A new report examines how “egregious violations” of medical care standards contributed to at least eight in-custody deaths of immigrants over a two-year period in Immigration and Customs Enforcement (ICE)-operated detention facilities.

Fatal Neglect: How ICE Ignores Deaths in Detention, released last week by the American Civil Liberties Union, the Detention Watch Network, and the National Immigrant Justice Center, shines a light on how 2009 immigration detention reforms have failed to quell in-custody deaths. The report’s authors analyzed government death reviews and facility inspection documents, finding that inadequate medical care continues to contribute to the deaths of immigrants in federal custody.

Back in 2009, in response to sustained criticism from immigrant rights advocates and the media over medical neglect and unnecessary deaths of immigrants in detention, the Obama administration announced reforms that, among other things, included “hiring a medical expert to provide an independent review of medical complaints and denials of requests for medical services,” and creating the Office of Detention Policy and Planning, whose primary goals included ensuring “the timely provision of medical, dental, and mental health assessment and services.”

But over the course of Obama’s term, Fatal Neglect reports that there have been 56 deaths in ICE custody. Six of the deaths were suicides and at least one death occurred after an attempted suicide. The advocacy groups’ investigation focuses on eight deaths where ICE’s Office of Detention Oversight identified noncompliance with the agency’s own medical standards as a contributing cause, four of which were classified as “preventable.”

As the country’s fastest-growing form of incarceration, immigration detention is comprised of federal centers and county jails, as well as privately run prisons owned by for-profit businesses. ICE has more than 34,000 detention beds at any given time, and those beds are spread out across as many as 250 different facilities, with the bulk of them at detention centers under contract.

Private prison companies have come under intense scrutiny over the years for their treatment of immigrant detainees. As the Nation reported in January, private prisons often hire health-service subcontractors who provide medical care that is “separate and unequal, segregated on the basis of citizenship.” This takes shape in the form of licensed vocational nurses (LVNs) being the sole caregivers of critically sick people at immigrant-only prisons contracted by ICE. LVNs undergo a year of training to operate as support staff responsible for basic tasks, such as gathering patient information or checking blood pressure, in nursing homes or under the direction of registered nurses at hospitals. But in detention centers, according to the Nation, they’re performing duties “equivalent to those of registered nurses, a practice that prison medical staff confirm.”

According to Fatal Neglect, the eight deaths illustrate how ICE also has failed to meet detainees’ health-care needs in a timely manner; to refer individuals to higher-level medical care providers; to provide adequate levels of medical staff; to communicate critically important information about individuals’ medical conditions among staff; to adequately screen individuals for illnesses; and to proactively identify and rectify concerns about medical care during facility inspections.

In the case of Evalin-Ali Mandza of Gabon, a code-blue emergency was activated at Denver Contract Detention Facility on April 12, 2012 at approximately 5:24 a.m. when other detained individuals told an officer that Mandza was experiencing chest pain. At approximately 5:50 a.m., a doctor was finally alerted to the situation, determining that Mandza, 46, needed to go to the emergency room. At this time, the doctor directed a nurse to call 9-1-1. The call was not placed, however, until approximately 6:20 a.m., nearly one hour after the activation of the code-blue emergency. According to the report, this “unconscionably long delay” violated ICE PBNDS 2008, which requires “detainees who need health care beyond facility resources to be transferred in a timely manner to an appropriate facility where care is available.”

And Irene Bamenga, a 29-year-old French citizen who is currently the subject of a wrongful death lawsuit filed by her widower, died after 12 days in ICE custody when medical staff administered incorrect medicine dosages—both in missed and excessive dosages. According to the report, Bamenga even submitted two health-services request forms in the days preceding her death, but medical staff failed to address Bamenga’s concerns and deteriorating condition. Her certificate of death lists the immediate cause as cardiomyopathy, although the report conducted by a doctor as part of the death review raises questions about this conclusion.

In-custody deaths of immigrant detainees have made headlines in recent months. There was the damning Nation investigation into the deaths of dozens of men who lost their lives in disturbing circumstances in privatized, immigrant-only prisons. There have also been pushes by immigrant rights organizations to raise awareness around the issue. Shut Down Etowah, for example, recently held a memorial service for Teka Gulema, an Ethiopian national who died in January after contracting an infection that left him paralyzed while in custody. Gulema was detained at the Etowah County Immigration Detention Center in Gadsden, Alabama, before he was transferred to a hospital. Less than a month before Gulema’s death, ICE released him from its legal custody, “although at that point he had been paralyzed for months,” according to a statement from advocates.

Prior to the administration’s reforms, from January 2004 to November 2007, reports estimated some 66 deaths occurred in immigration custody in both private and ICE-operated facilities. The New York Times’ Nina Bernstein reported in 2009 that more than one in ten deaths in immigration detention in the six years prior had been overlooked and omitted from an official roster of detainee fatalities.

And in 2010, Bernstein wrote that for years, those dying in immigration detention were uncounted and unnamed in the public record. Despite the deaths privately generating “thousands of pages of government documents, including scathing investigative reports that were kept under wraps, and a trail of confidential memos and BlackBerry messages,” officials did everything possible to quash outside inquiries.

The immigrant rights organizations behind Fatal Neglect are recommending that ICE takes the following actions: immediately reduce immigration detention, improve the delivery of medical care in detention, ensure inspections provide meaningful oversight, and increase transparency of inspections, deaths, and serious medical incidents in detention.

For its part, ICE spokeswoman Yasmeen Pitts O’Keefe said in a statement to advocates that “several of the detention centers detailed in the report have implemented more rigorous standards … to ensure detainee safety,” including “the implementation of significant changes to the health care delivery system to ensure that those in ICE custody receive timely access to medical services and treatment.” 

“That includes establishing a cadre of Detainee Medical Coordinators who are assigned to each of the agency’s field offices to closely monitor complex cases. ICE has also since simplified the process for detainees to receive authorized health care treatment,” Pitts O’Keefe added.