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Death Review of Detainee Irene Bamenga ICE Report 2011

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Office of Professional Responsibility
U.S. Department of Homeland Security
950 L’ Enfant Plaza
Washington, DC 20024

DETAINEE DEATH REVIEW
Case Number
Detainee
Alien Number
Citizenship
Date of Death
Detention Facility
Facility Type

201111495
Irene BAMENGA
(b)(6), (b)(7)c

France
July 27, 2011
Albany County Jail – Albany, New York
IGSA
OVERVIEW

The U.S. Immigration and Customs Enforcement, Office of Professional Responsibility,
Office of Detention Oversight, initiated this review after receiving information that ICE
Detainee Irene BAMENGA, a citizen and national of France, died at the Albany
Memorial Hospital located in Albany, New York. At the time of her death, Detainee
BAMENGA was in ICE custody at the Albany County Jail (ACJ) pending removal
proceedings. Detainee BAMENGA died on July 27, 2011, due to cardiomyopathy.
This review found that Detainee BAMENGA was admitted into the United States on July
22, 2005, as a visitor for pleasure under the Visa Waiver Pilot Program. On July 15,
2011, US Customs and Border Protection (CBP) officers encountered BAMENGA at the
Lewiston Bridge Port of Entry in Lewiston, NY, after Canadian Immigration officials
denied BAMENGA entry into Canada. On the same date, CBP officers issued
BAMENGA a Notice to Alien Ordered Removed/Departure Verification, Form I-296,
charging removability pursuant to § 212(a) of the Immigration and Nationality Act (INA)
or deportable under the provisions of § 237 of the INA as a Visa Waiver Pilot Program
violator. On July 15, 2011, BAMENGA entered ICE custody at the Allegany County Jail
in Belmont, NY.
On July 21, 2011, ERO FOD Buffalo officers transferred BAMENGA to the Albany
County Jail for staging, as she was scheduled for removal through the John F. Kennedy
International Airport in New York, NY, on July 28, 2011.

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DEPARTMENT OF HOMELAND SECURITY

1. CASE NUMBER
201111495

Immigration and Customs Enforcement
Office of Professional Responsibility

PREPARED BY
(b)(6), (b)(7)c

REPORT OF INVESTIGATION

2. REPORT NUMBER
002

HB 4200-01 (37), Special Agent Handbook

3. TITLE
Bamenga, Irene/Unknown/0108 Death-Detainee/Alien (Unknown Cause)/ALBANY, ALBANY, NY
4. FINAL RESOLUTION

5. STATUS
Closing
Report

6. TYPE OF REPORT
Detainee Death Review

7. RELATED CASES

8. TOPIC
Closing Report for Detainee Death Review of Irene BAMENGA

(b)(6), (b)(7)c

9. SYNOPSIS
On July 27, 2011, the Joint Intake Center (JIC), Washington D.C., received notification regarding
the death of U.S. Immigration and Customs Enforcement (ICE) Detainee Irene BAMENGA.
Detainee BAMENGA, a citizen of France, died on July 27, 2011, at the Albany Memorial Hospital
in Albany, New York. The New York State Medical Examiner reported Detainee BAMENGA died
due cardiomyopathy.
On August 15, 2011, the ICE Office of Professional Responsibility (OPR), Office of Detention
Oversight (ODO) initiated a Detainee Death Review (DDR) of Irene BAMENGA's death. This
report documents the findings of the review.

10. CASE OFFICER (Print Name & Title)
(b)(6), (b)(7)c

Agent Supervisor

12. APPROVED BY(Print Name & Title)
(b)(6), (b)(7)c

11. COMPLETION DATE

14. ORIGIN OFFICE

- ICE-OPR Special
12-JAN-2012

ICE OPR Office of Detention Oversight (ODO)

13. APPROVED DATE

15. TELEPHONE NUMBER

12-JAN-2012

No Phone Number

- ICE-OPR Special

Agent Supervisor

THIS DOCUMENT IS LOANED TO YOU FOR OFFICIAL USE ONLY AND REMA NS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY. ANY FURTHER REQUEST FOR
DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTA NED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A
COPY OF THE DOCUMENT.
THIS DOCUMENT CONTA NS INFORMATION REGARD NG CURRENT AND ON-GO NG ACTIVITIES OF A SENSITIVE NATURE. IT IS FOR THE EXCLUSIVE USE OF OFFICIAL U.S.
GOVERNMENT AGENCIES AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY IT CONTAINS NEITHER RECOMMENDATIONS NOR CONCLUSIONS OF THE
DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEM NATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE
MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR.

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DEPARTMENT OF HOMELAND SECURITY

1. CASE NUMBER
201111495
PREPARED BY
(b)(6), (b)(7)c

REPORT OF INVESTIGATION
CONTINUATION
HB 4200-01 (37), Special Agent Handbook

2. REPORT NUMBER
002

10. NARRATIVE
On July 27, 2011, the JIC was notified of the death of Detainee Irene BAMENGA (Alien Number
(b)(6), (b)(7)c
). Detainee BAMENGA, a citizen of France was born on November 10, 1981 and
died on July 27, 2011 at the Albany Memorial Hospital located at 600 Northern Boulevard, Albany,
New York. Detainee BAMENGA was 29 years old at the time of her death.
Detainee BAMENGA was in ICE custody at the Albany County Correctional Facility (ACCF) on the
date of her death. The Albany County Sheriff's Office (ACSO) owns and operates the ACCF. The
ACCF is a mixed-use facility that houses inmates received from area law enforcement
jurisdictions, as well as adult male and female federal detainees over 72 hours. The ACCF is an
intergovernmental service agreement (IGSA) facility contracted by the United States Marshals
Service (USMS) to house federal detainees. ICE is an Authorized User in accordance with the
contract.
(b)(6), (b)(7)c
During the week of August 22, 2011, OPR ODO Special Agent (SA)
and
(b)(6), (b)(7)c
Supervisory Special Agent (SSA)
conducted the on-site segment of the ODO
(b)(6), (b)(7)c
DDR. The agents were assisted by Program Manager (PM)
PM (b)(6), (b)(7)c is
employed by MGT of America Inc. (MGT), a national management and consultant firm, contracted
by ICE to provide subject matter expertise in detention management and correctional health care.
As part of the review, agents interviewed staff at the ACCF, the Allegany County Jail (ACJ), U.S.
Customs and Border Protection (CBP), and the ICE Office of Enforcement and Removal
Operations (ERO). Additionally, agents reviewed immigration, medical, and detention records
pertaining to Detainee BAMENGA.

The following is a time-line of the events regarding Detainee BAMENGA while she was in ICE
custody.
(b)(6), (b)(7)c
On July 15, 2011, at approximately 5:35 p.m., CBP Officer (CBPO)
encountered
Irene BAMENGA at the Lewiston Bridge Port of Entry (POE) in Lewiston, New York. Irene
(b)(6), (b)(7)c
(b)(6), (b)(7)c
BAMENGA, her husband
and
attempted to enter Canada from the
United States. BAMENGA was denied entry into Canada due to lack of a valid I-94
(Arrival-Departure Record) from the United States. All three individuals attempted to re-enter the
United States and were detained by CBP officers at the Lewiston Bridge POE. CBP officers
researched BAMENGA's immigration status and learned that she entered the United States as a
Visa Waiver Pilot Program participant in 2005. BAMENGA was authorized to remain in the United
States until October 21, 2005.

SSA

(b)(6), (b)(7)c

and CBP Internal Affairs (IA) SA

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(b)(6), (b)(7)c

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interviewed CBPO

(b)(6), (b)(7)c

on August

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DEPARTMENT OF HOMELAND SECURITY

Page 15 of 20

1. CASE NUMBER
201111495
PREPARED BY
(b)(6), (b)(7)c

REPORT OF INVESTIGATION
CONTINUATION
HB 4200-01 (37), Special Agent Handbook

2. REPORT NUMBER
002

10. NARRATIVE
Death regarding BAMENGA (Exhibit 36). According to the Certificate of Death report, BAMENGA'
s immediate cause of death was cardiomyopathy and the time of death is listed as 1:17 a.m. The
death certificate indicates an autopsy was performed on BAMENGA. Coroner (b)(6), (b)(7)c
(b)(6), (b)(7)c
(b)(6), (b)(7)c
and
M.D., signed the Certificate of Death pertaining to
BAMENGA. ICE has been denied access to the BAMENGA autopsy report by the Albany County
Department of Law based on New York State County Law 677. The ICE Office of Principal Legal
Advisor (OPLA) has made efforts to obtain the autopsy report without success. According to
(b)(6), (b)(7)c
information supplied by Albany County Attorney
the autopsy report cannot be
disclosed at the request of the Department of Homeland Security (Exhibit 37).

MEDICAL COMPLIANCE REVIEW:
MGT of America, a national management and consultant firm, contracted by ICE to provide
subject matter expertise in detention management including health care, reviewed the medical
care of Detainee BAMENGA while housed at the ACCF and the ACJ. MGT of America found that
the ACCF and the ACJ were not compliant with the ICE NDS for medical care. Specifically, MGT
determined that the ACCF and ACJ failed to dispense ordered medications, delayed in starting
medications, failed to verify medications, and provided incorrect dosing of medications. The MGT
of America report is attached to this ROI (Exhibit 38).
MORTALITY REVIEW:
(b)(6), (b)(7)c
A mortality review was conducted by Dr.
, a clinical consultant medical doctor
contracted by ICE to evaluate the medical care provided to Detainee BAMENGA while in ICE
custody. Dr. (b)(6), (b)(7)c assessed the care provided by the ACCF as inadequate. Specifically, Dr.
(b)(6), (b)(7)c documented in her report that both the ACCF and the ACJ were remiss in not conducting
a thorough clinical evaluation and assessment of BAMENGA whose congestive heart failure would
deteriorate when poorly managed. According to Dr. (b)(6), (b)(7)c report, BAMENGA should have
been placed on a restricted sodium diet. Additionally, an electrocardiogram should have been
done and a chest x-ray should have been completed. According to Dr. (b)(6), (b)(7)c laboratory testing
should have been done to include digoxin levels, electrolytes, a complete blood count, and thyroid
function studies. Dr. (b)(6), (b)(7)c Mortality Review Report is attached to this report (Exhibit 39).

IMMIGRATION AND DETENTION HISTORY:
Irene BAMENGA, a native of Angola and citizen of France, entered the United States as a visitor
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DEPARTMENT OF HOMELAND SECURITY

Page 16 of 20

1. CASE NUMBER
201111495
PREPARED BY
(b)(6), (b)(7)c

REPORT OF INVESTIGATION
CONTINUATION
HB 4200-01 (37), Special Agent Handbook

2. REPORT NUMBER
002

10. NARRATIVE
under the Visa Waiver Program (VWP) at Boston, Massachusetts on July 22, 2005. Detainee
BAMENGA was authorized to remain in the United States until October 21, 2005.
On July 15, 2011, BAMENGA was encountered by CBP at the Lewiston Bridge, Lewiston, New
York, after having been refused entry into Canada for failure to provide a valid I-94, Nonimmigrant
(b)(6), (b)(7)c
Visa Waiver Arrival/Departure Form. CBP Assistant Port Director
issued an Order
of Removal for Detainee BAMENGA in accordance with Section 217 of the Immigration and
Naturalization Act (INA).
From July 15, 2011 to July 21, 2011, Detainee BAMENGA was housed at the Allegany County
Jail, located in Belmont, New York pending removal from the United States.
On July 21, 2011, Detainee BAMENGA was transferred to Albany County Correctional Facility,
located in Albany, New York. Detainee BAMENGA was scheduled for removal from the United
States on July 28, 2011.
CRIMINAL HISTORY:
According to the National Crime Information Center (NCIC), Detainee BAMENGA was assigned
(b)(7)e
the FBI #
NCIC records indicate Detainee BAMENGA has no additional arrests prior
to her encounter with CBP on July 15, 2011.
INVESTIGATIVE FINDINGS:
Detainee BAMENGA came into ICE custody on July 15, 2011, and her congestive heart failure
was documented consistently while in ICE custody. The New York State Department of Health
Certificate of Death documents that Detainee BAMENGA's immediate cause of death was
cardiomyopathy. A review of the Medical Administration Records (MAR) pertaining to BAMENGA
revealed the ACCF and ACJ failed to dispense ordered medications, delayed in starting
medications, failed to verify medications, and provided incorrect dosing of medications. According
to information provided by Dr. (b)(6), (b)(7)c "missed medication dosing as well as incorrect medication
dosing were significant factors that contributed to the decompensation of her congestive heart
failure." [Agent's note: decompensation is failure of the heart to maintain adequate blood
circulation, marked by labored breathing, engorged blood vessels, and edema (www.
medical-dictionary.thefreedictionary.com.)]
This review revealed the ACJ and the ACCF were not in compliance with the ICE NDS Medical
Care Standard. The ICE NDS, Medical Care, Section (I), Policy, indicates all detainees shall have
access to medical services that promote detainee health and general well-being. MGT of America
reviewed Medical Administration Records (MAR) and determined that the ACCF and ACJ failed to
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DEPARTMENT OF HOMELAND SECURITY

Page 18 of 20

1. CASE NUMBER
201111495
PREPARED BY
(b)(6), (b)(7)c

REPORT OF INVESTIGATION
CONTINUATION
HB 4200-01 (37), Special Agent Handbook

2. REPORT NUMBER
002

10. NARRATIVE
the BAMENGA's medical records from her community provider, or ordering laboratory tests. ACJ
policy does not address handling of medications received with new detainees, including
documenting receipt, inventory, disposal or release by either booking or medical staff. Interviews
with ACJ medical staff revealed that in ACJ practice, medications are turned over to the medical
unit when received, and returned to ICE detainees upon release or transfer.
A review of the contract between the United States Marshals Service (USMS) and the ACCF for
housing detainees at the ACCF revealed ICE is listed as an "Other Authorized Agency User"
(Exhibit 40). According to the contract, "Detainees shall also be housed in a manner that is
consistent with federal law and the Federal Performance-based Detention Standards." ICE does
not have a separate and independent contract with the ACCF that specifies requirements of the
ICE NDS for housing ICE detainees.

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DEPARTMENT OF HOMELAND SECURITY

Page 19 of 20

1. CASE NUMBER
201111495
PREPARED BY
(b)(6), (b)(7)c

REPORT OF INVESTIGATION
Exhibit List
HB 4200-01 (37), Special Agent Handbook

2. REPORT NUMBER
002

01 - Form I-213, Record of Deportable/Inadmissible Alien (7/15/2011)
02 - I-94 Arrival/Departure information related to BAMENGA
03 - CBP Vehicle Utilization Log (7/15/2011)
04 - ACJ Vehicle Log used to document activity at the facility (7/15/2011)
05 - Homeland Security Form I-203 Order to Detain or Release Alien (7/15/2011)
06 - ACJ Booking Observation Report (7/15/2011)
07 - ACJ History and Physical Examination (7/18/2011)
08 - ACJ Medication Record
09 - ICE Detainee Interview Log (7/19/2011)
10 - Certificate of Issuance of Immigration Detainee Handbook (7/19/2011)
11 - ICE Personal Property Notice (7/19/2011)
12 - Detainee Interview /Visitation Worksheet (7/19/2011)
13 - ACJ Grievance Records
14 - ACJ Vehicle Log used to document activity at the facility (7/21/2011)
(b)(6), (b)(7)c
15 - Email from SDDO
(7/20/2011)
16 - Homeland Security Form I-203 Order to Detain or Release Alien (7/21/2011)
17 - Copy of Allegany County Sheriff's Office check number (b)(6), (b)(7)c (7/20/2011)
18 - Memorandums pertaining to Detainee Transfer Sheets
19 - Form I-216 Record of Persons and Property Transferred (7/21/2011)
20 - ACCF Offender Management System (OMS) data (7/21/2011)
21 - Correctional Medical Services Medical and Mental Health History and Screening form
(7/21/2011)
22 - ACCF Interdisciplinary Progress Notes
23 - Correctional Medical Services Physician Orders
24 - ACCF Medication Administration Record
25 - ACCF Housing Assignments for BAMENGA
26 - Correctional Medical Services Health Services Request Forms (7/25/2011)
27 - ACCF Inmate Service Unit Intake Interview packet (7/26/2011)
28 - ACCF Register Log (7/26/2011)
29 - Detainee Interview/Visitation Worksheet (7/26/2011)
30 - ACCF Inmate Classification Test results (7/26/2011)
31 - ACCF Classification Policy
32 - ACCF Post Log for 6 West (7/27/2011)
33 - Colonie EMS Prehospital Care Report
34 - ACCF Incident Report # 11-106
35 - Albany Memorial Hospital Emergency Department Report (7/27/2011)
36 - New York State Department of Health Certificate of Death (7/27/2011)
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Page 20 of 20

1. CASE NUMBER
201111495
PREPARED BY
(b)(6), (b)(7)c

REPORT OF INVESTIGATION
Exhibit List
HB 4200-01 (37), Special Agent Handbook
(b)(6), (b)(7)c
37 - Albany County Attorney
Email (8/11/2011)
38 - MGT of America Medical Compliance Review (6/29/2011)
(b)(6), (b)(7)c
39 - Mortality Review by Dr.
40 - U.S. Marshals Service IGSA Detention Contract with ACCF

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2. REPORT NUMBER
002

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Review of Detainee Death
(b)(6), (b)(7)c
Irene Bamenga, A-Number
Medical Record Review Findings
Allegany County Jail, Belmont, New York
Albany County Correctional Facility, Albany, New York
Section 1: Timeline
As requested by the ICE Office of Professional Responsibility, Office of Detention Oversight,
MGT of America, Inc. participated in a review of detainee Irene BAMENGA’s death while in
(b)(6), (b)(7)c
(b)(6), (b)(7)c
ICE custody. MGT accompanied Special Agents
and
for
site visits to the Allegany County Jail and Albany County Correctional Center August 23 – 25
2011, and participated in interviews of correctional and medical staff at both facilities.
Additionally, MGT reviewed the medical record of detainee BAMENGA and inspected
documentation of staff training in emergency response and distribution of medication. MGT’s
participation was requested to determine compliance with ICE National Detention Standards
(NDS) governing medical services.
The following chronicles detainee BAMENGA’s period of detention at the Allegany and Albany
County facilities based on documented and reported information. Italicized text in parenthesis
defines or explains medical terminology and abbreviations. MGT’s findings with respect to
compliance with ICE NDS and general observations for which there are no applicable NDS
components are documented in commentary.
Background
ICE Significant Event Notification – Significant Incident Report documents that on July 15,
2011 detainee Irene BAMENGA was issued a Notice to Alien Ordered Removed/Departure
Verification by Customs and Border Protection (CBP) officers after being denied entry into
Canada by Canadian immigration officials. An Order to Detain or Release Alien signed by CBP
Enforcement Officer (b)(6), (b)(7)c directed her detention at the Allegany County Jail (ACJ)
pending removal proceedings. In the Remarks section of the form was documented, “Congestive
Heart Failure she takes medications to control her medical problem. Subject has medication with
her.”
Friday, July 15, 2011
ALLEGANY COUNTY JAIL
Allegany County Sheriff’s Office Inmate Personal Property Receipt documents detainee
BAMENGA’s personal property as $20 in currency, white sneakers, yellow brazil shirt, and
shorts.
Suicide Prevention Screening Questionnaire completed by Deputy

(b)(6), (b)(7)c

Saturday, July 16, 2011
Allegany County Jail Booking Observation Report completed by Deputy( )(6), (b)(7)cdocuments
detainee BAMENGA responded affirmatively when asked if she was on medication, stating “lots
of them.” In addition, she reported an allergy to Tramadol (treats moderate to severe pain) and
DDR Medical Compliance Review: Detainee Irene BAMENGA
Section 1: Timeline

Page 1

positive tuberculosis (TB) test 12 years ago. No medical conditions or special needs
documented.
COMMENT: The Booking Observation Report includes health-related observation and
interview questions intended to identify immediate medical or special housing needs.
Facility policy J-3.10 assigns responsibility for completion of the report to booking
officers and includes provisions for referral for immediate medical attention if required.
ICE NDS, Medical Care, section (III)(D) requires that all new arrivals receive initial
medical and mental health screening by a health care provider or an officer trained to
perform this function. MGT verified officers are trained in the intake screening function.
Compliance is met.
According to Deputy(b)(6), (b)(7 cdetainee BAMENGA was received with a large bag of medications
which he took directly to the Medical Unit. Because of the hour, medical staff was not present to
directly receive the medications.
COMMENT: ACJ policy does not address handling of medications received with new
detainees, including documenting receipt, inventory, disposal or release by either booking
or medical staff. MGT was informed that in practice, medications are turned over to the
Medical unit when received, and returned to ICE detainees upon release or transfer.
(b)(6), (b)(7)c
Registered Nurse (RN), per interview.
Detainee BAMENGA was screened by
RN (b)(6), (b)(7)c stated she reported to the facility on a Saturday because she was on-call for the
purpose of performing TB testing and follow-up medical screening on new prisoners. RN
(b)(6), (b)(7)c
documented the encounter by noting the following on the Booking Observation
Report completed by Deputy(b)(6), (b)(7) Congestive Heart Failure (CHF) and high blood pressure;
ASA (aspirin to reduce risk of heart attack), Digoxin (heart medication), Lisinopril
(hypertension), and Furosemide (diuretic) on a daily basis; Spironalactone (diuretic) twice a
day; and Carvedilol (HTN, heart failure, and angina/chest pain), dosage frequency documented
as “?”. In addition, RN (b)(6), (b)(7)c documented a previous positive TB test in 2002, “was
treated;” and blood pressure of 138/92 (slightly elevated).

During interview, RN (b)(6), (b)(7)c stated detainee BAMENGA was not certain of Carvedilol
dosing. She reported the detainee’s lungs were clear, her heart rate was regular, and she
observed no swelling. A TB test by PPD was not planted because the detainee previously tested
positive; instead, authorization for chest x-ray was to be requested. RN (b)(6), (b)(7)c stated
detainee BAMENGA voiced no medical complaints, and was not asked for information on her
private provider or when she was last seen. RN (b)(6), (b)(7)c reported there were two large
medication organizers belonging to the detainee “stuffed” with various medications. The
detainee informed her she had taken her medications the day before and asked why she could not
have them. RN (b)(6), (b)(7)c stated she informed detainee BAMENGA the facility does not allow
prisoners to take their own medications because they are not verified. She instructed the detainee
to obtain information on dosages from her husband. Upon inquiry, RN (b)(6), (b)(7)c stated
procedures are in place for off-hours consultation with a provider concerning medications or
other matters; however, because BAMENGA’s screening was normal, she did not believe action
before Monday was necessary.
DDR Medical Compliance Review: Detainee Irene BAMENGA
Section 1: Timeline

Page 2

(b)(6), (b)(7)c
COMMENT: According to RN (b)(6), (b)(7)c and Nurse Practitioner (NP)
The ACJ Medical Unit does not document encounters or actions in Progress Notes or
other chronological record. RN (b)(6), (b)(7)c she typically makes a note in the SOAP
format (Subjective, Objective, Assessment, Plan) if there are findings of significance.

MGT was informed detainee BAMENGA’s medications were placed in her personal property.
Monday, July 18, 2011
“Informed Consent – Consent for Detainees” form signed.
COMMENT: ICE NDS, Medical Care, section (III)(L) requires health care providers to
obtain signed and dated consent forms from all detainees before any medical examination
or treatment, except in emergency circumstances. Compliance is met.
NP (b)(6), (b)(7)c conducted a physical examination, making hand-written notes on the same Booking
Observation Report used by RN Harrington to document the medical screening, and generating a
type-written “History and Physical Examination” report. Findings were documented as follows:
History and Physical Examination
• Past medical history: CHF (congestive heart failure- excessive amount of fluid in lungs),
HTN (hypertension/high blood pressure), and anemia (reduction of circulating red blood
cells)
• Past surgical history: right lung
• Medications: ASA daily, Spironalactone twice a day, Lasix (diuretic) daily, Digoxin
daily, Carvedilol daily, and Lisinopril daily.
• Allergies: Tramadol (pain medication)
• Denies tobacco, alcohol and illicit drug use
• Suicide and mental health referral: negative
• General appearance: 29 year-old black female, “appears as stated age;” alert and oriented.
• Vital signs: temperature 99.8, pulse 88, respirations 20, blood pressure (BP) 128/84
(slightly elevated), weight 206 lbs.
• Cardiac: Regular rate and rhythm.
COMMENT: ICE NDS, Medical Care, section (III)(D) requires that health care providers
conduct a health appraisal and physical examination on each detainee within 14 days of
arrival. Compliance is met.
COMMENT: Detainee BAMENGA was not placed on a restricted diet despite her weight
and history of hypertension.
NP (b)(6), (b)(7)c generated the following:
Problem List
• Height, 67 inches; weight, 206 lbs.
• Previous positive PPD
DDR Medical Compliance Review: Detainee Irene BAMENGA
Section 1: Timeline

Page 3

•
•
•

Problems: HTN, CHF, and Anemia
Treatment: ASA 81 mg daily, Spironalactone 25 mg twice daily, Lasix 20 mg daily,
Digoxin 0.25 mg daily, Carvedilol 20 mg daily, and Lisinopril 20 mg daily.
Date documented for listed problems and treatment: 7/7/2011. During interview,
NP Ralyea, the incorrect date was a typographical error.

Medication List
• Allergies: Tramadol
• Medications (start date July18, 2011)
o ASA 81 mg daily
o Spironalactone 25 mg twice daily
o Lasix 20 mg
o Digoxin 0.25 mg daily
o Carvedilol 20 mg daily
o Lisinopril 20 mg daily
Orders
• Diagnosis: CHF, HTN, anemia
• Allergies: Tramadol
• Date order of 7/18/2011 and Date Stop of 10/18/2011 for the following:
o Tylenol 2 tablets by mouth as needed for fever or pain
o ASA 81mg daily
o Spironalactone 25mg twice daily
o Lasix 20 mg daily
o Digoxin 0.25mg daily
o Lisinopril 20mg daily
o Carvedilol 20mg daily
COMMENT: The order for medications was made three days following the detainee’s
arrival. During interview, NP b)(6), (b)(7)c stated the medications ordered, including dosage,
were as reported by detainee BAMENGA. She did not attempt to verify the medications
before ordering them. According to the Nursing 2010 Drug Handbook, Carvedilol is to
be administered twice daily, and according to WebMD, pulse should be taken when
Digoxin is administered to ensure it is not too slow. The order for Digoxin did not
include this provision. NP (b)(6), (b)(7)c stated she did not consider pursuing the detainee’s
medical records from her community provider, or ordering laboratory tests.
Treatment Authorization Request approved for chest x-ray due to positive PPD history.
Approved July 19, 2011.
COMMENT: ICE NDS, Medical Care, section (III)(D) requires that all new arrivals
receive TB screening by PPD (mantoux method) or chest x-ray. PPD is to be the primary
screening method unless contraindicated, as was the case with detainee BAMENGA.
ACJ took appropriate action to request authorization for a chest x-ray, though it was not
completed prior to her transfer on July 21, 2011. NP b)(6), (b)(7)c stated that though not

DDR Medical Compliance Review: Detainee Irene BAMENGA
Section 1: Timeline

Page 4

documented, detainee BAMENGA was screened for, but did not exhibit signs or
symptoms of TB.
Medication Administration Record (MAR) documents Officer
BAMENGA her evening dose of Spironalactone.

(b)(6), (b)(7)c

gave detainee

COMMENT: MGT was informed medications are distributed by officers trained in the
function when medical staff is not on site. MGT verified Officer(b)(6), (b)(7)ccompleted
training. ICE NDS, Section (III)(I) requires that written records be maintained of all
medications given to detainees. Compliance is met for the term of detainee
BAMENGA’s detention in the ACJ.
Tuesday, July 19, 2011
MAR documents detainee BAMENGA was given ASA, Lasix, Digoxin, Lisinopril, Carvedilol,
and Spironalactone by RN (b)(6), (b)(7)c in the morning, and her evening dose of Spironalactone in
by Officer (b)(6), (b)(7)c
COMMENT: There was no documentation supporting Officer
training in distribution of medication.

(b)(6), (b)(7)c

completed

Wednesday, July 20, 2011
MAR documents detainee BAMENGA was given ASA, Lasix, Digoxin, Lisinopril, Carvedilol,
and Spironalactone by RN (b)(6), (b)(7)c in the morning, and her evening dose of Spironalactone in
by Officer (b)(6), (b)(7)c
NP (b)(6), (b)(7)c stated she was notified by Intake that detainee BAMENGA was being transferred.
She prepared a Medical Summary of Federal Prisoner/Alien in Transit form documenting the
detainee had a previous positive PPD and treatment in 2000; chest x-ray “not done yet.”
Departure date was recorded as July 20, 2011; “Destination” and “Reason for Transfer” left
blank. Current Medical Problems were documented as HTN, CHF, and anemia; recorded
medications, dosage, and “Medication Requirements for Care En Route” were consistent with
Medication List, Orders and MAR. No special needs affecting transportation noted. NP (b)(6), (b)(7)c
stated the transfer summary was placed in a sealed envelope bearing the detainee’s name and
marked, “CONFIDENTIAL.” She stated the envelope and blister packs containing detainee
BAMENGA’s remaining medications were forwarded for transfer.
COMMENT: ICE NDS, Detainee Transfers, section (III)(D)(6) requires that health care
providers be given advance notice prior to the release, transfer or removal of a detainee
so that medical staff may determine and provide for any medical needs. Section
(III)(D)(6) further requires IGSA facilities to prepare transfer summaries documenting
TB clearance, current mental and physical health status, medications, and contact
information for the transferring medical official. In addition, ICE NDS, Medical Care,
section (III)(N) requires placement of medical information in sealed envelopes marked
“MEDICAL CONFIDENTIAL.” Compliance with all requirements is met.

DDR Medical Compliance Review: Detainee Irene BAMENGA
Section 1: Timeline

Page 5

COMMENT: Facility physician Dr. (b)(6), (b)(7)c did not increase Coreg to twice daily,
and did not order that detainee BAMENGA’s pulse be taken before giving Digoxin.
Problem List documented chronic problems as CHF, HTN, and anemia.
Detainee signed Informed Consent for urine pregnancy test and consent for HIV testing.
COMMENT: No documentation of pregnancy or HIV testing. It is noted, however, RN
documented negative in the “Pregnancy Test Results” of the intake screening
form.

(b)(6), (b)(7)c

During interview, RN b)(6), (b)(7)cstated the medications were received with the detainee in blister
packs; further, that medications received from another facility in this manner may be
administered upon physician approval. RN b)(6), (b)(7)cstated detainee BAMENGA made no
comments concerning her medications and expressed no concerns or complaints.
MAR documents detainee BAMENGA was given all medications this date as ordered. MGT
was informed only medical personnel distribute medications.
Friday, July 22, 2011
MAR documents detainee BAMENGA was given morning doses of all medications; “NS” (No
Show) recorded for evening dose of Spironolactone.
COMMENT: HSA (b)(6), (b)(7)c provided policy J-D-02.06, “Medication Administration
Record,” which states “Absent” is to be documented if the prisoner is “not present, and
no reason for the absence was given.” She stated the expectation is that the nurse goes to
the cell to determine the reason for the absence or refusal; further, that the prisoner be
referred to the ordering practitioner following three missed doses. She provided the
Medication Administration Documentation lesson plan supporting nurses are trained
accordingly. HSA (b)(6), (b)(7)c stated she reviewed nursing staff’s medication distribution
practices in light of the fact “NS” was recorded on detainee BAMENGA’s MAR on July
22, 24, 25 and 26, 2011. On none of the days “NS” was recorded did the nurse seek out
the detainee, and no action taken to notify the provider after the third dose was missed.
HSA (b)(6), (b)(7)c stated failure to follow policy was addressed with three specific staff
members who recorded “NS,” and correct procedures have been reviewed with all staff.
Saturday, July 23, 2011
MAR documents detainee BAMENGA was given all medications as ordered.
Sunday, July 24, 2011
MAR documents detainee BAMENGA was given morning doses of all medications; “NS”
recorded for evening dose of Spironolactone.
Monday, July 25, 2011
MAR documents detainee BAMENGA was given morning doses of all medications; “NS”
recorded for evening dose of Spironolactone.
DDR Medical Compliance Review: Detainee Irene BAMENGA
Section 1: Timeline

Page 7

MAR documents a new entry for Digoxin: “Digoxin to be given daily and to hold dose if apical
pulse is [less than] 60 and notify MD.” MAR documents apical pulse was 88 and Digoxin given.
COMMENT: As noted previously, checking pulse prior to giving Digoxin is
expected practice, however, there is no corresponding Physician’s Order or other
documentation reflecting what precipitated the instruction.
Tuesday, July 26, 2011
Health Services Request Form: “I am not being given the full dosage of my medications. Two
of the six different meds are meant to be take twice a day and so far I have only be given 1
dosage in the morning. The two medecines are spironolactone and carvedilol [sic].” Date and
time received illegible, as are the initials of the individual who conducted triage and referred the
detainee for nurse’s sick call. Documented in the “Health Care Documentation” section of the
form are, “Seen on 7-26” and “Coreg ordered [twice per day].”
Health Services Request Form submitted by detainee: “Shortness of breath at night especially
when laying down, palpitations when laying down. Dizziness upon standing up when palpitation
and shortness of breath occur.” “FOR MEDICAL USE ONLY” section of form for documenting
date and time received are blank, as are sections for recording triage and “Health Care
Documentation.” According to HSA (b)(6), (b)(7)c the “FOR MEDICAL USE ONLY” section is to
be completed when a medical staff person is handed a request form directly by a detainee. It is
not completed if received through another source. HSA (b)(6), (b)(7)c further stated both the triage and
Health Care Documentation sections should have been completed.
COMMENT: ICE NDS, Medical Care, section (III)(F), Sick Call, requires facilities to
have a mechanism that allows detainees the opportunity to request health care services.
Facility policy J-E-07.00 supports compliance with the standard. In addition, section
(III)(F) requires health care providers to review request slips to determine when the
detainee will be seen. Compliance is supported with respect to one of detainee
BAMENGA’s sick call requests.
9:40 AM
Physical Assessment completed by NP (b)(6), (b)(7)c Weight documented as 200 lbs; BP 110/80
(normal range); other vital signs within normal limits. History of positive PPD; treated in 2000
in Paris, France. Past medical history of HTN, CHF for five years; past surgical history of right
lobectomy (surgical removal of lobe of any organ or gland). Current medications recorded.
Described as cooperative and alert and oriented to person, place & time; denied chest pain and
shortness of breath.
COMMENT: Compliance with ICE NDS, Section (III)(D) requiring physical
examination within 14 days of arrival is met.
COMMENT: Detainee BAMENGA was not placed on a restricted diet despite weight
and history of hypertension.

DDR Medical Compliance Review: Detainee Irene BAMENGA
Section 1: Timeline

Page 8

ACCF Incident Report by Officer

(b)(6), (b)(7)c

documents the following:

“On July 27, 2011 I was working on the 6 West Housing Unit 11 to 7 shift. At
approximately 12:15 AM I was notified by inmates in Bay L3 that inmate Bamenga was
sick. I then called for a relief officer so the inmate could be taken to medical. At
approximately 1219 I notified the Unit Supervisor because inmate would not answer me.
At 1223 I entered L3 Bay to rouse Bamenga. Inmate Bamenga did not respond. I then
notified Medical via my portable radio to respond immediately while inside L3 Bay. I
then left the bay to activate the units alarm system At 1224 Medical staff entered the bay
and CPR was commenced. I administered chest compressions for inmate Bamenga while
nurse (b)(6), (b)(7)c worked the ambu bag. EMS arrived at 1235 and took over care for
inmate Bamenga. At 1253 EMS transported inmate Bamenga from the unit.”
During interview Officer b)(6), (b)(7)creported that when he conducted count at 11:00 PM, detainee
BAMENGA was lying in bed. He stated she appeared to be awake because her eyes were open.
He stated that when first notified by her dorm-mates that she was ill, he followed standard
operating procedure by calling for an escort officer. While waiting, inmates stated “she is really
sick,” so he decided to walk from his station to her housing area. From outside, he called her
name a few times and asked if she was OK. Receiving no reply, he returned to his station to
verify escort was on its way. He then walked back to the housing area and decided to enter. He
stated detainee BAMENGA looked “really sick,” so he grabbed her arm and finding her nonresponsive, notified Medical via his radio and returned to his station to hit the alarm. Nurse
(b)(6), (b)(7)c
(b)(6), (b)(7)c
and Nurse
arrived “quickly” and together, they removed
detainee BAMENGA from her upper bunk. Once she was on the floor, Nurse (b)(6), (b)(7)c applied
the ambu-bag and Nurse (b)(6), (b)(7)c initiated CPR, subsequently being relieved by Officer (b)(6), (b)(7)c
and Nurse (b)(6), (b)(7)c
COMMENT: Asked why he did not enter the housing unit when he called for detainee
BAMENGA and did not receive a reply, he stated that as a male, he did not want to enter
a female unit; further, he did not feel it was necessary because he could see everyone. He
further stated, “They tell us not to go in because it could be a trap and you don’t want to
go in alone.” During interview, Captain (b)(6), (b)(7)c stated officers are trained not to enter
cells by themselves except in medical emergency. It is noted Officer (b)(6), (b)(7)c report
documents four minutes elapsed between being alerted detainee BAMENGA was sick
and finding her unresponsive upon calling to her from outside the housing unit. Instead
of returning to his station to notify his supervisor as documented in his report, or to check
on escort as reported during interview, Officer b)(6), (b)(7)ccould legitimately have called
medical emergency by radio and entered the unit. Another four minutes elapsed before
he entered and attempted to wake detainee BAMENGA, whereupon he called Medical by
radio and again returned to his station to activate the alarm system. A total of nine
minutes elapsed between notification the detainee was ill and commencement of CPR.
COMMENT: MGT was provided with a memorandum on Albany County Sheriff’s
Office letterhead stating Officer b)(6), (b)(7)ccompleted cardio-pulmonary resuscitation (CPR)
re-certification training March 1, 2011. In addition, CPR certification cards expiring in
(b)(6), (b)(7)c
(b)(6), (b)(7)c
2012 were produced for Nurse
and Nurse
ICE
DDR Medical Compliance Review: Detainee Irene BAMENGA
Section 1: Timeline

Page 10

NDS, Medical Care, section (III)(H) states detention staff must be trained to respond to
health-related emergencies within a four-minute timeframe. Compliance with training
requirements is met.
12:58 AM
Interdisciplinary Progress Notes documents, “EMS [with patient] to Memorial Hospital, life
support machines on [patient].”
1:00 AM
Interdisciplinary Progress Notes documents, “Health Services Administrator
of situation.”
1:05 AM
Interdisciplinary Progress Notes documents, “MD

(b)(6), (b)(7)c

(b)(6), (b)(7)c

informed

notified of incident.

1:20 AM
Interdisciplinary Progress Notes documents, “Dr. (b)(6), (b)(7)c from Memorial Hospital stated the
[patient] was pronounced dead at 0115.”

Albany Memorial Hospital Emergency Department Reports dictated by Doctor
documented the following:

(b)(6), (b)(7)c

“Chief Complaint: cardiac arrest.
History of Present Illness: This is a 29-year-old female who arrives from the Albany
County Jail in full cardiopulmonary arrest. History obtained from EMS providers, and
some history from her family when I had called them. She is a 29-year-old with a history
of anemia and congestive heart failure who has been taking multiple medications,
apparently laying in bed, not terrible [sic] responsive for several hours, but her cellmates
were not initially concerned because her eyes were open and they thought she was simply
not communicative. However, when the [sic] tried to rouse her, they were unable to. At
that point, the guards were summoned. Jail medical staff responded and started CPR.
EMS was called simultaneously. On EMS arrival, the guards had performed
approximately ten minutes of CPR. EMS found her to be asystole…”
Certificate of Death documents manner of death as natural cause; cased referred to coroner;
autopsy performed. Immediate cause of death: cardiomyopathy (disease that affects heart
muscle, diminishing cardiac performance).

DDR Medical Compliance Review: Detainee Irene BAMENGA
Section 1: Timeline

Page 11

MEDICAL COMPLIANCE REVIEW
Section 2: Missed Medication Summary
Detainee Irene BAMENGA

Following are medications detainee BAMENGA reported she was taking at the time of her arrest,
subsequently ordered by Allegany and Albany County providers. Column A summarizes doses not
given as ordered by the providers. Column B summarizes doses missed pending provider order at
Allegany County, failure to distribute ordered medications at Albany, and incorrect dosing of Carvedilol.

*

A

B

EC ASA

None

3

Lasix

None

3

Lisinopril

None

3

Digoxin*

None

3

Pulse taken for
Digoxin

2

9

Carvedilol/Coreg

1

15

Spironalactone

2

9

MORTALITY REVIEW REPORT

NAME: Bamenga, Irene

ID#:

(b)(6), (b)(7)c

DATE OF BIRTH: November 10th, 1981

FACILITY: Albany County Correctional Facility
DATE OF DEATH: July 27th, 2011

The preliminary autopsy report and certificate of death indicated that 29 year old Irene Bamenga, a
citizen of France, died of cardiomyopathy. This mortality review was conducted based on a review of
booking, classification, investigative reports and statements, as well as medical records from Allegany
County Jail, Albany County Correctional Facility and Albany Memorial Hospital Emergency Room.

Narrative Summary:
7/15/2011:
Bamenga was brought to the Allegany County Jail with documentation indicating she
had congestive heart failure and was on several medications which she had on her person. The booking
officer conducted a booking observation and a suicide screening questionnaire which indicated no
special circumstances that required immediate intervention.
7/18/2011:
The nurse practitioner conducted a medical history and physical examination on
Bamenga. No information regarding a chief complaint was elicited from the patient. A past medical
history of treatment for latent tuberculosis infection, hypertension, congestive heart failure and anemia
was noted and her current medications were as follows: aspirin 81 mg daily, spironolactone 25 mg twice
daily, lasix 20mg daily, digoxin 0.25mg daily, carvedilol 20mg daily and lisinopril 20mg daily. On
examination, Bamenga’s vital signs indicated a low grade fever with a temp of 99.8, pulse=88,
respirations=20 and blood pressure=128/84. Her cardiac and respiratory examination was documented
as normal with no signs of congestive heart failure. Her medications were ordered by the nurse
practitioner. A review of the medication administration records only documented administration of her
medications on 7/19 and 7/20/2011. It is not clear whether she received her medications from the
evening of 7/15/2011 to 7/18/2011 as well as on the morning of 7/21/2011. She was transferred to the
Albany County Correctional Facility on 7/21/2011 early that morning.
7/21/2011:
Bamenga arrived at the Albany County Correctional Facility at approximately 6:00pm.
She received a medical and mental health history. The history of anemia, congestive heart failure,
hypertension and positive PPD was given including medications listed on transfer sheet. However, no
further medical history was elicited at that time to determine the severity of her medical conditions that
might have triggered an earlier than scheduled evaluation by the nurse practitioner or physician. A call
was placed to the physician who gave verbal orders for her current medications. A chest xray was
ordered to rule out active tuberculosis and Bamenga was placed in general population.
7/25/2011:
Bamenga completed two health services request forms. In her own words, she wrote,
“Shortness of breath at night especially when laying down; palpitations when laying down; dizziness
1

upon standing when palpitations and shortness of breath occur.” “I am not being given the full dosages
of my medication. Two of the six different medications are meant to be taken twice a day and so far I
have only been given one dosage in the morning. The two medications are spironolactone and
carvedilol.” Sometime on or after 7/26/2011, the triage nurse wrote on the slip that Bamenga was seen
on 7/26 and that coreg 25mg twice daily had been ordered. Legibility of the medication administration
record was poor in some instances; however, it appears that the nursing staff documented with “NS”
that Bamenga did not show for her 9pm spironolactone dosages on 7/22, 24 and 26.
7/26/2011:
The nurse practitioner conducted a physical assessment of Bamenga. Her vital signs
were temp=97.9, pulse=82, resp=16, B/P=110/80. She documented that Bamenga denied
pain/discomfort and also denied chest pain or shortness of breath. She found no abnormalities in the
cardiovascular and respiratory evaluation and no edema in the lower extremities. She did increase the
carvedilol (coreg) to 25mg twice daily. I could find no documentation indicating that the nurse
practitioner had appropriately explored the patient’s symptoms of shortness of breath at night, of
palpitations when lying down and of dizziness upon standing. On completion of the examination, there
was no indication as to status of Bamenga’s chronic medical conditions nor were any tests ordered to
make that determination.
7/27/2011:
At approximately 12:15am inmates in the housing unit notified the correctional officer
that Bamenga was sick. The officer responded but was unable to arouse Bamenga and at 12:23am, he
activated the medical response system and the unit’s alarm system.CPR as instituted with chest
compressions and the ambu bag. There was no documentation that an automatic external defibrillator
was applied by the facility’s staff. At 12:35am, the community emergency medical system/ambulance
arrived, took over care and transported the patient to Albany Memorial Hospital. Efforts to resuscitate
this patient were unsuccessful and the patient was pronounced dead at 1:15am.

Conclusions and Recommendations:
If we are to believe the physical assessments conducted by the two nurse practitioners at the Allegany
County Jail and the Albany County Correctional Facility on July 18th and July 26th respectively, then, it is
highly unlikely that this patient’s immediate cause of death would be cardiomyopathy due to her
congestive heart failure. The clinical course of congestive heart failure is usually slowly progressive with
symptoms of worsening shortness of breath that becomes visible, swelling of the lower extremities
known as peripheral edema, and lung findings such as a productive cough and rales in the lungs on
auscultation. None of these findings were documented. Based on the patient’s complaints on
7/25/2011, we can conclude that this patient’s congestive heart failure was worsening; this may have
been due to the combination of incorrect dosing of carvedilol, missed doses of spironolactone, a
diuretic, and increase in dietary sodium. Carvedilol should be prescribed at a twice daily dosage and in
her case, the initial dose should have been documented as 25mg and not 20mg. The formulation does
not exist in a 20mg form. I am not clear as to why she was a “no show” for some of her 9pm
spironolactone doses. Was she sleeping and not aroused for those doses? Did the nursing staff
2

recognize the severity of her disease and make any attempts to ensure medication compliance? I saw no
documentation of such efforts. Because this patient’s congestive heart failure did not appear to have
worsened severely, I believe that we must look at other causes of her death. Based on her symptoms of
palpitations on July 26th, she may have died from a cardiac arrhythmia which would not be found on
autopsy. What would cause a cardiac arrhythmia in this patient? Digoxin toxicity and alterations in
potassium level can both cause fatal cardiac arrhythmias. Digoxin concentrations are increased by about
15% when digoxin and carvedilol are administered concomitantly. Therefore, increased monitoring of
digoxin is recommended when initiating, adjusting, or discontinuing carvedilol. Was this patient
hyperthyroid? We do not know because we did not investigate the complaint of palpitations. Did this
patient have a myocardial infarction due to her cardiomyopathy? Did this patient throw a pulmonary
embolus? Toxicology studies will be crucial in helping to determine the final cause of death.
However, regardless of this patient’s final cause of death, both facilities were remiss in not conducting a
thorough clinical evaluation and assessment of this patient whose congestive heart failure would
deteriorate when poorly managed. The assessments by both nurse practitioners did not include
whether Bamenga’s congestive heart failure and hypertension were controlled. There was no plan to
determine what type of anemia this patient suffered from. This patient should have been placed on a
restricted sodium diet, an electrocardiogram should have been done, the chest x-ray should have been
completed and laboratory testing should have been done to include digoxin levels, electrolytes, a
complete blood count and thyroid function studies. Previous medical records were being sent by
Bamenga’s attorney but there was no documentation that the records had been received. The physician
should have been consulted for guidance in initial management of this young cardiac patient and this did
not occur in either facility. Subsequent early follow up by the physician would have been appropriate.
Finally the early use of an automatic external defibrillator (AED) is standard practice in responding to a
life threatening emergency and it is recommended that an AED be obtained and the facility’s medical as
well as correctional staff be trained in its use.

Submitted by:

(b)(6), (b)(7)c

MD, Clinical Consultant

Diplomate of the American Board of Family Medicine

Date of Review: September 4, 2011

3

From:
To:
Subject:
Date:

(b)(6), (b)(7)c

Re: BAMENGA mortality review follow up questions
Thursday, September 29, 2011 2:52:50 PM

QUESTION 1: What bearing, if any, may have missed medications had on detainee
BAMENGA’s death? For example, Coreg is usually prescribed twice a day but
BAMENGA only received it once a day. Did receiving it once a day instead of twice a
day make a difference in her health?

ANSWER 1: This patient suffered from a chronic cardiac condition namely,
congestive heart failure. Appropriate medication management including appropriate
dosing and patient compliance is critical in controlling this condition. Based on
Banenga's medical complaints on her sick call request forms on July 25th, it is clear
that her congestive heart failure which was stable on entry, had now decompensated.
Yes, missed medication dosing as well as incorrect medication dosing were
significant factors that contributed to the decompensation of her congestive heart
failure. Other factors were increased sodium intake through dietary intake.
QUESTION 2: To what degree did failure to take the actions referenced in the final
paragraph of the Mortality Review Report have relevance to detainee BAMENGA’s
death; i.e., had they been taken, could the death have been prevented?
ANSWER 2:  If this patient's death was indeed cardiomyopathy due to congestive
heart failure, then this death could have been prevented if the appropriate steps were
taken to determine the severity of her congestive heart failure followed by an
appropriate treatment plan to control her cardiac condition.
QUESTION 3: Should nurse practitioners/medical personnel at both facilities have
known that Coreg is usually prescribed twice a day?

ANSWER 3:  If nurse practitioners in New York State have prescriptive authority (can
order medications), then the expectation is that they would have the training,
knowledge and skills to prescribe medications appropriately. Yes, we providers do
make errors in prescribing if we are not using electronic prescribing systems.
However, our health care system's check and balance is the pharmacist who has
electronic drug pharmacy systems. Normally, when a dose of medication that does
not follow the drug manufacturer's prescribing recommendations, is prescribed, the
pharmacist will contact the prescribing practitioner to determine if this was an error. I
could not determine if this communication occurred nor whether the practitioners had

access to electronic prescribing systems.
Dr.(b)(6), (b)(7)c we are unable to obtain the autopsy report for this case due to New York state privacy laws. 
However, regarding the mortality review you provided in this case, can you please answer the following 3
questions.

QUESTION 1: What bearing, if any, may have missed medications had on detainee BAMENGA’s death? For
example, Coreg is usually prescribed twice a day but BAMENGA only received it once a day. Did receiving it
once a day instead of twice a day make a difference in her health?

Detainee BAMENGA reported she took her medications the day she was taken into custody, July 15, 2011.
Based on documentation and interviews, the following summarizes medications received and missed July 16 –
26, 2011. Detainee BAMENGA was found unresponsive shortly after midnight on July 27, 2011.

ASA
<![if !supportLists]>·

<![endif]>Physical exam July 18, 2011: detainee reported taking daily

<![if !supportLists]>·

<![endif]>Ordered July 18, 2011: 81 mg daily

<![if !supportLists]>·

<![endif]>Received July 19 – 26, 2011

<![if !supportLists]>·

<![endif]>Missed doses: 3 (July 16, 17, 18)

Lasix
<![if !supportLists]>·

<![endif]>Physical exam July 18, 2011: detainee reported taking daily

<![if !supportLists]>·

<![endif]>Ordered July 18, 2011: 20 mg daily

<![if !supportLists]>·

<![endif]>Received July 19 – 26, 2011

<![if !supportLists]>·

<![endif]>Missed doses: 3 (July 16, 17, 18)

Lisinopril
<![if !supportLists]>·

<![endif]>Physical exam July 18, 2011: detainee reported taking daily

<![if !supportLists]>·

<![endif]>Ordered July 18, 2011: 20 mg daily

<![if !supportLists]>·

<![endif]>Received July 19 – 26, 2011

<![if !supportLists]>·

<![endif]>Missed doses: 3 (July 16, 17, 18)

Digoxin
<![if !supportLists]>·

<![endif]>Physical exam July 18, 2011: detainee reported taking daily

<![if !supportLists]>·

<![endif]>Ordered July 18, 2011: 0.25 mg daily

<![if !supportLists]>·

<![endif]>Received July 19 – 26, 2011

<![if !supportLists]>·

<![endif]>Missed doses: 3 (July 16, 17, 18)

<![if !supportLists]>· <![endif]>Order amended July 25, 2011: dose to be held if apical pulse is less than 60.
Recorded pulse July 26: 88; July 26: 82

Carvedilol/Coreg
<![if !supportLists]>·

<![endif]>Physical exam July 18, 2011: detainee reported taking daily

<![if !supportLists]>·

<![endif]>Ordered July 18, 2011: 20 mg daily

<![if !supportLists]>·

<![endif]>Received one dose per day July 19 – 25, 2011

<![if !supportLists]>· <![endif]>Ordered July 26, 2011: 25 mg twice daily in response to detainee report she
should receive the medication twice per day. Detainee did not receive second dose July 26, 2011.
<![if !supportLists]>· <![endif]>Missed doses: 14, based on Dr (b)(6), (b)(7)(C) statement concerning twice per
day administration (none received July 16, 17, 18; received one per day July 19 – 26, 2011)

Spironalactone
<![if !supportLists]>·

<![endif]>Physical exam July 18, 2011: detainee reported ordered twice per day

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<![endif]>Ordered July 18, 2011: 25 mg twice per day

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July 25.

<![endif]>Received twice per day starting evening, July 18 – July 21, 2011; July 23;

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<![endif]>Missed doses: 9 (two per day July 16, 17, 18; evening July 22, 24, 26)

QUESTION 2: To what degree did failure to take the actions referenced in the final paragraph of the Mortality
Review Report have relevance to detainee BAMENGA’s death; i.e., had they been taken, could the death have
been prevented?

QUESTION 3: Should nurse practitioners/medical personnel at both facilities have known that Coreg is usually
prescribed twice a day?

(O) 202-732-(b)(6), (b)(7)c

 

 

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