A recently unearthed internal report by a federal civil rights agency found serious deficiencies in suicide prevention practices at a privately run immigration detention centre in Louisiana, including poor staff training and mental health screening procedures that “likely resulted in the underreporting and underidentification of detainees at risk of suicide.”
The 2017 report by the US Department of Homeland Security’s Office for Civil Rights and Civil Liberties is included in a package of detention centre inspections released to NPR this year, following a Freedom of Information Act lawsuit the news organisation filed against the department in 2020.
In 2017, in response to reported problems, including three detainee deaths in 2016, at the Central Louisiana ICE Processing Center – then known as the LaSalle Detention Facility – the Civil Rights Division conducted a “general review” of the facility, the second-largest U.S. Immigration and Customs Enforcement detention center in Louisiana, which is operated by the GEO Group, a Florida-based private prison company that works with ICE across the country.
While none of the deaths in 2016 were suicides, suicide prevention was one of three broad topic areas covered in the report, along with medical care and conditions of confinement.
An investigator from the office, who was 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 identifying suicide risk”, policies that only “vaguely addressed the basic requirements for ‘suicide resistant’ housing”, and substandard suicide intervention policies and practices. The investigator was also never given access to data on staff compliance with GEO or ICE suicide prevention training, policies and practices.
“Maintaining data on staff training compliance is a fundamental component of any quality assurance programme,” the report states.
The investigator made a number of recommendations, including updating several policies and procedures, to bring the detention centre into compliance with ICE suicide prevention standards.
ICE’s public reports on detainee deaths show no record of a detainee committing suicide while in custody at the Jena facility, which opened in 2007. However, these reports do not cover suicide attempts or incidents of serious self-harm. The internal suicide prevention report notes a “serious suicide attempt in March 2016, which resulted in the detainee being transported to a local hospital for emergency medical treatment.”
In a statement, GEO spokesman Christopher Ferreira said: “We take our role as a federal service provider very seriously and strive to treat all those entrusted to our care with dignity and respect. We follow strict federal standards regarding 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 comment on the report or respond to questions from Verite News.
‘It’s really like a concrete cage’
One of the most serious problems identified in the report was the housing of detainees on suicide watch. According to the report, as well as a detainee advocate who spoke to Verite, they are essentially kept in isolation, a practice that the report says “not only escalates the detainee’s sense of alienation, but also serves to further remove the individual from proper staff supervision”.
Mich González, deputy executive director of the immigrant rights nonprofit Freedom for Immigrants, toured the facility in late 2021 and said the cells in the segregation unit – where detainees on suicide watch are placed when beds in a medical unit are full, according to the report – are not appropriate for detainees at risk of suicide.
“If I didn’t have suicidal thoughts before I went in there, I definitely would after a couple of hours,” Gonzalez said. “It’s really like a concrete cage.”
One detainee, M.W., a Muslim man who asked that his initials be used out of fear for his safety while in the facility, said the segregation rooms offer only enough space to pray and not much else.
The cells are secured behind a large metal door with a small rectangular window for guards to see through, according to Gonzalez and M.W. Another small window to the outside offers a sliver of sunlight.
“There’s nothing remotely warm in there. It’s all metal and concrete,” Gonzalez said.
The report recommended that inmates on suicide watch or in segregation for mental health issues should be granted all privileges – including time out of their cells to spend time in a communal area, if possible – and not be placed on lockdown.
M.W. said that people placed in the segregation unit who are not there for disciplinary reasons have access to a telephone and a handheld video game device, which are passed around and shared by everyone housed in the cell block. They are taken to recreation for about an hour, but are kept in a large cage and are otherwise allowed to leave their cells to use the showers or sinks.
The 2017 report also raised concerns about the equipment in the cells. While the cells in the medical unit were mostly suicide-resistant, their metal bunks had ventilation holes that prisoners could use as anchors for hanging attempts. The segregation unit, however, was not suicide resistant. Each of the segregation cells had double metal bunks, handrails and window bars “that could easily be used as anchor points in a suicide attempt by hanging”, the report said.
The report also said that detainees and some staff told the investigator that people on suicide watch were sometimes denied mattresses, but were provided with safety gowns and blankets. The investigator recommended that all detainees on suicide watch be provided with mattresses unless they attempt to damage the mattresses or use them to cover cell doors and obstruct the view into cells.
Training materials and procedures inadequate
The report also found problems with staff training, policies and procedures for identifying detainees at risk of suicide or self-harm and for providing life-saving intervention when a detainee has engaged in self-harm or a suicide attempt, problems that can be attributed to both the GEO Group and ICE, which provides medical care at the detention centre through its ICE Health Services Corps. .
In a section on training, the investigator suggested that GEO appeared to have recycled its suicide prevention training curriculum from the jails and prisons it operates, rather than tailoring it to a population of immigrant detainees.
“One PowerPoint slide read: ‘Many of the inmates/detainees are in the facility because of terrible crimes. Some may be there for murder, rape or child abuse. Such a statement is obviously untrue,” the report said.
Time spent on training was also an issue. ICE standards call for all detention centre staff to receive at least eight hours of suicide prevention training each year. But according to the report, GEO’s suicide recognition and prevention curriculum included a course that was only 2.5 hours long and “included outdated research”.
Although staff working at the facility are responsible for screening incoming detainees for mental health problems, the intake forms provided and administered by ICE were severely lacking when it came to identifying suicide risk, the investigator found.
The intake forms contained only five questions, including ones about previous suicide attempts and diagnosis of mental illness, another about hallucinations, and another about family history of mental illness. The investigator suggested that use of the form could lead to under-identification of prisoners at risk of suicide. Between January 2016 and February 2017, 24 people were identified as being at risk of suicide. The investigator said this number was “extremely low” given that more than 1,000 people were held in the detention centre every day. Ongoing screening after admission was also inadequate, according to the report. Mental health forms used during rounds did not include a genuine suicide risk assessment.
Finally, the report found that the facility lacked measures to intervene in the event of a suicide attempt. Neither GEO nor ICE protocols adequately addressed how medical or guard staff should respond in the event of a suicide. What’s more, guards were not even provided with the appropriate equipment.
Given that GEO staff stationed in detainee dormitories 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 guards had keys.
One kit inspected by the investigator was not adequately stocked. Although GEO’s training and policy materials called for kits to include 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 staff,” the investigator wrote.
The report recommended a more robust intake screening, including an examination of suicide risk at other points of contact while in DHS custody, including with the transferring officer or the officer who may have arrested or apprehended the detainee, and questions about recent significant loss and feelings of hopelessness or helplessness.
For GEO to comply with ICE’s national detention standards, the investigator said it should update its training policies and practices to include an eight-hour initial suicide prevention training for new employees and update annual precautions so they can’t 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 could access the kits to retrieve a life-saving tool.
More than six years later, it’s not clear whether the recommendations have been implemented at the facility. GEO Group did not respond to questions about updates to its policies and practices at the Central Louisiana ICE Processing Center.
Gonzáles, of Freedom for Immigrants, could not specifically say whether the issues highlighted in the report have been addressed, but added that he is often concerned about the mental health of detainees, particularly those held in isolation at Jena and other facilities.
Those he works with, he said, “often feel like they’ve been forgotten”.
