[Pnews] Dozens of men have died in disturbing circumstances in privatized, immigrant-only prisons
ppnews at freedomarchives.org
Thu Jan 28 13:50:10 EST 2016
‘This Man Will Almost Certainly Die’
By Seth Freed Wessler
Where Claudio Fagardo-Saucedo grew up, on the colonial streets of the
Mexican city of Durango, migrating to the United States was almost a
rite of passage. It was following the stream of departures from Durango
in the 1980s that the lanky young man left his family and traveled
north. His mother, Julieta Saucedo Salazar, heard that he’d found jobs
working as a laborer in Los Angeles. But they soon lost touch. “We did
not know much about him, really,” his younger sister told me.
This article was reported in partnership with the Investigative Fund at
the Nation Institute, with support from the Puffin Foundation. It will
be part of the February 6 episode of /Reveal/, a new podcast and public
radio show produced by The Center for Investigative Reporting and PRX.
Fagardo-Saucedo worked, his jobs sometimes taking him out of California,
and occasionally he got into trouble—once for “possession for sale” of
cocaine, another time for stealing jewelry. Every seven or eight years,
his mother recalled, he’d return to her house—but never by choice. “They
caught him all the time for being illegal,” Julieta said. She always
hoped her wandering son might stay, get to know the family again, but he
never did. “He would be here a month, and then he’d go again.”
In the summer of 2003, immigration agents detained Fagardo-Saucedo on
his way back to California, but this time the Border Patrol referred him
to federal prosecutors, who charged him with “illegal re-entry,” or
returning to the United States after deportation. He served nearly five
years before being sent back to Mexico. Again, he tried to return. Early
one morning in August of 2008, Fagardo-Saucedo triggered an infrared
sensor as he and two others ran across the border near Tijuana. He
pleaded guilty in a US District Court to another “illegal re-entry”
charge. The judge sentenced him to four years in federal prison.
When Fagardo-Saucedo arrived at Reeves, a prison complex in rural West
Texas, he entered a little-known segment of the federal prison system.
Over the previous decade, elected officials and federal agencies had
quietly recast the relationship between criminal justice and immigration
enforcement. These changes have done as much to bloat the federal prison
population as the War on Drugs; they have also helped make Latinos the
largest racial or ethnic group sentenced to federal custody.
Until the 1990s, border crossing was almost always treated as a civil
offense, punishable by deportation. But in the late 1980s, Congress
started to change that. By 1996, crossing the border after deportation
was punishable by years of imprisonment, with enhanced sentences for
people previously convicted of crimes—most often drug offenses. Though
federal investigators have found no evidence that criminalization has
reduced the pace of border crossings over the long term, prosecutions
for illegal entry and re-entry rose from fewer than 4,000 a year at the
start of Bill Clinton’s presidency, to 31,000 in 2004 under George W.
Bush, to a high of 91,000 in 2013 under President Obama.
By the late 1990s, the flood of inmates from this new class of prisoner,
coupled with a raging War on Drugs, sent the Bureau of Prisons searching
for places to put them. The BOP turned to private companies to operate a
new type of facility, low-security prisons designed to hold only
noncitizens convicted of federal crimes. As of June 2015, these
facilities—which are distinct from immigration detention centers, where
people are held pending deportation—housed nearly 23,000 people.
Three private companies now run 11 immigrant-only contract prisons. Five
are run by the GEO Group, four by the Corrections Corporation of
America, and two by a privately held company called the Management &
Training Corporation. (A third MTC prison was recently shut down after
inmates ransacked it in a protest.) Except for a prison largely used to
house inmates from Washington, DC, these 11 facilities are the only
privately run prisons in the federal criminal-justice system. In 2013,
the BOP spent roughly $625 million on them. The contracts include the
provision of medical care, for which the companies often hire
health-services subcontractors. In one such facility in Reeves County,
Texas, the BOP entered into an agreement with the county, which in turn
hired GEO to operate the prison and Correct Care Solutions to manage
The BOP’s contracts with these facilities are meant to cut costs. Though
the prisons are part of the federal infrastructure, the companies that
run them operate under a different—and less stringent—set of rules in
order to allow cost-cutting innovations. As a retired BOP contracting
official said in an interview, “The more specificity you put in the
contract, the more money the contractors are going to want for
performing the service.”
Repeated federal audits and reports have found these facilities to be in
crisis. Prison medical care is notoriously bad, but for years,
immigrant- and prisoner-rights advocates have sounded the alarm about
these sites in particular, describing them as separate and unequal,
segregated on the basis of citizenship. “These prisons operate without
the same systems of accountability as regular Bureau of Prisons
facilities, and prisoners suffer,” said Carl Takei, an ACLU attorney who
co-authored a 2014 report documenting the subpar conditions.
Yet the full scale of the medical neglect at these immigrant-only
contract prisons has remained opaque—until now. After two years of
negotiations with the BOP in and out of federal court over an
open-records request, I obtained more than 9,000 pages of medical
records that contractors submitted to the BOP. They include the records
for 103 of at least 137 people who have died in federal contract prisons
from 1998 (the year after the first one opened) through the end of 2014.
The records all concern men; women are sent to regular BOP-run prisons.
The documents include nurse and doctor notes, records from hospital
visits, psychological files, autopsies, and secret internal
investigations. In their pages can be found striking tales of neglect.
Each case file—sometimes hundreds of pages long—was reviewed by at least
two independent doctors who rendered opinions on the adequacy of the
medical care provided. Some of the case files are meager and appear to
be missing pages. But of the 77 that provided enough information to
render a judgment, the doctors found that 38 contained indications of
inadequate medical care. In 25 of these—a third of the total—the
reviewers said the inadequacies likely contributed to the premature
deaths of the prisoners. In only 39 cases did at least one reviewer find
indications that the care had likely been in accordance with recognized
Combined with interviews with relatives and cellmates of the deceased
inmates, and with correctional officers and medical staff, the files
tell the story of men sick with cancer, AIDS, mental illness, and liver
and heart disease, forced to endure critical delays in care. They show
prison medical units repeatedly failing to diagnose patients correctly
despite obvious and painful symptoms, as well as the use of
underqualified workers pressed to operate on the borders of their legal
scope of practice. The files also show men dying of treatable
diseases—men who very likely would have survived had they been given
access to adequate care.
Fagardo-Saucedo, then 43, was booked into Reeves, run by the GEO Group
and a separate medical contractor, on January 27, 2009. When he arrived,
the facility was in tumult. Six weeks earlier, inmates at the sprawling
3,700-bed complex had rioted, protesting the death of a man who was left
in solitary confinement for a month without proper treatment for his
epilepsy; he died after suffering a seizure. Four days after
Fagardo-Saucedo’s arrival, the prisoners rioted again when another sick
man was reportedly placed in segregation.
According to the BOP, prisons holding people who will be deported don’t
require the same level of inmate services as regular prisons. (Josh Begley)
Reeves was still recovering from the unrest when a prison physician
scrawled a cursory note in Fagardo-Saucedo’s file. The doctor noted that
the inmate had arrived from pretrial detention with records indicating
that he’d tested positive for latent tuberculosis and had complained of
headaches. BOP rules require that TB-positive inmates also be tested for
HIV, but an HIV test was never performed. Indeed, over the next two
years, Fagardo-Saucedo wasn’t seen by a medical doctor even once.
After three weeks in Reeves, he began to show up in the clinic
complaining of pain—first tooth pain, then headaches, then nausea and
back pain. Over two years, Fagardo-Saucedo went to the clinic 18 times.
He was seen on nearly all of these occasions by one of a rotating group
of licensed vocational nurses, or LVNs. Usually, the LVN sent him back
to his bed with a prescription for Tylenol or ibuprofen. Meanwhile, his
body was signaling a fatal breakdown, something that doctors who
reviewed his case said should have been caught by the facility’s care
The training for LVNs (known as licensed practical nurses, or LPNs, in
some states) takes only a year. They are taught to change dressings,
check blood pressure, help patients bathe, and gather basic information.
They’re often hired to provide routine care in nursing homes or to
assist registered nurses in hospitals. Unlike the RNs, who provide
patients with substantive medical care and perform triage and
evaluations, LVNs are intended as support staff.
This is the reason that BOP-run prisons rarely hire LVNs, said Sandy
Parr, a vice president in the federal correctional officers’ union and
formerly a registered nurse in a federal prison. “LVNs are too limited
to make sense to hire,” she said. Yet in the BOP’s immigrant-only
contract prisons, LVNs often appear in the files as the sole caregivers
that sick prisoners see for days or weeks. They seem to perform jobs
equivalent to those of registered nurses, a practice that prison medical
staff confirm. In 19 of the cases reviewed, at least one medical doctor
flagged the overextension of LVNs as a factor impeding proper medical care.
In only 39 of 77 cases did a reviewer find that the care had likely been
in accordance with recognized medical standards.
Martin Acosta, a Salvadoran man who served time in Reeves for illegal
re-entry at the same time as Fagardo-Saucedo, began complaining of
abdominal pain late in the summer of 2010. Over four and half months, he
went to the clinic more than 20 times. Other than a doctor’s visit a
month after his complaints began, he saw only nursing staff until the
last two weeks of his incarceration; on 14 of those occasions, he saw
only LVNs. Notes in the handwritten medical logs and nursing templates
reveal a cascade of missed signs indicating serious illness, said
doctors who reviewed the files. The prison medical staff described
Acosta as a difficult patient; one thought he was simply trying to
obtain a prescription for narcotics. Acosta was sent back to his room
with nothing but Maalox nine times. Physicians who reviewed the files
said the nurses appear to have missed the larger story of a protracted
“For prison medicine to work, a doctor has to be able to trust the
people who work there,” said Dr. Neal Collins, a retired BOP and
immigration detention-center physician and clinical director who
reviewed the Acosta files. “If they have competent nurse practitioners,
then they can trust that the system is catching it. But when people
don’t know what to look for, that’s what you worry about.”
In significant discomfort on one of his many trips to plead for help,
Acosta told an LVN that he’d vomited a dark substance and had seen blood
in his stool. He asked to be sent to a hospital, and the LVN took a
stool sample. Leafing through the file, I expected to find a hospital
referral or at least the test results. Instead, the records suggest that
the LVN eyeballed the stool sample and deemed it unremarkable. There’s
no indication in the files that lab tests were performed or a doctor was
called. When Acosta finally saw a physician at Reeves in December 2010,
he could no longer eat. He was transferred to a hospital, where a
massive tumor was found in his abdomen. Acosta was ultimately diagnosed
with severe metastatic stomach cancer.
In early 2014, an LVN at another facility—this one run by MTC—similarly
failed to complete a basic test. Tasked with evaluating a man who
complained of chest pains, the LVN attempted to use an electrocardiogram
machine. But he wrote in his notes that he couldn’t get the machine to
work because the patient’s “skin is oily and electroids [sic] did not
stick.” Rather than call a doctor, the LVN checked a box marked “No
action indicated at this time” on the form for chest-pain complaints.
The patient later died of a heart attack, despite subsequent treatment.
Doctors who reviewed the file were divided about whether the shoddy care
contributed to his death.
In the aftermath of the 2008 and 2009 riots at Reeves, BOP monitors
began to visit the facility more regularly to check on healthcare
conditions. But the increased oversight accomplished little: Each time
the monitors returned, they found that Reeves had failed to fix the
problems. One year after the riots, Reeves remained derelict. “The lack
of an internal system of administrative and clinical controls has
contributed to the provision of less than adequate medical care,” the
Acosta’s common-law wife, Guillermina Yanez, showed me a photograph of
him before his illness. Acosta appeared youthful and strong, his T-shirt
hugging muscular arms. Then Guillermina showed me a picture taken after
she and the couple’s 2-year-old daughter, Tania, boarded a bus from
Atlanta to visit him in the hospital. Acosta’s frame was now skeletal,
his face sunken, his chest tattoo pinned to paper-thin skin. “I asked a
question to the guards: ‘Looking at him, how could you have left him to
look like that?’” Guillermina recalled.
Acosta died in late January 2011. In a will that a nurse’s assistant at
the hospital helped him prepare, Acosta wrote: “I want the deed to my
house and land”—in a small town by a river on El Salvador’s far eastern
edge—“to be placed in the name of the mother of my daughter.” Salvadoran
officials facilitated the return of Acosta’s body to the country of his
Martin Acosta’s daughter, Tania, shows pictures of her father before and
after stomach cancer drained away his body, and life. (Courtesy of the
Martin Acosta family)
“By the time he got to the hospital, it was too late,” said Collins, the
retired prison doctor. “If this case went to court, would they win a
malpractice suit? Yes, I think they would.”
Reeves continued to fall short. The Justice Department’s inspector
general, Michael Horowitz, released the results of an audit of the
facility in April 2015. The audit found that Reeves’s medical contractor
at the time, Correctional Healthcare Companies, had failed to meet
contractual staffing obligations in the medical unit for at least 34 of
the 37 months from 2010 to 2013. The BOP may have incentivized the
understaffing: The financial penalties for failing to fill open LVN
positions were so modest that it cost CHC less simply to leave them vacant.
The inspector general is currently conducting a broader investigation of
the BOP’s contracting. About the understaffing in the medical unit at
Reeves, Horo- witz asks: “Why was it happening for 34 to 37 months? Why
wasn’t that caught before we showed up?”
Brain-Dead on Arrival
Two hours east of Reeves, the GEO group operates another federal prison,
this one in Big Spring, Texas, where 3,400 noncitizens are held in a
decommissioned Air Force base. GEO’s medical subcontractor is Correct
Care Solutions. Gary Austin, an LVN there, was the lone medical worker
on the night shift when staffers radioed to report a medical emergency
around 1:30am on June 26, 2014.
Gustavo Ochoa Jaen, a Honduran man serving 52 months for illegal
re-entry, had been startled awake by the sound of moaning from the bed
above him, where one of his cellmates, Nestor Garay, slept. “He was
having nightmares,” Ochoa Jaen thought. He had become friends with
Garay, who was convicted for selling meth near his parents’ modest home
in California’s wine country, where he’d lived for the past 20 years.
Garay, who was 39 at the time of his arrest, was popular at Big Spring:
One of the few inmates whose family could afford to fill his commissary,
he would share his snacks and stamps.
Garay’s moaning didn’t stop, and it eventually woke the other men in the
10-bed room. They turned on the light and saw that Garay was dripping
with sweat. “Half of his body was off the bed, about to fall,” Ochoa
Jaen said. Garay’s eyes were fixed: a “/mirada perdida/,” another
cellmate told me in a letter.
“Call a helicopter to take him to the hospital—this man is dying!”
—Irineo Espinoza-Zepeda, inmate
Together, the men lowered Garay to a bottom bunk, then yelled to an
officer for help. They said it took 30 minutes—15 minutes, according to
prison records— before Austin, the LVN on duty, arrived at the cell. An
officer who arrived first told Austin that Garay had had a seizure and
nearly fell from the bed, according to Austin’s notes. The captain
ordered four of Garay’s cellmates to use the mattress as a stretcher to
haul him down the stairs and to the clinic, three of the prisoners said.
The prison records describe a disaster once he arrived there.
In the clinic, Austin wrote, Garay was unresponsive; his right hand was
weak, and he was unable to focus his eyes. He had urinated on himself
and was sweating profusely. Austin phoned the on-call physician’s
assistant, Russell Amaru, who was asleep at his home in Midland, Texas,
45 minutes away. Over the phone, Amaru ordered Austin to administer a
heavy dose of an antiseizure drug called Dilantin, the notes say. But
Garay couldn’t swallow the pills, and Austin called Amaru again.
Ochoa Jaen held on firmly to his friend’s hand as he listened to the
call. Another of the prisoners, Irineo Espinoza-Zepeda, said to the
captain in the clinic: “Call a helicopter to take him to the
hospital—this man is dying!” Instead, according to Austin’s notes, Amaru
instructed him to send Garay “back to unit and place on mattress on
floor and follow up with midlevel”—i.e., a physician’s assistant or
nurse practitioner—“in the AM.”
The captain ordered the prisoners to return Garay to their cell. The
cellmates looked at one another and refused, one by one. After a brief
exchange—and a threat by the captain to send them to a segregated
housing unit, or SHU—the captain ordered the men to their cell without
Garay. “We went to sleep thinking they were going to give him proper
medical care,” Espinoza-Zepeda said.
Instead, according to Austin’s notes, he and the captain had Garay moved
to another cell, where he was placed on a mattress on the floor. The LVN
checked his vital signs once at 3:15 am. By the time the morning nurse
arrived at 6:15 am, the right side of Garay’s face was drooping, his
eyes were open but unresponsive, and his right arm was contracted. The
new nurse called the clinical director, a physician, who ordered that
Garay be taken immediately to the nearest ER, two miles away. It was
another hour before the van left the prison.
The hospital intubated Garay and performed a CT scan. He had suffered a
massive stroke, hospital records show. He was flown by helicopter to
Midland Memorial Hospital, 40 miles away. When Ochoa Jaen and the other
men learned what had happened the next morning, they quickly began
searching through Garay’s belongings for a relative’s phone number.
Garay’s parents, Alvara and Indalecio, live in a neatly kept home off
the boutique-lined Main Street in Napa Valley’s St. Helena. They were
accustomed to hearing from their son in Texas: He’d call them several
times each week to tell them about the books he’d read, the
conversations he’d had about God. After Alvara’s cell phone rang at 6 am
Pacific Standard Time, waking her before she went to her job as a
cleaner at a local winery, an unfamiliar voice introduced himself as a
friend of Nestor’s.
“We’re going to give you some news,” said the man, who was using a
contraband cell phone. “Something happened to Nestor.”
“What happened? Where is my son?” Alvara asked.
John Foster is the neurologist at Midland Memorial who treated Garay
when he arrived that morning. “You have a three-hour window to give a
clot buster” for the kind of stroke that Garay had suffered, he said.
But by the time Garay made it to Midland, at least six hours had passed
since his cellmates first heard him moaning. “It was pretty futile,”
Foster said. “The time to fix him…may have been when he fell out of bed.”
Two days after the phone call, Garay’s family gathered in his hospital
room. Alvara rushed to embrace her son, who lay on his back with his
eyes closed and his feet shackled to the bed. “My mom hugged Nestor, and
he cried,” said his brother Enrique. “That’s something I’m never going
to forget—somehow Nestor was still there.” But the doctors told Alvara
and Indalecio that their son was brain-dead, and the tear was just a
reflex. The machines were all that were keeping him alive.
Only after Garay was declared dead did the officers remove his shackles.
“It was as if they were saying, ‘If you’re still alive, then you’re
under my control,’” Alvara told me later in the room where her son had
slept, his closet still full of clothes.
The prison’s mortality review, performed by the contractors, faulted
both Austin and Amaru for failing to alert the clinical director or
director of nursing when Garay’s condition did not improve under
observation. Four medical doctors who independently reviewed Garay’s
records said that both Amaru and Austin should have immediately ordered
him taken to an ER, and the mortality review found that Amaru “did not
respond correctly to the initial report from nursing describing new
onset of presumed seizure of a previously healthy 41 year old male.” It
also found that neither diagnosis nor treatment was “appropriate and
Big Spring’s own mortality review found that the care the prison
provided to Nestor Garay was not not timely or appropriate.
I recently sat down with Amaru in his condo in Midland. While he said
that he knows now that the events that night constituted a breakdown in
medical procedure, he adds that Austin’s notes are a revisionist account
of what happened. “I don’t think they’re totally accurate,” Amaru said
at his kitchen table. “It leaves a bad taste in my mouth.”
Amaru said that when his phone rang that night, Austin was imprecise. He
described a man who “was responsive” but “felt weak” and was “groggy,”
Amaru said. Austin wrote in the notes that Garay was “unable to swallow
pills at this time.” Amaru said he understood that Garay simply
struggled to swallow the large Dilantin tablet.
“I can make a list of people who were involved, but who’s really
responsible? Who’s the boss?” — Nestor Garay’s brother Carlos
The mortality review backs Amaru’s story, at least in part: “The
information communicated to the physician’s assistant was incomplete,”
it reads, followed by a recommendation that the facility’s nursing staff
“be retrained on telephone orders.” But Amaru doesn’t blame Austin. “The
fact is that the system—BOP and GEO—allows people to be short-staffed
and in positions that they’re not properly trained for,” he said. “I am
therefore operating in the dark.” Austin didn’t respond to messages
seeking comment. According to Amaru, Big Spring took no meaningful
action as a result of Garay’s death.
Had Nestor Garay become a US citizen like his parents and younger
brother, he would never have ended up at Big Spring. He would have
served his time at a BOP-run prison with access to the same healthcare
that the federal government provides to US citizens in its custody. BOP
rules require that after-hours “coverage will be provided by registered
nurses and/or EMTs, where available.” Sandy Parr, the nurse with the
federal correctional officers’ union, told me that prisons generally
cover their night shifts with paramedics, who are trained to deal with
emergencies. “That’s what you have to deal with at night—emergencies,”
Garay’s older brother Carlos, who lives 20 minutes from his parents,
wants to empty out Nestor’s closet and “move forward.” But he also wants
answers about why his brother wasn’t sent to a hospital sooner. “I can
make a list of people who were involved,” he said, “but who’s really
responsible? Who’s the boss?”
Separate, Unequal, and Unaccountable
In 2008, Dr. John Farquhar retired from his longtime family medical
practice in Big Spring. Boredom quickly set in, however, so in 2010 he
took a job as Big Spring’s clinical director—the lone medical doctor for
“3,500 bad boys,” he said. Farquhar, who left the job late in 2013, is
85 years old, tall and slim, with a military posture and a haircut to
In the thousands of pages of medical records I obtained from the 12
immigrant-only prisons in operation as of 2014, sparse nursing
notes—often from LVNs—are the norm. When doctors do appear, they often
simply co-sign what the nurses write. Farquhar was different: His
handwritten notes show him attending to sick patients as late as 11 pm.
He’d come in on weekends and answer his phone when not on call. “He was
nearly holding up a system that was ready to collapse around him,” a
doctor who reviewed the files said.
Yet Farquhar found himself in a medical system that didn’t meet the
standards he’d expected. “This is Gov’t medicine—obviously—and it is now
going to apply to all of us!” Farquhar scrawled in one patient file. “I
feel badly for his shabby care,” he wrote in another. I asked him about
the notes. He would not comment on individual cases, but said, “I stand
by that statement.” The deficiencies, he added, stemmed from a culture
of austerity: “The pressure of budget is always felt.”
Farquhar often treated inmates whose health conditions were simply
beyond the capacity of the bare-bones prison clinic and its
stripped-down staff. But when he did request that prisoners be
transferred to a federal-prison medical center or a local hospital, he
was often denied. “This man will almost certainly die,” he wrote about
an 81-year-old who arrived at Big Spring in 2010, and whom Farquhar
tried and failed to have transferred.
Farquhar felt the pressure to cut costs immediately. Administrators for
the medical subcontractor traveled to Texas to tell him that the rate of
ER referrals had been too high in the past, he said. They asked him, “Is
there a way that we can cut this down?”
Donna Mott started working as a prison guard for the BOP in the 1980s
and remained with the bureau until she retired in 2014. For the last
seven years of her career, she supervised the performance of seven
private contracts. Mott says the kinds of performance issues described
in the monitoring reports and medical records are a direct result of the
effort to cut costs via privatization.
BOP-run facilities are obligated to manage populations in accordance
with rules set forth in dozens of detailed “program statements”—rules
that have produced what many consider the country’s best-run prison
system. The rules require BOP facilities to provide inmates with access
to educational programs, addiction treatment, mental healthcare, and
rehabilitative services. But according to a review of five contract
solicitations, the BOP’s agreements with private-prison operators
include only a fraction of these requirements and list others merely as
“If you put in specificity exactly like BOP program statements,” Mott
said, “then it is basically going to cost the contractor the same amount
to operate their facility as it does a bureau facility, which then takes
the draw for private contracting off the table—because the draw is that
it costs the government less money.”
According to government reports and interviews with BOP officials, the
contracts specified that the BOP would increase or dock fees based on
performance, rather than stipulating extensive rules. The GEO Group says
that, in practice, it follows the same rules as BOP facilities. In a
statement, GEO wrote that its prisons “adhere to strict contractual
requirements set by the FBOP [Federal Bureau of Prisons] as well as all
of the same policies and program statements enforced at FBOP-operated
facilities…. All medical standards, policies, and practices in place at
GEO-operated facilities strive to meet those in place at FBOP-operated
GEO’s medical subcontractor, Correct Care Solutions, said it provides a
“comprehensive scope of healthcare services per our contractual
Neither MTC nor CCA responded to questions about their operations or
particular deaths at their sites.
Yet Mott said because the contracts lack clear and specific requirements
in many areas of operation, the BOP’s monitors on the ground “had no
“I think that very often, the quality suffered because they try to save
on cost.” —Gerald Gaes, who oversaw a review of the BOP’s privatization
The companies say they secure accreditation from two agencies that each
set dozens of standards. But a 2013 Government Accountability Office
report on mental healthcare in federal prisons found that seven of the
13 contract facilities then in operation were not fully compliant with
the mental-health-related standards of the Joint Commission, one of the
Since the Taft facility near Bakersfield, California, which opened in
1997, was the BOP’s pilot privatization effort, it received special
scrutiny. In 2005, the Justice Department released two reports on Taft,
one by an outside research firm and another performed by an economist
contracted directly by the BOP. The outside researchers found that GEO,
then the facility’s operator, had cut costs. But the BOP-contracted
economist found that even these savings were eclipsed by the extra costs
to the BOP of monitoring the prison and administering its contract.
“The more rigorous analysis showed that there really were not any
savings, which was the purpose,” said Gerald Gaes, who managed the BOP’s
research division when the studies began. “I think that very often, the
quality suffered because they try to save on cost.”
Death in Solitary
Among the many rules that some contract prisons were not required to
follow were the program statements that relate to mental healthcare. If
they had been in effect, those policies would have guided how Taft
treated Jesus Enrique Zavala Montes when he stepped off a bus on
February 7, 2013, to serve a five-month sentence for illegal entry.
On the bus that transported him from Arizona to Taft, run since 2007 by
MTC, the 28-year-old was already acting strangely. Guards separated him
from other prisoners because he thought “other inmates wanted to harm
him,” records say. By the time he arrived at Taft, prison staff said he
seemed nervous, continuously watching the door.
Zavala’s sister Lisbia, who lives in the Mexican state of Sinaloa, told
me she’s not sure when her brother’s troubles began. Sometimes she
thinks they stem from their childhood—a violent father, the instability
of bouncing from one relative’s house to another. Or maybe, she says,
“it was just his mind.” What’s clear is that Zavala became an addict in
his early 20s. When he was high—and sometimes when he wasn’t—Zavala
would pace his room in his mother’s apartment, talking to himself. In
2008, he was incarcerated for more than a year in a Mexican jail after a
fight and tried to kill himself while in solitary.
In 2010, Zavala’s mother forced him into a rehab program, where he was
diagnosed with bipolar disorder and sent home with two bottles of pills,
which Lisbia confirmed were the anti-anxiety medication diazepam and a
drug for bipolar disorder called carbamazepine. His mind now organized
and clear, Zavala told his sister he was leaving for the United States.
The next two years were marked by constant departures and returns,
arrests and removals. He’d do 60 days in federal prison for illegal
entry and then return to Mexico. On December 17, 2012, Zavala’s sister
says, he left for the last time. He was arrested by border agents,
criminally charged for crossing the border, and sentenced to five months.
When he arrived at Taft, Zavala filled out a standard psychological
questionnaire. In messy script, he wrote that he’d taken “deasepan” and
“carmanasipin.” Speaking though a translator, Zavala told a therapy
intern with a master’s degree that he had tried to kill himself in 2008.
She noticed the scars on his wrists and asked why he’d done it. In the
Mexican prison, “they would just throw food at him,” the intern wrote.
She recommended Zavala for psychiatric consultation and therapy, but
cleared him for admittance to the general population, writing that the
inmate had “no debilitating mental disabilities” despite his statement
that he had previously taken psychiatric drugs. A subsequent review also
indicates she believed he’d been placed on a “hot list” of prisoners who
may pose a danger to themselves.
At 1:29 am, four days before he was scheduled to finally see a
psychiatrist, Zavala was discovered dead in his cell.
A registered nurse intervened and the prison’s medical doctor ordered
that Zavala be held in an observation unit overnight so that
mental-health staff could see him in the morning. By 9:15 am, the
intern, after consulting chief psychologist Christopher Cummins, had
again cleared Zavala from observation*. *There is no indication in the
records that Cummins ever saw Zavala. “I met inmate in the infirmary to
assess his mental status,” the intern wrote. “Inmate presented well.”
But Zavala was not well. According to a confidential investigation by
MTC, which operates Taft, in his first two days there, Zavala told a
prison worker that he thought people were “out to get him.” Prison staff
placed Zavala in solitary on a “protective custody” hold pending a
review. That review did not take place; nor did Zavala ever see a
psychiatrist. Instead, he sat in the bare room, alone.
Eight days later, Zavala smashed the window of his cell and scrawled
graffiti on the wall. There is no record that Cummins was alerted.
Instead, on February 22, the prison held a disciplinary hearing to
punish Zavala for breaking the window. Four days later*, *a correctional
counselor e-mailed Cummins to ask for a psychiatric referral because
Zavala was suffering from stress, anxiety, and sleeplessness. Now, 10
days after Zavala had acquiesced to the voices and smashed a window,
Cummins finally scheduled Zavala for a psychiatric consultation. Falling
deeper into psychological chaos, Zavala used a razor to shave off his
eyebrows. A guard performing the required 30-minute rounds in the SHU
noticed the change but failed to report it.
On March 1, at 1:29 am, four days before he was scheduled to finally see
a psychiatrist, Zavala was discovered dead in his cell; an officer found
him hanging from a sheet that he’d tied to the handle of the top bunk.
A String of Suicides
Just six months before Zavala’s death, another inmate, Luis Alonso
Zamora Villa, also killed himself at Taft. Zamora Villa had been held in
a room like Zavala’s, with a window looking out over a dirt yard and a
bunk bed, which he too used to hang himself. As with Zavala, his records
show that he told the therapy intern he’d considered suicide before. She
referred him to a psychiatrist, but there’s no indication he was ever
seen by one. And although Cummins, the psychologist, saw him once, he
arrived without a translator.
“In regular BOP prisons, mental-health treatment is part of the mission,
because rehabilitation is part of the mission,” a BOP official, who
spoke on the condition of anonymity, said. “For criminal-alien prisons,
it’s just, ‘Hold them.’”
I asked Robert Trestman, a professor of psychiatry at the University of
Connecticut and a national expert on correctional mental health, to
review the two men’s files from Taft. “The care here was at best
incredibly lackadaisical,” he said. “This is by no means an acceptable
standard of care.”
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According to the MTC report in the Zamora case, officers assigned to the
SHU had in the past failed to conduct their required rounds. Zamora
killed himself during a one-hour-and-17-minute span at dawn when no SHU
checks were performed. The BOP had redacted significant portions of the
post-death report on Zamora’s suicide in the documents I obtained.
Two months before Zamora died, the BOP warned Taft’s operators that
“security procedures” in the SHU “were not always followed.” Nor were
they at the GEO Group’s Big Spring prison, where five correctional
officers were criminally charged because they falsely claimed that
rounds were performed. There, a prisoner killed himself in his solitary
cell on a night when the guards failed to perform their required rounds.
“In regular BOP prisons, mental health is part of the mission. For
criminal alien prisons, it’s just, ‘Hold them.’” —BOP official
Between 1998 and 2014, there were at least seven suicides in the BOP’s
immigrant-only contract prisons. In Reeves, over seven months from 2008
to 2009, two men killed themselves, each in solitary cells, each using
prison-issued shaving razors to slash their own necks.
The therapy intern, who told me she’s working in another prison now,
declined to discuss the Zavala and Zamora cases, though she remembered
them clearly. She was unavailable to investigators during an internal
review of Zavala’s case; she was out on extended stress leave.
Many of the failures in Zavala’s case in particular might have been
prevented if the BOP’s contract prisons were bound by the same program
statements that mandate care in BOP-run facilities. The BOP’s program
statement on suicide prevention mandates that prisons set up a “hot
list” of prisoners who may pose a danger to themselves. The list is to
be “distributed to Correctional Services, Health Services, and Unit Team
After Jesus Enrique Zavala Montes’s suicide, MTC's “after action”
report found a litany of mental health failings that amount to what one
doctor called “lackadaisical” care.
Though the contract solicitation for Taft did not include that rule, it
did put a hot list in place in the wake of Zamora’s suicide. When Zavala
broke the window or shaved off his eyebrows, that list would have
alerted staff to his psychiatric distress. But Cummins, the only prison
mental-health staffer who could add a name to it, never made the
designation, a failure cited in the prison’s confidential after-action
review. The review also found “a lack of follow-up when signs existed
that suggested urgent attention was required.”
Cummins, who no longer works at Taft, declined to speak about the
suicides, but he described Taft’s psychological services as
under-resourced and understaffed. He said it was challenging to work
with a Spanish-speaking population when translation services were
unavailable or unreliable. (Amaru, the physician’s assistant at Big
Spring, said that the medical team there sometimes conscripts bilingual
prisoners to provide translation.)
I asked the BOP if it took any action after Zavala’s death. The bureau
did not respond. Technically, MTC may not have violated its contract,
but the company was worried about liability. The after-action review was
conducted “in anticipation of ligation,” it said.
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No lawsuit was ever filed. Zavala’s family only learned of his death a
year later, when a man from the Mexican consulate in Bakersfield,
California, finally called. Zavala’s ashes were mailed in a box to a
Foreign Relations office where a functionary told Zavala’s mother, Maria
Elena Montes Garcia, that her son had killed himself in a prison called
When I spoke with her by phone, she told me she had wondered what he’d
done to find himself locked up, if it had been hell again inside. I was
the first one to tell her that he’d been convicted only for the crime of
trying to re-enter the United States.
Ignoring the Problem
Unlike the BOP’s mental-health and staffing guidelines, federal
authorities do require contractors to follow the bureau’s
infectious-disease policies, likely due to the risks of an outbreak. In
January 2008, a year before Fagardo-Saucedo arrived at Reeves with a
positive tuberculosis screen, BOP monitors issued an annual compliance
review to Reeves County that found at least two dozen inadequacies,
largely in medical care. (The review was obtained by independent
attorney Steven Raher.) Among the findings, Reeves’s medical unit had
repeatedly failed to provide HIV tests to patients with past
In their responses to the review, Reeves officials told the BOP that
they understood the requirement to test TB-positive inmates for HIV was
open to “interpretation.” The BOP replied that the facility was
mistaken. Even in the wake of this warning, Fagardo-Saucedo was never
screened for HIV. Monitoring reports indicate that other contract
facilities also failed to follow the rules on infectious-disease treatment.
In July 2010, six months after Fagardo-Saucedo’s arrival, monitors
returned and again cited the prison for failing to properly care for
inmates with tuberculosis.
Meanwhile, Fagardo-Saucedo’s symptoms were growing worse: acute
headaches, intense nausea, and back pain. After 17 months of steady
complaints, an LVN noted that a medical doctor should see him. Instead,
two weeks later, a physician’s assistant evaluated him and again sent
him back to his cell with ibuprofen. Fagardo-Saucedo missed three
medical appointments. An LVN simply wrote, “No show for scheduled
[appointment]. Security unable to deliver.” In a review of the files
months later, a BOP doctor wrote: “It certainly looks like one could
locate the inmate.” When Fagardo-Saucedo reappeared in the files three
weeks later, saying that the ibuprofen hadn’t worked, he told a nurse,
“I want to see a doctor.” He was not seen by one.
In mid-December of 2010, BOP monitors returned again to Reeves. This
time, the deficiencies were severe enough to be flagged as a
“significant finding.” “The lack of an internal system of administrative
and clinical controls has contributed to the provision of less than
adequate medical care,” they wrote, expressing particular concern about
the infectious-disease clinics.
As he had for nearly two years, Fagardo-Saucedo described his severe
pain and nausea. He died just days later, shackled to a bed.
As monitors toured Reeves in December, the head of the BOP’s
Privatization Management Branch—the office responsible for the routine
monitoring of contract facilities—wrote an e-mail to staff: “[W]e have
been informed they have identified serious issues in health
care—specifically their infectious disease program.”
Reeves’s medical clinic had fallen into such disrepair that the BOP was
finally grappling with whether to renew the contract with Reeves County.
The BOP team listed the pros and cons. The five pros focused solely on
logistics, noting that closure would place a “burden on [the] BOP inmate
On the 15-item cons list: 230 citations and $2 million in penalties for
compliance failures, as well as a lack of healthcare that has “greatly
impacted inmate health and well being.” Officials also called into
question whether the contract was saving them any money at all: “While
contract price appears reasonable, the oversite [sic] involved reduces
At 10:30 pm on New Year’s Eve 2010, a correctional officer contacted the
clinic by radio and said that Fagardo-Saucedo appeared sick and that
medical staff should check in on him. As he had for nearly two years,
Fagardo-Saucedo described his severe pain and nausea. The LVN he saw
called a doctor, who instructed her to administer an injection of pain
A portion of the Reeves facility’s mortality review indicates that the
prison itself knew the care it provided to Fagardo-Saucedo was substandard.
On his way back to his bunk early on New Year’s Day, Fagardo-Saucedo
collapsed. “My legs gave out and I fell,” he told the LVN back in the
clinic. After watching him struggle for the rest of the morning, the LVN
called the doctor. Upon hearing of Fagardo-Saucedo’s condition, the
physician ordered that he be taken to an ER. Two hours later,
Fagardo-Saucedo was loaded into a security van and delivered first to a
local hospital and then to another, one hour away in Odessa. There, he
had a seizure.
Fagardo-Saucedo died four days later, shackled to the bed, alone but for
the two guards assigned to watch him. The hospital had finally screened
him for HIV; he tested positive. According to a county autopsy report,
Fagardo-Saucedo died of an HIV-related infection in his brain.
The BOP and Reeves produced a trail of reports after his death. “An HIV
test should have been offered based on his history of positive [TB]
test,” the prison’s mortality review said. A BOP doctor who reviewed the
case noted that HIV could have accounted for the headaches. “A more
complete evaluation by the doctor…could have helped in providing an
earlier intervention,” the physician wrote. In the months after
Fagardo-Saucedo’s death, the BOP extended its contract with Reeves
County. The GEO Group and Correct Care Solutions continue to manage the
prison. In early 2015, BOP monitors cited the facility for again failing
to properly follow up on positive TB tests.
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