CASE OF MARDOSAI v. LITHUANIA
No violation of Article 2 - Right to life (Article 2 - Positive obligations;Article 2-1 - Effective investigation) (Procedural aspect)
Egidijus Kūris;Ganna Yudkivska;Iulia Motoc;Paulo Pinto De Albuquerque;Georges Ravarani
5. The first and second applicants were born in 1981 and 1971 respectively and live in Jurbarkas. They are wife and husband. 6. On 15 May 2009 the first applicant, who was nine months pregnant and already past her due date, was admitted to the obstetrics and gynaecology ward of Jurbarkas Hospital. 7. On the morning of 20 May 2009 she was given medication in order to induce labour, but the medication was subsequently discontinued and she was given sedatives. In the late afternoon her waters broke. The doctors noticed that the heartbeat of the foetus was weak and decided to perform a Caesarean section. Following the surgery, the first applicant gave birth to a daughter. The newborn baby was in a serious condition, so she was taken to a hospital in Kaunas for intensive care. 8. On 22 May 2009 the baby died. The applicants decided not to have an autopsy performed on her body – according to them, they were informed by doctors that an autopsy was not necessary. The Government contested this and submitted that the applicants had been informed that an autopsy had been necessary but refused it nonetheless. 9. Following the baby’s death, Jurbarkas Hospital conducted an internal inquiry into the medical services provided to the first applicant. The inquiry report, issued on 16 June 2009, found that some erroneous entries had been made in the first applicant’s medical file, the assessment of her and the baby’s condition had probably been inadequate, and certain actions to resuscitate the baby had been taken too late. 10. At the applicants’ request, the Ministry of Healthcare also conducted an inquiry into the medical services provided to them at Jurbarkas Hospital. A provisional report, issued on 22 June 2009, found that the first applicant’s labour had not been induced in compliance with the relevant rules, the condition of the foetus had not been properly monitored, there had been shortcomings in the resuscitation of the baby, and one of the doctors (R.B.) had not been properly qualified to provide obstetric services. The report issued a series of recommendations to the hospital, and also suggested that the State Inspectorate for Medical Inquiries conduct a more in-depth inspection of the medical services at Jurbarkas Hospital. 11. The State Inspectorate for Medical Inquiries issued its report on 26 August 2009, in which it identified several shortcomings in the work of doctors who had provided care to the first applicant, and concluded that the medical services had been inadequate. 12. Subsequently, doctor R.B. was dismissed from Jurbarkas Hospital, and the hospital stopped providing obstetric services, citing a lack of qualified medical personnel. V.K., a gynaecologist, and three other doctors were officially reprimanded for having provided inadequate medical services to the first applicant and V.K. was later dismissed at her own request. 13. On 22 June 2009 the applicants asked the Jurbarkas district prosecutor (hereinafter “the prosecutor”) to open a pre-trial investigation into the medical negligence at Jurbarkas Hospital which had led to their newborn daughter’s death. The pre-trial investigation was opened on the same day and carried out by the Jurbarkas police. In July and August 2009 the applicants were interviewed and granted victim status in the investigation. 14. On 7 August 2009 a court-appointed doctor delivered a specialist opinion (specialisto išvada) that the applicants’ daughter’s death had resulted from asphyxia during birth and meconium aspiration syndrome. 15. In August and September 2009 the police interviewed the doctors who had provided medical services to the first applicant, and obtained various documents from Jurbarkas Hospital. 16. In September 2009 the applicants asked the prosecutor to exhume their daughter’s body so that an autopsy could be performed and the cause of her death could be more precisely determined. However, the prosecutor denied their request, relying on an opinion from medical experts that performing an autopsy more than three months after the baby’s death would not give any results because of the significant post-mortem changes to the body during that time. 17. In October 2009 the police asked four court-appointed doctors for a specialist opinion on the causes of the baby’s death and the actions of the doctors at Jurbarkas Hospital. The applicants also submitted questions and their questions were forwarded to the specialists. The opinion, delivered on 5 May 2010, stated that no causal link between the doctors’ actions and the death could be established, and that it was not possible to determine whether the death could have been avoided because an autopsy of the body had not been performed. Subsequently, the applicants asked the police to order another opinion from specialists, and they submitted additional questions. On 10 February 2011 three other court-appointed doctors provided answers to the applicants’ questions. Their overall conclusions were the same as those of the previous specialists. 18. On 4 March 2011 the prosecutor discontinued the pretrial investigation on the grounds that no causal link between the actions of the doctors at Jurbarkas Hospital and the baby’s death had been established. On 24 March 2011 a senior prosecutor upheld that decision, but on 2 May 2011 the Jurbarkas District Court upheld a complaint submitted by the applicants and reopened the pre-trial investigation. The court found that the two specialist opinions (see paragraph 17 above) had not answered some of the questions submitted because certain medical data had not been made available. It also found that the investigation had not established why an autopsy had not been performed (see paragraph 8 above). Therefore, the court ordered the prosecutor to ask additional questions of some of the witnesses and order a comprehensive forensic examination. 19. On 2 June 2011 the prosecutor asked the court to order a forensic examination of the causes of the baby’s death and the causal link between the doctors’ actions and the death. The applicants submitted a list of additional questions to be forwarded to the forensic expert. On 27 June 2011 the Jurbarkas District Court ordered the examination, but that order included only the prosecutor’s questions and did not provide any reasons as to why the applicants’ questions had not been included. The applicants appealed against it, but on 14 October 2011 the Kaunas Regional Court dismissed their appeal on the grounds that deciding which questions to forward to the expert was the lower court’s prerogative. 20. On 25 October 2011 the applicants again submitted their questions to the prosecutor and asked for an additional forensic examination. On 5 December 2011 the Jurbarkas District Court ordered an additional forensic examination, and that order included the applicants’ questions. However, the court’s order was only forwarded to the forensic expert on 5 February 2013. 21. On 29 January 2013 a court-appointed forensic expert delivered the answers to the prosecutor’s questions (see paragraph 19 above). The expert found that the cause of the baby’s death had been determined correctly, the medical services provided to the first applicant had been adequate, and there was no causal link between the doctors’ actions and the death. 22. On 13 February 2013 the applicants submitted a complaint to the Prosecutor General, stating that the pre-trial investigation was being conducted inefficiently and with undue delays. They complained, in particular, that the court’s decision of 5 December 2011 to order an additional forensic examination (see paragraph 20 above) had not been forwarded to the expert until 5 February 2013, one year and two months after it had been issued. The Prosecutor General’s Office conducted an official inquiry, which on 18 June 2013 concluded that Jurbarkas prosecutors had committed disciplinary violations, and that the pre-trial investigation had not been properly conducted and supervised. The inquiry found that the Jurbarkas district prosecutor’s office had been reorganised in 2012, which was the likely reason for the above-mentioned shortcomings. No individuals were penalised. 23. On 25 June 2013 a court-appointed forensic expert delivered the answers to the applicants’ questions (see paragraph 20 above). Among other things, the expert found that some of the doctors’ actions had not been in line with the relevant requirements, but there was no direct causal link between their actions and the applicants’ daughter’s death. 24. On 5 July 2013 the prosecutor discontinued the investigation on the grounds that no causal link between the actions of the doctors at Jurbarkas Hospital and the applicants’ daughter’s death had been established (see paragraphs 17, 21 and 23 above). The applicants appealed against that decision, and on 4 November 2013 a senior prosecutor reopened the pretrial investigation and assigned it to a different police department. The senior prosecutor considered that, following the decision to discontinue the investigation, new relevant circumstances had emerged, although he did not specify what those circumstances were. 25. On 28 February 2014 V.K., the gynaecologist, was served with a notice that, under Article 229 of the Criminal Code, she was suspected of having failed to perform her official duties (see paragraph 37 below). On 8 April 2014 the case was referred to the Jurbarkas District Court for examination on the merits. 26. On 28 April 2014 the Jurbarkas District Court held an oral hearing. V.K. was not present and her lawyer informed the court that she had been admitted to hospital, although no medical certificate was submitted. The court adjourned the case until 12 May 2014. 27. On 12 May 2014 V.K. was again not present, and the court received a medical certificate confirming her hospitalisation until 14 May 2014. The court decided to adjourn the case and proposed three alternative dates: 13 May, 16 May and 19 May 2014. V.K.’s lawyer stated that V.K. would not be well enough by 13 May, and that on the later dates he would be unable to represent her. The court adjourned the case until 25 June 2014. 28. On 23 June 2014 the applicants applied to the court to reclassify the charges against V.K. as negligent homicide in violation of special conduct security rules under Article 132 § 3 of the Criminal Code (see paragraph 38 below). The court adjourned the case until 14 July 2014 in order to give the accused enough time to acquaint herself with the case file. 29. On 14 July 2014 the Jurbarkas District Court terminated the case on the basis that it was time-barred. It held that V.K. had been charged with a crime of negligence, and the five-year statutory limitation period had ended on 21 May 2014 (see paragraphs 8 above and 39 below). The court also dismissed the application to reclassify the charges and noted that, in any event, reclassification would not alter the statutory limitation period. 30. The applicants appealed against that judgment. They submitted that, in line with the Criminal Code, the statutory limitation period must have been suspended while the examination of the case had been adjourned owing to V.K.’s illness (see paragraph 40 below). 31. On 6 November 2014 the Kaunas Regional Court dismissed the applicants’ appeal and upheld the judgment of the first-instance court. It firstly held that the legal provision cited by the applicants had been adopted after the alleged offence had been committed, and that at the time the alleged offence had been committed domestic law had not provided for suspension of the statutory limitation period during the adjournment of a case (see paragraphs 39-40 below). The court further held that, in any event, the examination of the case had been adjourned for an important reason V.K.’s hospitalisation – so there were no grounds for suspending the statutory limitation period. 32. On 24 February 2015 the Supreme Court refused to examine a cassation appeal lodged by the applicants, on the grounds that it did not raise any important legal questions. 33. The Government in their observations informed the Court that on 15 September 2011 the applicants instituted civil proceedings against Jurbarkas Hospital, claiming compensation in respect of pecuniary and nonpecuniary damage caused by inadequate medical services provided to the first applicant and their newborn daughter. They revised their claim in December 2011 and August 2013. The applicants claimed a total of 600,000 Lithuanian litai (LTL – approximately 173,770 euros (EUR)) in respect of non-pecuniary damage and a total of LTL 16,295 (approximately EUR 4,720) in respect of pecuniary damage, consisting of funeral expenses and the second applicant’s lost earnings during his time off work after their daughter’s death. 34. On 26 November 2014 the Kaunas Regional Court granted the applicants’ claim in part. Relying on the available inquiry reports, as well as the specialist opinions and results of the forensic examinations delivered in the criminal proceedings (see paragraphs 9, 10, 11, 17, 21 and 23 above), the court held that the doctors at Jurbarkas Hospital had breached their duty of care and that their actions “had contributed” (turėjo įtakos) to the death of the applicants’ daughter, so there were grounds for the hospital incurring civil liability. However, the court considered that the doctors’ actions had not been premeditated or grossly negligent, so the applicants’ claim in respect of non-pecuniary damage was granted in part, and they were awarded a total of LTL 80,000 (approximately EUR 23,170) under that head. They were also awarded a total of LTL 6,716 (approximately EUR 1,945) in respect of pecuniary damage, on the basis of the documents in the court’s possession. 35. The applicants and the hospital appealed against that judgment, but on 17 September 2015 the Court of Appeal upheld the lower court’s findings. The hospital transferred the awarded amount to the applicants’ bank accounts in November and December 2015.