CASE OF RÕIGAS v. ESTONIA
Remainder inadmissible (Article 35-3-a - Ratione personae);No violation of Article 2 - Right to life (Article 2-1 - Effective investigation) (Procedural aspect)
Jon Fridrik Kjølbro;Julia Laffranque;Ledi Bianku;Robert Spano;Stéphanie Mourou-Vikström
6. The applicant was born in 1963 and lives in Tallinn. 7. In 2006 the applicant’s son O., who was born in 1983, was diagnosed with malignant melanoma. He was operated on in 2006, and underwent regular check-ups. In April 2009 a metastasis was removed from his brain, and he received radiation therapy. 8. In September 2009 O.’s state of health deteriorated. He was vomiting and felt weak and dizzy. 9. On 19 September 2009 the applicant called an ambulance and O. was taken to the North Estonia Medical Centre (“the NEMC”) (Põhja-Eesti Regionaalhaigla) for examination. A computerised tomography (CT) scan was performed on him. According to the applicant, O. was told that the scan had not revealed any problems with his health. He was prescribed an anti-vomiting drug and discharged from the hospital the same evening. 10. On 24 September 2009 the applicant again called an ambulance for O., who had been complaining of feeling generally unwell, of a numbness of one side of his face, a rash around his nose and dizziness. O. was admitted to the NEMC. A CT scan and magnetic resonance imaging (MRI) of O.’s brain were performed the same day and the following day, respectively. An additional CT scan of O.’s neck, lungs, abdomen and pelvic area was performed on 29 September 2009. The MRI scan and the CT scan of 29 September 2009, taken together, indicated a leptomeningeal pathological process involving the cranial nerves, a probable meningeal metastatic process and probable multiple metastases in the liver and other organs of the abdominal cavity. He was given hormonal and infusion therapy, but his health deteriorated rapidly. He developed breathing and walking problems and a speech impediment, and his eyesight worsened. On 28 September 2009 a hospital medical council decided to proceed with palliative care. It found that because of the spread of the tumour, oncological treatment would not be effective. The applicant pointed out that the medical council’s decision had not been signed by O. 11. For one week starting from 5 October 2009, O. was physically restrained to a bed with magnetically locking restraints on both arms, apparently in order to prevent him from hurting himself, given his disturbed state of mind. 12. On 6 October 2009 O. was transferred to an intensive care unit because he was suffering from progressive respiratory failure and a disturbed state of mind. He was also diagnosed with pneumonia and, in the light of that finding, was given additional antibacterial treatment. According to the medical record (nurse’s notes), on 6 October 2009 O. was intubated because he was having breathing difficulties. On the same day the medical council found that a surgical cure would not be possible and decided to continue with palliative treatment supporting the vital functions. The applicant again pointed out that the medical council’s decision was not signed by O. 13. On 9 October 2009 a tracheotomy was performed on O. 14. On 12 October 2009 O. stopped breathing and mechanical ventilation was applied. On 13 October 2009 characteristics corresponding to brain death were ascertained. According to information in a report drawn up by the Estonian Forensic Science Institute based on an analysis of O.’s medical records, an electroencephalogram performed the same day revealed serious diffuse brain damage and only minimal electrical activity. O.’s active treatment and feeding were discontinued, but the infusion therapy was continued. The applicant disagreed with this finding and rather considered that O. had fallen into a coma following an overdose of medicine. She maintained that O.’s pulse had reacted to her speech the following day, 14 October 2009, which had indicated that O. had not been brain-dead. According to the applicant, the protocol for verifying brain death was never fully and properly carried out. The administration of food and medicines was not resumed, despite the applicant’s requests. The applicant alleged that during the night of 14 October 2009, O.’s blanket had been removed and he had been left with only a sheet near an open window, which had caused his body temperature to drop to 35 degrees Celsius. 15. On 15 October 2009 O.’s heart stopped and the mechanical ventilation was terminated. 16. On 15 October 2009 the applicant called the police on the general emergency number, complained about O.’s treatment and asked that an expert examination be commissioned. Her phone call was registered as an information notice (infoteade) and not as the reporting of a crime. The applicant was advised to contact the Expert Committee on the Quality of Health Care Services (Tervishoiuteenuse kvaliteedi ekspertkomisjon; hereinafter “the Expert Committee”). 17. On 16 October 2009 an autopsy was performed at the NEMC. The medical death certificate (arstlik surmateatis) indicated cerebral oedema as the immediate cause of death, and melanoma with multiple metastases as the medical condition that had brought about the immediate cause of death. According to the autopsy report (lahangu protokoll), O. died of malignant melanoma with multiple metastases in the brain, which also caused cerebral haemorrhage and oedema as complications. 18. On 2 November 2009 the applicant complained to the Health Board (Terviseamet) of O.’s inhuman treatment and about the circumstances of his death. 19. On 8 March 2010 the Health Board informed the applicant that the case had been transmitted to the Expert Committee. The Expert Committee examined O.’s medical records, obtained written explanations from several members of the medical staff who had treated O., and ordered two expert opinions, one to be prepared by one of its members and the other by another doctor, both professors emeriti. The Expert Committee also heard the applicant. In its decision given on 25 March 2010, it found no medical malpractice in O.’s treatment. According to the report of the Expert Committee’s meeting of 25 March 2010 at which the applicant was also present, the Expert Committee gave oral answers to the applicant’s questions regarding the possible radiation of O. during his previous treatment; the decision not to offer chemotherapy to O.; and the alleged late detection of pneumonia. In addition, the Expert Committee’s decision contained written answers to the applicant, stating that O. had not suffered from a stroke; that the deterioration in his health had not been caused by the administration of specific medication or the withdrawal thereof, but rather by the metastatic developments in his brain; and that based on the medical records, O. had not been starved, nor had his mechanical ventilation been stopped before his death. The applicant was also notified of the possibility to request an alternative medical expert opinion and was informed that tissue samples gathered while the patient was alive as well as after his death, would be maintained for thirty years at the NEMC pathology centre and were available on demand. The applicant considered that the Expert Committee had not been impartial, that it had lacked a quorum at its meeting of 25 March 2010 and that the decision it had adopted contained false statements. An action lodged by the applicant to have the Expert Committee’s report declared unlawful and claiming damages for it was dismissed by a final judgment of the Supreme Court on 2 December 2015. 20. In the meantime, on 22 March 2010 the applicant lodged an offence report with a prosecutor’s office. Criminal proceedings under Article 123 of the Penal Code (placing or leaving another person in a situation which is life-threatening or likely to cause serious damage to the person’s health) were initiated on 1 April 2010. 21. In the course of the criminal investigation, several individuals (doctors, nurses, the applicant, and O.’s friends who had visited him in the hospital) were interviewed. Requests for documentary evidence (the Expert Committee’s opinion, O.’s medical file as well as the autopsy report) were submitted and documents were received; a forensic medical examination was ordered from the Estonian Forensic Science Institute. The prosecutor posed ten questions to the forensic medical experts addressing, inter alia, O.’s diagnoses; the adequacy of the treatment with respect to his state of health (including the tracheotomy); the restraining of O. to the bed; the administration of medicine on 12 October 2009 and whether this could have caused O.’s breathing to stop; the decision to cease the administration of medicine and food on 13 October 2009; the assertion that O. was brain-dead; and the decision to stop mechanical ventilation. 22. According to the forensic medical report dated 30 August 2012, O. had received treatment appropriate for his condition. The forensic medical experts also concluded that the medicine administered to O. had been appropriate and had not caused his breathing to stop. They considered that the restraining of O. to the bed could have been justified in the instant case. As the characteristics corresponding to brain death had been ascertained, the discontinuation of feeding and the continuation of infusion therapy had been medically justified. The experts also concluded that the mechanical ventilation had been turned off only after his heart had stopped and thus could not have been the cause of his death. The forensic medical assessment found that O.’s death had been caused by malignant melanoma with multiple metastases, with further complications of cerebral haemorrhage and oedema. 23. On 25 October 2012 the criminal proceedings were terminated as the commission of an offence had not been proven based on the evidence gathered. An appeal lodged by the applicant with the Office of the Prosecutor General was dismissed on 10 December 2012. On 28 January 2013 the Tallinn Court of Appeal dismissed a further appeal lodged by the applicant. 24. Following the termination of the criminal proceedings, the Office of the Prosecutor General dismissed complaints lodged by the applicant regarding the refusal to initiate additional criminal proceedings against the chief inspector of the Health Board’s supervisory department, against the experts of the Estonian Forensic Science Institute who had drawn up the forensic medical report during the original criminal proceedings (this refusal was later upheld by the Court of Appeal), against two prosecutors and the judge of the Court of Appeal. The Office of the Prosecutor General also dismissed an application lodged by the applicant to reopen the original criminal proceedings.