The staffing capacity of the psychiatry department of the Nikšić General Hospital has not been strengthened, even after several recommendations from the Ombudsman and a suicide case within the institution, and only two psychiatrists continue to work with patients. The institution is short of five psychiatric specialists, six nurses/technicians, and the department does not have a single psychologist, although the systematization provides for two.
This follows from the report of the National Preventive Mechanism (NPM) team, which operates within the institution of the Protector of Human Rights and Freedoms.
Limited access to mental health care
During a regular, unannounced visit to the Niksic hospital, there were ten patients in the psychiatry department, while this department had 223 hospital admissions and 213 discharges from the beginning of the year until October 15th.
"The NPM team was informed that outpatient examinations are not available through the electronic appointment system, i.e. they cannot be scheduled through the program. Despite this, doctors accept patients for examination if they personally report and come to the department. Compared to the previous period, when a significantly larger number of outpatient examinations were carried out, they are now performed exclusively in accordance with the possibilities and available staff, which further limits access to healthcare in the field of mental health," the Ombudsman noted in the report.
They argue that the fact that the NPM recorded a total of 1.263 outpatient examinations in June 2023 clearly indicates the exceptional importance of this service for the population that gravitates to the Nikšić General Hospital. They state that the number of outpatient services testifies to the high level of need for psychiatric health care outside of hospital treatment, as well as the role of outpatient examinations in the early recognition, continuous monitoring and control of mental disorders.
The NPM team explains that hospitalizations decided upon by a psychiatrist are exclusively voluntary and are carried out after the patient has been informed about the therapeutic program, the method of performing the medical procedure, the advantages, risks and side effects, as well as the risks of not performing the procedure, and a written consent and statement are signed. They point out that the department also hospitalizes so-called "court" patients with a court-ordered mandatory psychiatric treatment for addiction (more often alcoholism, and less often addiction to psychoactive substances).
In circumstances where a person refuses treatment, and it is deemed necessary by a doctor, they are sent by ambulance to the Special Psychiatric Hospital in Kotor, accompanied by a nurse/technician and with the assistance of the police.
Risk of inhumane treatment
"At the time of the NPM team's visit, it was determined that the department did not have a psychologist, given that the psychologist had left the institution approximately six months ago. For this reason, psychological services, including psychological exploration, were not provided during the aforementioned period, which represents a significant limitation in the implementation of standard diagnostic procedures, especially for patients on their first hospitalization," the Ombudsman's institution concluded.
The NPM team found that the hospital rooms were clean, tidy, with sufficient natural lighting, while no patient complained about the diet, quality and quantity of meals, or the way they were served.
It was also noted that the individual treatment plan is developed by a social worker without the participation of a psychiatrist, which is not in line with standards.
The Ombudsman also states that last year, the measure of physical restriction of freedom of movement - mechanical fixation - was applied three times. By reviewing the fixation sheets, the NPM team determined that they are not kept up to date, not all necessary data is entered, and it is not possible to determine the duration of fixation based on these sheets.
"The identified shortcomings in maintaining fixation sheets represent a serious problem from the aspect of legality, professionalism and protection of patients' rights," the Ombudsman's institution stressed. The documentation indicates that there is a possibility of applying prolonged fixations without adequate supervision and control, which poses a particular risk of inhuman or degrading treatment.
The NPM team also noticed that there was no information (e.g. brochure, notice) on how a patient could contact the patient rights ombudsman and other institutions dealing with the protection of human rights.
The Protector reiterated earlier recommendations - to strengthen staff capacities in accordance with the systematization, to create brochures-informants for patients on the protection of their rights, but also to create an individual treatment and rehabilitation plan for each patient in accordance with standards.
They were additionally recommended to ensure a multidisciplinary approach to treatment and develop individual treatment plans in accordance with standards, as well as to precisely document the application of fixation measures, while strictly adhering to the principles of last resort, time limits, and constant patient monitoring.
There were no perpetrators of the suicide within the hospital grounds.
The Ombudsman found in mid-last year that the hospital had violated the right to life of a patient who committed suicide in April 2024 within the institution by not even providing him with a psychiatric examination. It was then determined that the patient's family had brought him to the hospital for two consecutive days, but that there was no psychiatrist on duty to examine him, after which he committed suicide upon leaving the institution. A court expert from Croatia, hired by the Ombudsman, found, however, that a telephone consultation with a psychiatrist could not have been a substitute for an examination. However, both the internal and external commissions of the Ministry of Health claimed that the hospital had complied with all medical criteria and the treatment algorithm, and that no one was held liable in the case.
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