A federal investigation into the deaths of two immigrants who died in federal custody found that the U.S. immigration agency does not effectively monitor its detention facilities' compliance with its own detention standards.

In a report released last week, the Department of Homeland Security Office of Inspector General (OIG) says that "[ICE] Staff conducting routine oversight of facilities has not been effective in identifying certain serious problems at facilities."

One of the deaths the OIG investigated was that of Maria Iñamagua, who died from neurocysticercosis at Ramsey County Jail in St. Paul, Minnesota, in April 2006. The National Immigrant Justice Center received 2005 ICE inspection reports for Ramsey County last year as part of a Freedom of Information Act request and raised concerns similar to those expressed in the OIG report.

The November 2005 inspection report that NIJC received was completed three months after one detainee at Ramsey County Jail suffered a miscarriage, and seven months before the death of Iñamagua. Human rights advocates have reported that both Iñamagua and the woman who miscarried were denied medical treatment, but the ICE inspection rated Ramsey County's compliance with access to medical care standards as "acceptable," the highest possible rating. According to the OIG report, the ICE inspection report for November 2006-four months after Inamagua's death-also awarded the jail an "acceptable" rating for access to medical care.

The OIG report also highlights major deficiencies in Ramsey County's tuberculosis-testing practices. ICE detention standards require that jails administer TB tests to detainees within one day of their arrival at detention facilities. The OIG report states that according to the checklist in the November 2006 inspection report for Ramsey County, the facility did not abide by ICE's tuberculosis screening standards. Ramsey County had also been marked as deficient in this area in the 2005 inspection report obtained by NIJC. On the 2005 report, the inspector noted that tuberculosis tests were done at the facility "after 14 days."

In its analysis, the OIG questions ICE's rating system: "Screening for tuberculosis is central to the safety of facility staff and other detainees. Compliance in this area should be a leading factor in a facility's overall rating in the access to medical care area. However, the facility received an acceptable rating for that general standard."

In fact, the OIG found that ICE has no way of tracking whether jails even complied with its basic medical screening standards.

According to a sampling of cases taken by OIG in its investigations, Ramsey County Jail failed to abide by ICE standards that require that all detainees undergo a basic medical screening within 14 days of their arrival at a facility.

The OIG reports:

For the Ramsey County facility, only 43 ICE detainees admitted in the first 6 months of 2007 were housed for more than 14 days. Of the 43 detaines, 10, or 23%, had information regarding a physical exam in their medical file. Those with a completed physical often received the exam beyond 14 days ... in 3 of the 10 cases, no physical exam had been provided. For the seven cases with an exam date, an average of 40 days elapsed between the detainees' intake and the exam.

In its response to the report, ICE agreed to include regular sampling of detainee case files as part of its oversight procedures.

ICE's failure to enforce its own detention standards has long been a concern of NIJC and other detention reform advocates. The vague inspection reports we have had access to raised questions about whether the agency's monitoring practices provided sufficient oversight of facilities. This OIG report, following recent reports of more than 83 deaths in ICE detention (and an 84th death that was reported just this week), provides even more evidence that the U.S. government must be held responsible for respecting the standards it developed to ensure detainees are treated humanely.

Recommendations from the OIG's full report are:

Recommendation #1: Work with the Office of Inspector General to create a policy that would lead to the prompt reporting of all detainee deaths to the Office of Inspector General.

 

Recommendation #2: Work with the Division of Immigration Health Services, the Centers for Disease Control, and other experts, to enhance existing medical standards, rules for special needs individuals, and coverage guidance related to infectious disease.

 

Recommendation #3: Revise medical intake screening forms and physical exam questionnaires at detention facilities to include questions regarding the detainee's family history of cysticercosis.

 

Recommendation #4: Revise the notification section of ICE's detainee death standard to ensure that the agency and its detention partners report a detainee's death in states that require notification in the event of a death in custody. Documentation of this reporting should appear in a detainee's file.

 

Recommendation #5: Seek to enter into a memorandum of understanding with the Department of Justice, Office of Federal Detention Trustee that establishes a process that enables OFDT and ICE to regularly share information resulting from facility site visits.

 

Recommendation #6: Revise monitoring protocols and the medical detention standard to require sampling and continuous oversight of the 14-day physical exam standard across ICE's detention facilities.

 

Recommendation #7: Revise monitoring policies and other guidance given to reviewers regarding the materiality of site visit report findings to ensure that standards, such as tuberculosis screening and others related to access to medical care, weigh more heavily on a facility's compliance level.

 

Recommendation #8: Require reviewers preparing monitoring reports to use narratives to illuminate special areas of concern and provide additional details about issues relevant to a facility's compliance status.

 

Recommendation #9: Develop a standard that requires facilities housing ICE detainees to implement an internal review function.

 

Recommendation #10: Expedite all necessary discussions and resources to develop a system of electronic health records for ICE detainees.

 

Recommendation #11: Work with the Division of Immigration Health Services to identify all clinical staff shortages, then work with ICE's clinical partners to develop and implement a strategy to fill clinical staff shortages at immigration detention facilities.