Continued ill-treatment of psychiatric patients by staff demonstrates, once again, a continuing serious failure by the Ministry of Health to prevent and eradicate such unacceptable behaviour, says the Council of Europe’s anti-torture committee (CPT) in a new report about its ad hoc visit to Bulgaria in March 2023.
Therapy opportunities in psychiatric institutions remain deficient, staffing levels insufficient and the use of mechanical restraint not in conformity with international standards, according to the report.
The CPT has observed, however, some progress in social care institutions and hopes for the continuation of genuine deinstitutionalisation. The report has been published together with the response of the Bulgarian authorities.
The CPT delegation visited Tserova Koria State Psychiatric Hospital for the first time, as well as Byala State Psychiatric Hospital, previously visited by the Committee in 2020.
The delegation carried out first-time visits to the social care homes in Draganovo and Tri Kladentsi for people with learning disabilities . The objective of the visit was to examine the implementation of the previous recommendations of the Committee and of the public statement issued by the CPT in November 2021.
Regarding ill-treatment by staff, in Byala Hospital, the delegation received a number of allegations from patients that, apart from staff shouting at patients, orderlies would also slap, punch and kick patients (including in the groin).
In Tserova Koria Hospital, staff shouting at patients was allegedly routine; orderlies would reportedly also occasionally hit patients.
“Such findings demonstrate, once again, a continuing serious failure by the Ministry of Health to prevent all forms of ill-treatment of patients, to convey a clear and unambiguous message to the staff of psychiatric hospitals that the ill-treatment of patients will not be tolerated and will be the subject of appropriate sanctions, and to act to eradicate such unacceptable behaviour”, the committee says.
As for material conditions, patients’ accommodation in the two hospitals was generally bare, many rooms were overcrowded, the environment in wards was distinctly carceral, with external bars on the windows and a lack of decoration.
As during previous visits, the staff numbers in the two hospitals visited were grossly insufficient to adequately provide the necessary treatment for patients and to ensure a safe environment; Byala Hospital, in particular, continued to experience a dire shortage of psychiatrists.
Opportunities for psychological, occupational, and creative therapies continued to be very limited, with most patients just lying on their bed or wandering around idly. The CPT therefore reiterates that patients in Bulgarian psychiatric hospitals are not provided with anything approaching the full range of modern psychosocial treatments required, which is both neglectful and harmful to patients.
Regarding means of restraint, seclusion, mechanical and chemical restraint of patients was practiced in both hospitals visited. However, as previously, international guidelines regarding the use of such measures were not being adhered to, and the recording of mechanical restraint measures was formulaic and did not appear to reflect reality.
As in previous CPT visits to Bulgaria, a number of patients deemed de jure voluntary were not truly consenting to their hospitalisation and said that they wanted to leave but were de facto deprived of their liberty. Most of such patients did not seem to be informed of their rights as voluntary patients, including the right to be discharged upon their request.
The committee also requests that the Bulgarian authorities provide the conclusions of the audit into the clinical trials ongoing in Tserova Koria State Psychiatric Hospital (including the copies of the ethical approvals of such trials) following the CPT’s concerns during the visit to the hospital regarding informed consent, proper documentation, and remuneration of participants.
In social care homes visited, the atmosphere appeared generally relaxed, and most residents spoke positively about the staff.
The delegation received few to none allegations of the physical ill-treatment of residents by staff or verbally inappropriate behaviour. On the contrary, all residents who were able to, spoke positively about the staff’s kind and warm attitude towards them, which the delegation itself witnessed throughout the institution.
The high commitment of the staff of the Draganovo Social Care Home for people with learning disabilities “is especially commendable considering the challenges faced by the extremely low numbers of staff caring for many residents requiring personal assistance”, the CPT says.
The delegation was pleased to note that the seclusion and mechanical restraint of residents was not practiced in the homes visited, thus respecting the provisions of the Bulgarian legislation.
Turning to living conditions, in the two homes visited, residents were accommodated in dormitories which were generally clean, well-lit, and ventilated; however, the state of personalisation in the accommodation blocks varied a lot.
Regarding care staff, as found in other Bulgarian social care institutions in the past, despite the full official staff complements being deployed and there being no vacancies, the numbers of nurses and orderlies were totally inadequate to provide proper care to residents.
Besides, the numbers of psychologists, social workers and occupational therapists were also insufficient to provide a proper range of psycho-social, occupational, and recreational input.
The CPT notes the recent adoption of the Ordinance on the Quality of Social Services which determines a coefficient of the number of employees in each social service in relation to the number of residents, and that this coefficient has been increased compared to previous requirements, so that social service providers could now employ more staff than the previous minimum requirement. It is hoped that social care homes will be able to strengthen their staffing numbers.
The CPT concludes that some progress appears to being made in social care institutions and, despite delays with the closure of some social care homes; it hopes that genuine deinstitutionalisation will continue, with proper community facilities and care being provided for service users.
In their response, the Bulgarian authorities provide information on various measures, taken or envisaged, to implement the recommendations made by the committee in the visit report.
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