Pablo Gracida-Conte had reported problems with vomiting, nausea and chest pains during his 142 days in immigrant custody in 2011, according to a government review of his case.
A heart test had come back with an abnormal result on October 24 of that year, but the undocumented 54-year-old Mexican wasn't sent to hospital. He struggled to complete a sentence at a follow-up appointment the next day and finally went to hospital. His condition deteriorated.
Gracida-Conte died on October 30, 2011 and, according to a doctor who participated in the review of his death, it might have been prevented.
The American Civil Liberties Union, Detention Watch Network and National Immigrant Justice Center highlighted his story in a report released on Thursday, which is based on internal Immigration and Customs Enforcement documents they obtained.
The report focuses on eight immigrants who died in detention from 2010 to 2012. In each case, reviews from within the agency found that a contributing cause had been non-compliance with the agency's medical standards. The internal reviews identified four of those deaths are specifically as preventable.
ICE has been producing reviews of deaths in custody since 2009. Yet all but one of the facilities the civil rights groups highlighted were given a passing grade, even after those deaths and the reviews that found failures in health care, the report found.
“They made these findings in the death reviews and then swept them under the rug”
"They made these findings in the death reviews and then swept them under the rug," said Carl Takei, an ACLU attorney who worked on this report, told The Huffington Post.
ICE spokeswoman Jennifer D. Elzea said in a statement on Thursday that the agency "takes seriously the health and welfare of all those in its custody," and will review the report "to assess what actions, if any, should be taken in response."
The death review for Gracida-Conte concluded multiple problems with his medical treatment at Eloy Detention Center in Arizona, which the for-profit Corrections Corporation of America operates. The review said there was a failure to provide efficient care and difficulties in communication because he spoke "very little Spanish" and an interpreter was never called in to talk to him in Mixteco. One doctor cited in the report wrote that his "death might have been prevented if the providers, including the physician at [Eloy], had provided the appropriate medical treatment in a timely manner."
The report drew similar conclusions in other cases, including that of Amra Miletic. The 47-year-old from Bosnia-Herzegovina was in ICE custody at Weber County Correctional Facility in Utah, died in 2011 after 47 days in detention. She had complained of abdominal pain, blood in her stool and a fever, but did not receive lab tests until she had been in detention for five weeks, according to the review. She lost 15 pounds in a nine-day period and was eventually placed under doctors' supervision, but in a separate unit because the medical segregation unit was full.
On the day she died, Miletic had shown signs of distress. Her last known movement was around 6:30 p.m. She wasn't discovered until about 45 minutes later. A doctor said in a mortality review that it "was a death that was preventable" and questioned the competence of the physician who failed to understand the urgency of emergency care.
The ACLU, Detention Watch Network and National Immigrant Justice Center called on ICE to make changes, including reducing the number of people in detention in general by using alternatives so people with serious health needs can access care and have support from their families.
They also called for ICE to stop using private for-profit detention facilities and medical care subcontractors, and to end contracts for centers if there were repeated preventable deaths. Inspections should report on whether the problems in death reviews had been addressed before giving any facility a passing rating, they argued.
"The delivery of medical care and the inspection process both need to safeguard the welfare of the people inside detention," Takei said.
The ACLU filed subsequent requests for reports on deaths after those provided in the initial release, but has not yet received them.
Elzea said the agency has implemented “significant changes” to ensure more efficient access to medical care, including staffers at each ICE field office to monitor complex cases.
Notably, six of the eight facilities referenced in the report, including the Adelanto Detention Facility, Eloy Detention Center, ICA Farmville, Denver CDF, Elizabeth CDF, and the El Paso SPC, have since transitioned to meet ICE’s 2011 Performance Based National Detention Standards, the most rigorous operating requirements imposed by the agency. A seventh site, Weber County, has not been used by ICE to house immigration detainees since 2011.
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