Between 2017 and 2021, there were 52 recorded deaths in Immigration and Customs Enforcement (ICE) detention centers. A recent American Civil Liberties Union report found that 49 of those deaths could have been prevented with adequate medical care.

The study, released in late June with American Oversight and Physicians for Human Rights (PHR), determined that 95 percent of those deaths — including suicides — were caused in part by “persistent medical care failures.”

“Each of these deaths represent a preventable tragedy and underscores the systematic danger posed by placing people in immigration detention,” said Eunice Cho, a senior staff attorney at the ACLU’s National Prison Project and report co-author, in a statement. “Abuses in ICE detention should no longer go ignored. It’s time to hold ICE accountable and end this failed, dangerous mass detention machine once and for all.”

The report is one of the first to thoroughly examine recent known deaths that occurred in U.S. immigration detention centers. According to the nonprofit Freedom for Immigrants, at least 185 migrants have died in U.S. custody since 2003, when ICE first started publicly reporting the information.

Since 2017, ICE has reported the death of 70 people in their custody, though the ACLU notes that these figures do not include detained people who died immediately after they were released from custody. Four deaths were reported by ICE last year, with 8 deaths counted so far in the fiscal year 2024.

Researchers found that during the study period, medical staff made incorrect diagnoses in 88 percent of all deaths and provided incomplete or delayed treatment that directly contributed to these deaths. The report also found that detention centers failed to take basic COVID-19 precautions, resulting in at least 21 deaths in 2020.

According to the ACLU, the neglect extends to ICE death investigations, with evidence like video footage being destroyed, key witnesses not being interviewed and key facts being omitted in reports. Frequently omitted were facts that would “embarrass, or suggest fault by detention facilities.” Medical staff were found to have falsified or incompletely filled out documentation in 61 percent of deaths in detention.

The deaths were also found to be caused by flawed or delayed emergency response, chronic understaffing and improper training as well as a lack of adequate translation or communication by medical providers.

The report highlighted the death of detainee Maria Celeste Ochoa, who had told staff that she “felt like she was dying.” Poor translation led to staff isolating Ochoa for suicidal ideation instead of providing her with proper care for liver failure. She died while in custody.

“This report reinforces a grim reality that has been well documented over the last 20 years: Health care in ICE detention is often profoundly flawed,” said Dr. Michele Heisler, the medical director at PHR and professor of internal medicine at the University of Michigan. “Effective and more humane alternatives to detention enable people seeking asylum and other immigrants in the United States to receive medical care in their local communities.”

On average, ICE detains about 38,000 people each day in about 130 detention centers across the country. Recent budget increases have allowed the agency to detain up to 41,000 people each day.

Researchers said lack of oversight, accountability and systemic change do little to prevent future deaths and found that investigations into ICE facilities tend to center the blame on low-level staff without considering flawed policies or practices.

“Until now, the full extent of ICE’s systemic failures has remained shrouded in secrecy — a direct result of its unlawful delays and unjustified withholdings in releasing public records,” said Chioma Chukwu, the interim executive director of American Oversight, in a statement. “The documents underpinning this report can’t undo the harm caused by ICE’s failures, but they can provide something invaluable: accountability.”

The report offered guidance to protect the health and dignity of detainees and called for the end of the “dehumanizing and abusive immigration detention machine” altogether. Barring the complete abolition of the immigration detention and surveillance system, advocates said ICE should implement a rule to prevent solitary confinement of people with a disability, mental illness, who are pregnant or postpartum or who identify as LGBTQ+ or gender nonconforming.

Researchers also called for “meaningful consequences” for detention facilities responsible for the deaths of detained people and for ICE to terminate contracts with these centers, including for deaths occurring within 30 days of release. Advocates are hoping Congress will reduce funding for detention centers and instead invest in community and legal representation organizations.