System of Neglect

By their calculations, officials said, the mortality rate among detainees has declined since 2004 to a level that is lower than that in U.S. jails and prisons. The deaths, the statement said, "highlight the tremendous responsibility and potential liability the government faces in providing medical care to a population that often did not have access to adequate health care before coming into our custody."

To this end, the agency recently increased its inspections of facilities and is creating an inspection group at headquarters to review serious incidents, including deaths or allegations that standards are not being met.

ICE declined to comment on specific cases, citing internal policies on patient privacy or pending litigation.

Neil Sampson, who ran the DIHS as interim director most of last year, left that job with serious questions about the government's commitment. Sampson said in an interview that ICE treated detainee health care "as an afterthought," reflecting what he called a failure of leadership and management at the Homeland Security Department. "They do not have a clear idea or philosophy of their approach to health care [for detainees]," he said. "It's a system failure, not a failure of individuals."

A new director for health services arrived six months ago, following a stretch when the agency was run first by Sampson and then by a second interim director. The new boss is LaMont W. Flanagan, who brought with him the credential of having been fired in 2003 by the state of Maryland for bad management and spending practices supervising detention and pretrial services. An audit found that Flanagan had signed off on payments of $145,000 for employee entertainment and other ill-advised expenditures. His reputation was such that the District of Columbia would not hire him for a juvenile-justice position.

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"Another death that needs to be added to the roster," Diane Aker, the DIHS chief health administrator, tapped out in an e-mail to a records clerk at headquarters on Aug. 14, 2007.

Juan Guevara-Lorano, 21, was dead.

Guevara, an unemployed legal U.S. resident with a young son, was arrested in El Paso for driving illegal border-crossers farther into the city. He was paid $50.

An entry-level emergency medical technician, with barely any training, had done Guevara's intake screening and physical assessment at the Otero County immigration compound in New Mexico. Under DIHS rules, those tasks are supposed to be done by a nurse.

After two difficult months in detention, Guevara had decided not to appeal his case. He would go back to Mexico with his family. But on Aug. 4, he came down with a splitting headache, what he called a nine on a pain scale of 10, his medical records show. The rookie medical technician prescribed Tylenol and referred Guevara to the compound's physician "due to severity of headache . . . and dizziness," according to medical records.

But Guevara never saw a doctor. Eight days after the first incident, he vomited in his cell. The same junior technician came to help but was unable to insert a nasal airway tube. Guevara was taken to a hospital, where doctors determined an aneurysm in his brain had burst.