ice investigation into the wyatt detention center

8/14/2019 ICE Investigation into the Wyatt Detention Center

1/33

OFFICIAL USE ONLY SENSITIVE

DEPARTMENT OF HOMELANDSECURITY

Immigration and Customs EnforcementOffice o f Professional Responsibility

REPORT OF INVESTIGATIONH8420041

Ng. HluluilUnknawnllncldent CrIticellSlgnlllcantlCENTRAL FALLS.PROVIDENCE, AIRESOLUTION

7. RELATED

Conclusion of Investigation: Hiu lu i Ng

Page 1 of 33

On August e, 2008. the Joint Intake Center (JIC). Washtnglon. D.C received Infonnation reportingthe death of U.S. Immigration Enforcement(ICE). Dellntlon and Removal (ORO)detainee. named H1u L.ulNg Mr. Ng was hospitalized In Rhode Island on August 1.2008. when he was Slage center. On August 6, 2008, Mr. Ng passedaway at the Rhode Island Hospital Cenler, Providence, RI, while stUl detaIned by the Donald WyattDetention Facility (WDF) InCentral Falls. RI.

The ICE. Offtce of Professional Responsibility (OPR), ResIdent Agent In Charge (RAe).Portsmouth. New Hampshire was assigned 10 Inveatlgall the conditions of delantlon endcircumstances preceding Mr. Ng's death.

OFFICIAl. USEONLY SENSITIVE


2/33

OFFICIAl.USE ONLY seHSITNEPag' 2 of 33

DEPARTMENT OFHOMELANDSECURITY 1. CASE NUMBER

BACKGROUND:

REPORT OF lNVESTlGAnoNCONTINUAnoN

. . .


3/33

OFFICIALuse ONLY 8EN8Il1YE P . 8 3 of 33

DEPARTMENTOF HOMELANDSECURITY 1. CASE NUMBER

10. NARRATIVE

REPORT OF INVESTIGATIONCONTINUATION

HB420lWll

On August 27, 2007, Mr. Ng's motion to reopen his removal hearing was denied by the Immigrationjudge who ruled thai Mr. Ng fated to artlcutete sufficfentjustification 10 excuse his failure to appaaral his Fabruary 2, 2001. removal hearing.

On August31,2007, an appeal of Iha immigrationjudge's danlal to reopen Mr. Ng's case wasappealed to the Board of Immigration Appeals (BIA).

On 0cI0bar 3, 2007, a Stey of Removal for Mr. Ng was granted by Iha Board of ImmigrationAppeals.

On October 18, 2007, the BIA dlsmiued Mr. Ng's appeal an d rescinded the stey of removal.

On October 19, 2007, Mr. Ng wea advised by ICE ORO thellhay were In possession of a traveldocument to faciHtete his removal to the People's Republic of China. Mr. Ng was also advised thathis removal would occur someUme In November 2007. Subsequently, Mr. Ng's removal wasscheduled for Novembar 16, 2007.

On November 7, 2007, a petition for review (PFR) was flied on Mr. Ng's behalf with the U.S. Courtof Appeals for the Second Circuli, requesting that the Court raview the BlA's decision affirming theimmlgraUonjudge's danial of Mr. Ng's MoHon to Reopen. In addiUon, a Slay of Removal was alsorequesled. The Second Circuli granted a stay of removal while Iha court consldared the maills ofMr. Ng's petition for review.

On the same dale, e Petillon for Wril of Habeas Corpus with Emergency Order \0 Show causewilhlnIh re i i ! !Eda uant to 28 U.S.C. 2241 erseq., was also flied on Mr. Ng's behalf byAltomeys and _ In this petition, ItIs also claimed that Mr. Ng was denied medicaltreatment an access to counsel.

Mr. Ng's Stay at the Wyatt Detention Facllty (July 20.2007 - January 10. 2008)

On Mr. Ng was to Iha Donald W. Wyatt Delentlon

OFFICIALUSE ONI.Y SENSITIVE


4/33

OFFICIALUSE ONLY SENSITIVIPage4of33



HB4:zoo.o1

Central Falls. RI. Mr. Ng remained detained at the WDF until January 10. 2008.

On the same dale, Mr. Ng was proceued Into the WDF. Upon his admission to WDF, he receiveda standard medical evaluatIOn and mental health screening. Mr. Ng's initial medical evaluation did

nol reveal anyhealth Issues.

His mental health evaluation, however, notedthat

Mr.Ng

exhibitedsigns of depression. During the medical evaluation, Mr. Ng was lestad for tuben:ulosls with astandard skin Iell. On July 23, 2007, Mr. Ng was examined via chest X-ray to determine if he wasInfected with tubefculosis. According to the records, the chest X-ray was reed on July 23, 2007, byD r . _ , MO. The X-ray was reported es negaUve for signs of tuberculosis.

On October 9, 2007, while detained at the WDF. 8 WOF Incidentreport regarding Mr. Ng from Shift Commander, According to the report,Mr. Ng was ordered to dress for e scheduled proceedings.Captain _ s t a t e d hat Mr. Ng was noncompliant when directed to dress In proper attire fortransPort out of the facility.

C a p t a i n _ r e p o r t related \hat Mr. Ng advised him \hat ha wee In fear of deportation;t h e r e f o r e ~wanl to be transported to his appointment Next, Mr. Ng removed his shirtand tied It loosely around his neck. To ensure his safety, Mr.Ng was In acell. Mr. Ngwas Immediately evaluatad by Ucensed Prectical Nurse 10Identifyany potential Injuries stemming from him being restrained. No werenoted. Mr. Ng eventuallybecame compllanl and was transportad 10 his scheduled appointment.Upon return, Mr. Ng was placed In edminlstrativedetention, to await e decision on disciplinarysancllon resulting from his non-compnanl behavior earlier \hat morning.

UntilMr. Ng's transfer from the WDF on January 10. 2008, no other Incidents were reported. Mr.Ng never requeslsd special attention or advised of any medical needs, with the exception ofblisters on his raet and his need for cleaning aolulion for his c:onlact lenses.

Mr. Ng's Stay at the Franklin County House of CorrecUons (January 10 , 2008 - April 17. 2008)On January 10, 2008, Mr. Ng was transferred to Franklin County House of Corrections (FCHC)InGreenflald, Massachusetts, In order to maintain detention equilibrium within the Jurl8dlctlonof theHartford, DRO offlce. Mr. Ng's Intake Mental Heallh Screening and Assessment Form rrorn hisadmission to FCHC reflects no report or detection of menial or medical Issues, with theexception of a positive Purified Protein Oerlvatlve test reaction. for which Mr. Ng was

Isoniazid and 8-6 vitamins for a of e months. As of the standardOFFICIALuse ONLY SENSITIVe


5/33

OFFICIALUSE ONLY

10.

SENSmVE

DEPARTMENT OF HOMELAND SECURITY


H8 4 ~ 1(371. SpecIaIAg.nIHoml_

PageSof33

1. CASE NUMBER

procedure for medical evaluations at the FCHC, a blood specimen was taken from Mr. Ng onJanuary 1. 2008. According to the laboratory report, the results of the tests were within the normalrange.~

2008, Mr. Ng was givan a physicel assassment by Family Nurse Practitioner_ According tohis medical records, Mr. Ng did not advisa N u r s e _ of anymedlcellssues.

Mr. Ng's Stay at the Franklin County Jail (April 17, 2008 July 3,2008)

On April17, 2008, Mr. Ng was transferred from the FCHC In Greenfield, MA,to the FranklinCounty Jail (FCJ) in St. Albans, Vermont, In order to maintain detention equilibrium within thejurisdiction of the Hartford ORO offica. Upon his arrival to the FCJ, Mr. Ng wes processed throughIhe standard Intake procedures, Including a medical evaluation. Mr. Ng advised that he did nothave eny existing medical conditions, only that he had an allergy to some clothes and hed dry skin.

On June 11, 2008, Mr. Ng filed a grievance form Indicatingthat he wished to sae e nursa toevaluate his skin condition.

On June 12,2008, Mr. Ng was seenprescribed an anti-ltch cream, and she ad1#1seldreevaluate him.

Registered Nurse (RN). R N _that If the rash developed further, she would

Mr. Ng filed an additional grievance form during his stay at the FCJ. The form Is undated, thus, It Isunclear whether this grlevanca was Died before or after the June 12th grievance. On his undatedgrievance form, Mr. Ngexplained that he needed to see a doctor for his skin problem. Mr. Ngfurther advised that he believed that something was wrong with his body, resulting in his skinproblem. Mr. Ng asked that If the FCJ did not have the power to arrange an examination by a

doctor. he requested that ICE be notified. Mr. Ng's medical records provide no documentaryevidence that Mr. Ngwes saen by a doctor or that ICE was contacted.

On June 27, 2008, In a letter to ICE authored by Mr. Ng's Mr. Ng a statedthat he was suffering from chronic back pain and akin Irritation. claimed that Mr.Ng made many requests, but arrangements had not been made for Mr. Ng to sae a doctor. Whileaddressed to ICE, tha leHerwas Instead maUed \0 the Frenklln County Jail, 30 Uncoln Ave., S tAlbans. VT. ICE does not melntaln an office at the FCJ. Is believed that the leller was not

OffiCIAL USE ONLY SENSITIVE


6/33

OFFlCIALUSEONLY sl!Nsmva pag of 33

DEPARTMENTOF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVE8T1GAnoNCONnNUAnON

H84200-01

received by ICE unlll several weeks after Mr. Ng was lransferred back to Ihe WOF.)

On July 2. 2008. Mr. Ng was afforded the opportunityto lransfer to a facility with outdoorrecreation. Mr. Ng accepted and signed the form tilled"Waiver Form eo Day Transfer OpUonRequest The form II dated July 2. 2008 and signed by Mr. Ng.

Mr. Ng's Stey atlhe Wyatt Detention Facility(July 3. 2008 - August 6. 2008)

On July 3. 2008. Mr. Ng retumed to the WOF In Central Falls. RI. Upon his atrivalto the WOF. Mr.Ng was processed through the standard intake procedures Includinga medical evaluation. Amedical historyand screening was conduclad by L P N _ nd signed by Mr. Ng. Accordingto the WOF medical records. currant medical conclUons and medical hIstory ware negallve. withthe excepUon of the rash on his body. and prior treatment for TB from July 22,2007. In the IniUalevaluaUon Mr. Ng reeponds "yes when asked if there are any medical problems the facilityshouldknow about The medical condition II noted as "resh - all ovar: There Is no wrillen indication thatMr. Ng reported any back problems. In addition to SCl8enlng. a mental healthevaluation was also conducted. According to LPN no mental health problems werereported or observed. Mr. Ng was also given a screening. which also appeared to banormal. Mr. Ng was approved for housing within WDPsgeneral population. Mr. Ng wasprescribed Benadryl for his skIn condlilon. An X-ray of Mr. Ng's chest was taken to datermlnewhethar he was Infected with TB.

On July 5. 2008. Mr. Ng filled out a WOF Heath SarvIcas Request Form. On that form. Mr. NgadVised that he was experiencing a rash aD ovar his body for two months. Mr. Ng staled thai thefacilitythat he was detained at prtor to tha WDF had no medical cara. Mr. Ng also advised that hewas expertancing back peln, which had started a wask prtor. WOF medical records indicate thatpar WOF protocol. Mr. Ng was prescribed 600 m I ~for a five Mr. Ng'scomptalnt appaere to have baen reviewed by RN___ nd Dr. MD.On J u t 6. 2008. the X-nlYtaken to verll'ywhelher Mr. Ng was Infecled with TB was reviewed byDr. MD, and Indicated no active disease.

On July 7. 2008. Mr. Ng was evaluated by Drcondilionand low back pain. AI this Ime.and Benadryl for Mr. NO's rash andHeath Services Administratorassurence. to his

MD. regarding his comptalnts of a skinMD. praecrlbad Betamethaaone cream

NO'S beck pain. On the same data.ravieWed Mr. NO'S medical records for qualHyMD. statad that tha "normal practice for iniUeI

OFFICIALU ll ONLY SIN81TM!


7/33

OFf'ICIALUSE ONLY SI!NSIT1VI PIli ' 7 of33

DEPARTMENT OF HOMELANDSECURnY 1. CASE NUMBeR

REPORT OF INVEsnGATIONCONTINUAOON

HB 4200-01 (371. SpecIII AgIIII"_10. NARRAnVE

back pain" Is to presc:l1be pain medications. possible muscle relaxers. and heat to the back. Uponreviewing his notes. Dr._ . D. stated that Mr. Ng's back pain was "not severe enough forMotrln.which I cancelled and prescribed Tylenol."

On July 8. 2008. Mr. Ng requested to see a doctor, advising thathe

had not slapt for two nlghlsbacauH of back psIn. HIs Tylenol prescripUon remained In effect for back pain.

On July 10. 2008. Mr. Ng again requested to sea a doctor for back pain relief. His Tylenolprescription remained In effect. In his request Mr. Ng states "Please arrange doctor visit for mewhen he comes to facilitynext Ume.

~ 0 8 .WDF Warden Wayne Sansbury received an email from __ of Mr. Ng. In tha eman, Mr._adv i sed that s l n c e i l ! r . i"iiTIVida'i'ie WDF. herepeatedly asked for medical attention. specificallyhis back pain. Mr. statad that the medicalstaff did not care about his health problems or his back pain. Mr. advised Warden Salisburythat Mr. Ng nlHlCHdimmediate attention.

July 14. 2008:

was forwarded to the Directorof Nursingadvised Warden Salisbury that Mr. Ng hed

was pniSiilIiid "heavy-duty"narcotic analgesics, as wellas muscle relaxers.acMsad Warden Salisbury thai he would advise Ifany addiUonal medical slips ware racllived.

records Indicate that Mr. Nil was examined by Dr._ . D. on the 88me date.MD. prescribed F1exalil (a muscle relaxant) and Vlcodln (painkiller)for two weeks.MD, recommended lhat Mr. Nil should be moved to a bottom bunk in his cell to

;;;;irA. for Mr. Ng to get Into his bed.

_ July 11. 2008. amall to Wartlen SaUsbury. ONhe could not provIda much datal! due 10 pallentidalalnae privacy

~ ! ! : : ~that the prescribed medications and treatment was therecomrnendel:l IF for chronic back pain. ON _ r u r t h e r advised that everydetaineeIn cuslody at tha WDFwas treated with a high leval~ professional care.OffICIAL UBI ONLY BEN8mllE


8/33

OFFICIALUSE ONLY SENSITNE Page 8of 33

DEPARTMENT OF HOMELANDSecURITY 1. CASE NUMBER


H84zoo,ol r.m........ A G a n l H _

July 17. 2008:

Mr. Ng lilled out a WDF Heath SeIViceS Request Fonn. In which he aclYlsed that he needed anX-ray of his back and requested a cane because he could not walk. WDF medical reCOlUs IndiCateIhatthe request was received on July 18. 2008. by L P N _ . and was triaged

toa medlcel

doctor.

July 18. 2008:

Mr. Ng was examined by Dr.Ng'lI spine and right hlp. Dr.period of two waeks. (The ~ s c r i l , t I o l 1 8

July 20. 2008:

MD. D r . _ O, ordered an X-ray of Mr.also authorized the use of a cane for Mr. Ng for s

Flexatil and Vicodin continued).

An X-rayof Mr.Ng's right hlp and lumbar spine was reviewed by Dr._ _ MD. Dr._. D. Is a radlofoglst with Mobilex USA. The right hlp Xray ~ m b a rspinex:rayTndicated slight sccHOlIls. but was otherwise unremalt


9/33

OFFICIAL US! ONLY seNSmYe

DEPARTMENTOF HOMeLANDSECURnY

REPORT OF INVESnGAnONCONnNUAOON

He 42(JO.Q1 (3n

Pagalof33

1. CASE NUMBER

A physical examlnallon of Mr. Ng was conducted by an unknown person, beHaved to be from !heWDF medical staff. WhIle It occurred on the 20th day of his stay at WDF, Itappeara thisexamination may have been the 14-day physical examination as required by the ICE NOS. Thenotes on !he form tilled "Physical Asseasment notes that Mr. Ng's back pain had not Improved,

and he was unable to stand or put pressura on his right leg. It Is also noted !het Mr. Ng hes p08IUvepain while voiding since b a c k ~Is mede for a CT scan. At this time, Itappaara that Nuraa PracUlioner ( N P ) _ a d v I s e d O r . - . MO,that a CT scanwas needed to help determine the cause of Mr. Ng's pain.

July 24, 2008:

A Health Services Request form was received by LPN _ ; rom Mr. Ng advising that he couldnot walk with a cane and requested a Wheelchairor something he could use to help him welk.

Dr. _ MD,submitled a consultation request for a CT seen of Mr. Ng'8 right hip and lowerspine, indicating that Mr. Ng had peln and weakness and wes unable to stand or walk. ThIsconsultetion request resulted from the physical evaluation findings on July 23, 2008. There Is nochart entry recording any further evaluation on this date.

AW _ requested ICE, ORO, Supervisory Detentionand 15ijiOriationOfficer CT. At this lime, S O D a _advised that she would have the r e q u ~ d l t e dthrough the Department of Health and HumanService's Public Health Service. AW _ f u r l h e r advised ICE ORO that Mr. Ng was raquesllngthat he be moved into segregation so that he could have his medication brought to his cell.

AW_alsorequested ON regarding Mr. Ng's medicalaasessment and his transfer to ON replied that the treelmant for musclestrain was exaclly what had been prescribed. However, Mr. Ng advised that he had noimprovement. additional taaIlng was necessary to confirm Mr. Ng's diegnosls.

authored by Mr. Ng'8 a t t o m a y _ , o Deportation OfficerHartford, CT, ORO, 450 Main St. ~ r t f o r d ,CT, MrMr. ~ u f l ' e r l n gserious and rapidlydeteriorating health

adviised DO _ t h a t t that Mr. Ng ba raJeaaed fromcustody to adequate medical traalment. that Mr. deniedmedical treatment. According to her aftldavlt. DO Nghad been admitted to the and, therefore.

OFFICIALuse ONLY


10/33

OFFICIALUSE ONLY SENIIIT1VIPaga10of33

DEPARTMENTOF HOMELANOSecURITY 1. CASE NUMBER


H8 4200.01 (37).

letter.

July 25. 2008:

ON _ advised that the CT acan was approved by ICE and was acheduJed for July 29.2008, at Rhode Islend Medlcallrnaglng.

Reid 011108 Director lAFIODlen a t t o m ~ e n u n g

I)rivI.!ltept!ySlc:lan,AFOO_ advised~ I c a ltreatment for its_ d/scuSsed the conversation withslluaUon and "was being addressed.Mr. Ng's status, Including that he was scheduled

July 26, 2008:

was oontacled that same day byhis client be examined by a

WDF medical staff detetmlnesinformWDF ataff of his concerns. AFOO

advised that she was aware of theP i O ' ~ l d e t d A F O O_ with updates on

Mr. Ngwas scheduled to have his attomey. According to an email messagefrom ShiftCommander Captain to his superiorS, Including Warden Salisbury andAW _ , Mr. Ng refused to his attorney unless he was brought to th emeating space by wheelchair. that he advised ~ he hed beenIssued a cane and would not be given According to Captain_ . r. Ngrefused to attend the appointment and Mr. Ng'a attomey was noUfied that Mr. Ng declined the visit.According to the recorda. this incident occurred between approximately 15:00-18:00 hours.

Captain _ further advised thetlaler that same day. at approximately 17:10 hours, Mr. Ngwas obsiiVid"b"Yen olllcar having dllllculty getting up from his call floor. According 10 the ofIIoer.Mr. Ng required the asslatanoe of another datalnee 10 11ftMr. Ng Inlo a seaL Cap ta ln_stated that he advised the medical staff of the situation. At this Ume, Mr. Ng was evaluatad by AN

_ . fter Mr. Ng fell to the floor when he demptad to stand up with the usaof his cane. Itwas determined that he would need to be sent 10 MemorialHospital In Pawtucket. RI. In order 10 be

evaluated further. Captain _adv i sed hat Mr. Ng was removed from the call area viawheelchair and eacorted 10 the Health Servlcas Unit(HSU).

Mr. Ng was brought 10 the MemorialHospitalof Rhode Island. According 10 the hospital recorda,Mr. Ng arrived at 20:15 hours on July 26. and was admitted 10 a room at 20:18 hours. According tothe incident WOF staff utitlzed a wheelchair to move Mr. Ng to the van for

OfFICIAl.use ONLY SENSITIVE


11/33

OFFICIAL USE ONLY SENSITIVE

DEPARTMENT OFHOMELANDSECURITY

REPORT OF INVESTIGATIONCONTINUATION-

Page 11 of 33

1. CASE NUMBER

ll'ansportallon to the hospital. Mr. Ng was examined by MO. In theemergency room (ER). Mr. Ng advised that ha recently of his hips and beck and that hawas experiencing leg pain fo r several days and was unable to bear walght on his lags. Accordingthe hospital records. Mr. Ng denied having any direct trauma to the area. but advised that the painbagan several weeks age and became worse In the last week.

with Sclallca (low back pain) and prescribed Ibuprofen. Valium. andMD. advised that Mr. Ng should have his physician schadula an MRI fer

July 28. to evaluate whether Mr. Ng had any disc problems In his Jowar back er if hahad any problems. Further. after the MRI was complete. sha advised that Mr. Ng shouldbe seen by a Neurcstlrgacn. In addition. Dr._ . D. advised that If poulble. Mr. Ng shouldbe receiving pain medlcatJcns fo r his oondilion.

Mr. Ng was discharged from Memorial Hospital and returned to the WDF HSU. As part of thedischarge precess. Mr. Ng was provided paperwcrll ragardlng his diagnoses and treatment ferLumbar Redlculcpathy Scialica (low back pain). The fonn tetter provided to Mr. Ng fisted a numberof treatmant cptJcns for individuals who hava been diagnosed with sciatica. The treatment optJcnsnoted on the form renge from encouraging patJanls partJclpate In acUve exercise to recommendingslerold Injecllonsor surgerY. The medical dlrecUcns are general medical advice provided In a letterformal. The above direcUons were provided to Mr. Ng at the hospital and ware addad to Mr. Ng'smedical records at the WOF.

July 27. 2008:

Mr. Ng was asslIISed by RN _ . N _ advised that Mr. Ng appeared to be stable.bul needed 10 follow-upwith a doclor.

On the same data. according to the medical records Mr. Ng was offered all of his prescribedmedlcatJcn. bul rafused to get out of bed. According to LPN _ . r. Ng was spckan 10 altangth regarding his back pain and his noncomplisnce

withthe prescribed treatment. Mr. NgRlfused to come to IhB cell door to racelve his medlcatJcn. Acc;ording to IhB WDF medical racon:Is,

Mr. Ng was dlspenlied his preSCribed rnsdlcatJcn Istar that same evening and through the f o ~ o w i n gday.

July 28. 2008:

advlsedAW

OFFICIALUSE ONLY

Mr. Ng had been

SENSITIVe

with low back and It was


12/33

OFFICIALUSE ONLY SENSITIVE

DEPARTMENTOF HOMELANDSECURITY


Page 12of33

1. CASE NUMBER

recommended that further testing should conUnue. D N _ urther advIsad thai a CT scanwas already scheduled for July 29. 2008.

July 29. 2008:

Mr. Ng was scheduled for a CT scan al Rhodel&landImaging. According to WOF records, theWOF staff describes Mr. Ng as having "refusad" to attend his CT scan.

According to a DF incident report by Sergeant ( S g l ) . . - o n July 29,2008, he wasa&8lgned to escort Mr. Ng to a scheduled medical appotntmenlearliar thet day. Upon arriving 10Mr. Ng's cell in the HSU, he noticed Mr. Ng slldng on the bed, crying and smUng that ha could notmove. S g l _ s t a l e d that he advised Mr. Ng that by attending the medical appointment. itwould a&8lstIn determining the nature of his Sgt. _ advised Mr. Ng had a walkingcanenear his bedside that could be used 10 In walking, and that tha medicIIIstaff determined.!I!!!..!fdid not need a wheelchair. Sgt. that he dld.!!.91!W!mpt 10 move Mr. Ng. Sg l_ f u r t h e r staled thai he nodlled ON Captain _ and the appalntment wascancaned.

Sgt. _ advised his supervisors that ICE ORO, ImmigmUonEnforcement Agent ( I E A ) _~ r t f o r d .CT, was notified t h a t ~ d 1 oattend his scheduled CT scan earlier thaimorn!! !Enl ter that seme day, M a j o r _ a d v i s e d Warden Salisbury, A W _ a n dAW thet Mr. Ng had been scheduled to ~ e ICE ORO office In Hartford. CT, 10meet with lEA . Accordlng to M a j o r _ I E A _ advised that a meellng between Mr.Ng and his attorney would also be facIIltaIed.

AW _ senl an emaU to Warden Salisbury asking whal the plan would ba if Mr. Ng stated thathe could not move and "refused" to go. Later Ihat evening, In msponse to amalls sent 88r11ar thatday. Warden SalISbury replied, "VIdeotape the movement and place him on the vant Gendy ofcourse. In his affidavit 10 OPR for this Invasllgsl/on,Warden Salisbury slated that he "did notknow at that dm. that he (Ng) was physically unable 10 attend his appointment as It was reported tome In the emaD as a 'refusar. t Warden SaBsbury &Isostated that the reason for sending the emailabout videotaping was 10 "make sura the enUre Incident Is videotaped per poUcyas I considered itto be a polandel U.e of Force. I did nol know at lIlelime ha was physlcaUy unabla 10 attend hisappointment as Itwas reported 10 me In the email as a 'rafusar.

Later lha\ same evening, Mr. Ng was examined by Oradvlsad In his notas that Mr. had

OFFICIALuse ONLY seNSITIVE

MO. O r . _ M D ,was unable 10 stand and


13/33

OFFICIALUSE ONLY

10.

SENSITIVE


REPORT OF INVESnGATIONCONnNUAnON

H8 4 2 0 ~ t1371. -

Pagl13 of33

1. CASE NUMBER

was constipated. Dr._ . he explained to Mr. Ng that a CT scan needed10 be done as soon as poSSIble. Dr. MD, edvlsed that Mr.with lransportation and authorized the use a wheelchair at that time.completed an Interagency Health Cara raquast for a CT scan for Mr. Ng.

An activity watch remained in effect for Mr. Ng while In the HSU. Severallnddent reports warsgenerated on July 29. 2008. with moslly However. according to a WOFIncident raport by Corrections Officer (CO) Mr. Ng. stated 10 her that no onebellaved that he could not walk.

July 30. 2008:

At approximately06:00 hours. officers from the WOF attempted to facilitate lransportatfon from theWOF to the ICE ORO office In Hartford. CT. The movement was videotaped by overhead mountadsurveillance cameras and by hand held camcorder. The ovelf1ead mounted cameras ramainconstant and view the entira movement However. Happears obvious that the hand heldcemcorder Is shul on and off several times.

The video begins by showing Captain _ Ng that he had been Issued acane. and would not be given a wiheelchalr. Captain further edvIsed Mr. Ng that he

move on hts own. Mr. Ng edvIsed the could not walk. CaptaIn10 Mr. Ng that he had been sean by a doctor and that he was fine. captainedvIsed Mr. Ng to stand Mr. Ng was visibly crying and appeared to havethis lime. appears 10 signal 10 the offfcer holding tha

Ide ll/INK!as CO slop recording.

_r. N then ettampled to put his shoes on. Mr. Ng advised that he could not walk. Caplaln

advised Mr. that he needed 10 walk to the Receiving and Discharge (R&D) unit. Mr.9 rapaa that walk. C a p t a i n _ d i r e c t e d Mr. Ng 10 pili hil8hoes on. Mr.

Ng asked to believe him that ha could not move his legs. Mr. Ng continued toMr. Ng appeared 10 be In pain at that tIn1e. After a short Ume.advised Mr. Ng to get his shoes on mora quickly. that he needed to get to the

go court. Mr. Ng statad that he did not want to go 10 court. It Is notad that Mr. Ngdid not have a 8dladuled court appearanca; rather he was scheduled for an Intarvlew at theHartford ORO off1ce.

For a short Ume. continued 10 ..y,..,"" ..... words. Mr. advised

OFFICIALU810NLY 8ENSmYE


14/33


DEPARTMENT OF HOMaAND SeCURITY

REPORT OF INVesTIGATIONCONTINUATION

H84200-01

Page 14of33

1. CASe NUMBER

caplain _ that he could not move. caplaln _ repled that the doctor Iold him thathe was okay 10 move. Mr. Ng continued 10 appear a"ilTiii'Was unable or unwilling 10 move. Atthis tlma, Caplain _ auisted Mr. Ng with placing his shoes on his feel Mr. Ng appeared10 be experiencing soma level of discomfort at this time. Mr. Ng explained that he wanted 10 lakecare of his Injuryend aee a doctor. Mr. Ng continued 10 advise Caplain _ that he couldnot walk.

At Ihls lima, Cepta ln_ and the assisting oftIcer (Jatar Idantlfled~ his bed, Urid8r"iliSshoulders in the_ l i f t ed Mr. Ng.he began 10 scream loudly. Capltainproceeded to carry Mr. Ng down the hallway, face folWSrd. allOllYing feet to dreg on the ground.Mr. Ng continued to scream as he was being canied.

A short l i m . ' Isler the video shows Mr. Ng now lying on the ground In another area of the WDF.Captain advised Mr. Ng that to be moved to a sllUng position. Mr. Ngadvisad t e could not move. Caplaln Mr. Ng that his cane was ava.able sothat he could help himself up. Mr. Ng cane did not wort. Duri1l9tha next fewmomenls. Mr. Ng asked for tha aeslsblnca of a wheelchair. Captain _ advised Mr. Ng thathe could walkon his own, and he was then moved from the floor and positioned against tha walt.Mr. Ng continued to explain to C a p t a i n _ t h a t he could not walk. Mr. Ng was than placedin transport mlralnls for movement to~ ORO office.As Mr. Ngwas restraints, that the madlcal staff becontacted. Mr. Ng the nurse check him before hewas placed on the statad that he could not go. At this time. the video depicls Mr. Ngbeing moved against the wall. Ng screamed In peln and advised t h ~ egoing to breakhis leg. Mr. Ng advised that he could not make the Irip. which Captain _ rep l i ed hat hehad to. Mr. Ng again advised that he was in pain.

At this Uma, LPNthat he was unatlkithatLPN

Ol'l'1C1AL use ONLY

restlonded to Mr. Ng's location. Mr. Ng advised L P N _advised Mr. Ng that he hed been sent out for a tast andthe CT scan. Mr. Ng replied that he could nol walk.

wanted his madk:allon. Mr. Ng repUed thet he did and thethe WDF madical records Mr. Ng was given 100mg of

edvlisad Mr. Ng that he needed to go to court. Mr. Ngslaled that he could go; he was just refusing 10 go.

SENSITIVE


15/33

OFFICIALUSE ON!.Y PIIlIe150U3



H1142QO.01

1. CASE NUMBER

"""""in,,,.and that ha wanled 10 take the test. but no onestsllild thai she was to through the S8me

LPN to

Mr. Ng advised thai his legs werewould give him a wheelchair.conversaUon with Mr. Ng. Captainhave left the area. In her partlng ~ ~ ~ ~ ~ ~ : ~ I he waswould asslsl

ble to be transported. but refusas to go.him onto the bus.

A short time laler. Captain _ advised Mr. Ng that he would nol be given a wheelchair. Atthis lime. four otIIcers, picked up Mr. Ng and brought him to the bus welting In the sally port area ofthe WOF. As Mr.Ng WEll being lifted. he made slmMarcrias of pain thel he had made earlier. Aftera short time. Mr. Ng was carried onto the bus and transported 10 the Ic e ORO Hartford. CT offica.

II ia noted that the hendheld video camera was tumed on end off approxlmalely nina times duringthe approxlmataty 40 mlnule movement of Mr. Ng from his cell In the HSU to the bus In the outdoorseRy port area. (E N 1)

On the same data. Captain _ provided a report of the Incldent involvtng Mr. Ng. Captain_ advised that he was assigned to assist in the escort of Mr. Ng to the R&Dunit inpraparation for court that day. captain _ raported that Mr. Ng was ~ i a n twith hisinslrUctlonsand needed to be ~ I ; i i ' i i i l i i i i f t othe R&D unit Captain _ reported thatMr. Ng was assessed by LPN _ to ensure that he was not injured whHe being assiated.

Captain _ f u r t h e r eported that aftar the conclusion of Mr. Ng's medical assessment, hewas provided his prescnbed medication and placed In transportation reslralnts. Ca p ta ln _reported thai Mr. Ng was physically Ufted under his arms and by his feel. and placed on enawaiting bus for IransportaUon 10 court . ! i ! ! ! ! I I _ f u r t h e r aported that the escort wasvideo taped per Instructions rrom M a j o r _

prelparEKIa WDF Incident raport explaining hia involvement with the T ensport ofreported that he was Instructed by the Shift Commander to assist in movingR&D unit and then 10 en awaiting bus. 6 g 1 . _ eported that he was

Ng because he was unable to walk on his own.

OFI'JCJALUSE ON!.Y

a WDF Incidentreport explalnlng his Involvement with theM",f>rtold that he was assigned 10 8ssial In escorting a

thet Mr. Ng advised thai he could nol walk. Officercarried Mr. his arms and onto en

8ENSITMl


16/33

OFFICIALUSE ONLY SENSITIVE Page 16 of 33

DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

10.

COMr.bus.


HB 42QO.()! (37). $petia) Agenl Handboo'

pre:palred a WDF incident report explaining his involvement with the transport ofreported Ihal he was assigned to move Mr. Ng from the R&D uoillo an awaiting

SU I l e u Ihal he carried Mr. Ng by his len arm.

DfllDa,reda WDF Incidenl report explaining her Involvemenl with Ihe transportadvised Ihal she was inslructed 10 video lape the movement of Mr. Ng on

July 30. that she was instructed by Calpta,inrecording the movement Ng. in order to deescalate Mr. Ng's bellaviar.reported that while recording. it was determined Ihat Mr. Ng's behavior escalated.further reported that once Mr. Ng was secured in a cell and the door was closed. the camera wasshut off and turned over to C a p t a i n _

COMr.awaiting bus.and legs. (EN 2)

o r ~ ! o a . r e da WDF incidenl report explaining his involvemenl with the Transport ofr"nnr".nlhal he was assigned to escort Mr. Ng from Ihe R&D un II 10 an

t eDOm!O Ihat Mr. Ng was noncomplianl and was carried oul by his arms

' r i ~ ~ ~ ~ ~ e ~ aWDF Incidenl report explaining his involvemenl with Ihe T r a l n s ~ ' o r tMr. Ng. Ihal he was assigned 10 escort Mr. Ng to the R&Dreported Ihal Mr. was several orders to stand and PUI his shoes on.that Mr. Ng failed to inslructtons. slaling that he could not move.thaI he and Caplain Mr. Ng in pulling on his shoes and then movinghim 10 lhe R&D unit. Ihal the detainee decided not to use the muscles in hislegs and was carried arms to the R&D unit.

Mr. Ng arrived at the Hartford ORO office and was carried off the bus by Hartford ORO officers andplaced inlo a wheelchair and brought to the ORO offICe on Ihe 5th Roor. AI the office. Mr. Ng metwilh I ~ Mr. Ng was interviewed as to why he did not attend his scheduled CT scanon July 29. 2008. Mr. Ng was afforded Ihe opportunily 10 make numerous phone calls 10 his family

and his attorney. It was noled thai while althe Hartford ORO office. Mr. Ng did not appear tobe

inpain. Mr. Ng was released back to the cuslody of lhe WOF officer without incident.

Mr. Ng arrived back to the WDF at approximately 17:30 hours. Mr. Ng waS again carried byseveral officers from the transport van to his cell in the HSU. There is a videotape of themovement of Mr. Ng from Ihe transport van 10 his cell. This is video from stationary cameras inWOF and Ihere is no sound. On Ihe video. Mr. Ng is shown being carried stomach down by four(4) WOF guards. One guard is holding each arm and leg. Mr. Ng has restraints on his hands and

OffiCIAL USE ONLY SENSITIVe


17/33

OFFICIAl. USEONLY

DEPARTMENT OF HOMeLAND Sl!CURITY

REPORT OF INVESnGAnONCONTINUAnON

HB 42lIII-01

Page 17 o f 33

1. CAS!! NUMBER

feet. The WDF guards place Mr. Ng on his bed faee-down. The reslnlints are removed from hisfeet and hands. The guards tum Mr. Ng over 80 he Is laying on his back and a medical slaff; Itappears to be a doctor, kneels down by Mr. Ng and appears to be evaluating him. No wheelchairwas provided for his movement.

P ~ I ~ ~ l i i a ~ W ~ D ~ Fincident report explaining his involvementwhen Mr. Ngreturned to the IF CO reported thet upon the arnval of the transport van. he openedthe rear door and observed Mr. Ng sitting upright. CO _ reported that Mr. Ng would not getout of the van. CO _ repQrIed thai supervisors were on the scene and Mr. Ng was thenearned to !he medlcsl unit. CO _reportedthet he observed Mr. Ng hed urinated on himselfwhile lyingon his bunk.

Incident report explelnlng his Involvementwhen Mr. Ngreported thai he assislad In moving Mr. Ng from the InInaport

van securing Mr. Ng'sleft ann asslsled him to the medical unit. CO _ r e p o r t e d thet heprovided Mr. Ng with his dinner and a second rnsttraas par medical ardara.

CO a WDF Incidenl report elq:.'alrlinghis InvolvementwhBI1Mr. Ng_reported to the WDF, Mr. Ng rel'used tostandup and walk by himself Inlo the facility. CO reported that he and three other officerswere dlrecled by a supervisor to pickUp Mr. Ng by hI1I anns and legs to the HSU forevaluation.

COreturned to theby himself. COvan to !he HSU.

incident report explaining his Involvementwhen Mr. Ngreported thet upon erT1val to the WDF, Mr. Ng refused to walk

he and three othar officers earned Mr. Ng from the InInsport

CO Incident report explaining his involvementwhen Mr. Ng

returned to !he theI~

the activity watch for Mr. Ng thai evening, heobServed Mr. Ng lying on his back asleep. CO _ further reported thai Mr. Ng received hisdinner withoutany Issues.

The CO incident reports were reviewed by their supervisors thet same day. Despite theirknowledge that Mr. Ng hes complained about back pain and his requests for a wheelchair, theWDF Suparvlsotl characterize Mr. Ng'S behavior as "non-compliant"and a "distraction.'

the raUOnale for shutting off the numerous Urnes the move of

OFFICIAL USE ONLY SENSITIve


18/33

OFF1CIAl. USE ONLV SENsmVE


REPORT OF INVESnGAlIONCONTINUAnON

lIB &20041 (37). $l l l lCl l lAeln t_

Page 1. of 33

1. CASE NUMBER

Mr. Ng from his room \0 the traMpart van was \0 "de-escalate the situation"; however, there Is noevidence of what behavior Mr. Ng was exhlbilingthat would necessitate any sortof de-escalation.(EN 3)

July 31,2008:

CO prepared a WDF Incident report explaining his involvement afler Mr. Ng wasretumed \0 the HSU. C O _ r e p o r t e d that he did nol nolice Mr. Ng performingany type ofacttvitybetween 23:00 hours, on July 30, 2008, until08:00 hours on July 31, 2008. He stated thatMr. Ng appeared \0 be sleeping on his back and his rightside during the night.

At approximately 08:00 hours, CO _ prspared a WDF report explaininghisInvolvement eller Mr. Ng returned to the WDF on that date. CO reported that he did notwitness Mr. Ng perfonning any activities during the aCtivitywatch 23:00 hours, on July 30,2008, until06:00 hours, on July 31, 2008.

PAlIP81'E1d a WDF incident rep01l explaining his Involvementwith Mr. Ng in thereporleld that he witnessed Mr. Ng eat his breakfast lind lunch, and that he

on his bunk and storege bin.

Mr. Ng was scheduled for a visit with his attorney. ~ this time, Mr, Ng was transferred from theHSU \0 the contaet visitation sscUon of the WDF. The movement was recorded via hand heldcamcorder. During the movement. Mr. Ng did no! appear to be In any pein end appeared tocooperate with ollieara and medical staff. Mr. Ng did no! display any discomfortIn his movements.

The video eteerly shows Mr. Ng being transported vie wheelchair to his appointment atapproximately 16:50 hours. At approximately 19:45hours. Mr. Ng's visit with his allomeyconcluded. and he was transported back to the HSU vie wheelchair. Mr. Ng did nol display enysigns of discomfortor pain during this movement.CO _ _ repared e WDF Incidentreport explaining his Invotvamentwith Mr. Ng. CO~ t he observed Mr. Ng lilting on hie storage bin In his cell. CO _ r e p o r t e dthat Mr. Ng hed b e ~ na change of clothes and was put In a wheelchair, In order to attend anattomey visit. CO _ s t a t e d that Mr. Ngwas given his dinner tray withoutan y Issues.

a WDF incident his Involvementwith Mr. COOFF1CIALUSE ONLY 8ENSITM!


19/33

OFFICIAL USE ONLY 8EN81TNE



H84200-01

P 8 8 111 0 ' "

1. CASE NUMBER

_ r e p o r t e d that he observed Mr. NO after he attended his visit with his attemev. C O _reported that Mr. NO was escorted, via wheelchair, to his HSU. CO reported that h ehelped Mr. NO out of the wheelchair with the help of m.ne reported that theenUre Incident was reClOl'ded on video by Shift Commander U B ! J l e ~ l a n l

prepared a WDF Incidant report explaining his InvolvementreportEld thaI Mr. N ~ from a wheelchair 10 his bed after

relurnlng from a visit attorney. MY_ r epo r t did not Identify any speallc Issuesregarding Mr. Ng'l condition.

August 1. 2008:

prelparEld a WOF~ o r texpleining his lnvoIvement with Mr. NOHSU. C O _ r e p o r t e d that Mr. Ng.lay In hie bed throughoutreported thaI Mr. Ng urinated and defecated on himself. CO

medical staff and other officers cleaned Mr. Ng.

Dr. _ MD, scheduled an emergency CT scan for Mr. Ng at the Memorial Hospital InPawtuckaI. RI. At approximately 14:50 hours, Mr. NO was transported to MemOllalHospital InPawtucket, Rhode lsIand by members of the Central Falls. RI, Rescue Squed. The movement wasvideotaped by WDF ofllcers. At the time of the movement, Mr. Ng appeared 10 be calm and notexperlenang any discomfort.

In the video. the voice of one of the Rescue Squad omcers clearly asked the nurse on duty (laterIdenURed as LPN_IfMr. Ng could walk. The nurse repned thet Mr. Ng could not walk, butthat he could cry end whine. At this time. the Rescue omcer advised Mr. NO that they were goingto bring him 10 the hospital. At this time, Mr. Ng was placed on a whealed gumey without Incident.

While lying in the gurney, one of the Rescue omcars observed bruising on Mr. Ng's arm, and asked

how he received those bruises. Mr. Ng replied that he was dragged through the hanway. At thisUme, Mr. Ng wa l placed In transport restralnls withoutIncident. During this movement. Mr. Ng didnot appear to be experiencing any discomfort. Mr. Ng was moved out of the HSU wlthoullncldent.

A WDF Incident report was prepered by H S A _ . HSA_ epened that Mr. NO wesunable ~ t on his legs and was periodically Incontinent. HSA further reportedthaiDr._MO.ordered an emergeney CT acen and Mr. NO was 10 MemOl'iaI

In Pawtucket, RI.

OFFICIAL USE ONLY SEN8ITIVE


20/33

OFFICIALUSE ONLY SI!NSlnve ' ... 2Oof33



H842QO.111

Another Incidenl report '!!!!.I!!!pared by regarding his contact with Mr. Ng alMemorial Hospilal. CO _ reported thai to him that "Whatever Captain draggedme In R&Don Wednesday Is going to should jus t sign the house over to my wife, goback to Hong Kong and kll myself." reported that after Mr. Ng made the commentsregarding suicide, he advised Mr. Ng that he needed 10 remain posil lve and consider his family.

CO further reported that he was present while the Doctor explained the resulls of his MRI.CO that the Doctor edvlsed Mr. Ng that his injuries were praexJstlng. Mr. Ng toldthe that they happened while in the faeRlly. The Doctor then notad the bruising on Mr. Ng'sarms. Mr. Ng edvlsed thai they were a result of being dragged from the facIHIyand the courthouse.CO _ fur!l!!!!:.!:!Por thai the Doctor advised thai i t may be something for social services 10look into. CO _ reported thai the Information was passed on to his supervisor.

1'II1hll'1I19:52hours, M a J o r _ e d l l l s e d , l I l a emall .WardenSallsbury.AW_andMr. Ng was admitted to th e hOSPItal and that an MRI revealed potantlaillertebrae

problems and a possible tumor In his liver.

hours. C a p t a i n _ a d v i s e d , via email. the HSU, Warden Salisbury.and M a J o ~ ato the results of Mr. Ng's MRI. II wes necessary

the hospital for further observation.

At a ~ m a t e l y21:30 hours, M e J o r _ a d v i s e d , via emall, Warden Salisbury, AW _ andAW _thatMr. Ng was golng 10 be moved to 10 be pieced in aneurological bad. At approximately 23:41 hours, edvlsed thai Mr. Ng was moved toRhode Island HOSPItal.

ICE ORO was notified that M : . ~ mthe WOF 10 Rhode Island Hospital, 2 DudlayStreet. ProIIldence. RI. ( S I R " - -

Augusl 2, 2008:Beginning on this dille, email correspondence between Warden Salisbury and other WOF staffmambers. Indicated that necessary arrangements were made to facilitate family and legel counselIIlslts at the Rhoda Island Hospital.

Augusl4. 2008:

OfFICIAL USE ONLY 8EH81T1VE


21/33

OFFICIAl.USE ONLY 8EH81T1VE


REPORT OF INVCSnOAnONCONnNUAnON

HlI42IJO.01 (37). S;oodaI

PageZ1of33

1. CASE! NUMBER

In a letter 10 WDF Security Staff, Warden Salisbury informed officers that Mr. Ng was 10 remainresIraIned (soft reslnllnts) and under dose observatlon. Further. an unarmed oftIcer was 10 remainIn \he room with Mr. Ng at aD Umes. Telephone calIS and television ware authorized and needed 10be documented In the log book. Femllyand attomey visits were authorized. Wardan SalisbUry

advised that theee dlrecUves ware a deviation of normal policy and only pertained10

Mr. Ng.August 5, 2008:

Multiplerelellves ware scheduled 10 visit Mr. Ng In the hospital. At approximately20:01 hours,Major_ dvised \het Mr. Ng's familyhad visited him and lhen left the hospltel withoutIncident.

AugustS, 2008:

ICE ORO S D D O ~ a snotified by WDFAW _ l h ! r t ~ r . t mhad passed away al \heRhode Island Hospltelal approximately 01:22 hoUIS. ~ i m m e d i a t e l yadvised ORO~ S I I U a l l o nand a Significant Event Notillcetlon was created. (SIR

INITIATIONOF THE INVESTIGATION:

On August 19, 2008, the Investigation was assigned 10 the ICE, Office of Professional~ ~ (CPR). Rellidenl Agent In Charge (RAC). Portsmouth. NH ofllce under file

On December 11, 2008,ICe received the Autopsy Report from the Rhode IsIend Department ofHealth. In this report, \he Chief Medical examinerconcluded that Mr. Ng cause of death wascomplication of metastatic hepatooellular carcinoma and the manner of death was nalurel.

During the course of Its InvasligaUon, OPR intervieweda loIal of 15 8 Individuals10 Include: ICEORO Hllltford. CT employees; personnel and detalneas al the Franklin County Jail In St. Albans,VT; the Franklin County House of CorrecUons In Greenfield, MA; and the Wyatt Delention FaclntyIn Cenlnll Falls, RI. In eddltlon 10 the Interviews conducted. CPR was able to review and obtaindocumentary Information at each locallon 10 Include: medical records. detainee files. facUltypolicies and reports, video surveDlance tapes and Intamal correspondence.

ISSUE ONE: Danlal of Medical Care

OFFICIALUSE ONLY IBNsmvE


22/33


23/33

OFFICIALUS! ONLY SEN8lnv!



H 9 4 ~ t

Peg.nofl3

1. CASE NUMBER

cell door wIIhout proper assistance. By failing to lake appropriale action bringing the presc:r1bedmedlcetion direclly to Mr. Ng, the facility had ~ e n l e dMr. Ng his medication. (EN 8) Thisrepresents leilure to perform on the pert or LPN _ . f Mr. Ng stated !hat he couldn't come tothe door for his medicallons. il was her duty to either ensure that he rec:elvas his medication or toobtain a signed medical refusal from the detainee and 10 report this to a medical authority. Withoula signed refUsal It Is noIln 8 nurse's scope of precUca to withhold rnadlc:atlon ordered by aphysician. DoIng so represents medical d a c : i s I o n m a k ~ n dher aulhorlty Ell an LPN. ThereIs no record In the medical chart to indicalethal LPN _ I n f o r m e d 8 medical provider of hisincidenl nor Is there 8 medical refusal form In Mr. Ng's file.

The second specific denial occurred on July 29, 2008. Mr. Ng was schsduled for a CT scan alRhode Island Imaging on thai date. Mr. Ng requesled a w h s e l c ~ e rto attend this scan.According10 facility records, the wheelchair was denied by ON _ because Ihsre was nostanding order In placa at that time for Mr. Ng to utilizea wheelchair. (EN 9)

The WOF recorda describe this as a "refusal" by Mr. Ng: however, there is nothing In the WOFrecords thai indicates Ihst Mr. Ng actually "refused" 10 attend Ihs appointment Relhsr heIndicaled thai he was unable 10 move without the assistance of a wheelchair or oIhsr moblltydevice. WOPs denial of Mr. Ng's request for a wheelchair constructively denied Mr. Ng access tothe presaibed scheduled CT scan. (EN 10)

In addillon 10 the denials of access to approprlale medical care on July 27 and July 29, It is unclearfrom the records whether a WDF doctor properiy evaluated Mr. Ng after his trip 10 the PawluclcstHospital emergency room on July 26. The medical progress notes dated July 26, stale that Mr. Ngwas unable 10 walk or bear welghl on his legs and he WEll &enllo the hospital for an evaJualion.He was sent back 10 WDF with discharge papers and three (3) presc:r1ptions. The only note In thefile aflar he was released from the Pawtuckel Hospital on July 26 is dated July 27 stating that Mr.Ng returned 10 WOF, appears stable, and Dr. _ MD, was aware of Mr. Ng's "situation.While Mr. Ng was seen by RN _ o n he July 27. there Is no Indical/on thai a doctor met

with or evalualed Mr. Ng after his retum from the hospital. There is no Indicallon thel a doctorevaluated Mr. Ng'8emergency room dlecharge papers 10 determine a course of treatment. In fact.according 10 the medical records Ills not untIlJuly 29lhst Mr. Ng Is 8981n seen by a doctor. (EN11)

This is a failure on the pert of RN _ t o lther properly inform the physician of Ihs ERevaluaUon or 10 sutllclenUydocuni8riiihli1O the medical record. The ER documents have clearorders and InstruClions thaI were neither translated to the WDF medical record nor shown to have

OfFICIALuae ONLY SEN8ITIVE


24/33

OI'FlCIALUSE ONLY SEN8ITIVE



H 8 4 ~ 1

Page 24of33

1. CAse NUMBER

been evaluated and dismissed by a WDF provider. Thisconstitutes medical decision-making onthe part of the RN and Is beyond her scope of practice or authority.

ISSUE TWO: Denial of Access to Counsel

Findings:The Investlgallon revealed that while detained et the Frankftn County Sheriff's OffIce In Greenfield.MA.and Franklin County Jail In St. Albans. VT. there was never any Indlcetion that Mr. Ng wasdenied acce. . to his altomey. However. our invesUgation revealed that on July 26. 200B. whOedetained at the WOF. Mr. Ng was constructively denied access to his attorney.

The InvestigaUon revealed that Mr. Ng did not meet with his attorney on July 26, 2008 because anot provided to take him to this scheduled meeting. Through the on-site CO.Cap ta ln_ nformed Mr. Ng that he would not be allowed use of a

Instead ~ u l r e dto walk to the attorney visitation room. (EN 12)

According to Captain_ . hat decision came from M a l o r _ . he on-duty supervisor atthe facility. Based on this denial. Mr. No decfmed the altomey visit. Mr. Ng's ~ sInformed that Mr. Ng had declined the visit by the on-duty supervisor Cap ta ln_Given that on July 24th. just two days prior. 0,._MO. hed submitted a consultationrequest for a CT seen for Mr. Ng. noting that Mr. Ng was suffering from pain and weakness andwas unable 10 stand or walk. It Is clear that he was not "refusing" to meet with his altomey on July26th as notad In the facility reports. A mora apt description Is that he was physlcaDyunable to doso by walldng under his own strength or with the use of the prescribed cane. In fad. the amcerattending to Mr. Ng at the time of this requested a wheelchair for Mr. Ngrelaying to his commanding oflk:er. Captain Mr. Ng was "In need of a wheelchairand wasn'actually refusing his attorney It Is evident that at the time, officialsat Wyatt were viewing Mr.Ng as being purposefully "non-complalnt" an d classified this incident as

a "rafusal" to cooperata. Given Mr. Ng's condition as documentad In his medical reports, end thacircumstances of the Incident as repoded by the CO who was physicaDy present with Mr. Ngand Inthe bast poslUon at the lime 10 essess his behavior and needs, by denying Mr. Ng a wheelchair orlike mObilitydevica, the facility conslrUclively denied him access to his attorney. Further, It wasmedically epproprlate to accommodate Mr. Ng's reported pain and inabUItyto ambulate with theuse of the cane. This should have been determined by a medical provider and not by Captain- .

non-medical officer. (EN 13) This represents a failure to provide orf8clNtate edequate~ are or accommodaUon.OI'FICIALUII ON!.Y


25/33

OFF1C1AL use ONLY SENSITIVE

DEPARTMENT OF HOMELAND SECURITY


HI 421JO.01 ( 3 1 ~

ISSUE THREE: Inappropriate Denial of Use of Whaalchalr

Findings:

Page2Sof33

1. CASE NUMBER

The Invesllgallonrevealed that Mr. Ng requested and was specllically denied use of a wheelchairon July 26. 29. and 30.

As detailed above, on July 26 Mr. N ~ e da wheelchair to facilitate his attomey client visit.His request was denied by Captain _ and Mr. Ng was unable to meet with his attomey atJhat tima. At Jhe Ume of the denlel, no medical personnel were consulted end the on-dutysupervisor denied the request at approximately 16:00 hours.

Less Jhen two hours later, Mr. Ng was evaluated by RN _ w h o mede the determination thatMr. Ng could not walk and was In need of a wheelchair and made the request that he be sent to alocal hospital for fUrther evaluation. (EN 14) Mr. Ng was given a wheelchair and transported to thehOSpital where he was examined by a doctor and diagnosed with sciatica (lower beck pain). Thedoctor slated Mr. Ng should receive pain medlcaUons for his condition and that Mr. Ng beschacllied for en MRlto further evaluate his condition.

On July 29. Mr. Ng requested In order 10 attend his scheduled CT scan. S O t . -notifiedhis supervisor Caplain and department. AccordIng to fscllltyrecords, the wheelchair was the DN because there was no standing order Inplace at that time for Mr. Ng to utilize a wheelchair. Due to the denial, the on..


26/33


DEPARTMENTOF HOMELANDseCURrrY

REPORT OF INVESTIGAnONCONTINUATION

H a . 2 0 ~ l

Page 2S of 33

1. CASE NUMBER

He further slated thai he did nol know althallime lIat Mr. Ng was physlcally unable" to attend hisappointment because his staff reported tha incident as Mr. Ng "refusing" his medical treatment.

On July 30, Mr. Ng was scheduled 10 attend an appolntmenl at the Hartford ORO office. As nowheelchair was provided for the trensport, Ills apparent that either Or. _ MO's, Slandlngorder authorizing I wheelchair for transport that was contained In Mr. Ng's medleal records waseither nol known 10 facility slaff conducting the transport or was Ignored.

Mr. Ng's transport to Hartford was videotaped per the Warden's order. The videotape clearlyshows that:

1. Mr. Ng requested a wheelchair and that request was denied by C a p t a l n _

2. The camere wes repaatedly shul off and tumed beck on altha request of Cap ta ln_ ndirect vlolaDonof WOF Policy Number 206(K) and the Warden's order; and

3. The on-duty nurse, LPN was presenl during the transport and by slaOng thatMr. Ng was In fact able to an Inappropriate medical assessment outside the aoope ofher authority withregard 10 the medleal sllueUon. This assessment directly contributed 10 thes u ~ c t I v I t yby the detention steff In moving Mr. Ng without the aid of a wheelchair. HadLPN _ performed her duty and contacted a medical provider, the physician notes end orderfor a wheelchair given the previous day would have been discovered;

After r e v l e w I ~videotape of Mr. ~ ' s trensport of July 30, the Warden verbaUy instructed AWs_ a n d _ a n d M a j o r _ o ensure that Mr. Ng ulillzed a wheelchair for all movementwithin the facility andthat those movements be videotaped. It appears those Instructions warefollowed whenMr. Ng was videotaped being transported to visit with his attorney on July 31.

Accordingly,the faclnty Inapproprialely denied whselchair 8CC8$S to Mr. Ng on July 26, July 29,

and July 30. Any argumenllhal a wheelchelr maybe

provided with a specific medicalaulhorizaUon Is undermined by the fact that on at least one occasion (the evening of July 26), awhee/cheir was used without eny specific medical authorization form. The failure to provide Mr. Ngwith a wheelchair constructively denied Mr. Ng access to both his attorney and medical care, asexplained above.

ISSUE FOUR: VloisUonof Use of Force Policy

OFFICIALuse ONLY SENSITIVE


27/33

OFFICIAl. USEONLY SINSlTIVE P8118 27 of 33

DEPARTMENT OF HOMELANDSECURITY 1. CASE NUMBER

10.

Findings:

REPORT OF INVeSTIGATIONCONTINUATION

" 4 2 G 0 4 1 (31). 8 p e c i l l l A I I ' . U _

WDF staff vlolated applicable Use of Force policies during July 30 transport of Mr. Ng.

It is apparent that Mr. Ng did not "rafuse"10 meet with l E A _ I n Hartford. CT. on July 30 (EN15); rather he was physically unable to do so by walking under his own strength or with the use ofthe prescribed cane. Fully appreciating thai Mr. Ng's phyalcal condition and associaled physicalpain progressively worsened over a very short period of time. he had cleady bean diagnosed withsevere back pain by July 14. 2008. at which point Dr._.MD. prescribed the drugs Flexerland Vicodln, and also recommended accommodation or his physical condition by moving him to abottom bunk to make It easier to get into his bed.

Between July 14. 2008. and 30,2008. the record Is repleta with Incidents where both Wyattmedical steff on notice that Mr. NO suffers from back pain. On July 16, DN

Informed Mr. was being treated for chronic back painDI'II!l:lIerilbAdmedications. auIhoI1zes use of a cane due to

back pain and difficulty walking. On July 22. ON notified by Mr. Ng'sthai Mr. Ng's condltlon continues to worsen. On Ng Is examined end the recc)rdsIndicate that his back I!!!!:!..!!!s not Improved and he una\)le to stand or put pressure on his rightleg. AccordIngly,AW _ requests from ICE, and recaJves, approval for an expedlled CT scan.

On July 26, Mr. Ng Is observed by a WDF officer hsvlng dlmcully getting up from his calilloor and.according to Captain_ , equired the another detainee to 11ft Mr. Ng Into aseat. That same day he Is also observed by RN falUng to the floor when he attempted tostand up with the use of his cane. On July 29, a report by Sergeent (Sgt.) __ Indlcetes thai Mr. Ng Is observed silting on his bed, crying and stating thel he could notmove and Is unable to attend his medical appointment. Latar that same evening, Mr. Ng wasexamined by D r . _ D, who advised In his p r o g ~ a IMr. Ng had weakness inhis right leg. was una\)le to stand and was constlpaled. Dr. _ MD, edvlsed thai he

explained to Mr. Ng that a CT seen needed to be done as soon as possible. D r . _ MD,advised that Mr. Ng may need asSistance wHh trensponaUon end aulhDrized the use of awheek:hslr at thet time.

Over approximately the same period or time, Mr. Ng was placed under an "activity walch" todetermine the veracity of his medical complaints. That acllvlty watch, however, apparenlly foundlitUeor note as the relevant ac\lvIty reports offer nothing or note.

OFfiCIAl.USI ONLY IINSlTIVE


28/33

OFFICIALuse ONLY sENSInve


REPORT OF INVESTIGAnONCONnNUATION

H84200001

Page28of33

1. CASE NUMBER

Simply stated, we lind no evidence supporting Ihe Isseltlon lhet Mr. Ng was In fact beingnon-compliant" In any wilIng sense, or that It was reasonable 10 view his as rafUslng or beingnon-complaintduring the operative time frame. Moreover, there are no IndrcaUons or allegationsfor that matter that he waa In anyway offering resistance 10 guards or medical staff at Wyatt. Use

offorce In this

contextIs

in complete violationofth l ICE

NationalOetenUon

Slandard(NOS) on

Use of Force. whk:h prohibits use of force against I detainee offering no raslstance. Even Ifhewas viewed as non-compliant. there Is absolutely no IndlcaUon that Mr. Ng offered any resistance.

Even assuming, however. that Ng could reasonably be viewed as "non-compltant" and that the useof force was appropriate. Warden SaUsbury concedes that Wyatt officers then violated their ownuse of force policies during thalr contact with Mr. Ng on July 30, 2008.

According toWOF Policy Number 206. Section K. the Shift Commander willdesignate a slaffmember qualified to operate the video recorder to record the movement Each video recordedIncident waJ be InlUated verbaUy on tape by Ihe assigned recorder with the follOWingInfonnaUon:

1. Current data and Ume;2. Neme and tlUe of person operaUng the video recorder;3. General and spedllc location where Incident Is being recorded:4. Names and tiUes of staff members Involved In Ihe use of forca;5. Name and tiUe of on-scene Commander;6. Namas and titles of s1Bff members ancllor visitorswllnsssing the incident: and7. Name of dalalnee(s) Involved In the incident

All incldenlsare to be recorded In their enUrety. If there Is an equipment failure during therecorcrll1g of Ihe incident, a fullwritten report willbe submitted by tha assigned operator.

Upon review of Ihe vldeolape and reports, Warden Salisbury Identifies numerous direct violations

of the WOF policy and his eman directive of July 29. Based on the WOF poncy, the videotapefailed to Include Ihe title of person operating the video recorder; location of the incident beingrecorded; name and title of staff Involved;neme and title of the on-scane Commander; name anduue of staffanellor visitors witnessing the incident. Additionally,the Warden noted that !hera wens12 breaks In the taping. which Is another violationofWOF policy. The Werdan commented In hisaffidavitthat the vldeolaplng slopped after "a winkof Ihe eye" fron1 captain _ thesupervising officar.

OffiCIAl. ua l ONI. Y SENSITIVE


29/33

OFFICIAl.USE ONLY SENSITIVE

DEPARTMENTOFHOMELANDSECURnY


HS42QO.Ot

1. CASE NUMBER

In addition, WDF PoDcy Number 206, VIII.Po. 3. specifies that "Inevery case, only the minimumforce necessary shaD be uaed. As Is made dear from the videotape and reports of the July 30,incident.Wyattolflclals look Mr.Ng by his upper extremities and dmgged him from his cell to theR&Dunit and Inlo the awaiting van. Wardan Salisbury offers that policy and procedure In such

circumstance dictate that oftlcers use a wheelchair or gurney 10 effectuate a transport. Bydragging him Instead, Wyatt ofllcars did not UBe the mtnlmum force necessary and violatedeslabUshed usa offorce policy.

AW _ a l s o eviewed the videotape and Incidentreports of July 30, 2008. In addHlon 10 theWarden's affidavit. AW_AfterAction Report supporlsour ftndlngs thet the WDF staff did notfollowIts estabUshad policy and procedures and there was an overall fallum 10 exercise goodjUdgment in tha transport of Mr. Ng from his room 10 tha transport ven. (EN 16)

OFFICIAl.use ONLY


30/33

OFFICIALUSE ONLY

ENDNOTES

SENSITIVe


REPORT OF INVESTIGATIONExhlbltUat

H84200001

PI l i ' 31 of 33

1. CASE NUMBER

1.) A count by_Inspec tor, Professional Standards Unil. WOF, revealed that thecamera was s ~ a l o t a lof 13 tlmas. The breaks in taping range from a few seconds toa few minutes.

to Warden Salisbury. after reviewing omcer__ rtginalreport. CaptaindullmUlod thai raport and ordered Officer _ ~ r a p o r t .While Captain

was O f f l c e r _ oriOlnal report 10 be illegible, aCCOrding to theiiiii1iiiI'sed..!!2!!!.!!lcludethat Mr. Ng wal being

non-compuanL nor C a p t a i n _ a g r e e d 10 be Interviewed by OPR forpurposes of this Investigation.

3.) Major_ and Associate Warden a WOF Incident report.dated A u ~ b s s e dupon review of an submitted end videotapes of the July 30incident. The report summery findings are as follows:

a. Captain _ w a l he senior officer in charge overseeing Mr. Ng's move for transport 10

and from w"'Y8R"OiiTuly30.

b. C a p t a l n _ f a l t e d to exercise good judgment in violating established polley by direcllngand signaling the video operator 10 tum off the video camera no less than 9 tlmas.

c. Captain _ f e l l e d o Utilizeproper transport options (wheelchair and gurney). Insleadforcibly c a ~ d r e g g l n gMr. Ng from the Health Sarvlcas Unll to Receiving and DIscharge.This Is spscified a. a violation of established policy and procadura.

d. Captain _ e x h i b i t e d otal disregard for staff and detainee safely by transporting Mr. NgIn a mannerciiif1Y'UnauthOrized by polley and procadure.

e. Captain _ B l C h l b l l e d c o n d ~ 1unbecoming a senior officer by telling Mr. Ng to stopw h l n l n g a n ~ h l m 8__ dIof". \!JOrd ~ ( l ( k db-.j ?fO:pC.mv\f. Captain _ l a c k f Judgment and failure to adhere to established policy and proceduresubjected iheTaCiiiiYTofederal and clv"lawsulta.

The report wall received by the Warden's office on August 7. 2008.

Du.in" the 16-18.2008. revlaw Creative Correcllons of America,

OFFICIALUSE ONLY SEN8I11V&


31/33

OFFICIAL USE ONLY SI!HSmvE

DEPARTMENTOF HOMELAND SECURITY

REPORT OF INVESTIGATIONExhibit List

' lge31 0133

CAse NUMBER

was found not to be In compliance with the NOS requlremenlthal all detainees receive a medicalexamlnaUon within14 days of admission to a lacnlty. Wyatt hes been working with ORO oncorrective actions to address this.

5.) The file reflects thai Mr. Ng was given a 14-dayexam; however, the exam occurred on 7123. 20days after his arrival at WOF. Also. Ills unclear If the exam was done because of NOS or because

of his repealed sick allps.6.) According to C O _ ncidenl Report of thai day, at approximately 1 03p.m, nursesentared Mr. Ng. room to distribute medicine but when Mr. Ng "would not gel up to receive medicinetherefore he refused to take medicine.. Ifunable to move to receive his medlcatton. this should notbe charecterized .. "refusal" to take his pf88Crlbed madlclne. DlII:!!:Jl..!!!!evening Mr. Ng againstated ha could not get off the bed. Al dinnertime, according to CO _ I n e l d a n t Report. whenMr. Ng staled he could nolgel oul orbed to receive his dinner lood tray, C O _ " w a n 1 overand handed delalnee Ng his trey."

7.) WOF polley has subsequently been changed. As 01 November 5,2008.11 the delalnee cannotattend the Medication Une, medical personnel wnl respond 10 tha delalnee's call or Iocatton to

administer the medication.8.) Affidavitsof Wyatt employees. MT_ RN _ and others. Indlcale that leading up tothis Urneframe. it was a common theme of discussion that Ng was having difficulty coming to themadlcatton line and using the assistance of other detainees and a chair to get his med'lC8tton.

9.) II was not untillater that evening that Mr. Ng was evaluated byDr._.MO. whoapproved an order for the use 01 a wheelchair.

10.) AddlUonally. onJuly 8. 2008. Mr.Ng requesled to see a doctor. advising that he had not sleptfor two nights because of back pain. Again. on July 10. 2008. Mr. NO again requested to see adoctor for beck pain relief. In his requesl Mr. Ng sliltes "[PJIease arrange doctor visit for me whenhe comes to facilitynext time. The WDF medical records It was not unlll July 14,2008. that Mr. No was examined by

Dr._MD. MD. then prescribed Flexeril

(a muscle relaxant) and Vicodln (palnldlliijlO'i"iWO waek8. MD. rurthal'recommended thai Mr. Ng should be moved to 8 bottom bunk make It easier for Mr.Ng to get Into his bed.

11.) Althoughnot seen by a doctor. on July 27 LPN _ "Instructed" Mr. Ng to start "backexerciaes." The medical file does not indicate any madleel order that Mr. Ng do In y 801'\ of "backexercises' and there Is no Indicalion that Mr. was advised 01 particular exatd . . or thaOFFICIALUSE ONLY SEH8I11VE


32/33

OFFICIALUSE ONl..Y SENSITIVE


REPORT OF INVESTIGATIONexhibit List

1. CASE NUMBER

duration 0'exercISes for his condltlon. Additionally, characterizes Mr. Ng as "veryresistant to an insIJUctionand refused to stand and come for mads." Again, thecircumstances support a finding that Mr. Ng was very likely unable to walk and his actions were nota "refusal" but an lnablilly to move.

12.) Wyaltemployee COneed of a wheelchair to

that on July 26, 2008, Mr. Ng was Inalso noted that a nurse hed

commented that he, Ng, needed a whl,elchalrneeds.

could not adequalely care for Ng's

13.) In addition, whUaltIs not claar e x a c ~ M a J o r _told Captain _ regardingthe wheelchair and to what extent Majo r_ was aware of Mr. NO'S medlcai history at Wyalt, ata minimum there should have been further inquiry Rlgardlng the true nature of Mr. Ng's condltlon.

14.) RN _ hed been called by Captain_to lSess whether Mr. ~ I e toambulate after he had declined his attorney visit. WhHe evaluating Mr. Ng, N u r s e _ r e q u e s tthat Mr. Ng stand up by using his cane. Whle attempting to foUowthe Nurse's orders, Mr. NgcoIlapsad to the floor. Nurse _ then recolI"lIended that Mr. Ngbe sent to the MemorialHospital in Pawtucket, RI, for further evaluation as she was concerned that he may have hurthimselfwhen he fell.

15.) Warden Salisbury Identifies numerous other vlolalionsof pOlicyor his spsclfic instructions:

a. Medlcaistart Is not visible nor are they making medical decision during movemant from theHealth Services UnIt;

b. Mr. Ng is "dragged" In contravention of policy for movement of detainees;

c. Mr. Ng is placed on the floor for severel mInutes with no medical attention (Instead she (theattending nurse) yans at Mr. NO from outside the cameras view); and

d. The supervising officer, Captain_ does not accurately report the Incidentes perrequired poUcy.

In a d d ~ r t i C I J l a r l yO f f l c e r _rewrlle the report. WhIleto be tothatOFFICIALuaE ONlY 8EN81TMi

to


33/33

OFFICIALUSE ONlY SENSITM!


REPORT OF INVESTlGAnONExhlbltU.t -

Pa.a33 of33

1. CASE NUMBER

16.) As Identlfted by the Warden, that Captain violated establishedpolicy and procedures by . ~ the video oIf the video cameraa number of imes. Capta ln_ was found to have faled to utilize "proper and availablelransport options (wheelchair and gurney) and "elected" for "forcibly carry" Mr. Ng from his room tothe transport Braa.

OFFICIALUSI!ONLY SENSI1lVI!

ice investigation into the wyatt detention center

Documents