Death by malpractice in an institution in The Netherlands

Death by malpractice in an institution in The Netherlands

Last year on March 13th 2012, Roelie a 44 year old women with a cognitive disability, died from the violent behavior of the caretakers in the residential institution in the Netherlands where she stayed voluntarily. The surveillance camera’s registered everything. When the inspection later on investigated the images, they ruled that the caretakers proceeded unprofessionally and aggressively. The public prosecutor decided though to sue neither the caretakers or the service provider NOVO. Also, when Roelie’s sister appealed, the court agreed with the public prosecutor. The Dutch TV show ‘Nieuwsuur’ (‘News hour’) came to be possession of the video tapes of this horrible incident. NOVO wanted to stop the broadcast via the judge in this case but this was declined.

Voluntary stay?

Roelie was living for over two months at NOVO- the institution where the incident took place. Roelie had an IQ from about 80, behavioral problems and  she sometimes had paranoid psychoses. Earlier on the day of the 13th March 2012, she ran away from the institution.   Roelie was mentally competent, she stayed in NOVO voluntary and Roelie’s sisters had an agreement with the facility on this matter, she was allowed to leave the institution at all times. Later that day, a taxi driver found her in the city. Roelie looked confused, so the man informed the police, who brought her back to NOVO.

Back in the institution, the caretakers ordered Roelie back to her room to write an apology letter for her ‘behaviour’. According to the later report , this procedure is for young people and not appropriate for a 44 year old women like Roelie. Around 10.30 p.m. the tension rose. Roelie again tried to leave the premises. Four members of the staff tried to hold Roelie back and force her into an isolation cell using violent measures.  These kinds of actions make the violence escalate, instead you should make counter movements, says Francis Bollen from the professional association of caretakers.

Constraint leading to death

The surveillance tapes recorded everything. When the inspection later on investigated the images, they stated that the caretakers proceeded in an unprofessional and aggressive manner. “None of these four people searched for alternatives to prevent this from happening”, tells Jenneke Van Veen, in the broadcast of ‘Nieuwsuur’ about Roelie. Three caretakers forced Roelie to lie on the ground. They held her down by putting a significant amount of pressure on her body. Another caretaker stood on Roelies ankle. “These are risky proceedings for which you need to be knowledgable and skilled” comments Brenda Frederiks, specialist in the rights of people with a cognitive disability.

The staff of the facility called the police, who decided to take Roelie with them for a night in jail. When the police arrived, forty minutes later, they ascertained that women had died.

Illegal but unpunished

The forensic investigation showed that the persistent, excessive pressure on Roelie’s body and neck became fatal to her. “Even a kid knows that you cannot put that much pressure on someone’s body” says the sister of Roelie.

Not allowing Roelie to leave the facility and to isolate her was in breach of the rules. The freedom of a person that stays in an institution voluntarily cannot be imposed upon and restricted. An institution such as NOVO, in which people only stay on a voluntary basis, should not even have an isolation cell or anything similar to this. Also, the use of a ‘time-out room’ was not mentioned in Roelies treatment plan. “There are a lot of things happening outside of the law, and often it is not seen as freedom restriction by the members of the staff, is it part of the daily routine, a step plan, agreements or an element of punishment and reward” says Brenda Frederiks.

The public prosecution decided though not to sue the caretakers or the management of NOVO. Also, when Roelie’s sisters appealed, the court agreed with the public prosecutor. Despite the forensic evidence proving that the violent actions were the cause of the death of Roelie, no one has been held responsible or liable for her death. The Director of the Facility thanked the care workers in writing for their professional conduct, this has only added more pain for the relatives of Roelie.

A year after the inspection vetted NOVO after the incident in relation to Roelie, another inspection was carried out to investigate what the institution had accomplished in terms of adjustments in the context of their inspection report. It seemed that little or no adjustments had been made over the course of the year. This inspection resulted in the department concerned being place under strict supervision and sometime later NOVO closed this department.

The “Roelie” case does not stand alone

The Dutch TV show ‘Nieuwsuur’ (‘News hour’) came in possession of the video tapes of this incident. NOVO says the broadcasting of these images would be a violation of privacy and asked for summary proceedings. This was declined on August 7th.

Further investigation by ‘Niewsuur’ showed that the “Roelie” case does not stand alone. This year a number of unannounced inspections were conducted in The Netherlands in institutions for people with a cognitive disability, such as NOVO.

The inspection visited 44 of the 140 similar institutions in The Netherlands. Out of this investigation it appears that 64% of them do not even meet the minimum normal standards. Only 9 % of the remaining institutions meet the norms partly and merely 27% meet them fully.  In what areas do these institutions score so badly on? Well, in 52% of the cases it is about the quality of the staff. Also, many times freedom restricting measures are taken in situations in which they are not allowed. Freedom restriction measures mean, isolating, locking up, tying a person down or the forced administration of medication. 14% of the institutions in which only voluntary patients are residing still use freedom restricting measures, even though this is against the law.

According to Vera Bergkamp, member of parliament for D66 (a social liberal party), the following two points are highly important in the upcoming months in terms of care for people in an institution. At first, there is an enormous need for a wide investigation on the situation in institutions in order to form a global view on this. Secondly, there is the law ‘care and coercion’ that needs to be discussed in the parliament as soon as possible, so there will be more clarity in terms of the use of freedom restricting measures.

‘Nieuwsuur’ invited NOVO to their studio to talk about the case. They reacted in writing-“NOVO thinks privacy is majorly significant. Because of these images the personal interests of the involved clients and employees could be compromised. ‘Nieuwsuur’ came into possession of these images incorrectly and that is why NOVO does not want to cooperate. NOVO also points out that Justice has dismissed the case because the action taken was in self-defense and that the tribunal decided there was no wrongful death. This does not take away that we regret this incident highly and that we sympathize with all people involved.”

What do we learn from this?

If cases such as ‘Roelie’ can happen in a country like The Netherlands, it seems very naïve and even stupid to believe that something like this cannot happen all over Europe. This is not just something from a dark past or poor and corrupt countries. Not so long ago, we also had the case ‘Van Inghen’ in the Netherlands, where young Brandon was chained to a wall for years in a windowless cell. In the U.K the systematic abuse of disabled people in the ‘Winterbourne View’ institution was revealed. In Flanders a few years ago a caretaker was condemned for sexual assault of several disabled people in a residential institution.

ENIL & the Independent Living Movement is of course deeply shocked and indignant by the death of Roelie. Not only is the behavior of the caretakers and the responsible management impermissible, it is also infuriating that neither Justice or the Government held someone liable. Again the conclusion is that we, disabled people, can be deprived from our human rights easily and without someone being held accountable and that we cannot enjoy equal protection by law, even in prosperous West-European democracies.

This is especially a threat when in institutional care. The life of a disabled person is apparently worthless? Human rights don’t count any more when you have the label of ‘handicap’?

A lot of services and institutions for disabled people do a good job and without a doubt their staff engages itself with heart and soul for their clients good. But, if  people live in separately, in ‘separate’ groups, then there is a possibility that people become institutionalized. This always holds a threat for someone’s development, life chances, freedom and rights. Institutional ‘care’ always has some risks and can lead to horrible situations. Disabled people can still be treated like second class citizens and this is still tolerated and accepted by society. To really solve this issue, we need to change society.

This is why ENIL keeps on pleading for de-institutionalization and the complete change of course from care in separated institutions to support people to live and be a part of society. The choice to choose a day care center or residential facility can be a possibility, but only if it is a truly free, informed choice between different alternatives. The current situation in Europe, without an absolute effective right on Independent Living, does not really allow such a free choice. As a social movement, we try to support disabled people to be strong and to let us take our full place in society. That is why we keep on striving for personal assistance, community based services and the full implementation of the UNCRPD, so we disabled people can take and hold our lives in our own hands.

Weblink to the Nieuwsuur TV broadcast (in Dutch):

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