Medical experts in the report identified numerous incidents of substandard care, including failure to follow up on symptoms that required attention.

While it is CIVIC’s “ultimate goal” to end immigration detention, both CIVIC and HRW make a series of recommendations in the report, including ways to reform the monitoring system and the medical care contracting process as well as increase transparency of detention operations.

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“Dangerous and substandard medical care” are the primary reasons for in-custody deaths in immigration detention centers, according to a new report from Human Rights Watch (HRW) and Community Initiatives for Visiting Immigrants in Confinement (CIVIC).

When people die in detention centers, the report revealed, it is often because of systemic failures in the form of unreasonable delays in care and unqualified medical staff. Medical experts in the report identified numerous incidents of substandard care, including failure to follow up on symptoms that required attention; medical personnel apparently practicing beyond the scope of their licenses and expertise; severely inadequate mental health care; the misuse of solitary confinement for people with mental health conditions; and sluggish emergency responses.

“The data reveals that people in immigration detention died needlessly under the Obama administration, even with its attempts at reform,” Grace Meng, senior U.S. researcher at HRW, said in a press release. “The Trump administration has already announced its intent to roll back key reforms while detaining even more immigrants, which would likely mean more people will die needless and preventable deaths.”

HRW provided a summary of its findings to Immigration and Customs Enforcement (ICE). The agency has not responded.

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The report, “Systemic Indifference: Dangerous & Substandard Medical Care in Immigration Detention,” is based on independent medical experts’ analyses of records from ICE’s investigations into 18 deaths in detention from 2012 to 2015 and the medical records of 12 people from ten privately and publicly operated facilities across the country. HRW interviewed more than 90 people who are or were detained, as well as family members, attorneys, immigration advocates, and correctional health experts, according to the report.

The 18 death reviews based on ICE records cover deaths at 13 facilities. Those who died included citizens of Mexico, Honduras, El Salvador, Canada, Jamaica, Antigua-Barbuda, Mozambique, and Guatemala. Some were lawful permanent residents and others were undocumented, including at least six refugees. All were between 24 and 50 years old.

The report outlines the stories of people like Manuel Cota-Domingo, a 34-year-old diabetic man who arrived at what is considered one of the nation’s most deadly detention centers—Eloy in Eloy, Arizona—with a bag of medicine for his diabetes, which nurses failed to administer to him.

On the night of December 19, 2012, Cota-Domingo complained he could not breathe and that he was having chest pain. Eight hours passed before facility staff sent him to the emergency room—not in an ambulance, but in a van. Cota-Domingo died as a result of untreated diabetes and pneumonia. Medical experts in the report ruled his death as preventable.

When Santiago Sierra-Sanchez, 38, entered Utah County Jail, he told an intake nurse that for the past six-to-seven months, he’d had worsening lower back pain. Video of Sierra-Sanchez in the intake area shows him unable to stand without assistance. Sierra-Sanchez told ICE officers he was “‘dying’ from the pain in his back.” In reviews, nursing and jail staff reported that Sierra-Sanchez “might be playing games to get narcotic pain medication” and failed to assess him, including the basic task of taking his temperature and other “standard protocols regarding back pain,” according to the report.

Around 8 p.m. on the night he died in July 2014, Sierra-Sanchez told a nurse he was “spitting blood,” but the nurse told ICE there was no evidence of this. At 3:30 a.m., a correctional officer noticed Sierra-Sanchez was unresponsive. Staff did not enter his cell for six minutes and when they did, they found him “in a pool of bloody vomit.”

The correctional officer called for medical assessment, not an emergency, so the registered nurse arrived without emergency equipment, which delayed CPR and the call for emergency medical services. Sierra- Sanchez died that morning of a staph infection and pneumonia. The medical experts who reviewed his case for CIVIC and HRW’s report said “medical staff essentially abandoned” Sierra-Sanchez and his death could have been avoided.

Medical staff at immigration detention facilities often fail at the most basic of protocols.

For example, at the Hudson County Correctional Facility in New Jersey, ICE officials asserted to HRW that registered nurses review requests for care and that everyone is seen “within 24 hours.” This is in opposition to facts outlined in medical records. In one case, a man requested care and indicated he was having abdominal pain so severe, he couldn’t walk. He was seen a month later. In another case of a 2014 in-custody death, an ICE investigation found a licensed vocational nurse attempting to record vital signs four weeks after the fact “from memory.”

Since 2003, 170 people have died in ICE custody, and six in-custody deaths have occurred this year.

The most recent in-custody death happened April 13. Sergio Alonso Lopez was the sixth person to die in ICE custody in 2017, and the second to die this year after being detained at California’s Adelanto Detention Facility.

While it is CIVIC’s “ultimate goal” to end immigration detention, both CIVIC and HRW make a series of recommendations in the report, including ways to reform the monitoring system and the medical care contracting process as well as increase transparency of detention operations. The organizations recommend Congress appoint an Independent Medical Oversight Board to be comprised of medical doctors and advocates at the national level and encourage ICE and its contractors to begin implementing local medical oversight boards at individual detention facilities.

The organizations behind the report assert that the U.S. government “lacks effective means to monitor and correct these problems in facilities under its control.”