"Directly Contributed . . ."
Failures in GEO's medical care "directly contributed" to a 57 year-old asylum-seeker's death in the company's Folkston Facility, ICE found. Now ICE and GEO plan to nearly triple Folkston's Capacity.
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IHSC Mortality Review Finds Deficient Medical Care Directly Contributed to Jaspal Singh’s Death
ICE’s medical reviewers could not have been clearer: The care Jaspal Singh received at GEO’s Folkston Main ICE Processing Center in south Georgia “deviated beyond safe limits and directly contributed to his death,” according to the agency’s response to a Freedom of Information Act (FOIA) request I filed in March.
“The Mortality Review Committee (MRC) determined the care FMIPC provided Mr. Singh deviated beyond safe limits and directly contributed to his death.”
If you or anyone you know might be able to connect me with Mr. Singh’s surviving family members in New York City, I would greatly appreciate it. I have significantly more detailed records through FOIA litigation, and have been trying for nearly two months to share them with his surviving loved ones. The records discussed below are not part of the FOIA litigation and came separately.
Specifically, ICE found the evidence it reviewed showed GEO allows Licensed Practical Nurses (LPNs) to conduct sick call triage, which is outside the scope of practice for LPNs in Georgia.
IHSC’s MRC also found “Health staff did not consistently refer Mr. Singh to a higher level of care.” That’s MRCspeak for “providers should have done things they didn’t do.”
The agency’s detailed findings show multiple medical misses in the care Singh received — misses that could have kept him alive, if they had not occurred.
It is unclear whether anyone involved here was reported the out-of-scope practice to a Georgia licensing authority. Similarly unclear is whether Biden’s ICE levied a penalty through a Contract Discrepancy Report or requested restaffing or other contract changes based on the Mortality Review Committee’s findings, as has happened in other cases.
What is clear is that ICE has not updated its (now-archived) post-death statement about Mr. Singh’s death, which claims, falsely:
“All people in ICE custody receive medical, dental and mental health intake screening within 12 hours of arriving at each detention facility, a full health assessment within 14 days of entering ICE custody or arrival at a facility, and access to medical appointments and 24-hour emergency care. At no time during detention is a detained noncitizen denied emergent care.”
Mr. Singh died from being denied emergent care. Like so many before him, his survivors are victims of this mendacious post-death propaganda.
Emergency Failures
Public records work has a way of revealing where even the supposedly unbiased, science-based official Mortality Review plays at the margins. As we meticulously documented in last year’s Deadly Failures report, not only were 95% of all deaths in ICE custody likely preventable, the agency’s post-death investigations often failed to accurately and thoroughly collect and report the facts of those deaths—facts that could save lives in the future, avoid families losing loved ones, and prevent the trauma of losing a patient due to preventable systems failures from being inflicted on correctional medical staff.
Jaspal Singh’s death has all of these features. But there’s one in particular that feels really urgent to share, because it’s apparently about to get much worse in Folkston and imperil the lives of many more people.
ICE’s Story about the 911 Call
ICE’s preliminary death report and the IHSC Mortality Review both contain the statement that “At approximately 1:13 a.m.custody staff requested [EMS] via 911” while health staff performed CPR.
EMS arrived a 25 minutes later, ICE claims and other the records confirm
In the context of emergency response time for a cardiac arrest, 25 minutes is an eternity.
Medical professionals who save lives for a living will tell you there are periods of time (generally 4-6 minutes) within with an emergency response can meaningfully increase the chances of survival and recovery for patients. Every minute of delay after that window decreases your chance to live 7-10%, according to some estimates. And for cardiac emergencies like heart attacks, there is a “golden hour” within which drug interventions can prevent death.
Bottom line: ICE’s timeline reflects a significant delay between the alleged 1:13 a.m. 911 call and EMS’s arrival to Mr. Singh’s bedside at 1:38 a.m. that dramatically reduced his chances of survival.
The Rest of the Truth About the 911 Call
ICE’s story would be bad enough if it were true: The agency paid a for-profit prison company to detain people in a jurisdiction that’s 25 minutes away from the nearest emergency department, and the contractor can’t manage to respond to 911 calls for another 25 minutes. This means ICE and GEO are conspiring to imprison people nearly an hour away from an E.R.
But ICE’s story isn’t true. Not really. It’s only half-true.
Yes: Security personnel tried to call 911 at 1:13 a.m. Except the 911 operators with responsibility for Folkston did not receive GEO’s call until ten minutes later, according to Charlton County EMS records:
That’s because GEO’s 911 call didn’t go to the nearest dispatcher—Charlton County. Instead, it originally went to Clinch County’s 911 system, whose operators heard a call from “the prison” and figured it was a Georgia State prison in Waycross. Consequently, they transferred the call to Ware County EMS, where “the prison” is. Ware County finally figured out what was going on and transferred the call to Charlton County, where Folkston is.
You’re reading this right: GEO—one of the largest and most-favored detention contractors in ICE’s detention system and a critical node in the deportation machine—is incapable of ensuring its staff timely dial three numbers on a phone.
Not to make light of an incredibly tragic situation, but people literally teach household pets how to perform this simple function.
The Part IHSC Mortality Reviewers Left Out
Why didn’t GEO’s 911 call go to the Charlton County EMS line? I have confirmed that the answer lies with the company’s failure to heed the County’s repeated instructions to all residents that they would need to ensure their telephone service provider updated their 911 registration information with the County as a result of its transition to a more modern 911 system.
GEO didn’t do this. It used a Voice Over Internet Protocol system, Windstream, at the Folkston facility, preventing accurate call location by 911. Then the company’s local management didn’t follow instructions, so calls to 911 got transferred to other counties on multiple occasions before and after Singh’s death in April 2024. Indeed, 911 call transfers into Charlton County from other counties that reflect a disconnect and delay involving medical emergencies at Folkston continued through at least January of 2025, according to records I recently obtained.
By failing to fully investigate and note the delay in reaching local dispatch, IHSC, ICE, and GEO, neglected to include this vital detail in the Mortality Review. Overlooking it (and several other things we’ve learned about in our FOIA suit that are the subject of a forthcoming article) made it possible to move past this death in custody without addressing the problem.
The Impending Folkston Expansion
In 2019, the first Trump administration created a new set of watered down detention standards for jails and prisons that couldn’t meet the “Performance-Based” National Detention Standards the Obama Administration promulgated in 2011. Tellingly, the administration calls them the “2019 National Detention Standards.” That is, they removed the “performance-based” part of the inquiry. Not that it ever was based on performance anyway.
This week, ICE plans to reward GEO for its fatal non-compliance by nearly tripling the size of its detention operations in Folkston. A planned $102 million contract expansion will increase the a current capacity at Folkston from over 1100 folks by more than 1800 folks, bringing the facility’s total detention capacity to just under 3,000.
The proposal seems to line up with one that was on the table in 2022, which Asian Americans Advancing Justice-Atlanta and Project South vigorously opposed.
If passed, this will make GEO’s Folkston ICE prison the largest civil immigration detention site in the continental U.S. (so far.)
Charlton County Commissioners will case their votes this Thursday evening to allow the County Administrator to approve the contract expansion.
According to the agenda item associated with this vote, the contract amendment has already been executed.
The County Administrator notes this expansion will represent a “strategic augmentation of our county’s infrastructure.” Which is weird, because GEO (not the county) is going to own all of it, and everything they’re augmenting already exists:
What it seems like they’re doing is taking the prison space Joe Biden’s executive order terminating BOP’s private prison contracts left unused and putting the civilly detained immigrants Joe Biden wanted to keep in private prisons into that space.
Failing Up
The pattern here, as with other facilities, is familiar and tragic: A private company that makes its money by providing as cost-effective a service to the government as possible cuts corners. A person dies as a result. Instead of reducing the money it pays the contractor or penalizing the business for its failure to comply with standards, the federal government doubles down, paying it more, and putting more people in harm’s way in the process. It’s not a death penalty. It’s a death reward.
The local community, in turn, salivates at the imagined jobs and sales tax increase, refusing (conveniently) to consider the harms of the massive federal expansion, primarily because their leaders see the plight of people inside as separate and distinct from the economic needs of the public. The folks inside are not neighbors but strangers. They are, to the local faithful, children of a lesser God. In the insatiable push for detention dollars, the community’s leadership fails to consider the interconnections of what happens behind the wire with what goes on in the free world.
In the case of Charlton County, adding nearly 2000 residents to a population of 13,000 people will do at least one of two things, and probably both:
First, it will cause a severe strain on existing public health infrastructure that is not going to be accounted for in the incoming detention contracts, because nearly all of the money goes to the Wall Street-banked prison profiteers whose Chairman flies a private jet to the little towns his company takes over, and only trickles down to the community members through $30,000 administrative fees, jobs, and sales taxes. Charlton County residents will see increased 911 wait times, more mutual aid requests to other counties, like Camden, and more instances of illness and communicable disease (statistically 3x higher during COVID) as a result of dangerous conditions inside the 3,000-person GEOville they’ve invited.
Second, the strain on local resources will result in an intentional reduction in use by the facility. They’ll call 911 less, and that will lead more people to suffer and face increased chances of dying.
The prison has existed in Folkston since 1998.
About 22–23% of Charlton County residents live below the poverty line, nearly double the U.S. average (12.4%). In 1998, Charlton County’s poverty rate was 24.6%.
Approximately 36% of children in Charlton County live in poverty today, estimates show.
As Innovation Law Lab highlights in its 2024 Freedom to Thrive update, people supposedly benefitting from these jobs would rather lose a finger:
There are better ways to build sustainable, vibrant communities, and $100 million would go a long way toward achieving them.