Case Title: Pembroke Hospital v. D.L.

Citation: 

Docket Number: SJC-12599

State: massachusetts

Court: Massachusetts Supreme Court

Date: 2019-05-23T00:00:00Z

Document:
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SJC-12599 
 
PEMBROKE HOSPITAL  vs.  D.L. 
 
 
 
Plymouth.     January 10, 2019. - May 23, 2019. 
 
Present:  Gants, C.J., Lenk, Gaziano, Lowy, Budd, Cypher, & 
Kafker, JJ. 
 
 
 
Incompetent Person, Commitment.  Practice, Civil, Commitment of 
mentally ill person.  Moot Question.  Words, "Discharge." 
 
 
 
Civil action commenced in the Plymouth Division of the 
District Court Department on January 6, 2016. 
 
 
A motion to dismiss was heard by Michael A. Vitale, J. 
 
 
The Supreme Judicial Court granted an application for 
direct appellate review. 
 
 
 
Devorah Anne Borenstein, Committee for Public Counsel 
Services, for the defendant. 
 
Michael T. Porter for the plaintiff. 
 
Lester D. Blumberg, Special Assistant Attorney General, & 
Jeffrey Mackenzie, for Department of Mental Health, amicus 
curiae, submitted a brief. 
 
Kathryn Rucker, Robert D. Fleischner, Nicole Holbrook, 
Phillip Kassel, Stanley Eichner, & Richard Glassman, for Mental 
Health Legal Advisors Committee & others, amici curiae, 
submitted a brief. 
 
 
2 
 
 
 
BUDD, J.  "The right of an individual to be free from 
physical restraint is a paradigmatic fundamental right."  Matter 
of E.C., 479 Mass. 113, 119 (2018), quoting Commonwealth v. 
Knapp, 441 Mass. 157, 164 (2004).  General Laws c. 123 governs 
involuntary civil commitment due to mental illness, and thus may 
curtail that freedom, but only in particular circumstances, and 
by way of specified procedures designed to protect due process 
rights.  See Williams v. Steward Health Care Sys., LLC, 480 
Mass. 286, 292 (2018), citing O'Connor v. Donaldson, 422 U.S. 
563, 576 (1975) (statute "written in recognition of psychiatric 
patients' fundamental right to liberty").  See also Matter of 
N.L., 476 Mass. 632, 636 (2017) (recent legislative reforms to 
G. L. c. 123 intended "to afford individuals more due process in 
civil commitment and medical treatment hearings than had been 
available previously" [citation omitted]). 
Here, D.L. was held involuntarily at Pembroke Hospital 
(Pembroke) on a temporary basis due to mental illness.  Upon the 
denial of Pembroke's petition to extend D.L.'s confinement, 
Pembroke allegedly "discharged" D.L., but simultaneously 
detained and transported him without his permission to a second 
hospital for another mental health evaluation.  This second 
evaluation ultimately led to an order for involuntary 
confinement for a period of up to six months.  In this appeal we 
are called upon to interpret the meaning of the word "discharge" 
3 
 
 
as that term is used in G. L. c. 123 to determine whether an 
individual may be said to have been "discharged" from a facility 
if his or her liberty has not been restored.  We conclude that 
the answer is no.1 
1.  Statutory framework for civil commitments.  General 
Laws c. 123, § 12, which provides for the temporary emergency 
involuntary restraint and commitment of persons with mental 
illness in certain circumstances, is the "primary route" for the 
involuntary civil commitment of an individual.  Guardianship of 
Doe, 391 Mass. 614, 621 (1984).  Section 12 (a) provides in 
pertinent part: 
"[any mental health professional qualified under G. L. 
c. 112] who, after examining a person, has reason to 
believe that failure to hospitalize such person would 
create a likelihood of serious harm by reason of mental 
illness may restrain or authorize the restraint of such 
person and apply for the hospitalization of such person for 
a [three]-day period at [an authorized facility]."2 
                     
 
1 We acknowledge the amicus briefs submitted by the 
Department of Mental Health, and by the Mental Health Legal 
Advisors Committee, the Disability Law Center, and the Center 
for Public Representation. 
 
 
2 "Likelihood of serious harm" is defined as:  "(1) a 
substantial risk of physical harm to the person himself as 
manifested by evidence of, threats of, or attempts at, suicide 
or serious bodily harm; (2) a substantial risk of physical harm 
to other persons as manifested by evidence of homicidal or other 
violent behavior or evidence that others are placed in 
reasonable fear of violent behavior and serious physical harm to 
them; or (3) a very substantial risk of physical impairment or 
injury to the person himself as manifested by evidence that such 
person's judgment is so affected that he is unable to protect 
himself in the community and that reasonable provision for his 
4 
 
 
 
Once an individual is detained under § 12 (a), he or she 
may be admitted for care and treatment if a designated physician 
of the facility "determines that failure to hospitalize such 
person would create a likelihood of serious harm by reason of 
mental illness."  G. L. c. 123, § 12 (b).  Commitment pursuant 
to § 12 (b) may last only three business days.  G. L. c. 123, 
§ 12 (a) and (d); Mass. R. Civ. P. 6 (a), 365 Mass. 747 (1974).  
By the end of that period of time, the individual must be 
discharged unless the facility files a petition for continued 
involuntary commitment pursuant to G. L. c. 123, §§ 7-8, or the 
person chooses to stay voluntarily.  G. L. c. 123, § 12 (d). 
An individual who has been admitted involuntarily to a 
hospital pursuant to § 12 (b) is entitled to legal 
representation and may request an emergency hearing in District 
Court if he or she has reason to believe that the admission is 
the result of an "abuse or misuse" of § 12.  G. L. c. 123, § 12 
(b).  See Newton-Wellesley Hosp. v. Magrini, 451 Mass. 777, 784 
(2008) (Magrini). 
A court order is required if a facility seeks to hold an 
individual involuntarily beyond the temporary emergency 
commitment allowed by § 12.  The facility must file such a 
                     
protection is not available in the community."  G. L. c. 123, 
§ 1. 
5 
 
 
petition within the initial three-day period and must allege 
that "the failure to hospitalize would create a likelihood of 
serious harm by reason of mental illness."  G. L. c. 123, § 7 
(a).  The court shall order the commitment of an individual only 
if it finds that the individual is mentally ill, that his or her 
discharge would create an imminent likelihood of serious harm, 
and there is no less restrictive alternative to continued 
involuntary hospitalization.  G. L. c. 123, § 8 (a).  
Commonwealth v. Nassar, 380 Mass. 908, 917 (1980).  Such 
findings must be made beyond a reasonable doubt.  Superintendent 
of Worcester State Hosp. v. Hagberg, 374 Mass. 271, 276 (1978).  
See Aime v. Commonwealth, 414 Mass. 667, 678 n.14 (1993).3 
Once the petition is filed, the court is to schedule a 
hearing within five days, with certain exceptions, G. L. c. 123, 
§ 7 (c), after which the court ordinarily must render its 
decision on the petition within ten days, G. L. c. 123, § 8 (c).  
While the outcome of the petition is pending, the facility may 
continue the involuntary commitment.  G. L. c. 123, § 12 (d).  
Periods of commitment under § 8 may last for periods of six to 
twelve months -- depending on the circumstances -- before 
                     
 
3 The burden of proof for civil commitment in Massachusetts 
is higher than the Federal standard, which requires at least 
"clear and convincing" evidence for civil commitment.  See Aime 
v. Commonwealth, 414 Mass. 667, 678 & n.14 (1993); Addington v. 
Texas, 441 U.S. 418, 433 (1979). 
6 
 
 
additional judicial review is required.  G. L. c. 123, § 8 (d).  
Under G. L. c. 123, § 9 (b), "[a]ny person" may also file a 
written application for a patient's discharge prior to the 
expiration of an order for commitment. 
 
2.  Background.  The material facts are undisputed.  On 
December 16, 2015, D.L. was committed involuntarily to Pembroke 
under § 12 (b) based on suicidal statements that he had made.  
Pembroke timely filed a petition for continued involuntary 
commitment pursuant to G. L. c. 123, §§ 7-8, alleging that D.L. 
had not been "eating or drinking for several days," and he would 
die in the following one to two weeks without intervention. 
 
At the hearing, a Pembroke doctor testified that D.L. had 
been unresponsive, minimally cooperative with staff, and 
selectively mute during his stay.  The doctor further testified 
that D.L. had been refusing food and medication, and that he was 
drinking no more than a minimal amount of fluids.  The doctor 
expressed concern that "if this continues [D.L.] will completely 
stop eating, drinking, and die."  Finally, the doctor testified 
that, in his opinion, there was no less restrictive setting 
appropriate and available for D.L.  On cross-examination, 
however, the doctor agreed that progress notes indicated that 
D.L. had been eating and drinking "when hungry."  After hearing 
the testimony and arguments, the District Court judge denied the 
petition, finding that Pembroke had not met its burden. 
7 
 
 
 
In the hours following the denial of the petition to 
continue D.L.'s involuntary commitment, staff at Pembroke were 
unable to locate a family member willing to house D.L.  
Thereafter, Pembroke determined that, because D.L. was psychotic 
and his family would not take him in, D.L. needed "continued 
inpatient psychiatric care for his own safety in the context of 
worsening psychosis."  Pembroke asserts that it then discharged 
D.L.4 but, without allowing him to leave the hospital, Pembroke 
arranged to have D.L. transported without his permission to 
South Shore Hospital (South Shore) for a second evaluation 
pursuant to § 12 (a).5  After being examined by a different 
doctor at South Shore, D.L. was returned to Pembroke in the 
early morning of December 31, 2015, this time pursuant to South 
Shore's § 12 (a) application.  Once back at Pembroke, D.L. was 
rehospitalized involuntarily under § 12 (b). 
Pembroke thereafter timely filed a second petition for 
D.L.'s continued commitment pursuant to G. L. c. 123, §§ 7-8.  
D.L. moved to dismiss the petition, claiming that the District 
Court lacked jurisdiction to rule on it because of the "abuse or 
                     
4 The record does not contain information regarding the 
steps Pembroke took to "discharge" D.L.; however, as discussed 
infra, because D.L. did not regain his liberty he was not 
properly discharged. 
 
 
5 In the § 12 (a) application, Pembroke alleged the same 
facts that had been alleged in the commitment petition that had 
been denied that same day. 
8 
 
 
misuse" of the § 12 procedure that occurred prior to the filing 
of the petition.  The judge denied the motion to dismiss and, 
after a hearing, ordered D.L.'s commitment to Pembroke for a 
period of up to six months.6  D.L. appealed from the denial of 
his motion to dismiss and from the District Court judge's order 
of commitment to the Appellate Division of the District Court 
Department, which affirmed the District Court judge's rulings 
and also found that there was no abuse of the involuntary 
commitment procedure under G. L. c. 123, § 12.  We granted 
D.L.'s application for direct appellate review. 
3.  Discussion.  Pembroke does not dispute that it had no 
authority to hold D.L. after its first petition to continue 
D.L.'s involuntary confinement was denied.  See Thompson v. 
Commonwealth, 386 Mass. 811, 816 (1982) ("once the conditions 
justifying confinement cease to exist, the State's power to 
confine terminates, and the person is entitled to be released").  
See also G. L. c. 123, § 6 (a).7  Pembroke argues, however, that 
                     
6 The District Court judge found that there were "several 
intervening acts" between the denial of the first petition and 
the subsequent § 12 commitments; those intervening events 
included the new information that no one in D.L.'s family was 
willing to take him home from the hospital, and that an 
independent evaluation occurred at South Shore. 
 
7 General Laws c. 123, § 6 (a), provides in relevant part:  
"No person shall be retained at a facility . . . except under 
the provisions of [§§ 10(a); 12 (a)-(c); 13; 16(e); and 35] or 
except under a court order or except during the pendency of a 
9 
 
 
it followed proper procedure by discharging D.L. and 
simultaneously arranging for his involuntary transportation to 
and psychiatric examination by South Shore pursuant to § 12. 
D.L. contends that Pembroke did not discharge him within 
the meaning of G. L. c. 123, and that the continued restraint 
was an "abuse or misuse" of § 12.  Thus, he argues, that 
everything that took place subsequently, including the second 
petition for continued confinement, was tainted, and therefore, 
his motion to dismiss the petition was improperly denied.  We 
review questions of statutory interpretation de novo.  See 
Meikle v. Nurse, 474 Mass. 207, 209 (2016), quoting Commerce 
Ins. Co. v. Commissioner of Ins., 447 Mass. 478, 481 (2006). 
a.  Mootness.  As an initial matter, Pembroke argues that 
because D.L. is no longer in the hospital's custody, this case 
is moot.8  We disagree.  Wrongfully committed patients have a 
surviving interest in establishing, after discharge, that the 
orders by which they were committed were unlawful, "thereby, to 
a limited extent, removing a stigma from [their] name and 
record."  See Matter of F.C., 479 Mass. 1029, 1029-1030 (2018), 
quoting Seney v. Morhy, 467 Mass. 58, 62 (2014).  Even without 
                     
petition for commitment or to the pendency of a request under 
[§ 14]." 
 
8 D.L. was discharged from Pembroke prior to the argument 
before the Appellate Division. 
10 
 
 
D.L.'s surviving interest in the matter, it is well established 
that cases involving the confinement of mentally ill persons 
present "'classic examples' of issues that are capable of 
repetition, yet evading review," which thus warrant appellate 
review even after the confinement ends.  See Magrini, 451 Mass. 
at 782, quoting Acting Supt. of Bournewood Hosp. v. Baker, 431 
Mass. 101, 103 (2000).  Thus, we exercise our discretion to 
address the merits of this case. 
b.  "Discharge" within the context of G. L. c. 123.  The 
question whether Pembroke discharged D.L., as staff members of 
the facility claim to have done, depends on what the Legislature 
meant by the term "discharge" within the context of G. L. 
c. 123.  The statute does not define "discharge"; however, the 
relevant dictionary definition is "to set at liberty:  release 
from confinement, custody or care."  Webster's Third New 
International Dictionary 644 (1993).  See Commonwealth v. 
Campbell, 415 Mass. 697, 700 (1993), quoting Commonwealth v. 
Zone Book, Inc., 372 Mass. 366, 369 (1977) ("We derive the 
words' usual and accepted meaning from sources presumably known 
to the statute's enactors, such as their use in other legal 
contexts and dictionary definitions").  See Commonwealth v. 
Scott, 464 Mass. 355, 358 (2013) (term with multiple meanings 
may have only one within context of statute). 
11 
 
 
"Our primary duty is to interpret a statute in accordance 
with the intent of the Legislature."  See Pyle v. School Comm. 
of S. Hadley, 423 Mass. 283, 285 (1996).  See also Boston Police 
Patrolmen's Ass'n v. Boston, 435 Mass. 718, 719-720 (2002), and 
cases cited.  With that in mind, we note that G. L. c. 123 was 
"written in recognition of psychiatric patients' fundamental 
right to liberty," which is curtailed considerably by an 
involuntary commitment.  Williams, 480 Mass. at 292, and cases 
cited.  See Magrini, 451 Mass. at 785 (involuntary commitment 
implicates "significant liberty interests").  The multiple 
procedural protections built into the statute, discussed supra, 
seek to balance an individual's involuntary restraint against 
his or her right to be free from confinement.9 
Reading the statute in light of the legislative intent to 
protect the patient's right to be "free from physical restraint" 
(citation omitted), see Matter of E.C., 479 Mass. at 119, it is 
clear that a facility "discharges" an individual under G. L. 
c. 123 only when that individual is set at liberty from 
involuntary restraint, and not when released from care as 
                     
 
9 In fact, the modern version of the statute reflects a 
fundamental shift in our law toward the destigmatization of 
mental illness and the "elevation of the dignity of [human 
beings]," which warrants constitutional protection against 
involuntary restraint.  See Flaschner, The New Massachusetts 
Mental Health Code -- A Magna Carta or a Magna Maze, 56 Mass. 
L. Q. 49, 50 (1971). 
12 
 
 
happened here.  Otherwise, the protections of the statute would 
be impermissibly weakened, if not rendered meaningless.  See 
also 2A N.J. Singer & S. Singer, Statutes and Statutory 
Construction § 45:11 (7th ed. 2010, rev. April 2014) ("The fact 
that one among alternative constructions involves serious 
constitutional difficulties is reason to reject that 
interpretation in favor of a reasonable, constitutional 
alternative, if available"), and cases cited. 
 
c.  Application.  Because we hold that "discharge" under 
c. 123 requires that an individual regain his liberty, we 
conclude that, contrary to Pembroke's assertion, D.L. was not 
discharged within the meaning of the statute after the initial 
petition pursuant to §§ 7 and 8 was denied.  Instead, Pembroke 
continued to confine D.L. following the denial of the petition 
until transferring him to South Shore in order to recommence the 
§ 12 commitment process.  Pembroke then admitted him for a 
second time as an involuntary patient under § 12, and filed a 
second petition seeking a further confinement pursuant to §§ 7 
and 8. 
As justification for its actions, Pembroke points to the 
fact that after the first petition had been denied and D.L. was 
supposed to be released, staff members were unable to secure 
housing for D.L. with family members.  See 104 Code Mass. Regs. 
§ 27.09(1)(a), (b) (2018).  Id. at § 27.09(1)(b) ("A facility 
13 
 
 
shall make every effort to avoid discharge to a shelter or the 
street").10  Because they determined that, given D.L.'s 
condition, he would be unsafe in a homeless shelter, they 
continued to confine him and arranged for a different hospital 
to make an independent determination under § 12.  Although we 
have no reason to believe that Pembroke acted in bad faith -- to 
the contrary, the staff seem to have moved quickly out of 
genuine concern for D.L.'s well-being -- we nonetheless cannot 
conclude that Pembroke was in compliance with the strict 
requirements of G. L. c. 123.  As the District Court judge 
initially had found that D.L.'s mental illness did not create a 
"likelihood of serious harm," the fact that D.L. did not have a 
place to live upon his release was not a proper ground for 
Pembroke to involuntarily restrain him.  See Commonwealth v. 
Blake, 454 Mass. 267, 277-278 (2009) (Ireland, J., concurring) 
(confinement must cease once fact finder determines standard for 
civil commitment is not met).11 
                     
 
10 This regulation, which requires "[a] facility [to] make 
every effort to avoid discharge to a shelter or the street" 
plainly should not be read to mean that a facility should go so 
far as to involuntarily commit an individual if accommodations 
cannot be secured upon discharge.  See 104 Code Mass. Regs. 
§ 27.09(1)(b).  Instead, the facility is to "take steps to 
identify and offer alternative options to a patient and shall 
document such measures, including the competent refusal of 
alternative options by a patient, in the medical record" 
(emphases added).  See id. 
 
11 Had the judge found that discharging the patient would 
create a likelihood of serious harm, he would have gone on to 
14 
 
 
In essence, Pembroke substituted its judgment for that of 
the judge in contravention of G. L. c. 123.  This constituted an 
"abuse or misuse" of the authority afforded to facilities and 
health care professionals under § 12.12  As a result, the 
subsequent examinations by South Shore and Pembroke were 
improper, as was Pembroke's second petition under §§ 7 and 8.  
The fact that South Shore independently made a § 12 
determination and admission is of no moment; nor is the fact 
that a different District Court judge came to a different 
conclusion regarding the second petition for continued 
confinement.  Each of those events occurred as a direct result 
of Pembroke having failed to restore D.L.'s liberty.13 
                     
determine whether a less restrictive alternative to involuntary 
confinement at the facility existed (such as releasing the 
patient to the care of his family).  In such a case, if the 
patient's family members were not available to care for the 
patient, that fact would constitute a changed circumstance 
warranting judicial reconsideration of the petition. 
 
12 As D.L. correctly points out, "[i]f not required to 
comply with a court ruling denying its commitment petition, a 
hospital is free to engage in serial involuntary admissions 
under § 12 by supplanting judicial determinations with medical 
opinion.  This is fully at odds with the legal process our 
Legislature adopted in 1970 that only allows civil commitments 
based on proof of mental illness and likelihood of serious harm.  
G. L. c. 123, §§ 7 (c), 8 (a)."  See Sullivan v. Brookline, 435 
Mass. 353, 360 (2001) ("statutory language should be given 
effect consistent with its plain meaning and in light of the aim 
of the Legislature unless to do so would achieve an illogical 
result"). 
13 We note that requiring that an individual's liberty be 
restored prior to being restrained and readmitted pursuant to 
§ 12 (a) imposes neither time nor distance prerequisites between 
15 
 
 
 
4. Conclusion.  Pembroke failed to discharge D.L. within 
the meaning of G. L. c. 123 after the denial of its petition to 
continue D.L.'s confinement; this was a violation of the 
statute.  See G. L. c. 123, § 6 (a).  In addition, Pembroke's 
§ 12 (a) application to South Shore for evaluation and 
subsequent readmission and involuntary confinement of D.L. was 
an "abuse or misuse" of § 12.  See G. L. c. 123, § 12 (b); 
Magrini, 451 Mass. at 784.  Finally, because D.L. was not held 
lawfully under § 12 (b), the District Court did not have 
jurisdiction to rule on the petition for civil commitment 
pursuant to G. L. c. 123, §§ 7 and 8.  For these reasons, the 
decision and order of the Appellate Division denying D.L.'s 
motion to dismiss is reversed.  The order of civil commitment 
pursuant to §§ 7 and 8 is vacated. 
 
 
 
 
 
 
 
So ordered. 
                     
admissions.  However, an involuntary readmission pursuant to 
§ 12 must be based on new information that was unavailable to 
the judge during the previous petition hearing.  Here, as the 
judge denied the first petition -- finding D.L. not to be a 
danger to himself or others -- Pembroke needed new information 
pertaining to D.L.'s dangerousness in order to readmit him 
properly pursuant to § 12.