This case challenges the failure of the District of Columbia government to protect some of its most vulnerable patients from back-to-back crises at their treatment facility: first, an extended water outage in the fall of 2019, and second, the COVID-19 pandemic in the spring of 2020.

For more than three weeks, Saint Elizabeths Hospital, an inpatient mental health facility operated by the District, did not have clean running water. The crisis caused the facility to drastically reduce the availability of therapy sessions and cease providing some medical care altogether.

Patients and staff were not able to regularly flush toilets, resulting in fecal matter, urine, and menstrual blood overflowing onto bathroom floors. Indoor showers were turned off. The outdoor showers that the District obtained were clogged and dirty. Patients had to walk to those showers in groups and wait outside, dripping wet in cold temperatures, for other members of their group to finish showering before they could go indoors. The conditions in St. Elizabeths attracted insects and produced a stench that one patient compared to the smell of dead rats.

In response, the District chose not to transfer patients to new facilities or even cease admitting new residents. Instead, it confined patients in filth and disorder, subjecting them to trauma that could exacerbate their mental health disabilities.

The conditions that festered at St. Elizabeths and the District’s response to them shock the conscience. They also violate patients’ rights under the Fifth Amendment. On October 23, 2019, in collaboration with the Washington Lawyers’ Committee for Civil Rights and Urban Affairs and Arnold & Porter, the ACLU-DC filed suit to demand that St. Elizabeths provide patients the care they deserve.

The same day we filed our lawsuit, the District restored clean running water at St. Elizabeths. It has not, however, explained how it will address the fallout from this crisis or prevent similar crises from arising the next time an emergency occurs at the facility. We will therefore still be seeking appropriate orders from the court.

In December 2019, the District asked the court to dismiss the complaint, and in January 2020, the court granted us discovery to respond to the District’s arguments.

Before discovery concluded, it became clear in the spring of 2020 that the District’s lack of emergency preparedness was again jeopardizing patients’ health and safety when the COVID-19 pandemic hit Washington, D.C. Despite clear guidance from the Centers for Disease Control, the D.C. Department of Health, and the Mayor’s orders, the District is not ensuring that patients at Saint Elizabeths Hospital are properly protected from the risk of contracting COVID-19. Patients at Saint Elizabeths Hospital are unable to properly practice social distancing. Symptomatic patients are not tested at all, or not tested in a timely matter. Symptomatic patients are not medically isolated from other patients who reside in their unit. Known or suspected cases of COVID-19 have generally not been transferred to other facilities where they can receive appropriate treatment. Patients who test positive for COVID-19 are not quarantined from other patients. The Hospital has continued to be open for new admittances.

By April 16, 2020, the Department of Behavioral Health reported that four Saint Elizabeths Hospital patients have died of coronavirus, and 32 patients and 47 staff at the Hospital have tested positive for COVID-19.

That day, plaintiffs moved to amend their complaint to challenge the unconstitutional and unconscionable conditions at the Hospital and seek patient releases, individualized patient assessments, and conditions reform.

The court granted the plaintiffs’ motion to amend their complaint, and after two telephone hearings, granted plaintiffs’ motion for emergency relief on the two issues we identified as most pressing—the failure to medically isolate patients who have been exposed to the virus, and the failure to adhere to CDC guidance in deciding when to release patients from isolation. In an order issued early Saturday morning, April 25, the court noted that the number of patient deaths had risen to seven and recognized that “the risks to Plaintiffs are immediate and manifest.” The court concluded that “Plaintiffs have offered compelling evidence (on the extremely expedited schedule governing their motion for a [temporary restraining order]) that the challenged practices substantially depart from accepted professional standards.” Accordingly, the court ordered the District to conform to CDC guidance by increasing its use of medical isolation at the Hospital and by imposing more stringent criteria before releasing patients from isolation.

The court appointed three experts as “friends of the court” to investigate and report on the conditions at St. Elizabeths. Following their report, the court on May 11 extended and expanded the original TRO—adding requirements that the Hospital limit staff movement between units and test staff for the virus. On May 24, the court issued a preliminary injunction requiring the Hospital to continue with the court-ordered measures regarding isolation, staff movement, and staff testing for the duration of the litigation. As the court explained in its May 24 order, “roughly one out of every twenty patients has died and more than one out of every three patients have been infected.” Further, the court found that the District could not defend, as a matter of professional judgment, its “perilous practice” regarding isolation prior to the TRO, and the court “conclude[d][ that Defendants’ delay in testing all staff and their lack of a plan to continue testing all patients and staff constitutes a substantial departure from professional judgment.”

The government appealed the preliminary injunction in June 2020. While the appeal proceeded, the government also filed a motion to dismiss the case in the district court, even though the preliminary injunction was still in place. Briefing on the government’s motion concluded in December 2020. At the end of April 2021, we moved the court to lift its injunction because of the high vaccination rate for patients and staff, significant improvements in the care and testing for patients and staff, and adherence to the Centers for Disease Control’s COVID-19 protocols. At the time of the court’s order in May 2020, 187 had tested positive and 14 individuals had died in the 2 ½ months since the pandemic began. In the 11 months the Hospital operated under the court’s order, by contrast, there were 18 positive cases and one death. We believe the injunction did its job and was a life-saving measure for patients at St. Elizabeths. The court vacated the preliminary injunction in early May 2021, and the court of appeals dismissed the District’s appeal as moot.

After extensive negotiations, the parties reached a settlement of the entire case in February 2023. Under the settlement agreement, the District will take affirmative steps to protect patient safety, to ensure they are receiving the medical and mental health care they need, and to ensure they are not placed in unwarranted restrictive settings as the result of an emergency. Specifically, the District has agreed to provide documentation that the water contamination has been remediated; has agreed to procure and maintain a supply of personal protective equipment for patients and staff; has agreed to maintain agreements with other District hospitals to ensure they can accept St. Elizabeths patients in the event of an emergency and that resources are available for the patient to continue receiving medical and mental health treatment at those facilities; and has agreed that patients, families, and the community will be informed about future emergencies at St. Elizabeths. The District has also made substantive improvements to its Outbreak/Pandemic Management Plan in compliance with the standards set by the D.C. Department of Health and CDC. In exchange for these measures, we dismissed the case. We believe this settlement will help ensure that the government meets its constitutional obligation to provide a safe environment for the patients of St. Elizabeths.

Pro Bono Law Firm(s)

Arnold & Porter Kaye Scholer LLP, Washington Lawyers' Committee for Civil Rights and Urban Affairs

Date filed

October 23, 2019