CEDH · CASELAW;DECISIONS;ADMISSIBILITY;ENG — 29 avril 2008

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She was represented before the Court by Ms A. Mircheva, a lawyer practising in Sofia. The Bulgarian Government (“the Government”) were represented by their Agent, Ms M. Kotseva, of the Ministry of Justice. The applicant had two previous applications with the Court (nos.   46587/99 and 77117/01), in both of which she complained, inter alia , about her conditions of detention between 1993 and 2001 and the medical care she received in custody (see below). In application no. 46587/99 the applicant also raised a complaint in respect of the fairness of the 1993 ‑ 96 criminal proceedings against her (see below). These applications were declared inadmissible by committees of three judges, acting under Article   28 of the Convention, on 27 April 1999 and 8 November 2002 respectively. A.     The circumstances of the case The facts of the case, as submitted by the parties, may be summarised as follows. 1.     The criminal proceedings against the applicant, her convictions and terms of imprisonment Between 1971 and 1987 the applicant was convicted six times of various offences and sentenced to several terms of imprisonment, which she served before 1990. Between 1991 and 1993 the applicant committed a number of offences of fraud in Sofia. She was arrested on 1 July 1993. Later she was charged and prosecuted. On 6 June 1996 the Sofia District Court found her guilty and sentenced her to ten years’ imprisonment. Her conviction and sentence were upheld by the Supreme Court on 11 December 1996. On 11 July 1997 the Sliven District Court convicted the applicant of insulting a prison officer and sentenced her to six months’ imprisonment. On 17 December 1999 the Sofia District Court convicted the applicant of falsely accusing two investigators and another official of bribery, and sentenced her to three years’ imprisonment. In a decision of 7 December 2000 the Sofia District Court joined the three punishments and imposed a global term of imprisonment of thirteen years. In a decree of 16 July 2001 the President of the Republic partially pardoned the applicant. 2.     The applicant’s medical conditions According to the medical documents in the file and the applicant’s submissions in her observations, she suffers from the following medical conditions: (i) chronic bronchitis, diagnosed in 1997, but having first developed a few years earlier; (ii) bronchial asthma, diagnosed in 1998 as a complication of the chronic bronchitis; (iii) arterial hypertonia, diagnosed for the first time in 1998; (iv) chronic hydronephrosis of the right kidney, diagnosed in 1998, but which had first occurred earlier; (v) a cyst on the left ovary; (vi) polyallergy to contrast media; (vii) reactive depression; and (viii)   neurosis. 3.     The applicant’s detention between 1994 and 2001 The applicant started serving her sentence in the Sliven Prison for female offenders on 6 January 1994. On 15 April 1998 her sentence was interrupted until 8 June 1998 for medical reasons. As she did not return to prison, she was put on the national list of wanted persons and on 15 August 1998 was arrested and sent back to Sliven Prison. The applicant’s sentence was interrupted again on 7 November 1998 until 8 January 1999. As she failed to return once more, she was arrested on 14 January 1999 and sent to Sliven Prison on 1 February 1999. A further interruption was granted on 19 May 1999, until 15 November 1999. As she again did not return to prison, she was arrested on 27 April 2000 and sent there. Another interruption was granted between 5 April 2001 and 23 June 2001. The applicant returned to prison on 25 June 2001. It seems that each time the applicant was arrested and returned to prison, she did not produce any documents showing that she had used the interruption of her sentence for medical treatment and provided no specifics of the medical examinations of treatments she had undergone while at liberty. On one occasion, in 1999, she claimed that she had consulted three doctors from the hospital of the Ministry of Internal Affairs. When contacted by the prison authorities, the doctors denied ever having met the applicant. The latest interruption of the applicant’s sentence for medical reasons was granted on 13 December 2001, until 10 June 2002. She did not return to prison. While in prison, the applicant underwent many medical examinations and tests. On a number of occasions she refused to submit to tests. 4.     The applicant’s detention since February 2004 (a)     The detention in the Pirdop investigation detention facility On 18 February 2004 the applicant was arrested by the Pirdop police on suspicion that she had used a forged identity card to pass herself off as another person. She was charged with knowingly using false documents. On 20 February 2004 the Pirdop District Court decided to place the applicant in pre ‑ trial detention. She was sent to an investigation detention facility in Pirdop. On admission she was medically examined. The facility was situated on the premises of the Pirdop police department in the town centre. According to the description provided by the Bulgarian Helsinki Committee on the basis of a visit carried out in 2004, it had three cells, each measuring approximately three by two metres, with high ceilings. Each cell had a two ‑ level metal bed with mattresses, two blankets and pillows, as well as a small table and two small chairs. Additional blankets and bed sheets were provided upon request. The mattresses and blankets were clean but worn out. The cells did not have sanitary facilities. They did not have windows, but only openings in the doors, and were equipped with not very bright luminescent light bulbs, with the result that the lighting in them was dim, especially when the windows in the corridor, which were painted brown, were closed. The cell walls were frequently repainted and were in a satisfactory condition. While no outdoor exercise was available, the detainees were taken out of the cells for meals and the toilet for about thirty minutes three times a day; during this time the cell doors and the windows in the corridor were left open for ventilation. Meals were served in a separate room with a table, chairs, a sink and metal lockers for the detainees’ personal belongings. Adjacent to this room were the bathroom and the toilet. The toilet, which was of the Asian type, was quite dilapidated. The bathroom had a boiler, which made possible a shower twice a week. No time ‑ limits were placed on showering. The detainees were not forced to use buckets to relieve themselves in the cells. The facility did not have a medical unit or resident medical staff. On arrest detainees were taken to the Pirdop local emergency service for examination. Whenever a detainee needed a doctor or a dentist, he or she was transported in a police car to the local hospital or an outside doctor was called. There were eleven officers on the staff, none of them female. When necessary, a female police officer was called from the local police station. The facility was closed at the end of 2006 as part of a programme for the improvement of pre ‑ trial detention facilities in the country in the run ‑ up to its accession to the European Union. During her stay in the facility the applicant was apparently not banned from accessing the toilet every time she needed to do so. However, each time she had to notify the guards, who were all male. On 28 March and 8 April 2004 the applicant was medically examined. On both occasions she complained of pain in the chest and the lumbar area; the doctors’ conclusions were that her state of health did not require hospitalisation and that she could remain in the facility. The applicant’s stay in the facility was interrupted several times by transfers to another investigation detention facility in Sofia, where she had to appear for court hearings. These transfers took place between 25   February and 5 March, between 16 and 23 March, and between 9 and 15   April 2004. This facility provided better conditions; there was abundant access to natural light during the day and proper lighting at night, sanitary facilities in the cells and good ventilation. On being admitted to the investigation detention facility in Sofia on 16   March 2004, the applicant informed the resident doctor that she suffered from hydronephrosis. She was then taken for an examination at the Sofia Prison hospital, where she was prescribed medication. According to the doctor servicing the medical centre of the Sofia detention facility, the applicant had not mentioned other conditions or symptoms and had not exhibited external signs of illness during the routine admission check ‑ ups. On 9 April 2004 the applicant, represented by an ex officio counsel, entered into a plea agreement with the prosecution in respect of the charges of using false documents. The agreement was upheld by the Pirdop District Court at a public hearing held on 20 April 2004. The applicant was sentenced to six months’ imprisonment, which she was to serve after the expiry of her initial thirteen ‑ year sentence. On 21 April 2004 the Pirdop District Prosecutor’s Office sent a copy of the plea agreement to the Ministry of Justice, advising it that the applicant was to be transferred to Sliven Prison within three days. However, due to a lack of suitable transport she remained in Pirdop. On 26 April 2004 the applicant complained to the prosecution authorities about not being transferred to Sliven Prison. After conducting an inquiry, in a decision of 16 June 2004 the Sofia Regional Military Prosecutor’s Office refused to open a criminal investigation against the officials allegedly responsible for the delay. The applicant did not appeal against this decision. In the meantime, on 3 May 2004, the applicant was transported to Sliven Prison. (b)     The detention in Sliven Prison On admission to Sliven Prison the applicant underwent a medical check ‑ up. It was found that she was suffering from a viral infection and she was treated with antibiotics. As the applicant apparently made a number of complaints relating to her state of health, in June 2004 the prison administration arranged for her to be transferred to the Sofia Prison hospital for tests. On 21 June 2004 the applicant was offered the opportunity to go to that hospital but refused. However, some time later, on 1 July 2004, the applicant was admitted to the Sofia Prison hospital. She remained there until 20 July 2004. On 12 July 2004 a medical committee from the hospital informed the warden of Sliven Prison and the Sliven Regional Court that the applicant’s main ailment was a chronic hydronephrosis of the right kidney and that none of her other conditions required hospital treatment. They further noted that the applicant had refused to undergo tests which she had been offered in an outside hospital. Their conclusion was that the applicant’s conditions were not in an acute phase and did not require an urgent interruption of her sentence on medical grounds. On 8 September 2004 the Sliven Regional Prosecutor’s Office turned down a request by the applicant for an interruption of her sentence. On 16 November 2004 the applicant was examined by a urologist in a hospital in Sliven. He was of the opinion that surgery might be necessary if her kidney problems worsened. On 23 November 2004 the applicant had a consultation with a psychiatrist. In a decision of 24 November 2004 the Sliven Regional Prosecutor’s Office rejected another request by the applicant for an interruption of her sentence on medical grounds. The office stated, after having obtained the observations of the warden of Sliven Prison and a medical certificate, that the medical treatment required could be dispensed in the Sofia Prison hospital. It was thus unnecessary to release the applicant from custody. On 28 January 2005 the applicant was transferred to a detention facility in Sofia, so as to be able to attend a hearing listed before the Sofia District Court. She remained in that facility until 9 February 2005. On admission she underwent a medical check ‑ up. She informed the medical staff that she was suffering from bronchial asthma, arterial hypertonia, a valvular defect and hydronephrosis. She accordingly underwent three further check ‑ ups and was monitored throughout her stay in the facility. In view of the applicant’s stable condition the facility medical staff saw no need to refer her to an outside hospital. On 22 February 2005 the applicant was sent for tests to a hospital in Sliven where she was allegedly given an injection. It seems that on 23 February 2005 the applicant was admitted to the Sofia Prison hospital for treatment for an unspecified amount of time. On 14 March 2005 the applicant was examined by a special medical committee for pulmonary diseases for the purpose of establishing the degree of her disability for pension purposes. The committee found that the applicant was suffering from asthma and chronic hydronephrosis, and concluded that she was 44% disabled. On 23 June 2005 the applicant was again examined by the central special medical committee for pulmonary diseases. In a decision of 30 June 2005 the commission reversed the other medical commission’s finding and established that the applicant was suffering from light to intermediate persistent bronchial asthma, a cyst on the left kidney, a cyst on the left ovary and a dissociative personality disorder, and concluded that she was 36% disabled. The commission recommended that the applicant refrain from hard physical labour and avoid damp or dusty spaces, as well as cold environments. On 11 June 2005 the applicant and four other inmates, who were, like her, in group 7 (see below, paragraph 84 of the report of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment from their visit in Bulgaria in 2006), were not allowed to attend a play staged by a theatre company from Sofia for the inmates. The warden had based this decision on security considerations, after an incident which had taken place in the prison cinema a few days earlier, on 8 June 2005, and because the maximum number of persons who could attend the play was 220, whereas the total number of prisoners was 321. On 26 July 2005 the applicant was examined by a cardiologist and prescribed medication. On 7 October 2005 the Sliven Regional Military Prosecutor’s Office, after conducting an inquiry, rejected the applicant’s request to open a criminal investigation against members of the prison staff who had allegedly breached the law by not allowing her to attend the theatre play. On 5 October 2005 the applicant asked to be admitted to the Sofia Prison hospital. This happened on 21 October 2005. On admission she complained of breathing difficulties and pain in the right lumbar area. She remained there until 26 October 2005 and was diagnosed with chronic non ‑ obstructive bronchitis, bronchial asthma, high blood pressure, hydronephrosis, and neurosis with mood swings. She underwent urine and blood tests and several medical examinations. The conclusion of the doctors was that her overall state of health was satisfactory and that she could return to Sliven Prison as she had requested. They expressed the view that the real cause of her admission to hospital had to do with “non ‑ medical” issues and her behaviour was actuated by “her neurosis with mood swings”. According to Government, during her stay at the hospital the applicant had been rude to the medical staff and had refused to submit to certain medical tests. According to the applicant, there was no need for her to remain in the hospital any longer, as the doctors had refused to subject her to certain tests which she had considered important. On 4 November 2005 the applicant was examined by a surgeon in Sliven who found that she had a verruca on her left thigh. He proposed removing it on the spot, but the applicant refused. On 28 November 2005 the applicant was examined by a urologist. He apparently recommended that she undergo kidney surgery. He also suggested that she undergo a scintigraphy and an isotope nephrogram and noted that she had a polyallergy to contrasting matters. The Sliven Prison medical staff informed the applicant that the prescribed tests could be administered at the Sofia Prison hospital, but she refused to undergo such tests. On an unspecified date in November or December 2005 the applicant requested an interruption of her sentence, citing the need to undergo kidney surgery and to have a mole removed. By a decision of 12 December 2005 the Sliven Regional Prosecutor’s Office refused the request, noting that, according to the opinion of the medical committee at Sliven Prison, the applicant could be treated in the Sofia Prison hospital, which obviated the need for such an interruption. On 5 January 2006 the Sliven Regional Prosecutor’s Office turned down a further request for an interruption of the applicant’s sentence on medical grounds. It reasoned that the applicant had on numerous occasions been treated at prison hospitals in Sliven and in Sofia and that the necessary medical tests and treatment could be carried out at the Sofia Prison hospital. According to the opinion of the medical committee at Sliven Prison, there was no need to interrupt her sentence on medical grounds. On 18 January 2006 the applicant was taken out of prison to be examined by a cardiologist in Sliven and undergo a electrocardiogram. The doctor who examined the applicant was of the opinion that she had to remain as an inpatient because of a worsening of her bronchitis. A hospital bed was made available, but the applicant refused to submit to treatment. However, she underwent an X-ray and laboratory tests. On 2 March 2006 the Sliven Regional Military Prosecutor’s Office, after interviewing the applicant and taking note of a number of relevant medical documents, refused to open criminal proceedings pursuant to her allegations that the warden and medical staff of Sliven Prison were not doing what was necessary to preserve her health while she was in custody, and were understating her health problems in their letters to the competent prosecutor’s offices. On 30 June 2006 the applicant was taken out of prison and examined by a cardiologist. She underwent a cardiogram and an echocardiography. It was found that she was suffering from arterial hypertonia. She was prescribed drug treatment whose costs were borne by the prison’s medical centre. On 1 August 2006 the applicant was examined by a pulmonologist, as she had had a bronchial attack. She was prescribed medication, but refused to take it. On 13 August 2006 a medical committee of the Sofia Prison hospital expressed the opinion that the applicant’s conditions were all chronic and could be treated with medication. None of them required urgent admission to a hospital. In particular, the problem with her right kidney had been stable for five years and there was no obvious need to remove the kidney. The commission further noted that on previous occasions the applicant had abused the interruptions of her sentence, and recommended that her request for a further interruption be turned down. She could be treated in the Sofia Prison hospital or as an outpatient in Sliven Prison. In reply to a request for an interruption of the applicant’s sentence on medical grounds, on 25 September 2006 the head of the medical centre of the Sliven Prison expressed the opinion that it was possible to treat her in the prison hospital system or in the Sliven Regional hospital, if she expressed such a wish. Between 15 December 2006 and 1 January 2007 the applicant was granted an interruption of her sentence for the purpose of medical treatment. It is unclear whether she in fact submitted to such treatment. On 29 November 2007 the applicant was apparently examined by three urologists. On 22 and 30 January 2008 the applicant was seen by a doctor in Sliven. He examined her lungs, found that she suffered from asthma, with attendant chronic obstructive pulmonary disease, and prescribed treatment with pills and inhalers. It seems that during most of her stay in Sliven Prison after 2004, the applicant visited its medical centre at least once a week. The journal of the centre recorded fifty ‑ four such visits in 2005. During 2004 and 2005 the applicant received disciplinary measures eight times and was cautioned more than twenty times, most often for rude and aggressive behaviour towards other inmates and prison staff. Throughout the years the prosecution authorities opened a number of inquiries pursuant to complaints by the applicant against prison guards and other officials. However, each time they decided not to open criminal proceedings. Apparently the applicant did not appeal against these decisions. (c)     The applicant’s attempts to have the criminal proceedings against her reopened From 2004 to 2006 the applicant apparently made several requests to have the 1993 ‑ 96 criminal proceedings against her reopened, which were all turned down. B.     Relevant domestic law and practice 1.     The 1974 Code of Criminal Procedure Under Article 425 § 3 of the 1974 Code of Criminal Procedure, a prison sentence can be interrupted if the inmate is suffering from a serious medical condition, until recovery. There is no reported case ‑ law clarifying what may be considered a “serious medical condition”. Under Article 426 § 1 of the Code, in force until 1 January 2000, the authority competent to interrupt a sentence in all cases was the regional prosecutor. From that date until the end of April 2001 the regional prosecutor could only order an interruption of up to seven days. If the interruption was for a longer period, it could be ordered by the chairperson or a specifically authorised deputy chairperson of the appropriate regional court (Article 426 § 1 of the Code, as in force between 1 January 2000 and the end of April 2001). In April 2001 the Code was amended to provide that interruptions for periods longer than seven days could only be ordered by a panel of the appropriate regional court (Article 426 § 1 of the Code, as amended in April 2001). In May 2003 competence to order an interruption was again vested in the regional prosecutor, irrespective of the period of the interruption. 2.     The 2005 Code of Criminal Procedure Under Article 447 § 3 of the 2005 Code of Criminal Procedure, which entered into force on 29 April 2006, a prison sentence may likewise be interrupted if the inmate is suffering from a serious medical condition, until he or she recovers. The authority competent to interrupt a sentence is the regional prosecutor (Article 448 § 1 of the Code). This Code makes no provision for appeal to a court, which means that the prosecutor’s decision is subject to appeal before the higher prosecutor, whose decision is not subject to further appeal (Article 200 of the Code). 3.     The 1969 Enforcement of Punishments Act („Закон за изпълнение на наказанията“) Under section 22(1) of this Act, as amended in 2002, medical treatment for inmates is provided, as a rule, by medical establishments attached to the Ministry of Justice (that is, the prison hospitals). Section 22(2) of the Act provides that if these medical establishments are not suitably equipped to provide certain kinds of treatment, prisoners are to be sent to other hospitals, but are to remain under the same regime, isolation or escort. C.     Relevant Council of Europe documents 1.     Recommendation No. R (98) 71 of the Committee of Ministers Recommendation No. R (98) 71 of the Committee of Ministers of 8 April 1998 concerning the ethical and organisational aspects of health care in prison, provides, in so far as relevant: “ A.     Access to a doctor 1.     When entering prison and later on while in custody, prisoners should be able at any time to have access to a doctor or a fully qualified nurse, irrespective of their detention regime and without undue delay, if required by their state of health. All detainees should benefit from appropriate medical examinations on admission. ... 2.     In order to satisfy the health requirements of the inmates, doctors and qualified nurses should be available on a full-time basis in the large penal institutions, depending on the number and the turnover of inmates and their average state of health. 3.     A prison’s health care service should at least be able to provide out-patient consultations and emergency treatment. When the state of health of the inmates requires treatment which cannot be guaranteed in prison, everything possible should be done to ensure that treatment is given, in all security, in health establishments outside the prison. 4.     Prisoners should have access to a doctor, when necessary, at any time during the day and the night. Someone competent to provide first aid should always be present on the prison premises. In case of serious emergencies, the doctor, a member of the nursing staff and the prison management should be warned; active participation and commitment of the custodial staff is essential. ... 8.     Where appropriate, specific services should be provided to female prisoners. ... ... B.     Equivalence of care 10.     Health policy in custody should be integrated into, and compatible with, national health policy. A prison health care service should be able to provide medical, psychiatric and dental treatment and to implement programmes of hygiene and preventive medicine in conditions comparable to those enjoyed by the general public. Prison doctors should be able to call upon specialists. If a second opinion is required, it is the duty of the service to arrange it. 11.     The prison health care service should have a sufficient number of qualified medical, nursing and technical staff, as well as appropriate premises, installations and equipment of a quality comparable, if not identical, to those which exist in the outside environment. ... C.     Persons unsuited to continued detention: serious physical handicap, advanced age, short term fatal prognosis 50.     Prisoners with serious physical handicaps and those of advanced age should be accommodated in such a way as to allow as normal a life as possible and should not be segregated from the general prison population. Structural alterations should be effected to assist the wheelchair-bound and handicapped on lines similar to those in the outside environment. 51.     The decision as to when patients subject to short term fatal prognosis should be transferred to outside hospital units should be taken on medical grounds. While awaiting such transfer, these patients should receive optimum nursing care during the terminal phase of their illness within the prison health care centre. In such cases provision should be made for periodic respite care in an outside hospice. The possibility of a pardon for medical reasons or early release should be examined. ... E.     Refusal of treatment, hunger strike 60.     In the case of refusal of treatment, the doctor should request a written statement signed by the patient in the presence of a witness. The doctor should give the patient full information as to the likely benefits of medication, possible therapeutic alternatives, and warn him/her about risks associated with his/her refusal. It should be ensured that the patient has a full understanding of his/her situation. ...” 2.     Report of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment on their visit to Bulgaria from 17 to 26 April 2002 In this report (CPT/Inf (2004) 21) the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (“the CPT”) described in detail their findings from visits carried out by them in a number of detention facilities, including the facility where the applicant was brought on three occasions in February, March and April 2004.. The CPT’s findings in respect of this facility were as follows: “...50.     Material conditions at the investigation detention facility at “Major Vekilski” Street in Sofia were distinctly superior to those found elsewhere, and in many respects could serve as a model for the rest of the country. With an official capacity of 112, the facility was holding 82 detained persons (including 3 women). There were twenty-eight cells (measuring some 16 m²) designed to hold up to 4 persons each. Access to natural light, artificial lighting and ventilation were adequate. The cells were furnished with beds with full bedding and personal cupboards, and were neat and clean. All cells were equipped with a sanitary annexe (toilet and sink), screened by a waist-high wall. The corridor areas were monitored by closed circuit television cameras. ...” 3.     Report of the CPT on their visit to Bulgaria from 10 to 21 September 2006 In this report (CPT/Inf (2008) 11) the CPT described in detail their findings from visits carried out by them in a number of penitentiary establishments, including Sliven Prison and the Sofia Prison hospital, in September 2006. The CPT’s findings in respect of them, in so far as relevant, were as follows: “... 83.     Sliven Prison is the only penitentiary establishment for women in Bulgaria. It comprises a closed prison, set up in 1962 on the outskirts on the town of Sliven, a reformatory hostel for girls and a transitory-type prison hostel at the same location, and an open-type prison hostel “Ramanusha” some 10 km from Sliven (not visited by the delegation). With an official capacity of 320, on the first day of the visit the establishment was holding 373 prisoners, of whom 69 were women on remand, 243 were sentenced women held in the closed prison and the transitory facility, 48 were sentenced women accommodated in the open ‑ type hostel, and 13 were sentenced men employed on maintenance jobs in the closed prison. The female prisoner population included 7 juveniles, 3 life-sentenced prisoners and 6 foreign prisoners. 84.     Prisoners were distributed into 10 groups [including Group 7: lifers and other prisoners under special regime] in accordance with their legal status and regime. Prisoner accommodation was provided in the original three-storey building to which two wings had been added over the years, holding, inter alia, the reformatory hostel for girls (...) and the transitory-type hostel (...). Due to ongoing refurbishment works on one of the floors of the main building, there had been some reshuffling of prisoners which had resulted in overcrowding in certain of the cells. For example, in Group 4, five women were being held in a cell of some 14 m², and eight women in a cell of 19   m². In the unit for remand prisoners (Group 2), all the cells were overcrowded (e.g. cells of some 16 m² were accommodating five or six women). In Group 6, cells measuring some 7.5 m² were holding two prisoners each. Access to natural light and ventilation were not a problem, due to the fact that all cells had large, unscreened windows. Artificial lighting was also adequate; however, the electricity supply was reportedly intermittent. The cell equipment (single beds and/or bunks, individual lockers, a table and stools) was generally in a good state, and the cells had a personal touch (curtains, small carpets on the wooden floors, plants, some decoration on the walls). Further, general hygiene was very good. However, the top floor of the main building (Groups 5 and 6) showed signs of disrepair (because of a leaking roof, there was mould on the walls). 85.     There was no integral sanitation in any of the cells. During the day, prisoners could circulate around their units and access to a toilet was not a problem (each unit had a common sanitary facility). However, at night, low staffing levels resulted in delays or failure to provide access to toilets, and prisoners relied on buckets inside their cells. This is not acceptable; as already stressed (...), all prisoners should have access to toilets at all times. Given the special needs of women for ready access to sanitation during menstrual periods, this situation must be addressed as a matter of urgency. 86.     As regards possibilities to maintain personal hygiene, the unit sanitary facilities (with showers, sinks and floor-level toilets) were somewhat dilapidated but clean. Some complaints were heard about the fact that all prisoners in a group had to use the washing facilities during the same limited period of time in the morning and evening, which resulted in conflicts. Hot water was provided for some 20 minutes in the evenings, during which time prisoners also washed their clothes and bed linen. Further, there was hot water for showering for one hour at the weekend. The lack of supply of personal hygiene products was reportedly a problem for some inmates (only the most destitute prisoners received help from donations); apparently, only washing powder and basic materials for women’s monthly needs were provided by the prison. ... 89.     The food appeared to be well prepared and very few complaints were heard about it. Meals were eaten in two dining rooms, with large windows providing a sense of space and light. The delegation was told of plans to refurbish the dining rooms in 2007. The kitchen was scrupulously clean and well organised, despite the ageing equipment. Quantity, quality and hygiene control appeared to be functioning well. 90.     The CPT recommends that steps be taken at Sliven Prison to: –     reduce cell occupancy rates to an acceptable level (a minimum of 4 m² per prisoner); cells measuring 7 m² should not accommodate more than one prisoner (save in exceptional circumstances when it would be inadvisable for a prisoner to be left alone); –     provide sufficient staffing levels at night to enable all prisoners to have ready access to a toilet around the clock; –     provide all inmates with basic hygiene products and seek ways to increase the time during which prisoners have access to hot water during the week; –     pursue the refurbishment programme, in particular on the top floor of the main prison building. ... 92.     Outdoor exercise of one hour per day was provided in various yards in the grounds of the prison. The large central garden and courtyard around which the main prisoner accommodation and educational facilities were situated provided generous space for exercise and recreation, although it appeared to lack shelter from inclement weather. The yard for juveniles and women from the transitory-type hostel had benches, trees and plants. However, the delegation observed that the time taken to escort prisoners to and from the workshops was counted as part of the outdoor exercise time. Whereas the escort time was undoubtedly spent in the open air, this should not be counted as part of the daily hour of exercise. 93.     Some 45% of inmates in the closed prison had work at the time of the visit. Jobs were provided in a sewing workshop (49 prisoners), a workshop for cleaning household goods (34 prisoners) and a workshop for machine parts (21 prisoners), as well as on various tasks related to the upkeep of the prison (23 female prisoners and 13 male prisoners). Complaints regarding work mainly centred on the difficulty of filling the production quota; if the required total was not completed, the day did not count towards reduction of time served or there was a reduction in pay. 94.     The prison had a well ‑ equipped school with a good range of educational facilities and courses. This was important given the estimated need for education, including the 40% illiteracy of the female sentenced population. 82 prisoners were enrolled at the beginning of the new school year. The school also had a computer room and offered vocational training classes as preparation for work in the sewing workshop. Additional vocational training courses (for hairdressers, chefs, pastry-cooks, beekeepers) were organised periodically, when there were sponsors. The pre ‑ release programme included a job club providing individual and group preparation for life after release, using outside trainers. 95.     As regards other activities, the prison had a library with some 16,000 books. The selection of books appeared to be varied; each group had a day for visiting the library for about one hour and prisoners could take out as many books as they wanted. Further, there was a large multi-functional hall where concerts and cinema projections took place, a video club, and a room on each unit where prisoners could watch TV in the evenings. An attractive chapel had been set up, using profits from the prison production and donations, and a part-time post for a priest was being funded from the Ministry of Justice budget. The gym appeared to be the least used facility. It was sufficiently large for basketball games, but was in need of repair. The delegation was told that adult prisoners had access to the gym for one hour per week; however, this was not confirmed by many prisoners with whom the delegation spoke. ... 97.     To sum up, the management team was making strenuous efforts to involve as many prisoners as possible in a variety of activities. The CPT welcomes these efforts and encourages the management of Sliven Prison to continue its efforts to engage more prisoners in work and other purposeful activities. The Committee also invites the prison management to increase the use of the gym and to provide the exercise yards with shelters from inclement weather. ... At the time of the visit, health care at Sliven Prison was provided by a feldsher, a dentist and a part ‑ time gynaecologist; further, a paediatrician periodically visited the creche. The post of director of the prison’s medical centre had been vacant for several months, following the retirement of the GP who used to fill that post. The delegation was informed that the recruitment of a new medical director was being blocked pending the adoption of legislative amendments. There was also a psychiatrist’s post which had been vacant since 2004; as a result, psychiatric care was provided by outside specialists. No qualified health ‑ care staff were present at night and during weekends. 107.     The above-mentioned staff resources were clearly insufficient and had resulted in major failings in the health-care provision at both prisons. Health-care staff were overburdened and failed to provide the requisite food and general hygiene control. Further, the absence of nursing staff led to unacceptable situations, such as the use of prison officers or prisoners working as orderlies for the distribution of medication. At Sliven Prison in particular, the lack of a doctor placed an overwhelming burden on the feldsher (who was doing her best in very difficult circumstances) and resulted, inter alia, in an increased number of referrals to outside consultations. As mentioned in paragraph 7, at the end of the visit the delegation made an immediate observation under Article 8, paragraph 5, of the Convention, requesting the Bulgarian authorities to take urgent action to ensure that a doctor was employed full time at Sliven Prison. In their letter of 13 December 2006, the Bulgarian authorities indicated that the procedure for the selection of candidates for the vacant post was ongoing. The CPT recommends that urgent steps be taken to reinforce the health-care resources at Sofia and Sliven Prisons, and in particular to: –     immediately fill the post of doctor at Sliven Prison; –     fill the post of psychiatrist at Sliven Prison; –     appoint one more general practitioner as well as a psychiatrist at Sofia Prison; –     ensure that both establishments have a sufficient number of nursing staff - as a first measure, immediate action is required to appoint at least two full-time qualified nurses at Sofia Prison and at least one at Sliven Prison; –     ensure that someone qualified to provide first aid, preferably with a recognised nursing qualification, is always present on the premises on Sliven Prison, including at night and weekends; ... 108.     There appeared to be delays as regards transferring inmates for treatment to hospital facilities and access to medical specialists outside the penitentiary system. The procedure for transferring inmates from prisons other than Sofia and Lovech to the two prison hospitals involved a recommendation by the prison doctor which had to be approved first by the prison director and then by the medical division of the General Directorate for the Execution of Sentences, following which the prison had to organise transportation. A random examination of medical files revealed that this chain of administrative decisions could take quite a long time (up to 3 months). The CPT would like to receive the comments of the Bulgarian authorities on this question. ... 109.     Medical examination on admission generally took place on the day of arrival or the following day, but there were a few isolated cases of delays of several days, undoubtedly a reflection of the meagre staff resources. Further, during the month spent in the reception unit, newly arrived prisoners underwent a number of examinations (including of suicidal risk). As regards screening for transmissible diseases, it varied from one prison to another. At Sliven Prison, newly arrived prisoners were screened on admission for syphilis and HIV; the delegation was told that prisoners verbally gave consent to HIV testing. At Sofia Prison, screening for HIV was carried out by an NGO on a voluntary basis. As regards screening for tuberculosis, a mobile X-ray unit visited the prisons once a year and all prisoners were screened. There was no screening for hepatitis at either prison. The CPT recommends that measures be taken to ensure that all newly arrived prisoners are seen by a health ‑ care staff member within 24 hours of their arrival. The medical examination on admission should be comprehensive, including appropriate screening for transmissible diseases. Further, prisoners should be provided with counselling before (and, in the case of a positive result, after) any screening test as well as with information concerning the prevention of transmissible diseases. ... 111.     The CPT remains concerned about the handling of medical data. All inmates had individual medical files; however, the delegation observed that the medical information contained in them was far from being comprehensive. Further, the confidentiality of medical examinations was not always observed, non ‑ medical prison staff often being present during such examinations. The CPT recommends that steps be taken to ensure that: –     prisoners’ individual medical files are properly kept and prisoners are entitled to receive copies of medical documents; –     all medical examinations are conducted out of the hearing and – unless the doctor concerned expressly requests otherwise in a particular case – out of the sight of non-medical prison staff and law enforcement officials; ... 113.     More generally, it would appear that the difficulties in recruiting medical specialists to work in prisons and the other related failings referred to above are part of the wider problem that prison health care is not integrated into the national health-care system. This results in a failure to comply with the principle of “equivalence of care”, according to which prisoners should benefit from the same level of medical care as persons living in the community at large. During the visit, the delegation received a copy of a draft Ordinance on prison health ‑ care prepared by a joint working group from the Ministries of Justice and Health, which addresses many of the problematic areas mentioned above. In particular, it establishes the principles of equivalence of care and doctors’ professional independence. Other provisions concern the supply of free-of-charge medication to prisoners and the Ministry of Health’s responsibility for providing methodological guidance to and control of health care in prisons. As regards screening for HIV, the WHO recommendations concerning confidentiality, informed consent and pre- and post-test counselling are to be observed. The Ordinance also stipulates that whenever signs of violence are observed, health-care staff should immediately notify the prison director and issue a medical certificate; however, as regards the contents of the latter, reference is only made to a detailed description of the injuries observed (in this context, see the recommendations [made earlier in the report]). Pursuant to Section 7 of the Ordinance, prisoners with medical training who have not been deprived of the right to practise can be employed in their speciality under the supervision of a medical member of staff. The CPT has already expressed in the past its concern about the employment of inmates as orderlies (see paragraph 102 of CPT/Inf (2004) 21); the same goes for the employment of prisoners on other health-care related jobs. As a matter of principle, prisoners should not be put in a position to exercise control over other prisoners. The CPT recommends that the Bulgarian authorities take into consideration the comments and recommendations made in this report in the new regulations on the provision of health care to prisoners. More generally, the Committee invites the Bulgarian authorities to review their strategy for implementing health ‑ care policy in prisons with a view to ensuring harmonisation with the national health-care system and respect of the principles of equivalence of care and professional independence. 114.     The prison hospital at Sofia Prison had three wards: surgery, internal medicine and neuropsychiatry; in addition, there was a section for female prisoners and an area for infectious diseases. At the time of the visit, 40 prisoners were being treated at the hospital; the delegation was informed that, on average, 60 to 70 prisoners were hospitalised on any given day. The hospital also performed outpatient consultations of prisoners from Sofia Prison. 115.     Living space in the patients’ rooms was satisfactory (e.g. five prisoners in a room measuring some 30 m², including a sanitary annexe). Th