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The nurse only gave me ibuprofen and that only alleviates me for a few hours.Let me know if you can help me.” At the time of ICE’s report on its investigation, the final cause of death had not yet been determined, but as detailed below, the facts revealed in the ICE investigation show that systemic indifference to his suffering and systemic failures in the healthcare system spurred his death.

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A correctional health expert said of the care he received, “Medicalabandoned this patient by not properly assessing him or following up.” Medical experts identified numerous and significant delays in the care “Jose L.” received while detained at Adelanto Detention Facility for three years, including a failure to act quickly to address vision problems that likely led to him becoming legally blind in his right eye.

“Carlos H.” tore his ligament while detained at Yuba County Jail in California, but it was not properly diagnosed for three months because he kept seeing licensed vocational nurses who did not refer him to a doctor, and then ICE further delayed his scheduled surgery repeatedly without providing any clinical reason.

They also found numerous examples of systemic substandard and dangerous medical practices in other cases—such as overreliance on unqualified medical staff, delays in emergency responses, and requests for care unreasonably delayed.

The cases examined represent a small but not necessarily representative sample—though many of them point to much larger, systemic failures of healthcare provision and government oversight that have likely put many more thousands of other detained individuals at risk.

The mental health care she received was deemed “woefully inadequate” by an independent expert.

Santiago Sierra-Sanchez, detained at Utah County Jail, died of a staph infection and pneumonia.At time of writing, it was unclear how the Trump administration would address the issue, but its pledge to sharply increase the number of immigrants subject to detention and reports it is also planning to roll back protections for immigrants in detention, raise serious concerns that the problems fueling the unnecessary suffering could grow even worse.As with our assessment of the Morales-Ramos case above, this report is based in large part on review by independent medical experts of ICE’s own investigations into deaths in custody and, in a range of other cases that did not involve deaths, independent review of detained individuals’ medical records as well as interviews with people who have been detained, family members, and those who have worked closely with them.He was first detained at Theo Lacy Facility, operated by the Orange County Sheriff’s Department, and then at Adelanto Detention Facility, operated by the private company Geo Group, both of which had contracts with US Immigration and Customs Enforcement (“ICE”) to hold non-citizens for immigration purposes.An ICE investigation into the death of Morales-Ramos found that the medical care he received at both facilities failed to meet applicable standards of care in numerous ways.On April 6, 2015, Raul Ernesto Morales-Ramos, a 44-year-old citizen of El Salvador, died at Palmdale Regional Medical Center in Palmdale, California, of organ failure, with signs of widespread cancer.

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