50
which she described the circumstances surrounding the death of her son, Damião
Ximenes-Lopes, on October 4, 1999.95
112(61)
On October 18, 1999 the Coordinadora Municipal de Control, Evaluación y
Auditoría de la Secretaría de Salud y Asistencia Social (Control, Evaluation and Audit
Municipal Coordinator for the Health and Social Services Bureau ), by order of the
Municipal Secretary of Health and Social Services of the Municipality of Sobral, issued
Administrative Resolution No. 001/CCAA, ordering the creation an Administrative
Investigation Commission** to inquiry into the facts reported by Albertina VianaLopes. On February 18, 2000, the Administrative Investigation Commission, after
two supervisory visits to Casa de Reposo Guararapes (Guararapes Rest Home),
interviewing nineteen people and analyzing several documents, issued its final
report, in which it concluded that Casa de Reposo Guararapes “[did] not meet the
required standards and [did] not conform to professional medical ethics.” 96
112(62)
The last inspection at Casa de Reposo Guararapes (Guararapes Rest
Home) was carried out on May 15, 1996 by the Grupo de Acompañamiento de Asistencia
Psiquiátrica del Ministerio de Salud (GAP) (Psychiatric Care Support Group of the Ministry
of Health), on which occasion it was recommended that two infirmaries of the Casa
de Reposo Guararapes (Guararapes Rest Home), which operated in a place known as
the “basement” be closed due to poor operating conditions, leaks and other
irregularities. In addition, the report documented the fact that patients outnumbered
available hospital beds, which evidenced the existence of the so-called “floor beds”,
which meant that patients were sleeping on the floor. 97
112(63)
On October 21, 1999, the Departamento de Vigilancia Sanitaria de la
Secretaría de Salud y Asistencia Social (Sanitary Surveillance Department of the Health
and Social Services Bureau) conducted an inspection at Casa de Reposo Guararapes
(Guararapes Rest Home), and reported the following findings:
from the point of view of sanitary surveillance [,…] all actions and services at Casa de
Reposo Guararapes do not comply with reasonable identity and quality standards […In
addition, ...] it was verified that:
hospital unit does not provide staff with personal protection equipment ; […]
staff has not been vaccinated against tetanus or hepatitis B;
no recreational activities are offered to patients;
95
Cf. report on the Administrative Investigation prepared at the request of the Coordinadora
Municipal de Control, Evaluación y Auditoría de la Secretaría de Salud y Asistencia Social (Control,
Evaluation and Audit Municipal Coordinator for the Health and Social Services Bureau), issued on February
18, 2000, supra note 43; and complaint filed by Albertina Viana-Lopes with the Coordinadora Municipal de
Control, Evaluación y Auditoría de la Secretaría de Salud y Asistencia Social (Control, Evaluation and Audit
Municipal Coordinator for the Health and Social Services Bureau) on October 13, 1999, supra note 49.
**
In the original, in Portuguese: Comissão de Sindicância.
96
Cf. Administrative Resolution No. 001/CCAA issued by the Control, Evaluation and Audit Municipal
Coordinator on October 18, 1999 (record of appendixes to the answer to the application, appendix I,
volume I, page 1548); and report on the Administrative Investigation prepared at the request of the
Coordinadora Municipal de Control, Evaluación y Auditoría de la Secretaría de Salud y Asistencia Social
(Control, Evaluation and Audit Municipal Coordinator for the Health and Social Services Bureau), issued on
February 18, 2000, supra note 43.
97
Cf. report issued by the Grupo de Acompañamiento y Evaluación de la Asistencia Psiquiátrica
Hospitalaria (Hospital Psychiatric Care Support and Evaluation Group) on November 5, 1999, supra note
91; and statement made by Lídia Dias Costa on July 31, 2003 (record of appendixes to the brief of
requests, arguments and evidence, appendix 1, pages 897 to 903).