CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 10 avril 2025

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ITALY (Application no. 4953/22)   JUDGMENT Art 3 (substantive) • Inhuman and degrading treatment • Continued placement of elderly applicant, convicted of leadership of a Mafia-type criminal organisation, under special restrictive prison regime (section   41   bis regime), despite his progressive cognitive deterioration • Applicant’s advanced age and length of time (almost twenty years) spent under special regime required particularly compelling reasons for any further extension • Domestic authorities’ failure to provide such reasons • Legitimate doubt as to whether applicant, due to his progressive cognitive decline, still represented a danger and could maintain meaningful, practical contact with his criminal organisation • Domestic authorities’ failure to address allegations that limited human interactions could be detrimental for the applicant’s mental state and to consider lifting or easing some of the restrictions to accommodate his potential needs despite his explicit requests • In case-circumstances, extended application of the section   41   bis regime, during the period under the Court’s examination, insufficiently justified and entailing a breach of Art   3 • Applicant’s continued detention in prison per se , during the same period, not in breach of Art   3 in light of the adequate medical treatment provided to him for his multiple diseases   Prepared by the Registry. Does not bind the Court.   STRASBOURG 10 April 2025   FINAL   10/07/2025   This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision.   In the case of Morabito v. Italy, The European Court of Human Rights (First Section), sitting as a Chamber composed of:   Ivana Jelić, President,   Erik Wennerström,   Alena Poláčková,   Frédéric Krenc,   Alain Chablais,   Anna Adamska-Gallant, judges,   Antonio Balsamo, ad hoc judge, and Ilse Freiwirth, Section Registrar, Having regard to: the application (no.   4953/22) against the Italian Republic lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by an Italian national, Mr   Giuseppe Morabito (“the applicant”), partially on 7 January 2022 and partially on 6 June 2022; the decision to give notice to the Italian Government (“the Government”) of the complaints raised under Article 3 of the Convention and to declare the remainder of the application inadmissible; the withdrawal from the case of Mr Raffaele Sabato, the judge elected in respect of Italy (Rule 28 § 3 of the Rules of Court), and the decision of the President of the Section to appoint Mr Antonio Balsamo to sit as an ad hoc judge in the case (Article 26 § 4 of the Convention and Rule 29 § 1 of the Rules of Court); the parties’ observations; Having deliberated in private on 11 March 2025, Delivers the following judgment, which was adopted on that date: INTRODUCTION 1.     The case concerns the alleged incompatibility of the applicant’s state of health with his continued detention in prison, the medical care provided to him, and his continued placement under the special prison regime provided for by section 41 bis of Law no. 354 of 26 July 1975 (“the section 41   bis regime”) notwithstanding his progressive cognitive deterioration. THE FACTS 2.     The applicant was born in 1934 and is currently detained in the Milan Opera Prison. He was represented by Ms G.B. Araniti, a lawyer practising in Reggio Calabria. 3.     The Government were represented by their Agent, Mr L. D’Ascia. 4.     The facts of the case may be summarised as follows. 5.     The applicant, currently aged 90 years old, was convicted of being a leading member of a mafia-type criminal organisation. After several years of being a fugitive, in 2004 the applicant was arrested and imprisoned under the section 41 bis regime. After initially being detained in various prisons, in 2014 he was transferred to the Milan Opera Prison where he is currently still detained. 6 .     The applicant suffers from a number of diseases, the most severe being a prostate enlargement which has obliged him to use a catheter for over ten years and which causes frequent urinary tract infections; a bilateral inguinal hernia which has become worse over the years; hypertensive heart disease with episodes of angina; and polyarthritis. The applicant has also been diagnosed with progressive cognitive deterioration. The medical evidence on the applicant’s health and treatment The prison medical journal 7 .     The Government has provided the applicant’s medical journal in respect of the entire period of his detention in the Milan Opera Prison, which shows that he has been taking a large number of medications, has been examined regularly by the doctors working in prison as part of the regional health administration (hereinafter, “prison doctors”) and has undergone several examinations by specialists in various fields (including cardiology, psychiatry, neurology, urology, orthopaedics, and orthodontics). Generally, the applicant’s condition was described as moderate or stable. 8 .     The medical journal provides some information on the treatment of certain of the applicant’s health issues. In 2014 the doctors suggested that it might be advisable to operate on the hernia, although a thorough risk assessment should be conducted. However, the applicant repeatedly refused surgery. From 2017 onwards, the doctors advised against surgery, since it presented excessive risks for a patient of advanced age who was suffering from multiple diseases: only in the case of acute complications would surgery be indicated. In the meantime, the applicant had been provided with a hernia belt, which he declined to use, and subsequently with a special support underwear, about which, equally, he complained to the prison doctors. In 2021 he was authorised to purchase other special underwear and, since he did not do so, on 3 May 2021 he was provided with a tailored bodysuit. In respect of the hypertension, the journal shows that the applicant’s condition was monitored by prison doctors and that he underwent multiple cardiology examinations, took medication and that his blood pressure was considered to be sufficiently under control. The applicant’s catheter was replaced regularly and antibiotics were prescribed to prevent infection; however, the applicant often refused the medication or asked for a different prescription, which according to the doctors was not indicated. 9 .     Several notes in the journal show that the applicant had also been assigned help with cleaning his cell, and that despite some mobility issues he could move autonomously in his cell, although he used a wheelchair for longer distances. 10 .     As regards the applicant’s mental state, prior to his arrival at the Milan Opera Prison he had been diagnosed with depression. In Milan, he was regularly examined by the prison’s psychiatrists, and no sign of any major psychiatric disease was reported. Notably, at a psychiatric examination on 19   November 2018, the specialist observed that the applicant was lucid and oriented and that he did not fully comply with the doctors’ directions because of a personality characterised by persecutory traits and stubbornness, but he did not show other psychiatric symptoms. 11 .     In July 2014 the doctors observed signs of possible cognitive deterioration. A neurological examination was carried out in November   2014, when the applicant was described as partially oriented in space and time. He was diagnosed with cognitive deterioration and possible depression, for which antidepressants were prescribed. He was examined again in January   2015, when he was described as alert and well oriented in space and time, and in May 2017. 12 .     Neuropsychological examination and tests carried out in November 2017 showed multiple compromised areas of cognition combined with mild disorientation and generally slowing down which however, according to the specialist, could have been affected by the applicant’s defeatist attitude. At a further examination carried out on 14 November 2018, the specialist observed that the applicant replied correctly to questions but that the nursing personnel had reported short-term memory loss and diagnosed mild cognitive impairment. On 14 December 2020 the applicant underwent another neurological examination and the specialist observed that he showed a marked slowing down and a tendency to confabulation, but no other disability. 13 .     Most of the prison doctors’ notes over the years said that the applicant appeared lucid and oriented. Only occasionally did they mention signs of confusion and disorientation. On 25 July 2022, the prison doctors observed that the applicant was in a state of confusion and took him to hospital, where he was diagnosed with Alzheimer’s disease. 14.     Finally, the applicant was on multiple occasions placed in solitary confinement and excluded from activities with other prisoners, for unknown reasons. On these occasions, the prison doctors stated that the applicant would be able to cope with solitary confinement. The prison medical reports 15 .     A prison medical service report of 5 December 2017 listed the applicant’s diseases with some additional clarifications. It stated, among other things, that the applicant’s hernia was asymptomatic and that the doctors were now advising against surgery because of the high risk of an operation for an elderly person suffering from multiple diseases; and that his hypertension was under control. It further stated that the applicant had undergone neurological examinations and testing, which had shown some pathological results combined with other normal results, as well as some disorientation and delayed answers which could however also have been influenced by his defeatist attitude; at the same time, during a psychiatric assessment he had shown good understanding, a good attention span and an active will. Overall, the applicant’s condition was reasonably good and was stable, in so far as was possible for a detainee of advanced age. 16 .     A report dated 30 August 2018 reiterated the same considerations, adding that the applicant could be adequately monitored and treated in prison. 17 .     A report by the prison medical service on 29 September 2022 repeated the same information, adding that the applicant had refused some of the examinations that had been advised and that he was provided with the necessary aids and treatments. It concluded that the applicant’s condition was reasonably good, stable and compatible with detention in prison. Furthermore, in the daily management of the applicant’s health he had not shown signs of an advanced cognitive deterioration and appeared lucid, oriented and capable of performing daily tasks. 18 .     Another report, dated 19 November 2022, stated that the applicant did not suffer from cancer; that he did not need an orthopaedic chair, no such suggestion having been made at any of the orthopaedic examinations that had been conducted over the years; that he was able to manage his own personal hygiene, although he had help with cleaning his cell and changing his bedsheets; that he moved autonomously in the cell and had a wheelchair for out of cell transfers; and that he had been provided with a tailored bodysuit. The private expert reports 19 .     Over the years, the applicant obtained a large number of private expert reports on his health. Of those that have been provided to the Court, the first is an expert report produced by Dr F.L. on 24 February 2015, which – relying on neurocognitive tests – diagnosed a state of mild cognitive impairment which would likely develop into a form of dementia. That development, which could be slowed mainly by keeping mentally active doing things and maintaining relationships, would be aggravated by his being kept in detention, especially in the section 41 bis regime. 20.     Another private report, provided by Dr F.M. on 15   December 2015, confirmed the progressive cognitive deterioration and added that the applicant was at high risk of cardiovascular events and suffered from frequent urinary tract infections. Overall, his diseases were chronic and would get worse, and required a large number of medical checkups and treatments that the applicant, because he suffered from cognitive deterioration, was unable to follow. He therefore considered that the applicant could not be adequately treated in prison. 21 .     A private report by Dr C.G. on 9 February 2017 stated that the applicant suffered from multiple diseases including cognitive deterioration that had been detected as early as 2015 and that his diseases were chronic, would inevitably worsen over time and required constant treatment including, in some cases, surgical intervention. It concluded that, taking into account the applicant’s advanced age and his multiple diseases, his overall state of health was incompatible with detention in prison and required placement in an external healthcare facility. 22.     A private report by Dr G.B.G. on 25 September 2021 reiterated that the applicant had a moderate form of dementia and needed assistance in performing daily tasks and in walking as well as multidisciplinary treatment for his various diseases, and concluded that his health condition was incompatible with detention in prison. the Section 41 bis regime PROCEEDINGS 23.     When the applicant was imprisoned in 2004, the Minister of Justice ordered that he be held under the section 41 bis regime. That order was subsequently extended every two years. 24 .     The applicant’s account of events starts with an order made by the Minister of Justice on 7 February 2018, extending the section 41 bis regime for two further years. The additional restrictions imposed on the applicant consisted of: limited visits by family members and no visits by non-family members; a prohibition on using the telephone; limits on receiving money and parcels from outside the prison; a prohibition on participating in the elections for prison representatives; and a maximum of two hours out of doors per day and in a group of no more than four persons. Additionally, incoming and outgoing correspondence was to be monitored, subject to prior judicial authorisation. The reasons given by the Minister of Justice to justify the extension of the special regime rested on information provided by the anti-mafia prosecuting authorities, according to which the applicant had been the leader of a criminal group which was still active, as shown by various criminal proceedings against its members. The applicant had not distanced himself from that organisation and there was no indication that he no longer had a leading role. The applicant also had a violent and aggressive attitude to the prison personnel, for which he had been subject to disciplinary and criminal proceedings. The Minister therefore considered that the applicant’s ties with the criminal organisation were still in place and that, in the absence of restrictive measures, he would be likely to resume contact with the organisation. 25 .     On 15 February 2018, the applicant filed a challenge to the extension order in the Rome court responsible for supervising the execution of sentences ( tribunale di sorveglianza – “the sentence supervision court”), claiming among other things that the extension did not take into account his progressive cognitive deterioration, which affected his capacity to maintain contact with the criminal organisation, or the various other diseases he had which required constant specialist treatment and assistance. He supported his challenge with the private expert reports of 24 February 2015 and of 9   February 2017 (see paragraphs 19 and 21 above). The applicant asked mainly for the revocation of the special regime or, alternatively, for the lifting or easing of some of the restrictions. 26 .     Before any decision could be taken on the applicant’s challenge, on 4   February 2020 the Minister of Justice ordered a further two-year extension. The reasons given, and the restrictions imposed, were the same as those in the previous order. 27.     On 19 February 2020, the applicant filed a challenge to the new extension, on the same grounds as his earlier challenge. 28 .     The Rome sentence supervision court joined the two proceedings and appointed a medical expert to assess the applicant’s state of health with particular regard to any physical or psychiatric conditions which could affect his mental capacity. 29 .     On 4 May 2020 the court-appointed expert, Dr M.F., filed his expert report, which included also a neuropsychological evaluation. He confirmed that the applicant suffered from several physical diseases and from cognitive deterioration. The expert asserted that the applicant’s numerous ailments had been underestimated by the prison medical service, and observed that the conclusions of prior medical reports stating that the applicant was in reasonably good condition were no longer true. In particular, he noted that the applicant suffered from frequent urinary tract infections with potentially serious and even lethal consequences. He also criticised the delays in diagnosing the cognitive deterioration, which had already been apparent in 2015 but had been diagnosed only on 14 November 2018 (see paragraph   12 above); the delays in taking note of the applicant’s beliefs that he was being persecuted and in prescribing antipsychotics, despite the applicant’s abnormal behaviour and his refusal of treatment; the underestimation of the hernia, which had been incorrectly described as asymptomatic; the fact that his hypertension was only partially under control; and the failure to test the applicant for diabetes despite his showing some symptoms of it. Overall, the expert concluded that the applicant’s physical diseases, if taken individually, did not affect his mental capacities, but that a combination of comorbidities in an elderly person could aggravate cognitive deterioration. As to the applicant’s cognition, the expert – who also relied on the results of neuropsychological tests – found that the applicant suffered from a major vascular neurocognitive disorder, commonly known as dementia. While it did not yet affect his capacity to perform basic daily tasks (and in this sense it was described as mild), it caused altered behaviour, confusion, memory loss and attention deficits. The tests demonstrated that there was no simulation of symptoms, showing rather that the applicant tried to hide his disease. The expert therefore concluded that the applicant’s cognitive deficit significantly affected his mental capacity. 30 .     By a decision of 16 October 2020, the Rome sentence supervision court rejected the applicant’s challenges to the two extension orders. As to the applicant’s physical problems, it stated that the section 41   bis regime did not entail any restriction on access to medical treatment. Nevertheless, noting that the court-appointed expert had expressed criticism of the medical care provided to the applicant, it observed that that issue was outside its jurisdiction and transmitted the case to the Milan sentence supervision court. As to the applicant’s cognitive state, the Rome sentence supervision court observed that – despite the expert’s conclusions – the applicant’s behaviour in prison and the content of his conversations with his family members showed that he had no remorse about his past, was anchored to a typical mafia mentality and still showed a strong and rational personality. The cognitive deterioration, therefore, was having less impact than had been suggested by the expert and did not affect the applicant’s capacity to maintain contact with the criminal organisation. 31 .     The applicant appealed to the Court of Cassation which, on 8   July 2021, confirmed the sentence supervision court’s findings. 32 .     On 7 January 2022, the applicant lodged the present application before the Court, complaining under Article 3 of the Convention about his continued placement under the section 41 bis regime despite his deteriorating health. He also lodged a request for an interim measure under Rule 39 of the Rules of Court, which was rejected by the Court (the duty judge) on 2 February 2022. 33.     By an order of 2 February 2022, the Minister of Justice extended the application of the special prison regime for a further period of two years, with the same restrictions. The order contained, in addition to the grounds listed in the previous orders, some remarks on the applicant’s cognitive state, affirming that – as stated by the sentence supervision court – the applicant’s dangerousness remained unchanged. 34.     The applicant filed a challenge to the new extension order, again relying on his cognitive decline and asking for an additional expert report. 35 .     On 3 November 2022, the Rome sentence supervision court rejected the applicant’s challenge. The sentence supervision court took note of the above ‑ mentioned report by Dr M.F. (see paragraph 29 above) and an additional expert report filed by Dr M.L. in separate proceedings on 10   August 2022 (see paragraph 49 below). The additional expert report said that the applicant’s mental capacities had remained the same, or had slightly worsened, since Dr M.F.’s report: the applicant was described as suffering from a major neurocognitive disorder, with a mild cognitive decline which was progressing slowly; he appeared lucid but was partially disoriented as to time and had memory loss, diminished reasoning capacity, attention deficits and a reduced ability to concentrate. When he had behaved aggressively towards some prison guards in March 2020, he had therefore been incapable of understanding what he was doing and in 2022 he had been incapable of following a court hearing. The applicant’s age and progressive dementia meant that this incapacity was irreversible and he was not socially dangerous. The sentence supervision court found, however, that the conclusions of the experts’ reports had to be read in the light of the updated evidence, in particular that of a prison medical report dated 27 October 2022 which stated that the applicant’s condition of health was fair, stable and consistent with his age and chronic diseases; that in his daily activities he did not show signs of significant cognitive deterioration, and he appeared lucid, oriented and capable of performing daily tasks. The sentence supervision court further observed that the applicant still denied all responsibility for his actions and exhibited aggressive behaviour, that during family meetings he continued to make accusations against state bodies and to receive information on outside events, making hidden references to people involved in the criminal organisation he had previously belonged to. Overall, the sentence supervision court concluded that the applicant’s dangerousness and capacity to maintain contact with the criminal organisation remained unchanged. 36 .     The applicant appealed to the Court of Cassation and the outcome of these proceedings is unknown. The APPLICATIONS for release on health grounds 37 .     On 31 July 2015, the applicant filed an application for the replacement of his detention in prison with home detention under Articles 147 of the Criminal Code and Article 47 ter of Law no. 354 of 26 July 1975. The application was rejected, on a provisional basis, by the Milan sentence supervision judge ( magistrato di sorveglianza ) on 28 September 2015 and then by the Milan sentence supervision court on 26 February 2016. The Milan court relied in particular on reports by the prison medical service, according to which the applicant’s health condition was stable and adequately monitored. 38 .     On an unspecified date, the applicant filed a further application, which was rejected by the Milan sentence supervision judge on 17 August 2017 and by the Milan sentence supervision court on 18 December 2017. The domestic courts relied, in particular, on two reports produced by the prison medical service on 12 October and 5 December 2017 (see paragraph 15 above), according to which the applicant, despite his multiple diseases and a mild disorientation, was overall in a reasonably good and stable condition. The sentence supervision court therefore considered that the applicant could appropriately be treated in prison. 39.     The applicant appealed to the Court of Cassation, which found on 2   August 2018 that the examination of the applicant’s state of health and the compatibility of it with his continued detention had not been sufficiently detailed, quashed the decision and remitted the case to the sentence supervision court. 40 .     In the meantime, the applicant had filed a new application on the same grounds. The sentence supervision court joined the proceedings and, on 29   November 2018, it rejected them both. It relied, in particular, on two reports produced by the prison medical service on 21 September and 15   November 2018, which reiterated that the applicant’s condition was stable and reasonably good and that he could be treated in prison if he complied with the doctors’ directions. The decision also pointed out that, if the applicant was released, he would be treated in the same manner. As to the applicant’s cognitive deterioration, it referred to a neurological examination carried out on 13 November 2018 and found that the deterioration was still at an initial stage. 41.     The applicant appealed, arguing that the decision had the same deficiencies that had previously been criticised by the Court of Cassation and insisting that an expert should be appointed; the public prosecutor agreed. Nevertheless, on 17 October 2019, the Court of Cassation dismissed the appeal, finding that the decision had been fully reasoned and that it was based on recent medical evidence. 42 .     On 20 March 2020, the applicant filed a further application for the replacement of his detention in prison with home detention, again asking for an expert report. On 9 June 2020, the Milan sentence supervision judge rejected the application, citing a medical report of 28 May 2020 according to which the applicant’s state of health was stable and his conditions could be treated in prison. On 2 March 2021, the sentence supervision court also rejected the application. It took into consideration the expert report issued by Dr M.F. in the Rome proceedings (see paragraph 29 above) and a recent report from the prison medical service according to which the applicant’s condition was stable and reasonably good. The applicant appealed to the Court of Cassation which, on 9   February 2022, dismissed his appeal. 43 .     On 20 May 2022, the applicant filed a new application for the replacement of his prison detention with home detention pointing out, among other things, that he had no caregiver. The outcome of this application is unknown, although in November 2022 the Government stated that the proceedings were still pending. 44.     In addition to the proceedings discussed above, the applicant’s lawyer and family members made a number of complaints to other domestic authorities, including criminal complaints, for lack of medical care and assistance. The outcome of these complaints is unknown. 45.     On 6 June 2022, the applicant lodged an additional complaint before the Court, complaining under Article 3 of the Convention that his continued detention in prison was incompatible with his state of health and was preventing adequate treatment of his multiple diseases. He also lodged a second request under Rule 39 of the Rules of Court, in respect of which the Court informed him that the prior decision (see paragraph 32 above) still stood.   The disciplinary and criminal proceedings against the applicant 46.     The applicant had carried out acts of aggression and caused damage in the prison. He was subject to an unspecified number of disciplinary and criminal proceedings. 47 .     In November 2019, a disciplinary sanction was imposed on the applicant for having thrown a dish and insulted a police officer. In a decision of 15 June 2020 the Milan sentence supervision court, relying on the expert report of Dr M.F. (see paragraph 29 above), found that the disciplinary proceedings had not taken into due account of the applicant’s cognitive deterioration, and annulled the sanction. 48 .     Criminal proceedings had been commenced about an act of aggression towards the prison police which had occurred on 2 March 2020. On 28   April 2022, in the preliminary hearing of that case, the Milan judge observed that the applicant appeared to be “completely disoriented”. She therefore postponed the hearing and ordered an expert report on his mental capacity at the time of the events of the case and on his capacity to stand trial. 49 .     The expert, Dr M.L., produced his report on 10 August 2022. The report has not been provided to the Court in full, but parts of it were cited in subsequent court decisions. The report stated that the applicant suffered from a major neurocognitive disorder, with a mild cognitive decline which was progressing slowly; he appeared lucid, but was partially disoriented in time, had memory loss, a diminished reasoning capacity, a short attention span and a reduced ability to concentrate. It concluded that, at the time of the events in question, the applicant had been incapable of understanding his situation and at present he did not have the attention span and capacity for concentration required to follow a court hearing. His incapacity would be irreversible, since it arose from his age and progressive dementia. Additionally, given his physical and intellectual ailments, the risk of further criminal behaviour was very limited, and he therefore should not be considered dangerous (see also paragraph   35 above). 50 .     On this basis, on 3 November 2022 the Milan District Court acquitted the applicant by reason of insanity in respect of the act of aggression which had occurred on 2 March 2020 (see paragraph 48 above). 51 .     On 14 November 2022, the Milan District Court took note of the applicant’s incapacity to stand trial and discontinued other criminal proceedings against the applicant for acts that had taken place in 2017. Subsequent developments 52 .     The applicant’s medical journal during the second half of 2022 and 2023 shows that he continued to be examined by prison doctors and specialists on frequent occasions. He was usually described as lucid and oriented and in reasonably good condition. 53 .     On 4 February 2023, the applicant filed a new application for the replacement of his prison detention with home detention. On 6   April 2023, the Milan sentence supervision judge rejected the application, relying, in particular, on a report of the prison medical service of 1   February 2023 according to which the applicant was in a fair and stable condition. The report further stated that the applicant had no acute symptoms; that he could manage his own personal hygiene and had been assigned help with cleaning his cell; that he used a wheelchair to move around outside his cell; and that he appeared oriented, had an active will and did not show any lack of understanding when questioned. 54 .     On 24 May 2023, the applicant was taken to hospital urgently because of acute abdominal pain and other symptoms. The hospital said that surgical intervention for his hernia had become vital, despite the high risk it would pose for an old and sick patient. The Milan sentence supervision judge therefore ordered that the applicant’s detention in prison be replaced by home detention, to be served at Milan Hospital, for a period of 15 days. 55 .     The surgery took place on 29 May 2023. According to a subsequent medical report dated 7 June 2023, the patient had some post-operative complications but his situation had gradually stabilised; he was now alert, cooperative and reasonably well-oriented and would reply rationally when questioned. He needed help for some daily tasks, such as eating and personal hygiene. 56 .     On 12 June 2023, the Milan sentence supervision judge extended the home detention order, to last as long as the doctors considered it necessary for the applicant to remain in hospital. The sentence supervision judge took note of the applicant’s request to be transferred to a healthcare facility and of the opposition to home detention of the anti-mafia prosecuting authority, which considered that the applicant, if placed in home detention, might resume the management of the activities of the criminal organisation. The sentence supervision judge considered that the applicant could be adequately treated in prison and ordered that, once discharged, he should return there. 57.     On 14 June 2023, the applicant lodged another request under Rule   39 of the Rules of Court, arguing that his return to prison would pose significant risks for his health. On 15 June 2023, the Court (the duty judge) rejected the request. 58.     On 20 June 2023, the applicant was discharged from hospital. The hospital discharge report said that he was lucid and cooperative, needed help with eating, moving about and personal hygiene, and that he should continue to take exercise and, if possible, should have physiotherapy. 59 .     The applicant returned to prison the next day. The section 41   bis regime was treated as having come to an end because of the period of home detention and the applicant was placed on an ordinary wing. 60 .     The medical journal for this period states that the applicant was in a reasonably good condition. At first he was assigned nursing assistance for personal hygiene and walking. He had a cycle of physiotherapy, was regularly monitored and followed the treatment prescribed for him. 61 .     On 20 June 2023 the applicant filed a new application for the replacement of prison detention with home detention. On 24 July 2023, the sentence supervision judge rejected the application, relying on a prison medical service report of 6 July 2023 which said that he was being assisted with his personal hygiene by paramedics; that he had initially had help with mobility but had regained his autonomy and could now walk in his cell and used a wheelchair for longer distances; and he could now feed himself. He could therefore be adequately assisted in prison. 62.     The applicant filed an additional private expert report which Dr   G.B.G. had produced on 24 August 2023. This report reiterated that the applicant suffered from dementia and mobility issues with a high risk of falling and that he needed help with performing daily tasks, and that his condition was therefore incompatible with detention in prison. 63 .     On 6 December 2023, the Milan sentence supervision court also rejected the application, based on an updated report of the prison medical service of 9 November 2023 which contained essentially the same conclusions as the previous report (see paragraph 61 above). 64 .     The applicant appealed to the Court of Cassation which, on 12   July 2024, quashed the earlier decision and remitted the case to the sentence supervision court for a more thorough assessment of the impact of detention in prison on the applicant’s state of health. According to the latest information, these proceedings are still ongoing. 65 .     On 14 November 2023, the Minister of Justice ordered the reinstatement of the section 41 bis regime. The applicant filed a challenge, relying on a new private expert report produced by Dr F.R. on 25   January 2024. This said that the applicant had moderate to severe dementia, was fragile and suffered from mobility issues, and should be placed in a residential facility instead. On 30   May 2024, the Rome sentence supervision court ordered a new expert report on the applicant’s cognitive abilities. The report, issued on 14   October 2024, reiterated that the applicant suffered from senile dementia and found that his capacity of understanding was severely limited, if not entirely absent. No further update on these proceedings has been provided to the Court. RELEVANT LEGAL FRAMEWORK AND PRACTICE Deferral and replacement of detention 66.     The domestic law concerning the provision of medical care in prison and the requests for deferral of the execution of a sentence for health reasons or its replacement with home detention have been recently summarised in Tarricone v. Italy , no. 4312/13, §§ 44-52, 8 February 2024 and in S.M.   v.   Italy , no. 16310/20, §§ 24-27, 17 October 2024. Section 41 bis regime 67.     Section 41 bis of Law no. 354 of 26 July 1975 (“the section 41   bis regime”), as amended by subsequent legislation, gives the Minister of Justice the power to suspend the application of the ordinary prison regime. The relevant domestic law in this respect has been summarised in Provenzano v.   Italy , no. 55080/13, §§ 83-90 and 92, 25 October 2018. 68 .     In particular, the suspension of the ordinary prison regime may be ordered for four years for detainees who have been convicted of a number of serious crimes, including membership of a mafia-type criminal organisation and related crimes, in order to prevent further contact with the criminal organisation (subsection 2). The special regime may subsequently be extended for further periods of two years, where the ability of the detainee to maintain contact with the criminal organisation to which he belonged has not abated (subsection 2 bis ). 69 .     The Court of Cassation has clarified in this respect that the extension of the section 41 bis regime must be justified by a persistent capacity of the prisoner to maintain contact with the criminal organisation, and also that the ability to maintain contact may be affected by the deterioration of a detainee’s health, especially when he or she suffers from a particularly serious disease (see, for instance, judgments no. 16019 of 2016 and no. 32405 of 2017). THE LAW 70.     The applicant complained under Article 3 of the Convention about two distinct but overlapping issues: his continued detention in prison despite his multiple diseases and without adequate medical treatment and assistance, and his continued placement under the section 41 bis regime, despite his progressive cognitive deterioration. The relevant provision reads as follows: “No one shall be subjected to torture or to inhuman or degrading treatment or punishment.”         ADMISSIBILITY The parties’ arguments 71.     The Government objected to the admission of those parts of the applicant’s complaints which were based on new facts that had arisen after the domestic courts’ decisions which had been challenged in the initial complaints submitted to the Court on 7 January and 6 June 2022. They argued that those parts of the complaint were inadmissible for non-exhaustion of domestic remedies, in that proceedings were still pending at the domestic level. 72.     While they raised the objection in general terms in respect of both parts of the applicant’s complaints, they referred more specifically to the diagnosis of Alzheimer’s disease (see paragraph 13 above), the decision of the Milan judge in the preliminary hearing of 2022 (see paragraph 48 above) and, more generally, to the circumstances raised with the domestic court on 20 May 2022 (see paragraph 43 above). 73.     Additionally, the Government claimed that the complaints were inadmissible because they were of a fourth-instance nature and would require the Court to reassess issues which were of their nature a matter for the domestic courts. 74.     The applicant insisted that his complaints, including the additional submissions and documents, were admissible. 75.     The applicant further argued that the Government’s observations on the admissibility of his complaints had been submitted out of time. The Court’s assessment 76 .     As a preliminary consideration, the Court notes that the Government’s observations were submitted on 29 November 2022, within the deadline set. The Court therefore dismisses the applicant’s allegations in this respect. 77.     The Court notes that, after lodging the application, the applicant submitted further information on subsequent events. 78.     The Court reiterates that nothing prevents applicants from clarifying or elaborating upon their initial submissions during the Convention proceedings; if they do so, the Court has to take the additional submissions into account when it conducts its examination. However, if such additions amount in effect to raising new and distinct complaints, those complaints must comply, like any other, with the admissibility requirements (see, Radomilja and Others v. Croatia [GC], nos. 37685/10 and 22768/12, §§   122 and 135, 20 March 2018 and Fu Quan,