## Facts

- Thomas S., a young adult with intellectual and adaptive-functioning impairments, was a patient at a North Carolina state psychiatric hospital.
- Hospital professionals developed a discharge plan calling for community-based habilitation in a small, structured group home, with training in self-care, social skills, and community living.
- After discharge, state and local officials did not place Thomas in the recommended setting and instead placed him in more restrictive and inappropriate facilities, including a detoxification center not designed for his condition.
- Officials failed to implement key parts of the prescribed training and supervision plan.
- Thomas attempted suicide during this period, which the district court treated as evidence of deficient protection and failure to carry out the plan.
- Thomas, through a guardian ad litem, sued state and related officials; the district court granted summary judgment and entered detailed injunctive relief requiring implementation of a professionally approved plan in the least restrictive appropriate setting.
- The Secretary of the state human resources department appealed, arguing (among other points) that *Youngberg* did not apply, local entities were responsible, and factual disputes barred summary judgment; Thomas’s court-appointed guardian also appealed aspects of the order in a companion appeal.

## Issues

1. Whether substantive due process required state officials to provide treatment/training consistent with accepted professional judgment, including placement in the least restrictive appropriate setting.
2. Whether *Youngberg v. Romeo* applied where the individual was placed in community facilities under government supervision rather than continuously confined in a state institution.
3. Whether the state secretary could be held responsible for constitutional violations when local agencies were involved in placement and service delivery.
4. Whether the district court properly granted summary judgment and ordered injunctive relief.

## Decision

- The Fourth Circuit affirmed the district court’s judgment, with minor modifications to the remedial order.
- The court held that *Youngberg*’s substantive due process protections applied because the government had assumed responsibility for Thomas’s custody, care, and treatment, including through supervised community placements.
- The court agreed that the failure to implement the professionally prescribed plan, and placements substantially inconsistent with it, constituted a substantial departure from professional judgment sufficient to establish a due process violation.
- The court rejected the argument that state-level responsibility was negated by local participation, concluding the state secretary had ultimate authority over the relevant system.
- The court upheld summary judgment because the material facts regarding the professional plan, placements, and nonimplementation were not genuinely disputed.

## Legal Principles

- When the government assumes responsibility for a person with significant disabilities, substantive due process requires care and training consistent with accepted professional judgment.
- Under *Youngberg*, constitutional minima include reasonably safe conditions and minimally adequate training related to safety and freedom from undue restraint, assessed under a “professional judgment” standard.
- A substantial departure from accepted professional judgment, practice, or standards can establish a due process violation.
- The duty to provide constitutionally adequate care is not limited to the walls of a traditional institution; it may extend to supervised community placements where the government controls placement and treatment.
- State officials with ultimate authority over a mental health system may be held accountable for constitutional deficiencies, even if local entities participate in service delivery.

## Conclusion

The Fourth Circuit held that substantive due process required implementation of a professionally prescribed habilitation plan, including placement in the least restrictive appropriate setting, and affirmed injunctive relief compelling state-level compliance under the *Youngberg* professional-judgment standard.


Thomas S. v. Morrow, 781 F.2d 367 (4th Cir. 1986)