This report is part of a series regarding Human Rights Conditions at the Northwest Detention Center in Tacoma, Washington, based on ongoing research efforts and released to highlight initial findings in the urgent context of the COVID-19 pandemic.
Allegations of Medical Neglect
This report is part of a series regarding Human Rights Conditions at the Northwest Detention Center in Tacoma, Washington, based on ongoing research efforts and released to highlight initial findings in the urgent context of the COVID-19 pandemic. As described in our methodology section, our research team has conducted research on the human rights implications of federal immigration enforcement in our state, including the conditions of confinement at Tacoma’s Northwest Detention Center or NWDC (officially known as the Northwest ICE Processing Center, or NWIPC) since 2017. This research involves the acquisition and analysis of DHS, ICE, and GEO documents released to UWCHR through ongoing FOIA litigation, as well as the review of accounts provided by detained and formerly-detained migrants, in collaboration with human rights defenders from organizations including La Resistencia, the Whatcom Civil Rights Project, the ACLU of Washington, and others.
Under international human rights law, civil (or administrative) detention should be a measure of last resort, rather than a routine practice immigration enforcement. While in detention, the UN Standards of Rules for the Treatment of Prisoners, known as the “Nelson Mandela Rules,” stipulate that, “Prisoners should enjoy the same standards of health care that are available in the community, and should have access to necessary health-care services free of charge without discrimination on the grounds of their legal status.” There is a great deal of evidence that suggests that these standards are routinely violated by ICE in its detention facilities, including the NWDC.
The NWDC’s medical facilities
The Northwest Detention Center is owned and operated by GEO Group, a private company. As one of 21 ICE-designated facilities in the United States, health care services within the facility are provided by Public Health Service personnel employed by ICE Health Service Corps (IHSC) and governed by the standards established in the PBNDS 2011 (revised in 2016). According to ICE, the facility employs 36 medical/mental health personnel and its clinic is staffed 24 hours a day, 7 days a week; its physical infrastructure includes six examination rooms, an urgent care room, and a Short Stay Unit with one double occupancy room and seven single occupancy rooms, four of which are equipped with negative pressure rooms for respiratory isolation.
ICE and GEO tout the medical care provided at the facility. In a September 2019 media tour of the NWDC, Director Nathalie Asher “maintained that medical and mental health care was a top priority,” and ICE appears to consider the NWDC’s medical facilities amongst the best in the agency’s detention network. For example, in January 2020, when the transgender unit at Cibola Correctional Facility in New Mexico was closed over findings that it was providing inadequate health care, 13 women from the unit were transferred to Tacoma. When asked why the NWDC had been selected as their destination, an ICE spokesperson emphasized that while multiple factors figure into decisions about where to detain a given person, “it is well-known that the medical care provided by the NWIPC’s Public Health Service officials (under the ICE Health Services Corps) is first-class. They are equipped to handle some of the most complex medical cases.” UWCHR’s review of internal ICE records suggests that the NWDC is also seen as a place with specialized knowledge of hunger strike management.
The NWDC is also subject to a proliferation of oversight mechanisms. Per ICE rules, the facility is inspected annually by the agency’s Office of Detention Oversight (ODO) and by the Nakamoto Group, an outside company contracted by the Custody Management Division (CMD); both of these evaluations include scrutiny of the health care services provided. In addition, according to the U.S. Government Accountability Office, “ICE uses various other oversight mechanisms, like Field Medical Coordinator (FMC) site visits and on-site Detention Service Managers (DSM), to assess compliance with detention standards in more detail. For example, FMC site visits and IHSC quality improvement audits look at the quality of medical care at facilities in relation to detention standards by reviewing medical care processes in more detail than the CMD inspections.” ICE has also equipped its Medical Quality Management Unit (MQMU) to review medical records from its facilities and detect any deficiencies. In addition, ICE, GEO, and DHS also make available a wide array of grievance mechanisms that permit detained people, their families, and advocates to voice complaints. These include an in-facility grievance system through which those detained can file formal and informal complaints with ICE, GEO, or IHSC, and appeal them, if unsatisfied, through various tiers, in addition to complaint lines monitored by DHS’ ostensibly independent bodies, the Office of the Inspector General (OIG) and Office of Civil Rights and Civil Liberties (CRCL).
Unfortunately, there is little reason to believe these mechanisms are effective. ICE’s own employees have deemed the inspection process meaningless; in recent years, a growing number of medical employees have become whistleblowers about the quality of care in ICE facilities, asserting that the agency’s reporting requirements intended to enable internal oversight are routinely flouted, either by failing to review Significant Event Notifications altogether or by ignoring Medical Quality Management Unit interventions when deficiencies in health care are detected.
For many years, detained people have raised concerns about medical neglect at the facility through all channels available to them: they have shared personal accounts with the media; included demands for access to improved medical care in hunger in declarations of collective protest, such as hunger strikes; requested their release on medical grounds; filed grievances through the facility’s internal grievance system, and lodged complaints with the Department of Homeland Security’s Office of the Inspector General and/or its Civil Rights and Civil Liberties division.
While it is easy to observe patterns amidst the complaints, evaluating individual claims is difficult. Many detained people report that ICE health personnel keep them in the dark about their own medical treatment, leaving them unfamiliar with what diagnoses they have received or what medications they are taking. While access to detailed medical records would enable researchers to understand the treatment plans recommended by medical providers and to evaluate the care actually received against such recommendations, many people in detention find it difficult to access their own records, so complaints made public through the above means are typically based only on patients’ own understanding of their health. This can introduce inaccuracies and pose challenges to assessment.
Despite these challenges, the complaints asserted by detained people are simply too voluminous, and the issues they raise are too serious, to discount them as hearsay. What’s more, trained professionals who have gained access to other detention facilities—including their patients’ medical records—have documented very similar patterns, suggesting that systematic deficiencies exist in ICE’s health care system. And in recent years, volunteer medical professionals who have initiated a program of visiting those detained at NWDC in an attempt to monitor their treatment have also reported grave problems in medical care at the facility. In the below, we trace patterns of health care practice that UWCHR researchers were able to substantiate using multiple of these sources, in violation not only of international human rights standards, but ICE’s own rules.
Longstanding concerns about medical care at the NWDC
People detained at the NWDC have consistently raised concerns about the lack of access to quality medical care within the facility. In hunger strikes in 2014, 2017, 2018 and 2020, immigrants within the facility demanded improved access to medical care. They have also shared concerns about medical neglect with journalists, even when this may have led to retaliation or accelerated their deportation.
Since 2018, a group of volunteer medical professionals associated with La Resistencia, a grassroots organization working to end the detention and deportation of immigrants, have been visiting detained people with serious medical concerns at NWDC and documenting their concerns through regular follow-up; where possible, they have also obtained copies of relevant medical records. UWCHR researchers interviewed a member of this group, nurse practitioner Wendy Mironov, who shared her perception of recurrent patterns of medical neglect in the facility and provided records and background of specific case studies to illustrate these broader trends.
As a means of investigating recurring concerns raised by detained people and their advocates, UWCHR also sought copies of internal documentation about complaints filed with DHS’ OIG and CRCL, ICE, and GEO about conditions at the NWDC. Through litigation, we obtained copies of internal grievances filed with GEO and ICE; and under FOIA, UWCHR researchers were able to access a log of NWDC complaints about the NWDC registered with DHS CRCL. Our review of both sets of documents revealed that allegations of medical neglect were foremost among the complaints registered by detained people. Of the roughly 3500 pages of grievances from 2012 to 2018 reviewed to date, after questions about the deportation process, this was the most common area of concern. Among the 101 complaints logged by DHS CRCL from 2014 through 2019, thirty-five involved the lack of access to quality medical care.
The scope of concerns articulated through these mechanisms is far too broad to represent them all here; furthermore, lack of access to records limits the extent to which many can be investigated. We therefore focus in the below on three overriding areas where the evidence assessed from multiple sources related to the NWDC coincided with patterns documented in other facilities around the country, suggesting a systematic concern. These areas are the denial or delay of treatment, cruelty to patients, and the mismanagement of chronic conditions, especially mental health.
Care denied or delayed
ICE’s PBNDS chapter on Medical Care stipulates that “Detainees shall be able to request health services on a daily basis and shall receive timely follow-up,” noting also that “twenty-four hour emergency medical and mental health services shall be available to all detainees.” Yet detained people at NWDC routinely report that when seeking access to medical care, their concerns are ignored, either because GEO guards deny them permission to visit the medical clinic or, more frequently, because in the clinic, the medical staff belittles their concerns. Many people report that those who experience illness and seek treatment at the NWDC clinic are simply told to drink water, or occasionally given over-the-counter pain medications, without any serious analysis of their health needs. This pattern of dismissals of patient concerns is also reflected in investigative reports on conditions in other ICE facilities nationwide. At the NWDC, it is articulated in grievances submitted to ICE, GEO, and the IHSC, complaints registered by the DHS CRCL, and in records shared with us by advocacy organizations, including La Resistencia and the Whatcom Civil Rights Project.
Grievances filed through the NWDC’s internal mechanisms include space for the facility’s response. Typically, facility staff refer those who complain that they have been denied care to the clinic’s daily “sick call” at 5:30 am, in most cases not addressing the fact that the grievance itself describes at least one prior visit to the clinic in which the patient was unsatisfied with the care received; simply sending them back for more of the same seems unresponsive to their concerns. Indeed, grievances were almost universally labeled “not a grievance.” Occasionally, facility staff deflect concerns by insisting, on GEO grievances, that the issues should be raised with ICE, and on ICE grievances, that they should be raised with GEO.
- On May 5, 2015, a detained person from El Salvador noted in a grievance submitted within NWDC that “I have a bad cough and was in the clinic last night and this morning, but they didn’t give me anything, I drank water, my chest, throat, and head hurt a lot and I don’t know what to do, I can’t sleep, I feel that I can’t breathe, and I don’t want to stay like this, I need medicine.” The response, apparently by the facility commander, was, “This is not a grievance,” and instructed the person to go to sick call the next morning, an apparently unpersuasive response given that the person reported twice having been to the clinic without receiving care.
- On October 4, 2015, a Salvadoran national reported having been unable to sleep all night due to excruciating stomach pain and repeated vomiting; their complaint was that they had asked the GEO officer for permission to go to the medical clinic, but the officer refused to give permission. On October 8—four days later—the Commander responded directing the person to go to sick call the following morning at 5:30 am.
- On June 14, 2016, a detained person from Mexico reported chest pain, saying, “I am afraid of dying here, I’ve seen all the doctors and it doesn’t get better, I want them to take me to the hospital, I’m tired of asking for help and no one helps me.” The facility’s response was, “This is not a grievance – if you require medical assistance, you can always attend sick call, available to all detainees.”
In other cases, detained people presented more complex medical needs than the facility could be expected to handle in-house, yet they were denied access to speciality care. ICE’s PBNDS requires that, “[a] detainee who is determined to require health care beyond facility resources shall be transferred in a timely manner to an appropriate facility,” but in several well-documented cases, medical providers within the facility deemed the care to be “elective” and denied authorization for off-site treatment. According to a report by the United States Government Accountability Office, “The IHSC Detainee Covered Services guidance, issued in 2010 and under revision in fiscal year 2016, …states that ICE ‘must provide medically appropriate treatment to ICE detainees who have identified any serious medical needs.’ The guidance goes on to define ‘serious medical need’ as a condition that when left untreated could result in further significant injury or unnecessary pain.” Yet many of the accounts reviewed by UWCHR researchers involved immigrants with apparently worsening injuries and/or significant pain for whom off-site treatment was denied.
For example, one of the cases documented by medical providers associated with La Resistencia involved a man who had been the victim of assault in El Salvador in 2012, resulting in a radius and ulnar fracture which Salvadoran doctors treated by placing rods and a screw in his wrist. Due to the circumstances of the assault itself, he later fled the country to seek political asylum in the United States. During his time in NWDC detention, he sought treatment for growing pain in his wrist which resulted from the initial fracture, as the screw was visibly emerging from the bone, causing the skin to form a “tent” at the site of the injury that was clearly visible to the medical witness even when viewed through the glass barrier in the visiting room during the interview. In the NWDC clinic, a physician’s assistant told him surgery was needed to correct the problem, but deemed it “elective” surgery and did not refer him to a specialist for consultation. At the time of his deportation in 2020, the injury was still untreated.
In another case, on August 10, 2016, a detained person from Honduras complained that one month after suffering an injury while playing soccer at NWDC, his knee was still swollen and painful. He had been taken to the emergency room and was told he would be referred for an MRI, but the MRI never happened. In response, his provider wrote, “I am sorry to hear that you continue to be in pain. …When you went to the ER the intent was to get an MRI but instead the ER got X-rays that were NEG (normal). Still when you returned I submitted a request for an MRI, but this was denied. …I then referred you to physical therapy. An appointment is pending for you to go and see them. Unfortunately this can take a lot longer than we want because we have limited resources/private clinics we contract with to deliver you care while detained.” The patient appealed, reiterating that over a month had gone by and the pain he was experiencing was “unbearable”; upon reviewing the appeal, the Clinical Director responded “I have reviewed your medical records and the care provided by [name redacted]. Based on the review, the conservative management afforded to you to date appears to be sensible and in keeping with appropriate standards of care.”
The same language about “conservative management” of a condition appears in a series of grievances filed in July and August 2016 by a detained person from Mexico who was seeking treatment for a painful, growing lump that had appeared on his head after his arrival at NWDC. In the first grievance, on July 18, the detainee complains that he has already visited the clinic three times without receiving treatment, and now wanted to see a dermatologist. The grievance is then forwarded through a series of facility personnel, one of whom writes, “I have reviewed your case and have discussed with Commander [name redacted]. Based upon review, his plan for conservative management appears appropriate.” On July 28, the patient again appeals for help, and an NWDC provider reviews the medical record again, noting that it says the growth has existed for years—contrary to the patient’s own description—and is “minimally tender.” On August 3, the patient again complains, “Again I have not gotten any response from anybody in my request to get my medical problem resolved,” to which one of the providers responds, “the lesion does not restrict your movement or impair your function and thus cannot be justified to be sent outside for removal. Additionally, I am not trained on how to remove them from the scalp. I want to reassure you that this is not an emergency or a serious condition but as a result will probably not be removed either.”
Even in cases where a detained person receives a diagnosis of a serious condition while in detention, complaints persist about denials of access to care. One case that illustrates this pattern is that of Angel Padilla, a Salvadoran immigrant whose case was documented in NWDC grievances, complaints registered by CRCL, media reports, and by advocacy organizations. In mid-November 2015, while detained at the Mesa Verde Detention Center in Bakersfield, California, he complained of back pain, eventually leading to the detection of a cancerous mass on his left kidney. In December 2015, he collapsed at the facility and was rushed to an emergency room, where a surgeon examined him and said the mass needed to be removed as soon as possible. In 2016, he was told that the detention center in California could not accommodate his medical needs, and that he would be sent to the NWDC for this reason.
Upon arrival in Tacoma, however, Padilla still did not receive treatment. On February 18, 2016, while waiting to see a visitor he became dizzy and asked for help, but was told he could not be seen in the clinic because he did not have an appointment. After vomiting and passing out, he was taken to St. Joseph’s Hospital. The next day, he filed a grievance about this incident: “On 2/18/16 I was in intake and I got sick which ended with me going to the hospital. I let [name redacted] know that I was having medical issues and all he could do is worry at the fact that I was hitting the window in order to get someone’s attention there. He told me that I didn’t have an appointment for med and I was going back to my pod. I kept banging on the window and he kept refusing me medical treatment, it didn’t matter how hard I tried he wouldn’t help me. I also asked [name redacted] and she refused me as well.” The facility’s response to this grievance was “Your issue is noted; however this is a GEO issue. Please refer your issue to GEO.”
“They kept passing the ball around so that they didn’t have to do anything,” Padilla later told a reporter, describing his experience seeking medical care at the NWDC. Furthermore, after filing the above grievance, Padilla began receiving onions in his food—something strictly prohibited under the medical diet he was on. He filed repeated grievances about this, on March 19 writing, “I have been having a constant problem with onions being on my meals medically I can’t eat them and I can’t seem to get this problem resolved with staff every time that I ask for a new tray staff seem to get bothered by it, so now I am being retaliated by being fed a pile of beans and rice and it seems to be a laughing matter or like my health is a joke of some kind I need help with this matter.” The facility response was “This is not an ICE grievance. Please submit your request to GEO to resolve.”
On April 19, Padilla again filed a grievance about the facility’s noncompliance with his medically restricted diet, noting “I have tried to address this with GEO but it is clear that they don’t care about this issue, so now I am coming to ICE with it. I need help with this issue, it has been going on for months now and they are playing with my health and life.” ICE responded,”There is a 3 level grievance procedure. GEO needs to elevate the grievance you filed if it has not been resolved.” It is unclear why GEO would be the only party able to elevate a grievance if the grievance in question is filed against them. In fact, Padilla responded to this effect on April 20: “What am I to do when GEO doesn’t allow me to follow the three level procedure and just closes out my grievances by making them unappealable???? this is not the first time that they do this and they have done this with most of my grievances that I have filed on them??” The facility responded, on April 21, “Not a grievance.”
Throughout this time, he continued to await treatment for cancer. Multiple organizations, as well as the office of Rep. Adam Smith, advocated on Padilla’s behalf. Due to the gravity of his medical condition, a judge ruled in late April 2016 that he was eligible for release on bond, and thanks to the efforts of multiple organizations who raised the $15,000 bond, he was able to return to California for cancer treatment.
More recently, the case of Jamaican national Karlena Dawson illustrates some similar trends. Dawson developed cirrhosis while in detention, and was hospitalized for several days in June 2019 for “intractable abdominal pain,” according to an ICE document reviewed by UWCHR. Since that time, she reported pain, swelling, and gastrointestinal problems, and was eventually told by doctors that she required a liver transplant. She received no follow-up treatment for liver care, though according to Wendy Mironov, standard procedures for a patient whose ongoing pain indicates an active disease process would include monitoring by a hepatologist, with visits to track her platelet counts and administer medication. Instead, NWDC medical staff reportedly gave her acetaminophen for pain, which she recognized as contraindicated for liver patients. Dawson was eventually released in March 2020 after a lawsuit brought by the ACLU and Northwest Immigrant Rights Project named her lead plaintiff among a group of medically vulnerable people whose existing conditions placed them at great risk if they were to contract COVID-19 in the NWDC.
Given the presence of an onsite medical clinic, the NWDC has the capacity to design and implement a treatment plan for chronic illnesses like diabetes or hypertension. For example, diabetic patients could have their sugar levels checked on a regular basis; indeed, some of the trans women transferred from Cibola, New Mexico, had their sugars checked twice daily, according to Wendy Mironov. Yet regular monitoring of sugars does not appear to be routine practice in the facility for patients whose needs have not attracted external attention. A review of a diabetic patient’s records provided by Wendy showed that although he was receiving insulin, it was unclear how consistently his sugar levels were being checked; reportedly, after several hypoglycemic episodes over the course of 6 months in detention, his sugars soared into the 400 range in an apparent case of mismanagement.
Similarly, the group of volunteer medical providers associated with La Resistencia documented the case of one Mexican patient who was first detained in 2013. During his first year in detention, he reported chest pain after physical exertion. It is unclear why NWDC providers did not apparently investigate his complaints of chest pain, but they placed him on an antipsychotic drug, risperidone, which is known to raise cholesterol. He was not examined by a cardiologist, and did not recall ever having had bloodwork done. In late 2018 or early 2019, he lost consciousness while playing basketball in the recreation yard; when he failed to recover after an unknown period of time in the NWDC clinic, staff called 911 and he was rushed to the hospital. In the ambulance, an EKG showed he was having a massive heart attack at the age of 35. Eventually, some five stents were surgically inserted in his heart, and he was deported shortly thereafter.
Wendy Mironov believes that had the medical staff at NWDC done bloodwork on this patient during the 5-6 years he was in their custody, they would have detected his high cholesterol, but perhaps because he was diagnosed as mentally ill, they did not take his health complaints seriously. Furthermore, like many patients, he was deported with sufficient medicine to cover his needs for only 4-5 days, and without medical records detailing his prior treatment; because of the time it took for him to gain access to Mexican public health system upon arrival, he spent some 8 months unmedicated following deportation, a grave threat to his health. This violates ICE’s own requirements under the PBNDS, which stipulates that “Upon removal or release from ICE custody, the detainee shall receive up to a 30 day supply of medication as ordered by the prescribing authority and a detailed medical care summary.” Sadly, it is not a unique case: New York Lawyers for the Public Interest has accused ICE of routinely “dump[ing] detainees on the streets of New York without providing them temporary medications or any plan for their medical treatment.”
Cruelty and abuse
Many people detained at the NWDC complain about treatment that generally lacks compassion, sometimes attributing this to racism on the part of GEO and ICE officials. But some grievances speak to a level of degrading treatment that merits particular concern. For example:
- On July 11, 2016 a detained woman from Mexico described an incident of abject cruelty experienced at the hands of her medical provider at the NWDC: “Today at 11 am I went to a medical appointment where I saw Dr. [Name redacted]. He started asking me questions about my medical history. One was if my mother was still alive, and I answered him yes, after I answered him yes he told me that your mom’s biggest mistake was having you as a daughter. Then he asked me if I had children and I answered yes, I have 4, then he told me that was my kids’ biggest mistake having me as a mother. I don’t understand why he told me these things, he really did hurt me, as soon as I got back to my pod I started crying for what he told me, it’s hard enough being here and away from family and then just for a stranger to tell me all these things it’s just not fair.” The NWDC’s Clinical Director responded: “I am very sorry for the recent experience you had. The medical provider you mentioned will be disciplined and he will not be seeing you again.”
- On January 20, 2016, a Salvadoran national reported that “On January 19, 2016, I was seen by Nurse [name redacted]. She took me into an interviewing room to ask me questions about my medical. She asked me how I was feeling and I stated to her that I was in pain, my back, joints, and kidney, she asked how do I know that. I told her because I know, that’s why I am here. She stated, “You are here because you are here illegally.” That’s when I told her that I didn’t want to talk or be seen by her.” The facility responded, “As the nurse administrator, I can assure that we will respect your wishes and you are always entitled to ask for a different provider. I have talked with the staff involved but am unable to validate the specifics of your grievance. After reviewing your medical record, it does appear your medical needs are being met.”
While in both cases noted above, the facility’s response to the grievance was respectful, these incidents suggest deliberate and unnecessary cruelty. The fact that any medical provider would deliberately demean a patient should be grounds not only for disciplinary action, but potentially dismissal or professional sanctions.
Relatedly, UWCHR reviewed photographs, video testimony, medical records, and a Tacoma police report provided by a Salvadoran asylum seeker who reported that an IHSC staff member had physically assaulted her during an October 4, 2019 visit to the NWDC clinic. The patient reported that she had disagreed with the medical provider’s recommendation that she take a higher dose of pain medicine, since a lower dose already left her feeling heavily sedated and she reported spending most of the day asleep. When she refused to take the higher dose, the provider became verbally abusive, balled up the paper on which the prescription was written and threw it at her, and struck her on the leg with a closed fist, leaving a large bruise. The patient was subsequently deported.
Incidents like this, in the context of many other detained people’s grievances about providers lacking compassion or belittling their concerns, suggest the quality of medical attention received at the facility merits more in-depth scrutiny.
Mismanagement of mental health
Many researchers have noted poor quality mental health services at other ICE detention facilities, including cases where the poor care contributed directly to preventable death. In 2017, Human Rights Watch and Freedom for Immigrants enlisted the support of medical experts to review ICE’s own published investigations into deaths in custody, finding “clear-cut instances of subpar medical care, including inadequate care that contributed to seven deaths in detention.” On the basis of reviews of medical records of a dozen other detained individuals, these organizations reported ”systemic substandard and dangerous medical practices,” including inadequate mental health care that contributed to at least one documented suicide. Ken Klippenstein of The Young Turks obtained an internal memo written by an IHSC employee denouncing numerous preventable deaths in ICE custody, including cases where mentally ill patients were administered inappropriate or negligent care that culminated in their suicides; the same memo noted that ICE personnel never reviewed notifications that should have alerted them to a problem. Jeremy Redmon of The Atlanta Journal-Constitution investigated two suicides of men who were remanded to solitary confinement despite known mental health issues, accounts that only became public after the state of Georgia conducted its own inquiry. An ICE whistleblower report prepared by DHS’ Office of Civil Rights and Civil Liberties, a copy of which was later obtained by Buzzfeed News, included allegations that “Immigration and Customs Enforcement’s (ICE) ICE Health Service Corps (IHSC) has systematically provided inadequate medical and mental health care and oversight to immigration detainees in facilities throughout the U.S.,” and that ICE employees simply ignored quality control mechanisms intended to provide oversight. Of the cases of medical neglect mentioned, one was from the NWDC.
Unfortunately, the grievances we reviewed suggested that in several cases, mental health needs were not being met. In some cases, this appears to be because the patient’s mental health needs went unrecognized and untreated. For example, at least two cases were reported to CRCL, one apparently by a whistleblowing IHSC employee:
- In February 2016, CRCL received correspondence from the Immigration Center for Women and Children on behalf of a man detained at NWDC who was allegedly receiving inadequate medical care. The organization reported that he was epileptic, paraplegic, had hypertension, and gastrointestinal bleeding. In addition, he suffered from chronic mental illness and had been found by an immigration judge to be mentally incompetent to represent himself. No one from the mental health unit has evaluated him at the time of this communication, and he was not provided with his psychiatric medication, despite a history of suicide attempts and suicidal ideation. The complaint asserted that the only medication he had been provided at NWDC is for treatment of epileptic seizures.
- Similarly, in 2018 DHS CRCL received a referral from the DHS OIG regarding information provided by a source within the US Public Health Service about a person detained at the NWDC. According to the source, the individual had a significant psychiatric history, but “had not been identified by facility mental health staff as having met seriously mentally ill (SMI) criteria, therefore, he was not closely monitored and tracked in order to determine whether he received appropriate care and follow-up care. Further. MGMU notified IHSS senior leadership in the Behavioral Health Unit (BHU) that he was at high risk for suicide. Allegedly, leadership was unable to identify him as seriously mentally ill.”
In other cases, it appears that patients with mental illness were placed in solitary confinement. The placement of mentally ill inmates in solitary has been questioned by many, including Human Rights Watch in a report on deaths of people in immigration detention in 2017 and 2018. ICE’s 2013 directive on the use of solitary confinement mandates that it only be used “as a last resort” for suicidal inmates, and that “any setting used to house detainees who are at risk for suicide or other self-harm permits close supervision and minimizes opportunities for self-harm.” Yet a recent study found as many as 40% of immigrants held in solitary confinement by ICE had diagnosed mental illness.
At the NWDC, numerous complaints document the placement of mentally ill migrants in segregated housing. For example:
- On October 12, 2015, a person whose country of origin was redacted wrote, “I have a problem with voices and I am tired of starting all over, always I come to get help and I always get the same shitty situation, they put me on segregation all over and again and again and again. I am tired of all that, it’s a hard torture and punishment without reason …. I want to get out of here as soon as I can and not return to being alone in the little rooms, I’m tired of telling you that I don’t like it and you keep doing it to me… fuck that shitty situation… no more, never, I want my freedom and my life back.” Nine days later, the facility responded, “You have an upcoming mental health appointment. I encourage you to discuss your concerns with your psychiatrist so he can assist you in coping.”
The November 2018 death by suicide of Mergensana Amar in NWDC custody could form part of this documented pattern of negligence. According to the Detainee Death Report issued by ICE on his case, Amar arrived healthy in NWDC in December 2017, and initiated a hunger strike in August 2018 to protest the length of time the courts were taking to resolve his petition for asylum. In October he was placed on suicide watch and held in segregation; as reporter Lilly Fowler wrote in Crosscut, the length of time he was held in solitary and on suicide watch remains unclear, and ICE’s statements on the matter are disputed by other detained people. On November 15, he was found hanging in his cell, sustaining injuries that led to his eventual death days later.
The case raises lingering questions about the adequacy of care provided at NWDC. Writing for the Seattle Times, journalist Nina Shapiro reviewed a written note Amar gave to a visitor on November 3 which described him being placed in segregation naked, with only a small blanket, when ICE determined him to be suicidal. This “blanket” may be a reference to a suicide smock, which are used in place of clothing “per suicide watch protocols” according to an ICE document reporting a different suicide attempt reviewed by UWCHR researchers. ICE’s national standards specifically prohibit holding detainees naked, noting in the chapter on suicide and self-harm that “under no circumstance shall detainees be held without clothing.” However, journalists have documented this practice in other ICE detention facilities, and other detained people at NWDC have reported the same practice to representatives of the Human Rights Clinic at the University of Washington School of Law.
UWCHR researchers have reviewed Significant Incident Reports filed by ICE regarding 21 suicide attempts at the NWDC between January 1, 2015 and September 1, 2019. Several describe mentally ill individuals obligated to relinquish their clothing through the use of force, including pepper spray; sometimes, this happens after a Hostage Negotiating Team was deployed to attempt to secure compliance, despite the fact that no hostages were involved. In one incident, the person was subsequently placed in four-point restraints (cuffed at both ankles and both wrists). While ICE is obligated by law to publicly disclose deaths of people in its custody, there is no public reporting about suicide attempts, so it is not known whether 21 attempts represents a higher-than-average number.
Taken together, these accounts present a troubling picture of health care at the NWDC. Though the facility claims to pride itself on its medical services, these patterns of delayed or denied treatment, deliberate cruelty, and mismanagement of chronic conditions, including mental illness, suggest that problems researchers have documented at other ICE facilities are also present at the NWDC. Without access to patients’ complete medical records, we cannot draw conclusions about the quality of the care received by specific individuals, but we can observe the frequency and apparent gravity of these problems reflected in complaints filed about this facility since 2012.
Many political leaders have commented on the NWDC as a threat to the health and safety of those detained there. In 2018, Washington Governor Jay Inslee wrote John Kelly, the director of DHS, that he was “deeply troubled” about the “safety and well-being of detainees at the NWDC,” demanding “immediate, independent inspection of the health and safety conditions” at the facility. The inspection Inslee demanded never occurred. The following year, Senators Patty Murray and Maria Cantwell and Reps. Adam Smith and Pramila Jayapal asserted that “a broader atmosphere of abuse and mistreatment exists at the NWDC” in a 2019 letter to DHS. No public action was taken in response to these letters.
This spring, in the context of the COVID-19 pandemic, leaders continued to issue strongly-worded missives. On March 21, Sens. Cantwell and Murray and Reps. Smith, Jayapal, Heck, and Kilmer sent a letter to the GEO Group, posing important questions about conditions within the NWDC. On March 23, Reps. Smith and Jayapal joined three other members of Congress in demanding that ICE take precautions to halt the spread of COVID-19 within detention centers. Also in 2020, the Washington State Legislature passed HB 2576, a law mandating that the Department of Health conduct a study of oversight mechanisms at the NWDC, to ensure more effective oversight.
At this point, however, it is clear that effective guarantees of detained people’s right to access decent medical care within the NWDC is not possible within the current structures, for three reasons:
- DHS, ICE, and GEO have instituted a variety of overlapping complaint and oversight mechanisms, but the differences between them are unclear, their results are not made public, and UWCHR’s review of the records they produce shows that these mechanisms themselves are used to deflect responsibility more effectively than to identify and solve problems.
- With unprecedented numbers of detained people dying in ICE custody, there is already abundant evidence of systemic problems in ICE’s Health Service Corps. Yet DHS, ICE, and GEO are the only parties able to access the medical records necessary to conduct any deeper analysis—and they are insufficiently committed to transparency to do so in a credible way.
- Given this, a truly rigorous investigation of health care within the facility is not possible: internal mechanisms are ineffective, and external parties lack access to the full records necessary to conduct such an analysis. At this point, however, what is needed is not further analysis, but action to stop the abuse.
 ICE lacks the authority to detain people pursuant to criminal charges, so all of the migrants detained at the NWDC are held in civil (also known as administrative) detention. Some may have previously served criminal sentences in other facilities.
 UN Working Group on Arbitrary Detention (UNWGAD), Country report visit to the United States of America, A/HRC/36/37/Add.2, ¶ 21.
 The United Nations Standards of rules for the treatment of prisoners (“Nelson Mandela Rules”). Rule 24, paragraph 1.
 ICE’s detention standards for “Dedicated Facilities” like the Northwest Detention Center are laid out in the agency’s Performance-Based National Detention Standards 2011 (PBNDS 2011), which was last revised in 2016. For ICE’s description of the IHSC, see: https://www.ice.gov/ice-health-service-corps
 U.S. Department of Homeland Security Immigration and Customs Enforcement Office of Detention Oversight Compliance Inspection. Enforcement and Removal Operations, Seattle Field Office, Northwest Detention Center. June 24-26, 2014.
 Nina Shapiro, “To dispel ‘bad information,’ ICE opens detention facility in Tacoma to first-of-its kind media tour,” Seattle Times September 10, 2019.
 Email from ICE Community Relations Officer Melissa Nitsch to Angelina Godoy, February 11, 2020
 For example, ICE records reviewed by UWCHR show that in 2016 a Somali hunger striker was transferred from a facility in the midwest to the NWDC because “it was determined that FOD [Field Office Director] Seattle was best suited to manage the case of a hunger striker, and so on March 16th, she was transported to the NWDC at the recommendation of IHSC [ICE Health Service Corps].” Relatedly, in August 2018 a Russian migrant was transferred to NWDC custody from FCI [Federal Correctional Institution] Sheridan, in Oregon, “for medical treatment due to exposure to scabies and to better monitor what appeared to be the beginning of meal refusals.”
 United States Government Accountability Office, Report to the Ranking Member, Committee on Homeland Security, House of Representatives. Immigration Detention: Additional Actions Needed to Strengthen Management and Oversight of Detainee Medical Care. February 2016. p. 22
 DHS’ Office of the Inspector General found, in a 2018 report, that even ICE staff considered these inspections to be “useless” and “very, very, very difficult to fail,” and concluded that the monitoring system had no effect on actual compliance with standards. See DHS OIG, ICE’s Inspections and Monitoring of Detention Facilities Do Not Lead to Sustained Compliance or Systemic Improvements, OIG-18-67, June 26 2018. Relatedly, in 2019 the USA TODAY Network analyzed inspection reports since 2015, identifying 15,821 violations of detention standards, yet ICE considered 90% of the facilities to have passed inspection. See USA Today Network, “Deaths in custody. Sexual violence. Hunger strikes. What we uncovered inside ICE facilities across the U.S.”, December 22, 2019.
 In recent years a growing number of professionals from within DHS have either leaked documents or come out publicly as whistleblowers to denounce substandard, even lethal, medical care in immigrant detention. For example, an internal agency document from December 2018, obtained by The Young Turks, noted that “preventable harm and death to detainees has occurred” due to systematic failures in the provision of health care at detention facilities across the nation. In 2019, Scott Allen and Pamela McPherson, physicians who had long inspected detention centers for CRCL, publicly denounced family and child detention as a grave threat to the health of immigrants; and a separate ICE whistleblower report prepared by DHS’ Office of Civil Rights and Civil Liberties and obtained by Buzzfeed included allegations that ICE Health Service Corps (IHSC) systematically provided substandard medical and mental health care in facilities throughout the country.
 Hamed Aleaziz, “Deaths, Surgeries, Drugs: Health Care For Jailed Immigrants Criticized In Memo About Secret ICE Whistleblower”, Buzzfeed, December 12, 2019.
 See for example: Pilar Marrero, “Sin tratamiento tras ser diagnosticado con cáncer,” La Opinión, April 21, 2016; Ansel Herz, “Fighting Cancer and Deportation at the Same Time”, The Stranger, February 24, 2016; Ansel Herz, “Angel Padilla, Still Fighting Cancer and Deportation, Is Now Eligible for Release from Tacoma Detention Center”, The Stranger, April 21, 2016; and Melissa Hellmann, “Incarcerated and Infirmed: How Northwest Detention Center Is Failing Sick Inmates”, Seattle Weekly, October 10, 2018.
 Nina Shapiro, “Immigrant detainees vulnerable to coronavirus file suit seeking release from Tacoma detention center”, The Seattle Times, March 16, 2020.
 Chapter 4.3. Section BB of the PBNDS 2011 stipulates that detainees can obtain access to their medical records by filing a request (see PBNDS p. 277) and ICE spokesperson Melissa Nitsch affirmed, in a April 16, 2020 email to Angelina Godoy, that this was a “very straightforward” process. Despite this, many detained people report great difficulty in accessing their medical records.
 See for example, DHS Office of the Inspector General, Concerns About ICE Detainee Treatment and Care at Four Detention Facilities, OIG-19-47, June 3, 2019.
 The monitoring this team is able to provide is limited, as they themselves acknowledge; they are only allowed to visit with detained people through glass, so cannot conduct exams, take vital signs, or otherwise provide medical care; while they have compiled some detainees’ medical records, they have not discussed patients’ records or treatment plans with NWDC medical providers.
 In an email to Angelina Godoy, ICE spokesperson Melissa Nitsch disputes that hunger strikes occurred during these years.
 See for example the case of Saja Tunkara: Melissa Hellmann, “Incarcerated and Infirmed: How Northwest Detention Center Is Failing Sick Inmates”, Seattle Weekly, October 10, 2018.
 Under FOIA, UWCHR requested “a copy of all documentation related to grievances, formal or informal, and their resolution, at the Northwest Detention Center in Tacoma, WA, from January 1, 2012 to March 10, 2018.” Under the PBNDS 2011 standards, each facility is expected to maintain a grievance log, described on page 416 of the standards, into which information about the resolution of informal grievances and the processing of formal (written) grievances should be entered. There are three types of grievances filed in the facility, to GEO, ICE, and the ICE Health Service Corps which provides medical care within the facility; our request encompasses all three types. Pursuant to litigation against DHS, UWCHR has received digital copies of the NWDC’s grievance logs, in addition to (as of March 28, 2020) 3240 pages of an estimated 4000 pages total of grievances filed by people detained in the facility from 2012 to 2018.
 In 2016, for example, following a detailed analysis of detainee death reports, the American Civil Liberties Union, Detention Watch Network, and National Immigrant Justice Center concluded that “poor medical care contributes to the death of immigrants in federal immigration custody with alarming frequency.” Among the problems documented was delayed attention to medical needs. Similarly, New York Lawyers for Public Interest (NYLPI) analyzed complaint forms and conducted interviews with 47 individuals with chronic medical conditions detained in the New York area, concluding in 2017 that that “recurring deficiencies in medical care, including incomplete intake assessments, lack of interpreters for patient-doctor communication, denied or severely delayed medical care, and inadequate departure planning for continuing medical care” were putting immigrants’ lives at risk.
 Except in cases where the forms were submitted in English, quotations from grievance forms included in this report have been translated by the authors from the original Spanish. Many times they have also been lightly edited, correcting spelling and grammar to improve readability. For this reason, we also include links to the grievance forms to permit readers to view them in their original form.
 United States Government Accountability Office, Report to the Ranking Member, Committee on Homeland Security, House of Representatives. Immigration Detention: Additional Actions Needed to Strengthen Management and Oversight of Detainee Medical Care. February 2016. p18
 Melissa Hellmann, “Incarcerated and Infirmed: How Northwest Detention Center Is Failing Sick Inmates”, Seattle Weekly, October 10, 2018
 On March 16, 2016, a letter signed by 48 rights advocacy organizations was sent to ICE’s Field Office Director and Assistant Field Office Director asking for Angel Padilla’s release so that he could obtain cancer treatment. The #Not1More campaign also featured Padilla in a call to action.
 For reasons that are unclear, bond rates issued at the NWDC are among the highest in the country. UWCHR researchers reviewed an ICE document about a suicide attempt in May 2018 by a person who had been granted parole but was unable to raise the funds to cover bond, attesting to the desperation this can produce.
 Jeremy Raff, “Being an ICE Detainee Amid the Coronavirus Crisis”, The Atlantic, March 28, 2020.
 The document reviewed is an ICE Significant Incident Report. Because Significant Incident Reports contain details of an individual’s medical, migratory, and criminal history, for privacy reasons we are refraining from publishing the documents themselves.
 Dawson v. Asher: Motion for Temporary Restraining Order, Case No. 2:20-cv-409, March 16, 2020.
 See for example: Monsy Alvarado et al., “Deaths in custody. Sexual violence. Hunger strikes. What we uncovered inside ICE facilities across the US”, USA Today Network, December 19, 2019; see also
See also New York Lawyers for the Public Interest, Detained and Denied: Healthcare Access in Immigration Detention, 2017.
 Jeremy Redmon, “Report shows South Georgia facility failed to follow federal standards,” The Atlanta Journal-Constitution, January 4, 2019.
 Hamed Aleaziz, “Deaths, Surgeries, Drugs: Health Care For Jailed Immigrants Criticized In Memo About Secret ICE Whistleblower”, Buzzfeed, December 12, 2019.
 The case involved inadequate monitoring of a detained individual with serious mental illness who was at risk of suicide.
 American Civil Liberties Union, Detention Watch Network, and the National Immigrant Justice Center, Code Red: The Fatal Consequences of Dangerously Substandard Medical Care in Immigration Detention, June 20, 2018.
 U.S. Immigration and Customs Enforcement, 11065.1: Review of the Use of Segregation for ICE Detainees, September 4, 2013.
 Project On Government Oversight, ISOLATED: ICE Confines Some Detainees with Mental Illness in Solitary for Months, August 14, 2019.
 Lilly Fowler, “An asylum seeker vowed never to return to Russia. His death in ICE custody sent him back”, Crosscut, June 10, 2019.
 Nina Shapiro, “What happened to Mergensana Amar? The Russian immigrant’s handwritten note raises questions about treatment at Northwest Detention Center”, The Seattle Times, November 30, 2019.
 Ian Urbina, “The Capricious Use of Solitary Confinement Against Detained Immigrants,” The Atlantic, September 6, 2019.
 Email from Alejandro Sanchez to Angelina Godoy, January 22, 2020.
 Washington State Legislature, HB 2576 – 2019-20: Concerning private detention facilities, signed April 2, 2020.