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A Mexican Immigrant In ICE Custody Died After Officials Waited More Than Seven Hours To Transfer Him To A Hospital

"This is a horrible breach of standards of care," one public health expert said.

Posted on October 17, 2019, at 5:19 p.m. ET

Gregory Bull / AP

A detention center holding immigrant detainees waited more than seven hours to transfer an ailing 37-year-old Mexican man to a hospital, where he died from bleeding in his brain, according to internal documents obtained by BuzzFeed News that reveal previously undisclosed details about the death and raise new questions about the man’s treatment.

“In the absence of ICE providing an explanation, a seven-hour delay in responding to this patient does not seem consistent with adequate care,” said Marc Stern, a public health expert and faculty member at the University of Washington. “This may have been a preventable death.”

The details uncovered by BuzzFeed News provide a rare glimpse of the inner workings of the detention centers contracted by Immigration and Customs Enforcement (ICE) at a time when the agency is under fire from Democrats for its record-setting expansion of the system, which relies primarily on private and local county jails. By September, ICE was detaining around 55,000 people — an unprecedented number that has since dropped to just over 50,000 in recent days.

The undocumented immigrant man in ICE custody at the McHenry County Adult Correctional Facility in Illinois, Roberto Rodriguez-Espinoza, died on Sep. 10 at a local hospital where doctors treating him issued a preliminary cause of death as a subdural hematoma — the eighth death of the last fiscal year ending on Sept. 30.

When ICE officials reported the death publicly two days later to Congressional officials and the media, they noted that Rodriguez-Espinoza had indicated alcohol abuse and explained why he was taken to a hospital: “On Sept. 7, facility staff observed Rodriguez-Espinoza acting confused and the facility’s physician ordered Rodriguez-Espinoza transported to the Northwestern Medicine Woodstock Hospital emergency room in Woodstock, Illinois, for further evaluation due to his confusion and history of alcohol consumption.”

But an internal ICE detainee notification sent shortly after the death and obtained by BuzzFeed News provides new details from Sept. 7, including a previously unknown timeline of Rodriguez-Espinoza’s transfer to a hospital.

The documents show that officials waited more than seven hours to take Rodriguez-Espinoza to the hospital after he first began exhibiting symptoms.

On that day, at around 3:30 p.m., Rodriguez-Espinoza began acting “confused and unfamiliar with his surroundings,” the report states. Medical staff at the facility re-evaluated him and took his vitals before transferring him to a separate part of the medical unit for more attention. It was at this point, the staff held him for observation.

“Medical staff indicated that Rodriguez-Espinoza could be detoxing and commenced an alcohol detoxing treatment per the physician’s order,” the report states. The internal report details that it wasn’t until 10:47 p.m. that the doctor at the facility ordered him taken to a local hospital due to “his altered mental status as a result of reported history of alcohol abuse.” The hospital transferred him to another medical center the next morning, where he was diagnosed with a brain hemorrhage and later died.

An ICE report on his death was published online a day after BuzzFeed News sent a series of questions to the agency regarding the circumstances of the death earlier this week. An ICE spokesperson said the reports are posted when they are ready and that the timing in this instance did not coincide with the questions on the matter.

The public report reiterated the timeline, including additional details, like the fact that at 3:30 p.m. on Sept. 7, after an officer noted that Rodriguez-Espinoza was acting confused, the facility’s licensed practical nurse felt that Rodriguez-Espinoza’s behavior was consistent with potential alcohol withdrawal. The nurse initiated protocols for treatment of alcohol withdrawal and advised he be transferred for medical observation. The public report indicates he received a pill.

The public report, which differs slightly on timing, states that by 9:45 p.m., the facility’s doctor ordered Rodriguez-Espinoza to be taken to the hospital after being informed of the case. He arrived at the hospital an hour later, the public report states.

“He should have been immediately sent to the hospital,” said Homer Venters, a former chief medical officer for the New York City jail system who has closely studied care in correctional facilities. “This is a horrible breach of standards of care.”

Stern, the University of Washington faculty member, told BuzzFeed News that the licensed practical nurse appeared to make a medical diagnosis in the case, an action that is beyond the scope of their license.

“That should be investigated,” he said.

In response to a series of questions from BuzzFeed News, ICE officials said it was committed to the health and welfare of all those in its custody.

“Fatalities in ICE custody, statistically, are exceedingly rare and occur at a small fraction of the rate of the US detained population as a whole,” an agency spokesperson said.

ICE said Rodriguez-Espinoza was a documented Latin Kings gang member with a 2016 burglary conviction and 2008 theft conviction in Chicago.

The facility Rodriguez-Espinoza where had been detained, the Mchenry County Adult Correctional Facility, was previously investigated by the Department of Homeland Security’s Civil Rights and Civil Liberties division. The jail houses local inmates and federal detainees, including those held for the US Marshals Service. The county sheriff generates $85 per day per inmate in revenue from the federal government.

Both Stern and Venters raised multiple issues with the details provided in the internal death document and the public report. One key issue: Both reports make no mention of whether the detention center screened, monitored, or treated Rodriguez-Espinoza for alcohol withdrawal after he told them he drank a six-pack of alcohol every day when he was initially detained on Sept. 3. It’s at this point that medical staff would have been able to provide treatment and begin monitoring him for potential signs of withdrawal, experts said.

The public report also states that a nurse reviewed his medical screening that day and no further actions were noted.

“We know that alcohol withdrawal is sometimes fatal, so that is why in every detention setting — in jail or a prison — we must ask and use a universal screening for risk factors of alcohol withdrawal,” Venters said. “With the full knowledge that he is at a high likelihood for alcohol withdrawal, they decided they weren’t going to do anything.”

ICE’s own detention standards state that those providing care for immigrant detainees must screen for alcohol abuse and treated, if necessary. The Bureau of Prisons lists guidelines for its facilities to immediately screen all inmates for alcohol use disorders and to quickly treat those with suspected withdrawal symptoms with various medications.

“These details raise the concern that a very common and potentially fatal health problem was either ignored or inadequately treated in this patient and it raises concerns about the safety and risk of death for other people in ICE custody,” Venters added.

Jails across the country have long had issues with alcohol withdrawal — a recent study in Washington found that nearly 20% of deaths among women inmates were due to alcohol or drug withdrawal.

Venters said that because alcohol withdrawal is prevalent in prisons and a common cause of preventable death, it’s essential that detention officials screen for it immediately. The symptoms tied to alcohol withdrawal — like psychosis — can mimic other serious medical issues, like bleeding in the brain.

“These are potentially fatal but treatable emergencies, all of which require immediate transfer to the hospital,” he said.

It wasn’t until the fourth day in custody, Sept. 7, that both the internal and public reports make note of any treatment or assessment for alcohol withdrawal for Rodriguez-Espinoza.

Stern, who previously assisted the Department of Homeland Security (DHS) in investigations of immigrant detention facilities, said detention staffers needed to screen, monitor, and potentially treat him for alcohol withdrawal on the first day he appeared in custody.

“On Sept. 7, the sudden change in his condition required evaluation by a qualified medical professional, but instead he was evaluated by a licensed practical nurse practicing outside the scope of their legal license and that failure along with an unexplainable delay of more than six hours [to the hospital] may have resulted in his death,” he said. “It requires further investigation.”

ICE officials and the local Mexican consulate failed to find family members connected to Rodriguez-Espinoza to notify them of his death.


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