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(Part 1)
Report to the Government of Greece
on the visit to Greece
carried out by the European Committee
for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment (CPT)
from 4 to 6 November 1996
The Government of Greece has agreed to the publication of this report and of its response.
Strasbourg, 13 September 2001
CONTENTS
Copy of the letter transmitting the CPT's report
I. INTRODUCTION
A. Dates of the visit, composition of the delegation and establishment visited
B. Context of the visit to Greece
C. Co-operation received by the delegation
II. FACTS FOUND DURING THE VISIT TO THE ATTICA STATE MENTAL HOSPITAL FOR CHILDREN AND ACTION PROPOSED
1. Ill-treatment
2. Patients' living conditions and treatment
a. preliminary remarks
b. situation during the CPT's second visit
3. Discharge of patients
Copy of the letter transmitting the CPT's report
Strasbourg, 24 March 1997
Dear Sirs,
In pursuance of Article 10, paragraph 1, of the European Convention for the prevention of torture and inhuman or degrading treatment or punishment, I have the honour to enclose herewith the report to the Government of Greece drawn up by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) after its visit to Greece from 4 to 6 November 1996. The report was adopted by the CPT at its 32nd meeting, held from 10 to 14 March 1997.
The CPT requests the Greek authorities to provide, within six months, a report setting out details of the measures adopted to implement the recommendations in this report, and their reactions and responses to the comments and requests for information made therein (the Committee's recommendations, comments and requests for information appear in bold in the text).
I am entirely at your disposal to answer any questions concerning either the report or the future procedure.
Finally, I would be grateful if you could acknowledge receipt of this letter.
Yours faithfully,
Claude NICOLAY
President of the European Committee for
the prevention of torture and inhuman
or degrading treatment or punishment
Ministry of Justice
Directorate for Drafting Legal Texts,
Specific Legal Affairs and
International Relations
96, rue Messoghion
GR - 115 27 ATHENS
I. INTRODUCTION
A. Dates of the visit, composition of the delegation and establishment visited
1. In accordance with Article 7 of the European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (hereinafter referred to as "the Convention"), a delegation of the CPT carried out a visit to Greece from 4 to 6 November 1996.
2. The CPT's delegation comprised Mrs Ingrid LYCKE ELLINGSEN (Head of the Delegation), Mrs Christina DOCTARE and Mrs Jagoda POLONCOVÁ, all members of the CPT. The delegation was assisted by two interpreters, Mrs Myrto ROUSSOU-ATZITIRIS and Mr Alexander ZAPHIRIOU, and was accompanied by Mrs Geneviève MAYER, Deputy Secretary to the CPT.
3. The delegation visited Attica State Mental Hospital for Children, located at Rafina.
B. Context of the visit to Greece
4. This was a visit which appeared to the Committee to be required in the circumstances (cf. Article 7 (1) of the Convention). The hospital had previously been visited in 1993 (cf. doc. CPT/Inf (94) 20) and the conditions prevailing there at the time had prompted a series of recommendations by the Committee. Subsequently, the Committee received communications to the effect that an inquiry had been opened into the conditions of patients' accommodation at the hospital. The Committee had accordingly asked the Greek authorities for detailed information about the situation at the establishment. In the light of the information received, describing certain changes in patient care and accommodation, the CPT decided to make a visit in order to see on the spot the progress made since its earlier visit in 1993.
C. Co-operation received by the delegation
5. The delegation had fruitful discussions with Mr SKOULAKIS, Deputy Minister of Health and Social Welfare, and Mr YANNOULATOS, Director of Mental Health.
6. The delegation received an excellent reception at the mental hospital for children. The CPT wishes to thank Mrs PEPONI, Chairperson of the Administrative Board, as well as the members of the medical, paramedical and nursing teams whom it met, for the considerable time they devoted to discussions with the delegation. They all demonstrated great open-mindedness throughout the visit. Ms FAFOUTI of the Ministry of Health, who acted as the delegation's liaison officer during the visit, was also most helpful.
7. The CPT welcomes the spirit of co-operation which prevailed during its second visit to Greece, which was fully in accordance with Article 3 of the Convention.
1. Ill-treatment
8. The delegation heard no allegations and gathered no other evidence of ill-treatment of patients by staff at the Attica State Mental Hospital for Children.
9. The delegation noted that the medical and nursing staff were very attentive to the patients' well-being and fully committed to their work. The atmosphere in the units and pavilions visited appeared relaxed and friendly and staff-patient relations were good.
2. Patients' living conditions and treatment
a. preliminary remarks
10. In the report on its first periodic visit to Greece (CPT/Inf(94)20), the CPT criticised the material conditions of accommodation in some of the pavilions of the hospital, particularly pavilions C, E and Z (cf paragraphs 226 and 234 of the report). It also expressed serious concern about the therapeutic activities offered to patients and the use of isolation and physical restraints.
b. situation during the CPT's second visit
11. At the time of the second visit, the hospital had 139 patients, somewhat fewer than in 1993. These patients presented the same diagnoses as those described in paragraph 194 of the report on the first visit, namely behavioural disorders, moderate and severe mental deficiencies and/or motor handicaps. The delegation observed that, in addition, there were some patients suffering from mental illness. The great majority were adults (the average age was twenty); the others were aged between 5 and 20. As before, they were mainly civil law referrals; one had been remanded by a court for an evaluation of his mental state, in accordance with the provisions of the Penal Code.
12. The medical team in charge of the patients consisted of ten part-time child psychiatrists (as compared with 12 in 1993), three paediatricians, one neurologist and twelve doctors undergoing their training in the hospital. Twelve psychologists (one more than in 1993), three occupational therapists (compared with the previous five) and one physiotherapist were there to run therapeutic activities. As at the time of the previous visit, most of the staff divided their time between four outside units, the child guidance centre attached to the hospital and the hospital's internal services. The establishment had no speech therapist (speech therapy training was not established in Greece until 1996 and its beneficial effects have not yet been felt).
The delegation was informed that several doctor's posts were vacant but were due to be filled. The hospital authorities especially deplored the lack of qualified staff for running therapeutic activities. In this respect, it is true that the available resources are not yet sufficient for developing varied programmes of activities involving a full range of treatment (somato-, psycho-, socio- and occupational therapy).
The nursing staff numbered 158, with regular assistance from nine outside health-care staff involved in activities with patients. Most importantly, the numbers of qualified nursing staff had increased substantially since the CPT's first visit. Of the present nursing staff, forty had full three-year training and nearly a hundred two years' training.
13. The CPT cannot but express satisfaction with the positive developments as regards the hospital's nursing staff. Further effort is needed, however, particularly with regard to qualified staff for therapeutic activities. Accordingly, it recommends that the Greek authorities take steps to increase substantially the number of such staff. It also wishes to know whether the vacant doctor's posts have now been filled.
14. There has been a considerable improvement in patients' material living conditions. Out of a total of 11 units, four pavilions/sections have been renovated since the 1993 visit. The delegation was particularly pleased to note that this included Pavilion E, which had been seriously criticised by the CPT. The patients had been transferred to a new, more functional, very well-appointed and decorated unit with a stimulating environment, called "Rainbow". Pavilion Z, which had also been visited in 1993, had been closed and the patients transferred to a new unit, where the bedrooms and day-rooms were also cheerful and well-appointed.
Current renovation plans included the so-called emergency unit, the neurology unit and Pavilion C (also known as Section 3). The delegation noted this with interest, particularly as regards Pavilion C. Conditions in that pavilion were the same as described in the CPT's previous report. The patients' sleeping and living areas were still bare and devoid of any personal touches, offering them virtually no stimulation (no personal items, nothing to play with or to entertain them, except a TV set in a common room, no decoration). The toilets and washrooms still showed certain deficiencies: in particular, the floors were slippery and dangerous both for patients - especially those with reduced or limited motor capacity - and for the staff in charge of the patients' personal hygiene; the sanitary facilities were dilapidated and not suitable for patients who have become adults. The situation was similar in Pavilion A (also called Section A or 1), about which the delegation was unable to find out precisely whether there were any plans for renovation or refitting in the short or medium term.
However, all the patients' sleeping and living areas in the various units and pavilions visited were clean and well kept. The efforts made in this respect by the nursing and auxiliary staff, especially those in charge of patients with severe mental and psychomotor handicaps, were praiseworthy. The CPT can only welcome this development (cf. paragraph 234 of its previous report).
15. The hospital
administrative and medical authorities indicated that they were very anxious to
remedy the above-mentioned deficiencies in the course of current renovation
plans. Personalisation of patients' living areas was among their priorities and
they were also endeavouring to find ways of enabling the patients to have
stimulating items, such as toys. In the much shorter term, the Chairperson of
the Board of Management was also trying to deal with other practical problems,
such as making sure that every patient was provided with a pillow.
16. The CPT once again expresses its satisfaction with the progress made since its last visit as regards some of the patients' living areas. It recommends the Greek authorities to actively pursue the execution of the works planned, following the example of the Rainbow Unit, and to include Pavilion A in them. In this context, special attention must be paid to providing a differentiated therapeutic and pedagogic environment affording patients stimulation appropriate to their age and pathology (visual stimuli, personal possessions, toys or other suitable items). In the meantime, ways must be found of reducing the risk of accidents in the toilets and washrooms of Pavilions A and C.
17. In its report on the 1993 visit, the CPT found that there was very little basic equipment suitable for patients with severe psychomotor handicaps. The number of such patients and of patients with limited or very limited motor functions was not inconsiderable at the State Mental Hospital for Children.
At the time of the second visit, there was still a lack of the necessary basic equipment for such patients, despite the urgency which the Committee attached to its recommendation on this subject in 1993 (paragraph 232 of its first report). Such equipment would not only enable the staff to administer care (including bodily care) much more readily, but would also help enable patients to be lifted from their beds or to leave their rooms or even their units.
The CPT reiterates its recommendation that the basic hospital equipment appropriate to the patients' needs be made available without delay.
18. With regard to patient treatment, on its previous visit the CPT had been unable, for lack of sufficient information, to make a precise assessment of the quality of therapeutic activities. However, the delegation had observed at the time that the patients were generally under-stimulated and were offered few individual activities. Attention had also been drawn to the apparent absence of therapy specific to psychomotor and mental handicaps.
During the second visit, the delegation gathered a certain amount of information, including statistics, on patients' activities. There is no denying that, where therapeutic activities are concerned, progress has been very slow. Some forty patients were able to attend occupational therapy sessions in ten workshops (e.g. crafts, pottery, woodwork, painting, gardening, etc). A very small number of patients attended school; as in the past, most of the patients were above school age.
Apart from that, therapeutic care for the patients can only be described as embryonic. Admittedly, efforts had been made in the units to provide for certain activities (behavioural programme for learning to perform everyday life activities, occupational therapy, physiotherapy, musical therapy, sport and other forms of recreation, sometimes outside the hospital), but they were provided on an irregular basis and could only be offered to a rather limited number of patients. Furthermore, some units had no occupational therapy or physiotherapy activities and in one the therapeutic programme had come to an end when the member of staff responsible left. As regards individual activities, the situation was the same as in 1993 and the delegation found no sign of a therapeutic programme sufficiently elaborated and structured to deal with psychomotor and mental handicap. The delegation observed that there was a large number of patients in need of sustained care of this kind.
The main reason for this situation is the lack of therapeutical oriented and trained staff. However, it also emerged from discussions with the hospital staff that the therapeutic efforts made in recent years had mainly benefitted the external services and the child guidance centre which were said to have programmes not available at the hospital. This policy was in particular intended to avoid hospitalisation as far as possible. While recognising the importance of this aim, which deserves to be encouraged, the CPT nonetheless points out that it must not be pursued to the detriment of the quality of treatment offered to the patients in the hospital.
19. In the light of the foregoing, the CPT recommends that the Greek authorities intensify their efforts to develop substantially differentiated treatment activities using the full range of therapies (somato-, psycho-, socio- and occupational therapy). In this respect, it refers to the recommendation in paragraph 13 above.
20. In this connection, the CPT also points out that the conduct of satisfactory therapeutic programmes largely depends on a policy of differentiating patients according to their pathology and state of development. The delegation found that there was room for improvement in this respect. This was particularly flagrant in the so-called emergency unit, where there were patients requiring urgent psychiatric treatment, patients no longer in the acute phase and patients whose pathologies did not necessitate placement in an intensive care unit.
The CPT would like to receive the Greek authorities' comments on this point.
21. The CPT would also indicate that the delegation was not persuaded that all patients whose state of health so permitted were allowed out daily into the open air in the exercise or recreation areas around the pavilions/units. This was brought to the attention of the Chairperson of the Administrative Board, who indicated that she would take immediate action accordingly. The CPT would like to receive confirmation of the measures taken in this respect.
22. As regards the supervision of the state of physical health of patients, the CPT would like to stress that during the 1996 visit its delegation found that this was satisfactory and that patients benefitted from regular medical controls which were duly recorded in the medical files. In this context, the CPT would like to know whether the hospital authorities have developed a preventive policy against transmissible diseases (e.g. hepatitis).
23. As already indicated, on its previous visit the CPT expressed serious concern about the use of isolation and physical restraint (cf paragraphs 250-256 of the report on the 1993 visit). The situation has considerably improved since.
It was now hospital policy not to isolate patients. An isolation room was seen during the 1996 visit, in the so-called emergency unit. The isolation room had been equipped for video surveillance since 1993 but access to natural light was still limited and the small window was unglazed. However, the medical staff said that the room was not used and the delegation found nothing to suggest otherwise in the nursing and doctors' instructions registers. In its present state, this room must remain out of use.
As for the use of physical restraint, the CPT is satisfied that its delegation no longer found the situation described in paragraph 253 of its previous report. In the so-called emergency unit, the delegation found that physical restraint was confined to exceptional cases. Detailed instructions were given to the nursing staff by the doctors in respect of each patient. These instructions required the staff in particular to increase surveillance if the patient was agitated and to inform the doctor on duty of the use of physical restraint. In addition, the circumstances and duration of the restraint measure were recorded in the nursing register.
The CPT considers that this procedure largely meets the recommendations it made in paragraph 256 of the previous report. However, it would be desirable to provide in addition for all measures of physical restraint to be recorded in the patient's file and in a specific register established for this purpose, indicating the time of the beginning and end of the measure, the circumstances of the case, the reasons for resorting to the measure and an account of any injuries sustained by patients or members of staff. The CPT recommends that the Greek authorities take appropriate measures to this effect.
24. As regards the actual means of restraint, the delegation observed that the leather straps were, as in the past, fixed to the bed with a padlock; this is not ideal, particularly if the patient has to be unstrapped for an urgent reason.
The CPT noted that in their follow-up report (CPT/Inf (96) 8, p.34), the Greek authorities indicated that as regards the Committee's recommendation on means of restraint, the views of the Scientific Committee of each of the three hospitals visited in 1993 had been requested and that their reply was expected. The CPT would like to know whether that reply is now available.
3. Discharge of patients
25. In general, considerable efforts were being made at the Mental Hospital for Children in the sphere of dehospitalisation of chronic patients (e.g. programmes for autistic children; development of fostering families or return to the child's biological family). Such efforts naturally take time and also depend on the existence of outside facilities. The CPT dealt with this matter at length in its previous report. It has taken note of the information supplied by the Greek authorities in their replies and encourages them to continue their efforts in this direction.
26. However, the delegation was concerned by the situation in the so-called emergency unit, where it found several patients no longer in need of hospital psychiatric treatment or whose period of observation had been completed and the report sent to the competent authority. In one case, the placement had been made almost a year ago. The delegation was informed that the doctors and the Administrative Board had sought several times, but in vain, to have these persons admitted to appropriate institutions.
The CPT recommends that the Greek authorities take appropriate measures to ensure that patients do not stay longer at the Attica State Mental Hospital for Children than their state of health requires.
*
* *
27. In conclusion, the CPT wishes to raise the question of the present function of Attica State Mental Hospital for Children. Originally intended to be a psychiatric hospital for children, it now has over a hundred chronic, mostly mentally handicapped adult patients cared for by a medical team mainly specialising in child psychiatry. In order to ensure satisfactory care for these patients, particularly from the therapeutic point of view, particular attention should be given to this development in their age and condition.
The CPT would welcome the Greek authorities' comments on this point.