DEPARTMENT OF DEFENSE
UNITED STATES SOUTHERN comma
9301 aw sane STREET
norm. FL 33172

 

 June 23. 2013

Of?ce of the Staff Judge Advocate, Ref: SC 13-063
Of?ce of Freedom of Information

Dr. Jeffrey S. Kaye

Dear Mr. Kaye:

This is our Agency?s partial response to your electronic Freedom of Information Act request
dated December 13, 2012. Your request sought a copy of the full report with any appendices of
the AR 15-6 concerning to ISN 156 (Adnan Farhan Abdul Latif, aka Allal Ab Aljallil Abd a]
Rahman).

The search for information returned several documents of which we have completed review
of the enclosed document consisting of seventy-nine (79) pages. After our line-by-line review of
the enclosed documents we have made the following determination regarding releasability:

1) Portions of the redacted information are currently and properly classi?ed in accordance
with Executive Order 13526, Section 1.4 which pertains to intelligence activities, intelligence
sources or methods. Release of such information is not permitted under 5 U.S.C. 552 

2) Potions of the redacted information are exempted from disclosure by statute, namely 10
U.S.C. 130b, which authorizes protection of names of personnel overseas, or in senstitive or
routinely deployable units. Thus, this information is not released under 5 U.S.C. 552 

3) Portions of the redacted information pertain to the internal personnel rules and practices
of our agency, the release of which could allow circumvention of our agency rules and practices;
or is deliberative in nature, predecisional, and contains subjective evaluations, opinions and
rccorrunendations, which if disclosed would inhibit the decision making process. Thus, this
information is exempted from release under 5 U.S.C. 552 

4) Portions of the redacted information contain information that, if released would
constitute a clearly unwarranted invasion of the persooal privacy of individuals under 5 U.S.C.
552 (blt?l;

5) Portions of the redacted information contain information that, if released, could
reasonably be expected to constitute an unwarranted invasion of personal privacy of a living
person, including surviving family members of an individual identified in such a record. Thus,
this information is not released under 5 U.S.C. 552 

6) Portions of the redacted information, if released, would disclose techniques and
procedures for law enforcement investigations or prosecutions. or would disclose guidelines for
law enforcement investigations or prosecutions, such disclosure could reasonably be expected to
risk circumvention of the law. Thus, this information is not released under 5 U.S.C. 552 
and

7) Portions of the redacted information, if released, could reasonably be expected to
endanger the life or physical safety of any individual, as such this information in not released
under 5 U.S.C. 552 

Accordingly, the redacted portions of information are withheld and their release is denied
under 5 552 :5 (W1), (W3), (W5), (W05), (M0003), and by M?j?f
General (Select) Mark C. Nowland, US. Air Force, Chief of Staff, United States Southern
Command.

Should you deem Maj or General (Select) Nowland?s decision to withhold this information to
be an adverse action, you may submit an administrative appeal to the Director of Administration
and Management through the Defense Policy Of?ce. Any such appeal should be postmarked
within 60 calendar days of the date above to: Defense Freedom of Information Policy Of?ce,
Attn: Mr. James Hogan, 1155 Defense-Pentagon, Washington, DC. 20301-1155. Both your
letter and envelope should be clearly marked ?Freedom of Information Act Appeal." Include a
copy of this letter with your appeal. Please refer to our case control number SC 13-063.

We will continue to diligently process the remainder of the responsive documents to your
FOIA request. There are no assessable fees associated with this response. Please address any
further questions to the undersigned at (305) 43 7-1 108. Refer to our case control number SC 13-
063 for any future inquiries.

Sincerely,

(N/pxzr/
 dialogs


mmand FOIA Manager

Enclosures

(0) AR 15-6 INVESTIGATION

(U) REPORT ON THE FACTS AND CIRCUMSTANCES SURROUNDING
(U) THE 8 SEPTEMBER 2012 DEATH OF DETAINEE
(U) ADNAN FARHAN ABD LATIF
(U) (ISN US9YM-000156DP)
(U) AT JOINT TASK FORCE-GUANTANAMO (JTF-GTMO)

 

meal (bxemmc) 
(U) INVESTIGATING OFFICER

We) 
(U) LEGAL ADVISOR

 

 

 

 

(U) 8 NOVEMBER 2012

CLASSIFICATION DERIVED ROM JTF-GTMO SECURITY CLASSIFICATION GUIDE
DATED 5 FEBRUARY 2009

 

Classi?ed Ilnvestigating Officer
Derived From: Multiple Somes
Declassify On: 10 years after completion of detention operations

A A



Table of Contents
(U) Part 1: FACTS.
I. (U) Life of ISN156 at JTF-GTMO..
A. (U) Personal Background. .
Rm Communications with Family and Attorneys.
CW) Capture.
Diagnoses.

E. {941413696} History of Disciplinary Events and Self-Harm.

F. (U) Behavioral Incidents: JUne 2012.
G. (U) Behavioral Incidents: July 2012.
H. (U) Behavioral Incidents: August 2012.
1. (9.1391499 August-September 2012.
J. was) Events of 6 September 2012. .
K. Events of 7 September 2012. .
LEM-BUG) Events of 8 September 2012. .
M. (U) .Timeline.
11. (U) Listing of 56's Recent Prescribed Medications. .
A. (U) Prescribed, As-Needed Medications. .
B. (U) Prescribed, Scheduled Medications. .
C. (U) Administration of Invega.
(U) Cause of Death of ISN156.
IV. (U) Joint Task Force-Guantanamo 
(U) Joint Detention Group (JDG). .
A. (U) Leadership and Command Structure. .

VON-DUI

B. (U) Camp V, Detainee Hospital, Behavioral Health Unit..

C. (U) Training.

D. (U) JDG Standard Operating Procedures (SOPs). .
l. (U) JDG Procedure #27: General Guidelines for Camp Operations.
2. We) JDG SOP #53: Sally Port Operations.
3. M91499 JDG Procedure #22: Wildlife and Pest Control.

4. JDG Procedure #30: Detainee Camp Rules and Standards of

Conduct.
1% JDG Procedure #34: Search and Inspection. .
6. We) JDG Procedure #56: Line of Sight.
1% DG Procedure #66: Medication Pass Procedures.
8. JDG Procedure #82: Detainee Death.
(U) JOINT MEDICAL GROUP (JMG). .

A. (U) Leadership.

B. (U) Training.

C. (U) JMG Standard Operating Procedures 
JTF-JMG #1 Medication Administration Policy. .
#60: Cardiac Arrest Procedures.

(U) Part 2: FINDINGS.

(0) Part  

(U) Executive Summary

1. (-5-) This Army Regulation 15-6 Report provides the facts. findings. and recommendations of
the United States Southern Command (USSOUTHCOM) ittvestigation into the facts and
circumstances surrounding tlte death of detainee Adnan Farhan Ahd Latif ISN 156.
a 31-year old citizen of Yemen, had been a detainee at Joint Task Force?Guantamuno UTF-
GTMO). Naval Station Guantanamo Bay. Cuba sineeEllanaary diedB. .. .. .
September 2012 in his cell at Camp at This Report makes ?fteen findings and
offers seventeen recommendations.

[bli?liSEC lite)

2. {Wi?he Armed Forces Medical Examiner (AFME) determined the cause of death of
156 to be suicide by overdose of paliperidone (lnvega). [56 had 24 capsules of lnvega.
an drug. in his stomach at the time of death. The toxicology examination revealed
the presence of paliperidone (lnvega). codeine (Tylenol oxycodotte {Percocel}, quetittpine
(Seroquel). mirtazpinc (Renteron). and citalopram (Celexa). morphine (by-product of Tylenol
oxymorphone (active ingredient in Pereocet). and loraxepam (Alivtut) were prescnt in the
system of at the tinte of his death. lSNl?? also had acute pneumonia.

3. (W83 156 had an extensive history of disciplinary and self-harm attempts while
detained at JTF-GTMO. Because of his unique issues. guards and medical personnel frequently
treated 56 differently than other detaittees. Many guards attd ntedical personnel indicated
that ISN 156 was an exceptionally challenging detainee.

4. W?uards and medical personnel repeatedly violate various Joint Detention Group
(3 DO) and Joint Medical Group Standard Operating Procedures (SOPs). In some cases.
the guards and medical personnel are unfamiliar with the SOPs. other cases. the guards and
medical personnel are familiar with the requirements but for various reasons. fail to follow them.

5. [Win the case of lSNle. the JDG guard force failed to follow the JDG Line ofSight
SOP and the JDG Med Pass SOP. and failed to take remedial measures after appeared to

be sleeping an unusual length oftime. Likewise. the JMG personnel violated the JMG Med Pass
SOP.

ti. (W  56 hoarded medications and ingested them shortly before he was found
unresponsive in his cell. Several factors contributed to the ability of to hoard
medications. These factors inconsistent JDG and JMG SOPS with respect to Med Pass,
confusion on the part of the guards. leadership (camp. JDG. and MG) regarding what
the SOPs require. and in many cases. failure to comply with Med Pass SOP requirements.

7. {Wt-l MG training procedures and record keeping were also ?awed. This contributed
to the Med Pass violations and to confusion of personnel. The MG commander and JMG
senior leadership. including the Senior Nurse Executive. appear largely removed from several

 

SC000004

 a
I 

asme of what is going on at the tactical level at the Behavioral Health Unit Detainee HOSpital
and the camps.

Other SOP violations impact the operations of the camps. Generally, the JDG and
IMO leadership do not communicate effectively to ensure that their respective detainee
operations practices and policies are consistent and These commanders must
improve communications between their respective units. The JDG and IMO should 
their SOPs, train the guard force and medical personnel, and supervise execution of the SOPs.

9mg) should establish, with USSOUTHCOM oversight, a rigorous
inSpection program designed to detect tactical level de?ciencies in detainee operations at HP-
across a broad spectrum of operations, to include medical, legal, intelligence, and
security.

lam Many of the recommendations in this investigation have been made in previous
investigations. Because it appears that JTF-GTMO has not implemented some of the required
changes, the TF-GTMO Commander should provide a detailed implementation plan and
timeline with respect to any recommendations connected with this investigation.

iv





(U) List of References and Enclosures
(U) REFERENCES.
l. (U) AR 15-6, Procedures for Investigating Officers and Boards of Officers, 2 October 2006
2. (U) Uniform Code of Military Justice

3. (U) AR 190-8, Enemy Prisoners of War, Retained Personnel, Civilian intemees and other
Detainees, 1 October 1997

4. (U) Geneva Convention Relative to the Treatment of Prisoners of War of August 12, 1949
(Geneva Convention 111), 12 August 1949

5. (U) Directive 2310.01E, The Department of Defense Detainee Program, S?September
2006

6. (U) Directive 2310.08E, Medical Program Support for Detainee Operations, 6
June 2006

7. (U) AR 3- 9.40, Internment Resettlement Operations, September 2007

8. (U) Army Regulation 15-6 Investigation Guide for Informal Investigations, USSOUTHCOM,
May 2010

9. WJTF-GTMO Security Classi?cation Guide, 5 February 2009

10. (Ski-F) Report on the Facts and Circumstances Surrounding the Death of Detainee Haji
Naseem (AKA Anayatullah) USN-10028) at Joint Task Force-Guantanamo (JTF-GTMO) on 18
May 2011 (31 July 2011)

ll. (Shir-6F) Report on the Fact and Circumstances Surrounding the Death of Detainee Awal Gul
USN-782) at Joint Task Force-Guantanamo on 1 February 201 1 (10 March 201 1)

ENCLOSURES

I. USSOUTHCOM Memorandum of Appointment appointing 
as Investigating Of?cer (10 September 2012)

 

 

 

 

 

11.655999) Email approving appointmentl (busiomc) l  l,
and]  to investigation (15 October 2012)

111. (U) Email approving extension of time through 29 October 2012 (17 October 2012)

 

IV. WEmail approving request to appointl Marciano) Ito investigation (17
October 2012)

V. (U) DA Form 1574 (29 October 2012)
VI. (U) Exhibit List

 



(U) FACTS
I. (U) Life of ISN156 at JTF-GTMO
A. (U) Personal Background

1. (-3-) Adnan Farhan Abd A1 Latif USQYM-000156DP) was detained at Joint

Task Force Guantanamo (J TF-GTMO) since his arrival on .ti.n1e.of.his. .?Tiff We)
death on 8 September 2012, he was approximately 31 years old.' was a citizen of

Yemen, born in Aluday, Yemen. His native language was Arabic and during his over ten years

of detention at JTF-GTMO, ISN156 learned some English. (Exhibit 51)

2. ISN156 had an extensive family in Yemen, including a 10-year old son. ISN156
frequently wrote letters to his family, including his grandmother. father, mother, brother. cousin,
son and nephew. In 2012, ISN156 sent twenty-two outgoing letters to family members, fourteen
of which were to his brother, Muhammad Farhan.2 Coincidentally, it appears that lSN156?s
mother also died on 8 September 2012.3 (Exhibit 59)

B. W07 Communications with Family and Attorneys

3. (Bail-1666) From 2010 to 2012, made 14 video phone calls (VPCs) or telephone calls
to his family in Yemen. ISN156 made three calls in 2010, seven calls in 201 l, and four calls in
2012. In 2012, made calls on 1 February (1-hour VPC), 9 March (1-hour regular call),
2  May (1?hour can?), and 1 1 July (1-hour VPC). (Exhibits 36, <50)5

4. also frequently communicated with his attorneys regarding his ltabeas
corpus proceedings. According to an entry in the Detainee Information Management System

 

mm The precise date of birth of is unknown. .12 (HUME) ports indicate a birth date of 1

January 1981. but a recent press release quoting lSN156?s lawyer statct at 15 passport and other records indicate

that he 35 or 36 cars old. (Exhibit 86)
 

 

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esteem (Wee. 1-4(c) I

 

Classi?ed I USA. Investigating Of?cer
Derived From: Multiple Sources
Declassify On: 10 years after completion of detention operations

SIB-SW



lbl?ithl-ls?il??bl 

(El-(billch


1 I 

(DIMS), 5 around 14307 on 7 September 2012 (the day before ISN156 was pronounced dead),
ISN156 insisted that a letter be mailed to his a't'tomey.a The same entry also re?ects that
ISN156 stated that ?to die is better than to live? but ISN 156 would not specify what he meant by
the statement? (Exhibit 63)

2012, ISN156 was to have a total of six scheduled telephone calls or meetings
with his attorneys. On 14 June, ISN156 had a call with his attorneys, David Remes and Brian
Foster. On 21 May, met with his attorneys David Remes and David Kudzin, and on 24
August, ISN156 met with attorney David Remes. The remaining visits with his attorneys were
canceled (21 March and 9 May, canceled by attorney; 28 August, canceled due to Hurricane
Isaac; lSSeptember, canceled following ISN156 death). (Exhibit 61)

CW Capture

6- WI

 

(blil 1 Alt)

 

 

 

(Exhibit 5 l)

TWISNI 56 disputed these claims, and asserted that he had left Yemen in August
2001 on what ultimately turned out to be a fruitless quest to receive medical treatment for. head

 

DIMS is the primary tool used to track day-to-day informal ion about detainees, and is made up of
electronic entries regarding each detainee.

(U) All times in the report are in local time.

The O?ice of the Staff Judge Advocate (OSJA) for United States Southern Command
(USSOUTHCOM) and Joint Task Force -- Guantanamo (ITF-GTMO) have asked Naval Criminal Investigative
Services (NCI S) and the Department of Defense Of?ce of General Counsel (OGC) whether the letter is covered by
the attomey-client privilege. As such, the Investigative Team was not able to obtain a copy of the letter.
9% As discussed later in this report, ISN156 ?'equently made passive statements about death and dying
during his over ten ears of detention at Although the report indicates that this conversation took

   
 

place through the DOMEX Cell Weekly Schedule re?ects that the interpreter on
duty Lhayiaxwas I I or 2012, an individual from Dom clari?ed in a teIe hone 11 with the

  
    

Investigative Team - same interpreter alternated using the cell block names of a 
Interpreters are sometimes mes?temcms. On 23 tiring a
telephone conversation'with the (1:000:10 USC indicated he did not recall the Speci?c
conversation.

(U) A federal district courtjudge found the govemment?s report to be unreliable and granted ISN156's petition for

a writ of habeas corpus on the basis of the confession?s unreliability and other factors. The district court?s decision
was subsequently reversed and remanded. (Exhibit 131)





. .
a

injuries he suffered in a 1994 car accident.ll claimed that he traveled to Pakistan and
then Afghanistan to meet up with a Yemeni who he had met at a charitable organization in
Yemen. claimed that after waiting in vain for several weeks for the individual, 
then attempted to return to Yemen on his own, ?eeing United States-supported forces he had
been told were advancing from northern Afghanistan. Pakistani police seized ISN156 near the
border of Afghanistan and Pakistan in late 2001, and transferred him to U.S. custody in
December 2001. With respect to his alleged confession, claimed that his interrogators
misunderstood what he asserted, and that their summary bore no relation to what he actually had
stated. (Exhibit 131)

8489-1814156 arrived at the detention facilities at Naval Station (NAVSTA) Guantanamo Bay,
january 2002. He was initially housed at Camp X-Ray until Camp Delta
opened in June 2002. During his over ten years of detention at JTF-GTMO, ISN156 moved from
camp to camp at least 67 times. was housed in Camps 1, II, V, VI, and the
Behavioral Health Unit and the Detainee Hospital A breakdown ofthe last three
years is of external camp movements is as follows: 2012 12 moves; 2011 three moves; 2010
eight moves.? (Exhibits 5 l, 66, 67, 68)

D. Diagnoses

9. (MG-HQ) Guantanamo Bay Joint Medical Group (JMG) doctors? diagnosed with
Bipolar Disorder and Borderline Personality Disorder with antisocial traits. His most recent
episode was characterized as manic with features, possibly affected by Traumatic
Brain Injury a cognitive disorder, or personality changes secondary to Over the
course of his detention at JTF-GTMO, 1 56 was an occasional hunger striker. (Exhibits 24,
28)

 

 

 

that was almost completely blind in his ieit eye, and the Jr's-omo
optometrist in rest at blindness was consistent with a traumatic injury. a Ema-douse 


airtime)

oxalibWXCi

(bil?lklo 

(W

lit .


the JMG Commander, (memo usc to determine whether the can I work with Jordan (where the (?Hummer

        
  

    

 

hospital 1 2 that -c alrne -- cad injury)to obtain recordsoftreatment oflSN156 car
,accidentt  dicated that although the JMG would normally not request such records, she pursue 
I use she felt the records might assist her in treating 156. 156 died befo mmnusc 513m,-

      

matter Io 
. I records. (Exhibit 24) 

Camps I, ll. [11. and IV are no longer used to house detainees.
The details surrounding many of these speci?c moves, including the reasons the moves were made.
are set forth later in the report. I
security reasons, this report refers to JMG medical personnel and interpreters by their block
names. Certain billets at including medical personnel and interpreters, Operate under ?block names"
for force protection. (Exhibits may lead to brain damage to the frontal lobes (the part of the brain that controls personality),
making the individual impulsive and aggressive. A cognitive disorder usually implies problems  basic thinking.
memory, and intellectual deveIOpment (mental retardation or dementia. for example). thereby explaining some of the
individual's behavior. The diagnoses of ISN156 evolved over the course of his detention at 

24, 128)

(bii?idbl?ilci



in. 4  I

Bipolar Disorder is considered an ?Axis l? mood disorder, where the individual?s
moods swing either high or low. According to the diagnosis, in the case of themost
recent swing was to the ?high? mood (mania) to the point that he lost some touch with reality
features). (Exhibits 24, 128)

Personality Disorder (Borderline PD) is a considered an ?Axis ll?
personality disorder. Axis II disorders are generally characterized by mismatches between the
perSOnality (basic way that an individual relates?to the world) and society. As such, Axis II
disorders are long-lasting and dif?cult to change. individuals with Borderline PD generally are
unstable in how they view themselves and in their relationships with others. They tend to view
people very concretely (all good or all bad) but frequently and impulsively change their
assessment (the previously all good person is all bad suddenly, and the previously all bad person
is suddenly all good). They are impulsive, like to generate crises, and frequently harm
themselves, classically by cutting to ?feel something.? individuals with Borderline PD are
unstable in their relationships and try to manipulate people into divided groups, or set groups and
individuals against each other.? (Exhibit 128)

PersonalityDisorder (Antisocial PD) is another ?Axis personality
disorder. Individuals with Antisocial PD generally show a ?pervasive disregard for the rights of
others.? They tend to be impulsive, aggressive, and-reckless. As such, they tend to engage in
conduct that society disapproves of, such as promiscuity and criminality. (Exhibit 128)

13. M0140) In layman's terms,all of these diagnoses translate into an individual that would
be unstable in mood, personality and relationships." The diagnoses also mean that the individual
would be ?very difficult to work or live with? and would be ?prone to impulsivity and to harm
self 'or others,? generally living life from one crisis to another. (Exhibit [28)

14. {Elma-The Healthcare Ethics Committee at the Naval Medical Center, Portsmouth,
Virginia (l-Iealthcare Ethics Committee), assessed the condition of as treatable with anti-
medications but not reversible. The Healthcare Ethics Committee?also noted 
chronic Impulse Control Disorder, and stated that all of these conditions were associated in
ISN156 with acts of self-harm and violent behavior. The Healthcare Ethics Committee noted
that due to Borderline PD and possible cognitiveeffects from thought
process was often illogical, and he engaged in near daily debates and negatiations with JMG
medical staff regarding compliance with oral medications. When not compliant with oral
medications, 56?s condition became ?critical and emergent? as evidenced by harmful
actions directed at himself and others. (Exhibit 96)

 

with Borderline PD were o?en sexually abused at a young age. Borderline PD is more
?'cquently seen in women than men. (Exhibit l28)



 I.
a .A

15.693388 0n 6 August 2012, the JMG Deputy Commander] Iasked the

Healthcare Ethics Committee for assistance in determining whether it would be ethical to
involuntarily administer depot level medication doses) to ISN156. At
the time, ISNIS6 was refusing to take his daily administered doses of 
medications, which was resulting in behavior harmful to him and others.? (Exhibits 24, 96)

 

16. On 31 August 2012, a subcommittee concluded that there existed an ethical
basis for the depot level medication.l8 (Exhibits 24, 96)

17. MEN 1 56 had standin week] appointments (separate a - intments, on different
days) with the JMG nd the JMG The

appointments lasted approximately 30-45 minutes each. (Exhibits 24, 37)

 

  

18. physician for Camps and Vi was the rim care provider
for During 156?s frequent sta at the however, oted as the
attending physician to 156, wivailable for consult as needed. Over the course
of his detention at ISN156 had also been seen by specialists, including a
gastroenterologist and an optometrist, routinely brought in to see detainees. '9 (Exhibit 27)

 

 

 

E. W?istory of D?mciplinary Events and Self-Harm

19W had a long history of disciplinary and self-harm events while detained at
various camps in These events Spanned his over 10 years of detention at JTF-
GTMO, with a significant spike in late 2008. Disciplinary events spanning from 2002 to 2012
included, but are not limited. to, assaults on the guard force, inappropriate use of bodily ?uids,
failures to comply, possession of contraband, cross block talking, and writing on cell walls.
(Exhibits 51, 52)

20.4915501409- ISN156 self-harm events began in 2003 with two head-banging incidents,
followed by three separate wrist-cutting events in 2006, and a spike in 2008 of nineteen self-

 

 
   

The specific behavior - 15N156 is detailed later in the re rt. and includes ISN156 throwing rocks at
amil Splashing a nurse and guards-
"W?e subcommittee was esta 15 spect tea avy Medicine East ethics concerns and those
at The data nil. I - initial question and the decision by the committee is explained by the fact
at 3 :10 usc _tha_t,the,eommitteeasked . gather additional data, and the committee chair was on leave at one point.
JMG Behavioral Health Services (BI-IS) 01c and
mm?? sychiatrist for (Exhibit 96)
(mum use 5139p, ?Imamu?snw?ms so complex-the ad scheduled a forensic consult. A
forensic has expertise with assaultive behawor an regularly works with correctional populations. Emmuusc 91m.

   

ndicated that the consult was scheduled for 6-13 October 2012. (Exhibit 24) Momma
{examine} 
5

1

harm attemPts, involving choking, ingestion of inedible items, hanging, head-banging, and
cuttihg.10 (Exhibit 51)

 

21 ISN 156 frequently made passive statements to him?? ?50 513?N?ll?ll?li7l?asking to

die,'such as wish could die here" and"?you could?nd meds that would kill me.? 

would also ask prescribe a ?suicide pill? to him so that he- could die.     Wlhitiig?a ?9,330?.
indicated that she advised ISN156 that there was no such thing, and reminded him that she was

there to help him.21 (Exhibits 24, 37)

 

 

 

 

noted that while at JTF-GTMO, ISN156 ?'equently wrote dark poems
with suicidal themes, and wrote long letters to Joint Detention Group (JDG) leadership with
quality of life complaints. ISN156 watched virtually unlimited television,22 and periodically
moved from communal to single?cell environments to ?take a break from the pressures of
communal living.? noted that triggers for included perceived slights, noise
during prayer call, pressures from communal living, and not being allowed to watch enough
television. (Exhibit 51)

23. (Ema-Guards noted speci?c instances of misconduct and aberrant behavior by ISN156

War the course of his detention. One ard noted that ?had alwa done weird stuff?
and noted that ISN156 (W6) I

(Due) IISNISG would also put a sheet around his neck like a cape, run
up the wall, and do a back?ip off the wall. (Exhibits 6, 14, 29)

24.6%9809 The Cam a Of?cer in Chare OIC recounted incidents
where 156 would She indicated that several guards
placed written complaints about the (hue)  the complaint 130:: in the Camp break room.

ndicated that she raised the issue with the former battalion commander of the
525th Military Police Battalion at the time. However, no disciplinary action was taken against
ISN 56 because ?he was a special case.? According to (?magma?- the SOPs were ?de?nitely
not consistently followed? with respect to ISN156. (Exhibit 16)

  
    

 

 

 

 

 

 

 

 

2" (848089) One such instance occurred at Camp or VI in 2008. An interpreter recalled ISN156 approaching
him and saying something like ?here, I could eat these pills if I wanted to kill myself? and showing him a ?st-full of
four or ?ve pills. ?Ihc interpreter indicated that the guard con?scated the pills from 156. The interpreter
indicated that he had heard of other instances of detainees (including ISNIS6) hoarding pills, but the 2008 instance

 
  
 
 
 

was the only time the interpreter-had actually seen a detainee produce . xhibit fair! well as a    ?Ewin?gwouscgquu
(antitrust; Newman .   indicated that he often saw SN156's sense of humor, with 
ISN 156 Jolung that all he wo - to get out GTMO was a boat and an island, and that he would not even need

to go back to Yemen. (Exhibits 24discussed later in the repOrt, ISNISG hadl 

 

 

  
   

 

(btmtEl  lowed him to watch unlimited television. (Exhibit 4331's)
6

8C000012

21% One guard indicated that he understood the policy requiring line of sight duty to
be rotated every stemmed from behavior by ISNI 56 speci?cally, that 
would] (bits) land do all sorts of crazy things? and that ?they did not
want guards to have to watch that for more thanl a time." Another guard noted
that it was ?horrible? to have to be on line of sight duty for ISN 56 because of these types of
actions, many of which ISN156 would do right near the cell window. (Exhibits 6, l4)

noted that the ?ease by which ISN156 transferred between
camps? con?rsed her. She felt that the moves caused stress on the guard force and ISN156. She
noted that at one point, other detainees were usin ISN156 as a messenger to pass information
between blocks and between camps. indicated that she raised the matter with

 

 

and did not understand ?why ISN156 was not a permanent resident at the (Exhibit

16)

21m Several individuals complained about what they perceived as special treatment
for ISN156, noting things such as his unlimited television and recreation time. Some guards
expressed that they were concerned about interacting with ISN156 because he was ?special? and
they were ?afraid of getting into trouble." (Exhibits 6, 12, 16, 17, 35)

F. (U) Behavioral Incidents: June 2012

3.6999693 Multiple sources at JTF-GTMO indicated that lSN156?s most recent downward
spiral of behavior. began in June 2012.23 It appears that on 14 June 2012, ISN156 learned during
a phone call with his attorney (David Remes) of the Supreme Court?s denial of review of his
habeas petition. indicated that after the phone call, ISN156 ?came back furious and
really started saying crazy stuff.? (Exhibits 16, 24, 37, 61)

 

 

 

 

29.619999) A?er the call with his lawyer, ISN156 was voluntarily admitted to the BHU for

them use ISN 56 talking about his 10-year old

(HOMER)

23
throne usc 513m-" M-
enammct

son in Yemen and his hopes to see him again, which she took as a good sign as it demonstrated a
future orientation. During this same time, 
in lots of talk regarding death, which for ISN156 was fairly, common behavior. (Exhibits 24, 68) 

appears that during this stay at the BHU, began to discuss stopping his
hunger strike, indicating that routine foods were making him nauseous and that he had no

 

  
    
        

. . - referenced July 2012 as the date of the Supreme Court decision and the start of
down 2 . . She may have been mistaken as the date of the decision denying lSN156's petition for a
writ of cediorari was 11 June 2012, and the date that ISNI 56 had the phone call with his attorneys was 14 June
2012. (Exhibit 16)



 

 

 

 

24 tenet-.10 use USO . .
appetite. ?mi?fm-?m onsulted the primary care prowder for ISN 156, to asswt 

 

 

a gastrointestinal (GI) evaluation 3? With the. encouragement began

eating solid foods. ISN156 also began to express interest in movmg to amp V1, whic ?Mgg?b?ggeu
supported because she believed it would provide ISN156 opponunities for socialization. 
(blottousc??nb. saw no issue with moving ISN156 to Camp as he had been at Camp only

?mama because he was an enteral feeder, not because he was there on disciplinary status. (Exhibit 24)

31. (959969 While at the BHU, ISN156 started requesting to receive his medications in the
mmiousc yard.le Ireported that she told ISN156 that the current Standard Operating
1

 

 

 

 

   
(Exhibit 24)
32. On 25 June 2012, discharged from the BHU to Camp V. intolerant:va
reported that while at Camp VJ 7 
Irma" indicated that she

 

 

 

felt that ISN156 was attempting to manipulate the system. She noted, for example, that if
knew his medications pass was scheduled for 0500, he would request to go to the
recreation yard at 0445. Nonetheless understood that the guards told ISN156 that he
I (mans) (Exhibits 24, 68)

with ISN156 for his normal post-discharge visit, 156
told her that he had learned that she was the one who ?personally chan ed the and
I (blmiEl I "Fr-u xplained 
that this was not true, and that the policy was long-standing. ISN156 dismiss - WNW) 

the appointment, essentially, as he stated, ?firing? her.29 continued..to.see_.._..__.. aziatigipxgiaou.
(hit 1 MC)



 

 

 

 

?m The report re?ects the dates indicated in the DIMS Detainee Movements Report. Because individual
recollections vary, the actual sworn statements sometimes re?ect dates distinct ?om the dates in the DIMS Detainee
lamina example, recalled that ISN156 was admitted to the BI-IU
(?Wilbmci on 14 June 2012 (consistent with the DIMS l- race 7 o'vements Report) and again approximately a week or two
later. 11m subsequent BHU stay, however, is not re?ected in the Detainee Movements Report. Relying on
the veracity of the DIMS Detainee'Movements Report rather than the recollection of one individual, the

     

Investigative Team concluded that there-was only one BHU stay for lSNi?SG'in June 2012. (Exhibits 24, 68)
1? As oted above, because ISNISG was at the ?amuse 5mm
vailable for consult. (Exhibit 27) m" (chrome;
2366150909 Camp IS communal. Detainees at Cam Vi live in communal bl as osed to sin cells.
7 - As discussed later in the report, the] (Bil?l?l I

   
  
 

 

 

 

 

 

 

 

(131F959) As discussed later in the report, not all guards. nurses, and oorpsmen understood or were complying
 the  Medication  POI. 91'. The  records BIG inconsistent  a - mtgm_u4mar1o U50 5139}.
mmwu??m The medical has authorizing corpsmen to wibiibmci
I I: the audiovnsual (TV) roam around this same time. (Exhibits 9, 21. 34, 35.98)
mm?, ?mm-~23 x?u-em- ndicated that it was not unusual for a patient like-ISN156 to dismiss those persons
Mel?ml?cl attempting to help him. (Exhibit 24)

 

8C000014

ammo use 5139);?

 

__lS.H_156.focmentaJ.health issues, andremained involved for 56?s GI issues.
(Exhibit 24)

34. 0n 5 July 2012, in anticipation of the start of Ramadan, ISN156 moved from
Camp to Camp Vl as part of the ?Ramadan gm?? At the time, 56 was housed in a
single cell at Camp VI MUKE) 

(W05) At Camp VI, 56 was housed in a communal block with
approximately/Mother detainees. (Exhibits 24, 68)

the JMG that he was feeling ?overwhelmed? by Camp V1.32 Around
this time, ISN156 steppe ta ng his medications and began fasting for Ramadan. The JMG
ISN156 that he was not required to fast because he was sick,33and
she indicated that JMG professionals were concerned about the effect of fasting on his mental
state. (Exhibits 24, 37)

35. WAppi-oximatel tea days after arriving at Camp VI, ISN156 began expressing to
511m: Expino usc
130a. 6

 

G. (U) Behavioral Incidents: July 2012

36. We; Beginning on 25 July 2012, there were multiple incidents involving ISN156.

Major events, highlighted below, include: a rock-throwing incident; I

I a splashing incident with urine and feces; and a
(Exhibit 51)

 

 

 

nemesis; On 25 July 2012 around 0800, while in the Recreation Yardof Camp v1,
56 and another detainee told the watch commander (WC) that they wanted to
speak to him via an Arabic interpreter. The WC told them that they ?rst needed to speak to the
Block Non-Commissioned Of?cer (BNCO), followed by the Assistant Watch Commander
(AWC). ISN156 started yelling insults as the WC walked away to continue his inventory.

 

(814F060) The JDG Commander grants certain "gifts" (to include absolving detainees ?'om discipline time or
moving detainees from camp to camp) as part of Ramadan. Ramadan began 20 July 2012. The DIMS Detainee
Movements Report is confusing in that it re?ects ISN156 moving from Camp VI to Camp on 18 July 2012, and
back again from Camp to Camp on the same day. (Exhibits 24, 68, 107)

There are 'several reasons, to include medical and disciplinary, that a detainee might be housed at

   
  

travelers, li'orn fasting. (Exhibit 106)

8C000015

ISN156 then began throwing rocks at the Recreation Yard ower, damaging the tower
spotlight.? (Exhibits 53,58, 100)

38.9mm At this point, having heard the radio traf?c about the rock-throwing, the WC
returned to the recreation'yard. As the WC returned, ISN156 began throwing rocks at the WC,
hitting him in the left elbow with a rock. ISN 156 then walked across the recreation yard and
began throwing rocks at the Super Recreation Yard Tower, striking one of the tower windows
and a tower guard in the head with a rock. ISN156 also hit a guard standing near the guard tower
in the hand with a rock.? (Exhibits 53, 58)

31Wmappmached ISN156 and tried to calm him down. ISN156 continued
throwing rocks, only stapping when the OIC and the Camp VI Response Team approached the
Super Recreation Yard. At approximately 0825 hours, the Response Team restrained ISN156
and led him out of the Super Recreation Yard.? (Exhibits 53, 53)

40.6% As a result of the rock-throwing incident, ISN156 was given a verbal warning.?

 

le3}:10 use 
(bushibmtc:

 

met with ISN156 at Camp VI after the incident, reminding him that he needed to take

 

 

KC)

his medications and not fasting. (Exhibits 24, 53, 58)

Later that day, 25 July 2012, ISN156 was transferred to the BHU on line of
sight.33 At the time, ISN156 was on three medications: Celexa (anti-depressant);
Remeron (anti-depressant); to help control impulsivity). (Exhibits
24, 68)

42. WM approximately 1740 25 July 2012, while in the-BHU Recreation Yard l,

lSNl56 

I39 ISN156 was able to

 

There are no photographs re?ecting the damage to the tower or tower spotlight from the time of the
incident. The Investigative Team requested that photogaphs be taken as part of the investigation into the death of
lS?Nl 56.

?(Um In a telephone conversation with the-InVestigative team on 24 October 2012, the IDS Joint

Operations Center (JOC) 
gfleased them, as the guardssuffcred no real in

(Mm 10 USC 

 

indicated that medical personnel assessed the guards and
uries.

 

 

USC 1.4{0}

 

(Exhibits 12, 57)
According to the discipline matrix, the discipline for Damage to Government Property is HEREB-

and for Failure to Follow Camp Rules, (bimtE) The Campw recommended a verbal warning and the JDG
Commander (COL Bogdan) approved the recommendation on 27 July 2012. (Exhibit 
As discussed later in the report, line of sight can be direct (person), electronic (camera), or both.

 

 

(Exhibit 45)


 

 

 
  

 



[The lnvestigativej'ream requested that photographs be taken as

 

part of the investigation into the death of ISN 156. (Exhibits 37, 

10



6

(chitin 113%  AlsooanSJ Lily?20 i?Z, .

mitaitb?imtc)

.hecofthesituationcindicated that she would come in, and

?alibi? KC)

 

 


(Exhibits i7, 57, 10])

a result ofthe was given (bi?ilE) 
consistent with the Discipline Matrix for ?Altering Cell or Modi?cation of
GovernmentProperty?"1 (Exhibits 24, 57)

 

 

 

 

 

   

tarted ISN156 on Remeron, an anti-depressant

with side effects of stimulating appetite and causing drowsiness, whichl segment]- mm 
deemed helpful as ISN156 was trying to eat solid foods and frequently complained of insomnia. momma
(Exhibit 24)

 

 

41% On the night of 31 July 2012, ISN156 was agitated about recent events and was
in his cell at the At one point, ISN156 began jumping around in the cell, from the bed to
the sink to the table to the toilet. I '?xfigai?aiigml, the nurse on duty at the BHU that night, observed
ISN156 andasked him 'to stop what she explained was ?very unsafe" behavior. ISN 156 would
stop oncespoke to him, but as soon as she left the 'tier, ISN156 would startjumping
again. At one point, ISN156 did fall, but not seriously. (Exhibits 24, 35)

46. magma fairly certain that 56 had not taken his medications, to

include Zyprexa (used to control impulsivity) that day. After thejumin had gone on for some
time and because she was very concerned for the safety of ISN156,called 

 

 

 

 

. stash,


 

suggested that they consider giving the Zyprexa to ISN156 as an injection to prevent an accident
that could aggravate (Exhibits 24, 35)

 

 

47. sunset-Jo; While ?sighting?- was discussing the situation witl?il
to calm down and indicated that he wanted to go to the Audio-Visual (AV) room.? The guards
moved ISN156 to the AV room and he agreed to take the injection of Zyprexa. then

- 

(bii?ubimim

 

 

 

 

 

 

The issue of passing food at the recreation areas is linked to the issue of detainees feeding the wildlife
at as detainees at Camp V, Camp VI, the BHU, and the DH encounter wildlife while in the recreatiOn yards.
'The JDG Wildlife and Pest Control SOP, and instances of the SOP not being enforced, are included later in the

re it.

?rth? 3,11, .51, 55,1qu
Wlhe 01C recommended

and COL Bogdan approved the
recommendation on 26 July 2012. Discipline time?is'n'o'f'nT'ss?ce I'm?'56 immediately. (Exhibit 57)

 

 

 

(?3,110 ":59 5mg,? .32. i dicated that lSNl56 was upset because he felt that his meals were not arriving on time and that

 

 

 

me use sta was not paying suf?cient attention to him. (Exhibit 35)
xplained that'once a patient has had one 1?31, :1 second TBI can be more damaging. (Exhibit 24)
015151710! t. discussed later in the report. ISN156, unlike other detainees, received unlimited television time.
(unite 05; indicated that television helped to distract ISN156 and ?re-focus on Other things." (Exhibits 48-3)
(OMBMIIXHCI
i 


8C000017



refused to sit in the restraint chair, however, and indicated that he would only receive the
injection if he could o've it to himself. At that point,alked in to the AV room. 
According to ISN156 was doin up until that point, but upon seeingl 
(Diamou ?g ISN156 got very angry ?6&me ?waking up the doctor." (Exhibits 24, 35)

(?6le
- - 'scussed the unsafe behavior with ISN 156 and told him that he would
take the medication one way or another, either by injection or by mouth. ISN156 refused both.
-At thatpoinudicated that she would leave and deal with the'situation in the mOming.
'I'hejumping continued throu the ni t, with lling update her
_periodically.-told to continue monitoring ISN156 closely on line ?of sight.
In the middle of the night, 56 went into the recreation yard, and in fact never went to sleep

in his cell.45 (Exhibit 35)

 

 

 

 

 

 

 

 

 

 

49. W?e next morning, onl August 2012 at approximate] 0555 hours, ISN156
asked to see in BHU Recreation Yard 2, where "?m?wsc 

 

   
   

s1
I
56.46 The NCOIC for the escorted magmas?- down the tier.
When they arrived at the Recreation Yard 2, ISN156 was holding a large white'Styrofoam cup
with a lid in his right hand. Stating something like have something for you,? ISN156 removed

 

 

 

 

 

 

 

 

 

 

the lid and made three motions with the cup ?rst throwing the contents of the cup at 
.en at then a (Exhibits 17, 35)
50. i The contents were a brown substance with a ?pungent smell? and consistency of

feces. ?sitting?: as splashed with the substance on her face, hair unifo and boots-and

landlw-?h- on their faces, uniforms and boots. informed
ISN 156 that he would be Written up for Splashing the staff with feces. (Exhibits 17, 35, 56,

 

 

 


KC)

 

 

 

 

 

102)"
tated that it was ?still not clear" to her how was
able to get a cup of feces and urine out to the recreation yard, the

 

 



II Iindicated that (bxma)
ml?ltE) lSNi.56 took a sheet outside with him to the-recreation yard. indicated

that out of concern that would be able to use the sheet to make a noose, she raised the

 

 

 

 

 

 

 
   
 

mmuoupcsum I. - -- 3 understood that ISN156 had unlimited recreation time, but thel I
?35mm? does not re?ect suc a premium (Exhibit 48-3)
As noted above, there are no photographs re?ectingl JUKEJQJ mm I

we Investigative Team requested that photographs be taken as part of the nves?gaton into the death of
tnxnamm? 1514156
4?

   

 

 

 

 

 

I
10:. 102)


12

I 



mm: to use
(theith

tbu3rtuUSCA?1m.Xpialned that it was possible for a detainee to walk with a cup of feces and urine,



(exam: MCI

tartaric use 5130:.?


5.13.0.9. H. issue. w'
xc:



 

 

. .
{extremity  Indtcated-that- - -

ISN156 tried to make a noose, the guards would stop him.
52. (EACH-9909 mastitis? explained. that frequently, ISN156 would wrap the sheet over his
back and appear to kneel and pray, all the while shielding himself with the sheet. ?mitigate?-

explained that sometimes would rock under the sheet as though he was meditating.

 

 

 

 

 

 

. ismissed her concerns, stating that if
(Exhibits 24, 35, 48-3)

 

 

 

 

 

 

 

 

 

stated that she saw 56 doing this the morning she and the guards were

 

 

 

(customer
splashed. ?gagging? tated that in retrospect, she believed that ISN156 was in fact defecating

and urinating tn cup, which he later used to splash her and the guards. Similarly

 

.s. mmaxaahusc ?130b.
Ml?ib?xcl

covered, from his cell to the recreation yard.also said that it was possible for a
detainee to defecate and urinate in a cup in the recreation yard by wrapping himself inside the

ISOMATS and shielding himself. (Exhibits 35)

 

51W As a result of the splashing incident, ISN156 receivedl (bil?fllE) 
consistent with the Discipline Matrix for ?Major Assault of Staff or Another Detainee.?43

(Exhibit 56)
H. (U) Behavioral Incidents: August 2012
54

. Later that same day, uncomfortable with thehandlin? of the "umping incident the
leuaxtoUE-ig?jli . _night before; at with the Senior Medical Officer! :1 land discussed

 

 

 

 

6
issues re arding guard safety, clarifying that anyone (guard Or maicaii could call a 

(DWKEJ . I [is used to indicate a detainee is committing self-harm in a
particular location. (Exhibits 24, 47)

51% On 2 August 2012 at approximatel 0610 hours, while in BH Recreation 
2, ISN156 told the NCOIC of the i I), that he wanted to speak to 'b 
and the 01C of the along with an interpreter. ISN156 told 

 

 

 

 

 

(MELMUXC)

 

 

at if they did not arrive in the next ?fteen minutes, there would be ?big problems.?

 

ISN156 then started to  (Exhibits 11, 17, 102)
tux3r10U5C 513%.?

56. Wm that point, (mmc, alled for extra personnel to come over ?'om the DH,
and instructed them to use interpersonal communication (IPC) skills to try to de-escalate the
also called the Joint Operations Center (JOC) to advise them of the



 

 

 

 

 

 

 

 

 

?(amine 01c recommendedl (ems) land COL Bogdan approved the
geommendation.


[3

8C000019

motto uscsmu.


innaizio 0,533,139,, 

(bXSlibliTKC)

(31133110 

ib?elleHCl


I A

situation, and requested the Quick Reaction Force (QRF). Approximately four to ?ve minutes
later, the ICC dispatched tho the BHU. (Exhibits 1 1, 17)

51% During this entire time, the guards continued to talk to who eventuall

 

 

 

le then, according (bitTNEttbl?ltF)
(ammonium awesome) 

 

 

 

Also during this time, ISN156 continued threatening the guards with statements
such as ?you have ?ve more minutes!" in broken English. (Exhibits 1 1, l7)

 

 

Sometime after 0700, the QRF arrived at the back gate. Upon seeing the QRF,
ISN156 got more agitated, threatening that ?if those people come in here, there are going to be
big problems." then stated that he'did not have an issue with

the uard'force and that he
just wanted to speak to ISN156 stated that ifhe could talk tohe would go

peaceably back to his ce . ibits ll, 17)
and an interpreter had an'ived.  gigs;

at ard, escorted nto the tier, and told her that ISN156 wanted to
talk to her. When siaoopxom came onto the tier and  mmei.ibmn [she stated that she
would not go out to talk to ISNI 56. When she turned around and started walking down the?tier
and away from ISN156, land ?just ex_ loded.? lSNl56
lunged, the guards closed their shields together, thereby shielding  continued
walking off the tier. (Exhibits ll, 17, 104)

  
 

59..

 

 

By that timei

 

 

 

 

 

60. (Haiti-13939) At that point, the QRF entered the BHU through the main entrance and

approached the recreation yards down the tier.? 156 had 

I land was swinging wildly, throwing himself at one of the guards

ISNISG was able toneck, near the base of his head. 

. 'ed to subdue ISN156 but ISN156 attempted to  enumerate..-
as well. Icombat patch, but did not penetrate the uniform." ISN156

    
   
 
  

 

 

 

 
  
   

 

 

 

 



 

 

 

 

 

 

 

 

 

 

 

then land started swinging a metal chair. During this time, a guard

. mfg, b' was Sprayin with Oleorcsin Capsicum (OC) 5 ray. ISN156 was able
to reach for a mag light in the (blunts) and throw the light a (Exhibits 1 l,
17)

 

5? (Ema-The QRF initially tried to enter therecreation area (a small, enclosed area that is adiacent to the neural
recreation yards) through the exterior gate but
leT?m barricade himselfin.
it arrived down the tier-
whereas 
SExhibits I 1, l7)
a telephone conversation with the Investigative Team on 24 October 2012, the IDS JOC 01C
indicated that medical personnel assessed the guards and released them, as the guards suffered no

 
 
 
 
 

 

 

   
 

14


-



(casino USO 


mam Usenet ?We

(bilatt?ltmci

waldo USC 



meme
. .

 

?ufm) 156 then I into BHU Recreation Yard 2. The
thenrestrainedJSNiso?i?Nume entered BHU Recreation Yard 2 and administered

- injections of emergency medications to ISN156, and irrigated 56's because he had
been sprayed by DC spray.? appeared completely compliant at this point. Thel 
then moved ISN156 back to his cell, where he slept for 12 to 14 hours. ISN156 was continued I
on line of sight observation and techs checked on ISN156 frequently throughout the day,
common practice a?er administration of emergency medications?4 (Exhibits ll, 17, 24)

61% As a result of thel thTHEHbl?ltF) I ISN156 receivedl I
for ?Aggravated Assault on Staff" andl Ifor ?Major
Damage to Property?? (Exhibits 54, 55)

61min) Following the] 
Review (AAR). The AAR contained several recommendations, including] I
I lensuring- that the Cultural Adviser be brought
on scene as soon as possible, reinforcing proper use of brevity codes and their meanin
(speci?cally, that at the BHU, the guard force have a lower threshold on calling a
because of the heightened risk of self-harm by BHU patients), and enforcing adherence to SOPs.

Speci?cally, ?any deviations or changes to the SOP must be included in pass down notes and
incorporated during SOP updates.? (Exhibit 83)

 

 

 

 

 

 

 

 

?l the IDG ordered an A?er Action

 

indicated that her concern was ?not so much with the medical reSponse
but the guard response.? She expressed serious concerns about her ability to conduct medical
Operations given that it did not a car to her that die guard force had ?suf?cient ability to control
I prevent incidents like this.? felt that the JDG senior leadership was very supportive
of the medical staff during the AAR, and the senior leadership instructed the guard force that

 

 

 

1

tbx?lltEMbK'lltF) 
It

?3 mluthough ?1933,3339? ferred to the nurse administering four injectionsErcfemedjojhtgem __mnoysc?130l
injections, which was wt HUIDH practice. (Exhibit 24) 
?Mme JMG Commander indicated that he did not believe the incident was reported to USSOUTHCOM

as the incident was considered a ?standard [Force Cell Extraction] (Exhibit 5)

3? W?e Discipline Matrix for A a vated Assault on Staff recommendedl I
but the 01C of the recommendedor the vated Assault on Sta in con'unction withl_ 
the ?Major Damage to Property", must at with the {b t7 (E . COL Bogdan
- the recommendations on 3 August 2012. The IDG SOP speci?ed a tscipline time for
certain offenses, including ?Major Assault of Staff? to be served at Camp V, (blUKEl Although not included in
hissutgiternentghe?mmpnuAOI . a -- indicated during the interview that Camp Echo Block
was closed in late August 2012. (Exhibit 41)

to l;

,2 B.

I

tcr. usch
tblt7 



 

 

 

 

 

 

 

 

 

   

8C000021

. 
I .l 

they were authorized to act in a crisis to protect other detainees and staff, without waiting for
approval from the JOC. (Exhibit 24)?5

1. W99) August-September 2012

the incidenLalled batik to Portsmouth, Vir' 'a to Speak with the

Specialty Leader for the Navy .discussed with her the

possibility of using a depot medication (a once per month in'ection, rather than a?

daily, oral medication) to assist with managing impulsivity.ecalled that
lsupported the depot injection idea. (Exhibit 24)

66. maiseussed the issue with ISN156, and he initially agreed to the deot
injection. ISN 156 also began taking his medications again. On2 August 2012,
ordered several months of Invega oral medications, as well as the depot

injection.? (Exhibits 24, 95)

 

 

61% Around thistime Ramadan was coming to a close and 56-was the only
patient left at the BHU. indicated that was having fewer outbursts and
incidents, and overall was doing well. ISN156 often complained that loneliness led to his ?bad
thoughts" and that he did not want to be alone at the BHU. On 9 August 20] 2, 156 was
transferred from the BHU to the DH, for increased socialization with other detainees. (Exhibits
24, 68)

 

that ISN156 did extreme] well at the DH, and was getting a
lot of support from other detainees at that point. One day,noted that ISN156 seemed 
?extraordinarily happy? in the recreation yard, singing, dancing and kicking a soccer ball.
that because ISN156 had been diagnosed with bipolar disorder, she talked to him
regarding scaling back the Celexa medication, as the risk with anti-depressants is they can make
a bipolar patient manic. (Exhibit 24)

69. On 21 August 2012, ISN156 started the oral Invega, an 
medication. si?iixwim lintended to increase the Invega and titrate ISN156 old? the Zyprexa, his
earlier prescribed medication. (Exhibits 24, 99)

 

 

 
   
  
 
        
    

 
 

 

 

 

 

 

?animus; The interpretation 0 - - incidentandmew immense swab.
AARonseveral- . A rd' inher?buko 
- 
mm?, use my,? -. . minim- .meunt 0 rec necessary,
mitottu?nici - - been able to dmcalate situations simply by talking to the detainee. (Exhibit 17)
mom usc - xplained that normally, before being administered a depot injection, a patient would do an
Matthias: . - fine icauons. According to the date oftbe invoice and the Healthcare Ethics Committee Memorandmn,
mam 05cm? .. .t rdered the oral and injectable Invega before the Joint Medical Group Deputy Commander m? .-.  sum
pproacbed the committee regarding the ethics of administering the medication against ISNI. 6?s will. Ibn?uhmc)

II 24, 95, 96)

16

8C000022

70.94.4590an ISN156 was moved twice in the next week for operational reasons. On 23
August 2012, ISN156 was moved to Camp v   58 On 26
Au 2012, ISN156 was moved back from Camp to the DH, Ward 2, Bed 4  

(bums: When met with ISN156 ISN156 informed her
that she was a ?horrible doctof?and that he felt the medication was not helpin him.60 ISN156
shared a love letter withthat he had written for one of the guards: Iindicated
that she informed ISN156 that he knew that kind of relationship was not appropriate and that she
would not deliver the letter to the guard. also noted that during this period, ISN156
was drafting many dark poems." (Exhibits 24, 68, 105)

 

 

 

71. WG-99) On 31 August 2012, the Medical Ethics Review Committee determined there
existed an ethical basis for the JMG to administer the depot level medication
(lnvega) to ISN156. (Exhibit 96)

72% The days went on fairly unremarkably, and on 5 September 2012,
noted that ISN156 seemed ?much improved" on his daily Oral medications, and appeared to be
suffering no side effects from the oral Invega. The plan was to transition ISN156 to the depot
injection. noted that ISN156 said that he had written a letter to his lawyer asking
whether he thought that ISN156 should take the injection.? (Exhibit 24)

Lemar-900) Events of 6 September 2012

 

73. W99 0n 6 September 2012, the Senior Medical Of?cer (3M0) dtexatto use 5130b.rbx6).tb317)tC)'
andtalked to COL Bogdan, the JDG Commander, about moving ISN156 back to Camp
Delta communal) brook.? They agreed that rsmso would move on 10 or 11 September
2012. discussed the matter with ISN156, who seemed happy about the plan and even
asked which detainees were at Camp Delta. (Exhibit 24)

 

 

 

 

 

 
 

s:
l? more; I 
ma- ndicated that she advocated leaving at Camp V. but was told that all detainees
madame) would be returne to err] (Exhibit 24)
(mmusc 5,3th not indicate what medication she understood ISN156 was referencing. (Exhibit 24)
.- indicated that had been drafting poetry in one form or another since his arrival at
JTF-GTMO In 24)

[came U59 man.
exammc)

 

 

?1 W066) From the dates in DIMS, it appears that this may have been the letter 56 attempted to send to his
attorney on 7 September 2012. Because NCIS and 06C have not yet determined whether the letter is covered by

the attomey-c?ege, as discussed above, the Investigative Team has not that! talked to earlier about leaving the DH. Bo

 

concerned that which is entirely communal, would be too much stimul ion or . 6
reluctantly agreed. and appeared open to the idea of moving to Camp Delta (communal) block. (Exhibit 24)

17



8C000023

(aminouscsisoel-u-n-r- Imet with ISN156 to talk with him regarding why he had not taken his morning dose of

extreme)

74. mace) Later that same day, on 6 September 2012, however, ISN156 began
spontaneously yelling and kicking, and threw his portable urinal thereby Splashing?a guard.?4
Another detainee, attem sted to intervene and asked not to request discipline
for infraction. M5) offered to talk to ISN156 aout not splashing. ISN156 took
his night dose of Rememn (anti-depressant) that night. (Exhibits 24, 28)

   

 

75. (LWEOUO) About 2200 that night, ISN156 was demanding his urinal back, and sprayed
several guards with urine from ?ip-top water bottles. He threatened that if he did not get his
urinal back, he would keep Splashing. ISN156 also defecated on a paper towel and threatened to
throw feces unless he was able tosspcak to a linguist. indicated that she viewed this as
a ?guard management issue" and not a medical issue. ISN156 ?nally quieted down around 0400,
the morning of 7 September 2012. (Exhibit 24)

K. We) Events of 7 September 2012

76. (W990) That morning, ISN156 refused his morning dose of Invega.65 Also that morning,
ISN156 handed a note to the Watch Commander, telling him gm-l note to the JDG
Commander COL Bogdan. In the note, ISN156 claimed thawas ?rushing him
towards death? and that she was the ?cause of the problems in the detainee hospital?? (Exhibit
63)

71W Sometime around 1100 or 1 130, the Mental Health Nurse scan.

(0)161.th HG)

Invega. offered ISN156 the Invega capsules, and this time, he accepted them.

le?gm?gm lindicated that she watched ISN156 take the capsules, put them in his mouth, drink
water, and swallow them." (Exhibit 28)

 

 

 

78. WHO) Later that morning, on 7 Se tember 2012, asked the Senior

Medical O?iccr andl 51350! rim-mm Lvhether there was a med cal or reason
. I I I

that could not serve his discipline time. indicated to that she

viewed recent behavior as willful, and that there was no medical or reason

that ISN156 could not serve his discipline time. COL Bogdan indicated that based on that, he

 

 

 

 

 

 

(1:393:10 usc ether ISN156 intended to splash the guard, 01' whether he  meant to

(DilaMblU Cl

 

throw his portable urinal. (Exhibit

{814139963 The morning dose for ISN156 was 9 mg, which was in two capsules - one 6 mg and one 3 mg.
(Exlu?bit 28)

We) The Investigative Team did not see the actual note but rather relied on a summary. re?ected in the
QIMS Report for 7 September 2012. (Exhibit 63)

As discussed We in the report, there are speci?c 501?s goveming medication administration.
(Exhibits 46, 50)

[8

SEW

8C000024

(hilariousc use?


terms use 51101:. 


KC)

memo use 

(usmeedecided to send to Camp for discipline.?58 The plan was to transfer ISN156 around
1500. However, based on erratic behavior the previous day, medical personnel and
guards were concerned about telling ISN156 about his pending transfer. They therefore decided
to wait untiljust before 1500 to notify ISN156 of the transfer. Medical personnel and guards
kept the movement team off the tier so as not to alert other detainees of ISN 1 56?s pending
transfer. (Exhibits 5, 28)

   
    

71mm; Around 1345 - 1430mm same day as still trying to convince
ISN156 to take the depot injection of Invega. Around 1605 the Watch

Commander and an interpreter approached and told him he would be
transferring to amp . At first, ISN156 appeared calm, ISN156 that

 

 

ad agreed to accompany ISN156 to Camp According is when

ISN156 became more agitated, saying that it was prayer time, and that he would go after prayer.
(Exhibit 28)

prayer call around 1623, ISN156 became increasingly agitated and
repeatedly asked for another 30 minutes to pack his things. The guards-and the medical team
told ISN156 that. he would not receive additional time and that he needed to pack his things and
be ready to move. At that point, ISN156 began ripping the magazine photos from his wall and
threw a shoe and remote control out of the cell bean hole. Throughout all of this, was
trying to calm ISN156. (Exhibit 28)

8LWOHSN156 andwanted to know what specific tier they were going to at
Camp V. Camp control indicated to they did not have that information, but

that ISN156 and would be kept together. '0 (Exhibit 23)

 

 

 

 

?WSeveral of the cells at Camp are designed for single cell detention, distinct from the communal cells
on Camp Delta (communal) block, where it was originally envisioned ISN156 would be transferred. The single
cells are used to house detainees on discipline who meet certain criteria of the detainee disciplinary matrix. (Exhibit
41)
"What! been accompanying through the camps in recent moves. He was considered a
close'?'iend of and one of the few people 'who could calm him. (Exhibit 24)

7? WCamp houses several categories of detainees on its ?ve blocks. One block is for communal,
compliant detainees. Another block contains cenvicted detainees, and another block is used for single cell detention
for those detainees in a disci linary status. There was considerable discussion regarding where 56 would be
"housed .aLCamchl-.-? dicated, for example, that 56 had ?a lot of bad memories" of Alpha Block --
events that occurre unng earlier rotations including 5 lashin self-harm, and Forced Cell Extractions (FCEs).

 

  
 
   
 
  

(Accordingly mmended against housing in Alpha Block. However; because there were issues
inVOlVinE ?"01 cf 1" r- _r ast had encouraged detainees to commit suicide) on
iscussed the ma with mainline) They agreed to allow the 1 ard force to determine the

 

- 

best location or . The guards placed - on amp Alpha Block, wi 


him.  was directly across from ISN156. Because of the way the cell doors and glass are positioned. both
   could see into parts of 56's cell. (Eidtibits 15. 37, 123)

   
   

8C000025

82. (Isl-4439399 Around 1650, 56 lookedat (I said something along the lines
of ?when I die, it will be on you" and ?you lmow that you have killed me sending me [to Camp
swimmers interpreted these as very passive threats but asked ISN156 if he had a speci?c
plan. intervened at that point, and indicated wOuld ?handle? the
matter. (Exhibit 28)

 

 

 

83 ?(Um 156 spent a few more minutes gathering his things, and the movement team
then took ISNISG in the transport van to Camp V. Approximately five minutes later, a separate
movement team followed withm (Exhibit 28)

aetiouse tea..- with the O?icer?in-Charge (01C) of empty,
iahii?i?giigg?itta - recommended that ISN156 be put on line of sight, and she and
(31335005051305.     I
(Exhibit 24)

toxemiach
recalled that earlier in the day, around 1400, a (mime) analyst
arrived with a Force Protestion Report indieatin that

saying that ISN156 was suicidal and was going to kill himself.
recalled asking the analyst whether he knew what method 15M 56 intended to use to kill himself.
The analyst indicated that he did net know, and followed up the exchange with an email.?
(Exhibits 16, 123)

86. The JTF-GTMO Cultural Advisor also received the same Force

Protection Report; in a high. priority entgili?tol?jlsi??ogatab September 2012.73
I {bieiibaci 

   
    
 
    

 

 

 

 

 

forwarded the email to COL Bogdan, (the Deputy JDG Commander), and
others in a high priority email. adding at ?pushing 156 to the corner never works to our
advantage." COL Bogdan indicated he was not aware of the email until sometime the following
day, Saturday.? (Exhibits?S, 

87. W36) Upon arriving at Camp V, ISN156 was placed in cell Al 05 (cell 105 on Alpha
Block lower) mama A107, diagonal from him. By I800, ISN156 had ?ooded his cell

 

 
 
     

 
 
 
 
   
 

ked whether becaus issues, electronic line of sight
clent.  . at site recommended ISN 156
be placed on direct (p real line of sight. I "i . 111.31.181.11- ?lh meusc ?m
respect to line of eight. called being very conce -- having ISN156 bar: at . and-w (shimmer 

ordering that on no an eleetmnielin i t. (Exhibits 16,24)
I_t was recalled ordering ISN156 on direct and electronic sight.
(Deanna?th (,Exhi it 16)

 

 

USC 1.4(comma to sen 15 to Camp on 15pr inc would have stood
even if he had seen the email on Friday, as he knew to make melodramatic statements. (Exhibit 5)

20


.



 

and was banging on his cell door, generally ?causing a racket? on the tier. Based on 
behavior at the BHU. he had a splashbox on his cell at Camp V5"s (Exhibits 20, [03. I23)

 

88. The AOIC at Camp i talked to and tried to
convince him to settle down?? gave  a speech about respect, saying that
he did not like to be pressured. ISNISG also said something like am a sick man and because

of that. I am not afraid to die.? recalled that 1 56 insisted that his personal
belongings be returned to him. (Exhibit 20)

  

89. Understanding that was ?banging and yelling" because he wanted his

belongings. the block non-commissioned of?cer (BNCO), searched them.
After removing the items that ISN156 was not allowed because he was on discipline. including
extra towels and T-shirts, the guards gave [56 his belongings, including a foam pillow and
linens.77 ISN156 indicated that he did not want his mattress. (Exhibit 19)

 

 

 

90. (W989) At the time, there weruards (I (blt3itto usc ?130b.tbtt6).tht7KCJ I
posted on direct of sight for for the night shift on Alpha Block
At the start of their shift.  tbit3i110 USC ?130b.tb)t6).tbtt7)tC) [agreed to rotate line of sight
dutylWI and that if either guard ?got sleepy" he would ask the other guard to take over.
(exam usc informed of their intent.? (Exhibits 1. 6. l9)

 

 

 

 

 

 

 

 

 

 

 

 

91. (WAround 1830, at the request of [56 mama?? gave 156 cereal, apple
juice, and milk. Around I920, ISNI56 ?mash[ed] up the cereal? using the milk and apple juice.
jumped from the sink and smeared hiswith the food mixture. (Exhibit l)

 

 

 

7? (W999) Only certain cells at Camp have splashboxes. which are employed to minimize the risk that a
detainee is able to "splash" uards with feces, urine. or other materials.
7" lSNl56 told bet it would be a sign of respect to talk to him without the splashbox.

      
    

completion of their disciplinary time. Exhibit 41)

?3 

As discussed later in the report. there are speci?c SOPs that gove in procedures. ?$31233??-
?mm?i?g" WEE-.2   ndicated that he knew that the 30? required ards to rotate out every (meals) but that he and PFC 
Eg?g??f?i decided to rotate out it E) For his art  indicated that he knew that the SOP required uards

tom - Although (bll3lilO USC all recall 

were rotating line of sight approximatel indicated he reccivc

permission ?'om  0 stay off the tier for ?at most complete administrative duties.
ndicated that at one point. he pulled line of sight duty on [56
mm 10 US i for approximately ?l   alert that 7 September 2012 was the first time be

extreme: JJ'liatl ever been in tare of or done line of sight. 9 indicated that he allowed (exam use 

rotate every Hg] because he thought it won - "caster on the Soldiers" to I ~?Ig?gw?g?gf?m
epitome that I56 died. 9 September 20l2. he was told that the SOP sa 5 that uards are
supposed to rotate out every (mam . The AOIC on duty the night of 7 September 20 2 

indicated that ?guards usually rotate every (bll7ltEi when pulling line of sight duty" and state I i not

think the SOP required anything speci?c about rotation times. (Exhibits 1. l-A. 6. 6-A. l9. l9-A. 20. 45)

 

    



 

 

  
 

      

 

 

 

    
 

 

 

 

     

 

 

 

 

 

 

 

2l
SEER-W

8C000027

(piano USO 





 
   
  
  

92. (814139963; Around 2200, 156 was still jumping around, now with a towel tied around
his neck sing as a cape and smearing honey on his face. At some point, the night
1.0.1 gamma" came to deliver ISN l56 his prescribed medications.recalled
"3?1wa71 leaving the'rnedications-in the splashbox, but did not recall taking the
medications that night.80 (Exhibits 6, 9-A)

 

in

L. (3133666) Events of 8 September 2012

93. (WSometime shortly before midnight, 156 ?nally appeared to go to sleep.?
did not recall seein ?lift his head or move all night? but did recall seeing
ISN156 breathing. Magma?- noted that in his experience, it was ?odd? that 156 would
have slept that long, as he was usually a very active sleeper. {baggage-m noted that he had
?never seen sleep that much," pointing out that IS so usually slept for only a few
hours at a time. and even then, continued to move all over his cell in his sleep. (Exhibits 1, 6. 6-
A)

 

 

 

 

 

94. (WG-69) At 0455 the morning of 8 September 2012, Managua? was on line of sight
durin the call to prayer. banging on the door at that point. along with HN
who had come bac with another round of medications, to wake up lSN156i ?sagging??-
noted that other detainees were calling lSN156?s name to wake him up for prayer, as the were

3 At some 

an that ISN156 was missing prayer call.8
hat had been sleeping for "quite a while.? (Exhibits 1, 6)

95. (-LWFQUQ) (exam use indicated they did not see ISN156 ingest any pills.
They also indicated that they did not leave their duty, and did not look away from for
more than two to ?ve seconds while they were on line of sight duty. (Exhibits 1 -A, 6-A)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

96. (W686) Around 0600 8 September 20] tblt3)r10 USC 
over line of sight duty on ISN156 from] tb)t3):10 USC ?130b.tb)t6).tb)t7)tcl j. 

      

It

 

8" WM discussed later in the report. there is a JMG SOP governing medicatibn administration. As

ex lained several uartls and on men when a detainee was aslee nd had a splashbox on his cell, 
I (bimlE) I When the detainee awoke. the guard was

to alert the cogpsmanl

(bli3li10 USC 

 

 

 

(Exhibits l-A. 6. 9. IO. 23. 25-A, 50)

WAlthough he was authorized two hours at the recreation yard per day while on discipline. ISN156 did
not go to the recreation yard that night. (Exhibit 2.0)
82 (me) Although the calendar dictates the speci?c prayer time. detainees at detention facilities
customarily initiate the call toprayer on their own.

22
SEW

8C000028

358W

when the shift changed over at (matte) ISN156 was still asleep, ?vigorously snoring.? emit-System

 

 

 

(attair'to'usc sierra. tsou. .
took over from 3mm?, 5 the for Alpha Block (Lower). . 

 

 

 

 

 

recalled the Watch Commander. 1mm)? ~Wbriet?ing at guard mount that 156
had come back to Camp during the night and that the guards needed to ?all stay on [their]
toes?"3 (Exhibits 

 

 

 

 

97. (UH-7999) (baggage- as on his ?rst day of guard duty when he showed up for the

morning shift on 8 September 2012. He had just recently arrived at on 7 August

2012. and had been settling in after completing his pro-service training on 30 August 20] 
indicated that he never received any instruction concerning line of sight rotation times the

morning or 8 September 2012.34 (Exhibits 

98. Egalit?giyubm took theof line of sight duty on ISNI56, from

approximate] HUME) ?"i?iit??x?ift?iam indicated that he was told that he an would
rotate (blmtE) [line of sight. the BNCO, was aware that 
[were going to rotate line of sight duty tb)t7)tE) 8? (Exhibits 10. 25, 25-A)

99. that when he took over line of sight duty at he saw two
small paper cups, one ?lled with a cream, in splashbox. size-treatise) noted that at the
time, ISN 156 appeared to be asleep on his back, rolling from side to side, ?dreaming and
mumbling?? (Exhibit 3)

too. (UHF-986) Amunti?g?took over, and indicated that ISN 156 still appeared

to be sleeping and mumbling, as though he was dreaming. The two cups were still in the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8? (615F696) At guard mount. the Watch Commander briefs the inconting shift regarding signi?cant detainee
updates from the previous night. Guard mount takes place outside the camp. in formation. approximately one-hall?
hour before the shift change. (Exhibit 8)

3? (8155:6891 Pre-service training records do not re?ect a instruction for line of si ht. See JDG
PODI BLOCK GUARD Job Quali?cation Requirement fo ?tissues? 3t August 2012.) 
. . I
[bun-lbw? 
(hm I?I?lml'wm that he was not told

anything about line of sight rotation times at the pro-service training stated that at the training, pans of
the SOPs were read to the guards. but the guards never saw actual copies 0 . Ps. As discussed later in the
report, there are speci?c SOPs that govern requirements for line of sight duty, including rotation times. (Exhibits

IO. 45)
?5 (?Hidit'iimmlindicated that he knew that the SOP required guards to rotate line of sight duty eve


inutes. but that he generally allowed Soldiers on duty to decide how lon the wanted to rotate line of sight. 
I 0 I - .


that the day after [56 died, 9 September 20l2 .  .
at

 

 

 

 

 

  
       
     
   

- put out information at guard mount

   
 

 
  

m5? 1 at me of sightwouldherotated everyaninutes from then on. - 1, . indicated that although he knew the

. . - - . - . . - - - - a 3 :10 use 130m.
SOP re utter}:- I minutes. told mm to out with .{h?eimmcf
. t- to. 8. 25
uremic?- .

?ould not recall at what time he last saw ISNISG breathe. but recalled that it was right
berune he switched duty with (Exhibit 8)

23

 

8C000029

(I: Kim a I 

(bit It . ll)" 
(?17110)



 

 

 

splashbox. Wmderstood that iflSN 156 awoke, he was to alert the
corpsman. (Exhibit 10)

101. WMound 0800, arrived for the morning med pass for ISN156, but
appeared to be asleep all morning. brought a suppository and Colace that

 

(steamer
helps with bowel movements. At that time, noted that there were two pill cups -
one with a cream and one-with a pill alr in the splashbox." did not leave
the 0800 medications'for ISN156 in the splashbox, as there were already other medications there.

indicated that as a matter ofpractice, he never leaves medications in a detainee?s
splashbox. (Exhibits 10, 23)

 

 

 

 

102W ISN156 did not wake up for his recreation time scheduled for 1000-1200. The
Watch Commander recalled that the last time he saw ISN 156 alive was around
1100. At that time, he checked on ISN156 to see whether he wanted to go to recreation, but
because ISN156 appeared to be asleep, he did not disturb (Exhibit 15, 25-A)

101W ISN156 did not wake up for the noon prayer call.39 recalled
checking on ISN156 around [245, and indicated that ISN156 was ?definitely?still breathing at
that point.? I Irecalled mentioning to the guard on line of sight (he did not
remember whether-it was] (Dustin USO lat the time) that the breathing of ISN156
looked ?rapid or labored.? (Exhibits 23)

 

 

0:103:10 USO ?130Mb?llbiimci

104. I Iindicated they did not see ISN 1.56 ingest any pills. They also
indicated they never left their duty, and did not look away from for more than 30 to 60
seconds while they were on line of sight duty. ?352.3532? stated, however, that he was not
looking at breathing pattern and was focused on verifying that 56 was not trying
to hurt himself. (Exhibits 8-A, 23-A, 25-A)

[01% Around 1400, as on line of sight duty, preparing for ?resigns,? to
take over- indicated that he had not seen ISN156 snore or mumble for a whileeand

therefore called was doing a tier check at the-time. tapped on

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the lass of ce 1, am! when ISN156 did not respond, USC called
lieved ISN156 was still

 

over to the cell. that 

 

 

 

    
 

 

-i dicated that guards frequently discuss whether to Wake a detainee for recreation, time.
-- - ed that because ISN156 was so unpredictable. he decided to allow ISNISG to continue to sleep,
an [3 to give him recreation time later. (Exhibit 15)

39% There are no DIMS entries during this period of time. As discussed later in the report. there is a.
speci?c SOP that governs entry of information into during line of sight duty. (Exhibit 45. 56)

   

24



 0' a A

?breathin at that point, because blanket had moved. To be sure, however, they called
?ml who arrived at Camp 20 to 30 seconds later. (Exhibits 3, 10)

 

 

    

106. Wm the same time, the Watch Commander, reassess,?- was on the tier talkin
to another detainee. I USC IcalledWr. Around 1400, name).

ocked on the glass of iSNlS6's cell, and when he did not receive a response, call a
Code veiiow.90 (Exhibits to, 15)

 

 

 

 

107. M5986) Several Camp guardsJ U50 

(bltalzw USC (?the guard team?) responded to the Code
Yellow." Once members of the guard team donned their protective gear,?2 they stacked up on
the cell door of ISN156 and waited for the other NCOs to arrive. called for the door
to be opened, central control released the cell door lock, and pushed the door Open,
with the guard team rushing in. indicated that when the guard team entered, ISN156
was lying on his right side with his head on a foam pillow, a blanket covering him, and his right
arm extended. (Exhibit 3)

 

 

 

 

     

 

head, she saw ?chunky vomit? and when she
turned ISN156's head to the side, she stated that a large quantity of ?yellowish bloody goo?
drained out of month.93 By this time, secured 56's hands with
restraints as a safety precaution. m3": "scs?amm the corps'man, arrived, took pulse,
and indicated that there was no pulse. told the Watch Commander he thought

ISN156 was dead and to call the nurse. (Exhibits 3, 23)

 

 

 

A Code Yellow is used to indicate a tentially life-dueatening medical condition requiring an
iinmediate response. The cup nu indicated that she receives approximately ?ve to Seven Code
Yellows per week. As discussed later in repo ere is a IDG SOP governing brevity codes. (Exhibits 16. 47)
M31210 the equivalent of the Assistant Watch Commander at Camp that
Manama) day.  was assign . to Blochm already on Alpha Block (Lower) as the NCOIC,
assigned as the Recreation Yard I NCO. (Exhibits 3, 25, 26, 34)

 
 

 

 
 



 
 

II.

  
 
 
 

    

recalled similarly, he saw vomit on right arm when he entered the cell. (Exhibits 25, 34)
After Action Report (AAR) determined that although a Code Yellow was appropriately called by
the guard force initially, the situation sh uld hav . - upgraded to a i mediater upon veri?cation that
ISN156 had no pulse or respirations. Auld have ?appropriate precipitated the recall of emergency
medical support and triggered noti?cation uty provider for potential [Advanced Cardiac Life Support] ACLS
response."
?5 . Lu; I called that when he anived in the cell, Was still wann (?not cold 
had a ?yellow, sweaty on When be bent down to see if he could hear breaths or see chest 5m,
mmnousesoted that he saw and smelled vomit, which looked to him like mashed up cornflakes and milk. it 
maritime} 

 
 
 
 

  

25






4 I i

 

109% Using the keys she had on her beltas ?3mm I?builiilliesgi'dmlremoved the
restraints on ISN156 to begin chest compressions, and began rescue breaths.?

Withperforming rescue breaths,  exam USC ?1soutblt?ttbl?-ngcontinued with the
chest compressions, alternating approximately?every four minutes. (Exhibits 3, 23, 26)

 

 

 

 

  
   

 

momma)
_v graded the situation to ISN156 was in cardiacarrest. mm -
(baggagg?gs?igw - a paused the chest compressions for milliliteg??i?i" to attach the de?brillator pads to
56. Upon a reading of ?shock not advised,? usc continued

alternating chest compressions for approximately 18 to 20 minutes. (Exhibits 3, 23, 3'3)

       

 

Other guards passed a backboard into the cell, and the guard team secured
ISN156 to the backboard, carried him out, and loaded him into the ambulance. By this time,

?Dxmg?f?f?fm another nurse from Camp VI, had arrived. She got into the back of the

ambulance, performin chest com "essions on ISN156. Also in the ambulance were
91 use 5130b. 


 

 

 

 

greeninfo (driving andmamp guards. The ambulance left the Sally Port
of Camp around 1426, and arrived at the a few minuteslater. (Exhibits 3, 13, 23,
29. 30)

112M989) Once at the out of the ambulance to prepare a bed for
ISN156. At the same time, a nurse at the BHUIDH 13m, bile assessed ISN156 in the
ambulance and instructed (new use (a co?rpsman at the DH) to proceed
directly to the Hospital.? (Exhibits 22, 32)

 

 

 

 

 

 

113. (HALF-GHQ) The ambulance, at that point containing USC ?130Nbll6libll7?cl I
the two camp guards and withdriving, left the DH for the NAVSTA Hospital.
En route, ?magmas-t") ontinued chest compressions, withmaintaining an airway,
performing rescue suctioning. Upon arrival at the NAVSTA Hospital, a doctor and
cor'psman came out and mshed ISN156 into the Emergency Room. There, medical staff

 

 

 

 

        

- - -  ed a pocket mask and breathed into the nozzle which contains a one-way valve to
protect the individual providing the breaths from any contamination ?om the patient to start the rescue breaths.
(Exhibit 23)
(blt3l110 USC [are both certi?ed as Emergency Vehicle Operators (EVOs).
(Exhibit 23)
?5 (Um

 

 

?Eliza?s,? explained that'the NAVSTA t?ospiat is]
{Ultl? 

laining that there are usually no medical doctors at the on the weekean

indicated he would have proceeded di?'erently had it been a weekday, as there would have been more in tea staff

present. In the AAR, the JMG recommended that in all cases involving codes from Camp V, VI, and Echo, where

ACLS is not available on site, the patient ?shonld have [Basic Life Support] BLS initiated immediately and then be

evacuated to the Naval Hospital for ACLS response.? (Exhibits 32. 85)

 

 

 

26



I i 0

administered epinephrine and intravenous drugs. and continued life-saving measures. They
declared ISN156 dead at 1443.99 (Exhibits 13, 23, 30)

114.9% The guards understood their mission was to remain with the body of ISN156 at
all times. At some point around 1543, NCIS, the FBI, and Combat Camera arrived to examine
the body and take photographs. 56 was moved to the X?Ray room around 1725. The
guards escorted the body via ambulance to the morgue. (Exhibit 2.9)

1 l5. next day, 9 September 2012, a team including a medical examiner,

pathologist, and a Muslim Chaplain arrived at GTMO. The Muslim Chaplain?s role was to care
for the remains of 1 56 and prepare them in accordance with the Muslim faith. The Muslim
Chaplain noted that the?handling of the body was in accordance with the requirements of Islam.

(Exhibit 127)

M. (U) Timeline

1 l6. Table 1 re?ects key events in the timeline leading up to the death of ISN156,
beginning with his transfer from the DH to Camp on 7 September 2012. The information for

Table was compiled from several witness Statements, DIMS reports, and medical records for
ISNISG.

 

      

-c indicated that there was no response, no pulse, and no respirations from from

 

    

i
an .m
463111 c:

the tim entered the cell to the time they arrived at the NAVSTA Hospital. (Exhibit 23)
27



 

(U) Table 1 ?Timeline.



 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

     
 

[approximate Time Events
W53: 2012
?27 lSNli? starts move Front Detainee Hospital to Camp 
1738 arrives Camp Cell 5A 105
1739-1300 floods cell
1300 Sti begins banging, on cell door, causine a racket on Alpha (Lower) Block
?25 eats dinner rice. beef, shrimp, soup, and apple-juice
2006 ISNIEG speaks with AOIC about respect issues; conversation ends with AOIC
explaining that it would take cempliance and respect to remove the splashbox
2018 begins altering cell and covering?blii?liElIwith a fond substance A
2230-2359 ISNISG appears to fall asleep
8 Sep 2012
0400 - lleaves medications in cell Splasltboa? [Si-lle
[blt?llblii'iCi appeal-S to 1e 65 cc?
0600 Shift change from night to day shifi; 56 appears to remain asleep, misses
?yer andbreaicfast 
0300 Corpsman tries to adnj in' dications to but 

 

appears to be as ecp; me teations from  - 

 

 

 

 

 

must 4} ,m Watch Commanderq It comes for ISN156 to go to recreation, but 56 
appears to be asleep
__1g00 ISNISG appears to remain asleep
,biamugc 51m? - indicates I 56 breathing had become abnormal, and attempts to gain
attention; unresponsive
  muscmus 1405 . WatchCommandertI - calls Code Yellow 

 

 

   
 

Team 0 guards?cnlers cell, iollowed by! 1 team secures iSle'iG;
assesses ISM 56 and calls for nurse; 

begin performing cltest compressions with] Ipt?oviding rescue breaths

1405

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

?1.1.3.55 5m; El 1 Registered Nurse  -- arrives and determines further assistance is needed
73112 Registered Nurse It is called
116 '??gfiftfbi?i??im' Mimics iSNl 56; determines an ambulance is required 
?17 Ambulance is dispatched
1417 ISNISG is secured to backboard
9 Ambulance arrives
1420 ISNISG is loaded into ambulance and taken to 
1422 Ambulance arrives at BHU
1424 to send ambulance to NAVSTA Hospital
{mm Ambulance departs for NAVSTA Hospitalzl basic CPR
Ambulance arrives NAVSTA HoSpital and Sb taken into emergency room;
emergency room doctors take over
1443 56 is pronounced dead 
1740 bodi is transported to morgue 
23

SC000034



11. (U) Listing of Recent Prescribed Ilriedieations

A. (U) Prescribed, As~Needed Medications

1 tar-oesoeog Table 2 re?ects prescribed medications for 56 beginning in 2010

through his death on 8 September 2012.??

Ef?e-935 Table 2 PRN Medications for {September 2010 September 2012).

1 

 

 

 

 

 

 

 

 

Prescribed Name of Medication. Dosage

Start Date

9 Sep 2010 Tuclts pads 1 pad, once a day. at night

9 Sep Sea Soft nasal Spray 2 sprays each nostril, twice a day, as needed {for

dr}r nasal passages)

9 Sep 2010 Hydroeortisone suppository Per rectum, four times per day. as needed (for
hemorrhoids)

28 Sep 2010 Proctosol - HC 25% Apply to roots! area. twice a day, as needed {for
external hemorrhoids}

21 Dec 2010 Hibiclens wash As needed (tor legs}

20 Feb 201 Surtal: 240 me, by mouth, once a day. at night

13 May 2011 Seroquel 50-100 mg. by mouth, three times per day, as

needed (for anxiety or agitation)

 

23 Dec 20?

Clotrimazolo cream 1%

Apply to aliiscted area, twice :1 day, as needed
(for rash) (should use for 1-2 weeks, if not
effective, request provider alga-ointment}

 

 

 

23 Dec 2011 Hydrocortisone cream Apply to affected area. twice a day. as needed
(for itching} (not to exceed four doses per week
without doctor's review}

23 Dec 2011 Eucerin Cream 30 ml, apply to affected area, twice a day, as

needed (for dry skin) (not to exceed four doses
per week without doctor's review)

 

 

 

 

 

 

23 Dec 20] Claritin 10 mg, by mouth, once a day, as needed
(rhinorrhea, sneezing. watery eyes) (not to
exceed four doses per week without doctor?s
review) 
?Pitt?s? indicates ?as needed" medications and items, and are different from the scheduled. prescribed

medications re?ected in Table 4. Sonic medications and items on the PRN Medications Records are "over the
counter" items (such as ice, tape, or Tucks pads), but some require it prescription (such as Haidoi. Percocet. and
Tylenol with Codeine). In a detainee could request FRN medications from a corpsman or nurse on an as
needed basis. and so long as the medication and request was consistent with what was re?ected in the PRN
Medieations Records for the detainee, or nurse was authorized to dispense it. Accordingly, a detainee
w0uld not necessarily be taking all the PRN medications at one time. The PRN Medications Records also contain a
column where the corpsman or nurse indicates when a detainee took a particular PEN medication {see Table 3,
bciewj. The information in Tobie 2 was compiled from PRN Medications Records for [Exhibits St}. 97)

{Wield-93A reference ofmedical pharmacological abbreviations and their meanings is included as Exhibit

[17.

SC000035

 

 

Prescribed Name of Medication Dosage
Start Date 

 

 

23 Dee 2011 Cepaeol 1 lozenge. in mouth, every six hours, as needed
(for sore throat) (not to exceed six doses per
week without doctor?s review)

 

23 Dee 20H Pepto-bismol 2 tabs, by mouth, four times per day, as needed
(for minor abdominal distress) (not to exceed
t'our doses per week without doctor?s review)

 

23 Dec 201] Tylenol 630 mg, by mouth, every Four ltours (minor
aches and pain, headache) (not to exceed two
doses per day without doctor's order)

 

23 Dec 20! i Mylanta 15~30 ml, by mouth, every six hours. as needed
(for heartburn or indigestion) (not to exceed four
dos?per week without doctor?s order)

 

23 Dec 20] I Milk ot?Magnesia (laxative) 30 ml with 3 oz of water, by mouth, twice a day,
as needed (for heartburn or indigestion) (not to
exceed [our doses per week without doctor?s
order)

 

23 Dec 201] Zantae 150 mg, by mouth. twice a day, as needed (for
heartbum or indigestion) (not to exceed four
doses per week without doctor's review)

 

23 Dee 20H Robitussin 10 ml, by mouth, four times per day, as needed
(for cough) {not to EXceed four doses per week
without doctor?s review)

 

 

 

 

 

 

 

 

 

 

 

 

 

23 Dec 2m 1 Ensure 1-3 cans, three times per day. as needed (not to
exceed four doses per week without doctor's
review)

23 Dec 201 1 ice Apply to affected area for 15 minutes, four
times per day, as needed (minor injury)

29 Dee 20H Zoi'ran 4 mg, by mouth, every six hours, as needed, for
?ve months (for nausea)

29 Dec 201) Tape Buddy tape right second digit to right big toe,
for four weeks (for stability due to injury)

23 Jan 2012??2 Percocet 1 tab, by mouth, every six hours, as needed (for
severe back pain)

25 Jan 2012 Flonase 2 sprays each nostril, twice a night (prior to
enteral feeds)

111 Feb 20! 2 Naprosyn 500 mg, by mouth. twice a day, as needed, for
for four weeks (for pain)

14 Mar 2012 Atarax 50 mg. by mouth, once a day, for ninety days
(for itch)

25 Apr 2012 Motrin 400 mg. by mouth. every six hours, For thirty
days (for pain)

 

 

Hm There is also a later start date for Pereoeet, 30 August 2012, for the same dosage but for "pain" as
opposed to ?severe back pain.? {Exhibit 

30

 

SC000036

major 10 use
5130:: totsrrum
{Cl

 

Prescribed
Start Date

Name of Medication

Dosage

 

:4 Jun 2012'?

?ii


25 mg. intramuscular. every eight rs
needed (WITH Haldol) (NOTIFY .
PRIOR TO newsrooms) '05

 

 

 

 

 

 

 

Jun 2012 Ativan 2 mg, per oral or intramuscular, every four

hours. as needed (for acute anxiety) (NOTIFY
PRIOR TO ADMINISTERTNQ)

[4 Jun 2012 Haldol 10 mg, intramuscular, every eight hours, as
needed (for aaitation WITH Benadryl)
(NOTLFY  - 
ADMINISTERJNG)

 9 Jun 2012 Triarncinolone Ora'oase dental paste, at night, tip to three times
per day, during day

[9 Jun 20l2 lJase-line Offer Vaseline petroleum jelly, three times per
day, as needed {for dry lips}

1 Jul 2012 Lactose~free milk 25 oz" by mouth, once a day. as needed

25 Jul 20l2 Selenium shampoo 30cc. apply to hair. two times per week. as

needed

 

 

 

 

 

 

 

 

 

25 Jul 201219? Benadryl 25 mg intramuscular injection (to be given with
Haldol per medical of?cer)

25 Jul 2012 Ativan 2 mg, by mouth or intramuscular injection,
every four hours, as needed (agitation)

26 Jul 2012 Haldol 10 mg intramuscular injection daily, as needed
(for agitation) (to be given with Benadryl per

medical of?cer)

29 Aug 2012 Arti?cial tears 1 drop, left eye. four times per day, as needed

29 Aug 2012 ophthalmic ointment H4 inch strip inside lower lid, left eye, each
night

31 Aug 2012 Tylenol with codeine 1 tab, by mouth, once a day. as needed [for pain)

7 Sep 2012 Tylenol #3 1 tab, by mouth, once a day, as needed (for pain)

 

 

 

 

WM noted above, 14 June 2012 is the date that ISNISG had a telephone call with his attorney
following the Supreme Court decision on 1 I June 2012 denying his petition for a writ of cera?omrr? in his battens
corpus proceedings. TheCamp OK: indicated that ISNISE- came back furious and saying, ?only
slu?'" a?er the call. The phone call with "5 awyer Is cited as the beginning oftlte most recent downward spiral of
(Exhibit 16)
'04 A series oi'thrce injections, Bcnadryl (to counteract the effect ofitelting caused by the Ativan and
Haldol), Ativau, and Haldol are considered "emergency medications." {Exhibit 97)

mm The all caps appear in the original PRN Medications Records. [Exhibit 

mfg-tenancies July 20l2 is the date ofthe ?rock-throwing incident" detailed above, when threw reel-ts at
Camp VI guards and recreation tower. lSh-Zl 56 was transferred to the BHU as a result ol'the incident. Later that

same day, 25 July 20i2, ISNISM
um it .thu 

{Exhibits 53. :54. 53]

3]



tats; to us: gear-t.

ibi'l'r'itC'

Humid); 'p-j IJSC 5 not.



,tt'rz; message-r.-


SC000037

110%) Table 3 re?ects the ?High-Risk DEA Classi?ed Drugs? that were on ISNIS-S's

PRN medications chart, and that he requosted and took in 201

E1 Him: .99 Tame 3 Highness- DEA Classi?ed Drugs for ISNISG (2012).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

WET-99
Date and Time of Drug Quantin
Administration?)3
25 Jan 2012 2000 l?crcocct 1 tab
26 Jan 2012 1300 Pcreocet 1 tab _d
26 Jan 2012 2235 Percocet 1 tab
28 Jan 2012 1930 Pcrcocct 1 tab
30 Jan 2012 2004 Percoeet tab
3 Feb 2012 0330 Pereocet 1 tab
23 Jul 2012 0001 Pereoect 1 tab
28 Aug 2012 0130 l?crcocet 1 tab
28 Aug 2012 0530 Percoeet 1 tab
28 Aug 2012 1445 Percoeet 1 tab
28 Aug, 2012 2045 Percocet i tab
29 Aug 2012 2030 Percocet 1 tab
3 Aug 2012 2040 Percocet 1 tab
29 Aug 2012 2045 Pcrcocet 1 tab
31 Aug 2012 0508 Percocct 1 tab 
3] Aug 2012 1445 Percocct I tab
31 Aug 2012 0015 Tylenol with codeine 1 tab 
2 Sep 2012 1003 Tylenol with codeine 1 tab
3 Sep 2012 0505 Tylenol with codeine 1 tab 
4 Sep 2012 0205 Tylenol with codeine 1 tab
5 See 2012 0630 Tylenol with codeine 1 tab
7 Sep 2012 0 i 20 Tylenol with codeine 1 tab
h_2__2'tug 2012 0705 Ativart 1 tab
4 Aug 2012 0155 Ativan tat:-
25 Aug 2012 2200 .r?ttivan 1 tab
26 Aug 2012 0500 Nisan 1 tab 
27 Aug 2012 0500 Ativan 1 tab
6 Sep 2012 1500 r-?ttivan 1 tab
2 Aug llaldol 10 mg, by injection 

 

 

 

 

11"? .. According to the SDP, Pcreocet. Tylenol with Codeine. and Ativan tt'ere drugs that we (0)0053
tmt'r?ltEi and Haldol and Seroquei {nitrite} As- discussed later in the report, not all nurses and
{bm'HE}  Aithottgh the investigative Team unaiyzed ai'l medications on

 

 

dtcT?RN Medications Records tor on. tor the purposes ofthe report. a table re?ecting onlyr the most medically
signi?cant medications, speci?cally, narcoticsu is included. The information for Table 3 is compiled from the PRN
Medications Records for ISNISG. {Exhibits 50. 97')
m5  ?Administration? is used as opposed to "Ingestion." Based on interviews with nurses and corpsmen
regarding current practice within the camps, the Medications Reports indicate when the medication is provided
to the detainee, not necessarin when he ingests it.

32

SC000038

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date and Time of Drug Quantity
Administrationm

261011 2012 2220 Seroquel 100 me.
23 Jan 2012 0000 Seroque] 100 m;
23 Jan 2012 1930 Seroque] 100 mg
30 Jan 2012 2100 Seruquel 100 mg
1 Feb 2012 2000 Seroquel 100 mg
3 Feb 2012 2100 Seroque] 100 mg
5 Feb 2012 2030 Seroquel 100 mg
7 Feb 2012 2010 Seroquel 100 mg
9 Feb 2012 0100 Seroquel 100 mg
10 Feb 2012 2100 Seroquel Hm mg
11 Feb 2012 2000 Seroquel 100 mg
14 Feb 2012 0000 Seroque] 100 mg
15 Feb 2012 2000 Seroquel 100 mg
16 Feb 2012 2030 Seroquel 100 mg
1? Feb 2012 2100 Seroquel 100 mg
19 Feb 2012 0000 Seroquel 100 mg
20 Feb 2012 2000 Seroquel 100 mg
23 Feb 2012 2015 Sernquel 100 mg
24 Feb 2012 2315 Seroquel 100 mg
25 Feb 2012 2322 Seroquei 100 mg
26 Feb 2012 2200 Serequel 100 mg
27 Feb 2012 1909 SeroHUel 100 mg
3 Mar 2012 2100 Seroquel 100 mg
4 Mar 2012 2230 Seroquel 100 mg
7 Mar 2012 2056 Seroquel 100 mg
11 Mar 2012 2315 Seroquel 100 mg
XX Mar 2012 0015110 Serequel 100 mg
14 Mar 2012 0015 Seroquel 100 mg
2 Apr 2012 2200 Seroquel 100 mg
3 Apt 2012 2000 Seroquel 100 mg
13 Apr 2012 0000 Seroqttel I00 mg
14 Apr 2012 0000 Seroguel 100 mg
18 Apr 2012 0000 Seroguel 100 mg
13 Apr 2012 2050 Seroque] 100 mg
19Apr 2012 2213 Seroquel 100 mg
100% 2 August 2012  {010113201010} It?er the entries on the Medication

 

Administration Record (MAR). it appears that the l-laldol was given via injection. This is consistent with sworn
statements indicating that a nurse administered emergency medications to [$55156 following the incident. (Exhibits
17, 99

?0 Mis?t: virtually all entries on the PRN Medications Reports, the date is very difficult to read, and is in
fact illegible, but appears to fell between I I and 14 Morel} 2012 and 14 Mar 12. As discussed later in the report,
because ofthe way the PRN Medications Reports are struetured. it is extremer difficult to reconstruct a chronology
oft-then a particular medication was taken. These tables re?ect the Investigative Team?s effort to do so. (Exhibit

92)

SC000039

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date and Time of Drug Quantity
Administratinnms

23 Apr 2012 0000 Scruqucl 100 mg
4 May 2012 2300 Seroquel 100 mg
'1 May 2012 2109 Scroqucl 100 mg
10 May 2012 2213 Seroqucl 100 mg
15 Jun 2012 0015 Seroquul 100 mg
16 Jun 2012 0020 Seroquel 100 mg
17 Jun 2012 0021 Seroquel 100 mg
17 Jun 2012 2300 Semquel 100 mg
19.11111 2012 0020 Seroquel 100 mg
20 Jun 2012 0205 Scroqucl 100 mg
22 Jun 2012 0145 Scroquel 100 mg
22 Jun 2012 2405?? Saroquel 100 mg
16.1ul2012 0000 Semqucl 100 mg
13 Jul 2012 2200 Sci-equal 100 mg
26 Jul 2012 2010 Seroquel 100 mg
30 Jul 2012 2020 Scroqucl 100 mg
3 Aug 2012 0155 Seroquel 100 mg
13 Aug 2012 0155 Seroguel 100 mg
25 Aug 2012 2105 Semquel 100 mg
27 Aug 2012 0005 Scroqucl ?1.005;;
28 Aug 2012 0550 Seroquel 100 mg
30 Aug 2012 2345 Sergqyul 100 mg
31 Aug 2012 0508 Baroque] 100 mg
1 Sep 2012 0320 Seroquel 100 mg
2 Sep 2012 0530 Semquel 100 mg
3 Sep 2012 0000 Semquel 100 mg
3 Sep 2012 21 15 Semqucl 100 mg
4 Sap 2012 0945 Scroqucl 100 mg
4 Sep 2012 2240 Semquel 100 mg
5 Sep 2012 0940 Seroquel 100 mg

 

 

WTM small size uftlic boxes on 111: PRN Medications Reports somelimcs makes it dif?cult to disccm
whether a date is for "Jan" or "Jun", or "Mar" or ?May?. for example. {Exhibit 

34

SC000040

B. (U) Prescribed, Scheduled Medications

19. We) Table 4 re?ects prescribed, scheduled medications for 1804056 that he was
prescribed at the time this death on 8 September 2012.?2

Table 4 Prescribed, Scheduled Medications for ISN156 (5 -8 September


 

 

 

 

 

 

 

 

 

 

 

 


Prescribed Date and Time of Drug Dosage
Start Date Administration'?
Minn 2012 5 Sep 2012 0430 Zanlac 1 tab. by mouth, twice a day
5 Sep 2012 2200
6 Sep 2012 0430
6 Sep 2012 2200
'1 Sep 2012 2200
8 Sep 2012 0430
14 Jun 2012 2012 0430 Lidcx Cream Apply to lesions. twice a do},r
5 Sep 2012 2200
6 Sep 2012 0430
6 Sep 2012 2200
7 Sep 2012 2200
3 Sep 2012 0430
14 Jun 220l2 NONEI ?3 Benzoyl Peroxide Use in shower dailyr
Solution 10 ?Va
14.11111 2012 6 Sep 2012 2200 Salicylic Acid Wash Apply to legs. twice a day
14 Jun 2012 5 Sep 2012 2100 Calcium and Vitamin 1 tab. by mouth, ever}r day
6 Sep 2012 2100
7 Sep 2012 2100
14 Jun 2012 7' Sep 2012 2100 Glucosamine/ 1 tab, by mouth. every day

 

 

As noted above. prescribed, scheduled medications are distinct from PRN medications. The
scheduled medications are offered to the detainee at particular titties each day based on the doctor's order. {Exhibit
99}

{-55.029150} The information for Table 4 is compiled from the Medications Administration Records for ISNISG.
(Exhibit 99}

Because none ofthc scheduled medications appeared on the ?Higli~Risk DEA Classi?ed Drugs? list
(see Table Table 4 only re?ects the dates and times ofadministration going back three days from ISi?s1 156's death
on 3 September 2012. As with the PRN Medications Records. "administration" is used as opposed to "ingestion".
Based on testimony from guards and 1 50 did not take any medications after 2200 hours 7 September
20 2. as he appeared asleep the entire time. it appears the Medication Administration Record for 7 and 8 September
20 [2 is improperly completed as it indicates that ISNI 56 accepted medications during that time,I which is
inconsistent with the statements and photographs. Based on the lit-ct that there were medications in pill cups in the
splashbox at the time ofhis death. it is possible that the MAR is re?ecting when the medications were
oft-red to the detainee were left in his splashbox}, not when 156 accepted them. Those medications after
2200 7 September 20 [2 are included in Table 4 because they were discovered in his splashbox following his death.
(Exhibits 1. 6. 3. 9. ll}, 23. 99. 129)

"5  15-51156 refused certain scheduled drugs from 5 to 3 September 2012. In Such cases, Table 4,
Column 2 re?ects 

35

SC000041

 

Prescribed
Start Date

Date and Time 03:
2111:1111inistl'otittnu

Drug

Dosage

 

chondroitin

 

 

19.1un2012

 Sep 2012 0300
5 Sep 2012 2100
6 Sep 2012 0800
6 Sep 2012 2100
7 Sep 2012 2100
8300 2012 0800

{201000

100 mg, by mouth, twice a day

 

19.1u112012

5 Sep 2012 0800
552p 2012 2100
0 Sep 2012 0300
0 Sept 20122100
2 Sep 2012 2100
8 Sep 2012 0300

1-1ydroeortisone
suppository

insert by rectum. twice a day

 

19.111112012

5 Sep 2012 0430
5 Sep 2012 2200
6 Sep 2012 0430
6 Sep 2012 2200
7 Sep 2012 2200
8 Sep 2012 2200""

Hydroeortisone 2.5%
Rectal Cream

 

19.11.1171 2012

5 Sep 2012 2100

Triumeittoione in
Oralbase Denta] Paste

Each night (ovar lower lip}

 

25 .1012012

5 Sep 2012 2200
6 Sep 2012 2200
Sep 2012 2200

1H
Remeron

15 mg. by mouth, each night, for
three months

 

2? J012012

6 Sep 2012 no time]

Throat lozenges

Offer ever}r 4 hours, while awake,
for sore throat

 

 

22 Aug 2012

 

5 Sep 2012 0430
0 Sep 2012 0430
7 Sep 2012 0430
8 Sep 2012 0430

 

Invega

 

9 111g,I ?5 by mouth, every morning

 

 

 

appears that the corpsmun initialed in the wrong box 1151501156 was no longer in his 0011 by 2200 8
September 2012.

"i  Remerorl and 11112030 were the only two scheduled. medications that was taking at
the time ofhis death on 11' September 2012. (Exhibit 24)

 . . ndieated that starting 22 August 2012, the dose was made up oftwo capsules 11

1003110020 01200..  .. I
one 3 mg cepsu on one 6 111g capsule. (End-11121124)

rtfr?? 10:12.13}

36



SC000042

C. (U) Administration ofInvega

120. fbh?r?FG?-G) Table 5 re?ects the administration times and dates ofinvoga for which
prescribed start date was 21 August 2012. (Exhibit 99)

We) Table 5 Invega August 2012 3 September 

 

 

 

 

Prescribed Date and Time of Drug Dosago Number of Total
Start Date Administration Capsuies in Dosage
21 Aug 21 Aug 2012 0430 [uvoga :5 mg 1
201213?
22 Aug 2012 22 Aug 2012 0430 Invoga I5 mg 1
23 Aug 2012 0430 Invoga 9 mg 2
24 Aug 2012 0430 invoga 9 mg 2
25 Aug 2012 0430 lnvoga 9 mg 2
25 Aug 2012 0430 Invoga 9 mg 2
27 Aug 2012 0430 lnvoga 9 mg 2
23 Aug 2012 0430 Invoga 9 mg 2
29 Aug 2012 0430 invoga 9 mg 2
30 Aug 2012 0430 invoga 9 mg 2
31 Aug 2012 0430 Invoga 9 mg 2
1 Sop 2012 0430 Invoga 9 mg 2
2 Sep 2012 0430 Invoga 9 mg 2
3 Sop 2012 0430 Invoga 9mg 2
4 Sop 2012 0430 Invoga 9 mg 2
5 Sep 2012 0430 Invoga 9 mg 2
6 Sep 2012 0430 invoga 9 mg 2
7 Sop 2012 01130m Invegu 9 mg 2
8 Sep 2012 0430'? invoga 9 mg 2

 

 

 

 

 

 

 

mm The information for Table 5 is compiled from tin: Medication administration Records foriSNiSo.

 

{Exhibit 99) .
13? There are two proscribed start dates re?ected for lnvoga. On 21 August 2012   ordered. "114.53 min
m, ,?uswm $1912.15 En _s Uf??tg. . onslaught the [mega dose to _9 _mg. i - 1 a. a) 
It'm?. $92711? W6) The Administration Rocord indicates that Emit-5' II: administered the daily 

   

 

dose to 1519156 at 0430 on 2 September 2012. That time is inconsistent mt t: information provided by. . mus: mm

muse 51n her statement, in which she indicated that isNii? initialiv ofus dose of invoga that morning, tit tat 
It: was abio to convince him around 1100 or 1130 to take them. indicated that showtimth ISJ ?i?ti m3; 51m

take tho capsules. put them in his mouth. drink Water, and swallow thorn. (Exhibit 23} itii?hutmict
Medication Administration Record indicates that on 3 September 
9 mg ofinvega to 15N156. It appears 01101514156 did not ingest the dose, as HCIS phOtDS co and spinsth '93-

indimto two capsules ofInvogn [pii] cup in tho SplasthX. NCIS arrived at the scene and took
tho photographs atthat time. (Exhibits [19. 129]

37

SC000043

I

111. (U) Cause of Death of ISN156:

121 .W The Armed Forces MedicalExaminer (AFME) determined the cause of death
of 56 to be suicide by paliperidone toxicity.m The AFME noted that resuscitative efforts
were initiated at the scene and that ISNI 56. was transported to the hOSpital, where he was
pronounced deceased. The AF MB review of medical records'shOwed a?history of multiple
disorders, suicidal ideation with previous attempts, intentional harm to others and
reported traumaticbrain injury. The autopsy examination showed a fracture of a rib, compatible
with resuscitative efforts. An examination of the lungs showed acute bilateral pneumonia.
(Exhibits 130, 131)

122. (wit-13099) The toxicology examination revealed the presence of palipeiidone (Invega),
codeine (Tylenol oxycodone (Percocet), quetiapine (Seroquel), mirtazpine (Rememn), and
citBJOpram (Celexa) in the blood of ISN156. Morphine (by-product of Tylenol 
oxymorphone (active ingredient in Percocet), and lorazepam (Ativan) were present in the urine
without detectable blood levels. (Exhibit 131)

123. MOB-99 The AFME was?not able to determine a precise time of .death for ISN156, nor
was he able to pinpoint a precise time that ISN156 ingested the 24 capsules of Invega, found in
the stomach at the time of death. (Exhibit 131)

04.644339) The AFME concluded that died-of paliperidone toxicity resulting from
an overdose. The AFME determined that it is uncertain to what extent theacute pneumonia
contributed to the death of ISN156. The AFME indicated that ?no evidence was identi?ed to
suggest that [lSN156?s] actions were other than purposeful and (Exhibits 130,
l31)

IV. (U) Joint Task Force Guantanamo (JTF-GTMO)

121W The commander of Joint Task Force Guantanamo is Rear
Admiral John W. Smith. The deputy commander of JTF-GTMO is Brigadier General James
Lettko. The chief-of-sta?? is Captain William Docherty. The mission statement for 

 

?3 Paliperidone is the pharmacological name for the brand name drug Invega. The certi?cate of death is in the
name Allal The name that is attached at JTF-GTMO is "Adrian Farhan Abd Al
Latif." The AFME. indicated that the Federal Bureau of Investigation (FBI) determined that the ?ngerprints on the
person matched an individual known as "Ad-Rahman. Alla] An internet search reveals Several
names very similar to Ad-Rahman as aliases for Adrian Farhan Abd Al Latif. (Exhibit 130)

38



is l) safe, humane, legal, and transparent care and custody of detainees; 2) intelligence
collection; and 3) commissions support. (Exhibit 69)124

V. (U) Joint Detention Group (JDG)
A. (U) Leadership'atld Command Structure

Dona-359GB) The commander of the JDG is COL John Bogdan. COL Bogdan arrived at
JTF-GTMO 29 May 2012, and took command on 7 June 2012. The JDG and the Joint Medical
Group (JMG) fall under the command and control (Exhibits 5, 69, 108)

Elma-The JDG is composed of a Headquarters element (HQ) and the Joint Operations
Center (JOC). The 525th Military Police Battalion (525th MP BN) and the Navy Expeditionary
Guard Battalion (NEGB) both fall under the HQ. (Exhibit 69)

128. mm: 525th MP BN is ADCON to United States Army South (ARSOUTH), and
TACON to JDG. (Exhibit 4)

129. move) The commander of the 189th Military Police Company (189th MP CO) is his
is also the Camp em. The 189th MP co is an active duty unit

and provides the guard force for Carnp and Camp Echo. She arrived at JTF-GTMO December

2011, took over Camp on 15 February 20] 2, and took command of the 189th MP CO on 23

March 2012. She is currently the most senior 01C of the comm at GTMO. (Exhibit 16)

 

130. W666) The 193rd MP CO is an active duty unit, and provides the guard force for
Camp and Camp Echo. (Exhibit 4)

 

 

The commander ofthe 314th Military Police Company (314th MP CO) is ?tiittis?ii?
The 314th MP co is a reserve unit out of Southern California. The 314th MP
C0 provides the guard force for the BHU, DH, Camp Iguana. and Camp VI. is
also the 01C of the BHU, DH, and Camp Iguana. arrived at JTF-GTMO 14

December 2011. At the time of the report, the 314th MP CO had redeployed. (Exhibit 18)

 

 

 

 

 

 

 

 

 

 

mm CAPT provided the slides to the Investigative Team on 1 1 September 2012. The slides
themselves are undated. One slide titled ?Detention Conditions: Safe? lists as a bullet ?Troops adhere to 
Adherence, and the lack thereof, to 8095 is discussed at length below in this report. (Exhibit 69)

"5 JDG Procedure Command and Control establishes the procedures for Command and Control of the JDG.
Paragraph 2?4c. establishes a ?Field-Grade-in?the?Wire? Program to provide leadership presence in the camps

ni tl . (W5)
1 It 

39

 

 



messes-Rae
4 a

131% The 348th MP CO is a reserve unit out of Iowa, and provides the guard force
for Camp VI. (Exhibit 4)

133. 695417-9999 The 755th MP C0 is a National Guard unit out of Puerto Rico, and provides
external security, including manning the traffic control points and sally ports for the camps, and
serving as the Quick Reaction Force (QRF). (Exhibit 4)

134. mayo; Together, the 189th MP CO, the l93rd MP C0, the 314th MP CO, the 348th
MP C0, and the 755th MP CO fall under the command and control of the 525th MP BN and
provide the guard force for camps and external security. The rotation dates for the units'are
detailed in Exhibit A to Exhibit 4. (Exhibits 4, 69)

B. (U) Camp V, Detainee Hospital, Behavioral Health Unit

135. Camp houses compliant and non-compliant detainees in sin?ejells and communal

blocksI as well as a prisoner mpulation in single cells?!

U50 

 

 

 

(Exhibit 16)

 

136. The houses mentally and physically ill detainees, as well as long-term hunger
strikers, in single cells. 

 

 

USC 

 

 


C. (U) Training

the JDG is responsible for training camp guards. The 525th MP
BN, speci?cally, the 83 section, conducts the actual training over 12 days, with the ?nal two
days being on-the?job training (OJT). (Exhibits 4, 70)

 

Because ISN156 was housed at Camp at the time of his death and was transferred ?om the DH the
day before, only the guard structures for Camp and the are set forth in the report.
Alpha (Upper) is empty. (Exhibit 16(ammo use statement, prowded the information dunng a telephone
?mm? call with the investigative Team on 12 October 2012. -

40



(exam usearaa


pears to have been conducted by the NEGB on 2 August 20l2 for dirty at Camp Iguana. Again, althoua


138days, the guards must pass a Job Quali?cation
Requirement (JQR). The QR is divided into three sections. The '100 Section, Fundamentals,
covers SOPs, guard mount messages, and night orders, and is designed to enable Soldiers to
understand the guard post I work station duties. Fundamentals covers such items as block
cleanliness, rules for the use of force, and detainee discipline levels.I29 (Exhibits 4, 71, 72, 73,
74, 75, 76, 77, 78, 79, 80, 

139. We) The 200 Section, Basic Knowledge, is designed to acquaint Soldiers with the
systems they will be required to operate at the guard post I work station. Basic Knowledge
includes sections on proper restraint procedures, medication administration, medical emergency
codes, detainee search policy, and detainee feeding policy and procedures. (Exhibits 4, 71, 72,
73, 74, 75, 76, 77, 78, 79, 80, 81)

140. The 300 Section, Guard Posts, is made 11p of taslG Soldiers are required to
satisfactorily perform to pass the ?nal JQR. Guard Posts includes Sections on how to properly
conduct a cell search and open feed tray slots)? (Exhibits WTraining for the DHU BNCOs and DIMS operators is divided into four
sections. The 100 section, Prerequisites, is similar to the 100 section for the JDG Pod lBlock
Guard JQRs, and cover SOPs and other directives necessary to understand the watch station.
(Exhibits 4, 82, 83)

I42. (era-99311?: 200 Section, Camp Speci?c Knowledge, includes sections on weight
refusal and hunger striker protocols, detainee restraint levels, and priority of force. (Exhibits 4,

81. 82)

143. 300 Section, Introduction to Watch Standing is made up of tasks Soldiers
must satisfactorily perform to pass the ?nal JQR. (Exhibits 4, 82, 83??

 

"9 W666) While the that page and other parts of the training packets vary between the JDG Pod!

Block Guard, the NCO, and the ??0ch JQRs, the substance of the training is very similar. The training of 15:30,

 

page and other parts of the training packets vary, the substance of the training is virtually identical
to the training for other camps. . I .
WTmining on line of sight duty is not listed in any of the three sections. Also not listed rs any training
by the JMG to provide an overview of the MG operations and expectations of the guards with respect to JMG
0361360115 in the camps. This item addressed in the Recommendations of the report. 
We) The training for the JDG Camp Guard Force and the JDG Guard Force is very similar
except that the JDG BHUIDH Guard Force JQR includes two sections covering systems (Sections 200 and 300'-
one general and one speci?c to the whereas the DO Camp Guard Force JQR includes only one section

(Section 200).
4 


. .



144. We) The 400 Section, Watches, Which is similar to the 300 Section of the JDG
Camp Guard Force JQRs, is the validation section where the Soldier must complete the tasks
required to pass the ?nal JQR. (Exhibits 4, 82, 83)

D. (U) Standard Operating Procedures (SOPs)

There are a total of 90 JDG SOPs governing a wide range of detainee
operations, from Standard Operating Procedures Changes, Detainee Movement Operations,
Wildlife and Pest Control, Restraint Devices, External Security, and Medication Pass
Procedures, to Detainee Death.132 (Exhibit 39)

1. (U) JDG Procedure #27: General Guidelines for Camp Operations

JDG Procedure #27 addresses General Guidelines for Camp Operations. The
SOP notes that ?fair, ?rm, and impartial enforcement of mics and regulations facilitates the
control of detainees.? The SOP also notes that ?[c]ustody and control measures maintain good
order and discipline and protect the welfare of all camp personnel and detainees alike.?
Speci?cally, security requires all personnel to ?continually maintain an e??ective working
knowledge of rules, regulations, and Special orders; maintain constant vigilance throughout their
daily duties; review/evaluate (Exhibit 40)

141% Several guards and medical personnel indicated a lack of familiarity with
speci?c provisions of various SOPs. (Exhibits 9, 10, 14, 18, 20, 24, 28)

Other guardsand medical personnel indicated that although they were familiar
with speci?c provisions of the SOP and what the SOP required, they did not always follow the
SOPs. Indeed, guards indicated that enforcement of the SOPs is one of the biggest challenges
they face at memo)? (Exhibits 1, 6, 8, 18, 25)

149. MAE-GHQ) The Camp OIC noted that] I
inconsistent application. of SOPs to ISN156 caused ?stress on the guard force? and also ISN156.
dicated that she was frustrated that ?consistency? was the ?watchword? and yet,

 

 

Although the current SOP Version List goes to 95, three of the SOPs are archived and two are not
used, for a total of 90. The 106 SOPs and Procedures that the Investigative Team received were signed by the
previous IDG Commander. However, the current JDG Commander indicated that one of his signi?cant projects
since taking command has been to ?update and the SOPs, to ensure that they are re?ecting current
practice.? Although some are entitled and some are entitled Procedures? they are thesame type
of document a Standard Operating Procedtu'e. (Exhibits 5, 39)

We) Specific examples ofguards following, and in many cases not following. the SOPs are laid out later
in the report, following the speci?c corresponding SOP, rather than here in the ?General Guidelines" section.
mm One guard noted that when the 314th MP Company took over, Sailors ?'om the Navy unit they
replaced would say ?this is what the SOP says" and then would say "but this is how we do it.? He indicated that
detainees would observe the right seat! le? seat handover and would state things like ?he sure to tell the 314th how
to do it the right way." (Exhibit 17)

42

I .





 

 

 

in her opinion, ?there is not a consistent application of the cited several
other examples of inconsistent application of the (Exhibit 16)

 

2. W939) JDG SOP #53: Sally Port Operations
15am JDG addresses Sally Port Operations. I
(lelE)
 (Exhibit 44)

 

 

 

 

 

151 .MQUQQ 0n the day lSNl56 was found unresponsive in his cell at Camp V, several
witnesses stated the ambulance arrived to Camp ?very quickly,? within minutes of having
been called.??5 The guards and medical personnel indicated they were not aware of any issues
with the Sally Port when the ambulance left Camp for the Furthermore guards and
medical personnel indicated they arrived at the entering through 
The guards and medical personnel indicated they left the expeditiously, and
arrived at the NAVSTA Hospital "7 (Exhibits 10, 15, 23, 25, 29, 30, 34)

 

 

 

 

151W Having been identi?ed by the Camp Watch CommanderCamp guards
accompanied ISN156 from the time the ambulance departed Camp V, arrived at the 
departed the and arrived at the NAVSTA Hospital, through the time the body of
was transferred to the morgue. (Exhibits I3, 15, 29)

3.WJDG Procedure #22: Wildlife and Pest Control

153. WJDG Procedure #22 addresses Wildlife and Pest Control. The Chief, Joint
Task Force (JTF) Preventive Medicine shall ensure that inspectors are trained and pro?cient in
conducting an environmental inspection, and shall ensure that inspections are scheduled and
completed. Commanders and subordinates shall ensure that camp leadership and guard force
personnel are trained and ?are aware of their responsibilities with respect to wildlife and pest
control.? (Exhibit 109)

The SOP notes that iguanas ?can and will become aggressive once they have
been domesticated through feeding by humans.? Accordingly, guards are instructed to not
attempt to ?feed, capture, Or harm an iguana.? ?At no time will a detainee be allowed to feed an
iguana.? Similarly, noting that banana rats will bite if fed by guards or detainees, ?at no time

 

"5m Those examples are addressed in turn throughout the report.

Willem is an unmanned ambulance permanently stationed outside Camp I VI. (Exhibit 15)
WW Immediately after the incident, several of the medical personnel created timelin of the events
surrounding death. Copies of thOSe hand-written timelines are attached as exhibits to the witness
statements. (Exhibits 13, 30, 22, 32, 33)

43





will abanana- rat be.fed.?133 If a banana rat is found in a camp, the SOP directs the individual-to
contact NAVSTA security for removal. Finally, because of the number of human diseases that
pigeons carry, ?[d]etainees that feed and give water to the birds should be discouraged from
doing so. At no time should a detainee touch or pet these birds.? (Exhibit 109)

155. Quill-19893 On numerous occasions, the Investigative Team observed stray cats, iguanas,
and pigeons lined up at the BHUIDH recreation yards.

156. (Lilli-009; Several guards and medical personnel spoke of detainees regularly feeding
wildlife. A nurse at the for example, noted that one of the things that
stuck out in her mind about 56'was that he was allowed to leave food out for the iguanas at.
the recreation yards. She noted that stray cats, i guanas, and banana rats sometimes line
up outside of the recreation yards, waiting for food. She also noted that one detainee,

has pigeonsregularly come and sit on his shoulder.?9 (Exhibit 35)

liamouoynte me for the and Camp Iguana indicated he
understood that although generally not allowed, certain detaineesiwere allowed to-interact with

 

 

 

 

 

 

 

 

the wildlife. ?tagging? indicated thatFWadl (bl?llE) 
MORE) . He also noted that was ?usually allowed to feed animals

 

 

on doctor?s orders becauseiit helped keep him (Exhibit 18)

JDG and JMG leadership, however, had an understanding-quite different from
that of the guards and medical personnel. Commander indicated detainees should not
be feeding wildlife, and was not aware of it being an issue other than with pigeons. The JMG
Commander stated that he was ?not aware that the detainees are feeding wildlife,? adding ?in my
opinion, no detainee should be feeding wildlife.? (Exhibits 5, 31.)

4. (UHF-980) JDG Procedure #30: Detainee Camp Rules and Standards of Conduct

159% JDG Procedure #30 covers Detainee Camp Rules and Standards of Conduct.
The SOP sets out a long list of specific rules for detainees, including that they may not create
unsanitary conditions in the camp, such as throwing or storing feces, urine, saliva,.or vomit. The
SOP authorizes discipline time and the loss of privileges for failure to comply with the rules.
(Exhibit 41)

 

     

?a I qua I

(U) Commonly referred to. as banana rats, hutlas - mm use 5mm 
{36430899 Although not lncluded in her statement, ??ered that she was concerned about the failure

to follow the SOP, and did not think that allowing detainees to and interact with wildlife was a ?good idea.?

 

 

(Exhibit 35) 
memoir 

 

 

 

.  There is nothing in these SOPs or mat-ice! records (ISNISGJ that indicates that either ISN156 oil  
were actually authorized to feed or interact'with the wildlife. (Exhibits 48, 48-8. 48-C, 48-D)

44





160. 645999) Detainees are classi?ed in a ?compliant? or ?discipline? status. Detainees who
commit ?serious offenses? may, at the discretion of the JDG Commander, be re-assigned to
Camp V. (Exhibit 41)

161. We) JDG Procedure #30 also establishes a matrix for Basic Issue/Comfort 
items for detainees. Generally, items of may be exchanged on a one-for-one basis.?2
(Exhibit 41)

162. Gallup-939) When a detainee commits a camp rules infraction or an offense listed in the
Detainee Offense Matrix, 

 

 

 

 

 

 

 

 

 

 

 

 

(bl?llEl
[The maximum recommendation for any single punishment,
(mans) IE:
guard force will inform the detainee he has been placedl I The
detainee will serve the discipline time in an assigned cell in Camp VI MWE) I

 

 

animus) 

According to the SOP, the JDG Commander has the authority to assign
detainees who have committed certain offenses to Campll 

I'I'hose offenses include
(DWKE)

 

 

 

 

 

 

 

 

164. WAS discussed earlier in the report, ISN156 had a long history of disciplinary
events at Several witnesses indicated that not allof those disciplinary events were
consistently addressed. The Camp example, indicated that she
was made aware of the fact that ISN156 was  [during

 

 

 

 

WHO) A detainee may lose certain items if he is placed on self-harm precautions or on discipline status.
(Exhibit 4! 

"2 W89) The [0 interviewed a noncommissioned o?ieer watch commander who related anecdotally that
because the one-fomne exchange policy is sometimes violated by the orders of the medical team ?give the
detainee extra blankets), some of the guard force feels compelled to take home and wash detainee items ratherthan
risk a detainee outburst upon only receiving one blanket in return from detainee laundry.

We) A GTMO Form 508 is a detainee report addressing discipline incidents. The Detainee Offense
Matrix is in JDG Procedure #30. The section for the Detainee Discipline Matrix is blank, and indicates ?pending
a proval." (Exhibit 41)
There are two detainee disci line levels Detainees who
complete the speci?ed time onl (DWE) Iwill ed period of
time. Once both the Iare complet out a new violation, the detainee will
its returned to comp .iant status. (Exhibit 41)

 

 

 

 

(DWXE) [detainees serve their
diseip me time V.
45

8C000051




movements.I46 indicated, however, that when she raised the issue with the previous
525th BN Commander he told her that she needed to understand that ISN156 was a special case,
and that there were strategic level issues at play. indicated that she was not aware
of the previous command having done anything to "truly address the Soldiers? complaints about

(Exhibits 16, 51)

165. {Elm Other guards reported that up through the days leading up to his death, 
was engaging in indecent behavior. In fact, one guard understood the! thME) line of light
rotation policy stemmed from 56's behavior, and that camp leaders 1p 1 not want guards
to have to watch [the indecent behavior] for more thanl lat a time.? Several guards
indicated that they had to watch ISN156F (one) 
I (bite)  ?right up near the window.? (Exhibits 6, 14, 29)

166. (Bail-F669) Similarly, a nurse at the ?31333;?? i noted that ISN156 would
hile on line of sight and (tutti) i? noted that it was
?very dif?cult for guards to watch" this behavior. There is nothing in the ?le of ISN156 to

indicate that any discipline time was imposed for this type of indecent behavioum (Exhibit 35)

 

 

 

 

[67. On 1 August 2012, 156 received a Detainee Report for throwing feces at a
nurse and guards from a cup in the recreation yard. As a result of the incident, ISN156
was given discipline time. (Exhibits 35, 56)

 

 

 

 

0n 2 August 20l2, ISN156 also received 508 Detainee Reports for ?Major

Dama to Pro and ravated Assault on . both reports stemming from
I As a result of the incident, ISN156 was given a total 0 
discipline time for the Major Damage to Pmperty and for the

Aggravated Assault on Staff, not to exceed the for a single event.) (Exhibits
54, 55)

169. was) Furthermore, in the daysat the DH leading up to his death, ISN156 had again
splashed urine on a guard and thrown items onto the tier. (Exhibits 24, 28)

 

 

 

 

 

?5m These events occurred under the previous leadership of the I06 and the S2Sth MP BN.
learned of the issue when Soldiers laced comment cards in the suggestion box of the break room, complaining

 

 

 

mm", 059 about noted that the assaults wouldhappen I
momma (bx-me, mo procedure #33 i: According to mformation from

 

 

 

 

s. (WINE) l5 l6.42
"mono; According to JDG Procedure #30, 
disci line time at Cam V. ?Indecent assault? however. :3 not . Accor mg to etamee ensc tux,
(mama) (Exhibit 41)

7 . 

and also assault - save 

 

    
  
 

 

 
 

8C000052


I i A

new In fact, it was this type of ?out of control" behavior that led the JDG
Commander to approaehthe morning of 7 September 2012 and ask her whether there
m?afxany medical reason that would prevent from serving his discipline time,?9
Imgg?m sponded that in her opinion, this was ?very volitional behavior? and that there was ?no
tatric reason" to prevent ISN156 from serving his discipline time. The JDG Commander
indicated that based on that, he decided on 7 September to transfer ISN156 to Camp 
I (Exhibits 5, 24)

 

5. JDG Procedure #34: Search and Inspection

171.6%999 JDG Procedure #34 covers Search and In5pection. The SOP requires that
detainees be searched every time they are moved from one area to another, regardless of the
circumstances or reason for the move]

 

 

 

 

 

 

 

 

 

 

 

 

MORE)
[(Exhibit 43)





I(Exhibit 43)

new

MINE)

[Exhibit 43)

 

 

"9 W660) it is unclear for which of the offenses ISN 156 was being sent to Camp to serve discipline time.
What is clear is that because of his behavior in the weeks leading up to his death, ISNISS had a large amount of
giuscipline time to serve.

 

 

 

 

.WL. winter I
thinner The JDG Commander indicated that he is currently in the process of reviewing the  
(mama) 

 

 

[The 010 of the BHUIDH and Camp iguana indicated that COL Bogdan

called the Camp 0le in 24 September 2012 to discuss a modi?ed search ro ram and an
implementation process. understood that there would be

FEXHIEIIS 5, 
on an 13 any item, ame e, or so stance not issued to detainees, authorized for their use or

altered by the detainee.? (Exhibit 4 l)

 

 

 

 

47

8C000053

    
   

    

I74. W996) The Camp 01C I
are conducting 
Noting that the most common thing guards find during searches are excess quantity items (such
as too many books), she acknowledged that on other occasions, guards have discovered

and water ?avoring bubbles in the cells.?52 (Exhibit 16)
Several guards indicated they properly understood prOvisions of the search and

I inspection 
I One guard noted that in his opini?l (mama)

 

 

 

 

I76. ISN156 moved from the DH to Camp on 7 September 2012, guards at
Camp indicated they searched his belongings and removed items (extra towels, T?shirts) that
he was not allowed to have because he was on discipline time, and gave him the remainder of his
things, including a foam pillow and linens.?53 (Exhibit 19)

6. We) JDG Procedure #56: Line of Sight

111W
. (mama)

Detainees may be designated for line of sight fod
Detainees on line of sitht will be 

 

 

 

 

 



(DJUXEJ

?t?Li

 

 

JThe will brief the guards on

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

line of sight procedures prior to them assuming line of sight duty, I
I (HUME)
179. WHO) The SOP requires the line of sight guard] WW5)
I The line ofsight guard is required] r-
gbgruei 
"2  noted the ?avoring bubbles are distinct from the ?avoring packets that detainees are

 

a ay.  suspects the source of the ?avoring bubbles (contraband) to be certain guards,
but she has not been ab 1 en which uards are brin?g in the ?avoring bubbles. She indicated the

_i (Exhibit 16)

We) Although ISNI 56 was authorized a mattress, he indicated that he on wanted the foam pillow.
Accordingly, when was found unresponsive, he was lying directly on the cell floor, where he had appeared
to be asleep. (Exhibits 15, 19)

   
 

 

8C000054

(?310 0: 



(ammo uses
mmomm

 

 

 

 

 

 

-.. (DHTHE) I

 

 

 

 

 

 

 

MIKE)
(Exhibit 45)
13am The SOP states 
(DHTKE) I ?umlarly, if
a detainee covers Ior otherwise obstructs the View of the guards, I ems) 

mmE If there is no response, the guard shall (bx?in Iimmediately.'

 

181. (819F986) Guards failed to require ISN156 to uncover hiser he covered it with
a food mixture the night of 7 September 2012. (Exhibit 1)

182. Several guards indicated that they were unfamiliar with what the line of sight
SOP required with respect to rotation times. (Exhibits 10, l4, 19, 20)

181W Other guards indicated they knew what the line of sight SOP required, but for
various reasons, chose to ignore the SOP and devised their own rotation times. (Exhibits I, 6, 8,

25)

184. W009 Once it was determined on '7 September 2012 that 1.56 would be transferred

from the DH to Camp V,recommended ISN156 be on line of sight. Although the

Camp 01C asked whether it could be electronic line of 
(physical) line of sight'? In the end, ordered that ISN156 be placed on electronic mum?)
and direct line of sight. (Exhibits 16, 24)

 


indicated that although he knew the SOP required guards to rotate every

evised a system where they would rotate like] - --

l3 Tim
indicated that he knew the SOP required line of sight guards to rotate every I 

oted that ?some NCOs require us to rotate out everyl (bitTXE) Isome NCOs say

 

 

51300.
(Maritime)

 

 

 

 

 


and (mums) was At one point, le?

 

 

 

 

to work on an additional duty (?lling out counseling statements). indicated that he
then pulled line of sight duty for  I. (Exhibits 1, l-A, 6)

 

 

WAMindicates a detainee is committin self-harm in a articular location.
Althou the SOP indicates that the

 
 

W11 $351300.
x7310)

 

(Exhi bit 24)

8C000055

 
   

The night of 7 September 2012 was the ?rst time that the Alpha BNCO
I was in charge of or had conducted line of sight. Acknowledging that he did not know
what the line of sight SOP required, indicated he understood that r: 
were rotatingl (bll?lE) lindicated he allowed the rotation time
because he thought it would be easier on them. indicated that the day following
lSN156?s death, 9 September 2012, he learned the SOP required line of sight guards to rotate
every cums) 5? (Exhibit 19)

sectional.?
?4

 

 

 

 

 

 

 

 

 

 

 

187. (IMF-9393 On the morning of 8 September 2012, the day ISN156 was pronounced dea

Roxana usc [were the designated line of sight guards on ISN156. ?"ngg?i?ii?im

was on his ?rst day of duty and accordin was ulling line of sight duty for the ?rst time. imitated)
he was told that he an would be rotating line of sight duty (bums)
157 Iindicated that although the pre-service training addressed line of sight duty,

it did not address rotation times. (Exhibit 10)

    
 
   
 

 

 

 

 

188. MO) The Alpha BNCO on the morning of 8?September 2012 indicated
that although he knew the SOP required the guards to rotate everyI (WEE) generally, he
permitted Soldiers to ?decide how long they want[ed] to rotate line of sight." 
indicated no one ever told him speci?call that day that line of sight duty would be rotat every
He indicated the WC ?13?Eih?flmt7l put out information at the guard mount on 9
September 2012 that line of sight would be every (mama) ?from now (Exhibit 25, 25-
A)

189M999) Generally?uards understood that the]
MITRE)

 

 

 

 

 

 

 

 

JExhibits 1, 8, 10)

 

 
  
 
   

"tantamoqu [did not re?ll who told him ofthe line of sight sor requirements. 
indicated that tood that the rule exists ?so that guard - a tired or complacent.

 

 

         
  

 

 

  
 

 

 

 

($913689) 1333? to did not recall who told him that he and . uld be mum. . .. ._ht duty
eve (tame: The recollections 0 large except lh?t did not
trauma use giaooh_ ma" 5 ecl?lcall Matingwtouth -

?mm-?WW -3133 MUXE) because he ea ed havm to a: With another 
no and; -
mastic u(sc Jeri, WEI-119. mono vanes notably from

 

- murjroyse 51308.
to tumor his rounds on Alpha Block on 8 tern 
l'or ISN156 would beI (DWXE) 

 

 

 

 

?Exhibit 15)



7. meme Procedure #66: Medication Pass (Med Pass) Procedures
190. {Uni/F990) JDG Procedure #66 governs Medication Pass (Med Pass) Procedures. '59

?Generallx, the SOP indicates that] x? 
(b The SOP notes the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7 
(le ll limit,?
46)
According to the SOPJ

MORE)

 (Exhibit 45)





I(_Exhibit 46)

193. mono; For ?high risk" DEA-controlled drugs, the SOP establishes that?
I toms) The
JDG SOP notes the 

 

 

 

There is an entirely separate .IMO SOP that also governs medication administration procedures.
There is some overlap between the JDG and JMG SOPs governing medication administration. Where items are
solely addressed in the MG SOP, those items are discussed below in the corresponding IMG SOP discussion

section rather than here. (Exhibit 50)

 

 

 

 

 

 

 

noted below in the JMG SOP subsection in there he SOP ardin Med Pass differs
notably ?om the IDS SOP governing Med Pass. Signi?cantly,l

[(-Exhibits 28. 50)
1" The provision requiring the BNCO to verify that]

ibit 46)

 

 

As discussed below. the speci?c drugs that qualify as high-risk DEA classi?ed drugs are Set forth in
the MG SOP. (Exhibit 50)

51

8C000057

88m

 

I (niain I
(Exhibit 46)

 

194. MFG-HG) Several corpsmen indicated that they are]

MITRE)

 

 

(Exhibits 21, 23)
195. (W939) Indeed, the JMG Training indicated that

 

 

 

 

 

 

(b)(3)I10 USC 

 

 

 

196. W) Furthermore, a registered nurse assigned to the noted

 

lbil3lfl 0 USC 

 

 

 

[97. We) The understanding of the Training Of?cer, is entirely inconsistent
with that of the JMG Commander and the Senior Nurse Executive 
indicated at With respect to Med Pass, he understood that the

. birtth . . . . . . .
1' corpsman rs to provrde one medication at a time, and the corpsman rs to 



l6] 
(DWKE)

M00931 tbl?ltE) Several corpsmen acknowledged that there

was a real risk of detainees hoarding medications. w: example, noted that because of the risk, he

does not ever leave medications in a detainee's splash x. 1 its 6, 21)

(395999) In addition to being the mental health nurse at GTMO, 51309,

Training Officer for the JMG. Unlike the JDG. Who relies on the B) to con uct guard 

JMG is required to conduct its own training. It is unclear whether is MCQQE) 51m
(nitrite: or the MG SOP (mama) 

(ems) (Exhibits 4, 23)

?6 WBased on her experience as a registered nurse in civilian hospital a . usc 5,30?.

a more robust medication administration program at JTF-GTMO than the Med Pass program currently on ined in ?nalist?ch

the JDG and IMO SOPs. (Exhibit 35)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

52

8C000058

 

(him: 1 0 USC 

 

 

 

 

Exhibits 31, 38)
that the olic is a ?signi?cant change" since he took
command of the JMG on 2  May 2011.163 i Egg [indicated that because a detainee had

 

just died by hanging on 18 May 2011, it was immediately clear to him that ?the risk of suicide
was a very serious issue here." Windicated that he devised the policy because he
learned that no detainee had actually killed himself by an overdose, but that certain detainees
?had attempted to do so by hoarding and (Exhibit 31)

I99. anemone; 59.3575; 95 ?f6? Iindicated that. consistent with the JDG and JMG SOP, he

(blt?tE)
The    x:ch) a

registered nurse ,l (lama) 

(Exhibits 31, 35, 33)

200. WNonetheless, in contrast to the SOP and the understanding 0 r:
none of the corpsmen interviewed by the Investigative Team indicated that

I70
(blt'lltEl 

 

 

 

 

 

 

 

 

 

 

8. WC) Procedure #82: Detainee Death

201 JDG Procedure #82 covers procedures in the event of a detainee death. In the
case ofan unresponsive or dead detainee, 

 

 

 

 

 

 
  

'57 {Him Another example of the apparent d'scn t' etween the MG leadership and the medical personnel
betthunmments ofa nightcorpsmam indicated ?Since I began my duties here at Camp 
28APR12, I do not recall ever being visited by anyone in my eadership chain. have felt invisible with no one

  
  
 

     
 

seeming to even know! was workin here.? xhibit 9-A)

Mimi-?ght: statement of  indicates that he took comman on 27 May 2012 and that

a detainee died by hanging on 18 2 12 these dates should read 20l i. A Am? use ?m
uniformed mums/lo who has been at GTMO for over a year. Again, w: it is (Dmmi??m

 

 

 

 

{ammo 1155513913.. .whether W85 fe 0   01' ?18   vernin medication administration.
?it?ll-?mm uithermore. it is unclear whetlieriibi??ilg??cm?miis aware that the JMG SOPI



(Exhibit 3 l)

The Cultural Ad?sor has been at since 29 September zoos, and accordingly has been
present for all nine detainee deaths that have occurred at JTF-GTMO to date (seven suicides and two natural deaths).
An interpreter re?ned to a speci?c instance hoarding pills, noting that at one point in 2008, ISNIS6 said
something like ?here. I com ese pills if I wanted to kill myself? and showed him and the guard a ?st of

 

 

taste.-- illse?stmaybetl-or?-pill  adicated that the guard con?scated the pills ?'om (Exhibits 2, 12, 

Because 0 lg of the investigation. interviews. and the dra?in of statements, the statements
ofthe oorpsmen do not reflect any speci?c information regarding the (lame) - at being followed.

53

 

8C000059

 

 

 

 

 

 

 

 

{blim?l
[(Exhibit 1 11)
202.
Mimi?)
(Exhibit 111)

201%) Once it was determined that was unresponsive and would be
transferred out of Camp for emergency medical treatment, the Camp Watch Commander,

?353,323? !tasked an NCO and a guardI usc Ito
accompany N156.- The gnards remained with ISN156 from Camp to the from the

 

 

DH to the NAV STA Hospital, and from the NAVSTA HOSpital to the morgue. Correctl
lg that their orders were ?to stay with the body the whole time,?l mi?" 35?33?? land

stayed with the body until it was brought into the morgueand the morgue door was
closed. (Exnibits 13,) 29)

 

 

 

 

 

 

VI. MEDICALGROUP (JMG)
A. (U) Leadership

205. W99) As noted above, the JMG falls under the command and control of 
The commander of the IMO is Captain Richard Stoltz. (Exhibit 69)

 

 

We) Many of the provisions of IDG Procedure I
at was not

 

 

(ma?a
the case with ISN 156, as he was found unresponsive 1n IS cell, guards and medical personnel initiated life-saving
efforts, andISN156 was pronounced dead at the NAVSTA Hospital. (Exhibit 111)

explained above, MUTE) lin accordance with the SOP. - I, i
sent the ambulance?om the DH to once assessed and determined he wo -
receive care more quickly there than it?they waited for medical o?'icers to respond to the DH I BHU. (Exhibit 32)

 

  

 

54



(Dh?hibi?ml'm' 

inhumane use .


tCISer. 1.4th

(b usgjt 395M,

ammonium



7 

206. {39439-993 The JMG Headquarters element (HQ) is composed of the Joint Tro0p Clinic
(JTC), the Detainee Hospital (DH), and J-Smart. (Exhibit 69)

ITM

leYNEl.
(limit?)

207. Milli-GUS) The total number of detainees at 
any given time is froml I Approximatel

under mental health services at
of those detainees see only the JMG

 

 

 

 

 

 

 

who only need medications and do not require request
counseling) nly see the JMG who only need

counseling but do not require request medications), and the remainder see both the MG
and (Exhibit 24)

B. (U) Training

The JMG is responsible for training the medical personnel providing detainee
medical care. The training consists of Skill Validation (RN and technicians), 
Orientation, Camp WV I Orientation, Care of Detainees, Enteral Feed Orientation, and
Ambulance Operation.?4 There is a Speci?c block on medication preparation lMed Pass,
including ?How to pass medications.? (Exhibits 87, 88, 89, 90, 91, 92, 93, 94)

There is a separate Medication Adminisn-ation Competence, including a
Competency Statement, initialed by the instructor and the trainee. The Competency Statement
includes blocks on how to verify a detainee has swallowed the medication, and how to correctly
document on the [Medication Administration Record] MAR when medications are given or
refused.?5 (Exhibits s7, 88, 39, 90,91, 92, 93, 94)

 

 

etainees who he has concerns about their lon term care.

 

MULSEC- 14(6)

 

 

 

 

Cum" -- 
v- -- so expressed concern about the ability of to provide longvterm care for t" (else; titt?i

 

inhuman) 'bits 12, 
{59936) The JMG produced incomplete records for corpsman and muse training. From the records, it appears
that th tra' ee?s rank and duty title determine which blocks of training the trainee receives. The Training Of?cer

   

 

 

 

 

 

 

was .  Although her signature :rtify the trainee's knowledge of the requirements of the
om stateg
- 
[As of Feb 2012,  (bx'ntE) Corpsmen also acknowledged not looking
(bf/XE) lone noted that ?we were told during our

 

 

in cctrination tramin not to do so, because it-woultl make the detainees mad." The understanding of the JMG
quite different, as he indicated that the Corpsman indicates that the train 
(bll7llEi

 

 

 

 
  

        
   

55

SEW

8C000061

name) There is also a separate Medication Administration Understanding, signed by
the trainee. The Medication Administration Understanding indicates that!

 

 

(HUME)

 

 

 

ICExhibits 87(U) JMG Standard Operating Procedures (SOPs)

211. W999 There are a total of 79 MG SOPs goVeming a wide array of detainee
operations, ranging from Medical Management of Detainees on nger Strike, In-Serv ice

 

 

 

 

 

 

 

 

 

 

 

 

    
     

    
  

  

JMG SOP #l 17.? The trainee will be able tozr
(blUllE)
I In her ?at she was told i?e prewous wave Had trioq
 . 
"ma LWIU

 

 

 
        

ned that she regularly asks (bll o: .

and that [I?Igrmxe) complies.
offered that in her. opinion.  m! grind the
Egan that he I she has been able to establish with the detainee. (Exhibits 3594}

tenures: ento n'I -

 

(MITRE)

 

 

 

56?

8C000062

Training, Nursing Guidelines, Detainee Refusal of Care, and Pharmacy, to Medication
Administration Policy?? (Exhibit 126)

JT -JMG #117: Medication Administration Policy
212. We; 17 covers the Medication Administration Policy."3 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ibimlEJ
IfExhibit 50)
2  3. WAccording to the 
(DWKE)
(Exhibit 50)
214. ml

(Exhibit 50)
215. After each medication pass, 
(blUHEl
[(Exhibit 50)
manages) Although the cumin ibimi?i for a
total of 79 active SOPs. 4
As noted above. there isl ibimiei 
(b10305) The JMG Commander (CAPT Stoltz) indicated that shortly after he took command, he changed the
SOP speci?cally! (bu?mEi l" CAPT Stoltz indicated the M6 is again rc-

emminin the Pass SOP as he'i HUME)
lone can more easdy gtoltz also
no 6 JMU IS

Eights) 
The JDG Common er to mate at IS wo its very as: w: to nize

egerauons.? (Exhibits 5, 46)
flew-F969) The MO SOP governing nursing guidelines also addresses the MAR and how it is to be completed.
(Exhibit 49)

57

8C000063

 



(blUllE)

 

 

 

[(Exhibit 50)

 

gamma]

GIMME)

 

 

 (Exhibit 50)

 



(DHTHE)

 

 

[(Bxhibit 50)

 

 

219. {Biff-9863'

"3303(5)

 

 

 

I (Exhibit 50)

 

The SOP establishes that 
(Exhibit 50)

221 .MOUQJ Finally, the SOP indicates that 
I (bums) . (Exhibit 50)

 

 

 

 

 

 

 

 

 

 

 

memes) High Risk DEA medications arel 1 Those medications um
ISNISG had been recently administered (Table 3 of this report) include Ativan, Percocet, Tylenol Haldol, and

Seroquel. (Exhibit 50)
1" i- The MO sopli (lame) 

 

      



 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMO sorl (lama 
(Exhibit 50)
. . The JD 
(bimiei
WW The JDG 509 
ibimie:

?We, The JDG sorl
minus)
I
58

8C000064

 am 



 

222% As noted above, 

(HUME)

 

 

 

(Exhibit 46, 50)

223. WWith'respect to the administration of PRN medications, a review of' the medical
records for ISNI 56 seems to indicate that the corpsmen are not properly annotating those
instances where the detainee requested a PRN medication more than 
period. (Exhibit 97)

 

 

 

 

224. We) Regarding the locations of Med Pass,l

(b31145)
(Exhibits 9, 21, 

 

 

mo Commander, COL Bogdan, himself indicated that  tutt?tei I
(bl?ttE) I COL Bogdan indicated that he
(WIRE) I including
ISN156. COL Bogdan indicated that the policy was in place ?well before" he assumed
command, and that he understood that ISN156 needed to get medications at certain times, and it
(WWE) (Exhibit 5)

 

 

 

 

 

i lbl?'XEl

 

226. 6599959869 One corpsman indicated that he] 
?during Ramadan, but not before or after!?as Another corpsman indicated without reservation

that] (limits) I (Exhibits 9, 21, 23A)

 

 

227. Not all corpsmen are complying with the SOP requirementl

 

 

Wei-The 01c orthe BHUIDH and a oorpsman assigned to the 

 

 

 

 

 

 

    

 

 
  
  
   

 

 

 

 

 

 

 

correctly indicated that it was theirl (mama,
(Exhibits 18, 22, 50) 
"7 M8863 The seal [bli'r?KEl
INOti?g um 
- .
Mime) Am 3 ?1 PO mob.
writin The medical records for ISN156 inclu -. could 
For her part, (membrane:
{bit 1 
ibits 24, 35, 48-8, 98)

 

 

Idid not indicate why he understood the rules to be different during Ramadan. (Exhibit 9)

59

8C000065



 

 

UllEl

 


9, 50)

 

2. W99) JTF-JMG #60: Cardiac Arrest Procedurs

 

228. (UH-989) JMG SOP #60, Cardiac Arrest Procedures, provides that in the event of a
Ithe following will I (blmtEl
mama) I

 

 

 

 

 

(U) Part 2: FINDINGS

LW Finding: ISN156 had an extensive history of disciplinary and self-harm
attempts while detained at (Facts 19-64)

(U) Discussion:

Disciplinary events spanned from 2002 to 2012 and included assaults on
guard force, inapprOpriate use of bodily ?uids, and possession of contraband. Self-harm events
spanned from 2003 to 2012, and included ingestion of inedible items, attempted hanging, and
cutting. ISNISG frequently expressed suicidal ideations, including writing dark poems, talking
about'death, and making passive statements about suicide. At various times during his detention,
ISN156 was on hunger strike, and at certain points required enteral feeding.

awe) There was also a signi?cant spike in disciplinary issues in the several
weeks before his death. ISN156 threw rocks, strikingthe guard tower, the tower spotlight, and 7

two guards. Later that same day, while in 9 1514155 (blUHEl.lblUl(F) I
The night of 31 July 2012,
156 began jumping around in his cell and refused to comply with an order to stepjumping.

The following morning, ISN156 threw a cocktail of feces and urinefrom a Styrofoam cup at a
nu and te ds, striking them in the face and neck. Later that week, while at BHU


During a ?t of rage, 1 56 lunged at sausage}.

.?Mm a. assaulted several guards. 0n 6 September 2012, while still at the DH, ISN156 began
spontaneously yelling and kicking, threw his urinal, and thereby splashed a guard.

 

 

 

 
 

 

    
  

 

2. W639) Finding: Because of his unique medical issues and temperament, ISNISG was
not treated like any other detainee. This disparate treatment resulted in signi?cant
deviations from SOPs and protocols and caused signi?cant pressure on the guard force.
(Facts 22-27)

60



 

(U) Discussion:

a. We) There were several instances where 56 was either not disciplined or
was not required to serve discipline time immediately 56 was
able to have a cup full of feces and urine at the recreation yard because of an order by 
permitting 56 to take a sheet with him to the recreation yard. The order allowing ISN156 to
have a sheet at the recreation yard violated the SOP, and created risk. 156 frequently made
demands on the guard force (demanding the guards loca - or a threat of ?big
problems").

 

 

 

 

  

b. 681693980) Much of the guard force and medical personnel felt that ISNISG was not
subject to the same boundaries that other detainees were, and that certain provisions of the
general JDG and IMO SOPs did not apply to him. Other guards were unfamiliar with what the
Speci?c SOP provisions required. Accordingly, guards and medical personnel frequently did not
enforce JDG and MG SOPs with respect to 56. Some guards expressed concerns
regarding reprisals from leadership if they were to exercise too much force with respect to
56.

c. (WG-96) Over the course of his ten-and-a?half years of detention at TF-GTMO,
ISNISG moved from camp to camp over 67 times. He was variously housed at Camp X?Ray,
Camps I, V, VI, the BHU and the DH. Some of these moves did cause stress on the guard
force and ISN156, but nothing that was overly unusual. Although had bad memories of
the cell where he was ultimately moved and at least one detainee stated that moving 156 to
the cell would cause him to c0mmit suicide, the moves themselves did not contribute to the
detainee?s death.

1% Finding: JDG leadership failed to take remedial action to address the
problems with the (blUKE).tblt7ltF) 
(Facts 42-43, 54-64)

 

 

?fe-?36) Discussion: Recognizing the potential dangers caused when I

 



 

 

mm Finding: Despite the Force Protection report indicating that ISN 156 may be
suicidal, COL Bogdan acted reasonably in ordering ISN156 to be moved to Camp to
serve his disciplinary sentence. (Facts 73-91, 170; Exhibit 5)

61

8C000067

(ammo use such .mlitionalmAccordinglga 



5%

move) Discussion: On 6 September 2012, while still at the DH, ISN156 began
spontaneously yelling and kicking, threw his urinal, and thereby splashed a guard. On 7
September 2012, COL Bogdan asked whether there was a medical or 
reason that ISN156 could not serve his discipline time at Camp V. sunbeam: indicated that
recent behavior, including his splashing the guard the day ore, was entirely
indicated there was no reason that could not serve his
discipline time at Camp V. After the decision was made to move him}

 

 

 

 

 

Ito 



 

 

IUpon receiving the infortnation, the JTF-GTMO Cultural Advisor
forwarded the information to COL Bogdan and others. Although COL Bogdan did not receive
the email until the following day, he stated that it would not have affected his decision to transfer
ISN156 to Camp V, because ISN156 was known to make ?melodramatic? statements. In this
instance, COL Bogdan actedrcasonably as he had to address the ?'equentmisconduct by
ISN156. On balance, the suicidal ideation did not stand out compared to any of the other
instances. Additionally, line of sight was ordered in an attempt to prevent any self-harm by

156.

5. Finding: Although guards followed the SOP regarding search and
inspection, there are opportunities and ways for a detainee to conceal contraband,
including medications. (Facts 89, 120,139-40, 171-76; Exhibit 5)

(U) Discussion.

a. {Semi-Before giving belongings to him after he arrived from the DH,
Camp guards searched them in accordance with the SOP. Guards removed certain
unauthorized items, such as extra towels and T-shirts, and gave the remaining, authorized items
(Dili'ilEl

[This creates extraordinary opportunities for detainees

 

 

 

 

to conceal contraband should they choose.

b. W9) Additionally, IAW SOP, guards did not search ISN156's Koran. The
current version of the 106 SOP, only the Cultural Adviser or interpreters may search a Koran.

e. We) was able to success?illy conceal contraband, speci?cally, 24
capsules of Invega, at some point from when he was initially prescribed and administered the
medication through the date that he was found unresponsive on- 8 September 2012. The way that
the JDG and IMO SOPs are drafted created numerous oportunities for ISN156 to conceal the
capsules. mm? ?mm xpressed his concerns with the (MIME) I

(BHBXUIC)
tbtt'IKE) I He also noted that his staff is in the process of

 

 

62

8C000068


I

searching for where that ?directive? initiated. So while the guards did follow proper search SOP,
the current version allows opportunities for detainees to hide contraband.

6. (WE-BUG) Finding: The guard force failed to follow the JDG Line of Sight SOP,
violated the JDG and JMG Med Pass SOPs, and should have taken remedial measur
after ISN156 appeared to be sleeping an unusual length of time. (Facts 90-106, 177-89, 190-
200, 212-27)

(U) Discussion.

am?e failure of guards within the camps to follow theline of

sight rotation time and the failure of the leadershi - both of?cers and non-commissioned
officers within Camp to enforce the {btmt?i line of sight rotation time increases the risk

that a line of sight guard, because of fatigue or distraction, will fail to recognize signs that a
detainee?s behavior or actions have changed over an extended time. Where guards fail to
recognize these signs, there is an increased risk that a detainee may, for a variety of reasons,
ultimately be found unresponsive.

hm When ISN156 arrived at Camp V, he was on electronic and direct line of
sight. After he arrived, ISN156 covered hisith a food mixture. The guard monitoring
the was not able to continue to see what ISN [56 was doing. When this occurred, the
SOP requires the guard to knock loudly on the cell door and uncover the If the detainee
does not respond immediately, the guard is to call (mime; Guards violated the SOP
when they failed to require to uncover his? line of sight, and failed to
call a This failure may have contributed to the death of ISN156 in that it
prevented the guard from being able to monitor ISN156 electronically, and from discovering

whether something was in fact wrong with during the time that the direct line of sight
guards say 1 56 was sleeping.

c. memo line of sight guards on the night shift were rotating outo

The guards knew that the SOP required a rotation, but elected
not to follow it. On the day shi?, several guards were either not familiar with the 
rotation requirement set forth in the JDG SOP, or were familiar with the requirement and chose
to disregard it. At the time that ISNISG was f0und unresponsive, the day shift line of sight guards
for ISN156 were rotating outhj The AOIC of Camp on duty knew that guards
usually rotated outl (bums) I, and did not know that the line of sight SOP speci?cally
addressed rotation times. The tier NCO that night was on his ?rst duty as an NCO of line of
sight, and did not know what the SOP required. He allowed the line of sight guards to rotate out

ecause he thought it would be easier on the guards. The failures by the night and
day shift line of sight guards to follow the SOP, and the failure of the NCO to enforce the

 

 

 

 

 

 

63

8C000069

 A

standards of the SOP, may have contributed to the death of 56 as the failures meant that the
guards were not as vigilant as the SOP required initheir monitoring of 156.

d. We) Additionally, around 0400,[ 
I thXE) IThe SOP does not allow for
medications to be distributed in any other way other than that authorized by the SOP. This
particular failure to follow the SOP the morning of 8 September 2.012 did not contribute to the
death of ISNI 56, as the medications were still in the splashbox at the time that ISN156 was
found unresponsive. However, similar failures by medical staff over time, to follow the SOP,
may have contributed to ISN 156?s ability to hoard medications, as discussed below.

 

 

e. The IDG SOP governing line of sight requires the Watch Commander to
check detainees placed on line of sight at a minimum od annotate events in
DIMS. The Watch Commander failed to make the line of sight entries into DIMS as required by
the SOP. While the failure to make the entries did not contribute to the death of ISN156, the
lack of entries did make it dif?cult after the fact to re-create the immediate events leading up to
the point that the guards found unresponsive. .

f. The guard force noted that ISN156 generally had an unusual sleep pattern,
in that he usually slept for only a few hours at a time, and even then, continued to move all over
his cell in his sleep. From the time he appeared to fall asleep around 2359, 7 September through
the morning, the guard force had several opportunities to wake or further check on ISN156. At
0400, the corpsman attempted to wake ISN156 with medications, but ISN156 continued to
appear asleep. He also appeared to sleep through morning call to prayer at 0455. ISN156 did
not wake up for his recreation yard time, scheduled for WOO-1200. The Watch Commander
recalled that the last time he saw ISN 156 alive was around 1100. At that time, he checked on
to see whether he wanted to go to recreation, but because 56 appeared to be asleep,
he did not disturb ISN156. Around 1200, 156 missed the noon call to prayer. At this point
lSNl56 had appeared to be asleep for approximately 12 hours, had missed both the breakfast and
lunch meal, and had not taken medications for more than 12 hours. Although there was no
requirement to awake a detainee, it would have prudent to have attempted to do so in these
circumstances.

1% Finding: There is inconsistency between the SOP governing brevity
codes and the JDG SOP governing line of sight. This inconsistency did not contribute to
the death of ISN156. The guard force overall performed admirably with respect to their
promptness in reaponding to the code, their entry into the cell, and their life-saving
attempts. (Facts 63, 106-14, 177-89, 201-03; Exhibits 45, 47)

(U) Discussion.

64


W. ..



a. (EEG-99) The JDG SOP governing brevity codes requires a guard to call a
when a detainee is obviously not breathing, as indicated by unresponsiveness, lack of chest
movement, and discoloration of the face. The SOP governing brevity codes requires a
when a detainee is cemmitting self-harm and a Code Yellow when there is a
potentially life-threatening medical condition requiring immediate response.

b. (unearned The JDG sop governing line of sight does not address a or a
Code Yellow, but does require a guard to call ahen a guard suspects a detainee
is not breathing or loses line of sight and does not get a response from the detainee alter
knocking on the cell door. The provisions in the two SOPs are inconsistent with respect to when
aI?(I?El?Ishould be called. The inconsistent provisions lead to confusion as to when a

guard should call al Ivice a 

c. W999) The day shift Watch Commander looked into the cell for and
immediately determined that there was something wrong 1 56?s eyes were open at the
point, staring blankly at the cell door and skin color looked gray. At that point the
Watch Commander called a Code Yellow. Based on his observations of 1814156, the Watch
Commander could have immediately called a  [or a I Mime} [instead of a Code
Yellow. The JTF-GTMO AAR evaluating the emergency reSponse found the Watch
Commander?s call of Code Yellow to be appropriate based on the guard force determining that
ISN156 could no longer be seen de?nitively breathing. The nurse arrived and upgraded the
situation to a The Watch Commander?s initial call of Code Yellow instead 0

toxrxetlor a [did not signi?cantly affect the medical response to the incident nor did
the failure in any way contribute to the ultimate death of ISN156.

 

 

 

d. {816439-993 Available guards and the 'corpsmen from Camp responded immediately
to the arriving to the ten shortly aaet l400. The guard team donned their 
protective entered the cell, secured ISN156, and began basic life support, 
and ?"f?Jfr??i?b??gm Ialternating chest compressions. Adhering to appropriate SOPs, the guard team'
performed admirably with respect to their promptness in responding to the code, their entry into
the cell, and their life-saving attempts.

 

 

8.4UWQ-UQ) Finding: The JMG SOPs require that all detainees requiring medical
attention should be immediately transported to the DH. However, the SOP does not
account for the unavailability of medical doctors at the DH on weekends. (Facts Ill-l3,
Exhibit 112)

(91603999) Discussion. Around 1425, the ambulance arrived from Camp to the DH.
i . assessed the situation, and based on
the condition of ISN156 and the fact that it was a weekend and there were no medical doctors on
site, sent the ambulance to the NAVSTA Hospital. The registered nurse at the BHU

 



demonstrated quick thinking and sound decision-making based on the circumstances. The stop
at the DH did not contribute to death but could waste time in other circumstances.

9. Wei-l9) Finding: Several "factors contributed to the ability of ISN 156 to hoard
medications. These factors include inconsistent JDG and JMG SOPs with respect to Med
Pass, confusion on the part of the guards, corpsmen, leadership (camp, JDG, and JMG)
regarding what the SOPs require, and in many cases, failure to comply with Med Pass SOP
requirements. These failures contributed to the death of in that they permitted
ISN156 to be able to hoard medications. (Facts 190-200, 208-10, 212-27)

(U) Discussion.

at. W?e JDG SOP and the JMG SOP governing Med Pass are inconsistent
with ect to ke revisions

(blil'liE)

 

 

 

b. The JDG'and JMG SOPs reguirer

(mam

 

 

 

 The failure contributed to the ability of 56to conceal medications.
c. (UM-10809 The JMG SOP prohibits]

 

 

(DIUKE)

 

 

 

[l'he failure may have contributed to the ability of ISN156 to ultimately hoard the

 

pills that were found in his stomach.

10% Finding: The JMG training procedures and record keeping are ?awed.
This contributed to the Med Pass SOP violations and to confusion of JMG personnel.
(Facts 208-27)

66



(U) Discussion.

a. The JMG does not have a training of?cer or section devoted solely to the
training of JMG procedures. The JMG training o?iccr is a mental health nurse at the
She is required to see detainees, administer medications, and also oversee other
aspects of nursing operations with respect to the nurses and corpsmen under her charge.
Accordingly, she is not able to devote the necessary time and resources to ensure that the training
and training records of nurses and corpsmen are consistent and proper.

hm The training records for the JMG nurses, corpsmen, and other medical
personnel are in many cases missing, incomplete, andlor do not re?ect what the trainees later
indicate they understood from the training. Several of the training records were signed off on by
the Senior Nurse Executive, as recently as 16 October 2012, for training that was allegedly
conducted in May 2012. The Senior Nurse Executive is responsible for the execution of the
JMG training program. Ultimately, the JMG Commander is responsible for the JMG training
program itself. The Senior Nurse Executive acknowledged de?ciencies in the maintenance of
the training records, and indicated he is working to prevent the problem from happening again.

c. W999) There exist de?ciencies not only in how the JMG training records are
maintained, but in how the actual JMG training is being conducted. Either the information being
put out at the training is incorrect, or the training is not being conducted vigorously enough.
Either way, the end result is that nurses and corpsmen are confused about what the SOPs require
with resPect to many aspects of MG operations, or are aware of the SOPs and are choosing not
to follow them.

d. W999) Finally, although the JMG training certi?cates provided indicate that
corpsmen and nurses are being trainch (DJUKE) I, several corpsmen noted that
they in fact were told not I Ibecause it would anger the detainees. The
JMG Training Of?cer herself indicated that as of February 20] 2, the (WINE)
I (bit'lltE) I. The few complete training records that exist for the nurses and
corpsmen indicate that in May 2012, trainees were required to sign a  

omits) 

 

 

 

 

 

 

 

 

 

 

 

 

11. We) Finding: The JDG training program is well-supported, in that there is an
entire battalion headquarters 8-3 section (from the 525th MP Battalion) devoted'to
ensuring that, among other things, guards are properly trained. (Facts 137-44)

(U) Discussion.

a. The battalion SS conducts the training of the JDG guards. The 100
training records were provided to the Investigative Team and were very well-
documented and maintained.

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 . A

hm However, the guards at the are not currently receiving training
on the unique challenges presented by detainees housed at the While the
responsibility to provide medical and mental health care to the detainees ultimately rests with the
JMG, the guards would better be able to perform their guard functions if they were at
least familiar with certain aspects of how the MG administers care to detainees.

12. (ii-#13969) Finding: There are other SOP violations impacting the operations of the
Camps..(Facts 145, 147, 153?58, 159, 161; Exhibits 41, 109) 

(U) Discussion.

a. W999) The JDG SOP prohibits detainees from feeding the wildlife, including
banana rats, iguanas, and stray cats, at JTF-GTMO. Guards and medical personnel are failing to
enforce this SOP, and detainees consistently feed wildlife while at the recreation areas. This
failure to enforce the SOP in no way contributed to the circumstances surrounding the death of
Permitting detainees to feed the wildlife, however, is creating serious risk that a
detainee could be bitten by a wild animal, and is a dangerous practice. The JDG Commander is
not aware that detainees are feeding the wildlife, other than pigeons, and the JMG Commander is
unaware that detainees are feeding any wildlife.

The JDG SOP establishes a strict method of control for detainee basic
issue and comfort items, which shall be exchanged on a one-for-one basis. Medical personnel at
the are causing stress on the guard force by providing detainees additional,
unauthorized comfort items, such as blankets. Detainees are aware of the policy that items
turned in through of?cial laundry channels will only be replaced by the set number of items
authorized. To avoid creating problems withthe detainees, the guards at the are taking
it upon themselves to launder the additional, unauthorized comfort items, and are returning them
to the detainees. Medical personnel, including leadership, are not always aware of the impact
that their decisions have on the guard force.

13. WThe JDG and JMG leadership are not communicating suf?ciently with each
other to ensure that their respective detainee operations practices and policies are
consistent and (Facts 125-26, 147-48, 158, 195-200, 205-07)

We) Discussion: The JDG and JMG leadership are not ensuring that the policies
set forth by each are being communicated to the other. Examples of this lack of communication
have been provided above in discussions of the di?'erences with brevity codes SOPs and Med
Pass SOP. Guards working at the are not familiar with all of the policies and practices
of the JMG and the JMG SOPs. When the JMG changes its SOPs, it is not always pushing that
information down to the guards at the 

68



 I 

14% Finding: The JMG would be better served by a command and staff that is
solely focused on JMG operations. (Facts 205-07; Exhibits 31, 38)

(U) Discussion.

a. sucrose) The Joint Medical Group Commander also serves as the Commander of
the Guantanamo Bay Naval Station Hospital. As such is dual-batted. Although
there is some degree of overlap between medical operations, the operations at the Joint Medical
Group require a great amount of resources and attention due to their unique and challenging
nature. Because of how the current commands are structured, is not able to devote
the time and attention that JMG medical operations require.

 

 

 

 

b. We) The JMG commander and senior leadership, including the Senior Nurse
EXecutive, are largely removed from several aspects of what is going on at the tactical level at
the and the camps. For example, the JMG Commander and the Senior Nurse
Executive both understand]

 

 

 

(blUllE)

 

IAnother

example is that the JMG leadership are unaware that detainees are feeding wildlife, and
acknowledge that the practice could be extremely dangerous.

HMO-HO) Finding: The de?ciencies and failures identified at the JDG and the JMG
are not solely attributable to the short rotation times. (Facts 125-228)

W999) Discussion: Many of the de?ciencies and failures identi?ed in this
investigation are due to a failure to JDG and JMG SOPs, a failure of the JMG to
preperly train the material contained in the SOPs, and a failure of the JDG and IMO to enforce
the SOPs once trained. Ultimately, the DG Commander and the JMG Commander are
responsible for the SOPs, and JTF-GTMO is responsible for ensuring the of the
SOPs.

(U) Part 3: RECOMMENDATIONS

1. Recommendation: The JDG and JMG Commanders and leadership should improve and
expand the scope of their communications between the JDG and the JMG.

Discussion: Because the Battle Update Brief does not provide a suf?cient forum for the
JDG and JMG Commanders to exohange information regarding systemic problems affecting
JTF-GTMO detention operations, the JDG and JMG Commanders should, at a minimum, meet
biweekly to address such systemic problems.

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2. Recommendation: The JDG and JMG should JDG and JMG SOPs to
ensure that they are consistent.

Discussion: By SOPs, the JDG and JMG will eliminate inconsistent
provisions that currently exist, for example with respect to Medication Administration ("Med
Pass?) and Brevity Codes and actions to be taken in cases of detainee emergency. The SOPs
should be revised to ensure that JDG and I MG personnel are able to execute their respective
missions while taking on only acceptable risk. The JDG and JMG Commanders should be the
ones ultimately responsible for their respective SOPs.

3. Recommendation: Once the DC and JMG Commanders their SOPs, they
should ensure that changes and updates are passed down to the guard force and medical
personnel.

Discussion: Where them are speci?c provisions in the JDG and JMG SOPs that affect or
assign responsibility to the guards or medical personnel, the JDG and JMG Commanders should
ensure that the information is notjust ?owing vertically (from the Commander down to the
operator) but also horizontally between the JDG and JMG.

4. Recommendation: The JMG Commander must better understand how the SOPs are in
fact carried out vs. his current understanding which contradicts actual practice.

5. Recommendation: Because of the special challenges presented by detainees with mental
health issues at the the JDG should incorporate a block of training for guards
that are assigned to the 

Discussion: The training should familiarize the guard force with general medical
principles that apply to detainees under medical or mental health care to enable the guards to
better execute their mission. The JMG should be responsible for developing and conducting the
additional block of familiarization training.

6. Recommendation: Medical personnel should not have the authority to make decisions
that contradict JDG SOPs, without previous command coordination.

Discussion: The JMG Commander should impress upon the medical personnel the fact
that their decisions affect the guard force.

7. Recommendation: The 525th MP BN should continue with the current rigorous and
comprehensive training program and training records maintenance it currently has in
place to train JDG guards.

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 I a

8. Recommendation: The JMG should establish a training section, whose sole
responsibility and mission is planning, coordinating, executing, and documenting all
training of JMG personnel.

Discussion: The training of JMG personnel should be reinvigorated and reinforced to
ensure that JMG personnel are familiar with SOPs and understand the critical need for the
highest compliance with SOPs.

9. Recommendation: JDG and JMG Commanders and leadership must re-enforce and re-
train all personnel with respect to SOP requirements for line of sight.

Discussion: To emphasize the real-world importance of following the SOPs, the line of
sight training should include speci?c reference to how failures to follow the SOP regarding line
of sight may have contributed to the death of 56. JDG and JMG training should include a
Speci?c block, to be certi?ed on the training records by the training officer, regarding line of
sight. JDG and JMG Commanders should also consider re-introducing a document to re?ect a
detainee?s actions at regular intervals 1 MIKE) I during line of sight.

 

 

10. Recommendation: JDG and JMG Commanders and leadership must re-enforce and
re-tmin all personnel with respect to SOP requirements for Medication Administration
(?Med Pass?).

Discussion: The training should cover key provisions of the SOPs, including (but not

 

 

 

limited to), I (WINE) I how to properly dispose of refused
medications (Emmi) I
[To emphasize the real-world importance of following the

 

SOPs, the Medication Administration training should include speci?c reference to how failures
to follow and enforce the SOP regarding Medication Administration contributed to the attempted
suicides by several detainees. This training should only be conducted after the JDG and JMG
Commanders have and made consistent their SOPs regarding Medication
Administration.

11. Recommendation: In the process of their respective SOPs, the JDG and
JMG Commanders must analyze the risks and bene?ts associated with either not

5 ecificall 
IOnce the JDG and JMG

Commanders have analyzed the matter from a risk bene?t standpoint, they should revise
and ?nalize their SOPs to clearly reflect their determination regarding whether

(bJUllE)

12. Recommendation: JDG and JMG Commanders must revenforce and re-train all
personnel with respect to SOP requirements regarding not feeding wildlife.

 

 

7i



Discussion: Commanders should engage the Preventive Medicine section to ensure that
the Preventive Medicine section is aggressively addressing the issue of wildlife in the camps.

13. Recommendation: The JDG Commander should revisit the issue of whether to

 

(mama)

 

 

 

Discussion: In revisiting the issue, the IDS Commander sh0uld consider consulting with
the JMG Commander as the matter relates directly to the opportunities for detainees 

omits) 

14. Recommendation: Commander JTF-GTMO, in coordination with 
will review the command and control structure of the JMG and provide a recommendation
to address concerns raised in this report.

 

 

 

 

 

Discussion: Because of the critical nature and unique complexities presented?by detainee
medical care, the current JMG Deputy Commander would be a logical choice for an interim
commander. The current JMG Commander should continue his role solely as the 
Hospital Commander. During this interim period, USSOUTHCOM should engage the Navy to
assess and determine whether an additional command billet is required for future rotations.

15. Recommendation: JTF-GTMO should establish, with USSOUTHCOM oversight, a
rigorous inspection program designed to detect tactical level de?ciencies in detainee
operations at JTF-GTMO across a broad spectrum of Operations, to include medical, legal,
and intelligence, and security.

Discussion: The inapection program should require checklists for each section to identify
speci?c de?ciencies and should include USSOUTHCOM assets who have training and
background with respect to JTF-GTMO and how to conduct-rigorous.inspections. The
inspection program must include a mechanism whereby the inspectors are following through and
verifying that .ITF-GTMO is and effectively correcting identi?ed de?ciencies. The
Field-Grade-in-the-Wire program should be entirely revamped and invigorated or eliminated
altogether, as it is currently not detecting critical de?ciencies in detainee operations at HP-
GTMO.

16. Recommendation: the Commander, JTF-GTMO must provide a concrete, detailed plan
and timeline to USSOUTHCOM with respect to how he plans to implement any
recommendations made here",

 

?89 Many of the recommendations in the report minor recommendations ?-om earlier investigations, speci?cally
Recommendations 8 and 13 from the investigation into the death of [81410028 (18 May 2011) and

72



SEW


Discussion: JTF-GTMO has not implemented many of the required changes identi?ed in
previous detainee death investigations. The JTF-GTMO Commander should also provide
consistent feedback and updates as to how the actual recommendations are being implemented.
The JTF-GTMO Commander should determine how best to implement the actual
recommendations, but should require the JDG and JMG Commanders to provide him
information with respect to the speci?c recommendations that fall to the JDG and MG
Commanders.

17. Recommendation: Commander, USSOUTHCOM, refer this investigation to
Commander, JTF-GTMO, for appropriate corrective andlor administrative action.

Discussion: As noted in the ?ndings, many of the deficiencies and failures identi?ed in
this investigation are due to a failure to JDG and JMG SOPs, a failure of the JMG to
properly train the material contained in the 501?s, and a failure of the JDG and JMG to enforce
the 301?s once trained. it should be noted that while ultimately, the JDG and JMG Commanders
are responsible for the SOPs, and JTF-GTMO is responsible for ensuring the of
the SOPs, both the current JDG and JTF-GTMO Commanders were in the ?rst 90-days of
command at the time of ISN 56 deaths.

 

Recommendations from the investigation into the death oflSN782 (l Febnrary 2011).
(Exhibits 124. 125)

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