This is a documented case of emergency care unavailable in a publicly funded emergency medical system.
I. What the Family Didn’t Know
“We were told to wait.”
It was July 23, 2025.
Sunny and unusually hot from the early morning hours. The temperature rose quickly, and summer showed its full strength that day. From the morning on, people were heading toward the city’s largest public recreation and bathing area along the river. Beaches were filling up, the sun was scorching, and the city sought relief by the water.
Just two kilometers away, in the same part of the city, in an apartment on Lješka Street, the sounds of that summer day could almost be felt through the open windows.
But in that apartment, there was no space for summer carefreeness.
The health condition of 71-year-old S. K. suddenly worsened.
The family reacted immediately.
Without hesitation.
Without panic.
Before calling the Emergency Medical Service, they contacted the physician who had been treating him and was familiar with his medical history. She listened carefully to the symptoms—without interrupting, without guessing.
After that, she left no room for doubt.
She said clearly:
Call the Emergency Medical Service and have him transported immediately to a tertiary hospital facility.
This was not a dilemma.
This was not advice “just in case.”
This was a clear medical recommendation.
With that knowledge—and with trust in a system that is meant to respond in such situations—the family called the Belgrade Emergency Medical Service.
At that moment, they could not know that just a few kilometers away, in the same municipality, emergency medical teams would be engaged in a pre-planned assignment, while they themselves would be told to wait.
II. The First Arrival — Help That Delays and Stops
According to the medical report of the Belgrade Institute for Emergency Medicine, the call to the Emergency Service was received at 11:08 a.m. via the emergency number 194 and classified as a second-degree urgency.
In the extraordinary internal control report, however, the time of receiving the call is stated as 11:06 a.m.
A difference of two minutes may seem insignificant.
What followed was not.
According to the medical documentation, the call was forwarded to the field team only at 11:22 a.m.—14 minutes after it was received.
The team arrived at the apartment at 11:35 a.m.
From the moment the call was made until the team arrived, 27 minutes had passed.
The medical report states that the patient was conscious and oriented, but in generally poor condition, with elevated body temperature, pronounced weakness, and impaired communication. Therapy was administered, after which a short-term subjective improvement was noted.
Nowhere in the documentation is it stated that hospital treatment was unnecessary.
On the contrary—based on the actions taken and the communication with the family, it clearly follows that sanitary transport was planned.
However, the transport was not carried out.
What does not appear in the medical report, nor is explicitly stated in the conclusion of the internal control—but emerges from later statements by the healthcare workers involved—is the following:
- the field team consisted of one doctor and one medical technician,
- the patient had extremely high body weight,
- the team was not physically able to perform the transport on its own.
That circumstance, however, was not recorded in the official medical documentation at the time of the intervention.
It was not stated as the reason for the unexecuted transport.
It was not translated into an operational request for additional assistance.
Instead, the family was informed that transport would arrive in about one or two hours.
At that moment, the system had already failed.
Not because of an incorrect medical assessment,
but because of the lack of operational capacity to implement its own assessment.
III. Waiting That Lasts
After the first intervention ended, the family was told that sanitary transport would be organized.
Following the instructions of the medical technician, the patient’s son called the Emergency Medical Service again immediately after the team left, requesting that transport be provided as soon as possible.
At that moment, there was no dilemma.
Everyone assumed that transport was only a matter of time.
At the same time, according to his own statement, the medical technician contacted the dispatch center for transport, explained the patient’s condition and the circumstances on site, and clearly stated that hospital care was necessary.
The response was the same.
The transport team was not available.
They were told to wait.
In the apartment on Lješka Street, time began to stretch.
The family did the only thing they could:
they tried to lower the high body temperature, to cool the patient, to ease his breathing, to keep him conscious.
They relied on the instructions they had received—but without what was crucial: hospital care.
Through the open windows came the sounds of the city. Summer noise. Laughter. Music. Cars heading toward the riverside recreation area.
Just two kilometers away, people were entering the water, spending a day they would remember as another beautiful summer day.
In that apartment, time did not have the same meaning.
As the hours passed, S. K.’s condition did not improve. The temperature continued to rise. Weakness intensified. Exhaustion became visible.
Around 16:30 p.m., the family called the Emergency Service again, asking when the sanitary transport would finally arrive.
There was no precise answer.
There was no arrival time.
There was no explanation.
Only the repeated sentence:
Transport is still not available.
IV. The Moment of Silence
As the hours passed, nervousness in the apartment grew—not sudden or panicked, but quiet and exhausting.
At one point, S. K. fell asleep.
His breathing seemed calmer. His body more relaxed.
For a brief moment, the family thought that perhaps the therapy had worked. That transport would arrive before the condition worsened again.
It was a short and deceptive respite.
From the open windows, the sounds of summer could still be heard.
Then the silence changed.
The family was the first to notice that something was wrong. The breathing became irregular. Then—it stopped.
At 5:10 p.m., they called the Emergency Service again.
This time, they did not ask for transport.
They asked for someone to come immediately.
The same Emergency Medical Service team that had already been there earlier that day arrived again.
This intervention was short.
Without therapy.
Without conversation.
Without further decisions.
The doctor could only confirm death.
That morning, everything still seemed solvable. It was a summer day filled with hope that help would arrive, with trust that the system exists precisely for such moments.
By the afternoon, in the same apartment, one life was extinguished.
V. The System That Was Occupied That Day
While in the apartment on Lješka Street a quiet drama unfolded over more than five and a half hours, just two kilometers away the system functioned in an entirely different mode.
At the city’s main public bathing and recreation area along the river, on that same day, the Belgrade Institute for Emergency Medicine had engaged four complete emergency medical teams, including one sanitary transport team, based on a commercial contract for medical coverage of the location.
Those teams were not on standby for the entire city.
They were tied to one location.
Under contractual obligations, the teams engaged at the recreational area were not allowed to leave their position, except within the boundaries of that location—regardless of emergencies elsewhere in the city.
In practice, this meant that at the very moment when the family of S. K. was waiting for sanitary transport, a transport team existed.
It was formed.
It was equipped.
It was only minutes away.
But it was not available.
The document shown above is the official duty roster for medical coverage at the Ada Ciganlija public bathing area on the day in question.
The medical teams assigned to this duty were composed of healthcare workers employed by the Belgrade Institute for Emergency Medicine and paid from mandatory public health insurance funds, financed by contributions from all citizens.
Despite being fully staffed, equipped, and located less than two kilometers away, these teams were not available to respond to emergency medical needs outside the bathing area.
Their unavailability was not the result of medical judgment or operational overload, but of contractual restrictions. Under a commercial agreement, the teams were engaged exclusively for on-site medical coverage and were not permitted to leave the location, even when urgent medical needs arose nearby.
This commercial engagement generated approximately five million dinars in revenue for the Institute, recorded as its own-source income, while the cost of labor for the same teams continued to be borne by the public health insurance system. As a result, publicly funded emergency medical resources were physically present, operational, and nearby—yet functionally inaccessible to the citizens who finance them.
For this engagement, the Institute generated nearly five million dinars in revenue during the summer season, recorded as the institution’s own income.
At the same time, the doctors, medical technicians, and drivers on duty at the recreational area—who would otherwise serve all citizens—were paid from mandatory public health insurance funds, into which S. K. had contributed for more than 53 years.
This is not a question of an individual doctor’s decision.
Nor of an on-site medical assessment.
Nor of a “difficult case.”
It is a question of system design—in which publicly funded emergency resources are systematically redirected from their core mission by planned contractual arrangements, without adequate replacement capacity.
The system that day was not overloaded.
It was occupied.
Occupied by a contract.
Occupied by a schedule.
Occupied by revenue.
And the cost of that occupation does not appear in financial reports.
It appears in apartments where help is awaited—and never arrives.
Epilogue: What the System Concluded
After the death of S. K., the Belgrade Institute for Emergency Medicine conducted an extraordinary internal control.
The commission concluded that no procedural violations occurred and that decisions were made in accordance with available information and system capacities at that time.
However, the control did not examine the actual availability of sanitary transport at the moment the need was identified.
It did not address the fact that, just minutes away, one transport and three medical teams from the same institution were contractually prevented from responding.
The control reviewed procedures.
It did not question priorities.
And it is precisely in that space—between procedure, contract, and public interest—that the unanswered question remains.
Voices of Justice — Stories That Must Not Remain Untold
This is a new story in the Voices of Justice series, through which the Movement Right to Life – MERI documents testimonies of families who lost their loved ones due to systemic failures in emergency medical services—and due to the silence that follows.
Lives lost in the silence of the system obligate us to ensure that this silence never remains without an answer.
