September 6, 2019
from the United States District Court for the Northern
District of Illinois, Eastern Division. No. 13-cv-07237 -
Sharon Johnson Coleman, Judge.
Flaum, Sykes, and St. Eve, Circuit Judges.
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. Sal eh
Obaisi-were deliberately indifferent to his medical needs
after he underwent spinal surgery in March
2011. Specifically, Walker alleges defendants
failed to: (1) ensure 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
the relevant period, the State of Illinois subcontracted 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 Director from August 2012 until his death in December
Healthcare at Stateville
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 employees.
All the medical providers at Stateville, whether employed by
Wexford or not, followed IDOC's administrative policies
and procedures. Nonetheless, Wexford's corporate
representative testified that when deciding how to provide
the best care for patients, clinicians relied on their
training and experience first, and the governing policies
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 Illinois
at Chicago Medical Center ("UIC"). Typically,
referrals had to go through a collegial peer review process,
which Wexford 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.
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 decision.
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
appointment. 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.
authorizations were valid for ninety days. From 2011 to 2014,
however, Wexford did not have a system in place to alert its
staff when an authorization expired before the inmate had
Walker's Treatment History at Stateville
March 1, 2010, a Wexford physician's assistant examined
Walker, noting that he had right leg twitching and reports 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 surgery and
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 discharge 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 lawsuit. 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 have improved if he had been sent back to UIC
within three months of his March 2011 surgery.
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 infirmary discharged Walker, reporting
his minimal discomfort and giving him permits for low bunk,
low gallery, and special medical restraints.
four weeks after the surgery, Walker received a physical
therapy examination at Stateville. The therapist stated that
Walker explained that his pain had resolved, and that the
surgical scar was well-healed with minor adhesion (excessive
growth of scar tissue). Between May 26, 2011, and August 31,
2012, the record shows that Walker saw Stateville 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 irritation,
however, is unclear from Walker's testimony.
Obaisi first examined Walker on September 26, 2012, almost
exactly eighteen months after Walker's surgery. He
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
suspected that Walker might have upper motor neuron syndrome.
As a result, Dr. Obaisi ordered x-rays and provided Walker
with muscle relaxers and anti-inflammatory medication. 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
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
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 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 repeat MRI of the lumbar spine, an
imaging test of the right lower extremity to rule out a
myelopathygiven his blood test, and a rereferral to
• On May 23, 2013, Walker received an MRI that showed
some degenerative changes to his L3-L4 spinal segments.
• On May 28, 2013, Walker had a neurosurgery
consultation at UIC. The examining neurosurgeon observed that
Walker's back pain and radiculopathysymptoms had
improved, but that he had "right inguinal
[(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 SI. There is
a suggestion of lu-cency around the bilateral SI 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 identified a loose surgical screw at his SI
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 consult he had
recommended had not been done.(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 neurosurgery and the
pain clinic. Additionally, Dr. Zeldman'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 voluntarily stopped
taking pain medications because he felt they made him
constipated. The UIC pain physicians instructed Walker to
resume taking the pain ...