Shocking report gives glimpse into ICE detention facility where nooses were found in cells

Overly restrictive segregation, inadequate medical care cited in report

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CALIFORNIA – A new report from the Department of Homeland Security’s Office of the Inspector General states that nooses were found in detainee cells at an ICE detention facility in California May.

The report details information gathered at an unannounced inspection of the ICE processing center in Adelanto.

Multiple issues were found that violate the 2011 Performance-Based National Detention Standards. In addition to the nooses, improper and overly restrictive segregation and untimely and inadequate detainee medical care were discovered.


The report, which was released last Thursday, says braided bed sheets, referred to as nooses, were found in 15 out of the 20 male detainee cells.

“I’ve seen a few attempted suicides using the braided sheets by the vents and then the guards laugh at them and call them ‘suicide failures’ once they are back from medical,” one detainee told DHS senior official John V. Kelly.

Two contract guards said the bedsheets were not removed because it wasn’t a high priority, according to the report.

At least seven suicide attempts were made at the Adelanto ICE processing center from December 2016 to October 2017, at least one of which resulted in the death of a 32-year-old man who was found hanging from his bedsheets.

"While at the center, we identified serious issues relating to safety, detainee rights, and medical care that require ICE’s immediate attention. These issues not only constitute violations of ICE detention standards but also represent significant threats to the safety, rights, and health of detainees,” Kelly said as part of the report.

This issue isn’t unique to the Adelanto facility.

Nationwide, self-inflicted strangulation accounts for four of the 20 detainee deaths reported between October 2016 and July 2018, according to ICE news releases.

Improper Segregation

All 14 detainees who were in disciplinary segregation during the surprise inspection were found to have been placed there prematurely -- meaning before they were found to have violated any rules.

Another detainee had requested to be placed in administrative segregation and was instead placed in disciplinary segregation where he’d been for more than one week.

"File reviews indicated that this segregation placement is also done before the disciplinary panel assesses a penalty for the violation and the detainee has the opportunity to appeal, thereby violating the detainee’s right to due process,” the report says.

Detainees were also found to be shackled and handcuffed unnecessarily, which the report says, "gives the appearance of criminal, rather than civil, custody."

Inadequate Medical Care

Medical doctors were observed stamping their name on 10 out of 14 detainee records, indicating they visited with the detainee, when they actually had zero contact.

"For the four detainees a doctor did speak with, the doctor asked if the detainee was “OK” in English, not necessarily a language the detainee understood. We confirmed with guards that these four detainees were non-English speakers, and the doctor left without any acknowledgment or response from the detainee,” Kelly wrote in the report.

Detainees filed 80 medical grievances from November 2017 to April 2018 stating they hadn’t been seen for months and weren’t receiving prescribed medication.

A review of ICE detainee deaths at the Adelanto center confirm three detainees died in the last three years due to medical care deficiencies.

To read the full report from the Department of Homeland Security, click here.

ICE Executive Associate Director Nathalie Asher responded to the report saying in part, “ICE is concerned by the OIG’s findings. However, the OIG’s draft report lacks important context on some issues.”

Another inspection of the facility is scheduled for Oct. 10.

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