medical report. The Commission considers that the delay in beginning to take the steps aimed at producing evidence in the investigation necessarily had an impact on the possibilities of clarifying the facts, for as the Inter-American Court has established repeatedly, it is in the initial stages of the investigation in which all measures should be taken to safeguard the evidence. 153. The Commission also observes that despite the request from the family on at least three occasions to have the exhumation of the body and the respective autopsy ordered, to date it has not been done. The State has not offered an explanation that would enable one to understand the lack of response with respect to the request for an autopsy, even though it is crucial evidence140 for establishing the causes of death of Mr. Poblete Vilches and the possibility that his death occurred as the result of negligence by the medical personnel at the hospital. In addition, an autopsy would have made it possible to investigate the acts of torture and cruel treatment alleged by Mr. Poblete Vilches’s family members on several occasions. 154. The Commission observes that the expert medical report by the Forensic Medicine Service (Servicio Médico Legal), which indicates that there was no breach of the professional standards141 and that Mr. Poblete Vilches died as the result of his serious health situation, does not get into a detailed analysis as to whether the decision to discharge Mr. Poblete Vilches was in keeping with his health needs. Nor does it provide an explanation of the severe deterioration suffered by Mr. Poblete Vilches just three days after leaving the hospital, consisting of pneumonia and septicemia. Along the same lines, that report only affirms that in the second hospital admission it was not possible to give Mr. Poblete Vilches intensive care treatment but only intermediate care treatment, due to the lack of beds, but it does not offer any analysis of the way in which this situation may or may not have led to Mr. Poblete Vilches’s death in the ensuing hours. Despite these omissions in the expert medical report, the Commission does not have information that indicates that corrective measures were adopted to obtain an expert opinion that responds to these essential questions to determine possible responsibilities for the death of Mr. Poblete Vilches. 155. The Commission also takes note that the statement by the accused Luis Carvajal Freire was never taken, even though the First Civil Court verified that he continued working at the Hospital Sótero del Río. Nor were some of the statements requested in the proceeding by Mr. Poblete Vilches’s next-of-kin obtained; nonetheless, according to them, those statements might offer information on the care provided to their loved one, as well as his condition when discharged. 156. The Commission emphasizes that despite these evidentiary omissions and even though fundamental investigative steps were not pursued, the judicial authorities ordered the case dismissed on two occasions, in December 2006 and June 2008, under the argument that “based on the facts gathered in the proceedings, the existence of the alleged crime has not been sufficiently established.” In addition, the Commission observes that since the second re-opening of the investigation it has no information that allows it to establish that efforts have been made to correct those omissions. Indeed, the Commission does not have information about the current state of the investigations. 157. Finally, the Commission has argued that in the cases in which human rights violations have been committed by public officials, the states also have the obligation to investigate the systemic failures that led to those violations, so as to avoid their repetition. 142 In addition, both the inter-American system and the United Nations system have recognized that states must hold 140 See I/A Court HR. Ximenes Lopes. Para. 187; and IACHR. Report on the Merits No. 119/10, Case 12,004, Marco Bienvenido Palma Mendoza et al, Ecuador, October 22, 2010, para. 118. 141 Annex 48. Forensic Medical Service, Pericia médico legal No. 140-2005 of June 8, 2006 (attached to communication from the State of September 23, 2008). 142 IACHR, Report No. 80/11, Case 12,626, Jessica Lenahan (Gonzales) et al., United States, Merits, July 21, 2011, para. 17. IV 170. 31