Immigrants held in Immigration and Customs Enforcement jails around the US received medical care so bad it resulted in two preventable surgeries, including an 8-year-old boy who had to have part of his forehead removed, and contributed to four deaths, according to an internal complaint from an agency whistleblower.
The allegations appear in an explosive Department of Homeland Security memo, obtained by BuzzFeed News, containing reports of detainees being given incorrect medication, suffering from delays in treating withdrawal symptoms, and one who was allowed to become so mentally unstable he lacerated his own penis and required reparative surgery.
The whistleblower reported that three people had died in ICE lockup after receiving inadequate medical treatment or oversight, and said official reports on a fourth person’s death were “very misleading.” One man died from meningitis following “grossly negligent” care. Another killed himself after saying he would do exactly that months earlier.
The allegations were laid out in a March 20 memorandum signed by Cameron Quinn, DHS’s officer for Civil Rights and Civil Liberties, and sent to top ICE leadership. The memo describes the whistleblower as someone within the ICE Health Service Corps, or IHSC, which provides medical care and oversight for detainees in the agency’s custody. BuzzFeed News does not know the person’s identity.
The whistleblower’s allegations were first received by the Homeland Security’s inspector general in April 2018. In July of that year, the inspector general sent the allegations to Quinn’s office, which will investigate the medical care and oversight IHSC provides at a time when President Donald Trump demonizes immigrants, detains them in record numbers, and enacts restrictive policies to keep them out of the US.
The allegations in the DHS memo, if corroborated, are a cry from someone working for ICE echoing what advocates, lawsuits, and other media reports have been saying for years: The medical care ICE provides and oversees for immigrants in private and local jails could be very bad.
This internal memo is one of a trove of remarkable secret documents — including emails, briefing materials, and draft reports — BuzzFeed News has obtained throughout 2019 uncovering how the Trump administration’s immigration policies were formed and executed, and how those policies confused or harmed people who sought to immigrate to the US. These records have revealed how immigrants locked up at the US border had no access to showers and how children were held in closed and crowded cells; that US border officials apparently pressured the asylum office to deny immigrants entry into the US; that a Texas detention center 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; and that in the final days before launching a controversial plan to deport Central American asylum-seekers to Guatemala, US officials scrambled to answer basic questions such as how people would get shelter, food, and social services.
BuzzFeed News has retyped the memo based on the whistleblower’s allegations, providing its full text, because metadata or other information in the original could compromise a source’s identity. BuzzFeed News redacted the names of most immigrants and ICE middle managers and their contact information.
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The memo describes what happened to 17 different immigrants who were held at nine facilities across six states, from Georgia to Washington. The allegations include:
That immigrants received incorrect medications. One man was given an antidepressant instead of an antipsychotic drug, likely worsening his condition. Another was given aspirin despite having thin blood — he nearly died.
That four immigrants endured severe withdrawal symptoms while in ICE custody. One man addicted to opioids was the subject of a “medication error”; two men with a benzodiazepine addiction saw delays in treatment; and one man “went into severe alcohol withdrawal and delirium and was admitted to the hospital in the intensive care unit.”
That IHSC leadership was unresponsive or even dishonest when confronted. They “failed to take appropriate action” when told of policy violations in 10 of the cases; “did not respond” to concerns about one case in which a detainee with non-Hodgkin’s lymphoma died under “deplorable” conditions; and were “erroneous” and told others to “hold off” when looking into several cases.
Overall, the memo says, the whistleblower alleged that IHSC “has systematically provided inadequate medical and mental health care and oversight to immigration detainees across the U.S.” The memo also says the inspector general will investigate the whistleblower’s allegation that they were retaliated against for raising the issues.
The memo was distributed within the agency — but a former senior ICE official who was aware of the allegations and the response told BuzzFeed News that ICE leadership appeared to not take a close look at the allegations.
“This is significant and very damning,” the former official, who requested anonymity in order to speak freely, said. “It blows up a lot of the ICE responses to allegations of poor medical care and about how it provides ‘the highest care of detainees.’ This makes that seem pretty false, which it is.”
An ICE spokesperson told BuzzFeed News in a statement it “is committed to ensuring that those in our custody reside in secure, humane environments and under appropriate conditions of confinement. The agency takes very seriously the health, safety and welfare of those in our care, including those who come into ICE custody with prior medical conditions or who have never before received appropriate medical care. It also uses a multi-layered inspections program to ensure its facilities meet a certain threshold of care as outlined in our contracts with facilities, as well as the National Detention Standards and the Performance Based National Detention Standards.”
The agency added that it maintains a detainee helpline and created an independent oversight body “to conduct independent oversight of detention conditions for ICE detainees through facility reviews and targeted site visits.” The agency also said senior officials have a council that examines serious issues, especially “critical incidents,” to make sure leadership knows about incidents and “and that all required investigation and coordination is undertaken in a timely fashion.”
ICE referred BuzzFeed News to DHS for questions about investigations into the memo’s allegations. DHS didn’t return a request for comment by deadline.
ICE has expanded the number of people it detains to record levels under Trump. Thousands of immigrants in its custody had passed their initial asylum screenings, a practice that in the past generally led to release from custody.
The peak came this summer when around 55,000 immigrants were in custody in local jails and private prisons across the country. To pay for it all, DHS had to transfer money earmarked for disaster relief and other efforts. In recent weeks, it has dipped to around 44,000 people in custody, still above the numbers during the Obama administration.
In the 2019 fiscal year, eight people died in ICE custody. The highest number of deaths in recent years came in the 2017 fiscal year, which included the end of the Obama administration, when 12 people died in ICE custody.
ICE’s sprawling detention system relies on a variety of methods to provide medical care. In some facilities, the agency provides it directly; in others, it has a few ICE employees assist private or public contractors; and in many, it oversees care provided by a contractor.
On Dec. 5, 2017, an 8-year-old boy’s mother told officials at the South Texas Family Residential Center in Dilley that her son’s earache had been worsening for two weeks, the memo says. Medical personnel diagnosed him with swimmer’s ear — an external ear infection — and gave him ear drops.
More than two weeks later, on Dec. 23, the boy had seizures and was taken to the hospital. Doctors there diagnosed him with Pott’s puffy tumor, a rare infection inside the skull that spread from the child’s ear to his facial bone and formed abscesses under the skull. To treat it, they surgically removed part of the boy’s frontal bone, which makes up the forehead.
The whistleblower said that ICE’s Medical Quality Management Unit analyzed the case, and found that the “inadequate medical care provided by [the detention center] was a contributory factor resulting in harm.”
The quality control unit’s report was forwarded to IHSC leadership who, the whistleblower said, “failed to take appropriate action."
“Allegedly, delayed medical care and misdiagnosis led to an infection that spread from the child’s ear to his facial bone, requiring a partial bone resection. According to the information provided, on December 5, 2017, the child’s mother first reported that her child had a progressively worsening earache for the past two weeks. The child was subsequently treated using nursing guidelines for Allergies/Fever/Pain, diagnosed with Swimmer’s Ear, and given ear drops. However, on December 23, 2017, the child was noted to have seizure activity and was transferred to the hospital where he was diagnosed with Pott’s Puffy Tumor with epidural and subdural abscess resulting in partial frontal bone resection. Further, the complainant alleged that MQMU performed an analysis of the case and found that the inadequate medical care provided by STFRC was a contributory factor resulting in harm. MQMU’s report was forwarded to IHSC leadership and MQMU requested findings and/or interventions from Clinical Services, yet IHSC leadership failed to take appropriate action.”
At the Stewart Detention Center in Lumpkin, Georgia, a man was “was reportedly bleeding through his skin and having vision changes,” the whistleblower said.
Instead of taking him to the hospital, a doctor continued his aspirin regimen — which thins the blood — for six days “despite [the detainee] having extremely thin blood,” the memo reads.
The result was “his coughing up large amounts of blood.” He was taken “in critical condition” to the hospital, where he was “not expected to survive.”
The quality control unit reviewed the case “and determined that that Asprin therapy may have caused harm that could have resulted in a fatality.”
“A delay in care,” the memo reads, “occurred after medical staff were notified of the detainee's critical lab result that should have resulted in immediate medical intervention.”
The quality control unit notified IHSC of “policy and procedure violations,” the memo reads, but “leadership failed to take appropriate action.”
“Allegedly, a delay in care occurred after medical staff were notified of the detainee’s critical lab result that should have resulted in immediate medical intervention. [Name withheld by BuzzFeed News] was reportedly bleeding through his skin and having vision changes. Despite having extremely thin blood, the physician allegedly kept him on aspirin regimen for six days, resulting in his coughing up large amounts of blood. [Name withheld by BuzzFeed News] was taken to the hospital in critical condition and not expected to survive. MQMU performed an analysis of the case and determined that that Asprin therapy may have caused harm that could have resulted in a fatality. The findings were forwarded to IHSC leadership for consideration of a root cause analysis, yet IHSC leadership failed to take appropriate action.”
And at the Eloy Federal Contract Facility in Arizona, the quality control unit notified the detention center’s psychiatrist several times about an immigrant’s “worsening psychosis-related symptoms, but the psychiatrist failed to treat him,” the memo reads.
The man “became so unstable that he lacerated his penis, requiring hospitalization and surgery.”
“According to the complaint, IHSC Medical Quality Management Unit (‘MQMU’) notified the facility psychiatrist several times about [Name withheld by BuzzFeed News] worsening psychosis-related symptoms, but the psychiatrist failed to treat him. [Name withheld by BuzzFeed News] allegedly became so unstable that he lacerated his penis, requiring hospitalization and surgery.”
The whistleblower referred to the case of Ronald Cruz, whose real name is Ronal Romero.
Romero came to the US in 2002 and lived for more than a decade in Missouri, where he found a community of friends and worked long hours at local restaurants in management positions, his family told BuzzFeed News.
In January 2016, he was convicted of driving under the influence and sentenced to two days in jail. Romero had a previous deportation order, and was picked up by ICE officials and sent back to Honduras.
Romero returned to the US because of the lack of opportunity and dangerous conditions in his home country, his family said. Romero was arrested by Customs and Border Protection officials on May 9, 2018, and was transferred to ICE’s Port Isabel Detention Center in Los Fresnos, Texas, on May 14.
By the next day, he began feeling sick and was in serious pain, according to a death review conducted by ICE’s Office of Professional Responsibility and obtained by the Project on Government Oversight.
He told the medical staff at the ICE facility that he had been receiving ear drops and antibiotics for an ear infection while he was in CBP custody. He was treated and given medication. But later that day he became confused, not knowing where he was, and had trouble waking up. He died the next day in a hospital.
His family did not hear from him while he was in ICE custody, they said, and his death came as a shock: “I cried deeply — I was like a father and an oldest brother to him,” said one of his brothers, who requested anonymity to speak freely. Their father, the brothers explained, had been murdered years ago in Honduras.
An autopsy performed by a private entity found that Cruz died of “sepsis complication with meningitis.” An internal death review conducted by ICE found the facility was compliant with its medical standards.
But the whistleblower called the medical care rendered to Cruz "grossly negligent" and challenged ICE’s review, alleging "that the mortality review committee was erroneous in concluding that the care rendered to Mr. Cruz was appropriate."
Cruz’s two older brothers have tried to convince people that the treatment their brother received was substandard.
“I’m grateful to the whistleblower for the strength to share this information in this way — it’s very sad what happened with my brother,” one of Cruz’s siblings told BuzzFeed News. “We believe he should be here with us. He was our little brother — he was everything to us. He was treated like an animal.”
Andrew Free, an immigration attorney in Georgia who represents Cruz’s family, said the existence of the memo was illuminating: “To hear an insider who has knowledge of government records saying this was grossly negligent is at once tragic, and oddly validating.”
“You should know,” his older brother said, “he was a hard worker who treated others well. He wasn’t a bad person. He was a good brother and a good friend.”
“According to the complainant, the medical care rendered to Mr. Cruz was ‘grossly negligent.’ Mr. Cruz’s preliminary cause of death on May 16, 2018 was ruled as meningitis. The complainant alleged that the mortality review committee was erroneous in concluding that the care rendered to Mr. Cruz was appropriate.”
The whistleblower alleged other widespread issues, such as detainees with psychological problems who were allegedly left without observation or provided incorrect medication.
Officials were notified about Efrain De La Rosa’s deteriorating mental health at Stewart Detention Facility in Lumpkin, Georgia. De La Rosa said on April 26, 2018, that he’d be dead in three days — he killed himself about 11 weeks later.
“Mr. De La Rosa’s preliminary cause of death was ruled a suicide. According to the complainant, IHSC leadership was notified of Mr. De La Rosa’s deteriorating mental health condition via SEN report on several occasions between April 25, 2018 and May 6, 2018. On April 26, 2018, a SEN report indicated that while on suicide watch, Mr. De La Rosa’s had stated to staff that he would be dead in three days. The complainant noted that several months earlier, IHSC leadership directed MQMU to cease reviewing SEN and segregation reports, despite concerns raised to IHSC leadership that this restriction could negatively impact detainee safety.”
De La Rosa has been the subject of investigations by the Intercept, the Atlanta Journal-Constitution, and the Young Turks. The Young Turks previously obtained an internal email sent to ICE’s current acting director, Matthew Albence, that relayed issues with ICE’s medical care.
These outlets reported that De La Rosa was diagnosed with schizophrenia and bipolar disorder and was being held in solitary confinement on suicide watch. He seemed obsessed with death. When he was transferred from a mental health facility to Stewart, the staff there didn’t register his issues. ICE said it is “committed to the health and welfare of all those in its custody and is undertaking a comprehensive agency-wide review of this incident.”
One man at Eloy Federal Contract Facility in Arizona was supposed to receive antipsychotic medication — but allegedly got antidepressants instead, the memo said, “which likely worsened his psychosis.” Senior leadership allegedly told colleagues “to ‘hold off’ on notifying IHSC Clinical Services unless and until the detainee became psychotic and suicidal again."
“Allegedly, [Name withheld by BuzzFeed News] was not treated appropriately for serious mental illness with psychotic-like symptoms. According to the complainant, MQMU warned IHSC senior leadership on two occasions about [Name withheld by BuzzFeed News] increased risk of adverse outcomes due to his auditory hallucinations and suicidal ideations. This allegedly resulted in [Name withheld by BuzzFeed News] not receiving anti-psychotic medication, despite the IHSC chief psychiatrist’s agreement with the MQMU’s findings and recommendation that [Name withheld by BuzzFeed News] receive anti-psychotic medication. Instead, [Name withheld by BuzzFeed News] received an anti-depressant which likely worsened his psychosis. The complainant further claimed that following MQMU’s second notification of inadequate mental health care and treatment, IHSC senior leadership allegedly advised MQMU to ‘hold off’ on notifying IHSC Clinical Services unless and until the detainee became psychotic and suicidal again.”
Four cases alleged forcible medication at two facilities: the El Paso Service Processing Center in Texas and the Jena/LaSalle Detention Facility in Louisiana. In these cases, the memo was concerned with “policy and procedure violations” around the injections. And each time, the memo said, “IHSC leadership failed to take appropriate action."
Both cases in Louisiana involved forced injections of Ativan, a medication that aims to treat patients with mental illness and agitation. There, a woman was sent to the hospital for erratic behavior and convulsions. When she returned, she was found eating toilet paper and Styrofoam. She was allegedly “given forced intramuscular injection of Ativan.”
“[Name withheld by BuzzFeed News] was sent to the hospital Emergency Room due to erratic behavior and convulsions. When she returned to the facility, she was observed eating toilet paper and styrofoam in the Medical Housing Unit (MHU). According to the complainant, [Name withheld by BuzzFeed News] was placed at higher than normal risk for mental status deterioration and given forced intramuscular injection of Ativan. Further, the complainant alleged that MQMU performed an analysis of the case and the findings included policy and procedure violations, which were forwarded to IHSC leadership for review and action, yet IHSC leadership failed to take appropriate action.”
“Allegedly, [Name withheld by BuzzFeed News] was forcibly medicated with multiple Ativan injections for repeated behavioral issues. Further, MQMU performed an analysis of the case and the findings included policy and procedure violations, which were forwarded to IHSC leadership for review and action, yet IHSC leadership dialed to take appropriate action.”
“According to the information provided, [Name withheld by BuzzFeed News] was observed with a sweatshirt around his neck and four correctional officers held him down while medical staff administered a haloperidol intramuscularly by force. According to the complainant, MQMU performed an analysis of the case and the findings included policy and procedure violations, which were forwarded to IHSC leadership for review and action, yet, IHSC leadership failed to take appropriate action.”
“Allegedly, [Name withheld by BuzzFeed News] was forcibly medicated for reported behavioral issues. MQMU performed an analysis of the case and the findings included policy and procedure violations, which were forwarded to IHSC leadership for review and action, yet IHSC leadership failed to take appropriate action.”
In at least four cases, detainees were allegedly not appropriately treated for their alcohol or opioid withdrawal.
“Allegedly, facility medical staff did not follow policies and procedures concerning withdrawal protocols for [Name withheld by BuzzFeed News] alcohol withdrawal. [Name withheld by BuzzFeed News] a stated during his intake screening that he consumed one bottle of vodka and two bottles of beer daily. [Name withheld by BuzzFeed News] subsequently went into severe alcohol withdrawal and delirium and was admitted to the hospital in the intensive care unit (ICU). Further, according to the complainant, MQMU performed an analysis of the case and the findings included policy and procedure violations, which were forwarded to IHSC leadership for review and action, yet IHSC leadership failed to take appropriate action.
“Allegedly, facility medical staff did not follow policies and procedures concerning withdrawal protocols for [Name withheld by BuzzFeed News] opioid withdrawal. According to the complainant, the detainee was not treated until MQMU staff called the facility following a review of a significant event notification (SEN). The detainee was subsequently found to be in severe benzodiazepine withdrawal and was admitted to the hospital. Further, the complainant alleges that MQMU performed an analysis of the case and the findings included policy and procedure violations, which were forwarded to IHSC leadership for review and action, yet IHSC leadership failed to take appropriate action.”
“Allegedly, facility medical staff did not follow policies and procedures concerning withdrawal protocols for [Name withheld by BuzzFeed News] benzodiazepines withdrawal. According to the complainant, medical staff did not address his withdrawal at intake, despite his reporting high levels of daily consumption of benzodiazepines. [Name withheld by BuzzFeed News] subsequently went into drug withdrawal seizures and was admitted to the hospital. Further, the complainant alleges that MQMU performed an analysis of the case and the findings included policy and procedure violations, which were forwarded to IHSC leadership for review and action, yet IHSC leadership failed to take appropriate action.” “Allegedly, facility medical staff did not follow policies and procedures concerning withdrawal protocols for [Name withheld by BuzzFeed News] opioid withdrawal, and a medication error occurred during the course of his treatment. Further, according to the complainant, MQMU performed an analysis of the case and the findings included policy and procedure violations, which were forwarded to the IHSC leadership for review and action, yet IHSC leadership failed to take appropriate action.”
And Roger Rayson died in ICE custody at the LaSalle Detention Facility of bleeding in the brain. The whistleblower described the care provided to him as “deplorable.”
“According to the complainant, Mr. Rayson healthcare was ‘deplorable.’ Mr. Rayson’s preliminary cause of death was ruled as subdural hemorrhages resulting in a traumatic brain injury. The complainant claimed that multiple requests for the Uniform Corrective Action Plan (UCAP) and Root Cause Analysis (RCA) were made to IHSC leadership, but IHSC did not respond.”
Rayson, a 47-year-old Jamaican immigrant, died approximately two months after being taken into ICE custody and a month “after being transferred to a hospital for nausea, vomiting, and pain,” according to a report by four advocacy groups. At the hospital, the report said he was diagnosed with “a fast-growing but treatable form of non-Hodgkin’s Lymphoma, and died nine days later.”
Medical experts interviewed by BuzzFeed News said the series of allegations required additional scrutiny, including from Congress.
“The allegations, if they are true, are serious and deserve really careful scrutiny about what went wrong, why it went wrong, and it is very possible they represent a more fundamental problem with the ICE health care system,” said Marc Stern, a public health expert and faculty member at the University of Washington.
Homer Venters, a former chief medical officer for the New York City jail system who has closely studied care in correctional facilities, told BuzzFeed News he was concerned that “IHSC is not acting in a way to not repeat the same type of preventable death over and over in different places around the country.”
Venters said that, in his experience, when health professionals such as the whistleblower take their complaints outside of their own system, “they do so because they don’t see a path to improving the system from the inside — they don’t see hope for addressing what are detention-related deaths that are preventable that flow from lack of access to quality health services.”
ICE has been criticized for its detainee medical care for years. In 2019 alone, the family of an Iranian man who the ACLU claims failed to receive proper treatment for methadone withdrawal and later died in ICE custody in Colorado sued the private prison contractor he was held in, GEO Group. In August, immigrant advocates sued ICE on behalf of 15 individuals detained at 8 different facilities in 6 states over what they described as the federal government’s failure to provide adequate medical and mental health treatment. The groups allege that the detainees have been denied necessary surgeries or even provided medication, such as insulin, for serious medical issues.
ICE officials have long said that they are dedicated to providing timely and comprehensive medical care to immigrants in their custody, noting that they have access to a daily sick call and 24-hour emergency care. The agency has publicized that it spends more than $269 million each year on health care services.
The former senior ICE official told BuzzFeed News that some at the agency brush away allegations of substandard medical care. “‘The care is better than they got in their home countries’ — you hear that a lot,” the former official said.
The official said it was unlikely that the agency would dramatically alter or add resources to its medical care system.
“It’s not going to happen under this administration,” the former official said. “That would take away money from beds and they are high on beds. They are not going to want to use that money in a different way.” ●