Ombudsman Annual Report 2018-2019

34 Ombudsman Sixth Annual Report 2018 - 2019 0U )·V PHGLFDO UHFRUGV VKRZHG WKDW RQ -DQXDU\ KH ZDV DGPLWWHG WR WKH HPHUJHQF\ ZDUG DW WKH 6DOPDQL\D 0HGLFDO &RPSOH[ VXIIHULQJ IURP FKHVW SDLQ +H UHPDLQHG LQ KRVSLWDO XQWLO -DQXDU\ 2Q -DQXDU\ WKH GDWH RI KLV GHDWK 0U ) FROODSVHG unconscious in his cell and was transferred immediately WR WKH 5HKDELOLWDWLRQ &HQWUH·V FOLQLF $W WKH FOLQLF LW ZDV found that he had no pulse and was not breathing. (IIRUWV WR UHVXVFLWDWH KLP ZHUH PDGH IRU PLQXWHV EXW were unsuccessful. ,QYHVWLJDWRUV DOVR H[DPLQHG 0U )·V PHGLFDWLRQ prescription record and found that he had been SUHVFULEHG ;DQD[ D EHQ]RGLD]HSLQH PHGLFDWLRQ XVHG WR WUHDW DQ[LHW\ DQG SDQLF GLVRUGHUV VLQFH DQG that the prescription was renewed by his doctor every GD\V 0HGLFDO UHFRUGV DOVR VKRZHG WKDW 0U ) ZDV XQGHU WKH care of a psychologist at the department of health and social affairs at the Ministry of Interior. An investigator LQWHUYLHZHG WKH SV\FKRORJLVW ZKR VWDWHG WKDW 0U ) was suffering from psychological and neurological disorders resulting from his use of heroin before his admission to the Reform and Rehabilitation Centre. +H ZDV SUHVFULEHG ;DQD[ IROORZLQJ KLV ÀUVW YLVLW WR D SV\FKRORJLVW RQ 0D\ DQG FRQWLQXHG WR WDNH WKH medication until his death. The medication was renewed on 19 December 2018 and was due to be reviewed again on 1 March 2019. The psychologist added that 0U ) ZDV QRW SHUPLWWHG WR KROG KLV RZQ PHGLFDWLRQ DV it was administered daily by a nurse. Investigators examined CCTV footage from the time RI 0U ) ORVW FRQVFLRXVQHVV 7KH IRRWDJH VKRZHG WKDW SROLFH PHPEHUV WUDQVIHUUHG 0U ) WR WKH FOLQLF LPPHGLDWHO\ IROORZLQJ KLV FROODSVH EXW WKDW PHGLFDO VWDII GLG QRW DV SUHYLRXVO\ UHFRPPHQGHG E\ WKH 2PEXGVPDQ DWWHQG DW WKH VFHQH 7KH 2PEXGVPDQ·V RIÀFH KDV FRQWDFWHG WKH 3XEOLF Prosecution to request its investigations into the FLUFXPVWDQFHV RI 0U )·V GHDWK DQG WKH UHODWHG IRUHQVLF reports. Ombudsman investigation into the full circumstances of WKH GHDWK RI 0U ) LV RQJRLQJ Death in Detention Investigation 7 Name Mr. G Age 34 Cause of Death Under Investigation Date 7 March 2019 Location Psychiatric Hospital 2Q 0DUFK WKH -DX 5HIRUP DQG 5HKDELOLWDWLRQ &HQWUH QRWLÀHG WKH 2PEXGVPDQ 2IÀFH RI WKH GHDWK E\ suicide of Mr. G at the Psychiatric Hospital. Mr. G had EHHQ WUDQVIHUUHG WR WKH KRVSLWDO RQ )HEUXDU\ 7KH 2PEXGVPDQ 2IÀFH LPPHGLDWHO\ RSHQHG DQ investigation and secured all of the Rehabilitation &HQWUH PHGLFDO UHFRUGV UHODWLQJ WR 0U * LQFOXGLQJ family visit and telephone records. Inmate witness interviews were carried out. Ombudsman investigators carried out an initial review of the medical records of Mr. G. from the date of his admission to the Reform and Rehabilitation Centre until his death. It was noted that Mr. G was suffering from a personality disorder and adjustment disorder and had been visiting the Psychiatry Clinic since 24 December ,W ZDV QRWHG DOVR WKDW RQ WKH UHFRPPHQGDWLRQ RI WKH PHGLFDO WULEXQDO DW WKH 0LQLVWU\ RI +HDOWK 0U * had been admitted to the Psychiatric Hospital on 18 2FWREHU ZKHUH KH UHPDLQHG XQWLO 1RYHPEHU 2018. After a brief period back at the Jau Rehabilitation &HQWUH KH ZDV WKHQ DJDLQ DGPLWWHG WR KRVSLWDO RQ )HEUXDU\ Ombudsman investigators met with inmates who had shared a cell with Mr. G in the Rehabilitation Centre. The inmates said that there was nothing unusual about 0U * ·V GD\ WR GD\ LQWHUDFWLRQV ZLWK WKHP EXW WKDW KH was constantly contacting his family and they were aware that he was attending the psychiatry clinic. 7KH LQYHVWLJDWRUV DOVR PHW ZLWK WKH VHFXULW\ RIÀFHU LQ charge of guarding inmate patients in the psychiatric KRVSLWDO 7KH RIÀFHU VWDWHG WKDW RQ 0DUFK KH was carrying out an inspection of the secure wing at WKH SV\FKLDWULF KRVSLWDO ZKHQ KH QRWLFHG WKH DEVHQFH RI 0U * :KHQ 0U * ZDV VWLOO DEVHQW PLQXWHV ODWHU WKH RIÀFHU VDLG WKDW KH ZHQW WR WKH ZLQJ·V WRLOHW DUHD DQG VWDUWHG FDOOLQJ RXW 0U *·V QDPH DQG NQRFNLQJ RQ WKH