CEDH · CASELAW;JUDGMENTS;CHAMBER;ENG — 8 juillet 2025

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font-family:Arial } .sFBC99493 { font-style:italic } .s2D9C6089 { margin-top:12pt; margin-bottom:12pt; text-indent:14.2pt; text-align:justify; page-break-inside:avoid; page-break-after:avoid } .s69DCC830 { margin-top:36pt; margin-bottom:0pt } .s4F597665 { width:33.22pt; display:inline-block } .sEEEC397 { width:146.09pt; display:inline-block } .s5A65B3DC { width:46.56pt; display:inline-block } .s44B8752F { width:177.11pt; display:inline-block }   SECOND SECTION CASE OF LEVON v. LITHUANIA (Application no. 27121/23)     JUDGMENT Art 2 (procedural) • Effective investigation • Domestic authorities’ sufficiently thorough and impartial examination into the applicant’s father’s death in hospital, allegedly as a result of medical negligence • Accessible and adversarial civil proceedings providing the applicant with a reasonable opportunity to present his case • Parallel pre-trial investigation, including the expert assessment, serving to complement the civil proceedings and contributing to clarifying the relevant facts   Prepared by the Registry. Does not bind the Court.   STRASBOURG 8 July 2025   FINAL   08/10/2025   This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision.   In the case of Levon v. Lithuania, The European Court of Human Rights (Second Section), sitting as a Chamber composed of:   Arnfinn Bårdsen , President ,   Saadet Yüksel,   Tim Eicke,   Jovan Ilievski,   Gediminas Sagatys,   Stéphane Pisani,   Juha Lavapuro , judges , and Hasan Bakırcı, Section Registrar, Having regard to: the application (no.   27121/23) against the Republic of Lithuania lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by a Lithuanian national, Mr Anton Levon (“the applicant”), on 20 June 2023; the decision to give notice to the Lithuanian Government (“the Government”) of the complaint concerning the effectiveness of the domestic proceedings relating to the death of the applicant’s father and to declare the remainder of the application inadmissible; the parties’ observations; Having deliberated in private on 17 June 2025, Delivers the following judgment, which was adopted on that date: INTRODUCTION 1.     The case concerns the effectiveness of the domestic proceedings relating to the death of the applicant’s father in hospital. THE FACTS 2.     The applicant was born in 1973 and lives in Vilnius. He was represented by Mr R. Mikulskas, a lawyer practising in Vilnius. 3.     The Government were represented by their Agent, Mr R. Dzikovič, and co-Agent, Ms L. Urbaitė. Death of the applicant’s father 4 .     On the morning of 25 December 2020 the applicant’s father, A., who was 78 years old, started to feel unwell – he was unable to sit up, had difficulty breathing and looked pale. At around 8.50 p.m. the applicant called an ambulance. The ambulance arrived in around twenty-five minutes and took A. to the Šalčininkai municipal hospital (hereinafter “the hospital”). 5 .     On the following day, at around 9.30 p.m., the applicant’s father died at the hospital. According to the death certificate, the direct cause of death was a pulmonary oedema, whereas the main disease or injury which had caused the death was an unspecified chronic cardiovascular disease ( tiesioginė mirties priežastis – plaučių edema; pagrindinė liga (trauma), sukėlusi mirtį – lėtinė išeminė širdies liga, nepatikslinta ). 6 .     The hospital considered that there were no indications that a post ‑ mortem examination might be necessary. The applicant confirmed in writing that he was against such an examination. It was therefore not performed. Internal inquiries 7 .     In March 2021 the applicant lodged a complaint with the Šalčininkai Primary Healthcare Centre (the institution in charge of the ambulance, hereinafter “the Šalčininkai PHC”) and with the hospital. He submitted that his father’s most recent health check-up had been in January 2020 and that no particular issues had been detected then; he had not had any chronic diseases or serious health problems and had led a healthy lifestyle. However, he had suddenly started to feel unwell on the morning of 25   December 2020. The applicant alleged that the ambulance had not provided his father with the necessary urgent medical assistance, had not chosen the right hospital to take his father to and had not provided accurate information about his father’s condition to the doctors at the hospital. He also alleged that his father had not been examined by a doctor at the hospital and that no measures had been taken to facilitate his breathing or to determine the cause of his ailment. 8.     Following the applicant’s complaint, the Šalčininkai PHC and the hospital each carried out an internal inquiry. 9 .     During both those inquiries it was found that in the preceding years the applicant’s father had consulted a cardiologist and had been diagnosed with paroxysmal atrial fibrillation ( paroksizminis prieširdžių virpėjimas ) and several other heart rhythm problems. 10 .     In the course of the inquiry conducted by the Šalčininkai PHC, the emergency medical technician who served in the ambulance submitted a written statement describing the assistance which she had provided to the applicant’s father. After arriving at A.’s home she had measured his blood pressure, blood sugar, blood oxygen saturation, heartbeat and temperature, had assessed his level of pain and had given him painkillers. A.’s condition had appeared unstable – he had been experiencing difficulty breathing and was complaining of pain in the heart area, and had lost consciousness – and he had therefore been immediately taken to the hospital; the Šalčininkai municipal hospital had been the nearest one with emergency and intensive care services. A. had been provided with oxygen while in the ambulance and his condition had improved. After arriving at the hospital, he had been taken to the reception in a wheelchair and all the relevant documents had been given to the hospital staff. On the basis of that statement, the inquiry of the Šalčininkai PHC concluded that the medical assistance provided to the applicant’s father in the ambulance had been adequate and that it had complied with the relevant regulations. 11 .     The inquiry conducted by the hospital found that, after arriving there, A. had been examined by the on-duty doctor and hospitalised in the internal diseases unit; according to the hospital’s internal rules, all new patients were placed in that unit while awaiting the results of a Covid-19 test. He had been regularly monitored by on-duty doctors, as attested by five records to that effect in his medical file. The inquiry also included a list of medication which had been administered to him and the examinations which had been performed (an electrocardiogram, blood tests, urine tests and a Covid-19 test). His condition had been stable until it suddenly deteriorated at around 9 p.m. on 26   December 2021. The hospital informed the applicant that, according to the conclusions of the inquiry, the medical assistance provided to his father had been adequate; his death had been caused by a disorder of the cardiovascular system, but a more precise answer as to the cause of the death could not be given because his family had objected to a post-mortem examination (see paragraph   6 above). Civil proceedings Proceedings before the Commission for the Determination of Damage Caused to Patients’ Health 12.     In June 2021 the applicant lodged a complaint with the Commission for the Determination of Damage Caused to Patients’ Health ( Pacientų sveikatai padarytos žalos nustatymo komisija ; hereinafter “the Commission” – see paragraph 86 below). In the complaint form the applicant indicated that his father had not had any serious health issues prior to his death and that the ambulance and the hospital had not provided his father with medical assistance. He claimed 5,000   euros (EUR) in compensation in respect of non-pecuniary damage. 13 .     The Commission was composed of six members: three doctors, a nurse, a health-sciences professional and a lawyer. It had before it the applicant’s previous complaints to the Šalčininkai PHC and the hospital (see paragraph 7 above) and the medical records provided by the Šalčininkai PHC and the hospital, including the documents referred to in paragraphs   9-11 above. The Commission also obtained written statements from two doctors who had attended to the applicant’s father at the hospital: (i)     The internal-medicine doctor submitted that when A. had arrived at the hospital he had been complaining of shortness of breath, vertigo and loss of consciousness. He had been diagnosed with acute pulmonary heart disease and anaemia. His overall condition had been average. The doctor had ordered blood tests, chest and liver scans and a consultation with an intensive care specialist, who had been busy at that time. A. had been placed under the supervision of an on-duty doctor. (ii)     The doctor who had been on duty on 26   December 2020 submitted that on the morning of that day A. had complained of shortness of breath, feeling weak and vertigo. At around 12 a.m. he had stated that he was feeling slightly better and that the shortness of breath had decreased; the doctor had measured his blood pressure, heartbeat, blood oxygen saturation, increased the provision of oxygen and administered the medication which the patient had been taking for his paroxysmal atrial fibrillation. At 2.20   p.m. there had been no significant changes to his condition. At 6.10   p.m. he had complained of feeling weak when trying to get up, but his breathing had improved. His blood pressure, heartbeat and blood oxygen saturation had been measured on both those occasions. At around 9 p.m. his condition had suddenly deteriorated – he was not breathing and his heartbeat could not be detected. The doctor had attempted to resuscitate him by applying external cardiac massage and mechanical ventilation, but the resuscitation had not been effective and at 9.30 p.m. he had been declared dead. 14 .     In September 2021 the Commission informed the applicant and the respondents that it had decided to obtain an expert assessment of the relevant medical records. The examination of the applicant’s complaint would be resumed after the delivery of the assessment. The parties would then be informed of the questions which had been put to the expert and his or her conclusions. 15 .     The Commission forwarded A.’s medical records to a different hospital and asked it to provide an analysis of those records and answer questions regarding the adequacy of the medical assistance. The analysis of medical records was conducted in November 2021 by an internal-medicine doctor practicing in that hospital and read, in its relevant part: “... The copies of the documents are of a very poor quality [and] it is difficult to read and understand the doctors’ hand-written records. According to the available medical records, [the hospital] interviewed patient [A.] on 25-26 December 2020, examined his medical history and overall condition, performed blood tests, established a diagnosis, and scheduled a consultation with an intensive care specialist, which did not take place because the specialist was busy. [A. was] hospitalised in the internal diseases unit, in quarantine, because a Covid-19 infection could not be ruled out. He was prescribed treatment: infusion, intravenous diuretics, antibacterial treatment, oral anticoagulants, oxygen therapy, [and] supervision by a doctor. The patient had low blood pressure, an increasing need for additional oxygen [and suffered from] episodes of loss of consciousness; I believe that a consultation with an intensive care specialist would have been appropriate ( būtų buvusi tikslinga ) regarding a more active monitoring of the patient’s condition and his treatment in the intensive care unit. ... The emergency medical technician of the Šalčininkai PHC ... accurately assessed the patient’s health ... ... Having assessed all the circumstances, it may be said that the patient’s son, [the applicant], delayed contacting the medical services. The absence of timely provision of medical help could have had an impact on the deterioration of the patient’s health. ... The death of the patient was caused by the worsening of [multiple] chronic diseases. The doctors of [the hospital], having regard to the patient’s condition and the hospital’s competences, did everything in order to protect the patient’s life and health. ... The death of the patient was caused by diseases: advanced heart failure, paroxysmal atrial fibrillation, an unspecified bacterial infection, the worsening of a chronic kidney disease, [and] moderate anaemia of chronic disease. ... ... No professional errors or inaction in the provision of medical services have been established.” 16 .     The applicant submitted to the Commission his comments on the above analysis. In his view, even though his father should have been hospitalised in an intensive care unit, he had not received intensive care and had not been examined by an intensive care specialist because the latter had been busy. The applicant also contended that the ambulance ought to have taken his father to a different hospital because the Šalčininkai municipal hospital did not have a cardiologist or an intensive care specialist. Furthermore, the aforementioned analysis had not addressed the actions of the doctor who had been on duty on 26   December 2020 – the applicant alleged that the doctor had not provided any assistance to his father when he had lost consciousness, which had led to his death. The applicant had spoken to his father on the phone at around 5 p.m. on that day and his father had told him that a doctor had not seen him; the applicant had called the hospital at around 7   p.m. and had been informed that the doctor had been busy. He also contested the finding that he himself had delayed contacting medical services – he submitted that he had called the ambulance immediately after his father had fainted. Accordingly, he argued that the hospital had not provided his father with prompt and adequate medical assistance and that all the ailments which had led to his death had occurred only because of the actions and omissions of the hospital staff. 17 .     In a decision issued on 7 December 2021, the Commission unanimously concluded that the staff of the ambulance and the hospital had acted in accordance with the law and that there had been no causal link between the healthcare services provided to the applicant’s father and his death. Accordingly, the applicant was not entitled to compensation. Proceedings before the Vilnius Regional Court The applicant’s claim 18 .     In January 2022 the applicant signed a legal services agreement authorising a lawyer to prepare a claim for compensation for damage caused by medical negligence, lodge requests and submit documents to the Vilnius Regional Court. 19 .     In February 2022 the applicant lodged a claim with the Vilnius Regional Court, seeking compensation from the State and the Šalčininkai municipality for the damage caused by allegedly inadequate medical treatment provided to his father. He reiterated the arguments which he had raised in his complaint to the Šalčininkai PHC and the hospital (see paragraph   7 above) and disputed the decisions by those institutions concerning that complaint (see paragraphs   10 and 11 above). 20 .     The applicant submitted that the Šalčininkai PHC had not provided sufficient reasons to justify the decision by the ambulance staff to take his father to the Šalčininkai municipal hospital. He contended that a patient with serious health issues should have been taken to a hospital with better medical equipment and a wider range of professional staff, whereas the hospital in issue did not have a cardiologist or certain other specialists. 21 .     He further submitted that the hospital had not taken any active steps to address his father’s symptoms, namely shortness of breath, feeling of weakness and vertigo. Active attempts to resuscitate him had started only after his condition had dramatically worsened, but they had been belated and therefore ineffective. Moreover, the treatment plan prepared by the hospital for his father had not contained any urgent measures aimed at eliminating the life-threatening ailments; it was therefore evident that that plan had been ineffective as well. The applicant contended that, as his father had complained of shortness of breath, oxygen therapy ought to have been applied immediately. 22 .     In addition, he contested the conclusion of the Commission (see paragraph   17 above). In particular, the Commission had not properly assessed the fact that his father had not been examined by an intensive care specialist. Moreover, it had not taken due regard of the fact that, after being hospitalised, his father had merely been placed under supervision, without the provision of oxygen or other urgent medical assistance. Nor had it properly assessed the choice of the hospital by the ambulance staff. The applicant contended that the Commission had been biased and had possibly sought to protect the doctors involved. 23 .     He submitted that the conclusions of medical establishments and the opinions of experts were not binding on the court and that the court had to objectively assess the circumstances of his father’s death. He asked the court to establish that the medical assistance had been inadequate, quash the Commission’s decision and award him compensation of EUR   15,000 in respect of non-pecuniary damage. 24 .     In his claim the applicant indicated that he “[might] have a lawyer” ( galiu turėti advokatą ) and enclosed a copy of the legal services agreement (see paragraph 18 above), but he signed the claim himself. Hearings before the Vilnius Regional Court 25 .     On 1 June 2022 the Vilnius Regional Court held a preparatory hearing at which the parties were present. They were asked whether they had any requests and whether they wished to submit any additional material to be included in the case file; the applicant did not make any requests or submit any material. 26 .     On the same day, the court decided to start the examination of the merits of the case. As submitted by the Government and not disputed by the applicant, in his replies to the questions posed by the judge and by one of the respondents, the applicant mentioned that his claim had been prepared with the assistance of a lawyer. 27 .     The next hearing was held on 23 June 2022. In both hearings, the parties were given an opportunity to make requests. The applicant made several requests for data relating to his telephone calls to the hospital to be included in the case file, but the court dismissed them. Decision of the Vilnius Regional Court 28.     On 30 June 2022 the Vilnius Regional Court dismissed the applicant’s claim. 29.     The court observed that the Law on the Rights of Patients and Compensation for Damage to their Health ( Pacientų teisių ir žalos sveikatai atlyginimo įstatymas ; hereinafter “the Patients’ Act”) enshrined the right of patients to receive healthcare services of good quality (see paragraph   83 below). In order for civil liability for inadequate healthcare services or denial of such services to arise, the following elements had to be established: (i) unlawful actions or omissions; (ii) damage; (iii) a causal link between the unlawful actions or omissions and the damage; and (iv) the fault of the person who caused the damage – the fault was presumed, although that presumption could be rebutted. 30 .     According to the Supreme Court’s case-law, cases relating to damage caused by inadequate treatment concerned professional civil liability. Doctors and healthcare facilities had an obligation towards their patients to make the greatest possible effort – that is to say, to ensure the highest possible degree of attentiveness, care, caution and professionalism. The unlawfulness of a doctor’s actions and his or her fault could be established on the basis of a violation of the duty to act with care and diligence, which was a lower bar than in other cases concerning civil liability. 31.     At the same time, the Supreme Court had acknowledged that a doctor’s liability had objective limits determined by the biological processes taking place in a human body and the level of development of medical science and practice. Despite continuous scientific progress, it was an unavoidable fact of life that some diseases could not be cured and that a doctor could only do what was possible in the light of the state of the medical science and the patient’s condition. Civil liability was based on the principle that nobody could be required to achieve that which was impossible ( impossibilium nulla obligatio est ). Accordingly, where a doctor had fulfilled his or her duties with care, attention and professionalism but damage to the patient’s health had occurred nonetheless, such damage had to be considered accidental and the doctor could not be held liable for it. 32.     Moreover, according to the Supreme Court, determining whether specific actions or omissions of doctors met the standard of honest, reasonable and attentive professional activity required specialist knowledge. Therefore, only specialists in the relevant field could assess whether the actions taken in the particular situation had been appropriate, having regard to the existing diagnostic and treatment possibilities. 33.     At that juncture, the Vilnius Regional Court observed that in civil proceedings each party bore the burden of proving those circumstances on which it based its requests and arguments. Thus, a patient who alleged that a healthcare facility had acted unlawfully had to show that the duty to provide professional and attentive medical assistance had been violated, that damage had arisen and that there had been a causal link between the doctor’s negligence and the damage in question. 34.     According to the Supreme Court’s case-law, the actions of a doctor had to be assessed against the standard of a reasonable and attentive professional. Each case had to be assessed on an individual basis because the same action could be considered lawful and contributing to the saving of a patient’s life in some cases, while in other cases it could be deemed unlawful and harmful to the patient. Furthermore, the obligation to make the greatest possible effort did not mean that a doctor had to perform all available examinations and apply all existing methods of treatment; rather what needed to be assessed was whether the doctor had acted as an honest, attentive, cautious, careful and professional specialist in his or her field, relying on the relevant medical and other scientific knowledge, rules of doctors’ professional ethics, established medical practice and relevant legal regulations. The courts had to assess doctors’ actions from the perspective of the obligation of means, not of result. 35 .     The Vilnius Regional Court then turned to the circumstances of the case before it. Regarding the medical services provided to the applicant’s father in the ambulance, the court examined the documents provided by the Šalčininkai PHC (see paragraph 10 above) and concluded that the staff of the ambulance had acted in accordance with the law and with a high level of professionalism, attentiveness and care; there were thus no grounds to find that their actions had caused any damage to the patient’s health. 36 .     With regard to the treatment provided at the hospital, the court firstly took note of the analysis of medical records ordered by the Commission, which had found that the doctors at the hospital had done everything in order to protect the life and health of the applicant’s father and that his death had been caused by his pre-existing diseases (see paragraph   15 above). The court also examined the documents which indicated the medical procedures that had been carried out with respect to the applicant’s father (see paragraphs 11 and 13 above). It observed that, although the applicant had asserted that his father had not had any health issues, according to the available information A. had been diagnosed with various cardiovascular diseases – in February 2019 he had been diagnosed with a hypertensive heart disease without heart failure ( hipertenzinė širdies liga be širdies nepakankamumo ) and in January 2020 – with paroxysmal atrial fibrillation. According to his death certificate, the main disease which had caused the death had been a chronic cardiovascular disease (see paragraph 5 above). 37.     The court observed that, according to relevant legal instruments, damage which would have occurred even upon provision of adequate medical treatment had to be considered unavoidable (see paragraphs 89 and 91 below). Moreover, the law provided for compensation only where there was a causal link between the damage and the unlawful actions of the healthcare institution. No compensation could be awarded where the damage had occurred as a result of the patient’s state of health which had already existed before the treatment in question had been provided and which could not have been improved by the currently available means of treatment. 38 .     In the light of all the available evidence, the court concluded that the death of the applicant’s father had resulted from two factors: his pre-existing diseases and the delay in seeking medical help. Accordingly, it had not been proved that the ambulance crew or the hospital staff had acted unlawfully or that there had been a causal link between A.’s death and the healthcare services provided to him. Proceedings before the Court of Appeal The applicant’s appeal 39 .     The applicant lodged an appeal against the decision of the Vilnius Regional Court. The appeal was signed by a lawyer (a different lawyer than the one with whom the applicant had signed the legal services agreement mentioned in paragraph 18 above). 40 .     The applicant submitted that the analysis of medical records on which the court had relied (see paragraph 15 above) had been based in part on illegible documents and that it contained contradictions – for example, the author of the analysis had considered that a consultation by an intensive care specialist would have been appropriate, but then nonetheless concluded that the hospital had done everything to preserve the patient’s health and life (see paragraph 15 above). Moreover, the direct cause of his father’s death had been a pulmonary oedema, and the main disease which had caused the death – a chronic cardiovascular disease (see paragraph 5 above), yet the analysis had been prepared by an internal-medicine doctor, whose competence did not include cardiovascular diseases. The applicant therefore contended that the analysis had been superficial and lacking in detail and that it could not be treated as an expert assessment within the meaning of the Code of Civil Procedure (see paragraph 77 below). 41 .     According to the Supreme Court’s case-law, assessing whether doctors’ actions or omissions met the standard of honest, reasonable and attentive professional activity was a question which required specialist knowledge. However, the Vilnius Regional Court had not obtained an expert assessment, testimonies of relevant specialists or other reliable evidence; the available medical records were contradictory or even appeared to have been forged. Under the Code of Civil Procedure, in cases where the available evidence was insufficient, the court had the right to suggest to the parties that they submit additional evidence (see paragraph 75 below). However, the Vilnius Regional Court had not suggested to the applicant that he ask for an expert assessment to be ordered and had not explained to him his right to do so. The applicant submitted that, during the proceedings before the first-instance court, he had not been represented by a lawyer and that he did not have sufficient legal knowledge to represent himself properly. In view of the importance of the values which were at stake – protection of human life and health and the public interest in receiving good quality healthcare services ‑ the court should have undertaken a more active role; it should have ordered an expert assessment of its own motion or should have explained to the applicant his right to be properly represented (see paragraph 81 below). 42 .     The applicant contended that the available evidence contained contradictions which the Vilnius Regional Court had failed to address. For example, it had been indicated that his father’s condition upon hospitalisation had been average (see paragraph 13(i) above), yet he had died the following day, which showed that his health had deteriorated rapidly and that the doctors had failed to notice it. Moreover, according to the medical records, no medical examinations had been performed on the day of the hospitalisation (25 December 2020). His father had not been properly monitored by doctors – the applicant had spoken to his father on the phone on 26   December 2020 and the latter had told the applicant that nobody had attended to him during the day. The applicant’s father had been placed in the internal diseases unit and not in the intensive care unit, even though his rapid death showed that he had required constant supervision. Had he been placed in the intensive care unit he would have received continuous supervision and immediate resuscitation as soon as it had become necessary. Furthermore, the doctor who had prepared the analysis of medical records had noted that a consultation with an intensive care specialist would have been appropriate but that it had not taken place because the specialist had been busy (see paragraph   15 above). What is more, some of the medical records provided by the hospital appeared to have been forged because they indicated that certain medical procedures, such as the taking of his father’s temperature, had been performed on 27   December 2020, that is already after his death. Accordingly, the applicant contended that the Vilnius Regional Court had failed to duly assess the available evidence and that its decision was not properly substantiated. 43 .     The applicant also submitted that the Vilnius Regional Court had not addressed his argument that his father ought to have been taken to a different hospital because the Šalčininkai municipal hospital did not have a cardiologist (see paragraph 20 above). 44 .     The applicant contended that the case could not be properly examined without an expert assessment and asked the Court of Appeal to order such an assessment (see paragraph 77 below). He submitted a number of questions that the expert should answer regarding the choice of the hospital, the adequacy of the healthcare services provided at the hospital, the accuracy of the official cause of his father’s death (see paragraph 5 above) and discrepancies in the medical records (see paragraph 42 above). Additional material submitted by the applicant to the Court of Appeal 45 .     In August 2022 the applicant’s lawyer lodged a request with the Court of Appeal for new material to be included in the case file – namely, notices from the prosecutor’s office of the Vilnius Region and from the Šalčininkai police, whereby the applicant had been informed that a pre-trial investigation had been opened following his complaints (see paragraph 61 below). He submitted that those documents were important for the proper examination of the case and that adding them to the file would not prolong the proceedings. The lawyer did not ask that the civil proceedings be stayed pending the pre-trial investigation. Decision of the Court of Appeal 46.     On 24 January 2023 the Court of Appeal dismissed the appeal lodged by the applicant and upheld the decision of the Vilnius Regional Court. 47 .     The Court of Appeal firstly addressed the applicant’s request to order an expert assessment (see paragraph 44 above). It noted that, according to the Supreme Court’s case-law, a decision to order an expert assessment could not be based on speculation but rather had to be based on the court’s belief that such an assessment was necessary in order to examine the case fairly and properly. The Code of Civil Procedure provided that no type of evidence had pre-determined weight in the eyes of the court; while that rule was subject to some exceptions, an expert assessment did not fall among them. Accordingly, when the question of ordering an expert assessment arose in a given case, the court had to make a decision in accordance with the rules laid down in the Code of Civil Procedure (see paragraph 77 below), the general principles of law, the parties’ arguments and supporting material, as well as the impact that it was likely to have on the fair examination of the case. Where a request for an expert assessment was based on doubts or guesses rather than on a well-founded belief that specialist knowledge was necessary to elucidate certain issues arising in the case, such a request had to be refused. 48 .     The Court of Appeal further observed that the purpose of the proceedings before the appellate court was to review whether the lower court’s decision had been lawful and well founded. Appellate courts did not examine cases afresh; appeals could not be based on new circumstances or contain new claims or new evidence. In the case before it, the applicant’s request for an expert assessment had been lodged too late – he had made that request only in his appeal, although nothing had prevented him from doing so during the proceedings before the first-instance court. Although the applicant had submitted that the Vilnius Regional Court had not suggested that he should ask for such an assessment to be ordered (see paragraph 41 above), the Court of Appeal emphasised that the court had not had an obligation to do so. The civil proceedings were adversarial, with each party bearing the burden of proving the circumstances on which they sought to rely. The court’s role was to assess the available evidence according to its inner conviction. In this case, the Vilnius Regional Court had assessed all the evidence and had not considered that specialist knowledge had been necessary in order to properly examine the case. Therefore, it had not been obliged to suggest to the applicant that he request an expert assessment. 49 .     The Court of Appeal considered that the available written evidence was sufficient to examine the questions arising in the case and that the applicant had not proved that specialist knowledge was necessary to elucidate any of those questions. It therefore refused his request to order an expert assessment. 50.     The Court of Appeal next observed that, according to the Patients’ Act and the relevant case-law, damage caused to a patient’s health had to be compensated regardless of the fault of any specific individual (see paragraph   88 below). However, that did not mean that compensation had to be paid in all cases where a patient sustained some negative consequences; instead, it was necessary to establish a causal link between the unlawful actions of a healthcare institution and the damage caused to the patient. Once the Commission had found that the applicant was not entitled to compensation for damage (see paragraph 17 above), it was for him to show that the healthcare institutions could have avoided the damage by acting in line with the relevant medical standards – that is, to prove that the healthcare institutions had acted unlawfully and that there was a causal link between their unlawful actions and his father’s death. 51.     The Court of Appeal reiterated the case-law of the Supreme Court, according to which the courts had to assess doctors’ actions from the perspective of the obligation of means, rather than of result – namely, whether in a given situation healthcare had been provided with the greatest possible effort, by taking all the available and necessary means and by using them in an attentive, careful and professional manner. 52.     The Court of Appeal stated that, having examined the available written documents and the parties’ submissions, it agreed with the conclusion reached by the Vilnius Regional Court that it had not been demonstrated that the ambulance or the hospital had acted unlawfully. 53 .     In particular, the Court of Appeal rejected the applicant’s argument that the ambulance should have taken his father to a different hospital (see paragraph 43 above). It held that, according to relevant regulations, an ambulance had to take a patient to the nearest healthcare facility providing relevant medical services. The Šalčininkai municipal hospital provided emergency and intensive care services, and the applicant had not proved that the hospital had not had the capacity or the competence to provide his father with the necessary medical treatment. 54 .     Moreover, having examined the available written evidence – the medical records, the doctors’ written statements (see paragraph 13 above) and the analysis of medical records (see paragraph 15 above) – the Court of Appeal endorsed the lower court’s conclusion that the death of the applicant’s father had been caused by his pre-existing diseases and the delay in seeking medical help (see paragraph 38 above). The documents in the medical file disproved the applicant’s allegations that the hospital had not performed any medical examinations with respect to his father, that he had not been properly monitored and that he had not been provided with timely medical assistance; those allegations were not supported by any evidence. 55 .     As to the applicant’s arguments regarding the analysis of medical records (see paragraph 40 above), the Court of Appeal noted that that analysis had not been the only material on the basis of which the Vilnius Regional Court had reached its decision but that the latter court had also itself examined the relevant medical records. The Court of Appeal considered that there had been no reason not to rely on the analysis. In addition, it referred to regulations regarding the competences of an internal-medicine doctor and dismissed as unfounded the applicant’s argument that that doctor had not had the necessary competence to provide such an analysis (see paragraph 40 above). 56.     In the light of the foregoing, the Court of Appeal concluded that the applicant had not proved that the ambulance crew or the hospital had acted unlawfully, or that there had been a causal link between his father’s death and the allegedly inadequate medical treatment. 57.     Lastly, in response to the applicant’s argument that the Vilnius Regional Court should have offered him legal representation (see paragraph   41 above), the Court of Appeal noted that, according to the Code of Civil Procedure, the court examining the case “may suggest” to a party that it find a representative (see paragraph 81 below). Contrary to the applicant’s position, the fact that the Vilnius Regional Court had not made such a suggestion or had not explained to him his right to be represented by a lawyer did not mean that the proceedings had not been fair or that the court’s decision was unlawful. Moreover, the applicant had indicated in his claim that he might be represented by a lawyer (see paragraph 19 above), which showed that he had been aware of his right to have a lawyer but had made the decision not to, thereby assuming the risks associated with that decision. Proceedings before the Supreme Court 58.     The applicant lodged an appeal against that decision on points of law, reiterating the arguments which he had raised in his previous appeal (see paragraphs   39-43 above). In addition, he submitted that the Court of Appeal should have stayed the civil case pending the criminal proceedings, about which he had informed the court (see paragraph 45 above). Moreover, he contended that in cases concerning alleged medical negligence the parties were not in an equivalent position because the claimant usually did not have specialist medical knowledge and all the evidence was either in the respondent’s possession or could only be obtained with the use of specialist knowledge. Thus, in such cases the courts should not be allowed to remain passive but should be required to take all necessary measures to rectify the imbalance between the parties. In particular, where a case could not be resolved without specialist knowledge, the courts should not only have the right, but also the obligation, to order an expert assessment on their own initiative. 59.     On 13   March 2023 the Supreme Court refused to accept the appeal on points of law for examination on the grounds that it did not raise any important legal issues. Criminal proceedings The applicant’s request that an investigation be opened 60 .     In August 2022 the applicant lodged a request with the Vilnius regional prosecutor’s office to open a pre-trial investigation in respect of the hospital. He alleged that the hospital had committed the criminal offence of falsification of documents (Article 300 § 1 of the Criminal Code, see paragraph 74 below): his father’s medical file contained records indicating that some medical procedures, such as measuring his temperature, had been performed on 27 December 2020 – the day after his death – which clearly showed that those records were false. Moreover, the death certificate contained contradictory information: on the one hand, a pulmonary oedema was identified as the direct cause of death, while on the other hand, the principal cause of death was a chronic cardiovascular disease (see paragraph   5 above). In addition, the medical file contained a record of various medical examinations which had allegedly been performed on 26   December 2020, but the applicant had spoken with his father on the phone at around 5   p.m. that day and his father had told him that nobody had attended to him during the day, which also gave grounds to believe that the records had been falsified. The applicant also alleged that his father had been taken to a hospital which had not been able to provide qualified treatment and that the treatment which he had received at the hospital had been inadequate; thus, there were grounds to believe that the doctors had committed the criminal offence of causing death by negligence (Article 132 § 1 of the Criminal Code, see paragraph 73 below). Investigative measures taken by the authorities 61 .     On 12 August 2022 the Šalčininkai police opened a pre-trial investigation into the applicant’s allegations under Article   132   §   1 and Article 300 § 1 of the Criminal Code. 62.     The police requested the State Accreditation Service for Healthcare Activities under the Ministry of Health (hereinafter “the Accreditation Service”) to evaluate the healthcare services provided to the applicant’s father in the ambulance and at the hospital. 63 .     The Accreditation Service delivered its report to the police in March 2023. It found that the ambulance crew had complied with all the relevant legal requirements: they had arrived within the time-limit prescribed by law, assessed the patient’s health and taken him to the nearest hospital which provided internal-medicine services and intensive care. By contrast, the hospital had breached several requirements of the law. In particular, the doctor who had been on duty on the night of 25 to 26 December 2020 had failed to record a detailed description of the patient’s condition and medical history, to call an intensive care specialist to examine him, to arrange for an X-ray of the chest and a biochemical blood examination, and to provide an assessment of the results of the