1 Thursday, 29 November 2001
2 [Open session]
3 [The accused entered court]
4 [The witness entered court]
5 --- Upon commencing at 9.29 a.m.
6 JUDGE HUNT: Call the case, please.
7 THE REGISTRAR: Yes, Your Honour. This is the case number
8 IT-98-32-T, the Prosecutor versus Mitar Vasiljevic.
9 JUDGE HUNT: Now, sir, would you please make the solemn
10 declaration in the card that the usher has handed you.
11 THE WITNESS: I solemnly declare that I will speak the truth, the
12 whole truth, and nothing but the truth.
13 WITNESS: BORISAV MARTINOVIC
14 [Witness answered through interpreter]
15 JUDGE HUNT: Sit down, please.
16 Mr. Domazet.
17 MR. DOMAZET: Thank you, Your Honour.
18 Examined by Mr. Domazet:
19 Q. [Interpretation] Mr. Martinovic, good morning to you.
20 A. Good morning.
21 Q. Mr. Martinovic, I shall be asking you questions on behalf of the
22 Defence counsel of Mr. Mitar Vasiljevic. I should like to ask you, before
23 we start, that we make pauses between question and answer. I will do my
24 best to do the same. This will facilitate the work of the interpreters,
25 and also, the French interpretation takes a little longer so would you
1 please wait a few moments before you answer, and you have the screen in
2 front of you which will help you to see when the interpretation has been
3 typed out.
4 Dr. Martinovic, would you begin by introducing yourself to the
5 Court. Give us your particulars; your name, surname, the place and date
6 of birth.
7 A. I am Primarius Doctor Borisav Martinovic, neuropsychiatrist,
8 therapist, I was born in Zajecar, Serbia, in 1934. And I graduated from
9 the faculty of medicine in Belgrade in 1962, I completed my specialist
10 training in 1970, and since then, I have been a specialist, that is the
11 work that I do today. I have been in the field for 40 years and I am -- I
12 have been a Primarius for 15 years.
13 Q. I think that is sufficient.
14 A. I was also the head of the department, that is to say, the
15 psychiatric department, when the case which is before the Court today
17 Q. Thank you. I was just waiting for the interpretation to be
18 completed. As I said a moment ago, please try and speak slowly so that we
19 get everything in. Thank you. I can see all the particulars relevant to
20 your career.
21 Could you tell me, please, where you are employed at present.
22 A. I have my own private practice at present. I omitted to say that
23 for 30 years, I have been a forensic expert.
24 Q. Thank you. In 1992, where were you and what did you do?
25 A. At that time, I was the head of the psychiatric department. We
1 had just separated psychiatry from neurology. That occurred sometime in
2 1991, and since that time, we opened a purely psychiatric department, a
3 separate department. I was oriented towards what we call social
4 psychiatry which, at that time, was the leading doctrine in the field of
5 psychiatry, generally speaking. I was the department head. I don't know
6 whether you want me to tell you what a department head does, what his job
8 Q. Thank you. I think it would be a good idea if you were to explain
9 to the Court what your duties at that particular time were and, to the
10 best of your recollections, to tell us which doctors worked on the
11 department with you, if you can remember them all and perhaps their
13 A. Well, it was a long time ago now, but what I can tell you is what
14 the tasks and duties of the department head were. First of all, it is the
15 authorised individual responsible for everything that occurs in the
16 department. Next, he is in charge of work organisation at all levels,
17 that is to say, supervises everything from the cleaning ladies to the
18 head. And then an important function is the education and training of
19 cadres, and Mr. Simic, Dr. Simic, was a case in point. He was a doctor
20 attending specialist training.
21 As a forensic expert, I always insisted on the constant control of
22 medical documents because I always said that one day it could be needed
23 for court purposes, and I think I succeeded in that respect. I instilled
24 this idea and concept into my colleagues. I always said that everything
25 that is written down as a medical document can be, at some point in time,
1 the subject of forensic expertise or be brought up in a case tried in
3 Of course, it is the head of the department head as well to
4 implement modern doctrines state-of-the-art doctrine in the field for
5 which he is head, and as this was the initial stage of psychiatry in
6 European psychiatry as well, we always insisted upon this and held
7 seminars and I organised almost 50 seminars in the sphere of modern
9 That, briefly, would be what I did. I think that is enough.
10 Q. Thank you for those explanations. And now, to go back to the
11 second part of my question: As far as you remember, could you tell us
12 which other doctors were working at that time in your department and how
13 many staff you had, how big the department was.
14 A. The department and ward actually had 50 beds. I don't know the
15 exact number of nurses but there were certainly 15, headed by a head nurse
16 which had a higher training level, and there was Dr. Simic, Dr. Slavica
17 Jevtovic who will be coming after me, there was myself, and there was
18 another -- a man called Zoran Dimitrijevic, I think he was still there. I
19 don't think there were any other doctors. Yes, there were, there was
20 Rada -- what was her surname? -- Rada Bukvic, and she is still there.
21 Of course, there was social workers, there was a psychologist, but
22 they were auxiliary educators or people who assisted us in our diagnosis
23 and therapy, and of course, there was a working therapist as well; I
24 forgot him.
25 Q. Thank you. You said that Dr. Simic was a young doctor at the time
1 and Dr. Slavica Jevtovic?
2 A. She was the mentor.
3 Q. Dr. Martinovic, in view of the fact that you were department head,
4 did you personally have your own patients or was -- were the patients
5 assigned to the other doctors in the department?
6 A. I also had my own patients because it is a relatively small
7 service, so I had time to have my own patients and I didn't want to give
8 them up. I didn't want to give up having my own patients because it was
9 important to me for my work that I continue as a working psychiatrist.
10 But let me say that, as department head, I had to know each and every
11 patient and they would always, during their doctor's rounds and other
12 contacts and the mentor in charge of the doctor doing his specialist
13 training, would always refer to me. So as head of department, I would
14 have to know every single patient in my department and on the ward.
15 Q. You said, Doctor, as far as I understood, that sometime in 1991,
16 your department was established when it was separated from neurology and
17 became an independent, autonomous department; is that right? A separate
19 A. Yes.
20 Q. In view of the year we are interested in, 1992, as it was a year
21 of various conflicts, was this reflected, were the general circumstances
22 reflected on your department and especially so perhaps on your department
23 or less than other departments?
24 A. In psychiatry, we know that, in the course of direct stress,
25 psychiatric disorders did not occur straight away. They usually occur
1 once the stress has gone. So during the war in Bosnia, we didn't have
2 many more patients coming in from the war zone, from that area. However,
3 there were individual patients, such as Mitar, who, for various reasons,
4 developed a psychotic disorder and, like anybody else, any other patients,
5 he automatically ended up in the psychiatric department after being
6 treated in the orthopaedic ward. But there weren't large numbers of
7 people coming in at that time
9 Q. If I understand your answer to my question, you said that there
10 was a delayed action and that psychological disorders and the stress that
11 caused them were manifest later on; is that right?
12 A. Yes.
13 Q. Dr. Martinovic, you mentioned a moment ago, and I would like to --
14 you mentioned him a moment ago but let me ask you, do you remember patient
15 Mitar Vasiljevic from 1992? And if you do, tell us what you can remember
16 about him before we show you some documents which I will ask explanations
17 about. But first of all, tell us what you remember with respect to the
19 A. I don't remember the patient at all. I absolutely do not remember
20 him. We have many people coming in, and from the medical documents, I can
21 just read what it says there but I have no direct recollection of him, no,
22 I don't.
23 Q. So he was not one of the patients that you said were your personal
25 A. No, he was not.
1 Q. Would you please wait for me to complete my question before you
2 give an answer. So he was not one of your personal patients, the patients
3 that you were in charge of personally?
4 A. No, he was not my patient.
5 Q. Would you now have a look at the case history of Mitar Vasiljevic.
6 MR. DOMAZET: [Interpretation] Could the witness please be shown
7 Exhibit 138.
8 Q. Mr. Martinovic, would you take a look at the first page, please,
9 with the general data.
10 A. Yes, I see it.
11 Q. As a doctor who worked there at the time and as the head of
12 department who probably came into contact with case histories of this
13 type, could you tell me what you see from this case history with respect
14 to patient Mitar Vasiljevic.
15 A. First of all, I can see -- I don't want to repeat the dates, you
16 all know them, but that he was treated in -- at two departments, the
17 orthopaedic department and the psychiatric department. The final
18 diagnosis was 298.9, and the signature were the doctors on duty, Dr. Simic
19 from psychiatry and Dr. Jovicevic from orthopaedics. Everything else is
20 clear: What was done; the surgical interventions at the orthopaedics
21 department and, of course, treatment at the psychiatric department.
22 Q. Could you have a look at what your doctors or your department
23 noted down and the importance of it.
24 A. He was transferred to our department on the 8th of July, 1992.
25 Here and on the following page, it says that he was transferred by the
1 neuropsychiatrist on duty who was called in by the orthopaedist because
2 his behaviour was conspicuous and that kind of behaviour required a
3 psychiatric examination.
4 On the following day, my colleague under whose patient he was -
5 because the doctor who transferred him was neurology, from the
6 neurological department, and we were all on duty, both neurology and
7 psychiatry. So he appeared on the 8th of July, Dr. Simic was in charge of
8 the patient, he came under Dr. Simic, and Dr. Simic describes here that he
9 was in a very agitated, restless state. He describes the patient as
10 singing, shouting, resisting personnel, it was difficult to establish
11 contact, and so on and so forth, which meant that it was a very seriously
12 disturbed patient due to a psychosis which existed.
13 I don't know whether you have the temperature chart and the
14 therapy medicines chart because if I were to look at the temperature chart
15 and the therapy sheet, I would be able to see he probably got neuroleptic,
16 strong neuroleptic therapy, which would be a sign that he was highly
17 distressed, so if I would look at the temperature chart and therapy sheet,
18 I would be able to tell you that more exactly.
19 After receiving therapy, the patient calmed down and in the
20 decursus, or repeated examination on the 15th of July, it states that he
21 was calmer, his behaviour was adequate so that was the decursus morbi on
22 the 15th of July.
23 Then we take the wife's statement, the heteroanamnesis from the
24 wife, as we call it, and she explains what he was like, what his behaviour
25 was like before he came into hospital.
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 JUDGE HUNT: Mr. Domazet, I don't think we need all of this.
2 MR. DOMAZET: Yes, yes.
3 JUDGE HUNT: I don't think we have a temperature chart but we
4 certainly have the medicines that he was on in some other exhibit.
5 MR. DOMAZET: Yes, it will be the next exhibit, yes.
6 Q. [Interpretation] Dr. Martinovic, if I have understood you
7 correctly, he was examined by the neuropsychiatrist who was not working at
8 your own department but was a psychiatrist from neurology; is that right?
9 A. Yes, and that's his signature, Bora Bogdanovic, I've known him for
10 30 years or more. Unfortunately, he is no longer amongst us. That is
11 clear here, on the 7th of July.
12 Q. Did you recognise the remark made by Dr. Bogdanovic?
13 A. Absolutely so, and I know his handwriting very well. I know him
14 very well and I know his handwriting very well.
15 Q. So on the 7th of July, Dr. Bogdanovic wrote down those remarks.
16 Would you read out what it says for the 8th of July. I don't think you
17 interpreted the date of Mitar Vasiljevic's transfer to your department
19 A. It says here that on the 7th of July, he was examined by the
20 neuropsychiatrist on duty and that he wrote "Transfer the patient to the
21 psychiatric department." The next piece of information that I can see
22 from this is that, on the 8th of July, the first comment was made as to
23 the objective psychiatric finding, which was when the psychiatrist came on
24 duty the following day, he probably got the patient to examine. So that's
25 one day. So if he was transferred, probably it was in the afternoon
1 because the doctor on duty works in the afternoon and during the night.
2 So if on the 7th of July, he was transferred to the psychiatric department
3 and that the doctor on duty gave him drugs, when Dr. Simic came to work
4 the next day, he took the patient over and wrote down the 8th of July. I
5 think that's clear.
6 Q. Thank you. Do you remember whether the 7th of July was a national
8 A. Yes, the 7th of July, at the time, was a national state holiday.
9 Q. I should now like to ask you to take a look at the therapy chart.
10 MR. DOMAZET: [Interpretation] And would the doctor be shown
11 document P165, please.
12 A. May I comment? May I make a comment?
13 Q. Yes, please, but slowly for the interpreters and because of any
14 medical terms that you might come across. So nice and slowly, please,
15 along with your comments. What does the therapy sheet tell you?
16 A. We can see here that a neuroleptic therapy was ordered,
17 prescribed, which is administered to the most disturbed patients. It is
18 Topral. Topral is a very strong neuroleptic, and the dose was very high,
19 four times one tablet a day up until the 12th. What is that, July? Are
20 we talking about July? Nozinan, another neuroleptic, on the 9th the
21 dosage was increased to three times 100 milligrams. And let me say that
22 Topral is administered intramuscularly, which means it is a serious
23 therapy, and Nozinan was in the form or tablets.
24 Quite obviously, looking at this therapy sheet, we can see that he
25 was exceptionally disturbed, probably fixed - tied up - we sometimes have
1 to fix the patient to prevent injury. They are not usually dangerous, but
2 to prevent them from injuring themselves.
3 So quite certainly, it was a very serious psychotic disorder
4 which, luckily, quieted down after four or five days. The only thing that
5 could have been given was intravenous application of drugs but that is
6 risky business and we tend to avoid it. That was the only other thing
7 that could have been done, but what was administered and prescribed was
8 sufficient and, as we can see, the patient responded to the therapy and
9 did calm down.
10 Q. Have you had a look at the therapy list to the end, towards the
11 end of treatment, what was prescribed, according to the therapy chart?
12 Were there any deteriorations or were drugs increased at a certain point,
13 anything like that?
14 A. Well, we can see that on the 19th, there was a relapse, probably,
15 because the Largactil therapy was increased to 200 milligrams, which is an
16 exceptionally high dosage, and that went on for -- that went on until the
17 27th when it was reduced again to three times 100 milligrams. So there
18 was a relapse episode where the condition deteriorated and, according to
19 this, it lasted 6, 7, no, as much as 10 days, I see from the therapy
21 With psychosis, that is quite possible and does occur in the
22 course of treatment despite the therapy. The process is repeated; the
23 patient becomes very disturbed and we have to increase the doses.
24 Q. Dr. Martinovic, according to what you have seen in the therapy
25 chart, you consider that the dosages were very high to begin with, which
1 indicates the seriousness of the disorder that the patient was suffering
2 from, Mitar Vasiljevic. Have I understood your answer properly?
3 A. Yes, absolutely. It is a sure sign of a very serious psychotic
5 Q. In addition to the drugs administered, the doses were increased
6 again, and from that, you deduced that his condition must have
7 deteriorated. Dr. Martinovic, would you now please have a look at the
8 discharge sheet from your department. It is Exhibit D30 or D30.1.
9 A. Have you got a question for me?
10 Q. Yes. Would you look at this document, which I think has your
11 signature as department head. Could you comment on that document?
12 A. It gives the time spent in hospital and the diagnosis; psychosis
13 298.9. At that time, according to psychiatric nomenclature, is a code
14 which denotes a psychotic disorder without precisely defining the entity
15 of the disorder.
16 I have to say in the doctrine of psychiatry, diagnosis are never
17 written -- let me explain it this way: If a patient comes in to us for
18 the first time with a schizophrenic picture, we are sure that it is the
19 initial schizophrenic onset but we never write down that diagnosis because
20 the man might never suffer from this psychosis again but we don't want to
21 burden the patient with a diagnosis which will stay with him for the rest
22 of his life, so that is psychiatric doctrine. We never do that to begin
24 So in this case, looking at this case, we were not able to reach
25 the right diagnosis, that is to say, to differentiate the exact group, so
1 we put a general psychotic group. We classed into a general psychotic
2 group and gave it that general psychotic code. For you to be able to
3 understand this better, the most important symptom of a psychosis is the
4 patient's lack of contact or loss of contact with reality and that is what
5 Mitar Vasiljevic suffered from.
6 Let me also say that diagnosis in psychiatry is also a function of
7 time so a diagnosis is not static, it is dynamic. A psychiatric diagnosis
8 is dynamic and if symptoms are manifest, then the diagnosis becomes
9 crystalised, so you never put the ultimate diagnosis first, you wait to
10 see the patient's development and manifestation of the disorder before a
11 final ultimate diagnosis is written down.
12 We have the description of his behaviour here when he was brought
13 in; after prescribed therapy, it says that his condition improved; and it
14 is important to note that he was discharged at the request of his spouse,
15 which means that the physician did not consider that the time was -- had
16 come for him to go home. The doctor would usually have kept a person
17 suffering from this kind of condition at the psychiatric ward for a month
18 or two, but the wife, for some reason, asked that he be released, and so
19 with her signature and on her responsibility, he was released.
20 This shows that three times 100 milligrams of a drug was to be --
21 of Largactil, was to be taken by the patient in future. This is a very
22 large dosage, which shows that he should not have been discharged at that
23 time. It is a large dose to be taken in an outpatient form. And of
24 course, he was told to come back for a control examination in 14 days'
25 time and was accorded sick leave.
1 Q. Dr. Martinovic, you told us when you gave your curriculum vitae
2 that you have been a forensic expert in Yugoslavia for many years. You
3 have seen diagnosis and the other information that you had in front of
4 you. Since you did not participate in the actual treatment of Mitar
5 Vasiljevic, can you, on the basis of what you just saw, describe his
6 mental state of health, as a forensic expert, at the time he was first
7 examined by a psychiatrist? Was he a responsible person or not, and to
8 what degree, of course, if you're able to do so?
9 A. As I have been a forensic expert, I know very well what competence
10 means. So as to avoid any confusion, competence is always evaluated for a
11 particular crime. There is no general incompetence, but Mitar's condition
12 was such that qualifies him as a man who was outside reality, which means
13 that he had an actual interruption in his contact with reality from the
14 moment he entered the hospital. This probably started much earlier, in
15 orthopaedics, but they didn't recognise it. So he was outside reality.
16 If he were to commit a crime, then he probably would not have been
17 considered competent, but I must underline that competence is always
18 evaluated in relation to a particular criminal offence. There is no such
19 thing as general incompetence.
20 Q. Dr. Martinovic, could you please examine another exhibit that we
21 have here, P162, please.
22 MR. DOMAZET: [Interpretation] 162.1 is the B/C/S version to be
23 shown to Witness Martinovic.
24 Q. Look at it, it is a letter.
25 THE INTERPRETER: Interpreter's correction, 161.1. 161.
1 MR. DOMAZET: [Interpretation]
2 Q. Have you been able to read through the letter? After all, it's in
3 handwriting. You see from the contents that it was written by Mitar
4 Vasiljevic on the 13th of July, 1992, that is at the time that he was in
5 your department, and it appears to have been addressed to Dr. Slavica
6 Jevtovic. In view of the contents of the letter, could you tell us
7 something, first in general terms, about this letter. How do you view it
8 as a psychiatrist?
9 A. First of all, on the 13th of July, he was already sedated. This
10 can be seen from the temperature chart, and the fact that he wrote a
11 letter, it happens quite frequently among patients to address doctors in
12 this way, with a letter.
13 The letter is quite realistic. He says how he took some candy
14 without paying for it, then he's saying that he asked for it on trust and,
15 of course, he pledges that it was not stolen, that he just borrowed it,
16 but after all, there's something that deviates from normal behaviour.
17 Someone can't take some candy from a shop and tell the salesperson, whom
18 he doesn't know, that he's taking it on credit and that he will pay for it
20 In the second part of the letter, again, it reflects inadequate
21 behaviour because if he has some physical illnesses, he could normally
22 tell the doctor and ask for an examination. However, here, he says that
23 he will go on a hunger strike, which is quite inadequate in relation to
24 his request. And the last sentence is pathognomonic; it is indicative of
25 a disturbance, and he says, "I would like to ask you also to tie my arms
1 and legs." This is an interesting phenomenon that we encounter in the
2 case of highly agitated patients who, themselves, in spite of the drugs
3 they are taking, ask to be tied down, and this restlessness that they feel
4 is most unpleasant for them and, if they are tied down, then there is a
5 possibility that they will calm down as a result of that too.
6 Q. Doctor, on the first page, when he says that he wanted to take the
7 candy on his honesty, as he puts it, that on trust, but that -- that he
8 was checking out the salesman, as if he had the money but he wanted to
9 check out the salesman and his honesty; is that a normal reaction,
10 especially by a person who had a similar profession?
11 A. To check out the salesman, well, that, too, is an indication of
12 inadequate behaviour. Why should he check out the salesman? This is
13 nothing to do with the honesty of the salesman or his ability to check him
14 out, so this is also an indication of disturbed behaviour.
15 Q. Thank you. Dr. Martinovic, you have seen some of these documents.
16 You have seen how Mitar Vasiljevic was transferred to your department. In
17 view of the fact that this was a wartime year and that you had many
18 reservists; is it possible for this patient to be one who was faking
19 illness so as to avoid going to war and having to fight? Because such a
20 suspicion has been expressed. Would that be possible, on the basis of
21 what you now know about his disease?
22 A. Psychiatry as a medical science is a very precise science.
23 Believe me, in my career of almost 40 years, I haven't come across a
24 single malingerer. You know, we often say, talking loosely, he's
25 pretending, he's faking, but only a person of low intelligence can fake
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 something because he cannot judge whether he will succeed or not so
2 somebody who is only insane can try.
3 In this particular case, in the case of Mitar, it is absolutely
4 impossible for him to have tried to simulate a mental disease first
5 because of -- I've already given the first reason -- and secondly because
6 we would all immediately recognise it. There was not just Dr. Simic, who
7 was a beginner, but there was his mentor, there was me. I must have been
8 involved in the therapy, in the prognosis and diagnosis, also regarding
9 the time of discharge. So I can say with emphasis that it is absolutely
10 impossible that Mitar could have faked his disease.
11 Q. Thank you, Dr. Martinovic. Let me ask you something else. We
12 have some data and written evidence that Mitar Vasiljevic underwent
13 treatment for alcoholism and he has been suspected of being an alcoholic.
14 To what extent could that effect, if at all, his mental disorder? Are the
15 two directly related, not related, or it may have a certain degree of
17 A. Alcoholism is a condition resulting from excessive use of alcohol
18 over a long period of time and it can be a good basis for psychiatric
19 disorders. In this particular case, there is no clear indication that
20 alcoholism was the exclusive reason of the psychotic disease but it could
21 have, to some extent, contributed to the psychosis. If he had not been an
22 alcoholic, the psychosis may not have set in. Alcoholic psychoses are
23 quite clear, they can clearly be diagnosed. Alcoholism is easily
24 recognizable among people, but in answer to your question, alcohol was not
25 the only reason of this psychotic condition but it could have contributed
1 to its development but we can't know that nor to what extent it could have
3 Q. Dr. Martinovic, mental disorders of this kind, can they be
4 inherited? Can they be traced back to ancestors, to parents? If you had
5 some indication of that, would that be relevant, the fact that Mitar's
6 mother was a mental patient, that she had tried to commit suicide and
7 actually committed suicide and died when Mitar was young? If we had any
8 such information, could that have an impact? I apologise, you have to
9 wait now.
10 JUDGE HUNT: Where is there any evidence of that, Mr. Domazet? I
11 don't recall your client mentioning a word of it. Is that the basis of
12 your objection?
13 MR. GROOME: Yes, Your Honour, it appears that Mr. Domazet is
14 testifying at this point.
15 MR. DOMAZET: [Interpretation] I'll tell you, Your Honour, and it
16 is up to you to judge whether it is quite true. Not only has Mitar
17 Vasiljevic failed to say that in answer to my questions and the questions
18 of the Prosecution, but he did say that his mother died when he was a
19 little boy, but this is information that I obtained from the psychiatrist,
20 Dr. Lopicic, who talked to him in the detention unit and to whom he told
21 these details and he said that he concealed it because it was considered
22 shameful for the whole family that anything like that happened. So he
23 never told me that, in spite of the many conversations that we have had,
24 and that is how I learnt about this.
25 I really, at this point in time, have no other source, though
1 probably I could reach a proper source because he obviously concealed this
2 for reasons of his own, but it is well-known that these kind of things,
3 like mental disease and suicide, are considered tragedies and a disgrace
4 for the family so I assume that was the only reason. But he did tell us
5 that his mother died when he was a little boy and I have just told you how
6 I learnt about this.
7 JUDGE HUNT: Well, Mr. Domazet, that's very interesting, but
8 nevertheless you are not giving evidence. You are going to call Dr.
9 Lopicic, are you?
10 MR. DOMAZET: [Interpretation] Yes, Your Honour. May I put this
11 question as a hypothetical one? If there was such an incident in Mitar
12 Vasiljevic's family, could that have any bearing as something, an
13 inheritance factor, a hereditary factor?
14 JUDGE HUNT: Mr. Domazet, we still haven't seen her report, of
15 course. I hope we're going to see it soon. Assuming that she is going to
16 give that as a hearsay piece of evidence, there is a problem then, of
17 course, as to the weight to be given to it but it would enable you, if you
18 undertake to call her to say that, that she was told by your client this,
19 then you are permitted to ask the doctor this question. But all of your
20 explanations and your thoughts about the circumstances are not evidence, I
21 want to make that very, very clear, and all of that explanation that you
22 have given to us, we must ignore in relation to the weight to be given to
23 Dr. Lopicic's evidence of a hearsay statement by your client.
24 I'll see whether, in the circumstances, Mr. Groome still maintains
25 his objection. With that undertaking, Mr. Groome, I think that it's
1 admissible; what weight we give to it is another matter.
2 MR. GROOME: Yes, Your Honour. I think that Dr. Martinovic, as
3 one of the doctors responsible for his care, it's certainly proper to ask
4 him if Mr. Vasiljevic said anything of this nature to him.
5 JUDGE HUNT: But simply as a legal question, if he undertakes to
6 call a doctor to give hearsay evidence as to what she was told by the
7 accused, that would make this question admissible, but I emphasise, the
8 weight we give to it is a different matter. But can you suggest that he
9 should not be entitled to ask the question on that undertaking?
10 MR. GROOME: The only thing I would add, Your Honour, it was my
11 understanding that Dr. Martinovic was not being called as an expert to
12 answer such hypothetical questions but rather as the person who actually
13 provided care for Mr. Vasiljevic.
14 JUDGE HUNT: He says that he can't remember him and I doubt
15 whether he will be able to give us any evidence of anything other than
16 that which is written down. But he is an expert. I don't know, I haven't
17 seen his statement or whether this was in his statement or not, or whether
18 you've been given fair warning of it, but I'm still anxious to know if
19 you've got any legal basis for an objection still if we have the
20 undertaking that that hearsay evidence will be produced.
21 MR. GROOME: Your Honour, I do not have any previous statement of
22 Dr. Martinovic. The only thing I do have is a one-sentence summary in the
23 65 ter submissions, saying that he would testify about Mr. Vasiljevic's
24 mental condition at the time that he was treated, so this is a surprise to
25 me that he's going to be asked such hypothetical questions.
1 JUDGE HUNT: Well, you are building up a case in reply as it goes,
2 I'm afraid, but you will be able to obtain from your doctor this -- his or
3 her reaction to this evidence.
4 Well, Mr. Domazet, it produces a number of practical problems but,
5 legally, it must be admissible. It is a shame, if I may say so, that we
6 were not given -- or the Prosecution was not given fair warning of this.
7 When are we going to get her report?
8 MR. DOMAZET: [Interpretation] What I can say, Your Honour, is that
9 I spoke to her last night. She's working on the report. I can tell you,
10 if that is of any interest to you, what the conclusions will be. Of
11 course, she will provide the explanations. Judging by what she told me,
12 the conclusion will be that Mitar Vasiljevic, at the time he was
13 hospitalised, was an incompetent person and who could not control his
14 behaviour but that, in the period relevant for the indictment, the June,
15 that he had diminished competence. To what degree, that will probably be
16 explained in her report, so according to her finding, which I hope we will
17 receive by the end of the week, it is diminished responsibility in the
18 relevant period covered by the indictment.
19 I don't know whether I have answered your question.
20 JUDGE HUNT: I am probably only repeating myself but, Mr. Domazet,
21 this is an appalling way of running the case. There has been no notice
22 given under the Rules. You were required to give it a long time ago.
23 This is an issue which arose a very long time ago. It is making it very
24 difficult for the Prosecution and the Trial Chamber to deal with these
25 sorts of things but that is what we will deal with when we get the report,
1 and I am grateful that you have told us what we are likely to see in it,
2 but it is not, if I may say so, a good picture so far as efficiency is
4 You ask the question of the doctor and we'll proceed from there.
5 MR. DOMAZET: [Interpretation]
6 Q. Dr. Martinovic, my question was a disorder of this kind, could
7 there be a hereditary factor involved if any such disorder or disease
8 existed in one of the parents?
9 A. Absolutely so. Psychiatry today attaches increasing importance to
10 hereditary factors and it is well-known in our practice that psychosis can
11 be traced through several generations. If it is true that his mother
12 committed suicide and that she had, prior to that, made several attempts
13 to do so, then it is highly probably that she was a mentally-disturbed
14 person, and under those conditions in Bosnia, she was probably never
15 examined or treated and this ended, tragically, with her suicide. And if
16 this fact were true and if I were to know it as a psychiatrist, it would
17 be very important for me in establishing the diagnosis and for the
19 If there is such a powerful hereditary factor, the very fact of
20 suicide itself need not mean so much, but if there were several attempts
21 and a suicide at the end, this is certainly a symptom of a mental
22 disorder. What kind, I can't say, of course, now.
23 MR. DOMAZET: [Interpretation] Thank you, Dr. Martinovic. I have
24 no further questions for this witness.
25 JUDGE HUNT: Mr. Groome.
1 Cross-examined by Mr. Groome:
2 Q. Good morning, Dr. Martinovic, my name is Dermot Groome and I will
3 be asking you some questions for the Prosecution.
4 A. Good morning.
5 Q. Doctor, let me ask you about this hereditary matter that has just
6 come up. From what you say, it seems that it is -- could be of important
7 or significant diagnostic -- or would have significance for diagnostic
8 purposes; is that correct?
9 A. Yes.
10 Q. Now, given the significance that it would have, shouldn't we
11 expect to see somewhere in the medical records or in the interview of Mrs.
12 Vasiljevic some questions or some attempt by Dr. Simic or the other
13 doctors to explore this, to explore the mental history of the family?
14 A. Yes, absolutely so. It is a question which a psychiatrist always
15 asks his patient, whether there have been any mental disorders in the
16 family, whether there was suicides. Those are practically compulsory
17 questions. Now, why that is not included in this case history, if I may,
18 I can make an assumption. What Defence counsel said, in our country, it
19 is something that is very often hidden, even in such serious situations
20 where husbands are undergoing treatment. This is just in the realm of
21 speculation and a hypothesis that she didn't give the proper answer.
22 Of course, Dr. Simic didn't say: "I asked her if there were any
23 cases of suicide in the family or psychosis in the family," and she said,
24 "No." We don't write that, we just say what the patient did say, so the
25 positive response. But as I say, that is a compulsory question and I
1 don't think he didn't ask it. I cannot believe that he didn't ask it.
2 Whether she answered is another matter, and what she said is another
4 Q. Let me see if I'm understanding you correctly. It seems what
5 you're saying is that you're quite confident that the doctors did ask
6 questions regarding family mental history but that the fact that there's
7 nothing recorded in the record, it appears that they were told, the
8 doctors were told that there was nothing of significance in the family
9 mental history; is that correct?
10 A. Absolutely so. That's correct.
11 Q. And it appears the first indication that we have of some previous
12 mental history which could have impact on a finding of Mr. Vasiljevic's
13 competence was brought to light this past weekend in an interview with a
14 psychiatrist by the name of Dr. Lopicic; correct? I need to have you
15 answer yes or no, for the transcript.
16 A. Absolutely. A talk with a psychiatrist tete-a-tete, like the
17 Scheveningen one, opens up -- as we say, people open up their souls. If
18 she has established a good emotional link with the patient, then he could
19 have told her much more than his Defence counsel or even here in the
20 courtroom. It is an intimate atmosphere, where the patient opens up,
21 opens his heart and soul, and possibly he said that for the first time
22 then and had not mentioned that before and hence the Defence counsel never
23 heard about it. That is possible.
24 Q. Well, this opening of the soul that you talk about, would you
25 agree with me that, that in the course of therapy, a patient learns to
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 trust their psychiatrist and, over the course of time, reveals more and
2 more information about what's troubling them and their previous history;
4 A. Of course. This was not possible in the first stage while he was
5 agitated and the large quantity of drugs that he was prescribed, but 10 or
6 15 days later, yes, he could have given much more information if he had
7 been asked and we could have learned much more. That is what we usually
8 do to substantiate our objective findings.
9 Q. And wouldn't it be reasonable for us to assume that Mr. Vasiljevic
10 was more inclined to trust and be open with the psychiatrists over his
11 three-week course of treatment in Uzice than in a single meeting with a
12 psychiatrist for the first time last week?
13 A. I think it is possible because the lady doctor probably talked to
14 him at length. She used all her methods, it is a short period of time,
15 but she was able to establish a transfer relationship, that is to say, the
16 emotional relationship between patient and physician. And I think it is
17 absolutely possible. She managed to get that feedback whereas the doctor
18 in Uzice didn't. Perhaps he didn't ask him the way she did. He should
19 have -- not should have, he absolutely certainly should have.
20 But the doctor in Uzice had before him a very highly-agitated
21 patient. He was not able to talk to him for seven or eight days. His
22 condition had calmed down and what was important for the doctor, that the
23 patient was calm and that the psychosis had calmed down. So maybe he
24 didn't go into a further exploration. The important thing was that the
25 worst was over. He was able to contend the worst, the dramatically
1 psychotic stage, which was quite certainly present.
2 Q. Now --
3 A. And after that, it calmed down.
4 Q. Now, this letter that was written, P161, that was written to a Dr.
5 Slavica -- and I forget her last name, but the letter is just to your left
6 there. Would you agree with me that, from the tone of that letter, we
7 could conclude that he had some type of trusting relationship with this
8 female psychiatrist?
9 A. Of course. That is why he addresses her, because she was Dr.
10 Simic's mentor. He was a doctor specialising in psychiatry and she was
11 the mentor and present during the examinations and so on.
12 Q. Now I think you were very candid with us at the start of your
13 testimony, saying that you have no direct recollection of Mitar Vasiljevic
14 whatsoever. Everything you've told us has been based upon your review of
15 the records; correct?
16 A. Absolutely correct, yes.
17 Q. And you've told us how important it is to keep detailed records
18 and that is something you've tried to instill in the people that work
19 under you; correct?
20 A. Yes, absolutely correct, because I'm also a forensic expert.
21 Q. Now, you were asked to give a conclusion regarding your experience
22 or expertise in forensic psychology and you said that you did not believe
23 Mr. Vasiljevic was competent, legally competent during the time he was in
24 your ward. What I want to ask you is would you consider everybody that
25 has a diagnosis of 298.9, would everybody who has that diagnosis be
1 considered legally incompetent, in your expertise?
2 A. I apologise to this august Tribunal but I have to say -- tell you
3 the basics in forensic expertise, in psychiatry. Competence is determined
4 for a concrete crime, criminis in tempore -- I think I've got it right.
5 At the time a crime was committed, for that particular act and crime,
6 accountability and responsibility and competence are determined. So there
7 isn't general incompetence or unaccountability.
8 May I give you one example? If somebody has a -- suffers from
9 schizophrenia and commits a crime within that disorder, he has the idea
10 that his boss is abusing him and he kills his boss, that is completely
11 incompetent. But if that same schizophrenic patient goes and robs a bank
12 and takes money, then he is competent. He is responsible. The same
13 patient doing two different things.
14 So when you ask me whether he was competent when he was in
15 hospital, if we're speaking about this, we must say what he did. During
16 the time of treatment he did nothing. He's not in this court of law for
17 that, for his time there. So I can only say hypothetically, in the
18 condition he was in, agitated, for example, if he hit somebody and killed
19 him while under this agitated condition, then that would be incompetent,
20 unaccountable so that is how we assess competence and accountability.
21 JUDGE HUNT: Mr. Groome, I suggest that you just put to the doctor
22 the facts as you allege them to be that happened on the 14th of the month.
23 I think it was what, 10 days before he went into the psychiatric ward.
24 MR. GROOME: Yes, Your Honour. At this time, I'm just trying to
25 explore what he based that conclusion on.
1 JUDGE HUNT: Yes, but You see, the doctor did mention that before
2 and I've made a note, I was rather curious that he was able to say that he
3 was incompetent to do anything without knowing what it was he was charged with,
4 but that's a different matter. He did make the point that it had to be
5 determined by reference to the particular acts which are alleged against
6 him. I would be anxious to hear what he wants to say about what is
7 alleged to have happened here.
8 MR. GROOME: Yes, Your Honour.
9 JUDGE HUNT: I don't know whether this takes it back as far as the
10 shooting incident but that's another matter I suppose you will have to
12 MR. GROOME: Thank you, Your Honour.
13 Q. Doctor, given what you have seen before you in the medical
14 records, are you able to give us any assessment or any opinion about an
15 event that may have happened on the 14th of June?
16 A. What happened then? I have no information about what happened on
17 the 14th of June. It was one month before the disorder -- before the
19 Q. My question is: --
20 THE INTERPRETER: Interpreter's correction, one month before the
22 MR. GROOME:
23 Q. Can you, through your assessment of the medical records that are
24 before you, is it possible for you to give us any kind of opinion about an
25 event that would have happened one month earlier, on the 14th of June?
1 A. The information given by the wife in the case history indicates
2 that it was a man with some sort of disturbed behaviour. If I remember
3 correctly, it says he was nervous, he stayed at work longer than was
4 necessary, that he couldn't keep to one place. He was restless, he kept
5 going somewhere. He was hyperactive, as we psychiatrists would say; he
6 couldn't sit still.
7 But to reconstruct his psychological condition and state during
8 that event, and I assume it was a crime that took place, is a very
9 hypothetical business and I don't think I could and I don't think any
10 expert would be able to assume what was going on at that particular
11 moment, only if there were witnesses who could say what his conduct was
12 like, then we could do a bit of reconstruction but otherwise, it is
13 difficult to say because it was one month before.
14 But let me tell you something in general terms, psychoses never
15 set out - how shall I put this? - like a flash of lightning, they never
16 come suddenly, they always have a prehistory somewhere, going back a
17 month, two months; something was happening. It needn't be remarked by his
18 family members or even doctors. And his stay in the orthopaedic ward,
19 where his behaviour was conspicuous, the doctors didn't realise straight
20 away that it might be a psychological disturbance; they only called in the
21 doctor, the psychiatrist, when the agitation had reached a peak.
22 So it is difficult for me to assume, it would just be in the realm
23 of hypothesis and I don't know if that would be useful to you, but in
24 principle, in general terms, always -- or not always but mostly one would
25 see signs a month or two prior to the actual psychosis becoming manifest,
1 which is when the patient would go to hospital, so there might have been
2 some signs along the way.
3 Q. Now, when you say that there may have been signs, that's very
4 different than saying that somebody is disturbed enough that they might be
5 incompetent; correct?
6 A. Absolutely.
7 Q. It would be more along the lines of maybe somebody showing the
8 initial signs of some physical disease but really not having the
9 full-fledged disease until a month or two later; correct?
10 A. Yes. Yes. So his competence at the beginning and later on when
11 he becomes psychotic, there's a big difference, so you have to look at it
12 at the time the crime took place.
13 Q. Now, what I want to ask you is the diagnosis of 298.9, from what I
14 understand you've told us, that is kind of a large group of unclassified
15 types of psychoses; correct?
16 A. Absolutely so, yes.
17 Q. And just because somebody has -- has been diagnosed as that,
18 doesn't mean that they are legally incompetent; correct?
19 A. Absolutely correct. Incompetence is linked to the actual crime,
20 directly linked to the actual crime.
21 Q. Now, you've looked over the therapy sheet and you've looked at the
22 medicines that Mr. Vasiljevic was receiving. Those types of medicines in
23 and of themselves don't indicate that he was incompetent, do they?
24 A. No.
25 Q. Now, I want to ask you a couple of questions about that letter.
1 And you've read it now. The whole narration about the taking of the candy
2 and whether it was right or wrong and whether to take it on trust, would
3 you agree with me that that letter written on the 13th of July still shows
4 that Mr. Vasiljevic, despite whatever mental disorder he was suffering,
5 still had the capacity to distinguish between what is right and what is
6 wrong? Would you agree with that?
7 A. You know, if you're asking me about his ethical behaviour, then we
8 psychiatrists never make a judgement as to ethics, whether people know
9 what is right and wrong. But, if you're asking me cognitively whether he
10 knew, he knew that something mustn't be taken without paying for it, he
11 certainly knew that, although he was not in an actual psychotic state, and
12 he says so, but his way of communicating with the salesperson and his
13 behaviour indicate that there are disturbances. Everybody knows that you
14 can't steal, you can't take something from somebody. So he says I'm going
15 to take it and I haven't got the money now, so if you will trust me, I
16 will pay for it later on. He wants to him to believe in his honesty.
17 Q. But cognitively, he knew that taking candy without paying for it
18 would have been wrong; correct?
19 A. Absolutely correct. He knows that he can't do that. And that's
20 why he goes into his story of justification, I'll bring you the money,
21 trust me, show confidence in me. But that is quite obviously inadequate
22 behaviour. Regardless of the fact that he knows.
23 Q. And on the other side of the letter, where there is this
24 discussion about different physical ailments that he's feeling, and he
25 makes a request to -- for treatment, would you agree with me that that
1 shows that on the 13th of July, he was still capable of intentional,
2 deliberate action? He was able to intend something and then to act in
3 accordance with that intent?
4 A. Absolutely. But his intention was not generally justified because
5 if he says, if that is not done for him, he will go on a hunger strike.
6 Can you imagine somebody who has come to a hospital for treatment says to
7 the doctor, well, if you don't want to treat me, I'm going to go on a
8 hunger strike. That is absolutely inadequate behaviour and indicates a
10 Q. And I believe when you described that letter, you used the word it
11 was quite realistic, that it showed that he still, at the time he wrote
12 this letter, was aware of reality; is that correct?
13 A. Well, you know, in the condition he was in at the time he wrote
14 the letter, he was coming back to reality. But I'm certain that in the
15 first six or seven days when he was under that great therapy, he was
16 absolutely outside reality. Now do you want me to explain what it means
17 to be outside reality? But as his condition improved, and as he went to
18 get the candies in the first place, quite obviously he was returning to
19 reality, but not sufficiently. His explanations of his motives are
21 He first says he wants the salesperson to trust him and that he
22 would bring in the money. She probably said, "Well you have to pay," and
23 was angry. In the second part of the letter, he threatens that he will go
24 on a hunger strike for something very banal, which was an examination. So
25 partially he is in reality and partially he is outside reality. If we can
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 say that; it's not the best illustration. But I -- what I want to say is
2 that he still showed signs of behavioural disturbance, and this can be
3 seen from the contents of the letter.
4 Q. Doctor, would you agree with me that, in the records that you have
5 before you and that you've seen, that none of the doctors make a
6 conclusion that he is outside of reality? They describe his agitation,
7 his singing, his speech patterns, but there is no conclusion in any of the
8 records saying he was outside of reality; do you agree with that?
9 A. Absolutely, yes. We don't write it down in the case history. I
10 said "outside reality" to help the Court understand what a psychotic state
11 and condition is. That is my explanation and it is an explanation given
12 by psychiatry as the main explanation of psychosis is loss of contact with
13 reality. You will find that in every psychiatric textbook, so that is
14 something that a doctor does not mention right in the case history because
15 it's not a component part of an objective psychiatric finding, it is only,
16 if I can say that, a general rule of thumb for psychosis, this loss of
17 sense of reality.
18 Q. Doctor, I want to ask you, aren't there specific psychoses that
19 are related to hospitalisation? For example, a person who is not used to
20 being confined to a particular area, can't psychoses set in when that
21 person is confined to a very limited space and time for a long period of
23 A. Of course. And it's a well-known phenomenon of penal psychosis,
24 people who are in prison can be psychotic. But if you are asking about
25 Mitar, he was not in a prison. A ward and department is a closed
1 department, but it is not a prison. There are other people, other
2 patients, other -- there is communication, there is trust. He knows it's
3 a hospital. Perhaps he didn't know for the first five or six days, but,
4 generally, he knew.
5 And if you're asking me about Mitar, whether he could have entered
6 a psychosis because he was in hospital, that is absolutely not possible.
7 We have not had any cases recorded where somebody came to hospital and
8 became psychotic. You know a hospital and a prison are not the same
9 thing, I'm sure you will agree. In prison, we have what is called penal
10 psychosis, that is a generally-known fact, but in this case, it could not
11 have been that because it is not a prison.
12 Psychosis can emerge in hospital as happened in the orthopaedic
13 department. He was in the orthopaedic ward and a psychosis developed but
14 not because he was in a closed space. And in orthopaedics, people come
15 and go. He could go out -- he had a fractured leg, but he could go out
16 any time. In our department, he can't go out; in the psychiatric
17 department, he could only go out in the courtyard, for example.
18 Q. Well, Doctor, would it change your opinion if I were to tell you
19 that he was in traction and could not leave his bed for a period of weeks,
20 would that change your opinion as to whether his confinement to his bed
21 could have been a contributing factor to the psychosis which was observed
22 in your department? And let me couple that with we've heard testimony
23 here that he was being regularly teased by other patients and possibly
24 even some members of staff regarding how he received his injury. Could
25 they have been contributing factors to his condition?
1 A. I must go back to your first question. I understood you to say
2 that you thought that psychosis can break out because it was a confined
3 space and a movement was restricted, what I compared to penal psychosis.
4 But when you asked me whether that could activate a psychosis, that is
5 absolutely possible and let me explain why.
6 I assume on the basis of scant information that his wife gave us
7 that he was in a state of increased activity and this can be seen most
8 often with what we call manic psychosis, manic depressive or just manic, a
9 manic episode. And when you tie a patient like that, and he was fixed
10 because of his traction, he had to be still, kept still, and
11 psychologically and psychiatrically he was disturbed, he was in what we
12 call the plus phase of hyperactivity, hyperspeech, everything was hyper,
13 insomnia sets in and so on, possibly the fact that he was tied up could
14 have contributed to the outbreak of this psychosis. That is absolutely
15 possible and it is highly probable.
16 Q. Now, you said that when somebody is transferred into the
17 psychiatric ward, that they are given a psychiatric exam; is that correct?
18 A. Absolutely.
19 Q. Can you tell us what would be the standard battery of
20 psychological tests that are administered to a patient being admitted to
21 your ward in 1992?
22 A. It's like this; standard tests don't exist in an objective
23 psychiatric examination. If the need for tests arises, we send them to a
24 psychologist, who performs those tests. For us to reach a diagnosis, the
25 initial diagnosis, the first diagnosis, and the need for hospitalisation
1 and treatment in the psychiatric department is a psychiatric examination
2 is enough, and there are no tests there. They are in the following, first
3 of all: The physician gets information from the people, the staff of the
4 orthopaedics department, and they tell him he shouted, he swore, he does
5 -- has refused to take his medicines. He is making the general chaos on
6 the department, that is the first piece of information.
7 Next, the psychiatrist sees the patient. He sees that he is
8 agitated, he is not responding properly to questions or whatever. There
9 are a few questions that we do ask. I don't want to tire you with that.
10 For example, we ask him, "Do you hear voices? Does somebody wish to
11 poison you?" a few questions of that kind, and on the basis of that, we
12 reach a diagnosis, the doctor doing the examination reaches a diagnosis
13 and decides whether to move the patient to the psychiatric ward.
14 I always thought that, with any disorder, for example, a fracture,
15 if he is tied and showing psychotic signs, I usually say, "Send him over
16 to us," and then we give him therapy. I always insist it. If a patient
17 was showing psychotic symptoms, transfer him to psychiatry. There was
18 less chance of him injuring himself. There were people who jumped out of
19 the window, I know cases of that kind, people who jumped out of a window,
20 and that's very dramatic when you get that type of case.
21 Q. And Doctor, this initial diagnosis based on this test, where would
22 that be recorded? Would that be recorded on the case history somewhere?
23 A. You mean the doctor that said he should be transferred to
24 psychiatry, that doctor, before psychiatry?
25 Q. Well, whatever doctor would have administered this test and asked
1 these questions. Would that doctor not have recorded the results of that
2 examination somewhere on the medical record?
3 A. No, no, that is not customary. He just wrote down, as far as I
4 remember, "Transfer the patient to the psychiatric ward." There's no
5 diagnosis by that doctor. And he signed it. I know the way he works.
6 I've worked with that doctor for 30 years.
7 I personally, when I go, I do write a diagnosis but some
8 physicians don't write their diagnosis, they say, "Transfer the patient to
9 the psychiatric department," and then leaves it to us, and as I can see,
10 there isn't a diagnosis there, and that's how that particular doctor used
11 to work. He would refer him to the psychiatric department, and he wasn't
12 duty-bound to write down the diagnosis. He works in neurology whereas we
13 psychiatrists are better able to write down and reach a diagnosis. And
14 the diagnosis isn't important. The important thing is he is psychotic,
15 showing psychotic symptoms and has to be referred to psychiatry. Perhaps
16 the doctor on duty that day had a lot of other business to attend to. So
17 he would have to -- the patient was transferred to psychiatry for the
18 therapy to be prescribed.
19 JUDGE HUNT: We'll adjourn until 11.30.
20 --- Recess taken at 11.00 a.m.
21 --- On resuming at 11.31 a.m.
22 JUDGE HUNT: Mr. Groome.
23 MR. GROOME: Thank you, Your Honour.
24 Q. Doctor, I want to just pick up where we left off and we were
25 talking about an initial diagnosis. My question to you is, wouldn't it be
1 necessary to at least have a provisional diagnosis of a patient before one
2 could decide what medications and other therapies would be appropriate for
3 that patient?
4 A. The practice in psychiatric treatment is, of course, to bear in
5 mind the diagnosis, but what is most important is the so-called syndrome
6 approach, which means if a patient is restless, regardless of which
7 disease he has, a certain medication is administered. If it's
8 schizophrenia, manic depressive, or this general psychosis. Therefore,
9 the drug depends on the symptoms and the diagnosis is not so important.
10 It is important to remove the symptoms. If somebody has hallucinations,
11 he gets the appropriate drugs. If someone is agitated, again, he gets the
12 appropriate medicines. Of course, the diagnosis is important for the
13 verification of the disease, and for future prognosis. I think I've made
14 myself clear. It's the symptom that matters at first, not the diagnosis,
15 as a sign of the disease.
16 Q. Is it common that -- well, we know that the discharge diagnosis in
17 this case was 298.9, and we know that that is a group of unclassified
18 psychoses. My question to you is: Is it common for a patient to be
19 discharged from the ward under this classification which is essentially a
20 nonclassification? Is that common?
21 A. Yes, indeed, and it happens very frequently. At the beginning of
22 my testimony, I said that in psychiatry, a diagnosis is established along
23 the way, so in hospital, it may be diagnosed as 298.9, and then a month
24 later, it might be 295.0, schizophrenia or depressive psychosis, so the
25 diagnosis is not established as in somatic, physical disease. Even then,
1 it can't always be established at once but almost always over a certain
2 period of time, following the so-called horizontal course of the disease,
3 so it's quite possible that the diagnosis be established after several
4 months and that is why we have this general basket into which all the
5 psychoses are put when we don't know exactly which one it is.
6 And the practice is that it's better not to establish
7 schizophrenia at first contact with the patient but that that diagnosis be
8 established during the second or third course of treatment.
9 Q. Now, Doctor, after the initial examination of a patient by a
10 doctor on your ward, is there a set protocol of continued examinations or
11 continued evaluative steps?
12 A. In this specific case, the intern admitted the patient, examined
13 him, established some sort of a diagnosis of his own, and his own therapy.
14 As he was still studying, he had to consult his mentor - in this case, Dr.
15 Slavica Jevtovic - and together with her, to explore the condition of the
16 patient to establish some kind of initial hypothetical diagnosis which is
17 probable but not 100 per cent certain. In this case, the patient was tied
18 up, a large quantity of medicines, so he was not suitable for further
19 exploration for the first week or so because there's no verbal
20 communication, or at least, very limited verbal communication, so I
21 believe that for the first six or seven days, he didn't make any further
22 explorative examinations, apart from what he was able to see; his
23 restlessness and so on.
24 So the first control check-up was done after five, six days and we
25 see in the case history that he had quietened down which, of course,
1 doesn't mean that there was no psychosis, and we can see that, judging by
2 the therapy given. We even see that there was a relapse after that.
3 The procedure is that this intern, together with his mentor,
4 establish the final diagnosis, in this case, 298.9, that he should consult
5 her over the medicines, whether he needs to be put on sick leave - because
6 I assume he was involved in the wartime operations, I don't know what he
7 was doing - and to see with the mentor and the head of department, most
8 frequently with the head of department as well, though this is not
9 obligatory but, in most cases, he is consulted, especially if it's
10 something complicated. Sometimes the whole team in the department,
11 including the social worker and the psychologist, if it's something
12 complicated, has to be consulted.
13 But as a matter of routine, the doctor and the mentor of that
14 doctor are consulted, after which he is treated as an outpatient.
15 Q. Doctor, that was actually my next question. Are there periodic
16 consultations where the key medical staff meet to discuss a particular
17 patient, and if so, how often are they held; once a week? How often are
18 they held?
19 A. Consultations in complicated cases when things are not clear are
20 scheduled for each individual patient if there is a need to do so. I
21 think in practice, this would be once or twice a week for the 50 or so
22 patients because most of them are quite clear cases. Frequently, they are
23 recidivists, patients who have been treated for years and we recognise
24 them as soon as they walk through the door so there are no consultations.
25 So we have consultations once or twice a week for so-called borderline
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 cases between psychosis and neurosis and when the diagnosis is not clear.
2 In this case, in Mitar's case, the diagnosis was so clear that
3 consultations of a team were not required. His doctor and his mentor was
4 sufficient and, of course, the head of the department and other doctors
5 making the daily rounds in the morning would see him.
6 Q. Now, Doctor, could you tell us what the symptoms of delirium
7 tremens are?
8 A. Of course. I think I have treated at least 1.000 such cases in
9 these 30 years. It is a very frequent disease in our country, an area in
10 which people drink a lot. They drink slivovitz, brandy, especially at the
11 time when plum brandy is being made. Though more recently, in the last
12 few years, there are fewer such cases. So I am very familiar with this
13 and I can tell you if you are interested.
14 Q. Yes, please tell us what are the symptoms of delirium tremens.
15 A. Delirium tremens is a brief mental disorder that develops
16 exclusively in alcoholics. It consists of the following: First of all,
17 the patient most frequently suffers from insomnia, fear, and
18 hallucinations. Hallucinations are typical in this stage of visual
19 optical hallucinations, so he most frequently sees small animals; ants,
20 worms, flies that he tries to shake off. He asks for assistance to get
21 rid of them. Then there is a lack of orientation, disorientation in time
22 and space; he doesn't know where he is nor what the time is. And also in
23 relations with other people, he is disoriented very frequently; he doesn't
24 know that he is in hospital, he doesn't know why he's there, what's wrong
25 with him, a total loss of touch with reality.
1 And if you're also interested, they can be very suggestive. You
2 give him a piece of paper and read what it says and he'll start reading
3 from a blank page. So he's extremely restless, very frequently you have
4 to give a certain medicine intravenously and, thank God, nowadays there's
5 a drug called Heminervin which removes the psychosis in a day or two so
6 that nowadays it's not a serious problem. And there's a very pronounced
7 tremor. That's why it's called tremens, the whole body shakes and the
8 hands and the sweating. So it's a very dangerous situation. In a certain
9 percentage of cases, it ends in death, it can be fatal.
10 So as I have said, in a day or two, it can be treated and it is
11 most welcome for the benefit of the patient.
12 Q. Now, it seems from your description of delirium tremens that, at
13 least to some extent, the symptoms of delirium tremens overlap with the
14 symptoms of the psychosis you've described Mr. Vasiljevic as having; is
15 that correct?
16 A. Yes. But the difference is enormous.
17 Q. And how would you characterise the difference?
18 A. Let me explain. In Vasiljevic's case, there was no tremens, no
19 trembling of the body, no perspiration, no hallucinations, which are
20 typical of delirium tremens, so that is quite sufficient for me to say it
21 was not delirium, it's an acute psychosis. What is common to both is loss
22 of orientation. Vasiljevic didn't know where he was nor what was
23 happening nor who was around him. Verbal communication was also something
24 that it was difficult to establish with him.
25 Q. Doctor, would it change your opinion or your conclusion that
1 you've just given us if you knew that prior to this hospitalisation, Mr.
2 Vasiljevic had, on several other occasions, been treated by a
3 neuropsychiatrist for delirium tremens and that, just prior to his
4 hospitalisation, he was using a great deal of alcohol, would that change
5 your conclusion of whether that, at least in some part, some of his
6 symptoms could have been attributed to delirium tremens?
7 A. No, no. It is so different that there is absolutely no
8 possibility of me making a mistake and saying psychosis instead of
9 delirium tremens.
10 As I said a moment ago, for tremens, you give intravenous
11 medicines. In Vasiljevic's case, very powerful neuroleptics were
12 administered which are exclusively given for psychosis, never for delirium
13 tremens. It would be a terrible mistake for the doctor to make, not just
14 he, but three or four of us. That is quite impossible. Delirium tremens
15 is such a typical disorder that one simply cannot go wrong. Everything
16 else could be questionable but not delirium tremens.
17 MR. GROOME: Thank you, Doctor. I have no further questions.
18 JUDGE HUNT: Re-examination, Mr. Domazet.
19 MR. DOMAZET: [Interpretation] Thank you, Your Honour.
20 Re-examined by Mr. Domazet:
21 Q. Dr. Martinovic, linked to this last question by Mr. Groome, when
22 you totally rejected, it seems to me, that this could have been delirium
23 tremens but that it was a typical case of psychosis as you described it,
24 does that change in any way your answer with respect to the influence of
25 alcohol for the development of psychosis? Could we clear that up a
1 little, if you will?
2 A. Yes. Regarding this point, I said, if you remember at the
3 beginning, that alcoholism could have been a sort of basis for the
4 development of psychosis. It is highly probable that he - I've also said
5 that - that he was in a plus stage, as we call it, for a month or two
6 prior to hospitalisation and, of course, he drank excessively, then he
7 came to orthopaedics because of his fracture, which can always be a
8 triggering factor for psychosis, a bodily injury can activate delirium
9 tremens and other acute diseases. So I abide by what I said that alcohol
10 could have had some effect on the outbreak of the disease and the clinical
11 picture but I say again, delirium tremens is out of the question. It is
12 quite impossible.
13 Q. Thank you. Dr. Martinovic, answering Mr. Groome's question about
14 what the doctor should have and probably did do to inquire about these
15 things such as mental diseases in the family or suicides, you gave your
16 answer and the questions mostly had to do with whether that information
17 would be provided by the patient himself or his wife. So there were two
18 possibilities for the doctor to learn about this; isn't that so?
19 A. Yes.
20 Q. With respect to the patient himself, to what extent was he
21 capable, in view of his condition at the time, and his answers even later
22 with that regard? Were they relevant?
23 A. For the first six or seven days, he couldn't say anything. I've
24 already described the situation. He was out of touch with reality. He
25 doesn't know what he's saying or where he is. After that, he could have
1 said it but I am 100 per cent sure that Dr. Simic must have asked him that
2 because the first thing we teach them when they start specialising is to
3 ask relatives, including the patient, whether there are mental diseases in
4 the family or suicides in your family.
5 So I'm 100 per cent sure that he did ask him. Why he didn't write
6 down the answer is because neither he nor his wife told him that. You
7 see, even he refused to say anything about that to you and you have spent
8 so much time with him. I was saying that, in our part of the world,
9 suicide is a terrible act. It is anathema, you know, the attitude of
10 religion towards it, and of course, mental disorders which are,
11 regrettably still, considered a disgrace and he -- his mother lived in
12 Bosnia where she probably never had any chance to see a psychiatrist and
13 that is how she ended her life.
14 Q. I was asking you this about him in person. So you said he could
15 have said later but he also could have concealed it. Would that have had
16 any effect, perhaps not on further treatment but would he have been kept
17 in hospital longer? Because obviously both he and his wife wanted to
18 shorten his stay in this hospital as much as possible because they asked
19 to be discharged against doctors' advice. It's difficult to explore that
20 further so I'll move on.
21 As regards the wife, the only possibility that we did not consider
22 is whether she, herself, knew as this was a long time prior to when they
23 got married so that I really don't know whether she could have said
24 anything. So this is a fact that you have no note of, nor do you
25 recollect of ever hearing about it?
1 A. No.
2 Q. If I understood you, your answers correctly, when you were
3 describing his competence at the time when you can speak of, that is, at
4 the time he was being treated, you said that depended on the act and gave
5 an example that if, in the course of hospitalisation, he were to hurt
6 somebody physically or kill him, that he would not be competent but if he
7 broke open a safe, that he would be considered competent. But would he be
8 fully competent or reduced, would his competence be reduced? But that is
9 also questionable, and you still stand by that answer?
10 A. Yes.
11 MR. DOMAZET: [Interpretation] Thank you, Dr. Martinovic, I have no
12 further questions for you.
13 JUDGE HUNT: Thank you, Doctor, for coming along to give evidence
14 and for the evidence that you have given. You are now free to leave.
15 THE WITNESS: [Interpretation] Thank you too.
16 [The witness withdrew]
17 [The witness entered court]
18 JUDGE HUNT: Madam, will you please make the solemn declaration in
19 the document which the usher is showing you.
20 THE WITNESS: [Interpretation] I solemnly declare that I will speak
21 the truth, the whole truth, and nothing but the truth.
22 WITNESS: SLAVICA JEVTOVIC
23 [Witness answered through interpreter]
24 JUDGE HUNT: Please sit down.
25 Mr. Domazet.
1 MR. DOMAZET: Thank you, Your Honour.
2 Examined by Mr. Domazet:
3 Q. [Interpretation] Mrs. Jevtovic, good morning.
4 A. Good morning to you.
5 Q. Madam Jevtovic, I will be examining you on behalf of the Defence
6 counsel and will you please, when you hear my question, wait a few moments
7 before giving your answer as we speak the same language and this is
8 necessary to facilitate the simultaneous interpretation of your questions
9 and answers.
10 Also, in front of you, you have the screen with the transcript in
11 English so you will see when the court reporters complete their recording
12 of the translation, so please bear that in mind during your conversation.
13 Will you please give us your basic particulars; your name, place
14 and date of birth and your place of residence.
15 A. My name is Slavica Jevtovic. By occupation, I am a
16 neuropsychiatrist. I am living and working in Uzice. I have been working
17 for 35 years. I was born in Osijek, in Croatia.
18 Q. Madam Jevtovic, you are working in the general hospital in Uzice?
19 A. Yes.
20 Q. Since when have you been working in the hospital in Uzice?
21 A. I have been working continuously in Uzice since June 1966 and that
22 is also the date when I started living in Uzice.
23 Q. You told us that your -- what your occupation is, you're a doctor,
24 a neuropsychiatrist. In which department are you working and have you
25 been working at that department throughout?
1 A. With the exception of a few months that a young doctor has to work
2 as an intern, touring various departments, I have been continuously in the
3 neuropsychiatric ward, and ten years ago when the university department
4 was separated into psychiatry and neurology, I have been assigned to the
5 psychiatric ward.
6 Q. Could you tell us, please, as 1992 is relevant for us, could you
7 tell us where you were working at that time.
8 A. I was working continuously in psychiatry. It is called the
9 psychiatric service ever since 1991 to this day.
10 Q. Would you please tell me, in 1992, what post you held, who was
11 your superior, and who were the other doctors working with you.
12 A. In 1992, I was a specialist, holding the post of specialist. Our
13 head of department was Dr. Borisav Martinovic. I had fellow specialists
14 Bukvic and we had young doctors who had still not officially started their
15 specialisation but were doctors' assistants as we called them, secondary
16 doctors. And they were Dr. Simic and a lady doctor, Mirjana Perunicic.
17 Q. Mrs. Jevtovic, was that sufficient for the task in hand at the
18 time regarding the organisation of your department?
19 A. Quite certainly it was not sufficient, but I said that we had
20 divided up into two services and the existing staff, specialist staff had
21 to be divided up too, into two services. And that is why we employed new,
22 young doctors, who were to begin their official specialist training and
23 education, which they later did receive and graduated from. But of course
24 it wasn't enough, it wasn't sufficient for, if I can say so, the
25 misfortunes that were to engulf us. We had a lot of sick people coming
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 into our hospital from the whole of Bosnia, practically speaking, and this
2 went on for several years. So in addition to our regular work, and we
3 have a hospital section with 50 beds, and inpatients and we have a
4 specialist outpatients department throughout the working hours every day.
5 And we also had compulsory presence, or rather, shifts lasting 24 hours in
6 the ward on the department.
7 Because of that, we were forced as -- us older doctors had two
8 specialisations, neurology plus psychiatry. For a long period of time, in
9 fact, until three years ago, we were duty-bound to ensure -- to provide
10 the second and third shifts. From the psychiatric department we could go
11 and work -- we would go and work in the neurology department, and vice
12 versa, the neurologists would come to do shifts in the psychiatric
13 department, which made our work even more difficult because it is always
14 easier to treat a patient for whom you admitted and are supervising his
15 treatment rather than taking over a patient from a doctor who has just
16 gone off duty and who you are replacing in the shift.
17 Q. Dr. Jevtovic, you explained about the young doctors, Dr. Simic and
18 Dr. Mirjana Perunicic, cases in point, that they were called secondary
19 doctors. Now, my question is in concrete terms, Dr. Simic, did he have
20 his patients and his department? Did they have their patients and
21 departments? Were they doctors on the ward in the department?
22 A. The department was not divided and the young doctors, on a regular
23 basis, received patients but they didn't work independently, or
24 autonomously, they worked under our supervision. And their status was
25 what we called "secondary." Each senior physician was given an assignment
1 by the head of the service, the head of the department, was given a doctor
2 to supervise, to help him in reaching diagnoses, to help him in therapy,
3 to help him in final diagnoses and writing the discharge sheet.
4 But once these young doctors began their official specialist
5 training, which was determined by the ministry of health, then they are
6 ascribed an official mentor and that mentor is duty-bound to help the
7 young physician in gaining the knowledge and training he needed in the
8 field of psychiatry. And the mentor would have to confirm everything with
9 his own signature. When the doctor enters into the second stage of
10 specialist training, which he does at the institute in Belgrade -- that's
11 where our young specialist doctors usually go to sit for their specialist
12 final exams, they go to the institute in Belgrade to sit for that
14 Q. Mrs. Jevtovic, who was Dr. Simic's mentor at that time?
15 A. I was his mentor. Before his specialist training and in the
16 course of his specialist training, I was his official mentor.
17 Q. You explained that in your previous answer, but I should
18 nonetheless like to ask you to explain to us what it actually meant in Dr.
19 Simic's work. What did he have to consult to you about or what did he
20 have to report back to you about and how did your relationship as mentor
21 and doctor-trainee function?
22 A. In practical terms, it was his duty to inform me everything about
23 the patient and then, from time to time, I would talk to his patient to --
24 I would get an insight into all the documents, and I would give my
25 agreement for therapy. We would discuss the diagnosis and what we call
1 the differential diagnosis, all with the aim of his education and training
2 in mind.
3 There were doctor's rounds every day and we would all be present
4 except the head of department who would be present on certain days but on
5 others, he would have other things to attend to. Where we had
6 exceptionally complicated, unclear cases, we would present the case before
7 the head of department and all the doctors would take part in discussing
8 that particular case together before the head of department.
9 Q. Explain to us about the rounds, doctor's rounds. You said they
10 were daily rounds. Would you explain when the rounds took place, who
11 would attend, and whether you moved from bed to bed or patient to patient.
12 So could you tell us, in practical terms, what a doctor's visit or round
13 consisted of.
14 A. Yes, I will be happy to. A doctor's round is official and
15 compulsory for all doctors in the department except the head of
16 department. The head nurse is present as is a psychologist and the
17 working therapist, and quite literally, we move from bed to bed each
18 morning. We do our rounds very early on for practical reasons. First of
19 all, our patients must receive therapy in time intervals and therefore
20 have usually an 8-hour cycle.
21 Secondly, this might sound a little strange to you, but they could
22 get breakfast first in the morning because breakfast is distributed from
23 the central kitchens to the wards and not everybody can receive breakfast
24 at the same time. Our patients were not physically ill for the most part,
25 and relatively they were younger people and they were hungry so they
1 couldn't always wait for a late breakfast and dinner is 6.00 -- or 5.30 or
3 Neuroleptic drugs, the drugs that are used for mental patients,
4 increase appetite, that is the first point. Secondly, we take in patients
5 from the whole region and they don't have visits very often which means
6 that their nearest and dearest and friends cannot bring food in. These
7 people from Uzice are privileged in that way because visitors can bring in
8 food so food is distributed at regular hours. In order to improve the
9 food which, in recent years, was of a very poor quality, people would
10 bring in extra food.
11 If you have any more questions about doctor's rounds, please ask
13 Q. So you and the other doctors, with the exception of the department
14 head who didn't have to attend the rounds every day, you were duty-bound
15 to see the patient at least once a day by his bed or in his bed, together
16 with the doctor whose patient he was and all the other people you
17 mentioned. Have I understood your answer correctly?
18 A. Yes, that's right. The rounds include agreements about therapy
19 and consultative examinations as well. The need to have consultative
20 examinations are recorded by the head nurse in a separate notebook, a
21 notebook of agreement, and then she phones up and calls the necessary
22 specialists who we wish to consult.
23 The daily rounds consist of short chats to the patient along with
24 observation. We observe the behaviour and conduct of the patient, his
25 ability to communicate with us and you can assess a great deal during that
1 time. More detailed interviews and conversations are held separately in
2 the doctor's office because there are some very interesting things that
3 required discretion and confidentiality and we never discuss these things
4 in the presence of other patients.
5 I don't know how laymen imagine psychiatric wards to be.
6 Psychiatric patients are not dislocated somewhere over there and that we
7 doctors are in a sort of protected, separate place. The department and
8 ward in which we are discussing in the period of 1992, it was a long
9 barracks, linear in design, the rooms followed on one from another and
10 then had you a doctor's office and dormitory and a doctor's office and a
11 dormitory so nothing could happen in the department or on the ward without
12 it being heard.
13 Doctors' offices are not locked during working hours. Our
14 patients have the freedom to move around within the department and ward.
15 It is locked to the outside, but patients can come into the doctor's
16 office any time they like. Whether they stay a longer or shorter period
17 of time will depend on the doctor's requirements, whether he is scheduled
18 for an interview with the patient on that day. But very often the
19 patient, especially at the beginning of the treatment, has a great need to
20 see his therapist because the greatest problem and basic symptom are
21 anxiety and fear. Sometimes they come and say, "Just let me sit there for
22 a while, please, Doctor, sit with you." They don't have to talk to you.
23 So they are not separate. They are not isolated, they are not closed off
24 anywhere as far as we and the rest of the staff are concerned.
25 Second, the modern approach to psychiatry is the principle of a
1 treatment through a therapy community. All persons employed, the whole
2 staff and the patients, form one large group and each patient, depending
3 on his condition and state takes part in the work of the department as a
5 THE INTERPRETER: Could the witness please slow down.
6 A. The president of the therapy community is elected each week.
7 Certain days are designated where we all meet together to talk about the
8 life of the patient.
9 JUDGE HUNT: Madam, I'm sorry to interrupt but you are causing
10 troubles for the interpreters you are speaking so quickly. So slow down,
12 THE WITNESS: I'm sorry. I'm sorry.
13 MR. DOMAZET: [Interpretation]
14 Q. Mrs. Jevtovic, you have heard the remarks, just a little slower,
15 please. And may we focus on my questions and I shall be asking you
16 additional questions for additional explanations, if the need arises, to
17 prevent long answers to my questions and I'm sure we'll cover everything
18 that is necessary.
19 If I understood you correctly and what you were saying, it emerges
20 that you and all the other doctors had constant contact and continuous
21 contact with your patients. Am I right in concluding that from what you
22 said as to the distribution of the rooms and the way in which your
23 department worked; am I right?
24 A. I apologise for being so long-winded but I wanted to paint a
25 picture for you of our daily contacts and not only daily contacts but if
1 the need -- if a patient had a specific need, then we would see him
2 several times a day, even for brief periods.
3 Q. So in addition to your obligatory daily morning round where you
4 would see each patient individually, you and the rest of the doctors
5 throughout your working hours would be available for contact with patients
6 in view of the organisation of your department; is that right? Can we
7 make that conclusion from your explanations?
8 A. Yes, absolutely.
9 Q. When you say that that was how things were organised, and that
10 there were dormitories and then the doctor's room, then another dormitory
11 and then another doctor's room, and so on and so forth, does that mean
12 that, literally speaking, at all times patients would be able to come and
13 find you or you would be able to find a patient?
14 A. Yes, absolutely correct.
15 Q. You also said that you held separate interviews and conversations
16 with patients in separate rooms without the presence of others. You would
17 have a one-on-one meeting with the patient when you considered that to be
18 necessary. When the young doctors were concerned, like Dr. Simic, for
19 example, would he have separate one-on-one meetings, would you have them,
20 or would you hold these sessions together? Could you explain to us how
21 these sessions took place and how you were mentor to the younger doctor.
22 How would this work?
23 A. Official talks which we decurs or take note of after a certain
24 time is done together with the mentor and the young physician together.
25 We have no separate rooms; they were doctor's offices where all the
1 administrative work is conducted, where we have sessions with the
2 patients. They were also the same offices where members of the family
3 would come when they visit in order to receive the necessary information
4 and also for additional work with the family members.
5 We have to give a lot of information to parents and spouses. They
6 ask us a great deal of things, so all this is done in the doctor's room,
7 the doctor's office. And the sessions are recorded in the decursus and
8 the mentor is there and we discuss diagnoses and possible further
9 examination. We have the possibility of carrying out
10 electroencephalography today. We have a computerised tomography system,
11 or rather, a scanner, and we also discuss any changes to therapy or any
12 other procedure which is deemed necessary in the treatment of a patient.
13 Q. Mrs. Jevtovic, when the patient is admitted to your department and
14 if it is a patient whom you have not seen before who is coming for
15 treatment, does the doctor take down all the family particulars, that is
16 to say, information about the ancestors, diseases, or anything --
17 hereditary diseases or anything that could be relevant in the treatment of
18 the patient?
19 A. Correct procedure is the following: To collect as much
20 information and data as possible, especially if, as you have just said, we
21 are dealing with a newly-admitted patient. If it is possible to arrive at
22 that information, if there's a family member present accompanying the
23 patient, which is frequently the case, then we research into the patient
24 since his childhood. We look at the key elements, which are possible
25 behavioural difficulties in childhood, during puberty, adolescence, during
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 compulsory military service, and of course, changes in behaviour for which
2 the patient was brought to our department with an insistence upon the way
3 in which their behaviour has changed, the time that this change of
4 behaviour occurred, and possibly treatment, the treatment of the patient
5 before coming to our institution, what treatment the patient had prior to
6 coming to us.
7 A vital piece of information is delving into family anamnesis,
8 family case history, so we always ask whether there were any physical
9 diseases and, most particularly, whether there was any mental diseases in
10 the family. Those are regular questions that we ask. We always ask
11 whether any family member has been treated for a mental illness, whether
12 any family member committed suicide, whether they committed a murder or
13 any other criminal act, whether they were convicted, and whether,
14 generally speaking, in the family, there were members who stood out
15 through their behaviour which stepped outside the norms of normal, regular
17 Q. Mrs. Jevtovic, asking these questions and coming by this type of
18 information and getting the answers, is that the duty and obligation of
19 each doctor treating a patient?
20 A. It is his duty and need. It is a requirement for future work. If
21 we are able to, we try and contact an individual who could give us the
22 information we need. Very often, patients themselves come to us forcibly,
23 they are forced to come. They are brought by a police escort without any
24 family members in attendance, so whether they are brought in from their
25 homes or whether they are brought in because they have been found in some
1 public place where their conduct was inadequate, inappropriate.
2 Q. When you say this, Mrs. Jevtovic, in situations of that kind, are
3 these situations where you are unable to come by the information you need
4 or do you somehow manage to get answers to your basic questions?
5 A. In our service and department, we have a social worker and it is
6 the task of that social worker, when we're talking about that sphere of
7 activity, to see in every way possible if he can contact family members
8 for us to be able to get the necessary information. That does not mean
9 that the social worker amasses that information himself, it means that he
10 invites family members to come to the hospital and to talk to the doctors.
11 Q. Thank you. That's an explanation regarding the information that
12 you seek to collect from family members. What about the patient himself?
13 Are they the same questions that you put to the patient and is it always
14 possible to do so and is it done?
15 A. Heteroanamnesis is a part of our work with the aim of obtaining
16 information for the diagnosis. Another part --
17 JUDGE HUNT: Doctor, just one moment. You don't have to go that
18 slowly. All that we are concerned about is that you don't start to answer
19 the question until you see the typing finish. They are very quick, our
20 court reporters, but they are following the interpreters and the problem
21 arises that the interpreters can't keep up if you come in straight after
22 the answer or if you speak quickly. So you don't have to dictate it, as
23 it were, to somebody who is taking it down in handwriting. You can speak
24 a little bit more quickly than you are now.
25 A. Another area of work is this so-called interview. It is a
1 conversation with the patient which involves collecting information and
2 also it includes a clinical examination. Collecting information from the
3 patient, we don't consider to be absolutely valid, especially if we are
4 dealing with a psychotic patient, and that is quite normal, I think.
5 Q. Just one more question in this area. Was this the procedure that
6 you instructed the doctors whose mentor you were to apply?
7 A. Yes, quite.
8 Q. Mrs. Jevtovic, will you please look at an exhibit of ours. It is
9 the case history for Mitar Vasiljevic.
10 MR. DOMAZET: [Interpretation] Could the witness be shown, please,
11 Exhibit P138.
12 Q. Have you had a chance to look at it, Mrs. Jevtovic?
13 A. Yes.
14 Q. Could you tell us, as a neuropsychiatrist in the ward, what do you
15 read from this case history?
16 A. If we go in chronological order --
17 Q. Excuse me, I would like to ask you the psychiatric part, leaving
18 out the orthopaedic part - that will be explained by orthopaedists - but
19 only what you see related to psychiatry.
20 A. I understand. If we go chronologically, on the 5th of July,
21 because of conspicuous behaviour, a psychiatrist was invited for
22 consultation, which means something was happening with the patient. No
23 consultation was done and we see that, on the 5th of July, "Should be
24 transferred to psychiatry," and the signature is that of Dr. Bogdanovic
25 who at the time was in the situation that I have described; he was working
1 at the neurology department and he did duty for us and the 7th of July is
2 a national holiday in our country.
3 Then the patient was transferred to our ward, Dr. Simic
4 examined him on the 8th, which is a working day, and he found him in this
5 condition as he describes, in this condition of excitation. We can see
6 that the situation changed, it improved; a heteroanamnesis was done from
7 which it can be seen that the changes in behaviour started before his
8 arrival in hospital.
9 According to the wife's statement from the beginning of the war
10 conflicts that, since then, he started drinking more, that he was
11 restless, that he found it difficult to concentrate. Then regarding the
12 decursus, after that, there was an improvement. There is still minor
13 incidents in behaviour but, at the request of the spouse, he was released.
14 The final diagnosis is 298.9, which stands for an acute psychotic
16 When the general symptoms are established for the diagnosis of a
17 psychotic disorder and there are no specific disorders, so-called
18 psychopathological phenomena which would determine more specifically the
19 type of mental disorder, one could see this as a provisional working
20 diagnosis even though, according to the classification, this diagnosis
21 does exist. It could include certain unspecified alcoholic psychoses
22 because there are unspecific alcoholic psychoses, also reactive psychoses,
23 which were also covered by this code. These are old codes from the former
24 international classification.
25 Nowadays, different codes are in use, and not only the codes have
1 changed but, in some cases, the method of classifying psychiatric diseases
2 has also changed.
3 Q. Maybe I'll come back to that diagnosis a little later because I
4 haven't reached that point yet though we do find it in this case history,
5 you have already started explaining it, but I would like to ask you first
6 when you were talking about the information that is collected from family
7 members and you told us what kind of information is solicited as being
8 relevant, you said that that information is taken note of. Where would
9 that information be recorded in the specific case of this patient if
10 information of that kind had been collected such as that members of the
11 family had been ill or something like that?
12 A. Exclusively in the case history, but it doesn't mean that every
13 doctor was able to solicit such information. In our population, such
14 facts are concealed relating to suicides and mental disease so it is quite
15 possible that this was covered up. I don't believe that my colleague
16 didn't ask about it.
17 Q. So if such important matters were raised such as mental diseases
18 of ancestors, parents, or close relatives, or suicides, in the event of a
19 positive answer, then you are telling us that that would necessarily have
20 to have been recorded in the case history?
21 A. Yes, it would have.
22 Q. Would you please look at the next exhibit, the therapy sheet.
23 MR. DOMAZET: [Interpretation] Could P165 be shown to the witness,
25 Q. Would you look at the therapy sheet for the treatment of patient
1 Mitar Vasiljevic.
2 Have you looked at the document?
3 A. Yes.
4 Q. Will you please tell us what you conclude -- what you can conclude
5 from the therapy sheet regarding the therapy administered and whether you
6 can make any conclusions regarding the intensity of the disease of Mr.
7 Vasiljevic on the basis of that therapy sheet.
8 A. From the beginning of treatment on the 7th, 8th, 9th, the patient
9 was having intensive anti-psychotics and neuroleptics. We have not -- we
10 are not familiar with a stronger neuroleptic than Topral and Nozinan has a
11 sedative and anti-psychotic effect. These are the two strongest drugs in
12 use in our country. Unfortunately, we don't have Topral any longer. We
13 had it for a year or two and not since then.
14 Also, we can see that the patient was given injections, which
15 means that he was extremely restless and refused therapy. We avoid vials
16 because neuroleptics are most unpleasant, they have very unpleasant side
17 effects and the reason for such high dosages must exist because it would
18 be absolutely wrong and even criminal to give such strong medicine if they
19 weren't necessary. After a time, he calmed down and he was treated with
20 Largactil tablets, which are milder, but again, 400 milligrams a day is a
21 large dosage.
22 Then he -- the dose was increased to 600 so that, on the 19th,
23 there were problems. This is my handwriting. I must have been on duty.
24 Flormidal is a very strong hypnotic which has a very speedy effect and
25 puts the patient to sleep, so there was a relapse on the 19th and it's
1 quite possible, because he was on tablets, that he omitted to take them,
2 because this happens. They are very clever in concealing a pill. You
3 wouldn't believe what kind of tricks they resort to so that, sometimes, we
4 give the tablets in powder form. We don't have neuroleptics in solutions,
5 which is much more convenient.
6 Then we also see that he was discharged with a considerable dose
7 of Largactil, of 300 milligrams which is, again, quite a considerable dose
8 for treatment at home, so I assume that his situation was not fully
9 resolved, and this is confirmed by the fact that it was at the request of
10 the wife that he was sent home. So this dosage was not quite appropriate
11 for taking at home.
12 Q. Mrs. Jevtovic, when you're talking about this dose and the therapy
13 administered for home or outpatient treatment, could you be a little more
14 precise? Because you said, "quite a considerable dose," it could mean
15 sufficient or it could mean above average. Was that what you meant to say
16 when you were commenting on his discharge prior to such a decision being
17 made by the doctors?
18 A. Maybe I didn't use the best term but I was saying that the
19 strength of the dose is explained by the premature discharge. If a
20 psychotic disorder, which usually is the first treatment, the dosage is
21 too high for outpatient treatment. For an old psychosis that has been
22 treated for a long time, then a patient could be discharged with such a
24 Q. When you were speaking about the beginning of therapy, and you
25 mentioned Topral as one of the strongest medicines that you had access to
1 in those days, does that mean that that was one of the most effective
2 medicines for such a disease which you resorted to in the treatment of
3 Mitar Vasiljevic?
4 A. Topral was administered for extremely agitated patients as the
5 strongest neuroleptic that we had at the time, which means that the
6 patient, at the time, was extremely agitated.
7 Q. That's as far as Topral is concerned, but generally speaking, when
8 you look at the therapy administered for this period of time, can you tell
9 us how serious the disorder was? Was it average, below average, or above
10 average on the basis of the therapy that he was given?
11 A. From this therapy, we can see that this was an extremely agitated
12 patient and one can also see that this was an unspecified psychosis
13 because there are no other neuroleptics which are more targeted for a
14 particular specific psychosis and there are no antidepressants or
15 something else that are prescribed for other specific psychoses. And this
16 confirms that 298.9 was justified.
17 One could suspect that this was a maniform disorder and one may
18 ask why this was not indicated. A mania, it's an affective disorder which
19 affects the mood and it rarely occurs alone. It is usually combined with
20 depressive states and it could be called mania co-depressive affective
21 disorder. The rule in our work is to wait for at least two such episodes
22 before we can define it as such a psychosis. On the basis of the first
23 psychosis, it is not proper to diagnose it immediately. These are usually
24 younger people who are manifesting such problems early on and having such
25 a fixed diagnosis can harm them in their later life so we need a little
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 time to establish the diagnosis.
2 We can't be hasty upon the first episode and to claim the patient
3 a manic patient, which is a very serious disease and it can cause him
4 great difficulty in later life, so we need time.
5 Q. If I understood you correctly, Dr. Jevtovic, in this case, this
6 was not registered in the case of Mitar Vasiljevic, no such disorder was
8 A. We would not add to the basic diagnosis, especially as the old
9 codes did not allow it. According to the old classification, we didn't
10 have an acute subschizophrenia as a separate disease. There's a separate
11 code for this disease in the new classification which we didn't have
12 before so we were taught not to do that and that was the practice that we
14 Q. You referred to the first and second episode. What would be the
15 first episode? Would that be a disorder of this kind and a treatment of
16 that patient as one episode? So in the event of a repeated episode, you
17 would make that conclusion? Could you explain that a little?
18 A. Acute psychotic disorders need not always develop into a chronic
19 psychosis. It may occur once and never again. But with time, it may
20 develop and become differentiated, and that is why I said the diagnosis of
21 chronic mental disorders have to be followed over time.
22 Though this is a maniform disorder, one needs at least two
23 episodes before being able to qualify this as a manic psychosis.
24 Q. You said, Mrs. Jevtovic, that this resembled a maniform disorder,
25 but as it was, the first episode, it was difficult to make such a
1 conclusion and you would like that -- time for that to be confirmed, I
2 understood that part, but I'm asking what was it that resembled a maniform
3 disorder? What were the symptoms pointing in that direction?
4 A. The extreme restlessness of the patient and very conspicuous,
5 uncritical behaviour. Then, also, there is some information here in the
6 decursus about his incoherent speech which says that his thought process
7 was accelerated, accelerated but not contextually disordered thoughts,
8 crazy ideas. There are no deceptions. There are no hallucinations that
9 would lead us in another direction.
10 Also, in the anamnesia by the wife, alcohol was referred to.
11 Alcohol also could be referred to as an etiological factor and have some
12 effect on our conclusion and that's why they opted for an acute psychotic
13 disorder because the code 298.9 in those days included nonspecific
14 alcoholic psychosis, as I said at the beginning.
15 Q. Dr. Jevtovic, do I take it that what you now found was there were
16 a number of elements of a maniform disorder, but without a fresh
17 verification, a repetition of some situation, you did not wish to take
18 note of such a thing?
19 A. It is not our practice to do that. It doesn't depend on our wish.
20 Q. You mentioned the etiological factor, in this case alcohol. How
21 does alcohol or alcoholism affect what you have been telling us about so
23 A. Such behaviour could lead us to conclude that this was an
24 unspecific alcoholic psychosis because, according to this classification,
25 alcoholic nonspecific psychoses come under this code and their
1 manifestations are similar; general agitation, fear, inconsideration,
2 noncritical behaviour. As for a -- we cannot say that it was specific
3 alcoholic psychosis because they are very characteristic, easily
4 recognisable and no mistake can be made.
5 Q. What do you mean "no mistake can be made"? Are you referring
6 to specific alcoholic psychosis?
7 A. Yes. It's an acute, peracute serious alcoholic psychosis known as
8 delirium tremens, and because of vegetative neurosystem disorders, there
9 are specific visual deceptions, hallucinations of tiny animals. These are
10 very specific that do not occur in other mental disorders. They are very
11 typical of delirium tremens.
12 Then there is general bodily tension, fatigue of the whole body,
13 fear, disorientation. The patient sees himself as being in two different
14 places at the same time. This is a very picturesque symptomatology so one
15 can't make a mistake. Then there is alcoholic halluncinosis, which is a
16 specific mental disorder of a more chronic type which again is
17 characterised by numerous hallucinations of the auditive type when the
18 patient is constantly hearing voices, voices that keep telling him off,
19 that threaten him, that speak badly of him and he's fearful, restless, an
20 insomniac, and as a result he cannot behave rationally. He cannot
21 separate reality from his hallucinations.
22 JUDGE HUNT: Mr. Domazet, I think if you ask another question, the
23 answer may take us well into the lunch hour. We'll take the break now and
24 resume again at 2.30.
25 --- Luncheon recess taken at 1.00 p.m.
1 --- On resuming at 2.30 p.m.
2 JUDGE HUNT: Mr. Domazet.
3 MR. DOMAZET: Thank you, Your Honour.
4 Q. [Interpretation] Mrs. Jevtovic, we'll pick up where we left off
5 just before the break. If you remember, we were discussing certain
6 symptoms, that is, we were talking about alcoholic psychosis and delirium
8 Taking into account the documents that you have and that are in
9 front of you and that you are familiar with, in this particular case of
10 Mitar Vasiljevic, could it have been delirium tremens?
11 A. Under no circumstances.
12 Q. Could you please elaborate a little and tell us the reasons why
13 you believe it could not have been delirium tremens.
14 A. In answer to your question before the break, I think I described
15 in detail the symptoms of delirium tremens as a very specific, particular,
16 conspicuous psychosis with a number of physical manifestations,
17 irritability of the vegetative neurosystem reflected in excessive
18 sweating, trembling, redness in the face, and psychologically pronounced
19 restlessness, extreme fear, and numerous hallucinations. Not just any
20 kind of hallucinations but very particular ones, that is, seeing small
21 animals crawling over one's body, and the patient keeps shaking his
22 clothing, shaking them off. Such patients also experience paraesthetic
23 hallucinations coming from the body, as if they have a hair in their
24 mouth. They keep spitting it out.
25 So I think what I've said shows that it is a very specific type of
1 psychosis and that it is not possible to be misled in establishing the
3 Q. From what you have said, I gather, Mrs. Jevtovic, that you are
4 quite certain that in this case of Mitar Vasiljevic it is not delirium
6 A. It definitely was not.
7 Q. From what you have been able to see in the documents, my question
8 is: Do you personally remember Mitar Vasiljevic as a patient?
9 A. I do not. It was ten years ago. He was not my patient, he was
10 the patient of a young doctor. I had my own patients. I had a day when I
11 was on duty all day in the outpatient's dispensary as it was July, it is
12 quite possible that I supervised the work of another young doctor or maybe
13 we all took care of all the patients at the same time, I can't remember
14 those details now.
15 Q. Mrs. Jevtovic, when you were telling us who was working with you
16 among the doctors, I notice you mention another doctor with the same first
17 name as you, Slavica?
18 A. Not at the psychiatric ward, at the neuropsychiatric ward. There
19 was a young doctor, Slavica Ivkovic, and she specialised in neurology and
20 so she was automatically attached to the neurological department so that,
21 in 1992, she was not in our ward.
22 Q. Yes, but I am asking you about your own department. So there was
23 no other lady by the name of -- lady doctor by the name of Slavica?
24 A. No.
25 MR. DOMAZET: [Interpretation] Could the witness please be shown
1 Exhibit P161, please.
2 Q. Madam, will you please look at this exhibit which was found
3 together with the other documents taken by the Prosecution and the
4 Prosecution has tendered it into evidence. So would you please carefully
5 read both pages upon which I can ask you a few questions.
6 Have you looked at both pages on both sides of the paper?
7 A. Yes.
8 Q. Could you please tell us, Madam Jevtovic, do you perhaps recognise
9 this letter? Was that a letter addressed to you and do you have any
10 recollection of that letter?
11 A. No, I don't.
12 Q. Is it rare or frequent for patients to write letters of that kind?
13 A. Patients often write to us, either making a request of some sort
14 or expressing their gratitude or sending us a verse of poetry or trying to
15 convince us that they are well and that they should go home, which is the
16 most frequent case, and that they are being held by mistake, so it's no
17 wonder that I don't remember this as it is not at all unusual for patients
18 to write letters.
19 Furthermore, from this letter, one can see that the patient still
20 has problems with his thought process. It is still confused, spread out.
21 The request he makes, and as he addressed me personally, that is -- I
22 assume that it was because, during the rounds, he must have assessed that
23 I was a doctor of some importance, more important than the young doctors,
24 and he hoped he would achieve more through me.
25 Then also, it is absolutely not necessary for anyone to write a
1 letter if they wish to have additional physical examinations. We always
2 ask them, "Are you feeling any pains?" Especially when we have serious
3 patients, we feel that we may neglect physical disease, so we always
4 inquire, and especially if he's taking neuroleptics, a patient may be
5 sleepy, so this request that he makes is quite unnecessary.
6 The second thing that is excessive, which indicates his effective
7 disorder are these threats, as far as I am able to read it - he threatens
8 to go on a hunger strike - that it is quite illogical. People are going
9 for examinations daily, to see the eye doctor, the nose doctor. If he had
10 been in good shape, he would have realised that, but obviously this was
11 written early on in the course of his treatment while he was still not
13 Also, this Serb symbol, a symbol of Serbhood, the figures on the
14 letter is just something one doesn't put all over the place, so this also
15 corroborates my opinion that this was a milder hypermanic behaviour, at
16 least, as far as this part of the letter is concerned.
17 The other things that he mentions about the purchase of sweets in
18 a shop, this also shows that he was a bit accelerated, that it was in
19 haste. He ran to the hospital lobby to make that purchase. That must
20 have been when he was in the orthopaedics department because he couldn't
21 have left our department, and in that haste, he incurred a debt. So I
22 have nothing more to say unless you have some more questions for me.
23 Q. In view of the date that you find in two places in this letter,
24 maybe you could look in the therapy sheet to see how that fits in with the
25 therapy because I think the letter was written already in the second stage
1 of his treatment. So would you check that, please, and tell us.
2 A. I noticed the date. That was the sixth day after his -- he was
3 transferred to our ward and I have noted that this was in the first stage
4 of his treatment, if it was written on the 13th, that is only after six
5 days. He was transferred on the 7th and this was on the 13th. So by that
6 time, he couldn't have considerably improved.
7 Q. Will you please look at this last sentence before his signature on
8 the second page, where he says, "I would also like to ask you to tie both
9 my hands and legs."
10 A. This may sound strange, but we hear this sometimes in our
11 department. This maniform disorder that I have described, and his
12 restlessness and -- is very tiring. Imagine as if you were on the move 24
13 hours a day, it's very tiring. And this happens to many patients. And
14 also among these -- as a result of the medicines, they have a hypnotic
15 effect which can make them drowsy, but it doesn't mean that if somebody is
16 drowsy, he is calm. The neuroleptics have their effect through brain
17 centres, they have a sedative effect and a hypnotic effect. If all these
18 things are not properly adjusted, a person can't fall asleep and sometimes
19 the patients say, "Please tie me up," and that would be my interpretation.
20 Q. Do you meet such requests of your patients when they want to be
21 tied up, or do you make your own judgement as to whether it is necessary?
22 A. Yes, we do as they ask because experience tells us that they calm
23 down, and after that, we untie them. Also, we have specially leather
24 collars lined with felt so they don't touch the skin directly. They're
25 wide, they don't cause any damage. So it's not as awful as one might
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 think, at first glance.
2 Q. Madam Jevtovic, would you please look at the discharge paper.
3 MR. DOMAZET: [Interpretation] Could I have Exhibit D30.1.
4 A. It's fine.
5 Q. In that discharge certificate, the same number of the diagnosis
6 can be found, the same code that you spoke about. I think there's also a
7 description. Will you please look at it and see whether there is
8 something additional to what we've seen in the other documents, and then I
9 will ask you a question.
10 A. The discharge certificate says all that is important taken over
11 from the case history, as far as the psychiatric condition is concerned,
12 only in summary.
13 Q. The condition that you, yourself, described as acute psychosis,
14 the condition Mitar Vasiljevic was in when he was brought to your
15 department, do you find those characteristics here, and could you tell us
16 what precedes that, that is, the period that precedes such a condition,
17 what would be the characteristics of the behaviour of such a person? Is
18 there something that has been medically established regarding conduct of
19 such a person?
20 A. His behaviour, prior to hospitalisation at the psychiatric ward,
21 as far as I can see from the case history, we have the information given
22 by the wife, which were particularly pronounced after he was called in to
23 the Territorial Defence, intensified drinking and changes in behaviour.
24 As far as the orthopaedic department is concerned, the decursus tell us
25 that the problem started on the 5th when consultation was first required.
1 As for the beginning of the psychotic disease, it can start quite suddenly
2 but that is rare. We can have reactive psychoses that start suddenly, and
3 these can start after exposure to very great stress, then also post-natal
4 psychosis, the next day after delivery, because of sudden hormonal changes
5 in the body. We've also said that delirium tremens is acute psychosis
6 which can start suddenly. And these unspecified acute psychoses cannot
7 start so suddenly. Their development can be can be monitored over several
8 weeks and even three or four months sometimes.
9 The problem is that the patient is not constantly drastically
10 changed and that is why relatives don't bring him. They would tell us,
11 you know, "We wanted to bring him in and then he was better the next day,"
12 and these things develop gradually. And then psychotic decompensation
13 occurs when reality is completely eliminated when the patient can no
14 longer control himself. We call that acute psychotic decompensation and
15 that is when hospitalisation is essential and that is the condition in
16 which they usually come. If that was your question.
17 Q. Does that mean, Madam Jevtovic, that in the prior period, there
18 were fluctuations, there were times when you can notice deviant behaviour
19 and there are times when the patient appears to be acting quite normally,
20 like any other person? Am I correctly interpreting your answer?
21 A. Yes, quite so.
22 Q. Madam Jevtovic, you mentioned reactive psychoses. Would you tell
23 us what that is.
24 A. Those are psychotic, acute psychotic conditions that occur
25 immediately after exposure to a stressful situation. This is a kind of
1 psychosis that can break out immediately or the very day or the following
2 day after the stressful event.
3 Q. For such a stressful event, a stress of greater proportions is
5 A. Yes, it is described as an extremely stressful situation.
6 Q. Could that be the death of a close relative?
7 A. Yes, certainly, it could.
8 Q. And could it be attending the killing of several persons or the
9 murder of several people and witnessing such an act? Could that be
10 considered a sufficiently stressful situation for a person who never
11 witnessed any such thing before?
12 A. I said that reactive psychotic conditions occur quite abruptly,
13 shortly after exposure to stress, but stress can trigger earlier
14 conditions which were about to explode. For example, in alcoholics,
15 people who genetically were prone to act psychotically, then we needed a
16 trigger for the process to be set in motion. Then it wouldn't be reactive
17 psychosis but psychotic reactions when already there was preparation for
18 such reaction, alcoholism or genetic, the genetic factor when younger
19 people develop some hereditary diseases. Psychiatrists acknowledge this
20 as an important etiological factor.
21 Q. In view of the fact that the condition of acute psychosis that he
22 manifested, one of the symptoms being incomprehensible speech, out of
23 context, is it possible that in the period prior to that period, similar
24 such occurrences may be seen such as illogical speech?
25 A. Yes, that is possible, only milder in intensity and shorter in
1 duration, and so people ignored it without attaching too much importance
2 to it.
3 Q. If in such situations there were to be excessive consumption of
4 alcohol, would that increase the possibility?
5 A. All those etiological factors build on one another and increase
6 the intensity of the disorder in the event of excessive alcoholism.
7 Q. Perhaps -- could one say that in such a state, people are prone to
8 exaggerate things, to overestimate one's self and what one is doing? Could
9 that also be a manifestation of this disorder?
10 A. In answer to this question, two possibilities exist or a
11 combination of the two. A pre-morbid personality, which means a person
12 prior to the outbreak of the disease, these things can have an important
13 role. There are people that are histrionic, who attach too much
14 significance to themselves, who expose themselves, who wish to draw
15 attention to themselves, and within the maniform disorder that we have
16 been discussing in his behaviour, this, too, could have an effect. These
17 maniform psychotic patients have intensified reactions, intensified action
18 in everything; they are hyper, they interfere everywhere, they have an
19 opinion on everything, they stand out everywhere.
20 Q. Thank you. Such persons, can they be influenced more easily than
21 others because of this condition of theirs in this particular respect?
22 A. Not literally, but the overall situation, if a patient is in the
23 midst of certain extraordinary events or activities, gatherings, he may
24 easily join in even if he is not invited to do so. I don't know if I make
25 myself clear. He has no breaks. He doesn't have sufficient control to
1 set himself limits. He is literally prone to being influenced.
2 Q. In such a case, if we were talking of some unlawful activity,
3 could we talk about reduced competence because of this condition?
4 A. I don't think competence can be assessed in a general way. In
5 order to evaluate competence, very strict rules are required; the time of
6 the act, the type of the act, statements of witnesses, detailed
7 statements, a serious interview with the patient, if he is capable of
8 interpreting his experiences. So the question of competence is not raised
9 in clinical work, these are legal matters and legal categories. It is a
10 highly specific undertaking and I'm afraid you can't assess it just like
12 Q. Thank you. I should just like to go back to one point that we
13 discussed but I didn't actually ask you this question. When you spoke
14 about the information that you seek from each patient or family member,
15 and you told us what the important points to focus on are, do you ask for
16 information about previous hospitalisation for some disorder that could be
17 linked to the patient and why he was brought into hospital?
18 A. Well, we've already spoken about that. We said that one of the
19 first questions is that we ask him whether he was treated for a mental
20 illness of any kind. In the case history, it was noted that he had been
21 treated for alcoholism.
22 Q. Is it necessary to record this and was this checked out in this
23 concrete case, judging on the case history you have before you?
24 A. Usually we ask for the discharge sheet to have a look at it, and
25 the family members bring this in. If the discharge sheet is lost, then we
1 look for the patient card where a copy of the discharge sheet should
2 exist, and if that is lost, then in the card or file, we see what the
3 general practitioner says, and all instances of hospitalisation have been
4 -- were recorded. But in cases like this one, it was probably
5 unsuccessful, a futile attempt because it was war, it was a period of war;
6 communications were very poor, it was difficult to travel, and between
7 Visegrad and Uzice, there was the front, the war line. And you couldn't
8 cross that line whenever you wanted to unless you had special permits and
9 so on and so forth, so it was war.
10 Q. Yes. I am aware of that. But if you were told that in 1984, the
11 patient was treated for alcoholism in your hospital in Uzice twice, would
12 that have been recorded and would you have been able to get at the case
13 history when he came, was admitted to your department, had you had that
14 piece of information, had you known that at the time?
15 A. This information of previous hospitalisation was given to the
16 patient by the patient to his doctor during the first interview, but he
17 said he was hospitalised three times. I said in acute cases, the
18 anamnesis are not -- that you get from a patient is not always valid and
19 so perhaps the doctor didn't look for those case histories precisely
20 because of that. But when the wife came and she was able to confirm that,
21 he was taken home that day, so once again, there was no time to do that.
22 But I have explained several times in explaining the diagnosis that the
23 question of alcoholism was discussed here and that it was one of the
24 factors that made us class this into a nondifferentiated psychosis, which
25 would include an alcoholic nonspecific psychosis as well, alcohol-related.
1 MR. DOMAZET: [Interpretation] Thank you, Mrs. Jevtovic, I have no
2 further questions for you.
3 JUDGE HUNT: Cross-examination, Mr. Groome.
4 MR. GROOME: Thank you, Your Honour.
5 Cross-examined by Mr. Groome:
6 Q. Good afternoon, Madam Jevtovic, my name is Dermot Groome and I
7 will be asking you a few questions on behalf of the Prosecution.
8 A. Good afternoon.
9 Q. I just want to clarify a few matters that you discussed in your
10 testimony. You said that you have no specific memory of Mr. Vasiljevic;
11 is that correct?
12 A. That's correct, yes.
13 Q. Can I take it from that that you don't have any specific memory
14 regarding how much direct contact that you may have had with Mr.
16 A. I can't remember exactly, but the principle of my work is to have
17 continuous contact and this is a continuous principle so there is no
18 reason why I shouldn't have the same amount of contacts with him. The
19 number of contacts depends on the type of disorder that the patient is
20 suffering from. Some patients with mental illnesses which lead them to
21 have some ideas, we have crazy ideas we have more need to see them. For
22 us, it was not as interesting that way; we didn't get any contents and
23 substance from him, we just saw that he was very agitated and we had to
24 follow that condition of agitation to see how it would develop.
25 Q. Now, in your testimony you used the word "differential diagnoses."
1 Can you please explain what you mean by "differential diagnoses."
2 A. To examine the patient clinically, when you draw the conclusion on
3 the basis of heteroanamnesis interview and clinical examination and
4 possibly an additional psychological testing and all the other tests that
5 I mentioned, it is customary that older doctors too should give thought to
6 what the disease could be with all this kind of symptomatology. We use
7 that when we have young doctors in training; we give them food for
8 thought. We can combine these systems and there is no clear-cut form or
9 clear-cut things. Symptoms can be a disruption of physical symptoms but
10 whether he is more affective or whether his personality is disintegrated ,
11 or his system of thinking, there's a dilemma; you have to weigh it all
12 up. And there is a group of psychoses which are called schizophrenic
13 psychoses, for example, or paranoid schizophrenic psychoses. It can lead
14 us astray to begin with. We might think it's paranoid psychosis, pure
15 paranoid psychosis because the symptoms are at the same, particularly in
16 the beginning at the initial stages, so that too is a subject for
17 discussion and differential diagnostics, as we call it.
18 Q. Now you've touched upon, in that last answer, about a clinical
19 examination, and there were a few questions I wanted to ask you about
20 that. Given that you were supervising young doctors at the time, was
21 there a standard battery or protocol of tests or steps that you expected
22 the doctors working under you to take when they conducted a clinical
23 examination of a new patient on your ward?
24 A. To conduct a psychiatric examination, that is standardised. There
25 are methods to test each psychological function and each psychological
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 function must be recorded. The examination begins with the description of
2 the patient's appearance. Young doctors are taught that patients must be
3 looked at clinically even before he comes to the department, for example.
4 If he has been brought in handcuffed, for example, if he has come in
5 dirty, unkempt, if he is without shoes and it's winter. All that is --
6 demands our full attention because it is the way we assess and appraise
7 the condition of the patient, so this entire protocol of examination must
8 be recorded and we must see that a young doctor has looked into all this.
9 There is a small intelligence test as well and the clinician is
10 duty-bound to apply this IQ because intellectual testing is done by
11 psychologists because they have international tests, but our clinical
12 appraisal includes that too. So -- and then we have standardised
13 questionnaires, for example, for certain symptoms of a disease. For
14 depression, for example, there are several tests for depression. One of
15 them is Hamilton's scale for depression where this is expressed
16 numerically, and you can look at Hamilton's scale, you can see the degree
17 of depressiveness. So if two scales coincide with a high coefficient of
18 depressiveness, that means that that psychopathological disorder is a
19 depressive one. Then you have one for fear, for anxiety. There are lots
20 and lots of tests to determine anxiety.
21 So there is the possibility of objectivising a young doctor's
22 work. I don't have to stand over him all the time, he brings it to me or
23 we go through it verbally, orally, because you have seen the number of
24 doctors that were working in the hospital at the time. I know the
25 importance of documents. I go to court and a nice case history is an
1 enormous help to me but, quite honestly, under the circumstances in those
2 conditions, it was not always possible to do these things, which doesn't
3 mean that we didn't discuss them orally.
4 Q. Well, you've mentioned at least four tests just now; appearance, a
5 test for intelligence, certain questions such as the Hamilton's scale, and
6 certain queries made for the level of anxiety. Are there other tests that
7 you would expect a doctor working under you to check into when they do a
8 clinical examination of a new patient? And if you could just list them
9 and I will maybe ask you to explain a few of them afterwards.
10 A. I mentioned that there is an order in which we test psychological
11 functions and that is a type of psychiatric examination that you learn at
12 school; verbal contact, his appearance, his thinking, his affective
13 response, intelligence. It is all standard. Critic -- his able -- his
14 ability to have a critical appraisal and so on, so that is what the young
15 doctor reports to me on. Not all these functions need be impaired but we
16 have to take them in their order to see where the prevalent disturbance
17 and disorder occurs and then we'll move in that direction and sound out
18 the patient further.
19 Q. Would you agree with me that, in order for you to properly
20 supervise a patient - for example, to decide that a suggested therapy is
21 the proper one - that you really need to have this assessment done and
22 presented to you; is that correct?
23 A. Of course, but I have daily insight into the therapy, how far the
24 therapy is being tolerated. Those are things that we can do externally.
25 We can't determine the level of neuroleptics in the blood, for example.
1 In developed countries, this is done, but it is a laboratory experimental
2 finding but not used in daily practice. There is only one neuroleptic
3 whose level we set on a daily basis and that is Lithium, and we do that
4 regularly, in the frequency that is necessary and depending how long the
5 patient has taken these neuroleptics, but externally, through the clinical
6 impression, how much he has been sedated, how much his condition has
7 improved, how somnolent he is. I said that neuroleptics, earlier on, or
8 anti-psychotics are very unpleasant for the patient, they have unpleasant
9 effects on certain parts of the brain and, therefore, create side effects
10 or neuroleptic syndromes which are visible. The patient has enormous
11 salivation, he is rigid, his face appears rigid, he can have very
12 unpleasant contraction of the muscles, muscular contraction, and his spine
13 might contract, very bizarre positions and poses which are painful, so you
14 can see all this, can you observe it in a patient.
15 Q. Now, Doctor, you said the patient was seen on the daily rounds and
16 you said that three people see the patient; the head nurse, the
17 psychologist, and the working therapist. Could I ask you; Dr. Simic, was
18 he the psychologist or the working therapist in this case?
19 A. Dr. Simic was a young doctor who was being trained from the
20 beginning. Our young doctors are employed in a targeted fashion, he is
21 educated in one stream, but it takes a long time for the ministry of
22 health to authorise a specialist training for a doctor and to wait for
23 this status to be authorised, he is what we call a secondary doctor but
24 doing practically the same work so we know that he is going to be one of
25 our doctors ultimately, we don't wait for him to receive authorisation, he
1 starts this process straight away.
2 Q. Doctor, let me ask you; who would have been the psychologist who
3 would have seen Mr. Vasiljevic on a daily round? Who would that person
4 have been?
5 A. In our service, we have two psychologists who have graduated from
6 the faculty of psychology. They do psychological testing, diagnostics,
7 psycho-social support for the family and they are regularly employed in
8 the department.
9 Q. Can you tell from the records before you which -- what was the
10 name of the psychologist who saw Mr. Vasiljevic on a daily basis?
11 A. With an acute psychotic disorder, that has nothing to do with the
12 psychologist. Psychologist uses healthy parts of a personality to pull
13 the patient out of his disorder. Acute psychosis, acute psychotic
14 processes excludes patients from reality as a whole so that, for that
15 domain, for that type of illness, a psychologist is no good to you. It is
16 only when the condition is improved and when a patient's condition has
17 improved, can we go on to do psychological testing to assess personality
18 to see how far we have come in our treatment, although that is
19 clinical. The psychologist has quite a different role to play.
20 Q. Now, the working therapist, who can you tell us what would be the
21 name of the working therapist that would have seen Mr. Vasiljevic on the
22 daily round?
23 A. A working therapist visits the patients to get to know them and
24 for the patients to get to know the technicians so that when he starts his
25 working therapy it is not somebody they don't know, but they don't go to
1 working therapy straight away. A person goes to attend working therapy
2 when the therapist believes that he has the patience to --
3 JUDGE HUNT: Doctor, please, let's just answer the question.
4 If you know, say so. If you don't know, say so. You weren't asked to
5 describe what happened. What was the therapist?
6 MR. GROOME:
7 Q. Was there a working therapist working with Mr. Vasiljevic, if you
9 A. No.
10 Q. Now, you talked about, in addition to the daily rounds, that there
11 being a -- I think you described them as being official talks in the
12 doctor's office, and you described this as the place where some of the
13 most sensitive material or subject matter was discussed with a patient; is
14 that correct?
15 A. Yes.
16 Q. Now, would the occurrence of such an office visit or office talk,
17 would that be recorded in the medical history somewhere?
18 A. They are recorded if they are substantive. We mentioned the
19 disorders where there are massive ideas, crazy ideas, hallucinations and
20 so on, but this is a psychosis which was manifest only in agitation. He
21 didn't have anything to tell the doctor. He just demonstrated his
22 agitation and restlessness, his acceleration, his hyper mood.
23 Q. Doctor, from the fact that there are no such official talks or
24 visits to the doctor's office recorded here, can we conclude from that
25 that either Mr. Vasiljevic had no talks within the doctor's office or, as
1 you suggest now, there was nothing substantive that was discussed in
2 those visits?
3 A. We have a decursus morbi on the 8th of July and the 15th of July
4 and also on the 28th of July.
5 Q. Would that indicate that on those two dates there had been office
6 visits that -- your office visits that you described?
7 A. May I read you the decursus of the 15th of July?
8 Q. Actually, Doctor, that's in evidence, and we've heard it many
9 times now. If you would just answer my question.
10 Does that indicate to you that -- that note there, does it
11 indicate to you that there was this visit or this discussion with
12 Mr. Vasiljevic inside the doctor's office?
13 A. The decursus shows this because the doctor describes his manner of
14 speech. The doctor describes his conduct and way of talking. This is
15 done on the 15th of July.
16 Q. Now, Doctor, I want to ask you to just clarify what you said in
17 response to a question by Mr. Domazet. I believe you stated that the last
18 line in that letter from Mr. Vasiljevic to you that's P161, the last
19 letter where Mr. Vasiljevic requests to be tied up, you said that such a
20 request could quite possibly be the result of the medications that he was
21 on; is that correct?
22 A. Not the medication, the basic disorder, the basic disorder, that
23 is, that therapy had not still reached its goal of recovery.
24 Q. But you had mentioned, I believe, that these neuroleptics have a
25 number of side effects and one of them was this amount of hyperactivity;
1 is that correct?
2 A. Not hyperactivity. Hyperactivity is a symptom of the disease.
3 The neuroleptic syndrome is with muscular rigidity, salivation. And due
4 to the muscular rigidity, the patient assumes bizarre positions, and his
5 body is constricted when the paravertebral muscles are constricted and it
6 is very painful but we deal with this symptom with additional therapy.
7 According to this therapy, Vasiljevic did not have neuroleptic
8 disturbances. Had he had them, he would have been given Artan or Procipar
9 which deal with that. We can't work without neuroleptics, of course, but
10 there are medicines which can deal with these side effects. And if we see
11 that the patient is in a bad condition, we give him an intravenous drip,
12 deal with that situation, make a small pause, and then go ahead and
14 Q. Doctor, let me ask you about the delirium tremens. I believe what
15 you've told us is that the symptoms of delirium tremens are very obvious
16 symptoms; is that correct? There's no need to repeat them all but just
17 that they are very obvious symptoms; is that correct?
18 A. Yes, completely.
19 Q. And would I be correct in thinking that any trained doctor, not
20 a -- a doctor wouldn't have to necessarily be a neuropsychiatrist to
21 recognise them? Any competent doctor would recognise the symptoms of
22 delirium tremens; correct?
23 A. Well, my experience tells me that not every doctor would. Very
24 frequently, they call abstinence delirium tremens, ordinary abstinence,
25 and every kind of restlessness, inadequate, inappropriate behaviour. They
1 tend to use the term loosely and say he's entered into a delirium. And we
2 see that there are no signs of delirium and then seek another explanation.
3 Q. Is the word "delirium" sometimes used as an abbreviated way of
4 saying "delirium tremens," as I believe you just did in your last answer?
5 Is that a common way to use the word "delirium," as an abbreviation for
6 "delirium tremens"?
7 A. No, "delirium tremens" is a set category, and "delirium" itself,
8 on its own, is the state of disturbance in the conscious, disturbance of
9 orientation, which is disturbance and disorder of consciousness.
10 Q. Is it possible that somebody on sedatives, that the sedatives
11 would mask the symptoms of the delirium tremens?
12 A. They can mask them if they are administered in high doses and can
13 even -- it is treated not with neuroleptics but with other types of
14 benzidines, zepin [phoen], epinephrine, other types of drugs. Rarely
15 neuroleptics. And if you have to, then for very brief periods of time.
16 There is a specific haloperidol anti-psychotic which affects the
17 hallucinations. It attacks the hallucination syndrome. So only in that
19 Q. Doctor, can I draw your attention to the case history, P138, and
20 the note from the 5th of July from Dr. Stojkovic. And the portion of the
21 note that I'm interested in discussing with you is the portion where
22 Dr. Stojkovic says: "The patient shows signs of a stage preceding
23 delirium. He has not been taking the prescribed sedatives for days."
24 In that context, is it possible that what Dr. Stojkovic is
25 describing is his observation of Mr. Vasiljevic entering into the delirium
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
2 A. There is the precise qualification here that I said pre-deliriant
3 state. It doesn't say "deliriant," it says "pre-deliriant," which means
4 changes in a behaviour which they were not able to qualify, which was, in
5 fact, this psychosis, agitation, restlessness, uncontrolled behaviour,
6 disobedience. But "pre-deliriant" means nothing. He is either deliriant
7 or he isn't.
8 Q. Now, you were asked a number of questions regarding reactive
9 psychoses, and you've stated that that could start suddenly immediately
10 after a high-stress situation; correct?
11 A. Yes.
12 Q. And one of the examples that was used was that if somebody had
13 witnessed a number of people being killed, that be a precipitating event
14 for reactive psychoses; correct?
15 A. It could unleash that, yes, precipitate it.
16 Q. Now, isn't it equally possible that it could be precipitated --
17 such a reactive psychoses could be precipitated, let's say in the case of
18 a man who, getting very drunk and upset, killed members of his family.
19 Couldn't that be the kind of situation that when he sobers up and
20 confronts having done that act, couldn't that be a precipitating event for
21 reactive psychoses?
22 A. We said that the effects of alcohol on the mental functioning,
23 especially of individuals who have a certain predisposition in the
24 central nervous system towards that type of reaction which had it not been
25 for that alcohol, would never have entered into a state of psychosis. And
1 as far as your question is concerned, including reactions to a stress
2 situation, I don't think I quite understood you, the last portion of what
3 you said. I'm not quite clear on that.
4 Q. I apologise. I think I complicated it with the alcohol. Let's
5 just say that a man becomes enraged, kills his wife, and when he calms
6 down and realises the terrible thing he did, could that not be the kind of
7 high-stress incident that could push that man into having reactive
9 A. The newspapers are full of such cases. Do you know how many
10 drunken husbands kill their wives, in our country, or in-laws, and then
11 sometimes take their own lives as a result too? Alcohol sets into motion
12 the worst in human beings. If there is a predisposition, either in the
13 structure of the personality or some genetic predisposition, then alcohol
14 is the drop that tips the scale, and if he is aggressive and an explosive
15 personality, then that will be one more superimposed element.
16 Q. So would you agree with me that an overpowering sense of guilt of
17 having done something very horrible would be something that could
18 precipitate somebody's decline into psychoses?
19 A. He would enter into a state of depressive psychosis. The feeling
20 of guilt and depression go hand in hand. The feeling of guilt is a
21 symptom of depression, one of the symptoms of it.
22 Q. Now, if a patient in the past has suffered a psychiatric or -- a
23 psychiatric event or had psychiatric problems every time he has previously
24 withdrawn from alcohol, is it possible for him to withdraw from alcohol
25 and not have a similar psychiatric event?
1 A. There is less possibility that it is recurrent, but the
2 possibility exists. If he abstains from alcohol, the possibility of that
3 happening is lower.
4 Q. Now, Mr. Domazet asked you a few questions regarding competence
5 and my question to you is, you said that, in order to make a determination
6 on competence, you would need a very thorough interview of the person who
7 was charged with the crime as well as know, in great detail, the
8 circumstances surrounding the crime; is that correct?
9 A. Yes. And ...
10 Q. One of the questions you would ask -- or would you explore the
11 person's state of mind or their own assessment of their state of mind at
12 the time of the crime; is that one of the areas that you would explore?
13 A. The difference is in the validity of the statements of the
14 perpetrators immediately after the act he committed and much later, on the
15 condition that he has treated and has recovered and that he is capable of
16 providing valid information and interpreting the event properly that is
17 what it was that spurred him on to commit the act because his statement
18 immediately after is one thing. I know a drastic case. A young man cut
19 up his girlfriend because she had poisoned herself with food. The whole
20 procedure was respected. Many years later, he was treated regularly. He
21 had a far more critical attitude towards it because he disassociated
22 himself from that because he realised that he was sick, and in paranoid
23 psychosis, this can be achieved through treatment because they are not
24 deteriorated intellectually, the personality is not disintegrated to the
25 same extent as in schizophrenia and, after prolonged therapy, they are
1 able to interpret what they thought then, what they felt and what they
2 did, if it is successful.
3 Q. I want to put to you a question and answer, a question put to Mr.
4 Vasiljevic and an answer that he gave. And so you have some understanding
5 of when this question was asked of him, it was asked about a year ago
6 under a time that we're not aware he was suffering any type of
7 psychological disorder. And then I want to ask you a question
8 afterwards. The question was:
9 Q. Okay. What I am interested now is at the time of the
10 incident by the river, was your mental state -- were you
11 having any kind of mental problems or psychiatric problems at
12 that time?
13 The answer Mr. Vasiljevic gave was:
14 No, I had problems after that incident, especially since
15 a colleague of mine was killed there.
16 Now, how much weight can we put on Mr. Vasiljevic's own assessment
17 that he was not suffering a psychological disorder at the time of this
18 incident which occurred at a river and it was a crime, that was a
19 reference to a crime? How much weight can we put on his own assessment
20 that he was not suffering from a psychological disorder?
21 A. I would be able to give you a more correct answer if at the time
22 he gave you that statement he was examined by a psychiatrist who would be
23 able to assess his condition at the time and the validity of his statement
24 at the time.
25 Q. Unfortunately, we don't have that information. All I can provide
1 you with is that we were not aware of any psychological disorder at that
2 time. Can I ask you: Are you able to tell us how much weight we can put
3 in this statement, assuming that there were no obvious manifestations of a
4 psychological disorder present at the time he made that statement?
5 A. It depends who said that there were no manifestations of disease.
6 I have to know a lot in order to be able to judge somebody's competence
7 and degree of responsibility.
8 Q. Doctor, let me ask you, for the purposes of this question, if you
9 would assume that there was no psychological disorder present at the time
10 the statement was made. Can I ask you to make that assumption and then
11 tell us can we not put some weight in his own assessment that, at the time
12 of a crime, he was not suffering from a psychological disorder?
13 A. These are highly hypothetical statements. On that basis, it is
14 not possible to make any conclusions about somebody's mental condition and
15 especially not on the degree of his competence. I am very sorry but I am
16 unable to make -- give you an opinion on that.
17 Q. Okay. Thank you, Doctor.
18 MR. GROOME: No further questions.
19 JUDGE HUNT: Re-examination?
20 MR. DOMAZET: [Interpretation] Yes, Your Honour.
21 Re-examined by Mr. Domazet:
22 Q. If I understood well Mr. Groome's question on page 90, row 14, it
23 appears that Mitar Vasiljevic, when asked about his mental state at the
24 time of the incident by the river, said that, at the time, he wasn't
25 having any problems but that, after that, he did, "Because a colleague of
1 mine was killed," it says. And as we're referring to that incident, is it
2 possible if he was present at such an event when, before his very eyes,
3 among others, a colleague of his is executed and, as he said, a good
4 friend of his, would that be the kind of situation that could trigger this
5 reactive psychosis?
6 A. I have said several times all the things that can provoke a
7 reactive psychosis; various extremely stressful situations, especially if
8 there is a predisposition on the part of the nervous system to react in
9 this way. And we already have one element, that is alcoholism, which
10 could have contributed to his instability as a personality and to find it
11 difficult to accept loss and exposure to stress.
12 Q. Thank you. In answer to a question from Mr. Groome about the
13 daily rounds by doctors of all patients, I think it wasn't quite clear in
14 what you said who made those rounds because it follows from Mr. Groome's
15 statement that, in addition to the head nurse, there was a psychologist
16 and a social worker, and indeed that is what you said. But to make things
17 quite clear for me and all of us, could you please repeat who were all the
18 people who made the morning rounds of patients?
19 A. Specialist doctors, young doctors in training, the head of the
20 department when that was planned, the main psychologist, and a work
21 therapist if we had one. These are persons who regularly attend the
22 morning rounds.
23 Q. So in addition to the psychologist and possibly this work
24 therapist, all the doctors with the exception of the head of department.
25 A. Yes.
1 Q. And then you make your rounds from one patient to another?
2 A. Yes, literally so.
3 Q. So in that case, it doesn't matter whether a patient needs a
4 psychologist, a work therapist, or whatever?
5 A. I have said that the team makes these rounds according to needs.
6 The work therapist goes to meet the patient so that when he goes for work
7 therapy, he will know him. Then also, the therapy sheets are checked and
8 therapy prescribed for that day. We carry them with us, they're not on
9 the beds, for understandable reasons; so that the patient shouldn't
10 scribble anything on them.
11 Q. In the course of your round, do you already agree on therapy or do
12 you not do that in front of the patient but later?
13 A. The therapy is written down on the sheet immediately. The
14 assessments are made on the basis of the reports of the second and third
15 shifts and the doctor on duty the previous day. We have to hear what
16 happened to the patient from the time we left at 1.00 p.m. until the next
17 day in the morning, and what other therapy he was given, and then in the
18 morning, we prescribe the therapy for that day. This need not be the same
19 therapy throughout the day, it may change in the course of the day.
20 We don't have discussions in front of the patient, but we fill in
21 those therapy sheets and there is a special folder for each room and we
22 hand it over to the main nurse and she passes it on to the nurses, who
23 administer the therapy.
24 Q. In answer to a question from Mr. Groome as to whether the work
25 therapist had worked with Mitar Vasiljevic, you said no. My question is:
1 How do you know that and why there was no work therapy. Was there some
3 A. I didn't have time to give the Prosecutor a full answer. At the
4 time, we didn't have a work therapist, we got one much later in 1994,
5 maybe 1995, and this was 1992. But even if we had, Mitar Vasiljevic could
6 not have gone to work therapy. He was not in a condition to attend work
7 therapy during his hospitalisation.
8 MR. DOMAZET: [Interpretation] Thank you. I have no further
10 JUDGE HUNT: Thank you, Dr. Jevtovic, very much for coming to give
11 evidence and for the evidence which you have given. You are now free to
13 [The witness withdrew]
14 JUDGE HUNT: Yes, Mr. Groome.
15 MR. GROOME: Your Honour, while we're waiting for the next
16 witness, after examining the ledgers, the Prosecution will only be seeking
17 to have the pages that were in the initial application D26 analysed by a
18 document examiner, so I just wanted to update the Court on that.
19 JUDGE HUNT: What about the other books?
20 MR. GROOME: The other books, we will not be seeking to conduct
21 examinations on. And with respect to the expert report filed yesterday on
22 the legal expertise, the Prosecution will not be seeking to cross-examine
23 that witness.
24 JUDGE HUNT: Thank you very much. Well, we'll need to get those
25 books back so that somebody down in the registry can start photocopying
12 Blank page inserted to ensure pagination corresponds between the French and
13 English transcripts.
1 them. Well, we will not need the original books now other than D26; is
2 that right?
3 MR. GROOME: Yes, Your Honour.
4 JUDGE HUNT: Well, Mr. Domazet, maybe if you nominate which pages
5 of the other two books you want copied, the books themselves can go home,
6 back to Uzice, and only D26 will need to be kept and that's the one you've
7 already copied, isn't it, D26?
8 MR. DOMAZET: [Interpretation] Yes.
9 MR. GROOME: Actually, Your Honour, perhaps I wasn't clear.
10 Although I'm not seeking to have these books examined by a document
11 examiner, there is some important information that I think will be
12 relevant in the Court's determination of these issues so I would ask that,
13 to the conclusion of the trial, that they do be kept.
14 JUDGE HUNT: All right, well, then that makes it clear. We'll
15 have to get a copy made so that it can go back to the hospital.
16 [The witness entered court]
17 JUDGE HUNT: Doctor, will you now make the solemn declaration that
18 is in the document that the usher is showing you there.
19 THE WITNESS: I solemnly declare that I will speak the truth, the
20 whole truth, and nothing but the truth.
21 WITNESS: Ivan Jovanovic
22 [Witness answered through interpreter]
23 JUDGE HUNT: Sit down, please.
24 Yes, Mr. Domazet.
25 MR. DOMAZET: Thank you, Your Honour.
1 Examined by Mr. Domazet:
2 Q. [Interpretation] Mr. Jovanovic, good afternoon.
3 A. Good afternoon.
4 Q. Mr. Jovanovic, on behalf of the Defence, I will be examining you
5 today and asking you some questions. Please answer my questions but after
6 waiting for a few moments, and also, you can follow on the monitor when
7 the court reporters have completed the transcription since we speak the
8 same language and it is more difficult for the interpreters to keep up
9 with us.
10 Dr. Jovanovic, will you please introduce yourself; tell us your
11 first and last name, the date and place of birth and where you are living
13 A. My name is Ivan Jovanovic. I am 40 years old. I was born in
14 Arilje, where I still live, and I am working at the general hospital in
15 Uzice. I've been working there since 1989.
16 Q. You are working in which department of the general hospital at
18 A. Since the 23rd of January, 1989, I have been working at the
19 orthopaedics and traumatology department of the general hospital in Uzice.
20 And I was granted a specialisation course in that hospital on the 12th of
21 April and I completed those studies on the 12th of October, 1994. And
22 since then, I have been working independently as an orthopaedic surgeon, a
23 specialist for traumatology and orthopaedic surgery.
24 Q. All this time, Mr. Jovanovic, as you have told us, you have spent
25 at the orthopaedics department of the hospital in Uzice; did I understand
1 you correctly?
2 A. The only interruption I had from September 1992 until 1994 because
3 I had to do part of my specialisation course in Belgrade. Also, from June
4 1995, for six months I was in the United States and those are the only
5 interruptions that I have had.
6 Q. Mr. Jovanovic, I am particularly interested in the period when you
7 were working in 1992. And you told us that you were working in the
8 orthopaedics ward until September of that year; is that right?
9 A. Yes.
10 Q. Would you be kind enough to try and look back to that period and
11 the period immediately preceding and after it and tell us, if you can, in
12 those days, that is, sometime in mid-1992, what post you held and who was
13 working with you in the department.
14 A. At that time, I had the status of a doctor on specialist
15 training. With me at the department in the same status was Nada Gordic,
16 Dr. Miroslav Jevtic, and already specialists, as qualified specialists,
17 Dr. Stanisavljevic; Dr. Milosavljevic, who is now retired; Dr. Jovicevic;
18 Dr. Stojkovic; Dr. Moljevic; and Dr. Stojanovic. He left the hospital
19 around about then, so I'm not quite sure whether he was there that very
20 month or not.
21 Q. Do you remember anything in particular concerning that period as
22 compared to any other period? Was something different in this period of
23 time that I asked you about?
24 A. The period was characterised by a great deal of work that we had
25 primarily because of wartime traumas, and as a department, we were
1 overcrowded. There was a very large influx of patients. I think that was
2 the most characteristic trait of that period.
3 Q. When you said, Mr. Jovanovic, that one of the characteristics of
4 the period, in addition to a large number of patients, was the state of
5 war, what state of war are you referring to or, rather, where was such a
6 state of war in existence?
7 A. When I say that, I mean exclusively the situation in Bosnia, the
8 events on the left bank of the Drina River from which the injured arrived
9 whom we called the injured from the war zone, loosely speaking, without
10 entering into the details as to how those injuries occurred.
11 Q. Do you remember, Dr. Jovanovic, whether you had the wounded or
12 patients coming from that area of Bosnia and Herzegovina belonging to both
13 ethnic groups, that's Serbs and Muslims, or only one ethnic group? Can
14 you remember that?
15 A. I remember in particular the atmosphere that prevailed during
16 those days, months, and weeks. I remember the atmosphere more than I do
17 faces and names. I remember, and I remember the specific nature of war
18 injuries. And this is unique for one's experience. In my field, you
19 couldn't get such experience anywhere else. So in answer to your
20 question, I remember very well that at first, we had patients belonging to
21 all the ethnic groups, I mean both Christians and Muslims.
22 Q. In view of the fact that a few years prior to that you had
23 started working, Dr. Jovanovic, do you remember that in the period prior
24 to the state of war, as you described it, did you, in those days, also
25 have patients coming from that part of Eastern Bosnia who came to Uzice
1 for hospitalisation or treatment as outpatients? Was this commonplace in
2 the previous period as well?
3 A. The hospital I work in is a regional hospital in Yugoslavia. It
4 covers 500.000 patients, of which 150.000 are from the border area of
5 Bosnia, and it was quite customary before the events in Bosnia, during the
6 events, and even today. And let me add in passing that to this day I have
7 quite a number of patients that I have operated on who are of Muslim
8 faith, and three of them are waiting for me to return from The Hague to be
10 I specialise in, or, rather, my greatest interest is in hip
11 replacement, and at least a third of those patients are of Muslim faith.
12 JUDGE HUNT: It's time.
13 MR. DOMAZET: Yes. Yes.
14 JUDGE HUNT: I'm sorry, Doctor, but we have to adjourn now. We
15 will resume again at 9.30 in the morning.
16 --- Whereupon the hearing adjourned
17 at 4.00 p.m., to be reconvened on Friday
18 the 30th day of November, 2001, at
19 9.30 a.m.