72
183. In view of the lack of clarity concerning the circumstances surrounding the
death of Mr. Ximenes-Lopes, their relatives took the body to the Forensic Institute of
Fortaleza city, the capital of the state of Ceará, for an autopsy examination.
184. The Forensic Institute conducted an autopsy examination of Mr. Damião
Ximenes-Lopes, from which it established that this was a case of “death of
undetermined caused” and stated the presence of several injuries, but failed to
state how they had been inflicted. It also failed to describe the examination of the
alleged victim’s brain. This led the Attorney General´s Office to request the chief of
police to elicit from the Medico-Legal Institute a clarification of the autopsy report
concerning the injuries described therein. After the Chief of Police’s second request,
the Institute further stated that “[the] injuries […] were caused by the force of a
blunt object (or by multiple blows or falls)” ( supra para. 112(14) and 112(15)). It is
worth noting that no photographs were taken of the body of Mr. Damião XimenesLopes.
185. On June 20, 2001, the 5th Chamber in Civil Matters hearing the civil action for
damages required that the body of the alleged victim be exhumed. The conclusive
report reaffirmed that the death of Mr. Ximenes-Lopes was a “death of undetermined
caused” (supra para. 112(16) and 112(54)).
186. In this regard, Ms. Lídia Dias-Costa, in her expert report rendered in the
public hearing before the Court, stated that as a result of the exhumation of the
body of Mr. Damião Ximenes-Lopes it was possible to verify that his brain had been
dissected as it is regular procedure for autopsy examinations, but that she found no
justified reasons for failing to state so in the autopsy report made in 1999. According
to the expert witness, this is a routine procedure and there is no reason not to
examine the brain or to fail to describe what was examined. In addition, she stated
that, based on the patient’s clinical progress, a diagnosis of violent death caused by
traumatic brain injury could be established (supra para. 47(4)(a).
The postexhumation examination report confirms that the skull showed a “transversal
craniotomy” as a result of the previous expert examination (supra para. 112(16)).
187. This Court considers that the guideline for the autopsy performed on Mr.
Damião Ximenes-Lopes on October 4, 1999, failed to meet the internationally
recognized standards for forensic investigations, as it failed to include, inter alia, a
thorough description of external injuries and of the object that caused them; the
opening and description of the three body cavities (head, thorax and abdomen); the
conclusion reported that the death was due to “an undetermined cause,” and
therefore the object that caused it was not mentioned either. Moreover, the
Technical and Scientific Department of the Medico-Legal Institute that performed the
exhumation also concluded that the case involved “death of undetermined cause.”
This Court considers that the States, pursuant to their obligation to prosecute
crimes, must charge a competent authority with the duty of performing forensic
inquiries, including autopsy examinations, pursuant to domestic and international
guidelines. In the instant case, it is clear that the Forensic Institute failed to establish
or document the findings of the autopsy examination in accordance with forensic
standard practice.
188. In addition, it has been proved that the police investigation of the death of
Mr. Damião Ximenes-Lopes was commenced by the Sobral Police Station on
November 9, 1999, 36 days after the events in the Guararapes Rest Home (supra
para. 112(18)).