35 112(11) Mr. Damião Ximenes-Lopes died a violent death on October 4, 1999 at 11.30 am, at Casa de Reposo Guararapes (Guararapes Rest Home), approximately two hours after being medicated by the clinical director of the hospital, and without any physician to provide medical care at the time of his death as, at the time, there was no doctor present in the public health care unit in which he had been admitted to receive psychiatric care. No adequate medical attention was provided to Mr. Damião Ximenes-Lopes and, as a result of this lack of care, the patient was at the mercy of all kinds of life-threatening accidents and aggression.44 112(12) After the death of Mr. Damião Ximenes-Lopes, Doctor Francisco Ivo de Vasconcelos was called to Casa de Reposo Guararapes (Guararapes Rest Home). He examined the body of the alleged victim, declared him dead and included in the record that the body did not show any external injuries and that the cause of death had been a “cardio respiratory arrest.”45 The doctor did not order an autopsy of the body of Mr. Damião Ximenes-Lopes. Mrs. Albertina Viana-Lopes learned of her son’s death when she arrived home, located in the Municipality of Varjota. 112(13) On the same day of his death, the next of kin of Mr. Damião XimenesLopes requested an autopsy, and his body was transferred from the city of Sobral to the city of Fortaleza, where the autopsy was to be performed. During the journey, the body bled profusely and when they arrived at their destination the sheet covering the body was soaked in blood. 112(14) On October 4, 1999, the autopsy on the body of Mr. Damião XimenesLopes was performed at the Instituto Médico Legal Dr. Walter Porto (Dr. Walter Porto Medico-Legal Institute), where Francisco Ivo de Vasconcelos also worked as a doctor. The autopsy report contained the following findings: At 10.40 pm of [October] 4, 1999, a male body was brought into the morgue of the [Medico-Legal Institute], accompanied by police report No. 796/99 issued by the Comisaría Regional de Sobral (Sobral Regional Police Station) - [Ceará], stating that “he was Control, Evaluación y Auditoría Coordinadora Municipal de Control, Evaluación y Auditoría Coordinadora Municipal de Control, Evaluación y Auditoría (Control, Evaluation and Audit Municipal Coordinator) on November 5, 1999 (record of appendixes to the application, appendix 14, pages 112 and 113), statement made by Albertina Viana-Lopes before the Comisaría Regional de Sobral (Sobral Regional Police Station) on December 7, 1999, supra note 42; and report on the Administrative Investigation prepared at the request of the Coordinadora Municipal de Control, Evaluación y Auditoría de la Secretaría de Salud y Asistencia Social (Control, Evaluation and Audit Municipal Coordinator for the Health and Social Services Bureau), issued on February 18, 2000 (record of appendixes to the application, appendix 31, pages 185 to 212). 44 Cf. statement made by Francisco Ivo de Vasconcelos before the Coordinadora Municipal de Control, Evaluación y Auditoría (Control, Evaluation and Audit Municipal Coordinator) on November 5, 1999, supra note 43; statement made by María Salete Morais-Melo de Mesquita before the Coordinadora Municipal de Control, Evaluación y Auditoría (Control, Evaluation and Audit Municipal Coordinator) on November 5, 1999 (record of appendixes to the application, appendix 14, pages 113 and 114); report on the Administrative Investigation prepared at the request of the Coordinadora Municipal de Control, Evaluación y Auditoría de la Secretaría de Salud y Asistencia Social (Control, Evaluation and Audit Municipal Coordinator for the Health and Social Services Bureau), issued on February 18, 2000, supra note 43; and report of the corpus delicti examination - post-mortem- conducted on Damião Ximenes-Lopes at the Instituto Médico Legal Dr. Walter Porto (Dr. Walter Porto Medico-Legal Institute) on October 4, 1999 (record of appendixes to the application, appendix 41, page 246). 45 Cf. statement made by Francisco Ivo de Vasconcelos before the Coordinadora Municipal de Control, Evaluación y Auditoría (Control, Evaluation and Audit Municipal Coordinator) on November 5, 1999, supra note 43.