Stories

The incident

Francesco Mastrogiovanni, a 58-year-old primary school teacher, died on 4th August 2009 after being restrained for almost 90 hours in the psychiatric ward of the San Luca hospital in Vallo della Lucania.

On 31st July Mastrogiovanni was seized by a squad of Carabinieri police officers, municipal police and coastguards while bathing in the sea at a beach campsite resort called Club Costa Cilento – Marina Piccola. He was accused of having driven at high speed through the pedestrian zone of Acciaroli (a village near Pollica in the province of Salerno, south of Naples) at about 11:30 the previous evening and then, in the early hours of the following morning, of having crashed into some cars. As a result of these alleged traffic offences, a compulsory treatment order was issued for Mastrogiovanni, although, as the Francesco Mastrogiovanni Truth and Justice Committee points out, there is no actual evidence of the offences having been reported at the time. Also, because of discrepancies between different reports and logs, it is not clear whether the Mayor of the municipality of Pollica (which, incidentally, was neither Mastrogiovanni's municipality of residence nor the one he was in at the time of arrest) signed the compulsory treatment order before or after the arrest and validation of the document by doctors.

Nevertheless, Mastrogiovanni was made to come out of the water, sedated and taken to the psychiatric ward of the San Luca hospital. After a couple of hours, during which he showed no signs of aggressive behaviour, Mastrogiovanni – deeply asleep because of the psychotropic drugs he had been given – was tied to his bed by his wrists and ankles by two nurses and fitted with a catheter. The time was then 2:24 pm From then on, for more than three days, he was given no food or water – apart from being hydrated occasionally with a physiological-glucose solution via an intravenous drip. All the guidelines clearly state that containment should be used only in exceptional circumstances and that if it is used there must be constant monitoring and precautions must be taken to protect the patient's physical integrity, but these guidelines were not observed in any way. Mastrogiovanni was to remain tied to that bed, alive, for 82 hours, during which time not a single doctor or nurse came near him. Nor, it seems, did anybody realise that his physical condition was continually worsening and that he was suffering from increasing respiratory distress. Only once, in all this time, was his incontinence pad and bed linen changed, and only once was he perfunctorily washed. The health personnel didn't realise he was dead until five hours after his death occurred, at about 2 in the morning on 4th August.
The autopsy revealed that he died of acute pulmonary edema – a direct consequence of the way he was physically restrained.

The trial

The trial began in 2010 in Vallo della Lucania Law Court. Public Prosecutor Francesco Rotondo informed the court that nineteen doctors and nurses were to be charged with abduction and causing the death of a person while engaged in the commission of a criminal act, that the doctors were to be charged with falsification of public documents and that all the defendants were to be suspended from practice. This suspension was ordered as a precautionary measure for fourteen of the defendants by the Preliminary Investigations Judge, a measure that was subsequently revoked by the Salerno Court of Review and then reintroduced by the Court of Cassation following an appeal by Rotondo. In the meantime, as a consequence of the Mastrogiovanni case, the Parliamentary Commission of Inquiry into the Effectiveness and Efficiency of the Italian National Health Service questioned the Director of the Salerno District Health Authority, Luigi Pizza. The answers given were not complete, but the District Health Authority finally decided to file a civil lawsuit.

The first instance trial, headed by Public Prosecutor Renato Martuscelli, who had in the meantime taken over from Rotondo, ended on 30th October 2012. The judge, Elisabetta Garzo, imposed sentences of three to four years plus five years' disqualification from practice on five of the six doctors – Michele Di Genio, Raffaele Basso, Rocco Barone, Americo Mazza and Anna Ruberto – for abduction, causing the death of a person while engaged in the commission of a criminal act and falsification of public documents. The sixth doctor, Michele Della Pepa, found guilty only of abduction and the falsification of public documents, was sentenced to two years imprisonment. The nurses were all acquitted.

Just over a month earlier, in response to a request made by Mastrogiovanni's family via the association A Buon Diritto, video footage of the agony of Mastrogiovanni – minute by minute, filmed by a hospital surveillance camera – was published in the magazine l'Espresso.