<p>Detention staff did not adhere to safe medical care standards for at least six detainees who died in U.S. Immigration and Customs Enforcement (ICE) custody in 2025, according to internal reviews that were posted on and later removed from ICE’s website.</p>
<p>The reviews indicated that staff at multiple ICE detention centers mismanaged medication, skipped physical exams, ignored lab orders, and delayed treatments for sick detainees. Staff often failed to document or communicate the status of deteriorating patients, and in several instances, they did not provide timely or appropriate life-saving care during emergencies.</p>
<blockquote><p>“Rampant systemic medical abuse is a core feature of the immigration detention system.”</p></blockquote>
<p>Stacy Suh, program director of the Detention Watch Network, stated, “It’s very clear that the rampant systemic medical abuse is a core feature of the immigration detention system. You can’t get well in a detention center.”</p>
<p>At least 56 individuals have died in ICE custody during the second Trump administration. ICE’s Health Services Corps conducts a “mortality review” following an in-custody death to evaluate whether appropriate medical care was provided. The findings of these reports are based on medical records and staff testimony. ICE did not immediately respond to a request for comment.</p>
<p>A total of eight reviews related to detainee deaths from 2025 were published in a collection of over 25 documents on ICE’s public records library on September 25. Four days later, after a lawyer representing this reporter in a Freedom of Information Act lawsuit noticed these documents, ICE appeared to have removed them from the website and de-indexed them.</p>
<p>While the documents were no longer accessible through internet searches, they remained available on internet archives of the webpage. The larger collection of mortality reviews was first reported by The American Prospect and the San Francisco Chronicle.</p>
<p>The eight reports provide detailed accounts of the medical events leading up to the deaths in custody of Johnny Noviello, Lorenzo Antonio Batrez Vargas, Marie Ange Blaise, Nhon Nguyen, Oscar Duarte Rascon, Santos Reyes Banegas, Tien Xuan Phan, and Chaofeng Ge. They offer a comprehensive view of the increasing death toll in detention during President Donald Trump’s second term.</p>
<h2>“Egregiously Managed Care”</h2>
<p>The mortality review for Vargas, a 32-year-old from Mexico, found multiple instances of what ICE’s reviews termed “inappropriate” care.</p>
<p>Vargas complained of dizziness and blurred vision upon arrival at the Florence Detention Center in Arizona on August 4, 2025. His lab results indicated uncontrolled diabetes. Ten days later, Vargas tested positive for Covid and was moved to a medical unit for isolation, where his symptoms were treated with only a one-time dose of acetaminophen.</p>
<p>When Vargas’s chest X-rays later indicated pneumonia, he was treated with antibiotics that did not align with Centers for Disease Control and Prevention guidelines, according to his ICE mortality review. On August 30, shortly after being released from isolation, Vargas reported difficulty breathing and was treated with albuterol, which was deemed insufficient for someone in his condition, according to Dr. Katherine Peeler, a medical adviser with Physicians for Human Rights.</p>
<p>A day later, Vargas’s condition worsened, and he complained of shoulder pain but was not checked for oxygen levels. He was later found unresponsive.</p>
<p>Dr. Peeler described the situation as a case of “pretty egregiously managed care,” emphasizing that waiting for an emergency is not an appropriate way to treat sick individuals.</p>
<p>The findings align with a new report by the Florence Immigrant and Refugee Rights Project, which surveyed 64 detainees at Arizona ICE facilities, highlighting the lack of oversight that makes it difficult for individuals in detention to receive assistance for urgent medical issues.</p>
<h2>Preventable Death</h2>
<p>Another mortality review provided new information regarding the death of Noviello, a 49-year-old Canadian national, on June 23, 2025, at ICE’s Federal Detention Center in Miami. His autopsy ruled his cause of death as a preventable form of kidney failure.</p>
<p>Upon entering the ICE facility, Noviello had a documented history of seizures and high blood pressure, for which he was medicated. The intake nurse ordered labs but allowed Noviello to continue taking his prescription medications himself.</p>
<p>The labs were never completed. On May 29, a corrections employee flagged Noviello for a possible hunger strike, and medical staff noted an increase in symptoms of depression, disorientation, and poor hygiene. By June 20, he was placed in solitary confinement for observation, and his medication was confiscated.</p>
<p>Three days later, a behavioral specialist noted that Noviello had not received his medication and referred him to a psychiatrist. The ICE death review found that the provider in charge failed to conduct necessary medical assessments and did not provide effective CPR when Noviello was found unresponsive.</p>
<h2>Botched Emergency Responses</h2>
<p>Botched emergency responses were noted in two other cases. Blaise, a Haitian national and the only woman to die in ICE custody during Trump’s current term, entered the Broward Transitional Center in Florida with elevated blood pressure in April 2025. Twenty days later, she collapsed.</p>
<p>Her mortality review indicated that health staff did not provide rescue breaths and failed to initiate CPR despite her pulselessness. Staff monitored her condition while waiting for EMS personnel instead of actively attempting to resuscitate her.</p>
<p>The review of Ge’s suicide death at the Moshannon Valley facility in Pennsylvania also pointed to inadequate medical care. Ge had a history of mental health issues, but the provider in charge did not take appropriate action when he was found hanging in a bathroom stall.</p>
<p>Four days into his detention, guards found him hanging and delayed life-saving measures by first calling for help instead of immediately cutting him down.</p>
<h2>Revelatory Reports</h2>
<p>The reviews of Nguyen and Rascon, in which ICE auditors determined that medical care met adequate standards, still revealed significant issues. Both men entered ICE custody in poor health, with Nguyen diagnosed with dementia and Rascon appearing to have late-stage Alzheimer’s and multi-organ failure. ICE’s medical staff noted that they did not have the resources to care for Nguyen and requested his release from custody.</p>
<p>As the Trump administration increased deportations, the number of individuals in immigration detention rose from 40,000 in January 2025 to nearly 66,000 by December 2025, according to the American Immigration Council. Concurrently, the Department of Homeland Security reduced oversight and transparency mechanisms.</p>
<p>Suh from the Detention Watch Network noted that the current system funnels individuals with serious medical issues into detention, which does not provide adequate healthcare.</p>
<p><em>The National Suicide Prevention Lifeline offers 24-hour support for those experiencing difficulties or those close to them, available by chat or telephone at 988.</em></p>