## Facts

- Damião Ximenes-Lopes, a person with mental illness, was admitted on October 1, 1999 to Casa de Reposo Guararapes, a private psychiatric clinic operating within Brazil’s public health system (SUS) in Sobral, Ceará.
- During a visit, his mother reportedly found him restrained and visibly injured (including bleeding and swelling) and he asked her to call the police.
- He died on October 4, 1999, shortly after medication was administered.
- The autopsy recorded superficial injuries and listed the cause of death as undetermined, without clarifying the circumstances that produced the injuries.
- Evidence before the inter-American bodies indicated inhuman and degrading conditions at the clinic and a broader pattern of violence toward patients.
- The family, led by his sister Irene Ximenes Lopes Miranda, petitioned the Inter-American Commission on Human Rights in 1999; Brazil did not provide requested information during the Commission phase.
- The Commission found responsibility and referred the case to the Inter-American Court in 2004; Brazil raised preliminary objections and partially accepted international responsibility.

## Issues

1. Whether Brazil was internationally responsible for abuses and death occurring in a private psychiatric facility integrated into the public health system, and for subsequent omissions by authorities.
2. Whether the hospitalization, treatment, and death violated the rights to life and humane treatment under the American Convention, in relation to the duty to respect and ensure rights.
3. Whether failures to investigate and provide effective judicial remedies violated the rights to a fair trial and judicial protection.
4. Whether persons with mental illness are entitled to heightened State protection in mental-health institutions, including regulation, supervision, and least-restrictive care.

## Decision

- The Court held Brazil responsible for violations of the American Convention rights to life (art. 4) and humane treatment (art. 5) to the detriment of Damião Ximenes-Lopes, in conjunction with the duty to respect and ensure rights (art. 1(1)).
- The Court also found violations of the rights to a fair trial (art. 8) and judicial protection (art. 25), based on the lack of an effective, prompt investigation and the resulting impunity.
- The Court treated the clinic’s conduct as attributable to Brazil because it provided psychiatric services within the SUS framework and under State responsibility for regulation and oversight of an essential public service.
- Reparations included orders to investigate, prosecute, and punish those responsible; provide medical treatment to certain family members; pay compensation and costs; and publish the judgment.

## Legal Principles

- A State’s duty to respect and ensure Convention rights applies to essential public services delivered through private providers; delegation does not remove international responsibility.
- The right to life entails positive obligations to create and operate a legal and institutional framework that prevents foreseeable harm and ensures an effective system of justice addressing violations by public and private actors.
- Persons with mental illness are in a situation of special vulnerability; States must provide effective mental-health care that respects dignity, autonomy, and intimacy, and is delivered in the least restrictive manner compatible with the patient’s welfare.
- In cases of death or serious harm in institutional settings, the State must conduct a prompt, serious, and impartial investigation capable of identifying, prosecuting, and sanctioning those responsible; deficient investigations and impunity breach arts. 8 and 25.

## Conclusion

The Court held that Brazil bore responsibility for lethal and abusive treatment in a SUS-linked private psychiatric clinic and for the failure to deliver effective investigation and judicial protection, and it ordered both individual reparations and measures aimed at accountability and oversight of mental-health services.


Ximenes-Lopes v. Brazil, Inter-Am. Ct. H.R. (ser. C) No. 149 (2006)