After reviewing the evidence that was collected in the course of this inquiry the following findings may be made regarding the circumstances surrounding the death of Dr. Milan Kovacevic:

Findings of fact

1. Upon his admission in the United Nations Detention Unit Dr. Kovacevic was suffering from, inter alia, severe hypertension and cardiac rhythm disturbances.

2. During the course of his detention, since the prognosis on his life span was considered poor, the health condition of Dr. Kovacevic was being closely monitored.

3. In February 1998, an aneurysm of the abdominal aorta was detected. It was estimated that the aneurysm was approximately five centimetres in diameter. Since the possibility of rupture was therefore small, and on account of his health condition, it was decided that for the time being the best approach was to monitor the aneurysm by way of abdominal catheterisation every six months. He was scheduled to undergo the next examination in mid-August 1998.

4. On 30 July 1998, Dr. Kovacevic was seen by a nurse employed by the Penitentiary Complex Scheveningen for the purpose of taking his blood pressure. Nothing unusual was detected.

5. According to the clock which registers the presence of the guards at particular locations throughout the Detention Unit, during the night of 31 July to 1 August 1998, prior to the incident, the guards on duty checked the cell of Dr. Kovacevic at 10:12 pm., 11:02 p.m., 11:48 pm., 1:04 am. and 1:32 am.

6. At approximately 2:15 a.m., Dr. Kovacevic contacted the security booth complaining that he was in severe pain. The guards immediately proceeded to his cell, and for the next thirty-five minutes they continuously tried to contact the doctor on duty. After they had reached him, at approximately 2:50 a.m., and had explained the situation, he drove at once tio the Detention Unit, arriving at the cell of Dr. Kovacevic at 3:15 a.m..

7. Dr. Kovacevic, who had been a registered physician for over twenty-five years, informed the duty doctor that he believed that the pain he was suffering was caused by a colic.

8. Conscious of the fact that he had been diagnosed as having an abdominal aortic aneurysm, the duty doctor asked Dr. Kovacevic to describe the pain. After examining his back and abdomen, he determined that it was caused by a renal colic. He administered a painkiller, and waited in the Detention Unit for approximately one hour and fifteen minutes to ensure that the drug took effect.

9. The duty doctor then examined Dr. Kovacevic once more. Since the pain had subsided, and there was no indication that the aneurysm was seeping, he believed that his original diagnosis was correct. The duty doctor requested a urine sample, however, Dr. Kovacevic asked if he could postpone giving it until the morning, as he was extremely exhausted and wished to go to sleep. The duty doctor agreed.

10. Before leaving the Detention Unit, at approximately 4:30 a.m., the duty doctor instructed the guards to check the condition of Dr. Kovacevic at least every hour and to contact him immediately should the pain return.

11. From 2:15 a.m., when the guards first became aware Dr. Kovacevic was in pain, to 4:30 a.m., when the duty doctor left the Detention Unit, at least one guard remained in the cell of Dr. Kovacevic at all times.

12. Following the departure of the duty doctor the cell of Dr. Kovacevic was checked every thirty minutes.

13. Shortly after 9:00 am. one of the guards on the morning shift entered Dr. Kovacevic's cell on order to give him his daily medication. As he was not fully awake the medication was placed on the table next to his bed.

14. At approximately 9:15 a.m. the guards on the morning shift noticed that Dr. Kovacevic was experiencing pain. They contacted the duty doctor immediately, who proceeded at once to the Detention Unit.

15. As Dr. Kovacevic's condition was rapidly deteriorating, an ambulance was requested . However, before it arrived, he had slipped into a state of unconsciousness, and after a short while no vital signs were detected. With the assistance of one of the detainees, a guard performed cardiopulmona resuscitation, although to no avail. Shortly after 9:37 a.m. the duty doctor reported that Dr. Kovacevic was dead.

16. On 4 August 1998, an autopsy was performed on the body of Dr. Kovacevic. It revealed that death was caused by the rupture of the abdominal aortic aneurysm. The autopsy also confirmed that the heart of Dr. Kovacevic was enlarged as a result of his raised blood pressure, his coronary arteries showed severe atherosclerosis, and that he had previously suffered a heart attack. A single-cholesterol stone was also detected in his gall bladder.

Ana1ysis

17. The death of Dr. Kovacevic raises several issues regarding the manner in which those sections of the Rules of Detention relating to the medical and mental care provided to detainees were complied with.

18. In accordance with Rule 15 of the Rules of Detention, Dr. Kovacevic was examined by the medical officer shortly after his admission into the Detention Unit, and, by the date of his initial appearance, he had been examined by a number of specialists and had commenced extensive antihypertensive treatment to reduce his blood pressure.

19. Pursuant to Rule 29 (A), the medical services for the detainees at the UN Detention Unit, including psychiatric and dental care, are provided by the host prison under the general supervision of the Registrar. To this end a medical officer from the host prison has been assigned as the person responsible for the care of the physical and mental health of all detainees at the Detention Unit. Although, if necessary, he can refer a detainee to the care of the host prison hospital.

20. In regard to Rule 29 (B), as part of a prison officer's basic training they are required to undergo a first aid course during their basic training, and thereafter are obliged to attend revision courses annually.

21. During is detention, Dr Kovacevic was visited by several doctors appointed by the Defence, pursuant to Rule 30, in order to determine whether the care and treatment he was receiving was appropriate. All the recommendations they made were referred to the medical officer, because he had, according to paragraph (C) of Rule 30, the sole authority for deciding whether such treatment should be administered.

22. In connection with Rules 31, although the medical expert team appointed by the Defence in July 1997 criticised that the standard of health care being provided to him in The Hague, no evidence was found during the course of the inquiry to conclude that either the prison hospital, or civil hospitals nearby, were incapable of providing the specialised care he required

23. In accordance with Rule 32, the Registrar and the defence counsel of Dr. Kovacevic were immediately notified of his death. As his defence counsel was a native Serbian speaker, and a friend of the family, he was asked if he could inform Dr. Kovacevic's wife and son of the tragic events.

24. Pursuant to Rule 33, during his period of detention, the medical officer closely monitored the care of the physical and mental health of Dr. Kovacevic, and, when necessary, referred him to a specialist for flirther examination.

Conclusion

25. The Rules 5 of Detention, as shown above, were observed and complied with during the entire period of Dr. Kovacevic's detention and, in particular , during the night of Dr. Kovacevic's death. The inquiry revealed no indication of negligence on the part of the duty doctor, who acted according to the leges artis of the medical profession, or any other person in the treatment of Dr. Kovacevic's health condition.

26. In connection to the events of 1 August 1998, no individual can be faulted for the fact that the Dr. Kovacevic was not examined by a doctor until almost one hour after the guards became aware of the fact that he was suffering severe pain.

27. Althoug some criticism may be levelled against the medical emergency procedures however, such procedures were not the causal effect of the death of Dr. Kovacevic - I have proposed that certain measures be implemented to ensure that the medical care provided to detainees in an emergency is not unnecessarily delayed.

Judge Almiro Rodrigues

Dated this twenty-seventh day of August 998
At The Hague
The Netherlands