Cordell Sanders v. Andrea Moss

In the
United States Court of Appeals
For the Seventh Circuit
____________________
No. 23-1335
C ORDELL SANDERS,
Plaintiff-Appellant,
v.
A NDREA M OSS, et al.,
Defendants-Appellees.
____________________
Appeal from the United States District Court for the
Central District of Illinois.
No. 1:16-cv-1366 — Jonathan E. Hawley, Judge.
____________________
A RGUED F EBRUARY 10, 2025 — DECIDED A UGUST 28, 2025
____________________
Before EASTERBROOK, R OVNER , and LEE, Circuit Judges.
LEE, Circuit Judge. Despite suffering from serious mental
health issues, Cordell Sanders, an inmate formerly at Pontiac
Correctional Center, was forced to spend eight years in segre-
gation housing after committing multiple disciplinary of-
fenses. Pursuant to 42 U.S.C. § 1983, he sued the prison’s
health care provider, Wexford Health Sources, as well as his
mental health care providers, Andrea Moss, Kelly Haag, Todd
Nelson, Linda Duckworth, and Stephen Lanterman, for

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2 No. 23-1335
exhibiting deliberate indifference to his mental health needs
in violation of the Eighth Amendment.1 The district court
granted summary judgment for the defendants.
On appeal, Sanders contends that the individual defend-
ants failed to provide adequate mental health services and to
advocate for him during his disciplinary proceedings to
lessen his sanctions. As for Wexford, Sanders argues that the
company employed a widespread practice of denying mental
health treatment to inmates until they were in crisis. He also
claims that Wexford had an obligation to enact a policy its
mental health providers could follow when participating in
disciplinary proceedings, but failed to do so.
This case is a tragic one. We have no doubt that Sanders
struggled with severe mental health needs while at Pontiac
and that his prolonged time in segregation did little to address
them. But the question before us is whether the record con-
tains evidence from which a rational jury could find that the
defendants’ conduct violated Sanders’s Eighth Amendment
rights. This is a difficult standard to meet, and, despite the vo-
luminous record, we discern no evidentiary basis from which
a jury could find in Sanders’s favor and affirm.
I
Because Sanders challenges the district court’s order
granting summary judgment to the defendants, we recount
1 In addition, Sanders sued the Illinois Department of Corrections and
certain of its correctional officials in this action, and the district court
granted them summary judgment which Sanders also appealed. Sanders
eventually settled with the Department and its officials and dismissed his
appeal.

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No. 23-1335 3
the facts in a light most favorable to him. See Burton v. Downey,
805 F.3d 776, 783 (7th Cir. 2015).
In 2004, Sanders was sentenced to twenty years in prison
for homicide. He was sixteen at the time. Since entering the
Illinois Department of Corrections (IDOC), Sanders has com-
mitted a myriad of offenses, including assaulting and threat-
ening staff, repeatedly engaging in sexual misconduct, and
damaging property. These incidents generated “tickets” for
which he received disciplinary action. Such sanctions took the
form of segregation, reduction of outdoor yard access, and
other restrictions. Relevant here, as a result of his violations,
Sanders was placed in segregation at Pontiac for over eight
years from 2009 until 2017.2
A. Sanders’s Providers
IDOC contracts with Wexford Health Sources to provide
mental health services for inmates at Pontiac. Moss, Haag,
Nelson, Duckworth, and Lanterman are current and former
Wexford health professionals who treated Sanders at Pontiac.
Moss, Haag, and Lanterman are licensed clinical social work-
ers, while Nelson and Duckworth are employed as mental
health professionals. (For ease of reference, we will call them
2 Defendants formally refer to his placement as “segregation hous-
ing,” while Sanders applies the label “solitary confinement.” We use the
term “segregation” as reflected in the record. While the parties also dis-
pute how to characterize the conditions Sanders faced during his place-
ment, they agree that the privileges and freedoms of inmates in segrega-
tion housing were severely limited compared to those in the general
prison population. For example, inmates assigned to segregation housing
at Pontiac are held in their cells for at least 22 hours a day. And for most
of Sanders’s time at Pontiac, segregation inmates were allowed out of their
cells only for showers, yard, visits, and use of the law library.

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4 No. 23-1335
“the Providers.”) They, along with other mental health pro-
fessionals at Pontiac, diagnosed Sanders with various mental
issues, including antisocial personality disorder, intermittent
explosive disorder, schizoaffective disorder, and depressive
disorder.
The Providers evaluated Sanders when he attended peri-
odic individual and group therapy sessions. According to
Sanders, some of these sessions lasted no longer than five to
ten minutes. The Providers also performed brief assessments
outside of his cell while he was in segregation. And they met
with him when he engaged in suicidal behavior. And, alt-
hough the Providers did not treat Sanders on a consistent, on-
going basis while he was at Pontiac, the undisputed record
indicates that other mental health providers offered similar
mental health services to Sanders during this time frame.
In addition to these providers, Wexford also employed
psychologists and psychiatrists to treat inmates at Pontiac.
These professionals assessed Sanders on a regular basis, cre-
ated individualized treatment plans for him, and managed
his medications, which included antidepressant, psycho-
tropic, and mood-stabilizing drugs.
1. Andrea Moss
Moss first evaluated Sanders during an individual therapy
session in April 2013. During this session, Sanders com-
plained to Moss about having to “do 100% of [his] time” and
not having the opportunity for good-time credit. Moss did not
treat Sanders again that year, but, throughout 2014, 2015, and
early 2016, Moss observed Sanders more than a dozen times
while he was in segregation and evaluated him during indi-
vidual therapy sessions.

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No. 23-1335 5
Whenever Moss met with Sanders, he denied having sui-
cidal or homicidal ideations. Sanders had remarked to Moss
that “the only time” he left the cell was when he met with her.
In Moss’s view, however, Sanders generally presented appro-
priately and only occasionally displayed inappropriate mood,
behavior, concentration, and affect.3
Moss recommended that Sanders receive an outpatient
level of care, except for one instance on October 27, 2015,
when Sanders tried to commit suicide.4 After the attempt,
Lanterman met with Sanders to evaluate him.
Sanders would meet with Moss again eight days later. At
that meeting, he denied being suicidal. Rather, Sanders was
upset that his shoes had been taken away and told Moss,
“This is the only way I get anything done [because] no one is
responding to my grievances.” Out of an abundance of cau-
tion, Moss evaluated his suicide risk, placed him on suicide
watch, and recommended that he receive crisis care.
3 According to Sanders’s medical file, mental status examinations gen-
erally measured the propriety of his appearance, behavior, mood, affect,
concentration, memory, speech, and thoughts.
4 Prior to his treatment by the Providers, Sanders attempted to commit
suicide at least once when he overdosed on his pain medication in 2010.
Sanders also claimed he attempted suicide in 2012, when he suffered an
episode of psychosis and cut himself around his stomach area. Defendants
dispute this 2012 attempt, pointing out that Sanders cites no corroborating
medical records and concedes he never told anyone about this incident.
However, we accept self-serving testimony on summary judgment so long
as it based on personal knowledge. See Whitlock v. Brown, 596 F.3d 406, 411
(7th Cir. 2010).

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6 No. 23-1335
2. Stephen Lanterman
Lanterman initially encountered Sanders while he was
conducting rounds in the segregation housing area in April
2015. He noted that the meeting was unremarkable.
When they met three months later, Sanders relayed that
he heard unintelligible voices and felt suicidal. Sanders also
complained that a correctional officer spat on him and falsely
accused him of some unspecified misconduct. Lanterman was
concerned about Sanders’s appearance, behavior, and mental
status, but Sanders denied experiencing suicidal or homicidal
ideations. Nevertheless, based on his observations, Lanter-
man placed Sanders on suicide watch, so that he could be
monitored every ten minutes.
The next day, Sanders reported to Lanterman that he felt
better and had time to cool off. He again denied feeling sui-
cidal and said that he was taking his medication. For his part,
Lanterman noted that Sanders’s mood and mental state were
stable. And, while Lanterman took Sanders off suicide watch,
he recommended that Sanders be placed in crisis care.
Lanterman next treated Sanders on October 27, 2015, the
day Sanders attempted suicide. During the examination,
Sanders told Lanterman that he had overdosed on pills. At the
conclusion of the appointment, Lanterman diagnosed Sand-
ers with major depression with psychotic affects, recom-
mended that he receive crisis care, and placed him on suicide
watch.
Lanterman examined Sanders again the next day. Sanders
explained that he was depressed and angry the day before be-
cause the facility had taken away his yard access. But he once
again denied having suicidal or homicidal thoughts.

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No. 23-1335 7
Lanterman noted that Sanders was calm, coherent, and had a
congruent affect (that is, his emotional expressions aligned
with his mood). Lanterman maintained his recommendation
that Sanders receive crisis care and placed him on suicide
watch.
Two days later, on October 30, 2015, Sanders met again
with Lanterman and said that Prozac seemed to be helping
his mood. He also reiterated that he was not having suicidal
thoughts. And so, Lanterman took Sanders off suicide watch
but continued crisis care.
August 2016 was the next time Lanterman encountered
Sanders while performing rounds in the segregation unit. He
continued to see Sanders during routine segregation rounds
through November 2016 with no reported concerns.
3. Todd Nelson
Nelson first assessed Sanders in January 2015. Sanders had
called for a crisis team member because, he claimed, he had
no access to the yard for a year or a TV for the prior three
years. During their session, Sanders told Nelson that he was
not contemplating suicide and was not a danger to others.
Nelson marked down three risk factors (feelings of hopeless
or helplessness, signs of depression, and increased anxiety)
and five protective factors (opposition to suicide, future ori-
entation/sense of hope, support system, sense of responsibil-
ity, and compliance with medication). Based on this evalua-
tion, Nelson did not order crisis care and recommended that
Sanders be returned to segregation housing. Nelson ex-
plained to Sanders that he should direct his concerns about
yard and TV privileges to security personnel.

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8 No. 23-1335
A year passed before Nelson saw Sanders again for an in-
dividual therapy session in January 2016. According to Nel-
son, Sanders seemed fine and presented no issues of note.
Nelson continued to see Sanders when he made segregation
rounds and during individual therapy sessions through April
2016. During this period, the only problem Sanders raised re-
lated to the expiration of his medication, which Nelson reme-
died by arranging for it to be re-ordered.
On July 24, 2016, Sanders overdosed on medication and
was placed on suicide watch. Nelson was assigned to treat
Sanders the following day. Sanders told Nelson that he had
dislocated his thumb “during a staff assault” and became su-
icidal when the medical staff failed to see him. And so, he
overdosed on Motrin. However, Sanders informed Nelson
that he felt better and did not have any suicidal or homicidal
ideations. Nelson observed that while Sanders was fully ori-
ented, appropriately groomed, and had a clear and coherent
thought process, he was guarded and suspicious and exhib-
ited a flat affect. At the same time, Nelson found Sanders to be
cooperative, appropriate, stable, and noted that there were no
signs of psychosis. Nelson nonetheless recommended that
Sanders remain on suicide watch.
Nelson then evaluated Sanders daily for four consecutive
days. On one of the days, Sanders bit his own arm. Sanders
told Nelson that the biting was his attempt to get medical at-
tention for his injured thumb. The next day, Sanders pro-
fessed his realization that biting his arm to get medical atten-
tion displayed poor judgment. He told Nelson that he knew
the appropriate procedure to obtain medical attention.
After repeatedly observing that Sanders was stable, coop-
erative, and presenting appropriately, as well as the absence

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No. 23-1335 9
of any psychotic affects, Nelson removed him from suicide
watch on August 2, 2016. Nelson continued to see Sanders
during segregation rounds through February 2017 with no re-
ported concerns.
4. Kelly Haag
Haag met Sanders for the first time when conducting seg-
regation rounds in August 2015. Sanders informed her then
that he was “o.k.” and Haag did not notice anything amiss.
Her observations of Sanders during segregation rounds in
November 2015, June 2016, and July 2016, were similarly un-
remarkable.
Haag next saw Sanders in December 2016 during his
group therapy session. Based on their interactions, Haag
found that Sanders displayed improved impulse control and
insight with no observable signs of psychosis, agitation, or
distress. According to Haag, she explained to Sanders how to
go about requesting mental health services or crisis care in
times of need. He acknowledged understanding this process.
Haag met with Sanders in at least seven additional group
therapy sessions from December 2016 through March 2017.
Haag also continued to see Sanders during segregation
rounds in March and April 2017, all without any reported
concerns. On one occasion, Haag noted that Sanders’s inabil-
ity to refrain from behaviors that resulted in disciplinary in-
fractions indicated poor impulse control. But, at Haag’s as-
sessments, Sanders repeatedly denied having suicidal or
homicidal ideations and generally presented appropriately.
5. Linda Duckworth
Duckworth met with Sanders only a handful of times be-
tween February 2015 and August 2016. During their first

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10 No. 23-1335
encounter, Sanders told Duckworth that he was upset about
receiving a disciplinary ticket for masturbating in front of a
female officer, so he broke a sprinkler. Sanders refused to talk
further about it in front of the other officers who were present.
At the conclusion of the examination, Duckworth found Sand-
ers’s behavior, mood, and affect inappropriate but recom-
mended an outpatient level of care.
Later that same afternoon, Sanders threatened to cut him-
self with a paper cup, and Duckworth came by his cell to
speak with him. According to Sanders, he had been falsely ac-
cused of the ticket for masturbating, and his property had
been taken away for three days. Duckworth provided Sanders
with deep breathing and meditation exercises to help him
cope with stress. She observed him to be alert, attentive, fully
oriented, mildly distressed, and at minimal risk of suicide
and, thus, recommended that he continue outpatient care.
Duckworth later treated Sanders in two individual ther-
apy sessions in May and July 2015 and saw him during one
segregation round in May 2016. At no time did she see any-
thing of concern. Duckworth assessed Sanders with various
disorders, including mood disorder, antisocial personality
disorder, schizoaffective disorder, intermittent explosive dis-
order, adjustment order, and narcissistic traits.
Duckworth’s final encounter with Sanders was in August
2016 to evaluate his suicide risk. She assessed certain risk fac-
tors, including Sanders’s concerns about serving too much
segregation time and having lost his underwear in May 2015;
his difficulty adjusting to the loss of freedom, status, and priv-
ilege; his murder conviction; and his prior suicide attempts.
Duckworth also found countervailing factors, including
Sanders’s opposition to suicide, his support system, his

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No. 23-1335 11
coping and problem-solving skills, and his compliance with
psychotropic medication. Based on her examination, she rec-
ommended that Sanders return to segregation housing rather
than crisis care.
B. Sanders’s Disciplinary Proceedings
When an inmate is accused of a major violation of prison
rules, the case is heard by the “Adjustment Committee.” The
committee holds a hearing and determines whether the indi-
vidual committed the alleged offense. It then recommends
what it believes to be the appropriate discipline to the warden,
including possible segregation.
For inmates, like Sanders, whom IDOC has designated as
being “seriously mentally ill,” the Adjustment Committee fol-
lows a 2014 IDOC administrative directive and solicits input
from the relevant Wexford mental health providers in a Men-
tal Health Disciplinary Review form. To complete the form,
the mental health provider reviews the inmate’s mental
health records and the disciplinary report and opines on
whether: (1) the individual’s mental illness may have contrib-
uted to the behavior at issue; (2) segregation is likely to signif-
icantly impact the inmate’s mental health; and (3) the of-
fender’s mental health should be considered when determin-
ing the appropriate discipline. The mental health provider
can also recommend a specific term of segregation or no seg-
regation time at all. The provider plays no role in deciding
whether the inmate committed the alleged misconduct.
Under the IDOC directive, the Adjustment Committee
must consider the opinions of the mental health provider in
the Mental Health Disciplinary Review form. If the mental
health provider recommends a specific term of segregation or

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12 No. 23-1335
no segregation, the directive requires the committee to adopt
the provider’s recommendation. If the committee disagrees
and believes that a more restrictive disciplinary action is nec-
essary, it must appeal that decision to the warden, who makes
the final determination.
At one time or another, each of the Providers either com-
pleted a Mental Health Disciplinary Review form or partici-
pated on the Adjustment Committee for Sanders.
For example, in May 2015, Sanders faced the Adjustment
Committee for sexual misconduct, and Moss recommended
no more than six months of segregation time, yard restriction,
and “C grade” placement.5
In September 2015, Sanders came before the committee for
writing “a sexually graphic and wholly inappropriate” letter
to a court reporter. Nelson recommended a recreation re-
striction. The Adjustment Committee, which included Lanter-
man, followed Nelson’s recommendation and assessed one
month of yard restriction. Days later, after Sanders committed
another sexual misconduct offense, Nelson recommended a
segregation term of two months, and the committee followed
Nelson’s recommendations.
Sanders was brought before the Adjustment Committee
again on October 27, 2015, after disobeying multiple orders to
remove items covering his cell window. Haag recommended
zero to three months of segregation as well as other less severe
restrictions. The committee, which included Moss, adopted
5 C Grade indicated a further restriction in institutional privileges.

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No. 23-1335 13
Haag’s recommendations and did not recommend segrega-
tion.
Duckworth sat on the Adjustment Committee to hear two
sets of violations by Sanders on July 24, 2016, and July 27,
2016. He had been ticketed with assaulting staff after throw-
ing liquid on officers, threatening to stab them, disobeying
multiple orders, damaging property, and impairing surveil-
lance. The committee adopted the mental health provider’s
recommendation of one year of segregation along with lesser
restrictions.6
C. Wexford
According to Sanders, Wexford employed a practice of ig-
noring the mental health needs of inmates until they reached
a crisis state. At his deposition, he testified that on November
3, 2015, he knocked on his cell door while Moss was walking
down the gallery to tell her that he needed to talk, but Moss
did not respond. He was later informed by a prison guard that
Moss told the guard that she did not want to speak with Sand-
ers unless he was suicidal. Sanders also testified that Moss
had indicated to him on another occasion that she would only
see him if he was suicidal, but he could not remember when
that occurred. Sanders admitted, however, that he was seen
by another mental health professional on November 3, just
not Moss.
Sanders also faults Wexford for failing to issue guidance
explaining exactly what a mental health provider must do
when participating in disciplinary proceedings. He points to
6 It is not clear from the record which mental health provider com-
pleted the Mental Health Disciplinary Review forms for these violations.

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14 No. 23-1335
Nelson’s testimony that he did not review Sanders’s mental
health records prior to completing the Mental Health Disci-
plinary Review form but relied on input from colleagues who
regularly treated Sanders. In a similar vein, Lanterman testi-
fied that he did not necessarily meet with an accused inmate
every time he completed the form and that, when he sat on
the Adjustment Committee, he relied on the opinions of the
reviewing provider. Additionally, Sanders points to Duck-
worth’s testimony that she does not consider an inmate’s seg-
regation history when she fills out the Mental Health Discipli-
nary form.7
II
Sanders initiated this action pro se in September 2016.
Shortly after he brought the case, IDOC reduced Sanders’s
segregation term, and he was transferred to the general pop-
ulation in September 2017. In an amended complaint, Sanders
alleged that Wexford and the Providers violated his right to
be free of cruel and unusual punishment under the Eighth
Amendment. As to the former, Sanders contends that Wex-
ford had a practice or custom of ignoring inmates’ mental
health needs until they were in crisis. As to the latter, he
claims that the Providers were deliberately indifferent to his
mental health needs and failed to advocate for his removal
from segregation housing.
This is the third appeal Sanders has filed in this case. The
first time, we reversed the district court’s decision to revoke
7 Sanders also cites testimony from Haag, but she did not, as Sanders
claims, admit that she disregarded his segregation term during discipli-
nary proceedings. Rather, she stated that she did not calculate the term
when completing an assessment after segregation rounds.

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No. 23-1335 15
his in forma pauperis status (IFP) and dismiss his complaint on
the grounds that his allegations did not demonstrate immi-
nent danger of serious physical harm. Sanders v. Melvin, 873
F.3d 957, 959–60 (7th Cir. 2017). Sanders had to make this
showing because he already had three strikes under 28 U.S.C.
§ 1915(g). Id. at 959. On remand, Sanders retained counsel,
paid the filing fee, and filed the operative complaint.
In the second appeal, we reversed the district court’s order
dismissing Sanders’s case as a sanction for misrepresenting to
the court that he received mental health treatment only when
he had harmed himself or had credibly threatened to do so.
Sanders v. Melvin, 25 F.4th 475, 484–85 (7th Cir. 2022).
In both instances, “Sanders ha[d] not yet been directed to
substantiate his allegations.” Sanders, 873 F.3d at 962. Since
then, the parties were provided an opportunity to conduct
discovery, and the defendants moved for summary judgment,
which the district court granted on all counts. The latest order
is the subject of this appeal.
III
We review the district court’s order granting summary
judgment de novo after construing all factual disputes in Sand-
ers’s favor. See Burton, 805 F.3d at 783. We begin with Sand-
ers’s claims against the Providers before turning to his claims
against Wexford.
A. The Providers
Sanders contends that the Providers were deliberately in-
different to his mental health needs in two ways. First, they
provided a course of treatment they knew to be ineffective.
Second, during disciplinary proceedings, they recommended

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16 No. 23-1335
additional time in segregation (and other restrictions) rather
than recommending less.
“The Eighth Amendment’s ban on ‘cruel and unusual
punishments’ obligates prison officials to provide medical
care to prisoners in their custody.” Dean v. Wexford Health
Sources, Inc., 18 F.4th 214, 234 (7th Cir. 2021) (quoting Estelle v.
Gamble, 429 U.S. 97, 102 (1976)). A prison official’s “deliberate
indifference to serious medical needs of prisoners” violates
the Eighth Amendment. Estelle, 429 U.S. at 104.
To prove a deliberate indifference claim, a plaintiff must
first show that he suffers from an “objectively serious medical
condition.” Petties v. Carter, 836 F.3d 722, 728 (7th Cir. 2016)
(en banc). Additionally, a plaintiff must establish that the
prison official acted with a “sufficiently culpable state of
mind.” Farmer v. Brennan, 511 U.S. 825, 834 (1994) (quoting
Wilson v. Seiter, 501 U.S. 294, 297 (1991)).
A prison official has a sufficiently culpable state of mind
when the official “knew of a substantial risk of harm to the
inmate and acted or failed to act in disregard of that risk.” Id.
(citation omitted). A court considers “the totality of an in-
mate’s medical care” to assess “whether that care evidences
deliberate indifference to serious medical needs.” Petties, 836
F.3d at 728–29 (citing Cavalieri v. Shephard, 321 F.3d 616, 625–
26 (7th Cir. 2003)). The standard to prove deliberate difference
is a difficult one: a medical professional’s treatment decision
“must be such a substantial departure from accepted profes-
sional judgment, practice, or standards as to demonstrate that
the person responsible did not base the decision on such a
judgment.” Id. (internal quotation marks omitted).

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No. 23-1335 17
One way to establish such a departure “is where a prison
official persists in a course of treatment known to be ineffec-
tive.” Id. at 729–30 (citing Walker v. Peters, 233 F.3d 494, 499
(7th Cir. 2000)); see, e.g., Greeno v. Daley, 414 F.3d 645, 654–55
(7th Cir. 2005). That said, “[a] medical professional is entitled
to deference in treatment decisions unless no minimally com-
petent professional would have so responded under those cir-
cumstances.” Stewart v. Wexford Health Sources, Inc., 14 F.4th
757, 763 (7th Cir. 2021) (internal quotation marks omitted).
And “expert medical evidence is often required to prove” a
substantial departure from accepted professional judgment,
practice, or standards. Eagan v. Dempsey, 987 F.3d 667, 683 (7th
Cir. 2021) (internal quotation marks omitted).
1. Sanders’s Treatment
The parties do not dispute that Sanders’s mental health
needs presented an objectively serious medical condition. Ra-
ther, the parties focus on whether the Providers acted with
deliberate indifference when they continued to provide, as
Sanders sees it, knowingly ineffective treatment. We find that
the record lacks sufficient evidence from which a reasonable
jury could make this determination.
The Providers’ notes documented both complaints from
Sanders about his mental state and segregation as well as
statements confirming that he was fine and had no mental
health concerns. Sanders urges us to disregard the latter, cit-
ing the unreliability of self-reporting. But, even if we construe
the record in Sanders’s favor (as we must), in an area as mul-
tifaceted as mental health and its treatment, we cannot dis-
cern how a jury would be able determine the effectiveness of
the course of treatment provided to Sanders without expert
evidence. See Petties, 836 F.3d at 729 (observing “the need for

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18 No. 23-1335
specialized expertise to understand the various implications
of a particular course of treatment” in cases where the risk of
harm is not obvious). In this way, this case is markedly differ-
ent from an obvious case of deliberate indifference such as
when a prison official gives an aspirin to a patient facing a
serious risk of appendicitis. See Sherrod v. Lingle, 223 F.3d 605,
611–12 (7th Cir. 2000).
Here, Sanders retained psychiatrist Dr. Stuart Grassian as
a mental health expert, but Dr. Grassian’s opinions were lim-
ited to the psychiatric impact of Sanders’s incarceration at
Pontiac. He offered no opinions about the effectiveness of the
specific treatment Sanders received from the Providers. For
instance, when asked to evaluate whether Sanders’s group
therapy was beneficial, Dr. Grassian responded: “I do not
know enough about the group therapy. I didn’t attend it. I’m
telling you what his experience was.”
To be sure, Dr. Grassian does criticize the Providers for
failing to spend sufficient time with Sanders to “really get[] to
know him.” But he does not suggest that the time they did
spend with Sanders demonstrated a “complete abandonment
of medical judgment.” See, e.g., Murphy v. Wexford Health
Sources, Inc., 962 F.3d 911, 916–17 (7th Cir. 2020) (affirming
summary judgment on the ground that expert’s opinions
“d[id] not go so far” to make this showing) (citing Norfleet v.
Webster, 439 F.3d 392, 396 (7th Cir. 2006)). And while Dr.
Grassian expressed some disagreement with the treatment
Sanders received (which we must credit at summary judg-
ment), he offers no opinion as to whether the treatment the
Providers gave to Sanders represented a substantial depar-
ture from accepted professional standards or suggested that
such decisions were not actually based on their professional

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No. 23-1335 19
judgment. See Norfleet, 439 F.3d at 396 (“[A] difference of opin-
ion among physicians on how an inmate should be treated
cannot support a finding of deliberate indifference.”).
2. Discipline
Sanders also contends that the Providers acted with delib-
erate indifference to his mental health needs during the disci-
plinary process. Sanders insists that he is not challenging the
discipline he received. Instead, he argues, a reasonable jury
could find that the Providers knew of the obvious harms from
segregation and, despite this, failed to exercise their clinical
judgment when recommending segregation and similarly re-
strictive sanctions. But, even if we were to assume that the
Providers were aware of the risk as Sanders describes and
take Sanders’s factual assertions to be true, the record is de-
void of any evidence from which a reasonable jury could con-
clude that no minimally competent mental health profes-
sional would have made the recommendations they did.
Furthermore, Moss, Nelson, and Haag each recommended
that Sanders be docked yard time. And, because access to ex-
ercise is an essential human need, we have recognized that
failure to provide exercise time can violate the Eighth Amend-
ment. See Delaney v. DeTella, 256 F.3d 679, 683 (7th Cir. 2001);
Anderson v. Romero, 72 F.3d 518, 528 (7th Cir. 1995). Still, for
the reasons explained, the record before us lacks a basis upon
which a jury could conclude that Nelson’s recommendation
under these circumstances substantially departed from pro-
fessional norms.
Sanders also criticizes the Providers for “fail[ing] to un-
dertake a meaningful review of [his] medical history before
recommending solitary confinement.” He cites the testimony

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20 No. 23-1335
from Nelson, Lanterman, and Duckworth discussed earlier.
But of these three Providers, only Nelson completed a form
for Sanders. And Nelson stated that, although he did not re-
view Sanders’s mental health records prior to completing the
form, he relied on information from colleagues who treated
Sanders on a regular basis. Nothing in the record indicates
that this was such a stark departure from professional stand-
ards as to constitute deliberate indifference.
Lastly, even if no minimally competent mental healthcare
provider would have made the recommendations the Provid-
ers did here, Sanders has not demonstrated a genuine dispute
of fact as to whether the recommendations caused him harm.
By the time the Providers began participating in Sanders’s
disciplinary proceedings—the earliest being Moss in May
2015—he was already serving a term of segregation set to ex-
pire in January 2022 and was released from segregation in
September 2017. Thus, no reasonable jury could conclude that
the recommendations of the Providers caused him to serve
more time in segregation than he otherwise would have.
For these reasons, the district court did not err when grant-
ing summary judgment in favor of the Providers.
B. Wexford
Sanders asserts two grounds for his Monell claim against
Wexford. First, he contends that Wexford has a widespread
practice or custom of ignoring the mental health problems of
inmates until they are in crisis. Second, he faults Wexford for
failing to give direction to its mental health professionals on
how to complete a Mental Health Disciplinary Review form.
We have recognized three types of entity action that can
support Monell liability under § 1983: “(1) an express policy

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No. 23-1335 21
that causes a constitutional deprivation when enforced; (2) a
widespread practice that is so permanent and well-settled that
it constitutes a custom or practice; or (3) an allegation that the
constitutional injury was caused by a person with final poli-
cymaking authority.” Id. at 986 (internal quotation marks
omitted). Moreover, inaction can give rise to liability under
Monell if it reflects “a conscious decision not to take action”
where necessary to “remedy a potentially dangerous prac-
tice.” Glisson v. Ind. Dep’t of Corr., 849 F.3d 372, 381 (7th Cir.
2017) (en banc) (internal quotation marks omitted); see also
J.K.J. v. Polk Cnty., 960 F.3d 367, 377–78 (7th Cir. 2020) (en
banc).
1. Refusing Treatment
Sanders contends that Wexford has a practice or custom of
refusing mental health treatment until an inmate harms him-
self or threatens to do so.8 But, assuming such a practice ex-
isted, Sanders has not created a genuine issue of fact as to
whether such a practice was widespread. Sanders points to
only one occasion when Moss told him that she did not want
to see him unless he was suicidal.9 And, while a plaintiff may
8 It does not appear that Sanders raised this precise Monell theory
when responding to defendants’ summary judgment motion below. Ra-
ther than asserting a widespread refusal of treatment until a crisis occurs,
Sanders submitted that Wexford lacked a policy that ensured consistent
and effective mental health treatment. Defendants do not complain, so we
will take Sanders’s theory as he has articulated it here.
9 The other incident was relayed by a guard to Sanders and constitutes
at least one level of inadmissible hearsay. See Washington Cnty. Water Co.,
Inc. v. City of Sparta, 77 F.4th 519, 529 (7th Cir. 2023) (“[I]nadmissible

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22 No. 23-1335
be able to “demonstrate the existence of an official policy or
custom by presenting evidence limited to his own experi-
ence,” Grieveson v. Anderson, 538 F.3d 763, 774 (7th Cir. 2008),
one incident cannot “plausibly be described as ‘so persistent
and widespread as to practically have the force of law.’”
Bridges v. Dart, 950 F.3d 476, 480 (7th Cir. 2020) (quoting Con-
nick v. Thompson, 563 U.S. 51, 61 (2011)).
Sanders also points to purported gaps in treatment by the
Providers as evidence of a widespread practice of refusing
mental health care until a crisis arises, but the record clearly
shows that many other mental healthcare providers, includ-
ing multiple psychiatrists and psychologists, were regularly
treating him during the times that he was not seeing the Pro-
viders. In fact, on this record, there can be no genuine dispute
that Sanders was receiving continuous treatment for his men-
tal health conditions, including before and after each suicide
attempt.
2. Lack of Policy
Lastly, Sanders argues that Wexford had an obligation to
promulgate a policy describing what a mental health profes-
sional should do when participating in a disciplinary pro-
ceeding, but failed to issue one. It is not clear from the briefing
what Sanders thinks such a policy should contain. For exam-
ple, does he believe that Wexford should require mental
health professionals to review an inmate’s mental health rec-
ords in all cases, consider an inmate’s overall segregation
hearsay evidence does not create a factual dispute at summary judg-
ment.”) (citation omitted).

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No. 23-1335 23
time, meet with the inmate in person before making a recom-
mendation, or always recommend a reduced segregation time
(or, perhaps, all the above)?
What is clear is that IDOC already had a procedure in
place to ensure the involvement of mental health profession-
als in the disciplinary process for seriously mentally ill in-
mates. And his own proceedings before the Adjustment Com-
mittee demonstrates the significant impact that their recom-
mendations could have on the outcome.
Furthermore, given the existing policy, there is no evi-
dence in the record from which a reasonable jury could find
that the failure to promulgate a more detailed policy created
a risk so obvious as to constitute deliberate indifference. And
Sanders has presented no evidence to show that the absence
of such a policy caused the Providers to treat him in a way
that violated the Eighth Amendment.
Dr. Grassian does vaguely suggest that Wexford failed to
adequately train its mental health providers regarding the
risks posed by solitary confinement to inmates suffering from
mental illness, but he says nothing about whether the detailed
policy Sanders proposes was necessary or, if so, whether the
need would have been obvious to Wexford. Thus, the district
court did not err in granting summary judgment to Wexford
on Sanders’s Monell claims.
IV
For these reasons, the district court’s grant of summary
judgment is AFFIRMED.

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24 No. 23-1335
R OVNER , Circuit Judge, concurring. Although I agree that
there can be no liability for these defendants under our delib-
erate indifference standard, I write separately to emphasize
what I have said more extensively in my dissent in Johnson v.
Prentice, 29 F.4th 895, 906 (7th Cir. 2022), and what my brother,
Judge Hamilton, has written recently in his concurrence in
Jackson v. Anastasio, No. 23-1703, 2025 WL 2437947, at *10 (7th
Cir. Aug. 25, 2025) (Hamilton, J., joined by Rovner, J., concur-
ring), about our evolving understanding of solitary confine-
ment and its deleterious effects.
It is undisputed that Cordell Sanders was living with seri-
ous mental illness. Because of repeated rules infractions,
Sanders spent eight continuous years in solitary confinement.
This isolation was all-encompassing. Sanders was held in his
cell for 22 to 24 hours a day. Occasionally, he was let out to
shower, for visits, to use the solitary confinement law library,
or to attend “yard” in slightly larger cells that look like very
narrow, chain-link-fenced dog runs, which Wexford’s own
expert described as “isolated cubicles.” He did not have ac-
cess to out-of-cell religious, educational, or vocational pro-
gramming. When he did leave his cell, Sanders was shackled,
even during medical appointments. His cell had no outside
windows and little air flow, subjecting him to extreme tem-
peratures and stifling conditions. He had little to no ability to
interact with other prisoners. For at least five of the eight
years of his solitary confinement, he was on “yard re-
striction,” meaning that he was only allowed to leave his cell
for exercise in the isolated cubicle once a month, for a single
hour, and often he did not get even that miniscule relief.
Despite (or perhaps because of) spending eight years in
continuous solitary confinement, he was unable to conform

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No. 23-1335 25
his behavior to prison expectations or to act in a manner that
benefited his own interest. During his time in solitary confine-
ment, Sanders expressed suicidal thoughts, harmed himself,
and attempted to take his life multiple times. He overdosed
on pain medication in 2010. He sliced his stomach in 2012. He
overdosed on 69 pills on October 27, 2015, and overdosed
again on pills on July 24, 2016—his fourth suicide attempt in
six years. Two days later, in continued distress, he began to
bite his wrist.
Sanders’ experience with solitary confinement is not
unique. The amicus briefs of former correctional officials, as
well as that of mental health professionals with extensive ex-
perience studying the psychological and physiological effects
of solitary confinement detail the abundant research describ-
ing the destructive and devastating mental health effects of
even the most minimal time spent in solitary confinement. See
R. 53 and 54. The effects are universal. According to one re-
searcher’s survey, “[t]here is not a single published study of
solitary or supermax-like confinement in which nonvoluntary
confinement last[ing] for longer than 10 days … failed to re-
sult in negative psychological effects.”1
Of course prison staff must have measures to enforce rules
violations and to keep inmates and staff safe. But the amicus
brief from former correctional officials claims that the in-
creased use of solitary confinement is “not associated with re-
ductions in facility or systemwide misconduct and violence.”2
1 Craig Haney, Mental Health Issues in Long-Term Solitary and “Super-
max” Confinement, 49 Crime & Delinquency 124, 132 (2003)).
2 Benjamin Steiner & Calli M. Cain, U.S. Dept. of Justice Programs,
Bureau of Justice Statistics, The Relationship Between Inmate Misconduct,
(continued)

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26 No. 23-1335
In fact, “data reveal[] a clear relationship between the use of
restrictive housing in facilities and [] indicators of facility dis-
order.”3 Studies have also demonstrated that reducing soli-
tary confinement decreases prison violence dramatically.4 In
light of the uncontroverted harm to prisoners, forty-five states
have introduced bills to regulate, limit, or ban solitary con-
finement.5 As of 2023, twenty states had introduced bills to
limit solitary confinement to fifteen days or less, three of
which have passed, and only Iowa, Idaho, Utah, North Da-
kota and Wyoming had not yet introduced a single bill on the
topic.6
Institutional Violence, and Administrative Segregation: A Systematic Review of
the Evidence in Restrictive Housing in the U.S.: Issues, Challenges, and Future
Directions, at 179 (Nov. 2016), http://www.nationaljailacademy.org/_doc-
uments/resources/administrative-segregation/doj-restrictive-hous-
ing.pdf. [https://perma.cc/5PS9-TG3E]
3 Allen J. Beck, U.S. Dept. of Justice, Office of Justice Programs, Bureau
of Justice Statistics Use of Restrictive Housing in U.S. Prisons and Jails,
2011–12, at 10 (Oct. 2015), https://bjs.ojp.gov/con-
tent/pub/pdf/urhuspj1112.pdf. [https://perma.cc/4SVJ-6GYQ]
4 See, e.g., Marc A. Levin, Texas Public Policy Foundation, Testimony of
Marc A. Levin, Esq., Director of the Center for Effective Justice at the Texas Pub-
lic Policy Foundation Before the U.S Senate Judiciary Subcommittee on The Con-
stitution, Civil Rights and Human Rights, at 3 (Feb. 2014) (noting decreases
in violence associated with reducing solitary confinement across multiple
states), https://www.judiciary.senate.gov/imo/media/doc/02-25-14Levin-
Testimony.pdf. [https://perma.cc/L3UU-QFY5]
5 Jean Casella, New Report and Public Database Track Legislation to Limit
or End Solitary Confinement, Solitary Watch (January 2023), https://solitary-
watch.org/2023/01/25/new-report-and-public-database-track-legislation-
to-limit-or-end-solitary-confinement. [https://perma.cc/65XX-RSDP]
6 Id.

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No. 23-1335 27
And so, in the end, Sanders suffered terribly for, at most,
a minimal positive effect on prison security, and possibly
even a negative effect. Although we once looked at outdoor
exercise time in prison as recreational, our “evolving stand-
ards of decency” allow us to understand that “conditions
which may have been acceptable long ago may be considered
unnecessarily cruel in light of our growing understanding of
human needs and the changing norms of our soci-
ety.” Delaney v. DeTella, 256 F.3d 679, 683 (7th Cir. 2001) (in-
ternal quotation marks omitted). For several decades, we
have recognized that exercise is one of the basic human neces-
sities and an essential component of health. Anderson v.
Romero, 72 F.3d 518, 527–28 (7th Cir. 1995). It “is no longer
considered an optional form of recreation but is instead a nec-
essary requirement for physical and mental well-be-
ing.” Delaney, 256 F.3d at 683. Consequently, “long stretches
of [solitary] confinement can have serious adverse effects on
prisoners’ psychological well-being” and can be described as
cruel under the Eighth Amendment if “unrelieved by oppor-
tunities for out-of-cell exercise.” Pearson v. Ramos, 237 F.3d
881, 884 (7th Cir. 2001); see also Davenport v. DeRobertis, 844
F.2d 1310, 1313 (7th Cir. 1988) (“[I]solating a human being
from other human beings year after year or even month after
month can cause substantial psychological damage.”). Of
course, that basic human need must be balanced against secu-
rity and penological interests of the prison, but “‘[t]o deny a
prisoner all opportunity for exercise outside his cell would,
the cases suggest, violate the Eighth Amendment unless the
prisoner posed an acute security risk if allowed outside of his
cell for even a short time.’” Delaney, 256 F.3d at 687 (quot-
ing Anderson, 72 F.3d at 527).

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28 No. 23-1335
This case addresses the level of care mental health care
providers owe to a prisoner in solitary confinement. In Jack-
son, Judge Hamilton addressed the question of when discipli-
nary solitary confinement implicates a prisoner’s liberty inter-
est. Both cases at their core, however, ask courts to consider
when solitary confinement breaches norms of humane and
ethical treatment of prisoners. As Judge Hamilton points out,
the United States sponsored rules in the United Nations enti-
tled “Standard Minimum Rules for the Treatment of Prison-
ers” which prohibit as a form of torture solitary confinement
of more than fifteen consecutive days. Jackson, 2025 WL
2437947, at *10 (Hamilton, J., concurring). Sanders endured
solitary confinement for more than eight years. And as Judge
Hamilton further notes, “recent case law … reflects a judicial
intuition that prolonged punitive solitary confinement should
be a thing of the past, ” as it is not consistent with “’evolving
standards of decency that mark the progress of a maturing
society.’” Id. at *16 (quoting Walton v. Nehls, 135 F.4th 1070,
1072 (7th Cir. 2025)).
Although we find no liability for these defendants given
their limited role in the assignment of Sanders’ solitary con-
finement, it is my hope that our evolving understanding of
the psychological effects of solitary confinement on the one
hand, and lack of penological benefit, on the other, will in-
form our understanding of deliberate indifference, liberty in-
terests, and Eighth Amendment standards in cases where de-
fendants were, in fact, responsible for imposing the condition.
With our growing understanding of human needs, mental ill-
ness, and the devastating effects of solitary confinement, our
standards of decency and humaneness must evolve to reflect
the changing norms of a civilized society.

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