Click to expand Image A demonstrator carries a mock coffin, representing migrants who have died, outside the U.S. Immigration and Customs Enforcement detention center in Eloy, Arizona. © 2016 Associated Press

(Washington, DC) – Newly released United States government records summarizing investigations of the deaths of 18 migrants in the custody of US immigration authorities support a conclusion that subpar care contributed to at least seven of the deaths, Human Rights Watch said today.



The death reviews, from mid-2012 to mid-2015, reveal substandard medical care and violations of applicable detention standards. Two independent medical experts consulted by Human Rights Watch concluded that these failures probably contributed to the deaths of 7 of the 18 detainees, while potentially putting many other detainees in danger as well. The records also show evidence of the misuse of isolation for people with mental disabilities, inadequate mental health evaluation and treatment, and broader medical care failures.



“In 2009, the Obama administration promised major immigration detention reforms, including more centralized oversight and improved health care,” said Clara Long, US researcher at Human Rights Watch. “But these death reviews show that system-wide problems remain, including a failure to prevent or fix substandard medical care that literally kills people.”



The death reviews, released by Immigration and Customs Enforcement (ICE) in June 2016, cover 18 of the 31 deaths of detainees that the agency acknowledges have occurred since May 2012. ICE has not released its reviews of the other 13 deaths in that time period.

The US maintains the capacity to hold 34,000 noncitizens in civil detention at any one time, in an expansive network of more than 200 facilities including county jails, private detention centers, and a handful of federal lockups. Most of the hundreds of thousands of people held in this system each year are subject to harsh mandatory detention laws, which do not allow for an individualized review of the decision to detain them during their immigration proceedings.





[T]hese death reviews show that system-wide problems remain, including a failure to prevent or fix substandard medical care that literally kills people. Clara Long US Program researcher

The ICE Office of Detention Oversight (ODO) conducted the death reviews and identified decisions it considered violations of the applicable detention standards, but did not reach conclusions about whether identified deficiencies in care contributed to the detainees’ deaths.Human Rights Watch asked two independent experts to review the circumstances of the deaths, as detailed in the ICE ODO reviews. Dr. Marc Stern is a correctional health expert who is an assistant affiliate professor of public health at the University of Washington and a former subject matter expert for investigations conducted by the US Department of Homeland Security, as well as the former health services director for Washington State’s Department of Corrections. Dr. Allen Keller is an associate professor at New York University (NYU) School of Medicine, associate professor at the NYU Gallatin School of Individualized Study, director of the Bellevue/NYU Program for Survivors of Torture, and director of the NYU School of Medicine Center for Health and Human Rights and a general internist with an expertise in evaluation and treatment of immigrants and in access to health care for prisoners.The medical experts identified evidence of substandard and potentially dangerous care in most of the reviews, including failure to follow up on symptoms that required attention, medical personnel apparently practicing beyond the scope of their licenses and expertise, the misuse of solitary confinement for mental health patients, and sluggish emergency responses.In seven cases, both medical experts agreed that inadequate care may have contributed to the detainees’ deaths. Both experts had serious concerns about the quality of mental health care in three additional cases of people who committed suicide – and in one of those cases the experts agreed subpar care contributed to the person's death.In 16 of the reviews, the independent medical experts agreed there was evidence of substandard medical practices that could pose a risk to current or future detainees in those facilities, even where inappropriate care did not appear to contribute to the deaths documented in the reviews. The medical experts found no evidence of inappropriate care in only two of the 18 cases.One of the people the two medical experts identified as having received substandard care was 34-year-old Manuel Cota-Domingo, who died of heart disease, untreated diabetes, and pneumonia in December 2012 at St. Joseph's Hospital and Medical Center shortly after being transferred there from Eloy Detention Center, a private facility run by the Corrections Corporation of America (CCA).The death review contains persuasive evidence that correctional officers did not respond to calls for help for approximately three hours while Cota-Domingo was having trouble breathing. When officers finally notified medical providers of his condition, they delayed evaluating him and finally sent him to the hospital in a van instead of an ambulance. Both medical experts concluded that the combination of these delays likely contributed to a potentially treatable condition becoming fatal.The other deaths that both medical experts concluded were probably linked to substandard medical practices, were those of Raul Ernesto Morales Marjorie Annmarie Bell , and Tiombe Kimana Carlos . In the cases of Tiombe Kimana Carlos Clemente Mponda , and Jose de Jesus Deniz Sahagun , all of whom committed suicide after demonstrating signs of serious mental health conditions, the experts concluded that inadequate mental health care or the misuse of isolation may have significantly exacerbated their mental health problems.In the vast majority of the 18 cases, the reviews revealed evidence of substandard medical practices that could put detainees throughout the facilities in question at risk of serious harm.The 18 cases relate to a tiny fraction of the hundreds of thousands of immigration detainees held during the period in question, and do not speak directly to conditions in most of 200-plus different facilities ICE uses to house detainees. However, the reviews raise serious concerns about ICE’s ability to detect, respond appropriately to, and successfully correct serious lapses in medical care that arise in any of these facilities – even in cases in which the agency has conducted detailed investigations into detainee deaths.

A prior report by the American Civil Liberties Union (ACLU), Detention Watch Network (DWN), and the National Immigrant Justice Center (NIJC) found that violations of medical care standards played a significant role in another eight in-custody deaths from 2010 to 2012, and that ICE’s inspection and oversight mechanisms had failed to identify or address problems that contributed to the deaths.



“The tragic deaths described in these newly released investigations are disturbingly similar to the 2010-2012 deaths described in our report, Fatal Neglect,” said Jennifer Chan, a co-author of the ACLU/DWN/NIJC report and NIJC’s associate director of policy.



The reviews of these 18 detainees’ deaths demonstrate that the US government continues to fail to ensure that all detention facilities provide adequate health care to immigrants in detention. This failure is all the more egregious because many people in immigration detention should not be there to begin with. The US government makes indefensibly wide use of immigration detention, which should be limited to situations in which an individualized review determines that legitimate government interests cannot be met by other, less restrictive means.



The Obama administration should take immediate action to improve oversight mechanisms and stop using detention facilities that are unable or unwilling to provide adequate healthcare, Human Rights Watch said. The Obama administration should also end the use of solitary confinement for detainees with mental disabilities.



“Many of the dangerous medical practices found in these reviews should have been apparent in routine federal audits of immigration detention facilities,” said Long. “Yet ICE failed to catch or address substandard care before these deaths occurred, and the reviews of multiple deaths at one facility in particular indicate problems were not addressed adequately after the deaths either.”



For more details about Human Rights Watch’s analysis of the 18 death reviews, see below.



The Detainee Death Reviews



Human Rights Watch and two medical reviewers analyzed the findings of 18 ICE “detainee death reviews” for deaths from May 2012 through June 2015, conducted by the ICE Office of Detention Oversight (ODO) and first made publicly available on the ICE website in June 2016. The death reviews are publicly available here. Our analyses below rely upon the facts and conclusions included in the ODO’s report of each investigation.



Each death review was analyzed by Dr. Marc Stern, an expert in correctional health, assistant affiliate professor of Public Health at the University of Washington, former health services director for Washington State’s Department of Corrections, and former subject matter expert for investigations conducted by the Department of Homeland Security Office of Civil Rights and Civil Liberties, and by Dr. Allen Keller, associate professor at New York University (NYU) School of Medicine, associate professor at the NYU Gallatin School of Individualized Study, director of the Bellevue/NYU Program for Survivors of Torture, and director of the NYU Center for Health and Human Rights.



Though Dr. Stern previously investigated medical care in ICE facilities for the Department of Homeland Security, his conclusions communicated to Human Rights Watch are not based upon any confidential information obtained through that work and were drawn exclusively from his review of publicly available ODO death reviews and in one case, that of Tiombe Kimana Carlos, a review of her medical records at York County Prison obtained by Human Rights Watch. Human Rights Watch made these documents available to Dr. Stern for review after he discontinued his work with the Department of Homeland Security.



Dr. Stern and Dr. Keller assessed whether care was adequate considering standard practices in correctional health. Under international standards, detainees are entitled to the same level of medical care as individuals in the community at large and must be treated with humanity and respect for inherent human dignity.



The ICE portion of the DHS detention system consists of 165 county jails, privately run facilities, and ICE-run facilities that are permitted to hold detainees for more than 72 hours. Several hundred additional facilities may hold ICE detainees for less than 72 hours. The over-72-hour facilities are required to abide by one of three sets of detention standards prescribing guidelines for medical care, depending on the contract. Non-family detention facilities are covered by either the 2000 National Detention Standards (2000 NDS), the 2008 Performance Based National Detention Standards (2008 PBNDS), or the 2011 Performance Based National Detention Standards (2011 PBNDS). Customs and Border Protection additionally operates short term detention centers at and between ports of entry into the United States.



ODO death reviews are based on medical and other records; interviews with relevant medical, custodial, and ICE staff; and in most cases a security and healthcare compliance report by Creative Corrections, a national management and consulting firm contracted by ICE to provide expertise in detention management and compliance with detention standards. The death reviews include the detainee’s immigration and criminal history (if any), and a timeline of relevant medical and detention events. The reviews conclude with specific findings as to which detention standards were violated, and note further “areas of concern,” but most of the 18 reviews also explicitly state these findings are included “for information purposes only,” and “should not be construed as having contributed to the death of the detainee.” ICE released these reviews, without attached exhibits such as primary medical records or the Creative Corrections report if any, in its online FOIA Library.



The 18 death reviews cover deaths at 13 facilities. Those who died include citizens of Mexico, Honduras, El Salvador, Canada, Jamaica, Antigua-Barbuda, Mozambique, and Guatemala, some of them lawful permanent residents and others unauthorized migrants, including at least six who sought protection under refugee law. All of the detainees who died were between 24 and 49.



Human Rights Watch provided a summary of these findings to ICE in advance of publication but at the time of publication had not received a response from the agency. Human Rights Watch also provided summaries of our analysis of the deaths that occurred at facilities operated by GEO Group, Corrections Corporation of America (CCA), and Ahtna Technical Services (ATS) to those companies along with a request for comment. CCA and GEO Group provided written responses to Human Rights Watch. ATS did not respond by the time of publication.



GEO Group operates Brooks County Detention facility, where two people whose deaths are described in this report were detained. At the time of those deaths, Brooks was operated by LCS Corrections, which GEO acquired in 2015. The GEO Group stated that as a matter of company policy, it is unable to comment on any of the individual cases described below. It emphasized, however, that two of the eighteen deaths ocurred at the Brooks County Detention Facility before GEO Group took over management of that facility, and noted that our medical experts found that another detainee who died in a GEO Group-operated facility appeared to have received adequate medical care. GEO Group also stated that it employs a robust internal auditing framework to ensure compliance with all “mandated standards and requirements.” It also stated that “Our company takes all recommendations made by ICE very seriously, and for instances in which corrective actions are required, our company has had a long-standing, steadfast commitment to allocating the necessary resources and to working in partnership with ICE to ensure compliance.”



CCA emphasized in its response that it does not directly provide or oversee the provision of healthcare to ICE detainees in its facilities. CCA asserted that “because we are not the healthcare provider, we do not have access to medical-specific information about detainees” and suggested that questions about treatment protocols and the treatment received by individual detainees should be referred instead to ICE. CCA also stated that the company “adheres strictly” to ICE’s Performance-Based National Detention Standards and that onsite ICE contract monitors have “unfettered, daily access” to CCA facilities to “provide accountability and oversight and ensure the standards are met.” CCA also responded to several questions about the individual cases described below; these are incorporated into our findings as appropriate.



Evidence that Substandard Medical Care Contributed to 7 of the 18 Deaths in ICE Custody



Although the 18 death reviews do not make any findings as to whether failures in medical care contributed to the detainee’s death, Dr. Stern and Dr. Keller provided expert opinions, based on detailed information provided in these death reviews that substandard care was likely to have contributed to the deaths of seven detainees:

ODO’s death review for Raul Ernesto Morales-Ramos, 44 when he died in April 2015, notes that he was first referred for a follow-up with a doctor for gastrointestinal symptoms in April 2013, while detained at the Theo Lacy Facility. But more than a year later, this consultation had not occurred, which the ODO review called a “critical lapse in care.” In May 2014, he was transferred to the GEO Group-operated Adelanto Detention Facility with no documentation of his gastrointestinal symptoms. There, he was seen several times over the next nine months by registered nurses after submitting sick call requests for body aches, weight loss, pain in his joints, knees and back and diarrhea.

In February 2015, Morales-Ramos submitted a grievance in which he wrote, “To who receives this. I am letting you know that I am very sick and they don’t want to care for me. The nurse only gave me ibuprofen and that only alleviates me for a few hours. Let me know if you can help me. I only need medical attention.” Four days later, he was seen by a nurse practitioner who documented that his symptoms were resolved and “instructed him to increase his water intake and exercise to promote bowel regularity.”

In early March 2015, a registered nurse seeing Morales-Ramos after a sick call request documented that he was complaining of abdominal pain and asking again to see a doctor. The nurse who saw Morales-Ramos on March 2, 2015 told ODO that she noted Morales-Ramos had a distended abdomen but that she “did not detect a mass or protrusion.” A consultation with a doctor occurred on March 6, 2015. The doctor, who held a certification in medical oncology, told ODO that at that visit Morales-Ramos had “the largest [abdominal mass] she has ever seen in her practice,” which was “notably visible through the abdominal wall.”

Based on the doctor’s findings and referrals Morales-Ramos was scheduled for a colonoscopy, which did not occur until about one month later. During the colonoscopy, he began to experience abdominal bleeding after the doctor attempted to remove “a huge rectal mass.” Morales-Ramos was transferred to the hospital and died three days later after a surgical attempt to stop his bleeding.

Expert comments: Both medical experts noted that it appears Morales-Ramos suffered from symptoms of cancer starting in 2013, at least two years before he died, but the symptoms went unaddressed until a month before he died. “Had Mr. Morales’ gastrointestinal symptoms been evaluated much sooner as was clinically indicated, it is possible that the malignancy from which Mr. Morales died, might have been caught at a time when it was still treatable,” Dr. Keller said. Dr. Stern similarly noted that Mr. Morales “was not appropriately referred for specialist care” until a month before his death, when it was too late.

ODO’s death review for Santiago Sierra-Sanchez, 38 at his death in July 2014, records that he told an intake nurse at the Utah County Jail that he had a six- to-seven-month history of lower back pain that had been worsening in the preceding few days. ODO reviewed video showing that he was unable to stand without assistance in the jail intake area. ODO reports that Sierra-Sanchez told ICE officers that he was “’dying’ from the pain in his back.”

The review says that nursing staff at the jail suspected Sierra-Sanchez “might be playing games to get narcotic pain medication” and did not thoroughly assess him – including by taking his temperature – or follow standard protocols regarding back pain. The ODO review notes that Sierra-Sanchez’s medical history included a prior history of drug use. The review also states his pulse and blood pressure increased between his intake and his evaluation by an RN, “which warranted a consultation with a provider,” but this did not occur. His temperature was not taken; Creative Corrections noted, “an elevated temperature can signal an infection.” On the night he died, Sierra-Sanchez told a nurse he was “spitting blood” around 8 p.m. but the nurse told ICE that there was no evidence of this.

Around 3:30 a.m., a correctional officer (CO) saw he was unresponsive. Six minutes elapsed before staff entered his cell, where they found him in a pool of bloody vomit. The CO called for medical assessment, not an emergency, so the RN arrived without emergency equipment, which the ODO found delayed CPR and the call for emergency medical services. Sierra-Sanchez died that morning of disseminated Staphylococcus aureus and pneumonia.

Expert comments: “Medical staff essentially abandoned this patient by not properly assessing him or following up. If they had, there is a chance the patient's emerging infection would have been noted and treated, avoiding death or at least greatly increasing the odds of survival," Dr. Stern said. Dr. Keller had similar comments. “When someone has a fulminant bacterial infection as was the case with Mr. Sierra-Sanchez, rapid treatment including intravenous antibiotics can make all the difference between life and death,” said Dr. Keller. “But it appears they even missed some of the basics like monitoring his temperature.”

ODO’s death review for Peter George Carlysle Rockwell, 46 when he died in February 2014, notes that he was admitted to CCA’s Houston Contract Detention Facility with a history of hypertension for which he took medication. At a physical examination on intake, a nurse practitioner developed a treatment plan that included daily blood pressure monitoring. However, according to the ODO review, this monitoring did not occur. An electrocardiogram ordered to be performed two weeks after Rockwell’s physical exam was not completed. When he complained of blurred vision five days after intake, a physician’s assistant determined he should be seen by a health care provider within one day but “[m]edical records staff did not schedule the vision appointment, and [Rockwell] was never seen by a provider for the blurry vision.”

When Rockwell collapsed in full view of a correctional officer 10 days after first complaining of blurry vision, the review found that staff took eight minutes to call 911, that three more minutes elapsed before CPR was started and that two minutes after that staff applied an automated external defibrillator (AED). The ODO notes that according to the American Heart Association’s Adult Basic Life Support guidelines, “as soon as [Rockwell] was determined to have ineffective or agonal breathing (abnormal breathing characterized by gasping, labored breaths), 911 should have been called, an AED should have been used, and CPR should have been initiated.”

ODO said that the delays occurred due to the failure of medical staff to recognize the emergency and bring emergency equipment to the scene as required by facility policy, and to malfunctioning medical equipment. Rockwell was transported to the hospital while nonresponsive, and placed on a ventilator in the intensive care unit until his death seven days later which was determined to have been due to a hemorrhagic stroke.

Expert Comments: Both medical experts found that substandard care contributed to Rockwell’s death. “The facility knew about his blurred vision and other systemic symptoms and did not manage them,” said Dr. Stern. “The providers missed what may have been a telltale sign of an intracranial bleed when he reported the blurry vision,” said Dr. Keller. “It could have been something else but it merited investigation.” Both experts also pointed to the delayed emergency response as inadequate. Dr. Keller raised concerns about whether the facility appropriately addressed the inadequate emergency response after it occurred. “The review notes there was no debriefing of the emergency response with corrections staff. Such debriefings are crucial to identifying errors and correcting future problems.”

Lelis Rodriguez, 50 at the time of his death, entered Border Patrol custody on July 16, 2013 and died on July 31, in ICE custody. ODO’s review notes that the cause of his death was an intracranial hemorrhage – a stroke – and hypertension. The review says he was first screened for health issues two days after his initial arrest. ODO’s review documented that at this screening, on July 18, a Border Patrol officer “checked ‘no’ after the question, ‘Does alien have health problems/issues?’” but “‘yes’ after the question, ‘Was the alien prescribed medication?’” The agent did not provide any more information on the medication, despite a specific direction on the form to do so.

Border Patrol agents later told ODO investigators that Rodriguez did not possess medication while in Border Patrol custody. However, when he entered ICE custody at the Brooks County Detention Center (BCDC) six days after his initial arrest he was screened by a correctional officer who documented that Rodriguez said he had been taking medication for high blood pressure. This screening form was never sent to the BCDC medical unit. BCDC also “failed to verify and inventory medication” in Rodriguez’s property. On July 24, a BCDC Certified Medical Assistant (CMA) generated a record of an intake medical screening for Rodriguez, stating that he had no history of hypertension and no current medication.

On the evening of July 29, ICE transferred Rodriguez to Rio Grande Valley Staging (RGVS), an ICE facility operated by Ahtna Technical Services, which holds detainees for periods under 12 hours immediately prior to their removal to their country of citizenship, in Rodriguez’s case, Honduras. Several hours after his arrival, a licensed vocational nurse documented that he had a headache and blood pressure of 172/90. She said he also told her that he had high blood pressure and he had informed BCDC staff about the hypertension medication in his property bag.

The nurse searched the property bag, and found the tablets for hypertension, but left them in the bag. She told him she would recheck his blood pressure in an hour but took no other action. Three hours later, a nurse checked Rodriguez’s blood pressure again and found it to be 200/110. The ICE review fails to note what the nurse did at this point. Then, at a time unspecified in the ICE report, Rodriguez collapsed, complaining of right shoulder pain and a headache. A nurse noted that his right arm and right leg were twitching. The nurse called emergency medical services and he was transported to a hospital emergency department. He quickly fell into a coma and was pronounced brain dead the next day.

Expert comments: “This was an avoidable death,” Dr. Stern said after his review of the ICE investigation. Medical staff “failed to react immediately when [they] learned that Mr. Rodriguez had a blood pressure of 172/90, was on blood pressure medication and had a headache. These were symptoms that required immediate contact with a practitioner for further action that may very well have saved his life.” Dr. Keller made similar comments. “Hypertension is sometimes referred to as a ‘silent killer’ given that there often no symptoms. However, in its severe manifestation it can cause symptoms including headaches.” Dr. Keller said. “In this case, Mr. Rodriguez’ symptoms were by no means silent. Unfortunately, it appears that medical staff did not connect these symptoms with his hypertension and delayed responding. This delay might have cost him his life.”



Both experts noted that decisions made by Border Patrol agents also contributed to the mismanagement of Rodriguez’s care. Though the death review indicates that Rodriguez reported taking medication, this information was not passed along. “Had someone identified that the patient was taking – and needed – medications for high blood pressure and gotten those medications restarted at some point in the two weeks he was held by US authorities, the death may have been averted,” Dr. Stern said. Dr. Keller added, “this death review showed one mistake after another with regard to missing and then mismanaging his symptoms, with fatal consequences.

ODO’s death review for Marjorie Annmarie Bell records that she died on February 13, 2014, due to sudden cardiac death, acute coronary syndrome and multivessel coronary artery disease. She was 48. She came into US custody on December 24, 2013 when she crossed the US-Mexico border at the San Ysidro port of entry. The death review says that she told Customs and Border Protection officers that she did not feel well and had diabetes, and that she was transported to Sharp Chula Vista Medical Center (SCVMC) where she was admitted. There, ODO notes, she reported she had a history of heart disease and had at least three stents in her heart. SCVMC placed one additional stent.

Bell was admitted to the CCA-operated San Diego County Detention Facility on January 2. There, medical staff responded to her requests for care and at one point in late January sent her to the emergency room for chest pain. The discharge summary from the hospital stated, “treatment of her congestive heart failure should be done,” but the nurse practitioner who saw Bell at the detention facility did not include congestive heart failure in her assessment. The facility did not seek expert assistance from a cardiologist. Bell repeatedly requested nitroglycerin tablets to take as needed for her chest pain and medical staff became concerned she was overusing nitroglycerin. In early February, Bell told a psychologist that she was dissatisfied with the medical care she was receiving at the facility and that “medical staff did not listen to her.”

On February 13, 2014, Bell saw a doctor for chest pain who decided to send her to the emergency room, but waited 15 minutes to instruct a medical officer to call 911. The ODO noted, “the apparent 15-minute delay remains unexplained.” It was another six minutes before emergency responders received a call from the facility. Bell died later that day of a heart attack.

Expert Comments: Both experts found that substandard medical care contributed to Bell’s death. “On multiple occasions medical staff did not adequately address and evaluate her chest pain, Dr. Keller said. “Given the severity of her heart disease and the fact she had just recently undergone a cardiac procedure, there should have been a very low threshold for sending her back to the hospital. It took her being near death for them to finally do that but it was too late,” Dr. Keller said. “This is a woman with a known history of heart attacks,” said Dr. Stern. “On six separate occasions she informed nurses that she was having chest pain, and on none of those occasions did a nurse contact a physician or call an ambulance. She ultimately died of another heart attack.” Both doctors agreed that if a stent needed to be placed on December 25, 2013, it should have been clear that Bell required close observation and monitoring by a heart expert, which she did not receive.

Tiombe Kimana Carlos, 34, died in October 2013, after committing suicide while detained at the York County Prison (YCP). She showed symptoms of an acute and serious mental health condition from the start of her two-and-a-half-year detention at York. ODO’s review states that before she died, she was placed on suicide watch five times and attempted suicide once. ODO found that the facility violated ICE’s standards for detention conditions, by having no “overall treatment plan with measurable goals and objectives,” and by failing to communicate with ICE regarding her treatment until shortly before her death. Carlos was held in isolation while at YCP for at least 9 months over 12 separate instances because of her “behavioral issues and associated mental health concerns.” ODO found that “Carlos’s records show the rationale for placing her in segregation was valid on all occasions.” The ODO notes a licensed professional counselor (LPC) decided more than once that Carlos was not suicidal. After her first suicide attempt by hanging on August 13, 2013, the LPC told ODO that “he considered her action…a suicidal gesture, not a suicide attempt, because she waited for officers to enter her cell before dropping from the stool.” Another correctional officer told ODO her August 2013 attempt was “done for attention.” On August 20, 2013, a contract psychiatrist saw Carlos, documented that she declined any medication changes or increases, described her as “animated” and “angry,” and “ordered no change in her treatment with follow up in eight weeks.” The review cites Creative Corrections, which “highlights that Dr. [redacted]’s [August 20, 2013] note about Carlos’s medication is the first reference in her medical record to a possible change or increase in her medication,” over two years after she entered the facility and after she had repeatedly refused her medication and attempted suicide once. After her August 2013 suicide attempt, Carlos remained in isolation.

Before Carlos’ death in October 2013, the YCP warden requested that ICE “look into placing Carlos in a long-term mental health facility.” ICE’s response was that “an appropriate alternative facility was not available at that time.” The death review states that Carlos’ record contains “no documentation YCP mental health staff ever pursued alternative placement with ERO [ICE Enforcement and Removal Operations].” Carlos hanged herself on October 23, 2013.

Expert Comments: Both experts found that subpar mental health care likely contributed to Carlos’ death. Dr. Keller called the mental health evaluation and treatment Carlos received while at YCP “woefully inadequate” and raised concerns about the apparent failure to develop, document and implement a mental health treatment plan for Carlos. Dr. Stern had similar comments. “Staff were aware that this patient suffered from an acute and serious mental illness and was a) not getting treatment for it, and b) was not transferred to a facility that could provide that treatment,” said Dr. Stern. “Instead, medical staff keep doing the same thing and expecting a different outcome. They keep giving her [anti-psychotic medication] and no therapy and she keeps trying to kill herself.”



Dr. Keller particularly called attention to the substantial amount of time Carlos was held in isolation. “This is counter to accepted norms for treating mental illness whereby segregation and use of restraints are temporizing measures for use in emergencies and as a last resort-rather than a routine response,” Dr. Keller said. “If viewed separately, each of the many episodes of segregation Carlos was subjected to might seem justified, but when viewed in their totality this overuse of segregation was inappropriate and likely harmful to Carlos’ mental health.”



Dr. Stern criticized the ODO review team for failing to include a psychiatrist or psychologist who would be best qualified to evaluate the quality of mental health care she received. He also disagreed with ODO’s assessment that care was appropriate. “The psychiatrist’s decision to schedule follow-up in eight weeks is much too long for such an unstable person, seven days after a suicide attempt and three days after being taken off of constant observation,” said Dr. Stern.

ODO’s death review for Manuel Cota-Domingo, 34 at his death in December 2012, notes that he entered CCA’s Eloy Detention Center with a plastic bag containing medicine for diabetes but that it was stored with his property and not given to nurses. Later, a licensed practical nurse doing his intake recorded that he denied having insulin with him or being diabetic. In an interview with ICE, Cota-Domingo’s cousin who was also detained at Eloy at the same time, said he encouraged Cota-Domingo to talk to medical personnel about his medical condition but that Cota-Domingo refused because he believed he would “have to pay for medical care he could not afford.” CCA told Human Rights Watch there are no fees for medical care delivered at Eloy.

The review includes interviews with three detainees who were present when Cota-Domingo began to have problems breathing, at about 10 p.m. on the night of December 19, 2012. His cellmate began to bang his cell door and call for help at about 11 p.m.; he stated correctional officers did not respond until 2 a.m. The review documents further delays, including a decision by a registered nurse to wait two hours to attend to Cota-Domingo’s complaint of chest pain, failure to call 911 because of an Eloy Detention Center policy that only certain medical staff could call 911, and a decision by facility staff to send Cota-Domingo to the emergency room in a van rather than an ambulance.

Taken together these delays meant that Cota-Domingo did not arrive at the emergency room until at least eight hours after he first began to have trouble breathing. He was pronounced dead at the hospital days later of hypertrophic and atherosclerotic cardiovascular disease with diabetic ketoacidosis, or untreated diabetes, and pneumonia.

Expert comments: The medical experts found that this death was very likely preventable. “If diagnosed properly and treated, diabetic ketoacidosis and pneumonia are treatable, ” Dr. Keller said. “But both of these life-threatening diagnoses were missed at the detention facility.” Both experts further agreed that the inappropriate delays in responding to Cota-Domingo’s condition on the night and morning before he was transported to the hospital likely contributed to his death. “Each delay – getting out of the cell, getting an initial medical assessment, and going to the hospital by van – all added to overall delay which made a probably reversible condition fatal,” said Dr. Stern.



Misuse of Isolation and Inadeaquate Treatment of Detainees with Mental Disabilities



Prolonged solitary confinement may amount to torture or cruel, inhuman, or degrading treatment, which is prohibited under international human rights law. Because solitary confinement may severely exacerbate previously existing mental health conditions, the United Nations special rapporteur on torture believes that solitary confinement of any duration for those with mental disabilities is cruel, inhuman, or degrading treatment.

The death review for Tiombe Kimana Carlos, summarized above, states she was in isolation for a significant period of time, including two stints in 2013, one for four-and-a-half months and another for two-and-a-half months immediately before her death. The dangers of isolation for people with mental health issues is well-documented, yet the ODO review indicates that the safeguards set by national detention standards were not followed. It says that the facility did not record isolation orders, in violation of the applicable detention standards. The ODO also noted that for six of the months Carlos spent in isolation, the facility only reviewed its necessity monthly. Weekly checks started in June 2013, but documentation was inconsistent and there was no evidence they were adequate to evaluate whether Carlos should have remained in isolation.

In another case involving a migrant who committed suicide in ICE detention, that of Clemente Mponda, 27, the medical experts noted that the repeated placement in isolation may well have exacerbated his mental health disability. For eight months of his 15-month detention at CCA-operated Houston Contract Detention Facility (HCDF), Mponda was in isolation, including administrative segregation, disciplinary segregation and three days on suicide watch. The ODO found numerous violations of standards for placing someone in isolation or for reviewing whether continued isolation was justified, including failure to medically clear him for isolation, a violation of the 2008 PBNDS and of the Immigrant Health Service Corps policy that “a qualified healthcare professional … review the detainee’s health record to determine whether existing mental health needs contraindicate placement in segregation.” When Mponda was returned to the general population from isolation in January 2013, the death review says, he “functioned well,” with one stint in disciplinary isolation, followed by another five months without incident.

Shortly before his death, the ODO says, Mponda physically attacked another detainee and he was cleared by medical staff “to be moved to ‘Special Housing Unit (Segregation)’.” During his transfer to isolation, the ODO states, correctional staff did not search him as required by facility policy. During the investigation, another detainee told ODO he had seen Mponda place medication in one of his socks prior to the altercation. The ODO also noted a bottle of pills, medication Mponda had been prescribed, had been found in his cell, but this did not trigger facility staff to search Mponda and ensure he was not secreting medication. Two days later, he was found unresponsive in his cell. The autopsy found he died from toxicity after consuming a large amount of the medication he had been prescribed.

Mponda was one of two cases in which both experts expressed serious concerns about the quality of mental health care provided. In both cases, Dr. Keller thought that this substandard care may have contributed directly to their deaths while Dr. Stern thought this was very possible but that more information was needed.

In addition to the facts described above, the ODO states that Mponda was identified as having significant mental health needs early in his detention at HCDF when facility medical staff diagnosed him with depression or schizophrenia. However, the ODO cited as violations of detention standards delays in evaluating Mponda’s mental health after two suicide attempts in July 2012. After the first attempt, no mental health professional assessed him until five days later. The second time, he was found hanging, was cut down, and taken to the hospital, where he stayed for two weeks. He was placed in isolation when he returned. Despite this clear pattern of a risk for suicide, the ODO points out that the medical staff did not create a mental health treatment or management plan in violation of the 2008 PBNDS.

Expert comments: Dr. Stern, upon reviewing Mponda’s death review, stated, “This case might be the poster child for misuse of isolation for mental health patients.” Although the death review identified many problems with Mponda’s care and custody, he noted the ODO team failed to include a mental health care expert and did not fully examine how segregation could have adversely impacted Mponda’s mental health.

Dr. Keller emphasized that isolation is a stressful and highly disruptive and traumatizing event. “Standard psychiatric care is to utilize segregation and restraints as temporizing measures for short-term use in only urgent situations, rather than as a routine means of addressing psychiatric illness,” Dr. Keller said. “While Mr. Mponda may have benefited from psychiatric hospitalization or from close follow up and care in a community-based mental health program, these were never considered as options. Instead, repeated segregation was the preferred punishment and treatment of choice.”



“The repeated overuse of segregation without considering other options may well have contributed to an unstable individual becoming even more unstable and ultimately contributed to his death,” Dr. Keller said.



Both experts noted that Mponda’s ability to hoard potentially lethal medications he was taking without detection represented a dangerous failure of the facility’s security system.

Jose de Jesus Deniz-Sahagun, 31 at death, committed suicide on May 20, 2015 in CCA-operated Eloy Detention Center less than 12 hours after a doctor moved him from suicide watch to mental health observation status with 15-minute checks and no restrictions on his property. According to the review, Deniz-Sahagun ultimately used an item from his property – a sock – to end his life. Before arriving at Eloy, while in Border Patrol custody, ODO documented that Deniz-Sahagun exhibited self-harming behavior. He jumped twice from a bench and landed on his head. Border Patrol agents transported him to the hospital on May 17, 2015, where he “told the emergency room physician he was attempting to break his own neck because he feared his life was in danger by both Mexican coyotes and USBP [US Border Patrol].”

On May 18, 2015, when Deniz-Sahagun was transferred to Eloy, ODO noted that Border Patrol agents informed a nurse in Eloy’s booking area that Deniz-Sahagun had been taken to the hospital the day before for his suicide attempt and that he had since been “observed banging his head against a wall at the Border Patrol Station and behaved erratically during transport.” ODO noted however that “the Medical Alert section of his [Border Patrol] Alien Booking Record was blank, and no medical or mental health documentation accompanied him to [Eloy].” The pre-screening and intake nurses at Eloy determined that Deniz-Sahagun was not suicidal and referred him for a routine, rather than urgent, mental health follow-up. Deniz-Sahagun was cleared for placement in general population in the early afternoon. Around 10 p.m. that evening, Deniz-Sahagun requested to be placed in protective custody “because he believed his cellmate [redacted] was going to kill him.”

On the morning May 19, 2015, ODO discussed four separate use of force incidents “used to control Deniz-Sahagun” over the course of approximately three hours. The ODO reviewed video of each of these events, including “a video recording shows Deniz-Sahagun struggling on the floor as four officers hold him in place. He screams in English and Spanish, ‘Help me,’ ‘Call my lawyer,’ ‘This is brutality,’ and ‘They want to kill me.’” A facility doctor determined that Deniz-Sahagun suffered from delusional disorder and placed him on suicide watch from May 19 to 26, 2015. The order required nursing checks every eight hours, mental health checks every 24 hours and one-on-one observation by an officer. The doctor also ordered anti-psychotic and anti-anxiety medications assuming that “involuntary administration would be necessary.” These medications were not administered by medical staff, but no documentation of this was made in Deniz-Sahagun’s medical record and the doctor was not informed.

On the morning of May 20, 2015, a doctor removed Deniz-Sahagun from suicide watch “because he believed the detainee was no longer a danger to himself.” The doctor told ODO that it was “not clear to him what prompted Deniz-Sahagun’s change, but he assumed the detainee had been administered a sedative.” Around 5:30 p.m. that day, Deniz-Sahagun was discovered unresponsive in his cell. His airway was blocked by an orange sock which caused him to asphyxiate.

Expert comments: Dr. Keller emphasized that medical staff failed to adequately elevate the level of Deniz-Sahagun’s treatment to his symptoms. “This patient was severely unstable. He had been taken to the hospital after a suicide attempt days before and was placed on suicide watch at Eloy,” said Dr. Keller. “Based on one report of him claiming he was not suicidal he was downgraded to 15-minute checks.” Instead he should have been thoroughly evaluated by a psychiatrist and strongly considered for hospitalization.



Dr. Keller further noted that detention itself could have excacerbated Deniz-Sahagun’s mental health condition.



Dr. Stern also raised serious concerns about the appropriateness of Deniz-Sahagun’s mental health care, in particular the doctor’s decision to downgrade Deniz-Sahagun from suicide watch. He faulted the ODO’s death review for not adequately analyzing that decision and not including an appropriate subject matter expert in psychiatric health.



Evidence of Broader Medical Care Failures in the Detainee Death Reports



In 16 of the death reviews, the medical experts found evidence of substandard medical practices that, in their view, would have put many other detainees at the facilities in question at risk to the extent that they reflected normal practice. They also saw evidence of faulty systems whose operation would inevitably create danger for other detainees.



The risk to other detainees is particularly stark in the death reviews for the four deaths that occurred at Eloy Detention Center during this time. The ODO found in its review of Cota-Domingo’s death that Eloy Detention Center medical staff believed they could not call 911 without first receiving a “provider’s order” per Eloy Detention Center’s Local Operating Procedure on Emergency Medical Services. The ODO did not cite this policy as a violation in this case. Four months later, Jorge Garcia-Maldonado and Elsa Guadalupe-Gonzalez hanged themselves within days of each other. In reviews of these deaths, ODO found that “confusion as to who has the authority to call for local emergency medical assistance” led to three-minute and five-minute delays in calling 911, respectively in each case. The ODO reviews of their deaths indicate that Eloy Detention Center policy did then allow security personnel to call 911 under CCA Policy 8-1A on medical emergencies, but not before alerting others within the facility, and that security staff believed they had no authority to call 911 without an assessment from medical staff. In these latter cases, the ODO found the facility violated the 2011 PBNDS requirement of “access to specified 24-hour emergency medical, dental, and mental health services” due to the confusion over who could call 911. CCA, the company that operates the Eloy Detention Center, told Human Rights Watch that “there has never been a CCA policy that specifically indicates who can or cannot contact 911 for emergency services.”



“While it is unclear whether their lives could have been saved in the absence of this delay, waiting five minutes to call 911 can be a matter of life or death,” said Dr. Keller. “Any staff member should be able to call 911 in an emergency,” said Dr. Stern, further adding, “A timely review of Mr. Cota-Domingo’s death should have remedied the 911 confusion before Ms. Guadalupe-Gonzales and Mr. Garcia-Maldonado’s deaths.”



The death reviews for the three suicides at Eloy similarly identify the recurrent problems. The death reviews for Guadalupe-Gonzales and Garcia-Maldonado already pointed out as violations of the 2011 PBNDS CCA’s failure to conduct “a multidisciplinary debriefing to review critical elements” surrounding both deaths. In both reviews the ODO states “All [Eloy Detention Center] staff members interviewed by ODO stated EDC did not hold a multidisciplinary debriefing to review critical elements surrounding” Guadalupe-Gonzales's suicide and Garcia-Maldonado’s suicide. Asked whether debriefings were conducted for both suicides, CCA told Human Rights Watch “on April 29, 2013, CCA, ICE and IHSC conducted several debriefings to discuss the incident.” The Guadalupe-Gonzales suicide occurred on April 28, 2013 and the Garcia-Maldonado suicide occurred on April 30, 2013.



Two years later, in the death review of Jose de Jesus Deniz-Sahagun, who also committed suicide at Eloy, the ODO noted that Eloy Detention Center “did not convene a multi-disciplinary debriefing in contravention of IHSC Local Operating Procedure 1501, Suicide Prevention and Intervention which requires, ‘A formal debriefing with …multidisciplinary team members to convene the next business day for a formal debriefing to review critical elements that contributed to the death and measures to prevent future deaths.”



“It’s quite alarming to me that based on these death reviews, how often it appears that debriefings are not done by medical and security staff at the facility following deaths to determine whether mistakes were made,” said Dr. Keller. “A basic tenet of medical care is that we do our best to learn from mistakes when they are made.”



Both the Guadalupe-Gonzales and the Garcia-Maldonado reviews point to Eloy Detention Center’s failure to have a local suicide prevention plan, “in contravention of the PBNDS and CCA Policy 9-19… which require the facility to develop a local Suicide Prevention Plan, to be reviewed annually, addressing "specific facility initiatives and the facility's plan for compliance" with the policy.” Both reviews indicated that the facility was “currently in the process of developing a Suicide Prevention Plan.”



Two years later, in the death review of Jose de Jesus Deniz-Sahagun, the ODO again noted the requirement that the facility develop a “’Suicide Prevention Plan which is reviewed annually and addresses specific facility initiatives for suicide prevention. The ODO review found “no evidence [Eloy Detention Center] has developed such a plan, despite detainee Deniz-Sahagun’s suicide being the third at EDC since April 2013 and the fifth since 2005.” CCA told Human Rights Watch that the facility has been engaged in a process of reviewing and revising the facility’s suicide prevention plan since 2013.



In some facilities, the ODO found medical staffing was inadequate or the staff was insufficiently experienced. In Brooks County Detention Center, the ODO found “[m]ost medical care is provided by low level medical professionals such as LVNs [licensed vocational nurses] and certified medical assistants.” The one doctor was at the facility for only two hours each week, for 652 ICE detainees and other inmates.



A dearth of qualified staff was apparent during ODO’s investigation of the death of Federico Mendez-Hernandez. During the two weeks that he showed symptoms of a serious medical condition, which turned out to be rabies, he did not see a physician. The ODO stated in its review of Mendez-Hernandez’s death that at one point, when he was found unconscious, nursing staff roused him by sprinkling water on his face, which the review noted was an “inappropriate nursing practice.” Dr. Stern also noted other important indicators of substandard care, notably staff’s recording of vital signs after the fact “from memory.”



Similarly, in Adelanto, the ODO noted many Adelanto medical staff cited “a high turnover rate among nurses [as] a great concern,” and that “approximately 50 percent of ADF’s medical staff hires are new graduates” with a “definite difference between their skills and those of more experienced nurses.” The ODO’s investigation found that an RN who saw Morales-Ramos on March 2, 2015 noted that his abdomen was distended but “did not detect a mass or protrusion.” The doctor who saw Morales-Ramos four days later described his abdominal mass as “the largest she has ever seen in her practice.”



Dr. Stern told Human Rights Watch he believed seven other reviews pointed to the conclusion that licensed vocational nurses, certified medical assistants, and registered nurses were providing medical care and making critical decisions they were not qualified to make in a way that was dangerous.



In one of these cases, that of Pablo Ortiz-Matamoros, 25, both experts concluded there was probably nothing that could have been done to prevent his death from metastatic cancer in February 2013. He first reported symptoms indicating a larger problem – loss of appetite, dark yellow urine and weight loss – in mid-January 2013. However, the ODO review of his death contains evidence that licensed vocational nurses at GEO Group’s Joe Corley Detention Facility (JCDF) were regularly conducting clinic visits and clinically assessing patients for any danger that might follow from placing them in isolation, outside of their scope of practice as defined by their license to practice nursing. The ODO, however, did not flag this as a problem requiring resolution. The ODO review notes that a registered nurse employed in the Joe Corley Detention Facility clinic during this time “resigned her position with GEO at JCDF … over her concerns with the JCDF medical clinic.”



In the case of Marjorie Annmarie Bell, whose death by heart attack Dr. Stern and Dr. Keller considered preventable, the ODO noted, “several nurses indicated that they were unsure whether San Diego Contract Detention Facility had chest pain guidelines, or were unsure of the guidelines’ contents.” Creative Corrections, a contractor hired by ICE to assess medical care at the facility, said that training and adherence by nurses to established guidelines on chest pain, however, “is critical.”



In two of the 18 cases, that of Jorge Umana-Martinez and Jose Javier Hernandez-Valencia both Dr. Stern and Dr. Keller found based on the evidence in the death reviews that the detainee received appropriate care.