FIFTH SECTION
CASE OF V v. THE CZECH REPUBLIC
(Application no. 26074/18)
 
 
JUDGMENT
Art 2 (substantive) • Life • Positive obligations • Use of force • Patient admitted for acute care in psychiatric hospital, unsuccessfully restrained in prone position by police, dead following repeated tasing and nurse’s administration of tranquiliser • Absence of strategy and measures to prevent and limit use of means of restraint • State’s failure to put in place appropriate legal and administrative framework
Art 2 (procedural) • Inadequate investigation
 
Prepared by the Registry. Does not bind the Court. STRASBOURG
7 December 2023
 
FINAL
 
07/03/2024
 
This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision. In the case of V v. the Czech Republic,
The European Court of Human Rights (Fifth Section), sitting as a Chamber composed of:
 Georges Ravarani, President,
 Lado Chanturia,
 Mārtiņš Mits,
 Stéphanie Mourou-Vikström,
 María Elósegui,
 Kateřina Šimáčková,
 Mykola Gnatovskyy, judges,
and Victor Soloveytchik, Section Registrar,
Having regard to:
the application (no. 26074/18) against the Czech Republic lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by a Czech national (“the applicant”), on 30 May 2018;
the decision to give notice to the Czech Government (“the Government”) of the complaints concerning Articles 2 and 3 of the Convention and to declare inadmissible the remainder of the application;
the observations submitted by the respondent Government and the observations in reply submitted by the applicant;
the comments submitted by the Czech Public Defender of Rights, who was granted leave to intervene by the President of the Section;
the decision to grant anonymity to the applicant ;
Having deliberated in private on 19 September and 7 November 2023,
Delivers the following judgment, which was adopted on the latter date:
INTRODUCTION
1. The application concerns the death of the applicant’s brother, hospitalised in a psychiatric hospital following the use of a taser by the police and administration of a tranquiliser by a hospital nurse, as well as the ensuing criminal investigation into the circumstances of his death (Articles 2 and 3 of the Convention). THE FACTS
2. The applicant was born in 1974 and lives in Brno. She was represented by Mr M. Matiaško, a lawyer practising in Prague. 3. The Government were represented by their Agent, Mr V.A. Schorm, of the Ministry of Justice. 4. The facts of the case may be summarised as follows. 5. The applicant’s brother P.Z., suffering from paranoid schizophrenia, was a long-term outpatient of the Psychiatric Clinic of Olomouc University Hospital (“the clinic”). EVENTS AT THE CLINIC
6. On the evening of 5 November 2015, a member of P.Z.’s family called an emergency line, stating that P.Z., who was 30 years old at the time, had become aggressive and had been threatening members of his family. At 9.30 p.m. he was taken by ambulance – accompanied by a police patrol – to the clinic and was then admitted to its acute care unit. The staff on duty that night comprised one female doctor, two female nurses and one medical orderly. After the doctor examined him and established his medical history – noting, inter alia, that he had been treated for paranoid schizophrenia since 2005 and for hypertension since 2015 and that he had taken an unspecified drug – P.Z., who had already calmed down by that time, agreed to be administered anti-psychotic medication (Haloperidol and Apaurin) and was placed in an ordinary room. The Government submitted in their observations that all the intensive care rooms had been fully occupied at the time. 7. Early the next morning, at around 4 a.m., P.Z. (who was 1.88 m tall and weighed 127 kg) began to grow restless, so the nurses started preparing an intensive care room for him (equipped with a solid metal door and a bed with magnetic straps to restrain aggressive patients) by moving another patient out. Following a verbal altercation with the staff, P.Z. began to destroy fixtures and furnishings, breaking a washbasin and several doors (including the doors to other patients’ rooms). When the orderly tried to prevent him from grabbing a fire hose, P.Z. knocked him to the ground and started beating him severely, shoving a doctor out of the way. According to subsequent accounts of the incident given to the police by the staff on duty that day, P.Z. had tried to strangle the orderly with the fire hose; he had clearly been highly agitated and capable of killing when he had attacked the orderly, causing him to fear for his life. He had then started ripping out ceiling tiles and pulling out electrical wires and spraying water onto them. After two security guards (not armed) called by the staff had tried and failed to subdue P.Z., at 4.53 a.m. a nurse had called a police emergency line; four police officers – P., S., Š. and T. – had subsequently arrived at the hospital at around 5 a.m. According to the applicant, who cited the below-mentioned report issued by the Public Defender of Rights (see paragraph 26 below), P.Z.’s behaviour had, in principle, been defensive and had indicated an increased level of restlessness, given that he had been acting calmly until he had realised that the nurses were preparing a seclusion room for him (upon which he had engaged in a verbal confrontation with the medical orderly). Indeed, his posture at the time in question would have indicated his wish to maintain a clear space around himself rather than a desire to launch an attack; moreover, he had not a priori attacked the orderly – rather, he had simply not wanted to allow the orderly to take the fire hose away from him, which was why a fight over it had begun. He had only started damaging the ceiling and the wiring at a later point, when he had seen the police officers approaching. The police officers had acted very quickly and had only briefly first consulted one of the nurses, who had not witnessed the attack and who had told them only that P.Z. had been aggressive and presented a “severe psychosocial disability”; his health status, in terms of medication or hypertension, had not been discussed, and nor had there been any attempt to communicate with P.Z. or to turn off the water or electricity supply. The Public Defender of Rights (see paragraph 26 below) acknowledged that P.Z. had posed a serious threat to the paramedics and the doctor, but considered that the latter had already been out of danger by the time the police officers had arrived. According to her report, there had been no imminent threat to others at that point because he had not been “moving in” on them. P.Z. had nevertheless posed a threat to the property of the clinic and, given that he had been spraying water on exposed cables, had created a risk of short circuit. 8. The subsequent police intervention took place in a 2.25-metre-wide corridor right outside the patients’ rooms. According to the police officers, they had had to intervene without delay (after only briefly conferring with each other), since P.Z.’s spraying water on electrical wires had threatened the lives of all those present. Using a mattress as a shield, two of them had approached P.Z. (who had ignored their warnings to desist in his behaviour), and had forced him to the ground. Owing to his physical strength and the intensity of his resistance, they had been able neither to restrain him nor to force his hands behind his back; the two other police officers – P. and T. – had been unable to help them owing to the fact that there had been only restricted space in which to manoeuvre. Deeming that all the conditions for using a taser had been met, and given that other means of coercion (tear gas, stun grenade, firearms) could not be used or would have been ineffective, T. had decided to fire his taser (but only after first warning P.Z. to desist in his behaviour), aiming at the lower back area from a range of about 1.5 meters. Although the two taser darts had connected with P.Z.’s body and should have delivered a shock, P.Z. – who had still been lying down and holding the fire hose – had continued to put up active resistance, which had prevented officers S. and Š. from securing his hands and getting him under control. Accordingly, at S.’s request, T. had fired the taser again several times until S. had managed to partially immobilise P.Z.’s arm; this had enabled a nurse to administer two injections (Apaurin and Tisercin) to P.Z. (as instructed by the doctor). 9. The police officers’ description of the events tallies with the accounts given by the hospital security guards and by the doctor and the nurses on duty. They confirmed that (i) P.Z.’s attack on the medical orderly had been very serious, leaving the latter in pain and in a state of shock (according to a subsequent forensic medical opinion, the orderly’s life had been in imminent danger – in particular because of the strangulation to which he had been subjected), (ii) the police officers had been unsuccessful in subduing P.Z. and (iii) P.Z. had still been screaming and trying to shake them off when the nurse had administered the medication to him at 5.05 a.m. According to the nurse, when P.Z. had been turned over onto his back after the injections had been administered, he had been slightly “cyanotic” in the face and had had no palpable pulse; the medical staff (assisted by the police officers) had therefore immediately embarked upon efforts to resuscitate him, using, among other things, an automated external defibrillator and adrenaline. A specialised team had arrived a few minutes later and had pursued the standard resuscitation procedure for forty-five minutes, but to no avail. At 6.08 a.m. the resuscitation efforts had been terminated and P.Z. pronounced dead – presumably as the result of a cardiac arrest. 10. On the very day of the intervention the four police officers drew up an official record regarding the coercive measures employed against P.Z. – namely, various types of grips and holds, together with blows, kicks and the use of a taser. Concerning the latter measure, on 21 November 2015 T. added to the record the fact that he had used his taser in order to overcome P.Z.’s resistance, because P.Z. had posed an imminent threat to the life and health of all the persons present (including other patients), and also to prevent him from further damaging medical facilities and equipment. In T.’s view, under the circumstances, it had been clear and beyond doubt that, given P.Z.’s physical stature, less severe means would not have been effective. 11. The incident was recorded on several video cameras in the clinic building; the footage showed, inter alia, P.Z. attacking the orderly and the doctor, handling the fire hose and spraying water onto live electrical wires, and being approached by police officers holding a mattress in front of themselves. The video camera whose footage directly captured the police officers’ intervention against P.Z. stopped working at 5.02 a.m. on the day of the intervention; according to a subsequent expert opinion, the outage had been caused by P.Z. spraying water. 12. According to the software record of the taser used in the incident, it was fired three times: the first discharge lasted for eight seconds, the second for eleven seconds, and the third for ten seconds. ENSUING INVESTIGATIONGeneral Inspectorate of the Security Forces and the prosecution authorities

13. P.Z.’s death was directly reported to the General Inspectorate of the Security Forces (hereinafter “the GISF”), which immediately initiated criminal proceedings for negligent homicide (usmrcení z nedbalosti). 14. On 6 November 2015 the GISF examined the scene of the incident and secured evidence (including the above-mentioned taser record and video recordings) and requested an expert opinion regarding the time and cause of the damage to the video camera that had been recording the police intervention (see paragraph 11 in fine above). The intervening police officers were instructed to draw up official reports on the use of coercive measures (see paragraphs 8 and 10 above), which they did on the very same day; an autopsy of P.Z.’s body was performed at 10 a.m., and experts in forensic medicine and toxicology were commissioned to produce an expert report (see paragraph 18 below). 15. Between 20 and 24 November 2015 the GISF asked the Olomouc Regional Police Directorate to produce documents relating, inter alia, to the training undergone by the intervening police officers, to the taser used and to the supplier thereof; it also asked the Directorate to provide it with the audio recording of the call made to the police on 6 November 2015 by the clinic staff to report P.Z.’s aggressive behaviour. 16. Between 25 November and 8 December 2015 the GISF interviewed the nurses, the doctor and the hospital security guards who had been on duty on the day of the incident, and the police instructor who had trained officer T. in the use of tasers. Officers T., S. and Š. were heard on 26 November 2015, and officer P. on 2 December 2015. After they had provided their account of events, questions were posed to them by the investigator regarding (i) whether they had received training in the use of tasers and been instructed as to the circumstances in which tasers should not be used, (ii) whether and when the water valve had been shut off, and (iii) their assessment of P.Z.’s frame of mind and behaviour before the intervention. 17. Subsequently the GISF requested information and material pertaining to: taser testing on humans; the training programme and the content of the training provided to Czech police officers in the use of tasers; the technical information registered on the memory chip of the taser used in the present case; the audio recording of the phone call made by P.Z.’s brother on 5 November 2015; a full copy of P.Z.’s medical records; and a copy of the above-mentioned expert opinion regarding the injuries suffered by the medical orderly. 18. On 2 March 2016 an expert report was drawn up by three medical experts, according to which the immediate cause of P.Z.’s death had been cardiac arrhythmia, which had disrupted the supply of blood to all organs, so that it had not been possible to restore a regular heartbeat by means of resuscitation. The experts deemed that, in this particular case, the absence of pertinent data rendered it impossible to establish unequivocally whether and to what extent the death had been due to natural causes. On the other hand, cardiac arrhythmia could have many causes, ranging from hormonal disorders, stress and strain (which could be generated by a psychotic episode), to side-effects of certain drugs – including those used by and administered to P.Z. Furthermore, P.Z.’s autopsy had revealed anomalies in the course of the blood vessels supplying the heart muscle with blood (anomálie v průběhu tzv. věnčitých tepen srdečních, tj. cév, zásobujících srdeční sval krví), but the experts were unable to establish the relevance of that anomaly to P.Z.s sudden death. Lastly, the experts noted that the fact that P.Z. had been repeatedly tasered (even though the electrical discharges had not been directly aimed at the chest and heart area) might be viewed as a possible contributory cause of his uncontrollable arrhythmia disorder. The experts were not asked to comment on any possible interaction between the medication that had been administered to P.Z. and the use of the taser. 19. On 6 April 2016, the GISF issued a decision setting aside the case of suspected negligent homicide by T., holding that the investigation had led to the unequivocal conclusion that the police intervention against P.Z. had been in accordance with applicable law and internal police regulations. The GISF noted that T. had been authorised to use a taser and properly trained in that respect, and that his choice to use it had been fully in line with the rules on the use of coercive measures. In their view, P.Z.’s behaviour had posed a direct threat to the lives of the intervening police officers and other persons in the vicinity, and there had been no other way of eliminating that risk. Moreover, because P.Z. had continued to actively resist even after the initial tasering, T. had continued to fire the taser repeatedly (in compliance with all safety precautions and rules), aiming at points away from the heart and other vital organs. In the light of the above, the GISF concluded that no blame for P.Z.’s death could be attributed to any particular person or action. 20. P.Z.’s family lodged a request for review of that decision, which the Ostrava Regional Prosecutor’s Office rejected as ill-founded on 2 May 2016. The Office found no wrongdoing (either on the part of the police officers or the hospital), deeming that the use of a taser had been justified in view of the fact that the scene of the intervention had been too confined for all the police officers present to participate in subduing P.Z.; it further found that the repeated firing of the taser had been necessary because of P.Z.’s continuing resistance. Furthermore, given the circumstances of the present case, neither the police officers nor the doctor on duty could have foreseen P.Z.’s cardiac anomaly. 21. The applicant challenged that decision by means of lodging a request for supervision with the Olomouc High Prosecutor’s Office. She was informed on 13 October 2016 that no shortcomings had been determined in the procedure followed by the police and the Ostrava Regional Prosecutor’s Office, whose conclusions could thus be upheld. 22. On 21 November 2017, the Constitutional Court (by decision no. IV. ÚS 4150/16) dismissed as manifestly ill-founded a constitutional appeal lodged by the applicant. It held that the investigation authorities had not breached their statutory obligations and had based their decisions on sufficient and comprehensive rea soning. Other authorities
23. On 6 March 2017, the applicant lodged a complaint with the Olomouc Regional Authority regarding the poor standard of the healthcare services afforded to P.Z. during his hospitalisation at the clinic. 24. In an expert psychiatric opinion, an independent medical expert found that the procedure followed by the medical staff in this case had been entirely lege artis and that there had been no direct link between P.Z.’s death and his medical treatment, which had included an injection of standard anxiolytic medication. 25. On 26 October 2017, referring to that opinion, the regional authority dismissed the applicant’s complaint as ill-founded. 26. The circumstances of P.Z.’s death were also examined, on her own initiative, by the Public Defender of Rights. In her report of 26 May 2017, which was based on the written material available and the investigation file, she stated (emphasis removed):
“A. Object and outcome of the examination
Regarding the issue of the nature of a taser as a means of coercion in the legal system of the Czech Republic:
A taser should be perceived as a law-enforcement device [carrying] a lower risk of causing death (less lethal) [but] a high risk of causing unnecessary pain – not as an inherently non-lethal device, as it is currently perceived by Czech law and the common practice of the Czech Republic’s police force. Czech legislation should therefore reflect the real risks associated with the use of tasers as a means of law enforcement and with its actual nature as a less lethal weapon, but [one which is nevertheless] unequivocally lethal. In my opinion, it is completely inappropriate for tasers to be legally classified [as being] among the ordinary law enforcement devices provided by the Police Act, as its nature and level of dangerousness are more akin to [those of] weapons. This should also be reflected in the legal requirements and conditions [governing] its use in practice – including, of course, the corresponding training and education of police officers who are equipped with tasers, as well as [that of] their colleagues and their supervisors. The training of police officers itself is currently burdened by three basic deficiencies. Firstly, officers are not given full and realistic information about the dangers of tasers, which they consequently regard as a non-lethal means of law enforcement, without being aware of the actual and real risks associated with its use. The training of police officers in this respect also lacks emphasis on [the need for] special caution when dealing with persons [who pose] risk factors. Furthermore, I consider that it is not sufficient to train only those police officers who are physically in possession of [a taser]. I consider it essential that training should also be extended to [those] colleagues of these officers and [those of] their supervisors who may come into contact with tasers in practice or who have a duty to monitor the use of a taser by a subordinate officer. Last but not least, I believe that ... police officers who are to be in possession of a taser and be authorised to use it should be [selected] according to predetermined criteria – including a high level of resistance to stress. As regards the investigated intervention [undertaken by] the Czech Republic’s police force and the subsequent [investigation into] the use of a taser:
... In the case under investigation, the supervisors of the intervening officers did not in fact carry out [any investigation into] the use of coercive measures –or [if they did, they] did so in only a formalistic manner, as they had in fact no objective information at their disposal. The official records [drawn up by] the intervening officers regarding the use of coercive measures lacked a detailed description of the events, on the basis of which it would have been possible to assess the appropriateness of their use. Oversight mechanisms within the police therefore need to be improved in respect of the use of tasers. Records of their use should be sufficiently detailed and informative (and include a record of the time and duration of each discharge and a description of the situation and the person’s behaviour throughout the intervention in question). Supervisors must not take a formalistic approach to assessment and should be adequately trained for this purpose ... In respect of preventive and methodological activities in the field of the protection of persons suffering from mental disorders:
From the case under investigation, it is clear from a strategic and methodological point of view that it would be very useful in future to coordinate the practices of police officers and medical staff in hospitals in the event of an intervention. This means ensuring [that there are] both sufficient methodological guidance and functioning oversight mechanisms within the Czech Republic’s police force and medical institutions through the Ministry of Health, as well as establishing cooperation and coordination between those two segments, whose members shall then deal with the situations that arise in practice. In the Czech Republic, increased attention should be paid to protecting persons with mental disorders. Among other things, regular training should be provided to persons who may come into contact with persons suffering from mental disorders during their work, and appropriate methodological guidance [should be provided] by the relevant public authorities ... C. Evaluation of the matter
... For the above-noted reasons I am inclined to the view of the [European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment] and Amnesty International that a taser is to be seen as a means of coercion [carrying] a lower risk of causing death (being less lethal) [but carrying] a high risk of causing unnecessary pain, but not [as a means of coercion that is] inherently non-lethal, as it is currently perceived by Czech law and the [common] practice of the Czech Republic’s police force ... Legitimacy and proportionality of the police intervention in the case under examination
In the case under examination – in which the police intervention was aimed at protecting lives and health of persons in the hospital – the police officers used against the victim a degree of force that was from the very beginning capable of amounting to ill-treatment and, under certain circumstances, also [causing] death ... However, as described above, police officers are not trained in the use of tasers in such a manner as to be made aware of the above-mentioned health risks ... Firstly, I would like to point out that I generally consider that the use of a taser in situations where the person concerned is on the ground, and two police officers are kneeling on top of him, as unreasonable and unacceptable. In my view, a taser cannot be used to facilitate the physical restraint of a person and as a substitute for the force [used in] other means of coercion. It can only be justified by the existence of a realistic and imminent threat to life or a danger of serious injury. In the case under review, such a reason appears to me to have [applied by reason of] the danger [posed by] the damaged power lines. Although I have paid great attention to reconstructing the course of events, I cannot say with certainty, in hindsight, whether this danger was in point of fact real or why the officers should not have considered it to be real and imminent. [P.Z.] posed a serious threat to the paramedics and the doctor, but when the officers entered the ward, they were already out of danger. A threat to others was not imminent because the patient was not ‘moving in’ on them. He [posed] a threat to the property of the clinic and the peace of the ward – given that he was shouting and spraying water – but this could have been dealt with by the police by turning off the water mains ... and perhaps – with a shield in the form of a mattress – they could have entered through the door and started negotiating. [P.Z.], however, at the sight of the officers, began to tear down the ceilings and spray water into the electrical wiring, and the officers unanimously stated that they had taken this into consideration [in reaching] their decision to act very quickly. This constitutes a very specific circumstance ... When it came to the use of force, the police officers at first chose a means of restraint other than a taser. A subsequent examination of the victim did not show that he had been subject to significant ill-treatment (that is, beating). The taser was used three times. All the police officers stated that the taser had been used while [P.Z.] had been putting up active resistance ... I believe that the intervening police officer acted according to how he had been trained ... I can only assume that the death of P.Z. was the result of an unfortunate combination of circumstances ... I also note that the experts gave their opinion on the [use of a] taser but not on the issue of positional asphyxia, which should have been examined in the instant case ... Therefore my conclusion is that in general terms, I consider it to be disproportionate to use a taser against a person who is lying on the ground and whom two or more police officers are trying to secure unless the situation is marked by exceptional, special circumstances that justify the need to secure the person [in question] and to end the situation in the shortest possible time. Such circumstances may include, for example, a risk of electric shock posed to officers, the secured person or other persons by exposed cables in a wet environment. Preventive and methodological activities in the field of police interventions in healthcare facilities aimed at protecting persons suffering from mental disorders
... The above-noted [evaluation] shows that the Czech Republic lacks sufficient analytical and strategic measures to protect persons with mental disorders, including regular training and methodological guidance [provided] by the relevant administrative authorities. The aim of such [measures] should be to prevent situations in which it is necessary to request the intervention of the Czech Republic’s police force. However, if police intervention is necessary, this activity should be aimed at minimising the use of force and [at developing,] through the use of appropriate tactics, alternatives to the use of force ... by the Czech Republic’s police force, the proper coordination of paramedics and police officers, etc. The legal expression of this objective is the above-mentioned positive obligations of the State arising from the right to life and the prohibition of ill- treatment.”
RELEVANT LEGAL FRAMEWORK AND PRACTICE
POLICE ACT (LAW NO. 273/2008)
27. Under section 51, a police officer is authorised, during an intervention, to use coercive measures and weapons that he or she has been trained to use. 28. Section 52 provides a list of coercive measures that a police officer is entitled to use; these include discharging a device with temporarily incapacitating effects that has the characteristics of a “firearm”, as defined by the Firearms Act. According to a commentary (Vangeli, B., 2nd edition, 2014, C. H. Beck) cited by the Government, these devices are classified, in terms of their effects, as non-lethal devices, and include “flash-balls” (hollow rubber balls fired against the body of the perpetrator), and “tasers” (two dart projectiles – electrical contacts carrying a conductive wire, which, after contact with the perpetrator’s body, create an electrical circuit and deliver an incapacitating electrical discharge to the body). All these devices are used principally to subdue perpetrators of violent crimes or perpetrators who are intoxicated or armed with a weapon [that is not a firearm]. They are therefore particularly useful in dangerous situations that would otherwise require the use of a firearm to maintain a safe distance from the perpetrator. 29. Under section 53(1) and (3), police officers are entitled to use coercive measures to protect public order or their own or another person’s safety or property and to choose the coercive measure which will enable them to achieve the objective of the intervention in question and which is necessary to overcome the resistance of or an attack by the person concerned. Section 53(2) requires a police officer, before using a coercive measure, to call on the person concerned to desist from acting unlawfully, failing which coercive measures will be used; such a warning may be omitted if an individual’s life or health is in danger and the intervention cannot be delayed. Under section 53(4), police officers have the right to use an electrical coercive device only if the use of a different coercive measure would obviously not be sufficient to achieve the aim pursued by the intervention. Under section 53(5), when using coercive measures police officers must be sure not to cause such harm to the person concerned as would be disproportionate to the nature and level of dangerousness presented by that person’s unlawful conduct. 30. Section 56(1) defines situations in which a police officer is authorised to use a weapon. These include (a) for the purpose of self-defence or through necessity, (b) situations in which a dangerous perpetrator refuses to surrender when called upon to do so by a police officer, and (c) preventing the escape of a dangerous perpetrator whom the police officer in question would otherwise be unable to apprehend. 31. Under section 58(1), devices which have a temporarily incapacitating effect and which have the “characteristics of a firearm” cannot be discharged against evidently pregnant women, elderly persons, persons with an evident physical impairment or disease, or persons who are evidently under 15 years of age, unless there is an imminent threat to the life or health of a police officer or another person or there is a risk of substantial property damage that cannot be otherwise averted. INTERNAL POLICE REGULATIONS
32. According to a document entitled “Specific Police Training Programme P2/0232 – Training in the use of a taser as a coercive measure”, which was issued by the training division of the Police Presidium of the Czech Republic and which has been applicable since 1 September 2013, the aim of that training is to ensure that police officers use tasers in a safe and proficient manner. Point 3 of the document stipulates that the course’s target group is officers in the position of instructor responsible for the in-house training of a unit that has been assigned a taser for the exercise of duties. The criteria according to which the competence of participants in the training (once they have completed the course) is assessed include: the ability (i) to recall and apply in practice the safety rules governing the use of a taser, (ii) to describe the components of a taser and to handle it safely in practice, (iii) to describe the different types of taser darts and their use and to explain their distribution with respect to their effectiveness, and (iv) to explain the health risks associated with the use of a taser, and to use a taser correctly in practice. At the end of the training, the participants take an examination comprising a written test and a practical test of their ability to safely handle a taser in a simulated test situation. 33. The requirements and content of the training in the form that it has taken since 1 May 2018 are described in a document entitled “Police Training Programme P2/0232 – The taser as a coercive measure”, issued by the police force’s education and in-house training unit. According to that document, the training should cover the health risks of using a taser and the safe handling of a taser; focus should also be placed on individuals who present risk factors in respect of the health-related risks of using a taser. 34. The system of organising and providing training to police officers on the use of tasers is governed by instruction no. 3/2015 of 29 October 2015 issued by the head of the Czech police’s education and in-house training unit. Under its Article 3, police officers are authorised to use a taser if they have completed a training course delivered by a properly certified instructor or lecturer under the police’s “TASER Training” programme. They are required to attend such training every two years and to take part in practical taser training at least twice a year. 35. Police Guide no. 1/2017 on the use of coercive measures and weapons by officers of the Czech Republic’s police force (updated on 1 July 2018), issued by the head of the Riot Police Service Directorate of the Police Presidium of the Czech Republic, details the conditions governing the use of coercive measures. It includes (in Part II) a description of a special procedure applicable to vulnerable persons. Part III of the guide deals, inter alia, with the use of electrical means of temporarily incapacitating a person (including tasers). According to the guide, police officers use electrical devices primarily against armed or aggressive individuals who have disobeyed a police officer’s command or instruction. The guide notes that the principle of subsidiarity applies also to the use of tasers: that is, in the event of an intervention in which other coercive measures have failed to overcome active resistance, the use of a taser constitutes a measure of last resort before a weapon is used. Moreover, when used from a distance, a taser should not be aimed at the facial area of the head, and medical treatment should be administered to an individual on whom a taser is used.
law no. 349/1999 on the public defender of rights
36. Section 1(3) provides that the Public Defender of Rights carries out systematic visits to places where persons are deprived of their liberty, with a view to strengthening the protection of such persons from ill-treatment. Such places include healthcare facilities, facilities providing institutional care or protective treatment and social services facilities. 37. Under section 9, the Public Defender of Rights can act upon an individual complaint, at the instigation of one of the chambers of the Czech Parliament and of their members, or at his or her own initiative. CASE-LAW OF THE CZECH CONSTITUTIONAL COURT
38. In its judgment no. I. ÚS 1974/14 of 23 March 2015, concerning a judicial review of the involuntary hospitalisation of a mentally disabled person, the Constitutional Court observed that, in the past, the rights of mentally disabled persons had often been overlooked and that such persons had been the object of stigmatisation, ostracisation, prejudice and serious human-rights violations; however, such marginalisation was no longer acceptable. The Constitutional Court was of the view that the fact that, historically, mentally disabled persons had constituted a vulnerable group should be reflected by adopting a particularly cautious interpretation of legal provisions concerning them, and that that interpretation should be fully compliant with their fundamental rights. Mentally disabled persons enjoyed all human rights; that fact ensured that they enjoyed the protection of and respect for their natural human dignity. 39. In its judgment no. I. ÚS 860/15 of 27 October 2015, which concerned the execution by the police of an order for the administrative expulsion of an alien, the Constitutional Court noted that such an act had to be conducted in a humane and respectful fashion. Like any other State security forces, the police were obliged to carry out interventions not only with respect for the dignity and rights of the persons concerned but also in a manner that enabled them to calm possible conflict-laden situations rather than escalating tensions or generating conflict. RELEVANT INTERNATIONAL DOCUMENTS
RECOMMENDATION REC(2004)10 OF THE COMMITTEE OF MINISTERS TO MEMBER STATES CONCERNING THE PROTECTION OF HUMAN RIGHTS AND THE DIGNITY OF PERSONS WITH MENTAL DISORDERS (ADOPTED ON 22 SEPTEMBER 2004)
40. The relevant parts of this Recommendation read as follows:
Article 11 – Professional standards
“1. Professional staff involved in mental health services should have appropriate qualifications and training to enable them to perform their role within the services according to professional obligations and standards. 2. In particular, staff should receive appropriate training on:
i.  protecting the dignity, human rights and fundamental freedoms of persons with mental disorder;
ii.  understanding, prevention and control of violence;
iii.  measures to avoid restraint or seclusion;
iv.  the limited circumstances in which different methods of restraint or seclusion may be justified, taking into account the benefits and risks entailed, and the correct application of such measures.”
Article 32 – Involvement of the police
“1. In the fulfilment of their legal duties, the police should coordinate their interventions with those of medical and social services, if possible with the consent of the person concerned, if the behaviour of that person is strongly suggestive of mental disorder and represents a significant risk of harm to him or herself or to others.
2.  ... 3. Members of the police should respect the dignity and human rights of persons with mental disorder. The importance of this duty should be emphasised during training. 4. Members of the police should receive appropriate training in the assessment and management of situations involving persons with mental disorder, which draws attention to the vulnerability of such persons in situations involving the police.”
41. An explanatory memorandum in respect of Article 11 of the Recommendation emphasises that training designed to ensure the protection of dignity and human rights is important for all staff who have contact with persons with a mental disorder. The memorandum also emphasises the importance of training in respect of how to handle violent (or potentially violent) situations; the memorandum states that staff should receive such training if it is appropriate to their work. The central principle is that staff should aim to prevent situations escalating into violence – both by understanding factors that may lead to such escalation (so that staff can as far as possible minimise such factors) and by the use of techniques (such as verbal de-escalation) that can reduce the risk of violence and in particular reduce the need to use either restraint or seclusion. 42. An explanatory memorandum in respect of Article 32 of the Recommendation states that members of the police force have a duty to respect the dignity and fundamental rights of persons suffering from a mental disorder from the time that they commence their duties. This duty should be emphasised during the training of police staff. However, not having undertaken such specific training does not absolve a member of the police of the need to respect the principle. REPORTS ISSUED BY THE EUROPEAN COMMITTEE FOR THE PREVENTION OF TORTURE AND INHUMAN OR DEGRADING TREATMENT OR PUNISHMENT (“THE CPT”)Twentieth General Report of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment

43. This report, published in 2010, states:
“65. It is becoming increasingly common in countries visited by the CPT for police officers and other law enforcement officials to be issued with electrical-discharge weapons (EDW), and the presence of such devices in places of detention (in particular prisons) has also been observed by the Committee in certain countries. There are various types of EDW, ranging from electric shock batons and other handheld weapons requir ing direct contact with the person who is the intended target to weapons capable of delivering dart-like projectiles which administer an electric shock to a person located at some distance ... 66. The use of EDW by law enforcement and other public officials is a controversial subject. There are conflicting views as regards both the specific circumstances in which resort to such weapons can be justified and the potential negative effects on health that the weapons can cause. It is also a fact that by their very nature, EDW lend themselves to misuse.
... 68. The CPT understands the wish of national authorities to provide their law enforcement officials with means enabling them to give a more graduated response to dangerous situations with which they are confronted. There is no doubt that the possession of less lethal weapons such as EDW may in some cases make it possible to avoid recourse to firearms.
... 70. In the CPT’s view, the use of EDW should be limited to situations where there is a real and immediate threat to life or risk of serious injury. Recourse to such weapons for the sole purpose of securing compliance with an order is inadmissible. Furthermore, recourse to such weapons should only be authorised when other less coercive methods (negotiation and persuasion, manual control techniques, etc.) have failed or are impracticable and where it is the [last] possible alternative to the use of a method presenting a greater risk of injury or death.
 ... 78. Electrical discharge weapons issued to law enforcement officials commonly offer different modes of use, in particular a ‘firing’ and a ‘contact’ (drive-stun) mode. In the former, the weapon fires projectiles which attach to the person targeted at a short distance from each other, and an electrical discharge is generated. In the great majority of cases, this discharge provokes generalised muscular contraction which induces temporary paralysis and causes the person concerned to fall to the ground. In contrast, when the ‘contact’ mode is used, electrodes on the end of the weapon produce an electrical arc and when they are brought into contact with the person targeted the electrodes cause very intense, localised pain, with the possibility of burns to the skin. The CPT has strong reservations concerning this latter mode of use. Indeed, properly trained law enforcement officials will have many other control techniques available to them when they are in touching distance of a person who has to be brought under control. 79. The potential effects of EDW on the physical and mental health of persons against whom they are used is the subject of much argument ... In the absence of detailed research on the potential effects of EDW on particularly vulnerable persons (e.g. the elderly, pregnant women, young children, persons with a pre‑existing heart condition), the CPT believes that their use vis-à-vis such persons should in any event be avoided. The use of EDW on persons who are delirious or intoxicated is another sensitive issue; persons in this state of mind may well not understand the significance of an advance warning that the weapon will be used and could instead become ever more agitated in such a situation. Deaths during arrest have been attributed to these medical conditions, in particular when EDW have been deployed. Therefore, particular caution is warranted and the use of EDW should be avoided in such a case and, in general, in situations where EDW might increase the risk of death or injury.
... 82. Following each use of an EDW, there should be a debriefing of the law enforcement official who had recourse to the weapon. Further, the incident should be the subject of a detailed report to a higher authority. This report should indicate the precise circumstances considered to justify resort to the weapon, the mode of use, as well as all other relevant information (presence of witnesses, whether other weapons were available, medical care given to the person targeted, etc). The technical information registered on the memory chip and the video recording of the use of the EDW should be included in the report ...”
CPT’s comments concerning the prone position
44. In the document CPT/Inf/E (2002) 1 – Rev. 2010, published on 8 March 2011, the CPT noted, in respect of the deportation of foreign nationals, that in cases where resistance was encountered, escort staff usually immobilised the detainee completely on the ground, face down, in order to place him or her in handcuffs. Keeping a detainee in such a position – in particular in the event that escort staff put their weight on various parts of the body (for example, exerting pressure on the ribcage, placing knees on the back, immobilising the neck) after the person concerned has put up a struggle – entails a risk of positional asphyxia. The CPT has made it clear that the use of force and/or methods of restraint capable of causing positional asphyxia should be avoided whenever possible and that any such use in exceptional circumstances must be subject to guidelines designed to reduce to a minimum the risks to the health of the person concerned. 45. In its report on the visit to the Netherlands carried out in October 2011 (CPT/Inf (2012) 21), published on 9 August 2012, the CPT stressed the risks inherent in the use of certain restraint techniques (in particular, the use of the neck hold) in order to control agitated patients in mental health institutions, as well as the need to avoid immobilisation techniques that might quickly lead to positional asphyxia (paragraph 106). 46. In its report on the visit to the United Kingdom carried out in June 2021 (CPT/Inf (2022)13), published on 7 July 2022, the CPT noted that the MHA Code of Practice stated that patients must not be restrained in the prone position unless “there are cogent reasons” for doing so, and NICE Guidelines recommended the supine position if patients have to be forced to the floor. It considered positive that at Priory Hospital Enfield, the prone position was no longer applied following a clear commitment by the management to phase out its use (paragraph 165). Means of restraint in psychiatric establishments for adults (CPT/Inf(2017)6)
47. In this document, published on 21 March 2017, the CPT consolidated its revised standards regarding the use of means of restraint vis-à-vis psychiatric patients. It stressed that the ultimate goal should always be to prevent the use of means of restraint by limiting as far as possible their frequency and duration. To this end, it considered it to be of paramount importance that the relevant health authorities and the management of psychiatric establishments develop a strategy and take a panoply of proactive steps, which should inter alia include the provision of a safe and secure material environment (including in the open air), the employment of a sufficient number of healthcare staff, adequate initial and ongoing training of the staff involved in the restraint of patients, and the promotion of the development of alternative measures (including de-escalation techniques). It was noted that in most countries visited by the CPT, one or more of the following types of restraint may be used:
(a)  physical restraint (staff holding or immobilising a patient by using physical force – “manual control”);
(b)  mechanical restraint (applying instruments of restraint, such as straps, to immobilise a patient);
(c)  chemical restraint (forcible administration of medication for the purpose of controlling a patient’s behaviour); and
(d)  seclusion (involuntary placement of a patient alone in a locked room). Report of 31 March 2015 (CPT/Inf (2015) 18)
48. On 31 March 2015 the CPT’s report on a periodic visit to the Czech Republic from 1 until 10 April 2014 was published. The report stated (emphasis removed):
“168. It became clear during the visit that uniformed police officers were frequently called upon to assist in restraining agitated patients whenever health-care staff at Kosmonosy Psychiatric Hospital were not able to control the situation themselves. This state of affairs is not acceptable and cannot be justified by the lack of male nurses. The CPT recommends that the Czech authorities take the necessary steps to put an end to the practice of involving police officers in restraint of agitated patients at Kosmonosy Psychiatric Hospital. Further, all nursing staff should be trained in the appropriate use of means of restraint and refresher courses should be organised at regular intervals. Such training should not only focus on instructing staff how to apply means of restraint but, equally importantly, should ensure that they understand the impact the use of restraint may have on a patient and that they know how to care for a restrained patient.”
Report of 1 June 2017 (CPT/Inf (2017) 13)
49. In its report on a visit to Germany conducted from 25 November until 7 December 2015, published on 1 June 2017, the CPT acknowledged that, in exceptional situations (that is, when weapons or hostage taking were involved), the assistance of the police might be unavoidable. However, in the Committee’s view, hospital staff should generally be sufficient in number and able to handle violent situations without recourse to the police, including at night (paragraph 127). UNited nations publication entitled “Guidance on Less-Lethal Weapons in Law Enforcement”
50. This publication, issued in 2020 by the Office of the United Nations High Commissioner for Human Rights, observes the following in its section 7.4 on conducted electrical weapons (“tasers”):
“7.4  CONDUCTED ELECTRICAL WEAPONS (“TASERS”)
UTILITY AND DESIGN
7.4.1  Conducted electrical weapons are typically used to deliver pulses of electrical charge that cause the subject’s muscles to contract in an uncoordinated way, thereby preventing purposeful movement. This effect has been termed “neuromuscular incapacitation”. The charge is delivered through metal probes that are fired towards the subject but which remain electrically connected to the device by fine wires. During the period of uncoordinated muscle activity, law enforcement officials are able to intervene to restrain the subject using conventional methods, such as handcuffs. Many models use compressed nitrogen to fire two darts that trail electric cable back to the weapon’s handset. When the darts strike the human body, pulses of high-voltage charge pass down the cable.
7.4.2  Many conducted electrical weapons can also deliver an electric shock when pressed directly against an individual (a use sometimes referred to as “drive-stun mode”), though the effect relies on pain compliance and does not result in neuro-muscular incapacitation. CIRCUMSTANCES OF POTENTIALLY LAWFUL USE
7.4.3  Among other uses, conducted electrical weapons are used by law enforcement officials to incapacitate individuals at a distance posing an imminent threat of injury (to others or to themselves).
7.4.4  To prevent a prolonged charge from being applied to a suspect, every conducted electrical weapon should have an automatic cut-off of the electrical charge. This is often set at no more than five seconds. Currently, not all weapons have an automatic cut-off feature. SPECIFIC RISKS
7.4.5  The risks caused by the discharge of a conducted electrical weapon include primary injury from the electrical charge or the barbs imbedded in the skin. Elderly people may be more prone than others to musculoskeletal injury from the muscle contractions produced by the weapon. Conducted electrical weapons should not be used against persons in elevated positions owing to the risk of a secondary injury, especially to the head; such injuries can be sustained in particular as a result of falling to the ground from a height or onto a hard surface, as individuals who have received an electrical charge will typically be physically incapable of using their hands to break a fall.
7.4.6  The risk of significant injury or even death is increased in certain conditions, including where the individuals who have been electrically shocked have heart disease; have taken certain prescription or recreational drugs, or alcohol, or both; or are for other reasons more susceptible to adverse cardiac effects. TASERTM guidance recommends that, when possible, users should avoid targeting the frontal chest area near the heart, in order to reduce the risk of potentially serious injury or death. Children and slender adults may be at greater risk of internal injury from tissue-penetrating barbs, as their body wall is generally less thick. The discharge of a conducted electrical weapon may trigger seizures in those affected by epilepsy, irrespective of barb location. Law enforcement officials should also avoid using conducted electrical weapons against genitals or other sensitive body areas.
7.4.7  Certain types of aggressive behaviour that may lead law enforcement officers to use conducted energy devices can be caused by mental health issues, language barriers, hearing disorders, visual impairment, neurodevelopmental or neurobehavioural disorders or learning difficulties. Law enforcement agencies should ensure that those working in situations where they are likely to encounter persons with pre-existing vulnerabilities have had detailed guidance and training in identifying such risks, and that they possess the knowledge, ability and tools necessary to understand, and if possible de-escalate, violent situations that could trigger the use of conducted energy weapons.
7.4.8  The use of conducted electrical weapons in the presence of flammable liquid or explosive vapour may result in fire or deflagration, or even an explosion. Some irritant spray solvents may be flammable, and the solvent may be ignited by the arc discharge from a conducted electrical weapon.
7.4.9  The use of conducted electrical weapons against an individual to prevent or limit self-harming behaviour must be justifiable in the circumstances.
7.4.10  Even when drive-stun use of conducted electrical weapons is lawful, it may not be effective on persons with serious mental health issues or on others who may not respond to pain, for example owing to a mind-body disconnect. In such instances, there is a heightened risk of serious injury. CIRCUMSTANCES OF POTENTIALLY UNLAWFUL USE
7.4.11  Conducted electrical weapons should not be used with a view to overcoming purely passive resistance to an official’s instructions through the infliction of pain. Repeated, prolonged or continuous discharge should be avoided whenever possible.
7.4.12  The risk of inflicting pain or suffering so severe that it may amount to an element of torture or cruel, inhuman or degrading treatment or punishment is especially high when a weapon is used in drive-stun mode to apply electricity directly to an individual without incapacitating them. Such applications may also raise the individual’s level of aggression, as a result of the pain inflicted.”
AMNESTY INTERNATIONAL STUDY ENTITLED “PROJECTILE ELECTRIC-SHOCK WEAPONS: AN AMNESTY INTERNATIONAL POSITION PAPER”
51. This study, published in February 2019, observes:
“2.3.1  Dart-firing mode – operational gap: the need to incapacitate a person? The key feature of PESWs [projectile electric-shock weapon] is their ability to instantly incapacitate through directly impacting a person from a certain distance (several meters, the precise distance depending on the type of PESW to be used): this mode causes neuromuscular incapacita tion through which the person instantly loses control of his/her muscles and is unable to act. Other weapons able to respond to any threat at such a distance would be either a lethal option, such as a firearm, or – as a less‑lethal option – a gun that fires kinetic impact projectiles (commonly referred to as rubber bullets). All other options require a much closer range: open hand techniques, the baton, pepper spray. The rubber bullet firing weapon relies principally on causing pain and surprise to the person. It is not designed to have an instantaneously incapacitating effect; the targeted person keeps control over their body functions and remains able to act. It is therefore not reliable as a means to instantane ously stop a person who shows the clear determination to cause serious harm. Thus, the introduction of PESWs may be an appropriate response to fill an operational gap when seeking an effective means to stop a serious threat from a distance without resorting to the use of lethal force.
2.3.2  Drive-stun mode – operational gap: the need to achieve compliance through pain? In drive-stun mode, the PESW is applied directly on the body of the person over whom control is sought, which means it will be applied in a close contact situation, often during wrestling with officers trying to control a violent and/or resistant person. Because the two points of con tact of the weapon that are releasing the electric current are too close to each other to complete an electric circuit, this mode will not cause neuro‑ muscular contraction and the concomitant incapacitation. It relies on obtaining the individual’s compliance through the extreme pain it causes. This means that this mode is useless in response to the situations frequently cited to justify the introduction of PESWs: their use against per sons who are resistant to pain, such as due to the effects of alcohol or drugs, which makes other means and methods of use of force ineffective – the PESW used in drive-stun mode will be equally ineffective in these cases. Furthermore, in a close contact setting, in which drive-stun mode can be applied, there are a range of other means available: Empty hand techniques, pure body weight from the officers, the baton. In addition, pepper spray might be used just before any wrestling starts (in a wrestling situation, pepper spray would present too high a risk for the officer him/herself). As such, and in clear contrast to the obvious advantage when used as an incapacitating weapon at a distance (i.e. in dart-firing mode), PESWs used in drive-stun mode might widen the available use- of-force-options in close-contact situations, but do not fill a relevant or significant operational gap. Furthermore, compared to other techniques that not only inflict pain, but can also immobilize a person, such as certain empty hand techniques [i.e. techniques to control a person without the use of any device or weapon], the infliction of immense pain can have the contrary effect and make a person even more violent and angry, thus being ineffective in terms of the desired result.”
52. The also report indicates that a taser may fail in a sizeable proportion of cases – particularly when used in dart-firing mode:
“[T]here is a risk of the weapon not being effective – as also explicitly stated in the manufacturer’s ‘Taser’ user manual. Some reports cite failure rates of up to 30% in dart‑firing mode. Depending on the mode used, there are many reasons why the weapon can fail to be effective: the darts can hit too close to each other resulting in no electric circuit; one or both darts may not stick to the target or can be impeded by thick clothing; or technical failure or physical conditions of the person targeted can reduce the effect of the weapon ... A study in Austria found that out of 111 discharges in dart-firing mode, 19 were only effective after several discharges, 17 had no effect at all (which amounts to a definite failure of more than 15% or one failure within every 6 discharges!) ... [A British study] even mentions reports of 30% of failure to subdue a subject in probe-mode (= dart‑firing mode).”
THE LAW
ALLEGED VIOLATION OF ARTICLE 2 OF THE CONVENTION
53. The applicant complained that the police officers who had intervened against her brother in a psychiatric hospital had used a taser, which had led (on its own or in combination with the medication administered on admission and following the tasering) to the death of her brother. She asserted that the intervention had not been planned, that the medical staff had not been consulted about it, that there had been no regulatory framework laying down rules for the use of force against persons with mental disorders and that the police officers had not been trained in how to use a taser against such persons. The applicant further complained that the authorities had failed to carry out an adequate investigation into the incident. She argued that there had been a breach of Article 2 of the Convention, which provides:
“1. Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law. 2. Deprivation of life shall not be regarded as inflicted in contravention of this Article when it results from the use of force which is no more than absolutely necessary:
(a)  in defence of any person from unlawful violence; ...”
Admissibility
54. The Court notes that this complaint is neither manifestly ill-founded nor inadmissible on any other grounds listed in Article 35 of the Convention. It must therefore be declared admissible.

Article of the Convention at issue: Article 2
Outcome: violation