From unofficial sources the STA news agency has learned that the findings of the international commission, which carried out the audit, state that those most responsible for the critical state of affairs are the Israeli surgeon David Mishaly, his Slovene apprentice Robert Blaumauer, and the management of UKC Ljubljana.

In the biggest period covered by the audit the UKC was led by Simon Vrhunec and Brigita Drnovšek Olup. The commission's findings say that between 2007 and 2014, a little more than 30 children died in the Slovenian children's cardiac surgery program. Previous reports by the media, that 10 children died due to medical errors, are not true. The audit has found that four children died as a result of inadequate treatment in the program. All four deaths happened in 2012. The audit report also describes each case in detail.

An unnamed source told the STA that it was very difficult to determine the total number of children who have died because of inadequate treatment. The source also added that the commission had difficulties in obtaining the documentation and statistics for the treatment in the program. Reportedly, the UKC did not keep adequate statistics or records on the treatment of children. They even failed to enter information of medical complications and deaths in the European database.

Falsifying information
"If they would have entered such information, in two years the European database would have warned that something was wrong with the program," said STA's source. The UKC is also accused of falsifying information in the past of the program's success and presenting it to the public. The death rate in the children's cardiac surgery program was in fact double the figure presented to the public.

In its report the audit commission also warns that the program cannot be implemented in such a way, for a surgeon to be present at the ward only three days a month. Mishaly came to Slovenia once a month and always stayed for only a few days, when he operated on more children. He then always flew back to Israel.

The audit report also reveals that in the whole period in which Mishaly operated, his share of surgeries always stayed the same. That clashes with the statements of the UKC management of that time, that Slovene surgeons under the mentorship Mishaly improved and started conducting more and more surgeries on their own.

Some cases investigated by the police
The police is investigating some of the deaths in the children's cardiac surgery program. The investigations are still at a pre-trial stage. The Ljubljana Police Directorate confirmed that they are also working closely together with other institutions, investigating the surrounding circumstances. The police launched the investigations in May last year. In October it already presented the prosecution office with some of its findings and with an interim report.

G. K.; translated by K. J.