When Jose de Jesus Deniz-Sahagun entered US Border Patrol custody in May 2015, he told agents that he thought Mexican coyotes were going to kill him, and he wanted to kill himself.
Inside a temporary holding room for immigration detainees, he launched himself from a concrete bench, head first, hoping to snap his own neck.
In an interview during his intake to the Eloy Detention Center, a long term Immigration and Customs Enforcement (Ice) facility in Arizona, he again told a registered nurse that he had wanted to kill himself because he feared the coyotes, who are smugglers who bring people across the US border illegally.
As Deniz-Sahagun moved through Ice custody, person after person failed to make a note in his official records of his past suicide attempts and ongoing suicidal thoughts.
Two days after entering Eloy, the guards did put Deniz-Sahagun on round-the-clock suicide watch, which should have meant check-ins every 15 minutes. The guards did their rounds at random intervals, sometimes after just five minutes, or after nine, or seven, 15, 25. They filled out the pre-printed time sheets as if the checks happened at 15 minute intervals, as prescribed.
Between the final two check-ins – 15 minutes apart – on 20 May 2015, Deniz-Sahagun asphyxiated himself in his cell.
His suicide was the third in two years and the fifth since 2005. Despite that history, the staff had no comprehensive suicide prevention plan, a fact that Ice noted in a review of Mr Deniz-Sahagun’s death.
A new report by the Human Rights Watch and Community Initiatives for Visiting Immigrants in Confinement (Civic) found that detainees received subpar medical care in 16 of 18 Ice death investigations obtained by the group, and evaluated by several health professionals.
By Katie Shepherd for BBC News
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