The Protector of Citizens identified shortcomings in the work of the social protection authorities and the competent inspection of the Ministry of Labour, Employment, Veteran and Social Affairs regarding the case in which, in early January 2023, in the "Bežanijska kosa" nursing home, according to media reports, one beneficiary took the life of another, and requested a review of the work of the commission that decided on the admission of that beneficiary.
On 11th January 2023, after learning from the media that a beneficiary of the services of the Gerontological Centre Belgrade, department "Bežanijska kosa" home in Zemun, killed another beneficiary housed in that institution, the Protector of Citizens launched an own-initiative investigation to assess the legality and regularity of work of the Ministry of Labour, Employment, Veteran and Social Affairs, the Centre for Social Work in Stara Pazova and the mentioned gerontological centre.
The Protector of Citizens established that the "Bežanijska kosa" Home made a mistake in its work because it admitted a beneficiary to that institution, who, according to the media reports, took the life of another beneficiary, without complete documentation, i.e. without a health certificate. This shortcoming of the social protection authority was not determined by the Social Protection Inspection of the Ministry of Labour, Employment, Veteran and Social Affairs during the extraordinary supervision over the work of the "Bežanijska Kosa" Home.
The Protector of Citizens also established that information on the health condition of the beneficiary who, according to the media reports, took the life of another beneficiary, were not known to the Stara Pazova CSW during the initial evaluation of the beneficiary, nor to the Gerontological Centre Belgrade - "Bežanijska kosa" Home when he was admitted. The doctor's findings and opinion for this beneficiary, which his relative subsequently submitted to the "Bežanijska kosa" home only after his admission to the home, show that his health condition represented a contraindication for placement in an institution for adults and the elderly, and based on such a health condition, he could not have been placed in the nursing home on Bežanijska kosa if that institution had possessed information about his health at the time of admission.
Another omission by the competent Social Protection Inspectorate, determined by the Protector of Citizens, is that during the supervision over the work of the private home for the elderly in which the beneficiary who, according to the media reports, took the life of another beneficiary, had previously resided, it did not determine whether this home properly maintained documentation about the beneficiary during his stay. Namely, by inspecting the file of the beneficiary maintained in the private home, the Protector of Citizens established that the private home had knowledge of the beneficiary’s state of health and that it assessed as his priority needs the provision of regular therapy, going to the chosen doctor in the health care centre and to a specialist doctor for regular controls, as well as preservation and stabilization of the beneficiary’s general health condition. However, it was not possible to determine from the beneficiary’s file whether the therapy was actually given to the beneficiary and which therapy it was, as well as whether the necessary health examinations were performed, nor whether the social protection inspection determined this during the inspection supervision. That is why the Protector of Citizens asked the Social Protection Inspectorate to re-supervise the work of the private nursing home in order to determine whether the social protection service provided to the beneficiary (including regular therapy and medical examinations) was in accordance with regulations and standards or he was medically neglected when he left the private home and started using the services of the "Bežanijska kosa" home, where a tragic event occurred.
The Protector of Citizens also established that the Commission for the reception of beneficiaries of the "Bežanijska kosa" home made an omission when considering the medical documentation for the reception of this beneficiary, because it accepted the specialist reports and the findings of the doctor from the private health centre, despite the fact that they were made almost exclusively on the basis of information that was received by the doctor from relatives and from the beneficiary personally. For this reason, the Protector of Citizens recommended that in the future, the Commission should consider the submitted documentation at the time of admission as complete, only if it contains a medical certificate on the beneficiary’s state of health and other documentation on the basis of which information on the current diagnosis, medical history and contraindications can be obtained, and it asked the competent ministry to send an instruction to all gerontological centres with the same recommendation.
Also, the Protector of Citizens asked the director of the "Bežanijska kosa" home to review the work of the Commission in the specific case, as well as to inform the members of the commission about the recommendation of the Protector of Citizens for future action. This institution should also supplement the Rulebook on the use of the home accommodation service, by stipulating that the beneficiary’s accommodation ceases if it is determined that information about the beneficiary’s health condition are being concealed in order for the beneficiary to be admitted to the institution, and the competent ministry should instruct all gerontological centres to prescribe the same conditions for the termination of accommodation in their internal acts.