TABLE OF CONTENTS

Bulgaria

Arbitrary detention and ill-treatment of

people with mental disabilities

Introduction

“This place is not for human beings. You should close it down. People die here.”

R.H., resident of a social care home for adults in Dragash Voyvoda

“The culture was one of simply controlling and warehousing people. The residents who had obviously been abandoned by society were left with nothing to do and nothing to hope for. They were herded together…with absolutely no purpose to their days.”

Dr Mary Myers, a consultant psychiatrist who visited social care homes

in Bulgaria as an Amnesty International representative

People with mental disabilities in Bulgaria suffer serious violations of their human rights and discrimination because of their disabilities. Research by Amnesty International in hospitals and social care homes in Bulgaria has uncovered arbitrary detention, ill-treatment and other cruel, inhuman and degrading treatment of people with mental health disorders or developmental disabilities.¹

In psychiatric hospitals, patients are arbitrarily confined and subjected to treatment against their will without recourse to an independent or judicial appeal process. Children who live all their lives in social welfare establishments receive practically no therapy or rehabilitation. Those with the most severe disabilities may be left all day in their beds, without stimulation or organized activities. High death rates in care homes for adults testify to their lack of sufficient food, warmth or medical care. Physical restraint and seclusion – confinement in special rooms or cells – is used excessively and inappropriately. State funding for social care homes is grossly inadequate. Sited far from centres of population, they are often out of the sight and minds of officials and health professionals who have responsibilities to protect and care for their residents.

Abuses against people with mental disabilities violate binding commitments that Bulgaria has made under international human rights treaties, which require all individuals to be treated without distinction of any kind. Yet the human rights violations described in this report amount to systematic discrimination against people with mental disabilities. Although good health and the ability to enjoy life without physical, mental or sensory impairment are not universally shared, the Universal Declaration of Human Rights applies equally to everyone, regardless of disability. No one should be denied their dignity and worth as a human being. Governments must protect the rights of all – to life, to equal protection of the law, to adequate standard of living and to education. In all cases, they should protect people from arbitrary deprivation of liberty and from cruel, inhuman or degrading treatment or punishment.

This report is a summary of a document, Bulgaria: Far from the eyes of society (AI Index: EUR 15/005/2002), in which Amnesty International details the findings of its research in Bulgaria and its recommendations for reforms needed to bring psychiatric hospitals and social care homes into conformity with international human rights standards. Research for the report was conducted in close cooperation with the Bulgarian Helsinki Committee, a human rights group that has conducted detailed research into the mental health system in Bulgaria, and draws considerably on its research of psychiatric hospitals.²

In October 2001 and January 2002 representatives of Amnesty International, the Bulgarian Helsinki Committee and Mental Disability Rights International examined the legal provisions and procedures used to confine patients, living conditions and treatment in psychiatric hospitals and social care homes for children and adults with mental disabilities. Experts on the delegation included a psychiatrist, specialist in learning disabilities, mental disability law attorneys, a clinical psychologist, a forensic physician and a specialist in psychiatric health care administration and system reform. The delegates spoke to patients at three state psychiatric hospitals in Karlukovo, Patalenitsa and Kardzali, and in Sofia met the directors of other state psychiatric hospitals. They also visited five social care homes for children in Borislav, Dzhurkovo, Strazha, Mogilino and Vidrare, and eight homes for adults in Sanadinovo, Radovets, Razdol, Pastra, Podgumer, Dragash Voyvoda, Samuil and Cherni Vrh. Amnesty International and Bulgarian Helsinki Committee representatives made further visits to social care homes in 2002: in April in Dragash Voyvoda, in June in Oborishte, Gorni Chiflik, Fakia and Radovets, and in July in Kachulka, Tri Kladentsi, Radovets and Mogilino.

Hospitals and homes visited (map courtesy of Bulgarian Helsinki Committee)

The Bulgarian authorities and the staff in these institutions cooperated fully in the delegations’ visits, and provided comprehensive information in most cases about the residents’ lives and the operation of each establishment. Amnesty International’s representatives met administrators and staff who were committed to providing the best possible care to the residents, given the limitations of their training and available resources. Their determination to improve the situation is commendable and warrants full support.

The Bulgarian government has stated its intention to reform the current psychiatric care system. In June 2001 it adopted a five-year mental health program which included plans to close many psychiatric institutions; to provide more care within general hospitals, in the community and in patients’ own homes; to modernize psychiatric services and treatments; and to increase respect for patients’ human rights. The program does not, however, include steps to improve social care homes for people with mental disabilities, which are the responsibility of the Ministry of Labour and Social Policy, not the Ministry of Health.

Following appeals by Amnesty International and other human rights organizations about ill-treatment and harsh conditions at a social care home for women with mental disabilities in Sanadinovo, in June 2002 the government closed it down.³ In a meeting with an Amnesty International representative in the same month, the Deputy Minister for Labour and Social Policy, Christina Christova, said that the government had “a firm political will to deal with the serious situation in social care homes”. However, concerns raised with the authorities in April 2002 about the high level of deaths at a home for men with mental disorders in Dragash Voyvoda, reportedly from pneumonia and malnutrition, had received no response from the General Prosecutor of Bulgaria by September 2002.⁴ On 8 August 2002 the Ministry of Labour and Social Policy announced that this institution would be closed down before the end of the year and its residents transferred to a more appropriate facility.

Amnesty International has for many years campaigned to end conditions of imprisonment and confinement of political and other prisoners that amounted to torture or to cruel, inhuman or degrading treatment or punishment. This report focuses on the violations of the civil and political rights of people with mental disabilities that result from appalling living conditions, lack of medical treatment and rehabilitation therapies, the inappropriate use of restraint and seclusion, and failure to address complaints of ill-treatment. However, enjoyment of these rights is clearly dependent on attaining such economic, social and cultural rights as the rights to an adequate standard of living, to education and to take part in cultural life. The failure to provide adequate medical treatment to anyone deprived of their liberty, for example, infringes the right to the enjoyment of the highest attainable standard of physical and mental health – a right guaranteed under the International Covenant on Economic, Social and Cultural Rights – as well as the right not to be subjected to torture or cruel, inhuman or degrading treatment or punishment.

Amnesty International’s findings underline the need for long-overdue, comprehensive reforms of the mental health care services and for those reforms to apply to social care homes for people with mental disabilities as well as psychiatric hospitals. The report concludes with recommendations to the Bulgarian authorities that should be implemented without delay. There is a pressing need to improve the life-threatening living conditions in care homes for adults. Without immediate and continuous therapy and rehabilitation, the lives of mentally disabled children will be irreparably damaged. Once Bulgaria has a comprehensive program of reform of its mental health care services, the international community should provide support for the implementation of the program.

Psychiatric hospitals

State psychiatric hospitals in Bulgaria fail to meet international human rights standards for conditions and treatment in psychiatric institutions. Patients are often placed for compulsory treatment after proceedings that allow no right of judicial review. They complain of assault by police officers and non-medical staff. Living conditions are generally poor and unhygienic. Almost no therapeutic activities or opportunities for rehabilitation are provided, and electroconvulsive therapy continues to be administered inappropriately. Low salaries, poor working conditions and the remoteness of some hospitals inhibit recruitment of qualified staff. Large numbers of released patients are readmitted because of the lack of support and services within the community.

Of more than 34,000 people admitted to psychiatric institutions in Bulgaria in 2000, just over 1,500 were admitted to state psychiatric hospitals for “compulsory” or “involuntary” treatment. Those assessed as criminally irresponsible receive “involuntary treatment” under the provisions of the Criminal Procedure Code. This report focuses on patients given “compulsory treatment” under the civil law. However, in some cases, people without symptoms of a mental illness requiring active treatment have been placed in psychiatric hospitals for social rather than medical reasons, while patients needing urgent treatment for acute mental illness were found in social care homes.

Living conditions and treatment

In the psychiatric hospitals visited by Amnesty International, the buildings required major refurbishment. Hot water was generally not available all the time. Bedrooms were often large and overcrowded, and the walls bare. Few patients had lockers where they could keep personal belongings. “Day rooms” were often areas set aside in corridors and furnished with a television set, a table and a few chairs or benches.

International human rights standards

The European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) elaborated standards in 1998 for conditions and treatment in psychiatric institutions which require the provision of:

● the necessities of life, including adequate food, heating, clothing and appropriate medication;

● a positive therapeutic environment, including visual stimulation and lockable space for each patient;

● material conditions conducive to the treatment and welfare of patients, including maintenance of the building and meeting hospital hygiene requirements;

● psychiatric treatment to involve rehabilitative and therapeutic activities;

● access to suitably equipped recreation rooms and outdoor exercise.

The hospital in Karlukovo had insufficient funding for medication and food or for general maintenance. Its management estimated they received only 50 per cent of the funding they needed, but the most recent accreditation assessment by the Ministry of Health in 1998 made no recommendations for increased resources. The hospital would not be able to function without the support of humanitarian organizations.

Patients in a “closed ward” at Karlukovo hospital, October 2001. A television provides the only distraction for the patients, who spend all of their time on the ward. © MDRI

The psychiatric hospital in Patalenitsa, in a mountainous region, did not have adequate heating in January 2002. There were insufficient funds to complete a central heating system and patients’ rooms were heated with electric heaters which could barely bring the temperature to 14 or 15°C. A police academy had donated overcoats for the patients.

Patients in psychiatric hospitals in Bulgaria have few opportunities for rehabilitative and recreational therapy. In one hospital, the gym had not been in use for a long time and occupational therapy had been discontinued. In another, aerobic workouts in the corridor of the ward were the only form of exercise for patients receiving compulsory treatment, who were generally not allowed outside at all. Television provided the only diversion.

An important safeguard to protect the well-being of patients in compulsory psychiatric treatment is free and informed consent to treatment. However, procedures for seeking and obtaining informed consent from patients undergoing voluntary treatment are inadequate. In some cases, relatives who are not legal guardians have given consent to treatment – even to electroconvulsive therapy – for patients who have not been legally declared incapable of giving consent.

Electroconvulsive therapy

The use of electroconvulsive therapy (ECT), a form of treatment for severe depressive disorders in which a controlled electric current is passed through the brain. “Modified ECT” may only be given with a general anaesthetic and a muscle relaxant, under the supervision of an anaesthetist.

Following a visit to Bulgaria in 1995, the CPT recommended that electroconvulsive therapy (ECT) be used only in its modified form. The CPT has found “unmodified” ECT unacceptable in modern psychiatric practice; it risks bone fractures and is degrading for both the patients and the staff concerned.

However, eight psychiatric institutions in Bulgaria have continued to use unmodified ECT. In January 2002, at a meeting on psychiatric care and human rights, representatives of the Bulgarian Psychiatric Association and of the Ministry of Health failed to explicitly condemn the use of unmodified ECT.

Ill-treatment and excessive use of force

There are no procedures to assist patients to make complaints if they are the victims of abuse. Some hospitals are never visited by the local prosecutor, who has a statutory obligation to supervise the conditions and treatment of people in involuntary confinement.

Many patients told Amnesty International of rough and sometimes violent treatment by police officers. In Karlukovo hospital, a 22-year-old man was brought to the hospital by police officers on 15 July 2001, reportedly for involvement in a fight. After he was handcuffed, police officers allegedly kicked him all over his body and hit him on the head. He said that he made a complaint but that his injuries were not properly examined or recorded.

One hospital director reported that police officers sometimes brought in patients with bruises and lesions which could have resulted from physical violence. He did not report such cases, as an officer’s explanation that force had been required to restrain a violent patient was likely to be given more credibility than a patient’s allegation of unwarranted assault.

A number of patients complained that orderlies used excessive force when restraining patients. Such conduct appeared to result from insufficient staffing levels and from lack of training in the management of violent or what was considered as bothersome behaviour.

Restraint and seclusion

International human rights standards

The UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care (Principle 11) require that restraint or seclusion should be used only to prevent harm to the patient or others, should not be prolonged unnecessarily and should be recorded in the patient’s medical record. The patient must be held in humane conditions and under close care and supervision.

In the hospitals visited by Amnesty International, there were no protocols for the use of restraint and seclusion and no special records kept of their use. In Kardzali hospital, three men in a padlocked room, one of whom had been locked up for 10 days, had only a bucket for a toilet. One of the men, Feris M., said that he had been locked up after he tried to escape. Although the nurse in charge of the ward said that records were kept, a list of names in a notebook appeared to have been written in some haste. The hospital director said that doctors prescribed seclusions but no record was made in the patients’ medical files and no special register kept.

In a locked section of the acute female ward in Kardzali, a metal bed fixed to the cement floor of a seclusion room had a wet, torn mattress stained with faeces. When asked to demonstrate how staff would restrain a patient on a bed, one staff member asked: “Shall I go to get the belts?” A colleague said that they did not use belts, but fumbled attempts to secure a volunteer visitor with sheets instead demonstrated that the staff had little experience of using sheets to restrain patients.

Seclusion appeared to be used as punishment for “attempted escapes”, even for voluntary patients. In the locked and guarded acute male ward in Kardzali, there were four patients supposedly receiving voluntary treatment at the time of Amnesty International’s visit. One of the men, Suleiman O., had not signed the voluntary admission form himself, having reportedly been sent to the hospital by relatives after he ran away from home. There was no record of his seclusion being prescribed by physicians, as claimed. The hospital director said that the four men were secluded because “[W]e want to make sure that on their release they will go home and be safe,” but that they were free to discharge themselves from the hospital “against medical advice”.

Compulsory placement

International human rights standards

The UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care state that: “Every patient shall have the right to be treated in the least restrictive environment and with the least restrictive or intrusive treatment appropriate to the patient’s health needs and the need to protect the physical safety of others” (Principle 9).

The CPT recommends that placements for compulsory or involuntary psychiatric treatment should be decided or confirmed by a judicial authority. Any person who is involuntarily placed in a psychiatric establishment by a non judicial authority must have the right to challenge the lawfulness of the detention promptly before a court.

Placement for compulsory treatment in Bulgaria does not meet these international requirements. The procedures for placement are also discriminatory in comparison to those for “involuntary” placement under the criminal law, which make mandatory provision for legal representation and which require the prosecutor to obtain a medical opinion and to investigate whether the person presents any danger to society.

The Public Health Act provides for compulsory treatment for patients deemed a serious danger to themselves or others. The district prosecutor carries out investigations and orders psychiatric examinations, usually to be carried out in closed psychiatric wards. Such assessments should be completed in 30 days but in exceptional circumstances can last up to three months. At the end of the assessment a district court must decide on the proposal for compulsory treatment and review every six months any subsequent proposal for the continuation of the treatment. Legal counsel for the patient is allowed but is not obligatory.

In a judgment in October 2000, the European Court of Human Rights found that the Bulgarian authorities had contravened the European Convention on Human Rights and Fundamental Freedoms.⁵ The court ruled that a decision to detain someone for psychiatric assessment was unlawful if it was not based on medical opinion, that the Public Health Act did not explicitly authorize prosecutors to order detention for the purpose of psychiatric examination or provide for a judicial review challenge of such detention. A subsequent amendment to the Public Health Act gave powers to prosecutors to detain people for inpatient psychiatric assessment, but failed to require prosecutors to seek medical opinions beforehand or to provide a right of judicial review.

A serious danger?

“I had a few drinks. At around 4am I knocked on theneighbours’ door to ask for a cigarette and they called the police… [T]wo officers…roughly pushed and pulled me into their car. I was held at the police station for 72 hours… The doctor told the officers that he needed a letter from the prosecutor in order to carry out the examination and I was subsequently released. Five days later I was in a café and one of the [same] officers…took me…to the local Accident and Emergency Unit where a doctor on duty wrote a psychiatric diagnosis. I was kept for 24 hours in the [police] station and then another two days in the regional psychiatric dispensary where they wanted to give me injections which I refused. They called the police, and two officers…held me while a nurse gave me an injection. I was then belted down (legs, hands and waist)… The following day I escaped to my village. Five days later I returned to the dispensary to collect my belongings but they said that I should go to the police station. The police then brought me here. I was treated previously 10 years ago. Staying here makes me ill. No one has told me anything [or] why I have to undergo compulsory treatment. I asked to make a telephone call at my own expense but was not allowed.”

Yordan S., a patient in the acute ward in Karlukovo hospital

The courts are inconsistent in interpreting “serious danger”. This legal provision is so broad as to allow for arbitrary interpretation. Psychiatric assessments and court decisions have not always specified the behaviour deemed dangerous or have considered actions such as puncturing car tyres or playing loud music to constitute a danger. Too much weight has been given to factors such as previous hospitalization of the patient or the wishes of relatives for a patient to be confined. Lawyers have sometimes been recruited by the court to represent patients at committal proceedings only minutes before hearings, and have often agreed without question with the recommendations of the prosecutor and medical experts.

The 30-day period allowed for inpatient psychiatric assessment is extended in nearly all cases because court hearings cannot be scheduled in time. Judicial reviews of recommendations to discharge patients from compulsory treatment are also often delayed. One patient in Karlukovo hospital told Amnesty International that he had been held in a secure ward for five months while waiting for a court hearing, even though his condition had improved and he had been recommended for discharge.

Social care homes for children

Until recently, living conditions in many homes for children were so poor that they amounted to cruel, inhuman or degrading treatment. In February 1997 Amnesty International expressed its concern about the deaths of six children and one 18-year-old from hypothermia and malnutrition in the Dzhurkovo social care home where more than 80 children were without adequate food and heating for several weeks. The Bulgarian Helsinki Committee found life-threatening conditions in the social care home in Fakia in the Burgas region, where in January 2000 two boys reportedly died as a result of medical neglect. In August 2000, in the social care home in Medven, three children died of dysentery. These institutions did not have enough state funding to buy sufficient food.

An investigation was opened into the deaths in Dzhurkovo but is not known to have been completed. However, there were no criminal investigations into deaths in other children’s care homes, although they may have resulted from criminal negligence.

There have been improvements in the material conditions in homes such as Dzhurkovo and Fakia, although many serious deficiencies remain. There have been improvements in the material conditions at some other homes as well.

However, children are still placed in social care homes on the basis of inadequate diagnoses and without the prospect of monitoring or reassessment. The lack of specialist therapeutic or educational training impairs their development and the possibility of leading a more meaningful and useful life. If active and appropriate treatment is not started soon, these children will be permanently and severely affected, condemned to spend the rest of their lives in social care homes.

Lack of therapy and rehabilitation

The lack of early and continuous assessment, treatment and rehabilitation by therapists, psychologists and physicians is profoundly damaging to the development of the children and deprives them of their fundamental right to life with dignity and respect in violation of international human rights standards.

International human rights standards

The UN Convention on the Rights of the Child requires Bulgaria, as a state party, to ensure that:

● a mentally or physically disabled child should enjoy a full and decent life, in conditions which ensure dignity, promote self-reliance and facilitate the child’s active participation in the community,

● assistance…shall be designed to ensure that the disabled child has effective access to and receives education, training, health care services, rehabilitation services, preparation for employment and recreation opportunities in a manner conducive to the child’s achieving the fullest possible social integration and individual development, including his or her cultural and spiritual development.

Most children in care institutions are assessed by the age of three, when those diagnosed by a psychiatrist as having “moderate, severe or profound retardation” are transferred to social care homes without any prescription for medical or educational therapy and development. Some are sent to homes for “social reasons” such as being abandoned or severely neglected. Medical records of children in homes contain no evidence of the use of diagnostic methods such as biochemical analysis or encephalographic examinations. At the age of 16, when they qualify for disability benefits, the children are re-examined. In some cases, they are reportedly diagnosed as suffering from a more severe degree of disability solely to secure the highest possible state benefits. At the age of 18, those with the more severe disabilities are transferred to institutions for adults.

Few children are visited by their parents, and contacts with the community are rare. At the home in Strazha, however, staff reported that attitudes in the village were gradually changing and that some children were being invited into private homes on special occasions.

None of the social care homes visited by Amnesty International provided rehabilitation programs by therapists, teachers or psychologists for children with developmental disorders. Generally, special activities were organized by “educators” with general teaching qualifications. Only in the home in Strazha were there “educators” who had some training in learning disabilities. Orderlies are generally recruited from the local village and have no training in working with children or with children with developmental disabilities.

Mogilino

At the care home in Mogilino, children continued to die from disorders that are common among children with severe developmental disabilities living in environments with few resources. One nine-year-old boy who died of pneumonia in November 2001 suffered from cerebral palsy, which impedes swallowing. In July 2002 the most severely disabled children were being fed in a reclining position in which there is an increased risk of food entering the windpipe and causing pneumonia.

A dormitory at the children’s care home in Mogilino, January 2002. © AI

The home suffers frequent cuts in power and heating in the winter. Dormitories had bare and chipped walls, providing no visual stimulation. The most disabled children spent their entire lives in bed. It was clear that the staff did not interact with the children beyond feeding and cleaning them.

Dzhurkovo

At the home in Dzhurkovo, improvements include a new heating system in the playroom, a well-equipped room for physical rehabilitation and a “sensory room”, where children can listen to music and watch light effects projected onto the walls and ceiling. However, there is still neglect and insufficient active treatment or organized activities. Early neglect has resulted in emotional distress, withdrawal, distorted and atrophied limbs. Many children in the playroom have developed behavioursuch as head banging, repetitive finger movements and pushing of others.

In October 2001, the 12 most severely disabled children lay on beds with only plastic sheeting. Some were wet and needed changing. Flies swarmed about one boy who seemed in great distress if anyone approached him. There were no toys in the children’s beds. The most seriously ill of these children was 13-year-old Vera D., emaciated by a terminal liver disease. She held the visitors’ hands and appeared to be very calm and pleased with the attention she was receiving. Her medical record showed a diagnosis of cerebral palsy but not of learning difficulties, suggesting that she may have fully understood her condition but was unable to verbalize her thoughts or feelings. Staffat the home did not appear to consider that she merited any special attention or care.

In a large dormitory in Dzhurkovo, 12 children with Down’s syndrome were kept in cots. Although they were reportedly five and six years old, they had the physical development of one-year-olds and none could stand unsupported, indicating gross neglect. There did not seem to be any interaction between the children and staff. One orderly appeared unaware that one girl had been driven to chew through the wooden frame of her cot from lack of attention or means to occupy herself.

Medical care

Few children’s homes have resident physicians. In Mogilino, the general medical practitioner was 17km from the home, the paediatrician and psychiatrist 30km away. Assessment and treatment by specialists, including psychiatrists, is infrequent. Few homes complied with a Ministry of Health directive that all children with disabilities under the age of 16 should be reassessed by the end of 2001.

When Amnesty International visited the home in Strazha in January 2001, the most recent visit by a psychiatrist had been in March 2000. The medical records of children in the home contained clearly inappropriate diagnoses, for example, in the case of a 17-year-old boy whose record suggested that he had Down’s syndrome when he clearly did not.

Several children in the home appeared to be autistic. Although autism is frequently found in people with severe learning disabilities,their condition was unrecognized and their special needs were not addressed.

Some instances of inappropriate medication were found.⁶ At the home in Strazha, one very underweight 13-year-old boy was being treated for aggression with an adult dosage of antipsychotic drugs daily. He was also being given diazepam (“Valium”) although this can increase aggression.

Allegations of ill-treatment

Although allegations of ill-treatment of children are rare, this may reflect the lack of supervision of social care homes and the inability of the children to complain. There appears to be little supervision of the homes by municipal authorities and practically none by the Ministry of Labour and Social Policy.

After newspaper reports in August and September 2001 that an orderly had been ill-treating children at a care home in Trnava, Veliko Trnovo region, its director confirmed that an orderly had been dismissed. She had allegedly beaten children with a stick, had forcibly fed, slapped and tied down a four-year-old boy, and had burned another boy with scalding water.

An inquiry by the Ministry of Labour and Social Policy, whose findings were made known in October 2001, found that a police investigation into the case of the four-year-old boy had been suspended for lack of evidence. It had found that a blind girl with impaired hearing had been placed in seclusion, apparently for crying and preventing other children from sleeping, but it reported that children were not secluded for prolonged periods. The inquiry did not reveal how the child burned with scalding water had been injured, what medical care he received in the three days before he was taken for hospital treatment, and whether any inquiry had been carried out at the care home, including into other alleged ill-treatment by the orderly. Nor did it clarify the circumstances in which children were secluded, on whose authority or for how long.

The inquiry concluded that children had been ill-treated at the home but suggested that the dismissal of the staff responsible was the end of the matter. It made no recommendations on how to prevent and act upon similar misconduct, although such serious offences could potentially be considered to be torture, and did not make clear its reasons for not referring the case to the prosecutor. Amnesty International is concerned that this inquiry did not meet international human rights standards for such inquiries into ill-treatment.⁷As the allegations of ill-treatment had already been made public, the prosecutor could have initiated an investigation.

Social care homes for adults

Most children in social care homes will eventually be transferred to adult facilities. Other residents in homes for adults have been admitted there after their legal guardians or families could not, or would not, provide the necessary care. The material conditions in these homes are often appalling and rehabilitative treatment practically non-existent. Many of the residents of these institutions would be able to live independently in the community if they had been rehabilitated and trained in the institutions where they lived as children, and if they were provided with support and community-based care and assistance.

The living conditions in most homes were impoverished and overcrowded. Compounded by negligence and inadequate medical care, the conditions may have led to the deaths of some residents. Physical restraint and seclusion are used excessively and inappropriately, and psychiatric and medical care is generally inadequate. The staff are insufficient in number and lacking in the professional skills required.

High rates of death

Few records were accessible about the rates of deaths among residents, although information available at homes in Radovets and Dragash Voyvoda indicated that the mortality rates were high. Post-mortem examinations were rarely carried out and the police or other authorities usually did not investigate deaths.

International human rights standards

The UN Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment includes the following provision: “Whenever the death…of a detained…person occurs during his detention…, an inquiry into the cause of death…shall be held by a judicial or other authority… The findings of such inquiry…shall be made available upon request…” (Principle 34).

At the home in Razdol, no data was available on deaths in 2001. At an institution in Radovets, 14 out of 91 male residents died in 2001. The general medical practitioner said that he established the causes of deaths from clinical data provided by staff on duty. He had never requested an autopsy in seven years and apparently was unaware that the regulations allowed him to do so.

The death of Kostadin K.

Kostadin K. was 37 years old when he died at the social care home in Radovets on 5 January 2001. Although the cause of death was registered as “sepsis resulting from Bürger’s disease”, his medical record contained no mention of the disease, and stated only that on 3 or 4 January 2001 his condition deteriorated and that he suffered from a cardiac condition.

A medical examination in December 2000, after being transferred from the social care home in Terter where conditions were very poor, had not revealed anacute condition although the director said he had appeared ill and seemed to have frostbite on his legs. Another resident said: “The pain gradually increased and he kept asking for medical assistance. His legs and feet were very swollen from the calves down. …It had been very cold in Terter but it was also cold here when we arrived. We were not examined immediately upon our arrival…he was just taken to a bedroom.”

At the care home for men in Dragash Voyvoda, out of a total of 140 residents, at least 22 died in the coldest months of 2001. Most of the deaths appeared to result from inadequate medical treatment and lack of food and heating. Staff said that the number of deaths had been even higher in harder winters. Although in most cases the cause of death was recorded as “acute heart and respiratory insufficiency”, post-mortem examinations in five cases in February and March 2002 revealed that the deaths were caused by pneumonia and malnutrition. There appears to have been no investigation into the high rate of deaths. In April 2002, 16 residents suffering from bronchial conditions were not receiving prescribed antibiotics because of lack of resources.

Living conditions

Most of the social care homes visited by Amnesty International representatives were unsuitable for the care of people with special needs and many were not fit for human habitation.

The road to the social care home at Razdol, January 2002. © AI

The location of some homes makes them unsuitable for long-term residence. At an altitude of 1,100 metres, the home in Razdol is sometimes inaccessible in winter. In January 2002, the buildings were derelict, filthy and dangerous, and there was no central heating. One dormitory, measuring 10m x 10m, contained 33 beds. The orderly explained that only two beds had sheets because: “The women are ill and they would only soil the sheets.” Some mattresses were heavily soiled and torn. A small wood-burning stove was not lit for most of the day, and residents – some barefoot – were walking on icy paths between the buildings.

At the home in Pastra, 107 men were housed in three fenced-off blocks. In one block, a dormitory was filled with smoke from the stove in which twigs and leaves were burned to supplement the inadequate central heating. Two bedrooms did not have functioning lights. Old metal beds with thin, worn-out mattresses were the only furnishings in the dormitories. The toilet was in an outhouse 30 metres away along a snow-covered path. Faeces blocked the hole in the ground and covered the snow around the outhouse. In another block, some beds had no mattresses. On the evening of Amnesty International’s visit, only two orderlies and a nurse were on duty in the three blocks.

“An overcoat is placed on the bed instead of a mattress”, explained an orderly at the home in Pastra.© AI

In a dirty dormitory for the most disabled residents at the home in Radovets, a blind man who appeared to have severe impairment of the limbs had a full toilet bucket under his soiled bed. The next day, the floor had been hosed down and the mattresses were gone. Two residents were carrying the man, now in clean clothes, up a staircase to the barber’s room.

Male residents at the care home in Samuil were accommodated in a two-room house in the yard. In one dingy room for six men, the windows had no glass and were almost entirely boarded up. In an adjoining, unlit room, four men shared three beds. A seclusion cell containing a cage was reportedly not used.

The basement of the “acute ward” at the care home in Podgumer, January 2002. © AI

At the social care home in Podgumer, the distinction between living quarters and seclusion was somewhat blurred for 21 residents restricted to a cramped two-storey building called the “acute ward”. In one dormitory there were seven beds for 12 men. Residents ate meals in a narrow corridor. In the freezing basement there were two cells and a room with six beds, none of which had glass in the windows or any heating. A resident, Ilian, had been brought to the basement at 5am by staff and a guard armed with a truncheon, reportedly after he tried to break a dormitory window. Heavily sedated, he was lying on a bed, covered with thick blankets. Another resident of the “acute ward” said: “We come up and are sent down. And up again and down again.” Although records were more systematic at this home than at others, there were no records kept of the residents confined in the “acute ward”.

Food, clothing and heating

In practically all homes residents complained that the food was of poor quality and insufficient quantity. None of the homes kept weight or height records in residents’ medical files. Only one home served meals on tables with tablecloths.

At the home in Razdol, the meal of bean soup, bread and halva was served on 10 bare tables and the women ate standing up. The staff said that the chairs were removed because the residents threw them at each other. The food was taken in buckets to the women who were confined to their beds.

Women eating a meal at the home in Razdol, January 2002. © AI

In all the homes, residents were dressed in ragged clothing or old army uniforms. Almost none had their own clothing. In Radovets, several men complained that they were subjected to short haircuts associated with prisoners or army recruits. In Dragash Voyvoda, an elderly man was bleeding after being shaved. The barber, who shaved all 144 residents, said that he used the same razor blade to shave six or seven men.

Old stoves are used to heat homes without central heating, or to supplement inadequate heating systems, and they pose a constant fire hazard. Maintaining adequate supplies of heating fuel is a continuing concern for social care homes.

The toilets in an outhouse at the care home in Samuil

consisted of six holes in the ground, January 2002. © AI

Sanitary facilities

In many homes, crude and often non-functional bathing facilities were available in a separate building, some distance from the dormitories. Residents were allowed to use them once a week. The home in Razdol, with 110 female residents, had only part of the laundry room as a bathroom. One resident complained that it was difficult to bath in winter as they had to walk through the snow back to the dormitories.

In January 2002 the home in Samuil had been without running water since May 2001. There was only one filthy toilet in the building for over 100 women residents. An outhouse 150 metres away along an icy path had six holes in the ground. It was not possible to avoid stepping deep into excrement, which extended onto the path outside. The staff said that they were only able to hose it down once a day.

Reports of ill-treatment

There are no effective safeguards to protect residents from ill-treatment or harassment and no means for them to bring complaints or to seek remedies for ill-treatment.

In most institutions, residents complained of ill-treatment by orderlies, although many were afraid to talk about such incidents. A 56-year-old woman in Razdol told Amnesty International’s representative that some orderlies beat and locked up residents, but was too afraid to point out where they were confined. A resident in Radovets described how the orderlies would beat male residents with a piece of rubber hose or a stick covered in bandages.

Residents in Dragash Voyvoda said that orderlies sometimes beat them with a stick. A resident, who had left the home without permission, was brought back at around 6pm on 1 April 2002 with a prominent swelling on the right cheekbone and bruising around the eye. He could not explain how he had suffered this injury, possibly because two orderlies were present.

Seclusion and restraint

Methods of seclusion and restraint were used which constituted cruel, inhuman and degrading treatment and violated international human rights standards. No detailed records were kept of how and when seclusion and restraint were used and they appeared to be ordered by nurses or orderlies. Even in the home in Cherni Vrh, where staff appeared caring and concerned, the use of unacceptable methods of seclusion and restraint indicated that most staff had not been trained to manage behaviour by means other than drugs, force, or isolation.

A seclusion cell under the stairs at the home in Radovets, October 2001. © AI

At the home in Radovets, a nurse said “We have ‘jails’ but we do not use them frequently” for aggressive behaviour between residents. In one building, residents showed the delegation an enclosed space under the stairs, about 1.5m deep and 1.6m at the highest point. There was no room for an adult to stand upright. Residents alleged that some of them had been detained there for many days as punishment. In June 2002, an Amnesty International representative saw inside this space a worn mattress, a soup bowl and a half-eaten piece of bread. Resident Petko K. said that he had been held under the stairs for two weeks and then kept for 10 days in a seclusion room. In June 2002, of two rooms used for seclusion, one had practically no natural light and was occupied by one man, and another had three beds and was occupied by four men who said that they were being punished for trying to escape.

In one seclusion room at the home in Dragash Voyvoda, a corner had been fenced off with wire. Residents said a bench would be placed in the cage when someone was held there for “punishment”.

International human rights standards

The Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, to which Bulgaria is party, requires states to prevent torture or ill-treatment by officials. It obliges the authorities to guarantee “the right to complain” and further requires that “steps shall be taken to ensure that the complainant and witnesses are protected against all ill-treatment or intimidation as a consequence of his complaint or any evidence given.”

The seclusion house at the home in Cherni Vrh had recently been refurbished. One room was subdivided into three cells with barred doors, each not much larger than the single bed inside it. In one cell was 38-year-old S.T., who had been there for a month. She said that a bucket in the cell served as the toilet. The nurse said that she was in seclusion “because she fights with other residents and will be allowed out only if she is well behaved”. M.D., a 50-year-old woman, had been in the seclusion room for over a year, at the request of her brother and approved by a psychiatrist, after she had escaped on several occasions. The only records kept, a notebook containing simply the names of residents in seclusion and occasionally a brief remark, did not document when seclusion had been ordered and by whom. The staff explained that the decision was usually taken after a telephone consultation with the psychiatrist.

In another room, in January 2002 R.G., a young woman diagnosed as “moderately retarded”, was restrained by a strait-jacket every evening and sometimes during the day. She was apparently restrained because she had wound thread tightly round a finger in July 2001 and subsequently had to have the finger surgically amputated. In the third room, 28-year-old J.S. was lying on her bed, with her ankle chained to the wall. She had been chained up for a year “because she had escaped from the institution”.

An orderly demonstrates restraint with a strait-jacket, causing R.G. to cry in distress, Cherni Vrh, January 2002. © AI

Professional staffing and skills

Social care homes are grossly understaffed and both medical and non-medical staff lack appropriate training to work with people with mental disabilities. Levels of pay are low. The homes are far from urban centres and it is difficult to recruit staff with appropriate training.

In some homes, a psychiatrist attended each month or residents attended the local psychiatric clinic. In others, there was no regular contact. Psychiatric treatment often appeared to consist of prescribing medication on the basis of information provided by the medical staff in the home. In the home in Radovets, a nurse said that during his most recent visit the psychiatrist had examined 30 patients in about four or five hours and had written out new prescriptions for their medication.

Social care home directors are not required to have specialist qualifications. Every home has a team of about six nurses, supervised by a senior nurse, some of whom have had some psychiatric training. Orderlies are usually recruited from the local community and have little, if any, training.

With insufficient resources and training to enable staff to meet the most basic needs of residents, residents’ needs for social and emotional relationships or for a sense of self-esteem are disregarded. Staff were expected to deal with behavioural problems with no understanding of behavioural management. Staff attitudes ranged from genuine concern to provide good care to excessive paternalism.

Understaffing was at dangerously low levels. In Dragash Voyvoda, an institution with over 140 male residents, three orderlies were on night duty at the time of the Amnesty International visit in January 2002 and only two orderlies and a nurse in April.

Women at the social care home in Razdol,

January 2002. © AI

Medical care and inappropriate medication

General practitioners were contracted in the local community and mostly visited the home once a week or less frequently. At the home in Radovets, the records of a retired paediatric physician who had been contracted to visit twice a week for about two-and-a-half hours appeared to have been completed in advance and did not document the treatment administered to residents.

Poor records of medical treatment and injuries suffered by residents were observed in other homes. At the home in Razdol, incidents in which residents suffered injuries were recorded in a daily report book but not reported to any outside authority or investigated in any manner. One woman resident was unable to explain why she had bruises under her eyes. A nurse said that she had fallen and hit her head a week earlier, but there was no record of this incident in the report book.

Specialist medical and dental care was rare. In Dragash Voyvoda, a resident complained that he had requested an eye examination over a year ago but without result. A resident in Radovets had a large tooth abscess on the right side of the jaw, which had been treated with aspirin for a few days.

Psychotropic medications used in psychiatry were widely and inappropriately administered to subdue behaviour which may not have been psychotic but an expression of distress or anger. Amnesty International’s representatives were surprised to find that none of the 700 residents encountered on their visits had a diagnosis of depressive disorder or had been given antidepressants. They expected to find higher levels of depressive disorders in such communities.

International human rights standards

The UN Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care (Principle 10) state that:

● Medication shall meet the best health needs of the patient, shall be given to a patient only for therapeutic or diagnostic purpose and shall never be administered as a punishment or for the convenience of others. …mental health practitioners shall only administer medication of known or demonstrated efficacy.(Principle 10)

● All medication shall be prescribed by a mental health practitioner authorized by law and shall be recorded in the patient’s records. (Principle 10)

● No treatment shall be given to a patient without his or her informed consent… [T]reatment may be given to a patient without a patient’s informed consent if…[a]n independent authority, having in its possession all relevant information…is satisfied that…the patient lacks the capacity to give or withhold informed consent. (Principle 11)

In many care homes the choice of drugs depended on their availability at little or no cost. At the home in Podgumer, Amnesty International representatives learned that 10 residents with developmental disabilities were medicated with the cheapest sedative available. This was not being used to treat them but simply to subdue them.

At the home in Samuil, there had been no psychiatric visits since May 2001 when the contract ran out. The general medical practitioner, although unable to initiate psychotropic medication, could renew prescriptions. At the time of Amnesty International’s visit, several residents continued to be given potentially hazardous anticholinergic drugs even though they were no longer being treated with antipsychotic medication.

Residents’ right to free and informed consent to medication is not recognized. Supplies of diazepam (“Valium”) were lying around openly which, although useful as a short-term treatment, can rapidly become addictive.

Psychiatric medication

Drugs used in psychiatry are referred to as psychotropic because they mainly, but not exclusively, affect mental symptoms. Until about 40 years ago drugs including barbiturates were used to sedate the whole nervous system of patients suffering mania and severe schizophrenia. Since the 1960s more targeted “major tranquillizers” (neuroleptic or antipsychotic drugs) have calmed behaviour and psychotic thoughts without affecting clarity of consciousness. Excessive doses of the older tranquillizers, chlorpromazine (“Largactil”) and haloperidol, and of newer antipsychotic drugs, which have fewer side effects, can leave the patient “zombie-like”.

The therapeutic aim of medication is to liberate people from distressing experiences and not in effect to paralyse them. However these drugs, and the drugs used to correct their side effects (anticholinergic drugs), may produce long-term neurological disorders.

Occupational therapies organized in the past had been stopped and workshops closed down because of reduced resources. In most homes, occupational therapy consisted of residents doing work such as cleaning, doing the laundry. In most homes, the only activity available was watching television. In Samuil, residents who were bed-ridden with a physical disability were deprived of any activity.

Placement and guardianship proceedings

The rights of most residents to due process and freedom from arbitrary detention are violated during their placement in care homes and by the procedures in which their affairs are placed in the hands of a guardian.

International human rights standards

The UN High Commissioner for Human Rights, reporting to the Economic and Social Council in 2001, said: “Persons with mental disabilities are particularly vulnerable to abuse, including through their unwarranted committal to mental institutions. The [International] Covenant [on Civil and Political Rights]…refers to the right to liberty and security of person (Article 9) and to due process guarantees, including the right to defence and the right to be informed of the reasons for one’s arrest (Article 14). These provisions are of considerable importance for the protection of persons with mental disabilities, particularly with regard to their right not to be subjected to arbitrary and unnecessary detention.”

Ordinance No. 4 of 16 March 1999, issued by the Ministry of Labourand Social Policy, provides for placement in social care homes by local authority officials, usually at the request of families or guardians. However, the Ordinance contains no provision for legal representation or for judicial review at the time of the initial placement. It states that placement in a home can be terminated at the request of the person concerned – if they have not been declared “incapacitated” –or of their guardian, or if their “psychological and/or physical condition are no longer appropriate for the home's designated profile”. However, no provision is made for periodic assessment or review of the placement. Even the few genuinely “voluntary” residents, who have not been placed under guardianship or who have been admitted at their own request, may have difficulty in exercising their entitlement to leave the home.

Guardians have control of the resident’s property and state disability pension. The family, a public prosecutor or any person with a legal interest may apply for a declaration of incapacitation. The Bulgarian authorities have reportedly directed social care homes to maximize their income by initiating legal proceedings to declare the incapacity of residents who do not have a guardian. However, there is no requirement that the person who is the subject of the application should be represented by a lawyer. Following the government directive, the social care home in Podgumer initiated procedures for incapacitation of the residents in their care. At 25 court hearings held at the home over three days in June and July 2001, not a single resident was represented by a lawyer. Most hearings lasted between 10 and 15 minutes, some for an even shorter time if the resident was unable to speak. Although the Family Law Act prohibits the appointment as guardian of a person “who might have a conflict of interest with the interest of the ward” (Article 116), this is not interpreted to include staff at the social care home. There is no legal requirement for any review of the status of incapacitation.

These procedures do not comply with international human rights standards. A number of residents complained to Amnesty International representatives that their relatives had abused the incapacitation procedure to take control of their property and assets. Subsequently placed in a social care home, they found it impossible to approach a lawyer or prosecutor to obtain a review of their status.

Supervision by state authorities

Supervision of social care homes is the responsibility of the District Service for Social Assistance. Other bodies with powers of inspection include those responsible for hygiene and disease prevention and fire prevention. Implementation of their recommendations is dependant on available resources.

The National Service for Social Assistance, which is established within the Ministry of Labour and Social Policy, approves the opening and closing down of social care homes and issues guidelines and minimum standards for their operation. Its inspectorate officials had not been to any of the homes visited by Amnesty International. Medical services in social care homes are not subject to any specific regulations or inspections. In the home in Cherni Vrh, reports of visits by the supervisory authorities in 2000 and 2001 made no comment on the home’s seclusion and restraint practices.

Amnesty International’s recommendations

Amnesty International urges the Bulgarian government to carry out the following measures to end violations of the rights of people with mental disabilities, to safeguard those rights and to prevent future abuses.

• The government should publicly acknowledge that the treatment and care of people with mental disabilities has been inadequate and state its intention to reform the mental health care system and to combat discrimination against people with mental disabilities. Public awareness programs should stress that people with mental disabilities have the same human rights as everyone else;

• Social care homes for people with mental disabilities should be included in planned reforms of the mental health care services. All reforms must meet international professional and human rights standards;

• Standards should be established for the living conditions, treatment and care of patients receiving compulsory psychiatric treatment and of residents of social care homes with mental disabilities. These standards should accord with international human rights standards. An independent monitoring body should be established to maintain an oversight of conditions, treatment and care; to monitor the statutory supervision of psychiatric hospitals and care homes by the authorities; to visit homes unannounced; to examine complaints; and to make recommendations, including for referral to the prosecuting authorities;

• The restraint and seclusion of patients in psychiatric hospitals and of residents in social care homes should be prescribed or authorized only by a doctor, recorded and supervised by medical staff and strictly restricted in duration, in accordance with international human rights standards. Instructions should be provided on the use and recording of restraint and seclusion.

Psychiatric hospitals

• Compulsory treatment should not be considered except to prevent immediate and present danger to the health or safety of the patient or others. All patients subject to compulsory treatment should have the right to seek a second professional opinion and should have their cases thoroughly and promptly reviewed by a judicial authority. Anyone found to be unlawfully detained should be released and should have an enforceable right to compensation;

• Electroconvulsive therapy should be administered only in its modified form, in a way that meets international standards for best practice and is not degrading for patients and medical staff;

• Patients placed for compulsory hospital treatment should be medically examined on admission, and any claims of police ill-treatment or observed injuries reported to the public prosecutor.

Social care homes for children

• Every child with developmental disorders should receive, as a matter of urgency, active and appropriate treatment based on individualized assessment by specialists of their developmental needs;

• Placement in social care homes should be based on a professional assessment of the child’s impairments and support needs. This assessment should be regularly monitored and reviewed by specialists;

• Sufficient resources should be allocated to bring living conditions for children in social care homes in line with international human rights standards;

• Links between children in social care homes and their families and the community should be encouraged and facilitated;

• Medical care should conform to international human rights standards, and there should be monitoring and regular assessment by medical specialists.

Social care homes for adults

• All psychiatric diagnoses and placements of residents in social care homes should be reviewed to ensure that their rights to due process and freedom from arbitrary detention have not been violated. Residents should regularly be attended by, and have easy access to, a psychiatrist. The Ministry of Health should be made responsible for the supervision of medical services in social care homes, and should ensure safeguards against abuse of medication and the informed consent of residents to medication;

• Living conditions that amount to cruel, inhuman and degrading treatment should be improved as a matter of urgency in accordance with international human rights standards, notably in the maintenance and heating of buildings and the provision of adequate food, clothing, bedding and sanitary facilities;

• Active therapy and recreational activities should be organized, and materials provided such as writing materials, books, newspapers and games;

• The authorities should instruct all staff to respect the rights of residents and should make clear that physical or psychological ill-treatment of residents will not be tolerated. Staff should receive specialized training to work in social care homes and qualified health care staff should closely supervise non-medical staff;

• Social care home should have adequate numbers of appropriately trained medical and non-medical personnel;

• Residents should have a full medical examination on admission. Their medical records should contain a record of diagnoses, of their ongoing state of health and treatment, and of any injuries. Any findings suggesting assault or ill-treatment should be reported to the investigative authorities;

• The deaths of residents should be recorded and monitored by the national authorities. Thorough and impartial investigations, including by post-mortem examination, should be conducted into all such deaths and the results made public. The deaths of residents described in this report should be investigated with a view to bringing to justice anyone found to have committed a criminal offence;

• The Family Law Act and Civil Procedure Act should be revised to ensure that in incapacitation and guardianship proceedings, the interests and rights of the person concerned are safeguarded. Legal representation of the person concerned and periodic judicial review should be mandatory.