THIRD SECTION
 
 
 
 
 
 
CASE OF NICOLAOU v. CYPRUS
 
(Application no. 29068/10)
 
 
 
 
 
JUDGMENT
 
 
Art 2 • Effective investigation • Investigation into death of a conscript undermined by serious initial omissions and passage of time
 
 
STRASBOURG
 
28 January 2020
 
 
 
 
FINAL
 
28/05/2020
 
This judgment has become final under Article 44 § 2 of the Convention. It may be subject to editorial revision. In the case of Nicolaou v. Cyprus,
The European Court of Human Rights (Third Section), sitting as a Chamber composed of:
 Paul Lemmens, President,
 Georgios A. Serghides,
 Helen Keller,
 Alena Poláčková,
 María Elósegui,
 Gilberto Felici,
 Erik Wennerström, judges,
and Stephen Phillips, Section Registrar,
Having deliberated in private on 7 January 2020,
Delivers the following judgment, which was adopted on that date:
PROCEDURE
1. The case originated in an application (no. 29068/10) against the Republic of Cyprus lodged with the Court under Article 34 of the Convention for the Protection of Human Rights and Fundamental Freedoms (“the Convention”) by five Cypriot nationals, Ms Andriana Nicolaou (“the first applicant”), Mr  Charalambos Nicolaou (“the second applicant”), Mr Nicos Nicolaou (“the third applicant”), Mr Andreas Nicolaou (“the fourth applicant”) and Ms Parthenope-Ariadne Nicolaou (“the fifth applicant”), on 16 April 2010. 2. The applicants were represented by Mr C. Candounas, a lawyer practising in Nicosia. The Cypriot Government (“the Government”) were represented by their Agent, Mr C. Clerides, Attorney General of the Republic of Cyprus. 3. The applicants complained that the investigation into the death of their relative Athanasios Nicolaou (“Mr Nicolaou” or the “deceased”) had been inadequate. 4. On 10 June 2015 the applicants’ complaint was communicated to the Government under the procedural aspect of Article 2 of the Convention. 5. On 6 November 2018 the President of the Section to which the case had been allocated decided under Rule 54 § 2 (c) of the Rules of Court to request the parties to submit further written observations on the admissibility and merits of the application. THE FACTS
I. THE CIRCUMSTANCES OF THE CASE
6. The applicants are the relatives of Mr Nicolaou who died on 29 September 2005. The first and second applicants are his mother and father. They were born in 1948 and 1943 respectively. The remaining applicants are the deceased’s siblings. They were born in 1972, 1980 and 1982 respectively. All the applicants currently live in Limassol. The deceased himself was also a Cypriot national born in 1979. A. The background facts and Mr Nicolaou’s death
7. The first and second applicant lived in Australia for numerous years. Their four children were born there. In 2003 the whole family moved back to Cyprus. 8. In the summer of 2005 Mr Nicolaou, at the age of twenty-six, was drafted into the army to perform six months’ mandatory military service. After receiving basic training at the Recruits Training Centre (Κέντρο Εκπαίδευσης Νεοσυλλέκτων) in Limassol, he was assigned to Camp Evmenios Panayiotou, in Polemidia, Limassol. 9. On 28 September 2005 Mr Nicolaou was granted overnight leave and was due to return to the camp at 6.50 a.m. the next morning. He spent the night at home and on 29 September 2005 left around 6.30 a.m., after having had breakfast and taking his bag, which he himself had prepared, with clean clothes and food. He failed, however, to report back to his unit. Being unable to contact him, the camp called his mother at around 11.00 a.m. At 3.45 p.m. his mother reported his disappearance to the police, who launched a search. At around 4 p.m. a police officer found his car parked on the side of the road, 150 m before the bridge in Alassa in the Limassol district, and at around 4.20 p.m. found his body under the bridge. An ambulance arrived around 5.40 p.m. with a nurse. The first and third applicants arrived just afterwards, and the first applicant recognised the body and identified it as her son’s. A doctor from the Limassol General Hospital, who happened to be passing in the area, came and examined Mr Nicolaou and established that he was dead. 10. Members of the Lania Police Station (“LPS”) and of the Limassol Crime Combating Department (Τμήμα Καταπολέμησης Εγκλημάτων -“the CCD”), among others, visited the scene, which had been cordoned off. A forensic pathologist, Dr P.S., was called to the scene and arrived at around 6.30 p.m. He examined the body in situ and established Mr Nicolaou’s death in the presence of his parents, police officers and a second forensic pathologist. P.S. also conducted an inspection of the site. Samples and evidence were taken from the scene for testing. The scene was photographed by police officers and the deceased’s car was searched. According to police records, P.S. had expressed the view on-site that the cause of death had been suicide due to a fall from a height, namely from the bridge, and that there had been no suspicion of a criminal act. During the subsequent investigation and the inquest proceedings P.S. denied that he had stated that the cause of death had been suicide (see paragraph 45 below). 11. The body was then transferred to the Limassol General Hospital for further examination. B. The post-mortem report by P.S. 12. In the morning of 30 September 2005 a post-mortem examination of the deceased’s body was conducted by P.S. at the morgue of the Limassol General Hospital. He released his post-mortem report on 16 June 2006. 13. P.S. noted that the deceased had been found lying on his back twenty metres directly under the bridge: his clothes were wet and his body was still warm. Cadaveric hypostases had just started to appear on the dorsal surface of the upper body and the limbs, which subsided with pressure. Rigor mortis had started to set in (πτωματική ακαμψία στάδιο της εισόδου). He estimated that the deceased had died within four hours before being found. Lying on the left side of the body was a pair of glasses. On the ground, underneath the deceased’s back, there was a wristwatch, the strap of which was cut on one side. A wallet was found outside the right pocket of his tracksuit trousers. Vomit was found near his left arm. 14. During the post-mortem examination, samples were taken of the deceased’s cranial cavity, blood, urine and vitreous fluid as well as of the contents of his stomach for toxicological exams. 15. According to the report of the State General Laboratory the deceased had 44 mg% [sic] alcohol in his blood and 31mg% [sic] in his vitreous fluid. His DNA was also matched to two beer cans found in the deceased’s military bag and near the car. 16. P.S. noted that there was no evidence to indicate violent injuries caused by a fight. The deceased had a fracture in the area of the right wrist, the right knee and right femur (thigh) as well as a small wound on the right side on the surface of the tongue. 17. P.S. also observed the following:
–  Head: there were no skull fractures, or injuries. There was a brain oedema as well as pervasive epidural and subarachnoid brain haemorrhage.
–  Neck and thorax: the deceased had fractures of the intervertebral spaces of the cervical spine. A haemothorax (accumulation of blood) took up the entire right side of the thorax. He had rib fractures of the 9th, 10th, 11th on the left and 10th on the right paravertebral fractures from the 1st to the 10th intercostal space. Further, a sternal fracture was observed. There was liquid, possibly water with sand, in the oral cavity. There were blood and food remains in the trachea. The left lung presented fractures, the right lung presented ruptures. Although the heart was normal, haemopericardium rupture was observed as well as rupture of the pericardial sac.
–  Abdomen: haemoperitoneum was observed. The stomach contained a few watery half-digested cereals. There was a small rupture in the lower surface of the liver and the right adrenal gland presented a contusion. The left adrenal gland was normal, as was the spleen. The right kidney presented a rupture and the left kidney was atrophic. P.S. observed mesenteric cuts, bruising of the intestinal strands of the sigmoid colon of the large intestine (ορθοσιγμοειδους τμήματος του παχέου εντέρου), contusions of the right ilio‑psoas muscle (this is near the upper femur), a diffused retroperitoneal hematoma and contusion of the bladder. 18. The report concluded that:
“Death was due to subdural and subarachnoid haemorrhage, broken ribs and sternum, a rupture of the right lung with haematothorax, a ruptured right kidney, a rupture of the mesentery with haemoperitoneum, fatal injuries which can also occur from fall from a height. No signs of criminal activity were found.”
C. The first police investigation
19. On 1 October 2005 a police investigation was formally opened. This was carried out by the LPS. 20. In the course of the investigation the police carried out a new inspection of the site for the purpose of finding Mr Nicolaou’s mobile phone. This was not found. Mr Nicolaou’s family also informed the police that during their own subsequent visits to the scene on 20 October 2005, they had collected a sample of soil which they suspected contained Mr Nicolaou’s blood and which they had found about 3 metres from the location where his body had been found. They gave the sample to the police and also showed them, on the scene, where they had found the red-tinged soil. Following tests, it was confirmed that it was the deceased’s blood. 21. On the basis of information from the State’s Meteorological Department it was confirmed that on 29 September 2005 between 12.55 p.m. and 2.45 p.m. there had been a storm with heavy rainfall and also hail in the area. 22. Between 1 October 2005 and 28 June 2006 the police obtained statements from over fifty witnesses. The witnesses included the deceased’s family, his last employer, his priest, military personnel with whom he had served, his military superiors, passers-by and farmers from the area where his body had been found, and drivers who had crossed the bridge on the day of death. Those statements included, inter alia, the following. 23. Fellow soldiers gave statements describing Mr Nicolaou as being, among other things, quiet, solitary and reserved. On the day of his death he was not seen entering or leaving the camp by any of the soldiers on guard. 24. According to the statements given by the first applicant and Mr Nicolaou’s priest, E.E, during his military service Mr Nicolaou had often confided to them that the situation at the camp was “unbearable”, explaining that he had been verbally insulted, humiliated and bullied by his fellow soldiers on several occasions. Although on several occasions they had urged him to report the alleged incidents of bullying to his commanding officer, he had been afraid to do so in case his comrades turned against him. According to the first applicant, Mr Nicolaou wished to be transferred to another unit while he was also keen to secure an early discharge from the army. A couple of days before his death he had told his mother that certain soldiers had thrown papers at him and called him “an Australian” and that he had reported this incident to his commanding officer. The first applicant alleged that the persons implicated in the event had ambushed him outside the camp on the day of his death. 25. From the evidence given it transpired that Mr Nicolaou had been disciplined and hard-working but did not get on well with the soldiers in his squadron and had complained in general about this to his superiors, (Captain P.D. and M.C). His commanding officer, Lieutenant D.I. was also informed of this. Both P.D and M.C. stated that they had noted that two or three days before his death Mr Nicolaou had been very uneasy and nervous, and that something serious had been bothering him. Mr Nicolaou refused to confide in P.D., so P.D. sent him to D.I. D.I and two others (Colonel K.V., the Chief of Staff of III Brigade Support, and soldier I.D.) confirmed that on 25 September 2005 Mr Nicolaou was called “the English” by his fellow‑soldier (I.D.). D.I. discussed the incident with the two and made recommendations daily to all soldiers not to call each other names, especially not the new recruits; and to be careful. 26. In his report dated 28 June 2006, the police officer from LPS in charge of the investigation observed that the deceased’s family’s allegations that a crime had been committed and that certain soldiers had information about the case and had been involved in his death had been examined, but no evidence had been found to support this. From the evidence collected and the findings of the forensic pathologist, P.S., it transpired that the cause of death had been a fall from a height; the commission of a criminal act was excluded. The report did not address any issues that Mr Nicolaou had had at the camp with his fellow soldiers, apart from briefly mentioning what Mr Nicolaou’s priest had said in his statement. The report was transmitted to the District Court of Limassol for the inquest proceedings (see paragraph 30 below). D. The military investigation
27. In parallel, a military investigation into the causes of the death and the circumstances under which the deceased had been discovered dead was also conducted by Major Y.I. who had been overseeing the camp’s security. Y.I. had belonged to a different unit from Mr Nicolaou. According to a letter in the case file from the Ministry of Defence dated 18 August 2015, Y.I. did not know Mr Nicolaou and he was not his subordinate (δεν υπήρχε διοικητική υπαγωγή μεταξύ τους). 28. Y.I. submitted a first report dated 18 April 2006. In this he provided a summary of the statements given to the police investigator by eleven witnesses, who were military personnel and soldiers at the camp, Mr Nicolaou’s last employer, his priest and the first applicant. Y.I. concluded that on the basis of the facts ascertained during the investigation, Mr Nicolaou had committed suicide during his overnight leave and proposed that, in the absence of a criminal offence, the investigation be closed. 29. Following instructions by the National Guard General Staff of the Ministry of Defence for further investigation, Y.I. prepared a second report, dated 4 July 2006, in which he provided a summary of statements given by fifty-three witnesses, mainly the statements given to the police investigator during the police investigation and the supplementary statements he took between 5 May 2006 and 28 June 2006. He concluded that, taking into account nearly all the witness statements and the forensic report, Mr Nicolaou had been distant, reserved, solitary and pious, had not had any major problems and had committed suicide during his overnight leave. Y.I. proposed that, in the absence of a criminal offence, the investigation be closed. E. The first inquest before the District Court of Limassol (inquest no. 104/05)
30. An inquest into the deceased’s death took place and on 21 November 2007 the coroner found that there was no evidence to indicate any criminal liability on the part of a third party for the deceased’s death. The cause of death was the injuries sustained from a fall from a height. Her finding was that the death had occurred under conditions resembling suicide. 31. On 6 December 2007 the President of Limassol District Court affirmed this finding. F. Forensic opinions by private experts
1. The forensic opinion produced by Dr O.P. 32. After the finding of the first inquest, the first applicant asked a private forensic pathologist and sociologist practising in Greece, Dr O.P., for a second opinion as to the causes of her son’s death. 33. In his report dated 8 February 2008, O.P. criticised a number of aspects of the first post-mortem examination. He noted the following, inter alia:
–  no toxicological analysis of the stomach content had been conducted because the vial holding the content of the stomach had, for unspecified reasons, not been sealed.
–  P.S. had failed to enquire into: the position of the body on site; the fact that the deceased’s wristwatch had been found behind the body with the watch strap detached by a missing spring; and into the bruising on the deceased’s wrists and thumb which, inter alia, were signs that his hands had been held behind his back
–  the fact that the cereals Mr Nicolaou had eaten (according to his mother at 6.30 a.m. the morning of his death) had only been half-digested, was incompatible scientifically when considering the time it takes for cadaveric hypostases to start to show and rigor mortis to set in.
–  on the post-mortem photographs the right ankle joint was hidden by the left one and there had been blood on the table in the direction of the right foot. 34. O.P. also explained that the fractures sustained by the body could have been caused by repeated fierce punches or blows with a blunt instrument. He considered that the possibility that the deceased had committed suicide was completely unfounded and that the injuries he had sustained had been inflicted intentionally. In his view, Mr Nicolaou had been tortured. He had then lost consciousness from the blows which he had received and had gone into a fatal coma. P.S.’s conclusion that the fatal injuries sustained “can also result from a fall from a height” (see paragraph 18 above), left open the possibility that there might be other causes of death. 35. O.P. concluded that the post-mortem examination had been flawed and had reached unjustifiable conclusions. The findings of the post-mortem examination could not be considered as specialised (μη ειδικά) given the absence of all the main macroscopic features (τα κύρια μακροσκοπικά στοιχεία ελλείπουν). 2. The forensic opinion produced by Dr P.K. 36. At around the time the first applicant had sought the opinion of O.P. (see paragraph 32 above), she had also requested the forensic opinion of Dr P.K., a forensic pathologist and the head of the Forensic Medical Service of Athens. In his report dated 11 February 2008 P.K. observed, inter alia, the absence of: DNA testing of the glasses, wallet and finger nails, laboratory testing of the stomach content and the vomit found next to the body, histological exams on the intestines and evaluation of the blood found under the bridge. 37. P.K. concluded that various factors in the case were not compatible and detracted from the hypothesis of a fall from 30 metres; the complete absence of even any minor external injuries on the whole body or of any skeletal and intestinal injuries, characteristic of a fall from a height, the position of Mr Nicolaou’s body, the presence of sand and possibly water in his oral cavity, the fact that he had bitten his tongue, the presence of sand on his face and other parts of his body, the fact that his clothes were wet, his spectacle lenses had not been broken and that the frame had not been deformed, as well as the position in which the wallet had been found. He noted that P.S.’s report did not rule out the possibility that Mr Nicolaou’s internal injuries had been caused by an event other than a fall. G. The family’s legal challenge to the first inquest
38. Having obtained O.P.’s and P.K.’s opinions, the first applicant submitted a request to the Attorney General for the case to be re-opened; however, the request was denied on the grounds that the fresh forensic reports had produced no new evidence. 39. The first applicant then applied to the Supreme Court for certiorari (application no. 51/2008) on the grounds that the coroner had exceeded her powers as no evidence had been adduced at the inquest to prove that the death had been a result of suicide. 40. On 31 December 2008 the Supreme Court quashed the coroner’s verdict and ordered a second inquest before a different coroner. It observed, inter alia, that for a coroner to reach a finding of suicide there had to be evidence that the deceased had wanted to kill himself. The coroner had not stated which parts of the evidence ruled out the possibility that death was caused by something other than suicide, for instance, a criminal act or accident. This would have indicated, if not beyond reasonable doubt then at least to a high degree of certainty, that it had been a case of suicide. The coroner had not held that it had been suicide, but that it looked like suicide which conclusion she was not empowered to reach. If, on the basis of the evidence, she had not been satisfied that it had been suicide, she could have reached an “open verdict”. H. The second inquest
41. The second inquest was conducted before another coroner at the District Court of Limassol between 5 May 2009 and 5 October 2009. Mr Nicolaou’s family relied on O.P.’s report and his findings therein. They argued that the investigation conducted by the police and P.S. had been substandard and that the police, influenced by the view taken by P.S. quickly drew the conclusion that Mr Nicolaou had killed himself. In their application for DNA tests on certain of the evidence, the police had recorded “Unnatural death –Suicide”. They further argued that the police had failed to collect DNA samples from the deceased’s car and personal belongings and that they had delayed in testing the blood later found at the scene. 1. The evidence at the second inquest
42. Five witnesses testified at the second inquest: two members of the LPS, a chemist from the State General Laboratory and P.S. were summoned by the police and cross-examined by the applicants’ lawyer. O.P. was also summoned by the applicants. 43. A member of the LPS testified that no evidence had been found showing the movements of the deceased prior to his death. The police investigation had been oriented towards an ordinary case of unnatural death, because P.S. had ruled out the possibility of criminal activity while on the scene. For this reason, no DNA tests had been obtained from the deceased’s car. 44. The chemist from the State General Laboratory explained, inter alia, the content of the stomach had not been examined because under the laboratory’s methods of alcohol and drug testing, priority was given to blood, urine and vitreous fluid samples. She confirmed that the vial containing samples of the gastric fluid had not been sealed by the police and that this was an irregularity. The chemist explained that testing the stomach content could have established the time of death and whether the body had been moved. 45. P.S. testified that, taking into consideration the body’s position and the other findings, there had been a strong possibility that the deceased had fallen from the bridge. With reference to the glasses and the watch, there was a strong possibility that the glasses had been separated from the body during the fall and it was possible that the watch had been cut from the strap when the hand bearing it hit the ground. The possibility of the body having been moved to the site from another area could be ruled out owing to cadaveric hypostases found on the surface of the deceased’s back; had the body been moved, these hypostases would have been different. It was also unlikely that the deceased’s blood could have remained in the area for days after the incident. He denied, however, stating on the scene that the cause of death had been suicide. 46. With reference to the stomach content, he explained that he had requested toxicological examinations, but the laboratory had failed to carry them out. In any event, given the results from the other tests (blood, urine and vitreous fluid) they would not have added anything new. Similarly the injuries to the intestines could be explained without such a histological examination. 47. P.S. also pointed out that most of the indications pointed to the conclusion that Mr Nicolaou had not been subjected to violence as there were no injuries or bruises on the soft tissues of the head
48. O.P. supported the submissions of the family and was adamant that the injuries found on the deceased’s body had not been the result of a fall from a bridge, but intentional and the result of pre-meditated crime. Had the body fallen from a height of thirty metres, the speed would have been so great that there would have been a variety of external injuries. 2. The verdict at the second inquest
49. In his verdict of 19 October 2009 the second coroner focused on the testimonies of the two forensic pathologists, P.S. and O.P.: the other evidence was not important enough to strengthen or weaken the position of either side. He concluded that there was insufficient evidence to satisfy him –  to the degree required in such proceedings – that the death of the deceased had been the result of suicide or of a criminal act. The coroner gave his verdict in the following terms:
“The testimonies, the evidence and generally all the data provided can only lead the court to one safe conclusion and this is my finding, namely that the deceased’s death is the result of injuries caused by falling from a height.”
50. On 25 November 2009 the Attorney General decided that, having received the verdict of the second coroner, he was satisfied that there were no grounds for bringing criminal proceedings. I. Additional reports by private experts
1. Criminological report produced by D.G. 51. The applicants sought the opinion of the criminologist D.G, practising in Athens. In his report of 30 April 2009. D.G. questioned P.S.’s findings and, inter alia, as O.P. and/or P.K, the positioning of the body, of the wrist watch and the marks on the deceased’s hands which arguably pointed to the involvement of third persons in his death. As did the abovementioned experts, he noted the failure to seal test the stomach contents and the fact that the police had not sealed the bottle, hence tainting the sample. In addition, D.G. considered that the liquid and the sand found in Mr Nicolaou’s oral cavity should have been tested. He also noted that it was unheard of for no injury to have been caused to the soft tissue on the scalp following a fall from such a height and a supine collision. 52. In conclusion, D.G. excluded the possibility of suicide and considered that it was possible that (an) other person(s) had been involved in Mr Nicolaou’s death. He also observed that there had been serious omissions in the investigation and collection of evidence in the case, both by the police as well as the forensic services. 2. Medical report produced by M.G. 53. The applicants also requested Mr M.G., a consultant in Accident and Emergency Medicine at the University College of London Hospitals, to compile a forensic medical report providing an opinion as to whether Mr Nicolaou’s injuries had been compatible with a fall from the said bridge. 54. In his report of 11 February 2010 M.G. noted that the deceased’s internal injuries did not match the external appearance of the body. He concluded, inter alia, as follows:              
“In conclusion this tragic case is medico-legally bizarre in, that the ‘figures do not add up well’. There are significant internal injuries to show that the body was subjected to a ferocious insult but little evidence of sufficient external trauma as one would have definitely expected to see in a case of a fall from significant height, to justify the distribution and severity of the internal injuries. I strongly believe that other mechanisms of trauma would have been far more likely than a fall from such a height in causing Mr Athanasios Nicolaou’s death. ...”
J. The investigation by the criminal investigators appointed by the Council of Ministers
55. Following persistent efforts by the first applicant who sent letters to various officials requesting a fresh investigation into the cause of death of her son, on 29 March 2011 the Council of Ministers, under Section 4(2) of the Criminal Procedure Law (Cap. 155), appointed two criminal investigators, a lawyer and a former senior police officer, to investigate the circumstances of Mr Nicolaou’s death (Council of Ministers’ decision no. 71.922). The Ministry of Defence, which had submitted the relevant proposal, agreed to conduct the investigation, having considered all the circumstances of the case, the first applicant’s allegations concerning her son’s cause of death and the Attorney General’s observation to the Ministry of Defence that the conduct of the army officers during the period in which Mr Nicolaou had served his military service and particularly at the time preceding his death, was a matter that had not been investigated at the time. 56. The investigation commenced on 9 May 2011. 57. The investigators’ request to the Council of Ministers for the appointment of an independent forensic pathologist was approved (Council of Ministers’ decision no. 73.036), and following a competition Dr M.M. (“M.M.”) was appointed by the Ministry of Defence. 1. The forensic opinion produced by M.M. 58. In his report of 27 April 2012 M.M. forcefully questioned P.S.’s conclusions and criticised the manner in which the police investigation had been carried out. During the investigation he visited the site where the body was found with one of the investigators, and once again with the deceased’s parents. 59. M.M. expressed the view that the forensic inspection at the scene as well as the post-mortem examination and the police investigation had not been of the requisite standard and suffered from numerous shortcomings. He detailed his findings in this respect. 60. With regard to the inspection and the post-mortem examination, he observed, inter alia, as follows:
–  the time of death was estimated by measuring the deceased’s temperature by touching the body, rather than by the use of a thermometer, leading to a misleading and unreliable estimation;
–  it had been clear from a photograph taken at the scene on the day the body was found, that there had not been any cadaveric hypostases on the dorsal surface of deceased’s body, unlike on the photograph taken the next day at the morgue after the body had remained in a supine position overnight. Consequently, the cadaveric hypostases, were at the time either not present or so slight that they did not show up on the photograph. They could not therefore be used to support the finding that the body had not been moved or transferred to the site where it was found;
–  the bridge was in fact thirty, not twenty metres high, and the parapet of the bridge had not been measured by P.S.;
– the fact that the body was found directly under the bridge did not support the view of a voluntary fall but rather the view that Mr Nicolaou had been thrown off the bridge in an unconscious state or already dead or that his body had been placed under the bridge by (a) third person(s) or after an accidental fall. If Mr Nicolaou had jumped off the bridge, his body would have followed a curved trajectory and would have struck the ground some metres away from the vertical side of the bridge.
–  P.S. had failed to spot and evaluate a significant quantity of blood which had been found three metres from the body (see paragraph 20 above). The presence of this blood increased the odds that the body had been moved to that position by a third person or third persons. During the inquest P.S. had been unable to satisfactorily to explain how the blood had been found at that distance from Mr Nicolaou’s body and why Mr Nicolaou had no open wound that could have bled;
–  no photographs had been taken of the alleged fractures to the right wrist, the right knee and right femur which had been noted in P.S.’s report;
–  no tests had been carried out on Mr Nicolaou’s sock, which appeared to have blood on it. 61. Referring to O.P and P.K’s reports, he stated that he was inclined to agree with the serious questions they had raised of the validity of the on-site inspection and of the post-mortem examination by P.S. and his findings. Like O.P. and/or P.K he observed, among other things, the lack of explanation as to Mr Nicolaou’s glasses remaining intact after the fall, the absence of tests on: the fluid and sand in the oral cavity, the stomach fluids and the vomit found next to the body, the finger nails. He also observed the lack of explanation concerning the absence of skeletal and external injuries in light of the fall from a height of thirty metres, and the failure to explain the contusions/bruising on Mr Nicolaou’s left hand which in his view resembled finger marks. He also noted as O.P., from the photographs, the existence of blood on the mortuary table coming from the deceased’s right foot; there was however no mention in P.S.’s report about an injury to that foot and no photograph had been taken. 62. With regard to the police investigation, M.M. noted that after the on‑site inspection and, in particular, the post-mortem examination, the police had treated the case as suicide and the CID had not investigated further, but had left the handling of the case to the local police. The police investigator which had been in charge of the case did not have the required forensic experience to investigate such a case. In his view there had been major oversights in the investigation such as the failure to investigate the disappearance of Mr Nicolaou’s credit card, military overnight leave card and mobile. The police had also failed to cross reference statements given by passers-by with the forensic report as regards the time of the events on the bridge which were crucial in assessing of the time of death. 63. M.M. concluded that the absence of multiple, serious and characteristic skeletal injuries, rendered the findings of the two inquests to the effect that Mr Nicolaou had died after falling from the thirty-metre-high bridge unreliable and unacceptable (επισφαλή και μη αποδεκτή). It was sad but also unjustifiable that the death of Mr Nicolaou had not been subject to the requisite thorough investigation, both in forensic terms and as regards the police involvement, and it was unfortunate that both inquests had failed to identify this fact. M.M.’s professional opinion was that it did not follow from the investigation carried out into Mr Nicolaou’s death that he had died following a fall from a bridge. The only finding that could be reached at an inquest was that the cause of death remained indeterminable and that the possibility of a criminal act had not been ruled out. An exhaustive police investigation was therefore needed, even at this late stage. 2. The steps taken by the investigators and their findings
64. In the course of the investigation, the investigators took statements from sixty-five persons and a number of steps to collect further evidence in the case. In particular, they managed to track down most of the soldiers who had served with Mr Nicolaou; they requested data from the Limassol Water Development Department (WDD), according to which on the day Mr Nicolaou’s body had been found the river had not been flowing; and, in view of the inconsistent references in the police investigation and forensic reports concerning the height of the bridge, they proceeded to measure the bridge themselves, finding that it was actually twenty metres high. 65. The investigators sent Mr Nicolaou’s right sock as an item of clothing which he had been wearing on the day of his death for testing to the Cyprus Institute of Neurology and Genetics (CING), with reservations as to the manner in which they had been stored; Mr Nicolaou’s parents had kept them for all those years. According to the report from CING dated 8 November 2012, the blood on the sock as well as blood on his tracksuit trousers and T-shirt had been that of the deceased. The DNA of three unknown men was found on the external part of one of his socks, on his tracksuit trousers and on the inside of his underwear. The director of the forensic genetics laboratory of CING, in his statement to the criminal investigators, observed that the passage of time had negatively affected the quality of the genetic material and therefore the results of the DNA tests. Similarly, the manner in which objects were stored and handled, if not correct, would also negatively affect the tests. (a)  Findings concerning the first police investigation
66. On 21 December 2012 the investigators submitted a lengthy report on the investigation procedure and their findings as well as the investigation file submitted to the Council of Ministers. 67. In their report they pointed to a number of deficiencies on the part of the police in the investigation of the case from the very outset. According to the police officers’ statements, P.S. had expressed the view at the scene that on the face of it there was nothing to suggest a criminal act and that the cause of death had been suicide. This appeared to have oriented the police investigation towards an ordinary case of unnatural death, and thus the investigation was conducted by an ordinary LPS officer rather than by experienced CCD investigators. The investigators observed that from that moment on the police had committed significant oversights in the investigation; P.S. had also been responsible for some of these shortcomings. In particular, they noted the following:
–  instructions had not been given to immediately cordon off the area where the body was found. This, as mentioned by the police’s fingerprint expert in his statement to the investigators, had led to a contamination of the scene;
–  no DNA samples had been taken from the inside or the outside of the deceased’s car. From the outside, samples should have been taken at least from the door handles as they may have not been wet from the rain;
–  it appeared that no thorough examination had been conducted of the scene where the body had been found, bearing in mind that the deceased’s blood had subsequently been found three metres away from his body. The police’s Criminalistic Service Department (Υπηρεσία Εγκληματολογικών Ερευνών; ΥΠΕΓΕ) should have been called to examine the scene;
–  Mr Nicolaou’s gastric fluid had not been tested. The vial with the gastric fluid had not been sealed, leading to the contamination of this evidence;
–  no samples had been taken for testing (i) the vomit found next to the deceased’s body to ascertain what the deceased had eaten which would have helped determine the time of his death; and (ii) the sand and water found in his mouth in order to determine whether they came from the area or not;
–  no DNA samples had been taken from his glasses, wrist watch, wallet or clothes;
–  no statement had been taken by the police from the WDD to find out whether the river had been flowing the day on which the deceased had been found;
–  statements had not been taken from all of the soldiers serving in Mr Nicolaou’s squadron. The investigators had made great efforts to trace them and take statements, but seven years on they had not been able to find all of them.
–  no effort had been made to find out where Mr Nicolaou had obtained the beers;
–  no request had been made for an official and full recovery of Mr Nicolaou’s mobile telephone data, and no such recovery took place. The investigation in this regard had been confined to an unofficial record (κατάσταση) of incoming and outgoing calls without the names of the persons associated with the numbers. As these records were only retained for six months by the Cyprus Telecommunication Authority it was no longer possible for the investigators to trace the calls. 68. The investigators noted that the omissions and shortcomings in the police investigation had rendered their investigation extremely difficult. The principal errors in the case had been made by the police, and these had resulted in a deficient investigation and the unquestioning adoption of P.S.’s position. Had these errors not been made the outcome of the case might have been different. 69. The investigators stated that they would have expected experienced police officers to be puzzled by the intact state of Mr Nicolaou’s body, which, according to P.S., had fallen from such a high bridge. This fact should have set them thinking. 70. Lastly, they referred to M.M’s comments on the police investigation and agreed with his standpoint (see paragraph 60 above). (b)  Conclusions
71. The investigators expressed regret for the delay in their investigation and stated that this was due to difficulties they had faced and the procedures that had to be followed in order to appoint an independent forensic pathologist. 72. In their report they relied mainly on the opinion given by M.M., who had been appointed as an independent forensic pathologist, because they found that his report had been complete, reasoned and rational. They too excluded the possibility that Mr Nicolaou’s cause of death had been the fall from a height, and specifically from the bridge. This was primarily because of the absence of skeletal injuries, that is, external injuries on his body. However, in reaching this conclusion they also attached importance to the fact that his wrist watch had been found under his body, his glasses had been intact and there was sand and water in his oral cavity (whereas he had been found in a supine position), in conjunction with the fact that the river had not been flowing on the day of his death, indicating that the “presence of the sand” had stemmed from another area at another time. 73. In so far as it could be argued that the absence of external injuries had been due to the consistency of the soil near the riverbed, this was contradicted by the views of O.P, P.K. and M.M., but also by the on-site inspection which the investigators had carried out. The investigators adopted O.P.’s position, which had also been taken by M.M., that because the soil was a mixture of sand and stones, there should have been external injuries. Further, they considered that if the soil had been soft there would have been a pothole (“λακκούβα”) where Mr Nicolaou had fallen. 74. In their view, P.S.’s stance and his statements during the inquest proceedings had been unsatisfactory and/or unconvincing. and Mr Nicolaou’s body temperature could only have decreased with the passage of time. 75. The investigators stated that they believed that Mr Nicolaou had not been enjoying his army service. At the same time, they did not consider that the circumstances had been as unbearable or nightmarish as his mother described them. There certainly had been buffoonery, immature teasing, joking and annoying behaviour during resting times, and instances of disorderly behaviour and anarchy which had been brought about by the lax atmosphere that prevailed in his squadron. This atmosphere had been, in general, incompatible with his polite, rule-abiding and serious personality. There had been no systematic ill-treatment, physical or psychological. Nor was there evidence that I.D. or any of the soldiers had ill-treated Mr Nicolaou at any time or, apart from the one incident between I.D. and Mr Nicolaou, had had an argument with him. 76. It was a fact that in his last two or three days Mr Nicolaou had been troubled and nervous, but he had not spoken about this to anyone, even in general terms, as he had done in the past about issues that bothered him. The investigators considered that they could not find any responsibility on the part of his superiors who had tried to help him adapt and had intervened following the incident with I.D. They found that the first applicant’s allegations and accusations in this respect were unfounded and contradictory. They also found that there had been contradictions in the first applicant’s statements and claims as to the alleged murder of her son by soldiers from his squadron. 77. They concluded as follows:
“... this case was the subject of a thorough and deep investigation with the aim of finding out the real cause of the death of the soldier, Athanasios Nicolaou. It is a fact that we have been unable to find evidence indicating the exact cause of death, that is to say whether it was the result of a criminal act, an accident or suicide. There is, however, sufficient evidence, mostly scientific, provided by five experts, and evidence which we characterise as circumstantial, which overturns the verdict of the second inquest and the opinion of Dr P. S., as recorded during the inquest proceedings, that Athanasios Nicolaou’s death was the result of injuries caused by falling from a height. At the same time, it is our personal view that quite possibly the death was the result of a criminal act, although we cannot be certain about that. We do not have any cogent evidence as to the motive or suspect(s) in this case. We propose, however, that the case be re-examined by the police on the basis of new evidence (δεδομένων) and [we suggest] an investigation along the lines that Athanasios Nicolaou’s death could possibly be the result of a criminal act.”
(c)  Further steps and the investigators’ supplementary report
78. On 24 February 2014, following a decision by the Council of Ministers (Council of Ministers’ decision no. 75.110), the criminal investigators submitted a supplementary report. In this they adopted their conclusions in their previous report. It does not appear that they took any further steps. They noted that the case file had been given to them six years after the event and despite a thorough investigation they had been unable to find evidence shedding light on the real cause of Mr Nicolaou’s death. They repeated that they adopted in particular the findings of M.M. and P.K., and reiterated their suggestion that the case be re-examined by the police, as they considered that a police questioning of witnesses might produce more information, some of the witnesses having been reluctant to talk to them. (d)  The Attorney General’s decision following the supplementary report
79. On 8 April 2014 the Attorney General decided that given the passage of nine years, the police, just like the investigators, would not be able to secure evidence indicating the real cause of death. Accordingly, a fresh investigation by the police was not warranted. 80. On 23 April 2014 the Council of Ministers decided to give a copy of the whole investigation file, including the investigators’ report, to the deceased’s parents and to provide them financial support for the purposes of further investigating the causes of their son’s death, should they request such support (Council of Ministers’ decision of 23 April 2014, no. 76.781). K. The second police investigation
1. Further steps ordered by the Attorney General
81. On 3 November 2014 the Attorney General reviewed the decision referred to in paragraph 79 above and instructed the Chief of Police to investigate the case further in order to ascertain the real causes of death of Mr Nicolaou. Having regard to the long lapse of time, the admittedly significant omissions on the part of the police during the initial investigation which could no longer be offset, and the failure of the criminal investigators to reach a conclusion, the Attorney General questioned whether a further investigation by the police could achieve any substantive outcome. Nevertheless, observing, that the right to life entailed an obligation on the part of the Republic to take all necessary steps to establish the real causes of death of every person, he considered that the State should pursue all possible and available means for the purposes of establishing the cause of Mr Nicolaou’s death. 2. The second police investigation
(a)  The fresh investigative steps taken by the police
82. On 19 February 2015, in accordance with the Attorney General’s instructions, a police lieutenant from the Limassol CCD was appointed to reinvestigate the case. However, following vigorous complaints from the first applicant questioning the independence and objectivity of the Limassol police officers, Constable D.S (“D.S.) from the CCD at the Nicosia HQ took over the investigation. 83. D.S took statements and/or supplementary statements from, inter alia, the first and fourth applicants, soldiers from Mr Nicolaou’s squadron and military personnel. She also spoke to M.M. who clarified certain points in his report and answered questions put to him. 84. DNA samples were taken from two soldiers, including I.D., and were tested by the CING. The relevant report of 23 July 2015 stated that their DNA did not match that of the three unknown men that had been found on Mr Nicolaou’s clothes (see paragraph 65 above). In this connection, she noted that in September 2012 it was Mr Nicolaou’s parents who had taken his clothes and underwear to CING for DNA testing (see paragraph 65 above) in spite all the risks this involved bearing in mind how and where the clothes had been stored and the fact that they had been tainted by numerous other persons who had handled or touched the body after it had been found. 85. Although the possibility of testing Mr. Nicolaou’s clothes was also considered, this was not done as the first applicant had insisted on taking the clothes to the laboratory herself, which was not permissible since the case was under police investigation. 86. On 8 November 2016, following a meeting at the Attorney General’s office, a forensic pathologist was appointed, Dr S.S. He was invited to deal with thirty-three specific questions that had arisen following the examination of the post-mortem report and the various opinions given in the case. (b)  The opinion produced by S.S. 87. In his report of 10 March 2017 S.S. dealt with the questions put to him and set out his conclusions. He observed, inter alia, the following:
–  there had been cadaveric hypostases on Mr Nicolaou’s body at the time of the post-mortem examination, contrary to what some of the forensic opinions had stated; he agreed with P.S’s findings on the matter;
–  although it would have been better if the police had measured the height of the bridge during the inspection of the scene, the difference in the bridge measurement did not make a significant difference as in any event the fall had been from a significant height and the injuries caused, in his view, would have been more or less the same;
–  there were no injuries which indicated that violence had been used, or bodily harm, for example from strangulation or shooting, as a possible cause of death;
–  if Mr Nicolaou had been wearing his glasses at the time, they could have remained on his face until he hit the ground and then fallen off, which would explain why they had not been broken. If the wrist watch had been in his right pocket at the time, this could explain where it had been found;
–  on the basis of P.S.’s reports and the photographs on file, he considered that Mr Nicolaou’s face had not touched the ground. He had hit the ground with the right side of his body, which was why his injuries had been on that side;
–  there had been no point in examining Mr Nicolaou’s fingernails as there had been no indication on his body of injuries caused by a fight or him resisting;
–  S.S. disagreed with M.M.’s view that the contusions and bruising present on Mr Nicolaou’s left hand resembled finger marks: they were multiple small contusions of different diameters which might have been caused when his hand hit the ground; whence the fracture;
–  testing the vomit found would not have added anything of substance, given that body fluids had been sent for testing to locate any possible substances and there had been a thorough inspection of the site and the existing conditions. Nor did he consider that testing the stomach content would have shed more light on the time of death. In order to determine the time of death a number of other factors had to be taken into account such as the existence of cadaveric hypostases, rigor mortis, body temperature and the temperature of the environment. But even these factors were not decisive;
–  there could have been a brain oedema, pervasive epidural and subarachnoid brain haemorrhage without an external injury on the head. The existence of oedema had been due to the fact that death had not been immediate. Pervasive epidural and subarachnoid brain haemorrhage could be caused by a sudden displacement of the head, more specifically the skull, or by a sudden violent movement of the head;
–  in view of the brain oedema and the fact that there had been remains of food in the trachea, he considered that Mr Nicolaou had not died instantly. He agreed with P.S. on this matter. It was not possible, however, to determine whether Mr Nicolaou had made any movements at all before dying. He could not therefore exclude that Mr Nicolaou had been alive for a certain amount of time before his death;
–  he considered that if there had been wounds on Mr Nicolaou’s lower limbs, these would have been noted by P.S., as the latter had done with all other injuries. It was not possible to say whether the blood on the mortuary table was that of Mr Nicolaou or if it had remained there after a post‑mortem conducted on another person;
–  S.S. disagreed with P.K’s and M.G’s positions: in his view there were no specific positions a body would take up after falling from a height, and that the characteristics of a fall depended on a number of factors, such as height, the manner of the fall, the ground, the person’s characteristics (weight, height, etc.) and the weather conditions;
–  he observed that P.K. had not taken into account the skeletal injuries referred to in P.S.’s report;
–  if Mr Nicolaou had received blows as described by O.P. he would have had external bruising on his body or internal haemorrhagic infiltration (αιμορραγικές διηθήσεις εσωτερικά);
88. In conclusion, S.S. stated that after examining all the evidence before him he considered that Mr Nicolaou’s death had been caused from multiple injuries such as would be caused by a fall from a height. He also referred to and submitted photographs of another incident that had occurred on 21 December 2012, when another person had died after falling from a height on a hard surface but had had no external injuries other than minor abrasions. (c)  The investigator’s findings
89. In her report of 25 June 2018 D.S. made, inter alia, the following observations and findings. 90. She observed that it was clear from all the evidence given that Mr Nicolaou had been introverted, reserved and retiring. During his service he had been taciturn and did not really have any relations with the other soldiers. He was very religious. It was certain from the evidence given by soldiers serving in his squadron, that Mr Nicolaou had been the victim of hazing (καψωνιών), teasing (πειραγμάτων) and mockery (κοροϊδία) by other soldiers due to his age, character, and the facts that he would be serving a reduced military service and that he often took leave. There was also evidence that he had complained to his superiors that he had not been able to adapt to army life and had asked to be transferred to another unit, but this had not happened. By virtue of army order 7-1 of 2012 (subparagraph 6(a) point 5), which applied to army units and concerned the function of the National Guard’s healthcare services, it was one of the duties and obligations of the Commander, in cooperation with the doctor, to identify problematic soldiers and to take all necessary measures to help them adjust to army life. It appeared that in the case of Mr Nicolaou the requisite measures had not been taken. His commanding officer knew of the problems and the Chief of Staff had confined himself to reassuring him and telling him to be patient until he was released from service and to come and see him when he had a problem or felt under pressure. Steps should also have been taken for his transfer. Although no criminal liability could be attributed to these persons, it was possible that disciplinary offences had been committed and should have been investigated by the army authorities. 91. She stated that it was beyond doubt that during the period just before his death Mr Nicolaou had been troubled by the fact that he could not adjust to life at the camp, but was also concerned about whether his period of service would be reduced. It was also possible that he had been troubled by something else but had not spoken to anyone about it. 92. With regard to the opinions submitted by P.K, D.G and M.G, criticising P.S.’s report and findings in particular, she noted that none of these experts had referred to the possible cause of Mr Nicolaou’s death. Although M.G. considered that other mechanisms of trauma would have been far more likely to have caused Mr Nicolaou’s death than a fall, he did not explain what these were (see paragraph 54 above). She pointed to S.S.’s observation that if Mr Nicolaou had received blows as described by O. P. he would have had external bruising on his body or internal haemorrhagic infiltration (see paragraph 87 above). 93. In addition, D.S. observed that it was an undisputed fact that prior to his death Mr Nicolaou had consumed alcohol despite his family’s claims that he never drank alcohol. Only his DNA had been found on the beer cans which indicated that he had drunk the beers alone. 94. She considered that the position where the body was found under the bridge indicated that Mr Nicolaou’s fall had not been due to a malicious act by a third person or persons. In view of the presence of cadaveric hypostases on his body, the possibility that he had been killed in another place and then transferred was overruled. 95. D.S. concluded that on the basis of all the evidence before her it had not been possible to ascertain whether Mr Nicolaou’s death had been due to a deliberate fall or an accident. Although the possibility of a criminal act could not have been ruled out, she emphasised that no evidence had been secured, despite all the efforts made since his death, to support such a criminal act or the responsibility of a third person in relation to his death. The absence of such evidence did not imply a cover-up, or unwillingness, inefficiency and/or indifference on the part of the police authorities or the State in general, as occasionally mentioned by the first applicant. From all the evidence before her, and in accordance with the opinion of S.S., she concluded that Mr Nicolaou had died of multiple injuries caused by a fall. The circumstances in which he had fallen from the bridge could not be determined, and this, in her view, should have been stated in the first inquest. The fact that the assumption had been that Mr Nicolaou had committed suicide had given Mr Nicolaou’s family grounds to contest the inquest. (d)  The Attorney General’s decision
96. In September 2018, after examining the file, the Attorney General decided that even though all the leads and possible sources of information that were available for ascertaining the circumstances of Mr Nicolaou’s death had been exhaustively pursued, it had proved impossible to secure evidence indicating that his death had been the result of a criminal act. 97. On 15 November 2018 the Attorney General forwarded D.S.’s report to the Chief of the National Guard and to the Permanent Secretary of the Ministry of Defence. He informed them that D.S. had concluded that Mr Nicolaou had been the victim of hazing, teasing and mockery by his fellow soldiers and that his superiors had known about this. Although there was no evidence of any criminal acts, he urged them to establish a system of effective monitoring and identification of such practices within the army for the purposes of eliminating them and, if necessary, intervening and punishing those responsible. L. Further developments: civil proceedings brought by the applicants against the Republic
98. On 2 September 2016 the applicants brought a civil action against the Republic before the Nicosia District Court (no. 4142/16) for, inter alia, a declaratory judgment that the competent State authorities had failed to protect Mr Nicolaou’s life and to effectively investigate his death and claiming general, special and punitive damages. These proceedings are still pending. An application by summons by the applicants during these proceedings for an order to compel the Attorney General and the police to expedite and complete the fresh investigation (see paragraph 81 above) was dismissed by the court on procedural grounds. II. RELEVANT DOMESTIC LAW AND PRACTICE: THE DOMESTIC INQUEST SYSTEM
99. The holding of inquests in Cyprus is governed principally by the Coroners Law 1959 (Cap. 153) as amended by Amending Laws 171(I)/2011 and 13(I)/2017. An inquest has an investigative character and there are no parties involved in the procedure (re: certiorari application by Andreas Epiphaniou concerning the verdict in inquest 33/2004 - judgment of the Supreme Court of 25 October 2010 in civil appeal 237/2009, (2010)1 C.L.R. 1682). Every interested party may either appear in person or be represented by counsel in the proceedings and may examine, cross‑examine or re-examine, as the case may be, any witness (section 14; see also Andreas Epiphaniou, cited above). 100. It is no part of a coroner’s task to assess criminal or civil liability. A coroner has no authority to assign charges and commit a person for trial, as under Article 113 of the Constitution of Cyprus, powers of prosecution are vested solely in the Attorney General (Republic v. Pandelides (Coroner), ex parte Costas Papadopoulos (1969) 1 C.L.R. 27). 101. Section 25 of the 1959 Law provides that, following the viewing, if any, of the body and the hearing of evidence, the coroner shall give his or her verdict and certify it in writing, showing, in so far as such particulars have been proved to him, who the deceased was, and how, when and where he came by his death. Under section 26, if at the close of the inquest the coroner is of the opinion that there are grounds for suspecting that some person is guilty of an offence in respect of the matter inquired into, but cannot ascertain who such person is, he shall certify his opinion to that effect and transmit a copy of the proceedings to the police officer in charge of the district in which the inquest is held. 102. Where the President of the District Court is not satisfied as to the accuracy, legality or propriety of any finding or verdict he may, after affording the Attorney General an opportunity to be heard, exercise any of the powers vested in him by section 30, namely, in sum, to order the holding or re-opening of an inquest or to quash an inquest or verdict. 103. The lawfulness of the procedure of an inquest and the findings of a Coroner are subject to review by the Supreme Court by way of the prerogative writ of certiorari. An order of certiorari is corrective in nature (Andreas Epiphaniou, cited above).

Article of the Convention at issue: Article 2
Outcome: violation