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ICE Delivers Deficient Death Reviews on Dia de los Muertos — #DetentionKills Transparency Initiative FOIA Journal, Vol. 22-1:
After more than three years of unlawful stalling, ICE reveals secret mortality findings in 13 in-custody deaths. The results don’t match the story ICE’s leaders and contractors tell.
Over three years ago, the #DetentionKills Transparency Initiative (DKTI) sought records from ICE about deaths in custody. This past week, on Dia de Los Muertos, ICE responded. The response was 196 pages comprised of 13 Mortality Reviews completed by IHSC between January 1, 2017 and May 8, 2019.
The individuals whose deaths are reviewed in ICE’s responsive records are as follows:
Huy Chi Tran
Ronal Francisco Romero
Carlos Armando Mejia-Bonilla
Olufbunmi Toyin Joshua
Osmar Epifanio Gonzalez-Gadba
Atulkumar Babuhai Patel
Agustina Ramirez Arreola
This request came after Jean Jimenez’s family and Estate sued ICE and other agencies in federal court for failing to respond at all to any of their Freedom of Information Act (FOIA) requests for information and records about Jean’s death. Though Jean’s family resolved their claims for damages, their FOIA suit for records remains pending more five years after his death in May 2017.
As part of this FOIA lawsuit, the ICE Health Services Corps (IHSC) released dozens of policies governing provision of care to people imprisoned by ICE. (#DetentionKills partner organization CREEC, which, along with partners in the Fraihat litigation have challenged ICE’s provision of medical care to people in custody, generously helped index those policies so they’re more easily accessible, because IHSC failed to provide a table of contents or Index. Cf. 5 U.S.C. 552(a)(2) (requiring a publicly accessible policy index).
ICE’s in-custody death policy at the time required the agency to conduct a Mortality Review:
ICE’s FOIA responses in the Chaverra litigation revealed how IHSC discharges this responsibility. Buried within the barrage of IHSC policies was a previously unreleased IHSC Operations Memorandum on Mortality Reviews. It sets forth specific, non-discretionary, time-limited requirements on various actors within ICE’s medical system following an in-custody death, or, if the ICE Director requests a Mortality Review in such instances, a death 30 days or less after the person leaves ICE custody.
Goals & Methods of the FOIA Request
We wanted to see how IHSC carried out this mandatory task in the wake of other in-custody deaths. So we FOIA’d and waited.
As part of our Forensic Intelligence FOIA model, we also filed a series of more compact requests aimed at defining the universe of records we could expect to receive in response to our FOIA for Mortality Reviews. We asked ICE to list its open death investigations as of the day we filed our Mortality Reviews FOIA. ICE denied our request, claiming that revealing that information would cause foreseeable harm to any open investigations the agency had underway when we made the request.
We also asked ICE’s parent agency, the Department of Homeland Security (DHS) for the same information—i.e., which investigations into in-custody deaths ICE had open on May 8, 2019. In March of 2022 — nearly three years later — we got our answer from ICE:
ICE had four open death investigations, corresponding to deaths that occurred on (1) November 15, 2018 at GEO’s Northwest Detention Center in Tacoma, Washington (Russian hunger striker Mergensana Amar); (2) November 30, 2018 at Baker County (FL) Sheriff Department (Russian national Guermann Volkov, who “vomited feces” prior to death) 3) April 3, 2019, at CoreCivic’s Florence Service Processing Center in Florence, Arizona (54 year-old alleged Mexican national Abel Reyes-Clemente); and (4) on May 3, 2019, at La Paz County, Arizona (21 year-old alleged Indian national Simratpal Singh).
NB: We use “alleged” to denote nationality because of ICE’s high error rate in the detention and deportation of U.S. citizens.
By combining and comparing the time periods and FOIA responses in our Mortality Reviews FOIA with our Open Death Investigations FOIA, we can then review ICE’s own affirmative disclosures to see how complete the responses to both might be, and how well the agency discharged its obligations under ICE post-death policies and FOIA.
In response to our Mortality Reviews FOIA, ICE says it completed a total of 13 Mortality Reviews between January 1, 2017, and May 18, 2019, when the agency acknowledged receiving our FOIA request.
In response to our Open Death Investigations FOIA, ICE says it had a total of 4 Open Death Investigations on May 8, 2019, when we sent the request.
ICE’s Detention Deaths public reading room reveals an important missing record: The Mortality Review of Efrain Romero de la Rosa, who died experiencing what the UN Special Rapporteur describes as “torture” inside a solitary confinement cell at CoreCivic’s Stewart Detention Center in July 2018.
Further widening the aperture beyond ICE’s time-limited deaths page (which it created after Congress mandated death reviews be completed and reported within 90 days), AILA’s collection of other ICE death announcements documents reveals that ICE’s Dia de los Muertos FOIA response did not provide Mortality Reviews for the following humans who perished in ICE custody between January 1, 2017, and May 8, 2019:
24 human beings passed away in ICE custody between January 1, 2017, and May 8, 2019. 4 of those deaths were under “open” investigation as of May 8, 2019. Of the remaining 20 Mortality Reviews that should exist, ICE released only 13 to our project.
A review of the records ICE did release points to a possible explanation: The Mortality Reviews are a coverup and a sham.
Take, for instance, the very first review in this week’s Mortality Reviews records set, which we’ve annotated in DocumentCloud. The Mortality Review Committee’s assessment of the care Huy Tran received found his providers at Eloy:
Failed to enter the prescribed behavioral health medication in to records system, resulting in Tran being denied that medication;
Documented potentially dangerous changes in Tran’s health but failed to make a referral or change monitoring;
Referred Tran to segregation for mental health observation but failed to communicate the specific monitoring required to CoreCivic guards;
Failed to obtain signed, informed consent for administering Mr. Tran psychotropic medication for an entire week;
Altered the timing for Mr. Tran’s medications in the middle of his decompensation, resulting in him missing those doses;
Did not realize the changes in Mr. Tran’s mental state required a higher level of care and referral; and
Failed to monitor the observation by CoreCivic guards of Mr. Tran in solitary closely enough to realize that the one guard assigned to protect up to 40 individuals was not conducting the required checks or accurately documenting them.
The conclusion the Mortality Review Committee reached after listing the “weaknesses” above?: [Behavioral Health] care at [Eloy] was within safe limits of practice.”
According to a report from the House Government Oversight Majority Staff, CoreCivic guards failed to monitor him and falsified their logs, as they have done in the cases of Jean Jimenez, Efrain de la Rosa, and others. Mr. Tran had been a Lawful Permanent Resident of the United States since 1984.
The ICE Mortality Reviews #DetentionKills Transparency Initiative received will be submitted to a team medical professionals familiar with professional obligations medical reviewers have in conducting mortality reviews. This independent review team will specifically assess the representation, as in Mr. Tran’s case, that care besotted with “weaknesses” documented above can comport with “safe limits of practice.”
No psychological autopsy accompanies any of the records relating to an in-custody suicide. ICE’s Mortality Review policies require a psychological autopsy. #DKTI will be pursuing these gaps in a variety of FOIA request and litigation contexts.
FOIA appeals to ICE and DHS are forthcoming, and we’ll share those when they’re ready.
In the coming weeks, we’ll annotate the 12 remaining Mortality Reviews and compare them against other extant official government records, like facility inspections and contract discrepancy reports, to assess the validity of ICE’s claim that it:
Conducts a comprehensive, agency-wide review of all deaths;
Provides all detained immigrants with 24-7 access to high-quality care; and
Takes seriously the life and safety of the humans it hunts, cages, and excludes.