The Seventh Circuit Court of Appeals held on August 10, 2012 that a district court's jury instructions concerning deliberate indifference in a prisoner's lawsuit were misleading and prejudicial, and therefore required a new trial.

In November 2004, Illinois River Correctional Facility prisoner Peter Cotts suffered a painful, two-inch inguinal hernia that was diagnosed by Dr. Seth Osafo, employed by Wexford Health Sources, a for-profit company that provides medical care to Illinois state prisoners. An inguinal hernia is when the intestines or bladder protrudes through a weak spot in the surrounding muscles of the abdominal wall near the groin.

Over the next five months, Cotts requested surgery for his painful hernia 16 times, claiming that the "pain was interfering with his ability to walk, sleep, and use the restroom."

Medical staff "treated his hernia by 'reducing' it, that is, by manually shoving it back into Cotts's abdomen." This extremely painful procedure provided only temporary relief, because "when he returned to a seated position, the hernia would pop right back out."

Dr. Osafo told Cotts that "no matter how much he complained of the pain," he would not receive surgery because the hernia was reducible. Cotts was released on parole in 2005 but couldn't afford to pay for surgery to fix his hernia; he violated parole and was returned to prison on May 9, 2006.

Ten days later, Cotts's hernia was the size of a grapefruit. A prison doctor examined him and said the hernia looked "very bad" and required surgery.

Over the next eight months, however, Cotts was repeatedly denied surgery because the hernia was reducible. On February 9, 2007, he was finally allowed to see a physician who surgically repaired his hernia three days later.

Cotts filed suit in federal court, alleging that Dr. Osafo and Wexford Health Sources were deliberately indifferent to his serious medical needs for failing to provide prompt and adequate treatment for his hernia.

The district court denied the defendants' motion for summary judgment and the case proceeded to trial. Cotts introduced Wexford's hernia treatment guidelines as evidence, which supported his position that he was denied treatment "because Wexford's policy on hernias did not allow surgery for 'reducible' hernias, regardless of pain level, and because Wexford would have been responsible for paying for the surgery."

The parties agreed to the Seventh Circuit's pattern deliberate indifference jury instructions. Despite this agreement, and over the objection of the parties, the district court refused to give the proposed instructions and instead gave the jury confusing and misleading deliberate indifference instructions that "suggested that 'cruel and unusual punishment' was an independent element of liability above and beyond a showing that the defendants were deliberately indifferent." Applying the instructions, the jury returned a verdict in favor of the defendants. Cotts appealed.

The Seventh Circuit found the district court's jury instructions to be "puzzling" and "unclear." The appellate court noted that "no mention of 'cruel and unusual punishment' was necessary or wanted by the parties," and "a reasonable juror might read the instruction as directing that Cotts needed to make an independent showing of cruel and unusual punishment in addition" to evidencing a serious medical need and deliberate indifference to that need.

"Indeed, the inclusion, and repeated inclusion, of 'cruel and unusual punishment' in the instructions only had the potential to confuse the jury," the Court of Appeals stated. "To inject the idea of 'punishment' into a deliberate indifference case like this one only makes the instruction more confusing for the jury."

The Seventh Circuit also agreed with Cotts "that the elements instruction wrongly required him to prove he 'suffered damage' to show liability." The appellate court found that "like the use of 'cruel and unusual punishment,' the inclusion of the term of art 'damage' in the elements instruction made the instruction more confusing, with the result that it did not clearly state the law for the jury."

The Court of Appeals further held that the confusing jury instructions were prejudicial to Cotts. "This was not a slam-dunk victory for the defendants," the Court observed. "A reasonable jury could have believed evidence suggesting that for almost three years, the defendants refused to repair Cotts's hernia surgically because they followed an inflexible policy against surgery for reducible hernias. They might also have believed that the fact that Wexford would have to pay for any surgery impacted the decision not to allow it. In short, a factfinder could have reasonably concluded that the defendants 'substantially departed from professional judgment by refusing to authorize surgical repair for [Cotts's] painful hernia.'"

As such, the appellate court held a new trial was necessary. See: Byrd v. Ill. Dep't of Pub. Health, 423 F.3d 696 (7th Cir. 2005) ("If an instruction is so misleading that an appellant is prejudiced, reversal is required").

The Seventh Circuit encouraged the district court to follow Woodward v. Correctional Medical Services, 368 F.3d 917 (7th Cir. 2004) [PLN, Dec. 2004, p.10] on remand, with respect to crafting a jury instruction concerning the elements needed to establish Wexford's liability. The appellate court noted that Woodward had found evidence of an actual practice – as opposed to a written policy – sufficient to show deliberate indifference.

Finally, the Court of Appeals informed the district court that it could consider Cotts's request for an instruction "telling the jury it could consider 'the physical, mental and emotional pain and suffering' he experienced." The judgment of the lower court was reversed and remanded. See: Cotts v. Osafo, 692 F.3d 564 (7th Cir. 2012).

Following remand, the case settled in January 2013 under confidential terms prior to a new trial.

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