ACLU, AMERICAN OVERSIGHT, AND PHR RESEARCH REPORT

Deadly Failures

Preventable Deaths in U.S. Immigration Detention

AMERICAN

OVERSIGHT

PHR

Physicians for
Human Rights

Executive Summary

1

ACLU, AMERICAN OVERSIGHT, AND PHR REPORT

Deadly Failures

Preventable Deaths in U.S. Immigration Detention

© 2024 ACLU, AMERICAN OVERSIGHT, AND PHYSICIANS FOR HUMAN RIGHTS

ACLU

AMERICAN

,OVERSIGHT

Physicians for
Human Rights

Acknowledgements
This report is dedicated to the memory of people who
have perished after enduring immigration detention.

Lead Authors
Eunice Hyunhye Cho (ACLU National Prison Project);
Tessa Wilson (Physicians for Human Rights)
Contributing Authors
Andrew Free; Anna Skarr (formerly Physicians for
Human Rights)
Medical Expert Reviewers
Drs. Chanelle Diaz, Michele Heisler, Elena JiménezGutiérrez, Katherine McKenzie, Ranit Mishori, and
Radha Sadacharan
FOIA Requests and Litigation
This report relies heavily on materials discussed in
publication for the first time and obtained under the
Freedom of Information Act by Aadam Barclay and
Taylor Stoneman (American Oversight), and Andrew
Free. The authors also thank Buzzfeed News, the
Project on Government Oversight, the Young Turks,
Transgender Law Center, and Jose Olivares, for
publicly posting or sharing materials obtained under
FOIA or state public records acts, which also formed
the basis of this report.
Report Coordination
Eunice Hyunhye Cho (ACLU National Prison
Project); Aadam Barclay, Alissa Lopez, Dera
Silvestre, Taylor Stoneman (American Oversight);
Anna Skarr, Brittney Bringuez, Christian De Vos,
Tessa Wilson (Physicians for Human Rights)
Research Interviews
Eunice Hyunhye Cho (ACLU National Prison
Project); Anna Skarr, Tessa Wilson (Physicians for
Human Rights)

Research Support
Jessica Carns, Samantha Weaver (ACLU National
Prison Project); Marina Jerry, Maya Mackey,
Analiese Vasciannie, Jack Warshal (ACLU National
Prison Project interns); Anna-Theresa Unger
(Physicians for Human Rights intern)
Report Review
David Fathi, My Khanh Ngo, Naureen Shah, Kyle
Virgien (ACLU); Alissa Lopez, Amanda Teuscher,
Chioma Chukwu, Taylor Stoneman (American
Oversight); Christian De Vos, Michele Heisler, Karen
Naimer, Saman Zia-Zarifi (Physicians for Human
Rights); Adam Richards (Physicians for Human
Rights Board), Parveen Parmar (Physicians for
Human Rights expert)
Photos
Eunice Cho; Family of Carlos Escobar Mejia; Family
of Jean Jimenez; Family of Jesse Dean; Family of
Carlos Mejia Bonilla; Tania Bernal; Family of Maria
Ochoa Yoc; Neda Samimi Gomez; Jose Olivares;
Tammy Jane Owen; Mike Mirminian
Report Design
Patrick Moroney
Special Thanks: David Fathi (ACLU National
Prison Project); Emily Greytak (ACLU Research);
Maribel Hernandez Rivera, Silvana Caldera, and
Anu Joshi (ACLU NPAD), Gabby Arias (ACLU
Communications); Sara Neel (ACLU of Colorado);
Tammy Owen; Neda Samimi Gomez; Clara Long;
Rebecca Cassler; Jeremy Jong; Jose Olivares
(formerly of the Intercept and NY Public Radio)

Contents
Executive Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Summary of Findings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Key Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Methodology.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Findings and Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
ICE’s Current Oversight and Accountability Mechanisms Regarding Death in
Detention Are Critically Flawed and Do Little to Prevent Future Deaths.. . . . . . . . . . . . . . . 26
ICE’s detention death investigations have allowed the destruction of
evidence, have failed to interview key witnesses, and have omitted key
inculpatory facts... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Detention death investigations fail to include analysis of key structural
factors that have led to death of detained people, and ICE fails to require
systemic changes that would prevent future deaths in custody. . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
ICE’s oversight process has failed to result in meaningful consequences
for detention facilities.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Systemic Failures in Medical and Mental Health Care Have Caused
Preventable Deaths in ICE Detention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
The overwhelming majority of deaths of detained immigrants could have
been prevented if ICE had provided clinically appropriate medical care.. . . . . . . . . . . 34
Medical staff made incorrect or incomplete diagnoses in the overwhelming
majority of deaths... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Incomplete, inappropriate, or delayed treatment or medication. . . . . . . . . . . . . . . . . . . . . . . . . 37
Flawed or delayed emergency response. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Suicides caused by failure to provide mental health care, properly manage
medication, and adequate mental health staff. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Failure to provide necessary and required interpretation and translation
by medical and mental health providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Failure to follow COVID-19 protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Chronic understaffing, inadequate and improper staff training, and care
outside the scope of practice. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Insufficient and falsified documentation of patient checks and provision
of medical care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Conclusion and Full Recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Appendix. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Endnotes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Executive Summary
Since January 1, 2017, Immigration and Customs
Enforcement (ICE) has reported that 70 people have
died in its custody. This number does not include
detained people who ICE released immediately prior
to their deaths, which ICE has admitted reduces the
number of reported deaths, and allows the agency
to avoid accountability requirements.1 These deaths
raise serious concern about continued, systemic
problems with medical and mental health care
provided in immigration detention facilities, and

ICE currently detains, on
average, approximately 38,000
people each day in a network
of approximately 130 detention
facilities nationwide.
the absence of accountability or consequences faced
by facilities where detained people have died. ICE
currently detains, on average, approximately 38,000
people each day in a network of approximately 130
detention facilities nationwide. 2 Congress, however,
recently increased ICE’s budget to detain 41,500
people on a daily basis for FY 2024, at a cost of $3.4
billion.3
This report, a joint project of the American Civil
Liberties Union (ACLU), Physicians for Human
Rights (PHR), and American Oversight, provides
a comprehensive examination of the deaths of 52
people whom ICE reported to have died in its custody

6

between January 1, 2017 and December 31, 2021.
Our analysis is based on a review of over 14,500
pages of documents obtained from the Department
of Homeland Security (DHS) and ICE through
Freedom of Information Act (FOIA) requests; from
local government agencies through state public
record act requests; and from civil litigation. Report
analysis also incorporates the review of ICE’s own
investigatory reports into deaths in custody by
independent medical experts, as well as interviews
with two family members of people who died in ICE
detention during the studied period.
Deadly Failures exposes the ways in which the
Department of Homeland Security’s (DHS) internal
oversight mechanisms have failed to conduct
rigorous investigations, impose meaningful
consequences, or improve conditions that cause
immigrants to die in ICE detention. Based on
independent medical expert reviews of deaths, the
report further examines the ways in which systemic
failures in medical and mental health care in ICE
detention have caused otherwise preventable deaths.

Summary of Findings
Key findings from our study include:
ICE’s current oversight and accountability
mechanisms regarding death in detention are
critically flawed and do little to prevent future
deaths.
• ICE’s detention death investigations have
allowed the destruction of evidence, have

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

failed to interview key witnesses, and have
omitted key inculpatory facts.
• In at least two different cases, ICE released
key detained eyewitnesses from custody
immediately before investigators could
speak to them, and investigators did not
further attempt to make contact with these
eyewitnesses. For example, ICE released
detained eyewitnesses from custody mere
hours before—and even during—investigator
facility visits regarding the deaths of Ben
Owen and Efrain de la Rosa.
• In at least two cases, ICE allowed detention
facilities to destroy or overwrite video
evidence critical to its investigations into
detention deaths. Detention facilities
destroyed video evidence highly relevant to
investigations into the deaths of Roxsana
Hernandez and Gourgen Mirimanian.
• ICE’s investigatory reports omit critical facts
that may embarrass, or suggest fault by,
detention facilities or ICE in cases of detainee
death. For example, ICE investigatory reports
failed to disclose that internal oversight staff
had ignored reports of dangerous conditions
in the death of Efrain de la Rosa. ICE
investigators also chose to omit evidence that
the Kay County Detention Center failed to
accurately translate Maria Celeste Ochoa
de Yoc’s requests for medical attention.
Because Kay County staff did not speak
Spanish, they interpreted Ochoa’s statement
that “she felt like she was dying” as suicidal
ideation, placing her in solitary confinement
under suicide watch, instead of providing her
proper treatment for liver failure. Ochoa died
soon after.
• ICE lacks standardized criteria for
autopsies and autopsy reports in cases of
detention deaths, leading to inconsistent and
potentially unreliable results.
• DHS and ICE investigations into detention
deaths exclude analysis of key structural

factors that have led to the deaths of
detained people, and fail to require systemic
changes that would prevent future deaths in
custody.
• Detention death investigations typically
focus on and assign blame to the lowestlevel employees involved, but fail to address
facility-wide policies and practices, and do not
consider those who have the most authority
to address these factors. Investigators also
frequently fail to make recommendations for
policy changes that would prevent similar
deaths in the future.
• ICE’s oversight process has failed to result
in meaningful consequences for detention
facilities, including those whose conditions
have caused the greatest number of deaths.
• Although Congress has legislated that ICE
cannot expend funds on detention facilities
that have failed two consecutive agency
inspections, ICE has not terminated any
detention contract and no facility has failed
an ICE inspection in the period covered by
this report, even where ICE’s death reviews
have found multiple violations of detention
standards.
• To the authors’ knowledge, ICE has issued
financial penalties against detention facilities
on only three occasions out of the 70 deaths
that have taken place between 2017 and June
2024, the date of this report’s publication.
These financial penalties, however, had little
impact on contractors’ bottom line, as ICE
soon after expanded the scope of its detention
contacts at the facilities in question.
Systemic failures in medical and mental health
care have caused preventable deaths in ICE
detention.
• The overwhelming majority of deaths
likely could have been prevented if ICE had
provided clinically appropriate medical
care. Medical experts concluded that of the
52 deaths reported by ICE between January 1,

Executive Summary

7

2017 and December 31, 2021, that 49 deaths (95
percent) were preventable or possibly preventable
if appropriate medical care had been provided.
Only three deaths were deemed not preventable.
• Medical experts considered a death to be
preventable where the person’s life could
have been saved or the outcome could have
been different with appropriate medical care;
a death was considered possibly preventable
where there was a reasonable possibility that
the person’s life could have been saved or
the outcome could have been different with
appropriate medical care.

or took a chest x-ray. Two days later, Reyes
Clemente died in a medical isolation cell.
• ICE detention medical staff provided
incomplete, inappropriate, or delayed
treatment and medication. In 79 percent
of the 52 death cases reviewed, ICE detention
medical staff provided treatment that did not
meet evidence-based medical standards, was
inadequate to resolve the medical issue, or was
unreasonably delayed. Medical staff also failed
to appropriately manage necessary medication,
and prescribed contraindicated medications. For
example:
• Carlos Mejia-Bonilla struggled to receive
his prescribed medication for cirrhosis while
detained at the Hudson County Department
of Corrections and Rehabilitation in New
Jersey. Ultimately, the facility’s careless
approach to medication management may
have proved fatal. Mejia-Bonilla died of
gastrointestinal bleeding four days after
the detention facility prescribed him with
naproxen, which is contraindicated for
patients with cirrhosis.

• ICE detention medical staff made
incorrect or incomplete diagnoses in the
overwhelming majority of cases of death.
In 88 percent of the 52 death cases reviewed,
ICE detention medical staff made incorrect,
inappropriate, or incomplete diagnoses. For
example:
• Jesse Jerome Dean, Jr. died in ICE custody
from an undiagnosed gastrointestinal
hemorrhage after his detention at the
Calhoun County Jail in Michigan. Although
Dean was unable to eat, lost almost 20
pounds in three weeks, and suffered from
severe nausea, the detention facility’s
medical staff never even referred Dean to be
seen by a physician. The night before Dean’s
death, medical staff moved him to the medical
observation unit after he had collapsed to
the floor. But no one checked on him that
night: surveillance footage showed that “for
at least 2 hours and 45 minutes throughout
her shift, [the nurse] was reclining in the
nursing station chair with her feet propped
up, texting on her cell phone.”4
• Emigdio Abel Reyes Clemente died
of undiagnosed and untreated bacterial
pneumonia, after the detention facility
medical staff assumed, without testing, that
he had influenza. The detention facility never
prescribed antibiotics, provided oxygen,

8

• Wilfredo Padron died of a heart attack
at the Monroe County Detention Center
in Florida after detention facility medical
staff failed on multiple occasions to conduct
an EKG test or refer him to a doctor when
he complained of radiating chest pain and
elevated blood pressure.
• Medical staff at the Aurora Detention
Center in Colorado discontinued medication
assisted treatment for opioid use disorder
that Kamyar Samimi had been prescribed
and had used for over two decades, putting
him into withdrawal. Samimi deteriorated
rapidly, experiencing nausea, repeated
vomiting to the point of vomiting blood, and
seizures, until he passed away sixteen days
later.
• ICE detention facilities failed to provide
timely and appropriate emergency care.

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

In 40 percent of the 52 death cases reviewed,
ICE detention facilities failed to provide timely
emergency health care or operable emergency
equipment.
• Henry Missick (a/k/a Anthony Alexander
Jones) died alone of a heart attack at
the Adams County Detention Center in
Mississippi, after medical staff failed to check
on him in the medical unit waiting room.
Medical staff did not discover him until 45
minutes after his heart attack and waited
another 10 minutes before they initiated
CPR. An ambulance did not arrive until 42
minutes after first being called.
• After staff discovered that Nebane Abienwi
had suffered a stroke at the Otay Mesa
Detention Center, it took 50 more minutes
for emergency medical services to arrive
and provide the required higher-level care,
because the on-call medical provider at
the detention facility did not respond to a
nurse’s request for authorization to call an
ambulance.
• After Huy Chi Tran was found unresponsive
in his cell due to cardiac arrest at the Eloy
Detention Center, medical staff failed to
place automated external defibrillator pads
in the correct position on his chest, and had
no backup pads when the equipment failed to
properly adhere to his body.
• Confusion over who was responsible for
calling an ambulance among staff at the El
Valle Detention Facility in Texas caused a
half-hour delay in calling an ambulance for
Elba Maria Centeno Briones after her
oxygen levels dropped dangerously low.
• ICE detention facilities have faced repeated
and increased deaths by suicide due to their
failure to provide adequate mental health
care, manage psychiatric medication, and
ensure sufficient staff.
• Efrain de la Rosa deteriorated for weeks
and ultimately died by suicide at the Stewart

Detention Center in Georgia after medical
staff failed to ensure that he receive his
prescribed antipsychotic medication used
to treat his schizophrenia. After he died by
suicide, nursing staff falsely recorded their
administration of psychiatric medication.
• Mergansana Amar died by suicide at the
Northwest Detention Center in Washington
within hours after ICE officers told him
that the Board of Immigration Appeals had
denied his case and that ICE had scheduled
his deportation to Russia. Although Amar
had exhibited several warning signs of
suicidal ideation the previous days, ICE
failed to provide him mental health support
upon providing him news of his impending
deportation. Moreover, had ICE officers fully
informed Amar of his rights while providing
him news of his deportation, he might have
known that he could have further appealed
his case and requested a stay of removal to
prevent deportation during his appeal.
• ICE detention facilities have failed to
provide necessary interpretation and
translation to detained people who do not
speak English.
• The nurse on duty at the La Paz County Adult
Detention Facility in Arizona confirmed that
the only words Simratpal Singh seemed to
know in English were “court” and “lawyer,”
but decided that he did not exhibit any
suicidal ideations based on her observation
of his appearance alone. The facility provided
no security rounds of Singh’s cell to ensure
suicide prevention. Three days after he was
detained at the facility, Singh died by suicide.
• ICE detention facilities failed to take basic
precautions during the COVID-19 pandemic,
depriving detained immigrants of basic
protections such as soap and masks during a time
where no vaccine or antiviral treatment existed.
ICE transferred detained people from facilities
with COVID-19 outbreaks across the country,
further spreading the virus, and delayed or failed

Executive Summary

9

to release medically vulnerable people from
custody in time for them to avoid the virus.
• James Thomas Hill, a 72-year-old man,
died of COVID-19 after contracting the virus
at the Immigration Centers of America
Farmville in Virginia, during a time when no
vaccine or antiviral medications for the virus
were available. Although an immigration
judge had ordered Hill removed in May 2020,
ICE did not set his deportation flight back to
Canada until two months later. This delay
proved fatal: Hill soon contracted COVID-19
after ICE transferred dozens of people from
detention facilities in Florida and Arizona
that had recently experienced COVID-19
outbreaks.
• ICE detention facilities have consistently
failed to provide adequate medical and
mental health staff who are trained and
licensed to ensure patient health and safety.
Health care providers in detention facilities
frequently provide care outside their licensed
scope of practice. ICE detention facilities rely
heavily on the lowest-level providers, and often
prevent detained patients from receiving care
from doctors. In 44 percent of the 52 detainee
death cases reviewed, records indicated serious
staffing issues, including shortages, improper
training, or care outside the scope of practice.
• Kamyar Samimi died after medical staff
at the Aurora Detention Center in Colorado
discontinued medication assisted treatment
for opioid disorder. At the time of his death,
the facility had only one doctor responsible
for the entire facility and left multiple medical
positions vacant. Samimi never received
a health appraisal by either a physician or
registered nurse during his detention. ICE’s
own investigation concluded that “clinical
supervision was inadequate to assure
adherence to provider orders and necessary
and appropriate care.”5
• Jean Jimenez died by suicide at the Stewart
Detention Center in Georgia after failing to

10

receive timely mental health care treatment.
At the time of Jimenez’s death, Stewart
provided tele-psychiatry to detained people
for six hours a week—a level of less than 20
precent of required staffing, with backlogs of
10-12 weeks for mental health services.
• ICE detention staff falsified or made
improper or insufficient documentation of
patient checks and provision of medical care
in 61 percent of detainee death cases.
• Detention center officers at the Baker County
Detention Center in Florida falsified records
to show that they had conducted wellness
checks of Ben Owen in the hours before
he was discovered to have died by suicide.
The officers, moreover, reported that their
method of logging security rounds without
making visual contact of detained people
was consistent with their training and an
accepted practice at the facility.

Key Recommendations
To the Department of Homeland Security:
ICE’s reliance on immigration detention is
unnecessary, expensive, and deeply harmful. We
strongly urge that ICE dismantle the mass
immigration detention machine. ICE should
phase out the immigration detention system,
invest in community-based social services
instead of placing people in detention, and avoid
surveillance of immigrants as an alternative
to detention. As ICE shifts from a detentionbased system, ICE should adopt the following
recommendations to reduce the number of people
held in detention and prevent deaths of people in
detention:
• Issue a directive ensuring the prompt
release from ICE detention of people with
medical and mental health vulnerabilities.
It should include a presumption of release
for people with medical and mental health

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

vulnerabilities, ensure prompt medical screening
of detained immigrants to identify those who face
increased medical and/or mental health risk in
detention, and set forth procedures to ensure the
prompt release of these individuals from custody.
• Immediately release from ICE detention
people who have prevailed in their
immigration cases before an Immigration
Judge, instead of continuing detention upon
ICE’s administrative appeal.
• Require the release of people from and
prohibition of the use of ICE detention
facilities upon a finding by DHS’s Office of
Civil Rights and Civil Liberties that health
and safety standards are not being met, or
cannot be met.
• Prohibit solitary confinement. Until it is fully
prohibited, issue and implement a directive
barring solitary confinement for anyone who
has a disability, has a diagnosed mental health
condition, is pregnant, postpartum, or caring for
a child, or has identified or is known or perceived
to be LGBTQ+ or gender non-conforming.
• Ensure meaningful consequences for
detention facilities that have caused deaths
of detained people. Promptly terminate ICE
detention contracts for facilities with any death
resulting from substandard medical and mental
health care, including deaths that occur within 30
days of release from custody.
• Undertake full, comprehensive, and
unbiased investigation of deaths in
detention. Ensure preservation of all relevant
evidence, and ensure that interviews of detainee
witnesses are conducted and included in death
investigations and ensure protection from
retaliation and deportation of detainee witnesses.
Require that all detention facilities provide
investigators unimpeded access to staff and
contractors, and require full physical autopsies
and full-spectrum forensic toxicology screen for
all people who die in custody, and psychological
autopsies for any apparent suicides.

• Provide timely, quality medical and mental
care to all in ICE detention, with the caveat
that increased funding for detention has not
resulted in improvement of health conditions for
those in detention.
• Ensure that all detention facilities, whether
care is provided by ICE Health Service
Corps (IHSC) or another entity, are bound
by IHSC directives and standards for the
provision of medical and mental health care
through contract modifications or uniform
updates to all detention standards. Violations
of these directives and standards shall be
immediately remedied.
• Ensure that all detention facilities are
bound by, and in compliance with, the 2016
Performance Based National Detention
Standards.
• Ensure routine collection and reporting
on the number of individuals in detention
with medical vulnerabilities, including
chronic conditions, communicable and noncommunicable diseases, and severe mental
illness.
• Ensure that all detention facilities provide
sufficient and adequate levels of health care
staffing by tracking and publishing vacancy
rates for medical and mental health staff at
each facility.
• Require that detention population levels do
not exceed medical and mental health staffing
levels for the facility at any time.
• Ensure that all ICE detention facilities
strictly prohibit medical and mental health
professionals from practicing outside the
scope of licensed practice, and improve
access of those in detention to physicians,
nurse practitioners, and physicians’
assistants.
• Ensure that all healthcare and detention staff
are trained in and routinely participate in
emergency (code) drills.

Executive Summary

11

• Ensure that all facilities are required
to provide medical interpretation at all
encounters, and that metrics of rates of
medical interpretation use are publicly
reported.
• Create and enforce protocols for strict
documentation and reporting of acute
medical situations.
• Create and enforce protocols for immediate
consultations 24/7 with physicians on call. ​​
• Ensure that all ICE detention facilities
provide translation and interpretation for
all medical encounters, including the ability
to request medical care, in accordance with
Performance-Based National Detention
Standards (PBNDS) standards.
• Ensure that all ICE detention facility medical
staff are trained in and utilize screening
tools for the Clinical Institute of Withdrawal
Assessment (CIWA) and Clinical Opiate
Withdrawal Symptoms (COWS).
• Create, enforce, and audit protocols and
implementation of regular wellness checks,
every 15 minutes, to engage with the person
in custody, evaluate and treat any urgent
health needs, and attempt de-escalation if
needed. ​​
• Create and enforce protocols for routine and
frequent inspection of medical equipment​​.
• Perform regular quality audits of medical
documentation and create mechanisms to
identify gaps in management, errors, and
other practice failures.
• Comply with Requests for Public Records
Under the Freedom of Information Act.
Comply with FOIA requests more expeditiously,
apply a “presumption of openness” at the outset
when evaluating records, and share with the
requester information about the scope of the
agency’s search.

12

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

To the Department of Justice:
• Ensure full implementation of the Death in
Custody Reporting Act (DCRA). Ensure that
DHS fully complies with its reporting obligations
under the DCRA, and releases annual reports on
key data trends of deaths in DHS custody.

​​​To Congress:
• Substantially reduce funding for
immigration detention. Increase funding
for community-based social support and legal
representation programs as alternatives to
detention that are far more effective and humane.
• Conduct rigorous oversight of detention
conditions, including through hearings with
senior government officials. Request a GAO
investigation into ICE’s failure to prevent the
deaths of detained people, including those who
have died in custody and those who have died,
while hospitalized, within 30 days of release from
ICE custody.
• Require that ICE track, publicly report, and
investigate the death of any detained person
who died while hospitalized or within 30
days of release from ICE custody.
• Require that ICE make publicly available on
its website, as a matter of course, detainee death
reviews, Healthcare and Security Compliance
Analyses, Mortality Reviews, Root Cause
Analyses, autopsy reports, and psychological
autopsy reports, regarding all individuals who
have died in ICE custody or those who have died
while hospitalized, or within 30 days of release
from ICE custody. Ensure disclosure of cause of
death. Make only those redactions necessary to
comply with federal privacy laws.
• Require monthly publication of all medical
and mental health vacancies by facility,
as well as average length of time for detained
patients to be seen by a physician, physician’s
assistant, or nurse practitioner.

• Require that ICE make publicly available
within 30 days any corrective actions taken
to enforce contract terms for the provision of
medical or mental health care in ICE detention
facilities or any other contract violations that may
have contributed to a death in custody, as well
as ODO inspection reports, OPR detainee death
reviews, and IHSC mortality reviews.
• Hold ICE accountable for meeting specific
standards with regard to provision of care
and data reporting.
• Pass the Dignity for Detained Immigrants
Act (H.R. 2760/S. 1208), and the End Solitary
Confinement Act (H.R. 4972/S. 3409).
To State and Local Governments:
• Pass legislation to prohibit
intergovernmental services agreements
between state or local agencies and the federal
government for civil immigration detention,
and to prevent contract modifications to expand
detention.
• Pass local ordinances or legislation to
prohibit the physical expansion of detention
facilities that would allow increased capacity for
detention.
• Pass legislation that provides causes of
action against for-profit detention facilities
that deviate from contractually binding
standards.
• Require and ensure that local facilities that
detain people in ICE custody expeditiously
release and provide records relevant to deaths
in detention for release under FOIA.
• Pass legislation prohibiting 287(g)
agreements and collaboration with ICE in civil
immigration enforcement.

Executive Summary

13

Introduction
Medical and Mental Health
Care in ICE Detention
Immigration detention in the United States is
a relatively recent phenomenon: in the 1980s,
fewer than 2,000 people were held in immigration
detention nationwide.6 During the 1990s, however,
immigration detention expanded dramatically
following the passage of a range of criminal justice
and immigration laws,7 which are now widely
recognized as having fueled the mass incarceration
and detention of communities of color.
As of May 2024, ICE, under the direction of the
Department of Homeland Security (DHS), detains
over 36,000 people each day in approximately 135
detention facilities nationwide.8 As the federal law
enforcement agency responsible for enforcing laws

91% of people detained by ICE
are held in detention facilities
owned or operated by private
prison corporations.
ACLU analysis of ICE data

governing border control and immigration, ICE
frequently employs detention as a means of holding
people who may not have up-to-date immigration
paperwork to reside legally, asylum-seekers, or those
who are awaiting deportation.

14

Despite the legal distinction between civil detention
and criminal incarceration, ICE detention facilities
are carceral in nature. ICE frequently contracts with
prisons and jails to hold detained immigrants on its
behalf, with significant reliance on facilities owned
or operated by private prison corporations. In 2020,
under the Trump administration, 81 percent of people
detained by ICE were held in facilities owned or
operated by private prison corporations.9 Since then,
private prison control of the ICE detention system
has only grown. As of July 2023, 90.8 percent of
people detained by ICE are held in detention facilities
owned or operated by private prison corporations.10
Contracts with ICE continue to generate a significant
amount of revenue for private prison corporations
like the GEO Group, CoreCivic, LaSalle Corrections,
and the Management and Training Corporation
(MTC). In 2022, GEO made $1.05 billion in revenue
from ICE contracts; CoreCivic similarly made $552.2
million from ICE detention contracts in 2022.11
Medical and public health experts have widely
documented the significant harm to physical and
mental health suffered by people in detention.
Increased exposure to infectious disease, inadequate
nutrition, substandard health care, punitive practices
such as sleep deprivation, solitary confinement,
physical and psychological abuse have a cumulative
and measurable negative effect on detained people’s
health.12 Clinicians have noted the severe impact that
delayed access to care, medication interruptions,
and barriers to mental health care have had on
detained immigrants, even after release. A survey of
85 clinicians across the United States in 2022 found
that, of the approximately 1,300 patients they had

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

seen, all of them had experienced adverse health
conditions related to their time in detention.13
This report – a collaboration between the American
Civil Liberties Union, American Oversight, and
Physicians for Human Rights, focuses on systemic
failures in detainee death analyses and accountability
mechanisms employed by DHS, and deficient medical
and mental health care received by detainees in ICE
detention.
This report builds on previous reports published
by advocacy organizations including the ACLU,
Detention Watch Network, Freedom for Immigrants
(formerly known as Community Initiatives for
Visiting Immigrants in Confinement), Human Rights
Watch, and National Immigrant Justice Center
regarding deaths in ICE detention between 2010 to
2017,14 investigatory reports by journalists,15 as well
as research studies by medical and public health
researchers.16 Like these prior reports, Deadly
Failures examines publicly released records by ICE
about deaths in custody, including those obtained
as a result of FOIA litigation. In addition, this study
relies on a wider variety of DHS and ICE investigatory
reports developed during investigations into detainee
deaths, including Detainee Death Reviews, Health
Security Compliance Analyses, Mortality Reviews,
and independent autopsies. Where available, the
report analyzes internal agency email communications
and medical records obtained under FOIA and state
public records requests, publicly-available documents
obtained in litigation via discovery, such as emails,
deposition transcripts, and detention contracts, and
interviews with surviving family.

Background
Oversight of Medical and Mental Health
Care in ICE Detention
The ICE Health Service Corps (IHSC) is responsible
for oversight of medical and mental health care
for people in ICE detention. IHSC provides direct
medical and mental health care at 19 detention
facilities nationwide.17 Private prison companies

and local jails, however, are responsible for directly
providing or contracting medical and mental health
care at over 120 other ICE detention facilities--the
vast majority of facilities. Seventy-three percent, or
3 out of 4 detained people, are held at facilities where
on-site care is provided by non-IHSC staff, including
employees of private prison corporations, their
private medical contractors, or local government
staff.18
Although IHSC has promulgated directives regarding
the provision of medical and mental health care at
the 19 facilities in which it directly provides care,
these directives are not binding on the vast majority
of the ICE detention system. Instead, medical care
at facilities that are not staffed by IHSC personnel
are required to comply only with very general
requirements regarding the provision of medical
and mental health care included in one of five sets of
ICE detention standards.19 No single set of detention
standards is applicable to all ICE detention facilities;
each facility is subject to a different set of detention
standards by contract. Although ICE has pledged its
intention to update all facility contracts to adhere to
the most recent, and most stringent version of the
Performance Based National Detention Standards,
updated in 2016, 92 of 135 current detention facilities
are not subject to these standards.20
Instead, ICE has permitted scores of detention
facilities to abide by only lax standards for the
provision of medical and mental health care. For
example, the 2000 National Detention Standards,
which are still in effect in at least 19 facilities
nationwide,21 do not require a minimal time by which
the facility must conduct initial medical screening;
include no provisions for mental health care; do
not specify the minimal staffing levels or require
that medical staff are available at all times; do not
include minimal requirements for the provision or
prescribing of prescription medication; do not specify
requirements for accommodations in the delivery of
medical or mental health care to detained people with
disabilities; and have no gender-specific medical care
standards.22
The ICE Office of Detention Oversight (ODO)
conducts compliance inspections to assess

Introduction

15

compliance with detention standards. However, as
the DHS Office of Inspector General has noted, these
inspections are “too infrequent to ensure the facilities
implement all deficiency corrections,” and ICE “does
not adequately follow up on identified deficiencies or
consistently hold facilities accountable for correcting
them.”23 Moreover, ICE ODO inspections are not
comprehensive and focus only on a limited number
of standards.24 Because binding detention standards
often lack specificity to benchmarks for the delivery
of medical care, such compliance inspections mean
little in ensuring even a minimal standard of care at
facilities.
IHSC also states that it monitors the quality of
medical care provided at detention facilities where
on-site care is provided by private prison corporations
or local government staff with field medical
coordinator site visits. During these site visits, IHSC
staff are tasked with assessing facility compliance
with detention standards, and conducts a “Quality
of Medical Care” review against 20 medical care
practices.25 These site visits, however, are infrequent:
IHSC reportedly does “its best to go at least once
per year to each facility,” and such site visits may be
conducted virtually, not in-person.26 Moreover, as an
internal IHSC whistleblower complaint published
by Buzzfeed News in December 2019 noted, IHSC
has “systematically provided inadequate medical
and mental health care and oversight to immigration
detainees across the U.S.”27 Along with a series of
allegations of life-threatening lapses in medical
care affecting a child and adults in ICE custody, the
complaint includes claims that four deaths between
2017 and 2019 were linked to dangerous, neglectful
care that IHSC leadership knew or should have known
about but failed to address.28

immigrants died while detained in its custody (see
Table 1 and Figure 1). Of these, at least 14 people
died by suicide, while at least 9 people died as a
result of COVID-19.29 At least 15 died as a result of
cardiovascular disease. ICE has not publicly provided
a cause of death for 13 of the 68 deceased individuals.
These numbers, however, do not include people that
ICE detained, but formally released from its custody
while they were hospitalized, upon imminent death.
Between 2019-2021, ICE released at least three
detained people during hospitalizations prior to their
deaths, allowing the agency to avoid public reporting
and accountability requirements. These cases were
reported by the media only after family members or
advocates alerted the public.30 This suggests that the
death toll of people detained by ICE is likely higher
than officially reported, particularly in light of the
high incidence of COVID-19 in ICE detention and
fatality rates during the pandemic.31
TABLE 1.

Reported Deaths in ICE Detention, 2017–2024*
Year

Number of
Reported Deaths

2017

10

2018

11

2019

9

2020

18

2021

5

2022

3

2023

7

2024

7

Total

70

FIGURE 1.

Reported Deaths in ICE Detention, 2017–2024*
20

Reported Deaths in ICE Detention by the
Numbers, 2017-2024
This report primarily analyzes deaths that took
place between January 1, 2017 to December 31, 2021,
instead of all deaths to the present, because of ICE’s
failure to promptly release full records about deaths
in detention. However, between January 1, 2017 and
June 20, 2024, ICE reported that at least 70 detained

Number of
Reported Deaths

15

10

5

0
2017

2018

2019

2020

2021

2022

2023

*(as of June 20, 2024); Source: Immigration and Customs Enforcement

16

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

2024

ICE has failed to impose meaningful consequences
on facilities after a death has occurred, including
contract termination, and that oversight and
accountability measures have failed to address deadly
conditions.

Public Reporting of Deaths in ICE
Custody

Memorial for those who have died at Stewart Detention Center, 2024.
Photo: Eunice Cho

Between 2017 and 2024, at least ten people died after
being detained at the Stewart Detention Center in
Georgia, while at least six people died after being
detained at the Krome North Service Processing
Center in Florida. (See Table 2). Although healthcare
failures are systemic across ICE’s detention
network, repeated deaths raise grave concern that

Since its inception, ICE has only reluctantly
provided information about deaths in detention to
the public. Over the last two decades, advocates and
media representatives have had to resort to FOIA
litigation to obtain basic information regarding
the deaths of detained immigrants. In 2005, a
National Public Radio investigation into the deaths
of detained immigrants32 prompted a Congressional
investigation of the issue.33 ICE reportedly issued
standard procedures for deaths to be reported in
detail to headquarters, but actively fought to control
public disclosure of any information regarding these
cases.34

TABLE 2.

Highest Number of Deaths by Detention Facility, 2017–2024*
Name

Operator

Number of Reported
Deaths (2017–2024)

Stewart Detention Center, GA

CoreCivic, Inc.

10

Krome North Service Processing Center, FL**

Akima Global Services

5

Otay Mesa Detention Center, CA

CoreCivic, Inc.

4

Port Isabel Detention Center, TX

Ahtna Corp

4

Adelanto Detention Facility, CA

GEO Group, Inc.

3

Adams County Detention Center, MS

CoreCivic, Inc.

2

Denver Contract Detention Facility (Aurora), CO**

GEO Group, Inc.

2

Baker County Detention Center, FL

Baker County Sheriff

2

Calhoun County Jail, MI

Calhoun County Sheriff 2

Central Louisiana ICE Processing Center, Jena, LA**

GEO Group, Inc.

2

Karnes County ICE Processing Center, TX**

GEO Group, Inc.

2

Northwest ICE Processing Center, WA**

GEO Group, Inc.

2

Prairieland Detention Center, TX

LaSalle Corrections

2

Torrance County Detention Facility, NM

CoreCivic, Inc.

2

Winn Correctional Facility, LA

LaSalle Corrections

2

*(June 19, 2024)
**ICE has renamed
these facilities
between 2017-2024,
current name is listed.

Source: Immigration and Customs Enforcement

Introduction

17

In 2009, the ACLU filed a FOIA lawsuit for records
related to the approximately 107 deaths counted
in ICE custody since the creation of the agency
in 2003.35 As the New York Times reported based
on files recovered from the lawsuit, the Obama
administration also disclosed that one in 10
immigration detention deaths had been omitted
from a list submitted to Congress, and that the
agency had also discharged detainees shortly
before they died, leading to a reduction in the
number of reported deaths.36
In October 2009, ICE promulgated its first official
policy regarding detainee deaths, including
investigation, notification, and reporting
requirements. The directive outlined agency
requirements for notification of in-custody deaths to
next-of-kin, consular officials, members of Congress,
the media, and non-governmental organizations. The
directive also required the ICE Office of Professional
Responsibility (OPR) to initiate investigations into
the circumstances of death, the Office of Detention
and Removal Operations (DRO) Assistant Director
for Management to conduct an internal review of all
facility inspection reports and review of contracts of
the detention facility, and provide autopsy and other
forensic information for a mortality review by the
DHS Office of Health Affairs. ICE reapproved this
directive in 2012.37
As a result of ICE’s 2009 directive, the ICE OPR’s
Office of Detention Oversight (ODO) began to issue
detainee death review documents that summarized
investigations of detention center deaths. The death
reviews were carried out by a centralized team of
ICE personnel and subject-matter experts who
interviewed local personnel and reviewed medical
and custody records to evaluate medical care related
to the death.38 These detainee death reviews typically
included an accounting of relevant facts leading up
to the death, analysis and assessment of the care
provided, and a comparison of the care provided to
the relevant standards in place at the facility.39 Over
the last decade, advocacy organizations and the
media have had to resort to FOIA litigation to obtain
copies of these detainee death reviews. Analyses of
these reviews in prior reports published by ACLU
and its partners,40 as well as by medical and public
18

health scholars,41 have revealed a consistent pattern
of deficient investigations, inadequate care, and deep
systemic issues with the standard of medical care that
directly led to the deaths of detained immigrants.
In 2018, recognizing the importance of these detainee
death records, Congress required that ICE “complete
and make public an initial report regarding any
in-custody death within 30 days of such death,” and
to complete and release subsequent reporting about
the death within 60 days of the initial report.42 In
practice, ICE frequently ignores these requirements
and has failed to post reports regarding deaths
within the required time. In some instances, ICE
instructed advocates and the media to file FOIA
requests for information or claimed that its press
release constituted an initial report.43 When news
agencies filed suit under FOIA for records related
to detainee deaths, however, ICE’s response has
often been to simply point to this brief initial report
on its website.44 In addition, ICE’s media advisories
include little information regarding deaths in
custody, providing only cursory details about
the circumstances of a detained person’s death.
Currently, ICE publishes a truncated report, titled
“Detainee Death Report,” which provides a brief,
bulleted summary of a selection of events prior to
each death, on its website.45
ICE is also obligated to report detainee deaths to the
Department of Justice under the Death in Custody
Reporting Act of 2013 (DCRA). DCRA requires federal
law enforcement agencies to report to the Attorney
General “the death of any person” who is “en route
to be incarcerated or detained, or is incarcerated or
detained at . . . any facility (including any immigration
or juvenile facility) pursuant to a contract with such
Federal law enforcement agency.”46 Unfortunately, the
Department of Justice has failed to collect reliable data
nationwide, or to publish studies that use this data to
identify ways to reduce deaths in custody as required
under the DCRA.47

ICE’s Current Approach to Investigating
and Reporting Deaths in Custody
In October 2021, ICE issued a revised directive that
currently governs the agency’s investigation of

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

deaths of detained people. ICE Directive 11003.5,
“Notification, Review, and Reporting Requirements
for Detainee Deaths” outlines its “multilayered,
interagency approach” to investigate deaths of
noncitizens in ICE custody. 48 According to ICE, the
agency “conducts medical reviews as well as oversight
and compliance investigations, timely prepares
reports based on the finding of reviews and shares
reports with appropriate parties and stakeholders.”49
Within 12 hours after a death occurs in ICE custody,
the Field Office Director with oversight of the
relevant facility must report the death to ICE’s
Assistant Director for Field Operations, ICE’s
Custody Management Division, ICE’s Joint Intake
Center (JIC),50 and ICE’s Office of the Principal Legal
Advisor (OPLA). Within two business days, ICE must

post a news release with “relevant details” of the
death on the agency’s public website.51
The ICE Office of Professional Responsibility (OPR)
then “examines the circumstances surrounding the
individual’s death and drafts a report to determine
whether the agency adhered to all policies and
protocols.”52 Once ICE completes its review, “the
results are provided to ICE senior management and
the DHS Office of Civil Rights and Civil Liberties.”53

The Paper Trail: Relevant Documents
Regarding ICE Detainee Deaths
ICE Directive 11003.5 identifies several documents
that the agency produces when reviewing a detainee
death. Including those listed in Table 3.

TABLE 3.

Documents Released Upon Death in ICE
Document Name

Description

Interim Notice of a
Detainee Death

An “objective statement announcing the death of a death in ICE custody, as well as additional
facts, circumstances, and information relevant to a particular death at issue, that is timely posted
to ICE’s public facing website.”54

Detainee Death
Report

A “publicly available document, detailing relevant information and circumstances regarding any
detainee death, in accordance with congressional reporting mandates.”55 These reports should not
be confused with “Detainee Death Reviews,” which typically include a more complete accounting
of relevant facts leading up to the death, analysis and assessment of the care provided, and a
comparison of the care provided to the governing standards in place at the relevant facility.

Detainee Death
Review (also titled
the “Detainee Death
Review Findings
Memo”)

ICE describes this document as “an objective examination of the facts and circumstances
surrounding the detention and death of an individual in ICE custody or post release (when a death
occurs within a reasonable time, not to exceed 30 days of release from ICE custody and review
is requested by the ICE director), to determine whether or not the deceased detainee received
treatment in accordance with applicable detention standards on health, safety, and security.56
Prepared by the ICE Office of Professional Responsibility’s (OPR) ICE Inspections and Oversight
Division, this memorandum is prepared for ICE Office of Enforcement and Removal Operations
(ERO) and summarizes ICE OPR’s review of the death. The memo often includes a summary of the
chronology of the individual’s death and identified deficiencies against ICE detention standards.
To the authors’ knowledge, ICE has never ordered any discretionary review of the death of an
immigrant who died after release.

Private government contractors such as Creative Corrections or the Nakamoto Group often
prepare a Healthcare and Security Compliance Analysis (also referred to as a Medical and
Healthcare and
Security Compliance Analysis) upon request by the ICE OPR’s External Reviews and Analysis Unit
Security Compliance
(ERAU). This report includes a synopsis of the death, description of the relevant detention facility
Analysis (also referred and its medical services, a narrative summary of events, and conclusions regarding compliance
to as a Medical and
with detention standards governing medical care and security operations. These government
Security Compliance
contractors may conduct site visits and telephone interviews with witnesses.57 Notably, Creative
Analysis)
Corrections is also currently tasked to conduct annual ICE detention inspections for the ICE Office
of Detention Oversight, which may determine eligibility for a facility’s contract renewal.58
Prepared by the ICE Health Service Corps (IHSC), this document is “conducted to determine
the appropriateness of the clinical care provided and the effectiveness of the facility’s policies
IHSC Mortality Review and procedures relevant to the circumstances surrounding the death.”59 The Mortality Review
includes an “administrative review, a clinical review, and in the event of a suicide, a psychological
autopsy.”60

Introduction

19

Custody
Additional documents created by ICE or other
sources can provide further information regarding
deaths in detention, including those in Table 4.
In addition to documents generated by ICE, state
agencies may also conduct investigations into deaths
that occur in ICE detention facilities.

International Legal Standards for
Immigration Detention
In addition to domestic regulations and standards,
international human rights treaties that the United
States has ratified also provide necessary protections
against cruel treatment and arbitrarily prolonged
detention. These treaties provide a framework by
which the actions of the United States regarding
immigration detention may be assessed in the context
of global standards for practice in these settings.
In most cases, international treaties include
provisions to enact domestic legislation to enforce
accountability mechanisms. Relevant treaties

that the United States has ratified include the
International Covenant on Civil and Political
Rights (1992), which establishes rights to life,
liberty, dignity, and security of persons, as well
as protections against arbitrary detention. The
Covenant explicitly states that “all persons deprived
of their liberty shall be treated with humanity and
with respect for the inherent dignity of the human
person.”61
The United States has also ratified the Convention
Against Torture and Other Cruel, Inhuman or
Degrading Treatment and Punishment, and is
therefore subject to the absolute prohibition of
torture under international law.62 The Committee
Against Torture—the monitoring body of the
Convention —has found that failure to provide
adequate medical care can violate the Convention’s
prohibition of cruel, inhuman or degrading
treatment.63 Solitary confinement that lasts more
than 15 consecutive days is recognized by the United
Nations64 and multiple human rights organizations65
as torture.

TABLE 4.

Additional Relevant Documents Regarding ICE Detention Deaths
Document Name

Root Cause Analysis (RCA)

Description
In the past, IHSC has conducted a “root cause analysis” to determine the “root cause” of
an event, and to identify opportunities for risk reduction. The “root cause” is “typically a
finding related to a process or system that has a potential for redesign to reduce risk.”66
This standardized IHSC form summarizes the sequence of key events and responsible
providers, and provides prompts to identify vulnerabilities in the detention process or
system, with space for an action plan with specific risk reduction strategies.
The requirement that IHSC conduct a root cause analysis is no longer included in ICE
Directive 11003.5, the current operative version of ICE’s detainee death protocol.

Independent Autopsy

An autopsy conducted by a medical examiner lays out the cause and manner of death for
a person who has died. The examiner conducts an external and internal examination of the
body of the deceased as well as a toxicology report.

Office of the Inspector
General (OIG) Report of
Investigation

If the Department of Homeland Security (DHS) Office of Inspector General (OIG) chooses
to investigate a death in custody, it publishes a report of its investigation.

Medical records and
communications regarding
detainee death

Medical records and other records of communication regarding a detained person,
obtained under FOIA or other litigation, provide the most fulsome view of incidents that
took place in the treatment of a detained person in custody.

20

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

In addition to these binding international treaties,
the United Nations Standard Minimum Rules for
the Treatment of Prisoners, Basic Principles for the
Treatment of Prisoners, and the Body of Principles
for the Protection of All Persons under Any Form
of Detention or Imprisonment collectively establish
a consensus regarding the entitlement of detained
individuals to a level of medical care equivalent to that
accessible to the general community, irrespective
of their legal immigration status.67 These standards
underscore the importance of non-discriminatory
access to healthcare for detainees. The Body of
Principles for the Protection of All Persons under Any
Form of Detention or Imprisonment mandates the
prompt provision of a proper medical examination
upon admission to a detention facility, followed by
necessary medical care and treatment.
Finally, the U.N. High Commissioner for Refugees
(UNHCR), in its Guidelines pertaining to the
detention of asylum-seekers and alternatives to
detention, underscores the obligation to provide
appropriate medical treatment, including
psychological counseling, to detained people
requiring such care. It highlights the importance
of transferring detained people in need of medical
attention to suitable facilities or providing on-site
treatment when available.

This report is based on a review of records for the
53 people whom ICE reported to have died in its
custody between January 1, 2017 and December 31,
2021.68 Between January 1, 2022 and the completion
of this report in May 2024, ICE reported that 17
additional people died in its custody. These deaths
are not included in the report’s analysis, as ICE has
not yet released a comprehensive set of records to the
authors for these deaths.

Documents Obtained Under the Freedom of
Information Act (FOIA)
This report is based on a review of over 14,000
pages of documents. These documents include
records that DHS components regularly prepare or
incorporate when an individual dies in its custody,
including Detainee Death Reviews, Healthcare
and Security Compliance Analyses, Root Cause
Analyses, Mortality Reviews, autopsy reports, as
well as medical records and emails obtained from
the United States government under the Freedom
of Information Act (FOIA). Where available, the
report also reviewed public agency statements, media
coverage, and Congressional reports regarding
deaths of detained immigrants.

Introduction

21

Methodology
The report reviewed records regarding the deaths
of 53 people in ICE detention, including over 10,000
pages of records for 41 people obtained by American
Oversight as the result of FOIA litigation.69 The
report also reviewed over 4,622 pages of records
regarding 19 deaths (including 12 not covered under
the American Oversight disclosures) obtained
under FOIA or state public records laws, and made
publicly available by Buzzfeed News70, the Project on
Government Oversight (POGO),71 Andrew Free,72
Transgender Law Center,73 and the Young Turks.74
In addition to these records, the report also analyzed
records posted publicly on ICE’s FOIA website.75 In
addition, the report analyzed additional documents
obtained under FOIA or state public records requests
shared with the authors by Jose Olivares (formerly of
the Intercept and NY Public Radio) and Tammy Jane
Owen, as well as documents made available to the
public in Congressional reports.
In 2019, American Oversight began investigating
the deaths of individuals held in the custody of
the Department of Homeland Security (DHS)
components, filing dozens of FOIA requests with
DHS, Immigration and Customs Enforcement (ICE),
and Customs and Border Protection (CBP). ICE and
CBP, however, regularly failed to provide substantive
responses or produce records within the time period
required by law. To enforce its rights under FOIA,
American Oversight filed four lawsuits against
DHS components for documents related to deaths
in custody.76 These lawsuits have since resulted in
the release of nearly 10,000 pages of records. Many
of the records produced to American Oversight
were partially or fully redacted under various FOIA
exemptions. After extensive negotiation and briefing,

22

ICE lifted certain of these redactions voluntarily and
was ordered by the court to lift the remainder.
ICE’s failure to appropriately address American
Oversight’s FOIA requests meant that documents
were often delayed or incomplete. Indeed, the
failure to appropriately respond to FOIA requests
led American Oversight to litigate to obtain the
records that form much of the basis of this report.
In the course of the litigation process, the court
concluded that ICE had not sufficiently justified its
withholding of certain records and redactions or
the adequacy of its search for records. As a result,
the court ordered ICE to produce all redacted
records at issue and to redo its search for records.
ICE and CBP failed to search appropriate locations,
use effective search terms, or use efficient and
up-to-date methods to process electronic records.
Indeed, ICE often redacted information disclosed to
American Oversight that it had previously disclosed
in response to other FOIA requests, including key
inculpatory information.77 By slowing the FOIA
process and consuming resources through litigation,
in conjunction with the assertion of unjustified
withholdings, ICE obstructed access to information
that the public has the legal right to view.

Documents Obtained in Civil Litigation
This report is also based on documents and testimony
obtained in discovery in civil litigation related to
deaths of detained immigrants.78 These documents
include transcripts of deposition testimony of ICE
employees, internal agency emails, medical records,
and documents related to contracts and contract
performance between ICE and detention facility

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

operators. None of these records are subject to
protective orders.

Reviews of ICE Oversight and Investigations
The report compares ICE’s official reports related
to the deaths of detained people with other sources
of information. Specifically, we reviewed final
ICE investigatory reports, including Detainee
Death Reviews, Mortality Reviews, Root Cause
Analysis reports, Healthcare and Security
Compliance Analysis reports, and reports issued
by the DHS Office of Inspector General (OIG).
We examined these documents to analyze areas
where oversight investigation reports indicated
incomplete investigations, omission of key facts or
factors that contributed to deaths in detention, and
recommendations and consequences for facilities
upon a detained person’s death. We compared these
with internal emails regarding those investigations
and in one case, testimony from agency personnel
regarding the death of a detained immigrant. Where
available, we also examined reports of independent
autopsies conducted on behalf of survivors or
estates, and compared their findings to the autopsy
reports conducted on behalf of ICE. Finally, we
examined detention contracts and documents
regarding contractor performance made available in
Congressional reports or in civil litigation.

Reviews of Medical Care Received in ICE
Detention and Other Documentation
This report uses a retrospective document review
methodology, which is a widely used research method
in various health and biomedical disciplines. The
methodology is intended to assess events and actions
that had already happened and are recorded in official
documents such as hospital or institutional records
for the purpose of identifying errors, trends, practice
patterns, or other recurring themes, among others.
A team of medical doctors reviewed the documents
available for each death and, following the review,
were asked to assess each case and note whether the
death may have been preventable, in their clinical
opinion and based on the information they had
reviewed. Even though the documentation available

for each case was not identical, all but one case had
sufficient information to permit comprehensive
review of what was documented in the reviews as
the medical care received. In total, medical doctors
reviewed 52 cases of reported deaths that occurred
between 2017 and 2021, and were unable to review
one case that took place in 2018 due to incomplete
documentation made available by ICE. The reviewers,
Drs. Radha Sadacharan, Katherine McKenzie,
Elena Jiménez-Gutiérrez, Chanelle Diaz, Michele
Heisler, and Ranit Mishori, are all experts with deep
knowledge of, and experience in, assessing clinical
care as well as in health conditions in places of
detention.79
Dr. Sadacharan, a correctional health expert, was
retained by the ACLU to conduct an independent
review of all 52 cases. Drs. McKenzie, JimenezGutierrez, and Diaz are part of PHR’s Asylum
Network, and Dr. Heisler is Medical Director for PHR.
Dr. McKenzie conducted an independent review
of 15 cases; Dr. Jimenez-Gutierrez conducted an
independent review of 19 cases; Dr. Diaz conducted
an independent review of 16 cases; and Dr. Heisler
conducted an independent review of two cases. Dr.
Mishori, PHR senior medical advisor, served as an
additional reviewer for six cases in which the original
reviewers’ classifications were considered “materially
different.” The reviewers did not discuss the specifics
of any case with each other or share reviews until all
were complete.
The reviews were completed using a standardized
form which asked the physicians to assess whether,
in their independent medical judgment, the
death was “preventable,” “possibly preventable,”
“not preventable,” or “indeterminate.” These
determinations reflect the professional and expert
opinion of the physicians. If the medical reviewers
identified errors in the provision of care, they were
further asked to elaborate on the errors in clinical
care or other non-clinical areas that led them to make
this assessment. Based on the documents that were
available to them, the medical reviewers also noted
whether ICE had identified any failings or deficiencies
within their own documentation.
The definitions listed in Table 5 below were agreed
upon by all physicians involved in the review process
Methodology

23

and are based on studies discussing consensus
mechanisms for categories of preventable deaths.80
Combined determinations of “preventable” or
“possibly preventable” (n=28) were not considered
to be materially different, given the substantial
likelihood that, in either instance, the outcome would
have been different if there was a more appropriate
standard of medical care or better management
of the detainees’ health condition. If, however, one
reviewer determined a death was either preventable
or possibly preventable, and the other determined
that the death was not preventable, the reviewers’
classifications were considered to differ materially
(n=6). This methodology was decided upon after
considering the available medical literature, which
indicates that while having reviewers meet to discuss
determinations can increase consensus in record
review determinations, they do not necessarily
increase reliability of determinations.81 In the six
cases where Dr. Mishori served as an additional
reviewer, the final determination for each of these
cases was the classification reached by the majority of
the three reviewing physicians.
TABLE 5.

Medical Review of Deaths in Detention:
Definitions
Classification

Definition

Preventable

The person’s life could have been
saved or the outcome could have been
different with appropriate medical care,
intervention, or management of the
health condition.

Possibly
Preventable

There is a reasonable possibility that,
based on the documents reviewed,
the person’s life could have been
saved or the outcome could have been
different if the person had received
appropriate medical care, intervention, or
management of the health condition.82

Not
Preventable

Indeterminate

24

It is clear that the person’s life could
not have been saved or the outcome
could not have been different, regardless
of the medical care, intervention, or
management of the health condition.
It is not possible to determine whether
the outcome could have been different,
regardless of the medical care,
intervention, or management of the
health condition

Interviews
In addition to the medical case reviews, PHR and the
ACLU also conducted two interviews with relatives
or friends of individuals who died in ICE custody to
better understand who they were, their life, and the
context of their detention and death. These family
members or friends were identified through contact
with attorneys or community-based organizations
who have worked with them.
The methodology for these interviews was reviewed
and approved by PHR’s Ethics Review Board
(ERB) and the ACLU’s Human Subject Research
Protections Protocol to ensure compliance with U.S.
requirements for human subject research. Interviews
were conducted in English, and took approximately
an hour each. Researchers obtained informed consent
orally with the interview participants before moving
forward, ensuring that the participants understood
the purpose of the research, and potential risks and
benefits of their participation. Interviews followed
a semi-structured format, and were conducted via
videoconference. Recruitment for interviews was
conducted through attorneys working with or in
contact with the ACLU, and researchers obtained
the consent of interview subjects and their counsel
to participate. Participants were given the option to
have legal counsel present in the interviews, though
neither subject elected to do so. Both subjects have
filed – or seek to file — FOIA requests or wrongful
death suits against ICE and/or detention facilities.

Limitations
The report findings and conclusions are limited due
to a few factors.
Oversight and Accountability. The cases
examined in our discussion of ICE’s oversight and
accountability mechanisms were limited to those
where additional internal agency communications
regarding detainee death investigations and contract
performance assessment information were available
through FOIA or civil wrongful death litigation or
investigation. ICE often redacted or withheld large
swaths of information disclosed under FOIA. As
such, there may be information or considerations

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

not able to be included in this study, and it is possible
that there are considerations that the authors were
unaware of that, if known, may have impacted their
analysis.
Medical Review. Expert physicians who assessed
medical care provided in death cases based their
assessments on the information available to them
at the time of the review process. They were not
involved in providing healthcare to the deceased
patients, did not have access to the original, official
medical records, and their evaluations were based
on a combination of secondary assessment of official
government documentation or, occasionally, other
independent primary documentation. Additionally,
portions of these documents were redacted, or some
were redacted in their entirety.
Interviews. The two interviews conducted of
family members may not be representative of the 53
deaths in the sample set, nor of all family members’
perspectives. Specifically, because the two subjects
interviewed were identified by attorneys, they may
differ from those not involved in litigation.

Disclosure
Some of the deaths analyzed in this report have
been the subject of past litigation, are the subject
of ongoing litigation, and may be subject to future
litigation regarding wrongful deaths. The principal
authors of this report are not involved in any of
this litigation; the determinations made herein are
independent of these efforts. While some ACLU
affiliates may be involved in litigation, the ACLU’s
National Prison Project, which co-authored the
report, is a separate legal entity. Contributing
author Andrew Free, who provided analysis for the
accountability and oversight portion of the report,
provided representation in cases related to Jean
Jimenez, Efrain de la Rosa, Ronal Francisco Romero,
Ben Owen, Gourgen Mirimanian, Roylan Hernandez
Diaz, Yulian Castro Garrido, and Onoval Perez
Montufa.
Evidence from the review of documents and
interviews were considered together to make overall
assessments about individual deaths in detention and
related ICE and DHS protocols and practices. Specific
data sources for claims are included in the cited
endnotes.

Methodology

25

Findings and Analysis
Our investigation examined the deaths of 52
detained immigrants, comprising all but one death
reported by ICE to have taken place in its custody
between January 1, 2017 and December 31, 2021.
This investigation revealed two findings. First,
ICE’s oversight and accountability mechanisms
are critically flawed, and do little to prevent future
deaths. Second, medical experts concluded that of
these 52 deaths, 49 (95 percent) were preventable
or possibly preventable if ICE had provided
clinically appropriate medical care. Systemic
failures in the delivery of medical and mental health
care in detention have caused or contributed to an
overwhelming number of deaths that would likely
otherwise have been prevented in ICE detention.

ICE’s Current Oversight and
Accountability Mechanisms
Regarding Death in Detention
Are Critically Flawed and Do
Little to Prevent Future Deaths
ICE’s investigations, formal and informal reports,
and recommendations in response to deaths in
custody are structured to avoid fault and disclaim
agency accountability for the death of detained
immigrants. Flaws in ICE’s review and remedial
processes for deaths in detention have led to
continued error and system failure, leading to
continued deaths of detained people. Furthermore,
ICE’s flawed oversight process has failed to levy
meaningful consequences, including contract
termination, for conditions that have led to repeated
deaths in detention.

26

ICE’s detention death investigations have
allowed the destruction of evidence, have
failed to interview key witnesses, and have
omitted key inculpatory facts.
Public reports and final internal analyses of the
deaths of detained people created by ICE often fail to
provide a complete recounting of deaths and omit key
information regarding the agency’s failure to ensure
proper care to people in detention.
A close analysis of documents regarding ICE’s
investigations of detained people’s deaths reviewed
here indicate that ICE’s investigations have failed
to preserve evidence, omitted key facts, and did not
follow obvious leads for causes of wrongful death.
Instead, ICE has omitted critical facts that are
potentially inculpatory to the agency and private
prison companies with which it contracts, including
likely or contributory causes of death.
In several cases, ICE failed to ensure that evidence
connected to deaths was preserved for investigation,
allowing detention officials to destroy critical
video footage without consequence. ICE also failed
to ensure that all key witnesses are available for
investigatory interviews. On at least two documented
occasions in separate cases, ICE suddenly released
crucial detained eyewitnesses from custody within
hours of an investigator’s arrival to the facility;
investigators did not follow up with the eyewitnesses
who were released from custody.
• ICE fails to ensure preservation of evidence
in detention death investigations, and
contract detention facilities have destroyed
evidence highly relevant to investigation

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

of deaths, including video surveillance
recordings. For example:
• ICE failed to ensure the preservation of
video evidence in the death of Roxsana
Hernandez. Hernandez, a transgender
woman from Honduras, died in ICE custody
on May 25, 2018, after her detention at the
Cibola County Correctional Center in New
Mexico, which is run by CoreCivic, Inc. After
ICE investigators requested a copy of video
of Hernandez’s medical examinations at the
facility that they had previously reviewed
onsite, CoreCivic reported that the video had
been overwritten, and that “the requested
video is no longer available.” CoreCivic
claimed that the video was automatically
overwritten after “up to around 90 days,”
even though ICE and CoreCivic had been put
on notice to preserve video evidence relevant
to Hernandez’s death.83
• ICE also failed to ensure the preservation
of video footage relevant to the death
of Gourgen Mirimanian. Mirimanian, a
54-year-old man, died in ICE custody on April
10, 2018, while detained at the Prairieland
Detention Center in Alvarado, Texas, which
is operated by the private prison corporation,
LaSalle Corrections. Although the facility
made available some footage “of limited
value” of the dorm in which Mirimanian was
located prior to his death, this footage was
“compromised by distance,” while another
video “was not retained.”84
Internal emails from ERAU staffers noted
their frustration with the ICE Office of
Detention Oversight’s failure to secure and
send video surveillance recordings from
the facility, noting that “[i]t is impossible to
properly prepare a witness list or accurately
prepare for the review” without video
recordings. The staffer further noted that,
“I really feel the need to make a record of
the limitations ODO is placing on us by not
getting us the required materials in advance
of the review.”85

• ICE fails to interview and releases key
detained eyewitnesses from custody
immediately before investigators can speak
to them. Because investigators either did not
attempt to or could not contact eyewitnesses after
witnesses’ release, any information available
from these eyewitnesses was not factored into
ICE’s investigation. For example:
• ICE investigators
failed to interview
a key eyewitness
to the death of Ben
Owen. Owen, a
39-year-old national
of the United
Kingdom, died by
Photo courtesy Tammy Jane Owen
suicide in ICE
custody at the Baker County Detention
Center in Florida on January 25, 2020. ICE
investigators identified a detained eyewitness
on its list of people to interview in relation to
Owen’s death. The investigators were unable
to interview him, however, as the agency
released him from custody during the
investigator’s visit to the facility. As internal
emails reveal, the investigator noted that “we
won’t be able to interview [name redacted]
today. I just pulled his record up . . . and he
was released on bond at noon today.”86
• Less than two hours after a Georgia
Board of Investigators (GBI) agent arrived
at the facility to investigate the death of
Efrain de la Rosa at the Stewart Detention
Center in Georgia, authorities released a
detained immigrant who was a witness to
the death from custody. De la Rosa, who had
schizophrenia, died by suicide at the age of
40 on July 10, 2018, after spending 21 days
in solitary confinement. The witness had
been detained in the cell immediately next
to De la Rosa’s on the night of his death.
GBI investigators, however, never had
the opportunity to interview the witness,
because he had been released at 3:06 a.m.,
less than two hours after the GBI investigator

Findings and Analysis

27

arrived at the facility. The GBI investigator
arrived at the facility at 1:36 a.m., and began
to take photos of the cell where de la Rosa had
died at 2:20 a.m.87
• ICE’s detention death investigations have
failed to investigate or have omitted critical
facts that would suggest fault by detention
facilities or ICE. Our review shows that ICE
failed to investigate important leads, or omitted
critical facts that would suggest fault by the
detention facility or ICE.
• ICE investigatory
reports failed to
disclose that
internal oversight
staff had ignored
reports of
dangerous
conditions in the
Photo courtesy of Jose Olivares.
death of Efrain de
la Rosa. In the month prior to his death at
Stewart Detention Center, medical staff
failed to ensure that de la Rosa, who had
schizophrenia, receive his prescribed
antipsychotic medication. Indeed, de la Rosa
received no doses of the ordered psychiatric
medications, even though he was under an
order to receive the medication
intramuscularly if he refused it.88 Not only
did medical staff fail to provide this
medication—but nursing staff falsely
recorded their offer and administration of
psychiatric records.89 As Dr. Sadacharan
concluded, the acute destabilization caused
by failure to receive his medication “most
likely contributed to a preventable suicide.”90
Notably, internal agency documents from
ICE, written by a separate IHSC supervisor,
stated that “[s]uicide victim, Mr. Efrain
De La Rosa, could have been saved.”91 The
IHSC supervisor noted that “those in IHSC
listed as recipients on the [Significant
Event Notification] reports do not actually
review them,” and that the behavioral
health unit “has long ignored SEN reports

28

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

reflecting severe mental illness.”92 IHSC
headquarters staff had “received a total of
12 SEN reports prior to [de la Rosa’s] death,
depicting suicidal ideation and psychosis.”93
However, instead of intervening and
ensuring that de la Rosa was treated with
psychotropic medication, “he was remanded
to segregation,” where he died by suicide.94
Indeed, a CRCL whistleblower complaint
later noted that IHSC leadership had
instructed its Medical Quality Management
Unit to cease reviewing SEN and segregation
reports, “despite concerns raised to IHSC
leadership that this restriction could
negatively impact detainee safety.”95 This
information, however, never appeared in
ICE’s investigatory reports regarding de
la Rosa’s death. In addition, although the
U.S. Attorney’s Office reviewed de la Rosa’s
death for prosecution, the office declined to
prosecute the matter.96
• ICE investigators
failed to include
critical facts
regarding
detention staff’s
failure to provide
proper Spanish
interpretation and Photo courtesy family of Maria Ochoa
de Yoc
translation in the
death of Maria Celeste Ochoa de Yoc,
which led to incorrect diagnoses and use of
solitary confinement, in their final
investigatory reports. Ochoa, a 22-year-old
asylum-seeker from Guatemala, died in ICE
custody on March 8, 2020, after ICE had
detained her for almost six months. An
autopsy documented her cause of death as
liver failure due to probable acute viral
hepatitis. At the time of her death, ICE had
detained Ochoa for five months at the Kay
County Detention Center in Newkirk,
Oklahoma, and then for another month at the
Prairieland Detention Center in Alvarado,
Texas.97

While detained at Kay County Detention
Center, medical staff who did not speak
Spanish repeatedly failed to utilize
translation and interpretation services
while also failing to provide proper diagnosis
and treatment to Ochoa. Kay County staff
incorrectly concluded that Ochoa was bulimic
and suicidal, noting in clinical notes that she
repeatedly vomited and expressed that she
“wanted to kill herself.”98 But Kay County’s
failure to provide adequate translation led
them to make this misdiagnosis, and lock
Ochoa, who was on the brink of liver failure,
in solitary confinement under a suicide
watch protocol.99 Kay County’s misdiagnosis
was based on the staff’s failure to properly
translate Ochoa’s communication. Internal
notes from ICE investigators’ review of
Ochoa’s written requests for medical
attention concluded that “she may have been
misunderstood when they claim she said
she wanted to die. I believe it is likely she
said she felt like she was dying.”100 Although
ICE’s Detainee Death Review notes that
medical providers failed to use interpretation
assistance while providing care to Ochoa,
the review fails to report this error in detail,
instead more generally concluding that “the
language barrier may have interfered with
delivery of care.”101 Inadequate treatment
led Ochoa’s mental and physical condition
to even further deteriorate. As medical
experts noted, likely untreated hepatic
encephalopathy due to liver failure may have
affected her mental functioning.102
Ochoa called someone outside the facility
on February 6, 2020, the same day she
submitted nine sick call requests and
was placed in solitary confinement. A
translation of the recorded call underscores
her desperation and the facility’s failure to
provide her with adequate treatment: Ochoa
stated that “she felt like she was going to die,
and wanted her mother and father told that
she loved them very much and was sorry if
she ever did anything wrong. She then said

that she loved them and could not take it any
longer; also, that she felt like her heart was
failing, and she no longer had any energy to
move or even talk. The [person on the other
line] asked her if someone could help her,
and she said no one would; she said that all
[Kay County Detention Center] had was
incompetent nurses, and they would not help
her.”103
• ICE does not require standardized
autopsies for in-custody deaths, nor does it
have consistent standards for conducting
autopsies.
Autopsies are a critical component in
determining the cause of death and in the
collection of medical evidence that may be
useful in court proceedings. Although ICE
is a federal agency and detains people in its
custody nationwide, ICE lacks a standardized
practice for conducting autopsies of people who
have died in its custody. Instead, ICE defaults
to minimum standards established by local
jurisdictions, and generally relies upon each
facility to develop its own procedures for ordering
and scheduling an autopsy “in accordance
with established guidelines and applicable
laws.”104 This lack of standardization means the
decision to conduct an autopsy, and the quality
of the autopsy, if conducted, will vary widely
depending on the location of the person’s death.
In addition, forensic pathologists who conduct
autopsies for ICE do not consistently order fullspectrum forensic toxicology screenings upon
examination, which prevents a full assessment
of what substances were present in the body
upon death, and the role that they may have
played in the death itself. The failure to conduct
autopsies by a certified forensic pathologist
in accordance with national standards105 may
result in incomplete, unreliable, and inconsistent
results that impede full accountability measures,
whether civil or criminal. In contrast, the
National Association of Medical Examiners, for
example, recommends that “[a]n autopsy must
be performed on all deaths in custody where the

Findings and Analysis

29

death may be deemed unnatural, regardless of
phase and time since injury . . . to correlate and/
or confirm the reported circumstances, establish
the cause of death, identify potential competing
causes of death, document other significant
pathologic conditions, and to assess claims of
wrongful death, mistreatment, or neglect.”106 In
addition, detainees “with known natural disease
who are expected to die and are under medical
supervision should be investigated as a death in
custody and receive an autopsy if appropriate.”107
Properly conducted autopsies are important to
assess the cause of death, and the degree to which
a death may be preventable. For example:
• An autopsy of Ronal Francisco Romero
(aka Ronal Cruz), a 39-year-old man
from Honduras, revealed that his cause
of death was a sepsis infection caused by
bacterial meningitis and complications
of diabetes. Bacterial meningitis is a lifethreatening infection of brain and spinal
cord fluid, although patients provided with
timely antibiotic treatment can make a
full recovery.108 Because the health risk
posed by bacterial meningitis is so high, the
Centers for Disease Control and Prevention
(CDC) requires reporting of all cases, and
can declare an outbreak with as few as two
patients in a location; preventative antibiotic
treatment must be provided to anyone
who had close contact with a patient.109
ICE, however, did not initially disclose
that bacterial meningitis caused Romero’s
death, instead reporting that he died of
“diabetic ketoacidosis (a life-threatening
complication of diabetes mellitus) and sepsis
(infection).”110 Only after Romero’s family
notified ICE that they planned to perform an
autopsy did ICE commission one itself. Both
autopsies concluded that he died as a result of
bacterial meningitis.
IHSC’s mortality review committee
concluded that the medical care provided at
the Port Isabel Detention Center in Texas
“was provided within the safe limits of

30

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

practice and did not directly or indirectly
contribute to his death.”111 But as an IHSC
whistleblower stated in an internal memo
first disclosed by Buzzfeed News,112 the
medical care provided to Romero was
“grossly negligent,” and alleged that the
“mortality review committee was erroneous
in concluding that the care rendered to Mr.
Cruz was appropriate.”113 Indeed, as medical
expert reviewer Dr. Radha Sadacharan
concluded, “if [Mr. Romero] had been started
on broad spectrum antibiotics the morning
he felt unwell, or more appropriately sent
to the emergency room when he met sepsis
criteria and had ketonuria and glucosuria, he
likely would not have passed away.” 114
The mortality report identified several
weaknesses regarding Romero’s medical
treatment in detention, including a group
intake screening, where the detention facility
nurse did not respond to his attempt to share
any medical conditions. According to the
video footage, Romero “raised his hand,
pointed to his left ear,” but the nurses did
not recall his response or record it.115 The
mortality review also noted that “medications
were not delivered in a timely manner after
an [Advanced Practice Provider] gave a
verbal order to administer a stat medication,”
and that scheduled medication was not
administered in a timely manner.”116Upon
Romero’s admission to the medical health
unit, nurses did not review [Advanced
Practice Provider] orders, and no orders or
rechecks of his abnormal blood sugar levels
were obtained.117 But as Dr. Sadacharan
noted, ICE’s review of Romero’s death failed
to find and propose sufficient remedies for
the source of the error itself. “If diabetic
ketoacidosis and sepsis were identified more
quickly, this may have saved the patient’s
life.” ICE, however only considered, but
did not require, a training on diabetic
ketoacidosis and meningitis for relevant
staff, and no other relevant measures were
suggested to prevent future error.118

Detention death investigations fail to
include analysis of key structural factors
that have led to death of detained people,
and ICE fails to require systemic changes
that would prevent future deaths in
custody.
DHS detention death investigations are designed
such that they have failed to include analysis of
key structural factors that have led to the deaths
of detained people. For example, DHS has limited
the scope of investigation only to the subagency in
which the deceased person was most recently held.
For example, if someone died shortly after being
transferred from Customs and Border Protection
(CBP) custody to ICE custody, the death review
would ignore the medical care that person received—
or did not receive—in CBP custody. This precludes
evaluation of systemic issues that have contributed to
or caused death. DHS’s failure to ensure continued,
consistent care upon a detained person’s transfer
between detention facilities, including CBP and ICE
facilities, can be a significant contributing factor to
deaths in custody. Lapses in prescribed medication
and required treatment, for example, can endanger
a person’s health, or lead people with mental
health disabilities to decompensate to the point of
suicidality.
ICE investigators also typically fail to interview or
evaluate Field Office or Headquarters-level decisions
that have contributed to the death of detained people.
Instead, detention death investigations typically
focus and levy fault on the lowest-level employees
involved. This focus fails to address facility-wide
policies and practices that become significant
contributing factors to the death, and those who
have the most authority to address these factors. In
addition, investigators often fail to identify systemic
changes that address key factors that contributed
to deaths in custody and would likely prevent future
deaths.
For example:
• ICE’s root cause analysis of Ronal Francisco
Romero’s death, described above, failed to
address failures in communication and care by

Customs and Border Protection (CBP), and failed
to provide any proposed solutions for delays in
ambulance transport at the facility. Romero died
of bacterial meningitis, a brain infection that
can be effectively treated with broad-spectrum
antibiotics if timely provided.119 ICE’s root cause
analysis noted that CBP transferred Romero
to ICE custody without any known medical
evaluation or communication regarding his
medical needs. Romero presented with symptoms
of a meningitis infection almost immediately
upon arrival at ICE’s Port Isabel detention facility
in Texas, after his transfer from CBP custody.
Lack of communication between CBP and ICE,
and lack of information regarding Romero’s
medical needs from CBP, likely contributed to a
delay in appropriate treatment.120 ICE, however,
made no recommendations or plan to address this
lack of information from CBP. ICE’s root cause
analysis also noted that detention facility staff
delayed the ambulance from treating Romero
for at least 16 minutes, as staff failed to timely
provide a facility escort vehicle in and out of the
facility. ICE, however, provided no proposed
solutions to decrease delays in ambulance
transport in its recommendations.121
• ICE investigators failed
to interview or
evaluate any officials
responsible for
ensuring adequate
staffing of mental
health personnel at the
Stewart Detention
Courtesy family of Jean Jimenez.
Center, operated by
CoreCivic, in their investigation of the death of
Jean Jimenez. Jimenez, a 27-year-old native of
Panama, died by suicide by hanging on May 15,
2017, after experiencing schizophrenic
hallucinations. ICE’s review of Jimenez’s death,
however, failed to require any increases in
psychiatric staffing or failsafe measures to
ensure that individuals with decompensation
were treated in a timely fashion at the facility.
Instead, ICE’s remedies focused only on
prescreening policies and conducting low-level

Findings and Analysis

31

trainings. As Dr. Sadacharan concluded, “ICE did
not propose to enact any solutions that would
actually prevent error in the future.”122
Jimenez had a well-documented case of
schizophrenia, and had notified behavioral
health practitioners at Stewart four times
prior to his death that his medications were not
effectively controlling his auditory hallucinations
and impulsivity. Each time, however, mental
health providers failed to timely respond, in one
instance scheduling a follow-up tele-psychiatry
appointment for two weeks later. As all medical
reviewers concluded, lack of adequate mental
health staffing at Stewart clearly contributed
to Jimenez’s death: 123 at the time of Jimenez’s
death, ICE required one full-time equivalent
psychiatrist for a facility that held nearly
2,000 detainees. The ICE Health Services
Administrator at Stewart later testified that
this required level of staffing was not adequate
for a facility of Stewart’s size, and that he
had raised concerns to ICE leadership about
the need for additional mental health staff at
Stewart.124 CoreCivic and ICE, however, failed
to meet even this minimal level of staffing: at
the time of Jimenez’s death, Stewart provided
tele-psychiatry to detained people for six
hours a week—a level of less than 20 percent of
required staffing, with backlogs of 10-12 weeks
for services.125 ICE’s investigatory reports,
however, include no recommendations for
increasing staffing at the facility, or decreasing
the population at the facility.
• ICE’s investigation of the death of Jose
Leonardo Lemus-Rajo failed to result in any
policy changes that could prevent similar
deaths in the future. Lemus-Rajo, a 23-year-old
man from El Salvador, died of complications of
alcohol withdrawal during his detention at the
Krome Detention Center in Florida on April 28,
2016. Alcohol withdrawal syndrome occurs when
an individual discontinues alcohol intake after a
period of prolonged consumption. Withdrawal
can result in a broad range of symptoms from
mild tremors, to severe seizures that can progress
to death if not promptly treated. As medical
32

expert Dr. Chanelle Diaz noted, “death from
acute alcohol withdrawal is always preventable
with adequate identification of withdrawal and
treatment,” which did not occur here.126
The basic established clinical practice is to
conduct a Clinical Institute for Withdrawal
Assessment (CIWA) to monitor symptoms
and determine the need for medical treatment,
including provision of medications such as
benzodiazepines to prevent escalating symptoms
and death. ICE investigators noted that medical
staff at Krome did not administer the CIWA
during intake, even after Lemus-Rajo reported
heavy alcohol use and symptomatic tremors. As
medical expert Dr. Radha Sadacharan noted,
“CIWA scoring should be initiated for every
single individual who passes through booking
and reports alcohol use, given the high prevalence
of substance use disorders and the significant
morbidity and mortality associated with acute
alcohol withdrawal.”127 ICE, however, made no
policy changes as a result of its investigations,
and IHSC officials noted only that “medical
professionals rely on their training, education,
and experience to make medical decisions and it
would not be appropriate to make policies which
interfere with those decisions.”128

ICE’s oversight process has failed to result
in meaningful consequences for detention
facilities.
ICE’s oversight process has failed to result in
meaningful consequences for detention facilities.
Since 2009, congressional appropriations have
included a provision that ICE cannot expend funds
to detention facilities that fail two consecutive ERO
inspections.129 The applicable inspections, conducted
by ICE’s Office of Detention Oversight (ODO),
however, do not consider the detainee death reviews
that identify any violations of contract obligations or
detention standards. Inspection reports have, from
time to time, merely mentioned that a death occurred
at the facility or that the facility is facing “significant
litigation.” Similarly, ERAU and IHSC Detainee
Death Reviews do not consider prior findings of

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

standards violations by facilities and contractors
when assessing the events leading up to a detainee’s
death. No facility, however, has lost a detention
contract, much less failed an ICE inspection, after
a detainee death in the period of this report’s study,
even where ICE’s death reviews have found multiple
violations of detention standards.
Several DHS oversight bodies investigate conditions
that may contribute to deaths in ICE detention
facilities, including DHS’s Office of Civil Rights and
Civil Liberties (CRCL) and DHS Office of Inspector
General (OIG). However, ICE’s investigatory process
for deaths in custody fails to consider findings
regarding health and safety risks by these oversight
bodies. Instead, ICE IHSC and ERAU detainee death
investigations proceed in silos that do not consider
or account for any conclusions made by CRCL or
OIG. Similarly, ERAU and IHSC Detainee Death
Reviews do not consider prior findings of standards
violations by facilities and contractors when
assessing the events leading up to a detainee’s death.
To the authors’ knowledge, ICE has issued financial
penalties against contractors on only three occasions,
of the 63 deaths that have taken place between 2017
and 2023. However, these financial penalties had
little impact on contractors’ bottom line, and in
these instances, ICE even expanded the scope of
its detention contracts at the facilities in question.
Because ICE does not make information available
regarding financial penalties related to detainee
deaths against contractors, this information is based
on information made available in Congressional
reports and in civil litigation. These cases include:
• In April 2018, ICE issued a contract discrepancy
penalty against the GEO Group, Inc., which
operates the Aurora Detention Center, after
reviewing the death of Kamyar Samimi. The
penalty, which ICE levied after finding that
GEO was “deficient” in meeting medical care
standards, consisted of “a one-time deduction
of 20% based on the December 2017 invoices
amount,” or approximately $750,000.130 However,
less than a year later, ICE expanded its detention
space at Aurora by 432 beds, increasing detention
capacity by 20 percent.131

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Page1 of S

Contract Discrepancy Report for Stewart Detention Center,
Department of Homeland Security.

• In February 2018, ICE issued a contract
discrepancy penalty against CoreCivic after
finding that it had failed to comply with suicide
prevention guidelines following the death of Jean
Jimenez.132
• In October 2018, ICE issued a penalty against
CoreCivic for the deaths of Efrain de la Rosa
and Jean Jimenez, both of whom died at the
Stewart Detention Center in 2017 and 2018
respectively.133 These financial penalties totaled
40% of CoreCivic’s monthly “Bed day detention”
invoice for May 2017, or an estimated total of
approximately $1.4 million, and a 20% deduction
of the same for July 2017, or approximately
$700,000. 134 In comparison, ICE paid CoreCivic
$441 million for detention contracts in 2017.135
One month after issuing this penalty, ICE
awarded CoreCivic a new contract to provide

Findings and Analysis

33

medical care to detainees at Stewart.136 Between
2017 and May 2024, ten people detained at
Stewart died in ICE custody, the highest number
of detention deaths in the entire nation. Despite
that record, Stewart remains fully operational as
an ICE detention facility.

Systemic Failures in Medical
and Mental Health Care Have
Caused Preventable Deaths
in ICE Detention
This report examines the deaths of 52 detained
people who died in ICE custody between January 1,
2017 and December 31, 2021. As detailed above, ICE’s
investigatory reports often fall short in the scope
of investigation, and do little to identify solutions
that will prevent future deaths. Even so, ICE’s
investigatory reports contain important, and often,
the only publicly available information regarding
medical and mental health care provided to people
detained by ICE prior to their death.
Our team of medical experts closely reviewed these
official investigatory reports, and examined whether
the death was preventable based on the information
released by ICE to the public. These expert reviews
identified consistent failures that contributed to
preventable deaths of people in ICE detention, as
detailed below. Many examples described not only
illustrate a specific systemic failure but also reveal
how these instances often intersect with other
systemic issues, highlighting the interconnectivity
and prevalence of ICE’s failures. These issues include:
• Incorrect, incomplete diagnoses of medical
conditions by detention medical staff;
• Incomplete, inappropriate, or delayed
treatment or medication, with a particularly
high occurrence in cases involving manageable
hypertension or cardiovascular issues;
• Flawed or delayed emergency responses,
including failure to immediately intervene,
provide care, or call emergency medical services,

34

on-site delays of ambulances that delayed
emergency care during medical crises, and
insufficient or malfunctioning medical equipment
necessary to prevent death;
• Suicides caused by failure to provide mental
health care and proper medication management,
lack of mental health staff, and use of solitary
treatment;
• Failure to provide necessary and required
interpretation and translation services;
• Failure to follow COVID-19 protocols, including
failure to release medically vulnerable people who
had pending orders for release from custody;
• Chronic understaffing, inadequate and improper
staff training, and inappropriate provision of care
outside the scope of practice; and
• Insufficient and falsified documentation.

The overwhelming majority of deaths of
detained immigrants could likely have
been prevented if ICE had provided
clinically appropriate medical care.
Medical experts examined documents available for
each death to assess whether, in their clinical opinion,
the death would have been prevented, or if there was a
reasonable possibility that the death could have been
prevented, if ICE had provided clinically appropriate
medical care, intervention, or management of the
health condition.
Medical experts concluded that of the 52 deaths
reported by ICE between January 1, 2017 and
December 31, 2021, that 49 deaths (95 percent) were
preventable or possibly preventable if appropriate
medical care had been provided. Only three deaths
were deemed not preventable.
Medical experts considered a death to be preventable
where the person’s life could have been saved or the
outcome could have been different with appropriate
medical care; a death was considered to be possibly
preventable where there was a reasonable possibility
that the person’s life could have been saved or the

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

outcome could have been different with appropriate
medical care.

Medical staff made incorrect or
incomplete diagnoses in the overwhelming
majority of deaths.

TABLE 6.

Preventable Deaths In Ice Detention
(of 52 deaths 2017-2021)
Determination137

Total

Percentage

Preventable. Both expert reviewers
concluded that death was
preventable if appropriate care had
been provided.

6

12%

Likely Preventable. One expert
concluded that the death was
preventable with appropriate care;
one expert concluded that the
death was possibly preventable,
where there was a reasonable
possibility that death could have
been prevented if appropriate care
had been provided.

28

54%

Possibly Preventable. Both
experts concluded that there was
a reasonable possibility that death
was preventable, if appropriate care
had been provided.

15

29%

Not Preventable. Both experts
concluded that the death was not
preventable.

3

6%

Indeterminate. Both experts
concluded that there was insufficient 0
information to draw a conclusion.

0%

FIGURE 2.

Preventable Deaths In Ice Detention
(of 52 deaths 2017-2021)

Not Preventable

6%

Possibly
Preventable
-----------

Preventable

12%

29%

54%

*Likely preventable indicates a case where
one expert concluded that the death was
preventable and the other expert concluded
that it was possibly preventable.

Likely
Preventable*

A correct diagnosis by a qualified medical provider
is a basic precondition for appropriate medical care.
Without a well-informed understanding of underlying
causes of a patient’s symptoms and signs, a medical
professional might not prescribe an accurate and
adequate treatment, or they might treat symptoms
without treating the root cause.
ICE detention center medical staff made incorrect,
inappropriate, or incomplete diagnoses in 88 percent
of deaths reviewed (n=42 of 52). In these cases,
medical staff did not triage patients to the appropriate
level of care, ignored key symptoms, failed to
provide patients with the opportunity to be seen by a
physician, did not order appropriate diagnostic tests,
failed to collect or interpret information that could
have led them to an appropriate response, and even
threatened disciplinary action for filing repeated
medical requests. For example:
• Jesse Jerome Dean, Jr.,
died in ICE detention at
the Calhoun County Jail
in Battle Creek,
Michigan, on February 5,
2021. Dean, a 58-year-old
man from the Bahamas,
died from an
Photo courtesy family of Jesse Dean.
undiagnosed
gastrointestinal hemorrhage caused by a
bleeding ulcer in the digestive tract. All medical
experts who reviewed Dean’s case agreed that his
death would have been prevented had he received
proper medical care. As medical expert Dr.
Chanelle Diaz observed, “there is evidence of
gross medical negligence in this case.” 138
In the five weeks prior to his death, Dean
submitted at least 27 requests because of his
inability to eat, dramatic weight loss of almost
20 pounds in three weeks, and severe nausea,
pain, and weakness, all of which should have
led to referral to a specialist, or at least, an
appointment with a physician. On multiple

Findings and Analysis

35

occasions, Dean’s symptoms were so severe that
he requested medical evaluation at a hospital—
and even offered to pay the cost. During this time,
however, Dean did not receive care from a doctor,
but rather, was seen only by nurses practicing
outside the scope of their training and authority,
who ordered incorrect diagnostic tests, and
provided him only with laxatives, stool softeners,
Tums, Pepto Bismol, and painkillers.139 Detention
facility medical staff failed to conduct a full
review of symptoms (e.g., whether he had blood
in stool that might suggest GI bleeding), did not
conduct abdominal exams, assess his vital signs,
conduct appropriate triage for his symptoms,
or order diagnostic tests appropriate for these
severe symptoms, including an endoscopy or CT
scan.140 Instead, facility staff threatened him with
a citation for submitting excessive requests for
medical care and labeled him a “malingerer.”141
Two days before Dean’s death, the Bahamian
embassy contacted ICE, inquiring about his
medical condition and stating that it had sent
travel documents to allow his release to the
Bahamas. In response, detention facility medical
staff wrote that “Mr. Dean is doing well,” stated
that he was “hoarding food,” and that “he does
have an appointment scheduled for next Monday
to see his psychiatrist.”142

an ambulance, where he died on the way to the
hospital.144
IHSC’s mortality review committee determined
that Dean’s medical care “was not provided
within safe limits of practice,” and could “pose
a future risk for adverse outcomes.”145 ICE,
however, continues to detain 127 people at
Calhoun each day.146
• Emigdio Abel Reyes Clemente died on
April 3, 2019 in a solitary confinement
medical isolation cell in ICE’s Florence
Service Processing Center in Arizona.
Reyes Clemente, a 54-year-old man from
Mexico, died after experiencing significant
upper respiratory symptoms caused by
undiagnosed and untreated bacterial
pneumonia.147 On April 1, 2019, he requested a
visit with detention facility medical staff because
he had fever, chills, sore throat, and a cough.
Contrary to the standard of care, the physician’s
assistant assumed, without any testing, that
he had influenza, and prescribed Tamiflu, an
antiviral drug that is ineffective against bacterial
pneumonia.148

On the night before his death, Dean collapsed
twice, hit his face on a door, and fell to the floor.
Even after medical staff decided to move him
to the medical observation unit, he was never
referred for evaluation by an advanced practice
provider or doctor. ICE’s own investigation found
that no medical staff checked on Dean that night.
Although one nurse stated that she checked on
him after an initial assessment, ICE’s review
of surveillance footage showed that she did not,
and indeed, “for at least 2 hours and 45 minutes
throughout her shift, [the nurse] was reclining in
the nursing station chair with her feet propped
up, texting on her cell phone.”143 The next
morning, Dean was so weak that he could barely
get up. Three hours later, medical staff called

36

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Reyes Clemente’s condition rapidly deteriorated
in the next two days, with progressively critical
vital signs and signs of physical decompensation,
such as dangerously low oxygen levels, weakness,
and inability to sit or walk without assistance.
Despite these abnormal vital signs, which
should have raised concern, facility staff did
not call a provider. On April 2, 2019, the day
before his death, Reyes Clemente’s oxygen
levels plummeted to 83 and 79 percent, which
constitutes a medical emergency requiring
immediate attention. Nursing staff, however, did
not provide him with necessary oxygen therapy,
nor did they send him to the emergency room
for evaluation or x-rays, which would have been
the appropriate immediate medical response to
such a critically abnormal oxygen value. Instead,
medical staff placed him in a medical isolation
(solitary confinement) unit and offered him no
additional treatment.149

The next morning, at 6:09 a.m. on April 3, 2019,
an officer entered his medical isolation cell, and
found that Reyes Clemente’s “eyes were wide
open and his chest did not rise and fall.” The
officer called for assistance but did not start CPR
because he believed that Reyes Clemente “was
already dead.” A few minutes later, medical staff
arrived with a mobile oxygen tank.150 Within two
hours, the county coroner arrived, and exited the
solitary confinement unit with Reyes Clemente’s
body. 151
Reyes Clemente’s autopsy report confirmed that
he had bacterial pneumonia at the time of his
death, and that his corpse tested negative for
influenza. The autopsy report, however, listed his
cause of death as “complications of liver cirrhosis,
diabetes, and hypertensive cardiovascular
disease.”152 But expert medical reviewers
found that this conclusion was erroneous: the
progression of Reyes Clemente’s treatment and
illness do not indicate that these underlying
conditions were the primary causes of his death.
Instead, both medical reviewers concluded that
Reyes Clemente died a preventable death due to
misdiagnosis of bacterial pneumonia and lack of
appropriate medical care. 153 Reyes Clemente was
likely even more vulnerable to infection due to
his uncontrolled diabetes, as the facility stopped
providing blood glucose checks the week before
his death.154

Incomplete, inappropriate, or delayed
treatment or medication
Our medical experts concluded that medical staff
provided incomplete, inappropriate, or delayed
treatment or medication that caused or contributed
to death in 79 percent of cases reviewed (n=38). ICE
detention medical staff administered treatment
that was inconsistent with evidence-based medical
standards or was inadequate to resolve the medical
issue, or delayed care beyond a reasonable timeframe.
These cases also include instances where medical
staff failed to appropriately manage necessary
medication, and prescribed medications that were

contraindicated or had harmful interactions with
already prescribed drugs. Medical staff also failed to
appropriately administer oxygen support, pain relief,
or other support when needed.
In 14 deaths, ICE detention medical staff also failed
to provide appropriate care related to cardiovascular
disease, failing to take EKG readings when presented
with heart attack symptoms, or delaying the
provision of emergency CPR. As our medical experts
concluded, this failure directly caused or contributed
to preventable deaths. For example:
• Carlos Mejia-Bonilla155,
a 46-year-old man from
El Salvador, died of
gastrointestinal bleeding
in ICE custody on June
10, 2017, after being
detained at the Hudson
Photo courtesy family of Carlos Mejia
County Department of
Bonilla
Corrections and
Rehabilitation in New Jersey. During the 10
weeks that ICE detained him, Mejia-Bonilla
struggled to receive the medication that he had
been prescribed for anemia and cirrhosis.
Ultimately, the facility’s careless approach to
medication management may have proved fatal.
Unlike ICE’s medical review, our medical expert
reviews noted that the detention facility’s
primary care provider—without seeing
Mejia-Bonilla in person—prescribed him
naproxen, which poses a significant risk of
gastrointestinal bleeding and renal failure
in patients with cirrhosis of the liver and was
thus contraindicated. Four days later, Mejia
died of gastrointestinal bleeding. As Dr.
Radha Sadacharan concluded, “this medical
decision, combined with the poor attention to
detail the medical staff had in assessing Mr. Mejia
at intake, and the lack of appropriate and timely
follow-up care for any of his medical needs are
evidence of substandard medical care at Hudson
County Jail that will continue to lead to
unnecessary morbidity and mortality if it is not
improved.”156

Findings and Analysis

37

Mejia-Bonilla had lived in Long Island for 25
years with his wife and children, where he had
established a successful construction business.
He was detained in a case of mistaken identity
by ICE, whose officers arrested him after
searching for a different person.157 When MejiaBonilla first entered ICE custody, he informed
the medical staff that he had diabetes, anemia,
and cirrhosis of the liver, and that he was on
prescription medication to treat these conditions.
Although the facility nurse entered these
preexisting medical conditions into his chart,
she provided him only with diabetes medication,
but never started medication for anemia or
cirrhosis, even after his local pharmacy verified
his current medication. The facility made no
attempts to identify and seek medical records
from his medical providers who had ordered
his medications. The nurse also failed to order
required laboratory diagnostic testing to
determine iron and liver function blood levels. In
a later investigatory interview, the staff physician
confirmed that laboratory work should have
been ordered, stating that “I don’t know what
she was thinking.”158 Mejia repeatedly requested
that the facility provide him with his prescribed
medication, which went unanswered.159

and lack of timely access to necessary and
appropriate higher level of care.”160
• Wilfredo Padron died in ICE custody on
November 1, 2018, at the Monroe County
Detention Center in Key West, Florida.
Padron, a 58-year-old man from Cuba, died of
coronary artery disease due to atherosclerotic
cardiovascular disease – blocked heart arteries
which resulted in a heart attack. Medical expert
reviewers concluded that detention facility
medical staff repeatedly failed to provide critical
interventions where Padron reported symptoms
of chest pain, which would have likely prevented
his death.

As Dr. Elena Jimenez Gutierrez noted about
Mejia-Bonilla’s care, “there were various missed
opportunities for intervention and gaps in
clinical care, including no documented use of
interpretation assistance, insufficient monitoring
of blood pressure and blood glucose, absence of
medication reconciliation, lack of review of initial
health appraisal by clinical medical authority,
break in continuity of chronic disease treatment/
inadequate clinical management of chronic
conditions, prescriptions of inappropriate
medications, lack of communication about
abnormal findings amongst clinical staff,
inappropriate nursing call protocol, lack of
notification regarding laboratory studies’
cancellation, lack of referrals for mental health
professional, dentist, and medical providers,
care delivery outside the safe limits of practice,

38

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Mr. Padron’s health began to deteriorate on
October 19, 2018, when he submitted a request
for medical attention regarding elevated blood
pressure in Spanish, but detention facility
medical staff mistakenly read it as a request to
be seen for depression and placed him on a list
for mental health support, thereby delaying his
medical request by a week. In the week before his
death, facility medical staff failed to intervene
appropriately when Padron complained of chest
pain and elevated blood pressure. On October
26, Mr. Padron again complained of chest pain
that radiated to his left arm and back, which
are symptoms of a heart attack. Medical staff
conducted an EKG, and he was transported to
the emergency room. However, the emergency
room was informed that Mr. Padron was suffering
from abdominal pain instead of chest pain,
and the emergency room concluded that he had
constipation. He was returned to the facility three
hours later, with his chest pain and elevated blood
pressure untreated.161 The facility staff did not
follow up on the cardiac symptoms, nor did they
send Padron back for reevaluation, which, as Dr.
Sadacharan noted, would have likely changed the
outcome of his case.162 Two days later, on October
28, Padron again requested medical attention
due to a pain in his chest that radiated down his
left arm. The detention facility nurse did not
conduct an EKG, or follow treatment procedures
for hypertensive patients, and instead provided

him Motrin for pain.163 The next day, on October
29, Padron again complained about chest pain.
Despite his ongoing and severe chest pain,
detention medical staff did not order an EKG
test.164
On October 31, 2018, the day before his death,
Padron once again complained of chest pain and

was seen in the medical unit. Detention medical
staff, however, did not obtain an EKG test or refer
him to a higher level of care. At 11:00 p.m. that
night, he showed a guard his ID card through his
cell window during count. That was the last time
anyone saw him alive.165 The next morning, on
November 1, around 6:41 a.m., another detainee
went to Padron’s cell, and could not wake him

PROFILES

Kamyar Samimi
Neda Samimi-Gomez keeps a memory box of
the things she remembers about her father,
Kamyar Samimi. “My biggest fear is forgetting
about things with him,” she said. She
remembers her father as the one who always
took her to doctor’s appointments, girl scout
meetings, and the movies,
an incredible cook who
loved sweets, and as the
family prankster with a
dramatic sense of humor.
“He was very much a part
of the small moments
that make relationships
so special. He loved his
family and wanted to
make sure we were happy
and safe,” she recalls.
Neda’s father came to
the United States from
Iran in the 1970s to study Photo courtesy Neda Samimi-Gomez
computer science and
was a legal permanent resident. He lived with
his family in Colorado for over 40 years, until
November 2017, when ICE officers detained
him at the Aurora ICE Detention Center.
Neda found out that ICE had detained him
when she couldn’t reach him to invite him
for Thanksgiving dinner. The family assumed
that he would be released from custody on

the day of his first immigration court hearing,
December 4, 2017. But Kamyar never made
it to that hearing. Instead, Neda received a
call that day from an ICE officer, who told
her that her father had died in detention of
cardiac arrest two days before.
After Neda contacted the ACLU of Colorado,
she and her family
filed suit against the
government and the
GEO Group, Inc.,
the private prison
corporation that
operates the Aurora
detention facility. As
a result, they learned
more details about
his treatment — and
lack thereof — in ICE
detention. “He was
failed by ICE and GEO,
and the medical staff,”
Neda concluded,
noting the multiple
times that his requests for medical attention
went ignored. “He was unjustly detained.
Two weeks later, after none of his medical
concerns were heard, he died. There is
nothing in the world that can bring back my
father. What I want is for no one else to ever
experience this.”

Findings and Analysis

39

up. Officers tried to rouse Padron but found his
body “cold and blue.” Medical staff arrived soon
after, and unsuccessfully administered CPR.166
An autopsy concluded that he had died of a heart
attack caused by thrombosis of the right coronary
artery due to atherosclerotic cardiovascular
disease.167
• Kamyar Samimi, a 64-year-old-man from
Iran, died on December 2, 2017, at the Aurora
Detention Center in Colorado. Samimi came to
the United States in the 1970s to study computer
science, married, and had three children. He
had been prescribed and had successfully taken
methadone for over two decades to manage
opioid use disorder, which had started as a
child in Iran when he was given opium for
tooth pain.168 Detention medical staff, however,
discontinued medication assisted treatment
for opioid use disorder upon his arrival at
Aurora on November 17, 2017, putting him into
withdrawal from methadone. Over the next
sixteen days, Samimi’s condition deteriorated
rapidly. Samimi experienced tremors, pain and
weakness, nausea, vomiting, an inability to sit up
in bed or a wheelchair, incontinence, and signs of
dehydration. He also attempted suicide, telling
staff that he wanted to die due to his symptoms
of methadone withdrawal. Facility medical staff,
however, did not transfer him into acute care in
a timely manner, did not monitor his vital signs
as ordered, and never completed monitoring
of his withdrawal symptoms using the Clinical
Opiate Withdrawal Scale (COWS) assessment, as
ordered. During this time, the facility’s physician
never physically examined Samimi. The nurses
who treated him viewed him as “malingering
or seeking drugs,” and “did not see an urgent
need to notify the physician of his worsening
condition.”169
On December 1, 2017, the night before his
death, Samimi began to spit up blood, vomited
frequently, and began to have seizure symptoms,
leading facility staff to call an ambulance. Samimi
stopped breathing shortly after their arrival, and
paramedics were unable to resuscitate him.170

40

As expert medical reviewer Dr. Chanelle Diaz
noted, Samimi’s autopsy “demonstrated
evidence of aspiration pneumonia and a
gastrointestinal bleed, both of which could have
resulted from repeated vomiting due to opioid
withdrawal, which could have been treated with
medication and prevented.”171 Dr. Diaz concluded
that detention facility staff inappropriately
discontinued Samimi’s medication assisted
treatment for opioid use disorder putting
him into acute withdrawal. As she noted,
Samimi’s “withdrawal symptoms were then
inadequately monitored and under-treated,
resulting in his death. He was treated with
callous disregard by nursing staff who thought he
was ‘drug-seeking. He did not receive treatment
aligned with existing evidence-based guidelines
for the management of opioid withdrawal. There
were multiple missed opportunities to escalate
his care that could have prevented his death.”172
• Kuan Hui Lee, a 51-year-old man from Taiwan,
died on August 5, 2020 as a result of hypertensive
left thalamic hemorrhage, a type of stroke caused
by bleeding in the brain due to longstanding
uncontrolled high blood pressure. He died in
ICE custody after being detained at the Krome
North Service Processing Center and the
Broward Transitional Center, both in Florida.
Lee had a significant history of severely elevated
blood pressure, requiring tight control given his
cardiovascular risk. However, detention facility
medical staff failed to provide Lee with blood
pressure medications during the 48 hours prior
to his medical emergency, which occurred early
on July 31, 2020.173 As Dr. Sadacharan concluded,
the detention facility’s failure to provide Lee with
his blood pressure medication in the 48 hours
prior to his medical emergency, combined with
staff’s failure to alert doctors to severely elevated
blood pressure, directly contributed to Lee’s
death.174

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Medical experts who reviewed Lee’s case noted
multiple occasions where facility medical staff
failed to appropriately respond to Lee’s
symptoms and the facility’s significant delay

in providing emergency care. Reviewers
noted repeated failures, including insufficient
blood pressure monitoring, failure of nurses
to notify providers regarding abnormal vital
signs, including high blood pressures, and the
administration of clonidine and ibuprofen by
nurses without provider orders, practicing
outside the scope of their license.
Medical expert reviewers also raised concerns
with the detention facility’s failed emergency
response. On July 31, 2020, detention center
staff failed to immediately initiate medical
emergency and 911 notifications.175 Medical
staff did not conduct any vital sign checks or
assessments for 12 minutes after Lee was found
in his cell, and instead, tried to wake Lee and
adjust his position.176 It took 10 minutes for a vital
sign machine to be brought into the room and a
further eight minutes to check Mr. Lee’s oxygen
level. Medical staff only provided him with oxygen
27 minutes after he was found unconscious.
Although medical staff reported hearing heavy
breathing with phlegm, which required suction,
nurses did not immediately suction Lee because
they did not know how to use the machine and
could not find an electrical outlet for the machine.
After clearing Lee’s airway, medical staff placed
him on his back for 28 minutes, which is contrary
to basic life support guidance. When emergency
medical staff arrived, they found Mr. Lee still
unconscious and without supplemental oxygen.177
Emergency medical staff took Lee to a local
hospital, where he remained unresponsive and
was pronounced dead five days later.178
• Samuelino Pitchout Mavinga, a 40-year-old
man from Angola, died in ICE custody after
being detained at the Otero County Processing
Center in New Mexico on December 29, 2019.179
During Mavinga’s detention, medical staff at
Otero missed multiple opportunities for clinical
intervention, failed to work up abnormal imaging
and clinical findings, failed to assess his mental
capacity to refuse treatment, failed to manage
severe malnutrition over the course of his

detention, and did not consult with neurology or
psychiatric experts upon symptoms of psychosis.
Upon his arrival at Otero, Mavinga began to
demonstrate symptoms of mental illness.180 On
November 17, 2019, several other individuals
detained with Mavinga complained to staff
about his behavior and poor hygiene, such as
urinating in his bed and refusing meals and
medication.181 However, nursing staff did not
follow mental health protocol, and Mavinga did
not receive a timely and appropriate consultation
with a mental health provider.182 Staff also did
not evaluate Mavinga’s neurological state,
mental capacity, or legal competency to refuse
assessment or treatment despite his evident
agitation and rapid weight loss; indeed, he lost
30 pounds in about 30 days. Between November
18, 2019, to December 11, 2019, Magina ate only
two full meals, 18 apples, and one slice of pizza.
Although medical staff documented this rapid,
significant weight loss, they did not actively
manage this medical problem. Although Mavinga
agreed to take liquid nutritional supplements
such as Ensure, facility staff never provided any
because the ICE Health Service Administrator
“was trying to find it at a ‘reasonable or
discounted price.’”183 The ICE detention medical
team was responsible for following up on
concerning symptoms and providing appropriate
treatment. Instead, medical staff allowed him to
deteriorate for over a month, until ICE sent him
to the hospital on December 12, where he died 17
days later.184 Mavinga’s death was determined
to be caused by coccidioidomycosis, a fungal
infection of the lungs, as well as complications
from refractory shock caused by sepsis.185

Flawed or delayed emergency response
Appropriate and timely medical response in an
emergency is critical to saving lives.186 Detention
facilities are required to ensure the delivery of 24hour emergency health care, and that medical and
safety equipment be made available and maintained
for staff use. Our review, however, found that in
40 percent (n=21) of the reviewed cases of death,

Findings and Analysis

41

ICE detention facilities failed to provide timely
and appropriate emergency care. In 13 percent of
cases (n=7), the equipment used during the medical
response either failed or was insufficient to effectively
respond to the medical emergency. ICE detention
facilities also delayed emergency medical personnel
from accessing patients by failing to call 911 in a
timely manner or blocking ambulances from entering
the facility. For example:

almost 45 minutes later, at approximately 9:14
a.m., when a facility officer entered the waiting
room and found Missick slumped over. It then
took medical staff nine more minutes to initiate
CPR.189 During this time, none of the staff who
first responded, including the facility officer,
registered nurse (RN), or licensed practical nurse
(LPN), initiated CPR, nor did they retrieve any
emergency equipment, a gurney, or an automated
external defibrillator, which is used to revive
someone from sudden cardiac arrest. At 9:22
a.m., other medical staff initiated CPR and
attempted to defibrillate Missick without success.
Paramedics arrived on the scene at 9:56 a.m.,
40 minutes after first being called. Soon after,
paramedics declared Missick deceased.190

• Henry Missick (a/k/a Anthony Jones), a
51-year-old man from the Bahamas, died of
a heart attack in the waiting room of an ICE
detention facility medical unit after staff
repeatedly failed to provide timely emergency
care necessary to save his life. Missick died
on December 17, 2020 at the Adams County
Detention Center in Mississippi.187
On the morning of December 17, 2020 at 7:24
a.m., Missick reported to a guard that he was
experiencing burning chest pain that also
radiated down his arms, classic symptoms
of a heart attack that require an immediate
emergency response. Detention facility officials,
however, did not allow Missick to go to the
medical unit until guards finished their morning
count of detainees. Missick was forced to wait
12 minutes to go to the medical unit, and then
waited an additional 18 minutes to be assessed
with an electrocardiogram or EKG. At 7:54
a.m., the EKG test resulted in findings that
indicated a heart attack or reduced blood flow to
the heart, which should have led medical staff to
immediately call emergency medical services or
request a transfer to the emergency department
for further evaluation and management. Medical
staff, however, did neither. Instead, at 8:01 a.m.,
detention medical staff instructed Missick to
remain in the clinical waiting room for an hour
before he could be released back to his housing
unit.188
According to video surveillance footage, Missick
began to move his arms and slumped over in his
chair while sitting in the waiting room at 8:30
a.m. Seconds later, he began to convulse, and
then laid motionless in his chair. It was not until

42

Dr. Elena Jimenez Gutierrez, a medical expert
who reviewed ICE’s reports, concluded that Mr.
Missick’s abnormal clinical and EKG findings
“were not managed appropriately,” nor was
CPR initiated in a timely manner. Dr. Jimenez
Guiterrez further noted that ICE’s review
“failed to note lack of appropriate emergency
triage and escalation to higher level of care for
probable acute coronary syndrome in an adult
patient with active chest pain and risk factors
for cardiovascular disease. ICE failed to address
systemic problems, including communication
channels and protocols for triage and
escalation of care to improve quality of care and
accountability.”191
• When Nebane Abienwi, a 37-year-old asylumseeker from Cameroon, entered ICE detention on
September 19, 2019, he told medical staff at the
Otay Mesa Detention Center that he had recently
been hospitalized for hypertension (high blood
pressure). Detention medical staff, however, did
not monitor him for high blood pressure despite
this known medical history. One week later, on
October 1, 2019, he had a stroke in detention and
died soon after of a hypertensive basal ganglia
hemorrhage, a brain hemorrhage that results
from poorly controlled high blood pressure.192

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

At 3:26 a.m. on September 26, 2019, one week
after ICE detained him, a detention officer

reported to the medical unit that Abienwi had
fallen from the top bunk of his bed to the floor.
Medical staff arrived within two minutes at
3:28 a.m. and found that Abienwi was unable
to answer questions and had slurred speech
and jerky movements. It took 50 more minutes
before emergency medical services arrived
to treat Abienwi, because the on-call medical
provider did not respond to the nurse’s request
for authorization to call for emergency medical
services. At 3:45 a.m., the nurse decided to call
for an ambulance. The facility, however, delayed
paramedics’ ability to provide immediate
treatment, as the facility hampered their ability
to move through the facility upon arrival because
it was “count time.”193 As Dr. Sadacharan noted,
“this delay in EMS services and a higher level
of care may have changed the outcome for Mr.
Abienwi.”194
• Huy Chi Tran, a 47-year-old man from Vietnam,
was found unresponsive in his cell due to cardiac
arrest on June 5, 2018 while detained at the Eloy
Detention Center. He died a few days later after
being taken off life support on June 12, 2018.195
While detained at Eloy, medical providers
focused primarily on Tran’s mental health
symptoms, prescribing him with antipsychotic
medications for schizophrenia. On June 5, 2018,
facility medical staff observed Tran with altered
consciousness, as well as sweating, shaking,
and hand tremors during an appointment.196 As
medical expert reviewer Dr. Sadacharan noted,
the nurse should have at this time referred
Tran to be seen in person by a doctor, as he
had symptoms for undiagnosed neuroleptic
malignant syndrome, a life-threatening reaction
to neuroleptic medication that can lead to
seizures or heart attacks.197 Instead of referring
Tran to a doctor, however, medical staff placed
him in a mental health segregation unit at 2:54
p.m., without completing the authorization
process required to place someone in solitary
confinement.198
Although officers were supposed to check on Tran
every 15 minutes in the solitary confinement

cell, video evidence shows that this did not
take place. Over the next 51 minutes, an officer
walked by his cell five times, never looking in to
confirm Tran’s welfare. At 4:06 p.m., the officer
placed a meal through a flap in the cell door,
which remained untouched. Six minutes later,
the officer looked inside Tran’s cell, removed the
meal from the door, and opened the cell door. The
officer reported that when he entered the cell,
he shook Tran’s back, which “was warm.” The
officer then exited the cell and reported a medical
emergency. Additional staff arrived at Tran’s
cell at 4:15 p.m. and began to start CPR. Three
minutes later, medical staff arrived. Medical staff
detected a faint, irregular pulse, and attempted
defibrillation. However, medical staff did not
place the automated external defibrillator (AED)
pads in the correct position on Tran’s chest,
nor did the pads adhere to his chest, which are
necessary to provide accurate analysis and
effective shock during a sudden cardiac arrest.
The nurse practitioner later surmised that
the AED pads were expired, which may have
caused the pads to be dry and non-adhering;
the emergency bag inventory, however, had
no extra pads available.199 Emergency medical
services arrived at 4:30 p.m. and transported
Tran to a local hospital, where he was placed on a
respirator and admitted to intensive care.
One week later, on June 12, 2018, Tran was
declared brain dead and removed from life
support.200 Tran’s death underscores the danger
of overlooking serious medical symptoms in
patients with mental health issues. His death also
highlights staff’s failure to adequately monitor
people in medical isolation, and malfunctioning
emergency equipment.
Elba Maria Centeno Briones, a 37-yearold woman from Nicaragua, died on August
3, 2021 of COVID-19 after her detention at El
Valle Detention Facility in Texas.201 Confusion
amongst staff over who was responsible for
calling an ambulance led to a half-hour delay in
calling 911.

Findings and Analysis

43

On July 27, 2021, between 4:00 and 5:00 p.m.,
a nurse took Centeno Briones’s vital signs and
found her oxygen saturation levels at 70 percent,
with blue fingernails, shortness of breath, and
wheezing in her right lung. Centeno soon after
tested positive for COVID-19 on a rapid test,
and medical staff determined that she needed
emergency transport via ambulance to the
hospital. At 5:26 p.m., medical staff notified a
facility lieutenant that Centeno Briones needed
an ambulance. The facility, however, did not call
911 for an ambulance until 6:18 p.m., 52 minutes
after medical staff had requested one, because of
“confusion as to responsibility to call 911.”202 As
ICE’s investigatory report showed medical staff
understood that security personnel should call
911 when an ambulance was needed, but security
staff thought that medical staff or central control
officers were responsible for calling emergency
services. The detention facility nurse did not
know that no one had called 911 until 30 minutes
after the medical staff requested an ambulance,
when a sergeant asked her if she was calling
911. The nurse then left the medical unit to find
an outside phone line and called 911 herself,
because there were no outside phone lines in the
medical unit. Paramedics did not reach Centeno
Briones until 6:30 p.m., over an hour after the
medical unit had determined the need for an
ambulance.203

Suicides caused by failure to provide
mental health care, properly manage
medication, and adequate mental health
staff
Our analysis shows that ICE detention facilities
have failed to provide mental health care necessary
to address suicidal ideation and prevent deaths by
suicide. This failure has led to a precipitous rise in
the rate of deaths by suicide in ICE detention. Since
2017, at least 15 people in immigration detention have
died by suicide, and ICE has not disclosed the cause
of death for several additional cases that may be by
suicide.204 In 2020 alone, the rate of deaths by suicide
while in ICE custody rose 11 times higher than the

44

prior 10-year average, when adjusted for admissions
per year.205
Of the cases examined by our experts, 21 percent of
cases (n=12) were deaths by suicide. All 12 cases were
listed in autopsies or other documents as the result of
hanging by the neck, in some cases deemed “asphyxia
by hanging” or “anoxic encephalopathy.”
These cases were marked by an alarming lack of
mental health care support provided in ICE detention
facilities, including absence or near absence of
mental health care providers in detention facilities
and consistent failure to appropriately manage or
provide psychiatric medication. Detainees who died
by suicide had frequently expressed despair about
systemic barriers to justice in the days before their
deaths, noting barriers such as prolonged detention,
delayed adjudication, lack of access to legal resources,
failed case outcomes, and miserable conditions.
Detention facilities failed to promptly identify or
prevent suicidal behavior due to a significant lack of
staffing and staff failure to conduct welfare checks
and security rounds. In some cases, other detainees
alerted security staff that there was an urgent
situation regarding a fellow detainee before action
was initiated. ICE’s reliance on solitary confinement
of people in psychological distress, instead of
appropriate treatment and support in non-carceral
settings, further heighten the likelihood of suicide.
This report has discussed above the deaths of Jean
Jimenez and Efrain de la Rosa by suicide at
Stewart Detention Center in Georgia. In both cases,
medical and mental health staff failed to ensure
that Jimenez and de la Rosa received prescribed
medications for schizophrenia, which directly
contributed to decompensation, and ultimately, death
by suicide. The following examples also underscore
ICE’s failure to protect detained immigrants from
suicide:
• 43-year-old Cuban asylum-seeker, Roylan
Hernandez Diaz, died by suicide on October
15, 2019 after participating in a hunger strike
to protest conditions he endured while in ICE
custody. Hernandez Diaz, was being held at the
Richwood Correctional Center in Louisiana.

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Although Hernandez Diaz had passed a credible
fear screening, making him eligible for release
from detention on parole, ICE’s New Orleans
Field Office denied his release, as it had done with
99 percent of all parole applications.206 Although
Hernandez Diaz had submitted requests for
mental health support and had participated
in a hunger strike, the detention facility never
provided him any mental health interventions.
Notably, Richwood failed to hire an on-site mental
health specialist at the time of Hernandez Diaz’s
death.207
On October 9, an immigration judge told
Hernandez Diaz that he needed to provide more
evidence of persecution to establish his asylum
claim—evidence overwhelmingly difficult to
obtain while in detention. Thereafter, Hernandez
Diaz began his second and final hunger strike.208
The next day, on October 10, the detention
facility placed him in administrative segregation
(solitary confinement) for threatening a hunger
strike. Although a health care provider should
have reviewed whether to keep Hernandez Diaz
in segregation within 72 hours no evidence exists
that this review occurred.209
Detention facilities are required to monitor
anyone in a segregation cell at least every 30
minutes. However, video surveillance of the
hallway outside his cell showed that in the hour
before Hernandez Diaz was found hanging in
his cell, officers walked by his cell and logged an
entry into the binder by the door, without ever
looking in the window. At 2:04 p.m., a jail captain
noticed a “strong odor” coming from the cell, and
then unlocked the cell. He opened the door, and
discovered that Hernandez Diaz hanging from
the post of his bunk bed, with a sheet tied around
his neck.210
Officers prohibited facility medical staff from
entering the cell to cut Hernandez Diaz down or
to resuscitate him. More than an hour passed
between the time that officers found Hernadez
Diaz hanging in his cell and the time that the
county coroner’s office arrived and cut him
down.211

• Mergansana Dabaevich Amar, a 39-year-old
man from Russia, died by suicide on November
18, 2018 after his detention at ICE’s Northwest
Detention Center in Washington.212 Amar’s case
underscores how failure to provide mental health
support, and systemic barriers to justice, can lead
to preventable death.
Amar came to the United States seeking asylum
after reportedly being beaten and imprisoned
for demonstrating for the independence of
Buryatia, a province in Russia.213Amar was
detained immediately upon arrival while his
asylum application was pending. On August 7,
2018, after nine months of detention, Amar lost
his case before an immigration judge and was
given a September 6, 2018 deadline to appeal to
the Board of Immigration Appeals.214 Ten days
later, Amar complained to the staff that he was
suffering depression and isolation, because
he had lost his immigration case and because
there was no one he could speak to in Russian.
Although he requested a change to another
housing unit where other Russian-speaking
detainees were held, GEO Group, Inc., the private
prison corporation that owns the facility, denied
his request.
On August 22, 2018, Amar announced that he was
starting a hunger strike. In response, ICE placed
him in solitary confinement, and on September
7, 2018, won a federal court order that would
allow the government to administer intravenous
fluids and forcibly restrain Amar if he refused.
As a result, Amar agreed to begin taking liquid
nutritional supplements.215 He also submitted
a belated appeal in his case on October 1, 2018,
explaining that he had missed the deadline
because he had been in medical isolation and
lacked access to the law library.216
Amar began to gain weight again, but over the
next few weeks, exhibited warning signs of
suicide. On October 26, 2018, medical staff placed
him on suicide watch after finding a six-foot rope
under his mattress. The next day, however, the
facility discontinued suicide watch and ordered
mental health observation. On November 4,

Findings and Analysis

45

2018, an officer found a sheet torn in thirds
in his cell, but failed to notify medical staff or
report this fact, despite this clear indication of
his deteriorating mental condition. The next
day, the facility discontinued mental health
observation, but Amar remained in solitary
confinement. Amar requested that he be moved
to general population, and on November 15, 2018,
the facility approved his release from solitary
confinement.217

previously had heart attacks, was particularly
vulnerable to COVID-19, especially as vaccines
or antiviral treatments were not yet available at
that time. Ahn had petitioned for release from the
Mesa Verde ICE Processing Center in California
on at least three different occasions at the height
of the COVID-19 pandemic. Each time, however,
Ahn’s petitions were denied.
After returning from an offsite medical visit on
May 14, 2020, detention facility officers placed
Ahn in a solitary confinement cell.221 The next
day, Ahn learned that a judge had denied his
request for release from custody. Ahn began to
refuse meals and medication, stating that he was
depressed at the prospect of being deported. A
facility provider diagnosed Ahn with unspecified
depressive disorder, noting that he appeared to
be “a high suicide risk if deported.”222 Facility
officials were well aware that Ahn had a history of
mental health issues, including severe depression
that had led to three prior suicide attempts. The
most recent attempt occurred in 2019, one year
before he was placed in ICE detention.223

At 1:40 p.m. that day, officers placed Amar in
handcuffs, and escorted him to an administrative
office, where an ICE official informed Amar that
the Board of Immigration Appeals had dismissed
his appeal, and that he was scheduled to be
deported to Russia. Amar had not known of this
information, even though his appeal had been
dismissed two weeks earlier. Despite knowing of
Amar’s fragile mental state, ICE failed to provide
mental health support upon notifying Amar of his
impending deportation.218 In addition, had Amar
been adequately treated and provided access to
legal resources to fully inform him of his rights,
he might have known that he could have appealed
his case to the Ninth Circuit Court of Appeals
and requested a stay of removal to prevent
deportation during his appeal.219

On May 17, 2020, the day of his death, Ahn spoke
to his brother and sister, telling them that “the
attorney was going to have news” the following
day. At 8:53 p.m., Ahn hung himself with a
bedsheet around his neck.

Less than two hours later, at 3:06 p.m., an
officer found Amar hanging in his cell with a
sheet wrapped around his neck. Paramedics
arrived and transported Amar to a local hospital,
where he was placed in intensive care. A doctor
concluded that day that Amar was brain dead, but
kept him on a ventilator. On November 24, 2018,
after discussions with his family in Russia, Amar
was removed from life support.220
• Choung Woong Ahn
died by suicide on May 17,
2020 at the Mesa Verde
ICE Processing Center in
California. Ahn, a
74-year-old man from
South Korea who had
lung disease, diabetes,
hypertension, and had

46

Drawing of Choung Woong Ahn by
Tania Bernal

Expert reviewer Dr. Elena Jimenez Gutierrez
noted that detention and isolation in ICE custody
appears to have significantly deteriorated Ahn’s
mental health, and that release from detention
would likely have prevented his death. Dr.
Jimenez Gutierrez also faulted the facility’s low
frequency of mental health assessments relative
to a standard of care for a patient with depressive
symptoms, passive suicidal ideation, a history of
depression, and prior suicide attempts.224
• Osmar Epifanio Gonzalez Gabda, a 32-yearold man from Nicaragua, died by suicide on
March 22, 2017, while detained at Adelanto
Detention Facility in California.225 Two weeks
before his death, Gonzalez was transferred from
Adelanto and admitted to a local psychiatric

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

hospital after refusing meals for several days and
reporting that he had been sexually assaulted
while detained.226 Gonzalez was diagnosed with
paranoid schizophrenia, psychosis, and suicidal
thoughts. After a week of treatment, Gonzalez
was discharged back to Adelanto. Upon his return
to Adelanto on March 15, detention medical staff
placed Gonzalez in medical segregation (solitary
confinement), even though, as Dr. Chanelle Diaz
noted, “isolation is a known risk factor for selfharm and suicide.”227
At approximately 7:50 p.m. on March 22, a nurse
and officer making rounds found him hanging
in his cell with a sheet tied around his neck.228
Medical staff activated emergency medical
services at 7:56 p.m. after laying him on the floor
and administering CPR.229 EMS arrived at 8:16
p.m. and transferred Gonzalez to Victor Valley
Global Medical Center at 9:00 p.m. after his pulse
was restored.230 He went into cardiac arrest later
that night and died.231
In the week prior to his death, Gonzalez had
been prescribed a high dose of haloperidol,an
antipsychotic drug. Records show that he
failed to take psychiatric medication in the two
days before his death. Medical expert reviewer
Dr. Sadacharan concluded that “it is not
surprising that Mr. Gonzalez suffered an acute
destabilization that led to suicide.”232
It is unclear from the records released by the
government what medical intervention, if
any, the facility took to address this refusal of
medicine.233

Failure to provide necessary and required
interpretation and translation by medical
and mental health providers
ICE detention standards consistently require
that detention facilities provide professional
interpretation and translation, particularly in health
encounters.234 This is especially important in a
medical setting, as consent for medical assessment
and treatment must be conducted in a language the

detainee understands in order to qualify as informed
consent. Medical staff must also understand the
person detained to assess and manage medical
complaints. However, records indicated that some
cases (n=12) involved inappropriate interpretation
or failures to translate between staff and detainees,
often leading to disastrous consequences.235
This report has discussed the Kay County Detention
Center’s failure to provide Spanish language
interpretation when treating Maria Celeste Ochoa
de Yoc. As a result of the facility’s lack of proper
translation, medical staff incorrectly concluded that
Ochoa was bulimic and suicidal and placed her in
solitary confinement under a suicide watch protocol,
instead of properly treating her for liver failure.
• Simratpal Singh died by suicide on May 3, 2019
in ICE custody at the age of 20, after his detention
at the La Paz County Adult Detention Facility
in Arizona. Singh, a native of India, spoke
Punjabi, not English. Over the course of his 3-day
detention at La Paz, facility medical staff did not
use interpreters to communicate with Singh.236
The nurse on duty during his medical intake
recalled that the only words that Singh knew in
English were “court” and “lawyer,” but marked
in his medical record that he was not allergic to
any medications. The nurse further decided that
Singh did not exhibit any suicidal ideations based
on her observation of his appearance alone.237
The intake nurse did not screen Singh for mental
health issues or assess his suicide risk, although
hospital records later made clear that he had
previously attempted suicide. The intake nurse
also failed to follow up on troubling vital signs,
including elevated pulse and blood pressure, as
well as difficulty breathing and poor appetite.238
Security and nursing staff at the facility did not
receive periodic training on suicide prevention
and intervention.239 No security rounds were
recorded on May 2, 2019.240 At 5:13 p.m. that
day, a detention staff member gave Singh a
pair of socks, per his request. Singh was last
seen moving in his cell on video surveillance at
approximately 5:43 p.m. When another detainee
informed an officer at 5:50 p.m. that Singh was

Findings and Analysis

47

hanging in his cell, the officer on dutywrongly
believed that Singh was already deceased. The
officer did not immediately call the medical
emergency over the radio or lift Singh upward
to protect his airway before additional staff
arrived.241 Singh was transferred by EMS to La
Paz Regional Hospital and subsequently to the
Abrazo West Campus hospital, where he died the
following day.
Medical expert Dr. Sadacharan concluded
that there was a reasonable possibility that
Singh’s death could have been prevented with
appropriate treatment, in light of the medical
staff’s apparent lack of training and their
decision not to use interpretation services.242 She
also noted that a “likely diagnosis of anxiety/
panic attack may have been missed” and that
“there could have been time to save Mr. Singh’s
life” if the emergency response had not been
delayed.243 Dr. Katherine McKenzie, a medical
expert reviewer, similarly identified a lack of
adequate mental health assessment, “inadequate
language interpretation,” and “a delay in
giving... emergency care.”244 She cited several
systemic failures in Mr. Singh’s case, including
an overall lack of training across facility staff
in interpretation services, emergency response
(including CPR certification), and suicide
prevention.245

Failure to follow COVID-19 protocols

ICE, however, failed to take basic precautions to
protect detained people in its care from COVID-19.
Detained immigrants staged hunger strikes and
begged for basic protections from the virus, including
soap, masks, and cleaning supplies.247 ICE failed
to test detained people for COVID-19 at facilities
nationwide, leading to a dramatic undercount of
cases. ICE also transferred detained people from
facilities with COVID-19 outbreaks across the
country, further spreading the virus.248
ICE reported that nine detained immigrants died of
COVID-19 during the pandemic. These cases reflect
ICE’s failure to protect detained immigrants from
the virus, made especially clear in cases where ICE
insisted on detaining people who had been granted
compassionate release from criminal custody, and
where ICE failed to timely release people from its
custody, even when a legal basis existed to do so.
In addition, these reported deaths do not include
individuals who were released from ICE’s legal
custody immediately prior to death.249
• James Thomas Hill, a 72-year-old citizen of
Canada, died on August 5, 2020 of COVID-19,
after his detention at the Immigration Centers of
America Farmville in Virginia. Hill should have
been released from detention and returned to
Canada months before he contacted COVID-19 in
detention. An immigration judge had ordered Hill
removed on May 12, 2020, but ICE did not set his
deportation flight back to Canada to take place
until July 9, nearly two months later.250 This delay
would prove fatal.

As early as February 2020, DHS medical experts
began to warn of the threat posed by COVID-19
to people held in ICE detention. At a time when
no vaccine or known treatment for COVID-19 was
available, experts warned of a tinderbox scenario,
where the virus would spread rapidly in congregate
settings and lead to devastating consequences.
These experts recommended that ICE immediately
implement preventative measures to allow for social
distancing by releasing medically vulnerable people
from detention. Experts also recommended that ICE
enact rigorous mitigation processes of screening,
testing, and quarantine.246

48

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

On June 2, 2020, ICE flew 74 people from
detention facilities in Florida and Arizona that
had active outbreaks of COVID-19 to Farmville
Detention Center in Virginia.251 This transfer
ultimately sparked a COVID-19 outbreak at
Farmville, where over 300 people, including Hill,
eventually contracted the virus.252 On July 1,
2020, detention facility officers pepper-sprayed
more than 40 detainees, including Hill, after
detainees voiced frustration over their lack of
access to ICE staff. Detainees also voiced their
desire to be released or deported in order to
protect them from COVID-19. Two days later, Hill

reported body aches, weakness, and an elevated
temperature, and was taken to the hospital with
a diagnosis of suspected COVID-19. By July 10,
2020, Hill’s oxygen levels dropped, and he was
taken again to the hospital, where he tested
positive for COVID-19 and was moved to the
intensive care unit. His condition deteriorated
until his death on August 5, 2020.
• Cipriano Chavez-Alvarez, a 61-year-old man
from Mexico and father of six children,253 died on
September 21, 2020, after contracting COVID19 at the Stewart Detention Center in Georgia.
Chavez-Alvarez had already been granted
compassionate release from the Edgefield
Federal Correctional Institution by a federal
judge in light of his medical vulnerabilities to
COVID-19, which included gout, lymphoma, and
hypertension. Chavez-Alvarez looked forward to
his rapid deportation to Mexico, but ICE officials
kept him in detention instead.254 Eleven days
after Chavez-Alvarez was detained at Stewart, he
began to feel ill. His oxygen saturation rate had
fallen to 76 percent, and medical staff ordered
to transfer him by ambulance to a local hospital.
Chavez-Alvarez never left the hospital and died in
the intensive care unit six weeks later.

They are also required to either ensure that there
are adequate numbers of medical providers to meet
the needs of the detained population or decrease the
population to a level where adequate medical care can
be provided.
ICE detention facilities lack adequate staffing and
frequently fail to hire staff for unfilled positions.
When there are not enough staff at a location, time
pressure can drive patient visits to be shorter and less
comprehensive. High rates of staff turnover can also
intensify issues of inadequate and improper training,
which can have deadly consequences. Staff who are
unaware of emergency procedures, interpretation
resources, or the limits to their scope of practice can
make mistakes that delay or prevent appropriate
patient care. Ensuring safe ratios of medical and
mental health staff to detainees is essential to ensure
that medical and mental health services are actually
met. Patients may not receive basic care, such as
receiving medication, monitoring of symptoms
and vital signs, or timely attention or treatment.
A shortage of mental health staff may mean that
people with emergent mental health care issues are
never treated, leading to escalation of symptoms or
decompensation that can lead to suicide.

Chronic understaffing, inadequate and
improper staff training, and care outside
the scope of practice

ICE detention facilities also rely heavily on care
provided by low-level providers and often prevent
detained patients from accessing care from more
highly-trained professionals. ICE’s own investigatory
reports found frequent examples of care provided
outside the scope of licensed practice, leading to
deadly consequences. For example, registered
nurses frequently provided medication without
prescriptions. Licensed Vocational Nurses (“LVN” or
“LPN”), who have only one year of post-high school
training, also provided unauthorized care to detained
patients. Lower-level staff were often unable to
locate higher-level providers, such as doctors, nurse
practitioners, or physicians’ assistants, who are
licensed to assess patients, provide treatment, and
prescribe medication.

Prison and detention systems are constitutionally
required to provide sufficient medical staff who
are competent to diagnose illnesses, treat medical
problems or refer patients to qualified providers.

Agency reports frequently noted medical and mental
health positions that had not been filled for months,
and ICE investigation reports are replete with
statements from medical staff reporting overwork.

ICE Health Service Corps’s mortality review
determined that Mr. Chavez-Alvarez’s
medical care was “not provided within safe
limits of practice,” and that medical care at
Stewart “or lack thereof, could pose a future risk
of adverse outcomes.” Specifically, the mortality
review concluded that the facility failed to receive
Chavez-Alvarez’s COVID-19 test results in a
timely manner. The facility also failed to provide
timely follow-up care when needed.255

Findings and Analysis

49

In 40 percent (n=21) of all cases, records indicated
a staffing issue, including shortages, improper
training, or care outside the scope of practice.

a Clinical Institute for Withdrawal Assessment
without supervision by a RN, and administered
chlordiazepoxide, without a prescription or a
provider order. 257

For example:
• The Aurora Detention Center in Colorado,
operated by the GEO Group, a private prison
corporation, had multiple critical medical
staff vacancies that contributed to the death
of Kamyar Samimi. Samimi died because
medical staff had discontinued medication
assisted treatment for opioid disorder. At the
time of his death, GEO Group had only one
practicing physician responsible for the
entire facility. It also left vacant multiple
required positions — including a mid-level
provider, such as a nurse practitioner or
physician’s assistant, or a nursing director
position — for longer than six months. The
midlevel provider was responsible for conducting
initial health appraisals for detainees with
chronic conditions, and Samimi never received
a health appraisal by a physician or a
registered nurse (RN). ICE’s own investigators
concluded that “absent a Director of Nursing or
other nurse supervisor . . . clinical supervision
was inadequate to assure adherence to provider
orders and necessary and appropriate care.”256
• Roberto Rodriguez Espinoza, a 37-year-old
man from Mexico, died on September 10, 2019,
after ICE detained him at the McHenry County
Correctional Facility in Illinois. One week
after he was detained, Rodriguez died from a
subdural hematoma and complications of chronic
alcoholism. Facility officers — not medical staff —
conducted Rodriguez Espinoza’s medical intake
when he entered the facility. Although Rodriguez
Espinoza informed officers upon intake that
he regularly consumed a six-pack of beer a day,
which would be enough to trigger withdrawal
symptoms in a detention setting, the facility’s
medical staff did not follow up. Five days later,
after Rodriguez Espinoza began exhibiting
acute mental status changes, a licensed
practical nurse — who is not licensed to provide
medication without a prescription — completed

50

• As noted earlier in the
report, Jean Jimenez
died by suicide on May
15, 2017 at the Stewart
Detention Center in
Georgia. The lack of
adequate mental health
Photo courtesy family of Jean Jimenez.
staffing clearly
contributed to Jimenez’s
death. ICE required only one full-time equivalent
psychiatrist for a facility that held nearly 2,000
people. The ICE Health Services Administrator
at Stewart testified that this level of staffing was
inadequate, and that he had raised concerns to
ICE about the need for additional staff, to no
avail. 258Even so, at the time of Jimenez’s death,
Stewart provided tele-psychiatry to detained
people for six hours a week — a level of less than
20 percent of required staffing, with
backlogs of 10-12 weeks for services.259

Insufficient and falsified documentation
of patient checks and provision of medical
care
Accurate and truthful record keeping is vital to
ensure continuity of medical care. For example,
officers must document each time they have
conducted a required check on a detained person’s
welfare, particularly those who are in solitary
confinement or on suicide watch. However, in 46
percent (n=24) of cases, there was at least one
occasion where a wellbeing check was either not
conducted or made without visualization of the
detained person. Many of these instances also
involved falsification of records. In some cases,
documentation of medical care and wellbeing were
absent from records at the facilities in which they
were housed. In other cases, the incorrect form was
filled out or the correct form only partially completed.
In some cases, documentation was falsified,

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

PROFILES

Ben Owen
Ben Owen, from the United Kingdom, was 39
years old when he died at the Baker County
Detention Center in Florida on January 25,
2020. Ben was newly married to his U.S.
citizen wife, Tammy Owen, and father to their
baby girl. The young family lived in Daytona
Beach, Florida.
Tammy describes Ben as being an amazing
soul and a loving, doting husband, a good
father to his daughter, and a good son to
his mother. He worked
hard as a successful
sound engineer for bands
including Metallica
and Five Finger Death
Punch. Ben tended to
and cooked for Tammy.
She says he loved life
and being a father to his
newborn daughter. “He
was amazing, or I wouldn’t
have married him.”

about being “freezing.” He also mentioned
difficulty breathing due to extensive mold,
and that he had not seen daylight. He was
becoming increasingly isolated, as he was the
only person detained in his unit who spoke
English as a first language.
Tammy has spent the last four years trying
to piece things together as best she can. She
believes that ICE “pushed him to [a] breaking
[point]” and that he was “treated worse than
an animal on the street.” She also stated that
“he was told he was going to be sent back
[to the UK] and taken
away from his family.
No human being should
have to go through that.”

Tammy could tell Ben’s
mental health may have
been deteriorating from
what he said on phone
calls, but she believes
he kept her in the dark
about how bad he was
feeling. He died less
than two weeks after
Their lives changed
first being detained.
abruptly on January 12,
Tammy and Ben Owen, Photo © Savannah Payne
Tammy has since found
2020, when Ben was
out that Ben was never seen or assessed by a
arrested. While he was not detained in
psychiatrist at Baker. Worse, Tammy believes
criminal custody, his encounter with the police
ICE has covered up facility staff’s failings. By
led him to be “picked up” by ICE on January 15.
the time she found out about how poor the
He was held in ICE custody at Baker Country
conditions were in the detention facility, it
Detention Center, despite the fact that he was
was too late — Ben had died.
married to a U.S. citizen and was not in the
U.S. illegally, according to Tammy.
Tammy wants to help other families so they
don’t have to suffer like her and her daughter.
Tammy spoke with Ben numerous times while
Tammy wants to know the truth about what
he was detained by ICE, conversations during
happened to Ben and says she will not stop
which he told her he was “very, very scared.”
fighting. “He was my best friend and I miss
While Tammy felt that Ben had protected
him every day. Our daughter knows he’s in
her from the reality of how bad conditions
heaven. She knows about her Daddy.”
in Baker County really were, he did tell her

Findings and Analysis

51

sometimes after the person had already died. Overall,
issues with documentation occurred in 61 percent
(n=32) of cases.
For example:
• Ben Owen, a 39-year-old
British man, died by
suicide on January 25,
2020, only 10 days after
being detained at the
Baker County Detention
Center in Florida.260 At
the time of his detention, Photo courtesy Tammy Jane Owen.
Owen, who had moved
from London only seven months before, had a
pending green card petition sponsored by his U.S.
citizen wife. 261
Although Owen had no demonstrated history of
mental health conditions at the time of intake, his
behavior while in detention pointed to increasing
levels of psychological distress. Over the 10day period, for example, he made 129 phone
calls to his wife and expressed feeling that he
was losing his mind.262 On the day of his death,
which was also the same day of his wedding
anniversary, Owen shut himself in his cell with
the privacy screen lifted.263 Detention center
officers logged two wellbeing checks at his cell.264
But the detention center had falsified these
records. The officers had not completed the
checks — they had never entered the cell or
seen Owen.265 The officers, moreover, reported
that this method of logging security rounds was
consistent with their training and an accepted
practice at the facility.266 Two hours after he had
shut himself in, another detained person notified
staff that Owen was hanging from a sheet in his
shared cell.267
Baker County Detention Center lacks any
accreditation to provide healthcare services as a
correctional facility.268 ICE, however, continues to
detain over 200 people at the facility each day.269
• Anthony Oluseye Akinyemi, a 56-year-old
man from Nigeria, died by suicide on December

52

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

21, 2019, less than 24 hours after being detained
by ICE at Worcester County Jail in Maryland.
At intake, Akinyemi demonstrated significant
mental distress and visible agitation, showing
restlessness while sitting, jumping during
telephone conversations, pacing, and rubbing
his head. Akinyemi also verbalized his inability
to cope emotionally, and verbalized concerns of
losing his family. Facility staff, however, failed to
provide him with timely mental health support.
Although the intake licensed practical nurse
informed the supervising registered nurse of the
statement, nothing was reported to the on-call
provider, as required.270
On the night before his death, facility staff
placed Akenyemi in a solitary confinement
unit. Medical expert reviewer Dr. Katherine
McKenzie concluded that confinement in a
segregation unit likely exacerbated Akinyemi’s
mental distress.271 At 5:03 a.m. on December
21, an officer discovered that Akinyemi had
hung himself from a ventilation grate. Although
medical staff started CPR and attempted
defibrillation, Akenyemi was pronounced dead
at 5:23 a.m. Although the officer claimed to
have completed six security checks over the
course of approximately five hours, the facility
could not produce a time-stamped report. The
officer claimed his reader device, used to track
and verify that officers completed his rounds
on time and in the appropriate location, had
malfunctioned.272 On review, the warden of the
facility verified the functionality of the reader,
implying that the officer conducting rounds
either failed to document at the beginning of his
shift that his reader was not working and went to
complete his duties regardless, or he falsified his
use of the reader, failing to document that he did
not use the reader appropriately over the course
of his shift.273
ICE’s mortality review committee “unanimously
determined that Mr. Akinyemi’s medical care
. . . was not provided within the safe limits of
practice.”274

• Guerman Volkov, a 56-year-old man from
Russia, died of a bowel obstruction with
gastrointestinal hemorrhage. Before he was
hospitalized, Mr. Vokov was detained in ICE
custody at Baker County Detention Center in
Florida prior to his death on November 30, 2018. 275
Mr. Volkov entered Baker on June 26, 2017.276
He consented to initial medical exams after
entering the facility, at which time medical
staff discovered that Mr. Volkov had a history of
hypertension and seizure disorder.277 However,
soon after his intake exams, Mr. Volkov began
repeatedly refusing medical assessments and
treatment.278 Among other medical exams,
Mr. Volkov refused a physical assessment
from medical staff on July 7, 2017;279 a medical
appointment on July 23, 2017;280 chronic care
appointments on Dec 7, 2017, March 8, 2018, June
5, 2018, and September 6, 2018;281 and his annual
medical evaluation on August 9, 2018.282 He also
repeatedly refused medications.283
When Mr. Volkov did consent to assessments,
it was clear that he was suffering from serious
mental illness. Mental health professionals noted
that his behavior was characterized by anxiety
and delusional thinking,284 and his mental health
continued to deteriorate throughout his time at
Baker.285

medication dosage.289 Additionally, medical
staff administered psychotropic medication to
Mr. Volkov without first obtaining his informed
consent, as is required before administering such
medication.290
On November 26, 2018, Mr. Volkov was
transferred to Memorial Hospital of Jacksonville
after being found unresponsive at Baker.291 Two
days later, Mr. Volkov was returned to Baker
against medical advice.292 Medical staff at Baker
were ordered to check on Mr. Volkov every
15 minutes; however, this did not happen.293
Staff failed to log at least 42 wellbeing rounds
accurately and within the time restriction
over the next three days, according to video
surveillance footage and timestamps.
On November 30, 2018, medical staff failed to
check on Mr. Volkov for at least two hours. After
that, correctional staff noticed that Mr. Volkov
was experiencing trouble breathing, a distended
abdomen, and severe abdominal pain.294 He was
then transported to a local hospital and died that
same day.295

Medical staff made serious errors when
attempting to manage Mr. Volkov’s medical
conditions. They routinely failed to properly
document Mr. Volkov’s medical care; refusal
forms often were not filled out when he refused
medical assessment, and when they were, they
were often late or incomplete.286 Medical staff
also failed to document the medical and mental
health conditions that Mr. Volkov developed
while in custody and failed to provide appropriate
treatment that had been ordered.287 For example,
on September 12, 2017, a medical provider
ordered that Mr. Volkov receive a hernia belt;
however, staff never provided him with one.288
Similarly, medical staff renewed Mr. Volkov’s
prescriptions on multiple occasions without
re-evaluating him to determine the proper

Findings and Analysis

53

Conclusion and
Full Recommendations
The stories of the people who died while locked
in ICE detention facilities shock the conscience.
Investigatory reports and documents, however, are
incomplete reflections of the entire story. Missing
from this report are the voices of detained people
who died alone, without proper medical and mental
health attention, and without loved ones near during
their final moments. The ultimate tragedy, of course,
is that none of these people needed to be detained,
and the provision of proper medical care could have
prevented these deaths. Although this report focuses
on death — the most extreme consequence of ICE
detention — tens of thousands of people continue to
face lasting medical and psychological consequences
as a result of immigration detention each day.
This report also laid out the many ways in which
ICE’s investigations allow the agency to avoid fault
and disclaim accountability for the death of detained
immigrants. ICE’s review and remedial process has
allowed the continued deaths of detained people, and
failed to levy meaningful consequences — including
contract termination — for conditions that have led
to repeated deaths in detention. In the interest of
preventing additional deaths in ICE detention, the
report offers the following recommendations below.

To the Department of Homeland Security:
Our organizations believe that ICE’s reliance
on immigration detention is unnecessary,
expensive, and deeply harmful. We strongly
urge that ICE dismantle the mass immigration
detention machine that has resulted in far too
many deaths. ICE should phase out the immigration
detention system, invest in community-based social

54

services instead of placing people in detention, and
avoid surveillance of immigrants as an alternative
to detention. As ICE shifts from a detentionbased system, ICE should adopt the following
recommendations to reduce the number of people
held in detention and prevent deaths of people in ICE
detention:
• Issue a directive ensuring the prompt
release of people with medical and mental
health vulnerabilities from ICE detention.
It should include a presumption of release
for people with medical and mental health
vulnerabilities, ensure prompt medical screening
of detained immigrants to identify those who face
increased medical and/or mental health risk in
detention, and set forth procedures to ensure the
prompt release of these individuals from custody.
• Immediately release people who have
prevailed in their immigration cases before
an immigration judge, instead of continuing
detention upon ICE’s administrative appeal.
• Require the release of people from and
prohibition of the use of ICE detention
facilities upon a finding by DHS’s Office of
Civil Rights and Civil Liberties that health
and safety standards are not being met,
or cannot be met. Reasons may include lack
of medical and mental health staff, unlicensed
medical and mental health staff or provision of
medical services outside the scope of licensed
care, and prolonged or delayed emergency
medical care services.

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

• Prohibit solitary confinement. Until it is fully
prohibited, issue and implement a directive
barring solitary confinement for anyone who
has a disability, has a diagnosed mental health
condition, is pregnant, postpartum, or caring for
a child, or has identified or is known or perceived
to be LGBTQ+ or gender non-conforming.
• Ensure meaningful consequences for
detention facilities that have caused deaths
of detained people.
• Promptly terminate ICE detention contracts
for facilities with any death resulting from
substandard medical and mental health care,
including deaths that occur within 30 days of
release from custody.
• Require that Enforcement and Removal
Operations (ERO) and Office of Detention
Oversight (ODO) inspectors review and
include agency death review documents
for all deaths that have occurred at a given
facility in their inspection reports, and
evaluate and report on corrective actions
taken, including imposition of contract
penalties, as a result of the death review.
• Undertake full, comprehensive, and
unbiased investigation of deaths in
detention.
• Ensure preservation of all relevant
evidence, including video surveillance,
emails, medical records, and the content
of the individual’s detention file. Ensure
that all final investigatory reports include a
comprehensive list of evidence requested,
any records that were not produced by the
facility, and the reason why such records
were not available.
• Ensure that interviews of detainee witnesses
are conducted and included in death
investigations and ensure protection from
retaliation and deportation of detainee
witnesses. If a facility or ICE elects to release
an eyewitness from custody prior to the
investigation, ensure that the investigators

interview the eyewitness, and note the
circumstances of the witness’s release from
custody in the investigatory report.
• Require that all detention facilities provide
investigators unimpeded access to staff
and contractors, without interference or
retaliation, for participation in investigations
regarding detainee deaths.
• Require tracking, reporting, and
investigation of deaths that occur in medical
facilities within 30 days of release from
detention.
• Require full physical autopsies and fullspectrum forensic toxicology screen for all
people who die in custody, and psychological
autopsies for any apparent suicides. Ensure
that family members and estates of all
people who have died in custody can conduct
independent autopsies, and that all autopsies
performed by ICE comply with the National
Association of Medical Examiners (NAME)
Forensic Autopsy Performance standards.296
Autopsies should also be performed by
a pathologist who is board certified in
Anatomic and Forensic Pathology by the
American Board of Pathology, with a valid
license to practice medicine.
• Ensure that investigations of deaths
in detention follow best practices for
morbidity and mortality reviews, including
multidisciplinary, comprehensive
discussions that document and disseminate
recommendations to ensure action.297
• Provide timely, quality medical and mental
care to all in ICE detention, with the caveat
that increased funding for detention has not
resulted in improvement of health conditions for
those in detention. Detention is fundamentally
harmful to health and wellbeing of all who are
detained.
• ​​​Ensure that all detention facilities, whether
care is provided by ICE Health Service
Corps (IHSC) or another entity, are bound

Conclusion and Full Recommendations

55

by IHSC directives and standards for the
provision of medical and mental health care
through contract modifications or uniform
updates to all detention standards. Violations
of these directives and standards shall be
immediately remedied.

• Create and enforce protocols for strict
documentation and reporting of acute
medical situations.
• Create and enforce protocols for immediate
consultations 24/7 with physicians on call. ​​
• Ensure that all ICE detention facilities
provide translation and interpretation for
all medical encounters, including the ability
to request medical care, in accordance with
Performance Based National Detention
Standards (PBNDS).

• Ensure that all detention facilities are
bound by, and in compliance with, the 2016
Performance Based National Detention
Standards.
• Ensure routine collection and reporting
on the number of individuals in detention
with medical vulnerabilities, including
chronic conditions, communicable and noncommunicable diseases, and severe mental
illness.

• Ensure that all ICE detention facility medical
staff are trained in and utilize screening
tools for the Clinical Institute of Withdrawal
Assessment (CIWA) and Clinical Opiate
Withdrawal Symptoms (COWS).
• Create, enforce, and audit protocols and
implementation of regular wellness checks,
every 15 minutes, to engage with the person
in custody, evaluate and treat any urgent
health needs, and attempt de-escalation if
needed. ​​

• Ensure that all detention facilities provide
sufficient and adequate levels of health care
staffing, by tracking and publishing vacancy
rates for medical and mental health staff at
each facility.

• Create and enforce protocols for routine and
frequent inspection of medical equipment​​.

• Require that detention population levels do
not exceed medical and mental health staffing
levels for the facility at any time.
• Ensure that all ICE detention facilities
strictly prohibit medical and mental health
professionals from practicing outside the
scope of licensed practice, and improve
access of those in detention to physicians,
nurse practitioners, and physicians’
assistants.

• Perform regular quality audits of medical
documentation and create mechanisms to
identify gaps in management, errors, and
other practice failures.
• Comply with Requests for Public Records
Under the Freedom of Information Act.

• Ensure that all healthcare and detention staff
are trained in and routinely participate in
emergency (code) drills.
• Ensure that all facilities are required
to provide medical interpretation at all
encounters, and that metrics of rates of
medical interpretation use are publicly
reported.

56

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

• ICE should comply with FOIA requests more
expeditiously, including by better organizing
files related to deaths of detained people to
enable more rapid productions.
• ICE frequently withholds significant portions
of productions, later lifting redactions when
challenged either informally or in litigation.
As instructed in Attorney General Garland’s
March 15, 2022 Memorandum regarding
Freedom of Information Act Guidelines, ICE
should apply a “presumption of openness”

at the outset when evaluating records rather
than trickling out previously redacted
material as a case continues.298 (“In case of
doubt, openness should prevail.”)
• In all stages of the agency’s response to a
FOIA request — during the initial response,
administrative appeal, or in litigation
— ICE should share with the requester
information about the scope of the agency’s
search. Search transparency will encourage
discussion regarding the parameters used,
increasing the opportunity for consensus and
possibly avoiding litigation and/or briefing
on the adequacy of ICE’s search.
• In practice, ICE’s initial productions of
records are physical copies of records sent
by postal mail. ICE should instead produce
records electronically, which will increase
efficiency and align ICE with the FOIA
practices of the majority of other federal
agencies.
• When producing documents electronically,
the PDF files of records should not be
password protected. FOIA is a statute
granting the public access to public records:
the records produced are not confidential,
and thus there is no justification for
maintaining password protection over the
files at the time of production.

To the Department of Justice:
• Ensure full implementation of the Death in
Custody Reporting Act (DCRA). Ensure that
DHS fully complies with its reporting obligations
under the DCRA, and release annual reports on
key data trends of deaths in DHS custody.

​To Congress:
• Substantially reduce funding for immigration
detention. Increase funding for community-based
social support and legal representation programs

as alternatives to detention that are far more
effective and humane.
• Conduct rigorous oversight of detention
conditions, including through hearings with
senior government officials. Request a GAO
investigation into ICE’s failure to prevent the
deaths of detained people, including those who
have died in custody and those who have died,
while hospitalized, within 30 days of release from
ICE custody.
• Require that ICE track, publicly report, and
investigate the death of any detained person
who died while hospitalized or within 30 days of
release from ICE custody.
• Require that ICE make publicly available on its
website, as a matter of course, detainee death
reviews, healthcare and security compliance
analyses, mortality reviews, root cause analyses,
autopsy reports, and psychological autopsy
reports regarding all individuals who have died
in ICE custody or those who have died while
hospitalized or within 30 days of release from ICE
custody. Require that ICE discloses the cause of
death, and make only those redactions necessary
to comply with federal privacy laws.
• Require monthly publication of all medical and
mental health vacancies by facility, as well as
average length of time for detained patients to
be seen by a physician, physician’s assistant, or
nurse practitioner.
• Require that ICE make publicly available within
30 days any corrective actions taken to enforce
contract terms for the provision of medical or
mental health care in ICE detention facilities
or any other contract violations that may have
contributed to a death in custody, as well as Office
of Detention Oversight (ODO) inspection reports,
OPR detainee death reviews, and IHSC mortality
reviews.
• Hold ICE accountable for meeting specific
standards with regard to provision of care and
data reporting. At a minimum, all facilities that
detain individuals who are in ICE custody must

Conclusion and Full Recommendations

57

be held to the Performance Based National
Detention Standards (rev. 2016), though more
stringent standards are required to ensure
delivery of quality health care. ICE facilities
should be subject to regular independent
inspections with enforceable penalties and
ongoing monitoring and defunding when
standards are not met.

• Pass legislation prohibiting 287(g) agreements
and collaboration with ICE in civil immigration
enforcement.

• Pass the Dignity for Detained Immigrants Act
(H.R. 2760/S. 1208), which would significantly
reduce the number of people held in immigration
detention and set enforceable standards to
ensure those who remain in custody are in a
system that is safe, transparent, subject to robust
independent oversight, and accountable to the
public.
• Pass the End Solitary Confinement Act (H.R.
4972/S. 3409), which would ban solitary
confinement in federal facilities with limited
exceptions.

To State and Local Governments:
• Pass legislation to prohibit intergovernmental
services agreements between state or local
agencies and the federal government for civil
immigration detention, and to prevent contract
modifications to expand detention.
• Pass local ordinances or legislation to prohibit
the physical expansion of detention facilities that
would allow increased capacity for detention.
• Pass legislation that provides causes of action
against for-profit detention facilities that deviate
from contractually binding standards. See, e.g.
California’s AB 3228.
• Enact measures that promote local oversight and
accountability of state and local facilities.
• Require and ensure that local facilities that
detain people in ICE custody expeditiously
release and provide records relevant to deaths in
detention for release under FOIA.

58

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Appendix 1: Medical Experts
Dr. Chanelle Diaz
Dr. Diaz is a board-certified General Internist
practicing primary care in New York City. She is the
Internal Medicine Medical Director at the Charles
Rangel Community Health Center and an Assistant
Professor of Medicine at Columbia University Medical
Center. She attended Williams College, received her
MD/MPH from the University of Miami Miller School
of Medicine, and completed her residency training
in Primary Care and Social Internal Medicine at
Montefiore Medical Center/Albert Einstein College
of Medicine. Dr. Diaz’s work focuses on communityengaged approaches to address immigrant health
inequities. Dr. Diaz volunteers with the PHR Asylum
Network where she providers forensic medical
examinations for survivors of torture and/or trauma.
She is a volunteer and steering committee member
of the New York Lawyers for the Public Interest
Medical Providers Network, a community-medicallegal partnership linking volunteer clinicians
to individuals with serious medical conditions
in immigration prisons to assess and document
unmet medical needs. Dr. Diaz has published peer
reviewed studies and opinion pieces in the media on
the health harms of immigration detention. She has
collaborated with other medical and legal experts to
develop best practices in the medical evaluation of
individuals in immigration detention and has trained
dozens of residents and medical students.

Dr. Elena Jiménez Gutiérrez
Elena Jiménez Gutiérrez is an Associate Professor
in the Division of Hospital Medicine, Co-Director
of the Health Equity track for Internal Medicine
residents, Medical Director of San Antonio Refugee
Health Clinic, and Director of the Human Rights

and Asylum Medicine elective for medical students
at the University of Texas Health Science Center
at San Antonio. Over the years, she has attended
to medically underserved communities in Chinle,
Arizona, Pittsburgh, Pennsylvania, San Antonio,
Texas, Chiapas, Mexico, La Romana, Dominican
Republic, and Beira, Mozambique. As a member of
the Physicians for Human Rights (PHR) Asylum
Network, she has expertise in reviewing medical
records of individuals held in U.S. Immigration
and Customs Enforcement detention centers and
in conducting forensic physical and psychological
evaluations of asylum-seekers. She served on the
Asylum Medicine Training Initiative (AMTI), a
national working group that developed a peerreviewed, virtual asylum medicine curriculum to
standardize best practices in the field and improve
access to high quality educational content. With
the support of peers and trainees, she created and
presented an AMTI module. Her passions include
health equity, care of underserved populations,
asylum medicine, medical education and evidencebased clinical practice in low-resource settings, and
chronic kidney disease of unknown etiology.

Dr. Katherine McKenzie
Katherine C. McKenzie, MD, FACP is a faculty
member at Yale School of Medicine and the director
of the Yale Center for Asylum Medicine (YCAM). She
teaches undergraduates, students, and residents, and
is a member of Yale Refugee Health Program. She is a
physician advocate for social justice and human rights.
Dr. McKenzie founded and directs YCAM. In this
capacity, she performs forensic evaluations of
asylum-seekers at Yale and in detention facilities, and
testifies as an expert witness in immigration court

Appendix A

59

for individuals referred by law schools, human rights
organizations, and immigration attorneys. She leads
the asylum medicine teaching program for trainees
and faculty at Yale, mentors clinicians across North
America, and lectures extensively on topics of
asylum, detention, and physician advocacy. She is
an expert advisor for Physicians for Human Rights
and serves on the boards of the Society for Refugee
Healthcare Providers, Project Access New Haven,
and Integrated Refugee and Immigrants Services.
She is involved in medical legal partnerships and
collaborates with attorneys on civil litigation that
supports human rights. She is a founder and director
of the Society of Asylum Medicine.
She has written reviews, clinical case reports, and
opinion essays in publications including the New
England Journal of Medicine, the Journal of the
American Medical Association, the Journal of General
Internal Medicine, the British Medical Journal, Time
magazine and CNN, among many others.
At Yale, she received the Leonard B. Tow Award for
Humanism in Medicine and the Faculty Award for
Achievement in Clinical Care. She has been named
a “Top Doctor” for many years by Connecticut
Magazine. She is a Fellow of the American College of
Physicians and has been certified by the American
Board of Internal Medicine since 1995.

Dr. Ranit Mishori
Ranit Mishori is a former professor of family medicine
at the Georgetown University School of Medicine,
and served as Georgetown University’s Chief Public
Health Officer, helping lead their COVID-19 response.
A former journalist, she has built a multi-dimensional
career that includes academia, scholarship, clinical
care, mentorship, and leadership roles in public
health, global health, medical education, the care of
underserved populations, and human rights.
Dr. Mishori has been a champion of migrant
health for the past two decades, through intensive
engagement in various activities, including clinical
care of immigrants, refugees and asylum-seekers
in the primary care setting, documentation of
human rights violations affecting forced migrants
domestically and abroad, education, and scholarship
on these issues.
60

Dr. Mishori has been a member of PHR’s Asylum
Network since 2006, has served as an expert
consultant to PHR’s Program on Sexual Violence
in Conflict Zones since 2011, and has served as the
faculty advisor to Georgetown University’s Asylum
Program since its inception in 2014.
At PHR, she provided technical and medical expertise
to multiple programs, in particular the Asylum
Program, the Program on Sexual Violence in Conflict
Zones, and the MediCapt project.
Her training includes an MSc in International
Human Rights Law from Oxford University; an MD
from Georgetown University School of Medicine, and
a residency in family medicine, also at Georgetown;
and an MHS in International Health from Johns
Hopkins Bloomberg School of Public Health.

Dr. Michele Heisler
Michele Heisler, MD, MPA is the medical director
at Physicians for Human Rights, a board-certified
internist, a practicing clinician at the VA Ann Arbor
Healthcare System, and a professor of internal
medicine and of public health at the University
of Michigan. Before assuming the role of medical
director, she served on PHR’s board of directors from
2010 to 2019. She has participated in multiple PHR
field investigations and co-authored PHR reports
since she was a medical student in the mid-1990s.
Before medical training, Dr. Heisler was in charge
of human rights and poverty programs in Latin
America and the Caribbean as a program officer at the
Ford Foundation.
Dr. Heisler received her MD degree from Harvard
University and MPA degree from Princeton
University’s School of Public and International
Affairs. She completed residency training in internal
medicine and health services research training
as a Robert Wood Johnson Clinical Scholar at the
University of Michigan.

Dr. Radha Sadacharan
Dr. Radha Sadacharan is a correctional health
physician who has worked in multiple jail and prison
settings.

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Appendix 2: Deaths in ICE Custody
Jan. 1, 2017 to May 31, 2024
Name

Gender

Age at
Death

Country
of Birth

Date
of Death

Detention Center

Reported Cause of Death

Roger Rayson

M

47

Jamacia

3/13/2017

LaSalle Detention Facility, LA

Remote subdural hemorrhage

Osmar Epifanio Gonzalez Gabda

M

32

Nicaragua

3/22/2017

Adelanto Detention Facility, CA

Suicide - Asphyxia by hanging

Sergio Alonso Lopez

M

55

Mexico

4/13/2017

Adelanto Detention Facility, CA

Gastrointestinal bleed from esophageal
varices
secondary to liver cirrhosis secondary to
alcohol abuse

Jean Jimenez

M

27

Panama

5/15/2017

Stewart Detention Center, GA

Suicide by hanging

Atulkymar Babubhai Patel

M

58

India

5/16/2017

Atlanta City Detention Center, GA

Congestive heart failure with
complications from diabetes

Vincente Caceres

M

46

Honduras

5/31/2017

Adelanto Detention Facility, CA

Cardiomegaly and hepatomegaly

Carlos Mejia-Bonilla
(aka Rolando Arnulfo Meza Espinoza)

M

44

El
Salvador

6/10/2017

Hudson County Department of
Correctional and Rehabilitation, NJ

Gastrointestinal bleed

Osvadis Montesino-Cabrera

M

37

Cuba

9/1/2017

Krome Services Processing Center, FL

Suicide by hanging

Felipe Dionisio Almazan-Ruiz

M

51

Mexico

9/17/2017

IAH/Polk County Detention Center, TX

Necrotizing cholecystitis with rupture and
hemoperitoneum
associated with cirrhosis and
thrombocytopenia

Kamyar Samimi

M

64

Iran

12/2/2017

Denver Contract Detention Facility, CO

Undetermined, contributing factors COPD
and GI bleeding

Yulio Castro-Garrido

M

33

Cuba

1/30/2018

Stewart Detention Center, GA

Bronchopneumonia with pulmonary
abscesses and viral influenza

Luis Ramirez-Marcano

M

59

Cuba

2/19/2018

Krome Detention Center, FL

None provided

Gourgen Mirimanian

M

54

Armenia

4/10/2018

Prairieland Detention Center, TX

Hypertensive and atherosclerotic
cardiovascular disease

Ronal Francisco Romero
(aka Ronald Cruz)

M

39

Honduras

5/16/2018

Port Isabel Detention Center, TX

Sepsis infection caused by bacterial
meningitis and complications of diabetes

Roxsana Hernandez

F
33
(Transgender)

Honduras

5/25/2018

Cibola County Correctional Center, NM

Multicentric Castleman disease Due to
Acquired immunodeficiency syndrome

Appendix B

61

Name

Gender

Age at
Death

Country
of Birth

Date
of Death

Detention Center

Reported Cause of Death

Huy Chin Tran

M

47

Vietnam

6/12/2018

Eloy Detention Center, AZ

Coronary artery disease

Efrain Romero de la Rosa

M

40

Mexico

7/10/2018

Stewart Detention Center, GA

Suicide

Augustina Ramirez-Arreola

F

62

Mexico

7/25/2018

Otay Mesa Detention Center, CA

Complications of aortic valve replacement
(AVR), due to rheumatic heart disease,
with coronary artery disease, pneumonia,
and tuberculosis (TB) as contributing
factors

Wilfredo Padron

M

58

Cuba

11/1/2018

Monroe County Detention Center, FL

Coronary artery disease due to
atherosclerotic cardiovascular disease

Mergensana Dabaevich Amar

M

40

Russia

11/24/2018

Northwest Detention Center, WA

Suicide - Anoxic encephalopathy due to
hanging

Guerman Volkov

M

56

Russia

11/30/2018

Baker County Detention Center, FL

Small bowel obstruction, with
gastrointestinal hemorrhage

Emigdio Abel Reyes-Clemente

M

54

Mexico

4/3/2019

Florence Service Processing Center, AZ Complications of liver cirrhosis, diabetes,
and hypertensive cardiovascular disease
(Bacterial pneumonia)**

Simratpal Singh

M

20

India

5/3/2019

La Paz County Adult Detention Facility,
AZ

Suicide

Yimi Alexis Balderramos-Torres

M

30

Honduras

6/30/2019

Houston Contract Detention Facility,
TX

Cardiac death associated with biventricular cardiac dilation

Pedro Arriago Santoya

M

43

Mexico

7/24/2019

Stewart Detention Center, GA

Valvular Heart Disease with Cardiomegaly.

Roberto Rodriguez Espinoza

M

37

Mexico

9/10/2019

McHenry County Correctional Facility,
IL

Subdural hematoma and complications of
chronic alcoholism

Nebane Abienwi

M

37

Cameroon

10/1/2019

Otay Mesa Detention Center, CA

Hypertensive basal ganglia hemorrhage

Roylan Hernandez-Diaz

M

43

Cuba

10/15/2019

Richwood Correctional Center, LA

Suicide

Anthony Olyseye Akinyemi

M

56

Nigeria

12/21/2019

Worcester County Jail, MD

Suicide - Asphyxia by hanging

Samuelino Pitchout Mavinga

M

40

Angola

12/29/2019

Torrance County Detention Facility, NM Coccidioidomycosis

Ben James Owen

M

39

England

1/25/2020

Baker County Detention Center, FL

Suicide

Alberto Hernandez-Fundora

M

63

Cuba

1/27/2020

Krome North Service Processing
Center, FL

Congestive Heart Failure

David Hernandez-Colula

M

34

Mexico

2/20/2020

Northeast Ohio Correctional Center,
OH

Suicide - Asphyxia by hanging

María Celeste Ochoa-Yoc de Ramírez

F

22

Guatemala 3/8/2020

Prairieland Detention Center, TX

Liver failure due to complications of
probable acute viral hepatitis

62

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Name

Gender

Age at
Death

Country
of Birth

Date
of Death

Orlan Ariel Carcamo-Navarro

M

27

Honduras

Ramiro Hernandez-Ibarra

M

42

Carlos Ernesto Escobar-Mejia

M

58

Detention Center

Reported Cause of Death

3/18/2020

Karnes County Family Residential
Center, TX

Suicide – Asphyxia by hanging

Mexico

3/21/2020

Port Isabel Detention Center, TX

Multiorgan failure and metformin overdose

El
Salvador

5/6/2020

Otay Mesa Detention Center, CA

Acute respiratory failure, pneumonia
secondary to

Choung Woung Ahn

M

74

South Korea 5/17/2020

Mesa Verde ICE Processing Facility, CA

Suicide - Asphyxia by hanging

Santiago Baten-Oxlaj

M

34

Guatemala 5/24/2020

Stewart Detention Center, GA

Acute respiratory distress
syndrome (ARDS) to COVID-19

Onoval Perez-Montufa

M

51

Mexico

Glades County Detention Center, FL

COVID-19 pneumonia

Luis Sanchez-Perez

M

46

Guatemala 7/15/2020

Catahoula Correctional Center, LA

Complications of diabetes mellitus
with hypertensive artherosclerotic
cardiovascular disease

James Thomas Hill

M

72

Canada

8/5/2020

Immigration Centers of America, VA

COVID-19

Kuan Hui Lee

M

51

Taiwan

8/5/2020

Krome North Service Processing
Center, FL

Hypertensive left thalamic hemorrhage

Jose Freddy Guillen-Vega

M

70

Costa Rica 8/10/2020

Stewart Detention Center, GA

COVID-19

Fernando Sabonger-Garcia

M

50

Honduras

8/28/2020

Joe Corley Processing Center, TX

Acute myocardial infarction

Cipriano Chavez-Alvarez

M

61

Mexico

9/21/2020

Stewart Detention Center, GA

COVID-19

Romien Jally

M

56

Marshall
Islands

9/26/2020

Winn Correctional Center, LA

COVID-19

Henry Missick (aka Anthony Jones)

M

51

Bahamas

12/17/2020

Adams County Detention Center, MS

Atherosclerotic cardiovascular disease

Felipe Montes

M

57

Mexico

1/30/2021

Stewart Detention Center, GA

Cardiopulmonary arrest, secondary to
complications of COVID-19

Jesse Dean

M

58

Bahamas

2/5/2021

Calhoun County Correctional Center, MI

Gastrointestinal hemorrhage

Diego Fernando Gallego-Agudelo

M

45

Colombia

3/15/2021

Port Isabel Detention Center, TX

Acute myocardial infarction

Elba Maria Centeno-Briones

F

37

Nicaragua

8/3/2021

El Valle Detention Facility, TX

COVID-19

Pablo Sanchez-Gotopo

M

40

Venezuela

10/1/2021

Adams County Detention Center, MS

Pneumonia with HIV and COVID-19

Benjamin Gonzalez-Soto

M

36

Mexico

7/8/2022

Florence Service Processing Center, AZ Spontaneous bacterial peritonitis

Kesley Vial

M

23

Brazil

8/24/2022

Torrance County Detention Facility, NM Suicide

Melvin Calero

M

39

Nicaragua

10/13/2022

Aurora ICE Processing Center, CO

Pulmonary embolism tied to untreated
injury

Cristian Dumitriscu

M

50

Romania

3/5/2023

Otay Mesa Detention Center, CA

None provided

7/7/2020

Appendix B

63

Name

Gender

Age at
Death

Country
of Birth

Date
of Death

Detention Center

Reported Cause of Death

Salvador Rosales-Vargas

M

61

Mexico

4/4/2023

Stewart Detention Center, GA

None provided (stroke in custody)*

Ernesto Rocha-Cuadra

M

42

Nicaragua

6/23/2023

LaSalle Detention Center, LA

Cardiac Arrest

Julio Cesar Chirino Peralta

M

32

Nicaragua

10/8/2023

Port Isabel Detention Center, TX

None provided (stroke in custody)*

Subash Shrestha

M

34

Nepal

11/13/2023

Karnes City ICE Processing Center, TX

None provided (likely suicide)*

Carlos Juan Francisco

M

42

Guatemala 12/4/2023

Krome Service Processing Center, FL

None provided

Frankline Okpu

M

39

Cameroon

12/6/2023

Moshannon Valley ICE Processing
Center, PA

MDMA (ecstasy) toxicity

Ousmane Ba

M

33

Senegal

2/24/2024

Winn Correctional Center, LA

None provided (likely cardiac arrest)*

Charles Leo Daniel

M

61

Trinidad
3/7/2024
and Tobago

Northwest Detention Center, WA

None provided (reported suicide)*

Jaspal Signh

M

57

India

4/15/2024

Folkston ICE Processing Center, GA

None provided

Edixon Del Jesus Farias-Farias

M

26

Venezuela

4/18/2024

Joe Corley ICE Processing Center, TX

None provided

Cambric Dennis

M

44

Liberia

5/21/2024

Stewart Detention Center, GA

None provided

Hugo Boror Urla

M

39

Guatemala 5/22/24

Calhoun County Jail, MI

Suicide

Jhon Jaier Benavides-Quintana

M

32

Ecuador

Otero County Processing Center NM

None provided

6/15/24

*ICE has not reported a cause of death, but initial reporting or public sources have provided relevant detail regarding suggested cause of death
**ICE has provided a cause of death, but medical experts concuded an alternative cause of death

64

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Endnotes
1

Nina Bernstein, “Officials Hid Truth of Immigrant Deaths in
Jail,” New York Times, January 9, 2010, https://www.nytimes.
com/2010/01/10/us/10detain.html [https://perma.cc/E9AHY7YL]; Andrea Castillo & Jie Jenny Zou, “ICE Rushed to Release
a Sick Woman, Avoiding Responsibility for Her Death. She Isn’t
Alone,” LA Times, May 13, 2022, https://www.latimes.com/
world-nation/story/2022-05-13/ice-immigration-detention-deathssick-detainees [https://perma.cc/8J7D-VH8M]. ACLU NPP has
also filed a pending FOIA request regarding these “hidden deaths,”
see ACLU of Southern California. “ACLU Files Lawsuit Against ICE
for Withholding Documents Related to Practice of Releasing People
from Custody Prior to Imminent Death,” July 12, 2022, https://
www.aclusocal.org/en/press-releases/aclu-files-lawsuit-against-icewithholding-documents-related-practice-releasing.

2

ICE, “ICE Facilities Data,” April 15, 2024, https://www.ice.gov/
doclib/detention/FY24_detentionStats04252024.xlsx.

3

“Fiscal Year 2024 Homeland Security Appropriations Bill.”
House Republicans Appropriations, accessed May 10, 2024,
https://appropriations.house.gov/sites/evo-subsites/
republicans-appropriations.house.gov/files/documents/FY24%20
Homeland%20Security%20-%20Bill%20Summary%20Updated%20
6.21.23.pdf [https://perma.cc/MN9E-7RT7].

4

ICE Office of Professional Responsibility, “Detainee Death Review
Report: Jesse Dean,” August 19, 2021, 22 n.151, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p1682/a2558299.

5

Creative Corrections, “Detainee Death Review: Kamyar
Samimi: Medical and Security Compliance Analysis,”
March 14, 2017: 63, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1943/
a2558311.

6

Doris Meissner, et al., “Immigration Enforcement in the United
States: The Rise of a Formidable Machinery,” Migration Policy
Institute, 2013: 126, https://www.migrationpolicy.org/research/
immigration-enforcement-united-states-rise-formidable-machinery.

7

Antiterrorism and Effective Death Penalty Act of 1996, Pub. L. No.
104-132, § 440(a), 110 Stat. 1214 (1996); Illegal Immigration Reform
and Immigrant Responsibility Act of 1996, Pub. L. No. 104-208, §
133, 110 Stat. 3009 (1996).

8

TRACImmigration, “Immigration Detention Quick Facts,” May
5, 2024, https://trac.syr.edu/immigration/quickfacts/ [https://
perma.cc/BY7G-9S27]; ICE ERO Custody Management Division,
“Authorized Dedicated Facility List” and “Authorized NonDedicated Facility List,” April 1, 2024, https://www.ice.gov/doclib/
facilityInspections/dedicatedNonDedicatedFacilityList.xlsx.

9

ACLU, Human Rights Watch, National Immigrant Justice Center,
Justice Free Zones: U.S. Immigration Detention Under the Trump
Administration (2020), 17. https://www.aclu.org/publications/
justice-free-zones-us-immigration-detention-under-trumpadministration.

10

Eunice Cho, “Unchecked Growth: Private Prison
Corporations and Immigration Detention, Three Years
into the Biden Administration,” ACLU, August 7, 2023,
https://www.aclu.org/news/immigrants-rights/
unchecked-growth-private-prison-corporations-and-immigrationdetention-three-years-into-the-biden-administration.

11

Id.

12

Altaf Saadi, Caitlin Patler, Maria-Elena De Trinidad Young,
”Cumulative Risk of Immigration Prison Conditions on Health
Outcomes Among Detained Immigrants in California,” Journal
of Racial and Ethnic Health Disparities 9 (2022): 2518, https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC8628823/; Physicians
for Human Rights, Immigration and Refugee Clinical Program
at Harvard Law School, and Peeler Immigration Lab at Harvard
Medical School, “Endless Nightmare”: Torture and Inhuman
Treatment in Solitary Confinement in U.S. Immigration Detention
(2024), Physicians for Human Rights, https://phr.org/our-work/
resources/endless-nightmare-solitary-confinement-in-usimmigration-detention/.

13

Kathryn Hampton et al., “Clinicians’ Perceptions of the Heath
Status of Formerly Detained Immigrants,” BMC Public Health 22
(March 23, 2022): 1575, Bmcpublichealth.biomedcentral.com/
articles/10.1186/s12889-022-12967-7.

14

ACLU, DWN, NIJC, Fatal Neglect: How ICE Ignores Deaths in
Detention (2016), https://www.aclu.org/publications/fatalneglect-how-ice-ignores-death-detention; Human Rights Watch,
CIVIC, Systemic Indifference: Dangerous and Substandard
Medical Care in US Immigration Detention (2017), https://
www.hrw.org/report/2017/05/08/systemic-indifference/
dangerous-substandard-medical-care-us-immigration-detention;
Human Rights Watch, ACLU, NIJC, DWN, Code Red: The
Fatal Consequences of Dangerously Substandard Medical
Care in Immigration Detention (2018), https://www.aclu.
org/publications/code-red-fatal-consequences-dangerouslysubstandard-medical-care-immigration-detention; ACLU,
Human Rights Watch, NIJC, Justice Free Zones at 32; Human
Rights Watch, CIVIC, Systemic Indifference: Dangerous and
Substandard Medical Care in US Immigration Detention (2017),
https://www.hrw.org/report/2017/05/08/systemic-indifference/
dangerous-substandard-medical-care-us-immigration-detention.

15

Kendall Taggart, Hamid Aleaziz, Jason Leopold, “More Than 40
Immigrants Have Died in ICE Custody in the Past Four Years.
Here Are Thousands of Records About What Happened,” Buzzfeed
News, October 29, 2020, https://www.buzzfeednews.com/
article/kendalltaggart/here-are-thousands-of-documents-aboutimmigrants-who-died, https://perma.cc/N7JL-JMHH.

16

See, e.g. Parveen Parmar, et al., “Mapping Factors Associated
with Deaths in Immigration Detention in the United States,
2011-2018: A Thematic Analysis,” The Lancet Regional Health
Americas 2 (October 2021): 100040, https://doi.org/10.1016/j.
lana.2021.100040; Sophie Terp, et al., “Deaths in Immigration and
Customs Enforcement (ICE) Detention: FY2018–2020[J],” AIMS
Public Health 8(1) (2021): 81-89, doi: 10.3934/publichealth.2021006;
Cara Buchanan, et al., “Deaths in Immigration and
Customs Enforcement (ICE) Detention: A Fiscal Year (FY)
2021–2023 Update,” AIMS Public Health 11, no. 1 (2024):
223-235, doi: 10.3934/publichealth.2024011.

Endnotes

65

17

ICE, “ICE Health Service Corps,” accessed January 23, 2024,
https://www.ice.gov/detain/ice-health-service-corps [https://
perma.cc/PDK4-3F97].

18

U.S. Government Accountability Office [“GAO”], Immigration
Detention: ICE Needs to Strengthen Oversight of Informed Consent for
Medical Care, GAO-23-105196, October 2022, 8, https://www.gao.
gov/assets/gao-23-105196.pdf [https://perma.cc/AN33-QXQQ].

19

These standards include: (1) the 2000 National Detention Standards
(NDS); (2) the 2008 Performance-Based National Detention
Standards; (3) the 2011 Performance-Based National Detention
Standards, as amended in 2016; and (4) the 2019 National Detention
Standards. See Immigration and Customs Enforcement, 2000
National Detention Standards (2000), available at https://www.
ice.gov/detain/detention-management/2000; Immigration and
Customs Enforcement, 2008 Operations Manual ICE PerformanceBased National Detention Standards (2008), available at https://
www.ice.gov/detain/detention-management/2008; Immigration
and Customs Enforcement, 2011 Operations Manual ICE
Performance-Based National Detention Standards (2011), available
at https://www.ice.gov/detain/detention-management/2011;
Immigration and Customs Enforcement, ICE Performance-Based
National Detention Standards 2011, Rev. 2016 (2016), available
at https://www.ice.gov/doclib/detention-standards/2011/
pbnds2011r2016.pdf; Immigration and Customs Enforcement,
National Detention Standards for Non-Dedicated Facilities, Revised
2019 (2019), available at https://www.ice.gov/doclib/detentionstandards/2019/nds2019.pdf.

20

ICE ERO Custody Management Division, “Authorized Dedicated
Facility List” and “Authorized Non-Dedicated Facility List,”
April 1, 2024, https://www.ice.gov/doclib/facilityInspections/
dedicatedNonDedicatedFacilityList.xlsx.

21

Id.

22

Immigration and Naturalization Services, “INS Detention
Standard: Medical Care,” September 20, 2000, ICE, https://www.
ice.gov/doclib/dro/detention-standards/pdf/medical.pdf [https://
perma.cc/WS9F-W3HB].

23

24

25

Department of Homeland Security Office of Inspector General,
“ICE’s Inspections and Monitoring of Detention Facilities Do
Not Lead to Sustained Compliance of Systemic Improvements,”
OIG-18-67 (2018), https://www.oig.dhs.gov/sites/default/
files/assets/2018-06/OIG-18-67-Jun18.pdf [https://perma.cc/
J35A-3TS9].
DHS ICE, “Office of Detention Oversight Inspections: Fiscal Year
2021 Report to Congress,” March 23, 2022, https://www.dhs.
gov/sites/default/files/2022-05/ICE%20-%20Office%20of%20
Detention%20Oversight%20Inspections.pdf [https://perma.
cc/75VA-N5DQ].
GAO, Immigration Detention: ICE Needs to Strengthen Oversight of
Informed Consent for Medical Care, 10.

26

Deposition of Jennifer Moon, Coreas v. Bounds, No. 20-780 (D. Md.),
Sept. 15, 2021 (on file with authors).

27

Hamed Aleaziz, “A Child’s Forehead Partially Removed, Four
Deaths, The Wrong Medicine: A Secret Report Exposes Health
Care for Jailed Immigrants,” Buzzfeed News, December 12,
2019, https://www.buzzfeednews.com/article/hamedaleaziz/

66

Deadly Failures

ice-immigrant-surgeries-deaths-jails-whistleblower-secret [https://
perma.cc/8MPH-P9U2].
28

Memorandum from Cameron Quinn, Office for Civil Rights
and Civil Liberties, to Ronald Vitiello, Deputy Director of U.S.
Immigration and Customs Enforcement, Re: ICE Health Service
Corps (IHSC) Medical/Mental Health Care and Oversight (March
20, 2019), https://www.documentcloud.org/documents/6575024ICEWhistleblower-Report.html.

29

31 percent of medical deaths in ICE detention in 2020 were related
to COVID-19. See Sophie Terp, et al., “Deaths in Immigration and
Customs Enforcement (ICE) Detention: FY2018–2020,” AIMS
Public Health 8(1) (2021): 81-89, doi: 10.3934/publichealth.2021006.

30

The ACLU is currently litigating a FOIA suit to obtain additional
information about unreported deaths of detained people. Am. C.L.
Union Found. of S. California v. United States Immigr. & Customs
Enf’t, No. 2:22-CV-04760-SB-AFM, 2023 WL 8539484, at *1 (C.D.
Cal. Dec. 8, 2023).

31

See Dan Glaun, “How ICE Data Undercounts COVID-19 Victims,”
PBS Frontline, August 11, 2020 https://www.pbs.org/wgbh/
frontline/article/how-ice-data-undercounts-covid-19-victims/;
Isabelle Niu and Emily Rhyne, “4 Takeaways from Our Investigation
into ICE’s Mishandling of COVID-19,” New York Times, April 26,
2021, https://www.nytimes.com/2021/04/25/video/immigrationdetention-covid-takeaways.html [https://perma.cc/757M-CV37];
Maura Turcotte, Rachel Sherman, Rebecca Griesbach, and Ann
Hinga Klein, “The Real Toll From Prison COVID Cases May Be
Higher Than Reported,” New York Times, July 7, 2021, https://
www.nytimes.com/2021/07/07/us/inmates-incarcerated-coviddeaths.html.

32

Daniel Zwerding, “The Death of Richard Rust,” NPR Radio,
December 5, 2005, https://www.npr.org/2005/12/05/5022866/
the-death-of-richard-rust [https://perma.cc/26LP-W3EF].

33

Daniel Zwerding, “Lawmakers Seek Probe into Alien Detainee’s
Death,” NPR Radio, December 14, 2005, https://www.npr.org/
templates/story/story.php?storyId=5053781 [https://perma.
cc/BTR5-LDX9]; Letter from Sen. John Conyers, et al., to David
Walker, Comptroller General, U.S. GAO, Dec. 14, 2005, https://
legacy.npr.org/programs/atc/features/2005/dec/gaoletter/
gaoletter.pdf [https://perma.cc/78J7-EMKS].

34

Nina Bernstein, “Officials Hid Truth of Immigrant Deaths
in Jail,” New York Times, January 9, 2010, https://www.
nytimes.com/2010/01/10/us/10detain.html [https://perma.
cc/52YH-LLMV].

35

ACLU v. U.S. DHS, 738 F.Supp.2d 93 (D.D.C. 2010).

36

Nina Bernstein, “Officials Hid Truth of Immigrant Deaths in Jail,”
New York Times, January 9, 2010.

37

ICE, ICE Office of Policy, “Notification and Reporting of Detainee
Deaths,” Directive No. 7-9.0, October 1, 2012, https://www.ice.
gov/doclib/dro/pdf/11003.1-hd-notification_reporting_detainee_
deaths.pdf [https://perma.cc/G3GF-KLW9].

38

Fatal Neglect, supra note 14, 3.

39

ACLU, NIJC, HRW, Justice Free Zones,
32, https://www.aclu.org/publications/

justice-free-zones-us-immigration-detention-under-trumpadministration.

50

The JIC is an agency investigation arm established to receive
complaints involving ICE or CBP employees. Allegations of
misconduct are screened by the Office of Inspector General and
when warranted, are returned to the JIC for appropriate action
by the ICE Office of Professional Responsibility or CBP’s Office of
Internal Affairs. U.S. Federal Relations Authority, U.S. Department
of Homeland Security, U.S. Immigration and Customs Enforcement
and American Federation of Government Employees, National
Immigration and Customs Enforcement, Council 118, AFL-CIO, Apr.
29, 2016, https://www.flra.gov/node/78125#_ftn2 [https://perma.
cc/WS33-YUL5].

51

ICE, “Detainee Death Reporting.” Detainee deaths are currently
reported at: ICE, “News Releases and Statements.” accessed May
13, 2024 https://www.ice.gov/newsroom [https://perma.cc/
SN5E-TB3H].

52

ICE, “Detainee Death Reporting.”

53

Id.

54

Id.

Report, H.R. 3355, Dep’t of Homeland Sec. Appropriations Bill,
2018, H.R. Rep. No. 115-239, 2017 WL 3113989 at *33 (July 21,
2017).

55

Id.

56

Id.

43

Kate Sosin, “ICE is Refusing to Release a Legally Mandated Review
of Roxsana Hernandez’s Death,” INTO, November 29, 2018,
https://www.intomore.com/impact/ice-is-refusing-to-release-alegally-mandated-review-of-roxsana-hernandezs-death; https://
perma.cc/7CJD-Z324.

57

See, e.g. American Oversight, “FOIA Request to DHS Seeking ICE
Healthcare and Security Compliance Analyses,” October 12, 2021,
https://www.americanoversight.org/document/foia-request-to-dhsseeking-ice-healthcare-and-security-compliance-analyses.

58
44

ACLU, “Justice Free Zones,” 32; ICE, “Detainee Death Reporting,”
accessed May 13, 2024, https://www.ice.gov/detain/detainee-deathreporting; https://perma.cc/WF5M-42MG .

Creative Corrections, Department of Homeland Security,
ICE/OPR/DOD/CBP, accessed May 13, 2024, https://
creativecorrections.com/contracts/u-s-department-of-homelandsecurity [https://perma.cc/2BYX-8DFA].

45

ICE, “Detainee Death Reporting,” ICE, “News Releases and
Statements,” https://www.ice.gov/newsroom [https://perma.cc/
GD5Q-HXK5].

59

ICE Health Service Corps, “Operations Memorandum OM 16-907,”
Mortality Review, March 18, 2016, https://www.documentcloud.
org/documents/6025551-IHSC-Operations-MemorandumMortality-Review.

46

Death in Custody Reporting Act of 2013, Pub. L. 113-242, 128
Stat. 2860 (2014), https://www.govinfo.gov/content/pkg/PLAW113publ242/html/PLAW-113publ242.htm; https://perma.
cc/9W42-KQT2.

60

Id. A “psychological autopsy” is a collection of data to “reconstitute
the psychosocial environment of individuals who have committed
suicide and thus better understand the circumstances of their
death.” INSERM Collective Expertise Centre, Suicide: Psychological
Autopsy, a Research Tool for Prevention, 2005, https://www.ncbi.
nlm.nih.gov/books/NBK7126/.

61

United Nations, “Article 14: Liberty and Security of the Person,”
accessed May 13, 2024, https://www.un.org/esa/socdev/enable/
rights/ahcstata14refinthr.htm [https://perma.cc/4GX6-WXU6].

62

United Nations, Convention Against Torture and Other
Cruel, Inhuman or Degrading Treatment or Punishment,
G.A. Res. 39/46 (December 10, 1984), https://www.
ohchr.org/en/instruments-mechanisms/instruments/
convention-against-torture-and-other-cruel-inhuman-or-degrading.

63

United Nations, “Human Rights Office of the High Commissioner,”
accessed May 13, 2024, https://www.ohchr.org/en/treaty-bodies/
cat.

40

See supra note 14.

41

See, e.g. Chanelle Diaz, et al.,” Harmful by Design—a Qualitative
Study of the Health Impacts of Immigration Detention,“ Journal
of General Internal Medicine 38 (2023): 2030-2037, https://doi.
org/10.1007/s11606-022-07914-6; Chanelle Diaz, et al., “Advancing
Research to Address the Health Impacts of Structural Racism
in U.S. Immigration Prisons: Commentary Examines Health
Impacts of Structural Racism in U.S. Immigration Prisons,” Health
Affairs 42, no. 10 (2023): 1448-1445, https://www.healthaffairs.
org/doi/pdf/10.1377/hlthaff.2023.00479; Amy Zeidan. et al.
“Medical Mismanagement in Southern U.S. Immigration and
Customs Enforcement Detention Facilities: A Thematic Analysis
of Secondary Medical Records,” Journal of Immigrant Minority
Health 25 (2023): 1085–1097, https://doi.org/10.1007/s10903023-01451-y; Joseph Nwadiuko, et al., “Adult Hospitalizations from
Immigration Detention in Louisiana and Texas, 2015-2018,” PLOS
Global Public Health 2, no. 8 (2022), https://journals.plos.org/
globalpublichealth/article?id=10.1371/journal.pgph.0000432.

42

47

48

49

Project on Government Oversight, “A Matter of Life and Death: The
Importance of the Death in Custody Reporting Act,”2023, https://
civilrightsdocs.info/pdf/reports/DCRA-Report-2023.pdf [https://
perma.cc/WQ68-354R].
ICE, ICE Directive 10003.5: Notification, Review, and Reporting
Requirements for Detainee Deaths (October 25, 2021),https://www.
ice.gov/doclib/detention/directive11003-5.pdf [https://perma.
cc/T49B-4QEQ]. Since 2012, ICE has issued revised directives
regarding the agency’s investigation of detainee deaths, but has not
made these directives publicly available, despite FOIA requests.
See ICE, ICE FOIA Log, April 2023, https://www.ice.gov/doclib/
foia/icefoialogs/foiaLog04_2023.xlsx (noting that Al Otro Lado
requested copies of ICE Directive 10003.4: Notification, Review, and
Reporting Requirements for Detainee Deaths, (December 2, 2020),
as well as copies of all prior ICE directives numbered 11003 and
related to death reporting.).
ICE, “Detainee Death Reporting.”

Endnotes

67

64

65

66

67

68

69

70

71

68

United Nations, “Solitary Confinement Should Be Banned in Most
Cases, U.N. Expert Says,” October 18, 2011, https://news.un.org/
en/story/2011/10/392012 [https://perma.cc/5Q99-Z8S6].
United Nations, “Nelson Mandela Rules,” accessed May 13, 2024,
https://www.un.org/en/events/mandeladay/mandela_rules.shtml
[https://perma.cc/QL6A-BZ35]; Physicians for Human Rights,
et al., “Endless Nightmare: Torture and Inhuman Treatment in
Solitary Confinement in U.S. Immigration Detention,” PHR, 2024,
https://phr.org/our-work/resources/endless-nightmare-solitaryconfinement-in-us-immigration-detention/.
ICE Health Service Corps, “Root Cause Analysis and Action Plan,
Efrain Romero de la Rosa,” January 29, 2020, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p872/a2558242.
United Nations, Body of Principles for the Protection of All
Persons Under Any Form of Detention or Imprisonment,
G.A. Res. 43/173 (Dec. 9, 1988), https://www.ohchr.org/en/
instruments-mechanisms/instruments/body-principles-protectionall-persons-under-any-form-detention#:~:text=No%20person%20
under%20any%20form,or%20degrading%20treatment%20or%20
punishment.
Authors determined that ICE had released insufficient information
for review in one case; reviewers also analyzed the case of one death
in 2016 regarding agency oversight and accountability, based on
publicly-available information. This report addresses the period
between January 1, 2017 and December 31, 2022, as prior reports
have discussed in depth deaths that took place prior to 2017, and
because the authors did not have complete records for deaths that
occurred in 2016. See Human Rights Watch, ACLU, NIJC, DWN,
“Code Red: The Fatal Consequences of Dangerously Substandard
Medical Care in Immigration Detention,” HRW, 2018, https://www.
aclu.org/publications/code-red-fatal-consequences-dangerouslysubstandard-medical-care-immigration-detention.
American Oversight obtained documents associated with 50 cases
of detainee deaths between April 2016 and October 2021. Two cases
were removed from consideration from the pool of 50 as they related
to deaths occurring while people were in the custody of Customs and
Border Patrol (CBP) custody, rather than those who were held in
ICE detention.
Kendall Taggart, Hamed Aleaziz, and Jason Leopold, “More
Than 40 Immigrants Have Died in ICE Custody In the Past Four
Years. Here Are Thousands of Records About What Happened,”
Buzzfeed News, October 29, 2020, https://www.buzzfeednews.com/
article/kendalltaggart/here-are-thousands-of-documents-aboutimmigrants-who-died [https://perma.cc/8KSU-KT84]; Hamed
Aleaziz, “A Child’s Forehead Partially Removed, Four Deaths, The
Wrong Medicine: A Secret Report Exposes Health Care for Jailed
Immigrants,” Buzzfeed News, December 12, 2019, https://www.
buzzfeednews.com/article/hamedaleaziz/ice-immigrant-surgeriesdeaths-jails-whistleblower-secret [https://perma.cc/8MPH-P9U2].
Katherine Hawkins, Emma Stodder, “Past Deaths in Custody
Highlight Dire Risks for Immigration Detainees During
Coronavirus Outbreak,” Project on Government Oversight
(POGO), April 29, 2020,https://www.pogo.org/investigations/
past-deaths-in-custody-highlight-dire-risks-for-immigrationdetainees-during-coronavirus-outbreak [https://perma.cc/
PV9N-X6CL].

72

Andrew Free is a contributing author of the report.

73

“Roxsana Hernandez,” Transgender Law Center, accessed
May 15, 2024, https://transgenderlawcenter.org/case/
roxsana-hernandez/.

74

Ken Klippenstein, “ICE Detainee Deaths Were Preventable:
Document,” The Young Turks, June 3, 2019, https://tyt.com/
reports/investigates/2019/06/03/688s1LbTKvQKNCv2E9bu7h
[https://perma.cc/SLK3-Q3TC].

75

ICE, “FOIA Library,” https://www.ice.gov/foia/library [https://
perma.cc/5JGU-48V4] (last updated Nov. 15, 2022).

76

American Oversight v. U.S. Dep’t of Homeland Sec., et al., No. 19-cv1764 (RDM) (D.D.C. filed June 18, 2019); American Oversight v. U.S.
Dep’t of Homeland Sec., et al., No. 19-cv-1817 (RCL) (D.D.C. filed
June 21, 2019); American Oversight v. U.S. Dep’t of Homeland Sec.,
et al., No. 19-cv-1901 (EGS) (D.D.C. filed June 26, 2019); American
Oversight v. U.S. Dep’t of Homeland Sec., et al., No. 20-cv-2018
(BAH) (D.D.C. filed July 23, 2020); American Oversight v. U.S. Dep’t
of Homeland Sec., et al., No. 21-cv-3030 (TNM) (D.D.C. filed Nov. 16,
2021).

77

See, e.g. Draft Memorandum from Capt. [REDACTED],
IHSC, to IHSC Assistant Director, Mortality Review,
Ronal Francisco Romero, December 6, 2018, https://www.
documentcloud.org/documents/23258037-dkti-mortalityreviews-ero_of__2019-icfo-38745-nov-1-2022#document/p11/
a2170480.

78

Barrientos, et al. v. CoreCivic, Inc., No. 4:18-v-70 (M.D. Ga.);
Chaverra v. United States, No. 4:19-cv-91 (M.D. Ga.); Romero-Garcia
v. CoreCivic, Inc., No. 4:20-cv-158 (M.D. Ga.). Civil litigation often
leads to disclosure of more information than FOIA lawsuits, as close
court supervision of discovery may lead to more rapid disclosure
of records, and because the government cannot attempt to redact
information subject to FOIA exemptions.

79

Biographies of all reviewers can be found in the Appendix.

80

Daniel Kobewka, et al., “The Prevalence of Potentially
Preventable Deaths in an Acute Care Hospital: A Retrospective
Cohort” Medicine, 96, no. 8)(2017), http://dx.doi.org/10.1097/
MD.0000000000006162; Sanda Montmany, et al., “Preventable
Deaths and Potentially Preventable Deaths. What Are Our
Errors?” Injury, 47 (2015): 669-673, http://dx.doi.org/10.1016/j.
injury.2015.11.028; Robert Dubois, Robert Brook, “Preventable
Deaths: Who, How Often, and Why?” Annals of Internal Medicine
109 (2004): 582-589; Jud C. Janak, et al., “Comparison of Military
and Civilian Methods for Determining Potentially Preventable
Deaths: A Systematic Review.” JAMA Surgery, 153, no. 4 (2018):367375. doi:10.1001/jamasurg.2017.6105.

81

Timothy P. Hofer, et al., “Discussion between Reviewers Does Not
Improve Reliability of Peer Review of Hospital Quality,” Medical
Care 38 (2000): 152-161.

82

There is no standard definition of “reasonable possibility” in
medicine, as clinicians tend not to quantify the likelihood of
clinical outcomes (positive or negative) because of the nuances and
variations that are dependent on the interplay of various factors.
However, this definition would be analogous to “more likely than
not.”

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

83

Email between ICE Albuquerque SDDO and Management
& Program Analyst, ICE, August 29, 2018, https://
transgenderlawcenter.org/wp-content/uploads/2019/10/Emailexchange-re-destroyed-surveillance-footage.pdf.

84

Detainee Death Review: Gourgen Mirimanian, Medical and
Security Compliance Analysis, June 24, 2018, 18 (p. 146 of pdf
file), https://www.documentcloud.org/documents/236912252022-icli-00026-8ir-december-2022-pt-1#document/p146/
a2238373.

85

86

Email from Management & Program Analyst, Apr. 21, 2018,
FW: MIRMIANIAN PBNDS 2011 (2016 revisions), 47,
https://www.documentcloud.org/documents/236912432022-icli-00026-9ir-january-2023-p_1#document/p47/
a2213244.
Email from Inspections and Compliance Specialist, ICE, February
7, 2020, RE: ICE OPR Interview of Detainee [REDACTED],
https://www.documentcloud.org/documents/23875812-owenopr-response-june-2023-of-2022-icli-00026-2#document/p230/
a2420235.

97

ICE Office of Professional Responsibility, “Detainee
Death Review Report, Maria Ochoa-Yoc de Ramirez,”
March 17, 2021, 3, https://www.documentcloud.org/
documents/24656099-part-2-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p56/
a2558323.

98

Id., 18 (noting that Medical Synopsis Memorandum stated that “a
third-party statement regarding OCHOA’s threat is on file, and upon
request of the documentation from [REDACTED], he was unable to
provide them.”

99

Id., 18.

100 Email from Inspections and Compliance Specialist,
Office of Professional Responsibility, April 20, 2020, Re:
Ochoa Sick Calls, 15, https://www.documentcloud.org/
documents/24428406-owen-v-ice-19th-ir-opr-response-of-2022icli-00026-2_redacted-nov-29-2023#document/p108/a2428659 .
101 ICE Office of Professional Responsibility, “Detainee Death Review
Report, Maria Ochoa-Yoc de Ramirez,” March 17, 2021, 35-36.

Geogia Bureau of Investigation, Region 3 Investigative Summary,
No. 03-0008-01-19, Ex. 39 (noting that the witness, held in cell 106,
had been “released at 3:06 a.m.”), https://www.documentcloud.
org/documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p2561/
a2559107.

102 Dr. Elena Jimenez Gutierrez, “Medical Review of Death of Maria
Celese Ochoa Yoc de Ramirez,” January 1, 2023 (on file with
authors).

88

Georgia Bureau of Investigation, Region 3 Investigative Summary,
No. 03-0008-01-19, 45, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p2366/
a2559108.

104 See, e.g. ICE, Performance-Based National Detention Standards
(2011, rev. 2016), Sec. 4.7, Terminal Illness, Advance Directives
and Death, at 342, https://www.ice.gov/doclib/detentionstandards/2011/4-7.pdf.

89

Id., 4 and 47.

90

Dr. Radha Sadacharan, Medical Review of Death of Efrain De La
Rosa, February 4, 2023 (on file with authors).

91

Ken Klippenstein, “ICE Detainee Deaths Were Preventable:
Document,” The Young Turks, June 3, 2019, https://tyt.com/
reports/investigates/2019/06/03/688s1LbTKvQKNCv2E9bu7h
[https://perma.cc/SLK3-Q3TC].

87

92

Id.

93

Id.

94

Id.

95

Memorandum from Cameron Quinn, Office for Civil Rights
and Civil Liberties, to Ronald Vitiello, Deputy Director of U.S.
Immigration and Customs Enforcement, Re: ICE Health Service
Corps (IHSC) Medical/Mental Health Care and Oversight, March
20, 2019: 7, https://www.documentcloud.org/documents/6575024ICEWhistleblower-Report.html.

96

DHS Office of Inspector General, Memorandum of Activity,
Case No. I18-ICE-ATL-34012, Efrain de la Rosa, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p834/a2558241 at 871.

103 ICE Office of Professional Responsibility, “Detainee Death Review
Report, Maria Ochoa-Yoc de Ramirez,” March 17, 2021,17.

105 For example, see National Association of Medical Examiners,
Position Paper: Recommendations for the Definition, Investigation,
Postmortem Examination, and Reporting of Deaths in Custody, 7-14,
https://name.memberclicks.net/assets/docs/2e14b3c6-6a0d-4bd3bec9-fc6238672cba.pdf (detailing consistent standards for autopsies
for deaths in custody).
106 Id.
107 Id.
108 “Meningitis,” Mayo Clinic, accessed May 14, 2024, https://www.
mayoclinic.org/diseases-conditions/meningitis/symptoms-causes/
syc-20350508# [https://perma.cc/2ZRD-KKCR].
109 “Meningococcal Disease,” Centers for Disease Control and
Prevention, accessed May 14, 2024, https://www.cdc.gov/
meningococcal/outbreaks/index.html [https://perma.cc/
T3HG-93AE].
110 ICE, “Detainee Death Report: Romero, Ronal Francisco
(aka Cruz, Ronald),“ 2, https://www.documentcloud.org/
documents/24428448-ddrromeroronalfranciscoakacruzronald at 2
111 Memorandum from Deputy Medical Director, ICE Health
Service Corps, to Stewart Smith, Assistant Director, ICE Health
Service Corps, Mortality Review – Ronal Francisco Romero,
December 6, 2018, 2, https://www.documentcloud.org/
documents/23258037-dkti-mortality-reviews-ero_of__2019-icfo38745-nov-1-2022#document/p11/a2170480 .

Endnotes

69

112 Hamed Aleaziz, “A Child’s Forehead Partially Removed, Four
Deaths, The Wrong Medicine: A Secret Report Exposes Health Care
for Jailed Immigrants,” Buzzfeed News, December 12, 2019, https://
www.buzzfeednews.com/article/hamedaleaziz/ice-immigrantsurgeries-deaths-jails-whistleblower-secret [https://perma.
cc/8MPH-P9U2].
113 Id.; Memorandum from Cameron Quinn, Office for Civil Rights
and Civil Liberties, to Ronald Vitiello, Deputy Director of U.S.
Immigration and Customs Enforcement, Re: ICE Health Service
Corps (IHSC) Medical/Mental Health Care and Oversight (March
20, 2019), https://www.documentcloud.org/documents/6575024ICEWhistleblower-Report.html.
114 Dr. Radha Sadacharan, “Medical Review of Death of Ronal
Francisco Romero,” November 2, 2022 (on file with authors).
115 Memorandum from Deputy Medical Director, ICE Health
Service Corps, to Stewart Smith, Assistant Director,
ICE Health Service Corps, Mortality Review – Ronal
Francisco Romero, December 6, 2018, 3-4, https://www.
documentcloud.org/documents/23258037-dkti-mortalityreviews-ero_of__2019-icfo-38745-nov-1-2022#document/p11/
a2170480.
116 Id., 5.
117 Id., 6.
118 Dr. Radha Sadacharan, “Medical Review of Death of Ronal
Francisco Romero,” November 2, 2022 (on file with authors).
119 “Meningitis,” Mayo Clinic, accessed May 14, 2024, https://www.
mayoclinic.org/diseases-conditions/meningitis/diagnosistreatment/drc-20350514 .
120 Dr. Radha Sadacharan, “Medical Review of Death of Ronal
Francisco Romero,” November 2, 2022 (on file with authors).
121 ICE Health Service Corps, “Root Cause Analysis and Action
Plan, Ronal Franscisco Romero,” October 1, 2019, https://www.
documentcloud.org/documents/24656099-part-2-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p1142/a2558394.
122 Dr. Radha Sadacharan, “Medical Review of Death of Jean Carlos
Alfonso Jimenez Joseph,” March 1, 2024 (on file with authors).
123 Id.; Dr. Chanelle Diaz, “Medical Review of Death of Jean Carlos
Alfonso Jimenez Joseph,” March 18, 2024 (on file with authors).
124 Deposition of James Blankenship, Chaverra v. United States, No.
4:19-cv-81 (M.D. Ga. February. 10, 2021), at 185, https://www.
documentcloud.org/documents/23690745-chaverra-v-united-statesof-america-md-ga-james-blankenship-deposition-transcript.
125 Memorandum from Dr. Ada Rivera, Deputy Medical
Director, ICE Health Service Corps, to Stewart Smith,
Assistant Director, ICE Health Service Corps, Mortality
Review – Jean Carlos Alfonso Jimenez Joseph, December
15, 2017, ,5, 30, https://www.documentcloud.org/
documents/24427317-ex-16-jimenez-mortality-review.
126 Dr. Chanelle Diaz, “Medical Review of Death of Jean Jose Leonardo
Lemus Rajo,” January 24, 2023 (on file with authors).

70

127 Dr. Radha Sadacharan, “Medical Review of Death of Jean Jose
Leonardo Lemus Rajo,” January 12, 2023 (on file with authors).
128 DHS Office of Inspector General, Memorandum of
Activity, Personal Interview, Case No. 116-ICE-MIA-11471,
Lemus Jose, 1883, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reports-andrelated-documents-of-ice-detainees#document/p1852/a2558309 at
1883.
129 Department of Homeland Security Appropriations Act, 2010,
Pub. L. 111-83, 123 Stat. 2149 (2009), https://www.congress.gov/
bill/111th-congress/house-bill/2892/text.
130 U.S. Dep’t of Homeland Security, Contract Discrepancy Report, No.
HSCEDM-11D-0003, April 12, 2018, https://www.documentcloud.
org/documents/24529296-2019-icfo-38991#document/p19/
a2445080.
131 Elise Schmelzer, “The ICE Detention Center in Aurora
Added 432 Beds Last Month. Those Beds Are Expected
to Be Filled Almost Immediately.” Denver Post, February
6, 2019, https://www.denverpost.com/2019/02/06/
aurora-ice-detention-center-additional-beds/.
132 Expert Report, Dr. Dora Schriro, Romero-Garcia v.
CoreCivic, Inc., No. 4:20-cv-158 (M.D. Ga. February
8, 2023), 63, https://www.documentcloud.org/
documents/23774018-stewart-romero-death-expert-reports.
133 U.S. Dep’t of Homeland Security, Contract Discrepancy Report,
no. CDRFY18-0004, December 11, 2018, https://web.archive.
org/web/20220216153610/https://oversight.house.gov/sites/
democrats.oversight.house.gov/files/Stewart%20Contract%20
Discrepancy%20Dec%202018.pdf [https://perma.cc/GV8J-FDGE].
134 This estimate is based on a per diem rate of $62.76/day and average
daily population of 1876 people at Stewart Detention Center in FY
2017, see Amendment of Solicitation/Modification of Contract, ICE
and Stewart County, Sept. 26, 2017, Exhibit 17, Inter-Governmental
Service Agreement and Modification, Barrientos, et al. v. CoreCivic,
Inc., No. 4:18-v-70 (M.D. Ga. Aug. 21, 2023), ECF No. 387-20 at 93.
135 CoreCivic, Inc., 2017 Annual Report Form 10-K,
February 22, 2018, https://ir.corecivic.com/static-files/
f242d017-6ce3-4bb5-ae33-f6888059dc9b.
136 Amendment of Solicitation/Modification of Contract, ICE and
Stewart County, Sept. 26, 2017, Exhibit 17, Inter-Governmental
Service Agreement and Modification, Barrientos, et al. v. CoreCivic,
Inc., No. 4:18-v-70 (M.D. Ga. Aug. 21, 2023), ECF No. 387-20 at 92.
137 In six cases where reviewers diverged in opinion between a finding
that a death was possibly preventable, and not preventable or
indeterminate, an additional medical expert conducted a review
of the case. The final determination reflected here was the
classification reached by the majority of the three reviewing experts.
138 Dr. Chanelle Diaz, “Medical Review of Death of Jesse Dean,”
February 13, 2023 (on file with authors).
139 Memorandum from IHSC Senior Investigator to IHSC
Assistant Director, Mortality Review—Report on Findings,
Jesse Dean, May 17, 2021, 3-8, https://www.documentcloud.
org/documents/24656097-part-1-selected-death-review-reports-

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

and-related-documents-of-ice-detainees#document/p1790/
a2558305.

151 Id., 27.
152 Id.

140 Dr. Chanelle Diaz, “Medical Review of Death of Jesse Dean,”
February 13, 2023 (on file with authors); Dr. Radha Sadacharan,
“Medical Review of Death of Jesse Dean,” February 17, 2023 (on
file with authors); Memorandum from IHSC Senior Investigator to
IHSC Assistant Director, Mortality Review—Report on Findings,
Jesse Dean, May 17, 2021, 3-8, https://www.documentcloud.
org/documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1790/
a2558305.

153 Dr. Radha Sadacharan, “Medical Review of Death of Abel Reyes
Clemente,” September 28, 2022 (on file with authors); “Dr. Chanelle
Diaz, Medical Review of Death of Abel Reyes Clemente,” February
14, 2023 (on file with authors).
154 Creative Corrections, “Detainee Death Review: Abel Reyes
Clemente, Healthcare and Security Compliance Analysis,” July 2,
2019, at 11-14.

141 Memorandum from IHSC Senior Investigator to IHSC
Assistant Director, Mortality Review—Report on Findings,
Jesse Dean, May 17, 2021, 8, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1790/
a2558305.

155 ICE has listed Mr. Mejilla Bonilla as Rolando Arnulfo MezaEspinoza, from Honduras, due to a case of mistaken identity. See
Hannan Adely, “A Case of Mistaken Identity, Then the Death
of an ICE Detainee,” NorthJersey.com, July 27, 2017, https://
www.northjersey.com/story/news/watchdog/2017/07/27/
case-mistaken-identity-then-death-ice-detainee/514969001/.

142 ICE Office of Professional Responsibility, “Detainee Death
Review Report, Jesse Dean,” August 19, 2021, 19, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p1682/a2558299.

156 Dr. Radha Sadacharan, “Medical Review of Death of Carlos Mejilla
Bonilla,” February 24, 2024 (on file with authors).

143 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Jesse Dean,” August 19, 2021, 22 n.151, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p1682/a2558299.
144 Id., 26-27.
145 Memorandum from IHSC Senior Investigator to IHSC
Assistant Director, Mortality Review—Report on Findings,
Jesse Dean, May 17, 2021, 3, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1790/
a2558305.
146 ICE ERO Custody Management Division, “Authorized Dedicated
Facility List” and “Authorized Non-Dedicated Facility List,”
April1, 2024, https://www.ice.gov/doclib/facilityInspections/
dedicatedNonDedicatedFacilityList.xlsx.
147 Dr. Radha Sadacharan, “Medical Review of Death of Abel Reyes
Clemente,” September 28, 2022 (on file with authors); Dr. Chanelle
Diaz, “Medical Review of Death of Abel Reyes Clemente,” February
14, 2023 (on file with authors).
148 Creative Corrections, “Detainee Death Review: Abel Reyes
Clemente, Healthcare and Security Compliance Analysis,”
July 2, 2019, 14, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p970/
a2558261.
149 Id., 12-16; Dr. Chanelle Diaz, “Medical Review of Death of Abel
Reyes Clemente,” February 14, 2023 (on file with authors).
150 Creative Corrections, “Detainee Death Review: Abel Reyes
Clemente, Healthcare and Security Compliance Analysis,” July 2,
2019, 24-26.

157 Adely, “A Case of Mistaken Identity.”
158 Creative Corrections, “Detainee Death Review: Carlos MejiaBonilla, Compliance Review,” February 12, 2018, 6, https://www.
documentcloud.org/documents/6772759-Carlos-Mejia-BonillaSearchable.js#document/p64/a560628.
159 Adely, “A Case of Mistaken Identity.”
160 Dr. Elena Jimenez Gutierrez, “Medical Review of Death of Carlos
Mejilla Bonilla,” March 5, 2024 (on file with authors).
161 ICE Office of Professional Responsibility, “Detainee Death
Review: Wilfredo Padron,” January 31, 2020, 17-21, https://www.
documentcloud.org/documents/24656099-part-2-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p1652/a2558417.
162 Dr. Radha Sadacharan, “Medical Review of Death of Wilfredo
Padron,” February 4, 2023 (on file with authors).
163 Creative Corrections, “Detainee Death Review, Wilfredo
Padron, Healthcare and Security Compliance Analysis,”
January 13, 2019, 22, https://www.documentcloud.org/
documents/24656099-part-2-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1691/
a2558418.
164 Id., 23.
165 Id., 25-28.
166 Id., 29.
167 “Autopsy Report, Wilfredo Padron,” November
1, 2018, https://www.documentcloud.org/
documents/24656099-part-2-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1733/
a2558419.

Endnotes

71

168 “Government’s Own Experts Found ‘Barbaric’ and “Negligent’
Conditions in ICE Detention,” National Public Radio, August 16,
2023, https://www.npr.org/transcripts/1190767610.

184 Id., 24, 26.

169 ICE Office of Professional Responsibility, “External
Reviews and Analysis Unit, Detainee Death Review: Kamyar
Samimi,” May 22, 2018, 2, https://www.dropbox.com/scl/
fo/p6k68gawjclsk2jc0wecc/h?dl=0&e=3&preview=11++SAMIMI+-+Memo+on+Findings+(POGO).
pdf&rlkey=wn1brjrxzhd5u1b4lr0fnurrp.

186 See also Anette Dekker, et al., “Emergency Medical Responses
at US Immigration and Customs Enforcement Detention
Centers in California,” JAMA Network Open 6, no. 11 (2023),
e2345540-e2345540.

170 Id.
171 Dr. Chanelle Diaz, “Medical Review of Death of Kamyar Samimi,”
February 8, 2023 (on file with authors).

185 Id., 2, 28.

187 Henry Allen Messick was also known as Anthony Jones.
Memorandum from Deputy Medical Director, ICE Health Service
Corps, to Assistant Director, ICE Health Service Corps, Mortality
Review – Report of Findings, Anthony Alexander Jones (a.k.a. Henry
Allen Messick), April 14, 2021.
188 Id., 8-9.

172 Id.
189 Id., 12.
173 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Kuan Hui Lee,” September 7, 2021, 41, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p2033/a2558314.
174 Dr. Radha Sadacharan, “Medical Review of Death of Kamyar
Samimi,” February 13, 2023 (on file with authors).
175 Memorandum from Deputy Medical Director, ICE Health
Service Corps, to Stewart Smith, Assistant Director, ICE Health
Service Corps, Mortality Review – Report of Findings, Kuan
Hui Lee, December 6, 2018, 17, https://www.documentcloud.
org/documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p2327/
a2558318.
176 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Kuan Hui Lee,” September 7, 2021, 42.
177 Id. 45-46.
178 Id. 46-47.
179 ICE Office of Professional Responsibility, “Detainee
Death Review Report: Samuelino Pitchout Mavinga,”
November 12, 2020, 2, https://www.documentcloud.org/
documents/24656099-part-2-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1341/
a2558406.
180 Dr. Radha Sadacharan, “Medical Review of Death of Samuelino
Pitchout Mavinga,” May 15, 2023 (on file with authors).
181 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Samuelino Pitchout Mavinga,” November 12, 2020, at 7.
182 Id., 7; Dr. Radha Sadacharan, “Medical Review of Death of
Samuelino Pitchout Mavinga,” May 15, 2023.
183 ICE Office of Professional Responsibility, “Detainee
Death Review Report: Samuelino Pitchout Mavinga,”
November 12, 2020, 21, https://www.documentcloud.org/
documents/24656099-part-2-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1381/
a2558407.

72

190 Id., 9.
191 Dr. Elena Gutierrez, “Medical Review of Death of Anthony
Alexander Jones,” March 1, 2023 (on file with authors).
192 Creative Corrections, “Detainee Death Review: Nebane
Abienwi, Medical and Security Compliance Analysis,”
January 12, 2020, 1, 13-14, https://www.documentcloud.org/
documents/24656099-part-2-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p477/
a2558341.
193 Id., 7-9.
194 Dr. Radha Sadacharan, “Medical Review of Death of Nebane
Abienwi,” February 1, 2023 (on file with authors).
195 ICE Office of Professional Responsibility, External
Reviews and Analysis Unit, “Detainee Death Review—
Huy Chi Tran,” 1, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1456/
a2558288.
196 Creative Corrections, “Detainee Death Review: Huy Chi
Tran, Healthcare and Security Compliance Analysis,”
August 2018, 17, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1490/
a2558290.
197 Dr. Radha Sadacharan, “Medical Review of Death of Huy Chi
Tran,” November 19, 2022 (on file with authors); Leslie V. Simn,
Muhammad F. Hashmi, Avery L. Callahan, “Neuroleptic Malignant
Syndrome,” Aprril 24, 2023, https://www.ncbi.nlm.nih.gov/books/
NBK482282/ [https://perma.cc/5JVA-Z7H5].
198 Creative Corrections, “Detainee Death Review: Huy Chi Tran,
Healthcare and Security Compliance Analysis,” August 2018, 18.
199 Id., 22.
200 Id., 29-30.
201 ICE Office of Professional Responsibility, “Detainee
Death Review Report: Elba Maria Centeno-Briones,”

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November 18, 2021, 2, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p913/
a2558257.

213 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Mergansana Dabaevich Amar,“ May 7, 2020, 2.
214 Id., 3

202 Id., 3-5; https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p934/
a2558259.

215 Id., 6, 9, 10.

203 Creative Corrections, “Detainee Death Review: Elba Maria CentenoBriones, Healthcare and Security Compliance Analysis,” October
14, 2021, 6.

217 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Mergansana Dabaevich Amar,” May 7, 2020,17-18.

216 Lily Fowler, “An Asylum Seeker Vowed Never to Return to Russia.
His Death in Custody Sent Him Back,” Crosscut, June 10, 2019.

218 Id., 17.
204 See, e.g. ICE, “Detainee Death Report: Shrestha, Subash,” https://
www.ice.gov/doclib/foia/reports/ddr_subashShrestha.pdf
[https://perma.cc/3YW7-FP5D]; ICE, “Venezuelan National Passes
Away in ICE Custody,” April 19, 2024, https://www.ice.gov/news/
releases/venezuelan-national-passes-away-ice-custody [https://
perma.cc/ZGS8-67BF] (Edixon Del Jesus Farias-Farias); ICE,
“Indian National in ICE Custody Dies in Hospital,” April 17, 2024,
https://www.ice.gov/news/releases/indian-national-ice-custodydies-hospital [https://perma.cc/3K6A-J8NB].
205 Parsa Erfani, et al., “Suicide Rates of Migrants in United States
Immigration Detention (2010-2020),” AIMS Public Health 8, no. 3
(2021): 416-420, doi:10.3934/publichealth.2021031.
206 ACLU, Justice Free Zones, 34; Hamed Aleaziz and Adolfo Flores,
“A Cuban Asylum-Seeker Died of An Apparent Suicide After
Spending Months in ICE Detention,” Buzzfeed News, October 16,
2019, https://www.buzzfeednews.com/article/hamedaleaziz/
cuban-asylum-ice-death-suicide-louisiana-detention [https://perma.
cc/94XP-M4LD].
207 Creative Corrections, “Detainee Death Review: Roylan
Hernandez-Diaz, Healthcare and Security Compliance Analysis,”
February 10, 2020, 2, https://www.documentcloud.org/
documents/24656099-part-2-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1299/
a2558403.
208 Nomaan Merchant, “The Preventable Death of an Asylum Seeker in
a Solitary Cell,” Associated Press, March 9, 2020, https://apnews.
com/article/immigration-us-news-ap-top-news-cuba-asylumseekers-618df9aa77288cab0cc987bd75966e17 [https://perma.
cc/3W6D-Y9WU].

219 De Leon v. INS, 115 F.3d 643 (9th Cir. 1997); U.S. Court of Appeals
for the Ninth Circuit, General Orders § 6.4(c)(1).
220 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Mergansana Dabaevich Amar,” May 7, 2020, 20.
221 See Erika Bryant, “Solitary Confinement is Torture, Not COVID
Medical Care,” Vera March 25, 2022, https://www.vera.org/news/
solitary-confinement-is-torture-not-covid-medical-care.
222 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Choung Woung Ahn,” April 9, 2021, 19, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p471/a2558218.
223 Id., 13.
224 Dr. Elena Jimenez Gutierrez, “Medical Review of Death of Choung
Woong Ahn,” February 2, 2023 (on file with authors).
225 DHS Office of the Inspector General, “Report of Investigation,
I17-ICE-LAX-12566,” August 27, 2019, 2-3, https://www.
documentcloud.org/documents/24656099-part-2-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p1845/a2559113.
226 Id.
227 Dr. Chanelle Diaz, “Medical Review of Death of Osmar Epifanio
Gonzalez Gabda,” February 5, 2023 (on file with authors).

209 Id.

228 DHS Office of the Inspector General, “Report of Investigation, I17ICE-LAX-12566,” Augugst 27, 2019, 11.

210 Id.

229 Id., 22, 35.

211 Creative Corrections, “Detainee Death Review: Roylan HernandezDiaz, Healthcare and Security Compliance Analysis,” February 10,
2020, 25.

230 Id., 26, 35, 65.

212 ICE Office of Professional Responsibility, “Detainee
Death Review Report: Mergansana Dabaevich Amar,”
May 7, 2020, 2, https://www.documentcloud.org/
documents/24656099-part-2-selected-death-review-reports-andrelated-documents-of-ice-detainees#document/p213/a2558327; Lily
Fowler, “An Asylum Seeker Vowed Never to Return to Russia. His
Death in Custody Sent Him Back,” Crosscut, June 10, 2019, https://
crosscut.com/2019/06/asylum-seeker-vowed-never-return-russiahis-death-ice-custody-sent-him-back.

232 Dr. Radha Sadacharan, “Medical Review of Death of Osmar Epifanio
Gonzalez Gabda,“ January 21, 2023 (on file with authors).

231 Id., 26, 35, 65.

233 Dr. Chanelle Diaz, “Medical Review of Death of Osmar Epifanio
Gonzalez Gabda,” February 5, 2023 (on file with authors).
234 See, e.g. ICE, Performance Based National Detention Standards
(2011 rev. 2016), Sec. 4.3 Medical Care, https://www.ice.gov/
doclib/detention-standards/2011/4-3.pdf.

Endnotes

73

235 See also Parveen Parmar, et al., ”Mapping FactorsAssociated with
Deaths in Immigration Detention in the United States, 2011-2018:
a Thematic Analysis,” The Lancet Regional Health–Americas 2
(2021), https://www.thelancet.com/journals/lanam/article/
PIIS2667-193X(21)00032-6/fulltext.
236 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Simratpal Singh,“ March 30, 2020, 8, 21, https://www.
documentcloud.org/documents/24656099-part-2-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p1500/a2558412.
237 Id.
238 Id., 8, 10, 17, 21; Dr. Radha Sadacharan, “Medical Review of
Death of Simratpal Singh,” November. 4, 2022 (on file with
authors); Creative Corrections, “Detainee Death Review:
Simratpal Singh, Healthcare Security and Compliance
Analysis,” August 26, 2019, 18, https://www.documentcloud.
org/documents/24656099-part-2-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1532/
a2558413.
239 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Simratpal Singh,” March 30, 2020, ,20.
240 Id., 14, 24.
241 Id., 15, 28.
242 Dr. Radha Sadacharan, “Medical Review of Death of Simratpal
Singh,” November 4, 2022 (on file with authors).
243 Id.
244 Dr. Katherine McKenzie, “Medical Review of Death of Simratpal
Singh,” January 23, 2023 (on file with authors).
245 Id.
246 Letter from Dr. Scott Allen and Dr. Josiah Rich to Hon. Bennie
Thompson et al. (March 19, 2020), https://whistleblower.org/
wp-content/uploads/2020/03/Drs.-Allen-and-Rich-3.20.2020Letterto-Congress.pdf; Jaime P. Meyer, et al., “COVID-19 and the
Coming Epidemic in U.S. Immigration Detention Centres,” The
Lancet Infectious Diseases 20, no. 6 (2020): 646-648; Open Letter
to ICE from Medical Professionals Regarding COVID-19, https://
nylpi.org/wp-content/uploads/2020/03/FINAL-LETTER-OpenLetter-to-ICE-From-Medical-Professionals-Regarding-COVID-19.
pdf.
247 Physicians for Human Rights: Praying for Hand Soap and Masks
Health and Human Rights Violations in U.S. Immigration Detention
during the COVID-19 Pandemic, PHR, (2021), https://phr.org/
our-work/resources/praying-for-hand-soap-and-masks/.
248 See, e.g. Isabelle Niu and Emily Rhyne, “4 Takeaways from Our
Investigation into ICE’s Mishandling of COVID-19,” New York
Times, April 26, 2021, https://www.nytimes.com/2021/04/25/
video/immigration-detention-covid-takeaways.html [https://perma.
cc/757M-CV37].
249 See Dan Glaun, “How ICE Data Undercounts COVID-19 Victims,”
PBS Frontline, August 11, 2020, https://www.pbs.org/wgbh/
frontline/article/how-ice-data-undercounts-covid-19-victims/;

74

Maura Turcotte, Rachel Sherman, Rebecca Griesbach, and Ann
Hinga Klein, “The Real Toll From Prison COVID Cases May Be
Higher Than Reported,” New York Times, July 7, 2021, https://
www.nytimes.com/2021/07/07/us/inmates-incarcerated-coviddeaths.html.
250 Hannah Critchfield, “Released from a North Carolina Prison During
the Pandemic, a Canadian Man Was Detained by ICE. Five Months
Later, He Died in Their Custody,” NC Health News, August 18, 2020,
https://www.northcarolinahealthnews.org/2020/08/18/releasedfrom-a-north-carolina-prison-during-the-pandemic-canadian-manwas-detained-by-ice-five-months-later-he-died-in-their-custody/
[https://perma.cc/5AUQ-DP4Y].
251 Antonio Olivo and Nick Miroff, “ICE Flew Detainees to Virginia
So the Planes Could Transport Agents to D.C. Protests. A Huge
Coronavirus Outbreak Followed,” The Washington Post, September
11, 2020, https://www.washingtonpost.com/coronavirus/
ice-air-farmville-protests-covid/2020/09/11/f70ebe1e-e861-11eabc79-834454439a44_story.html.
252 “Ontario Man in U.S. ICE Custody Dies after Getting Coronavirus,”
Canadian Press, August 7, 2020, https://www.cbc.ca/news/
canada/toronto/canadian-us-ice-custody-covid-dies-1.5678963
[https://perma.cc/X8VK-QU6E].
253 “Cipriano Chavez Alvarez,” Mourning Our Losses, accessed May 15,
2024, https://www.mourningourlosses.org/memorials/ciprianochavez-alvarez https://perma.cc/LE3S-W6AC].
254 Hamed Aleaziz, “A Judge Ordered Him Released From Prison Due
To COVID-19 Concerns. He Died Of The Disease Two Months Later
In ICE Custody,” Buzzfeed News, September 23, 2020, https://www.
buzzfeednews.com/article/hamedaleaziz/immigrant-releasedthen-dies-of-covid-in-ice-custody [https://perma.cc/manage/
create?folder=217167].
255 Memorandum from Deputy Medical Director, ICE Health Service
Corps, to Assistant Director, ICE Health Service Corps, Mortality
Review – Cipriano Chavez Alvarez, April 29, 2021, 3, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p544/a2558223.
256 Creative Corrections, “Detainee Death Review: Kamyar
Samimi, Medical and Security Compliance Analysis,”
March 14, 2017, 63, https://www.dropbox.com/scl/fo/
p6k68gawjclsk2jc0wecc/h?dl=0&e=2&preview=11+-+SAMIMI++Medical+and+Security+Compliance+Analysis+(POGO).
pdf&rlkey=wn1brjrxzhd5u1b4lr0fnurrp.
257 ICE Office of Professional Responsibility, “Detainee
Death Review Report: Roberto Rodriguez-Espinoza,”
October 20, 2020, 14, https://www.dropbox.com/scl/
fo/p6k68gawjclsk2jc0wecc/h?dl=0&e=2&preview=30Rodriguez+Espinoza-Detainee+Death+Review.
pdf&rlkey=wn1brjrxzhd5u1b4lr0fnurrp.
258 Deposition of James Blankenship, Chaverra v. United States,
No. 4:19-cv-81 (M.D. Ga. Feb. 10, 2021), 185, https://www.
documentcloud.org/documents/23690745-chaverra-v-united-statesof-america-md-ga-james-blankenship-deposition-transcript.
259 Memorandum from Dr. Ada Rivera, Deputy Medical
Director, ICE Health Service Corps, to Stewart Smith,

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Assistant Director, ICE Health Service Corps, Mortality
Review – Jean Carlos Alfonso Jimenez Joseph, December
15, 2017, 5, 30, https://www.documentcloud.org/
documents/24427317-ex-16-jimenez-mortality-review.

278 Id., 5-8.
279 Id., 8.
280 Id., 9.

260 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Ben James Owen,” November 20, 2020, 2-3, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p335/a2558198.

281 Id., 11.
282 Id., 37.
283 Id., 32.

261 Id., 3.
284 Id., 14.
262 Id., 7, n.39.
285 Id., 17.
263 Id., 10.
264 Id., 11.
265 Id.
266 Id., 13.

286 Memorandum from Acting Assistant Director, Inspections
and Detention Oversight Division, to Enrique M. Lucero,
Executive Associate Director, Detainee Death Review Findings—
Guerman Volkov, 2, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p1428/
a2558286.

267 Id., 12.
287 Id.
268 Creative Corrections, “Detainee Death Review: Ben James
Owen, Healthcare and Security Compliance Analysis,”
August 2020, 2, https://www.documentcloud.org/
documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p364/
a2558200.
269 ICE ERO Custody Management Division, “Authorized Dedicated
Facility List” and “Authorized Non-Dedicated Facility List,”
April 1, 2024, https://www.ice.gov/doclib/facilityInspections/
dedicatedNonDedicatedFacilityList.xlsx.
270 Memorandum from Deputy Medical Director, ICE Health
Service Corps, to Stewart Smith, Assistant Director, ICE
Health Service Corps, Mortality Review – Anthony Oluseye
Akinyemi, March 19, 2020, 2, https://www.documentcloud.
org/documents/24656097-part-1-selected-death-review-reportsand-related-documents-of-ice-detainees#document/p213/
a2558186.

288 Id.
289 Id., 3.
290 Id.
291 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Guerman Volkov,” September 28, 2020, 40.
292 Memorandum from Acting Assistant Director, Inspections and
Detention Oversight Division, to Enrique M. Lucero, Executive
Associate Director, Detainee Death Review Findings—Guerman
Volkov, 3; ICE Office of Professional Responsibility, “Detainee
Death Review Report: Guerman Volkov,” September 28, 2020, 41-42.
293 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Guerman Volkov,” September 28, 2020, 43.
294 Id., 46.

271 Dr. Katherine McKenzie, “Medical Review of Death of Anthony
Oluseye Akinyemi,” January 11, 2023 (on file with authors).
272 Memorandum from Deputy Medical Director, ICE Health Service
Corps, to Stewart Smith, Assistant Director, ICE Health Service
Corps, Mortality Review – Anthony Oluseye Akinyemi, March 19,
2020, 6.

295 Id., 47.
296 Roger A. Mitchell, et al., “National Association of Medical
Examiners Position Paper: Recommendations for the Definition,
Investigation, Postmortem Examination, and Reporting of Deaths
in Custody,” Academic Forensic Pathology 7, no. 4 (2017): 604-618,
doi:10.23907/2017.051.

273 Id.
274 Id., 2.
275 ICE Office of Professional Responsibility, “Detainee Death Review
Report: Guerman Volkov,” September 28, 2020, 2, https://www.
documentcloud.org/documents/24656097-part-1-selected-deathreview-reports-and-related-documents-of-ice-detainees#document/
p1344/a2558283.
276 Id., 6.

297 See. e.g. Corey Joseph, Marie Garruba, and Angela Melder,
“Informing Best Practice for Conducting Morbidity and Mortality
Reviews: A Literature Review,” Aust. Health Rev. 42, no. 3 (2018):
248-257, https://doi.org/10.1071/AH16193.
298 Memorandum from Attorney General Merrick Garland to Heads
of Executive Departments and Agencies, Freedom of Information
Act Guidelines (March 5, 2022), https://www.justice.gov/d9/
pages/attachments/2022/03/15/freedom_of_information_act_
guidelines_0.pdf [https://perma.cc/8VXB-RBD6].

277 Id.

Endnotes

75

AMERICAN
76

OVERSIGHT

Deadly Failures: Preventable Deaths in U.S. Immigration Detention

PHR

Physicians for
Huma n Rights