In December 2018, in the hospital of the village of Novosheshminsk in Tatarstan, 16-year-old Milena Mukhametzanova underwent a three-hour operation. The operation was performed by a local radiologist, who was consulted by doctors from the Kazan hospital via video link. However, the necessary blood was not found in the department. The girl died, and her parents have been trying for 2.5 years to find out what happened in the hospital and who is responsible for Milena’s death.
The Russian service of the BBC has examined the case files and attended a court hearing. On the morning of December 18, 2019, Khussein Rakhimov, a radiologist at the Novosheshminsk hospital, received a patient in the dressing room. In addition to his main specialization, he also worked part-time as a surgeon in the polyclinic, and since September he also held the position of a surgeon in the inpatient department. He had a certificate for such work, but little experience in performing operations independently. Later in the trial, it was revealed that Rahimov had been trying for almost four months to refuse an offer to replace a fellow surgeon who had left for retraining. The doctor cited lack of experience.
One morning in December, Rahimov found gynecologist Alexey Trunov in the dressing room. He informed Rahimov that a seriously ill patient, Milena Mukhametzanova, had been admitted to the hospital with internal bleeding. At 10:15 a.m. Rahimov began the operation in the presence of Trunov, deputy chief physician Ravil Alukaev and anesthesiologist-resuscitator Maxim Konanerov. The girl had lost a lot of blood by then, and the bleeding continued. There was nothing to restore the falling red blood cell level: the required group components were not available in the hospital. The patient was given plasma and infusion solutions. Thirty minutes after the start of the operation, Alukaev began to call the Children’s Republican Clinical Hospital in Kazan. Doctors from Novosheleminsk consulted with the surgical department via video: a 30-second recording was made at 11 a.m. “In the splenic angle in the projection of the omentum, everything is impregnated [soaked] with blood, a large amount of blood especially in the projection of the splenic vein,” – says Rahimov on the video. Attempts to stop the bleeding were unsuccessful, and the doctors had to call the DRKB for help. Oleg Suchkov, a surgeon working at the center, later said that he learned of the need to fly for about 11 hours and was at the airfield by noon.
The district hospital in Novoshešminsk is a small building located on one of the rural roads among private houses. We explain quickly, simply, and clearly what happened, why it matters, and what happens next. The number of episodes should remain: episodes. The End of the Story Advertising Podcasts
Rakhimov claims to have found the source of the bleeding. According to the medical records, this happened at 11:40 a.m., which corresponds approximately to the memory of the parents, who claim that they learned about the cessation of bleeding from the head doctor at about half past eleven. Later, however, the surgeon Rakhimov changed his testimony: he said that he had mistakenly stated this time in the surgical protocol, and in fact the source of bleeding was discovered an hour later – at 12:40. Alukaev, who stayed in the operating room until the end, will tell the court two and a half years later that the source of the bleeding was never found. At about 13:20, the Kazan surgeon Suchkov, who had been brought by helicopter, appeared in the operating room. Milena’s blood pressure could no longer be determined, and the blood loss was enormous. “The operating surgeon stated that there were at least two liters of blood in the abdomen and that the blood loss continued during the operation. In the suction device – which is usually a five-liter canister – there was almost a full canister of blood,” Suchkov later recalled in court. The Kazan surgeon saw staples in the area of the presumed wound, but did not examine the actual injury: the moment he approached the table, the resuscitator reported that the heart was not contracting. “We defibrillated twice, then administered an intracardiac injection of adrenaline, but there was no effect. After that I strongly recommended… ordered to incise the diaphragm and start direct cardiac massage… It seemed like the heart was starting to work. There were contractions, but then they stopped. For about 30-40 minutes, as required by the protocol, we performed CPR. At the end of resuscitation, it was determined that the heart could not be revived, and the diagnosis of “death” was established,” Suchkov said in court in March 2021. The blood, ordered from the transfusion center in Nizhnekamsk, which is about an hour and a half away, arrived at the Novosheshminsk hospital after Milena’s death.
The Muhametzanovs have been trying for 2.5 years to understand why doctors were unable to save their daughter. This is the official chronology of events that Milena Ildar and Antonina Mukhametzanov’s parents do not trust. They are convinced that their daughter died earlier than announced due to the lack of qualified help and mandatory blood supply. “They kept her on life support, creating the illusion that she was alive… They were waiting for Suchkov,” Antonina Mukhametzanova believes. The Muhametzanovs have spent the last 2.5 years trying to figure out why doctors were unable to save their 16-year-old daughter and who should be held responsible for her death. Novosheshminsk, where the Mukhametzanov family lives, is a town with a population of four and a half thousand, several intersecting streets of rural houses and low-rise apartment buildings at right angles, neat school and gymnasium buildings, and a district hospital adjacent to private fences. Here, everyone knows each other: one of the neighbors supports the parents, one supports the doctors. Antonina recalls that one of the residents even wrote a letter to Vladimir Putin in support of the health workers. “I closed it and stopped reading everything because I realized that if I continued, I would die,” she says. Milena was the third of the Mukhamedzanovs’ four biological children. Shortly before her birth, in 2001, the family suffered a tragedy: their eldest daughter died in an accident. Several years later, the Muhammadzhanovs realized that even though they had three growing children of their own at home, they still wanted more and began adopting those who were left without parents. Currently, the family has six adopted children, three of whom, Antonina and Ildar, were taken in after Milena’s death. During the conversation, a gray cat with a white face appears in the window. “This is Grisha,” Antonina calmly introduces the cat, adding, “Milena found him when she was little.
Milena adopted a cat named Grisha, who still lives with her family. On the evening of December 17, 2018, the teenage company went to the movies. “Some movie was brought to the rural club. They took a hundred rubles from all our older children and went with their friends,” recalls Milena’s mother. When the daughter returned in the evening, she sat with her parents for a while. While they were drinking tea, she mentioned in passing that she felt something uncomfortable on her left side, but it didn’t worry her or her parents: Milena had recently been diagnosed with gastritis. The girl went to her room to sleep, but around one o’clock at night she came down to her parents’ room again – this time with severe stomach pains. The Muhametzanovs called an ambulance and went to the hospital. It is a few minutes’ drive from the Muhametzanov house to the two- or three-story building of the district hospital. Milena was taken to the ward at the beginning of the second night. Antonina remembers that the doctor came down 10 minutes after the nurse from the outpatient clinic called. “It was [Maxim] Konanerov. He was our night doctor. He is a transfusiologist, an anesthesiologist-reanimatologist… But besides the duty doctor, there is no laboratory assistant, no one, they are all at home. They are called when necessary. He looked at me and said, ‘Are you going to lie down? I said, ‘What do you mean? Are you not going to do anything? Well, at least do some tests!” – describes Milena’s mother the conversation.
Antonina Mukhametzanova drove Milena to the hospital when she began to feel unwell. We sent for the lab technician. A few hours later, the results of the general blood and urine analysis came back, but they were not clear, says Antonina: “[He] says, ‘Here, the tests are normal’ – ‘Well, then what does she have?’ – ‘How should I know? It could be pancreatitis, it could be gastritis, she could have violated her diet… everything is doubtful. Will you be admitted?'” “I say, ‘Milena, are you going to bed? She says, ‘Mom, what are they going to do to me?’ I say, ‘Maxim Vladimirovich, what are you going to do?’ – ‘We’re going to watch,'” Antonina recalls. At that moment, according to her parents, Milena began to feel better – she was given painkillers and an anti-nausea drug at the hospital. The doctor promised that an ultrasound specialist would come to the hospital by 8 a.m. and that a biochemical test could be done. The family wrote a refusal to be admitted to the hospital and returned home at 4 a.m. Milena fell asleep immediately. “I went up to her and looked at her. She was sleeping somewhere until 8 o’clock. The other children went to school. And at nine o’clock we woke her up. She drank half a glass of water and went upstairs to get dressed… And then I hear a crash, a fall, just a “boom”… The children always make noise there, but here I immediately panicked. I ran into the room, she was sitting on the floor and she said, “Mom, I feel bad. I look, her eyes roll back, roll back, she starts falling, falling, falling, she starts having seizures…”. – Antonina recalls. The girl was immediately taken to the ultrasound room. Doctor Alexander Shishkin asked the parents to leave: they were nervous and, as the doctor later told the investigator, they were making noise. Shishkin’s colleagues from the hospital also gathered there: gynecologist Trunov and deputy chief doctor for medical work Alukaev. Milena remained conscious until the moment she was put on the operating table. Her mother says that while the doctors were preparing, the girl told them what she had heard in the ultrasound room. Mom, you know what Uncle Sasha said? – What? “What I have in my stomach is not liquid, but blood. Well, Milen, it could just be a liquid, he can’t say for sure through the ultrasound machine. Milen, did he not say how much? He said “about a liter”. While Milena was being prepared for surgery, her parents caught the head of the therapeutic department, Alukaev, and asked him to call a doctor from Kazan. They were even willing to pay for transportation. According to Mukhatmazanova, Alukaev assured them that it was not necessary. About an hour after the operation began, there was no news. Then Milena’s relatives learned that the chief surgeon, Rafis Vafin, had arrived at the hospital, and they asked him to find out what was happening to their daughter. Around half past twelve, Antonina said, Vafin reported that his colleagues had found the source of the bleeding in the spleen and had stopped it.
Time passed, but the operation did not end. “My husband called the head doctor again. He came and said that an ambulance had been called. He went back into the operating room, stayed there for a while and came out. We asked, “What’s going on? He replied, “What can I tell you? We have to pray to God. At about 13:20 the surgeon Oleg Suchkov from Kazan joined the doctors in Novosheshminsk. And already at 14:00 the Kazan surgeon came out with the deputy head of the hospital Alukaev and reported about Milena’s death. “We have a riot going on, we have… All the other doctors ran out the back door. They wouldn’t come out the door where we were,” says Milena’s mother. The examination conducted in Chistopol – the nearest city to Novozyeshminsk, located 60 kilometers away – concluded that the cause of death was angiopathy, i.e. vascular damage. However, the source of the bleeding could not be identified and examined: according to the expert, it was in the area of the hematoma that the doctors removed during the operation. The parents tried to find out if their daughter could have been injured in some way that she hadn’t been paying attention to. But her friends were unanimous: there were no falls or careless bumps. The doctors who examined Milena in the ultrasound room and on the operating table saw no bruises. After a criminal case was opened against the Muhametzanovs, investigators and employees of Roszdravnadzor (Russia’s health watchdog) were repeatedly called, but for a long time, they say, no active action was taken.
The case of Milena’s death is currently before the courts. In September 2019, the chief physician Vafin approached the parents through a mutual acquaintance and asked for a meeting. According to Milena’s mother, the doctor spoke for a long time about the hospital’s problems and possible financial difficulties due to the conflict between them. “If we don’t settle this now, his relationship with the Ministry of Health will be disrupted, and he won’t get any money to repair the food unit,” the woman said, recounting the conversation. According to Antonina, Vafin did not directly offer money, but she is convinced that the whole conversation was a veiled attempt to negotiate. After the Mukhametzanovs told the investigator about this, a case was opened against Vafin under two articles – obstruction of preliminary investigation and incitement of victims to give false testimony. Vafina was dismissed from the post of chief physician and placed under house arrest.
During the appeal of the preventive measures, the doctor insisted that he “never committed any illegal actions” and called the case of obstruction of investigation “fabricated,” the publication “Real Time” wrote.
Then, in September 2019, a few days after the conversation with the chief doctor, the Mukhametzanovs came to the head of the Investigative Committee, Alexander Bastrykin, with a complaint about the poor investigation. The atmosphere, Antonina recalls, was tense: Bastrykin expelled a subordinate of the Investigative Committee in Tatarstan from his office. “He said, ‘Get out of here! And I began to feel sorry for him: it was such an unsightly picture when he chased them there. It turns out that they are weak and can blush and sweat…” – she remembers.
The criminal case on the death of Milena was transferred to the central apparatus of the Investigative Committee, and the exhumation and re-examination were ordered outside the region – in St. Petersburg. In the summer of 2020 the experts came to the conclusion that the cause of death was a rupture of the wall of the splenic cyst. This rupture led to massive intra-abdominal bleeding, which resulted in hemorrhagic shock. The panel of experts concluded that several circumstances were “directly causally related” to Milena Mukhametzanova’s death: the emergency surgery performed by an inexperienced surgeon, the lack of erythrocyte-containing blood components in the hospital, and the delayed request for donor material.
Milena’s parents adopted three more children after her death. The chief physician of the hospital, Vafin, and the anesthesiologist-resuscitator Konanerov, who also held the position of transfusiologist and, according to the investigation, should have been responsible for monitoring the blood supply, were accused of negligence. Initially, investigators considered Deputy Chief Physician Alukaev a suspect, but he was later transferred to the status of a witness. The ongoing case of obstruction of justice did not go to trial. However, another charge was added against the suspended chief physician Vafin – falsification of official documents. According to the investigators’ version, he forged a letter to the Republican Ministry of Health requesting a replacement surgeon from Kazan in the absence of the staff surgeon. In addition, he forged an order retroactively transferring the duties of the outgoing surgeon to Rahimov.
On the last day of August 2019, three and a half months before the girl’s death, Rafis Vafin called Dr. Husein Rahimov into his office. Rakhimov was employed as a radiologist, and he is still listed in that capacity on the Tatarstan health portal. However, with an additional certificate as a surgeon in hand, he also worked part-time at the clinic in that position. Ilgiz Fazliev was the permanent surgeon at the hospital. But in early September, he left for retraining. Someone had to replace the surgeon until his return on December 24. The conversation with the boss, caused by Rahimov, decided to record.
Eventually, the head doctor, Vafin, convinced his subordinate to conduct regular patient examinations in the surgical department and to do the paperwork himself.
The conversation with the boss, Rahimov says, he decided to record on his phone because Vafin “sometimes didn’t keep his word. “I had to do it – if he refused his words, then you can say: here are your words,” he explains. The recording of the conversations between Vafin and Rahimov later ended up in the materials of a criminal case.
Many of those now testifying in court have known the Mukhametzanovs for half their lives. Antonina explains that she has known Alukaev’s family for 30 years. His wife is a pediatrician who treated the deceased girl since birth. The reanimatologist-anesthesiologist Conanerov is a classmate of the eldest daughter, “his parents were closely connected to ours,” says Milena’s mother. “We all know each other. This is Ivanova – the head nurse… We have known each other for a long time and very closely… I asked her [in court], ‘Tan, was it difficult for you to say when we were preparing Milena for surgery? You could have said – there is no blood, there is no surgeon. We wouldn’t have taken Milena to the operating room… We were in a panic…'”
Tatyana Ivanova, a nurse at the Novozeshminskaya district hospital, participated in the operation. During the court session to which she was called as a witness, after a pause, she quietly replied to Muhametzanova’s question about why she didn’t say that there was no surgeon in the hospital at the time: “Because he was there.”
This is the main line of defense of the dismissed chief physician Vafin and anesthesiologist-reanimatologist Konanerov: Rahimov had certificates not only as a radiologist but also as a surgeon, which means that the accusations that the hospital was left without a highly qualified specialist at the time of the admission of the seriously ill patient are unfounded.
Vafin and Konaner were accused of negligence. “Now they want to remove Rahimov, claiming that he… They ask everyone if there is an official concept of a “highly qualified specialist…” Yes, we all understand that this is an ordinary phrase! It does not mean that he is a shining star of medicine… But based on their statements [in court], it looks like they want to put Rahimov and [Leonid] Roshal together, right? Two identical doctors…” – Milena’s father, Ildar Mukhametzanov, is outraged. “They both have diplomas…” – adds his wife Antonina. “So they are interchangeable? Let’s bring Roshalya here and put Rahimova there [in Moscow],” suggests the girl’s father.
Sam Rakhimov is a young man with a quiet voice. In response to defender Vafin’s question whether he considers himself a highly qualified doctor, he replied: “In the field of radiology, I consider myself, in the field of clinical surgery, I consider myself – yes, but not in the field of hospital surgery”. Under questioning as a witness in court, Rahimov said that since receiving his surgeon’s license in 2012, he had performed only about 10-12 abdominal surgeries: several appendectomies and emergency care for a person with penetrating wounds in the abdomen and chest. According to Rahimov, he resorted to complex surgeries only when there was no other option: “If there was no surgeon available, I had to assist. If a patient came in with a knife wound in the abdomen, I couldn’t say, ‘Sorry, guys, I can’t do it.'”
Doctors and residents say there is a constant shortage of staff. Some doctors apparently hold multiple positions at the hospital. Despite his lack of experience in independent oral surgery, Rahimov had already replaced surgeon Fazliev several times by the time Milena arrived. When the girl’s father asked the young doctor how it was possible that there were significantly more such surgeries listed after his name in the operation journal, the doctor admitted that sometimes his name in the documents was just a formality. “This happened during periods when [Fazliev was officially] studying, on sick leave, or [absent] due to various situations, while he was at home. In fact, they had no right to include [him] in the anamnesis, to include him in the operation, but he did it. And they wrote my surname in connection with it,” Rahimov calmly explained to the court. In court, he continued to insist on his position: even before the departure of the staff surgeon, he warned the chief physician that he was not ready to perform this task. According to the doctor, in August 2018 he agreed to take over the formal responsibilities of his colleague who went for retraining – but only for a month and on condition that it would be limited to examinations and signing papers.
Vafin, a resuscitator and transfusiologist who was fired as chief of staff, denies negligence. During the investigation, Vafin initially stated that Rahimov did not refuse to take the position of the deceased surgeon. Then, when presented with an audio recording of a conversation with a subordinate, the suspended chief doctor admitted that the subordinate had talked about a lack of experience in surgery. However, “he did not believe Rahimov’s words because he had performed surgeries before,” according to the case documents. Vafin allegedly did not know about the lack of donor blood, “otherwise he would have immediately organized the delivery of the necessary components”. Transfusionist and intensive care physician Konanerov, according to his testimony in the case materials, explained during the investigation that it is not advisable to store blood components constantly, because “their shelf life is one month, after which they must be disposed of”.
“At the beginning of the operation, the hemoglobin content of Milena Mukhametzanova’s blood was normal, and the introduction of erythrocyte-containing blood components into the bloodstream was not necessary. Therefore, these components were not ordered immediately. In addition, it was hoped that the surgeon Rahimov would quickly stop the source of bleeding, and the introduction of blood components would not be necessary”, – the testimony of the transfusiologist was retold by the investigation.
The family keeps every piece of their deceased daughter. In court, the doctors insist that in the morning, when the ambulance took Milena to the hospital, she already had about 2-2.5 liters of free blood in her stomach. The number of offers should remain: to begin transfusion of erythrocyte mass was necessary immediately, as soon as the first confirmations of intraperitoneal bleeding were received – the results of tests and ultrasound, said Kazan surgeon Suchkov in court. But even in this case, he believes, with a blood loss of two liters at the time of admission, there was no chance to save the girl. “We had to transfuse red blood cells, but the question of saving life by transfusion is very doubtful. A loss of two liters of blood means that the child was in a state of hemorrhagic shock. Transfusion in such a case… well, I don’t know… I don’t think it would have saved the patient’s life,” Suchkov explained. When Milena’s mother asked if a girl in such a state could speak, perform any actions, and respond to questions, Suchkov shook his head in the negative: “Confused consciousness, cold sweat, lack of reaction to questions from others, that is, a soporific [state], well, a coma, you could say. The question of the amount of blood loss at the time of hospitalization remains open for Milena’s parents: they believe that their daughter had not yet gone into shock and that with the availability of blood components, she could have been saved.
The parents are sure that Milena could have been saved. At the personal consultation with the doctor Alexander Shishkin, Milena’s mother remembered the words of her daughter, who recounted the conversation that took place in the diagnostic room before the operation: according to the girl, they talked about the volume of one liter. Shishkin assures that the difference between the estimates could be a result of the device’s error. During the personal interview during the investigation phase, he admitted that the girl’s life could have been saved if she had received a blood transfusion directly from a suitable donor. In addition, it was possible to postpone the operation until another specialist arrived, if the doctors were able to maintain the necessary volume of circulating blood, according to the case documents. The former deputy chief physician who was present during the operation, as well as another anesthesiologist, Alukaev, insisted during questioning in court that the doctors adequately compensated for the blood loss with the help of plasma and infusion solutions such as Polyglucin, and artificial lung ventilation continued to supply the patient’s body with oxygen.
“In the absence of red blood cells and other substitute components, is it possible to supply tissues with oxygen?” – asked Alukaev’s family representative, lawyer Andrey Suchkov, who works with the “Zona Prava” organization, during the court hearing. Ravil Alukaev: I will say it again: she was on artificial lung ventilation, with oxygen supply. Andrey Suchkov: Well, okay, answer the question. Ravil Alukaev: Well… oxygen was delivered to the tissues by artificial lung ventilation… Andrey Suchkov: Then please tell me how oxygen is delivered from the lungs to the tissues? Ravil Alukaev: By blood.
Andrey Suchkov: How exactly? By which blood component? Ravil Alukaev: Through arterial blood. Andrei Suchkov: Yes, I understand that there is arterial blood and venous blood. What should be in the blood for oxygen to be delivered? Ravil Alukaev: Erythrocytes. Andrey Suchkov: Okay, I understand, so we finally addressed this issue.
Later, during the interrogation in court of his namesake, the surgeon of the Republican Children’s Hospital Suchkov, the lawyer asked to clarify whether it is really possible to replace erythrocyte mass with other drugs. “No, not yet. We have such “Jehovah’s Witnesses” [recognized as an extremist organization in Russia], they believe that there is a drug that can replace the function [of blood], but it hasn’t been invented yet,” said surgeon Suchkov.
The defense of the dismissed chief physician Vafin and resuscitator Kanonerov refused to speak to the BBC’s Russian service until the end of the judicial investigation. They have not yet been questioned in court. The responsibilities of the chief doctor have now been transferred to one of Vafin’s colleagues. Maxim Konanerov has taken over the position of deputy chief doctor, which was previously held by Ravil Alukaev – the deputy chief doctor in charge of the medical department. Both were written about by the local newspaper “Sheshminskaya Nov” during the pandemic – as doctors working with severe coronavirus patients in the hospital in Chistopol. In 2019, Alukaev received the award “For Distinguished Work in the Healthcare System”. According to the authorities of Tatarstan, at the beginning of 2019, the average staffing level of stationary hospitals in the republic did not exceed 61%. But even against this backdrop, the statistics for rural hospitals looked even more dismal: in the Novoshcheshminsk district, only 44% of the medical staff was filled. The problem of staff shortage, which the doctors of Novoshekhminsk spoke about during the trial, has not been solved. In March, a new surgeon who came to Novoshekhminsk after Milena’s death left the hospital. Currently, the surgical department is headed by Hussein Rakhimov. In the same year, 2019, another patient – a 10-month-old girl – died in the Novoshezhminsk hospital. Initially, investigators opened a criminal case into her death and examined the work of Vafin and Alukaev, but they found no criminal activity in their actions. The case was closed.
Milena’s parents adopted three children in August 2020 – two sisters and her brother. They range in age from two and a half to eight years old. “We brought the children and our life has changed a bit. We are busy 24 hours a day. You know, to not think about things too much… These children are our salvation. We should be grateful to these children for living with us and absorbing everything so that our heads don’t explode. These children help us to survive, you know?” says Antonina.
The children’s bedrooms are upstairs, on the second floor of the Muhametzanovs’ house. Toys are scattered here and there, and the children learn music: there is a piano on the first floor, and an accordion on the second, which Milena’s younger brother, Bogdan, plays. Antonina remembers that he didn’t want to talk about Milena’s death for about a year, and he still tries not to enter his sister’s room. Nobody lives there, it looks sterile, there are no random things, on the shelves there are photographs, candles and icons. On the way out of the room, Antonina opens the door of the closet a little: teenage clothes are hanging neatly on hangers. “Here… I can’t,” Milena’s mother breaks down, crying and covering her face with her hand. “I can’t do anything with them.”