Last Updated on December 7, 2023 by LawEuro
Judgment 7.12.2023 [Section V]
Use of force
Respondent State’s failures due to psychiatric hospital patient dying following repeated tasing by police and administration of tranquiliser by a nurse: violation
Facts – On the evening of 5 November 2015, the applicant’s brother, P.Z., having been treated for paranoid schizophrenia since 2005 and for hypertension since 2015, was admitted to a psychiatric hospital after threatening members of his family. He was admitted to the acute care unit and administered anti-psychotic medication. Early the following morning, after a verbal conflict, P.Z. became hyperaggressive and highly agitated. Since neither medical staff nor hospital security guards were able to control him police was called in. Two officers placed him in the prone position but were unable to restrain him. Considering that P.Z. posed an imminent threat to the life and health of the others present, an officer then tasered him three times, following which a nurse administered a tranquiliser. Following P.Z.’s loss of pulse, resuscitation efforts were unsuccessful and he was pronounced dead. The autopsy and forensic reports concluded that the immediate cause of his death had been cardiac arrhythmia.
Law – Article 2:
(a) Substantive –
(i) Failure to protect P.Z’s life – The case revealed a number of shortcomings as to the manner in which the hospital and the police had dealt with the situation.
Firstly, as a long-term outpatient it could have been reasonably foreseen that P.Z. could become psychotic or violent on his admission. Secondly, although the medical staff had decided to call in the police, they had apparently not informed the officers of P.Z.’s condition and of the health risks associated with it, nor of his state of agitation. Thirdly, the officers had attempted to restrain him by placing him in the prone position which could lead to positional asphyxia because of pressure exerted on the neck, and which also made it impossible to observe whether the person concerned was actually breathing. Fourthly, placing P.Z. in the prone position had lowered the risk of his escaping or posing a further direct threat to the lives of those present, which raised the question whether his subsequent tasing had been absolutely necessary. It could not be ruled out that the electrical shocks produced by the taser had indeed caused the cardiac arrhythmia that had led to his death. The Court was struck by the fact that P.Z. had been tasered three times in a very short lapse of time, following which anxiolytic medication had been administered.
The Court concluded that as a result of the combined actions of a number of people the State had failed in its positive obligation to provide P.Z. with adequate care and preserve his life.
(ii) Relevant legal and administrative framework –
Under the Police Act and an internal guide, officers had been authorised to use a taser only where there was no other coercive measure capable of attaining the aim of the intervention, bearing in mind the principle of proportionality. That framework was very general and did not reflect the particular nature of that device as an “intermediate weapon”, nor the health risks associated with its use. In particular, there were no specific provisions concerning the use of a taser on persons with mental disorders or, more generally, on persons who had been hospitalised and likely medicated, though not included in the category of vulnerable persons specifically mentioned in the Police Act.
At the relevant time there had been no requirement of cooperation and coordination between police officers intervening at hospitals and health professionals. A recommendation to that effect had been issued by the Czech Public Defender of Rights after the death of P.Z. and was currently being implemented.
The foregoing considerations were sufficient to conclude that the State had failed to observe its primary duty to secure the right to life by putting in place an appropriate legal and administrative framework concerning, on the one hand, coordination between health professionals and the police when the latter’s intervention in medical establishments was unavoidable and, on the other hand, the possible health risks associated with tasing in general and, in particular, of persons with mental disorders – notably in situations where it had not been established whether those persons had been medicated. In particular, the system in place had not afforded to police officers clear guidelines on how to proceed when intervening against psychiatric patients such as P.Z.
Conclusion: violation (five votes to two).
(b) Procedural – The investigative steps had been taken by the General Inspectorate of the Security Forces (GISF), an independent body. An investigation aimed at establishing the cause of P.Z.’s death had been opened on the day on which that death had occurred (6 November 2015). Evidence had been secured, the intervening police officers had been instructed to draw up official records on the use of coercive measures, an autopsy of P.Z.’s body had been performed and an expert report had been ordered. Between 25 November and 8 December 2015 the GISF had interviewed several eyewitnesses, including the four police officers. The case had been closed on 6 April 2016 and the investigation had therefore been sufficiently prompt.
However, the Court could not overlook a number of omissions and shortcomings capable of undermining the thoroughness and reliability of the investigation.
The investigating authority had not immediately isolated and questioned the police officers involved in the incident, thereby failing to prevent possible collusion. During those interviews, they had more or less reiterated the content of the official records they had drawn up on the day of the incident. According to the Czech Public Defender of Rights, those official records had lacked a detailed description of the events, on the basis of which it would have been possible to assess the appropriateness of the coercive measures used.
Furthermore, while the Court acknowledged that although (i) quite extensive evidential material had been collected (including video recordings, the backup memory of the taser, and a full copy of P.Z.’s medical records), and (ii) a forensic medical examination and a toxicology examination had been ordered for the purpose of producing an expert report, the scope of the investigation had remained somewhat narrow. In particular, it had not focused on the information exchanged between the police officers and the medical staff, and the experts had not been asked to comment on the possible interaction between the medication administered to P.Z. before and after the use of the taser. Failing to follow an obvious line of inquiry had undermined to a decisive extent the investigation’s ability to establish the circumstances of the case and the identity of those responsible. The various deficiencies in the investigation had not enabled it to be properly established whether the liability of the State had been engaged on the grounds of cumulative shortcomings on the part of the authorities.
In the light of the foregoing, the investigation carried out into the death of P.Z. had been inadequate.
Conclusion: violation (unanimously).
Article 41: EUR 25,000 in respect of non-pecuniary damage.
(See also Scavuzzo-Hager and Others v. Switzerland, 41773/98, 7 February 2006, Legal summary; Shchiborshch and Kuzmina v. Russia, 5269/08, 16 January 2014, Legal summary; Anzhelo Georgiev and Others v. Bulgaria, 51284/09, 30 September 2014, Legal summary; Armani Da Silva v. the United Kingdom [GC], 5878/08, 30 March 2016, Legal summary; Tekın and Arslan v. Belgium, 37795/13, 5 September 2017, Legal summary; Boukrourou and Others v. France, 30059/15, 16 November 2017, Legal summary; Znakovas v. Lithuania [Committee], 32715/17, 19 November 2019)