Title: Massachusetts General Hospital v. C.R.
Citation: N/A
Docket Number: SJC-12844
State: Massachusetts
Issuer: Massachusetts Supreme Court
Date: April 14, 2020

NOTICE:  All slip opinions and orders are subject to formal 
revision and are superseded by the advance sheets and bound 
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error or other formal error, please notify the Reporter of 
Decisions, Supreme Judicial Court, John Adams Courthouse, 1 
Pemberton Square, Suite 2500, Boston, MA, 02108-1750; (617) 557-
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SJC-12844 
 
MASSACHUSETTS GENERAL HOSPITAL  vs.  C.R. 
 
 
 
Suffolk.     January 9, 2020. - April 14, 2020. 
 
Present:  Gants, C.J., Lenk, Gaziano, Lowy, Budd, Cypher, 
& Kafker, JJ. 
 
 
Mental Health.  Incompetent Person, Commitment.  Practice, 
Civil, Commitment of mentally ill person.  Due Process of 
Law, Commitment. 
 
 
 
 
Petition for involuntary civil commitment filed in the 
Central Division of the Boston Municipal Court Department on 
August 16, 2018. 
 
 
The case was heard by Robert J. McKenna, Jr., J. 
 
 
The Supreme Judicial Court granted applications for direct 
appellate review. 
 
 
 
Emily Kanstroom Musgrave for the petitioner. 
 
Karen Owen Talley, Committee for Public Counsel Services, 
for the respondent. 
 
The following submitted briefs for amici curiae: 
 
Steven J. Schwartz, Robert Fleischner, Kathryn L. Rucker, 
Anna Krieger, Phillip Kassel, Jennifer Honig, & Tatum A. 
Pritchard for Center for Public Representation & others. 
 
Lester D. Blumberg, Special Assistant Attorney General, 
Jeffrey MacKenzie, & John DiPietrantonio for Department of 
Mental Health. 
2 
 
 
 
Matthew E. Sroczynski for Massachusetts Health & Hospital 
Association & others. 
 
Thomas F. Schiavoni, pro se. 
 
 
 
KAFKER, J.  After exhibiting signs of a mental illness at 
Logan Airport, C.R. was brought to the emergency department (ED) 
of Massachusetts General Hospital (MGH) by police pursuant to 
G. L. c. 123, § 12 (a).  She was detained at the ED for five 
days while an appropriate placement was sought for her in a 
psychiatric facility pursuant to G. L. c. 123, § 12 (b).  C.R. 
was ultimately admitted to a psychiatric facility, which in this 
case was a separate unit at MGH.  The day after she was admitted 
to a psychiatric facility, but six days after she was initially 
brought to the ED, MGH filed a petition for commitment pursuant 
to G. L. c. 123, §§ 7 and 8. 
The issue on appeal focuses on the time allowed to perform 
the different activities required under G. L. c. 123, § 12 (a) 
and (b).  During the § 12 (a) period, the patient is 
preliminarily evaluated and an application is made to an 
appropriate psychiatric facility.  The statute contains no 
specific time period for § 12 (a).  In contrast, § 12 (b) 
provides for a more thorough evaluation of the patient that must 
be conducted within three days.  The issue is whether the three-
day window under G. L. c. 123, § 12 (b), begins running when the 
patient is initially restrained under G. L. c. 123, § 12 (a), as 
3 
 
 
the Appellate Division of the Boston Municipal Court concluded, 
such that MGH's petition was untimely, or whether that three-day 
period only begins when a patient is admitted to a facility for 
purposes of § 12 (b).  We conclude that the activity governed by 
G. L. c. 123, § 12 (a), is separate from the three-day 
involuntary hospitalization period established under G. L. 
c. 123, § 12 (b), and therefore reverse the decision of the 
Appellate Division of the Boston Municipal Court.  The three-day 
period under G. L. c. 123, § 12 (b), is necessary to fully 
evaluate the patient, and was not intended by the Legislature to 
be shortened by the § 12 (a) time period. 
We also conclude, however, that the time encapsulated by 
G. L. c. 123, § 12 (a), was intended by the Legislature to be an 
expedited emergency process, during which time the patient would 
be stabilized and preliminarily evaluated by a qualified medical 
professional, who would then apply for the hospitalization of 
the patient at a facility authorized to further evaluate and 
care for such patient.  Due to many complicating factors 
discussed infra, however, the time for application to and 
acceptance by an authorized facility has extended well beyond 
original expectations, particularly for the most vulnerable 
patients.  The record and briefing, however, also establish that 
there is a concerted effort by the executive branch to address 
this crisis, including the establishment of specific time frames 
4 
 
 
for hospitals and insurance providers to initiate escalation 
steps for placement searches within the § 12 (a) period, and 
ongoing communication between the executive branch and the 
Legislature regarding this effort.  Furthermore, the Legislature 
has not yet amended G. L. c. 123, § 12 (a), despite the 
unexpected enlargement of time spent in EDs, often referred to 
as "ED boarding," even as the Legislature has amended other 
provisions of the statute to tighten other time frames.  Absent 
constitutional violations, we will not impose such a time 
deadline, when the Legislature has chosen not to do so. 
Although her argument is primarily statutory, C.R. suggests 
that her rights to due process may be violated if § 12 (a) is 
not time defined.  Based on the record before us, we discern no 
constitutional violation with regard to C.R.'s confinement given 
the difficulty of finding her an appropriate placement.  We also 
consider the larger questions of the constitutionality of 
§ 12 (a) and ED boarding times more generally to be premature at 
this time, as this case was not brought as a class action or a 
declaratory judgment, nor did C.R. contend that § 12 (a) was 
unconstitutional on its face.  Our decision to decline to 
consider these additional constitutional questions is also 
informed and influenced by the urgent efforts being made on the 
part of the executive branch to specify and shorten permissible 
ED boarding times, and its active engagement with the 
5 
 
 
Legislature.  As we perform our responsibilities of judicial 
review, we recognize and show due respect for the diligent 
efforts made by the other branches of government responsible for 
performing the functions we are reviewing, particularly when 
they involve complicated policy choices.  Finally, we do, 
however, strongly encourage the Legislature to identify a 
§ 12 (a) time deadline to clarify the statute and avoid future 
constitutional difficulties and to do so as expeditiously as 
possible.1 
 
1.  Background.  C.R. was admitted to MGH's ED on Friday, 
August 10, 2018, after experiencing symptoms of a mental illness 
at Logan Airport.  C.R. was agitated and screaming at the 
airport, which led to police restraining her and bringing her to 
the ED pursuant to G. L. c. 123, § 12 (a).2  After arriving at 
the hospital, C.R. was agitated and was yelling, screaming, and 
threatening staff.  C.R. was administered antipsychotic 
                                                 
 
1 We acknowledge the amicus briefs submitted by the 
Department of Mental Health; Center for Public Representation, 
Disability Law Center, and Mental Health Legal Advisors 
Committee; Massachusetts Health & Hospital Association, 
Massachusetts Association of Behavioral Health Systems, 
Massachusetts Psychiatric Society, and Massachusetts College of 
Emergency Physicians; and Thomas F. Schiavoni. 
 
 
2 The facts giving rise to the police officer's initiation 
of the G. L. c. 123, § 12 (a), application process are not a 
part of the record before us; nor is the G. L. c. 123, § 12 (a), 
application that was filled out that same day by a doctor at 
MGH, as MGH was unable to locate these documents. 
6 
 
 
medication, secluded, and put in four-point restraints.  Medical 
professionals at MGH decided to apply for C.R.'s hospitalization 
at an authorized psychiatric facility pursuant to G. L. c. 123, 
§ 12 (b).  Doctors concluded that C.R. required a private 
facility room due to the level of her agitation when she 
presented at the ED and throughout her stay there.  For that 
reason, C.R. remained in the ED at MGH until a bed in a private 
facility room became available on Wednesday, August 15, 2018. 
 
On that day, C.R. was admitted to MGH's inpatient 
psychiatric department (Blake 11), which is a psychiatric unit 
licensed by the Department of Mental Health (DMH).3  A new G. L. 
c. 123, § 12 (a), application was completed on August 15 by the 
same doctor who authorized C.R.'s admission to the facility that 
day.  When she arrived at the facility, C.R. remained agitated; 
she shouted and gestured in a threatening manner.  On August 16, 
MGH filed a petition for commitment pursuant to G. L. c. 123, 
§§ 7 and 8.  In the petition, MGH stated that, "because of her 
florid mania and delusional thinking, [C.R.] appears unable to 
take care of her basic needs in the community." 
 
Also on August 16, C.R. filed a pro se petition for an 
emergency hearing pursuant to G. L. c. 123, § 12 (b), which a 
                                                 
3 Unlike Blake 11, MGH's ED is not a DMH-licensed facility.  
To obtain a license from DMH, a facility must meet certain 
requirements and submit an extensive application, as discussed 
infra.  See 104 Code Mass. Regs. § 27.03(10)(c) (2019). 
7 
 
 
judge in the Boston Municipal Court denied without a hearing.  
Counsel was appointed for C.R. and filed a second request for an 
emergency hearing on August 17.  An emergency hearing was held 
on August 20.  The court denied C.R.'s request for immediate 
release. 
 
On August 23, C.R., through counsel, filed a motion to 
dismiss MGH's petition for lack of jurisdiction, arguing that 
MGH filed its petition for commitment outside the three-day 
window provided under G. L. c. 123, § 12.  The court denied the 
motion on the same day at a hearing on MGH's petition for C.R.'s 
commitment pursuant to G. L. c. 123, §§ 7 and 8.  At that 
hearing, the court heard testimony from Dr. Stuart Beck, a staff 
psychiatrist at Blake 11.  Beck articulated C.R.'s symptoms for 
the court and testified that C.R. suffers from bipolar affective 
disorder type 1.  He also explained how patients brought to the 
hospital's ED under G. L. c. 123, § 12 (a), often wait for an 
available bed before being involuntarily admitted to a facility 
pursuant to § 12 (b), and why there are often multiple § 12 (a) 
forms for the same patient before he or she is admitted: 
"[W]hen people come into the emergency room or they're on 
the medical floor and there's a thought about them going to 
an inpatient [psychiatric] unit, they institute a [§ 12 (a) 
application].  They [(the patients)] can sit there for days 
to weeks . . . .  [S]ometimes there's new information that 
comes up or the clinical situation changes and the previous 
[§ 12 (a) application] doesn't seem relevant or appropriate 
and they [(MGH medical professionals)] sometimes write new 
ones." 
8 
 
 
 
When individuals in need of inpatient psychiatric 
hospitalization wait in hospital EDs for extended periods of 
time, as described supra, it is known as ED boarding.  Executive 
Office of Health and Human Services & Executive Office of 
Housing and Economic Development, Expedited Psychiatric 
Inpatient Admission Protocol 2.0 (Nov. 14, 2019) (EPIA 2.0).  
See Matter of the Detention of D.W. v. Department of Social & 
Health Servs., 181 Wash. 2d 201, 204 (2014) ("Such overcrowding-
driven detentions are often described as 'psychiatric 
boarding'"). 
 
After denying C.R.'s motion to dismiss the petition, the 
judge allowed MGH's petition for commitment and ordered that 
C.R. be civilly committed for a period not to exceed two weeks.  
C.R. timely filed her notice of appeal on August 29, appealing 
from both the denial of her motion to dismiss and the court 
order involuntarily committing her pursuant to G. L. c. 123, 
§§ 7 and 8. 
 
On September 5, 2019, the Appellate Division of the Boston 
Municipal Court reversed the lower court's denial of C.R.'s 
motion to dismiss the petition for lack of jurisdiction.  The 
Appellate Division acknowledged that G. L. c. 123, § 12 (a), "is 
silent on whether the three day detention period begins when a 
patient arrives at an emergency department, or if the period 
9 
 
 
does not begin until a patient is admitted to a psychiatric 
facility."  The court nevertheless concluded that the three-day 
detention period under § 12 (b) "begins when a patient arrives 
at an emergency department or a psychiatric facility."  Because 
the facility superintendent in this case filed the G. L. c. 123, 
§§ 7 and 8, petition one day beyond the three-day period under 
this calculus, MGH failed to timely file the petition and was 
required to discharge C.R. at that point under G. L. c. 123, 
§ 12 (b).4,5  MGH filed a timely notice of appeal, and we granted 
both parties' applications for direct appellate review. 
 
2.  G. L. c. 123, § 12.  General Laws c. 123, § 12, governs 
the emergency restraint, evaluation, care, and hospitalization 
of persons posing a risk of serious harm due to mental illness.  
It contains multiple sections with different purposes, 
procedures, and evaluators, and, most importantly for our 
purposes, different time deadlines.  Those deadlines are tightly 
tailored to the tasks at hand.  Although time is of the essence 
                                                 
 
4 For the reasons stated in Pembroke Hosp. v. D.L., 482 
Mass. 346, 351 (2019), we address the issue of the timeliness of 
the filing even though C.R. had been discharged from the 
hospital before the order of the Appellate Division had been 
issued.  We do so given the stigma associated with involuntary 
commitment and because the issue of the timeliness of the filing 
is of the classic type capable of repetition yet evading review.  
See id. 
 
 
5 The Appellate Division did not address the merits, as 
opposed to the timeliness, of the commitment petition, and that 
issue is not before us on appeal. 
10 
 
 
in all sections, different time periods are necessary to 
accomplish the different purposes of each section.  At issue in 
the instant case is the time allowed to perform the tasks set 
out in § 12 (a).  Unfortunately, this is one section without a 
specific deadline. 
 
Section 12 (a) provides: 
"[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 a public facility or at a private 
facility authorized for such purposes by [DMH].  If an 
examination is not possible because of the emergency nature 
of the case and because of the refusal of the person to 
consent to such examination, the physician, qualified 
psychologist, qualified psychiatric nurse mental health 
clinical specialist or licensed independent clinical social 
worker on the basis of the facts and circumstances may 
determine that hospitalization is necessary and may apply 
therefore." 
 
The statute also provides that, in an emergency situation where 
a qualified medical professional or a clinical social worker is 
unavailable, "a police officer, who believes that failure to 
hospitalize a person would create a likelihood of serious harm 
by reason of mental illness may restrain such person and apply 
for the hospitalization of such person for a [three]-day period 
at a public facility or a private facility authorized for such 
purpose by the department."  Id.  The statute further provides: 
"Whenever practicable, prior to transporting such person, 
the applicant shall telephone or otherwise communicate with 
11 
 
 
a facility to describe the circumstances and known clinical 
history and to determine whether the facility is the proper 
facility to receive such person and also to give notice of 
any restraint to be used and to determine whether such 
restraint is necessary." 
 
Id. 
 
A "facility" is defined by G. L. c. 123, § 1, as "a public 
or private facility for the care and treatment of mentally ill 
persons, except for the Bridgewater State Hospital."  DMH 
further defines "facility" as a "[DMH]-operated hospital, 
community mental health center with inpatient unit, or 
psychiatric unit within a public health hospital; a [DMH]-
licensed psychiatric hospital; a [DMH]-licensed psychiatric unit 
within a general hospital; or an intensive residential treatment 
program for adolescents that is either designated as a facility 
under the control of [DMH] or licensed by [DMH]."  104 Code 
Mass. Regs. § 27.02 (2019). 
Facilities are heavily regulated for the particular mental 
health services they provide.  To obtain a license from DMH, a 
facility must submit an extensive application including written 
plans for delivery and supervision of clinical services by 
qualified personnel, its plan for assuring adequate and 
appropriate staffing, and plans for physical adaptations, such 
as provision of single-occupancy bedrooms when necessary for 
patients with high behavioral acuity, such as the patient in the 
instant case.  See 104 Code Mass. Regs. § 27.03(10)(c) (2019).  
12 
 
 
Facilities are required to have sufficient trained staff and to 
maintain staffing to meet the operational capacity of the 
facility at levels deemed appropriate by DMH.  104 Code Mass. 
Regs. § 27.03(11) (2019). 
DMH has also identified specific qualifications for 
facility directors, physicians, and nurse leaders to be hired at 
licensed facilities.  Id.  DMH conducts a survey at least every 
two years of each licensed facility to ensure each facility 
complies with Massachusetts law and DMH regulations.  104 Code 
Mass. Regs. § 27.03(20) (2019).  Although DMH and these licensed 
facilities make it their objective to meet the mental health 
needs of the Commonwealth, as further explained infra, a 
patient's application and admission into a facility has become 
an increasingly complicated task. 
Once the patient has been transported to a facility for 
admission, the procedures and time deadlines set out elsewhere 
in G. L. c. 123, § 12, apply.  General Laws c. 123, § 12 (b), 
states: 
"Only if the application for hospitalization under the 
provisions of this section is made by a physician 
specifically designated to have the authority to admit to a 
facility in accordance with the regulations of [DMH], shall 
such person be admitted to the facility immediately after 
his reception.  If the application is made by someone other 
than a designated physician, such person shall be given a 
psychiatric examination by a designated physician 
immediately after his reception at such facility.  If the 
physician determines that failure to hospitalize such 
person would create a likelihood of serious harm by reason 
13 
 
 
of mental illness he may admit such person to the facility 
for care and treatment." 
 
A person admitted under § 12 (b) "is entitled to legal 
representation and may request an emergency hearing in the 
District Court if he or she has reason to believe that the 
admission is the result of an 'abuse or misuse' of § 12."  
Pembroke Hosp. v. D.L., 482 Mass. 346, 348 (2019), quoting G. L. 
c. 123, § 12 (b).  The court must hold that hearing on the day 
the request is filed with the court, or not later than the next 
business day.  G. L. c. 123, § 12 (b). 
The statute further provides that "[a] person shall be 
discharged at the end of the three day period unless the 
superintendent applies for a commitment under the provisions of 
[§§ 7 and 8] of this chapter or the person remains on a 
voluntary basis."6  G. L. c. 123, § 12 (d).  See 104 Code Mass. 
Regs. § 27.09(7) (2019).  The time periods prescribed or allowed 
                                                 
 
6 General Laws c. 123, § 7 (a), permits the superintendent 
of a facility to petition the court for the commitment of a 
patient at the facility if the superintendent "determines that 
the failure to hospitalize would create a likelihood of serious 
harm by reason of mental illness."  The statute requires a 
hearing on these petitions; when a superintendent brings a 
commitment petition for a patient initially hospitalized 
pursuant to G. L. c. 123, § 12 (b), to extend the involuntary 
commitment period, the G. L. c. 123, § 7, hearing must be 
commenced within five days from when the superintendent filed 
the petition.  G. L. c. 123, § 7 (c).  General Laws c. 123, § 8, 
governs court orders for commitment petitions filed under G. L. 
c. 123, § 7. 
14 
 
 
under G. L. c. 123, § 12, are computed pursuant to Mass. R. Civ. 
P. 6, 365 Mass. 747 (1974).7  G. L. c. 123, § 12 (e). 
The three-day time period established in § 12 (b) was 
intended for qualified medical professionals to evaluate a 
patient and make a determination as to what treatment that 
patient may or may not require, and how long that prospective 
treatment may last.  The three-day window carved out by the 
Legislature in § 12 (b) provides a facility with the appropriate 
time frame to assess and monitor a patient, and to determine 
whether commitment pursuant to a court order is appropriate for 
that patient.  Shortening this time period risks jeopardizing 
                                                 
 
7 Rule 6 (a) of the Massachusetts Rules of Civil Procedure, 
365 Mass. 747 (1974), provides: 
 
"In computing any period of time prescribed or allowed by 
these rules, by order of court, or by any applicable 
statute or rule, the day of the act, event, or default 
after which the designated period of time begins to run 
shall not be included.  The last day of the period so 
computed shall be included, unless it is a Saturday, a 
Sunday, or a legal holiday, in which event the period runs 
until the end of the next day which is not a Saturday, a 
Sunday, or a legal holiday.  When the period of time 
prescribed or allowed is less than [seven] days, 
intermediate Saturdays, Sundays, and legal holidays shall 
be excluded in the computation." 
 
Thus, in computing the three-day period for purposes of G. L. 
c. 123, § 12, we have recognized that the day on which the 
person is admitted to a facility does not count toward the 
three-day time limit of that person's hospitalization under 
G. L. c. 123, § 12 (b).  See Newton-Wellesley Hosp. v. Magrini, 
451 Mass. 777, 780 n.6 (2008); 104 Code Mass. Regs. § 25.04 
(2016). 
15 
 
 
the careful evaluation of patients requiring treatment, and 
limits the ability of qualified medical professionals to 
accurately determine whether the "failure to hospitalize [the 
patient] would create a likelihood of serious harm by reason of 
mental illness."  G. L. c. 123, § 12 (b).  As explained by the 
ad hoc committee tasked with reviewing G. L. c. 123, § 12, prior 
to a 2000 legislative amendment, the Legislature "spent a great 
deal of time in seeking to determine what would constitute the 
most efficient and effective time lines to accomplish the 
purposes of the statute while minimizing the length of any 
involuntary hospitalization periods for the patients involved."  
District Court Committee on Mental Health and Retardation, 
Report of the Ad Hoc Committee to Review G. L. c. 123, § 12, at 
2 (Oct. 21, 1997).  It also concluded that "a three business day 
period is necessary to make a valid clinical determination of a 
patient's need for continued psychiatric hospitalization" under 
G. L. c. 123, § 12 (b).  Id. at 4. 
Shortening this time period in any way would not only 
violate the express terms of the statute, but would contradict 
the statutory purpose.  The determination here is difficult and 
designed to protect the interests of both the patient and the 
public.  It must be done thoroughly and deliberately.  See, 
e.g., Williams v. Steward Health Care Sys., 480 Mass. 286, 293 
(2018). 
16 
 
 
After a patient has been evaluated during the three-day 
time period established under § 12 (b), other provisions of the 
statute come into play that also contain particular time 
deadlines.  If the superintendent of a facility moves for 
commitment of the patient before the end of the three-day time 
period, a court generally has five days to commence a hearing.  
G. L. c. 123, § 7 (c).  The court then generally has ten days 
from the completion of the hearing to render its decision.  
G. L. c. 123, § 8 (c).  Under this framework, a patient may thus 
be hospitalized in a licensed facility for as long as eighteen 
days before a decision on his or her commitment is made.  G. L. 
c. 123, §§ 7 (c), 8 (c), 12 (b). 
 
A comprehensive reading of G. L. c. 123, § 12 (a) and (b), 
thus demonstrates that these subsections describe different 
tasks by different evaluators applying different standards.  For 
example, a qualified medical professional or clinical social 
worker, or in emergency situations a police officer, may 
restrain an individual and apply for his or her hospitalization 
if the medical professional or clinical social worker "has 
reason to believe that failure to hospitalize such person would 
create a likelihood of serious harm by reason of mental illness" 
(emphasis added).  G. L. c. 123, § 12 (a).  To admit a patient, 
however, a physician qualified and designated to admit patients 
to a psychiatric facility must determine "that failure to 
17 
 
 
hospitalize such person would create a likelihood of serious 
harm by reason of mental illness" (emphasis added).  G. L. 
c. 123, § 12 (b).  See Newton-Wellesley Hosp. v. Magrini, 451 
Mass. 777, 779 & n.4 (2008) (determination of whether "failure 
to hospitalize such person would create a likelihood of serious 
harm by reason of mental illness" is "quite different from the 
'reason to believe' standard . . . required for restraint and 
application for hospitalization" [citation omitted]); Reida v. 
Cape Cod Hosp., 36 Mass. App. Ct. 553, 556 (1994) ("The 
admitting physician has the role of determining whether, in 
fact, a failure to hospitalize would create a likelihood of 
serious harm, in contrast to the applying physician, whose 
function is only to determine whether there is reason to believe 
that such may be the case").8 
 
In sum, G. L. c. 123, § 12 (a) and (b), reflects distinct 
phases that should not be collapsed into one.  We also respect 
the legislative determination that three days may be required to 
correctly perform the § 12 (b) evaluation process.  That leaves 
unresolved the question of how long the Legislature allowed the 
                                                 
 
8 Relatedly, a court may only commit an individual pursuant 
to G. L. c. 123, §§ 7 and 8, if it finds beyond a reasonable 
doubt that a person has a mental illness, that his or her 
discharge would create an imminent likelihood of serious harm, 
and that there is no less restrictive alternative to the 
continued involuntary hospitalization.  Pembroke Hosp., 482 
Mass. at 348-349. 
18 
 
 
§ 12 (a) process to last, and whether such process as currently 
employed violates constitutional due process standards. 
 
Where a statute "is simply silent on a particular issue," -
- as is the case here with the undefined time period of 
restraint under § 12 (a) -- "we interpret the provision in the 
context of the over-all objective the Legislature sought to 
accomplish" (quotations and citation omitted).  Wing v. 
Commissioner of Probation, 473 Mass. 368, 373 (2015). 
 
With regard to the period of restraint of patients under 
G. L. c. 123, § 12 (a), our review of the statutory language and 
legislative history reveals that the Legislature envisioned an 
expedited, emergency process that took no longer than was 
necessary to transport the patient to an ED, conduct a 
preliminary evaluation necessary to determine whether further 
evaluation and hospitalization in a licensed facility was 
necessary, and apply to such a facility for admission.9  What the 
Legislature apparently failed to foresee was the increasing 
                                                 
9 The statute also contemplates that a patient may be 
brought directly to a licensed facility.  G. L. c. 123, § 12 (a) 
("Whenever practicable, prior to transporting such person, the 
applicant shall telephone or otherwise communicate with a 
facility to describe the circumstances and known clinical 
history and to determine whether the facility is the proper 
facility to receive such person and also to give notice of any 
restraint to be used and to determine whether such restraint is 
necessary"). 
19 
 
 
complexity and difficulty of the application and admission 
process. 
 
3.  ED boarding and the reality of the admissions process.  
The most significant problem the Legislature failed to foresee 
when it contemplated a short period of restraint under G. L. 
c. 123, § 12, was the difficulty of placing patients with high 
behavioral acuity or significant comorbidities.  See 
Commissioners of Insurance, Mental Health, and Public Health, 
Bulletin 2018-01, Prevention of Emergency Department Boarding of 
Patients with Acute Behavioral Health and/or Substance Use 
Disorder Emergencies (Jan. 3, 2018) (Bulletin 2018-01).  
Although facilities are required to have a plan in place to 
provide single occupancy bedrooms when necessary to address 
behavioral acuity in their patient population, see 104 Code 
Mass. Regs. § 27.03(10)(c), it remains especially difficult to 
find placement for certain patients, i.e., minor patients, or 
patients with comorbidities requiring extensive care outside of 
psychiatric care, exhibiting dangerous behavior, or otherwise 
exhibiting behavior requiring a private room, like the plaintiff 
here.  See Bulletin 2018-01, supra.  In addition to a shortage 
of beds or single-occupancy rooms, there also might be a 
shortage of psychiatrists or other physicians who staff 
inpatient facilities with resources for these types of patients.  
Where there might be an open bed, there may not always be the 
20 
 
 
appropriate staff to treat the patient.  Insurance company 
approvals further complicate this process.  See, e.g., Bulletin 
2018-01, supra at 2-3.  See also G. L. c. 176O, § 16 (b). 
 
These problems have unexpectedly extended the period of 
time necessary to apply to a facility for admission.  Thus, 
there is some disconnect between the intent of the Legislature 
to provide for a short period of restraint, preliminary 
evaluation, and application to an appropriate facility pursuant 
to § 12 (a), and the reality medical professionals face when 
trying to find a placement for psychiatric patients, 
particularly the most vulnerable ones. 
 
Although there is disagreement about the time permitted for 
ED boarding, the record presented to this court reveals no 
realistic alternative to ED boarding itself.  A physician, 
qualified mental health professional, or, in an emergency, a 
police officer has made a preliminary determination that there 
is reason to believe that failure to hospitalize such person 
would create a likelihood of serious harm by reason of mental 
illness.  G. L. c. 123, § 12 (a).  Thus, releasing the patient 
poses a risk of serious harm to the patient or the public.  
Compare Pembroke Hosp., 482 Mass. at 353 (after judge found 
patient's mental illness did not create likelihood of serious 
harm, inappropriate to confine him).  Taking the patient into 
police custody is clearly a worse alternative.  EDs are thus the 
21 
 
 
only identified alternative, and one clearly contemplated by the 
Legislature, albeit for a short period of time.10 
 
The EDs themselves have no choice in the matter, and no 
incentive to prolong the patient's stay there.  EDs are legally 
obligated to accept patients with emergency medical conditions 
-- including emergency psychiatric conditions -- and are not 
able to turn patients away in anticipation that ED staff will 
not find a facility bed right away.  See 42 C.F.R. 
§ 489.24(d)(1) (2013) (mandating that hospitals must provide 
treatment or ensure appropriate transfer of patient who arrives 
with emergency medical condition).  As explained in the record 
and briefing, ED boarding causes overcrowding and strains 
hospital resources. 
                                                 
 
10 We note that the Legislature appeared to be aware when 
enacting G. L. c. 123, § 12, that patients are often first 
brought to EDs before they are admitted to facilities.  See, 
e.g., Minority Report of the Ad Hoc Committee to Review G. L. 
c. 123, § 12, at 1 n.1 (Oct. 21, 1997) (identifying "the role of 
the police in restraining and transporting persons to 
hospitals"); Testimony of Robert D. Fleischner to Subcommittee 
on Involuntary Commitment and Mental Health Services, at 3 (Oct. 
21, 1997) ("after being seen by an emergency service team[], 
individuals may be admitted to a private hospital").  See also 
National Center for State Courts, Guidelines for Involuntary 
Civil Commitment, 10 Mental & Physical Disability L. Rep. 409, 
445 (1986) (guideline allowing police officers to leave after 
screening application of patient is complete "protect[s] against 
misuse of the no-decline policy and 'dumping' of troublesome 
individuals at the emergency room door").  However, our review 
of the legislative history suggests that the practice of ED 
boarding was not expressly contemplated by the Legislature at 
the time. 
22 
 
 
Nothing in the record suggests that hospitals have any 
incentive to perpetuate ED boarding unnecessarily; rather, they 
have every incentive to place a psychiatric patient requiring 
treatment in a facility as soon as possible, and are trying to 
do so.  They are also understandably concerned about simply 
releasing such patients, as they fear being sued if harm befalls 
such patients or the public.  Cf. Williams, 480 Mass. at 293-297 
(discussing potential theories of liability of hospitals and 
their personnel subsequent to release of psychiatric patients 
who present likelihood of serious harm).  At the very least, EDs 
ensure that patients in psychiatric crisis are being cared for 
and can do no physical harm to themselves or to others during 
the application process.  Matter of E.C., 479 Mass. 113, 119 
(2018) ("The provisions of G. L. c. 123 balance the rights of 
and protections for incompetent persons with the Commonwealth's 
interest in protecting the public from potentially dangerous 
persons who may be unable to control their actions because of 
their mental condition" [quotation and citation omitted]). 
 
The record also demonstrates that the executive branch of 
the Commonwealth is actively engaged in addressing the length of 
time of ED boarding, imposing numerous deadlines during the ED 
boarding process.  See Testimony of Commissioner of Mental 
Health, Joint Hearing of the House and Senate Committees on Ways 
and Means (Mar. 11, 2019) (Commissioner Testimony).  As a part 
23 
 
 
of its initiative, the Commissioner of Insurance, the 
Commissioner of Mental Health, and the Commissioner of Public 
Health issued Bulletin 2018-01, supra.  Among other things, 
Bulletin 2018-01 -- subsequently updated by Bulletin 2019-08 
(Nov. 13, 2019) -- described its expedited psychiatric inpatient 
admission protocol (EPIA), aimed at reducing ED boarding times. 
 
The EPIA provides that twenty-four hours "is the maximum 
threshold for initiating escalation steps to obtain placement 
for a patient who is boarding in an ED."  EPIA 2.0, supra at 1.  
If placement has not been identified within twenty-four hours 
from when a patient arrives to the ED, the ED must make a formal 
request for assistance to the insurance carrier, which must help 
ED staff members gauge availability in facilities when a patient 
requires accommodation for his or her admission under G. L. 
c. 123, § 12 (b).  Id. at 3.  The insurance carrier must respond 
within two hours of the submission of a request for assistance 
during normal business hours; when a request for assistance is 
made outside of normal business hours, the carrier must 
acknowledge receipt of the request no later than the morning of 
the next calendar day after the request is made.  Id.  If a 
patient has been in the ED for ninety-six hours, the ED and the 
insurance carrier must notify DMH that the patient has not yet 
been placed.  Id. at 5.  The protocols give detailed "play-by-
play" information and a timeline of what steps must be taken by 
24 
 
 
the insurance carrier to assist in identifying a placement for 
the patient, and are evidence of the extensive efforts DMH and 
other entities have made to solve problems and shorten ED 
boarding times with the resources they have available.11 
 
The record before us also shows that the Legislature has 
been made aware of ED boarding times and the actions DMH has 
taken to address them since at least March 2019, when the 
Commissioner of Mental Health (commissioner) testified at a 
joint hearing of the House and Senate Committees on Ways and 
Means.  During that testimony, the commissioner discussed the 
initiative to improve ED boarding times.  Commissioner 
Testimony, supra at 8.  According to the commissioner, the EPIA 
"establishes clear steps and responsibility when placement [of a 
patient] has not been achieved in a reasonable period of time 
                                                 
 
11 Relatedly, DMH has promulgated regulations making it 
unlawful for a facility to create "exclusion criteria that would 
result in the refusal to admit a patient."  104 Code Mass. Regs. 
§ 27.03(5)(c) (2019).  A facility may only deny admission if it 
would result in the facility operating beyond its operational 
capacity or its licensed capacity.  104 Code Mass. Regs. 
§ 27.05(3) (2019).  See Bulletin 2019-08, supra at 1 ("inpatient 
psychiatric facilities are expected to admit all [G. L. c. 123, 
§ 12 (b),] patients, so long as they have the capacity [an 
available bed] and the capability [ability to meet the clinical 
needs of the patient]").  Facilities operating below their 
licensed capacities must specify the reasons why and provide a 
plan to meet staffing requirements to operate at full licensed 
capacity.  104 Code Mass. Regs. § 27.03(11) (2019).  When 
denying admission, a facility must show that, "despite its best 
efforts, it is unable to accommodate the additional capacity."  
104 Code Mass. Regs. § 27.05(3)(b). 
25 
 
 
and a protocol for escalating cases to senior clinical 
leadership at insurance carriers, inpatient psychiatric units, 
and ultimately to DMH in order to achieve placements for the 
most difficult to place patients."  Id.  The commissioner 
acknowledged that EDs were acting to reduce boarding times, but 
that, during the first twelve months of the EPIA's 
implementation, DMH received 481 requests for assistance for 
patients who had waited at least ninety-six hours.12  Id. 
It is thus apparent to us that the Legislature understands 
that the period of restraint and application under § 12 (a) 
makes at least temporary ED boarding a necessity for at least 
the most difficult-to-place patients.  However, the Legislature 
has not yet amended G. L. c. 123, § 12 (a), to reflect that the 
application process is taking more time than what was originally 
envisioned because of a number of complex developments regarding 
mental health care.  The March 2019 testimony of the 
                                                 
 
12 As the EPIA and DMH bulletins make clear, those for whom 
it is most difficult to find a bed in a facility are often those 
the most in need of one.  See EPIA 2.0, supra at 1.  This is 
why, if we were to apply the three-day time limit in G. L. 
c. 123, § 12 (b), to patients in ED boarding -- as the Appellate 
Division has done -- the individuals most vulnerable in the 
Commonwealth would be the ones released after just three days.  
Such vulnerable individuals include children; the poor, 
including the homeless; and those with special needs, high 
behavioral acuity, or intellectual disabilities.  These patients 
will decidedly not benefit from being released from an ED after 
just three days before receiving the treatment and evaluation 
they need. 
26 
 
 
commissioner provided to us in the record illustrates that the 
Legislature has become aware of this problem, as well as the 
ensuing concerted effort by the executive branch, through DMH, 
to address this problem by enlisting all relevant actors, 
including medical professionals, EDs, hospitals, and insurance 
carriers.  The Legislature has also been informed that DMH has 
established specific time frames that initiate escalation steps 
to be taken by hospitals and insurance carriers.  For example, 
DMH has identified the time period of ninety-six hours after a 
patient has entered an ED as the time when the ED and insurance 
carrier must request assistance from DMH in placing a patient.13  
See EPIA 2.0, supra at 5. 
Despite this effort, the Legislature has not yet taken any 
action to impose a specific time period on § 12 (a) as it 
further evaluates the complex problem of ED boarding.  It has 
not done so, even though it has amended G. L. c. 123, § 12, 
multiple times over the decades to, among other things, revise 
deadlines in the commitment process without ever specifying the 
length of time a person may be restrained under § 12 (a).  See, 
                                                 
 
13 This also makes clear that, contrary to the decision of 
the Appellate Division in this case, neither the Legislature nor 
DMH understands the period of restraint under § 12 (a) to be the 
same as, or collapsed into, the three-day period of evaluation 
and hospitalization under § 12 (b), as ninety-six hours exceeds 
the three-day time period established in § 12 (b), yet was 
tacitly accepted by the Legislature when DMH issued its 
protocols. 
27 
 
 
e.g., St. 2000, c. 249, §§ 4-6 (reducing initial period of 
evaluation and hospitalization without court order from ten to 
four days); St. 2004, c. 410, § 2 (further reducing same period 
to three days); St. 2010, c. 278, § 1 (adding social workers to 
list of individuals who may restrain patient if they have reason 
to believe patient presents risk of harm). 
We are also aware that the issue of ED boarding is being 
actively considered in the current legislative session.  The 
Senate passed a mental health bill on February 13, 2020, that 
includes an amendment to that bill that would put a forty-eight 
hour cap on the amount of time patients younger than twenty-two 
years old may spend in an ED before admission to a facility.  A 
bill is, of course, not law, but is nevertheless reflective of 
the Legislature's active consideration of the problem.  As 
explained infra, such consideration informs our approach to the 
constitutional questions ED boarding raises. 
In these circumstances, absent constitutional violations, 
we will not impose a specific time deadline into a statute where 
no such deadline has been included.  In so concluding, we 
recognize that the time period for the application and 
acceptance process has been greatly enlarged beyond original 
expectations through complex developments.  However, we also 
recognize that the executive branch is actively engaged in 
addressing the problem, imposing numerous time deadlines that 
28 
 
 
trigger escalation steps in the process of placing patients, and 
the Legislature is aware of the problem and has not yet sought 
to impose its own more specific time requirements, even in an 
area that it has closely monitored and for which it has 
tightened time deadlines in the past. 
4.  Constitutional questions.  "The right of an individual 
to be free from physical restraint is a paradigmatic fundamental 
right," Pembroke Hosp., 482 Mass. at 347, quoting Matter of 
E.C., 479 Mass. at 119, and those who are involuntarily 
committed, even on a temporary basis, experience "a massive 
curtailment of their liberty" (quotation and citation omitted), 
Newton-Wellesley Hosp., 451 Mass. at 784.  We have previously 
recognized that the Legislature, in enacting and subsequently 
amending G. L. c. 123, § 12, "intended to protect the 
individual's due process rights by minimizing the length of time 
for which he or she could be involuntarily committed prior to 
judicial review."  Matter of N.L., 476 Mass. 632, 636-637 (2017) 
("It is illogical that the Legislature would shorten the period 
for conducting [civil commitment and medical treatment] hearings 
and have it inure to the detriment of the individual's due 
process right to prepare a meaningful defense").  In this vein, 
we have previously recognized that G. L. c. 123 provides for 
tight time limits, "and any violation of those limits would risk 
running afoul of due process protections."  Matter of E.C., 479 
29 
 
 
Mass. at 122 n.8.  See Hashimi v. Kalil, 388 Mass. 607, 610 
(1983) ("That the statute imposes a restraint on liberty also 
compels the conclusion that the time limit on the holding of the 
hearing goes to the essence of the public duty"). 
We do not, however, decide constitutional questions 
unnecessarily or prematurely.  See Beeler v. Downey, 387 Mass. 
609, 613 n.4 (1982) (this court must "fulfill[] its duty to 
avoid unnecessary decisions of serious constitutional issues," 
and "[t]he question whether this court should use its power to 
declare a statute unconstitutional is of wide public importance 
and extends far beyond the bounds of the instant case").  The 
instant case is also not a class action or a declaratory 
judgement action.  C.R.'s primary argument is statutory.  
Although in making that statutory argument, she contends that 
there must be an outer constitutional time limit to § 12 (a), 
she does not argue that § 12 (a) is unconstitutional on its 
face, nor does she fully develop the argument that § 12 (a) is 
unconstitutional as applied to her.  In this context, we decide 
only the constitutional questions necessary to resolve this case 
and to provide required guidance to the governmental and 
nongovernmental actors involved in resolving the ED boarding 
crisis. 
First, we recognize the grave impairment of liberty for 
C.R.  C.R. was deemed to be so agitated as to require four-point 
30 
 
 
restraints.  While in that condition, she was restrained in an 
ED for five days while qualified medical personnel applied for 
her admission to a licensed psychiatric facility.  The 
application process was complicated by the fact that she was 
deemed to require a private room in a facility.  During this 
time period she had no right to counsel or other procedural 
protections beyond the original preliminary determination by a 
qualified medical professional that there was "reason to believe 
that failure to hospitalize [C.R.] would create a likelihood of 
serious harm by reason of mental illness."  See G. L. c. 123, 
§ 12 (a).  Her restraint here for five days clearly raises 
constitutional concerns. 
We also emphasize that the important constitutional liberty 
interests at stake require that the involuntary restraint 
pursuant to § 12 (a), including the time period allowed for that 
restraint, must be narrowly tailored to serve a compelling 
governmental interest.  The law must also be the least 
restrictive means available to vindicate that interest.  See 
Matter of a Minor, 484 Mass. 295, 309 (2020) ("Laws that 
directly infringe on fundamental rights, such as liberty from 
constraint, are subject to strict scrutiny.  To pass the strict 
scrutiny standards, the [law] must be narrowly tailored to 
further a legitimate and compelling governmental interest and be 
the least restrictive means to vindicate that interest" 
31 
 
 
[quotation and citations omitted]); Commonwealth v. Weston W., 
455 Mass. 24, 35 (2009).  See also Pembroke Hosp., 482 Mass. at 
347 ("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"). 
Here, that compelling interest is the patient's health and 
safety and the safety of the public.  The restraint must be 
narrowly tailored to protect that compelling patient and public 
safety interest, employing the least restrictive means possible 
to accomplish that objective.  Restraint here is only justified 
long enough to find an appropriate facility to evaluate the 
patient.  Any unnecessary delay is unconstitutional.  The 
suitability of the location of that restraint must also be 
considered. 
In the instant case, however, there is no indication in the 
record that the period of restraint was any longer than was 
necessary to find the patient an appropriate facility for 
evaluation.  Her intense agitation and the requirement of 
finding her a single room lengthened the process.  Nothing in 
the record indicates any lack of effort on the part of MGH to 
identify an appropriate placement for C.R.  Nor did MGH have any 
incentive to keep her in the ED any longer than was necessary.  
Finally, no suitable, less restrictive location than an 
32 
 
 
emergency room was identified for the restraint and application 
process to occur.  In these circumstances, we discern no 
constitutional due process violation in the instant case. 
We also recognize that the record indicates that the 
boarding time here was not exceptional.  Rather, the record 
describes a widespread problem of ED boarding exceeding ninety-
six hours.  We recognize that the scale and scope of the problem 
may very well present a different set of constitutional 
questions.  That being said, we follow the precautionary 
principle of not deciding constitutional questions unnecessarily 
or prematurely for a number of interrelated reasons in the 
instant case. 
Our precautionary approach is also informed and influenced 
by the concerted, ongoing efforts on the part of the 
Commonwealth to address the ED boarding crisis, including the 
time frames established by DMH for hospitals and insurance 
carriers to escalate steps in the placement process pursuant to 
the EPIA, and the active engagement of the executive branch with 
the Legislature to attempt to address the problem.  The issue of 
widespread ED boarding has thus generated a concerted response 
by the Commonwealth.  As we perform our responsibilities of 
judicial review, we must also recognize and demonstrate due 
respect for the diligent efforts made by the other branches of 
government responsible for performing the functions we are 
33 
 
 
reviewing, particularly when they involve complicated policy 
choices.  Hancock v. Commissioner of Educ., 443 Mass. 428, 457 
(2005) (Marshall, C.J., concurring) ("Here, the independent 
branches of government have shown that they share the court's 
concern, and that they are embracing and acting on their 
constitutional duty . . .").  See Sunstein, Foreword:  Leaving 
Things Undecided, 110 Harv. L. Rev. 4, 38 (1996) ("[A] broad, 
early ruling may have unfortunate systemic effects.  It may 
prevent the kind of evolution, adaption, and argumentative give-
and-take that tend to accompany lasting social reform").  For 
this combination of reasons, we consider it premature to decide 
these larger constitutional questions at this time.  See McDuffy 
v. Secretary of the Executive Office of Educ., 415 Mass. 545, 
621 (1993) ("No present statutory enactment is to be declared 
unconstitutional," but court will continue to monitor planned 
legislative and executive actions). 
 
We do, however, strongly encourage the Legislature to 
identify a time period capping the time of ED boarding to 
clarify the over-all § 12 (a) time deadline and avoid future 
constitutional difficulties, and to do so as expeditiously as 
possible.  Cf. Jean W. v. Commonwealth, 414 Mass. 496, 499 & n.3 
(1993) (Liacos, C.J., concurring) (announcing court's intention 
to abolish public duty rule "at the first available opportunity 
after the conclusion of the 1993 session of the Legislature" and 
34 
 
 
"inviting the Legislature to consider the forthcoming change in 
decisional law, and to make any preparations for the change that 
it deems appropriate"); Whitney v. Worcester, 373 Mass. 208, 
210-213 (1977) (urging Legislature to take action to abrogate 
sovereign immunity and refine formulation and principles 
stressed in court's opinion).  Establishing such a cap within a 
reasonable time frame is necessary to ensure the protection of 
the important liberty interests at stake. 
5.  Conclusion.  We reverse the decision of the Appellate 
Division dismissing the petition as untimely.  The time period a 
patient is restrained pursuant to G. L. c. 123, § 12 (a), is 
distinct from the time period a patient may be hospitalized 
pursuant to § 12 (b).  The three-day period under G. L. c. 123, 
§ 12 (b), is necessary to properly evaluate the patient, and was 
not intended by the Legislature to be shortened by the 
activities undertaken during the § 12 (a) period.  Although the 
§ 12 (a) time period for application to and acceptance by an 
authorized facility has extended beyond the Legislature's 
original expectations, the Legislature has not yet chosen to 
include a specific deadline despite its recognition of the 
issue.  Absent demonstrated constitutional violations, we will 
not impose such a specific requirement ourselves.  As applied to 
C.R., we conclude that the statute did not violate due process, 
as the § 12 (a) period of confinement was no longer than 
35 
 
 
necessary given the difficulty of finding her an appropriate 
placement.  We also conclude that any additional constitutional 
ruling regarding § 12 (a) or ED boarding times generally is 
premature in the instant case, which has not been brought as a 
facial challenge to the statute or as a class action or request 
for declaratory judgment.  Our decision that any further 
constitutional ruling is premature is informed and influenced by 
our recognition that the executive branch has engaged in a 
concerted effort to address and resolve the crisis, including 
developing time frames for hospitals and insurance providers to 
initiate escalation steps for facility placement searches during 
the § 12 (a) period, and so informed and engaged the 
Legislature, which continues to evaluate the problem.  We do, 
however, encourage the Legislature to include a time deadline 
for the § 12 (a) evaluation process as expeditiously as possible 
to clarify the statute and ensure the protections of the 
important liberty interests at stake. 
 
 
 
 
 
 
 
So ordered.