Inmate’s cell proved to be an execution chamber – magistrate

Magistrate Donatella M Frendo Dimech in a sentence handed down Monday said that a patient at the forensic unit of Mount Carmel Hospital who needed a safe and secure environment and constant watch was not well cared for. The patient’s cell turned out to be his “death chamber”.

The patient, concluded the Court, committed suicide in January 2016 due to the ‘carelessness and unskilfullness” of a nurse and the shortcomings of others in the way patients were watched over.

The Court fined the nurse Yulia Toteva the sum of €5,000. But the Court added that the nurse “should not be the only one to carry the brunt of responsibility” for the demise of the patient. In the opinion of the Court “others were negligent thereby failing the inmate and ultimately the system itself.”

The patient was suicidal and for this reason had to be placed under constant surveillance and watched for 24 hours on CCTV. However the camera did not cover the whole cell and the monitor was blurred.

Although Toteva was responsible to monitor the patient it was another nurse who noticed that the patient had committed suicide. Another nurse had checked on him and did not even notice that he was dead.

Rope hidden in cell

The Court noticed that somehow the patient was allowed to get hold of and hide in his room a piece of rope. The Court described this as “appalling and disgraceful, revealing lack of expertise of those called to safeguard the inmates’ well-being; undermining all efforts by the authorities.”

In its sentence the Court noted that the guards searching the cell did not find the rope as they “were oblivious to the fact that the mattress contained four cavities at each of its corners thus rendering futile any search conducted in his cell.”

High risk patients should never be provided with mattresses of this type, noted the Magistrate.

In the opinion of the Court, however, such shortcomings by others did not totally absolve the nurse from her responsibility as she “should never have allowed the patient to stay out of sight and if he had done so, she was duty-bound to exercise a much greater supervision over him; her duty was precisely that of ensuring that for the while he was out of sight, he was at all times kept away from harm’s way, if necessary engaging in conversation with him to allay any cause for concern.”