By Tim Hull, Courthouse News Service

(CN) - Despite inspection reforms, the nation's immigration detention centers provide inadequate medical care and have caused unnecessary deaths, according to a report released Thursday by several immigrant-rights groups.

The report details eight deaths in Immigration and Customs Enforcement facilities between 2010-2012, including that of Pablo Gracida-Conte, a 54-year-old Mexican national who died in Arizona's Eloy Detention Center - which the report calls the "the deadliest immigration detention center in America."

Jennifer Chan, Associate Director of Policy with the National Immigrant Justice Center, told reporters in a telebriefing Thursday that Gracida grew sicker and sicker and vomited after nearly every meal over four months while in custody, but never received proper care for his treatable heart condition. He eventually died at a Tucson hospital in 2011 of cardiomyopathy.

"It should not have taken a medical professional to see that he was a very ill man, but even the medical professionals in this case failed to respond," Chan said.

ICE's investigation of the death, one of several reforms instituted by Congress and the Obama administration in recent years to improve health care and accountability in ICE facilities, found that "Gracida's death might have been prevented if Eloy's medical provider had provided appropriate medical treatment in a timely manner," and that there were "significant deficiencies in how the staff communicated" with Gracida, who spoke the Mixteco dialect.

"The facility never once brought in or called an interpreter to make sure he and the medical personnel understood each other," Chan said.

Chan noted that despite being without a medical director for four years and recording 10 deaths since 2003, the Eloy facility did not fail an ICE inspection between 2006 and 2012, the most recent year for which records are available.

"Today, Eloy is known as the deadliest immigration detention center in America," the report states. "Four years after Mr. Gracida's death, the facility still does not have a doctor on staff."

There have been four deaths at the Eloy facility since 2011, according to the report. In June 2015, Rep. Raul Grijalva, D-Arizona, asked the Justice Department to investigate recent deaths at the for-profit facility, which is operated by Corrections Corporation of America.

"Remarkably, the Office of Detention Oversight inspection claimed that Mr. Gracida's death was the first death 'to ever occur' at Eloy when, in fact, it was the 10th death at the facility," Chan said.

Gracida's and the seven other deaths outlined in the report, "Fatal Neglect: How ICE Ignores Deaths in Detention," reveal "egregious violations of ICE's medical care standards," co-author Carl Takei, a staff attorney with the American Civil Liberties Union, said.

The ACLU partnered with Detention Watch Network and the National Immigrant Justice Center to review ICE death investigations and facility inspection reports obtained through the Freedom of Information Act.

Takei said the groups looked at those death reviews that "found noncompliance with medical standards, and that identified noncompliance as a contributing cause of the death."

He added, "What is especially disturbing is what we discovered when we put these death reviews side-by-side with ICE's annual inspection reports. In a functioning system, these death reviews would play a role similar to a hospital's post-mortem analysis. When a patient dies at a health care institution that's committed to quality care, the post-mortem analysis isn't just filed away after being completed. It's used to improve the delivery of health care for the next patient who comes through the door.

"But that is not what is going on at ICE. The inspection reports show that instead of using the death-review findings to force changes in the culture, systems and processes to reduce future deaths, ICE's deficient inspection system simply swept the agency's own death-review findings under the rug."

Dora Schriro was special adviser to Department of Homeland Security Secretary Janet Napolitano when some of the inspection reforms were enacted. She told reporters on Thursday that in 2009, the ICE health care system "was determined to be uneven, poorly equipped and lacking in infrastructure," including "variation in credentialing of medical personnel, and staffing varying by facility to facility."

Subsequent reforms started the death-review process, and created a "new detention facility inspection process under Office of Detention Oversight that was intended to provide a more rigorous review of detention standards compliance than the routine Enforcement and Removal Operations inspections," as well as "centralization of health care under the ICE Health Service Corps and the introduction of a more robust set of detention standards," the report states.

Schriro said that while some of the issues she saw have been addressed, "many other issues that were left still to be done."

The report states that while the number of deaths in ICE custody has decreased in recent years, "comparison of the death reviews from 2010-2012 with Office of Detention Oversight and Enforcement and Removal Operations inspections conducted at facilities before and after deaths occurred demonstrates that the inspection reforms have failed to hold detention facilities accountable for providing adequate medical care."

There have been 56 deaths in ICE custody during the Obama administration, according to the report.

"The risks posed by substandard medical care will continue to endanger people detained in these facilities until the violations are corrected," the report states. "Indeed, forcing such corrections is perhaps the most important reason to conduct death reviews in the first place."

The report offers a number of recommendations, including to "immediately terminate contracts for facilities with repeated preventable deaths such as the Eloy Detention Center in Arizona."

ICE spokeswoman Gillian Christensen said that the report's findings "are the result of exhaustive case reviews conducted by ICE's own Office of Detention Oversight, which was established in 2009 as part of the agency's comprehensive detention reforms to perform independent reviews of ICE detention facilities and ensure compliance with the agency's rigorous operating standards."

She also said in an email that eight of the detention facilities cited in the report, including Eloy Detention Center, "have since adopted ICE's 2011 performance-based national detention standards, the most rigorous operating requirements imposed by the agency."

Noting that these developments aren't mentioned in the report, Christensen said they "reflect ICE's continuing resolve to improve the conditions of confinement for all those in the agency's custody. ICE has made substantial progress on implementing reforms across its detention system and that important work is ongoing."

To Learn More:

Immigrant Detention Breaks up Families, Enriches Private Prison Companies (by Danny Biederman and Noel Brinkerhoff, AllGov)

Federal Judge Orders Obama Administration to Release Children Held in Immigration Detention Centers by October 23 (by Noel Brinkerhoff and Danny Biederman, AllGov)

ICE Keeps Secrecy Lid on Detention of Thousands of Immigrants (by Noel Brinkerhoff, AllGov)