McALLEN, Texas (Border Report) — The death in May of an 8-year-old Panamanian migrant girl in U.S. Customs and Border Protection custody in South Texas was “clearly preventable” had protocols been in place to identify vulnerable youth, according to a court report submitted this week by an independent auditor.

The Tuesday report noted numerous medical failures by the federal agency. It was produced by a California pediatrician who oversees CBP facilities in West Texas and in the Rio Grande Valley of South Texas, to ensure the facilities comply with a federal court settlement known as the Flores Settlement that dictates the conditions and 72-hour maximum holds for migrant children.

Anadith Reyes Alvarez died May 17 after suffering cardiac arrest while at the CBP processing facility in Harlingen, Texas, where she was being isolated for a high fever and the flu. She had been held for eight days.

The girl had a previous heart condition and sickle cell anemia, and according to the report, there were “systemic procedures and policies that proved catastrophically inadequate to prevent the deterioration of (her) condition.”

Namely, the report criticizes a lack of medical consultations, or follow-ups for children with previous medical conditions who are in custody; a hesitancy by the federal agency to transfer ill individuals to local hospitals; and overcrowding of migrants that could have led to Anadith’s condition being overlooked during her nine days in custody.

Her “death raise a series of other profound concerns regarding not only the direct care she received but also the custodial and medical systems that failed to prevent ADRA’s clinical deterioration and death,” according to the report.

The report was submitted by Dr. Paul Wise, juvenile care monitor, who was appointed by the U.S. District Court for the Central District of California. Anadith’s name is not used in the report, only her initials.

‘Systemic failures’

“The death of ADRA was a preventable tragedy that resulted from a series of failures in the CBP medical and custodial systems for children. The proximate cause was poor clinical decision-making by the health providers responsible for her care in the Harlingen BP Station on the day of ADRA’s death. However, this report is focused on the systemic failures that permitted poor clinical decision-making by several health providers to result in a child’s death. These failures occurred at multiple levels and should not be viewed as rare anomalies but rather as systemic weaknesses that if not remedied, are likely to result in future harm to children in CBP custody,” Wise wrote.

Transfer out children

The Harlingen facility is no longer being used for medical care of vulnerable migrants, but going forward, Wise suggested these overall changes agency-wide to prevent future incidents:

• Reduce the number of medically-fragile migrant children in CBP custody by transferring them to other agencies more equipped to handle them.
• Prioritize their movement by identifying those who are at elevated medical risk.
• Medical providers must report medically vulnerable children in custody and track their cases.
• More consults with pediatric advisors of children who are medically at risk.
• All children put in medical isolation wards must first receive enhanced medical monitoring, regular assessment of vital signs and other clinical studies.

The report suggests children at risk should be medically assessed at least once per shift.

Anadith’s mother, according to a CBP report, took her for medical care three times in three days prior to the girl’s death. She repeatedly requested the girl be sent to a local hospital.

CBP issued a report blaming contract medical personnel for failing to transfer her to a hospital.

But Priscilla Orta, a supervising attorney for  Project Corazon, a part of Lawyers For Good Government, told Border Report on Wednesday the processing of children should be immediate so they can be transferred to other federal agencies that are more equipped to meet their needs.

“CBP was never designed to house children. And it was never designed to house anyone long term. And it was never designed to really house people with serious medical needs. That was never ever ever the design. CBP was designed to process people at the border, check their papers and and then either give them to ICE (Immigration and Customs Enforcement), or parole,” Orta said.

Orta said the additional responsibilities placed on CBP officers, such as conducting credible fear interviews, further strains their resources and stretches thin services, and can lead to more dire consequences.

When Anadith’s family crossed from Matamoros, Mexico, into Brownsville, Texas, on May 9, she was among thousands crossing the border into South Texas in the days leading up to the expiration of Title 42. After that public health order was lifted, the Department of Homeland Security has put in Title 8 enforcement guidelines, which prevent migrants from claiming asylum if they illegally cross the border, or if they don’t apply via the CBP One app.