Case Study

Letting Moises Die: Perishing in Immigration Detention (US)

Case study

Moises Tino Lopez, a 23-year-old native of Guatemala, was being held in an Immigration and Customs Enforcement (ICE) detention facility pending his removal from the United States. He suffered several seizures while in detention, the last two taking place in solitary confinement. Instead of taking him to a hospital so that he could receive proper care, jail and medical staff basically let him die.

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Aboriginal and Torres Strait Islander viewers are respectfully advised that this case study may contain images of and references to deceased persons.

All viewers are respectfully advised that this study contains images of and references to the deaths in custody of Indigenous peoples, Black people and refugees that may cause distress.

At the same time, each screen of these case studies testifies to target communities' strength and courage, as they respond to repeated deaths in custody through myriad creative forms, through lines of solidarity and through an unwavering call for justice.

Letting Moises Die

Moises Tino Lopez

Moises Tino Lopez grew up in the small town of Joyabaj in the highlands of Guatemala. There he met and married Petrona Juarez. They had one daughter together. It doesn’t appear that Moises and Petrona had any plans to migrate to the United States. However, the supporters of a mayoral candidate they had opposed threatened them. In mid-2016, fearing for their lives, they sought refuge in the U.S.

Moises and Petrona settled in Grand Island, Nebraska, where Moises’ sister lived. The town has a vibrant job market and a large meat-packing plant. As such, scores of new migrants, particularly from Somalia and Latin America, have been drawn to the area.

On August 26, 2016, only a couple of month after settling in Grand Island, Moises drove Petrona to an appointment with immigration officials. For unknown reasons, ICE agents questioned Petrona about Moises and their daughter, who were waiting in a parking lot nearby. After Petrona’s appointment was over, agents arrested Moises and detained him in Hall County Corrections, a local jail, for having reentered the United States without inspection. In 2012, during a previous stint in the U.S., he had been arrested by ICE, ordered removed, and deported to Guatemala.

Moises died in detention on September 27 while waiting to be deported. He was only 23 years old. The official cause of death was ‘anoxic brain injury due to cardiac arrest due to seizure’.


Picture taken at Hall County Department of Corrections.

Picture taken at Hall County Department of Corrections.

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Courtesy Photo. ©Hall County Department of Corrections. This photo is a ‘mug’ shot taken the day that Moises was booked into HCDC.

Hall County Department of Corrections

Hall County Department of Corrections (HCDC) is located in Grand Island, Nebraska. It is a maximum/medium/minimum security jail owned and operated by the County of Hall. It was built to warehouse criminal detainees. However, under an Intergovernmental Service Agreement with ICE, the jail also houses a small number of immigration detainees. The ICE detainee bed capacity is about 68, with the average immigrant detainee population being about 40.

HCDC has 10 units in which detainees are housed, including dormitory style minimum security units, medium and maximum security cell blocks, and a segregation (or solitary confinement) unit. Because Moises had no criminal record, he was considered a low-risk detainee and thus initially assigned to a minimum security dormitory style unit.

While HCDC is run by the County, its medical services are contracted out to Advanced Correctional Healthcare (ACH), a private company headquartered in Peoria, Illinois that delivers health care services to correctional institutions across the country. Four ACH Licensed Practical Nurses (LNPs), working in shifts, provide medical care at HCDC on a 24 hours a day, 7 days a week basis. There is also an LNP who serves a Site Nurse Manager and provides administrative oversight of medical care at the facility. Finally, an ACH Nurse Practitioner (NP), or Advanced Practice Registered Nurse, delivers onsite care 1-3 hours per week and is on call around the clock. There is no physician available  at HCDC (although the NP can consult one based in Peoria).


Dormitory style, minimum security unit at Hall County Corrections.
Dormitory style, minimum security unit at Hall County Corrections. Moises was initially assigned to a unit like this one.







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©Hall County Department of Corrections.



Advance Correctional Healthcare publicity photos from their Facebook Page.
Advance Correctional Healthcare publicity photos from their Facebook Page.








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Seizing in Detention

Records show that an LPN performed a medical intake screening on Moises when he first arrived at Hall County Corrections. The medical history form indicates that he only suffered from occasional headaches. There is no suggestion that he had a history of seizures.

Moises first few days at HCDC appear to have been uneventful. Then, on September 6, an HCDC officer conducting rounds in Moises minimum security unit saw him lying on his bed, the upper part of a bunk bed, having a seizure. The officer called for medical assistance. An LPN immediately came to the unit to assess Moises.

After the assessment, two officers moved Moises to a lower bunk in the same unit. Following standard (albeit unwritten) protocol for seizures at HCDC, the LPN also placed Moises on 15 minute security checks, which required officers, as opposed to medical staff, to check on him at regular intervals. He was on this status September 6-8. Additionally, the LPN, per orders of the Nurse Practitioner, administered an anti-seizure medication (Depakote) to Moises. He was to be given two doses daily. Lastly, Moises was prescribed Tylenol since he complained of headaches following the seizure.

On September 7, Moises received post-seizure follow-up care from the NP. The NP ordered that he continue to be given Depakote and Tylenol. She also noted that ICE should be contacted about the probable need for a CT (computerized tomography) scan of the head and a consult with a neurologist. The neurology consult never happened. Moises did receive a CT scan. The radiology report suggested there was a possible abnormality and that an MRI could better determine if there was a problem. An MRI for Moises was never ordered.


Moises Tino Lopez medical history taken on August 26, 2016.
Moises Tino Lopez medical history taken on August 26, 2016.












Moises Tino Lopez CT scan results.
Moises Tino Lopez CT scan results.

Punished to Solitary

In the days following his seizure, Moises developed severe headaches and vision problems. He saw an LPN for these issues on the afternoon of September 15. He thought that the headaches were caused by his anti-seizure medication and asked to stop taking Depakote. The LPN consulted with the NP, who ordered that he be taken off Depakote and put on a different anti-seizure medication, Keppra.

Later on the 15th, in the evening, Moises had an encounter with another detainee. He reported to an officer that the detainee had pushed him in the shower room and tossed his personal items on the floor. A sergeant at the facilities interviewed Moises and the other detainee about the incident and determined that both should be consigned to segregation, a code word for solitary confinement, pending a disciplinary hearing. At HCDC, it is standard procedure to place all inmates involved in a physical altercation in administrative segregation until the issue can be sorted out. Moises was placed in Unit E, initially in cell 205 on the upper tier.

Detainees in segregation spend most of their time confined to their cells. As such, they tend to experience extreme isolation, sensory deprivation, and idleness (little access to recreation, programming, and congregate activities). Research show that prison segregation aggravates existing physical and mental illnesses.


Moises was placed in this segregation unit.
Moises was placed in this segregation unit, E. He was initially in cell E205.










An individual cell in the segregation unit E.
An individual cell in the segregation unit E.







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Both images ©Hall County Department of Corrections.

A Second Seizure

Records show that while in isolation Moises refused to take most doses of his new anti-seizure medication. The refusal forms that were filed do not indicate a reason for the refusal. Given that not taking the medication could lead to further seizures, it’s unclear why medical staff did not intervene to make sure Moises either took his medication or was prescribed a different one. This lapse, along with other failures, would prove fatal.

On September 19, shortly before 12:30 pm, an officer who was passing out lunch trays in Unit E was called over to Moises’ cell by an inmate assisting with lunch. The officer saw that Moises was having a seizure. He was lying rigid on his bed, shaking slightly and with his eyes rolled back. The officer immediately radioed for medical and officer assistance.

When the LPN arrived, Moises was still seizing slightly, with his eyes closed and his mouth drooling. She administered an ammonia inhalant and performed a sternal rub to help arouse Moises. After he regained some consciousness and was able to sit up, the LPN went to the medical unit to call the NP (an officer remained with Moises). The NP prescribed a new medication, Avitan, but it would not be available that day. At this point, the NP was not aware that Moises had not been taking his anti-seizure medication. She thus assumed that Keppra was not working.

After speaking to the NP, the LPN returned to Moises’ cell. He was more alert by this point. He could follow commands and stand up with help. A decision was made to move him to a cell in the lower tier of Unit E in order to facilitate 15 minute security checks. It’s not clear why Moises was not moved to the medical unit instead, where he could have been more continuously monitored. As he was descending the stairs to the new cell, Moises vomited and had to be carried the rest of the way. He had vomited twice before.


Refusal of treatment form for September 17, 2016.
Refusal of treatment form for September 17, 2016. Indicates that Moises refused to take Keppra.













HCDC incident report of officer who found Moises seizing. The office was also interviewed by immigration officials for a detainee death review. That interview has not been made available to the public.
HCDC incident report of officer who found Moises seizing. The officer was also interviewed by immigration officials as part of an ICE death review investigation (discussed later). The interview is not available but is referenced in the death review report.

Dying in Isolation

After Moises had settled in his new cell, the LPN went back to the medical unit to call the NP again. The NP said that Moises should be sent to the emergency room (ER), which was located in a local hospital, if he did not show signs of improvement over the next 30 minutes. The LPN then called Unit E and asked that they prepare Moises to be transported to the ER.

Moises was not sent to the ER however. In reviewing his medical records, the LPN learned that Moises had stopped taking his anti-seizure medication. She called back the NP to relay this information. The NP surmised that Moises’ failure to take his medication likely brought on the seizure. She ordered that Moises be monitored for 30 minutes and be educated about the importance of taking his medicine.

After the conversation, the LPN went back to Moises’s cell to relay the NP’s instructions about the anti-seizure medication, which Moises agreed to resume taking, and to monitor him. At this point, the LPN could still have sent Moises to the ER if she deemed it necessary. However, she determined that he was improving and that the right thing to do medically was simply to monitor him. She stayed to watch Moises for a few minutes and then had to leave to perform other duties. He would not be seen again by medical staff until two and a half hours later when there was a medical emergency call from Unit E. Only officers checked in on him (about every 15 minutes).

At about 4:15 pm, an officer doing a 15 minute check noticed Moises lying on his stomach, with his face straight down on the mattress. He had suffered another seizure. The officer knocked on the window of the cell door. When he received no response, he decided to go in. Once in the cell, the officer first shook Moises, who did not respond. He then turned Moises’ head and vomit came out of his mouth. The officer called for assistance at this point. While waiting for others to arrive, he checked Moises breath and pulse. He was not breathing and did not have a pulse.

Officers performed CPR and chest compressions on Moises until an ambulance arrived. He was then transported to St. Francis Medical Center and placed on life support in the intensive care unit. Moises never regained consciousness. Tests showed that he was brain-dead. On September 27, Moises’ family approved the discontinuation of life support. He was pronounced dead at 4:05 p.m. The official cause of death was brain injury, which resulted from seizure-induced cardiac arrest.


Nebraska State Patrol interview with LPN.
Nebraska State Patrol interview with LPN. She too was interviewed by immigration officials for the detainee death review. Her interview is also not available.














Incident report of officer who found Moises after his final seizure.
Incident report of officer who found Moises after his final seizure.

Failure to Care

There were numerous serious problems with the care that Moises received at Hall County Corrections. Three are highlighted here. Other will be brought up later in the discussion of Moises’ detainee death review.

First, there was no real effort made to diagnose his seizures. After the first seizure, he should have been placed under the care of a physician who could look into the underlying cause(s) of the seizures. In her testimony before the grand jury convened to examine Moises’s death, Dr. Erin Linde, who conducted Moises’ autopsy, noted that diagnosing acute onset seizures begins with a good clinical history, followed by basic laboratory work, neural imaging, and electroencephalograms. Moises never saw a physician and no steps, with the exception of a CT scan, were taken to diagnose his condition.

Second, there was a clear breakdown in the medical staff’s management of Moises’ medication. Given the potentially severe consequence of failing to take anti-seizure medication, someone should have intervened when he stopped taking Keppra.

Third, the placement of a detainee with a serious medical illness in solitary confinement is highly dangerous. In Moises’ case, if he had been in his initial unit or the medical unit when the second and third seizures occurred, another inmate or medical personnel would have likely noticed the seizures when they began and could have alerted others or taken appropriate steps to intervene early. But in solitary, where Moises was locked alone in his cell with guards only checking on him intermittently, his seizures were likely not caught early (certainly not the last, fatal one). Dr. Linde also noted in her grand jury testimony that Moises’ ‘cardiac arrest definitely could have been triggered by the seizure. When you get—I don’t know how long that final seizure period was, but you can have cardiac arrest associated with it, especially in prolonged seizure states’.

Put together, these and the failures discussed later, proved deadly. Indeed, if Moises had received proper care, he would likely still be alive.


Excerpts from the testimony of Dr. Erin Linde before the Hall County, Nebraska grand jury convened to investigate the death of Moises Tino Lopez.


Testimony of Dr. Erin Linde before the Hall County, Nebraska grand jury.
Excerpts from the testimony of Dr. Erin Linde before the Hall County, Nebraska grand jury convened to investigate the death of Moises Tino Lopez.

Profiting While Inmates Suffer

That there were serious problems with the care Moises received at Hall County Corrections is not a surprise. Advanced Correctional Healthcare has been sued more than 150 times over the last twelve years in connection with inmate injuries and deaths. ACH has essentially been accused of providing inadequate care in their quest for profit.

Three of the lawsuits involved inmates who died while incarcerated at Madison County Jail in Huntsville, Alabama. Their conditions were all eminently treatable. Deundrez Woods developed gangrene after a wound on his foot was left untreated; Tanisha Jefferson had a bowel obstruction that was nursed with laxatives; and Nikki Listau suffered a fall after experiencing seizures related to untreated alcohol withdrawal.

A basic claim made in the three lawsuits, which were all filed by civil rights attorney Henry Sherrod, was that ACH and Madison County ‘established deliberately-indifferent customs or policies concerning inmate medical care, including but not limited to a custom or policy of delaying or denying necessary medical treatment to avoid liability for inmate medical bills’. Such customs essentially reflect ACH’s business model, which ‘succeeds by underbidding the competition and implementing severe cost control measures, the necessary result of which is unnecessary inmate suffering and liability claims (dealt with through liability insurance)’.

Brian Sonenstein, who has written widely about the privatization of correctional healthcare for the independent press organization Shadowproof, came to a similar conclusion about ACH practices: ‘ACH controls costs by understaffing facilities, often with personnel that lack the appropriate skills and training, and favoring policies that substitute costly off-site, emergency and specialized healthcare, with only that which can be provided by nurses, who occasionally consult with doctors over telephone’.


Lawsuit brought by the mother of Deundrez Woods against Madison County and Advanced Correctional Healthcare.
Lawsuit brought by the mother of Deundrez Woods against Madison County and Advanced Correctional Healthcare.













Article by Brian Sonenstein in Shawdowproof about the privatization of correctional healthcare and ACH.
Article by Brian Sonenstein in Shawdowproof about the privatization of correctional healthcare and ACH.
Click here

©Favianna Rodriguez. The image was created by Rodriguez the day that the Associated Press decided to stop using the word ‘illegal’. She is an interdisciplinary artist, cultural organizer, and political activist based in Oakland, California. Her art and collaborative projects address migration, economic inequality, gender justice, and ecology.


The Violences of Detention

Border as a Mobile Technology

The death of Moises Tino Lopez in immigration detention needs to be understood in the context of the pervasive criminalization and heavy policing of immigrants. Over the last few decades, immigrants, particularly those without legal documents, have come to be heavily criminalized in the United States. The main solution to the putative problem of undocumented immigration has traditionally be to militarize the nation’s borders. However, since the late 1990s, political and other authorities have also placed increasing emphasis on the interior policing of the nation. What has happened is that the border, as a regime of security and immigration control, has been deterritorialized and projected into the nation’s interior. As part of this border deterritorialization, certain spaces of everyday life—workplaces, homes, neighborhoods, and a variety of public spaces—have been identified as strategic sites and become subject to intensified policing. As such, numerous locales across the interior of the United States have been turned into border zones of enforcement. The border is thus no longer simply (if it ever really was) a location at the nation’s edge where the regulation of movement takes place, but also a mobile technology—a portable, diffused, and decentered control apparatus interwoven throughout the nation. Indeed, we are in the presence of the border any time and in any space where immigration policing and control takes place.


Below are some stories and videos of border zones of enforcement across the United States:

Ann Arbor, Michigan

Immigration and Customs Enforcement (ICE) arrests 3 workers after eating at Michigan restaurant.

Albuquerque, New Mexico

ICE agents arrest father on his way to work.

Los Angeles, California

Man arrested by ICE after dropping off his daughter at school.

Queens, New York

After 37 years as an undocumented immigrant, a Queens, New York man is being deported, leaving family behind.

Fairfax County, Virginia

ICE agents arrest men leaving a church shelter.

Policing the Interior

This turn to interior enforcement, or what could be called the bordering of the interior, is part a new explicit border security doctrine developed by the Department of Homeland Security (DHS) and implemented by Immigration and Customs Enforcement (ICE). The thinking is that only by developing a ‘continuum of border security’, treating the territorial boundaries of the U.S. and the interior as a seamless security space, will it be possible to buttress the physical border and deter the flow of illicit immigration.

One important mechanism ICE has employed to carry out its interior policing mission is the raid. A raid is a practice whereby immigration authorities, sometimes with the help of other policing agencies, descend en mass on homes, places of work, and other spaces with the express purpose of apprehending individuals believed to be in the country illegally.

Another strategy ICE has employed in policing the interior is to partner with local and state police forces, sometimes using them as proxy immigration officers. The idea behind these partnerships, and the devolution of immigration authority from federal powers to non-federal law enforcement agencies, is that they serve as a “force multiplier” for the DHS, significantly expanding the reach of immigration policing authority.



Images from workplace raid on June 20, 2018 at Fresh Mark, a meatpacking plant in Salem Ohio. ICE arrested 146 suspected undocumented workers.

Images from workplace raid on June 20, 201
Images from workplace raid on June 20, 2018 at Fresh Mark, a meatpacking plant in Salem Ohio. ICE arrested 146 suspected undocumented workers.











Click here

©U.S. Immigration and Customs Enforcement.



The Drive to Deport

Today’s immigration enforcement climate, both at the border and the interior, has resulted in the massive detention, incarceration, and deportation of immigrants. ICE’s stated objective has been to remove all removable aliens from the United States (there are approximately 11 million undocumented migrants residing in country). While this goal is unrealistic, the number of removals, that is, official deportations, has gone up significantly in the post-9/11 period, part of a steep upward trend that began in the 1990s. In fiscal year 2012, at the highpoint of deportations, ICE removed 409,849 noncitizens from the United States. This compares to 189,026 in 2001 and only 50,924 in 1995.

Importantly, ICE’s deportation practices amount to a form of racial governance, functioning as mechanisms for managing the conduct of somatically different, and putatively “unruly,” populations. The populations most affected by the current deportation drive are Mexicans and Central Americas. Over the past decade, nationals from Mexico, Guatemala, Honduras, and El Salvador have consistently been at the top of the deportation charts. In 2016, for example, these nations accounted for 94 per cent of all removals, with Mexico constituting the largest share at 64 per cent.



Total removals as reported in
Total removals as reported in Fiscal Year 2016 ICE Enforcement and Removal Operations Report.


Removal by country of citizenship
Removal by country of citizenship as reported in Fiscal Year 2017 ICE Enforcement and Removal Operations Report.
RELEVANT KEY TERMS: Racial governance

Archipelago of Detention

To facilitate the current deportation drive, the DHS has developed, over the past decade and a half or so, a vast archipelago of carceral spaces in which to detain immigrants pending their removal from the United States. The growth has been such that ICE’s Enforcement and Removal Operations (ERO) directorate now runs the largest detention operation in the nation. In 2016, ICE detained approximately 360,000 foreign nationals, more than four times the number of people held in 1994 (81,707) and about a 72 percent increase from 2001 (209,000).

ICE houses its detainee population in a variety of facilities. These include 6 ICE owned Service Processing Centers (SPCs), 7 privately owned Contract Detention Facilities (CDFs), and several hundred Intergovernmental Service Agreement facilities—basically local and county jails (like Hall County Corrections) which contract with ICE to hold immigrant detainees. Notably, for-profit prison corporations play a huge role in managing the immigrant detention archipelago. They house more than 73 percent of all detainees. This delegation of immigrant confinement to organizations whose main purpose is to generate profits perversely produces pressure to increase detentions: the more immigrants confined, the higher the profits. Immigrant bodies have thus become valuable commodities whose worth lies in being placed and kept behind bars.



Map with location and approximate size of U.S. immigration detention facilities overseen by ICE
Map with location and approximate size of U.S. immigration detention facilities overseen by ICE. From U.S. Government Accountability Office.

Abuses in Detention

Immigration detention in the United States is not a criminal form of confinement but a civil one. This means that migrants held in spaces of detention are not there as punishment for having broken criminal laws. Rather, they are there so that their immigration/asylum cases can be processed, with the resolution generally being deportation.

Although the detention system is not supposed to be punitive in nature, the reality is that detention spaces tend to have the feel of and function like prisons. In fact, they are often worse than prisons. Immigration detention facilities are subject to more lax oversight than prisons and detainees have less rights than prisoners. As such, immigration detainees are routinely subject to a variety of abuses.

Routine problems in immigration detention include: sexual assault; physical abuse and excessive use of force; racists and homophobic verbal abuse; punitive disciplinary procedures; misuse of isolation; unsanitary and overcrowded facilities; failure to provide sufficient food and clean clothing; lack of outdoor recreation; retaliation if detainees complain; lack of due process; inadequate access to meaningful grievance procedures; and lack of review of detainee complaints.

‘The Warden of the WTDF hit me in the face four times, while I was at the nurse’s station. I asked two of the medical officers who were present, ‘Are you going to let this happen”? They responded, “We didn’t see anything”. I was then placed in solitary confinement, where I was forced to lie face down on the floor with my hands handcuffed behind my back while I was kicked repeatedly in the ribs by the Warden.’

Dalmar, a detainee at West Texas Detention Facility (WTDF) in Sierra Blanca, Texas

‘Once the sexual attack and rape were over, the effects were so awful. I felt like I’m not the same person. I was scared all the time. I used to be a really outgoing, friendly, confident, strong woman. But then I could hardly look people in the eye. I must express my deep frustration and sense of outrage toward the DHS that apparently knew, or should have known, that when I was placed in the sole custody of Wilfredo Vazquez I would be a likely victim.’

M.C., raped in 2007 by an ICE officer who transported her to a detention facility

For more on the abuses above and others see the following reports and statement: I Was Treated Like and AnimalDehumanizing DetentionShadow Prisons

Just Enough Medical Care

In addition to the abuses described above, detainees often suffer as a result of substandard medical care. Moises case is thus far from unique. Detention centers, particularly those run by private corporations, appear to routinely skimp on healthcare. Indeed, it appears that the system is designed to keep health care costs to a bare minimum. For example, staffing levels are often too low for the size the patient population. Furthermore, it’s not uncommon for staff operate beyond the scope of their training, performing duties that should be reserved for more qualified (and more expensive) personnel. Finally, the hiring of poorly trained and incompetent medical personnel is also an issue.

The result of skimping on healthcare is that detainees often receive poor quality care or no care at all. Problems that plague detention facilities include: inadequate initial medical screenings and physical examinations; delayed or lack of response to sick call requests; unreasonable delays in obtaining off-site care; improper mental health care and misuse of isolation; inadequate care of physically disabled patients; and denied, insufficient ,and mistaken prescription medication.

Overall, the provision of health care in immigration detention amounts to a bare biopolitics—a biopolitics that barely fosters life. The goal is to nurture the lives of detainees only modestly—to give them just enough care so that they are in good enough health to be released or deported.

‘I feel like my condition has worsened during my time at the detention center. It is very frustrating to be deprived from my medical treatment. In January, once I finished the first prescription that was approved, it took almost another month to have access to my medications again. I struggled a lot with my pain during this period. When I asked for my medications through a kite [a written request], by going to the clinic in person, or by asking the nurses when they did rounds, I would get mixed messages from the medical staff at the detention center. Sometimes the nurses would tell me that the doctor at the detention center had not signed the prescription and other times, the nurses told me that the clinic had run out of pills.’

Miguel, a 28-year-old Mexican man who suffers from Hemophilia A

‘I think the medical staff here do a horrible job of taking care of people. I have been getting so many seizures. I asked the doctors for a helmet or other protective wear that people with seizures have but they have not given me anything. When I have an episode, I pass out without warning and often fall and hurt myself. I have gotten multiple black eyes and have hurt my head, chin, knees, legs, and shoulders when I have episodes.’

Laurenzo, is a 40 year-old man who suffers frequent seizures

For for more information about the above and other cases see Failures at Dever Contract Facility and Systemic Indifference.

Death by Care

Not surprisingly, the just enough approach to health care in detention has disastrous consequences for detainees. Many migrants need more than just enough health care. Since 2010, there have been at least 74 deaths, including Moises’, in immigration detention. ICE has released deaths reviews in 52 of these cases. Analyses of these reviews suggest that substandard care contributed or led to at least 23 of the deaths (see Code Red). And in almost all of the cases there were signs of unsafe and shoddy medical care practices.

There are four particular medical care failings that stand out as leading to detainee deaths: 1) botched emergency responses, 2) mediocre care by facility and medical staff, 3) excessive delays in the delivery of care; and 4) holding detainees suffering from mental illnesses in isolation. Some specific cases include: a nurse ignoring acute symptoms of a heart attack; the misdiagnosing and mismanagement of congestive heart failure; an inexplicable three-day delay in transferring a detainee with dangerously low oxygen to a hospital; complications from initially untreated alcohol withdrawal; poorly-managed hypertensive cardiovascular disease; an officer refusing to call for emergency help, leading to a delay in responding to symptoms of a heart attack; and the solitary confinement of detainees with psychosocial disabilities who subsequently committed suicide.

Below is a partial list migrants who have died as a result of negligent medical care since 2010:

Amra Militec

•Irene Bamenga

Anibal Ramirez- Ramirez

•Mauro Rivera- Romero

•Pablo Gracida- Conte

•Fernando Dominguez- Valivia

•Evalin-Ali Mandza

•Tiombe Kimana Carlos

•Marjorie Annmarie Bell

•Peter George Carlysle Rockwell

•Raul Ernesto Morales Ramos

•Jose Manuel Azurdia Hernandez

•Thongchay Saengsiri

•José Leonardo Lemus Rajo

•Igor Zyazin

•Olubunmi Toyin Joshua

For more information about the deaths listed above see Code RedSystemic IndifferenceFatal Neglect.

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Alter commemorating the lives of those who perished in immigration detention. The alter appears to have been developed as part of a protest in Washington, D.C. against deaths in ICE detention.


No Justice, No Accountability

Blaming Moises

Moises’ death seems to have mattered little. It does not appear that anyone has been held accountable for his death.

The state of Nebraska requires that a Grand Jury be convened when an individual dies while being apprehended or while in custody. The role of the Grand Jury is to inquire into the death and decide if formal criminal charges need to be made against anyone in connection with that death.

In Moises’s case, a Grand Jury was convened on January 27, 2017. Only five people were called as witnesses: two corrections officers, the LPN who “cared” for Moises the day he died, an investigator with the Nebraska State Patrol, and the doctor who performed the autopsy (Erin Linde). No detainees who interacted with Moises and who could have provided independent testimony about the care he received were interviewed.

As noted earlier, Dr. Linde, in her testimony, hinted at the fact that Moises did not receive proper care for seizures. But the grand jury found that there was nothing wrong with the care that Moises was given. They instead noted that Moises had not been taking his anti-seizure medication. Essentially, they blamed Moises for causing his own death.

Findings of the Grand Jury and Grand Jury Report.
Findings of the Grand Jury and Grand Jury Report. The report notes that Moises might have had a history of seizures. But there is actually no indication that he had seizures prior to being detained. There is one medical form in Moises’ files that indicates a history of seizures. This form should have been completed when Moises first arrived at Hall County Corrections, but was not filled out until after he had his first seizure.

Wasted Death Review

While the Grand Jury found no problems with the care that Moises received in detention, an ICE investigation revealed that Hall County Corrections was not in compliance with a number ICE health care standards.

Since 2009, ICE has produced what have come to be known as the Detainee Death Reviews. A death review is a document that summarizes the findings of investigations into the death of an individual in detention. The investigations are carried out by ICE personnel and subject-matter experts, who interview personnel at the facility where a death has occurred, as well as review custody and medical records.

Moises death review documents numerous deficiencies in the provision of care and security at HCDC. Included among these deficiencies is not having ‘a medical staff large enough to perform basic exams and treatments for all detainees’. The report points out that no physician provides onsite services at HCDC and that the RN only visits 1-3 hours per week.

The report also notes that there was a general failure to provide Moises with interpretation services. When language difficulties make communicating with a detainee difficult, personnel are expected to obtain translation assistance. Moises spoke little to no English and limited Spanish. His primary language was K’iche’, a Mayan language. Interpretation assistance was only documented for three medical interactions with Moises. On at least one occasion, language barriers prevented a nurse from asking Moises follow-up questions about his health. And it’s not clear if translation services were provided when Moises refused to take his anti-seizure medication. The report concludes that ‘Without documentation of whether or not language assistance was provided and the reason for the refusal, it remains unclear if TINO understood the potential consequences of non-compliance’.

Other deficiencies include not having a written protocol for how to deal with seizures, not documenting the justification ‘for charging TINO with disciplinary violations and placing him in administrative segregation’, and failing to address Moises’ refusal of anti-seizure medication.

While Moises’ detainee death review documents a number of deficiencies, it also states that ‘Their inclusion in the report should not be construed in any way as indicating the deficiency contributed to the death of the detainee.’ It is thus not likely that the review was used or will be used to hold anyone accountable for Moises’ death.


Moises Tino Lopez's Detainee Death Review.
Moises Tino Lopez’s Detainee Death Review.












Journalist Robin Urevich’s excellent account of Moises’ death and his detainee death review.
Journalist Robin Urevich’s excellent account of Moises’ death and his detainee death review.


Ineffective Inspections

In general, the process for holding detention facilities accountable for the ill-treatment and neglect of detainees is quite weak. It doesn’t appear that detainee deaths reviews result in any substantial punishment for the operators of detention facilities nor for the personnel involved in mistreatment. Moreover, ICE’s inspections program, which is designed to ensure that facilities meet ICE’s detention standards, is ineffective at identifying and correcting dangerous and unhealthy conditions in detention.

There are two offices within ICE that conduct inspections of detention facilities: the Office of Enforcement and Removal Operations (ERO) and the Office of Detention Oversight (ODO). The ERO inspections are used to determine whether ICE will continue to contract with specific facilities, while the purpose of ODO inspections is to ensure better compliance with detention standards. Neither office appears to do a good job providing oversight and holding detention facilities accountable.

In 2015, the National Immigration Justice Center (NIJC) and Detention Watch Network (DWN) released a seminal report about the inspections process, concluding that it was merely perfunctory, designed to result in passing ratings for detention facilities. The report was based on an analysis of the inspections reports produced by ODO and ERO. Among NIJC and DWN’s findings are the following: detention facilities are informed of inspections in advance, which gives facilities time to clean up; there are major inconsistencies between ODO and ERO inspections reports for the same facilities, raising questions about the general validity of the inspections process; both ERO and ODO inspections focus on security within a facility and de-emphasize the humane treatment of detainees; and, even when human rights violations or suspicious deaths have occurred, facilities rarely fail inspections and lose their ICE contracts.


Seminal report by the National Immigration Justice Center and Detention Watch Network about the ICE inspections process.
Seminal report by the National Immigration Justice Center and Detention Watch Network about the ICE inspections process.














Report by the Department of Homeland Security Office of Inspector General Detailing the inadequacies of the ICE inspections process.
Report by the Department of Homeland Security Office of Inspector General Detailing the inadequacies of the ICE inspections process.


Inspecting Hall County Corrections

The failures of inspection process are readily apparent in the ODO reports produced for Hall County Corrections. ODO conducted a compliance inspection at HCDC on June 13-15, 2017, about nine months after Moises’ death. The inspection found three deficiencies related to medical care. First, medical privacy was routinely not maintained in interactions between medical personnel and detainees. Second, medical intake screenings were not always conducted within 12 hours of a detainee’s arrival. And third, HCDC’s suicide prevention program does not require consultation with a medical director in order for a detainee to be released from suicide watch.

Importantly, the ODO report makes no mention that a death occurred at HCDC less than 9 month before the inspection. The report also fails to point out a number of the general problems discussed in Moises’ detainee death review. For example, there is no mention of the medical staff not being large enough to ‘perform basic exams and treatments for all detainees’. The report also fails to document that there is no written protocol for how to deal with seizures.

As the National Immigration Justice Center and Detention Watch Network argue in their report, such failures of the inspections process are important, for they put detainees’ lives in peril. Indeed, the failure to identify and correct substandard conditions in detention endangers lives.


Office of Detention Oversight Compliance Inspection, conducted June 13-15, 2017.
Office of Detention Oversight Compliance Inspection, conducted June 13-15, 2017.

Anti-Detention Human Rights Work

While the picture of how migrants and asylums seekers are treated in detention is depressing, it’s important to note that there are a number of human and civil rights organizations working both to call attention to the plight of people in detention and to improve the conditions in these spaces.

The reason the public knows about migrants dying in detention is in large part because of the work of Human Rights Watch, the American Civil Liberties Union, the National Immigrant Justice Center, and Detention Watch Network. They have produced a series of key reports, cited earlier, on deaths in immigration custody.

The reason we know about the failings of the detention inspections process is because of the work of the National Immigrant Justice Center. Through their Immigration Detention Transparency and Human Rights Project, they fought in the courts to have ICE release thousands of pages of immigration detention contracts and inspections reports.

With the continued work of these and other organizations, the hope is that immigration detention will be transformed in such a way that not only will immigrants be treated better but also so that they don’t end up in detention in the first place.

Human Rights Watch






National Immigrant Justice Centre






Detention Watch Network





Logos (with links to home pages) of important human and civil rights group working to improve the treatment of migrants in detention facilities.
Logos (with links to home pages) of important human and civil rights groups working to improve the treatment of migrants in detention facilities.
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‘Not1More Deportation’. ©Malanie Cervantes. Cervantes is a Xicana activist-artist whose role is to translate the hopes and dreams of justice movements into images that agitate and inspire.

Globalizing Deathscapes

For other case studies dealing with the violence that migrants and indigenous peoples experience in spaces of incarceration, see:

Villawood: A Suburban Deathscape in Plain Sight (Australia)

At a Lethal Intersection: the Killing of Ms Dhu (Australia)

Extraterritorial Killings: The weaponisation of bodies (Australia)

Letting Moises Die: Perishing in Immigration Detention

This case study was  authored by Jonathan Xavier Inda of the United States hub of the Deathscapes project. Research assistance was provided by Beatriz Maldonado. Many thanks to Robin Urevich for sharing crucial material she collected while writing her article on Moises.

To cite this research: Inda, Jonathan Xavier. ‘Letting Moises Die: Perishing in Immigration Detention’. Deathscapes: Mapping Race and Violence in Settler States, 2018,

Corresponding author:

Crisis Support Lines:

Lifeline (Aus): 13 11 14
A free interpreting service for people who do not speak English is available for 13 11 14. To access this service please:
1) Call TIS on 131 450 and ask to talk to Lifeline on 13 11 14 in the language required.
2) TIS will call 13 11 14 on behalf of the caller.
Crisis Services Canada (Can): 1 833 456 4566
Samaritans (UK): 116 123
Suicide Prevention (US): 1-800-273-8255
International Support: International Association for Suicide Prevention and


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Aboriginal and Torres Strait Islander viewers are respectfully advised that this website contains images of and references to deceased persons.

All viewers are respectfully advised that the site contains images of and references to the deaths in custody of Indigenous peoples, Black people and refugees that may cause distress.