In Rusland is een organisatie die toezicht houdt in gevangenissen. De POC, ofwel de Public Oversight Commission.
Hun rapport dat ik hieronder heb herplaatst, kunt U het best lezen van deze website: https://c4.100r.org/media/2017/10/Public-Oversight-Commission-report.pdf
Ik heb niet alle 20 pagina's gelezen, maar wel voldoende om te weten dat
- Magnitsky over alles klaagde: gemiddeld meer dan 1 klacht per dag.
Hij klaagt dat hij geen kkoud water had. Dat de warm water kraan niet werkt. Dat zijn waterkokewr kapot is. dat hjij in een cel zit waar geen grodijn voor de wc hangt. Dat hij in een cel kwam waar de ruit kapot is ( van 8 tot 10 september, dan is de temperatuur in Moskou gemiddeld + 14 garden.)
Het vervelendste probleem was dat de toiletten soms kapot waren en over liepen. Een keer werden de gevangenen onmiddellijk naar een andere cel overgeplaatst. Op een andere keer kon de loodgieter het probleem niet oplossen, en was er geen ander cel vrij. Dat was heel vervelend, maar het was niet met opzet gedaan en niet tegen magnitsky gericht om hem te 'martelen' zoals Browder steeds zegt. Het was gewoon de zeer slechte toestand van die oude gevangenissen.
- Niet slechter werd behandeld dan de andere gevangenen.
- Nooit werd gemarteld tijdens zijn gevangenschap
- Inderdaad vaak naar een andere cel werd overgeplaatst, maar dat dit nooit was om hem te bestraffen.
Het leven in Russische gevangenissen is zwaar. Net als in de meeste gevangenissen. Ook in Amerika. In Arizona leven gevangenen in tenten, ook in de zomer als het 35 graden heet is.
In de USSR was het al armoedig, maar onder Yeltsin werd het nog veel slechter. In 2009 was Putin al 9 jaar de baas, en je mag hem verwijten dat de gevangenissen nog zo slecht waren. Maar er is geen opzet geweest om juist Magnitsky het leven zuur te maken.
Wel was er een arts, mevrouw Gauss, die mogelijk uit boosheid, Magnitsky niet voldoende medische zorg heeft verleend.
Dat Magnitsky met knuppels is doodgeslagen is onjuist. Niemand gelooft dat. Ook niet de moeder en de advocaat van Magnitsky. Maar Bill Browder zegt dit overal waar hij spreekt. En dat is op erg veel plaatsen.
Ook zegt Browder steeds dat Magnitsky 358 dagen lang is gemarteld in de gevangenis.
Een totale leugen.
Lees het rapport van deze Human Rights comissie, en U zult het begrijpen.
PUBLIC OVERSIGHT COMMISSION
For human rights observance in Moscow detention centers and assistance to the persons held in
custody in the places of forced detention
Address: Room 22, Entrance 3, 4 Luchnikov per.; tel.: (495) 6211594
Chairman of the Commission: Borschev Valery Vasilievitch 8-916-588-64-67
Deputy Chairman: Volkova Lyubov Vasilievna 8-916-588-64-50
Kovalev Sergey Adamovich (495) 433-13 65
Khymanych Vladimir Grigorievitch 8-963-750-65-12
OF PUBLIC OVERSIGHT COMMISSION
FOR HUMAN RIGHTS OBSERVANCE IN MOSCOW DETENTION CENTERS
ON THE INSPECTION OF S.L. MAGNITSKY CONTAINMENT CONDITIONS AT
PTDCs (PRE-TRIAL DETENTION CENTERS) OF MOSCOW
Since November 20, 2009 shortly after it became known about S.L. Magnitsky’s case and his
death the members of Moscow Public Oversight Commission (POC) including V.V. Borschev
(Chairman), L. V. Volkova (Deputy Chairman), T. A. Flerova (Secretary), L.I. Alpern, L.B.
Dubikova, Z.F. Svetova have examined the detention condition of S.L. Magnitsky at the pre-trial
Detention Centers of Moscow. The Federal Detention Center FBU IZ-77/2 (Butyrka PTDC) and
The Federal Detention Center FBU IZ-77/1 (Matrosskaya Tishina PTDC) have been visited on a
number of occasions. The Commission members have met with and interviewed the Head of
Moscow Directorate of the Federal Penitentiary Service (UFSIN for Moscow) Vladimir
Anatolievitch Davydov, Chief Medical Officer of Moscow Directorate of the Federal
Penitentiary Service (UFSIN for Moscow) Service Olga Filippovna Grigoryeva, Moscow
Directorate of the Federal Penitentiary Service (UFSIN for Moscow) Head Assistant for Human
Rights Ms. Anastasiya Nikolaevna Chzhu, as well as with the heads, employees, and medical
personnel of Moscow Directorate of the Federal Penitentiary Service (UFSIN for Moscow)
Detention Center FBU IZ-77/1, Moscow Directorate of the Federal Penitentiary Service (UFSIN
for Moscow) Detention Center FBU IZ-77/2, and the Russian Penitentiary Service (FSIN) FBU
Sergey Leonidovitch Magnitsky
Birth date: 08.04.1972
Education: Higher (Master’s Degree)
Married, with two children.
Occupation and employer: auditor, Firestone Duncan law firm.
Had no previous criminal record.
Charged as per Part 2, Article 199 of the Russian Federation Criminal Code
Held in custody since November 28, 2008
MATROSSKAYA TISHINA (DETENTION CENTER 99/1)
TO BUTYRKA (DETENTION CENTER77/2)
On July 25, 2009, S.L Magnitsky was transferred from Russian FSIN Detention Center IZ - 99/1
to Moscow UFSIN Detention Center FBU IZ-77/2. A 16 square meters large cell provided
accommodation for 3 individuals which accords with the prescribed standards; the medical
assistance was available to him as Matrosskaya Tishina has an in-patient clinic with medical
doctors of various specializations and medical equipment. In the clinic, on July 01, 2009,
Magnitsky had ultrasound investigation of abdominal cavity organs with the purpose of detecting
the digestive organ pathema signs. As per the results of the ultrasound investigation the detected
pathema was determined to be the calculous cholecystitis. Upon his examination by a surgeon, a
further, reference, ultrasound examination was prescribed to be conducted a month later, as well
as a planned surgical operation. This opinion was signed by V. Stepanov, Head of the Medical
Unit, Lieutenant-Colonel of the Internal Service and D. Vasiliev, Colonel of the Internal Service.
Then, a week prior to the assigned reference ultrasound investigation to be followed by the
operation Magnitsky was transferred to Detention Center IZ-77/2 (Butyrka) which has no
ultrasound machine and none of the necessary surgical or medical facilities in place. What were
the reasons for such transfer?
The head of the Russian Penitentiary Service (FSIN) Detention Center 99/1 Ivan Pavlovitch
Prokopenko gave the following explanation:
Prokopenko: “We had decided to do a renovation, and we needed to vacate one floor. I talked to
several investigators and got consent from some of them for the transfer of persons under their
investigation to another Detention Center. Magnitsky’s investigator Oleg Silchenko was one of
them. As a result, we vacated the floor.
POC: “How many people were transferred to other Detention Centers?”
Prokopenko: “I cannot recall.”
POC: “Some two, three or five people?”
Prokopenko: “Around five.”
If the 3rd floor was vacated just by transferring to other detention centers of “approximately
five” residents then the other residents of the same floor cells were somehow able to continue to
stay in the Detention Center why did Magnitsky who was in need of serious medical assistance
not find himself among the ones who stayed but was transferred with those ones whose quantity
was ‘approximately five’?
Prokopenko: “I did not consider Magnitsky sick. The detainees are often trying to put on a mask
of a sick person in order to improve the conditions for themselves. We are all sick. I, for
instance, have osteochondrosis.”
However I.P. Prokopenko’s subjective assessment of Magnitsky’s state of health is not relevant
now; the relevant thing now is the objective opinion of the medical doctors. Prokopenko was
aware of that opinion. By transferring Magnitsky to Butyrka I.P. Prokopenko deprived him of the
possibility to receive the needed medical assistance. The renovation plans cannot justify the
decision. As this report is published, there is no renovation underway, despite the fact that
Magnitsky was transferred five months ago.
Was Magnitsky’s transfer to Butyrka solely Prokopenko’s initiative? This question arose in light
of the fact that on February 21, 2009, pursuant to the order of Interior Ministry Investigator Oleg
Silchenko, Magnitsky was transferred from Detention Center 77/5 Temporary Confinement Cell
№ 1 of the Moscow GUVD (Moscow Ministry of the Interior). Magnitsky’s lawyers filed a
complaint with the Russian Federation General Prosecutor’s Office, which read: In the absence
of an objective, justified and lawful need for Magnitsky’s transfer from the investigatory
Detention Center to a temporary confinement cell to conduct investigative actions, even more so,
for actions which had already been conducted with respect to him in the Detention Center, and
nothing prevented such further actions in the same center, such decision by the investigator
testifies solely to the intention to put psychological and moral pressure on him.” I.P. Prokopenko
said that it was entirely his initiative and that investigator O.F. Silchenko supported it. Russian
law regulates transfers of convicts from colony to colony, and transfers of accused persons and
suspects from investigatory Detention Centers to temporary confinement cells, which gave the
lawyers the grounds to appeal against the investigator’s actions, whereas transfers between
Detention Centers are not regulated by law. Therefore, the law did not limit Prokopenko and
Silchenko in deciding on Magnitsky's transfer from Matrosskaya Tishina to Butyrka, and they
could justify their action by the “renovations” which are still apparently pending after five
months. This is a serious gap in the laws governing the Russian penal system.
ON MAGNITSKY’S CONDITIONS AT INVESTIGATORY DETENTION CENTERS
On October 13, 2009, a month before his death, Magnitsky submitted a statement to Mr.
Gritsay, an Investigator of the Investigative Committee of the Interior Ministry, which was
attached to the materials of his criminal case held by the Investigative Committee of the Interior
Ministry, to the effect that unbearable conditions were being created for him with investigators’
Magnitsky wrote: “I think that with the participation of investigator Silchenko O.F. or
with his tacit approval inhuman conditions were created for me in the Detention Center, which
humiliate human dignity. While in custody, I have been transferred five times to four different
Detention Centers. I am tired of counting the cells to which I have been transferred innumerable
times. I am denied medical assistance. On many occasions, for artificial and unjustifiable
reasons, my mother’s and wife’s visits were prohibited, as well as telephone conversations with
my little children. While in custody, situations have been created for me where I was deprived of
the right to have a weekly shower, to watch television, to use a refrigerator, and simply to live
under normal conditions, to the extent they can be “normal” in a Detention Center. I am
convinced that such intolerable conditions are being created for me with my investigators’ full
knowledge. I am convinced that the only possibility to stop this humiliating treatment is for me
to accept false accusations, to incriminate myself and other persons.”
In the course of the inspection of Magnitsky’s detention conditions at the Detention
Center the POC members found out that while in custody, he was, indeed, transferred between
three different investigatory Detention Centers and among several cells in these Detention
Immediately after his arrest on December 2, 2008, Magnitsky was put in Investigatory
Detention Center №5. During the nearly five months of his stay here, he was transferred a
number of times from cell to cell (in total, he was held in four cells):
- Cell 206, with 12 beds, 10 inmates, net room area – 48.2 square meters;
- Cell 309 (transferred in connection with the work requirements), net room area - 32.1
sq. м, with 8beds, 7 inmates;
- Cell 417, net room area 56.2 square meters, with 14 beds, 12 inmates.
- Cell 503, net room area 36.4 square meters, with 9 beds, 8 inmates.
The cells were equipped with the partitioned toilets, wash-basins, a table, benches, a
wardrobe, hangers, daytime and the night duty lighting, windows for daylight, and with the
Before he was arrested Magnitsky was in good health. His medical record at the outpatient
clinic does not contain any information about any diseases, about his seeing medical
doctors. He fell ill within less than five months of custody.
On April 28 he was transferred to Detention Center-1 (Matrosskaya Tishina) where he
was kept until July 25, 2009.
On July 01, Magnitsky who at that time was held in custody at Detention Center 1
(Matrosskaya Tishina) had ultrasound of abdominal cavity organs to check for the pathema
signs. The ultrasound revealed a disease, and “calculous cholecystitis” was diagnosed. Upon
examination by a surgeon, a further ultrasound was prescribed to be carried out a month later, as
well as a planned operation (the report was signed by V. V. Stepanov, Head of the Medical Unit,
Lieutenant-Colonel of the Internal Service and D. I. Vasiliev, Colonel of the Internal Service).
On July 25, 2009 Magnitsky was transferred from Detention Center 1 (hereinafter referred to as
Matrosskaya Tishina DC) to Detention Center 77/2 (hereinafter referred to as Butyrskaya prison
DC). The later ultrasound and the planned surgery were never carried out.
On November 13, 2009, his condition seriously deteriorated. On November 16, 2009, at
17:22 he was driven in an ambulance car to Matrosskaya Tishina, where he died.
The above is the brief background of the case.
During the course of our investigation of Magnitsky’s conditions in Butyrka detention
facility we have come to the conclusion that the circumstances which lead to the detainee S.L.
Magnitsky’s death cannot be reviewed separately from the course of the investigation of the
incriminated case. He believed that the conditions created for him in Butyrskaya Detention
Center were the evidence of the pressure on him with the aim to suppress his will by means of
the torturous detention conditions and force testimonies admitting guilt, so Magnitsky wrote:
“I am convinced that such intolerable conditions are being created for me with my
investigators’ full knowledge. I am convinced that the only possibility to stop this humiliating
treatment is for me to accept false accusations, to incriminate myself and other persons.”
Of particular concern are two facts:
1. On October 16, 2009 Magnitsky made a statement about the large-scale fraud
involving theft of state budget money by high-ranking officials of the Russian Interior Ministry.
He gave a detailed description of the fraudulent scheme and named names.
2. Second, on November 24, the one year in pre-trial detention was due to expire.
The investigations did not have sufficient prove of his guilt in order to start the court
proceedings. That is why on November 13, Tverskoy court session adopted the decision to
extend the period of detention in custody. As a matter of fact, employees Butyrka Detention
Center had admittedly, apparently by accident, submitted an unduly executed certificate of his
health, which was a formal pretext for the court’s decision not to release the severely ill inmate
from custody on bail or recognizance not to leave.
Based on the conditions of Magnitsky at Butyrskaya Detention Center 2 the members of
the Public Oversight Commission arrived to the conclusion that Sergey Magnitsky was in fact
subject to organized physical and psychological pressure. It appears that Detention Center
employees realized this as well. Head of Butyrka Detention Center 2, D. Komnov, showed to the
POC members the note which he obtained from Magnitsky prior to the latter’s leaving Butyrka
Detention Center, which read: “During my stay at Butyrka, no pressure was exerted on me,
either physical or psychological, on the part of either the administration personnel or fellow
inmates.” Why did he do that? One understands only too well the value of such notes of
acknowledgement written in confinement. This is the way Komnov explained the note: “In 2008,
a certain Shcherbakov left the Butyrka Detention Center and a week later died at Matrosskaya
Tishina. Therefore, I asked Magnitsky to write this.” The description of the actual conditions
shows that pressure was, undoubtedly, exerted. But there was also another fact about which
Magnitsky wrote to the head of the medical unit, “In the evening of October 18, 2009, a man was
put into Cell 18 where I was held, who introduced himself as Denis (the man said later that his
name was Leonid). The man behaved in a strange way.” In particular, he asked Magnitsky, why
he had “done that to him,” although Magnitsky was only meeting him for the first time. The man
produced the impression of being mentally disturbed. Concerned about their safety, Magnitsky
and his fellow inmate slept in turn. After this disturbed man’s visit, Magnitsky’s health further
The right to decent conditions not humiliating to human dignity was violated.
• It is unprecedented that within a year in custody he was transferred among three
investigatory detention centers. As an inmate moves from one detention center to another,
from one cell to another, he leaves necessarily leaves personal items and items brought by
relatives to provide comfort during his detention.
• During his last three months alone, Magnitsky was moved from cell to cell, each new cell
being worse than the previous one. Thus, until August 31, Magnitsky was held in Cell 267.
In Butyrka, in violation of the European penitentiary rules (agreed to by the Russian
Federation) requiring at least two showers a week, inmates are taken to the shower room only
once a week according to schedule. For Cell 267 the shower day was Tuesday, the day of
Magnitsky’s arrival. That day, on arrival to the detention center Magnitsky was not given the
possibility to take a shower in violation of the requirement to have newly arrived inmates
• On July 26, Magnitsky had requested a shower, but got no response.
From July 25 to November 16 2009 Magnitsky was held in the following cells of Butyrka
DC -2: 35 , 52, 61, 59, 267, 305, 714, and 708. Magnitsky took notes of the conditions in those
Cell 267 (from July 25 to September 01, 2009). The living space in this cell was 10.8
square meters. There were two other 2 persons together with him during one day. Then, for one
day he was alone. After that there were always two people in the cell. The cell had four beds.
The cell lacked the cold water tap. On August 4, he requested that a tap be installed. No
response. The cells in Butyrka have hot water supply, but hot water is not running, the taps are
stopped. In keeping with the Internal Regulations, if there is no hot water in the cells, the
administration is required to provide hot water every day for laundering and boiling water for
drinking. Cell 267 where Magnitsky was put when transferred to Butyrka had no hot water, no
water-heater, and no kettle. Upon arrival, he had his water-heater taken and sent to the storeroom.
He immediately made a written request to have his water-heater returned from the storeroom.
He asked for boiling water. He was denied boiling water, and the water-heater was
returned only a week later. As a result, for 6 days he had no access to boiled water, which
affected his health.
At night the electric mains are disconnected.
On July 26, 2009 during the morning round, Magnitsky handed over to representatives of
the Butyrka detention center several written requests, including requests to have his personal
items and his water-heater returned from the store-room. In violation of Article 91 of the Internal
Regulations approved by the October 14, 2005 Order № 189 of Russian Federation Ministry of
Justice, Magnitsky’s requests were not accepted, the reason given that requests are not accepted
on weekends. His requests were only accepted the next day, on July 27On July 29, 2009
Magnitsky voiced the complaint that his water-boiler has not been given back to him.
On July 29, during the daily round, Magnitsky made a verbal complaint to the effect that
he could not get his water-heater back.
On July 30, suggested that he should write another request about having his water-heater
back, because his previous request had been lost. He did not get his water-heater back on that
On August 5, Magnitsky asked for hot water supply to be arranged for washing and
personal hygiene purposes. The detention center’s administration responded by saying that they
were not obliged to supply hot water to the cells, and the fact that the other detention centers
where Magnitsky had been held were having hot water was a violation of the rules. They invited
him to file a complaint against the head of Detention Center since there was hot water there in
violation of the rules.
On August 13, Magnitsky filed a written complaint against the outlets being disconnected
at night. He never got a response.
On August 31, Magnitsky filed a complaint with the Moscow UFSIN saying that the
detention center’s administration would not receive suggestions, complaints and statements from
accused inmates on a daily basis and that the conditions did not meet the Internal Regulations of
the Center. The next day, on September 1, Magnitsky was transferred from Cell 267 to Cell 59,
which made his conditions significantly worse. Sergey Magnitsky considered the transfer to be
retribution for filing the complaint. D. Komnov, the head of the Detention Center gave a vague
explanation: “He was transferred because of psychological incompatibility. It was an operating
officer’s decision. There was probably some conflict.” Magnitsky never said anything about any
conflict. If there was a conflict, his lawyers would have certainly known about it.
Cell 59. (From September 1 to 8, 2009). The living space in this cell was 8.2 square meters.
There were four beds and four inmates. The minimum 4 square meters per person required by
Russian law (Art. 23 of Federal Law №103-FZ) was not met. The sewage needed to be repaired,
there was intolerable odor coming out of the toilet. The cell did not have a table and benches
with the number of seats corresponding to the number of inmates, only one person could be
seated at the table. The cell had no shelf for toiletries, no wall-mounted mirror, no radio, no
refrigerator, and no television. The toilet was not partitioned. During Magnitsky’s stay in that
cell, the inmates would use bed-sheets as a screen not to be seen when using the toilet. The
distance between the toilet and the bed is less than one meter. There is a strong sewage smell
coming from the toilet, and the inmates have to plug the sewage hole with plastic bottles. The
only electrical outlets were located above the toilet, forcing the inmates to boil water for hot
drinks in the stench of sewage. The toilet is located immediately adjacent to the wall, the
platform above it is small, and it is difficult to use such toilet. The conditions in this cell ought to
be considered as degrading to human dignity. In the evening of September 8, raw sewage began
to flow up over the toilet bowl. On that same evening, the inmates were moved from to Cell 35.
Cell No. 35. (from September 8 to 10, 2009). Magnitsky was held there for three days.
The living room here is 10.1 square meters. There are 6 beds, and there were three inmates in it.
The cell windows had no glass in them; the walls of the cell were wet. On Magnitsky’s second
day in this cell, raw sewage under the toilet began to rise, and by evening sewage water covered
half of the cell. The inmates asked that the problem be fixed, the plumber did not come until 10
p.m., and he was not able to fix the problem. The inmates asked to be moved to another cell, but
they were left in the cell till morning. The next day, the plumber did not come, and the sewage
water continued to flood the entire cell floor. The inmates moved around the cell by walking on
beds. The plumber only came in the evening, he was trying to fix the trouble for a long time, but
he failed. Both the plumber and the warden who brought the plumber were expressing
indignation over the conditions in which the inmates had to live. They were asked to move the
inmates to another cell, but those employees were not in a position to decide on their transfer
without their superiors’ approval. The permission was only received at 11 p.m., after which the
inmates were moved to Cell 61. Magnitsky and his fellow inmates had lived in the midst of raw
sewage for 35 hours.
Cell No. 61. The living space is 8.2 square meters. There are four beds. Cell №61 lacked
not only window glass, but window frames as well. On September 11, Magnitsky made a
complaint requesting that window glass and window frames be installed, but got no response.
Because of the cold, the inmates had to sleep with their clothes on and cover themselves with
jackets. Yet the window frames would not be installed. On September 18, the inmates filed a
complaint saying that they had got a cold because of the lack of the windows, and only after that
the window frames and glass were installed. By the time the POC members visited the cell, a
television had been installed in Cell 59, and there were 3 inmates there. The space standards
were violated, leaving only 2.7 to 2.8 square meters per person.
Cell No. 708. The living space was 8.2 – 8.5 square meters. There are four beds. There is
no daylight because the window looks on the exercise yard. There is a further external screen
preventing any light from getting in. When members of the POC came to see the cell at 2 p.m.,
daylight was not penetrating into the cell. The window was dark.
Cell No. 714. The living space is 8.2 square meters. There are four beds. There is no
daylight because the window looks on the exercise yard. There is a further external screen
preventing any light from getting in. When members of the POC came to see the cell at 2 p.m.,
daylight was not penetrating into the cell. The window was dark.
On November 12, 2009 Magnitsky S.L. was taken to a pre-trial hearing at Tverskoy
District Court, from which he returned to the detention center at 7 p.m. Until midnight, he was
kept in the collection chamber, and then he was informed that he was being transferred from Cell
714 to another cell. He requested that the transfer be put off till morning, and that he should not
be transferred at night-time, but was refused that. He could only collect his personal items, but
was not given time to cook hot meals he had been deprived of the whole day of November 12.
He did not get into Cell 305, where he was transferred, until around 1:30 in the morning,
and due to late time and fatigue, he was not able to make hot meals. He was thus deprived of the
right to have an 8-hour sleep and deprived of hot meals for over 24 hours.
On November 13, 2009 Magnitsky wrote a complaint to the head of Detention Center 2:
“On November 12, during 24 hours, I was deprived of the possibility to have hot meals
and deprived of the 8-hour sleep during the night, which may have caused exacerbation of the
pain in the area of the pancreas and a fairly discomforting pain in the area of the liver, which I
did not have before, as well as nausea. Therefore, I request a recommendation as to whether I
should take some medicine for liver treatment, unless the above described pain stops or if it
continues systematically. In addition, I ask you to inform me at last when the ultrasound
prescribed for as far back as August is going to be done.”
This complaint was written three days before Magnitsky’s death. Yet the head of the
Detention Center 2 persisted in his claim: “Magnitsky never requested a meeting with me, and he
never submitted any complaints. Neither did his lawyer.”
We showed him the response of V. Davydov, Head of the Moscow Directorate of the
Federal Penitentiary Service, in which he was answering the questions which we addressed to
Komnov. And the latter brought us the log for registration of complaints and requests. And the
log did not contain records of Magnitsky’s, his lawyers’ or his mother’s requests or complaints.
This shows either negligence or, if such records were made, the log was subsequently rewritten.
We looked at the log records, and we had the impression that they had been made with the same
hand and with the same pen.
Members of the POC have also met with some of Magnitsky’s inmates. Zelenchuk was a
witness of Magnitsky’s last hours in Butyrka and told us “Sergey was very much unsettled by the
substitution of criminal case documents at the November 12 court session. On November 24, one
year in custody was to expire.” Members of the POC had the impression that he did not tell us
everything he knew. Kharitonov left a similar impression: “I was in custody together with him
for two months. I did not have much contact with him. He wrote a complaint when water flowed
from the toilet bowl in Cell 35. Based on his complaint, we were transferred to another cell.”
Namazov told us, “I was in custody with him. He was of no interest to me because of age
difference. I saw him taking medicine. I did not have much contact with him, because I have a
problem of my own”. Kharitonov and Namazov looked very anxious and scared.
Participation in the court hearings was conducted with severe humiliation under
degrading and dangerous conditions.
Magnitsky was brought to the court hearings for the extension of his pre-trial detention
on a few occasions.
He described this process in his notes in detail.
Inmates with court appearances are forced to leave your cell at about 7.00 to 7.30 a.m.,
i.e. before scheduled breakfast. Then you are detained in the so-called Collection Cell up until
9.00 to 10.00 am. After that the process of delivery to different court locations begins.
The members of the POC examined the Collection Cells, where the suspects being held in
groups before dispatched to a different Moscow courts for hearing. The Collection Cell is about
20 to 22 square meters with no windows. There could be up to 70 suspects to be squeezed in
such cell, as a result it is very hard for them to find a place to stay in such cell, we are not even
mentioning a possibility to seat. A lot of suspects do smoke in the cell and taking into account
that there is no air ventilation in this cell. It is very difficult to breathe. Nearly in all such cells
there is no separation made between toilet facility and cell itself. In others there is a tap with cold
water, but it is impossible to drink such water without boiling it first. Indeed, during the
inspection the members noted that the toilets do not equipped even with wash-out mechanisms
and the toilets were not separated from the main the cells by drapes for privacy. A temporary
curtain was fixed only during out inspection of such cells. We noticed that only during our
second inspection visit, although the employees of the detention centre tried to convince us that
curtains were in place at all times.
On September 10, 2009, Magnitsky was kept in such cell from 11 am to 7.30 pm without
any hot meal to be served or drinking water. He also missed his scheduled time to take a shower.
(This day was his scheduled day for taking a shower, which occurred only once a week.) On that
particular day he was not delivered anywhere and ultimately returned to his cell.
For transportation purposes the Detention Centers use special transportation vehicles,
which are equipped with special compartments for suspects, having size of approximately of 3.2
meters in length, 1.2 meters wide and 1.5 meters in height. Such compartments are designed to
accommodate not more than 15 people, however, usually about 17 to 18 people are squeezed in,
and as a result some of them have to remain bended in uncomfortable positions for the entire
journey. On average a journey to a court hearing takes about an hour, however, on one occasion
Magnitsky spent in such position about 4.5 hours in the evening, due to the fact that the vehicle
did not go directly from the court to the detention center, but was collecting other suspects from
Usually the vehicle is returning back to the detention center about at 7 or 7.30 pm,
however, the guards are keeping the suspects in the vehicles up until 8 pm justifying this by the
fact that they require to complete the documents.
Thereafter, the just-arrived suspects are placed again into the collection cells and kept
there for additional 3 to 3.5 hours. Magnitsky never managed to get into his regular cell earlier
than 11 pm on his return from court hearings.
On such days when suspects are transported to courts they receive dry packed meals,
however, it is impossible to utilize them as there is simply no hot boiled water provided in the
Tverskoy Court of Moscow in order to mix it with this dry meal. As has been described above all
inmates return back to their cells late at night. Hot supper could not be provided to them due to
the night time, as such effectively it might be that a person could be without any hot meal for 38
hours. If the court hearing is continued for a few days in a roll then the interval between hot
meals consumption increases even more.
August 13, 2009 Sergey filed a complaint to the Head of the Tverskoy District Court of
Moscow in relation to the fact that there was no boiled water provided for hot drinks during the
transportation process. No reply received.
September 14, 2009, again there was no boiled water provided during the court hearings
on the extension of his detention. During the court hearing Sergey Magnitsky requested Judge
Krivoruchko to provide him with a chance to have a hot meal. The judge declined his request
justifying it by the fact that it was not part of responsibilities of the court.
We would like to note that the above mentioned are related to all inmates, who are facing
the transportation process to the courts. These violations were brought to the attention of the
authorities quite a long time ago, however no progress has been made since.
No Interaction with Family
Magnitsky was under more restricted conditions in Butyrka Detention Center if compared
to Matrosskaya Tishina, in particular in relation to contact with his family. Russian law provides
the right to correspond with relatives and other people. The established instructions and rules
impose a direct responsibility of the detention center administration to collect all correspondence
from inmates on a daily basis, to check it and further dispatch to ultimate addresses within three
days from such collection being made. Instead inmates are required to leave their
correspondence on a special box located in the exercise yard, where the administration is
supposed to collect such correspondence in time and further dispatch. Magnitsky’s letter, which
he left on September 9, 2009, was still there on September 15. The letters from the relatives,
which were sent within Moscow, were received with 10 or 12-day delays. The letters from other
cities from Sergey’s relatives were received on the 25th day from the day it was sent.
During the 11 months of Magnitsky’s detention he was not provided even with one
opportunity to see his mother, wife or other relatives.
It should be pointed out that the prosecutor’s office responsible for overseeing adherence
of conditions in detention to law did not perform its functions.
• On September 11, 2009, Magnitsky’s attorney Dmitry Kharitonov filled complaints with the
Russian General Prosecutor Yuri Chaika, the Head of Investigative Committee of the Interior
Ministry Anichin and with the Interior Ministry investigator Oleg Silchenko, in which he
requested the following:
• To conduct the investigation of the circumstances, which were described in Magnitsky’s
complain in particular in relation to violations made against him by administration and
employees of Butyrka Detention Center, and in this regard to question other inmates who
were delivered together with Sergey to the Tverskoy District Court for hearings on August 6,
10 and 18, 2009.
• To conduct an investigation into the multiple transfers of Magnitsky between the detention
centers and to explain the legal grounds for such transfers;
• To compel the administration of the detention centers to provide Magnitsky with his lawful
rights for which purpose to demand from Detention Center 77/2 and from the Moscow
Directorate of the Federal Penitentiary Service the copy of the text of his complaint dated
August 31, 2009 and the information of its lodging and forwarding to the addressee.
• To request Detention Center 77/2 to provide the information in relation to the registration in
the logs as per the order prescribed by the Internal Rules and Regulations items 92 and 93 of
the applications and complaints submitted by the lawyer; the copies of the above complaints
and applications; the data regarding the response to them; the data on the medical
examination and treatment measures prescribed to S.L. Magnitsky; the details of the medical
inspections available in his personal medical dossier.
THE QUALITY OF MEDICAL ASSISTANCE TO GIVEN TO MAGNITSKY AT MOSCOW
In late April of the year 2009 Sergey Magnitsky was transferred from Investigatory
Detention Center No. 5 to the Russian Penitentiary Service Detention Center 99/1 (Matrosskaya
Tishina). Neither Magnitsky nor his lawyers were informed about the reason of the transfer.
According to his lawyers already when he was at Investigatory Detention Center No. 5,
Magnitsky felt periodic pains in the area of the left side hypochondrium. In Matrosskaya Tishina
the pains persisted and he complained to the doctor.
On July 1, 2009 at Detention Center 99/1 Magnitsky had the ultrasound investigation of
the abdominal cavity and was referred to the surgeon. Physician Valery Sholokhov, the medical
doctor who performed the ultrasound diagnosed: “acute pancreatitis with underlying calculous
On July 13, 2009 Magnitsky was examined by David Galustov, a surgeon from
Matrosskaya Tishina hospital.
On November 23, 2009 года when meeting with members of the POC, Galustov said the
following about that consultation: “Magnitsky had cholecystitis, pancreatitis. A planned
operation was recommended for him. The verification ultrasound, scheduled after one month, to
check on the growth of calculi. Based on the results of the second ultrasound, a planned
operation could be insisted upon.”
Thus, based on the recommendation of surgeon Galustov, the verification ultrasound for
Magnitsky was scheduled for August 1, 2009. Nevertheless, on July 25, 2009, he was transferred
to Butyrka Detention Center where it was impossible to do an ultrasound. Members of the POC
were not able to find out if Magnitsky’s transfer was agreed with medical doctors of
Matrosskaya Tishina. In the absence of a legislative act establishing a clear procedure for
inmates’ transfer from detention center to detention center, there is room for abuse and arbitrary
actions on the part of detention center administration and investigators with regard to persons
The reasoning given by Ivan Prokopenko, Head of Matrosskaya Tishina detention center
– that Magnitsky’s transfer was connected with repairs at the Detention Center – is not credible.
Prokopenko could not help but know that within a week’s time Magnitsky was to undergo
ultrasound. He was, therefore, to be driven back to Matrosskaya Tishina from Butyrka. As one
knows from subsequent developments, Magnitsky was never brought for ultrasound, despite his
numerous requests and complaints and despite his lawyers’ complaints to various authorities.
The following is the description of the situation with provision of medical assistance to
Magnitsky at Butyrka as described by Magnitsky himself.
Upon getting to Butyrka, Magnitsky was not examined by a medical doctor.
On June 26, 2009, Magnitsky submitted a written request to the administration to have an
appointment with a doctor. There was no response.
On August 9, Magnitsky requested a meeting with the head of the detention center,
noting that the health was in danger. There was no response.
On August 11 Magnitsky wrote a request for an appointment with a doctor, noting that
the scheduled time for prescribed medical examination had long passed. There was no
appointment with a doctor and no response.
Besides written requests, Magnitsky made verbal requests during paramedics’ rounds
(once or twice a week). The response: “Write a request. You did? Then wait.”
On August 14, Magnitsky submitted a request that the medicines prescribed by the
medical doctor in Matrosskaya Tishina could be passed from his relatives.
On August 17, Natalya Magnitskaya, Magnitsky’s mother, brought the medicines. They
were not passed over. After the mother’s applying to the administration, it was found out that the
medicines had been passed over to another cell by mistake. Natalya Magnitskaya bought the
medicines again, and only after that, on September 4, the medicines were passed – 18 days later.
On September 18, 2009. Magnitsky’s lawyers applied to Komnov, the head of the
detention center. In accordance with the medical doctor’s recommendation, a second ultrasound
was prescribed to be performed in early August. They requested:
- ensure the performance of the second ultrasound;
- to inform the lawyers about the results of the examination and the prescribed treatment
August 24, “The disease has become so acute that I could no longer lie in bed. At 4 p.m.,
the fellow-inmate began to kick the door, demanding that I should be taken out to see a doctor.
The warden promised to invite a doctor. The fellow-inmate repeatedly demanded an appointment
with a doctor. I was taken to a doctor only five hours later. The doctor was dissatisfied.
Concerning the complaints and the lack of treatment she said that the medical record said that I
had already been treated. To my request to have clinical nutrition prescribed, she said that I
needed to get an appointment with a surgeon, and he would resolve the matter.”
August 25, Magnitsky wrote a request for an appointment with a surgeon. There was no
Clinical nutrition was never provided for Magnitsky.
August 26, as the deputy head of Butyrka Detention Center was making a round of the
cells Magnitsky complained that medical assistance is not provided, that the prescribed
examination has not been performed. He tried to show the letter indicating the diagnosed disease.
He was not given the possibility to do that, receiving the response, “You are delaying us.”
August 31, there was another visit. Magnitsky wrote to his lawyer, “A similar round.
Another detention center administration official came and took the letter. The head of the
medical unit promised to sort out the matter. Concerning the operative therapy he said: “You will
have it when you are released. Here, nobody is obliged to provide it to you”. And he left.”
(Cited from Magnitsky’s letter to the defense).
• There was no initial medical examination or sanitization performed upon
Magnitsky’s arrival to Butyrka Detention Center.
• Medical assistance was not initially provided, and the first appointment with a
medical doctor was arranged only 30 days after his written request.
• The medical examination (a second ultrasound of the organs of abdominal cavity)
prescribed by medical doctors of Matrosskaya Tishina and scheduled for early August was not
During the meeting with the POC members the head of Butyrka Detention Center
Dmitriy Komnov said that upon arrival on July 25, 2009, Magnitsky was examined by paramedic
Chepylyova. He presented no complaints. He did not complain of heart troubles. Whereas
Magnitsky, in his statements, points out that upon his arrival to Butyrka he had no medical
examination. One is surprised by paramedic Chepylyova’s statement that Magnitsky did not
complain of anything during the initial examination. In any case, he was to mention the need to
have a second ultrasound.
On August 24, 2009 Magnitsky felt unwell and asked that a medical doctor be called for.
According to his statement, he was given medical assistance only five hours later. He was
examined by paramedic Khokhlova. She diagnosed intercostal neuralgia. According to
Magnitsky’s complaint, he told Khokhlova that he wanted to be examined by a doctor.
According to Magnitsky, Khokhlova read in his presence an excerpt from his medical record,
which said what treatment Magnitsky had been given in Matrosskaya Tishina.
Nevertheless, paramedic Khokhlova never transmitted Magnitsky’s request for an
appointment to Dr. Larissa Litvinova, the head of the medical ward of Butyrka. It was Larisa
Litvinova herself who told this to the POC members. What is surprising is that the medical
personnel of Butyrka do not keep diaries recording the details of provision of medical assistance
Members of the POC have met twice with Dr. Litvinova, the head of the therapeutic ward
of Butyrka. She told members of the POC that she first saw Magnitsky on October 7, 2009:
“During the doctor’s round, he complained of exacerbation of chronic cholecystitis. He had with
him a hospital discharge record preceding custody. I read the record and gave it back to him.
Magnitsky said that he was having aggravation of osteochondrosis. We placed him in the
therapeutic ward.” Magnitsky stayed at the therapeutic ward of SIZO Butyrka from October 7 to
November 12, 2009.
Dr. Litvinova told members of the POC that she studied his medical history from his
medical record book. She could not but know that he had had ultrasound of abdominal cavity in
Matrosskaya Tishina. And during the conversation with members of the POC, Litvinova said that
she “did not recall” that a second ultrasound was prescribed for him to be performed after one
Members of the POC noted that both Litvinova and Dmitry Kratov, the chief medical
officer of the detention center were trying to dodge the question of the second ultrasound.
Members of the POC were persistent in their questions, to which Dmitry Kratov responded
grudgingly: “An escort is needed to take Magnitsky to Matrosskaya Tishina for ultrasound. And
one does not know when the escort is going to be available.”
Dmitry Kratov told members of the POC that Magnitsky had never complained to him
during the doctor’s rounds of the lack of medical assistance. This statement is surprising.
According to the text of the notes “On Conditions in Butyrskaya Detention Center,”
written by Magnitsky, he spoke with Kratov on September 4, 2009, about having ultrasound,
when Kratov brought him the medicines delivered by his relatives, and Kratov said that he had
written a report on Magnitsky’s transfer to Matrosskaya Tishina for performing ultrasound.
Kratov promised that this can be done not earlier than three weeks later. Kratov gave the same
promise to Magnitsky’s mother during their face-to face meeting.
The question arises why Kratov said nothing to members of the POC that he had written a
report on the need for Magnitsky to have ultrasound? Did he actually write such report? Or did
Kratov deceive Magnitsky and his mother Natalia Magnitskaya?
Magnitsky’s Treatment in Butyrka
Physician Larisa Litvinova informed POC members that she examined Magnitsky every
day from October 78 to November 12, 2009. She said, “He had positive dynamics. During last
two weeks in therapy he didn’t complain. He reacted badly to the ongoing court rulings and
investigation. He asked me to give him written confirmation that he was hospitalized.”
Physician Litvinova gave Magnitsky the confirmation he was asking for. The text of the
confirmation certificate read, “Magnitsky has been treated in hospital with the following
diagnosis: gallstones and acute cholecystopancreatitis. His general health conditions are
satisfactory. Electro cardiogram – sinusoid rhythm is correct, 66 beats per minute, EOS
(electrical axis of heart) is normal, blood pressure – 120/70, pulse 72 beats per minute. Deemed
able to participate in court and investigative activity. Deemed able to be held in pre-trial
The names of the Head of Butyrka Dmitry Komnov and Deputy Head for Medicine
Dmitry Kratov are written on this document, but there are neither signatures nor any stamp it.
Judge of Tverskoy Court Stashina declined to accept this document for the case, although she
had all the opportunities to verify the validity of this information. We should also point out here
that this is the same Judge Stashina who at the request of investigators has kept in pre-trial
detention Mr. Tkachenko, an inmate to has extremely severe medical conditions and who has
suffered four heart attacks. He is accused of economic crime and has spent three years in pre-trial
detention and could die at any moment. Only after POC members visited Matrosskaya Tishina
was the detention measure against Mr. Tkachenko was changed and he was released under bail.
He remains alive. If the court had made similar decision regarding Magnitsky, he could have
stayed alive. We believe that the Supreme Court and the legal community must review the
current situation not only with judge Stashina, but also in general with seriously ill detainees.
While there is a list of diseases for convicted persons that gives them right for release from
prison, there is no similar list for people in pre-trial detention. Without any doubts it is necessary
to identify the list of diseases, the presence of which will give enough reason for release
suspected and accused people from pre-trial detention and change their detention measures. As it
was mentioned above, on November 12, 2009 Magnitsky was discharged from Butyrka’s
medical center and returned to the cell. Nevertheless, already on November 13, 2009, after
questioning by the investigator Magnitsky felt badly and was hospitalized again.
Physician Litvinova told the POC members that she was already absent on the second
half of Friday, November 13, 2009. Magnitsky complained about vomiting and severe pain on
his right side. He was hospitalized by a medical assistant who informed Litvinova about his
medical conditions According to Litvinova she fully trusts medical assistants who over the
weekend (when she was not present) were applying to the same therapy as earlier when he was
staying at the hospital as an in-patient.
POC members found this approach of Litvinova questionable. If a person who was
released after improvement in his status subsequently shows a deterioration in his medical
conditions, does it not mean that requires additional, more qualified medical assistance?
Litvinova claimed to members of POC that “if she believed she would not be able to deal
with Magnitsky herself, then she would have hospitalized him.”
According to Litvinova at the morning on Monday November 16, 2009, when she
examined Magnitsky she spotted that “his stomach is reasonably tensed, acute belting pain,
vomiting every three hours.” Litvinova decided that his status “required surgical examination,
because the gallstone could close the canal.” Besides that, as Litvinova admitted to POC
members “it was necessary to push for an examination – I thought he had a chronic disease.”
This statement of Litvinova – “it was necessary to push for an examination” – could not be
described as only a slip of tongue. It looks like somebody was preventing Magnitsky’s treatment
and Litvinova used his worsening conditions to initiate the treatment that was prescribed to him
almost four months before.
The ambulance was called at 14:47. Litvinova informed the investigator who came for
the next questioning that Magnitsky has acute medical conditions. Members of POC paid
attention to the fact that Litvinova’s reaction on medical conditions of Magnitsky differed from
reaction of Dmitry Kratov. He assured members of POC that emergency doctor didn’t consider
Magnitsky status hard enough to move him to Matrosskaya Tishina. The conversation he had
over the phone with doctors in Matrosskaya Tishina and which he told about to members of POC
Kratov: “I made a call to Matrosskaya Tishina and said to Olga Alexandrovna (doctor of
Matrosskaya Tishina, ‘We are transporting a patient to you. It would be nice to examine him.
Olga Alexandrovna: “Does he have pancreonecrosis? (a lethal condition requiring
Olga Alexandrovna: “Then why are you transporting him?”
Kratov: “Just acute Pancreatitis.”
According to the head of Butyrka Detention Center, the ambulance took away Magnitsky
to Matrosskaya Tishina at 17:10.
Dmitry Kratov and Dmitry Komnov insisted on the fact that Magnisky status was not
critical and he “left Butyrka on his own legs.”
The POC members expressed the desire to talk to the escort officers who escorted
Magnitsky in the ambulance to Matrosskaya Tishina in order to find out what was his condition
during the transfer. Komnov said, - ‘I will not give you the name of the escorting officer. I don’t
want him to be killed.’ We do not know the reason for Komnov’s fears.
Upon reviewing the medical attention given to Magnitsky, we can unequivocally
conclude that the appropriate medical assistance was not provided to Magnitsky in Butyrka
His requests for visits with doctors were ignored, doctors didn’t undertake
necessary steps to send Magnitsky to Matrosskaya Tishina for the second ultrasound which
was prescribed to Magnitsky and registered in his medical record.
We do not know the reason for such an unprofessional attitude from medical staff to their
medical duties. Members of POC who tried to get more details about circumstance of Magnitsky
treatment in Butyrka during the second visit failed to talk to therapist Litvinova. Deputy Head of
the Moscow Directorate of the Federal Penitentiary Service A. Chzhu took Litvinova away and
didn’t provide any opportunity for members of POC to speak to her. Furthermore, during their
first visit, members of POC were informed that medical assistant Khokhlova is not at her
working place, but by accident members of POC met Khokhlova by chance during the course of
that visit. Why had members of POC not been provided an opportunity to speak to medical
assistant Khokhlova despite the fact that she examined Magnitsky under his request on August
Why did the head of Butyrka’s medical ward, Larisa Litvinova, who described the
positive dynamics of Magnitsky disease and who returned him on November 12 back to his cell,
was not surprised with the fact that on November 13 he again complained about acute status of
his disease? In report which was read to us in Matrosskaya Tishina, it was said that Magnitsky
was hospitalized on 16 November due to negative developments in his condition. It is clear even
to a non-specialist that the disease progressed quite fast and he should have been hospitalized
starting with 13 November when he again asked for medical assistance.
Why was not he moved to Matrosskaya Tishina hospital with the needed ultrasound
system and the specialists available on November 14 or 15?
Perhaps the question should be: Did management Butyrka not get permission for
Magnitsky’s transfer from the investigator? Why did it take so long on November 16 to move
Magnitsky to Matrosskaya Tishina? Physician Litvinova identified that he required surgery
examination already during the morning round. Did his movement from PTDC to PTDC have to
be reconciled with the investigators?
What was the position of investigator Silchenko in this matter In his reply to the request,
which was sent to him by the advocates of Sergey Magnitsky in accordance with Article 11 of
the Criminal Conduct Code of Russia, requesting him to force the administration of the pre-trial
detention ward to “conduct the ultrasound examination of abdominal section of the suspect –
Sergey Magnitsky …” he stated that the request had been considered and that “on August 31,
2009 he issued a full denial to such request …as the current legislation does not empowered an
investigator to control a health condition and treatment of a detained suspect.”
Taking into account this whole story which had been lasting for more than 3 months
about some sort of barrier which was impossible to overcome in order to provide the scheduled
ultrasound investigation Silchenko’s statement was the most cynical showing the reluctance of
investigator O.F. Silchenko to comply with Article 11 of the Russian Criminal Procedural Code
which clearly formulates that: “The courts, prosecution office, investigator or operating officer
must provide all required explanations to a suspected person and/or an accused person, and /or a
victim or any other civil claimant or defendant, or any other participants in the criminal court
proceeding their lawful rights, responsibilities and provide them with ability to utilize their
In this case investigator O.F. Silchenko did not want to provide [Sergey Magnitsky] with ability
to utilize [his] rights.” Why?
In addition, another provision of the law was ignored by him, the provisions of Article
122 of the Russian Criminal Procedural Code, which requires an investigator to convey his reply
to the knowledge of the suspect. Bodies conducting preliminary investigations are required to
provide a copy of their reply or statement to a claimant or establish a time for the claimant to be
acquainted with such reply or statement, for the purposes of the latter to consider the lawfulness
of such reply or statement and to have the opportunity to challenge it in the court in accordance
with the current legislation. Not a single copy was provided by the investigator to the advocates.
Therefore, provisions of Articles 7 and 11 of the Criminal Procedural Code were abolished by
the investigator, which further caused breach of the right for an appeal. The actions of
Investigator Silchenko evidence either his negligence or a deliberate intent to conceal the
motivation of his refusal to provide a medical examination, which was requested in the
appropriate complaint by Magnitsky on August 31, 2009.
On September 15, 2009 Magnitsky’s lawyer, Kharitonov, filed a complaint requesting to
inform the defense with the issued denial in response to the filled complaint of August 31, 2009.
On September 23, 2009, Kharitonov filed a complaint with the Federal Directorate of the
Penitentiary Service (UFSIN).
The conclusion that can be made from the situation analysis can be summarized as
follows: the actions of medical staff at detention center was not just negligence, it was not just
‘non-provision of medical care.’ These actions raise the question of the violation of his right to
THE LAST DAY OF SERGEY MAGNITSKY
According to Butyrka physician Dr. Litvinova, Magnitsky had acute pancreatitis pains
that started on Friday, November 13, when the doctor had already left for the weekend. The
patient suffered from nausea and pains in the right part of the adnominal area. However, the
“seasoned medical staff” (in her words) arranged for proper treatment over the weekend: “they
placed the patient in a medical room and gave him some anti-spasm medication. They were
ready to call an emergency if needed.”
Dr. Litvinova saw Magnitsky on Monday morning, during the regular survey of the
patients. He was very stressed and agitated and she understood that it was a “psycho-emotional
stress.” According to her, Magnitsky usually had such acute pains when emotionally stressed
although this time he said he had eaten some fish, thus violating the diet.
When the doctor examined Sergey Magnitsky’s abdomen she found it very tense which
she thought was a symptom of the acute pancreatitis pains. She decided to move the patient to
the hospital located at Matrosskaya Tishina detention center to conduct an additional ultrasound
and to perform a possible surgery.
The ambulance was called, but sources differ on the exact timing: Litvinova said it
arrived at 2pm while Olga Grigorieva from the Medical Division of the Moscow Department of
the Federal Penitentiary Service indicated 2:47 p.m.
It is not clear when the ambulance arrived at Butyrka Detention Center but, according to
the head of Butyrka, Dmitry Komnov, it left “in the direction of Matrosskaya Tishina” at 5:10
p.m. So, more than 5 hours passed between the moment when the decision to send Magnitsky to
the hospital was taken and the time of actually transporting him to the hospital.
Apparently, all that time was spent on all sorts of consultations involving the investigator,
the Moscow department of the Federal Penitentiary Service and the administration of Butyrka
and Matrosskaya Tishina Detention Centers.
In particular, we have an account of the discussion between the medical director of
Butyrka, Dr Kratov, with Alexandrovna at Matrosskaya Tishina. Dr. Kratov told us: “I didn’t see
the patient myself. I spoke with the ER doctor. She said that the patient’s condition was not that
bad to require the transfer to Matrosskaya Tishina. But I called Olga Alexandrovna at
Matrosskaya Tishina and told her that we were going to deliver to their hospital a patient with
pancreatitis. I said it would be good to examine him. Olga Alexandrovna asked if the patient had
pancreonecrosis. I said, no. “Why then are you bringing him to us?” she asked.
Dr Litvinova from Butyrka also referred to the opinion of the ER doctor: “The ER doctor
looked at the abdomen and confirmed my diagnosis.”
However, this ER doctor disappeared and it was some “young nurse” who brought
Magnitsky to Matrosskaya Tishina. This is known from the surgeon Alexandra Gauss from
Matrosskaya Tishina. She said that, “In Detention Center No. 2 the document regarding the
transfer of Magnitsky was delivered to her by a “young nurse.” Dr Gauss interpreted this fact as
a sign that the patient’s illness was not dangerous. “Otherwise he would have been accompanied
by the doctor”, she said.
This young nurse was also mentioned by those who recounted what happened to Sergey
Magnitsky in the ambulance. This girl was said to be sitting next to the driver while the patient
was sitting next to the guard so the nurse and the patient didn’t see each other. The commission
failed to get any details on the ambulance crew or the guards from the officers of the detention
center. When asked if it would be possible to talk to the guards, the head of Butyrka, Mr.
Komnov replied, “No, he can be killed for that.”
Therefore, Magnitsky left Butyrka at 5:10 p.m. The commission members watched the
video tape showing his exit from the detention center. The tape showed a man in a light jacket
going down the corridor accompanied by two other men. Magnitsky was holding 2 bags and 2
plastic bags. The two men accompanied him to the door. According to Komnov, they are not
allowed to go beyond that point as they are the service staff of the detention center. Then the tape
shows Magnitsky’s profile. He bends down to pick his bags. Then the camera shows him from
above. However, Magnitsky’s relatives have not seen this tape yet, so it not possible to confirm
at the moment that the man on the tape is actually Magnitsky.
What happened to Sergey Magnitsky in Matrosskaya Tishina?
There is no video tape that would show how Magnitsky arrived at Matrosskaya Tishina.
The head of Matrosskaya Tishina Detention Center, Fikret Taguev recounts the last hours
of Sergey Magnitsky the following way:
“He was brought to the detention center at 6:30pm. He walked in by himself, holding his
bags. He was in a normal condition. He was brought to the nurse on duty. The nurse called for
the surgeon, Dr Gauss. The patient started “to play”, which means he went hysterical. He asked
“Why have you brought me here?” Then he started to threaten. He didn’t want to leave the
nurse’s room. The stuff on duty “pacified” and handcuffed him. They called a psychiatric doctor
and put Magnitsky into the single 15 square meter room where he “awaited” the arrival of the
doctor. However, the psychiatrists did not enter that room as the patient felt badly by the time
they arrived. His heart stopped beating at 9:50pm after the reanimation attempts which were
carried out by the nurse named Sasha who was later joined by doctors.
Tagiyev showed to the commission members the following abstract from the medical
November 16, 2009
6:30 p.m. Review by the doctor on duty. Diagnosis: Acute Cholecystitis and Pancreatitis.
Hospitalized to the surgery department. For dynamic monitoring and treatment.
7:00 p.m. The patient behaves inadequately. Talks to a “voice,” looks disorientated, and
shouts that someone wants to kill him. He condition is diagnosed as psychosis. The emergency
doctor was called (order No. 904253). There are no body damages apart from traces of handcuffs
on the wrists. It was planned to make an anti-spasm therapy prior to the arrival of the psychiatrist
but such therapy was not possible due to the aggressive behavior of the patient.
9:15 p.m. The patient was surveyed again as his condition deteriorated. When the
psychiatrist was examining the patient the latter’s condition deteriorated sharply. He lost
conscience. The reanimation procedure was started (indirect heart massage and ventilation of
lungs using the Ambu pillow). The patient was transferred to the special room where he was
received an artificial ventilation of lungs and a hormones injection. Reanimation procedure
lasted 30 minutes. At 9:50pm the patient died.
The body was transferred to morgue No. 11. The preliminary diagnosis is cardiomiopathy
– an acute cardiac deficiency. Gallbladder and pancreas are in a perfect condition.” This
diagnosis stemmed from an indentified source as the result of the official autopsy was not known
yet. As Tagiyev learnt from a colleague who participated in the autopsy, it turned out that
Magnitsky had an abnormally large heart, twice larger than normal. One has to search for the
cause of his death in the four days following the November 12 court decision that rejected his
request to release him from the jail.
Here’s the version of surgeon Alexandra Gauss:
She saw Magnitsky in the nurse’s cabinet. He was accompanied by the guard from
Butyrka and he was already in a special isolation cell.
As it was mentioned earlier, the transfer documents were delivered by the young nurse
from the ambulance. Magnitsky said that he had been sick since Thursday, November 12 when
he started feeling abdominal pains.
During the survey, his abdomen was tense; he felt pains in both the left and right parts of
the area which is an obvious symptom of pancreatitis. In the medical records, she read about a
prescription to undergo a repeat ultrasound examination. During the survey, Magnitsky had
twice a desire to vomit (with no actual vomiting), and she gave him a hygienic bag. Initially, he
was calm, agreed to a hospitalization and signed on the medical records.
At 7 p.m. suddenly he started to behave anxiously, started to talk: “Why are you
inspecting my bags?” He had three bags and two plastic bags. She replied to him “Nobody is
inspecting your bags.” He: “No, you see that they are being inspected now!” and seized the
bench that was in the isolation cell where he was during the questioning. (Afterwards we
observed this isolation cell, and it was apparent that it would be hard to swing the bench inside
the cell due to the cell’s small size.) He then sat down and covered himself with a plastic bag and
said that they want to kill him. It continued for a short period of time and he hit twice the floor
with the cot, then put it back and scared and started to hide behind the plastic bag again, which
she gave to him. According to her opinion it looked like acute psychosis and delirium of
persecution. That is why they called for psychiatric emergency.
When asked whether his hands were damaged, she replied that there were signs of
handcuffs and it was reflected in medical card. When asked how the psychiatric emergency was
called, what her own actions were, she said that called for enforcement DPNSI (Fedorovich) who
came with approximately eight people. They put handcuffs on Magnitsky’s hands. He didn’t
oppose them, but stayed in handcuffs, looked inadequate and gazed round. After handcuffs she
ordered to make him injection in order diminish pain in stomach.
Medical assistant Sasha made injection under her prescription. Injection was made in her
absence, she left entrance department and came to surgery. She didn’t see psychiatrists.
At 21:20 a female voice called from entrance department and informed that a patient is on
the floor in the fourth isolation cell. Medical conditions are questionable.
The doctor on duty, Nafikov, ran in to perform resuscitation procedures. The medical
assistant Sasha was conducting resuscitation procedures with the help of special equipment
(cushion of Ambu). There were no handcuffs on Magnitsky’s hands. At 21:50 heart stopped.
Testimony of DPNSI Officer Dmitry Markov (Fyodorych) who was pacifying
Markov was accompanied by his deputy, Lieutenant Kuznetsov. When we asked him
whether Magnitsky’s hands were blue (as it was known from Magnitsky’s mother, she found that
his hands were damaged), he replied that he saw only signs of handcuffs. He was brought to
Matrosskaya Tishina in handcuffs. He came to the entrance department himself. Thirty minutes
after fit of psychosis already in the isolation cell, the handcuffs were taken off him, he was
normal. Psychiatric emergence came to the room and during the examination he felt bad, he was
sitting on the floor, he had obvious difficulty breathing and he was sweating.
Medical attendant Alexander Alexandrovitch Semenov (Sasha), in the presence of
Head of Medical Department of Matrosskaya Tishina Ibatulina and Head of SIZO Matrosskaya
Tishina Tagiyev said that he made injection before psychosis. He made an anti-spasm injection
and left the room. Returned back during the psychosis, heard that Magnitsky shouted “Where is
my stuff?” Psychosis started at 7 p.m.
Psychiatric emergency was called for examination at 7.30 p.m. Emergency team arrived
at 8.48 p.m. When emergency doctors entered to the special cell, Sergey was sitting on the cot,
felt very badly with his eyes unfocused. Al the time from 7.30 p.m. up until the arrival of the
Emergency team, he was left unattended without medical support. The supervision was
conducted by the guard on duty through the little box in the cell door. The guard also uncuffed
Sergey. Unfortunately we have not received any answer to our question: whether it is a normal
behavior to leave the patient unattended without any medical supervision, due to the fact that
medical superiors did not allow medical assistant Sasha to speak. Sasha was looked scared.
To our question what he thinks about all of this, he replied that it is a typical event:
psychosis and death.
Our conversation with Dr. Vitaly Vladimirovich Karnilov, the psychiatrist from the
emergency ward (over the telephone) helped to understand more in details:
The ambulance arrived to the Matrosskaya Tishina Detention Center at 8 p.m., and not at
8.48 p.m. as it was reported earlier by the administration, however, the doctors were not allowed
to go through to see the patient, as such they were waiting for an hour. Dr Karnilov further
added: “Being the doctors from the Emergency Services, we were waiting in case our help in
providing reanimation actions would be requested. Finally we were called upon. We entered into
the cell. The patient was lying on the floor lifeless and we concluded that he had already died.
There were a number of medical personal there. Then a male doctor came in. I do not recall
seeing any female doctor there.”
Many statements hardly match. The emergency ambulance doctor appears to be
‘missing,’ the stories by Dr Gauss and Medical Assistant Sasha about the timing of injection
before or after he allegedly developed symptoms of psychosis contradict each other. Statements
by various people are conflicting about every detail of the timing of events, his behavior during
the psychotic episode, and everything that happened to him after placing him in isolation ward
There is no plausible explanations could be given to these, as all these people have been
questioned on a number of occasions now by the investigators.
The Head of Matrosskaya Tishina insisted on the heart failure being the cause of death, as
was presented by the investigators, saying that pancreatitis is not the correct diagnosis, that
everything was conducted in correct manner, in particular initial transfer of Magnitsky to
Butyrka Detention Center, further supporting himself that Magnitsky was not required any
medical treatment. He also added that possibly Magnitsky was under deep stress, when the court
on November 12, 2009 extended his pre-trial detention and that fact could provoke his death,
saying that the heart is unpredictable and this could happen with anyone.
The inflamed stomach and echocardiogram heart examination conducted shortly prior to
Magnitsky’s death do not support this version. As for his psychosis – based on Sergey saying
that someone wants to murder him – it could have been an appropriate response to what was
happening to him. In addition, he was demanding his personal belongings to be returned (and
indeed his notes were gone missing), which further explains how his reaction was indeed
adequate to the surrounding reality at that time.
The reaction and behavior of Dr Gauss raises more questions. Why did she leave
Magnitsky unattended in this special cell in a critical medical condition without any medical
support? Dr Gauss mentioned that Magnitsky was attempting to vomit repeatedly, which clearly
confirms worsening of the pancreatitis. Also she mentioned that Magnitsky’s psychosis was
short and he came down quite quickly. Why he then was not transferred immediately to the
Based on the witness statements provided by the medical personal of the Matrosskaya
Tishina Detention Center, the members of the POC could not came to a conclusion as to what
really happened with Magnitsky when he arrived there. One thing is clear to us: the reports by
doctors contradict each other. It is obvious that they are deliberately concealing the truth. Indeed,
there is no assurance that Magnitsky was indeed experiencing psychosis, which prevented him
being transferred to the surgery unit.
The main conclusion that can be made is that no medical help was provided to
Sergey Magnitsky in Matrosskaya Tishina Detention Center when it was urgently required
and for which purpose he had been transferred from Butyrka Detention Center.
An ill person in severe condition was effectively left without medical attention (for 1
hour 18 minutes) to die in an isolation ward.
A man who is kept in a detention center is not capable of using all the necessary means to
protect either his life or his health. This is a responsibility of a state which holds him captive.
Therefore, the case of Sergey Magnitsky can be described as a breach of the right to live. The
members of the of the civic supervisory commission, have reached the conclusion that
Magnitsky had been experiencing both psychological and physical pressure in a detention center,
and the conditions in some of the wards of Butyrka can be justifiably called torturous. The
people responsible for this must be punished.
The reform of the penitentiary system, when it was split out of the Interior Ministry and
transferred to the Ministry of Justice, was aimed at the separation of the latter from the inquest.
The prosecution must be independent from the detention. It must keep detainees and convicts in
the respective institutions following the conditions set out by the law and not by inquest’s
attitude to them. The interference of the inquest in determining the conditions for the convicts
and accused ones is not acceptable. Nevertheless, this happens quite often. It is an offense
against the law. The members of the Public Oversight Commission believe that it is necessary to
find out the role of the investigators in creating conditions and subjecting Magnitsky to them in
detention, and the degree of their responsibility.
Magnitsky’s situation highlighted the fact that the doctors of the investigative isolation
ward failed to fulfill their responsibilities. We believe that this is due to their dependence on the
administration of the penitentiary system’s institutions. The health care in the above-mentioned
institutions must not be a part of the prosecution authority, it must be independent.
It is necessary to set out the legal framework of transfers of the detainees from one
detention center to another, clearly define the rules of the transfer from one isolation ward to
another, the responsibility for the unlawful worsening of jail conditions. We must prevent what
happened to Sergey Magnitsky from happening again.
We must provide the solution to the long overdue question of choosing the right punitive
measures for the accused in custody, especially for ones accused in economic crimes. We must
use alternative measures of restraint; we do have them.
We must define by law under which conditions an accused person must not be placed in
the isolation ward, when he or she must be set free, when the alternative measures of restraint
must be used. Courts, while deciding on the measures of restraint, must take into consideration
the health conditions of the accused.
We must put the Russian normative acts in accordance with the European penitentiary
rules. This discrepancy was a precise reason for the complaints of Magnitsky regarding the
conditions under which detainees are kept in the isolation wards, limitations of the shower use,
the failure to provide the necessary medical help, isolation from the communication with the
family and public members and others.
The participation in the court hearings is accompanied by the cruel and disgraceful
conditions which disgraces a human life. This includes the preparation procedures of
transportation to court and the transportation itself, and the conditions in court, including
deprivation of hot meals. This is an old and general problem, but the one which is not at all
V. Borschev, Chairman of the Public Oversight Committee, Moscow
L.Volkova, Deputy Chairman of the Public Oversight Committee, Moscow
T. Flerova, Secretary of the Public Oversight Committee, Moscow
L. Alpern, Member of the Public Oversight Committee, Moscow
L. Dubikova, Member of the Public Oversight Committee, Moscow
Z. Svetova, Member of the Public Oversight Committee, Moscow