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"ICE has a legal obligation to perform meaningful inspections at all detention facilities—and it is critical that it implement immediate reforms to guarantee deaths are prevented," says Detention Watch Network. (Photo: Getty)

New Report Shows How ICE Neglect Makes Detention a 'Death Sentence'

Routine inspections of ICE immigrant detention facilities ignored "egregious" violations of medical care standards, ACLU and other rights groups found

Nadia Prupis

U.S. Immigration and Customs Enforcement (ICE) failed to implement critical reforms to medical care standards at its migrant detention centers, which contributed to the deaths of eight people between 2010 and 2012, civil and human rights groups said on Friday.

A report published jointly by the ACLU, Detention Watch Network, and National Immigrant Justice Center (NIJC) found that routine inspections of ICE facilities before and after the deaths of eight detainees did not acknowledge "egregious" violations of medical care standards, and essentially swept those findings under the rug.

Fatal Neglect: How ICE Ignores Deaths in Detention highlights the human toll of ICE's inadequate inspections system, coming amid sustained outcry over U.S. detention facilities and mass deportation raids.

"Immigration detention in the United States should not be a death sentence," said Silky Shah, co-director of Detention Watch Network. "No matter where someone came from or how they arrived in the United States they must be treated with dignity and respect. ICE has a legal obligation to perform meaningful inspections at all detention facilities—and it is critical that it implement immediate reforms to guarantee deaths are prevented."

In one case that occurred at the Denver Contract Detention Facility (DCDF), a man named Evalin-Ali Mandza, a citizen of Gabon, died after medical staff were unable to assist him during a severe heart attack. The nurse on duty had not been trained how to use an electrocardiogram (EKG) machine and could not get a reading of his heart waves, while other staff prioritized filling out Mandza's transfer paperwork instead of dialing 911, waiting nearly an hour before calling an ambulance.

Mandza arrived in an emergency room at 6:58am, about an hour and a half after he was first discovered in distress in his cell. He was pronounced dead at 8:38am.

While conducting a special review of the case, ICE investigators determined that staff at the center were unfamiliar with DCDF's "Chest Pain Protocol," that the appropriate medications were not administered, and that there was an excessive delay in transferring Mandza to a proper facility, "all of which may have been contributing factors to Mr. Mandza's death," the agents wrote.

However, despite these failings, DCDF passed its Enforcement and Removal Operations (ERO) inspections—which determine whether detention facilities should be allowed to renew their contracts with ICE—both before and after Mandza's death. DCDF is operated by the notorious private prison firm Geo Group.

In fact, the ERO inspections include "worryingly inaccurate" summaries of his death, describing Mandza as being from Ghana, rather than Gabon, and claiming that he received "a timely and comprehensive medical and mental health screening and physical assessment, reported no significant past medical history and denied any significant risk factors for heart disease," the report states.

"ICE has a mandate to care for the people in their custody."
—Mary Meg McCarthy,
National Immigrant Justice Center
Since the time President Barack Obama took office, 56 people have died while in ICE custody, including six suicides and one death that came after an attempted suicide, the groups said. The report focuses on the eight deaths that occurred from 2010 to 2012 for which the Office of Detention Oversight (ODO) identified "non-compliance with ICE medical standards" as contributing factors, even after the Obama administration announced reforms to the detention centers as a response to outcry over unnecessary deaths in custody.

"There is no guarantee that people detained by ICE will leave detention alive, even under Obama administration policies that sought to decrease the number of people who die in ICE custody," said NIJC executive director Mary Meg McCarthy. "ICE has a mandate to care for the people in their custody. If detention centers cannot deliver prompt and quality medical care, ICE must implement corrective actions for those facilities or terminate contracts with facilities that do not comply."

The groups called on ICE to immediately reduce immigrant detention; improve delivery of medical care; ensure that inspections provide meaningful oversight; and increase transparency of inspections, deaths, and serious medical incidents.

"ICE's inadequate responses to these deaths show the stark gap between the promise and the reality of the Obama administration's immigration detention reform initiatives," said Carl Takei, staff attorney at the National Prison Project of the ACLU. "Instead of ignoring its own internal investigations, ICE must learn from its deadly errors. That means providing swift, quality medical care to those who need it, and overhauling the inspections process to stop more people from dying in detention. No family deserves to wonder if their loved one died a preventable death in ICE custody."

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