Analysis Human Rights

Report: In-Custody Deaths of Immigrants Were ‘Preventable’

Tina Vasquez

A new report from the American Civil Liberties Union, the Detention Watch Network, and the National Immigrant Justice Center shines a light on how 2009 immigration detention reforms have failed to quell in-custody deaths.

A new report examines how “egregious violations” of medical care standards contributed to at least eight in-custody deaths of immigrants over a two-year period in Immigration and Customs Enforcement (ICE)-operated detention facilities.

Fatal Neglect: How ICE Ignores Deaths in Detention, released last week by the American Civil Liberties Union, the Detention Watch Network, and the National Immigrant Justice Center, shines a light on how 2009 immigration detention reforms have failed to quell in-custody deaths. The report’s authors analyzed government death reviews and facility inspection documents, finding that inadequate medical care continues to contribute to the deaths of immigrants in federal custody.

Back in 2009, in response to sustained criticism from immigrant rights advocates and the media over medical neglect and unnecessary deaths of immigrants in detention, the Obama administration announced reforms that, among other things, included “hiring a medical expert to provide an independent review of medical complaints and denials of requests for medical services,” and creating the Office of Detention Policy and Planning, whose primary goals included ensuring “the timely provision of medical, dental, and mental health assessment and services.”

But over the course of Obama’s term, Fatal Neglect reports that there have been 56 deaths in ICE custody. Six of the deaths were suicides and at least one death occurred after an attempted suicide. The advocacy groups’ investigation focuses on eight deaths where ICE’s Office of Detention Oversight identified noncompliance with the agency’s own medical standards as a contributing cause, four of which were classified as “preventable.”

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As the country’s fastest-growing form of incarceration, immigration detention is comprised of federal centers and county jails, as well as privately run prisons owned by for-profit businesses. ICE has more than 34,000 detention beds at any given time, and those beds are spread out across as many as 250 different facilities, with the bulk of them at detention centers under contract.

Private prison companies have come under intense scrutiny over the years for their treatment of immigrant detainees. As the Nation reported in January, private prisons often hire health-service subcontractors who provide medical care that is “separate and unequal, segregated on the basis of citizenship.” This takes shape in the form of licensed vocational nurses (LVNs) being the sole caregivers of critically sick people at immigrant-only prisons contracted by ICE. LVNs undergo a year of training to operate as support staff responsible for basic tasks, such as gathering patient information or checking blood pressure, in nursing homes or under the direction of registered nurses at hospitals. But in detention centers, according to the Nation, they’re performing duties “equivalent to those of registered nurses, a practice that prison medical staff confirm.”

According to Fatal Neglect, the eight deaths illustrate how ICE also has failed to meet detainees’ health-care needs in a timely manner; to refer individuals to higher-level medical care providers; to provide adequate levels of medical staff; to communicate critically important information about individuals’ medical conditions among staff; to adequately screen individuals for illnesses; and to proactively identify and rectify concerns about medical care during facility inspections.

In the case of Evalin-Ali Mandza of Gabon, a code-blue emergency was activated at Denver Contract Detention Facility on April 12, 2012 at approximately 5:24 a.m. when other detained individuals told an officer that Mandza was experiencing chest pain. At approximately 5:50 a.m., a doctor was finally alerted to the situation, determining that Mandza, 46, needed to go to the emergency room. At this time, the doctor directed a nurse to call 9-1-1. The call was not placed, however, until approximately 6:20 a.m., nearly one hour after the activation of the code-blue emergency. According to the report, this “unconscionably long delay” violated ICE PBNDS 2008, which requires “detainees who need health care beyond facility resources to be transferred in a timely manner to an appropriate facility where care is available.”

And Irene Bamenga, a 29-year-old French citizen who is currently the subject of a wrongful death lawsuit filed by her widower, died after 12 days in ICE custody when medical staff administered incorrect medicine dosages—both in missed and excessive dosages. According to the report, Bamenga even submitted two health-services request forms in the days preceding her death, but medical staff failed to address Bamenga’s concerns and deteriorating condition. Her certificate of death lists the immediate cause as cardiomyopathy, although the report conducted by a doctor as part of the death review raises questions about this conclusion.

In-custody deaths of immigrant detainees have made headlines in recent months. There was the damning Nation investigation into the deaths of dozens of men who lost their lives in disturbing circumstances in privatized, immigrant-only prisons. There have also been pushes by immigrant rights organizations to raise awareness around the issue. Shut Down Etowah, for example, recently held a memorial service for Teka Gulema, an Ethiopian national who died in January after contracting an infection that left him paralyzed while in custody. Gulema was detained at the Etowah County Immigration Detention Center in Gadsden, Alabama, before he was transferred to a hospital. Less than a month before Gulema’s death, ICE released him from its legal custody, “although at that point he had been paralyzed for months,” according to a statement from advocates.

Prior to the administration’s reforms, from January 2004 to November 2007, reports estimated some 66 deaths occurred in immigration custody in both private and ICE-operated facilities. The New York Times’ Nina Bernstein reported in 2009 that more than one in ten deaths in immigration detention in the six years prior had been overlooked and omitted from an official roster of detainee fatalities.

And in 2010, Bernstein wrote that for years, those dying in immigration detention were uncounted and unnamed in the public record. Despite the deaths privately generating “thousands of pages of government documents, including scathing investigative reports that were kept under wraps, and a trail of confidential memos and BlackBerry messages,” officials did everything possible to quash outside inquiries.

The immigrant rights organizations behind Fatal Neglect are recommending that ICE takes the following actions: immediately reduce immigration detention, improve the delivery of medical care in detention, ensure inspections provide meaningful oversight, and increase transparency of inspections, deaths, and serious medical incidents in detention.

For its part, ICE spokeswoman Yasmeen Pitts O’Keefe said in a statement to advocates that “several of the detention centers detailed in the report have implemented more rigorous standards … to ensure detainee safety,” including “the implementation of significant changes to the health care delivery system to ensure that those in ICE custody receive timely access to medical services and treatment.” 

“That includes establishing a cadre of Detainee Medical Coordinators who are assigned to each of the agency’s field offices to closely monitor complex cases. ICE has also since simplified the process for detainees to receive authorized health care treatment,” Pitts O’Keefe added.

News Human Rights

Feds Prep for Second Mass Deportation of Asylum Seekers in Three Months

Tina Vasquez

Those asylum seekers include Mahbubur Rahman, the leader of #FreedomGiving, the nationwide hunger strike that spanned nine detention centers last year and ended when an Alabama judge ordered one of the hunger strikers to be force fed.

The Department of Homeland Security (DHS), for the second time in three months, will conduct a mass deportation of at least four dozen South Asian asylum seekers.

Those asylum seekers include Mahbubur Rahman, the leader of #FreedomGiving, the nationwide hunger strike that spanned nine detention centers last year and ended when an Alabama judge ordered one of the hunger strikers to be force-fed.

Rahman’s case is moving quickly. The asylum seeker had an emergency stay pending with the immigration appeals court, but on Monday morning, Fahd Ahmed, executive director of Desis Rising Up and Moving (DRUM), a New York-based organization of youth and low-wage South Asian immigrant workers, told Rewire that an Immigration and Customs Enforcement (ICE) officer called Rahman’s attorney saying Rahman would be deported within 48 hours. As of 4 p.m. Monday, Rahman’s attorney told Ahmed that Rahman was on a plane to be deported.

As of Monday afternoon, Rahman’s emergency stay was granted while his appeal was still pending, which meant he wouldn’t be deported until the appeal decision. Ahmed told Rewire earlier Monday that an appeal decision could come at any moment, and concerns about the process, and Rahman’s case, remain.

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An online petition was created in hopes of saving Rahman from deportation.

ICE has yet to confirm that a mass deportation of South Asian asylum seekers is set to take place this week. Katherine Weathers, a visitor volunteer with the Etowah Visitation Project, an organization that enables community members to visit with men in detention at the Etowah County Detention Center in Gadsden, Alabama, told Rewire that last week eight South Asian men were moved from Etowah to Louisiana, the same transfer route made in April when 85 mostly Muslim South Asian asylum seekers were deported.

One of the men in detention told Weathers that an ICE officer said to him a “mass deportation was being arranged.” The South Asian asylum seeker who contacted Weathers lived in the United States for more than 20 years before being detained. He said he would call her Monday morning if he wasn’t transferred out of Etowah for deportation. He never called.

In the weeks following the mass deportation in April, it was alleged by the deported South Asian migrants that ICE forcefully placed them in “body bags” and that officers shocked them with Tasers. DRUM has been in touch with some of the Bangladeshis who were deported. Ahmed said many returned to Bangladesh, but there were others who remain in hiding.

“There are a few of them [who were deported] who despite being in Bangladesh for three months, have not returned to their homes because their homes keep getting visited by police or intelligence,” Ahmed said.

The Bangladeshi men escaped to the United States because of their affiliations and activities with the Bangladesh Nationalist Party (BNP), the opposition party in Bangladesh, as Rewire reported in April. Being affiliated with this party, advocates said, has made them targets of the Bangladesh Awami League, the country’s governing party.

DHS last year adopted the position that BNP, the second largest political party in Bangladesh, is an “undesignated ‘Tier III’ terrorist organization” and that members of the BNP are ineligible for asylum or withholding of removal due to alleged engagement in terrorist activities. It is unclear how many of the estimated four dozen men who will be deported this week are from Bangladesh.

Ahmed said that mass deportations of a particular group are not unusual. When there are many migrants from the same country who are going to be deported, DHS arranges large charter flights. However, South Asian asylum seekers appear to be targeted in a different way. After two years in detention, the four dozen men set to be deported have been denied due process for their asylum requests, according to Ahmed.

“South Asians are coming here and being locked in detention for indefinite periods and the ability for anybody, but especially smaller communities, to win their asylum cases while inside detention is nearly impossible,” Ahmed told Rewire. “South Asians also continue to get the highest bond amounts, from $20,000 to $50,000. All of this prevents them from being able to properly present their asylum cases. The fact that those who have been deported back to Bangladesh are still afraid to go back to their homes proves that they were in the United States because they feared for their safety. They don’t get a chance to properly file their cases while in detention.”

Winning an asylum claim while in detention is rare. Access to legal counsel is limited inside detention centers, which are often in remote, rural areas.

As the Tahirih Justice Center reported, attorneys face “enormous hurdles in representing their clients, such as difficulty communicating regularly, prohibitions on meeting with and accompanying clients to appointments with immigration officials, restrictions on the use of office equipment in client meetings, and other difficulties would not exist if refugees were free to attend meetings in attorneys’ offices.”

“I worry about the situation they’re returning to and how they fear for their lives,” Ahmed said. “They’ve been identified by the government they were trying to escape and because of their participation in the hunger strike, they are believed to have dishonored their country. These men fear for their lives.”

Analysis Human Rights

ICE Releases Reports for 18 Migrants Who Died in Detention, Medical Neglect Is Suspected

Tina Vasquez

Though the death reviews released by ICE provide further insight into the conditions inside detention centers, the bigger concern among researchers and advocates is what they don't know.

A new report from Human Rights Watch (HRW) documents the deaths of 18 migrants in Immigration and Customs Enforcement custody from mid-2012 to mid-2015. In some cases, the deaths were likely preventable and the result of “substandard medical care and violations of applicable detention standards.”

These are not the only deaths that occurred, however. ICE acknowledges on its website that 31 deaths have occurred between May 2012 and mid-June of this year. It is unclear whether ICE intends to release information about the additional 13 deaths that have occurred.

Even so, these new findings add to a growing body of evidence showing what HRW calls “egregious violations” of medical care standards in detention centers. A February report found such violations contributed to at least eight in-custody deaths over a two-year period.

The public is just beginning to learn more about the deeply rooted problem, Clara Long, a researcher with Human Rights Watch and the lead researcher on the report, explained to Rewire. Long referenced an ongoing investigation by reporter Seth Freed Wessler at the Nation, which explores the numerous deaths that have occurred inside immigrant-only prisons.

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Though the death reviews released by ICE provide further insight into the conditions inside detention centers, the bigger concern among researchers and advocates is what they don’t know. For example, HRW worked with two independent medical experts to review the 18 death reviews released by ICE. The experts concluded that substandard medical care “probably contributed to the deaths of seven of the 18 detainees, while potentially putting many other detainees in danger as well.” Long told Rewire that the information provided by ICE simply wasn’t enough for their independent medical experts to determine that all 18 deaths were related to inadequate medical care, but that it was “likely.”

So there is the larger, systemic issue of inadequate medical care. Researchers at HRW also don’t know exactly how ICE collects information or why the agency releases information when it does. There’s also the core of the issue, as Long noted to Rewire: that the United States “unnecessarily” detains undocumented immigrants in “disturbing conditions” for prolonged periods of time.

Major Failures Lead to Death

The new HRW report identified two of the most dangerous ways ICE is failing migrants in detention: not following up on symptoms that require assistance and not responding quickly to emergencies. Both failures are illustrated by the case of 34-year-old Manuel Cota-Domingo, who died of heart disease, untreated diabetes, and pneumonia after being detained at the Eloy Detention Center in Eloy, Arizona.

ICE’s death review for Cota-Domingo suggests there was a language barrier and that Cota-Domingo was worried about having to pay for health care, which isn’t surprising given that detention centers make migrants pay for things like phone calls to their attorneys and family members. HRW asked Corrections Corporation of America, the company that runs the Eloy Detention Center, about potential fees for medical care, and it said there are no fees for such services at Eloy. For whatever reason, Cota-Domingo was not aware he had a legal right to access the medical care he needed.

When it became clear to his cellmate that Cota-Domingo was in serious need of medical attention and was having trouble breathing, the cellmate “banged on a wall to get a guard’s attention. His cellmate said he did that for three hours before anyone came to help,” Long said. The researcher told Rewire the death report outlines how investigators checked to see if the banging would have been audible to correctional officers.  It was. “Once [the cellmate] got their attention, our medical experts said this was something that should have been followed up on immediately, but the nurse decided to wait several hours before doing anything. All of these sluggish responses went on for eight hours. This is not how you treat an emergency,” Long said.

As Human Rights Watch noted in the report, “When officers finally notified medical providers of his condition, they delayed evaluating him and finally sent him to the hospital in a van instead of an ambulance. Both medical experts concluded that the combination of these delays likely contributed to a potentially treatable condition becoming fatal.”

In other death reviews by ICE, the agency’s own records show “evidence of the misuse of isolation for people with mental disabilities, inadequate mental health evaluation and treatment, and broader medical care failures.” Tiombe Kimana Carlos, Clemente Mponda, and Jose de Jesus Deniz-Sahagun all committed suicide in ICE detention after showing signs of “serious mental health conditions.” HRW’s independent experts determined that “inadequate mental health care or the misuse of isolation may have significantly exacerbated their mental health problems.”

It’s important to note that none of the death reviews released by ICE admit any wrongdoing, and that’s primarily because they don’t seek to examine whether medical negligence was at play. The reports simply present information about the deaths.

“There is no conclusion drawn, really,” Long told Rewire. “There’s one [report] in particular that even goes beyond that; it doesn’t even take into account the quality of care that led to the death, even though it’s clearly an issue of quality of care. That raises the question: What is the report for? ICE doesn’t conclude the cause. If you read [the death reviews], you can see there’s a lot of detailed information included in them that allows someone with expertise in correctional health care and who is familiar with how these systems should work, to make an assessment about whether care contributed to death, but that’s not something ICE doesat least not in the information we are able to access.”

ICE’s Murky Death-Review Process 

In a statement to Rewire, ICE explained that when a person dies while in the agency’s custody, their “death triggers an immediate internal inquiry into the circumstances.” The summary document ICE releases to the public is “the result of exhaustive case reviews conducted by ICE’s own Office of Detention Oversight (ODO), which was established in 2009 as part of the agency’s comprehensive detention reforms,” Lori K. Haley, a spokesperson with ICE, told Rewire in a prepared statement.

In fact, the ODO was created as a direct result of a series of reforms from the Obama administration after reports of human rights abuses and deaths in detention centers. The death review it produces includes a mix of findings from ICE’s own investigators and from a Beaumont, Texas-based company called Creative Corrections.

According to its website, Creative Corrections serves “local, state and federal government agencies,” offering “training, advising, professional management and consulting services” in “correctional, law enforcement, rule of law, and judicial systems.” The company contracts include the Department of Homeland Security (DHS).

“From what we can see from the documents, both ICE and Creative Corrections interview various people involved, check records, do what seems to be a pretty robust investigation for the death review,” Long said. “Unfortunately, in the set of death reviews that we used for this investigation, [the public doesn’t] have access to the Creative Corrections reports or any of the exhibits that go along with them.”

As the ICE spokesperson noted, the summary documents are typically written by ICE staff. The documents released to the public do not include medical records, full reports from Creative Corrections, or any exhibits that would provide more insight into the apparent medical neglect resulting in an estimated 161 people dying in ICE custody since October 2003. Six migrants have died in ICE custody since March 2016, two of whom died at two different detention centers in the same week. The causes of these most recent deathsand whether they can be attributed to medical neglect—is still unknown.

“If we had access to all of the information gathered during these investigations, including the reports from Creative Corrections, they would be very rich sources of information,” Long said.

Long and other researchers are also hoping for more information regarding the deaths that happen just after migrants are released from ICE custody. Teka Gulema, an Ethiopian asylum seeker detained at Etowah County Detention Center in Gadsden, Alabama, was released from ICE custody in November 2015 while in the hospital after becoming paralyzed from a bacterial infection acquired in detention. He died in January.

“One concern we have, and it’s a very big fear, is that there are multiple reports of folks who are released from ICE custody while in critical condition,” Long said. “When they die, they are no longer counted as in-custody deaths [by ICE]. We’re worried that’s a loophole being exploitedand for obvious reasons, we don’t have a number in terms of how often this is happening.”

The researcher said she has “no idea” when or why ICE decides to release information, including death reviews.

ICE did not respond to Rewire‘s request for information about its schedule or process for releasing such information.

“Maybe they released the 18 reports because they were cleared for release. Maybe a congressional office asked for them. Maybe they decided to be transparent. It could have been a [Freedom of Information Act] request from the ACLU. I wish I knew, but we really have no idea who decides—or why they decide—to release information, especially without making anyone aware that it’s been released,” the researcher told Rewire.

In April, ICE posted a series of spreadsheets about the inner workings of the detention system on their website that Long said provided a lot of information about how detention operates. The spreadsheets were removed from the site in a matter of days, too soon for many researchers—including HRW—to download them all.

“It’s a big system. We still don’t totally know how it works, which in itself is a major problem,” Long said. “One of the biggest lessons we’ve learned is to always check the ICE website. You never know what you’ll find.”

Rethinking Detention

DHS secretary Jeh Johnson is engaging in what some advocates are calling an “enforcement overdrive,” by funneling more undocumented immigrants into an already overcrowded detention system thanks to the detention bed quota established in 2009. This quota requires 34,000 undocumented migrants be locked up each day. It is in place to ensure more people get deported, though it’s costing taxpayers $2 billion a year while also creating “a profitable market for both private prison corporations and local governments,” the National Immigration Forum has said.

Reporting for the Nation, Michelle Chen recently noted that “migrants are warehoused under convoluted partnerships involving private vendors and state, local, and federal agencies. Homeland Security may contract out security duties to, or use facilities owned by, private vendors—dominated by Corrections Corporation of America (CCA) and GEO Group—with preordained headcount distributions ranging from 285 in Newark to more than 2,000 in San Antonio.”

Long told Rewire that 80 percent of migrants currently in detention are in what is considered “mandatory detention,” which, according to the Immigrant Legal Resource Center, means that “non-citizens with certain criminal convictions must be detained by ICE. People who are subject to mandatory detention are not entitled to a bond hearing and must remain in detention while removal proceedings are pending against them.” This also means that those in mandatory detention aren’t allowed to have an individual assessment by ICE of their case, “so they just sit in immigration detention indefinitely,” Long said.

“This system doesn’t work. We’re detaining far too many people for far too long and not determining on an individual level if they should be detained in the first place, taking into account all of the options available,” Long said. Options include being monitored by ICE using telephonic and in-person reporting, curfews, and home visits.

Long joins a long list of undocumented community members, researchers, organizers, activists, and other advocates pushing for the Obama administration—and whoever comes after it—to see detention as a last resort, rather than the only resort.

“We spend a lot of time talking about the disturbing conditions in detention centersthat’s what our report is about. But step one requires taking a step back and rethinking this system and how it’s unnecessary and also abuses vulnerable peoples’ rights,” Long said. “In terms of the legality of treating people this way, under U.S. and international law, people who are detained are entitled to medical treatment. The state has an obligation to provide care to this population. They are failing, and people are dying.”