Miscarriages of JusticeUK

[UK Government has a 'Duty of Care' To Prevent Suicide in Prison]

Chamber judgment in the case of Ketreb v. France(application no. 38447/09), which is not final', the European Court of Human Rights held, by a majority, that French Authorities Failure to Prevent Suicide in Prison had been:

Violation of Article 2 (right to life) of the European Convention on Human Rights; and,

Violation of Article 3 (prohibition of inhuman or degrading treatment) of the Convention.

The case concerned the suicide in prison, by hanging, of a drug addict convicted of armed assault. The Court found that the State had failed in its duty to show particular vigilance to prevent a vulnerable prisoner from committing suicide.

Principal facts
The applicants, Houria Serghine, nee Ketreb, and Noura Khiat, nee Ketreb, are French nationals who were born in 1969 and 1975 and live in Montigny-Ies-Cormeilles and Sannois (France) respectively. They are the sisters of Kamel Ketreb.

On 10 June 1998 Kamel Ketreb was remanded in custody in La Sante prison (Paris) on a charge of armed assault, as a reoffender, against his partner, resulting in her total unfitness for work for more than eight days. The following day, having been a polydrug addict for several years, he was allowed to see a psychiatrist from the prison's Regional Medical and Psychological Service (RMPS), and subsequently continued to see the psychiatrist once or twice a month.

From July 1998 onwards he saw a psychiatrist between once and three times a week. On 4 October 1998 he was placed in the punishment block following an incident with a prison guard. On 8 January 1999 he was given a ten-day disciplinary sanction for insulting and jostling a member of staff, and on the same date a doctor prescribed him Mogadon and a Valium injection, and scheduled a consultation for him with a psychiatrist. The doctor mentioned in writing in the medical file that, according to the guards, Kamel Ketreb had already made two attempts to commit suicide. On 13 January 1999 a psych iatrist from the RM PS observed that he was not at a II well a nd seemed "capable of putting his suicidal inclinations into effect".

On 16 March 1999 Kamel Ketreb was sentenced to five years' imprisonment.

On 20 May 1999 he was brought before the disciplinary board for having wounded a fellow prisoner with a broken glass and insulted two prison officers. He was also accused of hoarding medicinal drugs. He was given two weeks in a disciplinary cell.

On his first day in the disciplinary cell he had to be moved to another cell after breaking a Plexiglas window. In the new cell he partly dislodged the concrete table, broke the sanitary fittings and hurled chunks of concrete at the window.

On 21 May 1999 Kamel Ketreb broke the window in the visiting room door when one of his sisters went to visit him, cutting his forearm and hand in the process. After that incident he was examined by a doctor from the Outpatient Unit, who gave him an anxiolytic. On 23 May 1999 a doctor from the Outpatient Unit found him unwell.

On 24 May 1999 the guard who did his round between 8 and 8.20 p.m. said that he had seen Kamel Ketreb standing in the middle of his cell. At 9.15 p.m. the same guard found him hanging from a bar of the inner door of his cell by a fabric belt fastened with a metal buckle. The prison medical staff and the emergency medical team attempted to revive him, but to no avail. His time of death was recorded as 9.30 p.m.
Complaints, procedure and composition of the Court

Relying on Article 2 (right to life), the applicants complained that the authorities had failed to take proper steps to protect their brother's life when he was placed in the disciplinary cell in La Sante prison.

Relying on Article 3 (prohibition of inhuman or degrading treatment), they complained that the disciplinary measure applied to their brother was unsuitable for a person in his state of mind.

Decision of the Court - Article 2
The Court had already emphasised in previous cases that persons in custody were in a vulnerable position and that the authorities were under a duty to protect them. There were general measures and precautions available to diminish the opportunities for selfharm without infringing on personal autonomy. Lastly, the Court reiterated that in the case of mentally ill persons it was necessary to take their particular vulnerability into consideration.

The Court observed that as early as 11 June 1998, the day after his arrest, Kamel Ketreb had seen a psychiatrist from the Regional Medical and Psychological Service (RMPS) at the prison, as well as a psychologist. The Court further noted that it had been mentioned that some months before he committed suicide, Kamel Ketreb had already tried to commit suicide twice while placed in the punishment block. On 13 January 1999 the psychiatrist had noted that he talked quite openly about his intention to kill himself.

The days leading up to his suicide had been marked by violent incidents that bore witness, if not to a serious psychological crisis, at least to an alarming deterioration in his state of health. According to the experts, it was likely that his transfer to the punishment block had occurred at a time when his mental balance was already fragile. In their opinion the conditions of detention in the punishment block and the pronouncement of the judgment sentencing him to five years' imprisonment were what spurred him to action and predisposed him to take his own life, in addition to his mental condition, which was one of depression or considerable distress.

The Court had to determine whether the authorities had done all that could reasonably have been expected of them to prevent the risk of a new suicide attempt.

The Court noted that from the time when he was remanded in custody Kamel Ketreb had had access to general practitioners and specialists. He had been monitored by the doctor in charge of the drug addiction branch of the RMPS. The consultations were more or less frequent, depending on his changing mood, and he had also seen a psychologist from the prison two or three times a week. It also appeared from the expert opinion and the second opinion commissioned by the investigating judge that the treatments prescribed were justified by his psychiatric condition and his state of agitation.

The Court also noted a number of shortcomings, however. No particular notification had been given to the competent medical service prior to or at the time of the decision to place the prisoner in a disciplinary cell, and no special surveillance instructions had been issued to ensure the compatibility of the disciplinary measure with Kamel Ketreb's mental health. The Court pointed out that Recommendation R(98)7of the Committee of Ministers of the Council of Europe recommended that the risk of suicide should be constantly assessed by both medical and custodial staff.

The Court noted that the mention of the two suicide attempts by hanging in January 1999 when Kamel Ketreb was in the punishment block, his self-mutilation and his behaviour at the origin of the disciplinary measure should have alerted the authorities to his psychological vulnerability. It saw no particular reason to justify the failure to consult the psychiatric branch of the prison's RMPS, which was actually responsible for monitoring the prisoner's mental health. In the days preceding the suicide, different duty doctors from the Outpatient Unit had examined Kamel Ketreb during his stay in the punishment block and found him unwell. Yet they had not informed the RMPS, or requested the urgent assistance of an outside psychiatrist, even though, as revealed by the investigation division's judgment, a psychiatrist from the Sainte Anne Hospital Centre had been on duty.

It must have been clear to both the prison authorities and the medical staff that Kamel Ketreb's state was critical, and placing him in a disciplinary cell had only made matters worse. That should have led the authorities to anticipate a suicidal frame of mind, as had already been noted during a previous stay in the punishment block some months earlier, and to alert the psychiatric services, for example. Nor had the authorities set in place any special measures, such as appropriate surveillance or regular searches, which might have found the belt he used to commit suicide.

The Court considered that the authorities had failed in their positive obligation to protect Kamel Ketreb's right to life. It followed that there had been a violation of Article 2.

Article 3: The assessment of whether the treatment or punishment concerned was incompatible with the standards of Article 3 had, in the case of mentally ill persons, to take into consideration their vulnerability and their inability, in some cases, to complain coherently or at all about how they were being affected by any particular treatment.

Although in the opinion of the experts Kamel Ketreb had no chronic mental disorder or acute psychotic symptoms, his history of suicide attempts, his psychological condition which the doctors diagnosed as "borderline", and his extremely violent behaviour called for special vigilance on the part of the authorities, who should at least have consulted his psychiatrist before placing him in the punishment block, and generally kept him under proper supervision during his stay.

The Court considered that the prisoner's placement in a disciplinary cell for two weeks was not compatible with the level of treatment required in respect of such a mentally disturbed person. Accordingly, there had been a violation of Article 3.

Just satisfaction (Article 41)

The Court held that France was to pay the applicants jointly 40,000 euros in respect of non-pecuniary damage.

Separate opinion: Judge Zupancic expressed a separate opinion, which is annexed to the judgment.

The judgment is available only in French.

The application was lodged with the European Court of Human Rights on 3 June 2009.
Judgment was given by a Chamber of seven judges, composed as follows:
Dean Spielmann (Luxembourg), President, Mark Villiger (Liechtenstein),
Karel Jungwiert (the Czech Republic), Bostjan M. Zupancic (Slovenia),
Ann Power-Forde (Ireland),
Angelika NuBberger (Germany), Andre Potocki (France),
and also Claudia Westerdiek, Section Registrar.

1 Under Articles 43 and 44 of the Convention, this Chamber judgment is not final. During the three-month period following its delivery, any party may request that the case be referred to the Grand Chamber of the Court. If such a request is made, a panel of five judges considers whether the case deserves further examination. In that event, the Grand Chamber will hear the case and deliver a final judgment. If the referral request is refused, the Chamber judgment will become final on that day.

Once a judgment becomes final, it is transmitted to the Committee of Ministers of the Council of Europe for supervision of its execution. Further information about the execution process can be found here: www.coe.int/t/dghl/monitoring/execution