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Minich v. Spencer

Superior Court of Massachusetts, Suffolk

May 12, 2016

Joanne Minich [1] et al. [2]
v.
Luis S. Spencer et al. [3] No. 133923

         Filed May 17, 2016

          MEMORANDUM OF DECISION AND ORDER ON DEFENDANTS' MOTION TO DISMISS

          Paul D. Wilson, Justice of the Superior Court.

         The plaintiffs, severely mentally ill individuals, allege that they were secluded and restrained unnecessarily and for prolonged periods at Bridgewater State Hospital (" Bridgewater") where they were involuntarily civilly committed. Claiming that the seclusion and restraint violated their state and federal rights, they commenced this lawsuit against the Commonwealth, the Department of Correction (" DOC"), former DOC Commissioner Luis S. Spencer (" Spencer"), and former Bridgewater Superintendent Robert Murphy (" Murphy") (collectively, " defendants")[4] seeking damages for violations of 42 U.S.C. § 1983 (Count I), G.L.c. 123, § 21 (Count II), and the Americans with Disabilities Act (" ADA") and the Rehabilitation Act (Count IV); and seeking declaratory judgments for violations of G.L.c. 123, § 21, and the Massachusetts Declaration of Rights (Count III), and for violations of the ADA and the Rehabilitation Act (Count V). Before me is the defendants' motion to dismiss. For the following reasons, the defendants' motion is ALLOWED in part and DENIED in part.

         PROCEDURAL HISTORY

         In March 2014, the plaintiffs[5] filed a prior lawsuit in Norfolk County[6] against the current defendants, as well as the Massachusetts Partnership for Correctional Healthcare, LLC, and Marcia Fowler in her capacity as commissioner of the Massachusetts Department of Mental Health (" DMH") (" Norfolk Action"). See Amended Complaint, pars. 53-59 (discussing Norfolk Action). In the Norfolk Action, the plaintiffs alleged that the illegal restraint and seclusion at Bridgewater violated G.L.c. 123, § 21; violated Article 10 of the Massachusetts Declaration of Rights; violated G.L.c. 12, § 11I; violated 42 U.S.C. § 1983; and breached the 1987 settlement agreement concerning seclusion and restraint at Bridgewater between two Bridgewater patients and the Secretary of Health and Human Services, the Commissioner of Correction, and the Superintendent of Bridgewater. See Amended Complaint, pars. 22-24 (discussing 1987 agreement).

         The parties sealed the Norfolk Action in December 2014 pursuant to a Settlement Agreement. See Amended Complaint, par. 59 (discussing Settlement Agreement). The Settlement Agreement " represent[ed] a full and fair resolution of the claims for relief alleged in" the plaintiffs' amended complaint, Settlement Agreement, par. 103; and " address[ed] issues concerning the use of Seclusion and Restraint at [Bridgewater], including Plaintiffs' allegations about the purported prolonged, inappropriate, and/or non-emergency placement of Patients in Seclusion and/or Restraint in violation of G.L.c. 123, § 21, and Plaintiffs' inadequate medical and mental health care claims under the state and federal constitutions related solely to the use of Seclusion and Restraint." Settlement Agreement, par. 38. The parties agreed that certain matters were outside the scope of the Settlement Agreement and therefore not settled but are still open:

The Parties disagree as to whether the following practices at [Bridgewater] constitute Restraint under G.L.c. 123 but agree not to attempt to resolve their differences in this Action or Agreement. Therefore, for the purposes of this Agreement solely, Restraint shall not refer to: (a) the temporary use of mechanical devices with a Patient for safety or security purposes when the Patient is being transported within [Bridgewater]; or (b) the temporary use of mechanical devices with a Patient for safety or security purposes to prevent injury to Patients as a result of any medical or physical impairment.
The Parties disagree as to whether the following practices at [Bridgewater] constitute Seclusion under G.L.c. 123 but agree not to attempt to resolve their differences in this Action or Agreement. Therefore, for the purposes of this Agreement solely, Seclusion shall not refer to: (a) placement of a Patient in his room on a housing unit for the night at the regular hour of sleep or after 6:30 p.m. upon the Patient's request; (b) temporary placement of a Patient alone in a room for not longer than ninety (90) minutes to await medical assessment and/or treatment; (c) voluntary, temporary placement of a Patient in a room designated by the Superintendent as a Quiet Room; or (d) temporary placement of a Patient in a room for patient and inmate counts and movement. Likewise, the Parties disagree as to whether Seclusion or Restraint orders can be renewed only upon personal examination by a physician or psychiatrist after a Patient has been in Seclusion or Restraint for more than six (6) hours.

         Settlement Agreement, pars. 40-41. The parties also agreed that:

Nothing in this Agreement shall constitute a waiver by any Plaintiff . . . of any individual claim against any Defendant in a court of competent jurisdiction for monetary damages or concerning matters outside the scope of this Agreements . . . Defendants agree that plaintiffs John Doe, Peter Minich, and Felipe Zomosa shall be able to file any claim for monetary damages in any court of competent jurisdiction after execution of this Agreement, subject to any applicable notice requirements. In any such action by these three Plaintiffs, Defendants shall not raise as a defense the failure of these three Plaintiffs to seek monetary damages in this [Norfolk] Action and Defendants shall waive the defenses of res judicata, issue preclusion, and collateral estoppel with regard to this [Norfolk] Action.

         Settlement Agreement, par. 119.

         This court (Wilson, J.) approved the Settlement Agreement on March 3, 2015.

         BACKGROUND

          For purposes of a motion to dismiss under Rule 12(b)(6), the court must " accept as true the allegations in the complaint and draw every reasonable inference in favor of the plaintiff." Curtis v. Herb Chambers I-95, Inc., 458 Mass. 674, 676, 940 N.E.2d 413 (2011).[7]

          Pursuant to G.L.c. 123, § 21 (the " Restraint Law"), Bridgewater patients can only be secluded or restrained " in cases of emergency, such as the occurrence of, or serious threat of, extreme violence, personal injury, or attempted suicide[, ]" G.L.c. 123, § 21, third par.; only physicians can authorize restraint lasting more than six hours, G.L.c. 123, § 21, seventh par.; and " no adult shall be restrained for more than six hours beyond which time an order may be renewed only upon personal examination by a physician." Id. ; Amended Complaint, par. 29. Bridgewater has also adopted regulations governing seclusion and restraint, 103 BSH § 651.00 et seq., which provide, among other things, that seclusion and restraint cannot " be used for punishment, convenience, discipline, or failure to take non-court-ordered medication[, ]" 103 BSH § 651.02(2); and set forth certain preliminary interventions for staff to take before secluding or restraining a patient. 103 BSH § 651.03; Amended Complaint, par. 28.

         The " Intensive Treatment Unit" (" ITU") is the separate unit where Bridgewater places secluded and restrained patients. Amended Complaint, par. 33. The thirteen cells have solid steel doors, a window for observation, and a slot for meal delivery. Id. While inside, patients are denied exercise, adequate clean clothes, adequate showers, and sensory stimulation including reading materials, and access to visitors and telephone calls is restricted. Amended Complaint, pars. 2, 7, 33.

         Patients at Bridgewater fall into four categories: mentally ill prisoners; individuals who have been found not guilty by reason of insanity; individuals undergoing criminal competency or responsibility evaluations; and individuals who have been found to be incompetent to stand trial or not criminally responsible and are civilly committed to Bridgewater for " care and treatment." Amended Complaint, pars. 183-84; see G.L.c. 123, § 15(b), § 16(b). Bridgewater makes no distinction among these categories. Amended Complaint, par. 186. The plaintiffs fall into the fourth category, which comprises the majority of Bridgewater patients. Amended Complaint, pars. 184-85.

         Plaintiff Peter Minich (" Minich") has been diagnosed with schizophrenia. After being criminally charged, he was confined to Bridgewater from January 14, 2013, through June 26, 2014, first for a competency evaluation pursuant to G.L.c. 123, § 15(b), then, upon being deemed incompetent to stand trial, he was committed pursuant to G.L.c. 123, § 16(b). Amended Complaint, par. 60. While at Bridgewater, he spent over 6, 600 hours in seclusion[8] and over 800 hours in restraint, [9] rates that are more than 1, 000 times the 2013 national average for psychiatric facilities. Amended Complaint, pars. 2, 68; see Amended Complaint, par. 102 (detailing Massachusetts Disabled Persons Protection Commission investigation concluding that Minich " was placed in seclusion and restraint on occasion when he was not presenting threatening behavior").

         Plaintiff Felipe Zomosa (" Zomosa") has been diagnosed with schizophrenia and bipolar disorder. Amended Complaint, par. 103. Zomosa was committed to Bridgewater pursuant to G.L.c. 123, § 15, following his alleged assault of a psychiatrist at another psychiatric hospital; after six months, his civil commitment was extended because of paranoid delusions. Amended Complaint, par. 103. Zomosa was at Bridgewater from April 24, 2013, to May 29, 2014. Amended Complaint, pars. 110, 131. Immediately upon his arrival in April 2013, Zomosa was placed in seclusion despite the lack of emergency situation. Amended Complaint, par. 110. During his first year at Bridgewater, Zomosa spent over 4, 400 hours in seclusion--[10] more than half of his time at Bridgewater--and over 337 hours[11] in mechanical restraints, with some periods of seclusion and restraint lasting for months. Amended Complaint, par. 106; see Amended Complaint, par. 135 (detailing Massachusetts Disabled Persons Protection Commission investigation concluding that Zomosa " was placed in seclusion and restraint on occasions when he was not presenting threatening behavior"). These rates are more than 500 times the 2013 national average. Amended Complaint, par. 2.

         Plaintiff Jeffrey Doe (" Doe") has been diagnosed with autism, intellectual disability, and schizophrenia. Amended Complaint, par. 137. After being charged with misdemeanor assault and battery on a public employee on November 21, 2013, Doe was sent to Bridgewater for a competency evaluation; he was deemed incompetent to stand trial and was civilly committed to Bridgewater for care and treatment. Amended Complaint, par. 141. Doe spent ten months at Bridgewater, from November 28, 2013, through September 2014. Amended Complaint, par. 142, 171. On his first day at Bridgewater, Doe was immediately placed in seclusion even though there was no indication that he was acting in an assaultive manner. Amended Complaint, par. 151. During his first six months, he spent approximately 1, 532 hours--almost half of his time at Bridgewater--in seclusion.[12] Amended Complaint, par. 143. He was not placed in seclusion because of emergency situations but rather because he gave " latent responses, " was difficult to understand, and placed his hands down his pants. Amended Complaint, par. 153; see Amended Complaint, pars. 155-56, 161-62; see also Amended Complaint, par. 181 (detailing Massachusetts Disabled Persons Protection Commission investigation concluding that Doe " was placed in seclusion and restraint on occasions when he was not presenting threatening behavior"). He was also secluded as a means of punishment. Amended Complaint, par. 163.

         All three plaintiffs were subjected to seclusion and restraint for punitive and disciplinary purposes, not under emergency situations. Amended Complaint, par. 30. As a matter of custom and practice, DOC staff did not attempt to de-escalate situations or treat the plaintiffs to avoid seclusion and restraint. Amended Complaint, par. 74, 84 (Minich); Amended Complaint, pars. 117, 119 (Zomosa). Correctional officers made the decisions to seclude and restrain the plaintiffs, and often used excessive force.[13] Amended Complaint, pars. 32, 186. Nurses, rather than licensed physicians, would often renew the plaintiffs' seclusions and restraints after six hours, and renewals would occur when they were calm, compliant, or sleeping. Amended Complaint, pars. 93-94 (Minich); Amended Complaint, pars. 125-26 (Zomosa); Amended Complaint, pars. 157-60, 173-74 (Doe). The plaintiffs allege that this seclusion and restraint constituted undue restraint and unsafe treatment in violation of their constitutional liberty interest, and caused them severe physical and psychological injuries. Amended Complaint, pars. 32, 38, 207; pars. 82, 100 (Minich); Amended Complaint, pars. 133, 134 (Zomosa); Amended Complaint, pars. 133, 134, 167-70, 172, 179-80 (Doe); see Amended Complaint, par. 102 (Minich), par. 135 (Zomosa), par. 181 (Doe). Seclusion and restraint rates for the plaintiffs decreased after they filed this suit in March 2014. Amended Complaint, par. 8.

         The seclusion and restraint that the plaintiffs experienced were common practice at Bridgewater. Amended Complaint, par. 31. Between 2004 and 2013, total hours of seclusion and restraint at Bridgewater rose sixteen percent, from 1, 215 hours per 1, 000 patient days in 2004, to 1, 410 hours per 1, 000 patient days in 2013. Id. ; see G.L.c. 123, § 21, twelfth par. (requiring that Bridgewater keep " statistical records" of restraints). Further, Bridgewater patients were secluded and restrained at a rate of more than 100 times the patients at DMH facilities and the patients at other psychiatric hospitals in the United States. Amended Complaint, par. 31.[14]

         After they left Bridgewater, the plaintiffs went to DMH facilities; while there, they were provided with more extensive treatment services than they received at Bridgewater; at the DMH facilities, the plaintiffs were barely secluded or restrained at all. Amended Complaint, par. 209. As contrasted with patients at DMH facilities, Bridgewater patients have boilerplate treatment plans, are denied exercise programs and other activities, and do not receive regular therapy with licensed mental health professionals; there are insufficient mental-health-worker-to-patient ratios and restrictive visitation procedures; and it is an inadequate facility to treat mentally ill individuals. Amended Complaint, pars. 189-98. Additionally, DMH has adopted regulations to minimize and protect patients from the use of seclusion and restraint. Amended Complaint, pars. 199-204, citing 104 Code.Mass.Regs. § § 27.12, 27.14.

         In their positions as commissioner and superintendent, respectively, Spencer and Murphy[15] were aware of the undue seclusion and restraint at Bridgewater, but they failed to take any corrective action. See Amended Complaint, par. 35 (allegations concerning Murphy's knowledge); Amended Complaint, pars. 39-49 (allegations concerning Spencer's knowledge); see also Amended Complaint, par. 9 (noting that Spencer and Murphy received " formal reprimands . . . for misconduct relating to investigations into the 2009 death of a Bridgewater patient in restraints" and that there have been " [t]hree restraint related deaths since 2009"). The Restraint Law required Spencer, as commissioner, to receive " [c]opies of all restraint forms . . . [and] review and sign them within thirty days . . ." G.L.c. 123, § 21, twelfth par. Spencer refused to comply with this statutory obligation, thereby delaying the discovery that the plaintiffs were subjected to undue restraint and unsafe treatment in violation of their constitutional liberty interest. Amended Complaint, pars. 4, 46; see Amended Complaint, pars. 48, 98, 129, 177. The Restraint Law obligated Murphy, as superintendent of Bridgewater, to authorize " [t]he maintenance of any adult in restraint for more than eight hours in any twenty-four hour period . . ." G.L.c. 123, § 21, ninth par. The Restraint Law also imposed on Murphy " [r]esponsibility and liability for the implementation of the provisions of the Restraint Law. G.L.c. 123, § 21, thirteenth par. Murphy did not comply with his statutory obligations, causing the plaintiffs to be placed in prolonged seclusion and restraint. Amended Complaint, par. 5; see Amended Complaint, pars. 35, 97, 128, 176.

         Spencer's and Murphy's failures to comply with their statutory obligations under the Restraint Law resulted in seclusion and restraint occurring at Bridgewater at a rate of more than 100 times the 2013 national average. Amended Complaint, par. 6; see Amended Complaint, par. 41 (alleging that reports of seclusion and restraint at Bridgewater that Spencer received quarterly documented that rate of seclusion and restraint was 100 times higher than national averages). The plaintiffs allege that they have a " constitutional right to . . . protections to minimize the harsh affects [sic] of prolonged seclusion and restraint . . . [including] the right to reasonable exercise, the right to adequate food, hygiene and clothing, the right to minimally adequate treatment, the right to safe conditions of confinement and the right to reasonable visitation from family members." Amended Complaint, par. 29.

         DISCUSSION

         I. Standard of Review

          A party moving to dismiss pursuant to Mass.R.Civ.P. 12(b)(6) contends that the complaint fails " to state a claim upon which relief can be granted . . ." " While a complaint attacked by a . . . motion to dismiss does not need detailed factual allegations . . . a plaintiff's obligation to provide the 'grounds' of his 'entitle[ment] to relief' requires more than labels and conclusions . . ." Iannacchino v. Ford Motor Co., 451 Mass. 623, 636, 888 N.E.2d 879 (2008) (ellipses and alteration in original), quoting Bell A. Corp. v. Twombly, 550 U.S. 544, 555, 127 S.Ct. 1955, 167 L.Ed.2d 929 (2007). " Factual allegations must be enough to raise a right to relief above the speculative level . . . [based] on the assumption that all the allegations in the complaint are true (even if doubtful in fact) . . ." Id. (ellipses and alteration in original), quoting Bell A. Corp., 550 U.S. at 555. Therefore, the pleading stage requires " factual 'allegations plausibly suggesting (not merely consistent with)' an entitlement to relief, in order to 'reflect[ ] the threshold requirement of [Fed.R.Civ.P.] 8(a)(2) that the " plain statement" possess enough heft to " sho[w] that the pleader is entitled to relief." '" Id. (alterations in original), quoting Bell A. Corp., 550 U.S. at 557.

         II. Claims Under 42 U.S.C. § 1983--Count I

         In Count I, the plaintiffs seek damages for violations of their federal constitutional rights under 42 U.S.C. § 1983. Section 1983 of Title 42 of the United States Code provides that " [e]very person who, under color of any statute, ordinance, regulation, custom, or usage of any State . . . subjects, or causes to be subjected, any citizen of the United States . . . to the deprivation of any rights, privileges, or immunities secured by the Constitution and laws, shall be liable to the party injured in an action at law, suit in equity, or other proper proceeding for redress . . ." In Count I, the plaintiffs allege that Murphy and Spencer violated 42 U.S.C. § 1983 by their tolerance of the systemic abuse of restraint and seclusion at Bridgewater. Murphy and Spencer seek the dismissal of this claim on the basis that the plaintiffs cannot state a claim for supervisory liability and that, regardless, Murphy and Spencer are entitled to qualified immunity.[16]

         A. Supervisory Liability

         The defendants argue that, to hold Murphy and Spencer liable as supervisors, the plaintiffs must allege more than mere negligence, and the plaintiffs must allege a link between the employee's misconduct and the supervisor's act or omission. The defendants have correctly stated the law.

[A]n official cannot be held vicariously liable for the conduct of his subordinates--instead, such official can only be held liable on the basis of his own acts or omissions . . . A supervisor may be held liable for a subordinate's acts where [1] the subordinate's behavior resulted in a constitutional violation and [2] the supervisor's action or inaction was " affirmatively linked" to the behavior in that [3] it could be characterized as " supervisory encouragement, condonation or acquiescence" or gross negligence amounting to " deliberate indifference."

Williams v. Bisceglia, 115 F.Supp.3d 184, 188 (D.Mass. 2015) (internal citation omitted) (emphasis in original); see Ramirez-Lluveras v. Rivera Merced, 759 F.3d 10, 19 (1st Cir. 2014); Clancy v. McCabe, 441 Mass. 311, 317, 805 N.E.2d 484 (2004). Therefore, " proof of mere negligence, without more, is inadequate to ground supervisory liability." Maldonado-Denis v. Castillo Rodriguez, 23 F.3d 576, 582 (1st Cir. 1994). The plaintiffs " must allege facts to support [their] supervisory claim[s] . . . [and] it is not sufficient for [them] to simply formalistically recite the necessary elements of such a claim." Williams, 115 F.Supp.3d at 188, citing Iqbal, 556 U.S. at 681; see Maldonado-Denis, 23 F.3d at 582 (" [Supervisor] may be liable for the foreseeable consequences of such conduct if he would have known of it but for his deliberate indifference or willful blindness, and if he had the power and authority to alleviate it"). As explained below, the plaintiffs have met their burden here.

         1. Constitutional Violation

          The United States Supreme Court has held that involuntarily committed individuals have certain constitutionally protected rights. See Youngberg v. Romeo, 457 U.S. 307, 314, 102 S.Ct. 2452, 73 L.Ed.2d 28 (1982). First, " the right to personal security constitutes a 'historic liberty interest' protected substantively by the Due Process Clause." Id. at 315. It is therefore " unconstitutional to confine the involuntarily committed . . . in unsafe conditions." Id. at 316. Second, " [l]iberty from bodily restraint always has been recognized as the core of the liberty protected by the Due Process Clause from arbitrary governmental action." Id. (alteration in original) (citation omitted). Third, an individual's " liberty interests require the State to provide minimally adequate or reasonable training to ensure safety and freedom from undue restraint." Id. at 319; see Hopper v. Callahan, 408 Mass. 621, 624-25, 562 N.E.2d 822 (1990) (relying on Youngberg for holding that involuntarily committed psychiatric patient had " Federal due process right (a) to essential medical care and (b) not to be physically restrained unduly").

          To determine " whether a State adequately has protected the rights of the involuntarily committed[, ]" the court must balance the individual's " liberty interests against the relevant state interests." Youngberg, 457 U.S. at 321. In making this determination, " the Constitution only requires that the courts make certain that professional judgment in fact was exercised." Id. (citation omitted); see Hopper, 408 Mass. at 626-27, 630-32 (reciting and applying Youngberg standard). " [T]he decision, if made by a professional, is presumptively valid; liability may be imposed only when the decision by the professional is such a substantial departure from accepted professional judgment, practice, or standards as to demonstrate that the person responsible actually did not base the decision on such a judgment." Youngberg, 457 U.S. at 323 (footnote omitted).

         The plaintiffs have alleged facts plausibly suggesting that the seclusion and restraint that the plaintiffs experienced constituted a substantial departure from accepted professional judgment, practice, or standards. For example, Bridgewater staff[17] secluded and/or restrained the plaintiffs when they were not presenting threatening behavior; their seclusion and/or restraint orders were renewed even when they were calm, compliant, or sleeping; and they were secluded and/or restrained in the absence of emergency situations. Moreover, the high rates of seclusion and restraint that the plaintiffs each experienced at Bridgewater as compared not only to DMH facilities but also to the national average support the inference that the seclusion and restraint decisions were a substantial departure from accepted professional judgment, practice, or standards.

         The plaintiffs have therefore alleged facts plausibly suggesting that " the subordinate's behavior resulted in a constitutional violation . . ." See Williams, 115 F.Supp.3d at 188; see also Ramirez-Lluveras, 759 F.3d at 19.

         2. Deliberate Indifference

          Massachusetts federal courts " have typically formulated the deliberate indifference inquiry as a three-part test that requires plaintiffs to show: (1) 'that the officials had knowledge of facts, ' from which (2) 'the official[s] can draw the inference' (3) 'that a substantial risk of serious harm exists.'" Ramirez-Lluveras, 759 F.3d at 20 (alteration in original) (citations omitted); see Clancy, 441 Mass. at 318. " Under this rubric, a supervisor may be held liable for what he does (or fails to do) if his behavior demonstrates deliberate indifference to conduct that is itself violative of a plaintiff's constitutional rights." Maldonado-Denis, 23 F.3d at 582. " Therefore, substandard care, malpractice, negligence, inadvertent failure to provide care, and disagreement as to the appropriate course of treatment are all insufficient to prove a constitutional violation." Ruiz-Rosa v. Rullan, 485 F.3d 150, 156 (1st Cir. 2007).

         The plaintiffs allege that, as superintendent and commissioner, Murphy and Spencer had the " responsibility and liability" to ensure that Bridgewater employees complied with constitutional requirements, and the requirements of the Restraint Law and Bridgewater's restraint regulations. Sec G.L.c. 123, § 21, thirteenth par. " [Section] 1983 liability[, however, ] cannot rest solely on a defendant's position of authority." Ramirez-Lluveras, 759 F.3d at 19. The plaintiffs also allege that Murphy knew of the prolonged and unconstitutional seclusion and restraint to which the plaintiffs were subjected, but he failed to stop the practice.

         It is a fair inference that facility superintendent Murphy, working every day at a facility housing many mentally ill persons being subjected to the extraordinarily high rates of restraint and seclusion alleged in the amended complains must have been aware of these rates. In addition, in 2009, Murphy received a formal reprimand for misconduct with respect to the death of a restrained Bridgewater patient. Knowledge of this misconduct could also have led Murphy to infer that a substantial risk of serious harm existed, i.e., the unconstitutional restraint of patients at Bridgewater.[18] See Ramirez-Lluveras, 759 F.3d at 20. Against the backdrop of this inference, then, the allegations that Murphy knew of the unconstitutional seclusion and restraint plausibly suggest that Murphy's conduct amounted to deliberate indifference. See Ramirez-Lluveras, 759 F.3d at 19; Williams, 115 F.Supp.3d at 188.

         Spencer received quarterly reports that documented seclusion and restraint practices at Bridgewater. These reports revealed that the occurrence of these practices was 100 times the national seclusion and restraint averages. Knowledge of these facts could have led Spencer to draw the inference that Bridgewater unconstitutionally secluded and restrained its patients and that, therefore, a substantial risk of serious harm existed. See Ramirez-Lluveras, 759 F.3d at 20. Accordingly, these facts plausibly suggest that Spencer's conduct also amounted to deliberate indifference. See id. ; Williams, 115 F.Supp.3d at 188.

         3. Affirmatively Linked

          " To succeed on a supervisory liability claim, a plaintiff not only must show deliberate indifference or its equivalent, but also must affirmatively connect the supervisor's conduct to the subordinate's violative act or omission." Maldonado-Denis, 23 F.3d at 582. This " showing of causation must be a strong one, as that requirement 'contemplates proof that the supervisor's conduct led inexorably to the constitutional violation.'" Ramirez-Lluveras, 759 F.3d at 19 (emphasis in original). " [D]eliberate indifference to violations of constitutional rights can forge the necessary linkage between the acts or omissions of supervisory personnel and the misconduct of their subordinates." Maldonado-Denis, 23 F.3d at 582; see Clancy, 441 Mass. at 321 (holding that " this affirmative connection requires something . . . such as 'tacit approval of, acquiescence in, or purposeful disregard of, rights-violating conduct'" (citations omitted)).

         Therefore, the plaintiffs' facts plausibly suggesting that Murphy and Spencer were deliberately indifferent to the constitutional violations at Bridgewater also plausibly suggest this affirmative link: as superintendent and commissioner, Murphy and Spencer had statutory obligations to monitor the seclusion and restraint practices at Bridgewater; [19] failure to satisfy those obligations through their deliberate indifference " led inexorably to the constitutional violation[s]" that the plaintiffs experienced.[20] Compare Hannon v. Beard, 979 F.Supp.2d 136, 142 (D.Mass. 2013) (dismissing ...


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