Shoddy records help Korean hospitals conceal abuse of mentally ill

Posted on : 2024-07-05 12:41 KST Modified on : 2024-07-05 12:41 KST
Figures from the country’s human rights watchdog suggest that guidelines for seclusion and restraint of those seeking psychiatric treatment are being flagrantly violated at many smaller hospitals
Still from CCTV footage showing a patient at a psychiatric hospital in Chuncheon, South Korea, as he looks toward the door the nurse just left through shortly before his death. 
Still from CCTV footage showing a patient at a psychiatric hospital in Chuncheon, South Korea, as he looks toward the door the nurse just left through shortly before his death. 

Editor’s note: His hands, feet and chest were tightly bound. He was strapped to the bed as if nailed to a crucifix. But no salvation awaited the man at this small mental hospital in Chuncheon, equipped with only 299 hospital beds. CCTV footage obtained by the Hankyoreh shows the patient slowly suffering, crying out and moaning in pain, until his death. Not the doctors, nor the nurses, nor the orderlies did anything to save him. All the people who appear in the footage only look like accomplices who facilitated the patient’s death.

A psychiatric hospital is a place for treating psychiatric conditions. But even today, there are such hospitals where the actions labeled as “treatment” border on torture, including restraining or neglecting patients. The Hankyoreh uses CCTV footage to expose the conditions of seclusion and restraint at psychiatric hospitals and explore possible alternatives.

A 15-year-old girl who had been institutionalized after being sexually assaulted was complaining about a stomachache when a nurse, in annoyance, stood up and shouted to the orderly.

“Throw that bitch in the padded cell. She’s acting up again today.”

The orderly immediately escorted the girl to a seclusion room and locked the door behind her.

The incident occurred at a Psychiatric Hospital A in Ansan, Gyeonggi Province, in January 2020. The orderly (identified here by the pseudonym Kang Min-ja), who had been working there for four months, felt she could no longer remain silent about what was happening there.

When Kang first got a job at the hospital, she was shocked to see a female patient being dragged by her hair into a seclusion room. “I can’t stand it when you’re lounging around with your hair undone like that,” one of the workers had told the patient.

Kang had worked at other psychiatric wards for five years, but she’d never seen anything of this sort. The other nurses gave her meaningful looks, indicating she should pretend nothing had happened.

It was routine at this hospital for patients to be confined and restrained for no apparent reason, and without any instructions from a doctor. When the nurses confined patients unofficially, they would write instructions in pencil rather than in ink. These pencil notes weren’t added to the electronic medical records, and when patients were placed in restraints, the instructions were not even written in pencil.

Eventually, Kang reported these incidents to the police. But the police who paid a visit left without taking any action. The only result was that she was transferred to a different position, given a three-month suspension and harassed on the job.

Kang eventually asked the National Human Rights Commission to look into human rights abuses at the hospital. In July 2020, commission investigators found that 35 individuals had been unjustly confined.

Kang filed a criminal complaint against the hospital director for violating the Public Interest Whistleblower Protection Act, and the director was given a fine of 5 million won (US$3,620) by a district court in June 2023.

But the head of the general affairs department — the person actually running the psychiatric hospital — got off scot-free. That individual continues to receive patients today, after renaming the hospital and bringing on a new doctor to serve as director.

There were two incidents in recent years (in April 2021 and April 2023) when patients jumped from windows to their deaths.

Flagrant violation of standards of practice for seclusion and restraint

On Wednesday, the Hankyoreh examined a case in which a patient who was admitted to a psychiatric hospital in Chuncheon was secluded and restrained for 251 hours and 50 minutes. The patient, Kim Hyeong-jin (pseudonym), 45, died after 289 hours and 20 minutes (12 days, 1 hour) in the hospital’s custody. While a doctor had given orders for Kim to be restrained and secluded, these were carried out with no regard for guidelines put in place for the protection of patients. But certain other hospitals are violating guidelines in yet another way: by not placing patients requiring seclusion and restraint in separate, designated quarters that are not hospital rooms. 

Whether due to a lack of adequate space for seclusion or out of willful negligence, two hospitals in Incheon detained patients in standard hospital beds, resulting in the patients’ deaths. 

In July 2021, Psychiatric Hospital B in Incheon tied a patient’s hands and feet to the bed after the patient caused a disturbance. While hospital staff were absent, however, another patient choked the restrained patient to death. The killer was being treated for anger management issues, and reportedly clashed with the victim regularly before the incident. Both patients were staying in a six-person room.

At Psychiatric Hospital C in Incheon, a restrained patient was beaten to death by another patient in November of last year. The patient died from abdominal trauma.

The Ministry of Health and Welfare’s regulations dictate that patients who are restrained or secluded must be kept in separate designated quarters, isolated from other patients. This standard exists because if a patient is restrained in a room with others, he or she is likely to cause a commotion by shouting for help and attempting to break free of the restraints, elevating the risk of a scuffle with another patient. Yet even facilities that violate these regulations are not subject to legal sanctions, making them paper tiger rules.

Investigations by human rights authorities have revealed that Hospital D in Incheon regularly restrained patients in regular quarters. According to the findings of the National Human Rights Commission of Korea’s (NHRCK) ex officio investigation of the hospital in question in November 2022, patients were frequently tied to their beds for not sleeping and disturbing the rest of other patients, or being aggressive with other patients. This also occurred when seclusion facilities were full or when the patient refused to be moved to a seclusion room. Patients had their arms tied to their beds’ side rails in a two-point restraint or had both arms and legs tied to their beds in a four-point restraint at least once or twice a week — sometimes daily. They were restrained for anywhere from one to four hours.

According to the human rights watchdog’s figures for the past five years (2019-2023) regarding complaints filed against mental health facilities, there were 463 petitions regarding unjust seclusion or restraint, making it the fifth-most common reason for complaint after forced admission (2,169 cases), violence or abuse (697 cases), improper or insufficient treatment (685 cases), and verbal abuse (525 cases). Considering that figures for unjust restraint complaints, however,  counted repeated incidents for a single patient as a single incident, the actual number is likely to be much higher. 

Experts say that it’s not easy to identify violations of treatment guidelines. If a doctor files the relevant paperwork after the patient’s death, or if a patient is detained without a doctor’s orders, it’s difficult to prove neglect or abuse. The NHRCK found evidence pointing to repeated incidents of improper restraint at an Incheon hospital over a six-month period, including internal paperwork, nurses’ transfer documents, and staff and patient testimonies. But the commission failed to uncover adequate evidence pointing to habitual improper restraint and seclusion at the hospital where a patient was killed while tied to their hospital bed. 

Lack of evidence is why among the 463 petitions brought to the NHRCK, only 28 went on to result in warnings, charges, or requests for investigation. The majority of cases were dismissed (304) or rejected (127) by authorities, while three ended in a settlement.

The sad reality is that many psychiatric hospitals do not even keep basic records of their use of restraint or seclusion. When the Hankyoreh requested such records, the Health and Welfare Ministry simply responded that such data was “unavailable.” The statistics do not exist.

Private hospitals lacking staff and funds

The Act on the Improvement of Mental Health and the Support for Welfare Services for Mental Patients prohibits the forced restraint or seclusion, including binding or tying up, of a mental patient unless dictated by a licensed psychiatrist. Guidelines by the Health Ministry and elsewhere recommend restraint or isolation only when a patient poses a threat to themselves or others. Mental health professionals acknowledge that restraint and seclusion is unavoidable when dealing with patients whose behavior cannot otherwise be controlled. Occasionally, those experiencing visual or auditory hallucinations will request isolation for themselves.

The problem is that many hospitals do not follow regulations that require restrained patients to be freed from their restraints every four hours and allowed to exercise their limbs every two hours. In more serious cases, nurses or orderlies will restrain patients without a doctor’s orders. Kang, who reported Hospital A in Ansan, said, “Smaller hospitals with 300 beds or fewer are often administered by wage slave doctors, and it's these types of facilities where abuses happen the most.”
Hospitals A, B, C, and D mentioned thus far have had 300 or fewer beds.

“University hospitals often reject patients with acute symptoms or those suffering from a relapse, who often require emergency admission, so these patients invariably end up in smaller private hospitals that lack staff and proper facilities,” said Lee Young-moon, the former president of the National Center for Mental Health.

“Smaller hospitals often lack infrastructure and staff,” said Ki Seon-wan, the head of the National Mental Health and Welfare Commission.

Realistically, it’s difficult for such facilities to improve their services. Many mental patients are beneficiaries of medical aid, a form of public assistance for low-income groups. This means the hospitals that treat them have to rely on state subsidies and support, which often aren’t enough. 

“Unlike other specialties, psychiatric clinics get lump sums when they admit or treat medical aid beneficiaries,” said Ki.

When medical aid beneficiaries are admitted to psychiatric hospitals with a G2 classification, the hospitals receive a daily stipend of around 70,000 won (US$50) per patient, which works out to about 2 million to 2.2 million won (US$1,448-1,593) a month.

“Around 60% of our patients are subsidized. Normally, this figure is around 5% at hospitals of different specialties,” said the director of a mental hospital in Seoul that has around 200 beds.

“Unlike other hospitals that deal with internal medicine and surgery, subsidies for admitting medical aid beneficiaries to a psych ward amount to only 60% of what the National Health Insurance typically covers,” they added.

Moreover, the state does not pay “intensive monitoring fees” (employing guardians for patient safety) in hospitals’ isolation wards and “protective isolation fees” (seclusion/restraint) for beneficiaries of medical aid. However, “emergency patient handling fees” (subduing or sedating aggressive patients) began being calculated separately starting four years ago, with the state paying hospitals 54,850 won per instance. 

“Is this the state of human rights in Korea?” “Let me out of here.” “Let me make a phone call.”

Notes for Kim Hyeong-jin’s stay at the hospital in Chuncheon showed that on Dec. 27, 2021, he requested that he be able to contact his family after he was subject to emergency hospitalization by police after an outburst at a convenience store. While the hospital claims that Kim was demonstrating “strong violent tendencies,” his family told the Hankyoreh that Kim “was perfectly aware of his illness” — bipolar disorder — “and regularly received outpatient treatment for it.” 

But the hospital denied Kim’s requests, and without contacting his family, immediately placed him in restraints and seclusion before administering a shot. The hospital did not keep a note of why staff responded with these measures. Perhaps it was simply the manner of treating patients they were most accustomed to. 

By Koh Kyoung-tae, senior staff writer

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