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Washington D.C.
Tuesday, March 28, 2023

No Systemic Issues Found in OIG’s Review of CBP and ICE Deaths in Custody

Previously, during an unannounced inspection of the Adams County Correctional Center in Natchez, Mississippi, OIG identified concerns about one of the five individuals who died in ICE custody and made recommendations for corrective action.

The Office of Inspector General has reviewed the deaths of five individuals in custody reported by U.S. Immigration and Customs Enforcement (ICE) and the deaths of a further five individuals in custody reported by U.S. Customs and Border Protection (CBP) in fiscal year 2021. 

Contracted medical professionals reviewed the circumstances of each death, and OIG looked at the deaths overall to ascertain whether systemic factors, policies, or processes played a role. OIG’s report includes detailed case studies for each of the deaths it reviewed.

It is worth noting that ICE and CBP have different ways of defining “death in custody.” ICE defines “death in custody” as a case in which an individual dies under ICE’s supervision in a detention facility, medical facility, or in transit between facilities, or post release (within 30 days). CBP has extensive criteria to establish “death in custody” because it detains individuals in a variety of settings, including CBP vehicles, inspection locations, and holding facilities. CBP criteria categorize deaths as “in custody (reportable),” “not in custody (reportable),” and “not reportable” for the purposes of required annual reporting.

OIG found that no underlying systemic factors, policies, or processes played a role in the deaths of 9 of the 10 individuals and that both components reported their deaths to the Office of Inspector General as required. The watchdog was unable to evaluate the remaining individual’s death due to an ongoing criminal investigation. 

Previously, during an unannounced inspection of the Adams County Correctional Center in Natchez, Mississippi, OIG identified concerns about one of the five individuals who died in ICE custody and made recommendations for corrective action. An autopsy conducted by the Mississippi Office of the State Medical Examiner ruled the cause of death was atherosclerotic cardiovascular disease. OIG’s contracted physician noted that the individual’s ECG from December 17, 2020, showed significant changes from an ECG performed approximately 1 year prior — indicating an event that required more immediate action. Based on a review of medical records and the autopsy report, OIG’s medical contractor concluded that had the Adams medical staff compared the 2019 ECG with the one conducted on December 17, 2020, it should have prompted the medical staff to call 911 and send the detainee to the hospital, where life support care would have been readily available. Ultimately, the contracted medical physician found that care for this episode was not appropriate and further determined that the delay in getting the detainee to a higher level of care potentially contributed to his death. OIG said the facility has addressed the concerns raised during the unannounced inspection.

The contracted medical team reviewed the other four deaths in ICE detention in FY 2021 and found one individual was not provided timely or appropriate care by medical staff at the Calhoun County Jail in Battle Creek, Michigan. The individual experienced abdominal pains for approximately five weeks while in custody. His symptoms worsened and he also had significant weight loss, hypotension, and fall events. The medical team determined that appropriate actions to address his continued gastrointestinal complaints were not taken.

The contracted medical team found that measures taken by detention center medical staff for the other three individuals who died were appropriate. For example, in the case of an individual detained at Stewart Detention Center in Lumpkin, Georgia who died as a result of COVID-19 complications, the medical team determined that facility staff had performed COVID-19 screening and the emergency response at the facility was appropriate.

For CBP, as noted above, the contracted medical team could not fully evaluate circumstances related to one individual’s death due to an ongoing criminal investigation and insufficient medical records. On August 2, 2021, a group of migrants including Jason Gonzalez-Landaverde (a citizen of El Salvador) was spotted on a Border Patrol camera inside a ranch near Eagle Pass, Texas. Border Patrol agents located and apprehended seven migrants while several others fled. Agents continued to search for the individuals, and shortly thereafter apprehended five more migrants, including Mr. Gonzalez-Landaverde. He was initially handcuffed together with two other migrants, using two sets of handcuffs. According to CBP reports, Mr. Gonzalez-Landaverde became unruly and began causing discomfort to the other two individuals. When agents removed the handcuffs to separate him from the others, he attempted to escape and managed to run a short distance before being apprehended again. Agents reportedly restrained him with his hands behind his back and secured him on the hood of a nearby Border Patrol vehicle. Agents secured two other migrants on the front bumper of the vehicle and two in the back seat of the vehicle and then drove back to the location where the first group was apprehended. Upon arrival at that location, the Border Patrol agents removed Mr. Gonzalez-Landaverde from the hood of the vehicle and placed him on the ground; he remained restrained. Agents likewise removed the other migrants from the vehicle and then directed all migrants to sit on the ground nearby to await the arrival of a transport vehicle. When the Border Patrol transport vehicle arrived, approximately 1 hour later, agents discovered Mr. Gonzalez-Landaverde was unresponsive. The agents removed his restraints, began chest compressions, and requested EMS. When the Eagle Pass Fire Department arrived on the scene, medical personnel determined that Mr. Gonzalez-Landaverde was dead. CBP’s Office of Professional Responsibility (OPR) responded to the scene, interviewed migrants involved in the incident, and subsequently notified the Federal Bureau of Investigation, OIG, and the local sheriff’s department. CBP OPR and the Webb County Medical Examiner’s Office are reviewing this incident, which is under investigation by the Texas Rangers. At this time, the criminal investigation is ongoing. 

For the other four individuals who died in CBP custody, the medical team concluded that all measures taken by CBP and medical staff were consistent with applicable standards. 

Because OIG and its contracted medical team found no systemic issues warranting corrective action, it is not making any recommendations to ICE or CBP.

Read the full report at OIG

Kylie Bielby
Kylie Bielby has more than 20 years' experience in reporting and editing a wide range of security topics, covering geopolitical and policy analysis to international and country-specific trends and events. Before joining GTSC's Homeland Security Today staff, she was an editor and contributor for Jane's, and a columnist and managing editor for security and counter-terror publications.

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