System of Neglect | Human Costs of an Overburdened System
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.
"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.
- Parts of an e-mail about the death of Juan Guevara-Lorano
- Portions of the review of the care provided to Martin Hernandez Banderas
- Roberto Ledesma Guerrero's Sick Call Request
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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 aneurism in his brain had burst.
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."
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 chicken pox 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."
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.
Key terms and acronyms from the Careless Detention series.
Read the original government documents related to the people and cases detailed in this story.
Based on confidential medical records and other sources, The Washington Post identified 83 deaths of immigration detainees between March 2003, when the federal Immigration and Customs Enforcement agency was created, and March 2008.