# Williams v. State of Illinois

> District Court, S.D. Illinois · February 2, 2023

URL: https://www.frixlaw.com/law-library/cases/10156139

## Case

- **Court:** District Court, S.D. Illinois
- **Decided:** February 2, 2023
- **Opinion:** 100trialcourt
- **Cited by:** 0 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/10156139

## How later opinions describe it (automated extraction)

- holding plaintiff did not inappropriately add new claim during summary judgment briefing when factual basis was alleged in complaint

## Opinion text

IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ILLINOIS

JEANETTA WILLIAMS, )
as Independent Administrator for the )
Estate of Dontrell Taquon Mundine- )
Williams, deceased, )
) Case No. 3:19-CV-739-MAB
Plaintiff, )
)
vs. )
)
ILLINOIS DEPARTMENT OF )
CORRECTIONS, JOHN R. BALDWIN, )
and WEXFORD HEALTH SOURCES, )
INC., )
)
Defendants. )

MEMORANDUM AND ORDER

BEATTY, Magistrate Judge:
This matter is currently before the Court on the motions for summary judgment
and motions to exclude Plaintiff’s experts filed by Defendants John Baldwin, the Illinois
Department of Corrections, and Wexford Health Sources, Inc. (Docs. 140, 142, 144, 145).
For the reasons explained below, the motions for summary judgment as well as the
motions to exclude Plaintiff’s experts are granted.
BACKGROUND
Plaintiff Jeanetta Williams brought this suit in her capacity as independent
administrator for the estate of her son, Dontrell Taquon Mundine-Williams, who
committed suicide on December 1, 2017, while incarcerated at Lawrence Correctional
Center. Ms. Williams alleges, in short, that Defendants were well aware of Dontrell’s
mental health issues but failed to provide him with adequate care and treatment due to
systemic deficiencies within the IDOC, which led to Dontrell committing suicide.

In the Second Amended Complaint, (Doc. 95), which is the operative complaint,
Plaintiff expressly set forth the following claims:
Count 1: Eighth Amendment deliberate indifference claim against John
Baldwin for placing Dontrell in extended solitary confinement
rather than providing effective treatment for his mental illness;
Count 2: Claims under the Americans with Disabilities Act against the
IDOC for discriminating against Dontrell based on his mental
illness and failing to accommodate his mental illness;
Count 3: Claims under the Rehabilitation Act against the IDOC for
discriminating against Dontrell based on his mental illness and
failing to accommodate his mental illness;
Count 4: Claim against John Baldwin under the Illinois Wrongful Death
Act, 740 ILL. COMP. STAT. 180/1, and the Illinois Survival Act, 755
ILL. COMP. STAT. 5/27-6, based on negligence;
Count 5: Wrongful death and survival action against Wexford based on
negligence;
Count 6: Wrongful death and survival action against John Baldwin for
willful and wanton conduct; and
Count 7: Wrongful death and survival action against Wexford for willful
and wanton conduct.

FACTS
The following facts were established by the summary judgment evidence and
largely address only the details of Dontrell’s incarceration. Other facts relevant to
Plaintiff’s claims are set out in the respective discussions of those claims later in this
Order.
Defendant John Baldwin was the Director of the IDOC from August 2015 to May
2019 (Doc. 144-2, pp. 8–9). Wexford is a private corporation that is contracted with the
State of Illinois to provide medical and mental health care to prisoners in IDOC custody.
Dontrell Williams had a history of mental illness and treatment, including
multiple inpatient hospitalizations and partial hospitalizations by the time he was 13

years old (Doc. 174-1). The records from those hospitalizations show that Dontrell was
diagnosed with mood disorder, and at times given a co-diagnosis of attention deficient
hyperactivity disorder (Doc. 174-1, pp. 3, 9, 13, 17, 25).1 The records reflect that Dontrell
was irritable, easily agitated, and explosive; restless, hyperactive, and fidgety (Doc. 174-
1). He was impulsive and unable to control himself or follow directions, and disruptive
at school and during therapy (Id.). He was aggressive and threatening toward others, got

into verbal and physical altercations with siblings and peers, and acted oppositional and
defiant toward adults (Id.). He destroyed property and had to be held down during
tantrums (Id.). And he was suicidal at times (Id.). Dontrell was treated with medication
and therapy (see id.). In particular, he was prescribed lithium and Concerta, and at times
Risperdal and Ritalin (Id.).

There is a gap in the record regarding Dontrell’s mental health from age 13 to age
21. The information picks up again on June 1, 2017, when Dontrell arrived at the Northern
Reception and Classification Center (“NRC”) at Stateville Correctional Center, following
a parole violation, where he stayed for approximately two months (Doc. 144-1; see Doc.

1 There was also one occasion where he was diagnosed with depressive disorder and oppositional defiant
disorder (Doc. 174-1, p. 21).
141-5, p. 361).2 A Mental Health Screening was conducted upon his arrival,3 and Dontrell
self-reported diagnoses of impulse control disorder and bipolar disorder,4 four previous

suicide attempts, and 15 previous psychiatric hospitalizations, the most recent being in
2016 after he tried to hang himself (Doc. 172-6, pp. 12–15). Dontrell was evaluated for
suicide potential and determined to be a non-risk (see id. at p. 13).5 Dontrell reported that
he was “good,” and the MHP noted that he was calm, cooperative, and presented as
stable. The screening documented that Dontrell was taking divalproex, which was also
confirmed in a psychiatrist’s note from the same day (Id. at p. 11).6 It was noted that the

2 Dontrell was initially incarcerated in the IDOC in March 2016 and released in October 2016 (Doc. 144-1).
While mental health records exist from this period of incarceration, they were not provided to the Court.

3 IDOC Administrative Directive 04.04.100(e) defines a Mental Health Screening as “a generalized review
and interview process to identify offenders who may require mental health services.” (Doc. 144-4, p. 3).

4 It is unclear when Dontrell received a diagnosis of bipolar disorder and who made the diagnosis. Bipolar
disorder was listed as a “provisional diagnosis” in the January 2010 records from Hartgrove Hospital but
not as a final “discharge diagnosis” (Doc. 174-1, p. 3). And various records from Dontrell’s incarceration
reflect that he self-reported a diagnosis of bipolar disorder, as well as at least one occasion where he self-
reported a diagnosis of schizophrenia (Doc. 172-7; Doc. 144-12, p. 2; Doc. 172-6, p. 1). However, as far as
the Court can tell, there are no medical records in evidence in which a mental health provider actually
diagnosed Dontrell with bipolar disorder.

5 Plaintiff erroneously claimed that Dontrell did not receive an Evaluation of Suicide Potential until 11
days after his Mental Health Screening in violation of the requirements of IDOC Administrative Direction
04.04-100 (Doc. 173, p. 15).

6 The psychiatrist’s note lists Depakote as the medication and also includes a reference to “VPA,” which is
a common abbreviation for valproic acid. Divalproex sodium and valproic acid are “similar medications
that are used by the body as valproic acid.” MEDLINE PLUS, Valproic Acid,
https://medlineplus.gov/druginfo/meds/a682412.html (last visited Feb. 1, 2023). Depakote is listed as a
brand name for both divalproex sodium and valproic acid. Id.; MAYO CLINIC, Divalproex Sodium,
https://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/description/drg-
20072886 (last visited Feb. 1, 2023). It appears that practitioners in this case essentially used the three
names—divalproex, VPA, and Depakote—interchangeably. The medication is an anticonvulsant used to
treat certain types of seizures. MEDLINE PLUS, Valproic Acid. It is also used to treat mania in people with
bipolar disorder and to prevent migraine headaches. Id.
medication was prescribed by medical staff, and not as a psychotropic for a mental health
condition (Id.). The medication was “bridged for 30 days” while Dontrell waited “to see

psychiatry” (Id.; see also id. at p. 15).
Dontrell’s two-month stint at the NRC was troubled. He was put on crisis watch
on two occasions, the first after he purportedly drank bleach7 and the second after he
was found making cuts on his arm with a staple and said he “want[ed] to die” (Doc. 172-
6, pp. 16–29, 36, 64–68; Doc. 172-7, p. 1). He was seen for a crisis response another four
times; three because he was “going crazy” and “bugging” about the lack of information

as to whether a home site had been found so he could be released from prison (Doc. 141-
5, pp. 19–26). The fourth time was at the request of security because Dontrell was “hostile,
agitated, and uncooperative” regarding a housing placement (Id. at pp. 25–26). Dontrell
also received three disciplinary tickets at the NRC. The first for threatening an officer and
for kicking and banging on the door of his cell (Doc. 144-8, pp. 20–21). The second for

throwing urine on another inmate (Id. at pp. 1, 19). And the third for putting pages from
a book over the windows of his cell and refusing to remove them when ordered to do so
(Id. at pp. 15, 18). He was given one month segregation on each ticket, which was
approved by a reviewing MHP (Id. at pp. 1, 15–17; Doc. 144-7).
Dontrell saw Dr. Aswin Jayachandran for a psychiatric diagnostic evaluation on

July 6, 2017—halfway through his time at the NRC (Doc. 141-5, pp. 1–18). The doctor

7 According to the report of Dr. Michael Jarvis, who is Wexford’s retained expert witness, Dontrell stated
the following day on June 5, 2017, “I was trying to get out of my cell. I said I drank bleach but I didn’t. I got
family. I’m not trying to die.” (Doc. 142-4, p. 3). The mental health record from June 5, 2017 does not appear
to be part of the records provided to the Court (see Doc. 141-5, Doc. 144-15, Doc. 172-6).
wrote that Dontrell’s “Chief Complaint” was “‘Depression’ ‘Bipolar.’” The doctor also
noted that Dontrell was currently taking Depakote for his seizures, and had previously

taken lithium, Abilify, and Remeron, but not since 2015. Dontrell reported some “low
moods, frustration due to personal stressors” but denied persistent depression. He also
reported some increased insomnia, increased fatigue, and decreased appetite. He denied
having any current suicidal ideations. The doctor indicated that Dontrell was a moderate
suicide risk due to his history of multiple suicide attempts and hospitalizations and
“current depression.” He also noted that Dontrell exhibited certain personality

characteristics, including repeated lawless behavior, impulsivity, repeated physical fights
or assaults, reckless disregard for others, lack of remorse, and affective instability. The
doctor’s diagnosis was adjustment disorder with mixed emotions and conduct
(“adjustment disorder”), depressive disorder, and anti-social personality disorder
(“ASPD”) traits. The doctor also wrote “[rule out] disruptive impulse control disorder.”

He did not designate Dontrell as SMI. He prescribed Remeron, which is an
antidepressant, “for moods/insomnia” and ordered a follow-up appointment in one
month, per the requirements of IDOC policy (Doc. 144-16, p. 3; see Doc. 144-16, p. 3,
Administrative Directive 04.04.101). The follow-up appointment never occurred,
however, because Dontrell was transferred to Lawrence Correctional Center on July 28,

2017, where he remained until his death on December 1, 2017 (see Doc. 144-1).
Upon his arrival at Lawrence, a mental health screening was conducted (Doc. 141-
5, pp. 27–40). Dontrell misreported that he had never been hospitalized for psychiatric
treatment and had never attempted suicide (Id. at p. 27). The screener noted that
Dontrell’s behavior was unremarkable, he was cooperative, in a good mood, and able to
stay focused on the session (Id. at p. 30). His diagnosis was listed as adjustment disorder

and his current medications were listed as Remeron, Depakote, and Benadryl (Id. at pp.
36, 40). The screener determined that Dontrell was not a suicide risk and referred him to
a psychiatrist and for a mental health evaluation and services (Id. at pp. 30, 31–34, 36–37).
The mental health evaluation was completed approximately two weeks later, on
August 11th (Doc. 141-5, pp. 43–59). Dontrell reported that “he [didn’t] have any mental
health concerns” and the only issue he had was trouble sleeping (Id. at pp. 43, 45, 56, 58).

He also apparently misreported he had no history of psychiatric hospitalizations,
outpatient treatment, suicidal behavior, or suicide attempts, that he was not hyperactive
or prescribed Ritalin/Adderall/Concerta as a child, and that he does not have fluctuating
moods (Id. at pp. 46, 47, 56). The misinformation led the MHP to conclude that Dontrell
had “no past [mental health] or psych [history] on the outside” and did not have any

symptoms or meet any criteria for a mental health diagnosis, although his chart listed a
diagnosis of adjustment disorder (Id. at pp. 43, 58). The MHP indicated that Dontrell
would continue to follow-up with MHP every 60 days and he was referred to psychiatry
because he was taking Remeron (Id. at p. 43).
A note in Dontrell’s medical record from the next day indicates that Dontrell had

a history of non-compliance with his seizure medications (Doc. 172-6, pp. 2–3). He told
the nurse that he does not take his morning medications because the Remeron “makes
him ‘sleep hard’” so he is unable to hear the morning call for medications (Id.). The day
after that, Dontrell received a ticket for fighting with his cellmate, whom he claimed was
stealing his stuff (Doc. 144-7; Doc. 144-8, pp. 13–14). Dontrell was apparently not
designated as SMI at this time, and it does not appear that mental health was consulted

regarding potential punishment on this ticket (see Doc. 144-7; Doc. 144-8, pp. 13–14; Doc.
141-5). He was given one month in segregation (Doc. 144-8, pp. 13–14).
On August 17th, MHP Leann Hartleroad met with Dontrell at the request of
security because Dontrell was cutting his arm with a staple and banging his head on the
cell door (Doc. 172-6, p. 4; Doc. 141-5, pp. 63–83). Dontrell stated that he was going to kill
himself, was refusing medication, and was angry his parole site was not approved (Doc.

141-5, pp. 83). He was deemed a suicide risk and placed on crisis watch until August 20th,
when it was discontinued (Id. at pp. 83–94). It was resumed four days later when Dontrell
told an officer that “he wanted to hurt himself” and threatened to cut himself with a
staple (Doc. 141-5, pp. 97–99). The next morning, Dontrell told the MHP “that he was
‘stressed out’ the night before and needed to speak with mental health” but “officers ‘lied

on him’ about reports of cutting himself with a staple” (Id.). Dontrell said he was no
longer stressed out and wanted to leave crisis watch (Id.). Later that same day, Dontrell
once again reported that he was fine (Id. at p. 117). The MHP noted that he presented as
stable and indicated “an understanding of the coping skills needed to maintain stability”
and “an intent to implement deep breathing and relaxation techniques in an effort to

reduce anxiety” (Id.). It was determined that he was no longer a suicide risk and he was
released from crisis watch (Id. at pp. 117, 119–22).
An MHP met with Dontell ten days later on September 4th for post-crisis watch
follow-up and to update his treatment plan (Doc. 141-5, pp. 125–36). He presented as
stable and denied any acute mental health symptoms or current issues (Id.). However, a
number of incidents occurred throughout the month. On September 9th, Dontrell was

ticketed for insolence and drugs after he yelled and cursed at and threatened a nurse who
discovered he had been hoarding his seizure medications (Doc. 144-8, pp. 10–12). He was
punished with three months in segregation (Id.) He later said he was not taking the
medications because they made his head and stomach hurt (Doc. 141-5, p. 211).
On September 12th, Dontrell called for a crisis team member (Doc. 141-5, pp. 139–
42; see also id. at pp. 143–47). He said he had “been buggin’ up” since the fire alarm went

off that morning, and he also vented frustrations about being in segregation—not having
his time adjusted, the wing being loud, and not getting along with his neighbor. The MHP
helped Dontrell calm himself down and no crisis watch was implemented (Id.). Two days
later, however, Dontrell was put on crisis watch after he “braided and tied a sheet around
his neck” (Doc. 141-5, pp. 149–73). The next day, he said he did not actually want to harm

himself, he just wanted to get an MHP to come to his door (Id. at p. 167). Crisis watch was
terminated, and Dontrell was returned to segregation (Id.). He was given a ticket for
damage or misuse of property for tearing up his bed sheet and punished with one month
on C Grade (Doc. 144-7; Doc. 144-8, pp. 8, 9).
On September 19th, Dontrell called for a crisis team member and stated that he

“wants to [be] back on watch” because he sleeps better over there and can talk with his
friends through the vents (Doc. 141-5, p. 175–78). He presented as stable and his request
was denied (Id.). However, a week later on September 26th, he was put on crisis watch
after he met with an MHP and was upset about various things (Id. at p. 211). He reported
that “earlier in the day, he had a sheet tied around his neck and he was going to jump off
his bed but was caught,” and he threatened to hang himself if he was sent back to his cell

(Id.). The next day, an MHP met with Dontrell and wrote:
[Dontrell] continues to express anger over segregation time. He is unable to
exercise patience and cannot tolerate being told “no.” He acts out
aggressively, throws feces, and threatens self-harm if he thinks his needs
are unmet or that he is being ignored. Patient continued to yell and make
demands and has not calmed enough for a thorough mental health
assessment.

(Id. at p. 213). In the days that followed, Dontrell continued to demand that he be taken
off crisis watch and threatened to cut himself with a staple (that he did not actually have)
if he wasn’t (Id. at pp. 215, 217). On September 30th, his fifth day on crisis watch, Dontrell
had calmed down and reported that he was “ready to come off watch” (Id. at p. 219). He
was returned to his cell in segregation, with an MHP to follow-up in seven days and
every 30 days thereafter for six months (Id.).
On October 2nd, two days after his crisis watch was discontinued, Dontrell saw
psychiatric Physician Assistant Travis James for a diagnostic evaluation (Doc. 141-5, pp.
225–34; see also id. at pp. 241–46). This was only Dontrell’s second contact with a
psychiatric provider (the first occurring three months prior in July 2017 at Stateville). PA
James noted that Dontrell had medication orders for adjustment disorder and unspecified
depressive disorder. He asked Dontrell questions relating to his psychiatric history, social
history, suicide potential, potential for aggressive behavior, medical conditions,
psychiatric symptoms, personality, substance abuse history, and family history (see id.).
He documented Dontrell’s diagnosis as “309.4 Adjustment disorder with disturbance of
conduct and emotion,” continued Dontrell’s prescription for Remeron, and indicated that
outpatient level of care was appropriate for Dontrell (Id. at pp. 233, 234).

The following day, on October 3rd, Dontrell attended what appears to be his first
group therapy session (Doc. 141-5, p. 237). It was a two-hour, out-of-cell session (see id.).
MHP Leann Hartleroad documented that Dontrell was “positive and cooperative” (Id.).
Dontrell attended group twice more that same week, where he interacted appropriately
and positively, showed interest in the group, and gave appropriate feedback (Id. at pp.
247, 249). An MHP’s notes from rounds that same week documented that Dontrell

“presented as stable” with no mental health concerns (Id. at p. 239).
Dontrell continued attending and participating in group therapy sessions over the
next couple weeks (Doc. 141-5, pp. 251, 253, 261, 265). MHP Basnett wrote during rounds
that Dontrell had “much improved behaviors – no distress observed” (Id. at p. 239). After
the group therapy session on October 24th, Dontrell met one-on-one with MHP

Hartleroad “at the request of security” (Id. at p. 267). Hartleroad noted that Dontrell was
angry about not yet having an approved parole site and stated that “the IDOC is
purposefully keeping him incarcerated” (Id.). She spoke to Dontrell about parole
placement procedures and discussed coping skills that he could use “to avoid . . . re-
emergence of impulsive behaviors” (Id.). And on October 25th, MHP Basnett wrote

during rounds that she had no mental health concerns regarding Dontrell (Id. at p. 240).
The following morning, however, Dontrell was involved in an incident where he
managed to pull an officer’s arm through the cuff port of his cell, injuring the officer (Doc.
144-7; Doc. 144-8, pp. 3–7).
Mental health records indicate that Dontrell had been upset since the early
morning hours, which “prompted yelling, threatening harm to staff, taking his

chuckhole, and assaulting staff” (Doc. 141-5, p. 289). MHP Basnett met with Dontrell
throughout that day due to his combative, threatening behavior, and assisted him in
calming himself down (Id.). But by the end of the day, Dontrell was “inconsolable” “due
to peers making fun of him, and constantly stressful stimuli” (Id.). Around 2:00p.m.,
Basnett put Dontrell on crisis watch due to “threatening behavior, rapidly increasing
agitation, and inability to calm down” (Id. at pp. 289, 269–71). She wrote that it was “more

for a respite than any type of crisis . . . to allow for processing the day’s events . . . in a
quieter environment” (Id. at p. 289; see also id. at pp. 274, 279).
Basnett went to see Dontrell the next morning (Doc. 141-5, p. 291). Before she
entered the wing, officers reported that Dontrell had “taken his chuckhole hostage,
grabbed the shield stand, and was throwing feces at anyone nearby.” As Basnett entered

the wing, she observed feces on Dontrell’s window, door, and floor, and on the staircase.
And as she approached Dontrell’s cell door, she observed feces “everywhere.” He had
his arm through the chuckhole and began yelling about his frustrations. Dontrell was
“eventually, after quite some time,” able to calm himself down. He agreed to clean his
cell and give up his chuckhole in exchange for a shower, a move to a clean cell, and

permission to have a book. Dontrell’s crisis watch was continued (Id. at. pp. 293–97).
The next day (October 28th), MHP David Penk saw Dontrell on crisis watch (Doc.
141-5, p. 297). Dontrell reported that he was not getting his medications for schizophrenia
and ADHD and said, “I won’t come out of here until I get my medication or a
psychological evaluation. I’m going to bang my head.” According to Dontrell, he was
diagnosed with schizophrenia at age six because he was hearing voices, but he denied

that he was currently experiencing hallucinations. Dontrell also said that he took Zoloft
and lithium on the outside and had been taking them since age 12. Penk noted that
Dontrell “was wrapped in his safety mattress” and his “mental health symptoms [were]
negatively impacting his daily functionality.” Dontrell’s crisis watch was continued.
The next day (October 29th), MHP Amy Deel-Hout saw Dontrell on crisis watch
for five minutes (Doc. 141-5, pp. 299–300). He reported that officers and porters “keep

picking on me” and stated once again that he needed Zoloft and lithium. Deel-Hout wrote
that she talked with Dontrell about his seizure medication and that the reason he was in
segregation was because he was not taking it and was hoarding it. He told Deel-Hout that
he had been taking it. Deel-Hout also discussed “managing conflict with others in a
positive way.” Dontrell was released from crisis watch and returned to segregation (Id.

at p. 299; see also id. at pp. 301–04). But he called for a crisis team member the next morning
(Doc. 141-5, pp. 305–08). He was shouting and threatening harm on staff because he was
upset that his hygiene products and a few of his personal items were missing. MHP
Basnett wrote that Dontrell “continues to take incidents [such] as these very personally,
which makes him increasingly angry and combative.” She told Dontrell that he could

speak with the Lieutenant but he first had to organize his thoughts and be able to identify
the problem and offer a potential solution. Basnett determined that crisis watch was not
warranted and left once Dontrell appeared stable. She later took him some mental health
worksheets to complete.
During the first week of November, Dontrell attended group therapy three times
(Doc. 141-5, pp. 313, 317, 319). Each time, MHP Hartleroad noted that Dontrell was

cooperative and positive, interacted appropriately, showed interest in the topics, and
gave appropriate feedback (see id. at pp. 247, 249, 251, 253, 265, 313, 317, 319). Haley
Basnett indicated during rounds that she had no mental health concerns about Dontrell
(Id. at p. 340). And during a one-on-one post-crisis follow-up on October 3rd, Basnett
wrote that Dontrell was “in good spirits,” presented as stable, and had been able to abide
by segregation rules without any incidents with peers or staff since the previous week

(Id. at pp. 309–12, 315). Basnett wrote that she commended Dontrell “on his commitment
to decreasing his impulsivity,” and noted that he had been attending group therapy,
during which he was cooperative and participative, and demonstrated healthy
communication skills with staff and peers. She and Dontrell spoke about using
mindfulness exercises when feeling frustrated and he said, “I can’t believe how good it

works.” Basnett’s note from the session indicated that Dontrell was designated as SMI.
On November 8th, MHP Haley Basnett updated Dontrell’s treatment plan to
reflect the problems he was having, the therapeutic goals for addressing those problems,
and the treatments/activities that he required (Doc. 141-5, pp. 321–26). She indicated that
Dontrell was not SMI (Id. at p. 321). The plan was signed off on by other members of the

Multidisciplinary treatment plan (see id. at p. 325). The following day, Dontrell attended
group therapy (Id. at p. 327), and the day after that Dontrell met with Psychiatric PA
Travis James for 20 minutes (Id. at pp. 329–36). Dontrell reported that he was “stressing
more and more.” James noted that Dontrell was diagnosed with impulse control disorder
and was “constantly agitated.” He wrote that the “MHP gives [Dontrell] activities but
[he] is in need of a mood stabilizer to reduce mania,” however, Dontrell “refuses mood

stabilizers.” When asked to describe his mood, Dontrell said, “I just get stressed and mad
quick. I hated Depakote. I know Zoloft kept me straight when I was on the outside.”
James documented that Dontrell was taking Remeron and compliant with the
medication, which was “somewhat effective.” In the diagnostic section of the note, James
wrote that Dontrell was a moderate risk. Specifically, at the time of the appointment,
Dontrell was no or low risk, but he “gets agitated so quickly” and “when he does, he is

high risk.” Dontrell did not have any suicidal thinking or plans. He had limited insight
into his issues and poor overall judgment. Regarding impulse control issues, James wrote,
“daily almost, kicks cell, yells at staff, is inappropriate.” James wrote a prescription for
50mg of Zoloft for Dontrell.
On November 14th, the Adjustment Committee held its hearing on the tickets

Dontrell received for the October 26th incident (see Doc. 144-8, p. 3). Dontrell was not
designated as SMI at the time of the incident, or apparently at the time of the hearing. An
MHP was present at the hearing but there is no indication that they were consulted
regarding a potential punishment (see id.). The Committee gave Dontrell six months in
segregation and revoked three months of good conduct credit (Doc. 144-7, Doc. 144-8, pp.

2–3). The decision was not served on Dontrell until November 26th (Doc. 144-9, p. 2).
On the morning of November 15th, Dontrell told the MHP on rounds that he was
“good” (Doc. 141-5, p. 339). That afternoon, however, Dontrell met with PA Travis James
and said that he was “having hallucinations and shit” and asked James to “lower [his]
meds” (Id. at p. 337). James lowered Dontrell’s Zoloft dosage to 25 mg.
On November 16th, Dontrell attended group therapy; per usual, MHP Hartleroad

documented that Dontrell interacted appropriately and positively, showed interest in the
group, and gave appropriate feedback (Doc. 141-5, p. 341). On November 18th, Dontrell
met one-on-one with MHP David Penk for 10 minutes “per security request” (Id. at p.
343). Penk wrote that Dontrell was “experiencing some anxiety” due to the lack of
information regarding his parole placement. Dontrell stated, “I aint been nothing. I don’t
know nothing. I’m trying to get in a half-way house in Chicago but nobody is helping

me.” Penk wrote that Dontrell was “functioning appropriately in segregation and his
mental health symptoms [were] not negatively impacting his daily functioning.” The
plan was to continue encouraging Dontrell to utilize the coping skills he had learned
when feeling depressed and anxious.
On November 20th, Dontrell met one-on-one for 10 minutes with MHP Leann

Hartleroad for post-crisis follow-up assessment (Doc. 141-5, pp. 345–50). He reported that
he was “doing good,” was compliant with his medications, and intended on attending
group the next day. Hartleroad determined that Dontrell was not a suicide risk. MHP
Haley Basnett’s notes from rounds two days later indicate that Dontrell said he was
“buggin up” and wanted information on the halfway house but Basnett also wrote there

were no mental health concerns (Id. at p. 339).
On November 28th, Dontrell attended group therapy; the note from this session is
the same as all the others and indicated that Dontrell interacted appropriately and
positively, showed interest in the group, and gave appropriate feedback (Doc. 141-5, p.
353). The note makes no mention of the fact that Dontrell actually left group early because
of dizziness caused by the Zoloft (see id. at pp. 351, 353). Travis James discontinued

Dontrell’s prescription for Zoloft, apparently without any face-to-face interaction with
Dontrell (Id. at p. 351).
MHP Basnett’s notes from rounds on November 29th stated that Dontrell “wants
to move to B-wing; wants seg. cut” but she had no mental health concerns (Doc. 141-5, p.
355). Dontrell attended group therapy on the morning of November 30th and the note
once again states that Dontrell interacted appropriately and positively, showed interest

in the group, and gave appropriate feedback (Id. at p. 357). Later that afternoon, around
3:20 p.m., Dontrell met for 15 minutes with MHP Hartleroad for “patient follow-up” (Id.
at p. 359). Dontrell “report[ed] continued frustration about not having an approved
parole site or not yet being transferred from [Lawrence].” His mood was “frustrated, but
overall positive,” and he was mostly able to concentrate on the topic at hand but required

redirection to stay on task. Hartleroad gave Dontrell positive feedback on maintaining
compliance with his medication and encouraged him to keep it up. She helped him
process his feelings about not having a place to parole to and they discussed his feelings
about the possibility of staying in custody until his discharge date. Hartleroad gave
Dontrell parole information from the counselor as well as extra journaling papers to

occupy his time over the weekend. Dontrell said he was going to work on the group
therapy homework assignment and write in his journal papers.
The following day, December 1st, Dontrell hung himself with a bed sheet (Doc.
141-5, pp. 361–65). Officers and inmates alike reported that Dontrell had been upset that
morning and had been yelling at correctional officers and the inmate porter and also
flooded his cell (Doc. 172-1, pp. 2–22; see also Doc. 141-5, pp. 361–65). The inmate

witnesses reported that Dontrell asked correctional officers more than once to speak with
a crisis team member and an MHP, and he told correctional officers that he was going to
kill/hang himself (Doc. 172-1, pp. 2–22). The officers, however, never called for a crisis
team or an MHP (Id.). The witnesses reported that after Dontrell said he was going to
hang himself, they did not hear anything more from him. He did not respond when an
officer came to his door with lunch. He did not respond when an officer told him his

water had been turned back on and asked if he was okay. He did not respond when an
officer came to his door with soap and toilet paper. And he did not respond when an
MHP came to his door on rounds. Dontrell’s body was found around 3:45p.m. by an
officer passing out dinner trays. He was cold to the touch and stiff.
PRELIMINARY MATTERS

As a general matter, the Court must note that the briefing in this case was not ideal.
At times, both sides overplayed their hands and made arguments unsupported by any
relevant legal authority. Wexford’s statement of facts is in paragraph form, with a string
of citations at the end of each paragraph. The Court had to try to figure out which
citation(s) matched each fact asserted in the paragraph. Plaintiff’s responses to

Defendants’ facts and her own statement of facts are no better (which Wexford went to
great lengths to hypocritically point out). Plaintiff’s briefs are extremely lengthy and
simultaneously provide too much and too little information. Wexford’s briefs were often
harsh in tone and spoke in absolutes. Their arguments were often poorly articulated and
poorly organized, making it difficult to discern the contours of Plaintiff’s claims and the
parties’ arguments

The Court seriously contemplated striking all of the briefing and ordering the
parties to redo it. But the Court had already spent an inordinate amount of time pouring
through the record in this case and trying to make sense of the issues. The undersigned
does not levy this criticism lightly, and in fact does so reluctantly, but finds it necessary
because it is largely the reason for the significant lapse in time between when briefing
concluded and the issuance of this decision (see Docs. 168, 191, 193).

The Court also wants to stress that although the allegations and some of the
evidence in this case raise significant concerns for all inmates in the IDOC who suffer
from mental illness, the Court’s analysis in this Order must stay within the confines of
specific allegations regarding Dontrell. Additionally, the Court’s analysis throughout this
Order addresses only those arguments made by the parties in their briefs and does not

attempt to independently evaluate arguments that may have been available but were not
made.8
EVIDENTIARY RULINGS
Along with their requests to exclude Plaintiff’s experts, Defendants brought up a

8 See Nelson v. Napolitano, 657 F.3d 586, 590 (7th Cir. 2011) (“Neither the district court nor this court are
obliged to research and construct legal arguments for parties, especially when they are represented by
counsel.”); Alioto v. Town of Lisbon, 651 F.3d 715, 721 (7th Cir. 2011) (“Our system of justice is adversarial,
and our judges are busy people. . . . [T]hey are not going to do the plaintiff's research and try to discover
whether there might be something to say against the defendants' reasoning.”); Tyler v. Runyon, 70 F.3d 458,
465 (7th Cir. 1995) (“The responsibility for the identification, framing, and argument of the issues . . . is that
of the lawyers, not that of the judges. . . . So, if [a party] fails to make a minimally complete and
comprehensible argument for each of his claims, he loses regardless of the merits of those claims as they
might have appeared on a fuller presentation.”).
number of other evidentiary challenges. As the party moving to exclude evidence prior
to trial, Defendants have the burden of establishing the evidence is not admissible for any

purpose. In re Depakote, 87 F. Supp. 3d 916, 920 (S.D. Ill. 2015) (quoting Euroholdings Capital
& Inv. Corp. v. Harris Trust & Sav. Bank, 602 F.Supp.2d 928, 934 (N.D. Ill. 2009)).
A. CERTIFICATE OF MERIT
Illinois law requires medical malpractice claims to be supported by an affidavit
from the plaintiff’s attorney and a written report from a qualified, licensed physician who
has reviewed the case and determined “there is a reasonable and meritorious cause for

the filing of such action.” 735 ILL. COMP. STAT. 5/2- 622(a). This report is often referred to
as a “Certificate of Merit.” Wexford takes issue with the physician’s report attached to
Plaintiff’s Second Amended Complaint, arguing that because Plaintiff has not disclosed
the identity of the author nor endorsed the author as an expert in this case, the report is
hearsay and should be barred (Doc. 142, pp. 1–2, 23). The statute, however, explicitly

provides that the report does not have to identify the physician who authored it, 735 ILL.
COMP. STAT. 5/2- 622(a)(1), and furthermore, neither Plaintiff nor her experts cite to or
rely on this report in any way (see Doc. 173). Therefore, the admissibility of the report is
simply not at issue and Wexford’s motion as to the § 622 report is denied.
B. IDOC INVESTIGATIONAL REPORT

Defendants IDOC and John Baldwin argue that the investigational report
concerning Dontrell’s suicide is inadmissible (Doc. 145, p. 5). Their argument consists of
one sentence: “Defendants contend such proposed information and/or testimony is
inadmissible based on the fact it is irrelevant, unfairly prejudicial, concerns subsequent
remedial measure(s), and/or in inadmissible hearsay with no applicable exception.”
(Doc. 145, p. 5). Despite the brevity and vagueness of Defendants’ argument, Plaintiff

provided a thorough response, primarily arguing that the report is admissible under the
hearsay exceptions for business records and/or government reports (Doc. 171, pp. 16–
18). See FED. R. EVID. 803(6), (8)(c). In their reply brief, Defendants did not address any of
the arguments made by Plaintiff and simply reasserted in conclusory fashion that the
report is irrelevant and poses a risk of being unfairly prejudicial, confusing the issues,
and/or misleading the jury (Doc. 183, p. 3). Defendants’ undeveloped objections do not

provide the Court with enough information to truly understand their position, nor is it
sufficient to carry their burden as the objecting party. The Court further notes that the
Investigational Report is cited to in this Order only for the purpose of recounting the
events on the day of Dontrell’s death. The Court does not in any way rely on the Report’s
analysis of the “actions and/or inactions of non-parties,” which seems to be the heart of

Defendants’ concerns (see Doc. 183, p. 3). For these reasons, Defendants’ objection is
overruled at this time.
C. RASHO MATERIALS

Rasho is a class action lawsuit against the IDOC officials alleging systemic and
constitutionally deficient mental health treatment at IDOC facilities. See Rasho v. Jeffreys,
22 F.4th 703, 706 (7th Cir. 2022) (“Rasho appeal”). The parties signed a settlement
agreement in May 2016 requiring the IDOC to meet certain benchmarks across more than
a dozen areas of mental-health treatment. Id. The settlement agreement also provided for
the appointment of a monitor, Dr. Pablo Stewart, to evaluate the IDOC’s progress,
provide updates, and prepare annual reports. Id. at 707. Several months after Dr. Stewart
issued his first annual report in June 2017, the plaintiffs moved for and were granted a

preliminary injunction. Id.; see also Rasho v. Walker, No. 07-1298, 2018 WL 2392847 (C.D.
Ill. May 25, 2018) (“Rasho preliminary injunction”). Shortly thereafter, Dr. Stewart issued
his second annual report in June 2018, and the plaintiffs moved for and were granted a
permanent injunction. Rasho appeal, 22 F.4th at 708; see also Rasho v. Walker, 376 F. Supp.
3d 888, 892–93 (C.D. Ill. 2019) (“Rasho permanent injunction”).
In both of the orders granting injunctive relief, the district court determined that

the IDOC was not complying with the terms of the settlement agreement in five particular
areas—(1) mental health evaluations; (2) treatment planning; (3) medication
management; (4) crisis care and transition; and (5) access to mental health treatment in
segregation—and the non-compliance was driven primarily by inadequate staffing. Rasho
permanent injunction, 376 F. Supp. 3d at 902, 906, 915–16; Rasho preliminary injunction, 2018

WL 2392847, at *11. The district court held that as a result of the inadequate staffing,
inmates were effectively denied access to constitutionally adequate mental health care.
Rasho permanent injunction, 376 F. Supp. 3d at 915. The district court further determined
that the defendants had been aware of the deficiencies in the five areas of non-compliance
for an unreasonable period of time, and their failure to address the deficiencies amounted

to deliberate indifference. Rasho permanent injunction, 376 F. Supp. 3d at 916, 917.
These rulings, however, were reversed on appeal. Rasho appeal, 22 F.4th 703. The
Seventh Circuit found that although the IDOC was not providing the level of care
prescribed by the settlement, that did not equate to a constitutional violation because
there was “no evidence that the terms of the settlement and IDOC’s staffing plan matched
the constitutional floor . . . .” Id. at 711. But even if the terms of the settlement did

correspond with Eighth Amendment minimums, the defendants were not deliberately
indifferent because they “made reasonable efforts to cure the deficiencies in the five areas
identified in the plaintiffs’ claim and to alleviate the staffing shortage,” even though they
were ultimately unsuccessful in achieving their goals. Id. at 710, 711. Critically, the
Seventh Circuit explained that the actions taken by IDOC administrators
“demonstrate[d] a commitment to addressing the problem,” which is “the antithesis of

the callous disregard required to make out an Eighth Amendment claim.” Id. at 710.
1. Use of Rasho Materials in This Case
In the instant action, Plaintiff seeks to use various materials from the Rasho
litigation to establish disputes of material fact and/or impute knowledge to Defendants
(see Doc. 173). In particular, Plaintiff cites to (1) transcripts from the preliminary

injunction hearing (Rasho docket entries 1757–1758 and 1903–1906) (Doc. 173, pp. 2–22,
24); (2) transcripts from the permanent injunction hearing (Rasho docket entries 2354 and
2370–2377) (Doc. 173, pp. 2–22, 24); (3) the district court order granting permanent
injunctive relief (Rasho docket entry 2460) (Doc. 173, p. 11); (4) Dr. Stewart’s First Annual
Report from May 2017 (e.g., Doc. 173, p. 27; Doc. 165-31); and (5) Dr. Stewart’s Mid-Year

Report from November 2017 (e.g., Doc. 173, pp. 19, 25; Doc. 165-32).
Wexford takes the blanket approach that any and all of the Rasho documents are
inadmissible because they “constitute irrelevant, inadmissible hearsay and . . . lack
proper foundation” (Doc. 142, pp. 4–6). Similarly, the IDOC argues that all of the Rasho
documents are inadmissible because they are hearsay, irrelevant, unfairly prejudicial,
and/or concern a subsequent remedial measure (Doc. 144, p. 17).

Plaintiff, however, contends that the transcripts are the equivalent of affidavits and
are therefore appropriate evidence to consider on summary judgment (Doc. 173, pp. 23–
25). Indeed, the Seventh Circuit has instructed that “depositions from one case may be
used at the summary judgment stage of another” if two conditions are met. See Alexander
v. Casino Queen, Inc., 739 F. 3d 927, 978 (7th. Cir. 2014). First, the deposition testimony
must satisfy Rule 56’s requirements for an affidavit, meaning the testimony is based on

personal knowledge and sets out facts that would be admissible at trial, and the deponent
is competent to testify on these matters. Id. Second, “the depositions from the other case
must be part of ‘the record’ in the present case[.]” Id. Both conditions appear to be
satisfied here, which Defendants do not dispute (see Docs. 180–183). Consequently, the
transcripts from Rasho will not be excluded at this juncture.

As for the Rasho district court’s order granting preliminary injunctive relief,
Plaintiff seeks to use it to establish a material issue of fact that John Baldwin acted with
deliberate indifference (see Doc. 173, p. 11). As a general matter, one district court’s
decision may be persuasive but it is not binding on another district court. Townsel v. DISH
Network L.L.C., 668 F.3d 967, 970 (7th Cir. 2012) (“[D]istrict courts' decisions are not

authoritative, even in the rendering district (other district judges may disagree)”). But
more importantly, the Rasho district court’s finding of deliberate indifference was
overturned by the Seventh Circuit. Rasho appeal, 22 F.4th at 710–11. For these reasons, the
Rasho district court’s order is excluded as evidence in this matter.
Last but not least, Dr. Pablo Stewart’s reports. The Seventh Circuit has repeatedly
held that reports of this sort are inadmissible hearsay and thus their contents cannot be

offered for the truth of the matter asserted. Stockton v. Milwaukee Cnty., 44 F.4th 605, 617
(7th Cir. 2022); Dean v. Wexford Health Sources, Inc., 18 F.4th 214, 232 (7th Cir. 2021); Wilson
v. Wexford Health Sources, Inc., 932 F.3d 513, 522 (7th Cir. 2019); Daniel v. Cook Cnty., 833
F.3d 728, 743 (7th Cir. 2016). Plaintiff nevertheless argues these reports should come in
under the hearsay exception in Federal Rule of Evidence 807 (Doc. 173, pp. 25–28). In the
alternative, Plaintiff argues that the Court should take judicial notice of the contents of

the reports and/or admit them for the limited purpose of establishing notice (Id. at pp.
28–30). The Court need not make a decision as to whether these reports are admissible
for any purpose, however, Plaintiff cannot defeat summary judgment with or without
the reprots, as explained in depth later in this Order.
D. PLAINTIFF’S EXPERT REPORTS

The admission of expert testimony is governed by Federal Rule of Evidence
702 and the principles announced by the Supreme Court in Daubert v. Merrell Dow Pharm.,
Inc., 509 U.S. 579 (1993). Krik v. Exxon Mobil Corp., 870 F.3d 669, 673 (7th Cir. 2017). See also
Manpower, Inc. v. Ins. Co. of Pennsylvania, 732 F.3d 796, 806 (7th Cir. 2013) (explaining that
the general standards derived from Daubert are “essentially codified in the current

version of Rule 702” and Daubert “remains the gold standard for evaluating the reliability
of expert testimony”) (citation omitted); accord Gopalratnam v. Hewlett-Packard Co., 877
F.3d 771, 779 n.1 (7th Cir. 2017).
Under Rule 702, expert testimony is admissible if (1) the witness is qualified as an
expert by knowledge, skill, experience, training, or education; (2) the witness’s
specialized knowledge will help the trier of fact to understand the evidence or to

determine a fact in issue; (3) the testimony is based on sufficient facts or data; (4) the
testimony is the product of reliable principles and methods; and (5) the witness has
applied the principles and methods reliably to the facts of the case. FED. R. EVID. 702. In
short, Rule 702 “requires the district court to act as an evidentiary gatekeeper,” Krik, 870
F.3d at 674 (citing Daubert, 509 U.S. at 589), to ensure that expert witnesses are qualified
to give the opinion they seek to offer and that their testimony “is not only relevant, but

reliable.” Manpower, 732 F.3d at 806 (quoting Daubert, 509 U.S. at 589). It is “a flexible
standard with broad discretion given to district court” to determine the admissibility of
the expert opinion testimony. Krik, 870 F.3d at 674 (citations omitted). In determining
relevance and reliability, the party offering the expert testimony bears the burden of
proof. Brown v. Burlington N. Santa Fe Ry. Co., 765 F.3d 765, 772 (7th Cir. 2014) (citing Lewis

v. CITGO Petroleum Corp., 561 F.3d 698, 705 (7th Cir. 2009)).
The Court did not conduct a hearing on the Daubert motions because the record is
adequate to decide the motions without one. Additionally, the parties did not indicate a
hearing was necessary or set forth what missing information a hearing would supply. See
Niam v. Ashcroft, 354 F.3d 652, 660 (7th Cir. 2004) (“[A] Daubert hearing is [not] always

required.”); Kirstein v. Parks Corp., 159 F.3d 1065, 1067 (7th Cir. 1998) (no automatic
entitlement to a Daubert hearing because the Seventh Circuit has “not required that the
Daubert inquiry take any specific form”).
1. Michael Brady9
Michael Brady was retained by Plaintiff as an expert in corrections from an
administrative and operational standpoint. He worked as a public policy consultant for

the California state legislature on mental health issues and operational problems in
corrections, amongst other things (Doc. 142-1, pp. 108–14; see also Doc. 145-2, pp. 9–106).
He then spent over a decade with the California Department of Corrections, serving in
rank-and-file and executive-level positions. Following his retirement from the
Department of Corrections, Brady worked as a consultant for approximately ten years,

advising federal, state, and local governments on running cost effective and
constitutionally adequate prison, jail, parole, parole board, and probation operations—
focusing specifically on ADA compliance, health care provision, suicide prevention, and
restrictive housing, among other things.10 He also served as an independent or neutral
expert and court-appointed monitor in multiple class actions involving state correctional

systems in various states.
Mr. Brady stated in his report that he was asked to render an expert opinion as to
whether the following things contributed to Dontrell’s death: (1) the IDOC’s failure to
comply with the Rasho settlement agreement; (2) staffing shortages; and (3) violations by
IDOC correctional officers and Wexford mental health professionals of the IDOC’s

9 Mr. Brady’s original report, CV, and supplemental report are at Doc. 142-1, pp. 54–115. Another copy of
just the original report is at Doc. 145-1. In this version, the page numbers imprinted by CM/ECF at the top
of the pages match the original page numbers at the bottom. Therefore, for the sake of ease and clarity, this
is the version that the Court primarily cites to throughout this Order. The transcript of Brady’s deposition
testimony is at Doc. 142-3 and Doc. 145-2.

10 Mr. Brady sadly passed away during the pendency of this case.
policies and procedures specifically designed to prevent suicides by inmates housed in
segregation housing (Doc. 145-1, pp. 2–3).

In forming his opinions and preparing his report, Mr. Brady reviewed an extensive
number of documents from Rasho and spent approximately 21 pages—about half of his
report—recapping the district court record from Rasho (Doc. 145-1, pp 3–5, 7–28). Mr.
Brady also reviewed Dontrell’s IDOC records, including his medical file, his disciplinary
file, the autopsy, the psychological autopsy, and the IDOC’s investigational report into
his death (Id. at pp. 3–5).

Mr. Brady’s overarching opinions, as summarized here by the Court, were that:
• The IDOC and Wexford had been aware for years, by virtue of the Rasho
litigation, that the mental health delivery system in the IDOC was
“dangerously deficient” (Doc. 145-1, pp. 48, 49). The IDOC and Wexford
were likewise aware that the systemic deficiencies created a substantial
risk of harm to mentally ill inmates, particularly those in segregation
(Id.). But the IDOC and Wexford were indifferent to the risk of harm and
failed to comply with the terms of the Rasho settlement agreement or
otherwise provide the minimum level of mental health care for inmates
(Id. at pp. 47, 48, 49–50, 53). This indifference was a “major contributing
factor in the suicide of [Dontrell].” (Id. at p. 50).

• Correctional officers were derelict in their duties on the morning of
Dontrell’s death by failing to ask a mental health professional to speak
with him and failing to properly conduct the required 30-minute safety
checks (Id. at pp. 51–53). Their misconduct was a major contributing
factor in Dontrell’s suicide (Id. at p. 53).

• Dontrell was placed in segregation due to his disability, he was denied
services in segregation, and Defendants failed to provide him with
reasonable accommodations for his disability (Id. at p. 54).

Defendants collectively make a multitude of arguments as to why Mr. Brady’s
report should be excluded, including (but not limited to) that he impermissibly relied on
Rasho, he offered opinions outside the scope of his expertise, his opinions were based on

insufficient facts and inadmissible evidence, and he did not apply a reliable methodology
in reaching his opinions (Doc. 142, pp. 2, 4–8, 10–14; Doc. 145, pp. 4–8). For the reasons
set forth below, the Court agrees that Mr. Brady’s report must be excluded.
The Court turns first to Mr. Brady’s opinion that Dontrell’s death resulted from
the systemic deficiencies in the IDOC’s mental health care system. The Court assumes for
now that the deficiencies Mr. Brady identified did actually exist. Specifically, Brady

opined that the IDOC was non-compliant in the five specific areas of the settlement
agreement identified in Rasho, which resulted in a backlog of evaluations, inadequate and
perfunctory treatment plans, inadequate medication management, inadequate crisis
treatment and transition, and lack of access to mental health treatment for inmates in
segregation (Doc. 145-1, p. 48). Brady further indicated the most fundamental issue

underlying the IDOC’s non-compliance was the persistent failure to maintain adequate
psychiatry and mental health staff (see id. at pp. 47, 48–49; see also id. at pp. 9–11, 19–22).
From there, Brady opined that the various systemic deficiencies rendered the
mental health care provided to inmates in the IDOC constitutionally inadequate, to which
Defendants were deliberately indifferent. However, Brady did not employ a reliable

methodology—or really any methodology—in reaching these opinions. Instead, he relied
solely on the findings of the district court and court-appointed monitor in Rasho in
formulating his “opinions.” (Doc. 145-2, p. 190; see also id. at pp. 110, 132, 145–46, 168–69,
208, 216, 236–37, 239, 278–79). He did not review any of the underlying data (other than
what was in the monitor’s reports) or conduct any independent analysis of that data (see
Doc. 145-2, pp. 107–09, 110, 190, 208). He did not do any investigation of his own or obtain

any additional data (see id.). He did not critically evaluate the Rasho monitor’s findings or
the Rasho court’s conclusions, nor offer a reaction or an independent assessment of those
findings based on his own experience and expertise (see id.). Rather, Brady blindly
adopted the conclusions of a federal judge as his own “opinions.”11 In short, there is
nothing that indicates Brady employed any of his own experience or expertise to
formulate any sort of opinion of his own regarding the adequacy of the mental health

services in the IDOC and Defendants’ response.
“[T]he entirety of an expert's testimony cannot be the mere repetition of ‘the out-

11 In fact, in more than one instance during his deposition, Brady made clear that he did not know the
meaning of, or the reasoning behind, a particular district court finding that he included in his report and
adopted wholesale as his own opinion (see Doc. 145-2, pp. 132–33, 218–19).

In one instance, the following exchange took place:
Q: Back to your report on page six. You discuss, "There is systemic and gross deficiencies in staffing
facilities, equipment and procedures?"
A: Yes, I took that out of the judge's findings.
Q: So you're relying on Rasho for those –
A: Yes.
Q: -- findings? Do you know what equipment is being referred to here?
A: I do not. (Doc. 145-2, pp. 132–33).

In another instance, defense counsel was discussing actions that John Baldwin and the IDOC took after the
execution of the settlement agreement, including efforts to address staffing and trainings offered to IDOC
employees, and the following exchange took place:
Q: And, again, that would be indicative of the fact that they were making attempts to correct these things,
and not turning a blind eye or being deliberately indifferent?
A: Well, it's hard for me to substitute my judgment for that of the court, but I think -- I could acknowledge,
based on the testimony, that he's making efforts. For whatever reason, the court decided that those efforts
still did not absolve him of the finding of deliberate indifference, but I can't go behind what the court
thinking is. I only know the court came to the conclusion based on the testimony. Maybe it was the length
of time. I'm not sure. (Doc. 145-2, pp. 215–18).
of-court statements of others . . . .’” United States v. Brownlee, 744 F.3d 479, 482 (7th Cir.
2014)) (citations omitted). “An expert who parrots an out-of-court statement is not giving

expert testimony; he is a ventriloquist's dummy.” Id. Accord Factory Mut. Ins. Co. v. Alon
USA L.P., 705 F.3d 518, 524 (5th Cir. 2013) (“Rule 703 ‘was not intended to . . . allow a
witness, under the guise of giving expert testimony, to in effect become the mouthpiece
of the witnesses on whose statements or opinions the expert purports to base his
opinion.’” (quoting Loeffel Steel Prods., Inc. v. Delta Brands, Inc., 387 F.Supp.2d 794, 808
(N.D. Ill. 2005))); Eberli v. Cirrus Design Corp., 615 F. Supp. 2d 1357, 1364 (S.D. Fla. 2009)

(“While it is true that an expert’s testimony may be formulated by the use of the facts,
data and conclusions of other experts . . . such expert must make some findings and not
merely regurgitate another expert’s opinion.”); See also Schoen v. State Farm Fire & Cas. Co.,
No. CV 21-00264-JB-N, 2022 WL 16579767, at *6 (S.D. Ala. Nov. 1, 2022) (collecting cases
in which experts were excluded for parroting the opinions of other experts or wholesale

adopting other experts' opinions without independent analysis).
Mr. Brady’s reliance on the district court’s findings in Rasho regarding the
constitutional inadequacy of the mental health care system and the IDOC’s deliberate
indifference is even more problematic in this instance because, as previously explained,
those findings were reversed by the Seventh Circuit. Mr. Brady did not divulge or describe

any basis independent of the district court’s findings that could be used to salvage his
opinions. In fact, his deposition testimony made clear that there was no basis for his
opinions other than the Rasho court’s now-overturned findings. For example, he did not
consult or formally rely on any national standards, statutes, regulations, and/or relevant
case law regarding what level of care was constitutionally required, or even what
constituted best practice (Doc. 145-2, pp. 190–91). He had no information regarding

Defendants’ actions to address the deficiencies in care following the settlement
agreement (Id. at pp. 214, 215–219). And he did not have an opinion as to the timeframe
in which Defendants should have fully satisfied the terms of the settlement agreement,
but acknowledged that such large-scale, systemic changes may take years to implement
(Id. at pp. 198–200).
For these reasons, Brady’s opinions as to the unconstitutionality of the IDOC

mental health care system as a whole and Defendants’ deliberate indifference must be
excluded.
Mr. Brady’s opinion that the systemic deficiencies affected the care Dontrell
received in the IDOC and contributed to his death must also be excluded because he did
not employ an identifiable or reliable methodology in formulating this opinion. Mr.

Brady’s report discusses problems with the IDOC generally but conspicuously does not
connect those problems to Dontrell’s personal experience in any way, shape, or form. “It
is critical under Rule 702 that there be a link between the facts or data the expert has
worked with and the conclusion the expert’s testimony is intended to support.” United
States v. Mamah, 332 F.3d 475, 478 (7th Cir. 2003). “[E]xperts cannot offer opinions based

merely on their say-so.” Smith v. Nexus RVs, LLC, 472 F. Supp. 3d 470, 480 (N.D. Ind. 2020)
(citing Kumho Tire Co. v. Carmichael, 526 U.S. 137, 157 (1999)). See Kumho, 526 U.S. at 137
(“[N]othing in either Daubert or the Federal Rules of Evidence requires a district court to
admit opinion evidence that is connected to existing data only by the ipse dixit of the
expert.”) (citation omitted). Rather, the expert’s report must be “complete and detailed”
and set forth the “basis and reasons” for their opinions and conclusions. Ciomber v.

Cooperative. Plus, 527 F.3d 635, 641 (7th Cir. 2008) (citing FED. R. CIV. P. 26(a)(2)(B)(i)). See
also Salgado v. General Motors, 150 F.3d 735, 741 n.6 (7th Cir. 1998) (“A complete report
must include the substance of the testimony which an expert is expected to give on direct
examination together with the reasons therefor . . . . [It] must include ‘how’ and ‘why’ the
expert reached a particular result, and not merely the expert's conclusory opinions.”). The
expert's opinion must offer more than a ‘bottom line.’” Minix v. Canarecci, 597 F.3d 824,

835 (7th Cir. 2010) (quoting Wendler & Ezra, P.C. v. Am. Int'l Group, Inc., 521 F.3d 790, 791
(7th Cir. 2008) (per curiam)). “An expert who supplies nothing but a bottom-line supplies
nothing of value to the judicial process.” Wendler & Ezra, P.C. v. Am. Int'l Grp., Inc., 521
F.3d 790, 791–92 (7th Cir. 2008) (internal citations omitted). See also Mamah, 332 F.3d at
478 (“As we have observed, ‘experts’ opinions are worthless without data and reason.’”)

(citation omitted).
To begin with, Brady focused heavily on inadequate staffing, which he
characterized as the biggest problem and the root of all the other deficiencies with the
mental health care system (see Doc. 145-1, p. 47, 48, 49). But his statements regarding
inadequate staffing were made with respect to the IDOC system as a whole (Doc. 145-2,

pp. 208–09). He never discussed staffing levels at Lawrence specifically (see Doc. 145-1);
in fact, he never reviewed any information regarding such (Doc. 145-2, pp. 122–24, 167–
72). He did not know how many offenders were at Lawrence, how many offenders were
on the mental health caseload, or the number of mental health professionals and
psychiatrists needed for Lawrence to be “fully staffed” (Doc. 145-2, p. 122). He only knew
that one of Pablo Stewart’s reports in Rasho indicated that Lawrence had a psychiatric

vacancy and MHP vacancies (Doc. 145-2, pp. 122–24, 255). But Brady did not elaborate
any further on the significance of those vacancies and whether they had any
constitutional implications. It is clear that Brady’s opinion that inadequate staffing
contributed to Dontrell’s death is purely an assumption and is not based on any actual
data (see also Doc. 145-2, pp. 169-71, 171–72).
Similarly, with respect to the specific systemic deficiencies in the mental health

care delivery system identified in Rasho, Brady did not evaluate whether Lawrence was
non-compliant in each of those five areas. As a matter of fact, he testified that he did not
have enough information to do so, and he could not extrapolate that Lawrence was non-
compliant from determinations regarding any other facility or the IDOC system as a
whole (145-2, pp. 207–09, 239). Brady also did not explain how the five specific systemic

deficiencies were manifested in the care that Dontrell personally received or led to his
death (see Doc. 145-1, pp. 47–54). Brady seemed to take the position that the deficiencies
in the IDOC’s mental health services were so severe and pervasive that Dontrell must
have been impacted. But this opinion regarding causation amounts to nothing more than
an inferential leap, untethered from any explanation or facts regarding Dontrell’s own

personal experience. Metavante Corp. v. Emigrant Sav. Bank, 619 F.3d 748, 761 (7th Cir.
2010) (expert testimony cannot “be based on subjective believe or speculation.”).
For instance, Brady said nothing about the treatment Dontrell received on crisis
watch, such as the number of contacts, who he saw, etc. (see Doc. 145-1, pp. 28–54). Brady
stated in a conclusory fashion that Dontrell was not given “proper evaluations,” but he
did not identify any specific issues or problems with the evaluations (e.g., the timing of

the evaluations, who conducted them, what they contained, etc.) to support that opinion
(see id. at p. 54).12 Brady did not point out any deficiencies in Dontrell’s treatment plans;
in fact, he made no mention of them at all in the “Expert Opinions” section of his report
(see id. at pp. 47–54).13 Brady likewise made no mention of medication management in
the “Expert Opinions” section of his report (see id.).14 Finally, Brady stated in a conclusory
fashion that Dontrell was deprived of mental health services and programming in

segregation, but again, never specified what those services or programs were (see id.).
What is more, Brady acknowledged at his deposition that group therapy was provided
to inmates in segregation at Lawrence, which Dontrell “actively participated in” (Doc.
145-2, pp. 118, 119, 177, 186). Even more crucially, Brady admitted that Dontrell had
“sufficient” and “appropriate” number of contacts with mental health providers “in the

weeks leading up to his death” (Id. at p. 144). This, of course, suggests Dontrell was not
deprived of any services while in segregation that were necessary to achieve the level of

12 Elsewhere in his report, Brady indicated that in the 90 days before Dontrell’s death, there was “only one
psychiatric evaluation, which was performed by a psychiatrist assistant” (Doc. 145-1, p. 33). To the extent
this statement implies something else was required, Brady failed to identify what that was or elaborate any
further (see Doc. 145-1).

13 Elsewhere in his report, Brady stated that Dontrell’s “Mental Health Treatment Plan updates were
completed by MHP or the Psychiatrist Assistant” (Doc. 145-1, p. 33). To the extent this statement implies
something else was required, Brady did not identify what that something was (see Doc. 145-1).

14 Elsewhere in his report, Brady indicated that Dontrell rarely took his morning medications (Doc. 145-1,
p. 32). But that is basically all he said. He did not indicate what medications he was talking about, what
conditions they were intended to treat, or what (if anything) the mental health and/or medical staff did to
address the issue (see Doc. 145-1).
care required by the Constitution. In sum, Brady failed to connect the dots between the
systemic deficiencies that existed in the IDOC as a whole and the personal experience of

Dontrell and his ultimate death. This opinion is therefore excluded.
Next, Brady discussed the failures of Officers Goble and Givens on the day of
Dontrell’s death and opines that these failures were major contributing factors to
Dontrell’s death (Doc. 145-1, pp. 51–53).15 But this case is not about the individual failures
of any particular person. Plaintiff made the conscious decision to frame this case as one
about systemic failures. Brady opines in a wholly conclusory fashion that the officers’

failures “are consistent with and the result of the long-term systemic failures” of the
IDOC, John Baldwin, and Wexford’s conscious indifference to the mental health needs of
inmates (id. at p. 53). But he never mentioned the failure to follow the IDOC’s suicide
prevention policies as one of the systemic problems plaguing the IDOC (see Doc. 145-1).
Nor did Brady discuss any evidence of other instances where this failure occurred (see

id.). Furthermore, Plaintiff does not contend that the specific officers’ (in)actions on the
day of Dontrell’s death were part of a systemic problem (see Doc. 173, pp. 30–62).
Consequently, Brady’s opinion regarding the failures of Officers Goble and Givens must
be excluded as irrelevant, unreliable, and unlikely to assist a trier of fact in any way.
Finally, the Court turns to Mr. Brady’s opinions that pertain to Plaintiff’s ADA and

Rehab Act claims. These opinions seem to have been tacked onto the end of his report as

15 He also claims that Leann Hartleroad was guilty of the same failures (Doc. 145-1, pp. 51–53). However,
it was clarified at his deposition that he was under the mistaken impression that Hartleroad was a
correctional officer when really she is an MHP (Doc. 145-2, pp. 186–87).
an afterthought and consist of only the following four sentences (see Doc. 145-1, p. 54):
IDOC, [Wexford], and Baldwin knew that [Dontrell] was disabled by way
of his mental health condition, and they owed him benefits, programs, and
services because of that disability. Placement in segregation denied him
services, and the placement was due to his disability. They failed to provide
him with reasonable accommodations because of that disability. Their
practices created a disparate impact on [Dontrell].

At his deposition, Brady initially forgot about these opinions, testifying that he
was not asked to form an opinion as to the IDOC’s compliance with the ADA and
agreeing that his report had nothing to do with the ADA (Doc. 145-2, p. 207). It was only
after Brady was reminded by Plaintiff’s counsel that the complaint contained claims for
violations of the ADA and Rehab Act, that he remembered he had opined that both
statutes had been violated (Id. at pp. 260–61). And it was only after he was repeatedly
pressed by defense counsel as to what his opinions were based on that he finally gave
actual, concrete reasons (Id. at pp. 283–84). But even then, he was not able to offer a full
explanation of the “basis and reasons” for his opinions (see id. at pp. 283–90).
Under Rule 26(a)(2), Plaintiff was required to furnish by the date set forth in the
scheduling order Mr. Brady’s report “containing, among other information, ‘a complete
statement of all opinions’ . . . ‘and the basis and reasons for them.’” Ciomber, 527 F.3d at 641
(quoting FED. R. CIV. P. 26(a)(2)(B)(I), (a)(2)(C)) (emphasis added). While an expert report
does not have to “replicate every word that the expert might say on the stand,” it must
“convey the substance of the expert's opinion . . . so that the opponent will be ready to
rebut, to cross-examine, and to offer a competing expert if necessary.” Metavante Corp. v.

Emigrant Sav. Bank, 619 F.3d 748, 762 (7th Cir. 2010) (quoting Walsh v. Chez, 583 F.3d 990,
994 (7th Cir. 2009)). Brady’s terse opinions in his report regarding the ADA and Rehab
Act are the type of undeveloped and deficient expert opinions that fail to convey the

substance of the opinions and adversely affect opposing counsel’s ability to depose the
expert. Ciomber, 527 F.3d at 641, 642 (“Rule 26(a)(2) does not allow parties to cure deficient
expert reports by supplementing them with later deposition testimony . . . to provide
information they should have initially included in their Rule 26(a)(2) report.”) (citing
Salgado v. General Motors Corp., 150 F.3d 735, 741 n.6 (7th Cir. 1998)). Consequently, Mr.
Brady’s opinions regarding the ADA and Rehab Act must be excluded.

In conclusion, Defendants’ motion to exclude the expert report and testimony of
Michael Brady is granted and Brady’s report is excluded in its entirety.
2. Sanjay Adhia, M.D.16
Dr. Sanjay Adhia is Plaintiff’s other expert witness. He is a board-certified
physician in psychiatry, brain injury medicine, and forensic psychiatry (Doc. 142-1, p. 47).

Dr. Adhia has worked as a practitioner and an educator, as well as an advisor/committee
member with the Governor’s Advisory Committee to the Texas Board of Criminal Justice
on Offenders with Medical or Mental Impairments and the American Academy of
Psychiatry and the Law (Id. at pp. 47–50; Doc. 142-2, pp. 28–29, 93–94). Dr. Adhia has
treated patients in a prison and also a jail, as well as other facilities associated with the

legal-correctional system, such as state hospitals and a competency restoration unit, and
he is familiar with assessing suicide risk (Doc. 142-2, pp. 42, 46–72, 95; see Doc. 142-1, p.

16 Dr. Adhia’s original report, CV, and supplemental report are at Doc. 142-1, pp. 1–53. Another copy of
just his original report is at Doc. 145-3. The transcript of his deposition testimony is at Doc. 142-2.
48). He has also prepared expert reports and offered opinions regarding adequate care at
correctional centers on multiple occasions (Doc. 142-2, pp. 23–25).

Dr. Adhia did not specify in his report what type of opinions he was retained to
provide (see Doc. 142-1, pp. 1–53). As the Court sees it, Dr. Adhia was retained to opine
on Dontell’s mental health generally, the quality of the mental health care Dontrell
received, and whether any deficiencies in his care were consistent with the systemic
deficiencies identified by Michael Brady and the Rasho proceedings.
As with Mr. Brady, Defendants make a multitude of arguments as to why Dr.

Adhia’s report should be excluded, including that he impermissibly relied on Rasho, he
offered opinions outside the scope of his expertise, his opinions were based on
insufficient facts and inadmissible evidence, and he did not apply a reliable methodology
in reaching his opinions (Doc. 142, pp. 2, 8–9, 15–23; Doc. 145, pp. 3, 10–11). Dr. Adhia’s
report is unlike any report the undersigned has ever seen from a retained expert medical

professional and agrees that a host of problems require the report to be excluded.
As a general matter, the Court has concerns as to whether Dr. Adhia ’s report was
actually prepared by him, as required by Rule 26(a)(2)(B). Dr. Adhia testified that by the
time his report was finished, he had spent 13 hours working on the case (Doc. 142-2, p.
98). Yet his report is 46 pages long, and he claims to have reviewed nearly 5,000 pages of

documents specific to Dontrell’s care and treatment, along with thousands of pages of
documents from Rasho (Doc. 142-1, pp. 44–46; see also Doc. 171, p. 29).17 The Court finds

17 In comparison, Michael Brady testified that he spent 40-60 hours reviewing documents and another 40
hours preparing his report (Doc. 145-2, pp. 5–7)
it highly unlikely this extensive amount of work could be completed in just 13 hours.
Additionally, the contents of Dr. Adhia’s report were almost entirely lifted from

Michael Brady’s report. The body of Dr. Adhia’s report (from the “Introduction” on page
2 to the end of his “opinions” on page 44) is roughly 43 pages long (see Doc. Doc. 142-1,
pp. 1N53). Of those 43 pages, approximately one page is original content (see id. at pp.
42–43). Just 14 sentences. The rest was copied verbatim from Michael Brady’s report (save
for some typos that were corrected and some minor word insertions, deletions, and/or
modifications), including most of the actual substantive “Opinions” section.

The problem with copying and pasting from Brady’s report is that the information
Brady was concerned with as a correctional administrator/expert is very different from
the information that would be relevant to Dr. Adhia. As a result, large swaths of the
information in Dr. Adhia’s report are entirely irrelevant to his purposes. For example, Dr.
Adhia spent five and a half pages recounting inmate and staff interviews, which were

done as part of the IDOC’s investigation into Dontrell’s death and were aimed at
determining whether Dontrell asked to speak to a crisis team and threatened to harm
himself on the day of his death and how the correctional officers responded (Doc. 142-1,
pp. 27–33). This information has little to no bearing on the opinions Dr. Adhia was
retained to provide. Dr. Adhia then copied Mr. Brady’s opinion that correctional officers

were derelict in their duties on the day of Dontrell’s death (Doc. 142-1, p. 41), which is
certainly not the type of opinion he was retained to provide.
While Dr. Adhia spent over five pages recounting irrelevant information, when it
came to recounting Dontrell’s mental health care, he was shockingly brief. He simply
copied and pasted the summary that Michael Brady provided and did not attempt to add
any additional details about Dontrell’s evaluations, treatment plans, medications,

contacts with MHPs or psychiatric staff, etc. One would think that an expert psychiatrist
would not only be interested in the details of these encounters, but that the details would
be essential to providing an opinion. As an example, Dr Adhia gave a very hasty
summary of Dontrell’s mental health care records during the final 90 days of his life,
which is the period most critical to this lawsuit (Doc. 142-1, p. 26). He stated:
During [Dontrell’s] final 90 days of life, he was placed on crisis watch on at
least four occasions. He was evaluated for suicide potential by MHP staff .
. . multiple times—once requesting crisis placement which was denied—
but the records show only one psychiatric evaluation, which was
performed by a Psychiatric Assistant. His Mental Health Treatment Plan
updates were completed by MSP of the Psychiatrist Assistant . . . and
reflected diagnosis such as “Other Specified Disruptive, Impulse Control,
and Conduct D/O w/ Mixed Emotions & Conduct” [and] “Adjustment
Disorder with Disturbance of Conduct and Emotion” or “crisis,” omitting
his specific diagnoses of Bipolar Disorder and Schizophrenia.

(Doc. 142-1, p. 26). That’s it. Approximately 100 pages of mental health records reduced
to just three sentences. No additional details, context, comments, or criticisms. In
dramatic contrast, Wexford’s expert psychiatrist’s summary of the same mental health
records is almost four, single-spaced pages long (Doc. 142-4, pp. 2–10).
Unfortunately, Dr. Adhia’s deposition testimony was just as problematic as his
report. The Court agrees with Wexford that his testimony shows he was “unclear on his
own opinions and startlingly unfamiliar with the records” (Doc. 181, p. 4). He could not
recall what documents he reviewed, background information integral to his report, basic
information related to Dontrell’s incarceration and care, or the specifics of his own
opinions. A few examples include:
• Dr. Adhia could not recall the five areas of the settlement agreement in
which the IDOC was found non-compliant in Rasho (Doc. 142-2, pp. 115–16,
166–67, 170–71), even though almost 20 pages of his report were dedicated
to this exact information (see Doc. 142-1, pp. 5–23).

• He could not recall whether he reviewed Dr. Stewart’s November 2017
report or relied on any of its findings, (Id. at pp. 171–75), which is incredible
as this document is particularly noteworthy given that it specifically
analyzed the mental health care system at Lawrence during the time that
Dontrell was there.

• Dr. Adhia could not recall if he had reviewed Dontrell’s disciplinary
records (Doc. 142-2, pp. 156–57).

• He had no idea where Dontrell’s purported diagnosis of bipolar disorder
or schizophrenia originated (Doc. 142-2, pp. 151, 251).

• He could not remember how much time Dontrell spent out of his cell
and/or participating in group therapy (Doc. 142-2, pp. 206–07; see also id. at
pp. 155–56).

• He could not recall anything about the treatment Dontrell received or his
contacts with MHPs at significant times, such as after he made his bedsheet
into a noose in September 2017, during his last placement on crisis watch in
late October 2017, or in the days immediately preceding his death (Doc. 142-
2, pp. 137–41, 154, 164–65).

All of these circumstances beg the question whether the opinions are truly those
of the expert, as required by Rule 26(a)(2)(B). Even if that weren’t the case, Dr. Adhia’s
report would still be deficient. It inexplicably does not contain the words “standard of
care” insofar as it relates to Dontrell’s care (see Doc. 142-1).18 There are no other

18 Dr. Adhia actually said “standard of care” one time in his entire 40-plus page report, and it was in
reference to the witness testimony in the Rasho case (Doc. 142-1. at p. 6). He never used that phrase in
reference to Dontrell’s care (see id.)
statements in the report that could be interpreted as coherently providing a standard of
care for the mental health professionals and psychiatric staff employed by Wexford (see

id. at pp. 24–44). Likewise, there is nothing that even remotely speaks to a standard of
care for Wexford as an organization in terms of institutional liability (see id.).
Additionally, when it comes to actions/inactions by Wexford employees that Dr.
Adhia took issue with, they were identified in a conclusory fashion with no supporting
explanation or facts (Doc. 142-1, pp. 39–44). As one example, Dr. Adhia opined “[t]here
was a lack of evaluation, care, and treatment of [Dontrell], despite his known problems,”

but he did not bother to explain what was wrong with the treatment Dontrell did receive
and/or what additional evaluations, care, and treatment Dontrell should have gotten. As
already explained above, Rule 26 requires more. Dr. Adhia also did not intelligibly
explain how any of the actions/inactions caused or contributed to Dontrell’s death to a
“reasonable degree of medical certainty” (see Doc. 142-1). In fact, those words are never

mentioned in his report (see id.).
Dr. Adhia’s report and testimony is so deficient on its face that it cannot be
considered reliable or likely to assist a trier of fact in any way (and his deposition
testimony was no better). As a result, his report and his opinions are excluded in their
entirety.

As a final note, to the extent that Plaintiff contends Dr. Adhia offered opinions that
the ADA and Rehab Act were violated, these opinions are also excluded. They consist of
nothing more than the same four conclusory sentences that were tacked on to the end of
Mr. Brady’s report (see Doc. 142-1, p. 44; Doc. 145-1, p. 54). They are unsupported by any
facts or explanation whatsoever (see Doc. 142-1, p. 44). And Dr. Adhia offered absolutely
no testimony regarding the ADA or the Rehab Act at his deposition (see Doc. 142-2).
MOTIONS FOR SUMMARY JUDGMENT

Summary judgment is proper when the moving party “shows that there is no
genuine issue as to any material fact and the movant is entitled to judgment as a matter
of law.” FED. R. CIV. P. 56(a). Under Rule 56, the movant has the initial burden of
informing the court why a trial is not necessary. Modrowski v. Pigatto, 712 F.3d 1166, 1168
(7th Cir. 2013) (citing Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986)). When the movant

does not bear the burden of persuasion on a particular issue at trial, like Defendants in
this case, the movant is not required to “support its motion with affidavits or other similar
materials negating the opponent’s claim.” Modrowski, 712 F.3d at 1168 (citation omitted;
emphasis in original). Rather, the movant can discharge their initial burden by pointing
out to the court that there is an absence of evidence to support the nonmovant’s case. Id.

The party opposing summary judgment, in this case Plaintiff, bears the burden of
coming forward with properly supported arguments or evidence to show the existence
of a genuine issue of material fact.” Treadwell v. Office of Ill. Sec'y of State, 455 F.3d 778, 781
(7th Cir. 2006). “Factual disputes are genuine only if there is sufficient evidence for a
reasonable jury to return a verdict in favor of the non-moving party on the evidence

presented, and they are material only if their resolution might change the suit’s outcome
under the governing law.” Maniscalco v. Simon, 712 F.3d 1139, 1143 (7th Cir. 2013) (citation
and internal quotation marks omitted).
In deciding a motion for summary judgment, the court “must view all the evidence
in the record in the light most favorable to the non-moving party and resolve all factual

disputes in favor of the non-moving party.” Hansen v. Fincantieri Marine Grp., LLC, 763
F.3d 832, 836 (7th Cir. 2014). The court need only consider the cited materials, but it may
consider other materials in the record. FED. R. CIV. P. 56(c)(3). However, the Seventh
Circuit has repeatedly stressed that courts are not required to “scour every inch of the
record” for evidence that is potentially relevant to the summary judgment motion before
them. E.g., Grant v. Trustees of Ind. Univ., 870 F.3d 562, 572–73 (7th Cir. 2017).

DISCUSSION

The Court will first address the deliberate indifference claim against John Baldwin
and then the negligence claim against him. After that, the Court will address those same
claims against Wexford but in reverse order. And lastly, the Court will address the
ADA/Rehab Act claims.
A. CLAIMS AGAINST JOHN BALDWIN
1. Deliberate Indifference (Count 1)
A prison official who acts with deliberate indifference to a substantial risk of
serious harm to an inmate violates the Eighth Amendment.” Eagan v. Dempsey, 987 F.3d
667, 693 (7th Cir. 2021) (citing Farmer v. Brennan, 511 U.S. 825, 828 (1994)). To succeed on

her deliberate indifference claim, Plaintiff must first show that “the harm that befell”
Dontrell was “objectively, sufficiently serious and a substantial risk to his . . . health or
safety.” Eagan, 987 F.3d at 693. Plaintiff must then show that Defendant was deliberately
indifferent to the substantial risk and that Defendant’s deliberate indifference injured
Dontrell. Id.; Stockton v. Milwaukee Cnty., 44 F.4th 605, 614 (7th Cir. 2022). See also Reck v.
Wexford Health Sources, Inc., 27 F.4th 473, 489 (7th Cir. 2022) (noting the plaintiff failed to

provide evidence that chronic understaffing at the health care unit harmed him); Gayton
v. McCoy, 593 F.3d 610, 620 (7th Cir. 2010) (succeeding on a § 1983 claim requires the
plaintiff to show the defendant’s deliberate indifference caused her some injury).
The first, objective element is not disputed here, (see Doc. 141, Doc. 144), as “it goes
without saying that suicide is a serious harm.” Collins v. Seeman, 462 F.3d 757, 760 (7th
Cir. 2006) (quotation omitted); accord Quinn v. Wexford Health Sources, Inc., 8 F.4th 557, 565

(7th Cir. 2021). See also Sanville v. McCaughtry, 266 F.3d 724, 733 (7th Cir. 2001) (“The need
for a mental illness to be treated could certainly be considered a serious medical need.”);
Wellman v. Faulkner, 715 F.2d 269, 272 (7th Cir. 1983) (“Treatment of the mental disorders
of mentally disturbed inmates is a “serious medical need.”). The parties’ dispute centers
on whether Baldwin was deliberately indifferent. Deliberate indifference “is a subjective

mental state; the official must have actually known of and consciously disregarded a
substantial risk of harm.” Rasho v. Jeffreys, 22 F.4th 703, 710 (7th Cir. 2022) (“Rasho appeal”)
(citing Petties v. Carter, 836 F.3d 722, 728 (7th Cir. 2016) (en banc)). “This is a high
bar ‘because it requires a showing [of] something approaching a total unconcern for the
prisoner's welfare in the face of serious risks.’” Rasho appeal, 22 F.4th at 710 (quoting

Rosario v. Brawn, 670 F.3d 816, 821 (7th Cir. 2012)). Mere negligence, or even gross
negligence, will not suffice. Lisle v. Welborn, 933 F.3d 705, 717 (7th Cir. 2019).
In this case, Plaintiff made the choice not to advance claims against individual
MHPs, psychiatric providers, or correctional officers like Goble and Givens.19 Nor did
she sue the individuals in charge at Lawrence Correctional Center where Dontrell was

incarcerated, such as the warden or the medical director. Instead, she chose to frame this
individual action concerning her son’s death as a case about systemic deficiencies within
the IDOC in an effort to hold those at the highest level accountable. As a result, Plaintiff’s
claims are against the individual in charge of the entire IDOC and the entity in charge of
its medical services, system wide: John Baldwin and Wexford Health Sources. Plaintiff
contends that Dontrell’s death was the result of systemic problems in the IDOC’s mental

health care system, to which Baldwin and Wexford were deliberately indifferent.
In her brief, Plaintiff never laid out in a clear, orderly fashion the systemic
problems that existed in the IDOC that she believes affected Dontrell’s care. Instead, she
sprinkles references to various problems throughout her brief. The Court has done its
best to collect those references here and outline the various systemic issues that Plaintiff

had identified or at least alluded to, including:
• inadequate services on crisis watch (Doc. 173, pp. 3, 46);
• inadequate mental health services for mentally ill offenders in
segregation (Id. at pp. 13, 37, 46, 51);
• issues with records, such as incomplete records and cut-and-pasted
records (Id. at pp. 10, 19);
• improper medication management (Id. at pp. 21, 36);
• inadequate staffing (Id. at pp. 21, 47);
• insufficient psychiatric contacts (Id. at pp. 21, 37, 61)’ and

19 See Glisson v. Indiana Dep't of Corr., 849 F.3d 372, 378 (7th Cir. 2017) (“It is somewhat unusual to see an
Eighth Amendment case relating to medical care in a prison in which the plaintiff does not argue that the
individual medical provider was deliberately indifferent to a serious medical need.”); Daniel v. Cook Cnty.,
833 F.3d 728, 733 (7th Cir. 2016) (“Most inmates who believe their right to health care has been violated . . .
seek damages from individual doctors or other health care professionals, or from correctional staff who
might have ignored or interfered with the inmates' efforts to seek the health care they need.”)
• MHPs mishandling review of disciplinary cases (Id. at pp. 19, 20, 21, 46,
48).20

The question now is whether Plaintiff has any evidence that those systemic
problems impacted the care Dontrell received and whether Baldwin can be held liable.
As a senior prison official, Baldwin can be liable for a constitutional violation based on
alleged systemic deficiencies if he was “aware of a systemic lapse in enforcement of a
policy critical to ensuring inmate safety” but “fail[ed] to enforce the policy” Daniel v. Cook
Cnty., 833 F.3d 728, 737 (7th Cir. 2016) (citation omitted); accord Sinn v. Lemmon, 911 F.3d
412, 423 (7th Cir. 2018). See also Reck v. Wexford Health Sources, Inc., 27 F.4th 473, 489 (7th
Cir. 2022) (“As a practical matter, deliberate indifference . . . can be demonstrated by
proving there are such systemic and gross deficiencies in staffing, facilities, equipment,

or procedures that the inmate population is effectively denied access to adequate medical
care.” (quoting Wellman v. Faulkner, 715 F.2d 269, 272 (7th Cir. 1983))) (internal quotation
marks omitted). However, even if the prison official is actually aware of a systemic
problem that poses a substantial risk of serious harm to inmates, “[e]vidence that the
defendant responded reasonably to the risk, even if he was ultimately unsuccessful in

preventing the harm, negates an assertion of deliberate indifference.” Rasho appeal, 22
F.4th at 710 (citing Farmer, 511 U.S. at 844); see also Sinn, 911 F.3d at 423–24; Rosario, 670

20 The Court also notes that Plaintiff does not appear to be challenging the IDOC’s use of segregation for
mentally ill inmates as unconstitutional in and of itself. In response to Wexford’s statement of material
facts, Plaintiff asserted that “segregation was not appropriate for inmates with mental illness as it leads to
decompensation” (Doc. 173, p. 8). However, she never developed this argument in the body of her brief or
submitted the necessary evidence to support this type of claim, such as evidence regarding the conditions
in segregation at Lawrence (see Doc. 173).
F.3d at 821–22 (“[T]he officers may escape liability even if they did not take perfect
action.”). Similarly, “the mere failure of the prison official to choose the best course of

action does not amount to a constitutional violation.” Rasho, 44 F.4th at 710 (citation
omitted).
Here, Plaintiff contends that Dontrell was denied access to proper services,
evaluations, or treatment due to systemic deficiencies in the IDOC’s mental health care
system that Baldwin knew about but failed to address (Doc. 95, pp. 12–13; see also Doc.
173, pp. 51, 56). More specifically, Plaintiff seems to be alleging that John Baldwin failed

to ensure the policies and practices regarding mental health care were being followed.
Baldwin makes several arguments as to why he cannot be held liable for deliberate
indifference (Doc. 144, pp. 14–21). The Court opts to skip straight to Baldwin’s argument
that he is entitled to summary judgment because he took substantial steps during his
tenure to improve the IDOC’s mental health care system (Doc. 144, p. 20).

As an initial matter, the Court notes that the Seventh Circuit already determined
there was no deliberate indifference to the systemic deficiencies in the IDOC’s mental
health delivery system because “the evidence establishes that IDOC made reasonable
efforts to cure the deficiencies in the five areas identified in the plaintiffs' claim and to
alleviate the staffing shortage.” Rasho appeal, 22 F.4th at 710. Plaintiff, however, argues

that the Seventh Circuit focused on “various remedial steps taken ‘in the first half of
2018’” and its holding that the IDOC was not deliberately indifferent “was therefore
specific to actions in 2018,” which was after Dontrell died (Doc. 192) (citing Rasho appeal,
22 F.4th at 708, 712). In other words, Plaintiff claims the Seventh Circuit’s opinion in Rasho
leaves open the possibility of finding Baldwin deliberately indifferent based on his
conduct in 2017, prior to Dontrell’s death.

Even if the Court assumes Plaintiff’s interpretation of the Rasho decision is
correct, there is evidence that a number of actions were taken between the time the
settlement agreement was signed in May 2016 and Dontrell’s death on December 1, 2017.
See also Rasho appeal, 22 F.4th at 707 (acknowledging that witness testimony at the
preliminary injunction hearings “revealed that the IDOC had clearly made progress in
revamping its mental-healthcare system.”)21 For instance, Plaintiff admits Baldwin

addressed staffing concerns by speaking with the IDOC’s chief fiscal officer, requesting
and sending letters to Wexford concerning contractual staffing obligations, partnering
with Southern Illinois University to provide additional mental health services at specific
institutions, and expanding the use of telehealth services (Doc. 144, p. 9, ¶27; Doc. 173, p.
13, ¶27). See also Rasho preliminary injunction, 2018 WL 2392847, at *19 (recognizing that

the IDOC had “made efforts to recruit and attract [psychiatric and mental health]
professionals.”).
Baldwin also put forth evidence that he obtained funds and undertook
construction and remodeling projects, such as establishing inpatient beds at Elgin,
building a new inpatient facility at Joliet, and finalized and opened residential treatment

units (Doc. 144-2, pp. 36, 57, 61, 145–46, 147). See also Rasho v. Walker, CDIL Case No. 07-

21 The preliminary injunction hearings were held shortly after Dontrell’s death on December 18 and 19,
2017, and February 27–March 2, 2018. Rasho v. Walker, No. 07-1298, 2018 WL 2392847, at *6 (C.D. Ill. May
25, 2018) (“Rasho preliminary injunction”).
1298, Doc. 1646, pp. 8–9 (November 29, 2017) (Pablo Stewart’s Mid-Year Report)
(indicating that the RTU at Joliet began accepting patients on November 6, 2017 and

construction on the RTU at Dixon was close to being finished); Rasho appeal, 22 F.4th at
707 (describing witness testimony at the preliminary injunction hearings that IDOC had
spent $45 million to build new residential treatment units at several facilities, spent $75
million to develop a new data system for intake assessments, procured another $150
million to construct a new inpatient facility).
Baldwin also implemented additional mental health training for all staff through

a program developed and taught by the National Alliance of Mental Illness (Doc. 144-2,
p. 147). See also Rasho appeal, 22 F.4th at 707 (describing witness testimony at the
preliminary injunction hearings that the IDOC had delivered mental-health training to
its entire staff). And Plaintiff admitted that Baldwin had numerous meetings and
modified the policy regarding discipline for mentally ill inmates, in particular to have

MHPs more involved in the disciplinary process (Doc. 144, p. 7, ¶23; Doc. 173, p. 13, ¶23;
see also Doc. 144-6).
The Court also notes that Dr. Pablo Stewart stated in his First Annual Report
issued in May 2017 that “significant improvements to the mental health care delivery
system in IDOC” had been made in the first year of the settlement agreement. Rasho v.

Walker, CDIL Case No. 07-1298, Doc. 1373, p. 9. Similarly, Dr. Stewart noted in his Mid-
Year Report issued in November 2017 that the IDOC “ha[d] made significant progress on
a number of requirements.” Id. at Doc. 1646, p. 17; see also pp. 8–9. This report cited, in
particular, to a number of improvements and positive aspects in the mental health care
at Lawrence specifically. Id. at pp. 23, 25, 26, 27, 30, 31, 33, 36, 43, 66, 67, 101. Moreover,
Dontrell’s own medical records reflect a marked difference in the care he was receiving

in the two months preceding his death (see Doc. 141-5, pp. 225–359). He attended group
therapy at least twice a week, almost without exception. He had contact with an MHP
every week on rounds. He had one-on-one sessions with MHPs numerous times. And he
saw the psychiatric PA twice.
Plaintiff did not make even a minimally complete argument, or present any
evidence, that these efforts did not constitute a reasonable response to the systemic

problems (see Doc. 173). Plaintiff’s entire argument is one sentence: “[W]hile Baldwin has
made some efforts to improve, it was not sufficient to resolve the constitutionally
inadequate care, and therefore is not enough to absolve Baldwin of liability for known
continuing constitutional violations” (Doc. 173, p. 57). Undeveloped and conclusory
analysis such as this is simply not enough to survive summary judgment. See United States

v. Useni, 516 F.3d 634, 658 (7th Cir. 2008) (“We have repeatedly warned that perfunctory
and undeveloped arguments, and arguments that are unsupported by pertinent
authority, are waived.”). Nor is it the Court’s responsibility to research, construct, and
then develop any argument that could have been made for Plaintiff. Nelson v. Napolitano,
657 F.3d 586, 590 (7th Cir. 2011); Alioto v. Town of Lisbon, 651 F.3d 715, 721 (7th Cir.

2011) (“Our system of justice is adversarial, and our judges are busy people. . . . [T]hey
are not going to do the plaintiff's research and try to discover whether there might be
something to say against the defendants' reasoning.”) (citation omitted).
Consequently, Baldwin is entitled to summary judgment on Plaintiff’s deliberate
indifference claim against him. In light of this conclusion, there is no need to reach the
question of whether Baldwin is entitled to qualified immunity.
2. State-Law Claims (Counts 4 and 6)

Plaintiff brought claims against John Baldwin under the Illinois Wrongful Death
Act, 740 ILL. COMP. STAT. 180/1, and the Illinois Survival Act, 755 ILL. COMP. STAT. 5/27-
6, based on negligence and willful and wanton conduct (Doc. 95, pp. 18–26). Baldwin
argues these claims are barred by sovereign immunity under the Illinois State Lawsuit
Immunity Act, 745 ILL. COMP. STAT. 5/1 (Doc. 144, p. 24-26). The Court agrees.

The Illinois State Lawsuit Immunity Act “protects the State against being ‘made a
defendant or party in any court.’” Murphy v. Smith, 844 F.3d 653, 658 (7th Cir. 2016)
(quoting 745 ILL. COMP. STAT. 5/1). Protection under the statute also extends to state
employees, even when they are sued in their individual capacity, if the claim against the
employee equates to a claim against the state. Richman v. Sheahan, 270 F.3d 430, 441 (7th

Cir. 2001). However, sovereign immunity does not apply and “affords no protection” in
suits where the plaintiff alleges that state employees violated “statutory or constitutional
law.” Murphy, 844 F.3d at 659 (citation omitted). See also Turpin v. Koropchak, 567 F.3d 880,
884 (7th Cir. 2009) (“The officer suit exception provides that when an officer of the State
commits an unconstitutional act or violates a statute, the suit is not against the State,

because the State is presumed not to violate its own constitution or enactments.”).
The Court previously declined at the pleadings stage to dismiss Plaintiff’s state-
law claims against Baldwin on the basis of sovereign immunity because Plaintiff alleged
that the conduct underlying the state-law claims also violated Dontrell’s constitutional
rights (Doc. 85, pp. 12–14). Now, however, the Court has determined that Plaintiff’s
constitutional claim against Baldwin failed to survive summary judgment. Therefore,

sovereign immunity is back in play, and it bars Plaintiff’s state-law claim against Baldwin
because there is no question it is actually a claim against the State of Illinois. “Where a
charged act of negligence ‘arose out of the State employee's breach of a duty that is
imposed on him solely by virtue of his State employment, sovereign immunity will bar
maintenance of the action’ in any court other than the Illinois Court of Claims.” Turner v.
Miller, 301 F.3d 599, 602 (7th Cir. 2002) (quoting Currie v. Lao, 592 N.E.2d 977, 980 (Ill.

1992)) (emphasis in original). See also Murphy, 844 F.3d at 659 (setting forth three factors
for evaluating when a claim against a state employee is a claim against the state).
Baldwin’s conduct that Plaintiff complained of certainly involved matters normally
within the scope of his employment. And Baldwin is accused of breaching duties he owed
to Dontrell and other inmates solely based on their status as prisoners and Baldwin’s

employment as the Acting Director of the IDOC. Consequently, Plaintiff’s state law
claims against Baldwin are deemed to be claims against the State of Illinois, and, as such,
they are barred in this Court by the Illinois State Lawsuit Immunity Act. Summary
judgment is granted in favor of Baldwin as to Counts 4 and 6.
B. CLAIMS AGAINST WEXFORD

1. State-Law Claims (Counts 5 and 7)
As with Baldwin, Plaintiff brought claims against Wexford under the Illinois
Wrongful Death Act, 740 ILL. COMP. STAT. 180/1, and the Illinois Survivor Act, 755 ILL.
COMP. STAT. 5/27-6, based on negligence and willful and wanton conduct (Doc. 95, pp.
18–26). Wexford makes several arguments as to why these claims should be dismissed,
including that (1) “willful and wanton conduct” cannot stand as an independent cause of

action, (2) the certificate of merit attached to the complaint failed to sufficiently state that
a reasonable and meritorious cause of action existed against Wexford for institutional
negligence or vicarious negligence, and (3) Plaintiff does not have any expert testimony
that can be used to establish the elements of his claims, as required by Illinois law (Doc.
141, pp. 9–22).
The Court turns first to Wexford’s argument that the “willful and wanton” claim

should be dismissed because it is not a proper claim (Doc. 141, pp. 9–10). Plaintiff did not
respond to this argument (see Doc. 173). Even still, the Court is not convinced that
dismissal is required. It is true that the Illinois Supreme Court has said “[t]here is no
separate and independent tort of willful and wanton conduct.” Krywin v. Chicago Transit
Auth., 938 N.E.2d 440, 452 (Ill. 2010) (citing Ziarko v. Soo Line R.R., 641 N.E.2d 402, 406 (Ill.

1994)). However, Wexford did not cite to any binding authority indicating that a willful
and wanton claim must be dismissed when a claim of ordinary negligence is also alleged
(Doc. 141, pp. 9–10). E.g., Townsel v. DISH Network L.L.C., 668 F.3d 967, 970 (7th Cir. 2012).
And there are courts that have permitted the two claims to co-exist. Doe v. Coe, 135 N.E.3d
1, 20 (Ill. 2019) (affirming appellate court’s decision to reinstate willful and wanton counts

that overlapped with negligence counts); McCoy v. Iberdrola Renewables, Inc., No. 11 C 592,
2013 WL 4027045, at *4 (N.D. Ill. Aug. 7, 2013) (quotation marks omitted) (denying motion
for summary judgment as to the plaintiff's willful and wanton claim because it was “no
more than a supplemental allegation of negligence. . . a claim in name only.”) (internal
quotation marks and citation omitted).22 In this instance, there is simply no harm in
allowing the willful and wanton claim to proceed and analyzing it contemporaneously

with the ordinary negligence claim. See Doe-2 v. McLean Cnty. Unit Dist. No. 5 Bd. of
Directors, 593 F.3d 507, 514 (7th Cir. 2010) (“Under Illinois law, a plaintiff pleading willful
and wanton misconduct must establish the same basic elements of a negligence claim . .
. .”) (citing Krywin, 938 N.E.2d at 890)).
Next, the Court opts to skip over Wexford’s argument regarding the certificate of
merit and go straight to the argument regarding the sufficiency of Plaintiff’s evidence.

Plaintiff alleges that Wexford acted negligently or willfully and wantonly in seventeen
different respects (Doc. 95, pp. 20–21, 24–25). Plaintiff made clear in her response brief
that these claims are based on both Wexford’s own institutional negligence as well as
vicarious liability for the negligence of its employees (Doc. 173, p. 42). E.g., Groeller v.
Evergreen Healthcare Ctr. LLC, 31 N.E.3d 869, 875 (Ill. App. Ct. 2015) (“Under Illinois law,

a hospital may be found liable in a medical negligence case under two separate and
distinct theories: (1) liability for its own institutional negligence and (2) vicarious liability

22 Willful and wanton claims are also routinely permitted when the claim is against a governmental entity
or employee subject to an immunity statute that recognizes willful and wanton misconduct as a basis for
liability. It does not appear to the Court that this is one of those cases. See Krywin, 938 N.E.2d at 452
(analyzing the merits of a willful and wanton claim in a case that was tried by a jury on counts of negligence
and willful and wanton conduct); Gordon v. Devine, No. 08 C 377, 2008 WL 4594354, at *8 (N.D. Ill. Oct. 14,
2008) (acknowledging “lingering confusion” as to whether there is an independent tort for willful and
wanton conduct in Illinois and concluding that a claim against a public official subject to the Illinois Local
Government and Governmental Employees Tort Immunity Act, 745 ILL. COMP. STAT. 10/2-102, should be
permitted but not a claim against private individuals); Owens v. Fleet Car Lease, Inc., No. 09-CV-0967-MJR,
2010 WL 11566100, at *2 (S.D. Ill. Jan. 15, 2010) (same); Mercury Skyline Yacht Charters v. Dave Matthews Band,
Inc., No. 05 C 1698, 2005 WL 3159680, at *10 n.7 (N.D. Ill. Nov. 22, 2005) (noting willful and wanton is a
proper claim when it is against one of various governmental entities or employees and citing cases as
examples).
for medical negligence of its agents or employees.”). Under either theory, Plaintiff has the
burden of establishing the applicable standard of care, the unskilled or negligent manner

in which the standard was breached, and a causal connection between the breach and the
injury sustained. Donald v. Wexford Health Sources, Inc., 982 F.3d 451, 461 (7th Cir. 2020)
(citation omitted). With respect to the willful and wanton claim, Plaintiff must also prove
“[a] deliberate intention to harm or a conscious disregard for the plaintiff’s welfare.” Jane
Doe-3 v. McLean Cnty. Unit Dist. No. 5 Bd. of Directors, 973 N.E.2d 880, 887 (Ill. 2012)
(citation omitted).

In Illinois, “[t]he general rule is that expert testimony is required to establish” the
standard of care, breach, and causation. Donald, 982 F.3d at 461 (citation omitted). But
certainly “proximate cause ‘must be established by expert testimony to a reasonable
degree of medical certainty.’” Miranda v. Cnty. of Lake, 900 F.3d 335, 348 (7th Cir. 2018)
(quoting Morisch v. United States, 653 F.3d 522, 531 (7th Cir. 2011)).

Here, because Plaintiff’s expert psychiatrist, Dr. Sanjay Adhia, has been excluded,
Plaintiff has no expert competent to testify about the standard of care, how the standard
was breached, or how the breach caused Dontrell’s injury. Nor does she have any
evidence to rebut the testimony of Defendants’ experts Dr. Shane Reister and Dr. Michael
Jarvis that the mental health professionals who treated Dontrell rendered appropriate

care (Doc. 144-5 pp. 26–27; Doc. 142-4, p. 12). And Plaintiff did not provide any
explanation as to how she could establish the elements of her claims by evidence other
than expert testimony (see Doc. 173). Consequently, Wexford is entitled to summary
judgment as to Counts 5 and 7.
2. Deliberate Indifference
Plaintiff spends nearly ten pages of her response brief arguing that Wexford is
liable for deliberate indifference for providing constitutionally insufficient mental health

care to Dontrell (Doc. 173, pp. 32–42). This argument came as a surprise to the Court and
apparently to Wexford as well, (see Doc. 180, pp. 1–2), given that Plaintiff did not assert
an Eighth Amendment claim against Wexford in the operative complaint (see Doc. 95).
That being said, a plaintiff is not required to plead legal theories in the complaint. E.g.,
Hatmaker v. Mem'l Med. Ctr., 619 F.3d 741, 743 (7th Cir. 2010). Furthermore, as Plaintiff

notes, she has consistently alleged that Wexford exhibited “utter indifference and/or
conscious disregard” in failing to provide constitutionally adequate mental health care to
Dontrell (Doc. 95, pp. 24–25; Doc. 52; Doc. 1), which is essentially the same thing as
asserting an Eighth Amendment claim for deliberate indifference. See Chapman v. Keltner,
241 F.3d 842, 847 (7th Cir. 2001) (“[T]he standard for assessing whether conduct is willful

and wanton is ‘remarkably similar’ to the deliberate indifference standard.”) (citation
omitted). In other words, Plaintiff is simply offering “an alternative legal
characterization” of the same factual allegations, Whitaker v. Milwaukee Cnty., Wisconsin,
772 F.3d 802, 808 (7th Cir. 2014), which the Seventh Circuit has said should be permitted
“unless the changes unfairly harm the defendant or the case's development—for

example, by making it ‘more costly or difficult’ to defend the case, or by causing
unreasonable delay.” Chessie Logistics Co. v. Krinos Holdings, Inc., 867 F.3d 852, 859 (7th
Cir. 2017) (citation omitted). See Whitaker, 772 F.3d at 808–09 (7th Cir. 2014) (holding
plaintiff could proceed on new summary judgment theory that recharacterized already-
alleged facts and did not offer “any unfair surprise”); CMFG Life Ins. Co. v. RBS Sec., Inc.,
799 F.3d 729, 743–44 (7th Cir. 2015) (holding plaintiff did not inappropriately add new

claim during summary judgment briefing when factual basis was alleged in complaint).
Although it may seem unjust to allow Plaintiff to pursue a deliberate indifference claim
against Wexford given the pleading history in this case, (see Doc. 180, pp. 1–2; see also
Docs. 85, 95, 104), Wexford failed to persuasively argue that it would cause unfair harm
(see Doc. 180, pp. 1–2). Consequently, the claim will be permitted.
That being said, if Plaintiff does not have the expert evidence necessary to prove

that Wexford’s conduct was negligent, then she cannot possibly prove that it amounted
to deliberate indifference, which is an even higher standard. See Farmer v. Brennan, 511
U.S. 825, 835 (1994) (“deliberate indifference entails something more than mere
negligence”). At any rate, Plaintiff fails to mount an argument that would allow the Court
to rule in her favor on the deliberate indifference claim. Much of Plaintiff’s argument as

to why Wexford is liable for deliberate indifference sounds in vicarious liability (see Doc.
173, pp. 32–42), but there is no vicarious liability under § 1983. E.g., Dean v. Wexford Health
Sources, Inc., 18 F.4th 214, 235 (7th Cir. 2021) (private corporations acting under color of
state law “are not vicariously liable for the constitutional torts of their employees or
agents.”); Shields v. Illinois Dep't of Corr., 746 F.3d 782, 789 (7th Cir. 2014 (“Respondeat

superior liability does not apply to private corporations under § 1983.”). Rather, a
corporation that has contracted to provide essential government services, like Wexford,
can only be held liable under § 1983 based on the Monell theory of municipal
liability. Glisson v. Indiana Dep't of Corr., 849 F.3d 372, 378–79 (7th Cir. 2017) (en banc).
Under Monell, a plaintiff must show that his constitutional rights were violated by
the corporation's own actions. Pyles v. Fahim, 771 F.3d 403, 409–10 (7th Cir. 2014) (citation

omitted). There are at least three recognized types of corporate action that may give rise
to liability under Monell: “(1) an express policy that causes a constitutional deprivation
when enforced; (2) a widespread practice that is so permanent and well-settled that it
constitutes a custom or practice; or (3) an allegation that the constitutional injury was
caused by a person with final policymaking authority.” Dean, 18 F.4th at 235. See also
Glisson, 849 F.3d at 379 (noting this list of actions is likely not exclusive).

Plaintiff does not explicitly indicate which theory she is proceeding under (see Doc.
95, Doc. 173), but it appears to the Court that Plaintiff is proceeding on the second theory:
a widespread practice or custom that also affected other inmates.23 The question then
becomes what is the allegedly widespread practice or custom at issue? Plaintiff never
specifically identified the exact practice or custom that allegedly caused Dontrell’s injury

(see Doc. 173, pp. 32–44), which is “critical” to properly analyzing whether summary
judgment is appropriate. Levy v. Marion Cnty. Sheriff, 940 F.3d 1002, 1011 (7th Cir. 2019).
In fact, in the portion of her brief dedicated to arguing in support of liability against
Wexford, Plaintiff never even used the words “practice” or “custom” (see Doc. 173, pp.
32–44), aside from when she set forth the legal standard for a Monell claim (id. at pp. 32–

23 The Court arrives at this conclusion by a process of elimination. The first theory is not viable because, as
Plaintiff admitted, all of the express policies at issue in this lawsuit are IDOC policies (see Doc. 173, p. 2),
and she did not argue that any of the policies as written are unconstitutional, (see Doc. 173), nor do any of
the policies seem constitutionally problematic on their face. Nor can it be the third theory because Plaintiff
does not appear to argue that an official with final policy-making authority caused the deficient mental
health treatment Dontrell purportedly received (see id.). That leaves the second theory: that, by custom and
practice, Wexford denied Dontrell adequate mental health treatment.
33). Plaintiff spent over eight pages recounting aspects of Dontrell’s mental health care
and how it purportedly violated the IDOC’s policies and directives, but never articulated

how the purported problems were emblematic of a widespread practice or custom (see id.
at pp. 34–42). Nor did she set forth evidence suggesting that each of these purported
problems was actually a systemic issue in the IDOC (see id.); for the most part, she only
presented evidence of Dontrell’s own experience (see id.). However, “[t]o prove an official
policy, custom, or practice within the meaning of Monell,” a plaintiff “must show more
than the deficiencies specific to his own experience, of course.” Daniel v. Cook Cty., 833

F.3d 728, 734 (7th Cir. 2016). Plaintiff’s entire discussion is devoid of any legal reasoning
or analysis and does not include a single citation to legal authority (see id.).
At this late stage of litigation, neither the Court nor Defendants should have to
speculate as to what, exactly, Plaintiff is claiming. A primary purpose of summary
judgment is “to weed out unfounded claims.” Gates v. Caterpillar, Inc., 513 F.3d 680, 688

(7th Cir. 2008). It would defeat this purpose if Plaintiff were allowed to proceed to trial
on a claim whose contours she has never clearly articulated. See Murphy v. White Hen
Pantry Co., 691 F.2d 350, 353 (7th Cir. 1982) (“The district court is not required, however,
to speculate over the nature of the plaintiffs' claim or to refuse to enter summary
judgment for the defendant simply because the plaintiffs may, theoretically, be entitled

to recover under a cause of action based on facts never alleged in the complaint.”).
The Court once again concludes that Plaintiff has failed to provide the Court with
any argument sufficient to show the existence of a genuine issue of material fact.
Summary judgment is therefore appropriate.
C. CLAIMS UNDER THE ADA AND THE REHAB ACT (Counts 2 & 3)
Plaintiff claims that Dontrell was discriminated against, or otherwise denied
access to services, programs, or activities, due to his disability, in violation of Title II of

the ADA and the Rehabilitation Act (Doc. 95, pp. 3, 14–18; Doc. 173, pp. 45–49).
Specifically, Plaintiff alleged that Dontrell was so seriously mentally ill that he required
“intensive psychiatric therapy and treatment,” which the IDOC did not have the ability
to provide (Doc. 95, ¶¶62, 65; see also Doc. 122, pp. 7–8). Rather than transferring Dontrell
to another IDOC facility or an outside hospital where he could receive proper care, the

IDOC put Dontrell in segregation because of his mental illness, where he “was deprived
of access to services, programs, and activities, including education, programming,
recreation, exercise, human interaction, and mental health treatment and services” (Doc.
95, ¶¶3, 67, 68; see also Doc. 122, pp. 7–8).
Because the ADA and the Rehab Act, as well as the federal regulations

implementing them, are “materially identical,” claims under either statute require the
same analysis. 24 A.H. ex rel. Holzmueller v. Illinois High Sch. Ass'n, 881 F.3d 587, 592 (7th
Cir. 2018) (citing Steimel v. Wernert, 823 F.3d 902, 909 (7th Cir. 2016)). See also 42 U.S.C.
§12132; 29 U.S.C. § 794(a). For the sake of ease, the Court generally refers only to the ADA,
but the analysis applies to both the ADA and Rehab Act claims, unless otherwise stated.

To succeed on her claim of disability discrimination, Plaintiff must prove that

24 The only notable difference is that the Rehab Act includes as an additional requirement the receipt of
federal funds, but this element is incontrovertible because all states accept it for their prisons. Wagoner v.
Lemmon, 778 F.3d 586, 592 (7th Cir. 2015); Jaros v. Illinois Dep't of Corr., 685 F.3d 667, 671–72 (7th Cir. 2012).
Dontrell was “a qualified individual with a disability,” that he “was denied the benefits
of the services, programs, or activities” of the prison, or “otherwise subjected to

discrimination” by the prison, and that the denial or discrimination was because of his
disability. Shuhaiber v. Illinois Dep't of Corr., 980 F.3d 1167, 1170 (7th Cir. 2020), cert. denied,
141 S. Ct. 2475 (2021) (citing Wagoner v. Lemmon, 778 F.3d 586, 592 (7th Cir. 2015)). The
IDOC does not contest that Dontrell was a qualified individual with a disability by virtue
of his “severe mental illness” (Doc. 95, p. 14; see Doc. 144, pp. 21–23; Doc. 182). The
disputed issues are whether Dontrell was discriminated against and whether that

discrimination was by reason of his disability.
Discrimination can be established in three different ways: (1) “the defendant
intentionally acted on the basis of the disability” (disparate treatment claim), (2) “the
defendant refused to provide a reasonable modification” (failure to accommodate claim),
or (3) “the defendant’s rule disproportionally impacts disabled people” (disparate impact

claim). A.H., 881 F.3d at 592–93 (citation omitted). Regardless of which theory Plaintiff’s
claim rests on, the Seventh Circuit has held the language of both statutes “requires [the
plaintiff] to prove that

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/10156139. Public record. Not legal advice.