Federal report on the death of Pedro Tavarez

8/9/2019 Federal report on the death of Pedro Tavarez

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OFFICIAL USE ONLY SENSITIVE Page 1 of 3

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

Immigration and Customs EnforcementOffice of Professional Responsibility

PREPARED BY

REPORT OF INVESTIGATION 2. REPORT NUMBERHB 4200-01 (37), Special Agent Handbook 001

3.TITLETavarez, Pedro/Unknown/Death - Detainee/Alien (Known Cause i.e Terminal Illness/BOSTON,SUFFOLK, MA

4. FINAL RESOLUTION

5.STATUS 6. TYPE OF REPORT 7. RELATED CASES

Initial

Report

Allegation

8. TOPIC

Detainee death in Boston, MA.

9.SYNOPSISOn October 19, 2009, the Joint Intake Center (JIC), Washington, D.C., received informationreporting the death of an Immigration and Customs Enforcement (ICE) detainee. On October 16,2009, Mr. Pedro Juan Tavarez (A ) was transported to Shattuck Hospital after themedical staff from Suffolk County House of Correction (SCHOC) diagnosed a possible case ofpneumonia that was affecting his heart. After being transferred from Shattuck Hospital, to the

Faulkner Hospital and finally to the Brigham and Women's Hospital, Mr. Tavarez's conditioncontinued to deteriorate. On October 19, 2009, Immigration Enforcement Agent (IEA)

, Boston, MA was informed that Mr. Tavarez had passed away. Mr. Tavarez's body willreportedly be examined today by a Massachusetts State Medical Examiner to determine thecause of death.

10. CASE OFFICER (Print Name & Title) 11. COMPLETION DATE 14. ORIGIN OFFICE

- Joint Intake Specialist 20-OCT-2009 Joint Intake Center12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER

- ICE-OPR Special AgentSupervisor 20-OCT-2009 No Phone Number

THIS DOCUMENT IS LOANED TO YOU FOR OFFICIAL USE ONLY AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY. ANY FURTHER REQUEST FORDISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH ACOPY OF THE DOCUMENT.

THIS DOCUMENT CONTAINS INFORMATION REGARDING CURRENT AND ON-GOING ACTIVITIES OF A SENSITIVE NATURE. IT IS FOR THE EXCLUSIVE USE OF OFFICIAL U.S.GOVERNMENT AGENCIES AND REMAINS THE PROPERTY OF THE DEPARTMENT OF HOMELAND SECURITY IT CONTAINS NEITHER RECOMMENDATIONS NOR CONCLUSIONS OF THEDEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BEMADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR.


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REPORT OF INVESTIGATIONCONTINUATION

2. REPORT NUMBER

HB 4200-01 (37), Special Agent Handbook 001

10. NARRATIVE

None


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4. FINAL RESOLUTION


Interim

Report

Detainee Death Review

8. TOPIC

Detainee Death Review TAVAREZ, Pedro

9.SYNOPSISOn October 19, 2009, the Joint Intake Center (JIC), Washington, D.C. received notificationregarding the death of ICE detainee Pedro Juan TAVAREZ ( who was housed at theSuffolk County House of Corrections (SCHOC), Boston, MA. TAVAREZ, a Dominican Republicnational, died on October 19, 2009 at Brigham and Women's (B&WH) in Boston, MA, due tocardiac arrest resulting from natural causes.

On October 22, 2009, the Office of Professional Responsibility (OPR), Office of DetentionOversight (ODO), initiated an OPR Detainee Death Review to investigate the facts andcircumstances surrounding the death of TAVAREZ. Per ICE policy, all deaths of ICE detaineesare reviewed by OPR ODO. This report documents the immigration and criminal histories ofTAVAREZ.


- ICE-OPR Special Agent 16-FEB-2010 ICE OPR Detention Facilities Inspection12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER

- ICE-OPR SpecialAgent Supervisor 15-MAR-2010 No Phone Number




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10. NARRATIVE

On October 19, 2009, the JIC, Washington, D.C. received notification regarding the death of ICEdetainee Pedro Juan TAVAREZ (DOB: 07/25/1960; TAVAREZ, a 49 year oldDominican Republic national, died on October 19, 2009 at the Brigham & Women's Hospital inBoston, MA due to cardiac arrest resulting from natural causes. At the time of his death,TAVAREZ was in ICE detention awaiting immigration proceedings at the Suffolk County House ofCorrections (SCHOC), an ICE Intergovernmental Service Agreement (IGSA), located in Boston,

MA. Docket control of TAVAREZ' immigration case was held by the ICE Detention and RemovalOperations (DRO) Boston Field Office.

On October 22, 2009, the Office of Professional Responsibility (OPR), Office of DetentionOversight (ODO), initiated an OPR Detainee Death Review investigation to obtain the facts andexamine the circumstances surrounding the death of TAVAREZ. Pursuant to the investigation,ODO reviewed data obtained through queries of ICE enforcement databases to establish thecriminal and ICE custody histories of TAVAREZ. This Report of Investigation (ROI) documentsthe criminal, immigration, and detention histories of TAVAREZ.

According to records, TAVAREZ was a native and citizen of the Dominican Republic. On August

4, 1976, he first entered the United States at the New York, NY Port of Entry as a lawfulpermanent resident of the United States. The following is a synopsis of TAVAREZ' criminal history(see Exhibit 001):

- On January 20, 1987, pursuant to a July 30, 1986 arrest, TAVAREZ was convicted in the state ofNew York upon a plea of guilty to Intent to Sell of a controlled substance (marijuana), andsentenced to time served and five years probation.- On October 1, 1987, pursuant to a February 10, 1987 arrest, TAVAREZ was convicted in thestate of New York upon a plea of guilty to criminal possession of a controlled substance andsentenced to five days.- On January 9, 2007, pursuant to a June 12, 2006 arrest, TAVAREZ was convicted in the state of

Rhode Island upon a plea of "Nolo Contendere" to felony possession of a controlled substanceand sentenced to 2 years probation.- On April 8, 2008, pursuant to a traffic stop, the Rhode Island State Police arrested TAVAREZwhen an NCIC query disclosed an outstanding ICE warrant for his arrest. TAVAREZ wassubsequently turned over to ICE.- The NCIC criminal history record identifies alias names for TAVAREZ as: Pedro TABRE; andFelix BAEZ.- The NCIC criminal history record identifies an alias DOB for TAVAREZ as: 11/23/1958.


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The following is a synopsis of detainee TAVAREZ' immigration history:- Pedro Juan TAVAREZ was a native and citizen of the Dominican Republic. On August 4, 1976he entered the United States at the New York, NY Port of Entry as a lawful permanent resident ofthe United States.- On June 24, 1987, the Immigration & Naturalization Service (I&NS) issued and served a warrantfor his arrest.

- On March 4, 1992, I&NS issued a warrant of deportation against TAVAREZ for removal from theUnited States.- On April 27, 1992, TAVAREZ failed to surrender to immigration officials.- ICE records do not indicate any direct encounter by immigration officials until his arrest on April8, 2008. According to ICE records, TAVAREZ assumed the alias Felix BAEZ, under which he wasable to elude police and immigration officials.- On April 28, 1998, an immigration hearing was held with TAVAREZ in absentia. At this hearinghe was ordered removed by an Immigration Judge (IJ).- On April 8, 2008, detainee TAVAREZ was turned over to ICE by the Rhode Island State Policewho encountered him during a traffic stop. An NCIC query conducted pursuant to the stopdisclosed an outstanding ICE warrant for his arrest. TAVAREZ was subsequently turned over to

ICE.- On August 9, 2008, detainee TAVAREZ filed a Motion to Re-open, which the IJ granted.- On February 19, 2009, the IJ ordered TAVAREZ removed.- On March 6, 2009, detainee TAVAREZ filed an appeal to the Board of Immigration Appeals(BIA), who remanded the case to the IJ.- On September 17, 2009, the IJ ordered TAVAREZ removed.- On September 21, 2009, TAVAREZ was transferred from the Plymouth County House ofCorrections to the Suffolk County House of Corrections to await receipt of a travel document andremoval to the Dominican Republic.

The following is detainee TAVAREZ' detention history:

- 4/8/2008 - 4/9/2008: Wyatt Detention Center- 4/9/2008 - 6/4/2008: Bristol County Jail- 6/4/2008 - 8/26/3008: Suffolk County House of Corrections- 8/26/2008 - 11/24/2008: Varick Street Service Processing Center- 11/24/2008 - 12/16/2008: Monmouth County Jail- 12/16/2008 - 12/17/2008: Varick Street Service Processing Center- 12/17/2008 - 9/21/2009: Plymouth County House of Corrections- 9/21/2009 - 10/19/2009: Suffolk County House of Corrections


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10. NARRATIVE

Detainee TAVAREZ died on October 19, 2009 at the Brigham & Women's Hospital, Boston, MAwhile in ICE detention at the Suffolk County House of Corrections awaiting immigrationproceedings.


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REPORT OF INVESTIGATIONExhibit List

2. REPORT NUMBER



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4. FINAL RESOLUTION


Interim

Report


8. TOPIC

Detainee Death Review TAVAREZ, Pedro


On October 22, 2009, the Office of Professional Responsibility (OPR), Office of DetentionOversight (ODO), initiated an OPR Detainee Death Review to investigate the facts andcircumstances surrounding the death of TAVAREZ. Per ICE policy, all deaths of ICE detaineesare reviewed by OPR ODO. This report documents interviews of ICE management personnelresponsible for SCHOC.


- ICE-OPR Special Agent 16-FEB-2010 ICE OPR Detention Facilities Inspection12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER

- ICE-OPR SpecialAgent Supervisor 15-MAR-2010 No Phone Number




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On October 22, 2009, the Office of Professional Responsibility (OPR), Office of DetentionOversight (ODO), initiated an OPR Detainee Death Review investigation to obtain the facts andexamine the circumstances surrounding the death of TAVAREZ.

Pursuant to the investigation, on October 27th and 28th, 2009, OPR ODO Senior Special Agent(SSA) and ICE contracted Subject Matter Expert Registered Nurse (RN)conducted a site visit at SCHOC located at 20 Bradston St., Boston, MA. SSA interviewedDRO staff having oversight of detention operations at SCHOC, and obtained ICE DRO Boston

Field Office electronic correspondence related to the hospitalization and death of TAVAREZ. Thisreport of investigation documents the interviews of DRO staff, and the review of ICE proceduresregarding the hospitalization and death of an ICE detainee.

On October 27, 2009, SSA interviewed DRO Assistant Field Office Director (AFOD)who provided a brief summary of the events following the admission of detainee TAVAREZ

into Brigham & Women's Hospital (B&WH), Boston, MA. AFOD reported he receivednotification via email to his Blackberry device of the hospitalization of detainee TAVAREZ late inthe evening on October 16, 2009. The email informed him of TAVAREZ' health condition andadmission into B&WH. AFOD initiated detainee hospitalization protocol to include contactof the immediate family and assigning ICE personnel to the hospital to act as the ICE points of

contact (POCs) for ICE management. AFOD stated the sister of TAVAREZ arrived at thehospital to visit TAVAREZ on the morning of October 17, 2009, and family was at his bedside atthe time of his death on October 19, 2009.

This concludes the interview of AFOD

On October 27, 2009, SSA interviewed Supervisory Detention & Deportation Officer (SDDO)who provided the following overview with regards to the detention of detainee

TAVAREZ while at SCHOC. Upon questioning SDDO stated he was not aware of any


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health care issues related to TAVAREZ. He was first informed of TAVAREZ' health condition andhospitalization via an email received late in the evening on October 16, 2009. The email was sentby Supervisory Immigration Enforcement Agent (IEA) informing of the hospitalizationof detainee TAVAREZ. SDDO initiated notification protocol and forwarded the email toBoston Field Office senior management and the Division of Immigration Health Services (DIHS)point of contact.

In addition to two Suffolk County Deputies assigned to the hospital for security purposes, SDDOstated on October 17, 2009, in coordination with AFOD ICE personnel were

assigned to the hospital on a round-the-clock basis to act as POCs for ICE management. ThePOCs were identified as IEA's and and DDO

This concludes the interview of SDDO


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None


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4. FINAL RESOLUTION


Interim

Report


8. TOPIC

TOPIC: Detainee Death Review Pedro TAVAREZ; SCHOC Interviews


On October 22, 2009, the Office of Professional Responsibility (OPR), Office of DetentionOversight (ODO), initiated an OPR Detainee Death Review to investigate the facts andcircumstances surrounding the death of TAVAREZ. This report documents interviews of SCHOCcorrections and medical staff regarding the care and treatment of TAVAREZ.


- ICE-OPR Special Agent 16-MAR-2010 Office of Dentention Oversight (ODO)12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER

- ICE-OPR SpecialAgent Supervisor 01-JUL-2010 No Phone Number




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This Report of Investigation (ROI) documents an overview of SCHOC operations, and theinterviews of SCHOC management, correctional, and contract medical personnel.

SCHOC is an IGSA facility contracted under the ICE DRO Boston Field Office area of

responsibility. This facility has a total bed-space of 1993, to include 300 beds for male ICEdetainees and 40 beds for female ICE detainees. The average daily population of SCHOC isapproximately 1300 pre-trial and convicted county inmates, 270 male ICE detainees, and 40female ICE detainees. Both male and female ICE detainees are housed separately from theinmate population in Building 8, which is used solely for the housing of ICE detainees at SCHOC.Building 8 is located on SCHOC premises, but is a stand-alone structure separated from thefacilities primary structure.

Prison Health Services (PHS), INC., a private medical contract health provider specializing incorrectional health care, provides comprehensive medical services at SCHOC. The initial contractbetween SCHOC and PHS was initiated on April 9, 2005. On November 1, 2009, the contract was

renewed for a three year period. The PHS medical staff at SCHOC includes a full-time HealthServices Administrator, a full-time Medical Director, who is also the full-time PHS staff physicianproviding direct patient care, two part-time physicians, Mid-Level Providers (MLP) to includePhysician Assistants (PA), Nurse Practitioners (NP), and a cadre of Registered Nurses (RN), andLicensed Practical Nurses (LPN).

The infirmary is located in Building 6 of the facility, and is attached to the primary structure ofSCHOC. A separate health clinic, designated as an out-patient clinic, is located in Building 8.This clinic provides routine care and treatment to ICE detainees to include daily MLP and nursing


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sick call, medication administration, and physical examinations of all ICE detainees. The clinic isoperational Sunday - Saturday, 7:00 a.m. to 11:30 p.m., and staffed full time with nursingpersonnel. Daily supervision is conducted by Clinical Coordinator , LPN.

SCHOC is accredited by the National Committee of Correctional Health Services. In September2009, OPR ODO conducted a Quality Assurance Review of SCHOC. No deficiencies were found

with regards to PHS' implementation of the 2000 ICE National Detention Standard (NDS) "MedicalCare." A review of the 2007 and 2008 annual DRO compliance reviews of SCHOC showedoverall final ratings of "Good." Specifically, a review of the inspection findings of each of the threerecent reviews of the SCHOC medical clinic resulted in no deficiencies found with regards to theICE NDS "Medical Care."

On October 27, 2009, SSA interviewed SCHOC Superintendant ESQ whoprovided the following overview with regards to the detention of detainee TAVAREZ while atSCHOC. TAVAREZ was at the facility approximately 3 weeks arriving on September 21, 2009 atapproximately 10:00 a.m. He arrived via J-PATS and was initially scheduled to depart onSeptember 22, 2009. He completed intake processing at about 6:00 p.m., that same day. During

his stay at SCHOC, TAVAREZ was housed in Building 8, Unit A4, Room 2. He experienced nodisciplinary issues, and was confirmed by medical to have hypertension and diabetes. Uponquestioning, stated he understood the reason for TAVAREZ' extended stay at SCHOCto be a venue issue related to the immigration case.

This concludes the interview of Superintendant

On October 27, 2009, SSA interviewed PHS Health Services Administrator (HSA)RN who provided a brief time-line of detainee TAVAREZ's interaction with PHS

medical personnel at SCHOC. TAVAREZ arrived on September 21, 2009 and was medicallyscreened at approximately 6:00 p.m. that day. He was identified as being on medication for both

hypertension and (non-insulin dependent) diabetes. He received a physical exam (PE) onOctober 1, 2009, and a mental health exam (MHE) on October 7, 2009. On October 7, 2009, asick call slip submitted by TAVAREZ for "pain between (the) legs" was triaged by medicalpersonnel. He was seen on October 8, 2009, diagnosed with orchitis (inflammation of the testicle)for which the antibiotic bactrim was prescribed.

On October 14, 2009, a sick call slip submitted by TAVAREZ citing fever and headache wasreceived and triaged. TAVAREZ was seen that same day and observed to be experiencing chills.He was treated for cold symptoms. Late that evening, during the 3:00 p.m. to 11:00 p.m. evening


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shift, TAVAREZ was admitted into the infirmary with abdominal pains and chills. On October 15,2009, he was seen by a Nurse Practitioner (NP), who noted TAVAREZ had difficulty urinating andhis condition was worsening.

On October 16, 2009, in treating TAVAREZ, medical staff inserted a catheter to relieve his bladderof urine. After continued monitoring and evaluation, Dr. , a staff physician and the

facility Medical Director, referred TAVAREZ to Lemuel Shattuck Hospital (LSH) located in Boston,MA for further evaluation.

HSA explained LSH is a critical care hospital with no emergency room or services. LSHhas correctional housing ward enabling them to provide care and treatment for correctionalfacilities. She added the (SCHOC) Medical Director is aware of the services provided by LSH andwill make a medical determination as to whether LSH can handle a medical referral.

HSA continued, Dr. requested SCHOC transport for TAVAREZ to LSH.Emergency transport was not utilized as it was determined TAVAREZ had no immediatelife-threatening condition requiring emergency services or transport.

Note: Information provided by Superintendant during a subsequent interview indicatedLSH is a Massachusetts state hospital providing medical care for inmates at county correctionalfacilities that is not available at the correctional facility. Money is appropriated by the state andmade available through a state-sanctioned arrangement between LSH and SCHOC.

Upon arrival at LSH, intra-venous (IV) fluid was administered for dehydration, and lab resultsrevealed TAVAREZ had experienced a heart attack. Additionally, TAVAREZ began to complain ofchest pain. Since LSH does not provide emergency services, TAVAREZ was transported via anambulance to Faulkner Hospital (FH) located in Boston, MA. Upon arrival at FH, it wasdetermined TAVAREZ needed intensive care. A bed was not available in the Intensive Care Unit

(ICU) at FH and he was subsequently transported via an ambulance to Brigham and Women'sHospital (B&WH) located in Boston, MA.

On October 17, 2009, B&WH called for last rites (a process of notification of pending death toimmediate family members). On October 18, 2009, an infectious disease team was "called in" byB&WH to evaluate the detainee's condition and determine the source/cause of his medicalcondition.

On October 19, 2009 at approximately 9:30 a.m., detainee TAVAREZ was pronounced dead by


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B&WH medical personnel.

According to HSA , this brief time-line of events related to the medical care and treatmentof TAVAREZ was obtained from the medical record and notes taken in communication with thehospitals involved.

This concludes the interview of HSA .

On October 27, 2009, SSA interviewed SCHOC Corrections Officer (CO) ahousing unit officer assigned to Unit A4. CO stated she works the 7:00 a.m. to 3:00 p.m.day shift, and saw detainee TAVAREZ everyday that she worked since his arrival in the unit. Shedescribed him as "very quiet," remembered "nothing remarkable" about his behavior, and statedshe was not aware of any medical complaints from him and was surprised at his sudden passing.Upon questioning, CO said she learned of the detainee's removal from the housing unit tothe infirmary by reading the housing unit officer's logbook. CO pointed out Unit A4 has 75beds and houses an average of 75 detainees. When asked about heating issues in the housingunit, CO stated several weeks prior with the change of the weather, parts of the building

were warm and other areas were cold, but the issue has since been resolved.

This concludes the interview of CO

On October 27, 2009, SSA interviewed , LPN, as witnessed by RN .LPN is routinely assigned to the 7:00 a.m. to 3:00 p.m. (day-shift) at the ICE detaineehealth unit located in Building 8, a building used solely for ICE detainees. Upon questioning, LPN

stated due to the high number of detainees seen on a daily basis, she does notremember all encounters with detainee TAVAREZ. She did recall he was diabetic and when hefirst arrived at SCHOC he received "finger sticks" twice a day to measure his blood sugar. Sheremembered he was taking oral diabetic medication, but after a few days refused to take it stating

it made him "feel down". LPN stated she was able to communicate with TAVAREZbecause he spoke a little bit of English and she speaks a "little Spanish."

Upon continued questioning, LPN stated she remembered TAVAREZ had an issue ofpain between in his legs and was placed on bactrim (an antibiotic) for an infection. She added hewas compliant with taking this medication and did not refuse taking it. When asked about thetreatment regimen for the bactrim, LPN replied she was not sure whether it wasadministered to him everyday, nor did she specifically remember the regimen. LPNstated she was not aware of TAVAREZ being sick in the days prior to his admission into the


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infirmary on the night of October 14, 2009.

LPN stated sick call request slips are available in each of the housing units. Eachdetainee is informed of the sick call process upon arrival. Once a slip is filled out it is to be placedinto the sick call box located in each housing unit. Sick call slips are removed by a staff nursedaily, triaged, and placed in the medical record. Due to the sick call slip review and triage

process, a detainee may be seen one to two days after submitting a sick call slip.

Note: SSA confirmed the availability of sick call slips and the presence of a sick call slip boxin each of the housing units. Each box is clearly labeled. If a detainee were to submit a sick callslip after the daily pick-up, it will not be retrieved until the following day. Once triaged, it ispossible the detainee will not be seen that day, but the following day, two days after submitting theslip.

This concludes the interview of LPN

On October 27, 2009, SSA interviewed Dr. as witnessed by RN The

following is a chronological synopsis of the information provided by Dr. regarding herinvolvement in the care and treatment of detainee TAVAREZ. Detailed medical data isdocumented in the medical report attached to this case's file, and summarized in ROI 005.

Dr. stated she was aware TAVAREZ was diabetic and hypertensive and was onmedication for these conditions prior to his arrival at SCHOC. He was prescribed medication incontinued treatment. A few days after arrival he began to refuse to take the diabetic medicationclaiming they brought him "down."

Dr. provided TAVAREZ was diagnosed with orchitis (inflammation of a testicle) by PAfor which bactrim was prescribed. She added orchitis can be caused by a number of

things, and was not sure if TAVAREZ' testicular problem (pain and slight swelling) was the resultof an infection. By the time she saw him for his fever and chills on October 15, 2009, the orchitis "seemed to be getting better."

On October 15, 2009, Dr. encountered TAVAREZ as a patient in the infirmary while makingher morning round. A review of the nurses monitoring throughout the night revealed TAVAREZcomplained of fever and chills and a vital sign assessment indicated the onset of a fever. Dr.

stated that upon her initial evaluation of TAVAREZ he denied a cough, complained of asore throat, headache, and abdominal pain, and stated the pain in his testicle was better; she also


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observed him to be negative Murphy's (indicator of significant inflammation in the abdomen, mostoften due to gallbladder or liver disease). Dr. described this initial exam as "unimpressive,"and assessed his condition as a "fever of unknown origin." She ordered throat and urine cultures,prescribed Tylenol, and advised increased fluid intake and continued monitoring. Dr.concluded her statements regarding the October 15th assessment saying TAVAREZ did notpresent as being sick and was ambulatory (able to walk on his own power), but due to the fever

and chills required further monitoring.

On Friday morning, October 16, 2009, Dr. reviewed the results of chest and KUB (kidney,ureter, and bladder) x-rays performed on TAVAREZ that morning. During the CXR, TAVAREZwas observed to have rigors (shaking). The KUB x-ray was negative (organs were free of air andbowel obstructions). The chest x-ray (CXR) revealed a possible issue in the lower lobe of the rightlung, but showed no pulmonary disease. Dr. examined TAVAREZ and observed him to befeverish, sweating profusely, to have rigors, which she described as shaking from having chills,and continued pain in the abdomen. His sore throat was better, and a catheter inserted into hisbladder overnight had produced urine. Dr. added TAVAREZ reported no chest pain ordifficulty with breathing. Based on the assessment, Dr. determined a need for blood

cultures and further evaluation, which could not be performed at SCHOC and decided to referTAVAREZ to LSH.

Dr. related TAVAREZ was ambulatory, and was "sick", but not "so sick he required EMS(Emergency Medical Services)." She therefore opted to send TAVAREZ to LSH via SCHOCtransport. The transport officer arrived at the infirmary, which she remembered as being sometimebefore noon, and escorted TAVAREZ out, who left walking on his own power.

Note: According to the SCHOC Vehicle Log dated 10/16/09, at 11:57 a.m., detainee TAVAREZwas transported to "Shatt" (LSH) by SCHOC officers and . Arrival time at LSH wasnoted as 12:12 p.m.

This concludes the interview of Dr.

On October 28, 2009, SSA conducted a telephonic interview of PA . PAstated he remembered only two encounters with detainee TAVAREZ, but due to the high

number of patients he sees on a daily basis, did not remember specific dates and times of theencounters. PA indicated the first encounter was related to TAVAREZ's diabeticcondition. TAVAREZ refused to take his diabetes medication because he did not like them. Thematter was brought to PA attention, and after a review of (diabetic) finger sticks


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performed on TAVAREZ daily, he observed the blood glucose level to be under control and in thenormal range. PA stated he reviewed the oral medication TAVAREZ was taking and aftertalking with TAVAREZ determined the diabetic condition could be controlled by diet.

PA stated the second encounter occurred when TAVAREZ presented with inflammationof the testicle. A review of the nursing notation by RN indicated an un-descended testicle,

which was resolved. PA noted inflammation and tenderness of the testicle. Uponresearching the condition, he diagnosed the condition as "classic" orchitis (inflammation of thetesticle), and prescribed the antibiotic bactrim as treatment. PA concluded his commentsstating this was the last interaction he had with TAVAREZ.

This concludes the interview of PA


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None


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4. FINAL RESOLUTION


Interim

Report


8. TOPIC

Detainee Death Review Pedro TAVAREZ; Follow-up Interviews


On October 22, 2009, the Office of Professional Responsibility (OPR), Office of DetentionOversight (ODO), initiated an OPR Detainee Death Review to investigate the facts andcircumstances surrounding the death of TAVAREZ. This report documents follow-up interviews ofSCHOC Superintendant and Health Services Administrator

.







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Pursuant to the investigation, on November 24, 2009, Senior Special Agent (SSA) andODO Detention and Deportation Officer (DDO) conducted follow-up and additionalinterviews of SCHOC staff and contract medical personnel. This Report of Investigationdocuments the follow-up interviews of SCHOC Superintendant and HealthServices Administrator .

On November 24, 2009, SSA and DDO conducted a second interview ofSuperintendant In response to questions about the sick call request process at SCHOC,

stated the majority of medical concerns that arise are unfounded. Inmates anddetainees often complain about the process or of not being treated properly, but upon review andquestioning, the complaints are unfounded. Many of the complaints are resolved by simply talkingwith the complainant about their issue and explaining the process. added while therehave been sporadic instances of a sick call slip not being seen, the system works well with themajority being responded to within one day, two days at the most, dependent on the triageprocess. further stated the current system for sick call requests should ensure all sickcall slips are seen.

Superintendant stated in the event of a medical emergency within the facility, he is madeaware immediately if he is on duty. Otherwise, all medical emergencies are recorded in a shift

summary. In the event of non-emergency medical related events, such as a transport to LSH forfurther evaluation and the person is ambulatory, he would not be notified.

was asked about the SCHOC relationship with LSH. stated LSH is aMassachusetts state hospital contracted to provide medical care for inmates at county correctionalfacilities that is not available at the correctional facility. Money is appropriated by the state andmade available through a state-sanctioned arrangement between LSH and SCHOC. Thephysician on-call (at SCHOC) is responsible for making the medical decision as to whether LSHcan medically handle the referral of a patient from SCHOC.


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When asked about handling language issues with detainees, replied the facility isactively cognizant of language issues particularly with the ICE detainees. Specific to detaineeTAVAREZ, stated his understanding, based on questioning of medical staff, is thatTAVAREZ spoke English and the medical staff was able to communicate with him.

SSA requested copies of any surveillance video recording of TAVAREZ. Superintendant

stated surveillance video recordings were preserved, but SCHOC legal counsel advisedthey could not be immediately provided to ICE. SSA did view select surveillance videorecordings of TAVAREZ recorded on the evening of October 14, 2009, and on October 16, 2009.

The October 14, 2009 recording shows TAVAREZ on an elevator. He appeared responsive andalert to the escorting officer and is seen exiting the elevator on his own power. A second videoclip time stamped 10/16/2009 shows TAVAREZ walking on his own power escorted by an officerafter leaving the infirmary, presumably being taken to the Booking Department for transport toLSH. In each of the recordings, TAVAREZ is moving about on his own power with his head erect,and is responsive to the escorting officer.

This concludes the interview of Superintendant

On November 24, 2009, SSA and DDO conducted a second interview of HSAHSA advised on November 18, 2009, PHS general counsel notified PHS

personnel at SCHOC that PHS had been named in a lawsuit filed by the family of detaineeTAVAREZ. On November 20, 2009, local legal counsel for PHS advised HSA and PHSstaff to not discuss the TAVAREZ matter. was able to answer questions regardingpolicy and procedures related to medical services.

Upon questioning regarding the PHS Mortality Review of the death of TAVAREZ, HSAstated it was completed with a final analysis performed by Dr. and herself. The analysis

resulted in a plan of action of "None." Due to legal counsel advisement, a copy could not beprovided to ICE.

In response to questioning regarding the relationship with LSH, HSA stated that acontract is in place allowing SCHOC to refer inmates and detainees requiring medical care "beyond the scope of PHS," to LSH. She added LSH has a correctional unit set up to handleinmates. continued, because of the contract with LSH, they are the first choice ofthe on-call physician when off-site care is needed. If care needed is beyond the scope of LSH, thepatient will be sent to a hospital that provides the needed care. In the event of a referral to LSH,


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transport of the patient is arranged through the SCHOC Booking Department. LSH does not havean emergency room; therefore, in the event of a medical emergency, 9-1-1 will be called, and thepatient will most likely be transported to Boston Medical Center, Boston, MA.

When asked if medical personnel accompany patients to LSH, replied it is notprocedural to send medical staff with the transport officers.

Note: SSA obtained a copy of PHS Health Services Policy & Procedures Manual, SCHOC,Hospital and Specialty Care.

HSA was asked about sick call slip procedures at SCHOC. HSA stated alldetainees are informed at the intake in-briefing and via the detainee handbook of the process.She added she is aware detainees complain about the response time to sick call slips, and therehave been claims by detainees that sick call slips have not been responded to. She continued,there have been instances where the detainee has claimed a sick call slip was submitted, but themedical record shows one was not received. concluded her remarks stating, inreviewing the sick call slip process she found the nursing staff followed procedures, and

appropriately triaged and responded to the request.

This concludes the interview of HSA .


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4. FINAL RESOLUTION


Interim

Report


8. TOPIC

Detainee Death Review Pedro TAVAREZ; Detainee Interviews


On October 22, 2009, the Office of Professional Responsibility (OPR), Office of DetentionOversight (ODO), initiated an OPR Detainee Death Review to investigate the facts andcircumstances surrounding the death of TAVAREZ. This report documents follow-up interviews ofwitness interviews of SCHOC detainees.







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Pursuant to the investigation, on November 24, 2009, SSA and ODO Detention andDeportation Officer (DDO) conducted follow-up and additional witness interviews ofSCHOC detainees. This Report of Investigation (ROI) documents the detention status andinterviews of the detainees.

SCHOC housing unit staff of Building 8, Unit A4, provided SSA with a detainee roomassignment roster for room 2, TAVAREZ' room while he was housed at SCHOC. The roommatesof TAVAREZ were identified as:

- Detainee (A , a citizen and national of Guatemala, arrived SCHOC on7/23/2009. Interviewed by OPR/ODO on 10/27/2009.

- Detainee (A ), a citizen and national of the Dominican Republic, arrivedSCHOC on 9/24/2009. On 10/27/2009 at 8:44 a.m., he was out-processed from SCHOC by ICEand transferred to Puerto Rico for expedited removal.

- Detainee ( ), a citizen and national of Guatemala, arrived SCHOCon 8/27/2009. On 10/16/2009 at 2:14 p.m., he was out-processed from SCHOC by ICE andremoved to Guatemala.

- Detainee (A , a citizen and national of El Salvador, arrived SCHOCon 10/12/2009. Interviewed by OPR/ODO on 10/27/2009.

- Detainee (A ), a citizen and national of the Dominican Republic,


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arrived SCHOC on 9/21/2009. On 10/27/2009 at 8:41 a.m., he was out-processed from SCHOCby ICE and subsequently transferred to Puerto Rico for expedited removal.

Additionally, SSA identified the following detainees as being associated with TAVAREZ whilehe was housed at SCHOC:

- Detainee (A ), a citizen and national of the Dominican Republic, arrivedat SCHOC on 11/14/2008. Interviewed by OPR/ODO on 10/27/2009 and 11/24/2009.

- Detainee (A ), a citizen and national of Portugal, arrived SCHOC on12/3/08. Interviewed by OPR/ODO on 11/24/2009.

On October 27, 2009, SSA interviewed SCHOC detainee witness (A a roommate of detainee TAVAREZ. described TAVAREZ as "easy to get along with,"

talkative, a Spanish speaker, and someone who exercised often. stated TAVAREZ "worked out" everyday. He would run every time outdoor recreation was held, and did pushupsand sit-ups regularly. Upon questioning, responded TAVAREZ always spoke Spanish, thathe was not sure how well TAVAREZ spoke English, and added another detainee would ofteninterpret for TAVAREZ when he needed assistance with explaining something to a nurse.

Detainee stated TAVAREZ began looking sick of couple of days before he was taken to theinfirmary (on October 14, 2009). He (TAVAREZ) complained of fever and feeling "cold" andseveral detainees advised him to fill out a sick call slip. related TAVAREZ asked him for anextra blanket, which he provided. On the evening TAVAREZ was taken to the infirmary, he did notparticipate in outdoor recreation. stated late in the evening, he and a couple otherdetainees were in the room with TAVAREZ. He looked sick, was wrapped in a blanket, and toldthem he was feeling sick. At some point, one of the detainees left and informed the housing unitofficer about TAVAREZ' condition. The officer came to the room, observed TAVAREZ, then left

and called the infirmary. A few minutes later, a nurse from the infirmary arrived and escortedTAVAREZ out of the unit.

Upon inquiry about the housing conditions, detainee related the housing unit was both hotand cold. One side of the hall was very warm, and the other side was very cold. He statednumerous detainees complained about this condition, but nothing was done. He added the dayroom was always cold, whereas his room, where he and TAVAREZ slept, was very warm, and heand some other detainees think the temperature (fluctuation) contributed to TAVAREZ' illness.

identified as a close friend of TAVAREZ.


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Note: As noted above, on October 27, 2009, at 8:44 a.m., Detainee (A ) wasout-processed from SCHOC by the ICE DRO Boston Field Office and subsequently transferred toPuerto Rico for expedited removal to the Dominican Republic.

On October 27, 2009, SSA interviewed SCHOC detainee witness (A ) a roommate of TAVAREZ. described TAVAREZ as a good guy, who worked out all

the time, and was happy. When asked about the days leading up to TAVAREZ being taken fromthe unit to the infirmary, detainee responded TAVAREZ had been sick with fever forthree to four days, spent three days in bed, and submitted 2-3 sick call request slips, but was "never called." stated TAVAREZ looked sick, was sweating profusely, was always cold,and had the chills. He asked for tea a couple of times, and when in bed would cover himselfcompletely with a blanket.

When asked what he meant when he said TAVAREZ was "never called," respondedevery time the nurses have sick call, the names of the detainees to be seen are announced, andhe ( never heard TAVAREZ' name.Upon questioning, detainee stated he did not see TAVAREZ actually fill out a slip, and didnot know for certain if TAVAREZ was seen by a nurse for his illness. related part of thehousing unit was cold and their room was very warm and stated, "Maybe going from the cold dayroom to the hot cell caused problems" (for TAVAREZ). identified and

as friends of TAVAREZ.

On October 27, 2009, SSA interviewed SCHOC detainee witness (A ) a friend of TAVAREZ. stated he was very surprised when he heard TAVAREZ

had died, stating TAVAREZ worked out everyday and was in good shape for an older man.According to , TAVAREZ did not have any health problems until about three days prior tobeing taken to the infirmary (on October 14, 2009) when he complained of a headache and got a

cold. surmised TAVAREZ got sick "probably because his room was hot and the rest of theplace was cold."

Detainee stated, TAVAREZ put in 2-3 sick call slips but "they didn't call him."continued stating the nursing staff used to call "right away" after a sick call slip was submitted.When asked to elaborate, responded that 2-3 months prior, when a detainee would submita sick call slip, it was usually responded to within a day. Recently however, it was taking two tothree days for a response, and sometimes there is no response.


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Upon questioning, reported he did not actually see TAVAREZ fill out a sick call slip. Hestated when he advised TAVAREZ to submit a sick call request slip TAVAREZ told him that hehad done so several times.

In describing the events of the evening TAVAREZ was taken to the infirmary, statedTAVAREZ was lying in bed, commented several times about being cold, but was otherwise not

talking, and he was visibly sweating and "very hot" to the touch. Another detainee called for thehousing unit officer, who came to the room and upon seeing TAVAREZ called the infirmary.Infirmary staff arrived a few minutes later and immediately escorted TAVAREZ out of the unit.

Upon being asked if he had known about detainee TAVAREZ' medical conditions, relatedshortly after his arrival at SCHOC, TAVAREZ began refusing to take medications for somemedical condition, stating it was making him feel "down," and claiming it was the "wrong type"because it was making him "sick." A few days after refusing to take the medication, he began tofeel better and exercise regularly. estimated it was about ten days after stopping themedication that TAVAREZ caught a cold and became sick. identified himself and

as TAVAREZ' friends, stating was his closest friend in the unit, adding they

arrived around the same time.

On November 24, 2009, SSA and DDO conducted a follow-up witness interview ofdetainee The interview was conducted in both English and Spanish, withinterpretation of the Spanish by DDO

Upon questioning, stated TAVAREZ submitted a total of three sick call slips during his stayat SCHOC. He claimed he knows this because TAVAREZ told him he had submitted two slips,and he saw " " (fellow detainee ) write one for TAVAREZ. Detaineespeaks both Spanish and English and would often translate for Spanish-speaking detainees andfill out sick call slips for most of the detainees who could not write well in English.

According to the first sick call slip was submitted three to four days prior to TAVAREZbeing taken to the infirmary, but he did not know what TAVAREZ complained of in the slip. Thesecond slip was filed for the headache and fever one to two days prior. The third slip wassubmitted again for headache and fever on the day TAVAREZ went to the infirmary. He added

wrote one of the slips for certain, but he could state for sure which one.

commented that often (at SCHOC) when detainees inform medical staff of a sickness i.e.headache and cold, they are advised to fill out a sick call request slip and to drink water. In the


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meantime, it takes the medical staff several days to respond with treatment. Describing the sickcall process, stated once a request slip is filled out, it is placed into the "Sick Call" boxlocated in the unit. The box is clearly marked and separate from the "Grievances" and "Mail"boxes. The slips are picked up everyday by nursing staff. claimed sometimes the nursingstaff forgets to retrieve the slips. Upon continued questioning, related medical staff is inthe housing unit three times each day for "pill call." Sometimes detainees will directly give the "pill

call" nurse a sick call request slip, and often the slip will be addressed immediately.

Upon questioning regarding TAVAREZ' last day in the housing unit, recalled TAVAREZ atebreakfast, lunch and dinner, walking out of his room to each meal, and did not participate inoutdoor recreation, which was held between lunch and dinner.

was asked if anything had changed or developed (at SCHOC) since the death ofTAVAREZ. responded he had been interviewed by jail (SCHOC) officials and the attorneyof the Tavarez family. He added they asked the same questions, and he gave them the sameanswers, "no more and no less," because he doesn't "want to say anything or add things that arenot true."

also stated he and several detainees decided to write a letter to the family of TAVAREZ.wanted the family to know what had happened to TAVAREZ while in SCHOC

regarding his sickness and treatment. Detainee was asked to write the letterbecause he was a good writer. The letter was written in Spanish to the sister of TAVAREZ, andwas signed by at least five detainees. could not remember all the names of the detainees,but identified four as himself, , , and .According to the letter described TAVAREZ' condition as being healthy, and advised thefamily to have his death investigated. added it needed to be investigated because "he(TAVAREZ) was healthy, he got sick, and passed away very quickly after getting sick."

stated, overall, TAVAREZ did not look sick. He worked out and jogged everyday, and hadan exercise routine in his room. When he became sick, 2-3 days before he was taken to theinfirmary, he "went down quickly" and "didn't get the attention he needed."

On November 24, 2009, SSA and DDO interviewed SCHOC detainee witness, who was identified as having signed a letter to the Tavarez family. The interview

was conducted in the Spanish language, as interpreted by DDO


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Upon questioning, related he arrived at SCHOC on October 9, 2009. He met TAVAREZ thatsame day because he was a "countryman", both being from the Dominican Republic.described TAVAREZ as a good, humble, and honest person who went to church services, washealthy, and worked out almost every day. According to they used to work out and spartogether and TAVAREZ could do 500 push-ups. As far as could tell, TAVAREZ was in goodshape for a 49 year old man and appeared healthy.

stated the day TAVAREZ became ill he complained about the medications he was taking,blaming them for making him feel "weak and worse." When asked to elaborate, replied themedication made TAVAREZ feel "down." When asked to describe what he meant by "down,"replied it was not a physical down but a "mental" down. According to upon discussing sickcall slips with TAVAREZ, he mentioned he had filled out three sick call request slips prior for notfeeling well and the medication issue. When asked if TAVAREZ had been seen by medical staffregarding the alleged sick call slips, replied he did not know, but he never heard TAVAREZ'name called for sick call.

stated on the evening of October 14th, TAVAREZ came out of his room for dinner and afterdinner watched television. asked him why he was not at outdoor recreation, to whichTAVAREZ responded he had a fever and was not feeling well. At approximately 7:30 p.m.,observed TAVAREZ speaking with the nurse, followed by the nurse taking his temperature, andTAVAREZ returning to his room. Later that evening, went into TAVAREZ' room andobserved him lying in his bunk, wrapped in a blanket, and his face was flushed. According to

Detainee felt TAVAREZ and stated he was very hot and sweaty. stated atthis point another detainee called for the housing unit officer who came quickly. Upon seeingTAVAREZ, the officer called a nurse, who arrived a short time later and escorted TAVAREZ out ofthe housing unit. stated TAVAREZ left walking unassisted on his own power.

was asked if anything had changed or developed (at SCHOC) since the death of TAVAREZ.He responded he had been interviewed by jail (SCHOC) officials who asked him similar questions,adding, "What I saw and what I've seen here is all I say." also stated the (immigration) judgehas ordered a stay for him so he could be deposed, which was to take place the first week ofDecember (2009).

Upon being asked about the letter to the Tavarez family, stated a letter was written by one ofthe detainees and sent to the sister of TAVAREZ. The letter was written out of respect forTAVAREZ to give condolences to the family and to explain he (TAVAREZ) became sick while atSCHOC. When asked to elaborate, related they (the detainees) were surprised when they


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read in the newspaper that TAVAREZ was sick prior to arriving at SCHOC. stated (astranslated from Spanish), "This was not true because TAVAREZ was very healthy and he used towork out. He only got sick a few days before he died."

With regards to the letter, stated it was written by and signed by himself, , , and some other guys who have been deported and he does not remember

their names. According to he did not read the letter, he just signed it. He stated heunderstood the letter was written to say condolences to the family and explain when and howTAVAREZ became ill. Upon confirming this statement of not having read the letter, joked (astranslated from Spanish), he "could have been signing something agreeing to him being killed"and he would not have known it.

On November 24, 2009, SSA and DDO interviewed SCHOC detainee witness. stated he was not a roommate of TAVAREZ, nor was a close friend, but he did

interact with TAVAREZ in the unit, at a bible study, which leads, and had written severalsick call request slips on behalf of TAVAREZ. described TAVAREZ as happy, active,always working out, liked boxing and very energetic, and added TAVAREZ often attended the

bible study led by

According to because of his English ability he writes sick call requests for most of thedetainees in the unit. stated TAVAREZ spoke a little English and often needed atranslator when speaking with the nurses. He recalls he wrote at least 6-8 slips for TAVAREZthroughout the time he (TAVAREZ) was at SCHOC. Upon questioning, explained hewrote three slips during TAVAREZ' last week in the unit. The first slip was written four days priorto TAVAREZ leaving the unit (on the evening of October 14th); the second slip was written threedays prior; and the third slip was written one day prior. He explained when he fills out a slip onbehalf of another detainee, with each successive request slip for the same problem he writes inthe upper corner if it is the second or third request. He stated he had done this with several of the

requests he wrote on behalf of TAVAREZ.

stated the usual response time by medical staff to a sick call request slip was about twodays. According to , the nurses never responded to the slips TAVAREZ submitted. Whenasked how he knows the slips were not responded to, replied, his (TAVAREZ') name wasnever called for sick call, adding he doesn't know if the nurses responded to the slips during a pillcall, but if they did, he did not hear that they did, nor was he used as a translator by nursing staff inattending to TAVAREZ. stated what he remembered about TAVAREZ' request slips werecomplaints of aches and sweats, and in the third slip of fever.


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stated on the evening of October 14th, he noticed TAVAREZ did not attend bible study.After the study ended, around 10:15 p.m., checked on TAVAREZ and found him in hisroom, lying in his bunk, wrapped in a blanket, shivering and sweating. recalled TAVAREZcomplained he was cold, but the room was warm. A detainee left the room and returned with thehousing unit officer. The officer returned to the unit desk, called the infirmary, and advised thedetainees a nurse was on the way. Upon arrival, the nurse escorted TAVAREZ out of the housing

unit. stated TAVAREZ walked on his own power.

Upon questioning, stated the housing unit officers make regular rounds of the unit and do"walk-bys" of all the rooms, and it is normal for people to be in their bunks at all times of the day.

This concludes the detainee interviews.

Detainees , , and each stated TAVAREZ had filled out two or three sick callrequest slips during his final days at SCHOC. Detainee stated he wrote at least 6-8 slipsfor TAVAREZ throughout the time he (TAVAREZ) was at SCHOC.

Upon questioning by SSA none of the detainees interviewed could confirm how many sickcall request slips TAVAREZ actually filled out. No detainee witnessed TAVAREZ filling out arequest slip. Detainee stated he witnessed detainee filling out one sick callrequest slip on behalf of TAVAREZ. Two of the detainees stated in response to them advisingTAVAREZ to submit a request slip, TAVAREZ told them he had done so.

During his interview, detainee stated TAVAREZ' name was "never called" for sick call.When asked to elaborate explained every time the nurses have sick call, the names ofthe detainees to be seen are announced, and he never heard TAVAREZ' name. Several of thedetainees interviewed made similar statements. Observations include:

- A review of sick call procedures at SCHOC revealed each day medical staff collects detaineesick call request slips from the sick call box located in each housing unit. Often times a detaineewill hand a request slip to medical staff during pill call or visits by staff to a unit. Sick call slipssubmitted late in the day are not retrieved by staff until the following day. Each slip collected istriaged the day it is in received. According to medical staff all request slips are responded towithin 72 hours of receipt depending on triage placement. Sick call is initiated in each unit bycalling out each of the detainee's names triaged for that day.

- SSA questioned each detainee about their knowledge of medical treatment of TAVAREZ.


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No detainee could state for a certainty whether TAVAREZ was actually seen by medical staff ornot in response to a sick call request. Detainee observed TAVAREZ speaking with a nurseon the evening of October 14, 2009 during a "pill call."

Based on interviews of SCHOC contracted medical staff and a review of TAVAREZ' medicalrecord, TAVAREZ submitted a total of two sick call request slips during his stay at SCHOC. SSA

and RN examined each of the slips. Observations include:

- The first sick call slip was submitted on October 6, 2009, in which TAVAREZ requested to see adoctor because of pain between his legs. Notations on the request slip indicate it was receivedand triaged by medical staff on November 7, 2009 at 2:35 p.m., with a disposition of "Medical".

- The medical record indicates on October 9, 2009, TAVAREZ began receiving the anti-bioticBactrim.

- An entry in the medical record dated October 12, 2009, states TAVAREZ was diagnosed with acondition known as "orchitis" (inflammation of a testicle), and prescribed the anti-biotic Bactrim as

treatment.

- The second sick call request slip was submitted by TAVAREZ on October 14, 2009, in which hecomplained of headache, requested medication, and stated he thought he was getting "the cold."Notations on the request slip indicate it was received and triaged by medical staff on the same dayat 10:30 p.m., with a disposition of "NSC".

- An entry in the medical record dated October 14, 2009, with no time stated, records TAVAREZ'vital signs and states medication was ordered for the treatment of cold, cough and feversymptoms.

Detainee stated he had filled out 6-8 sick call request slips on behalf of TAVAREZ duringhis stay at SCHOC. He explained with each successive request slip for the same problem, hewrites in the upper corner if it is the second or third request. He stated he had done this withseveral of the requests he wrote on behalf of TAVAREZ. claimed the nurses neverresponded to any of TAVAREZ' sick call requests. SSA interviewed SCHOC medical staff,reviewed the medical file, and examined all sick call request slips submitted by TAVAREZ.Observations include:

- Interviews of SCHOC contracted medical staff and a review of TAVAREZ' medical record


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revealed TAVAREZ submitted a total of two sick call request slips during his stay at SCHOC.

- Examination of each of the request slips submitted showed differences in handwriting betweenthe two slips in the sections to be completed by the detainee. A comparison and analysis by SSA

indicates within the October 6, 2009 slip, the detainee sections were completed on behalf ofTAVAREZ while the signature is that of TAVAREZ. On the October 14, 2009 slip, it appears the

stated sections were completed by TAVAREZ and signed by TAVAREZ.

- Neither of the two slips contained a notation indicating whether it was the second or third time arequest was submitted for the problem indicated, or whether a previous request had been filed.

- Review of the medical record revealed TAVAREZ was seen by medical staff for each of the tworequest slips submitted.


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None


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Closing

Report


8. TOPIC

Detainee Death Review Pedro TAVAREZ; Final Report

9.SYNOPSISOn October 19, 2009, the Joint Intake Center (JIC), Washington, D.C. received notificationregarding the death of ICE detainee Pedro Juan TAVAREZ ( who was housed at theSuffolk County House of Corrections (SCHOC), Boston, MA. TAVAREZ, a national of theDominican Republic, died on October 19, 2009 at Brigham and Women's (B&WH) in Boston, MA,due to cardiac arrest resulting from natural causes.

On October 22, 2009, the Office of Professional Responsibility (OPR), Office of DetentionOversight (ODO), initiated an OPR Detainee Death Review to investigate the facts andcircumstances surrounding the death of TAVAREZ. This report documents the findings of theinvestigation.


- ICE-OPR Special Agent 01-JUL-2010 Office of Dentention Oversight (ODO)12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER





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10. NARRATIVE

On October 19, 2009, the Joint Intake Center, Washington, D.C. received notification regardingthe death of ICE detainee Pedro Juan TAVAREZ (DOB: 07/25/1960; TAVAREZ, a49 year old national of the Dominican Republic, died on October 19, 2009 at the Brigham &Women's Hospital (B&WH), Boston, MA. At the time of his death, TAVAREZ was in ICE detentionawaiting immigration proceedings at the Suffolk County House of Corrections (SCHOC), an ICEIntergovernmental Service Agreement (IGSA) facility, located in Boston, MA. Docket control of

TAVAREZ's immigration case was held by the ICE Enforcement and Removal Operations (ERO)Boston Field Office.

On October 22, 2009, the Office of Professional Responsibility (OPR), Office of DetentionOversight (ODO), Senior Special Agent (SSA) initiated an OPR Detainee Death Reviewinvestigation to obtain the facts and examine the circumstances surrounding the death ofTAVAREZ.

IMMIGRATION AND DETENTION HISTORY

On August 4, 1976, TAVAREZ, a native and citizen of the Dominican Republic, first entered the

United States at the New York, NY Port of Entry as a lawful permanent resident of the UnitedStates. On June 24, 1987, the Immigration & Naturalization Service (INS) determined TAVAREZwas deportable due to his conviction on January 20, 1987 of a controlled substance violation andissued a warrant for his arrest. On March 4, 1992, INS issued a warrant of deportation againstTAVAREZ for removal from the United States, to which TAVAREZ failed to surrender. On April28, 1998, an immigration hearing was held with TAVAREZ in absentia, at which an ImmigrationJudge (IJ) ordered him removed from the United States.

ICE records indicate TAVAREZ assumed the alias Felix BAEZ, under which he presumably eludedpolice and immigration officials. It is unclear when TAVAREZ began using this alias. ICE recordsdo not show any direct encounter by immigration officials with TAVAREZ until April 8, 2008.

On April 8, 2008, the Rhode Island State Police encountered TAVAREZ during a traffic stop. ANational Crime Information Center (NCIC) query conducted pursuant to the stop disclosed anoutstanding ICE warrant for his arrest. TAVAREZ was arrested and turned over to ICE officialsand placed in ICE detention to await immigration proceedings.

From April 8, 2008 to September 21, 2009, TAVAREZ was transferred among six detentionfacilities with varying lengths of stay at each as follows:


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-4/8/2008 - 4/9/2008: Wyatt Detention Center-4/9/2008 - 6/4/2008: Bristol County Jail-6/4/2008 - 8/26/3008: Suffolk County House of Corrections-8/26/2008 - 11/24/2008: Varick Street Service Processing Center-11/24/2008 - 12/16/2008: Monmouth County Jail-12/16/2008 - 12/17/2008: Varick Street Service Processing Center

-12/17/2008 - 9/21/2009: Plymouth County Correctional Facility (PCCF)

On August 9, 2008, TAVAREZ filed a Motion to Re-open his case, which an IJ granted. OnFebruary 19, 2009, an IJ ordered TAVAREZ removed from the United States, resulting inTAVAREZ filing an appeal to the Board of Immigration Appeals (BIA). The BIA subsequentlyremanded the case to the IJ, who on September 17, 2009, ordered TAVAREZ removed from theUnited States. On September 21, 2009, TAVAREZ was transferred from the Plymouth CountyCorrectional Facility to the SCHOC in preparation for his removal from the United States to theDominican Republic.

On October 16, 2009, due to medical reasons, TAVAREZ was transported to Lemuel Shattuck

Hospital (LSH), Boston, MA, and subsequently to Faulkner Hospital (FH), Boston, MA for furtherevaluation of his medical condition. At FH it was determined TAVAREZ needed to be admittedinto an Intensive Care Unit (ICU). No beds were available in the ICU at FH resulting in TAVAREZbeing transported and admitted to Brigham & Women's Hospital in Boston, MA.

SCHOC corrections staff maintained extensive documentation, related to TAVAREZ, of round theclock guard postings, visits by facility personnel, and visits by family members, dating fromOctober 16, 2009, until TAVAREZ's death on October 19, 2009. Additionally, ICE DRO Bostonfield office maintained daily communication with SCHOC and hospital personnel regardingTAVAREZ's condition and on-going treatment, and made appropriate notifications to identifiedfamily members of TAVAREZ.

CRIMINAL HISTORY

On August 4, 1976, TAVAREZ, a native and citizen of the Dominican Republic, first entered theUnited States at the New York, NY Port of Entry as a lawful permanent resident of the UnitedStates. On January 20, 1987, TAVAREZ was convicted in the stat

Documents

Federal report on the death of Pedro Tavarez