A newly released report examining the death of an immigrant in the custody of U.S. Immigration and Customs Enforcement (ICE) found that the government failed to meet multiple standards intended to protect detainees' health. Investigators wrote that the facility did not complete a required health assessment on time and ignored an abnormally high blood-pressure reading, and the report suggests nursing staff may have missed the signs of an ultimately fatal blood clot.
Though the death occurred last year and the investigation was completed more than seven months ago, ICE had declined to release its report, and only relented after pressure from members of congress, immigration lawyers and public records requests from media organizations, including NPR.
ICE's investigation does not attribute the immigrant's death to the failures identified in the report. Still, the findings raise additional questions about long-standing problems inside ICE detention centers at a time when the Biden administration is locking up increasing numbers of migrants amid an increase of border crossings. The government's own inspectors have found "barbaric" and "negligent" conditions in ICE detention, according to a trove of more than 1,600 pages of secret inspection reports NPR recently obtained through a years-long reporting effort.
Melvin Ariel Calero-Mendoza, a 39-year-old man from Nicaragua seeking asylum in the U.S., died while in the custody of the Aurora ICE Processing Center in Colorado on Oct. 13, 2022. A coroner's report found that Calero-Mendoza's sudden collapse and death were caused by a pulmonary embolism — a blockage of the blood-flow to the lungs that originated in his lower limbs.
Calero-Mendoza had told the facility's medical staff three times that he was experiencing serious pain in his legs and feet prior to his death, according to the report. But his medical care in ICE detention was handled almost entirely by licensed practical nurses (LPNs), who are generally qualified to provide basic care, and not doctors.
"For the most part, LPNs are people that have gone through one or two years of schooling after high school and are really there to take blood pressure [and] check vital signs," said Dr. Parveen Parmar, a professor of clinical emergency medicine at the University of Southern California, who reviewed the ICE investigation. "They're not really people that should be giving definitive care and making final clinical decisions."
During an exam two weeks before his death, a nurse noted that Calero-Mendoza reported severe pain, his blood pressure was elevated, his blood oxygen level was below normal and the painful area of his leg was "warm to the touch."
Those symptoms are consistent with the presence of a potentially dangerous blood clot, said Dr. Parmar. But the ICE's investigation does not indicate that the nurse who examined Calero-Mendoza ordered any additional tests.
Dr. Parmar, who has studied dozens of deaths in ICE custody, said doctors have more training to recognize the significance of the kind of symptoms Calero-Mendoza had and could have taken potentially life-saving action.
"If this patient had come to an emergency department, for example, and if somebody had put this together and done an ultrasound," said Dr. Parmar, "they could've been put on blood thinners and their life could've been saved."
The facility's medical director later explained the nurse's decision-making to investigators, in part, by saying that lower blood oxygen levels are "commonly seen in high altitude locations like Denver."
The report notably does not address a 911 call made from the facility after Calero-Mendoza collapsed, hit his head on a wall and began foaming at the mouth.
On that call, the detention officer at the ICE facility appeared unable to answer basic questions from the 911 dispatcher. The officer said he did not know the facility's address or how the ambulance could access the building; he did not know what the medical emergency was; he gave the wrong age for Calero-Mendoza; and he put the dispatcher on hold multiple times.
NPR and Colorado Public Radio first reported the contents of the 911 call, which was obtained under a public records request. Experts in emergency medical response told NPR that the call appeared to indicate gaps in training and a disorganized response.
The fact that ICE omitted the 911 call from their investigative report "calls into question the completeness and the methodology they used during their investigation," said Elizabeth Jordan, an attorney representing Calero-Mendoza's family.
A spokesperson for ICE did not address NPR's questions about whether agency investigators reviewed the 911 call and if not, why.
Calero-Mendoza's family has questioned the medical treatment he received in ICE custody and fought for the release of the ICE's investigation for months.
ICE's report was completed in March 2023. Despite multiple requests under the Freedom of Information Act (FOIA), including from NPR, ICE declined to release the document. In September, U.S. Rep. Jason Crow and Senators Michael Bennett and John Hickenlooper, all of whom are Democratic members of Colorado's congressional delegation, sent a letter to ICE's acting director, pushing for its release.
In the end, ICE only released the report after Jordan filed a lawsuit, which cited NPR's reporting, and asked a court to compel the agency to release the document under FOIA.
Jordan called ICE's delay in releasing the report "inexcusable."
"The family is deeply frustrated that it has taken this long and taken federal litigation to shake the report loose," said Jordan. She said they "would like to know what happened, and the government is the only actor involved here who can explain what happened."
Jordan continues to seek Calero-Mendoza's detailed medical records, which ICE has not yet handed over.
"Mr. Calero-Mendoza died in an ICE facility over a year ago, the death report was completed over seven months ago, and the family is just now seeing it. That's unacceptable," said Rep. Crow, who represents Aurora and has made oversight of the city's ICE detention center a priority. "Every person should be treated with dignity and respect, and the private, for-profit immigration detention system fails too many communities like ours."
In an emailed statement, an ICE spokesperson did not address any of the findings in the detainee death review. The statement said that, "All facilities that hold ICE detainees are evaluated regularly under ICE's detention standards, which have requirements for detainee health and safety, legal access, visitation requirements and more."
The spokesperson did not address why the agency delayed the release of the report.
ICE also contended in its email to NPR that all detainees receive an initial health screening within 12 hours and a full health assessment within 14 days of arrival at a detention facility.
ICE's own review of Calero-Mendoza's death, however, directly contradicted the agency's claim.
The investigation found that the facility took 19 days to conduct a full health assessment, a violation of ICE standards. Other government investigations have found that intake health screenings are a persistent problem. A recent inspector general report examined one of the largest ICE facilities in the country, the Stewart Detention Center in Georgia. In a majority of cases examined by the inspector general, detainees received no intake health screening before being locked up.
An ICE spokesperson did not provide any comment on the discrepancy between the findings of ICE's own investigation and its statement to NPR.
ICE holds the vast majority of immigrant detainees in facilities run by for-profit companies, while a smaller number are placed in county jails. During the 2020 presidential campaign, Joe Biden promised to end the government's reliance on for-profit companies to detain immigrants. In office, however, the Biden administration has more than doubled the number of immigrants held in ICE detention. The White House has said that it continues to support "moving away" from for-profit detention and blamed congress for inaction.
The Aurora ICE Processing Center is run by the GEO Group, a for-profit government contractor. Calero-Mendoza's death has further intensified scrutiny of the Aurora facility and the medical care it provides detainees.
"As previously and publicly expressed, we offer our condolences to Mr. Calero-Mendoza's family and remain committed to ensuring the health and safety of all those in our custody and care," said a GEO Group spokesperson in an emailed statement. While the statement emphasized GEO Group's commitment to protecting detainees' health and safety, the spokesperson noted, "We do not comment on specific cases that relate to individuals in the care of U.S. Immigration and Customs Enforcement."
A 2018 report by the Department of Homeland Security's Office for Civil Rights and Civil Liberties found that the Aurora ICE Processing Center's medical staff did not notify a detainee that they had been diagnosed with HIV, failed to treat detainees' diabetes and delayed another's cancer treatment for months. The expert inspector examining the facility wrote that if such problems were found in a hospital, it could be forced to shut down.
The report also rebuked the facility for the death of a 64-year-old immigrant from Iran named Kamyar Samimi, who succumbed to complications of opioid withdrawal while in custody.
"The complete lack of medical leadership, supervision and care that this detainee was exposed to is simply astonishing and stands out as one of the most egregious failures to provide optimal care in my experience," the medical expert wrote. "It truly appears that this system failed at every aspect of care possible."
Dr. Parmar said that Calero-Mendoza's death in 2022 appears to fit a pattern she's observed in ICE detention facilities across the country.
"We see the same mistakes getting made over and over again," said Dr. Parmar.
This story has been updated with comments from U.S. Rep. Jason Crow.
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