New Report Finds Nearly All Deaths in ICE Custody Over 5 Years Were Preventable

Nearly all of the deaths in U.S. immigration detention facilities over a five-year period were preventable, but no officials have faced serious accountability, a new report found.

Of the 52 people who died in detention under the custody of Immigration and Customs Enforcement (ICE) from January 2017 to December 2021, 49 of the deaths, or 95%, were preventable or possibly preventable if appropriate medical care had been provided. The new report, “Deadly Failures: Preventable Deaths in U.S. Immigration Detention,” reviewed more than 14,500 pages of documents published by the American Civil Liberties Union (ACLU), Physicians for Human Rights, and American Oversight on June 25.

None of the private prison corporations — which currently hold more than 90% of the detainees under ICE custody — have faced meaningful consequences as million-dollar contracts have been doled out to the same facilities where preventable deaths have occurred, the report showed.

“It is a system that’s rotten to the core,” said Eunice Hyunhye Cho, senior attorney at ACLU’s National Prison Project and lead co-author of the report. “From bottom to top, you see some very minimal slaps on the wrists and blaming of the lowest level employees, but there’s really no true accountability regarding the disaster of the medical care system in ICE’s detention facilities,” she said.

After deaths in detention, ICE failed to conduct rigorous investigations — failing to interview key witnesses, omitting key inculpatory facts, and allowing evidence to be destroyed, the report stated. ICE also withheld information from the relatives of the deceased. To obtain the medical record of a loved one, a family has to take ICE to court and litigate for years to receive often incomplete files.

“It is a system of impunity and lack of transparency as ICE and private corporations are working hand in hand in perpetuating dangerous and deadly conditions,” Cho said.

Amid medical neglect, cruelty, and abuse, more than 38,000 immigrants are held each day in an ICE network of some 190 detention facilities across the country, as of June 16. That number will only increase as Congress approved a record annual budget for ICE to detain 41,500 people daily at a cost of $3.4 billion this year. Most of the detention budget will go to the private prison companies — The Geo Group and CoreCivic being the largest — where most preventable deaths occur.

“The answer that we see over and over again to the failures that produce deaths is to give the detention system more money,” said Andrew Free, an attorney involved in more than 30 cases of deaths in ICE custody and contributor to the report. “That’s been the response at all levels of the system. It’s not just one facility. It’s not just one contractor. It’s not just one fiscal year,” he said.

ICE did not respond to a request for comment.

The report also found that facilities’ medical staff provided treatment that did not meet evidence-based medical standards, did not resolve the issue, or was unreasonably delayed in 79% of the deaths between 2017 and 2021. To this day, no steps have been taken to remedy what the report calls “systemic failures in medical and mental health care.”

Take the case of Jeancarlo Alfonso Jiménez Joseph, a 27-year-old Panamanian and DACA recipient with a diagnosis of schizophrenia who died by suicide in the Stewart Detention Center in Georgia on May 15, 2017. A United Nations expert says confining someone in a solitary cell for longer than 15 consecutive days amounts to torture, and it should never be used on individuals with mental health issues. Jiménez had spent 19 consecutive days in solitary confinement when he died.

According to Jiménez’s family and official documents, he had notified the medical staff at Stewart four times that his medications were not controlling his auditory hallucinations and impulsivity. He wrote on the walls of his cell that voices in his mind told him to take his own life, his mother Nerina told Prism. “There was no way to ignore that something was not normal and that he intended to hurt himself,” Joseph said. “But they ignored all this; they ignored it again and again.”

Inadequate Penalties

Stewart Detention Center in Georgia is the deadliest immigrant jail in the U.S., where at least 10 people have died from 2017 to May 2024, followed by Krome North Service Processing Center in Florida, with six fatalities. Stewart is owned by CoreCivic, a corporation that reported $1.9 billion in revenue for fiscal year 2023 and a profit margin of 3.6%. Despite the deaths, Stewart has been steadily receiving ICE contracts to hold a similar number of detainees — more than 1,500 — at least since 2006.

At the time of Jiménez’s death, ICE required Stewart to have one full-time psychiatrist for its nearly 2,000 detainees — a ratio that the ICE health services administrator considered inadequate in court testimony. Stewart did not even comply with that contractual mandate as it provided telepsychiatry at less than 20% of its required staffing. Despite the violations, ICE did not recommend Stewart to increase its staffing after Jiménez’s death.

“ICE did not propose to enact any solutions that would actually prevent error in the future,” stated Radha Sadacharan, one of the medical experts who analyzed Jiménez’s case for the report.

ICE did issue a contract discrepancy penalty against Stewart for failing to comply with suicide prevention guidelines following the deaths of Jiménez and Efrain Romero De La Rosa in 2018. The penalties came close to $1.4 million — a fraction of the $441 million that CoreCivic received for ICE detention contracts in 2017. However, only one month after imposing the penalty, ICE awarded CoreCivic a new contract to provide medical care to detainees at Stewart.

ICE has issued financial penalties on three occasions out of the 68 deaths that have taken place between 2017 and June 2024. That figure does not consider the individuals whom ICE released immediately before their deaths — a practice used to reduce the official death toll, according to the report. In that period, not a single facility has lost a contract or failed an ICE inspection despite the documented wrongdoings.

So far this fiscal year, 10 people have died in ICE custody, more than twice as many as last year and three times as many as in 2022, when three fatalities were recorded. This year’s deaths include Charles Leo Daniel, who died in March after being held for almost four years in solitary confinement in the Northwest Detention Center in Washington — a facility owned by The Geo Group — despite suffering from severe mental health issues.

The cruelty of ICE’s detention system extends to the families. Jiménez’s family has been litigating for six years to obtain his medical records. They want to know why a preventable death such as his happened, and they also want ICE, CoreCivic, and Stewart to acknowledge their mistakes to avoid more deaths in detention. That has not happened.

“The government’s response every time a death occurs in their facilities is the same: They say that the individual’s safety is their priority,” said Jiménez’s sister Karina. “But the data shows us otherwise: that the systems and practices in these centers are deadly. Not only do they not prevent harm, but they also torture people. That’s what happened to Jean and to many others like him.”

Prism is an independent and nonprofit newsroom led by journalists of color. We report from the ground up and at the intersections of injustice.