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Horrific Death Of A Patient Exposes 'Inhumane' Practices In Bulgaria's Psychiatric Hospitals

"It seems like this is the group that we can most easily abandon. And all we can do for them is to build sheltered housing where they can live shut out and isolated," one mental-health campaigner noted.
"It seems like this is the group that we can most easily abandon. And all we can do for them is to build sheltered housing where they can live shut out and isolated," one mental-health campaigner noted.

Georgi had been treated in the State Psychiatric Hospital in Lovech, Bulgaria, for almost a month, when a fire broke out on the third floor of the building. Everyone else managed to escape except the 25-year-old man. The fire started in his room, but he was tied down to his bed and the door was locked.

Other patients heard the fire alarm and saw the smoke. One of them said he heard Georgi screaming from inside the locked room. "I heard him screaming and shouting: 'I'm on fire, I'm on fire,'" the patient, whose identity was not disclosed, told state broadcaster BNT.

But nobody among the personnel apparently saw the flames in time or heard the fire alarm. When everyone else was evacuated and two medical workers returned for Georgi, they could not enter his room as the heat and smoke were too intense. The forensic medical examination later found that Georgi had suffocated to death.

Georgi's death highlights what a report by the office of ombudswoman Diana Kovacheva called the "cruel, inhuman, and degrading" treatment of patients with mental illnesses in Bulgarian psychiatric hospitals. Her office conducted an independent probe into the October 2 incident and uncovered disturbing circumstances surrounding the man's death.

At the time the fire started, he had been isolated and tied down for hours, longer than allowed under Bulgarian law. And although he was supposed to be under constant medical supervision, no members of the hospital staff apparently saw the flames or the smoke until it was too late.

This is not an isolated case, reports by the European Committee for the Prevention of Torure show. Over the years it has repeatedly reported that patients in psychiatric facilities in Bulgaria are often restrained using means that do not conform with international guidelines, as well as ill-treatment, neglect, and lack of support.

Not Care But Punishment

The Lovech State Psychiatric Hospital is situated in the regional center of Lovech, 125 kilometers northeast of Bulgaria's capital. The patient who died in the fire, identified as Georgi G., was being treated in the hospital's four-story Male Block, built in the 1950s.

According to the ombudswoman's office, he was admitted to the hospital on September 9, nearly a month before the incident. "Almost a month after his admission and in view of his ongoing treatment, it should be assumed that the acute phase of his illness was under control," the report said.

It cited interviews with other patients who said they knew Georgi and noted that he did not appear to exhibit any aggressive behavior. "All patients said that they got along well with G. and that he constantly treated them to cigarettes and coffee. One of the patients said they were friends," the report said.

The only other occasion when Georgi was isolated for medical reasons, according to the hospital records, was on the day of his admission. But the day of the fire he had been left alone in a seclusion room for hours with his arms and legs tied down to a bed.

Seclusion and mechanical restraint of patients in psychiatric hospitals are allowed by Bulgarian law for brief periods. But when such measures are taken it must be medically justified, says Valentina Hristakeva, head of the Sofia office of Global Initiative on Psychiatry, an international nonprofit foundation that campaigns for humane mental-health services in Central and Eastern Europe.

"We must have done everything else possible before tying down a person.... Only then can we take any action in regard to them being restrained, and only on the grounds that they are a danger to themselves or to others," she told RFE/RL.

But the ombudswoman's office suggested that Georgi was not in fact restrained and isolated for clinical reasons, but the measure was instead used as punishment - something forbidden by Bulgarian law and by two conventions for the prevention of torture by the Council of Europe, and the United Nations.

According to Hristakeva, several circumstances around Georgi's death, detailed in the ombudswoman's report, point to that conclusion.

Under Bulgarian law, a patient cannot be isolated for more than six hours and cannot be physically restrained for longer than two hours. But when the fire broke out in Georgi's room, he had been isolated for nearly 10 hours, and had been restrained three times - six hours in total - in one day.

Ombudswoman Kovacheva's team said in its report that it "does not understand what necessitated the application of such extreme coercive measures," given the lack of reports of aggressive behavior from the patient throughout the whole period of his treatment. It said that it was "inhumane and degrading treatment of a patient being tied up for hours in one day and isolated."

The fact that Georgi was both isolated and restrained at the same time is also concerning, according to Hristakeva.

The patient was isolated in a so-called "soft room," a specially upholstered room where patients exhibiting violent behavior can be isolated instead of being tied down to prevent self-harm. "The point of the soft room is to limit the use of restraint measures," Hristakeva said. "But the man was locked in a soft room and tied down."

"This suggests that he was locked not because he was aggressive, but as a form of punishment," she added.

The ombudswoman's team reached the same conclusion: "instead of using the soft room as a safe place of isolation, it was used as a punishment room," the report said.

'Disturbing' Practices

Kovacheva's team reported that it found other cases in which patients in the hospital in Lovech were isolated or restrained several times in one day or in consecutive days. Such practices are contrary to the recommendations of the European Committee for the Prevention of Torture.

In its latest report on Bulgaria, published in October 2022, the committee called on the Bulgarian authorities to ensure that "patients are only restrained as a measure of last resort, to prevent imminent harm to themselves or others, and restraints are always used for the shortest possible time (usually minutes rather than hours)."

According to Hristakeva, however, it is not uncommon in Bulgarian psychiatric hospitals to restrain patients without any indication that they represent a direct threat to themselves or the others.

"Colleagues who are directors of psychiatric hospitals will say - we don't have enough staff, we can't have one nurse on night shift for 30 patients and expect that in the event of a conflict or escalation, they will deal with the situation in a humane way. They will probably be right," Hristakeva said, pointing to the understaffing that was repeatedly criticized by the Committee for the Prevention of Torture.

"At the same time, people go to these hospitals for help," she added.

In its reports over the years, the committee has reported "disturbing" practices for restraint in some psychiatric hospitals in Bulgaria. During its visit to Bulgaria in 2020, the committee found that in the Tsarev Brod State Psychiatric Hospital, located near the regional center of Shumen, patients were restrained to beds with metal chains.

In 2021 it discovered that patients in the psychiatric hospital in the city of Kardzhali were being placed alone with their arms and legs tied down to beds in special rooms for over 48 hours. They had no access to toilets and were only given incontinence pads. Some patients also complained that their hands were fixed above their head, causing pain, swelling, and loss of sensation.

"Despite years of recommendations made by the committee, the use of means of restraint still does not conform with international guidelines," the committee's most recent report said.

According to statistics provided by the Health Ministry at the request of lawmaker Stela Nikolova in July, nearly 600 patients were restrained for different periods in psychiatric hospitals in Bulgaria in 2022.

But the Committee for the Prevention of Torture has warned that the use of restraint measures was often recorded "fraudulently or not at all" and thus did not reflect reality.

Absence Of Continuous Supervision

Bulgarian law and international bodies require constant medical supervision of restrained or isolated patients. The law states that nurses who rotate every hour must carry out the monitoring through direct visual control or remote means when the patient is isolated and that they must be present at the bedside of the patient when they are restrained.

But apparently that was not the case for Georgi. No staff was in the room where he was restrained. Members of the hospital staff told the ombudswoman's team that he was monitored through a surveillance camera, but that the fire had not been detected in time.

"Apparently, there was no continuous monitoring of the patient during the immobilization, which is a direct violation" of the relevant regulation, the report said.

This again does not appear to be an isolated case as the Committee for the Prevention of Torture has previously highlighted "the absence of any continuous personal supervision by staff" as "unacceptable."

"Patients thus held had no reliable way to call for staff attention, being left to call out in vain from within the locked room or try and wave their tied hands at a CCTV camera, the screen of which was in a distant and often unattended office," the committee said in its last report.

Another question posed by the ombudswoman's team regarding Georgi's case was why the hospital staff did not report hearing the fire alarm.

Three patients interviewed by Kovacheva's team said they had been near his room at the time of the fire and had heard the fire alarm. However, personnel claimed the sound of alarm was barely audible outside of the seclusion rooms at the facility.

The head of the State Psychiatric Hospital in Lovech did not respond to requests for comment by RFE/RL. The head of the ward where the fire occurred, Katya Edreva, declined to comment on the report, adding that she planned to raise objections to it with ombudswoman Kovacheva's team.

The local district prosecutor's office in Lovech has launched a probe into the circumstances of the blaze that led to Georgi's death.

Contacted by RFE/RL, the European Committee for the Prevention of Torture declined to comment on the case, but pointed to previous statements and reports on Bulgaria, some of which detail "a persistent failure" by the Bulgarian authorities to address the shortcomings in psychiatric hospitals.

Stigma And Lack Of Support

Over the years, the committee has recorded complaints about patients being slapped, punched, kicked, and hit with objects by the staff in psychiatric hospitals.

The committee has also noted that patients with psychiatric disorders in Bulgaria are not provided with a range of modern psychiatric treatments, "which is in itself neglectful and harmful to their well-being." It has also raised concerns over the lack of progress with de-institutionalization in psychiatric services, which results in many persons being "inappropriately held in large psychiatric institutions without hope of return into the community, greatly affecting their well-being."

In its report on the case in Lovech, ombudswoman Kovacheva's team noted that reform in the of the psychiatric care system is needed. "State psychiatric hospitals are not places of punishment, but hospitals for the active treatment of patients who suffer from mental illness," the report said.

Hristakeva notes that people in Bulgaria who suffer from mental illness are not only stigmatized by society but often find little if any support from the country's social-welfare system.

"It seems like this is the group that we can most easily abandon. And all we can do for them is to build sheltered housing where they can live shut out and isolated."

Written by Elitsa Simeonova in Prague based on reporting by Boris Mitov of RFE/RL's Bulgarian Service
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    Boris Mitov

    Boris Mitov has been a correspondent for RFE/RL's Bulgarian Service since 2019 and has more than 15 years of experience as an investigative reporter. He has followed the work of Bulgaria's security services and judicial system for various media outlets, including for the Bulgarian News Agency (BTA), Sega, and Mediapool.

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    Elitsa Simeonova

    Elitsa Simeonova is a correspondent in RFE/RL's Central Newsroom in Prague. She previously was a correspondent in Sofia for RFE/RL's Bulgarian Service.

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