5.  The applicant was born in 1947 and lived until his arrest in the city of Velikiy Novgorod, Novgorod Region. 6.  On 30 October 2008 criminal proceedings were instituted against the applicant. The prosecution authorities suspected that, having organised a criminal group and made threats of violence, the applicant had committed two counts of aggravated extortion. 7.  In July 2009 an investigator issued a bill of indictment and a warrant for the applicant’s arrest. The applicant was placed on an international list of wanted persons because the authorities believed that he had left Russia. That assumption was based on the impossibility, on a number of occasions, to summon the applicant to a prosecutor’s office. He could not be found at the place of his permanent registration or any other known place of residence. 8.  On 4 August 2009 the Novgorod Town Court, in his absence, authorised the applicant’s placement in custody on the grounds that the charges against him were very serious and that there was strong reason to believe that he had left his place of residence and fled Russia in 2007 in an attempt to abscond from the investigation and trial. There was evidence that the applicant intended to remain on the run and carefully hid any information which could disclose his whereabouts. The court also noted that several victims and witnesses had complained to the investigating authorities that acquaintances of the applicant had tried to convince them, either by threats or incentives, to make statements in his favour. The applicant’s lawyer objected to the decision, arguing that the applicant was undergoing in-patient treatment in Armenia and was not fit to travel to Russia. The decision was upheld on appeal by the Novgorod Regional Court, which found the Town Court’s reasoning well-founded. 9.  On 27 August 2010, having learnt that the applicant was in Armenia, the deputy Prosecutor General of the Russian Federation dealing with the case sent a letter to the relevant deputy Prosecutor General of Armenia, seeking the applicant’s arrest and extradition. Two weeks later, the Armenian authorities granted that request and on 24 September 2010 the applicant was apprehended and placed in the Nubarashen detention facility, where he remained until his extradition to Russia on 22 October 2010. 10.  On 30 October 2010, as the applicant was suffering from a serious heart disease and there had been a deterioration in his state of health, he was admitted to the Gaaza Federal prison hospital in the Leningrad Region. Having suffered a stroke in the night of 24 November 2010, the applicant was transferred to the resuscitation unit of the hospital.  On the following day, after release from the resuscitation unit, he was served with the bill of indictment in the presence of one of his lawyers. 11.  The applicant’s lawyers lodged a complaint with the St. Petersburg Oktyabrskiy District Court about the investigator’s decision to serve the applicant with the bill of indictment in a hospital in disregard of his poor state of health and his being under the influence of strong sedatives. 12.  On 10 December 2010 the District Court dismissed the complaint, finding no evidence that the applicant’s defence rights had been violated. The court noted that the applicant’s attending doctor had consented to the service of the bill of indictment, considering the applicant’s health to be satisfactory, and that a lawyer had been present to assist the applicant when it was served. The decision was upheld on appeal by the St. Petersburg City Court on 14 March 2011. 13.  According to the applicant, on 14 December 2010 the Erebuni and Nubarashen District Court in the Republic of Armenia declared his detention in Armenia unlawful as it had been authorised by an official who did not have the power to do so. 14.  On 17 December 2010 the Novgorod Town Court granted the investigator’s request for the extension of the applicant’s detention until 22 February 2011. The District Court’s reasoning was as follows:
“The court accepts the investigator’s arguments that the investigation in the present case is particularly complicated. Two particularly serious crimes were committed in 1998 and 2004. The law-enforcement authorities only learned about them in 2008. Two persons are charged with criminal offences within this criminal case. The case file has 40 volumes.
[The applicant] is charged with two intentional particularly serious criminal offences which were directed against property [and] committed by a group of persons in concert; it is clear that the criminal offences present a serious danger to society. The Criminal Code of the Russian Federation lays down a maximum penalty of fifteen years’ imprisonment for each of the crimes.
[The applicant] has not been convicted before and is not charged with an administrative offence. He is not registered as a psychiatric patient or a drug addict.
The following grounds were taken into account when detention was chosen as a preventive measure for [the applicant]: sufficient information to enable a conclusion that [the applicant] is liable to abscond from the investigation and trial and to interfere with the proceedings by tampering with witnesses [and] victims.
Those circumstances, as listed in Article 97 of the Russian Code of Criminal Procedure, have not changed.
The case-file materials contain information indicating that [the applicant] was placed on a wanted persons’ list in the course of the pre-trial investigation – first, the federal warrant for his arrest [was issued], and then an international warrant [followed]; [he] did not respond to the investigator’s summonses to take part in investigative actions; for a long period of time [he] did not live at the place of his registration; he has a travel passport and also has immovable property in foreign countries; on a number of occasions between 2007 and 2009 he crossed the border out of the Russian Federation. The court therefore has sufficient evidence to conclude that, if released, [the applicant] may leave the territory of the Russian Federation, including by going to countries with which Russia has no visa policy. In these circumstances, a more lenient preventive measure cannot ensure [the applicant’s] participation in the criminal proceedings, also taking into account the gravity of the charges and the amount of damage caused by the crimes. The above-mentioned circumstances are confirmed by copies of the warrant for [the applicant’s] arrest, copies of the investigator’s summonses and records, copies of responses from the migration service and the airline companies ‘Armavia’ and ‘Aeroflot’, and also by certificates in reply to orders of the investigator.
Moreover, the case-file materials contain sufficient evidence showing that if [the applicant’s] preventive measure is revoked or changed to a more lenient one, he will be able to interfere with the proceedings in the case by tampering with witnesses and victims either through his own actions or with the help of intermediaries. This conclusion is confirmed by the interview records [of two victims and two witnesses]; during [their questioning] the above-mentioned persons stated that [the applicant] had exerted pressure on them or that there was a possibility that such pressure would be applied by [the applicant] or individuals from his close circle.
[The applicant] suffers from a number of illnesses; [this fact] is confirmed by medical documents. At the same time, the court has established that the applicant received and continues receiving the necessary medical and consultative assistance in detention.
The defence did not present any evidence showing that [the applicant’s] state of health precludes his detention. It follows that the fact that [the applicant] suffers from a number of illnesses cannot be taken as an absolute ground calling for a change of the preventive measure to a more lenient one. The court does not take into account the information on [the applicant’s] state of health contained in the response by the cardiologist Mr B. from the State Mechnikov Medical Academy in St. Petersburg to a lawyer’s letter of 7 December 2010 because this medical specialist is not [the applicant’s] attending doctor, he does not [examine] the applicant on a daily basis but only provides consultative services. Moreover, [the applicant’s] attending doctor, when questioned by the investigators, did not indicate that there was a risk to [the applicant’s] life; to the contrary, he explained that [the applicant] was being provided with the necessary medical assistance and his numerous complaints about the state of his health were connected to his psychological and emotional condition.
The court does not see any grounds to change the preventive measure [applied to the applicant] ... to a more lenient one, including bail, because such a lenient measure cannot comply with the purposes of the criminal proceedings in the present case, in particular it will not prevent the possibility of witness tampering, which [the applicant] is liable to do if released, and will not preclude his absconding.
The measure chosen for [the applicant] corresponds to the gravity of the charges, his personality, his behaviour before and during the criminal proceedings, and the seriousness of the penalty which [he may face].” 15.  The applicant’s lawyers appealed, arguing, among other things, that the applicant was seriously ill and his health was rapidly deteriorating in the conditions of the detention facility and in the absence of adequate medical care. 16.  On 11 January 2011 the Novgorod Regional Court upheld the decision of 17 December 2010, endorsing the Town Court’s reasoning. 17.  On 18 February 2011 the Novgorod Town Court again extended the applicant’s detention, until 24 April 2011. The Town Court’s reasoning was similar to that given in its previous detention order of 17 December 2010. The new extension decision, however, was based on additional evidence which, in the Town Court’s opinion, confirmed the reasonable suspicion that the applicant was liable to abscond. In particular, the Town Court noted that the case-file materials showed that the applicant, acting through intermediaries, had taken steps to transfer title to his property to other people. The Town Court also dismissed the lawyers’ arguments pertaining to the state of the applicant’s health, finding no evidence in support of the allegation that his life and health were at imminent risk in view of his continued detention in an ordinary detention facility or prison hospital. The applicant was absent from the hearing because a medical commission comprising three doctors from the Gaaza prison hospital had found him unfit to participate. 18.  That detention order was upheld on appeal by the Novgorod Regional Court on 3 March 2011. The Regional Court also supported the Town Court’s conclusion that the applicant’s state of health was not such as to interfere with his further detention. 19.  On 22 April 2011 another extension order was issued by the Novgorod Town Court. The reasoning was identical to that given in the previous detention decisions. The detention was extended until 24 July 2011. 20.  The Novgorod Regional Court authorised further extensions of the applicant’s detention on 22 July and 22 August 2011. Each time it relied on the gravity of the charges against the applicant and his liability to abscond and obstruct justice. The Town Court interpreted the fact that the applicant had obtained a new travel passport as an indication of his intention to abscond if released. The lawyers’ arguments pertaining to the deterioration of the applicant’s health were again dismissed as unfounded. 21.  The detention order of 22 August 2011 was appealed against by the applicant’s lawyers three days later. According to the Government, having received the lawyers’ appeal on 25 August 2011 and the prosecutor’s comments on 8 September 2011, the Regional Court fixed a hearing for 28 September 2011. That hearing was postponed for two days because the applicant needed time to consult his defence team. On 30 September 2011 the appellate division of the Novgorod Regional Court upheld the detention order. 22.  In the meantime, on 19 September 2011 the applicant was served with an amended version of the bill of indictment. On 3 November 2011 the investigation was completed and the applicant was committed to stand trial before the Novgorod Regional Court. 23.  Another extension order followed, on 21 November 2011, with the Novgorod Regional Court concluding that the risk of the applicant absconding and interfering with the course of justice was still present and could not be mitigated by the applicant’s poor health. The Regional Court interpreted the receipt of a new travel passport by the applicant through a secret arrangement in St. Petersburg and not at the place of his registration in Novgorod, together with his selling or giving away property in Russia, as clear signs of his intention to flee the country if released. Finally, the Regional Court noted that there was no medical evidence that the applicant was not fit to continue being detained. 24.  Having received the applicant’s lawyers’ appeal statement on 29 November 2011 and the prosecutor’s submissions in response on 12 December 2012, the appellate division of the Regional Court returned the case file to the lower court, stating that the matter was not ready for consideration. After the case file was returned on 22 December 2011, the appellate division scheduled the hearing for 11 January 2012, when it upheld the detention order of 21 November 2011. 25.  A similar conclusion – that no preventive measure other than remand would ensure the applicant’s participation in the trial and prevent him from fleeing the country or tampering with witnesses – was reached by the Novgorod Regional Court on 21 February 2012. The applicant’s detention was extended until 24 May 2012. The court noted that the authorities had taken promptly all necessary steps to complete the investigation. There were no delays in the proceedings which could be attributed to them. The major stays in the proceedings had occurred in view of the necessity to respect the applicant’s right to health and his need to undergo various medical procedures. The applicant and his lawyers had been studying the case file since the end of November 2011 and had read through twenty-five out of its forty volumes. The Regional Court also took into account information received from police security officials pertaining to threats which had been made against investigators and the prosecutor in the applicant’s case. An inquiry was opened into the matter. 26.  On 16 April 2012, in a lengthy and detailed decision, the appellate division of the Regional Court upheld the detention order of 21 February 2012. 27.  The most recent detention order submitted to the Court by the parties was issued on 3 May 2012 by the Novgorod Regional Court. The applicant’s detention was extended until 24 August 2012. One of the reasons on which the court based its decision to authorise a further extension was the seriousness of the risk of collusion. In particular, the Regional Court took into consideration that security measures had been taken in respect of the prosecutor in the applicant’s case following threats which had been mounted against her by persons who could have been acting in the applicant’s interest. The court attributed particular weight to the applicant’s previous attempts to influence witnesses and victims and noted that the fact that the applicant had studied their pre-trial statements at the material time could make the witnesses and victims particularly vulnerable to further intimidation or tampering. The Regional Court did not establish any circumstances which could warrant the applicant’s release. 28.  On 20 June 2012 the appellate division of the Regional Court heard the prosecution and the applicant’s lawyers. It rejected the lawyers’ argument that the investigating authorities were not efficient, that they had not taken any steps to expedite the proceedings, having deliberately extended the applicant’s detention for over two years, and that they had long collected every possible item of evidence, thus excluding any threat of collusion. However, the appellate bench was convinced by the prosecutor’s pleadings. In particular, as can be seen from the record of the appeal hearing, the prosecutor informed the court that one of the victims had left the country, fearing for her life and for the safety of her family members. She reminded the court that the victim had testified that the applicant had threatened her and the family member with violence, either personally or through intermediaries. Two other witnesses had testified that they had been approached by four armed men, who had threatened them and urged them to testify in favour of the applicant. One prosecutor involved in the case was under security surveillance following threats against her. According to the prosecutor, the applicant was doing everything possible to delay the trial, having been promised by his lawyers a judgment of the European Court by July 2012. He, a Russian national who had spent the major part of his life in Russia, had summoned an Armenian interpreter and forced the investigator to read him documents from the case-file while the interpreter gave a simultaneous translation. The applicant had refused to sign a form confirming that he had completed his study of the case-file and his preparation for the trial. The prosecutor concluded by citing medical records which showed that during the entire period of the applicant’s detention following his receiving second-degree disability status, his condition had not deteriorated. 29.  Despite the applicant’s lawyers disputing every argument raised by the prosecutor, as well as the reasoning of the detention order, the appellate division upheld the order, being entirely convinced by its reasoning. As follows from materials available to the Court, the applicant is still detained on remand and the criminal case against him is still pending before the trial court. 30.  Both parties provided the Court with an extensive medical file, put together after his arrest and including expert reports, opinions by various medical specialists and medical certificates. The file shows that the applicant suffers from coronary disease accompanied by severe stenocardia, arterial hypertension, blood circulation deficiency, disturbance of the blood supply to the brain, chronic encephalopathy, and post-ischemic stroke symptoms. 31.  Following the applicant’s extradition from Armenia, on 30 October 2010 he was admitted to the Gaaza prison hospital on account of his acute heart condition. He was examined by the prison physician on duty, who recorded a further deterioration in his condition. The applicant signed a consent form stating that he had been informed of the state of his health, his illness, his diagnosis, the treatment methods and the risks he faced with the chosen type of treatment. He consented to any type of medical procedure made necessary by his condition. On a number of further occasions he confirmed, in writing, his consent to any medical procedure doctors considered necessary for his condition. The applicant was provided with urgent assistance. He remained in the hospital for intensive cardiovascular treatment, and also underwent a large number of tests, including frequent clinical blood testing, ultrasound examinations and electrocardiogram testing (ECG testing). 32.  After the applicant suffered a stroke, he applied to the head of the Gaaza hospital asking to undergo a complex medical examination to determine the degree of his disability. That request was granted, as well as his request for an examination by a cardiologist, Mr B., from the State Mechnikov Medical Academy. The examination was performed on 18 November 2010. 33.  The records drawn up at that time showed a long list of medicines which had been administered to the applicant. The hospital also allowed medicines which had been brought for the applicant by his relatives. The records meticulously recorded the schedule and dose for every medicine taken by the applicant. They also showed that he was attended on by prison doctors daily, frequently several times per day, and was seen by various medical specialists, including a cardiologist, a neurologist and resuscitation specialist; his blood pressure and temperature were measured every morning and evening. His complaints, including those which related to the refusal to take certain medicines, were listened to, recorded and addressed. The applicant was also systematically subjected to ECG testing, the results of which did not show any negative dynamics. The medical specialists who had regularly examined the applicant noted that his condition was “relatively satisfactory” and that he did not need any therapy in addition to that which he was already receiving. 34.  On 30 November 2010 cardiologist B. from the State Mechnikov Medical Academy issued his report following an examination of the applicant. He confirmed the applicant’s diagnosis, noting that, given the risk of further cardiovascular complications, the applicant’s condition “absolutely called for another diagnostic coronary angiography followed by a consultation with a cardiologist and a heart surgeon to develop a further treatment plan and to choose a method of myocardial revascularisation”. Doctor B. also stated that the applicant required permanent active supervision by a cardiologist and another consultation with a neurologist to adjust the therapy and to determine whether it was necessary to perform a magnetic resonance tomography (MRT) of the brain and a duplex scan of the brachial arteries. Doctor B. compiled a list of medicines which were to be included in the applicant’s therapy. According to the same report, the applicant received all of them. 35.  Another examination of the applicant by cardiologist B. took place on 3 December 2010. The doctor’s only recommendation was to continue regular medical supervision and to limit stressful situations which could affect the applicant’s emotional state. 36.  In addition to being monitored by prison medical personnel, the applicant continued being regularly seen by cardiologist B. In December 2010 examinations took place at least once every three or four days. Recommendations by cardiologist B. concerning the drug therapy, various medical tests and supervision by other medical specialists, including a neurologist and a psychiatrist, were closely followed, the one exception being the recommendation of an MRT scan. Following a joint examination of the applicant on 24 December 2010, the head of the medical department of the prison hospital and cardiologist B. noted in the applicant’s medical record that his state of health precluded his participation in investigative actions. A medical commission comprising a number of prison doctors issued a report on 28 December 2010 confirming that the applicant’s condition remained relatively stable and did not exhibit any positive changes despite the treatment he had received in the hospital. The commission recommended continuing with the intensive therapy. Two days later cardiologist B. performed another examination of the applicant. Although noting no positive dynamic in his condition, he nevertheless stressed that consultations with the head of the Therapeutic Department of the State Mechnikov Medical Academy had confirmed the appropriateness of the therapy chosen for and administered to the applicant. 37.  Cardiologist B. continued seeing the applicant regularly in January 2011, each time noting that the patient had received the prescribed therapy in full. He addressed the applicant’s complaints by amending the chemotherapy regimen or recommending consultations by other medical specialists. The applicant was examined by a surgeon and neurologist upon the recommendation of cardiologist B. The only recommendation which was not immediately complied with was that of a diagnostic coronary angiography to determine whether there was any possibility that the applicant’s coronary disease could be treated by surgery. That recommendation was subsequently repeated by the head of the medical department of the prison hospital. 38.  On 1 February 2011 doctor B., having studied the results of the coronary angiography, which, as appears from the parties’ submissions, was performed in January 2011, and noting a deterioration in the applicant’s state of health, made the following entry in his medical record:
“... at the material time there is a very high risk of myocardial infarction and a negative outcome to the course of the illness. [The applicant] needs in-patient treatment in a specialised cardiac hospital”.
Having prescribed a long list of medicines for the applicant, doctor B. also noted that his participation in investigative actions was “undesirable”. 39.  Three days later, the director of the Gaaza prison hospital dismissed a request by the applicant’s lawyers for a medical examination of the applicant to identify whether his health was compatible with the conditions of the detention facility. The director’s report, in so far as relevant, reads as follows:
“[The applicant] has been diagnosed with:
coronary disease; atherosclerosis of the coronary and cerebral arteries; atherosclerotic cardiosclerosis; stenocardia ...; third-degree essential hypertension; third-degree arterial hypertension ... a condition resulting from the placement of a stent in the circumflex branch of the left coronary artery in 2010; cerebrovascular disease; the consequences of an acute disturbance of the blood supply to the brain in 2009 in the form of left-sided hemiparesis; second or third-degree encephalopathy.
It follows that the [applicant’s] diagnosis does not fall into the category of severe illnesses which prevent the detention of suspects or accused persons established by Government Decree no. 3 of 14 January 2011 ‘On Medical Examinations of Suspects and Persons Accused of Criminal offences’.” 40.  In February 2011 the applicant continued to be attended on by cardiologist B. Examinations took place at least once every four days. The results of these consultations were similar. Doctor B. noted a negative dynamic in the applicant’s condition, informed the prison authorities of a possible negative outcome of the situation, including the applicant’s death, and recommended his transfer to a specialised cardiac hospital for high-tech medical assistance. While the applicant’s transfer to a cardiac clinic was not carried out, the remaining recommendations by the attending cardiologist were followed through. 41.  On 15 February 2011 a forensic medical commission determined that the applicant was suffering from a second-degree disability. On the following day, on the order of the head of the Service of Execution of Sentences of the St. Petersburg and Leningrad Region (“the Execution Service”), the applicant was subjected to a medical examination in the presence of a member of the St. Petersburg Public Review Board in the Sphere of Human Rights Protection, an assistant to the head of the Execution Service supervising human rights matters in detention facilities, the head of detention facility no. 5, doctors from the prison hospital, doctor B., and the applicant’s lawyers.
The relevant part of the expert report issued upon the medical examination of the applicant on 16 February 2011 reads as follows:
“Following the medical examination the medical commission established that [the applicant] suffers from a chronic heart illness with blood circulatory deficiency, complications and permanent impairment of bodily functions leading to substantial limits on vital functions and requiring lengthy treatment in the setting of a specialised cardiac medical facility. This type of illness is included in the list of severe illnesses which prevent the detention of suspects or persons accused of criminal offences”. 42.  In March 2011 the applicant continued to be under close medical supervision by the prison personnel, with a regular schedule of examinations by cardiologist B. being maintained. An examination by a neurologist on 18 March 2011 led to a recommendation to call a council of neurosurgeons to determine whether it was necessary to perform surgery given the failure of conservative therapy. The applicant continued to complain of severe chest pain and headache, particularly after participating in investigative actions. Doctors also recorded high blood pressure, dizziness and shortness of breath after physical exercise. On 30 March 2011, after another spate of complaints by the applicant, cardiologist B. again recommended a diagnostic coronary angiography to determine whether it was necessary for the applicant to undergo surgery, and concluded that the applicant’s participation in investigative actions was “extremely undesirable”. A neurosurgeon who saw the applicant on the following day recommended an MRT scan to finally settle the issue of surgery. 43.  After regularly observing the applicant in April and May 2011, the cardiologist and neurologist repeated their recommendations for an urgent coronary angiography and an MRT scan of the lumbosacral spine to decide whether the applicant’s condition required immediate surgery. The doctors also forbade his participation in investigative actions, on account of the extremely high risk of the development of complications in his coronary disease. The prison hospital doctors issued a report noting that despite the treatment the applicant had received, he continued to suffer from serious angina pectoris attacks even while resting, as well as during minor physical exercise. The applicant continued to complain about heart pains and headache, dizziness and fatigue. These complaints, however, led to no or very slight amendments in the applicant’s chemotherapy regimen. 44.  On 20 May 2011 professor M., a doctor of medicine, examined the applicant and noted his complaints of constant severe chest and heart pain. Although noting that the applicant’s condition was relatively stable, professor M. agreed that his health was continuing to deteriorate and the illness to progress. He refused to assess the quality of the therapy administered to the applicant without seeing the results of a coronary angiography, and recommended that the test be performed as soon as possible. At the end of May 2011, cardiologist B. scheduled a long list of procedures for the monitoring of the applicant’s health. Every procedure on the list was performed without delay, save for one. Despite the cardiologist’s recommendation, repeated in the reports following every examination of the applicant, a coronary angiography had still not yet been performed. 45.  Examinations of the applicant by the cardiologist and neurologist in June 2011 led to similar recommendations that a coronary angiography and MRT scan needed to be done. The specialists also continued insisting on the applicant’s transfer to a cardiac hospital for specialised treatment. The progress of the applicant’s coronary disease did not go without notice by the prison hospital personnel, who recorded and addressed his daily complaints. On a number of occasions the doctors also precluded the applicant from taking part in investigative actions, given the risk to his health flowing from any emotional pressure. 46.  On 27 June 2011 the applicant suffered a heart attack and was immediately transferred to the resuscitation unit of the prison hospital, where he was placed on a drip to begin receiving intensive symptomatic therapy. His condition was described as moderately severe. In the evening of the same day a resuscitation specialist noted in the record that the therapy had had a positive effect on the applicant’s condition. In the morning of 28 June 2011 he was taken back to the therapeutic department of the hospital, where he was seen by cardiologist B. The doctor compiled a long list of medicines which were to be included in the applicant’s regimen, scheduled regular ECG tests and blood pressure monitoring, and forbade any investigative actions involving the applicant’s participation. 47.  The applicant’s daily examinations by prison personnel or cardiologist B. did not reveal any positive changes in his condition. He continued complaining of chest pain, dizziness and headache. Doctors recorded high blood pressure and unstable stenocardia. The daily ECG tests showed that the applicant’s health was continuing to deteriorate. The applicant was prescribed bed rest and relieved of any obligation to take part in the investigative actions. On 4 July 2011 cardiologist B., the head of the therapeutic department of the prison hospital, Ms C., and the applicant’s attending physician, Ms S., issued a report on the basis of the daily monitoring and specific tests employed for the assessment of the applicant’s condition. The relevant part of the report reads as follows:
“Taking into account the results of the instrumental examinations; the presence of episodes of stable depression of segment ST during the repeated ECG tests, together with the expressed negative dynamic in February 2011, which remains unchanged according to the daily monitoring in June 2011; the nature of the coronary lesion shown by the results of the coronary angiography; the picture of exertional angina progressing to the fourth functional group and the clinical picture of angina when at rest; and the progress of the chronic heart failure against a background of maximum cardiovascular therapy, the reserves of conservative therapy have been exhausted for the present time.
The patient now faces a very high risk of the development of acute cardiac infarction and a high risk of an unfavourable outcome to his illness, including death. According to the recommendations of the neurologist and neurosurgeon, the patient also needs an MRT scan of his lumbosacral spine to confirm the diagnosis of the formation of a hernia in the lumbosacral spine, in order to develop a further plan of treatment ...
At present the patient has progressive impairment of his bodily functions, leading to significant limitations on his vital activities; [he] needs lengthy in-patient treatment in the setting of a specialised cardiac hospital where he can receive specialised high-tech medical assistance, including coronary angiography and cardiac surgical treatment in the shortest possible period of time”. 48.  The same routine of daily medical check-ups in response to the applicant’s complaints and the negative manifestations of his condition, including extreme instances of hypertension, unstable heart rate, and poor ECG test results, continued throughout July and August 2011. The doctors also introduced tranquilisers into the applicant’s regimen as his emotional state was raising serious concerns. While the applicant was provided with every medicine prescribed to him, the doctors, on a number of occasions, reaffirmed the necessity to perform a coronary angiography to determine the proper course of treatment. With the applicant being confined to his bed for the major part of the day, the ban on his participation in the pre-trial investigation was maintained throughout July 2011. A single attempt to lift the ban by authorising a meeting with the investigators in the hospital led to the applicant suffering another hypertension attack. On a number of occasions the attending doctors also described the applicant’s condition as severe. In August 2011 investigators invited the applicant to take part in interviews and other investigative actions. Each encounter with the investigators led to the applicant suffering another hypertension attack and tachycardia, which, in their turn, resulted in a doctor’s decision to limit such encounters. 49.  On 25 August 2011 the applicant was sent to the Mariinskiy hospital in St. Petersburg for an in-depth examination, including a coronary angiography. At the hospital the applicant was examined by a heart surgeon and a radiologist, who gave their recommendations concerning the chemotherapy regimen and also strongly recommended surgical treatment of the coronary disease, namely, revascularisation of the coronary arteries (coronary artery grafting). Following the applicant’s return to the prison hospital, the head of the therapeutic department of the hospital issued a certificate confirming the necessity to urgently transfer the applicant to a specialised clinic for lengthy cardiac and neurological surgical treatment by high-tech methods. She also recommended adjourning any procedural actions involving the applicant’s participation, citing a high risk of the development of further cardiac complications. 50.  On 6 September 2011 the applicant was examined by a medical commission comprising the vice-chancellor of the St. Petersburg Medical Academy, the director of the clinics attached to the Academy, a deputy head of the therapeutic department of the Academy, a leading cardiologist at the Academy, the head of the second cardiology department of the Academy, the head of the X-ray department, the head of the neurology department, and the applicant’s attending doctor. The commission concluded that the applicant’s illness did not fall into the category of severe illnesses precluding detention, and it recommended surgery in the form of myocardial revascularisation, and a heavy drug regimen. On 13 September 2011 the applicant was examined by a surgeon, a resuscitation specialist and a physician in response to his complaints of serious heart pain. Noting that the applicant suffered from hypertension, they gave him an injection to lower his blood pressure and noted that he could only be transported in the presence of a cardio-resuscitation unit. On the same day the acting head of the prison hospital, supported by the head of the therapeutic department and the applicant’s attending doctor, again cited the necessity to perform urgent cardiac surgery to prevent the development of further complications, including the applicant’s death. At the same time, the prison doctors authorised his release from the hospital to detention facility no. 5, where he was to continue with in-patient treatment. 51.  In the late evening of 14 September 2011 an ambulance was called to the applicant, who had already been transferred to detention facility no. 5. Emergency doctors diagnosed him with coronary disease, aterosclerotic cardiosclerosis, third-degree essential hypertension and second-degree cerebral claudication. Having provided the applicant with urgent medical assistance, the emergency doctors left the detention facility with assurances that the applicant would remain in the medical unit of the detention facility. 52.  In the morning of 20 September 2011 an investigator summoned the applicant for an interview. The applicant did not feel well, complained of severe pain, fatigue, high tension, dizziness and temporary loss of consciousness, and asked for a doctor to be called. After an hour the doctor had still not appeared, so the applicant’s lawyers wrote a note to the head of the detention facility seeking the provision of urgent medical services to the applicant. 53.  On the basis of various medical reports issued at the beginning of September 2011, and citing the urgent necessity to perform surgery to prevent the risk to the applicant’s life and limb, the applicant’s lawyers sent a complaint to the head of the Federal Service for the Execution of Sentences, seeking the applicant’s transfer to the prison hospital. They argued that detention facility no. 5 was not equipped to provide the applicant with the requisite medical care, that the prison doctors did not have adequate qualifications, that emergency doctors had not been called to the facility, and that the applicant had been forced to participate in investigative actions despite his extremely poor health. Similar complaints were sent to various prosecution officials. The lawyers attached copies of records and certificates issued by various doctors from civilian hospital recommending staying the applicant’s participation in the criminal proceedings in view of his extremely fragile health and the fact that he was being administered sedative medicines influencing his physical and mental condition. Citing the medical opinions, the lawyers insisted that the applicant’s condition was likely to deteriorate under stress, including by possibly leading to the applicant’s death. 54.  On 23 November 2011 the applicant was again transferred to the Gaaza prison hospital, where he remained until 16 December 2011. Having taken note of the applicant’s complaints of headache, dizziness, a pressing chest pain, shortness of breath, and unstable heart rate, the prison physicians concluded that his condition was relatively satisfactory. However, after comparing the results of the ECG testing in September 2011 and a test performed in November 2011, the cardiologist noted a negative dynamic in the applicant’s condition and stressed that an urgent examination by a neurologist and a surgeon was absolutely necessary. He also drew up a long list of medicines to be taken by the applicant. The applicant’s condition was assessed as moderately severe and the doctors scheduled various tests, including an MRT scan of the brain and the lumbosacral spine, ECG tests, and an ultrasound scan of the heart, to determine the proper course of therapy. After the recommendation for the tests and procedures had been fully complied with, the head of the therapeutic department of the hospital authorised the applicant’s release from the hospital for in-patient treatment in the setting of an ordinary detention facility. 55.  Twelve days later the applicant was sent back to the Gaaza prison hospital. On admission to the hospital the applicant signed a memo indicating his commitment to undergo any medical procedure that the doctors considered necessary to maintain his health. According to the medical record drawn up on the basis of the new round of tests performed on the applicant in the hospital, his condition had not changed. He received similar drug therapy and remained under daily medical monitoring, including ECG testing. Doctors continued recording the applicant’s complaints and noted the failure of the chemotherapy in respect of his extreme case of hypertension and stenocardia. In January 2012 the cardiologist recorded a negative dynamic in the applicant’s state of health on the basis of the ECG tests results. He also noted a significant increase in ischemic episodes, as well as an increase in their length. Convinced that the applicant’s heart disease was progressing, the cardiologist persistently cited the urgent necessity to perform a revascularisation of the coronary arteries. He also indicated that the applicant’s drug regimen was pushed to its maximum capacity, with the drugs being prescribed at maximum doses of tolerance. On 16 February 2012 a forensic medical commission confirmed that applicant should be classed as category 2 disabled. On the same day the applicant was sent back to detention facility no. 5, where he was to receive in-patient treatment and remain under close supervision by the personnel of the medical unit. 56.  According to a letter of the head of the medical unit sent to the applicant’s lawyers at the end of April 2012, the applicant’s condition was considered to be “close to satisfactory, stable”, and he was receiving treatment. However, the head of the unit refused to authorise the applicant’s examination by a cardiologist, stating that it was for the investigators to determine the matter. In response to the lawyers’ complaints about inadequate medical assistance in detention, including the investigators’ refusals to authorise the applicant’s examination by a cardiologist, the head of the North-Western Department of the Prosecutor General’s office sent a letter stating that an investigator was not competent to deal with any matters pertaining to the medical assistance of a detainee. 57.  The applicant provided the Court with a written opinion by cardiologist B., who was his attending doctor from October 2010 until March 2012, when he was no longer allowed access to the applicant in detention facility no. 5. Basing his conclusions on the results of the applicant’s daily check-ups and the various medical tests and procedures to which he had been subjected since his arrest, cardiologist B. stated as follows:
“... I consider myself competent to issue the following opinion about the patient. The patient [the applicant] has a multifocal coronary lesion and an extremely high coronary risk, taking into account the stress echocardiography testing presented to me. The patient has absolute indicators calling for a surgical revascularisation of the coronary arteries - coronary artery grafting. As a cardiologist who has been seeing the patient since October 2010, who has assessed the clinical picture and the results of clinical laboratory and instrumental tests in their dynamics (repeated daily monitoring of ECG tests, the coronary angiography of 25 August 2011, echocardiography, [and] stress echocardiography), I can state unequivocally that the diagnosis presented has been fully confirmed. According to national and European recommendations, the lesion affecting more than 50% of the trunk of the left coronary artery, combined with the three arterial coronary atherosclerotic lesions, serve as the indication for urgent cardiac surgery – coronary artery grafting. It is also necessary to stress that the question of cardiac surgery, given the seriousness of the coronary lesions, should have been determined as soon as the results of the diagnostic coronary angiography were received and the consultation with the heart surgeon had taken place in August 2011! In addition, given the results of the cardiac angiography, it may be stated that further conservative treatment of [the applicant] will not be effective, will certainly lead to the patient becoming fully disabled, and to the development of an acute cardiac infarction and complications in the course of the heart ischemic disease, including sudden coronary death. Cardiac surgery will unequivocally lead to the improvement of the patient’s condition, the improvement of his life expectancy [and] will sufficiently decrease his need for drug therapy”.