Document - Romania: Memorandum to the government concerning inpatient psychiatric treatment



Memorandum to the government concerning inpatient psychiatric treatment

Amnesty International is concerned that the placement, living conditions and treatment of patients and residents in many psychiatric wards and hospitals in Romania are in violation of international human rights standards and best professional practice in this field. The situation in the psychiatric hospital in Poiana Mare described in a report published by Amnesty International on 20 February 20041, unfortunately, is not an exception in the Romanian mental health care system. The deaths of 18 patients in Poiana Mare in January and February 2004, reportedly mostly as a result of malnutrition and hypothermia, underlined the urgency with which the Romanian government should take steps to protect the lives, dignity and well-being of all patients and residents in psychiatric wards and hospitals in the entire country. The deplorable situation in many psychiatric facilities also requires that the authorities implement with utmost urgency a comprehensive and effective reform of the mental health services which would be in line with international human rights standards and best professional practice.

Amnesty International welcomes the statement published by the Ministry of Health on 11 March 2004 that all psychiatric wards and hospitals in the country would be inspected in order to improve the provision of medical treatment and care. The organization is addressing this memorandum to the Romanian Government to ensure that in this process the basic rights of all people with mental disorders or intellectual disabilities2, and others, who are placed in psychiatric facilities, are protected and that they are provided with treatment and care that is in line with international human rights standards and best professional practice.

Amnesty International considers that people who are placed for treatment in psychiatric hospitals are in a particularly vulnerable position. They require particular protection with regard to their physical and intellectual integrity as well as their basic rights to be free from arbitrary detention and to be free from cruel, inhuman and degrading treatment or punishment. In November 2003 and February 2004 a delegate of Amnesty International visited six psychiatric hospitals in Bucharest, Poroschia, Mocrea, Gǎtaia, Ştei and Nucet. Amnesty International highly appreciates the cooperation of the staff of the institutions visited, who allowed its delegate to inspect the institutions and, in most places, provided information concerning some aspects of the patients/residents’ lives and the operation of the establishment. In the course of the visits Amnesty International’s delegate met many administrators and staff members who appeared genuinely committed to provide the best possible care to the people in their institutions, given the limitations of their training and available resources. This report is based on the findings of the visits but also on a substantial amount of information the organization has received from people who have worked in many psychiatric wards and hospitals in Romania over a period of many years. Many of them were concerned about the abuses that they had observed but equally anxious that their access to the institutions might be restricted and that, as a result, the people who depend on their assistance will suffer, because they had disclosed information to Amnesty International. Any such action by the authorities would be considered by Amnesty International to be in breach of the Declaration of Basic Principles of Justice for Individuals, Groups and Organs of Society to Promote and Protect Universally Recognized Human Rights and Fundamental Freedoms (the Human Rights Defenders Declaration). Amnesty International has also referred to reports published in the Romanian press, which in most instances had not been challenged by the responsible authorities.

Summary of Concerns

In Romania, the placement of people for involuntary psychiatric treatment who have not been charged with any criminal offence or people who have been placed in hospitals on non-medical grounds (referred here as residents) amounts to arbitrary detention and denial of fair trial rights, including Articles 9 and 14 of the International Covenant on Civil and Political Rights (ICCPR) and Articles 5 and 6 of the European Convention for the Protection of Human Rights and Fundamental Freedoms (ECHR). Romania has ratified both of these treaties and is bound to enforce them fully. The reported living conditions in many of the psychiatric wards and hospitals, the ill-treatment of patients, methods of restraint and enforcement of seclusion, the lack of adequate habilitation and rehabilitation or adequate medical care as well as the failure to investigate impartially and independently reports of ill-treatment would amount to violations of Article 7 of the ICCPR and Article 3 of the ECHR which prohibit torture or inhuman or degrading treatment or punishment. The denial of adequate medical care for people with mental disorders and intellectual disabilities, placed in psychiatric wards and hospitals in Romania, would also be in violation of Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) which sets out the right to the enjoyment to the highest attainable level of physical and mental health. Furthermore, Principle 1(5) of the UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care (hereafter referred to as MI Principles)3states that: “Every person with a mental illness shall have the right to exercise all civil, political, economic, social and cultural rights as recognized in the Universal Declaration of Human Rights, the International Covenant on Economic, Social and Cultural Rights, the International Covenant on Civil and Political Rights and in other relevant instruments…”.

Placement in psychiatric wards and hospitals

The Law on Mental Health and Protection of People with Psychological Disorders (Legea sănătăţii mintale şi a protecţiei persoanelor cu tulburǎri psihice, hereafter referred to as Law on Mental Health) which came into force in August 2002 prescribed the procedure for the placement of patients for involuntary treatment. A special psychiatric commission should confirm within 72 hours of a person’s admission to a hospital the treating psychiatrist’s decision that she/he remain for involuntary treatment. Furthermore, this assessment should be reviewed within 24 hours by the public prosecutor, whose decision, in turn, may be appealed before a court. The provisions of the Law on Mental Health, however, are still not being implemented because the government has failed to adopt necessary regulations for its enforcement. Therefore, Amnesty International considers all patients who are subjected to psychiatric treatment against their will in Romania as being arbitrarily detained as their treatment is not subject to an independent and impartial review as required by international standards, including the MI Principles and the Eighth Annual Report4 of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT).

Many of the people placed in psychiatric wards and hospitals throughout the country apparently do not suffer an acute mental disorder and many do not require psychiatric treatment. Their placement in psychiatric hospitals cannot be justified by the provisions of the Law on Mental Health and they should also be considered as people who have been arbitrarily deprived of their liberty. They had been placed in the hospital on non-medical grounds, apparently solely because they could not be provided with appropriate support and services to assist them and/or their families in the community. Often, because of their disability they are more vulnerable to abuse, which apparently is not taken into consideration by hospital staff as in most places such residents were not segregated from people who have different needs for care. A large number of people, who are sometimes referred to by the hospital staff as ‘social cases’, are young adults who had been placed in the psychiatric hospitals following their release from institutions for children with mental disabilities. Their needs, particularly to be integrated into the life of the community, are not being addressed. Amnesty International is concerned that many such residents may not have been properly assessed. Many have been diagnosed with “oligophrenia5 with behavioural disorder” and are given psychotropic medications to subdue behaviours which may not have a psychiatric basis, but result from distress and/or anger arising from the environment. Some of them have been assessed as ‘chronic psychiatric patients’ and placed in medical-social centres, which had been set up in some instances on the premises of a psychiatric hospital where such residents had previously been held. Residents with similar needs, being similarly treated, were also observed in rehabilitation and recovery centres, long-term institutions which are subordinated to the National Authority for Persons with Handicap.

In some of the psychiatric hospitals which are designated as establishments with “maximum security measures” (spitalul pentru măsuri de siguranţă maximă) those who are being held for treatment under the provisions of the Penal Code are not effectively segregated from other patients and residents, further increasing the risk of abuse of those who are more vulnerable.

In November 2003 a representative of Amnesty International, who visited a closed male psychiatric ward in the Obregia Hospital in Bucharest, was told that many of the people who are brought to the hospital initially refuse to be admitted but are ‘persuaded’ that this is in their best interest. The patients then sign a form consenting to the treatment. Twenty men in a locked ward were all being treated on a “voluntary basis”. Some of the men complained that they would like to leave the hospital but were not allowed to. One man was reported not to suffer from any mental health problem and was not receiving any pharmacotherapy. He had been brought to the hospital by the police and was described as homeless and suffering from “oligophrenia”, following his release from an orphanage where he had been brought up. During his stay in the hospital he had not been engaged in any kind of educational or therapeutic activity and had never been visited by a social worker to establish his needs for reintegration into the community and to assist him in this process.

In the psychiatric hospital in Poroschia, Amnesty International’s representative spoke to Gheorghina Podcoreanu, who is 24 years old and had been brought to the hospital at the age of 18. She was brought up in an institution for children with intellectual disabilities. On reaching adulthood she was sent to the municipality where she had been born and then inappropriately placed in the psychiatric hospital as there were apparently no social services to provide her with assistance for life in the community. She was in good health at the time of the visit, at mid-day, yet she was in bed reading a book, because there was no heating and no appropriate activities for her in the hospital.

In Mocrea although only one patient was considered as being treated on an involuntary basis, the vast majority of male patients and half of the women patients were held in locked wards. There was no clear policy and procedure for placing patients into the locked dormitories. There were also about 20 patients diagnosed as “oligophrenic”, who had inappropriately been placed in the hospital and some of whom did not receive any psychiatric treatment. One of them was a minor and her placement in a psychiatric hospital for adults is in violation of Romania’s commitments under the UN Convention on the Rights of the Child. Anghela Ciurar, who was 17 years old, was brought to the hospital by the police when she was 13. She was assessed as suffering from “second degree oligophrenia”. The police in Bocsig had issued her with a birth certificate but she apparently was not entitled to a medical file as she had not been registered with the National Health Insurance Fund.

In Gǎtaia Amnesty International’s delegate was initially told by the director that 40 to 50 residents did not require any specific treatment program. Most of them had been transferred to the hospital from an institution for children with intellectual disabilities in Lugoş. Later, however, the director stated that around 100 patients/residents would not need to be in the 450-bed hospital if there had been appropriate social services to assist them in the community.

The management of the psychiatric hospital in Nucet, apparently with good intentions, was attempting to implement the Law on Mental Health, although this did not appear to be appropriate and systematic. In February 2004, at the time of the visit of Amnesty International’s delegate, there were four cases of involuntary treatment for schizophrenia. The admission of such patients was carried out at the request of the patient’s family or the police, following complaints about the patient’s conduct. Most of the patients receiving treatment on an involuntary basis apparently had a history of treatment and the diagnosis which had been made earlier served as the basis for their current admission. The hospital informed the public prosecutor about the decision to place a person for involuntary treatment. There were no records that the patients or their legal representatives had been informed of the commission’s and the prosecutor’s decisions and advised of their right to a judicial appeal. A commission composed of psychiatrists working in the hospital reviewed the need for the treatment every 15 days. Amnesty International’s delegate was informed that the procedure for the implementation of the Law on Mental Health had been discussed, immediately following its adoption in the summer of 2002, at the Bihor County Department of Public Health, an authority that appeared to be supporting psychiatric facilities for which it was responsible more effectively than those in other counties visited. In 2003 they had three or four cases of involuntary treatment. A patient interviewed by Amnesty International’s delegate had been admitted for treatment for substance abuse at his own request on 13 January 2004. His treatment, upon a request by the patient’s mother, was “reclassified” on 2 February 2004, as involuntary for reasons which the staff were unable to clarify. The patient’s file did not contain a copy of the letter to the prosecutor regarding the grounds for his involuntary treatment or the prosecutor’s confirmation of the commission’s decision. The patient had not been informed whether the prosecutor had approved this decision; he had not been informed of his right to a judicial appeal; and did not know of any possibility to be represented by a lawyer in this process.

Similarly to other psychiatric hospitals visited, the institution in Nucet accommodated 15 to 20 residents who had been placed there for “social reasons”. As of 1 December 2003, a hospital ward had been transformed into a medical-social centre. The vast majority of its 98 residents had been transferred to Nucet from institutions for children. The most recent such admission took place on 1 December 2003, though it was not clear why no attempt had been made to place this person in a rehabilitation and recovery centre. The assessment of the residents was carried out by the hospital over a six-month period. This assessment may not have been adequately carried out for all residents. When questioned how many of the residents suffered from an autistic spectrum condition the psychiatrist responsible for the centre replied: “Autism is a condition found only in children. It later changes into another psychiatric condition.” The centre also cares for about 20 residents who had been placed in a sheltered home in the village.

Living conditions

Many of the buildings containing psychiatric hospitals visited by Amnesty International’s representative as well as those described in the reports received by the organization were in a poor state of repair and required major refurbishment. Most wards were inadequately furnished and decorated; in many place the mattresses and bedding were poor, sometimes completely inadequate. The general level of sanitation in many places was unsatisfactory, sometimes unhygienic. Hardly any psychiatric facility in Romania provides patients and residents with adequate space to ensure their privacy. Overcrowding in some hospitals resulted in patients having to share beds. In some instances patients shared beds as this was the only way to keep warm in unheated wards. The situation was worse in wards and hospitals for long-term patients and for those with the most severe disabilities and therefore more complex care requirements. Many of these hospitals were in remote rural areas and patients had no contact with the community.

Most hospital administrators stated to Amnesty International’s representative that the funding for the maintenance of the facilities was insufficient. One hospital director was reportedly told by the county public health official to find “sponsors” who would fund the modernization of the hospital. Although the situation varied somewhat among the counties, hospital budgets were frequently not sufficient to provide even for the nourishment of patients and residents. Therefore hospital food was of insufficient quantity and quality and long-term patients in many wards and hospitals appeared to be malnourished.

In many wards and hospitals the level of personal hygiene was generally inadequate. Patients and residents took showers in poor facilities, usually only once a week. Toilets were frequently malfunctioning and inappropriate for people with disabilities. Long-term patients had few if any personal belongings. Reports about long-term patients described many as being poorly clothed, sometimes without any shoes; some were scantily clothed or allowed to go naked.

Most wards and hospitals had very limited if any provisions for recreational or leisure activities, particularly in winter months. In some wards and hospitals the patients had no access to any outdoor activity at all.

The problem of heating the psychiatric hospitals has been a chronic one and many establishments in the 2003/2004 winter period were again unable to provide, or experienced great difficulties in ensuring, adequate living conditions for their patients and residents. This had an adverse effect on the psychological and psychical state of health of patients and residents, particularly those who are being held on a long-term basis. Reports about the consequences of such conditions were incidental. In December 2001 lack of heating in the psychiatric hospital in Jebel reportedly resulted in the deaths of five patients from hypothermia. Recent reports from psychiatric hospital in Poiana Mare, where 18 patients had died in January and February of 2004, reportedly mostly from malnutrition and hypothermia, confirm that the situation in many places may be critical.

The majority of the patients in the women’s psychiatric ward of the Tǎrnaveni general hospital were accommodated in 2003 in two large rooms which were kept constantly locked. There were around 100 patients in the so-called ‘upper locked ward’ and about 50 patients in the ‘lower locked ward’. Adjacent to the latter was the ‘lower locked side ward’ where about 10 women with very severe disabilities were held with no access to running water and the toilet had no plumbing. Patients did not have access to basic toiletries and had only one opportunity a week to shower. All women on the wards were expected to shower within two hours when hot water was available on Fridays and no towels were provided. Staff did not ensure that women in the ‘lower locked ward’ and ‘lower locked side ward’ were appropriately dressed. Patients often walked around scantily clothed or naked and very few had shoes. The hospital floor was often cold and wet. In the ‘lower locked side ward’ the floor was often covered in faeces and urine because many patients held there were incontinent. Some patients spent the entire day in urine-soaked or faeces-covered clothing and bedding. Patients did not have an adequate and varied diet. In the ‘lower locked ward’ and ‘lower locked side ward’ the patients were made to take their meals in the dormitory area, although there was a dining area close by. They were served through a small opening in the door and were not supervised by the staff during the meal. They were not provided with cutlery and ate using their hands. Metal bowls used at mealtimes were often thrown by patients at each other, frequently resulting in injuries. The bowls were not collected immediately after mealtimes. At lunch time patients had to hand in the bowls that they had used for the soup, which were then reused by another patient without being washed. Women in the locked wards had their hair cut very short or shaved. Patients often had to share beds, particularly in the ‘lower locked wards’ where, because of shortage of adequate mattresses and blankets, patients were sometimes huddled three to a bed.

The psychiatric hospital in Gǎneşti, which cared for around 150 people in the summer of 2003, comprises three units. Living conditions were reportedly poor in 2003 throughout the facility though somewhat better in a unit which held less disabled patients. The mattresses were dilapidated, often with springs sticking out. When wet they would be taken out to dry, without first being cleaned. Most of the beds were provided with linen which was soiled and infrequently changed. The majority of the patients were inappropriately dressed, mostly in pyjamas which were in some cases in tatters. Few had their own clothes. An incontinent resident would not be cleaned before his/her pyjamas were changed. Many residents did not have underwear and women were not provided with sanitary wear when they had their periods. At mealtimes there were always disturbances, fights breaking out between patients and residents who were poorly supervised. The quality of food appeared very poor and no drinks of water were served with the meal. Only spoons were used for cutlery.

In May 2003 lack of medication, food, elemental hygiene and even electricity was reported in the Socola Psychiatric University Hospital in Iaşi. Patients complained that their diet only consisted of soup, potatoes and rice. Hospital management reportedly claimed that funds allocated for psychiatric care were much less sufficient for the delivery of the service than funds for some other types of medical inpatient care.

For at least three weeks in July 2003, in the psychiatric ward of the Bacǎu county hospital, overcrowding in some instances resulted in patients having to share beds. The situation in the emergency room was described by a psychiatrist on the ward as “unbearable”.

On 8 December 2003 the psychiatric hospital in Gǎtaia, which cared for around 450 patients and residents, reportedly had no heating because of shortage of coal although the outside temperature had been -2 degrees Celsius (the lowest temperature that day had been -6 degrees). The situation was only slightly better though not adequate at the time of the visit of Amnesty International’s delegate in February 2004. Three of the ten pavilions had been closed for the winter as they had no heating boilers and the patients and residents were transferred into other pavilions exacerbating over-crowding. The canteen was also closed down because of lack of heating. Some of the patients/residents were reportedly able to use dining rooms which had been set up in some of the pavilions. One such room was very small and narrow. There were some plastic tables and chairs, which had been stacked up, but it was difficult to conceive that this area was ever used. The mattresses and bedding in many dormitories were inadequate and in an unacceptable condition and there was an insufficient number of pillows for all the patients and residents. Some toilets were in an appalling condition. The toilets on the ground floor of pavilion number 32 were broken, without any doors and all water-flushing mechanisms were out of order. In the same pavilion a room for day-time activities contained some broken chairs and a television set which was out of order. Many rooms did not have bedside tables or cupboards which patients and residents could use to store their belongings. The hospital’s funds for food were described by the director as desperately inadequate. In the course of 2003 meals consisted mostly of pasta and rice. Some additional funds had been obtained in mid-December 2003 but still not sufficient to provide patients and residents with any milk products, fresh fruit or vegetables. In addition, the kitchen was in a poor state of repair and understaffed so that occasionally no cooked food was served in the evenings.

In late December 2003, the psychiatric ward of the Petroşani hospital, which occupies an old building, was in a poor state of decoration and had malfunctioning toilets. Because of the cold the patients who were in bed, were fully dressed, including hats. Some of the patients were able to use small electric hotplates to warm themselves in the daytime. However, the use of any electric appliances at night was prohibited because of old electrical installations and fire hazard concern. “The situation is the same as in the past. But it is even more acute now because there are no funds to repair the heating installations, to pay for electricity or even for the medication,” stated Dr Victor Marge, chief of the psychiatric ward, to a local journalist6.

At the beginning of January 2004 it was reported that the psychiatric hospital in Vulcan had had no heating for over a week even though outside the temperature sometimes reached below -10 degrees Celsius.

Also in January 2004 the conditions had reportedly deteriorated in the psychiatric hospital in Turceni, which cares for 105 patients and residents in a crumbling, damp building, smelling of urine and filth. The patients were suffering from lice and wore pyjamas that were dirty and tattered. Their food consisted only of rice or potato soup. The entire medication stock reportedly consisted of only a few doses of Diazepam and Levomepromazine7. The orders for medication were reportedly infrequently delivered and in insufficient quantities. After the only doctor in the hospital had left, the patients were visited once a week by a retired psychiatrist.

On 4 February 2004 at the time of the visit of Amnesty International’s delegate the psychiatric hospital in Mocrea did not have any electricity, water or heating due to a burst water-pipe which short-circuited the electrical installations and caused flooding in the kitchen. Because of inadequate funds the hospital was forced to use wood from its park as heating fuel. Most rooms have stoves which were fired only once in the morning. However, in three rooms in the men’s ward there were no stoves. One of these rooms accommodated at the time 22 men in 15 beds. Entrance to another room was blocked by the dining room benches and a long table. The windows in this small room were covered with plywood and there was no functioning lighting. There were four dilapidated beds for six men who reportedly suffered complex intellectual, physical and sensory impairments. Similarly appalling conditions prevailed in a locked room in the women’s ward where six women in five beds needed to be cleaned and required a change of clothing. There was only one bathroom for 115 patients/residents in the hospital. It contained two open showers and no separate space for changing. Long corridors leading to the bathroom were not heated.

Detailed standards for hospital conditions and treatment of patients with mental disorders or intellectual disabilities were elaborated by the MI Principles and the CPT’s Eighth Annual Report. In view of the Romanian government’s limited resources for the funding of social services, Amnesty International points to the following CPT statement regarding the obligation of a state to provide adequate conditions in psychiatric hospitals: “The aim should be to offer material conditions which are conducive to the treatment and welfare of patients; in psychiatric terms, a positive therapeutic environment… The quality of patients' living conditions and treatment inevitably depends to a considerable extent on available resources. The CPT recognizes that in times of grave economic difficulties, sacrifices may have to be made, including in health establishments. However, in the light of the facts found during some visits, the Committee wishes to stress that the provision of certain basic necessities of life must always be guaranteed in institutions where the State has persons under its care and/or custody. These include adequate food, heating and clothing as well as – in health establishments – appropriate medication.”8

Lack of medication and adequate therapy; restraining and seclusion practices; ill-treatment

Throughout 2003 Amnesty International received reports that many patients had been denied adequate medical treatment and that the psychiatric hospitals in general were unable to ensure adequate provisions of psychiatric medication because of lack of allocated resources. Lack of psychiatric medication affected even the best psychiatric hospitals in the country such as the psychiatric teaching hospital “Prof. Dr Alexandru Obregia” in Bucharest and the psychiatric teaching hospital “Socola” in Iaşi. In some reported instances lack of medication resulted in restraining and seclusion practices which were in violation of international human rights principles. In other instances restraining and seclusion practices, which were in violation of international human rights principles and best professional practice in the field, resulted from lack of respect for the patients/residents’ right to self-autonomy and/or inability of the staff to deal with what they perceived as challenging behaviour.

Moreover, few hospitals had staff and facilities to offer the full range of therapies and rehabilitative and therapeutic activities, including, inter alia, access to occupational therapy, group therapy, art, drama, music and sports. According to the CPT patients should have regular access to suitably equipped recreation rooms and have the possibility to take outdoor exercise on a daily basis; it is also desirable for them to be offered education and suitable work. Principle 14 of the MI Principles specifically lists the following resources which should be available in mental health facilities:

“a) Qualified medical and other appropriate professional staff in sufficient numbers and adequate space to provide each patient with privacy and a program of appropriate and active therapy;

b) Diagnostic and therapeutic equipment for the patient;

c) Appropriate professional care; and

d) Adequate, regular and comprehensive treatment, including supplies of medication.”

In some wards and hospitals occupational therapy meant that the patients and residents carried out the work of the staff (cleaning, washing, storing coal etc.) without receiving any remuneration for this.

Few patients interviewed by Amnesty International had been informed about the medication that had been prescribed to them and their effects. There appeared to be no systematic way of ensuring that free and informed consent to medication was obtained. For patients who were receiving medication against their will there was no independent mechanism in place to ensure that the administered treatment was appropriate and in their best interest. The CPT recommended that “every competent patient, whether voluntary or involuntary, should be given the opportunity to refuse treatment or any other medical intervention. Any derogation from this fundamental principle should be based upon law and only relate to clearly and strictly defined exceptional circumstances. Of course, consent to treatment can only be qualified as free and informed if it is based on full, accurate and comprehensible information about the patient's condition and the treatment proposed; to describe ECT [electroconvulsive therapy] as ‘sleep therapy’ is an example of less than full and accurate information about the treatment concerned. Consequently, all patients should be provided systematically with relevant information about their condition and the treatment which it is proposed to prescribe for them. Relevant information (results, etc.) should also be provided following treatment.”9 Principle 11 of the MI Principles also defines substantive and procedural provisions on free and informed consent to treatment.

In many wards and hospitals the patients did not apparently receive appropriate treatment for their somatic10 conditions which they had suffered in addition to their psychiatric condition. Some patients and residents in psychiatric hospitals were reportedly denied adequate medical treatment for their somatic conditions because other hospitals were unwilling to admit them for treatment.

Dental care was neglected in many wards and hospitals and many patients, particularly those who were held long-term, suffered from serious dental problems.

Amnesty International has also received reports that some doctors and nurses did not treat patients with due respect and engaged in inappropriate practices (see below for details) when examining patients and/or dispensing and storing medication. Understaffing, overcrowding and apparently inadequate organization of treatment may have contributed to such practices. Very few nurses had special psychiatric training.

Orderlies, who were also grossly understaffed and did not have any appropriate training, particularly to deal with challenging or what may be considered as bothersome behaviour, carried out most of the work of supervising the patients. Because of lack of respect for the patients or understaffing and lack of appropriate training, the orderlies often failed to protect more vulnerable patients from abuse, including sexual abuse. In some reported instances orderlies resorted to excessive use of force or to deliberate ill-treatment of patients. The orderlies also frequently assigned their work, such as cleaning of the wards, to patients/residents in their care.

Restraint and seclusion practices in many psychiatric wards and hospitals were not in line with international standards and in some instances amounted to cruel, inhuman and degrading treatment or punishment. There were no protocols for, nor records kept, regarding the use of restraint and seclusion. Seclusion was frequently enforced as a punishment. In some instances, when it concerned patients who were admitted for treatment on a voluntary basis, seclusion amounted to arbitrary deprivation of liberty and detention.

The CPT requires that there should be a clearly defined policy for the application of restraint. “That policy should make clear that initial attempts to restrain agitated or violent patients should, as far as possible, be non-physical (e.g. verbal instruction) and that where physical restraint is necessary, it should in principle be limited to manual control. Staff in psychiatric establishments should receive training in both non-physical and manual control techniques vis-à-vis agitated or violent patients. The possession of such skills will enable staff to choose the most appropriate response when confronted by difficult situations, thereby significantly reducing the risk of injuries to patients and staff.”11 Resort to instruments such as straps or strait-jackets should only be very rare and always be either expressly ordered by a doctor or immediately brought to the attention of a doctor.

With reference to seclusion, namely confinement alone in a room, of violent or otherwise “difficult” patients the CPT noted that this practice was being phased out in many countries. Furthermore, the CPT recommended that: “For so long as seclusion remains in use, it should be the subject of a detailed policy spelling out, in particular: the types of cases in which it may be used; the objectives sought; its duration and the need for regular reviews; the existence of appropriate human contact; the need for staff to be especially attentive. Seclusion should never be used as a punishment. Every instance of the physical restraint of a patient (manual control, use of instruments of physical restraint, seclusion) should be recorded in a specific register established for this purpose (as well as in the patient's file). The entry should include the times at which the measure began and ended, the circumstances of the case, the reasons for resorting to the measure, the name of the doctor who ordered or approved it, and an account of any injuries sustained by patients or staff.”12 Similar requirements for the administration of physical restraint or seclusion are set out in Principle 11(11) of the MI Principles13.

Some psychiatric wards and hospitals did not have systems to assist patients, who claimed that they had been ill-treated by police officers before being brought to the hospital. Only in very rare instances, if the victim of ill-treatment was not admitted into the hospital for involuntary treatment, or was released within a very short period, was it possible for that person to obtain a forensic medical certificate for injuries that may have been suffered as a result of ill-treatment and to file a complaint. Doctors in some hospitals have confirmed to Amnesty International’s delegate that some of the patients who were brought to the hospital by the police had injuries which were consistent with the patients’ allegations that they had been beaten. Such injuries were then recorded in the medical file but there was no system to assist the patients in filing a complaint.

In February 2003 it was reported that the psychiatric ward of the municipal hospital in Roman had resorted to “medieval practices” to restrain violent patients, tying them down to the beds. The head doctor of the ward told a local journalist that: “Since November [2002] we have not received any medication with sedative effect, so we have to resort to methods which are not too orthodox…”14. In addition to lack of medication, the ward with a capacity of 74 beds was grossly understaffed, with only a single nurse working in a shift.

In March 2003 in Poroschia psychiatric hospital in Alexandria county, five men were reportedly found by a journalist in a locked room with four beds. One of them was held to the bed with a chain around his right hand. There were no glass panes on the windows and the patients were forced to use a bucket in the corner of the room to relieve themselves. The director of the hospital at the time reportedly stated that they had no medication for treatment as the budget had been spent; that some of the patients therefore needed to be restrained; and others were confined to locked rooms because the staff were too few to accompany them to the toilets which in any case were malfunctioning. In May 2003 the Ministry of Health revoked its decision to close down the hospital having established that some improvements had been made.

However, unacceptable seclusion practices in this hospital were observed even in conditions in which adequate psychiatric medication was available. In November 2003 a representative of Amnesty International visited the Poroschia hospital, at the time managed by a new director. Though many of the rooms at the time of the visit had been freshly painted and provided with new beds and bedding, there was apparently little change in the treatment of patients. One room with a new steel door and two triple-barrelled locks held four patients described by the psychiatrist as ‘very aggressive’. This psychiatrist did not find that the rationale to keep ‘aggressive’ patients together in a locked room with apparently little supervision was professionally untenable. One of the patients who was elderly, very frail and suffered from dementia was asleep at the time of the visit. When the psychiatrist was questioned about the precise reason to keep him in a locked room he replied that the patient might attempt to leave the hospital. Another patient, who was also elderly, appeared to be unsteady on his feet, standing next to the bed. The condition of the third patient, who lay unconscious, was described by the psychiatrist as delirium tremens15. The fourth patient, a 41-year-old man who suffers from schizophrenia and who had been in treatment intermittently since 1981, did not, like the others, demonstrate any aggressive behaviour at the time of the visit. Similarly to other patients in the hospital, he was not receiving any therapy other than pharmacotherapy. He was also never allowed to leave the room which had a small toilet adjacent to it.

In the psychiatric hospital in Gǎneşti, in the summer of 2003 one of the three units held men who were reportedly considered under the Penal Procedure Code to be criminally irresponsible. In daytime, though most of the patients stayed in the unit, they had free access to other areas of the hospital and to mix with other patients/residents. The other two units held patients/residents of both sexes, though accommodated in segregated bedrooms. Some female patients complained that they had been repeatedly raped and otherwise sexually abused by male patients. One of them was reportedly sent for an abortion to a hospital in Galaţi on 29 July 2003. The staff reportedly were not concerned about how she came to be pregnant. Patients complained of violence by other patients, as a result of which they suffered injuries. In some instances the staff did not intervene even after this was brought to their attention. Some patients were reportedly used by the staff to maintain order or to restrain other patients/residents.

In the women’s psychiatric ward of the hospital in Tǎrnaveni doctors and nurses reportedly examined and treated patients in full view of the rest of the ward. Nurses reportedly gave medication to patients to distribute to other patients. They did not check that the medication had been given to the correct patient and that the patient had actually taken the medication. Medication was often left unguarded. Injuries due to accidents or violent conduct of other patients were not infrequent and assistance reportedly often slow. More vulnerable patients were not offered any protection. On 19 July 2002 a woman, whose identity is being kept confidential to protect her from harassment, refused to have her head shaved and began to shout. The orderly reportedly slapped her on the face, bent her arm backwards and with the help of another patient attempted to drag her across the floor towards the razor. The incident was reported by a volunteer working in the hospital to the head nurse who initially appeared to be concerned about the use of force but later justified it by saying that the patient had been agitated.

In Gǎtaia a group of residents with intellectual disabilities, who did not require any psychiatric treatment, worked in a workshop and did the work assigned to them by the staff, including regularly unloading and storing the coal used for the heating. They complained that they had not received any remuneration for their work since 2000.

In the same hospital the seclusion room had a door made of iron bars, broken window panes and a soiled mattress. Amnesty International’s delegate observed a rat in the room which was unoccupied at the time.

The psychiatric hospital in Mocrea could only provide pharmacotherapy; occupational therapy had been discontinued in 1989. Patients and residents had no access to a day room which was closed down. Dental care was only available in emergencies for those patients who could pay for the service. Patients/residents had little access to non-psychiatric medical care. A man who suffered from myasthenia (a neuro-muscular disease caused by an acquired immunological abnormality) had not received any treatment for this condition for two to three years. He had an aluminium walking frame which was broken and he could only move around with assistance from another patient or staff. The hospital was unable to provide appropriate treatment for another resident who had no mental health problems and who had suffered a serious head injury in 2001. As a result he was missing a large piece of skin on the forehead, leaving the skull bone fully exposed. Amnesty International’s representative observed at the time of his visit a 38-year-old woman who was naked, lying face down and only lightly covered. Two weeks earlier she had suffered burns all over her back after her nightdress caught fire while she was leaning against a stove. The general hospital reportedly refused to admit her for treatment. The ward psychiatrist prescribed treatment for her after telephone consultations with the specialist from the general hospital.

In the psychiatric hospital in Ştei the director explained to Amnesty International’s representative that in December 2003 and January 2004 the hospital had no Levomepromazine which had to be purchased by funds collected from the staff in order to ensure daily treatment for 50-60 patients. The hospital’s budget for medication was reduced from 1.7 billion lei in 2003 to 1.2 billion lei in 2004. Under regulations which had come into force at the beginning of 2004 hospitals purchased medication by public tender over the Internet. The hospitals have to wait 15 days for a response from an interested supplier and sometimes no response is received. At the time of the visit of Amnesty International’s delegate in February 2004 the hospital had Diazepam in stock for just one more day. A similar situation was reported in the psychiatric hospital in Nucet where the staff would prefer to use newer generations of psychiatric medication if they had the required resources. The budget for the medication in the social-medical centre in Nucet was reportedly even smaller than in the psychiatric hospital although the needs of its residents, according to the centre’s psychiatrist, were quite similar.

Lack of appropriate medication and of adequate staff in number and training considerably increased the risk to the safety and well-being of the staff themselves. On 8 August 2003, Dr Dan Chirculescu, chief of the psychiatric ward in the county hospital in Resiţa, reportedly suffered serious injuries after he was assaulted by a patient. It was reported that the shortage of medication was a major factor influencing violent behaviour of many patients. The patient who allegedly assaulted the psychiatrist was later transferred to the psychiatric hospital in Gǎtaia.

Deaths apparently resulting from the failure to protect patients from violence

In 2003 at least four patients in psychiatric hospitals died following assaults by other patients. These incidents reportedly occurred in circumstances in which patients had not been adequately supervised by staff of appropriate number and with appropriate training. The conduct of the violent patients may also have been influenced by inadequate medical treatment. These incidents illustrate the blatant failure of some psychiatric wards and hospitals to provide for the patients’ elemental needs, including ensuring their safety and well-being.

On 21 February 2003, in the psychiatric hospital in Gǎneşti a 59-year-old man was killed by another patient. The alleged perpetrator had reportedly assaulted other residents in the past. At the time of the incident an orderly on duty was reportedly dealing with a conflict in another room. The hospital was reportedly so understaffed that an orderly on duty was sometimes responsible for 50 patients.

In the morning of 30 May 2003, in the Braila psychiatric hospital, a nurse discovered the body of a 20-year-old patient, who had apparently been strangled with a sheet, had his testicles cut off and throat cut with a razor. The patient had been held in a room with 10 other men, two of whom were suspected of the killing. The incident reportedly took place during the night when all 10 dormitories on the third floor – accommodating patients who are considered as dangerous – were locked with only an orderly on duty. Dr Gabriel Gheorghiu, chief of the Brăila Department for Public Health, reportedly stated that the number of staff should be increased, as at the time there were only 35 people involved in the care of 140 patients.

In the same hospital, on 28 September 2003 a 33-year-old man died following an assault by two other patients. The police had been informed about the incident by the ambulance staff which established that the assaulted patient had died from injuries to the head.

On 12 September 2003 a patient in a psychiatric hospital in Arad, who had been admitted for treatment the previous day, reportedly assaulted another patient, hitting his head against the cement floor several times before biting off a testicle. The victim reportedly died from injuries suffered in the assault. The victim’s family claimed that the incident would not have happened if there had been more staff on duty other than a nurse and a doorman who controls access to the ward.

On 29 January 2004 in the psychiatric hospital in Beclean, 36-year-old Sorin Baciu was reportedly killed by Laurenţiu Tarmure, another patient. Four days before the incident Laurenţiu Tarmure reportedly assaulted another patient. He was then placed into a seclusion room together with Sorin Baciu, who had been placed there earlier. According to the investigating prosecutor, whose statement was reported in Ziua (“The Day”) on 31 January 2004, Laurenţiu Tarmure wanted to use a bed which was already occupied by Sorin Baciu. Baciu complained about this to a member of the staff who advised him to use another bed. At around 4.30am Laurenţiu Tarmure assaulted Sorin Baciu, punching and kicking him all over the body, causing multiple injuries and internal bleeding which resulted in death. The prosecutor had reportedly also established that there were only two orderlies on the night shift in this hospital which cared for 140 patients and that the living conditions in the wards were “miserable”.

Amnesty International’s Recommendations

People placed for treatment in psychiatric wards and hospitals in Romania suffer a broad range of human rights violations. The most effective way to address these violations is through enforcement of international human rights standards of particular relevance to people with mental disorders or intellectual disabilities as well as professional best practice in this field. In fact, the effective enforcement of many of these rights depends on a thorough and appropriate reform of the mental health care services in Romania. These should ultimately be community-based16 and aim to integrate people with mental disorders or intellectual disabilities into the community; ensuring that they are protected from abuse. Such reform should enable people with mental disorders or intellectual disabilities to fully exercise their right to health and other social, cultural and economic rights, such as right to education or right to family life. A national action program for people with chronic mental disorders and intellectual disabilities, who are cared for in institutions under the control of the National Authority for People with Handicap, was launched in 2003. However, the Romanian government has failed to introduce comprehensive community-based mental health services. These should include: supported housing, supported employment, case-management, psychosocial rehabilitation, respite care, appropriate and accessible medical care and emergency inpatient services in a community hospital. The authorities should also develop a careful, individualized plan for each person to be placed in the community to ensure the health, security and well-being of such persons and the host community. Furthermore, a successful reform of the mental health services would not be complete without putting in place all the safeguards for the protection of basic rights of people for whose full benefit these services should be designed. Every aspect of these services should ensure that the clients are protected from abuse.

Amnesty International particularly urges the Romanian authorities to implement the following recommendations:

Placement in psychiatric wards and hospitals

To put in place legal regulations for the implementation of the Law on Mental Health, ensuring that they are in line with international human rights principles.

To effectively assess all patients/residents currently placed in psychiatric wards, hospitals and medical-social centres and to ensure that their needs are being appropriately addressed. All those who do not require psychiatric treatment for an acute condition should be considered for placement in facilities under the control of the National Authority for Persons with Handicap and included in its program for reintegration into the community.

To ensure that people with significantly different needs are not placed together, thus putting at risk of abuse those who are more vulnerable.

To ensure that a patient's state of health and therapy is regularly reviewed particularly in view of a possible discharge from hospital or transfer to a less restrictive environment.

Living conditions and therapy/treatment

To establish standards for inpatient living conditions, particularly with regard to the diet, warmth and hygiene, and the full range of therapies to be provided to patients, which would be consistent with international standards. To provide adequate resources for the implementation of these standards. Particularly, to ensure that medication prescribed is in fact provided, and that a regular supply of appropriate medicines is guaranteed. To ensure that these standards are maintained in all institutions providing inpatient psychiatric treatment.

To ensure that adequate medical therapy for somatic conditions and dental therapy is provided to patients and residents by appropriate medical and dental services.

To ensure that all inpatient psychiatric facilities are adequately staffed by medical and non-medical staff of adequate number and training. To ensure that auxiliary staff who have contacts with patients are always closely supervised by the senior nursing or medical staff.

To establish regulations which would ensure that all patients are informed of their rights and that they can effectively exercise their right to free and informed consent to medication in a manner which would be consistent with international standards.

Ill-treatment, restraint and seclusion

To require medical examination of all patients on their admission and to refer reports of any injuries observed, including any relevant statement made by the person concerned and the doctor’s conclusions, to the public prosecutor in charge. To assist any patient claiming that they had been subjected to police ill-treatment during their admission into hospital to file complaints to the public prosecutor.

To establish regulations which would ensure that all patients are informed about their rights on their admission into a psychiatric establishment for inpatient treatment.

To ensure that patients’ contact with the outside world is not restricted, particularly if the establishment is located far from urban centres. For example: all patients should have access to a public telephone; patients should be treated in hospitals close to their place of residence or where their families live.

To ensure that public prosecutors regularly visit wards in which patients are placed for involuntary inpatient psychiatric treatment.

To ensure that all orderlies, including those who carry out security-related tasks, are adequately trained for work in the establishment and specifically trained in appropriate methods of restraint of patients exhibiting violent behaviour.

To establish a system for filing patient complaints and an independent mechanism which would have the authority to maintain an oversight of the conditions and treatment in compulsory psychiatric treatment, as well as to review all patient complaints concerning staff conduct and hospital treatment. This mechanism should have the necessary powers to investigate complaints and make appropriate recommendations, including referring complaints to authorities responsible for investigation of criminal offences. A complainant should be transferred out of the control of the alleged perpetrator while the complaint is reviewed.

To ensure that restraint and seclusion practices, which should be prescribed or authorized by a doctor, supervised by medical staff and strictly restricted in duration, are in line with international standards, particularly prohibiting the use of seclusion as a punishment. To provide guidelines for all inpatient psychiatric establishments on protocols for, and keeping of special records (as well as in the resident’s file) concerning, the use of restraint and seclusion and to monitor that they are effectively maintained.

Deaths in psychiatric wards and hospitals

To ensure that all deaths of patients and residents, wherever these may have occurred, are properly recorded and that post-mortem examinations are carried out in all instances of unexplained deaths.

To ensure that information on mortality in psychiatric wards and hospitals is collated at the national level and published. Any establishment with a significantly higher mortality rate than usual should be thoroughly investigated.

To ensure that all deaths of patients and residents are promptly, thoroughly, independently and impartially investigated and that the results are made public. If an investigation uncovers credible evidence that the death has resulted, directly or indirectly, from a criminal offence, those suspected of involvement must be brought to justice.

1 See Romania: Patients at the Poiana Mare psychiatric hospital AI Index: EUR 39/002/2004

2 International diagnostic terminology draws a distinction between mental “illness” and problems in mental “development”. The World Health Organization’s International Classification of Diseases (ICD-10) and the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) both describe these two major areas of mental health as “mental disorder” and “mental retardation”, respectively. In this memorandum, Amnesty International will broadly follow international diagnostic terminology with respect to mental illness but will refer to “mental retardation” by terms more commonly used by carers and advocates working in this field, such as “intellectual disability” or “learning disability”.

3 Adopted by the General Assembly, Resolution number 46/119 of 18 February 1992.

4 8th General Report on the CPT’s activities covering the period 1 January to 31 December 1997, Ref: CPT/Inf (98) 12[EN], published on 31 August 1998.

5 An old medical term still used in Romania to denote below average intellectual or mental development.

6 See “Pe patul de spital, imbracaţi in palton” (In hospital beds [the patients are] dressed in overcoats) in Evenimentul zileion 20 December 2003.

7 Diazepam and Levomepromazine are, respectively, a member of the benzodiazepine family of tranquillizers and a phenothiazine derivative used for the treatment of psychoses.

8 CPT Eighth report.

9 Ibid.

10 Physical

11 Ibid.

12 Ibid.

13 Principle 11 (11) states: “Physical restraint or involuntary seclusion of a patient shall not be employed except in accordance with the officially approved procedures of the mental health facility and only when it is the only means available to prevent immediate or imminent harm to the patient or others. It shall not be prolonged beyond the period which is strictly necessary for this purpose. All instances of physical restraint or involuntary seclusion, the reasons for them, and their nature and extent shall be recorded in the patient’s medical record. A patient who is restrained or secluded shall be kept under humane conditions and be under the care and close and regular supervision of qualified members of the staff. A personal representative, if any and if relevant, shall be given prompt notice of any physical restraint or involuntary seclusion of the patient.”

14 See Ziarul de Roman (Newspaper of Roman) “Din cauza crizei din sistemul sanital, bolnavii sint legati de paturi” (Because of the crisis in the health system, the patients are tied to the beds), 24 February 2003.

15 A severe consequence of alcohol withdrawal.

16 Community-based mental health care could be provided by decentralized clinics offering out-patient services. This would require that patients are provided with housing within the community, living as independently as possible with support from appropriate carers as necessary. Principle 7 of MI Principles states the: “every patient shall have the right to be treated and cared fro, as far as possible, in the community in which he or she lives”.

AI Index: EUR 39/003/2004 Amnesty International

How you can help