A nurse has been fined €5,000 for having failed to prevent the suicide of an inmate she was supposed to be constant watching over at the forensic unit of Mount Carmel Hospital.

But the court also found shortcomings in the way patients were watched over and said the condition of the cell was such that in this case it was "an execution chamber".  

The case was instituted by the police against nurse Yulia Toteva following the suicide death by hanging of an inmate. The case took place in the early morning of January 9, 2016.

She was accused of having "through imprudence, carelessness, unskillfulness in her art or profession, or non-observance of regulations” caused the inmate's death.

The court heard that the patient was placed under constant watch because of the risk of suicide. While he was in his cell, he was watched round the clock on CCTV.

The CCTV camera, however, did not cover the whole cell. The monitor was a blurred, black-and-white tube that had a diameter of only some 8cm. The case happened while the nurse was on her second successive shift.

The court found that he went out of view in his cell at 4.38am and his time of death was 4.42am. His body was discovered at 5.31am after the alarm was raised by another nurse.

“There is no doubt that it was the accused who was entrusted with the inmate's constant watch at the time of the incident. Knowing of his suicidal tendencies, fully aware that the side of the cell to where he had retreated was not captured on camera, she should either have told him to move away to a part which was visible and captured on the CCTV, or (she should have) made an effort to continue talking to him until she was certain he was out of harm’s way,” the court said.

“She could also have asked colleagues or the guards to physically check upon him given that she could not move away from the monitor desk.”

Rope not found during cell search

But Magistrate Donatella Frendo Dimech said this case was not just the nurse’s fault. Another nurse, though not directly responsible to maintain constant watch on the inmate, had checked on him just after 5am and had not noticed he was dead.   

Furthermore, he was allowed to mingle with other prisoners. Given his suicidal tendencies it became imperative to ensure that nothing in his room or on his person could lead to his self-harm. Yet, the rope still found its way to his cell.

"Needless to say, the fact that a high-risk patient, meant to be kept under constant watch at arms’ length, is allowed to come into possession of the rope and take it to his cell, is appalling and disgraceful, revealing lack of expertise of those called to safeguard the inmates’ well-being; undermining all efforts by the authorities,” the magistrate said.

“It is disturbing to learn that despite the various searches that guards were expected to carry out routinely on the inmate's cell, including the mattress, none of them thought it fit to examine it thoroughly. The guards 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.

“The mere fact that such high-risk inmates were given such mattresses is for want of better definition perplexing at best.”

An execution chamber

The court was even more scathing in its criticism of the cell where the prisoner was kept.

Instead of providing the inmate with a safe and secure environment, it proved to be their "execution chamber," it noted.

"Images from the scene of crime officers’ report distinctly shows this perilous opening in the cell door’s frame," the court said. 

Instead of providing the inmate with a safe and secure environment the cell proved to be his execution chamber!

The shortcomings, however, did not absolve the nurse of her responsibilities, the court said.

“It is imperative that a person entrusted with constant watch duties ensures that a high-risk patient is kept out of harm’s way at all times, no interludes, no pause, no exception. Toteva 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.

“The fact that he remained hidden and there was no communication with him, no intervention on her part to ensure he is not endangering himself, is tantamount to a dereliction of the duty of care.”

The court later added, however that Toteva should not be the only one to carry the brunt of responsibility for the inmate's demise. Others were also negligent thereby failing the inmate and ultimately the system itself.

In handing down judgment, the court noted that she had no criminal record, and her superiors had described her as "a hard worker, one of the best".