ASHOOR RASHO, еt al., Plaintiffs-Appellees, v. ROB JEFFREYS, Director of the Illinois Department of Corrections, and MELVIN HINTON, Acting Statewide Mental Health Supervisor of the Illinois Department of Corrections, Defendants-Appellants.
Nos. 19-1145, 19-1375 & 19-1978
United States Court of Appeals For the Seventh Circuit
ARGUED MAY 20, 2020 — DECIDED JANUARY 12, 2022
Appeal from the United States District Court for the Central District of Illinois. No. 07-C-1298 — Michael M. Mihm, Judge.
SYKES, Chief Judge. Ashoor Rasho, on behalf of a class of mentally ill inmates in the custody of the Illinois Department of Corrections (IDOC), sued IDOC officials for failing to provide constitutionally adequate mental-health care. The
The district judge held that the plaintiffs made such a showing in five areas of mental-health treatment and noted that IDOC‘s deficiencies were primarily attributable to a chronic, severe shortage of mental health staff. Because IDOC had known about its staffing problem for several years and displayed a “lack of a sense of urgency” in fixing the issue, the judge concluded that the defendants were deliberately indifferent to the risk of harm associated with inadequate mental-health care. He entered a permanent injunction requiring IDOC to hire and maintain a specific minimum number of staff in multiple areas of care and imposing other specific requirements for the delivery of mental-health services—all on a court-imposed, mandatory timetable.
We reverse the district court‘s order and vacate the injunction. IDOC officials took reasonable steps to cure the deficiencies identified by the plaintiffs—in particular, the understaffing—and those actions cannot be squared with the judge‘s finding of deliberate indifference. Even if those steps were not fully successful, their reasonable effort to address a known risk of harm shows that they did not recklessly disregard that risk.
The court‘s order also exceeds the remedial limitations set by the Prison Litigation Reform Act (“PLRA“). In the corrections context, prospective remedies must be “narrowly drawn, extend[] no further than necessary to correct the violation of the Federal right, and [be] the least intrusive means necessary to correct the violation of the Federal right.”
I. Background
The details of this lengthy litigation are largely irrelevant for present purposes. Here are the basics: in 2007 Rasho filed a pro se § 1983 complaint against several IDOC officials claiming that IDOC‘s treatment of his mental illness was constitutionally deficient in violation of the Eighth Amendment.1 With the help of counsel, Rasho amended his complaint to assert the same claim on behalf of a proposed class of all mentally ill IDOC inmates. The class-action complaint sought declaratory and injunctive relief compelling IDOC to overhaul its system of mental-health care. After the district court certified the class, the parties spent years in protracted settlement negotiations.
The parties entered into a comprehensive settlement agreement in 2016, almost ten years after the suit was filed. The agreement requires IDOC to make dozens of changes to
Dr. Stewart‘s first annual report, released in June 2017, sharply criticized IDOC‘s progress in fulfilling the agreement. After analyzing IDOC‘s compliance in exacting detail, Dr. Stewart reached a blunt bottom line: “[T]he lack and quality of psychiatric services negatively impacts all aspects of the Settlement and contributes to IDOC being non-compliant in the vast majority of areas of the Settlement.” Stewart‘s concerns persisted for several months, leading him
The judge held an evidentiary hearing on the plaintiffs’ motion over six days in late 2017 and early 2018. Witness testimony revealed that IDOC had clearly made progress in revamping its mental-healthcare system: it spent $45 million to build new residential treatment units at several facilities and $75 million to develop a new data system for intake assessments; it procured another $150 million to construct a new inpatient facility; it delivered mental-health training to its entire staff; and it hired administrative personnel to coordinate inmate care. Nevertheless, witnesses for both the plaintiffs and defendants opined that IDOC still could not provide treatment at the level required under the agreement. Undisputed testimony attributed IDOC‘s shortcomings to systemic shortages in mental-health staff. Dr. Hinton admitted that IDOC budgeted for 65 psychiatrists but currently employed less than half that many.
In May 2018 the judge entered a preliminary injunction. He concluded that IDOC‘s “persistent” staffing deficiencies had created an “emergency situation” and that IDOC‘s failure to address those deficiencies—despite being aware of them for “an unreasonable period of time“—amounted to deliberate indifference. He therefore ordered IDOC to take measures to address thе five areas identified by the plaintiffs
Two days later Dr. Stewart delivered his second annual report, again finding that IDOC was noncompliant in the same areas. The plaintiffs moved for a permanent injunction on the same grounds as the preliminary injunction.
Over several days in August and September 2018, the judge held an evidentiary hearing on the permanent-injunction motion. The parties agreed that pursuant to
Still, the evidence also showed that the situation had improved in the first half of 2018. Importantly, IDOC had taken several steps to cure the personnel shortage, including:
- increasing the number of full-time-equivalent psychiatric providers from 33.53 to 50.55 and qualified mental-health professionals from 111 to 117;3
- authorizing unlimited overtime;
- partnering with a local university to provide psychiatric care;
- expanding use of telepsychiatry;
- offering travel stipends and bonuses for providers willing to take on extra work at different facilities;
- setting salaries at the 90th percentile nationwide; and
- coordinating with state officials to streamline the licensing process for IDOC psychiatric providers.
These measures, along with revisions to care procedures, contributed to a decrease in treatment backlogs at several facilities.
IDOC witnesses also testified about the difficulties of recruiting mental-hеalth professionals in the corrections field. A nationwide shortage left 57% of Illinois counties without any such professionals, and it was hard to persuade medical professionals to move (or commute) from major cities to work in the challenging corrections environment. As a result, Wexford Health Sources, IDOC‘s staffing vendor, struggled to meet recruitment goals.
The judge granted the plaintiffs’ motion for a permanent injunction.4 Rasho v. Walker, 376 F. Supp. 3d 888, 892–93 (C.D. Ill. 2019). Before addressing IDOC‘s deficiencies in the five specific areas at issue, the judge emphasized that his finding was “based generally on the fact that there is insufficient mental health staffing at ... IDOC.” Id. at 901. Although he acknowledged that IDOC had made some improvements, he found that the use of unlimited overtime was “unsustain-
Against this backdrop, the judge issued an extensive injunction addressing staffing and the five areas at issue. The essential terms of the order are summarized as follows:
(1) Staffing. Within 90 days, IDOC must employ “7 Site Mental Health Service Directors; 12 Mental Health Unit Directors; [16] Staff Psychologists; 142.5 Qualified Mental Health Professionals; 102 Behavioral Health Technicians; 54.5 Registered Nurses—Mental Health; 24 Staff Assistants; 85.5 Psychiatric Providers; 1 Director of Nursing—Psychiatric; [and] 5 Recreational Theraрists.” Id. at 919–20. The order includes job descriptions for several of these positions and requires follow-up reporting and evaluation. The judge drew the staffing numbers from a 2014 Remedial Staffing Plan that IDOC voluntarily offered during settlement negotiations. Id. at 919–21.
(2) Crisis care. IDOC may use crisis care only for a patient dangerous to himself or others or upon a finding by a mental-health professional that no less restrictive treatment is appropriate. A mental-health professional must conduct a confidential, daily assessment of a patient‘s progress and update the patient‘s treatment plan no later than the time of discharge. For patients who do
(3) Segregation. A mental-health professional must assess and document an inmate‘s condition upon placement in segregation. For any inmate in segregation for 16 days or more, IDOC must conduct rounds at least every 7 days and provide out-of-cell time. If an inmate in segregation for more than 60 days refuses out-of-cell time, a mental-health professional must evaluate the inmate to determine the risk of deteriorating mental health. Id. at 923–24.
(4) Medication. Inmates prescribed psychotropic medication must be “evaluated by a psychiatric provider at regular intervals consistent with constitutional standards.” Id. at 924. IDOC must administer medications in a manner that provides “reasonable assurance” that the medications are actually delivered. Id.; id. at 924–25.
(5) Evaluations and treatment plans. IDOC must provide all class members an individualized treatment plan that includes lоng- and short-term objectives and regular reviews with the patient. Id. at 925.
II. Discussion
The defendants challenge the judge‘s ruling that the shortcomings in IDOC‘s performance under the settlement agreement amount to an Eighth Amendment violation. They also challenge the scope of the injunction under the terms of the agreement and the PLRA. We review the judge‘s factual findings for clear error, ADT Sec. Servs., Inc. v. Lisle-Woodridge Fire Prot. Dist., 724 F.3d 854, 863 (7th Cir. 2013),
A. Deliberate Indifference
Everyone agrees that each of the plaintiffs suffers from an objectively serious medical condition—here, mental illness—which is the first element of an Eighth Amendment claim premised on inadequate prison healthcare. The parties’ dispute centers on whether the IDOC officials were deliberately indifferent to the plaintiffs’ medical condition. Lockett, 937 F.3d at 1022. Deliberate indifference is a subjective mental state; the official must have actually known of and consciously disregarded a substantial risk of harm. Petties v. Carter, 836 F.3d 722, 728 (7th Cir. 2016) (en banc). This is a high bar “because it requires a showing [of] something approaching a total unconcern for the prisoner‘s welfare in the face of serious risks.” Rosario v. Brawn, 670 F.3d 816, 821 (7th Cir. 2012) (quotation marks omitted).
Evidence that the defendant responded reasonably to the risk, even if he was ultimately unsuccessful in preventing the harm, negates an assertion of deliberate indifference. Farmer, 511 U.S. at 844; Peate v. McCann, 294 F.3d 879, 882 (7th Cir. 2002); see also Sinn v. Lemmon, 911 F.3d 412, 423–24 (7th Cir. 2018) (holding that no reasonable juror could infer
The defendants maintain that the judge effectively ignored the subjective element. This case obviously involves a claim of systemically inadequate prison healthcare, which the judge referred to as a “second category of deliberate indifference claim[].” Rasho, 376 F. Supp. 3d at 914. The defendants read this statement as taking the subjective element off the table; they contend that the judge engaged in a solely objective analysis. We see it differently. The subjective state-of-mind element applies to claims of isolated incidents of indifference and pervasive deficiencies in prison medical treatment, and the judge recognized as much. His innocuous reference to a “second category” of claims—language that appears in our own caselaw, e.g., Phillips v. Sheriff of Cook Cnty., 828 F.3d 541, 554 (7th Cir. 2016)—merely invoked the well-settled principle that while a single negligent act cannot support an inference of deliberate indifference, persistence in a course of action known to be ineffective can, see Whiting v. Wexford Health Sources, Inc., 839 F.3d 658, 662–63 (7th Cir. 2016).
Although the judge recited the correct legal standard, we agree with the defendants that the record does not support his finding of deliberate indifference. To the contrary, the evidence establishes that IDOC made reasonable efforts to cure the deficiencies in the five areas identified in the plaintiffs’ claim and to alleviate the staffing shortage. These include increasing the number of psychiatric providers,
To be sure, IDOC‘s efforts fell short: the prison system has not yet provided the level of care prescribed by the settlement, nor has it hit the personnel targets laid out in its 2014 Remedial Staffing Plan. But that does not equate to a constitutional violation. For one thing, there is no evidence that the terms of the settlement and IDOC‘s staffing plan matched the constitutional floor, an issue we address below. But even assuming IDOC‘s goals corresponded to the Eighth Amendment minimums, the defendants cannot have been deliberately indifferent because they undertook reasonable measures to achieve those goals, even though they were ultimately unsuccessful. Peate, 294 F.3d at 882.
The judge was wrong to fault the defendants for their “unsustainable” use of overtime, continued reliance on Wexford for staffing, and “lack of a sense of urgency” in complying with the settlement. It is always possible to do more or move faster, but the existence of policies that may have been more effective does not mean an official recklessly disregarded the risk of harm. Smith v. Sangamon Cnty. Sheriff‘s Dep‘t, 715 F.3d 188, 191 (7th Cir. 2013); see also Lockett, 937 F.3d at 1022–25 (explaining that a nurse is not
Nor is this a case in which the prison officials persisted in taking steps that they knew were insufficient to prevent the harm. See Petties, 836 F.3d at 730–31. It was reasonable to expect that paying higher salaries and offering bonuses would attract more mental-health personnel, just as it was reasonable to believe that expanding the use of telepsychiatry and paying travel stipends would enable them to more efficiently deploy their limited resources. Indeed, the record shows that IDOC‘s multifaceted approach led to reduced backlogs in mental-health treatment and a substantial increase in the number of psychiatric providers—even though its efforts ultimately fell short. Put simply, IDOC officials took multiple reasonable steps to fix the complex problem of understaffing in mental-health services, so they cannot have been deliberately indifferеnt. It was error to find otherwise.
B. Scope of Injunction
The PLRA constrains a court‘s authority to enter an injunction with respect to prison conditions: “The court shall not grant or approve any prospective relief unless the court finds that such relief is narrowly drawn, extends no further than necessary to correct the violation of the Federal right, and is the least intrusive means necessary to correct the violation of the Federal right.”
Our decision in Westefer illustrates how
We held that the injunction went well beyond the limits imposed by the PLRA, explaining that the judge had “mistakenly conflated what is constitutionally adequate to satisfy due process with what is constitutionally required.” Id. at 683–84. While the Supreme Court had held that a 24-hour prehearing notice is constitutionally required, the injunction violated the PLRA‘s narrow-tailoring requirement in mandating 48-hour notice. Id. at 684. Likewise, setting a specific 10- or 30-day window for transfer hearings exceeded the constitutionally required “reasonable time” for such a hearing and in doing so defied the PLRA‘s least-intrusive-means prong. Id. at 684–85. It did not matter that the injunction included “hedging ‘whenever possible’ language” in its mandate; the PLRA requires that courts give prison administrators wide latitude to set constitutionally adequate procedures. Id. at 685. We summarized:
In short, the injunction goes well beyond what the Supreme Court has said is constitutionally required. By incorporating a highly specific notice-and-hearing system into the injunction, the district court has in effect established the details of that system as constitutional requirements. This is not the narrow tailoring that the PLRA requires. It is up to IDOC to craft transfer-review procedures that meet the requirements of due process. The court should do no more than to order IDOC officials to do so in general terms and to verify that the plan they submit satisfies the relevant constitutional standards.
The injunction here suffers from the same infirmities as the one we vacated in Westefer. Most egregiously, the judge ordered IDOC to hire and maintain precise numbers and types of personnel: “7 Site Mental Health Service Directors; 12 Mental Health Unit Directors; [16] Staff Psychologists; 142.5 Qualified Mental Health Professionals; 102 Behavioral Health Technicians; 54.5 Registered Nurses—Mental Health; 24 Staff Assistants; 85.5 Psychiatric Providers; 1 Director of Nursing—Psychiatric; [and] 5 Recreational Therapists.” This degree of specificity contravenes the PLRA‘s least-intrusive-means requirement. Could IDOC have provided constitutionаlly adequate care with 85 Psychiatric Providers instead of 85.5? What about using 103 Behavioral Health Technicians but only 22 Staff Assistants? Could IDOC continue to authorize unlimited overtime and expanded telepsychiatry—practices that had a proven effect of reducing treatment backlogs? There is no evidence in the record establishing that these specific numbers correspond to the constitutional floor, yet the PLRA demands that injunctive relief “extend no further” than necessary to remedy the constitutional violation. By exceeding that limitation, the judge‘s order impermissibly strips IDOC officials of the flexibility necessary to adopt and implement policies that balance prison resources, safety concerns, and inmate health.
The judge‘s error goes beyond staffing too. The injunction requires, for example, that class members in segregation for 16 days or more be examined by mental-health staff at least every 7 days. That may be a valuable way of preventing the deterioration of a segregated inmate‘s mental health, but the Eighth Amendment does not require the most effective solution. Rosario, 670 F.3d at 822; see also Ball v. LeBlanc, 792 F.3d 584, 599 (5th Cir. 2015) (holding that an injunction
The judge held that Westefer is inapplicable for two reasons. First, he noted that “the record here demonstrates a long history of the [d]efendants’ non-compliance with various terms they had agreed upon.” Rasho, 376 F. Supp. 3d at 918. The judge did not explain why he thought that the history of nonсompliance mattered. It doesn‘t; or more precisely, it doesn‘t make Westefer inapplicable or dilute the PLRA‘s remedial limitations. The PLRA applies of its own force and in full since the case involves “prison conditions,”
Second, the judge stated that the “[d]efendants’ proposal is wholly deficient in addressing their constitutional violations.” Rasho, 376 F. Supp. 3d at 918. The defendants’ proposal, however, would have required them to remedy the alleged violation “in general terms” in accordance with our instructions in Westefer, 682 F.3d at 686. And even if the proposal had been lacking, the judge was not free to go beyond the limits imposed by the PLRA in crafting an injunction.
We do not mean to say that an injunction imposing a specific numeric target automatically violates the PLRA. In Brown v. Plata, 563 U.S. 493, 538–41 (2011), the Supreme
In contrast to Brown, here the judge imposed specific benchmarks lifted from the settlement and IDOC‘s 2014 Remedial Staffing Plan without evidence that thosе plans matched the constitutional floor. In fact, the Staffing Plan explicitly stated that it set staffing at levels sufficient to exceed the constitutional minimum. Nor did the judge impose staffing targets “in a manner that [left] much to [IDOC‘s] discretion,” id. at 533; instead, he prescribed the exact numbers, types, and duties of IDOC personnel. That can hardly be the least intrusive means of correcting a constitutional violation.
III. Conclusion
IDOC officials took multiple reasonable steps to cure the staffing shortage and improve mental-health services in the five areas at issue in this claim. Those actions demonstrate due regard for the harms imposed by inadequate mental-health care, so the judge‘s finding of deliberate indifference was error. In addition, and as an independent reversible
Because deliberate indifference is a factual determination,2 I set forth in some detail the facts leading to the district court‘s permanent injunction order.
In response to Mr. Rasho‘s complaint alleging constitutional violations in the delivery of mental health services, the parties entered a comprehensive settlement agreement (“Agreement“) in May 2016. The Agreement addressed numerous areas where IDOC had been deficient including: the quality and timing of initial intakes; the development and revision of treatment plans; treatment space; staffing; confidentiality; and the housing and discipline of seriously mentally ill inmates. The Agreement provided for the hiring of a monitor, Dr. Pablo Stewart, to evaluate IDOC‘s progress, provide updates, and prepare annual reports.
Dr. Stewart submitted his first annual report in May 2017. The report noted the substantial cooperation of the leadership and staff at IDOC but concluded that IDOC still was struggling to meet the requirements of the Agreement. The Executive Summary of the report captures those shortcomings:
Among IDOC‘s challenges is the grossly insufficient and extremely poor quality of psychiatric services. This overwhelming shortage and lack of standards undermines all of the efforts of IDOC to meet the first-year requirements of the Settlement. These psychiatric services
deficiencies include but are not limited to problems with the proper continuation of medications for offenders entering IDOC, lack of timely follow-up for offenders prescribed psychotropic medication, dangerous practices related to the use of psychotropic medications including those offenders on forced medication, lack of following standard protocols for ascertaining side effects, extreme delays in obtaining psychiatric evaluations, non-participation of psychiatrists in the treatment planning process, lack of timely psychiatric follow up for offenders assigned to crisis beds, and problems related to those offenders designated as requiring inpatient level of psychiatric services. Of note, the overall quality of the psychiatric services provided to the mentally ill offenders of IDOC is exceedingly poor and often times dangerous. IDOC leadership is well aware of the problems related to the insufficient amount of psychiatric services and has taken decisive action to address this issue, but this has not yet been effective. At the time of the submission of this report, however, the lack and quality of psychiatric services negatively impacts all aspects of the Settlement and contributes to IDOC being non-compliant in the vast majority of areas of the Settlement.3
IDOC‘s continued failures in the areas identified by Dr. Stewart led the plaintiffs to file a motion to compel compliance with the Agreement. They later amended this motion to include a request for a preliminary injunction. The district court heard testimony on the plaintiffs’ motion for six days in late 2017 and early 2018. The evidence showed that IDOC had spent $45 million to build new residential treatment units at several facilities and $75 million to develop a new data system for intake assessments. It also had procured another $150 million to construct a new inpatient facility. Finally, it had provided mental health training to its entire staff and had hired administrative personnel to coordinate inmate care.
Dr. Stewart‘s Second Annual Report, filed in June 2018, continued to sound the alarm regarding staffing levels. The report first noted that the remedial targets set forth in May 2016 were “not sufficient to meet the requirements of the Settlement Agreement.”10 Moreover, IDOC had “never met its staffing goals through the life of the Settlement Agreement.”11
Nevertheless, the record contained evidence that lack of staff continued to pose a serious problem. Specifically, when asked whether the current staffing levels were adequate to meet the needs of inmates, Dr. Hinton would not directly answer the question.12 There were efforts to shift staff “from one area of concern to another” in order to establish that IDOC was meeting the residents’ needs.13 There also was testimony from IDOC psychiatrists that, although there had been reductions in backlogs, these were due in large part to the use of overtime, which not only “would be difficult to sustain,” but created another “problem” — loss of good staff due to burnout.14
[e]ven with the additional mental health staff hired after the preliminary injunction hearing, the numbers associated with mental health providers [we]re deficient to provide the constitutionally required care. In fact, the June 2018 monthly facility performance report showed Wexford had failed to supply more than 10,000 hours of required clinical staff for that month.18
The court further found that IDOC had been aware of these deficiencies “for an unreasonable period of time, and their failure to address these deficiencies amount[ed] to deliberate indifference.”19 “While some efforts ha[d] been
After reviewing the evidence, the court set forth the requirements for establishing an Eighth Amendment violation: “(1) the plaintiff ‘suffered an objectively serious harm that presented a substantial risk to his safety,’ and (2) ‘the defendants were deliberately indifferent to that risk.‘”21 Because there was no doubt that the prisoners had presented evidence of an objectively serious risk of harm, the court turned to the subjective component:
The subjective component requires a plaintiff to “provide evidence that an official actually knew of and disregarded a substantial risk of harm.” Petties v. Carter, 836 F.3d 722, 728 (7th Cir. 2016) .... In order to establish deliberate indifference, “a plaintiff does not need to show that the official intended harm or believed that harm would occur.” Id. ... However, medical malpractice, negligence, or even gross negligence do not equate to deliberate indifference. Johnson v. Doughty, 433 F.3d 1001, 1013 (7th Cir. 2006) ....
The Seventh Circuit has recognized claims of systemic deficiencies in a prison‘s health care facility as a second category of deliberate
indifference claims. Cleveland-Perdue v. Brutsche, 881 F.2d 427, 430–31 (7th Cir. 1989). In case of alleged systemic deficiencies, deliberate indifference can be demonstrated by “proving there are such systemic and gross deficiencies in staffing, facilities, equipment, or procedures that the inmate population is effectively denied access to adequate medical care.” Wellman, 715 F.2d at 272 .... The Seventh Circuit has concluded “that a clear consensus had been reached indicating that a prison official‘s failure to remedy systemic deficiencies in medical services akin to those alleged in the present case constituted deliberate indifference to an inmate‘s medical needs.” Cleveland-Perdue, 881 F.2d at 431.22
Although the record did show that IDOC had “recently made efforts to address many of the problems associated with the delivery of adequate mental health care,” the court “remain[ed] concerned with the overall lack of sense of urgency.”23 The problems, the court continued, dated “as far back as 2014 when the Defendants created their own remedial plan,” but they had yet “to fulfill any of their own staffing requirements.”24 They also had yet to meet many of the terms of the Agreement. As a result, “[i]t [wa]s clear [that] mentally ill inmates continue[d] to suffer as they wait[ed] for the IDOC
After soliciting IDOC‘s input regarding how to address the constitutional deficiency, the district court ultimately concluded that IDOC‘s 2014 proposed staffing plan27 provided a sound basis for injunctive relief. Thus, the district court required that IDOC reach the staffing levels that, back in 2014, IDOC itself had acknowledged were necessary. While this step would not solve entirely the present violation, it would at least require that IDOC make some forward progress toward meeting minimal staffing requirements.
II
I now turn to the majority‘s review of the district court‘s finding of deliberate indifference. The majority initially observes the “high bar” set by the deliberate indifference standard, which “‘requires a showing [of] something approaching a total unconcern for the prisoner‘s welfare in the face of serious risks.‘” Majority Op. 10 (citing Rosario v. Brawn, 670 F.3d 816, 821 (7th Cir. 2012)). Thus, evidence that “the defendant responded reasonably to the risk, even if he was ultimately unsuccessful in preventing the harm, negates an assertion of deliberate indifference.” Id. (emphasis added). The majority acknowledges that the district court‘s finding that this
My colleagues believe, however, that the record cannot support a finding of deliberate indifference. While “IDOC‘s efforts fell short” achieving the 2014 staffing levels, “that d[id] not equate to a constitutional violation.” Id. at 12. Even assuming that the 2014 staffing levels represented the “constitutional floor,” the majority continues, IDOC could not “have been deliberately indifferent because [it] took reasonable measures to achieve those goals, even though they were ultimately unsuccessful.” Id. (citing Peate v. McCann, 294 F.3d 879, 882 (7th Cir. 2002)). “It is always possible to do more or move faster,” it states, “but the existence of policies that may have been more effective does not mean an official recklessly disregarded the risk of harm.” Id. at 12.
Respectfully, this conclusion both misreads the record and fails to give sufficient deference to the district court‘s factual findings. First, the district court did not rely solely on the staffing numbers in the 2014 remedial plan or the Agreement to establish a constitutional violation. Rather, the district court relied on the testimony at the preliminary injunction hearing that, despite the passage of significant time, IDOC did not have the staffing necessary to provide psychiatric care to all of the patients in its system and that prisoners were not getting the care they needed.29 Moreover, despite some improvements made after the preliminary injunction order
The district court relied on relevant and probative evidence in concluding IDOC officials were deliberately indifferent. In Wellman v. Faulkner, 715 F.2d 269, 272 (7th Cir. 1983), we addressed whether certain deficiencies in a prison‘s provision of healthcare violated the Eighth Amendment. We explained:
As a practical matter, “deliberate indifference” can be evidenced by “repeated examples of negligent acts which disclose a pattern of conduct by the prison medical staff” or it can be demonstrated by “proving there are such systemic and gross deficiencies in staffing, facilities, equipment, or procedures that the inmate population is effectively denied access to adequate medical care.”
Id. (quoting Ramos v. Lamm, 639 F.2d 559, 575 (10th Cir. 1980)); cf. Whiting v. Wexford Health Sources, Inc., 839 F.3d 658, 663 (7th Cir. 2016) (noting that “evidence sufficient to create a jury question might include the obviousness of the risk from a
Here, a district court, which had overseen the litigation for more than a decade, conducted a comprehensive hearing prior to the preliminary injunction and another hearing prior to entry of the permanent injunction. It made specific credibility findings with respect to the administrators and the mental health professionals testifying on behalf of IDOC. It pointed to specific testimony that demonstrated that these officials knew that the new measures were not capable of meeting the needs of the inmates, that they were not sustainable in the long term, and that they would not cure effectively the constitutional violations. See R.2460 at 19 (Dr. Hinton evading the question whether IDOC‘s staffing levels were “adequate“); id. at 23 (Psychologist Administrator at Pontiac acknowledging that reduction in backlog was being effected through “people com[ing] from other institutions ... and ... additional overtime” which would be “difficult to sustain“); id. at 27 (“This colloquy between Plaintiffs’ counsel and Dr. Sim demonstrates the ongoing shift by the Defendants of their limited staff resources from one area of concern to another and the need to cover essential items by use of overtime. This is simply unsustainable.“).
Nevertheless, the majority concludes that IDOC officials “cannot have been deliberately indifferent” because they
“Clear error is a deferential standard of review that only merits reversal if ‘after reviewing the entire record, we are left with the firm and definite conviction that a mistake has been made.‘” LAJIM, LLC v. Gen. Elec. Co., 917 F.3d 933, 946 (7th Cir. 2019) (quoting United States v. Rangel, 872 F.3d 815, 818 (7th Cir. 2017)). When IDOC‘s recent “improvements” in the delivery of services are evaluated according to the entire
III
The panel majority‘s review of the scope of the district court‘s injunction also is cause for significant concern. Its parsimonious attention to the statute‘s language and to the significant consensus of judicial decisions interpreting that language sets our circuit on a lonely course. This solitary path now before us puts us in conflict with the controlling precedent of the Supreme Court and with the decisions of the other circuits. It also will create needless ambiguity and frustration for the district judges of our circuit who will have the unenviable task of following its apprоach in future cases.
A.
The PLRA provides in relevant part:
Prospective relief in any civil action with respect to prison conditions shall extend no further than necessary to correct the violation of the Federal right of a particular plaintiff or plaintiffs. The court shall not grant or approve any prospective relief unless the court finds that such relief is narrowly drawn, extends no further than necessary to correct the violation of the Federal right, and is the least intrusive means necessary to correct the violation of the Federal right. The court shall give substantial weight to any adverse impact on public safety or the operation of a criminal justice system caused by the relief.
While courts were already required to ensure injunctions are no broader than necessary, the PLRA emphasizes the importance of narrow tailoring in prison litigation by requiring courts to make specific findings that “such relief is narrowly drawn, extends no further than necessary to correct the violation of the Federal right, and is the least intrusive means necessary to correct
the violation of the Federal right.” § 3626(a)(1)(A) .
Ga. Advoc. Off., 4 F.4th at 1209.
Although the PLRA undoubtedly sets a high bar, its standards are not designed for application in the abstract world of appellate chambers but in the real-world courtroom of the practicing district judge dealing with very important human problems and very real parties. We cannot attribute to Congress the intent to create a practically unworkable standard designed to frustrate the conscientious district court in the performance of its already difficult duty. Indeed, the Supreme Court has instructed that “[t]he PLRA should not be interpreted to place undue restrictions on the authority of federal courts to fashion practical remedies when confronted with complex and intractable constitutional violations.” Brown v. Plata, 563 U.S. 493, 526 (2011). Instead, “[c]ourts should presume that Congress was sensitive to the real-world problems faced by those who would remedy constitutional violations in the prisons and that Congress did not leave prisoners without a remedy for violations of their constitutional rights.” Id.
B.
1.
In assessing the district court‘s decision, the panel majority takes as its centerpiece our decision in Westefer v. Neal, 682 F.3d 679 (7th Cir. 2012). In doing so, it asks that solid decision to carry weight that it was not designed to, and ought not be required to, bear. Westefer involved a prisoners’ due process challenge to the method employed to assign them to a maximum-security facility. After a bench trial, the district court concluded that the procedures violated the prisoners’ rights
IDOC challenged the order on appeal, and we reversed. We explained that the district court had “mistakenly conflated what is constitutionally adequate to satisfy due process with what is constitutionally required.” Id. at 683–84. The plan, we continued, went far beyond the constitutional requirements of “informal, nonadversarial due process” and therefore could not “be reconciled with the PLRA‘s requirement that injunctions in prison-conditions cases must be narrowly drawn and use the least intrusive means of correcting the violation of the federal right.” Id. at 684. We concluded:
By incorporating a highly specific notice-and-hearing system into the injunction, the district court has in effect established the details of that system as constitutional requirements. This is not the narrow tailoring that the PLRA requires. It is up to IDOC to craft transfer-review procedures that meet the requirements of due process. The court should do no more than to order IDOC officials to do so in general terms and to verify that the plan they submit satisfies the relevant constitutional standards.
Westefer is a thoughtful, straightforward applicatiоn of the core principle of equity practice in constitutional cases, “supercharge[d]” by the PLRA, Ga. Advoc. Off., 4 F.4th at 1209,
In the present case, the district court considered the Westefer decision, but did not believe that case governed the situation before it for two reasons: “First, the record here demonstrates a long history of the Defendants’ non-compliance with various terms they had agreed upon. Second, given this history of non-compliance, Defendants’ proposal is wholly deficient in addressing their constitutional violations.”33 The panel majority faults the district court for this conclusion; in its view, IDOC‘s history of noncompliance is not a relevant consideration here. See Majority Op. 17 (“The judge did not explain why he thought that the history of non-compliance mattered. It doesn‘t; or more precisely, it doesn‘t make Westefer inapplicable or dilute the PLRA‘s remedial limitations.“). Respectfully, the precedent of the Supreme Court and of the other circuits counsels otherwise.
Of key importance is the Supreme Court‘s decision in Brown v. Plata, 563 U.S. 493 (2011). Plata involved consolidated cases instituted by prisoners in California challenging various aspects of their confinement. There was no question that the constitutional violations were, in large part, rooted in overcrowding, and the courts in both cases had taken a number of
[a]lthough both the revised plan of action in Coleman and the appointment of the Receiver in Plata werе new developments in the courts’ remedial efforts, the basic plan to solve the crisis through construction, hiring, and procedural reforms remained unchanged. These efforts had been ongoing for years; the failed consent decree in Plata had called for implementation of new procedures and hiring of additional staff; and the Coleman Special Master had issued over 70 orders directed at achieving a remedy through construction, hiring, and procedural reforms. The Coleman Special Master and Plata Receiver were unable to provide assurance that further, substantially similar efforts would yield success absent a population reduction. Instead, the Coleman Special Master explained that “many of the clinical advances painfully accomplished over the past decade are slip-sliding away” as a result of overcrowding. And the Plata Receiver indicated that, absent a reduction in overcrowding, a successful remedial effort could “all but bankrupt” the State of California.
Plata, 563 U.S. at 515–16 (citation omitted).
The cases were consolidated and submitted to the same three-judge panel for a determination of whether a reduction in prison population should be ordered. After a fourteen-day hearing, the panel issued a lengthy opinion, with extensive findings of fact, in which it “ordered California to reduce its
On review, the Supreme Court first had to determine whether a three-judge panel had been properly convened. The State asserted, among other arguments, that its “later remedial efforts should have been given more time to succeed,” and consequently, it had not been given “a reasonable amount of time to comply with the previous orders” as required by
Having engaged in remedial efforts for 5 years in Plata and 12 in Coleman, the District Courts were not required to wait to see whether their more recent efforts would yield equal disappointment. When a court attempts to remedy an entrenched constitutional violation through reform of a complex institution, such as this statewide prison system, it may be necessary in the ordinary course to issue multiple orders directing and adjusting ongoing remedial efforts. Each new order must be given a reasonable time to succeed, but reasonableness must be assessed in light of the entire history of the court‘s remedial efforts. ....
... A report filed by the Coleman Special Master in July 2009 describes ongoing violations, including an “absence of timely access to appropriate levels of care at every point in the system.” A report filed by the Plata Receiver in October 2010 likewise describes ongoing deficiencies in the provision of medical care and
concludes that there are simply “too many prisoners for the healthcare infrastructure.” The Coleman and Plata courts acted reasonably when they convened a three-judge court without further delay.
Plata, 563 U.S. at 516 (emphasis added) (citations omitted).
The Court was equally practical in assessing whether the order was “narrowly drawn.” The Court explained that “[w]hen a court is imposing a population limit, this means the court must set the limit at the highest population consistent with an efficacious remedy.” Id. at 539. The Court then recounted the expert testimony explaining the rationale for how much the population should be reduced and concluded that
[t]here [we]re no scientific tools available to determine the precise population reduction necessary to remedy a constitutional violation of this sort. The three-judge court made the most precise determination it could in light of the record before it. The
PLRA ‘s narrow tailoring requirement is satisfied so long as these equitable, remedial judgments are made with the objective of releasing the fewest possible prisoners consistent with an efficacious remedy.
Id. at 541 (emphasis added).
Plata therefore establishes that, even when acting within the constraints of the
Cases from other circuits also make clear that the
The district court found, and the City does not contest, unconstitutionally unsanitary conditions in various areas of the facilities. As one remedy, the court ordered that all showers be power washed with bleach quarterly. The City contends that this requirement will damage its newly renovated grouted-tile showers. It also contends that other remedial directives, such as the requirement that showers be “thoroughly cleaned and sanitized at least once daily,” are sufficient to keep the showers in sanitary condition.
But, as the City acknowledges, since 1995 the DOC‘s own internal policies have required that showers be washed daily with sanitizing solution, and, as the district court observed, there is no evidence that this cleaning regimen “is equal to the task.” We, therefore, find no error in the court‘s conclusion that stronger remedial measures were necessary and affirm the power-washing requirement.
Id. at 55 (emphasis added) (citations omitted).
Ineffectiveness and recalcitrance also played a role in the First Circuit‘s decision to uphold an injunction in Morales Feliciano v. Rullan, 378 F.3d 42 (1st Cir. 2004). Morales Feliciano concerned the long-term and ongoing failures of the Puerto Rican prison system regarding delivery of healthcare to its inmate population. In 1998, the district court entered prospective injunctive relief that included “the proposed privatization of medical and mental health care throughout the correctional system.” Id. at 45. Five years later, the Commonwealth sought to vacate or terminate the injunction on the grounds (among others) that the district court had failed to make the necessary findings under the
The First Circuit observed that the
[t]he constitutional violations . . . [we]re substantial in both scope and degree. They have defied correction for more than two decades. The district court has tried more conventional measures, but found them wanting. It has afforded the Commonwealth ample opportunity to bring preexisting mechanisms up to speed or otherwise to correct the phalanx of problems. It has witnessed the Commonwealth‘s continued inability to cure the constitutional infirmities plaguing the delivery of health care in the correctional system. This record of abject failure matters in the narrowness-need-intrusiveness inquiry.
Id. at 54-55 (emphasis added) (citing Benjamin, 343 F.3d at 49). With respect to the healthcare of inmates, “the level of improvement still f[ell] well short of bringing serious violations into constitutional compliance.” Id. at 55. “In light of these facts,” the court had “no difficulty affirming the district court‘s finding that a need for ongoing injunctive relief exist[ed].” Id.
As to whether the relief was broader than necessary, the court noted that, ”if this were the district court‘s first attempt at remediation,” it likely would agrеe with the Commonwealth that the remedy was overbroad. Id. (emphasis added). However, the district court had “attempted narrower, less intrusive alternatives,” but those had failed.
For this reason, a more innovative remedy [wa]s justifiable. The increased intrusiveness and
broader scope of the privatization remedy is a direct response to the unique need created by the Commonwealth‘s own failure—for more than twenty years—to correct serious constitutional inadequacies. Drastic times call for drastic measures.
The Ninth Circuit relied explicitly on Morales Feliciano in upholding a district court‘s remedial order in Armstrong v. Brown, 768 F.3d 975 (9th Cir. 2014). Disabled prisoners in the California system filed the action in 1994, at which time the district court concluded that the State was in violation of the Americans with Disabilities Act and the Rehabilitation Act. In response, the State produced a remedial plan intended to ensure that disabled inmates had access to programs and facilities in California‘s prisons. In March 2001, the district court entered a permanent injunction directing enforcement of the remedial plan. However, by 2007, “the State had failed to bring its correctional facilities into compliance with the remedial plan and the 2001 Injunction.” Id. at 978. The district court therefore entered a second injunction, which required the defendants to “‘develop a system for holding wardens and prison medical administrators accountable for compliance with the Armstrong Remedial Plan and the orders of this Court.‘” Id. This system was to “‘track the record of each institution and the conduct of individual staff members who are not complying with these requirements.‘” Id.
In response to the 2007 injunction, the State issued a detailed memо outlining how complaints were to be tracked and investigated. Id. In 2012, however, the plaintiffs still believed that the State was not complying with the 2007 Injunction,
The State appealed the modified injunction on several grounds, including that it violated the
A court may . . . provide specific instructions to the State without running afoul of the
PLRA . While the injunction here might leave the State less discretion than injunctions typically approved in thePLRA context, we conclude that the level of intrusiveness is acceptable based on the history and circumstances of the case.Disabled inmates have been litigating to ensure that the State provides thеm with needed accommodation for over two decades—and yet the State still has a long, long way to go before it meets its obligations to these prisoners. The
ongoing, intractable nature of this litigation affords the district court considerable discretion in fashioning relief. Relief that might have raised concerns about breadth and intrusiveness in the first instance is acceptable in this context, because the district court “has attempted narrower, less intrusive alternatives—and those alternatives have failed. . . .”
Id. at 985-86 (emphasis added) (quoting Morales Feliciano, 378 F.3d at 55). The Ninth Circuit likened the facts before it to those in Morales Feliciano; it explained:
The First Circuit confronted a similar situation in litigation involving Puerto Rico‘s prison system, where constitutional violations pertaining to the delivery of health care were “substantial in both scope and degree” and had “defied correction for more than two decades.” Id. at 54. We face the same problem here. As we have previously noted, litigation in this matter has been ongoing for decades and the State has “resisted complying with [its] federal obligations at every turn.” Through a series of narrowly drawn, carefully-crafted, and thorough orders, the district judge here, like the district judge overseeing the Puerto Rico prison litigation, ”has tried more conventional methods, but found them wanting.” See Morales Feliciano, 378 F.3d at 54. “This record of abject failure matters in the narrowness-need-intrusiveness inquiry.” Id. at 55. Because the district court has previously tried to correct the deficiencies in California‘s prisons’ compliance
with the ADA andRA through less intrusive means, and those attempts have failed, relief prescribing more specific mechanisms of compliance is appropriate. See id. at 54-56; see also Plata, 131 S. Ct. at 1946.
Id. at 986 (emphasis added) (additional citations omitted).
The Ninth Circuit observed that “the core
All of these cases establish that, when addressing constitutional violations that institutional defendants have been slow to correct, district courts may impose increasingly detailed injunctions “to correct the violation of the Federal right.” These cases have distinguished—some implicitly, some explicitly—a district court‘s initial efforts from its later efforts. Moreover, they have identified the key factors in allowing a district court to impose more targeted requirements over time: a continuing constitutional violation that has defied correction, a begrudging (or at least slow) institutional response, and a lack of effort on behalf of the public defendant to propose a viable alternative. Thus, to both the Supreme Court and to our sister circuits, a “history of
Our decision in Westefer does not require—or even suggest—a different result. Westefer did not address a long-term, ongoing constitutional violation. In Westefer, the district court‘s dеtailed injunction, incorporating the ten-point plan, represented its first effort to redress the prisoners’ claims. Therefore, when we instructed the district court to “do no more than to order IDOC officials” to comply with the due process clause “in general terms and to verify that the plan they submit satisfies the relevant constitutional standards,” Westefer, 682 F.3d at 686, we were addressing a district court‘s first order involving remedial relief. In that context, district courts must give prison officials considerable leeway in crafting plans to redress constitutional violations. See id. at 683 (noting prison officials’ “broad administrative and discretionary authority over the institutions they manage” (quoting Hewitt v. Helms, 459 U.S. 460, 467 (1983))). We simply had no occasion to consider how a history of recalcitrance might alter the need-narrowness-intrusiveness inquiry.
2.
The second crucial shortcoming in the majority opinion is the lack of recognition that the district court occupies a superior position in evaluating the critical facts underlying the need-narrowness-intrusiveness inquiry. Complex and entrenched constitutional violations in public institutions do not lend themselves to simplistic solutions. In Plata, for instance,
[e]stablishing the population at which the State could begin to provide constitutionally adequate medical and mental health care, and the appropriate timeframe within which to achieve the necessary reduction, requires a degree of judgment. The inquiry involves uncertain predictions regarding the effects of population reductions, as well as difficult determinations rеgarding the capacity of prison officials to provide adequate care at various population levels.
Given the many variables at issue, other courts have recognized that district courts have an institutional advantage over appellate courts in fashioning appropriate remedies under the
The panel majority, by contrast, gives little weight to the district court‘s unique role. Unlike the Supreme Court and the other circuits that have confronted the problem, its opinion contains no acknowledgment of the district court‘s familiarity with the underlying constitutional violations, the recalcitrant actions of the defendants, or how that recalcitrance affected the inmates with serious mental health needs. Indeed, it is very difficult to find any deference at all to the district court‘s factual findings. Rather, much like its deliberate indifference analysis, the majority treats the need-narrowness-intrusiveness inquiry as one that is purely legal and therefore subject to de novo review. Such an approach cannot be reconciled with Plata, nor with that of our sister circuits. See generally Charles Allen Wright, The Doubtful Omniscience of Appellate Courts, 41 Minn. L. Rev. 751 (1957).
C.
When we evaluate the district court‘s injunction in light of IDOC‘s history of noncompliance and appreciate, as we should, the superiority of the district court‘s institutional vantage point to our own, it is clear that the injunctive relief crafted here passes muster under the
As in the cases discussed above, the conditions allowing a district court to be more focused in its remedial efforts are all present. There is no question that there is a constitutional violation that has defied correction. See R.2460 at 27-28 (“While some efforts have been successful, including the recent expansion of the use of tele-psychiatry, the Defendants ha[d] failed to achieve a minimum level of medical service to avoid the label of cruel and unusual punishment.“). And IDOC‘s responsе has been both begrudging and “reactionary.” R.2516 at 4 (“In its Orders, this Court specifically found that the Defendants’ efforts to comply with the Settlement Agreement (or its own general directives) only came at the time of, or after, the filing of the Plaintiffs’ initial Motion. Simply put, the Defendants’ actions have been largely reactionary.” (citation omitted)).
At the outset, the record is replete with evidence that the central contributing factors to IDOC‘s failure to provide constitutionally adequate mental health care (if not the only one) is its staffing shortage. Any effective remedy, therefore, must include guidelines for staffing levels. However, there was no serious effort by IDOC to participate in the crafting a remedial order. After the district court granted the plaintiffs’ motion for a permanent injunction, it asked IDOC to “submit their proposed action to address the constitutional deficiencies” outlined in the court‘s order.35 With respect to the most critical aspect of relief—staffing levels—IDOC proposed the following:
The Department shall adopt a staffing plan and achieve a level of staffing that provides a
sufficient number of mental health staff of varying types to provide class members with adequate and timely evaluations, treatment, and follow-up consistent with contemporary standards of care. The Department may use any reasonable means that it determines in its professional judgment to be appropriate to provide sufficient staffing.36
The district court legitimately concluded that this general recitation of its constitutional responsibilities did not reflect а serious effort by IDOC to contribute to the remedial analysis:
The Defendants’ most egregious attempt to cure their constitutional deficiencies is set forth in their proposal regarding mental health staffing. Defendants propose adopting the vague requirement that they have “a staffing plan and achieve a level of staffing that provides sufficient number of mental health staff of varying types to provide class members with adequate and timely evaluations, treatment and follow-up consistent with contemporary standards of care.” Yet, Defendants know they are understaffed, and they also know the staffing levels which are necessary to provide adequate care. In fact, Defendants are fully aware of all these deficiencies, as they have both
acknowledged the staffing problems at the Illinois Department of Corrections.37
Thus, absent any helpful contribution by IDOC, the district court turned to the staffing levels set forth in IDOC‘s own 2014 staffing plan. Notably, IDOC authored this plan and represented that, at least in 2014, it would “satisfy its constitutional duty to provide mental health care to seriously mentally ill . . . offenders.”38 According to the plan, it reflected “a measured approach for achieving the necessary transformation within a reasonable timeframe.”39
Given that, in 2014, this plan represented IDOC‘s best assessment of the staffing that would bring it into constitutional compliance in both a “measured” way and “reasonable” timeframe, it is difficult to see how the relief fails the need-narrowness-intrusiveness test. The district court‘s decision to use IDOC‘s remedial plan both recognizes that IDOC is in the best position to assess the staffing levels that will allow it to deliver constitutionally compliant mental health care and that it is unlikely to saddle itself with unnecessary burdens. Moreover, as the district court recognized, at this point, the 2014 numbers represent a bare minimum. They may not be sufficient to correct the
Although acknowledging that “specific numeric target[s]” do not “automatically violate[] the
Here, the district court made specific findings establishing that its permanent injunction “extend[s] no further than necessary to correct” the