William Sims v. Alexis Figueroa

[DO NOT PUBLISH]
In the
United States Court of Appeals
For the Eleventh Circuit
____________________
No. 21-10647
Non-Argument Calendar
____________________
WILLIAM SIMS,
Plaintiff-Appellant,
versus
ALEXIS FIGUEROA,
Sued in his individual capacity,
Defendant-Appellee.
____________________
Appeal from the United States District Court
for the Middle District of Florida
D.C. Docket No. 3:18-cv-00892-MMH-JBT
____________________
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2 Opinion of the Court 21-10647
Before WILLIAM PRYOR , Chief Judge, L UCK , and L AGOA , Circuit
Judges.
PER CURIAM:
William Sims, a state inmate, appeals the summary judg-
ment against his complaint that Dr. Alexis Figueroa acted with de-
liberate indifference by providing inadequate treatment for Sims’s
rectal bleeding. 42 U.S.C. § 1983. The district court ruled that
prison medical records “refute Sims’ claim.” After careful review of
the record, we affirm.
I. BACKGROUND
We divide our background into two parts. First, we describe
Sims’s medical treatment. Second, we describe the proceedings in
the district court.
A. Sims’s Treatment
As part of his treatment for prostate cancer, Sims took nar-
cotics that caused constipation, gastrointestinal bleeding, and hem-
orrhoids. On August 16, 2017, prison officers transported Sims for
a colonoscopy. Sims had a polyp removed and left with instructions
to return in eight weeks for a follow-up examination. A few days
later, Sims experienced rectal bleeding and received a “dose of mag-
nesia.” Sims’s gastroenterologist determined that “the cause of rec-
tal bleeding was an inflamed hemorrhoid.”
On August 30, 2017, Sims was transferred to Suwannee Cor-
rectional Institution Annex, where Dr. Figueroa became his
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21-10647 Opinion of the Court 3
primary healthcare provider. On September 8, 2017, Sims reported
“ongoing rectal bleeding,” and Dr. Figueroa referred Sims for a
“reg[ular] 1st post-op visit for biopsy results and [a] plan of care”
with a gastroenterologist. But after Dr. Figueroa consulted with
the regional medical director, the doctor cancelled his referral and
put Sims on an alternate treatment plan.
On October 12, 2017, Sims “was seen by Gastroenterology”
“for [a] follow up” examination, and his oncologist, Dr. Vernon
Montoya, prepared a progress note addressing Sims’s condition
and treatment plan. Dr. Montoya ordered that Sims “continue with
Lupron,” a hormone used to treat advanced prostate cancer, and
return for a “[f]ollow up in three months” for tests. Dr. Montoya
“ma[de] a referral back to Gastroenterology” because “[i]t [was] un-
clear why [Sims] was ATP’d as he had a colonoscopy and he was
found to have a polyp as well as hemorrhoids” and he had “contin-
ued GI bleeding,” which made “GI follow up actually appropriate.”
After Sims returned to Suwanee, he was “seen in hematology”
where a nurse recorded that Sims would see his doctor with lab
testing in three months, he had a “emergent referral for his gastro
matter,” and he complained of continuous bleeding after his colon-
oscopy.
The next day, Dr. Figueroa recorded that Sims had seen his
oncologist, that “no new changes in [his treatment] plan ha[d] been
order[ed],” that he should “continue on Lupron,” and that follow
up “will cont[inue] on site.” Dr. Figueroa ordered that Sims would
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4 Opinion of the Court 21-10647
receive “lab[oratory tests] in 3 months” and “if significant alteration
then it will be consulted again.”
On October 30, 2017, Sims reported that he had “gross rectal
bleeding” that started months ago, but he requested only renewal
of his medicine. On November 15, 2017, Sims requested medical
treatment for “gross rectal bleeding” and complained he “not been
evaluated nor treat[ed].” Sims submitted additional requests for
treatment of “gross rectal bleeding” on November 20 and Decem-
ber 1. Sims received “routine” treatment by a nurse after submit-
ting each request.
On December 6, 2017, Sims reported to sick call three times
for rectal bleeding. A nurse detected blood on Sims’s hemoccult
cards and scheduled a medical follow-up.
On December 14, 2017, Dr. Figueroa examined Sims. Sims
complained that he was “tired of this problem that won’t go away.”
Dr. Figueroa performed a “rectal exam[, which] show[ed] that in-
flamed hemorrhoids [were] still present” from being detected
when Sims “had polyps removed on 8/16/17.” The doctor pre-
scribed Sims a stool softener, a laxative, and hydrocortisone cream.
Two days before seeing Dr. Figueroa, Sims filed a grievance
alleging that he had “not received any form of medical treatment”
to address his rectal bleeding. Sims complained that the “regional
office,” which “denied his follow up with [the] gastro clinic” and
instead recommended an “alternative treatment plan” was being
“deliberately indifferent to his serious health care needs.”
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21-10647 Opinion of the Court 5
On December 28, 2017, Dr. F. Cruz denied Sims’s grievance.
Dr. Cruz responded that Sims was “being followed in Chronic
Clinic for [his] medical condition” and had been “seen in sick calls[,]
. . . referred to the MD[,] and seen on 12/14/17 to address these
concerns.” Dr. Cruz stated that Sims had a “pending consult to On-
cology to further address the bleeding” with an “appointment . . .
pending soon,” and he could “address [concerns] with medical by
access[ing] sick call.”
On January 11, 2018, Sims returned to Dr. Montoya, who
recorded that Sims “was supposed to get a follow up colonoscopy,
but this has not yet been done.” Dr. Montoya ordered a “follow up
in three months” for Sims’s “prostate cancer.” Dr. Montoya rec-
orded that Sims had “also been noted with GI bleeding on colonos-
copy” and “[w]e will re-consult Gastroenterology” as “[t]his is ur-
gent, due to possible GI bleeding.”
On January 16, 2018, Sims reported to sick call complaining
of dizziness and blurred vision. A registered nurse checked his
blood sugar and blood pressure and performed an eye exam. The
nurse sent Sims’s “[c]hart to MD for consideration of optometry
consult and renewal of Lupron injection.”
On January 20, 2018, Dr. Figueroa recorded that Sims, hav-
ing seen his oncologist, would have follow up “cont[inued] on site”
and receive “lab work . . . in 3 months.” Dr. Figueroa noted that
“rectal bleeding [was] already found and discussed with” Sims and
that there would be “no further action until [his] next onc[ology]
app[ointment].”
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6 Opinion of the Court 21-10647
On January 31, 2018, Sims requested medical treatment for
“continuous rectal bleeding,” and a nurse gave him ibuprofen and
vitamins recommended by his oncologist. On February 6, and
March 13, 2018, Sims reported rectal bleeding without requesting
medical treatment and received “routine” care from nurses on both
occasions. On April 16, 2018, Sims requested information about
“gastro,” and on April 23, 2018, Sims requested medication renewal
and information about “medical supplies” for his “continuous rec-
tal bleeding and pain.” Although Sims did not request treatment,
he saw nurses after submitting his two requests.
On February 23, 2018, Sims filed a second grievance, which
Dr. Cruz denied. Sims complained that Dr. Figueroa had not or-
dered a gastroenterology consult. Dr. Cruz responded that “there
was no indication that [Sims] had been denied access to or denied
medical care,” that Dr. Figueroa had performed a “record review”
on January 20, and that Dr. Montoya’s progress note regarding a
gastroenterology consult was a “recommendation,” which “the
staff MD reviews and determines the plan of treatment and care.”
Dr. Cruz stated that Sims was “followed in Chronic Clinic on a reg-
ular basis with appointments pending” and “[i]f [he] had medical
concerns . . . [he could] access sick call to have them addressed.”
Sims filed an appeal, which was returned to him as untimely.
On July 5, 2018, Sims saw Dr. Montoya for a follow-up ex-
amination. Dr. Montoya recorded that Sims had a “GI bleed on co-
lonoscopy . . . and even though a referral was made it has not yet
been done.” The doctor ordered that Sims return in three months
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21-10647 Opinion of the Court 7
and “again refer[red] [Sims] to Gastroenterology” because “[t]his is
urgent . . . to evaluate GI bleeding.”
On July 9, 2018, Dr. Figueroa recorded that Sims’s “request
for [gastroenterology] consult has been discussed with [the re-
gional medical director] and due to the fact that GI stated on
8/16/17 that the cause of rectal bleeding was an inflamed hemor-
rhoid[,]” “[t]his could be handled on site.” Dr. Figueroa also rec-
orded that Sims had “no complaint at site of rectal bleeding.”
On September 11, 2018, Sims requested medication renewal
and information about “medical supplies.” He reported a “reoc-
curence of rectal bleeding.” The nurse classified Sims’s condition
as “urgent.”
On October 4, 2018, Sims returned to Dr. Montoya, who
recorded that Sims had been “noted with a recent rectal bleed” and
had been “referred to Gastroenterology times two, but still has not
yet been seen.” Dr. Montoya recorded that Sims had a “[p]ossible
GI bleed” even though his “[s]tool is guaiac negative on examina-
tion.” But Dr. Montoya waited until January 10, 2019, to refer Sims
for a “routine” consultation with gastroenterology. Dr. Figueroa
added Dr. Montoya’s treatment plans to Sims’s medical records.
In June 2019, Sims was transferred to another prison. On
April 3, 2020, Sims saw Dr. Xiaoyo Li, a gastroenterologist, who
examined Sims to determine the cause of his “continued . . . con-
stipation, on/off GI bleeding, [and] severe hemorrhoids on narcot-
ics due to his prostate cancer meds.” Dr. Li recommended that
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8 Opinion of the Court 21-10647
Sims undergo a sigmoidoscopy and have his hemorrhoids banded.
The doctor also prescribed dulcolax and movantik to treat Sims’s
constipation.
B. Proceedings in the District Court
On July 20, 2018, Sims filed a complaint that alleged Dr.
Figueroa’s “deliberate indifference and delay in medical care re-
sult[ed] in advanced prostate cancer.” Sims alleged that Dr.
Figueroa agreed to refer Sims to a gastroenterologist, but canceled
the referral “because he had his own treatment plan in place.” Sims
also alleged that he received no “form of medical treatment” at Su-
wanee until he saw Dr. Figueroa in December 2017, and his refusal
to refer Sims to a gastroenterologist was “to save money” and
made Dr. Montoya “furious.” Sims requested an award of compen-
satory and punitive damages and an injunction requiring Dr.
Figueroa to “immediately arrange for . . . follow up treatment . . .
by an outside specialist in the field of gastroenterology.”
Dr. Figueroa filed a motion to dismiss, which the district
court granted in part and denied in part. The district court dis-
missed Sims’s claim against the doctor in his official capacity. The
district court rejected the doctor’s arguments to dismiss the com-
plaint for lack of exhaustion of administrative remedies, for failure
to state a claim of deliberate indifference, and as barred by qualified
immunity. The district court also rejected the doctor’s argument
to dismiss Sims’s claim for compensatory and punitive damages on
the basis his physical injuries were no more than de minimis. 42
U.S.C. § 1997e(e).
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21-10647 Opinion of the Court 9
Later, Dr. Figueroa moved for summary judgment, and the
district court granted the motion. The district court found that
“Sims’ exhibits establish” the doctor “regularly examined [him],
prescribed medication, discussed his treatment plan, and on two
occasion[s] requested a gastroenterology consultation for him” and
“refute Sims’ claim that Figueroa ignored Sims’ rectal bleeding.”
The district court also found that “Figueroa, in discussion with the
regional medical director, determined Sims’ rectal bleeding was
caused by his hemorrhoids and could be handled onsite at the
prison,” and “the gastroenterologist who saw Sims in April 2020
determined the same, although he prescribed a different treatment
plan.” “Based on this record, [the district court could not say] that
Figueroa ignored Sims’ serious medical issue” or that his treatment
“was so grossly incompetent as to shock the consci[ence] or that it
caused an exacerbation of his condition.” The district court also re-
jected as “unavailing” Sims’s argument that “cost-savings played a
role in Figueroa’s treatment.”
II. STANDARD OF REVIEW
We review
de novo a summary judgment.
Adams v. Poag,
61 F.3d 1537, 1542 (11th Cir. 1995). We view the facts and draw
all reasonable inferences from those facts in favor of the non-
movant.
See id. Summary judgment is appropriate when “there is
no genuine dispute as to any material fact and the movant is enti-
tled to judgment as a matter of law.” Fed. R. Civ. P. 56(a).
III. DISCUSSION
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10 Opinion of the Court 21-10647
To prevail on a claim of deliberate indifference, a prisoner
must prove that his physician knew of and disregarded a risk of se-
rious harm to his health.
Farrow v. West, 320 F.3d 1235, 1243
(11th Cir. 2003). “[D]eliberate indifference describes a state of
mind more blameworthy than negligence” and “requires more
than ordinary lack of due care for the prisoner’s interests or
safety.”
Farmer v. Brennan, 511 U.S. 825, 835 (1994). The physi-
cian “must both be aware of facts from which the inference could
be drawn that a substantial risk of serious harm exists, and he
must also draw the inference.”
Id. at 837. Medical treatment vio-
lates the prohibition against cruel and unusual punishment in the
Eighth Amendment “only when it is so grossly incompetent, inad-
equate, or excessive as to shock the conscience or to be intolera-
ble to fundamental fairness.”
Nam Dang by & through Vina Dang
v. Sheriff, Seminole Cty. Fla., 871 F.3d 1272, 1280 (11th Cir. 2017)
(internal quotation marks omitted).
Sims failed to establish that Dr. Figueroa was deliberately
indifferent to Sims’s rectal bleeding. Dr. Figueroa initially referred
Sims to see a specialist, but after reviewing his medical records
and consulting with a supervisor, the doctor concurred with the
gastroenterologist who treated Sims post-colonoscopy that his
hemorrhoids caused his bleeding. In the months following, when
Sims reported rectal bleeding, he received medical treatment
from the nursing staff and his bleeding lessened. And after a test
detected blood in Sims’s stool, Dr. Figueroa performed a rectal
exam, determined that the bleeding was due to Sims’s inflamed
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21-10647 Opinion of the Court 11
hemorrhoids, and prescribed a conservative treatment that caused
the bleeding to subside. Sims later reported a reoccurrence of
bleeding, but his guaiac test detected no blood in his stool. This
record refutes Sims’s argument that his “medical care . . . [was] so
cursory as to amount to no treatment at all.”
See Mandel v. Doe,
888 F.2d 783, 789 (11th Cir. 1989). Sims’s medical records establish
that Dr. Figueroa monitored Sims and administered treatment
that addressed the bleeding caused by his hemorrhoids.
Dr. Figueroa’s medical decision to disregard Dr. Montoya’s
four recommendations to refer Sims to a gastroenterologist did
not constitute deliberate indifference. “It is obduracy and wanton-
ness, not inadvertence or error in good faith, that violates the
Eighth Amendment in supplying medical needs.”
Adams, 61 F.3d
at 1543. Dr. Figueroa’s disagreement with Dr. Montoya’s opinion
about whether to “employ[] additional diagnostic techniques . . .
is a classic example of a matter for medical judgment . . . [that] is
not an appropriate basis . . . [to impose] liability [on Dr. Figueroa]
under the Eighth Amendment.”
See id. at 1545 (internal quotation
marks omitted).
Dr. Figueroa’s and his nurses’ first-hand observations led
him to ignore the recommendations that Dr. Montoya made
based on second-hand information. Dr. Montoya first proposed “a
referral back to Gastroenterology” because Sims had “continued
GI bleeding.” But Dr. Figueroa decided a specialist was unneces-
sary because a gastroenterologist had already determined that
hemorrhoids caused Sims’s bleeding. And in the months
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12 Opinion of the Court 21-10647
following, Sims required only “routine” treatment until a test re-
vealed blood in Sims’s stool, and Dr. Figueroa observed that
Sims’s hemorrhoids were inflamed. Relying on that examination,
Dr. Figueroa discounted Dr. Montoya’s second recommendation
to refer Sims to a gastroenterologist to investigate “possible GI
bleeding.” Dr. Figueroa discounted Dr. Montoya’s third recom-
mendation, which was based on Sims’s “GI bleed on colonos-
copy” almost a year earlier, because Sims made “no complaint at
[the] site of [his] rectal bleeding” to Dr. Figueroa or his staff.
Later, Dr. Figueroa ignored Dr. Montoya’s fourth recommenda-
tion for a referral based on a “[p]ossible GI bleed” as inconsistent
with his finding that Sims’s “stool [was] guaiac negative on exami-
nation.” Dr. Figueroa’s reasoned medical judgment that Sims did
not require a gastroenterology consult, even if incorrect, did not
amount to deliberate indifference to Sims’s medical condition.
That Dr. Li later recommended banding Sims’s hemor-
rhoids also did not evidence that Dr. Figueroa was deliberately in-
different to Sims’s condition. Like Dr. Figueroa, Dr. Li attributed
Sims’s bleeding to his hemorrhoids. Dr. Li’s ensuing recommen-
dation to tie off the hemorrhoids to alleviate bleeding rather than
to continue treatment with over-the counter remedies repre-
sented no more than a difference in medical judgment.
See Ad-
ams, 61 F.3d at 1543. Because the obligation to provide medical
care “doesn’t necessarily demand curative care,”
Hoffer v. Sec’y,
Fla. Dep’t of Corr., 973 F.3d 1263, 1272 (11th Cir. 2020), Dr.
Figueroa’s judgment to continue conventional treatment was no
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21-10647 Opinion of the Court 13
“more blameworthy than negligence,”
Farmer, 511 U.S. at 835,
and did not amount to the type of incompetent or inadequate
care that would violate the Eighth Amendment.
Sims argues that Dr. Figueroa was deliberately indifferent
by delaying treatment, but this argument fails. “An inmate who
complains that delay in medical treatment rose to a constitutional
violation must place verifying medical evidence in the record to
establish the detrimental effect of delay in medical treatment to
succeed.”
Hill v. DeKalb Reg’l Youth Det. Ctr., 40 F.3d 1176, 1188
(11th Cir. 1994),
overruled in part by Hope v. Pelzer, 536 U.S. 730,
739 n.9 (2002). For a delay to constitute deliberate indifference, it
must “seriously exacerbate the medical problem . . . [and be] med-
ically unjustified.”
Taylor v. Adams, 221 F.3d 1254, 1260 (11th Cir.
2000) (citing
Hill, 40 F.3d 1187–89). Sims submitted no evidence
that he required more than nursing care until blood appeared in
his stool or that waiting until December 2017 to obtain medicine
made his hemorrhoids worse. The records that Sims had inflamed
hemorrhoids before arriving at Suwanee, that the hemorrhoids
later flared up and required treatment by Dr. Figueroa, and that
Sims had “on/off bleeding” preceding his visit to Dr. Li belies
Sims’s argument that the delay in seeing a gastroenterologist
worsened his medical condition. Sims failed to provide any evi-
dence other than his speculation to establish that the delays in his
treatment exacerbated the bleeding caused by his hemorrhoids.
Sims also argues that the district court construed the record
in Dr. Figueroa’s favor, but we disagree. The record supported
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14 Opinion of the Court 21-10647
the finding of the district court “that medical staff, including
Figueroa, . . . regularly saw [Sims] for” his rectal bleeding. Sims
argues that the district court “erroneously inferred that his condi-
tion subsided under Dr. Figueroa’s care,” but Sims’s medical rec-
ords reflect that he required only “routine” treatment during the
fall of 2017; that he little to no bleeding after Dr. Figueroa pre-
scribed over-the counter medication in December 2017; and that,
into the summer of 2018, he responded well to “routine” care.
Sims falsely accuses the district court of “disregard[ing]” his
allegation that Dr. Figueroa was “trying to save money, not pro-
vide adequate medical care.” The district court rejected Sims’s
“assert[ion] [that] cost-savings played a role in [his] treatment” be-
cause he “present[ed] no evidence that Figueroa was motivated
by a desire to reduce costs.” And, alternatively, the district court
rejected Sims’s argument as “unavailing.”
See Hoffer, 973 F.3d at
1273. As the district court stated, prison officials like Figueroa can
consider the cost of treatment in making medical decisions when
no material dispute exists about whether “the care provided . . .
was not at least minimally adequate medical care.”
The district court did not err by entering summary judg-
ment in Dr. Figueroa’s favor. Sims’s medical records establish that
Dr. Figueroa provided at least minimally adequate treatment for
Sims’s hemorrhoids. That Dr. Montoya and Dr. Li had different
medical judgments did not establish that Dr. Figueroa was delib-
erately indifferent to Sims’s medical condition.
IV. CONCLUSION
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21-10647 Opinion of the Court 15
We AFFIRM the summary judgment in favor of Dr.
Figueroa.
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