On the basis of Order No. 157 of the Public Defender of Georgia of November 16, 2021, a group of specialists/experts was established to assess the adequacy and timeliness of the medical services provided to accused/convicted Mikheil Saakashvili.

On November 16, 2021, experts - Aida Gozalova, Tengiz Tsuladze, Giorgi Kacharava, Nino Zavrashvili, Grigoli Khurtsidze, Giorgi Grigolia, Giorgi Papiashvili - paid a visit to Establishment No. 18. They talked to Mikheil Saakashvili, assessed his medical condition, viewed the medical capabilities of Establishment No. 18, talked to the chief doctor and received information about the patient's health data.

Following the visit, the group of experts held a meeting on 17 November 2021 to discuss the monitoring results. Expert Mamuka Machaidze remotely participated in the discussion. The evaluations made by the group of specialists are based on the principle of ensuring the best interests of the patient.

I. Assessment of the patient's condition

Current status – critical

Risk factors:

1. 48 days of hunger strike confirmed
2. Wernicke encephalopathy
3. Persistent hypokalemia - since 08.11.2021
4. Anemia - thalassemia + high probability of gastrointestinal bleeding
5. Refusal of full treatment
6. Highly stressful environment

Expected complications in the near future

1. Aggravation of Wernicke encephalopathy – with coma, epileptic status
2. Lethal arrhythmia caused by hypokalemia, rhabdomyolysis, renal failure
3. Gastrointestinal bleeding
4. Hemolysis - thalassemia + hypophosphatemia
5. Pulmonary embolism (due to immobilization and dehydration)
6. Heart failure
7. Refeeding syndrome in case of calling off the hunger strike

II. The medical facility treating a patient with the above risks should have:

1. Relevant equipment and infrastructure
2. Multidisciplinary medical personnel
3. Teamwork experience in complex patient management
4. Urgent and 24-hour access to poly-profile medical services

III. Situational analysis of the medical facility treating the patient:

1. All the factual data we saw indicate that the clinic is currently at the formation stage. Part of the medical equipment is functional, while some are at the testing stage. The facility started hiring medical staff, according to the information provided to us, three weeks ago.
2. Part of high-tech examinations are not available on site (e.g. MRI, cardiac catheterization lab), making it impossible to create a closed cycle (meaning the removal of the need to transfer the patient to another clinic in case of aggravation of his clinical condition).
3. In terms of medical personnel, currently an internal medicine doctor and a resuscitation brigade are available 24 hours a day, while some of the specialists potentially needed for the patient are not constantly present on site.

In the event of possible aggravation of the patient’s condition, the above issue will be problematic as the management of the patient by the on-site team will not be sufficient. For example:

• - The Wernicke encephalopathy discovered by us had not been diagnosed due to the lack of regular consultation with a neurologist.
• - The necessity of exploring the probability of possible gastrointestinal bleeding, despite the need, has not been on the agenda.
• - The need for continuous cardio telemetry of the patient against the background of hypokalemia has not been considered - due to the lack of examination of the patient by a cardiologist.

4. The permanent availability of a resuscitator in the facility creates a feeling of safety, which does not correspond to reality. Given that the patient is quite depleted, resuscitation measures will most likely be ineffective if such a need arises.
5. In the event of life-threatening complication (e.g., heart attack, stroke, thromboembolism), according to the local staff, it is planned to transfer the patient to another medical facility, which would be a lost time given his condition, which in turn may pose a critical threat to the patient's life.
6. Given the patient’s specifics, making a decision on his emergency transfer will require lengthy coordination between various links.

Conclusion

Due to the critical condition of the patient, it is recommended to immediately continue his treatment in a well-functioning and well-experienced poly-profile hospital, in particular in an intensive care unit, the conditions of which cannot be provided by the clinic of Establishment No. 18.

Members of the group of specialists/experts:

Giorgi Grigolia

Grigoli Khurtsidze

Giorgi Kacharava

Giorgi Papiashvili

Aida Gozalova

Tengiz Tsuladze

Nino Zavrashvili

Mamuka Machaidze