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English Language Page 2.2.1. General data Demir Hisar psychiatric hospital is a regional hospital for residents of Southwestern Macedonia who are over 18 years old. The hospital is under the authority of the Ministry of Health. At the time of the visit no information was gathered on the budget of the facility, the source and regularity of financing because the Director was not in the hospital. Later, at the request of the delegation the Director provided information on the funding for maintenance of the hospital. According to this information the overall budget of the hospital for 2003 was 109,317,585 Denars (app. 1,792,091 Euro). The capacity of the hospital was 550 beds. There were 487 patients, both men and women, admitted to the hospital on the day of the visit, 49 of whom were absent (either run away or had been taken for a vacation by their relatives). The total number of the patients present was 438. During the visit it became clear that the Ministry of Health funded the expenditures for food, medicines, electricity, water, heating and salaries for the staff. However, it did not cover the expenses for the mentally retarded patients (who were around 90 persons) because of the presumption that the Ministry of Labour and Social Policy is obliged to cover them. The Ministry of Health did not cover the expenses of the patients in the forensic psychiatric ward either since it admits that the Ministry of Justice should be obliged to cover them. However, neither the Ministry of Justice, nor the Ministry of Labour and Social Policy allocate budget for these two groups of patients. Thus, the funding seemed to be insufficient, especially for the food provided in the hospital. The doctors on duty were not able to estimate the average stay of a patient in the hospital. But they stated that some of the patients come to the hospital only during the winter because they have financial problems to stay at home. Others do not have any other place where they can go after leaving the hospital. 2.2.2. Types of wards There were 10 wards in the hospital. The table below provides information on the types of wards and the number of patients in each on the day of the visit: 1. Psychotic women’s ward – 45 patients, 2 on leave 2. Adolescent acute ward for young men and women – 10 women, 2 women on leave, 18 men, 6 on leave 3. Chronic and sub-chronic men’s ward – 57 patients, 7 on leave 4. Psycho-geriatric men’s ward – 38 patients 5. Chronic men’s ward for older patients – closed – 51 patients, 4 on leave 6. Chronic men’s ward for patients with psycho-organic syndrome, resistant to therapy, no hygiene habits – closed – 40 patients, 2 on leave 7. Chronic women’s ward for patients resistant to therapy – closed – 40 patients, 1 on leave 8. Psycho-geriatric women’s ward – closed – 39 patients, 1 on leave 9. Alcohol users’ men’s ward for voluntary treatment – closed – 6 patients, 2 on leave 10. Forensic psychiatric men’s ward – closed – 52 patients, 22 on leave Total – 438 patients, 49 on leave There were 40 to 60 patients placed in each ward. The problem with the regime in the different wards did not become clear. According to the doctors on duty all wards were closed to some extent. But in the 5th, 6th, 7th, 8th, 9th and 10th wards the patients were not able and/or not allowed to go out of the buildings for the reason of their own safety. 2.2.3. Admission to the hospital During the visit it did not become clear how many patients were placed in the hospital against their will. But the doctors claimed that they were not segregated in a special ward or room. Actually it looked as if the staff of the hospital did not understand well the procedures for placement and could not distinguish between voluntary and involuntary placement. The doctors on duty said that most often the family of the person with mental disorder would address the local Center for Social Work. The Center would assess the need of placement in a hospital. If the person agrees to be treated in the hospital he/she is brought with an ambulance of the Emergency Unit or he/she goes to the hospital by him/herself. If a patient does not want to be placed or treated in the hospital he/she is brought to the hospital by the police. Then the hospital within 48 hours is obliged to inform the district court for that. The court is obliged to visit the hospital after the admission with two experts to pass the judgment on the placement and treatment of the person in the hospital. Unlike other district courts in Macedonia the district court in Demir Hisar does that in this hospital. During the time when the patient is placed in the hospital and the court has not arrived yet to review that placement the patient is being treated with medication even against his/her will. The court decides whether a person involuntarily placed in the hospital should stay in the hospital or should be released. After this judgment, theoretically, a person can be detained in the institution for the rest of his/her life. This is so because, after the mandatory treatment is over, no matter whether the patient’s condition is worse or better the court does not review it. According to the interviewed doctors the hospital was also obliged to report to the District Court for every patient who is admitted to the psychiatric hospital for the first time. If a patient is admitted to the hospital voluntarily but after a certain period of time he/she wants to leave it and the doctors are of the opinion that he/she might be dangerous for himself or for others, or that he/she needs treatment, they inform the family and it has to sign a document that it agrees to come and take the person from the hospital. If the patient might be “dangerous” and has no family (or the family does not want to take him/her) then the doctors would not let him/her go. 2.2.4. Living conditions and hygiene The buildings of the hospital had central heating and running hot water (heated by boilers during the spring, summer and autumn). The material conditions varied from one ward to another, according to the doctors, in correspondence to the mental condition of the patients placed there. The most dilapidated wards were those for the patients who had mental retardation and/or were resistant to therapy (5th and 6th wards). The material environment was utterly austere and impersonal, and there were hardly any personal possessions in evidence. The average number of patients who use one toilet and one shower was 10. The toilets and the bathrooms were not adapted to be used by people with physical disabilities. Besides, most of the sinks seen during the visit did not have taps, which made their use impossible. Although the patients could have a shower once a week (some of the staff were of the opinion that it was obligatory) and the patients from the acute ward were allegedly bathed every day, the hygiene in the 5th and the 6th ward was far from being maintained well. The smell of urine in the 5th and the 6th ward was very strong although the orderly on duty claimed that they use disinfectants and the floor was hosed before the delegation entered the building. The delegation was not able to find whether the patients were given enough personal hygiene items (soap, shampoo, toothpaste, toilet paper etc.). No such means were seen either in toilets or in the rooms. Diapers were given to the patients only if/when the family brings some. 2.2.4.1. The forensic ward According to the interviewed doctors the patients in the forensic ward were allowed to go out of the hospital to buy food. But this depended on their current mental condition and the type of the crime they were committed for. Sometimes the patients who had committed serious crimes were allowed to go to the shop accompanied by an orderly. Those who had committed minor crimes were allowed to go shopping in the town without companion. The patients said that they were allowed to stay outside of the ward in the yard for 1 to 1,5 hours per day. Patients in the forensic ward were accommodated in rooms, ranging in size from 15 to 22 sq. m. Most provided sufficient living space - 3 or 4 patients in 22 sq. m. The rooms were in a generally good state of repair and cleanliness and had access to natural light as well as adequate artificial lighting and ventilation. The floor in the rooms was covered with linoleum. Furnishing was of a very basic standard (beds and occasionally lockers). The bed clothing was enough in quantity and clean. The lockers for personal belongings were not enough for all patients but some of them shared one. The patients said they keep food, toothbrushes, toothpaste, towels, shaving items etc. in them. Patients wore civilian clothes. The forensic ward had three toilets (washed with a hose) on the second floor for around 30 persons. There were two showers in the bathroom and two basins. In the same room there were three sinks that did not work since they had no taps. On the first floor there were two showers in the bathroom for the rest 20 patients. The patients in the forensic ward were allowed to use a dayroom with a TV set and cable TV. The dayroom was poorly furnished with two benches, five chairs, a table and a wooden bunk bed. There was also a dining room on the first floor in the ward, which was also in need of repair. Both rooms were too small for all patients in the ward. 2.2.4.2. The 5th and 6th wards The 5-th and 6-th wards were in another two-storied building. It was far more dilapidated than the forensic ward. The building was dark and cold although it was 35°C outside. The hygiene in these wards was very poor. The mattresses on some of the beds were wet. The walls and the floors were dirty and renovation was a must. There were 4-5 beds in each room and they did not look overcrowded (being around 20 sq. m. in size). All rooms had large windows (some with bars), which provided direct access to sunlight and fresh air. The bed sheets and blankets were old, dirty and insufficient for all beds. Patients stayed all day in their dirty pajamas. Such a situation is not conducive to strengthening personal identity and self-esteem; individualisation of clothing should form part of the therapeutic process. The bathroom, the dining room, several rooms for the staff and the room for post-mortem examination and regular examination were placed on the first floor. The dining room was a big hall with large windows (some of which were broken), 12 tables, 48 chairs that were old and needed serious repair. There were no cloths on the tables. The hall was not clean and cozy although tidy. One of the rooms on the first floor had five beds with bed clothing. The floor was covered with linoleum; the walls were recently renovated and covered with tiles up to 1,50 m. But the tiles were broken. The orderly on duty there said that there were 40 people living there and 15 of them were incontinent. There were five toilets without seats, two of which without doors. Only two taps for cold water were functioning out of around ten. There were also six basins. Hot water was available only on Wednesdays according to the orderly on duty. This was also the day for taking bath for the patients. There were two nurses and seven orderlies in the 6th ward. 2.2.5. Food The daily food allowance in the Demir Hisar psychiatric hospital was less than 1 Euro per patient. The patients who were bedridden and the elderly patients were fed by the staff. Some of the patients with dementia were fed with infusion. According to the interviewed doctors when preparing the menu the cook and the doctors try to comply with the receipt book and the calories per meal recommended there. There was additional food for the patients who were on special diets. Breakfast was served at 7 a.m., lunch – at 11:30 a.m. and dinner – at 6 p.m. On the day of the visit the patients had for breakfast the so-called “aivokac” – flour with water. The lunch for the day of the visit was chicken with vegetables and the dinner was to be beans. The kitchen of the hospital was in relatively good state of repair although the cookers and the sink had been used for the last 20 years. According to the cook, patients have 3 meals every day and always some kind of meat for lunch. Food was the same for everybody, except in cases when doctors order special diet for some patients. 2.2.6. Therapy According to the interviewed doctors ECT was not applied in the hospital because the machine was not working. The severe depression was treated only with medicines or the patients who were resistant to medicines were sent to other hospitals for application of ECT. According to the interviewed doctors all patients receive medication and there were enough drugs for all the patients. Some of them were old and ought to be replaced with drugs from the new generation. However, only old drugs were on the so-called “positive list”.[ Positive list is the list of drugs, which can be obtained via doctor’s receipt and their price is covered by health insurance.] and were commonly used in entire Macedonia. If the patient or his/her family has enough money to pay for a modern drug, it could be used for treatment. There were no new nEuroleptics in the hospital (e.g. Rispolept). The ones most often used were Haloperidol and Moditen-Depo in ampules and pills. Leponex was available in pills but not in ampules. Diasepam, Flusepam and antidepressants were also available, as well as Tegretol and Fenobarbital. According to the doctors there were enough medicines for treatment of somatic symptoms. According to the interviewed doctors other types of therapy were also applied. These include group therapy, art, sports and occupational therapy. Groups for the group therapy consisted of 10-12 patients and sometimes family members were involved in the groups as well. The hospital had a locksmith workshop, which was used for the occupational therapy. 2.2.7. Seclusion and restraint There were two seclusion rooms in the forensic psychiatric ward situated next to each other on the second floor of the building. The staff claimed that only one of them (6-7 sq. m) was in use. It had a bed and a mattress, bed clothing and radiator. The floor was covered with linoleum; the walls were clean. There was sufficient natural light in the room coming from a window. There was no toilette and no access to water. The other room had no bed but a mattress and a door with a hole for watching. These rooms could be entered only from a bedroom – the first on the right at the beginning of the corridor on the second floor. According to the doctors the seclusion room was used for patients who are agitated and can hurt others or themselves or when there is a suspicion that the patient could escape. The patients placed in the seclusion room were allowed to go out of it for toilet and when examined. An orderly accompanied the person. The patient was allowed also to stay in the day room and to watch TV with the rest of the patients from the ward. According to the staff restraint could be prescribed by the head of the ward or the doctor on duty. The doctor who prescribes it usually records that on a separate sheet of paper and puts it into the patient’s personal medical file. The delegation was not able to see any document of this type. In cases of aggression the patients were fixed to the beds in their rooms with leather belts (no chains and straight jackets were used). Usually only one of the patient’s hands is fixed. Only when the patient is strongly agitated they fix one of his/her hands and the opposite leg. One of the doctors declared that the duration of the fixation could not be longer than 2 days (48 hours). Such a practice however cannot have any therapeutic justification and amounts to ill treatment. 2.2.8. Inspection Officials from the Ministry of Health were visiting the hospital at least once a year. The IHF delegation did not see any documents from these inspections. The delegation was told that the State Commission of Sanctions should visit the hospital regarding the patients in the forensic psychiatric ward. The Director later stated that no such inspections or visits had been performed till the end of July 2004. 2.2.9. Other human rights problems The delegation heard no allegations of torture or other forms of ill treatment of patients either at the forensic psychiatric ward or at the 5th and the 6th ward at Demir Hisar hospital. Relations between staff and patients at the forensic ward were generally positive and tension-free. The patients were allowed to call their families and friends if the head of the ward in which they stay gives permission for that. The cost of the phone calls is covered by the hospital. The delegation did not find any traces of visits of ministers of any religion in the hospital. The doctors on duty stated that there were no religious patients in the hospital. |
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