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TOKYO – Niculas Fernando died at a Tokyo immigration detention center sometime between 9:33 a.m. and 10:44 a.m. on November 22, 2014, according to the coroner.

But it wasn’t until shortly after 1 p.m. that day that guards realized something was badly wrong – even though Fernando had been moved to an observation cell monitored via closed-circuit television after complaining of sharp chest pain.

An inmate had to alert the guards before they rushed into Fernando’s cell and tried to revive him. They found him lying face down on a mattress stained with his urine. He was lifeless.

A devout Catholic from Sri Lanka, Fernando had come to visit his son, who lives in a Tokyo suburb where he works in a restaurant kitchen. He was the fourth person to die in Japan’s immigration detention system in 13 months. In total, 12 people have died in immigration detention since 2006, including four suicides. In 2015, 14 detainees tried to kill or harm themselves at the detention center where Fernando died, according to data from the facility.

A Reuters investigation into the circumstances surrounding Fernando’s death, including dozens of interviews with detainees, immigration officials and doctors, revealed serious deficiencies in the medical treatment and monitoring of Japan’s immigration detention centers. Guards with scant medical training make critical decisions about detainees’ health. Doctors visit some of the country’s main detention centers as infrequently as twice a week. And on weekends there are no medical professionals on duty at any of the immigration detention facilities, which held more than 13,600 people in 2014.

Three of the four deaths in detention between October 2013 and November 2014, including Fernando’s, occurred when there were no doctors on duty. Like Fernando, another one of the detainees died while in an observation cell.

Japan’s immigration system is under increasing strain. As a torrent of refugees pours into Europe, Japan also has record numbers of people landing on its shores in search of refuge. As of June last year, it had 10,830 asylum applications under review – small by Europe’s standards, but a new high for Japan, a nation that has long been reluctant to take in outsiders.

In February, more than 40 detainees went on hunger strike at a facility in Osaka to protest their conditions. Their main complaint: Poor medical care.

The system’s oversight, too, is limited. Members of the watchdog body tasked with monitoring Japan’s 17 detention centers are appointed by the justice minister, who oversees the detention system. The findings of the watchdog are edited by the Justice Ministry before being made public, and the ministry has failed to act on repeated recommendations for improving medical care, say its members.

“I wanted to shout at them when I heard that guards left him alone for such a long time,” said Tooru Tsunoda, a doctor and vice chairman of the watchdog body that monitors the center where Fernando died. A report by the oversight group said guards “misjudged the seriousness” of Fernando’s condition. By not sending him to hospital immediately, the report found, they “missed opportunities to avoid his death.”

“By not sending him to hospital immediately, they ‘missed opportunities to avoid his death.’” Report by immigration detention watchdog body on Niculas Fernando’s death

Justice Minister Mitsuhide Iwaki said the reports he received showed that in all four deaths, “appropriate medical steps” had been taken. “I do not acknowledge there were problems in the responses or the medical care provided.”

Fernando, who ran a travel agency back in Sri Lanka specializing in pilgrimages, hadn’t seen his son George for eight months when he reached Japan. Before he left home, he visited the many churches in his coastal hometown of Chilaw and “prayed for 24 hours,” said his wife, Magret.

A framed picture of Fernando sits on a table in the home where he and Magret lived from the time they wed in 1983. They had fallen in love and married within a month, even though Fernando’s family had initially opposed the union because Magret was nine years his elder.

The day before he died, Fernando called Magret from a payphone for inmates in the detention center. “He was not ill,” she said.

Sitting on a sofa and weeping quietly, she recalled Fernando’s last words before boarding the plane for Japan: “I’ll come back. Look after the children.”

He never returned. In fact, Fernando never made it through immigration at Tokyo’s Haneda Airport.

George and his wife waited in the arrival hall for Fernando after his plane landed at around 11 p.m. on Nov. 12. At 2 a.m. they learned Fernando had been detained by immigration officials who did not believe he was a genuine tourist.

“We would have loved to hear our father’s voice, but they didn’t give him the chance to talk to us,” said George, 27, speaking in Sinhalese through an interpreter at his apartment.

Two days later, George got to see his father. They met in a small room at Haneda Airport, separated by a glass partition.

“We couldn’t touch or hug,” said George.

George and his two brothers portray their father as a devoted family man who prayed daily, never drank and often took his family with him on work trips around Sri Lanka and India.

“He’d pray for at least an hour every morning, bowing down,” said his eldest son, Jerad, standing outside the home of a relative in a village near Chilaw. “His knees were black from the marks made from praying.”

One family photo shows Fernando playing a guitar as Catholic pilgrims dance behind him during a 2012 tour of churches in the north of Sri Lanka. George recalls his father joining a peace mission to a Tamil Tiger-controlled area in the late 1990s led by Bishop Malcolm Ranjith during Sri Lanka’s civil war.

Fernando “voluntarily joined our group and went as part of our pilgrimage,” Ranjith, who is now archbishop of Colombo, told Reuters. He described Fernando as “a very pious person.”

Fernando also was active in one of Sri Lanka’s main political parties, and that background may be key to understanding a surprising decision he made during his detention - to ask for asylum.

George said his father was a supporter of the United National Party (UNP), which now heads the ruling coalition in Sri Lanka, and had been the target of political violence in the past. With speculation growing that national elections were imminent, Fernando timed his visit to Japan so he could sit out the vote and escape any potential violence, George said.

But facing deportation after his arrest at Haneda Airport, Fernando decided to seek asylum, which would have allowed him to stay in Japan while his request was processed. He was going to return home once any election-related violence had subsided, his son said.

Elections in Sri Lanka were formally announced on Nov. 20. Fernando died two days later, before he could file the asylum papers, George said.

George and his Sri Lankan wife have been seeking asylum themselves in Japan for almost two years. A copy of his application says George faced death threats from political rivals when he worked for the UNP, which was in opposition at the time he sought asylum.

Asylum applications have jumped more than six-fold since Japan altered its immigration rules in 2010. The change allowed asylum seekers to obtain six-month renewable work permits while their applications are reviewed. But Japan is sparing when it comes to granting asylum: Only 27 people were approved in 2015.

The rule change, combined with Japan’s chronic labor shortage and strict immigration policy, has spawned a system of backdoor immigration, as Reuters illustrated last year in an article detailing Subaru’s heavy reliance on asylum seekers who toil in the factories that supply it with car parts.

Five days after arriving, Fernando was transported from a lock-up at the airport to the Tokyo Regional Immigration Bureau, a tower block overlooking the docks and a waste-incineration plant. A one-stop shop for visa renewals, asylum interviews and deportation orders, the complex also serves as a detention center for up to 800 people.

Fernando was placed in a cell in G-Block with two other detainees, from China and Peru. Fellow detainees described him as a serious man obsessed with cleanliness.

On the Saturday morning Fernando died, James Burke, a Canadian in the adjacent cell, was awakened by the Sri Lankan’s cries. It was around 7 a.m. Noise travels easily on the block and Fernando was in obvious pain, Burke said. “He was moaning and moaning and moaning.”

Fernando’s Peruvian cellmate called the guards and told them the Sri Lankan wanted to go to the hospital because his chest was hurting. The guards refused, saying the hospitals were closed on Saturdays, according to Burke and two other detainees who witnessed the events and asked not to be named.

At least two hospitals within a few miles of the detention center are open around the clock on weekends, including Saiseikai Central Hospital, where Fernando’s body would be taken later that day. Naoaki Torisu, a senior Justice Ministry official who oversees immigration detention, declined to comment on what specifically the guards told Fernando.

“His symptoms didn’t seem that serious,” Torisu said. “If his condition had worsened, we would have called an ambulance or taken him to hospital without hesitation.”

At 7:30 a.m., guards measured Fernando’s pulse and blood pressure, according to an internal report by the Tokyo Regional Immigration Bureau that was reviewed by Reuters. They found no abnormality, Torisu said.

But Fernando soon called for the guards again, this time more loudly. “He’s in real discomfort,” recalled Burke, who was being held at the time for overstaying his visa and is now on provisional release from immigration detention. “He was begging them, ‘I’m a Christian and I wouldn’t lie. I need to go to hospital or I’m going to die.’”

Just before 8 a.m., guards led Fernando to a room to check his condition. A report by the national Immigration Bureau, which is part of the Justice Ministry, said the guards “could not grasp the seriousness” of the situation because another Sri Lankan detainee who was acting as an interpreter did not translate Fernando’s words accurately. But the Justice Ministry’s Torisu told Reuters the guards did understand what Fernando was saying.

When the Sri Lankan returned to his cell a short while later, he looked relieved, said Burke. He gathered his Bible and clothes. “You could see it in his face – he was getting his stuff, thinking he would get help.”

“Japan’s immigration authorities must take responsibility for my father's death.” Niculas Fernando’s son George

But Fernando wasn’t taken to hospital. At 8:16 a.m., guards moved him to an observation cell fitted with closed-circuit television for around-the-clock surveillance of detainees who are ill, unruly or have tried to harm themselves.

Around 9 a.m. Fernando again called the guards from the cell. They told him to wait until the morning roll call was over, said Burke and two other detainees.

At 9:22 a.m., Fernando washed his hands and appeared to vomit. He then lay face down on a futon, according to the Tokyo Regional Immigration Bureau report on his death. At 9:33 a.m., he stopped moving.

A few minutes later, a guard brought a television to Fernando’s cell. He called out but Fernando didn’t respond. Thinking the Sri Lankan was asleep, the guard didn’t check to see if he was all right, the report said. For the same reason, guards did not check Fernando for the next several hours.

Immediately after cell doors opened at 1 p.m. to allow detainees out for the afternoon break, the Sri Lankan who had interpreted for Fernando hurried to the observation cell. Fernando’s breakfast – the standard white bread, jam and boiled egg – lay untouched. Fernando wasn’t moving. His body was cold.

Alerted by the detainees, guards rushed into the observation cell. It was 1:03 p.m. – three and a half hours since Fernando had last shown any signs of life.

Detainees described scenes of pandemonium as inmates crowded the corridor leading to Fernando’s cell. Anticipating unrest, some guards laid out helmets, shields and batons.

A guard performed CPR on Fernando, but it was too late.

An ambulance was called and his body was carried out of G-Block on a stretcher, his face uncovered, two detainees said. Two hours later, he was pronounced dead. He was 57 years old.

Koichi Uemura, a coroner asked by the national Immigration Bureau to write an in-depth autopsy report on Fernando’s death, told Reuters he was allowed to view the video footage of the Sri Lankan in the observation cell. He said it was possible to tell from the images that Fernando was struggling and moaning before he lay down in the cell.

Uemura said he was asked to compile a report after the Immigration Bureau had investigated Fernando’s death and found that “there was quite a high possibility that (the detention center) did not provide adequate medical care, and that his illness got worse because he was left unattended.” A doctor at the Tokyo Medical and Dental University who performs autopsies for the police and courts, Uemura stopped short of saying that Fernando’s death could have been avoided if guards had taken him to hospital.

The Justice Ministry rejected a public disclosure request by Reuters to view the video footage of the observation cell, citing privacy reasons.

Since 2010, the Immigration Detention Facilities Visiting Committee – the watchdog body – has repeatedly called for improvements to medical care at detention facilities. Six current and former members of the 20-person oversight body told Reuters that key recommendations have not been implemented.

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Inmates voice a similar grievance. In two handwritten letters, the hunger strikers at the detention center in Osaka complained about limited access to doctors and said guards without medical training were making judgment calls about the health of detainees.

Their protest didn’t impress the authorities. Tomohisa Takayama, a spokesman for the Osaka Regional Immigration Bureau, said there was no “rational reason” for the complaints, and that the hunger strike ended after five days.

In May, a former member of the watchdog wrote to then-Justice Minister Yoko Kamikawa calling for full-time doctors at detention facilities, better monitoring of detainees who are unwell and improved psychiatric care.

But the watchdog lacks teeth. It doesn’t perform surprise inspections. Its visits to detention centers are pre-arranged, and its members are escorted by immigration officials.

There has been little change since the deaths. Guards have been given “fresh instructions to call ambulances” in situations where they are having trouble “making judgments,” said the Justice Ministry’s Torisu. And two guards are being trained as assistant nurses in the entire detention system, which on Nov. 1 last year was holding 1,070 inmates.

It is “probably insufficient” that there are no doctors on duty at weekends, but that doesn’t mean medical care is lax, said Torisu.

On Nov. 22, the day Fernando died, George got a call from a family friend. “He asked me to calm down, to sit down,” George recalled, his eyes filling with tears. “He told us my father had passed away… I asked God why he took my father.”

The next day, George tracked Fernando’s body to a police station near the detention center. Officers there tried to stop him from opening the white body bag that contained his father’s body.

“But I opened the bag,” he said. “I asked them if they were investigating my father’s death. They said they were, and when they had the report they’d tell me.”

George has never received any of the reports on his father’s death. On Dec. 19, almost a month after he lost his father, George received the death certificate. It didn’t contain the answer he’d been seeking: Cause “unknown,” it said.

That same day, Fernando was cremated about three miles from the detention center where he died. His family had hoped for a Catholic burial in Chilaw, but could not afford to fly his body home. His third son, Jude, who traveled to Japan for the funeral, is also now seeking asylum.

It would be another three months before Fernando’s family learned from Sri Lanka’s Foreign Ministry that he had died of a heart attack.

“I can't believe that I lost my father,” said George. “Japan’s immigration authorities must take responsibility for my father's death.”

The Justice Ministry has not made public the findings of the investigation into the case nor released them to Fernando’s family.

In response to a public disclosure request, Reuters received a copy of the national Immigration Bureau’s report from March last year. It was heavily redacted. Under a section titled “Problems,” every line had been blacked out.

PATCHY CARE: Detainees mill around the Tokyo detention center where Fernando died. Doctors visit the center, which holds hundreds of inmates, three times a week for a few hours. REUTERS/Yuya Shino INSIDE VIEW: A cell at the East Japan Immigration Center in Ibaraki prefecture. In March 2014, two inmates died at the detention center in the space of two days. REUTERS/Yuya Shino CRITICAL DECISIONS: Guards with little medical training are making important decisions about the health of detainees. Here, guards are seen at the East Japan Immigration Center in Ibaraki prefecture. REUTERS/Yuya Shino ADEQUATE CARE: Justice Ministry official Naoaki Torisu says the fact that there are no doctors on duty in detention centers at weekends doesn’t mean medical care is lax. The picture shows a medical treatment room at the East Japan Immigration Center. REUTERS/Yuya Shino DEATH ON CAMERA: Niculas Fernando’s death at the detention center in the Tokyo Regional Immigration Bureau building, seen here, was captured on closed-circuit television. The Justice Ministry declined a Reuters request to view the footage. REUTERS/Yuya Shino

Additional reporting by Shihar Aneez in Chilaw and Antoni Slodkowski in Tokyo.