Fatal assaults, 96-day isolation expose failures at Ulsan hospital

Two patients with severe intellectual disabilities died after being assaulted by other patients at a hospital in Ulsan, where staff failed to intervene, the National Human Rights Commission of Korea said Tuesday, as it filed a criminal complaint against senior officials.

The commission said it has accused the hospital’s director and administrative chief of professional negligence resulting in death, following an investigation into Bangudae Hospital.

At least five patients died at the facility between 2022 and 2025, including two who died after being attacked by fellow patients, the commission said at a press briefing.

In one case in 2024, a 33-year-old patient surnamed Kim, who had schizophrenia, struck another patient, 49-year-old Kang, in the face. Kang fell, hit his head on the floor and lapsed into a coma before later dying.

In another case in 2022, a 32-year-old patient with severe intellectual disabilities was kicked and strangled to death by two other patients. Surveillance footage showed the two perpetrators high-fiving after the assault.

The commission said it reviewed about six hours of surveillance footage and identified at least 11 additional instances of patient-on-patient violence before the victim’s death.

It added that the hospital failed to take adequate measures to prevent or stop the assaults. At the time of the fatal incidents in 2022 and 2024, the ward was either left without medical staff or staffed by only one nurse, leaving patients unattended for extended periods.

The human rights body said the deaths reflected a failure by hospital management to ensure patient safety, and filed the complaint under Article 268 of the Criminal Act. The commission also detailed what it described as inhumane practices involving seclusion and restraint.

One patient with severe intellectual disabilities was kept in isolation for 2,282 consecutive hours, or about 96 days, in a space measuring roughly 6.6 square meters, far exceeding the Health Ministry’s 24-hour guideline.

The hospital used physical restraints eight times when the patient complained of pain or showed signs of self-harm risk, instead of attempting dialogue or other interventions, the commission said. It also arbitrarily restricted patient visits.

During the investigation, hospital officials refused on-site inspections and requests to submit materials, citing personal information protection, the commission said. Administrative fines of 10 million won ($6,800) were imposed on the administrative chief and 6 million won on a former administrative director.

“The hospital had maintained a closed and inhumane operating system instead of addressing the problem, even after fatal assaults between patients had already been reported by the media and the commission had issued repeated recommendations,” said Lee Sook-jin, a standing committee member of the commission.