No one is to blame for patient's suicide at hospital: Prosecutor's Office on suicide case in Nikšić healthcare facility

The Higher State Prosecutor's Office in Podgorica has determined that there are no grounds to initiate criminal proceedings against anyone from the Nikšić hospital in the case of a patient's suicide within the premises of that health institution, of which they have also informed his family.

The investigation was launched in June last year after "Vijesti" reported that a patient, after seeking help from a psychiatrist for two days in a row, committed suicide with a firearm on the ramp of the Nikšić hospital.

"The Higher State Prosecutor's Office in Podgorica, in a case formed in connection with the events of 28. 4. 2024, in which a person PR from Nikšić was found lifeless in front of the General Hospital in Nikšić, after an autopsy, collected information and other evidence, assessed that there were no grounds for criminal prosecution against any person for any criminal offense for which prosecution is undertaken ex officio, of which the family was informed...", the response reads.

Last month, the Protector of Human Rights and Freedoms, following an extensive procedure following a complaint from the mother and brother of a deceased patient, determined that the hospital had violated the patient's right to life. RP because she didn't even provide him with a psychiatrist's examination.

The General Hospital in Nikšić, the Ombudsman concluded, should have known that there was an immediate danger to the patient's life and did not use the possibility of forced hospitalization. A telephone consultation with a psychiatrist, on the basis of which therapy was included, could not be a substitute for a clinical examination by a specialist, which was not provided because the institution did not provide either an on-call or standby psychiatrist for two days.

The family of the deceased patient believes that the suicide could have been prevented the day before, when they brought him to the hospital, if a psychiatrist had been present at the examination. In their complaint to the Ombudsman, they stated that they insisted that their family member be hospitalized, and that the psychiatrist would have certainly kept him in the hospital if he had spoken to him directly.

A court expert from Croatia, consulted by the Ombudsman, stated that the day before the suicide, the internist doctor consulted the psychiatry specialist doctor as much as possible during the patient's examination, but that "the latter did not have the additional knowledge and skills to assess the severity of the patient's mental condition, nor to assess which procedure would be appropriate in the interest of protecting the patient's health, but also the protection of his environment."

She also stated that the doctor did not see the patient, did not interview him, or examine him, in order to be able to make the best decision and recommendation in the interest of the patient's health.

The then hospital administration informed the Ministry of Health about the suicide case about twenty days later, raising the problem of the organization of the psychiatric service. However, both the internal and external control of the Ministry determined that the hospital complied with all medical criteria and the treatment algorithm. The Protector assessed that both commissions had omitted important facts in their reports and made several recommendations to the Nikšić hospital and the Ministry of Health, and sent the opinion to the Supreme State Prosecutor's Office for review.

The Protector noted that these commissions “displayed a dominantly formal approach, which is reflected in the fact that an assessment of whether the General Hospital had taken everything reasonably necessary to prevent the fatal outcome was completely omitted, especially when it is known that this was a former psychiatric patient who had already been hospitalized, and all this despite the fact that the European Court has established that the state can be held liable not only for direct failures, but also for systemic and organizational deficiencies that lead to the absence of effective and accessible protection.”

The Ombudsman notes that the internal Commission for Quality Control of Professional Work, which concluded that the patient was treated in accordance with medical protocols, is neither independent nor impartial, because it was formed by a body that is solely responsible for the organization of work and the system of on-call and standby duty, and was composed of employees of that body.

He claims that even the Ministry of Health's commission for an extraordinary external review of the quality of professional work, which stated that "all medical criteria, i.e. the algorithm for treating the underlying disease, were respected", did not sufficiently consider systemic circumstances and organizational failures, focusing on the circumstances of treatment (prescribed therapy), and not on the availability and quality of service at the moment the patient was brought to the hospital.

According to the case files, the Commission did not interview family members, and explicitly conflicting claims regarding the symptoms the patient was experiencing upon arrival at the hospital were not objectively and fully investigated.

The Protector notes that both committees omitted facts that, in their opinion, should be taken into consideration, including that neither an on-call nor a standby psychiatrist was provided at the hospital throughout the weekend, and that the patient was not examined by a psychiatrist on either 27 or 28 April 2024, although he was given psychiatric therapy injections. The committees did not substantially address the telephone consultation with a psychiatrist, which is not, and cannot be, a substitute for a clinical examination.

"Since the submitted statement did not provide an explanation as to whether the risk of suicide was the subject of a medical assessment, it is not clear on what basis the submitted statement further states that neither the doctor on duty nor the psychiatrist, in this specific situation, had the right to involuntary hospitalization," states the recently published opinion of the Ombudsman, who assessed that the General Hospital in Nikšić violated the right to life of RP.

The Ombudsman recommended that the Ministry of Health conduct an urgent review of the network of health institutions and establish a continuous and adequate priority measure for the protection of the mental health of citizens, in accordance with the Law on Health Care, but also adopt national guidelines on dealing with psychiatric crisis situations, which will oblige institutions to react immediately and professionally.

It is necessary to introduce continuous and systematic professional training for medical staff on the topic of suicidal risk assessment and crisis intervention.

The Ombudsman also recommended that the Ministry review the opinion of the Commission for Extraordinary External Review of the Quality of Professional Work at the Nikšić General Hospital, taking into account the findings of an independent expert hired by the Ombudsman.

The hospital was reiterated its earlier recommendation to strengthen the staffing capacity of the Department of Psychiatry, in accordance with the Systematization Act.