System of Neglect

His wife, pregnant at the time with their second child, recalled that she rushed to the hospital, but ICE guards would not let her inside until the Mexican Consulate interceded. Guevara's mother waited five hours before they let her in. By then he was brain-dead.

"My son is not coming back," sobbed Ana Celia Lozano months later, sitting in Guevara's small mobile home as her grandson played on the floor. "I want to know how he lived and died, nothing more."

What appears to be the most incriminating document in Guevara's case has been partially blacked out. Still, what is left shows that he did not receive adequate care. "The detainee was not seen or evaluated by an RN, midlevel or physician. . . . At the time of the incident on 8/12/2007, the detainee was seen and examined by EMTs."

Each immigration facility is allotted a different number of positions, and a shortage of doctors and nurses is not unusual at centers across the country. Records from February show that about 30 percent of all DIHS positions in the field were unfilled. ICE officials said last week that the current vacancy rate is 21 percent. Concern about the vacancies is voiced repeatedly at clinical directors' meetings. "How do we state our concerns so that we can be heard? . . . this is a CRITICAL condition. . . . We have bitten off more than we can chew," a physician wrote in the minutes of one meeting last summer.

In some prisons, the staffing shortages are acute. The Willacy County detention center in South Texas -- the largest compound, with 2,018 detainees -- has no clinical director, no pharmacist and only a part-time psychiatrist. Nearly 50 percent of the nursing positions were unfilled at the 1,500-detainee Eloy, Ariz., prison in February. At the newly opened 744-bed Jena, La., compound, nurses run the place. It has no clinical director, no staff physician, no psychiatrist and no professional dental staff.

Last August, Sampson, who was then DIHS interim director, warned his superiors at ICE that critical personnel shortages were making it impossible to staff the Jena facility adequately. In a vociferous e-mail to Gary Mead, the ICE deputy director in charge of detention centers, he wrote:

"With the Jena request we have been re-examining our capabilities to meet health care needs at a new site when we are facing critical staffing shortages at most every other DIHS site. While we developed, executed and achieved major successes in our recruitment efforts we have been unable to meet the demand."

The slow ICE security-clearance process forced many job applicants to go elsewhere, Sampson wrote. Of the 312 people who applied for new positions over the past year, 200 withdrew, he wrote, because they found other jobs during the 250 days it took ICE, on average, to conduct the required background investigations. Last week, ICE officials said the average wait had decreased recently to 37 days.

These shortages have burdened the remaining staff. In July 2007, a year after Osman's death in Otay Mesa, medical director Hui strongly complained to headquarters about workload stress. "The level of burnout . . . is high and rising," she wrote in an e-mail. "I know that I have been averaging approximately 2-6 hrs of overtime daily for the past 2 months. I will no longer be able to sustain this pace and will be decreasing the number of hours that I work overtime. This being said, more will be left undone because we simply do NOT have the staff."

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The overcrowding has created a petri dish for the spread of diseases. One mission of the Public Health Service is to detect infectious diseases and contain them before they spread, but last summer, the gigantic Willacy center was hit by a chickenpox outbreak.

The illness spread because the facility did not have enough available isolation rooms and its large pods share recycled air, but also because security officers "lack education about the disease and keep moving around detainees from different units without taking into consideration if the unit has been isolated due to heavy exposure," noted the DIHS's top specialist on infectious diseases, Carlos Duchesne. The staff was forced to vaccinate the entire population in mid-July.

In one 2007 death, memos and confidential notes show how medical staff missed an infectious disease, meningitis, in their midst. Victor Alfonso Arellano, 23, a transgender Mexican detainee with AIDS, died in custody at the San Pedro center. The first three pages of Duchesne's internal review of the death leave the impression that Arellano's care was proper. But the last page, under the heading "Off the record observations and recommendations," takes a decidedly critical tone: "The clinical staff at all levels fails to recognize early signs and symptoms of meningitis. . . . Pt was evaluated multiple times and an effort to rule out those infections was not even mentioned."

Arellano was given a "completely useless" antibiotic, Duchesne wrote. Lab work that should have been performed immediately took 22 days because San Pedro's clinical director had ordered staff members to withhold lab work for new detainees until they had been in detention there "for more than 30 days," a violation of agency rules.

"I am sure that there must be a reason why this was mandated but that practice is particularly dangerous with chronic care cases and specially is particularly dangerous with . . . HIV/AIDS patients," Duchesne wrote. "Labs for AIDS patients . . . must be performed ASAP to know their immune status and where you are standing in reference to disease control and meds."

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Given the frequency with which ICE moves people within the detention network, keeping track of detainees is critical to stopping the spread of infectious illnesses. The purchase of an electronic records system named CaseTrakker in 2004 was supposed to help. But according to internal documents and interviews, CaseTrakker is so riddled with problems that facilities often revert to handwritten records.

A study at one site found that it took one-third more time to use CaseTrakker than to use paper. Thousands of patient files are missing. Recorded data often cannot be retrieved. Day-long outages are common.

When detainees are transferred from one facility to another, their records, if they follow them, are often misleading. Some show medications with no medical diagnoses or "lots of diagnoses but no meds," according to Elizabeth Fleming, a former clinical director at one compound in Arizona.

After Yusif Osman's death and the discovery of the problem with his computerized records, the DIHS ordered a review of all charts at the Otay Mesa center. During the review, auditors also found that 260 physical exams were never completed as required. The nurse responsible for the error in Osman's case was reprimanded, but the computer problem was not fixed.

The CaseTrakker system "has failed and must be replaced," Sampson, the DIHS interim director, wrote to his ICE supervisors in August.

In January 2008, medical director Shack told colleagues that CaseTrakker "is more of a liability than the use of paper medical record system," according to the minutes of a meeting. It "puts patients at risk."

ICE officials said last week that they are not satisfied with CaseTrakker and are working to replace it.

Along with being at the mercy of computer glitches, detainees suffer from human errors that deny or delay their care. And with few advocates on the outside, they are left alone to plead their cases in the most desperate ways, in hand-scribbled notes to doctors they rarely see.

"I need medicine for pain. All my bones hurt. Thank you," wrote Mexico native Roberto Ledesma Guerrero, 72, three weeks before he died inside the Otay Mesa compound.

Delays persist throughout the system. In January, the detention center in Pearsall, Tex., an hour from San Antonio, had a backlog of 2,097 appointments.

Luis Dubegel-Paez, a 60-year-old Cuban, had filled out many sick call requests before he died on March 14. Detained at the Rolling Plains Detention Facility in the West Texas town of Haskell, he wrote on New Year's Day: "need to see doctor for Heart medication; and having chest pains for the past three days. Can't stand pain."

Ten days later he went to the clinic and became upset when he wasn't seen. He slugged the window, yelled, pointed at his wristwatch. He was escorted back to his cell.

Another of his sick call requests said: "Need to see a doctor. I have a lot of symptoms of sickness . . . as soon as possible!" The next was more urgent: "I have a emergency to see the doctor about my heart problems . . . for the last couple days and I been getting dizzy a lot."

The next day, Dubegel-Paez collapsed and died. His medical records do not show that he ever saw a doctor for his chest pains.

Hanna Boutros, 52, who came to the United States 30 years ago, waited seven months for surgery after receiving a diagnosis of "high-grade" prostate cancer, which his urologist urged be treated immediately. ICE officials sent him to Krome Service Processing Center in Miami because, they said, it could best deal with his condition.

But he was seen by nurses, not a doctor, until he found an outside lawyer to threaten a suit. Boutros finally got surgery just before Christmas, before he was deported to Lebanon, leaving two children and a wife in the United States. "I was miserable. I was very, very scared. It was always burning," he said.

Juan Guillermo Guerrero, 37, was denied his seizure medication and given an ineffective substitute. Suffering from one or two painful seizures a week, he told his lawyer to drop his case, saying he preferred to be deported than to die inside an immigration prison. A few days after he returned to Mexico, Guerrero died of asphyxiation during a seizure, according to his lawyers.

Sometimes, to save money, the government releases detainees instead of treating them. Martin Hernandez Banderas, a 40-year-old Mexican, was released from custody last year while he was in the hospital following surgery to amputate his leg. An internal review found that the system failed him before the surgery: Nurses and doctors at Otay Mesa did not appreciate the severity of his diabetic foot wounds, did not properly treat them or prescribe the correct course of antibiotics, and did not bring in a qualified surgeon to evaluate the problem.

Simon Reyes-Altimirano, 25, a Honduran, was diagnosed with chickenpox and sent back to his cell with Benadryl, only to be hospitalized a day later and diagnosed with an inoperable brain tumor. He died two weeks later.

Shack, the medical director, found that Reyes-Altimirano's care at the El Paso detention center had been "appropriate and timely." But a nurse at the center poured out her remorse in a typed note placed in Reyes-Altimirano's medical file. "We always have to listen to the patient and the reason I say this is because" when he first reported his problems, "one of the nurses said, 'I think he is faking his illness' . . . this is not just a medical learning experience but also an emotional one."

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Three weeks after Reyes-Altimirano died, a nurse at the Krome Service Processing Center accused the Rev. Joseph Dantica of faking an illness, too. The 81-year-old Baptist minister had fled Haiti in the fall of 2004, fearing for his life after gangs set fire to the church overlooking Port-au-Prince where he ran a school, let people use computers for free and quietly handed out money to needy families.

As a younger man, Dantica listened to tapes to practice English every day, but he never wanted to live in the United States, said a niece, writer Edwidge Danticat, who was raised by him. He visited once a year, to see his brother in Brooklyn and raise money for his church.

But after U.N. peacekeepers and Haitian riot police seized the church to use as a base against gangs, and after the gangs retaliated by burning the altar, Dantica slipped on a woman's muumuu and wig and headed to the airport. He arrived in Miami with a valid visa but decided to seek asylum because he thought he might have to stay longer than his visa allowed. In an earlier time, Dantica would have been permitted to go on to New York while the government considered his claim. This time, he was detained.

Dantica and an immigration lawyer were sitting before an asylum officer when the minister began to vomit violently. The lawyer, John Pratt, said agents at the detention center had taken away his client's blood-pressure medicine.

Dantica "turned very cold. His eyes wandered around, and he appeared not to be conscious of his surroundings," the asylum officer, Miriam Castro, later told investigators, according to confidential documents. "Applicant assumed a rigid position with his legs stretched out and remained in this position."

Castro called for medical help. No one came for 15 minutes. When the public health nurse and a physician assistant arrived, the nurse said he believed that Dantica "was faking because Applicant kept looking at him randomly," Castro said. The nurse, Tony Palladino, "then went on to demonstrate that when he moved Applicant's head up and down, Applicant maintained his head rigid as opposed to limp, thus not allowing his head to fall back. [The nurse] stated that was another way he determined Applicant was faking symptoms."

Dantica died a day later in Miami's Jackson Memorial Hospital, shackled to a bed. Pratt had called the hospital repeatedly, trying to get information about his condition and permission for his family to see him. "They never said anything but they were doing tests," Pratt said. Security reasons, hospital officials told him, prevented visitors.

The government's internal medical records say Dantica died of pancreatitis. A one-page death certificate in his file has "VOID" stamped across it. Two outside doctors who reviewed his medical records for The Post said he probably died of heart problems.

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Yusif Osman had been living in Los Angeles as a legal resident for five years when he was detained crossing back from Tijuana in 2006 with a passenger, also from Ghana, who had a false ID. Osman was arrested on a smuggling charge, which he denied and was fighting while locked up at Otay Mesa. He seemed healthy to his friends and family who visited him or spoke to him by phone.

His girlfriend, Dorothy Weens, was stunned when she picked up the phone in late June and a stranger broke the news. "Yusif Osman passed away," the man said.

When Osman's lawyer called the compound to verify what had happened, he was told only that his client was no longer there. Weens and a cousin of Osman's called immigration officials several times for answers. They were told that the matter was under investigation. Eventually they stopped calling.

Osman's belongings from the prison arrived at his cousin's house one day by mail. Pants. Socks. Scraps of paper with prayer verses written in Arabic. His birth certificate. A letter from Dorothy: "Hey Babe! Hang in there. I'm trying everything I can do, to get you out of there. I love you and God love you. And that all you needs. I'm sending you $100.00. Love, Dot."

There was also an inventory of the rest of his personal property on the day he died: "4 yellow envelopes. 1 writing pad. 1 religious beads. 1 Chap Stick. 14 Ramen soups. 1 grape jelly. 1 jar peanut butter. 1 hot cocoa mix. 1 box Q tips."

The mortuary received a preliminary death certificate from the coroner's office. It noted Osman's cause of death as "pending," enough to release the body. His mosque collected money for a burial in a Muslim cemetery in the Mojave Desert. Male friends dug the grave. They laid his corpse, wrapped in white cloth, into the open earth and covered it with rocky dirt.

The final death certificate arrived in the mail sometime later. Under cause of death, it still read "pending." Osman's passing remains a mystery to his grieving relatives in Ghana and his adopted African community in Los Angeles.

An uneven, blank concrete headstone marks Grave 26. The truth of Osman's death is also buried, thousands of miles away, past the Statue of Liberty replica near the front door, inside a cabinet at the Division of Immigration Health Services, in file #077-987-986.

Staff researcher Julie Tate and database editor Sarah Cohen contributed to this report.