CoE report slams conditions in Bulgarian psychiatric, social care institutions

The Council of Europe’s anti-torture Committee (CPT) expressed grave concern in a report published on December 2 that many of its long-standing recommendations concerning the treatment, conditions and legal safeguards offered to psychiatric patients and residents of social care institutions in Bulgaria remain unimplemented.

In August 2020, the CPT’s delegation visited St Ivan Rilski State Psychiatric Hospital and Tsarev Brod State Psychiatric Hospital for the first time, as well as Byala State Psychiatric Hospital which had been previously visited by CPT in 2006.

The delegation also visited, for the first time, the social care homes for persons with learning disabilities in Kudelin and Samuil and the social care home for persons with psychiatric disorders in Govezhda.

In all hospitals and social care homes visited, the delegation received allegations of ill-treatment of patients and residents by staff – orderlies were verbally rude to patients and residents, pushed or slapped them, punched, kicked, and hit with sticks, the Council of Europe said.

Gate guards in Kudelin and Govezhda social homes carried and would occasionally hit residents with wooden sticks (sticks matching descriptions given by residents were found by the delegation in staff offices in all three establishments), it said.

As regards living conditions, the committee noted that some renovation has occurred in all three psychiatric hospitals, particularly in Tsarev Brod, and that material conditions in Byala had improved since the CPT’s last visit in 2006.

However, there was a clear scope for further general material improvement and personalisation of dormitories, the CoE said.

As for the social homes visited, Samuil provided for satisfactory internal décor and even en-suite sanitary facilities in many rooms but living conditions and sanitary facilities in Kudelin and Govezhda required major improvement.

“In all three hospitals visited, inadequate, and often grossly insufficient numbers of ward-based staff were found.”

The number of multi-disciplinary clinical staff, too, was totally inadequate to meet the many psycho-social treatment and rehabilitation needs of patients.

“Unfortunately, the findings of the 2020 visit suggest that the Bulgarian authorities still fail to fully grasp the importance of adequate numbers of staff and the need to assertively act to rectify that deficiency,” the committee said.

“The persistent staff shortages give the impression that, in the Ministry of Health, mental health care is not sufficiently valued; it clearly needs to be given a higher priority for investment and development.”

In social homes, too, the numbers of nurses and orderlies were totally insufficient, the CoE said.

Seemingly due to low salaries and the difficulties in attracting and retaining staff to work in the rather remote establishments, the professional quality of staff, especially orderlies, appeared to be poor; this, combined with inadequate training and supervision, undoubtedly increased the risk of ill-treatment of residents. The numbers of staff who could provide psycho-social, occupational and recreational input to residents were also inadequate, particularly in Kudelin and Govezhda.

As for means of restraint, seclusion, mechanical and chemical restraint of patients was practised in all hospitals visited, but it was not done in line with the CPT standards.

“The restraint equipment was inappropriate and caused pain to mechanically restrained patients,” the Council of Europe said.

“The most disturbing situation was found in Tsarev Brod where, despite the availability of properly designed padded restraint belts, patients were nearly exclusively restrained to beds with metal chains to wrists and ankles, secured with padlocks, often for days on end.”

The use of similar equipment was also alleged by the Kudelin social home residents, and chains and padlocks matching the residents’ descriptions were found in the establishment’s guard’s office.

“Many would believe that this behaviour had been eradicated from mental health establishments in Europe over a century ago. Such a shameful practice is totally unacceptable and could easily be considered as inhuman and degrading; it must stop immediately,” the committee said.

With regards to the regime and treatment available to psychiatric patients, the atmosphere on many of the wards in all three hospitals visited often appeared less than therapeutic, sometimes neglectful and even controlling, oppressive and punitive.

Treatment, as before, was predominantly pharmacotherapeutic, the Council of Europe said.

Many patients had no, or only very limited, access to daily outdoor exercise. Besides, a number of legally competent patients who had signed consent to hospitalisation forms and were still deemed voluntary, said that they wanted to leave but were not allowed to do so, and were thus de facto detained.

“The Covid-19 pandemic remains a serious risk to vulnerable patients and residents. The CPT recommends that the Bulgarian authorities develop a specific and comprehensive strategy to respond to the Covid-19 pandemic in psychiatric hospitals and social care institutions, review the total ban on visits to patients in the psychiatric hospitals instituted in response to the Covid-19 pandemic in March 2020, and take steps to ensure that patients can receive such visits in safe conditions, respectful of physical distancing and personal protective equipment requirements.”

Moreover, the committee recommends that the institution of a State-funded regime of regular PCR testing of all staff (and any psychiatric patient or social care resident who enters or re-enters the establishment) should be given serious consideration.

As to the general situation with social care institutions, the committee noted with regret that since previous visit in 2017 there has been little, if any, improvement.

“The Bulgarian authorities’ approach to predominantly just providing learning-disabled and mentally ill social care residents with food three times a day and a roof over their head is grossly insufficient and clearly needs to be urgently revisited,” CPT said.

“The continuation of the existence of such social care establishments in Bulgaria is not viable. The Committee strongly supports the Bulgarian authorities’ plan to close a number of social care establishments by 2022 and develop appropriate community care facilities. Moreover, the Committee strongly urges the Bulgarian authorities to rapidly accelerate their closure programme of the remaining old-style, outdated social care establishments, eradicating the need for them as soon as possible.”

In advance of such closure, the CPT called on the Bulgarian authorities to take concrete and urgent measures aimed at upholding the human dignity of all persons placed in the existing social care homes.

(Photo: Antonio Jiménez Alonso/

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The Sofia Globe staff

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