As the family of Slobodan Milosevic, the former Yugoslav leader, and the United Nations war crimes tribunal in The Hague spar over whether his death in prison on March 11 was avoidable, medical information released on May 31 provided new details about his death, his ailments and his stormy relationship with his court-appointed doctors.
The Milosevic family contends that his medical treatment in detention was inadequate. The court, in an internal review released last week, concluded that its doctors had delivered "proper care" and that Mr. Milosevic was an uncooperative patient.
But the new information suggests that there were a number of times when either Mr. Milosevic or the court could have done things differently, possibly altering the course of his illness.
Much of the court's report documents a turbulent, distrustful relationship between Mr. Milosevic and the detention center's officials, which almost certainly affected his care.
He sometimes refused to take pills, or took doses that had been dictated by doctors consulted by telephone, the report says. Visitors sometimes brought unapproved medicines and alcohol into his cell.
The report says he secretly took rifampicin, a tuberculosis drug that would have blunted the effect of medicine he took for high blood pressure. Rifampicin was found in a blood test in January. Mr. Milosevic denied taking it and said that someone was trying to kill him.
On the last day of Mr. Milosevic's life, prison guards who unlocked his cell initially decided not to examine him when he failed to move or respond to their greeting. It was only after an hour that that they decided to inspect him more closely and discovered that he had no pulse, the report said, raising a question of whether he could have been revived.
The court and Mr. Milosevic spent the months before his death wrangling over where he should get a cardiac work-up, with the result that it never occurred. He refused hospitalization for important cardiac testing at least once and possibly on other occasions.
"If he had been in a monitored setting on March 11, he certainly wouldn't have died," said Patrick Barriott, a French doctor and longtime friend of Mr. Milosevic.
Twice in his last six months, Mr. Milosevic petitioned the court to be sent for urgent treatment in Moscow — he refused to be treated in a NATO country. The last petition was on March 2.
Noting that the tests could be performed in the Netherlands, the court rejected the first petition. An appeal was pending when he died.
In its internal review, the court, the International War Crimes Tribunal, said, "In these circumstances it cannot be concluded that there was a failure to provide proper care."
Still, the report acknowledged that some of the detention center's systems for monitoring Mr. Milosevic's health had been inadequate. It cited opinions from prominent doctors that additional tests and procedures should have been performed.
April 5, a Russian cardiac surgeon, Leo Bokeria, wrote to the court that Mr. Milosevic "could have been treated easily at any place of the world" with a minimally invasive procedure in which a tube is used to open an artery.
On the other hand, René Tavernier, a cardiologist from Belgium who reviewed the case for the court, concluded, "There is no test that if carried out would have helped detect or prevent the cause of death."
In either case, it is clear from the documents that Mr. Milosevic was a sometimes difficult patient who defied doctors' orders.
Zdravko Mijailovic, who treated Mr. Milosevic at the military hospital in Belgrade in 2001, said, as quoted by the May 31 report, that important studies had never been completed, because of the patient's "lack of motivation."
From studies conducted around that time, Mr. Milosevic was known to have serious high blood pressure and a thickened heart wall — the result of years of hypertension.
All doctors who have reviewed his case have agreed that Mr. Milosevic was at high risk for stroke, heart attack or fatal heart rhythm problems. But little is known about the progression of Mr. Milosevic's heart disease during his time in the detention center. His lawyer, Zdenko Tomanovic, said after the study was released May 31 that Mr. Milosevic had frequently consulted Russian doctors by phone. "He did not want medical treatment in a country that was a member of NATO," Mr. Tomanovic said.
Doctors disagree about whether further tests would have changed anything.
An independent autopsy by the Dutch government showed that one of Mr. Milosevic's main coronary arteries was 50 percent narrowed — not generally enough to cause a heart attack in itself. At the same time, he had a severely thickened heart, with an unusual structure called a myocardial bridge, where a coronary artery plunges into the heart's muscle rather than lying on its surface.
There is disagreement over the significance and proper treatment of myocardial bridges, according to the medical literature.
