Findings of the Dokmanovic Inquiry

Friday, 24 July, 1998

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IWPR ICTY

A special working group will however, establish whether those rules were adequate in such a situation. Judge Almiro Rodrigues, from Portugal, led the inquiry. Its results, published on 23 July, can be summarised in four points:

1. The inquiry did not find evidence of any violence either in the accused's cell or on the accused's body that would suggest a criminal act . 2. Slavko Dokmanovic was suffering from depression, and because of that he was under particular medical care and special observation. The level of supervision, dictated by his physical and psychological condition, varied since the accused's arrival at the Detention Unit in June 1997. After he set fire to his cell in October last year Dokmanovic was put in isolation for some time and kept under 24-hour watch by closed-circuit TV. This measure was revoked in December 1997 after Dokmanovic's psychiatrist Dr Vera Petrovic from Belgrade concluded it was no longer needed given that "the detainee does not express any auto-aggressive elements which would lead towards suicide". From 23 June 1998, on the eve of the completion of his trial, the accused was being checked every half-hour during rest time. This is one of the highest levels of supervision besides 24-hour watch by closed-circuit TV. 3. On the night of 28/29 June, between these regular checks, Slavko Dokmanovic twice attempted unsuccessfully to commit suicide by trying to cut his veins with a razor blade and by attempting to hang himself with a tie. These attempts were not visible to the guards, whose checks consist of opening the little window on the cell door and looking through it into the cell. If the guard notices something unusual or abnormal, he must call at least one other guard to be present before opening the cell door itself. On the date in question nothing unusual was detected during last four checks from 10 p.m. until 11.30 p.m.. Between 11.30 p.m. and 00.05 a.m. Dokmanovic short-circuited the general power supply of his cell by placing the two outer prongs of a fork (the middle prongs of which had been deliberately bent) into one of the wall sockets. Then, he managed to hang himself from a second tie that he had fastened on to the top door hinge of his cell's wardrobe. Dokmanovic was found dead shortly after midnight. 4. All of the Rules of the Detention Unit concerning security and safety have been respected and no negligent behaviour was identified. Whether the existing rules were adequate to the conditions in the Tribunal's Detention Unit remains to be examined. Under the existing rules, a detainee may keep in his possession all clothes and personal items for his own use or consumption. That is the reason why items such as cutlery, ties, shoe laces, electric and manual razors, electric cables... are among those commonly found in a detainee's cell and were found in Dokmanovic's as well. Those personal items may be sequestrated only if--in the opinion of the commanding officer or the General Director--they constitute a threat to the security or good order of the detention unit or the host prison, or to the health or safety of any person therein.

Of course, everyone subsequently realises that those personal items -the tie, the razor blade and the fork- constituted a threat to Dokmanovic's health and safety, but the question is whether it could or should have been clear to them before midnight on 28 June 1998. On the morning of the critical day the Detention Unit officer suggested to Dokmanovic that a psychiatrist visit him to talk about his difficulties, but the accused refused, asking instead that the prison's medical officer, whom he trusted, visit him. After the visit and the discussion, which mostly concerned Dokmanovic's anxiety over the safety of his family, the medical officer concluded that it wouldn't be good to put the accused into isolation.

Instead he ordered the prison guards to keep the lights on in Dokmanovic's cell and to visit him every half an hour. According to the existing rules, a detainee may be confined to isolation "by order of the commanding officer in order to prevent the detainee from inflicting injury on other detainees... or as a punishment". All cases of isolation "shall be reported to the medical officer who shall confirm the physical and mental fitness of the detainee for such isolation".

Dokmanovic, however, did not represent a threat to other detainees, nor did he merit a punishment. Also, according to doctors, he was not fit for isolation, even though it was he who first asked to be isolated. He then changed his mind and said he would rather stay in his cell and watch a football game on television. Nonetheless, given the persistency with which Dokmanovic tried to kill himself that night it is doubtful whether even isolation would have prevented him.

In order to ensure that lessons are learnt from the tragic death of Slavko Dokmanovic, Judge Rodrigues is in the process of establishing a working group, including international experts, which will study the issue of suicide in prison and will review the preventive measures applied in various detention systems. If necessary, the working group will suggest possible amendments to the existing Rules of Detention. The Dutch Police conducted its own separate investigation into the circumstances surrounding Dokmanovic's death. According to an announcement the results may be published this week.