ICE detainee deaths could have been prevented, ACLU report says

Most of the deaths of detainees in the custody of Immigration and Customs Enforcement from 2017 to 2021 could have been prevented if the agency had not failed to provide proper medical care, the American Civil Liberties Union and other human rights organizations said in a report released Tuesday. The latest report builds on existing ACLU research into ICE detention deaths.

“The vast majority of deaths that occurred in immigration detention could have been prevented if ICE had provided adequate medical care to people in detention,” Eunice Cho, a lead author of the report and a senior staff attorney with the ACLU National Prison Project, said.

The 76-page report, a project of the ACLU, Physicians for Human Rights and American Oversight, examines the deaths of 52 people in ICE custody from Jan. 1, 2017, to Dec. 31, 2021. ICE detainees are typically awaiting immigration hearings, sometimes for years, including those seeking asylum in the U.S.

The report’s authors analyzed more than 14,500 pages of documents obtained through Freedom of Information Act requests, state public record requests and civil litigation. The deaths and their corresponding records, including ICE’s investigatory reports, were then reviewed by six medical experts, according to the report.

The medical experts, which include an assistant professor of medicine at Columbia University; the co-director of the internal medicine residency health equity track at UT Health in San Antonio; and an associate professor of medicine and director of the Yale Center for Asylum Medicine at Yale School of Medicine, concluded that of the 52 deaths reported in the five-year period, 49 were preventable, likely preventable or possibly preventable, the report said. Three deaths were deemed not preventable.

“I really saw significant deviations from what is really considered standard of care,” said Dr. Chanelle Diaz, an assistant professor of medicine at Columbia University Medical Center who reviewed the detainee records for the report.

ICE did not immediately respond to a request for comment about the report. The agency has said that it “takes very seriously the safety of those in its custody and remains committed to ensuring that all those in its custody reside in safe, secure and human environments. Comprehensive medical care is provided from the moment individuals arrive and throughout the entirety of their stay.”

The agency has said no detainee is denied emergent care.

In one case highlighted in the report, which analyzed a series of ICE documents, Jesse Jerome Dean Jr., a 58-year-old man from the Bahamas, died from an undiagnosed gastrointestinal hemorrhage while detained at the Calhoun County Jail in Michigan. Although Dean was unable to eat, lost about 20 pounds in three weeks and had severe nausea, the detention’s medical staff did not take him to be seen by a physician, the report said citing ICE’s investigation into Dean’s death. Dean collapsed on the floor twice and was moved to a medical observation unit the night before he died, the report said, but was still not referred to a doctor or an advanced practice provider.

A nurse claimed to have checked on Dean during the night, but according to ICE’s own reports on his death, the nurse never did, and Dean died the next day on the way to the hospital.

The Calhoun County sheriff’s office did not respond to a request for comment about Dean’s death.

In another case, Kamyar Samimi, a 64-year-old man from Iran, died in December 2017 after staff at the Aurora Detention Center in Colorado discontinued his medication-assisted treatment for opioid use disorder that he had been prescribed more than two decades after being exposed to opium as a treatment for pain in Iran, the report said citing details included in ICE’s investigation into Samimi’s death. Without his prescription, Samimi went into withdrawal and “deteriorated rapidly, experiencing nausea, repeated vomiting to the point of vomiting blood, and seizures, until he passed away sixteen days later,” the report said.

Diaz said Samimi’s case was a “completely preventable death.”

“His death was specifically related to the fact that he was detained. His treatment was stopped and his acute withdrawal was not treated and it just really was clear to me just that he was treated really inhumanely by the medical team,” she said.

The detention center’s operator, GEO Group, did not respond to a request for comment about Samimi’s death.

Michele Heisler, the medical director at Physicians for Human Rights and a medical expert reviewer of the report, said it was striking how “egregious” the cases were in terms of providing “poor medical care, wrong medical care, inadequate medical care, and the lack of monitoring.”

The report includes descriptions and a timeline of some of the detainee deaths and why doctors believed based on this information that a death was potentially preventable.

“This is kind of the tip of the iceberg of just how deficient medical care is” in ICE facilities,” Heisler said.

The report concluded that “ICE’s current oversight and accountability mechanisms regarding death in detention are critically flawed and do little to prevent future deaths.” The authors pointed to issues including destruction of evidence, falsification of medical information, and failure to interview important witnesses.

It also found the medical staff made incorrect or incomplete diagnosis in 88% of the reviewed cases, and provided incomplete, inappropriate or delayed treatment and medication in 79% of the cases. The report said ICE facilities also failed to provide basic precautions during the covid pandemic, when 18 people died in 2020.

In one case documented in the report, medical experts found that Emigdio Abel Reyes Clemente died in April 2019 in a solitary medical isolation cell at the Florence Service Processing Center in Arizona from undiagnosed and untreated bacterial pneumonia “after the detention facility medical staff assumed, without testing, that he had influenza,” the report said, citing ICE’s investigation into his case. The facility did not prescribe antibiotics, provide oxygen or take a chest X-ray, the report said. Reyes Clemente died two days later. An independent autopsy by the Pinal County Medical Examiner included in the report said that the man had bacterial pneumonia and tested negative for influenza, and that Reyes Clemente died of complications from heart disease, diabetes and liver cirrhosis.

“I think what our investigation shows is that it really peels back what ICE has done to really hide the details of the really, abject failure of medical care in immigration detention from the public’s view,” Cho said.

CoreCivic, the processing center’s operator, did not respond to a request for comment about Reyes Clemente’s death.

The report also said that ICE has seen an increase in deaths by suicide in facilities that lacked adequate mental health care, mismanaged psychiatric medication and had insufficient staffing.

Jean Jiménez, a 27-year-old man from Panama, died by suicide in May 2017 at the Stewart Detention Center in Georgia. Staff at the facility were aware that Jiménez had been diagnosed with schizophrenia and he told behavioral health practitioners four times that his medications were not effectively controlling his symptoms, which included auditory hallucinations and impulsivity, the report said, citing ICE’s investigation into the death. The report said staff at the facility did not respond to his concerns in a timely manner and in one instance scheduled a follow-up tele-psychiatry appointment two weeks later. An ICE memorandum linked in the report said that Jiménez’s symptoms were becoming progressively worse, his medication regimen was not treating his symptoms, and that the detention center did not have the appropriate psychiatric resources to properly manage his care.

The memo concluded that it would have been best practice to refer Jiménez to an in-patient psychiatric facility or another detention facility with adequate psychiatric resources.

Jiménez told ICE repeatedly about the suicidal thoughts he kept having as the medication he was given failed to control his symptoms, Karina Kelley-Jiménez, Jean Jiménez’s older sister, told NBC News. “There’s no way that they didn’t see this coming.”

The detention center’s operator, CoreCivic, did not respond to a request for comment about Jiménez’s death.

Kelley-Jiménez remembers her brother as “just so full of life.”

“He had so many years of life ahead of him. Extremely charismatic. A very talented young man,” said Kelley-Jiménez, adding that her brother was a musician and wanted to study engineering.

She said her brother was diagnosed with schizophrenia and bipolar disorder, and his life began to spiral.

“My brother was someone with acute mental illness,” Kelley-Jiménez said. “He should have been in a mental health facility all along. After he got detained by ICE, he spent about three months there, and 19 days of the three months were in solitary confinement, where he took his life.”

Kelley-Jiménez said that ICE failed her brother and that staff “should have increased his medication when he asked and they never did,” and did not provide adequate access to mental health professionals.

“People that have a real chance to leave these hellholes, move on with their lives and contribute to society, love their families and fulfill their life’s potential and purpose are dying premature and preventable deaths under their watch,” she said.

Heisler said the report ultimately calls for ICE to dismantle its detention program.

Until then, the advocates called for measures such as releasing people with medical and mental health vulnerabilities from custody and ensuring prompt medical screening of detained immigrants to identify those who face increased medical and mental health risk.