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Fatal Neglect - How ICE Ignores Deaths in Detention, ACLU DWN NIJ, 2016

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FATAL
NEGLECT

How ICE Ignores Deaths in Detention

Acknowledgements
This report was a collaborative effort of the ACLU, DWN,
and NIJC. Primary contributors were: Carl Takei of the
American Civil Liberties Union
For nearly 100 years, the ACLU has been our nation’s
guardian of liberty, working in courts, legislatures, and
communities to defend and preserve the individual
rights and liberties that the Constitution and the laws of
the United States guarantee everyone in this country.
aclu.org

ACLU; Mary Small and Carol Wu of DWN; and Jennifer
Chan of NIJC.
Other staff and interns also contributed crucial research
and editing, including David Fathi, Joanne Lin, Judy
Rabinovitz, and Chris Rickerd of ACLU; Carly Perez, Ana
Carrion and Silky Shah of DWN; Tara Tidwell Cullen,
Mary Meg McCarthy, Royce Bernstein Murray, Ross
Noecker, and Katherine Rivera of NIJC.
Design by: Strictly District, LLC.
Translation by: Eleana Gómez

Detention Watch Network
Detention Watch Network (DWN) works through the
collective strength and diversity of its members to
expose and challenge injustices of the U.S. immigration
detention and deportation system and advocate for
profound change that promotes the rights and dignity

Cover Image: Alonso Yáñez/La Opinión
© February 2016 American Civil Liberties Union,
Detention Watch Network, and Heartland Alliance’s
National Immigrant Justice Center

of all persons.
detentionwatchnetwork.org

National Immigrant Justice Center
With offices in Chicago, Indiana, and Washington, D.C.,
Heartland Alliance’s National Immigrant Justice Center
(NIJC) is a nongovernmental organization dedicated
to ensuring human rights protections and access to
justice for all immigrants, refugees, and asylum seekers
through a unique combination of direct services, policy
reform, impact litigation, and public education.
immigrantjustice.org

Fatal Neglect: How ICE Ignores Deaths in Detention

2

Introduction
Despite the Obama administration’s stated commitment to reform the U.S.
immigration detention system, driven in part by outrage over the high number of
deaths in custody,1 failure to provide adequate medical care has continued to result
in unnecessary deaths. The New York Times 2010 investigative report on deaths in

Pablo
Gracida-Conte

immigration detention found evidence of a “culture of secrecy” and a failure to address

Pablo Gracida-Conte died at

fatal flaws at detention centers.2 According to an analysis of newly public government

the Eloy Detention Center--the

death reviews, these problems persist and poor medical care contributes to the death
of immigrants in federal immigration custody with alarming frequency.
This report examines egregious violations of U.S. Immigration and Customs

deadliest detention center in
the nation--after four months
of worsening, untreated
medical problems including
vomiting after every meal. A

Enforcement’s (ICE) own medical care standards that played a significant role in

doctor concluded that Mr.

eight in-custody deaths from 2010 to 2012. An American Civil Liberties Union (ACLU),

Gracida’s death could have been

Detention Watch Network (DWN), and National Immigrant Justice Center (NIJC) review

prevented. Remarkably, the

of ICE death investigations and facility inspection reports reveals that even though
ICE’s own death reviews identified violations of ICE medical standards as contributing
factors in these deaths, ICE detention facility inspections conducted before and after
these deaths failed to acknowledge—or sometimes dismissed—the critical flaws

ODO inspection claimed that
Mr. Gracida’s death was the first
death “to ever occur” at Eloy
when, in fact, it was the 10th
death at the facility.

identified in the death reviews. The findings underscore how ICE’s deficient inspections
system, first exposed by DWN and NIJC in the October 2015 report Lives in Peril, exacts
a tragic human toll.3
The ACLU obtained ICE Office of Detention Oversight (ODO) Detainee Death Review
documents summarizing investigations into detention-center deaths through a
Freedom of Information Act (FOIA) request. These requests followed up on the ACLU’s
2007-2009 FOIA requests on deaths in ICE detention, which formed the basis for an
investigative series by The New York Times that, along with widespread NGO advocacy,
pushed the Obama administration to adopt its 2009 detention reforms.4 The death
reviews are a component of these 2009 reforms, and are carried out by a centralized
team of ICE personnel and subject-matter experts who interview local personnel

Methodology
The ACLU, DWN, and NIJC
analyzed 24 ICE death reviews
that the ACLU received through
its FOIA request. The eight cases
discussed in this report were
identified based on whether

and review medical and custody records to evaluate the medical care related to

ICE investigators found that

the death. The ACLU’s updated FOIA request sought the ODO reviews of 24 deaths

detention centers were non-

that occurred in ICE custody from January 2010 through May 2012. In response, ICE

compliant with ICE detention

produced documents regarding 17 deaths, but did not provide investigations for seven
individuals. Of these seven outstanding cases, four remained under investigation at
the time of ICE’s final document production, more than 400 days after these deaths
occurred. In the remaining three deaths, ICE did not conduct its own detainee death

standards for medical care.
The case summaries for these
deaths provide a summary of
the evidence provided in the
death reviews as well as ICE’s

review; in two cases, this was because the Office of Inspector General (OIG) in the

own findings on facility lack of

Department of Homeland Security (DHS) conducted the investigation, and in one case

compliance with ICE detention

(discussed below), it is not clear if anyone conducted an investigation.5 In nearly half of

standards.

the death reviews produced by ICE, the documentation suggests that failure to comply
with ICE medical standards contributed to deaths.

Fatal Neglect: How ICE Ignores Deaths in Detention

3

In addition to creating the death review process, ICE instituted
other reforms intended to reduce the number of in-custody
deaths. These included the creation of a new detention facility
inspection process under ODO that was intended to provide
a more rigorous review of detention standards compliance
than the routine Enforcement and Removal Operations (ERO)
inspections6, centralization of healthcare under the ICE Health
Service Corps (IHSC), and the introduction of a more robust set
of detention standards, the 2011 Performance-Based National

Contract Types
•	 Contract Detention Facilities (CDFs) are owned and
operated by private corporations that contract directly with ICE.
•	 Service Processing Centers (SPCs) are owned and
operated by ICE. However, ICE hires contractors to handle
many services within the facilities, such as transportation
and guard services.

Detention Standards (PBNDS 2011).

7

•	 Intergovernmental Service Agreements (IGSAs) are
The PBNDS 2011, which were not in operation at the time of
the deaths examined in this report, are the most thorough
standards promulgated by ICE. Even these standards,
however, fall short in significant respects compared to the

owned and operated by local governmental entities,
typically county or city governments. Many local
governments subcontract to private corporations to
administer the facilities and/or to provide other services.

National Commission on Correctional Health Care (NCCHC)

•	 U.S. Marshals Service (USMS) Intergovernmental

standards for medical care in prison and jail settings. And

Agreements (IGAs) are under contract with the

although PBNDS 2011 are an improvement over ICE’s earlier

Department of Justice’s U.S. Marshals Service. Many of

8

standards, ICE’s adoption of them has been slow; as of
January 2014, 139 facilities holding 44 percent of detained
immigrants still operated under other, outdated standards
that were promulgated as early as 2008 or even in 2000, prior

these contracts pre-date the 2003 creation of DHS and
frequently do not reference clear applicable standards for
detaining immigrants. Further, the majority of the USMS
IGA contract terms are indefinite, meaning that there
is no clear opportunity to renegotiate facility contracts,

to the creation of ICE. Further, as of January 2014, ICE held

upgrade them to the most recent detention standards, or

19 percent of detained immigrants in facilities where ICE did

contractually address other concerns.

9

not directly contract with the facility and instead contracted
through the U.S. Marshals Service (USMS). As two death
reviews from such USMS facilities noted, ICE did not have
contracts requiring those facilities to comply with any ICE
detention standards.10 This is of particular concern since most
USMS contracts are indefinite in duration, and may not be
easily modified.11
Congress also instituted an important reform in 2009. Since
then, congressional appropriations have included a provision
that ICE cannot expend funds to immigration detention
facilities that fail two consecutive ERO inspections.12 Although
the number of deaths in ICE custody has decreased in recent
years,13 comparison of the death reviews from 2010-2012
with ODO and ERO inspections conducted at facilities before
and after deaths occurred demonstrates that the inspection
reforms have failed to hold detention facilities accountable for
providing adequate medical care. The ACLU, DWN, and NIJC
call on ICE to take immediate action to improve the detentioncenter inspections process and the quality of medical care.
Fatal Neglect: How ICE Ignores Deaths in Detention

Photo: Alonso Yáñez/La Opinión

4

Key Findings
There have been 56 deaths in ICE custody
during the Obama administration, including
six suicides14 and at least one death after an
attempted suicide.15 This report focuses on

DEATHS

the eight deaths where ODO identified noncompliance with ICE medical standards as
contributing causes; the ODO identified four

There have been 56 deaths in
ICE custody during the Obama
administration, including six
suicides and at least one death
after an attempted suicide.

of these deaths as preventable. However, this
focus should not excuse several other cases
in which ODO identified similar violations
of ICE medical standards without drawing

Facility Type

causal links between these violations and

Deaths
Attributable
to Substandard
Care
Jan. 2010–
May 2012

Total
Deaths
Jan. 2010–
May 2012

the deaths.16 The risks posed by substandard

Intergovernmental Service Agreement (IGSA)

3

10

medical care will continue to endanger

Adelanto Detention Facility (CA)

1

1

people detained in these facilities until the

Clinton County Correctional Facility (PA)

0

1

violations are corrected. Indeed, forcing such
corrections is perhaps the most important

Columbia Regional Care Center (SC)

0

1

Eloy Detention Center (AZ)

1

1

Immigration Centers of America – Farmville (VA)

1

1

Mira Loma Detention Center (CA)

0

1

first place. In hospitals, for example, it is

North Georgia Detention Center (GA)

0

1

a common practice to conduct root cause

Orleans Parish Prison (LA)

0

1

analyses of serious adverse events (such as

Theo Lacy Facility (CA)

0

1

York County Prison (PA)

0

1

Contract Detention Facility (CDF)

2

4

Denver CDF (CO)

1

1

Elizabeth Detention Center (NJ)

1

1

Houston CDF (TX)

0

2

Our investigation shows that in ICE detention

Service Processing Center (SPC)

1

3

facilities, this process is broken; even in

El Paso Processing Center (TX)

1

1

reason to conduct death reviews in the

death, permanent harm, or severe temporary
harm) to identify changes to culture,
systems, and processes that could reduce
the probability of such events in the future.17

ICE ERO Processing Center (NV)

0

1

Krome SPC (FL)

0

1

U.S. Marshals Service (USMS) IGSA

2

2

ICE’s deficient inspections system essentially

Weber County Correctional Facility (UT)

1

1

Albany County Corrections Facility (NY)

1

1

swept those findings under the rug.

Bureau of Prisons (BOP)

0

3

Oakdale Federal Detention Center (LA)

0

2

Moreover, not all deaths are reviewed. In

Butner Federal Correctional Institute (NC)

0

1

one case, ICE claimed that it did not have

Hold Facility

0

1

San Bernardino Hold Room (CA)

0

1

Staging Area

0

1

Broadview Service Staging Area (IL)

0

1

the eight cases where ODO death reviews
concluded that violations of ICE medical
standards contributed to people’s deaths,

responsibility to review the death because
the individual had been in ICE custody for
less than six hours in a short-term hold
facility, and had not yet been transferred to a
detention facility designated for stays longer
than 72 hours.18 This response raises the

Fatal Neglect: How ICE Ignores Deaths in Detention

5

question of who is responsible for the care of individuals

preventable deaths in ICE custody.

in ICE’s short-term detention facilities, and whether such
gaps in responsibility are endangering other lives.

In addition, six out of the eight deaths involving
substandard medical care occurred at privately run

Three of the eight deaths profiled here—Fernando

facilities.20 The highest number of deaths during the

Dominguez-Valdivia (also written as Valivia in many ICE

period covered by the death reviews occurred at facilities

documents and some media reports), Irene Bamenga, and

in which ICE contracted with local governments through

Amra Miletic—led to wrongful death lawsuits by surviving

Intergovernmental Service Agreements (IGSA), and the

family members.19 However, not only are wrongful death

local governments then subcontracted with private, for-

lawsuits an insufficient resolution for families who must

profit prison companies to run the facilities. Private prison

still live with the loss of their loved ones, they do not

companies like Corrections Corporation of America (CCA)

resolve the systemic problems highlighted in this report.

and the GEO Group, which operate eight of the 10 largest

As described in further detail below, ICE must take

immigration detention centers,21 have long been criticized

effective measures to improve delivery of medical care

by advocacy organizations, government agencies, and the

in detention and overhaul the inspections process so

press for inadequate medical care, understaffing, violence,

that both can function to stop more people from dying

and other issues.22

Failures in Medical Care Cost Lives
The ODO death review documents that indicate

The ERO and ODO inspections should have detected gaps

violations of ICE medical standards reveal a failure to:

and flawed protocols that ICE or other facility operators
should have fixed. Instead, in some inspections, inspectors

1.	 Meet health care needs in a timely manner

failed even to mention deaths that had occurred at the

2.	 Refer individuals to higher-level medical care

facilities under investigation. Also, for all but one of the

providers, including transfer to external services

eight deaths described in this report, ICE ERO inspectors

such as emergency services

gave facilities passing ratings prior to and following deaths

3.	 Adequately staff medical personnel

related to egregiously substandard medical care, even

4.	 Communicate critically important information

where ODO inspections found facilities failed to meet

about individuals’ medical conditions between staff

medical care standards, and even where ODO death

and especially during transfers

reviews explicitly identified the deaths as preventable.

5.	 Adequately screen individuals for illnesses
6.	 Proactively identify and rectify concerns about

Overall, the systems designed to provide health care and

medical care during ERO and ODO facility

hold facilities accountable failed these eight individuals,

inspections

and may well have cost them their lives.

Fatal Neglect: How ICE Ignores Deaths in Detention

6

When Substandard Medical Care Can Kill
Death #1:

Evalin-Ali Mandza
Age

46

Country of Origin

Gabon

Cause of Death

Heart attack after egregious delays in calling 911and referring Mr. Mandza to a higherlevel provider.

Date of Death

April 12, 2012

Detention Standards
Non-Compliance with
Detention Standards for
Medical Care
Length of Detention

PBNDS 2008
Section (II)(2):	
Section (II)(7):	
Section (V)(O):	

Meet healthcare needs in a timely and efficient manner;
Timely transfer to an appropriate facility where care is available for
individuals whose healthcare needs are beyond facility resources;
Medical and safety equipment is available and maintained, and staff is
trained in proper use of equipment.

171 days

Detention Facility

Denver Contract Detention Facility, Aurora, CO

Facility Operator

GEO Group

Facility Contract Type

CDF

Evalin-Ali Mandza, a 46-year-old citizen of Gabon, died of a
heart attack after receiving inexcusably delayed emergency
care on April 12, 2012, after 171 days in custody at the
Denver Contract Detention Facility (DCDF) in Aurora,
Colorado. DCDF is operated by GEO Group.

The call to 911 also was delayed
because medical staff prioritized
filling out transfer paperwork
rather than placing the call.

On April 12, 2012, a code-blue emergency was
activated at DCDF at approximately 5:24 a.m. when
other detained individuals got an officer’s attention

Multiple other failures beyond the delays also occurred

to report that Mr. Mandza was experiencing chest

within that hour. Despite the fact that GEO’s nursing

pain. At approximately 5:50 a.m., a doctor was finally

protocol for chest pain27 requires vital signs to be taken

alerted to the situation, determined that Mr. Mandza

every five minutes, Mr. Mandza’s vital signs were taken at

needed to go to the emergency room, and directed a

5:28 a.m. and then not again until 6:20 a.m.28 Also, during

nurse to call 911.24 However, the call was not placed

this time an electrocardiogram (EKG) was performed,

to 911 until approximately 6:20 a.m., nearly one hour

but the nurse performing the test was initially unable

after the activation of the code-blue emergency. This

to get a reading because she was unfamiliar with the

unconscionably long delay clearly violated ICE PBNDS

machine.29 Then she performed the wrong test.30 Once she

2008, which requires “detainees who need health care

performed the correct test, she was unable to interpret

23

25

the results because she was not trained on the use of an

beyond facility resources to be transferred in a timely
manner to an appropriate facility where care is available.”

26

Fatal Neglect: How ICE Ignores Deaths in Detention

EKG or in the interpretation of EKG test results.31 Instead,

7

the nurse reports relying on her “gut instinct” to send

to appropriate medical care while detained in the DCDF.”35

Mr. Mandza to the hospital.32 These are violations of ICE
PBNDS requirements that medical and safety equipment

Despite these documented failings, DCDF passed its ERO

be available and maintained, and that staff be trained in

inspections immediately before and after Mr. Mandza’s

proper use of the equipment. The call to 911 also was

death, including the medical standards with which the

delayed because medical staff prioritized filling out transfer

facility is found non-compliant in the death review. In

paperwork rather than placing the call.33

the 2012 ERO inspection, there are two descriptions of
Mr. Mandza’s death. These summaries are worryingly

The death review conducted by ODO contractor Creative

inaccurate, describing Mr. Mandza as being from Ghana

Corrections found that DCDF medical staff were unfamiliar

rather than Gabon and failing to mention any concerns.

with the institution’s Chest Pain Protocol, that appropriate

Instead, inspectors state, “He received a timely and

cardiac medication was not administered, and that there

comprehensive medical and mental health screening and

was a delay in transporting the patient to a higher-level care

physical assessment, reported no significant past medical

facility, “all of which may have been contributing factors to

history and denied any significant risk factors for heart

Mr. Mandza’s death.”34 An IHSC review, included in the death

disease,”36 effectively whitewashing the quality of

review, similarly found that Mr. Mandza “did not have access

medical care.

Death #2:

Amra Miletic
Age

47

Country of Origin

Bosnia-Herzegovina

Cause of Death

Complications of chronic bowel inflammation and heart arrhythmia after nearly two
months of substandard care that failed to address Ms. Miletic’s rectal bleeding, vomiting,
abdominal pain, and nausea.

Date of Death

March 20, 2011

Detention Standards

NDS

Non-Compliance with
Detention Standards for
Medical Care

Section (II)(2):	 Facilities will provide its detained population with initial medical
screening, cost-effective primary medical care, and emergency care;
Section (III)(D):	 All new arrivals shall receive initial medical and mental health screening
immediately upon arrival by a healthcare provider or an officer
trained to perform this function, and health appraisals and physical
examinations will occur within 14 days of arrival in accordance with
NCCHC and JCAHO standards.

Length of Detention

47 days

Detention Facility

Weber County Correctional Facility, Ogden, UT

Facility Operator

Weber County Sheriff’s Office

Facility Contract Type

USMS IGA

While detained for nearly two months, Ms. Miletic suffered

of time. Ms. Miletic, originally from Bosnia-Herzegovina,

from rectal bleeding, vomiting, abdominal pain, rapid

passed away on March 20, 2011, at the McKay Dee Hospital

weight loss, and nausea—conditions that ought to raise

in Ogden, Utah, from “complications of chronic colitis

alarms even if experienced for a much shorter period

and atrial fibrillation,”37 or chronic bowel inflammation

Fatal Neglect: How ICE Ignores Deaths in Detention

8

and heart arrhythmia, after 47 days in ICE
custody while detained at the Weber County

Fatal Timeline: Amra Miletic

inflammation of the lining of the colon; it
should not be fatal if treated properly. The

Feb. 1

Correctional Facility (WCCF). Colitis is an

review completed after her death concluded
that “the WCCF was not in compliance with

given a full medical and mental health screening.48

sick, cold, that her stomach has been bleeding, and
Feb. 8

to provide Ms. Miletic with immediate “off-site

of nausea, vomiting, fever, and diarrhea.47 She is not

Ms. Miletic submits a sick slip saying that she is

the ICE NDS Medical Care Standard,”38 citing
various egregious violations including failure

Ms. Miletic is taken into ICE custody with complaints

that she is in pain.49 She is scheduled for a medical
appointment two days later. Medical staff do not

serious documented complaints of “rectal

and do not order lab tests.50

bleeding, nausea, vomiting, and diarrhea”39
as well as failure to document missed meals
(even while Ms. Miletic was on medical watch)

Feb. 11

record her weight (despite complaints of weight loss)

Ms. Miletic has a urinalysis and three stool tests.

Feb. 23

specialty care for her medical condition” after

The doctor refuses to see Ms. Miletic in the

According to the facility, Ms. Miletic submits one stool
sample which tests positive for blood.51

or to note missed medication.40
Despite arriving with seven different
medications and complaints of feeling sick
and vomiting, Ms. Miletic was not given a full

submitting a sick slip, with complaints of diarrhea
MAR. 9

her first month at WCCF, Ms. Miletic also
and 26) with complaints of feeling sick, finding

appointment.52
Ms. Miletic is seen by the medical unit 10 days after

medical and mental health screening.41 Within
submitted three sick call slips (February 8, 21,

evening because she had not come for an earlier

and abdominal cramping.53 Her stool is described
as “bloody, bright red and has some clots.” 54 She
weighs 134 pounds. Her first lab test is ordered after

blood in her stool, lower abdominal pain, and

five weeks in detention. This is also the first record of

a persistent fever.42 In response, the medical

the facility attempting to obtain Ms. Miletic’s medical
records.

staff prescribed Metamucil, hemorrhoidal
suppositories, and Tylenol.43 Although Ms.

Multiple times throughout the day, Ms. Miletic

Miletic was becoming visibly sicker and

reports feeling like she is dying. She weighs 119
pounds, a 15 pound weight loss in nine days, yet a

other detained women complained about

chart notes that “[Ms. Miletic’s] vitals do not reflect

her hygiene and smell due to her medical
condition, the medical staff delayed placing

MAR. 18

thinner (losing 15 pounds in nine days)44 and

her distress.” 55 When Ms. Miletic requests new
underwear because she is bleeding rectally, she is
asked to place the dirtied underwear outside of her

Ms. Miletic under observation.45 Even then,

cell and a deputy is asked “to visualize [the] amount

because there was no room in the medical

of blood.” 56

segregation unit, Ms. Miletic was placed in a

Ms. Miletic states that she has not eaten for seven

that she was unresponsive for almost 45

days and is bleeding heavily with severe abdominal

minutes,46 clearly delaying her transfer to the

pains. There is no documentation of the facility staff

hospital where she ultimately died.
Ms. Miletic had rectal bleeding for almost two
months and yet she did not see a physician
until 37 days after her arrival and lab tests
Fatal Neglect: How ICE Ignores Deaths in Detention

MAR. 20

separate housing unit where no one noticed

informing medical that Ms. Miletic was not eating.
According to video surveillance, Ms. Miletic shows
signs of distress at 6:25 p.m. Four minutes later, she
displays her last movement. At both 6:39 and 6:49
p.m., two deputies walk by her cell. At 7:13 p.m.,
a nurse discovers Ms. Miletic, unresponsive.

9

were not ordered until 11 days before she died. Despite a

No one noticed that she was
unresponsive for almost 45 minutes.

rapid, substantial weight loss and visual evidence that she
was sick, WCCF’s medical staff repeatedly failed to respond
appropriately to the signs that Ms. Miletic’s condition was
deteriorating. Even while she was ostensibly under their
observation, they failed to notice she was unresponsive for

and nursing must be questioned. The nursing staff,

45 minutes.

based on documentation, appears to be working outside
the scope of nursing practice. There is a general lack of

According to the doctor who was hired to conduct the

knowledge and application of the nursing triage process.

mortality review as part of the death review, “this was a

…The physician’s lack of understanding of the urgency

death that was preventable.” The consultant criticized the

of colonoscopy and referral to emergency care begs to

qualifications of WCCF’s medical staff, writing

question his competency.”58 ERO and ODO inspections are

“[c]ompetence in the practice of contemporary medicine

not available for review.

57

Death #3:

Pablo Gracida-Conte
Age

54

Country of Origin

Mexico

Cause of Death

Mr. Gracida succumbed to cardiomyopathy, a treatable disease of the heart muscle. He
died after four months of persistent requests for medical treatment that were ignored.

Date of Death

October 30, 2011

Detention Standards

PBNDS 2008

Non-Compliance with
Detention Standards for
Medical Care

Section (II)(2):	 Meet healthcare needs in a timely and efficient manner;
Section (II)(7):	 Timely transfer to an appropriate facility where care is available for
individuals whose healthcare needs are beyond facility resources.

Length of Detention

142 days

Detention Facility

Eloy Detention Center, Eloy, AZ

Facility Operator

Corrections Corporation of America (CCA)

Facility Contract Type

IGSA with the City of Eloy, AZ

Mr. Gracida died of heart disease after repeated failures

During Mr. Gracida’s 142 days in detention, he complained

to provide him with timely and efficient care. After four

of ongoing health issues such as vomiting after every

months of worsening, untreated medical problems, Mr.

meal and extreme upper abdominal pain. Eloy staff had

Gracida died on October 30, 2011, at the University of

difficulty communicating with Mr. Gracida, who spoke

Arizona’s University Medical Center in Tucson, Arizona. He

Mixteco. Although the facility has access to telephonic

became the 10th person since October 2003 to die while

interpreters and had ample time to find an interpreter,

incarcerated at the 1,550-bed, CCA-run Eloy Detention

it never obtained one.61 Mr. Gracida’s long list of sick

Center in Eloy, Arizona.59 The autopsy report states the

call requests reads as a desperate, repeated cry for help

cause of death for the 54-year-old as cardiomyopathy, a

that was ignored until it was too late. [See timeline on the

treatable disease of the heart muscle.

following page]

60

Fatal Neglect: How ICE Ignores Deaths in Detention

10

Fatal Timeline: Pablo Gracida-Conte
JUN. 10

ICE detains Mr. Gracida at Eloy.

JUL. 19

Mr. Gracida visits the medical clinic for vomiting and profuse sweating.

AUG. 10

Mr. Gracida reports decreased appetite and is examined by a registered nurse (RN) on August 12.

OCT. 5

An RN examines Mr. Gracida for complaints of nausea/vomiting, upper abdominal pain, and
bloating.
Mr. Gracida reports a 10 out of 10 pain level,62 burning abdominal pain, and daily vomiting.

OCT. 8

Medical staff schedule laboratory tests which occur on October 11 and tell him to eat
a bland diet.
Mr. Gracida complains of headache, nausea, and vomiting. He reports an eight-out-of-10

OCT. 14

pain level and that upper abdominal pain has kept him from sleeping for one month. An RN
refers Mr. Gracida to a nurse practitioner (NP).

OCT. 18

Mr. Gracida reports that his nausea, vomiting, and diarrhea has subsided.
Mr. Gracida appears at the medical unit with shortness of breath and reports an increased
level of pain during meals, pain while lying down, and difficulty sleeping. When the licensed

OCT. 22

practical nurse (LPN) asks the NP to see Mr. Gracida because of his shortness of breath, the
NP refuses. The LPN seeks assistance from an RN.63 Later, Mr. Gracida refuses to receive his
evening medications.

OCT. 23

Mr. Gracida requests to discontinue his medications because they make him feel ill and
dizzy, and give him heartburn. He again refuses to take his medication.
An RN examines Mr. Gracida and finds that he has an irregular heart rate, rapid respiratory
rate, low blood pressure, and a weight gain of five pounds within six days. He complains
of abdominal pain after taking his medications resulting in insomnia, poor appetite, and

OCT. 24

persistent weakness and dizziness. In addition, he discloses that he had a heart attack in
2000. The NP conducts an electrocardiogram (EKG), which is abnormal. Instead of referring
Mr. Gracida to higher-level care, the NP schedules a follow-up visit for the next day after his
court hearing, noting that he would be referred to cardiology if he remained in custody.64
Mr. Gracida is unable to complete a sentence without stopping to breathe. He has a second

OCT. 25

abnormal EKG and the facility finally refers him to the Casa Grande Regional Medical Center
(CGRMC) Emergency Room. CGRMC diagnoses Mr. Gracida with severe cardiomyopathy and
possible pneumonia.

OCT. 27

OCT. 28-30

A CGRMC doctor notes that Mr. Gracida is ailing from complex cardiac issues and
recommends transfer to the University Medical Center in Tucson (UMC).
Mr. Gracida is admitted to UMC on October 28 and dies after transfer to the hospital’s
intensive care unit on October 30.

Fatal Neglect: How ICE Ignores Deaths in Detention

11

After Mr. Gracida’s death, the ODO conducted a
death review in December 2011 and concluded that:
1.	 Eloy failed to provide medical care in accordance with
PBNDS 2008.
2.	 Eloy’s medical provider had failed to provide him with

Remarkably, the ODO inspection
claims that Mr. Gracida’s death
was the first death “to ever occur”
at Eloy when, in fact, it was the 10th
death at the facility.

timely and efficient care. A doctor who participated
in the ODO’s death review concluded that
“[Mr.] Gracida’s death might have been prevented
if the providers, including the physician at [Eloy],

and July 2012 ODO inspection mention his death, but do

had provided the appropriate medical treatment

not identify any problems at Eloy. ODO inspectors claim

in a timely manner.”65

that people at Eloy are seen for sick call in a timely manner

3.	 Eloy failed to send Mr. Gracida to the emergency room.

and sick call slips are effectively and expediently triaged.

In the ODO’s investigation, a doctor stated that Mr.

They conclude that medical staffing is adequate; however,

Gracida’s condition on October 24 “should have been

they also encourage Eloy to fill the clinical director position,

considered urgent, and he should have been referred to

which they claim had been vacant since May 2009, as soon

a cardiologist.”66

as possible.73 This assertion contradicts the ODO’s state-

4.	 Communication with Mr. Gracida happened only

ment that Eloy had been without a clinical director for the

at a “very basic level.” Although Spanish-speaking

past four years. Remarkably, the ODO inspection claims

staff documented that Mr. Gracida spoke “very little

that Mr. Gracida’s death was the first death “to ever occur”

Spanish,” they never obtained a Mixteco interpreter.67

at Eloy when, in fact, it was the 10th death at the facility.74

5.	 Language and cultural barriers were contributing

Today, Eloy is known as the deadliest immigration deten-

factors in the failure to address Mr. Gracida’s medical

tion center in the nation. Four years after Mr. Gracida’s

needs.

death, the facility still does not have a doctor on staff.75
Recent deaths at the facility led Rep. Raúl Grijalva (D-AZ)

Despite these concerns, the ODO death investigator

to write a letter to DHS Secretary Jeh Johnson express-

chose not to cite Eloy as non-compliant with ICE PBNDS

ing alarm and calling for greater transparency of facility

standards related to interpretation assistance.68 In

operations.76 If ODO and ERO inspectors held Eloy to ICE

addition, the ODO investigation uncovered evidence that

detention standards for medical care, Mr. Gracida’s death

Eloy staff were well aware of Mr. Gracida’s deteriorating

and possibly four other deaths since 2011 could have been

condition, revealing that a guard reported that Mr. Gracida

prevented.77

had been vomiting after every meal.69 The ODO death
investigator expressed concern that at the time of review,
Eloy did not have a clinical director, noting that an Eloy
doctor stated that the clinic is understaffed and she
“badly needs help.”70 In its investigation, the ODO states
that Eloy had been without a clinical director for four of
the five years it had been open; however, in its 2012 facility
inspection, the ODO states that Eloy opened in 1994.71 It
is unclear how long the facility has been without a clinical
director based on these documents.
Eloy passed its 2011 ERO and ODO inspections before Mr.
Gracida’s death.72 Both the January 2012 ERO inspection
Fatal Neglect: How ICE Ignores Deaths in Detention

Photo: Diane Ovalle of Puente

12

Death #4:

Anibal Ramirez-Ramirez
Age

35

Country of Origin

El Salvador

Cause of Death

Liver failure following failure to communicate critically important information,
inadequate medical screenings, and inexcusable delays in referral to higher-level care.

Date of Death

October 2, 2011

Detention Standards

PBNDS 2008

Non-Compliance with
Detention Standards for
Medical Care

Section (II)(2):	
Meet healthcare needs in a timely and efficient manner;
Section (II)(28) and (V)(B):	Clinical decisions are the sole province of the clinical medical
authority and in no event should clinical decisions be made by
non-clinicians;
Section (V)(I):	
Assessment of pain required;
Section (V)(O):	
Medical personnel must be immediately notified when
emergency care may be required;
Section (V)(C):	
Facilities required to develop written procedures governing
management of administrative segregation units consistent
with detention standards.

Length of Detention

5 days (Mr. Ramirez-Ramirez was in ICE custody 2 days prior to his placement at ICAF)

Detention Facility

Immigration Centers of America – Farmville (ICAF), VA

Facility Operator

Immigration Centers of America, LLC

Facility Contract Type

IGSA

Failure to communicate critically important information,

and picked himself up on several occasions” and vomited

negligent medical screenings, and inexcusable delays in

at least three times in the patrol car.84 While appearing

referral to higher-level care could have been contributing

before a magistrate, he defecated on himself and

factors to Anibal Ramirez-Ramirez’s death at the age

acted oddly enough that the judge made a note that he

of 35. Originally from El Salvador, Mr. Ramirez-Ramirez

appeared ill.85 At PWMRAD, Mr. Ramirez-Ramirez defecated

passed away from liver failure on October 2, 2011, seven

on himself again and facility staff had to support him to

days after entering ICE custody and five days after being

keep him from falling when being taken to the shower.86

processed into the privately operated Immigration Centers

During his transfer to ICAF, a driver reported hearing

of America in Farmville, Virginia (ICAF).

Mr. Ramirez-Ramirez dry heaving, and Mr. Ramirez-

78

79

Ramirez repeatedly lay across the laps of other men being
The narrative of the last week of Mr. Ramirez-Ramirez’s

transferred.87 None of this was relayed to staff at ICAF, a

life is a chronicle of medical symptoms ignored or

failure which was then compounded by inadequate care

misinterpreted as non-cooperative behavior. The Virginia

upon arrival there.

state troopers who initially took Mr. Ramirez-Ramirez into
custody,80 the magistrate before whom he appeared,81

In its comprehensive review as part of the death review,

officers at the Prince William-Manassas Regional Adult

ICE contractor Creative Corrections found that in addition

Detention Center (PWMRAD), and the officers who

to information about Mr. Ramirez-Ramirez’s vomiting,

transported Mr. Ramirez-Ramirez to ICAF all had evidence

involuntary bowel movements, and extreme disorientation

that something was very wrong. A state trooper report

not being communicated upon transfer between facilities,

stated that Mr. Ramirez-Ramirez “dropped to the ground

the intake screening at ICAF was inadequate, and when

82

83

Fatal Neglect: How ICE Ignores Deaths in Detention

13

the nurses checked on Mr. Ramirez-Ramirez, they failed to

hospital, Mr. Ramirez-Ramirez died at 3:10 p.m., 10

take his vital signs. They also concluded that the multiple

minutes after his scheduled appointment with a

delays in referring him to higher-level care may have

psychiatrist, who would have been the first doctor ever to

contributed to Mr. Ramirez-Ramirez’s death, violating

see him at ICAF.

88

89

medical-care standards which require detainees’ medical
needs to be met in a timely manner.90

The inspection which preceded Mr. Ramirez-Ramirez’s
death indicates that ICE was aware of the problems

The ICE Health Services Corp (IHSC) investigation, also

at ICAF. The ODO’s April 2011 inspection found seven

included in the death review, similarly lists several

deficiencies, which included failing a mandatory

concerns about Mr. Ramirez-Ramirez’s time at ICAF,

component regarding staff responsiveness to medical

including that he was placed on suicide watch for non-

emergencies.98 ICE has not made ERO inspections prior to

cooperative behavior during transfer early in the morning

Mr. Ramirez-Ramirez’s death publicly available; however,

of September 29 but he was not scheduled to see a

the October 2011 ERO inspection two days after

doctor until the afternoon of October 1, despite several

Mr. Ramirez-Ramirez’s death concluded that the facility

nurses raising concerns, including one nurse reporting

did not meet standards,99 though it did give ICAF a

her belief that Mr. Ramirez-Ramirez’s behavior was not

passing rating on its medical care. If these failings had

due to a “psychological issue but a medical issue.” IHSC

been addressed during the six months between the ODO

investigators also note that he was monitored every two

inspection and Mr. Ramirez-Ramirez’s death, then Mr.

hours instead of every 15 minutes while on suicide watch.

Ramirez-Ramirez would likely have received the care he

91

92

critically needed in a timely manner.
Even more concerning, Creative Corrections inspectors
document allegations that non-medical facility staff
interfered with medical recommendations from nurses93
violating standards which require clinical decisions to be
the sole province of the clinical medical authority and
never made by non-clinicians.94 On October 1, a nurse
requested access to Mr. Ramirez-Ramirez’s cell in order to
take his vital signs, but facility staff told her to wait since
he was already scheduled to see a doctor 15 hours later.95
When she insisted, she was told to take his vital signs
through the slot in the solitary confinement cell door. She
further insisted that he required a “higher level of medical
care, including intravenous hydration and laboratory
tests.”96 When she was finally allowed to take his vital signs,
she discovered that he had a “perilously high” heart rate
and recommended that he be transferred to emergency
care. Instead, corrections staff decided to wait for the
doctor’s appointment 14 hours later. Mr. Ramirez-Ramirez
never made this appointment; three hours later nurses
called 911 after finding him lying on the ground with blood
coming out of his mouth.97
Ultimately, after being transferred to the community
hospital and then quickly airlifted to a larger regional
Fatal Neglect: How ICE Ignores Deaths in Detention

Photo: Diane Ovalle of Puente

14

Death #5:

Irene Bamenga
Age

29

Country of Origin

France

Cause of Death

Ms. Bamenga died after being given the incorrect dosages of medication. Although the
death certificate indicates that cardiomyopathy was the immediate cause of death, a
doctor reviewing Ms. Bamenga’s death questioned this conclusion.

Date of Death

July 27, 2011

Detention Standards

NDS
Section (I):	

Access to medical services that promote detainee health and general
well-being;
Section (III)(D):	 all new arrivals shall receive tuberculosis screening;
Section (III)(F):	 healthcare provider shall review request slips and determine when
detainees will be seen.

Non-Compliance with
Detention Standards for
Medical Care
Length of Detention

12 days

Detention Facility

Albany County Corrections Facility, Albany, NY

Facility Operator

Albany County Sheriff’s Office

Facility Contract Type

USMS IGA

Ms. Bamenga’s case—which is currently the subject of
a wrongful death lawsuit filed by her widower

100

—is

Ms. Bamenga did not begin receiving medication at ACJ
until her fourth day in detention.108 Despite Ms. Bamenga

painfully straightforward. After only 12 days in ICE custody,

submitting two health-services request forms at ACCF in

the French citizen died after being given the incorrect

the days preceding her death,109 the ACCF medical staff

dosages of medication. She passed away on July 27,

did not take steps to address Ms. Bamenga’s concerns

2011,

101

at the Albany Memorial Hospital in Albany, New

York.102 The certificate of death lists the immediate cause
of death as cardiomyopathy

103

although the mortality

review report conducted by a doctor

104

review questions this conclusion.

105

as part of the death

The August 2011 death

or deteriorating condition.110 The first request on July 25,
2011, stated: “I am not being given the full dosage of my
medications. Two of the six different meds are meant to
be take [sic] twice a day and so far I have only be[en] given
1 dosage in the morning.” The second request reported

investigation following Ms. Bamenga’s death revealed

“[s]hortness of breath at night especially when laying down,

“the [Allegany County Jail] (ACJ) and the [Albany County

palpitations when laying down. Dizziness upon standing up

Correctional Facility] (ACCF) were not in compliance with

when palpitation and shortness of breath occur.” This was

the ICE NDS, Medical Care [Standard],”

106

including specific

exacerbated by ACCF medical staff administering incorrect

complaints that the ACCF and ACJ “failed to dispense

medicine dosages—both in missed and excessive dosages—

ordered medications, delayed in starting medications,

which contributed directly to Ms. Bamenga’s death.111 In

failed to verify medications, and provided incorrect dosing

fact, on the morning of July 27, 2011, before Ms. Bamenga

of medications.”

was found unresponsive in her jail cell, an ACCF nurse

107

practitioner gave Ms. Bamenga a physical assessment and
Ms. Bamenga was consecutively held at two different

found nothing wrong even though Ms. Bamenga insisted

facilities— first at the ACJ in Belmont, New York, for five days

that she was receiving incorrect medicine dosages.112

and then ACCF in Albany, New York, for the remaining seven

Upon reviewing the symptoms noted in Ms. Bamenga’s

days. ODO identified substandard care in both facilities.

medical file, a doctor participating in the death review

Fatal Neglect: How ICE Ignores Deaths in Detention

15

states that Ms. Bamenga’s death could have resulted

treatment plan to control her cardiac condition.”115

from a cardiac arrhythmia brought on by “digoxin toxicity
and alterations in potassium levels” due to incorrectly
prescribed high dosages of her medications.

113

According

ERO and ODO inspections were not available for
either facility around the time of Ms. Bamenga’s death.

to the doctor, “missed medication dosing as well as

Administering untimely and incorrect dosages of

incorrect medication dosing were significant factors that

medication, especially for life-threatening conditions like

contributed to the decompensation of [Ms. Bamenga’s]

congestive heart failure, is an obvious violation of even

congestive heart failure.”

114

Regardless, the doctor

the outdated detention standards that ICE applied to

concludes that, even if “this patient’s death was indeed

ACCF.116 Ms. Bamenga’s death is a clear failure by ACJ and

[caused by] cardiomyopathy due to congestive heart

ACCF medical staff to treat Ms. Bamenga’s worsening

failure, then this death could have been prevented if the

condition and to appropriately medicate her for a

appropriate steps were taken to determine the severity

known medical condition.

of her congestive heart failure followed by an appropriate

Death #6:

Fernando Dominguez-Valdivia117
Age

58

Country of Origin

Mexico

Cause of Death

Pneumonia, a preventable and treatable illness, following facility failures to perform
proper physical examinations and provide timely and appropriate access to off-site
treatments.

Date of Death

March 4, 2012

Detention Standards
Non-Compliance with
Detention Standards for
Medical Care

PBNDS 2008
“Failure to perform proper physical examinations in response to symptoms and
complaints, failure to pursue any records critical to continuity of care, and failure to
facilitate timely and appropriate access to off-site treatments”118 (specific standards not
cited within ODO inspection).

Length of Detention

82 days

Detention Facility

Adelanto Detention Facility, Adelanto, CA

Facility Operator

GEO Group

Facility Contract Type

IGSA

Mr. Dominguez-Valdivia contracted pneumonia—a

2011. The autopsy report, according to the 2012 ERO

preventable and treatable illness—during his 82 days in

inspection of ADF, lists the cause of death as “multi-organ

immigration detention, but died from it after receiving

failure due to sepsis, due to bronchopneumonia and

what ODO described as an “unacceptable level of medical

chronic alcoholic liver disease.”120

care.”119 He passed away on March 4, 2012, at the Victor
Valley Community Hospital in Victorville, California.

In the three months leading up to his death, Mr.

Originally from Mexico, Mr. Dominguez was 58 years old at

Dominguez-Valdivia was taken to the hospital twice with

the time and had been detained at the Adelanto Detention

“complaints of dizziness.” He was subsequently given a

Facility (ADF) in Adelanto, California, since November 26,

“stress test and an echocardiogram” but there was “no

Fatal Neglect: How ICE Ignores Deaths in Detention

16

Photo: Christina Fialho

definitive diagnosis.”121 On the morning of February 16,

of the ICE PBNDS 2008. The death review disclosed several

2012, a nurse administering medications observed Mr.

egregious errors committed by ACF medical staff in Mr.

Dominguez in the housing unit. It is unclear what she

Dominguez’s case, including “failure to perform proper

observed, but Mr. Dominguez was taken to the medical

physical examinations in response to symptoms and

department with complaints of “dizziness, tiredness and

complaints, failure to pursue any records critical to continuity

weakness.”

122

He was later admitted to the emergency

room at the Victor Valley Community Hospital where he died.

of care, and failure to facilitate timely and appropriate
access to off-site treatments.”124 The death review summary
concludes that Mr. Dominguez’s death “could have been

According to the 2012 ODO inspection of ADF, a death

prevented and that [he] received an unacceptable level of

review was conducted after Mr. Dominguez’s death.

medical care while detained at ACF.”125

The death review is not publicly available; it was one of
four that remained incomplete at the time of ACLU’s

Despite this unambiguous finding of medical neglect by

FOIA request. The ACLU submitted a follow-up request

ODO, ADF passed its October 2012 ERO inspection later

for these reviews, but ICE denied the organization’s

that year following Mr. Dominguez’s death. However,

request for expedited processing, claiming that there is

ADF had failed the 2011 ERO inspection prior to Mr.

no “urgency to inform your limited audience about past

Dominguez’s death126 because of a deficient mandatory

ICE actions” and that the information in Mr. Dominguez’

medical standard component. The component required

death review would not “have a bearing on immediate or

health appraisals and physical examinations to be

resultant future situations.” Because it is not clear when

performed within 14 days of arrival, and review of

ICE will produce the full death review, report authors

25 medical records showed that this was not being

have instead relied on a summary of the death review in

done.127 The summary of Mr. Dominguez’s death review

the 2012 ODO inspection. The review found that ACF123

demonstrates that this and other fatal deficiencies

medical staff failed to provide adequate health care to [Mr.

persisted, making it even more troubling that ADF passed

Dominguez], and failed to comply with the requirements

its 2012 inspection.

Fatal Neglect: How ICE Ignores Deaths in Detention

17

Death #7:

Victor Ramirez-Reyes
Age

56

Country of Origin

Ecuador

Cause of Death

Heart disease after health care providers failed to monitor and control Mr. Ramirez’s
blood pressure.

Date of Death

September 26, 2011

Detention Standards

PBNDS 2008

Non-Compliance with
Detention Standards for
Medical Care

Section (V)(F):	 Accountability for administering or distributing medications in a timely
manner and according to licensed provider orders;
Section (II)(5):	 Timely follow-up to healthcare requests

Length of Detention

20 days

Detention Facility

Elizabeth Detention Center, Elizabeth, NJ

Facility Operator

CCA

Facility Contract Type

CDF

Victor Ramirez-Reyes died of heart disease—a treatable

Medical staff did not properly
monitor Mr. Ramirez’s vital signs.

condition—after health care providers delivered grossly
substandard care by failing to monitor and control Mr.
Ramirez’s blood pressure. The 56-year-old Ecuadorian died
on September 26, 2011, at Trinitas Hospital in Elizabeth,

automated external defibrillator machine did not begin

New Jersey, following 20 days in ICE custody at the CCA-run

until emergency medical technicians arrived approximately

Elizabeth Detention Center in New Jersey. According to the

10 minutes later.131 A doctor declared Mr. Ramirez dead

New York State Medical Examiner, the immediate cause of

nearly an hour later, after he arrived at the hospital.

death was hypertensive and atherosclerotic cardiovascular
disease, or heart problems related to high blood pressure

The ERO and ODO inspections after Mr. Ramirez’s death

and plaque buildup of the arteries.

draw mutually inconsistent conclusions about the quality

128

of care at Elizabeth. ERO’s October 2011 inspection
Despite Mr. Ramirez’s disclosure at his initial interviews

occurred 22 days after Mr. Ramirez’s death. The inspection

with ICE and subsequent interview with Elizabeth medical

notes his death, but does not flag any areas of concern

staff that he had a medical history of high blood pressure,

about the quality of medical care. In fact, the ERO

medical staff did not properly monitor his vital signs to

inspectors found the facility in compliance with all 66

ensure his blood pressure was under control. Mr. Ramirez

medical standards reviewed. The inspectors note that the

received double doses of his medications on a daily basis

health services unit is “appropriately” staffed and provides

because medical staff did not follow proper protocols.

129

A

coverage 24 hours a day, seven days a week.132 At the time

sick call slip submitted by Mr. Ramirez was not forwarded

of inspection, the facility was in the process of expanding,

to medical staff scheduled to see him. Consequently,

making it even more critical to identify and address

medical staff failed to address the symptoms documented

existing deficiencies.133 It is troubling that Elizabeth’s

on the slip, including trouble breathing.130 On the morning

November 2011 expansion was allowed to continue given

of Mr. Ramirez’s death, he collapsed after receiving his

Mr. Ramirez’s death and the clear failure to improve the

medication. Cardiopulmonary resuscitation and use of an

quality of medical care.134

Fatal Neglect: How ICE Ignores Deaths in Detention

18

Photo: American Friends Service Committee Immigrant Rights Program

In contrast, the January 2012 ODO inspection found 22

of hypertension and was not given appropriate care.

deficiencies. Four of the deficiencies are for failure to meet

Although this second case occurred less than one month

PBNDS medical care standards related to inadequate

after Mr. Ramirez’s death, the facility made the same

medical staffing and failure to provide timely and

mistakes that led to Mr. Ramirez’s death. For instance,

appropriate medical care.

135

ODO notes that staffing levels

healthcare providers did not refer the individual to higher-

are “inadequate to address the health care needs of the

level care or to an external provider despite the person’s

detainee population” and that the staff vacancy rate is

having a “dangerously” high blood pressure for more than

particularly concerning given that the facility does not have

24 hours.137 Although this second individual was released,

an on-site physician or weekend provider coverage.136

it is deeply concerning that Elizabeth had not made
changes to its medical procedures to address the flaws

The ODO inspection does not mention Mr. Ramirez’s

that led to Mr. Ramirez’s death. It is unclear whether ICE

death, but it does identify a case very similar to Mr.

has addressed all medical-care deficiencies because ICE

Ramirez’s in which an individual also reported a history

has not publicly released more recent inspections.

Fatal Neglect: How ICE Ignores Deaths in Detention

19

Death #8:

Mauro Rivera Romero
Age

43

Country of Origin

El Salvador

Cause of Death

Disseminated cryptococcosis, an infection associated with immune-suppressed
individuals, following inadequate medical screenings, failure to transfer critical medical
information, and failure to timely address Mr. Rivera’s medical issues and refer him to a
higher-level provider.

Date of Death

October 5, 2011

Detention Standards

PBNDS 2008

Non-Compliance with
Detention Standards for
Medical Care

Section (II)(2):	 Meet healthcare needs in a timely and efficient manner

Length of Detention

3 days

Detention Facility

El Paso Processing Center, El Paso, TX

Facility Operator

ICE, Doyon-Akal JV oversees the detained population.138

Facility Contract Type

SPC

Negligent medical screening and failure to transfer critical

does not examine this possibility, a thorough and private

medical information led to Mauro Rivera Romero’s death

screening process sensitive to this dynamic may have been

from an infection at the age of 43. Mr. Rivera, a Salvadoran

able to induce Mr. Rivera to disclose his HIV status during

citizen, died on October 5, 2011, at the Del Sol Medical

his initial screening. Regardless, the ODO found that EPC

Center in El Paso, Texas, following three days in detention

failed to provide adequate care in several instances. [See

at the El Paso Processing Center (EPC). The County of El

timeline on the following page]

Paso Office of the Medical Examiner found that the cause
of death was disseminated cryptococcosis, an infection

The ODO concluded that EPC failed to comply with PBNDS

associated with immune-suppressed individuals.

requiring healthcare needs to be met in a timely and

139

efficient manner. Although the ODO does not cite failure
The ODO investigation of Mr. Rivera’s death found that

to follow up with Mr. Rivera’s doctor following his October

medical personnel at EPC failed to review information

2 screening as a technical deficiency, it acknowledges

in Mr. Rivera’s medical record, and should have referred

that such lack of action compromised Mr. Rivera’s initial

Mr. Rivera to a higher-level medical care provider. The

medical screening and missed “an opportunity to obtain

ODO also found that important medical information was

more accurate medical history critical to his care.”142

not transferred from U.S. Border Patrol when Mr. Rivera
was taken into ICE custody, and that EPC medical staff

The inspections process failed to meaningfully address

consistently failed to properly document his medical

inadequate medical care beforehand or account for

encounters.

140

The ODO notes that Mr. Rivera’s death

failure to provide adequate care afterwards. For example,

could have been prevented if he had accepted medical

the 2010 ODO inspection cites interviews with people in

care from Border Patrol or disclosed earlier that he

detention who complained about the facility’s medical

was HIV positive.

141

However, individuals with HIV are

care, specifically that “the wait to receive medical care

typically hesitant to disclose their status due to the stigma

after submitting a sick call request is too long, that medical

associated with the disease. Though the ODO death review

personnel complain about detainees having medical

Fatal Neglect: How ICE Ignores Deaths in Detention

20

problems, and that there is a lack of attention
to detainee complaints about pain.”143 The

Fatal Timeline: Mauro Rivera Romero

September 2011 ERO inspection gave EPC

Border Patrol apprehends Mr. Rivera aboard a

passing ratings on medical care, although it

Greyhound bus at a checkpoint in Texas. Mr. Rivera

found one deficiency related to dental care.144
EPC passed its September 2012 ERO

reports experiencing stomach pains and nausea
Oct. 1

and states that he had been diagnosed with a
stomach infection and released from a hospital on

inspection.145 Similar to the 2011 ERO

Sept. 29. He declines Border Patrol medical care

inspection, it finds no deficiencies with

and is transferred to EPC.

EPC’s medical care. In addition to the ERO

Mr. Rivera discloses at his initial medical screening

inspections, ODO inspected EPC in March
2012 – just five months after Mr. Rivera’s
death – but failed to mention his death

that he had been hospitalized in 2011for gastritis
Oct. 2

(related to stomach inflammation), but could not
remember the medication he was prescribed for

in the report and did not identify any

his condition.

deficiencies with medical care. If ODO and
During Mr. Rivera’s first sick visit to the medical

ERO inspections properly documented and
investigated medical care failures at detention

Oct. 3

facilities, Mr. Rivera’s death may well have

unit, a registered nurse (RN) finds that he has an
elevated pulse of 129, but fails to refer Mr. Rivera
for review by a higher-level provider.146

been prevented.

Mr. Rivera submits written complaints on three
separate occasions regarding his ailments,
including abdominal discomfort and his inability to
Oct. 3-4

walk. Despite the seriousness of these complaints,
approximately 24 hours pass between Mr. Rivera’s
first complaint and when he was first seen
for treatment.147

Oct. 5

Mr. Rivera dies.

Photo: Diane Ovalle of Puente

Fatal Neglect: How ICE Ignores Deaths in Detention

21

Conclusion
Deaths in detention are the most egregious and permanent consequence of an unaccountable and negligent immigration
detention system. DWN, NIJC, and ACLU’s review of deaths that occurred from 2010 to 2012 provide new evidence that ICE
inspections fail to hold detention centers accountable. The difficulties that the ACLU has experienced in obtaining additional
deaths reviews demonstrate that DHS’s culture of secrecy persists. Based on the findings in this report, the ACLU, DWN, and
NIJC call on DHS and ICE to:
1.	 Immediately reduce immigration detention.
a.	 Release people with serious medical and mental

3.	 Ensure inspections provide meaningful oversight.
a.	 Improve the inspections process by ensuring

health needs, particularly when individuals require

that inspections are more effectively used to hold

higher-level care.

facilities accountable, as set forth in the appendix.

b.	 Immediately terminate contracts for facilities with

b.	 Require ERO and ODO inspectors to read the death

repeated preventable deaths, such as the Eloy

review documents for all deaths that have occurred

Detention Center in Arizona.

at a given facility under inspection, and explicitly

c.	 Shift current funding for detention to community-

and publicly report on whether the issues raised

based alternatives, which will allow people to seek

in the death reviews have been addressed.

medical attention and receive support from family,

c.	 In response to each death where an ODO death

legal counsel, and community.

review identifies violations of ICE standards,

d.	 Apply current ICE detention standards to all

concludes the death was preventable, or identifies

facilities used by ICE and discontinue contracts

other areas of concern, require ERO and IHSC

where current standards are not being met.

to develop a corrective action plan with clear
deadlines to reduce the risk of future deaths or

2.	 Improve delivery of medical care in detention.

other significant events, and to provide those

a.	 Revise PBNDS 2011 to require that medical care

corrective action plans to ODO.

providers be held responsible for meeting the
health care needs of individuals in ICE custody

4.	 Increase transparency of inspections, deaths, and

as opposed to simply providing “access” to

serious medical incidents in detention.

health care.

a.	 Make the inspections process more transparent

b.	 Revise PBNDS 2011 medical care standards to

by making ERO inspections, ODO inspections, and

meet or exceed all analogous NCCHC standards

ODO death reviews available to the public within

for prison and jail health care.

three months of being finalized, and by providing

c.	 End the use of private for-profit detention facilities

regular public and congressional reporting on the

and for-profit medical care sub-contractors.

frequency and circumstances of sentinel events

Instead, ensure that IHSC is the direct health care

(as defined by the Joint Commission148) in detention.

provider at all immigration detention facilities.

b.	 Require ICE to publish all death reviews that occur,
including by the Office of Inspector General and

d.	 Remove IHSC from ICE supervision to maintain

Office for Civil Rights and Civil Liberties.

clinical independence and independent oversight.
e.	 Ensure all detention facilities have appropriate
clinical staffing plans, and include whether or not

c.	

Create an independent medical advisory committee
to investigate deaths that occur in detention.

positions are filled as a compliance component
during ERO and ODO inspections.

Fatal Neglect: How ICE Ignores Deaths in Detention

22

Appendix
In addition to the recommendations provided in the conclusion, inspections recommendations from DWN and NIJC’s
inspections report, Lives in Peril are included below, recognizing the need for meaningful, robust reforms to ICE’s
inspections system:149
1.	 Increase Transparency and Oversight of the Inspections Process
a.	 Make ERO and ODO inspections available to the public in a timely manner. To date, ICE has released its inspections
to the public only as a result of FOIA requests. FOIA requests are unnecessarily time-consuming and expensive
obstacles to accessing information about how the federal government treats thousands of people in its custody and
spends billions of taxpayer dollars. Instead, this information should be freely available.
b.	 Provide public reporting on suicide attempts, hunger strikes, work program stoppages, use of solitary confinement,
use of force, and other significant events at detention centers.
c.	 Submit quarterly reporting to Congress on inspection and oversight activities of detention facilities, which should be
made publicly available.
2.	 Improve the Quality of Inspections
a.	 Establish a DHS ombudsman outside of ICE to conduct unannounced inspections of immigration detention facilities
at least once per year, with complete findings made available to the public. These third-party inspections should
examine compliance with applicable detention standards and determine whether contracts will be renewed in
accordance with congressional appropriations requirements.
b.	 Prohibit facilities from taking an “à la carte” approach to compliance and make all detention standards provisions
mandatory during inspections. ICE must stop permitting some facilities to opt out of detention standards they have
been contracted to apply. If a facility cannot abide by detention standards in their entirety then it should not be
permitted to enter into or continue a contract with ICE.
c.	 Ensure that inspections involve more than checklists. Inspectors must rely on more than assurances by jail
administrators of compliance with detention standards and instead seek and document proof of their effective
implementation.
d.	 Engage detained immigrants during inspections, as well as other stakeholders such as legal service providers
and those who regularly conduct visitation, in order to capture the range of concerns at a facility that may not be
reported through formal institutional channels. Inspectors should document the content of those interviews.
3.	 Institute Consequences for Failed Inspections
a.	 Place detention facilities on probation and subject them to more intensive inspections after the first finding of
substantial non-compliance.
b.	 Terminate contracts within 60 days for those facilities with repeat findings of substantial non-compliance, including
inadequate or less than the equivalent median score in two consecutive inspections.

Fatal Neglect: How ICE Ignores Deaths in Detention

23

Endnotes
1.	

Nina Bernstein, “Officials Hid Truth of Immigrant Deaths in Jail,” The

11.	

Reveals Systemic Lack of Accountability in Immigration Detention

com/2010/01/10/us/10detain.html; Dana Priest & Amy Goldstein,

Contracting, Aug. 2015, available at: http://immigrantjustice.org/sites/

“System of Neglect,” The Washington Post, May 11, 2008, available at:

immigrantjustice.org/files/images/NIJC%20Transparency%20and%20

http://www.washingtonpost.com/wp-srv/nation/specials/immigration/

Human%20Rights%20Project%20August%202015%20Report%20

cwc_d1p1.html.
2.	

Id.

3.	

Detention Watch Network and National Immigrant Justice Center, Lives

FINAL3.pdf, p. 6.
12.	

Detention Abuse, Oct. 2015, available at: http://immigrantjustice.org/

fdsys/pkg/PLAW-111publ83/pdf/PLAW-111publ83.pdf, p. 9.
13.	

sites/immigrantjustice.org/files/THR-Inspections-FOIA-Report-October-

5.	

Environmental Research and Public Health, Nov. 2015.
14.	

suicides during the Obama Administration. The authors counted Jose

detention_us/incustody_deaths/index.html (collecting reporting

Nelson Reyes-Zelaya’s July 2010 death as the sixth suicide because

on deaths); Nina Bernstein, “U.S. to Reform Policy on Detention of

initial reports from ICE and news outlets indicate that the death was a

Immigrants,” The New York Times, at A1, Aug. 5, 2009, available at:

suicide. The 2012 ICE list of deaths in custody indicates Mr. Reyes-

http://www.nytimes.com/2009/08/06/us/politics/06detain.html.

Zelaya’s death was due to asphyxia, but ICE changed the cause of

Since then, the ACLU has issued two FOIA requests seeking additional

death in more recent lists to “Cancer.” ICE, List of Deaths in ICE Custody:

death reviews, including the four investigations that were still in

October 2003-January 25, 2016, Accessed Jan. 26, 2016, available at:

progress at the time of the original FOIA request. ICE has not yet

https://www.ice.gov/sites/default/files/documents/Report/2016/

produced documents in response to either of the new FOIA requests,

DetaineeDeaths2003Jan2016.pdf [hereinafter “ICE Deaths List 2016”];

and responded to each by claiming, among other things, that the

ICE, List of Deaths in ICE Custody, October 2003-December 6, 2012,

ACLU had not established “why you feel there is an urgency to

available at: http://immigrantjustice.org/sites/immigrantjustice.org/

inform your limited audience about past ICE actions [i.e., deaths in

files/Detainee%20Deaths%20in%20ICE%20Custody%202003-2012.pdf;

ICE custody],” concluding that the FOIA request would not make a

Seth Freed Wessler, Salvadoran Man Commits Suicide in Immigration

“significant” contribution to public understanding of government

Detention, Colorlines, Jul. 21, 2010, http://www.colorlines.com/articles/

operations or activities, and further concluding that the FOIA request

salvadoran-man-commits-suicide-immigration-detention; Man Held

was “primarily in the commercial interest” of the ACLU. The ACLU has

on Immigration Charges Dies in Orleans Prison, The Times-Picayne, Jul.

filed an administrative appeal with the ICE Office of the Principal Legal

18, 2010, available at: http://www.nola.com/crime/index.ssf/2010/07/

For more information about the creation of the ODO, see U.S.

man_held_on_immigration_charge.html.
15.	

New York Times, Aug. 17, 2009, available at: http://www.nytimes.

Immigration and Customs Enforcement Office of Detention Policy and

com/2009/08/18/us/18immig.html?_r=0 (describes Huluf Negusse’s

the Judiciary, Subcommittee on Immigration Policy and Enforcement

8.	

9.	

10.	

Nina Bernstein, Officials Say Detainee Fatalities Were Missed, The

Department of Homeland Security (DHS), Written testimony of U.S.
Planning Assistant Director Kevin Landy for a House Committee on

7.	

According to ICE’s 2016 list of deaths in custody, there were five

nytimes.com/top/reference/timestopics/subjects/i/immigration_

Advisor and is awaiting the results of this appeal.
6.	

Megan Granski, Allen Keller & Homer Venters, Death Rates among
Detained Immigrants in the United States, International Journal of

2015-FINAL.pdf [hereinafter “Lives in Peril”].
The New York Times, In Custody Deaths, available at: http://topics.

Department of Homeland Security Appropriations Act, 2010, H.R.
2892, P.L. 111-83, 111th Cong., available at: https://www.gpo.gov/

in Peril: How Ineffective Inspections Make ICE Complicit in Immigration

4.	

National Immigrant Justice Center, Freedom of Information Act Litigation

New York Times, Jan. 9, 2010, available at: http://www.nytimes.

death following a suicide attempt).
16.	

Qi Gen Guo (died 2/23/2011, detained at Clinton County Correctional

hearing on Performance-Based National Detention Standards

Facility, Pennsylvania): The ODO concluded that the facility was in

(PBNDS) 2011 (Mar. 27, 2012), available at: http://www.dhs.gov/

compliance with ICE NDS; however, the ODO noted that the facility did

news/2012/03/27/written-testimony-us-immigration-and-customs-

not meet NDS standards related to intake screening, communication

enforcement-house-judiciary.

during medical evaluation and examinations, completion of thorough

U.S. Immigration & Customs Enforcement (ICE), 2011 Operations

physical examination, medical visits in Special Management Unit, and

Manual ICE Performance-Based National Detention Standards,

documentation of refusal of medications. DHS, Death Investigation

available at: https://www.ice.gov/detention-standards/2011.

for Qi Gen Guo, Jun. 16, 2011, https://www.documentcloud.org/

ACLU, Written Statement of the American Civil Liberties Union, Holiday

documents/2698743-Guo-Qi-Gen.html, pp. 12-13. Jose Aguilar-

on ICE: The U.S. Department of Homeland Security’s New Immigration

Espinoza (died 1/31/2011, detained at Theo Lacy Facility, California):

Detention Standards: Hearing Before the Subcomm. on Immigration Policy

The ODO found that the facility was not compliant with PBNDS on

and Enforcement of the H. Comm. on the Judiciary, 112th Congress

medical care, specifically the initial screening form was incomplete,

(Mar. 28, 2012), available at: https://www.aclu.org/files/assets/aclu_

consent forms were not adequately documented, and a physical

detention_standards_hearing_statement_final_2.pdf.

exam was not completed. DHS, Death Investigation for Jose Aguilar-

Gov’t Accountability Office, Immigration Detention: Additional Actions

Espinoza, Mar. 6, 2012, available at: https://www.documentcloud.org/

Needed to Strengthen Management and Oversight of Facility Costs

documents/2698802-Aguilar-Espinoza-Jose.html, pp. 11-12. Ricardo

and Standards, at 30-32 (Oct. 10, 2014), available at: http://gao.gov/

Rojas-Martinez (died 12/19/2011, detained at Houston Contract

assets/670/666467.pdf.

Detention Facility, Texas): The ODO identified issues with clinical

DHS, Death Investigation for Irene Bamenga, Jan. 12, 2012, available

processes that require improvement. DHS, Death Investigation for

at: https://www.documentcloud.org/documents/2695498-Bamenga-

Ricardo Rojas-Martinez, Aug. 16, 2012, available at: https://www.

Irene.html#document/p21/a272801, p. 21 [hereinafter “Bamenga”];

documentcloud.org/documents/2698740-Rojas-Martinez-Ricardo.

DHS, Death Investigation for Amra Miletic, Aug. 17, 2011, available at:

html, pp. 147-148.

https://www.documentcloud.org/documents/2695509-Miletic-Amra.
html#document/p29/a272804, p. 29 [hereinafter “Miletic.”]

Fatal Neglect: How ICE Ignores Deaths in Detention

24

Endnotes cont.
17.	

The Joint Commission, Sentinel Events Policy, available at: http://www.
jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.pdf.

18.	

a273085, p. 156.
25.	

DHS, Death Investigation for Miguel Angel Sarabia-Ortega, Oct. 1, 2012,

available at: https://www.documentcloud.org/documents/2695514-

available at: https://www.documentcloud.org/documents/2698741Sarabia-Miguel.html#document/p8/a273595, p. 8.
19.	

Mandza-Evalin-Ali.html#document/p18/a273086, p. 18.
26.	

Shea Johnson, Wrongful Death Suit Headed to Mediation, Hesperia

a273085, p. 156.
27.	

Death of Lynn Woman Allowed to go to Jury, The Boston Globe, Sept. 15,
2015, available at: https://www.bostonglobe.com/metro/2015/09/15/

Mandza-Evalin-Ali.html#document/p12/a273179, p. 12.
30.	

Two deaths occurred at: GEO Group-run detention centers: Adelanto

a273196, p. 155.
31.	

Id., available at: https://www.documentcloud.org/documents/2695514-

32.	

Id., available at: https://www.documentcloud.org/documents/2695514-

33.	

Id., available at: https://www.documentcloud.org/documents/2695514-

34.	

Id., available at: https://www.documentcloud.org/documents/2695514-

35.	

Id., available at: https://www.documentcloud.org/documents/2695514-

36.	

2012 Denver Contract Detention Facility ODO Inspection, available at:

Center (IGSA) and Elizabeth Detention Center (CDF); one at a service
processing center (SPC) operated by Doyon-Akal JV: El Paso SPC; and

Mandza-Evalin-Ali.html#document/p12/a273179, p. 12.

one at a facility operated by Immigration Centers of America, LLC:
Immigration Centers of America - Farmville (IGSA).
21.	

Mandza-Evalin-Ali.html#document/p19/a273180, p. 19.

Grassroots Leadership, Payoff: How Congress Ensures Private Prison
Profit with an Immigrant Detention Quota, Apr. 2015, available at: http://

Mandza-Evalin-Ali.html#document/p13/a273193, p. 13.

grassrootsleadership.org/reports/payoff-how-congress-ensuresprivate-prison-profit-immigrant-detention-quota#1.
22.	

Mandza-Evalin-Ali.html#document/p16/a273194, p. 16.

ACLU, Warehoused and Forgotten: Immigrants Trapped in Our Shadow
Private Prison System, Jun. 2014, available at: https://www.aclu.org/

Mandza-Evalin-Ali.html#document/p15/a273195, p. 15.

sites/default/files/assets/060614-aclu-car-reportonline.pdf; Grassroots

https://www.documentcloud.org/documents/1699764-denver-county-jail-

Leadership, The Dirty Thirty: Nothing to Celebrate About 30 Years of
Corrections Corporation of America, Jun. 2013, available at: http://

geo-group-2012-ero-inspection.html#document/p105/a271519, p. 105.
37.	

documents/2695509-Miletic-Amra.html#document/p134/a273127,

Thirty_formatted_for_web.pdf ; Detention Watch Network & CIVIC,

p. 134 (State of Utah, Department of Health, Office of the Medical

Jail, Oct. 2015, available at: http://www.detentionwatchnetwork.org/

Examiner Report).
38.	

sites/detentionwatchnetwork.org/files/civicdwn_adelanto_report.pdf;
Grassroots Leadership, For-Profit Family Detention: Meet the Private
Oct. 2014, available at: http://grassrootsleadership.org/sites/default/

Miletic-Amra.html#document/p26/a273128, p. 26.
Id., available at: https://www.documentcloud.org/documents/2695509-

40.	

Id., available at: https://www.documentcloud.org/documents/2695509-

41.	

Non-compliance with ICE NDS, Medical Care, section (III)(D),

Miletic-Amra.html#document/p27/a273129, p. 27.

files/uploads/For-Profit%20Family%20Detention.pdf; Civil Rights
Division, U.S. Dep’t of Justice, Investigation of the Walnut Grove Youth

Id., available at: https://www.documentcloud.org/documents/2695509-

39.	

Prison Corporations Making Millions by Locking Up Refugee Families,

Miletic-Amra.html#document/p28/a273131, p. 28.

Correctional Facility, Mar. 20, 2012, available at: http://www.justice.

Medical Screening (New Arrivals); Miletic, available at: https://

gov/sites/default/files/crt/legacy/2012/04/09/walnutgrovefl.pdf;

www.documentcloud.org/documents/2695509-Miletic-Amra.

Inspector General, U.S. Dep’t of Justice, Audit of the Federal Bureau
of Prisons Contract No. DJB1PC007 Awarded to Reeves County, Texas to

html#document/p149/a273141, p. 149.
42.	

Operate the Reeves County Detention Center I/II,Pecos, Texas, Apr. 2015,
available at: https://oig.justice.gov/reports/2015/a1515.pdf; Brendan
Rap Sheet, PR Watch, Nov. 10, 2015, available at: http://www.prwatch.

Miletic-Amra.html#document/p9/a273145, p. 9.
Id., available at: https://www.documentcloud.org/documents/2695509-

45.	

Id., available at: https://www.documentcloud.org/documents/2695509-

46.	

Id., available at: https://www.documentcloud.org/documents/2695509-

47.	

Id., available at: https://www.documentcloud.org/

48.	

Non-compliance with ICE NDS, Medical Care, section (III)(D); Miletic,

Miletic-Amra.html#document/p28/a273146, p. 28.

Probes, The Clarion-Ledger, Oct. 15, 2014, available at:
http://www.clarionledger.com/story/news/2014/10/11/private-prisons-

Miletic-Amra.html#document/p16/a273600, p. 16.

face-suits-federal-probes/17122977;.
DHS, Death Investigation for Evalin-Ali Mandza, Oct. 2012, available

Miletic-Amra.html#document/p22/a273147, p. 22.

at: https://www.documentcloud.org/documents/2695514-MandzaEvalin-Ali.html, pp. 153-164 (describes timeline of events) [hereinafter

Id., available at: https://www.documentcloud.org/documents/2695509-

44.	

org/news/2013/09/12255/violence-abuse-and-death-profit-prisonsgeo-group-rap-sheet; Jerry Mitchell, Private Prisons Face Suits, Federal

Miletic, available at: https://www.documentcloud.org/
documents/2695509-Miletic-Amra.html, pp.75-77.

43.	

Fischer, Violence, Abuse, and Death at For-Profit Prisons: A GEO Group

24.	

Miletic, available at: https://www.documentcloud.org/

grassrootsleadership.org/sites/default/files/uploads/GRL_Dirty_
Abuse in Adelanto: An Investigation Into a California Town’s Immigration

23.	

Mandza, available at: https://www.documentcloud.org/
documents/2695514-Mandza-Evalin-Ali.html#document/p155/

Correctional Facility (IGSA) and Denver (CDF); two at Corrections
Corporation of America (CCA)-run detention centers: Eloy Detention

Non-compliance with ICE PBNDS, Medical Care, Section (V)(O); Mandza,
available at: https://www.documentcloud.org/documents/2695514-

Jail Files Federal Lawsuit, Salt Lake City Tribune, June 21, 2012, available
20.	

Id., available at: https://www.documentcloud.org/documents/2695514Mandza-Evalin-Ali.html#document/p155/a273178, p. 155.

29.	

[hereinafter “Valencia”]; Roxana Orellana, Family of Woman Who Died in
at http://archive.sltrib.com/story.php?ref=/54350757.

Id., available at: https://www.documentcloud.org/documents/2695514Mandza-Evalin-Ali.html#document/p19/a273177, p. 19.

28.	

lawsuit-over-death-lynn-woman-who-was-detained-immigrationviolations-allowed-jury/CON7Q7jUPmHT12rDFBRTiO/story.html

Mandza, available at: https://www.documentcloud.org/
documents/2695514-Mandza-Evalin-Ali.html#document/p156/

Star, Dec. 1, 2014, available at: http://www.hesperiastar.com/
article/20141201/NEWS/141209983; Milton J. Valencia, Lawsuit Over

Non-compliance with ICE PBNDS, Medical Care, Section (II)(7); Mandza,

documents/2695509-Miletic-Amra.html, pp. 148-149.

“Mandza.”]

available at: https://www.documentcloud.org/documents/2695509-

Mandza, available at: https://www.documentcloud.org/

Miletic-Amra.html#document/p149/a273141, p. 149.

documents/2695514-Mandza-Evalin-Ali.html#document/p156/

Fatal Neglect: How ICE Ignores Deaths in Detention

25

Endnotes cont.
49.	

Miletic, available at: https://www.documentcloud.org/

69.	

documents/2695509-Miletic-Amra.html#document/p75, p. 75.
50.	
51.	

53.	

a272780, p. 14; 2012 Eloy Inspection, available at: https://www.

Id., available at: https://www.documentcloud.org/documents/2695509-

documentcloud.org/documents/2644422-Eloy.html, p. 1.
72.	

Id., available at: https://www.documentcloud.org/documents/2695509Id., available at: https://www.documentcloud.org/documents/2695509-

58.	

org/documents/2644422-Eloy.html#document/p4/a266241, p. 4; ICE
Deaths List 2016.
75.	

suicides?, The Arizona Republic, Jul. 29, 2015, available at: http://www.
azcentral.com/story/news/arizona/investigations/2015/07/28/eloy-

Miletic-Amra.html#document/p177/a273171, p. 177.

detention-center-immigrant-suicides/30760545 [hereinafter “Jula &

60.	

DHS, Death Investigation for Pablo Gracida-Conte, Aug. 15, 2012,

González”].
76.	

Johnson, Secretary, U.S. Department of Homeland Security, Jul. 14,

Gracida-Conte-Pablo.html#document/p1/a272669, p. 1 [hereinafter

2015, available at: http://grijalva.house.gov/uploads/2015_7_14EloyDe
tentionLetter.pdf; Jula & González.

Non-compliance with PBNDS 2008, Medical Care, section (II)(37) or

77.	

ICE Deaths List 2016.

section (V)(I), require translation assistance for non-English speaking

78.	

DHS, Death Investigation for Anibal Ramirez-Ramirez, May 31, 2012,

detainees; Gracida, available at: https://www.documentcloud.org/

available at: https://www.documentcloud.org/documents/2695511-

documents/2695513-Gracida-Conte-Pablo.html#document/p14/

Ramirez-Ramirez-Anibal.html#document/p26/a273198, p. 26

a272707, p. 14.
Health professionals use this pain scale as a way to measure pain.

[hereinafter “Ramirez-Ramirez.”]
79.	

Ten describes the worst pain the person has ever known.
Non-compliance with PBNDS 2008, Medical Care, section (II)(2)

apprehension of Mr. Ramirez-Ramirez by Virginia State Police).
81.	

a272770, p. 13.
Non-compliance with PBNDS 2008, Medical Care, section (II)(7),

65.	

a273301, pp. 10-11.
84.	

Non-compliance with PBNDS 2008, Medical Care, section (II)(7)
requiring that “A detainee who needs health care beyond facility

67.	

Non-compliance with PBNDS 2008, Medical Care, section (II)(37) or

Id., available at: https://www.documentcloud.org/documents/2695511Ramirez-Ramirez-Anibal.html#document/p119/a273314, p. 119

89.	

a272707, p. 14.
68.	

Id., available at: https://www.documentcloud.org/documents/2695511Ramirez-Ramirez-Anibal.html#document/p10/a273301, pp. 10-11.

88.	

a272778, p. 6; Gracida, available at: https://www.documentcloud.
org/documents/2695513-Gracida-Conte-Pablo.html#document/p14/

Id., available at: https://www.documentcloud.org/documents/2695511Ramirez-Ramirez-Anibal.html#document/p5/a273221, p. 5.

87.	

Gracida, available at: https://www.documentcloud.org/
documents/2695513-Gracida-Conte-Pablo.html#document/p6/

Id., available at: https://www.documentcloud.org/documents/2695511Ramirez-Ramirez-Anibal.html#document/p4/a273220, p. 4.

86.	

https://www.documentcloud.org/documents/2695513-Gracida-ContePablo.html#document/p9/a272777, p. 9.

Id., available at: https://www.documentcloud.org/documents/2695511Ramirez-Ramirez-Anibal.html#document/p3/a273307, pp. 3-4.

85.	

resources will be transferred in a timely manner to an appropriate
facility where care is available.” Gracida, available at:

Id., available at: https://www.documentcloud.org/
documents/2695511-Ramirez-Ramirez-Anibal.html#document/p10/

documents/2695513-Gracida-Conte-Pablo.html#document/p12/
66.	

Ramirez-Ramirez, pp. 5-7 (describes interactions between PWMRADC
staff and Mr. Ramirez-Ramirez).

83.	

Gracida, available at: https://www.documentcloud.org/
a272776, p. 12.

Id., available at: https://www.documentcloud.org/documents/2695511Ramirez-Ramirez-Anibal.html#document/p4/a5, p. 4.

82.	

available at: https://www.documentcloud.org/documents/2695513Gracida-Conte-Pablo.html#document/p13/a272773, p. 13.

Ramirez-Ramirez, available at: https://www.documentcloud.org/
documents/2695511-Ramirez-Ramirez-Anibal.html, pp. 3-4 (describes

manner; Gracida, available at: https://www.documentcloud.org/
documents/2695513-Gracida-Conte-Pablo.html#document/p13/

ICAF is owned by a group of investors and run by Immigration Centers
of America, LLC.

80.	

requiring that health care needs be met in a timely and efficient

64.	

Letter from Raúl Grijalva, Representative, Arizona’s 3rd District, to Jeh

available at: https://www.documentcloud.org/documents/2695513“Gracida.”]

63.	

Megan Jula & Daniel González, Eloy Detention Center: Why so many

Id., available at: https://www.documentcloud.org/documents/2695509ICE Deaths List 2016.

62.	

2012 Eloy ODO Inspection, available at: https://www.documentcloud.

Miletic-Amra.html#document/p176/a273170, p. 176.

59.	

61.	

Id., available at: https://www.documentcloud.org/
documents/2644422-Eloy.html#document/p3/a266239, p. 3.

74.	

Id., available at: https://www.documentcloud.org/documents/2695509Id., available at: https://www.documentcloud.org/documents/2695509-

2011 Eloy ODO Inspection, available at: https://www.documentcloud.
org/documents/1865603-eloy-az-2011-odo-inspection.html, p. 16.

73.	

Miletic-Amra.html#document/p162/a273164, p. 162.
57.	

Id., available at: https://www.documentcloud.org/
documents/2695513-Gracida-Conte-Pablo.html#document/p14/

Miletic-Amra.html#document/p162/a273603, p. 162.
56.	

Gracida-Conte-Pablo.html#document/p13/a272779, p. 13.
71.	

Miletic-Amra.html#document/p153/a273156, p. 153.

Miletic-Amra.html#document/p154/a273159, p. 154.
55.	

Id., available at: https://www.documentcloud.org/documents/2695513-

Id., available at: https://www.documentcloud.org/documents/2695509-

Miletic-Amra.html#document/p154, p. 154.
54.	

a272760, p. 6.
70.	

Id., available at: https://www.documentcloud.org/documents/2695509Miletic-Amra.html#document/p151/a273152, p. 151.

52.	

documents/2695513-Gracida-Conte-Pablo.html#document/p6/

Id., available at: https://www.documentcloud.org/
documents/2695509-Miletic-Amra.html, pp.150-151.

Gracida, available at: https://www.documentcloud.org/

Id., https://www.documentcloud.org/documents/2695511-RamirezRamirez-Anibal.html#document/p120/a273318, p. 120.

90.	

Non-compliance with ICE PBNDS 2008 Medical Care, section (II)(2),

section (V)(I), require translation assistance for non-English speaking

Ramirez-Ramirez, available at: https://www.documentcloud.org/

detainees; Gracida, available at: https://www.documentcloud.org/

documents/2695511-Ramirez-Ramirez-Anibal.html#document/p27/

documents/2695513-Gracida-Conte-Pablo.html#document/p14/

a273319, pp. 27-28.

a272707, p. 14.

Fatal Neglect: How ICE Ignores Deaths in Detention

26

Endnotes cont.
91.	

92.	

Ramirez-Ramirez, available at: https://www.documentcloud.org/

Call; Bamenga, available at: https://www.documentcloud.org/

a273320, pp. 114-115.

documents/2695498-Bamenga-Irene.html#document/p131/a273422,

Id., https://www.documentcloud.org/documents/2695511-RamirezRamirez-Anibal.html#document/p19/a273322, p. 19.

93.	
94.	

p. 131.
111.	 Non-compliance with ICE NDS, Medical Care, section (III)(I), Delivery

Id., available at: https://www.documentcloud.org/documents/2695511-

of Medication; Bamenga, available at: https://www.documentcloud.

Ramirez-Ramirez-Anibal.html#document/p114/a273320, pp. 114-115.

org/documents/2695498-Bamenga-Irene.html, pp. 127, 130-132; Id.,

Non-compliance with ICE PBNDS, Medical Care, sections (II)(28) and (V)

available at: https://www.documentcloud.org/documents/2695498-

(B), Ramirez-Ramirez, available at: https://www.documentcloud.org/

Bamenga-Irene.html#document/p135, p. 135. Id., available at:

documents/2695511-Ramirez-Ramirez-Anibal.html#document/p28/

https://www.documentcloud.org/documents/2695498-Bamenga-

a273327, p. 28.
95.	

110.	 Non-compliance with ICE NDS, Medical Care, section (III)(F), Sick

documents/2695511-Ramirez-Ramirez-Anibal.html#document/p114/

Ramirez-Ramirez, available at: https://www.documentcloud.org/
documents/2695511-Ramirez-Ramirez-Anibal.html#document/p19/
a273322, p. 19.

Irene.html#document/p139, p. 139.
112.	 Bamenga, available at: https://www.documentcloud.org/
documents/2695498-Bamenga-Irene.html#document/p132/a273426,
p. 132.

96.	

Id., available at: https://www.documentcloud.org/documents/2695511Ramirez-Ramirez-Anibal.html#document/p19/a273333, p. 19.

would not have been detectable in an autopsy. Regardless, results

97.	

Id., available at: https://www.documentcloud.org/documents/2695511-

of the autopsy were withheld from DHS due to New York privacy

Ramirez-Ramirez-Anibal.html#document/p21/a273334, p. 21.

laws. Bamenga, available at: https://www.documentcloud.org/

2011 Immigration Center of America – Farmville (ICAF) ODO

documents/2695498-Bamenga-Irene.html#document/p138/

Inspection, available at: http://www.documentcloud.org/

a273432, p. 138; Id., available at: https://www.documentcloud.org/

98.	

documents/2388774-ica-farmville-va-2011-odo-inspection.html
99.	

2011 ICAF ERO Inspection, available at: https://www.documentcloud.
org/documents/2388770-ica-farmville-va-2011-ero-inspection.
html#document/p166/a267849, p. 166.

100.	 Valencia.
101.	 Bamenga, available at: https://www.documentcloud.org/
documents/2695498-Bamenga-Irene.html, pp. 14-15 (Although the

113.	 The results of digoxin toxicity and alterations in potassium levels

documents/2695498-Bamenga-Irene.html#document/p122, p. 122.
114.	 Bamenga, available at: https://www.documentcloud.org/
documents/2695498-Bamenga-Irene.html#document/p139/a273434,
p. 139.
115.	 Id., available at: https://www.documentcloud.org/documents/2695498Bamenga-Irene.html#document/p139/a273436, p. 139.
116.	 Non-compliance with NDS, Medical Care, Section (I), Policy, indicates

Certificate of Death lists time of death at 1:17 a.m., the emergency

all detainees shall have access to medical services that promote

room physician announced it at 1:15 a.m. as stated in ODO’s DDR

detainee health and general well-being; Bamenga, available at: https://

narrative).

www.documentcloud.org/documents/2695498-Bamenga-Irene.

102.	 Id., available at: https://www.documentcloud.org/documents/2695498Bamenga-Irene.html#document/p2/a273341, pp. 1-2.
103.	 Id., available at: https://www.documentcloud.org/documents/2695498Bamenga-Irene.html#document/p120/a273285, p. 120 (Certificate of
Death).
104.	 This doctor’s name was redacted under (b)(6), (b)(7)c exemptions.
105.	 Bamenga, available at: https://www.documentcloud.org/
documents/2695498-Bamenga-Irene.html#document/p137/a273344,
pp. 136-138.
106.	 Id., available at: https://www.documentcloud.org/documents/2695498-

html#document/p19/a273447, p. 19.
117.	 The results of Mr. Dominguez-Valdivia’s death review have not been
released yet. The account of his death in this report is based on ODO
inspection reports.
118.	 2012 Adelanto ODO Inspection, available at: https://www.
documentcloud.org/documents/2644420-2012-09-18-Adelanto.
html#document/p4/a266231, p. 4
119.	 Mr. Dominguez-Valdivia arrived at ADF on November 26, 2011 and
although the 2012 ERO inspection notes are vague, it is believed
that he was transferred to the hospital on February 16, 2012;

Bamenga-Irene.html#document/p20/a272807, p. 19; “INS Detention

2012 Adelanto East ERO Inspection, available at: https://www.

Standard, Medical Care,” available at:

documentcloud.org/documents/1692931-adelanto-east-2012-ero-

https://www.ice.gov/doclib/dro/detention-standards/pdf/medical.pdf.
107.	 Bamenga, available at: https://www.documentcloud.org/
documents/2695498-Bamenga-Irene.html#document/p20/a273346,
p. 20.
108.	 Id., available at: https://www.documentcloud.org/documents/2695498Bamenga-Irene.html#document/p10/a273421, p. 10.
109.	 On July 25, 2011, Ms. Bamenga submitted two health services request
forms. The first stated that, “I am not being given the full dosage
of my medications. Two of the six different meds are meant to be
take [sic] twice a day and so far I have only be given 1 dosage in the
morning.” The second stated that the problem was “[s]hortness of

inspection.html#document/p110/a237926, p. 111.
120.	 2012 Adelanto East ERO Inspection, available at: https://www.
documentcloud.org/documents/1692931-adelanto-east-2012-eroinspection.html#document/p110/a237926, p. 111.
121.	 Id.
122.	 Id.
123.	 The Adelanto Detention Facility (ADF) is also referred to as the
Adelanto Correctional Facility (ACF).
124.	 2012 Adelanto ODO Inspection, available at: https://www.
documentcloud.org/documents/2644420-2012-09-18-Adelanto.
html#document/p4/a266231, p. 4.

breath at night especially when laying down, palpitations when laying

125.	 Id.

down. Dizziness upon standing up when palpitation and shortness of

126.	 Although the facility was marked as not having met standards at the

breath occur.” Bamenga, available at: https://www.documentcloud.

end of the review, this was changed to having met standards in the

org/documents/2695498-Bamenga-Irene.html#document/p77/

final memo to the Los Angeles Field Office Director. 2011 Adelanto

a273348, p. 77; Id., available at: https://www.documentcloud.org/

East ERO Inspection, available at: https://www.documentcloud.org/

documents/2695498-Bamenga-Irene.html#document/p78/a273349,

documents/1692930-adelanto-2011-ero-inspection.html#document/

p. 78.

p161/a248078, p. 161; Id, available at: https://www.documentcloud.

Fatal Neglect: How ICE Ignores Deaths in Detention

27

Endnotes cont.
org/documents/1692930-adelanto-2011-ero-inspection.
html#document/p162/a248079, p. 162.
127.	 2011 Adelanto East ERO Inspection, available at: https://www.

140.	 U.S. Border Patrol apprehended Mr. Rivera on October 1, 2011 at a
checkpoint in Arizona. At the time, Mr. Rivera disclosed that he had
recently been discharged from the Los Angeles County Medical Center

documentcloud.org/documents/1692930-adelanto-2011-ero-

in California and had been diagnosed with a stomach infection. In

inspection.html#document/p91/a248080, p. 91.

addition, he complained of stomach pains and nausea for which he

128.	 Chronic obstructive pulmonary disease was also listed as a

refused medical attention. This is documented in his Form I-213,

contributing factor in Mr. Ramirez’s death, although it was not

Record of Deportable/Inadmissible Alien; however, no documented

considered an underlying cause; DHS, Death Investigation for

proof exists demonstrating that this information was relayed to EPC

Victor Ramirez-Reyes, Feb. 29, 2012, available at: https://www.
documentcloud.org/documents/2695510-Ramirez-Reyes-Victor.
html#document/p1/a272787, p. 1 [hereinafter “Ramirez-Reyes.”]
129.	 Non-compliance with PBNDS, Medical Care, section (V)(F) which
requires “[a]ccountability for administering or distributing medications
in a timely manner and according to licensed provider orders;”
Ramirez-Reyes, available at: https://www.documentcloud.org/
documents/2695510-Ramirez-Reyes-Victor.html#document/p12/
a272788, p. 12.
130.	 Non-compliance with PBNDS, Medical Care, section (II)(5), which
requires timely follow-up to health care requests; Ramirez-Reyes,
available at: https://www.documentcloud.org/documents/2695510Ramirez-Reyes-Victor.html#document/p12/a272790, p. 12.
131.	 ODO did not name these as deficiencies, but expressed concern
that the staff nurse was unaware of 2010 guidelines for basic life
support and failing to respond to the situation by using an AED
machine; Ramirez-Reyes, available at: https://www.documentcloud.

upon his transfer on October 2 to await removal proceedings.
141.	 Rivera, available at: https://www.documentcloud.org/
documents/2695515-Rivera-Romero-Mauro.html#document/p12/
a272698, p. 13.
142.	 Rivera, available at: https://www.documentcloud.org/
documents/2695515-Rivera-Romero-Mauro.html#document/p45/
a272664, p. 45.
143.	 2010 El Paso Service Processing Center ODO Inspection, available at:
https://www.documentcloud.org/documents/1865586-el-paso-spc-tx2010-odo-inspection.html#document/p9/a263165, p. 5.
144.	 2011 El Paso Service Processing Center ERO Inspection, available at:
https://www.documentcloud.org/documents/1865569-el-paso-spc-tx2011-ero-inspection.html#document/p83/a263156, p. 83.
145.	 2012 El Paso Service Processing Center ERO Inspection, available at:
https://www.documentcloud.org/documents/1865570-el-paso-spc-tx2012-ero-inspection.html#document/p102/a263147, p. 102.
146.	 Non-compliance with PBNDS, Medical Care, section (II)(2) requiring

org/documents/2695510-Ramirez-Reyes-Victor.html#document/p13/

that health care needs be met in a timely and efficient manner; Rivera,

a272792, p. 13.

available at: https://www.documentcloud.org/documents/2695515-

132.	 2011 Elizabeth ERO Inspection, available at: https://www.
documentcloud.org/documents/1735436-elizabeth-nj-2011-eroinspection.html#document/p117/a267558, p. 117.
133.	 Id., available at: https://www.documentcloud.org/documents/1735436elizabeth-nj-2011-ero-inspection.html#document/p117/a267555, p.
117.
134.	 Id, available at: https://www.documentcloud.org/documents/1735436elizabeth-nj-2011-ero-inspection.html#document/p117/a267555.
135.	 2012 Elizabeth ODO Inspection, available at: https://www.
documentcloud.org/documents/2647144-2012-ODO-InspectionElizabeth-NJ.html#document/p20/a267550.
136.	 Id, available at: https://www.documentcloud.org/documents/2647144-

Rivera-Romero-Mauro.html#document/p13/a272700, p. 13.
147.	 Non-compliance with PBNDS, Medical Care, section (II)(2) requiring
that health care needs be met in a timely and efficient manner; Rivera,
available at: https://www.documentcloud.org/documents/2695515Rivera-Romero-Mauro.html#document/p13/a272701, p. 13.
148.	 The Joint Commission, Sentinel Events Policy, available at: http://
www.jointcommission.org/assets/1/6/CAMH_24_SE_all_CURRENT.
pdf (defining a sentinel event as a patient safety event, not primarily
related to the natural course of the patient’s illness or underlying
condition, that reaches a patient and results in death, permanent
harm, severe temporary harm, or certain other specified harms).
149.	 Lives in Peril.

2012-ODO-Inspection-Elizabeth-NJ.html#document/p5/a267552.
137.	 Id, available at: https://www.documentcloud.org/documents/26471442012-ODO-Inspection-Elizabeth-NJ.html#document/p19/a267551.
138.	 2012 El Paso SPC ODO Inspection, available at: https://www.
documentcloud.org/documents/2644418-El-Paso-SPC-TX-2012-ODOInspection.html.
139.	 DHS, Death Investigation for Mauro Rivera-Romero, 2011, available at:
https://www.documentcloud.org/documents/2695515-Rivera-RomeroMauro.html#document/p4/a272643, p.4 [hereinafter “Rivera.”]

Fatal Neglect: How ICE Ignores Deaths in Detention

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