The Ombudswoman, Tena Šimonović Einwalter, has concluded the inquiry into the death of Mr. Vladimir Matijanić. Based on all statements and information received, she issued several recommendations to the Ministry of Health and highlighted which questions remain open – both in the specific case and with regard to systemic practices indicated by the case.

Scope of the Inquiry

In this procedure, the Ombudswoman examined the availability of healthcare for Mr. Matijanić (including access to medication for immunocompromised patients suffering from COVID-19, and more broadly beyond this particular case), as well as his right to full information.

In order to determine whether Mr. Matijanić’s right to health was violated, and whether he received adequate support and assistance in his efforts to obtain healthcare, the Ombudswoman requested statements and documentation from the Ministry of Health, the Croatian Medical Chamber, the Croatian Chamber of Nurses, the Emergency Medical Service of Split-Dalmatia County, the University Hospital Centre Split, and information from the State Attorney’s Office of the Republic of Croatia.

The inquiry was launched in August 2022, on the Ombudswoman’s own initiative, following media reports and based on the Ombudsman Act.

 

Inspections and Expert Committees Must Consider All Sources of Information

The healthcare inspections into the course of Mr. Matijanić’s medical treatment included statements from healthcare professionals involved in his care, and medical documentation was collected.

Subsequently, an expert committee was appointed (in accordance with Article 206 of the Health Care Act), which, based on the inspection reports, written statements, medical records, and after listening to publicly released phone recordings, issued a professional opinion on the medical treatment of Mr. Matijanić.

This expert opinion included chronological data based solely on the accounts of the healthcare professionals involved in the patient’s care. These statements were not further verified and were fully accepted without more detailed analysis or identification of potential shortcomings.

Healthcare inspections and expert committee opinions should include all available sources of information, beyond just statements of those directly involved in care, depending on the case and availability of additional sources. For example, statements could also be collected from family members.

There are no logical or legal barriers preventing members of expert committees from obtaining statements from persons outside the circle of healthcare professionals, such as family members. The committee in this case was formed under Article 206 of the Health Care Act, which regulates only the appointment of experts for specific professional tasks in the context of inspection activities but does not specify how the committee should operate.

 

Which Questions Remain Open?

The need to consider additional sources of information is underscored by the fact that the final assessment is partly based on the patient’s presumed level of responsibility for his own health. The expert committee also addressed Mr. Matijanić’s previous conduct as a patient, linking his failure to take prescribed therapy and his unvaccinated status with the tragic outcome, but did not investigate in detail the reasons behind these actions.

Furthermore, while the committee noted that certain relevant tests were not performed for various reasons, it failed to examine the role of the healthcare system in these omissions – such as whether patients were informed about the consequences or offered any alternatives or accommodations, given their individual circumstances.

Thus, the expert committee did not address broader institutional shortcomings or failures within the healthcare system that may have influenced Mr. Matijanić’s vaccination status or inability to undergo necessary testing. This leaves open the question of how the information Mr. Matijanić had previously received from healthcare professionals – even before contracting COVID-19 – may have contributed to the tragic outcome.

Instead, his unvaccinated status and failure to take chronic disease therapy were simply cited as causal factors, both in the expert opinion of the Ministry’s expert committee and that of the Croatian Medical Chamber. Beyond shedding light on this case, a more thorough examination of these issues is essential to prevent similar situations in the future.

At the same time, according to the Croatian Medical Chamber, the tragic outcome resulted from a combination of circumstances – the lack of antiviral treatment for COVID-19, failure to take chronic disease therapy, being unvaccinated, and a positive COVID-19 diagnosis.

However, it remains unclear whether an antiviral medication was even available – that is, whether Mr. Matijanić could have received hospital treatment with such a drug. While the University Hospital Centre Split stated that the medication was not available at that time, the Ministry claimed that Ronapreve was available that day in quantities sufficient to treat 820 patients. Yet UHC Split emphasized that this drug had not been recommended for COVID-19 treatment for some time, in line with both national and international guidelines and even the manufacturer’s instructions.

These contradictory statements raise doubts and may erode trust – not only in how potential medical oversights in Mr. Matijanić’s treatment were investigated but also in the healthcare system itself, which Mr. Matijanić relied upon, as well as in the professional judgment of its staff. While the Ministry has stated that the procurement of COVID-19 medication was organized at the EU level and thus not subject to unilateral action by member states, the fact remains that healthcare institutions lacked life-saving drugs during the epidemic. This is supported by UHC Split’s statement that the hospital pharmacy had data on unfulfilled orders for Remdesivir, showing that hospital departments had requested it, deeming it necessary for treating patients.

Therefore, even though the Croatian Medical Chamber concluded that the absence of antiviral treatment was among the contributing factors to the fatal outcome, neither its expert committee nor that of the Ministry examined why such treatment was omitted in Mr. Matijanić’s case.

Additionally, the protocol for treating SARS-CoV-2-positive patients at high risk due to pre-existing health conditions and vaccination status remains undefined, as do the criteria for deciding on the necessity of hospitalization.

This case also highlighted the importance of different physicians having access to relevant patient health information in order to provide appropriate care. The submitted statements show that healthcare workers lacked full information about Mr. Matijanić when he sought help.

For instance, Emergency Team 1 was unaware that the patient had already visited the emergency infectious disease unit, that he had previously called the unit, or that his general practitioner had referred him to the UHC Split’s emergency infectious disease department.

It is unrealistic – even impossible – to expect a patient, especially one who is feeling unwell and whose life is at risk, to be able to fully communicate all information about their health condition. Therefore, in order for a patient to receive adequate care, the system must ensure that necessary patient data is accessible to healthcare providers. This issue was not addressed by the Ministry’s expert committee.

All of the above shows that the Ministry has still not answered whether the patient received timely healthcare, nor whether autopsy findings were used to assess when the medical conditions that led to his death developed.

 

Unclear Criteria – How Does the Health System Respond to Citizen Complaints?

This case also brought attention to the workings of the Ministry of Health’s inspection services and their approach to complaints from citizens. The cases handled by the Ombudswoman show a lack of clarity on the criteria used to decide how to act on such complaints.

Based on available information, most complaints about medical professionalism are forwarded in full to the Croatian Medical Chamber for expert opinion. In certain cases, however, the health inspection conducts its own oversight and, pursuant to Article 206 of the Health Care Act, appoints healthcare professionals to perform expert tasks in connection with the inspection, whose opinions may form the basis for further actions by competent authorities.

 

Recommendations of the Ombudswoman

Following her inquiry into Mr. Matijanić’s case, the Ombudswoman issued several recommendations to the Ministry of Health:

  • To expand oversight in Mr. Matijanić’s case by including other sources of information, such as statements from his partner, and to thoroughly examine all circumstances contributing to the tragic outcome before issuing an expert opinion. This was not done; however, the recommendation also applies to all future inspection procedures under Article 206 of the Health Care Act – such reviews should not be limited solely to statements from healthcare professionals and patient medical records.
  • To define clear criteria for health inspection procedures to ensure every complaint regarding the quality, availability, and timeliness of care is investigated objectively, consistently, and thoroughly.
  • To ensure timely availability of medications.
  • To implement regular training for healthcare workers on patient rights and proper behavior and communication, in accordance with medical ethics. A positive step in this direction is the Ministry’s recent directive to hospitals, urging them to enhance awareness about the importance of quality communication with patients and their families, which was publicly announced.
  • To provide the Ombudswoman with requested documentation and information within the legal deadline. Although the Ombudsman Act obliges public authorities to provide access to information upon request, the Ministry of Health submitted documents late and partially, requiring repeated requests. This has also occurred in other cases and remains an ongoing issue. Finally, the Ombudswoman sent the final letter regarding this case to the Ministry at the end of April, but has not yet received a response.

 

What Guarantees the Right to Health in Croatia?

To better inform the public, it is important to emphasize that the right to health is a fundamental human right and a prerequisite for the realization of other rights. Croatian citizens are guaranteed this right by the Constitution, international law, and national legislation.

The Constitution guarantees the right to healthcare in accordance with the law (Article 59); the International Covenant on Economic, Social and Cultural Rights recognizes the right to health (Article 12); and under the European Pillar of Social Rights, everyone has the right to timely access to affordable, preventive, and curative healthcare of good quality.

According to General Comment No. 14 on the right to the highest attainable standard of health by the UN Committee on Economic, Social and Cultural Rights, the right to health includes four interrelated elements:

  • Availability – functioning public health facilities, goods, services, and programs must be present in sufficient quantity within the state;
  • Accessibility – healthcare services must be accessible to everyone without discrimination, particularly vulnerable and marginalized groups; this includes economic accessibility and access to information, as well as the right to seek and receive information;
  • Acceptability – healthcare facilities, goods, and services must respect medical ethics, be culturally appropriate, ensure confidentiality, and aim to improve health outcomes;
  • Quality – healthcare facilities, goods, and services must be scientifically and medically appropriate and of good quality, which includes qualified medical staff.

Finally, the Health Care Act stipulates that every individual has the right to healthcare and the opportunity to attain the highest possible standard of health in accordance with this law and the Mandatory Health Insurance Act.