47 statement, she was called to examine Ms. Chinchilla at around 9:20 a.m. and, according to the testimony of Ms. Claudia Fedora Quintana, she herself returned to Ms. Chinchilla’s room at approximately 10:30 a.m., by which time “she was blue,” so she called the nurse again. The Commission observes, then, that after the nurse’s superficial examination, Ms. Chinchilla did not receive any ex officio monitoring or any kind of health care for around one hour. The nurse only returned to see her when Ms. Claudia Fedora called her again. - Ms. Chinchilla died alone, without receiving any kind of care or supervision from a doctor On this point, the Commission recalls that the United Nations Standard Minimum Rules for the Treatment of Prisoners provide that “[a]t every institution there shall be available the services of at least one qualified medical officer. According to the testimony of Ms. Osiris Angélica Romano, the Center had three doctors: one attended on Mondays and Thursdays in the afternoon, another on Friday mornings, and the third on Saturday mornings. Accordingly, the IACHR notes that doctors were only ever there on a part-time basis and that on Tuesdays, Wednesdays, and Sundays there was no doctor available.357 May 25, 2004, the day Ms. Chinchilla died, was a Tuesday. Indeed, the Commission notes that Ms. Chinchilla’s fall was superficially attended to by a nurse, without any supervision by a medical officer. - There is testimony from one of the inmates that the nurse reportedly requested authorization for Ms. Chinchilla to be taken to the hospital as an emergency. The nurse said in her declaration that she reported the situation but does not specifically say that she made such a request. The Commission notes that the outcome in either version was that Ms. Chinchilla was denied hospital treatment, which, according to the statements of the doctors, was necessary in the event of an emergency. 168. In light of the above omissions and failings, the Commission concludes that, in spite of the multiple potentially life-threatening ailments from which Ms. Chinchilla suffered, the State of Guatemala failed to provide her with adequate medical treatment on the day she died. 3.5 Conclusion 169. Based on the foregoing, the commission finds that the state of Guatemala: (i) omitted to perform as an a meaningful and comprehensive diagnostic assessment of Ms. Chinchilla’s illnesses, their evolution, or their treatment; (ii) did not provide adequate treatment for her diabetes mellitus and related ailments, which worsened during her stay at the COF; (iii) neglected to adopt appropriate measures consistent with her condition as a disabled person; and (iv) failed to provide an appropriate and timely response on the day she died. 170. In light of these conclusions, the Commission finds the State responsible for violation of the rights to life and humane treatment recognized in Articles 4 and 5 of the American Convention to the detriment of Mrs. María Inés Chinchilla, including the progressive deterioration of her health, the inhuman and degrading treatment that she had to endure, the unfit living conditions for someone in her disabled condition, and her death without a proper diagnosis or treatment or having received timely emergency care. 4. Rights to a fair trial and judicial protection (Articles 8 and 25 of the American Convention) 171. Following, the Commission examines the arguments concerning the alleged failure of the State to provide judicial protection in two respects: (i) Whether or not Mrs. Chinchilla received judicial protection in relation to her health; and (ii) The inquiry into her death. 357 Appendix 11. Affidavit of Osiris Angélica Romano before a notary public. Appendix to the representatives’ brief of April 16, 2006.