1.3 Obiski psihiatričnih bolnišnic 1.3 Visits to psychiatric hospitals Ob pregledu evidenc in medicinske dokumentacije smo pri uvedbi posameznega PVU v vseh obiskanih bolnišnicah pogrešali opis tega, kateri milejši ukrepi so bili izvedeni pred uvedbo PVU. Na to je posebej opozoril tudi izvedenec, ki je sodeloval ob teh obiskih, pa tudi CPT ob svojem obisku Oddelka za psihiatrijo leta 2012. CPT je poudaril, da je pomembno, da pred uporabo takega ukrepa poskuša uporabiti vse druge ustrezne ukrepe, kakor to določa zakon. Obiskanim bolnišnicam smo predlagali, da zdravnike, ki odrejajo PVU, posebej opozori, da je PVU skrajni ukrep in da mora biti iz medicinske dokumentacije vedno razvidno, če so bili pred uvedbo PVU izvedeni milejši ukrepi in kateri točno. Ob tem smo predlagali, da se zdravnike znova opozori tudi na roke, ki jih tako glede trajanja ukrepa kot tudi glede obveščanja posameznih oseb določa ZDZdr. Predlagali smo tudi, da bolnišnice prilagodijo obrazce o izvajanju PVU z rubriko o izvedenih ukrepih pred uvedbo PVU (npr. pogovor, tehnike deeskalacije, dodatna medikamentozna terapija itd.). V primeru ene bolnišnice (PB Ormož) smo ugotovili, da Oddelek za psihogeriatrijo (še vedno) pojmujejo za odprtega, ker se ne zaklepajo vhodna oziroma izhodna vrata. Pojasnili pa so nam, da tamkajšnje paciente ustavijo in napotijo nazaj vanj, ko ga želijo zapustiti. Varuh oziroma DPM ugotavlja, da so v praksi očitno različni načini, ki jih bolnišnice uporabijo z namenom preprečitve izhoda z oddelka, s čimer se posamezniku omeji svoboda gibanja oziroma prostost. Ko osebe z demenco zaradi svojega bolezenskega stanja ne morejo razumeti in s tem premagati določene ovire, je to lahko ravno tako učinkovit način varovanja kot samo zaklepanje vrat. Ni namreč nujno, da bi nekomu zgolj tehnična sredstva morda preprečevala odhod iz zavoda (klasična ali elektronska ključavnica, različne oblike odpiral, ki dementnim osebam onemogočajo ali močno otežijo izhod z oddelka). Tudi ko zaposleni stanovalca, ki ga po prehodu zanke prestrežejo, praviloma vedno vrnejo na oddelek, lahko po stališču Varuha oziroma DPM govorimo o omejevanju svobode gibanja, ki je ne glede na opredelitev ali siceršnji značaj oddelka, na katerem je pacient nameščen, v enakem položaju kot če bi bil zadržan na oddelku pod posebnim nadzorom. V teh primerih gre očitno za »de facto« odvzem prostosti. 84 When reviewing records and medical documentation on the use of individual special protection measures in all visited hospitals, we could not find the description of which more lenient measures had been implemented before the use of individual special protection measures. This was particularly pointed out by the expert participating in the visit and also the CPT during its visit to the Department of Psychiatry in 2012. The CPT emphasised that it was important that other suitable measures as determined by the Act be implemented before the use of special protection measures. We proposed to the hospitals that physicians ordering special protection measures be informed that these measures were the last measures to be used and that medical documentation must always show that other more lenient measures had been implemented before the introduction of special protection measures and precisely which measures had been taken. We further suggested that physicians be warned about the deadlines stipulated by the ZDZdr relating to the duration of the measure and relating to informing individual persons. We also proposed that hospitals add an additional section to the form on the implementation of measures executed before the use of special protection measures (e.g. discussion, de-escalation techniques, additional medicament therapy etc.). In the case of one hospital (Ormož), it was established that the Department of Psychogeriatrics was (still) considered open because the entry or exit doors were not locked. Nevertheless, they explained that patients are stopped and directed back to the department if they want to leave. The Ombudsman or the NPM established that in practice different methods were used by hospitals in order to prevent patients exiting the ward, whereby individuals’ movement or liberty was limited. When persons with dementia cannot understand and thus overcome a certain barrier due to their medical condition, this may be an equally efficient manner of security as locking the door. Mere technical equipment may not be the only means of preventing someone from leaving the institution (classic or electronic lock, different forms of door openers which prevent or aggravate the exit from the ward for the persons with dementia). When staff intercept patients and direct them back to the ward, this may, according to the Ombudsman or the NPM, be considered a restriction of freedom of movement which, as per the present character of the ward where the patient is accommodated, is the same as if the patient were on the secure ward. These cases are obvious “de facto” deprivations of liberty. Najpomembnejše ugotovitve in predlogi DPM The most important findings and proposals of the NPM Prekoračitev kapacitet oddelka pod povečanim nadzorom zmanjšuje kakovost bivanja za vse paciente in pomeni povečano obremenitev osebja. Zato predlagamo, da bolnišnice v primeru, ko bi bilo treba zaradi novih namestitev namestiti začasno posteljo, rešitev iščejo predvsem v namestitvi pacienta na drug oddelek ali v drugo (čim bližjo) bolnišnico. V začasne postelje naj pacienta namestijo torej zgolj takrat, ko je oddelek povsem poln in so druge možnosti namestitve oziroma premestitve pacienta izčrpane. Exceeding the capacities of a secure ward reduces the quality of life of all patients and increases the burden on the staff. We thus propose that hospitals, when a new provisional bed is needed due to additional accommodation, seek the solution in accommodating the patient in another ward or another (nearby) hospital. Provisional beds should only be provided when a ward is completely full and other possibilities for accommodating or relocating patients have been exhausted. Ob tem z zadovoljstvom ugotavljamo, da je odprtje novega dela Enote za forenzično psihiatrijo, do katerega je prišlo kmalu po obisku DPM, vsaj začasno odpravilo hudo prostorsko stisko, ki je zaradi specifike te enote ni možno reševati s premeščanjem. We are pleased that the new Unit for Forensic Psychiatry was opened soon after the NPM visit, thus eliminating severe overcrowding at least temporarily, which due to the specifics of the unit cannot be resolved by relocation. PB Begunje je glede izpostavljene problematike v odzivu na predhodno poročilo med drugim navedla, da tudi sama obžaluje občasno prekoračitev kapacitet, toda včasih zaradi omejenih kapacitet PB Begunje, do katerih pride zaradi velikega števila akutno poslabšanih pacientov, takšnih pacientov, ki potrebujejo nadzor, ni možno namestiti na odprtih oddelkih. V takšnem primeru se v skupnem dnevnem prostoru namestita do dve zasilni postelji, sama postelja pa ustreza postelji v sobi. Bolnišnica tudi poudarja, da mora na oddelku pod posebnim nadzorom vendarle obstajati nadzor nad zagotavljanjem varnosti. Čim večja je stopnja nadzora nad varnostjo pacientov, tem manjša je stopnja zasebnosti. Regarding this issue, Begunje Psychiatric Hospital stated in its reply to the preliminary report that it regretted the occasional exceeding of capacities, but due to the limited capacities of the hospital, which is overburdened with a large number of patients with acutely deteriorating conditions, patients who require supervision could not be placed in open wards. In such cases, two provisional beds are installed in the common living area which are the same as the beds in rooms. The hospital also highlighted that safety must be ensured on secure wards. The greater the level of supervision of the safety of patients, the lower the level of privacy. poročilo o izvajanju nalog DPM v letu 2014 DržavnI preventivnI mehanizEm po Opcijskem protokolu h Konvenciji OZN proti mučenju in drugim krutim, nečloveškim ali poniževalnim kaznim ali ravnanju IMPLEMENTATION OF THE DUTIES AND POWERS OF THE NPM IN 2014 National Preventive Mechanism under the Optional Protocol to the UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment 85