Report says neglect at Houston facility contributed to men’s demise
By Lise Olsen, www.chron.com
May 15, 2017 Updated: June 8, 2017 4:52pm
Peter Rockwell with family members in Canada. His health issues were ignored while he was in detention.
Faulty procedures and subpar medical care contributed to at least two deaths at a for-profit Houston immigration detention center that is among those with the most reported immigrant deaths in the country, according to a new human rights report.
In one case, Clemente Mponda, a 27-year-old asylum-seeker from Africa who’d repeatedly threatened suicide was left in an isolation cell with more than enough hoarded psychiatric medications to kill himself – which he promptly did, according to Immigration and Custom Enforcement’s own records.
In the other case, no one administered CPR or called 911 immediately after a 46-year-old Canadian detainee, Peter Rockwell, who suffered from high blood pressure, collapsed in a crowded lunchroom in the Houston Contract Detention Center.
The detention center’s handling of both fatalities is criticized in the new report, issued jointly last week by Human Rights Watch and the California-based Community Initiatives for Visiting Immigrants in Confinement (CIVIC).
Medical experts reviewed ICE investigations into 18 deaths in immigration detention nationwide and found subpar medical care or other problems contributed to 10 deaths from 2013-2015 – including those of Mponda and Rockwell.
The Houston detention facility in a sprawling complex near the city’s international airport, has reported eight detainee deaths since 2003. Nationwide, only two other immigrant detention centers have reported more – Eloy Detention Center in Arizona with 15 and the Columbia Regional Care Center in South Carolina, which doubles as a mental hospital, with nine, according to a Chronicle analysis of ICE data on detainee deaths at 80 facilities since 2003.
The detention of immigrants has taken on new urgency since President Donald Trump ordered stepped-up efforts to round up and deport those in the country illegally and revealed plans for the construction of more centers.
Both Eloy and the Houston CDF are run by a for-profit company called Core-Civic (formerly known as CCA). In response to questions, Jonathan Burns, director of Public Affairs for Core¬Civic, emphasized that other contractors provide medical care at their facilities and that ICE employees have unfettered access and provide extensive oversight.
The numbers of deaths are small given that nationwide, more than 40,000 immigrants are held at any one time by ICE – 75 percent in privately owned facilities like Houston’s. But most detainees are relatively young and spend only months locked up. ICE has discretion to release the sick or dying and ICE generally defended the level of care provided to detainees in a statement issued this week.
ICE itself found multiple problems in its own investigations of both Mponda’s 2013 suicide and Rockwell’s 2014 death. Houston ICE spokesman Gregory Palmore declined comment.
In both cases, ICE’s own death reports weren’t released until 2016. Because ICE keeps most of its death reports under wraps for years or forever, some relatives are only now learning troubling details.
“I would agree that there is cause for concern regarding Peter’s treatment while in custody,” said Peter Rockwell’s brother Kris in a phone interview from his home in Canada. “There’s a lot of indications of incompetence and borderline abuse.”
Christina Fialho, co-founder and executive director of the immigrants rights group CIVIC, argued that ICE itself should stop placing immigrants at facilities that repeatedly report deaths and should hold facilities more accountable especially when ICE’s own death investigations find violations of government standards.
“The Houston Detention Center … is one of the deadliest immigration detention facilities in the country,” Fialho said. “CIVIC believes it is past time to shut down Houston Detention Center.”
Burns said it was important to look at the deaths at the facility “in context.”
“The Houston Processing Center is one of the largest detention facilities used by ICE in the country,” he said. “The number of deaths on a per-capita basis would indicate that it is on a comparable level to other ICE facilities.”
Mponda emigrated to the United States legally as a student from Mozambique in 2007, but suffered a mental breakdown and ended up homeless here, according to ICE records. He was placed in deportation proceedings after a misdemeanor conviction.
He filed an asylum claim, but was improperly classified among the most dangerous offenders in detention and repeatedly locked in an isolation cell, ICE’s own investigation shows.
As he waited 15 months for courts to review his case, he repeatedly threatened suicide before he successfully overdosed on hoarded medications. He left behind extra doses of the drugs with his suicide note.
In the Human Rights Watch/CIVIC report, Dr. Marc Stern, a physician at the University of Washington’s School of Public Health and a correctional care expert, described Mponda as “the poster child for misuse of isolation for mental health patients.” Both he and another expert also found Mponda’s ability to repeatedly hoard potentially lethal medications without detection represented a “dangerous failure of the facility’s security system.”
ICE’s investigation of Mpdona’s death – released in 2016 – uncovered more than a dozen violations of government detention standards, including improper documentation of the use of isolation cells; failure to perform an adequate search as well as failure to follow guidelines for medical care, suicide prevention, facility security and contraband. But the report includes no record of improvements made in Houston CDF procedures after that death.
Had health problems
Rockwell had lived in the United States for more than a 20 years when he was arrested in Beaumont on a Canadian criminal arrest warrant. He landed in Houston CDF in February 2014 and was immediately flagged by a medical team for high blood pressure and a family history of heart problems, ICE records say.
But the staff failed to follow up on orders for daily blood pressure checks and an EKG. They did little to investigate when Rockwell complained of blurred vision, which can be a symptom of a cranial bleed, Stern said.
After two weeks, Rockwell collapsed while heating food at a microwave. An emergency response team arrived, but no one brought oxygen, a defibrillator or other emergency equipment required by ICE. Nor did anyone immediately administer CPR, though Rockwell lost consciousness, foamed at the mouth and had no measurable blood oxygen level. Instead, a team hauled him through a hallway on a stretcher that they could not raise. It took eight minutes before anyone called 911.
Both Stern and another medical expert quoted in last week’s Human Rights Watch/CIVIC report found substandard care contributed to Rockwell’s early death.
In an email to the Chronicle, Dr. Dwayne Wolf, who performed Rockwell’s autopsy at the Harris County Institute of Forensic Sciences, separately confirmed the brain lesion that killed Rockwell was an “intracerebral hemorrhage … a direct consequence of small vessel damage in the brain caused from high blood pressure (hypertension). It’s a complication of high blood pressure.”
Medical team assailed
ICE’s own death investigation cited problems with emergency equipment, medical response, facility record-keeping and follow-up. The report faulted the medical team, which ICE directly oversees. It also found detention center staff failed to render aid, keep adequate supplies, fill out required reports, review the incident with staff and retain videos.
Rockwell’s stepmother and brother who live in Canada had never seen the ICE death investigation until it was sent to them by the Houston Chronicle.
“We could never find out what happened,” said Sandra Rockwell, Peter’s stepmother. “I really felt the whole thing was very suspicious. We received no death report, no paperwork. Nothing to my knowledge.”
In another case, Nho Thi Nguyen, 61, originally from Vietnam, collapsed in a shower and died after only three days in Houston CDF in 2015, according to a Harris County autopsy records and an ICE news release. Her death was not evaluated by experts in the Human Rights Watch/CIVIC report because ICE has never released its death investigation. Palmore declined comment.
The Houston Chronicle asked Stern, one of the experts who reviewed other immigrant death records, to review Nguyen’s autopsy and a death investigation report – and he identified troubling potential signs that Nguyen too may have received inadequate care for high blood pressure before her death.
Arrested upon return
Nguyen emigrated to the United States legally in 2000, according to federal court records. She lived with her husband in a two-story townhome near a section of Bellaire Boulevard where the street signs are posted in Vietnamese. Nguyen had traveled to Vietnam and was returning home when she was detained at the Houston airport in 2015. She was placed in deportation proceedings based on a five-year-old misdemeanor conviction. Court records show she had lied to an immigration official to help a 14-year-old sister, who used false immigration papers.
Her husband later told investigators that Nguyen was not getting medication for high blood pressure while in custody. Before her death, she’d been identified as a “fall risk” and her blood pressure readings had skyrocketed to 230/110 – a life-threatening level generally considered the highest risk category for heart attack, stroke or other crisis, county records show.
She collapsed in a shower and died in a hospital of an aneurysm, an autopsy record shows.
Based on county records, Stern said that if the detention center officials had identified Nguyen as a fall risk – as indicated by a bracelet she wore – they should have investigated and not allowed her to shower alone. He also said untreated high blood pressure could have contributed to her death from an aneurysm, though limited public records do not provide a complete picture.
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