In October of last year in Vanadzor rumors spread about the suspicious death of one of the prisoners at the city’s penitentiary institution. 

Slavik Voskanyan, 33, previously convicted three times was charged with the murder of Svetlana Kazazyan and banditry against Astghik Aghabekyan. On October 10, 2010 he was transferred to Vanadzor penitentiary institution completely healthy. Just two weeks later, October 24, prisoner Voskanyan died. No injuries, traces of violence were found on his body, as a representative of the investigative department of Lori region told Hetq. 

The Press Service of the Criminal-Executive Department of RA Ministry of Justice initially informed that the prisoner died suddenly. The real reason of the death was communicated later, when it appeared in the death certificate – systemic intoxication of the organism, caused by the gas gangrene of the left lower extremity (from the foot to the upper second hip) generated from the contaminated injury of the inner surface of the left shank. 

According to the official information the prisoner had injured himself by injecting saliva in his leg in order to move to the prisoners’ hospital criminal executive institution, where he could serve his prison term in better conditions. Moreover, during one of his previous convictions Slavik Voskanyan had made a failed prison-break attempt from the hospital. 

Shushan Voskanyan, the wife of Slavik told Hetq that she had met her husband three times after his detention, on October 8, 9, 10 and had talked to him on phone after his arrest. In Shushan’s words, her husband was totally desperate after moving to the prison. According to her, apparently Slavik had realized that “there was no way out anymore.” 

In the early morning of October 22, when the spouses were talking on the phone for the last time, Slavik’s health condition was poor. Shushan said that “his voice sound tired, he was frustrated, he couldn’t utter a word.” Slavik told his wife that he had injected saliva in his leg on October 18. As a result, his leg inflamed, “swelled up like a balloon” and grew numb. They had taken him to the first aid post, debrided the wound and had got 200g of pus out of the leg, but all the same – his health condition would not improve. 

“He said my leg is suppurating, it hurts, and I can’t walk. Two people are holding on to me on either side when I go to toilet, they bring me and help to lay down,” told Shushan, adding that two days after this conversation her husband passed away.   

Criminal proceedings were instituted upon Part 2 of Article 130, Failure to implement or improper implementation of professional duties by medical and support personnel, which had caused the patient’s death. According to the results of the medical expertise, assigned by the court, Marzpet Minasyan, Doctor of Vanadzor penitentiary institution has made a wrong diagnosis and has administered an improper treatment of prisoner Slavik Voskanyan. This means that the treatment was not administered proper to the diagnosis; otherwise “an improving outcome of the disease would be possible.” 

The medical expert conclusion is based on the materials of the investigation - the medical documents present in the case and the patient’s medical record made by Doctor Marzpet Minasyan. 

In the record of October 18, 2010 Slavik Voskanyan was diagnosed by the Doctor with post-infection injury caused by saliva injection. On October 19 the Doctor had mentioned in the patient’s ambulatory record that there were some signs of crepitation when palpating the surface. The Doctor had also mentioned that when making an incision, he had detected brown pus with an unpleasant odor. 

According to the expert commission this record of the Doctor is a sign of a grave pathology – gas gangrene.  And even though the Doctor had noted about these clinical symptoms, he had not diagnosed this disease. He had diagnosed the disease only when the patient died, on October 24. 

The expert conclusion stressed that the treatment administered by the Doctor did not even match the patient’s condition, which he had objectively assessed. He should have prescribed anti-anaerobic drugs for the treatment and should have transferred the patient to a hospital for further conservative and surgical care. 

The commission concluded that with his diagnosis the patient needed ambulatory care. Meanwhile, the same conclusion mentioned that the treatment of the patient at the penitentiary institution was not contraindicative, however it was ineffective. 

In the opinion of Artur Sakunts, Head of Helsinki Assembly of Vanadzor, imposing the responsibility for the death of the prisoner only on the Doctor of the penitentiary or the administration of this institution is not a comprehensive approach. This would violate the principles of objectivity, thoroughness and integrity of the investigation. 

Artur Sakunts assumes that the subject of the investigation must be the action of the penitentiary’s medical care department when dealing with the health issues of the prisoner. 

“Had the Doctor warned the medical care department of the penitentiary institution about the patient’s health issues? According to the information I posses, he had,” tells Artur Sakunts. 

After the prisoner’s death, during a talk with Artur Sakunts the head and the Doctor of the penitentiary had noted that they had informed the medical care department of the penitentiary about Slavik’s health condition. The penitentiary’s Doctor confirmed this information. 

Reminding that a day after the medical examination of the patient he had made an incision, Marzpet Minasyan said, “I haven’t made the incision without any reason. I felt that the injury was suppurating.” According to the Doctor, on that day he informed the penitentiary’s medical care department about the situation of the patient. 

Shushan also stressed that during the last call, her husband told her that the Doctor had already made a warning. According to the wife, starting from October 22 the Doctor was persistently demanding to transfer the patient to Vanadzor hospital or the hospital for prisoners. 

“On October 22, when I came and saw the patient, I said that something serious was going on, the patient should be transferred and you should not leave him here. On October 23 I came to change the bandages, and I asked to transfer him, since the health condition was getting worse. In the morning of October 24 I even made a skirmish,” told Doctor Minasyan. But as he noted, “Without the permission of the administration, none of the prisoners can make a step out of prison.” 

“It is the administration that deals with the issue of transferring, so it should had solved it. If they didn’t give permission, how could I transfer the patient?” added Doctor Minasyan. Pursuant to the procedure, the Doctor should inform the head of the penitentiary about the health condition of the patient, while the head should notify the upper ranks – the deputy heads of the penitentiary department or the very department head. Meanwhile, in the Doctor’s words he had personally reported to the medical care department of the penitentiary about the case of Slavik Voskanyan. But he had done this with the knowledge of the penitentiary’s administration. “Can the Doctor act of his own free will?” asks Minasyan.

The latter argues that several protocols about the health of the patient have been prepared and enclosed to the materials of prisoner Slavik Voskanyan, upon the order of the penitentiary head’s.

“If the nurse had already written that a swelling is noticeable, how come the head was not aware and didn’t know anything?” the Doctor asks and points out that when Slavik was ill he was on vacation (his vacation leave was approved until October 31). The administration had asked him to examine the patient unofficially. Moreover, according to Minasyan since he does not have any substitutes during his leave, the head of the penitentiary is responsible for the health of the prisoners. 

“If they called me and asked to examine the patient during my vacation leave, didn’t they see in what condition was the patient? Everyone was aware, even Mkhoyan, everyone knew about it. They knew that the guy had injected saliva. And I had described the situation that there is pus flowing. We have even written a protocol about this all. Now some people are refraining, when they know absolutely everything,” the Doctor expresses his indignation. 

Marzpet Minasyan says that the penitentiary’s administration had even invited a Doctor for examining the patient. On October 21, Vova Ghukasyan, head of Surgical Department of Vanadzor #1 hospital was at Vanadzor penitentiary. Doctor Minasyan reports that he was not at the penitentiary at that time and he had not seen Doctor Ghukasyan. Later, the nurse had told him that Ghukasyan had examined the patient and assessed his condition as normal.

“The issue is that they invite a Doctor from outside, while it’s me who has to bear the responsibility now. The Doctor came and examined. Well, when they invite a Doctor don’t they ask what has he done?” Marzpet Minasyan questions. 

Doctor Vova Ghukasyan did not deny that he was at the penitentiary but he did deny that he had examined the prisoner Slavik Voskanyan. He said that since the penitentiary’s Doctor was absent, he was asked to examine one of the prisoners. At that time the nurse had asked him for some advice regarding Slavik Voskanyan, whose leg did not stop suppurating.  Ghukasyan found the patient’s condition normal and suggested changing the bandage several times till the Doctor arrived. Ghukasyan alleges that the nurse had not tell him what the inflammation was caused by. 

Slavik’s wife Shushan tells that when talking with her husband on the phone, he told her that the prosecutor of Lori region had visited him. He saw his grave health condition and said, “putrefy, or do whatever you want, all the same you will stay here, we won’t transfer you to the prisoner’s hospital.” 

According to the information of Hetq, Karen Shahbazyan, prosecutor of Lori region, had indeed been at the penitentiary and visited the patient at the office of the penitentiary’s head. Moreover, Slavik was carried to the office by the shoulders and his health condition was poor. For getting more accurate information we addressed a written inquiry to prosecutor Karen Shahbazyan as to whether he had visited Slavik Voskanyan at Vanadzor penitentiary within October 10-24, 2010. In his answer he had mentioned that the movements of the regional prosecutor are not recorded, and it is not possible to provide clear information from memory. Doctor Minasyan had not diagnosed the patient with gangrene, but as he assumes he had some suspicions. “If I didn’t have any suspicions, I wouldn’t tell to transfer the patient. Which one of the prison employees didn’t hear my cries? I was yelling - you want the man to dye and me bear the guilt for his health, is that what you want?” 

Minasyan mentions that while there have been suspicions of a gangrene, no proper treatment has been administered since there are no facilities at the penitentiary for treating such a disease. In case of a gangrene a deep incision must be done under anesthetic, meanwhile, as he alleges, only first aid can be provided at the penitentiary’s health care department. 

Doctor Minasyan had diagnosed Slavik with gangrene at only at 10:15, October 24 and had notified the administration about it. At about 13:00 the patient was prescribed to consult a blood vessel surgeon. Blood vessel surgeon Artur Khachatryan from #1hospitalofVanadzorwas invited by the penitentiary’s administration for examining the patient. 

During the visit of the surgeon the patient was in an extremely bad condition. Doctor Khachatryan had diagnosed gas gangrene, general intoxication and suggested hospitalizing the patient quickly. The administration ordered to transfer the prisoner to hospital. But at 14:45 Slavik was dead. Artur Khachatryan says, “Doctor Minasyan did everything - antibiotics, instillation - that was possible to do in that conditions.” Meanwhile, Doctor Minasyan asserts that the treatment of the patient was administered in relation to his condition, and all his prescriptions are noted in the patient’s medical record.

“I am a surgeon for already 21 years, nobody died in my hands. This is the first time. This happened because my facilities were limited. For several months after this, I was so anxious that I insulted everyone, no matter he was my head or not. They know that I am not guilty. I want the case to go to court. Let them examine it objectively. How come I should stand before the court alone? If you call me without any written notice, when I am on a vacation leave… Or didn’t that institution have a head; didn’t he know that a prisoner is getting worse? The thing is that I am a very small person. If I say that you have to transfer this person, no one will hear me. I don’t have the authority to pursue, to say that it’s not the way it should be. Doesn’t the head of the institution have authority, if he doesn’t, how do I have? I am his subordinate,” Doctor Minasyan says. 

P.S. Hetq does not arrive to get answers to some questions. All our inquiries made to the penitentiary institution are left unanswered based on the fact that the Special Investigative Service (SPS) has instituted criminal proceedings for disclosing the circumstances of Slavik Voskanyan’s death and investigation is in process. The same reasoning is brought by the SPS. 

This investigation is done with support from the Danish Association for Investigative Journalism / Scoop.