Court Opinion

ID: 6076395
Source: CourtListenerOpinion
Date Created: 2022-01-13 18:00:52.331979+00
Date Added: 2024-06-11T08:53:03.639709
License: Public Domain

In the

    United States Court of Appeals
                For the Seventh Circuit
                    ____________________
Nos. 19-1145, 19-1375 & 19-1978
ASHOOR RASHO, et al.,
                                               Plaintiffs-Appellees,
                                v.

ROB JEFFREYS, Director of the Illinois
Department of Corrections, and MELVIN HINTON,
Acting Statewide Mental Health Supervisor
of the Illinois Department of Corrections,
                                        Defendants-Appellants.
                    ____________________

           Appeals from the United States District Court
                 for the Central District of Illinois.
            No. 07-C-1298 — Michael M. Mihm, Judge.
                    ____________________

     ARGUED MAY 20, 2020 — DECIDED JANUARY 12, 2022
                ____________________

   Before SYKES, Chief Judge, and RIPPLE and KANNE, Circuit
Judges.
   SYKES, Chief Judge. Ashoor Rasho, on behalf of a class of
mentally ill inmates in the custody of the Illinois Department
of Corrections (“IDOC”), sued IDOC officials for failing to
provide constitutionally adequate mental-health care. The
2                             Nos. 19-1145, 19-1375 & 19-1978

parties eventually reached a settlement requiring IDOC to
meet certain benchmarks across more than a dozen areas of
mental-health treatment. A year later IDOC had failed to
substantially comply with several portions of the agreement,
so the plaintiffs returned to the district court for relief.
Under the terms of the agreement, they needed to prove that
the defendants’ breach itself caused an Eighth Amendment
violation.
    The district judge held that the plaintiffs made such a
showing in five areas of mental-health treatment and noted
that IDOC’s deficiencies were primarily attributable to a
chronic, severe shortage of mental-health staff. Because
IDOC had known about its staffing problem for several
years and displayed a “lack of a sense of urgency” in fixing
the issue, the judge concluded that the defendants were
deliberately indifferent to the risk of harm associated with
inadequate mental-health care. He entered a permanent
injunction requiring IDOC to hire and maintain a specific
minimum number of staff in multiple areas of care and
imposing other specific requirements for the delivery of
mental-health services—all on a court-imposed, mandatory
timetable.
   We reverse the district court’s order and vacate the in-
junction. IDOC officials took reasonable steps to cure the
deficiencies identified by the plaintiffs—in particular, the
understaffing—and those actions cannot be squared with the
judge’s finding of deliberate indifference. Even if those steps
were not fully successful, their reasonable effort to address a
known risk of harm shows that they did not recklessly
disregard that risk.
Nos. 19-1145, 19-1375 & 19-1978                                  3

    The court’s order also exceeds the remedial limitations
set by the Prison Litigation Reform Act (“PLRA”). In the
corrections context, prospective remedies must be “narrowly
drawn, extend[] no further than necessary to correct the
violation of the Federal right, and [be] the least intrusive
means necessary to correct the violation of the Federal
right.” 18 U.S.C. § 3626(a)(1)(A). The permanent injunction
goes well beyond these bounds by prescribing specific
staffing levels and treatment timelines without evidence that
such requirements go no further than necessary to correct an
Eighth Amendment violation.
                         I. Background
    The details of this lengthy litigation are largely irrelevant
for present purposes. Here are the basics: in 2007 Rasho filed
a pro se § 1983 complaint against several IDOC officials
claiming that IDOC’s treatment of his mental illness was
constitutionally deficient in violation of the Eighth Amend-
ment. 1 With the help of counsel, Rasho amended his com-
plaint to assert the same claim on behalf of a proposed class
of all mentally ill IDOC inmates. The class-action complaint
sought declaratory and injunctive relief compelling IDOC to
overhaul its system of mental-health care. After the district
court certified the class, the parties spent years in protracted
settlement negotiations.
   The parties entered into a comprehensive settlement
agreement in 2016, almost ten years after the suit was filed.
The agreement requires IDOC to make dozens of changes to

1 The identity of the defendants has changed over time. The current
defendants are IDOC’s Director and Acting Statewide Mental Health
Supervisor.
4                                  Nos. 19-1145, 19-1375 & 19-1978

its mental-healthcare system, including implementing a
revised screening system for new inmates, providing indi-
vidualized mental-health treatment plans, and augmenting
mental-health staff. The parties appointed Dr. Pablo Stewart
to monitor IDOC’s compliance. They also agreed to cabin the
judge’s authority to fashion relief for violations of the
agreement: “[A]ny order granting such relief must include a
finding that the relief sought is narrowly drawn, extends no
further than is necessary to correct the violation of the
federal right, and is the least intrusive means for doing so.”
This remedial constraint, lifted verbatim from the PLRA,
effectively prohibits judicial enforcement unless IDOC’s
noncompliance causes an Eighth Amendment violation—the
“federal right” at issue. The district court retained jurisdic-
tion to oversee compliance with the agreement. 2
   Dr. Stewart’s first annual report, released in June 2017,
sharply criticized IDOC’s progress in fulfilling the agree-
ment. After analyzing IDOC’s compliance in exacting detail,
Dr. Stewart reached a blunt bottom line: “[T]he lack and
quality of psychiatric services negatively impacts all aspects
of the Settlement and contributes to IDOC being non-
compliant in the vast majority of areas of the Settlement.”
Stewart’s concerns persisted for several months, leading him

2 As such, the agreement is more accurately described as a consent
decree rather than a private settlement. See Doe v. Cook County, 798 F.3d
558, 562–63 (7th Cir. 2015) (explaining that under 18 U.S.C. § 3626, “if an
agreement is judicially enforceable—that is, if a violation means any-
thing other than restarting the litigation on the merits—the agreement
must be treated as a ‘consent decree’”). That distinction is irrelevant for
our purposes, so we use the terms “settlement” or “agreement” for
consistency with the nomenclature adopted by the parties and the
district court.
Nos. 19-1145, 19-1375 & 19-1978                              5

to write to Dr. Melvin Hinton, IDOC’s Chief of Mental
Health, that IDOC was “in a state of emergency.” On the
heels of this letter, the plaintiffs moved for a preliminary
injunction, focusing on IDOC’s noncompliance in five areas
identified by Dr. Stewart: mental-health evaluations, treat-
ment planning, medication management, crisis care, and
segregation care.
    The judge held an evidentiary hearing on the plaintiffs’
motion over six days in late 2017 and early 2018. Witness
testimony revealed that IDOC had clearly made progress in
revamping its mental-healthcare system: it spent $45 million
to build new residential treatment units at several facilities
and $75 million to develop a new data system for intake
assessments; it procured another $150 million to construct a
new inpatient facility; it delivered mental-health training to
its entire staff; and it hired administrative personnel to
coordinate inmate care. Nevertheless, witnesses for both the
plaintiffs and defendants opined that IDOC still could not
provide treatment at the level required under the agreement.
Undisputed testimony attributed IDOC’s shortcomings to
systemic shortages in mental-health staff. Dr. Hinton admit-
ted that IDOC budgeted for 65 psychiatrists but currently
employed less than half that many.
    In May 2018 the judge entered a preliminary injunction.
He concluded that IDOC’s “persistent” staffing deficiencies
had created an “emergency situation” and that IDOC’s
failure to address those deficiencies—despite being aware of
them for “an unreasonable period of time”—amounted to
deliberate indifference. He therefore ordered IDOC to take
measures to address the five areas identified by the plaintiffs
6                                Nos. 19-1145, 19-1375 & 19-1978

and to “provide sufficient staff” to remedy the constitutional
violations in those areas.
   Two days later Dr. Stewart delivered his second annual
report, again finding that IDOC was noncompliant in the
same areas. The plaintiffs moved for a permanent injunction
on the same grounds as the preliminary injunction.
    Over several days in August and September 2018, the
judge held an evidentiary hearing on the permanent-
injunction motion. The parties agreed that pursuant to
Rule 65(a)(2) of the Federal Rules of Civil Procedure, the
judge should also consider the evidence presented at the
preliminary-injunction hearing. The new evidence told a
familiar story: inadequate staffing had caused backlogs in
inmate care, failures to tailor treatment to individual needs,
and an overall inability to satisfy the terms of the settlement
in the same five areas.
   Still, the evidence also showed that the situation had im-
proved in the first half of 2018. Importantly, IDOC had taken
several steps to cure the personnel shortage, including:
    •   increasing the number of full-time-equivalent psychi-
        atric providers from 33.53 to 50.55 and qualified
        mental-health professionals from 111 to 117;3
    •   authorizing unlimited overtime;
    •   partnering with a local university to provide psychi-
        atric care;
    •   expanding use of telepsychiatry;

3 “Full-time equivalent” or “FTE” describes an employee who works
40 hours per week. A 0.5 FTE employee, for example, works 20 hours per
week.
Nos. 19-1145, 19-1375 & 19-1978                                            7

    •   offering travel stipends and bonuses for providers
        willing to take on extra work at different facilities;
    •   setting salaries at the 90th percentile nationwide; and
    •   coordinating with state officials to streamline the li-
        censing process for IDOC psychiatric providers.
These measures, along with revisions to care procedures,
contributed to a decrease in treatment backlogs at several
facilities.
    IDOC witnesses also testified about the difficulties of re-
cruiting mental-health professionals in the corrections field.
A nationwide shortage left 57% of Illinois counties without
any such professionals, and it was hard to persuade medical
professionals to move (or commute) from major cities to
work in the challenging corrections environment. As a
result, Wexford Health Sources, IDOC’s staffing vendor,
struggled to meet recruitment goals.
    The judge granted the plaintiffs’ motion for a permanent
injunction. 4 Rasho v. Walker, 376 F. Supp. 3d 888, 892–93
(C.D. Ill. 2019). Before addressing IDOC’s deficiencies in the
five specific areas at issue, the judge emphasized that his
finding was “based generally on the fact that there is insuffi-
cient mental health staffing at … IDOC.” Id. at 901. Although
he acknowledged that IDOC had made some improvements,
he found that the use of unlimited overtime was “unsustain-

4 In addition to the initial order, the judge also issued a slightly modified
order in response to IDOC’s postjudgment motion and a final order in
response to the plaintiffs’ motion that the orders be altered to comply
with Rule 65(d) of the Federal Rules of Civil Procedure. IDOC appealed
from all three orders. We consolidated the appeals and focus on the
April 22, 2019 final order, reported at Rasho v. Walker, 376 F. Supp. 3d 888
(C.D. Ill. 2019).
8                             Nos. 19-1145, 19-1375 & 19-1978

able” and that IDOC’s “efforts have been generally ineffec-
tive—and have gone on far too long without any significant
attempt to adapt or modify based on the knowledge gained
from their recruiting efforts.” Id. at 906–07. The judge also
criticized IDOC for continuing to rely on Wexford and for
exhibiting an “overall lack of a sense of urgency” in deliver-
ing adequate mental-health care. Id. at 916. As the judge saw
it, this all added up to deliberate indifference.
   Against this backdrop, the judge issued an extensive in-
junction addressing staffing and the five areas at issue. The
essential terms of the order are summarized as follows:
        (1) Staffing. Within 90 days, IDOC must employ
    “7 Site Mental Health Service Directors; 12 Mental Health
    Unit Directors; [16] Staff Psychologists; 142.5 Qualified
    Mental Health Professionals; 102 Behavioral Health
    Technicians; 54.5 Registered Nurses—Mental Health;
    24 Staff Assistants; 85.5 Psychiatric Providers; 1 Director
    of Nursing—Psychiatric; [and] 5 Recreational Thera-
    pists.” Id. at 919–20. The order includes job descriptions
    for several of these positions and requires follow-up re-
    porting and evaluation. The judge drew the staffing
    numbers from a 2014 Remedial Staffing Plan that IDOC
    voluntarily offered during settlement negotiations. Id. at
    919–21.
        (2) Crisis care. IDOC may use crisis care only for a pa-
    tient dangerous to himself or others or upon a finding by
    a mental-health professional that no less restrictive
    treatment is appropriate. A mental-health professional
    must conduct a confidential, daily assessment of a pa-
    tient’s progress and update the patient’s treatment plan
    no later than the time of discharge. For patients who do
Nos. 19-1145, 19-1375 & 19-1978                             9

   not stabilize, the treatment team must establish a plan to
   provide a higher level of care or explain in writing why
   establishing such a plan is not appropriate. Id. at 922–23.
       (3) Segregation. A mental-health professional must
   assess and document an inmate’s condition upon place-
   ment in segregation. For any inmate in segregation for
   16 days or more, IDOC must conduct rounds at least eve-
   ry 7 days and provide out-of-cell time. If an inmate in
   segregation for more than 60 days refuses out-of-cell
   time, a mental-health professional must evaluate the in-
   mate to determine the risk of deteriorating mental health.
   Id. at 923–24.
       (4) Medication. Inmates prescribed psychotropic
   medication must be “evaluated by a psychiatric provider
   at regular intervals consistent with constitutional stand-
   ards.” Id. at 924. IDOC must administer medications in a
   manner that provides “reasonable assurance” that the
   medications are actually delivered. Id.; id. at 924–25.
      (5) Evaluations and treatment plans. IDOC must
   provide all class members an individualized treatment
   plan that includes long- and short-term objectives and
   regular reviews with the patient. Id. at 925.
                       II. Discussion
    The defendants challenge the judge’s ruling that the
shortcomings in IDOC’s performance under the settlement
agreement amount to an Eighth Amendment violation. They
also challenge the scope of the injunction under the terms of
the agreement and the PLRA. We review the judge’s factual
findings for clear error, ADT Sec. Servs., Inc. v. Lisle–
Woodridge Fire Prot. Dist., 724 F.3d 854, 863 (7th Cir. 2013),
10                            Nos. 19-1145, 19-1375 & 19-1978

including his finding of deliberate indifference, see Lockett v.
Bonson, 937 F.3d 1016, 1023 (7th Cir. 2019) (“Whether a
prison official acted with the requisite state of mind ‘is a
question of fact subject to demonstration in the usual ways,
including inference from circumstantial evidence.’” (quoting
Farmer v. Brennan, 511 U.S. 825, 842 (1994))). We review a
decision to enter a permanent injunction for abuse of discre-
tion, Stone v. Signode Indus. Grp. LLC, 943 F.3d 381, 384 (7th
Cir. 2019), but a legal error is necessarily an abuse of discre-
tion, Westefer v. Neal, 682 F.3d 679, 683 (7th Cir. 2012).
A. Deliberate Indifference
    Everyone agrees that each of the plaintiffs suffers from
an objectively serious medical condition—here, mental
illness—which is the first element of an Eighth Amendment
claim premised on inadequate prison healthcare. The par-
ties’ dispute centers on whether the IDOC officials were
deliberately indifferent to the plaintiffs’ medical condition.
Lockett, 937 F.3d at 1022. Deliberate indifference is a subjec-
tive mental state; the official must have actually known of
and consciously disregarded a substantial risk of harm.
Petties v. Carter, 836 F.3d 722, 728 (7th Cir. 2016) (en banc).
This is a high bar “because it requires a showing [of] some-
thing approaching a total unconcern for the prisoner’s
welfare in the face of serious risks.” Rosario v. Brawn,
670 F.3d 816, 821 (7th Cir. 2012) (quotation marks omitted).
    Evidence that the defendant responded reasonably to the
risk, even if he was ultimately unsuccessful in preventing
the harm, negates an assertion of deliberate indifference.
Farmer, 511 U.S. at 844; Peate v. McCann, 294 F.3d 879, 882
(7th Cir. 2002); see also Sinn v. Lemmon, 911 F.3d 412, 423–24
(7th Cir. 2018) (holding that no reasonable juror could infer
Nos. 19-1145, 19-1375 & 19-1978                              11

deliberate indifference where prison officials took sensible
steps to address unsafe prison conditions). Similarly, “the
mere failure of the prison official to choose the best course of
action does not amount to a constitutional violation.” Peate,
294 F.3d at 882.
    The defendants maintain that the judge effectively ig-
nored the subjective element. This case obviously involves a
claim of systemically inadequate prison healthcare, which
the judge referred to as a “second category of deliberate
indifference claim[].” Rasho, 376 F. Supp. 3d at 914. The
defendants read this statement as taking the subjective
element off the table; they contend that the judge engaged in
a solely objective analysis. We see it differently. The subjec-
tive state-of-mind element applies to claims of isolated
incidents of indifference and pervasive deficiencies in prison
medical treatment, and the judge recognized as much. His
innocuous reference to a “second category” of claims—
language that appears in our own caselaw, e.g., Phillips v.
Sheriff of Cook Cnty., 828 F.3d 541, 554 (7th Cir. 2016)—merely
invoked the well-settled principle that while a single negli-
gent act cannot support an inference of deliberate indiffer-
ence, persistence in a course of action known to be
ineffective can, see Whiting v. Wexford Health Sources, Inc.,
839 F.3d 658, 662–63 (7th Cir. 2016).
    Although the judge recited the correct legal standard, we
agree with the defendants that the record does not support
his finding of deliberate indifference. To the contrary, the
evidence establishes that IDOC made reasonable efforts to
cure the deficiencies in the five areas identified in the plain-
tiffs’ claim and to alleviate the staffing shortage. These
include increasing the number of psychiatric providers,
12                            Nos. 19-1145, 19-1375 & 19-1978

authorizing unlimited overtime, paying travel stipends and
supercompetitive salaries, and increasing the use of telepsy-
chiatry (among other steps). These actions by IDOC adminis-
trators demonstrate a commitment to addressing the
problem—the antithesis of the callous disregard required to
make out an Eighth Amendment claim. See, e.g., Rosario,
670 F.3d at 822 (affirming a grant of summary judgment to
officers where their actions were “not perfect” but demon-
strated an “overall picture” of “protection and compas-
sion”).
    To be sure, IDOC’s efforts fell short: the prison system
has not yet provided the level of care prescribed by the
settlement, nor has it hit the personnel targets laid out in its
2014 Remedial Staffing Plan. But that does not equate to a
constitutional violation. For one thing, there is no evidence
that the terms of the settlement and IDOC’s staffing plan
matched the constitutional floor, an issue we address below.
But even assuming IDOC’s goals corresponded to the Eighth
Amendment minimums, the defendants cannot have been
deliberately indifferent because they undertook reasonable
measures to achieve those goals, even though they were
ultimately unsuccessful. Peate, 294 F.3d at 882.
   The judge was wrong to fault the defendants for their
“unsustainable” use of overtime, continued reliance on
Wexford for staffing, and “lack of a sense of urgency” in
complying with the settlement. It is always possible to do
more or move faster, but the existence of policies that may
have been more effective does not mean an official recklessly
disregarded the risk of harm. Smith v. Sangamon Cnty.
Sheriff’s Dep’t, 715 F.3d 188, 191 (7th Cir. 2013); see also
Lockett, 937 F.3d at 1022–25 (explaining that a nurse is not
Nos. 19-1145, 19-1375 & 19-1978                                 13

necessarily liable for an inmate’s chronic pain, even if he
could have prescribed more powerful opiates); Rosario,
670 F.3d at 821–22 (holding that an officer is not liable for an
arrestee’s suicide, even if he could have done more to pre-
vent the arrestee’s access to a razor blade); Frake v. City of
Chicago, 210 F.3d 779, 782 (7th Cir. 2000) (explaining that a
jail is not necessarily liable for a detainee’s suicide, even if it
could have designed cells differently to decrease the risk of
suicide). Prison officials undoubtedly could have done more
to address the deficiencies in IDOC’s mental-health services,
but their failure to pursue additional options does not
amount to deliberate indifference. See Rosario, 670 F.3d at
821–22 (noting officials may “escape liability even if they did
not take perfect action”).
    Nor is this a case in which the prison officials persisted in
taking steps that they knew were insufficient to prevent the
harm. See Petties, 836 F.3d at 730–31. It was reasonable to
expect that paying higher salaries and offering bonuses
would attract more mental-health personnel, just as it was
reasonable to believe that expanding the use of telepsychia-
try and paying travel stipends would enable them to more
efficiently deploy their limited resources. Indeed, the record
shows that IDOC’s multifaceted approach led to reduced
backlogs in mental-health treatment and a substantial in-
crease in the number of psychiatric providers—even though
its efforts ultimately fell short. Put simply, IDOC officials
took multiple reasonable steps to fix the complex problem of
understaffing in mental-health services, so they cannot have
been deliberately indifferent. It was error to find otherwise.
14                             Nos. 19-1145, 19-1375 & 19-1978

B. Scope of Injunction
    The PLRA constrains a court’s authority to enter an in-
junction with respect to prison conditions: “The court shall
not grant or approve any prospective relief unless the court
finds that such relief is narrowly drawn, extends no further
than necessary to correct the violation of the Federal right,
and is the least intrusive means necessary to correct the
violation of the Federal right.” § 3626(a)(1)(A). The Supreme
Court has repeatedly emphasized that prison administrators
have substantial discretion over the institutions they man-
age. See, e.g., Florence v. Bd. of Chosen Freeholders of Cnty. of
Burlington, 566 U.S. 318, 326 (2012). We have done the same.
See, e.g., Mays v. Dart, 974 F.3d 810, 820–21 (7th Cir. 2020).
This principle is embodied in the PLRA’s limit on remedies.
Westefer, 682 F.3d at 683.
    Our decision in Westefer illustrates how § 3626(a)(1)(A)
works in practice. After a group of inmates brought a due-
process challenge to the procedure IDOC used to transfer
prisoners to supermax facilities, IDOC voluntarily submitted
to the court a “Ten–Point Plan” proposing revisions to the
transfer process. Id. at 682. The district court used the Plan as
a model for its remedial order, “incorporating it almost
wholesale into a detailed 16–point injunction.” Id. Notably,
just a few years before, the Supreme Court had upheld a
scheme similar to the Ten–Point Plan against a due-process
claim. Id. at 683 (citing Wilkinson v. Austin, 545 U.S. 209, 230
(2005)). Among other things, the injunction required IDOC
to provide 48-hour notice before a transfer hearing and to
hold a hearing within 10 or 30 days of transfer (depending
on the type of transferee). Id. at 682–83.
Nos. 19-1145, 19-1375 & 19-1978                             15

    We held that the injunction went well beyond the limits
imposed by the PLRA, explaining that the judge had “mis-
takenly conflated what is constitutionally adequate to satisfy
due process with what is constitutionally required.” Id. at
683–84. While the Supreme Court had held that a 24-hour
prehearing notice is constitutionally required, the injunction
violated the PLRA’s narrow-tailoring requirement in man-
dating 48-hour notice. Id. at 684. Likewise, setting a specific
10- or 30-day window for transfer hearings exceeded the
constitutionally required “reasonable time” for such a
hearing and in doing so defied the PLRA’s least-intrusive-
means prong. Id. at 684–85. It did not matter that the injunc-
tion included “hedging ‘whenever possible’ language” in its
mandate; the PLRA requires that courts give prison adminis-
trators wide latitude to set constitutionally adequate proce-
dures. Id. at 685. We summarized:
       In short, the injunction goes well beyond what
       the Supreme Court has said is constitutionally
       required. By incorporating a highly specific
       notice-and-hearing system into the injunction,
       the district court has in effect established the
       details of that system as constitutional re-
       quirements. This is not the narrow tailoring
       that the PLRA requires. It is up to IDOC to
       craft transfer-review procedures that meet the
       requirements of due process. The court should
       do no more than to order IDOC officials to do
       so in general terms and to verify that the plan
       they submit satisfies the relevant constitutional
       standards.
Id. at 686.
16                           Nos. 19-1145, 19-1375 & 19-1978

    The injunction here suffers from the same infirmities as
the one we vacated in Westefer. Most egregiously, the judge
ordered IDOC to hire and maintain precise numbers and
types of personnel: “7 Site Mental Health Service Directors;
12 Mental Health Unit Directors; [16] Staff Psychologists;
142.5 Qualified Mental Health Professionals; 102 Behavioral
Health Technicians; 54.5 Registered Nurses—Mental Health;
24 Staff Assistants; 85.5 Psychiatric Providers; 1 Director of
Nursing—Psychiatric; [and] 5 Recreational Therapists.” This
degree of specificity contravenes the PLRA’s least-intrusive-
means requirement. Could IDOC have provided constitu-
tionally adequate care with 85 Psychiatric Providers instead
of 85.5? What about using 103 Behavioral Health Technicians
but only 22 Staff Assistants? Could IDOC continue to au-
thorize unlimited overtime and expanded telepsychiatry—
practices that had a proven effect of reducing treatment
backlogs? There is no evidence in the record establishing
that these specific numbers correspond to the constitutional
floor, yet the PLRA demands that injunctive relief “extend
no further” than necessary to remedy the constitutional
violation. By exceeding that limitation, the judge’s order
impermissibly strips IDOC officials of the flexibility neces-
sary to adopt and implement policies that balance prison
resources, safety concerns, and inmate health.
    The judge’s error goes beyond staffing too. The injunc-
tion requires, for example, that class members in segregation
for 16 days or more be examined by mental-health staff at
least every 7 days. That may be a valuable way of preventing
the deterioration of a segregated inmate’s mental health, but
the Eighth Amendment does not require the most effective
solution. Rosario, 670 F.3d at 822; see also Ball v. LeBlanc,
792 F.3d 584, 599 (5th Cir. 2015) (holding that an injunction
Nos. 19-1145, 19-1375 & 19-1978                            17

requiring air conditioning to decrease prison cell tempera-
ture violated the PLRA because the “plaintiffs are not enti-
tled to the most effective available remedy; they are entitled
to a remedy that eliminates the constitutional injury” (citing
Westefer, 682 F.3d at 683–84)). As in Westefer, the judge
“mistakenly conflated what is constitutionally adequate …
with what is constitutionally required” and in doing so
overstepped the bounds of the PLRA. 682 F.3d at 683–84.
    The judge held that Westefer is inapplicable for two rea-
sons. First, he noted that “the record here demonstrates a
long history of the [d]efendants’ non-compliance with
various terms they had agreed upon.” Rasho, 376 F. Supp. 3d
at 918. The judge did not explain why he thought that the
history of noncompliance mattered. It doesn’t; or more
precisely, it doesn’t make Westefer inapplicable or dilute the
PLRA’s remedial limitations. The PLRA applies of its own
force and in full since the case involves “prison conditions,”
§ 3626(a)(1)(A), and by dint of its inclusion in the settle-
ment’s remedial limits.
    Second, the judge stated that the “[d]efendants’ proposal
is wholly deficient in addressing their constitutional viola-
tions.” Rasho, 376 F. Supp. 3d at 918. The defendants’ pro-
posal, however, would have required them to remedy the
alleged violation “in general terms” in accordance with our
instructions in Westefer, 682 F.3d at 686. And even if the
proposal had been lacking, the judge was not free to go
beyond the limits imposed by the PLRA in crafting an
injunction.
   We do not mean to say that an injunction imposing a
specific numeric target automatically violates the PLRA. In
Brown v. Plata, 563 U.S. 493, 538–41 (2011), the Supreme
18                              Nos. 19-1145, 19-1375 & 19-1978

Court held that an order requiring California to reduce its
prison population to 137.5% of the prison facilities’ design
capacity satisfied the PLRA’s narrow-tailoring requirement.
Critically, however, the district court heard from multiple
expert witnesses who testified that a 130% limit “was neces-
sary to remedy the constitutional violations” and then
adjusted that metric upward “in light of the caution and
restraint required by the PLRA.” Id. at 540 (quotation marks
omitted). Moreover, the order did not require “achiev[ing]
this reduction in any particular manner” but rather “ordered
the State to formulate a plan for compliance and submit its
plan for approval by the court.” Id. at 510. Doing so gave
California “substantial flexibility” to reach its goal. Id. at 532.
    In contrast to Brown, here the judge imposed specific
benchmarks lifted from the settlement and IDOC’s 2014
Remedial Staffing Plan without evidence that those plans
matched the constitutional floor. In fact, the Staffing Plan
explicitly stated that it set staffing at levels sufficient to
exceed the constitutional minimum. Nor did the judge im-
pose staffing targets “in a manner that [left] much to
[IDOC’s] discretion,” id. at 533; instead, he prescribed the
exact numbers, types, and duties of IDOC personnel. That
can hardly be the least intrusive means of correcting a
constitutional violation.
                        III. Conclusion
    IDOC officials took multiple reasonable steps to cure the
staffing shortage and improve mental-health services in the
five areas at issue in this claim. Those actions demonstrate
due regard for the harms imposed by inadequate mental-
health care, so the judge’s finding of deliberate indifference
was error. In addition, and as an independent reversible
Nos. 19-1145, 19-1375 & 19-1978                           19

error, the scope of the injunction exceeded the bounds set by
the PLRA. Accordingly, we REVERSE the district court’s order
and VACATE the permanent injunction in its entirety.
20                               Nos. 19‐1145, 19‐1375 & 19‐1978

    RIPPLE, Circuit Judge, dissenting. For more than a decade,
Ashoor Rasho, as representative of a class of mentally ill Illi‐
nois prisoners, has been litigating the deficiencies of the Illi‐
nois Department of Corrections (“IDOC”) in the delivery of
mental health care to its inmate population. Although the par‐
ties reached a comprehensive, court‐approved settlement
agreement in May 2016 that called for increased staffing, im‐
proved processes, and updated facilities across service areas,
IDOC was slow to implement changes. The monitor repeat‐
edly reported the core problem: an overwhelming shortage of
staff. It was not until IDOC was faced with the threat of
court‐enforced remedies that it acted with any seriousness or
promptness. The district court found, however, that these
eleventh‐hour efforts were motivated at least in part by the
threat of court intervention, that they were not sustainable,
and that IDOC administrators knew that they were not sus‐
tainable. After considering the record as a whole, the district
court concluded that “systemic and gross deficiencies in staff‐
ing” had resulted in the denial of “access to adequate and con‐
stitutionally required care” that violated the Eighth Amend‐
ment.1 These findings were not clearly erroneous. Moreover,
the district court’s permanent injunction was limited to curing
the constitutional violation and was no broader than neces‐
sary to achieve this purpose. I therefore respectfully dissent.

1R.2460 at 41 (quoting Wellman v. Faulkner, 715 F.2d 269, 272 (7th Cir.
1983)).
Nos. 19‐1145, 19‐1375 & 19‐1978                                         21

                                    I
    Because deliberate indifference is a factual determination,2
I set forth in some detail the facts leading to the district court’s
permanent injunction order.
     In response to Mr. Rasho’s complaint alleging constitu‐
tional violations in the delivery of mental health services, the
parties entered a comprehensive settlement agreement
(“Agreement”) in May 2016. The Agreement addressed nu‐
merous areas where IDOC had been deficient including: the
quality and timing of initial intakes; the development and re‐
vision of treatment plans; treatment space; staffing; confiden‐
tiality; and the housing and discipline of seriously mentally
ill inmates. The Agreement provided for the hiring of a mon‐
itor, Dr. Pablo Stewart, to evaluate IDOC’s progress, provide
updates, and prepare annual reports.
    Dr. Stewart submitted his first annual report in May 2017.
The report noted the substantial cooperation of the leadership
and staff at IDOC but concluded that IDOC still was strug‐
gling to meet the requirements of the Agreement. The Execu‐
tive Summary of the report captures those shortcomings:
        Among IDOC’s challenges is the grossly insuf‐
        ficient and extremely poor quality of psychiatric
        services. This overwhelming shortage and lack
        of standards undermines all of the efforts of
        IDOC to meet the first‐year requirements of the
        Settlement.     These    psychiatric     services

2See Lockett v. Bonson, 937 F.3d 1016, 1023 (7th Cir. 2019) (observing that
“[w]hether a prison official acted with the requisite state of mind”—delib‐
erate indifference—“is a question of fact subject to demonstration in the
usual ways” (quoting Farmer v. Brennan, 511 U.S. 825, 842 (1994))).
22                                  Nos. 19‐1145, 19‐1375 & 19‐1978

           deficiencies include but are not limited to prob‐
           lems with the proper continuation of medica‐
           tions for offenders entering IDOC, lack of timely
           follow‐up for offenders prescribed psycho‐
           tropic medication, dangerous practices related
           to the use of psychotropic medications includ‐
           ing those offenders on forced medication, lack
           of following standard protocols for ascertaining
           side effects, extreme delays in obtaining psychi‐
           atric evaluations, non‐participation of psychia‐
           trists in the treatment planning process, lack of
           timely psychiatric follow up for offenders as‐
           signed to crisis beds, and problems related to
           those offenders designated as requiring inpa‐
           tient level of psychiatric services. Of note, the
           overall quality of the psychiatric services pro‐
           vided to the mentally ill offenders of IDOC is
           exceedingly poor and often times dangerous.
           IDOC leadership is well aware of the problems
           related to the insufficient amount of psychiatric
           services and has taken decisive action to ad‐
           dress this issue, but this has not yet been effec‐
           tive. At the time of the submission of this report,
           however, the lack and quality of psychiatric ser‐
           vices negatively impacts all aspects of the Settle‐
           ment and contributes to IDOC being non‐com‐
           pliant in the vast majority of areas of the Settle‐
           ment.3

3 R.1373   at 10.
Nos. 19‐1145, 19‐1375 & 19‐1978                              23

    As my colleagues note, Dr. Stewart’s concerns persisted
over the next several months. In October 2017, these concerns
led him to write to Dr. Melvin Hinton, IDOC’s Chief of Mental
Health, that IDOC was “in a state of emergency.”4 In the same
letter, Dr. Stewart addressed IDOC’s increased use of telepsy‐
chiatry to solve the mental health crises. Dr. Stewart ex‐
plained that telepsychiatry was not authorized for use in a
number of areas: for “initiating treatment,” for “evaluating
patients in crisis,” or for treating patients with some physical
and cognitive impairments.5 Moreover, although telepsychia‐
try could be one tool in the “overall solution, it [wa]s not the
solution in and of itself. Any solution to this emergency nec‐
essarily involve[d] the hiring of additional psychiatrists, psy‐
chiatric nurse practitioners and/or primary care physicians.”6
    IDOC’s continued failures in the areas identified by
Dr. Stewart led the plaintiffs to file a motion to compel com‐
pliance with the Agreement. They later amended this motion
to include a request for a preliminary injunction. The district
court heard testimony on the plaintiffs’ motion for six days in
late 2017 and early 2018. The evidence showed that IDOC had
spent $45 million to build new residential treatment units at
several facilities and $75 million to develop a new data system
for intake assessments. It also had procured another $150 mil‐
lion to construct a new inpatient facility. Finally, it had pro‐
vided mental health training to its entire staff and had hired
administrative personnel to coordinate inmate care.

4   R.1559‐2 at 3.
5 Id.

6 Id.
24                              Nos. 19‐1145, 19‐1375 & 19‐1978

    However, IDOC still was falling short in the provision of
mental health services due, in large part, to staffing shortages.
For instance, Dr. Hinton testified that IDOC employed less
than half of its budgeted number of psychiatrists. Indeed, “al‐
most all of the medical doctors at the hearing clearly stated,
in one form or another, [that] the system in place to treat men‐
tally ill inmates at the IDOC is in a state of emergency.”7 Cred‐
iting this testimony, the court concluded that IDOC was “un‐
able to provide the constitutionally required care.”8 The court
therefore entered a preliminary injunction. Although it de‐
tailed the areas that IDOC needed to address, it did not set
specific, numeric goals that IDOC had to meet. Instead, it in‐
structed that “[w]ithin 90 days of this order, Defendants shall
provide sufficient staff to address constitutional violations in
the five areas identified in this order”: medication, evalua‐
tions, treatment plans, segregation, and crisis treatment.9
    Dr. Stewart’s Second Annual Report, filed in June 2018,
continued to sound the alarm regarding staffing levels. The
report first noted that the remedial targets set forth in May
2016 were “not sufficient to meet the requirements of the Set‐
tlement Agreement.”10 Moreover, IDOC had “never met its
staffing goals through the life of the Settlement Agreement.”11

7   R.2070 at 13.
8   Id. at 20.
9 Id.   at 40.
10 R.2122    at 34.
11   Id.
Nos. 19‐1145, 19‐1375 & 19‐1978                               25

    Shortly thereafter, the plaintiffs moved for a permanent
injunction. The court conducted a second evidentiary hearing,
in which it again heard testimony from numerous witnesses.
IDOC presented evidence of substantial expenditures on res‐
idential treatment units at several locations; an increase in ad‐
ministrative staff to coordinate services; an increase in train‐
ing provided to staff; and new operating procedures and ad‐
ministrative directives. The evidence also showed that, be‐
tween January 2018 and the permanent injunction hearing,
the Department had increased staffing for mental health from
33.53 to 50.55 full time equivalent providers and had in‐
creased by six the number of qualified mental health profes‐
sionals.
    Nevertheless, the record contained evidence that lack of
staff continued to pose a serious problem. Specifically, when
asked whether the current staffing levels were adequate to
meet the needs of inmates, Dr. Hinton would not directly an‐
swer the question.12 There were efforts to shift staff “from one
area of concern to another” in order to establish that IDOC
was meeting the residents’ needs.13 There also was testimony
from IDOC psychiatrists that, although there had been reduc‐
tions in backlogs, these were due in large part to the use of
overtime, which not only “would be difficult to sustain,” but
created another “problem”—loss of good staff due to burn‐
out.14

12   See R.2372 at 47.
13 R.2460    at 27.
14 Id.   at 23 (quoting R.2376 at 356, 1433–34).
26                                     Nos. 19‐1145, 19‐1375 & 19‐1978

    The district court granted the plaintiffs’ motion for a per‐
manent injunction. Before addressing IDOC’s deficiencies in
the specific areas at issue, the court emphasized that its find‐
ing was “based generally on the fact that there [wa]s insuffi‐
cient mental health staffing at … IDOC.”15 Although it
acknowledged that IDOC had made some improvements, the
court found that the use of unlimited overtime was “unsus‐
tainable,”16 and that IDOC’s “efforts ha[d] been generally in‐
effective—and ha[d] gone on far too long without any signif‐
icant attempt to adapt or modify based on the knowledge
gained from their recruiting efforts.”17 More importantly,
              [e]ven with the additional mental health staff
              hired after the preliminary injunction hearing,
              the numbers associated with mental health pro‐
              viders [we]re deficient to provide the constitu‐
              tionally required care. In fact, the June 2018
              monthly facility performance report showed
              Wexford had failed to supply more than 10,000
              hours of required clinical staff for that month.18
   The court further found that IDOC had been aware of
these deficiencies “for an unreasonable period of time, and
their failure to address these deficiencies amount[ed] to delib‐
erate indifference.”19 “While some efforts ha[d] been

15 R.2460      at 17.
16   Id.
17 Id.     at 27.
18 Id.     at 20.
19   Id. at 27.
Nos. 19‐1145, 19‐1375 & 19‐1978                                               27

successful, including the recent expansion of the use of
tele‐psychiatry, the Defendants ha[d] failed to achieve a min‐
imum level of medical service to avoid the label of cruel and
unusual punishment.”20
    After reviewing the evidence, the court set forth the re‐
quirements for establishing an Eighth Amendment violation:
“(1) the plaintiff ‘suffered an objectively serious harm that
presented a substantial risk to his safety,’ and (2) ‘the defend‐
ants were deliberately indifferent to that risk.’”21 Because
there was no doubt that the prisoners had presented evidence
of an objectively serious risk of harm, the court turned to the
subjective component:
                 The subjective component requires a plain‐
            tiff to “provide evidence that an official actually
            knew of and disregarded a substantial risk of
            harm.” Petties v. Carter, 836 F.3d 722, 728 (7th
            Cir. 2016) … . In order to establish deliberate in‐
            difference, “a plaintiff does not need to show
            that the official intended harm or believed that
            harm would occur.” Id. … However, medical
            malpractice, negligence, or even gross negli‐
            gence do not equate to deliberate indifference.
            Johnson v. Doughty, 433 F.3d 1001, 1013 (7th Cir.
            2006) … .
                 The Seventh Circuit has recognized claims of
            systemic deficiencies in a prison’s health care fa‐
            cility as a second category of deliberate

20 Id.   at 27–28.
21 Id.   at 39 (quoting Minix v. Canarecci, 597 F.3d 824, 831 (7th Cir. 2010)).
28                                     Nos. 19‐1145, 19‐1375 & 19‐1978

              indifference claims. Cleveland‐Perdue v. Brutsche,
              881 F.2d 427, 430–31 (7th Cir. 1989). In case of
              alleged systemic deficiencies, deliberate indif‐
              ference can be demonstrated by “proving there
              are such systemic and gross deficiencies in staff‐
              ing, facilities, equipment, or procedures that the
              inmate population is effectively denied access
              to adequate medical care.” Wellman, 715 F.2d. at
              272 … . The Seventh Circuit has concluded “that
              a clear consensus had been reached indicating
              that a prison official’s failure to remedy sys‐
              temic deficiencies in medical services akin to
              those alleged in the present case constituted de‐
              liberate indifference to an inmate’s medical
              needs.” Cleveland‐Perdue, 881 F.2d at 431.22
     Although the record did show that IDOC had “recently
made efforts to address many of the problems associated with
the delivery of adequate mental health care,” the court “re‐
main[ed] concerned with the overall lack of sense of ur‐
gency.”23 The problems, the court continued, dated “as far
back as 2014 when the Defendants created their own remedial
plan,” but they had yet “to fulfill any of their own staffing re‐
quirements.”24 They also had yet to meet many of the terms
of the Agreement. As a result, “[i]t [wa]s clear [that] mentally
ill inmates continue[d] to suffer as they wait[ed] for the IDOC

22 Id.     at 41.
23 Id.     at 43–44.
24   Id.
Nos. 19‐1145, 19‐1375 & 19‐1978                                        29

to do what they said they would do.”25 Consequently, the dis‐
trict court concluded that IDOC “knew of, and disregarded, a
substantial risk of harm to the Plaintiffs.”26
    After soliciting IDOC’s input regarding how to address
the constitutional deficiency, the district court ultimately con‐
cluded that IDOC’s 2014 proposed staffing plan27 provided a
sound basis for injunctive relief. Thus, the district court re‐
quired that IDOC reach the staffing levels that, back in 2014,
IDOC itself had acknowledged were necessary. While this step
would not solve entirely the present violation, it would at
least require that IDOC make some forward progress toward
meeting minimal staffing requirements.
                                    II
    I now turn to the majority’s review of the district court’s
finding of deliberate indifference. The majority initially ob‐
serves the “high bar” set by the deliberate indifference stand‐
ard, which “‘requires a showing [of] something approaching
a total unconcern for the prisoner’s welfare in the face of seri‐
ous risks.’” Majority Op. 10 (citing Rosario v. Brawn, 670 F.3d
816, 821 (7th Cir. 2012)). Thus, evidence that “the defendant
responded reasonably to the risk, even if he was ultimately un‐
successful in preventing the harm, negates an assertion of de‐
liberate indifference.” Id. (emphasis added). The majority
acknowledges that the district court’s finding that this

25   Id.
26 Id.

27 “IDOC   Proposed Remedial Plan” dated April 17, 2014 (“2014 Reme‐
dial Staffing Plan”), was entered as an exhibit during the hearing on the
preliminary injunction. See R.1716, Exhibit and Witness List, Ex. 9.
30                                   Nos. 19‐1145, 19‐1375 & 19‐1978

standard has been met is a factual one subject only to clear
error review. See id.28
    My colleagues believe, however, that the record cannot
support a finding of deliberate indifference. While “IDOC’s
efforts fell short” achieving the 2014 staffing levels, “that d[id]
not equate to a constitutional violation.” Id. at 12. Even assum‐
ing that the 2014 staffing levels represented the “constitu‐
tional floor,” the majority continues, IDOC could not “have
been deliberately indifferent because [it] took reasonable
measures to achieve those goals, even though they were ulti‐
mately unsuccessful.” Id. (citing Peate v. McCann, 294 F.3d 879,
882 (7th Cir. 2002)). “It is always possible to do more or move
faster,” it states, “but the existence of policies that may have
been more effective does not mean an official recklessly dis‐
regarded the risk of harm.” Id. at 12.
    Respectfully, this conclusion both misreads the record and
fails to give sufficient deference to the district court’s factual
findings. First, the district court did not rely solely on the
staffing numbers in the 2014 remedial plan or the Agreement
to establish a constitutional violation. Rather, the district
court relied on the testimony at the preliminary injunction
hearing that, despite the passage of significant time, IDOC did
not have the staffing necessary to provide psychiatric care to
all of the patients in its system and that prisoners were not
getting the care they needed.29 Moreover, despite some im‐
provements made after the preliminary injunction order

28 Notably,  my colleagues explicitly reject IDOC’s argument that the dis‐
trict court applied an incorrect legal standard. See Majority Op. 11.
29 See   R.2460 at 15–16.
Nos. 19‐1145, 19‐1375 & 19‐1978                                  31

issued, the care still was “constitutionally deficient.”30 “In
fact, the June 2018 monthly facility performance report
showed Wexford had failed to supply more than 10,000 hours
of required clinical staff for that month.”31 Thus, the district
court did not simply look to target numbers; it looked instead
at the care that existing staff was providing and concluded
that the lack of staff was jeopardizing the welfare of the in‐
mates.
    The district court relied on relevant and probative evi‐
dence in concluding IDOC officials were deliberately indiffer‐
ent. In Wellman v. Faulkner, 715 F.2d 269, 272 (7th Cir. 1983),
we addressed whether certain deficiencies in a prison’s pro‐
vision of healthcare violated the Eighth Amendment. We ex‐
plained:
            As a practical matter, “deliberate indifference”
            can be evidenced by “repeated examples of neg‐
            ligent acts which disclose a pattern of conduct
            by the prison medical staff” or it can be demon‐
            strated by “proving there are such systemic and
            gross deficiencies in staffing, facilities, equip‐
            ment, or procedures that the inmate population
            is effectively denied access to adequate medical
            care.”
Id. (quoting Ramos v. Lamm, 639 F.2d 559, 575 (10th Cir. 1980));
cf. Whiting v. Wexford Health Sources, Inc., 839 F.3d 658, 663 (7th
Cir. 2016) (noting that “evidence sufficient to create a jury
question might include the obviousness of the risk from a

30 Id.   at 17.
31   Id. at 20.
32                              Nos. 19‐1145, 19‐1375 & 19‐1978

particular course of medical treatment [and] the defendant’s
persistence in ‘a course of treatment known to be ineffective’”
(internal citations omitted)). Thus, prison officials’ knowledge
of ongoing deficiencies that seriously affect inmates’ health
bears directly on whether the deliberate indifference standard
has been met. The same is true of prison officials’ knowledge
that certain “remedial” actions will not ameliorate the consti‐
tutional violation.
    Here, a district court, which had overseen the litigation for
more than a decade, conducted a comprehensive hearing
prior to the preliminary injunction and another hearing prior
to entry of the permanent injunction. It made specific credi‐
bility findings with respect to the administrators and the men‐
tal health professionals testifying on behalf of IDOC. It
pointed to specific testimony that demonstrated that these of‐
ficials knew that the new measures were not capable of meet‐
ing the needs of the inmates, that they were not sustainable in
the long term, and that they would not cure effectively the
constitutional violations. See R.2460 at 19 (Dr. Hinton evading
the question whether IDOC’s staffing levels were “ade‐
quate”); id. at 23 (Psychologist Administrator at Pontiac ac‐
knowledging that reduction in backlog was being effected
through “people com[ing] from other institutions … and …
additional overtime” which would be “difficult to sustain”);
id. at 27 (“This colloquy between Plaintiffs’ counsel and
Dr. Sim demonstrates the ongoing shift by the Defendants of
their limited staff resources from one area of concern to an‐
other and the need to cover essential items by use of overtime.
This is simply unsustainable.”).
   Nevertheless, the majority concludes that IDOC officials
“cannot have been deliberately indifferent” because they
Nos. 19‐1145, 19‐1375 & 19‐1978                                33

“took multiple reasonable steps to fix the complex problem of
understaffing in mental‐health services.” Majority Op. 13.
This conclusion only can be reached by evaluating the reason‐
ableness of IDOC’s actions in a temporal vacuum. Here, the
district court legitimately—and correctly—evaluated IDOC’s
actions in the context of what had come before: more than a
decade of failing to address seriously the constitutionally de‐
ficient mental health care provided to inmates. The district
court also understood what would come after: loss of staff
and services due to the inability to sustain the financial and
human resource burden of overtime requirements. When
IDOC’s actions are viewed through this lens—as the district
court certainly was entitled to do—they were not reasonable.
The district court concluded that IDOC had been recalcitrant
in addressing systemic problems in staffing until entry of the
preliminary injunction. See R.2460 at 27 (“There have un‐
doubtedly been efforts on the part of the Defendants to ad‐
dress the staffing needs regarding mental health; however,
these efforts have been generally ineffective—and have gone
on far too long without any significant attempt to adapt or
modify based on the knowledge gained from their recruit‐
ment efforts.”). Once the preliminary injunction was entered,
there was a surge of activity, but IDOC officials knew their ac‐
tions would not solve IDOC’s staffing issues, nor ensure the
delivery of constitutionally adequate care.
    “Clear error is a deferential standard of review that only
merits reversal if ‘after reviewing the entire record, we are left
with the firm and definite conviction that a mistake has been
made.’” LAJIM, LLC v. Gen. Elec. Co., 917 F.3d 933, 946 (7th
Cir. 2019) (quoting United States v. Rangel, 872 F.3d 815, 818
(7th Cir. 2017)). When IDOC’s recent “improvements” in the
delivery of services are evaluated according to the entire
34                               Nos. 19‐1145, 19‐1375 & 19‐1978

record, the district court’s conclusion that the IDOC officials
were deliberately indifferent is a sound one. It certainly does
not leave one with a “firm and definite conviction that a mis‐
take has been made.”
                                III
    The panel majority’s review of the scope of the district
court’s injunction also is cause for significant concern. Its par‐
simonious attention to the statute’s language and to the sig‐
nificant consensus of judicial decisions interpreting that lan‐
guage sets our circuit on a lonely course. This solitary path
now before us puts us in conflict with the controlling prece‐
dent of the Supreme Court and with the decisions of the other
circuits. It also will create needless ambiguity and frustration
for the district judges of our circuit who will have the unenvi‐
able task of following its approach in future cases.
                                A.
     The PLRA provides in relevant part:
        Prospective relief in any civil action with respect
        to prison conditions shall extend no further than
        necessary to correct the violation of the Federal
        right of a particular plaintiff or plaintiffs. The
        court shall not grant or approve any prospective
        relief unless the court finds that such relief is
        narrowly drawn, extends no further than neces‐
        sary to correct the violation of the Federal right,
        and is the least intrusive means necessary to
        correct the violation of the Federal right. The
        court shall give substantial weight to any ad‐
        verse impact on public safety or the operation of
        a criminal justice system caused by the relief.
Nos. 19‐1145, 19‐1375 & 19‐1978                                    35

18 U.S.C. § 3626 (a)(1)(A).32 As spelled out in the statutory lan‐
guage, these requirements are to be read in harmony with the
traditional limitations on the equitable powers of the federal
courts: “Nothing in this section shall be construed ... to repeal
or detract from otherwise applicable limitations on the reme‐
dial powers of the courts.” 18 U.S.C. § 3626(a)(1)(C). Conse‐
quently, “the limitations on injunctive relief imposed by …
traditional equity practice remain in force in cases governed
by the PLRA. The PLRA only adds to the preexisting limits on
injunctive relief; it does not subtract from them.” Ga. Advoc.
Off. v. Jackson, 4 F.4th 1200, 1209 (11th Cir. 2021). Traditional
principles for granting federal equitable relief therefore also
inform our understanding of the PLRA. A core traditional
principle is that a court’s task in fashioning equitable relief “is
to correct … the condition that offends the Constitution”; “the
scope of the remedy is determined by the nature and extent
of the constitutional violation.” Milliken v. Bradley, 418 U.S.
717, 738, 744 (1974) (internal quotation marks omitted). In the
words of one of our sister circuits, “the PLRA supercharges”
this traditional equitable principle:
       While courts were already required to ensure
       injunctions are no broader than necessary, the
       PLRA emphasizes the importance of narrow tai‐
       loring in prison litigation by requiring courts to
       make specific findings that “such relief is nar‐
       rowly drawn, extends no further than necessary
       to correct the violation of the Federal right, and
       is the least intrusive means necessary to correct

32 Courts frequently refer to this section as creating a “need‐narrow‐
ness‐intrusiveness” standard.
36                                  Nos. 19‐1145, 19‐1375 & 19‐1978

       the violation       of       the   Federal    right.”
       § 3626(a)(1)(A).
Ga. Advoc. Off., 4 F.4th at 1209.
    Although the PLRA undoubtedly sets a high bar, its stand‐
ards are not designed for application in the abstract world of
appellate chambers but in the real‐world courtroom of the
practicing district judge dealing with very important human
problems and very real parties. We cannot attribute to Con‐
gress the intent to create a practically unworkable standard
designed to frustrate the conscientious district court in the
performance of its already difficult duty. Indeed, the Supreme
Court has instructed that “[t]he PLRA should not be inter‐
preted to place undue restrictions on the authority of federal
courts to fashion practical remedies when confronted with
complex and intractable constitutional violations.” Brown v.
Plata, 563 U.S. 493, 526 (2011). Instead, “[c]ourts should pre‐
sume that Congress was sensitive to the real‐world problems
faced by those who would remedy constitutional violations in
the prisons and that Congress did not leave prisoners without
a remedy for violations of their constitutional rights.” Id.
                                B.
                                1.
    In assessing the district court’s decision, the panel major‐
ity takes as its centerpiece our decision in Westefer v. Neal, 682
F.3d 679 (7th Cir. 2012). In doing so, it asks that solid decision
to carry weight that it was not designed to, and ought not be
required to, bear. Westefer involved a prisoners’ due process
challenge to the method employed to assign them to a maxi‐
mum‐security facility. After a bench trial, the district court
concluded that the procedures violated the prisoners’ rights
Nos. 19‐1145, 19‐1375 & 19‐1978                               37

to due process. While the litigation was ongoing, IDOC had
reviewed its procedures and had submitted to the district
court a proposed ten‐point plan for revisions. The district
court then employed IDOC’s plan as the framework for its re‐
medial order.
    IDOC challenged the order on appeal, and we reversed.
We explained that the district court had “mistakenly con‐
flated what is constitutionally adequate to satisfy due process
with what is constitutionally required.” Id. at 683–84. The
plan, we continued, went far beyond the constitutional re‐
quirements of “informal, nonadversarial due process” and
therefore could not “be reconciled with the PLRA’s require‐
ment that injunctions in prison‐conditions cases must be nar‐
rowly drawn and use the least intrusive means of correcting
the violation of the federal right.” Id. at 684. We concluded:
       By incorporating a highly specific no‐
       tice‐and‐hearing system into the injunction, the
       district court has in effect established the details
       of that system as constitutional requirements.
       This is not the narrow tailoring that the PLRA
       requires. It is up to IDOC to craft transfer‐re‐
       view procedures that meet the requirements of
       due process. The court should do no more than
       to order IDOC officials to do so in general terms
       and to verify that the plan they submit satisfies
       the relevant constitutional standards.
Id. at 686.
   Westefer is a thoughtful, straightforward application of the
core principle of equity practice in constitutional cases, “su‐
percharge[d]” by the PLRA, Ga. Advoc. Off., 4 F.4th at 1209,
38                               Nos. 19‐1145, 19‐1375 & 19‐1978

that a federal court’s injunction should address only “the con‐
dition that offends the Constitution,” Milliken, 418 U.S. at 738.
In Westefer, the district court attempted to restrict the reach of
its injunctive relief by basing it on IDOC’s own submission.
The court nevertheless erred by requiring a remedy that im‐
plemented far more than required by the Constitution.
    In the present case, the district court considered the
Westefer decision, but did not believe that case governed the
situation before it for two reasons: “First, the record here
demonstrates a long history of the Defendants’ non‐compli‐
ance with various terms they had agreed upon. Second, given
this history of non‐compliance, Defendants’ proposal is
wholly deficient in addressing their constitutional viola‐
tions.”33 The panel majority faults the district court for this
conclusion; in its view, IDOC’s history of noncompliance is
not a relevant consideration here. See Majority Op. 17 (“The
judge did not explain why he thought that the history of non‐
compliance mattered. It doesn’t; or more precisely, it doesn’t
make Westefer inapplicable or dilute the PLRA’s remedial lim‐
itations.”). Respectfully, the precedent of the Supreme Court
and of the other circuits counsels otherwise.
   Of key importance is the Supreme Court’s decision in
Brown v. Plata, 563 U.S. 493 (2011). Plata involved consolidated
cases instituted by prisoners in California challenging various
aspects of their confinement. There was no question that the
constitutional violations were, in large part, rooted in over‐
crowding, and the courts in both cases had taken a number of

33 R.2516   at 3.
Nos. 19‐1145, 19‐1375 & 19‐1978                             39

preliminary, remedial steps in an attempt to eliminate the
constitutional violations. As recounted by the Court,
       [a]lthough both the revised plan of action in
       Coleman and the appointment of the Receiver in
       Plata were new developments in the courts’ re‐
       medial efforts, the basic plan to solve the crisis
       through construction, hiring, and procedural re‐
       forms remained unchanged. These efforts had
       been ongoing for years; the failed consent de‐
       cree in Plata had called for implementation of
       new procedures and hiring of additional staff;
       and the Coleman Special Master had issued over
       70 orders directed at achieving a remedy
       through construction, hiring, and procedural re‐
       forms. The Coleman Special Master and Plata Re‐
       ceiver were unable to provide assurance that
       further, substantially similar efforts would yield
       success absent a population reduction. Instead,
       the Coleman Special Master explained that
       “many of the clinical advances ... painfully ac‐
       complished over the past decade are slip‐sliding
       away” as a result of overcrowding. And the
       Plata Receiver indicated that, absent a reduction
       in overcrowding, a successful remedial effort
       could “all but bankrupt” the State of California.
Plata, 563 U.S. at 515–16 (citation omitted).
    The cases were consolidated and submitted to the same
three‐judge panel for a determination of whether a reduction
in prison population should be ordered. After a fourteen‐day
hearing, the panel issued a lengthy opinion, with extensive
findings of fact, in which it “ordered California to reduce its
40                                Nos. 19‐1145, 19‐1375 & 19‐1978

prison population to 137.5% of the prisons’ design capacity
within two years.” Id. at 509–10.
   On review, the Supreme Court first had to determine
whether a three‐judge panel had been properly convened.
The State asserted, among other arguments, that its “later re‐
medial efforts should have been given more time to succeed,”
and consequently, it had not been given “a reasonable
amount of time to comply with the previous orders” as re‐
quired by § 3626(a)(3)(A)(ii). Id. at 515. The Court rejected this
argument, detailing the State’s failed actions and explaining:
           Having engaged in remedial efforts for 5
       years in Plata and 12 in Coleman, the District
       Courts were not required to wait to see whether
       their more recent efforts would yield equal dis‐
       appointment. When a court attempts to remedy
       an entrenched constitutional violation through
       reform of a complex institution, such as this
       statewide prison system, it may be necessary in
       the ordinary course to issue multiple orders di‐
       recting and adjusting ongoing remedial efforts.
       Each new order must be given a reasonable time
       to succeed, but reasonableness must be assessed in
       light of the entire history of the courtʹs remedial ef‐
       forts. ….
           … A report filed by the Coleman Special
       Master in July 2009 describes ongoing viola‐
       tions, including an “absence of timely access to
       appropriate levels of care at every point in the
       system.” A report filed by the Plata Receiver in
       October 2010 likewise describes ongoing defi‐
       ciencies in the provision of medical care and
Nos. 19‐1145, 19‐1375 & 19‐1978                                41

       concludes that there are simply “too many pris‐
       oners for the healthcare infrastructure.” The
       Coleman and Plata courts acted reasonably when
       they convened a three‐judge court without fur‐
       ther delay.
Plata, 563 U.S. at 516 (emphasis added) (citations omitted).
   The Court was equally practical in assessing whether the
order was “narrowly drawn.” The Court explained that
“[w]hen a court is imposing a population limit, this means the
court must set the limit at the highest population consistent
with an efficacious remedy.” Id. at 539. The Court then re‐
counted the expert testimony explaining the rationale for how
much the population should be reduced and concluded that
       [t]here [we]re … no scientific tools available to
       determine the precise population reduction nec‐
       essary to remedy a constitutional violation of
       this sort. The three‐judge court made the most
       precise determination it could in light of the rec‐
       ord before it. The PLRA’s narrow tailoring re‐
       quirement is satisfied so long as these equitable,
       remedial judgments are made with the objective
       of releasing the fewest possible prisoners con‐
       sistent with an efficacious remedy.
Id. at 541 (emphasis added).
   Plata therefore establishes that, even when acting within
the constraints of the PLRA, a district court’s approach to
fashioning a remedy may be informed by the history of both
the constitutional violation and of the failed efforts to solve
the problem through other means. Additionally, in choosing
42                              Nos. 19‐1145, 19‐1375 & 19‐1978

among possible remedial options, the district court’s choice
need not meet standards of scientific precision.
    Cases from other circuits also make clear that the PLRA
allows district courts to consider not only the nature of the
constitutional violation but also the recalcitrance of the insti‐
tutional defendant when evaluating the scope of the injunc‐
tion. Benjamin v. Fraser, for instance, involved the conditions
under which pretrial detainees were held in the city jails of
New York. Benjamin v. Fraser, 343 F.3d 35 (2d Cir. 2003), over‐
ruled on other grounds by Caiozzo v. Koreman, 581 F.3d 63 (2d
Cir. 2009). The parties had entered into a consent decree
which included creation of an agency to monitor jail condi‐
tions. Twenty‐one years later, the City defendants moved to
terminate the decree. In response the district court terminated
some parts of the decree but kept others in place. On appeal,
the Second Circuit reviewed each aspect of the injunction; its
discussion regarding unconstitutional sanitation conditions
at the jails is particularly instructive:
           The district court found, and the City does
       not contest, unconstitutionally unsanitary con‐
       ditions in various areas of the facilities. As one
       remedy, the court ordered that all showers be
       power washed with bleach quarterly. The City
       contends that this requirement will damage its
       newly renovated grouted‐tile showers. It also
       contends that other remedial directives, such as
       the requirement that showers be “thoroughly
       cleaned and sanitized at least once daily,” are
       sufficient to keep the showers in sanitary condi‐
       tion.
Nos. 19‐1145, 19‐1375 & 19‐1978                               43

           But, as the City acknowledges, since 1995 the
       DOC’s own internal policies have required that
       showers be washed daily with sanitizing solu‐
       tion, and, as the district court observed, there is
       no evidence that this cleaning regimen “is equal
       to the task.” We, therefore, find no error in the
       court’s conclusion that stronger remedial measures
       were necessary and affirm the power‐washing re‐
       quirement.
Id. at 55 (emphasis added) (citations omitted).
     Ineffectiveness and recalcitrance also played a role in the
First Circuit’s decision to uphold an injunction in Morales Fe‐
liciano v. Rullan, 378 F.3d 42 (1st Cir. 2004). Morales Feliciano
concerned the long‐term and ongoing failures of the Puerto
Rican prison system regarding delivery of healthcare to its in‐
mate population. In 1998, the district court entered prospec‐
tive injunctive relief that included “the proposed privatiza‐
tion of medical and mental health care throughout the correc‐
tional system.” Id. at 45. Five years later, the Commonwealth
sought to vacate or terminate the injunction on the grounds
(among others) that the district court had failed to make the
necessary findings under the PLRA. The district court denied
relief, and the First Circuit affirmed.
    The First Circuit observed that the PLRA mandates the ter‐
mination of consent decrees unless the district court makes
specific findings, including finding that there is an ongoing
constitutional violation, as well as finding that the order “sat‐
isfies the statutory narrowness‐need‐intrusiveness criteria.”
Id. at 54. The court explained that “[t]he application of those
criteria is case‐specific and must be undertaken in light of
both the magnitude of existing constitutional violations and
44                                Nos. 19‐1145, 19‐1375 & 19‐1978

the available remedial alternatives.” Id. In the case before it,
the court continued,
       [t]he constitutional violations … [we]re sub‐
       stantial in both scope and degree. They have de‐
       fied correction for more than two decades. The
       district court has tried more conventional
       measures, but found them wanting. It has af‐
       forded the Commonwealth ample opportunity
       to bring preexisting mechanisms up to speed or
       otherwise to correct the phalanx of problems. It
       has witnessed the Commonwealth’s continued
       inability to cure the constitutional infirmities
       plaguing the delivery of health care in the cor‐
       rectional system. This record of abject failure mat‐
       ters in the narrowness‐need‐intrusiveness inquiry.
Id. at 54–55 (emphasis added) (citing Benjamin, 343 F.3d at 49).
With respect to the healthcare of inmates, “the level of im‐
provement still f[ell] well short of bringing serious violations
into constitutional compliance.” Id. at 55. “In light of these
facts,” the court had “no difficulty affirming the district
courtʹs finding that a need for ongoing injunctive relief ex‐
ist[ed].” Id.
   As to whether the relief was broader than necessary, the
court noted that, “if this were the district court’s first attempt at
remediation,” it likely would agree with the Commonwealth
that the remedy was overbroad. Id. (emphasis added). How‐
ever, the district court had “attempted narrower, less intru‐
sive alternatives,” but those had failed.
       For this reason, a more innovative remedy [wa]s
       justifiable. The increased intrusiveness and
Nos. 19‐1145, 19‐1375 & 19‐1978                                45

       broader scope of the privatization remedy is a
       direct response to the unique need created by
       the Commonwealth’s own failure—for more
       than twenty years—to correct serious constitu‐
       tional inadequacies. Drastic times call for dras‐
       tic measures.
Id.
    The Ninth Circuit relied explicitly on Morales Feliciano in
upholding a district court’s remedial order in Armstrong v.
Brown, 768 F.3d 975 (9th Cir. 2014). Disabled prisoners in the
California system filed the action in 1994, at which time the
district court concluded that the State was in violation of the
Americans with Disabilities Act and the Rehabilitation Act. In
response, the State produced a remedial plan intended to en‐
sure that disabled inmates had access to programs and facili‐
ties in California’s prisons. In March 2001, the district court
entered a permanent injunction directing enforcement of the
remedial plan. However, by 2007, “the State had failed to
bring its correctional facilities into compliance with the reme‐
dial plan and the 2001 Injunction.” Id. at 978. The district court
therefore entered a second injunction, which required the de‐
fendants to “‘develop a system for holding wardens and
prison medical administrators accountable for compliance
with the Armstrong Remedial Plan and the orders of this
Court.’” Id. This system was to “‘track the record of each in‐
stitution and the conduct of individual staff members who are
not complying with these requirements.’” Id.
    In response to the 2007 injunction, the State issued a de‐
tailed memo outlining how complaints were to be tracked and
investigated. Id. In 2012, however, the plaintiffs still believed
that the State was not complying with the 2007 Injunction,
46                                Nos. 19‐1145, 19‐1375 & 19‐1978

and the plaintiffs asked the court to issue an order to show
cause why the State should not be held in contempt. The mo‐
tion was accompanied by evidence that inmates were contin‐
uing to be denied access to needed accommodations and that
the State had failed to investigate and record numerous al‐
leged violations of the remedial plan. The district court con‐
cluded that the 2007 Injunction may not have stated the re‐
porting requirements clearly enough and therefore issued an
injunction clarifying the State’s obligations, explicitly requir‐
ing “that the State investigate and ‘track all allegations of
non‐compliance with the [remedial plan] and the orders of
this Court.’” Id. at 979.
    The State appealed the modified injunction on several
grounds, including that it violated the PLRA. In affirming the
district court, the Ninth Circuit acknowledged that “the dis‐
trict court gave the State several specific instructions on how
to implement its accountability system,” but nevertheless
concluded that the district court’s actions were “appropriate
here”:
       A court may … provide specific instructions to
       the State without running afoul of the PLRA.
       While the injunction here might leave the State
       less discretion than injunctions typically ap‐
       proved in the PLRA context, we conclude that the
       level of intrusiveness is acceptable based on the his‐
       tory and circumstances of the case.
           Disabled inmates have been litigating to en‐
       sure that the State provides them with needed
       accommodation for over two decades—and yet
       the State still has a long, long way to go before
       it meets its obligations to these prisoners. The
Nos. 19‐1145, 19‐1375 & 19‐1978                                  47

      ongoing, intractable nature of this litigation affords
      the district court considerable discretion in fashion‐
      ing relief. Relief that might have raised concerns
      about breadth and intrusiveness in the first instance
      is acceptable in this context, because the district
      court “has attempted narrower, less intrusive
      alternatives—and those alternatives have
      failed....”
Id. at 985–86 (emphasis added) (quoting Morales Feliciano, 378
F.3d at 55). The Ninth Circuit likened the facts before it to
those in Morales Feliciano; it explained:
          The First Circuit confronted a similar situa‐
      tion in litigation involving Puerto Rico’s prison
      system, where constitutional violations pertain‐
      ing to the delivery of health care were “substan‐
      tial in both scope and degree” and had “defied
      correction for more than two decades.” Id. at 54.
      We face the same problem here. As we have pre‐
      viously noted, litigation in this matter has been
      ongoing for decades and the State has “resisted
      complying with [its] federal obligations at every
      turn.” Through a series of narrowly drawn,
      carefully‐crafted, and thorough orders, the dis‐
      trict judge here, like the district judge oversee‐
      ing the Puerto Rico prison litigation, “has tried
      more conventional methods, but found them want‐
      ing.” See Morales Feliciano, 378 F.3d at 54. “This
      record of abject failure matters in the narrow‐
      ness‐need‐intrusiveness inquiry.” Id. at 55. Be‐
      cause the district court has previously tried to correct
      the deficiencies in California’s prisons’ compliance
48                               Nos. 19‐1145, 19‐1375 & 19‐1978

       with the ADA and RA through less intrusive means,
       and those attempts have failed, relief prescribing
       more specific mechanisms of compliance is appropri‐
       ate. See id. at 54–56; see also Plata, 131 S. Ct. at
       1946.
Id. at 986 (emphasis added) (additional citations omitted).
    The Ninth Circuit observed that “the core PLRA inquiry is
‘whether the same vindication of federal rights could have
been achieved with less involvement by the court in directing
the details of defendants’ operations.” Id. at 986. However, the
State’s actions over the past twenty years had shown “that the
same vindication of federal rights cannot be achieved with
less involvement by the district court.” Id. Moreover, the State
had not suggested other, less‐intrusive means of ensuring ac‐
countability. Given that the State’s failure to present a realistic
alternative, “its protestations that such alternatives exist
[were] hollow.” Id. Thus, the court concluded that the modi‐
fied injunction complied with the PLRA.
    All of these cases establish that, when addressing consti‐
tutional violations that institutional defendants have been
slow to correct, district courts may impose increasingly de‐
tailed injunctions “to correct the violation of the Federal
right.” These cases have distinguished—some implicitly,
some explicitly—a district court’s initial efforts from its later
efforts. Moreover, they have identified the key factors in al‐
lowing a district court to impose more targeted requirements
over time: a continuing constitutional violation that has de‐
fied correction, a begrudging (or at least slow) institutional
response, and a lack of effort on behalf of the public defendant
to propose a viable alternative. Thus, to both the Supreme
Court and to our sister circuits, a “history of
Nos. 19‐1145, 19‐1375 & 19‐1978                              49

noncompliance”34 does matter, and, indeed, is critical in eval‐
uating the scope of the district court’s remedial order
    Our decision in Westefer does not require—or even sug‐
gest—a different result. Westefer did not address a long‐term,
ongoing constitutional violation. In Westefer, the district
court’s detailed injunction, incorporating the ten‐point plan,
represented its first effort to redress the prisoners’ claims.
Therefore, when we instructed the district court to “do no
more than to order IDOC officials” to comply with the due
process clause “in general terms and to verify that the plan
they submit satisfies the relevant constitutional standards,”
Westefer, 682 F.3d at 686, we were addressing a district court’s
first order involving remedial relief. In that context, district
courts must give prison officials considerable leeway in craft‐
ing plans to redress constitutional violations. See id. at 683
(noting prison officials’ “broad administrative and discretion‐
ary authority over the institutions they manage” (quoting
Hewitt v. Helms, 459 U.S. 460, 467 (1983))). We simply had no
occasion to consider how a history of recalcitrance might alter
the need‐narrowness‐intrusiveness inquiry.
                               2.
    The second crucial shortcoming in the majority opinion is
the lack of recognition that the district court occupies a supe‐
rior position in evaluating the critical facts underlying the
need‐narrowness‐intrusiveness inquiry. Complex and en‐
trenched constitutional violations in public institutions do not
lend themselves to simplistic solutions. In Plata, for instance,

34 Majority   Op. 17.
50                               Nos. 19‐1145, 19‐1375 & 19‐1978

the Supreme Court noted the difficulty facing the district
court in fashioning a remedial order:
          [e]stablishing the population at which the
       State could begin to provide constitutionally ad‐
       equate medical and mental health care, and the
       appropriate timeframe within which to achieve
       the necessary reduction, requires a degree of
       judgment. The inquiry involves uncertain pre‐
       dictions regarding the effects of population re‐
       ductions, as well as difficult determinations re‐
       garding the capacity of prison officials to pro‐
       vide adequate care at various population levels.
Plata, 563 U.S. at 538.
    Given the many variables at issue, other courts have rec‐
ognized that district courts have an institutional advantage
over appellate courts in fashioning appropriate remedies un‐
der the PLRA. District courts, having presided over these
cases for years and sometimes decades, develop in‐depth
knowledge of the plaintiffs’ claims, the defendants’ institu‐
tional organization and structure, and, concomitantly, the
practical impediments that particular measures will face (or
the impediments that have rendered prior measures ineffec‐
tual). As a result, the district courts are in the best position to
evaluate what actions are possible, what will be effective, and
what actions are required to ameliorate a constitutional viola‐
tion. See Plata, 563 U.S. at 541 (“The adversary system af‐
forded the court an opportunity to weigh and evaluate evi‐
dence presented by the parties.”); Morales Feliciano, 378 F.3d
at 54–55 (recounting the district court’s two‐decade involve‐
ment in the litigation and its efforts at using less‐intrusive
means); cf. Benjamin, 343 F.3d at 52 (“Giving appropriate
Nos. 19‐1145, 19‐1375 & 19‐1978                                 51

deference to the district court, which has overseen these ef‐
forts for over twenty years, we see no reason to disturb either
conclusion.”). In recognition of this superior frame of refer‐
ence, the factual findings necessary for a need‐narrowness‐in‐
trusiveness determination are reviewed only for clear error.
See Plata, 563 U.S at 541 (explaining that the three‐judge
panel’s “weighing of the evidence” related to narrowness
“was not clearly erroneous”).
    The panel majority, by contrast, gives little weight to the
district court’s unique role. Unlike the Supreme Court and the
other circuits that have confronted the problem, its opinion
contains no acknowledgment of the district court’s familiarity
with the underlying constitutional violations, the recalcitrant
actions of the defendants, or how that recalcitrance affected
the inmates with serious mental health needs. Indeed, it is
very difficult to find any deference at all to the district court’s
factual findings. Rather, much like its deliberate indifference
analysis, the majority treats the need‐narrowness‐intrusive‐
ness inquiry as one that is purely legal and therefore subject
to de novo review. Such an approach cannot be reconciled
with Plata, nor with that of our sister circuits. See generally
Charles Allen Wright, The Doubtful Omniscience of Appellate
Courts, 41 Minn. L. Rev. 751 (1957).
                                C.
   When we evaluate the district court’s injunction in light of
IDOC’s history of noncompliance and appreciate, as we
should, the superiority of the district court’s institutional van‐
tage point to our own, it is clear that the injunctive relief
crafted here passes muster under the PLRA.
52                                Nos. 19‐1145, 19‐1375 & 19‐1978

    As in the cases discussed above, the conditions allowing a
district court to be more focused in its remedial efforts are all
present. There is no question that there is a constitutional vi‐
olation that has defied correction. See R.2460 at 27–28 (“While
some efforts have been successful, including the recent expan‐
sion of the use of tele‐psychiatry, the Defendants ha[d] failed
to achieve a minimum level of medical service to avoid the
label of cruel and unusual punishment.”). And IDOC’s re‐
sponse has been both begrudging and “reactionary.” R.2516
at 4 (“In its Orders, this Court specifically found that the De‐
fendants’ efforts to comply with the Settlement Agreement (or
its own general directives) only came at the time of, or after,
the filing of the Plaintiffs’ initial Motion. Simply put, the De‐
fendants’ actions have been largely reactionary.” (citation
omitted)).
     At the outset, the record is replete with evidence that the
central contributing factors to IDOC’s failure to provide con‐
stitutionally adequate mental health care (if not the only one)
is its staffing shortage. Any effective remedy, therefore, must
include guidelines for staffing levels. However, there was no
serious effort by IDOC to participate in the crafting a remedial
order. After the district court granted the plaintiffs’ motion
for a permanent injunction, it asked IDOC to “submit their
proposed action to address the constitutional deficiencies”
outlined in the court’s order.35 With respect to the most criti‐
cal aspect of relief—staffing levels—IDOC proposed the fol‐
lowing:
           The Department shall adopt a staffing plan and
           achieve a level of staffing that provides a

35   R.2460 at 50.
Nos. 19‐1145, 19‐1375 & 19‐1978                                 53

           sufficient number of mental health staff of var‐
           ying types to provide class members with ade‐
           quate and timely evaluations, treatment, and
           follow‐up consistent with contemporary stand‐
           ards of care. The Department may use any rea‐
           sonable means that it determines in its profes‐
           sional judgment to be appropriate to provide
           sufficient staffing.36
    The district court legitimately concluded that this general
recitation of its constitutional responsibilities did not reflect a
serious effort by IDOC to contribute to the remedial analysis:
           The Defendants’ most egregious attempt to cure
           their constitutional deficiencies is set forth in
           their proposal regarding mental health staffing.
           Defendants propose adopting the vague re‐
           quirement that they have “a staffing plan and
           achieve a level of staffing that provides suffi‐
           cient number of mental health staff of varying
           types to provide class members with adequate
           and timely evaluations, treatment and fol‐
           low‐up consistent with contemporary stand‐
           ards of care.” Yet, Defendants know they are
           understaffed, and they also know the staffing
           levels which are necessary to provide adequate
           care. In fact, Defendants are fully aware of all
           these deficiencies, as they have both

36   R.2473‐1 at 4.
54                                       Nos. 19‐1145, 19‐1375 & 19‐1978

            acknowledged the staffing problems at the Illi‐
            nois Department of Corrections.37
    Thus, absent any helpful contribution by IDOC, the dis‐
trict court turned to the staffing levels set forth in IDOC’s own
2014 staffing plan. Notably, IDOC authored this plan and rep‐
resented that, at least in 2014, it would “satisfy its constitu‐
tional duty to provide mental health care to seriously men‐
tally ill … offenders.”38 According to the plan, it reflected “a
measured approach for achieving the necessary transfor‐
mation within a reasonable timeframe.”39
    Given that, in 2014, this plan represented IDOC’s best as‐
sessment of the staffing that would bring it into constitutional
compliance in both a “measured” way and “reasonable”
timeframe, it is difficult to see how the relief fails the
need‐narrowness‐intrusiveness test. The district court’s deci‐
sion to use IDOC’s remedial plan both recognizes that IDOC
is in the best position to assess the staffing levels that will al‐
low it to deliver constitutionally compliant mental health care
and that it is unlikely to saddle itself with unnecessary bur‐
dens. Moreover, as the district court recognized, at this point,
the 2014 numbers represent a bare minimum. They may not
be sufficient to correct the Eighth Amendment violation. The
number of prisoners with mental health needs only has
grown over the past seven years, and there is some evidence
that the proposed staffing numbers are no longer sufficient.
Nevertheless, because the 2014 staffing levels never had been

37   R.2516 at 4–5 (citation omitted).
38   2014 Remedial Staffing Plan at 1.
39   Id. at 2.
Nos. 19‐1145, 19‐1375 & 19‐1978                                55

achieved, the district court could not say definitively that they
would be inadequate. As such, they represented a legitimate
estimate to achieve a constitutional floor.
    Although acknowledging that “specific numeric target[s]”
do not “automatically violate[] the PLRA,” Majority Op. 17,
my colleagues nevertheless fault the district court for impos‐
ing staffing targets that did not leave much to IDOC’s discre‐
tion, see id. at 18 (quoting Plata, 563 U.S. at 533). However, the
remedial plan was a product of IDOC’s discretion: All of the
staffing numbers used by the district court in its permanent
injunction originated with IDOC. The district court did noth‐
ing more than order IDOC to a conform to a plan of its own
making. Nothing in this action intruded on IDOC’s deci‐
sion‐making regarding allocation of resources, prison admin‐
istration, or public safety.
    Here, the district court made specific findings establishing
that its permanent injunction “extend[s] no further than nec‐
essary to correct” the Eighth Amendment violation, “is nar‐
rowly drawn,” and “is the least intrusive means necessary to
correct the violation” of the inmates’ rights. I would therefore
affirm the judgment of the district court entering permanent
injunctive relief against IDOC.