51
189. Of particular significance is the case of Mendoza et al. v. Argentina, in which the Court
examined the death of a person in State custody. The Court held that “the State authorities had the obligation
to follow up on a logical line of investigation designed to determine the possible responsibilities of the prison
staff for the death of Ricardo Videla, since the omissions related to his detention conditions and/or his state of
depression could have contributed to this act.” The Court specified that the State had “the obligation to
disprove the possibility of the responsibility of its agents, taking into account the measures that they should
have adopted in order to safeguard the rights of a person in its custody,” and “to collect the evidence that this
entailed.”367
190. In the present case, the Commission notes that the conclusions of the Prosecutor’s Office and
the Court were based on the fact that Ms. Chinchilla had died of a "pulmonary edema" and "hemorrhagic
pancreatitis," which led her to die of natural causes without there being a crime to investigate. However, at no
time did the authority in charge of the inquiry investigate the possible responsibilities of State officials,
including correctional, medical, and judicial officers, for alleged violation of their duty to ensure Ms.
Chinchilla’s rights to life and humane treatment or the omissions with respect to her conditions of
incarceration, the lack of adequate medical treatment, and the factors that could have contributed to her
death.
191. In that regard, the Commission finds that the information in the procedural records
connected with the enforcement of her sentence and the incidental motions presented pointed unequivocally
to the fact that her diseases were getting worse as a result of the lack of adequate treatment. Furthermore,
there was information that she was in a depressive state in the days leading up to her death and that she had
epigastric hardness on which an ultrasound scan was omitted to be carried out. Those circumstances were
not properly investigated.
192. The IACHR notes, in turn, that no authority conducted any analysis to identify the nature of
the appropriate responsibilities under the Guatemalan legal system. On this point, the Commission
emphasizes that the responsibility of agents of the state for acts such as the ones in the present may be
diverse in nature. In this regard, “the determination of criminal and/or administrative responsibility each has
its own substantive and procedural rules. Consequently, the failure to determine criminal responsibility
should not prevent the continuation of the investigation into other types of responsibilities, such as
administrative responsibilities.”368
193. Finally, the Commission notes that the failure to conduct an investigation has also meant a
failure to disclose truth, with the result that, to date, there has still not been a judicial determination as to
whether or not the "pulmonary edema" and "hemorrhagic pancreatitis" established as causes of death were
linked to Ms. Chinchilla’s diseases and whether or not they were caused by the lack of adequate medical
attention. This situation of uncertainty has been allowed to linger unreasonably to this day, almost 10 years
since Ms. Chinchilla died.
194. The State has suggested that there was a “lack of interest” on the part of the family in the
case, since they did not file a criminal complaint. However, the Commission recalls that where violations of
the life or well-being of a person in state custody are concerned, it is not necessary to examine the steps that
the relatives of the victim may or may not have taken with a view to the investigation of the facts, given that,
since that is an ex officio obligation of the State, the Commission must analyze the action taken by the latter on
September 29, 1999. Series C No. 71, par. 123. See also I/A Court H.R., Blake Case, Reparations, Judgment of January 22, 1999.
Series C No. 48, par. 65.
367
I/A Court H.R., César Mendoza et al. Argentina. Preliminary Objections, Merits and Reparations. Judgment of May
14, 2013. Series C, No. 260, par. 223.
368
I/A Court H.R., César Mendoza et al. Argentina. Preliminary Objections, Merits and Reparations. Judgment of May
14, 2013. Series C, No. 260, par. 224.