* * 177. While the State failed to create the conditions and to take the measures necessary for the inmates at the Center to live in dignity and build a decent life while deprived of their liberty and failed to fulfill the added obligations it has vis-à-vis children, it also kept the Center in conditions that invited fire; those conditions also meant that when the fires inevitably happened, they had terrible consequences for the inmates. And it neglected those conditions despite repeated warnings and recommendations from international and nongovernmental organizations about the danger that conditions at the Center posed. As a result of these fires, the following inmates perished: Elvio Epifanio Acosta Ocampos, Marco Antonio Jiménez, Diego Walter Valdez, Sergio Daniel Vega Figueredo, Sergio David Poletti Domínguez, Mario del Pilar Álvarez Pérez, Juan Alcides Román Barrios, Antonio Damián Escobar Morinigo and Carlos Raúl de la Cruz (supra para. 134.29).
178. From the facts proven in the instant case (supra para. 134.32), it has been shown that the State did not take sufficient preventive measures to respond to the possibility of a fire at the Center. Because the facility was not originally planned to serve as a Reeducation Institute, none of the safety, evacuation-related and emergency measures needed for an event of this kind were taken. For example, the Center was not equipped with either fire alarms or fire extinguishers and guards were not trained to respond to emergencies. The Court has previously held that in its role as guarantor, the State has an obligation “to design and apply a crisis-prevention prison policy,”114 the kind of crisis that could threaten the fundamental rights of inmates in the State’s care and custody.
179. In view of the foregoing, the Court concludes that the State’s failure to prevent resulted in the death of a number of inmates. If not for all inmates, the tragedy was particularly traumatic and painful for many of them, as the loss of life was caused by asphyxiation or burns, prolonging their suffering for a number of days. This is gross negligence on the State’s part, by virtue of which it is responsible for violation of Article 4(1) of the American Convention, in relation to Article 1(1) thereof, read in combination with Article 19 of the Convention, to the detriment of the inmates named above.
180. The Court would like to make special reference to three children in particular,115 who died at Paraguayan penal institutions but not as a result of the fires at the Center, and whose deaths are alleged to have engaged the State’s responsibility for violation of their right to life:
a) the deaths of Richard Daniel Martínez and Héctor Ramón Vázquez
181. On September 10, 2001, Richard Daniel Martínez, age 18, died from a wound inflicted by a blade in the juvenile cellblock at the Emboscada Regional Penitentiary for adults (supra para. 134.46). On March 14, 2002, Héctor Ramón Vázquez, age 17, was stabbed in the same penal institution and died on March 15, 2002 (supra para. 134.47). Both deceased inmates had been transferred from the Center to the Emboscada adult prison after the Center was closed (supra para. 134.47).
182. The State argued that it did not violate the right to life of these two juveniles, as they died in fights between inmates in Emboscada’s Juvenile Cellblock, as a result of wounds inflicted by home-made weapons. The State added that they were given immediate treatment and that everything possible was done to save their lives.
183. The comments concerning the conditions in which the inmates were kept (supra para. 134.3 a 134.24), which created a climate conducive to acts of violence, and the comments concerning the inmates who died as a result of the fires (supra paragraphs 177 to 179), are just as relevant and pertinent in the case of the deaths of Richard Daniel Martínez and Héctor Ramón Vázquez.
184. As previously pointed out, the State has an obligation to guarantee the right to life and the right to humane treatment of the inmates interned in its penal institutions (supra para. 151). Therefore, even though no State agent appears to have been the immediate cause of the deaths of the two juveniles incarcerated in the Emboscada penitentiary, the State had a duty to create the conditions necessary to avoid, to the maximum extent possible, fighting among inmates. The State did not fulfill that obligation and thus incurred international responsibility for the deaths of juveniles Richard Daniel Martínez and Héctor Ramón Vázquez, thereby violating Article 4(1) of the Convention, in combination with Articles 1(1) and 19 thereof.
b) the death of Benito Augusto Adorno 185. In its brief answering the application and then again in its final oral and written submissions, the State admitted to its violation of Article 4 of the Convention in the case of the death of Benito Augusto Adorno, an inmate who was shot by a staff member at the Center on July 25, 2001, and then died on August 6, 2001 (supra para. 134.35).
186. The Court therefore concludes that the State is responsible for the death of the juvenile Benito Augusto Adorno, and thus violated Article 4(1) of the American Convention, in relation to Articles 1(1) and 19 thereof.
187. The Court observes that the same considerations made in the case of the inmates who were deprived of their right to life (supra paragraphs 177 to 179), also apply in the case of those injured in the fires, all of whom were children, namely: Abel Achar Acuña, José Milciades Cañete Chamorro, Ever Ramón Molinas Zárate, Arsenio Joel Barrios Báez, Alfredo Duarte Ramos, Sergio Vincent Navarro Moraez, Raúl Esteban Portillo, Ismael Méndez Aranda, Pedro Iván Peña, Osvaldo Daniel Sosa, Walter Javier Riveros Rojas, Osmar López Verón, Miguel Ángel Coronel Ramírez, César Fidelino Ojeda Acevedo, Heriberto Zarate, Francisco Noé Andrada, Jorge Daniel Toledo, Pablo Emmanuel Rojas, Sixto Gonzáles Franco, Francisco Ramón Adorno, Antonio Delgado, Claudio Coronel Quiroga, Clemente Luis Escobar González, Julio César García, José Amado Jara Fernández, Alberto David Martínez, Miguel Angel Martínez, Osvaldo Mora Espinola, Hugo Antonio Vera Quintana, Juan Carlos Zarza Viveros, Eduardo Vera, Cándido Ulises Zelaya Flores, Hugo Olmedo, Oscar Rafael Aquino Acuña, Nelson Rodríguez, Demetrio Silguero, Aristides Ramón Ortiz Bernal, Carlos Raúl Romero Giacomo, Carlos Román Feris Almirón, Pablo Ayala Azola, Juan Ramón Lugo and Rolando Benítez. Thus, the State’s responsibility is by virtue of its gross negligence by failing to take the minimum necessary fire-prevention measures.
188. The inmates who sustained injuries in the fires and managed to survive, endured painful mental and physical suffering. Some are still suffering the physical and/or psychological after-effects (supra para. 134.48). The burns, wounds and smoke inhalation that the children identified in the preceding paragraph suffered as a result of the fires, which happened while they were in the custody and supposed protection of the State, and the after-effects of those burns, wounds and smoke inhalation, constitute treatment in violation of Articles 5(1) and 5(2) of the American Convention, in relation to Articles 1(1) and 19 thereof, to the detriment of the afore-named persons (supra paragraphs 177 and 187).