ICE Detention Center Inspections Covered Up Fatal Medical Missteps

Members of the immigrant rights group Puente Arizona protest the May 20 death of Jose De Jesus Deniz-Sahagun, who had been held in an immigration detention facility.
Members of the immigrant rights group Puente Arizona protest the May 20 death of Jose De Jesus Deniz-Sahagun, who had been held in an immigration detention facility.
Elizabeth Stuart

U.S. Immigration and Customs Enforcement has been aware for years that poor medical care in its detention centers is contributing to in-custody deaths, but the agency systematically has overlooked it, according to a new report by a coalition of advocacy groups.

The American Civil Liberties Union, Detention Watch Network, and the National Immigrant Justice Center examined 17 death reviews from 2010 to 2012 and found that ICE officials determined that detention facilities had failed to meet its own standards for medical care in nearly half of cases (24 people died during this time period, but ICE released documents for only 17).

Despite the fact that ICE determined in these death reviews that there had been wrongdoing, the agency gave detention centers top marks on their annual inspections, researchers found.

When Pablo Gracida-Conte died of cardiomyopathy while incarcerated at the Eloy Detention Center in 2011, for example, ICE’s Office of Detention Oversight concluded in its death review that medical staff could have saved his life if they had provided “the appropriate medical treatment in a timely manner.”

For four months before his death, Gracida-Conte, a 54-year-old Mexican migrant, complained persistently of extreme upper abdominal pain and shortness of breath, according to the report. A guard noticed that vomited after every meal.

“It should not have taken a medical professional to see that he was a very ill man, but even the medical professionals in this case failed to respond,” said Jennifer Chan, associate director of policy at the National Immigrant Justice Center, who co-authored the report.

In its death review, ICE determined detention center officials should have considered Gracida-Conte’s condition “urgent” and immediately referred him to a cardiologist after an electrocardiogram came back abnormal. Instead, officials delayed his treatment so he could attend a court hearing, noting that if he remained in custody, he would then be referred to a cardiologist. He died four days later.

Despite the conclusions made in the death review, however, when it came time for the Eloy Detention Center’s annual inspection, ICE did not identify any problems. ICE inspectors “claim that people at Eloy are seen for sick call in a timely manner and sick call slips are effectively and expediently triaged,” according to the report.

Inspectors said Gracida-Conte’s death was the first “to ever occur” at the facility.

But, according to ICE’s own records, Gracida-Conte was the 10th person to die at the Eloy center since 2003.

Since then, four more people have died, including Jose De Jesus Deniz-Sahagun, whose 2015 death sparked months of protests, inspiring Congressman Raúl Grijalva to petition the Department of Justice to conduct an investigation.

Chan called the detention center, which has not failed an inspection since 2006, the “deadliest” in the United States.

In response to the report, ICE spokeswoman Yasmeen Pitts O’Keefe pointed out that the agency has implemented a number of reforms since 2010, including simplifying the process of authorizing referrals to outside providers and is resolved to continue improving conditions in detention centers.

During fiscal year 2015, ICE spent more than $195 million on medical and dental care for detainees.

“ICE takes the death of any individual that occurs in the agency’s custody very seriously,” she said. 

Read the full report:


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