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South Korea’s national human rights watchdog has filed a criminal complaint against the director of Won Hospital, a psychiatric facility in Incheon, after an investigation found serious failures involving four patient deaths, prolonged isolation, restraints and restrictions on communication.
The National Human Rights Commission of Korea said on the 6th that it referred the hospital director to the Serious Crimes Investigation Office on allegations including professional negligence resulting in death, unlawful confinement, directing unlicensed medical activity and violating record-retention requirements. Nursing assistants and patient care workers were also referred over alleged violations of legally required isolation and restraint procedures.
Separately, the Incheon Metropolitan Police Agency searched the hospital that morning and reportedly obtained medical records and other evidence. Police said their investigation began after the family of one patient filed a complaint and that the search had not been coordinated in advance with the Serious Crimes Investigation Office.
Deaths During Gaps in Medical Staffing
The rights commission identified four patients who were found in cardiac or respiratory arrest between January and June and died either that day or within three days. Two were discovered during overnight hours when, according to the commission, no licensed medical personnel were present anywhere in the hospital.
In January, a patient with dementia who had been placed in an isolation room was found in cardiac and respiratory arrest at about 1 a.m. by a nursing assistant. The patient died from a traumatic subdural hemorrhage.
A patient with an intellectual disability had been kept alone for 325 days in a locked hospital room because the patient allegedly took food from others. The patient was found in cardiac arrest in February and later died from asphyxiation.
In March, a patient with schizophrenia was found in cardiac and respiratory arrest at about 10:30 p.m., also during a period without licensed medical staff. The patient died two hours later from gastrointestinal bleeding. A fourth patient, who had alcohol dependence syndrome, developed breathing difficulties while eating instant noodles in June and later died from multiple organ failure.
Prolonged Isolation and Alleged Unlicensed Care
The commission made an unannounced visit to the hospital July 2 after receiving a petition alleging inadequate meals and limits on patients’ ability to send letters and communicate with people outside the facility. Investigators found indications that patients had been restrained in hospital rooms and other locations not designated as isolation rooms. Some room doors had external locks.
The commission opened a formal investigation July 16. It found that one autistic patient had been isolated for 200 days in a locked room because the patient allegedly stole other patients’ coffee. Investigators found no order from a psychiatrist or required documentation explaining the isolation or restraint.
No licensed medical personnel were assigned to the hospital from 10 p.m. to 7 a.m. each day, the commission said. During those hours, the hospital director allegedly instructed nursing assistants and care workers to isolate and restrain patients. The commission concluded that those instructions amounted to unlicensed medical activity.
Six patients who had difficulty communicating were classified as voluntary admissions or admissions made with consent. Five other patients similarly classified told investigators they had never agreed to be hospitalized.
Only four of the hospital’s eight locked wards had public telephones. Patients were barred from possessing cellphones and allowed to make calls only once a week, restrictions the commission said violated their freedom of communication.
Calls for Stronger Oversight
The commission recommended that the local public health office consider administrative penalties against Won Hospital, including a suspension of operations under South Korea’s Medical Service Act. It also urged the Ministry of Health and Welfare to address what it described as improper isolation and restraint practices in psychiatric institutions.
Records obtained from the city of Incheon by Democratic Party lawmaker Heo Jong-sik show that the local health office issued four corrective orders to Won Hospital from 2024 through this year. Two involved failures to meet psychiatric facility staffing standards: one for an insufficient number of specialists in November 2024 and another for a shortage of mental health professionals in April.
The two other orders involved failures to submit financial records and to display required notices intended to prevent patient violence.
Heo said the hospital had twice been cited for staffing shortages, but the health office issued only corrective orders while patients continued to die. He called on the Health Ministry to strengthen penalties, including allowing suspensions for psychiatric facilities that repeatedly violate staffing requirements.
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