IACHR Files Application Before Inter-American Court of Human Rights in Case Concerning the Failure to Investigate Medical Malpractice in Babies' Deaths in Brazil

May 3, 2024

Washington, D.C. – The Inter-American Commission on Human Rights (IACHR) filed on March 22, 2024, an application before the Inter-American Court of Human Rights in Case 12,242, with regard to Brazil. This case concerns rights violations committed during investigations into the deaths of 96 babies over the period 1996–97, involving medical malpractice by employees of the Região dos Lagos Children's Hospital (CLIPEL).

The babies who died in this case were put in the CLIPEL's intensive care unit for various reasons. Their families said they noticed irregularities in medical treatment, poor hygiene, and other issues. Later, investigations exposed negligence and carelessness by the hospital's medical staff and other workers. Several administrative and judicial proceedings were launched, but suspects were cleared of charges of manslaughter and the relevant court decision was later upheld on appeal.

In Merits Report 267/22, the IACHR found deficiencies in medical care at the CLIPEL which caused the deaths of 96 babies. The IACHR also established that the State had failed to take effective action to prevent deaths and other effects on health, although it had a heightened obligation to protect those babies given their vulnerability.

The IACHR also assessed the judicial and administrative proceedings in this case and found serious deficiencies in the relevant criminal investigation, including a failure to establish individual responsibilities and to consider crucial evidence. Judicial decisions failed to adequately consider the evidence that was submitted and relied on deficient reports filed by health authorities. This led the suspects to be cleared of responsibility and civil actions to be shelved, showing a lack of due diligence by the State in the search for justice for victims and their families.

The IACHR found that the State had failed to comply with its responsibility to investigate and process this case with due diligence and that it had failed to comply with the principle of equality and non-discrimination by adopting gender-based stereotypes to blame mothers for their babies' deaths. Further, the lack of access to truth and justice caused suffering to the victims' families and violated their right to psychological and moral integrity.

The IACHR concluded that the State was liable for violations of the rights held in Articles 4.1 (right to life), 5.1 (right to personal integrity), 8.1 (right to a fair trial), 19 (rights of the child), 24 (right to equality before the law and to non-discrimination), 25 (right to judicial protection), and 26 (right to health) of the American Convention on Human Rights, concerning the obligations held in Article 1.1 of that instrument; as well as for violations of Article 7 of the Inter-American Convention on the Prevention, Punishment, and Eradication of Violence against Women (Convention of Belém do Pará). 

The Commission therefore recommended that the State adopt the following redress measures:

1. Provide comprehensive reparations, with a gender perspective, for the rights violations that have been identified, including financial compensation and other redress measures.
2. Provide any physical and mental healthcare necessary for the victims' families, in agreement with them.
3. Conduct a diligent, timely investigation to find out what happened and establish who should be held accountable for it, and provide legal assistance to the victims' families, free of charge.
4. Adopt non-recurrence mechanisms to ensure the following: i) improve the supervision of healthcare facilities, particularly those focused on newborns; ii) conduct an independent assessment of overcrowding and insufficient capacity in neonatal intensive care units; iii) train healthcare workers with a gender perspective, dismissing stereotypes; and iv) adopt protocols to address hospital-acquired infections in Brazil.

The IACHR is a principal and autonomous body of the Organization of American States (OAS), whose mandate stems from the OAS Charter and the American Convention on Human Rights. The Inter-American Commission has the mandate to promote the observance and defense of human rights in the region and acts as an advisory body to the OAS on the matter. The IACHR is made up of seven independent members who are elected by the OAS General Assembly in their personal capacity, and do not represent their countries of origin or residence.

No. 090/24

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