PROGRAMME OF THE JOINT VISIT BY REPRESENTATIVES OF …



THE EUROPEAN NPM PROJECT

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A councıl of europe/ european commıssıon joınt programme:

“Setting up an active network of national preventive mechanisms against torture,

an activity of the Peer-to-Peer Network”

co-funded by the

HUMAN RIGHTS TRUST FUND

Implementing partner:

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European NPM Project Inter-NPM Onsite:

Exchange of experiences on visiting methodology between the NPMs of Albania, ”the former Yugoslav Republic of Macedonia”, Serbia and Slovenia –

with a focus on the methodology of monitoring psychiatric establishments

Tirana, Albania, 4 – 7 July 2012

Debriefing Paper

INTER NPM MEETING AND ON-SITE VISIT

Tirana, 04 June 2012

Debriefing Paper[1]

Hosted by: NPM Albania

Participants: NPM of ”the former Yugoslav Republic of Macedonia”

NPM of Serbia

NPM of Slovenia

Supported by: The European NPM Project

Council of Europe

Summary

The three-lateral NPM meeting took place in Albania on 4 June 2012 in the premises of the Ombudsman office (for more details see Annex 1). The focus of the meeting was exchange of experience and sharing methodology of work in relation to monitoring Psychiatric Hospital Nr5 Tirana.

The meeting was opened by the Albanian Ombudsman Igli TOTOZANI, who welcomed the delegations from Slovenia, Serbia and Macedonia, shortly stressed the importance of the undertaken preventive role by the Ombudsman institution, the significance of monitoring the state’s authority to deprive persons of liberty and their treatment and the need to continuously increase the professional level of the NPMs work.

During Day 1, the NPM each separately presented their tools and checklists, afterwards discussing the best approaches and methods, sharing good practices and lessons learnt when it comes to conducting preventive visits to Psychiatric Hospitals. The NPMs discussed the APT’s manuals and recommendations on methodologies on monitoring psychiatric hospitals and provided joint comments, the structure and data contained in the separate reports on the visits with focus of drafting the recommendations issued to the authorities. During the final part of the day, the NPMs prepared for the on-site visit – the Albanian NPM provided the Slovenian, Serbian and Macedonian colleagues with information on the psychiatric hospital Nr5 Tirana- subject of the visit.

During Day 2, the NPMs conducted a joint on-site visit to the psychiatric hospital Nr5 Tirana, following the agenda prepared by the Albanian NPM. The total duration of the visit was 5 hours (between 10.00 and 15.00hrs) and all the visit steps were accordingly followed by the respective NPMs. The visit concluded with a short conclusive meeting with the Medical Doctor in chef in absence of General Director of hospital.

During Day 3, the NPMs discussed the on-site visit, their impressions, general findings, compared the Albanian NPM’s visit methodology with the manner in which their respective NPM conducts the inspections to their psychiatric hospitals. Finally, the NPMs shared their conclusions and recommendations from the on-site visit and their impressions from the inter-NPM meeting in general.

DAY 1: OVERVIEW ON THE NPMS’ METHODOLOGY OF WORK

Macedonian NPM – Methodology of work with regards to psychiatric institutions visits

A. Methodology of visits to psychiatric institutions – the Macedonian experience

The Macedonian NPM, due to lack of capacities and external expertise, has not yet initiated the preventive visits to mental health institutions. The Work Plan for 2012 foresees the NPM to conduct unannounced monitoring visits to the Macedonian psychiatric institutions and hospitals in the second half of the year, thus the NPM is currently in a process of developing modalities for inclusion of external expertise. From this point of view, the Macedonian NPM welcomes and is especially grateful to the Albanian NPM for sharing the experience they’ve gained over the last few years.

The Macedonian NPM has established close cooperation with the CPT’s former First Vice-President and a prominent psychiatrist from Macedonia. This expert has provided the NPM team with both theoretical and practical training regarding the NPM’s role in monitoring psychiatric hospitals and the relevant and applicable international and domestic standards. Accordingly, the NPM has accepted a short check-list that will be further developed into a full document to be used for the upcoming visits. This list sets the monitoring steps, minimum issues and standards that must be followed when conducting a visit to psychiatric institution.

1. Preparation for the visit – analysis on the legal framework regarding mental health and the applicable bylaws and internal acts of the psychiatric hospital to be visited.

2. Initial talk with the Head of the hospital

3. Visiting the premises – all accommodation rooms, toilets, isolation/fixation/restrain rooms, doctor’s rooms, kitchen, dining area, recreational rooms, etc.

4. Inspection of the hospital registries and patients medical files, including the review of the judicial decisions.

5. Interview selected number of patients (focus on the use of means of restrains, isolation and possible allegations/risks of violence committed by the staff or other patients)

6. Interview the staff – doctors, nurses, psychologists, etc.

7. Final talk with the Head of the hospital

The Macedonian NPM team would especially focus on the following issues:

- material conditions

- admission of patients – voluntary or non-voluntary basis and procedures on their accommodation in the rooms

- legal safeguards – procedure for forcible hospitalization, review the decisions for admission, hospital complains procedures

- daily activities aimed for the patients

- restriction on the use of personal items

- the procedures with vulnerable categories of patients (juveniles, long-term patients, persons with disabilities, etc.)

- contacts with the outside world

- Inter-patient violence – occurrence, procedures, prevention.

- use of means of restrain and isolation

- prevention from self-inflicting harm and committing suicide

The visits will be carried out by the three members of the Macedonian NPM and one external expert – psychiatrist. The NPM will ensure that the engaged psychiatrist is providing professional and objective service, through hiring a prominent expert who has previous knowledge and expertise in the torture prevention field and application of human rights standards, has private practice or is regularly employed by a private hospital, thus ensuring there is no conflict of interest.

The external expert of the Macedonian NPM during the visit will be tasked to address and discuss the medical related issues with the management and the staff of the institutions, to review hospital registries and patients’ medical files and to aid the NPM members in conducting the interviews with the patients. The expert will more specifically:

1. obtain and analyze the data related to personnel, patients, capacities, etc.

2. obtain data on the structure of the hospital and profile of the staff according to the different departments/units.

3. obtain number and address issues related to patients subjected to forcible hospitalization

4. obtain medical statistics and gather information on the offered treatment; special types of treatment, inspect medical documentation, etc.

5. assess the use of medications (dosage, over dosage and possible chemical immobilization).

6. assess the use of means of restrain and seclusion.

7. assess the training needs and supervision of the staff, etc.

After the visit, the National Preventive Mechanism will prepare separate report. The NPM separate reports are confidential and contain analysis of the situation, conclusions and recommendations for overcoming detected shortcomings. Each report will consist of positive and negative aspects, as well as recommendations on two levels:

• to the management of the visited psychiatric (mental health) institution on the conditions within the competence of that body and the ways and measures to be undertaken by the institution itself for the purpose of overcoming the detected weaknesses, and

• to the Ministry of Health, which demand meeting certain technical and material preconditions, budget implications, amendments to laws and regulations, for the purpose of improving the detected weaknesses.

Serbian NPM - The Methodology of Inspection in the Psichiatric Hosital Institutions

PREPARATION VISITS

In the process of preparation of monitoring of places of detention of persons deprived of liberty, the first step is to identify the priority visits according to the type of institutions and their situations and on the basis of the findings prepare the plan of visits to institutions (hereinafter: Plan of visit) .

The following types of visits exist: regular, control and emergency

REGULAR VISITS

Regular visits are periodic visits carried out with the view of systematic control of situation in institutions in relation to the respect of rights of persons deprived of liberty.

Regular visits are planned ahead and carried out according to the designed plan of visit.

Regular visits are announced.

CONTROL VISITS

Control visits are those carried out in order to check the situation in institutions in relation to the respect of persons deprived of liberty and compare it to the situation identified in the course of previous visit.

Control visit are planned ahead and carried out according to the designed plan of visit.

Control visits are, as a rule, announced.

EMERGENCY VISITS

Emergency visits are visits carried out in case of learning of the existence of serious irregularities related to the respect of rights of persons deprived of liberty.

A decision to carry out an emergency visit is made by the coordinator.

Emergency visits are not foreseen by the plan of visit.

Emergency visits are, as a rule, unannounced.

establihing THE PLAN OF VISIT

According to the current situation, in the first phase the activities of the Preventive Mechanism will be primarily directed towards the implementation of prison system monitoring, while the system of monitoring of other places of detention of persons deprived of liberty will be developed in the second phase.

The Plan of visit to an institution sets approximate date and length of visit (one or several days), as well as the character of visit (regular or control visit).

The Plan of visit always includes open time period when emergency visits can be conducted.

The length of visit depends on the type of visit, type and capacity of institution, number of monitoring group members and other factors.

The Plan of visit is issued by the coordinator.

DETERMINING PERSONNEL COMPOSITION OF A VISITING GROUP

. Depending on the type of institution, nature of visit and other concrete circumstances, the size and composition of visiting group is set up for each visit to institution.

. The visiting group leader is appointed for each visit.

. The coordinator determines the size and composition of the visiting group and appoints its leader.

. When forming the visiting group attention is paid that experts of profiles necessary for implementation of adequate monitoring be included, whereas the involvement of doctors and lawyers is mandatory (depending on the type of institution and concrete circumstances, first of all the specialists in general, internal and forensic medicine and psychiatrists, when needed also dentists, gynaecologist...). Depending on the type of institution, the group will also be comprised of psychologists, special pedagogues and experts of other profiles.

According to the existing specialization of a visiting group members, special subgroups for monitoring of specific areas (hereinafter: subgroup for specific area) will be established (e.g. team for general observation and treatment, team for legality of treatment, team for health care...)

GATHERING DATA ON INSTITUTION

Members of the visiting group will start gathering relevant information about the institution that will be visited.

The sources of information are:

1. ЕDPM (identity card of institution, direct insight into initial questionnaires, access to the architectural plan of institution, access to the existing reports, insight into the Protector of Citizens’ recommendations, press clippings, as well as other existing data on the institution)

2. REPORT OF THE COMPLAINT DEPARTMENT (Report on all complaints related to the visiting institution submitted to the Protector of Citizens within last year)

3. DATA OF EXTERNAL SUBJECTS (data on the institution that are not in the EDPM and have been obtained from external subjects: international bodies, state agencies, internal oversight bodies, other organizations that conducted monitoring of that institution, the media.)

Gathering of data on the institution is managed by the visiting group leader with technical support of the administrative secretary.

CONTACT WITH THE INSTITUTION TO BE VISITED

Prior to visit (regular or control), the contact is established with the visiting institution, the visit is announced and the questionnaire preceding the visit forwarded.

Regular visit is announced at least two weeks prior to it.

INFORMING THE INSTITUTION AND AGREEING ON THE VISIT

The institution is informed about the day and hour of the visit, its nature, members of the group and their functions, group leader, and possible special requirements (e.g. that in the course of visit heads of certain services, doctors etc. be present)

All important elements of the visit and visit procedures (e.g. use of camera or dictaphone) are agreed with the management of institution.

Contact with the institution is either directly established by the visiting group leader or through the administrative secretary.

DELIVERY OF THE QUESTIONNAIRE PRECEDING THE VISIT

The questionnaire preceding the visit is delivered to the institution for feedback.

The institution has a time limit (up to 7 days) to deliver filled-in questionnaire, which is sufficient for giving reliable answers, taking into account that the same questionnaire has to be timely delivered to the Preventive Mechanism so that it can be processed prior to the visit (at least 5 days).

Delivery of the questionnaire preceding the visit is managed by the visiting group leader with technical support of the administrative secretary.

ANALYSIS OF THE EXISTING DATA ON INSTITUTION AND PREPARATORY ACTIVITIES

Members of the visiting group organize consultations related to the situation in institution and the expected effects of monitoring:

1. All gather data on institution are accumulated.

2. Analysis of the gathered data is performed.

3. Circumstances that should be particularly taken into account in the course of visit are identified.

4. Questionnaires that will be used in the course of visit are chosen and adapted.

5. Operational material (questionnaires etc.) is prepared.

Analysis of the existing data on institution and preparatory activities are managed by the visiting group leader with technical support of the administrative secretary.

AGREEMENT ON PROCEDURE AND ORGANIZATION

Members of the visiting group agree on the upcoming visit to the institution:

1. Deciding on the appearance in front of the management of institution (attitude that should be expressed during the introductory interview with the management and appointment of persons who will actively participate in the interview together with the visiting group leader)

2. Determining the behaviour in the course of visit (determining the behaviour that the visiting group should demonstrate in the course of visit to the institution, in accordance with the mandate and the established operating principles of the Preventive Mechanism)

3. Visit dynamics (setting up the time that will be used for certain monitoring phases: joint interview with the management and joint visit of the institution, time left to subgroups for specific areas for interviews with heads of certain organizational units, with personnel and persons deprived of liberty and for review of documentation)

4. Division of tasks and special assignments of subgroups for specific areas (e.g. subgroup for general observation and treatment, subgroup for legitimacy of treatment, subgroup for health care...)

5. Operational material is distributed (questionnaires, cameras, notebooks etc.)

6. Administrative and technical organizational issues (agreement on time of outset of visit, engagement of transport means, schedule, payment of fees...)

The agreement on procedure and the entire organization is managed by the visiting group leader with technical support of the administrative secretary.

MONITORING PROCEDURE DURING VISIT TO THE INSTITUTION

In the course of visit to the institution one deals in accordance with the mandate, principles of operations and established goals of the visit.

Photos are taken only in case of reached agreement with the management of institution.

INTERVIEW WITH THE MANAGEMENT OF INSTITUTION

Upon arrival to the institution, all visiting group members participate in the interview with the management of institution.

In the first place, the manager of institution is invited to present the general outline of the institution to the visiting group.

Afterwards the Preventive Mechanism, its mandate, principles, goals and methods of work are presented; members of the visiting group are introduced; the activities that are to be implemented in the course of visit are indicated.

Bringing in of camera and taking of photographs is agreed with the management of institution.

On behalf of the visiting group its leader makes the presentation and conducts the interview.

Depending on the previous agreement and immediate permission of the leader, other visiting group members actively participate in the interview.

(In case of emergency visit the visiting group leader can decide to visit first a person or place in the institution due to which the emergency visit is carried out and only after that conduct interview with the management of institution, or to exclude this phase completely)

VISIT OF THE INSTITUTION

When the interview with the management of institution is finished all members of the visiting group make a joint visit of the institution.

During the visit of the institution the existing architectural plan of the institution is used and corrected.

The architecture of place is visually perceived, living area and accommodating conditions are accessed, with the view of gaining preliminary impression of the general atmosphere in the institution.

Special attention is paid to dormitories, isolation premises, bathrooms and sanitary premises, infirmary, kitchen, warehouse, dining room, living rooms, courtyards, walks, sport yards, workshops etc.

(In case of control or emergency visit the visiting group leader can decide to exclude this phase)

INTERVIEW WITH THE RELEVANT SERVICES STAFF

Interviews with the staff are conducted by members of the subgroups for specific areas (e.g. subgroup for general and legal affairs and security, subgroup for treatment, subgroup for health care...).

Interviews structured according to the questionnaire are conducted with persons responsible for specific areas and, when needed, with other staff as well.

It is recommended that the interview with the staff takes place in their working premises.

The interview with one staff is, as a rule, attended by two members of the subgroup for specific area, whereby the one who conducts the interview does not record anything (maintains eye contact all the time in order to develop trust), while the other member is in charge of recording.

In the course of interview with the staff one should demonstrate professionalism, present the PM, purpose of the interview and persons who conduct the interview; one should not deal with circumstances that are outside one’s competence, should respect the integrity of interlocutor, avoid any familiarity, not become involved in existing interpersonal conflicts in the institution, act politely in all contacts, point out the confidentiality and the possibility to refuse to talk, take care of safety of the source of information, not take photos of the staff without his/her consent, ask clear and precise questions, state reliable, clear, precise and comparative facts etc.

In the course of interview one should use the questionnaire but allow the interviewed person to go beyond the scope of asked questions.

VISIT OF SPECIAL PREMISES

Visit of the special premises is performed by members of the subgroups for specific areas (e.g. subgroup for general and legal affairs and security, subgroup for treatment, subgroup for health care...).

All premises that members choose can be accessed without any restrictions.

The premises that are checked in the course of visits are marked in the existing architectural plan of institution.

(This phase is not mandatory)

ACCESS TO DOCUMENTATION

Access to documentation is conducted by members of the subgroups for specific areas (e.g. subgroup for general and legal affairs and security, subgroup for treatment, subgroup for health care...).

Copies of particularly important documentations are made, by choice, regardless of degree of their confidentiality.

Documentation that cannot be copied on the spot will be asked to be subsequently delivered.

INTERVIEW WITH PERSONS DEPRIVED OF LIBERTY

Interviews planned before the visit to the institution are conducted (usually with persons who submitted complaints or whose rights are violated according to the existing information), with persons who asked for interview, as well as with other persons chosen by the system of random sampling (randomly chosen).

It is recommended that the interview with persons deprived of liberty takes place in the premises where these persons are held (visit them) and not in a special room assigned for this purpose by the management of institution (where they would be brought).

The interview with a person deprived of liberty is, as a rule, attended by two members of the visiting group, whereby the one who conducts the interview does not record anything (maintains eye contact all the time in order to develop trust), while the other member is in charge of recording.

In the course of interview with the staff one should demonstrate professionalism, present the PM, purpose of the interview and persons who conduct interview; one should not deal with circumstances that are outside one’s competence, should respect the integrity of interlocutor, avoid any familiarity, point out the confidentiality and the possibility to refuse to talk, show empathy for the suffering that the interlocutor refers to, not create unrealistic expectations for the interlocutor, take care of safety of the source of information, not take photos of the person without his/her consent, ask clear and precise questions, state reliable, clear, precise and comparative facts etc.

In the course of interview one should use the questionnaire but allow the interviewed person to go beyond the scope of asked questions.

VERIFYING OBTAINED INFORMATION THROUGH SEVERAL DIFFERENT SOURCES

Obtained contradictory information is checked by the means of different sources (conduct control interviews with other persons, additional check-up observation, additional review of records and documentation etc.)

(In case the credibility of the obtained information is beyond doubt it is possible to exclude this phase)

SHORT MEETING OF GROUP MEMBERS

Short meeting of all visiting group teams takes place.

First impressions of the subgroups for specific areas are exchanged; main problems in the institution are indicated.

Agreement on the short summary of the situation in institution that will be submitted to the management of institution is made.

Additional questions that the management of institution will be asked are settled.

Additional documentation that will be required from the management is identified.

(The visiting group leader can decide to exclude this phase)

FINAL INTERVIEW WITH THE MANAGEMENT OF INSTITUTION

The interview is attended by all members of the visiting group.

On behalf of the visiting group, its leader conducts the interview.

The visiting group leader first informs the manager of institution about the short summary – impression about the situation in institution.

The visiting group leader compliments on what is good, points out the serious omissions related to the position of persons deprived of liberty in the institution.

According to the agreement, certain members of the visiting group, especially representatives of subgroups for specific areas, can directly point out to the management of the institution some of their specific observations.

After that, the visiting group leader can ask from the manager additional information, clarification and supplementary documentation.

Finally, the visiting group leader announces and explains further steps (sending of letter, report).

(The visiting group leader can decide to exclude this phase)

ACTIVITIES FOLLOWING VISIT TO THE INSTITUTION

LETTER TO THE INSTITUTION AFTER THE VISIT

Following the visit, a courteous thank-you letter is sent to the institution (five days after the visit the latest)

If necessary, additional information, clarification or documentation is required in the letter.

The letter is delivered to the institution by the visiting group leader with technical support of the administrative secretary.

GROUP MEETING, EXCHANGE OF INFORMATION AND AGREEMENT ON DRAFTING OF REPORT

Meeting of all member of the visiting group takes place.

The meeting is managed by the visiting group leader.

During meeting impressions are exchanged and major problems or positive aspects in the institution detected.

Comparison of observations with previous reports findings is made.

The concept of report is determined.

Areas of the report are identified and drafting of sections of report assigned to subgroups for specific areas.

The deadline for drafting of sections of report by subgroups is determined as well as the deadline for drafting of the complete report.

The meeting is presided by the visiting group leader with technical assistance of the administrative secretary.

DRAFTING OF SECTIONS OF REPORT AND COMPILATION OF THE FULL REPORT

Subgroups for specific areas draft their sections of report.

Managed by its leader, the visiting group drafts the complete report.

Filled-in questionnaires, obtained copies of documentation and notes of the visiting team members represent the foundation for drafting of the report.

The reports have elements and structure determined in advance:

1. Basic facts about the visit (time, type of visit, team members, interlocutors...),

2. Relevant information about the institution that the visiting team obtained prior to visit (existing reports about the situation in institution),

3. Basic facts about the institution (type of institution, capacity, its description...),

4. Team activities implemented in the course of monitoring process (acts that the visiting team conducted in order to become aware of the situation in institution),

5. Identified factual situation in certain areas (facts that the visiting team identified as indisputable that relate to the position of persons deprived of liberty in the institution, e.g.: living conditions, health care, nutrition, hygiene; classification, categorization; treatment, work, education; correspondence, telephone calls, visits, parcels; special rights, application of coercive and special measures, disciplinary procedures and measures; complaints and actions taken upon complaints and grievances, provision of legal aid; position of juveniles, women, minorities and LGBT persons, religious rights, post-release assistance, internal controls and visits of external subjects; transfers, suspension of sentence; disciplinary procedures against the personnel; internal oversight over the work; attitude towards the Protector of Citizens...)

6. Identified irregularities in the work of institution (identified developments that are not in accordance with the regulations and standards in force),

7. Indication to relevant provisions of domestic and international regulations and standards related to the perceived developments of work irregularities

8. Recommendation of measures for elimination of noted irregularities in work and period of time for procedure i.e. for elimination of irregularities

9. General conclusion about the situation in institution

Report drafting is technically assisted by the administrative secretary.

DELIVERY OF REPORT TO THE VISITED INSTITUTION AND TO THE PROTECTOR OF CITIZENS

The report signed by the visiting group leader is delivered to the Protector of Citizens.

The report is delivered by the coordinator with technical support of the administrative secretary.

Together with the report, possible detached observations of certain members of the visiting group are also submitted to the Protector of Citizens.

Albania

In December 2009, the Ombudsman of Albania approved the NPM methodology for the inspection on psichiatric hospitals. Due to the new low on mental helth apoved resently by Albanian Parlament the updated version of metodologie have to be adopted son. A working grup has been set up by Albanian Ombudsman to right the new metodologie.

Slovenian NPM – Methodology on visits to psychiatric hospitals

Use of preliminary questionnaires

In the field of mental health care, the Ombudsman or his authorised person sends preliminary questionnaires to heads of social care institutions and specialised social care institutions (in future also to psychiatric hospitals). The institutions that are planned to be visited in the following year, according to the annual programme of visits, receive these questionnaires in the last month of the current year. A preliminary questionnaire must be structured so as to fulfil its purpose, which means that the questions should lead to conclusions about the essential aspects of the conditions to be checked during the visit of institution by the representatives of the National Preventive Mechanism (NPM).

Course of a visit

As a rule, a regular visit comprises the following successive phases: an introductory interview with the head of the psychiatric hospital, an inspection of the special supervision unit, an interview with patients and the personnel, a review of the documents and a final interview with the head of the hospital.

The head of the visit may also decide to skip any of the phases if he considers them unreasonable or if they cannot be carried out; the phases may also be carried out in a different order or simultaneously by individual sub-groups of participants of the visit, which are composed with regard to the number of participants and their qualifications. The head of the visit also considers the gender of the participants of the visit when this might be necessary for the appropriate implementation of the tasks (for example, interviews with patients in the female section should be conducted by female participants, etc.).

The purpose of the introductory interview is to obtain updated official information on all relevant circumstances in the psychiatric hospital and in the special supervision unit.

The introductory interview is conducted by the head of the visit. He first explains to the head of the hospital that the visit is being carried out within the framework of the NPM and introduces each individual participant of the visit. He further explains the course of the visit and invites the head of the hospital to present the basic circumstances in the psychiatric hospital and the possible recent or current extraordinary events; he may, however, immediately start asking the planned questions.

Other participants of the visit actively participate in the introductory interview by asking reasonable questions that have not yet been asked or questions related to the previously asked questions to which they might have received insufficient answers.

During the introductory interview, the participants of the visit request the submission of individual official information and records or notes required (a list of persons, a list of employees and their work schedules, house rules, agendas and similar).

The introductory interview is followed by the visit of the special supervision unit or units. The representatives of the NPM briefly acquaint the patients in their rooms with the purpose of their visit and invite them to speak about anything they might not like in the psychiatric hospital. At the same time, the representatives of the NPM try to objectively assess the suitability of the living quarters, in particular with regard to the number of persons living together, the surface area and tidiness of the living quarters, the lighting, ventilation and the hygienic conditions; they also check the furniture, beds and other equipment in the rooms, in particular with regard to their regular maintenance. They also consider the possibilities available to persons to give their rooms a personal touch.

Particular emphasis is placed on the procedure of admitting a patient to the psychiatric hospital (the patient's consent or consent of his legal representative, observance of time limits and conditions for the notification of the court on the involuntary detention of patients, timely notification of the court on the need for the extension of detention time) and the use of special security measures (restraints, use of a de-escalation room).

During each interview, the representatives of the NPM try to gain the confidence of the persons they talk to. They place emphasis on the confidentiality of the discussion and make every effort to have the persons understand as best as possible the purpose of the interview and to assure them that at no time during the interview they are forced to make a statement involuntarily.

Joint discussions are usually held during the visit of the premises, but only if it is reasonable during these discussions to acquire the persons' statements on the general conditions in the psychiatric hospital or the conditions that refer to these persons as members of a group of patients staying there.

If a personal interview can be carried out in the living quarters of a person, it should be carried out there; if this is impossible, a room is to be provided where the personal interview can be conducted at an appropriate level of confidentiality.

The representatives of the NPM visiting the psychiatric hospital also conduct interviews with staff members. It is essential that these interviews not take place in the presence of the head of the hospital or the superiors, or in a manner that would be similar to a hearing. The purpose of these interviews is to acquire new information, verify the statements of the head of the hospital or the superiors and the patients and find any possible contradictions.

During the visit, the relevant documents also need to be examined, including selected files of persons, legal documents on the basis of which the persons were sent to the psychiatric hospital, and any records that are kept or should be kept at the hospital. If considered reasonable on the basis of the visit, the representatives of the NPM may propose in the preliminary report or the final report (giving an appropriate explanation) that the psychiatric hospital should also introduce other records that it is not obliged to keep but would significantly improve the conditions in every aspect.

Prior to the final interview with the head of the hospital, the representatives of the NPM visiting the psychiatric hospital meet (unless this is impossible or unreasonable) to exchange the most important information obtained, as well as their proposals and opinions.

The final interview is held (at least) with the head of the psychiatric hospital. It is conducted by the head of the visit, who presents the most important findings of the NPM on the psychiatric hospital and draws attention to any possible deficiencies to be eliminated immediately and makes critical comments; he may also commend certain aspects of the conditions established and request further clarifications if necessary.

If all the information required could not be obtained during the visit of psychiatric hospital by the NPM, the head of the visit may separately request the information in the preliminary report.

Activities to be performed after the visit of the psychiatric hospital

Each participant of the visit submits his findings from the visit and his proposals for the improvement of the conditions and the treatment of persons in the institution visited to the head of the visit within eight days following the visit. On this basis, an employee of the Office of the Ombudsman or a representative of a non-governmental organisation (NGO) (if so agreed) draws up a preliminary report which, as a rule, needs to be submitted no later than 30 days following the visit. This report is to be prepared after the visit of the psychiatric hospital. It is then sent to the head of the hospital with the request that the head take a position on the statements in that report within the time limit set and inform the Ombudsman thereof. The head of the hospital may also be asked to submit any other information necessary. After a response is received from the hospital, the NPM draws up a final report on the visit, including the statement of the positions of the hospital. The final report should be submitted within 30 days. This report must be sent to the hospital, the Ministry of Health and the Professional Board for Psychiatry at the Ministry of Health.

The head of the visit submits the report on the visit drawn up by the NPM to all participants of the visit, and sets the time limit in which the participants must propose changes to the report or inform the head of the visit that they have no comments on the report.

Each representative of a NGO participating in a specific visit may request that the report should also highlight the position of the contracting NGO whose member he is, if this position differs from that stated by the representatives of the Ombudsman or another contracting NGO. The head of the visit may decide to separately state in the NPM report that a specific position refers to a finding, position or proposal submitted by a contracting NGO.

Publishing information on the visit

The Ombudsman's Annual Report contains a separate chapter entitled 'The Ombudsman as a National Preventive Mechanism'. The Ombudsman also publishes a special publication on the tasks and authorities of the NPM. The publication presents the most important findings in this field of the Ombudsman's work. It also refers the reader to the reports of the NPM drawn up for publication on the Ombudsman's official website. On the Ombudsman's website, a special page called 'The Ombudsman as the National Preventive Mechanism' has been designed where this field of the Ombudsman's work is presented. The findings of the NPM and its work may also be presented at a press conference organised by the Ombudsman.

DAY 2 and DAY 3: ON-SITE VISIT TO Psychiatric Hospital NR5 Tirana, AND FOLLOW-UP DISCUSSION AND FINDINGS

Findings and recommendations made by the Macedonian NPM

Visit to the Psychiatric Hospital Xhavit Gjata Tirana and Findings

The visit to the Psychiatric hospital Xhavit Gjata Tirana took place the second day of the inter-NPM dialogue in Tirana between the hours of 09:30–14:30. The visit was unannounced and none of the NPMs experienced any problems in terms of entering the premises, conducting talks and interviews with the staff and patients and access to all facilities and installations of the hospital. The visit was carried out in full cooperation by the management and the staff of the institution.

The psychiatric hospital Xhavit Gjata in Tirana has 5 departments: acute male, urgent male, acute female, urgent female and department for juveniles. The average hospitalization time is between 14 and 21 days.

The visit was carried out in the following manner: initial talk with the Deputy Director (the Director was not present at the hospital during the unannounced visit), visit to the hospital departments including the juvenile section, informal interviews with patients, talks with the Head doctor of each department. The visiting team then divided into 2 sub-teams: Team 1 reviewed the medical personal files of the patients who were locked in the isolation rooms at the time of the visit, and Team 2, which was headed by a clinical psychologist (external expert engaged by the Albanian NPM), that interview 1 social worker and 2 psychologist employed in the hospital. The meeting finished with presentation of the initial findings to the management of the Psychiatric hospital Xhavit Gjata.

During the visit the NPM, due to the short duration of the visit, focused mainly on assessing the material conditions.

The NPMs made the following observations and gave the subsequent remarks:

- The accommodation rooms although recently renovated, have been slightly damaged – the glass windows of the doors have been broken, which leads to a conclusion that cases of patients’ agitation and aggressive behavior occur in the hospital on frequent basis. Many of the accommodation rooms provided only beds for the patients and no additional accessories (no table, chairs, etc.)

- The small glass windows on the doors of the accommodation rooms might violate the privacy and personal integrity of the patients and in certain occasions might even constitute degrading treatment.

- The recreational rooms seem to be insufficiently equipped and rarely visited by the patients, i.e. during the time of our visit only in one department the NPMs came across two patients who were engaged in activities supported/guided by a hospital staff. also, these rooms do not provide enough sitting capacity for all the patients per department.

- There is no separate dining room – the patients consume their meals in the main hallway of the departments or in their rooms sitting on their beds.

- The toilets do not provide running water on regular basis - due to restrictions in the water supply system there is shortage of water in the hospital, or more precisely, there are periods of the day when the hospital is left without running water for 2 hours.

- The freedom of movement seems to be limited – there are no clear regulations on how many hours during the day the patients are allowed to spend outside on fresh air, taking into consideration that all departments’ exit doors were “guarded” by nurses, who strictly regulated the entrance/exit to the departments.

- There was no complaint procedure established in the hospital.

- The rights of the patients were made visible at various locations, however it was not clear how and whether they were in details explained to and discussed with the patients.

- The staff working in the institution is multidisciplinary, including at least psychiatrists, social workers and psychologists, however, there are general nurses employed since the Albanian medical educational system does not specifically provide courses for mental health nurses.

- There were no individual treatment plans for psychosocial rehabilitation of the patients.

- The establishment of Community Mental Health Centers should be welcomed – the NPM should always check the coordination and cooperation between the centralized mental health institution and the decentralized community centers.

Specific issues that require further close monitoring:

Use of means of restrain:

Due to the risk of abuse and ill-treatment, this issue should be a particular area of concern to the NPMs. During the visit, the NPMs were informed by the Deputy Director that the staff employed in the hospital does not use means of restrains, i.e. mechanical device to restrict a patient's movement. The practice was explained to involve solely the use of psychological means of calming the person down an also the involvement of the person’s family in this process. However, the last psychiatrist with whom the NPMs talked (the Head of the Women’s Acute Department) informed the participants at the visit that they use physical restrain in certain cases. The manner in which the restrain is applied is through use of physical force and bed sheets, meaning that special mechanical devices, such as straps or belts, are not used when restraining the hands or the legs of the patients.

The CPT has been very specific in requesting that establishments have a special register for recording the use of restraints, which was not the case in this hospital. Another issue that should be considered is the application of the means of restrain in the bedroom where the person is accommodated on regular basis with other patients. The NPM should suggest to the hospital that the immobilisation of patients, regardless of the time and the length, should never take place in the sight of other patients, since it might be viewed as degrading treatment. Finally, when a patient is fixated, a trained member of staff/the patient’s key worker should be continuously present to assist and provide therapy or at least to try to restore and maintain the therapeutic relationship. The regular check-ups and controls conducted by medical staff in specific time intervals would not be in line with the CPT’s recommendations. According to CPT, debriefing of patients after the restraints have been removed is considered important in diminishing psychological trauma, as well as restoring the doctor-patient relationship. There was no written policy/protocol on applying restraints.

Isolation rooms:

There are two isolation rooms in the hospital used for seclusion of aggressive patients (as explained by the staff). At the time of the visit, both rooms accommodated patients. The NPMs expressed concern on the material conditions in these rooms, i.e. whether they provide sufficient safeguards that would ensure that the persons would restrain from self-infliction of injuries.

In line with the CPT standards, during seclusion, the observer may be outside the patient's room - provided that the patient can see the staff and the staff can continuously observe the patient – this was not the case in the Tirana hospital at the time of the visit.

On 07 June the Albanian NPM hosted the follow-up discussion and exchange of findings and remarks after conducting the visit to the psychiatric hospital. At this meeting the following recommendations were provided by the participant from the Macedonian NPM:

Recommendations by the Macedonian NPM:

1. The hospital must establish register for recording the use of restraints. The Ministry of Health must establish written policy/protocol on applying means of restraint in psychiatric hospitals.

2. Since the patients often see and feel the use of the means of restrains as punishment, staff should debrief patients after the completion of the restrain process and explain them the need of the use.

3. There should be clear and visible regulations on the freedom of movement and the number of hours during the day the patients can spend outside on fresh air.

4. The hospital needs to improve the daily activities participation and psychosocial treatment of the patients.

5. The hospital should establish system of individual treatment plans for psychosocial rehabilitation of the patients, as part of the patient’s medical file.

6. Complaint procedure should be established in the hospital.

General Project Recommendations

1. The regional NPM cooperation in a form of exchange of preventive visits’ methodology and carrying out joint on-site visits to various types of places of deprivation of liberty should continue in future.

2. The South-East European (SEE) NPMs should continue to actively lobby and support the OPCAT ratification process in the region and provide guide to newly established NPMs in the region on peer-to-peer basis.

3. SEE NPMs should proceed towards signing a Declaration/Memorandum of understanding and cooperation that will set the basis for joint actions aimed to achieve the OPCAT goal, i.e. provide the necessary support to the initiatives for mutual cooperation and joint activities (recommended by the Albanian NPM).

Some of the main conclusions from the visit to Psychiatric Hospital No 5 in Tirana (NPM Slovenia)

- The hospital should be praised for displaying posters in some departments about individual diseases and their treatment and lists of patients’ rights in individual departments.

- The premises have been refurbished well; however, they are not maintained regularly. We noted a series of broken window panes, damaged power sockets (which can be life-threatening), lavatories without doors, and damaged ceilings, door jambs and entry doors. More effort should be made to repair damaged items immediately.

- While a nurse call bell system has been installed in certain places, it does not work.

- In the majority of rooms of individual departments, there are no television sets, radios or magazines. This means that patients are completely isolated from the outside world and from events outside the departments in which they are hospitalised.

- Whether it is really necessary to have bars on every window is open to question; we also do not know why the entry door of each individual department is fitted on the internal side with metal plates which enable locking with a padlock.

- The corridors are empty, usually containing no benches or chairs, or even tables. This is one of the reasons patients spend most of their time in their rooms, lying on their beds. The question arises as to how the patients eat, and also how daily activities (occupational therapy) are performed if there are no chairs, or if the patients always have to remove them from their rooms. The hospital staff claimed that a request for new chairs had already been made; this claim should be verified, and if not true, the relevant ministry should be notified.

- Whether it is appropriate to have transparent glass in room windows is open to question. While transparent glass makes it easier to supervise patients when there is a shortage of staff, patients are deprived off their privacy; they cannot even change their clothes without a member of staff, other patients or visitors being able to look into the room. The patients show their dissatisfaction with this by putting paper on the interior of some windows.

- We saw only plastic tableware and plates in the department. Although we did not receive (or did not understand) a satisfactory answer about when this kind of tableware is used, we are convinced that metal tableware and metal or ceramic plates should be used.

- We also have some questions regarding daily activities and, above all, occupational therapy. During our visit the patients were left on their own. They were lying on their beds, and it seemed that no one actively takes care of them.

- One lavatory each in two departments had no door. The doors had supposedly been damaged by patients, but even a month later, the lavatory doors had not been replaced or repaired.

- Toilet paper, soap and towels should have been available in lavatories. It was said that the patients can request towels from the staff, which is not appropriate. There was no water in one of the lavatories, so it was not possible to wash hands there.

- Some bathrooms lacked hot water (because of malfunctions), while elsewhere the staff had to be asked to provide hot water. This is not appropriate.

- The two solitary confinement rooms are completely inappropriate and dangerous to patients. The hard walls, unsecured door and missing window on the door could result in an injury to an aggressive patient. There is a question of supervision of patients in these rooms, because, as far as we can tell, there is no video or audio surveillance.

- Restraining patients with sheets or inappropriate straps can be dangerous; appropriate straps (for example, Segufix) should be used and precise records on their use should be kept.

- It is necessary to determine precisely how the records on the use of special security measures are kept and what these records must contain; the hospital should also consider introducing a record form, which would reduce the chances of something being omitted or forgotten. In a specific case, it was not possible to establish when the solitary confinement of a patient had begun.

- The hospital yard is neglected, not mown, with no natural shade, and there are no benches and tables there.

- Answers from the staff were unclear at times. We were told at the department for child psychiatry that ceramic plates stored in a cupboard are used primarily by the staff, because the children receive their food under the 'tablet' system. However, somewhat later, we saw a cook bring food to the department in the same containers for everyone, which suggests that food is distributed at the department.

- We think that the complaint system should be improved, and that patients should be informed about this (by means of leaflets and announcements on the bulletin board) and that boxes for collecting complaints and compliments should be placed in all departments. Perhaps the hospital should consider introducing a special form for complaints.

As the project concludes

As the project concludes, the Slovenian NPM would like to thank the Council of Europe for its assistance and support in its implementation. The project was an excellent opportunity to further deepen and strengthen our mutual cooperation. Above all, we were able to learn from the experience of others in a practical way. As we believe that such cooperation is necessary, we will certainly continue to cooperate as part of the network that we established on the basis of the project.

Observations of NPM Serbia

Visit to Psychiatric Hospital in Tirana

The premises in the hospital looks like premises in any other classic hospital - walls are white/gray, there are no paintings or posters, doctors and other medical staff are in white cloths.

Most of the patients were sleeping, although it wasn’t night,

The corridors and living rooms were empty, there are no enough chairs or tables, no television sets, radios, books, magazines or newspapers - maybe that it is one of the reasons that patients spend most of their time lying on their beds in dormitories.

Patients don’t have any information about fundamental rights of the patient; there is no brochure or poster setting out those rights.

Complaint system should be improved, in order to there is no any effective internal mechanism for examining patient’s complaints on treatment. Patients should be informed about this right (by means of leaflets and announcements on the bulletin board) and the boxes for collecting complaints and compliments should be placed in all departments.

In some lavatories was no water, and some are without doors. There is no toilet paper, soap and towels. Some bathrooms lacked hot water

The doors of dormitories have window panes - transparent glass for supervise patients. It deprived patients off their privacy;

Call bell system (alarm) doesn’t work properly.

Patients are locked inside the department. The entry door of each department is fitted on the internal side, bars are on every window.

This means that patients are completely isolated from the outside world and from events outside the departments in which they are hospitalised.

Impression is that there is no adequate occupational therapy and that the patients are left on their own.

The two solitary confinement rooms are completely inappropriate and dangerous to patients. The hard walls, unsecured door and missing window on the door could result for an aggressive patient to be injured. There are no precise record and book of supervision of patients in these rooms. In a concrete case, it was not possible to establish when the solitary confinement of a patient had begun.

Restraining patients with sheets or inappropriate straps can be dangerous; appropriate straps should be used and it should be kept precise records of their use. It is necessary to concretely determine how the records on the use of special security measures are kept and what these records must contain;

There is no video or audio surveillance in the hospital.

Patients are not offered every day outdoor exercise. The hospital yard is neglected, not mown, with any natural shade, and there are no benches and tables there.

There is no fire emergency exit, no emergency route.

The Serbian NPM would like to thank the Council of Europe.

The project was an excellent opportunity to further deepen and strengthen our mutual cooperation. Above all, we were able to learn from the experience of others in a practical way. As we believe that such cooperation is necessary, we will certainly continue to cooperate as part of the network that we established on the basis of the project.

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Unfortunately due to organizational changes in the Albanian Ombudsman Institution after the successful joint visit, the final findings and recommendation that we are preparing for the relevant authorities and the government of Albania will be shared with our colleges and the network in due course.

Annex 1:

THE EUROPEAN NPM PROJECT

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A councıl of europe/ european commıssıon joınt programme:

“Setting up an active network of national preventive mechanisms against torture,

an activity of the Peer-to-Peer Network”

co-funded by the

HUMAN RIGHTS TRUST FUND

Implementing partner:

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European NPM Project Inter-NPM Onsite:

Exchange of experiences on visiting methodology between the NPMs of Albania ”the former Yugoslav Republic of Macedonia”, Serbia and Slovenia

TIRANE, 4 – 7 July 2012

FINAL PROGRAMME

PROGRAMME OF THE JOINT VISIT BY REPRESENTATIVES OF THE SERBIAN, MACEDONIAN SLOVENIAN AND ALBANIAN NPM

Tirana, From 4 to 7 June 2012

Participants:

Albanian NPM

Alfred Kocobashi

V/Komissioner Albanian Ombudsman

Member of European Committee for the Prevention of Torture (CPT)

akocobashi@avokatipopullit .gov.al

alfred.kocobashi@coe.int

tel 355 0682512470

Iris Laci

V/Komissioner Albanian Ombudsman

ilaci@.al

Macedonian NPM

Donche Boshkovski

Counselor for Prevention of Torture

National Preventive Mechanism

Ombudsman of the Republic of Macedonia

Office e-mail: dboskovski@ombudsman.mk

Homepage: ombudsman.mk

Anica Tomshic Stojkovska

Counselor for Prevention of Torture

National Preventive Mechanism

Ombudsman of the Republic of Macedonia

e-mail:atstojkovska@ombudsman.mk,

npm@ombudsman.mk,ombudsman.mk

Slovenian NPM

Ivan Šelih, deputy ombudsman of Slovenia

Ivan.Selih@varuh-rs.si

Jure Markič, senior adviser

jure.markic@varuh-rs.si

Serbian NPM

Miloš Janković, Deputy Protector of Citizens (Ombudsman) of Serbia,

Head of National Preventive Mechanism of Serbia

e-mail: milos.jankovic@ombudsman.rs

Dr Vladimir Jovic, doctor of psychiatry, expert of Serbian  NPM,

PROGRAMME

DAY 1: Monday, June 4rth

Arrival and accommodation of NPM experts from Serbia , Slovenia and Macedonia

Hotel :Ferrari Tirana....Euro 50, breakfast incl..

DAY 2: Tuesday, June 5th

Albanian NPM Office (The Peaples Advokat Institution, Blv: “Zhan D’Ark”, Nr2 Tirana, .al)

9:00 – 10.00 Mr. Igli Totozani Albanian Ombudsman: Reception and opening address. Ervin Karamuço, Head of Albanian NPM : OPCAT implementation in Albania – in general.

10:00- 12:30 (with coffee break)

Introduction and discussion of each NPM model.

Round table with all NPM participants on methodology for visiting psychiatric hospitals(chair Ervin Karamuço).

12:30- 13:30 Lunch

13.30 – 17:00 (with coffee break)

Preparation for the JOINT VISIT.

Methodology of the visit, presentation of facility details and role of each NPM expert. Analyse of documents and information about the visit and the facility to be visited.

Round table with all NPM participants (chair Ervin Karamuço).

18:00 Dinner 

DAY 3: Wednesday, June 6th

Visit to: Psichiatric Hospital Nr 5 Tirana

 

09:00 Gathering at the Office of the Ombudsman of the Republic of Albania and departure to Psychiatric Hospital Nr 5 Tirana.

Guided by Ervin Karamuço and Iris Laci

13:00-14:00 Lunch

Dinner (after the visit)

DAY 4:Thursday, October 7th

Albanian NPM Office (Albanian Ombudsman Institution ).   

All participants of the joint visit.

09:00-13:00 (with coffee break)

Debriefing on the initial talk with hospital director. Debriefing on interviews with patients, staff and documentation. Debriefing on analysis of general findings. Exchange of experiences on drafting reports and recommendations.

13:00-14:00 Lunch

14:00 - Departure of NPM experts

Annex 2: Pictures from the meetings and the on-site visit

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[1] Drafted by the Albanian NPM in conjunction with and with contributions from the NPM participants.

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