounters took place during this period.
They appear, however, to be related only indirectly to Mr. Reck’s
Crohn’s disease. On July 27, Mr. Reck was seen by a nonparty social
worker in his cell (due to a lockdown). Mr. Reck told the social worker
he would be “‘ok’ until he can get pulled out to be seen.” R.151-1 at 133.
On the 28th, a nonparty nurse drew his blood. Two days later, a nonpar-
ty mental health employee observed Mr. Reck’s appearance during
group therapy. On August 6, 2015, Mr. Reck took a tuberculosis test. On
August 31, 2015, Mr. Reck told a nonparty social worker that he was “‘al-
right’ but could be better” and that he needed medical attention. R.151-1
at 135; see also R.153-2 at 7–8.
6                                                 No. 19-2440

normal connection between two hollow spaces—known as a
“fistula”—on his left buttock. The fistula had been there for
about a month. Dr. Trost also documented that Mr. Reck
previously had undergone surgery to remove a fistula.
Mr. Reck also had taken Humira in 2011 before his Crohn’s
went into remission.
    Dr. Trost prescribed Levaquin, an antibiotic, and Pentasa,
an anti-inflammatory. He also ordered a follow-up in one
month’s time. Mr. Reck further testified that Dr. Trost prom-
ised to refer him to a G.I. specialist.
   Mr. Reck’s abscess burst again on the following day. He
was outside when blood began to run down his leg, and a
correctional officer brought him to the Health Care Unit.
Mr. Reck told Nurse Smith that the abscess was “leaking
        8
now.” Nurse Smith noted an alteration in skin integrity but
did not otherwise examine Mr. Reck; nor did she refer him
to a physician. Instead, she relied on Dr. Trost’s examination
from the previous day. She instructed Mr. Reck to keep the
area clean and dry, and she provided Mr. Reck with gauze
and bandages. She gave him nothing for the pain.
   Mr. Reck passed out when his abscess burst for a third
time on September 12, 2015. He was brought to the Health
Care Unit, where a nonparty nurse tended to him, noted a
“beefy red” open area measuring one centimeter by one cen-
                                                        9
timeter, and told him to keep the area clean and dry.

8 R.151-1 at 6.

9 R.151-1 at 7.
No. 19-2440                                                        7

    Two days later, Mr. Reck submitted another sick call re-
quest to see Dr. Trost for his bloody stool, bursting abscess,
and severe pain. When Nurse Smith saw him three days lat-
er, on September 17, 2015, she noted that Mr. Reck com-
plained of constant bleeding but failed to examine Mr. Reck.
Mr. Reck told Nurse Smith that he “need[ed] to have surgery
               10
on this.” She again provided him with gauze.
    Mr. Reck’s abscess burst again on September 20, 2015. He
suffered severe pain and notified a nonparty correctional of-
ficer. On September 24, 2015, a nonparty nurse saw him and
noted that the abscess had “drained” “white stuff” and ob-
                                         11
served a boil the size of a nickel. Despite instructions that a
physician referral is required for draining or for signs of cel-
lulitis, the nurse did not make a referral. The nurse did not
note active draining and concluded that it looked “like a
                    12
healed boil.”
   Mr. Reck filed a grievance on September 23, 2015, com-
plaining of his repeated unanswered medical care requests.
In her deposition testimony, Administrator Walls noted that
Mr. Reck had experienced a “lengthy” delay but blamed it
                               13
on a “computer glitch.”             She said that Mr. Reck had been
                                                     14
“treated as medically deemed necessary.”                  Administra-

10 Id. at 9.

11 Id. at 10.

12 Id.

13 R.153-2 at 5; R.151-9 at 184:6–23; 190:8–192:9.

14 R.153-2 at 5.
8                                                 No. 19-2440

tor Walls did not mention Mr. Reck’s sick call requests sub-
mitted through the bars, nor did she review Menard policies
or procedures or speak with medical personnel about
Mr. Reck’s grievances.
    On September 27, 2015, Mr. Reck was scheduled to see a
doctor through the physician call line, but the nonparty phy-
sician did not show up.
   Dr. Trost saw Mr. Reck again on October 2, 2015. He did
not examine Mr. Reck. He noted: “[F]istula persists. Last co-
                                                    15
lonoscopy 2012. Humira 2011. No improvement.” He re-
ferred Mr. Reck to a gastrointestinal specialist and requested
a colonoscopy. He did not make a surgery referral at that
time. Dr. Trost continued the same course of treatment that
he had prescribed at the earlier encounter by continuing the
same antibiotic and the same anti-inflammatory. He further
authorized a ninety-day supply of ibuprofen.
   On November 2, 2015, Mr. Reck was back in the Health
Care Unit. He complained of pain and “[c]ont[inual] rectal
                16
bleeding.” Nurse Smith saw him but did not examine him
and did not consult a physician. Two days later, a prison
employee brought Mr. Reck to the Health Care Unit again
                                     17
for “[s]ubstantial bleeding.” Dr. Trost prescribed a third
round of antibiotics; Mr. Reck also received disposable dia-
pers.

15 R.151-1 at 12 (emphasis added).

16 Id. at 15.

17 R.151-10 at 6.
No. 19-2440                                                 9

    On November 6, 2015, Mr. Reck underwent a colonosco-
py. Ten days later, he had his two-year physical exam with a
nonparty physician. Mr. Reck told the doctor about the
bleeding from his buttock and his pain, which he described
as an 8 on a scale of 1 to 10.
     Mr. Reck complained of pain to a nonparty nurse on No-
vember 16, 2015, and on November 24, 2015, Mr. Reck saw a
nonparty medical employee for a colonoscopy follow-up.
Three biopsies had been done; one revealed “focal active co-
litis” in the rectum, which is “consistent with focal mildly
                        18
active Crohn’s disease.” The report described the colonos-
                                    19
copy results as “grossly normal.”
    Mr. Reck saw the gastrointestinal specialist on December
24, 2015, the first available appointment. This physician con-
firmed that Mr. Reck had Crohn’s disease and a rectal fistu-
la. He recommended that Mr. Reck receive Humira, to which
Mr. Reck had responded favorably in 2011 (the last time his
Crohn’s was active). The specialist also recommended that
Mr. Reck be referred to a surgeon. Dr. Trost followed up by
recommending that Mr. Reck be referred to surgery, and the
consultation was approved by Wexford after collegial re-
view on January 8, 2016. His Humira injections were ap-
proved on January 10, 2016.
    Mr. Reck was scheduled for a visit on the physician call
line on January 11, 2016, but no physician was present. He
was rescheduled for January 17 to renew his medication, but

18 R.151-1 at 40.

19 Id. at 33.
10                                                No. 19-2440

the line ran out of time, and he was not seen on that date ei-
ther.
   The surgery consult occurred on January 28, 2016. The
surgeon noted: “The patient is a known case of Crohn’s dis-
ease for over 10 years … . The patient states that he has had
perianal abscesses and fistulae in the past, and has had vari-
ous surgical procedures including seton placement, fistulot-
                                                   20
omy, fistula plug, and anorectal flap in the past.” A rectal
examination revealed “irregularity and scarring within the
                 21
anal canal.” The surgeon concluded that Mr. Reck needed
an examination under anesthesia with a possible stitch
placed and possible cavity drainage. Dr. Trost referred
Mr. Reck to surgery on February 2, 2016. Mr. Reck under-
went surgery on February 9, 2016. The procedure was suc-
cessful.
                             B.
   Mr. Reck filed his Section 1983 complaint on October 17,
2016. He alleged that Wexford, Dr. Trost, Nurse Smith, an
Unknown Medical Director, and three other individuals had
been deliberately indifferent to his serious medical needs.
   The district court appointed counsel for Mr. Reck and al-
lowed him to amend his complaint, but limited the com-
plaint to the following counts:
         Count 1–Eighth Amendment deliberate indif-
         ference claim against Wexford, Walls, and

20 Id. at 126.

21 Id. at 129.
No. 19-2440                                                               11

        Trost for implementing, monitoring, and over-
        seeing an ineffective sick call system;
        Count 2–Eighth Amendment deliberate indif-
        ference claim against Wexford, Walls, and
        Trost for understaffing and failing to fill neces-
        sary positions within the prison medical sys-
        tem;
        Count 4–Eighth Amendment deliberate indif-
        ference claim against Wexford, Trost, and
        Smith for failure to place plaintiff in the chron-
        ic care clinic and on an individualized treat-
        ment plan;
        Count 5–Eighth Amendment deliberate indif-
        ference claim against Dr. Trost for delaying his
        referral of [Mr. Reck] to a GI specialist despite
                                                                22
        having diagnosed the need for such referral[.]
   Dr. Hellerstein, the expert Mr. Reck retained for the liti-
gation, testified in his deposition that Dr. Trost’s care was
reasonable until October 2, 2015. On that date, his care be-
came inadequate. “Dr. Trost should have examined Mr. Reck
to determine the severity and urgency of his abscess/fistula
before starting yet another round of the same antibiotic
                                                                     23
which had previously failed to resolve these problems.” In
Dr. Hellerstein’s view, “[i]t should have been apparent to
Dr. Trost that conservative treatment for Mr. Reck’s ab-

22 R.112 at 7–8. Certain individuals named in the earlier iterations of the
complaint were dismissed from the litigation.
23 R.151-13 at 5.
12                                               No. 19-2440

scess/fistula had failed, would continue to fail, and that he
                              24
needed surgical intervention.” Dr. Hellerstein also testified
that Nurse Smith’s treatment of Mr. Reck, including her re-
peated failure to examine him, fell below the standard of
care. He testified that the decisions regarding Mr. Reck’s
care should not have been made by a registered nurse “and
required prompt consultation with a provider, or an urgent
             25
referral.”
    Wexford’s expert, Dr. Gage, testified to the contrary.
Dr. Gage testified that both Dr. Trost’s and Nurse Smith’s
treatments were reasonable. In her view, Dr. Trost’s con-
servative treatment seemed to have worked because
Mr. Reck was improving by late December 2015. She be-
lieved the fistula healed naturally. Nurse Smith also was
reasonable, in Dr. Gage’s view. The symptoms Mr. Reck pre-
sented to Nurse Smith were the natural healing course of a
fistula, and thus there was no need for Nurse Smith to exam-
ine Mr. Reck.
    The district court granted summary judgment for the de-
fendants. It concluded that Mr. Reck had a serious medical
condition but that no defendant had been deliberately indif-
ferent in addressing that condition. With respect to
Mr. Reck’s medical care requests from July and August 2015,
the court determined that there was no evidence that Ad-
ministrator Walls or Dr. Trost were aware of those requests.
In the court’s view, the record contained no evidence that

24 Id.

25 Id.
No. 19-2440                                                13

the medical staff had received Mr. Reck’s sick call requests.
Turning to the understaffing situation at Menard, the court
found no evidence that the situation had harmed Mr. Reck
or that Dr. Trost or Administrator Walls could have hired
additional medical workers. Evaluating Dr. Trost’s care of
Mr. Reck, the court could find no evidence that Dr. Trost’s
absences or his failure to repeatedly examine Mr. Reck or to
make an earlier referral to a GI specialist had had an adverse
effect on Mr. Reck. Likewise, the court could ascertain no
harm from Nurse Smith’s failure to examine Mr. Reck. Be-
cause no Wexford employee was held to have violated the
Constitution, Wexford itself could not be liable.
   Mr. Reck timely appealed and initially appeared pro se;
we set his appeal for decision under Rule 34. The panel de-
cided, however, to appoint counsel and to set the case for
oral argument.
                              II
                       DISCUSSION
    Mr. Reck makes three discrete arguments. First, he says
that Dr. Trost and Nurse Smith exhibited deliberate indiffer-
ence in their treatment of him. Second, he maintains that
Administrator Walls and Wexford operated an unconstitu-
tionally ineffective sick call system. Finally, he posits that
Administrator Walls, Dr. Trost, and Wexford were responsi-
ble for unconstitutional understaffing of the Health Care
Unit. We will address each in turn.
                             A.
    We first turn to Mr. Reck’s case against Dr. Trost. In es-
sence, Mr. Reck submits that Dr. Trost was deliberately in-
different when he persisted in pursuing a course of treat-
14                                                         No. 19-2440

ment known to be ineffective and in failing to refer Mr. Reck
                                                      26
to a specialist and a surgeon more promptly. The principles
that must guide our evaluation of Mr. Reck’s contentions are
well-established in our case law. A prison official violates
the Eighth Amendment by acting with subjective “deliberate
indifference” to an inmate’s “objectively serious” medical
                                                                        27
condition. Sherrod v. Lingle, 223 F.3d 605, 610 (7th Cir. 2000).
Deliberate indifference requires something more than negli-
gence or even medical malpractice; “[m]edical malpractice
does not become a constitutional violation merely because
the victim is a prisoner.” Estelle v. Gamble, 429 U.S. 97, 106
(1976). “[S]omething akin to recklessness” is needed. Arnett
v. Webster, 658 F.3d 742, 751 (7th Cir. 2011).
    Doggedly persisting in an ineffective treatment can estab-
lish deliberate indifference. In Greeno v. Daley, 414 F.3d 645,
654–55 (7th Cir. 2005), we reversed a grant of summary
judgment where the defendants repeatedly persisted in of-
fering weak medication despite the inmate’s protests that the
medicine was not working. Explaining Greeno, we have un-
derscored that “when a doctor is aware of the need to under-
take a specific task and fails to do so, the case for deliberate

26 Dr. Trost claims that Mr. Reck casts his argument in a manner that
exceeds the bounds of the order granting leave to file a second amended
complaint. Dr. Trost waived this argument by failing to object at the
summary judgment stage. “[A]rguments not raised to the district court
are waived on appeal.” Puffer v. Allstate Ins. Co., 675 F.3d 709, 718 (7th
Cir. 2012).
27 No one disputes that Mr. Reck’s Crohn’s disease and anal fistula con-
stituted a serious medical need. See Trost & Wexford Br. 25; Smith &
Walls Br. 16 (arguing only that they were not deliberately indifferent).
No. 19-2440                                                 15

indifference is particularly strong.” Goodloe v. Sood, 947 F.3d
1026, 1031 (7th Cir. 2020).
    We also must consider the patient’s pain. “A delay in
treating non-life-threatening but painful conditions may
constitute deliberate indifference if the delay exacerbated the
injury or unnecessarily prolonged an inmate’s pain.” Arnett,
658 F.3d at 753. Whether delay rises to the level of deliberate
indifference depends on how serious the condition is and the
ease of treatment. Compare Goodloe, 947 F.3d at 1031–32
(holding that a three-month delay in referring an inmate to
an outside specialist could establish deliberate indifference
where the inmate was in substantial pain), with Gutierrez v.
Peters, 111 F.3d 1364, 1374 (7th Cir. 1997) (affirming dismis-
sal where inmate waited six days to see a doctor for an in-
fected cyst). But “[e]vidence that the defendant responded
reasonably to the risk, even if he was ultimately unsuccessful
in preventing the harm, negates an assertion of deliberate
indifference.” Rasho v. Jeffreys, 22 F.4th 703, 710 (7th Cir.
2022).
    Mr. Reck asks us to consider that he first complained of
his worsening conditions due to the abscess in July of 2015.
Despite his efforts, he did not see Dr. Trost until September
1, 2015, about eight weeks after his initial complaint. By that
time, the abscess had burst. Although Dr. Trost told
Mr. Reck that he would refer him to a gastrointestinal spe-
cialist, he did not make the referral until October 2. Mean-
while the abscess continued to burst open and caused
Mr. Reck considerable pain and restricted significantly his
daily movements.
    On October 2, Dr. Trost made a referral to a gastrointes-
tinal specialist. This decision, Mr. Reck submits, was not in
16                                                        No. 19-2440

accord with the established standard of care. Relying princi-
pally on the report of his expert, Dr. Hellerstein, Mr. Reck
maintains that, at his appointment with Dr. Trost on October
1, it was clear that the previously prescribed conservative
regime of antibiotics had been ineffectual and that his condi-
tion, including his persistent pain, required a referral to a
specialist and a surgeon. Continuing minimal, ineffective
medical intervention, he submits, does not fulfill the institu-
tion’s responsibilities. He points out that he returned to the
clinic frequently in search of assistance to alleviate the condi-
tion and the accompanying pain, but that no effort was
made to alter his medication, even though his records noted
that he had responded well to the biological Humira.
    Dr. Trost takes a different view of the matter. In his view,
the record reveals a steady and appropriate management of
Mr. Reck’s condition within the limitations imposed by the
prison system’s review procedures. He notes that, in his first
encounter with Mr. Reck on September 1, he treated his pa-
tient with an anti-inflammatory (Pentasa) and an antibiotic
(Levaquin). He also scheduled a one-month follow-up. He
denies making any sort of promise of referral to a specialist
                    28
on that occasion.
    Mr. Reck’s own expert admits that Dr. Trost’s course of
treatment was reasonable prior to October 2, 2015. On Octo-

28 Dr. Trost’s testimony in this regard differs from Mr. Reck’s version,
but we do not believe that whether Dr. Trost promised a surgical referral
at the September meeting creates a genuine issue of triable fact. What
Dr. Trost promised is not the appropriate focus in evaluating Mr. Reck’s
contention. Rather, we must focus on what kind of care Dr. Trost actually
gave during the relevant period.
No. 19-2440                                                               17

ber 2, Dr. Trost determined that Mr. Reck’s condition had
not improved. He initiated the necessary process to arrange
a colonoscopy. That request was approved on October 8, and
this procedure was performed on November 6. After the Oc-
tober 2 encounter, Dr. Trost also initiated the process to se-
cure a consultation with a gastroenterologist. He presented
Mr. Reck’s case to a review board on October 29. The Board
approved the consultation on November 4, and an appoint-
ment with the specialist was made for December 24, the first
available appointment. The gastroenterologist recommended
a referral to a general surgeon. That referral was approved
and made in early January. A surgeon examined Mr. Reck
on January 28, and the recommended procedure was carried
out on February 9. No medical witness said that a fistula or
an abscess was discovered during that procedure.
    The main point of disagreement between the medical ex-
perts is whether Dr. Trost should have referred Mr. Reck di-
rectly to a surgeon on October 2 when he realized that his
initial conservative treatment with antibiotics had been inef-
         29
fectual. We therefore must examine carefully Dr. Trost’s
treatment decision in light of the deliberate-indifference
principles we have articulated. Delay, especially when it im-
plicates a worsening of the patient’s condition or prolonged
and unnecessary pain can constitute, under some circum-
stances, a violation of the Eighth Amendment. Here, Dr. Hel-
lerstein opined that he would have made the surgical refer-

29 Dr. Hellerstein testified that Dr. Trost’s failure on October 2 to order a
surgery consult fell below the standard of care. R.151-13 at 8 (“When
Dr. Trost saw Mr. Reck on October 2, it was apparent that Mr. Reck had
failed conservative treatment.”).
18                                                 No. 19-2440

ral on that date, but, notably, he could point to no harm to
Mr. Reck as a result of Dr. Trost’s decision. Dr. Gage testified
that she would have decided upon the same progression of
treatment as Dr. Trost. No doubt, we must consider the per-
sistence of pain during the last quarter of the year, but, as
Dr. Gage testified, the countervailing pain of surgery must
be weighed by a physician in determining a course of treat-
ment.
    The record reveals no support for an Eighth Amendment
violation. It shows, at most, a disagreement among physi-
cians which does, not, without more, establish the necessary
reckless disregard for patient harm and pain required for a
constitutional violation. Beginning on October 2, Dr. Trost
took the steps necessary to obtain approval of the review
board to secure Mr. Reck further treatment. The necessity of
the colonoscopy and the consultation with a gastroenterolo-
gist may be debatable among physicians, but these steps
hardly demonstrate a reckless disregard for Mr. Reck’s
well-being. We do not see here any indication that Dr. Trost
ignored the gravity of Mr. Reck’s condition or
“slow-walked” his treatment plan.
    Nor can we say that Dr. Trost’s pharmaceutical manage-
ment of Mr. Reck’s condition while awaiting surgery consti-
tuted reckless disregard for Mr. Reck’s medical well-being.
After the initial pharmaceutical intervention failed during
September, Dr. Trost prescribed on October 2 a fourteen-day
regimen of Levaquin and Ibuprofen, 800 mg three times a
day as needed. There is no evidence in this record that
would allow a reasonable jury to conclude that Dr. Trost act-
ed in a reckless manner in prescribing medications while
awaiting consultations with specialists.
No. 19-2440                                                            19

   The district court properly concluded that Dr. Trost’s
course of treatment of Mr. Reck’s medical condition will not
support an Eighth Amendment claim.
                                   B.
   We turn now to Mr. Reck’s submission that Nurse Smith
violated the Eighth Amendment by acting with deliberate
                                                                 30
indifference in her medical encounters with Mr. Reck.
    The same basic principles that governed Mr. Reck’s claim
against Dr. Trost apply to this claim. We have noted, howev-
er, that it is important to take into account the role that the
nurse plays in the care of a patient. As a general matter, a
nurse can, and indeed must, defer to a treating physician’s
instructions. See Rice ex rel. Rice v. Corr. Med. Servs., 675 F.3d
650, 682 (7th Cir. 2012); see also McCann v. Ogle Cnty., 909
F.3d 881, 887 (7th Cir. 2018). However, that deference cannot
be “blind or unthinking.” Berry v. Peterman, 604 F.3d 435, 443

30 We note that Mr. Reck has altered his argument on appeal. In his
complaint and at summary judgment, he contended that Nurse Smith
had acted with deliberate indifference by failing to place Mr. Reck in the
chronic care clinic and on an individualized treatment plan. Now, he
argues that Nurse Smith acted with deliberate indifference by failing to
examine him or by failing to refer him to a physician. See Appellant’s Br.
48.
     Arguments not raised in the district court are waived. Puffer,
675 F.3d at 718. But Nurse Smith does not raise the waiver issue in her
appeal brief, and a waiver argument can be waived. United States v. Mor-
gan, 384 F.3d 439, 443 (7th Cir. 2004); United States v. Adigun, 703 F.3d
1014, 1022 (7th Cir. 2012) (“An opposing party can ‘waive waiver’ if it
fails to assert the preclusive effect of the waiver before the appellate
court.”).
20                                                          No. 19-2440

                  31
(7th Cir. 2010). Under some circumstances when a nurse is
aware of an inmate’s pain and the ineffectiveness of the
medications, a delay in advising the attending physician or
in initiating treatment may support a claim of deliberate in-
difference. Id. “Nurses, like physicians, may thus be held lia-
ble for deliberate indifference where they knowingly disre-
gard a risk to an inmate’s health.” Perez v. Fenoglio, 792 F.3d
768, 779 (7th Cir. 2015) (citation omitted).
    The district court correctly concluded that a reasonable
jury could not find that Nurse Smith was deliberately indif-
ferent to Mr. Reck’s medical condition. She treated Mr. Reck
on two occasions during September 2015, on the 2nd and the
17th, before he was seen again by Dr. Trost on October 2.
During both encounters, she neither examined Mr. Reck nor
consulted a physician. Although the two expert witnesses
disagreed as to whether Nurse Smith’s care was profession-
ally appropriate, there is no support for a finding that her
approach was deliberately indifferent.

31 In Berry, we reversed a grant of summary judgment where the nurse
responded to the inmate’s complaints of dental pain and ineffective med-
ication for six weeks between the last time the doctor saw the inmate and
the inmate being transferred to a new facility. Berry v. Peterman, 604 F.3d
435, 443 (7th Cir. 2010). That six-week period was a “substantial passage
of time” that could allow a jury to “conclude that [the nurse] acted inde-
pendently rather than on [the doctor’s] instructions and was therefore
personally responsible for delaying” the inmate’s treatment. Id. In brief,
nurses “have an independent duty to ensure that inmates receive consti-
tutionally adequate care.” Perez v. Fenoglio, 792 F.3d 768, 779 (7th Cir.
2015).
No. 19-2440                                                         21

   Mr. Reck’s expert, Dr. Hellerstein, stated in his report
that, for a patient suffering from the same symptoms as
                                      32
Mr. Reck was suffering in 2015, the “[m]anagement deci-
sion making” is “beyond the scope of a Registered Nurse,
and required prompt consultation with a provider, or an ur-
                33
gent referral.” In Dr. Hellerstein’s view, requiring Mr. Reck
to wait two-and-a-half weeks for an appointment with a
                                                  34
physician fell “below the standard of care.” This testimony,
if accepted by a trier of fact, might support a determination
that Nurse Smith was negligent, but it cannot support a con-
clusion that she was deliberately indifferent. Her first clinical
encounter with Mr. Reck was immediately after his visit
with Dr. Trost. At that visit, Dr. Trost had set in place a par-
ticular treatment plan for Mr. Reck’s future care, including
the administration of an anti-inflammatory and an antibiotic.
Adhering to Dr. Trost’s patient plan while ensuring that
Mr. Reck had the necessary bandages to address the dis-
charge hardly amounts to deliberate indifference. In her sec-
ond clinical encounter with Mr. Reck later in the month, she
was confronted with Mr. Reck’s complaints that his fistula
had burst several times, causing “blood [to run] down his
legs,” and causing him “extreme” and “debilitating” pain—
pain so extreme that he “could not sit down,” pain “so in-

32 I.e., “a patient with Crohn’s disease[,] … recurrent drainage[,] and
increasing pain making walking and sitting extremely painful despite a
recent course of antibiotics.” R.151-13 at 5.
33 Id.

34 Id.
22                                                     No. 19-2440

                                  35
tense that [he] passed out.” In response to these com-
plaints, Nurse Smith continued to adhere to Dr. Trost’s
treatment plan and provided him with gauze and band-aids
to alleviate his immediate issues. Simply adhering to the
medication regime prescribed by Dr. Trost and ensuring that
Mr. Reck had adequate supplies of medication and bandages
may not have been the optimal course to follow in light of
Mr. Reck’s complaints of pain, but, because her deference to
Dr. Trost was not blind or unthinking, her conduct does not
                                   36
exhibit deliberate indifference.
    As in the case of Dr. Trost, our task here is not to deter-
mine whether Nurse Smith acted consistently with the high-
est standards of the nursing profession or even whether her
conduct might be deemed negligent. Our sole task is to de-
termine whether a reasonable finder of fact could determine
that she was deliberately indifferent. The district court cor-
rectly determined that no such finding reasonably could be
made on this record.
                                 C.
    Administrator Walls was the Health Care Unit Adminis-
trator. She is a nurse and was, during the relevant time peri-
od, an employee of the Illinois Department of Corrections.
Where the medical director would oversee the inmate care,
she handled the policy and administration of the Health
Care Unit. She also monitored Wexford’s compliance with

35 R.153-2 at 3–4, 7–8.

36 We note that Mr. Reck was scheduled to see Dr. Trost shortly after
this encounter, one month after the September 1 visit.
No. 19-2440                                                     23

the contract. She oversaw Department medical employees,
but she “did not personally deliver any medical care” or
“have any administrative authority over any Wexford em-
            37
ployees.”        She also lacked “authority to hire, discipline, or
                                                     38
terminate” Department or Wexford employees. She served,
along with Dr. Trost, on the Quality Improvement Commit-
tee.
    Mr. Reck submits that Administrator Walls acted with
deliberate indifference by ignoring his sick call requests dur-
ing the summer months of 2015. Mr. Reck contends that he
submitted several kites “through the bars” during this peri-
od and that they went unanswered. Had the Health Care
Unit properly responded to these kites, continues Mr. Reck,
his condition would have been treated earlier, and he would
not have endured much of the pain that he experienced.
   Administrator Walls frankly testified that there was a
greater chance that a kite would be lost if the inmate chose to
place it in the bars, as opposed to employing one of the other
                        39
available methods. She did not testify, however, as to the
frequency of loss with the “through the bars” method. Nor
does Mr. Reck point to any other evidence that Administra-
tor Walls was aware that the frequency of loss was so high
as to make this method of submission unacceptable absent
substantial reform through her intervention.

37 R.153-1 at 1.

38 Id.

39 See R.151-9 at 179:23–180:10.
24                                                           No. 19-2440

     Under these circumstances, it is clear that the district
court properly granted summary judgment to Administrator
Walls. A reasonable trier of fact could not conclude that she
recklessly failed to improve or discontinue an ineffective no-
tification system.
                                    D.
    Mr. Reck also maintains that Wexford violated the Eighth
Amendment by failing to collect and to respond to requests
for medical care. In Glisson v. Indiana Department of Correc-
tions, 849 F.3d 372, 379 (7th Cir. 2017) (en banc), we set forth
how a plaintiff can establish such liability against a corpo-
            40
rate entity such as Wexford:
             The critical question under Monell, reaf-
        firmed in Los Angeles [County] v. Humphries, 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 el-
        ement. First, she might show that “the action
        that is alleged to be unconstitutional imple-
        ments or executes a policy statement, ordi-
        nance, regulation, or decision officially adopt-
        ed and promulgated by that body’s officers.”

40 We questioned in Shields v. Illinois Department of Corrections, whether
private corporations might also be subject to respondeat superior liability,
unlike their public counterparts, see 746 F.3d 782, 790–92 (7th Cir. 2014),
but we have no need in the present case to address that question, and we
therefore leave it for another day.
No. 19-2440                                                           25

        Second, she might prove that the “constitu-
        tional deprivation was visited pursuant to
        governmental ‘custom’ even though such a
        custom has not received formal approval
        through the body’s official decisionmaking
        channels.” 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.” 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 ... .”
        Either the content of an official policy, a deci-
        sion by a final decisionmaker, or evidence of
        custom will suffice.
Id. (cleaned up) (internal citations omitted).
   “[E]vidence of a widespread practice of failing to review
inmates’ timely filed medical requests” can support a delib-
erate indifference charge against the entity responsible for
reviewing the requests. Thomas v. Cook Cnty. Sheriff’s Dep’t,
                                       41
604 F.3d 293, 303 (7th Cir. 2010). An entity “faced with ac-

41 In Thomas, the inmate presented evidence that the medical requests
were not timely retrieved from the lockboxes in which the inmates de-
posited them. Thomas v. Cook Cnty. Sheriff’s Dep’t, 604 F.3d 293, 303–04
(7th Cir. 2010). Several prison employees were aware of this practice and
knew the dangers of not answering medical requests promptly. Id. This
unofficial custom led to the death of the inmate where prompt retrieval
                                                          (continued … )
26                                                         No. 19-2440

tual or constructive knowledge that its agents will probably
violate constitutional rights, … may not adopt a policy of in-
action.” King v. Kramer, 680 F.3d 1013, 1021 (7th Cir. 2012)
(quoting Warren v. District of Columbia, 353 F.3d 36, 39 (D.C.
Cir. 2004)). Isolated acts of individual employees, however,
are not actionable; something more is required to establish a
widespread custom or practice for Monell liability. Thomas,
604 F.3d at 303. When a plaintiff relies on a widespread prac-
tice to establish an entity’s liability, “proof of isolated acts of
misconduct will not suffice; a series of violations must be
presented to lay the premise of deliberate indifference.”
Palmer v. Marion County, 327 F.3d 588, 596 (7th Cir. 2003).
   Here, Mr. Reck has submitted evidence that medical per-
sonnel took no action on a significant number of his kites.
These medical requests are supported by Mr. Reck’s testi-
mony, his contemporaneous copies of the sick call requests,
and his journal entries. There was no evidence, however,
that medical personnel received, with one exception, these
           42
requests. The logs of the medical department do not indi-
cate that these requests were ever received.

( … continued)

of the medical request forms would have alerted medical staff to the in-
mate’s condition. Id. at 304.
42 The record contains the following unanswered sick call requests from
Mr. Reck:
       x    July 10, 2015—Mr. Reck first complained about
            Crohn’s and fistulas. R.151-2 at 19:19–22, 41:21–42:2.
                                                           (continued … )
No. 19-2440                                                            27

( … continued)

        x   July 14, 2015—Mr. Reck complained to the medical
            technician drawing his blood about his need for
            medical help. Id. at 99:9–100:23.
        x   July 14, 2015—Mr. Reck submitted another sick call
            request. Id. at 110:1–16.
        x   July 19, 2015—Mr. Reck submitted another sick call
            request. Id.
        x   July 28, 2015—Mr. Reck again complained to the
            medical technician drawing his blood. Id. at 101:6–
            23.
        x   August 10, 2015—Mr. Reck submitted another sick
            call request. Id. at 110:1–16.
        x   August 18, 2015—Mr. Reck submitted another sick
            call request. Id.
        x   August 25, 2015—Mr. Reck sent a kite to his counse-
            lor requesting information about his medical issues.
            Id. at 110:21–111:4.
        x   Throughout this time Mr. Reck also verbally told
            other medical health professionals, including medi-
            cation nurses and his counselor, of his need for assis-
            tance. Id. at 84:1–12.
        x   September 1, 2015—Mr. Reck was finally seen by
            Dr. Trost in the Health Care Unit in response to an
            emergency. R.153-2 at 7–8.
The prison defendants admit to receiving one sick call request from
Mr. Reck dated July 26, 2015. They say that Mr. Reck was scheduled to
be seen in response to this request, but an “uncommon” “computer
glitch” caused Mr. Reck to not be seen for that request. Trost & Wexford
Br. 29. Either way, there is no evidence that this single incident was the
act of a policymaking official or “so persistent and widespread as to
                                                            (continued … )
28                                                           No. 19-2440

   Because this case comes to us in summary judgment pos-
ture, we must accept Mr. Reck’s testimony and evidence that
he submitted these requests and that he made some requests
directly to medical staff. Mr. Reck is also correct in maintain-
ing that his chosen method of submission, through the cell
bars, was an authorized method of making such requests.
However, if Wexford’s medical personnel never received
these requests, it is difficult to fault them, or Wexford, for
not having replied.
    There is, however, a more fundamental defect in
Mr. Reck’s case. There is no evidence that Wexford, or any of
its employees, had responsibility for the design, monitoring,
or maintenance of the system of transmitting a prisoner’s re-
quest through the bars. The documentation to which
Mr. Reck invites our attention simply does not address that
matter. Without some showing that Wexford had such re-
sponsibility, we cannot impose on it liability for the system’s
alleged malfunction.
                                    E.
    Mr. Reck’s next contention is that Dr. Trost, Administra-
tor Walls, and Wexford were deliberately indifferent to his
medical needs through a practice of chronically understaff-
ing the Health Care Unit. Deficiencies in staffing and delays
in treatment can give rise to a deliberate indifference claim.
Wellman v. Faulkner, 715 F.2d 269, 274 (7th Cir. 1983). “As a

( … continued)

practically have the force of law,” and thus Monell liability cannot attach.
See Connick v. Thompson, 563 U.S. 51, 61 (2011).
No. 19-2440                                                 29

practical matter, ‘deliberate indifference’ … can be demon-
strated by ‘proving there are such systemic and gross defi-
ciencies in staffing, facilities, equipment, or procedures that
the inmate population is effectively denied access to ade-
quate medical care.’” Id. at 272 (quoting Ramos v. Lamm,
639 F.2d 559, 575 (10th Cir. 1980)). Where a rule or regulation
is required to correct a known dangerous custom or practice,
a public entity’s failure to institute corrective policy is ac-
tionable. Thomas, 604 F.3d at 303.
    The magistrate judge found that Administrator Walls,
Dr. Trost, and Wexford were aware of the staffing issues but
also found neither Administrator Walls nor Dr. Trost had the
authority to fill the vacancies. If they cannot hire more doc-
tors, they cannot be responsible for the lack of doctors.
Dr. Trost might have been negligent in his duties, but a mere
failure to attend to one’s responsibilities, without more, does
not reach the level of deliberate indifference the Constitution
prohibits.
    Moreover, there is no evidence that the understaffing
harmed Mr. Reck. Prior to September 1, 2015, Mr. Reck was
not scheduled to see medical personnel, so lack of available
personnel cannot have harmed him. From September 1 to
October 2, the care Mr. Reck was receiving was, according to
his own expert, reasonable and thus cannot serve as the ba-
sis for a deliberate indifference claim.
    After October 2, Mr. Reck raises two potential instances
when he was harmed by understaffing: (1) On January 11,
2016, he was scheduled on the physician call line but was not
seen because no physician was present. That nonparty doc-
tor was absent due to a scheduling conflict, and Mr. Reck
was recalled for the following week. There is no evidence
30                                                  No. 19-2440

Dr. Lochard’s scheduling conflict was caused by Adminis-
trator Walls, Dr. Trost, or Wexford. (2) Mr. Reck was sched-
uled on the physician call line on January 17, 2016, for a re-
newal of his medicines. He was not seen because the call line
ran out of time. However, his medications were renewed
two days later, and he was seen by a physician on January
24. There is no evidence that the call line ran out of time due
to understaffing, a physician shortage, or because of
Dr. Trost’s absenteeism. Nor can we say on this record that
having his medication renewal delayed by two days effec-
tively denied Mr. Reck medical care.
   For these reasons the district court did not err in granting
summary judgment on the understaffing claim.
                          Conclusion
     In the end, the district court correctly determined that the
defendants are entitled to summary judgment. Accordingly,
its judgment is affirmed.
                                                  AFFIRMED
No. 19-2440                                                      31

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