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An Immigrant Died In ICE Custody After Staff Didn't Send Him To A Hospital, An Inspector Found

“This highlights the issue with urgent care in ICE detention,” a doctor who teaches at USC told BuzzFeed News.

Posted on June 24, 2021, at 3:08 p.m. ET

Ted S. Warren / AP

Detainees walk toward a fenced recreation area at an ICE facility in 2019.

An immigrant in ICE custody in rural Mississippi died of a heart attack after staff did not send him to the hospital for urgent medical care, according to a draft inspector general’s report obtained by BuzzFeed News.

Department of Homeland Security investigators found that Anthony Jones, a 51-year-old Bahamian man who had been in ICE custody for more than a year, was in need of urgent medical attention on the morning of Dec. 17, 2020. When he went to the jail clinic for chest and arm pain, medical staffers gave him medication and testing but did not send him to the hospital, according to the report. Jones was not named in the report, but the details directly correspond to information on his death previously released by ICE.

“During our unannounced inspection of Adams in Natchez, Mississippi, we identified violations of ICE detention standards that threatened the health, safety, and rights of detainees,” the report states. “Although Adams generally provided sufficient medical care, we identified one case in which the medical unit examined a sick detainee but did not send the detainee to the hospital for urgent medical treatment, and the detainee died.”

The existence of the report, which has yet to be released, comes at a time when the Biden administration has been pressed by immigrant advocates to make changes to the government’s detention apparatus. The administration has moved to no longer house ICE detainees in two facilities and has promised to evaluate the detention system as a whole. Still, the number of immigrants held by the agency has ballooned in recent weeks from around 15,000 to more than 26,000.

It also comes as congressional officials press the DHS to investigate how the pandemic was handled at the facility. Since last spring, more than 600 immigrants have tested positive for COVID-19 at Adams, according to the agency.

The draft report found that the jail did not consistently enforce COVID-19 precautions, like the use of facial coverings or social distancing, and investigators believe that it may have contributed to repeated transmissions.

An ICE spokesperson said they take the welfare and health of those in its custody very seriously.

“While deaths in ICE custody are exceedingly rare, these events are unfortunate and always a cause for concern,” the spokesperson said.

The agency, which spends more than $315 million a year on health services, has taken steps to prevent COVID-19 outbreaks, such as isolating new arrivals and those who have symptoms.

A spokesperson for CoreCivic, which operates Adams under a contract with ICE, said that they would not comment on a yet-to-be finalized report but that the company cares deeply about every person in its care. A spokesperson also said immigration facilities are closely monitored by the government and reviewed for standards of living. They added that at Adams “when emergency care becomes necessary for any detainee, patients are immediately evaluated and emergency care is provided in the most medically appropriate setting.”

Gregory Bull / AP

The company states that all detainees were given multiple masks, trained on how to wear and handle them properly, and required to wear them. The staff also encourages social distancing through town halls and flyers.

Medical care for ICE detainees has come under increasing scrutiny in recent years. In September, the House Oversight Committee found that ICE detainees died after receiving inadequate care and that jail workers “falsified records to cover up” issues. That same month, the House Homeland Security Committee released a report that found people detained by ICE are often given insufficient care, and that detention centers use segregation to threaten immigrants.

The report was based on interviews, facility inspections, and tours of eight ICE detention centers. The committee also found that the agency and its contractors frequently demonstrated an indifference to the mental and physical care of detainees.

ICE has publicly insisted that the detention facilities it runs, as well as those that are operated by private, for-profit corporations, provide thorough and adequate medical care to all detainees.

Jones, the detainee whose case was examined in the draft inspector's report on Adams, had been in ICE custody since 2019 and had previously been convicted of aggravated assault. A public report on his death posted by ICE earlier this year showed that on the morning of Dec. 17, Jones complained of burning in his arms and chest. He was examined at the facility’s medical unit and given aspirin, oxygen, and other medications between 7:40 and 8:25 a.m. He reported feeling better but said the burning in his right arm remained.

Medical staff also did an electrocardiogram to examine Jones’ heart and he was released, according to the inspector’s report.

Nearly an hour later, while he was waiting to return to his housing area, an officer at the jail found him slumped over in a chair. He was unresponsive and medical staff undertook life-saving measures. Jail staff called 911, and Jones was pronounced dead after first responders showed up at the facility. According to the autopsy, he died of atherosclerotic cardiovascular disease, a heart attack.

“Based on a review of medical records and autopsy, our medical contractor concluded that had the Adams medical staff compared the 2019 ECG with the one conducted on December 17, 2020, it should have prompted the medical staff to call 911 and send the detainee to the hospital where life support care would have been readily available,” the report states.

Dr. Elizabeth Burner, an associate professor of clinical emergency medicine at the Keck School of Medicine at the University of Southern California, agreed with the assessment provided by the inspector general after reviewing Jones’ medical records.

“This highlights the issue with urgent care in ICE detention,” she said. “This is a case of a classic emergency medical presentation that should not be missed. We call this a ‘can’t miss’ in emergency medicine.”

Jeremy Jong, an attorney representing Jones’ family, said the case is emblematic of wider issues in ICE detention about helping detainees requesting urgent medical assistance.

“This is a problem endemic to all detention centers,” he said.

The number of detainees in ICE custody has risen under the Biden administration. In recent weeks, it has jumped to more than 26,000, driven largely by immigrants who have been arrested at the border and transferred to ICE custody.

The inspector general’s office closely scrutinized the financial impact of the contract ICE has signed to keep Adams County as a place to detain immigrants.

ICE regularly contracts with detention centers in a way that guarantees payments for a minimum number of beds, regardless of whether they are filled. The practice of “guaranteed minimums” has come under criticism in recent years, especially during the pandemic.

The agency uses a similar contract for its detention of immigrants at Adams. In this case, the contract guarantees payment of nearly $4 million a month to house up to 1,100 detainees, according to the report. In 2020, as the pandemic swept through the country and forced ICE to limit its enforcement, the detention center had 35% of its space go unused; there were only six days during the year when its population went above 1,100.

The inspector general determined that the detention center was paid nearly $17 million for unused beds in 2020 as the overall detainee population shrunk during the pandemic.

A BuzzFeed News investigation, in partnership with the International Consortium of Investigative Journalists, based on thousands of documents the government didn't want you to see.