Kristi Rekand

Torture and other inhuman or degrading treatment is prohibited by § 18 of the Constitution of the Republic of Estonia. This prohibition is also supported by the European Convention for the Protection of Human Rights and Fundamental Freedoms[1] and the UN Convention against Torture[2]. All persons are protected against torture and other similar treatment, including those who are imprisoned, people with mental disability and patients.[3] This prohibition, therefore, includes degrading detention and living conditions.[4]

Torture is a form of abuse – the severest form of abuse. Other forms of abuse include cruel, inhuman or degrading treatment or punishment. The definition of “torture” consists of the following three elements: inflicting physical or psychological distress or suffering; intention and a specific purpose; the offender’s connection with public authority.[5] The abuse may not always reach the severity of torture or manifest itself solely in beating or inflicting pain on a person by a representative of public authority. The heads of closed institutions allowing violence between the persons detained there, unjustified round the clock video surveillance, inhuman living conditions etc may also be considered abuse.[6]

Perhaps the most attention in association with abuse in 2011 was paid to the conditions in nursing hospitals. In 2011 there were also significant changes in legislation regarding nursing homes[7] – the new wording of the Social Welfare Act was adopted.

Political, institutional and legislative developments

The amendment of the Social Welfare Act brought on several changes for general care homes and special care homes alike (the general care homes are for the elderly and for people with disabilities to live in, they receive care but no health services there; special care homes are for people with psychological special needs to live in, they receive care and rehabilitation there). The Social Welfare Act prescribes different requirements and obligations on the general and special care homes according to their differences.[8] To a larger extent the amendments to the Social Welfare Act had to do with the right to liberty (see the chapter on right to liberty). The new wording of the Social Welfare Act changes the principle of providing special welfare services to be on a more necessity basis, so that people may receive the service they need regardless of the severity of their disability or the percentage of loss of their incapacity for work.[9] It also sets higher educational requirements for the activity instructors, which supposedly helps to increase the quality of the special welfare service.[10] The wording of the Social Welfare Act that came into force in April of 2011 adopts the data register of social services and benefits (STAR) and dissolves the national social register (SIS). STAR is supposedly better able to apply a personal approach to assisting a person in welfare services.[11] The new register needs breaking in and it is therefore too early to appraise its functionality.

Noteworthy public discussions

In spring of 2011 the television program “Pealtnägija” raised the issue of quality of welfare services provided in Keila nursing hospital, which turned into a public debate.
The relatives of a patient accused the hospital’s staff of negligence.[12] After the story was published several patients in nursing hospitals across Estonia submitted complaints and claims regarding various problems in nursing hospitals. These complaints were gathered into a summary report by the Estonian Patient Advocacy Association in the spring of 2011 which demonstrates the following general problems with welfare services:[13]

  • Patients or their relatives are not given information about the treatment, care or the prognosis. The requests for this information are ignored and the patient and his or her relatives are left uninformed.
  • Patients and their relatives are treated without dignity, in a demeaning manner, at times crudely. The service providers cause the patients intense suffering with the following activities: the patients are not given the required care (causing bedsores), the bedridden patients are not fed, given drink or given help if they need it to go to the toilet, the patients are neglected and treated in a demeaning manner, the so-called problem patients are restrained illegally, patients are left without care for a long time, patients are left alone for long periods of time without checking up on their condition often enough, their pains are not relieved, medications or technical aids are not provided, the rooms’ conditions are neglected (temperature), patients are restrained physically and given sedatives without informing them of it, patients and their relatives are verbally abused by the staff, the patients are not provided so-called by-services (grooming, exercising, going outdoors etc).
  • Service providers try to knowingly induce patients’ death by overdosing them on sedatives or by not giving them the necessary medications, by knowingly letting them catch a cold etc.
  • The relatives of patients are pressured into paying bribes for continuation of the service or for a better service.
  • The patients’ possessions are not attended to, personal belongings are being stolen.
  • Complaints of patients and their relatives about the services provided are not taken seriously. Sometimes the nursing hospitals admit that the quality of the service is poor and claim that this is the way it should be.

The head of the Estonian Patient Advocacy Association explained that the summary report was essentially a patients’ version that hadn’t gone through official investigation, but since there were so many complaints (50 complaints from 16 different welfare institutions) and they were relatively similar, some conclusions can still be made.[14] On May 11th a member of the Social Affairs Committee of Riigikogu asked the Prime Minister a question about welfare services and hospitals.[15] Prime Minister Andrus Ansip replied that making conclusions based on one case is wrong, as just one specific case had been made public. The Prime Minister also said that in his appraisal the system for processing complaints in Estonia is not faulty. The North Estonia Medical Centre (PERH) instigated internal investigation in the spring to find out whether the case described in ETV’s program “Pealtnägija” contained mistakes in welfare service and whether there had been instances of negligence towards patients. On May 17th PERH provided an overview of the events at Keila hospital, which conceded that “according to the commission that appraised the work of the welfare and after care clinic the main problems that need solving are the shortcomings in the arrangement of work, management mistakes, the unorganised exchange of information with the relatives, the stress of the staff and the lack of staff, but also lack of feedback from patients and their relatives, more precisely fear of giving feedback. As it is, the hospital does not receive much feedback from patients or their relatives. Any feedback is essential to the hospital to improve their processes. I emphasise that we want a dialogue between the patients and their relatives as well as representative organs of the patients.”[16] The members of the Social Affairs Committee of Riigikogu submitted an interpellation to the Minister of Social Affairs on May 30th.[17] The Minister of Social Affairs’ reply revealed that there are plans to specify the regulation of welfare services and that among other things there are intentions to establish requirements for the service providers. The requirements to equipment and the interiors of hospitals need to be supplemented and the number of staff has to be increased depending on the number of beds in the establishment. The preparations to the health services draft act are being made, which regulates providing nursing care in general care homes in a more flexible manner, thereby improving the availability and expected quality of nursing care.[18] The Estonian Patient Advocacy Association submitted an official inquiry to Riigikogu on October 5th, which demanded essential and specific decisions in regard to improving the quality of health and social services and objective assessment.[19] Specific propositions included a recommendation on changing the model for funding health care, establishing efficient and independent supervision as well as a procedure for complaints, creating a Patient Act and creating new and efficient quality systems.

Good Practices

The Ministry of Social Affairs has in previous years compiled an “Estonian nursing care network development plan 2004–2015” [20] and a “Handbook for caring carers”[21].
Both of these documents are a very good example and guideline to how the target group could and should be approached and how to improve the situation. The promotion of an approach that focuses on the person rather than the service is remarkable. As a positive example the carers’ handbook emphasises orientation on a scheme that focuses on the personality of the elderly and on providing services in an integrated manner. The various methods and administrative models of nursing care as well as health sectors are not posed as opposing, but they form a base for providing various services (personal assistance) as an integrated system, which guarantees specific persons the selection of services and personal assistance that best suits his or her condition and coping abilities. After the problems that had arisen in public the Ministry of Social Affairs gave the Health Board the order to check on organisation of nursing care hospitals. As of writing of this chapter the results of the analysis have not yet been published, which means we can only rely on the article published in the press.[22] The article states that 50% of service providers have received a notice regarding partial deficiencies in the services provided. The deficiencies are identified as tying up of patients, absence of a system for summoning nurses, over crowdedness of wards, disregard for hygiene requirements etc. The analysis also states that small nursing care hospitals are incapable of offering a quality service due to being insufficiently funded. The article also provides the appraisal of the representative of the Ministry of Social Affairs, which states that the Ministry of Social Affairs acknowledges the shortcomings that were pointed out in the analysis of the Health Board, but nevertheless takes them lightly. In the opinion of the representative the general review of the Health Board had been a positive one and had not confirmed the image portrayed of the nursing care providers by the media. The representative claims that the fact that no service provider’s licence had to be revoked was a positive sign.

Court Practice

At the moment there is no court practice creating precedent in this field. However, based on the specific Keila case that caused the major discussion in 2011 and the numerous complaints filed with the Estonian Patient Advocacy Association after that, it can be concluded that there are problems. Therefore, the fact that claims concerning nursing care services filed against the service providers is rather more likely a sign that denotes that filing complaints with the court is something people are afraid of or that turning to court is considered useless.

Conclusion

Depending on the circumstances, it could be said that there may be cases of the most severe form of abuse – torture –in nursing care of welfare services in Estonia. There may also be cases of demeaning or inhuman detention or living conditions, disproportionate restriction of movement, degrading treatment, restraint and lack of complaint mechanisms in nursing care establishments. The fact that there are people who have been treated in a demeaning manner or who have been abused, but who clearly do not dare turn to the management of the establishment or to some other institution indicates that the system for complaints in place at the moment is not the best and/or that this right to file complaints has not been acknowledged and/or that people do not believe they could benefit from it. A so-called pre-court organ for efficiently investigating, processing and analysing patients’ complaints has to be established, and the quality mechanisms have to be improved in general.

Recommendations:

  • Review the quality of welfare services in all nursing hospitals and bring it into concordance with human rights. All organisations providing welfare services need to have an in-house quality system, a procedure for solving complaints and disputes and methods for receiving feedback from clients / receivers of the service.
  • A precise, uniform and effective order for processing complaints and for investigation and procedure has to be established. The clients of the welfare establishments need to be informed of this, they have to be explained in a clear and understandable manner what the in-house order is and of the options and the order of making external complaints.


[1] The European Convention on Human Rights. Signed in Rome 4 November 1950. Estonia signed it 14 May 1993. Ratified 16 April 1996.

[2] UN Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. New York. 10 December 1984.

[3] Maruste, Rait (2004). Konstitutsionalism ning põhiõiguste- ja vabaduste kaitse [Constitutionalism and the protection of basic rights and freedoms]. Tallinn 2004. Page 335.

[4] European Court of Human Rights. 21 January 2011 judgment M.S.S v. Belgium and Greece. Application no. 306969/09.

[5] Õiguskantsleri 2010.aasta ülevaade [Chancellor of Justice’s review of 2010]. Available at https://www.riigiteataja.ee/aktilisa/3141/0201/1001/Ylevaade%202010.pdf.

[6] Parrest, Nele. „Väärkohtlemine on ka tänase Eesti mure“ [Abuse is concern for Estonia today]. Maaleht 26.10.2010. Available at: http://www.maaleht.ee/news/uudised/arvamus/vaarkohtlemine-on-ka-tanase-eesti-mure.d?id=31819835.

[7] The health insurance fund explains the differences in more detail on its website (in Estonian): http://www.haigekassa.ee/kindlustatule/tervishoid/taastus/hooldus.

[8] The provider of the 24-hour special care service is also required, in addition to supporting in everyday activities, to: ensure the security of the person receiving 24-hour special care service, assist the person in taking care of himself or herself, adhere to the treatment schedule prepared for the person by a health care provider, create possibilities for the person place in social welfare institution by a court ruling for working or for an activity similar to working on the service provider’s territory and carry out other activities required to achieve the objective of 24-hour special care service. (Social Welfare Act, §1149 subsection 2).

[9] See the wording of Social Welfare Act that came into force in 13.03.2011.

[10] Special care service may be provided directly by a natural person (activity supervisor), who complies with at least one of the following requirements (Social Welfare Act, 1134 subsection 1 point 1).

[11] See explanatory memorandum to the draft act of Social Welfare Act. Available at: http://www.riigikogu.ee/?page=en_vaade&op=ems&eid=819652.

 

[13] Estonian Patient Advocacy Association. Kokkuvõte hooldusravi juhtumitest Eestis näidetega [Summary report of welfare service cases in Estonia with examples]. Available at: http://www.epey.ee/public/files/KOKKUVÕTE%20HOOLDUSRAVI%20JUHTUMITEST%20NÄIDETEGA.pdf.

[14] Kukemelk, Epp-Mare (ed. 2011). Patsientide esindus on saanud hooldusravi kohta poolsada kaebust [The patients’ representative organ has received 50 complaints about welfare services]. Delfi. Available at: http://www.delfi.ee/news/paevauudised/eesti/patsientide-esindus-on-saanud-hooldusravi-kohta-poolsada-kaebust.d?id=46746588.

[15] Riigikogu (2011). 12th Riigikogu shorthand notes for the 1st session. 11.05.2011. Available at: http://www.riigikogu.ee/?op=steno&stcommand=stenogramm&date=1305108300&pkpkaupa=1&paevakord=8454.

[16] Regionaalhaigla (2011). Põhja-Eesti Regionaalhaigla annab ülevaate Keila haiglas toimunust [The North Estonia Medical Centre gives and overview of events at Keila hospital]. Available at: http://www.regionaalhaigla.ee/?op=body&id=30&art=237.15.01.2012.

[18] Riigikogu (2011). 12th Riigikogu shorthand notes for the 2nd session. 19.09.2011. Available at: http://www.riigikogu.ee/?op=steno&stcommand=stenogramm&date=1316433900&pkpkaupa=1&paevakord=8834#pk8834.

[19] Estonian Patient Advocacy Association (2011). [Official inquiry to Social Affairs Committee of Riigikogu and the members of Riigikogu]. Available at: http://www.epey.ee/public/files/AVALIK%20PÖÖRDUMINE%20(HOOLDUSRAVI)%202011.pdf.

[20] Ministry of Social Affairs (2001). Eesti hooldusravivõrgu arengukava 2015 [Estoniana nursing care network development plan 2004–2015]. Available at:  http://rahvatervis.ut.ee/bitstream/1/2048/1/Sotsiaalministeerium2001.pdf.

[21] Ministry of Social Affairs (2009). Hooliva hooldaja käsiraamat [Handbook for caring carers]. Available at: http://www.sm.ee/fileadmin/meedia/Dokumendid/Sotsiaalvaldkond/Eakad/hooldaja_kasiraamat.pdf.

[22] Jõesaar, Tuuli (2012). „Terviseameti analüüs: vigu on enam kui pooltes hooldusravihaiglates“ [The analysis of the Health Board: mistakes have been made in more than half of the nursing hospitals]. Eesti Päevaleht. Available at: http://www.epl.ee/news/eesti/terviseameti-analuus-vigu-on-enam-kui-pooltes-hooldusravihaiglates.d?id=63733344.

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