94. It is important to stress that domestic rulings, in both the criminal and the civil courts, were based principally on the results of the expert reports that were prepared on the basis of information appearing in Ms. Cristina Britez’s clinical record, because when conducting the autopsy more than one month after her death, it was not possible to ascertain the cause of her death. 95. That said, in both criminal and civil proceedings, Ms. Britez’s next of kin questioned on various occasions the validity of that clinical record, stating in detail that it showed evidence of having been tampered. The expert report conducted by the University of Córdoba also pointed out various omissions and errors in the clinical record. In addition, in the judgment of appeal and nullification of case 27.985, of August 6, 1999, in connection with the accusation of omissions and errors in the clinical record, reference was made to the fact that “the alleged falsehoods and omissions were only discovered after” the medical examiners had worked with it. 96. Despite the above, on the basis of the analysis of the evidence appearing in the case filed with the Commission, there was no line of investigation that had been pursued indicating it had been specifically aimed at effectively clarifying whether or not the clinical record had been tampered with. 97. In its observations on the merits, the state asserted that “the irregularities of the clinical record were not upheld in the domestic courts, where it was considered that they arose from sloppiness and did not reflect the will to tamper with a document”; nevertheless, the state did not provide information on the steps taken by the investigation or evidence that, in the domestic proceedings, would have been sought to reach that conclusion. Furthermore, on the basis of the actions which the Commission has available, it is observed that said assertion about “sloppiness” to which the state is referring was made by the Government of the City of Buenos Aires in its challenge to the civil suit for damages, as established in the judgment of the court of first instance. 98. The Commission considers that, because the clinical record is such an important piece of evidence in the instant case and is the basis for expert reports and subsequently for the court rulings in which it was considered that sufficient elements were not available to ascertain the responsibilities for Ms. Cristina Britez Arce’s death, it is not enough to state that there was no intention to tamper with the document; rather it was the state’s obligation to demonstrate that all necessary lines of investigation were pursued to determine their validity. Clarifying whether or not there had been any tampering with the clinical record was relevant to establish possible criminal or civil responsibilities for the respective reparations. 99. Despite the many expert reports that were prepared, the Commission also observes that the omissions have led to the impossibility, to date, of clearly and convincingly determining what caused Ms. Cristina Britez’s death. The above, as recognized by the authorities themselves, has been an obstacle for the possibility of ascertaining the responsibility of the physicians involved (see paragraphs 29 and 50 above). 100. Finally, the Commission observes that were long periods of time in the civil proceedings during which no steps were taken by the judicial authorities to make any progress and finalize the proceedings. This shall be examined in the following section. 2.2. Reasonable delay 101. The Commission observes that, in June 1992, criminal proceedings were filed for the death of Ms. Cristina Britez Arce and, in December 1998, the prosecutor brought formal charges against the physician Patricia Carmen Anido and the physician Eduardo Mario Negri, professionals of the Hospital Público Sardá. The Commission also observes that, between the filing of the complaint and the prosecutor’s charges, a certain amount of complexity can be observed in terms of the expert reports that were questioned and the related criminal proceedings that were filed, in which the complaints against the experts Casavilla and Poggi and against the Medical Examiners Corps were heard. Nevertheless, since the prosecutor brought charges in December 1998 and the judgment of the court of first instance was issued in July 2003, the Commission does not observe any element being submitted that would have added any complexity to the matter and that would warrant the delay in producing a court judgment. The Commission does not have any information available about any steps that might have been taken over those almost five years. 22