Stories

The incident

On the morning of 17th November 2005 at about 9 o'clock Maria Patrizia Favero telephoned the Castiglione delle Stiviere closed psychiatric unit, where her daughter Katiuscia was an inpatient. She wanted to talk to the social worker because she needed some documents. Twice, she was told the social worker hadn't arrived yet. The third time she called she was put through to doctor, who told her that her daughter had done something “naughty”. Katiuscia had committed suicide.

Katiuscia suffered from a personality disorder that led to her taking drugs and committing minor offences. From a very early age, she had been alternating between periods of detention and treatment. Since the age of 13 she had been under a psychiatrist at the Savona mental health centre, who had helped her to detoxify. This psychiatrist had stated many times that the best way to have Katiuscia resume a normal life was to get her away from detention regimes and back into a family context, monitored by the mental health centre. But that didn't happen. At the beginning of 2002, before she was 30 years old, Katiuscia was locked up in the Castiglione delle Stiviere closed psychiatric unit (OPG – Judicial Psychiatric Hospital) after being convicted of stealing a watch. The reason given for committing her to the psychiatric unit was that her state of health made her unsuitable for prison. In February Katiuscia filed a complaint against a doctor for harassment and against two nurses for sexual assault. The next day two doctors discharged her from the psychiatric unit, declaring that the kind of psychiatric disorders manifested by the patient did not justify her admission to the unit and she was sent back to Pontedecimo prison.

In prison, Dr. Giacomo Toccafondi examined her and declared her to be a patient at risk. She had completely shaved off her hair and had cuts on her abdomen. On 12th February 2002 the prison gynaecologist, Elivia Burchielli, tried in vain to examine Katiuscia, who had a sharp pain in her genitals (so strong that she couldn't sit down). Twenty days later Katiuscia agreed to the gynaecological examination. Dr. Burchielli reported “cracks around the vaginal opening”, “abrasions” and “internal injuries”. The certificate pertaining to this report disappeared from the patient's medical record, leaving only the gynaecologist's notes and the recollections and verbal accounts of Patrizia Favero, who had seen the certificate before it disappeared. A complaint was lodged, but because of the missing medical reports the case was dismissed, and the two nurses and the doctor accused of sexual assault were acquitted for lack of evidence. But Katiuscia, in numerous interviews, never contradicted herself when reconstructing the incident, insisting that her hand had been injured by the keys on the two men's belts as they assaulted her. The nurses admitted strapping her to the restraint bed, and they have neither alibis for what they were doing at the time of the assault nor a single witness to back up their vague version of the facts. One of the two nurses was transferred: the other one is still there, in the same job.

On 12th May 2005, on completing her prison sentence, instead of being freed Katiuscia was declared a danger to herself and others and was committed to a new observation period in the same closed psychiatric unit where she was allegedly assaulted. She was taken back to the very place she had been taken away from three years earlier, but for the opposite reasons. Her mother said that there, in the psychiatric unit, she was strapped to the restraint bed often, for doing things such as drinking coffee or eating a sweet, and that once she was strapped to it for no less than twenty days. On 28th November 2005 Katiuscia was due to be discharged.

The phone call she made to her mother on 16th November began normally: Katiuscia asked how her 14-year-old sister Juliana was, asked for some money to be put into her account and for some clothes and food. Then, all of a sudden, her voice lowered – she didn't want to be heard. She said she was frightened, asked her mother to help her, said that strange things were happening to her. Patrizia tried to calm her down, advised her never to be alone and reminded her that she'd be coming to see her in three days' time. These were the last words she was to say to her daughter, who died that very evening, found in the psychiatric unit garden, in the night, a noose made from a wet sheet around her neck, tied to a shaky railing.

Her mother has never believed it was suicide. On hearing the news she went first to the psychiatric unit and then to a nearby Carabinieri police station to make a statement. In the police station an officer, a Maresciallo, tried to persuade Patrizia not to request the autopsy, telling her that the Public Prosecutor wouldn't agree and that the duty physician didn't think it was necessary because the cause of death was a broken neck – a hypothesis not confirmed by Dr. Franco Tagliaro, the doctor appointed to perform the autopsy. Patrizia didn't give up. The Carabinieri officers told her that the autopsy would be done a few days later, but when that day came they asked her to remove her daughter's body from where it was being kept in cold storage. Favero refused, went to the Mantua Public Prosecutor's Office and lodged a complaint. She thus found out that the Public Prosecutor had no knowledge of her doubts over the suicide of her daughter and of her demands for a more thorough investigation. She also discovered that the sheet had not been confiscated, that Katiuscia's room had been hurriedly repainted and cleared without being inspected and that somebody had taken Katiuscia's diary and returned it with some pages torn out.

The trial

A lawsuit against persons unknown was filed for voluntary manslaughter. Katiuscia had been found hanging from a shaky railing in the garden outside the psychiatric unit. First of all it was stated that patients were allowed into that garden only until 6 in the evening and that after that it was only doctors with a special passkey who had access to it. During the investigation, however, some personnel said that the garden was accessible until 11. It was also asked how Katiuscia could have gone from her room to the garden without anybody seeing her and, as her mother pointed out, the girl had a razor blade in her pocket and could have used that if she'd wanted to take her own life. When Patrizia saw her daughter's body she noticed a very narrow mark, as if caused by a cord, around her neck; on the back of her head she had a contused, lacerated wound for which no explanation has been given, and there was a puncture mark on her arm. A very high level of barbiturates was found in Katiuscia's blood, suggesting a large single dose. The girl's trousers were streaked with grass marks and were muddy, whereas the soles of her shoes were clean. The gauge of the mesh that she was found hanging from was too small for a sheet to pass through. Finally, as regards the autopsy, Katiuscia's body had been kept in cold storage for several days and was too frozen to establish the time of death. The physician requested samples for analysis from under her fingernails to look for traces of materials of relevance to the investigation.

Professor Tagliaro and Patrizia Favero maintain that such samples had actually been taken by the Mantua Carabineri Operations Unit (RONO), but that they had disappeared without ever being analysed. The Public Prosecutor initially heading the investigation, Marco Forte, was transferred. His replacement, Stefania Pigozzi, turned down the request for further clinical analyses and proceeded with the dismissal of the case. Patrizia Favero then sent a letter to the Brescia Public Prosecutor's Office asking for the investigation to be resumed and pursued more thoroughly. The Chief Prosecutor reopened the case, in the course of which the role of the duty doctor – the one who had been investigated for sexual harassment several years earlier – emerged. This doctor was charged with manslaughter for failing to take the necessary measures to prevent Katiuscia's death. In the preliminary hearing, however, it was ruled that there was no case to answer. The hospital offered 15 thousand euros as compensation for damages to Patrizia and Juliana, who refused to accept the money.