The High Council for Human Rights of The Islamic Republic of Iran
(18 October 2022)
In the implementation of paragraph (7) of Article 45 of the Internal Bylaw of the Islamic Consultative Assembly (Parliament) of the Islamic Republic of Iran and following an order issued by the Speaker of the Assembly dated 16 September 2022 appertaining to investigations into the death of Mahsa Amini on the same date in Kasra Hospital, the Internal and Councils Affairs Commission of the Parliament – in addition to forming a special committee by inviting relevant officials from the Greater Tehran Police Command, Public Security Police, the Law Enforcement Command of the Islamic Republic of Iran and the Inspectorate thereof, the Legal Forensic Organization and Tehran Emergency Center – thoroughly examined the incident, and presented the following report after hearing the explanations and receiving written reports from all relevant bodies:
- a) Report of the Greater Tehran Police Command (subject of letter No. 1716/04/7/06/1401 dated 17 September 2022)
At 18:30 on Tuesday, 13 September 2022, Mahsa Amini and the accompanying family members (two of her cousinesses and brother) were directed by the Public Security Police towards the police van, which was stationed in Sarv Street in front of Taleghani Park, due to the females’ attire. The attire of the two cousinesses was corrected at the same place, and they were subsequently discharged. However, the foregoing person and six other individuals were transferred to a conference hall belonging to the Department of Social Affairs and Education for Women in the Public Security Police. At 19:56, she suddenly experienced a loss of consciousness, after which the medical assistant stationed in the Public Security Police immediately rushed to her. The emergency personnel also went to the conference hall after only a few minutes. The resuscitation operation began, and she was successfully resuscitated. Given the clinical condition of the abovenamed, she was immediately transferred to the nearest hospital with an equipped ICU (Kasra Hospital, which is 500 meters away from the Public Security Police) by an emergency ambulance and in coordination with the Tehran Emergency Control Center.
- b) Report of Emergency Medical Services
At 19:25 on 13 September 2022, the Morality Security Police called Emergency Medical Services via 115 and reported a case of dyspnea in a 35-year-old man with a history of asthma. A motorlance arrived at the patient’s bedside at 19:34 and decided to send him to the hospital after taking initial measures. The ambulance was dispatching the sick man to the hospital when 115 received a report at around 19:58 sent from a building in front of the dispatching location about Mahsa Amini’s decreased level of consciousness. Therefore, emergency medical technicians visited the aforesaid, and considering the initial examinations, deterioration of the general health condition and lack of vital signs, they immediately performed cardiopulmonary resuscitation and intubation of the respiratory tract, set up a peripheral vein for injection and performed CPR and cardioversion.
- c) Report of Kasra Hospital (medical file No. 22-90-26/40111959 dated 14 September 2022)
Mahsa Amini, 22, was transferred to the emergency room at Kasra Hospital by the Emergency Medical Services at 20:30 on 13 September 2022. The initial assessment reads: “The patient had no vital signs on arrival. She was intubated with double mydriasis. A resuscitation operation was performed immediately, and because it proved effective, the patient was transferred to the ICU.” In the ICU, the patient had a systolic pressure of 80 to 110 and a heart rate of 130 with the help of inotrope and norepinephrine. The patient’s level of consciousness stood at 3 from the very beginning of arrival at the hospital. About three hours after the referral, the patient was resuscitated due to cardiac arrest (asystole), which proved fruitful.
It is necessary to mention that the patient’s medical record shows that back in 2007, she had brain surgery in Milad Hospital due to craniopharyngioma. In addition, the foregoing person was receiving desmopressin, hydrocortisone and levothyroxine pharmaceuticals due to diabetes mellitus and hypothyroidism.
Moreover, according to the assessments made by Kasra Hospital 24 hours after hospitalization: “EF=20% was detected in the initial echo performed on the night of hospitalization, and the cardiologist suggested dilated cardiomyopathy heart failure. The brain CT scan shows evidence of a lack of oxygen and blood flow to the brain (cerebral ischemia), but there is no evidence in favor of skull fracture or intracerebral hemorrhage. The traces of a skin cut (scars) caused by brain surgery in childhood can be seen on the right side of the forehead. The drug test results were negative. The physical examination of the head, neck, chest and trunk detected no evidence of trauma.”
The 13 December 2022 cardiovascular consultation reported moderate left ventricular dilatation with severe dysfunction, moderate to severe right ventricular dilatation with mild tricuspid as well as mitral valve insufficiency. During hospitalization, the patient received phenytoin due to myoclonus seizures, as recommended by a neurologist. It was also recommended to continue using phenytoin due to diffuse cerebral edema following consultations with the neurosurgeon.
In the CT scan of the lung, asbestosis (consolidation) of the left lung was reported.
The CT scan of the brain performed on the second day was reported by the radiologist to be completely normal, and there was no evidence of bleeding, skull fracture, or even ischemia.
Based upon consultations provided by infectious disease specialists, given the asbestosis of the left lung, pneumonia caused by aspiration or lung bleeding was reported, for which the administration of intravenous antibiotics began.
During nearly 62 hours of hospitalization, the patient’s creatinine gradually increased from 1.1 to 3.5 and 4.7 on the first, second and third days, respectively. For the same reason and considering the presence of acidosis, the patient underwent dialysis, and a Shaldon femoral was implemented for her, as recommended during consultations with the nephrologist. Prior to dialysis, she died at 14:35 on 16 September 2022.
- d) Report of the Legal Medicine Organization (subject of letter No. 114407 dated 15 October 2022)
A brief description of the report on the cause of the death of Mahsa Amini presented to the judicial authority – which has been compiled based upon the hospital record of craniopharyngioma surgery at Milad Hospital in 2007, the medical record of Kasra Hospital at the time leading up to her death, description of the physical examination of the body and autopsy, results of toxicology and pathology tests, judicial investigations and numerous specialized and sub-specialized expert committees – is hereby announced as follows:
After undergoing craniopharyngioma surgery to remove a brain tumor at the age of 8, the deceased developed a disorder in the important hypothalamus-pituitary axis and the glands under its’ command, including in the adrenal and thyroid. Due to this underlying disease, the deceased was treated with hydrocortisone, levothyroxine and desmopressin.
On 13 September 2022, at 19:56, she suddenly lost consciousness and subsequently fell to the ground. Given the underlying disease, the deceased did not have the necessary ability to cope with and get a hold of the situation; therefore, she developed a disorder in her heart rhythm and suffered from decreased blood pressure and subsequently a reduced level of consciousness. A cardio-respiratory resuscitation operation proved ineffective, and in the first critical minutes, she suffered from severe hypoxia and brain damage as a result. Notwithstanding the re-commencement of heart function following the resuscitation operation conducted by the emergency room personnel, the respiratory support proved ineffective. Despite her transfer to the hospital and efforts invested by the medical staff of Kasra Hospital, the patient was pronounced dead on 16 September 2022 due to multiple organ failure caused by cerebral hypoxia.
It should be noted that on the strength of hospital medical documents, the examination of CT scan of the brain and lungs, the results of physical examination of the body and autopsy as well as pathology tests, death was not caused by blows to the head or any vital organs and parts of the body.
- e) Statements Released by the Bereaved Family
Despite repeated invitations extended and numerous phone calls made by the Internal and Councils Affairs Commission and some honorable members of the Parliament to the family of the late Mahsa Amini to attend the said Commission, the bereaved family has insisted on following up through judicial authorities.
The Internal and Councils Affairs Commission, while expressing its’ sympathy with the family of the deceased and regret for the incident, offers its’ condolences to the grieving family.
According to the merits of the case, written announcements made by the relevant bodies, explanations of the relevant officials, full review of the footage recorded by CCTV cameras of the Public Security Police, minutes of the local examination and field investigations conducted by the Special Inspectorate of the Greater Tehran Police Command, statements produced by those present on the stage and in the conference hall of the Department of Social Affairs and Education for Women in the Public Security Police, several citizens, businesses and drivers of passenger cars located in the aforesaid place, examination of evidence and documents, the points enumerated hereinunder are presented for the awareness of the honorable people of Iran and esteemed members of the Parliament:
1) There has been no assault or physical attack during the dealing with, transfer to and stationing of the deceased in the Public Security Police Headquarters. According to the report of the Legal Forensic Organization (which has been prepared based upon hospital records, physical examination, autopsy, sampling, and specialized tests), it is declared that the death of the foregoing person has not been caused due to physical contact, beating or any blows to her body.
Based on this, those who made hasty and bogus statements without any investigations and before different dimensions of the matter had not even come to light, hurt public sentiments and laid the foundations for the abuse of the incident by enemies of the Establishment, the United States, the usurping and illegitimate Zionist regime and their followers as well as the rioters, shall either rectify their statements or be prosecuted according to the faults they committed.
2) Given the medical measures implemented for the foregoing person from the very first moment of the incident to the time of the death in the hospital, no negligence or fault has been observed on the part of the Emergency Medical Services and Kasra Hospital.
3) There are two critical points to take into account from a medical point of view when it comes to the period between the very beginning of the occurrence of the accident and the arrival of the foregoing person to the hospital:
- The level and quality of the effectiveness of treatment measures performed between the time of the accident (her falling to the ground) and the arrival of one of the emergency personnel at her bedside (all of them taking place in 10 minutes and 7 seconds) should be taken into consideration; and
- The time spent to remove the existing obstacles to the movement of the ambulance due to the crowding in front of the exit door of the Public Security Police building for dispatching the person in question to the hospital (which took 6 minutes and 44 seconds in total) impacted her treatment process.
While announcing the importance and irreplaceable role of the Law Enforcement Command of the Islamic Republic of Iran in providing the security of the society and emphasizing the continuation of the implementation of legal duties thereof in the field of social security, the Internal and Councils Affairs Commission notes the followings:
1) The timely and accurate notification of the Law Enforcement Command of the Islamic Republic of Iran about the details of the incident in question would have better shed light on the matter and enlightened public opinion, thereby reducing the scope of rumors, the enemy media outlets’ weaving of fabricated and unreliable narratives and minimizing the chance of exploitation thereof. Certainly, persuasion of public opinion and, if necessary, apologizing to people for any possible failures, which is one of the good Islamic traditions, would reduce the bitter social consequences.
2) It is necessary to pay particular attention to providing employees and officers with training for confronting and directing the defendants; and, the modus operandi and supervision of implementation thereof shall also undergo revision. Human error is possible, but it should be minimized through training, monitoring and modifying processes and structures.
3) Equipping the Public Security Police with facilities and requirements needed to perform legal duties thereof and missions assigned thereto, such as body cameras or dashcams for patrol cars, is considered – by virtue of Article 44 of the Code of Criminal Procedure – one of the legal necessities.
4) In order to facilitate and observe chastity and hijab, social excellence, and strengthen the health and foundation of the family, defining and determining the limits of Islamic hijab – as per the note to Article 683 of the Islamic Penal Code – as well as explaining and clarifying the ambiguous concepts pertaining thereto, is considered to be one of the requisite measures. According to the legal procedure and in order to comply with the principle of “separation of powers”, it is necessary to prepare an amendment bill by the Judiciary and submit it to the Parliament through the Administration, and the Parliament shall prioritize the adoption thereof.
5) It should also be emphasized that the most essential method of promoting and enjoining “hijab and chastity”, in addition to the implementation of laws and regulations by the law enforcement forces, is through cataphatic approaches and demanding from the responsible bodies that – according to the enactments of the Supreme Council of the Cultural Revolution – have clear duties in this field and suffer from many shortcomings, which should be put on the agenda by the aforesaid Council as well as the General Culture Council. The supervision by the Education, Research and Technology Commission of the Islamic Consultative Assembly as well as the Social Commission is recommended in this regard.
6) The structure, methods and executive processes of safeguarding social and public security need to be reviewed and amended, which must be followed by continuous meetings with the presence of all legal bodies of the social security promotion plan. The Internal and Councils Affairs Commission of the Parliament will seriously follow up on this matter.