Incheon psychiatric hospital referred over four patient deaths; police search it
In short
South Korea’s National Human Rights Commission said on Oct 6 it referred the director of Won Hospital, a psychiatric hospital in Incheon’s Michuhol district, to the Serious Crimes Investigation Agency on charges including professional negligence resulting in death, confinement and ordering unlicensed medical practice, after four inpatients died between January and June. The commission found no medical staff were stationed from 10 p.m. to 7 a.m., that an autistic patient was held about 200 days in a room locked from the outside without a doctor’s order, and recommended administrative action including a business suspension. Police began searching the hospital the same morning.
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South Korea’s National Human Rights Commission said on Oct 6 that it had referred the director of Won Hospital, a psychiatric hospital in Incheon’s Michuhol district, to the Serious Crimes Investigation Agency on charges including professional negligence resulting in death, confinement and ordering unlicensed medical practice, and violations of record-keeping duties. Nurses’ aides and caregivers were referred separately on charges of violating seclusion and restraint procedures. The commission said this was the first time it had referred a psychiatric hospital over long-term seclusion as confinement and the first time it had recommended that administrative punishment be considered against a medical institution, Yonhap and Kyunghyang Shinmun reported. Seoul Economic Daily reported that under a revised Criminal Procedure Act in force from Oct 2, criminal complaints filed by the commission go to the Serious Crimes Investigation Agency. [ 2 , 4 , 5 , 7 , 8 ]
According to the commission, four patients were found in cardiac or respiratory arrest between January and June and died the same day or within three days. Yonhap reported that a dementia patient in an isolation room was found in cardiac arrest in January during a dawn period when no medical staff were in the hospital and died of traumatic subdural haemorrhage; an intellectual-disability patient who had lived 325 days alone in a locked room was found in cardiac arrest in February and died of choking in the transfer vehicle; a schizophrenia patient died of gastrointestinal bleeding in March; and an alcohol-dependence patient died in June after breathing difficulty while eating cup ramen. Kyunghyang Shinmun reported that three of the four were found with no medical staff present at all, and that in one case, where a nurse was working at the hospital, no staff were on the floor where the incident happened and another inpatient carried out CPR and the Heimlich manoeuvre. Asia Economy reported that seven inpatients were transferred to other hospitals by ambulance in the first half of the year and four of them died, with causes given as choking, airway obstruction by a foreign object, traumatic subdural haemorrhage and suspected gastrointestinal bleeding. [ 2 , 4 , 5 , 7 ]
The commission found that the hospital did not station medical staff from 10 p.m. to 7 a.m., leaving nurses’ aides and caregivers to handle patients, and judged that the overnight seclusion and restraint amounted to unlicensed medical practice, the documents said. [ 4 , 5 , 7 ]
The commission also reported that an autistic patient was held about 200 days in a room locked from the outside, from Jan 3 to July 22, after being accused of stealing another patient’s coffee, with no psychiatric specialist’s order or records of the measure. Asia Economy reported that of 31 instances of seclusion and restraint recorded over one month from June, five were carried out by nurses’ aides and caregivers without a doctor’s instruction. Kyunghyang Shinmun and Seoul Economic Daily reported that of eight closed wards only four had public payphones, that patients’ mobile phones were banned and that calls were allowed once a week on a set day. [ 2 , 4 , 5 , 7 ]
Yonhap reported that six patients were processed as voluntary or consent admissions although they had difficulty communicating, and that five told investigators they had never agreed to be admitted. [ 7 ]
The commission recommended that the local public health office take administrative action including a business suspension or revocation of the hospital’s licence, and asked the health minister to correct the practice of not staffing night-duty medical personnel. Asia Economy reported that the hospital has 143 beds and had 111 inpatients as of July 22. [ 2 , 5 , 7 ]
Also on Oct 6, police began searching the hospital. Newsis reported that the Incheon Metropolitan Police Agency’s metropolitan crime investigation unit sent five investigators from 10 a.m. to seize medical records, that an earlier complaint of professional negligence had been filed over the hospital, and that police had learned from the commission of three further deaths. A police official said the search was under way and declined to give further details. The documents contain no response from the hospital to the allegations. [ 8 ]
Why it matters
The case puts the oversight of private psychiatric hospitals and the use of seclusion and restraint before prosecutors and police, with the commission recommending administrative punishment of a medical institution for the first time. If the recommended suspension or licence revocation proceeds, it would set a precedent for how regulators treat patient-safety failures in psychiatric care. The referral also tests the route that now sends the commission’s criminal complaints to the Serious Crimes Investigation Agency.
Key facts
- The National Human Rights Commission said on Oct 6 it referred the director of Won Hospital in Incheon’s Michuhol district to the Serious Crimes Investigation Agency on charges including professional negligence resulting in death, confinement, ordering unlicensed medical practice and violations of record-keeping duties. [ 2 , 4 , 5 , 7 , 8 ]
- Four inpatients were found in cardiac or respiratory arrest between January and June and died the same day or up to three days later. [ 4 , 5 , 7 , 8 ]
- The commission found the hospital stationed no medical staff from 10 p.m. to 7 a.m., leaving nurses’ aides and caregivers to carry out seclusion and restraint. [ 2 , 4 , 5 , 7 , 8 ]
- An autistic patient was held about 200 days in a room locked from the outside, with no psychiatric specialist’s order or records of the measure. [ 2 , 4 , 5 , 7 ]
- The commission recommended that the local public health office take administrative action including a business suspension, and asked the health minister to correct the practice of not staffing night-duty medical personnel. [ 2 , 4 , 5 , 7 ]
- Police began searching the hospital on Oct 6 from 10 a.m. with five investigators, seizing medical records. [ 8 ]
- The hospital had 143 beds and 111 inpatients as of July 22. [ 2 ]
- Of eight closed wards, four had public payphones; patients’ mobile phones were banned and calls were allowed once a week on a set day. [ 4 , 5 ]
Confirmed by several sources
- The commission referred the hospital director to the Serious Crimes Investigation Agency over the deaths, confinement and unlicensed medical practice, and referred nurses’ aides and caregivers over violations of seclusion and restraint procedures. [ 2 , 4 , 5 , 7 , 8 ]
- Four patients were found in cardiac or respiratory arrest between January and June and died the same day or within three days. [ 4 , 5 , 7 , 8 ]
- An autistic patient was confined about 200 days in a room with an outside lock, with no psychiatric specialist’s order or records of the measure. [ 2 , 4 , 5 , 7 , 8 ]
- The hospital left no medical staff on site from 10 p.m. to 7 a.m., leaving nurses’ aides and caregivers to handle patients. [ 2 , 4 , 5 , 7 , 8 ]
- The commission recommended that the local public health office take administrative action including a business suspension, and asked the health ministry to improve practices at psychiatric institutions. [ 2 , 4 , 5 , 7 ]
- The commission said it was the first time it had referred a psychiatric hospital over long-term seclusion as confinement and the first time it had recommended that administrative punishment be considered against a medical institution. [ 2 , 4 , 5 ]
Still unclear
- Whether the four deaths resulted from the hospital’s failures in a legal sense The commission judged that the director failed his duty of care and referred him; no court has ruled on the charges.
- The scope of the police investigation and any additional deaths it is examining One report, citing police, says police learned from the commission that three more patients had died at the hospital; other documents describe four deaths from January to June and give no further detail.
- Discrepancies in the accounts of the deaths Asia Economy says seven inpatients were transferred by ambulance in the first half of the year and four died, while other documents describe four patients found in arrest; Kyunghyang Shinmun says three of the four were found with no medical staff at all, while one occurred when a nurse was working at the hospital but not on that floor.
- The hospital’s response to the allegations and the referral The documents carry no statement or comment from the hospital or its staff.
- Whether the recommended administrative punishment will be imposed The commission only recommended action to the local health office and the health ministry; the documents do not say what those bodies decided.
What local media are saying
Timeline, local time
- January 3: the hospital places an autistic patient in a room locked from the outside, where the commission says he stayed until July 22, about 200 days. [ 2 ]
- January: a dementia patient in a protection room is found in cardiac arrest during a dawn period when no medical staff were at the hospital, and dies of traumatic subdural haemorrhage. [ 7 ]
- February: an intellectual-disability patient who had spent 325 days alone in a locked room is found in cardiac arrest and dies of choking in the transfer vehicle. [ 4 , 7 ]
- March: a schizophrenia patient is found in cardiac arrest at night with no medical staff present and dies of gastrointestinal bleeding. [ 7 ]
- June: an alcohol-dependence patient develops breathing difficulty while eating cup ramen and dies later of multiple organ failure. [ 4 , 7 ]
- Daily from 10 p.m. to 7 a.m.: no medical staff are stationed at the hospital, and nurses’ aides and caregivers handle seclusion and restraint, the commission found. [ 4 , 5 , 7 ]
- July 2: the commission makes an unannounced visit over a complaint about poor meals and restricted outside contact, and finds restraints and outside locks on wards. [ 5 , 7 ]
- July 16: the commission decides to open an own-initiative investigation. [ 5 , 7 ]
- Oct 6: police begin searching the hospital with five investigators and seize medical records. [ 8 ]
- Oct 6: the commission announces the criminal referral and its recommendations. [ 2 , 4 , 5 , 6 , 7 ]
- Oct 6: a report says police are carrying out the search and that the hospital director and staff were referred the same day. [ 8 ]