A recently unearthed internal report by a federal civil rights office found serious deficiences in suicide prevention practices at a privately managed immigration detention center in Louisiana, including poor staff training and mental health screening procedures that “probably resulted in the under-reporting and under-identification of detainees who are at risk for suicide.”
The 2017 report, by the U.S. Department of Homeland Security’s Office of Civil Rights and Civil Liberties is contained in a package of detention-center inspections released this year to NPR, following a Freedom of Information Act lawsuit that the news organization filed against the department in 2020.
In 2017, responding to reported problems, including three detainee deaths in 2016, at the Central Louisiana ICE Processing Center — then called the LaSalle Detention Facility — the civil rights office undertook a “general examination” of the facility, Louisiana’s second-largest U.S. Immigration and Customs Enforcement detention center, operated by the GEO Group, a Florida-based private prison company that works with ICE around the country.
Though none of the 2016 deaths were suicides, suicide prevention was one of three broad subject areas covered in the report, along with medical care and conditions of confinement.
An investigator for the office, sent to Jena in March 2017, delivered a 26-page report the following month. It revealed “inconsistent and disjointed” training on suicide prevention, intake forms that were “grossly inadequate for the identification of suicide risk,” policies that only “vaguely addressed the basic requirements for ‘suicide resistant’ housing,” and sub-standardsuicide intervention policies and practices. The investigator was also never granted access to data on staff compliance with GEO’s or ICE’s suicide prevention training, policies and practices.
“Maintenance of compliance data for staff training is a basic ingredient to any quality assurance program,” the report said.
The investigator laid out a series of recommendations, including updating several policies and procedures, to bring the detention center in line with ICE standards on suicide prevention.
Reports on detainee deaths publicly issued by ICE show no record of a detainee committing suicide while being held at the Jena facility, which opened in 2007. But those reports do not cover suicide attempts or incidents of serious self-harm. The internal report on suicide prevention notes a “serious suicide attempt in March 2016 that resulted in the detainee’s transfer to a local hospital for emergency medical treatment.”
In a statement, GEO spokesperson Christopher Ferreira said, “We take our role as a service provider to the federal government with the utmost seriousness and strive to treat all those entrusted to our care with dignity and respect. We follow strict federal standards as it relates to significant self-harm and suicide prevention and intervention; and we train all staff on GEO’s suicide prevention and intervention program, which is clearly defined in our policies and procedures.”
ICE did not provide a comment on the report or responses to questions from Verite News.
‘It’s really like a concrete cage’
Among the most serious problems noted in the report was housing for detainees on suicide watch. According to the report, as well as an advocate for detainees who spoke to Verite, they are essentially placed in isolation, a practice that the report says “not only escalates the detainee’s sense of alienation, but also further serves to remove the individual from proper staff supervision.
Mich González, associate executive director of immigrants’ rights non-profit Freedom for Immigrants, toured the facility in late 2021 and said cells the segregation unit — where detainees placed on suicide precaution are housed when beds in a medical unit are full,, according to the report — are not appropriate for detainees at risk of suicide.
“If I wasn’t experiencing suicidal ideation before going in there, I definitely would after a few hours,” Gonzalez said. “It’s really like a concrete cage.”
One detainee, M.W., a Muslim man who asked to use his initials out of fear for his safety while at the facility, said segregation rooms offer only enough room for him to pray and not much else.
The cells are secured behind a large metal door with a small rectangular window for guards to look through, according to Gonzalez and M.W. Another small window to the outdoors offers a sliver of sunlight.
“There’s nothing in there that is remotely warm. It’s all just metal and concrete,” Gonzalez said.
The report recommended that detainees on suicide watch or in segregation for mental health issues be afforded all priviledges – including time out of their cells to spend time in a communal space, if at all possible – and should not be on lock down.
M.W. said people placed in the segregation unit that are not there for disciplinary reasons, have access to a telephone and to a handheld video game device that are passed around and shared among everyone housed in the cell block. They are taken to recreation for roughly an hour, but are kept in a large cage and otherwise can leave their cells to use the showers or sinks.
The 2017 report also expressed concerns about equipment in the cells. While the medical unit cells were mostly suicide-resistant, their metal bunks had ventilation holes that detainees could use as anchors for hanging attempts. The segregation unit, meanwhile, was not suicide-resistant. Each of the segregation cells had double-metal bunks, grab bars and window bars “that could easily be utilized as anchoring points in a suicide attempt by hanging,” the report said.
The report also said detainees and some staff told the investigator that sometimes people placed on suicide watch were denied mattresses, but were provided safety smocks and safety blankets. The investigator recommended that all detainees on suicide watch be provided with mattresses unless they are attempting to damage the mattresses or use them to cover cell doors and obstruct visibility into the cells.
Training materials, procedures inadequate
The report also identified problems with staff training, policies and practices in identifying detainees at risk for suicide or self harm and in providing life saving intervention when a detainee has engaged in self harm or a suicide attempt, problems attributable to both the GEO Group and ICE, which provides medical care at the detention center through its ICE Health Services Corps. .
In a section on training, the investigator suggested that GEO appeared to have recycled its suicide-preveention training curriculum from jails and prisons the company operates, rather than tailoring them for a population of immigrant detainees.
“One PowerPoint slide stated ‘Many of the inmate/detainees are in the facility for terrible crimes. Some could be there because of murder, rape or child molestation.’ Such a statement is obviously untrue,” the report said.
Time spent on training was also a problem. ICE standards call for all staff at a detention center to receive at least eight hours of suicide prevention training each year. But according to the report GEO’s suicide recognition and prevention curriculum featured a course that was only 2.5 hours long and “contained outdated research.”
Though employees working at the facility have a responsibility to screen incoming detainees for mental health problem, but intake forms, provided and administered by ICE, were severely lacking when it came to identifying suicide risk, the investigator found
Intake forms provided only five questions, including ones about previous suicide attempts and mental illness diagnosis, another about hallucinations and another about family history of mental illness. The investigator suggestied that the use of the form could result in under-identification of detainees with suicide risk. Between January 2016 and February 2017, 24 people were identified with suicide risk. The investigator said that number was “extremely low” considering more than 1,000 people were held at the detention center daily. Ongoing screening after admission was likewise inadequate, according to the report. Mental health forms used during rounds did not include any real suicide risk inquiry.
Finally, the report said, the facility fell short on measures to intervene in the event of a suicide attempt. Neither GEO’s nor ICE’s protocols adequately covered how medical or guard staff should respond in the event of a suicide. What’s more, guards were not even provided the proper equipment.
Given that GEO staff stationed in detainees’ dorms or cell blocks are more likely to be the first responders to incidents of self harm, the investigator wrote that guards should have easy access to first aid kits. But the kits in Jena were locked, and only supervisors had keys.
One kit the investigator examined was not sufficiently stocked. Though GEO’s training and policy materials called for kits to have rescue knives to cut down inmates attempting to hang themselves, the kit contained only gloves and bandages.
“Contrary to this training directive, GEO did not have any emergency rescue tools available [to] its LDF personnel,” the investigator wrote.
The report recommended a more robust intake screening that included a look into suicide risk at other points of contact while in DHS custody, including with the transferring officer or with the officer who may have arrested or intercepted the detainee and questions about recent significant loss and feelings of hopelessness or helplessness.
In order for GEO to comply with ICE’s national detention standards, the investigator said, it should update it’s training policies and practices to include an eight hour initial suicide prevention training for new employees and annual eight-hour refresher courses for staff.
It also recommended that the furniture inside the medical cells used for suicide precaution be updated so they cannot facilitate suicide by hanging. It said the facility operator should add rescue knives to its first aid kits and update its intervention policy so that any staff member can access the kits to retrieve a life saving tool.
More than six years later, it’s not clear whether the recommendations have been adopted at the facility.. GEO Group did not answer questions about updates to its policies and practices at the Central Louisiana ICE Processing Center.
Gonzáles, of Freedom for Immigrants could not say, specifically, whether the issues highlighted in the report have been addressed.However, he added, he is frequently concerned about detainees’ mental health, particularly those placed in isolation at Jena and other facilities.
The ones he works with, he said, “often feel like they’re forgotten.”
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