CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 10 janvier 2012

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RUSSIA   (Application no. 48977/09)               JUDGMENT     STRASBOURG   10 January 2012   FINAL   10/04/2012   This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision . In the case of Arutyunyan v. Russia , The European Court of Human Rights (First Section), sitting as a Chamber composed of:   Nina Vajić, President,   Anatoly Kovler,   Peer Lorenzen,   Elisabeth Steiner,   Khanlar Hajiyev,   Mirjana Lazarova Trajkovska,   Julia Laffranque, judges, and Søren Nielsen, Section Registrar, Having deliberated in private on 6 December 2011, Delivers the following judgment, which was adopted on that date: PROCEDURE 1.     The case originated in an application (no. 48977/09) against the Russian Federation lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by a Russian national, Mr Armen Vladimirovich Arutyunyan (“the applicant”), on 6 August 2009. 2.     The applicant was represented by Mr O. Ivanov, a lawyer practising in Krasnodar. The Russian Government (“the Government”) were represented by Mr G. Matyushkin, Representative of the Russian Federation at the European Court of Human Rights. 3.     The applicant alleged, in particular, that he had been denied adequate medical assistance during an unreasonbaly long pre-trial detention, that a certain period of his pre-trial detention had lacked any legal basis and that the conditions of his detention had been unsuitable for a person in his state of health. 4.     On 11 March 2010 the President of the First Section decided to give notice of the application to the Government. It was also decided to rule on the admissibility and merits of the application at the same time (Article   29   §   1). Further to the applicant’s request, the Court granted priority to the application (Rule 41 of the Rules of Court). THE FACTS I.     THE CIRCUMSTANCES OF THE CASE 5.     The applicant was born in 1970 and lived until his arrest in Krasnodar. A.     Applicant’s state of health prior to his arrest 6.     In 2004 the applicant had two operations: a retinal laser coagulation of the left eye and amputation of toes of the right foot. In the same year, unsuccessful surgery led to the entire loss of sight in the applicant’s right eye. Two years later, he underwent a kidney transplantation.   In August 2007 he was admitted to Krasnodar Regional Clinical Hospital no. 1 where he underwent a number of tests and received treatment for diabetes. 7.     In 2008 the applicant’s hip joints were replaced with prostheses in the Heidelberg Town University Clinique in Germany. As follows from a letter issued on 22   July 2008 by the head of the Clinique Medical Service, the applicant was required to make multiple monthly visits to the Clinique for check ups and medical treatment. The first such appointment was scheduled for August 2008. 8.     Extract no. 46707 of the applicant’s medical record drawn up on 22   December 2008 by a medical commission in Krasnodar Regional Clinical Hospital no. 1 reads as follows: “[The applicant]... is a disabled person [officially recognised as having a] 1 st degree disability; [he] underwent inpatient treatment from 12 to 22 December 2008. Clinical diagnosis: subcompensated type 1 insular diabetes, severe state. Diabetic micro- and macroangiopathy. Diabetic glomerulosclerosis. End stage chronic renal failure, terminal stage. Diabetic retinopathy of both eyes; retinal detachment of the right eye. Dysmetabolic encephalopathy. Gastroenteropathy. Myelotoxic anaemia. Polyneuropathy. Polyserositis. Diabetic foot. Condition after amputation of the 4 th and 5 th toes on the right foot. Allotransplantation of a donor kidney (November 2006). Permanent immunosuppression therapy. Osteochondritis deformans juvenilis of hips. Condition after total hip replacement. Acute respiratory disease. Because of his main illness and associated complications, the state of the patient’s health is serious ... ... The patient was informed about the seriousness of his condition and was warned that if he failed to comply with the strict fluid balance, diet, mandatory lab control, [and in the absence of] strict and regular use of medicines (particularly the immunosuppressive drugs) kidney transplant rejection and diabetes could occur.” B.     Criminal proceedings against the applicant and detention 9.     On 1 February 2009 the Novorossiysk Town Investigative Department of the Krasnodar Regional Prosecutor’s Office instituted criminal proceedings against the applicant on suspicion of involuntary manslaughter. 1.     Arrest and authorisation of detention on remand 10.     Eleven days later, the applicant was arrested. According to the prosecution authorities, on 1 February 2009 in a local restaurant the applicant, a prominent criminal leader, organised an assault in which five individuals were severely injured. One of the victims died as a result. 11.     On 14 February 2009 the applicant’s detention on remand was authorised and he was placed in temporary detention facility no. 5 in Krasnodar. The facility occupied the ground and last floors of a four-storey building constructed in 1938. The administrative offices and technical facilities were located on the ground floor of the building while the cells were located on the fourth floor. The building was not equipped with a lift. 12.     On the applicant’s admission, the acting director of the facility issued a report allowing the applicant to have a number of objects usually prohibited for detainees. The list included a wheelchair, a glucometer, a tonometer, specific medicines, disposable masks, napkins, an additional mattress and a cushion for the wheelchair. 13.     A week later the applicant was charged with having organised aggravated involuntary manslaughter. 14.     On 21 February 2009 the applicant’s lawyers lodged a request with a senior investigator of the Krasnodar Regional Investigative Department, asking for the applicant to be transferred to a specialised prison medical facility and to have him examined by a number of medical specialists practising in the Krasnodar Region. They alleged that the detention facility was unequipped to accommodate the applicant’s needs. In support of their request the lawyers relied on medical certificates issued prior to the applicant’s arrest and argued that the applicant was a seriously ill person whose state of health was bound to deteriorate drastically in the conditions of the detention facility. 15.     The investigator dismissed the request on the same day, finding that prison doctors had examined the applicant on his admission to temporary detention facility no. 5 and had found him fit to be detained in a regular detention facility and to participate in investigative procedures. The investigator also stressed that the applicant was under constant medical supervision by prison doctors and that he received medical advice from other qualified and experienced medical specialists. According to the investigator, the applicant received the medicines necessary to maintain his health. 16.     On 24 February 2009 the head of the Krasnodar Regional Nephrological Centre (hereinafter – the Centre), assisted by another doctor from the Centre, examined the applicant. They found that, in addition to the illnesses listed in extract no. 46707 drawn up on 22 December 2008, the applicant suffered from gonarthrosis, cardiac dropsy, secondary hyperparathyroidism, hyperuricaemia, hypercholesteremia, viral hepatitis type C and chronic cytomegalovirus [salivary gland virus] infection. The doctors also concluded that the applicant’s diabetes was in the decompensation phase. They laid down a long list of recommendations to be followed, medical tests and examinations to be performed and drug regimens to be complied with, indicating, inter alia , the frequency and dosage of each medicine prescribed to the applicant. 17 .     In March 2009 the applicant’s lawyers, relying on extensive medical evidence, including extract no. 46707 from the applicant’s medical history, complained to the Oktyabrskiy District Court about the investigator’s refusal to admit the applicant to a prison hospital. On 6 March 2009 the lawyers amended their claims, citing paragraph 9 of Decree no. 54 issued by the Government of the Russian Federation on 6   February 2004, by virtue of which individuals suffering from diabetes whose 24-hour dose of insulin exceeds 60 units may be relieved from serving sentences in correctional institutions. The counsel argued that the applicant’s 24-hour regimen required 71 insulin units and therefore his detention in a regular detention facility ran contrary to the domestic legal requirements. 18.     The applicant’s medical history, submitted by the Government, shows that on 5 March 2009 he refused to submit to blood glucose level testing and to take an evening dose of prescribed medicines, including insulin, arguing that his treatment was inadequate. Between 6 and 20 March 2009 the applicant occasionally refused to take an increased dosage of medicines, complaining about side-effects such as nausea and fatigue. 19.     On 10 March 2009 a medical assistant of temporary detention facility no. 5 issued a medical certificate describing the applicant’s health. The relevant part of the certificate read as follows: “[The applicant] does not have any complaints at the time of the examination. ... 2.     Objective examination data: At the time of the examination [the applicant’s] state of health is satisfactory [and] corresponds to his existing illnesses ... 3.     Diagnosis: subcompensated type 2 insular diabetes; serious condition; [the applicant is receiving] insulinotherapy. Allotransplantation of a donor kidney (November 2006). 4.     Conclusion: no restrictions to [the applicant’s] detention in temporary detention facility ...” The applicant submitted that no medical tests or analyses had been performed during the examination on 10 March 2009. A simple observation by “three women wearing white coats” had resulted in a finding that his illnesses were not an obstacle to his detention in the detention facility. 20.     On 11 March 2009 the Oktyabrskiy District Court of Krasnodar dismissed the lawyers’ complaint, repeating verbatim the text of the investigator’s decision of 21 February 2009. In addition, the District Court noted that a medical commission had confirmed the applicant’s diagnoses but noted that he did not need urgent medical assistance and that his state of health did not preclude his participation in investigative procedures. The District Court concluded that the applicant could be effectively provided with medical assistance and treatment in the temporary detention facility. 21.     The applicant’s lawyers appealed. 22.     On 20 March 2009 the applicant went on a hunger strike and refused to take his medicines, notifying the authorities that the hunger strike was his last attempt to draw their attention to his situation. Three days later the applicant’s lawyers asked a senior prosecution investigator to authorise a complex medical examination of the applicant by specialists of the Health Ministry of the Krasnodar Region and to transfer him to a prison hospital. Similar requests were sent by those lawyers to various domestic authorities. The lawyers also complained about the conditions of the applicant’s detention, in particular the absence of daily outdoor recreation and physical exercise due to the impossibility for the applicant to descend in his wheelchair from the fourth floor of the detention facility, where his cell was, to a recreation yard. 23.     As follows from the applicant’s medical record, on 24 March 2009 he resumed taking the prescribed medicines and stopped his hunger strike. Between 10 and 29 April 2009 the applicant again refused to take his medicines, complaining of a rapid deterioration in his health and an absence of adequate medical attention. 24.     On 22 April 2009 the Krasnodar Regional Court upheld the decision of 11 March 2009, endorsing the District Court’s reasoning. 25.     A week later a medical commission comprising medical specialists of the detention facility and doctors from the Centre examined the applicant and issued the following report: “Having studied the health complaints, the medical history, objective data and results of the medical examination ..., the commission is bound to confirm that [the applicant’s] kidney transplant has been rejected as a result of his refusal to take prescribed immunosuppressants. The commission’s attention was drawn to the fact that despite numerous discussions about the consequences of such a refusal, [the applicant] firmly continued refusing to take the above-mentioned medicines. He also stated that he would refuse any treatment provided in detention facility no. 5 in respect of any complications arising from his refusal [to take the medicines]. [The applicant] stated that he had refused to take medicines prescribed by the doctors from the Centre because he considered that he had not received effective medical assistance in respect of his complaints about toothache, pain in the area of his hip replacements and problems with his eyes. In an efficient manner, [the applicant] was once again informed that the deterioration of his health was entirely due to his intentional refusal to take the medicines (immunosuppressants) prescribed by the specialists from the Centre and did not result from any other illnesses. The commission’s conclusion is as follows: The final diagnosis is: Type 2 insulin diabetes in an advanced form, [the patient is receiving] insulinotherapy. Diabetic nephropathy , nephroangiosclerosis, chronic renal failure [in the end stage], condition after the donor kidney transplant (2006). Kidney transplant rejection crisis on 28 April 2009 caused by an intentional refusal to take immunosuppressants. Diabetic proliferative retinopathy, condition after surgery on the retinal detachment of the right eye, partial massive hematopsia of the left eye, condition following laser coagulation of the left eye. Diabetic angiopathy of the vessels of the lower extremities, diabetic foot, condition following the amputation of the fourth and fifth toes of the right foot. Condition following complete hip replacement (2008). Morbid obesity (extreme condition). It is imperative that [the patient] starts undergoing outpatient haemodialysis and resumes taking the necessary medicines, in particular, immunosuppressants. [The applicant] was offered an outpatient course of the haemodialysis which is to be administered by specialists from the Centre with special medical equipment in [detention facility] no. 5. He was also notified that his refusal to take [medicines], irrespective of his decision to undergo haemodialysis, would lead to a full rejection of the transplant. Following this discussion [the applicant] gave his firm consent to undergo haemodialysis [and] a subclavian insertion and to take medicines in accordance with the course of immunosuppressants prescribed. Due to the fact that [the applicant’s] eyesight is very poor, a text of the document confirming his consent to undergo haemodialysis [and] a subclavian insertion and to take medicines in accordance with the course of immunosuppressant treatment prescribed was prepared and read out in the presence of the members of the commission and was signed by [the applicant].” 26.     On 30 April 2009 the applicant had his first session of haemodialysis which was performed in a specially equipped room on the ground floor of facility no. 5. The haemodialysis was carried out by specialists from the Centre, as the prison doctors were not licensed to perform the procedure. According to medical documents provided by the Government, the applicant received haemodialysis at least once every two days, with each session lasting from four to six hours. Prison medical personnel examined the applicant daily, recording his blood pressure, body temperature and blood glucose level, monitoring the fluctuation of his body weight (between 149 and 136 kilograms), controlling his intake of insulin, adjusting the drug regimen to meet his needs, and so on. The medical documents show that the applicant frequently underwent various X-ray exams and ultrasound scans, and was taken to the Centre and a civil hospital for clinical testing and examinations by various medical specialists. He also underwent a number of minor operations involving insertion and replacement of catheters and endured lengthy procedures, lasting for hours at a time, required to administer medicines intravenously. The medical personnel of the detention facility consulted specialists from the Centre on a daily basis, including its head, for advice on adjusting the applicant’s treatment to the changes in the state of his health and to his complaints. 27.     In the meantime, on 9 April 2009 the Oktyabrskiy District Court extended the applicant’s detention until 12 June 2009, having considered that the gravity of the charges, as well as the applicant’s liability to abscond, re-offend and obstruct justice warranted such an extension. On 12   June 2009 his detention was extended for an additional two months, until 12   August 2009, with the District Court using identical reasoning to that in its decision of 9 April 2009. The detention order of 12 June 2009 became final on 8   July 2009 when the Krasnodar Regional Court concluded that the District Court had correctly linked the applicant’s liability to abscond and interfere with the investigation to the gravity and the character of the charges against him. 28 .     On 11 August 2009 the Oktyabrskiy District Court again extended the applicant’s detention for an additional two months, finding that the gravity of the charges against him, information about his personal history and his liability to abscond warranted the extension. Having heard a prison doctor and studied medical certificates issued by the medical personnel of the detention facility, the District Court also found that the applicant’s state of health was stable and did not preclude his detention in the temporary detention facility. The decision was upheld on appeal on 26 August 2009. 29.     On 24 September 2009 the applicant’s scheduled haemodialysis session was interrupted due to the breakdown of the catheter. The catheter could not be replaced until the following day, when haemodialysis was resumed. On 5 October 2009 an ophthalmologist from the microsurgical department of the Regional Clinical Hospital, having examined the applicant and studied his medical history, found that given the deterioration of the applicant’s eyesight surgery had no prospects of success. 30 .     On 9 October 2009 the Oktyabrskiy District Court examined an investigator’s request for a further extension of the applicant’s detention until 24 November 2009. Having accepted the investigator’s request, the District Court ruled as follows: “[The applicant] organised a particularly serious criminal offence, as a result of which [the] victim ... died and serious health damage was caused to Mr P. and Mr V. Following an examination of [the applicant’s] personal history, it was established that on 20 June 1994 the Prikubanskiy District Court of Krasnodar had found him guilty of criminal offences proscribed by Article 218 § 2 and Article 224 §   1 of the RSFSR Criminal Code; the record of the criminal conviction had expired; previously [he] had been charged on a number of occasions with having committed criminal offences proscribed by Article 163 § 2 [and] Article 330 § 3 of the Russian Criminal Code; he was absolved from criminal responsibility on the basis of amnesty acts. Taking into account the information pertaining to [the applicant’s] personal history and having regard to the serious nature of the criminal offence committed by [the applicant], the investigation rightfully considers that, if released, [the applicant] will take active steps to influence witnesses, victims and other parties to the criminal proceedings, and that [he] will destroy evidence or, by other means, obstruct the objective investigation in the case. Moreover, [the applicant] may flee the territory of the Russian Federation to avoid criminal responsibility, rendering his criminal prosecution impossible. In this connection, the investigator concluded that there were no grounds to change the preventive measure [applied to the applicant] to one which did not involve him being isolated from society and being detained ... The defence lawyers and [the applicant] argued against the investigator’s request. [They] considered that the investigation had not put forward any item of evidence showing that [the applicant] could influence the witnesses and victims or [that he] could obstruct the investigation in any other way. [They] asked to take into account the impossibility for [the applicant] to continue being detained as he was very ill and relied on a wheelchair for mobility. He had a kidney transplant which functioned poorly and underwent haemodialysis four times a week. [They] asked for the applicant to be provided with adequate medical assistance in a medical facility under doctors’ supervision. Having studied the material presented [and] having heard the parties to the proceedings, the court finds that it is necessary to extend [the applicant’s] detention as [the applicant] is charged with having organised a particularly serious criminal offence, there is sufficient information to conclude that, if released, he may abscond during the investigation and trial or [he] may obstruct the criminal proceedings by other means. The investigator has still to perform a number of investigative procedures in the case. The information about the circumstances of the case which were presented to the court, the gravity of the charges, [and] the personal history of the accused, who has been criminally charged before [and] who is the breadwinner for a minor child, confirm the court’s conclusion that it is impossible to change the preventive measure [applied to the applicant] to a more lenient one. The court is of the opinion that detention is the sole preventive measure corresponding to the requirements of the criminal proceedings and ensuring the thoroughness and objectivity of the pre-trial investigation having regard to the particular seriousness of the criminal offence committed by [the applicant]. The court was not provided with material evidence showing the presence of extenuating circumstances which could have been taken into account by the court when it determined the issue of the extension of [the applicant’s] detention.” 31.     On 19 October 2009 the head of the Centre examined the applicant and issued the following conclusion: “[his] condition corresponds to the severity of the main and concomitant illnesses, in general [it] is stable and relatively satisfactory”. 32.     The applicant’s lawyer requested a senior investigator of the Krasnodar Regional Investigative Department to transfer the applicant to a prison hospital, arguing that his health had continued to deteriorate in the absence of adequate medical assistance. Three days later the senior investigator dismissed the request, stating that the deterioration of the applicant’s health was the direct result of his refusal to accept medical assistance and to follow the recommendations given by the medical personnel of the detention facility. The senior investigator also noted that the current state of the applicant’s health was stable and did not call for his admission to a prison hospital. 33.     Having decided to obtain an independent expert opinion on the applicant’s state of health, his lawyers submitted available medical records, including those drawn up in the detention facility, to the State-owned Scientific Research Institute of Transplantology and Artificial Organs in Moscow (hereinafter – the Institute). 34.     On 12 November 2009 they received a letter from the head of the Kidney and Liver Transplants Department of the Institute, which, in so far as relevant, read as follows: “... it is impossible to make a firm conclusion about [the applicant’s] state of health on the basis of the medical documents presented. However, it is plainly evident that at the present time the kidney transplant is not functioning and the patient’s life is supported by the haemodialysis prescribed. The non-functioning transplant may have to be removed if it is a source of intoxication. Another kidney transplantation is not warranted. Having regard to the severity of the [applicant’s] primary and corresponding illnesses, the presence of the non-functioning transplant, and [the applicant’s] detention in the temporary detention facility in the absence of adequate clinical instrumental laboratory control, there is a real risk that acute complications leading to [the applicant’s] death will develop. A full examination, preferably in a hospital, is advisable to determine the further course of medical treatment to be taken, namely, the provision of medicines and potential surgery.” 35 .     On 20 November 2009 the Oktyabrskiy District Court authorised a further extension of the applicant’s detention until 24 January 2010, finding that the grounds warranting his detention, including the gravity of the charges and the applicant’s liability to abscond, had not changed. The District Court concluded that the defence lawyers’ arguments pertaining to the applicant’s health did not outweigh the grounds calling for his detention. 36 .     On 3 and 15 December 2009 the District Court examined the lawyers’ requests for the applicant’s release and for his transfer to a medical institution respectively. Both requests were dismissed as the District Court considered that the applicant was receiving sufficient medical assistance in detention facility no. 5. A similar request for the applicant’s placement in a prison hospital was dismissed by the senior investigator on 16 December 2009. 37.     In the meantime, on 9 December 2009 the applicant was examined by a cardiologist and a phlebologist from civil hospitals. He was diagnosed with ischemic heart disease, diabetic angiopathy and thrombosis of the lower extremities. Treatment was prescribed. A week later the applicant again experienced problems with the intravenous catheter, making it impossible for him to complete the haemodialysis scheduled for that day. In the following week, urgent consultations between the medical personnel of the detention facility and specialists from the Centre took place for the purpose of finding a solution to the problem. On 25   December 2009 four leading medical experts from the Centre and a civil hospital performed surgery on the applicant in the detention facility with a view to installing a twenty-centimetre central vein catheter. Following a number of unsuccessful attempts, the doctors were finally able to insert it. Three days later the applicant refused to undergo haemodialysis, complaining of pain in the area of the catheter insertion and extreme fatigue and weakness. On the following day, given the serious deterioration of his health, the applicant agreed to go down to the ground floor to undergo haemodialysis. The applicant’s medical records show that whenever his catheter malfunctioned and was replaced, he was provided with a course of antibiotics to prevent infection. 38.     On 25 December 2009 a prison physician examined the applicant and issued a medical certificate describing his state of health. The relevant part of the certificate reads as follows: “Since the beginning of his detention in [detention facility no. 5] the patient has been under constant medical supervision; the level of glucose in his blood (before every meal), blood pressure, fluid balance, body temperature and other indicators are monitored daily. An examination of all the relevant biochemical blood parameters, including at cyclosporine level, and all additional medical examinations authorised by medical specialists (ultrasound scanning of the heart, vessels, abdominal cavity, kidneys ..., adrenal glands, bladder and prostate; X-ray examinations of the chest and hip joints, and electrocardiogram) are performed whenever necessary, but no less than once a week. On a number of occasions the patient has been examined by medical specialists (an endocrinologist, a urologist, a surgeon, a traumatologist-orthopaedist, an ophthalmologist, a vascular surgeon and a cardiologist) from municipal health institutions. The patient is under ongoing supervision by doctors from the Nephrological Centre, who perform scheduled outpatient haemodialysis three or, if necessary, four times a week. On a number of occasions [the applicant] was examined by a specialist in kidney transplantology – Professor Ya., Doctor of Medicine, in the detention facility; [Dr Ya.] is also constantly informed of the results of the clinical supervision, and of complex biochemical and other examinations. Medical specialists regularly organise consultations with Dr Ya.’s participation (the most recent one [took place] on 15   December 2009); the course of future medical treatment and necessary diagnostic measures are determined during [those consultations]. The patient is also under constant supervision by an endocrinologist; the level of glucose in his blood is measured daily before every meal; a log is kept of the dosage of glycaemia [and] insulin [he receives]; [and] consultations about the insulin dosage regimen take place. During his detention in [detention facility no. 5] [the applicant] constantly violated his dietary regimen [and] refused to keep a “dietary diary”; on a number of occasions [he] refused to take insulin and medicines; after 10 April 2009 he completely refused to take immunosuppressive medicines, which are necessary for his kidney transplant to function. [The applicant] willingly and knowingly impaired his health, despite regular discussions about the necessity of renewing the course of the immunosuppressive medicines and the patient’s awareness of the consequences of his refusal of the treatment ... As a result of those actions [the patient’s] kidney transplant stopped functioning and since 30 April 2009 [he] has been undergoing permanent haemodialysis, despite the fact that he has resumed taking medicines and begun complying with the [recommended] dietary regime. The haemodialysis is performed by specialists of the Regional Nephrological Centre in a special cell in [detention facility no. 5]. [The applicant] is afforded an opportunity to rest for the necessary period of time in a special armchair after each scheduled session of haemodialysis. After the glucose level in his blood has been checked ..., with the warders’ help and in the presence of a medical specialist [the applicant] ascends a staircase to his cell with the wheelchair. When ascending the staircase in small steps being held by the arms, [the applicant] rests in his wheelchair after every 2 or 3 flights of stairs for as long as necessary. If necessary, the above-mentioned parameters are measured. On the upper floor of the detention facility building [the applicant] is taken to his cell in the wheelchair, where he is examined by medical personnel if necessary. ... Medical specialists – an endocrinologist, ophthalmologist, traumatologist-orthopaedist, vascular surgeon and specialists of the Nephrological Centre – consider that at the present time the patient’s health is stable, despite his existing serious chronic illness. [The applicant’s] health does not at present call for urgent medical assistance or inpatient treatment. The necessary medical and diagnostic procedures prescribed by medical specialists are performed in corpore and timeously. Therefore, the deterioration of [the applicant’s] health was entirely caused by his willing and knowing actions. The administration of the detention facility and the medical unit of the detention facility, with the participation of medical specialists in the fields connected to [the applicant’s] illnesses, implemented an entire set of medical measures necessary to maintain [the applicant’s] health and to eliminate the consequences of his wilful actions. As a result of those measures [the applicant’s] state of health is stable and does not preclude his detention in [detention facility no. 5].” 39.     In January and February 2010 the applicant received haemodialysis at least once every two days. On 14 January 2010 a surgeon was called in to examine the applicant in response to his complaints of severe pain in the right knee, which intensified during physical activity. The applicant was diagnosed with degenerative arthritis of the right knee joint and prescribed treatment. On 22 January 2010 he underwent another replacement of the catheter in the detention facility. Another replacement was carried out in the detention facility a month later. 40 .     In the meantime, in the beginning of January 2010 the prosecution authorities closed the investigation and transferred the case file to the trial court. On 21 January 2010 the Oktyabrskiy District Court scheduled the first trial hearing and held that the trial proceedings were to be conducted in camera because the applicant and his five co-defendants had criminal records and were liable to threaten witnesses and other parties to the proceedings. The District Court also examined the lawyer’s petition for the applicant’s release and dismissed it, finding that the applicant’s health did not preclude his detention on remand and concluding that “the preventive measure applied in respect of [the applicant] should remain unchanged”. However, it agreed to call two medical experts proposed by the defence to determine whether the applicant was in need of a complex medical examination or any specific medical procedures. 41.     The applicant’s lawyers appealed, arguing that the applicant’s detention after 24 January 2010 had been unlawful, as the District Court had failed to extend his detention officially and its decision to dismiss the request for the applicant’s release could not substitute a proper detention order. 42 .     At the hearing on 28 January 2010 the lawyers again asked the District Court to release the applicant as there were no grounds for his continued detention. They also argued that the time-limit for the applicant’s detention had expired on 24 January 2010 and that his detention after that date had been unlawful as it was not covered by a proper legal order. A prosecutor lodged a counter-claim, asking to extend the applicant’s and his co-defendants’ detention until 11 July 2010. The District Court accepted the prosecutor’s request and collectively extended the applicant’s and his co-defendants’ detention until 11 July 2010, noting that there were no grounds for their release. 43.     On 17 February 2010 the Krasnodar Regional Court upheld the decision of 28 January 2010, having dismissed the argument that the applicant’s detention between 24 and 28 January 2010 had been unlawful. While acknowledging that on 21 January 2010 the District Court had examined the matter at the applicant’s lawyer’s request, the Regional Court reasoned that the examination constituted a de facto extension of the detention. 44.     On 18 May 2010 the Oktyabrskiy District Court found the applicant guilty as charged and sentenced him to eleven years’ imprisonment. 45.     As follows from the applicant’s medical history submitted by the Government, since March 2010 the applicant has fully complied with the prescribed course of drug treatment and has occasionally failed to adhere to the dietary recommendations of the prison’s medical specialists. He occasionally refused to submit to examinations by medical specialists from the Centre and civil hospitals, citing extreme weakness, fatigue and his poor state of health as reasons for those refusals. In the second half of April 2010 the amount of haemodialysis was intensified, becoming a daily procedure. As follows from the applicant’s medical history, the only days when he did not have haemodialysis were the days on which trial hearings took place. In May 2010 the applicant was examined by a surgeon, an ophthalmologist, a urologist and an endocrinologist, who, having confirmed the previous diagnosis and having noted no major changes in the applicant’s state of health, concluded that it did not preclude his detention in facility no. 5. 46 .     According to the Government, since the first day of his detention the applicant had lodged at least thirty complaints with the director of the detention facility concerning the conditions of his detention and quality of medical care. He had also lodged numerous similar complaints with various State authorities, including the prosecutors’ offices and the Federal Security Service. In particular, the Government provided a copy of the applicant’s complaint of 29 May 2009 in which he informed the director of his refusal to continue haemodialysis in view of his inability to continue to endure the “inhuman treatment” accompanying that procedure. He asked to notify his relatives of his wish to be buried in Yerevan. The complaint bears a handwritten note by the facility director stating that a discussion with the applicant had resulted in his consent to go on with the treatment. The applicant’s repeated complaints to the facility director regarding his inability to descend the stairs for his haemodialysis sessions either resulted in the applicant agreeing to continue the haemodialysis or the director’s promise to consult engineers on the subject of equipping the facility with a mechanism which would allow the applicant to descend and ascend the stairs more easily. One of the applicant’s complaints to State authorities brought a response from the Federal Supervision Service for the Health and Social Development Sectors. By a letter of 17 August 2010 the acting director of the service informed the applicant that “the performance of ... haemodialysis either in a temporary detention facility or in a correctional colony does not have any legal basis”. 47.     Another certificate provided by the Government shows that during the entire period of the applicant’s detention he was taken for a walk in the recreation yard of the facility twice: on 16 and 17 May 2010. The Government alleged that the applicant had consistently refused to leave the cell to be taken for a walk. Current state of the applicant’s health 48.     The applicant provided the Court with an expert report issued on 21   May 2010 by two leading forensic medical experts. Having studied his complete medical history, the experts concluded as follows: “... as a result of his main illness (insular diabetes) [the applicant’s] central nervous system, cardiovascular system, visual organs, kidneys, stomach [and] thyroid body were damaged. Progress of type-one insular diabetes is, usually, gradual; [however, it becomes] more rapid if stress or other illnesses are present ... [The applicant’s] body movement is restricted as he suffers from osteochondrosis of the whirl bones and has undergone a complete hip replacement. [The applicant’s] hepatitis C ... and chronic Wyatt’s syndrome substantially aggravate his main illness. ... the severity of the [applicant’s] main and concomitant illnesses, his non-functioning renal transplant, and his detention in facility no. 5 in the absence of proper clinical, instrumental and laboratory supervision make the risk of development of lethal complications very real. The fact that [the applicant] suffers from the listed illnesses leads to the conclusion that he is in need of constant supervision and treatment by medical specialists which could only be provided in specific hospitals ... It is virtually impossible for [the applicant] to receive the required [medical care] in the conditions of detention facility no. 5 ... Type-one insular diabetes and chronic renal failure in the terminal stage, from which [the applicant] suffers, are included in the List of Illnesses Precluding [a detainee] from Serving a Sentence, as adopted by Decree no. 54 on 6 February 2004 by the Government of the Russian Federation.” The experts were also under impression that the medical personnel caring for the applicant had “deliberately understated the seriousness of [his] condition and [had] deliberately amended [the] diagnosis previously confirmed by specialised clinical medical facilities”. 49.     On 5 July 2010 the applicant was sent to serve his sentence in correctional colony no. 2 in the Astrakhan Region. On arrival at the colony he was immediately admitted to the prison hospital. However, two days later, given the assessment of his state of health by the prison doctors, the applicant was transferred to the resuscitation department of the Aleksandro ‑ Mariinskiy Regional Clinical Hospital where he started receiving daily haemodialysis and extensive insulin and immunosuppressive therapy. Having examined the applicant on 6 August 2010 the medical commission, comprising a number of medical specialists, including those from the colony hospital, issued a report which, in its relevant part, read as follows: “The general condition of the patient is serious ... The patient suffers from obesity of the third degree – he weighs over 130 kilograms; it is clearly insufficient to [treat him] with haemodialysis as an out-patient three times a week; on days when haemodialysis is not performed [the applicant] suffers from excessive hydration, hyperpotassemia, and increasing uremic intoxication, which can only be treated with haemodialysis in the conditions of a resuscitation department in a hospital. Given the severity of his main illness, [the applicant’s] excessive body weight (insufficient haemodialysis) haemodialysis often has to be performed urgently outside the schedule ... in the conditions of the resuscitation department. The most a