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Walker v. Wexford Health Sources, Inc.

United States Court of Appeals, Seventh Circuit

October 15, 2019

George Walker, Plaintiff-Appellant,
v.
Wexford Health Sources, Inc., et al. Defendants-Appellees.

          Argued September 6, 2019

          Appeal from the United States District Court for the Northern District of Illinois, Eastern Division. No. 13-cv-07237 - Sharon Johnson Coleman, Judge.

          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. Sal eh Obaisi-were deliberately indifferent to his medical needs after he underwent spinal surgery in March 2011.[1] 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 affirm.

         I. Background

         During 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 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 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 second.

         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 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.

         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 decision.

         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 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.

         UM's 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 received treatment.[2]

         B. Walker's Treatment History at Stateville

         On 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 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 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.

         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 infirmary 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 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.

         Dr. 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 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 easily."

         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 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 myelopathy[3]given his blood test, and a rereferral to neurosurgery.[4]
• 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 radiculopathy[5]symptoms 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.[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 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 ...

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