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Legerr v. Jaimet

United States District Court, S.D. Illinois

November 2, 2017

WILLIAM P. LEGER, Plaintiff,


          STACI M. YANDLE United States District Judge.

         Plaintiff William Leger, currently 70 years old, is an inmate with the Illinois Department of Corrections (“IDOC”). In late November 2010, he injured his right shoulder while passing out laundry at Menard Correctional Center (“Menard”). Leger was transferred to Pinckneyville Correctional Center (“Pinckneyville”) the following year. He injured his shoulder again in February 2012 when he suffered a fall while climbing down from his bunkbed. An orthopedic surgeon later diagnosed Leger as having a complete rupture of the rotator cuff. Despite the injury, prison medical staff declined to provide Leger with surgery. Leger brings this action against Dr. Vipin Shah, asserting that Dr. Shah was deliberately indifferent to his serious medical needs in violation of the Eighth Amendment.

         Dr. Shah is a prison physician and an employee of Wexford Health Sources, Inc. (“Wexford”). Wexford is a contractor that provides healthcare services to IDOC inmates. Leger also seeks prospective injunctive relief. Therefore, the Pinckneyville Warden, currently Karen Jaimet, has been added as a defendant in her official capacity only.

         Defendants now seek summary judgment. (Docs. 69, 70, 71 and 72). Plaintiff opposes both motions. (Docs. 73, 74, 75, and 76). Defendants also filed reply briefs (Docs. 77 and 78) to Plaintiff's responses. For the following reasons, Defendants' motions are DENIED.

         Factual Background

         The following facts were obtained from Leger's deposition unless otherwise noted. (Leger Deposition, Doc. 70-1). Leger entered IDOC custody in 1988. Id. at 3. He is currently 70 years old. Id. at p. 2. In November 2010, Leger was working as a cell house custodian at Menard when he injured his right shoulder while passing out small bags of laundry to the inmates in the cell house. Id. at p. 6. “It felt like something ripped” in his shoulder when he threw a three to five pound bag to an upper gallery. Id. at p. 6. Menard medical staff examined Leger after the injury. Id. at p. 7. Leger's treating physicians provided medication, but he was not provided physical therapy or sent to an outside specialist. Id. at p. 7.

         On December 25, 2011, IDOC officials transferred Leger from Menard to Pinckneyville. (“Offender Health Status Transfer Summary” Form, Doc. 70-2, p. 3). On the medical transfer form, the nurse noted that Leger underwent a bowel resection in 2009, a colonoscopy and EGD in 2011 and had a history of back surgeries. Id. The nurse also noted that he had hypertension and dyslipidemia. Id. His medications included Metamucil, Vasotec (hypertension medication), Inderal (heart/hypertension medication), Digoxin (heart medication), Maxzide (hypertension medication), ECASA (coated aspirin) and niacin (used to manage cholesterol). Id.

         On February 12, 2012, Leger was admitted to the Pinckneyville infirmary after he fell from his bunkbed. (Doc. 70-2, p. 6). He was getting down from the top bunk when his shoulder “gave way, ” causing him to fall off the bed, hitting the toilet and floor. (Doc. 70-1, p. 8). Upon arriving at the Health Care Unit, Leger told the treating nurse that he was experiencing pain in his chest and having difficulty breathing. Id. at p. 10. In Leger's medical records, there is a nurse's entry from February 12, 2012 at 9:00 p.m. stating, “[inmate] brought over by leutinent [sic] [complaining of] injury to [left] posterior rib area - radiating to [left] front rib area [complains] also of low back pain.” (Doc. 70-2, p. 6). Leger told the nurse, “I fell off my bunk.” Id. The nurse contacted Dr. Shah and Dr. Shah examined Leger the following morning. Id. at p. 7.

         Dr. Shah's handwritten medical entries are almost entirely illegible, but according to his affidavit attached to his motion for summary judgment, he observed that Leger had a soft tissue injury to his left ribs. (Doc. 70-5, p. 2). Dr. Shah “ordered X-rays of [Leger's] left ribs, gave [Leger] low bunk privileges indefinitely, and told the nurse that he could be released to his housing unit but would need to be rechecked the following Friday.” Id.

         On February 16, 2012, Dr. Shah reviewed Leger's x-rays and noted he had two rib fractures. (Doc. 70-5, p. 2). Dr. Shah prescribed Tylenol and ordered a follow up appointment in four weeks. Id. It is unclear from the medical records whether he personally examined Leger on that date. Id. at p. 10.

         On May 21, 2012, Leger was examined by a nurse for complaints of pain in his shoulder. (Doc. 70-2, p. 11). The nurse noted that Leger's “shoulder still hurts from fall.” Id. The nurse observed no swelling or bruising, but Leger experienced discomfort when he lifted his arm above his shoulder. Id. The nurse issued Leger a prescription for Tylenol for one week and directed him to “[r]eturn to see provider if symptoms worsen or interfere with daily functioning.” Id.

         Leger continued to experience pain in his shoulder. He was next seen by a nurse on July 13, 2012. (Doc. 70-2, p. 12). The nurse referred Leger to see a physician and on July 17, 2012, he was examined by Dr. Shah. Id. at p. 13. Dr. Shah states in his affidavit that this was the first time he examined Leger's right shoulder. (Doc. 70-5, p. 3). Leger told Dr. Shah that his injury occurred in 2010 at Menard and that he was now “losing strength and feeling in his hand.” Id. Dr. Shah ordered that Leger's previous x-rays be sent to Pinckneyville and for Leger to receive an MRI examination of his right shoulder. Id.

         On July 19, 2012, Dr. Shah submitted a “Medical Special Services Referral and Report” to the Wexford Utilization Management Office (as part of a process referred to as “collegial review”), recommending that Leger receive an MRI examination. (Doc. 70-2, p. 97). He also discussed physical therapy with Leger and scheduled him to see a physical therapist. Id. at p. 17. Despite an initial scheduling of July 26, 2012, Leger was not seen by the physical therapist until November 19, 2012. Id. at p. 100. The physical therapist assessed Leger as having “[right] shoulder pain, significant rotator cuff and biceps strength impairment [and] loss of functional AROM [.]” Id. The therapist recommended physical therapy twice a week for eight weeks and to “continue to follow up [with] M.D. / N.P. for pain.” Id. Leger participated in physical therapy sessions from late November 2012 through mid-January 2013. (Doc. 70-5, p. 4).

         On July 26, 2012, Dr. Baker at the Wexford Utilization Management Office denied approval of the MRI examination. (Doc. 70-2 at p. 98). Dr. Baker noted:

Comments: Inmate with complaints of upper arm discomfort due to old injury. No limb atrophy or neurovascular comprimised [sic] noted on exam. Inmate's xrays were negative when he was at Menard cc. Dr. Baker advises starting PT for strengthening and ROM exercises. Dr. Shah in agreement with alternate plan. Represent if needed. Id.

         On December 17, 2012, Dr. Shah again submitted a request for an MRI to collegial review. (Doc. 70-2, p. 101). Wexford denied the request and directed that Leger receive the full course of physical therapy. Id. at p. 102. On January 17, 2013, the physical therapist drafted a re-evaluation report, assessing “[p]ersistent pain, persistent [right] shoulder weakness, probable rotator cuff dysfunction. No significant improvement in functional [range of motion].” Id. at p. 104. Dr. Shah then submitted another request for an MRI to collegial review which was approved on January 22, 2013. Id. at p. 106.

         Leger underwent an MRI on January 30, 2013 at Carbondale Memorial Hospital. (Doc. 70-2, p. 124). The reviewing physician's report states in part, “[f]ull thickness, full width tears of the supraspinatus and infraspinatus with tendon retraction and marked muscle atrophy.” Id. at p. 125. Dr. Shah examined Leger on March 12, 2013 and recommended that he receive an ...

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