Bureaucracy Killed a Man: Slovenia’s Health Care System Creates Another Tragedy

by Viktorija Plavcak
– Slovenia –

Two weeks ago in Celje, the third largest city in Slovenia, a fifty-year old man, barely able to drive himself to the hospital, walked into the ER in the middle of the night complaining about shortness of breath and severe chest pain. He worried that he was going to suffocate. Unfortunately, he had no doctor’s referral, and even worse, his medical card was invalid. Well aware of these facts, Bojan Kajtna was prepared to pay for his medical examination. Nevertheless, the attending nurse instead referred him to the health center just around the corner to fetch the required referral, a technicality that would allow him admission into the hospital. Unfortunately, Bojan never reached his destination. Just a few steps from the ER, he collapsed and died.

Bojan Kajtna’s family is indignant, unable to believe that in the 21st century an insignificant piece of paper should decide a man’s fate. Slovenia is enraged by the news. Both Bojan’s brothers seek justice. They want the hospital to conduct an inquiry demanding accountability for his death. Many Slovenians speculated that the hospital would try to blame Bojan’s death on the doctor’s malpractice, red tape, or even worse, would pin it on some poor nurse who merely followed the doctor’s orders.

And in essence, that’s what happened. In a hasty statement to the press, the director of the Celje hospital, Frančiška Škrabl Močnik, tried to clear the doctor’s name even before the investigation was concluded, “It was the nurse who sent the patient, Bojan Kajtna, who died of a blood clot on the way to fetch a referral. The doctor did not know anything about it. If he had been notified of the case, he would have taken time to see to the patient, but for an unknown reason the doctor knew nothing about it.”

The Internal Medical Board later criticized her statement, given that the investigation is was still in process. The general public and medical community are outraged that the director tried to put the blame on the nurse.

The Slovenian Minister of Health also spoke in favor of the doctor, explaining that the doctor on duty has the liberty to use his judgement to determine if the patient really needs an emergency treatment. He is convinced that this was so in Bojan Kajtna’s case. Sadly, no heads will be roll as a result of Bojan’s death. In Slovenia, few doctors are ever charged with malpractice, or if they are, they’re ultimately acquitted. Slovenian doctors answer only to their own conscience. There is no system to monitor their work, or patient results. Instructions for solving patient problems are only verbal; there is no disciplinary committee to face should something go awry. Further compounding matters, the only people complaining about malpractice are the distraught relatives of the dead. Even in cases where a patient has died unnecessarily, it is rare that the doctor looses his job or licence, let alone be sentenced to prison. In most cases the Medical Chamber is also silent. When its members do speak, they do so only to shield their colleagues.

In contrast, in neighboring Croatia many malpractice suits have been filed against doctors in the past few years. It seems that being a member of the European Union does not guarantee that the execution of laws is now better in our country, including those that apply to the “gods in white coats”.

The local hospital in Celje where Bojan died is known for what many call its “criminal record”, but the hospital has yet to be held accountable. Patients have been wrongly diagnosed and treated, and there have been operations with disastrous results. But in none of these cases have there ever been charges, because somebody is always covering the backs of the hospital staff responsible.

After a three week inquiry, the results of Bojan’s investigation were disclosed by Celje hospital. The Internal Medical Board stated the attending 31-year old nurse acted single-handedly. She did not observe the stroke symptoms, and so referred the patient to the local Health Center to obtain the referral without informing the doctor of the patient’s condition. The report also states that the nurse would have admitted the patient immediately had he told her that he was suffering from a heart condition. Bojan’s brothers are incredulous and say Bojan told the nurse about his chest pains and difficulty breathing, which should have been sufficient for admission. And while two involved witnesses have confirmed the report, Bojan’s brothers claims that quite a few details in the case have been altered, so there is much doubt about the report’s validity.

The Ministry of Health has promised to conduct another investigation, this time by and External Medical Board, which should take another 2 weeks. Bojan’s family has very little hope that the second investigation will reveal anything new. The nurse on duty has been charged with manslaughter and her criminal investigation has begun. While no names have been disclosed to the public, a short statement reveals that of the three staff working that night, one has been reinstated, one is working under strict supervision and while one is not working in the ER any more, nothing has been said about his dismissal.

Bojan’s family hopes that the criminal investigation will reveal the truth. They vow not to rest until justice is served and will exhaust every possibility for the guilty parties to get the punishment they deserve.

What the Slovenian National Health Care Center says

In their briefing, the SNHCC explain that emergency treatment in Slovenia must be given to anyone who seeks treatment at the ER, be they a resident or alien, and regardless of the possession of a referral, medical card or insurance coverage. Any doctor who admits such a patient is bound by medical ethics to treat the patient, but has the sole discretion to determine when such a treatment is constitutes an emergency.

According to the sole patients’ rights ombudsman in Slovenia, Magda Žezlina, “Emergency medical assistance is regulated by Article 43 of the Medical Act: ‘Emergency Assistance comprises emergency treatment or examination whose denial would result in a severe health damage or death. A doctor is bound by his oath to provide such medical assistance in accordance with the medical deontology codex, the science and technology achievements and with the use of verified methods. A doctor must not condition this kind of assistance with advance payment. The medical condition of a patient can only be decided on by a doctor and he is by no means allowed to condition the treatment with any kind of a request for payment, and he cannot use any of his colleagues to convey the message to the patient.’”

“In Celje the patient’s treatment was [refused until] a referral [could be] issued by the local health center, which in other words is a guarantee for the payment of [treatment]…In my work I have come across cases like that before but fortunately, none of them ended so tragically,” says Žezlina.

“The new law on patients’ rights is still being discussed in the parliament, but what is absolutely outrageous is that the representatives will be named by the Minister of Health. Since this law will be discussed inside the closed doors of the health organization, I fear it will merely regulate supervision over the medical health service providers rather than bring the solutions to the problems of the patients in need. All employees in the health services and institutions have organized professional chambers and syndicates which protect their interests, while patients should have an organized civil service aid which also includes the function of the patients’ rights ombudsman. For now, this kind of help is only provided in Maribor (Slovenia’s second largest city). I cannot help [but] notice that this kind of help would be of great welcome all over Slovenia,” concludes Žezlina.

No legal responsibility for doctors in Slovenia

On June 29th, the European Court of Human Rights in Strasbourg established that doctors in Slovenia have no legal responsibility to their patients based on the case of Gregor Šilih, who died at the Clinical Center in Ljubljana, the captal, in 1993. He sought medical attention in Slovenj Gradec for an allergic reaction. The attending doctor gave him two injections, but even after realizing that the wrong treatment had been administered, failed to save his life. Gregor fell into a coma and was transferred to the Clinical Center in Ljubljana, where he died two weeks later.

Until 2006, Gregor’s parents sought justice in civil and legal proceedings with no success. In the words of the presiding judges, there was insufficient evidence to prove malpractice, so the case was closed. After filing a lawsuit in Strasbourg, they have now finally won. The European Court does not believe that everything was done to seek justice in Slovenia. “In such cases an investigation is essential since we are talking about all the users of medical care,” wrote the European judges. According to the Court, the parents are entitled to a compensation of 7,540 euros ($10,264 USD) plus 2,000 euros ($2,722 USD) for reimbursement of legal costs.

Slovenia has violated Article 2 (Right to Life) of the European Convention on Human Rights relevant to several aspects of state power, one of them being the supply of medical services and the allocation of healthcare resources, because it did not give Gregor’s parents the option of exhausting every possible way to either prove or refute the doctor’s mistake in the death of their son.

The family’s lawyer, Bojan Gruber, hopes their victory will make doctors realize they are not above the law. “I have a feeling that we are knocking down the Berlin Wall. What is worse, the doctors act as though as they can never be mistaken.” In his opinion, Slovenia is too small a state where everybody knows everyone, so it’s best to seek an objective opinion abroad.

“What we need is an independent medical committee within the Ministry of Health which would handle the cases of the presumed mistakes,” says Gruber.

Slovenia and the proposed U.S. plans for Health Care

While the US government has realized that quality affordable health care for all is a must, Slovenia is doing exactly the opposite, and is regressing. Contrary to the oath he swore that he would act in the best interest of the public, the Minister is planning to privatize and commercialize health care. Private practices will see larger profits while less money will be available for the preservation and improvement of people’s health. As more health services have to be paid from the people’s own pockets, the division between social classes becomes increasingly evident – the gap between rich and poor is ever widening under a failing system that guaranteed health care to everyone under the old communist structure. Families whose loved ones fall seriously ill or sustain a serious injury will be reduced to poverty, which has been the case in the US.

Privatization is already showing negative effects – the once renowned and recognized school of dentistry in Europe is now failing– the almost eradicated prevalence of tooth decay is on the rise again.

It is apparent that Europe is dying under the pressure of globalization. Once praised for its health care system, the Slovenian government has become a captive to capital, having completely forgotten its main mission – to act in the public interest to protect the most vulnerable groups. The new health care system reforms bring nothing good to our country.

Where to go from here

Slovenia needs a new Health Care Plan. The plan must define the strategy, goals, tools and activities for achieving success, the means to measure and monitor the efficiency of such a system, and plans for quality, fair and accessible health care. The Strategic Goals and Measures for Health Care Plan drawn up by the Ministry in 2006 (in a paltry 3 weeks) is written proof of their unprofessional and sloppy work. In the past such discussion went on for years. Not surprisingly, none of the creators wanted to sign it. Worse still, Prime Minister Janez Janša shows no interest in the opinion of Slovenian citizens regarding the new plan Only 28 pages in length (counting tables and charts), it pales in comparison to those of other countries. (Dentistry, for instance, is slated to be eliminated from the system entirely.) More egregious than its grammar mistakes is that the document inappropriately uses terminology and fails to employ professional definitions. The plan does not contain any analysis of the present state of Slovenia’s health care or an international comparative analysis. Its goals are so foggy that it will be impossible to measure, monitor and assess results.

The health of an individual cannot only be his own responsibility, as the creators of the plan state. So far, the Ministry of Health has not revealed any plans to prepare a new document and has ignored criticism of its inappropriateness.

Recently, the Slovenian National Party (SNS) addressed a letter to the Prime Minister emphasizing that the health minister’s mandate has resulted in an unforgivable deviation from the constitution which explicitly guarantees the right of all people to publicly funded health care. The SNS recently asked the Minister of Health to step down, but he just plays dumb and sees no reason why he should resign.

We all hope that the Prime Minister will cave in to pressure and reconsider the dismissal of the Health Minister, and that the Medical Chamber will address the need for a new plan, which will protect patient’s rights. But most of all, we hope that some of the proposed healthcare plans by the US presidential candidates will eventually reach the right ears in Slovenia. If all else fails, it’s back to Strasbourg.

About the Author

Viktorija Plavcak is a freelance writer from Slovenia. An educator and professional translator, Viktorija has spent many summers abroad with her students as they attend language courses and works with various companies from organizers of trade fairs to ministries and institutes.

Through her love for and mastery of the English language, her ambition is to one day translate literature. A supporter of both women’s and global issues, she contributes regularly to magazines and enjoys taking part in discussion forums.