Deadly Failures: Preventable Deaths in U.S. Immigration Detention

Executive Summary

Since January 1, 2017, Immigration and Customs Enforcement (ICE) has reported that 68 people have died in its custody. This number does not include detained people who ICE released immediately prior to their deaths, which ICE has admitted reduces the number of reported deaths, and allows the agency to avoid accountability requirements.[1] These deaths raise serious concern about continued, systemic problems with medical and mental health care provided in immigration detention facilities, and the absence of accountability or consequences faced by facilities where detained people have died. ICE currently detains, on average, approximately 38,000 people each day in a network of approximately 130 detention facilities nationwide. Congress, however, recently increased ICE’s budget to detain 41,500 people on a daily basis for FY 2024, at a cost of $3.4 billion.[2]

This report, a joint project of the American Civil Liberties Union (ACLU), Physicians for Human Rights (PHR), and American Oversight, provides a comprehensive examination of the deaths of 52 people whom ICE reported to have died in its custody between January 1, 2017 and December 31, 2021. Our analysis is based on a review of over 14,500 pages of documents obtained from the Department of Homeland Security (DHS) and ICE through Freedom of Information Act (FOIA) requests; from local government agencies through state public record act requests; and from civil litigation. Report analysis also incorporates the review of ICE’s own investigatory reports into deaths in custody by independent medical experts, as well as interviews with two family members of people who died in ICE detention during the studied period.

Deadly Failures exposes the ways in which the Department of Homeland Security’s (DHS) internal oversight mechanisms have failed to conduct rigorous investigations, impose meaningful consequences, or improve conditions that cause immigrants to die in ICE detention. Based on independent medical expert reviews of deaths, the report further examines the ways in which systemic failures in medical and mental health care in ICE detention have caused otherwise preventable deaths.  

Summary of Findings

Key findings from our study include:

• ICE’s current oversight and accountability mechanisms regarding death in detention are critically flawed and do little to prevent future deaths.
  • ICE’s detention death investigations have allowed the destruction of evidence, have failed to interview key witnesses, and have omitted key inculpatory facts.
    • In at least two different cases, ICE released key detained eyewitnesses from custody immediately before investigators could speak to them, and investigators did not further attempt to make contact with these eyewitnesses. For example, ICE released detained eyewitnesses from custody mere hours before—and even during—investigator facility visits regarding the deaths of Ben Owen and Efrain de la Rosa. 
    • In at least two cases, ICE allowed detention facilities to destroy or overwrite video evidence critical to its investigations into detention deaths. Detention facilities destroyed video evidence highly relevant to investigations into the deaths of Roxsana Hernandez and Gourgen Mirimanian.
    • ICE’s investigatory reports omit critical facts that may embarrass, or suggest fault by, detention facilities or ICE in cases of detainee death. For example, ICE investigatory reports failed to disclose that internal oversight staff had ignored reports of dangerous conditions in the death of Efrain de la Rosa. ICE investigators also chose to omit evidence that the Kay County Detention Center failed to accurately translate Maria Celeste Ochoa de Yoc’s requests for medical attention. Because Kay County staff did not speak Spanish, they interpreted Ochoa’s statement that “she felt like she was dying” as suicidal ideation, placing her in solitary confinement under suicide watch, instead of providing her proper treatment for liver failure. Ochoa died soon after.

• ICE lacks standardized criteria for autopsies and autopsy reports in cases of detention deaths, leading to inconsistent and potentially unreliable results.

• DHS and ICE investigations into detention deaths exclude analysis of key structural factors that have led to the deaths of detained people, and fail to require systemic changes that would prevent future deaths in custody. Detention death investigations typically focus on and assign blame to the lowest-level employees involved, but fail to address facility-wide policies and practices, and do not consider those who have the most authority to address these factors. Investigators also frequently fail to make recommendations for policy changes that would prevent similar deaths in the future.

• ICE’s oversight process has failed to result in meaningful consequences for detention facilities, including those whose conditions have caused the greatest number of deaths.
  • Although Congress has legislated that ICE cannot expend funds on detention facilities that have failed two consecutive agency inspections, no facility has lost a detention contract or failed an ICE inspection in the period covered by this report, even where ICE’s death reviews have found multiple violations of detention standards.
  • To the authors’ knowledge, ICE has issued financial penalties against detention facilities on only three occasions out of the 67 deaths that have taken place between 2017 and June 2024, the date of this report’s publication. These financial penalties, however, had little impact on contractors’ bottom line, as ICE soon after expanded the scope of its detention contacts at the facilities in question.

• Systemic failures in medical and mental health care have caused preventable deaths in ICE detention.
  • The overwhelming majority of deaths likely could have been prevented if ICE had provided clinically appropriate medical care. Medical experts concluded that of the 52 deaths reported by ICE between January 1, 2017 and December 31, 2021, that 49 deaths (95 percent) were preventable or possibly preventable if appropriate medical care had been provided. Only three deaths were deemed not preventable.
    • Medical experts considered a death to be preventable where the person’s life could have been saved or the outcome could have been different with appropriate medical care; a death was considered possibly preventable where there was a reasonable possibility that the person’s life could have been saved or the outcome could have been different with appropriate medical care.

• ICE detention medical staff made incorrect or incomplete diagnoses in the overwhelming majority of cases of death. In 88 percent of the 52 death cases reviewed, ICE detention medical staff made incorrect, inappropriate, or incomplete diagnoses. For example:
  • Jesse Jerome Dean, Jr. died in ICE custody from an undiagnosed gastrointestinal hemorrhage after his detention at the Calhoun County Jail in Michigan. Although Dean was unable to eat, lost almost 20 pounds in three weeks, and suffered from severe nausea, the detention facility’s medical staff never even referred Dean to be seen by a physician. The night before Dean’s death, medical staff moved him to the medical observation unit after he had collapsed to the floor. But no one checked on him that night: surveillance footage showed that “for at least 2 hours and 45 minutes throughout her shift, [the nurse] was reclining in the nursing station chair with her feet propped up, texting on her cell phone.”[3]
  • Emigdio Abel Reyes Clemente died of undiagnosed and untreated bacterial pneumonia, after the detention facility medical staff assumed, without testing, that he had influenza. The detention facility never prescribed antibiotics, provided oxygen, or took a chest x-ray. Two days later, Reyes Clemente died in a medical isolation cell.

• ICE detention medical staff provided incomplete, inappropriate, or delayed treatment and medication. In 79 percent of the 52 death cases reviewed, ICE detention medical staff provided treatment that did not meet evidence-based medical standards, was inadequate to resolve the medical issue, or was unreasonably delayed. Medical staff also failed to appropriately manage necessary medication, and prescribed contraindicated medications. For example:
  • Carlos Mejia-Bonilla struggled to receive his prescribed medication for cirrhosis while detained at the Hudson County Department of Corrections and Rehabilitation in New Jersey. Ultimately, the facility’s careless approach to medication management may have proved fatal. Mejia-Bonilla died of gastrointestinal bleeding four days after the detention facility prescribed him with naproxen, which is contraindicated for patients with cirrhosis.
  • Wilfredo Padron died of a heart attack at the Monroe County Detention Center in Florida after detention facility medical staff failed on multiple occasions to conduct an EKG test or refer him to a doctor when he complained of radiating chest pain and elevated blood pressure. 
  • Medical staff at the Aurora Detention Center in Colorado discontinued medication assisted treatment for opioid use disorder that Kamyar Samimi had been prescribed and had used for over two decades, putting him into withdrawal. Samimi deteriorated rapidly, experiencing nausea, repeated vomiting to the point of vomiting blood, and seizures, until he passed away sixteen days later.

• ICE detention facilities failed to provide timely and appropriate emergency care. In 40 percent of the 52 death cases reviewed, ICE detention facilities failed to provide timely emergency health care or operable emergency equipment.
  • Anthony Alexander Jones died alone of a heart attack at the Adams County Detention Center in Mississippi, after medical staff failed to check on him in the medical unit waiting room. Medical staff did not discover him until 45 minutes after his heart attack and waited another 10 minutes before they initiated CPR. An ambulance did not arrive until 42 minutes after first being called.
  • After staff discovered that Nebane Abienwi had suffered a stroke at the Otay Mesa Detention Center, it took 50 more minutes for emergency medical services to arrive and provide the required higher-level care, because the on-call medical provider at the detention facility did not respond to a nurse’s request for authorization to call an ambulance.
  • After Huy Chi Tran was found unresponsive in his cell due to cardiac arrest at the Eloy Detention Center, medical staff failed to place automated external defibrillator pads in the correct position on his chest, and had no backup pads when the equipment failed to properly adhere to his body.
  • Confusion over who was responsible for calling an ambulance among staff at the El Valle Detention Facility in Texas caused a half-hour delay in calling an ambulance for Elba Maria Centeno Briones after her oxygen levels dropped dangerously low.

• ICE detention facilities have faced repeated and increased deaths by suicide due to their failure to provide adequate mental health care, manage psychiatric medication, and ensure sufficient staff.
  • Efrain de la Rosa deteriorated for weeks and ultimatelydied by suicide at the Stewart Detention Center in Georgia after medical staff failed to ensure that he receive his prescribed antipsychotic medication used to treat his schizophrenia. After he died by suicide, nursing staff falsely recorded their administration of psychiatric medication.
  • Mergansana Amar died by suicide at the Northwest Detention Center in Washington within hours after ICE officers told him that the Board of Immigration Appeals had denied his case and that ICE had scheduled his deportation to Russia. Although Amar had exhibited several warning signs of suicidal ideation the previous days, ICE failed to provide him mental health support upon providing him news of his impending deportation. Moreover, had ICE officers fully informed Amar of his rights while providing him news of his deportation, he might have known that he could have further appealed his case and requested a stay of removal to prevent deportation during his appeal.

• ICE detention facilities have failed to provide necessary interpretation and translation to detained people who do not speak English.
  • The nurse on duty at the La Paz County Adult Detention Facility in Arizona confirmed that the only words Simratpal Singh seemed to know in English were “court” and “lawyer,” but decided that he did not exhibit any suicidal ideations based on her observation of his appearance alone. The facility provided no security rounds of Singh’s cell to ensure suicide prevention. Three days after he was detained at the facility, Singh died by suicide.

• ICE detention facilities failed to take basic precautions during the COVID-19 pandemic, depriving detained immigrants of basic protections such as soap and masks during a time where no vaccine or antiviral treatment existed. ICE transferred detained people from facilities with COVID-19 outbreaks across the country, further spreading the virus, and delayed or failed to release medically vulnerable people from custody in time for them to avoid the virus.

• James Thomas Hill, a 72-year-old man, died of COVID-19 after contracting the virus at the Immigration Centers of America Farmville in Virginia, during a time when no vaccine or antiviral medications for the virus were available. Although an immigration judge had ordered Hill removed in May 2020, ICE did not set his deportation flight back to Canada until two months later. This delay proved fatal: Hill soon contracted COVID-19 after ICE transferred dozens of people from detention facilities in Florida and Arizona that had recently experienced COVID-19 outbreaks.

• ICE detention facilities have consistently failed to provide adequate medical and mental health staff who are trained and licensed to ensure patient health and safety. Health care providers in detention facilities frequently provide care outside their licensed scope of practice. ICE detention facilities rely heavily on the lowest-level providers, and often prevent detained patients from receiving care from doctors. In 44 percent of the 52 detainee death cases reviewed, records indicated serious staffing issues, including shortages, improper training, or care outside the scope of practice.

• Kamyar Samimi died after medical staff at the Aurora Detention Center in Colorado discontinued medication assisted treatment for opioid disorder. At the time of his death, the facility had only one doctor responsible for the entire facility and left multiple medical positions vacant. Samimi never received a health appraisal by either a physician or registered nurse during his detention. ICE’s own investigation concluded that “clinical supervision was inadequate to assure adherence to provider orders and necessary and appropriate care.”[4]
  • Jean Jimenez died by suicide at the Stewart Detention Center in Georgia after failing to receive timely mental health care treatment. At the time of Jimenez’s death, Stewart provided tele-psychiatry to detained people for six hours a week—a level of less than 20 precent of required staffing, with backlogs of 10-12 weeks for mental health services.

• ICE detention staff falsified or made improper or insufficient documentation of patient checks and provision of medical care in 61 percent of detainee death cases.  
  • Detention center officers at the Baker County Detention Center in Florida falsified records to show that they had conducted wellness checks of Ben Owen in the hours before he was discovered to have died by suicide. The officers, moreover, reported that their method of logging security rounds without making visual contact of detained people was consistent with their training and an accepted practice at the facility.

Key Recommendations

To the Department of Homeland Security:

ICE’s reliance on immigration detention is unnecessary, expensive, and deeply harmful. We strongly urge that ICE dismantle the mass immigration detention machine. ICE should phase out the immigration detention system, invest in community-based social services instead of placing people in detention, and avoid surveillance of immigrants as an alternative to detention. As ICE shifts from a detention-based system, ICE should adopt the following recommendations to reduce the number of people held in detention and prevent deaths of people in detention:

• Issue a directive ensuring the prompt release from ICE detention of people with medical and mental health vulnerabilities. It should include a presumption of release for people with medical and mental health vulnerabilities, ensure prompt medical screening of detained immigrants to identify those who face increased medical and/or mental health risk in detention, and set forth procedures to ensure the prompt release of these individuals from custody.

• Immediately release from ICE detention people who have prevailed in their immigration cases before an Immigration Judge, instead of continuing detention upon ICE’s administrative appeal.

• Require the release of people from and prohibition of the use of ICE detention facilities upon a finding by DHS’s Office of Civil Rights and Civil Liberties that health and safety standards are not being met, or cannot be met.

• Prohibit solitary confinement. Until it is fully prohibited, issue and implement a directive barring solitary confinement for anyone who has a disability, has a diagnosed mental health condition, is pregnant, postpartum, or caring for a child, or has identified or is known or perceived to be LGBTQ+ or gender non-conforming.

• Ensure meaningful consequences for detention facilities that have caused deaths of detained people. Promptly terminate ICE detention contracts for facilities with any death resulting from substandard medical and mental health care, including deaths that occur within 30 days of release from custody.

• Undertake full, comprehensive, and unbiased investigation of deaths in detention. Ensure preservation of all relevant evidence, and ensure that interviews of detainee witnesses are conducted and included in death investigations and ensure protection from retaliation and deportation of detainee witnesses. Require that all detention facilities provide investigators unimpeded access to staff and contractors, and require full physical autopsies and full-spectrum forensic toxicology screen for all people who die in custody, and psychological autopsies for any apparent suicides.

• Provide timely, quality medical and mental care to all in ICE detention, with the caveat that increased funding for detention has not resulted in improvement of health conditions for those in detention.
  • Ensure that all detention facilities, whether care is provided by ICE Health Service Corps (IHSC) or another entity, are bound by IHSC directives and standards for the provision of medical and mental health care through contract modifications or uniform updates to all detention standards. Violations of these directives and standards shall be immediately remedied.
  • Ensure that all detention facilities are bound by, and in compliance with, the 2016 Performance Based National Detention Standards.
  • Ensure routine collection and reporting on the number of individuals in detention with medical vulnerabilities, including chronic conditions, communicable and non-communicable diseases, and severe mental illness.
  • Ensure that all detention facilities provide sufficient and adequate levels of health care staffing by tracking and publishing vacancy rates for medical and mental health staff at each facility.
  • Require that detention population levels do not exceed medical and mental health staffing levels for the facility at any time.
  • Ensure that all ICE detention facilities strictly prohibit medical and mental health professionals from practicing outside the scope of licensed practice, and improve access of those in detention to physicians, nurse practitioners, and physicians’ assistants.
  • Ensure that all healthcare and detention staff are trained in and routinely participate in emergency (code) drills.
  • Ensure that all facilities are required to provide medical interpretation at all encounters, and that metrics of rates of medical interpretation use are publicly reported.
  • Create and enforce protocols for strict documentation and reporting of acute medical situations.  
  • Create and enforce protocols for immediate consultations 24/7 with physicians on call. ​​
  • Ensure that all ICE detention facilities provide translation and interpretation for all medical encounters, including the ability to request medical care, in accordance with Performance-Based National Detention Standards (PBNDS) standards. 
  • Ensure that all ICE detention facility medical staff are trained in and utilize screening tools for the Clinical Institute of Withdrawal Assessment (CIWA) and Clinical Opiate Withdrawal Symptoms (COWS).
  • Create, enforce, and audit protocols and implementation of regular wellness checks, every 15 minutes, to engage with the person in custody, evaluate and treat any urgent health needs, and attempt de-escalation if needed. ​​ 
  • Create and enforce protocols for routine and frequent inspection of medical equipment​​.
  • Perform regular quality audits of medical documentation and create mechanisms to identify gaps in management, errors, and other practice failures.

• Comply with Requests for Public Records Under the Freedom of Information Act. Comply with FOIA requests more expeditiously, apply a “presumption of openness” at the outset when evaluating records, and share with the requester information about the scope of the agency’s search.

To the Department of Justice:

• Ensure full implementation of the Death in Custody Reporting Act (DCRA). Ensure that DHS fully complies with its reporting obligations under the DCRA, and releases annual reports on key data trends of deaths in DHS custody.

​​​​To Congress:

• Substantially reduce funding for immigration detention. Increase funding for community-based social support and legal representation programs as alternatives to detention that are far more effective and humane.
  • Conduct rigorous oversight of detention conditions, including through hearings with senior government officials. Request a GAO investigation into ICE’s failure to prevent the deaths of detained people, including those who have died in custody and those who have died, while hospitalized, within 30 days of release from ICE custody.
  • Require that ICE track, publicly report, and investigate the death of any detained person who died while hospitalized or within 30 days of release from ICE custody.
  • Require that ICE make publicly available on its website, as a matter of course, detainee death reviews, Healthcare and Security Compliance Analyses, Mortality Reviews, Root Cause Analyses, autopsy reports, and psychological autopsy reports, regarding all individuals who have died in ICE custody or those who have died while hospitalized, or within 30 days of release from ICE custody. Ensure disclosure of cause of death. Make only those redactions necessary to comply with federal privacy laws.
  • Require monthly publication of all medical and mental health vacancies by facility, as well as average length of time for detained patients to be seen by a physician, physician’s assistant, or nurse practitioner.
  • Require that ICE make publicly available within 30 days any corrective actions taken to enforce contract terms for the provision of medical or mental health care in ICE detention facilities or any other contract violations that may have contributed to a death in custody, as well as ODO inspection reports, OPR detainee death reviews, and IHSC mortality reviews.
  • Hold ICE accountable for meeting specific standards with regard to provision of care and data reporting.
  • Pass the Dignity for Detained Immigrants Act (H.R. 2760/S. 1208), and the End Solitary Confinement Act (H.R. 4972/S. 3409).

To State and Local Governments: 

• Pass legislation to prohibit intergovernmental services agreements between state or local agencies and the federal government for civil immigration detention, and to prevent contract modifications to expand detention.
  • Pass local ordinances or legislation to prohibit the physical expansion of detention facilities that would allow increased capacity for detention.
  • Pass legislation that provides causes of action against for-profit detention facilities that deviate from contractually binding standards.
  • Require and ensure that local facilities that detain people in ICE custody expeditiously release and provide records relevant to deaths in detention for release under FOIA.
  • Pass legislation prohibiting 287(g) agreements and collaboration with ICE in civil immigration enforcement.

1 Nina Bernstein, “Officials Hid Truth of Immigrant Deaths in Jail,” New York Times, January 9, 2010, https://www.nytimes.com/2010/01/10/us/10detain.html [https://perma.cc/E9AH-Y7YL]; Andrea Castillo & Jie Jenny Zou, “ICE Rushed to Release a Sick Woman, Avoiding Responsibility for Her Death. She Isn’t Alone,” LA Times, May 13, 2022, https://www.latimes.com/world-nation/story/2022-05-13/ice-immigration-detention-deaths-sick-detainees [https://perma.cc/8J7D-VH8M]. ACLU NPP has also filed a pending FOIA request regarding these “hidden deaths,” see ACLU of Southern California. “ACLU Files Lawsuit Against ICE for Withholding Documents Related to Practice of Releasing People from Custody Prior to Imminent Death,” July 12, 2022, https://www.aclusocal.org/en/press-releases/aclu-files-lawsuit-against-ice-withholding-documents-related-practice-releasing.

2 ICE, “ICE Facilities Data,” April 15, 2024, https://www.ice.gov/doclib/detention/FY24_detentionStats04252024.xlsx

3 “Fiscal Year 2024 Homeland Security Appropriations Bill.” House Republicans Appropriations, accessed May 10, 2024, https://appropriations.house.gov/sites/evo-subsites/republicans-appropriations.house.gov/files/documents/FY24%20Homeland%20Security%20-%20Bill%20Summary%20Updated%206.21.23.pdf [https://perma.cc/MN9E-7RT7].

4 ICE Office of Professional Responsibility, “Detainee Death Review Report: Jesse Dean,”  August 19, 2021, 22 n.151, https://www.documentcloud.org/documents/24656097-part-1-selected-death-review-reports-and-related-documents-of-ice-detainees#document/p1682/a2558299.

5 Creative Corrections,“Detainee Death Review: Kamyar Samimi: Medical and Security Compliance Analysis,” March 14, 2017: 63,  https://www.documentcloud.org/documents/24656097-part-1-selected-death-review-reports-and-related-documents-of-ice-detainees#document/p1943/a2558311.