For weeks, Jesse Dean, a 58-year-old Bahamian immigrant being detained in Michigan by ICE, complained of stomach pain so severe he couldn’t eat. Over the course of 27 days, he lost 17 pounds, and he told deputies and medical staff he was going to die.
Days later on Feb. 5, 2021, he did die when he went into cardiac arrest and medics couldn’t revive him. A medical examiner would later determine that Dean died of a bleeding ulcer and hypertension while in ICE detention at the Calhoun County Correctional Facility in Battle Creek, Michigan.
ICE documents obtained through the Freedom of Information Act by the ACLU of Michigan and shared with BuzzFeed News show how Dean’s medical concerns, including his rapid weight loss, weren't thoroughly assessed. The 1,590 pages of documents related to his death also reveal that ICE’s own investigation found that CCCF staff failed to comply with nine of the immigration agency's 2019 National Detention Standards and identified eight other areas of concern surrounding the care Dean received.
ICE did not immediately respond to a request for comment.
In its report on Dean's death, ICE’s External Reviews and Analysis Unit said that these deficiencies and areas of concern were noted for informational purposes only and should not be construed as having contributed to his death. However, ICE emails show that at least two investigators believed there was a “very direct correlation” between Dean's cause of death and the health concerns he raised in detention.
ICE relies on a sprawling network of contracts worth millions of dollars with private for-profit companies and existing jails like Calhoun County’s to detain immigrants. Corizon Health, a Tennessee-based company, has a contract with Calhoun County to provide medical care to its detainees. By March 21, 2021, days after receiving Dean’s autopsy report, ICE had decided to transfer all chronic care medical patients out of CCCF to other facilities.
The Calhoun County Sheriff's Office, which oversees the jail Dean was detained at, and Corizon Health did not respond to requests for comment.
Ramis Wadood, an attorney with the ACLU of Michigan who is coordinating advocacy efforts for Dean’s family, said Dean’s medical records, sudden weight loss, and blood pressure readings should have put medical staff at the jail on notice that there was something seriously wrong.
“Instead, the nurses and medical professionals at the jail ignored his complaints or gave him over-the-counter medication,” Wadood said. “He was denied very basic medical needs.”
Dean complained of severe abdominal pain or related issues at least 27 times during his monthlong detention at CCCF. The investigative report includes a list of his documented complaints to medical staff and shows how his concerns escalated from gas pain to being dizzy and unable to stand.
“I do not have an appetite. I try to eat but can't. The stomach pains are horrible. I beg you to please put me on a liquid diet,” Dean wrote in a Jan. 13, 2021, medical complaint.
Thirteen days later, Dean wrote in another medical complaint that he had been in severe pain for three weeks and needed emergency medical care.
“I cannot sleep PLEASE HELP!” Dean wrote.
"I feel like I am going to die," Dean told medical staff on Jan. 30, 2021.
On Feb. 5, 2021, the day Dean died, he told staff he felt weak, ill, and dizzy and that he had never before felt that level of pain.
At one point, a licensed practical nurse told Dean that “repeated and excessive requests” could result in him getting a citation for “interfering with staff duties.” But he told jail employees he felt like he was going to die at least two times and begged for emergency care, telling nurses his family would pay for an emergency room visit if money was an issue.
Wadood said Calhoun County deputies and Corizon Health staff were indifferent to Dean's concerns or careless with his condition. The treatment is especially concerning, Wadood said, because the US government has a special responsibility to provide medical care to people it detains, who don't have the freedom to seek it on their own.
“It highlights the total lack of agency the government detention infrastructure imposes on people, where even if you know you're facing a medical emergency it's still in the hands of jail officers and medical staff who just don't care about [your] health,” Wadood said. “It's clear that ICE and Calhoun County are incapable of [meeting] even the most basic healthcare needs of people in [their] custody.”
On Thursday, the ACLU of Michigan sent letters to the Calhoun County Sheriff's Office and ICE, calling on the two agencies to terminate their contract with CCCF.
“ICE's own documents ... make it clear that Mr. Dean, a Black man from the Bahamas, would not have died if CCCF had provided him with even basic levels of medical care,” the letters state.
In 1997, Dean, who was working as an air traffic controller in the Bahamas and had an 8-year-old son, was convicted of conspiracy to import cocaine, importation of cocaine, and use of a communication facility in the commission of a felony, among other charges, and sentenced to 30 years in prison. Twenty-two years into his sentence, in 2019, ICE lodged a detainer notice against Dean that let the facility where he was imprisoned know the agency wanted to detain him once he was released.
On Dec. 31, 2020, when he was released from the Northlake Correctional Facility in Baldwin, Michigan, Dean was taken into ICE custody and sent to the Calhoun County Correctional Facility.
His brother, Clarence Dean, remembers Dean as being a stickler for time who would often pick up his nieces and nephews on the weekend to go on drives for ice cream or fishing in the Bahamas when he lived there.
During the 26 years Dean was imprisoned, both of their parents died and his son grew up without him. As his freedom drew nearer, Dean told his brother he wanted to spend time with his remaining family and open a fishing business when he got back home.
During the weeks he spent in ICE detention, Clarence recalled, Dean spoke to him over the phone and asked him for help on multiple occasions, telling his brother he was dying, his once-strong authoritative voice sounding weak.
The family called ICE and the Embassy of the Commonwealth of the Bahamas over his health concerns repeatedly to no avail, Clarence said.
“I felt helpless because, from what I experienced, nothing was really done,” Clarence said. "He said, ‘Clarence, if you don't get me out of here I'm going to die here.’”
On Feb. 3, 2021, two days before Dean died, the vice counsel of the Embassy of the Commonwealth of the Bahamas said the travel documents that would allow him to be deported from the US would be sent overnight and asked ICE about his health. Calhoun County jail staff told ICE that Dean had been taking all of his prescribed medication, was “doing well,” and was having his vital signs assessed by medical personnel at least twice a day, an ICE report stated.
But the next evening, Dean told deputies he was short of breath and felt dizzy when he stood up, according to ICE’s investigation. A sergeant at the jail told deputies to take Dean to an observation area.
At 9:42 p.m., a registered nurse took his vital signs, finding nothing abnormal but failing to conduct an abdominal examination despite Dean complaining of stomach pain, the report states. No one checked on Dean until 7:34 a.m., about 10 hours later, despite the fact that he was supposed to be under medical observation, according to the report.
The nurse told ICE investigators she checked on Dean again after her initial assessment, but surveillance footage showed she did not, the report found.
“In fact, for at least 2 hours and 45 minutes throughout her shift [the registered nurse] was reclining in the nursing station chair with her feet propped up, texting on her cellphone,” the report states.
Several times during the night of Feb. 4, 2021, Dean tapped on the cell window asking deputies to help him get water because he was unable to get up. For the most part, deputies ignored him, according to the report, and one deputy told Dean that he couldn’t give him a glass but that Dean could get water from the sink in his cell. Eventually, Dean struggled to lift himself up using the concrete partition in front of the toilet for support, walked to the toilet area hunched over, and drank out of the sink.
On the morning of Feb. 5, 2021, the report states, Dean said he was so weak he could barely “get up” and told the licensed practical nurse he could only eat the cereal and milk he was given for breakfast and had been surviving off tuna.
A physician's assistant told Dean he was concerned because Dean wasn't showing any signs that pointed to any specific medical issue. Minutes later, a vital-sign check revealed low blood pressure.
About three hours after that, a deputy told medical staff that “something did not seem right,” and a nurse entered the room with an electrocardiogram machine while a deputy announced a medical emergency over the radio.
Dean had become unresponsive, his breathing erratic. By the time EMS workers took over, his blood pressure wasn’t measurable, the report states.
Once inside the ambulance, a deputy started CPR on Dean on the order of a paramedic. Eventually, however, CPR efforts “proved futile,” the report states, and Dean was pronounced dead.
Among the nine ICE National Detention Standards requirements that CCCF failed to comply with was one stating that every facility shall provide detainees with comprehensive, routine, and preventive healthcare, as well as hospitalization as needed within the local community.
In Dean's case, the report on his death notes that, even after recording two blood pressure readings that almost met the American Health Association's criteria for hypertensive crisis on Dec. 31, 2020, staff didn't notify a healthcare provider.
“Additionally, although it would have been prudent nursing practice, medical staff did not order blood pressure checks to monitor Dean's blood pressure or monitor him to ensure he was not suffering the side effects of severely elevated blood pressure,” the report states.
Furthermore, despite at least 27 complaints about stomach issues and him offering to pay for an emergency room visit, Dean was never sent to an outside hospital, investigators found.
“The facility medical staff was just basically not taking Dean seriously because his vital signs were normal and all of them maintained during interviews that their care of him was appropriate,” an internal email between ICE inspectors states.
Inspectors also found that Dean’s dramatic weight loss wasn’t properly logged and that a licensed practical nurse who treated him was working with an expired CPR certification.
ICE's National Detention Standards establish conditions of confinement, program operations, and management expectations for the agency's detention system. The standards were revised in 2019 and designed for non-dedicated ICE facilities, such as state and local jails that the US government contracts with to detain immigrants.
But in the documents the ACLU obtained via FOIA, ICE inspectors refer to the 2019 National Detention Standards as “a dumbed-down version of the 2000” ones. And in the email chain, another ICE investigator referred to them as “lipstick on a pig.”
In the report, internal emails between ICE investigators whose names and titles are redacted, but who appear to be contractors or consultants, note that Dean's cause of death in the medical examiner’s report “seems to have a very direct correlation to what Dean was complaining to medical staff about/experiencing over and over for at least a month before his death. Abdominal pain, appetite changes (his weight loss).”
The inspector noted that, because of the direct correlation between Dean's complaints and his cause of death, they believed there was zero chance of Corizon Health lawyers allowing them to speak with medical staff.
"It’s really sad and (2) it’s a really bad day for Corizon health," the email said.
Wadood, the ACLU attorney, said this is just one example of what happens at county jails throughout the US that detain immigrants for ICE. Local police and jails shouldn’t be in the business of locking up immigrants on behalf of the federal government, Wadood added.
“It's a racist, profit-driven attack on immigrants,” he said.