SYSTEMIC INDIFFERENCE
Dangerous & Substandard Medical Care in US Immigration Detention

H U M A N
R I G H T S
W A T C H

Systemic Indifference
Dangerous & Substandard Medical Care in
US Immigration Detention

Copyright © 2017 Human Rights Watch
All rights reserved.
Printed in the United States of America
ISBN: 978-1-6231-34686
Cover design by Rafael Jimenez

Human Rights Watch is dedicated to protecting the human rights of people around the
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Toronto, Tunis, Washington DC, and Zurich.
For more information, please visit our website: http://www.hrw.org
Community Initiatives for Visiting Immigrants in Confinement (CIVIC) is the national
immigration detention visitation network, which is working to end U.S. immigration
detention by monitoring human rights abuses, elevating stories, building communitybased alternatives to detention, and advocating for system change. CIVIC currently has
over 1,400 volunteers in its network visiting at over 40 immigration detention facilities
throughout the United States.
For more information, please visit our website at: www.endisolation.org

MAY 2017

ISBN: 978-1-6231-34686

Systemic Indifference
Dangerous & Substandard Medical Care in
US Immigration Detention
Summary ........................................................................................................................... 1
Recommendations.............................................................................................................. 8
To the Department of Homeland Security ................................................................................. 8
To the United States Congress ................................................................................................. 9
To State and Local Governments .............................................................................................. 9

Methodology.................................................................................................................... 10
I. Background ................................................................................................................... 13
Overview of the US Immigration Detention System .................................................................. 13
Lack of Transparency .............................................................................................................. 18
Medical Care in the Immigration Detention System ................................................................ 20
Correctional Healthcare in the US ...........................................................................................24

II. Deaths in Detention, 2012 – 2015 ................................................................................. 27
Government Investigations Reveal Substandard Care .............................................................. 27
Responses from ICE and Companies Operating Private Facilities ............................................ 29
Substandard Care Contributed to Over One-Third of the Deaths ...............................................30
Misuse of Isolation and Inadequate Treatment of Individuals with Psychosocial Disabilities ... 40
Substandard Care Evident in 16 of 18 Death Investigations......................................................44
Questions about the Adequacy of the Death Investigations .................................................... 48

III. Further Evidence of Deficient Medical Care....................................................................51
Requests for Care Ignored or Delayed...................................................................................... 56
Barriers to Care...................................................................................................................... 60
Provision of Healthcare by Unqualified Personnel ................................................................... 61
Poor Quality Care by Facility Medical Providers ....................................................................... 65
Refusals of Care Not Properly Documented............................................................................. 68
Unreasonable Delays in Obtaining Off-Site Care ..................................................................... 69
Inadequate Mental Health Care and Misuse of Isolation .......................................................... 71
Inadequate Medical Recordkeeping ........................................................................................ 77

IV. Inadequate Oversight and Lack of Accountability ......................................................... 79

Failure to Take Prompt Corrective Action ................................................................................ 80
Failure to Identify Problems ....................................................................................................85
Inadequate Grievance Procedures.......................................................................................... 88
Inadequate Data Collection.................................................................................................... 90
Two Examples of Creative Medical Advocacy .......................................................................... 92

V. US and International Legal Standards ........................................................................... 97
Right to Reasonable Medical Care and Health .........................................................................97
Rights of Persons with Psychosocial Disabilities ................................................................... 101
Limits on the Use of Detention for the Control of Immigration ................................................ 101

Acknowledgments .......................................................................................................... 103
Appendix I .......................................................................................................................105

Summary
On April 6, 2015, Raul Ernesto Morales-Ramos, a 44-year-old citizen of El Salvador, died at
Palmdale Regional Medical Center in Palmdale, California, of organ failure, with signs of
widespread cancer. He had entered immigration custody four years earlier in March 2011.
He was first detained at Theo Lacy Facility, operated by the Orange County Sheriff’s
Department, and then at Adelanto Detention Facility, operated by the private company Geo
Group, both of which had contracts with US Immigration and Customs Enforcement (“ICE”)
to hold non-citizens for immigration purposes.
An ICE investigation into the death of Morales-Ramos found that the medical care he
received at both facilities failed to meet applicable standards of care in numerous ways.
Two independent medical experts, analyzing ICE’s investigation for Human Rights Watch,
agreed that he likely suffered from symptoms of cancer starting in 2013, but that the
symptoms essentially went unaddressed for two years, until a month before he died.
Throughout this time, Morales-Ramos repeatedly begged for care. In February 2015, he
submitted a grievance in which he wrote, “To who receives this. I am letting you know that I
am very sick and they don’t want to care for me. The nurse only gave me ibuprofen and that
only alleviates me for a few hours. Let me know if you can help me.” At the time of ICE’s
report on its investigation, the final cause of death had not yet been determined, but as
detailed below, the facts revealed in the ICE investigation show that systemic indifference to
his suffering and systemic failures in the healthcare system spurred his death.
***
This report examines serious lapses in health care that have led to severe suffering and at
times the preventable or premature death of individuals held in immigration detention
facilities in the United States. The lapses occur in both publicly and privately run facilities,
and have persisted despite some efforts at reform under the Obama administration,
indicating that more decisive measures are urgently needed to improve conditions. At time
of writing, it was unclear how the Trump administration would address the issue, but its
pledge to sharply increase the number of immigrants subject to detention and reports it is

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also planning to roll back protections for immigrants in detention, raise serious concerns
that the problems fueling the unnecessary suffering could grow even worse.
As with our assessment of the Morales-Ramos case above, this report is based in large
part on review by independent medical experts of ICE’s own investigations into deaths in
custody and, in a range of other cases that did not involve deaths, independent review of
detained individuals’ medical records as well as interviews with people who have been
detained, family members, and those who have worked closely with them.
***
The number of people held in immigration detention in the United States has grown
significantly over the past decade. It hit a record high under President Obama, over
400,000 people per year, and is likely to grow even higher under President Trump, who
soon after his inauguration signed executive orders calling for increased detention, both
through changes in detention policy and increased construction of or contracts for
detention centers along the US-Mexico border. Trump’s enforcement priorities, which now
encompass people who have no criminal convictions but have committed a “chargeable
offense,” are also likely to lead to a substantial increase in the number of people detained.
Medical care in the US immigration detention system, and the poor system of oversight
that allows substandard care, has long been the target of criticism by investigative
journalists and human rights advocates. This is the third report Human Rights Watch has
released on medical care in immigration detention since 2007, and one among many
reports by civil and human rights organizations on conditions in such facilities nationwide.
Gaining access to immigration detention facilities is difficult and information on
conditions there is hard to obtain. ICE took an important, if limited, step forward in June
2016 when it publicly released detailed reports of its investigations into 18 deaths in
custody (death reports) that occurred in such facilities between May 2012 and June 2015.
(A total of 21 people died in US immigration detention during that period.) To better assess
the evidence and gain insight into health care practices and responses to serious illnesses
in immigration detention facilities, Human Rights Watch and Community Initiatives for
Visiting Immigrants in Confinement (CIVIC) asked independent medical experts to analyze
the recently released reports. We also asked experts to review the medical records of a
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dozen other individuals, none of whom died in custody, recently held in 10 different
facilities across the country.
As detailed here, the experts identified repeated, clear-cut instances of subpar medical
care, including inadequate care that contributed to seven deaths in detention. They also
found numerous examples of systemic substandard and dangerous medical practices in
other cases—such as overreliance on unqualified medical staff, delays in emergency
responses, and requests for care unreasonably delayed. The cases examined represent a
small but not necessarily representative sample—though many of them point to much
larger, systemic failures of healthcare provision and government oversight that have likely
put many more thousands of other detained individuals at risk.
Manuel Cota-Domingo, detained at Eloy Detention Center, died of untreated diabetes and
pneumonia after numerous delays, including a policy that placed restrictions on which
staff could call 911, resulted in eight hours passing between the moment he started to
have trouble breathing and his arrival at an emergency room. Tiombe Carlos died by
suicide in York County Prison after being detained for two-and-a-half years. The mental
health care she received was deemed “woefully inadequate” by an independent expert.
Santiago Sierra-Sanchez, detained at Utah County Jail, died of a staph infection and
pneumonia. A correctional health expert said of the care he received, “Medical staff
essentially abandoned this patient by not properly assessing him or following up.”
Medical experts identified numerous and significant delays in the care “Jose L.” received
while detained at Adelanto Detention Facility for three years, including a failure to act quickly
to address vision problems that likely led to him becoming legally blind in his right eye.
“Carlos H.” tore his ligament while detained at Yuba County Jail in California, but it was not
properly diagnosed for three months because he kept seeing licensed vocational nurses who
did not refer him to a doctor, and then ICE further delayed his scheduled surgery repeatedly
without providing any clinical reason. “Luke R.,” detained at Orange County Jail in New York,
had been diagnosed previously with schizophrenia. The facility not only failed to provide
adequate mental health care—at one point changing a prescription for an anti-hallucinogen
to Benadryl, an anti-histamine—it also disciplined Luke and put him into solitary
confinement for actions that were clearly related to his mental health condition.

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As noted above, these are not new problems. ICE has been receiving reports of such
substandard medical care for years but has failed to take meaningful action. The Obama
administration implemented several new programs meant to improve oversight, but these
monitoring procedures remain inadequate, and the Trump administration has already
announced plans to reverse many of these reforms, including not including the most
recent detention standards for contracts with county jails. The Government Accountability
Office has faulted ICE for its failure to track and analyze its oversight mechanisms and
grievances from detained immigrants. ICE’s response to Human Rights Watch’s requests
under the Freedom of Information Act have been uninformative and in some cases appear
to indicate that the agency lacks important baseline information about the provision of
healthcare services to people in its custody.
Most disturbingly, there is significant evidence that ICE does know about many of the
deficiencies in its medical care system, but that it has failed to take swift and appropriate
action. Its own investigations into deaths in detention have shown that it lacks the
procedures necessary to take appropriate and timely corrective action. For example, Eloy
Detention Center (EDC), run by the private company CoreCivic/CCA1, has seen 15 deaths in
detention since 2003, more than any other detention facility in the US. The ICE death
report for Jose de Jesus Deniz-Sahagun, who died by suicide in 2015, flagged the lack of a
suicide prevention plan at the facility “despite Deniz Sahagun’s suicide being the third at
EDC since April 2013 and the fifth since 2005.”
Annual reports by the Office of Civil Rights and Civil Liberties at the Department of
Homeland Security make clear that recommendations stemming from allegations of
abusive conditions in detention facilities are regularly sent to ICE, but ICE often does not
respond for years or responds in ways that are deemed completely inadequate to CRCL. In
its 2015 report to Congress, CRCL states it sent ICE 49 recommendations regarding an
unnamed facility in Arizona that mentions the number of suicides in recent years, making
clear it is Eloy Detention Center. It took ICE two years to respond to these
recommendations, concurring in 19, but CRCL stated it “[d]oes not believe that ICE
responded appropriately to the other 30 recommendations.”

1 Corrections Corporation of America (CCA) changed its name to CoreCivic in October 2016. CIVIC, a co-author of this report,

has no connection or relationship with CoreCivic/CCA aside from the fact that CIVIC monitors CoreCivic/CCA facilities and
advocates on behalf of immigrants in these facilities. The company is referred to as “CoreCivic/CCA” throughout this report.

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Over two-thirds of individuals in immigration detention are held in facilities operated
by private prison companies, and these facilities in recent years have come under
particular scrutiny by advocates, investigative journalists, and government bodies. The
Bureau of Prisons (BOP), the federal prison system, also has private prisons run by the
same companies.
In August 2016, a report by the Office of Inspector General at the Department of Justice
found, “[I]n most key areas, contract prisons incurred more safety and security incidents
per capita than comparable BOP institutions and that the BOP needs to improve how it
monitors contract prisons in several areas.” Soon afterward, the Department of Justice
announced it would phase-out the use of private prisons in its own federal prison system,
“to ensure consistency in safety, security and rehabilitation services.” The US Department
of Homeland Security then announced it would review its own use of private facilities.
The report of the Homeland Security Advisory Council, summarizing the results of the
review, stated private detention would continue, but in the report’s release, the council
voted 17-5 to support one member’s dissenting recommendation of a “measured but
deliberate shift away from the private prison model.” At the same time, in October 2016,
the Department of Homeland Security decided to reopen Cibola County Correctional
Center, a private prison the Department of Justice had closed after a history of numerous
citations for deficiencies in medical care, including deaths after inadequate medical care.
President Trump’s administration has since reversed the DOJ decision to phase-out the use
of private prisons.
In researching this report, Human Rights Watch found significant problems with medical
care in facilities operated by private companies, but it also found evidence of subpar care
in county jails that contract to hold immigrants for Immigration and Customs Enforcement.
It should be noted that in many privately-operated facilities, the medical care is provided
by ICE’s Immigrant Health Service Corps (“IHSC”) and not by the private company.
Although private facility staff and policy can affect the provision of medical care in IHSCstaffed facilities, including in responses to emergencies, the lack of appropriate medical
care in public and private facilities, as well as those staffed by IHSC, underscore that
problems with medical care are systemic.

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The problem of poor medical care in immigration detention cannot be separated from the
enormous and unwieldy nature of the system itself. At present, the US immigration
detention system holds an average of 41,000 people on any given day. It holds asylum
seekers and long-term residents of the US, including those with lawful permanent resident
status. It holds men, women, and children, sometimes for days, and sometimes for months
or years. Most are detained without an individualized hearing as to whether their detention
is truly necessary.
The United States could meet its legitimate goals of ensuring appearance at removal
hearings, protecting public safety, and effectuating removal by releasing many of the
people who are currently detained and supervising them through community-based
programs that provide case support. Several studies have shown such programs would be
considerably less costly. A smaller detention system would also be more in keeping with
international human rights principles. The United Nations Working Group on Arbitrary
Detention has stated: “If there has to be administrative detention, the principle of
proportionality requires it to be a last resort.”
The Trump administration, however, has signaled it will rapidly expand the use of
detention. The challenges of adequately monitoring and holding accountable a diffuse and
disparate system with numerous operators, including those with a strong incentive to
reduce costs, will only be exacerbated in a system that rapidly expands.
The executive branch does not have unfettered power to expand the system: Congress
must allocate the funding and thus is in a position to push back and insist on reforms,
including increased use of alternatives to detention and measures to ensure effective
oversight and adequate provision of health care for those who are detained.
Because ICE relies on contracts with many local governments for detention space, states
also have a role to play in improving medical care and detention conditions more
generally. In California, which detains more immigrants than any state except Texas, a bill
is pending that could improve conditions. At the time of writing, Senate Bill 29, Dignity Not
Detention, would end localities’ contracts with private companies to hold immigrants in
detention; require localities that hold immigrants in detention for the federal government
to adhere to the most recent Performance-Based National Detention Standards; and make
these standards enforceable by the California Attorney General and local district and city
SYSTEMIC INDIFFERENCE

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attorneys. An earlier version of this bill passed the California legislature in 2016 but was
vetoed by Governor Jerry Brown, who cited the then-pending review of private facilities by
the US Department of Homeland Security.
Under the US Constitution and international law, anyone who is detained or incarcerated is
entitled to adequate medical care. The Trump administration is obligated to ensure that all
people in detention are treated humanely and with dignity, including through provision of
appropriate medical care, and to provide sufficient funding to meet these obligations.
Congress and state governments should work to limit the scope of detention to what is
truly necessary and ensure that those who are detained are treated humanely.

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Recommendations
To the Department of Homeland Security
•

Reserve detention for individuals who pose a danger or flight risk that cannot
reasonably be addressed with detention, and increase the use of communitybased alternatives to detention for those who are subject to statutory
mandatory custody.

•

Reform the monitoring system to task a single entity (created for the purpose or
existing) with both the responsibility and authority to review and approve
corrective action plans, monitor compliance, and impose sanctions for noncompliance, including closure of detention centers.

•

Reform the contracting process to ensure meaningful inspections by medical
experts before contracts are entered into or renewed, consistent application of the
most recent performance-based national detention standards, and clear terms
outlining penalties, including cancellation of the contracts, for failure to perform.

•

Do not detain people in facilities in which repeat, egregious violations of standards
for appropriate medical and mental health care have been documented.

•

Increase transparency of detention operations with regularly published statistics
on the number of people detained, incidents of violence, and other measures of
detention conditions, and publicly and regularly release investigations into deaths
in detention, inspections, and contracts. This data should be disaggregated by
gender, disability, and age.

•

End isolation (also called solitary confinement) for persons with psychosocial2
disabilities in immigration detention centers.

•

Refrain from detaining families and asylum seekers.

•

Refrain from detaining individuals with serious medical and mental health needs
that cannot be fully and adequately addressed in detention, and wherever possible
release under humanitarian parole individuals with serious medical and mental
health needs.

2 Psychosocial disability: the preferred term to describe persons with mental health conditions such as depression, bipolar,

schizophrenia, and catatonia. This term expresses the interaction between psychological differences and social or cultural
limits for behavior, as well as the stigma that the society attaches to persons with mental impairments.

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•

Expand the use of community-based alternatives to detention.

To the United States Congress
•

Deny additional funds for increased immigration detention; or at a minimum:
o

•

Ensure increased oversight accompanies any increased funds for detention.

Eliminate the “detention bed mandate” that requires the federal government to
maintain 34,000 detention beds at all times.

•

End mandatory detention and ensure all non-citizens are eligible for an
individualized bond hearing.

•

Require increased transparency regarding the immigration detention system,
including eliminating exemptions under the Freedom of Information Act that have
been applied to private companies operating detention centers.

•

Ban all use of isolation for people with psychosocial disabilities.

•

Appoint an Independent Medical Oversight Board to be comprised of medical
doctors and advocates at the national level and encourage ICE and its
contractors to begin implementing local medical oversight boards at individual
detention facilities.

To State and Local Governments
•

Pass legislation or enact policy reforms banning all use of isolation for people with
psychosocial disabilities in local jails.

•

Pass legislation or enact policy reforms addressing substandard medical care in
local jails.

•

Pass legislation to codify ICE’s most recent Performance Based National Detention
Standards and allow the state attorney general or any district attorney, city
attorney, or private individual to bring a civil action against an immigration
detention facility, an agent thereof, or a person acting on its behalf who violates a
detained person’s rights.

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Methodology
This report is a collaboration between Human Rights Watch and Community Initiatives for
Visiting Immigrants in Confinement (CIVIC). Human Right Watch conducted the interviews
and wrote the report, with substantial input from CIVIC during the initial stages and
through the investigation process. CIVIC consulted on the design, helped identify
individuals to interview, and reviewed and provided feedback on the final report and
policy recommendations.
This report is based on US government records summarizing investigations into deaths of
people in immigration detention from 2012 to 2015, interviews conducted between October
2015 and September 2016, analyses of independent medical experts of the detainee death
investigation records and other detained individuals’ medical records, and information
obtained from Freedom of Information Act (FOIA) requests. It also relies on reports by US
government agencies, nongovernmental organizations, and other publicly available sources.
The records summarizing investigations into 18 deaths in detention from 2012 to 2015 were
released by US Immigration and Customs Enforcement on its FOIA Library website in June
2016. Human Rights Watch provided these records to two independent medical experts who
reviewed and shared their conclusions with us separately. A press release Human Rights
Watch released in July 2016 summarized the findings of the experts’ analyses.3
The 18 cases relate to a tiny fraction of the hundreds of thousands of people held in
detention during the period in question, and do not speak directly to conditions in most of
200-plus different facilities ICE uses to house immigrants. However, the reviews raise
serious concerns about ICE’s ability to detect, respond appropriately to and successfully
correct serious lapses in medical care that arise in any of these facilities—even in cases in
which the agency has conducted detailed investigations into deaths in detention.
In addition, Human Rights Watch conducted more than 90 interviews with non-citizens
who were or had been in immigration detention at some point in the last 5 years; family

3 “US: Deaths in Detention: Newly Released Records Suggest Dangerous Lapses in Medical Care,” Human Rights Watch news

release, July 7, 2016, https://www.hrw.org/news/2016/07/07/us-deaths-immigration-detention.

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members; attorneys representing immigrants in detention; immigration advocates; and
correctional health experts. Many of the individuals we interviewed were identified by
volunteers with visitation programs in the CIVIC national network, and by CIVIC staff.
Others were referred to Human Rights Watch by attorneys, advocacy organizations, or
other individuals in detention, or identified by Human Rights Watch during facility tours.
The cases reviewed for this report involve individuals who have been detained in a total of
27 different facilities in 15 different states. Human Rights Watch interviewed individuals
who, at the time of the interviews, were detained at seven facilities across the country—
Adelanto, Eloy, Etowah, Hudson, Imperial, LaSalle, Santa Ana, and Theo Lacy.
Human Rights Watch provided 12 sets of medical records from 10 different facilities,
representing a diversity of facilities across the country to two independent medical experts
who reviewed and shared their conclusions with Human Rights Watch separately.
Individual medical records were obtained after the individuals consented to Human Rights
Watch requesting their records directly from the facilities, ICE, or their attorneys, with the
understanding that they might be provided to an independent medical expert for analysis
of the medical care they received.
Although the medical records speak directly to the experiences of only 12 detained
individuals, they include evidence of inadequate staffing and poor operational systems
that are unlikely to have affected only these individuals. The problems documented in
these records echo what dozens of individuals, families, and attorneys told Human Rights
Watch and CIVIC regarding immigrants’ experiences with medical care in these and other
facilities. They also echo many of the conclusions independent medical experts reached
after examining the death reviews (set forth earlier in this report), and are similar to
problems identified by other advocates.
Human Rights Watch and CIVIC also participated in facility tours and group discussions
with dozens of individuals detained in the Adelanto, Eloy, Etowah, and Hudson facilities,
which were requested under the ICE policy for stakeholder tours.4 These group discussions

4 In September 2011, ICE announced in response to requests from advocates a policy for organizations and other

stakeholders to request tours of immigration detention facilities, including meetings with individuals detained in those
facilities. US Immigration and Customs Enforcement, Enforcement and Removal Operations, Office of State, Local, and Tribal
Coordination, “Stakeholder Procedures for Requesting a Detention Facility tour and/or Visitation,”

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are not included in the overall count of interviews conducted for this report, but the
content of these discussions informed our understanding of detention conditions,
including medical care.
Interviews were conducted in person or by telephone, and in English, Spanish, and
Portuguese by Human Rights Watch staff fluent in these languages. All participants were
informed of the purpose of the interview and consented orally. Where medical records
were obtained from the detention facilities, consent was provided orally and through
signed waivers compliant with Health Insurance Portability and Accountability Act (HIPAA)
and ICE requirements. No interviewee received compensation for providing information.
Where appropriate, Human Rights Watch provided interviewees with contact information
for individuals and organizations providing legal, counseling, or other supportive services
at the conclusion of the interview. We have used pseudonyms to protect the privacy of
nearly all individuals who were detained at their request and, where we have done so, we
have so indicated in the relevant citations.
All of the medical experts who provided their opinions on the death investigations and
medical records did so in their personal capacities. The opinions do not represent the
official views of their employers or affiliated institutions.
Human Rights Watch sent written questions and requested comments on its findings from
private prison company executives and ICE officials. We have included their responses in
the report. The companies’ full letters are available on the Human Rights Watch website.

https://www.ice.gov/doclib/ero-outreach/pdf/access-directive-stakeholder.pdf (accessed April 18, 2017). See also,
Women’s Refugee Commission, “Immigration and Customs Enforcement Improves Access to Detention Centers,”
https://www.womensrefugeecommission.org/immigration-and-customs-enforcement-improves-access-to-detention-centers
(accessed April 18, 2017). On March 15, 2017, CIVIC filed a federal civil rights complaint detailing detention access denials
and restrictions at 14 immigration detention facilities across the country. Over 440 organizations, including Human Rights
Watch, signed on to a letter calling for continued access to immigration detention facilities. Christina Fialho, “Trump
Administration Restricts Access to Immigration Detention Facilities,” Huffington Post, March 15, 2017,
http://www.huffingtonpost.com/entry/trump-administration-restricts-access-toimmigration_us_58c99840e4b0537abd956d68 (accessed April 18, 2017).

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I. Background
Overview of the US Immigration Detention System
The US immigration detention system is the largest national immigration detention system
in the world, holding more than 400,000 people each year, at a cost of $2 billion per year.5
On November 16, 2016, then-Secretary of Homeland Security Jeh Johnson stated the US
government was holding more than 41,000 people, more than it had ever held before on
any single day.6 The Wall Street Journal also reported the number was expected to rise to
45,000 soon.7
Among the tens of thousands of people detained each day are asylum-seekers who have
been found to have a credible claim to protection; women and children fleeing violence
and persecution in Central America; and long-term residents, both with and without legal
status, many of whom have strong claims to remaining in the US.8
Many are held for months or even years while their claims are adjudicated.9 Many never
receive a bond hearing, which would provide them with a chance at release from detention
while their immigration cases are pending with the courts. Some are deemed ineligible for
bond because they requested asylum at a port of entry.10 Others are categorically deemed
ineligible for bond for a wide range of convictions—not only for serious crimes but also for
5 US Department of Homeland Security, Yearbook of Immigration Statistics, 2001-2013, https://www.dhs.gov/yearbook-

immigration-statistics (accessed September 6, 2016); Franco Ordonez, “Trump’s tough stand on immigrant detention will
cost taxpayers big,” McClatchy, February 13, 2017, http://www.mcclatchydc.com/news/politics-government/whitehouse/article132077414.html (accessed February 16, 2017).
6 US Department of Homeland Security, “Statement by Secretary Johnson on Southwest Border Security,” November 10,
2016, https://www.dhs.gov/news/2016/11/10/statement-secretary-johnson-southwest-border-security (accessed February
16, 2017).
7 Devlin Barrett, “Record Immigrant Numbers Force Homeland Security to Search for New Jail Space,” The Wall Street Journal,
October 21, 2016, https://www.wsj.com/articles/record-immigrant-numbers-force-homeland-security-to-search-for-new-jailspace-1477042202 (accessed March 27, 2017).
8 American Civil Liberties Union, “Shutting Down the Profiteers: Why and How the Department of Homeland Security Should
Stop Using Private Prisons,” September 2016, https://www.aclu.org/report/shutting-down-profiteers-why-and-howdepartment-homeland-security-should-stop-using-private (accessed January 4, 2017).
9 American Civil Liberties Union, “Prolonged Detention Fact Sheet,” https://www.aclu.org/sites/default/files/assets/
prolonged_detention_fact_sheet.pdf (accessed January 4, 2017); Transactional Records Access Clearinghouse, “Legal
Noncitizens Receive Longest ICE Detention,” June 3, 2013, http://trac.syr.edu/immigration/reports/321/ (accessed January
4, 2017).
10 US immigration law requires arriving aliens who establish a credible fear of persecution or torture to be detained.
Immigration & Nationality Act, Section 235(b)(1)(B)(ii). However, such individuals may be paroled, i.e., released, on a caseby-case basis for “urgent humanitarian reasons” or “significant public benefit,” provided they do not present a security risk
nor a risk of absconding. 8 C.F.R. Section 212.5(b).

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minor offenses including simple possession of marijuana. A person with a 20-year-old
criminal conviction and a long history of rehabilitation is viewed the same way as a person
convicted yesterday.11
The US immigration detention system was not always this large. In the past 15 years, the
detention population has more than doubled. In 2001, the US detained approximately
209,000 people. In 2013, the most recent year for which the Department of Homeland
Security has published official statistics, the US detained 440,5570.12 The recent growth of
the US immigration detention system has been fueled, in part, by Congressional efforts since
2004 to fund an increasing number of beds for immigrants in detention. With the 2010 DHS
Appropriations Act, Congress began to require the agency to maintain a “detention bed
quota,” currently set arbitrarily at 34,000 detention beds, regardless of enforcement needs.13
Private prison companies, through millions of dollars spent on lobbying, have sought to
influence debate on immigration reform and immigration detention.14 Between 2004 and
2014, the two largest for-profit companies, CoreCivic/CCA and Geo Group spent $18 million
and $4 million on lobbying, respectively.15 CoreCivic/CCA spent more than $8.7 million and
the Geo Group spent $1.3 million to lobby Congress solely on Homeland Security
appropriations between 2006 and 2015.16 CoreCivic/CCA and Geo Group have doubled
their revenues since 2005.17 During the 2016 presidential campaign, President Trump

11 Human Rights Watch, Forced Apart: Families Separated and Immigrants Harmed by US Deportation Policy, July 16, 2007,
https://www.hrw.org/report/2007/07/16/forced-apart/families-separated-and-immigrants-harmed-united-statesdeportation; Human Rights Watch, A Price Too High: US Families Torn Apart by Drug Deportations, June 16, 2015,
https://www.hrw.org/report/2015/06/16/price-too-high/us-families-torn-apart-deportations-drug-offenses.
12 US Department of Homeland Security, Yearbook of Immigration Statistics 2001, https://www.dhs.gov/immigrationstatistics/yearbook/2001; “Immigration Enforcement Actions: 2013,” https://www.dhs.gov/sites/default/files/
publications/ois_enforcement_ar_2013.pdf (accessed March 29, 2017).
13 Department of Homeland Security Appropriations Act, 2010, Public Law 111-83, October 28, 2009,
https://www.gpo.gov/fdsys/pkg/PLAW-111publ83/pdf/PLAW-111publ83.pdf (accessed March 27, 2017); National Immigrant
Justice Center, “Immigration Detention Bed Quota Timeline,” January 13, 2017, http://www.immigrantjustice.org/
immigration-detention-bed-quota-timeline (accessed March 27, 2017).
14 Sharita Gruberg, Center for American Progress, “How For-Profit Companies are Driving Immigration Detention Policies,”
December 18, 2015, https://www.americanprogress.org/issues/immigration/reports/2015/12/18/127769/how-for-profitcompanies-are-driving-immigration-detention-policies/ (accessed January 4, 2017).
15 Ibid.
16 Ibid.
17 Ibid.

SYSTEMIC INDIFFERENCE

14

spoke approvingly of private prison companies, and in the months after his election, these
companies saw their stock prices soar.18
Much of the recent spike in detention numbers is due to Obama administration
enforcement programs and detention policies. The Obama administration deported a
record number of people, more than 2.5 million over eight years.19
The Obama administration also changed its policy on release of asylum-seekers who have
been found to have credible fear of persecution in their home countries and greatly
expanded the detention of women and children, many of whom are also asylum-seekers.
In 2009, the administration announced a revised parole policy for asylum-seekers who
pass the first stage of the asylum application process, which resulted in increased
numbers of people being released from detention while their cases were pending.20 But at
the end of the Obama administration, this policy was no longer being consistently applied
throughout the country. In 2010, ICE detained 49 percent of people with positive credible
fear determinations; in 2014, ICE detained 84 percent of such people.21
In 2009, the administration stopped detaining families at Hutto Family Detention Facility in
Texas, effectively limiting family detention to a handful of women and children held at
Berks Family Residential Center in Pennsylvania.22 But after an increase in migrants fleeing
violence and persecution in Guatemala, Honduras, and El Salvador, the administration
reversed course and greatly expanded family detention capacity, from less than 100 beds
to almost 3,000 in 2014 and 2015. In June 2015, DHS announced reforms to discontinue
long-term detention of families who have passed the first stage of applying for asylum, but
some families have continued to be detained for prolonged periods of time.23

18 Jeff Somer, “Trump’s Win Gives Stocks in Private Prison Companies a Reprieve,” The New York Times, December 3, 2016,
https://www.nytimes.com/2016/12/03/your-money/trumps-win-gives-stocks-in-private-prison-companies-areprieve.html?_r=0 (accessed February 14, 2016).
19 US Department of Homeland Security, “Yearbook of Immigration Statistics, 2008-2015,” https://www.dhs.gov/yearbookimmigration-statistics (accessed January 4, 2017).
20 US Immigration and Customs Enforcement, “Revised Parole Policy for Arriving Aliens with Credible Fear Claims,” December
16, 2009, https://www.ice.gov/factsheets/credible-fear (accessed September 8, 2016).
21 Human Rights First, “Lifeline on Lockdown: Increased US Detention of Asylum Seekers,” July 2016,
http://www.humanrightsfirst.org/sites/default/files/Lifeline-on-Lockdown_0.pdf (accessed September 8, 2016).
22 US Immigration and Customs Enforcement, “2009 Immigration Detention Reforms,” December 12, 2011,
https://www.ice.gov/factsheets/2009detention-reform (accessed January 4, 2017).
23 “US: First Step to End Family Immigration Detention,” Human Rights Watch news release, June 24, 2015,
https://www.hrw.org/news/2015/06/24/us-first-step-end-family-immigration-detention; Michael Matza, “Immigrant
mothers detained at Berks center go on hunger strike,” The Philadelphia Inquirer, August 12, 2016,

15

MAY 2017

Department of Homeland Security Secretary John Kelly’s enforcement memorandum on
border security states that migrants who are apprehended will be detained while their
cases are pending. While it states the 2009 parole directive has not been revoked, it
makes clear grants of parole will become less frequent moving forward.24
In order to hold so many people and to sustain the “detention bed quota,” the DHS
maintains a sprawling network of county jails, privately run facilities, and DHS-run
facilities, including facilities for individuals in the custody of US Immigration and Customs
Enforcement (ICE) and US Customs and Border Protection (CBP).25 These facilities vary
widely in the number of people they hold and the way in which they are run. Some are large
facilities holding more than 1,000 people a day; some are county jails that hold a couple of
people for ICE each year. Some are only allowed to hold people for less than 72 hours;
others are authorized to hold people for more prolonged periods.26 According to ICE, about
70 percent of people in immigration detention are held in privately-run facilities.27
The decentralized, disparate nature of ICE’s detention system is apparent in the four
different versions of detention standards that apply to these facilities and in ICE’s
management of the system.
The over-72-hour facilities are subject to one of four different sets of detention standards:
the 2000 National Detention Standards (NDS), the 2008 Performance-Based National

http://www.philly.com/philly/news/20160812_Immigrant_mothers_detained_at_Berks_center_go_on_hunger_strike.html
(accessed January 4, 2017).
24 US Department of Homeland Security, Memorandum from Secretary John Kelly, February 20, 2017,
https://www.dhs.gov/sites/default/files/publications/17_0220_S1_Implementing-the-Presidents-Border-SecurityImmigration-Enforcement-Improvement-Policies.pdf (accessed March 3, 2017).
25 This report focuses on ICE facilities, although abuses have been documented in CBP facilities as well. See Fernanda
Santos, “Photos Offer Glimpse Inside Arizona Border Detention Centers,” New York Times, August 18, 2016,
http://www.nytimes.com/2016/08/19/us/photos-show-conditions-in-arizona-border-detention-centers.html (accessed
January 4, 2017).
26 Border Patrol holding cells are intended to hold people for less than 12 hours but Customs and Border Protection data
indicate people are regularly held for over 24 hours, and sometimes longer. These facilities have been the subject of a
federal lawsuit alleging the conditions in these cells are inhumane. American Immigration Council, “Way Too Long:
Prolonged Detention in Border Patrol Holding Cells, Government Records Show,” June 10, 2015,
https://www.americanimmigrationcouncil.org/research/way-too-long-prolonged-detention-border-patrol-holding-cellsgovernment-records-show (accessed March 24, 2017); “Images show miserable conditions at Border Patrol holding cells in
Arizona,” Fox News, August 18, 2016, http://www.foxnews.com/world/2016/08/18/images-show-miserable-conditions-atborder-patrol-holding-cells-in-arizona.html (accessed March 24, 2017).
27 Steven Nelson, “Private Prison Companies, Punched in the Gut, Will Keep Most Federal business,” US News & World
Report, August 18, 2016, https://www.usnews.com/news/articles/2016-08-18/private-prison-companies-punched-in-thegut-will-keep-most-federal-business (accessed March 23, 2017).

SYSTEMIC INDIFFERENCE

16

Detention Standards 2008 (2008 PBNDS), the 2011 Performance-Based National Detention
Standards (2011 PBNDS), and the 2007 Family Residential Standards, which apply only to
family detention centers.28 According to the GAO, in 2015, 62 percent of the average daily
population was in a facility required to adhere to the 2011 PBNDS. Almost 18 percent was still
in facilities operating under the NDS, and almost 14 percent was in facilities operating under
the 2008 PBNDS.29 Under-72-hour facilities are only subject to self-reporting requirements.30
Details on how these detention standards should apply are set out in the contracts for
each facility, and the terms of the contracts can vary widely. In a report analyzing more
than 90 contracts obtained through a FOIA lawsuit, the National Immigrant Justice Center
concluded, “The immigration detention contracting process … suffer[s] from a significant
lack of uniformity in how contracts are created, executed, and maintained.”31 NIJC found 45
of the contracts it received were indefinite and operating under outdated detention
standards. Since they have no expiration date, there is no set calendar for negotiating
terms and updating the detention standards that apply to a facility. The Trump
administration has indicated new jail contracts will no longer include any version of the
national detention standards and will instead, be evaluated based on an 18-page checklist
used by the US Marshals Service for federal criminal defendants.32
The use of privately-run facilities by federal agencies has been highly controversial. In
August 2016, the US Department of Justice announced it would phase out the use of
private prisons by the Bureau of Prisons (which incarcerates persons convicted of federal
crimes).33 Two weeks later, DHS announced it would review the use of private immigration

28 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management and
Oversight of Detainee Medical Care,” February 2016, http://gao.gov/products/GAO-16-231 (accessed September 8, 2016).
29 Ibid.
30 National Immigrant Justice Center, “Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center
Abuse,” http://immigrantjustice.org/lives-peril-how-ineffective-inspections-make-ice-complicit-detention-center-abuse-0
(accessed January 5, 2017).
31 National Immigrant Justice Center, “NIJC Freedom of Information Act Litigation Reveals Systemic Lack of Accountability in
Immigration Detention Contracting,” August 2015, http://immigrantjustice.org/immigration-detention-transparency-andhuman-rights-project-august-2015-report (accessed September 9, 2016).
32 Caitlin Dickerson, “Trump Plan Would Curtail Protections for Detained Immigrants,” New York Times, April 13, 2017,
https://www.nytimes.com/2017/04/13/us/detained-immigrants-may-face-harsher-conditions-under-trump.html (accessed
April 20, 2017).
33 US Department of Justice, “Phasing Out Our Use of Private Prisons,” August 18, 2016,
https://www.justice.gov/opa/blog/phasing-out-our-use-private-prisons (accessed September 6, 2016).

17

MAY 2017

detention centers (which detain persons accused of violating immigration laws).34 On
November 30, 2016, the Homeland Security Advisory Council released the results of its
review in an unusually contentious public meeting. Its official report concluded that the
agency would continue using privately run facilities because of “[f]iscal considerations,
combined with the need for realistic capacity to handle sudden increase in detention.”35
However, during the meeting, the council voted 17-5 to recommend “a measured but
deliberate shift away from the private prison model.”36 The council’s report also
recommended “improved and expanded ICE oversight,” including “reduce[d] reliance on
detention in county jails.”37
Since then, the Trump administration has reversed the Department of Justice decision to
phase-out the use of private prisons.38

Lack of Transparency
The ICE detention system is shrouded in secrecy, and the lack of transparency is
exacerbated by the system’s reliance on private detention centers, which are not subject to
public records acts in the same way that publicly run facilities are subject to them.39
There is no publicly available list of all of ICE’s detention facilities. ICE publishes a list of
112 facilities on its website but according to a 2016 report by the Government
Accountability Office, 165 facilities are permitted to hold immigrants for more than 72

34 “Statement by Secretary Jeh C. Johnson on Establishing a Review of Privatized Immigration Detention,” US Department of
Homeland Security press release, August 29, 2016, https://www.dhs.gov/news/2016/08/29/statement-secretary-jeh-cjohnson-establishing-review-privatized-immigration (accessed September 6, 2016).
35 Homeland Security Advisory Council, “Report of the Subcommittee on Privatized Immigration Detention Facilities,”
December 1, 2016, http://www.trbas.com/media/media/acrobat/2016-12/70003382918880-01141658.pdf (accessed March
3, 2017).
36 Kevin Johnson, “DHS panel raises concerns about privately-run detention centers,” USA Today, December 2, 2016,
http://www.usatoday.com/story/news/politics/2016/12/01/dhs-panel-raises-concerns-privately-run-detentioncenters/94727944/ (accessed December 6, 2016).
37 Homeland Security Advisory Council, “Report of the Subcommittee on Privatized Immigration Detention Facilities,
http://www.trbas.com/media/media/acrobat/2016-12/70003382918880-01141658.pdf.
38 Matt Zapotosky, “Justice Department will again use private prisons,” Washington Post, February 23, 2017,
https://www.washingtonpost.com/world/national-security/justice-department-will-again-use-privateprisons/2017/02/23/da395d02-fa0e-11e6-be05-1a3817ac21a5_story.html?utm_term=.2bb48dff1606 (accessed April 20, 2017).
39 Joe Watson, “Advocates Want Private Prisons Subject to Open Records Laws,” Prison Legal News, August 2, 2016,
https://www.prisonlegalnews.org/news/2016/aug/2/advocates-want-private-prisons-subject-open-records-laws/ (accessed
November 17, 2016).

SYSTEMIC INDIFFERENCE

18

hours.40 A database Human Rights Watch received in response to a request under the
Freedom of Information Act for information on individuals transferred between detention
facilities between 2011 and 2014 listed 867 facilities.41 CIVIC maintains a map of detention
facilities based on its own research.42 ICE does not publish a daily population count and
the most recent government-released data on detention numbers is from fiscal year 2013.
There is no published information on who is being detained, how long they are detained,
staffing ratios, incidents of violence, or the number placed in isolation. Even when
required by statute to publish the numbers of asylum-seekers who are detained under the
Haitian Refugee Immigration Fairness Act, ICE has failed to provide timely reports. The last
report was issued in August 2012, for fiscal years 2009 and 2010.43
Private companies have consistently argued they are not subject to open records laws,
such as the federal Freedom of Information Act. In one FOIA request made by nonprofit
advocacy organizations, ICE withheld staffing plans and per-diem rates for private
facilities, citing exemptions for commercial interests.44
The Bureau of Prisons, in comparison, provides a list of all federal prisons, and categorizes
them by type, including whether they are privately run, on its website.45 It provides a
weekly population count, including how many inmates are in privately run facilities.46 It
also provides demographic information on its inmate population, including age, ethnicity,

40 US Immigration and Customs Enforcement, Detention Facility Locator, https://www.ice.gov/detention-facilities (accessed
April 25, 2017; US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen
Management and Oversight of Detainee Medical Care,” http://gao.gov/products/GAO-16-231.
41 US Immigration and Customs Enforcement response to request by Human Rights Watch under the Freedom of Information Act.
42 Community Initiatives for Visiting Immigrants in Confinement, “Immigration Detention Map & Statistics,”
http://www.endisolation.org/resources/immigration-detention/ (accessed January 4, 2017).
43 US Immigration and Customs Enforcement, “Detained Asylum Seekers: Fiscal Year 2009 and 2010 Report to Congress,”
August 20, 2012, https://www.ice.gov/doclib/foia/reports/detained-asylum-seekers2009-2010.pdf (accessed January 4, 2017).
44 Detention Watch Network v. US Immigration and Customs Enforcement, Case No. 1:13-cv-00583 (Southern District of New
York), Opinion and Order, July 16, 2016, http://ccrjustice.org/sites/default/files/attach/2016/07/
2016.7.14.DWN_.v.ICE_.SJ_.opinion.pdf (accessed April 21, 2017). In July 2016, the district court ruled that per diem
payments and staffing plans are not exempt under FOIA. Geo and CoreCivic/CCA filed a motion to intervene, granted in
September 2016, and the companies are now appealing the lower court’s ruling to the US Court of Appeals for the Second
Circuit. Detention Watch Network, “A Toxic Relationship: Private Prisons and US Immigration Detention,” December 2016,
http://www.detentionwatchnetwork.org/sites/default/files/reports/A%20Toxic%20Relationship_DWN.pdf (accessed
December 5, 2016).
45 US Department of Justice, Bureau of Prisons, “Statistics,” https://www.bop.gov/about/statistics/ and “Facilities,”
https://www.bop.gov/about/facilities/ (accessed January 4, 2017); US Department of Homeland Security, “Yearbook of
Immigration Statistics,” https://www.dhs.gov/yearbook-immigration-statistics (accessed January 4, 2017).
46 Bureau of Prisons, “Population Statistics,” last updated December 29, 2016, https://www.bop.gov/about/statistics/
population_statistics.jsp (accessed January 4, 2017).

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type of offense, incidence of assault on inmates, the number placed in restrictive housing,
and staffing ratios.47

Medical Care in the Immigration Detention System
In the late 2000s, in the last years of the Bush administration and the first years of the
Obama administration, a number of reports by Human Rights Watch and other
organizations, investigations by the Washington Post and the New York Times, and
government reports uncovered evidence of severe medical neglect in immigration
detention facilities, including preventable deaths.48 These reports led to Congressional
investigations and hearings, and the Obama administration in 2011 announced several
reforms intended to “overhaul” the immigration detention system and move away from a
“decentralized, jail-oriented approach” to one designed for civil detention.49

47 Bureau of Prisons, “Inmate Statistics,” November 26, 2016, https://www.bop.gov/about/statistics/statistics

_inmate_age.jsp (accessed January 4, 2017).
48

Human Rights Watch, Detained and Dismissed: Women’s Struggles to Obtain Health Care in United States Immigration
Detention, March 17, 2009, https://www.hrw.org/report/2009/03/17/detained-and-dismissed/womens-struggles-obtain-

health-care-united-states; Americans for Immigrant Justice (formerly Florida Immigrant Advocacy Center), “Dying for Decent
Care: Bad Medicine in Immigration Custody,” February 2009, http://www.aijustice.org/dying_for_decent_care_bad
_medicine_in_immigration_custody (accessed January 5, 2017); Women’s Refugee Commission, “Migrant Women and
Children at Risk: In Custody in Arizona,” October 2010, http://www.womensrefugeecommission.org/resources/
doc_download/656-migrant-women-andchildren-at-risk-in-custody-in-arizona (accessed January 5, 2017); Nina Bernstein,
“Few Details on Immigrants Who Died in Custody,” New York Times, May 5, 2008, http://www.nytimes.com/2008/
05/05/nyregion/05detain.html?action=click&contentCollection=N.Y.%20%2F%20Region&module=RelatedCoverage&region
=Marginalia&pgtype=article (accessed January 5, 2017); Dana Priest and Amy Goldstein, “System of Neglect: As Tighter
Immigration Policies Strain Federal Agencies, the Detainees in Their Care Often Pay a Heavy Cost,” Washington Post, May 11,
2008, http://www.washingtonpost.com/wp-srv/nation/specials/immigration/cwc_d1p1.html (accessed January 5, 2017); US
Department of Homeland Security, Office of Inspector General, “Treatment of Immigrant Detainees Housed at Immigration
and Customs Enforcement Facilities,” December 2006, https://www.oig.dhs.gov/assets/Mgmt/OIG_07-01_Dec06.pdf
(accessed January 5, 2017).
49 US Immigration and Customs Enforcement, “2009 Immigration Detention Reforms,” https://www.ice.gov/factsheets/
2009detention-reform.

SYSTEMIC INDIFFERENCE

20

Previous HRW Reports on Medical Care in Immigration Detention
This report follows on previous work by Human Rights Watch on health care in immigration detention.
In 2007, Human Rights Watch released Chronic Indifference: HIV/AIDS Services for Immigrants Detained by

the United States, documenting the experiences of HIV-positive people in immigration custody whose HIV
treatment was denied, delayed, or interrupted, resulting in serious risk and often damage to their health.50
The report contributed significantly to revision of the HIV treatment guidelines and to ensuring more
comprehensive investigation of AIDS-related deaths.
In 2009, Human Rights Watch issued Detained and Dismissed: Women’s Struggles to Obtain Health Care in

United States Immigration Detention, documenting dozens of cases in which detention center medical staff
caused suffering and jeopardized women’s health by either failing to respond at all to the medical
problems of women in detention or responding only after considerable delays.51 At the time, the only
mention of women’s health care in the standards governing immigration detention was a passing reference
to pregnancy testing and prenatal care. The 2011 Performance-Based National Detention Standards
included for the first time a new standard addressing women’s medical care.52
In 2010, in the report Deportation by Default: Mental Disability, Unfair Hearings, and Indefinite Detention in

the US Immigration System, Human Rights Watch documented how immigrants with mental health
conditions are unjustifiably detained for years, during which time they often require emergency medical
care, and recommended exercise of prosecutorial discretion in cases involving such persons and the
development of alternatives to detention, including supervised release to families and placement in
community-based treatment programs.
In 2016, Human Rights Watch released the report, “Do You See How Much I’m Suffering Here?: Abuse

against Transgender Women in US Immigration Detention, documenting among other abuses, substandard
medical and mental health care and misuse of solitary confinement.53
Although the above reports helped prompt some reforms, substandard medical care in immigration
detention is a pervasive and continuing problem.

50 Human Rights Watch, Chronic Indifference: HIV/AIDS Services for Immigrants Detained by the United States, December 5,
2007, https://www.hrw.org/report/2007/12/05/chronic-indifference/hiv/aids-services-immigrants-detained-united-states.
51 Human Rights Watch, Detained and Dismissed, https://www.hrw.org/report/2009/03/17/detained-anddismissed/womens-struggles-obtain-health-care-united-states.
52 US Immigration and Customs Enforcement, “2011 Operations Manual ICE Performance-Based National Detention
Standards,” https://www.ice.gov/detention-standards/2011 (accessed December 16, 2016).
53 Human Rights Watch, “Do You See How Much I’m Suffering Here?: Abuse against Transgender Women in US Immigration
Detention,” March 23, 2016, https://www.hrw.org/report/2016/03/23/do-you-see-how-much-im-suffering-here/abuseagainst-transgender-women-us.

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Medical care in the detention system, today, however, remains jail-like, decentralized, and
dysfunctional. According to a 2016 report by the Government Accountability Office
(“GAO”), ICE lacks the tools to track and understand its own system of medical care, from
the actual cost of care to trends in off-site medical care.54
Medical care providers vary from facility to facility. The Immigrant Health Service Corps
(“IHSC”), comprised of US Public Health Service officers, federal civil servants, and
contract health professionals, provides medical care in 19 facilities. They also manage
some aspects of care at the non-IHSC staffed facilities authorized to hold people for more
than 72 hours.55 They adjudicate requests for off-site care, address complaints regarding
medical care received by other DHS components, such as the Office of Civil Rights and Civil
Liberties, and conduct investigations, including into detainee deaths.56 The 19 IHSCstaffed facilities include ICE-run detention centers, some private detention centers, some
facilities run by local governments but housing only people held for immigration purposes
(i.e., not county jails), and some family detention centers.57 These facilities hold about 48
percent of the total detained population.58 In the remaining facilities, medical care is
provided by the private company or local government running the facility or by a third
private company providing medical care.
Although facilities that contract with ICE to hold people are generally required to provide
medical care, there is little consistency in the terms set forth in the contracts and the
specifics of what is required. The 2008 contract for the Joe Corley Detention Facility, for
example, requires the facility to ensure on-site medical and health care coverage for at least
eight hours per day, seven days per week, and makes specific requirements regarding the
qualifications of medical staff: “the Service Provider shall ensure that all health care service
providers … hold current licenses, certifications, and/or registrations with the State and/or
City where they are practicing. The Service Provider shall retain a registered nurse to provide
health care and sick call coverage unless expressly stated otherwise in this Agreement.”59

54 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management and

Oversight of Detainee Medical Care,” http://gao.gov/products/GAO-16-231.
55 Ibid.
56 Ibid.
57 Ibid.
58 Ibid.
59 National Immigrant Justice Center, “Immigration Detention Transparency and Human Rights Project,” Intergovernmental
Service Agreement Between the US Department of Homeland Security, US Immigration and Customs Enforcement Office of

SYSTEMIC INDIFFERENCE

22

Adelanto Detention Facility, in contrast, is required to provide “[m]edical coverage at the
facility…[for] no less than twenty-four (24) hours per day, seven (7) days per week,” and no
specifications are made as to staffing requirements.60 When the National Immigrant Justice
Center deposed an ICE contracting officer in connection to litigation over its FOIA request for
ICE detention center contracts, it found his testimony revealed a “lack of protocol and quality
control in detention contracting.”61
Medical care costs can be generally categorized as on-site costs, usually included in the
per-diem rate paid to the facility per person detained, or as off-site costs, requested
through the Medical Payment Authorization Request (MedPAR) system. Off-site care must
be approved by ICE and is directly paid for by ICE.62 At the same time, the facility can incur
its own costs for off-site care, as it is often responsible for costs associated with providing
transportation and security for individuals taken out of the facility for care.63 For-profit
companies and county governments receiving payments from ICE for holding immigrants in
detention have a financial incentive to reduce costs related to both on-site and off-site
care, with little risk of real penalties for medical care that does not meet the applicable
detention standards.64

Detention and Removal and Montgomery County, Texas, http://www.documentcloud.org/documents/2157387-joe-corleydetention-center-montgomery-county-tx.html (accessed January 5, 2017).
60 National Immigrant Justice Center, “Immigration Detention Transparency and Human Rights Project,” Intergovernmental
Service Agreement Between the US Department of Homeland Security, US Immigration and Customs Enforcement Office of
Detention and Removal Operations and the City of Adelanto, https://www.documentcloud.org/documents/1633813adelanto-contract.html (accessed January 5, 2017).
61 National Immigrant Justice Center, “NIJC Releases 90 Immigration Detention Contracts, Launches Immigration Detention
Transparency and Human Rights Project,” August 13, 2015, http://www.immigrantjustice.org/press-releases/nijc-releases90-immigration-detention-contracts-launches-immigration-detention?q=press_releases/nijc-publishes-90-immigrationdetention-contracts (accessed March 23, 2017).
62 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management and
Oversight of Detainee Medical Care,” http://gao.gov/products/GAO-16-231.
63 For example, the contract for Adelanto Detention Facility states transportation and guard services are included in the perdiem rate. National Immigrant Justice Center, “Immigration Detention Transparency and Human Rights Project,”
Intergovernmental Service Agreement Between the US Department of Homeland Security, US Immigration and Customs
Enforcement Office of Detention and Removal Operations and the City of Adelanto,
https://www.documentcloud.org/documents/1633813-adelanto-contract.html. Similarly, the contract for Hutto Detention
Center states, “The Contractor is responsible for transporting detainees to the hospital and outside medical appointments as
needed and/or requested by DIHS personnel, at no additional expense to the Government.” National Immigrant Justice
Center, “Immigration Detention Transparency and Human Rights Project,” Detention Services Intergovernmental Agreement,
Hutto Detention Center, (Nov. 23, 2009) http://www.documentcloud.org/documents/1672355-hutto-county-corectionalcenter-williamson.html (accessed March 27, 2017).
64 For more information on penalties and the lack thereof, see the section on Inadequate Oversight.

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According to the Government Accountability Office, ICE is unable to calculate the exact
cost of medical care in its detention facilities. Expenditures in its IHSC-staffed facilities
totaled $206 million in fiscal year 2015, but in the other approximately 140 facilities
utilized in 2015, the cost of medical care was generally included in each facility’s per
diem.65 Per diem rates, according to documents provided to the National Immigrant Justice
Center via a FOIA request, range from $40 at Etowah County Detention Center to more than
$200 at family detention facilities.66 The GAO report also noted ICE is not able to analyze
trends in requests for off-site medical care, even though all requests for off-site care come
through the MedPAR system. It noted that advocacy organizations have complained of offsite care requests being adjudicated inconsistently, emphasizing that there are “no
specific written clinical guidance on which to base approval decisions.”67
Human Rights Watch submitted several requests to ICE for information under the Freedom
of Information Act for information on aspects of medical care in immigration detention
facilities, but the responses we received were incomplete and our appeals were still
pending at time of writing.

Correctional Healthcare in the US
The failure of the US immigration detention system to provide appropriate, timely medical
care cannot be isolated from the larger problem of abusive and negligent care in many jails
and prisons across the country. Although the immigration detention system is supposed to
be civil in nature and distinct from the penal, correctional model, ICE facilities are
overwhelmingly jails or jail-like institutions.68

65 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management and

Oversight of Detainee Medical Care,” February 29, 2016, http://gao.gov/products/GAO-16-231.
66 National Immigrant Justice Center, “Freedom of Information Act Litigation Reveals Systemic Lack of Accountability in
Immigration Detention Contracting,” August 2015, http://immigrantjustice.org/sites/immigrantjustice.org/files/images/
NIJC%20Transparency%20and%20Human%20Rights%20Project%20August%202015%20Report%20FINAL2.pdf (accessed
January 5, 2017). The per diem rates were redacted from the contracts NIJC requested and received, as ICE claimed they were
exempt as “[t]rade secrets and commercial or financial information obtained from a person and privileged or confidential,”
but they were not redacted from the cover pages of the inspection reports.
67 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management and
Oversight of Detainee Medical Care,” http://gao.gov/products/GAO-16-231.
68 US Committee on International Religious Freedom, “Assessing the US Government’s Detention of Asylum Seekers: Further
Action Needed to Fully Implement Reforms,” April 2013, http://www.uscirf.gov/sites/default/files/resources/ERSdetention%20reforms%20report%20April%202013.pdf (accessed October 27, 2016), concluding, “all detainees, including
asylum seekers, continue to be detained under inappropriately penal conditions.” See also, US Commission on Civil Rights,
“With Liberty and Justice for All: The State of Civil Rights at Immigration Detention Facilities,” September 2015,
http://www.usccr.gov/pubs/Statutory_Enforcement_Report2015.pdf (accessed October 27, 2016).

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Many inmates in US prisons fail to get the medical care they need. A 2009 study in the

American Journal of Public Health found that among inmates with chronic medical
problems, 68 percent of local jail inmates, 20 percent of state prison inmates, and 14
percent of federal prison inmates did not receive a medical exam while incarcerated.69
Human Rights Watch has documented the particular abuse people with psychosocial
disabilities often face in jails and prisons, including severely inadequate medical care.70
A recent investigation into medical care at federal prisons run by private companies found
overreliance on licensed vocational nurses (LVNs), called licensed practical nurses in
some states. The investigators reviewed dozens of medical records of people who died in
these prisons, and found “[i]n 19 of the cases reviewed, at least one medical doctor
flagged the overextension of LVNs as a factor impeding proper medical care.”71 It also
found that in some facilities, inmates went months without seeing a doctor, while others
who required emergency care were not transferred to a hospital, in an apparent attempt to
save costs.72 One doctor stated, “The pressure of budget is always felt.”73
The private companies who run the federal prisons at issue in the investigation—Geo
Group, CoreCivic/CCA, and the Management & Training Corporation—all run immigration
detention centers as well, including centers we investigated for this report.
Facilities that are publicly operated often contract with private companies to provide
medical care. Some of these companies have been the subject of lawsuits or
investigations alleging negligent medical care due to use of undertrained or unqualified
medical staff. In 2015, Corizon, one of the country’s largest for-profit prison healthcare
providers, and Alameda County in California settled a wrongful death lawsuit involving a
jail inmate who died in the midst of alcohol withdrawal. The lawsuit alleged that an LVN
put the inmate into the general population without alcohol withdrawal treatment, and that

69 Andrew P. Wilper, et al., “The Health and Health Care of US Prisoners: Results of a Nationwide Survey,” American Journal of

Public Health, April 2009, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2661478/pdf/666.pdf (accessed October 27, 2016).
70 Human Rights Watch, Callous and Cruel: Use of Force against Inmates with Mental Disabilities in US Jails and Prisons, May

12, 2015, https://www.hrw.org/report/2015/05/12/callous-and-cruel/use-force-against-inmates-mental-disabilities-us-jailsand#44aa12.
71 Seth Freed Wessler, “This Man Will Certainly Die,” The Nation, February 15, 2016, https://www.thenation.com/article/
privatized-immigrant-prison-deaths/ (accessed October 27, 2016).
72 Ibid.
73 Ibid.

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Corizon had hired LVNs instead of registered nurses to cut costs.74 In 2014, the New York
State Attorney General came to a settlement agreement with Correctional Medical Care, a
private prison health care contractor that provided medical services in jails in 13 New York
counties, after an investigation in which the attorney general found “the company
understaffed facilities and shifted work hours from physicians and dentists to less
qualified and lower-wage staff.”75

74 Henry K. Lee, “$8.3 million settlement in death of Alameda County inmage,” San Francisco Chronicle, February 10, 2015,

http://www.sfgate.com/news/article/8-3-million-settlement-in-death-of-Alameda-6073319.php (accessed December 5, 2016).
75 “A.G. Schneiderman Announces Settlement with Health Care Company That Provided Substandard Service to Jail Inmates

in 13 NY Counties,” Attorney General Eric T. Schneiderman news release, September 25, 2014, https://ag.ny.gov/pressrelease/ag-schneiderman-announces-settlement-health-care-company-provided-substandared-service (accessed March 27,
2017). See also, R.G. Dunlop, “Lawsuit Over 2013 Montgomery County Jail Death Settled,” Kentucky Center for Investigative
Reporting, February 9, 2017, http://kycir.org/2017/02/09/lawsuits-over-2013-montgomery-county-jail-death-settled/
(accessed March 27, 2017). The lawsuit involved a man who “lay in his cell in his own feces, wracked with pain from severe
drug withdrawal, before dying of a seizure.” A separate settlement was reached with Southern Health Partners, Inc., the
private health care provider in the jail, which replied on “advance-practice registered nurses” rather than regular visits to the
jail by the physician medical director.

SYSTEMIC INDIFFERENCE

26

II. Deaths in Detention, 2012 – 2015
Government Investigations Reveal Substandard Care
In June 2016, ICE publicly released government investigations into 18 of the 36 cases of
people who died in the custody of US Immigration and Customs Enforcement from May
2012 through June 2015. The investigations were conducted by the Office of Detention
Oversight (ODO), which conducts inspections at facilities where complaints or deficiencies
have been reported, and conducts investigations into all deaths in detention.76 Expert
analysis of the reports, detailed below, shows that substandard care contributed to the
deaths in 7 of the 18 cases.
The 18 death reviews cover deaths at 13 facilities. Those who died included citizens of
Mexico, Honduras, El Salvador, Canada, Jamaica, Antigua-Barbuda, Mozambique, and
Guatemala, some of them lawful permanent residents and others unauthorized migrants,
including at least six who sought protection under refugee law. All of the people who died
were between 24 and 50.
Human Rights Watch and CIVIC asked two independent experts to review the
circumstances of the deaths, as detailed in the ICE Office of Detention Oversight’s reports
of its investigations. Dr. Marc Stern is a correctional health expert, assistant affiliate
professor of Public Health at the University of Washington, former health services director
for Washington State’s Department of Corrections, and former subject matter expert for
investigations conducted by the Department of Homeland Security Office of Civil Rights
and Civil Liberties. Dr. Allen Keller is an expert in access to health care for prisoners,
Associate Professor of Medicine at New York University, associate professor at the NYU
Gallatin School of Individualized Study, director of the Bellevue/NYU Program for Survivors
of Torture, and director of the NYU Center for Health and Human Rights.

76 US Department of Homeland Security, “Written Testimony of US Immigration and Customs Enforcement Office of Detention

Policy and Planning Assistant Director Kevin Landy for a House Committee on the Judiciary,” Subcommittee on Immigration
Policy and Enforcement hearing on Performance-Based National Detention Standards (PBNDS) 2011, March 27, 2012,
https://www.dhs.gov/news/2012/03/27/written-testimony-us-immigration-and-customs-enforcement-house-judiciary
(accessed March 3, 2017).

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Though Dr. Stern previously investigated medical care in ICE facilities for the Department
of Homeland Security, his conclusions communicated to Human Rights Watch are not
based upon any confidential information obtained through that work and were drawn
exclusively from his review of publicly available ODO death reports and in one case, that of
Tiombe Kimana Carlos, a review of her medical records at York County Prison obtained by
Human Rights Watch, and on his review of individuals’ medical records (analyzed in the
following section). Human Rights Watch made these documents available to Dr. Stern for
review after he discontinued his work with the Department of Homeland Security.
Our analyses below rely upon the facts and conclusions included in the ODO’s report of
each investigation. ODO death reviews are based on medical and other records; interviews
with relevant medical, custodial, and ICE staff; and in most cases a security and healthcare
compliance report by Creative Corrections, a national management and consulting firm
contracted by ICE to provide expertise in detention management and compliance with
detention standards.
The death reviews include the immigrant’s immigration and criminal history, if any, and a
timeline of relevant medical and detention events. The reviews conclude with specific
findings as to which detention standards were violated, and note further “areas of concern,”
but most of the 18 reviews also explicitly state that the findings are included “for information
purposes only” and “should not be construed as having contributed to the death of the
detainee.” ICE released these reviews, without attached exhibits such as primary medical
records or the Creative Corrections report, if any, in its online FOIA Library.77
In their reviews, Dr. Stern and Dr. Keller assessed whether care was adequate considering
standard practices in correctional health and the standards applicable to individual ICE
facilities. Under international standards, detained individuals are entitled to the same
level of medical care as individuals in the community at large and must be treated with
humanity and respect for inherent human dignity.78

77 US Immigration and Customs Enforcement, FOIA Library, https://www.ice.gov/foia/library (accessed September 16, 2016).
78 For more information, see the section on US and International Legal Standards.

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Responses from ICE and Companies Operating Private Facilities
Human Rights Watch provided a summary of our findings to ICE but at time of writing had
not received a response from the agency. Human Rights Watch also provided summaries of
our analysis of the deaths that occurred at facilities operated by GEO Group,
CoreCivic/CCA, and Ahtna Technical Services (ATS) to those companies along with a
request for comment. CoreCivic/CCA and GEO Group provided written responses to Human
Rights Watch. ATS had not responded at time of writing.
GEO Group operates Brooks County Detention facility, where two people whose deaths are
described in this report were detained. At the time of those deaths, Brooks was operated
by LCS Corrections, which GEO acquired in 2015. The GEO Group stated that as a matter of
company policy, it is unable to comment on any of the individual cases we raised. It
emphasized, however, that 2 of the 18 deaths occurred at the Brooks County Detention
Facility before GEO Group took over management of that facility, and noted that our
medical experts found that another person who died in a GEO Group-operated facility
appeared to have received adequate medical care. GEO Group also stated that it employs a
robust internal auditing framework to ensure compliance with all “mandated standards
and requirements.” It also stated that “Our company takes all recommendations made by
ICE very seriously, and for instances in which corrective actions are required, our company
has had a long-standing, steadfast commitment to allocating the necessary resources and
to working in partnership with ICE to ensure compliance.”
CoreCivic/CCA emphasized in its response that it does not directly provide or oversee the
provision of healthcare to immigrants detainedin its facilities, and that medical care is
provided by ICE’s Immigrant Health Service Corps (“IHSC”). CoreCivic/CCA asserted that
“because we are not the healthcare provider, we do not have access to medical-specific
information about detainees” and suggested that questions about treatment protocols
and the treatment received by individual detainees should be referred instead to ICE.
CoreCivic/CCA also stated that the company “adheres strictly” to ICE’s Performance-Based
National Detention Standards and that onsite ICE contract monitors have “unfettered, daily
access” to CoreCivic/CCA facilities to “provide accountability and oversight and ensure the
standards are met.” CoreCivic/CCA also responded to several questions about the
individual cases described below; these are incorporated into our findings as appropriate.

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Substandard Care Contributed to Over One-Third of the Deaths
Although the 18 death reviews do not make any findings as to whether failures in
medical care contributed to the person’s death, Dr. Stern and Dr. Keller provided expert
opinions, based on the events described in the reviews, that substandard care was likely
to have contributed to the deaths of 7 people. Those cases are presented in
chronological order below:

Manuel Cota-Domingo: Death from Untreated Diabetes and Pneumonia
ODO’s death review for Manuel Cota-Domingo, 34 at his death in December 2012, notes
that he entered CoreCivic/CCA’s Eloy Detention Center with a plastic bag containing
medicine for diabetes but that it was stored with his property and not given to nurses.79
Later, a licensed practical nurse doing his intake recorded that he denied having insulin
with him or being diabetic. In an interview with ICE, Cota-Domingo’s cousin who was also
detained at Eloy at the same time, said he encouraged Cota-Domingo to talk to medical
personnel about his medical condition but that Cota-Domingo refused because he
believed he would “have to pay for medical care he could not afford.” CoreCivic/CCA told
Human Rights Watch there are no fees for medical care delivered at Eloy.80
The review includes interviews with three other detained people. His cellmate said CotaDomingo began to have problems breathing at about 10 p.m. on the night of December 19,
2012. His cellmate began to bang his cell door and call for help at about 11 p.m.; he stated
that correctional officers did not respond until 2 a.m. The review documents further delays,
including a decision by a registered nurse to wait two hours to attend to Cota-Domingo’s
complaint of chest pain, failure to call 911 because of an Eloy Detention Center policy that
only certain medical staff could call 911, and a decision by facility staff to send CotaDomingo to the emergency room in a van rather than an ambulance.81
Taken together these delays meant that Cota-Domingo did not arrive at the emergency room
until at least eight hours after he first began to have trouble breathing. He was pronounced

79 US Department of Homeland Security, Immigration and Customs Enforcement, “Report of Investigation: Cota-Domingo,

Manuel/Unknown/0109 Detainee/Alien – Death (Known Cause – Terminal Illness)/Eloy, Pinal, AZ,” June 10, 2013,
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-cotadomingo.pdf (accessed September 19, 2016).
80 Ibid.
81 Ibid.

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dead at the hospital days later of hypertrophic and atherosclerotic cardiovascular disease
with diabetic ketoacidosis, or untreated diabetes, and pneumonia.82
Expert comments: The medical experts found that this death was very likely preventable.
“If diagnosed properly and treated, diabetic ketoacidosis and pneumonia are treatable,”
Dr. Keller said. “But both of these life-threatening diagnoses were missed at the detention
facility.”83 Both experts further agreed that the inappropriate delays in responding to CotaDomingo’s condition on the night and morning before he was transported to the hospital
likely contributed to his death. “Each delay—getting out of the cell, getting an initial
medical assessment, and going to the hospital by van—all added to overall delay which
made a probably reversible condition fatal,” said Dr. Stern.84

Lelis Rodriguez: Death from Stroke and Hypertension
Lelis Rodriguez, 50 at the time of his death, entered Border Patrol custody on July 16, 2013,
and died on July 31 in ICE custody.85 ODO’s review notes that the cause of his death was an
intracranial hemorrhage—a stroke—and hypertension. The review says he was first
screened for health issues two days after his initial arrest. ODO’s review documented that
at this screening, on July 18, a Border Patrol officer “checked ‘no’ after the question, ‘Does
alien have health problems/issues?’” but “‘yes’ after the question, ‘Was the alien
prescribed medication?’” The agent did not provide any more information on the
medication, despite a specific direction on the form to do so.
Border Patrol agents later told ODO investigators that Rodriguez did not possess
medication while in Border Patrol custody. However, when he entered ICE custody at
the Brooks County Detention Center (BCDC) six days after his initial arrest he was screened
by a correctional officer who documented that Rodriguez said he had been taking
medication for high blood pressure. This screening form was never sent to the BCDC
medical unit. BCDC also “failed to verify and inventory medication” in Rodriguez’s
property. On July 24, a BCDC Certified Medical Assistant (CMA) generated a record of an

82 Ibid.
83 Human Rights Watch telephone interviews with Dr. Allen Keller, July 1-6, 2017.
84 Human Rights Watch email and telephone correspondence with Dr. Marc Stern, June 8, 26, 30, and July 1-6, 2017.
85 US Department of Homeland Security, Immigration and Customs Enforcement, “Report of Investigation: Rodriguez,

Lelis/Unknown/0109 Detainee/Alien – Death (Known Cause – Terminal Illness)/Harlingen, Cameron, TX,” February 11, 2014,
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-rodriguez.pdf (accessed September 19, 2016).

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intake medical screening for Rodriguez, stating that he had no history of hypertension and
no current medication.
On the evening of July 29, ICE transferred Rodriguez to Rio Grande Valley Staging (RGVS),
an ICE facility operated by Ahtna Technical Services, which holds immigrants for periods
under 12 hours immediately prior to their removal to their country of citizenship, in
Rodriguez’s case, Honduras. Several hours after his arrival, a licensed vocational nurse
documented that he had a headache and blood pressure of 172/90. She said he also told
her that he had high blood pressure and he had informed BCDC staff about the
hypertension medication in his property bag.
The nurse searched the property bag, and found the tablets for hypertension, but left them
in the bag. She told him she would recheck his blood pressure in an hour but took no other
action. Three hours later, a nurse checked Rodriguez’s blood pressure again and found it
to be 200/110. The ICE review fails to note what the nurse did at this point. Then, at a time
unspecified in the ICE report, Rodriguez collapsed, complaining of right shoulder pain and
a headache. A nurse noted that his right arm and right leg were twitching. The nurse called
emergency medical services and he was transported to a hospital emergency department.
He quickly fell into a coma and was pronounced brain dead the next day.
Expert comments: “This was an avoidable death,” Dr. Stern said after his review of the ICE
investigation. Medical staff “failed to react immediately when [they] learned that Mr.
Rodriguez had a blood pressure of 172/90, was on blood pressure medication and had a
headache. These were symptoms that required immediate contact with a practitioner for
further action that may very well have saved his life.”86 Dr. Keller made similar comments.
“Hypertension is sometimes referred to as a ‘silent killer’ given that there often no
symptoms. However, in its severe manifestation it can cause symptoms including
headaches.” Dr. Keller said. “In this case, Mr. Rodriguez’ symptoms were by no means
silent. Unfortunately, it appears that medical staff did not connect these symptoms with
his hypertension and delayed responding. This delay might have cost him his life.”87

86 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
87 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.

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Both experts noted that decisions made by Border Patrol agents also contributed to the
mismanagement of Rodriguez’s care. Though the death review indicates that Rodriguez
reported taking medication, this information was not passed along. “Had someone
identified that the patient was taking—and needed—medications for high blood pressure
and gotten those medications restarted at some point in the two weeks he was held by US
authorities, the death may have been averted,” Dr. Stern said.88 Dr. Keller added, “This
death review showed one mistake after another with regard to missing and then
mismanaging his symptoms, with fatal consequences.”89

Tiombe Carlos: Death by Suicide
Tiombe Kimana Carlos, 34, died in October 2013, after committing suicide while detained
at the York County Prison (YCP).90 She showed symptoms of an acute mental health
condition from the start of her two-and-a-half-year detention at York. ODO’s review states
that before she died, she was placed on suicide watch five times and attempted suicide
once. ODO found that the facility violated ICE’s standards for detention conditions, by
having no “overall treatment plan with measurable goals and objectives,” and by failing to
communicate with ICE regarding her treatment until shortly before her death.
Carlos was held in isolation while at YCP for at least nine months over 12 separate instances
because of her “behavioral issues and associated mental health concerns.” ODO found that
“Carlos’s records show the rationale for placing her in segregation was valid on all
occasions.” The ODO notes a licensed professional counselor (LPC) decided more than once
that Carlos was not suicidal. After her first suicide attempt by hanging on August 13, 2013,
the LPC told ODO that “he considered her action … a suicidal gesture, not a suicide attempt,
because she waited for officers to enter her cell before dropping from the stool.” Another
correctional officer told ODO her August 2013 attempt was “done for attention.”
On August 20, 2013, a contract psychiatrist saw Carlos, documented that she declined any
medication changes or increases, described her as “animated” and “angry,” and “ordered
no change in her treatment with follow up in eight weeks.” The review cites Creative
Corrections, which “highlights that Dr. [redacted]’s [August 20, 2013] note about Carlos’s

88 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
89 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
90 US Immigration and Customs Enforcement, “Detainee Death Review of Tiome Kimana Carlos, JICMS number 201400713,”

https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-carlos.pdf (accessed September 19, 2016).

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medication is the first reference in her medical record to a possible change or increase in
her medication,” over two years after she entered the facility and after she had repeatedly
refused her medication and attempted suicide once. After her August 2013 suicide
attempt, Carlos remained in isolation.
The death review states that Carlos’ record contains “no documentation YCP mental health
staff pursued alternative placement with ICE Enforcement and Removal Operations].” The
only effort made, according to an ICE official, was shortly before Carlos’ death in October
2013, when the YCP warden requested that ICE “look into placing Carlos in a long-term
mental health facility.” ICE’s response was that “an appropriate alternative facility was not
available at that time.” Carlos hanged herself on October 23, 2013.
Expert Comments: Both experts found that subpar mental health care likely contributed to
Carlos’ death. Dr. Keller called the mental health evaluation and treatment Carlos received
while at YCP “woefully inadequate” and raised concerns about the apparent failure to
develop, document, and implement a mental health treatment plan for Carlos.91 Dr. Stern
had similar comments. “Staff were aware that this patient suffered from an acute and
serious mental illness and was a) not getting treatment for it, and b) was not transferred to
a facility that could provide that treatment,” said Dr. Stern. “Instead, medical staff kept
giving her [anti-psychotic medication] and no other therapy, and she kept trying to kill
herself. In other words, the medical staff kept doing the same thing, expecting a different
outcome. That she finally killed herself should not have come as a surprise.”92 He also
questioned the psychiatrist’s decision to schedule a follow-up session eight weeks after
seeing Carlos, saying it appeared “too long for such an unstable person, seven days after a
suicide attempt and three days after being taken off of constant observation.”93
Dr. Keller particularly called attention to the substantial amount of time Carlos was held in
isolation. “This is counter to accepted norms for treating mental illness whereby
segregation and use of restraints are temporizing measures for use in emergencies and as
a last resort-rather than a routine response,” Dr. Keller said. “If viewed separately, each of
the many episodes of segregation Carlos was subjected to might seem justified, but when

91 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
92 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
93 Ibid.

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viewed in their totality this overuse of segregation was inappropriate and likely harmful to
Carlos’ mental health.”94
Dr. Stern also noted the ODO review team failed to include a psychiatrist or psychologist
who would be qualified to evaluate with more specificity the quality of mental health care
she received.95

Marjorie Annmarie Bell: Death from Heart Attack and Coronary Disease
ODO’s death review for Marjorie Annmarie Bell records that she died on February 13, 2014,
due to sudden cardiac death, acute coronary syndrome and multivessel coronary artery
disease.96 She was 48. She came into US custody on December 24, 2013 when she crossed
the US-Mexico border at the San Ysidro port of entry. The death review says that she told
Customs and Border Protection officers that she did not feel well and had diabetes, and
that she was transported to Sharp Chula Vista Medical Center (SCVMC) where she was
admitted. There, ODO notes, she reported she had a history of heart disease and had at
least three stents in her heart. SCVMC placed one additional stent.
Bell was admitted to the CoreCivic/CCA-operated San Diego County Detention Facility on
January 2. There, medical staff responded to her requests for care and at one point in late
January sent her to the emergency room for chest pain. The discharge summary from the
hospital stated, “treatment of her congestive heart failure should be done,” but the nurse
practitioner who saw Bell at the detention facility did not include congestive heart failure
in her assessment. The facility did not seek expert assistance from a cardiologist. Bell
repeatedly requested nitroglycerin tablets to take as needed for her chest pain and
medical staff became concerned she was overusing nitroglycerin. In early February, Bell
told a psychologist that she was dissatisfied with the medical care she was receiving at the
facility and that “medical staff did not listen to her.”
On February 13, 2014, Bell saw a doctor for chest pain who decided to send her to the
emergency room, but waited 15 minutes to instruct a medical officer to call 911. The ODO
noted, “the apparent 15-minute delay remains unexplained.” It was another six minutes

94 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
95 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
96 US Immigration and Customs Enforcement, “Detainee Death Review of Marjorie Annmarie Bell, JICMS Number 201404156,”
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-bell.pdf (accessed September 19, 2016).

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before emergency responders received a call from the facility. Bell died later that day of a
heart attack.
Expert Comments: Both experts found that substandard medical care contributed to Bell’s
death. “On multiple occasions medical staff did not adequately address and evaluate her
chest pain,” Dr. Keller said. “Given the severity of her heart disease and the fact she had
just recently undergone a cardiac procedure, there should have been a very low threshold
for sending her back to the hospital. It took her being near death for them to finally do that
but it was too late,” Dr. Keller said.97 “This is a woman with a known history of heart
attacks,” said Dr. Stern. “On six separate occasions she informed nurses that she was
having chest pain, and on none of those occasions did a nurse contact a physician or call
an ambulance. She ultimately died of another heart attack.”98 Both doctors agreed that if a
stent needed to be placed on December 25, 2013, it should have been clear that Bell
required close observation and monitoring by a heart expert, which she did not receive.

Peter George Carlysle Rockwell: Death by Hemorrhagic Stroke
ODO’s death review for Peter George Carlysle Rockwell, 46 when he died in February 2014,
notes that he was admitted to CoreCivic/CCA’s Houston Contract Detention Facility with a
history of hypertension for which he took medication.99 At a physical examination on
intake, a nurse practitioner developed a treatment plan that included daily blood pressure
monitoring. However, according to the ODO review, this monitoring did not occur. An
electrocardiogram ordered to be performed two weeks after Rockwell’s physical exam was
not completed. When he complained of blurred vision five days after intake, a physician’s
assistant determined he should be seen by a health care provider within one day but
“[m]edical records staff did not schedule the vision appointment, and [Rockwell] was never
seen by a provider for the blurry vision.”
When Rockwell collapsed in full view of a correctional officer 10 days after first
complaining of blurry vision, the review found that staff took eight minutes to call 911, that
three more minutes elapsed before CPR was started and that two minutes after that staff
applied an automated external defibrillator (AED). The ODO notes that according to the

97 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
98 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
99 US Immigration and Customs Enforcement, “Detainee Death Review of Peter George Carlysle Rockwell, JICMS Number

201404529,” https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-rockwell.pdf (accessed September 19, 2016).

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American Heart Association’s Adult Basic Life Support guidelines, “as soon as [Rockwell]
was determined to have ineffective or agonal breathing (abnormal breathing characterized
by gasping, labored breaths), 911 should have been called, an AED should have been
used, and CPR should have been initiated.”
ODO said that the delays occurred due to the failure of medical staff to recognize the
emergency and bring emergency equipment to the scene as required by facility policy, and
to malfunctioning medical equipment. Rockwell was transported to the hospital while
nonresponsive, and placed on a ventilator in the intensive care unit until his death seven
days later which was determined to have been due to a hemorrhagic stroke.
Expert Comments: Both medical experts found that substandard care contributed to
Rockwell’s death. “The facility knew about his blurred vision and other systemic symptoms
and did not manage them,” said Dr. Stern.100 “The providers missed what may have been a
telltale sign of an intracranial bleed when he reported the blurry vision,” said Dr. Keller. “It
could have been something else but it merited investigation.”101 Both experts also pointed to
the delayed emergency response as inadequate. Dr. Keller raised concerns about whether
the facility appropriately addressed the inadequate emergency response after it occurred.
“The review notes there was no debriefing of the emergency response with corrections staff.
Such debriefings are crucial to identifying errors and correcting future problems.”102

Santiago Sierra-Sanchez: Death from Staph Infection and Pneumonia
ODO’s death review for Santiago Sierra-Sanchez, 38 at his death in July 2014, records that he
told an intake nurse at the Utah County Jail that he had a six- to-seven-month history of lower
back pain that had been worsening in the preceding few days.103 ODO reviewed video
showing that he was unable to stand without assistance in the jail intake area. ODO reports
that Sierra-Sanchez told ICE officers that he was “‘dying’ from the pain in his back.”
The review says that nursing staff at the jail suspected Sierra-Sanchez “might be playing
games to get narcotic pain medication” and did not thoroughly assess him—including by

100 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
101 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
102 Ibid.
103 US Immigration and Customs Enforcement, “Detainee Death Review – Santiago Sierra-Sanchez, JICMS #201409551,”

https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-sierra.pdf (accessed September 19, 2016).

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taking his temperature—or follow standard protocols regarding back pain. The ODO review
notes that Sierra-Sanchez’s medical history included a prior history of drug use. The review
also states his pulse and blood pressure increased between his intake and his evaluation
by an RN, “which warranted a consultation with a provider,” but this did not occur. His
temperature was not taken; Creative Corrections noted, “an elevated temperature can
signal an infection.” On the night he died, Sierra-Sanchez told a nurse he was “spitting
blood” around 8 p.m. but the nurse told ICE that there was no evidence of this.
Around 3:30 a.m., a correctional officer (CO) saw he was unresponsive. Six minutes elapsed
before staff entered his cell, where they found him in a pool of bloody vomit. The CO called
for medical assessment, not an emergency, so the RN arrived without emergency equipment,
which the ODO found delayed CPR and the call for emergency medical services. SierraSanchez died that morning of disseminated Staphylococcus aureus and pneumonia.
Expert comments: “Medical staff essentially abandoned this patient by not properly
assessing him or following up. If they had, there is a chance the patient's emerging
infection would have been noted and treated, avoiding death or at least greatly increasing
the odds of survival,” Dr. Stern said.104 Dr. Keller had similar comments. “When someone
has a fulminant bacterial infection as was the case with Mr. Sierra-Sanchez, rapid
treatment including intravenous antibiotics can make all the difference between life and
death,” said Dr. Keller. “But it appears they even missed some of the basics like
monitoring his temperature.”105

Raul Ernesto Morales-Ramos: Death after Delayed Surgery to Remove Abdominal Mass
ODO’s death review for Raul Ernesto Morales-Ramos, 44 when he died in April 2015, notes
that he was first referred for a follow-up with a doctor for gastrointestinal symptoms in
April 2013, while detained at the Theo Lacy Facility.106 But more than a year later, this
consultation had not occurred, which the ODO review called a “critical lapse in care.” In
May 2014, he was transferred to the GEO Group-operated Adelanto Detention Facility with
no documentation of his gastrointestinal symptoms. There, he was seen several times over

104 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
105 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
106 US Immigration and Customs Enforcement, “Detainee Death Review – Raul Ernesto Morales-Ramos, JICMS #20505282,”
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-morales.pdf (accessed September 19, 2016).

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the next nine months by registered nurses after submitting sick call requests for body
aches, weight loss, pain in his joints, knees, and back, and diarrhea.
In February 2015, Morales-Ramos submitted a grievance in which he wrote, “To who
receives this. I am letting you know that I am very sick and they don’t want to care for me.
The nurse only gave me ibuprofen and that only alleviates me for a few hours. Let me know
if you can help me. I only need medical attention.” Four days later, he was seen by a nurse
practitioner who documented that his symptoms were resolved and “instructed him to
increase his water intake and exercise to promote bowel regularity.”
In early March 2015, a registered nurse seeing Morales-Ramos after a sick call request
documented that he was complaining of abdominal pain and asking again to see a doctor.
The nurse who saw Morales-Ramos on March 2, 2015 told ODO that she noted MoralesRamos had a distended abdomen but that she “did not detect a mass or protrusion.” A
consultation with a doctor occurred on March 6, 2015. The doctor, who held a certification
in medical oncology, told ODO that at that visit Morales-Ramos had “the largest
[abdominal mass] she had ever seen in her practice,” which was “notably visible through
the abdominal wall.”
Based on the doctor’s findings and referrals Morales-Ramos was scheduled for a
colonoscopy, which did not occur until about one month later. During the colonoscopy, he
began to experience abdominal bleeding after the doctor attempted to remove “a huge
rectal mass.” Morales-Ramos was transferred to the hospital and died three days later
after a surgical attempt to stop his bleeding.
Expert comments: Both medical experts noted that it appears Morales-Ramos suffered
from symptoms of cancer starting in 2013, at least two years before he died, but the
symptoms went unaddressed until a month before he died. “Had Mr. Morales’
gastrointestinal symptoms been evaluated much sooner as was clinically indicated, it is
possible that the malignancy from which Mr. Morales died, might have been caught at a
time when it was still treatable,” Dr. Keller said.107 Dr. Stern similarly noted that Mr.

107 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.

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Morales “was not appropriately referred for specialist care” until a month before his death,
when it was too late.108

Misuse of Isolation and Inadequate Treatment of Individuals with
Psychosocial Disabilities
Prolonged solitary confinement may amount to torture or cruel, inhuman, or
degrading treatment, which is prohibited under international human rights law.
Because solitary confinement may severely exacerbate previously existing mental
health conditions, the United Nations special rapporteur on torture believes that
solitary confinement of any duration for those with psychosocial disabilities is cruel,
inhuman, or degrading treatment.109

Tiombe Carlos: Death by Suicide After Prolonged Solitary Confinement
The death review for Tiombe Kimana Carlos, summarized above, states she was in
isolation for a significant period of time, including two stints in 2013, one for four-and-ahalf months and another for two-and-a-half months immediately before her death. The
dangers of isolation for people with mental health conditions are well-documented, yet the
ODO review indicates that the safeguards set by national detention standards were not
followed.110 It says that the facility did not record isolation orders, in violation of the
applicable detention standards. The ODO also noted that for six of the months Carlos
spent in isolation, the facility only reviewed its necessity monthly. Weekly checks started
in June 2013, but documentation was inconsistent and there was no evidence they were
adequate to evaluate whether Carlos should have remained in isolation.

108 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
109 UN Human Rights Council, Interim report of the Special Rapporteur on torture and other cruel, inhuman or degrading

treatment or punishment, Juan E. Mendez, A/66/268, August 5, 2011, https://documents-dds-ny.un.org/doc/
UNDOC/GEN/N11/445/70/PDF/N1144570.pdf?OpenElement (accessed September 19, 2016), para.78. See also, Human
Rights Watch, Callous and Cruel: Use of Force against Inmates with Mental Disabilities in US Jails and Prisons, May 12, 2015,
https://www.hrw.org/report/2015/05/12/callous-and-cruel/use-force-against-inmates-mental-disabilities-us-jails-and;
Maureen L.O’Keefe, et al., “One Year Longitudinal Study of the Psychological Effects of Administrative Segregation,”
submitted to the National Institute of Justice, October 31, 2010, https://www.ncjrs.gov/pdffiles1/nij/gr (accessed September
19, 2016).
110 US Immigration and Customs Enforcement, “Detainee Death Review of Tiome Kimana Carlos, JICMS number 201400713,”
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-carlos.pdf.

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Clemente Mponda: Death by Suicide After Repeated Use of Isolation
In another case involving a migrant who committed suicide in ICE detention, that of
Clemente Mponda, 27, the medical experts noted that repeated placement in isolation may
well have exacerbated his mental health condition.111 For eight months of his 15-month
detention at CoreCivic/CCA-operated Houston Contract Detention Facility (HCDF), Mponda
was in isolation, including administrative segregation, disciplinary segregation, and three
days on suicide watch.
The ODO found numerous violations of standards for placing someone in isolation or for
reviewing whether continued isolation was justified, including failure to medically clear
him for isolation, a violation of the 2008 PBNDS and of the Immigrant Health Service Corps
policy that “a qualified healthcare professional … review the detainee’s health record to
determine whether existing mental health needs contraindicate placement in
segregation.” When Mponda was returned to the general population from isolation in
January 2013, the death review says, he “functioned well,” with one stint in disciplinary
isolation, followed by another five months without incident.
Shortly before his death, the ODO says, Mponda physically attacked another detained
individual and he was cleared by medical staff “to be moved to ‘Special Housing Unit
(Segregation).’” During his transfer to isolation, the ODO states, correctional staff did not
search him as required by facility policy. During the investigation, another detained
individual told ODO he had seen Mponda place medication in one of his socks prior to the
altercation. The ODO also noted a bottle of pills, medication Mponda had been prescribed,
had been found in his cell, but this did not trigger facility staff to search Mponda and ensure
he was not secreting medication. Two days later, he was found unresponsive in his cell. The
autopsy found he died from toxicity after consuming a large amount of the medication he
had been prescribed.
In addition to the facts described above, the ODO states that Mponda was identified as
having significant mental health needs early in his detention at HCDF when facility medical
staff diagnosed him with depression or schizophrenia. However, the ODO concluded that
staff delays in evaluating Mponda’s mental health after two suicide attempts in July 2012

111 US Immigration and Customs Enforcement, “Detainee Death Review - Clemente Mponda, JICMS #201312347,”
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-mponda.pdf (accessed September 19, 2016).

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violated detention standards. After the first attempt, no mental health professional
assessed him until five days later. The second time, although Mponda was found hanging
and had to be cut down and taken to the hospital, where he stayed for two weeks, staff
placed him in isolation upon his return and did not create a mental health treatment or
management plan despite the clear risk of suicide.
Expert comments: Dr. Stern, upon reviewing Mponda’s death review, stated: “This case
might be the poster child for misuse of isolation for mental health patients.”112 Although
the death review identified many problems with Mponda’s care and custody, he noted the
ODO team failed to include a mental health care expert and did not fully examine how
segregation could have adversely impacted Mponda’s mental health.
Dr. Keller emphasized that isolation is a stressful and highly disruptive and traumatizing
event. “Standard psychiatric care is to utilize segregation and restraints as temporizing
measures for short-term use in only urgent situations, rather than as a routine means of
addressing psychiatric illness,” Dr. Keller said. “While Mr. Mponda may have benefited
from psychiatric hospitalization or from close follow up and care in a community-based
mental health program, these were never considered as options. Instead, repeated
segregation was the preferred punishment and treatment of choice.”113
“The repeated overuse of segregation without considering other options may well have
contributed to an unstable individual becoming even more unstable and ultimately
contributed to his death,” Dr. Keller said.114
Both experts noted that Mponda’s ability to hoard potentially lethal medications he was
taking without detection represented a dangerous failure of the facility’s security system.

Jose de Jesus Deniz-Sahagun: Death by Suicide After Being Moved Off of Suicide Watch
Jose de Jesus Deniz-Sahagun, 31 at death, committed suicide on May 20, 2015 in
CoreCivic/CCA-operated Eloy Detention Center less than 12 hours after a doctor moved him
from suicide watch to mental health observation status with 15-minute checks and no

112 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
113 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
114 Ibid.

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restrictions on his property.115 According to the review, Deniz-Sahagun ultimately used an
item from his property—a sock—to end his life. Before arriving at Eloy, while in Border
Patrol custody, ODO documented that Deniz-Sahagun exhibited self-harming behavior. He
jumped twice from a bench and landed on his head. Border Patrol agents transported him
to the hospital on May 17, 2015, where he “told the emergency room physician he was
attempting to break his own neck because he feared his life was in danger by both
Mexican coyotes and USBP [US Border Patrol].”
On May 18, 2015, when Deniz-Sahagun was transferred to Eloy, ODO noted that Border
Patrol agents informed a nurse in Eloy’s booking area that Deniz-Sahagun had been taken
to the hospital the day before for his suicide attempt and that he had since been
“observed banging his head against a wall at the Border Patrol Station and behaved
erratically during transport.” ODO noted however that “the Medical Alert section of his
[Border Patrol] Alien Booking Record was blank, and no medical or mental health
documentation accompanied him to [Eloy].” The pre-screening and intake nurses at Eloy
determined that Deniz-Sahagun was not suicidal and referred him for a routine, rather than
urgent, mental health follow-up. Deniz-Sahagun was cleared for placement in general
population in the early afternoon. Around 10 p.m. that evening, Deniz-Sahagun requested
to be placed in protective custody “because he believed his cellmate [redacted] was going
to kill him.”
On the morning of May 19, 2015, ODO discussed four separate use of force incidents “used
to control Deniz-Sahagun” over the course of approximately three hours. The ODO
reviewed video of each of these events, including “a video recording shows Deniz-Sahagun
struggling on the floor as four officers hold him in place. He screams in English and
Spanish, ‘Help me,’ ‘Call my lawyer,’ ‘This is brutality,’ and ‘They want to kill me.’” A facility
doctor determined that Deniz-Sahagun suffered from delusional disorder and placed him
on suicide watch from May 19 to 26, 2015. The order required nursing checks every eight
hours, mental health checks every 24 hours and one-on-one observation by an officer. The
doctor also ordered anti-psychotic and anti-anxiety medications assuming that
“involuntary administration would be necessary.” These medications were not

115 US Immigration and Customs Enforcement, “Detainee Death Review – Jose De Jesus Deniz-Sahagun, JICMS #201506640,”
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-denizshagun.pdf (accessed September 19, 2016).

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administered by medical staff, but no documentation of this was made in Deniz-Sahagun’s
medical record and the doctor was not informed.
On the morning of May 20, 2015, a doctor removed Deniz-Sahagun from suicide watch
“because he believed the detainee was no longer a danger to himself.” The doctor told
ODO that it was “not clear to him what prompted Deniz-Sahagun’s change, but he
assumed the detainee had been administered a sedative.” Around 5:30 p.m. that day,
Deniz-Sahagun was discovered unresponsive in his cell. His airway was blocked by an
orange sock which caused him to asphyxiate.
Expert comments: Dr. Keller emphasized that medical staff failed to adequately elevate
the level of Deniz-Sahagun’s treatment as his symptoms worsened. “This patient was
severely unstable. He had been taken to the hospital after a suicide attempt days before
and was placed on suicide watch at Eloy,” said Dr. Keller. “Based on one report of him
claiming he was not suicidal he was downgraded [from constant watch] … to 15-minute
checks.” Dr. Keller believes he instead should have been thoroughly evaluated by a
psychiatrist and strongly considered for hospitalization.116
Dr. Keller further noted that detention itself could have exacerbated Deniz-Sahagun’s
mental health condition.117
Dr. Stern also raised serious concerns about the appropriateness of Deniz-Sahagun’s
mental health care, in particular the doctor’s decision to downgrade Deniz-Sahagun from
suicide watch. He faulted the ODO’s death review for not adequately analyzing that
decision and not including an appropriate subject matter expert in psychiatric health.118

Substandard Care Evident in 16 of 18 Death Investigations
In 16 of the death reviews, the medical experts found evidence of substandard medical
practices that, if typical of the facilities, would put many other people detained in these
facilities in question at risk. These included the seven cases in which subpar care
contributed the patient’s death, as well as nine additional cases in which death was not

116 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
117 Ibid.
118 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.

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necessarily preventable, but in which they saw evidence of faulty systems whose operation
would create danger for others in detention.

Delays in Care and Emergency Responses
Several of the individuals who died experienced delays in care, including delays in
emergency responses.
In Eloy Detention Center, the death reviews for three of the four people who died during
this time period noted delays in the emergency responses. The ODO found in its review of
Cota-Domingo’s death that Eloy Detention Center medical staff believed they could not call
911 without first receiving a “provider’s order” per Eloy Detention Center’s Local Operating
Procedure on Emergency Medical Services. The ODO did not cite this policy as a violation
in this case. Four months later, Jorge Garcia-Maldonado and Elsa Guadalupe-Gonzalez
hanged themselves within days of each other.119 In reviews of these deaths, ODO found
that “confusion as to who has the authority to call for local emergency medical assistance”
led to three-minute and five-minute delays in calling 911, respectively. The ODO reviews of
their deaths indicate that Eloy Detention Center policy did then allow security personnel to
call 911 under CoreCivic/CCA Policy 8-1A on medical emergencies, but not before alerting
others within the facility, and that security staff believed they had no authority to call 911
without an assessment from medical staff. In these latter cases, the ODO found the facility
violated the 2011 PBNDS requirement of “access to specified 24-hour emergency medical,
dental, and mental health services” due to the confusion over who could call 911.
CoreCivic/CCA, the company that operates the Eloy Detention Center, told Human Rights
Watch that “there has never been a CCA policy that specifically indicates who can or
cannot contact 911 for emergency services.”

119 US Department of Homeland Security, Immigration and Customs Enforcement, “Report of Investigation: Garcia-Mejia,
Jorge/Unknown/0617 Detainee/Alien – Death (Suicide) / Eloy, Pinal, AZ,” October 7, 2013,
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-garciamaldonado.pdf (accessed September 19, 2016); US
Department of Homeland Security, Immigration and Customs Enforcement, “Report of Investigation: Guadalupe-Gonzales,
Elsa/Unknown/0617 Detainee/Alien – Death (Suicide) / Phoenix, Maricopa, AZ,” September 25, 2013,
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-guadalupegonzales.pdf (accessed September 19, 2016).

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“While it is unclear whether their lives could have been saved in the absence of this delay,
waiting five minutes to call 911 can be a matter of life or death,” said Dr. Keller.120 “Any
staff member should be able to call 911 in an emergency,” said Dr. Stern.121

System-Wide Failures with Staffing and Training
In some facilities, the ODO found medical staffing was inadequate or the staff was
insufficiently experienced. In Brooks County Detention Center, the ODO found “[m]ost
medical care is provided by low level medical professionals such as LVNs [licensed
vocational nurses] and certified medical assistants.” The one doctor was at the facility for
only two hours each week, for 652 people held for ICE and other inmates.
A dearth of qualified staff was apparent during ODO’s investigation of the death
of Federico Mendez-Hernandez.122 During the two weeks that he showed symptoms of a
serious medical condition, which turned out to be rabies, he did not see a physician. The
ODO stated in its review of Mendez-Hernandez’s death that at one point, when he was
found unconscious, nursing staff roused him by sprinkling water on his face, which the
review noted was an “inappropriate nursing practice.” Dr. Stern also noted other important
indicators of substandard care, notably staff’s recording of vital signs four weeks after the
fact “from memory.”
Similarly, in Adelanto, the ODO noted many Adelanto medical staff cited “a high turnover
rate among nurses [as] a great concern,” and that “approximately 50 percent of ADF’s
medical staff hires are new graduates” with a “definite difference between their skills and
those of more experienced nurses.” The ODO’s investigation found that an RN who saw
Morales-Ramos on March 2, 2015 noted that his abdomen was distended but “did not
detect a mass or protrusion.” The doctor who saw Morales-Ramos four days later described
his abdominal mass as “the largest she has ever seen in her practice.”
Dr. Stern told Human Rights Watch he believed seven other reviews pointed to the
conclusion that licensed vocational nurses (also called licensed practical nurses in some
120 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
121 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
122 US Department of Homeland Security, Immigration and Customs Enforcement, “Report of Investigation: Mendez-

Hernandez, Federico / Unknown / 0109 Detainee / Alien – Death (Known Cause – Terminal Illness) / Kingsville, Kleberg, TX,”
January 6, 2014, https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-mendezhernandez.pdf (accessed
January 5, 2017).

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states), certified medical assistants, and registered nurses were providing medical care
and making critical decisions they were not qualified to make in a way that was
dangerous. He further noted that such routine use of staff outside the scope of their
license should have been discoverable during inspections before contracting or during
routine follow-up inspections.123
In one of these cases, that of Pablo Ortiz-Matamoros, 25, both experts concluded there
was probably nothing that could have been done to prevent his death from metastatic
cancer in February 2013.124 He first reported symptoms indicating a larger problem—loss of
appetite, dark yellow urine and weight loss—in mid-January 2013. However, the ODO
review of his death contains evidence that licensed vocational nurses at GEO Group’s Joe
Corley Detention Facility (JCDF) were regularly conducting clinic visits and clinically
assessing patients for any danger that might follow from placing them in isolation, outside
of their scope of practice as defined by their license to practice nursing. The ODO,
however, did not flag this as a problem requiring resolution. The ODO review notes that a
registered nurse employed in the Joe Corley Detention Facility clinic during this time
“resigned her position with GEO at JCDF … over her concerns with the JCDF medical clinic.”
In the case of Marjorie Annmarie Bell, whose death by heart attack Dr. Stern and Dr. Keller
considered preventable, the ODO noted, “several nurses indicated that they were unsure
whether San Diego Contract Detention Facility had chest pain guidelines, or were unsure of
the guidelines’ contents.” Creative Corrections, a contractor hired by ICE to assess medical
care at the facility, said that training and adherence by nurses to established guidelines on
chest pain, however, “is critical.”
In two of the 18 cases, that of Jorge Umana-Martinez and Jose Javier Hernandez-Valencia,
both Dr. Stern and Dr. Keller found based on the evidence in the death reviews that the
patient received appropriate care.125

123 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
124 US Department of Homeland Security, Immigration and Customs Enforcement, “Report of Investigation: Ortiz-Matamoros,

Pablo/Unknown/0109 Detainee/Alien – Death (Known Cause – Terminal Illness)/Conroe, Montgomery, TX,” September 3,
2013, https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-ortizmatamoros.pdf (accessed January 5, 2017).
125 US Immigration and Customs Enforcement, “Detainee Death Review – Jorge Umana-Martinez, JICMS Case #201501038,”
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-umanamartinez.pdf and “Detainee Death Review – Jose
Javier Hernandez-Valencia, JICMS Number 201406153, https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddrhernandezvalencia.pdf (accessed January 5, 2017).

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The 18 cases relate to a tiny fraction of the hundreds of thousands of people held in
immigration detention during the period in question, and do not speak directly to conditions
in most of the 200-plus different facilities ICE uses to house immigrants. However, the
reviews raise serious concerns about ICE’s ability to detect, respond appropriately to and
successfully correct serious lapses in medical care that arise in any of these facilities—even
in cases in which the agency has conducted detailed investigations into individuals’ deaths.

Questions about the Adequacy of the Death Investigations
While the detainee death reviews reveal serious problems with the medical care provided
to the individuals who died, they also indicate weaknesses within the investigative and
monitoring process.
In each review, the Office of Detention Oversight explicitly and consistently refused to draw
conclusions as to whether the identified deficiencies contributed to the individual’s death.
The death investigations also appear to stop far short of analyzing the incidents in a way
that would improve medical care in facilities and prevent future harm, illness, and death.
In one review of a death in 2014, ODO stated, “ODO does not review quality of care during
a DDR, makes no determinations regarding the quality of care provided []..to Umana, and
recognizes that any thoughts regarding whether changes to its quality of care would have
affected the ultimate outcome are purely speculative.” The failure to draw conclusions and
effectively analyze incidents is a primary reason Human Rights Watch chose to work with
independent medical experts to review the ODO’s work.
In releasing these investigations, ICE did not provide any information as to the purpose of
these investigations, nor as to their outcome. ICE has not answered repeated requests for
information on what action was taken to remedy problems identified in these reviews.
Dr. Stern, who has experience investigating medical care in correctional facilities,
including immigration detention centers, also noted several ways in which the reviews
were deficient.

Failure to Properly Identify Deficient Care Decisions
In numerous cases, Dr. Stern identified events that constituted deficient care in the ODO’s
timeline of events that were not identified or emphasized adequately in the ODO’s

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findings. The ODO’s focus on technical violations and its failure to recognize major errors
is in keeping with what critics contend is the “checklist culture” of ICE oversight, as
described in a 2015 report from the National Immigrant Justice Center, which reviewed
hundreds of inspection reports for the 105 largest detention facilities from 2007 to 2012.126
It may also be due to a lack of expertise in the ODO’s investigation team.
In some cases, the ODO highlighted technical violations of the applicable detention
standards as “deficiencies” but described more serious errors as mere “areas of concern.”
Dr. Stern noted that in the review of the death of Welmer Alberto Garcia-Huezo, ODO
investigators focused on relatively unimportant omissions, like the failure to have GarciaHuezo sign a consent form before a tuberculosis skin test, yet seemed to miss the
importance of much larger failings. The latter includes their conclusion that the emergency
response when Garcia-Huezo was found unconscious was “appropriate and timely”
despite the fact that there was a four-minute delay in calling 911 and that staff loaded the
patient and moved him to the medical area while awaiting the ambulance, during which
time they could not monitor his condition nor continue CPR.127 The ODO also noted that
when Garcia-Huezo was given oxygen, medical staff found the oxygen level in the bottle
was very low and alternative oxygen bottles were all empty. Dr. Stern further stated there
may have been legitimate reasons to move Garcia-Huezo, such as security concerns, but
the failure of the ODO to consider these issues renders their analysis incomplete.128
In another case, the ODO deemed Rockwell’s care at Houston only violated one detention
standard and relegated other decisions that fall short of the standard of care, like the
failure to respond to the emergency call with all necessary emergency medical equipment,
to an “area of concern.” The applicable 2011 Performance-Based National Detention
Standards, Dr. Stern noted, “has a lot of holes, is poorly organized, and poorly written,”
but he said that many errors in Rockwell’s care should have been considered a violation of
the general standard, to “ensure detainees have access to appropriate and necessary
medical, dental and mental health care, including emergency services.”129

126 National Immigrant Justice Center and Detention Watch Network, “Lives in Peril: How Ineffective Inspections Make ICE

Complicit in Detention Center Abuse,” http://immigrantjustice.org/lives-peril-how-ineffective-inspections-make-icecomplicit-detention-center-abuse-0.
127 US Immigration and Customs Enforcement, “Detainee Death Review – Welmer Alberto Garcia-Huezo, JICMS #201410359,”
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-garciahuezo.pdf (accessed January 5, 2017).
128 Human Rights Watch email and telephone correspondence with Dr. Stern, June 8, 26, 30, and July 1-6, 2017.
129 Ibid.

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In many cases, Dr. Stern believed the failure of the ODO to identify key medical errors was
likely due to the absence of necessary medical expertise on the investigation team. In
nearly all of these 18 reviews, ODO contracted with Creative Corrections to provide a
subject matter expert. In the review of the 2012 death of Juan Flores Segura, no medical
subject matter expert was involved in the investigation. When specified, the review stated
the investigative team included a registered nurse or, in one case, a physician’s assistant.
“An RN does not have the requisite skill to evaluate all aspects of clinical care above the
level of an RN,” said Dr. Stern. “That some of the death investigations were not conducted
with a physician’s input ... suggests that the underlying process for conducting death
investigations is fundamentally flawed.”130 In the case of Deniz-Sahagun, where the critical
decision for analysis was the psychiatrist’s decision to remove the patient from suicide
watch, the death review could not have been done appropriately by a registered nurse or
even a non-psychiatrist physician.

130 Ibid.

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III. Further Evidence of Deficient Medical Care
The ICE death reports are not the only recent evidence of substandard care in US
immigration detention facilities. Serious allegations of substandard and inappropriate
medical care recently have been made regarding facilities around the country:
•

In February 2017, New York Lawyers for the Public Interest released a report
identifying serious and sometimes life-threatening deficiencies in medical care
experienced by people detained in three New York City-area county facilities.131

•

In May 2016, CIVIC filed a multi-party complaint with the Office of Civil Rights and
Civil Liberties summarizing complaints from 61 men and women detained at
Hudson County Correctional Facility, which include allegations of long delays in
receiving care and repeated failures by medical staff to use interpretation services
for non-English speaking patients, among others.132

•

A November 2016 report by the Southern Poverty Law Center included
numerous reports by detained people of inadequate medical care, including a
man who stated he broke his collar bone in detention but was denied
treatment for five months.133

•

In May 2015, a coalition of nongovernmental organizations, including CIVIC and the
American Civil Liberties Union, sent a letter alleging similarly substandard medical
care at Adelanto Detention Center.134

•

Many of the hundreds of people who have engaged in hunger strikes in
immigration detention centers in recent years have cited poor medical care as one
of the reasons for their strike.135

131 New York Lawyers for the Public Interest, “Health in Immigration Detention,” February 2016, http://www.nylpi.org/wpcontent/uploads/2017/02/HJ-Health-in-Immigration-Detention-Report_2017.pdf (accessed February 16, 2017).
132 Complaint filed by CIVIC, May 10, 2016, https://assets.documentcloud.org/documents/2829608/CIVIC-MedicalComplaint-Final.pdf (accessed January 5, 2017).
133 Southern Poverty Law Center, “Shadow Prisons: Immigrant Detention in the South,” November 2016,
https://www.splcenter.org/news/2016/11/21/new-splc-report-uncovers-abuse-and-neglect-immigrant-detention-centerssouth (accessed December 5, 2016).
134 Letter from American Civil Liberties Union of Southern California, et al., to US Department of Homeland Security, May
15, 2016, https://www.aclusocal.org/wp-content/uploads/2015/05/NGO-letter-re-Adelanto-medical-care.pdf (accessed
January 5, 2017).
135 Samantha Michaels, “Here’s Why Hundreds of Immigrants in Detention Have Gone on Hunger Strike,” Mother Jones,
December 3, 2015, http://www.motherjones.com/politics/2015/11/why-are-hundreds-detained-immigrants-going-hungerstrike (accessed January 5, 2017).

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In this chapter, we present additional evidence obtained from our own interviews with
more than 90 people who have experienced detention, family members, and attorneys,
and from expert medical analyses of the medical records of 12 individuals held by ICE in
2015 and 2016. The cases come from 10 different immigration detention facilities in
different parts of the country, including facilities operated by both private companies and
local county governments.
Expert analysis of the medical records identified numerous instances where
patients experienced:
•

Requests for care refused, ignored, or unreasonably delayed;

•

Provision of care by unqualified medical staff or professionals;

•

Poor quality care by facility nurse practitioners, physician assistants, and doctors;

•

Lack of informed refusals of care;

•

Delays in receiving off-site medical care;

•

Severely inadequate mental health care; and

•

Inadequate medical recordkeeping.

Our own investigations also identified serious logistical and linguistic barriers to care.
Although the medical records excerpted and analyzed below pertain to the experiences of
only 12 detained individuals, they include evidence of inadequate staffing and poor
operational systems that are unlikely to have affected only these individuals. The
problems documented in these records echo what dozens of individuals, families, and
attorneys told Human Rights Watch and CIVIC regarding the experiences of immigrants
detained in these and other facilities. They also echo many of the conclusions
independent medical experts reached after examining the death reviews (set forth earlier
in this report), and are similar to problems identified in a recent investigation of medical
care in private federal prisons operated by the same companies, a study which attributed
many of the failings to a “culture of austerity” reflecting constant pressure to cut costs.136

136 Seth Freed Wessler, “This Man Will Certainly Die,” The Nation, https://www.thenation.com/article/privatized-immigrantprison-deaths/.

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Human Rights Watch requested or obtained medical records for dozens of individuals who
said they had not received adequate or appropriate medical care while detained by ICE. All
individuals consented to having their medical records reviewed by medical experts for
analysis in this report. The 12 records analyzed by the experts were primarily chosen to
reflect individuals’ experiences with medical care in a diversity of facilities, and to reflect a
diversity of cases. The cases include people with preexisting chronic conditions, injuries
incurred while detained, and diagnoses of serious conditions, like cancer, while detained.
Three of the records come from facilities that were also investigated for a detainee death
from 2012 to 2015.
The medical records were reviewed independently by Dr. Marc Stern, who also reviewed
the detainee death investigations analyzed earlier in this report, and by Dr. Palav Babaria.
Dr. Babaria is the Chief Administrative Officer of Ambulatory Services at Alameda Health
System in Oakland, California, and Assistant Clinical Professor in Internal Medicine at the
University of California, San Francisco. She has over a decade of health-system
improvement and global health experience working in urban underserved areas of the
United States, South Africa, India and Haiti. She regularly provides expert opinions on
medical records for lawsuits involving medical care in correctional settings.
The experts assessed whether care was adequate, as reflected in the medical records,
considering standard practices in correctional health. Some of the people whose records
we obtained were still detained at the time we obtained their records, and for some of the
people who had been released, we were only able to obtain incomplete records. Therefore,
unlike the detainee death reviews, the experts were not asked to opine on whether
substandard medical care contributed to a particular outcome, but rather to identify
instances in which the care provided did not meet appropriate standards.
The experiences of the individuals below, as reflected in their medical records, do not
speak directly to the conditions in all of ICE’s detention facilities. But these medical
records add new evidence that substandard medical care is an ongoing and systemic
problem in the US immigration detention system.
Human Rights Watch provided summaries of the findings in this section to the private
companies that operate the facilities in question: Geo Group, CoreCivic/CCA, and
Management and Training Corporation. We did not request that these companies directly
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address the complaints in specific cases, as we had withheld the individuals’ real names
to protect their privacy. But where companies responded to specific cases, those
responses are included in our analysis.
CoreCivic/CCA stated that in all of the facilities named in this report, other than Laredo
Processing Center, IHSC provides medical care and is “solely responsible for contracting,
staffing and oversight of all medical and mental health services.”137
We have provided the companies’ full responses on our website.

After Three Years of Immigration Detention, 54-Year-Old with Serious Disabilities Deported
“Jose L.,” a 54-year-old former green card holder who had lived in the US for 32 years, was arrested by
immigration officials in February 2013 and detained at Adelanto Detention Facility, run by Geo Group, in
Adelanto, California. According to his medical records, he had a history of lower back pain and diabetes.
Both independent medical experts who reviewed his medical records for this report identified several
instances in which initial or follow-up care was unreasonably delayed. By the time he was deported in
2016, he was in a wheelchair, only able to walk short distances with a walker, and had lost vision in his
right eye.138
Jose told Human Rights Watch he was a lawful permanent resident and had lived in the US for 32 years. His
entire family—brothers, sisters, and extended family—are US citizens and permanent residents. His wife
passed away several years ago. He told Human Rights Watch that he was convicted in 2012 for transporting
drugs and had served 240 days of a three-year sentence. At the completion of that sentence, immigration
authorities took him to Adelanto.
In mid-2013, Jose was working in the facility kitchen when he slipped and fell, hitting his hip and back. He
did not feel a need to see a doctor at that time, but about a month later, he began to feel worsening pain
and asked to see a doctor. According to his records, he waited four months after a referral by the facility
doctor to an orthopedist to actually see the specialist. The orthopedist recommended a referral to a spine
surgeon. Jose had to wait another 18 months to see a surgeon.
Dr. Stern, upon analyzing the records, concluded that the first four months of the delay were reasonable
because the patient was responding to treatment of his pain. But once his pain could no longer be
controlled and he could not stand up for more than five minutes, the remaining 18 months of delay were

137 Letter from CoreCivic/CCA to Human Rights Watch, January 20, 2017.
138 Human Rights Watch interview with “Jose L.” (pseudonym), Adelanto, California, 2015 (exact date withheld).

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not reasonable. He pointed out the records do not indicate what recommendations the spine surgeon
made nor if any treatment plan was followed. Dr. Babaria noted there was some disagreement between
outside specialists as to the appropriate care, but concluded, “Ultimately [the facility] is responsible for
his care.” Dr. Stern similarly concluded, “Patient suffered a long time without proper care to his back
pain.” By the point the records end, “No specific treatment has been rendered and the patient remains in
pain with decreased function.”139
Jose told Human Rights Watch he was eventually scheduled for surgery but was deported before he could
have the surgery.140
In July 2014, Jose began to complain about losing vision in his right eye and severe pain, which was
eventually diagnosed as proliferative diabetic retinopathy, a common complication of diabetes. Both
experts pointed out problems with the steps the facility took in response. From the time he first
complained, it took five days for Jose to receive an initial evaluation by a physician, who thought he
might have a retinal detachment, which Dr. Stern deemed an emergency. Forty-eight hours later, the
optometrist found he had a hemorrhage within the eyeball and recommended that Jose see a retinal
specialist as soon as possible. It then took the facility doctor four days to submit a request for
authorization stating, “needs retinal specialist ASAP.” Over a month later, Jose was seen by a retinal
specialist. Both experts concurred with the need for a referral to a retinal specialist as soon as possible
and stated the facility failed to accomplish this. Afterward, numerous recommendations for follow-up
appointments with a retinal specialist were delayed. For example, a follow-up scheduled for one week
later would occur four weeks later. At one point, the retinal specialist cancelled the appointment due to
non-payment, presumably by ICE.
Both experts noted that proliferative diabetic retinopathy does not develop overnight, and they questioned
the competency of the facility eye doctor, who did his annual exam in February 2014—just five months
earlier—but failed to note any retinopathy. Dr. Babaria stated the facility in general did not manage his
diabetes well, and although his sugar level was high, the doctors did not make changes to his insulin
dosages. By the end of the records, Jose had become legally blind in his right eye.
Both doctors highlighted yet another significant delay. As Dr. Stern noted: “It took nine months after
discovering anemia and blood in the stool—a strong indication of the possibility of colon cancer in a 54year-old—for the patient to finally receive a colonoscopy [in January 2015]…”141 Dr. Babaria noted that a

139 Human Rights Watch email and telephone correspondence with Dr. Marc Stern, May 31, October 6 and 12, and December

13, 2016; January 17 and March 5 and 11, 2017.
140 Human Rights Watch telephone interview with “Jose L.” (pseudonym), June 2, 2016.
141 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,

2016; January 17 and March 5 and 11, 2017.

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new doctor in October 2014 noticed he had not had the colonoscopy and requested approval for the
procedure from ICE. ICE’s response was to cancel the colonoscopy, claiming it was not needed. Dr. Babaria
concluded, “This is completely inappropriate and not the standard of care.”142 Fortunately, when he did
eventually receive the colonoscopy, it was negative.143
In response to a summary of the problems identified above which we sent to the company without
identifying the patient, Geo Group wrote in a letter to Human Rights Watch that it did not have enough
information on this particular case to determine whether referrals to specialists occurred within an
appropriate time-frame, but noted that Geo policy requires detainees to be seen within seven days of the
original request for medical care, and that Jose’s first visit with a physician for his eyesight fell within that
time frame. Geo further noted with regard to delays in follow-up care: “The record is needed to determine
his condition upon return to the facility, specialist consultation notes, appointment availability, and timeframe of TAR approval for follow-up appointment.”144
Geo also said it could not evaluate the delays Jose faced in seeing a specialist for back pain without a
thorough review of the medical record, but noted pain management is provided “based on the clinical
judgment of the qualified health care professional founded on objective findings and assessment of the
current medical condition.”145 With regard to the delay in Jose’s colonoscopy, Geo did not address the
initial delay in ordering a colonoscopy after discovering anemia and blood in the stool but pointed out he
did get one three months after a doctor ordered one in October 2014.

Requests for Care Ignored or Delayed
In some of the medical records we examined, the patients requested medical care citing a
specific complaint, but were never seen for that complaint or were seen weeks later. The
records of “Henry P.” from his one-and-a-half year stay at Etowah County Detention Center
revealed spotty access to care. Although Henry—who experienced a range of ailments from
blurriness in vision to fever after being diagnosed with stomach cancer—sometimes was
seen quickly, on several occasions he received a written response, sometimes with a
prescription, without being seen at all. Both doctors flagged this as a serious problem. Dr.
Babaria expressed concern that the facility appears to “make a lot of medical decisions

142 Human Rights Watch email and telephone correspondence with Dr. Palav Babaria, October 3, 7, and 21, and November

10, 2016; April 18, 2017.
143 Another detainee at Adelanto, Raul Ernesto Morales-Ramos, died in May 2015 after similar delays in following up with

symptoms of colon cancer. See Section, “Deaths in Detention, 2012-2015, Raul Ernesto Morales-Ramos.”
144 Email from Geo Group to Human Rights Watch, January 17, 2017.
145 Ibid.

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without seeing the patient.”146 Dr. Stern described such “care by correspondence” as
“dangerous.”147 Dr. Stern detailed how in some cases Henry P. waited three weeks or more
to get treatment, including after a request for care describing “lower abdominal pain.”
When a nurse practitioner finally saw him, the encounter, as described by Dr. Stern, was
“severely deficient,” as the NP failed to do a full examination and assessment given his
age-related risk for colon cancer.148
Both experts flagged delays faced by a man in Imperial Regional Detention Facility in
California who requested emergency help because of a severe tooth pain that he rated as
pain level 10 on a scale of 1-10. He saw a nurse who gave him some pain medication and
was initially told he would see a dentist later that day, but the patient did not actually see
a dentist until four days later.149 Dr. Babaria further noted that the dentist eventually
diagnosed him with a periodontal abscess, which, left untreated, could have spread to the
rest of the body and developed into sepsis. She believes given the severity if his pain, he
should have been seen by a dentist that same day.150
The medical records for “Martin P.,” held in York County Prison in Pennsylvania, seem to
indicate the patient requested care for pain and loss of vision in his right eye on May 2, 2015,
but the records indicate he was not actually seen by a nurse practitioner until three weeks
later. Both experts flagged this as a serious problem. Dr. Stern noted it was possible the
records were missing pages, but in one of the requests for care, Martin states, “This is my
10th slip,” suggesting he had repeatedly sought care without success.151 “Sudden loss of
vision is an eye emergency,” Dr. Babaria stated. “The sooner you get treatment the better
your chances of full recovery. Patients with delays are at risk of permanent vision loss.”152

146 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
147 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,

2016; January 17 and March 5 and 11, 2017.
148 Ibid.
149

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13, 2016;
January 17 and March 5 and 11, 2017; and with Dr. Babaria, October 3, 7, and 21, and November 10, 2016; April 18, 2017.
150 Ibid.
151

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
152 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.

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Almost four months after his first request for care about his vision, Martin P. was seen by an
eye doctor who found he was legally blind after toxoplasmosis, a parasitic infection.
Records from people held in Orange County Jail in New York, Hudson County Correctional
Facility in New Jersey and Adelanto Detention Facility in California also reveal instances in
which requests for care were ignored or were addressed only after unreasonable delay.153
According to Dr. Stern, the records of a man held in Hudson County Correctional Facility
directly contradicted the claims of facility staff who told Human Rights Watch and CIVIC
volunteers during a tour that requests are triaged by registered nurses and everyone is
seen within 24 hours.154 The records, in fact, indicate that the facility responded to his
requests for care with written notes saying he had already been seen earlier, but those
earlier visits were for other ailments: he eventually was seen in connection with his
specific complaint, described by the patient as “strong pain in my glublodder [sic], I
cannot walk with the pain,” only one month after his initial request.155
The kind of delays and failures to provide care evidenced by these records are similar to
the problems reported by individuals and attorneys in other cases to Human Rights Watch.
A woman detained in Eloy Detention Center told Human Rights Watch she had benefited
from meeting with the psychiatrist there, but when she had a crisis with her depression
and asked to meet with him, she was told the doctor was not there and she could not see
him. Soon thereafter, she cut herself. Even after her self-harm she was only able to see a
psychiatrist four days later. She told us: “I feel impotent. It’s like talking to a wall because
they don’t listen to us.”156
Angel Rosa told Human Rights Watch that while he was held in Utah County Jail, he felt
pain in his groin for months and repeatedly sought care, but was denied access to a
doctor. When he was finally seen in November 2014, he was sent to the local hospital
where he was diagnosed with Fournier’s gangrene, a potentially life-threatening infection

153

Ibid.; Human Rights Watch email and telephone correspondence with Dr. Stern, March 27, May 31, October 6 and 12, and
December 13, 2016; January 17 and March 5 and 11, 2017.
154 Human Rights Watch stakeholder tour of Hudson County Correctional Facility, Kearny,

New Jersey, March 22, 2016.

155 Human Rights Watch email and telephone correspondence with Dr. Stern, March 27 and May 10, 2016. For months

afterward, this patient continued to complain of abdominal pain and was eventually diagnosed with gallstones and
recommended for surgery, which was scheduled but did not occur. Shortly after his release in December, six months after he
had first complained of severe abdominal pain, he received emergency gallbladder surgery. Human Rights Watch interview
(name withheld), New York, New York, February 21, 2016; medical records from emergency gallbladder surgery post-release
provided to Human Rights Watch by the patient.
156 Human Rights Watch interview (name withheld), Eloy, Arizona, 2016 (exact date withheld).

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in his testicles.157 As noted in the previous section, our medical experts concluded that a
preventable death had occurred in that same facility in July 2014.158
Attorney Brian Hoffman reported that he believed his client, a three-year-old boy held in the
South Texas Family Residential Center in Dilley, Texas, was seriously sick but the illness was
not being taken seriously by the facility medical staff, who gave him Tylenol. After consulting
the Texas Department of Family and Protective Services, Hoffman called 911, which led to an
ambulance taking the child to a hospital where he was diagnosed with pneumonia.159
Eduardo Beckett, an attorney in Texas, described how his client, a Mexican man with a
strong claim for asylum, was experiencing severe pain in his testicles and back, but was
told, “It’s in your head, you’re fine, you’re fine.” Soon after, he lost consciousness and was
taken to the hospital, where they prescribed several medications, but he reported to his
attorney that five days later, he was only getting one of the medications. He told his
attorney, “This medical pain is so bad, I’d rather just go back and be killed.”160 In another
case, Beckett described a client who was throwing up repeatedly and suspected she was
pregnant, but the facility continued to say she was not pregnant until she was sent to the
emergency room where a test quickly revealed she was, in fact, pregnant.161
A former correctional officer at a Geo Group immigration detention facility told Human
Rights Watch of an incident where a man who had seizures told her he had not gotten his
medicine and that he was in the top bunk. She said she called medical three times, but
found out later that they never came, he never got his medicine, and he then fell off his
bed.162 Geo Group stated in response to this allegation that it has specific “Clinical Practice
Guidelines” that follow national guidelines governing treatment of seizures and
medication management, and that physical location of bed assignments are considered
for detainees under treatment for seizure disorders.

157 Human Rights Watch interview with Angel Rosa, Spanish Fork, Utah, January 23, 2016.
158 US Immigration and Customs Enforcement, “Detainee Death Review – Santiago Sierra-Sanchez, JICMS #201409551,”

https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-sierra.pdf.
159 Human Rights Watch telephone interview with Brian Hoffman, December 17, 2015.
160 Human Rights Watch telephone interview with Eduardo Beckett, November 13, 2015.
161 Ibid.
162 Human Rights Watch telephone interview with former Geo Group correctional officer, October 29, 2015.

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Barriers to Care
Many people who have experienced detention, attorneys, and other persons with
knowledge of detention facilities interviewed by Human Rights Watch noted there are often
significant barriers to accessing any care at all.
A woman held in Eloy Detention Center told Human Rights Watch that to request medical
care, you had to go to sick call at 5 am and wait outside in the cold, and that it could take
three days to a week to get what you need.163 Individuals in other facilities, as well as a
former correctional officer with experience in immigration detention facilities, told Human
Rights Watch of sick call procedures that also required early morning wake-up, and that
people who were sick but asleep were unable to request help.164
All versions of the detention standards applicable in US immigration detention facilities
require health care providers to obtain translation assistance, through a telephone
translation service if necessary, but lack of language access continues to be an issue for
immigrants seeking medical care in detention.165 Laura Redman, director of the Health
Justice Program at New York Lawyers for the Public Interest, told Human Rights Watch that
several of the organization’s clients never received the detainee handbook telling them
how to make a sick call request, and that many, particularly those who did not read or
write English, were dependent on acquaintances to make sick call requests.166 She noted
that although facilities have a telephonic “language line” available facility staff can call for
interpretation assistance, their clients told them staff rarely called the line.167
A former correctional officer employed by Geo Group described linguistic challenges to
medical care at one Geo facility. “It starts from when they arrive,” she said. “The nurse
gets on the bus. They say in English, does anybody have any immediate medical
needs? Nobody responds and they get off the bus.”168 As one man detained at Etowah
163 Human Rights Watch interview (name withheld), Eloy Detention Center, Eloy, Arizona, 2016 (exact date withheld).
164 Human Rights Watch telephone interview with former Geo Group correctional officer, December 14, 2015.
165 The standards vary in that the 2000 National Detention Standards allow for another detainee to be used for translation
assistance “if they are proficient and reliable, and the detainee being medically screened consents,” whereas the 2011
Performance-Based National Detention Standards explicitly states detainees shall not be used for interpretation service,
unless in an emergency medical situation. US Immigration and Customs Enforcement, “2000 Detention Operations Manual,”
https://www.ice.gov/detention-standards/2000 , and “2011 Operations Manual ICE Performance-Based National Detention
Standards,” https://www.ice.gov/detention-standards/2011 (accessed December 16, 2016).
166 Human Rights Watch telephone interview with Laura Redman, Reena Aurora, and Sola Stamm, September 20, 2016.
167 Ibid.
168 Human Rights Watch telephone interview with former Geo Group correctional officer, December 14, 2015.

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Detention Center stated, “The nurses don’t speak Spanish, so if you don’t speak
English, you can’t complain.”169
According to Geo Group, its policies state: “At the time of intake, Detainees will be advised
both verbally and in writing of the site-specific procedure to access medical, dental, and
mental health care. This information is also provided in the Detainee Handbook in English
and Spanish.” It further noted its policies require all healthcare providers to ensure
detainees receive care and services in a manner compatible with their preferred language
and level of education.170

Provision of Healthcare by Unqualified Personnel
One of the recurring problems identified in the detainee death investigations described in
the previous chapter is provision of healthcare by unlicensed or under-licensed personnel.
In records for several of the non-death cases, our experts identified evidence of similar
practices, where licensed vocational or practical nurses and registered nurses appeared
not to have consulted with a medical provider and made medical decisions outside the
scope of their license.
Both medical experts flagged the case of Carlos H., held in Yuba County Jail in California,
as particularly egregious. His torn ligament and severe knee pain went unaddressed for
months while he repeatedly saw a licensed vocational nurse (see inset below for more
detail on his story).171
They also highlighted the cases of Maribel Z, a woman detained in Laredo Processing
Center, and Ali F., a man detained at Imperial Regional Detention Facility, as cases in which
licensed vocational or practical nurses and registered nurses seemed to be providing care
without sufficient input from a nurse practitioner, physician’s assistant, or physician.
Maribel Z.’s records show that she requested medical care because she was throwing up
blood. As Dr. Stern notes, the record suggests that the symptom was “not explored at all”
by the licensed practical nurse on duty. The LPN also described the patient’s neck as
169 Human Rights Watch interview (name withheld), Etowah Detention Center, Gadsden, Alabama, 2016 (exact date withheld).
170 Letter from Geo Group to Human Rights Watch, January 17, 2017.
171

Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10, 2016;
April 18, 2017; and with Dr. Stern, May 31, October 6 and 12, and December 13, 2016; January 17 and March 5 and 11, 2017.

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visibly swollen, but no further examination was done. Dr. Stern stated this was an
emergency until proven otherwise: “If the LPN really consulted with the nurse practitioner,
then this swelling was either not communicated, or the nurse practitioner failed to pursue
it. Either way it was very dangerous.”172
In response to our inquiry about this case, CoreCivic/CCA, which operates Laredo
Processing Center, stated that the case summary we provided in our letter did not set forth
sufficient information to identify the patient, and that it could not comment without the
patient’s permission even if it had been able to identify the patient. It further stated,
“Nursing staff are trained to operate first within their scope of practice, and to follow
specific nursing protocols related to patient care.”173
In reviewing the records of “Ali F.,” detained at Imperial Regional Detention Facility, the
medical experts noted that the RN did not conduct a thorough examination of Ali despite
seeing him several times. Ali’s principal complaint was with pain in his right leg, which he
believed stemmed from a fracture from a gunshot wound in 2006. A nurse’s entry in his
records from December 2015 notes that he had felt pain in his right leg for three months.
His records include the report of an X-ray eight days later, but it is of his left ankle, not his
right. Both experts noted there was no documentation a medical professional authorized
to order an X-ray had seen the patient before the X-ray was taken.174 No one noticed the
wrong leg was X-rayed.
Management and Training Corporation, which operates Imperial Regional Detention
Facility, stated in a letter to Human Rights Watch: “We only hire RN3- and LVN3-level
nurses who receive advanced medical training.” They further stated, “We have a rigid
internal checks and balances system overseen by a quality improvement committee which
reviews charts daily and creates monthly reports,” and noted they are audited multiple
172 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
173 Letter from CoreCivic/CCA to Human Rights Watch, January 20, 2017.
174 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,

2016; January 17 and March 5 and 11, 2017, and with Dr. Babaria, October 3, 7, and 21, and November 10, 2016; April 18,
2017. In general, only physicians are authorized to order X-rays. Under California law, a nurse practitioner may order an X-ray
if there is a standardized procedure in place. California Code of Regulations, Title 16, Division 14, Article 7, Section 1474; see
also State of California Department of Consumer Affairs, “An Explanation of Standardized Procedure Requirements for Nurse
Practitioner Practice,” http://www.rn.ca.gov/pdfs/regulations/npr-b-20.pdf (accessed March 23, 2017). There is no
indication in the records or in the response from the company operating the facility that such a standardized procedure was
in place.

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times a year.175 They did not directly address why there was no record of a physician
ordering the X-ray.

Poor Care and Delays by ICE Lead to Untreated ACL Tear and Severe Knee Pain for Months
On February 2015, “Carlos H.,” fell in the shower at Yuba County Jail where he was being held for
immigration authorities. His medical records confirm what Carlos told Human Rights Watch: long delays at
each stage of the process, from seeing a doctor, to being diagnosed with a torn anterior cruciate ligament
(ACL), to being scheduled for surgery, to receiving physical therapy.176 He essentially endured pain that
could have been treated or ameliorated for almost a year.
Both medical experts agreed that his records revealed dangerous substandard medical practices. Dr.
Babaria stated, “It is evident from reading the first 10 pages of his records the system is providing
substandard care.”177 Dr. Stern concurred, “It is clear that the health care is delivered mostly by LVNs
practicing independently. They call the MD when they think it’s necessary, but unfortunately, they do not
have sufficient training and licensure to know when that is.”178
Both medical experts noted that the records indicate Carlos requested medical care for his knee five times
over three months, and made two other requests for other medical issues without seeing a doctor or a
registered nurse. Instead, he was seen by a licensed vocational nurse who did not refer him to a doctor
until the fifth visit. Both experts agreed this constituted practice outside the scope of an LVN’s license. Dr.
Babaria explained LVNs are allowed to assess patients, but they are not allowed to make diagnoses or to
make treatment plan recommendations independently.179
Once he was seen by a doctor, his knee was appropriately examined and he was sent for an X-ray and MRI,
which revealed a torn ACL and possibly a meniscus tear. Dr. Babaria stated the MRI report also noted some
inflammation deep in the bone, indicating possible fracture as well. “The damage was more than you
would have seen just in a tear,” she said.180 Carlos was referred to an orthopedist who recommended
surgery and the facility submitted a request to ICE for approval at the end of July. Dr. Babaria was not
troubled by the two months it took from seeing a doctor to submitting a request for surgery since the injury

175 Email communication from Management and Training Corporation to Human Rights Watch, January 10, 2017.
176 Human Rights Watch interview with “Carlos H.” (pseudonym), (location withheld), March 7, 2016.
177 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
178

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
179 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
180 Ibid.

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did not require emergent surgery, but stated, “The consultation would have happened 3 months earlier if
he hadn’t seen only LVNs.”181
What followed then was unexplained delays by ICE in scheduling the surgery. Both experts flagged notes in
the record indicating that ICE twice requested delays, first from mid-August to the end of August, and then
again until the first week of October. Dr. Stern questioned the ICE delay. He did not find the delay
“clinically significant” because ACL surgery is not emergent, but stated, “I can’t imagine any good reason
for [the delay].”182 Dr. Babaria concurred, “It’s not clear to me this was run by a physician, if any clinical
decision making went into this.”183 A 2016 GAO report states IHSC does not have specific written clinical
guidance on which to base decisions for off-site care.184 The record did not contain notes from the surgery,
but Dr. Babaria noted there were indications the surgeon had found a fracture, due to the presence of
hardware in a later X-ray, although without an operative report, she cannot definitively state a fracture was
found. “If he did have a fracture, that is even more concerning,” she said. “The patient may have had a
broken bone and was walking around on it with a five-month delay not explained anywhere.”185
Even after his surgery, Carlos’s ordeal was not over. Dr. Stern noted that the surgeon had ordered narcotic
pain medications, but the facility doctor changed the order to a non-narcotic without explanation and
without setting up a mechanism to monitor post-operation pain. Two days after surgery, Carlos collapsed
with shortness of breath. The LVN who managed the emergency response measured his pulse and oxygen,
but not his respiration or blood pressure, and did not get the facility physician involved. Dr. Stern stated,
“This episode is particularly worrisome and dangerous because of the risk of blood clot and pulmonary
embolism. The failure to get the physician involved presented a major threat to the patient’s life.” He
further noted the episode may have resulted from not having adequate pain control, which would have
been prevented by the medications ordered by the surgeon.186
Both doctors emphasized the substandard care Carlos received indicates systemic problems at the facility.
“For five months, [Carlos] had this really severe pain and damage that just went untreated,” Dr. Babaria
said. “If there’s anyone at facility who’s unfortunate enough to develop cancer, a five-month delay is a
death sentence.”

181 Ibid.
182 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
183 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
184 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management

and Oversight of Detainee Medical Care,” http://www.gao.gov/assets/680/675484.pdf.
185 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,
2016; April 18, 2017.
186 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.

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Poor Quality Care by Facility Medical Providers
The quality of care is another concern. In their review of the medical records, the experts
identified situations in which potentially dangerous symptoms were not addressed
quickly; repeat visits regarding the same symptoms were treated in the same manner,
often with over-the-counter medication, rather than examined further; or symptoms were
too quickly ascribed to “anxiety.”
Both experts highlighted the poor care received by “Maria C.” at Eloy Detention Center—
whose symptoms of dizziness and headaches could have been a sign of a serious and
dangerous condition, but were too quickly ascribed to anxiety by nurses (her story is set
forth in more detail below).
Both experts also noted numerous instances of poor care for Henry P., a case already
mentioned above. In October 2014, Henry complained of pain in his lower abdomen when
he had a bowel movement. After waiting three weeks, he saw a nurse practitioner whom
both experts faulted for failing to examine his rectum. The NP prescribed antibiotics, which
both experts questioned. Dr. Babaria noted there was no diagnosis or testing, so “I don’t
know what [the NP] is treating.”187 Dr. Stern pointed out that if the NP thought Henry had a
bacterial infection, he should have received much closer follow-up monitoring.188 At other
points during his detention, Henry had abnormal lab results which were not addressed,
such as evidence of possible hypertension and liver malfunction.
A year later, soon after Henry P. was diagnosed with stomach cancer, he requested care for
a sore throat, cough, and fever in December 2015. He was seen by a nurse, who talked to a
doctor, and then gave him Tylenol and amoxicillin, an antibiotic, for seven days. Both
doctors noted that given his cancer diagnosis, he could have had a serious infection. Dr.
Babaria stated, “He should absolutely have been seen by a physician.”189 Dr. Stern noted
he was immunocompromised and that the safest course of action would have been to

187 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
188

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
189 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.

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keep him in the infirmary and monitor every four to eight hours to ensure he was getting
better, not worse, and the failure to schedule a follow-up was “wrong and dangerous.”190
Other examples of poor quality care the experts flagged included poor management of a
severe seizure disorder suffered by an individual detained at Adelanto Detention Center,
prescribing an antidepressant without any documented explanation to a woman at Hutto
Detention Center, spotty and poor administration of antibiotics at Imperial Regional
Detention Facility, and inadequate and dangerous monitoring and treatment of
detoxification from alcohol or drugs in two separate cases in Hudson County and York
County Prison.191
In the case of “Julio P.,” an HIV-positive man, the records indicate that in November 2015 a
nurse practitioner visually examined his rectum and concluded that he had a hemorrhoid.
In February 2016, he was referred to an outside specialist because a rectal mass was found
and he was diagnosed with anal cancer. Both doctors noted the lack of documentation
between November 2015 and February 2016, which should have explained who identified
the rectal mass and determined he needed an outside referral. Dr. Babaria further
concluded that Hudson County Correctional Facility, where he was held, was not following
appropriate HIV screening guidelines. She explained people who are HIV positive have a
higher risk of anal and cervical cancer, and should be given annual screenings, which were
not done in Julio’s case; the failure could have resulted in a meaningful delay in
diagnosing his cancer.192

190

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
191 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13, 2016;
January 17 and March 5 and 11, 2017, and with Dr. Babaria, October 3, 7, and 21, and November 10, 2016; April 18, 2017.
192 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017. See also, US Department of Veteran Affairs, “Anal Dysplasia and HIV,” October 28, 2011,
http://www.hiv.va.gov/provider/manual-primary-care/anal-dysplasia.asp (accessed November 30, 2016).

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Poor Care by Nurses Indicates Ongoing Problems at Eloy Detention Center
The medical records for “Maria C.,” a woman who reported a history of hypertension or high blood
pressure, indicate recent poor care by nurses at Eloy Detention Center, a facility that has been under
scrutiny because of four deaths from 2012 to 2015.
When Maria first entered Eloy, she was prescribed medication for her reported high blood pressure. From
October 2015 through March 2016, the records indicate Maria made repeated requests for care,
complaining of dizziness and headaches. In most instances, Maria saw a nurse who recorded low blood
pressure readings. In February 2016, she lost consciousness, which both experts noted could have been
due to low blood pressure. Dr. Stern stated, “This required [another] measurement of blood pressure and
pulse lying and standing,” which was not done.193 Dr. Babaria agreed more should have been done but
instead “[t]hey made her rest, drink water, and sent her back out.”194 Both experts questioned whether she
ever had high blood pressure and whether the medication prescribed for hypertension might have lowered
her blood pressure, causing these symptoms. Yet, throughout this time, no change was made to her blood
pressure medication.
Both doctors noted her repeat complaints of headache should not have been addressed simply with
ibuprofen. Dr. Stern found such care “dangerous,” stating: “There are a number of serious conditions that
can … manifest as eye/head/dental pain that at least needed to be considered.”195 Dr. Babaria agreed,
“Someone who has recurrent headaches needs to be evaluated by a nurse-practitioner or MD.… [But] she
keeps seeing a nurse, the nurse keeps treating her the same way, and no one evaluates her.”196
Dr. Stern pointed out other instances of dangerous practice, such as a urinalysis in April 2016 that was
abnormal and probably indicative of an acute urinary tract infection, but for which no action was taken.197
Dr. Babaria noted on February 22, 2016, Maria complained of menstrual cramps one year after she had her
last period. “Postmenopausal bleeding could potentially be endometrial cancer, and it should be

193

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
194 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
195

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
196 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
197

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.

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automatically evaluated by gynecologist to rule out cancer.”198 By the time the records end in April, this
issue had not been addressed.
In the records, nurses repeatedly ascribe Maria’s complaints to anxiety. Dr. Stern pointed out that on
November 25, 2015 a nurse who saw Maria for chest pain diagnosed her with difficulty coping without
doing a complete examination and without discussing the case with a practitioner, which he found to be
dangerous.199 Dr. Babaria was concerned by notes that indicate the nurses are “attributing all of these
symptoms to her anxiety, which may or may not be true, but until you rule out more concerning diseases
(like cardiac issues), it’s not appropriate.”200
“There was a repeat pattern of nurses making decisions they’re not qualified to make and little to no
oversight by nurse-practitioners or physicians, which is dangerous,” concluded Dr. Babaria.201

Refusals of Care Not Properly Documented
Several of the records include instances in which the patient seems to have refused
medication or treatment without any indication that the patient was adequately informed
of the risks. Under international human rights law and US law, individuals have the right to
refuse medication or treatment, but the experts raised concerns about the way the refusals
were documented and whether they were truly informed refusals. Dr. Stern explained, “A
patient contemplating consenting to—or refusing—a complex and dangerous surgical
procedure should receive a detailed explanation of the risks, benefits, and alternatives,
have an opportunity to have all his/her questions answered, and the event should be
memorialized in a written document.”202
Dr. Stern pointed out that in the case of “Martin P.” at York County Prison, the records
indicate he refused medication that was likely prescribed for withdrawal from alcohol,
which can be extremely dangerous. The refusals were obtained by a licensed practical

198 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
199 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,

2016; January 17 and March 5 and 11, 2017.
200 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
201 Ibid.
202 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.

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nurse without documented explanation of the risks.203 In Henry P.’s case, after major
surgery for his stomach cancer, he refused to be housed in the infirmary. Dr. Stern pointed
out that, given the importance of post-surgical monitoring, “This demanded a one-to-one
conversation by the MD with the patient to be sure he understood the reason for the
refusal and made every effort to change the patient’s mind or find an accommodation....
You don’t just throw up your hands and say, ‘Oh well, I tried.’” 204 Henry’s medical records
give no indication that this consultation took place.

Unreasonable Delays in Obtaining Off-Site Care
Long delays in receiving off-site care recommended by detention facility medical providers
was a common complaint among formerly detained people and attorneys who represent
them, as already illustrated in the multiple delays experienced by Carlos H, whose case is
detailed in an inset above.
When an individual requires medical care that the facility clinic cannot provide, the facility is
required to take the following steps: identify an off-site provider, schedule an appointment,
and submit a request through the MedPAR (Medical Payment Authorization Request) system,
which request is then reviewed by the Immigrant Health Service Corps (“IHSC”).205 A nurse at
Etowah County Detention Center stated that some requests, such as for a urinalysis, are
approved right away but some requests can remain pending for months.206
The medical records of Carlos H. indicate the delays in his care (described in more detail
above) were not only due to failures by facility nurses to refer him to a physician, but also
by ICE’s decision to repeatedly delay surgery for his torn ligament after the problem was
diagnosed. As both experts found, the notes indicated no clinical reason—such as pain
being effectively controlled by medication—for these delays. The delay may have been due
to budgetary considerations, as the last request for a delay pushed his surgery into the
next fiscal year.

203

Ibid.

204 Ibid.
205 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management

and Oversight of Detainee Medical Care,” http://gao.gov/products/GAO-16-231.
206 Human Rights Watch stakeholder tour of Etowah County Detention Center, Gadsden, Alabama, January 20, 2016.

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During a tour of Adelanto Detention Facility, the assistant field office director, Gabe Valdez,
told Human Rights Watch that decisions on outside treatment can be affected by whether
deportation is imminent. He stated, “Timelines for approval exist,” explaining that a man
who wants dentures but who will be deported in three days will not get dentures. He further
stated decisions are made in consultation with ICE and with IHSC.207 In many immigration
cases, however, it is not easy to predict when a person will be deported or released.
Delays in referring a patient to a gastrointestinal specialist were noted in the case of Raul
Ernesto Morales Ramos, detailed in the previous chapter.208 Dr. Stern observed that the case
also reveals an underlying flaw in the process for requesting off-site care—the facility is
supposed to make an appointment with an off-site provider before receiving approval from
IHSC. He explained this process risks cancellation of the appointment if IHSC does not
approve the request, which he criticized as wasting staff resources and risking specialists
being annoyed and unwilling to take future referrals. “It’s hard enough to find specialists
who are willing to see detainees in their community offices,” he said. “When annoyed, they
have a low threshold for severing their relationship with the detention facility.”209
In its letter to Human Rights Watch responding to our findings on off-site care, Geo Group
stated: “Community specialist appointments are based on availability and, on occasion,
can be beyond the scheduled time-frame requested by the facility provider.… If a detainee
is unable to be seen within the time-frame ordered, the request is returned to the provider
for an alternative treatment plan, extension, or referral to a hospital if appropriate.”210
Human Rights Watch and other organizations have long-criticized ICE for contracting with
facilities in remote locations far from the cities and towns where most immigrants are
apprehended, which are also far removed from legal service providers and other services.
A 2009 report by a corrections expert, commissioned by ICE, included a recommendation
to locate facilities nearby consulates, pro bono counsel, and 24-hour emergency care.211
The challenge of scheduling appointments with medical specialists, as acknowledged by
Geo Group, underscores another important reason for ensuring that facilities are not
207 Multi-organizational stakeholder tour of Adelanto Detention Facility, Adelanto, California, September 4, 2015.
208 US Immigration and Customs Enforcement, “Detainee Death Review – Raul Ernesto Morales-Ramos, JICMS #20505282,”

https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-morales.pdf.
209

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
210 Letter from Geo Group to Human Rights Watch, January 17, 2017.
211 Dora Schriro, US Department of Homeland Security, US Immigration and Customs Enforcement, “Immigration Detention

Overview and Recommendations,” October 6, 2009, https://www.ice.gov/doclib/about/offices/odpp/pdf/ice-detentionrpt.pdf (accessed February 14, 2017).

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located far from needed services. A recent DHS enforcement memorandum states most
migrants apprehended at the border will be detained until their proceedings are
concluded, and calls for increased detention capacity along the southern border, policies
that can be expected to exacerbate the problem.212
“Ali F.” told Human Rights Watch that facility staff had told him they could not provide care
for his leg injury because it stemmed from a shooting that occurred in his home country
years earlier.213 Such a statement would be incorrect—ICE is required to provide adequate
medical care for all medical issues, whether stemming from preexisting conditions or from
conditions that first appear in the facility. As noted above, many of the publicly available
contracts indicate that even when ICE pays for off-site care, the facilities are responsible
for transportation and security costs associated with off-site care, and therefore have a
financial incentive for limiting or denying off-site care.214

Inadequate Mental Health Care and Misuse of Isolation
Mental health care in US correctional facilities is often poor, and people with mental
health conditions frequently suffer appalling abuses, including isolation that amounts to
cruel, inhuman, and degrading treatment under international human rights law.
Individuals detained in some facilities suffer from both poor mental health care and
misuse of isolation. A recent investigation by The Verge found more than 160 cases of
individuals with mental health conditions placed in isolation in logs maintained through
2016 from three privately run ICE facilities.215 Another study found regular use of isolation
in multiple immigration detention centers as a form of control for people with psychosocial
disabilities.216 The Department of Homeland Security Office of Inspector General issued a

212 US Department of Homeland Security, Memorandum from Secretary John Kelly, February 20, 2017,

https://www.dhs.gov/sites/default/files/publications/17_0220_S1_Implementing-the-Presidents-Border-SecurityImmigration-Enforcement-Improvement-Policies.pdf.
213 Human Rights Watch interview with “Ali F.” (pseudonym), Calexico, California, 2016 (exact date withheld).
214 National Immigrant Justice Center, “Immigration Detention Transparency and Human Rights Project,” Intergovernmental
Service Agreement Between the US Department of Homeland Security, US Immigration and Customs Enforcement Office of
Detention and Removal Operations and the City of Adelanto, https://www.documentcloud.org/documents/1633813adelanto-contract.html; Detention Services Intergovernmental Agreement, Hutto Detention Center,
http://www.documentcloud.org/documents/1672355-hutto-county-corectional-center-williamson.html .
215 Spencer Woodman, “ICE detainees are asking to be put in solitary confinement for their own safety,” The Verge, March 10,
2017, http://www.theverge.com/2017/3/10/14873244/ice-immigrant-detention-solitary-trump-corecivic-geo (accessed
March 23, 2017).
216 National Immigrant Justice Center and Physicians for Human Rights, “Invisible in Isolation: The Use of Segregation and
Solitary Confinement in Immigration Detention,” September 2012, http://www.immigrantjustice.org/research-items/report-

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short report in 2016, following up on a 2011 investigation into mental health care in
immigration detention, that found that ICE continues to struggle to attract and retain
mental health providers, particularly in rural and remote areas.217
Dr. John Rubel, a clinical psychologist with decades of experience in the federal Bureau of
Prisons, spent two years providing mental health services at Hutto Detention Center in
Texas, and found a tremendous need for mental health care, but trying to provide it at
Hutto eventually posed a “ethical and moral dilemma” that led him to leave. Dr. Rubel
described the prevalence of trauma in the facility, which housed more than 500 women, as
“extremely high,” saying, “It’s not just a single event [for these women], but multiple
episodes of trauma.”218 Despite the great need, mental health staff at the facility consisted
of one to two full-time staff members and one half-time staff member. Without more
mental health staff, he said, it was impossible to provide the comprehensive mental
health services required under IHSC policy.
Dr. Rubel noted that many people he saw were diagnosed with post-traumatic stress
disorder or major depressive disorder, “pretty severe diagnoses.” For such cases, he said,
“The treatment is not a 15-minute ‘How are you feeling, how are you sleeping, are you taking
your medication?’ That’s not treatment.” Dr. Rubel created a group therapy program, similar
to ones he had run successfully in other institutions for years, and felt like that was one way
of working with limited resources, but he said in his second year, the administration stopped
supporting group therapy, and he felt he could no longer offer a real option of treatment to
the traumatized women he evaluated. In talking to mental health providers at other facilities,
he heard they faced similar challenges with limited resources.219

invisible-isolation-use-segregation-and-solitary-confinement-immigration?q=publications/report-invisible-isolation-usesegregation-and-solitary-confinement-immigration-detenti (accessed November 30, 2016).
217 US Department of Homeland Security, Office of Inspector General, “ICE Still Struggles to Hire and Retain Staff for Mental
Health Cases in Immigration Detention,” July 2016, https://www.oig.dhs.gov/assets/VR/FY16/OIG-16-113-VR-Jul16.pdf
(accessed January 5, 2017); see also, US Department of Homeland Security, Office of Inspector General, “Management of
Mental Health Cases in Immigration Detention,” March 2011, https://www.oig.dhs.gov/assets/Mgmt/OIG_11-62_Mar11.pdf
(accessed January 5, 2017).
218 Human Rights Watch telephone interview with Dr. John Rubel, February 17, 2017.
219 Ibid.

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“A Sad Excuse of a Detention System for Individuals with Mental Illness”
“Luke R.,” a 39-year-old lawful permanent resident from Guyana diagnosed with schizophrenia, was
detained in Orange County Jail in New York from November 2015 through March 2016. Our experts
reviewed his medical and disciplinary records from this time, and agreed his care was abysmal. Dr. Stern
stated, “The events of early March describe a sad excuse for a detention system for individuals with
mental illness.”220
At the time of his intake, the facility learned of Luke’s history of schizophrenia, which was diagnosed in
2001, and the medications he had been taking. The records seem to indicate he refused to continue taking
those medications. In December, a doctor noted he wanted something “stronger” and prescribed 100
milligrams of trazodone at bedtime. Dr. Babaria noted that trazodone is an anti-depressant, not an antipsychotic, and as an internist, she would prescribe the dose Luke was given for people with insomnia.221
Dr. John Rubel, a clinical psychologist, also noted the records provided no indication Luke was given any
therapy. Although there are visits with social workers that are described as “supportive therapy,” he
described the notes as “sparse” and “totally unacceptable,” as they provided no information on his mental
state, what the social worker did, and what plan there was for follow up.222
Both experts agreed the most serious problems began in early March. On March 4, Luke met with the
facility’s psychiatrist and complained of hearing voices and people shouting. The doctor at first decided to
prescribe Haldol, an anti-psychotic, but because of an allergy, he changed the order to Benadryl, which
both doctors noted is an antihistamine. Dr. Stern described in detail why this was a poor decision. He
noted that while the doctor confirmed Luke did not have suicidal or homicidal ideation, he failed to explore
the nature of the voices further to find out what they were saying and to determine to what extent the
voices were causing dysfunction. “It may not be urgent to treat auditory hallucinations if they are benign
and not interfering with function or bothering the patient,” he stated. “However, if they are, they need to be
treated.… Based on the treatment given, we have no reason to believe they would stop.”223
On March 7, Luke was written up for inmate misbehavior (not moving a grey bin back to his cell after
cleaning) and moved to “Delta 1,” which according to Luke’s attorney constituted solitary confinement
while awaiting disciplinary hearings. While in this unit the next day, according to an “Emergency Response
Team Incident Response Report,” Luke banged his head against the glass window, causing a large
laceration on his forehead and breaking the cell window. Seven minutes later, he was examined by a
nurse, who sent him to the emergency room at an outside hospital. There he received 11 stitches and was
seen by a nurse-practitioner who also works at the facility. Upon his return, this nurse-practitioner saw
Luke, described him as “psychotic & paranoid & delusional,” and prescribed Geodon and Cogentin. Luke
was then placed in disciplinary segregation.

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Dr. Babaria expressed serious concern about the initial response of the correctional officers. His 11
stitches indicate his injury was severe, but “the officers’ first response was not to stop the bleeding or
assess the patient,” but to put him in restraints and videotape what was happening. “From previous
experience, facilities where officers don’t respond to medical emergencies appropriately using basic life
support measures are facilities where patients are placed at increased risk. That to me is a red flag,”
she said. Medical professionals saw Luke six minutes after the Emergency Response Team was notified.
Dr. Babaria stated, “Depending on how severe the injury, that five- to seven-minute delay could be life
or death for someone.”224
From March 10 onward, when he had returned from the hospital, a nurse “cleared” him for placement in
isolation pending a disciplinary hearing. Dr. Babaria noted there were a number of refusals for medication,
but the recordkeeping was poor: they do not list which medications or why he refused. Although Luke had
a right to refuse, a facility is still required to take steps to ensure refusal is informed. The records did not
contain medicine administration records, so it was not clear to Dr. Babaria whether he was getting any
psychiatric medications upon his return from the hospital.
On March 11, the facility held a disciplinary hearing for Luke, which he refused to attend. He was found
guilty of all charges and sentenced to seven days in disciplinary segregation with six days’ credit for the
time he had already spent in segregation.
On March 14, Luke had a psychiatric consultation with a licensed clinical social worker, who recommended
that he be hospitalized. Dr. Babaria noted this was the first psychiatric evaluation he had had at the facility
since his self-harm attempt on March 8.
Dr. Stern, Dr. Babaria, and Dr. Rubel all expressed grave concerns about the way his self-harm attempt was
treated. “Clearly the behaviors of March 7 and 8 were psychiatrically induced,” stated Dr. Stern. “He
should not have been cleared to be placed in segregation and this should have been addressed at the
hearing.… Instead he was essentially punished for being mentally ill.”225 Dr. Babaria concurred: “They

220 Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
221 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
222 Human Rights Watch telephone interview with Dr. John Rubel, March 3, 2017.
223

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
224 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
225

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.

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[treated] him as a criminal when he has a mental illness and it’s completely uncontrolled.”226 Dr. Rubel
pointed out it was highly unlikely Luke was mentally competent to participate in the disciplinary hearing.
He also questioned why the mental health professional who recognized Luke had a serious mental health
condition did not advocate for him by requesting a competency hearing or speak on his behalf at the
disciplinary hearing. Dr. Rubel concluded, “The whole system failed.”227
Luke’s attorney, Luis Mancheno, told Human Rights Watch that when he met with his client two days after
the self-harming attempt, Luke told him that it was a suicide attempt, that he wanted to “finish it all.”
According to Mancheno, Luke was transferred in mid-March to the Columbia Regional Care Center in South
Carolina, far from his attorney and family. ICE told Mancheno that was the closest mental health facility
with which it had a contract. While in South Carolina, Mancheno reported Luke received appropriate care,
that he was able to communicate with him easily and he was taking his medication, which he stated,
“speaks volumes of the horrible care he was receiving at Orange.”
Mancheno also stated Luke was criminally charged with destruction of property and now has a pending
case in Orange County. He wrote, “I can’t believe ICE punished him after not giving him the appropriate
care for so long.”228

Luke’s experience is similar to those reported by other individuals and attorneys.
Reena Aurora, an attorney with New York Lawyers for Public Interest, told Human Rights
Watch one of her clients had attempted suicide at Orange County Jail (the same facility in
which Luke R. was held), and he was placed in isolation and never had a psychiatrist do an
evaluation or assessment.229
Diane Devore, a therapist in San Diego, regularly consults with attorneys to assess the
credibility of asylum applicants, and expressed serious concern about the impact of
detention on already traumatized people. In one particular case, her client had done well
in a psychiatric facility, but when she was returned to the detention center, she did not
receive the same medication she had received in the hospital. “[S]he became unstable
and suicidal,” Devore said. “Typically, she would get isolated, which is probably the very

226 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
227 Human Rights Watch telephone interview with Dr. John Rubel, March 3, 2017.
228

Email from Luis Mancheno to Human Rights Watch, April 25, 2016.

229 Human Rights Watch telephone interview with Laura Redman, Reena Aurora, and Sola Stamm, September 20, 2016.

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worst thing to do with someone who is suicidal.”230 Florence Weinberg, an attorney who
has worked with Devore, concurred, stating, “I’ve had clients, very mentally ill clients ...
who’ve suffered from schizophrenia and various psychotic episodes, and the way
[CoreCivic/CCA] responds to that is to put people in solitary.”231
Two attorneys of clients with mental health conditions detained in Adelanto Detention
Center told us their clients were regularly put into isolation because adequate mental
health care was unavailable.232 Kelsey Provo, a legal services attorney, said she had
encouraged one client to reach out to a staff psychologist when he told her he had suicidal
thoughts, but the response was to put him in isolation on suicide watch, unable to see or
speak to anyone for a long period of time.233 Geo Group stated in its response to our
inquiry on this issue that its policy on suicide watch requires the detainee to have access
to staff within sight or sound 24 hours a day, seven days a week, with regular observation
depending on the detainee’s level, and scheduled mental health rounds conducted on a
daily basis by qualified mental health providers.234
In September 2013, ICE issued a segregation directive creating more requirements for
facilities to notify ICE when a person is placed in segregation. In particular, facilities are to
notify the local ICE Field Office Director (“FOD”) immediately and no later than 72 hours after
placement if a person placed in segregation “has a serious mental illness or a serious
medical illness or serious physical disability.”235 The FOD is then supposed to notify IHSC,
who then shall, “For detainees with a medical or mental illness, or identified as being a
suicide risk or on a hunger strike, evaluate the appropriateness of the placement and ensure
appropriate health care is provided. Such detainees shall be removed from segregation if the
IHSC determines that the segregation placement has resulted in deterioration of the
detainee's medical or mental health, and an appropriate alternative is available.”236
Even the limited prescriptions of the ICE segregation directive may not be fully understood
by some facility officials. During a tour of Hudson County Correctional Facility, Human
230 Human Rights Watch telephone interview with Diane Devore, March 10, 2016.
231 Human Rights Watch telephone interview with Florence Weinberg, March 2, 2016.
232 Human Rights Watch telephone interview with Alisa Whitfield, November 18, 2015
233 Human Rights Watch telephone interview with Kelsey Provo, October 26, 2016.
234 Letter from Geo Group to Human Rights Watch, January 17, 2017.
235 US Immigration and Customs Enforcement, “ICE Segregation Directive,” September 4, 2013,

https://www.ice.gov/doclib/detention-reform/pdf/segregation_directive.pdf (accessed November 30, 2016).
236 Ibid.

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Rights Watch asked if anyone had ever been removed from isolation because of
deterioration of their mental health or other health condition. A facility official at HCCF
responded that such removals did not occur because, “We clear them before we put them
in here,” and that a nurse does “welfare checks” three times a day. When asked what the
nurse should do during such a check, he responded, “Asking ‘how are you?’”237
Dr. Stern, who accompanied Human Rights Watch on the tour, disputed that assessment,
stating that during such checks, the nurse should be trying to have a normal interaction
and check that there are no unmet needs, not just check that the person is still alive.238
Florence Weinberg, an attorney who practiced mainly in southern California, found such
perfunctory mental health checks to be common in her clients’ cases. “Let’s say a client is
in administrative segregation,” she said. “The therapist will stick their head in and say,
‘how are you feeling today?’ That’s the therapist checking in.”239

Inadequate Medical Recordkeeping
Several of the records examined for this report are missing crucial documentation of medical
care; sometimes there are gaps of several months. Both experts highlighted two cases in
which both patients were eventually diagnosed with cancer, but where documentation was
severely inadequate. Dr. Babaria explained, “In any facility where multiple providers are
seeing a given patient, if you’re not documenting why you’re treating people, it leads to a lot
of confusion.”240 With regard to the records for Henry P., Dr. Stern noted it was possible the
missing records could show a “failure to address this problem in a timely manner leading to
delay of diagnosis of what is most likely going to be a fatal problem.”241
Some records indicate crucial medical information was not provided when the individual
was transferred from one detention facility to another. The records of a man with a history
of seizures indicates when he was transferred from South Texas Detention Center in Texas
to Etowah Detention Center in Alabama, no transfer summary was sent with him.242

237 Human Rights Watch and CIVIC stakeholder tour of Hudson County Correctional Facility, March 22, 2016.
238 Human Rights Watch email and telephone correspondence with Dr. Stern, March 27 and May 10, 2016.
239 Human Rights Watch telephone interview with Florence Weinberg, March 2, 2016.
240 Human Rights Watch email and telephone correspondence with Dr. Babaria, October 3, 7, and 21, and November 10,

2016; April 18, 2017.
241

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017.
242 Ibid.

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Mayra Gamez, a legal services attorney who represents individuals who qualify for courtappointed representation due to mental health conditions under the settlement in Franco

v. Gonzalez, described a case in which her client was transferred, without notice to her,
from Adelanto Detention Center to Northwest Detention Center while she was in
discussions with ICE about releasing him on his own recognizance. In a complaint she filed
with DHS Office of Civil Rights and Civil Liberties, she wrote her client “suffers from chronic
mental illness … [and] is epileptic, paraplegic, has hypertension and gastrointestinal
bleeding.” Her client informed her that since his transfer two weeks earlier, he had not met
with a psychiatrist, nor been given his psychiatric medication, though he had received his
epilepsy medication.243
Geo Group stated in its response to our inquiry about these cases that medical care at
South Texas Detention Center is provided by IHSC, and further stated, “A detainee cannot
leave the Adelanto Detention Facility without a Medical Transfer Summary, as they will not
be accepted by ICE officials for transport…. The detainee was transferred to a facility where
medical care is provided by [IHSC].”244
Some of the medical records we requested we never received; others were so incomplete
they were not reviewable. While some attorneys told Human Rights Watch it was not
difficult to obtain copies of medical records, others reported they faced long delays or
were never able to obtain the records.

243 Human Rights Watch interview with Mayra Gamez, Los Angeles, California, April 25, 2016; CRCL complaint provided to

Human Rights Watch.
244 Letter from Geo Group to Human Rights Watch, January 17, 2017.

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IV. Inadequate Oversight and Lack of Accountability
In recent years, numerous reports by both US government and outside monitors have
identified serious failures of oversight in the US immigration detention system.245 Reforms
implemented by the Obama administration created numerous monitoring bodies, some of
which have identified problems, but these initiatives have had a mixed record and
typically have no authority to hold facilities accountable for even severe failures to meet
standards, even after deaths occur. Notably, in March 2016, the Office of Inspector General
at DHS announced it would start ongoing, unannounced inspections of ICE and CBP
detention centers.246 A March 2017 report from one of these unannounced inspections of
Theo Lacy Facility in California found detained individuals being served meat that
appeared to be spoiled, moldy showers, mixing of low- and high-risk individuals,
violations of ICE detention standards regarding the use of isolation; and failure to properly
document and ensure follow through on grievances.247 Although this is a welcome step, it
is too soon to tell whether deficiencies found in these unannounced inspections will be
treated any differently than deficiencies found through other oversight mechanisms.
The expert opinions Human Rights Watch obtained from medical professionals for this
report, our own investigations and those of numerous governmental bodies and other
NGOs, and the reports of investigative journalists all point to a seriously inadequate
system of oversight of medical care in detention facilities, in particular:
•

Failure to take corrective actions after problems are identified;

•

Failure of investigations to identify problems;

245 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management and
Oversight of Detainee Medical Care,” http://www.gao.gov/assets/680/675484.pdf; US Government Accountability Office,
“Additional Actions Needed to Strengthen Management and Oversight of Facility Costs and Standards,” October 2014,
http://www.gao.gov/assets/670/666467.pdf (accessed March 29, 2017); American Civil Liberties Union, Detention Watch
Network, and National Immigrant Justice Center, “Fatal Neglect: How ICE Ignores Deaths in Detention,” February 2016,
https://www.aclu.org/report/fatal-neglect-how-ice-ignores-death-detention (accessed January 5, 2017); National Immigrant
Justice Center, “Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center Abuse,”
http://immigrantjustice.org/research-items/report-lives-peril-how-ineffective-inspections-make-ice-complicit-detention-center.
246 US Department of Homeland Security, Office of Inspector General, “DHS OIG to Periodically Inspect CBP and ICE
Detention Facilities,” March 15, 2016, https://www.oig.dhs.gov/assets/pr/2016/oigpr-031516b.pdf (accessed January 5,
2017).
247 US Department of Homeland Security, Office of Inspector General, “Management Alert on Issues Requiring Immediate
Action on Theo Lacy Facility in Orange, California,” March 6, 2017, https://www.oig.dhs.gov/assets/Mga/OIG-mga030617.pdf (accessed March 24, 2017).

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•

Inadequate grievance procedures; and

•

Inadequate data collection.

Failure to Take Prompt Corrective Action
Since ICE released its reviews of 18 of the 36 deaths in detention that occurred between
2012 and 2015, it has not publicly announced any corrective action plans for the
deficiencies the investigations uncovered and has not provided evidence of any such
corrective action plans in response to requests from Human Rights Watch. Analysis of more
recent medical records indicate that in at least three of the facilities in the death reviews—
Eloy Detention Center, Adelanto Detention Center, and York County Prison—there have
been ongoing failures to provide appropriate care.
The detainee death reviews themselves indicate that problems are not addressed quickly,
even when reform is urgently needed. In the Eloy Detention Center, for example, one of the
contributing factors to Cota-Domingo’s death on December 23, 2012 was confusion over
who had the authority to call 911, due to facility policies. Four months later, GarciaMaldonado and Guadalupe-Gonzalez died within days of each other and in both of those
cases confusion over 911 authority again played a role. “A timely review of Mr. CotaDomingo’s death should have remedied the 911 confusion before Ms. GuadalupeGonzales’s and Mr. Garcia-Maldonado’s deaths,” Dr. Stern told us.248
The reviews of the deaths at Eloy identify other oversight failures. In the death reviews for
Guadalupe-Gonzales and Garcia-Maldonado, who both committed suicide, the Office of
Detention Oversight (ODO) states: “All [Eloy Detention Center] staff members interviewed
by ODO stated [Eloy Detention Center] did not hold a multidisciplinary debriefing to review
critical elements surrounding” the suicides.249 In its reply to Human Rights Watch,
CoreCivic/CCA contested this point, saying that “on April 29, 2013, CCA, ICE and IHSC

248 Human Rights Watch email and telephone correspondence with Dr. Marc Stern, June 8, 26, 30, and July 1-6, 2017.
249 US Department of Homeland Security, Immigration and Customs Enforcement, “Report of Investigation: Garcia-Mejia,

Jorge/Unknown/0617 Detainee/Alien – Death (Suicide) / Eloy, Pinal, AZ,” October 7, 2013,
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-garciamaldonado.pdf; US Department of Homeland
Security, Immigration and Customs Enforcement, “Report of Investigation: Guadalupe-Gonzales, Elsa/Unknown/0617
Detainee/Alien – Death (Suicide) / Phoenix, Maricopa, AZ,” September 25, 2013, https://www.ice.gov/sites/default/files/
documents/FOIA/2016/ddr-guadalupegonzales.pdf.

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conducted several debriefings to discuss the [Guadelupe-Gonzales] incident.”250 (Though
asked, it did not give an answer as to whether there had been debriefings for the GarciaMaldonado suicide.)
In any case, two years later, in the death review of Jose de Jesus Deniz-Sahagun, who
also committed suicide at Eloy, the ODO noted that Eloy Detention Center “did not
convene a multi-disciplinary debriefing in contravention of IHSC Local Operating
Procedure 1501, Suicide Prevention and Intervention which requires, ‘A formal debriefing
with … multidisciplinary team members to convene the next business day for a formal
debriefing to review critical elements that contributed to the death and measures to
prevent future deaths.”251
“It’s quite alarming to me … based on these death reviews how often it appears that
debriefings are not done by medical and security staff at the facility following deaths to
determine whether mistakes were made,” Dr. Keller told us. “A basic tenet of medical care
is that we do our best to learn from mistakes when they are made.”252
The ICE review of both the Guadalupe-Gonzales and the Garcia-Maldonado deaths point to
Eloy Detention Center’s failure to have a local suicide prevention plan, “in contravention of
the [Performance Based National Detention Standards] and CCA Policy 9-19 … which
require the facility to develop a local Suicide Prevention Plan, to be reviewed annually,
addressing ‘specific facility initiatives and the facility's plan for compliance’ with the
policy.” Both reviews indicated that the facility was “currently in the process of developing
a Suicide Prevention Plan.”253

250 Letter

from CoreCivic/CCA to Human Rights Watch, July 6, 2016. Human Rights Watch asked about debriefings after
both suicides. The Guadalupe-Gonzales suicide occurred on April 28, 2013 and the Garcia-Maldonado suicide occurred
on April 30, 2013.
251 US Immigration and Customs Enforcement, “Detainee Death Review – Jose De Jesus Deniz-Sahagun, JICMS #201506640,”
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-denizshagun.pdf.
252 Human Rights Watch telephone interviews with Dr. Keller, July 1-6, 2017.
253 US Department of Homeland Security, Immigration and Customs Enforcement, “Report of Investigation: Garcia-Mejia,
Jorge/Unknown/0617 Detainee/Alien – Death (Suicide) / Eloy, Pinal, AZ,” October 7, 2013,
https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-garciamaldonado.pdf; US Department of Homeland
Security, Immigration and Customs Enforcement, “Report of Investigation: Guadalupe-Gonzales, Elsa/Unknown/0617
Detainee/Alien – Death (Suicide) / Phoenix, Maricopa, AZ,” September 25, 2013, https://www.ice.gov/sites/
default/files/documents/FOIA/2016/ddr-guadalupegonzales.pdf.

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Two years later, in the death review of Jose de Jesus Deniz-Sahagun, the ODO again noted
the requirement that the facility develop a “Suicide Prevention Plan which is reviewed
annually and addresses specific facility initiatives for suicide prevention.” The ODO review
found “no evidence [Eloy Detention Center] has developed such a plan, despite detainee
Deniz-Sahagun’s suicide being the third at EDC since April 2013 and the fifth since
2005.”254 CoreCivic/CCA told Human Rights Watch that the facility has been engaged in a
process of reviewing and revising the facility’s suicide prevention plan since 2013.
Notably, the Office of Civil Rights and Civil Liberties (“CRCL”) at the Department of
Homeland Security, which conducts investigations of detention conditions at ICE facilities,
stated in its 2015 annual report to Congress that CRCL sent ICE 49 recommendations to
improve conditions at an unnamed facility in Arizona in which three deaths, including two
suicides, occurred between October 2012 and April 2013.255 Although the facility is not
named, these details make clear it is Eloy Detention Center. According to this report, it
took ICE two years to respond to these recommendations, concurring with 19 of the
recommendations. CRCL concluded, however, that it “[d]oes not believe that ICE
responded appropriately to the other 30 recommendations.”256
ICE investigations into the death of Federico Mendez-Hernandez at Brooks County
Detention Center also indicate a failure to act promptly to address a dangerous situation.
As described previously, the ODO report found most medical care was provided by LVNs
and certified medical assistants, and that one LVN recorded vital signs months after the
fact “from memory.” The ODO report stated the ODO team was at the facility in September
2013, and that IHSC’s investigatory team was there in June 2013. Dr. Stern pointed out that
meant an LVN who was interviewed and identified by the ODO team as making serious
mistakes was still employed three months after IHSC had visited the facility. Dr. Stern
emphasized the seriousness of the situation:
[T]he conditions extant at Brooks at the time of this patient’s death
constituted a clear, present, and ongoing danger to the health of detainees
254 US Immigration and Customs Enforcement, “Detainee Death Review – Jose De Jesus Deniz-Sahagun, JICMS #201506640,”

https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-denizshagun.pdf.
255 US Department of Homeland Security, Office for Civil Rights and Civil Liberties, “Fiscal Year 2015 Annual Report to
Congress,” June 10, 2016, https://www.dhs.gov/sites/default/files/publications/crcl-fy-2015-annual-report.pdf (accessed
January 5, 2017).
256 Ibid.

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housed at Brooks. At both these points in time—the IHSC visit in June 2013,
and the ODO visit in September 2013—the teams had a responsibility to
take immediate steps to take detainees out of harm’s way.257
ICE may have recognized the seriousness of conditions at Brooks County, even if it did not
act quickly. According to a spreadsheet released on ICE’s online FOIA Library for one day,
ICE detained 190 people in FY 2013 at Brooks County, 43 in FY 2014, one in FY 2015, and
zero in FY 2016. The contract between ICE and Brooks County Detention Center was signed
three months before Mendez-Hernandez died. Dr. Stern stated the substandard practices
found in the investigation into his death would have been apparent if a thorough
inspection had been done prior to entering into the contract.258
CRCL’s own reports make clear that it has investigated and made recommendations
regarding other facilities that similarly have resulted in an inadequate or seriously delayed
response from ICE. The 2015 report states that CRCL conducted site visits to an unnamed
detention facility in Alabama in 2006, 2008, and 2012 “[a]s a result of numerous
complaints” and made numerous recommendations for changes at the facility.259 ICE
responded to the recommendations in 2015, concurring with most of the
recommendations, but since the 2012 visit, CRCL wrote,
CRCL has opened more than 50 additional complaints related to
conditions at this facility. As a result, in May 2015 CRCL sent a “superrecommendations” memorandum to ICE formally notifying them of our
long-standing and continuing concerns. This memorandum also
recommended that ICE develop a comprehensive plan to address the
deficiencies at the facility, address the issues raised in complaints opened
since the 2012 site visit, and either transition the facility to the 2011
Performance Based National Detention Standards or cease use of the
facility. CRCL intends to close the complaint associated with the 2012 site

257

Human Rights Watch email and telephone correspondence with Dr. Marc Stern, June 8, 26, 30, and July 1-6, 2017.

258 Ibid.
259 US Department of Homeland Security, Office for Civil Rights and Civil Liberties, “Fiscal Year 2015 Annual Report to
Congress,” https://www.dhs.gov/sites/default/files/publications/crcl-fy-2015-annual-report.pdf.

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visit, and has asked ICE to address the facility’s ongoing deficiencies in its
response to the 2015 memorandum.260
ICE’s failure to promptly address CRCL’s recommendations to fix identified problems is
apparent in CRCL’s descriptions of several other facilities, including an unnamed facility in
New Jersey to which CRCL makes repeat visits due to continuing complaints, and an
unnamed facility in Louisiana, which CRCL investigated and sent recommendations about in
2012. ICE responded to the recommendations two-and-a-half years later, but “a large
number of the responses were deemed to be either incomplete or unresponsive by CRCL.”261
Regarding an unnamed facility in Massachusetts, CRCL states that during a follow-up visit
in 2012 after a 2009 investigation, “CRCL discovered that its recommendations from
December 2009 had never been provided to the facility by ICE and multiple earlier
recommendations had not been addressed.”262 After CRCL issued new recommendations in
January 2013, ICE took another two years to respond, and 23 of the 29 responses, including
recommendations involving medical care, mental health care, dental care, and suicide
risk, were deemed to be either incomplete or insufficient.263
In several other investigations, CRCL reported it had made recommendations regarding
other facilities, including one with “a grievance system [that] violates the 2011
Performance-based National Detention Standards,” but that ICE’s response was
inadequate. In one case, CRCL wrote, “Two of the responses are inadequate and CRCL
strongly disagrees with them.” CRCL reported it was continuing to work with ICE in fiscal
year 2016 to address ongoing concerns identified three to four years earlier.264
CRCL does conclude that ICE has “adequately addressed its recommendations” and closed
its complaints with regard to several facilities. However, even in some of those cases, ICE
did not respond to CRCL’s recommendations for months or even years. For example,
regarding the unnamed facility in New Jersey, CRCL reported it made nine
recommendations to ICE in May 2012 regarding conditions of detention, including medical

260 Ibid.
261 Ibid.
262 Ibid.
263 Ibid.
264 Ibid.

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care. ICE did not respond until April 2015.265 The CRCL also indicates ICE stopped housing
people in a couple of the facilities it was investigating, but that in many cases where
problems were identified, ICE responded slowly or inadequately. And as the analyses of
ICE death investigations and medical records indicate, delays in fixing dangerously
substandard medical practices can have severe and sometimes deadly results.
As described in the February 2016 report by the Government Accountability Office, there
are multiple systems of oversight over most immigration detention facilities. The vast
majority of inspection reports, CRCL recommendations to ICE, and other reports are not
publicly available. But even the little that has been made public makes clear ICE often fails
to act quickly or effectively to fix serious problems with medical care and other conditions
of detention. As long as these facilities remain open, thousands of people, perhaps more,
remain at risk.

Failure to Identify Problems
One of the principal ways ICE monitors conditions in detention facilities is through periodic
inspections conducted by the Office of Enforcement and Removal Operations (“ERO”)
Custody Management Division and the Office of Detention Oversight.266 Private companies
contracted by ICE Enforcement and Removal Operations conduct these inspections using a
checklist derived from the applicable detention standards.267 ERO inspections are used to
determine whether a facility—whether government-run or private—should continue
receiving funding to hold immigrants. Under a 2009 appropriations law, ICE is prohibited
from continuing any contract for the provision of immigration detention services if the two
most recent performance evaluations are less than “adequate.”268
Other components of ICE provide further oversight, including targeted medical oversight.
The ODO, for example, also conducts periodic inspections and investigations into detainee

265 Ibid.
266 United States Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen

Management and Oversight of Detainee Medical Care,” February 2016, http://www.gao.gov/assets/680/675484.pdf.
267 Ibid.
268 National Immigrant Justice Center, “Lives in Peril: How Ineffective Inspections Make ICE Complicit in Detention Center

Abuse,” http://immigrantjustice.org/lives-peril-how-ineffective-inspections-make-ice-complicit-detention-center-abuse-0,
citing “Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009,” 110th Congress, H.R. 2638,
P.L. 110-329 (accessed April 25, 2017).

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deaths, including those analyzed earlier in this report.269 Although each monitoring
mechanism does not cover every facility used by ICE, the Government Accountability Office
found 99 percent of the population in fiscal year 2015 would have been in a facility subject
to at least one oversight mechanism.270
These various oversight mechanisms, however, have often failed to identify or rectify
serious problems in medical care. Inspection reports are not routinely released publicly.
But the ones that are publicly available, on ICE’s FOIA Library website or posted publicly by
organizations who obtained them via the Freedom of Information Act, show no indication
that dangerous substandard medical practices, like the unlicensed practice of medicine by
low-level personnel or substantial use of isolation for individuals with mental health
needs, were flagged or resulted in any penalties for the facility.
Four of the 18 deaths investigated by ODO in the 2012-2015 period occurred at Eloy
Detention Center. As previously noted, the four reports identified recurring problems. In
the reports for the first three deaths, which all occurred in 2012, the ODO noted there was
confusion among medical and facility staff as to who had the authority to make an
emergency 911 call, and in the latter two cases of Garcia-Maldonado and GuadalupeGonzalez, the ODO found the facility violated the 2011 PBNDS requirement of “access to
specified 24-hour emergency medical, dental, and mental health services” due to this
confusion. The reports for the three suicides also noted that Eloy failed to have a local
suicide prevention plan, despite “detainee Deniz-Sahagun’s suicide being the third at EDC
since April 2013 and the fifth since 2005.”271
While significant problems with medical and mental health care at Eloy Detention Center
undoubtedly predated the deaths, the ERO and ODO inspections conducted before the
deaths failed to discover them. (No inspection reports after 2012 are publicly available.)
The 2012 ERO report, dated January 31 to February 2, 2012, noted there was one suicide

269 United States Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen

Management and Oversight of Detainee Medical Care,” February 2016, http://www.gao.gov/assets/680/675484.pdf.
270 Ibid.
271 US Immigration and Customs Enforcement, “Detainee Death Review – Jose De Jesus Deniz-Sahagun, JICMS #201506640,”

https://www.ice.gov/sites/default/files/documents/FOIA/2016/ddr-denizshagun.pdf.

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attempt in November 2011, and that there was appropriate policy and procedure for
suicide intervention.272
A 2016 report by the American Civil Liberties Union, Detention Watch Network, and National
Immigrant Justice Center, analyzed the death at Eloy of Pablo Gracida-Conte due to
cardiomyopathy. The ODO investigation into his death included the conclusions of an ODO
team doctor, who found “[Mr.] Gracida’s death might have been prevented if the providers,
including the physician at [Eloy], had provided the appropriate medical treatment in a timely
manner.”273 Yet the ODO’s 2012 inspection report, while it mentioned his death, found that
people detained in Eloy were seen for sick call in a timely manner and sick call slips were
effectively and expediently triaged. Eloy also passed its 2011 and 2012 ERO inspections.274
The inspections that occurred at York County Prison before and after Tiombe Carlos’s death
in October 2013 similarly raise questions about the adequacy of ICE’s oversight system.
ODO in its death review found several violations of the applicable detention standards,
including a failure to create a mental health treatment plan. However, in 2011, ICE
Enforcement and Removal Operations (“ERO”) inspected York and found the facility was in
compliance, even while noting there had been six suicide attempts, including by one
person held in ICE detention, since the previous ERO inspection.275 In 2014, after Ms.
Carlos’s death, an ODO inspection did not mention her death nor any of the deficiencies it
had found in her case, and whether these deficiencies had been corrected.276
The ODO review of the death of Morales-Ramos identified several problems with the care
he received at Theo Lacy Facility where he was detained from March 2011 to May 2014,
including that “[nursing staff] often assessed detainees without reviewing their medical
record prior to or during the assessments,” and that there was no “problem list” in each
272 National Immigrant Justice Center, Immigration Detention Transparency and Human Rights Project, “2012 ERO Inspection
of Eloy Detention Center, January 31, 2012 to February 2, 2012,” https://www.documentcloud.org/documents/1865593-eloyaz-2012-ero-inspection.html (accessed January 5, 2017).
273 American Civil Liberties Union, Detention Watch Network, and National Immigrant Justice Center, “Fatal Neglect: How ICE
Ignores Deaths in Detention,” https://www.aclu.org/report/fatal-neglect-how-ice-ignores-death-detention.
274 Ibid.
275 National Immigrant Justice Center, Immigration Detention Transparency and Human Rights Project, “2011 ERO Inspection
of York County Prison,” October 23, 2011, http://www.documentcloud.org/documents/2067782-york-county-pa-2011-eroinspection.html (accessed January 5, 2017).
276 US Department of Homeland Security, Immigration and Customs Enforcement, Office of Professional Responsibility,
Inspections and Detention Oversight, “Office of Detention Oversight Compliance Inspection, Enforcement and Removal
Operations Philadelphia Field Office, York County Prison, York, Pennsylvania,” March 18-20, 2014,
https://www.ice.gov/doclib/foia/odo-compliance-inspections/2014-York-County.pdf (accessed January 5, 2017).

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patient’s medical record. But the ERO and ODO inspections from 2010 through 2013 all find
that the facilities meet standards for medical care. The ERO inspection in 2010 did note
there were three deaths of non-ICE inmates related to medical issues, and in 2011, noted
three more deaths (one ICE, two non-ICE) related to medical issues.277
Other facilities in this set of death reviews similarly passed inspections before and after
these immigrants’ deaths.

Inadequate Grievance Procedures
Standard 6.2 of the 2011 Performance Based National Detention Standards provides
guidance on the procedures detention centers should have for the filing and logging of
grievances.278 Most, if not all, immigration detention facilities have at least three types of
grievance procedures: oral/informal grievances, written/formal grievances to facility head,
and written/formal grievances to ICE. In CIVIC’s experience, detention facilities typically
have a box for ICE and a box for the facility head so that people in immigration detention
can file their formal grievances.279 Under current interpretations of the Freedom of
Information Act (FOIA), general data on grievances submitted to the facility heads of
privately-run immigration detention facilities are not accessible to the public.
Upon arrival at the facility, people in immigration detention should be informed about the
facility’s informal and formal grievance procedures in a language or manner they
understand. However, people in immigration detention have reported to CIVIC that the
grievance procedures are not usually communicated verbally to people in detention upon
arrival at the facility. They usually learn about procedures from reading the Detainee
Handbook or by word of mouth from other people in detention. The Detainee Handbook is
usually only available in English and Spanish. Therefore, if the person is illiterate or does
not speak English or Spanish, they might not even know a grievance mechanism exists. A

277 National Immigrant Justice Center, Immigration Detention and Transparency Project, “2010 ERO Inspection – Theo Lacy,

California,” http://www.documentcloud.org/documents/2065560-theo-lacy-ca-2010-ero-inspection.html, and “2011 ERO
Inspection – Theo Lacy, California,” http://www.documentcloud.org/documents/2065561-theo-lacy-ca-2011-eroinspection.html (accessed January 5, 2017).
278 2011 Performance-Based National Detention Standards, Section 6.2, “Grievance System,”
https://www.ice.gov/doclib/detention-standards/2011/6-2.pdf (accessed February 16, 2017).
279 CIVIC, as a national network of visitation programs, has more than 1,400 volunteers at 43 immigration detention facilities
throughout the US who visit people in detention in-person or respond to calls at CIVIC’s hotline, which receives more than
3,000 calls per month. CIVIC’s understanding of how the grievance procedures work in practice is based on meetings and
phone calls with thousands of immigrants in detention.

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2009 report found 40 facilities failed to include any mention of a grievance policy or
omitted key portions.280
The 2011 PBNDS states, “Staff and detainees will mutually resolve most complaints and
grievances orally and informally in their daily interaction.” Numerous people in
immigration detention have complained to CIVIC that facility staff and ICE encourage oral
resolution by discouraging written grievances. The 2011 PBNDS states, “If an informal
grievance is resolved, the employee need not provide the detainee written confirmation of
the outcome, but shall document the result for the record in the detainee’s detention file
and in any logs or data systems the facility has established to track such actions.” Dozens
of people in detention have told CIVIC they asked for copies of the write-ups of their oral
grievances and were never provided with them.
In addition to these three types of grievance procedures, the 2011 PBNDS also allows for
emergency grievances, stipulating that they must be reviewed “as soon as practicable by
appropriate personnel.” Moreover, people in immigration detention can submit
complaints to the Office of the Inspector General at DHS through its hotline or to the
Office for Civil Rights & Civil Liberties (“CRCL”) at DHS by mail. CRCL investigations,
however, do not necessarily result in a quick response to the complainant. CIVIC has
filed more than 125 complaints with CRCL, and has found that when CRCL decides to
investigate a case, it takes approximately one year for the investigation to be completed,
and the organization or individual that submitted the complaint is not provided with a
report of the outcome. CIVIC has sought information on the outcome of investigations
but has never received a response.281

280

National Immigration Law Center, American Civil Liberties Union of Southern California, and Holland & Knight, “A Broken
System: Confidential Reports Reveal Failures in US Immigrant Detention Centers, 2009, https://www.nilc.org/wpcontent/uploads/2016/02/A-Broken-System-2009-07.pdf (accessed February 16, 2017). The report analyzed reviews by ICE
covering 53 facilities, out of which 40 were found to have inadequate grievance policies. According to the report, the
government was required to produce all facility reviews conducted by ICE in 2004 and 2005 in the course of litigation, but the
government failed to produce all the reviews. The report states, “There is no doubt, therefore, that the detention standards
violated reported and analyzed here comprise just a fraction of the violations documented by ICE in 2004 and 2005.”
281 For example, in one case, CIVIC filed a complaint with both CRCL and the Office of Inspector General. When it sought an

update, it received an email from the “Joint Intake Center” stating any information about the investigation would only be
available through a Freedom of Information Act request.

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Inadequate Data Collection
The 2008 and 2011 Performance-Based National Detention Standards specify that the
administrator overseeing a facility’s medical care “shall implement a system of internal
review and quality assurance.”282 The 2000 National Detention Standards make no
mention of quality assurance, but according to the National Commission on Correctional
Health Care, quality assurance, defined as “a process of ongoing monitoring and
evaluation to assess the adequacy and appropriateness of the care provided and to
institute corrective action as needed,” is “an essential aspect of any well-run system.”283
However, the US government’s own reports into ICE’s detention system and medical care in
particular have highlighted ICE’s inability to analyze data gathered through its various
oversight mechanisms, or to capture all medical care grievances received through various
channels. The 2016 GAO report stated that better tracking of costs, oversight mechanisms,
and grievances would help ICE improve its “ability to manage and oversee the provision of
medical care across facility types.”284
As part of its investigation, Human Rights Watch submitted four separate requests under the
Freedom of Information Act in January 2016 to ICE and other components of the Department
of Homeland Security on various aspects of medical care in the immigration detention
system. ICE responded to each but did not respond fully to all of our questions, giving no
explanation as to whether the information was exempt under FOIA or unavailable.
Even when ICE answered our questions, the information it provided was severely limited
and suggests ICE is not gathering basic data on its facilities in a consistent fashion. For
example, Human Rights Watch requested information on medical clinic staffing at the 100
facilities with the highest average daily population for fiscal years 2012 to 2016 in two
separate FOIA requests. In response to one request, we received a spreadsheet with what
appeared to be medical staffing information for 24 facilities. According to the spreadsheet,
Eloy Detention Center, South Texas Detention Facility, and LaSalle Detention Center, the

282 US Immigration and Customs Enforcement, “2008 Operations Manual ICE Performance-Based National Detention

Standards,” https://www.ice.gov/detention-standards/2008, and “2011 Operations Manual ICE Performance-Based National
Detention Standards,” https://www.ice.gov/detention-standards/2011.
283 National Commission on Correctional Health Care, “Correctional Health Care: Guidelines for the Management of an
Adequate Delivery System,” December 2001, http://static.nicic.gov/Library/017521.pdf (accessed December 16, 2016).
284 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management
and Oversight of Detainee Medical Care,” February 2016, http://gao.gov/products/GAO-16-231.

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field for “physician” is marked as “zero” for at three of the last five years. But it is not clear
exactly what that means. The fields are inconsistent—some years are marked “FY” for
fiscal year, some are marked “CY” for calendar year, and some just have the year.
In facilities where a physician is indicated, hours available are stated as “7 am – 9 pm/7
days per week.” According to Dr. Stern, it is highly unlikely one physician is working those
hours. He noted further that the lack of a physician on staff is not, in and of itself, evidence
of a substandard medical care system, but in his opinion, the data provided in this
spreadsheet was “useless” and indicative of inconsistent definitions of key terms. The
apparent lack of clear records suggested to him that ICE likely does not keep accurate
records on medical staffing at its facilities.285
This is consistent with reports by the Government Accountability Office of ICE’s inability to
analyze the outcome of its oversight mechanisms across facilities or grievances received
regarding medical care throughout the system.286 The GAO found that data from ICE’s
various oversight mechanisms are not collected in a way that allows for system-wide
analysis. According to the GAO, field medical coordinators (FMCs) do site-visits of facilities
that are not staffed by IHSC and hold people for more than 72 hours. FMC site visit results
are stored and tracked but no overarching analysis is done by FMCs or by IHSC. Selfassessments for facilities with an average daily population of less than 10 people are not
even stored in a database. Although the self-assessments provide a space to note if there
are repeat findings from previous years, ICE officials do not track this information.
Detention service managers (DSMs), ICE staff who are to provide “informal, on the spot
guidance for corrections of minor deficiencies,” are permanently based at 42 facilities,
with a roving DSM at another 11 facilities. DSMs only began tracking “key metrics from
weekly narrative reports” at the start of fiscal year 2016.287

285

Human Rights Watch email and telephone correspondence with Dr. Stern, May 31, October 6 and 12, and December 13,
2016; January 17 and March 5 and 11, 2017. Shortly before publication of this report, we received a response to a separate
FOIA request which also requested information on medical staffing. The documents we received did not respond fully to our
request, but we received another spreadsheet listing 117 facilities and what appears to be information on the number of full
and part time medical staff at each facility. This list does not include the facilities provided in the previous response we
received. It is unclear why some facilities are on one list and not the other.
286 US Government Accountability Office, “Immigration Detention: Additional Actions Needed to Strengthen Management

and Oversight of Detainee Medical Care,” http://www.gao.gov/assets/680/675484.pdf.
287 Ibid.

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The GAO explained, “Without such analysis, ICE management is not well-positioned to
assess the medical care performance of facilities over time, by contracted standards, or by
facility type; thereby, limiting ICE’s ability to plan and manage overarching changes to
detainee medical care.”288
The GAO identified a similar failure to analyze medical complaints. There are several
avenues by which individuals in detention can file a grievance regarding medical care,
including the Office of Civil Rights and Civil Liberties, the Office of Inspector General, and
the ICE Detention and Reporting Information Line. Medical complaints are forwarded to
IHSC. But only CRCL is required to review and report on the number of complaints it
receives and their disposition, and IHSC does not maintain a database that can be
searched and analyzed. Rather, it uses an IHSC tasking email inbox to process and store
complaints.289 As a result, the GAO concluded ICE is not able to readily determine the
overall volume of complaints, their status, or outcome. IHSC does not analyze the facilities
where complaints are most commonly filed or differences across facility type.290

Two Examples of Creative Medical Advocacy
Despite the documented failures of medical care in immigration detention facilities, there
have been relatively few lawsuits filed against ICE or immigration detention facilities.
In part this is likely due to the low rate of legal representation among people in
immigration detention. In the US immigration system, indigent persons do not have a right
to court-appointed counsel, and a recent national study found only 14 percent of people in
immigration detention have legal representation.291
In part, it is likely due to the relatively few remedies available for people in immigration
detention who suffer because of substandard medical care. ICE’s detention standards are
not legally enforceable. Although immigration detention is a federal form of confinement,

288 Ibid.
289 Ibid.
290 Ibid.
291 Ingrid Eagly & Stephen Shafer, American Immigration Council, “Access to Counsel in Immigration Court,” September

2016, https://www.americanimmigrationcouncil.org/sites/default/files/research/access_to_counsel_in_immigration
_court.pdf (accessed February 16, 2017).

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case law varies from state to state because each state has its own tort laws and medical
malpractice laws.
Lawsuits arising out of substandard medical care in detention are extraordinarily difficult
to win. Jonathan Feinberg, a lawyer who regularly litigates prisoners’ rights cases
explained that there exists a high standard for inadequate medical care currently in US
case law. “You have to prove deliberate indifference,” he explained. “[There are] a ton of
cases that say as long as the medical providers do something, it’s not deliberate
indifference.” There are also statutory limits placed on lawsuits against federal
agencies.292 The lawyer also pointed out that most medical care cases in correctional
contexts are “reactive to bad outcomes” after a person has already died or has
experienced irreversible damage to their health, and do not necessarily push the
correctional system to provide the necessary and appropriate care immediately.293
Given these barriers, individuals committed to improving medical care in immigration
detention facilities have turned to novel forms of advocacy. Two examples are
detailed below.

CIVIC’s Push for Independent Medical Oversight Boards
On May 10, 2016, CIVIC and its local affiliate First Friends of NJ & NY filed a multi-individual
complaint with the Office for Civil Rights and Civil Liberties at DHS summarizing complaints
from 61 women and men detained at Hudson County Correctional Facility (HCCF).294 The
complaint includes allegations of long delays or denials in care, repeated failures by
medical staff to use interpretation services for non-English speaking patients, and
unlawful co-pay charges, among others. These issues were not unknown to HCCF; as the
complaint noted, 121 people detained at HCCF submitted medical grievances between
January 2014 and March 2016, but HCCF only took corrective action in 2.48 percent of the
cases. CIVIC’s complaint urged ICE to terminate its contract with HCCF or take immediate
steps to improve HCCF’s health care practices.

292 Human Rights Watch telephone interview with Jonathan Feinberg, June 10, 2016.
293 Ibid.
294 Community Initiatives for Visiting Immigrants in Confinement, “Hudson County Correctional Facility,”

http://www.endisolation.org/Hudson (accessed December 1, 2016).See also, Nina Bernstein, “Health Care at New Jersey
Immigrant Jail is Substandard, Watchdog Groups Say,” New York Times, May 11, 2016, http://www.nytimes.com/
2016/05/12/nyregion/health-care-at-new-jersey-immigrant-jail-prompts-claim.html?_r=0 (accessed December 1, 2016).

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The complaint also recommended the formation of a board of independent medical
observers comprised of advocates who would meet with representatives of ICE, HCCF, and
Hudson County to discuss and address medical concerns.
Hudson County responded by retaining a committee to determine whether HCCF and its
private health care provider CFG Health Systems were currently providing all necessary and
appropriate medical services. The committee was composed of two doctors, one attorney,
and one retired judge, who received financial compensation. Their report, submitted on
October 24, 2016, conceded that “CFG and its medical staff have not fully complied with
ICE’s and the National Commission on Correctional Health Care’s national detention
standards for health services in jails.” According to CIVIC, however, it also essentially
absolved Hudson County, HCCF, and CFG of any wrongdoing.
On November 15, 2016, CIVIC and First Friends of NJ & NY submitted their responses to the
report, outlining their concerns over the committee’s flawed methodology, such as its
reliance on unverified statements made by HCCF staff.
Notably, the committee’s report ended with an attenuated version of the advocates’
original demand, recommending the establishment of an ad hoc committee of
representatives from not only advocacy organizations but also ICE, Hudson County, and
the medical provider, to meet on a regular basis to discuss and address medical care
concerns. Hudson County followed this recommendation and established the ICE Detainee
Medical Review Ad Hoc Committee by executive order on November 3, 2016, though it did
not solicit input from advocacy groups. CIVIC and other advocacy organizations were
disappointed by this failure to consult and by shortcomings in the executive order, such as
lack of full access to the facility for the committee and its status as a resolution rather than
an ordinance, but they are hopeful that it will pave the way towards improving medical
care at HCCF and consider it a transitional step towards the creation of a more permanent
independent medical oversight board.
Based on evaluations of medical oversight boards for detention centers in the United
Kingdom, CIVIC recommends independent medical oversight boards be comprised of nongovernmental physical and mental health clinicians, advocates, and other community
members. They should have the power to conduct unannounced inspections, privately talk
with all detained people who are interested and willing, review data on the medical
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grievances filed, investigate allegations of medical malpractice and abuse, and make
policy recommendations. CIVIC plans to closely follow the development and outcomes of
the ICE Detainee Medical Ad Hoc committee at HCCF, the first of its kind in the country, and
fight for the establishment of independent medical oversight boards at HCCF and at other
facilities as long as immigration detention continues.

New York Lawyers for Public Interest Health in Detention Program
New York Lawyers for Public Interest (NYLPI) created a Health in Detention program to
address lack of access to medical care in three New Jersey immigration detention facilities
that house New York City residents. Working with immigration attorneys, they conduct
advocacy on behalf of individuals who are detained or who were recently detained and had a
negative health outcome, and initiate impact litigation based on patterns they identify. They
are also developing a network of medical providers who are available to provide medical
reviews and analysis for advocacy related to lack of access to medical care in detention.
New York City is unique in funding a legal representation program for all indigent
individuals in detention, through the New York Immigrant Family Unity Project. But as
Laura Redman, director of the Health Justice Program, explained, even with universal
representation in immigration cases there is a need for a separate medical advocacy
project because immigration attorneys do not necessarily have the time or funding to
conduct advocacy that is not always directly related to the immigration case.
Reena Aurora, senior staff attorney, noted that their advocacy has found more immediate
success in some areas more than in others. “ICE has not been very responsive to inquiries
on medical care,” she said. She noted the handful of humanitarian parole requests they
made were denied. However, she stated, “We’ve been more successful with immigration
judges getting bond based on medical needs, so they can go back to their community and
get medical care that’s available to them.”295
Furthermore, because of the organization’s concerted advocacy in three facilities, they
have been able to develop a more sustained analysis of patterns of poor care than
individual attorneys or legal services organizations focused on immigration cases can do.
In July 2016, NYLPI filed a lawsuit on behalf of two individuals against Orange County, New
295 Human Rights Watch telephone interview with Laura Redman, Reena Aurora, and Sola Stamm, September 20, 2016.

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York, alleging county officials discharged two people with serious psychosocial disabilities
from immigration detention without medication or any continuity of care discharge
planning, in violation of their constitutional rights.296 The plaintiffs were held at Orange
County Jail, the same facility as “Luke R.,” who, in the analysis above, received severely
inadequate mental health care and was disciplined with solitary confinement instead of
getting reasonable accommodation for his psychosocial disability.

296 Charles

v. Orange County, Case No. 16-cv-5527 (US District Court, Southern District of New York), complaint, filed July

12, 2016.

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V. US and International Legal Standards
All persons deprived of their liberty shall be treated with humanity and with
respect for the inherent dignity of the human person.
-International Covenant on Civil and Political Rights, Article 10(1)297

Right to Reasonable Medical Care and Health
Right to Reasonable Medical Care Under US Law
The Eighth Amendment to the US Constitution protects all convicted prisoners from “cruel
and unusual punishment” and requires corrections officials to provide a “safe and humane
environment.”298 Prisoners have a right to health care that is not shared by the general
population. As Justice Marshall explained in the Supreme Court decision, Estelle v. Gamble:
These elementary principles establish the government's obligation to
provide medical care for those whom it is punishing by incarceration. An
inmate must rely on prison authorities to treat his medical needs; if the
authorities fail to do so, those needs will not be met. In the worst cases,
such a failure may actually produce physical torture or lingering death, the
evils of most concern to the drafters of the Amendment.299
In Estelle, the Supreme Court established a narrow interpretation of the Eighth
Amendment, requiring prisoners to demonstrate that officials were “deliberately
indifferent to serious medical needs.”300
People held in immigration detention, however, are not convicted prisoners. Rather, they
are in civil detention, held under administrative provisions. Their constitutional protection
derives from the Fifth Amendment, which prohibits the imposition of punishment upon any
person in the custody of the United States without due process of law.301

297 International Covenant on Civil and Political Rights (ICCPR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N.

GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), 999 U.N.T.S. 171, entered into force March 23, 1976, ratified by the
United States on June 8, 1992, art. 10(1).
298 Estelle v. Gamble, 429 U.S. 97 (1976).
299 Ibid. at 100.
300 Ibid. at 104.
301 Wing Wong v. United States, 163 US 228 (1896).

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Few courts have considered the precise scope of the right to health care for individuals in
immigration detention, as distinct from people in other civil or pretrial detention. Many
federal courts adjudicating claims of inadequate medical care brought by people in pretrial
and civil detention have applied the same “deliberate indifference” standard developed
under Eighth Amendment jurisprudence to these claims.302 Others have argued that a
distinct, and perhaps more stringent, standard should apply.303 The Court of Appeals for the
Ninth Circuit has held that the conditions of confinement for people in administrative
detention must be superior not only to those of convicted prisoners, but also to those of
people in pre-trial criminal detention.304

Right to Health under International Law
Under international law, people who are detained have a right to be treated with humanity
and respect for their inherent dignity, and that right includes access to appropriate
medical care.
The United States is a party to the International Covenant on Civil and Political Rights
(ICCPR).305 Under the ICCPR, governments should provide “adequate medical care
during detention.”306
More broadly, the Human Rights Committee has explained that states have a “positive
obligation towards persons who are particularly vulnerable because of their status as
persons deprived of their liberty,” stating that the deprivation of liberty itself should be the
only form of punishment:

302 See Cuoco v. Moritsugu, 222 F.3d 99 (2nd Cir. 2000) (“We have often applied the Eighth Amendment deliberate

indifference test to pre-trial detainees bringing actions under the Due Process Clause of the Fourteenth Amendment.… We
see no reason why the analysis should be different under the Due Process Clause of the Fifth Amendment.”).
303 See Cupit v. Jones, 835 F.2d 82 (5th Cir 1987) (“Today, we conclude that pretrial detainees are entitled to reasonable
medical care unless the failure to supply that care is reasonably related to a legitimate governmental objective. In so
holding, we recognize that the distinction as to medical care due a pretrial detainee, as opposed to a convicted inmate, may
indeed be a distinction without a difference, for if a prison official acted with deliberate indifference to a convicted inmate's
medical needs, that same conduct would certainly violate a pretrial detainee's constitutional rights to medical care.
However, we believe it is a distinction which must be firmly and clearly established to guide district courts in their evaluation
of future cases involving the constitutionality of all conditions imposed upon pretrial detainees.”)
304 Jones v. Blanas, 393 F.3d 918 (9th Cir. 2004), at 934. See also Hydrick v. Hunter, 500 F.3d 978, 994 (9th Cir. 2007) (finding
that “the Eighth Amendment provides too little protection for those whom the state cannot punish”).
305 International Covenant on Civil and Political Rights (ICCPR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 UN
GAOR Supp. (No. 16) at 52, UN Doc. A/6316 (1966), 999 UNTS 171, entered into force March 23, 1976, ratified by the U.S. on
June 8, 1992, arts. 6,7 10(1).
306 Pinto v. Trinidad and Tobago (Communication no. 232/1987), Report of the Human Rights Committee, vol. 2, UN Doc
A/45/40, p. 69.

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Not only may persons deprived of their liberty not be subjected to torture,
or other cruel, inhuman or degrading treatment or punishment, including
medical or scientific experimentation, but neither may they be subjected to
any hardship or restraint other than that resulting from the deprivation of
liberty; respect for the dignity of such persons must be guaranteed under
the same conditions as that of free persons. Persons deprived of their
liberty enjoy all the rights set forth in the ICCPR, subject to the restrictions
that are unavoidable in a closed environment.307
The Human Rights Committee has also urged states to specify in their reports whether
individuals in detention “have access to such information and have effective legal means
enabling them to ensure that those rules are respected, to complain if the rules are
ignored and to obtain adequate compensation in the event of a violation.”308
The United States is also a party to the Convention Against Torture. The Committee Against
Torture—the monitoring body of the Convention Against Torture—has found that failure to
provide adequate medical care can violate the CAT’s prohibition of cruel, inhuman or
degrading treatment.309
Other standards provide non-binding, but authoritative, interpretation of fundamental
human rights standards for all persons in detention. The Standard Minimum Rules for the
Treatment of Prisoners, the 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 establish the consensus that individuals in detention are entitled to a
standard of medical care equivalent to that available in the general community, without
discrimination based on their legal status.310 International standards support the
confinement of individuals in administrative and pre-trial detention in non-punitive
conditions.311 The Body of Principles for the Protection of All Persons under Any Form of

307 UN Committee on Human Rights,

General Comment No. 21, Article 10, Humane Treatment of Prisoners Deprived of their
Liberty, UN Doc. HRI/Gen/1/Rev.1 at 33 (1994), para. 3.
308 UN Human Rights Committee, “Replaces general comment 9 concerning humane treatment of persons deprived of
liberty,” General Comment No. 21, U.N. Doc. A/47/40 (1992), para. 7.
309 United Nations Committee Against Torture, “Concluding Observations: New Zealand,” 1998, UN Doc. A/53/44, para. 175.
310 UN Standard Minimum Rules for the Treatment of Prisoners, UN General Assembly Resolution 70/175 (2015); Basic
Principles for the Treatment of Prisoners, UN General Assembly Resolution 45/111 (1990); Body of Principles for the
Protection of All Persons Under any form of Detention or Imprisonment, UN General Assembly Resolution 43/173 (1988).
311 UN Standard Minimum Rules, supra, para.8.

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Detention or Imprisonment further provides that a proper medical examination shall be
offered to a detained or imprisoned person as promptly as possible after his admission
to the place of detention or imprisonment, and thereafter medical care and treatment
shall be provided whenever necessary.312
In its Guidelines on the applicable criteria and standards relating to the detention of
asylum-seekers and alternatives to detention, UNHCR (the UN’s refugee agency), states
that appropriate medical treatment must be provided where needed, including
psychological counselling. Detained individuals needing medical attention should be
transferred to appropriate facilities or treated on site where such facilities exist.313
In some cases, state obligations to protect prisoners’ fundamental rights, in particular the
rights to be free from ill-treatment, the right to health, and ultimately the right to life, may
require states to ensure a higher standard of care than is available to people outside
prison who are not wholly dependent upon the state for protection of those rights.314 In
prison, where most material conditions of incarceration are directly attributable to the
state, and inmates have been deprived of their liberty and means of self-protection, the
requirement to protect individuals from risk of torture or ill treatment can give rise to a
positive duty of care, which has been interpreted to include effective methods of
screening, prevention and treatment of life-threatening diseases.315
The right to health is most explicitly expressed in the International Covenant on Economic,
Social and Cultural Rights (ICESCR) which states that every person has a “right to the
highest attainable standard of health.”316 The United States has signed, but not ratified,
the ICESCR, a position that requires the government to, at minimum, take no action that
would undermine the intent and purpose of the treaty.317

312 UN Body of Principles for the Protection of All Persons under Any Form of Detention or Imprisonment, supra, principle 24.
313 UNHCR, UNHCR Detention Guidelines ("Guidelines on the Applicable Criteria and Standards relating to the Detention of
Asylum-Seekers and Alternatives to Detention") (2012), para. 48.
314 See, Rick Lines, “From equivalence of standards to equivalence of objectives: the entitlement of prisoners to standards of
health higher than those outside prisons,” International Journal of Prisoner Health, vol 2 (2006), p. 269.
315 See, e.g. European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT),
CPT Standards, CPT/IN/E2002, para. 31.
316 International Covenant on Economic, Social, and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Res. 2200A
(XXI), 21 U.N. GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976, supra,
Article 12.
317 Vienna Convention on the Law of Treaties (VCLT), adopted May 23, 1969, entered into force January 27, 1980, Article 18.
The US signed the ICESCR on October 5, 1977.

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Rights of Persons with Psychosocial Disabilities
The Convention on the Rights of Persons with Disabilities (CRPD) seeks to “promote,
protect, and ensure the full and equal enjoyment of all human rights and fundamental
freedoms by all persons with disabilities.”318 The UN Special Rapporteur on Torture has
pointed out that persons with disabilities are often segregated from society in prisons as
well as in other institutions. Inside these institutions, persons with disabilities “are
frequently subjected to unspeakable indignities, neglect, severe forms of restraint and
seclusion, as well as physical, mental and sexual violence.”319 The United States has
signed but not ratified the CRPD and is therefore not bound by it. The Convention is
nonetheless a useful and authoritative guide to how all states should undertake to protect
and respect the rights of people with disabilities.
In the context of detention centers, the CRPD principle of accessibility entails having
alternative modes of communication available to interact with immigrants in detention
centers who may require such support because of their disabilities. The obligation to provide
accommodation and procedural accommodation also applies, including the appointment of
a representative to assist them in the procedures (grievances, for example).

Further, the authorities should ensure protection of the person’s integrity, including
mental health. Without due regard to their condition, some of the rules of detention
centers could be harsh if applied to people with mental health conditions and may
constitute ill-treatment or even torture. Isolation should be prohibited for persons with
disabilities because of its potential harm to their health.

Limits on the Use of Detention for the Control of Immigration
The US government’s failure to provide adequate medical care to people in immigration
detention cannot be isolated from its broader failure to maintain a limited detention
system in keeping with human rights principles.

318 Convention on the Rights of Persons with Disabilities (CRPD), adopted January 24, 2007, G.A. Res. 61/106, U.N. Doc.

A/61/106 (2007), entered into force May 3, 2008, signed by the United States on July 30, 2009. The US has not yet ratified
the convention, but as a signatory, may not take actions inconsistent with it.
319 UN General Assembly, “Torture and other cruel, inhuman or degrading treatment or punishment, Note by the SecretaryGeneral,” A/63/175, July 28, 2008, http://www.refworld.org/docid/48db99e82.html (accessed September 27, 2016).

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Article 9 of the International Covenant on Civil and Political Rights states, “Everyone has
the right to liberty and security of person. No one shall be subjected to arbitrary arrest or
detention. No one shall be deprived of his liberty except on such grounds and in
accordance with such procedure as are established by law.”320 With regard to immigration,
detention is not per se arbitrary, but the Human Rights Committee has noted “detention
must be justified as reasonable, necessary and proportionate in the light of the
circumstances and reassessed as it extends in time.”321 The United Nations Working Group
on Arbitrary Detention has argued that “immigration detention should gradually be
abolished.... If there has to be administrative detention, the principle of proportionality
requires it to be a last resort.”322
While the United States has a legitimate interest in detaining some non-citizens to guarantee
their appearance at hearings and to ensure the deportation of those judged to be removable,
many people in detention, including thousands of asylum-seekers, are held under statutory
provisions that mandate detention without sufficient individualized review.
The Human Rights Committee has noted with regard to medical care, “Decisions regarding
the detention of migrants must also take into account the effect of the detention on their
physical or mental health.”323 The US detention system regularly detains individuals with
serious medical and mental health conditions, sometimes for prolonged periods of time, in
facilities ill-equipped to provide appropriate care, without sufficient consideration of the
impact of detention on these individuals’ health, leading to sometimes fatal consequences.
The damaging impact of detention and substandard medical care could be greatly reduced
by only detaining those who are determined, through individualized hearings, to be a
threat to public safety and by making every effort to make use of alternatives to detention
wherever possible.

320 ICCPR, Art. 9
321

UN Human Rights Committee, General Comment No. 35, Article 9 (Liberty and Security of person), CCPR/C/GC/35 (2014),
para. 18.

322 UN Commission on Human Rights, Report of the Working Group on Arbitrary Detention,

A/HRC/13/30, January 18, 2010,
para. 59.
323 UN Human Rights Committee, General Comment No. 35, Article 9 (Liberty and security of person), para. 18.

SYSTEMIC INDIFFERENCE

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Acknowledgments
This report was written and researched by Clara Long, US Program researcher, and Grace
Meng, US Program senior researcher with Human Rights Watch. Christina Fialho and
Christina Mansfield, co-directors of Community Initiatives for Visiting Immigrants in
Confinement (CIVIC), reviewed and edited the report. Alison Parker, US Program codirector, edited the report. Chris Albin-Lackey, senior legal advisor, and Joe Saunders,
deputy program director, reviewed the report, as did Megan McLemore, senior health and
human rights researcher; Carlos Rios-Espinosa, senior disabilities rights researcher and
advocate; and Shantha Rau Barriga, disabilities rights director. W. Paul Smith, US Program
coordinator, contributed to editing. Rebecca Balis, Karina Cazares, Madison Chapman,
Elizabeth Fulton, Bridget Grotz, Sophia Sleap, and Junteng Zhang, interns in the US
Program, provided research assistance. Fitzroy Hepkins, administrative manager, Jose
Martinez, administrative senior coordinator, and Olivia Hunter, photography and
publications associate, coordinated layout and production.
Organizations and individuals around the United States provided invaluable assistance in
identifying people in detention with medical issues for this report, including the
Detention Watch Network, the Florence Immigrant and Refugee Rights Project, First
Friends of New Jersey and New York, New York Lawyers for the Public Interest, the Kathryn
O. Greenberg Immigration Justice Clinic at the Benjamin N. Cardozo School of Law and the
Bronx Defenders.
We thank the many immigrants and their families and the attorneys who shared their
stories for this report in the hope that others would not suffer in the same way. Among the
people whose stories were reported to us, some remain detained, some were deported,
and some have died since our investigations began.
We are profoundly grateful for the assistance provided by Dr. Marc Stern, Dr. Allen Keller,
and Dr. Palav Babaria, who provided independent expert analysis of detainee death
investigations and medical records of individuals in detention, and the other medical
experts who wish to remain unnamed. We are particularly grateful to Dr. Stern for the
innumerable hours he spent providing Human Rights Watch with valuable insight into the
challenges of health care in incarcerative settings.

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For assistance with our Freedom of Information Act requests, we thank the law firm Nixon
Peabody for their generous and longstanding pro bono legal assistance.

SYSTEMIC INDIFFERENCE

104

Appendix I
Facilities in Which Medical Experts Found Evidence of Subpar Care in Detainee Death
Reports or in Individuals’ Medical Records
Medical Care
Name of Facility

Location

Type of

Facility

Provided by ICE’s

Facility

Operator

Immigrant Health
Service Corps?

Adelanto Detention

Adelanto,

Facility

California

Brooks County

Falfurrias, Texas

Average Daily
Population in
2016

Private Facility

Geo Group

No

1,476

Private Facility

LCS at time of

No

0

Detention Center

death; Geo Group
now

Eloy Detention Center Eloy, Arizona

Private Facility

CoreCivic/CCA

Yes

1,482

El Paso County

Colorado

County Jail

El Paso County,

No

11

Criminal Justice

Springs,

Center

Colorado

Etowah County

Gadsden,

No

261

Detention Center

Alabama

Houston Contract

Houston, Texas

Private Facility

CoreCivic/CCA

Yes

945

Hudson County

Kearny, New

County Jail

Hudson County,

No

453

Correctional Facility

Jersey

Hutto Detention

Taylor, Texas

Private Facility

CoreCivic/CCA

Yes

Imperial Regional

Calexico,

Private Facility

MTC

No

696

Detention Facility

California

No

798

Colorado

County Jail

Etowah County,
Alabama

Detention Facility

New Jersey

Center

Management and
Training
Corporation

Joe Corley Detention

Conroe, Texas

Private Facility

Geo Group

Facility

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Medical Care
Name of Facility

Location

Type of

Facility

Facility

Operator

Provided by

Average Daily

ICE’s Immigrant

Population in

Health Service

2016

Corps?
Laredo Processing

Laredo, Texas

Private Facility

CoreCivic/CCA

No

342

Orange County

Goshen, New

County Jail

Orange County,

No

169

Correctional Facility

York

Rio Grande Valley

Los Fresnos,

ICE

n/a

n/a

Staging Facility

Texas

San Bernardino Hold

San Bernardino,

ICE / Under 72- ICE

n/a

n/a

Room

California

Hour Facility

San Diego Contract

San Diego,

Private Facility

CoreCivic/CCA

Yes

678

Facility

California

South Texas

Pearsall, Texas

Private Facility

Geo Group

Yes

1,721

Orange,

County Jail

Orange County,

No

428

No

205

No

630

No

201

Center

New York
ICE

Detention Complex
Theo Lacy Facility

California
Utah County Jail

Spanish Fork,

California
County Jail

Utah
York County Prison

York,

Utah
County Prison

Pennsylvania
Yuba County Jail

Marysville,
California

SYSTEMIC INDIFFERENCE

Utah County,

York County,
Pennsylvania

County Jail

Yuba County,
California

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SYSTEMIC INDIFFERENCE
Dangerous & Substandard Medical Care in US Immigration Detention
The US immigration detention system is the world’s largest. Despite efforts at reform by the Obama administration, the detention
system grew to a record 400,000-plus people a year by 2016, with numerous reports of abusive conditions, including medical
neglect. President Trump has made clear he intends to increase detention capacity and roll back some of the limited reforms
initiated under Obama.
Systemic Indifference—based primarily on independent medical expert analysis of detainee health records and death investigation
reports—documents the many ways the current detention system is failing detained immigrants with medical needs, imposing
unnecessary suffering and contributing to premature deaths. Expanding the system without improving health care delivery and
accountability, as Trump has pledged to do, can only compound the problem.
Human Rights Watch calls on the US government to end wasteful and unnecessary immigration detention, and to ensure humane
and appropriate medical care for those who are detained.

© 2017 Mitch Blunt for Human Rights Watch

hrw.org

www.endisolation.org