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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

Immigration and Customs Enforcement PREPARED BY


Office of Professional Responsibility

REPORT OF INVESTIGATION 2. REPORT NUMBER


HB 4200-01 (37), Special Agent Handbook 001
3. TITLE
Tavarez, 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 Allegation
Report
8. TOPIC
Detainee death in Boston, MA.

9. SYNOPSIS
On October 19, 2009, the Joint Intake Center (JIC), Washington, D.C., received information
reporting 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 the
medical staff from Suffolk County House of Correction (SCHOC) diagnosed a possible case of
pneumonia 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 condition
continued to deteriorate. On October 19, 2009, Immigration Enforcement Agent (IEA)
, Boston, MA was informed that Mr. Tavarez had passed away. Mr. Tavarez's body will
reportedly be examined today by a Massachusetts State Medical Examiner to determine the
cause of death.

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

- Joint Intake Specialist 20-OCT-2009 Joint Intake Center


12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER
- ICE-OPR Special Agent
Supervisor 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 FOR
DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A
COPY 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 THE
DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE
MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR.

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HB 4200-01 (37), Special Agent Handbook 001
10. NARRATIVE
None

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

Immigration and Customs Enforcement PREPARED BY


Office of Professional Responsibility

REPORT OF INVESTIGATION 2. REPORT NUMBER


HB 4200-01 (37), Special Agent Handbook 002
3. TITLE
Tavarez, 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


Interim Detainee Death Review
Report
8. TOPIC
Detainee Death Review – TAVAREZ, Pedro

9. SYNOPSIS
On October 19, 2009, the Joint Intake Center (JIC), Washington, D.C. received notification
regarding the death of ICE detainee Pedro Juan TAVAREZ ( who was housed at the
Suffolk County House of Corrections (SCHOC), Boston, MA. TAVAREZ, a Dominican Republic
national, 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 Detention
Oversight (ODO), initiated an OPR Detainee Death Review to investigate the facts and
circumstances surrounding the death of TAVAREZ. Per ICE policy, all deaths of ICE detainees
are reviewed by OPR ODO. This report documents the immigration and criminal histories of
TAVAREZ.

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

- ICE-OPR Special Agent 16-FEB-2010 ICE OPR Detention Facilities Inspection


12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER
- ICE-OPR Special
Agent Supervisor 15-MAR-2010 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 FOR
DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A
COPY 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 THE
DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE
MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR.

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2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 002
10. NARRATIVE
On October 19, 2009, the JIC, Washington, D.C. received notification regarding the death of ICE
detainee Pedro Juan TAVAREZ (DOB: 07/25/1960; TAVAREZ, a 49 year old
Dominican Republic national, died on October 19, 2009 at the Brigham & Women's Hospital in
Boston, 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 of
Corrections (SCHOC), an ICE Intergovernmental Service Agreement (IGSA), located in Boston,
MA. Docket control of TAVAREZ' immigration case was held by the ICE Detention and Removal
Operations (DRO) Boston Field Office.

On October 22, 2009, the Office of Professional Responsibility (OPR), Office of Detention
Oversight (ODO), initiated an OPR Detainee Death Review investigation to obtain the facts and
examine the circumstances surrounding the death of TAVAREZ. Pursuant to the investigation,
ODO reviewed data obtained through queries of ICE enforcement databases to establish the
criminal and ICE custody histories of TAVAREZ. This Report of Investigation (ROI) documents
the 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 lawful
permanent 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 of
New York upon a plea of guilty to Intent to Sell of a controlled substance (marijuana), and
sentenced to time served and five years probation.
- On October 1, 1987, pursuant to a February 10, 1987 arrest, TAVAREZ was convicted in the
state of New York upon a plea of guilty to criminal possession of a controlled substance and
sentenced 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 substance
and sentenced to 2 years probation.
- On April 8, 2008, pursuant to a traffic stop, the Rhode Island State Police arrested TAVAREZ
when an NCIC query disclosed an outstanding ICE warrant for his arrest. TAVAREZ was
subsequently turned over to ICE.
- The NCIC criminal history record identifies alias names for TAVAREZ as: Pedro TABRE; and
Felix BAEZ.
- The NCIC criminal history record identifies an alias DOB for TAVAREZ as: 11/23/1958.

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HB 4200-01 (37), Special Agent Handbook 002
10. NARRATIVE
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, 1976
he entered the United States at the New York, NY Port of Entry as a lawful permanent resident of
the United States.
- On June 24, 1987, the Immigration & Naturalization Service (I&NS) issued and served a warrant
for his arrest.
- On March 4, 1992, I&NS issued a warrant of deportation against TAVAREZ for removal from the
United 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 April
8, 2008. According to ICE records, TAVAREZ assumed the alias Felix BAEZ, under which he was
able to elude police and immigration officials.
- On April 28, 1998, an immigration hearing was held with TAVAREZ in absentia. At this hearing
he was ordered removed by an Immigration Judge (IJ).
- On April 8, 2008, detainee TAVAREZ was turned over to ICE by the Rhode Island State Police
who encountered him during a traffic stop. An NCIC query conducted pursuant to the stop
disclosed 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 of
Corrections to the Suffolk County House of Corrections to await receipt of a travel document and
removal 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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CONTINUATION
HB 4200-01 (37), Special Agent Handbook 002
10. NARRATIVE
Detainee TAVAREZ died on October 19, 2009 at the Brigham & Women's Hospital, Boston, MA
while in ICE detention at the Suffolk County House of Corrections awaiting immigration
proceedings.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

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HB 4200-01 (37), Special Agent Handbook 002

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HB 4200-01 (37), Special Agent Handbook 003
3. TITLE
Tavarez, 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


Interim Detainee Death Review
Report
8. TOPIC
Detainee Death Review – TAVAREZ, Pedro

9. SYNOPSIS
On October 19, 2009, the Joint Intake Center (JIC), Washington, D.C. received notification
regarding the death of ICE detainee Pedro Juan TAVAREZ ( who was housed at the
Suffolk County House of Corrections (SCHOC), Boston, MA. TAVAREZ, a Dominican Republic
national, 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 Detention
Oversight (ODO), initiated an OPR Detainee Death Review to investigate the facts and
circumstances surrounding the death of TAVAREZ. Per ICE policy, all deaths of ICE detainees
are reviewed by OPR ODO. This report documents interviews of ICE management personnel
responsible for SCHOC.

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

- ICE-OPR Special Agent 16-FEB-2010 ICE OPR Detention Facilities Inspection


12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER
- ICE-OPR Special
Agent Supervisor 15-MAR-2010 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 FOR
DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A
COPY 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 THE
DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE
MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

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2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 003
10. NARRATIVE
On October 19, 2009, the JIC, Washington, D.C. received notification regarding the death of ICE
detainee Pedro Juan TAVAREZ (DOB: 07/25/1960; TAVAREZ, a 49 year old
Dominican Republic national, died on October 19, 2009 at the Brigham & Women's Hospital in
Boston, 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 of
Corrections (SCHOC), an ICE Intergovernmental Service Agreement (IGSA), located in Boston,
MA. Docket control of TAVAREZ' immigration case was held by the ICE Detention and Removal
Operations (DRO) Boston Field Office.

On October 22, 2009, the Office of Professional Responsibility (OPR), Office of Detention
Oversight (ODO), initiated an OPR Detainee Death Review investigation to obtain the facts and
examine 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 interviewed
DRO 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. This
report of investigation documents the interviews of DRO staff, and the review of ICE procedures
regarding 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 received
notification via email to his Blackberry device of the hospitalization of detainee TAVAREZ late in
the evening on October 16, 2009. The email informed him of TAVAREZ' health condition and
admission into B&WH. AFOD initiated detainee hospitalization protocol to include contact
of 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 the
hospital to visit TAVAREZ on the morning of October 17, 2009, and family was at his bedside at
the 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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2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 003
10. NARRATIVE
health care issues related to TAVAREZ. He was first informed of TAVAREZ' health condition and
hospitalization via an email received late in the evening on October 16, 2009. The email was sent
by Supervisory Immigration Enforcement Agent (IEA) informing of the hospitalization
of detainee TAVAREZ. SDDO initiated notification protocol and forwarded the email to
Boston 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, SDDO
stated 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. The
POCs were identified as IEA's and and DDO

This concludes the interview of SDDO

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Exhibit List
HB 4200-01 (37), Special Agent Handbook 003
None

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

Immigration and Customs Enforcement PREPARED BY


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HB 4200-01 (37), Special Agent Handbook 004
3. TITLE
Tavarez, 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


Interim Detainee Death Review
Report
8. TOPIC
TOPIC: Detainee Death Review – Pedro TAVAREZ; SCHOC Interviews

9. SYNOPSIS
On October 19, 2009, the Joint Intake Center (JIC), Washington, D.C. received notification
regarding the death of ICE detainee Pedro Juan TAVAREZ ( who was housed at the
Suffolk County House of Corrections (SCHOC), Boston, MA. TAVAREZ, a Dominican Republic
national, 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 Detention
Oversight (ODO), initiated an OPR Detainee Death Review to investigate the facts and
circumstances surrounding the death of TAVAREZ. This report documents interviews of SCHOC
corrections and medical staff regarding the care and treatment of TAVAREZ.

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

- 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 Special
Agent Supervisor 01-JUL-2010 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 FOR
DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A
COPY 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 THE
DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE
MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR.

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2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 004
10. NARRATIVE
On October 19, 2009, the JIC, Washington, D.C. received notification regarding the death of ICE
detainee Pedro Juan TAVAREZ (DOB: 07/25/1960; TAVAREZ, a 49 year old
Dominican Republic national, died on October 19, 2009 at the Brigham & Women's Hospital in
Boston, 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 of
Corrections (SCHOC), an ICE Intergovernmental Service Agreement (IGSA), located in Boston,
MA. Docket control of TAVAREZ' immigration case was held by the ICE Detention and Removal
Operations (DRO) Boston Field Office.

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

This Report of Investigation (ROI) documents an overview of SCHOC operations, and the
interviews 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 ICE
detainees and 40 beds for female ICE detainees. The average daily population of SCHOC is
approximately 1300 pre-trial and convicted county inmates, 270 male ICE detainees, and 40
female ICE detainees. Both male and female ICE detainees are housed separately from the
inmate 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 the
facilities primary structure.

Prison Health Services (PHS), INC., a private medical contract health provider specializing in
correctional health care, provides comprehensive medical services at SCHOC. The initial contract
between 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 Health
Services Administrator, a full-time Medical Director, who is also the full-time PHS staff physician
providing direct patient care, two part-time physicians, Mid-Level Providers (MLP) to include
Physician Assistants (PA), Nurse Practitioners (NP), and a cadre of Registered Nurses (RN), and
Licensed Practical Nurses (LPN).

The infirmary is located in Building 6 of the facility, and is attached to the primary structure of
SCHOC. 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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HB 4200-01 (37), Special Agent Handbook 004
10. NARRATIVE
sick call, medication administration, and physical examinations of all ICE detainees. The clinic is
operational Sunday - Saturday, 7:00 a.m. to 11:30 p.m., and staffed full time with nursing
personnel. Daily supervision is conducted by Clinical Coordinator , LPN.

SCHOC is accredited by the National Committee of Correctional Health Services. In September


2009, 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) "Medical
Care." A review of the 2007 and 2008 annual DRO compliance reviews of SCHOC showed
overall final ratings of "Good." Specifically, a review of the inspection findings of each of the three
recent reviews of the SCHOC medical clinic resulted in no deficiencies found with regards to the
ICE NDS "Medical Care."

On October 27, 2009, SSA interviewed SCHOC Superintendant ESQ who


provided the following overview with regards to the detention of detainee TAVAREZ while at
SCHOC. TAVAREZ was at the facility approximately 3 weeks arriving on September 21, 2009 at
approximately 10:00 a.m. He arrived via J-PATS and was initially scheduled to depart on
September 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 no
disciplinary issues, and was confirmed by medical to have hypertension and diabetes. Upon
questioning, stated he understood the reason for TAVAREZ' extended stay at SCHOC
to 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 medically
screened 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) on
October 1, 2009, and a mental health exam (MHE) on October 7, 2009. On October 7, 2009, a
sick call slip submitted by TAVAREZ for "pain between (the) legs" was triaged by medical
personnel. 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 was
received 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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HB 4200-01 (37), Special Agent Handbook 004
10. NARRATIVE
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 and
his condition was worsening.

On October 16, 2009, in treating TAVAREZ, medical staff inserted a catheter to relieve his bladder
of 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. LSH
has correctional housing ward enabling them to provide care and treatment for correctional
facilities. She added the (SCHOC) Medical Director is aware of the services provided by LSH and
will 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 immediate
life-threatening condition requiring emergency services or transport.

Note: Information provided by Superintendant during a subsequent interview indicated


LSH is a Massachusetts state hospital providing medical care for inmates at county correctional
facilities that is not available at the correctional facility. Money is appropriated by the state and
made available through a state-sanctioned arrangement between LSH and SCHOC.

Upon arrival at LSH, intra-venous (IV) fluid was administered for dehydration, and lab results
revealed TAVAREZ had experienced a heart attack. Additionally, TAVAREZ began to complain of
chest pain. Since LSH does not provide emergency services, TAVAREZ was transported via an
ambulance to Faulkner Hospital (FH) located in Boston, MA. Upon arrival at FH, it was
determined 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's
Hospital (B&WH) located in Boston, MA.

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

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

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 004
10. NARRATIVE
B&WH medical personnel.

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

This concludes the interview of HSA .

On October 27, 2009, SSA interviewed SCHOC Corrections Officer (CO) a


housing 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. She
described him as "very quiet," remembered "nothing remarkable" about his behavior, and stated
she 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 to
the infirmary by reading the housing unit officer's logbook. CO pointed out Unit A4 has 75
beds and houses an average of 75 detainees. When asked about heating issues in the housing
unit, 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 detainee
health 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 not
remember all encounters with detainee TAVAREZ. She did recall he was diabetic and when he
first arrived at SCHOC he received "finger sticks" twice a day to measure his blood sugar. She
remembered 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 TAVAREZ
because he spoke a little bit of English and she speaks a "little Spanish."

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

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 004
10. NARRATIVE
infirmary on the night of October 14, 2009.

LPN stated sick call request slips are available in each of the housing units. Each
detainee is informed of the sick call process upon arrival. Once a slip is filled out it is to be placed
into the sick call box located in each housing unit. Sick call slips are removed by a staff nurse
daily, 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 box
in each of the housing units. Each box is clearly labeled. If a detainee were to submit a sick call
slip after the daily pick-up, it will not be retrieved until the following day. Once triaged, it is
possible the detainee will not be seen that day, but the following day, two days after submitting the
slip.

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 her
involvement in the care and treatment of detainee TAVAREZ. Detailed medical data is
documented 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 on
medication for these conditions prior to his arrival at SCHOC. He was prescribed medication in
continued treatment. A few days after arrival he began to refuse to take the diabetic medication
claiming they brought him "down."

Dr. provided TAVAREZ was diagnosed with orchitis (inflammation of a testicle) by PA


for 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 result
of 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 making
her morning round. A review of the nurses monitoring throughout the night revealed TAVAREZ
complained 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 a
sore throat, headache, and abdominal pain, and stated the pain in his testicle was better; she also

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 004
10. NARRATIVE
observed him to be negative Murphy's (indicator of significant inflammation in the abdomen, most
often 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 not
present 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, TAVAREZ
was observed to have rigors (shaking). The KUB x-ray was negative (organs were free of air and
bowel obstructions). The chest x-ray (CXR) revealed a possible issue in the lower lobe of the right
lung, but showed no pulmonary disease. Dr. examined TAVAREZ and observed him to be
feverish, 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 his
bladder overnight had produced urine. Dr. added TAVAREZ reported no chest pain or
difficulty 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 refer
TAVAREZ 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 SCHOC
transport. The transport officer arrived at the infirmary, which she remembered as being sometime
before 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 TAVAREZ
was transported to "Shatt" (LSH) by SCHOC officers and . Arrival time at LSH was
noted as 12:12 p.m.

This concludes the interview of Dr.

On October 28, 2009, SSA conducted a telephonic interview of PA . PA


stated 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 the
encounters. PA indicated the first encounter was related to TAVAREZ's diabetic
condition. TAVAREZ refused to take his diabetes medication because he did not like them. The
matter was brought to PA attention, and after a review of (diabetic) finger sticks

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 004
10. NARRATIVE
performed on TAVAREZ daily, he observed the blood glucose level to be under control and in the
normal range. PA stated he reviewed the oral medication TAVAREZ was taking and after
talking with TAVAREZ determined the diabetic condition could be controlled by diet.

PA stated the second encounter occurred when TAVAREZ presented with inflammation
of 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. Upon
researching the condition, he diagnosed the condition as "classic" orchitis (inflammation of the
testicle), and prescribed the antibiotic bactrim as treatment. PA concluded his comments
stating this was the last interaction he had with TAVAREZ.

This concludes the interview of PA

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
Exhibit List
HB 4200-01 (37), Special Agent Handbook 004
None

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

Immigration and Customs Enforcement PREPARED BY


Office of Professional Responsibility

REPORT OF INVESTIGATION 2. REPORT NUMBER


HB 4200-01 (37), Special Agent Handbook 005
3. TITLE
Tavarez, 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


Interim Detainee Death Review
Report
8. TOPIC
Detainee Death Review – Pedro TAVAREZ; Follow-up Interviews

9. SYNOPSIS
On October 19, 2009, the Joint Intake Center (JIC), Washington, D.C. received notification
regarding the death of ICE detainee Pedro Juan TAVAREZ ( who was housed at the
Suffolk County House of Corrections (SCHOC), Boston, MA. TAVAREZ, a Dominican Republic
national, 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 Detention
Oversight (ODO), initiated an OPR Detainee Death Review to investigate the facts and
circumstances surrounding the death of TAVAREZ. This report documents follow-up interviews of
SCHOC Superintendant and Health Services Administrator
.

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

- 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 Special
Agent Supervisor 01-JUL-2010 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 FOR
DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A
COPY 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 THE
DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE
MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 005
10. NARRATIVE
On October 19, 2009, the JIC, Washington, D.C. received notification regarding the death of ICE
detainee Pedro Juan TAVAREZ (DOB: 07/25/1960; TAVAREZ, a 49 year old
Dominican Republic national, died on October 19, 2009 at the Brigham & Women's Hospital in
Boston, 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 of
Corrections (SCHOC), an ICE Intergovernmental Service Agreement (IGSA), located in Boston,
MA. Docket control of TAVAREZ' immigration case was held by the ICE Detention and Removal
Operations (DRO) Boston Field Office.

Pursuant to the investigation, on November 24, 2009, Senior Special Agent (SSA) and
ODO Detention and Deportation Officer (DDO) conducted follow-up and additional
interviews of SCHOC staff and contract medical personnel. This Report of Investigation
documents the follow-up interviews of SCHOC Superintendant and Health
Services Administrator .

On November 24, 2009, SSA and DDO conducted a second interview of


Superintendant In response to questions about the sick call request process at SCHOC,
stated the majority of medical concerns that arise are unfounded. Inmates and
detainees often complain about the process or of not being treated properly, but upon review and
questioning, the complaints are unfounded. Many of the complaints are resolved by simply talking
with the complainant about their issue and explaining the process. added while there
have been sporadic instances of a sick call slip not being seen, the system works well with the
majority being responded to within one day, two days at the most, dependent on the triage
process. further stated the current system for sick call requests should ensure all sick
call slips are seen.

Superintendant stated in the event of a medical emergency within the facility, he is made
aware 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 for
further evaluation and the person is ambulatory, he would not be notified.

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

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 005
10. NARRATIVE
When asked about handling language issues with detainees, replied the facility is
actively cognizant of language issues particularly with the ICE detainees. Specific to detainee
TAVAREZ, stated his understanding, based on questioning of medical staff, is that
TAVAREZ 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 advised
they could not be immediately provided to ICE. SSA did view select surveillance video
recordings 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 and
alert to the escorting officer and is seen exiting the elevator on his own power. A second video
clip time stamped 10/16/2009 shows TAVAREZ walking on his own power escorted by an officer
after leaving the infirmary, presumably being taken to the Booking Department for transport to
LSH. 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 HSA
HSA 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 detainee
TAVAREZ. On November 20, 2009, local legal counsel for PHS advised HSA and PHS
staff to not discuss the TAVAREZ matter. was able to answer questions regarding
policy and procedures related to medical services.

Upon questioning regarding the PHS Mortality Review of the death of TAVAREZ, HSA
stated 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 be
provided to ICE.

In response to questioning regarding the relationship with LSH, HSA stated that a
contract 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 handle
inmates. continued, because of the contract with LSH, they are the first choice of
the on-call physician when off-site care is needed. If care needed is beyond the scope of LSH, the
patient will be sent to a hospital that provides the needed care. In the event of a referral to LSH,

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 005
10. NARRATIVE
transport of the patient is arranged through the SCHOC Booking Department. LSH does not have
an emergency room; therefore, in the event of a medical emergency, 9-1-1 will be called, and the
patient will most likely be transported to Boston Medical Center, Boston, MA.

When asked if medical personnel accompany patients to LSH, replied it is not


procedural 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 all
detainees 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 there
have 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 the
medical record shows one was not received. concluded her remarks stating, in
reviewing 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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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
Exhibit List
HB 4200-01 (37), Special Agent Handbook 005
None

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

Immigration and Customs Enforcement PREPARED BY


Office of Professional Responsibility

REPORT OF INVESTIGATION 2. REPORT NUMBER


HB 4200-01 (37), Special Agent Handbook 006
3. TITLE
Tavarez, 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


Interim Detainee Death Review
Report
8. TOPIC
Detainee Death Review – Pedro TAVAREZ; Detainee Interviews

9. SYNOPSIS
On October 19, 2009, the Joint Intake Center (JIC), Washington, D.C. received notification
regarding the death of ICE detainee Pedro Juan TAVAREZ ( who was housed at the
Suffolk County House of Corrections (SCHOC), Boston, MA. TAVAREZ, a Dominican Republic
national, 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 Detention
Oversight (ODO), initiated an OPR Detainee Death Review to investigate the facts and
circumstances surrounding the death of TAVAREZ. This report documents follow-up interviews of
witness interviews of SCHOC detainees.

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

- 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 Special
Agent Supervisor 01-JUL-2010 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 FOR
DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A
COPY 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 THE
DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE
MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
On October 19, 2009, the JIC, Washington, D.C. received notification regarding the death of ICE
detainee Pedro Juan TAVAREZ (DOB: 07/25/1960; TAVAREZ, a 49 year old
Dominican Republic national, died on October 19, 2009 at the Brigham & Women's Hospital in
Boston, 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 of
Corrections (SCHOC), an ICE Intergovernmental Service Agreement (IGSA), located in Boston,
MA. Docket control of TAVAREZ' immigration case was held by the ICE Detention and Removal
Operations (DRO) Boston Field Office.

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

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

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

- Detainee (A , a citizen and national of Guatemala, arrived SCHOC on


7/23/2009. Interviewed by OPR/ODO on 10/27/2009.

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


SCHOC on 9/24/2009. On 10/27/2009 at 8:44 a.m., he was out-processed from SCHOC by ICE
and transferred to Puerto Rico for expedited removal.

- Detainee ( ), a citizen and national of Guatemala, arrived SCHOC


on 8/27/2009. On 10/16/2009 at 2:14 p.m., he was out-processed from SCHOC by ICE and
removed to Guatemala.

- Detainee (A , a citizen and national of El Salvador, arrived SCHOC


on 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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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
arrived SCHOC on 9/21/2009. On 10/27/2009 at 8:41 a.m., he was out-processed from SCHOC
by ICE and subsequently transferred to Puerto Rico for expedited removal.

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

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


at 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 on


12/3/08. 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 pushups
and sit-ups regularly. Upon questioning, responded TAVAREZ always spoke Spanish, that
he was not sure how well TAVAREZ spoke English, and added another detainee would often
interpret 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 the
infirmary (on October 14, 2009). He (TAVAREZ) complained of fever and feeling "cold" and
several detainees advised him to fill out a sick call slip. related TAVAREZ asked him for an
extra blanket, which he provided. On the evening TAVAREZ was taken to the infirmary, he did not
participate in outdoor recreation. stated late in the evening, he and a couple other
detainees were in the room with TAVAREZ. He looked sick, was wrapped in a blanket, and told
them he was feeling sick. At some point, one of the detainees left and informed the housing unit
officer 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 escorted
TAVAREZ out of the unit.

Upon inquiry about the housing conditions, detainee related the housing unit was both hot
and cold. One side of the hall was very warm, and the other side was very cold. He stated
numerous detainees complained about this condition, but nothing was done. He added the day
room was always cold, whereas his room, where he and TAVAREZ slept, was very warm, and he
and some other detainees think the temperature (fluctuation) contributed to TAVAREZ' illness.
identified as a close friend of TAVAREZ.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
Note: As noted above, on October 27, 2009, at 8:44 a.m., Detainee (A ) was
out-processed from SCHOC by the ICE DRO Boston Field Office and subsequently transferred to
Puerto 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 from
the unit to the infirmary, detainee responded TAVAREZ had been sick with fever for
three 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 himself
completely with a blanket.

When asked what he meant when he said TAVAREZ was "never called," responded
every time the nurses have sick call, the names of the detainees to be seen are announced, and
he ( never heard TAVAREZ' name.

Upon questioning, detainee stated he did not see TAVAREZ actually fill out a slip, and did
not know for certain if TAVAREZ was seen by a nurse for his illness. related part of the
housing unit was cold and their room was very warm and stated, "Maybe going from the cold day
room 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 to
being 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 the
place 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 submit
a sick call slip, it was usually responded to within a day. Recently however, it was taking two to
three days for a response, and sometimes there is no response.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
Upon questioning, reported he did not actually see TAVAREZ fill out a sick call slip. He
stated when he advised TAVAREZ to submit a sick call request slip TAVAREZ told him that he
had done so several times.

In describing the events of the evening TAVAREZ was taken to the infirmary, stated
TAVAREZ 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 the
housing 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, related
shortly after his arrival at SCHOC, TAVAREZ began refusing to take medications for some
medical 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 to
feel better and exercise regularly. estimated it was about ten days after stopping the
medication 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 of
detainee The interview was conducted in both English and Spanish, with
interpretation of the Spanish by DDO

Upon questioning, stated TAVAREZ submitted a total of three sick call slips during his stay
at SCHOC. He claimed he knows this because TAVAREZ told him he had submitted two slips,
and he saw " " (fellow detainee ) write one for TAVAREZ. Detainee
speaks both Spanish and English and would often translate for Spanish-speaking detainees and
fill 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 TAVAREZ
being taken to the infirmary, but he did not know what TAVAREZ complained of in the slip. The
second slip was filed for the headache and fever one to two days prior. The third slip was
submitted 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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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
meantime, it takes the medical staff several days to respond with treatment. Describing the sick
call process, stated once a request slip is filled out, it is placed into the "Sick Call" box
located 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 nursing
staff forgets to retrieve the slips. Upon continued questioning, related medical staff is in
the 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 ate
breakfast, lunch and dinner, walking out of his room to each meal, and did not participate in
outdoor recreation, which was held between lunch and dinner.

was asked if anything had changed or developed (at SCHOC) since the death of
TAVAREZ. responded he had been interviewed by jail (SCHOC) officials and the attorney
of the Tavarez family. He added they asked the same questions, and he gave them the same
answers, "no more and no less," because he doesn't "want to say anything or add things that are
not 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 letter
because he was a good writer. The letter was written in Spanish to the sister of TAVAREZ, and
was 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 the
family 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 had
an exercise routine in his room. When he became sick, 2-3 days before he was taken to the
infirmary, 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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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
Upon questioning, related he arrived at SCHOC on October 9, 2009. He met TAVAREZ that
same 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, was
healthy, and worked out almost every day. According to they used to work out and spar
together and TAVAREZ could do 500 push-ups. As far as could tell, TAVAREZ was in good
shape 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 the
medication 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 sick
call slips with TAVAREZ, he mentioned he had filled out three sick call request slips prior for not
feeling well and the medication issue. When asked if TAVAREZ had been seen by medical staff
regarding 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 after
dinner watched television. asked him why he was not at outdoor recreation, to which
TAVAREZ 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, and
TAVAREZ returning to his room. Later that evening, went into TAVAREZ' room and
observed 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 at
this point another detainee called for the housing unit officer who came quickly. Upon seeing
TAVAREZ, the officer called a nurse, who arrived a short time later and escorted TAVAREZ out of
the 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) judge
has ordered a stay for him so he could be deposed, which was to take place the first week of
December (2009).

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

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
read in the newspaper that TAVAREZ was sick prior to arriving at SCHOC. stated (as
translated from Spanish), "This was not true because TAVAREZ was very healthy and he used to
work 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 he
understood the letter was written to say condolences to the family and explain when and how
TAVAREZ became ill. Upon confirming this statement of not having read the letter, joked (as
translated 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 several
sick 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 the
detainees in the unit. stated TAVAREZ spoke a little English and often needed a
translator when speaking with the nurses. He recalls he wrote at least 6-8 slips for TAVAREZ
throughout the time he (TAVAREZ) was at SCHOC. Upon questioning, explained he
wrote three slips during TAVAREZ' last week in the unit. The first slip was written four days prior
to TAVAREZ leaving the unit (on the evening of October 14th); the second slip was written three
days prior; and the third slip was written one day prior. He explained when he fills out a slip on
behalf of another detainee, with each successive request slip for the same problem he writes in
the 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 two
days. According to , the nurses never responded to the slips TAVAREZ submitted. When
asked how he knows the slips were not responded to, replied, his (TAVAREZ') name was
never called for sick call, adding he doesn't know if the nurses responded to the slips during a pill
call, but if they did, he did not hear that they did, nor was he used as a translator by nursing staff in
attending to TAVAREZ. stated what he remembered about TAVAREZ' request slips were
complaints of aches and sweats, and in the third slip of fever.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
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 his
room, lying in his bunk, wrapped in a blanket, shivering and sweating. recalled TAVAREZ
complained he was cold, but the room was warm. A detainee left the room and returned with the
housing unit officer. The officer returned to the unit desk, called the infirmary, and advised the
detainees 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 call
request slips during his final days at SCHOC. Detainee stated he wrote at least 6-8 slips
for TAVAREZ throughout the time he (TAVAREZ) was at SCHOC.

Upon questioning by SSA none of the detainees interviewed could confirm how many sick
call request slips TAVAREZ actually filled out. No detainee witnessed TAVAREZ filling out a
request slip. Detainee stated he witnessed detainee filling out one sick call
request slip on behalf of TAVAREZ. Two of the detainees stated in response to them advising
TAVAREZ 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 of
the detainees to be seen are announced, and he never heard TAVAREZ' name. Several of the
detainees interviewed made similar statements. Observations include:

- A review of sick call procedures at SCHOC revealed each day medical staff collects detainee
sick call request slips from the sick call box located in each housing unit. Often times a detainee
will hand a request slip to medical staff during pill call or visits by staff to a unit. Sick call slips
submitted late in the day are not retrieved by staff until the following day. Each slip collected is
triaged the day it is in received. According to medical staff all request slips are responded to
within 72 hours of receipt depending on triage placement. Sick call is initiated in each unit by
calling 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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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
No detainee could state for a certainty whether TAVAREZ was actually seen by medical staff or
not in response to a sick call request. Detainee observed TAVAREZ speaking with a nurse
on the evening of October 14, 2009 during a "pill call."

Based on interviews of SCHOC contracted medical staff and a review of TAVAREZ' medical
record, 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 a
doctor because of pain between his legs. Notations on the request slip indicate it was received
and 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-biotic
Bactrim.

- An entry in the medical record dated October 12, 2009, states TAVAREZ was diagnosed with a
condition 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 he
complained 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 day
at 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 fever
symptoms.

Detainee stated he had filled out 6-8 sick call request slips on behalf of TAVAREZ during
his stay at SCHOC. He explained with each successive request slip for the same problem, he
writes in the 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. claimed the nurses never
responded 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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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 006
10. NARRATIVE
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 between
the 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 of
TAVAREZ 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 a
request 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 two
request slips submitted.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
Exhibit List
HB 4200-01 (37), Special Agent Handbook 006
None

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

Immigration and Customs Enforcement PREPARED BY


Office of Professional Responsibility

REPORT OF INVESTIGATION 2. REPORT NUMBER


HB 4200-01 (37), Special Agent Handbook 007
3. TITLE
Tavarez, 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


Closing Detainee Death Review
Report
8. TOPIC
Detainee Death Review – Pedro TAVAREZ; Final Report

9. SYNOPSIS
On October 19, 2009, the Joint Intake Center (JIC), Washington, D.C. received notification
regarding the death of ICE detainee Pedro Juan TAVAREZ ( who was housed at the
Suffolk County House of Corrections (SCHOC), Boston, MA. TAVAREZ, a national of the
Dominican 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 Detention
Oversight (ODO), initiated an OPR Detainee Death Review to investigate the facts and
circumstances surrounding the death of TAVAREZ. This report documents the findings of the
investigation.

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

- ICE-OPR Special Agent 01-JUL-2010 Office of Dentention Oversight (ODO)


12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER
- ICE-OPR Special
Agent Supervisor 01-JUL-2010 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 FOR
DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A
COPY 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 THE
DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE
MADE WITHOUT PRIOR WRITTEN AUTHORIZATION OF THE ORIGINATOR.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
On October 19, 2009, the Joint Intake Center, Washington, D.C. received notification regarding
the death of ICE detainee Pedro Juan TAVAREZ (DOB: 07/25/1960; TAVAREZ, a
49 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 detention
awaiting immigration proceedings at the Suffolk County House of Corrections (SCHOC), an ICE
Intergovernmental 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 Detention
Oversight (ODO), Senior Special Agent (SSA) initiated an OPR Detainee Death Review
investigation to obtain the facts and examine the circumstances surrounding the death of
TAVAREZ.

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 United
States. On June 24, 1987, the Immigration & Naturalization Service (INS) determined TAVAREZ
was deportable due to his conviction on January 20, 1987 of a controlled substance violation and
issued a warrant for his arrest. On March 4, 1992, INS issued a warrant of deportation against
TAVAREZ for removal from the United States, to which TAVAREZ failed to surrender. On April
28, 1998, an immigration hearing was held with TAVAREZ in absentia, at which an Immigration
Judge (IJ) ordered him removed from the United States.

ICE records indicate TAVAREZ assumed the alias Felix BAEZ, under which he presumably eluded
police and immigration officials. It is unclear when TAVAREZ began using this alias. ICE records
do 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. A
National Crime Information Center (NCIC) query conducted pursuant to the stop disclosed an
outstanding ICE warrant for his arrest. TAVAREZ was arrested and turned over to ICE officials
and placed in ICE detention to await immigration proceedings.

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

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
-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. On
February 19, 2009, an IJ ordered TAVAREZ removed from the United States, resulting in
TAVAREZ filing an appeal to the Board of Immigration Appeals (BIA). The BIA subsequently
remanded the case to the IJ, who on September 17, 2009, ordered TAVAREZ removed from the
United States. On September 21, 2009, TAVAREZ was transferred from the Plymouth County
Correctional Facility to the SCHOC in preparation for his removal from the United States to the
Dominican 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 further
evaluation of his medical condition. At FH it was determined TAVAREZ needed to be admitted
into an Intensive Care Unit (ICU). No beds were available in the ICU at FH resulting in TAVAREZ
being transported and admitted to Brigham & Women's Hospital in Boston, MA.

SCHOC corrections staff maintained extensive documentation, related to TAVAREZ, of round the
clock guard postings, visits by facility personnel, and visits by family members, dating from
October 16, 2009, until TAVAREZ's death on October 19, 2009. Additionally, ICE DRO Boston
field office maintained daily communication with SCHOC and hospital personnel regarding
TAVAREZ's condition and on-going treatment, and made appropriate notifications to identified
family members of TAVAREZ.

CRIMINAL 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 United
States. On January 20, 1987, TAVAREZ was convicted in the state of New York of a controlled
substance violation and sentence to time served and 5 years probation. On June 24, 1987, INS
determined TAVAREZ was deportable due to his January 20, 1987 conviction and issued a
warrant for his arrest. TAVAREZ failed to surrender to immigration officials and eluded authorities

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
under the assumed name Felix BAEZ.

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

MEDICAL REVIEW

Prison Health Services (PHS), INC., a private medical contract health care services provider
specializing in correctional health care, operates the SCHOC infirmary providing comprehensive
medical services to inmates and detainees housed at SCHOC. The PHS medical staff at SCHOC
includes a full-time Health Services Administrator (HSA), a full-time Medical Director, who is also
the full-time PHS staff physician, two part-time physicians, Mid-Level Providers (MLP) to include
Physician Assistants (PA), Nurse Practitioners (NP), and a cadre of Registered Nurses (RN), and
Licensed Practical Nurses (LPN).

The SCHOC infirmary is located in Building 6 of the facility attached to the primary structure of
SCHOC. A separate health clinic, designated as an out-patient clinic, is located in Building 8. All
ICE detainees are housed in Building 8. The clinic provides routine care and treatment to ICE
detainees to include daily nursing sick call, medication administration, and physical examinations
of all ICE detainees. The Building 8 clinic is operational Sunday - Saturday, 7:00 a.m. to 11:30
p.m., staffed full time with nursing personnel, and is supervised by a clinical coordinator.

MGT of America, a national management and consultant firm, contracted by ICE to provide
subject matter expertise in detention management, reviewed the medical records of TAVAREZ,
which were provided by SCHOC medical contract personnel. MGT produced a report
documenting the results of the medical review (Exhibit 01). The report provides a timeline
summarizing all encounters and actions taken by medical personnel at the SCHOC as
documented in the detainee's medical record. Observations related to specific events follow the
timeline, as do general observations on the contents of the medical record.

The MGT review resulted in 27 observations, which are described as areas of non-compliance
with the ICE NDS and applicable Division of Immigration Health Services (DIHS) or facility policy.
Additionally, the observations chart inconsistencies or omissions within the medical record.

On or about June 22, 2010, Clinical Consultant , MD, a contract physician with the

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
Bureau of Prisons (BOP), conducted a mortality review of the medical records of Detainee
TAVAREZ while in ICE custody. On June 28, 2010, ODO received a copy of the mortality review
report from the DIHS/ERO and Health Services Director with the ICE Office of Detention Policy
and Planning.

Dr. report is a narrative of the medical record with comments, and identified two areas
for improvement (Exhibit 02). Dr. cited the delay in early recognition of and treatment for
TAVAREZ' "septic condition" resulted in multisystem failure and myocardial infarction, adding that
the symptoms displayed by TAVAREZ should have prompted a review of antibiotic therapy and
blood tests. Additionally, DR. noted October 14, 2009 vital signs indicated the onset of a
septic condition and TAVAREZ would have benefited from a transfer to a hospital at that time for
further evaluation and inpatient management, which would be especially critical with a diabetic
patient who had been refusing diabetic medications as in the case of TAVAREZ.

Dr. identified two areas for improvement: 1. Medication reconciliation was ineffective
during TAVAREZ' transfer among the various detention facilities. Medications on transfer sheets
were often incomplete. 2. Information Management: Verbal orders were frequently not cosigned
by the provider. Progress notes were not written by the physician assistant (PA on two
occasions to document the reason for verbal orders given or treatment.

On October 20, 2009, The Commonwealth of Massachusetts, Office of the Chief Medical
Examiner, conducted an autopsy on TAVAREZ. The autopsy report is signed by ,
M.D. and was published on November 20, 2009. The autopsy report indicates TAVAREZ's
immediate cause of death as "cardiac arrest due to myocardial infarct, acute, due to small
intramyocardial coronary artery disease." The manner of death is identified as "natural" (Exhibit
03). The death certificate was issued on January 11, 2010 (Exhibit 04).

INTERVIEWS

On October 27, 2009, Dr. provided the following information during her interview with ODO
staff:

Dr. first encountered TAVAREZ on the morning of October 15, 2007. After reviewing his
medical history and the nursing notations from the previous night, she conducted an examination
with no objective findings to indicate a clear diagnosis other than "fever of unknown origin." Due
to time constraints on October 15, 2009, Dr. was unable to enter a contemporaneous
progress note of her examination of TAVAREZ on that day. Therefore, Dr. entered the

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
examination as a late entry on the morning of October 16, 2009, shortly after her follow-up
examination of TAVAREZ that morning.

Dr. ordered and reviewed chest x-ray and KUB [kidney, ureter, and bladder] x-rays. The
chest x-ray revealed a possible issue in the lower lobe of the right lung and showed no pulmonary
disease. Dr. review of the KUB x-ray revealed no anomalies. Dr. recalled the
radiology technician reported TAVAREZ having rigors [shaking, often occurring during high fever]
during the x-ray process.

During Dr. October 16th follow-up examination of TAVAREZ, TAVAREZ was observed to
be feverish, sweating profusely, and to have rigors. TAVAREZ reported continued pain in the
abdomen, his sore throat was better, and no chest pain or difficulty with breathing. Based on Dr.
assessment she could not make a clear diagnosis of his condition and determined further
evaluation and treatment beyond the scope of the SCHOC medical unit was needed and decided
to refer TAVAREZ to LSH. Further evaluation was explained as "blood cultures" (blood draw and
laboratory analysis), intravenous (IV) hydration and IV antibiotics.

TAVAREZ was ambulatory (could walk on his own power), had "good strength," and although he
presented with symptoms indicating he was sick, "he was not so sick he required EMS
(Emergency Medical Services)." Dr. had the option of sending TAVAREZ to LSH via EMS
or an SCHOC transport vehicle. Based on his apparent strength Dr. opted to send
TAVAREZ to LSH via SCHOC transport. Dr. remembered the transport officer arrived at
the infirmary shortly before noon and escorted TAVAREZ (Exhibit 05). TAVAREZ left walking on
his own power.

On October 27, 2009, SCHOC PHS Health Services Administrator (HSA)


RN provided the following information during her interview with ODO staff:

Based on information obtained from the medical record and notes taken by HSA in
communication with the hospitals involved, she gave an overview of events related to the medical
care and treatment of TAVAREZ at SCHOC.

LSH is a critical care hospital with no emergency room or services. LSH has a correctional
housing ward enablin to provide care and treatment for correctional facilities. The SCHOC
Medical Director, Dr. , is aware of the services provided by LSH and makes a medical
determination as to whether LSH can handle a medical referral.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
"On October 16, 2009, Dr. determined TAVAREZ required further evaluation beyond the
scope of SCHOC medical services and decided to refer TAVAREZ to LSH." TAVAREZ was
transported by SCHOC transport services as it was determined (by Dr. he had no
immediate life-threatening condition requiring emergency services or transport.

HSA review of the LSH medical records revealed when TAVAREZ arrived at LSH,
intra-venous (IV) fluid was administered for dehydration and TAVAREZ began to complain of chest
pain. LSH lab results indicated TAVAREZ had experienced a heart attack. Since LSH does not
provide emergency services, TAVAREZ was transported via an ambulance to Faulkner Hospital
(FH) located in Boston, MA. When EMS transport arrived at FH, medical personnel determined
TAVAREZ needed intensive care. A bed was not available in the Intensive Care Unit (ICU) at FH;
therefore, TAVAREZ was subsequently transported, via ambulance, to Brigham and Women's
Hospital (B&WH) located in Boston, MA. Upon arrival TAVAREZ was in need of life support
measures and was placed on an assisted breathing apparatus.

On October 17, 2009, B&WH called for last rites (immediate notification of family members of
pending death). On October 18, 2009, an infectious disease team was "called in" by B&WH and
was scheduled to arrive within the following days. The purpose of the team was to evaluate the
detainee's condition and determine the source/cause of his medical condition. On October 19,
2009, at approximately 9:30 a.m., TAVAREZ was pronounced dead by B&WH medical personnel.

On October 27, 2009, LPN provided the following information during her interview
with ODO staff:

Due to the high number of detainees seen on a daily basis, LPN did not remember all
encounters with detainee TAVAREZ. She did recall he was diabetic and when he first arrived at
SCHOC was taking oral diabetic medication, but after a few days refused to take it stating it made
him "feel down". LPN recalled TAVAREZ had an issue of pain between his legs and was
placed on Bactrim for an infection. TAVAREZ was compliant with taking this medication and did
not refuse taking it. LPN could not recall whether the treatment regimen for the Bactrim
was administered to him everyday, nor did she specifically remember when the regimen began.

Sick call request slips are available in each of the housing units and each detainee is informed of
the sick call process upon arrival. Once a slip is filled out it is to be placed into the sick call box
located in each housing unit. Sick call slips are removed by a staff nurse daily, triaged the same
day, and placed in the medical record. Due to the triage process, a detainee may be seen one to
two days after submitting a sick call slip.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

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2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
In reference to TAVAREZ being sick during the days prior to October 14, 2009, LPN
recalled TAVAREZ had issues with taking the medications prescribed for his diabetes and
complained one time of pain in his legs, but she was not aware of TAVAREZ being sick in the
days prior to his admission into the infirmary on the night of October 14, 2009.

On October 28, 2009, PA provided the following information during his interview with
ODO staff:

PA recalled TAVAREZ refused to take his diabetes medication because he did not like
them. The matter was brought to his ( attention, and after a review of (diabetic) finger
sticks performed on TAVAREZ daily, he observed the blood glucose level to be under control and
in the normal range. PA stated he reviewed the oral medication TAVAREZ was taking
and after talking with TAVAREZ, determined the diabetic condition could be controlled by diet. PA
stated he discontinued the administration of diabetic medication for TAVAREZ, but
ordered continued monitoring of his blood glucose levels via (diabetic) finger sticks.

PA was unable to recall the exact date he saw TAVAREZ for inflammation of the testicle.
PA encountered TAVAREZ after reviewing nursing notation indicating TAVAREZ had an
un-descended testicle. Upon PA examination of TAVAREZ, he noted inflammation and
tenderness of the testicle. PA researched the condition and determined it to be "classic"
orchitis [inflammation of the testicle], and prescribed the antibiotic Bactrim as treatment. PA
could not remember the specifics date he examined TAVAREZ, but was certain he
recorded the activity in the medical record.

On November 24, 2009, HSA provided the following information during her follow-up
interview with ODO staff:

HSA advised that 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 TAVAREZ. On November
20, 2009, local legal counsel for PHS advised HSA and PHS staff they were not to
discuss the "TAVAREZ matter" with any outside entities. HSA was however, allowed to
answer questions regarding policy and procedures related to medical services.

HSA and Dr. completed a Mortality Review with a final analysis, resulting in a
plan of action of "None." However, due to legal counsel advisement, a copy could not be provided
to ICE. A contract exists between SCHOC and LSH allowing SCHOC to refer inmates and
detainees requiring medical care "beyond the scope of PHS," to LSH. HSA noted LSH

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
has a correctional unit set up to handle inmates.

Because of the contract with LSH, LSH is the first choice of the on-call physician when off-site
care is needed. If the care needed is beyond the scope of LSH, the patient will be sent to a
hospital that provides the needed care. In the event of a referral to LSH, transport of the patient is
arranged through the SCHOC Booking Department. LSH does not have an emergency room;
therefore, in the event of a medical emergency, 9-1-1 will be called, and the patient will most likely
be transported to Boston Medical Center, Boston, MA.

It is not procedural to send medical staff with SCHOC transport officers when transporting patients
to LSH.

All detainees are informed at the intake in-briefing and via the detainee handbook of the sick call
slip process. HSA acknowledges detainees complain about the response time to sick
call slips and claim sick call slips have not been responded to. HSA noted there have
been instances in which the detainee has claimed a sick call slip was submitted, but the medical
record shows one was not received. Upon HSA review of the general sick call slip
process, she found nursing staff followed procedures, and appropriately triaged and responded to
the request.

During an interview with SCHOC Superintendant ESQ, SSA was advised by


Superintendant that surveillance video recordings of TAVAREZ, obtained from the
SCHOC surveillance video recording system, were preserved, but SCHOC legal counsel advised
Superintendant that surveillance video of TAVAREZ could not be immediately provided to
ICE. SSA was allowed to view select surveillance video recordings of TAVAREZ, which were
recorded on October 14, 2009 and October 16, 2009. The following are SSA observations
of the video:

The October 14, 2009 recording showed TAVAREZ in an elevator under escort to the SCHOC
infirmary. TAVAREZ stood on his own power, appears responsive and alert to the escorting
officer, and was seen exiting the elevator on his own power. A second video clip time stamped "
10/16/2009," showed TAVAREZ escorted by an officer in a hallway, walking on his own power.
TAVAREZ was en route from the infirmary to the Booking Department for transport to LSH. In
each of the recordings, TAVAREZ was moving about on his own power with his head erected and
appeared responsive to the escorting officer.

On October 27, 2009, SCHOC Corrections Officer (CO) , a housing unit officer

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

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2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
assigned to Unit A4, provided the following information during her interview with ODO staff:

CO stated she works the 7:00 a.m. to 3:00 pm shift, and saw detainee TAVAREZ
everyday that she worked since his arrival in the unit. She was not aware of any medical
complaints from him and was surprised at his sudden passing. CO confirmed the building
had experienced heating issues earlier in the month with the change of the weather, which had
been resolved.

Detainees and were roommates of TAVAREZ at SCHOC and


Detainee was a close friend of TAVAREZ. Additionally, Detainees and
were identified as having interacted with TAVAREZ. The following information was
obtained from these detainees during their interview with ODO staff in October and November
2009:

With regards to the overall health of TAVAREZ, the detainees stated TAVAREZ worked out
everyday, was in good shape and appeared to be healthy. TAVAREZ began to complain of
feeling ill one to two days prior to the day he was taken to the infirmary (October 14, 2009).
Detainees , and recalled TAVAREZ had submitted two to three sick call
request slips regarding his not feeling well, but was never called by the nurses during daily sick
call.

Detainee often filled out sick call request slips on behalf of detainees who do not speak
and/or write English well. He explained when completing a sick call slip on behalf of another
detainee, he writes in the upper corner if it is the second or third request. Detainee stated
although TAVAREZ could speak and write in English, he (TAVAREZ) asked Detainee to
write several of the requests on his behalf. Detainee claimed he filled out six to eight sick
call request slips on behalf of TAVAREZ over a two to three week period. Detainee
further stated, to his knowledge, TAVAREZ was not called by the nurses during daily sick call in
response to any of the submitted requests.

Detainee stated 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
meantime, it takes the medical staff several days to respond with treatment. Detainee
stated once a request slip is filled out, it is placed into the "Sick Call" box located in the unit, which
is clearly marked and separate from the "Grievances" and "Mail" boxes. Detainee stated
the slips are picked up everyday by nursing staff, but sometimes the nursing staff forgets to
retrieve the slips. also stated medical staff is in the housing unit three times each day for "

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

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2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
pill call." Often, detainees will give a sick call request slip directly to the "pill call" nurse.

Each of the detainees interviewed stated on the evening TAVAREZ was taken to the main
infirmary (October 14, 2009), TAVAREZ did not participate in outdoor recreation, complained of
headache, feeling cold and was wrapped in a blanket in his bunk. The detainees further reported
TAVAREZ was hot to the touch and was visibly sweating. Detainee stated during the
evening pill call he observed TAVAREZ speaking with the nurse, followed by the nurse taking
TAVAREZ's temperature and TAVAREZ returning to his room.

The detainees stated at approximately 10:30 pm, TAVAREZ appeared to be getting worse. A
detainee informed the housing unit officer of TAVAREZ's declining condition. The officer went to
TAVAREZ's room, and returned to the desk and called the main infirmary. A few minutes later a
nurse arrived and escorted TAVAREZ out of the housing unit. Each of the detainees reported
seeing TAVAREZ walk out of the unit on his own power.

Detainee stated shortly after TAVAREZ's arrival at SCHOC, he began refusing to take
medications stating it was making him feel "down," and claiming it was the "wrong type" because it
was making him "sick." Detainee stated a few days after refusing to take the medication,
TAVAREZ began to feel better and started exercising again.

Detainee stated the day TAVAREZ began feeling sick, he complained about the medications
he was taking, blaming them for making him feel "weak and worse." Detainee further stated
the medication made TAVAREZ feel "down," and described the "down" as more a "mental down",
than a "physical down."

Several of the detainees reported the day room and one side of the housing area were always
cold and the side where TAVAREZ's room was located was always very warm. The detainees
opined going from cold to warm may have contributed to TAVAREZ's illness. The detainees
stated the heating issue had since been resolved.

None of the detainees could confirm how many sick call request slips TAVAREZ actually filled out.
Additionally, no detainee witnessed TAVAREZ filling out a request slip. Detainee stated
he witnessed detainee filling out one sick call request slip on behalf of TAVAREZ. Two of
the detainees stated they advised TAVAREZ to submit a request slip, and TAVAREZ told them he
had done so.

None of the detainees could state, with certainty, whether TAVAREZ was actually seen by medical

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CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
staff or not in response to a sick call request. Detainee stated he observed TAVAREZ
speaking with a nurse on the evening of October 14, 2009, during a "pill call," and the nurse took
TAVAREZ's temperature, after which, TAVAREZ returned to his room.

FINDINGS:

On October 20, 2009, , M.D., of the Commonwealth of Massachusetts, Office of the


Chief Medical Examiner, conducted an autopsy on TAVAREZ. The autopsy report indicates
TAVAREZ's immediate cause of death as "cardiac arrest due to myocardial infarct, acute, due to
small intramyocardial coronary artery disease." The manner of death is identified as "natural."

On January 12, 2010, MGT of America, a national management and consultant firm contracted by
ICE to provide subject matter expertise in detention management, submitted a report based on a
review of the entire ICE detention medical record of TAVAREZ. The report documents a timeline
summarizing all encounters and actions taken by SCHOC contract PHS medical staff, and
concludes with 27 observations, 18 of which directly related to the care and treatment of
TAVAREZ while housed at SCHOC.

The lack of proper documentation included PHS medical staff documentation related to the
administration and discontinuation of diabetic finger sticks. The record indicates on September
30, 2009, diabetic fingers sticks of TAVAREZ were ordered to be discontinued. This order is not
signed. The medical record reflects TAVAREZ refused taking diabetic medications beginning
October 1, 2009, and diabetic finger sticks were ordered to be performed. This order is not
signed.

According to the medical record, on October 1, 2009, TAVAREZ began refusing to take diabetic
medications citing they "make him feel down. The refusal was properly documented and
addressed. PA acknowledged the refusal and ordered the continuation of diabetic finger
sticks to monitor TAVAREZ blood glucose levels. According to the Medicine Administration
Record, diabetic medication was last administered to TAVAREZ on October 6, 2009. On October
7, 2009, an order was placed and signed by the PA for the discontinuation of diabetic finger sticks
and medication for TAVAREZ. In his interview, PA stated TAVAREZ was able to control
his diabetes through diet. PHS appropriately documented the diabetic care and treatment of
TAVAREZ.

MGT identified a lack of contemporaneous documentation and clarity related to the examination of
TAVAREZ on October 9, 2009, for "pain between (his) legs." On October 12, 2009, a progress

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
note is entered introducing a "Continued historical note from 10/9." A review of the medical record
revealed no notes were recorded or dictated in the medical record on October 9th. A note entered
by nursing staff on October 8th, indicates the detainee was directed to be seen by the (medical)
provider-of-the-day on October 9th. The only medical documentation reflecting any treatment or
care of TAVAREZ on October 9th is a notation on the MAR indicating TAVAREZ was administered
(the antibiotic) Bactrim. Additionally, a review of all medications ordered for TAVAREZ during his
stay at SCHOC revealed no orders for the antibiotic Bactrim DS.

On October 14, 2009, following TAVAREZ's admittance to the infirmary, the on-call physician
ordered vital signs to be taken every four hours. According to the medical record, vital signs were
not consistently taken every four hours throughout TAVAREZ's stay in the infirmary, which ended
October 16, 2009, at approximately 12:00 pm.

See Exhibit 01 for additional observations resulting from the medical record review by MGT.

Clinical Consultant MD, a contract physician with the Bureau of Prisons (BOP),
concurred with the cause of death findings of the coroner's report and B&WH medical staff. Dr.
cited the delay in early recognition of and treatment for TAVAREZ' "septic condition"
resulted in multisystem failure and myocardial infarction, adding that the symptoms displayed by
TAVAREZ should have prompted a review of antibiotic therapy and blood tests. Additionally, DR.
noted October 14, 2009 vital signs indicated the onset of a septic condition and
TAVAREZ would have benefited from a transfer to a hospital at that time for further evaluation and
inpatient management, which would be especially critical with a diabetic patient who had been
refusing diabetic medications as in the case of TAVAREZ.

Dr. identified two areas for improvement: 1. Medication reconciliation was ineffective
during TAVAREZ' transfer among the various detention facilities. Medications on transfer sheets
were often incomplete. 2. Information Management: Verbal orders were frequently not cosigned
by the provider. Progress notes were not written by the physician assistant (PA on two
occasions to document the reason for verbal orders given or treatment.

See Exhibit 02 for additional comments by Dr. resulting from her review of the medical
record.

ODO interviewed SCHOC medical staff, reviewed TAVAREZ's medical record and examined all
sick call request slips submitted by TAVAREZ. TAVAREZ submitted a total of two sick call
request slips during his stay at SCHOC. An examination of each of the sick call request slips

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

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CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
revealed one was completed by someone on behalf of TAVAREZ, and the second was completed
by TAVAREZ. A comparison of the handwriting in each of the sick call request slips revealed the
October 6, 2009 slip was completed by someone on behalf of TAVAREZ, although the signature
appears to be that of TAVAREZ.

The sick call request slip dated October 14, 2009 appears to have been completed by TAVAREZ
and signed by TAVAREZ. According to the medical record and interviews of medical staff,
TAVAREZ was seen by medical staff in response to each of the two sick call request slips
submitted.

ODO confirmed the availability of sick call slips and the presence of a sick call slip box in each of
the housing units. Each box is clearly labeled. A review of sick call procedures revealed each day
medical staff collects detainee sick call request slips from the sick call box located in each housing
unit. PHS medical staff confirmed often a detainee will hand a sick call request slip directly to
medical staff during pill call or visits by staff to a unit. Sick call slips submitted after the daily
pick-up, are not retrieved by staff until the following day. Each slip collected is triaged the day it is
in received. According to medical staff all request slips are responded to within 72 hours of receipt
by medical staff.

SCHOC appropriately documented the housing of TAVAREZ at SCHOC and his transport to LSH.
Additionally, SCHOC maintained detailed records of round-the-clock guard postings and visitors
while TAVAREZ was under hospital care at B&WH.

ICE ERO Boston Field office appropriately conducted and documented staff-detainee
communications and related activity for TAVAREZ. Additionally, appropriate and timely
notifications were made to ICE management and family members of TAVAREZ regarding
TAVAREZ's hospitalization and death.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

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Exhibit List
HB 4200-01 (37), Special Agent Handbook 007
Exhibit 01: MGT Review of the Medical Record of TAVAREZ
Exhibit 02: Dr. Mortality Review
Exhibit 03: TAVAREZ Autopsy Report
Exhibit 04: TAVAREZ Death Certificate
Exhibit 05: SCHOC Vehicle Log re: 10/16/2009 Transport of TAVAREZ to LSH

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

Immigration and Customs Enforcement PREPARED BY


Office of Professional Responsibility

REPORT OF INVESTIGATION 2. REPORT NUMBER


HB 4200-01 (37), Special Agent Handbook 007
3. TITLE
Tavarez, 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


Closing Detainee Death Review
Report
8. TOPIC
Detainee Death Review – Pedro TAVAREZ; Final Report

9. SYNOPSIS
On October 19, 2009, the Joint Intake Center (JIC), Washington, D.C. received notification
regarding the death of ICE detainee Pedro Juan TAVAREZ ( who was housed at the
Suffolk County House of Corrections (SCHOC), Boston, MA. TAVAREZ, a national of the
Dominican 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 Detention
Oversight (ODO), initiated an OPR Detainee Death Review to investigate the facts and
circumstances surrounding the death of TAVAREZ. This report documents the findings of the
investigation.

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

- ICE-OPR Special Agent 01-JUL-2010 Office of Dentention Oversight (ODO)


12. APPROVED BY(Print Name & Title) 13. APPROVED DATE 15. TELEPHONE NUMBER
- ICE-OPR Special
Agent Supervisor 01-JUL-2010 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 FOR
DISCLOSURE OF THIS DOCUMENT OR INFORMATION CONTAINED HEREIN SHOULD BE REFERRED TO HEADQUARTERS, DEPARTMENT OF HOMELAND SECURITY, TOGETHER WITH A
COPY 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 THE
DEPARTMENT OF HOMELAND SECURITY. DISTRIBUTION OF THIS DOCUMENT HAS BEEN LIMITED AND FURTHER DISSEMINATION OR EXTRACTS FROM THE DOCUMENT MAY NOT BE
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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

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2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
On October 19, 2009, the Joint Intake Center, Washington, D.C. received notification regarding
the death of ICE detainee Pedro Juan TAVAREZ (DOB: 07/25/1960; TAVAREZ, a
49 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 detention
awaiting immigration proceedings at the Suffolk County House of Corrections (SCHOC), an ICE
Intergovernmental 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 Detention
Oversight (ODO), Senior Special Agent (SSA) initiated an OPR Detainee Death Review
investigation to obtain the facts and examine the circumstances surrounding the death of
TAVAREZ.

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 United
States. On June 24, 1987, the Immigration & Naturalization Service (INS) determined TAVAREZ
was deportable due to his conviction on January 20, 1987 of a controlled substance violation and
issued a warrant for his arrest. On March 4, 1992, INS issued a warrant of deportation against
TAVAREZ for removal from the United States, to which TAVAREZ failed to surrender. On April
28, 1998, an immigration hearing was held with TAVAREZ in absentia, at which an Immigration
Judge (IJ) ordered him removed from the United States.

ICE records indicate TAVAREZ assumed the alias Felix BAEZ, under which he presumably eluded
police and immigration officials. It is unclear when TAVAREZ began using this alias. ICE records
do 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. A
National Crime Information Center (NCIC) query conducted pursuant to the stop disclosed an
outstanding ICE warrant for his arrest. TAVAREZ was arrested and turned over to ICE officials
and placed in ICE detention to await immigration proceedings.

From April 8, 2008 to September 21, 2009, TAVAREZ was transferred among six detention
facilities 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. On
February 19, 2009, an IJ ordered TAVAREZ removed from the United States, resulting in
TAVAREZ filing an appeal to the Board of Immigration Appeals (BIA). The BIA subsequently
remanded the case to the IJ, who on September 17, 2009, ordered TAVAREZ removed from the
United States. On September 21, 2009, TAVAREZ was transferred from the Plymouth County
Correctional Facility to the SCHOC in preparation for his removal from the United States to the
Dominican 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 further
evaluation of his medical condition. At FH it was determined TAVAREZ needed to be admitted
into an Intensive Care Unit (ICU). No beds were available in the ICU at FH resulting in TAVAREZ
being transported and admitted to Brigham & Women's Hospital in Boston, MA.

SCHOC corrections staff maintained extensive documentation, related to TAVAREZ, of round the
clock guard postings, visits by facility personnel, and visits by family members, dating from
October 16, 2009, until TAVAREZ's death on October 19, 2009. Additionally, ICE DRO Boston
field office maintained daily communication with SCHOC and hospital personnel regarding
TAVAREZ's condition and on-going treatment, and made appropriate notifications to identified
family members of TAVAREZ.

CRIMINAL 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 United
States. On January 20, 1987, TAVAREZ was convicted in the state of New York of a controlled
substance violation and sentence to time served and 5 years probation. On June 24, 1987, INS
determined TAVAREZ was deportable due to his January 20, 1987 conviction and issued a
warrant for his arrest. TAVAREZ failed to surrender to immigration officials and eluded authorities

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under the assumed name Felix BAEZ.

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

MEDICAL REVIEW

Prison Health Services (PHS), INC., a private medical contract health care services provider
specializing in correctional health care, operates the SCHOC infirmary providing comprehensive
medical services to inmates and detainees housed at SCHOC. The PHS medical staff at SCHOC
includes a full-time Health Services Administrator (HSA), a full-time Medical Director, who is also
the full-time PHS staff physician, two part-time physicians, Mid-Level Providers (MLP) to include
Physician Assistants (PA), Nurse Practitioners (NP), and a cadre of Registered Nurses (RN), and
Licensed Practical Nurses (LPN).

The SCHOC infirmary is located in Building 6 of the facility attached to the primary structure of
SCHOC. A separate health clinic, designated as an out-patient clinic, is located in Building 8. All
ICE detainees are housed in Building 8. The clinic provides routine care and treatment to ICE
detainees to include daily nursing sick call, medication administration, and physical examinations
of all ICE detainees. The Building 8 clinic is operational Sunday - Saturday, 7:00 a.m. to 11:30
p.m., staffed full time with nursing personnel, and is supervised by a clinical coordinator.

MGT of America, a national management and consultant firm, contracted by ICE to provide
subject matter expertise in detention management, reviewed the medical records of TAVAREZ,
which were provided by SCHOC medical contract personnel. MGT produced a report
documenting the results of the medical review (Exhibit 01). The report provides a timeline
summarizing all encounters and actions taken by medical personnel at the SCHOC as
documented in the detainee's medical record. Observations related to specific events follow the
timeline, as do general observations on the contents of the medical record.

The MGT review resulted in 27 observations, which are described as areas of non-compliance
with the ICE NDS and applicable Division of Immigration Health Services (DIHS) or facility policy.
Additionally, the observations chart inconsistencies or omissions within the medical record.

On or about June 22, 2010, Clinical Consultant MD, a contract physician with the

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Bureau of Prisons (BOP), conducted a mortality review of the medical records of Detainee
TAVAREZ while in ICE custody. On June 28, 2010, ODO received a copy of the mortality review
report from the DIHS/ERO and Health Services Director with the ICE Office of Detention Policy
and Planning.

Dr. report is a narrative of the medical record with comments, and identified two areas
for improvement (Exhibit 02). Dr. cited the delay in early recognition of and treatment for
TAVAREZ' "septic condition" resulted in multisystem failure and myocardial infarction, adding that
the symptoms displayed by TAVAREZ should have prompted a review of antibiotic therapy and
blood tests. Additionally, DR. noted October 14, 2009 vital signs indicated the onset of a
septic condition and TAVAREZ would have benefited from a transfer to a hospital at that time for
further evaluation and inpatient management, which would be especially critical with a diabetic
patient who had been refusing diabetic medications as in the case of TAVAREZ.

Dr. identified two areas for improvement: 1. Medication reconciliation was ineffective
during TAVAREZ' transfer among the various detention facilities. Medications on transfer sheets
were often incomplete. 2. Information Management: Verbal orders were frequently not cosigned
by the provider. Progress notes were not written by the physician assistant (PA on two
occasions to document the reason for verbal orders given or treatment.

On October 20, 2009, The Commonwealth of Massachusetts, Office of the Chief Medical
Examiner, conducted an autopsy on TAVAREZ. The autopsy report is signed by ,
M.D. and was published on November 20, 2009. The autopsy report indicates TAVAREZ's
immediate cause of death as "cardiac arrest due to myocardial infarct, acute, due to small
intramyocardial coronary artery disease." The manner of death is identified as "natural" (Exhibit
03). The death certificate was issued on January 11, 2010 (Exhibit 04).

INTERVIEWS

On October 27, 2009, Dr. provided the following information during her interview with ODO
staff:

Dr. first encountered TAVAREZ on the morning of October 15, 2007. After reviewing his
medical history and the nursing notations from the previous night, she conducted an examination
with no objective findings to indicate a clear diagnosis other than "fever of unknown origin." Due
to time constraints on October 15, 2009, Dr. was unable to enter a contemporaneous
progress note of her examination of TAVAREZ on that day. Therefore, Dr. entered the

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examination as a late entry on the morning of October 16, 2009, shortly after her follow-up
examination of TAVAREZ that morning.

Dr. ordered and reviewed chest x-ray and KUB [kidney, ureter, and bladder] x-rays. The
chest x-ray revealed a possible issue in the lower lobe of the right lung and showed no pulmonary
disease. Dr. review of the KUB x-ray revealed no anomalies. Dr. recalled the
radiology technician reported TAVAREZ having rigors [shaking, often occurring during high fever]
during the x-ray process.

During Dr. October 16th follow-up examination of TAVAREZ, TAVAREZ was observed to
be feverish, sweating profusely, and to have rigors. TAVAREZ reported continued pain in the
abdomen, his sore throat was better, and no chest pain or difficulty with breathing. Based on Dr.
assessment she could not make a clear diagnosis of his condition and determined further
evaluation and treatment beyond the scope of the SCHOC medical unit was needed and decided
to refer TAVAREZ to LSH. Further evaluation was explained as "blood cultures" (blood draw and
laboratory analysis), intravenous (IV) hydration and IV antibiotics.

TAVAREZ was ambulatory (could walk on his own power), had "good strength," and although he
presented with symptoms indicating he was sick, "he was not so sick he required EMS
(Emergency Medical Services)." Dr. had the option of sending TAVAREZ to LSH via EMS
or an SCHOC transport vehicle. Based on his apparent strength Dr. opted to send
TAVAREZ to LSH via SCHOC transport. Dr. remembered the transport officer arrived at
the infirmary shortly before noon and escorted TAVAREZ (Exhibit 05). TAVAREZ left walking on
his own power.

On October 27, 2009, SCHOC PHS Health Services Administrator (HSA)


RN provided the following information during her interview with ODO staff:

Based on information obtained from the medical record and notes taken by HSA in
communication with the hospitals involved, she gave an overview of events related to the medical
care and treatment of TAVAREZ at SCHOC.

LSH is a critical care hospital with no emergency room or services. LSH has a correctional
housing ward enabling them to provide care and treatment for correctional facilities. The SCHOC
Medical Director, Dr. , is aware of the services provided by LSH and makes a medical
determination as to whether LSH can handle a medical referral.

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"On October 16, 2009, Dr. determined TAVAREZ required further evaluation beyond the
scope of SCHOC medical services and decided to refer TAVAREZ to LSH." TAVAREZ was
transported by SCHOC transport services as it was determined (by Dr. he had no
immediate life-threatening condition requiring emergency services or transport.

HSA review of the LSH medical records revealed when TAVAREZ arrived at LSH,
intra-venous (IV) fluid was administered for dehydration and TAVAREZ began to complain of chest
pain. LSH lab results indicated TAVAREZ had experienced a heart attack. Since LSH does not
provide emergency services, TAVAREZ was transported via an ambulance to Faulkner Hospital
(FH) located in Boston, MA. When EMS transport arrived at FH, medical personnel determined
TAVAREZ needed intensive care. A bed was not available in the Intensive Care Unit (ICU) at FH;
therefore, TAVAREZ was subsequently transported, via ambulance, to Brigham and Women's
Hospital (B&WH) located in Boston, MA. Upon arrival TAVAREZ was in need of life support
measures and was placed on an assisted breathing apparatus.

On October 17, 2009, B&WH called for last rites (immediate notification of family members of
pending death). On October 18, 2009, an infectious disease team was "called in" by B&WH and
was scheduled to arrive within the following days. The purpose of the team was to evaluate the
detainee's condition and determine the source/cause of his medical condition. On October 19,
2009, at approximately 9:30 a.m., TAVAREZ was pronounced dead by B&WH medical personnel.

On October 27, 2009, LPN provided the following information during her interview
with ODO staff:

Due to the high number of detainees seen on a daily basis, LPN did not remember all
encounters with detainee TAVAREZ. She did recall he was diabetic and when he first arrived at
SCHOC was taking oral diabetic medication, but after a few days refused to take it stating it made
him "feel down". LPN recalled TAVAREZ had an issue of pain between his legs and was
placed on Bactrim for an infection. TAVAREZ was compliant with taking this medication and did
not refuse taking it. LPN could not recall whether the treatment regimen for the Bactrim
was administered to him everyday, nor did she specifically remember when the regimen began.

Sick call request slips are available in each of the housing units and each detainee is informed of
the sick call process upon arrival. Once a slip is filled out it is to be placed into the sick call box
located in each housing unit. Sick call slips are removed by a staff nurse daily, triaged the same
day, and placed in the medical record. Due to the triage process, a detainee may be seen one to
two days after submitting a sick call slip.

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In reference to TAVAREZ being sick during the days prior to October 14, 2009, LPN
recalled TAVAREZ had issues with taking the medications prescribed for his diabetes and
complained one time of pain in his legs, but she was not aware of TAVAREZ being sick in the
days prior to his admission into the infirmary on the night of October 14, 2009.

On October 28, 2009, PA provided the following information during his interview with
ODO staff:

PA recalled TAVAREZ refused to take his diabetes medication because he did not like
them. The matter was brought to his ( attention, and after a review of (diabetic) finger
sticks performed on TAVAREZ daily, he observed the blood glucose level to be under control and
in the normal range. PA stated he reviewed the oral medication TAVAREZ was taking
and after talking with TAVAREZ, determined the diabetic condition could be controlled by diet. PA
stated he discontinued the administration of diabetic medication for TAVAREZ, but
ordered continued monitoring of his blood glucose levels via (diabetic) finger sticks.

PA was unable to recall the exact date he saw TAVAREZ for inflammation of the testicle.
PA encountered TAVAREZ after reviewing nursing notation indicating TAVAREZ had an
un-descended testicle. Upon PA examination of TAVAREZ, he noted inflammation and
tenderness of the testicle. PA researched the condition and determined it to be "classic"
orchitis [inflammation of the testicle], and prescribed the antibiotic Bactrim as treatment. PA
could not remember the specifics date he examined TAVAREZ, but was certain he
recorded the activity in the medical record.

On November 24, 2009, HSA provided the following information during her follow-up
interview with ODO staff:

HSA advised that 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 TAVAREZ. On November
20, 2009, local legal counsel for PHS advised HSA and PHS staff they were not to
discuss the "TAVAREZ matter" with any outside entities. HSA was however, allowed to
answer questions regarding policy and procedures related to medical services.

HSA and Dr. completed a Mortality Review with a final analysis, resulting in a
plan of action of "None." However, due to legal counsel advisement, a copy could not be provided
to ICE. A contract exists between SCHOC and LSH allowing SCHOC to refer inmates and
detainees requiring medical care "beyond the scope of PHS," to LSH. HSA noted LSH

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has a correctional unit set up to handle inmates.

Because of the contract with LSH, LSH is the first choice of the on-call physician when off-site
care is needed. If the care needed is beyond the scope of LSH, the patient will be sent to a
hospital that provides the needed care. In the event of a referral to LSH, transport of the patient is
arranged through the SCHOC Booking Department. LSH does not have an emergency room;
therefore, in the event of a medical emergency, 9-1-1 will be called, and the patient will most likely
be transported to Boston Medical Center, Boston, MA.

It is not procedural to send medical staff with SCHOC transport officers when transporting patients
to LSH.

All detainees are informed at the intake in-briefing and via the detainee handbook of the sick call
slip process. HSA acknowledges detainees complain about the response time to sick
call slips and claim sick call slips have not been responded to. HSA noted there have
been instances in which the detainee has claimed a sick call slip was submitted, but the medical
record shows one was not received. Upon HSA review of the general sick call slip
process, she found nursing staff followed procedures, and appropriately triaged and responded to
the request.

During an interview with SCHOC Superintendant ESQ, SSA was advised by


Superintendant that surveillance video recordings of TAVAREZ, obtained from the
SCHOC surveillance video recording system, were preserved, but SCHOC legal counsel advised
Superintendant that surveillance video of TAVAREZ could not be immediately provided to
ICE. SSA was allowed to view select surveillance video recordings of TAVAREZ, which were
recorded on October 14, 2009 and October 16, 2009. The following are SSA observations
of the video:

The October 14, 2009 recording showed TAVAREZ in an elevator under escort to the SCHOC
infirmary. TAVAREZ stood on his own power, appears responsive and alert to the escorting
officer, and was seen exiting the elevator on his own power. A second video clip time stamped "
10/16/2009," showed TAVAREZ escorted by an officer in a hallway, walking on his own power.
TAVAREZ was en route from the infirmary to the Booking Department for transport to LSH. In
each of the recordings, TAVAREZ was moving about on his own power with his head erected and
appeared responsive to the escorting officer.

On October 27, 2009, SCHOC Corrections Officer (CO) , a housing unit officer

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assigned to Unit A4, provided the following information during her interview with ODO staff:

CO stated she works the 7:00 a.m. to 3:00 pm shift, and saw detainee TAVAREZ
everyday that she worked since his arrival in the unit. She was not aware of any medical
complaints from him and was surprised at his sudden passing. CO confirmed the building
had experienced heating issues earlier in the month with the change of the weather, which had
been resolved.

Detainees and were roommates of TAVAREZ at SCHOC and


Detainee was a close friend of TAVAREZ. Additionally, Detainees and
were identified as having interacted with TAVAREZ. The following information was
obtained from these detainees during their interview with ODO staff in October and November
2009:

With regards to the overall health of TAVAREZ, the detainees stated TAVAREZ worked out
everyday, was in good shape and appeared to be healthy. TAVAREZ began to complain of
feeling ill one to two days prior to the day he was taken to the infirmary (October 14, 2009).
Detainees , and recalled TAVAREZ had submitted two to three sick call
request slips regarding his not feeling well, but was never called by the nurses during daily sick
call.

Detainee often filled out sick call request slips on behalf of detainees who do not speak
and/or write English well. He explained when completing a sick call slip on behalf of another
detainee, he writes in the upper corner if it is the second or third request. Detainee stated
although TAVAREZ could speak and write in English, he (TAVAREZ) asked Detainee to
write several of the requests on his behalf. Detainee claimed he filled out six to eight sick
call request slips on behalf of TAVAREZ over a two to three week period. Detainee
further stated, to his knowledge, TAVAREZ was not called by the nurses during daily sick call in
response to any of the submitted requests.

Detainee stated 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
meantime, it takes the medical staff several days to respond with treatment. Detainee
stated once a request slip is filled out, it is placed into the "Sick Call" box located in the unit, which
is clearly marked and separate from the "Grievances" and "Mail" boxes. Detainee stated
the slips are picked up everyday by nursing staff, but sometimes the nursing staff forgets to
retrieve the slips. also stated medical staff is in the housing unit three times each day for "

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pill call." Often, detainees will give a sick call request slip directly to the "pill call" nurse.

Each of the detainees interviewed stated on the evening TAVAREZ was taken to the main
infirmary (October 14, 2009), TAVAREZ did not participate in outdoor recreation, complained of
headache, feeling cold and was wrapped in a blanket in his bunk. The detainees further reported
TAVAREZ was hot to the touch and was visibly sweating. Detainee stated during the
evening pill call he observed TAVAREZ speaking with the nurse, followed by the nurse taking
TAVAREZ's temperature and TAVAREZ returning to his room.

The detainees stated at approximately 10:30 pm, TAVAREZ appeared to be getting worse. A
detainee informed the housing unit officer of TAVAREZ's declining condition. The officer went to
TAVAREZ's room, and returned to the desk and called the main infirmary. A few minutes later a
nurse arrived and escorted TAVAREZ out of the housing unit. Each of the detainees reported
seeing TAVAREZ walk out of the unit on his own power.

Detainee stated shortly after TAVAREZ's arrival at SCHOC, he began refusing to take
medications stating it was making him feel "down," and claiming it was the "wrong type" because it
was making him "sick." Detainee stated a few days after refusing to take the medication,
TAVAREZ began to feel better and started exercising again.

Detainee stated the day TAVAREZ began feeling sick, he complained about the medications
he was taking, blaming them for making him feel "weak and worse." Detainee further stated
the medication made TAVAREZ feel "down," and described the "down" as more a "mental down",
than a "physical down."

Several of the detainees reported the day room and one side of the housing area were always
cold and the side where TAVAREZ's room was located was always very warm. The detainees
opined going from cold to warm may have contributed to TAVAREZ's illness. The detainees
stated the heating issue had since been resolved.

None of the detainees could confirm how many sick call request slips TAVAREZ actually filled out.
Additionally, no detainee witnessed TAVAREZ filling out a request slip. Detainee stated
he witnessed detainee filling out one sick call request slip on behalf of TAVAREZ. Two of
the detainees stated they advised TAVAREZ to submit a request slip, and TAVAREZ told them he
had done so.

None of the detainees could state, with certainty, whether TAVAREZ was actually seen by medical

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staff or not in response to a sick call request. Detainee stated he observed TAVAREZ
speaking with a nurse on the evening of October 14, 2009, during a "pill call," and the nurse took
TAVAREZ's temperature, after which, TAVAREZ returned to his room.

FINDINGS:

On October 20, 2009, , M.D., of the Commonwealth of Massachusetts, Office of the


Chief Medical Examiner, conducted an autopsy on TAVAREZ. The autopsy report indicates
TAVAREZ's immediate cause of death as "cardiac arrest due to myocardial infarct, acute, due to
small intramyocardial coronary artery disease." The manner of death is identified as "natural."

On January 12, 2010, MGT of America, a national management and consultant firm contracted by
ICE to provide subject matter expertise in detention management, submitted a report based on a
review of the entire ICE detention medical record of TAVAREZ. The report documents a timeline
summarizing all encounters and actions taken by SCHOC contract PHS medical staff, and
concludes with 27 observations, 18 of which directly related to the care and treatment of
TAVAREZ while housed at SCHOC.

The lack of proper documentation included PHS medical staff documentation related to the
administration and discontinuation of diabetic finger sticks. The record indicates on September
30, 2009, diabetic fingers sticks of TAVAREZ were ordered to be discontinued. This order is not
signed. The medical record reflects TAVAREZ refused taking diabetic medications beginning
October 1, 2009, and diabetic finger sticks were ordered to be performed. This order is not
signed.

According to the medical record, on October 1, 2009, TAVAREZ began refusing to take diabetic
medications citing they "make him feel down. The refusal was properly documented and
addressed. PA acknowledged the refusal and ordered the continuation of diabetic finger
sticks to monitor TAVAREZ blood glucose levels. According to the Medicine Administration
Record, diabetic medication was last administered to TAVAREZ on October 6, 2009. On October
7, 2009, an order was placed and signed by the PA for the discontinuation of diabetic finger sticks
and medication for TAVAREZ. In his interview, PA stated TAVAREZ was able to control
his diabetes through diet. PHS appropriately documented the diabetic care and treatment of
TAVAREZ.

MGT identified a lack of contemporaneous documentation and clarity related to the examination of
TAVAREZ on October 9, 2009, for "pain between (his) legs." On October 12, 2009, a progress

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note is entered introducing a "Continued historical note from 10/9." A review of the medical record
revealed no notes were recorded or dictated in the medical record on October 9th. A note entered
by nursing staff on October 8th, indicates the detainee was directed to be seen by the (medical)
provider-of-the-day on October 9th. The only medical documentation reflecting any treatment or
care of TAVAREZ on October 9th is a notation on the MAR indicating TAVAREZ was administered
(the antibiotic) Bactrim. Additionally, a review of all medications ordered for TAVAREZ during his
stay at SCHOC revealed no orders for the antibiotic Bactrim DS.

On October 14, 2009, following TAVAREZ's admittance to the infirmary, the on-call physician
ordered vital signs to be taken every four hours. According to the medical record, vital signs were
not consistently taken every four hours throughout TAVAREZ's stay in the infirmary, which ended
October 16, 2009, at approximately 12:00 pm.

See Exhibit 01 for additional observations resulting from the medical record review by MGT.

Clinical Consultant MD, a contract physician with the Bureau of Prisons (BOP),
concurred with the cause of death findings of the coroner's report and B&WH medical staff. Dr.
cited the delay in early recognition of and treatment for TAVAREZ' "septic condition"
resulted in multisystem failure and myocardial infarction, adding that the symptoms displayed by
TAVAREZ should have prompted a review of antibiotic therapy and blood tests. Additionally, DR.
noted October 14, 2009 vital signs indicated the onset of a septic condition and
TAVAREZ would have benefited from a transfer to a hospital at that time for further evaluation and
inpatient management, which would be especially critical with a diabetic patient who had been
refusing diabetic medications as in the case of TAVAREZ.

Dr. identified two areas for improvement: 1. Medication reconciliation was ineffective
during TAVAREZ' transfer among the various detention facilities. Medications on transfer sheets
were often incomplete. 2. Information Management: Verbal orders were frequently not cosigned
by the provider. Progress notes were not written by the physician assistant (PA on two
occasions to document the reason for verbal orders given or treatment.

See Exhibit 02 for additional comments by Dr. resulting from her review of the medical
record.

ODO interviewed SCHOC medical staff, reviewed TAVAREZ's medical record and examined all
sick call request slips submitted by TAVAREZ. TAVAREZ submitted a total of two sick call
request slips during his stay at SCHOC. An examination of each of the sick call request slips

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
CONTINUATION
HB 4200-01 (37), Special Agent Handbook 007
10. NARRATIVE
revealed one was completed by someone on behalf of TAVAREZ, and the second was completed
by TAVAREZ. A comparison of the handwriting in each of the sick call request slips revealed the
October 6, 2009 slip was completed by someone on behalf of TAVAREZ, although the signature
appears to be that of TAVAREZ.

The sick call request slip dated October 14, 2009 appears to have been completed by TAVAREZ
and signed by TAVAREZ. According to the medical record and interviews of medical staff,
TAVAREZ was seen by medical staff in response to each of the two sick call request slips
submitted.

ODO confirmed the availability of sick call slips and the presence of a sick call slip box in each of
the housing units. Each box is clearly labeled. A review of sick call procedures revealed each day
medical staff collects detainee sick call request slips from the sick call box located in each housing
unit. PHS medical staff confirmed often a detainee will hand a sick call request slip directly to
medical staff during pill call or visits by staff to a unit. Sick call slips submitted after the daily
pick-up, are not retrieved by staff until the following day. Each slip collected is triaged the day it is
in received. According to medical staff all request slips are responded to within 72 hours of receipt
by medical staff.

SCHOC appropriately documented the housing of TAVAREZ at SCHOC and his transport to LSH.
Additionally, SCHOC maintained detailed records of round-the-clock guard postings and visitors
while TAVAREZ was under hospital care at B&WH.

ICE ERO Boston Field office appropriately conducted and documented staff-detainee
communications and related activity for TAVAREZ. Additionally, appropriate and timely
notifications were made to ICE management and family members of TAVAREZ regarding
TAVAREZ's hospitalization and death.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

PREPARED BY

REPORT OF INVESTIGATION
2. REPORT NUMBER
Exhibit List
HB 4200-01 (37), Special Agent Handbook 007
Exhibit 01: MGT Review of the Medical Record of TAVAREZ
Exhibit 02: Dr. Mortality Review
Exhibit 03: TAVAREZ Autopsy Report
Exhibit 04: TAVAREZ Death Certificate
Exhibit 05: SCHOC Vehicle Log re: 10/16/2009 Transport of TAVAREZ to LSH

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