(NewsNation) — Almost all of the deaths that occurred in immigration detention between 2017 and 2021 could have been prevented if not for “systemic failures in medical and mental health care” by federal authorities, a new report said. 

The report, released Wednesday by the ACLU National Prison Project, Physicians for Human Rights and nonprofit watchdog group American Oversight, examined all the deaths reported by U.S. Immigration and Customs Enforcement (ICE) between January 1, 2017, and December 31, 2021.

Of the 52 reported deaths, 49 likely could have been prevented if ICE had provided clinically appropriate medical care, according to the findings. There were only three cases where someone’s life could not have been saved regardless of medical treatment. 

In some of those deaths, ICE detention medical staff provided incomplete, inappropriate, or delayed treatment and medication, failed to provide timely and appropriate emergency care, and failed to provide adequate mental health care and ensure sufficient staff, among other missteps, according to the report. 

ICE and the report’s authors did not immediately return a request for comment by NewsNation. 

The immigration agency says it provides noncitizens with “comprehensive medical, dental and mental health care ” the moment they arrive at an agency facility, according to its website. ICE has a Health Services Corps, dedicated to “providing comprehensive health care for all noncitizens detained in ICE custody.”

When a noncitizen dies in an ICE detention center, it must report the death within 12 hours and the agency conducts all medical reviews and compliance investigations, according to its website. ICE’s Office of Professional Responsibility then drafts a report to determine whether the agency adhered to all policies and protocols.

“Many noncitizens may not have received recent or reliable medical treatment for existing conditions prior to entering ICE custody. For some individuals, this may represent their first access to comprehensive medical care,” the agency wrote on its website.

The report’s findings were based on 14,500 pages of documents obtained through public records requests from the Department of Homeland Security, ICE, local government agencies, and civil litigation. 

The report cited several cases of migrants whose medical needs were neglected or misdiagnosed. 

Jesse Jerome Dean Jr., a 58-year-old migrant from the Bahamas, died in ICE custody in 2021 from an undiagnosed gastrointestinal hemorrhage.

Dean was unable to eat, lost almost 20 pounds in three weeks, and suffered from severe nausea, but the Michigan detention facility’s medical staff didn’t refer him to a doctor, the report stated. 

Surveillance footage from the night of his death showed that “for at least 2 hours and 45 minutes throughout her shift, (the nurse) was reclining in the nursing station chair with her feet propped up, texting on her cell phone,” but did not check on Dean who had collapsed, according to the report. 

An ICE news release stated Dean was admitted to the medical monitoring unit the day before his death, after making complaints that day.

Cuban detainee Wilfredo Padron, 58, died of a heart attack in 2018 after medical staff at a Florida detention center failed on multiple occasions to conduct an EKG test or refer him to a doctor when he complained of radiating chest pain and elevated blood pressure, according to the report. 

In a news release, ICE said Padron was found unresponsive in his cell, and staff at the detention center began CPR and used a defibrillator before transferring him to a nearby hospital.

“These deaths raise serious concern about continued, systemic problems with medical and mental health care provided in immigration detention facilities, and the absence of accountability or consequences faced by facilities where detained people have died,” the report said. 

The report also said that after deaths took place, ICE staff allowed the “destruction of evidence, have failed to interview key witnesses, and have omitted key inculpatory facts” in order to insulate themselves from repercussions. 

In 61% of the detainee death cases, ICE detention staff “falsified or made improper or insufficient documentation of patient checks and provision of medical care.” 

ICE houses 38,400 people each day in over 120 public and private detention facilities nationwide. President Joe Biden recently increased ICE’s budget to detain 41,500 people on a daily basis at a cost of $3.4 billion. 

Over 200 organizations, including Human Rights Watch, the National Immigrant Justice Center and Amnesty International, called Biden’s funding “an utter betrayal of campaign promises” in a scathing open letter earlier this year.  

More than 90% of people detained by ICE are held in detention facilities owned or operated by private prison corporations, which are also responsible for providing medical care, according to the ACLU. 

But many of these centers have little to no oversight and have historically been riddled with underlying systemic abuse and inhumane treatment, federal investigations have found. 

Inspection reports by the Department of Homeland Security’s Office for Civil Rights and Civil Liberties examined multiple ICE facilities across 16 states from 2017 to 2019 and found “negligent” medical and mental health care, “unsafe and filthy” conditions, racist abuse of detainees, inappropriate pepper-spraying of mentally ill detainees and other problems that, in some cases, contributed to detainee deaths, reported NPR.

The number of detainee deaths is likely higher as ICE does not include people it releases immediately prior to their deaths, Wednesday’s report claimed. The agency has “admitted it reduces the number of reported deaths, and allows the agency to avoid accountability requirements,” it stated.

The report also offers several recommendations addressing DHS, the Department of Justice, Congress and state governments directly. 

Among the recommendations is for Homeland Security to dismantle mass immigration detention and instead invest in community-based social services for migrants. 

It also asks Congress to reduce ICE funding and to conduct rigorous oversight of detention conditions and calls on state and local governments to prohibit intergovernmental services agreements with the federal government for civil immigration detention.

“Medical and public health experts have widely documented the significant harm to physical and mental health suffered by people in detention,” the report stated. “ICE has permitted scores of detention
facilities to abide by only lax standards for the provision of medical and mental health care.”