3(C). Findings of this investigation


MDAC visited eight psychiatric facilities across the country in 2013, interviewing patients, staff and directors in all facilities about their experiences of cage beds, restraints and seclusion.

Cage beds have been removed entirely from one children’s psychiatric hospital visited (Opařany), and all but one removed from Prague Bohnice Psychiatric Hospital. But at the time of the monitoring, the majority of institutions still used cage beds in their every-day clinical practice. Kosmonosy Psychiatric Hospital reported 27 cage beds in response to MDAC’s 2012 freedom of information request, although the director told the monitoring team that there was a total of 29 when he met them in person. Notably, he refused MDAC access to wards where they were kept. Detailed findings in relation to cage beds are presented in Chapter 6 of this report.

Numerous people shared with MDAC their experiences of psychological devastation from being placed in a cage bed. One 33-year-old female patient at Kosmonosy Psychiatric Hospital, interviewed at a café at the institution, told MDAC that, “I did not want to be in a cage. I was afraid I would be there forever.” Monitors met a woman placed in a cage bed who shook with fear when she believed it was about to be locked by a doctor who was present. This woman had herself been a doctor at the same institution for many years previously. Other patients reported the degrading nature of being placed in cage beds, sometimes out of view of other patients, and at other times in full view of all. A recurrent theme was that placement in cage beds meant that patients would not be allowed out to go to the toilet. A 59-year-old woman at Kosmonosy Psychiatric Hospital told MDAC of a corner room at the institution which had five cage beds. She described them as being for people, “who cannot hold their urine and faeces.” Placement of elderly persons in cage beds meant they would be required to wear nappies. Another patient told MDAC that when he had been placed in a cage bed he was required to urinate in a bottle.

Monitors found that cage beds were disproportionately used for elderly patients, seemingly justified on safety grounds, such as the risk of them falling out of bed. Staff explained to monitors that they were also used to manage “difficult” or “agitated” patients in the context of staff shortages, and to punish bad behaviour. Overwhelmingly, psychiatrists, doctors and nursing staff expressed their preference for cage beds over other forms of restraints or seclusion. One hospital director said that “99.9%” of psychiatrists polled would choose this form of restraint over strapping.

The European Committee for the Prevention of Torture, the UN Committee against Torture, and the UN Human Rights Committee have all found that cage beds constitute ill-treatment and have called for them to be banned. Last year the UN Special Rapporteur on Torture specified that there can be, “no therapeutic justification for the use of solitary confinement and prolonged restraint of persons with disabilities in psychiatric institutions”.14

If a ban on cage beds were the only outcome of this report, it would be a Pyrrhic victory. A ban would not solve the extensive use of coercive practices in Czech psychiatric institutions. This report also presents findings on the use of chemical restraints, straps, seclusion and other coercive practices. In settings where the use of cage beds has decreased, the evidence is that staff have increased the use of these coercive “alternatives”.

Many clinical staff of the psychiatric institutions MDAC visited considered the framing of psychotropic medication as chemical restraint, which can lead to torture or ill-treatment, as offensive at worst and eccentric at best.15 Several doctors told MDAC monitors that medication is not a restraint, but “part of a continuous treatment of mental illness”, as one psychiatrist put it. Another said definitively that medication “is not seen as abuse in this country.” There is one issue which all clinicians can hopefully agree on, and that is preventing the death of children. MDAC heard from the director of Opařany Children’s Psychiatric Hospital that clozapine (Leponex) is sometimes used but the hospital does not carry out routine blood tests. The potential risks of using clozapine without monitoring blood include death.16 The practice can be easily changed.

Highlighting the problem of concurrent multiple forms of restraint, a male patient in his early 50s at Kosmonosy Psychiatric Hospital told MDAC that he received an injection every time he was put into straps, and that afterwards he felt sleepy, that his head spun and he had to kneel down or pass out. Multiple forms of restraint – caging, strapping and sedation – were prevalent. Sedatives were recorded as forms of restraint in non-psychiatric health care facilities, but they were not recorded when used on psychiatric patients in the same hospitals. This raises serious questions about discriminatory practice, the result of which is that fewer safeguards apply to mental health patients.

Strapping with fabric or leather straps was used in many institutions visited, often in conjunction with placement in cage beds or in seclusion rooms. As with other forms of coercion, strapping was used as a form of punishment for “troublesome” patients. A 20-year-old male patient at Opava Psychiatric Hospital told the monitoring team that he had seen people strapped down for two or three days and sometimes for up to a week. He had watched how staff fed meals to people while they were still strapped. People were strapped, he said, because, “they couldn’t adjust to life here – they couldn’t handle it”. He gave an example of a man who kept shouting. As staff couldn’t stop him from yelling they strapped him as a form of punishment.

When questioned about why straps are used, a doctor at Plzeň Hospital Psychiatric Department told the monitoring team that during the night there were only two nurses for 25 patients. Highlighting the way in which such coercive practices are associated with “managing” people rather than for any therapeutic benefit, he said that they were, “necessary for newly-admitted patients who are in acute conditions or patients who are trying to escape or attack [other] patients and nurses”. They are used for “the safety and benefit of the patients”, he argued.

In a number of institutions visited the reduction in the numbers of cage beds has led to the installation of seclusion rooms. In Prague Bohnice Psychiatric Hospital, staff reported that one person had been in seclusion for almost two months, notwithstanding that there are safeguards such as a doctor having to authorise the use, and nurses having to review the person every twelve hours. During their February 2013 visit to Bohnice, monitors met a young female patient in a seclusion room. She had been placed in seclusion the morning of the monitors’ visit. When asked why, she replied: ”I don’t know. I wanted to go home; I wanted to light a cigarette. I don’t know what I did wrong.”

14 Juan E. Mendez, Report of the Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, (United Nations: UN doc A/ HRC/22/53, 1 February 2013)

15 Austrian legislation, howver, provides a definition of ‘chemical restraints’, including a requirement that their use be registered. See, for example: European Committee for the Prevention of Torture, Report to the Austrian Government on the visit to Austria carried out by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 15 to 25 February 2009, (Strasbourg: Council of Europe, CPT/Inf (2010) 5, 11 March 2010), at para. 141.

16 See, for example: J. Munro et al, ‘Active monitoring of 12,760 clozapine recipients in the UK and Ireland. Beyond pharmacovigilance’, (British Journal of Psychiatry, 175: 576-580, 1999).

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