7.  The applicant was born in 1973 and is currently serving a prison sentence. 8.  On 30 March 2005 the applicant was convicted for the first time of drug trafficking, and was sentenced to two years in prison but released on probation. As disclosed by his medical file, prior to those criminal proceedings he had suffered serious cranial traumas, as a result of which his mental health had deteriorated. 9.  On 28 September 2005 the applicant was arrested again for possession of 3.84 g of heroin and 0.121 g of methadone (for a more detailed description of the circumstances surrounding his arrest and the subsequent criminal proceedings, see Jashi v. Georgia (dec.), no. 10799/06, 16 January 2007). He was detained in Tbilisi no. 5 Prison. 10.  On 28 December 2005 a psychiatric report, after having described the exact nature of the applicant’s mental disturbances, stated that it was impossible to reach a definite diagnosis without subjecting the applicant to a comprehensive psychiatric examination, which ought to be conducted in an appropriate medical setting. No such examination followed. 11.  On 20 January 2006, during a preparatory hearing of the applicant’s trial, the Zugdidi District Court, granting a request made by his lawyer which was based on the psychiatric report of 28 December 2005 and aimed at the determination of the applicant’s mental capacity to stand trial, ordered that the applicant be admitted to the Poti Psychiatric Hospital for one month in order to allow a forensic psychiatric examination to take place. The court specified that the applicant’s trial could only be resumed after the results of the forensic examination had been obtained. 12.  The Zugdidi District Court’s ruling of 20 January 2006 was final, but the authorities refused to enforce it despite numerous complaints being made by the applicant and his lawyers in that regard. 13.  On 9 March 2006 the applicant was transferred to Zugdidi Prison, under a strict regime. 14.  On 7 April 2006 the applicant’s representatives requested the Court under Rule 39 of the Rules of Court to indicate to the Government that the ruling of 20 January 2006 of the Zugdidi District Court, by which their client ought to have been admitted to the Poti Psychiatric Hospital, be enforced immediately. 15.  On 26 April 2006 the President of the Chamber decided not to indicate the interim measure sought. Instead, under Rules 40 and 54 § 2 (a) of the Rules of Court, urgent notice of the application was given to the Government, who were also asked to explain the reasons for the non‑enforcement of the ruling of 20 January 2006 and to submit documents accounting for the medical treatment provided to the applicant in prison. 16.  On 23 May 2006 the Zugdidi District Court ordered that the applicant be admitted for one month to the psychiatric ward of the National Forensic Bureau (“the NFB”) so that his psychiatric examination could be conducted. 17.  In enforcement of that order, the prison authority transferred the applicant on 31 May 2006 to the NFB. On 8 June 2006 the applicant requested that two psychiatric experts of his choice be allowed to take part in the examination, but that was not authorised. On 14 June 2006 a panel consisting of State psychiatric experts issued a report about the applicant’s mental health, and on the following day the applicant was sent back to Zugdidi Prison. 18.  According to the report of 14 June 2006, the applicant did not have any chronic or temporary psychiatric diseases or dementia but had an organic personality disorder which was mostly manifested by his anti‑social behaviour but did not, however, affect his capacity to understand the wrongfulness of his actions and thus be held liable for them. The report further confirmed that the applicant’s condition did not impair his capacity to take part effectively in the criminal proceedings and stated that he did not require any compulsory mental treatment in a specialised psychiatric hospital. 19.  On 24 May and 30 June 2006 the Court received, respectively, the Government’s reply, claiming that it was both unnecessary and procedurally incorrect to enforce the Zugdidi District Court’s ruling of 20 January 2006 at that stage of the criminal proceedings (the Government subsequently reiterated that argument in their observations, see paragraph 53 below), and the applicant’s repeated request for the indication of the above-mentioned interim measure. The applicant’s submissions disclosed that, on 15 June 2006, he had attempted suicide by slashing his wrists and that, in general, his behaviour had become aggressive upon his return to Zugdidi Prison on 14 June 2006. As was clear from the applicant’s submissions, neither he nor his lawyers had been acquainted with the content of the medical report of 14 June 2006 at that time. 20.  On 4 July 2006 the President of the Chamber, having examined the parties’ latest submissions, decided to apply Rule 39 of the Rules of Court. It was indicated to the Government that the applicant’s mental health should be examined in an appropriate medical establishment. The examination had to be conducted by a panel of psychiatric experts composed on a parity basis, and, having due regard to its conclusions, the Government were to provide the applicant with adequate medical treatment. 21.  On 12 July 2006 the applicant again attempted suicide in Zugdidi Prison by overdosing on certain, unspecified drugs. He was immediately provided with appropriate medical care in prison, which included pumping his stomach and treatment with tranquilisers. 22.  On 21 July 2006 the Zugdidi District Court, having regard to the interim measure indicated by the Court on 4 July 2006, ordered that the applicant be subjected to another psychiatric examination in an appropriate psychiatric establishment in line with the Court’s recommendations concerning the composition of the panel of experts. 23.  On 22 July 2006 the applicant, using electrical wiring, slashed his wrists again in Zugdidi Prison. He was immediately transferred from the prison to a civilian hospital in Zugdidi, where he was provided with the necessary emergency care. Subsequently, on 30 July 2006, a preliminary criminal probe was opened into that incident. The enquiry was closed by a prosecutorial decision of 28 December 2007 on the basis of the finding that the prison staff could not be held responsible for the applicant’s self‑harming behaviour because electrical wiring was not, according to the relevant prison rules, a prohibited item and the incident had itself resulted from the applicant’s own emotional disturbance, which was not imputable to the prison staff. 24.  On 27 July 2006, in enforcement of the Zugdidi District Court’s order of 21 July 2006, the applicant was again admitted to the psychiatric ward of the NFB, where his psychiatric condition was examined by a panel of experts composed on a parity basis, with the applicant and the State each nominating two psychiatrists. The examination lasted until 18 August 2006, and on the latter date the panel issued a report which mostly reiterated the results of the previous report of 14 June 2006. Notably, apart from an organic personality disorder, the panel determined that the applicant did not suffer from any serious psychiatric diseases, was responsible for his actions and did not require compulsory psychiatric treatment. The second report added that as a result of the applicant’s personality disorder he had symptoms of depression, which were manifested, inter alia, by behavioural and verbal indications that he was contemplating suicide, and by his irritable and aggressive behaviour and difficulties in communication. 25.  On 18 August 2006 the prison authority, having regard to the latest medical report concerning the applicant’s mental health, admitted him to the psychiatric ward of the prison hospital, where he stayed for the following two years, until 31 August 2008. 26.  On 25 August 2006 the applicant made another suicide attempt by taking a drug overdose in the prison hospital. As disclosed by an entry made in the applicant’s medical file by a doctor who supervised the subsequent emergency procedures (pumping of his stomach, blood transfusions and so on), the applicant had swallowed a cocktail of strong drugs, including antibiotics and tranquilisers. 27.  In a decision of 24 January 2007, the Zugdidi District Court endorsed a plea bargain reached between the prosecution and the applicant on the same day. The decision disclosed that, in the course of the plea‑bargaining, the applicant had confessed to the crime of large-scale drug trafficking and had agreed to be sentenced to nine years in prison, to pay a fine of 100,000 Georgian laris (EUR 55,815) and to undergo compulsory medical treatment for drug addiction. The decision became final. 28.   According to a report on the applicant’s medical examination conducted by the NFB in the prison hospital between 3 August and 12 October 2007 (“the first medical report”), he suffered from cardiac ischemia, class III-IV angina, arterial hypertension, and grade II-III heart failure. He also suffered from a number of diseases of the veins, such as varicose veins on both legs and venous insufficiency, and had certain neurocirculatory and neurovegetative disorders. The first medical report also noted that the applicant, being diagnosed with a personality disorder and showing clear suicidal tendencies, had several self-inflicted blade wounds on his forearms and abdomen. The report’s findings were that, from the cardiac point of view, the applicant could be considered to be in a grave condition and needed treatment in a specialised hospital. As to his neurovascular problems, he could be treated by a specialist on an outpatient basis. 29.  On 31 January 2008 the cardiologist who was treating the applicant in the prison hospital, having due regard to his cardiac diagnosis (see the preceding paragraph), to the nature of the pains in his chest and to his other symptoms, opined that, in order to develop a correct treatment plan, a special X-ray test – a coronary angiogram – was required. 30.  Another examination of the applicant’s state of health was conducted in the prison hospital, at the request of his representatives, by the NFB between 10 March and 2 June 2008. The relevant report (“the second medical report”) reiterated all the conclusions of the first report and added that the applicant also suffered from chronic obstructive pulmonary disease. It was noted that the applicant’s heart and neurovascular problems had deteriorated. The second medical report concluded that the applicant ought to be admitted to and adequately treated in a cardiology hospital; a coronary angiogram was required. From the cardiac point of view, the applicant was and had the propensity to remain in a grave condition. As to his vascular problems, the report noted that the applicant could still be treated by a specialist on an outpatient basis. However, in the event of any further deterioration, treatment in a specialised medical establishment would become necessary. 31.  On 7 July 2008 the applicant was diagnosed with viral hepatitis C (HCV). 32.  On 15 July 2008 the staff of the prison hospital offered the applicant the possibility of undergoing a coronary angiogram in a private cardiology hospital. The applicant turned down that offer, which was recorded in writing. 33.  As disclosed by the applicant’s medical file accounting for his treatment in the prison hospital between 18 August 2006 and 31 July 2008, on which latter date he was discharged from the prison hospital to Rustavi no. 2 Prison, he was repeatedly provided with appropriate psychotropic drugs (antipsychotics, antidepressants and tranquilisers) for his personality disorder and depression. The applicant also repeatedly underwent comprehensive medical examinations (which also involved a full analysis of blood and urine samples, including biochemical, thyroid, liver function and glucose level tests), an X-ray of the thorax, electrocardiography, scans of the abdomen and of the vascular system in the lower limbs and so on. He also had consultations with medical specialists such as a vascular surgeon, infectious disease specialist and cardiologist and, following the prescriptions of those medical specialists, was administered various drugs, including a number for his cardiac problems. 34.  On 11 September 2008 the applicant was again admitted to the prison hospital for treatment for his depression, which lasted until 25 September 2008. During his stay in the hospital, he had consultations with a psychologist and a psychiatrist, in addition to a cardiologist for his cardio-vascular problems. He also underwent various types of medical examinations, such as a comprehensive analysis of his blood (including liver function tests) and urine, an X-ray of his thorax, various scans of his abdomen and so on. After his discharge back to Rustavi no. 2 Prison, which was authorised by his attending doctor, the applicant was prescribed, on 26 September 2008, with antidepressant drugs to be administered on an out‑patient basis. 35.  On 6 October 2008 the applicant’s representatives asked the Head of the Prisons Department of the Ministry of Justice to transfer their client to a cardiology hospital, in accordance with the recommendations of the second medical report. The authority’s attention was brought to the applicant’s other medical problems, such as his mental disorder and HCV. The request went unanswered. 36.  On 3 November 2008 the applicant’s representatives requested the Court under Rule 39 of the Rules of Court to indicate to the Government that the applicant should be transferred from Rustavi no. 2 Prison to a cardiology hospital where adequate treatment for his heart problems could be dispensed. 37.  On 9 December 2008 the Court indicated to the Government that the applicant should be placed in a hospital specialising in cardiology treatment, where he should receive treatment consistent with the recommendations of the second medical report. 38.  A third examination of the applicant’s state of health, with an emphasis on his cardiac problems, was conducted at the request of his representatives by the NFB between 2 October and 25 December 2008. The relevant report (“the third medical report”) reiterated all the conclusions of the previous two reports concerning his heart problems. Notably, the third medical report confirmed that the applicant ought to be placed and adequately treated in a cardiology hospital. 39.  As disclosed by the relevant verbatim records, on 25 and 26 December 2008 and 5 January 2009 the staff of the prison hospital, having regard to the interim measure indicated by the Court on 9 December 2008, repeatedly offered the applicant a transfer to a civilian cardiology hospital for “an angiogram and appropriate medical treatment”. However, the applicant turned down all those offers, without giving an explanation. 40.  On 15 January 2009 the applicant’s representative asked the prison authority to arrange for the applicant’s transfer to a cardiology hospital for both an angiogram and follow-up medical treatment, rather than only for the medical scan itself. 41.  Finally, on 3 April 2009 the prison authority, after having obtained the applicant’s consent to receive “the necessary medical examinations and treatment”, arranged for his transfer to Guli Hospital, a private hospital in Tbilisi specialised in cardiology treatment. 42.  The applicant stayed in the private cardiology hospital until 15 May 2009, during which period he underwent various extensive medical examinations related to his cardiac problems. A cardiologist and allergist from that hospital, having noted that the applicant was highly allergic to iodine, the use of which substance was necessary for the conduct of a coronary angiogram, decided that it was more prudent to abstain from that scan. Instead, the applicant’s in-patient treatment there proceeded with a supervised intake of cardiology drugs. As a result of the treatment administered, the applicant’s cardiac condition, as confirmed by his attending cardiologist’s opinion of 15 May 2009, considerably improved. All his chest pain fully disappeared, the arterial tension stabilised and the results of an electrocardiogram were positive, and, as the medical specialist opined, it was thus possible to proceed with the applicant’s treatment by medication in a general medical establishment. During his stay in the private hospital, the applicant had consultations with an infectious diseases specialist in respect of his HCV and his blood samples were taken for analysis. At the time of the applicant’s discharge from the hospital on 15 May 2009, the results of that analysis were still not known. 43.  Accordingly, on 15 May 2009 the applicant, after having successfully completed the treatment for his cardiac problems, was transferred from the civilian to the prison hospital, where he then underwent a full biochemical analysis of his blood samples with the aim of developing an exact treatment plan for his HCV. As a result, on 8 June 2009 the prison hospital offered to start a course of treatment with the appropriate antiviral drugs (Intron A (interferon alpha-2b) and Rebetol (ribavirin)). However, given the strong neurologic side-effects of those drugs, the applicant decided to postpone the treatment until the improvement of his mental condition. 44.  In the prison hospital, the applicant then had, between May and August 2009, repeated consultations with a cardiologist, endocrinologist, psychiatrist, psychologist and infectious diseases specialist. None of them detected a worsening of the applicant’s condition. In particular, as confirmed by the results of the consultations with the psychologist and psychiatrist which took place on 3 June 2009, the signs of the applicant’s depression and personality disorder had disappeared by that time and he no longer required treatment with psychotropic drugs. 45.  Thus, having regard to the stabilisation of the applicant’s psychological condition and the cessation of his intake of psychotropic drugs, the prison hospital again offered the applicant, on 30 June 2009, treatment with a course of Intron A and Rebetol, which the applicant accepted. The applicant’s treatment with those drugs, which started on 1 July 2009, continued until 29 December 2009, and its results were successful. Notably, as confirmed by blood tests (involving a determination of the applicant’s hepatitis C virus RNA levels by the quantitative polymerase chain reaction (PCR) method) conducted on 29 January and 22 July 2010, the applicant’s viral load was “negative”, which indicated the non-progression of the disease. 46.  The relevant excerpts from the above-mentioned Report, bearing on the problem of psychiatric care for prisoners, read:
“As regards the provision of psychiatric care to prisoners, the situation observed at the establishments visited during the 2007 visit is a matter of serious concern to the CPT. Each of the penitentiary establishments accommodated a certain number of inmates with psychiatric or psychological problems. However, the lack of psychiatrists (even when there was a psychiatrist’s post, it was vacant) made it impossible to detect and care for prisoners suffering from mental disorders. Prison doctors were not allowed to prescribe any psychotropic medication and, as a result, there was often a discontinuation in the treatment started before imprisonment. The delegation was concerned to note that prisoners who had been sentenced by a court to undergo compulsory psychiatric treatment were not receiving any therapy. In most cases, the only chance of access to psychiatric care was transfer to the Central Prison Hospital. The CPT recommends that the Georgian authorities take steps to fill the psychiatrists’ posts at the establishments visited and to reinforce the provision of psychiatric care to prisoners.” 47.  The relevant excerpts from the above-mentioned Report read:
“The situation for psychiatric patients within the penitentiary system is grave. The Standard Minimum Rules require that ‘the medical services of the institution shall seek to detect and shall treat any physical or mental illnesses or defects which may hamper a prisoner’s rehabilitation. All necessary medical, surgical and psychiatric services shall be provided to that end.’ The CPT also pays particular attention to this category of individuals. As in other parts of the Republican Prison Hospital, conditions of detention for psychiatric patients were substandard and many detainees in need of care both in the hospital and in the regular prison facilities were clearly not able to receive it. ...
Prison authorities in various facilities acknowledged that there were detainees in their prisons with suspected or confirmed mental illnesses, but said these individuals were not transferred out of the regular prison facilities or treated within the medical wards of the facilities. Many also dismissed their conditions as not warranting special care. ...”