Findings of the Inquiry into Dr Kovacevic's Death

Once again, everything was done in accordance with the rules of detention and medical procedure but those rules and procedures should be reviewed and amended, in order to provide for more efficient reactions to future emergencies

The report, the Tribunal's second into circumstances surrounding death in the Detention Unit, was published on 7 September, five weeks after Kovacevic died in his cell on 1 August. In the absence of an official report, various rumours circulated about the circumstances surrounding the death. One version stated that Kovacevic died a slow and painful death. Another described "five hours of cries of a dying man" to which his fellow prisoners responded by banging the doors of their cells until they managed to wake up sleepy Dutch guards. That is reportedly the reason that detainees were revolted and ready to rebel (see Updates 88 and 89).

According to the findings of the inquiry, led by Portuguese Judge Almiro Rodrigues, upon Kovacevic's admission to the Detention Unit (10 July, 1997) it was established that he was suffering from, inter alia, severe hypertension and disturbed cardiac rhythm, therefore his health condition was closely monitored.

In addition, an aneurysm of the abdominal aorta was detected in February 1998, but it was decided that the possibility of rupture was small and on account of his poor health 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.

On the critical night, at approximately 2:15 a.m., Kovacevic contacted the security booth complaining that he was in severe pain. It took the guards half an hour to get in touch with the doctor on duty and it took the doctor another half an hour to get to the Detention Unit, arriving at the Kovacevic's cell at 3:15 a.m. Kovacevic, a registered physician for over 25 years, informed the duty doctor that he believed that the pain was caused by renal colic. After Kovacevic described the pain and after examining his back and abdomen, the duty doctor agreed with the patient. He administrated a painkiller and waited for approximately one hour and 15 minutes to ensure that the drug took effect.

Before leaving, the doctor examined Kovacevic once more and requested a urine sample. However, Kovacevic asked if he could postpone giving it until the morning, as he was extremely exhausted and wished to sleep. Before leaving, the duty doctor instructed the guards to check Kovacevic at least once an hour and to contact him immediately should the pain return. After that, Kovacevic was checked every 30 minutes.

At approximately 9:15 a.m. the guards noticed that Kovacevic was in pain and contacted the duty doctor immediately. As his condition was rapidly deteriorating an ambulance was requested, but before it arrived Kovacevic had slipped into unconsciousness. With the assistance of one of the detainees, a guard performed cardio-pulmonary resuscitation, but to no avail. At 9:37 a.m. the duty doctor pronounced Kovacevic dead.

According to the results of the autopsy, carried out on 4 August, death was caused by the rupture of the abdominal aortic aneurysm. The autopsy also confirmed that Kovacevic's was enlarged as a result of his raised blood pressure; his coronary arteries showed severe artherosclerosis; and he had previously suffered a heart attack. A single-cholesterol stone was also detected in his gall bladder. Although it was not stated in the Judge Rodrigues's report, the defence said that he was a chain smoker and heavy coffee drinker before and during his stay in the Detention Unit. Some of the prosecution witnesses at the trial-the first one for the crime of genocide-also maintained that Kovacevic was no stranger to drink.

In the conclusion of his report Judge Rodrigues states that the rules of detention "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... or any other person in the treatment of Kovacevic". Although some criticism may be levelled against the medical emergency procedures, the report concluded such procedures were not the causal effect of the death of Kovacevic.

However, Judge Rodrigues concludes that he had "proposed that certain measures be implemented to ensure that the medical care provided to detainees in an emergency is not unnecessarily delayed".