Expert Evidence, Causation, and Pattern Proof: Seventh Circuit Tightens Eighth Amendment and Monell Paths in Prison Mental-Health Cases

Introduction

In Cordell Sanders v. Andrea Moss, et al., the Seventh Circuit affirmed summary judgment for individual mental-health providers and their corporate employer, Wexford Health Sources, in a Section 1983 suit arising from an Illinois inmate’s prolonged placement in segregation. The plaintiff, Cordell Sanders—diagnosed with several serious mental illnesses—spent over eight years in segregation (commonly characterized as solitary confinement) at Pontiac Correctional Center following multiple disciplinary violations.

Sanders brought Eighth Amendment claims alleging deliberate indifference to serious mental-health needs and a Monell claim against Wexford for systemic failures, including an alleged practice of withholding treatment unless an inmate was in crisis and a failure to guide providers’ roles in disciplinary proceedings. The central questions were:

Whether the individual providers’ mental-health care and their recommendations in disciplinary reviews rose to “deliberate indifference.”
Whether Wexford’s practices or omissions constituted a policy or custom causing constitutional injury under Monell.

Writing for the court, Judge Lee (joined by Judges Easterbrook and Rovner) affirmed in full. Judge Rovner added a concurrence emphasizing the mounting empirical and legal concern over prolonged solitary confinement, while agreeing that the record did not support liability under existing deliberate indifference doctrine.

Summary of the Judgment

Eighth Amendment (Providers): The court held that the record did not permit a reasonable jury to find deliberate indifference. In the complex realm of mental-health care, the court underscored that plaintiffs typically need expert medical evidence establishing that providers’ chosen care represented a substantial departure from accepted professional judgment. Sanders’ expert addressed the harms of solitary confinement generally but did not opine that the specific treatment decisions by these providers fell below minimally competent standards. The record also failed to show causation between providers’ disciplinary recommendations and Sanders’ time in segregation, which predated those recommendations.
Monell (Wexford): The claim that Wexford had a widespread practice of denying treatment until crisis failed: the proof showed, at most, a single instance and ongoing care by multiple professionals. The “failure to promulgate policy” theory also failed because (i) IDOC already had a directive requiring mental-health input in disciplinary proceedings, (ii) there was no showing that a more detailed Wexford policy was obviously necessary in a way that made non-adoption deliberately indifferent, and (iii) no evidence tied the alleged policy gap to a constitutional injury.
Disposition: Summary judgment affirmed for all providers and Wexford.

Detailed Analysis

Precedents and Authorities Cited

Estelle v. Gamble, 429 U.S. 97 (1976): Establishes that deliberate indifference to serious medical needs violates the Eighth Amendment. The Seventh Circuit starts here as the foundational principle.
Farmer v. Brennan, 511 U.S. 825 (1994): Defines the subjective component—official must know of and disregard a substantial risk of serious harm. The court applies Farmer to assess the “culpable state of mind.”
Petties v. Carter, 836 F.3d 722 (7th Cir. 2016) (en banc): Directs courts to evaluate the “totality” of care and recognizes deliberate indifference where officials persist in known-ineffective treatment. Sanders invoked this pathway; the court held he lacked expert proof of a substantial departure from professional norms.
Greeno v. Daley, 414 F.3d 645 (7th Cir. 2005); Walker v. Peters, 233 F.3d 494 (7th Cir. 2000): Illustrate the “known ineffective course of treatment” doctrine. The court distinguished these on evidentiary grounds.
Stewart v. Wexford Health Sources, Inc., 14 F.4th 757 (7th Cir. 2021) and Eagan v. Dempsey, 987 F.3d 667 (7th Cir. 2021): Emphasize deference to medical judgment and the frequent need for expert evidence to show a “substantial departure” in complex medical contexts—pivotal here.
Murphy v. Wexford, 962 F.3d 911 (7th Cir. 2020); Norfleet v. Webster, 439 F.3d 392 (7th Cir. 2006): Disagreement among professionals is not deliberate indifference; plaintiffs must show complete abandonment or substantial deviation. Sanders’ expert did not make that link.
Delaney v. DeTella, 256 F.3d 679 (7th Cir. 2001); Anderson v. Romero, 72 F.3d 518 (7th Cir. 1995): Exercise is an essential human need; lack of out-of-cell exercise can violate the Eighth Amendment. The panel acknowledged this, but it did not convert the providers’ recommendations into deliberate indifference on this record.
Monell line: Monell principles frame entity liability (express policy, widespread practice, or final policymaker action). For inaction, see Glisson v. Indiana DOC, 849 F.3d 372 (7th Cir. 2017) (en banc) and J.K.J. v. Polk County, 960 F.3d 367 (7th Cir. 2020) (en banc), which permit liability where the need for action is obvious and the failure to act is a conscious choice. The court found no such obviousness or causal link here.
Pattern proof: Connick v. Thompson, 563 U.S. 51 (2011); Bridges v. Dart, 950 F.3d 476 (7th Cir. 2020); Grieveson v. Anderson, 538 F.3d 763 (7th Cir. 2008). One or a handful of incidents do not establish a widespread practice. Sanders’ evidence was too thin.
Summary-judgment evidentiary rules: Washington Cnty. Water Co. v. City of Sparta, 77 F.4th 519 (7th Cir. 2023) (inadmissible hearsay can’t create a genuine dispute); Whitlock v. Brown, 596 F.3d 406 (7th Cir. 2010) (self-serving but personal-knowledge testimony can be considered).

The Court’s Legal Reasoning

1) Deliberate Indifference: Mental-Health Treatment

The court accepted that Sanders’ mental-health needs were objectively serious. The dispute centered on the subjective component—whether providers knowingly disregarded a substantial risk by persisting in a known-ineffective course or otherwise substantially departing from accepted standards.

The court emphasized:

Mental-health treatment is multifaceted and non-obvious to lay jurors; thus, expert medical evidence is often required to show a substantial departure from professional norms.
Sanders’ expert (Dr. Grassian) opined on the general psychiatric harms of long-term segregation but did not address whether the providers’ specific decisions (frequency/duration of encounters, risk assessments, therapy, medication management coordination, suicide-watch determinations) were departures from minimally competent practice.
Without expert testimony tying provider decisions to a recognized standard and demonstrating a substantial deviation, a jury would be left to speculate—insufficient to withstand summary judgment.

2) Deliberate Indifference: Providers in Disciplinary Proceedings

Sanders did not contest the disciplinary findings per se; he argued that providers were deliberately indifferent when recommending segregation or other sanctions despite the known harms of isolation to mentally ill inmates.

The court held:

Even assuming providers knew segregation’s risks, the record lacked evidence that “no minimally competent professional” would have made their recommendations based on the presented behavior and clinical assessments.
Providers’ occasional recommendations of yard restrictions, while potentially problematic given exercise’s constitutional significance, were not shown—by expert testimony—to be a substantial departure from clinical norms in those circumstances.
Causation: By May 2015 (when providers began formally participating in disciplinary recommendations), Sanders was already serving a segregation term scheduled to extend into 2022; he left segregation in 2017. Sanders did not show that any provider recommendation lengthened his segregation or otherwise caused an Eighth Amendment injury. Absent causation, the claims fail independently.

3) Monell: Wexford’s Alleged Practice and Policy Omissions

Sanders advanced two Monell theories:

Widespread practice of withholding treatment until crisis: The proof was a single incident (Moss purportedly declining to speak unless he was suicidal), plus alleged gaps. The record also showed he was seen by numerous mental-health professionals, including psychiatrists and psychologists, before and after crisis events. One incident cannot establish a pervasive custom; the care records undermined the claimed pattern.
Failure to promulgate a disciplinary-participation policy: IDOC already had a directive requiring mental-health input and binding effect in many circumstances. Sanders did not articulate what specific additional Wexford policy was obviously required or show that the lack of such a policy caused a constitutional deprivation. Generalized training criticisms are not enough without showing an obvious need for a particular policy and causation.

Impact and Significance

While not announcing a new doctrinal rule, the decision clarifies and tightens proof pathways in a way likely to influence future prison mental-health litigation:

Expert Evidence Is Often Essential in Mental-Health Eighth Amendment Claims: Plaintiffs should expect to present expert opinions directly addressing whether specific provider actions depart from minimally competent professional standards—not just general harms of segregation.
Causation Matters, Especially in Disciplinary Contexts: When challenging providers’ roles in disciplinary recommendations, claimants must connect those recommendations to concrete harms (e.g., extended segregation or particular deprivations) beyond preexisting terms.
Pattern Proof for Monell: One-off incidents or isolated anecdotes will not suffice. Plaintiffs should marshal facility-wide data, multiple examples, or admissions showing permanent, well-settled practices.
Policy-Omission Monell Claims Require an “Obvious Need” Showing: Where some related procedure already exists (e.g., IDOC’s directive for mental-health input), plaintiffs must identify the missing policy’s content, show its obvious necessity, and tie the omission causally to a constitutional injury.
Exercise Deprivation and Medical Roles: The court reiterates that denial of exercise may violate the Eighth Amendment. But to translate that principle into liability against mental-health providers, plaintiffs must prove a clinical departure and causation—not merely the presence of exercise restrictions.

Beyond the black-letter holdings, Judge Rovner’s concurrence signals the court’s awareness of research and evolving norms condemning prolonged solitary confinement. While not dispositive here, this perspective may affect future Eighth Amendment and Due Process analyses where defendants are directly responsible for imposing or maintaining segregation, especially in the absence of meaningful exercise and programming.

Complex Concepts Simplified

Deliberate Indifference: More than negligence. The official must actually know of and ignore a substantial risk to health. In medical cases, this often requires showing a choice so far outside professional norms that it reflects a lack of genuine medical judgment.
“Substantial Departure” from Professional Judgment: A decision no minimally competent professional would make. Because what counts as a departure can be technical, courts often require expert testimony to explain it.
Monell Liability: You cannot sue a municipality or corporate equivalent (like Wexford) under respondeat superior. You must show your injury flowed from an official policy, a widespread practice, or a decision by someone with final policymaking authority. Policy omissions can qualify if the need for a policy is obvious and the failure to adopt it causes constitutional harm.
Summary Judgment: The case is decided without a trial if, after discovery, no reasonable jury could find for the non-movant on the evidence. Hearsay cannot create disputes; personal-knowledge statements can, but they must be specific and admissible.
Segregation (Solitary Confinement): Housing with severely restricted time out of cell (often 22+ hours/day). The Seventh Circuit recognizes that lack of exercise can violate the Eighth Amendment, but liability turns on who caused the deprivation and whether the legal standards are met.
Suicide Watch vs. Crisis Care vs. Outpatient: Suicide watch increases monitoring frequency (e.g., checks every 10 minutes). Crisis care provides acute, short-term intervention. Outpatient care involves routine therapy and medication management without heightened monitoring.
Adjustment Committee and Mental-Health Disciplinary Review: IDOC’s committee decides guilt and recommends sanctions. For seriously mentally ill inmates, a mental-health provider’s input must be considered; if the provider recommends specific segregation limits, the committee must adopt or appeal to the warden for a final decision.

Practice Pointers

For Plaintiffs:
- Retain experts who assess provider-specific decisions against accepted mental-health standards and explicitly opine on departures and causation.
- Trace how particular disciplinary recommendations extended or intensified segregation or other deprivations (dates, durations, appeals, outcomes).
- For Monell claims, gather pattern evidence: multiple incidents, facility data, audits, training materials, or internal communications showing settled practices.
- When alleging policy omissions, specify the missing policy, why the need was obvious, and how its absence caused the injury.
For Defendants:
- Document the totality of care, including non-provider encounters (psychiatrists, psychologists), to counter “gaps” narratives.
- Highlight existing directives (like IDOC’s) and show how providers complied.
- Challenge hearsay and insist on expert-level proof for treatment-based claims.
For Policymakers/Corrections Systems:
- Reassess prolonged segregation and exercise restrictions in light of robust empirical critiques and evolving legal standards.
- Clarify provider roles in disciplinary settings and ensure training aligns with best practices and constitutional minima.

What This Case Does and Does Not Decide

Does decide:
- On the record presented, no reasonable jury could find deliberate indifference or Monell liability.
- Expert testimony targeting provider-level decisions is often necessary in mental-health Eighth Amendment cases.
- Single-incident evidence cannot carry a “widespread practice” Monell claim.
- Policy-omission claims require a clear showing of obvious need and causation.
Does not decide:
- Whether prolonged solitary confinement itself violates the Eighth Amendment in general or in other factual configurations.
- Whether providers could ever be liable for recommending segregation; the court held only that the evidence here was insufficient.

Concurring Perspective: Evolving Standards on Solitary Confinement

Judge Rovner’s concurrence, echoing earlier Seventh Circuit writings, contextualizes the case within a growing body of research and reform movements condemning long-term solitary confinement. She highlights:

Substantial studies documenting harmful psychological and physiological effects even after relatively short durations in isolation.
Questionable penological efficacy of widespread segregation; some data link reductions in solitary to decreased violence.
Legislative trends to limit solitary confinement, including proposals capping its use to 15 days, paralleling international standards (the UN “Nelson Mandela Rules”).

While acknowledging these developments, Judge Rovner agrees that, under current deliberate indifference standards and this record, the defendants were not liable. Her concurrence nevertheless signals a judicial awareness that may influence future Eighth Amendment and due process analyses where decision-makers directly impose or perpetuate isolation.

Conclusion

Sanders v. Moss reinforces three pivotal litigation lessons in prison mental-health cases: (1) in complex medical contexts, plaintiffs generally need expert testimony pinpointing how provider decisions substantially departed from accepted standards; (2) deliberate indifference claims tied to disciplinary recommendations must show both the clinical departure and a causal link to the complained-of harm; and (3) Monell liability requires either robust pattern evidence or a demonstrably obvious and causative policy omission, which was absent here given IDOC’s existing directive.

Although the court affirms judgment for the defendants, the concurrence underscores a broader trend: the law’s evolving sensitivity to the severe mental-health costs of prolonged solitary confinement and to the constitutional significance of exercise as a basic human need. Going forward, litigants and policymakers should expect closer scrutiny of isolation practices, more rigorous demands for expert-driven proof, and a sharpened focus on causation and institutional patterns when constitutional claims arise from mental-health care in the segregation context.