Would the behavior of the authorities be different in relation to the deceased AP who was found this summer without signs of life in his apartment in Veliše Mugoše Street in Podgorica, led to such an outcome, it cannot be said with certainty, but there was a failure of the state in his adequate care.
This, among other things, is stated in the opinion of the Protector of Human Rights and Freedoms, which was submitted to "Vijesti", based on the inquiry that the editors sent to the Ombudsman on June 19, in connection with the actions of the authorities in this case. The protector then, after a journalist's inquiry, formed a case and on his own initiative started the interrogation procedure.
AP was found without signs of life in his apartment in Veliše Mugoše Street on June 19, after the neighbors called the police, as they did a few days before, stating that they had not seen the neighbor for several days and that unpleasant odors were emanating from his apartment. .
Neighbors also sent such a call on June 11, with the same allegations, but after the police officers went to the field, they received an explanation from them that they had received information from the Special Hospital "Dobrota" in Kotor that AP was staying with them.
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The neighbors then denied it, stating that they inquired at that institution and that they were told by the Kotor Hospital that the person named AP was not hospitalized.
According to what the Protector established during the investigation, AP was not in the Hospital in Dobrota at the time when the police told his neighbors the opposite, because he was discharged from the Special Hospital for Psychiatry about a month and a half earlier.
In this regard, the Protector found that two state bodies did not properly communicate data on the dismissal of AP
"...It follows from the case file that the acting officers of the OB Podgorica, when they went to the scene on June 11, did not know that the deceased XY was discharged from hospital treatment, although the Hospital informed OB Podgorica about this by phone on April 23. Furthermore, it appears from the case file that on the same day the officials of the OB Podgorica made telephone contact with the Hospital, from which they were informed that the deceased XY is receiving hospital treatment, although he was already discharged on April 23, 2024. It is clearly concluded that these two state bodies are not information about the dismissal of the deceased. XY from hospital treatment were communicated in an appropriate manner, nor did the OB Podgorica request information in this regard from the competent Center for Social Work", it is stated, among other things, in the opinion signed by the Deputy Protector Mirjana Radovic.
The fatal outcome could not have been prevented
The case of AP is specific in the actions of the Protector, because it was not possible to obtain explicit consent from a person who is considered to be injured in the sense of a victim of a violation of human rights and freedoms, in accordance with the law. Consent, as stated in the final assessment, could not be obtained from the heirs, that is, his family, because the late AP had no close relatives, nor did he address the Protector during his lifetime about the actions/inactions of the competent authorities towards him.
"However, bearing in mind the circumstances concerning the issue in question and adhering to the principles of justice and fairness, it is certain that the complaint will be examined from that aspect as well, in the way that the submitted documentation was inspected, the material of which is an integral part of the file of this case". it is stated in the opinion and adds that "on the basis of the investigation procedure conducted, the Protector could not determine all the relevant facts and circumstances necessary for giving a final assessment on whether the death of a person with a mental illness would have been deceased XY may or may not be prevented”.
"However, based on the state of the case files, the Protector has identified failures of the state (system) in his adequate care," he writes in the final evaluation.
Care during a break when going on vacation and sick leave
Namely, as it is added, several people reported the deceased AP to the Police Directorate, due to various inadequate reactions (stalking, harassment, threats, physical attacks, inappropriate statements, hate speech) and other actions towards them.
"Deceased According to all indications, and due to the nature of his illness, XY repeated violations, for which he was punished and for which a protective measure of compulsory psychiatric treatment was imposed on him - outpatient treatment. He refused to take psychiatric therapy, even though the Center for Social Work provided him with therapy, which the outpatient service could not implement due to his opposition," the opinion reads.
As further stated, after AP was hospitalized in the Special Hospital for Psychiatry in Kotor and then discharged, about which the Hospital informed the Center for Social Work in a letter dated April 24, 4, the case manager contacted by phone him, when he, among other things, stated that he was fine.
The head of the case, it is added, used annual vacation in May and June 2024 and was temporarily prevented from working (on sick leave), and during that time, it is stated in the final evaluation, no one replaced her, "because the Center does not practice redistributing cases during the case manager's absence".
In June, on the eleventh, then on the 19th, the neighbors of the now-deceased AP called the police, alleging that unpleasant odors could be felt and spread from his apartment, as well as that they had not seen him recently. During the second intervention, officers of the AP Podgorica police found no signs of life in his apartment.
In relation to the Podgorica Center for Social Work, the Protector states that, until the deceased was placed in the Special Hospital for Psychiatry, he had a proactive approach. However, as they add, "it follows from the case file that the deceased XY was not the subject of the Center's actions in the period after his discharge from the Hospital on April 23, until the discovery of his lifeless body on June 19, 2024."
"In this regard, the Protector cannot accept the part of the statement of the acting Center in which it is stated that the head of the case used annual vacation in May and June and was excused from work (used sick leave), and that the Center does not practice redistributing cases during the absence of the head case, and that during that period the Center for Social Work had neither written nor oral reports from the tenants, nor from the competent services when it comes to user XY", it is written in the concluding rate.
The Protector therefore points out "that it is unacceptable that the continuity of service provision, that is, the timely and adequate action of state bodies in a broader sense, depends on personnel solutions, that is, the internal organization of work."
"On the contrary, the state authorities, in this specific case the Center, were obliged to act in accordance with the principle of respecting the best interests of the users in exercising their rights from social and child protection, precisely bearing in mind the previous findings (hygienic neglected apartment, etc.) that indicated to the reduced capacities of the deceased. XY for independent living", he writes in the final assessment.
The system does not recognize supervised medication in home conditions
The protector points out in his opinion that the laws cannot always treat all types of needs, and that "the system should respond and regularly undertake all available measures and activities in order to provide appropriate social, health and other necessary protection to persons with mental illness in a timely manner".
"First of all, the proper realization of the rights of these persons who need this protection, and ultimately the health of these persons, depends on timely action according to clear and pre-established procedures...", the opinion reads.
In relation to the case of AP, the Protector notes that, despite the fact that the Court for Misdemeanors in Podgorica has repeatedly issued a protective measure of mandatory psychiatric treatment at liberty - outpatient treatment, there was no supervised medication, taking the prescribed therapy.
"Which, judging by the specific circumstances of the case, was probably one of the key, if not the key factor in the inappropriate behavior of the deceased. XY to the environment. The Protector warns once again that our system does not recognize the importance and necessity of monitoring the treatment of patients with mental disorders at home. It is also not planned to visit a psychiatrist and monitor the patient at home," they state in the opinion, along with recommendations to the departments of health and social care, family care and demography, and the recommendations were also addressed to the Podgorica Center for Social Work.
To the Ministry of Health, of which he is the head Vojislav Šimun and the Ministry of Social Welfare, which he leads Damir Gutic, the same recommendations were sent, among other things, to strengthen the capacities of local mental health centers, to expand the services of mental health centers in the community from outpatient treatment to field work, and to, in cooperation with the Police Department, develop a protocol that would precisely define the role, procedures and cooperation of acting officials, including employees in mental health centers, centers for social work and police officers with the aim of a timely, synchronized and multisectoral approach in working with mentally ill persons.
The Podgorica Center for Social Work was recommended to internally organize its work in such a way as to ensure the continuous handling of the Center in cases of vacation, i.e. temporary incapacity for the work of an individual case manager.
Hospitals only if necessary, good services in the community are necessary
In his opinion, the protector reminds of an earlier incident, from December 2016, when the expert they engaged in the finding stated that "modern aspirations of psychiatry in the world ... are based on the so-called 'community psychiatrists'.
"Which implies the shortest possible stay of the patient in the institution (only in the worsening phase - when it is really necessary) and the fastest possible return to the community," the document says.
As an example, the Italian model is cited, where for years there have been no asylum-type psychiatric hospitals (such as the Special Hospital for Psychiatry in Dobrota), but there are well-developed services in the community, which, as they add, continuously monitor the functioning and behavior of patients in an extra-institutional environment.
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