April 28, 2015
Reargued En Banc December 1, 2015
Amended August 25, 2016
from the United States District Court for the Northern
District of Illinois, Eastern Division. No. 12 C 9353 George
M. Marovich, Judge.
WOOD, Chief Judge, and POSNER, Flaum, Easterbrook, Kanne,
Rovner, Williams, Sykes, and Hamilton, Circuit Judges.
Williams, Circuit Judge.
Petties suffered a debilitating rupture in his Achilles
tendon, which caused him extreme pain and impeded his
mobility over the course of three years. He brought a lawsuit
under 42 U.S.C. § 1983 against his doctors at Stateville
Correctional Facility alleging they failed to alleviate his
suffering and to enable his recovery from the injury We heard
this case en banc to clarify when a doctor's
rationale for his treatment decisions supports a triable
issue as to whether that doctor acted with deliberate
indifference under the Eighth Amendment. We conclude that
even if a doctor denies knowing that he was exposing a
plaintiff to a substantial risk of serious harm, evidence
from which a reasonable jury could infer a doctor knew he was
providing deficient treatment is sufficient to survive
summary judgment. Because we find that Petties has produced
sufficient evidence for a jury to conclude that the doctors
knew the care they were providing was insufficient, we
reverse the district court's grant of summary judgment to
was walking up the stairs of his cell house at Stateville in
January 2012 when he heard a loud pop and felt excruciating
pain and weakness in his left Achilles tendon. It was not the
first time he had suffered such an injury. In 2010 he
suffered a partial rupture in his right Achilles tendon at
the prison which had not fully healed.
Achilles tendon rupture is a tear in the tendon which impedes
the ability of the foot to point downward, causing pain and
limiting mobility. Walking around on a ruptured tendon
exacerbates the injury, increasing the gap between the torn
edges of a tendon because of the way that muscles contract in
the foot and calf. Immobilizing the injured foot prevents
stretching of the tear and allows the torn edges of the
tendon to sit together, and scar tissue to form, rejoining
the edges. When an Achilles rupture is not immobilized, the
stretching apart of the torn tendon edges when the injured
foot hits the ground causes severe pain and weakness.
went to Stateville's health clinic and eventually saw Dr.
Imhotep Carter, the medical director of Stateville (though
his actual employer was Wexford Health Sources, a private
contractor of medical services to correctional facilities).
Before Petties, Dr. Carter had seen approximately ten
Achilles tendon ruptures in his twenty-year career. As the
prison's medical director, Dr. Carter was in charge of
implementing Wexford's medical policies and procedures,
among which was a specific treatment protocol for patients
with ruptured Achilles tendons. The protocol advised that
patients receive a splint, crutches, and antibiotics if there
were lacerations to the site of injury, and then be sent to a
specialist for further treatment.
Carter's notes reflect that he thought Petties had an
Achilles tendon rupture, and that he followed some of
Wexford's protocol, but not all of it. He gave Petties
crutches, ice, and Vicodin. He also authorized one week of
"lay-in" meals, which meant that Petties did not
have to walk to the cafeteria, but could eat in his cell.
Finally, he referred Petties to a specialist, but that
appointment did not happen for almost six weeks. In the
meantime, Dr. Carter did not provide Petties with a splint,
boot, cast, or other device that would immobilize his foot.
About a month later, after Petties reported to the infirmary
that his tendon was "killing him" and keeping him
from climbing stairs, Petties saw Dr. Carter again and
received a renewed prescription for crutches, pain
medication, lay-in meals, and assignment to a lower bunk to
keep pressure off his foot. But he still did not receive a
March 2012, Petties had an MRI taken which showed an Achilles
tendon rupture. There was a gap between the torn ends of the
tendon that measured approximately 4.7 centimeters. About a
week later, Petties met with Dr. Anuj Puppala, an orthopedic
specialist, who noted that the lack of "any sort of
cast" was potentially creating the gapping at the tendon
rupture site. He recommended an orthopedic boot to prevent
further gapping and to alleviate pain, and gave one to
Petties. Finally, he thought that surgery might be necessary
due to the gapping, and referred Petties to an ankle
specialist. When Petties returned to Stateville, Dr. Carter
authorized use of the boot, along with crutches, ice, and
assignment to a lower bunk. Petties asserts that Dr. Carter
said he would not order surgery because it was too costly.
2012, Petties finally saw an ankle specialist, Dr. Samuel
Chmell, who ordered a second MRI after noting weakness in
Petties's ankle. Dr. Chmell also ordered physical
therapy, gentle stretching exercises, and follow-up
treatment. In August 2012, Dr. Carter was replaced as the
medical director of Stateville by Dr. Saleh Obaisi, another
Wexford employee. Dr. Obaisi approved the order for a second
MRI, but did not authorize physical therapy. According to
Petties, he also said that surgery was too expensive.
September, Petties had his second MRI, which showed a partial
tear in his tendon, indicating some healing. But he continued
to complain of pain, and Dr. Obaisi gave him Tylenol,
approved a low bunk permit, and continued his use of the
boot. Dr. Obaisi renewed the low bunk permit and use of the
boot in November, and again the following June. Petties
experienced pain, soreness and stiffness as late as March
2014, over two years after the injury
November 2012, Petties filed a lawsuit under 42 U.S.C. §
1983 against Dr. Carter and Dr. Obaisi for deliberate
indifference in violation of the Eighth Amendment. The
district court granted summary judgment to Dr. Carter and Dr.
Obaisi. Petties appeals.
review the district court's grant of summary judgment
de novo, viewing the record in the light most
favorable to Petties, and drawing all inferences in his
favor. Vagal v. TIN Inc., 695 F.3d 622, 624 (7th
Constitution does not mandate comfortable prisons, but
neither does it permit inhumane ones." Farmer v.
Brennan, 511 U.S. 825, 832 (1994) (internal citations
and quotation marks omitted). Every claim by a prisoner that
he has not received adequate medical treatment is not a
violation of the Eighth Amendment. Estelle v.
Gamble, 429 U.S. 97, 105 (1976). But the Eighth
Amendment safeguards the prisoner against a lack of medical
care that "may result in pain and suffering which no one
suggests would serve any penological purpose."
Id. at 103. To determine if the Eighth Amendment has
been violated in the prison medical context, we perform a
two-step analysis, first examining whether a plaintiff
suffered from an objectively serious medical condition, and
then determining whether the individual defendant was
deliberately indifferent to that condition. Farmer,
511 U.S. at 834; see also Berry v. Peterman, 604
F.3d 435, 440 (7th Cir. 2010).
evaluating an Eighth Amendment claim, we start by determining
if the medical condition the plaintiff suffered was
objectively serious. Farmer, 511 U.S. at 834;
see also Walker v. Peters,233 F.3d 494, 498 (7th
Cir. 2000). Here, the parties agree that an Achilles tendon
rupture is an objectively serious condition, but they ...