Title: In re P.R.
Citation: N/A
Docket Number: SJC-13068
State: Massachusetts
Issuer: Massachusetts Supreme Court
Date: August 5, 2021

NOTICE:  All slip opinions and orders are subject to formal 
revision and are superseded by the advance sheets and bound 
volumes of the Official Reports.  If you find a typographical 
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-
1030; SJCReporter@sjc.state.ma.us 
 
SJC-13068 
 
IN THE MATTER OF P.R. 
 
 
 
Suffolk.     April 9, 2021. - August 5, 2021. 
 
Present:  Budd, C.J., Gaziano, Lowy, Cypher, Kafker, Wendlandt, 
& Georges, JJ. 
 
 
Mental Health.  Incompetent Person, Commitment.  Evidence, 
Expert opinion, Hearsay.  Practice, Civil, Commitment of 
mentally ill person, Standard of proof, Hearsay, Findings 
by judge.  Witness, Expert.  Words, "Likelihood of serious 
harm," "Very substantial risk." 
 
 
 
Petition for involuntary commitment filed in the Falmouth 
Division of the District Court Department on June 14, 2017. 
 
Following transfer to the West Roxbury Division of the 
Boston Municipal Court Department, the case was heard by 
Jonathan R. Tynes, J. 
 
The Supreme Judicial Court on its own initiative 
transferred the case from the Appeals Court. 
 
 
Devorah A. Vester, Committee for Public Counsel Services, 
for P.R. 
H. David Kim, Assistant Attorney General, for Department of 
Mental Health. 
The following submitted briefs for amici curiae: 
Thomas F. Schiavoni, pro se. 
2 
 
Brian C. Almeida, Michael C. Boyne, James T. Hilliard, 
Michael T. Porter, & Jessica L. Deratzian for Massachusetts 
Psychiatric Society, Inc., & others. 
 
Mark J. Murphy, of New York, Kathryn Rucker, Robert LeRoux 
Hernandez, Jennifer Honig, & Tatum A. Pritchard for Center for 
Public Representation & others. 
 
 
 
LOWY, J.  Civil commitments necessarily entail a loss of 
liberty.  For this reason, a person facing a possible commitment 
under G. L. c. 123, §§ 7 and 8 -- sections that govern long-
term, involuntary commitments -- is afforded various safeguards, 
including those provided by the law of evidence.  This case 
centers on what an expert witness may testify to on direct 
examination during a hearing held pursuant to these sections.  
As is well settled, experts may not testify on direct 
examination about the basis of their opinion when these facts 
are neither within their personal knowledge nor otherwise 
admitted in evidence during the proceeding.  See, e.g., 
Commonwealth v. Goddard, 476 Mass. 443, 448 (2017).  Applying 
this rule here, the judge erred in allowing the expert to do 
just that.  Because this error was prejudicial, we remand for a 
new hearing.1 
 
1 We acknowledge the amicus briefs submitted by the Center 
for Public Representation, Disability Law Center, and Mental 
Health Legal Advisors Committee; Massachusetts Psychiatric 
Society, Inc., Massachusetts Association of Behavioral Health 
Systems, and Massachusetts Health & Hospital Association; and 
Thomas F. Schiavoni. 
3 
 
 
Background.  In November 2016, P.R. was committed to the 
Pocasset Mental Health Center (Pocasset), a facility operated by 
the Department of Mental Health (department).  In June 2017, the 
department filed a petition to recommit P.R. pursuant to G. L. 
c. 123, §§ 7 and 8.  The petition alleged that P.R. had 
schizoaffective disorder, bipolar type, and was manic.  P.R. 
waived his right to a hearing and was recommitted. 
 
After being transferred to the Lemuel Shattuck Hospital 
(Shattuck), another department facility, however, P.R. requested 
a hearing regarding his commitment.2  In his motion before a 
judge in the Boston Municipal Court, P.R. argued that commitment 
at Shattuck no longer was necessary.  The judge subsequently 
held a full hearing on the merits of the underlying petition.  
Two witnesses testified:  P.R.'s psychiatrist at Shattuck, who 
testified for the department; and P.R., who testified on his own 
behalf. 
 
The psychiatrist testified that P.R. was diagnosed with 
paranoid schizophrenia and experienced delusions, such as 
beliefs that his medications were poisoned with cyanide, he had 
 
 
2 P.R. requested this hearing pursuant to G. L. c. 123, 
§ 6 (b), which allows a person who has waived his or her initial 
right to a hearing to request one concerning the reasons for 
continued commitment upon a showing of "good cause."  Because 
the judge reached the merits of the underlying G. L. c. 123, 
§§ 7 and 8, petition without first finding good cause and the 
parties do not raise the issue on appeal, we do not examine the 
issue further. 
4 
 
gotten married when he was two years old, Jewish people were 
trying to change his religion using birds, and he was the chief 
executive officer of several companies.  The psychiatrist 
testified that P.R. remained "quite delusional" at the time of 
the hearing.  Although P.R. was not violent or threatening 
toward others, the psychiatrist testified that the delusions 
caused him to suffer from poor judgment and to put himself in 
danger. 
 
According to the psychiatrist, this poor judgment 
manifested in several ways.  Along with his mental illness, P.R. 
also has chronic obstructive pulmonary disease, a condition for 
which he had been prescribed oxygen.  While at Pocasset, P.R. 
increased the flow from his oxygen tank to what the psychiatrist 
deemed "extremely harmful" levels because P.R. believed these 
levels were necessary.  Although P.R. eventually was prescribed 
nebulizers and his prescription was discontinued for oxygen,3 he 
did not take his prescribed medications every day.  In 
particular, P.R. had not been taking all of his medications 
during the two weeks before the hearing.  The psychiatrist 
further testified that, although P.R. was under a guardianship 
that authorized the administering of antipsychotic medications, 
his guardian would not be able to force P.R. to take his 
 
 
3 The last oxygen incident occurred more than one month 
before the time of the hearing. 
5 
 
medications after being discharged.  Based on these facts, the 
psychiatrist believed that P.R. required a supervised living 
arrangement. 
 
During direct examination, the psychiatrist also testified 
that P.R. had been living at an assisted living facility prior 
to his initial commitment in November 2016.4  This assisted 
living facility had been staffed by nurses who had provided P.R. 
with medications and food.  The psychiatrist testified that, 
despite this care, P.R. had not been "able to function and was 
putting himself in danger[]" there.  Furthermore, the 
psychiatrist added that even if P.R.'s prior assisted living 
facility could have provided adequate supervision, he could not 
now be discharged to it because it was unavailable.  All the 
information about the assisted living facility appeared to come 
from a medical report that the psychiatrist had consulted.  That 
report, which seems to have detailed the findings of a social 
worker who spoke with an unknown third party about P.R.'s 
previous living arrangements, never was entered in evidence and 
is not in the record. 
 
P.R. testified that he intended to accept prescribed 
psychiatric medications if he were discharged.  P.R. explained 
 
 
4 Precisely when P.R. resided at the assisted living 
facility is unclear.  Although the psychiatrist noted that this 
had been P.R.'s residence right before being hospitalized, P.R. 
contended that he had been living in an apartment. 
6 
 
that he knew how to use bus transportation and that if he had 
questions about his medication or treatment, he would consult 
his doctors.  P.R. also testified that before he was committed 
to Pocasset, he had been living in an apartment; he had a 
representative payee who had continued to pay the rent since his 
commitment to Pocasset; and he planned to return there after 
being discharged. 
 
The judge found that P.R.'s commitment should continue 
under §§ 7 and 8.  The Appellate Division of the Boston 
Municipal Court affirmed.  P.R. appealed to the Appeals Court, 
and we transferred the case to this court on our own motion. 
 
Discussion.5  General Laws c. 123, §§ 7 and 8, set out the 
statutory framework under which P.R. was committed.  Pursuant to 
these sections, by petitioning the Juvenile Court, the District 
Court, or, as in this case, the Boston Municipal Court, the 
superintendent of a mental health facility may seek to commit 
 
 
5 Although the parties do not dispute the timeliness of the 
appeal, the Appeals Court ordered them to address this issue 
before we took the case.  Generally, an appellant in a civil 
case has thirty days to file a notice of appeal after the 
Appellate Division issues its decision.  See G. L. c. 231, 
§ 109.  P.R. filed fifty-nine days after the decision issued.  
Where, like here, one of the Commonwealth's agencies is a party, 
however, the filing window is sixty days.  See Mass. R. A. P. 
4 (a) (1), as appearing in 481 Mass. 1606 (2019).  Because G. L. 
c. 231, § 109, defers to the Massachusetts Rules of Appellate 
Procedure, the statute and rule do not clash.  See Boston 
Seaman's Friend Soc'y, Inc. v. Attorney Gen., 379 Mass. 414, 
416-417 (1980).  Thus, rule 4 (a) (1) applies and the appeal was 
timely. 
7 
 
involuntarily -- initially for a period of six months, and then 
for subsequent one-year periods -- an individual who has been 
admitted to the facility.  G. L. c. 123, §§ 7 (a), 8 (d).  To 
order such a commitment, a judge must find both that the 
individual is mentally ill and that discharge from the facility 
would "create a likelihood of serious harm."  G. L. c. 123, 
§ 8 (a).  Much of this case centers on what a judge may consider 
in determining whether the second condition is fulfilled. 
 
1.  Likelihood of serious harm.  "Likelihood of serious 
harm" is statutorily defined in three ways; the applicable one 
here is the third.6  See G. L. c. 123, § 1.  It requires the 
judge to find that both (1) "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 (2) "reasonable 
 
 
6 General Laws c. 123, § 1, defines "likelihood of serious 
harm" as 
 
"(1) a substantial risk of physical harm to the person 
himself [or herself] 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 protection is not available in the 
community." 
8 
 
provision for his protection is not available in the community."  
Id.  The department must prove each of these elements beyond a 
reasonable doubt.7  See Matter of J.P., 486 Mass. 117, 119 
(2020). 
 
On appeal, P.R. advances two distinct evidentiary arguments 
regarding the likelihood of serious harm that he posed.  First, 
P.R. argues that the department failed to carry its burden as to 
the very substantial risk of harm that he posed to himself.  
Second, P.R. contends that the judge erroneously relied on 
hearsay evidence in determining that reasonable provision for 
his care in the community was unavailable.  Although there was 
sufficient evidence concerning the risk of harm, we agree that 
the judge committed prejudicial error by relying on hearsay 
evidence concerning the unavailability of alternatives to 
hospitalization. 
 
a.  Very substantial risk of harm.  To demonstrate a "very 
substantial risk of physical impairment or injury," the 
department needed to prove that P.R.'s "judgment is so affected 
 
 
7 P.R. also argues that the case of Matter of a Minor, 484 
Mass. 295, 309 (2020), requires as a matter of substantive due 
process that judges consider the least restrictive alternative 
to hospitalization before committing a person under G. L. 
c. 123, §§ 7 and 8.  We need not address the constitutional 
requirements because the statutory definition of "likelihood of 
serious harm" applicable in P.R.'s case contains the equivalent 
requirement:  the judge must find beyond a reasonable doubt that 
"reasonable provision for his protection [was] not available in 
the community" before ordering commitment.  G. L. c. 123, § 1. 
9 
 
that he is unable to protect himself in the community."  G. L. 
c. 123, § 1.  "The focus of the evidence, then, must be on 
[P.R.'s] degree of impaired judgment due to [mental illness and] 
the degree of likelihood that, as a direct consequence, [P.R.] 
will sustain or inflict injury . . . ."  Matter of G.P., 473 
Mass. 112, 129 (2015).  The risk also must be imminent, meaning 
"it will materialize 'in days or weeks rather than in months.'"  
Matter of J.P., 486 Mass. at 119, quoting Matter of G.P., supra 
at 128.  "In our review of the sufficiency of the evidence, we 
accept the findings of fact made by the hearing judge unless 
clearly erroneous; however, we review without deference whether 
the legal standard for civil commitment was met."  Matter of 
J.P., supra at 121. 
 
P.R. emphasizes that at the time of the hearing he was no 
longer on an oxygen prescription and thus could not harm himself 
by increasing the intake to dangerous levels as he had done 
previously.  Yet the underlying issues that created the "very 
substantial risk of physical impairment or injury" -- P.R.'s 
paranoid schizophrenia, delusions, and resulting impaired 
judgment -- still were present.  G. L. c. 123, § 1.  The oxygen 
incidents, which occurred only months prior to the hearing and 
had been a recurring issue throughout P.R.'s time at Pocasset, 
were but one particularly stark example of P.R.'s poor judgment.  
Even under the department's supervision, P.R. repeatedly 
10 
 
resisted taking his medications, which he believed were 
poisoned.  Indeed, the psychiatrist testified that P.R. had 
refused medication in the two weeks before the hearing, was 
still "quite delusional," and remained unable to care for 
himself. 
 
Therefore, although P.R. no longer could harm himself using 
the intake valve on his oxygen tank, the impaired judgment that 
led him initially to attempt these acts of self-harm remained.  
See Matter of D.K., 95 Mass. App. Ct. 95, 101-102 (2019) 
(affirming finding of imminent and very substantial risk of 
self-harm where conditions were same as had been present when 
patient was discovered in life-threatening condition two years 
prior).  We discern no error here. 
 
b.  Reasonable alternatives to hospitalization.  To 
demonstrate that reasonable provision for P.R.'s protection was 
unavailable in the community, the department relied on the 
psychiatrist's testimony that the assisted living facility where 
P.R. had resided prior to his commitment no longer was 
available.  In addition, the psychiatrist testified that even if 
it were available, P.R. had not been able to function there.  
All this information appeared to come from an unadmitted medical 
report filled out by a social worker who had spoken with a third 
party concerning P.R.'s prior assisted living facility.  P.R. 
argues that the judge committed prejudicial error by inquiring 
11 
 
on direct examination into the basis of the psychiatrist's 
opinion that no alternative to hospitalization at a department 
facility existed.  We agree. 
 
i.  Testimony about basis of expert opinion.  Our law of 
evidence applies to proceedings under §§ 7 and 8, see Matter of 
J.P., 486 Mass. at 121-122; standards 5.01-5.02 of the District 
Court Standards of Judicial Practice:  Civil Commitment and 
Authorization of Medical Treatment for Mental Illness (rev. Apr. 
2019), and limits both on what an expert's opinion may be based 
and when an expert may testify to the various bases for an 
opinion, see Mass. G. Evid. §§ 703, 705 (2021).  To start, an 
expert's opinion must be based on (1) facts within his or her 
direct personal knowledge, (2) evidence already in the record, 
or (3) facts or data not in evidence if the facts or data are 
independently admissible in evidence and are a permissible basis 
for an expert to consider in formulating an opinion.8  See 
Commonwealth v. Watt, 484 Mass. 742, 746 (2020).  Here, the 
psychiatrist's opinion was based on the unadmitted medical 
report, leaving only the third option as the possible basis. 
 
 
8 It is within a judge's discretion, however, to allow an 
expert to testify on direct examination to evidence that will be 
admitted in evidence.  See Mass. G. Evid. § 611(a).  See also 
Mass. G. Evid. § 703 note ("On direct examination, the expert 
witness's testimony regarding the basis of his or her opinion is 
limited to [1] facts within the witness's personal knowledge; 
[2] facts in evidence; or [3] with approval of the court, facts 
that a party will put in evidence"). 
12 
 
This third basis -- unadmitted but independently admissible 
evidence -- entails some nuance in determining when an expert 
may testify to it.  Although an expert may state an opinion 
based on unadmitted but independently admissible evidence, the 
expert may testify about this evidence only if asked about it on 
cross-examination.  See, e.g., Goddard, 476 Mass. at 448; 
Commonwealth v. Greineder, 464 Mass. 580, 583, cert. denied, 571 
U.S. 865 (2013); Commonwealth v. Barbosa, 457 Mass. 773, 785 
(2010), cert. denied, 563 U.S. 990 (2011); Commonwealth v. 
Nardi, 452 Mass. 379, 392 (2008); Commonwealth v. Markvart, 437 
Mass. 331, 338 (2002); Department of Youth Servs. v. A Juvenile, 
398 Mass. 516, 532 (1986).  This rule governs "both civil and 
criminal cases and applies to both sides."  Commonwealth v. 
Chappell, 473 Mass. 191, 204 (2015). 
In other words, "[t]he expert's direct examination may not 
be used to put before the [trier of fact] facts that are not 
(and will not be) properly in evidence."  Markvart, 437 Mass. at 
338.  Cross-examination, however, is a different story.  If the 
opponent of the testimony decides to inquire about the basis for 
an opinion when the underlying information is not in evidence, 
then that party owns the risks that follow:  not only will that 
evidence now be before the trier of fact, but the opponent has 
also opened the door to the proponent asking about it on 
redirect examination.  See Commonwealth v. Piantedosi, 478 Mass. 
13 
 
536, 543-544 (2017) ("If the door is opened by the opposing 
party, on redirect examination, the proponent of the evidence 
then may introduce the details surrounding the source of the 
expert's opinion").  Given that the evidence otherwise might not 
come in, the initial decision to ask about the information is 
properly for the opponent to make on cross-examination, not the 
proponent to make on direct examination. 
 
Why this rule matters in the context of §§ 7 and 8 bears 
emphasizing.  Involuntary hospitalizations under these sections 
can last up to a year before further review and thus involve a 
"massive" infringement of an individual's liberty.  See Matter 
of N.L., 476 Mass. 632, 637 (2017), quoting Newton-Wellesley 
Hosp. v. Magrini, 451 Mass. 777, 784 (2008).  Consequently, 
"[t]he provisions of G. L. c. 123 balance the rights of and 
protections for [mentally ill] 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 [as well as protecting such persons from 
self-harm]."  Matter of M.C., 481 Mass. 336, 344 (2019), quoting 
Matter of E.C., 479 Mass. 113, 119 (2018).  To strike this 
balance, a person facing involuntary commitment under §§ 7 and 8 
is afforded extensive procedural protections.  See Matter of 
M.C., supra. 
14 
 
 
Among these safeguards are the rights to introduce evidence 
and to cross-examine witnesses.  See id.  The rule disallowing 
experts from testifying on direct examination about unadmitted 
evidence protects both rights.  First, the rule obviates "the 
danger that the [proponent] would use an expert's opinion to 
inform the [trier of fact] of facts not in evidence," Barbosa, 
457 Mass. at 785, by limiting what an expert may testify to on 
direct examination.  See Nardi, 452 Mass. at 392, quoting Grant 
v. Lewis/Boyle, Inc., 408 Mass. 269, 273 (1990) ("expert witness 
may not, under the guise of stating the reasons for his opinion, 
testify to matters of hearsay in the course of his direct 
examination unless such matters are admissible under some 
statutory or other recognized exception to the hearsay rule").  
Moreover, the rule also protects the right to cross-examine 
witnesses by preventing inadmissible hearsay evidence -- which, 
by its nature, is not susceptible to cross-examination -- from 
slipping into a hearing.  See Greineder, 464 Mass. at 584. 
 
Turning to the testimony at issue, when asked on direct 
examination whether P.R. could be discharged safely, the 
psychiatrist replied that he could not "because the facility 
where he was before is not available."  At this point, P.R. 
objected as to the basis of the opinion and on hearsay grounds, 
arguing that the testimony was relaying information that had not 
15 
 
been admitted in evidence.9  In response to the objection, the 
department indicated to the judge that the social worker's 
findings were in a medical report reviewed by the psychiatrist.  
The judge requested that the department inquire into the basis 
of the opinion.  It did so, and the psychiatrist testified that 
the information came from a social worker who had contacted 
P.R.'s previous assisted living facility.  The medical report 
never was admitted in evidence, and the social worker did not 
testify. 
 
Over P.R.'s continued objections, the judge allowed the 
psychiatrist to continue to detail what she knew about the 
assisted living facility where P.R. previously had been, 
including his inability to function there.  Because this 
information appears to have come from the unadmitted medical 
report, allowing the psychiatrist to testify about it on direct 
examination was error.  By explaining the basis of her opinion, 
the psychiatrist's testimony served to "import inadmissible 
hearsay into" the hearing.  Goddard, 476 Mass. at 448. 
 
That the department inquired into the basis of the 
psychiatrist's opinion at the judge's request does not alter 
this conclusion.  After P.R. lodged his initial objection, the 
judge responded: 
 
 
9 The department concedes that the psychiatrist's testimony 
concerning the basis of her opinion was hearsay. 
16 
 
"Here's what I'm going to do, I'm going to allow the 
testimony.  You can cross on it and obviously argue whether 
or not it's reliable enough when it comes to no less 
restrictive means, but I think I need the information on 
what is available to [P.R.] if he were to be discharged.  
And if I don't know what his other options are or were, I 
don't see how I can make an informed decision" (emphasis 
added). 
 
Although a judge clearly may ask questions when acting as the 
trier of fact, the judge must be cognizant of his or her role as 
the judge of the law with the duty to consider the 
permissibility of the question.  Cf. Commonwealth v. Lucien, 440 
Mass. 658, 664 (2004).  Understandable as the judge's desire to 
discover further information was considering both his role as 
the trier of fact and the importance of the decision he was 
called upon to make, doing so took him beyond what the law of 
evidence allows, which otherwise would have prevented him from 
basing his ruling on the psychiatrist's testimony about the 
unadmitted medical report.  Hence, it was error. 
 
The department contends that this conclusion "misses the 
mark," arguing that the "question is not whether the medical 
records were actually in evidence, but rather whether they could 
have been admitted" under G. L. c. 233, § 79, a statute that 
allows a judge to admit certain hospital records.  The 
department, however, is aiming at the wrong target.  This 
framing, which focuses on the proper basis for expert opinion, 
overlooks the fact that the psychiatrist testified about the 
17 
 
unadmitted medical records on direct examination.  Allowing such 
testimony required either that the medical report on which the 
expert relied be admitted in evidence, or potentially other 
medical records of the facility.10  See Mass. G. Evid. § 703.  
See also Matter of J.P., 486 Mass. at 122 ("the emergency room 
records themselves were not admitted in evidence; thus, [the 
expert's] testimony regarding anything in those records . . . 
was hearsay that is not admissible under [G. L. c. 233, § 79]").  
Neither happened.  The department cannot now claim absence of 
error based on an unadmitted medical report.11 
 
ii.  Prejudicial error.  Once the erroneous testimony is 
removed, little else remains to attest to whether reasonable 
alternatives for P.R.'s protection were absent in the community.  
Compare Matter of J.P., 486 Mass. at 122 (expert testimony about 
 
 
10 Presumably, the social worker could have been called to 
testify as well.  We realize, however, that logistical hurdles 
often may make calling such witnesses difficult. 
 
 
11 P.R. also argues that because the basis testimony was 
admitted erroneously, the evidence concerning the unavailability 
of the alternatives to hospitalization was insufficient.  In 
evaluating sufficiency, however, we take into consideration all 
the evidence before the trier of fact, regardless of whether it 
was properly admitted.  See Commonwealth v. Bacigalupo, 455 
Mass. 485, 490 (2009) ("Ordinarily, in determining the 
sufficiency of the evidence, we include evidence improperly 
admitted").  Although reliance on the basis testimony was 
improper, it provided sufficient evidence that reasonable 
alternatives to hospitalization were unavailable, especially 
given the psychiatrist's testimony that, according to the 
medical report, P.R. was unable to function even at his previous 
assisted living facility. 
18 
 
basis on direct examination was error but not prejudicial 
because impermissible testimony was cumulative).  For example, 
although the psychiatrist testified that the assisted living 
facility would not have been appropriate even if it were 
available, this testimony would not have been before the judge 
but for the error.  Indeed, when P.R. objected to the 
information concerning how he had functioned at the assisted 
living facility, the psychiatrist confirmed that this 
information came from the unadmitted medical report. 
 
More importantly, it is impossible to ignore the judge's 
express reliance on the psychiatrist's testimony about the basis 
of her opinion.  In this, we recognize the judge's dilemma.  
Although the department argues that it could have admitted the 
medical report under G. L. c. 233, § 79, its failure to do so at 
the hearing left the judge, in his role as judge of the facts, 
conscientiously trying to obtain essential information and with 
little other option than to inquire into the basis of the 
psychiatrist's testimony when P.R. objected.  Unfortunately, in 
his role as judge of the law, the question led the judge to rely 
on impermissible information in rendering his decision.  Had the 
department offered the medical report in evidence, then the 
judge could have properly relied on the facts and data contained 
in it when issuing his order.  The department's failure to admit 
19 
 
the report, which it presumably could have, thus led to the 
error at issue.12 
Because this error was preserved, we cannot say that it did 
not influence the finder of fact "or had but a slight effect."13  
Commonwealth v. Pfeiffer, 482 Mass. 110, 129, cert. denied, 140 
S. Ct. 498 (2019), quoting Commonwealth v. Flebotte, 417 Mass. 
348, 353 (1994).  Therefore, the error was prejudicial.  A new 
hearing is necessary. 
 
2.  Written or oral findings.  Although the evidentiary 
issues resolve this case, we address another issue that may 
reoccur on remand:  P.R.'s contention that the judge erred by 
not making a statement of written or oral findings before 
ordering commitment under §§ 7 and 8.  To support this claim, 
P.R. analogizes to Matter of a Minor, 484 Mass. 295 (2020).  
There, we held that commitments under G. L. c. 123, § 35, which 
governs the short-term commitment of individuals with substance 
use disorders, required that judges make written or oral 
 
 
12 The medical report is not in the record.  Therefore, we 
cannot say with certainty whether it was admissible.  It is the 
department's position, however, that it was.  Thus, we assume, 
for the sake of argument, that it would have been admitted had 
the department sought to do so. 
 
 
13 Citing Commonwealth v. Adams, 434 Mass. 805, 812 (2001), 
the department argues that the error was not prejudicial because 
it did not alter P.R.'s strategy at the hearing.  Yet unlike in 
Adams, supra at 814, where the other evidence of sanity -- the 
issue in dispute -- was "substantial," the judge expressly 
relied on the erroneous testimony here. 
20 
 
findings on the record to satisfy due process.  Id. at 307.  
Commitments under both § 35 and §§ 7 and 8 entail deprivations 
of liberty.  Therefore, P.R. reasons, due process demands that 
commitments under either section entail the same procedural 
safeguards.  Because the differences between proceedings under 
§ 35 and those under §§ 7 and 8 dwarf the similarities, we 
disagree. 
 
Written or oral findings often are necessary when a law 
restrains a person's liberty.  See Brangan v. Commonwealth, 477 
Mass. 691, 693 (2017), S.C., 478 Mass. 361 (2017) (written or 
oral findings required in bail hearings "where it appears that a 
defendant lacks the financial resources to post the amount of 
bail set"); Commonwealth v. Hartfield, 474 Mass. 474, 484 
(2016), citing Commonwealth v. Durling, 407 Mass. 108, 113 
(1990) (written or oral finding of fact required for revocation 
of probation); Doucette v. Massachusetts Parole Bd., 86 Mass. 
App. Ct. 531, 539 (2014) (same requirement for revocation of 
parole).  Cf. Mendonza v. Commonwealth, 423 Mass. 771, 775 
(1996) (suggesting same requirement for pretrial detention on 
dangerousness grounds mandated by G. L. c. 276, § 58A [4]).  See 
generally Matter of a Minor, 484 Mass. at 306-307 (discussing 
instances where written or oral factual findings are required). 
 
It does not follow, however, that due process dictates 
written or oral findings in every case where a person's liberty 
21 
 
is restrained.  "Due process, by its nature, is a flexible 
concept."  Durling, 407 Mass. at 113.  Each case presents a 
unique assortment of individual and governmental interests that 
must be weighed.  See Querubin v. Commonwealth, 440 Mass. 108, 
117 (2003), quoting Mullane v. Central Hanover Bank & Trust Co., 
339 U.S. 306, 313 (1950) ("the features of the required hearing 
will be determined by the 'nature of the case'").  See also 
Mathews v. Eldridge, 424 U.S. 319, 334 (1976) ("'Due process,' 
unlike some legal rules, is not a technical conception with a 
fixed content unrelated to time, place and circumstances" 
[citation omitted]). 
 
A written or oral statement of factual findings is 
certainly necessary in a scenario such as a commitment hearing 
under § 35, where many procedural safeguards that protect a 
person's liberty interests are absent.  For example, the rule 
against hearsay does not apply to hearings under § 35.  See 
Matter of a Minor, 484 Mass. at 308 (hearsay allowed under § 35 
so long as evidence is reliable and "specific indicia of 
reliability" are detailed in finding).  See also Hartfield, 474 
Mass. at 485 ("Even if not required by court rule, we conclude 
that, where a judge relies on hearsay evidence in finding a 
violation of probation, the judge should set forth in writing or 
on the record why the judge found the hearsay evidence to be 
reliable").  A judge also need only find each element by clear 
22 
 
and convincing evidence to order commitment under § 35.  See 
Matter of a Minor, supra at 296.  See also Mendonza, 423 Mass. 
at 774 (clear and convincing standard applied in pretrial 
commitment for dangerousness under G. L. c. 276, § 58A); 
Commonwealth v. Holmgren, 421 Mass. 224, 226 (1995) 
(preponderance of evidence standard applied in probation 
revocation hearings). 
 
Yet when other protections are present, the scale of 
procedural due process may tip toward such a statement being 
unnecessary.  See generally Mathews, 424 U.S. at 334-335.  For 
example, criminal defendants are not entitled to written 
findings at a jury or bench trial because they have a "full 
panoply" of other protections.  Morrissey v. Brewer, 408 U.S. 
471, 480 (1972).  See Commonwealth v. Szewczyk, 89 Mass. App. 
Ct. 711, 714 (2016) (judge at jury-waived criminal trial "is not 
required to honor requests for findings of fact").  So the 
balance shifts here. 
 
Individuals facing a possible commitment under §§ 7 and 8 
already are afforded sufficient procedural protections.  Not 
only do such individuals have the right to present evidence and 
cross-examine witnesses as discussed infra, but they also have 
"the right to notice and a hearing, the right to an attorney, 
. . . [and] the right to an independent medical evaluation."  
Matter of M.C., 481 Mass. at 344.  All these rights are further 
23 
 
safeguarded by the requirement that the individual be provided 
at least two days after the appearance of counsel to prepare his 
or her case and that the hearing follow "forthwith" unless 
counsel requests a delay.  G. L. c. 123, § 5.  The hearings 
themselves must "be recorded and must operate as open, public 
proceedings."  Matter of M.C., supra at 338.  Finally, a person 
may not be committed unless the department proves each element 
beyond a reasonable doubt.  See Matter of J.P., 486 Mass. at 
119.  See also Matter of M.C., supra at 344, quoting Kirk v. 
Commonwealth, 459 Mass. 67, 72 (2011) ("commitment hearings have 
been increasingly clothed with procedural protections and 
formality typical of other civil [and criminal] trials"). 
 
A statement of findings and reasons helps to ensure that 
the judge has "weigh[ed] carefully the substantiality of the 
specific evidence."  Matter of G.P., 473 Mass. at 126.  But such 
a statement is not the only mechanism that ensures this.14  Taken 
together, procedural protections such as the application of the 
laws of evidence, the right to introduce evidence, the right to 
cross-examine witnesses, and the reasonable doubt quantum of 
 
 
14 P.R. argues that written findings are necessary because 
the facts at issue in a commitment hearing concern possible 
future harm.  Yet written findings are not required in criminal 
bench trials where, although the harm occurred in the past, the 
liberty interests are no less dear.  There is no reason to 
believe that written findings would increase accuracy where the 
harm is prospective rather than retrospective. 
24 
 
proof adequately ensure accuracy in the proceedings under 
consideration.  Whatever benefit another layer of procedure 
would provide in this regard under §§ 7 and 8 is outweighed by 
the additional burden it would place on the court system.  See 
Mathews, 424 U.S. at 334-335.  Therefore, where "the prescribed 
procedures are followed, 'an individual's due process rights 
. . . are protected at a hearing under G. L. c. 123, §§ 7 and 
8."  Matter of M.C., 481 Mass. at 344, quoting Matter of E.C., 
479 Mass. at 121. 
 
Conclusion.  The case is remanded to the Boston Municipal 
Court for a rehearing consistent with this opinion. 
 
 
 
 
 
 
 
So ordered.