George Walker v. Wexford Health Sources, Inc.

In the

United States Court of Appeals

For the Seventh Circuit

____________________

No. 17-2821

GEORGE WALKER,

Plaintiff-Appellant,

v.

WEXFORD HEALTH SOURCES, INC., et al.,

Defendants-Appellees.

____________________

Appeal from the United States District Court for the

Northern District of Illinois, Eastern Division.

No. 13-cv-07237 — Sharon Johnson Coleman, Judge.

____________________

ARGUED SEPTEMBER 6, 2019 — DECIDED OCTOBER 15, 2019

____________________

Before FLAUM, SYKES, and ST. EVE, Circuit Judges.

FLAUM, Circuit Judge. George Walker is an inmate at State-

ville Correctional Center. He has an incurable motor neuron

disease called primary lateral sclerosis (“PLS”) that causes

weakness in his voluntary muscles. Walker alleges that his

healthcare providers at Stateville—Wexford Health Sources

and Dr. Saleh Obaisi—were deliberately indifferent to his

medical needs after he underwent spinal surgery in March

2 No. 17-2821

2011.1 Specifically, Walker alleges defendants failed to: (1) en-

sure he received proper follow-up care after his surgery, and

(2) allowed undue delays in his treatment by outside experts.

Defendants’ failures, he asserts, delayed his diagnosis and

caused him to suffer from the undiagnosed PLS in the interim.

Defendants successfully moved for summary judgment on all

of Walker’s claims. We affirm.

I. Background

During the relevant period, the State of Illinois subcon-

tracted with Wexford Health Sources to provide healthcare

services to inmates at all the facilities managed by the Illinois

Department of Corrections (“IDOC”). Saleh Obaisi, M.D., was

a Wexford employee who served as Stateville’s Medical Di-

rector from August 2012 until his death in December 2017.

A. Healthcare at Stateville

Stateville’s onsite healthcare facilities included an urgent

care center, various medical clinics, and an infirmary. The

physicians, nurse practitioners, and physician’s assistants at

Stateville were Wexford employees; the nurses and other

medical personnel were a mix of Wexford and IDOC employ-

ees. All the medical providers at Stateville, whether employed

by Wexford or not, followed IDOC’s administrative policies

and procedures. Nonetheless, Wexford’s corporate repre-

sentative testified that when deciding how to provide the best

care for patients, clinicians relied on their training and expe-

rience first, and the governing policies second.

1Originally, Warden Michael Lemke was a defendant, but the parties

agreed to dismiss him from the case.

No. 17-2821 3

When the medical professionals and facilities at Stateville

could not address an inmate’s conditions, Wexford referred

such inmates to outside providers like the University of Illi-

nois at Chicago Medical Center (“UIC”). Typically, referrals

had to go through a collegial peer review process, which Wex-

ford called “Utilization Management” (“UM”). In the event of

a medical emergency, however, Stateville’s Medical Director

could make referrals to another hospital, St. Joseph’s Medical

Center, without securing UM’s preapproval.

In practice, UM consisted of a weekly conference call in

which medical professionals reviewed an inmate’s case and

the suggested treatment. Participants in the call included:

Wexford’s UM Director for Illinois, Wexford’s Corporate UM

nurse, Wexford physicians, Wexford staff, and IDOC’s

healthcare unit administrator. If the onsite Medical Director

was ever dissatisfied with the alternative treatment plan UM

authorized for a patient, the director could appeal that deci-

sion.

If UM approved a patient for an offsite consultation at

UIC, the UM department would enter the information into

Wexford’s computer program (“WexCare”), which triggered

an electronic notice to the prison and UIC. Then, the staff at

IDOC and UIC would coordinate to schedule the inmate’s ap-

pointment. With respect to surgery referrals, UM often issued

a “global approval,” which authorized both the surgery and

any necessary follow-up care. Whenever UIC received a

global approval, it would call Stateville directly to arrange the

follow-up care for the inmate.

UM’s authorizations were valid for ninety days. From

2011 to 2014, however, Wexford did not have a system in place

4 No. 17-2821

to alert its staff when an authorization expired before the in-

mate had received treatment.2

B. Walker’s Treatment History at Stateville

On March 1, 2010, a Wexford physician’s assistant exam-

ined Walker, noting that he had right leg twitching and re-

ports of weakness. Over the course of the next year, Walker

underwent several examinations with specialists and other

medical professionals. These appointments culminated in a

recommendation by a UIC neurosurgeon, Dr. Sergey

Neckrysh, that Walker have spinal surgery to decompress and

fuse the lumbar spine. UM gave a global approval for the sur-

gery and follow-up care.

Walker had spinal surgery at UIC on March 23, 2011. He

remained at UIC for three days following his surgery. When

he returned to Stateville, the infirmary admitted him; his dis-

charge note from UIC called for a follow-up appointment

with Dr. Neckrysh in three months, including a CT scan of the

lumbar spine. Walker testified that three UIC nurses told him

they would see him in six to eight weeks for a follow-up CT

scan. The follow-up appointment never occurred. It was the

first of many delays that prompted Walker to bring this law-

suit. As Walker testified, “it’s been all down hill ever since the

surgery.” Walker also testified, however, that none of his

treating doctors have ever told him that his condition would

2 Fortunately, Wexford has since eliminated this vulnerability in its

system; it now requires doctors to enter a “service completion date” when

they authorize an outside referral, and whenever treatment does not occur

before that service completion date, the inmate’s case returns to UM for

discussion and potential reauthorization.

No. 17-2821 5

have improved if he had been sent back to UIC within three

months of his March 2011 surgery.

The medical records tell a more complicated story. During

Walker’s first three days at the infirmary, five treatment notes

recorded that his surgical incision was healing well. When the

infirmary staff removed Walker’s staples on April 7, 2011,

they cleaned the incision site and did not record any signs or

symptoms of redness or infection. Later that day, the infir-

mary discharged Walker, reporting his minimal discomfort

and giving him permits for low bunk, low gallery, and special

medical restraints.

Approximately four weeks after the surgery, Walker re-

ceived a physical therapy examination at Stateville. The ther-

apist stated that Walker explained that his pain had resolved,

and that the surgical scar was well-healed with minor adhe-

sion (excessive growth of scar tissue). Between May 26, 2011,

and August 31, 2012, the record shows that Walker saw Stat-

eville medical providers on eight different occasions and that

he informed them of the improvement to his back following

the surgery. Walker also completed two eight-week courses

of physical therapy with an onsite provider at Stateville. He

then did sixteen months of physical therapy in his cell. During

Walker’s deposition, defendants’ lawyer asked: “Did your

condition improve at all through the physical therapy?”

Walker responded: “It seemed like after the physical therapy

I would become more irritated and when I was let out of my

cell to take a shower I fall flat on my face. I couldn’t walk. The

irritation was just so tight.” The timing and nature of this irri-

tation, however, is unclear from Walker’s testimony.

Dr. Obaisi first examined Walker on September 26, 2012,

almost exactly eighteen months after Walker’s surgery. He

6 No. 17-2821

documented that Walker complained of an unsteady gait,

weakness in his legs, upper thigh pain, and bilateral foot

drop. Dr. Obaisi’s appointment note also stated that he sus-

pected that Walker might have upper motor neuron syn-

drome. As a result, Dr. Obaisi ordered x-rays and provided

Walker with muscle relaxers and anti-inflammatory medica-

tion. Once Dr. Obaisi received the results from one of the

blood tests and learned that Walker’s levels were elevated, Dr.

Obaisi sought UM’s approval for a neurology consultation at

UIC. Wexford approved the referral on December 2, 2012, but

UIC did not schedule a neurology appointment until April 24,

2013.

At his deposition, Dr. Obaisi testified that his focus during

this initial visit was Walker’s condition; he did not “really pay

attention” to whether Walker had seen UIC neurosurgery for

his post-surgery visit. Nonetheless, when Walker’s attorney

specifically asked Dr. Obaisi why he did not send Walker back

to UIC neurosurgery for the follow-up, Dr. Obaisi explained

he wanted to see the results from some tests before presenting

Walker’s case to UM—this way, Dr. Obaisi could support his

concern regarding upper motor neuron syndrome. He also

testified that he did not have control over UIC’s scheduling,

that specialists generally prioritize scheduling by the urgency

of cases, and that Dr. Neckrysh does not call people “very eas-

ily.”

Walker continued to receive treatment from Dr. Obaisi

and several other medical professionals. A summary of this

later treatment appears below in chronological order.

 On April 9, 2013, Dr. Obaisi examined Walker for

swelling in his right leg that had persisted for two

weeks. Concerned that Walker was developing a

No. 17-2821 7

blood clot in one of his veins, Dr. Obaisi transferred

Walker to St. Joseph on an emergency basis. The

hospital’s discharge notes state that Walker needed

a repeat ultrasound of the right leg in one week to

check for a blood clot.

 On April 24, 2013, Walker was transferred offsite to

UIC neurology; he told Dr. Lawrence Zeidman that

his back “was not bothering him much,” that he

had pain in his legs and groin, but that he did not

want any medication. Dr. Zeidman requested a re-

peat MRI of the lumbar spine, an imaging test of the

right lower extremity to rule out a myelopathy3

given his blood test, and a rereferral to neurosur-

gery.4

 On May 23, 2013, Walker received an MRI that

showed some degenerative changes to his L3-L4

spinal segments.

3 “Myelopathy is an injury to the spinal cord due to severe compres-

sion that may result from trauma, congenital stenosis, degenerative dis-

ease or disc herniation.” Myelopathy, John Hopkins Medicine,

https://www.hopkinsmedicine.org/health/conditions-and-diseases/mye-

lopathy (last visited Oct. 15, 2019).

4 Dr. Zeidman testified that his recommendations for further treat-

ment are always directed at the referring physician—regardless of

whether the patient is an inmate or not—and “it’s optional to the prerog-

ative of the referring doctor whether they even want to follow the recom-

mendations.”

8 No. 17-2821

 On May 28, 2013, Walker had a neurosurgery con-

sultation at UIC. The examining neurosurgeon ob-

served that Walker’s back pain and radiculopathy5

symptoms had improved, but that he had “right in-

guinal [(i.e., groin)] pain.” As a result, the doctor

recommended an x-ray of the lumbar spine. An x-

ray was taken that same day; the impression note

states: “Postsurgical changes with posterior spinal

fusion from L4 to S1. There is a suggestion of lu-

cency around the bilateral S1 screws suggesting

hardware loosening.”

 On September 25, 2013, Dr. Zeidman examined

Walker, noting Walker was now in a wheelchair

and complaining of radiculopathy. Dr. Zeidman

further documented Walker’s May 2013 MRI iden-

tified a loose surgical screw at his S1 vertebrae, but

that UIC’s neurosurgery team, who had seen

Walker after the MRI, did not seem concerned

about it. Dr. Zeidman recommended reconsulting

with UIC’s neurosurgery team about the screw,

and having Walker receive another MRI due to his

presentment of a new symptom: brisk reflexes in

his ankle, and a referral to the UIC pain clinic for a

potential epidural steroid injection.

 On March 27, 2014, Dr. Zeidman examined Walker,

noting that the neurosurgery follow-up and pain

5 “Radiculopathy describes a range of symptoms produced by the

pinching of a nerve root in the spinal column.” Radiculopathy, John Hop-

kins Medicine, https://www.hopkinsmedicine.org/health/conditions-and-

diseases/radiculopathy (last visited Oct. 15, 2019).

No. 17-2821 9

consult he had recommended had not been done.6

(Dr. Zeidman believed the recommended cervical

and thoracic MRI repeat had occurred, but that the

images had not been sent to him.) Accordingly,

Dr. Zeidman again referred Mr. Walker to neuro-

surgery and the pain clinic. Additionally, Dr. Zeid-

man’s notes state that Walker reported that one of

his medications (gabapentin) was improving his

pain but that he did not feel he was getting enough

physical therapy in prison.

 On October 20, 2014, Walker received an MRI of his

cervical spine, which showed some degenerative

joint disease.

 On October 30, 2014, Walker received an evaluation

at UIC’s pain clinic for his back and hip pain. Notes

from that visit show that Walker reported he vol-

untarily stopped taking pain medications because

he felt they made him constipated. The UIC pain

physicians instructed Walker to resume taking the

pain medications and advised him they were con-

sidering giving him an epidural steroid injection.

 On November 6, 2014, Walker received a thoracic

spine MRI. The UIC radiologist found that that MRI

was similar to Walker’s 2011 (pre-surgery) MRI be-

cause both showed degenerative disc disease in his

back.

6 Dr. Zeidman testified that he does not know how scheduling works

with IDOC, Wexford, and UIC. He also opined that he did not think it

would be “unreasonable” for it to take “a couple months” for an inmate

to get an appointment with him.

10 No. 17-2821

 On January 8, 2015, Walker returned to UIC neurol-

ogy and reported continued back pain and that

switching prescriptions (from gabapentin to Mo-

bic) had helped his pain. Dr. Zeidman reviewed

Walker’s MRI and found that it showed degenera-

tive joint disease but no neural compromise. It was

Dr. Zeidman’s impression that Walker may have

had a stroke before the visit. Dr. Zeidman grew

concerned that Walker had started slurring his

speech and jerking his hands and fingers. Again,

Dr. Zeidman noted that despite his referrals,

Walker had not been sent to neurosurgery. Accord-

ingly, he issued another referral to neurosurgery.

He also asked to see Walker again in six months,

and he advised Walker to continue with physical

therapy and keep taking his pain medications.

 On February 3, 2015, Walker went to UIC neurosur-

gery for a consultation; the neurosurgeon found

Walker had radiculopathy in the left leg and recom-

mended a CT myelogram7 to delineate any possible

neurosurgical issues at the lumbar spine.

 On March 27, 2015, Walker received an MRI of his

brain that showed nonspecific scattered flare

changes but was otherwise unremarkable and

showed no acute or subacute stroke.

7 “A myelogram is a diagnostic imaging test generally done by a radi-

ologist. It uses a contrast dye and X-rays or computed tomography (CT)

to look for problems in the spinal canal.” Myelogram, John Hopkins Medi-

cine, https://www.hopkinsmedicine.org/health/treatment-tests-and-ther-

apies/myelogram (last visited Oct. 15, 2019).

No. 17-2821 11

 On May 28, 2015, Walker underwent a CT myelo-

gram.

 On July 1, 2015, Walker returned to UIC neurology

for a consultation. Dr. Zeidman noted that Walker

demonstrated problems with “word-finding.”

Dr. Zeidman concluded that Mr. Walker needed

“to see Dr. Neckrysh again given his ongoing lum-

bar radiculopathy issues.” He also recommended a

speech therapy consultation and that Walker con-

tinue taking pain medications and doing physical

therapy onsite at Stateville.

 On August 11, 2015, Walker received an x-ray that

showed “no definitive evidence of hardware mal-

function” regarding the screw. He also had a con-

sultation with UIC neurosurgery; Dr. Neckrysh

concluded that Walker’s May 2015 myelogram

showed evidence of adjacent segment degeneration

at L3-4 and a grade 1 spine at L3-4, and he proposed

extending Walker’s prior surgery “up to the L-3-4

level.”8

 On December 22, 2015, Walker returned to UIC

neurosurgery for an evaluation; the neurosurgeon

confirmed the 2011 surgery was effective and that

Walker did not complain of pain and weakness in

8Dr. Obaisi testified that he is typically inclined to follow UIC neuro-

surgery’s recommendations; specifically, in Walker’s case, Dr. Obaisi was

happy to acquiesce to the surgery extension recommendation, though he

did not believe it would affect Walker’s speech or any of the other prob-

lems Dr. Obaisi believed were caused by an issue with Walker’s nervous

system.

12 No. 17-2821

his legs for two years after the surgery.9 But be-

cause of Walker’s left-sided thigh pain, UIC neuro-

surgery recommended a revision and extension of

the 2011 spinal fusion to correct these newly-occur-

ring (as of 2015) complaints.

 On March 30, 2016, Walker received the revision

and extension spinal fusion surgery at UIC. Before

his discharge, UIC physical therapy noted that

there were “signs and symptoms of [upper motor

neuron] involvement,” and that “[his] gait will

likely remain with current impairments unless

other means for spasticity/clonus are utilized.” The

post-surgery notes state that Walker reported

“much improvement in ‘nerve’ pain in both legs”

and a reduced amount of “drooling.”

 While Walker remained at UIC following his sec-

ond spinal surgery, UIC’s medical staff diagnosed

him with PLS. During this time, Walker also con-

sulted with UIC speech and psychology staff re-

garding his diagnosis and what that meant for his

life going forward.

 On April 14, 2016, UIC discharged Walker.

C. Expert Opinions

Each of the parties retained medical experts. Walker hired

Nicholas Rizzo, M.D., who is board-certified in internal med-

9Walker admits that the medical notes state as much, but he disputes

the assertion that he did not complain of pain or weakness in his legs for

two years after surgery and only complained of left-sided thigh pain start-

ing in 2015. As Walker testified, he asserts that he experienced pain almost

immediately after his March 2011 surgery.

No. 17-2821 13

icine. He has neither worked in a prison or correctional insti-

tution, nor has he treated inmate populations. He provided

the following opinions: (1) Wexford and Dr. Obaisi failed to

follow the order for a three-month post-operative follow-up

with the UIC neurosurgeon after Walker’s March 23, 2011 sur-

gery; (2) Walker’s condition deteriorated as a result of not be-

ing seen by the neurosurgeon for two years following his

March 2011 surgery; (3) there was a lack of routine physical

therapy; (4) Walker suffered additional pain as a result of not

being treated in an appropriate and timely fashion; (5) Wex-

ford’s Medical Director at Stateville should have ensured that

Walker received timely and adequate treatment; and (6) Wex-

ford should have had a procedure in place to ensure that or-

ders for follow-up care were followed. Dr. Rizzo also gave the

following relevant testimony:

 The March 2011 surgery “was likely successful for

its goal at the time.”

 The three-month post-surgery visit was not op-

tional; it was (and is) the “standard of care” and it

should have been done by UIC neurosurgery. At

that appointment, a few hypothetical scenarios

could have played out: (1) “If there was new symp-

tomatology …, they would have ordered additional

imaging”; (2) “If … his progress postoperatively

was not what they would have otherwise antici-

pated, they could have ordered a subsequent three-

month follow-up which would have obviously in-

creased the chance of picking up progressive symp-

tomatology”; (3) “If he had a perfect recovery from

the surgery and no symptomatology whatsoever

and no progression of symptoms, they may have

dismissed him from their care for that particular

14 No. 17-2821

surgery”; and (4) “If [his recovery was not perfect],

a continuity of care for lumbar disk disease in gen-

eral would have not been unreasonable.”

 When asked whether it was his opinion that

Walker’s condition was going to deteriorate after

his March 2011 surgery, regardless of whether

Walker had had the three-month post-surgery fol-

low-up visit, Dr. Rizzo said: “There’s no way to

know if most patients are going to progress and de-

teriorate or not.”

Wexford employed William Davison, M.D., who is a

board-certified neurologist. He provided the following rele-

vant testimony:

 Walker’s condition deteriorated after his March

2011 surgery, but the lumbar surgery could “[a]bso-

lutely” be ruled out as the cause of that deteriora-

tion.

 Walker’s March 2011 surgery was a success because

the records suggest he had less pain going down his

right leg.

 The missed post-surgery appointment did not con-

stitute inadequate medical care because Walker’s

problems could not be solved by neurosurgery any-

way.

 The post-surgery follow-up visit was a recommen-

dation for the referring physician to consider.

 A few months was a reasonable amount of time to

wait before going back to neurosurgery.

 It was not inadequate medical treatment for de-

fendants not to refer Walker to the pain clinic be-

tween September 25, 2013, when Dr. Zeidman

No. 17-2821 15

made that recommendation, and March 27, 2014,

when Dr. Zeidman noted it had not yet occurred,

because Walker was being seen at his local clinic for

pain and was on medication.

Although not an expert, Neil Fisher, M.D., provided testi-

mony as Wexford’s designated Federal Rule of Civil Proce-

dure 30(b)(6) witness. At the time of his deposition, he served

as Wexford’s Corporate Medical Director for Quality Manage-

ment and Pharmacy. He previously served as Wexford’s Cor-

porate Director for UM from July 2012 until September 2014.

Dr. Fisher holds a medical degree and is a general medical

practitioner. He provided the following pertinent testimony:

 During this case, the WexCare system was able to

pull up a report of expired UM authorizations, but

he was not aware if there was a policy to pull that

report in 2011–2012.

 Wexford is “usually very good at getting people

back to [UIC] during the period of time that special-

ist is requesting” because “this is a no-charge ser-

vice for us so we—these are specialists that we par-

ticularly want to satisfy what they are asking for.”

D. This Lawsuit

The operative complaint in this case alleges that Dr. Obaisi

was deliberately indifferent to Walker’s serious medical needs

by (1) failing to timely return Walker to UIC after the March

2011 surgery and (2) generally ignoring the persistent delays

in Walker’s treatment after he assumed his care. Similarly,

Walker alleges that Wexford was deliberately indifferent to

his serious medical needs by (1) failing to promulgate a policy

16 No. 17-2821

to alert the Medical Director that a previously approved refer-

ral had lapsed before the authorized treatment came to frui-

tion and (2) relying on UIC doctors to schedule their own ap-

pointments with inmates.

Dr. Obaisi and Wexford moved for summary judgment on

all of Walker’s claims. They argued that Walker failed to ex-

haust his administrative remedies and that they were entitled

to judgment on the merits of Walker’s claims. The district

court agreed; it granted Dr. Obaisi and Wexford’s motion for

summary judgment after concluding: (1) the Prison Litigation

Reform Act’s exhaustion requirement barred Walker’s claims,

42 U.S.C. § 1997(e); (2) Dr. Obaisi was not working at the

prison during the relevant time when Walker wished to be

sent back to UIC for his three-month post-surgical neurosur-

gery follow-up appointment; (3) the totality of medical care

Dr. Obaisi provided to Walker did not support a finding of

deliberate indifference; (4) there was no testimony connecting

Walker’s condition to any failure by Dr. Obaisi; (5) some of

the delays Walker blamed on Wexford were actually caused

by UIC; and (6) there was no evidence that Wexford denied

any medical care that one of its medical directors requested

for Walker’s benefit or that any delay between appointments

with specialists at UIC caused Walker’s deteriorating condi-

tion; and (7) the only testimony about what could have been

done had Wexford personnel returned Walker to UIC for a

post-operative follow-up within three months of his 2011 sur-

gery was speculative, thus Walker could not establish the req-

uisite causal connection between Wexford’s allegedly uncon-

stitutional policies and practices, on the one hand, and his

medical condition, on the other.

No. 17-2821 17

Walker appeals the district court’s decision to enter sum-

mary judgment for Dr. Obaisi and Wexford.

II. Discussion

We review a district court’s grant of a motion for summary

judgment de novo, interpreting all facts and drawing all rea-

sonable inferences in favor of the nonmoving party. O’Brien

v. Caterpillar Inc., 900 F.3d 923, 928 (7th Cir. 2018). “Summary

judgment is appropriate where there are no genuine issues of

material fact and the movant is entitled to judgment as a mat-

ter of law.” Hess v. Bd. of Trs. of S. Ill. Univ., 839 F.3d 668, 673

(7th Cir. 2016) (citing Fed R. Civ. P. 56(a)). And summary

judgment is inappropriate “if the evidence is such that a rea-

sonable jury could return a verdict for the nonmoving party.”

Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). We may

affirm the grant of a motion for summary judgment on any

ground supported in the record, so long as the parties ade-

quately presented the issue in the district court and the non-

moving party had an opportunity to contest it. O’Brien, 900

F.3d at 928.

A. Dr. Obaisi

The Eighth Amendment prohibits deliberate indifference

to prisoners’ serious medical needs because it constitutes an

“unnecessary and wanton infliction of pain.” Estelle v. Gamble,

429 U.S. 97, 104 (1976) (quoting Gregg v. Georgia, 428 U.S. 153,

173 (1976)). A failure-to-provide-adequate-medical-care claim

requires proof that the prisoner suffered from “(1) an objec-

tively serious medical condition to which (2) a state official

was deliberately, that is subjectively, indifferent.” Duckworth

v. Ahmad, 532 F.3d 675, 679 (7th Cir. 2008). Defendants do not

18 No. 17-2821

dispute that Walker suffered from an objectively serious med-

ical condition; only the subjective component is at issue here.

To establish the subjective component, Walker must show

that Dr. Obaisi knew of facts from which he could infer that a

substantial risk of serious harm existed, and that he did, in

fact, draw that inference. See Farmer v. Brennan, 511 U.S. 825,

837 (1994); see also Petties v. Carter, 836 F.3d 722, 728 (7th Cir.

2016) (en banc). “[E]vidence of medical negligence is not

enough to prove deliberate indifference,” but evidence that a

medical professional “knew better than to make the medical

decision[ ] that [he] did” is enough to survive summary judg-

ment. Whiting v. Wexford Health Sources, Inc., 839 F.3d 658, 662–

63 (7th Cir. 2016) (quoting Petties, 836 F.3d at 730–31).

In practice, “[s]tate-of-mind evidence sufficient to create a

jury question might include the obviousness of the risk from

a particular course of medical treatment; … persistence in a

course of treatment known to be ineffective; or proof that the

defendant’s treatment decision departed so radically from ac-

cepted professional judgment, practice, or standards that a

jury may reasonably infer that the decision was not based on

professional judgment.” Whiting, 839 F.3d at 663 (citations

and quotation marks omitted). In cases such as this one—

where the plaintiff alleges the defendant delayed, rather than

denied, medical treatment—we have required that the plain-

tiff present “verifying medical evidence” that the delay, and

not the underlying condition, caused some harm. Jackson v.

Pollion, 733 F.3d 786, 790 (7th Cir. 2013) (citing Williams v.

Liefer, 491 F.3d 710, 714–15 (7th Cir. 2007)). Most importantly,

the plaintiff must show that the defendant’s actions or inac-

tion caused the delay in his treatment. See Pepper v. Village of

Oak Park, 430 F.3d 805, 810 (7th Cir. 2005) (“Under any theory,

No. 17-2821 19

to be liable under § 1983, the individual defendant must have

caused or participated in a constitutional deprivation.” (cita-

tion and internal quotation marks omitted)).

Walker argues on appeal that Dr. Obaisi repeatedly failed

to ensure that he receive treatment within the timeline re-

quested by UIC specialists, and that this failure delayed the

ultimate PLS diagnosis and precluded alternative treatment

options in the interim. Walker also disputes the notion that

Dr. Obaisi was powerless to ensure timely offsite appoint-

ments.

In response, defendants argue that Dr. Obaisi had a prin-

cipled reason for not immediately making a referral, as he tes-

tified: He wanted to obtain and review Walker’s lab test re-

sults before presenting any follow-up care to UM for ap-

proval. Indeed, Dr. Obaisi ordered tests the day he first saw

Walker. Similarly, defendants highlight that Dr. Obaisi

treated Walker’s symptoms while they awaited the test results

and continued to treat Walker’s changing condition in a vari-

ety of ways as noted above. Thus, defendants assert that there

is no evidence that Dr. Obaisi did (or failed to do) something

that (1) postponed Walker’s treatment and thereby caused his

need for a second spinal surgery, (2) delayed the diagnosis or

treatment of Walker’s PLS or other symptoms, or (3) pro-

longed Walker’s pain. Finally, defendants emphasize that it is

undisputed that Dr. Obaisi could not schedule appointments

at UIC. Given Dr. Obaisi’s lack of personal involvement in

UIC scheduling, defendants insist that Dr. Obaisi cannot be

held liable.

First, we conclude that Dr. Obaisi’s decision to wait for test

results before referring Walker to UIC, even though Walker

was months overdue for a follow-up appointment at UIC, is

20 No. 17-2821

not evidence of Dr. Obaisi’s deliberate indifference. As

Dr. Obaisi testified, during his first appointment with Walker,

he was focused on Walker’s complaints—unsteady gait, occa-

sional falls, and weak legs—and his assessment that Walker

likely had either upper neuron syndrome or a muscle disor-

der. To rule out a muscle disorder, Dr. Obaisi requested blood

tests, and he explained that he wanted those results—as well

as x-ray images—before making a case to UM that Walker

should be referred to UIC.

Perhaps an immediate referral to UIC would have been

beneficial, but as we have held before, “an inmate is not enti-

tled to demand specific care,” Arnett v. Webster, 658 F.3d 742,

754 (7th Cir. 2011), and medical professionals may choose

from “a range of acceptable courses based on prevailing

standards in the field,” Jackson v. Kotter, 541 F.3d 688, 697 (7th

Cir. 2008). We defer to medical professionals’ treatment deci-

sions unless there is evidence that “no minimally competent

professional would have so responded under those circum-

stances.” Pyles, 771 F.3d at 409 (quoting Sain v. Wood, 512 F.3d

886, 894–95 (7th Cir. 2008)).

Here, Dr. Obaisi made a reasonable medical judgment to

delay referring Walker until he had more information so that

he could make a more informed referral request to UM. See,

e.g., Zackery v. Mesrobian, 299 F. App’x 598, 601–02 (7th Cir.

2008) (“Although it may have been prudent for Dr. Mesrobian

to order diagnostic testing in 2001, his failure to choose the

best course of action does not amount to a constitutional vio-

lation.”).

Second, considering Walker’s treatment overall, we believe

that the records do not show a pattern of deliberate indiffer-

ence to Walker’s serious medical needs. To the contrary, the

No. 17-2821 21

record shows that Dr. Obaisi responded to Walker’s changing

symptoms and that he was receptive to the specialists’ recom-

mendations. He made referrals and re-referrals when neces-

sary, all the while treating Walker’s symptoms. This treatment

was not outside the bounds of medical professionalism. See,

e.g., Harrison v. Wexford Health Sources, Inc., 669 F. App’x 797,

799 (7th Cir. 2016) (“During these 17 months [of treatment

without a referral], Dr. Obaisi regularly altered [the inmate’s]

prescriptions for pain-relieving, anti-inflammatory, and mus-

cle-relaxing drugs based on [the inmate’s] condition.

Dr. Obaisi also ordered and reviewed [the inmate’s] MRI to

ensure that he properly diagnosed his injury. Because the rec-

ord does not contain evidence showing that Dr. Obaisi’s care

violated professional medical standards, the district court

properly granted Dr. Obaisi summary judgment.”).

That Walker’s pain and other symptoms did not subside is

not evidence of Dr. Obaisi’s deliberate indifference, especially

considering that Walker voluntarily stopped taking pain

medication at some point and Dr. Obaisi ordered a variety of

therapies and requested several referrals to address Walker’s

ongoing complaints.

Third, although there were clearly delays in Walker’s treat-

ment, the evidence suggests Dr. Obaisi did what he could

within the limits of his role to move the ball forward. The

question is whether we can place all the scheduling blame on

UIC, because we can only hold Dr. Obaisi liable if he had con-

trol over the circumstances that caused the delays. See Walker

v. Benjamin, 293 F.3d 1030, 1038 (7th Cir. 2002).

Defendants have presented evidence that UIC employs a

prioritization scheme for scheduling appointments and that

22 No. 17-2821

Stateville’s Medical Director was not involved in the schedul-

ing process. Similarly, nothing in the record suggests that

Dr. Obaisi’s actions or inaction caused any of the scheduling

delays with Walker’s appointments at UIC. Such lack of per-

sonal involvement saves Dr. Obaisi from liability here. See

Pepper, 430 F.3d at 810.

B. Wexford

The claim against Wexford “proceeds under the theory of

municipal liability announced in Monell v. Department of Social

Services, 436 U.S. 658 (1978), which we have held applies in

§ 1983 claims brought against private companies acting under

color of state law.” Chatham v. Davis, 839 F.3d 679, 685 (7th Cir.

2016) (citing Shields v. Ill. Dep’t of Corr., 746 F.3d 782, 795–96

(7th Cir. 2014)). Prevailing on such a claim requires evidence

that a Wexford policy, practice, or custom caused a constitu-

tional violation. Whiting, 839 F.3d at 664.

We held in Glisson v. Indiana Department of Corrections,

however, that this list is not exclusive; rather, a “policy” can

take the form of a hands-off approach or a policy to do noth-

ing (a “policy of inaction”). 849 F.3d 372, 379–80 (7th Cir. 2017)

(en banc); see also King v. Kramer, 680 F.3d 1013, 1021 (7th Cir.

2012) (explaining that when a municipality has “actual or con-

structive knowledge that its agents will probably violate con-

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

Thomas v. Cook Cty. Sheriff’s Dep’t, 604 F.3d 293, 303 (7th Cir.

2010) (“[I]n situations where rules or regulations are required

to remedy a potentially dangerous practice, the County’s fail-

ure to make a policy is also actionable.”); Sims v. Mulcahy, 902

F.2d 524, 543 (7th Cir. 1990) (“[I]n situations that call for pro-

cedures, rules or regulations, the failure to make policy itself

may be actionable.”).

No. 17-2821 23

When a § 1983 claim is based on a policy of inaction, the

plaintiff must present evidence that the institution made a

conscious decision not to act. Glisson, 849 F.3d at 381; see also

id. at 383 (Sykes, J., dissenting) (agreeing that a “a municipal-

ity’s failure to have a formal policy in place on a particular

subject may represent its intentional decision not to have such

a policy—that is, a policy not to have a policy—and that insti-

tutional choice may in appropriate circumstances form the ba-

sis of a Monell claim.”). Consequently, in prison litigation, in-

mates generally cite other examples where a constitutional vi-

olation similarly occurred. Id. at 381.

Walker challenges two aspects of Wexford’s operations on

appeal: (1) that Wexford did not have a policy or practice of

ensuring that offsite appointments authorized through UM

occurred; and (2) that Wexford had a practice of deferring to

UIC in scheduling offsite appointments. Walker attempts to

bolster his point that Wexford’s monitoring and scheduling

practices presented obvious risks by focusing on Dr. Obaisi’s

testimony that there was no guarantee that UIC would call to

schedule a follow-up appointment,10 and to Dr. Fisher’s testi-

mony in separate litigation that as of August 2012, a large

number of authorized appointments were not happening. See

Quinn v. Obaisi, No. 14-cv-6633, 2018 WL 1184736, at *8 (N.D.

Ill. Mar. 7, 2018).

In response, defendants deny responsibility for any offsite

appointments that were not scheduled as requested by plac-

10 Indeed, during his deposition Dr. Obaisi remarked that it was

“sometimes debatable” whether UIC would call certain inmates for their

follow-up appointments.

24 No. 17-2821

ing the blame for such errors on the onsite prison staff mem-

ber, who is “likely not a Wexford employee.” Defendants also

cast doubt on Walker’s assertion that it was foreseeable to

Wexford that its monitoring and scheduling policies were

“highly likely” to lead to harm. For example, defendants note

that despite Wexford’s financial incentive to avoid delays, it

had no control over UIC’s schedule. Indeed, Walker has not

produced any evidence that Wexford could control UIC’s

schedule; it is undisputed, as defendants emphasize, that UIC

is not in Wexford’s chain of command. Finally, defendants ar-

gue that Walker cannot prevail because he has no evidence

that other inmates faced the same treatment issues and his

case is not of the “rare” cases where evidence of his own ex-

perience is sufficient to establish deliberate indifference. See,

e.g., Woodward v. Corr. Med. Servs. of Ill., Inc., 368 F.3d 917, 929

(7th Cir. 2004) (affirming a finding of Monell liability where

the evidence showed the organization condoned its employ-

ees’ repeated decisions to ignore its policies).

Neither Walker’s own experience nor the testimony from

Drs. Obaisi and Fisher admitting awareness that referrals to

UIC were sometimes never scheduled or, if scheduled, signif-

icantly delayed, is enough to establish that Wexford was de-

liberately indifferent to Walker’s serious medical needs. See

Glisson, 849 F.3d at 381. Wexford’s knowledge that some re-

ferrals slipped through the cracks is not the same as Wex-

ford’s knowledge that constitutionally necessary referrals

were not happening with such frequency that it ignored an

obvious risk of serious harm. Similarly, Walker has not shown

that the standby options of Stateville’s onsite medical care fa-

cilities and the nearby hospital were not sufficient as a backup

plan in the intervening periods of time where an inmate

awaited treatment with an outside expert.

No. 17-2821 25

As for the coordination of schedules with UIC, Walker’s

instinct that Wexford should not be able to use UIC as a shield

is understandable. But Wexford cannot be accused of “defer-

ring” to UIC when Wexford had no control over UIC. To defer

to another suggests the relinquishment of power or control,

which did not exist here. Practically speaking, Wexford refers

many inmates, and the specialists at UIC have a finite number

of appointments available; thus, it seems unavoidable that, at

times, the wait for appointments will grow to a few months.

Absent evidence that Wexford was on notice that these wait

times were likely to cause constitutional violations, but failed

to act in response, we cannot hold Wexford liable.

C. Exhaustion

Because we conclude that the district court appropriately

entered summary judgment against Walker on the merits, we

need not address whether the district court correctly con-

cluded that Walker failed to exhaust his administrative reme-

dies.

III. Conclusion

For the foregoing reasons, we AFFIRM the judgment of the

district court.