Adequate medical assistance and care for a disabled prisoner. No degrading treatment was found
JUDGMENT
Normantowicz v. Poland 17.03.2022 (app. no. 65196/16).
SUMMARY
Detention conditions of a disabled person. Positive obligations of the state. Adequate medical care by national authorities.
The applicant, being held in prison for various offenses, complained of inhuman and degrading treatment in connection with his detention. He particularly complained that despite the serious health problems he was facing, spondylolisthesis and chronic back pain syndrome that eventually rendered him crippled in the lower extremities, he was not provided with the proper medical care and surgery. He also complained that he was not provided with equipment for mobility issues and his application for special leave was rejected due to his health condition.
The Court reiterated that Article 3 of the Convention could not be interpreted as imposing a general obligation to release a detainee for health reasons; however, this provision requires the state to ensure respect for human dignity, and the exceeds the inevitable level of inconvenience inherent in the reservation.
The ECtHR found that the doctors at the detention center were vigilant and constantly monitored his numerous medical problems. He received appropriate medical treatment and the authorities actively assisted the applicant in seeking treatment for his illness – often against his wishes. He was also provided with all the appropriate equipment, ie crutches, a wheelchair and a stair lift in order to address the issue of his mobility.
Taking into account that the medical care provided to the applicant was not incomplete or below the standard level of health care available to the general population and that the courts examining his application for leave had correctly assessed the facts, the ECtHR ruled that it did not Article 3 of the ECHR.
PROVISIONS
Article 3
Article 6
PRINCIPAL FACTS
The applicant, Rafał Normantowicz, is a Polish national who was born in 1983. He has a long criminal
record and is currently detained in Szczytno Prison.
The case concerns his complaints about inadequate medical care in detention and the authorities’
review of whether he was fit for prison given his multiple ailments.
Relying on Article 3 (prohibition of inhuman or degrading treatment) of the Convention,
Mr Normantowicz alleges that the authorities failed to ensure that he had surgery for his spinal
problems, which led to him being confined to a wheelchair.
Also relying on Article 6 (right to a fair trial within a reasonable time), he complains that it took the
authorities more than a year to examine his application for release, despite his being in need of
surgery and unfit for detention.
THE DECISION OF THE COURT…
Article 3
General principles
The Court reiterates that Article 3 of the Convention cannot be interpreted as laying down a general obligation to release a detainee on health grounds or to transfer him or her to a civil hospital – even if he is suffering from an illness that is particularly difficult to treat (see, inter alia, Sławomir Musiał. However, this provision does require the State to ensure that prisoners are detained in conditions which are compatible with respect for human dignity, that the manner and method of the execution of the measure do not subject them to distress or hardship of an intensity exceeding the unavoidable level of suffering inherent in detention, and that, given the practical demands of imprisonment, their health and well-being are adequately secured by, among other things, their being provided with the requisite medical assistance (see Kudła; Mouisel v. France, no. 67263/01, § 40, ECHR 2002‑IX; Sławomir Musiał, cited above, 86; and Kaprykowski).
There are three particular elements to be considered with regard to the compatibility of an applicant’s health with his stay in detention: (a) the medical condition of the prisoner, (b) the adequacy of the medical assistance and care provided in detention and (c) the advisability of maintaining the detention measure in view of the state of health of the applicant (see Mouisel,; Sakkopoulos v. Greece, no. 61828/00, § 39, 15 January 2004; and Melnik v. Ukraine, no. 72286/01, § 94, 28 March 2006).
i) The applicant’s medical condition
As to the prisoner’s health condition, the Court observes that the applicant suffers from a herniated disc, spondylolisthesis and chronic back pain syndrome. The applicant’s complaint refers mainly to these conditions. The Court will also take account of the fact that, over time, the applicant was additionally diagnosed with the following short‑term or chronic ailments: ulcers, epilepsy, urinary tract infection, sciatica, kidney stone disease, insomnia, anxiety disorder, hypertension, mood disorders and depression.
In late 2014 the applicant started using crutches and a stair walker. On an unspecified time, around May 2016, he became confined to a wheelchair.
ii) The adequacy of medical assistance and care provided to the applicant in detention
As regards the adequacy of the medical care provided to the applicant in detention, the Court firstly observes that in 2012 it was for the first time recommended that the applicant should undergo spinal surgery. The procedure continued to be recommended throughout the applicant’s detention. It was never considered that the need for surgery was urgent. Secondly, the applicant received a medical recommendation that he sleep in a bottom bunk, be exempted from physical work or effort, and be put on a light diet. Thirdly, the applicant was prescribed various medicines and, on one occasion, physical therapy.
The Court notes that during his detention the applicant was mainly committed to prison hospital wings, where his special needs were met. Whenever he was committed to a regular cell, he was assigned to a bottom bunk, as per medical recommendations. Moreover, the applicant received a light diet and was administered the medicines specified in the medical prescriptions issued to him, which were regularly reviewed. The physical therapy that was recommended as non-essential treatment was ultimately not carried out because the applicant did not consent to it.
Conversely, the recommendation that the applicant undergo backbone surgery was not complied with. In the Court’s view, however, that outcome was not caused by a lack of diligence or a deliberate omission on the part of the prison authorities. As to the latter, the Court reiterates that “[a]lthough the purpose of [the particular] treatment is a factor to be taken into account, in particular whether it was intended to humiliate or debase the victim, the absence of any such purpose does not inevitably lead to a finding that there has been no violation of Article 3” (see, in the context of health care, Sarban v. Moldova, no. 3456/05, § 75, 4 October 2005; see also, in the general conditions-of-detention context, Muršić v. Croatia [GC], no. 7334/13, § 100, 20 October 2016).
In that regard, the Court observes that the authorities at each of the detention establishments in which the applicant was held were active in seeking to have the applicant admitted for surgery in a specialised civilian hospital.
Moreover, they ensured that the necessary diagnostic procedures were followed in order to prepare the applicant for surgery. In particular, the applicant underwent two MRI scans and one CT scan. He also underwent multiple laboratory tests and examinations administered by various specialists – including orthopaedists, neurologists and neurosurgeons. A number of the applicant’s examinations took place in civilian medical establishments. In 2015, two reports concerning the applicant’s health expressly confirmed that further diagnoses in respect of his health could be made within the prison healthcare system. No document was issued indicating the contrary.
The Court acknowledges that the applicant’s diagnostic process was lengthy. In the Court’s view, however, this was because the applicant had, in the meantime, to be examined or treated for new ailments, such as epilepsy. He also suffered acute back pain, which required his transfer to a different prison infirmary . Lastly, the applicant developed a urinary tract infection and showed symptoms of further internal inflammation, which called for thorough medical examinations.
Given these objective complications, the Court does not find it established that the detailed planning of the applicant’s multi-phase treatment could not have been put in place sooner than it actually was – that is to say in October 2.
The Court also observes that the first-phase surgery was postponed owing to an independent factor – namely the applicant’s urological condition. That illness was monitored with the utmost frequency until at least January 2016 .
Additionally, the applicant had to be treated for hypertension and chronic gastritis, as well as depression, recurring inflammation, and ulcers.
In the absence of any rebuttal or explanation from the applicant, the Court accepts the Government’s submission that the applicant had later impeded the authorities from affording him adequate medical care. In particular, in May 2016, the applicant refused to take medicines prescribed for his internal inflammation and to undergo further tests that were necessary by way of preparation for his scheduled surgery. He also clearly undermined the authorities’ efforts to treat his ulcers in that, despite clear medical instructions, he did not prepare for a scheduled colonoscopy . Lastly, in subsequent months, the applicant appeared to intentionally skew his laboratory results, thus rendering it impossible to undertake the planned spinal surgery, which consequently had to be continually rescheduled.
In the light of the above elements, the Court concludes that the authorities made consistent and serious efforts to ensure that the applicant could receive surgery. The procedure had to be continually postponed over the years owing to (i) a series of independent developments, such as the necessity to diagnose and treat the applicant’s additional ailments, and (ii) the applicant’s own attitude, which undermined the authorities’ actions. It follows that the delay in the applicant undergoing surgery, albeit significant, was not attributable to the authorities but rather to independent factors and unpredictable developments. Overall, during the applicant’s detention, the authorities ensured adequate medical treatment not only in respect of his pre-existing spinal ailments but also all his remaining internal and mental disorders.
Moreover, the Court considers that the applicant’s special needs were sufficiently accommodated in prison. He was furnished with crutches, a stair‑climbing aid, and ultimately a wheelchair. He spent most of his time in hospital wings, where infirmary care was ensured. As for the shorter periods of detention in regular cells, the Court does not find it established that the applicant had to rely on his fellow inmates for helping in undertaking his daily activities.
iii) The advisability of maintaining the detention measure in view of the applicant’s state of health
The last point to be addressed by the Court is that of whether – given the impossibility of having the applicant operated on, and given his multiple ailments and physical disability – the applicant was fit for continued incarceration. In this regard, the Court must assess not only the substantive elements but also the adequacy of the procedure for reviewing the applicant’s fitness for detention – in particular, the speediness with which the authorities examined his first request for a licence for leave.
The Court notes that the authorities constantly monitored the course of the applicant’s illnesses and reviewed the advisability of his continued detention. In particular, apart from the 2015 reports, on 22 February 2016 two independent experts drew up a report which state that keeping the applicant detained did not threaten his life or health.
The Court also observes that the argument that the applicant was not fit for detention was duly examined by the domestic courts in the course of the proceedings concerning his application for a licence for leave.
In the first set of those proceedings, the courts relied on three separate reports produced by independent medical experts, on additional reports regarding the applicant provided by Gdańsk Remand Centre, and on the material obtained directly from the applicant at the hearings. The first- and second-instance courts consistently held that the applicant’s life or health was not threatened and that his release from detention was not called for.
In these the circumstances, the Court does not take issue with the merits of the authorities’ decision, delivered during the first set of the impugned proceedings, not to grant the applicant a licence for leave. Their reasons were indeed relevant and sufficient.
The Court, however, cannot disregard the fact that almost fourteen months passed between the time when the applicant first asked for a licence for leave and the final judicial decision regarding this matter.
Given the State’s duty of care and its obligation to ensure that the applicant (a special-needs prisoner) did not suffer treatment contrary to Article 3 of the Convention in view of his alleged unfitness for detention, the authorities were required to ensure a speedy judicial review of the applicant’s application for a licence for leave.
The Court considers that taking more than one year to decide on such an inherently urgent request was, in principle, not compatible with the requirements of Article 3. It must therefore be examined whether any exceptional circumstances existed in the case that would justify the protraction of the proceedings in question.
The Government acknowledged that the impugned proceedings had been lengthy. They argued, however, that the delay in reviewing the applicant’s first application for leave was attributable to the applicant being transferred between prison establishments located in two different administrative regions. Moreover, the case the case had required an assessment of medical records that were complex and had to be kept up‑to‑date.
The Court notes that a change of court jurisdiction (owing to a transfer of the applicant) occurred three times – namely, on 2 June 2015, 3 March 2016 and 1 April 2016. The site of actual court hearings followed the applicant when he was transferred between Barczewo and Gdańsk.
In the light of the available material and its finding that the applicant had received adequate medical treatment during his detention, the Court accepts that the applicant’s various transfers were necessary in order to ensure adequate specialised treatment of his ever‑developing ailments. It also observes that the applicant’s overall state of health was serious and that the transfers were aimed at facilitating not only short‑term remedies for particular illnesses but also a long-term improvement in the applicant’s physical well-being and thus rendering him fit for his spinal surgery. Given the circumstances, the resulting repercussions for the proceedings concerning the applicant’s application for a licence for leave were, inevitably, of secondary importance, especially given that the applicant’s fitness for detention was monitored at all times.
Furthermore, between the shifts in jurisdiction, the courts acted with diligence and without undue delays. For example, in 2015, the court handling the case obtained from the Barczewo Prison authorities three updated reports regarding the applicant’s changing state of health and a copy of a social inquiry report that had been requested by the applicant’s lawyer. It also held a hearing in the presence of the applicant. By the end of that year, that court, doing its utmost to secure objective evidence, was faced with a series of obstacles to it obtaining a report from medical experts not affiliated with the prison system. In the Court’s view, the domestic court was proactive in seeking to obtain the report in the shortest time possible. In 2016 – within the same month in which it received the case – the next court to which the case was transferred obtained additional reports on his health from Gdańsk Remand Centre . When in April 2016 the applicant’s case was again transferred to Olsztyn Regional Court, that court, within six weeks, obtained an updated report on the applicant’s health, held a hearing in Gdańsk Remand Centre and closed the case, issuing its ruling.
The Court considers that the first‑instance proceedings in respect of the applicant’s first request for a licence for leave were completed as quickly as possible, given the series of objective obstacles that arose (which the prison authorities could not have avoided) and given the complexity of the case.
Following the applicant’s appeal, the Bialystok Court of Appeal took approximately six weeks to issue the final ruling in the case. The appeal required a reassessment of numerous medical reports and certificates, as well as the submissions that had been made in the lower-instance court. In view of this, the Court accepts that the length of the appeal proceedings was not unreasonable.
Overall, the Court does not find any element in the case that would call into question the decision of the Białystok Court of Appeal to dismiss the applicant’s complaint regarding a breach of his right to a trial within a reasonable time.
All the above-mentioned efforts to provide the applicant with medical care demonstrate that the State authorities have shown sufficient care in taking appropriate action to ensure that the applicant underwent surgery at a civilian hospital that specialised in complex spinal ailments. They were also attentive to and constantly monitored the applicant’s other, numerous medical conditions. In their view, the applicant received appropriate medical care in detention and the Court sees no reason to find otherwise. The authorities actively assisted the applicant by seeking to have his ailments treated – often against the applicant’s own wishes. On the basis of the evidence before it, the Court does not find that the medical care provided to the applicant was deficient or below the standard level of health care available to the general population, or that the courts examining the applicant’s request for leave made a manifest error of judgment (see Wołkowicz v. Poland (dec.), no. 34739/13, § 110, 7 March 2017). Lastly, the authorities duly examined the question of the applicant’s fitness for detention and decided on his first application for a licence for leave as quickly as was possible, given the exceptional circumstances described above.
Having regard to the above, the Court concludes that the authorities provided the applicant with adequate medical care and made sufficient efforts to reasonably accommodate the special needs resulting from his disability. They also constantly monitored the advisability of holding the applicant in detention.
There has accordingly been no violation of Article 3 of the Convention in the present case
