Nacional is in possession of the findings made by Norwegian, German and Slovenian Physicians’ Chambers which unquestionably testify that Dragica Ivankić, mother of three young children, would still be alive today had the doctors at Sveti Duh hospital not made a catastrophic error during her fourth childbirth. The consequences were fatal as the doctors were unable to recognize a rupture of the uterus. These findings by the foreign medical experts casts a completely new light on the first and second rulings by the Court of the Croatian Physicians’ Chamber, which freed the doctors and clinic head Asim Kurjak of all responsibility in the death.

The foreign doctors have established that Dragica Ivankić died due to a ruptured uterus and not due to and abruption of the placenta, as Kurjak claimedThe findings, which to date have been hidden from both the professional structures and from the public, show that the domestic commissions, committees and the Court of the Croatian Physicians’ Chamber (HLK) were not at all interested in revealing the truth in the case and finding those responsible, but instead were more interested in covering up the error and thus saving the reputation of the doctors, led by Asim Kurjak, and in so doing, completely ignoring all the rules of their profession. Thanks to them, Kurjak has had the last year to deceive the public and to deny the facts which lead to the death of the young mother.

Kurjak under investigation

The reports by the foreign experts leave little doubt as to whether Dragica Ivankić really had to die, and thus it can be expected that these reports will play the deciding role in the investigation currently underway by the Zagreb County Prosecutor. According to Chief Zagreb Prosecutor, Krunoslav Canjuga, the criminal investigation against Kurjak is underway due to suspicions that, in addition to his responsibility for the death of Ivankić, that he illegally manipulated human egg cells in artificial fertilization and operations of the uterine septum.

The HLK sent the files in the Ivankić case to the Norwegian, German and Slovenian Physicians’ Chambers and sought their independent professional opinion, in accordance with conscience and the profession. The foreign chambers handed these cases over to their most respectable authorities: for Slovenia, Dr. Tanja Blejec, head of the Clinical Division of Perinatology; for Norway, Dr. Stein Tore Nilsen, a German professor at the University of Bergen and for Germany, Dr. Lutwin Beck, professor of gynecology and obstetrics at the University of Dusseldorf. Their task was to fill out a comprehensive questionnaire of ten questions.

The results of this independent review by foreign physicians were diametrically opposed to those of the domestic doctors. The foreign doctors assessed that Dragica Ivankić died due to a ruptured uterus and not due to abruption of the placenta as Kurjak had claimed. All three experts assessed that Dragica Ivankić would not have died had she been in expert hands and had the adequate medical care been offered to her. The harshest criticism of the capacities of the physicians on call, who were present at the birth, came from Dr. Nilsen, who stated, “such physicians are not competent to be on call at any hospital.”

Cardinal Error

The Norwegian and Slovenian experts assessed that the on call obstetricians had made a cardinal error. The foreign experts attributed this lack of professional capacities, which led to the death, to “a lack of basic medical education” and “a lack of experience in emergency obstetric cases”.

The German expert, Dr. Beck, concluded his findings with the comment “The birth took place at 4 a.m. and signs of acute bleeding were observed. The ultrasound examination of the abdomen should have been conducted as soon as possible in order to diagnose or rule out uterine bleeding. An anesthesiologist was called in at 5 a.m., and the surgeon at 5:30 a.m. By that time, the patient was already in a comatose state. At 6:15, the laparotomy and hysterectomy was conducted – certainly too late. With a sufficient blood supply and laboratory conditions, the laparotomy should have been conducted earlier – at about 5 a.m. The woman’s life might have been saved, provided that the coagulation disorder was brought under control.”

In order to fully comprehend the extent of the manipulations with the family of the deceased and the public, we should briefly review the affair which erupted in the Sveti Duh Hospital on 21 January 2002, when Dragica Ivankić gave birth to a stillborn baby, and then later died as well. Instead of calming the public will the claim that they would do everything possible to look into the circumstances of the tragic death, Asim Kurjak took the defensive and instead concentrated on covering up the scandal. He informed the hospital director, Dalibor Krpan, and the Croatian public via television that the patient had died from premature separation of the uterus and a blood coagulation disorder, even though the medical documentation testified that she had actually died from a ruptured uterus, which has since been confirmed by the foreign experts. The diagnosis of premature separation of the uterus is considered to by a smaller professional error and, in accordance with such, the fault of the doctors should also be smaller.

Inexperienced on call staff

However, journalists released findings which proved that the diagnosis for Dragica Ivankić was a forgery, and that the death was the consequence of a cardinal medical error, which also reveals the reason for the cover up. On that night, the Clinic was poorly organized, and the attending at the birth was Dr. Fadel Hassan, an inexperienced specialist, who was not even formally employed by the hospital and was not allowed to be on call. He was in fact employed on a two week contract “due to a temporary increase in the volume of work”. The supervisory role that evening was assigned to Dr. Renato Bauman, who had less than 10 years of specialist experience, the minimum required by the profession.

All that followed in the ad hoc investigation, statements and commission inspections further confirm that the facts were altered in order to cover the traces of the truth. In the first report on the birth on 21 January, Dr. Renato Bauman, the gynecologist on call, did not describe any symptoms of premature placental separation. However, in the second report written on the same day, he also added hematoma of the placenta. Even the finding of the pathologist was to Kurjak’s benefit: in the autopsy conducted on 22 January, the pathologist recorded the cause of death to be an abruption of the placenta, though the pathohistological analysis of the placenta and the blood did not confirm that diagnosis. In the hospital register of the inspection conducted and sent to the Health Ministry on 23 January, again the truth about the ruptured uterus was covered up.

However, the experts we spoke with claim that had this really been a ruptured uterus, which should not have freed the on call gynecologist from responsibility. Abruption of the placenta, the official name for premature separation of the placenta, could have been determined with a CTG test. Had that existed, the CTG would have indicated the alarming situation and the fetal suffering of the child. The procedure in such cases is as follows: the birth must be executed within 5 minutes, most commonly by C-section, and the infant must be tended to and re-animated by a pediatrician.

Medical Court backs doctors

Under public pressure, the case was finally handed over to the Croatian Physicians’ Chamber. The Committee for Expert Supervision of the HLK, led by Mirko Đurašin clearly claimed that this was the result of a professional error, and the cases was handed over the Court of the HLK for final ruling. However, both the first and second rulings from the Court rejected the suspicions and freed the doctors from all wrongdoing.

Unlike the foreign medical experts, the domestic physicians participating in the workings of the Court were receptive. They defended the on call gynecologist on every point – ruling that it was not an error, that the gynecologists did not fail to diagnosis the rupture in the uterus on time, and that they did not establish the cause of bleeding in the abdominal cavity, which could have and should have been discovered through exploration of the vagina. They also rejected the accusations that the woman’s life could have been saved had a laparotomy, the name for all operation which open the belly, been conducted on time.

That ruling was made on 28 June 2002 which freed the physicians and the remaining participant of responsibility, based on the fragile evidence. From this ruling, which is also in Nacional’s possession, it is difficult to find strong arguments. Particularly since none of the three court experts were in agreement as to the responsibility, though the court ruled on the findings of the one court experts who defended the physicians. However, the explanation regarding the ruling gives no evidence as to why this opinion is considered relevant, and the others are not. Without clear evidence proving the innocence of the doctors, the court ruled in their favors.

The contents of the ruling testify that a fiery debate was held among the court experts on the responsibility of the physicians. Duško Miličić assessed that a “cardinal error had been made by the doctors due to a lack of knowledge of classical obstetrics”. According to him, “the medical documentation unquestionably indicates that the cause of death was hemorrhaging shock which was the consequence of heavy bleeding following the birth, in the abdomen and a rupture of the wall of the womb of 10 centimeters and the full right side retroperitoneum to the kidney.” Miličević gave his opinions that the “on call gynecologists Bauman and Hassan, should have realized that the symptoms unconscious, pale with a rapidly decreasing pulse, in childbirth indicate acute blood loss, and other than revival, they did nothing to determine the cause of the bleeding, which in this case was crucial. They failed to investigate the inside of the vagina by hand to determine if the uterus wall was intact or not, and had they conducted an emergency laparotomy, the life of the patient would have been saved.”

However, his opinion was rejected by the court, and instead the opinion of Dr. Ante Draženčić was accepted in full, though his opinion had less of an argument behind it. “Following detailed analysis” (though he fails to mention which), Draženčić claimed that “in this concrete case there was no physician error for the required measures were all undertaken with one exception, that he would have ordered exploration and not ultrasound for the patient.” He had no recollection, though he has been a court expert many times, whether there were ruptures of the uterus following the Kristeller procedure.

Court expert Dušan Zečević remained undecided: he saw no elements to conclude on an obvious error in procedure which could suggest a criminal act.

CTG report not considered

It would appear that the members of the chamber of the Chamber court did not discuss the CTG report which showed the serious fetal suffering which the physicians failed to notice. The CTG showed a deep deceleration to 60 beats per minute, from the normal range of 120 to 160 beats per minute. For an experienced doctor, this would have been a sign that an emergency C-section was required. This means that already by 3:12 a.m., the child was in a state of pre-death, but the doctors continued to treat the delivery as normal. When the child was extracted using vacuum, it was already dead.

Dr. Renato Bauman described what happened that night and he said that he does not feel responsible for the death of the patient. “…When called by Dr. Hassan I came to the delivery birthing room at 3:50 a.m. because the birth had failed to progress and the baby had stopped. Prior to the delivery of the stillborn baby girl, according to the report, we executed pushing the abdomen several times. Following the delivery, the mother was conscious, however following the sticking of the perineum, Dr. Hassan noticed that she was losing consciousness and that her pulse was weakening, and the anesthesiologist Dr. Lončarić was called. She was given an inclusion on two veins and blood was ordered. The patient recovered but at 5:30 a.m., her condition continued to worsen. At 5:50, the surgeon was called in due to suspicions of bleeding in the upper abdomen and suspicions that her liver or spleen had been damaged. Bleeding was suspected and following the UVZ test, free fluids were noted in the abdominal cavity. The patient was still conscious, but showed early signs of shock and together with Dr. Rašić and Dr. Lončarić we decided to conduct an emergency operation in the gynecology operating room two floors below. During the transport, the patient was revived and in the operating room, asystole was confirmed. During the operation, CPR was conducted. Dr. Stilinović was called and at 7 a.m. he continued the operation underway. At 7.30 he left the operating room because he was feeling faint…”

Instead of believing Miličić, the Court took Draženčić’s assessment, and proved satisfied with the statements made by the accused and witnesses, but did not insist, for example, to call upon Dr. Žarko Rašić, the physician who began the operation. His statement, medical circles believe, could have significantly altered the outcome, and so he was not even invited. And, as such, the liberating ruling was made under some pretty suspicious circumstances.

Appeal Rejected

The prosecutor considered that this was a case of incorrectly determined facts and requested a review of the process. He claims that the key evidence was ignored and he sought further questioning of the witnesses, and he called for new court experts. However, the Court decided in the appeal procedure to reject his request, arguing that “additional questioning of the witnesses and new expert opinions would determine no new fact which could influence the ruling of this Court.” This part of the argument could have been of critical importance in a potential criminal investigation – considering that new evidence existed, this time from independent foreign medical experts. However, that appeared to not suit the case, and as such, they were covered up. President of the Court Council, Dr. Šime Mihatov rejected the appeal filed on 27 November 2002, despite the fact that the foreign and independent expert findings had already been received. All three experts unanimously agreed that the life of Dragica Ivankić could have been saved with professional emergency medical attention. However, the Council, made up of Dr. Zlata Beer, Dr. Višnja Latin, Dr. Višnja Kogler and Dr. Vladimir Gašparović confirmed the initial ruling, thus making the case ad acta for the Croatian Physician’s Chamber, as the appeal ruling is final.

Many questions have still been unanswered. Why under such delicate circumstances was Dr. Rašić, the surgeon who began the laparotomy, called in for questioning? Why did the judges of the first and second instance courts choose to believe Draženčić, the only court expert to wholeheartedly defend Kurjak’s doctors? Why didn’t anyone ask whether Dr. Draženčić could be unbiased, knowing that his son Filip is employed in the company TKO, owned by Kurjak’s son Alan? Considering that the findings by the domestic experts was undecided, why weren’t new experts called in to continue the process, thus respecting legal regulations? Why were the foreign medical expert findings hidden or ignored? Why didn’t anyone ask about a possible conflict of interest concerning Višnja Latin, who under several years ago had worked closely with Kurjak? Why didn’t anyone suspect that the pathologists findings appeared to be reworked, particularly since the practice is to conduct autopsies in such delicate cases at the Department of Forensic Medicine, in order to avoid pressures from within the hospital, which is this case occurred judging by the subsequent additions to the autopsy report…

Egidio Čepulić, president of the HLK, commented for Jutarnji List two weeks ago, saying that “the professors of gynecology gave completely opposing opinions and for that reason, the HLK sought an independent opinion, as it was obvious this was a case of polarization, not based on professionalism but on other factors.” As such, he implied that the HLK had sought out the foreign medical experts in order to rid the case of the antagonism of the domestic experts. However, the facts say something else. The first report arrived from Slovenia on 27 May 2002, the second from Norway on 16 October and the German report was received on 5 November. That is, the second instance proceedings of the Chamber Court either covered up the findings of the foreign experts or they chose instead to ignore them. Though he promised to send Nacional a written report on how the difference in opinion between the domestic and foreign medical experts came about, Čepulić has failed to do so. Meaning the physicians in the first and second instances of the Chamber Court have chosen to be silent. It is not cynical to assume that they were counting on the fact that the foreign findings would remain covered up. Egidio Čepulić refused to disclose these findings to the press two weeks ago, saying that according to HLK regulations, official medical documents could not be shown to the press.

This opened up the door for Asim Kurjak and his new manipulations. During a meeting with Nacional, Kurjak categorically denied the existence of any such reports. He convinced Nacional that “there is no foreign expert opinion, that is a falsehood” and that he had just sent in a correction to the Physician’s News in which a sentence had been published that German, Slovenian and Norwegian physician’s chambers had unanimously confirmed that an error had been made that that it was obviously due to a lack of knowledge and experience.

Vying for his old position

Regardless of how he tried before the family of Dragica Ivankić and the public to prove that as former Head of Gynecology, he was not responsible for the clinic’s organization or workings, he did his best to return to his former position, from which he resigned not in January but in May, when the Committee for Expert Supervision had him in a corner. Despite the fact that a tender had been issued for 6 new clinic heads at Sveti Duh Hospital, among them for the gynecology clinic. On Friday 3 January, five days prior to the closing date, Milan Bandić personally became involved on his behalf. He called the president of the hospital’s executive council, Dr. Ljubo Pavelić are ordered him to immediately call a session of the council to return Kurjak to his position as clinic head, even though his mandate had already expired. Ljubo Pavelić saw no reason to favoritize Kurjak over the other candidates and he told Bandić clearly that he would not given in to political orders, even if it meant his resignation.

After this, a war of the factions broke out. Due to a conflict over the coarse attempt to reinstate Kurjak, Zvonimir Šostar, head of the City Health Office and also a member of the Executive council of the hospital, resigned. The daily papers commented that new members for the Sveti Duh executive council would be appointed at a meeting on Thursday to replace Pavelić, Šostar and Josip Čulig, who resigned two months ago. However, Ljubo Pavelić, did not resign, which he confirmed in a telephone conversation.

Many see this appointment as Bandić’s strategic move to put favorable staff in control of the hospital, owned by the City, which will this time succeed in rehabilitating Kurjak. That will only be possible if they can eliminate the influence of those who had the strength to public speak out and say that a person currently under criminal investigation lacks the credibility to be at the head of the clinic.

The story about the tragic death of Dragica Ivankić, whose death was the result of negligence and unprofessionalism, is not only a story about Asim Kurjak, but also of the corrupt health care system. For had the doctors not considered their own personal interests, and had they instead held fast to the strict rules of the profession, Asim Kurjak would not have had the opportunity to lie. He likely would not have dared say, as he said to Nacional two weeks ago, that “on that night he was at home, sleeping with a clear conscience”. However, that night, due to poor hospital organization, the fate of Dragica Ivankić, her husband and three young children was left in the hands of inexperienced doctors.