## Facts

- Plaintiffs were adults with intellectual disabilities involuntarily confined in North Carolina public psychiatric hospitals.
- Prior litigation involving an individual patient established that keeping him institutionalized despite professional recommendations for less restrictive placement violated substantive due process.
- In the class phase, the district court certified a statewide class of similarly situated patients and held a bench trial.
- The district court found a pattern of noncompliance with treating professionals’ recommendations in areas including living arrangements (including community placement), medications, restraints, and habilitation plans.
- Defendant, the state official responsible for the hospital system, argued that facility accreditation supported a presumption that care met constitutional standards.
- The district court entered injunctive relief requiring decisions affecting class members’ care and placement to reflect professional treatment recommendations and professional judgment.

## Issues

1. Whether the district court properly certified a class of similarly situated institutionalized persons alleging denial of constitutionally required care and professional judgment.
2. Whether the state’s administration of care, treatment, and placement substantially departed from accepted professional judgment in violation of substantive due process.
3. Whether institutional accreditation creates a controlling presumption of constitutionally adequate treatment that bars or limits a finding of constitutional violations.
4. Whether the district court’s class-wide injunction was supported by the record and appropriately tailored to remedy the violations.

## Decision

- The court of appeals affirmed the district court’s judgment for the class.
- The court upheld class certification because common questions concerned statewide practices affecting treatment and placement decisions for the class.
- The court agreed that the evidence supported findings that the state failed to implement professional treatment plans and recommendations concerning placement, medications, and restraints, amounting to a substantial departure from professional judgment.
- The court rejected the argument that accreditation established a dispositive presumption of constitutional adequacy.
- The court affirmed the injunctive relief as supported by trial findings and directed to correcting the professional-judgment failures.

## Legal Principles

- Involuntarily confined persons with intellectual disabilities have substantive due process liberty interests in reasonably safe conditions, freedom from unreasonable bodily restraint, and minimally adequate training or habilitation necessary to protect those interests.
- The Constitution is satisfied when decisions about care and placement are the product of professional judgment; a substantial departure from accepted professional judgment, practice, or standards violates due process.
- Systemic, repeated failure to follow treating professionals’ recommendations—without valid professional justification—can constitute a substantial departure and support class-wide relief.
- Accreditation may be relevant evidence of general institutional conditions but does not displace judicial review of whether professional judgment is exercised in decisions affecting protected liberty interests.
- Injunctive relief may require state officials to implement or respond to professional treatment recommendations and to use individualized professional judgment in treatment and placement decisions.

## Conclusion

The Fourth Circuit held that North Carolina’s systemic failure to follow professional treatment and placement recommendations for institutionalized persons with intellectual disabilities substantially departed from professional judgment, and it affirmed class certification and a tailored injunction requiring constitutionally adequate professional decisionmaking.


Thomas S. v. Flaherty, 902 F.2d 250 (4th Cir. 1990)