CASE OF MESKHIDZE v. GEORGIA
Violation of Article 3 - Prohibition of torture (Article 3 - Degrading treatment;Inhuman treatment) (Substantive aspect)
Nona Tsotsoria;Síofra O’Leary
5. The applicant was born in 1960 and was serving a prison sentence at the time in question. The facts of the case, as submitted by the parties, may be summarised as follows. 6. The applicant was arrested on 20 July 2003 and sentenced by the first-instance court on 19 May 2004 to twelve years’ imprisonment for murder. His conviction was upheld on appeal by the Supreme Court of the Autonomous Republic of Adjara on 19 July 2004. 7. According to the available medical file (covering the periods between 30 July-10 September 2005, 25 January - 27 March 2008, and 5 June – 8 September 2008), the first time the applicant was transferred to the prison hospital after his arrest was on 30 July 2005. At that time he was diagnosed with viral hepatitis C, chronic cholecystitis, and radiculitis. The applicant complained of suffering from sleeping disorders and anxiety and was placed in the psychiatric ward of the prison hospital. On 16 August 2005 he was transferred to the infectious ward, where he was treated for his viral hepatitis C. The applicant was discharged from the prison hospital on 10 September 2005. 8. According to the applicant, in October 2007 he had an operation for an ingrowing toenail on his right foot. After the operation the scar became infected and the applicant was sent to the prison hospital on 25 January 2008 on account of his deteriorating health. At that time the applicant’s diagnosis was as follows: chronic arterial insufficiency of the lower limbs, arterial occlusion and obliterating arteritis, and subungual panaritium. 9. On 29 January 2008 the applicant had his toenail removed. He spent the post-surgery period under permanent medical supervision in the prison hospital. Although he was provided with painkillers and treated with antibiotics, the applicant, according to the case file, complained every day about severe pain in his right foot. On 25 February 2008 he was seen by an angiosurgeon, who recommended that he undergo a dopplerography of the legs and that his transcutaneous oxygen pressure (“Tc PO2”) be measured. The surgeon would decide on the need to amputate the big toe on the applicant’s right foot on the basis of these tests. 10. According to a note made by a prison hospital doctor in the applicant’s medical file on 25 March 2008, the dopplerography and Tc PO2 test could not be organised in the prison hospital for technical reasons. The doctor noted an improvement in the applicant’s general condition and concluded that in any event, and notwithstanding the specialist’s recommendation, there was no need for those examinations, given that there were no “absolute indications” that surgery was called for. On 27 March 2008 the applicant was discharged from the prison hospital and sent back to Tbilisi Prison no. 1 with a recommendation that he continue palliative treatment on an outpatient basis. 11. At the request of the applicant, on 5 May 2008 the board of forensic experts of the Ministry of Justice – having examined him – drew up a medical report (“the 5 May 2008 medical report”), which diagnosed the applicant as suffering from the following: arteritis, occlusion of the arteries in the right shin, stenosis of the arteries in the left shin, artery deficiency in the right lower limb (at stage IV of the disease), necrosis of tissue in the right big toe, cardiac ischaemia, second-degree angina pectoris, seconddegree arterial hypertension, second-degree cardiac insufficiency, and lowactivity chronic hepatitis C. The experts concluded that from a cardiological point of view the applicant’s condition was potentially serious. As for his vascular condition, the main blood vessels in both of his legs were damaged and his condition was serious. They recommended that he be placed in a specialist cardiology clinic and have his toe amputated. 12. On 20 May 2008 the applicant’s lawyers complained to the Director of the Prisons Department of the Ministry of Justice (“the Prisons Department”) that their client, who had been in the prison hospital since 25 January 2008, had been sent to Tbilisi Prison No. 1, despite the seriousness of his state of health, and that the treatment in that hospital had not produced any results. They complained that the applicant’s condition had deteriorated there. The lawyers requested that the applicant be taken to hospital on the grounds that his life was in danger. On the same day they sent the same request to the director and the head doctor at the medical unit of Tbilisi Prison No. 1. 13. On 27 May 2008 the head of the welfare unit of the Prisons Department referred the lawyers’ request to the prison governor and a group of qualified medical experts “for an opinion”. He observed that, in accordance with ministerial order no. 717, patients were hospitalised on the orders of the prison governor, following a report by the head doctor of the prison’s medical unit. 14. Following that letter, on 3 June 2008 one of the applicant’s lawyers contacted the prison governor reminding him of the terms of ministerial order no. 717 and asking him what the response of the head doctor had been and enquiring as to when the applicant would be hospitalised. 15. On 9 June 2008 the Prisons Department informed the lawyers that the applicant had been placed in the prison hospital on 5 June 2008. 16. According to the daily notes made in his medical file, the applicant continued to suffer from pain in the right foot. It can be seen from the contents of the medical file that his right foot was treated with antiseptic products and bandaged daily. During that period the applicant was examined by a vascular specialist twice: on 11 June and on 31 July 2008. On 11 June 2008 the vascular specialist recommended that the bandage be changed regularly and the toe treated with antiseptic products. He also prescribed Alprostapint infusions. On 31 July 2008 the vascular specialist recommended a Tc PO2 test in order to assess the possibility of amputating the toe, and prescribed continuing palliative treatment. It appears from the case file that the relevant drugs were administered to the applicant by his wife and other family members. 17. On 7 August 2008 the applicant underwent a Tc PO2 test at a specialist hospital. On the basis of the results of the test the examining doctor concluded that the microcirculation in the lower limbs of the applicant (particularly in the right foot) was very low. In his view, surgical intervention was not appropriate because the particularly low level of oxygen in the right foot would have hampered the healing of the resulting wound. 18. On 8 September 2008 the applicant was discharged from the prison hospital because of the appeal court’s decision to suspend his prison sentence (see paragraph 28 below). 19. On the basis of the 5 May 2008 medical report (see paragraph 11 above), and in view of the fact that his treatment at the prison hospital was producing no results, on 14 May 2008 the applicant applied to the Tbilisi City Court for his sentence to be suspended on health grounds (under Article 607 § 1 (a) of the Code of Criminal Procedure – “the CCP”). A representative of the Prisons Department opposed the application on the grounds that the prison hospital had “a medical service capable of treating the applicant” and that “if necessary he [would] be transferred to a specialist clinic”. One of the experts who had produced the above-mentioned report confirmed to the court judge that the applicant was seriously ill. However, as he had no knowledge of the medical facilities at the prison hospital, he said he could not judge whether it was appropriate to keep the applicant there. He also confirmed that the applicant’s right big toe had to be amputated. 20. On 11 June 2008 the Tbilisi City Court dismissed the applicant’s request, on the grounds that the prison hospital had a medical service capable of providing the necessary treatment and that the applicant, who was being looked after by specialist doctors, would be transferred to a specialist clinic if necessary. 21. On 18 June 2008 the applicant’s lawyer submitted to the court his comments on the record of the hearing of 11 June 2008. The record of the hearing, according to those comments, did not refer to the expert’s opinion in respect of the risk to the applicant’s life. The expert had said that the applicant’s gangrene, which was now at the fourth (and last) stage, could cause septicemia and death if not properly treated. Regarding the applicant’s heart condition, the expert had said that the applicant needed treatment in a specialist clinic to prevent sudden death. On 19 June 2008 the court granted that request and ordered that the record of hearing be amended by adding the expert’s comments. 22. The applicant appealed against the decision of 11 June 2008, pointing out that, according to the medical experts who had examined him, the treatment at the prison hospital had produced no results and that, if he was not properly treated, the question of the amputation of various parts of his right lower limb could arise. The applicant’s lawyers pointed out that prisoners frequently died as a result of a lack of treatment at the prison hospital. They also complained about the Prisons Department having joined the trial as a party to the proceedings, which was in breach of Article 617 § 4 of the CCP. In their view, a representative of the Prisons Department was not in a position to assess the danger that detention might pose to the life of the applicant. Subsequently, the lawyers requested that the applicant’s doctor and the doctor from the specialist hospital who had treated the applicant on 7 August 2008 be heard as witnesses (see paragraph 17 above). At the examination in the specialist hospital in question, apart from the findings of the above-mentioned expert report, Buerger’s disease of the lower limbs had also been diagnosed. 23. At a hearing before the Court of Appeal on 4 September 2008 the applicant’s lawyers requested that the representative of the Prisons Department be debarred from joining the proceedings as a party, in accordance with Article 617 § 4 of the CCP. The Court of Appeal allowed that request but authorised the representative in question to attend the hearing in order to reply to any questions. It also decided to call the prison hospital surgeon, the vascular specialist (see paragraph 17 above), and the forensic expert (see paragraph 11 above) as witnesses. 24. At the next hearing on 8 September 2008 the forensic expert repeated that the applicant’s state of health was serious, and that Article 7 § 2 of order no. 72/N (issued by the Health Minister) concerning the early termination of prison sentences on health grounds was indisputably applicable. He added that necrosis of the tissue of the lower limb had set in and was progressively affecting the limb from the bottom up. If that were to continue, the applicant might develop septicemia and die. In his view, it was impossible to cure the applicant completely. 25. The applicant’s doctor – a surgeon who was a member of the prison hospital’s permanent staff – also gave evidence before the Court of Appeal, explaining the diagnosis and confirming that his patient was seriously ill, with the arterial disease having reached the fourth and final stage. He said that he had seen the applicant in December 2007 and also in May 2008 and that no serious necrosis had been observed at that time. He further explained that at that stage of the disease the treatment usually prescribed was either palliative or surgical. The applicant was being given palliative treatment with medicines (antioxidants, protective drugs, sedatives). An operation was not recommended because it might make his condition worse. The likelihood of the scar healing was nil. The doctor was gradually removing the necrosed tissue in the right foot. The doctor also confirmed that the applicant’s illness was chronic, progressive and that he needed constant medical treatment. He added that he could not be cured at the prison hospital but that there was a clinic outside the prison that could treat this kind of patient. In answer to a question from the judge, the doctor said that the applicant had been hospitalised twice after his operation and that at the relevant time the necrosis had not reached such an advanced stage. At that time the prison hospital doctors had done all they could to halt the development of the necrosis but without much success. If the situation continued, the applicant might have to have his entire right leg amputated. 26. The vascular specialist – a doctor at the prison hospital – said that he had examined the applicant in December 2007 and found that the gangrene had already affected the big toe of the right foot. This had then quickly spread, despite the treatment administered. Shortly before the hearing the applicant had been prevented from lying down and had been made to stay in a sitting position. His state of health was worsening daily. The results of the Tc PO2 test had shown that the oxygen tension in the right foot stood at level 2 in the lying-down position and at level 21 in the sitting position (the normal level being 60-70; an indicator of 30 was necessary if the wound could be expected to heal properly). Accordingly, amputation was impossible. The vascular specialist said that the prison hospital was complying with his orders but that there was no specialist unit. In his view, the applicant’s lower left limb was also damaged, but not yet affected by gangrene. At the time it was a question of saving the applicant’s life and subsequently considering whether to amputate the right leg. 27. In his final address the applicant’s lawyer drew the Court of Appeal’s attention to the fact that, despite the presence of gangrene as early as December 2007, the applicant had been sent to Prison No. 1 and left there untreated. Given that, according to the doctors, the applicant could not be cured, the lawyer requested that her client be dispensed from having to serve the remainder of his prison sentence (under Article 608 § 1 of the CCP). 28. In a judgment of 8 September 2008 the Court of Appeal ordered that the applicant’s prison sentence be suspended pending a substantial improvement in his state of health, provided that he undergo a medical examination every six months and provide the court with the results thereof. The applicant was immediately released. 29. According to a medical report of 6 March 2009, the applicant suffered from cardiac ischaemia, second-degree angina pectoris, thirddegree hypertension and second-degree heart failure. From a cardiological point of view, his heart condition remained serious. With regard to his arteries, the applicant suffered from Buerger’s disease, occlusion of the arteries in the right tibia, stenosis of the arteries in the left tibia, chronic arterial deficiency in the right lower limb at the fourth stage of the disease and gangrene of the tissue in the right big toe. The gangrene was still described as progressive. The experts concluded that the applicant required cardiological and angiological treatment in a specialist institution. 30. Over May and June 2011 the applicant underwent another forensic examination. It appeared from the report of 21 June 2011 that on 6 February 2011 the applicant had had the lower part of his right leg amputated. At the same time he was diagnosed with gangrene on the big toe of the left foot. While confirming his diagnosis from a cardiological point of view as potentially serious the four experts involved in the examination also concluded that the applicant’s angiological condition had deteriorated as a result of ischemia. Thus, from the angiological point of view he was categorised as a seriously ill patient.