16194/18

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FIFTH SECTION CASE OF MĂTĂSARU v. THE REPUBLIC OF MOLDOVA (Application no. 16194/18) JUDGMENT STRASBOURG 16 July 2026 This judgment is final but it may be subject to editorial revision. In the case of Mătăsaru v. the Republic of Moldova, The European Court of Human Rights (Fifth Section), sitting as a Committee composed of: María Elósegui, President, Diana Sârcu, Sébastien Biancheri, judges, and Martina Keller, Deputy Section Registrar, Having regard to: the application (no. 16194/18) against the Republic of Moldova lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) on 22 March 2018 by a Moldovan national, Mr Andrei Mătăsaru (“the applicant”), who was born in 1969 and lives in Chișinău, and was represented by Ms D. Străisteanu, a lawyer practising in Chișinău; the decision to give notice of the application to the Moldovan Government (“the Government”), represented by their Agent, Mr D. Obadă; the parties’ observations; Having deliberated in private on 25 June 2026, Delivers the following judgment, which was adopted on that date: SUBJECT MATTER OF THE CASE 1.  The application concerns alleged ill-treatment and inadequate material conditions to which the applicant was subjected in a psychiatric ward, where he was undergoing treatment, and the allegedly ineffective investigation into his allegations of ill-treatment. The applicant relied on Articles 3 and 8 of the Convention. The case also concerns allegedly discriminatory treatment of the applicant in breach of Article 14 of the Convention.

2. In particular, after a car accident, the applicant developed mental‑health problems, for which he periodically undergoes treatment at the Chișinău Clinical Psychiatric Hospital (“the hospital”). The present case concerns his stay at the hospital in ward no. 24 (subsequently no. 10) from 11 January to 12 February 2016.

3. Upon his release, he showed signs of violent behaviour and ill‑health. His brother, acting as his legal representative since 12 June 2013, complained orally to the police that the applicant had been assaulted by another patient in ward no. 24, which had caused him to fall and faint, and that the applicant had fallen ill after his hospitalisation because the patients there had been subjected to cold showers from a hose.

4. The police investigation found that the applicant had been assaulted on 10 February 2016 by another patient in the ward, R.M. A medical report of 13 February 2016 confirmed the presence of injuries and a bruise on the lower right side of the lip, measuring 1.8 cm by 1 cm, which had been classified as injuries of minor severity. On 3 March 2016 R.M. was found responsible for inflicting minor injuries and an administrative fine of 500 Moldovan lei (equivalent at the material time to 23 euros) was imposed on him. The applicant’s legal representative was informed of these measures on the same day.

5. On 21 March 2016 the applicant’s legal representative lodged a written complaint in respect of the assault, noting that the applicant had fainted and that other patients had dragged him to another room; that the legal representative had not been informed of the assault when it had happened; that the applicant had been in ill-health at his discharge, allegedly because the female medical assistants in the ward had washed him with cold water from a hose; that he had been administered expired medication; and that he had been forced to clean the ward, beat the carpets to remove the dust and do other heavy physical work. The discharging doctor had explained that the medical staff had been unable to ensure the safety of the patients because of limited resources and a lack of conditions to provide for the separation of dangerous patients.

6. An inquiry into the complaint was initiated by the police and included interviews with the applicant, his legal representative, his lawyer, and medical staff from the hospital (two medical assistants and one doctor). The applicant and his representative reiterated their complaints (see paragraphs 3 and 5 above), while the medical staff stated that the material conditions in the ward had been adequate, as had the level of medical assistance, and that any violent incidents had been regularly reported.

7. On 26 April 2016 the prosecutor decided to refuse the initiation of a criminal investigation, finding that no elements of a crime existed. In addition to the witness statements, the decision cited a psychiatric expert opinion from 16 March 2012 which concluded that the applicant suffered from post‑traumatic dementia and lacked capacity to acknowledge and direct his own actions. The decision noted that the applicant’s statements had not reflected reality because he could not have assessed whether the medication had been expired owing to his inability to recall the current year and he could not have been asked to carry heavy food recipients objects to the third floor because the ward was on the first floor. It also cited an on-site visit to the ward, which had taken place on an unidentified date, and described the conditions in the ward as adequate and clean, with available cold and hot water, patients moving freely within the ward, no locks in the rooms and no water hoses in sight. The decision also cited discussions held by the prosecutor with unidentified patients, who had allegedly not complained about the conditions, and stated that it had been impossible to discuss the issue with most patients owing to their “special behaviour” and inability to understand the prosecutor’s questions. The prosecutor acknowledged the assault by R.M. but noted that the incident had been reported and investigated and that the record in the applicant’s medical file showed that he had been provided with assistance for the injuries inflicted (hydrogen peroxide for the wound). The prosecutor concluded that the applicant had not been subjected to ill‑treatment. The decision was upheld by the hierarchically superior prosecutor.

8. The applicant appealed against those decisions. The investigating judge rejected the applicant’s appeal. On 5 October 2016 the Chișinău Court of Appeal upheld the appeal and ordered further investigative measures. The court found that the prior investigation had been superficial and insufficient, noting that interviewing only the medical staff of the hospital had not amounted to a diligent and efficient inquiry into ill-treatment allegations, that the prosecutor had failed to consider in his assessment the independent reports which described the conditions in psychiatric wards as amounting to ill‑treatment and that the on‑site visit had been carried out without the applicant and his representatives present.

9. On 23 November 2016 the prosecutor carried out another on‑site visit, this time accompanied by the applicant and his lawyer. The Government supplied the Court with the video footage of this on-site visit.

10. On 1 December 2016 the prosecutor again refused to institute criminal proceedings, citing the exact same reasons as before (see paragraph 7 above) except for the addition of a brief reference to the on-site visit of 23 November 2016, which “had not revealed any violations”. The decision was upheld by the hierarchically superior prosecutor.

11. The applicant appealed against those decisions, noting, among other things, that he had felt intimidated during the on-site visit by the presence of the medical staff in respect of whom he had directed his complaint. On 20 March 2017 and on 18 May 2017 respectively the investigating judge and the Chișinău Court of Appeal upheld the applicant’s appeal and ordered the hierarchically superior prosecutor to re-examine the applicant’s appeal.

12. On 10 July 2017 the hierarchically higher prosecutor again upheld the decision of 1 December 2016 (see paragraph 10 above), finding that no further investigative measures could be carried out.

13. The applicant appealed against that decision, noting that it had never been served on him. On 3 August 2017 and on 23 October 2018 respectively the investigating judge and the Chișinău Court of Appeal upheld the applicant’s appeal, noting, among other things, that the prosecutor had failed to interview other patients in the wards, “who had been disregarded as potential witnesses on account of their disability”, and had failed to assess the location of the locks on the doors in the ward (which could be closed or opened only from outside of the patients’ rooms). Photographs taken in the ward did not clarify the situation. The courts ordered the reopening of the inquiry into the applicant’s complaint.

14. Without carrying out any additional investigative actions, on 12 December 2017 the prosecutor once again refused to initiate a criminal investigation. The decision cited largely the same reasons as before (see paragraph 7 above) and also concluded that the applicant’s complaints in respect of inadequate material conditions and improper medical assistance could not amount to ill-treatment because his stay in the ward had been voluntary. Moreover, the complaints had been made by a person with limited legal capacity who was not fully able to perceive reality. As there was no appeal, that decision became final. THE COURT’S ASSESSMENT ALLEGED VIOLATION OF ARTICLE 3 OF THE CONVENTION 15.  Relying on Articles 3 and 8 of the Convention, the applicant complained of allegedly inadequate material conditions in the psychiatric ward, the regime during his stay, neglect by the medical staff and ill‑treatment at the hands of other patients. He also complained that the domestic authorities had allegedly failed to efficiently investigate his complaints.

16. Being the master of the characterisation to be given in law to the facts of the case, the Court is not bound by the characterisation given by the applicant or a Government (see Rõigas v. Estonia, no. 49045/13, § 65, 12 September 2017). The Court considers that the applicant’s complaints should be examined from the standpoint of Article 3 of the Convention only (see, for instance, Radomilja and Others v. Croatia [GC], nos. 37685/10 and 22768/12, §§ 110-27, 20 March 2018, and Clipea and Grosu v. the Republic of Moldova, no. 39468/17, §§ 63-66, 19 November 2024). Admissibility 17.  The Government submitted that the applicant had failed to lodge a civil claim to seek compensation for improper conditions in the hospital and had failed to appeal against the prosecutor’s decision of 12 December 2017 refusing the initiation of criminal proceedings in respect of his complaints (see paragraph 14 above).

18. The applicant disputed the existence or the efficiency of the remedies indicated by the Government. He asserted that there was no judicial practice in respect of the civil remedy mentioned by the Government and also that it was irrelevant in respect of his complaints of ill-treatment. Furthermore, the applicant argued that the domestic courts had ordered the reopening of the inquiries a total of three times but the prosecutor had failed to carry out any meaningful investigation into his complaints, which had rendered a repeated appeal and potential reopening just as ineffective. Moreover, the applicant submitted that he had never been informed by the prosecutor of the decision of 10 July 2017.

19. The question of exhaustion of domestic remedies is inextricably linked to the merits of the complaint concerning the effectiveness of the investigation. The Court therefore considers that it should be joined and examined together with the merits of the complaint under Article 3 (see G.M. and Others v. the Republic of Moldova, no. 44394/15, § 66, 22 November 2022).

20. The Court notes that this complaint is not manifestly ill‑founded within the meaning of Article 35 § 3 (a) of the Convention or inadmissible on any other grounds. It must therefore be declared admissible. Merits The parties’ submissions 21.  The applicant argued that he had been treated in inhuman and degrading conditions, which exceeded the threshold of severity under Article 3 of the Convention. In particular, he had had no access to fresh air, the sanitary conditions had been substandard, access to hot water had been restricted, he had been exposed to violence from other patients and he had suffered neglect on a daily basis. He referred to various reports reflecting those conditions and argued that the fact that his placement in the facility had been voluntary could not be construed as consent to ill-treatment, considering that in Moldova, medical treatment for mental-health problems was available only in this specific hospital. For this reason, he had been forced to return for treatment in 2023. He also referred to the Ombudsman’s report from 15 March 2023 concerning a riot in ward no.10 on 27 October 2022, when patients had revolted against the conditions and special forces had intervened to quell the disturbance.

22. He further argued that the investigation into his allegations of inhuman treatment had not been effective. The prosecutor had relied on his psychiatric examination of 2012 to challenge the applicant’s credibility and on superficial interviews of the medical staff concerned as grounds for refusing a formal criminal investigation, without making a genuine attempt to verify the truthfulness of the allegations. Despite the repeated judicial orders to carry out a thorough investigation, the prosecutor had failed to undertake additional investigative action.

23. The Government submitted that the applicant had been treated in adequate conditions, comprising high-quality meals, central heating, well‑equipped and clean toilets and showers, large windows and clean and tidy rooms, as evidenced by the prosecutor’s visit and the photographs taken. Moreover, his placement had been voluntary, and he had repeatedly gone to the facility for treatment since 2011. Therefore, his placement in the hospital had not constituted detention, thus the conditions of his stay could not amount to treatment contrary to Article 3.

24. In respect of the assault, the Government noted that the injuries had been of minor severity, that the incident had been reported and that the perpetrator had been identified and punished, while the applicant had been provided with medical assistance. The applicant had not complained of ill‑treatment by the medical staff, while the allegations concerning expired medication and forced labour had not been confirmed by the investigation.

25. They asserted that the investigation into the applicant’s allegations had been thorough, and that the prosecutor had carried out all reasonable investigative actions, even though the investigation had been in the preliminary phase (see paragraphs 6, 7 and 9 above). The prosecutor had heard the applicant, the medical staff and some of the patients in the ward, and had visited the relevant units, taking photographs confirming the adequate conditions there. The applicant’s representative had not clarified which further investigative measures could have been taken. The Court’s assessment 26.  The general principles concerning the adequacy of material conditions in psychiatric wards, ill-treatment and investigation into ill‑treatment have been summarised in Clipea and Grosu (cited above, §§ 35‑45 and §§ 58‑62).

27. At the outset, the Court notes that it has found in the past that even when applicants had been admitted to a psychiatric hospital voluntarily, there had been sufficient elements of coercion so as to treat their subsequent stay and treatment there as being de facto involuntary (ibid., §§ 63‑66). There is no reason for the Court to distinguish the present case from Clipea and Grosu (cited above).

28. In respect of the investigation, the Court observes that the national authorities promptly initiated a preliminary inquiry into the applicant’s allegations, interviewing the applicant and certain medical staff. The preliminary inquiry partly confirmed the applicant’s statements concerning the assault by another patient. Numerous independent reports also described the difficult conditions in the wards. For this reason, the Court considers that the Moldovan authorities were faced with “arguable” claims. However, it does not appear that any criminal investigation was actually initiated to allow the collection of evidence (see Gasanov v. the Republic of Moldova, no. 39441/09, § 53, 18 December 2012).

29. The preliminary inquiry included the hearing of the applicant, his representatives and medical staff from the hospital. Although the prosecutor referred to “discussions” with patients in the ward, those persons were never identified and the prosecutor stated that most patients in the ward had been unreliable as witnesses on account of their mental-health issues (see paragraph 7 above). The domestic courts, while ordering the reopening of the inquiry, criticised the prosecutor’s approach in respect of relying on the medical staff’s statements, disregarding patients as potential witnesses and ignoring independent reports (see paragraphs 8 and 13 above); however, no further investigative action was undertaken.

30. The documents in the inquiry file submitted by the respondent Government do not contain any report of the on-site visit of 23 November 2016. The prosecutor’s decisions also do not contain any description of what was observed during that visit (see paragraph 10 above). The domestic courts explicitly criticised the prosecutor’s failure to assess various issues raised by the applicant after that on-site visit (locks on the doors, light shoes worn by patients and the fact that no one had been seen outside of the building; see paragraph 13 above), but no further clarification or investigative measures followed.

31. The applicant’s allegations of violence inflicted on him by another patient have been confirmed, but there is nothing in the inquiry file about whether the hospital fulfilled its obligation of carrying out a risk assessment of violence from other patients and, if such risk had been identified, of putting in place the necessary means to prevent such violence, for example separating aggressive patients.

32. Lastly, the applicant and his lawyer were insufficiently informed of the course of the investigation and the lawyer had to ask for updates on a number of occasions (see paragraphs 13 and 18 above). The applicant was thus not able to participate effectively in the inquiry.

33. In the light of its conclusions above that the investigation into the applicant’s allegations was ineffective, the Court considers that he was not required to lodge another appeal against the prosecutor’s refusal of 2017 in order to exhaust domestic remedies (see mutatis mutandis, G.M. and Others v. the Republic of Moldova, cited above, § 108). In respect of the civil remedy, a similar objection has been previously dismissed by the Court (see Clipea and Grosu, cited above, § 50, and V.I. v. the Republic of Moldova, no. 38963/18, §§ 82-84, 26 March 2024) and there is no reason to reach a different conclusion in the present case.

34. Accordingly, the Court dismisses the Government’s objection in respect of non‑exhaustion of domestic remedies (see paragraphs 17‑19 above) and finds that there has been a violation of the procedural limb of Article 3 of the Convention.

35. The Court notes the applicant’s description of his conditions in the hospital where he was treated (see paragraphs 5 and 21 above). They largely match those described by other applicants treated in the same hospital in 2014 and in respect of which a violation of Article 3 was already found (see Clipea and Grosu, cited above, §§ 9, 14, 72, 77-78, and V.I. v. the Republic of Moldova, cited above, §§ 25 and 156-57). The Government have failed to provide any information about the improvement of the material conditions from 2014 to 2016, when the applicant stayed there, in order to allow the Court to reach a different conclusion in the present case.

36. There has accordingly been a violation of Article 3 of the Convention in respect of the material conditions in which the applicant was treated.

37. In respect of the applicant’s complaint of violence at the hands of another patient in the ward, the Court observes that Article 3 of the Convention imposes on States a duty to protect the physical well‑being of persons who find themselves in a vulnerable position by virtue of being within the control of the authorities (see, mutatis mutandis, Premininy v. Russia, no. 44973/04, § 73, 10 February 2011). The Court has held that to successfully argue a violation of an applicant’s Article 3 right it would be sufficient for the applicant to demonstrate that the authorities had not taken all steps which could have been reasonably expected of them to prevent real and immediate risks to the applicant’s physical integrity, of which the authorities had or ought to have had knowledge (ibid., § 84).

38. In the present case, the applicant has not made any submissions that the hospital staff knew or ought to have known that he was at risk of violence, whether inflicted by other patients in general or by another patient in particular. While indirect elements in this regard may be discerned (see paragraph 5 above), the applicant did not argue anything specifically in this respect. The difficulty in determining whether there was any identifiable risk to the applicant’s well-being in the hospital also stems from the authorities’ failure to investigate his complaints in respect of his neglect by the medical staff, which has already resulted in a finding of a violation of the procedural limb of Article 3 of the Convention (see paragraphs 31 and 34 above). The Court concludes, therefore, that there has not been a violation of the substantive limb of Article 3 of the Convention in that connection. ALLEGED VIOLATION OF ARTICLE 14 OF THE CONVENTION TAKEN IN CONJUNCTION WITH ARTICLE 3 39.  Relying on Article 14 read in conjunction with his other complaints, the applicant argued that he had suffered discrimination in the enjoyment of his Convention rights on the ground of his medical condition.

40. The Court notes that this complaint is not manifestly ill‑founded within the meaning of Article 35 § 3 (a) of the Convention or inadmissible on any other grounds. It must therefore be declared admissible.

41. The applicant submitted that, owing to his medical diagnosis, he had been treated with distrust, stigma and prejudice. He had felt neglected, his complaints had been disregarded on the basis of his diagnosis and the prosecutor had focused on discrediting him rather than investigating the case.

42. The Government argued that the applicant had not been subjected to discrimination, as there had been nothing in the case revealing a biased or stereotyped attitude. The authorities had fully examined his complaints, in accordance with Article 3 standards, and had treated the applicant with due respect. The reference to his diagnosis and inability to recall the year had not reflected any stigma but had been a factual conclusion as to why the applicant had been unable to properly assess the validity of the medication.

43. The general principles concerning discrimination in situations such as that in the present case have been summarised in Clipea and Grosu (cited above, §§ 87‑90).

44. The Court notes that, similar to Clipea and Grosu (ibid., § 92), in the present case the prosecutor repeatedly relied on the applicant’s diagnosis in order to question his credibility and refuse the initiation of the criminal investigation (see paragraphs 6, 11 and 14 above).

45. The reasoning given by the prosecutor reveals a difference in treatment between the applicant and other alleged victims of inhuman and degrading treatment and that that difference was based on the applicant’s mental‑health condition and was one of the reasons for rejecting his complaints as unfounded. This discriminatory attitude against persons with mental‑health issues or intellectual disorders is further confirmed by the prosecutor’s failure to interview other patients in the ward on account of their alleged unreliability as witnesses, “special behaviour” and inability to correctly assess reality owing to their medical condition, despite the explicit court order to do so (see paragraphs 6 and 13 above).

46. In the Court’s view, there was no objective and reasonable justification for rejecting the applicant’s complaints on the sole basis of his mental‑health diagnosis and in the absence of any proper investigative actions (see Clipea and Grosu, cited above, §§ 95-97).

47. There has accordingly been a violation of Article 14 of the Convention taken in conjunction with Article 3 in the present case. APPLICATION OF ARTICLE 41 OF THE CONVENTION 48.  The applicant claimed 15,000 euros (EUR) in respect of non‑pecuniary damage. He referred to the suffering caused to him by his treatment in inadequate conditions and the discrimination against him. The applicant also claimed EUR 2,647 in respect of costs and expenses incurred before the Court and requested that the amount of the costs and expenses be paid directly into his lawyer’s bank account. He submitted a contract signed by both parties and a detailed description of the services provided signed by the lawyer only.

49. The Government submitted that the claim in respect of non‑pecuniary damage was excessive and inconsistent with the Court’s awards in similar cases, and that the claim for costs and expenses was unsubstantiated and excessive. They argued that the lawyer should have represented the applicant pro bono.

50. The Court considers that the applicant must have suffered a certain amount of stress and frustration as a result of the treatment contrary to Articles 3 and 14 of the Convention. Accordingly, ruling on an equitable basis, it awards the applicant EUR 7,500 in respect of non‑pecuniary damage, plus any tax that may be chargeable.

51. Having regard to the documents in its possession, the Court considers it reasonable to award EUR 2,500, plus any tax that may be chargeable to the applicant on that amount, in respect of costs and expenses, to be paid into the bank account indicated by the applicant’s representative (see G.M. and Others v. the Republic of Moldova, cited above, § 156). FOR THESE REASONS, THE COURT, UNANIMOUSLY, Joins to the merits the Government’s preliminary objection as to the non‑exhaustion of domestic remedies and dismisses it; Declares the application admissible; Holds that there has been a violation of Article 3 of the Convention in respect of the investigation into the applicant’s allegations of ill‑treatment; Holds that there has been a violation of Article 3 of the Convention in respect of the material conditions of the applicant’s treatment; Holds that there has been no violation of Article 3 of the Convention in respect of the applicant’s ill-treatment; Holds that there has been a violation of Article 14 of the taken in conjunction with Article 3 of the Convention; Holds that the respondent State is to pay the applicant, within three months, the following amounts, to be converted into the currency of the respondent State at the rate applicable at the date of settlement: EUR 7,500 (seven thousand five hundred euros), plus any tax that may be chargeable, in respect of non-pecuniary damage; EUR 2,500 (two thousand five hundred euros), plus any tax that may be chargeable to the applicant on that amount, in respect of costs and expenses to be paid into the bank account of his representative; that from the expiry of the above-mentioned three months until settlement simple interest shall be payable on the above amounts at a rate equal to the marginal lending rate of the European Central Bank during the default period plus three percentage points; Dismisses the remainder of the applicant’s claim for just satisfaction. Done in English, and notified in writing on 16 July 2026, pursuant to Rule 77 §§ 2 and 3 of the Rules of Court. Martina Keller María Elósegui Deputy Registrar President