CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 18 juillet 2017

.s800EAC49 { font-size:12pt } .s598389FB { margin-top:0pt; margin-bottom:0pt; text-align:center; font-size:14pt } .s29100277 { font-family:Arial; font-weight:bold } .sFE10DC93 { margin-top:0pt; margin-bottom:0pt; text-align:center } .sBB9EE52A { font-family:Arial } .sA36B60A1 { font-family:Arial; font-style:italic } .sF5E1C6CF { font-family:Arial; font-weight:bold; text-decoration:underline; color:#ff0000 } .sE208486F { font-family:Arial; color:#ff0000 } .s598389F8 { margin-top:0pt; margin-bottom:0pt; text-align:center; font-size:11pt } .s4ACA9207 { page-break-before:always; clear:both; mso-break-type:section-break } .s9793A85B { margin-top:0pt; margin-bottom:0pt; text-indent:14.2pt } .sCB9E0544 { margin-top:0pt; margin-bottom:0pt; text-align:left } .sB9D5CABB { width:28.35pt; display:inline-block } .sD3B63DAD { margin-top:36pt; margin-bottom:12pt; page-break-inside:avoid; page-break-after:avoid; font-size:14pt } .s79DE5897 { margin-top:18pt; margin-left:17.85pt; margin-bottom:12pt; text-indent:-17.85pt; page-break-inside:avoid; page-break-after:avoid } .sA8776625 { margin-top:18pt; margin-left:29.2pt; margin-bottom:12pt; text-indent:-17.6pt; page-break-inside:avoid; page-break-after:avoid } .sF7A86111 { margin-top:6pt; margin-left:21.25pt; margin-bottom:6pt; text-indent:7.1pt; font-size:10pt } .s88F430E9 { margin-top:0pt; margin-left:33.6pt; margin-bottom:0pt; text-indent:-21.25pt } .s72C8F48C { margin-top:12pt; margin-left:36.6pt; margin-bottom:6pt; text-indent:-15.05pt; page-break-inside:avoid; page-break-after:avoid } .sA20670C4 { margin-top:12pt; margin-left:48.75pt; margin-bottom:6pt; text-indent:-17pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt } .s59DEA84 { margin-top:12pt; margin-left:59.5pt; margin-bottom:6pt; text-indent:-17.85pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt } .sB206C230 { margin-top:12pt; margin-left:68.65pt; margin-bottom:6pt; text-indent:-16.75pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt } .sBB355983 { margin-top:6pt; margin-left:21.25pt; margin-bottom:6pt; text-indent:7.1pt; page-break-inside:avoid; page-break-after:avoid; font-size:10pt } .s583D00FA { margin-top:0pt; margin-left:17pt; margin-bottom:0pt; text-indent:-17pt } .s32563E28 { margin-top:0pt; margin-bottom:0pt } .s26FF04E7 { margin-top:0pt; margin-left:17.3pt; margin-bottom:0pt } .s64E792FA { margin-top:0pt; margin-left:39.7pt; margin-bottom:0pt } .s4B243ECC { margin-top:12pt; margin-bottom:0pt; text-indent:14.2pt; page-break-inside:avoid; page-break-after:avoid } .sF7A4323 { margin-top:36pt; margin-bottom:0pt; text-align:left } .sBAD0D18F { width:1.87pt; display:inline-block } .s3244ABDB { width:175.75pt; display:inline-block } .s7602FED2 { width:18.21pt; display:inline-block } .sC1AC44A4 { width:228.11pt; display:inline-block }       FOURTH SECTION             CASE OF NINA KUTSENKO v. UKRAINE   (Application no. 25114/11)                   JUDGMENT       STRASBOURG   18 July 2017   FINAL   18/10/2017   This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision. In the case of Nina Kutsenko v. Ukraine, The European Court of Human Rights (Fourth Section), sitting as a Chamber composed of:   Vincent A. De Gaetano, President,   Ganna Yudkivska,   Faris Vehabović,   Egidijus Kūris,   Georges Ravarani,   Marko Bošnjak,   Péter Paczolay, judges, and Marialena Tsirli, Section Registrar, Having deliberated in private on 27 June 2017, Delivers the following judgment, which was adopted on that date: PROCEDURE 1.     The case originated in an application (no. 25114/11) against Ukraine lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by a Ukrainian national, Ms Nina Ivanivna Kutsenko (“the applicant”), on 17   April 2011. 2.     The applicant, who had been granted legal aid, was represented by Mr   M.   Tarakhkalo and Ms O.   Protsenko, lawyers practising in Kyiv. The Ukrainian Government (“the Government”) were represented by their Agent, most recently Mr Ivan Lishchyna. 3.     The applicant alleged that the domestic authorities had been responsible for and had failed to effectively investigate the death of her son. 4.     On 26 June 2015 the application was communicated to the Government. THE FACTS I.     THE CIRCUMSTANCES OF THE CASE 5.     The applicant was born in 1949 and lives in Vyshneve, the Kyiv region. A.     Background 6.     The applicant’s son (born in 1972), V.K., had a long history of chronic alcoholism and opium addiction. He also suffered from a number of chronic diseases (see paragraph 51 below). 7 .     On 13 August 2001 an officer of the Fastiv railway station police, K.M., apprehended him on suspicion of a drugs-related offence. 8 .     In February 2002 V.K. complained to the prosecution authorities that for more than a year he had been suffering from psychological pressure and physical ill-treatment by the Fastiv railway station police officers. It is not clear whether there was any follow-up to that complaint. The fact that V.K. had raised it was established by the domestic courts during the subsequent criminal proceedings against K.M. The trial court dealing with that case stated in its judgment that it had inspected the documents regarding the above-mentioned events on 27   February 2007 (see paragraph 78 below). 9 .     From 17 June to 1 July 2003 the applicant’s son was treated for opium addiction in the Kyiv regional hospital. There is no information in the case file whether that treatment was successful and in what condition V.K. was discharged from the hospital. B.     V.K.’s disappearance and related events in August 2003 10.     On 13 August 2003 V.K. left home and never returned. 11.     On 18 August 2003 the applicant reported his disappearance to the Vyshneve town police. 12 .     On the same date an unidentified unconscious man was found in Vasylkiv, the Kyiv region. He was taken by ambulance to the local hospital with a preliminary diagnosis of “poisoning by unknown substance”, which was not, however, confirmed by laboratory tests. 13.     On 19 August 2003 the man regained consciousness and identified himself as V.K. As subsequently stated by many witnesses, he had no visible injuries at that time. The only available information about V.K.’s treatment is that his condition improved considerably. 14.     On 21 August 2003 an official of the Vasylkiv town police informed his counterparts in Vyshneve that the applicant’s son had been found and that he was in hospital. There was no follow-up to the message and it was not passed on to the applicant. 15 .     On 22 August 2003 V.K. left hospital without authorisation. 16.     Shortly after midnight on 25 August 2003 he was found injured and unconscious at Fastiv railway station (further details are provided in paragraph 20 below). 17.     After V.K.’s subsequent death (see paragraph 36 below), the domestic authorities tried to establish what had happened to him between the two above-mentioned events. It took them five years to establish some of the facts (see paragraph   74 below). 18 .     In that regard, several people who had been detained in the police unit at Fastiv railway station on the evening of 22 August 2003 stated that they had witnessed the following events. At about 8 p.m. two police officers had brought in an apparently drunk man (subsequently recognised as V.K.) and placed him in a cell. As V.K. had protested loudly against his detention, one of the officers, who already was at the police station when V.K. had arrived (subsequently recognised as K.M. – see paragraphs 7 and 8 above), had entered his cell and hit him in the face with a rubber truncheon. V.K. had fallen down and his nose had started bleeding. K.M. had then kicked him twice, on the head and torso. The two officers who had apprehended V.K. joined K.M. From that moment the other inmates chose not to watch the beating but heard it going on. At about 6 a.m. on 23 August 2003, after the other detainees had been taken out for various procedural acts, V.K. had remained in the police unit, lying motionless on the floor. By noon that day he was no longer seen there. 19 .     The time and circumstances of V.K.’s departure from the police unit and his arrival at the railway station have never been established. None of the police unit’s documents contained any information about his detention. The two officers who apprehended him and subsequently participated in his ill-treatment have never been identified. 20 .     About thirty minutes after midnight on 25 August 2003, supposedly after a telephone call from a passer-by whose identity remained unknown, K.M. called an ambulance for an unidentified, unconscious man (later identified as V.K.) found at the railway station. The incident was not mentioned in the police unit’s log. When the ambulance arrived, K.M., who was waiting for it, made no mention of knowing V.K. or of having any information about him. 21.     The applicant’s son was taken to the State-run Fastiv Central Town Hospital (“the Fastiv Hospital”; see paragraphs 25-36 below). 22 .     The case file contains fragmentary and contradictory information as to whether the police showed any interest in V.K. thereafter. As stated in a letter from the chief doctor to the applicant of 25   January 2005, the nurse on duty had immediately informed the Fastiv town police by telephone about the arrival of a man with injuries. Subsequently, on 13   August 2005 there was a confrontation between that nurse and the police officer who had been on duty that day, with the police officer denying any such telephone call. It is not clear in what context the above confrontation was conducted. Furthermore, two nurses stated during questioning in February 2010 (also in an unclear context) that at about 7   a.m. on 25   August 2003 two police officers had arrived at the hospital to see “the newly arrived patient with injuries”. Given the considerable lapse of time, the nurses were unable to recognise the officers or give any further details. However, none of the four patients with whom V.K. had shared his ward remembered seeing the police. 23.     On 28 August 2003 the applicant, who remained unaware of the whereabouts of her son, once again asked the police to look for him. 24 .     On the same day the police officer K.O., who was in charge of the search at Vyshneve police, issued a report on questioning Vasylkiv Hospital staff, which said V.K. had been discharged on 22   August 2003 in good health. As subsequently established (see paragraph 61 below), K.O. did not in fact talk to the hospital’s staff and forged the report. Relying on that document, he issued a decision refusing to open a criminal case concerning V.K.’s disappearance, which was approved by his superior, A.V. (see   paragraph 62 below). C.     V.K.’s treatment and death in Fastiv Hospital 25 .     At about 2.35 a.m. on 25 August 2003 the applicant’s son was taken by ambulance to Fastiv Hospital, where he was registered as an unidentified person. He was dirty and his wounds were covered with scabs. 26 .     He was examined by the admissions doctor, a traumatology doctor and the anaesthesiologist on duty. They diagnosed him as having a closed craniocerebral injury and cerebral contusion and contused wounds to the head. As subsequently stated by numerous doctors in the context of the criminal proceedings against their colleague P.V. (see paragraphs 63-73 below), an X-ray examination of V.K.’s skull was carried out and did not reveal any fractures. However, there were no X-rays in his medical file and none of the hospital’s staff could explain their disappearance. 27.     At about 9 a.m. on 25 August 2003 V.K. recovered consciousness, but hardly responded to any attempts of contact. He did not remember who he was. For most of the time his mental state was blurred and he mumbled incomprehensibly. 28 .     On the same day he was examined by a neuropathologist, who carried out a lumber puncture. It indicated elevated intracranial pressure. The doctor prescribed some drugs for V.K. via intravenous drip, but it appears that he received only glucose, which was administered on 29   August 2003 (see paragraph 34 below). 29 .     It is not clear what medicine was administered to V.K. during his stay in Fastiv Hospital. It appears that he was prescribed anti-edema drugs and two different types of antibiotic. As stated by numerous patients, including those sharing the ward with V.K., all medications were at their own expense. Furthermore, none of the nurses questioned in the course of the criminal proceedings against P. (see paragraphs 63-73 below) was able to say what medication the hospital had had at its disposal to administer to patients free of charge. 30.     On 26 August 2003 the traumatology doctor P.V. was appointed to oversee V.K.’s treatment and examined him. On that day and the next the applicant’s son was also examined by the head of the traumatology department and a neuropathologist. 31.     On 28 August 2003, following a serious deterioration in V.K.’s condition, a panel of six of the hospital’s doctors examined him and it was decided to consult a neurosurgeon. 32.     A neurosurgeon from Kyiv Regional Clinical Hospital examined V.K. that evening and stated that he needed a computerised brain tomography scan for a proper diagnosis. As there was no such machine at Fastiv Hospital he needed to be transferred to the regional hospital. 33.     However, for unknown reasons that recommendation was not followed. P.V. stated in the course of his trial (see paragraphs 63-73 below) that, firstly, he had considered V.K. to be too ill to be moved and, secondly, that it had been impossible to overcome all the administrative formalities needed to obtain the required vehicle, for which he blamed his superiors. 34 .     On 29   August 2003 V.K. was given an intravenous infusion of glucose and his condition improved slightly. That was the only intravenous infusion carried out. 35 .     On 2 September 2003 V.K. slipped into a coma. Although the change in his condition was brought to their attention, the medical staff did not react. V.K. was not examined by his doctor or any other specialist. He was kept in the same ward in the traumatology department and no resuscitation measures were undertaken. 36 .     He died at 6.20 p.m. on 3 September 2003. D.     Investigation into the death of the applicant’s son and related events 37 .     On 4 September 2003 a forensic medical expert, G.S., conducted an autopsy of V.K. (documented as an unidentified person) and issued a preliminary death certificate. He stated that V.K. had died of toxic hypoxic encephalopathy (a brain dysfunction caused by oxygen deprivation resulting from toxic exposure) complicated by swelling of the brain on a background of proliferative leptomeningitis (inflammation of the tissues surrounding the brain), pericarditis (inflammation of the sac surrounding the heart), and chronic hepatitis. The expert also reported some minor injuries but stated that they had had nothing to do with his death. He did not mention the numerous tattoos on V.K.’s body (see also paragraph 48 below). 38 .     On 5 September 2003 the chief doctor at Fastiv Hospital wrote a letter to the Fastiv town police informing them that an unidentified man with head injuries had been brought to the hospital on 25   August 2003 and that he had died on 3 September 2003. The hospital’s administration therefore requested that the police identify that person. 39.     On 9 September 2003 the applicant found out about her son’s death from unspecified sources and immediately went to the Fastiv police. However, V.K. had already been buried in Fastiv as an unidentified person earlier that day. The applicant identified him from photographs of his body. According to her, “he was all dirty, shaggy, wizened, and his hair was covered with dried blood”. 40.     On 12 September 2003, at the applicant’s wish, the body was reburied in Vyshneve. She had the coffin opened so she could see her son. According to her, his body bore signs of torture. She submitted, in particular, that there were numerous injuries, including handcuff marks on his wrists and traces of electrical burns between the fingers. The applicant also alleged that one of her son’s tattoos appeared to have been “burnt off”. It appears that she complained to the prosecution authorities about the above matters. 41 .     On 10 October 2003 G.S. issued a post-mortem examination report reiterating his earlier findings (see paragraph 37 above). 42 .     On the same date the Prosecutor General’s Office (“the PGO”) opened a criminal case in respect of the suspected murder of V.K., however, no suspects were identified. That case was subsequently joined to and eventually severed from numerous other related criminal proceedings (see the sections below). 43 .     On 29 October 2003 G.S. issued a forensic examination report with similar conclusions as before. He also stated that V.K.’s medical condition had been caused by lengthy alcohol and drug intoxication. As regards his injuries, they were insignificant and might have resulted from his falling on a hard surface. 44 .     On 30 October 2003 the applicant took her son’s clothes and shoes from Fastiv Hospital and handed them over to the prosecution (the exact name of the authority is not legible in the copy of the document concerned). The clothes were covered with stains which looked like blood and the shoes had no laces. Given that removing the shoelaces of detainees was a well-known police practice, the applicant suspected that her son had been detained and asked the authorities to investigate that possibility. 45 .     Forensic immunological examinations of the clothes and shoes, which were carried out on 5 December 2003 and 1 July 2005, established, respectively, that the stains were blood and that it could have been V.K.’s. 46.     The investigation was entrusted to various prosecution and law ‑ enforcement authorities at different times: the town prosecutor’s offices in Fastiv, Vasylkiv and Bila Tserkva, the Kyiv Regional Prosecutor’s Office and the PGO. It was discontinued and resumed on many occasions. Overall, from 2003 to 2016 the investigator in charge of the case was changed at least twenty times. 47 .     On 15 October 2004 V.K.’s body was exhumed on the PGO’s order. 48 .     On 15 November 2004 a forensic medical expert (S.A.) completed a report after examining the body. He documented the following injuries: a fracture of the nose, three wounds on the right side of the head, an unspecified number of haematomas in the soft tissues under the scalp and on the face, and three haematomas under the pericranium. All the injuries had been inflicted by blunt objects, possibly by hands and/or feet, without further specification being possible. The report also noted large tattoos on the arms and shoulders. 49.     According to the applicant, the forensic examination also found that the left kidney, the suprarenal glands and the pancreatic gland were missing from her son’s body. The expert report stated in that regard: “In the place where the left kidney should be is a greyish-brown mass resembling a kidney in texture. [...] It has not been possible to identify secretions from the suprarenal glands or the pancreatic gland.” 50 .     The mass resembling a kidney was taken for a forensic histological analysis, which did not discover anything of note. S.A. was asked during G.S.’s subsequent trial whether any organs were missing from the body and he replied in the negative. 51 .     Between 2004 and 2009 numerous forensic medical examinations were carried out on the basis of the material in the case file (at least six). They found that although, as established by the forensic histological examinations, V.K. had been suffering from various diseases (namely chronic leptomeningitis, chronic encephalopathy, granular myocardial dystrophy, interstitial hepatitis with the first signs of cirrhosis, granular kidney degeneration, diffuse proliferative nephritis and chronic bronchitis), none of them, either taken separately or together, could have caused his death. It was eventually established that the direct cause of death had been swelling of the brain and meninx, which had blocked the circulation of blood in the brain. Only a computerised brain tomography could have diagnosed that condition while V.K. was still alive, but that had not been done. The experts held that the fatal brain injuries could have resulted from him being beaten. It was stated in that connection that he had sustained at least eight blows to the head from blunt objects (possibly a rubber truncheon, fists and/or feet). At the same time, it was impossible to establish precisely the nature and scope of all the injuries to V.K.’s head given the omissions and deficiencies of the post-mortem examination. Details of additional forensic medical examinations, carried out in 2010 and 2012, are provided in paragraphs 65-66 and 81 below. 52 .     On 21 December 2008 the investigator in charge of the case inspected V.K.’s cell at Fastiv railway station police unit and took several samples from the walls and floor (see paragraph 75 below for the context of that investigative measure). A number of forensic immunological examinations were carried out in 2008, 2009 and 2010. They found that the samples contained traces of blood, which could have come from the applicant’s son. 53.     On 6 December 2012 an investigator at Bila Tserkva City Prosecutor’s Office (it is not known when and in what circumstances the investigation had been handed over to that authority) made an entry in the Unified Register of Pre-Trial Investigations regarding an investigation into abuse of office by two unidentified police officers on account of V.K.’s ill ‑ treatment on 22 August 2003. Such an entry was a new procedure for initiating a pre-trial investigation under the new Code of Criminal Procedure, which had come into effect on 19 November 2012. The case was transferred to the Kyiv Regional Prosecutor’s Office on 10 September 2013. 54 .     There is no information in the case file about further developments in the investigation. According to the Government’s observations, it was still ongoing as of September 2016. E.     Criminal proceedings against G.S. (the forensic medical expert who   conducted the autopsy) 55 .     On 7 April 2005 the PGO opened a criminal case against the forensic medical expert G.S. on suspicion of negligence. Further charges were subsequently brought against him (see below). 56 .     On 5 May 2010 the Kyyevo-Svyatoshynskyy District Court (“the   Kyyevo-Svyatoshynskyy Court”) found G.S. guilty of abuse of office and forgery in office leading to grave consequences and of delivering a knowingly false expert conclusion. More specifically, the trial court held that the expert had knowingly given false data on the cause of V.K.’s death, had failed both to collect all the requisite tissue samples and to carry out a number of essential analyses. However, it acquitted G.S. of concealing a serious crime. He was also exempted from punishment for forgery and a false expert conclusion as those charges had become time-barred. He was sentenced on the charge of abuse of office to three years and six months’ imprisonment and a three-year ban on holding expert positions. The Kyyevo-Svyatoshynskyy Court allowed a civil claim by the applicant in part. It awarded her 1,851 Ukrainian hryvnyas (UAH; at the time equivalent to 175 euros (EUR)) in respect of pecuniary damage and UAH   10,000 (about EUR 950) in respect of non-pecuniary damage, to be paid by G.S. In addition, the applicant was awarded UAH   50,000 (about   EUR 4,700) in respect of non-pecuniary damage, to be paid by the Kyiv Regional Bureau of Forensic Medical Examinations. 57 .     On 18 August 2010 the Kyiv Regional Court of Appeal (“the Regional Court of Appeal”) allowed an appeal by G.S., quashed the first ‑ instance court’s judgment in the part which convicted him of making a knowingly false expert conclusion and discontinued proceedings on that charge, because there were no constituent elements of an offence in his actions. The appellate court also reclassified the remaining charges. Instead of abuse of office and forgery in office leading to grave consequences, he was found guilty of professional negligence with grave consequences and was sentenced to three years’ imprisonment and a ban on holding expert positions for three years. As that new charge had become time-barred, the Regional Court of Appeal absolved him from the penalty. The judgment upheld the applicant’s civil claim. 58 .     On 18 October 2010 the Supreme Court rejected a prosecution request for leave to appeal on points of law. 59 .     On 28 October 2010 G.S. paid the amount due to the applicant. 60 .     According to the applicant, she has never received any money from the Kyiv Regional Bureau of Forensic Medical Examinations. F.     Criminal proceedings against the Vyshneve police officials 61 .     Following numerous complaints by the applicant about the inadequacy of Vyshneve police’s search for her son in August 2003, on 16   April 2007 the PGO opened a criminal case against officer K.O., who had been in charge of the search. Courts at two levels of jurisdiction (the Kyyevo-Svyatoshynskyy Court on 9 July 2012 and the Regional Court of Appeal on 9 April 2014) found him guilty of abuse of office with grave consequences and of forgery in office (see paragraph 24 above). They sentenced him to five years’ imprisonment and a prohibition on holding positions related to the performance of public duties for two years. He was, however, exempted from serving the sentence given the expiry of the statutory limitation period. The decision became final as there were no appeals on points of law. 62 .     The applicant also unsuccessfully sought the prosecution of A.V., K.O.’s supervisor. G.     Criminal proceedings against P.V. (the doctor in charge of V.K.’s treatment at Fastiv Hospital) 63 .     On unspecified dates the prosecution authorities refused to institute criminal proceedings in respect of V.K.’s death against the chief doctor, the head of the traumatology department, the anaesthesiologist and the neuropathologist at Fastiv Hospital. The case file does not contain any further information or documents in that regard. Nor is there any information as to whether there were any disciplinary proceedings. 64.     On 24 October 2007 the PGO opened a criminal case against P.V., the traumatology doctor at the hospital, on suspicion of failure to provide V.K. with the requisite medical care, which had led to the latter’s death. 65 .     On 14 September 2010 the investigator ordered a forensic examination of the case file by a panel of experts with a view to assessing the care provided to V.K. at Fastiv Hospital. The panel had to answer thirty specific questions, including the following: (a) Were there any legal standards for the treatment of craniocerebral injuries and, if so, had they been complied with in V.K.’s case? (b) Was the neurosurgeon’s recommendation to undertake a computerised brain tomography binding on P.V.? (c) How had the failure to carry out the computerised brain tomography influenced the quality of the medical care provided to V.K. and his health condition? (d) Would a timely computerised brain tomography have helped to detect the pathological developments that caused V.K.’s death? If so, would a timely medical response have made it possible to prevent them? (e) Had it been feasible to transport V.K. to the better equipped Kyiv Regional Hospital given the state of his health? (f) Were there any legal standards for such transportation? (g) Were any resuscitation measures carried out once V.K. had gone into a coma? (h) Did his coma result from low blood sugar? (i) Was V.K. so ill when he had arrived at Fastiv Hospital that he had been bound to die, regardless of any medical care? 66 .     The experts issued their report on 28 January 2011. It stated that there had been no legal standards for treating craniocerebral injuries until 13   June 2008. However, according to general practice, treatment was to consist of sedatives and pain relief; treatment of symptoms; an initial surgical debridement of wounds; anti-inflammatories, and, if required, hormonal, dehydrating, anti-edemic, antioxidant and nootropic treatment. The experts noted that the drugs prescribed for the applicant’s son (see   paragraph 29 above) appeared to correspond to that practice. The report also observed that there were no regulations that had obliged P.V. to comply with the neurosurgeon’s recommendation. A   timely computerised brain tomography would have helped to clarify the nature and scope of V.K.’s craniocerebral injuries, which, in turn, would have led to the right treatment. Accordingly, the failure to carry out that diagnostic measure had impaired the quality of the medical care given to V.K. and had contributed to aggravating his condition. Transporting him had been necessary and possible using a special intensive care vehicle, which the hospital had had at its disposal. In the absence of any relevant legal standards, questions concerning the transportation of patients were at the discretion of the doctor treating the patient and the hospital’s administration. The panel of experts further noted that V.K.’s medical file made no mention of resuscitation measures. As regards the cause of V.K.’s coma, there appeared to be no conclusive evidence that it had been due to low blood sugar. At the same time, the experts noted that given V.K.’s inability to eat and drink on his own it was probable his sugar level had dropped. Furthermore, they observed that although his condition had warranted regular infusions of glucose under the supervision of an endocrinologist, there had been only one such intravenous infusion, on 29 August 2003. Lastly, the report stated that there was no indication of an inevitable fatal outcome for V.K., regardless of any medical assistance. 67.     In March 2011 the investigation was completed and the case was sent for trial. 68.     On 19 September 2013 the Vasylkiv Town Court remitted the case for additional investigation. However, on 6 February 2014 the Kyiv City Court of Appeal quashed that ruling. 69 .     On 29 July 2014 the Kyyevo-Svyatoshynskyy Court (to which the case had been transferred at the applicant’s request) found P.V. guilty of a failure to provide the applicant’s son with the requisite medical care, which had led to grave consequences. The court held, in particular, that P.V., without any good reason, had failed to make sure V.K. was transferred to the regional hospital for a computer brain tomography, which had seriously undermined the effectiveness of his treatment. Furthermore, it was concluded that P.V. had failed to take even the minimum measures in response to V.K.’s coma on 2 and 3 September 2003. The court sentenced him to three years’ imprisonment, but released him from serving the sentence as the limitation period for that type of offence had expired. Furthermore, the court allowed a civil clam by the applicant in part and awarded her UAH   100,000 (at the time equivalent to about EUR 6,100) in respect of non-pecuniary damage, to be paid jointly by P.V., the Fastiv District State Administration and Fastiv Hospital. 70.     On 5 November 2014 the Regional Court of Appeal upheld that judgment. The only amendment it ordered was to make Fastiv Hospital solely responsible for paying the applicant. 71 .     As there was no appeal on points of law the judgment became final. 72 .     The Government submitted an information note from the unified register of enforcement proceedings along with their observations. It stated that the bailiffs service had on 23 January 2015 terminated enforcement of the above judgment at the applicant’s request. 73 .     Without commenting on that document, the applicant submitted that as of 1 August 2016 she had not received any payment from Fastiv Hospital. H.     Criminal proceedings against K.M. (one of the police officers who ill-treated the applicant’s son) 74 .     On 19 November 2008 the investigator questioned several persons, who had been detained at the Fastiv railway station police unit on the evening of 22 August 2003. They submitted that they had witnessed the ill ‑ treatment of another inmate (see paragraph 18 above). 75 .     On 8 December 2008 a former detainee, S.P., recognised K.M. as one of the police officers who had beaten V.K. On various dates thereafter several other former detainees made similar statements. 76 .     On 26 December 2008 the PGO detained K.M. 77.     Subsequently, several criminal cases were opened against him on suspicion of abuse of office by a law-enforcement official with grave consequences, the exceeding of authority associated with ill-treatment of the victim, also with grave consequences, and infliction of grievous bodily harm leading to the death of the victim. K.M. consistently denied being present at the police unit on the evening on 22   August 2003, let alone having beaten V.K. 78 .     On 7 September 2011 the Bila Tserkva City Court found K.M. guilty of abuse of office by a law-enforcement official with grave consequences, and exceeding his authority associated with ill-treatment of the victim, also with grave consequences. The court acquitted him in respect of the charge of inflicting grievous bodily harm leading to the victim’s death. It sentenced him to six years’ imprisonment and a prohibition on holding positions related to public duties for three years. It also ordered the confiscation of his property. The court noted that the applicant had lodged a civil claim, however, it left it without examination on the grounds that there were a number of related criminal proceedings still ongoing and that she could later bring a civil claim under the civil procedure. 79 .     On 7 December 2011 the Regional Court of Appeal quashed K.M.’s acquittal and remitted that part of the case for additional investigation. It upheld the rest of the judgment. 80.     On 7 March 2012 S.P. took part in a reconstruction of the events of 22 August 2003 (see paragraph 75 above). 81 .     On 12 March 2012 the investigator ordered a forensic medical examination to verify S.P.’s account. Furthermore, the expert was to establish the cause of V.K.’s death and the existence of any cause and effect between the death and his being beaten by K.M. The report was issued on 21   March 2012 and stated that the injuries sustained by V.K., as documented by the earlier forensic examination reports, could have been inflicted in the manner and in the circumstances described by S.P. As regards the cause of death, the panel referred to its earlier findings and stated that V.K. could have died of the brain and meninx injuries (see   paragraph 51 above). Lastly, they concluded that the injuries could have resulted from K.M.’s assault on V.K., as described by S.P. 82.     On 30 October 2012 the Higher Specialised Court for Civil and Criminal Matters upheld the lower courts’ decisions of 7 September and 7   December 2011 (see paragraphs 78 and 79 above). 83 .     K.M. was released on parole on 2 November 2012. 84 .     However, on 15 November 2012 he was remanded in custody as a preventive measure pending his trial on the remaining charge (see paragraph 79 above). 85 .     On 12 August 2013 the Kyyevo-Svyatoshynskyy Court found K.M. guilty of inflicting grievous bodily harm on V.K., which had led to the victim’s death, and sentenced him to ten years’ imprisonment. The court saw no aggravating or mitigating circumstances in the case. At the same time, the case file material referred to in the judgment included the testimony of two witnesses who stated that K.M. was prone to violence. One of them, Vo., a retired teacher, stated that he had been arbitrarily detained in December 2003 and that K.M. had punched him in the face and used a pepper spray on him when he had complained. Being scared, Vo. had written a statement that he had no complaints against the police. Another witness, M., submitted that she had been in a café in October 2005 when K.M., clearly drunk, had passed by her and pushed her. She was pregnant and had told him his behaviour was unacceptable. K.M. had reacted by punching her in the face. Later, in the presence of the police, he had hit her again and she had fallen to the ground. Both K.M. and his superior had subsequently apologised to her and asked her not to lodge a complaint so she had not. 86 .     On 27 November 2013 the Regional Court of Appeal quashed the first-instance court’s judgment and discontinued the proceedings in that part as time-barred. The appellate court noted that the statutory ten-year limitation period had not been interrupted as K.M. had not absconded or committed other criminal offences. K.M.   was released in the courtroom. 87.     The applicant appealed on points of law. She submitted, in   particular, that K.M. had for many years concealed the truth about both knowing V.K. and ill-treating him. Accordingly, the applicant contended that he had been seeking to evade justice. 88 .     On 21 August 2014 the Higher Specialised Court for Civil and Criminal Matters upheld the appellate court’s ruling. I.     Criminal proceedings against G.V. (the officer on duty at the Fastiv railway station police unit on 22 August 2003) 89 .     On 9 August 2012 the Baryshivka Town Prosecutor’s Office (in the Kyiv region) opened a criminal case against G.V., who had not stopped his colleague K.M. from beating the applicant’s son. 90.     During the pre-trial investigation and the trial G.V. consistently denied that either V.K. or K.M. had been present at the police unit on 22   August 2003. 91.     On 14 October 2013 the Kyyevo-Svyatoshynskyy Court found G.V. guilty of negligence with grave consequences and of concealing a criminal offence. It sentenced him to five years’ imprisonment and a prohibition on holding any office related to the performance of public duties for three years. G.V. was absolved from the penalty as the charges had become time ‑ barred. A civil claim by the applicant was allowed in part. The court ordered G.V. to pay her UAH   80,000 (equal to about EUR 7,100 at the time) in compensation for non-pecuniary damage. 92.     On 10 December 2013 the Regional Court of Appeal upheld the first-instance court’s judgment, increasing the compensation to UAH   100,000 (about EUR 8,800). 93 .     There was no appeal on points of law against those decisions. 94 .     The applicant states that as of 1 August 2016 she has received no payment. II.     RELEVANT DOMESTIC LAW 95.     The relevant provisions of the Criminal Code of 2001 (as worded at the material time) are summarised below. 96.     Article 49 provided for exemption from criminal liability on the grounds of the expiry of the statutory limitation period after five years in the case of a medium-gravity offence; ten years for a grave offence; and fifteen years for a particularly grave offence. It stated that the running of the limitation period would be interrupted if the offender absconded. 97.     Under Article 74, a court could deliver a verdict but decide to exempt the guilty person from punishment on the same grounds as in Article 49. 98.     Article 121 penalised the premeditated infliction of grievous bodily harm causing the victim’s death by imprisonment for seven to ten years. 99.     Article 139 provided for up to four years’ restriction of liberty or up to three years’ imprisonment, with or without a ban on holding certain offices or carrying out certain activities for a period of up to three years, as punishment for a medical specialist’s failure to provide assistance (§ 2). 100.     Article 364 provided for five to eight years’ imprisonment with a prohibition on holding certain offices or carrying out certain activities for a period of up to three years as punishment for abuse of power or office with grave consequences (§ 2). If the same offence was committed by a law ‑ enforcement official, the possible term of imprisonment was between five and twelve years, with confiscation of property, in addition to a three ‑ year ban on holding certain offices or carrying out certain activities (§   3). 101.     Article 365 envisaged three to eight years’ imprisonment with a prohibition on holding certain offices or carrying out certain activities for a period of up to three years as punishment for exceeding one’s power by engaging in the violent or degrading treatment of a victim (§ 2). The same acts, if they caused grave consequences, were punishable by seven to ten years’ imprisonment, with a prohibition on holding certain offices or carrying out certain activities for a period of up to three years (§ 3). 102.     Article 366 provided for imprisonment from two to five years, with a prohibition for up to three years on the holding of certain posts or the performance of certain activities, as the penalty for forgery in office (forgery of documents by an official) with grave consequences (§ 2). 103.     Article 367 sanctioned neglect of official duty with grave consequences by imprisonment for two to five years, with a prohibition for up to three years on the holding of certain posts or the performance of certain activities, and a fine of one hundred to two hundred and fifty times the amount of the non-taxable minimum-level income. THE LAW I.     ALLEGED VIOLATION OF ARTICLE 2 OF THE CONVENTION 104.     Relying on Articles 2, 6 and 13 of the Convention, the applicant complained that the State had been responsible for her son’s death and that there had been no effective domestic investigation. The Court considers that the complaints fall to be examined under Article 2 of the Convention only, which reads as follows: “1.     Everyone’s right to life shall be protected by law. No one shall be deprived of his life intentionally save in the execution of a sentence of a court following his conviction of a crime for which this penalty is provided by law. 2.     Deprivation of life shall not be regarded as inflicted in contravention of this article when it results from the use of force which is no more than absolutely necessary: (a)     in defence of any person from unlawful violence; (b)     in order to effect a lawful arrest or to prevent the escape of a person lawfully detained; (c)     in action lawfully taken for the purpose of quelling a riot or insurrection.” A.     Admissibility 105.     The Government did not raise any objections as regards the admissibility of the application. At the same time, they drew the Court’s attention to the numerous criminal proceedings brought in respect of the death of the applicant’s son, most of which had resulted in the conviction and sentencing of the persons concerned. The Government also stated in their observations on the merits of the case that adequate amounts had been awarded and paid to the applicant under her civil claims (see paragraphs 121 and 122 below). 106.     The circumstances referred to by the Government might be considered as suggesting that the applicant has lost her victim status. Regardless of the possible interpretation of those submissions, the Court notes that the issue of the applicant’s victim status concerns a matter of compatibility ratione personae , which goes to the Court’s jurisdiction and does not depend on the existence of an objection by the Government to that effect (see, for example, R.P. and Others v. the United Kingdom , no.   38245/08, § 47, 9 October 2012, and Buzadji v. the Republic of Moldova [GC], no. 23755/07, §   70, ECHR 2016 (extracts)). 107.     The Court considers it necessary to examine, of its own motion, whether the applicant can be regarded as having lost her victim status. 108.     The Court reiterates that a decision or measure favourable to an applicant is not in principle sufficient to deprive that person of his or her status as a “victim” unless the national authorities have acknowledged, either expressly or in substance, and then afforded redress for, the breach of the Convention (see Scordino v. Italy (no. 1) [GC], no. 36813/97, §   180, ECHR 2006 ‑ V, with further references). As to the redress which is appropriate and sufficient in order to remedy a breach of a Convention right at national level, the Court has generally considered this to be dependent on all the circumstances of the case, with particular regard to the nature of the right alleged to have been breached (see Gäfgen v. Germany [GC], no.   22978/05, § 116, ECHR 2010). 109 .     In the present case the question of the applicant’s victim status is closely linked to the issue of the State’s compliance with its procedural obligations under Article 2 of the Convention. The Court therefore joins this matter to the merits of that complaint (see Özcan and Others v.   Turkey , no.   18893/05, § 55, 20 April 2010). 110.     For the sake of the completeness of its analysis, the Court takes note of the fact that the applicant did not lodge an appeal on points of law in most of the criminal proceedings concerning her son’s death (see paragraphs 58, 71 and 93 above). That is a relevant factor for assessing whether she exhausted domestic remedies before lodging her application with the Court. 111.     It is noteworthy, however, that the scope of review of the applicant’s compliance with the rule on exhaustion of domestic remedies is limited by the Government’s objections. In other words, if the Government have not raised this point in their submissions, the Court is not in a position to rule, of its own motion, on whether the application is inadmissible for non ‑ exhaustion of domestic remedies (see, for example, Mechenkov v.   Russia , no. 35421/05, § 78, 7 February 2008, and, more recently, International Bank for Commerce and Development AD and Others v.   Bulgaria , no. 7031/05, §   131, 2 June 2016, with further references). Accordingly, the Court will not deal with this issue in the present case. 112.     The Court further notes that the application is neither manifestly ill ‑ founded within the meaning of Article 35 § 3 (a) of the Convention nor inadmissible on any other grounds. It must therefore be declared admissible. B.     Merits 1.     The parties’ submissions (a)     The applicant 113.     The applicant submitted that her son had died because of a chain of crimes and omissions by the State authorities, in particular, as a result of his ill ‑ treatment by the police and the subsequent failure to provide him with adequate and timely medical assistance. 114.     The applicant emphasised the arbitrariness of V.K.’s detention and the violence inflicted on him. She further drew the Court’s attention to the connivance with those crimes by other State officials and the overall environment of impunity in the State authorities and institutions involved. 115 .     She contended that in addition to having been severely beaten, her son had been tortured with electric current, without further details. Furthermore, referring to the forensic medical examination report of 15   November 2004 (see paragraph 48-50 above), the applicant stated that certain organs had been missing from V.K.’s body. 116.     As regards the deficiencies in the medical treatment provided to V.K. in Fastiv Hospital, the applicant maintained that they had been possible owing to numerous gaps in Ukrainian legislation. In that connection, she pointed to the absence at the time of any legal standards governing the treatment of cerebrocranial injuries or on decision-making on and the implementation of a patient’s transfer from one hospital to another. 117.     The applicant further contended that the lack of diligence by the Vyshneve police in searching for V.K. after his disappearance on 18   August 2003 had also to a certain extent c