Imprisonment of an epileptic, with a history of self aggression and mental disorder. Inadequate care. Inhuman and degrading treatment
JUDGMENT
Epure v. Romania 11.05.2021 (app. no. 73731/17)
SUMMARY
Detention of the mentally ill. Inhuman and degrading treatment.
The ECtHR has already ruled that the conditions of detention of a mentally ill criminal should in no case create feelings of fear, anxiety and inferiority capable of humiliating and devaluing him and possibly breaking his physical and moral resistance. Therefore, in order for the detention to be compatible with Article 3 of the ECHR, full treatment must be provided.
In the present case, the applicant complained about the lack of a permanent assistant nurse and the general lack of care throughout his detention (2.5 years) resulting in his deteriorating health.
According to the ECtHR, the decision to imprison him was compatible with his state of health and he considered it appropriate to examine the conditions of detention.
The Court found that not only did the domestic authorities fail to ensure the applicant’s health and well-being by placing him in a special facility where he could receive adequate treatment and supervision on a more stable basis, despite the complex situation and background He was kept in high security prisons, which had negative psychological and emotional consequences that worsened his mental state. Furthermore, leaving him without specialized help in such situations caused him considerable stress. Finally, when he was hospitalized after an attempt at self-injury, he was not provided with the required medical care.
The ECtHR considered that the inadequate medical care provided to the applicant did not provide him with conditions of detention compatible with respect for human dignity and found a violation of Article 3 of the ECHR. He claimed an amount of 3,000 euros for non-pecuniary damage.
PROVISION
Article 3
PRINCIPAL FACTS
The applicant, Culiță Epure, is a Romanian national who was born in 1978 and lives in a specialised
State institution providing care to disabled adults in Măicăneşti (Romania). He suffers from epilepsy
and has been diagnosed with slight to moderate mental impairment.
The case concerned the conditions of the applicant’s detention for the period from 6 December
2016 to 16 June 2019. He had been serving an eight-year sentence for rape dating from 2014. During
this time, he had been held under a maximum-security regime in Focşani, Galaţi and Giurgiu prisons.
Relying on Article 3 (prohibition of inhuman or degrading treatment) of the European Convention,
the applicant complained that the prison regime under which he had been placed was incompatible
with his mental condition; that he had not received appropriate medical treatment for his mental
disability; and that he had not been provided with a personal care assistant on a permanent basis, as
required by his state of health.
THE DECISION OF THE COURT…
At the outset, having regard to the fact that the applicant had the opportunity to apply to the domestic courts for an assessment of the compatibility of his detention with his health, the Court notes that the decisions reached by the domestic authorities, were based on medical conclusions or legal regulations which in the relevant court’s view confirmed the applicant’s real capacity to remain in prison under the detention regime complained of, as well as the necessity that he did so.
In the light of the above, and having also regard to the applicant’s complaint before it, as described in paragraph 51 above, the Court concludes that the present case does not concern the question of the applicant’s initial fitness to serve his sentence, but rather the quality of the care provided, and in particular whether the national authorities did everything that could reasonably be expected of them to provide him with the medical care he needed and to offer him some prospect of an improvement in his condition.
(i) Concerning the prison regime in which the applicant was placed
The Court observes that it has already found that the risk of significant deterioration in the applicant’s mental and physical health arising from the conditions of detention in a maximum security prison liable to aggravate the illness of a paranoid schizophrenic applicant was sufficient to give rise to a breach of Article 3 of the Convention.
Therefore, even though it cannot be said that detention in a high-security prison facility in itself raises an issue under Article 3 of the Convention, as public-order considerations may lead the State to introduce high-security prison regimes for particular categories of detainees, the State must nevertheless ensure that the manner and method of the execution of the measure do not subject a detainee with mental disorders to distress or hardship of an intensity exceeding that unavoidable level of suffering inherent in detention and that, given the practical demands of imprisonment, the person’s health and well-being are adequately secured.
In that vein the Court notes that obligations under Article 3 may go so far as to impose an obligation on the State to transfer prisoners (including those who are mentally ill) to special facilities in order to receive adequate treatment.
Turning to the present case, the Court considers that not only have the domestic authorities failed to ensure the applicant’s health and well‑being through his placement in a special facility where he could have received adequate treatment and supervision on a more consistent basis, but on the contrary, in spite of his complex condition and history of self-aggression, they considered it appropriate to place him under a maximum security prison regime, precisely on the basis of his aggressive behaviour.
The Court finds that the placement of the applicant under such a restrictive prison regime for a significant period of time has not facilitated the applicant’s rehabilitation or deterred him from committing further offences, these being, in the domestic courts’ view, the essential aim of his sentence ; most importantly, it has had severely negative psychological and emotional effects entailing a deterioration in his mental condition, as underlined by the medical authorities and by the courts .
(ii) Concerning the personal care assistant assigned to the applicant
The Court notes that the evidence from various medical sources confirmed that the applicant had several serious medical conditions which over time required more regular medical care and supervision.
The Court further notes that, keeping in mind the applicant’s general health and given the vulnerable and difficult situation in which he found himself because of his permanent disability, as attested by medical certificates , he should have been entitled, according to the national law, to the help of a personal care assistant, without having to make any special request.
However, during several periods, including while he was in transit between prisons or prison hospitals and in spite of several requests lodged by him in that regard, the applicant was left unaided. This in itself leads to a strong presumption of a violation of Article 3 of the Convention.
Furthermore, although the case file shows that at certain times the applicant had the assistance of various fellow inmates, the Court is particularly concerned about the quality of their assistance, as they had neither been trained nor have the necessary qualifications to provide such assistance to a person such as the applicant with a complex condition in the area of mental disability; indeed, the manner in which the applicant’s personal assistants were assigned appears to have been based on an assessment of their adequate physical shape and of whether they had or had not been subjected to disciplinary sanction, rather than on whether they had followed any type of medical training. In that connection, the Court refers to the medical evidence as well as to the applicant’s allegations showing that the applicant’s seizures were frequent and could occur at any time of the day or night, and involved episodes of high irascibility, aggressive behaviour and complete loss of self-control. Therefore, the applicant must have known that at any moment he risked a medical emergency with very serious effects and that no qualified medical assistance was available. Hence, leaving him without specialised assistance in such situations must have given rise to considerable anxiety on his part.
In that connection, the Court reiterates that in circumstances where prison staff felt that they had been relieved of their duty to provide security and care to more vulnerable detainees whose cellmates had been given responsibility for providing them with daily assistance or, if necessary, with first aid , it has already found a violation of Article 3 of the Convention on the basis that such assistance did not form part of any organised assistance by the State to ensure that the applicant was detained in conditions compatible with respect for his human dignity. That assistance could not therefore be considered suitable or sufficient in view of the applicant’s physical disability .
Moreover, the Court reiterates that the feeling of inferiority and powerlessness which is typical of individuals who suffer from a mental disorder calls for increased vigilance in reviewing whether the Convention has (or will be) complied with.
Having regard to the above and noting that the personal care assistants provided to the applicant on a somewhat occasional basis were clearly not trained to provide him with any first-aid measures, the Court considers that in the present case the help offered by the applicant’s fellow inmates did not form part of any effective assistance by the State to ensure that the applicant was detained in conditions compatible with respect for his human dignity. Such help cannot therefore be considered suitable or sufficient.
(iii) Concerning the medical care provided to the applicant
Moreover, the Court notes with concern that even on the occasions when the applicant was under the care and direct supervision of trained staff, namely while he was in a prison hospital, he managed to severely harm himself by inserting nails in his head. Those incidents, seen against the medical background of the applicant, should have alerted the authorities to a sufficient degree to put in place a more adequate strategy capable of responding consistently and effectively to the applicant’s serious mental illness.
The Court further notes the Government’s arguments relating to the applicant’s lack of therapeutic compliance. However, while it is mindful of the fact that the applicant was a vulnerable individual on account of his health condition and his detention, it considers that his cooperation is only one factor to be taken into account in assessing the effectiveness of the required treatment and that the duty to provide suitable care on the basis of individualised treatment lies primarily with the relevant authorities.
Having regard to the above, the Court considers that the Government’s argument that the applicant received care corresponding to his needs is not factually accurate. On the contrary, all the evidence in the case file, in particular the fact that the applicant was frequently in a situation of inflicting self-harm, even when under specialised supervision, and the only measures taken repeatedly at prison level were to sanction him for disciplinary misdemeanours, would appear to indicate a failure on the authorities’ behalf to correctly identify his medical needs and consequently to provide him with comprehensive therapeutic treatment and supervision, as required by his complex mental condition.
(iv) Conclusion
In view of all the foregoing considerations, the Court concludes that in the present case in view of the applicant’s state of health and his disability, in so far as concerns the relevant period, the national authorities failed to implement and provide a coherent and appropriate therapeutic strategy capable of responding adequately to the applicant’s medical needs, so as to avoid subjecting him to treatment contrary to Article 3 of the Convention.
There has accordingly been a violation of Article 3 of the Convention during the period from 6 December 2016 to the applicant’s release on 16 June 2019.
