How could a patient strangle another patient to death without anyone noticing in what is considered the most protected psychiatric ward in Israel? How did four ward nurses fail to hear the victim's screams? And why did neither the Health Ministry nor the hospital's management ensure that the ward was properly staffed, and that its physical layout enabled proper supervision, given that it houses some of Israel's most dangerous psychiatric patients?
All of the above questions arise from a Health Ministry investigation into the murder of one patient by another at the Sha'ar Menashe psychiatric hospital on November 15, 2007. The murder occurred in one of the government-run hospital's four maximum security wards, and in its report, which was submitted to the ministry's management last week, the inquiry committee expressed "astonishment at the ease with which such an event could occur in a ward that defines itself as a 'maximum security ward.'"
The committee found that even though the country's most dangerous psychiatric patients are referred to the Hadera-area hospital, it is understaffed, especially during the evening shift. Correcting this flaw is "essential," the committee wrote.
It also concluded that the ward's layout contributed significantly to the murder, because from the nurses' station, it was impossible to either see or hear what was happening in the rooms farthest away. That, the committee wrote, is apparently why "the victim's cries for help went unheard at the nurses' station." It suggested solving this problem by removing or shortening the rooms' doors.
Last week, another ministry committee began investigating another incident involving the murdered man, in the closed ward of another government psychiatric hospital, Beer Ya'akov. There, several months before the murder, the man raped another patient.
The inquiry into the murder found that four nurses were on duty on the evening in question - three circulating among the patients, and one at the nurses' station. The patients included Y., 37, a psychotic who had been hospitalized by court order after threatening the police, and A., 67, a paranoid schizophrenic who had been hospitalized by court order due to threats and indecent assault.
Dinner was served at 6 P.M., after which the patients scattered - some to their own rooms, some to the smoking or television rooms. The shift's head nurse, Guy Lev, said that shortly afterward, as he was standing near the smoking room, "Patient Y. suddenly appeared, stood at the door of the room, and said calmly: I strangled patient A."
Lev rushed to A.'s room, at the far end of the corridor from the nurses' station, and found A. "lying on his bed in the dark, covered with a towel, his face blue." Mouth-to-mouth resuscitation revived him enough to be taken to Hillel Yaffeh Medical Center in Hadera, but he died the next day.
Later, Y. claimed that A. had provoked him and spat at him, prompting him to pummel the victim before ultimately strangling him.
Sha'ar Menashe and the Health Ministry said in response, "The hospital and the ministry are studying the [inquiry] committee's recommendations with the ministry's security department."
In addition, they said, "organizational changes have been made in the maximum security ward's security staff, and some of the committee's recommendations for improving the ward's structure have been implemented."