Report: Medical woes at US immigrant detention centres
When Jose de Jesus Deniz-Sahagun entered US Border Patrol custody in May 2015, he told agents that he thought Mexican coyotes were going to kill him, and he wanted to kill himself.
Inside a temporary holding room for immigration detainees, he launched himself from a concrete bench, head first, hoping to snap his own neck.
In an interview during his intake to the Eloy Detention Center, a long term Immigration and Customs Enforcement (Ice) facility in Arizona, he again told a registered nurse that he had wanted to kill himself because he feared the coyotes, who are smugglers who bring people across the US border illegally.
As Deniz-Sahagun moved through Ice custody, person after person failed to make a note in his official records of his past suicide attempts and ongoing suicidal thoughts.
Two days after entering Eloy, the guards did put Deniz-Sahagun on round-the-clock suicide watch, which should have meant check-ins every 15 minutes. The guards did their rounds at random intervals, sometimes after just five minutes, or after nine, or seven, 15, 25. They filled out the pre-printed time sheets as if the checks happened at 15 minute intervals, as prescribed.
Between the final two check-ins - 15 minutes apart - on 20 May 2015, Deniz-Sahagun asphyxiated himself in his cell.
His suicide was the third in two years and the fifth since 2005. Despite that history, the staff had no comprehensive suicide prevention plan, a fact that Ice noted in a review of Mr Deniz-Sahagun's death.
A new report by the Human Rights Watch and Community Initiatives for Visiting Immigrants in Confinement (Civic) found that detainees received subpar medical care in 16 of 18 Ice death investigations obtained by the group, and evaluated by several health professionals.
Additionally, the doctors reviewed 12 sets of medical records from people who had reported inadequate medical care to a hotline run by Civic.
"We're not claiming that this is a representative sample," said Grace Meng, senior researcher at Human Rights Watch. "But the problems that were found were systemic problems that would put other people at risk."
Suicide isn't the only health concern that went overlooked in the records detailed in the report. A man who complained of symptoms of cancer for two years didn't get a diagnosis until two months before he died from the disease.
Another man with severe diabetes and pneumonia died after delays in emergency medical care, because of confusion around which detention centre employees could call 911.
"What was particularly interesting to us is that we found insufficient care in both private and public facilities, indicating that the problems are systemic," said Christina Fiahlo, co-founder and executive director of Civic.
Ms Meng and others who contributed to the report worry that a proposed ramping up of immigration enforcement could heighten the risks for detainees - many of whom haven't been convicted of crimes.
About 400,000 people are held in detention each year, with President Trump saying he wants to double that figure. In the recent budget approved by Congress, Ice received funding for an additional 5,000 mandated-detention beds,
"Now we have an administration that is trying to cram even more people into a system that is not effectively monitored," Meng said. "We're really looking at a recipe for more preventable deaths."
Ice officials have promised a careful review of the HRW report.
"(Ice) will review the report to determine what changes, if any, should be made based on its recommendations," said Jennifer Elzea, an Ice spokesperson, in a statement.
"Ice is committed to ensuring the welfare of all those in the agency's custody, including providing access to necessary and appropriate medical care."
The report warns that simple changes - like firing an ineffective nurse or putting in place a suicide prevention plan - will likely not be enough to improve the system overall. They recommend more comprehensive, top-down changes that can improve medical care on a systematic level.
"It's not just 'Sam's doctor had a bad day and made a mistake' but multiple mistakes on multiple days at multiple facilities and no indication that it is going to get better," said Marc Stern, the former medical director of the Washington State Department of Corrections, who reviewed the medical records evaluated in the Human Rights Watch report.
"The system being broken means the fix is at the system level, at the highest levels of the organization," he says. "It's not a quick fix."
Where to get help
If you are depressed and need to ask for help, there's advice on who to contact at BBC Advice.
From Canada or US: If you're in an emergency, please call 911. If you or someone you know is suffering with mental-health issues, call Kids Help Phone at 1-800-668-6868. If you're in the US, you can text HOME to 741741
From UK: Call Samaritans on 116123 or Childline on 0800 1111