Within the scope of performing the duties and powers of the National Preventive Mechanism (hereinafter: the NPM) on the basis of the Act ratifying the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, the Human Rights Ombudsman of the Republic of Slovenia (hereinafter: the Ombudsman) discovered upon visiting the Begunje Psychiatric Hospital that patients in secure wards are required to wear pyjamas. Furthermore, quite a number of female patients in the women’s secure ward expressed their wish to obtain their clothing, brassieres in particular. It was their opinion that they appeared unkempt in hospital pyjamas, which caused them to feel unpleasant, especially when receiving visitors. Employees responded by saying that pyjamas help female patients accept their illness, face it, and embrace it, and it was also supposed to represent a security feature, as the chances of pyjama-clad patients escaping was presumably smaller, and brassieres were said to be dangerous from the perspective of suicidal tendencies in female patients.

We disagreed with these clarifications. In our opinion, equal concern should also be shown for strengthening the self-respect of female patients and other patients in all phases of their treatment and for their later reintegration into the home environment. However, this is difficult to provide if they wear uniform sleeping attire. We warned that suicidal tendencies are indeed possible, but we emphasised that it is difficult to understand why sleeping attire would be safer in this regard than regular clothing. If a female patient intended to commit suicide, she could also use e.g. a sheet, a towel, or a hospital robe belt instead of a brassiere. Furthermore, we expressed our opinion that, if there is a risk of a patient escaping, this does not justify the use of sleeping attire instead of regular daytime clothing. If the security standards are well-constructed and strictly adhered to, the chance of escaping from a secure ward should be minimal anyway.

Because the hospital stressed in its response that experts should express their opinions on the matter, we turned to the Expanded Professional Board of Psychiatry at the Ministry of Health (hereinafter: the EPB) and asked for its opinion on the issue. We pointed out that, upon visiting psychiatric hospitals, the Ombudsman discovered variations in the practice of requiring patients in secure wards to wear hospital clothing. Moreover, we warned that the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (hereinafter: CPT) has already warned in its report on the visit to the Psychiatric Ward of the Maribor General Hospital in 2001 with regard to the wearing of pyjamas during the day, that wearing pyjamas throughout the day does not contribute to the strengthening of personal identity and self-respect. Therefore, the CPT recommended that patients who are not seriously ill or are not confined to their beds should be enabled, and if necessary encouraged, to wear their own daytime clothing, or they should be enabled to wear non-uniform hospital clothing.

The EPB also stressed in its response of 5 June 2009 that it agrees that the clothing worn by persons hospitalised in the secure wards of psychiatric hospitals is also extremely important for their self-esteem and personal dignity. The EPB thus encouraged wearing personal clothes in these wards and supported this by professional and humanistic factors, except in very rare cases when the specifics of a patient’s physical health or need for medical interventions make it more difficult or even prevent it. Furthermore, it encouraged personnel in psychiatric wards to wear personal clothing as well.

However, the NPM continued to notice varying practices regarding enabling the use of daytime clothing in the secure wards of psychiatric hospitals. While some hospitals not only encouraged the use of daytime clothing, but also provided them for their patients (e.g. the University Psychiatric Clinic in Ljubljana offers tracksuits to its patients, who wear them during the day, even in such wards – the exceptions are geronto-psychiatric wards), others insisted that their patients wear pyjamas despite the repeated recommendations of the NPM and the aforementioned opinion of the EPB. Specifically, we visited the Idrija Psychiatric Hospital in 2016 and noticed contrasting practices with regard to patients wearing daytime clothing in secure wards. Most of the patients in the geronto-psychiatric ward wore sleeping attire or hospital attire (pyjamas), two patients in the S3 ward wore pyjamas, and most female patients in the S2 ward also wore pyjamas. As one of the most important reasons for the use of sleeping attire, our partners in dialogue also emphasised the fact that, in the event that a patient wanders off to the town, they are quickly notified that “one of their people” is walking around. With regard to the clothing, we were told in wards S2 and S3 that there is an internal agreement that patients are not allowed to use “civilian” clothing for the first three days, as they might abuse this and escape.

The NPM reiterated that experience shows that the practice of wearing hospital clothes does not contribute to strengthening the patient’s personal identity and his or her self-confidence. Since the individualisation of clothing in secure wards might be an important part of the therapeutic process, the NPM once again proposed that the Idrija Psychiatric Hospital should inform the patients to the greatest extent possible of the possibility of wearing their own daytime clothing and encourage them to do so, except when such practice is hindered or prevented by the specifics of the medical condition of a patient. Furthermore, we once again warned of the EPB’s opinion, which was already given in 2009.
 
During this visit, the NPM warned of the inadmissible practice of wearing hospital clothing during the first few days at the hospital, as internally agreed, in order to prevent patients from leaving the hospital, especially those patients who are in secure wards based on their consent, and it also proposed that the Idrija Psychiatric Hospital should inform its patients to the greatest extent possible of the possibility of wearing their own, daytime clothing and even encourage them to do so, unless this is hindered or even prevented by the special characteristics of the health condition of individual patients.
With regard to this recommendation, the Hospital communicated, among other things, that it will continue to insist on internal agreements within its medical team concerning the wearing of daytime clothing by patients, taking into consideration the strengthening of the personal integrity, self-esteem, and dignity of patients and by taking into consideration the described specific criteria with the aim of reducing the portion of patients in hospital clothing.

On the basis of this and other similar recommendations during visits to some other psychiatric hospitals, the Ministry of Health once again turned to the EPB and warned that the EPB’s expert policy concerning the (inappropriateness of) wearing pyjamas during the day from 2009 has still not been fully implemented. Based on this, on 13 February 2017, the EPB (once again) adopted a decision concerning the wearing of pyjamas, which was forwarded by the Ministry of Health to all psychiatric hospitals in Slovenia. According to this decision, the EPB once again encourages that patients from all secure wards in psychiatric hospitals, including the forensic psychiatry ward, should wear personal clothing, except in cases of contagious somatic issues and illnesses, medical interventions, and special conditions, and in the case of geriatric patients in such wards, who require additional medical care and are impaired due to illness (dementia, incontinence, infections, hospital infections, and similar). Moreover, the EPB believes that the medical personnel should also wear protective clothing in such cases in order to protect their personal integrity and physical health. All patients in hospital yards and near exits should wear their own clothing as per the recommendation. According to the opinion of the EPB, this applies to the medical personnel and patients in open wards, with the exception of special cases (somatic medical indications).

As the highest expert authority in the Republic of Slovenia in this field, the EPB thus confirmed its opinion, which has been reiterated by the NPM for a number of years when visiting some psychiatric hospitals. It must also be noted that the opinion of the EPB is pursuant to CPT standards, which warn that the practice of the compulsory wearing of pyjamas or sleeping robes does not contribute to the strengthening of the personal identity and self-confidence of a patient; the individualisation of clothing should also be a part of the therapeutic process.