Background
Andrei Mătăsaru, a Moldovan national, was voluntarily admitted to the Chișinău Clinical Psychiatric Hospital from 11 January to 12 February 2016 for mental health treatment following a car accident. During his hospitalization in ward no. 24, he was assaulted by another patient, R.M., on 10 February 2016, sustaining minor injuries. Upon discharge, Mătăsaru alleged exposure to degrading conditions, including cold showers from hoses, expired medication, forced labor, and inadequate material conditions.
Mătăsaru’s legal representative lodged a complaint with police, which confirmed the assault and imposed a minor administrative fine on R.M. However, when the representative filed a comprehensive complaint on 21 March 2016 detailing the broader conditions and neglect, the prosecutor’s office initiated only a preliminary inquiry. On 26 April 2016, the prosecutor refused to initiate a criminal investigation, citing a 2012 psychiatric expert opinion stating that Mătăsaru suffered from post-traumatic dementia and lacked capacity to accurately perceive events.
Over the next 18 months, domestic courts repeatedly ordered the prosecutor to reopen the investigation and undertake proper investigative measures. Despite these orders, the prosecutor conducted no meaningful additional investigation and issued three successive refusals to prosecute (1 December 2016, 10 July 2017, and 12 December 2017), each relying on the same rationale and the applicant’s psychiatric diagnosis to discredit his complaints.
The Court’s Holding
The Court unanimously found a violation of the procedural aspect of Article 3 (prohibition of torture and inhuman or degrading treatment). The investigation into Mătăsaru’s allegations was ineffective. Although the prosecutor’s preliminary inquiry confirmed the assault by another patient and independent reports documented difficult conditions in psychiatric wards, no criminal investigation was actually opened to allow evidence collection. The prosecutor repeatedly relied on Mătăsaru’s psychiatric diagnosis to reject his credibility and refused investigative measures ordered by domestic courts. Critically, the prosecutor dismissed other patients in the ward as potential witnesses solely because of their mental health conditions and “special behaviour,” despite explicit court orders to interview them. The prosecutor also failed to properly document or follow up on an on-site visit or address the applicant’s concerns about ward security features and conditions.
The Court further found a violation of the substantive aspect of Article 3 regarding material conditions. Mătăsaru’s descriptions of hospital conditions—restricted access to hot water, inadequate sanitation, and physical neglect—matched conditions documented by other applicants treated in the same hospital in 2014, for which the Court had already found Article 3 violations. The Government provided no evidence of material improvements between 2014 and 2016. The applicant’s voluntary admission did not constitute consent to inhuman treatment, particularly where psychiatric care in Moldova was available only at this facility.
The Court also found a violation of Article 14 (prohibition of discrimination) taken in conjunction with Article 3. The prosecutor’s systematic reliance on Mătăsaru’s psychiatric diagnosis to discredit his allegations and refuse investigation revealed discriminatory treatment based on his mental health condition. The prosecutor’s approach of dismissing other psychiatric patients as unreliable witnesses on account of their medical condition reinforced this discriminatory pattern. The Court found no objective and reasonable justification for rejecting the complaints based solely on diagnosis and in the absence of proper investigation.
Key Takeaways
- States have an affirmative duty to investigate allegations of ill-treatment in psychiatric hospitals thoroughly and impartially, even when the complainant has a documented mental health condition.
- A psychiatric patient’s mental health diagnosis cannot be used as a blanket basis to discredit their complaints or dismiss other mentally ill persons as witnesses; doing so constitutes prohibited discrimination.
- Voluntary admission to a psychiatric hospital does not waive protection against inhuman or degrading treatment, particularly where institutional psychiatric care is a monopoly.
- Repeated court orders to conduct proper investigation create a procedural obligation that prosecutors must meaningfully implement; reopening inquiries without substantive investigative action violates Article 3’s procedural dimension.
Why It Matters
This judgment reinforces that persons with mental health conditions are an especially vulnerable population entitled to rigorous procedural protection against institutional abuse. The decision signals that judicial skepticism of psychiatric patients’ accounts—even when based on documented cognitive limitations—violates the duty to investigate impartially and amounts to impermissible discrimination. The Court’s ruling is significant for Moldova, which has faced multiple Article 3 findings concerning conditions in the same psychiatric hospital, indicating systemic deficiencies in both institutional standards and investigative accountability.
More broadly, the case establishes that states cannot outsource deference to medical professionals as a substitute for independent investigation when abuse is alleged. The prosecutor’s reliance on a 2012 psychiatric assessment to dismiss 2016 complaints—without reassessing the applicant’s credibility in the specific context of each allegation—exemplifies the kind of diagnostic gatekeeping that the Court now views as both procedurally deficient and discriminatory. The judgment will likely influence how prosecutors in member states approach complaints from institutionalized persons with disabilities and mental health conditions.