CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 29 octobre 2024

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ARMENIA (Application no. 53081/14)     JUDGMENT Art 2 (procedural) • Effective investigation • Effective criminal proceedings into the death of the applicant’s wife, allegedly as a result of medical negligence • Despite initial shortcomings during inquiry stage of investigation, domestic authorities eventually responded adequately to applicant’s allegation and clarified events surrounding his wife’s death   Prepared by the Registry. Does not bind the Court.   STRASBOURG 29 October 2024   FINAL   29/01/2025     This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision. In the case of Harutyun Karapetyan v. Armenia, The European Court of Human Rights (Fourth Section), sitting as a Chamber composed of:   Gabriele Kucsko-Stadlmayer, President ,   Tim Eicke,   Branko Lubarda,   Armen Harutyunyan,   Ana Maria Guerra Martins,   Anne Louise Bormann,   Sebastian Răduleţu, judges , and Simeon Petrovski, Deputy Section Registrar , Having regard to: the application (no. 53081/14) against the Republic of Armenia lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by an Armenian national, Mr Harutyun Karapetyan (“the applicant”), on 15 July 2014; the decision to give notice to the Armenian Government (“the Government”) of the complaint concerning the alleged lack of an effective investigation into the circumstances surrounding the death of the applicant’s wife and to declare the remainder of the application inadmissible; the parties’ observations; Having deliberated in private on 11 June and 17 September 2024, Delivers the following judgment, which was adopted on the latter date: INTRODUCTION 1.     The case concerns the alleged lack of an effective investigation into the death of the applicant’s wife, allegedly as a result of medical negligence. It raises an issue under Article 2 of the Convention . THE FACTS 2.     The applicant was born in 1957 and lives in Abovyan. He was represented by Mr T. Abgaryan, who was granted permission to represent him in the proceedings before the Court (Rule 36 § 2 of the Rules of Court). 3.     The Government were represented by their Agent, Mr G. Kostanyan, and subsequently by Mr Y. Kirakosyan, Representative of the Republic of Armenia on International Legal Matters. 4.     The facts of the case may be summarised as follows. death of the applicant’s wife and preceding events 5 .     On an unspecified date in March 2011 the applicant and his 53-year ‑ old wife, T. Simonyan, visited the Mother and Child Healthcare Centre in Yerevan (“the hospital”) because she was experiencing uterine problems. At the hospital Ms Simonyan was diagnosed with a uterine myoma . 6 .     The same day they met with Doctor G.O., who recommended that she undergo surgery without delay. According to the applicant, they had enquired about the level of complexity of the proposed intervention. In reply, G.O. had reassured them that the surgery was not considered to be complex, but should not be delayed. Having discussed the financial aspect of the proposed medical intervention, they agreed to the surgery and G.O. asked them to provide Ms   Simonyan’s medical records from her local clinic. 7 .     About one or two weeks later Ms Simonyan provided her medical records to the hospital. They contained an entry from 2007 concerning, inter alia , thrombophlebitis, as well as entries from 2010 concerning varicose veins in the lower extremities and the results of a Doppler ultrasound which had revealed venous insufficiency. 8 .     On 22 March 2011 Ms Simonyan underwent a hysterectomy (surgical removal of the uterus) at the hospital. 9 .     On 23 March 2011 at around 8 a.m. Ms Simonyan called the applicant, complaining of acute pain. The applicant immediately went to the hospital. At around midday he was informed that she had died. ensuing criminal proceedings 10 .     The hospital informed the police about Ms Simonyan’s death on the same date (23 March 2011). 11 .     On the same day the police ordered an autopsy, requesting the forensic experts to determine, among other things, the time and cause of the death, any illnesses that T. Simonyan had suffered from and their connection to the death, the adequacy of the medical care she had received, whether she had been given any injections before, during or after the surgery and whether it could have been possible to avoid the fatal outcome. 12 .     The autopsy was performed on 24 March 2011. 13 .     On the same date the forensic medical expert who performed the autopsy delivered a medical certificate attesting the death, according to which T. Simonyan had died as a result of pulmonary thromboembolism which had come about because of the varicose veins on her legs and thrombosis in the shank vessels. 14 .     On different dates in March and April 2011 the investigator took statements ( բացատրություն ) from the medical staff of the hospital. The relevant medical professionals were asked to give their account about the events without them having the formal procedural status of witnesses. 15 .     In particular, on 28 March 2011 the investigator took a statement (see paragraph 14 above) from S.K., the head of the gynaecology department at the hospital. S.K. stated, in particular, that prior to the surgery T. Simonyan had been examined by herself and an anaesthetist. No contraindications to the surgery had been detected. It had been decided to wrap the lower extremities in elastic bandages before the surgery to compress the veins. 16 .     On 29 March 2011 the investigator took a statement (see paragraph   14 above) from S.E., an intensive care anaesthetist at the hospital who confirmed, inter alia , that she had taken part in the examination of T.   Simonyan the day before the surgery (see paragraph 15 above). In accordance with the established practice, it had been decided to give her an injection of an anticoagulant medication (Fraxiparine) and to wrap the legs in elastic bandages prior to the surgery. S.E. had then administered T.   Simonyan’s anaesthesia on the day of the surgery, that is on 22 March 2011. 17 .     On 15 April 2011 the investigator took a statement (see paragraph 14 above) from S.Ba., the head of the department for anaesthesia and intensive care. He mentioned that he remembered T. Simonyan from 23 March 2011, when she was being taken to the department for operative gynaecology. She had stated that she did not feel well, after which she was immediately taken back to the intensive care room. After some time, T. Simonyan had started to have trouble breathing; an intensive care doctor and a cardiac emergency crew had been called in. S.Ba. then described the resuscitation actions that had been taken, which were ultimately unsuccessful. He further stated that prophylactic measures had been taken before the surgery – specifically, the patient’s legs had been wrapped in elastic bandages and she had been given medication to lower blood coagulation. That medicine had been Fraxiparine, if he was not mistaken. 18 .     On 27 April 2011 the autopsy report was received․ It stated that the cause of T. Simonyan’s death had been pulmonary thromboembolism, which had resulted from the varicose veins on her legs and venous phlebothrombosis, both of which she had suffered from while still alive and which were directly linked to her death. The biochemical examination had not shown the presence of any drugs or alcohol in her blood, liver or kidneys. The report lastly stated that questions concerning any possible medical negligence, injections given to T. Simonyan and the possibility that her life could have been saved were outside the scope of the autopsy. 19 .     On 3 June 2011 the investigator ordered a forensic medical examination by an expert commission, to be based on an examination of the medical documents it had been provided with. Those included T. Simonyan’s medical records from her local clinic (see paragraphs 6 and 7 above), her medical records from the hospital, and the autopsy report (see paragraph 18 above). The expert commission was requested to determine, inter alia , whether the pre-operative examinations had been complete, whether T.   Simonyan had been given any injections before or after the surgery, and whether there had been any prophylactic measures which should have been taken in order to prevent pulmonary thromboembolism. 20 .     On an unspecified date the expert commission issued a report, the relevant parts of which read as follows: “... Question: Was T. Simonyan given any injections before, during or after the surgery...? Answer: Prior to the surgery, during it and in the post-operative period T. Simonyan was given the necessary injections, including natrium chloride ... antibiotics ... as well as Fraxiparine for prophylactic purposes so as to prevent thromboembolism. ... Question: In the case at hand, would it have been possible to avoid the fatal outcome and, if so, who [among the medical team] could have done so and by taking what actions ...? Answer: The risk of the development of phlebothrombosis and ... thromboembolism were correctly assessed during the pre-operative phase. It should be noted that none of the currently existing preventive measures [guarantees] absolute safety. Pulmonary thromboembolism, which T. Simonyan developed, has a very high mortality rate and often ends with the patient’s death. ... Question: Did the scope of the surgery ... correspond to the diagnosis? Answer: ... considering the [patient’s] age – 53 years, the pain [she had been experiencing and the] regular bloody discharges coupled with hypochromic anaemia, [a hysterectomy] was justified and indicated. ... Question: ... was it possible to detect the varicose veins in T. Simonyan’s lower extremities and venous phlebothrombosis during her examinations [in her local clinic] and to decide against the surgery at the stage of the pre-operative examination in [the hospital] or to inform T. Simonyan and her relatives beforehand about the possible complication or to undertake corresponding comprehensive prophylactic measures to avoid thromboembolism ...? Answer: ... According to the patient’s medical records, varicose veins in the lower extremities were diagnosed for the first time on 3.08.2010. Before the surgery a contract was signed whereby the patient was informed in writing about possible complications, including death. Question: Did the pre-operative examinations in the [hospital] show the presence of varicose veins in the lower extremities and phlebothrombosis ...? Answer: According to [the hospital] medical records, T. Simonyan was diagnosed with varicose veins in the lower extremities during the pre-operative medical examinations, but there were no signs capable of raising suspicions of venous phlebothrombosis; therefore no omissions have been discovered during T. Simonyan’s examination and treatment.”   21 .     By decision of 5 August 2011 the investigator refused to open criminal proceedings on the ground that no elements of a crime had been discovered in the course of the inquiry ( նյութերի նախապատրաստում ) into the matter. 22 .     On 23 August 2011 the applicant appealed against the investigator’s decision to the Prosecutor General. 23 .     On 6 September 2011 the Yerevan prosecutor’s office annulled the decision of 5 August 2011 (see paragraph 21 above) and decided to institute criminal proceedings. The relevant parts of the prosecutor’s decision read as follows: “... it has been revealed that in the course of the inquiry the circumstances of [T.   Simonyan’s] death were not fully and objectively examined ... In her statement [S.E.], an intensive care anaesthetist at the [hospital], stated that on 21 March 2011 she had examined [T. Simonyan] before her surgery and discovered visible varicosity of the veins on the lower left leg. Since the biochemical blood analysis had not shown any abnormalities in [blood] coagulation level, it was decided to give [T. Simonyan] an injection of Fraxiparine anticoagulant medication and to wrap her legs in an elastic bandage. Unlike [S.E.], the head of [the hospital’s] gynaecology department, [S.K.], did not mention an injection of anticoagulant [medication] being given to [T. Simonyan]. [S.K.] stated, in particular, that during her examination of [T. Simonyan] with the intensive care anaesthetist [S.E.] on 21 March 2011 varicose veins had been discovered on her legs but, given that no contraindications to the surgery had been detected, it had been decided to wrap the legs in elastic bandages before surgery in order to compress the veins. ... an examination of the medical documents has revealed that there were conflicting data about whether the anticoagulant medication Fraxiparine had been prescribed and administered to [T. Simonyan] prior to the surgery. [The examination of] the medical documents [revealed that] the entry about the use of the medication was made on 22 March 2011 [and that] notably ... the colour of the ink of the entry is obviously different from other entries. ... The record of prescriptions [in T. Simonyan’s hospital records] does not contain any entries according to which [T. Simonyan] was prescribed Fraxiparine medication on 21   and 22 March 2011, although the same record contains a handwritten entry about the use of the medication in question. ... The above-mentioned facts lead to the conclusion that Fraxiparine was not prescribed and administered to [T. Simonyan] at the [hospital] and that the entries concerning its administration were made later. In order to clarify whether the entries ... were made later, the members of the medical staff who made entries in the [T. Simonyan’s hospital] records should be questioned again and a forensic document examination should be ordered. ... The body of inquiry had put a question to the commission of experts about the necessity and suitability of performing [a hysterectomy] on [T. Simonyan] in the light of the varicose veins on her legs; however the expert conclusion did not in fact address that question ... ... it follows that the members of the [hospital’s] medical staff have not properly fulfilled their duties and there are grounds to institute criminal proceedings under Article 130 § 2 of the [former] Criminal Code ...” 24 .     Following the opening of criminal proceedings, the applicant was recognised as the victim’s legal heir on 3 October 2011. 25 .     On 14 October 2011 the investigator ordered a forensic document examination of T. Simonyan’s hospital records, and in particular the section “Stages of anaesthesia”, which comprised a list of anaesthetics. The aim of the examination was to determine whether the entry about Fraxiparine in that section, which came at the end of the list, had been made in a different ink as compared to the entries about the other anaesthetics, and what had been the sequence in which the entries had been made. According to the ensuing expert report dated 10 November 2011, the entries from 22 March 2011 concerning medications in the section “Stages of anaesthesia” were probably made by the same pen; the temporal sequence of the given entries could not be established. 26 .     On 19 October 2011 an additional forensic medical examination (see paragraph 20 above) by an expert commission was ordered. The relevant parts of the resulting expert report issued by an expert commission headed by Doctor G.B., which was received on 24 November 2011 , read as follows: “... Question: Why did [T. Simonyan] develop pulmonary thromboembolism? Answer: ... pulmonary thromboembolism was brought about as a consequence of long-term chronic venous insufficiency as a result of varicose veins. ... Question: Were prophylactic measures taken to prevent thromboembolism? Answer: According to the [hospital] medical records, prophylactic measures in respect of thromboembolism were taken. Question: In this specific case ... were the prophylactic measures ... necessary and sufficient? Answer: According to the [hospital] medical records, prophylactic measures in respect of thromboembolism, that is compression therapy and use of anticoagulants, were indicated and implemented in full. Question: Did the discovery of varicose veins in the lower extremities not indicate the possible existence of venous phlebothrombosis? Answer: Varicose veins in the lower extremities [do not necessarily lead to] thrombosis and thromboembolism. Question: Did the biochemical examination of [T. Simonyan’s] blood show any abnormalities in blood coagulation level? Answer: ... the results of the biochemical examination of the blood were within the norm ...” 27 .     On 19 October 2011, S.Ba., the head of the department for anaesthesia and intensive care, was questioned again (see paragraph 17 above). He stated, in particular, that prior to the surgery an injection of Fraxiparine medication had been given to T. Simonyan. Before the surgery the intensive care Anaesthetist S.E. had approached him asking for advice as to whether or not to give an injection of Fraxiparine to T. Simonyan, to which he had replied the following: “... Fraxiparine could be injected or not since the results of the tests were within the norm. But I said that there was no harm in doing it. ... it can be seen from the ... register of anaesthetic medication that [Fraxiparine] was administered to T. Simonyan twice, [once] on 22 [March 2011], that is before the surgery, and [again] the next day. ...” 28 .     On 25 October 2011 the intensive care Anaesthetist S.E. was also questioned again (see paragraph 16 above). She stated, in particular, that she had examined T. Simonyan on 21 March 2011 and had indicated in the relevant record that her legs should be wrapped in an elastic bandage and that she should receive an injection of Fraxiparine. According to S.E., she had consulted about the injection with the head of the department, S.Ba., on the day of the surgery, before it was performed. Because that had happened on the day of the surgery and in S.Ba.’s office, it was possible that the entry about Fraxiparine had been made with a different pen. 29 .     On 20 March 2012 the investigator ordered another forensic document examination (see paragraph 25 above) to clarify whether there had been any alterations to T. Simonyan’s hospital medical records as regards the use of the anticoagulant medication in question (Fraxiparine). According to the ensuing expert report dated 16 April 2012, the entries from 22 March 2011 concerning medications in the section “Stages of anaesthesia” could possibly have been made by the same pen, or by different pens with the same consistency ink, and it had not been possible to establish the temporal sequence of the given handwritten entries because of the absence of the relevant capability at the forensic expert centre. 30 .     In May 2012 the investigator questioned S.B., a nurse anaesthetist, who stated that the register of anaesthetic medication contained her signatures in the entry for 22 March 2011; the doctor had prescribed two doses of anticoagulant medication (Fraxiparine) to T. Simonyan and she had administered those. She stated that she did not remember the details, but added that if her signature was in the register she had definitely given the injections. 31 .     On 25 June 2012 another additional forensic medical examination (see paragraphs 20 and 26 above) by an expert commission was ordered, which also included questions submitted by the applicant. 32 .     On 17 July 2012 the expert commission, headed by Doctor V.R., issued its report, the relevant parts of which read as follows: “... According to [T. Simonyan’s hospital medical records, she] was given injections which fully corresponded to the nature and scope of the surgery. ... According to the [information contained in the T. Simonyan’s hospital medical records], prior to the surgery an injection of Fraxiparine had been administered [for the] prevention of thrombosis ... [However,] the administration of anticoagulants could not completely negate the possibility of thrombotic complications. ... Being aged over 40, the [fact of undergoing] surgery, as well as the [presence of] varicose veins are [all] considered risk factors for thrombosis, which is why a prophylactic injection of anticoagulants was given prior to the surgery, but it is not always possible to avoid possible complications ... [T. Simonyan] had been diagnosed with a myoma the size of a foetus at fifteen weeks. Considering her age ... the surgical removal of the uterus was recommended, which was done in the present case in accordance with the diagnosis. [T. Simonyan] had suffered from varicose veins for years, whereas the venous phlebothrombosis occurred after surgery. Since the varicose veins were not coupled with phlebothrombosis prior to the surgery, there was no contraindication for the given surgery. In the light of the result of the lab tests, and having regard to [the level of blood] coagulation, an injection of Fraxiparine was given, which brought about the desired result ... As to the questions ... lodged by the victim’s heir ... the sharp deterioration in the patient’s state of health was mainly due to cardiovascular and pulmonary complications ...” 33 .     On 1 October 2012 the investigator ordered a further (see paragraphs   25 and 29 above) forensic document examination of various pages of T. Simonyan’s hospital medical records containing entries about the anticoagulant medication (Fraxiparine), and of the register of anaesthetic medication. In the ensuing report of 9 November 2012 the expert indicated that one entry in T. Simonyan’s medical records concerning the anticoagulant medication (Fraxiparine) had been made with a different pen than the other entries within the same column. Furthermore, there had been an alteration to the page indicating the daily medication consumption in the register of anaesthetic medication, in that the initial figure “1” had been written over and changed to a “2”. 34 .     In November 2012 Nurse S.B. (see paragraph 30 above) was questioned again. She stated, inter alia , the following: “... I made the 22 March [2011] entries on the page concerning the daily consumption of medication in the register of anaesthetic medication. Those entries concerned [T.   Simonyan]. It can be seen from that entry that I received one ampoule of Fraxiparine ... from Senior Nurse [L.G.] ... The first injection was given by Nurse-Anaesthetist [A.K.], not me. On 23 March 2011 I gave one injection [to T. Simonyan] on [S.Ba.’s] instructions ... ... When I was on duty on 22 March [2011], I had indicated one dose of Fraxiparine in the register of anaesthetic medication but, since on 23 March [2011] another dose was prescribed, I then changed the initial indication of one dose to two, in order to show the real consumption of the medication ... I have done nothing that was intentionally wrong. I simply showed the actual quantity that had been used ...” 35 .     Around the same time, that is in November 2012, the investigator questioned Nurse-Anaesthetist A.K. (see paragraph 34 above), who stated that on 22 March 2011 she had personally given an injection of one dose of anticoagulant medication (Fraxiparine) to T. Simonyan on S.E.’s instructions prior to the surgery. That fact was attested by the relevant entry in T.   Simonyan’s medical records, which contained A.K.’s signature. 36 .     On 23 November 2012 the investigator questioned the intensive care Anaesthetist S.E. again (see paragraphs 16 and 28 above) who stated, among other things, that on her instructions Nurse A.K. (see paragraph 35 above) had given T. Simonyan an injection of one dose of Fraxiparine on 22 March 2011 before the surgery. She was aware that on 23 March 2011, when T.   Simonyan’s condition had worsened, the latter had been given a second injection of the same medication by Nurse S.B. (see paragraphs 30 and 34 above). S.E. added that a follow-up dose of Fraxiparine was supposed to have been administered twelve hours after the first one but that that had not been done because it had not been considered necessary given the results of the blood coagulation level test performed late in the evening of 22 March 2011. 37 .     In December 2012 A.S., another nurse anaesthetist, was questioned. She stated, in particular, the following: “... seeing what is written on page ... of the register of anaesthetic medication ... I can say that ... [T. Simonyan] was given one dose of Fraxiparine [on 22 March] and then [she] was given another dose of Fraxiparine on 23 March 2011. That is to say, the overall consumption was two [units]. I put my signature on the given page as I was the day shift nurse ... [S.B.] was not issued any medication ... ... it is my responsibility to receive all the medication at the beginning of the day and then hand it over to the nurse on duty at the end of the day ... ... on 22 and 23 March [2011] I was at work and I can say that on those days two doses of Fraxiparine were issued for [T. Simonyan]: one dose on each day ... ... Senior Nurse [L.G.] issues the medication in our department ...” 38 .     On an unspecified date in January 2013 a confrontation was held between Doctor V.R. (see paragraph 32 above) and the applicant. The relevant parts of the record of the confrontation read as follows: “[Applicant]: You claim that Simonyan’s thrombus formed after surgery ... whereas the commissions of the first and second forensic examinations did not mention anything about that. [V.R.’s] reply: Since according to the results of the examination the woman suffered from varicose veins on her legs without symptoms of thrombosis, it can be assumed that the thrombus was formed either during surgery or at the early post-operative stage and moved [through the bloodstream to become] an embolism, which was the cause of death.” 39 .     On 5 February 2013 an interview with Doctor G.B. (see paragraph 26 above), during which he was asked questions on various issues concerning healthcare, was published in a newspaper. The relevant part of the interview reads as follows: “To what extent are the doctors responsible when death occurs as a result of varicose veins following uterine myoma surgery? ... I consider [operating in such situations] to be an error ... at all events varicose veins should be treated first and only then an operation be performed ...” The applicant submitted that interview to the investigator. 40 .     On 7 February 2013 the investigator questioned Doctor G.B., who reiterated the overall conclusion of the expert report of 24 November 2011 (see paragraph 26 above). When asked about the opinion he had expressed during the interview published on 5 February 2013 (see paragraph 39 above), Doctor G.B. stated that he had mentioned in general terms that complications linked to varicose veins, if there were any, should be treated first, and only then surgery performed. However, that did not concern T. Simonyan because no complications to do with varicose veins (swelling, fever, redness) had been noticed prior to her surgery, which was clear from her medical documents. There was therefore no contradiction between his statements during the interview and his earlier conclusion as a forensic expert. 41 .     On 4 March 2013 the investigator decided to terminate the criminal proceedings, finding that it had not been established that there had been any medical errors in T. Simonyan’s treatment at the hospital or that her medical records had been altered. That decision reads as follows: “... On 23 March 2011 a report was received ... about [T. Simonyan’s] death in [the hospital] ... During the inquiry ... [the applicant], [T. Simonyan’s] son and a relative ... made statements ... In the course of the inquiry it was discovered that ... [T. Simonyan] was treated and operated on by [S.K.], [S.E.], [other gynaecologists], [G.O.] and [S.Ba.], all of whom made similar statements according to which T. Simonyan had been provided with the requisite medical care and that her surgery had been carried out properly. T. Simonyan’s condition had sharply deteriorated only the day after the surgery, [at which point] they had undertaken the necessary resuscitation measures, which had, however, not made it possible to save her life. In the course of the inquiry statements were also obtained from [the doctors who had participated in the resuscitation measures]. [Citation of parts of the autopsy report  see paragraph 18 above]. [Citation of parts of the report issued by the first medical expert commission  see paragraph 20 above]. On 5.08.2011 a decision was taken to refuse to open criminal proceedings ... On 6.09.2011 that decision was set aside by [the Yerevan prosecutor’s office] and criminal proceedings were instituted under Article 130 § 2 of [the former Criminal Code] ... During the investigation [the applicant] was recognised as the victim’s legal heir and made a statement ... his son ... made a similar statement. [S.K.], [S.E.], [2 other gynaecologists] and [S.Ba.] all made similar statements to the effect that T. Simonyan had been provided with the requisite medical care and that her surgery had been carried out properly. T. Simonyan’s condition had sharply deteriorated only the day after the surgery, [at which point] they had undertaken the necessary resuscitation measures, which had, however, not made it possible to save her life. In the course of the investigation a forensic document examination was ordered in order to clarify certain entries in T. Simonyan’s medical records, [particular in terms of] the colour of the ink and their timing; additional forensic medical examinations were also ordered to clarify the cause of T. Simonyan’s death and ... [uncover any] possible medical errors. [The applicant] requested that certain questions be included in [the above-mentioned forensic examinations], which has been done within the framework of the additional forensic medical examination... [Citation from the expert report resulting from the forensic document examination  see paragraph 25 above]. [Citation of parts of the report issued by the second medical expert commission  see paragraph 26 above]. [The applicant] stated that his wife had not signed the contract with [the hospital] ... To clarify that point, a forensic document examination was assigned which confirmed that T. Simonyan had signed the contract ... [Citation from the expert report resulting from the additional forensic document examination  see paragraph 29 above]. [Citation of parts of the report issued by the third medical expert commission  see paragraph 32 above]. The [hospital’s register of anaesthetic medication] was seized and an additional forensic document examination was ordered. According to the ensuing report ... [citation from the expert report resulting from the additional forensic document examination  see paragraph 33 above]. In connection with that report [S.E.], [S.B.], [A.K.], [A.S.] were questioned and stated that T. Simonyan had received an injection of Fraxiparine medication. The register contained entries attesting to that. ... [G.B.] and [V.R.] were both questioned and confirmed their expert conclusions ... The varicose veins in the lower extremities in the case at hand had not been a contraindication for the surgery. A confrontation was held between [the applicant] and [V.R.] ... That is to say that the investigation substantiated that ... there were no errors in T.   Simonyan’s medical treatment ... As regards the falsification and alteration of T. Simonyan’s medical records, it was clarified and substantiated that ... there had been no alterations to the entries concerning Fraxiparine in the medical documents, which is to say that no falsification of medical documents has occurred and that was confirmed by the results of forensic document examinations. [References to various articles of the former Code of Criminal Procedure]. It was discovered and substantiated that [the employees of the hospital] have properly carried out their professional duties [and that] their actions thus lack the elements of a crime laid out in Article 130 § 2 of [the former Criminal Code]. As regards the falsification and alteration of T. Simonyan’s medical records by [the employees of the hospital], it was also substantiated that that has not occurred and that their actions thus lack the elements of a crime ... [reference to the relevant article of the former Criminal Code].” 42 .     On 26 March 2013 the applicant contested that decision with the Kentron and Nork-Marash District Court of Yerevan (“the District Court”). The applicant stated in his complaint that he had not had an opportunity to study the case file after the investigation had been completed. Therefore, in order to respect the time-limits for challenging the decision, he had been obliged to submit his complaint on that date with a view to submitting his arguments later, after he had had a chance to familiarise himself with the case file. 43.     The representative of the investigative authority argued in the District Court that it had been established in the course of the criminal proceedings that no medical errors had been committed and that the surgery in question had not been contraindicated for T. Simonyan. The applicant argued, inter alia , that the investigation had failed to clarify the circumstances surrounding the death of his wife. He requested the District Court to examine Doctor G.B., whose public statement (see paragraph 39 above) had not been adequately addressed during the investigation. That request was refused. 44 .     On 12 September 2013 the District Court rejected the applicant’s complaint, relying on the results of the forensic medical examinations and the fact that all the medical personnel who had been involved in T. Simonyan’s treatment had been questioned. As for the public statement of Doctor G.B. (see paragraph 39 above), the District Court noted that he had been questioned during the investigation and had confirmed his conclusion that no medical errors had taken place during T. Simonyan’s treatment, and that he had stated specifically that in the given case varicose veins had not been a contraindication to the surgery (see paragraph 40 above). 45 .     The applicant lodged an appeal against that decision, arguing, in particular, that the conclusions of the forensic medical examinations had been contradictory with regard to the timing of the appearance of the thrombus and on the question whether his wife should have been operated on given her varicose veins. 46 .     On 11 November 2013 the Criminal Court of Appeal upheld the District Court’s decision. In doing so it stated, in particular, that there were no contradictions between the three forensic medical conclusions of the various commissions of experts (see paragraphs 20, 26 and 32 above) and that they supplemented each other. Although the investigative authority had decided to order additional forensic medical examinations, those had in fact been supplementary examinations in order to clarify the issues raised by the applicant during the proceedings. Those issues had been clarified in full. 47 .     The applicant lodged an appeal on points of law against that decision. He argued, in particular, that the additional forensic medical examinations had been ordered only as a result of his persistence in trying to oblige the experts to provide clear answers to questions that had been avoided in the previous examinations. The doctors, he argued, had failed to conclusively answer the question whether the surgical intervention had provoked phlebothrombosis. He reiterated his arguments with regard to the failure to address G.B.’s public statement – which had clearly contradicted his expert opinion and his subsequent witness statement – (see paragraphs 39 and 40 above), and other arguments he had raised previously. 48 .     On 16 January 2014 the Court of Cassation declared the applicant’s appeal on points of law inadmissible for lack of merit. RELEVANT LEGAL FRAMEWORK criminal code 49.     Article 130 § 2 of the former Criminal Code (in force from 1 August 2003 until 1 July 2022) provided that failure to perform or the improper performance of professional duties by medical and support personnel, as a result of negligence or bad faith, which had negligently caused the death of the patient undergoing treatment, was punishable by imprisonment from two to six years, with or without deprivation of the right to hold certain positions or practise certain activities for a maximum of three years. civil code 50.     The relevant provisions of the Civil Code, as in force at the material time, provide as follows. 51.     Under Article 17 § 1, a person whose rights have been violated may claim full compensation for the damage suffered, unless the relevant law or contract provides for a lower amount of compensation. 52 .     Under Article 17 § 2, damages are the expenses borne or to be borne by the person whose rights have been violated, in connection with restoring the violated rights, loss of his property or damage to it (material damage), including lost income. 53 .     Article 1058 § 1 provides that damage caused to a person or to his or her property, as well as damage caused to the property of a legal entity, is amenable to compensation in full by the person who has caused such damage. A person who was not responsible for causing the damage may also be obliged to provide compensation where stated by law. 54 .     Under Article 1058 § 2, a person who has caused damage is exempted from providing compensation if it is established that the damage was caused without guilt on that person’s part. 55 .     Since 1 November 2014 Article 17 § 2 (see paragraph 52 above) has included non-pecuniary damage in the list of types of civil damage for which compensation can be claimed in civil proceedings. As a result, the Civil Code was supplemented by the new Articles 162.1 and 1087.2, which regulate the procedure for claiming compensation for non-pecuniary damage from the State for the violation of certain rights guaranteed by the Armenian Constitution and the Convention (a complete summary of the domestic law provisions in question is provided in Botoyan v. Armenia , no. 5766/17, §§ 52 and 57-58, 8 February 2022). THE LAW ALLEGED VIOLATION OF ARTICLE 2 OF THE CONVENTION 56.     The applicant complained that the authorities had failed to carry out an effective investigation into his wife’s death. He relied on Article 2 of the Convention, the relevant part of which reads as follows: “1.     Everyone’s right to life shall be protected by law ...” Admissibility 57.     The Court notes that the application is neither manifestly ill-founded nor inadmissible on any other grounds listed in Article 35 of the Convention. It must therefore be declared admissible. Merits The parties’ submissions (a)    The applicant 58 .     The applicant maintained that his wife’s medical condition had not necessitated an urgent surgical intervention. She should have been operated on only after having received treatment for her varicose veins. In the course of the entire investigation he had tried to find out at which point his wife had developed thromboembolism . The first two forensic medical examinations (see paragraphs 20 and 26 above) had failed to answer that question whereas the head of the third expert commission, Doctor V.R., had claimed – based only on assumptions – that thromboembolism had developed after the surgery (see paragraph 38 above). The investigation had failed to clarify the discrepancy between the conclusion of the second forensic medical examination (see paragraph 26 above) and the opinion subsequently expressed publicly by the doctor that had led it, G.B., that it was wrong to perform a uterine surgery on patients who had varicose veins before treating the latter issue (see paragraph 39 above). 59 .     Admittedly, on several occasions the applicant had been given an opportunity to put questions to the experts. However, he had not obtained clear and satisfying answers to his questions. The investigation had ultimately failed to conclusively establish when thromboembolism had occurred and what had provoked it; in other words, it had failed to reveal the real cause of his wife’s death. 60 .     While it was true that an investigation did not have to necessarily result in prosecution, it had to be effective, which, the applicant claimed, had not been the case with the investigation into the circumstances of his wife’s death. (b)    The Government 61 .     The Government submitted that, in order to eliminate any possible shortcomings in the initial stages of the inquiry, the Yerevan prosecutor’s office had annulled the decision of 5 August 2011 whereby the investigator had refused to institute criminal proceedings (see paragraph 21 above), and had opened a criminal investigation into the matter (see paragraph 23 above). However, even before that all the persons directly involved or otherwise connected with T. Simonyan’s medical treatment had already been questioned (see paragraphs 15-17 above), and both an autopsy and a forensic medical examination had been ordered (see paragraphs 11 and 18-20 above). 62 .     Several further forensic medical examinations had been ordered, all of which had established that no medical errors had been committed during T. Simonyan’s medical treatment. The relevant medical experts had confirmed that the necessary preventive measures had been taken, including that T. Simonyan had received the necessary injections. They had also confirmed that T. Simonyan had suffered from varicose veins in her lower limbs for years and that phlebothrombosis of the veins had developed after the surgery; since the varicose veins had not been associated with phlebothrombosis, there had been no contraindication for the surgery. 63 .     Furthermore, forensic document examinations had been ordered to confirm that the medication Fraxiparine had been administered; the results had confirmed that the relevant entries had not been added subsequently. 64 .     The Government referred to the several forensic expert examinations that had been carried out during the investigation (see paragraphs 20, 25, 26, 29, 32 and 33 above), as well as to the vast number of witness interviews that had been carried out (see, for example, paragraphs 15-17, 27-28, 30, 34-37 above), including the questioning of experts (see paragraph 40 above) and the applicant’s having been given an opportunity to cross-examine Doctor V.R., who had led the third forensic medical examination (see paragraph 38 above), to argue that the authorities had taken all necessary and sufficient measures to ensure an adequate examination of the case. 65 .     The Government further argued that the investigation had been prompt and that, given the vast number of investigative measures that had been undertaken, its length was reasonable. Furthermore, the investigation overall had been accessible to the victim party. After a criminal case had been initiated the applicant had been granted the status of the victim’s legal heir in the proceedings (see paragraph 24 above) and had actively participated in the investigation. The Court’s assessment (a)    Preliminary remarks 66 .     The Court observes that the applicant did not allege or imply that his wife’s death had been caused intentionally. Nor did he allege or imply that his wife had been denied access to medical treatment in general or to emergency medical treatment in particular. There is nothing in the present case to suggest that there existed, at the material time, any systemic or structural dysfunction in hospital services (see Lopes de Sousa Fernandes v.   Portugal [GC], no. 56080/13, §§ 190-92, 19 December 2017). While the applicant submitted that his wife had lost her life as a result of a hasty medical decision to operate on her before she had had a chance to have her varicose veins treated (see paragraph 58