Totality-of-Care Defeats Deliberate Indifference; Post-Transfer Claims Must Be Grieved Through Facility Counselor

Case: Buck v. Connors-Johnson, et al., No. 23-3128 (7th Cir. Dec. 3, 2024) (nonprecedential)

Panel: Easterbrook, St. Eve, and Maldonado, Circuit Judges

Appeal from: N.D. Ill., E. Div., No. 18-cv-04195 (Hon. Mary M. Rowland)

Disposition: Affirmed (summary judgment for defendants)

Introduction

This nonprecedential Seventh Circuit order resolves a prisoner’s Eighth Amendment deliberate-indifference claims and associated corporate-liability and Prison Litigation Reform Act (PLRA) exhaustion issues arising from dental care at two Illinois prisons. William Buck alleged that Wexford Health Sources, Inc., and various Illinois officials and nurses violated his rights by (a) causing two extra teeth to be extracted due to erroneous paperwork, (b) failing to provide prescribed heated compresses after surgery, and (c) failing to deliver approved dental treatment following his transfer from Stateville Correctional Center to Menard Correctional Center.

The court affirmed summary judgment for all defendants in two steps: first, it held that Buck failed to exhaust administrative remedies as to claims about post-transfer care at Menard; second, it concluded that the remaining claims failed on the merits because the record could not support a finding of deliberate indifference or, as to Wexford, of causation for corporate liability.

The decision underscores two recurring rules in prisoner litigation: (1) deliberate indifference is evaluated under a stringent “criminal recklessness” standard and in light of the totality of care provided; and (2) PLRA exhaustion is claim- and facility-specific—after a transfer, grievances about new events at the new prison must begin with that facility’s counselor.

Summary of the Opinion

• Nurses at Stateville (Lewandowska, Tomaras, Utke): Even accepting Buck’s account that nurses often failed to provide fully heated compresses, the record—considered as a whole—showed he received antibiotics, pain medication, follow-up appointments, and at least some heated packs. Without evidence that these nurses knew the care being provided was substantially inadequate and disregarded that risk, no reasonable jury could find deliberate indifference.
• Wexford’s Medical Records Director (Connors-Johnson): Her misreading of a dentist’s referral (noting four decaying teeth) as approving extraction of all four did not amount to deliberate indifference. There was no evidence she knew the treating dentist wanted only two extractions or that she consciously disregarded a serious risk. The error was, at most, negligence.
• Wexford corporate liability (Stateville events): Evidence that Wexford paperwork contained errors about 10% of the time did not establish causation because the outside oral surgeon testified he recognized the discrepancy and removed four teeth based on his independent medical judgment. Without causation, the corporate claim fails.
• Menard claims (Dr. Newbold and Wexford): Buck did not exhaust administrative remedies for post-transfer events. Illinois rules required him to start by grieving with his Menard counselor; he instead sent his grievance directly to the Administrative Review Board. The “opaque process” exception did not apply, and the Board’s “will not be addressed” response was not a merits ruling. The failure to exhaust bars those claims.

Key Facts and Procedural Background

• September 2016, Stateville: Prison dentist Dr. Jacqueline Mitchell documented two impacted and decaying wisdom teeth (17, 32) causing decay to adjacent teeth (18, 31) and referred Buck for outpatient removal of the two impacted teeth.
• Wexford Medical Records Director Debra Connors-Johnson prepared an approval form indicating all four teeth should be extracted.
• The outside oral surgeon noticed the paperwork discrepancy but decided, in his clinical judgment, to remove all four teeth.
• Post-operative course at Stateville: Buck developed complications (infected sores, exposed bone, swelling, severe pain). Dr. Mitchell ordered antibiotics, pain meds, and heated packs 2–3 times daily. Buck testified nurses often denied or supplied lukewarm packs; medical logs showed missing signatures for most pack entries.
• Transfer to Menard about a month later: Dentist Dr. Steven Newbold evaluated Buck and ordered x-rays and medicine, but treatment tapered off. Wexford later approved a dental prosthetic requested by Dr. Mitchell (December 2016) but never supplied it.
• Grievances: While at Menard, Buck sent a grievance to the Administrative Review Board addressing the extractions, heat packs, transfer, and Menard care. The Board identified technical issues and stated the grievance “will not be addressed.”
• District court: Two rounds of summary judgment. First, partial summary judgment for failure to exhaust Menard-related claims; second, summary judgment on the merits for Stateville-related claims against the nurses, Connors-Johnson, and Wexford.

Analysis

Precedents Cited and How They Shaped the Decision

• Holcomb v. Freedman Anselmo Lindberg, LLC, 900 F.3d 990 (7th Cir. 2018): Summary judgment lens—facts viewed in the light most favorable to the nonmovant. The panel accepted Buck’s version (e.g., frequent denial of heated packs) but still found the evidence insufficient under the governing legal standards.
• FARMER v. BRENNAN, 511 U.S. 825 (1994): The touchstone for Eighth Amendment claims—official must know of and disregard a substantial risk of serious harm; the standard is akin to “criminal recklessness” (subjective awareness and disregard). This high threshold controlled the analysis for the nurses and for Connors-Johnson.
• Machicote v. Roethlisberger, 969 F.3d 822 (7th Cir. 2020): Ignoring a doctor’s orders can evidence deliberate indifference. The court acknowledged this principle but emphasized it must be assessed in context.
• Lockett v. Bonson, 937 F.3d 1016 (7th Cir. 2019), quoting Dunigan ex rel. Nyman v. Winnebago County, 165 F.3d 587 (7th Cir. 1999): Courts evaluate the totality of an inmate’s medical care, not isolated lapses. This “totality-of-care” framework undercut Buck’s claim against the nurses, given his antibiotics, pain meds, follow-up, and at least some heated packs.
• Dean v. Wexford Health Sources, Inc., 18 F.4th 214 (7th Cir. 2021): For private medical contractors (like Wexford), liability requires a policy or practice that is the moving cause of the constitutional injury; causation is essential. The oral surgeon’s independent decision broke the causal chain from any Wexford paperwork error to Buck’s extractions.
• Ross v. Blake, 578 U.S. 632 (2016): PLRA’s exhaustion mandate yields only if administrative remedies are “unavailable,” including when procedures are so opaque that no ordinary prisoner could navigate them. The court held Illinois’s grievance process was sufficiently clear here.
• Jackson v. Esser, 105 F.4th 948 (7th Cir. 2024): State law defines the relevant grievance procedures. This reinforced reliance on Illinois’ regulatory steps for facility-specific grievances after transfer.
• Jones v. Bock, 549 U.S. 199 (2007): PLRA exhaustion is mandatory and claim-specific. Failure to follow the prescribed steps bars the suit.
• Williams v. Dieball, 724 F.3d 957 (7th Cir. 2013): Arguments not preserved below are forfeited on appeal. The court used this to reject Buck’s late-raised contention that the ARB decided his grievance on the merits.

Legal Reasoning Applied to Each Defendant

1) Nurses at Stateville (Heat Packs)

Assuming a serious medical need (post-extraction infection, swelling, and pain), the dispositive question was subjective culpability. The court stressed that:

• Buck received antibiotics, pain medications, a follow-up appointment, and some heated-pack therapy.
• While nurses may have deviated from Dr. Mitchell’s order by providing fewer or inadequately heated packs, Buck did not present evidence that the nurses knew the overall regimen was substantially inadequate and nonetheless consciously disregarded that risk.
• Under Farmer’s criminal-recklessness standard and the totality-of-care framework (Lockett/Dunigan), such partial noncompliance did not permit a reasonable jury to infer deliberate indifference.

Bottom line: Noncompliance with a component of the treatment plan can support deliberate indifference, but only if evidence shows the defendant’s subjective awareness that, in context, the care being provided was so deficient as to pose a substantial risk of serious harm. That showing was missing.

2) Connors-Johnson (Referral Approval and Paperwork)

Buck argued that Connors-Johnson recklessly approved extraction of four teeth when Dr. Mitchell referred him for two. The panel held:

• The referral described all four teeth as decaying. Misinterpreting it as approval for extraction of four, without more, reflected at most negligence—not the criminal recklessness Farmer requires.
• No evidence showed she knew Dr. Mitchell wanted only two extracted and consciously disregarded that directive.
• Evidence of general Wexford paperwork mistakes did not tie specifically to Connors-Johnson’s state of mind in this instance.

3) Wexford (Corporate Liability for Stateville Events)

The corporate claim faltered on causation. The oral surgeon:

• Noticed the discrepancy between the referral (two teeth) and Wexford’s approval (four teeth); and
• Decided independently, based on clinical judgment, to remove all four teeth.

Given that testimony, the alleged paperwork policy/practice—even if real—was not the moving cause of the injury, as required under Dean. The surgeon’s independent decision broke the chain of causation from any corporate paperwork error to the extractions.

4) Menard Defendants (Dr. Newbold and Wexford) and PLRA Exhaustion

Illinois regulations required Buck to initiate grievances about Menard events with his Menard counselor (20 Ill. Admin. Code § 504.810(a) (2016)). He instead sent a grievance directly to the Administrative Review Board (ARB), a route permitted for some circumstances (including pre-transfer events at another facility), see § 504.870(a)(4), but not for new care at the new prison.

The court rejected two attempts to avoid exhaustion:

• Opaque-process exception: The process was not “so opaque” as to be unavailable (Ross). State law clearly delineated the counselor-first step for Menard events (Jackson).
• Merits ruling by ARB: Buck forfeited the argument by not raising it below (Williams), and in any event the ARB expressly stated the grievance “will not be addressed,” which is not a merits disposition.

Result: Post-transfer claims against Dr. Newbold and Wexford were barred for failure to exhaust (Jones v. Bock).

Impact and Practice Implications

• Totality-of-care remains decisive: Plaintiffs relying on isolated lapses (e.g., missed compresses) must show that, given the overall treatment, defendants subjectively knew the residual risk was substantial and disregarded it. Partial noncompliance with orders can matter but is not automatically unconstitutional.
• Subjective knowledge is pivotal: Documenting a defendant’s awareness (through notes, direct complaints, repeated grievances, or admissions) that the care being provided was substantially inadequate is often outcome-determinative under Farmer.
• Corporate claims demand causation: For claims against Wexford, plaintiffs need evidence that a policy, custom, or systemic defect was the moving cause of injury. Independent clinical judgments by physicians can sever causation, as here.
• PLRA exhaustion is facility- and event-specific: After a transfer, grievances about new events at the receiving facility must begin with that facility’s counselor under § 504.810(a). Direct-to-ARB filings are limited and do not substitute for the counselor step for post-transfer events.
• Narrow scope for “opaque process” exceptions: Ross’s unavailability exceptions remain constrained; where written regulations are specific, courts regularly enforce them.
• Recordkeeping vs. knowledge: Missing treatment logs can support an inference that care was not delivered but do not, without more, prove subjective awareness and deliberate disregard by particular nurses.

Complex Concepts Simplified

• Deliberate Indifference (Eighth Amendment): Not mere negligence. The official must actually know of a substantial risk of serious harm and consciously disregard it—akin to criminal recklessness (Farmer).
• Totality-of-Care Assessment: Courts evaluate the entire course of treatment. A lapse or deviation from a physician’s order can be important but is weighed alongside other care provided (Lockett/Dunigan).
• Corporate Liability (Wexford/Monell-type): A private contractor is not vicariously liable for employee negligence. Liability attaches only if a policy or widespread practice caused the constitutional harm, and causation must be shown (Dean).
• PLRA Exhaustion: Prisoners must follow all steps of the prison’s grievance process before suing. For Illinois, that means starting with the facility counselor for events at that facility (20 Ill. Admin. Code § 504.810(a)), with limited circumstances for direct ARB filings (§ 504.870). If you skip a required step, the claim is barred unless remedies were truly unavailable (Ross; Jones).
• “Opaque” Process Exception: An exception to exhaustion when the grievance system is so confusing that no ordinary prisoner could use it. It is rarely found where written rules clearly outline the steps.
• Summary Judgment Standard: The court views facts in the nonmovant’s favor but asks whether any reasonable jury could find for that party under the governing legal standards. If not, judgment is entered without a trial (Holcomb).

Conclusion

The Seventh Circuit’s nonprecedential affirmance in Buck v. Connors-Johnson reinforces two bedrock features of prisoner medical litigation. First, deliberate-indifference claims must clear a high bar: plaintiffs must tie specific defendants to a subjective, criminally reckless disregard of a serious risk, evaluated across the totality of care. Partial noncompliance with a doctor’s order is not per se unconstitutional, particularly when other meaningful treatment is delivered and there is no proof defendants knew that the remaining care was substantially inadequate. Second, PLRA exhaustion is rigid and specific: after a transfer, grievances about new events must start with the receiving facility’s counselor; direct ARB filings do not preserve such claims. Finally, corporate liability requires proof that an institutional policy or practice was the moving cause of harm—independent clinical judgment can break the causal chain.

Though nonprecedential, the decision offers a clear roadmap for litigants: marshal evidence of subjective awareness and risk disregard for individual defendants, establish policy-based causation for corporate actors, and rigorously follow facility-specific grievance pathways to preserve claims.