40 135. In the light of the established facts, the Commission will examine the following aspects of the state’s response to Ms. Chinchilla’s situation: (1) The absence of a proper diagnosis of Ms. Chinchilla’s health situation and the shortcomings of the State’s response; (2) the treatment for Ms. Chinchilla’s diabetes and related ailments; (3) the State’s response to Ms. Chinchilla’s disabled condition; and (4) the State’s response on the day that Ms. Chinchilla died. 3.1 The absence of a proper diagnosis of Ms. Chinchilla’s health situation and the shortcomings of the State’s response 136. The European Court of Human Rights found in the cases of Tarariyeva vs. Russia and Kudhobin vs. Russia that when persons are deprived of their liberty and the authorities are aware of illnesses that require supervision and adequate treatment, the latter must “[keep] a record of [their] state of health and the treatment [they] underwent while in detention.”337 Likewise, in the Case of Iacov Stanciu v. Romania, the European Court found that the authorities must ensure that a “comprehensive record is kept concerning the detainee’s state of health and the treatment he underwent while in detention.” 338 That obligation is also described in the Third General Report of the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment. This Committee has stated that: A medical file should be compiled for each patient, containing diagnostic information as well as an ongoing record of the patient’s evolution and of any special examinations he has undergone. In the event of a transfer, the file should be forwarded to the doctors in the receiving establishment.339 137. In the present case, based on the information available, the Commission notes that this first fundamental obligation of diagnosing and keeping records in order to determine what medical treatment Ms. Chinchilla would require, in compliance with its obligation as guarantor of the rights to life and humane treatment of those in its custody, and ensuring that said treatment was provided, was not met by the state authorities. 138. Indeed, there are no certifications attesting to a comprehensive diagnosis or follow-up on all Ms. Chinchilla’s ailments. This is clearly reflected in the medical certifications contained in the record, which were requested by the Judge for two reasons: One, to verify whether or not it was necessary to grant permission requested by Ms. Chinchilla to leave the prison in order to go to medical appointments; the other, to determine if the illnesses were "terminal" when it came to deciding on the motions for early release and whether or not she could receive care at the detention center. 139. One example of the consequences of the absence of a meaningful, comprehensive diagnosis of Ms. Chinchilla’s health has to do with the multiple contradictory references in the record to possible cervical cancer. 337 European Court of Human Rights, Case of Kudhobin v. Russia, Judgment of 6 October 2006, para. 83. Available at: http://hudoc.echr.coe.int/sites/eng/Pages/search.aspx#{“fulltext”:[“medical diagnostic”],”documentcollectionid2”:[“GRANDCHAMBER”,”CHAMBER”],”itemid”:[“001-77692”]}. See, also, Case of Tarariyeva v. Russia, Judgment of 14 December 2006, para. 76. Available at: http://hudoc.echr.coe.int/sites/eng/Pages/search.aspx#{“fulltext”:[“medical diagnostic”],”kpthesaurus”:[“193”],”documentcollectionid2”:[“GRANDCHAMBER”,”CHAMBER”],”itemid”:[“001-78591”]} 338 European Court of Human Rights, Case of Iacov Stanciu vs. Romania, Judgment of 24 July 2012, para. 170. Available at: http://hudoc.echr.coe.int/sites/eng/pages/search.aspx?i=001-112420 339 European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment, 3rd General Report on the CPT’s activities covering the period 1 January to 31 December 1992 Ref.: CPT/Inf (93) 12 [EN] Publication Date: 4 June 1993, para. 39. Available at: http://www.cpt.coe.int/en/annual/rep-03.htm#III.

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