The Czech state is quietly tyrannizing its most vulnerable citizens. From Respekt.

First of two parts. 

The clock showed almost 9 a.m. and Dorota Sandorova was still not out of bed. This wasn’t her usual routine. Typically, she would have been up by seven, loudly demanding food, something to drink, or simple attention. The 37-year-old client of a facility for people with intellectual disabilities in the Czech town of Jindrichuv Hradec was one of those known in the world of social care services as “problematic” or “disrupting the collective.” Since childhood, she had been disobedient and restive. When there was something she didn’t like, she would scream, punch the door or roll around on the floor, defying the instructions of her carers. That, after all, was why she lived here in “Home 05”, a facility set up by the authorities of the South Bohemian Region a few years back for clients who required the highest level of assistance – precisely because of their behavior, which is related to their disability.

On the first Wednesday of January 2021, however, Dorota’s room was unusually calm. Around 9 a.m., the assistant on duty opened the door. Dorota was lying face-down in her bed, with her face buried deep in the pillow. Only a tuft of black hair was sticking out of the duvet. The body was cold –  she had clearly been dead for several hours. These things happen in social care facilities. People with a complex set of disabilities often do not live into old age. But in this case, something was off. Somebody who has died of natural causes in her sleep does not usually have her arms twisted high behind her back, nor a duvet pulled over her head.

A few hours later, the facility grounds were lit up by the flashing lights on police cars from the nearby city of Ceske Budejovice. Dorota’s room was covered in numbered tags as technicians searched for evidence. Soon, everything would point in one direction: The intellectually disabled client of the home, a place supposed to guarantee the best possible care for its residents, had been murdered.

“If you treated her in a friendly and at the same time consistent manner, she cooperated with a smile.”

Silence on the Iceberg

If you’re racking your brains in vain, trying to remember a news report about the murder of a woman in Jindrichuv Hradec, there’s no point: There was no news. The case of Dorota Sandorova, killed when her carer lied on top of her in her bed – to calm her down, he said – before brutally twisting her arms behind her back and using full force to push down on her chest until she lost consciousness and suffocated, was for some reason never mentioned in the media. “Some homeless guy who is knifed in a garden allotment gets mentioned on news sites within the hour,” says an incredulous Milan, one of several employees of the facility who were willing to be interviewed on condition of anonymity. (All of them signed employment contracts containing non-disclosure clauses, which they do not wish to publicly break, given the tense atmosphere.) “But after Dorota there was just silence.”

This silence continues. The crime has not become a subject for expert analysis, cited by social workers as examples of good or bad practice. Officials and politicians responsible for social issues have never talked about it. The director of the facility in Jindrichuv Hradec never explained to his employees what had actually happened. And nobody was invited to Dorota’s funeral, arranged by Jindrichuv Hradec town hall as her official guardian. No one from the regional authorities, the body in charge of facilities for people with special needs, even visited the facility after her death.

“I invited the director for a talk,” says Lucie Kozlova, a deputy governor of South Bohemia Region whose portfolio includes social affairs, about her reasons for not visiting. “And he assured me that what had happened was the unique failure of one specific person.”

But the director, Jiri Blizil, who no longer works at the facility and has refused to talk about the past, did not tell the responsible politician the truth. The death of his client was not the failure of an individual, an incident capable of being resolved by sentencing the perpetrator. It was the logical consequence of the long-term abuse in his facility of clients with challenging behavior. There had been a number of indications that this was the case, well known to the management. And not just that. The unknown case of Dorota Sandorova represents the tip of the iceberg of a systemic tragedy, which is as little known and talked about in the Czech Republic as the episodes of nighttime rage in Home 05.

The health care policies of some countries pay special attention to a specific group of people with mental disabilities or severe autism (or, sometimes, a combination of the two) – those who require permanent support and who also behave in non-standard and difficult ways. There’s a simple reason for that: Practical experience shows that people like Dorota Sandorova are at a higher risk of improper treatment than anyone else. Often, they are “marginalised, stigmatised, disempowered and excluded from mainstream society,” says the conceptual methodological document Challenging Behaviour: A unified approach, a joint volume by the UK’s Royal College of Psychiatrists, British Psychological Society, and the Royal College of Speech and Language Therapists. The authors state that these people are vulnerable to abuse, mistreatment, and restriction of their freedoms.

That is exactly what often happens in the Czech health care and social care systems. People born with a serious learning disability of this type are highly likely to be subjected at some point to completely inappropriate and unprofessional care, trauma and abuse, sometimes ending in tragedy. At the same time, the state is not sufficiently aware of this situation, nor is it trying to change it.

There are many examples of this. The author of this article has spent the last year mapping them. In psychiatric hospitals, in social care facilities, in special schools and in exhausted families caring for disabled children – everywhere there is a lack of knowledge and resources for work with children and adults with challenging behavior, even though the standards of such work are well known and described in Western countries.

In order to start paying off the debt of this great silence, we should first go back in time, to the story of a woman which should enter the textbooks as a memento. To the early 1990s, when two sisters with learning disabilities, removed from a poor Roma family, walked through the gates of the institute for children in Lasenice, in southern Bohemia. Zaneta and Dorota Sandorova.

Letting Them Know I’m Alive

“Zaneta was a star and Dorota was a problem,” Milan summarizes laconically. He knew the two girls in the mid-1990s as a young care provider. “Pretty much nobody liked her, because she was always causing trouble. And this bad reputation then followed her wherever she went.”

Even though we will not cover Zaneta’s fate in greater detail, the different perception of the two sisters is a good example of how the social service system determines the quality of life for people with serious disabilities. In the strict regime of institutional care, the rules at that time were heavily influenced by a generation of staff from the socialist era, who had their favorites among the clients – children who, in spite of their disability, were good, cuddly, socially capable, and obedient.

That was the case with Zaneta, who was pampered by the staff, almost like a doll. On the contrary, the wilder, more disobedient and challenging children became black sheep, without anyone thinking about the reasons for their behavior. “Dorka [Dorota] had a more severe mental disability, she could only speak a few words and the institutional environment wasn’t providing any stimuli to her, so she misbehaved. She wasn’t aggressive, but she would nudge people, she would protest, she would try to get people’s attention. She could scream like crazy and she would sometimes make a big ruckus, so everybody immediately felt they had to stop it somehow,” Milan recalls.

“She simply learned to get on people’s nerves. Perhaps it was the only way of letting them know she was alive.”

But this rebellious attitude was not beneficial to her life. When she did something bad, carers would punish her by confining her in a cage bed (still legal back then). When she had a fit of anger, they would automatically call the nurse to inject her with a sedative. “Sometimes she was so over-medicated that she would just sit in the corner, saliva coming out of the corner of her mouth,” Milan says. “And some female colleagues would also beat her up. There was a conviction that it was good if she got a beating, because she would then be quiet.”

Time went on. After several stops in other facilities, in 2013 the adult Dorota Sandorova came to a place that held a promise of a better future. The South Bohemia Region responded to the calls of exhausted parents of children with autism, as well as of social care professionals, and set up the specialized Home 05 within a facility in Jindrichuv Hradec housing 112 people with disabilities. Home 05 was home to seven clients with challenging behavior. More assistants with special training and pay bonuses were supposed to make sure that people like Dorota would get better support and fewer restrictions.

It started off quite promisingly. Assistants tried to provide their clients with a varied life, taking them out and engaging them in different activities. “We would meet Dorota in the corridors and sometimes it would get quite lively,” recalls Milan, who works in another part of the facility. “She would lie down on the ground right next to the main reception, screaming, pushing the staff out of their comfort zone, curious as to that they would do. But I gradually felt that the pressure was increasing for her to be put away somewhere, to avoid those unpleasant situations. And so she would gradually disappear from sight. The household closed itself off and we stopped seeing her.”

A young Dorota at a children’s home in southern Bohemia.

State Within a State

In order to better understand what was going on behind the closed door marked with the number 05, it makes sense to take a small detour. Since the 1980s, the Western (particularly the English-speaking) world has seen the gradual introduction of an approach that has helped care givers understand the situation of “challenging” clients much better. The fundamental thesis of this approach, which is most commonly called positive behavior support and is now the official framework of care provided in the UK, Ireland, and Australia, can be summarized as “behavior is always a form of communication.”

People like Dorota Sandorova are not mean, willfully aggressive, or ill-mannered. Just as healthy individuals express their needs in words and sentences, some intellectually challenged people express them through their behavior, because the neurobiology of their brains does not give them other options. 

“Difficult behaviors result from unmet needs,” writes one of the most prominent specialists in this field, the American author David Pitonyak. “In a sense, difficult behaviors are messages which can tell us important things about a person and the quality of his or her life.”

And these messages, which can outwardly manifest as aggression, insubordination, self-harm, or screaming, usually express common human desires. They can be expressions of physical pain which the person has no other way of demonstrating; of boredom and lack of meaningful stimuli; of feelings of danger, anxiety, unsatisfactory relationships; or frustration resulting from the inability to make decisions about their own lives.

Little by little, experts have built up a corpus of know-how on understanding the behavior of people with intellectual disabilities and how to respond to it correctly. It’s not always easy, with efforts sometimes reminiscent of detective work and results often far than perfect, as both biology and learned patterns maintain the client in well-worn tracks. But if we are persistent, behavior can always improve hand in hand with improvement in the quality of life, according to Brian McDonald, an Irish practitioner with 30 years of experience in support for people with intellectual disabilities.

Unfortunately there is also a dark side to this logic, making this group of people a particularly at-risk group. If carers cannot (or will not) identify what the disabled person needs, and are primarily focused on stopping the inappropriate behavior, it is as if they are preventing that person from speaking. Frustration grows and behavior deteriorates, and with it also the repressive response of the carer. The “problematic” client becomes an unwanted element in the system.

“When I started working there, one of the first things I was told was how terrible and impossible to control Dorota was,” says Karel, one of the carers who joined Home 05 in the year preceding her death. “Everyone was always complaining about her. My superior even recommended using the police hogtie as a technique for calming her down, which is completely unacceptable in the context of social work. But then when I worked with her, my experience was completely different. If you treated her in a friendly and at the same time consistent manner, she cooperated with a smile.”

Gradually, Karel noticed that the woman responded to the presence of some colleagues with restlessness. He would soon find out why. The increasingly closed-off environment of the special facility gradually became a kind of state-within-a-state with its own rules. According to several sources from the facility, neither the director nor the social workers would ever set foot in it. The long-term carers gradually started to lock their charges in their rooms, so as not to be bothered by them. In case of trouble, they would either call the nurse, who would administer a sedative, or an ambulance to transport the stressed-out clients to psychiatric hospitals located dozens of miles away. When a new manager, Alena Tomankova, took charge of the home in 2020, she eventually banned this practice and ordered the assistants to work actively with the clients instead. Without the use of tranquilizing drugs, however, conflicts kept happening more and more often.

Negligence Leading to Suffocation

“Once when I was changing Dorota’s clothes, I noticed she had a big bruise on her kidney, one she couldn’t have caused herself,” Karel says. “A few days later, another bruise showed up on her arm.” Subsequent investigation led to the suspicion that some assistants beat their clients with a cooking spoon (allegedly they had already broken two spoons on Dorota’s body) or kicked them, but there was no direct proof. It became clear that some carers from the 12-member staff were covering for each other. Bruises kept on appearing, as did other indications of abuse: testimony that a client had been beaten up by an assistant in the showers, a kicked-in door through which a locked-in person tried to get out, clients grabbed by their hair, intentional provocation of the clients. A photo taken in secret shows a fretful Dorota wearing a hoodie that the carer intentionally put on front to back to provoke her.

The new manager tried to solve the situation. She introduced a morning check for bruises and engaged in intensive communication with those team members who wanted to change the approach. At one point, she was considering suing some of her employees, but the director of the main home opposed that step. The attempt at rectifying the situation came too late.

On the night of 6-7 January 2021, when Dorota Sandorova woke up for a second time, she was covered in urine and demanded water. During the night shift, most carers were usually asleep, against regulations, and it might have been the annoyance resulting from being woken up that explained what followed next. The assistant on duty, Ondrej Bali, told another carer that he would take care of the situation, and he locked himself in with the client in her room. After a while he came out, saying everything was fine. In the morning, he handed his tasks over to the day shift without ever mentioning what had happened during the night. Two hours later, Dorota Sandorova was found dead.

While the investigation continued, Bali worked in the facility for almost two months longer. He was laid off shortly before the police identified him as the likely perpetrator and arrested him. The man who had killed his charge a few weeks back was fired for sitting on another man’s back in order to entertain his colleagues from Home 05. He rode the man like a horse.

Bali later confessed to killing Dorota, but he insisted his intention was to calm her, not murder her. Finding that the brutal manner of lying on top of someone and twisting their arms violated all valid regulations and could hardly have succeeded in calming the victim, in September 2021 a regional court sentenced him to 10 years in prison for murder. Bali immediately appealed the verdict, and the High Court in Prague subsequently re-qualified the deed as negligent homicide.

The reasoning behind this decision is quite difficult to understand, even after repeated readings. The court of appeals upheld all the main findings, then revised the original verdict, saying that when Dorota “gave way” under Bali’s arms and lost consciousness, the carer acted with negligence when he did not verify whether she could breathe with her head pressed into the pillow. Eventually sentenced to three years, he was released last summer on good behavior, having spent just 18 months inside. 

“It’s incredible,” Bali’s former coworker Karel says about the trial. “For me personally, that case is still about the murder of a defenseless, handicapped woman. If Dorota had a family that would fight for her, if the media followed the case or if politicians cared, it could never have ended in this way.”

The second part of this article will appear next week.

Petr Tresnak is an editor at the Czech newsweekly Respekt. He helped start Deti uplnku (Children of the Full Moon), an association of parents of children with autism. This article originally ran in Respekt and is republished by permission. 

Translated by Matus Nemeth.