Holding the Government Accountable

Medical Neglect at a Denver Immigration Jail

This joint POGO-Yahoo investigation was originally published in full on Yahoo News.

On Nov. 17, 2017, federal agents arrived at the home of 64-year-old Kamyar Samimi, who had lived in the United States for over four decades, and took him away. Samimi was a legal immigrant from Iran, who came to the United States as a student in 1976 and received a green card in 1979. But under Trump-era enforcement policies, a 12-year-old conviction for cocaine possession made him a target for detention and deportation.

Samimi was taken to the Aurora, Colo., detention facility, an immigration jail in the suburbs of Denver operated by the GEO Group, one of the largest private prison companies in the U.S. Just over two weeks later, he was dead.

An internal ICE review of one inmate's death found there were major deficiencies in his medical care for severe opioid withdrawal before his death, according to a source who viewed the document.

He is one of 24 people to die in Immigration and Customs Enforcement (ICE) detention since President Donald Trump took office. (That total excludes deaths of immigrants held in Customs and Border Protection custody or in Office of Refugee Resettlement shelters, including three Guatemalan children who have died since December.)

In at least a half dozen of these cases, there have been allegations that inadequate medical care preceded the deaths. Samimi’s case appears to be one of those —and an example of how government contractors running facilities like Aurora have struggled to provide adequate care for a drastically increasing detainee population.

An internal ICE review of Samimi’s death found there were major deficiencies in his medical care for severe opioid withdrawal before his death, according to a source who viewed the document. (See update at the bottom of this piece.) The source asked not to be named because they are not authorized to speak to the press and fear retaliation.

ICE’s detention standards provide that “detainees experiencing severe or life-threatening intoxication or withdrawal shall be transferred immediately to an emergency department for evaluation” and returned to the detention facility only if it is “staffed with qualified personnel and equipment to provide appropriate care.” Investigators found that Samimi’s treatment violated this standard and many others, according to the Project on Government Oversight’s source.

ICE’s official review of Samimi’s death has not yet been publicly released, despite multiple pending Freedom of Information Act lawsuits for such release. An ICE spokesperson said the agency could not comment on the case due to pending litigation.

According to an inspection report on ICE’s website, the 64-year-old Samimi “was placed in medical observation directly from intake” because he reported suffering from depression, methadone and heroin addiction, and abdominal pain, and “began rather quickly complaining of nausea and vomiting and was observed to vomit blood.”

On Nov. 28, 11 days after he was taken into custody, Samimi “was observed to have a bed sheet tied tightly around his neck” and was placed on suicide watch. On Dec. 2, “the detainee attempted to get into a wheelchair but vomited blood and collapsed” and stopped breathing. Soon after, he was pronounced dead at a local hospital. The inspection report, quoting from a source that it does not identify, states that “the most likely cause of death was noted as ‘the result of asphyxia secondary to aspiration of bloody vomitus.’”

The local coroner’s autopsy states that Samimi’s cause and manner of death are “undetermined,” but that emphysema and gastrointestinal bleeding were likely contributing factors. The forensic pathologist wrote that Samimi had been addicted to methadone since 1990 and that “methadone withdrawal cannot be ruled out as the cause of death, however, deaths due to methadone withdrawal are rare.”

Aurora is an illustrative example of the entire way the system fails.

Elizabeth Jordan, civil rights attorney

Samimi’s case is just one of many that critics of the Aurora detention center say shows a bigger problem with care there and throughout America’s growing immigrant detention complex, where around 50,000 people are detained on an average day.

complaint filed last year by the American Immigration Council and American Immigration Lawyers Association alleges a pattern of “dangerously inadequate medical and mental health care” at the jail in the Denver suburbs. Since the complaint was filed, ICE has drastically expanded the detention facility, putting even greater stress on its medical care system.

At the time of Samimi’s death, Aurora’s medical director — and sole full-time physician — was Jeffrey Elam Peterson, MD. He left Aurora a few months later, in approximately April 2018, to become medical director at the nearby Arapahoe County jail. It is unclear whether his departure was linked in any way to Samimi’s death. GEO Group did not respond to the Project on Government Oversight’s requests for comment.

Several former Aurora detainees and their attorneys have accused Peterson specifically of providing inadequate health care and attempting to intimidate detainees when they advocated for better treatment.

In one extreme case, a paralyzed detainee, Ronnie Keyes, alleged in a lawsuit against GEO Group that his leg had to be amputated as a result of Peterson’s negligent medical care. GEO Group settled the case for an undisclosed sum shortly before it was scheduled to go to trial in March.

According to his legal complaint, Keyes had two mild pressure ulcers at the beginning of his detention. As soon as he arrived, he requested a specialized air mattress to prevent them from deteriorating or new sores from forming. He was never provided one, and his ulcers deteriorated and eventually became severely infected.

The complaint alleges that between his detention at Aurora in June and his hospitalization in September, Keyes filed over 50 written complaints about his medical care. “Not one was taken seriously,” it says.

In July, Keyes wrote that Peterson had ordered that the dressing on his wounds be changed once every three days, when a daily change was required to avoid infection, and that several of the nurses at Aurora acknowledged that they were not equipped to properly treat him.

In August, he began requesting to be taken to the hospital, in part because his pressure ulcers “had gotten even worse, they were bleeding, and they smelled bad.” He was finally taken to the emergency room after “staff at the facility found him passed out in his wheelchair.”

The infection had spread to his blood and the bone in his foot. His left leg was amputated below the knee on Sept. 20, 2016.

Even after the amputation, Keyes’s pelvic bone remained infected, requiring multiple hospitalization and surgeries. Keyes’s attorney, David Lane, said in an interview, “The doctors believe it’s a matter of time until it kills him.”

Lane said that based on Keyes’s experience, medical care at Aurora was “abysmal.”

A paralyzed detainee, Ronnie Keyes, alleged in a lawsuit against GEO Group that his leg had to be amputated as a result of negligent medical care.

“I wouldn’t let Dr. Peterson give me a haircut,” he added.

Attorneys representing Aurora detainees have alleged that Peterson reprimanded their clients for filing grievances or seeking assistance from attorneys in obtaining medical care. Arash Jahanian of the ACLU of Colorado, wrote in a court declaration in 2017 that when a client of his filed grievances because he was not receiving treatment for an arterial blockage, Dr. Peterson and one other official “told him to stop filing grievances.”

Another former Aurora detainee, René Lima Marín, recently filed a legal claim alleging that he had received inadequate treatment for multiple fractures to bones in his face resulting from a fall in his cell. Lima Marín was taken to the emergency room the night of Feb. 7, 2018, and told that he needed to return in a week or two for surgery to ensure the bones healed properly. On Feb. 16, his attorneys wrote to Aurora’s warden, Johnny Choate, alleging that Lima Marín was not receiving adequate care.

In response, according to the legal claim, Peterson “berate[d] Mr. Lima Marín for involving his lawyers in his medical care,” and “accused him of lying and exaggerating his injuries.” Peterson also wrote in an email to Lima Marín’s attorneys that he perceived their letter as “an unprofessional and threatening document,” and was planning to file a formal complaint against them with the Colorado Bar Association.

Danielle Jefferis, one of Lima Marín’s lawyers, said in an interview that other clients of hers had also had experience with Peterson “telling them they’re faking it or they’re lying.”

Peterson did not respond to messages left with his previous and current employer, texts and calls to the mobile phone number listed on his state medical license, and letters sent to his home and work addresses.

Aurora isn’t the only ICE detention facility where detainee grievances have allegedly been met with threats. The Department of Homeland Security’s inspector general reported in December 2017 that detainees at other detention centers said “staff obstructed or delayed their grievances or intimidated them, through fear of retaliation, into not complaining. These deterrents may prevent detainees from filing grievances about serious concerns that should be addressed and resolved.”

The American Immigration Council and American Immigration Lawyers Association complaint from last summer describes the experiences of seven Aurora detainees, all identified by pseudonyms. One of them, identified as “Abdo,” a refugee from South Sudan, was placed in isolation for a month after a dispute with a guard despite suffering from post-traumatic stress disorder, as part of which he experienced auditory and visual hallucinations.

During fiscal year 2018, when most of these cases occurred, the Aurora detention facility had an average daily population of 644 ICE detainees. It now holds over 1,000 — but there is still just one full-time physician. (Nationally, the United States has 2.56 doctors per 1,000 peopleThe ratios in jails and prisons tend to be lower, and detainees’ medical needs higher.)

In late January, the GEO Group opened a 432-bed annex next door to the main detention center. The annex is the original Aurora detention center, where the GEO Group’s business of contracting with the federal government to detain immigrants for profit began in 1987. It had been vacant for several years after the GEO Group opened its newer, larger detention site nearby.

ICE and GEO initially contracted to operate the annex for 90 days. In late April, the contract was extended another year, for $14 million.

ICE has said the annex was recently remodeled. Elizabeth Jordan, an attorney for the Civil Rights Education and Enforcement Center, said in an interview that she saw little sign of that when she visited the facility. “It’s very clearly an old jail,” she said, that appeared to have been abandoned and used for storage.

According to Laura Lunn, who manages the Rocky Mountain Immigrant Advocacy Network’s detention program, the annex was filled with new detainees flown in from the U.S.-Mexico border “essentially overnight” after it opened in January 2019. Several flights of detainees arrived in quick succession, without a corresponding increase in guards or medical staff at the time.

A shackled individual boards an ICE flight around Chicago, Illinois.
(Photo: Department of Homeland Security / Josh Denmark)

“They were not scaling up to accommodate the needs of the people being detained,” said Lunn, whose organization offers legal orientation to newly arrived detainees at Aurora. GEO has since hired more staff, Lunn said, though it is not clear whether the pace of hiring has matched the expansion of the jail.

Lunn said that her own organization was “overwhelmed and overburdened” trying to conduct intake interviews with recent arrivals.

Weeks after the expansion, 357 detainees in Aurora were under quarantine for exposure to chicken pox and mumps. Detainees’ attorneys said that although Aurora had experienced quarantines for chicken pox before, they had not occurred on this scale, and quarantines for mumps were much rarer. Lunn said that “a shockingly high number of units” were quarantined and noted that there had been an “uptick of quarantines around the country.”

As of March 7, there were 2,287 ICE detainees in quarantine across the country, Reuters reported. There were 236 confirmed or probable cases of mumps in ICE detention in the past year, as opposed to zero in the previous two years.

At Aurora, most detainees under quarantine had their immigration court hearings canceled, which had the practical effect of lengthening their time in detention. They also lost access to outdoor recreation and visits to families.

Alethea Smock, an ICE spokesperson in Colorado, said in an email about the quarantines that “medical personnel are credited with reducing the further infection of detainees by their quick reaction.” She added, “Each detainee receives a medical examination upon arrival at the facility to check for potential signs of illness, however ICE has no way of knowing what viruses a person may have been exposed to prior to entering the facility.”

Detainees’ lawyers dispute this. Jefferis noted that the mumps outbreak “coincided with arrivals of large numbers of people, as they were filling the annex” and medical intakes were not happening promptly. One of her clients told her that two detainees in his housing unit who contracted mumps had gone untreated for days as they got sicker, and at least one eventually had to be hospitalized.

The quarantines have now been lifted in Aurora, but the facility’s chronic problems with medical care remain.

Another one of Jefferis’s clients has Type 1 diabetes, which requires daily insulin treatment. Between his arrest in early February and mid-March, she said, he rarely received the correct dosage of insulin at the correct time. He began suffering increasingly severe nerve damage, vision loss and pain as a result, and was eventually hospitalized with a blood sugar level that placed him at risk of a diabetic coma. Jefferis said that since returning from the hospital, the client had begun receiving the proper medication, but was still suffering from nerve damage and vision loss.

Aurora is located in the congressional district of Democratic Rep. Jason Crow. Anne Feldman, a spokeswoman for Crow, wrote in an email, “We’ve heard multiple reports of poor conditions and disease outbreaks at the GEO Group-run facility in Aurora from detainees themselves and some attorneys. Despite our concerns, DHS has yet to respond to our multiple letters on the topic.”

Crow was also turned away twice when he tried to visit the facility in February and March, before finally receiving a tour 24 days after his first request. He and 20 colleagues are now seeking to pass legislation requiring that members of Congress be given access to ICE detention facilities with 48-hours notice.

The medical care problems at Aurora, according to the American Immigration Council and American Immigration Lawyers Association complaint, are “the norm rather than the exception” in ICE custody.

Jordan, the attorney for the Civil Rights Education and Enforcement Center, agreed that medical care problems are pervasive in ICE detention centers, many of which are further from major hospitals and metropolitan areas than the jail in the Denver suburbs. Aurora, she said, is “an illustrative example of the entire way the system fails.”

Update: After this story was posted, Rocky Mountain PBS investigative reporter Brittany Freeman published the full ICE review of Kamyar Samimi’s death. The document, available here, is consistent with our source’s description but contains many more details about problems with Samimi’s medical care.