13. The petitioner alleged that in the petition that reported the case to the competent authorities, she requested that the Civilian Police initiate an inquiry, and that the Federal Public Ministry initiate an administrative proceeding. 3 She referred to several statements made by victims of said Casa de Repouso, 4 and she attached the Report prepared by the Group for Monitoring and Evaluation of Hospital Psychiatric Care –GAPH-CE 5 (Grupo de Acompanhamento e Avaliação da Assistência Psiquiátrica Hospitalar)– when it visited the Casa de Repouso Guararapes at the request of the Commission on Human and Citizen Rights of the Legislative Assembly of Ceará, after the complaint lodged by the petitioner with that Commission, and, notwithstanding that initiative, according to the petitioner, the case was not duly investigated, no action was filed, the Casa de Repouso continued operating, and the guilty persons continued to go unpunished. 14. The Group for Monitoring and Evaluation of Hospital Psychiatric Care – GAPH-CE, when visiting the Casa de Repouso in November 1999, just after the incident alleged here, collected information on the reports of the death of Damião Ximenes. In that respect, they concluded as follows: The “Damião Case” evidences the precarious medical care, abusive treatment, various shortcomings listed in this report, which should be denounced to the various councils related to psychiatric care, and to the Public Ministry, for it to take the appropriate measures. 15. The report by the group of specialists in psychiatry and signed by Dr. Raimundo Alonso Batista de Aquino, Coordinator of Mental Health Care for the state of Ceará, concluded what was explained by the petitioner, i.e. that said Casa de Repouso was inadequate for the purposes to which it was earmarked: The clinic does not have the conditions for operating, based on all the comments referred to above. Based on its strategic location, we suggest it be intervened, or that a similar measure be adopted, changing its management or having its license stripped by the Single Health System. Measures to be adopted by the municipal government of Sobral or in conjunction with the SESA. 16. Even though the petitioner had demonstrated the existence of a police inquiry and an administrative proceeding, there is nothing in the record about what happened in these procedures. Furthermore, the State has not provided the Commission any information as to the development and results of those procedures. 17. The petitioner alleged that the State is not fulfilling its obligation to carry out the judicial investigation in order to determine the responsibility for her brother’s death, and she alleged State responsibility, as the State allowed and allows –as it continues to operate– the operation of said Casa de Repouso, which, through its staff of physicians, nurses, and monitors, dispenses cruel and inhuman treatment to its patients, treatment that caused the death of her brother Damião Ximenes Lopes. B. The State’s position 18. The Commission, as per its Regulations, notified the Brazilian State, asking that it provide any information it deemed pertinent to the complaint; it then did so again on three more occasions. Nonetheless, the State let the time periods run, and as of the analysis of this Report, it did not present any response to the facts alleged by the petitioner, nor did it call into question the admissibility of the petition that is the subject of this Report. IV. ANALYSIS OF ADMISSIBILITY A. Competence of the Commission ratione personae, ratione materiae, ratione temporis, and ratione loci 3 Administrative Proceeding no. 08105.001068/99-62. 4 Statements made in Inquiry no. 404/99. 5 Report dated December 2, 1999. 3

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