“Infirmary (Hospitalito) where she could be better monitored and could be administered her medications at the times ordered by the doctors.” However, Mrs. Chinchilla said “that she [did] not want to go up to the infirmary and that she would be better off in her block with her fellow inmates, and that they were with her if the needed anything. 137 On April 9, 2004, the duty nurse at the COF reported the following regarding Mrs. Chinchilla’s particular needs: The inmate needs someone very special to be with her 24 hours a day and attend to her personally, because if she is taken up to the Infirmary she would have to be helped with all her personal and hygiene needs and the care that a special patient requires, as well as with administering her medication and everything else that she needs, in addition to giving her NPH insulin injections in the morning and the afternoon, as indicated by the doctor. She also needs a special diet and help with her aggressive mood swings and behavior, as well as special care when her condition becomes critical because of her generalized edema and breathing difficulties. It is impossible for us to provide the special care that this inmate needs because we have to tend to the other 146 inmates, […] this inmate needs to be in stable surroundings where she can receive emotional support and physical therapy that they prescribe for her. Also, […] she refuses to sign any paper with the treatment and instructions given to us in writing […] in order to attest to the fact that we are carrying out our written instructions.138 98. On April 17, 2004, the COF doctor informed the Medical Services Coordinator that “[t]he patient in question presents an epigastric induration that causes her a lot of pain and restricts her movement, especially “deflexion movements (bending) and flexion movements (putting her head back). Therefore, I consider it necessary to do an ultrasound to screen for any significant pathology.” He said that he was requesting “his intervention in order to perform the suggested procedure on the inmate.”139 B.3 Mrs. Chinchilla’s death on May 25, 2004 99. It is an undisputed fact that, between 6:00 and 08:30 on the morning of May 25, 2004, Mrs. Chinchilla Sandoval was sitting in her wheelchair at the entrance to the maternal block of the COF, and that she moved herself toward another area of the Center, where she fell on some steps; after her fall, other inmates helped her, returned her to her cell and called the duty nurse, who came immediately. 100. The duty nurse reported that at 9:20 am she was informed that Mrs. Chinchilla had fallen “between blocks c and d” and that when she [was] examined, her “blood pressure was 170/100, pulse 72x, breathing 16 x.” In addition, “she had a scraped knee, which was painful and hot on palpation” so she “administered two tablets of diclofenac and one tablet of captopril. Dr. Renato Estrada Chinchilla, the Medical Services Coordinator, was also informed of the inmate’s fall and the medications administered to her.”140 101. In a second report, the duty nurse said that around 11:05 a.m. the inmates informed her that Mrs. Chinchilla could not breathe and “upon examining her she presented Cf. Women’s Orientation Center. Communication from the duty nurse to the Director and Deputy Director of the COF of April 7, 2004 (evidence file, folio 737). 137 Cf. Women’s Orientation Center COF. Note from the duty nurse of the COF to the prison’s Health Director, dated April 9, 2004 (evidence file, folios 1321 and 1322). 138 Cf. Women’s Orientation Center. Official letter No. 120/CM Dr. RJQ. Communication from the COF doctor to the Medical Services Coordinator, April 17, 2004 (evidence file, folio 741). 139 Cf. Women’s Orientation Center. Communication from the duty nurse to the Deputy Director of the COF of May 25, 2004 (evidence file, folio 2330) 140 32