National Preventive Mechanism After the monitoring group had notified the aforementioned details to the administration, the director of the institution declared that, due to the lack of insurance, Sh.K.’s blood had really been taken in a car. S/he also acknowledged that the agency staff had not been able to find the child’s data in the insurance database before the hospitalization, and the policy arrived late. A week before the hospitalization, the child was already in a grave state and received food in an unstable manner. “I only lacked insurance policy for this child; all the other children had insurance, and I told it to the administration of the agency when the head of the administration of the agency, Bela Gogua, arrived in Senaki a week before.” The director of the institution showed us an email confirming the notification about the lack of insurance policy. The conversation with the director revealed one more important detail: Despite the fact that Sh.K. had an extremely severe syndrome with respiratory insufficiency, on May 6, 2012, s/he was first transported to the Senaki Children’s Hospital where they already knew it would be impossible to solve the child’s problem, because the Senaki hospital does not have the medical equipment necessary for the management of respiratory complications. As the director explained, the child was transferred to the Senaki hospital because the ambulance crew is only allowed to transfer patients to the Senaki hospital. Afterwards several hours later, the Senaki hospital called an ambulance from Kutaisi and the child was transferred to the Kutaisi hospital where it is possible to manage respiratory problems. When asked “What intervention was performed on the child in the Senaki hospital if they were unable to resolve the respiratory problem?” the director of the Senaki children’s house answered: “As they were unable to intervene and said they didn’t have any equipment, they called an ambulance from Kutaisi …” The inquiry into the aforementioned details of the case has made it clear to the Special Preventive Group that Sh.K. was provided with medical assistance late and in an inadequate manner. Accordingly, investigatory bodies must inquire whether the delay (with at least one week) of provision of qualified medical assistance to the child with respiratory problems was connected with his/her death; whether it was possible to avoid the lethal outcome if the State Care Agency had taken an action as soon as it received the notification (a week before the child was transferred to the inpatient unit); How seriously the medical staff of the children’s house violated the law by neglecting the child’s medical needs; and whether the information was hidden deliberately. Public Defender of Georgia addresses the Office of the Chief Prosecutor of Georgia with a recommendation to: Investigate the fact of death of Sh.K. and take adequate measures if the guilt of the aforementioned persons is confirmed. HEALTHCARE IN BOARDING HOUSES FOR PERSONS WITH DISABILITIES The monitoring conducted in the houses for people with disabilities in Dusheti and Martkopi, has shown that here, as in the other institutions for disabled persons, the beneficiaries’ right to health is not protected. The violations of the stated right are complex and are connected both with shortcomings of the work of inpatient facilities in relation to disabled persons and ineffective communication among different state agencies. The Case of D.S. – A shortcoming connected with the process of admission to a Boarding House On June 20, 2012, during the monitoring of the Dusheti Boarding House for Persons with Disabilities, one of the beneficiaries developed diabetic coma. As an explanatory note of a doctor of the Dusheti Boarding House makes it clear, beneficiary D.S. was admitted to the boarding house on June 19, 2012, at about 2 P.M., with a diagnosis of diabetes mellitus type 2, angiopathy, diebetic foot, and collapse of both retinas. The patient had received treatment by taking 30 units of Insulinretard and 20 units of Actrapid once a day. Since the Social Service Agency did not pay proper attention to the beneficiary’s health condition (to the contents of medical document Form #100) when s/he was being admitted www.ombudsman.ge NPM Report