Detention staff broke with safe standards of medical care for at least six detainees who died in U.S. Immigration and Customs Enforcement custody in 2025, according to internal reviews posted on — and later removed from — ICE’s website.
The reviews found that staff across multiple ICE detention centers mismanaged medication, skipped physical exams, ignored lab orders, and delayed treatments for sick detainees. Detention staff often failed to properly document or communicate the status of their deteriorating patients. In several cases, they failed to provide timely or appropriate life-saving care during emergencies.
“Rampant systemic medical abuse is a core feature of the immigration detention system.”
“It’s very clear that the rampant systemic medical abuse is a core feature of the immigration detention system,” said Stacy Suh, program director of the Detention Watch Network, upon reviewing the topline findings. “You can’t get well in a detention center.”
At least 56 people have died in ICE custody under the second Trump administration. ICE’s own Health Services Corps conducts a “mortality review” following an in-custody death to assess whether appropriate medical care was provided. The findings of this report are based on medical records and staff testimony. (ICE did not immediately respond to a request for comment.)
A total of eight such reviews related to detainee deaths from 2025 were published in a trove of 25-plus documents on ICE’s public records library on September 25. Four days later, a little after a lawyer representing this reporter in a Freedom of Information Act lawsuit noticed these documents, ICE appeared to have pulled them offline and de-indexed them.
While they were no longer available through internet searches, the records remained live on internet archives of the webpage. The larger trove of mortality reviews was first reported on by The American Prospect and the San Francisco Chronicle.
The eight reports contain granular details of the medical events leading up to 2025 deaths in custody of Johnny Noviello, Lorenzo Antonio Batrez Vargas, Marie Ange Blaise, Nhon Nguyen, Oscar Duarte Rascon, Santos Reyes Banegas, Tien Xuan Phan, and Chaofeng Ge. They provide the most comprehensive view yet into the escalating death toll in detention during President Donald Trump’s second term.
“Egregiously Managed Care”
The mortality review for Vargas, a 32-year-old from Mexico, found several clear examples of what ICE’s reviews called “inappropriate” care.
Vargas had complained of dizziness and blurred vision upon arrival at the Florence Detention Center in Arizona on August 4 last year. His labs also showed signs of uncontrolled diabetes. Ten days later, Vargas tested positive for Covid and was moved to a medical unit for isolation. His symptoms were treated with just a one-time dose of acetaminophen.
When Vargas’s chest X-rays later showed signs of pneumonia, he was treated with antibiotics that “did not align” with Centers for Disease Control and Prevention guidelines, his ICE mortality review concluded. On August 30, a few days after being released from isolation, Vargas reported having trouble breathing. He was treated with albuterol, an asthma inhaler.
This was “not the right or sufficient treatment for someone at this level of respiratory distress,” said Dr. Katherine Peeler, a medical adviser with Physicians for Human Rights and an assistant professor of pediatrics at Harvard Medical School, who reviewed the reports for The Intercept.
A day later, the symptoms worsened. He was complaining of shoulder pain, but wasn’t checked for oxygen levels. An employee found Vargas unresponsive later that day.
“This is a case of pretty egregiously managed care,” Peeler said. “Waiting for an emergency is not a way to treat people who are sick.”
The findings appear consistent with a new report by the advocacy group the Florence Immigrant and Refugee Rights Project surveying 64 detainees at Arizona ICE facilities.
“With essentially no oversight,” Liz Casey, a social worker and author of the report, said in a statement about the report, “it is nearly impossible for individuals in detention to get any assistance for urgent issues like medical neglect or abuse.”
Preventable Death
Another mortality review uncovered fresh information in the death of Noviello, a 49-year-old Canadian national, on June 23, 2025, at ICE’s Federal Detention Center in Miami. Noviello’s autopsy ruled that his cause of death was a preventable form of kidney failure.
When Noviello entered the ICE facility, he had a documented history of seizures and high blood pressure, for which he was medicated. The intake nurse at this facility ordered labs and allowed Noviello to continue taking his prescription medications himself.
The labs were never completed, according to the new documents. Noviello was referred to a behavioral health specialist because he reported using one of his anti-seizure medications, a benzodiazepine, for anxiety.
On May 29, a corrections employee flagged Noviello for “a possible hunger strike” and medical staff started logging an increase in depression, disorientation, and poor hygiene. By June 20, detention staff put Noviello in solitary confinement “for increased observation” and confiscated his medicine to administer at the officer’s station.
Three days later, a behavioral specialist documented that Noviello had not received his medication and referred him to a psychiatrist.
The ICE death review found that the provider in charge “did not place pill line orders, obtain vital signs, conduct a physical examination, or document a follow-up plan.” When Noviello was found unresponsive on the floor later, the staff did not “provide effective CPR or secure his body to the gurney during transportation,” the auditors concluded.
Botched Emergency Responses
Botched emergency responses were noted in two other cases.
Blaise, a Haitian national and the only woman who has died in ICE custody so far during Trump’s current term, entered the Broward Transitional Center in Florida with elevated blood pressure in April 2025. Twenty days later, she collapsed.
Her mortality review found that health staff didn’t give her rescue breaths and “failed to initiate” CPR “despite Ms. Blaise’s pulselessness.”
“Between 8:45 p.m. and 8:58 p.m., health staff monitored Ms. Blaise pending EMS personnel’s arrival,” the report notes, instead of actively trying to resuscitate her. They also did not record her vital signs during the response.
The review of Chaofeng Ge’s suicide death at the Moshannon Valley facility in Pennsylvania also pointed to insufficient medical care, said Peeler, the Physicians for Human Rights adviser.
Ge’s transfer summary had mentioned a past suicide attempt, a mood disorder, and use of antidepressants, but the provider in charge of his care “did not take appropriate action,” according to the review.
Four days in, guards found him hanging in a bathroom stall at around 5:20 a.m. Instead of immediately cutting him down, they left the scene to first call for help and thus “delayed life-saving measures” by 5 minutes, the report said. Staff “lacked knowledge” of basic life-saving measures, the report found, noting they did chest compressions too fast and delivered rescue breaths inconsistently.
Revelatory Reports
The reviews of Nguyen and Rascon, in which ICE auditors determined that medical care met adequate standards, were nevertheless revelatory. Both men entered ICE custody extremely unwell. Nguyen’s diagnoses included dementia; Rascon, 59, appeared to have late-stage Alzheimer’s, multi-organ failure, and several infections. Both volleyed back and forth between detention and local hospitals.
In Nguyen’s case, ICE’s own medical staff noted that it did not have the resources to care for Nguyen, who was 55, or assist him with his daily life — and requested his release from custody.
As the Trump administration undertook its deportation blitz, the number of people in immigration detention ballooned, from 40,000 people in January 2025 to nearly 66,000 by December 2025, according to the American Immigration Council.
At the same time, the Department of Homeland Security gutted oversight and transparency mechanisms.
“We’re seeing record numbers of people, including elderly people, people who are pregnant, people who have serious medical issues,” said Suh, of Detention Watch Network. “All of those folks are now being funneled into detention into a system that does not provide adequate health care — and has never provided adequate health care.”
The National Suicide Prevention Lifeline offers 24-hour support for those experiencing difficulties or those close to them, by chat or by telephone at 988.
