~~(,JUsT:'i?lQF()n.."'r

(U) 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) (lSN US9YM-000156DP)
(U) AT JOINT TASK FORCE-GUANTANAMO (JTF-GTMO)

EtJIJiQUQ~I",,---

(,;,.;.b~,;,.;.6).;.;.,(b,;,;.)(7)(,;,;.C. ;.)

....

(U) INVESTIGATING OFFICER

EU/JfOUO~

I

(b)(6).(b)(7)(C)

(U) LEGAL ADVISOR

(U) 8 NOVEMBER 2012

CLASSIFICATION DERIVED FROM JTF-GTMO SECURITY CLASSIFICATION GUIDE
DATED 5 FEBRUARY 2009
Classified By:l
(b)(6).(b)(1)(C)
Iinvestigating Officer
Derived From: M@tlple Sources
Declassify On: 10 years after completion ofdetention operations

SECRE'F:RiOFORN

 5ECRET/:?iorORii

Table of Contents
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5
7

9
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22
27

29
29
35
37

38
38
39
39

SECReT/me fORN

 ~ Iii CnET.'/?iQfQR)'

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

40

C. (U) Training.

40

D. (U) JOG Standard Operating Procedures (SOPs)..

42

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

42

2. flWFQlJQ) IDG SOP #53: Sally Pon Operations..

43

3.

(l:JA~9\J9)

JOG Procedure #22: Wildlife and Pest Control.

43

4. ~;';'FeUe~ JOG Procedure #30: Detainee Camp Rules and Standards of
Conduct.
44
5. (lJl/rQlJQ) IDG Procedure #34: Search and Inspection. .
6. (VI/rOUO) JOG Procedure #56: Line of Sight.

47
. 48

.

7. f1:1fsCrQW9) JDG Procedure #66: Medication Pass Procedures.

51

8. (lJ/JfQWQ) IDG Procedure #82: Detainee Death.

53
54

VI. (U) JOINT MEDICAL GROUP (JMG)..
A. (U) Leadership.

54

B. (U) Training.

55

C. (U) JMG Standard Operating Procedures (SOPs)..

56

1. ttJ;'}fOUO) JTF-JMG #117: Medication Administration Policy..

57

2. f1:1/JfOUo) JTF-JMG #60: Cardiac Arrest Procedures.

60

.

(U) Part 2: FINDINGS.

60

(U) Part 3: RECOMMENOATIONS..

70

ii

 SECRl;TIfN.OFORN

(ll) Executive Sumnmry
I. ('51 This Anny Regulation 15-6 Repol'! providcs the facts. findings, and recommendations of
Ihe United Slates Southern Command (USSOUTHCOM) investigation into the facts and
circumstances surrounding the dC<lth of dctainee Adn<ln Farhan Abd Al Latif (ISN 156). ISN 156,
a 31-year old citizen of Yemen, had bccn a dctaillcc:II Joint Task Force-Guantanalllo (JTF" "8- - - - - -(b)(1).SK
H(e)
GTMO), Navul Station Guantanamo Buy, Cuba since - anllary 2 002 .....IS N-' IS'\) (ICu.
- _
Seplember 20 12 in his cell al Camp V at JTF-GTMO. This Reporl makes fifteen findings and

[J

offers seventeen recommendations.
2. (UhfOUO) The Armcd Forces Medical Examiner (AFME) determined the cause of death of
ISN 156 to be suicide by overdose of palipcridone (fn\'cga). ISN 156 had 24 capsules of Invcg:\,
,Ill anI i-psychotic drug, in his stomach :It the time of death. The toxicology examination revc:llcd
the presence of p:diperidone (Invcga), codeine (Tylenol #3), oxycodone (percocet). quctiapine
(Seroqucl). mil1azpine (Remcron). and citalopr;1Il1 (Celcxa), morphinc (by-product of Tylenol
#3), oxymorphone (active ingredienl in Percocct), and lorazepam (Ativan) were present in the
system of ISN 156 at the tinll.:: of his death. ISN 156 also had acute pneumonia.
3. (UhTOUO) ISN 156 had all extensive history of disciplinary and self-harm attempts while
detained at JTF-GTMO. Because of his unique issues, guards and medical pcrsonnel freqllently
treated ISN 156 differently than other detainces. Many guards and medical per-mnnel indicated
that ISN 156 was all exceptionally challcnging detainee.
4. (Uh'FOUO~ Guards and medical personnel repeatedly violate various Joint Dctelltion Group
(JOG) and Joint Medical Group (JMG) Standard Operating Procedures (SOPs). In some cases.
the guards and medical personnel arc unfamiliar with the Sal's. in othcr cases, the guards and
medical personnel arc familiar wilh the requirements but for various reasons, fail to rollow them.
5. ~UHFOUO} In the case of ISN 156, the JDG guard force failcd to follow the JOG Line of Sight
SOP und the JDG Mcd Pass SOP, und failed to take remedial llleUSlIl'es after ISN 156 appeared to
be sleeping an unusuallcnglh of timc. Likewise, the JMG personnel violatcd the JMG Mcd P'ISS

SOP,
6. {b'NroUO~ ISN 156 hO:lrdcd medications and ingested them shortly before he was found
unresponsive in his cell. Several factors contributed 10 the ability of ISN 156 to hoard
medications. These factors include inconsistent JOG and JMG Sal's wilh respect 10 Med Pass,
confusion on the part of lhe guards, curpsmen, leadership (camp, JDG, and JMG) rt::garding what
the SOPs require, and in mallY cases, failure to comply with Med Pass SOP requirements.
7. (UHFOUO) JMG training prOl.:edures and record keeping were also 11:lwed. This contributed
to the Med Pass violations and (0 confusion of JfvlG personnel. The JMG commander and JMG
senior leadership, including the Senior Nurse Executive, appear largely removed from s~veral

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aspects of what is going on at the tactical level at the Behavioral Health Unit I Detainee Hospital
(BHUIDH) and the camps.
8. fUAq;Q\JQ~ Other SOP violations impact the operations of the camps. Generally, the JOG and
JMG leadership do not communicate effectively to ensure that their respective detainee
operations practices and policies are consistent and synchronized. These commanders must
improve communications between their respective units. The JOG and JMG should synchronize
their SOPs, train the guard force and medical personnel, and supervise execution of the SOPs.
9. EU(~Q\JQ~ JTF-GTMO should establish, with USSOUTHCOM oversight, a rigorous

inspection program designed to detect tactical level deficiencies in detainee operations at JTFGTMO across a broad spectrum of operations, to include medical, legal, intelligence, and
security.
10. (WHfQWQ) Many ofthe recommendations in this investigation have been made in previous
investigations. Because it appears that JTF-GTMO has not implemented some ofthe required
changes, the JTF-GTMO Commander should provide a detailed implementation plan and
time line with respect to any recommendations connected with this investigation.

iv
£ ECAET.'/NQFQRN

 (U) List of References and Enclosures

(U) REFERENCES

1. (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 Internees and other
Detainees, 1 October 1997

4. (U) Geneva Convention Relative to the Treatment of Prisoners of War ofAugust 12, 1949
(Geneva Convention 1Il), 12 August 1949
5. (U) DoD Directive 2310.0IE, The Department of Defense Detainee Program, 5 September
2006
6. (U) DoD Directive 231 0.08E, Medical Program Support for Detainee Operations, USD(P), 6
June 2006
7. (U) AR 3-19.40, Internment I Resettlement Operations, September 2007
8. (U) Anny Regulation 15-6 Investigation Guide for Infonnallnvestigations, USSOUTHCOM,
May 2010
9.

€g/~TF)

JTF-GTMO Security Classification Guide,S February 2009

10. (~i4~J~ Report on the Facts and Circumstances Surrounding the Death ofDetainee Haji
Naseem (AKA Anayatullah) (ISN-10028) at Joint Task Force-Guantanamo (JTF-GTMO) on 18
May 2011 (31 July 2011)
11. ESNtIF) Report on the Fact and Circumstances Surrounding the Death of Detainee Awal Gul
QSN- 782) at Joint Task Force-Guantanamo (JTP-GTMO) on 1 February 2011 (IO March 2011)
ENCLOSURES

_ l J O ) USSOUTHCOM Memorandum ofAppointment appointing
~as Investigating Officer (10 September 2012)

I

(b){6),(b)(7)(C)

II

II. fUHfOYO) Email approving appointmentl
(b)(6),(b)(7)(C)
(b)(6).(b)(7)(C)
andl
(b){6),(b)(7)(C)
Ito investigation (15 October 2012)

I
l

III. (U) Email approving extension of time through 29 October 2012 (17 October 2012)
IV. (U/ligy~ Email approving request to appoint
October 2012)

I

(b){6),(b)(7)(C)

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

v
gECI~T#NOFQRX

Ito investigation (17

 SEeftE'fitN6FORfrq

(U) FACTS

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

I, (~ Adnan Farhan Abd Al Latif (ISN US9YM-OOO 156DP)~SN 156") was detained at Joint
Task Force - Guantanamo (JTF-GTMO) since his arrival onL:JJanuar-y-2002.--At-the.timc-of his.(~~_~'.:::.cdeath on 8 September 20) 2, he wa~ approximately 31 years old. I ISN 156 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, ISN 156 learned some English. (Exhibit 51)
2. (U/Ift)UO) ISNI56 had an extensive family in Yemen, including a to-year old son. ISNI56
frequently wrote letters to his family, including his grandmother, father, mother, brother, cousin,
son and nephew. In 2012, ISNI56 sent twenty-two outgoing letters to family members, fourteen
of which were to his brother, Muhammad Farhan. 2 Coincidentally, it appears that ISNI56's
mother also died on 8 September 20 12:~ (Exhibit 59)
B. (tHIf'OUO) Communications with Family and Attorneys

3. (o{],'IfOUO) From 2010 to 2012, ISNI56 made 14 video phone calls (VPCs) or telephone calls
to his family in Yemen. ISN 156 made three calls in 2010, seven calls in 20 II, and four calls in
20 I2. In 2012, ISN I56 made calls on I February () -hour VPC), 9 March (I-hour regular call),
21 May (I-hour ca1l4 ), and II July (I-hour VPC). (Exhibits 36, 60)5
(U/fFOUO~

ISN156 also frequently communicated with his attorneys regarding his habeas
corpus proceedings. According to an entry in the Detainee Infonnation Management System

4.

I (tmJl6U6) The precise dale of binh ofISN 156 is unknown. J21 (b)(7)(E) Ircpons indicate a birth date of I
January 1981. but n recent press release quoting ISN 156'.'1 lawyer stllte that fils passport and other records indicate
that he w s 35 or 36
. old. Exhibit 86
2 f'SHNR

(b)(1 ),See. U(c)

t5HNFt
I
C.1. C
Cla.'lsitied By:
(b)(6),(b)(7)(C)
USA. Investigating Officer
Derived From: Multiple Sources
Declassify On: )0 years after completion of detention opemtions

SECRETlfNOFORP:l

1.4(C)

 SECRfi'f/lNOf6ftrt

(DIMS), 6 around 14307 on 7 September 2012 (the day before ISN156 was pronounced dead),
ISNI56 insisted that a letter be mailed to his attorney.s The same DIMS entry also reflects that
ISN156 stated that "to die is better than to live" but ISN 156 would not specify what he meant by
the statement.9 (Exhibit 63)
5. E\lJ'J¥QYQ) In 2012, ISN156 was to have a total of six scheduled telephone calls or meetings
with his attorneys. On 14 June, ISN1S6 had a call with his attorneys. David Remes and Brian
Foster. On 21 May, ISN156 met with his attorneys David Remes and David Kudzin, and on 24
August, ISN 156 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; 18 September, canceled following ISN156 death). (Exhibit 61)
C. (oti'I'Jti'8ti8) Capture

(b){1 ).(b)(5).Sec. 1.4(c)

(Exhibit 51)
7. €tJ{~OT JO~ ISN156 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

6 (t1"Jf6tJ6~ DIMS is the primary tool used to track dayoto-day infurmation about detainees, and is made up of
electronic entries regarding each detainee.
, (U) All times in the report are in local (GTMO) time.
s (tt/Jf6tJe, The Office oftbe StaffJudge Advocate (OSJA) for United States Southern Command
(USsoumCOM) and Joint Task Force - Guantanamo (ITF-GTMO) have asked Naval Criminal Investigative
Services (NCIS) and the Department of Defense Office ofGeneral Counsel (OGe) whether the letter is covered by
the attomey-cUent privilege. As such, the Investigative Team was not able to obtain a copy of the letter.
9 (t:;{W8e8) As discussed later in this report, ISN I S6 frequently made passive statements about death and dying
during his over ten ears ofdetention at GTMO. Although the DIMS report indicates that this conversation took
place through DX3):1
b .tD1l6},(D the DOMEX Cell Block Weekly Schedule reflects that the interpreter on
(blQ~IDUSCJI~b~_~u~!haJ~.ay-was - --n
c cr 2012. lin individual from DOMEX clarified in a tellhone call with the
lil-tbli7J(CI
Investigative Team . t
same intcrp~r alt~~ using the
block names
;~;t::1l6j.
Interpreters arc sometImes ref!
..
..
sw
statements. On 23
0 r
unng a
tclcphone conversation with the (b)(3):10 USC§130b.(bX6).(b)(7)(C) indicated be did not recall the specific
conversation.
10 (U) A federal district court judge found the government's report to be unreliable and granted ISNlS6's petition for
a writ of habeas corpus on the basis oCthe confession's unreliability and other factors. The district court's decision
was subsequently reversed and remanded. (Exhibit 13)

c

cell

2

or};;):

,

 SCCRE'F..,.?i8F811"j

injuries he suffered in a 1994 car accident. II ISN156 claimed that he traveled to Pakistan and
then Afghanistan to meet up with a Yemeni who he had met at a charitable organization in
Yernen. ISN156 claimed that after waiting in vain for several weeks for the individual, ISN 156
then attempted to return to Yemen on his own, fleeing 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 200 I. With respect to his alleged confession, ISN156 claimed that his interrogators
misunderstood what he asserted, and that their summary bore no relation to what he actually had
stated. (Exhibit 131)
8.~lSN156 arrived at the detention facilities at Naval Station (NAVSTA) Guantanamo Bay,
(b)(11.sec,-t,.4(e1•.

_Cuba(GrMO).08anuary 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. ISN156 was housed in Camps I, II, Ill, V, VI, and the
Behavioral Health Unit (BHU) and the Detainee Hospital (DH).12 A breakdown ofthe last three
years is of external camp movements is as follows: 2012-12 moves; 2011 -three moves; 2010
- eight moves. 13 (Exhibits 51, 66, 67, 68)
D. tufWatia~ Diagnoses
9. EhJlJ¥QhJQ~ Guantanamo Bay Joint Medical Group (JMG) doctors 14 diagnosed ISNl56 with

Bipolar Disorder and Borderline Personality Disorder with antisocial traits. His most recent
episode was characterized as manic with psychotic features, possibly affected by Traumatic
Brain Injury (TBI), a cognitive disorder, or personality changes secondary to TBI. IS Over the
course of his detention at JTF-GTMO, ISN 156 was an occasional hunger striker. (Exhibits 24,
28)

(b:(.l~10USC.l13llll. __ 2$~~ - -

~ieated that ISNIS6 was almost completely bl1Jindl n his left~ye, and the 1TF-GTM~
optometrist indIcated that blindness was consistent with a traumatic injury.
-- -ltlad-re,cent1y..c.ons.ulte.d..1Y!!h.. ~_._.(bX31.10JJSC§130b.
the JMG Commander. (b)(3);10 usc §130b.(b){6) 0 determine whether the G could work WIth Jordan (where the
(b)(6),ib)(7)(C)
hospital
that ISNI c me
e s i:ad injury) to obtain records oftreatment ofiSNIS6 related to the car
(!l)(3' OUSCj':DII.lb~...accldent.-··
. dleated that although the JMG would nonnally not request such records, she pursued the
_
, 1'(~llb)('TJtCj
matter' .._.._
use she felt the records might assist her in treating ISNIS6. ISNIS6 died before!
- ---llbmlQ.I,lSC§13Cb.
ib~3~1°~1~j>&
[::.:
• •
.
(b)(6 )(7"C)
(b;(3jl/\l~,'\:IcthC.-:> e 00 n e records. (Exhibit 24)
~Ib "
(81Ib){7){C)
12 (~'/;q;8~8) Camps I, 11, III, and IV are no longer used to house detainees.
13 (U')f8~8) The details surrounding many ofthese specific moves, including the reasons the moves were made,
are set forth later in the report.
14 (UOFetle) For security reasons, this report refers to IMG medical personnel and interpreters by their block
names. Certain billets at JTF·GTMO, including medical personnel and interpreters. operate under "block names"
for force protection. (Exhibits 114, lIS)
IS ~'q;gJ!gJ A TBI may lead to brain damage to the frontal lobes (the part ofthe brain that controls personality),
making the individual impulsive and aggressive. A cognitive disorder usually Implies problems with basic thinking,
memory, and intellectual development (mental retardation or dementia, for example), thereby explaining some oftbe
individual's behavior. The diagnoses ofISNIS6 evolved over the course ofhis detention at JTF-GTMO. (Exhibits
lbX6).lb]t7)(C)

24,128)

3

 10. (QlJfQQQ) Bipolar Disorder is considered an "Axis I" mood disorder, where the individual's
moods swing either high or low. Accordingto the diagnosist in the case oflSNI56 t the most
recent swing was to the "high" mood (mania) to the point that he lost some touch with reality
(psychotic features). (Exhibits 24 t 128)
11. ~/~glJgl Borderline Personality Disorder (Borderline PD) is a considered an "Axis U"
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 difficult 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 hann
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. 16 (Exhibit 128)
12. ~))li'gQQ) Antisocial Personality Disorder (Antisocial PD) is another "Axis II" 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 suc~ they tend to engage in
conduct that society disapproves of, such as promiscuity and criminality. (Exhibit 128)
13. (lJ~gyg) In layman's tenns,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
selfor others," generally living life from one crisis to another. (Exhibit 128)
14. fU/;<fQYQl The Healthcare Ethics Committee at the Naval Medical Center. Portsm()uth t
Virginia (Healthcare Ethics Committee), assessed the condition ofISNI56 as treatable with antipsychotic medications but not reversible. The Healthcare Ethics Committee also noted ISN156 t s
chronic Impulse Control Disorder and stated that all ofthese conditions were associated in
ISN156 with acts ofself-hann and violent behavior. The Healthc8(e Ethics Committee noted
that due to ISNl56 t s Borderline PD and possible cognitive effects from TBI, ISNI56's thought
process was often illogical, and he engaged in near daily debates and negotiations with JMG
medical staff regarding compliance with oral medications. When not compliant with oral
medicationst ISN I56's condition became "critical and emergent" as evidenced by hannful
actions directed at himselfand others. (Exhibit 96)
t

16 ~OT)~ Individuals with Borderline PO were often sexually abused at a young age. Borderline PO is more
frequently seen in women than men. (Exhibit 128)

4
SECRETNNQFQRN

 6ECR£Th'?i9F9RN

IS. EU'NfQ'WQ) On 6 August 2012, the JMG Deputy Commander (b)(3):10USCr~:Ob.(bX6~(b) asked the
HeaJthcare Ethics Committee for assistance in determining whether it would be ethical to
involuntarily administer depot level anti-psychotic medication (monthly doses) to ISNIS6. At
the time, ISN156 was refusing to take his daily administered doses of anti-psychotic
medications, which was resulting in behavior harmful to him and others. l ? (Exhibits 24,96)
16. ~tJ/JfQWQ) On 31 August 2012, a subcommittee concluded that there existed an ethical
basis for the depot level anti-psychotic medication. IS (Exhibits 24, 96)

.......,;,;==:......

The

~/~QyQ~ Th
.. Jor
Co
Camps V and VllllJ(J~lousc§13all.
.
.
18. V
i
e phYSlclan
(1lJ(61~llllT)(C)
was the ram
care provider
for ISNI56. During ISN1S6's frequent sta s at the BHUIDH, however, fl3Ob(b1l8l.lb)l71 cted as the
attending physician to ISN 156, wi b1l3~11~.~~g:cl·lb' vailable for consult as needed. Over the course
of his detention atJTF';GTMO, ISNl56 had also been seen by specialists, including a
gastroenterologist and an optometrist, routinely brought in to see detainees. 19 (Exhibit 27)

E. tt7/1F9:S9~ History of Disciplinary Events and Self-Harm

19. fUIJFQYQ~ ISN 156 had a long history of disciplinary and self-harm events while detained at
various camps in JTF-GTMO. Those events spanned his over 10 years ofdetention at JTFGTMO, 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 ofbodily fluids,
failures to comply, possession of contraband, cross block talking, and writing on cell walls.
(Exhibits 51, 52)
20. EU/~QUQ~ ISNI56 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 ofnineteen self-

17 ~WP8l:J8) The specific behavior
ISNlS6 is detailed later in the re rt, and includes ISNlS6 throwing rocks at
(b){7)(E),(b)(7)(F)
and splashing a nurse and guards.
a guard tower and guards
I' (bY/PSYS) The subcommmee was esta IS
speci lea y r e avy Medicine East ethics concerns and those
at JTF-GTMO. The dela~ between tb~nitial question and the decision by the committee is explained by the fact
(b)(3):10 u~1.3.o.L_!hll.tjh~tCQJt\mittee.asked :- ......gather additional data. and the committee chair was on leave at one point.
(IlJhll~~li~~Il.>-.!?urinJJleli~tiQJ1Sjbe..commlltee-consultedl--·
!the JMG Behavioral Health Services (BHS) Ole and
11lJ(6~(llmC)
p,sychiatrlst for ISNJ 56. (Exhibit 96)
(b:(3):10 USC.S139!l,
~.e JlWQllQ~ The...casc..o£.lSNJS6-was so c&mplex..tha~·· .~ad scheduled a forensic psychiatrist consull A
(ll)(6~(Il)i'l)(C)
forensic psychiatrist bas expertise with assaultive behaVior and regularly works with correctional populations.
~1llllJ):10USC §130b
'ndicated that the consult was scheduled for 6-13 October 2012. (Exhibit 24)
(llxilj.(bJ(1ltC) •

I

(bl(3I:10U:;RfJI>~-'IbJ(61.(bJ(1J(C)

5

 SECRET.YN8f8ftfi

hann attempts, involving choking, ingestion of inedible items, hanging, head-banging, and
cutting.2° (Exhibit S1)
21. EW/JfQl:lO~ lSN 156 frequently made passive statements tQ (b}(3):10 usc §130b,(Il)(6),(Il)(1)«jasking to

die, such as "I wish I could die here" and "you could find meds that would kill me!' ISNI S6
would also ask §1301l,(b)(6}.(b) prescribe a "suicide pill" to him so that he could die.1.
:.._. ···1·····_·
...
.
indicated 1hat she advised ISN1561hat there was no such 1hing, and reminded him that she was
there to help him.21 (Exhibits 24, 37)

_.UlX3};JQ!"SC 1130b.
(b)(6).(b)(7)(C)

22. ~'jq:euo~ Analysts noted that while at JTF-GTMO, ISN156 frequently wrote dark poems
with suicidal themes, and wrote long letters to Joint Detention Group (JOG) 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." Analysts noted that triggers for ISNlS6 included perceived slights, noise
during prayer call, pressures from communal living, and not being allowed to watch enough
television. (Exhibit 51)
23. fQ'IfOl:lO~ Guards noted specific instances of misconduct and aberrant behavior by ISN156
over the course of his detention. One guard noted that ISNIS6 "had always done weird stuff"
and noted that ISNI56 frequently
(b)(6)
(b)(6)
IISN1S6 would also put a sheet around his neck like a cape, run
up the wall, and do a backflip offthe wall. (Exhibits 6,14,29)

I

I

.

I

24. (lJI~OtJ~ The Cam V Officer in Char e OIC
recounted incidents
where ISNlS6 would
(b)(6)
She indicated that several guards
placed written complaints about the (b)(6) • the complaint box in the Camp V break room.
(b}(3cli£.~~~llb. ndicated that she raise t e Issue with the former battalion commander ofthe
525th Military Police Battalion at the time. However, no disci lin action was taken against
ISN) S6 because "he was a special case." According to (b)(::J:)~~~~~Ob. the SOPs were "definitely
not consistently followed" with respect to ISNlS6. (Exhibit 16)

EU';;O' TO) One such instance occurred at Camp V or VI in 2008. An interpreter recalled ISNl56 approaching
hint and saying something like "here, I could eat these pills if I wanted to kill myself" and showing him a fist-full of
four or five pills. The interpreter indicated that the guard confiscated the pills from ISN 156. The interpreter
indicated that he had heard ofother instances ofdetainees (including ISNlS6) hoarding pills, but the 2008 instance
was the only time tbe interpreter bad actually seen a detainee produce the pms (fxhibit 2)
2\ ~\&;;QIro)I~NlS~~ to
JIOS. patient with
-: "f,.t.ern>1SNl56.bad.amm"-(bJ(3~10U~11H~1I ~twn~ul~lat!ODShtp..'W1
dicated that he often saw lSNlS6's sense of humor, with
(b)(6),(b)(7XCI
ISNl56 joking that all he wo ne to g out 0 GTMO was a boat and an island. and that he would not even need
to go back to Yemen. (Exhibits 24. 37)
22 H;;OY9+ As discussed later in the report, ISNlS6 badl
(b)(7)(E)
(b}(7}(E)
IaJlowed him to watch unlimited television. (Exhibit 48-B)
20

:"f:"Iy
="·<4·_·--

I

e

6
SECRETJ/NOFOFL'.

.__ {\llt3t~OUSC §130\l,
<b)(Gi.{b)(7)(C)

 £ IS CIU::TON 0 FOR?l
25. EUJ.lfOUO) One guard indicated that he understood the policy requiring line of sight duty to
be rotated every
(b)(7)(E)
stemmed from behavior by ISN156 - specifically, that ISN156
(b){6)
and do all sorts of crazy things" and that "they did not
would
want guards to have to watch that for more than~
(b}{7)(E)
~t a time." Another guard noted
that it was "horrible" to have to be on line ofsight duty for ISN IS6 because ofthese types of
actions, many of which ISNI56 would do right near the cell window. (Exhibits 6,14)

27, ~/,*gUO) Several individuals complained about what they perceived as special treatment
for ISNI56, noting things such as his unlimited television and recreation time, Some guards
expressed that they were concerned about interacting with ISNl56 because he was "special" and
they were "afraid of getting into trouble." (Exhibits 6, 12, 16, 17,35)
F. (U) Behavioral Incidents: June 2012
28. E'l:J//f'Ol:::JO) Multiple sources at JTF-GTMO indicated that ISN156'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 attome (David Remes) ofthe Supreme Court's denial ofreview of his
habeas petition. {bl(~J~~~~~~Ob, indicated that after the phone call, ISN 156 "came back furious and
really started saying crazy stuff." (Exhibits 16,24,37,61)
29. E'l:J//f'Ol:::J~ After the call with his lawyer, ISN156 was voluntarily admitted to the BOO for
(bX3Y.10 usc s.POb.._.approximatelY-One..and-a-halfwecks,I---··
~ecaJled ISN156 talking about his 1O-year old
(llXG).Iti)(7)(C)
. Yernen and h·IS hopes to see h"1m agam, wh'Ieh she too k as a good·
. demonstrated a
SIgn as It
son m
future orientation. During this same time, however,1
. ~_L'so-reported-thaUSN156
F
.
. . engaged_JIll(3~JO.USCSI30b.
(ll)(G),(bJ(7)(C)
in lots oftalk regarding death, which for ISN156 was fairly common behaVIor, (Exhibits 24, 68)
30. ~lfeUe} It appears that during this stay at the BHU, ISNI56 began to discuss stopping his
hunger strike, indicating that routine foods were making him nauseous and that he had no

(b)Q):10USCj1~~b. __:'_{U:''igWQj -- - 1b)(8~lbl(1)(Cl

lreferenced July 2012 as the date ofthe Supreme Court decision and the start of
ISN1S6's downW8l'd spiIil. She may have been mistaken as the date ofthe decision denying ISN1S6's petition fora
writ of certiorari was 11 June 2012, and the dale that ISNIS6 had the phone call with his attorneys was 14 June
2012. (Exhibit 16)

7
EECIlET/;?lQIbQR~

 31. EUNfSUS) While at the BHU, ISN 156 started requesting to receive his medications in the
(b)(3~'OUSC~13.QlL.._rccreation.yant - re octed that she told ISNIS6 that the current Standard 0 erating
lllJ(6}.\bli:tXC)
7
Procedure (SOP)
(b){7)(E)
(Exhibit 24)
32. fU/IfSUS) On 25 June 2012, ISN156 was discharged from the BHU to Camp V. §130b~bl(6}'lb)(71
rted that while at Cam V
(b)(7)(E)
§13lIb.4b1l8l~b)\1) indicated that she
L::fe~lt~th-'--at~I~S~N:":'1":'S6':""'""w-as-atte~m-p~t':""in-g~to-m-an~ip-u':"'la":"'te~t~h-e
-sy-s":"'te-m-.-:S::;h~e-n-o":"'ted,~~fo~'
rl-e-x....lample, that if
ISN 156 knew his medications pass was scheduled for 0500, he would request to go to the
recreation yard at 0445. Nonetheless S130b'lbX61,lbl understood thatthe guards told ISNI56 that he
(b){7)(E)
8 (Exhibits 24, 68)
(bl(3)'10USC.1".OJl-.33.. fYI.q;Q~Q)~WhenlImet with ISN156 for his nonnal post-discharge visit, ISN1S6
(b)(6).(bX7XC)
.
told her that he had learned that she was the one who '·personally changed the SOP" and
(b){7)(E)
,-----~*Plainedto... _ _ --- lll.!13tJO.\!SC§130b,
.
(bi(61.(b)(711C)
ISNIS 6 that thIS was not true, an d that the poI'ICy was long-stand'mg. ISNIS 6"
dismiSS 13lIb.tbl(6l(b)
29
lbl(3I"OU~.§~-"
Ifrom the appointment, essentially, as he stated, "fIring" her.
-----Icontinued.to.se.e..... _. UllOJ;,10.USC§130b.
(bi(6),(bJ(7l(CI
(b)(G~ib)(7)(C)

I

II

o

I

Z4 fl.V.4'9We~ The report reflects the dates indicated in the DIMS Detainee Movements Report. Because individual
recollections vary, the actual sworn statements sometimes reflect dates distinct from the dates in the DIMS Detainee
(bl\31;10 U~g.H~!I~_~M.~vem.£!1~_.Inhcr..swomstatemen~~ . lor example, recalled that ISN156 was admitted to the BHU
(bl(6).(blGl(C)
on 14 June 2012 (consistent with the DlMSmeeMovements Report) and again approximately a week or two
later. That subsequent BHU stay, however, is not reflected in the DIMS Detainee Movements Report. Relying on
the veracity ofthe DIMS DetaineeMovements Report rather than the recollection ofone individual, the
Investigative Team concluded that there was only one BHU stay fur ISNlS6 in June 2012. (Exhibits 24, 68)
25 ~TI'5O'TO) ~ noted aOOl ~use ISNl56 was at th,e ~HU~
----Iwu1d-bavebeenJlu:.auendil)!tPhY.sicl~
tl!)Qr.!OVSC §130b,
(b~3l:10V~i13Qb~_-'Qr.1SNJ.56,..wi
._-_....
vaJlable for consult. (ExhIbit 27)
(b1l6l:<bX711Cl
(bX6~(bX7XCJ
f6 EUI/f=eW9) Camp vI is communal. Detainees at Camp VI live in communal bl~ as opposed to single cel1s.
~J TO) As discussed later in the report, the I
(b~
I
(b)(711El (Exhibit SO)
tu:'.4'9W9~ As discussed later in the report, not all guards, nurses, and corpsmen understood or were complying
with the JMG Medication Administration
ical records arc inConsiste~ . ---·_~t..__.."(blQ)'10 usc §130b
lbl(3J;10 ~!13.9~ __ The medical ~rdsforJSNlS6 indicatG-that -...
authorizing corpsmen to
(6)(lBE)
Ib)tlli.tb)(7J(Cl '
\bJ(6).(bll7lfCI
I
~; ijBIIIE!.
Uhe audioVlSu
room around this same time. (Exhibits 9, 21, 34, 35,98)
tUAIf
that it was not unusual for a patient like ISNl56 to dismiss those persons
(b)j6).(bll1XC)
attempting to help him. (Exhibit 24)

p0J=1 ;t:;P'

lb)(3):'O~i13Ill1._~

U ~-~_. ~ndicated

8

SECUE=FIINOFOIUI

 SI:CH£T;'!?iOFOUN

(b:O):10USci13~_JSm.s.6.fol:mentalhealth .issues, andl - -

IbX6MbmCI

lremained involved for ISN156's OJ issues.

(Exhibit 24)

34. ElJ:'A*QUQ) On 5 July 2012. in anticipation of the start of Ramadan. ISNI56 moved from
Camp V to Camp VI as part ofthe "Ramadan gift.,,30 At the time, JSNl56 was housed in a
single cell at Cam
(b)(7)(E)
r
(b)(7)(E)
3 At Camp VI. ISNl56 was housed in a communal block with
approximately (b)(7)(E) other detainees. (Exhibits 24. 68)

v}

35. fU/,q;Q~Q) Approximatel ten days after arriving at Camp VI, ISNl56 began expressing to
the JMO psychologi (b~~~~~ u~c that he was feeling "overwhelmed" by Camp VI. 32 Around
this time, ISNl56 stoppe ta ng is medications and began fasting for Ramadan. The JMG
psychiatris~(~Wi~~t:ltold JSNl56 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)
G. (U) Behavioral Incidents: July 2012

36. (U'JfQWQ) Beginning on 25 July 2012, there were multiple incidents involving ISN 156.
Major events, highlighted below, include: a rock-throwing incident; J
(b)(7)(E),(b)(7)(F)
(b)(7)(E),(b){7)(F)
a splashing incident with urine and feces; and a
(b){7)(E),lb)(7)(F)
(Exhibit 51)

I

Yardl

37. EUs'.CFQWQ) On 25 July 2012 around 0800, while in the Recreation
«M)'lofCamp VI,
ISN156 and another detainee (1l)(6).(Il)(1)(CI told the watch commander (WC) that they wanted to
speak to him via an Arabic interpreter. The WC told them that they first needed to speak to the
Block Non-Commissioned Officer (BNCO). followed by the Assistant Watch Commander
(AWC). ISN156 started yelling insults as the WC walked away to continue his inventory.

30 tu#PQWQ) The IDG Commander grants certain "gifts" (to include absolving detainees from discipline time or
moving detainees from camp to camp) as part ofRamadan. Ramadan began 20 July 2012. The DIMS Detainee
Movements Report is confusing in that it refleets ISN1S6 moving from Camp VI to Camp V on 18 July 2012. and
back again from Camp V to Camp VI on the same day. (Exhibits 24. 68. 107)
JI (~;'JT9\;9) There are several reasons. to include medical and disciplinary, that a detainee might be housed at

==rJ

cam-::~p~v~.~(~~·~.13Gb b 6

J: ~

indicated that the "somewhat chaotic" nature ofcommunal living was overwhelming
ISNIS6. (Exhi It 3 )
J3 (U) Islam excuses certain individuals, including children, the elderly, the mentally disabled, pregnant women. and
travelers, from fasting. (Exhibit 106)

9

 SfSCR£1i'P.C8F8RN

ISNlS6 then began throwing rocks at the Recreation Yardl(l»)(7~EI~ower, damaging the tower
spotlight. 34 (Exhibits 53, 58, 100)
38. €1 J{~OUg~ At this point, having heard the radio traffic 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. ISNI56 then walked across the recreation yard and
began throwing rocks at the Super Recreation Yard Tower, striking one ofthe tower windows
and a tower guard in the head with a rock. ISNIS6 also hit a guard standing near the guard tower
in the hand with a rock. 3s (Exhibits 53, 58)
39. EUllfQ{JQ)1 ~gf(~) lapproached ISNI56 and tried to calm him down. ISNl56 continued
throwing rocks, only stopping when the OIC and the Camp VI Response Team approached the
Super Recreation Yard. At approximately 0825 hours, the Response Team restrained ISNl56
and led him out ofthe Super Recreation Yard.36 (Exhibits 53, 58)

40. fQf~l,/~ As a result of the rock.throwing incldcn~ ISN156 was given a verbal warning."
met with ISN156 at Camp VI after the incident, reminding him that he needed to take
.
his medications and not fasting. (Exhibits 24, 53, 58)

(bI<3):10U?95UOll.-I--··(bJ(6MbJ(7)(Cl

41. (g//fQ\JQ) Later that day, 25 July 2012,ISN156 was transferred to the BHU on line of
sighl38 At the time, ISNI56 was on three psychiatric medications: Celexa (anti-depressant);
Remeron (anti-depressant); and Zyprexa (anti-psychotic to help control impulsivity). (Exhibits
24,68)
42. @JIJfQ{JQ) At approximately 174025 July 2012, while in the BHU Recreation Yard I,

ISNl561

139 ISNIS6 was able to

(b)(7)(E),(b}(7)(F)

(\J '''-0' !O~ There are no photographs reflecting the damage to the tower or tower spotlight from the time ofthe
incident. The Investigative Team requested that photographs be taken as part oCthe investigation into the death of
ISNIS6.
u (U(/.OUO~ In a telephone conversation with the Investigative team on 24 October 2012, the JOG Joint
Operations Center (JOC) OIC (b)(J~IOUSCS13Ob.(bX6).(bl(1)(Cl indicated that medical personnel assessed the guards and
released them, as the guards 5
no rea p YSIC lruuries.
3.

36~.,....-------------.;:.....;--~---------------_

(b)(1),(b)(3):10 USC §13Ob.(b)(6),Sec. 1.4(c)
I

,

~;;liliC~~ According to the discipline matrix, the discipline for Damage to Government Property is! (bRiHE) I
and for Failure to Follow Camp RUles,1 (b}(7}(E) The Camp VIOle recommended a verbal warning and the JOG

I

Commander (COL Bogdan) approved the recommendation on 27 July 2012. (Exhibit 41)
JS (U(!5'OUO} As discussed later in the report, line ofsight can be direct (person), electronic (camera), or both.
~~bit4S) ......._ .......
(D)(3):10USCSUPL _ _ _ . - _ . ,
ndicated that ISN156 had told the
IbX6).(Ii;aXC)

L.---::~-:-----.~~:----.---.---.--::,:=~~The Investigative Team requested that photographs be taken as
part ofthe investigation into the death ofISNlS6. (Exhibits 37,101)

10
SECRETN?lOF9R'i

 SISCAIii=f/,'){QFQRN

(b)(7)(E),(b)(7)(F)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _1(Exhibits 17,57, 101)

I

43. ft,VJiQUQ) As a result of the I
(b)(7)(E),(b}(7)(F)
rISNI 56 was given
(b)(7)(E)
(b)(7)(E)
~ consistent with the Discipline Matrix for "Altering Cell or Modification of
Government Property.'t41 (Exhibits 24,57)

I

(b1l3):10US9-1mll.. _~.L:J,,1:&Yf.QMQ) Also..on-2S-July-20l-2~- ..---~tarted ISN156 on Remeron, an anti-de ressant
(b1(6~(b)(7)(Cl
ffi
f ' I'
.
.
•
•
WI·th·d
51 e e ects 0 stlmu atmg appetite and causing drowsiness, which
.--d b(3ti~~~sg~~(b_. _.lJlX.3l!OUSC§I30b.
.
(I))(6):(D)(7)(0)
deemed helpful as ISNI56 was trying to eat solid foods and frequently complained of insomnia.
(Exhibit 24)

I

:Jan

45. (~/J.fQUQ) On the night of 31 July 2012, ISN156 was agitated about recent events and was
in his cell at the BHU.42 At one oint, ISN1S6 began jumping around in the cell, from the bed to
the sink to the table to the toilet. IDll~t~~,~~:~~OD, the nurse on duty at the BHU that night, observed
ISN156 and asked him 'to stop what she explained was "very unsafe" behavior. ISNI S6 would
stop once (D~:~~~:6~QD, spoke to him, but as soon as she left the tier, ISN156 would startjumping
again. At one point, ISN1S6 did fall, but not seriously. (Exhibits 24, 3S)
46. ElJl/rQwQ~1 (bll~J:l':$~~6b'lwas fairly certain that ISNI S6 had not taken his medications, to
include Zyprexa (used to control impulsivity) that day. After the jum in had gone on for some
time and because she was very concerned for the safety of ISN 156, (bl(~:::)~~~b~OD, called
~-·I· ,..¢lQJ;j9.YSC §130D
d.
.
(b)(6),(b)(7}(C)
(D1l3~10U§g§13!b,_athQDle_toJnfonn~0f-the-.sltuatIOJl:-_.... .
indicated that she would come In, an
(~X6~(bX7)(Cl
. • to prevent an acel'd ent
suggested that they CODSI' d
er "
gIVing the Zyprexa to ISN156 as an •
injection
43
that could aggravate ISN156's TBI. (Exhibits 24,35)

. . I

I' .

.

I

47. fU/JfQlJQ3 While (b)(~J)(:1:),~DSj(~~6~Ob. was discussing the situation withl
....Jt,lSN156 agreed......__ .tIlJ(3119"l,lSC§130D.
(I))(6JAD)(7l\Cl
to calm down and indicated that he wanted to go to the Audio-Visual (AV) room.44 The guards
moved ISN156 to the AV room and he agreed to take the injection ofZyprexa. ISNI56 then

~ E~;')fe~8) The issue of passing food at the recreation areas is linked to the issue of detainees feeding the wildlife

at GTMO. as detainees at Camp V, Camp VI, the BHU, and the DH encounter wildlife while in the recreation yards.

The JOG Wildlife and Pest Control SOP, and instances oCthe SOP not being enforced, are included later in the

~

rt.
( ;iXhi

(b)(7)(E).{b)(7)(f)

ItS 5, I J, ii, 3If 33, 109)

I

EW/KeW8) The BHUIDH OIC recommendedl
(b}(7}(E)
and COL Bogdan approved the
recommendation on 26 July 2012. Discipline time IS not necessarily servco Immediately. (Exhibit 57)
\D)(3)10USC§J3oc... ~J----'
~dieated that ISNI56 was upset because he feh that his meals were not arriving on time and that
lbX6).IDX7l<Cl
medical staft' was not paying sufficient attention to him. (Exhibit 35)
(~X3J:10USO.l13oc....-~~.(
.. _.....
xpJained that once a patient has had one TBI, a second TBI can be more damaging. (Exhibit 24)
(b)(~(bX1)(O)"
discussed later in the report, ISN156, unlike other detainees, received unlimited television time.
(b)(31:10U~g'§l3oc.- ...~····ndicated that television helped to distract ISNJ56 and "rc-focus on other things." (Exhibits 37, 48-B)

(b)(6UD)(7)(CI

11
SECRE:FHNQfQRX

 SECRETN?iOrORPi

refused to sit in the restraint chair, however, and indicated that he would only receive the
injection ifhe could o·ve it to himself. At that point,I"~;#:~~71lwalked in to the AV room;::,._ _
J
According to lbX3):10U~C§130I),
···-JblQl;10.1,ISC§13(1).
11))(8).11))(7)(C) ISNlS6 was doin "OK" up u.ntil that point, but upon seeinl'I
\I))I8),(bl(7)(C)
(bl(3t.1ousc§'u+;-"··
, ISN156 got very angry with (I)~li::):c~~ol). for "waking up the doctor." (Exhibits 24, 35)
lbl(6).lll)(7l1C)
(Il)(3t.l0usc~to~J~€UHf.eHe~--~scussed the unsafe behavior with ISNl56 and told him that he would
lb1(6).(Il5l111Cl
.
.
.1.
••1.
by .
. • or by mou.
th ISN 156 re fu sed bo.
th
take the medication one way or anOUler,
elUler
mJeetton
(olQ) 10 U~UQA. _At that.point;F--····
~dicated that she would leave and deal with the situation in the morning.
IllX8~(1jli7)(C)
.•.
..
):10USC§ 3C
•
•
The Jurnpmg contmued throu the D1 t, With \bX;)l8).(llX7)(~) I), 11lng §130b.lII)(8).III) to update her
(b)l3):10
USQ§1JOb_ -pedodioaUy;I·---······
Itold~~.~,;,;,;"..~
(1))(~~:I~:~b~Ob. to continue monitoring ISNI 56 closely on line of sight.
Ib)(8).lb)(7)(C)
.
In the middle ofthe night, ISNI 56 went into the recreation yard, and in fact never went to sleep
in his celJ.4S (Exhibit 35)

--·-1-·

49.
The next morning, on.1 August 2012 at approximate] 0555 hours, ISNI 56
asked to see (I)X~~3).,:.w:~01). in BHU Recreation Yard 2, where tllx~J3~:~~b~0b. as standing guard on
ISN156.46 The NCOIC for the BHUIDH 11I)(31:lJ\.~~~0Il,(II) escorted (II~~:).~g:b~(lb. 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 "I have something for you," ISNI rem01ed
the lid and made three motions with the cup - first throwing the contents ofthe cup at
--- ··__·-UlJW;..1JLUSC§1301l.
(bl(31'10USC §130b
••
(II)(8I.1b)(7)(C)
(bl(3PO~.§UOlI,·-"
en at IIlXS)(II)(7lCC)' and then a (1lX3l:~~~~:J:Oll,(b1 (ExhIbits 17, 35)
lbl(8).ltiX7XC)··fth
'
...........-:.=:;,;;,;,......

r

I

Ib)(3):10~m~_

(II)(6).\b XC)

50.
The contents were a brown substance with a '"pungent smell" and consistency of
feces. (IIJW~:).~~~~~OIl. as lashed with the substance on her face, hait unifo
and boots, and
(1))(3l:10USCli13C11l,
. ~laces, um·fiorms and boots • (1l)(3~10USC§130Il,
!_~
ed
. llCl- and --'"
on th·err
(b)(8l.1bX7)(C) llllorm
ISN156 that he would be written up for splashing the staffwith feces. (Exhibits 17,35,56,
7

102t

(bl(3l:10USQ§RQL-.5.L€lHtf10U9~
Althoughl---····
(b)(8).(b)(7){C)
.

rltated that it was "still not clear" to her how ISNIS6 was

able to get a cup of feces and urine out to the recreation yard, thel
(b)(7)(EI

rr::::~~~::::-r.~=--~~~or----~
II......
(11~)(~:'>.~~~;ob·lindicated that inJ (b)(7)(E) I
.......

t--...,.~~~-~~--~=--'":"":"'":"":"---=

(b)(7)(E)

..:;:;;=~

t ISN156 took a sheet outside with him to the recreation yard.llll)flll':,,~~:~~oll'lindicated

that out ofconcern that ISN156 would be able to use the sheet to make a noose, she raised the

lb)(3~tOU~S'30l1.._~S~Ai;Enj8)1--· lunderstood that ISN156 had unlimited recreation time. but
(b)(8).11l:(711Cl
does not reflect such a proVISion. (Exhibit 48-8)
46

IbX7JjEI,tIll(71lF1

ISN 156.
ttt/.f!8b'e)

47

(b}(7){EI.(b)(7){F)

noted above, there are no photographs reflecting I
(bl(7l<E).(b)(1)(F)
rChe Investigative Team requested that photographs be taken as part ofthe investigation into the death of

E1J'~OU~ As

__-1.-.. -

thel

I

(b)(7KE),(b)(7KF)

_.._.~(Exhiblts 101,102)

(bX7/(EI,\ll)(7J(f1

12
SECR£T/l!'ior8Ri'i

 SECRSTHNOFORN

I

d'tcate··
d that· ..'- ...
~..
" that If
lsmlssed her concerns statmg
.
'
ISNl56 tried to make a noose, the guards would stop him. (Exhibits 24,35, 48-B)

•
•
5130b''''}(G) (b)
(bl(3):10USCmQb,~.JS.sJJe..W_._ '\·~n
(ll)(6UbX7)(CI

(b)(3):10 USC 51JOb, •
·.(b){6MllK711C) -·10

....

52. EU/;WQYQ) (bJ%~~~i~~Ob. explained that frequently, ISNl56 would wrap the sheet over his
back and appear to kneeland pray, aU the while shielding himselfwith the sheet. (bX~~:)~~a6~Ob.
ex lained that sometimes ISN1S6 would rock under the sheet as though he was meditating.
(bX:it~,~,g~~~Ob, stated that she saw ISN156 doing this the morning she and the guards were
splashed. (bX~lt~.~~:J~Ob. tated that in retrospec~ she believed that ISNI 56 was in fact defecating
and urinating 10 e cup, which he later used to splash her and the guards. Similarly~-. -~I···_. -~I3);to_usC 5130b,
L
' d that It
• was POSSI'ble Color a d
'
f~
d'
{b)(6).(b)(7J(CI
Ib)(3t.10 US.<atJOD..-'·'
rXPlalOe
etamee
to wa1k·th
WI a cup 0 Jeces an unne,
(bXG),lb)7XC)
covered, from his cell to the recreation yard. (b)(~:).~b~~~~Ob, 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 17, 35)

I

53. PJI<iOUO) As a result of the splashing incident, ISNIS6 received I
(b)(7)(E)
the Discipline Matrix for "Major Assault of Staff or Another Detainee.,..18
(Exhibit 56)

I

IC bX7l\EII consistent with

H. (U) Behavioral Incidents: August 2011

54. flJNf01> Later that same day, uncomfortable with the handl~n ofthe 'um ing incident the
Let
with the Senior Medical Officer
.1
6'~
and discussed
11I
6
1
•
issues re arding guard safety, clarifymg that anyone (guard or mIca cou ca a (b)(7)(E)
(b)(7)(E) •
(b)(7)(E)
is used to indicate a detainee is committing self-harm in a
particular location. (Exhibits 24, 47)

(b~3~'OUSC.m.D. _night before, _n_
(t)(6),IllX7)(CI

I

I

I

I

55. fl.vJfQ~Q) On 2 August 2012 at approximatel 0610 hours, while in BHU Recreation Yard
2, ISNl56 told the NCOIC ofthe BHUIDH 1ll~::~~~Jrll, , that he wanted to speak to
:b
and the ole ofthe BHUIDH {b)(:~1~,~~~Jrb. ,along with an interpreter. ISNl56 told 1;~~6~~b~f
(b)(3~10U~§lJOC.-I-!that if they did not arrive in the next fifteen minutes, there would be "big problems."
• •
1ll)(6~lbJ(7XC)
.
9
ISNl56 then started to
(b)(7)(E),(b)(7)(F)
(Exhibits 11, 17, 102)

r

I

56. (W/JfQWQ) At that poin 11l)(3);~~~~J~abAb ailed for extra personnel to come over from the DH,
and instructed them to use interpersonal communication (IPC) skills to try to de-escalate the
situation. Ibl(3);::~~b~~~~Ob.(b: also called the Joint Operations Center (JOC) to advise them of the

(W/)fQWQ) The BHUIDH Ole recommended
recommendation.

48

(

I

(b){7){E)

Iand COL Bogdan approved the

~WQ)Ir.:.::':"'---------(b-){7-)(-E-).(b-)(-7-)(F-)--------------

13

8ECRETNNorORN

 6EC:RET/J?iO F8R?f

situation, and requested the Quick Reaction Force (QRF). Approximately four to five minutes
later, the JOe dispatched thq:b)(7)(Eto the BHU. (Exhibits 11, 17)
57. EU/IfOUO) During this entire time, the guards continued to talk to ISN156 who eventualI
(b)(7){E),(b)(7}(F)
B then, accordin to (bJ(3~1: c §6~0ll·(b)
(b)(7)(E).(b)(7)(F)

u:

F
Also during this time, ISN156 continued threatening the guards with statements
suc as 'you have five more minutes!" in broken English. (Exhibits 11. 17)

58. E\JIWQgQ~ Sometime after ()700, the QRF anived at the back gate. Upon seeing the QRF,
ISN156 got more agitated, threatening that Uifthose people come in here, there are going to be
big problems." ISN156 then stated that he did not have an issue with the uardforce and that he
just wanted to speak to §130b'!'JX61.(b) ISN156 stated that ifhe could talk to §130~(bl(6}.(b) he would go
peaceably back to his ce . E ibits 11, 17)

(Y/,'i=8\oI8) The QRF initially tried to enter the recreation area (a small, enclosed area that is ad'acent to the actual
recreation yards) througb the exterior gate but could n as ISNlS6
QbWbarricadC himself in.
• os 0 I ~ :W6'
d~;~~~iftl~Cred;~re~gard~~in~g~w~h~en~prec~isc~IY
e
arrived down the tier' (b)I~:I:I~5C§l~ ndicate
t c
was present uring the time that ISNIS6 was
(b)(3~10 usc inOll._}.~~ktg9u~ whereas - .,- .leat
the QRF did not arrive until after ISNlS6 had finished lashing out
(bX6}.(bX7XC)
~Exhibits 11, 17)
I
n a telephone conversation with the Investigative Team on 24 October 2012, the JOG JOe ole
(~ 6
. indicated that medical personnel assessed the guards and released them, as the guards suffered no
rca p YSlca lnJunes.
50

~

14
§EeIW5Ts's'~;QrQRN

 ~EC~T//N9FOAN

61. El:",,'FOUO) ISNlS6 then
(b)(1)(E),(b){1)(F)
d into BHU Recreation Yard 2. The
(bli3):10USC§13.1l!!....._~.b
_ then restrained-ISN.156.~~-Nurs---·ntered BHU Recreation Yard 2 and administered
(b)(61,(bJ(7J(Ci
injections of emergency medications to ISNI56, and irrigated ISNI56's eye because he had
been sprayed by OC spray. 53 ISN156 appeared completely compliant at this point. Th~ (b){1)(E)
then moved ISNl56 back to his cell, where he slept for 12 to 14 hours. ISN156 was continued
on line of sight observation and psych techs checked on ISN156 frequently throughout the day,
common practice after administration of emergency medications.54 (Exhibits II, 17, 24)

I

62. ~(JF9UO) As a result ofthe.L..:-_~(b)(1}(~E~).(b:..:){1.:...:)(~F)
(b}{1}(E) for "Aggravated Assault on Staff" andL....
Damage to Property."ss (Exhibits 54, 55)

I

I

a.:I:.:.SN:.:.:.;15::.:6:..:rec~e;:,;iv;.:ed.:.L_~(b::.:){7:;.)::(E:':')_.....J

.;. (b);.;.{1,;.;,)(E. ;,)

.....for "Major

63. (J WEOI IO~ Following thel
(b}(7)(E),(b)(7)(F)
~ the JOG ordered an After Action
Review (AAR). The AAR contained several recommendations, includingl
(b)(1)(E),(b)(7)(F)
(b)(7)(E).(b)(7)(F)
ensuring that the Cultural Advisor be brought
on scene as soon as possible, reinforcing proper use of brevity codes and their mean~in...gs~
_
(specifically, that at the BHU, the guard force have a lower threshold on calling al
(b)(7)(E)
because of the heightened risk ofself-hann by BHU patients), and enforcing adherence to SOPs.
Specifically, "any deviations or changes to the SOP must be included in pass down notes and
incorporated during SOP updates." (Exhibit 83)

I

I

lbX3;r10USC.§j.~Q...-64..-(l:J/,q:OUo~I---·(b)(61.(b1(lJ(Cl

lindicated that her concern was "not so much with the medical response
.
,•
•
but the guard response." She expressed serious concerns about her ablhty to conduct medical
operations given that it did not a ear to her that the guard force bad "sufficient ability to control
I prevent incidents like this." §130b:lb)(8),(b) felt that the JOG senior leadership was very supportive
of the medical staffduring the AAR, and the senior leadership instructed the guard force that

15

I
I

 they were authorized to act in a crisis to protect other detainees and staff, without waiting for
approval from the JOC. (Exhibit 24}S6
I. ttr/1F'8ti8) August-8cptember 2012

65. ~After the incident, gl~i1ll('I,(b)(7) ailed back to Portsmouth, Vir . .a to speak with the
Psychiatry Specialty Leader for the Navy ~
(b)(6)
~. .t3Qb,,(b)(6l.tbl discussed with her the
possibility of using a depot anti-psychotic medication (a once per month in'ection, rather than a
daily, oral medication) to assist with managing ISN156's impulsivity. §130b.tblt6l.lbl ecalled that
(b}(6)
~upported the depot injection idea. (Exhibit 24)

I

66. @:J(~lJg) §t30b.(b)(6). discussed the issue with ISNI56, and he initially agreed to the de ot
injection. ISN156 also began taking his medications again. On 2 August 2012, §130D.\1ll(&J.6.J(7)
ordered several months of Invega (anti-psychotic) oral medications, as well as the depot
injection.S7 (Exhibits 24, 95)
67. Ell/K8VO) Around this time Ramadan was coming to a close and ISN156was the only
patient left at the BHU. 'l~1~g)'(b)(1) indicated that lSN156 was having fewer outbursts and

incidents, and overall was doing well. ISN156 often complained that loneliness led to his "bad
thoughts" and that be did not want to be alone at the BHU. On 9 August 2012,lSN156 was
transferred from the BHU to the DH, for increased socialization with other detainees. (Exhibits
24,68)
68! (Uh'F8l:JO) §130~:lblt6Mbl 'ndicated that ISN156 did extreme1 well at the DH, and was getting a
lot of support from other detainees at that point One day, 1~lb)(').(Il1l7 noted that ISNI S6 seemed
"extraordinarily happy" in the recreation yard, singing, dancing and kicking a soccer ball. 'l3llll.U,l(6i.ibi
(Il){3):10U~.§130b(.~-"
~oted that because ISNl56 had been diagnosed with bipolar disorder, she talked to him
CIl116j.(b)t7)(CI
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 August2012t ISNl56 started the oral Invega, an anti-psychotic
medication. il~fD}(6Ub)(7J intended to increase the Invega and titrate ISN156 off the Zyprexa, his
earlier prescribed anti-psychotic medication. (Exhibits 24, 99)

16

SECIHSTH?iOIiiOIUJ

 SECRE'fNN8F8R?,

71. fU.vr9TJ9~ On 31 August 2012, the Medical Ethics Review Committee detennined there
existed an ethical basis for the JMG to administer the depot level anti-psychotic medication
(Invega) to ISNI56. (Exhibit 96)
72. ftYJf9U9) The days went on fairly unremarkably, and on 5 September 2012, tl~~11~lb)l7J

noted that ISNl56 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. 13l111.1Ii)(81.lbl{7) noted that ISN156 said that he had written a letter to his lawyer asking
whether he thought that ISNI56 should take the injection.62 (Exhibit 24)
J. (QlJl'QY~ Events of 6 September 2012

73. tu/lrSH9) On 6 September 2012, the Senior Medical Officer (SMO) dlbX3J:10USC5130b.lbXO).lb)(7)(Clt
and l3Ob.\tiliGMb1l7 talked to COL Bogdan, the IDG Commander, about moving ISN1S6 back to Camp
V Delta communal) block.63 They agreed that ISN156 would move on 10 or II September
2012. 11~%1(6',(b.'(7)
discussed the matter with ISN156, who seemed happy about the plan and even
I
asked which detainees were at Camp V Delta. (Exhibit 24)

"~~~---------'"""":'=::--------------,
(b)(7)(E)
--- .
ndicated at sea vocat ••eavmg ISNIS6 at Camp V, but was told that all detainees
retume to elrl
(01(1)(1:)
l (ExhibIt 24)
(bl\3l10USCJI3.0b
60 .ti'Ih!fel::l8~-"-- id not indicate what medication she understood ISNl56 was referencing. (Exhibit 24)
Ib~f~~tgt,~li3~JUl.q;Q_Wg .•_-dicated that ISNIS6 had been drafting poetry in one form or another since his arrival at
lb:t8UbX7;iCI
JTF-GTMO in
.
ibit 24)
Q «(;{;'f8t;8) From the dates in DIMS, it appears that this may have been the letter ISNI S6 attempted to send to his
attomeyon 7 September 2012. Because NCIS and OGC have not yet detennined whether the letter is covered by
the attomey-eQriv'
ege, as discussed above, the Investigative Team has nat R •
' . i't 63
Ibl(3);10USC§'UllD.~'U'/iO!IO - .. -"
ad talked to ISN1S6 earlier about leaving the DR. B o '
were
(b)(8).(bX7)(CI
concerned that
• which is entirely communal, would be too much stimul Ion or
6
reluctantly agreed. and appeared open to the idea ofmoving to Camp V Delta (communal) block. (Exhibit 24)
(blt31:10USC,j130D.._... _.'
lIl;(ill.lbj7l(Cl
would be

17
SECAE'F/INQFQRN

 SECRE'f//NeFe~N

74. El:W1fQHO) Later that same day, on 6 September 2012, however, ISN156 began
spontaneously yelling and kicking, and threw his portable urinal thereby splashing a guard.64
Another detainee, (bX6) attem ted to intervene and asked ~1:JOIl:tbl(G),(Il) not to request discipline
forlSN 156's infraction. (b)(6) offered to talk to ISN1.56 a out not splashing. ISN156 took
his night dose ofRemeron (anti-depressant) that night (Exhibits 24,28)
75. (I IlWQI IQ~ About 2200 that night, ISN156 was demanding his urinal back, and sprayed
several guards with urine from flip-top water bottles. He threatened that if he did not get his
urinal back, he would keep splashing. ISNlS6 also defecated on a paper towel and threatened to
throw feces unless he was able to speak to a linguist. fI3OllIb)18),\bX7J indicated that she yiewed this as
a"guard management issue" and not a medical issue. ISNlS6 finally quieted down around 0400,
the morning of 7 September 2012. (Exhibit24)
K. (tilIt'8ti8) Events of 7 September 2012

76. EUNfOU8} That morning, ISN156 refused his morning dose of Invega.65 Also that morning,
ISN1S6 handed a note to the Watch Commander, telling him
e note to the JDG
X6
Commander COL Bogdan. In the note, ISNIS6 claimed tha 51 Cllfl ),(/l) was "rushing him
towards death" and that she was the "cause of the problems in the detainee hospital.'066 (Exhibit
63)

lbJ(3):10USC §1:m.--~~/;F.:ei!8t.Ilwas.nol.deer-tol·--·
(1lj{6),(11)('111cl
throw his portable urinal. (Exhi61t 24)
6S

~ether ISNIS6 inlended to splash the guard, or whether be just meant to

fl;lJIF8(8) The morning dose for ISNlS6 was 9 mg, which was in two capsules - one 6 mg and one 3 mg.

~xhibit28)

(t:Jl'lfetf6) The Investigative Team did not see the actual note but rather relied on a summary reflected in the
DIMS Report for 7 September 2012. (Exhibit 63)
61 fW'lIf9U9) As discussed further in the report. there are spe<:itic SOPs governing medication administration.
(Exhibits 46. SO)

18

fiE€RE1Y/P10FOR?1

 6l::CRE'i'HNOFOFtPi

decided to send ISN 156 to Camp V for discipline.68 The plan was to transfer ISN156 around
1500. However. based on ISN I56's erratic behavior the previous day. medical personnel and
guards were concerned about telling ISNI56 about his pending transfer. They therefore decided
to wait until just before 1SOO to notifY ISNI S6 ofthe transfer. Medical personnel and guards
kept the movement team off the tier so as not to alert other detainees ofISNl56's pending
transfer, (Exhibits S. 28)

80. EU//f8U8~ After prayer call around 1623, ISNI56 became increasingly agitated and
repeatedly asked for another 30 minutes to pack his things. The guards and the medical team
told ISN 156 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 ofthis, (lI)(~~f)(71 was
trying to calm lSN 156. (Exhibit 28)

6a ~/JFe~8~ Several ofthe cells at Camp V are designed for single cell detention. distinct from the communal cells
on Camp V Delta (communal) block, where it was originally envisioned ISNIS6 would be transferred, The single
cells are used to house detainees on discipline who meet certain criteria of the detainee disciplinary matrix. (Exhibit

41)

69 ~had

been accompanying ISNIS6 through the camps in recent moves. He was considered a
close friend ~f'i'SN'iS6 and one ofthe few peoplc who could calm him. (Exhibit 24)
70 f{:fh'f8t;8) Camp V houses several categories ofdetainees on its five blocks. One block is for communal.
compliant detainees. Another block contains convicted detainees. and another block is used for single cell detention
for those detainees
disCjPI~ status. There was considerable discussion regarding where ISN IS6 would be
(bX3):10 usc § 13Q11_.h.O!lRd .aLCamp..V_-_·
dieated, for example, that ISN IS6 had "a lot ofbad memories" ofAlpha Block (Il)(6).(b")(7l<C)
events ~ oecum unng earlier rotatio~ includi~g p1;~?~. self-hann, and Forced Cell Extractions (FCEs).
IbX3t.10 usc §13.0ll. _ -~rding1Jr--~mmcndcd agamst housmg
. m Alpha Block. However, because there were ISSUes
(lI)(6),lbX7XC)
involving another detainee in Camp V ~, w . east had encouraged detainees to commit suicide) on
lbl\3l:10 usc 113Ob._.~.f!aJJie.B~- --'
Piscussed the ~th l~ibliS}~bl They agreed to allow the guard force to detennlne the
(b)(6~(bmCI
best location or ISNIS6. The guards placed ISNI on amp V Alpha Block,
-~iagonally-aemn.m..I!!
across from ISNI56. Because ofthe way the cell doors and glass are positioned. both
\ ,
could see into parts ofISNIS6's cell. (Exhibits IS, 37,123)

faa

withl -

,m;gs:sr.rdtrtly

19

_

fb){6t.ib)(7I(C)

 SECftE'f;Yl'c6F6RN

82. ~lUWQ(Jg) Around 1650, ISN156 looked at (b~;~)~:~~1°b. d said something along the lines
of"when I die, it will be on you" and "you know that you have killed me sending me [to Camp
V]." (b){3JJg)~:~~~Ob. interpreted these as very passive threats but asked ISN156 ifhe had a specific
plan. I
intervened at that point, and indicated to 'bJ(3~x1J'~~:J~Ob. that he would "handle" the
matter. (Exhibit 28)

,r

83. ~''i04tQ) ISN1S6 spent a few more minutes gathering his things, and the movement team
then took ISNIS6 in the transport van to Camp V. Approximately five minutes later, a separate
movement team followed withl (b$g~ (Exhibit 28)

I

(bl(3):10USC§UOb.-

lb/l~~~t~~~ll;
IBHb~TIIC,

_.84· Hl'~).Thataftemoonll--

(bJ(3):10USC§130b.(bJ{8l.lb1l7j(C)

ltalked with the Officer-in-Charge (Ole) of Camp V,

·E- Irecommended that ISNIS6 be put on line ofsight, and she and
-

.

(b~~:)~~=~~Ob. determined that ISN156I
(b){7)(E)
(Exhibit 24)

(b)(1XE)

I

8S.~~~~~~

86. ~ The JTF-GTMO Cultural Advisor (bll1).(bJ(3J~g~ ,~,~~Abll6~(b) also received the same Force
Protection Report, in a high priority email at 1430 on September 2012.73 ~~Jtf.:~~~)~~~~~
forwarded the email to COL Bogdan, (b)(:~:1~ ~sc §~30b. the Deputy IDO Commander), and
others in a high priority email. adding at "pushing 156 to the comer never works to our
advantage." COL Bogdan indicated he was not aware ofthe email until sometime the following
day, Saturday.74 (Exhibits 5, 12A)
81. EU'!fOUO) Upon arriving at Camp V, ISN156 was placed in cell Al 05 (cell lOS on Alpha
Block lower) withj(b)~cfj{lllin A107. diagonal from him. By 1800. ISNlS6 had flooded his cell

20

 SECRE'Th'NOfORN
and was banging on his cell door, generally "causing a racket" on the tier, Based on ISN] 56's
behavior at the BHU, he had a splashbox on his cell at Camp V. 7S (Exhibits 20, 103, 123)
88, (U/IFOUO) The AOIC at Camp V (bJ(3);10USC§13Ob~b)(6).fbJ(7)(C) talked to ISNl56 and tried to
76
a speech about respect, saying that
convince him to settle down. ISN] 56 gave I ): C c '
he did not like to be pressured. ISNI56 also said something like "I am a sick man and because
of that, I am not afmid to die." (bJ(3~IO ~~g~~~Ob.(ll'C6J. recalled that ISN 156 insisted that his personal
belongings be returned to him. (Exhibit 20)
89. (UI,q;:OUO~ Understanding that ISN 156 was "banging and ellin "because he wanted his
belongings, the block non-commissioned officer (BNCO) (b)(3)1°US;§ci30b,(bX6).(b) searched them.
After removing the items that ISN 156 was not allowed because he was on discipline, including
extra towels and T-shirts, the guards gave ISNl56 his belongings, including a foam pillow and
linens. 77 ISNI56 indicated that he did not want his mattress. (Exhibit 19)

I

(b)(3):10 usc §130b,(b)(6).(b){1)(C)
90. (U/,q;:OUO~ At the time, there wer~ I~l) ~uards q
~~~~;-~~~gl~~~8 posted on direct! (b)(7)(E) lline of si ht for ISNI56 for the night shift on Alpha Block
(Lower),78 At the start of their shift, (b)(3):10 usc §130b,(b)(6),(b){1)(C) agreed to rotate line of sight
dut
(b)(7)(E)
and that if either guard" ot slee .. he would ask the other guard to take over.
(b)(3):10 usc §130b,(b)(6),(b)(7)(C) informed IbJ(3):::~~l(~~b~Ob'(bJ of their intent. 79 (Exhibits 1, 6, 19)

91. (U/IPOUO) Around 1830, at the request of ISN 156 (b)(3r.::I~~~~~Gb,(b) gave ISN 156 cereal, apple
juice, and milk. Around 1920, ISN 156 "mash[ed] up the cereal" using the milk and apple juice.
jumped from the sink and smeared hisl (b){1)(E) IWith the food mixture. (Exhibit 1)

7S (WIII"GWe) Only certain cells at Camp V have splashboxes, which are employed to minimize the risk that a
detainee is able to "splash"lullrds with feces. urine, or other ITh1terials.
7/\ ~U#Jigw~ ISNI56 toldPSr.l6=AE(DJ\'I~hllt it would be II sign of respect to talk to him without the splashbox.
ibiiifMA{Ub'lretucumtIY agreed. (Exhibit 20)
"
etllmees in a disciplinary status lire given only basic issue items; comfort items lire removed pending the
completion of their disci Hoar time. (Exhibit 4 J)

r

(b)(1),Sec. 14(a),Sec. 1.4(C)

1lI

(UlIF8W?) As discussed later in the report, the.rc are specific SOPs that govern !jue of §i~ht procedures. r=;]_.~~~;:::(¥~g)§130b.
(bXJJ'.IO¥SC§1:~tb'~
_.....
ndlcated thllt he knew that the SOP reqUired urdll to rotate out everyL (b)(7)(E) 1but that he and PFC
79

~~!!."~,.

";1'

,-

decide.1l0 ..IO,e oul
E) For h~ DO ""!' . indi""'ed lhal he knew lhallhe SOP .....il~
to m ate out everv
.. Although
(b)(3):10 usc §130b,(b)(6).(b)(7)(C)
all recall that
.~ -_ ~~:~m:u'i~gJ§130b.
.
. . .
were rotating line of sight upproximutcl
b
)
I I ,;
IDdicatcd he receive
. 0 stay otT the tier for "at most (b)(7)(E) 'to complete administrative duties,
pennission from . " .
~m:x':~t~~·~£t~~i~.m.!ing.outcoun~ling.statemenl!t: 'ndicuted that atone point, he pulled line of sight duty on ISNIS6
.
for llpproximatelYI
(b)(7)(E)
oted that 7 September 20 12 was the first time he
·"Ji:\'~!1·"iiireveriiCCiiTn
~l or dcme line 01 ,18hL ",Iou • • indio"'" II... he allowed .",.."'" ''''''''''''''''''"
~~r~~~~~~c::Jtorotate cvery ll~ I because he thought it wou
c "easlcr on the Soldiers" to have
(
- :re~~~g)§130b.
~:<:llG usc §.~:?~.:.L. _.
Iindicated that e ~nY after ISI'llS6 died. 9 Scptember 2~ 12. he waHold thatthe SOP .s~ s that uards are
I )( ).lllJ(1'I{Cl.
supposed 10 rotate out everyJ (b)(7)(E) I. The AOl . on duty the mght of 7 September 2012 ,I I.~.':. (~l (
indicated that "guards usually rolate every (b)(7)(E) when pulling line ofsight duly" and state t t e l
think the SOP required anything specific about rOlation times. (Exhibils I. I-A, 6, 6-1\. 19, 19-A. 20,45)

Cij"C:

1

-

21
SBCRET/fNOFORN

 SECRE'flINOFORN

L. (U'1F8U8) Events of 8 September 2012
93. (U/If'OUO) Sometime shortly before midnight. ISN156 finally appeared to go to sleep.81
Ii 13011.(Il}(6),(Il)(7) did not recall seein ISN 156 "lift his head or move all night" but did recall seeing
ISN156 breathing. (IlX~~:}.~~~~~Ob. noted that in his experience. it was "odd" that ISN156 would
have slept that long. as he was usually a very active sleeper. (Il)(3~::~~3~6~OIl.(Il) noted that he had
"never seen [ISN 156] sleep that much:' pointing out that IS
6 usua y slept for only a few
hours at a time. and even then, continued to move allover his cell in his sleep. (Exhibits 1.6.6\

A)

95. (U/WOUO~

indicated they did not see ISN156 ingest any pills.
They also indicate t at t ey 1 not eave t eir duty. and did not look away from ISNI56 for
more than two to five seconds while they were on line of sight duty. (Exhibits I-A. 6-A)
(b)(3):10 usc §130b,(b)(6),(b)(7)(C)

96. (UlIfOUO) Around 0600 8 September 2012.
(b)(3):10 USC§130b.(b)(6),(b)(7)(C)
over line of sight duty on ISN156 from (b)(3):10 usc §130b,(b)(6),(b)(7)(C)

SCI (Hh'f6Ue) A-; discussed later in the report, Ihere is a JMG SOP governing medication administration. As
exnlained bv l;Cveral l!Uards and comsmen when a detainee Wa!' asleen and had a splashbox on his cell,I';"'~;";)(7;;")(""E)""'1
(b)(7)(E)
I When the detainee awoke, the guard was
to alert the comsman.I

(b)(3):10 USC §130b,(b)(6),(b)(7)(C),(b}(7)(E),(b)(7}(F)

I(Exhibits I-A. 6, 9, 10.23. 25-A, 50)

~u'r"jt~t:JfiN/i'::;ra9(;g9~) AAli'tithiiCo;Uugi!i'hllliitilc;'iw;iaiSsiiuuiiithhomriiiz:C;cdiitt\;wnio:'iihiOouurr:Ssiiiut"iithiitie;rI'Cicc;:;'re~ation yard per day while 011 discipline. ISN I56 did
not go 10 the recreation yard that night. (Exhibit 20)

112 ('='/1F9t:19) Although Ihe calendar diclates the specific prayer time, detainees at JTF·GTMO detention fUcilities

customarily initiate the call to prnyer on their own.

22
SECRETffNOJlORN

 SRCRE'fI!P,OFOR:N

IbX3):10 usc 5130b.

lbX3l'10 usc §130b.

97. (UlfFOUO) 1bX:)(~.~~~iob. as on his first day of guard duty when he showed up for the
morning shift on 8 September 2012. He had just recently arrived at JTF-GTMO on 7 August
2012. and had been settling in after completing his pre-service training on 30 August 20 12.1-----1b~lbfll~~~r30b.
$~~il)l(81 indicated that he never received any instruction concerning line of sight rotation times the
morning of 8 September 2012. 84 (Exhibits 10, lO-A)
98. (tHfl~ofA1i1---ll::....-.-t r.;=~~~~
approximatel
rotate
(b;ml0 usc §130b,

lblI6J.(b)(7KCl·..·····-

.'-

100. (UOFOUO, Aroun~ 1b~~:)~;'~~~OD. took over, and indicated that ISN 156 still appeared
to be sleeping and mumbling, as though he wus dreaming. The two cups were still in the

'taled thut he was not told
anylhing about line of sight rotation times al the pre-service training lbll~~~g~~g* tatcd that at the training. parts of
the SOPs were read to the guards. but Ihe guard.. never saw actual COPICS 0 I C. Ps. As discu...sed luter in thc
report. there are specific SOPs lhul govern requirements for line of sight duty. including rotation times. (Exhibit..

10.45)
IS

(U;lfel::Jei(l)ll;~~g)~-.hndicated thut he knew that the SOP required guards to rotate line of sight duty eve~

(in~te). but that he generally allowed Soldiers on duty tu dccidc how Ion . t
wanled to rOlate line of sight. t::::::::r~~~~i:(~~g)§130b.
'ndieatcd that the day after ISN 156 died. 9 Septcmber 2012 I
put oul information at guard mount
.
(Ill(7)iEI
t at I~J~f.!iig,btwouldbe-rotated everyDninulcs from thcn on.
Ii-v,
indicated that although he knew lhe
Ib)(7J(E1 -- .n"-~6~ ~EU!~~,gUw:.d" tQ.TJ1.tulcJinc. of.sight evcry..~minutes. 1~~: 8, I)' told him to switch out with
·l.l:~:~l(¥~gl§13Qb.
(blO):lOUS~§"13~jj,~ _-'
whene~",)~x..,gldcdtu, (Exhibits 8. 25}""'
(b,(6)1b)(7){C~..(t:J/1f8e8~13Oll1+~).lbliE 'ould not recall at what time he last saw ISN156 breathe, but recalled thai it was right
before hc switched duty wilh (b){~~~gl~:MJJJOb (Exhibit 8)
~~;::;;~~~~...-

I -.-.

23

 SECRET/RiaraRN

splashbox. b1(3)~~~.~~J'~fUlb. understood that ifISNI56 awoke, he was to alert (bJ(3I:~~~~~~iOb.lbI the
corpsman. (Exhibit 10)
101. EYl.q:'gUO) Around 0800, (lll(3).1:).~;~~~~Ob.lbl arrived for the morning med pass for lSN156, but
lSN156 appeared to be asleep all morning. IbX3r.~:'~l(~~~~Qb.(bl brought a suppository and Colace that
helps with bowel movements. At that time. (bl(3r.;:~~~~~Qb.(bl noted that there were two pill cups one with a cream and one with a pill- air 'Y m e sp ashbox.87 (bl(3):::I~~~b~Ob.(b1 did not leave
the 0800 medications· for ISN 1S6 in the splashbox, as there were already other medications there.
'bJ(3)::~.~~~;Ob,(bl indicated that as a matter ofpractice, he never leaves medications in a detainee's
splashbox. (Exhibits 10, 23)
102. fl:1l.q:'0T:10~ ISN156 did not wake up for his recreation time scheduled for 1000-1200. The
Watch Commander tbl(l:l(1J').~~:Jiob. recalled that the last time he saw ISN156 alive was around
1100. At that time, he checked on ISNI56 to see whether he wanted to go to recreation, but
because ISNI56 appeared to be asleep, he did not disturb ISN156. 88 (Exhibit IS, 2S-A)

103. EYl/fO'=:JO) ISN156 did not wake up for the noon prayer call. 89 (bJ(3):):I::~~~~Qb·(ll) recalled
checking on ISNlS6 around 1245, and indicated that ISNlS6 was "definitely still breathing at
that point." (bX31:::I::~:~~Ob'(bl called mentioning to the guard on line ofsight (he did not
remember whether it was (b)(3):10USC§130b.(b)(6).(b)(7}(C) at the time) that the breathing of ISN156
looked "rapid or labored." (Exhibits 10, 23)

I

104.1 (bJ(3):10USC§130b,(bllS).(b)(7J(CI
indicated they did not see ISN156 ingest any pills. They also
indicated they never left their duty, and did not look awa from ISN156 for more than 30 to 60
seconds while they were on line of sight duty. b~~:J~I~%.~~ stated, however. that he was not
looking at ISN 156'5 breathing pattern and was focused on verifying that ISN156 was not trying
to hurt himself. (Exhibits 8-A, lO-A, 23-A, 25-A)

~'JF9~Q)ltD:(~x~I,~~~:~!uD'lstated that the cups may have been stacked two bigh, for a total ofrour pill CUPS. but
he was not certain. Photographs taken following the incident indicate a total of four pill cups in the splashbox.
(Exhibits 23, ~
88 4J:1P~
.'.~ ~
dicated that guards frequently discuss whether to wake a detainee for recreation time.
eel that because ISN156 was so unpredictable, be decided to allow ISNIS6 to continue to sleep,
an p ann to give him recreation time later. (Exhibit IS)
89 tti....P 8'tfe) There are no DIMS entries during this period oftime. As discussed later in the report, there is a
specific SOP that governs entry of infonnation into DIMS during line ofsight duty. (Exhibit 4S. S6)
87

1~)(3):10 us.g~1J

lb'l~veIR~.nl1"I~-~'
18ilblil)tC)

24
SEeR:ETN!'TOfOIl.'j

 SECR£T.'/NOF8Rl'i

107.

Several Cam V
(bX3):10 usc §130b,{b)(6).(b){7)(C)
(b){3):10 usc §130b,(b){6),(b}(7)(C)
("the guard team") responded to the Code
Yellow. Once members ofthe guard team donned their protective gear,92 they stacked up on
the cell door of ISN 156 and waited for the other NCOs to arrive. b)(3j;~~,~~~r·lb called for the door
to be opened, central control released the cell door lock, and (b)(~~;:g"~I~j3Ob· pushed the door open,
with the guard team rushing in. ib)(~:I:gl=Jlib, 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)
108. fUY¥OYO) As Ib)(~m)~~3Ob. secured ISNlS6's head, she saw "chunky vomit" and when she
turned ISN156's head to the side, she stated that a lar e
tity of"yellowish bloody goo"
drained out ofISN156's mouth.93 By this time, (Dll~~:)~~~~fD, d secured TSN156's hands with
restraints as a safety precaution. (b143):1:USC§~30D.(Il1 the corpsman, arrived, took ISN156's pulse,
and indicated that there was no pulse. (D)(3~~.~~~:~~OD.(Il1 told the Watch Commander he thought
ISN156 was dead and to call the nurse. (Exhibits 3, 23)

ty//FEH;e~ A Code Yellow is used to indicate a tentially life-threatening medical condition requiring an
immediate response. The Camp V OIC ,::C: J' 8.ID. ,indicated that she receives approxima1ely five to seven Code
Yellows per week. As discussed later in e repo t ere is a IDG SOP governing brevity codes. (Exhibits 16,47)
(b)(3l:10USC.ill9b~.. _~I.
---as!lbX701 ~the equivalent ofthe Assistant Wa1ch Commander (AWC» at Camp V tha1
tbX8).(bj;7XCI
day.
was assign to e ta Block,l ~m~tb~;f
already on Alpha Block (Lower) as the NCOle,
an
assigned as the Recreation Yard 1 NCO. (Exhibits 3, 25, 26, 34)
9%
•
e roteetive gear included a neck protector face shield and gloves. (Exhibit 3)
93 ~ 1It:Ei0' J~ I I~: 8M
escription is similar to that Of~:;;'u::$1{jWhO inidicated that when t~ rolled
ISNlS6, a large amount 0 red Ouid and water" (enough to
a 750 bottle of water) flowed
recalled similarly, noting tha1 he saw vomit on ISN156's right ann when he entered the cell. (Exhibits 2S, 34)
94 ty;,;;:et;e~ An After Action Report (AAR) determined that although a Code Yellow was appropriately called by
the guard force initially, the situation sh uld hav
n upgraded to a I (bllTIIE) Fmedia1cly upon verification that
lSN156 bad no pulse or respirations. A (bJ(7)(E1
uld have "appropnateiy precipitated the recall of emergency
medical support and triggered notification 0 t e uty provider for potential [Advanced Cardiac Life Support} ACtS
response." (Exhibit 85
9S
c . called that when he arrived in the cen, ISNl56 was still ""'8rI1l ("not COldlG'
d
had a "yellow, sweaty 00
When he bent down to see ifhe could hear breaths or see chest movemen
- - -----..{~lmtll.USC§1301l.
(bl(3r.l0USC.~~-"p:toted tha1 he saw and smelled vomit, which looked to him like mashed up cornflakes and milk:
It
(DX81.ibX711CI
(D)(61.(b)(7)(CI
23)
90

I·

!was

~

25
~EGRE+:'.,);QFQI4?i

out.1J~:ltblli:~~Ub·1

 SECUf}fh7iOF6ltN

109. flJllfeHe~ Using the keys she had on her belt.as (b)(7)(E) (Ill(~~J:,=3CIt. removed the
restramts on ISNI56 to begin chest compressions, and (b)(3~::~~:~~1l,(ll) began rescue breaths.96
Withl (1l)(1tl(~)JWi930Il'lperforming rescue breaths, (b)(3):10 usc §130b.(b)(6),(b)(7)(C) continued with the
chest compressions, alternating approximately every four minutes. (Exhibits 3, 23, 26)

III. fLVJfg\te~ Other guards passed a backboard into the cen, and the guard team secured
ISNI56 to the backboard, carried him out, and loaded him into the ambulance. By this time,
(ll)(m:g)~~JI301l. another nurse from Camp VI, had arrived. She got into the back of the
~~~
ambulance, performin chest com ressions on ISN I 56. Also in the ambulance were ~~t~~~~r
§13~1l.(bl(\6~ (driving)97, (b}(3~)1guSC§1301l. an~mp V guards. The ambulance left the Sally Port
ofCamp V around ]426, and arrived at the BHUIDH a few minutes.later. (Exhibits 3, 13,23,
29,30)
(b}{3):10 usc 51301l
112. EW:/JfQ~g~ Once at the DH, Il 6
• got out ofthe ambulance to prepare a bed for
ISNI56. At the same time, a nurse at the BHUIDH 1301l ~16. C assessed ISN156 in the
ambulance and instructed (b)(3):10 usc §130b.(b){6),(b)(1)(C) a corpsman at the DH) to proceed·
directly to the NAVSTA Hospital. (Exhibits 22, 32)

I

113. fYl/fQl::TQ~ The ambulance, at that point containing ISN156J (b)(3):10 usc §130b.(b)(6).(b)(7}(C)
the two Cam V uards and with (1lJ(3~:g)~~~gOb.lb) driving, left the DH for the NAVSTA Hospital.
En route, (b)(3~~:~~:~rll.(ll) ontinued chest compressions, with (llJ(:~:)~:~~~~Oll. maintaining an airway,
perfonning rescue breaths, and suctioning. Upon arrival at the NAVSTA Hospital, a doctor and
corpsman came out and rushed ISN156 into the Emergency Room. There, medical staff

fQ'j'f8W8~lbWJ:l?:y~tl~dD. ~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 from the patient - to start the rescue breaths.
(Exhibit 23)
'!11 fC/;rege>I (b)(3):10 usc §130b.(b){6),(b){1}(C) lare both certified as Emergency Vehicle Operators (EVOs).
(Exhibit 23)
98 ~tIiQ{JQ) (bJI~~;::'~~IJCb. explained tbat the NAVSTAHospital i

96

~~~~_rlaining that there are usually no medical doc10rs at 1he BHUIDH on the weekends,

I I

~U61

indicated he would have proceeded differently bad it been a weekday, as there would have been ...
m....
ore=m...,.lca~Staff
present. In the AAR, 1hc JMG recommended that in aU cases involving codes from Camp V, VI, and Echo, where
ACLS is not available on site, the patient "should have [Basic Life Support] BLS initiated immediately and then be
evacuated to the Naval Hospital for ACLS response." (Exhibits 32, 85)

26
SECll£TlRfOfOnPi

 SECRE'F/;,mFe.llN

administered epinephrine and intravenous drugs, and continued life-saving measures. They
declared ISN156 dead at 1448.99 (Exhibits 13,23,30)
114. fUHfOUO~ The guards understood their mission was to remain with the body oflSN156 at
all times. At some point around 1543, NCIS, the FBI, and Combat Camera arrived to examine
the body and take photographs. ISNl56 was moved to the X-Ray room around 1725. The
guards escorted the body via ambulance to the morgue. (Exhibit 29)
liS. fY/4'Q\JQ~ The next day, 9 September 2012, a team including a medical examiner,
pathologist, and a Muslim Chaplain arrived at OTMO. The Muslim Chaplain's role was to care
for the remains ofISN1S6 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

116. fL'J4'Q\JQ~ Table 1 reflects key events in the timeline leading up to the death of ISN156,
beginning with his transfer from the DH to Camp V on 7 September 2012. The information for
Table 1 was compiled from several witness statements, DIMS reports, and medical records for
ISNIS6.

119~~~f;6~b~~~' indicated that there was no response, no pulse, and no respirations from .JSNIS6 from
lD

""---==---'

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

27

 S5 eKE7::::0:--0 ::?:
(lI) Table 1 - Timeline.

ArlOroximatc Time
7 Sep 2012
1727
1738

1739-1800
1800
1925
2006
2018
2230-2359
8 Sen 2012

It),)):IO usc iUO~
lt1l6JOlJ(1)(Cl

o,_1!!L.-

--

0600

/Il:O~IOUSC-.il~O'
1'Il~8UcJ(111CI

--

\t:n l'USCJ1:ll'
\c:Alllt};1)1C)

(:AJl;10trSC i1JOQ...
~X81(:k111CI

I03Q.

-

-

1200
t4QS_

1416
1417
1417
1419

1420
1422
1424
Ib)(11
IEl

1448

1740

Corpsman-t .
t leaves medications in ISN1 56 cell splnshbox - ISNI56
an~ to be as ce
Shift change from night to day shift; ISNI 56 appears to remain asleep, misses
oraver and breakfast
dications to ISN156 buIISN156
Corpsman. \ ~~)~II'll;JC.>\l . Ptries to ad - - - still-in.solashbox-_
aooears to be as ee ; me Ications from
Vcomes lor ISNI56 to go to recreation, but ISN156
_\\~atch Commander_Q appears to bc asleen .
ISNI56 anocars to remain asleen
_._indicatcs ISNI S6 breathing had become abnormal, and attempts to gain
ISNI56's attcntion; ISNI56 unresooosive
Watch.Commander f .
h calls Code Yellow
Team Ofll(!-,' guards cn cr.; ce I, allowed byl \ ~~,' ~~~¥ team secures ISN156;
, ~~~'( -;;;,:,." •. assesses ISN IS6 and calls for nurse;
l~:OI"'O usc J 110ll,ltX'UIlXlXCI
I
begin ocrfonninl! chest compressions withl' ,(tt~~"'l.-nC~ '. Iproviding rescue breaths
b arrives and determines urther assistance is needed
Re..istercd NutSe~Registered Nurse \D~~~l(b'f1!igo, is called
lC~i~(fil ~b~.nlir.~v .
ives an asscsses ISNI56: dctcnnines an ambulance is reouired
Ambulance is dispatched
ISN156 is seeured to buckboard
Ambulance arrives
!SN156 is loaded inlo ambulance and taken to BHU/DH
Ambulance arrives at BHU
~.;~'~'f7" I . delennincs to send ambulance 10 NAVSTA Hosoital
Ambulance deoarts for NAVSTA HosDital;l ,c'(i:'&\ll:~&)·'·loerformin2. basic CPR
Ambulance arrives NAVSTA Hospital and ISN 15f1 taken IOto emergency room;
emer~eney room doctors take ovcr
ISN\56 is Ptonounc.cd dead
ISNI56 body is transported to morgue

-

-

140S

1406
1411
1412

ISN156 stam move from Detainee Hosoital BED4·DH 10 Camo V
ISN156 arrives Camo V Cell 5A 105
ISNlS6 floods cell
ISN156 begins bancing on cell door, causine. a racket on Aloha (Lower) Block
ISNI56 eats dinner- rice. beef. shrimo, SaUD, and aoole iuice
ISNI56 speaks with AOIC about rcspeet issues; conversation ends with AOIC
explainino: that it would take comoliance and resnect to remove the solashbox
ISNl56 be 'ins alterin' cell and coverin' {b)(7)(E) with a food substance
JSNI56 aooears to fall asleep

,

0800
,

Events

•

--

28
SEcr:':':T.:7:0 FO ::.':

~;nl!OUSC5m~.

'txe;]'ll7~C)

 SECRET,"':-\GTeR~~

11. (U) Listing ofISN156's Recent Prescribed Medications
A. (U) Prescribed, As-Needed Medicutions

117. (b'HFOUO) Table 2 renec!s prescribed PRN 100 medications for ISN 156 beginning in 2010
through his death on 8 September 2012. 101

(uNFOUO) Table 2 - PRN Medications for ISN t56 (September 201 0 - September 2012).

,
Prescribed
Stgn Date9 Sen 2010
9Sep2010

Tucks nads
Sea Soft nasal spray

9Sep2010

Hydrocortisone suppository

28 Sep 2010

Proctosol -

21 Dec 2010
20 Feb 2011
18 May 2011

HibicJens wash
Surra.1.:.
SeroqucJ

23 Dec 201l

Clotrimazole cream 1%

23 Dec 2011

Hydrocortisone crcam 1%

23 Dec 2011

Euccrin Cream

23 Dec 2011

Claritin

Name of Medication

Dosage

I 1 nad, once a da '. at nil'ht

12 sprays each nostril, twice a day, as needed (for
drv nasal pa~sap'es\
Per rectum, four times per day, as needed (for
hcmorrhoids)
Apply to rectal are\~wice a day, as needed (for
external hemorrhoids
As needed for lel'''~
240 me, bv mouth, once a day. at nioht
50-100 mg, by mouth, three ti~)es per day, as
needed (for anxietv or a ·itation
Apply to afiected area, twice 11 day, as needed
(for rash) (should usc for 1-2 weeks, i~l~ot
efTective, rec uest nrovider annointment
Apply to affected area, twice a day, as needed
(for itching) (not to exceed four doses per week
without doctor's review)
30 ml, apply to affectcd area, twice a day, as
needed (for dry skin) (not to exceed four doses
I ncr week without doctor's review)
10 mg, by mouth, once a day, as needcd
(rhinorrhea, sneezing, watery eyes) (not 10
exceed four doses pt:r week without doctor's
review)

He 25%

100 ~...:,rr8T::i8) "PR!'>:'" indicates "as need..:d"' medications and items, and arc different from the scheduled, prescribed
medications reflected in Table 4. 50l11e medications and items on the PRi"J Meditations Records arc "over the
tounter" items (such as ice, lape, or Tucks pads), but sonIc require a prescription (such as Haldol, Percocet, and
Tylenol with Codeine). In eilher case. a detainee could request PRN medications from a corpsman or nurse on an as
needed basis, and so long as tl1e medic:ltion and request was consiSlent with what was reflecled in Inc PR.'N
Medications Records for the detainee, lhe corpsm'lrl or nurne was authorized to dispense it. Accordingly, a detainee
would not necessarily be taking all the PRN medic~tions at one time. The rRN Medications Records also contain a
column where the corpsman or nurse indicates when a detainee took a particular PRN mediealion (sec Table 3,
below). The information in Table 2 was compiled from PRN Medications Records for ISNI56. (Exhibits 50, 97)
101 (t"NfeUe, A reference of medical I phannneologiclIlllbbrevifltions and their meanings is included as Exhibil

117.

29
SEGRET::?iS:-"OR::

 :EGF£T:,":orO:1:?i
Dooag,

Prescribed

Name of Medication

Stan pate
23 Dec 2011

Ce:pacol

23 Dec 2011

Pepto-bismol

23 Dec 2011

Tylenol

23 Dec 201 I

Mylanta

23 Dec 2011

Milk of Magnesia (laxative)

23 Dec 2011

Zantac

23 Dec 2011

Robitussin

23 De<: 201 1

Ensure:

23 Dcc20ll

10,

29 Dec 2011

Zofran

29 Dec 2011

Tap<:

23 Jan 2012

Pereocet

25 Jan 2012

Flonase

14 Feb 2012

Naprosyn

14 Mar 2012

Atamx

25 Apr2012

MOlfin

1 lozenge, in mouth, every six hoUl'S, as needed
(for sore: throat) (not to exceed six doses per
week without doctor's review)
2 tabs, by mouth, four times per day, as nceded
(for minor abdominal distress) (not to exceed
four doses ner week without doctor's review)
650 mg, by mouth, every four hours (minor
aches and pain, heaililche) (nO! [0 exceed two
doses per day without doctor's order)
15-30011, by mouth, every six hours, as needed
(for heartburn or indigestion) (not to exceed four
doses [ler week without doctor's order)
30 ml with 8 ozofwater, by mouth, twice 3 day,
as needed (for heartburn or indigestion) (not to
exceed four doses per week without doctor's
order)
ISO mg, b)' mouth, twice a day, as needed (for
heartburn or indigcstion) (not to exceed four
doscs Ilcr week without doctor's revicw)
to 011, by mouth, four times per da)', as needed
(for cough) (not to exceed four doses per week
without doctor's review)
1-3 cans, three times per day, as needed (nol to
exceed four doses per week without doctor's
review)
Apply to affected area for 15 minutes, four
times ocr day, as nceded (minor iniu~)
4 mg, by mouth, every six hours, as nceded, for
five months (for nausea)
Buddy tape right second digit to right big toe,
for four weeks (for stabilitY due to iniurY)
I lab, by mouth, every six hours, as nceded (for
severe back pain)
2 sprays each nostril, twice a night (prior to
enteral feeds)
500 mg, by mouth, twice a day, as needed, for
for four weeks (for oain)
SO mg, by mouth, once a dny, for ninety days
I (for itch)
400 mg, by mouth, every six hours, for thirty
davs
oain)

rio,

la:: (t,0'!fQts'Q) There is also 1I laler stan dale for Percocet, 30 AugusI2012, for the same dosage but for "pain" as
opposed to scvere back pain." (E..-rnibil 97)
M

30

:::CRE. ,.:riO:-e:Ci

 SCCRE. :::-iorORN
Prescribed
Start Date
14 Jun 2012 u~

I

Name of M~dicalion

Dosage

Bcnadryln.

14 Jun 2012

Ativen

[4 Jun 2012

Haldol

25 mg, intramuscular, every eight hOlies jlS
needed (WITH Haldol) (NOTlryl
PRIOR TO ADMISTERING) lOS
2 mg, per ornl or intramuscular, every four
hours. as needed (for acute an.xiety) (NOTIFY

----1-. -

·.tIllJl;IO usc ~m~

- PRIORCW ADM[NISIER~G)

lIl':{J)'lO

19 Jun 2012

Triamcinolone

19 Jun 2012

Vaseline

1 Jul2012
25 Jul 2012

Lactosc·free milk
Selenium shampoo

25 Jul2012 l llC>

Senadryl

25 Jul 2012

Ativan

26 Jul2012

Haldol

29 Aug2012
29 Aug2012

Anifieial tears
Erythromyclin ophthalmic ointment

31 AUl!2012
7 So 2012

Tvlenol with codeine
Tylenol #3

-

IPRIOR-TO__

--

-

ADMINISTERiNG
Orabase dental paste, at night, up to three times
Der day, durin.. day
Offer Vaseline I petroleum jelly, three times per
day, as needed fior drY lins)
25 oz.. bv mouth, once a dav. as needed
30ce. apply to hair. two times per week, as
needed
25 mg intramuscular injection (to be given with
Huldol per medical officer)
2 mg, by mouth or intmmuscular injection,
cvcrv four hours, as needed (agitation)
10 mg intramuscular injection daily, as needed
(for agitation) (to be given with Benadryl per
medical officer)
1 drop. left eye, four times er day, as needed
11/4 inch strip inside lower eye lid,left eye, each
night
I 1 tab. bv mouth. once a dav. as needed for oain
I I tub. bv mouth, once a dav, as needed (for nain)

tOl (L'/;'f8U8) As noted above, 14 June 2012 is the ulIle that ISN156 hau a Ielephone call with his attorney
following the Supreme Court decision on II June 2012 denying his petition for a writ of cer/iorari in his habeas
(tlHJ).tO usc
corl!...ll! proceedings. _The..Camp V Olcl- -' -.
indicated that ISN 156 came back furious and saying ··cr.!.Zy
§lJOtll~~Hll)(')-sl~[f" alier the call. The phone call with IllS Illwyer IS cited as the beginning ofthc most f(..'Ccnt downward spiral of
ISNI56. (Exhibit 16)
I(l.\ ('z'fWQVQ) A series ofthree injections, Bcnadryl (10 eountcr:J.ctlhe effect of itching caused by the Alivan and
Haldol), Ativan. and Haldol are considered "emergency medications." (Exhibit 97)
lOS (' "'VOl '0) The all caps appear in the original PRN Medications Records. (Exhibit 97)
106 (b'Vf'Q's'Q) 25 July 2012 is the date of the "rock-throwing incident" detailed above, when ISN 156 threw rocks lit
Camp Vt guards and recreation lower. ISNJ 56 was transferred 10 the BOO as a result aflhe incident. Later that
same day. 25 July 2012, ISN 156[
(b)(r)(El,(b)(l)(F)
I 1blt7/1El.lbil'7HFl
I (Exhibits 53, 54. 57. 58)

I

I

31

usc § nOb.

(b)l6llbXiJlC)

10 mg, intramuscular, every eight hours, as
needed (for agitalion, WITH Benadryl)

(NOTIFyl

(~Xe),lbXi)l,C)

_.J~Dl-JOUSC

§IlOb

(b~ene)(7~C)

 s::c:K:r....~: c:-: ::~:
118. ELt,l,q"'OUO) Table 3 reflects the "High-Risk DEA Classified Drugs" that were on lSNI56's
PRN medications chart, und that he requesled and took in 20t2. 1Cf7
(L'I:q:gUO) Table 3 - High-Risk DEA Classified Drugs for ISN156 (20l2).

(HI,CFOUO)
Date and Time of
Admini!:l1mtion lOS
2S Jan 2012 2000
26 Jnn 2012 1300
26 Jan 2012 2235
28 Jan 20121930
30 Jan 2012 2004
3 Feb 2012 0330
23 Jul2012 0001
28 Au!! 2012 0130
28Au 20120530
28 Aug 20121445
28 Aua.2012 2045

29Au.20122030
29Au 20122040
29 Aug 2012 2045
31 AU2:2012 0508
31 Au 20121445
31 Aug20120015
2 SeD2012 1003
3 SeD 2012 0505
4Se 20120205
5Se 20120630
7 SeD 2012 0120
2 Aut!. 20 120705
4 AuQ. 2012 0155
25 Au' 2012 2200
26 Aue. 20 12 0500
27 Au!!: 2012 0500

6 Sen 2012 1500
2Aul!2012

1

Drug

Quantit)·

Pereocci
Percocet
Pcrcotel
Percocel
Percocet
Percocet
Percoce!
Percocet
Percocet
Percocet
PercQcct
Pcrcocet
PcrcQcct
Percocei
Pcrcocet
Percocet
Tylenol wilh codeine
Tylenol with codeine
Tvlenol with codeine
Tvlenol with codeine
Tvlenol with codeine
Tylenol wilh codeine
Ativan
Alivan
Ath'an
Ativan
Ativan
Ativan
Haldol

I tab
I tab
I lab

Itab
I tab
I tab
I lab
I tab
I tab
I lab
\ tab
1 tab
1 tab
I tab
I tab
I tab
I lab
I tab
I tab
t lab
I lab
1 lab
I tab
1 tab
I lab
llab
I tab
I tab
10 mg. by injection

iLl.reUO) According to the SOP, Pcrcocet., Tylenol \\1m Codeine, and Ath'3n wen: drugs that w~ (b)(7)(E)
(DXIltE)
As discussed 11Ite:r in the report, not all nurses and
(b1(fME)
)Altbough the: Invcstigntive Te:am analyzed all medic:ations 00
the: pm Me<hc:atlons RecordS tor ISNI,6. lor the: purposes ofthe report. a uable n:Oecting only the most medically
signifiennt m«lic:ations, specifically, narcotics, is include:d. The information for Table 3 is compiled from the PR,'l
Medic.'tions Re:cords for ISNI56. (Exhibits 50. 97)
101 (15:'/FEll:/O) "Administmtion" is used as opposed to "Ingestion." Based on interviews with nurses and corpsmc:n
regarding current practice within the camps, the PRJ>I Medications Rcpons indicate when the medication is provided
to the dctainee, not necessarily .....hen hc ingests it.
LOl

I (bX7XE) land Haldol and Seroquell

I

r

32

SESlET'?"O:-O:'_":

I

 SE::HET:,";'iS;:-;;:C;
Date and Time of

Drug

Quantity

26 Jan 2012 2220
28 Jan 2012 0000
28 Jan 20121930
30 Jan 2012 2100
1 Feb 2012 2000
3 Fcb20122100
5 Feb 2012 2030
7Fcb20122010
9 Feb 2012 0100
lOFeb20122100
11 Feb 2012 2000
14 Feb 2012 0000
15 Feb 2012 2000
16 Feb 2012 2030
17 Feb 2012 2100
19 Feb 2012 0000
20 Fcb2012 2000
23 Feb 2012 2015
24 Feb 2012 2315
2S Feb 2012 2322
26 Feb 2012 2200
27 Feb2012 1909
3 Mar 2012 2100
4 Mar2012 2230
7 Mar 2012 2056
11 Mar2012 2315
1lV
XX Mar 2012 OOl5
14Mar20120015
21\pr20122200
3 Apr2012 2000
13 Am 2012 0000
14 Anr 2012 0000
18 Apr 2012 0000
18 Apr 2012 2050
191\0r2012221)

SeroQucl
Serooucl
Scroaucl
Sera ucl
Seroauel
Scroauel
Sero uel
ScraCluc]
Seraaucl
ScroClucl
ScrOQuel
Seroauc1
Seroauel
Seroqucl
SeroQllel
Scroouel
Seroauel
ScroQucl
SeraQuel
Scroaucl
Scroquel
ScrOQuel
Seroauel
Seroouel
SerOQucl
Scroaucl
Seraqucl
SerO<lucl
Seroauel
Seroqucl
ScroQLtcl
Seroauel
Sera uel
Seroauel
SeroQuel

100 mg
lao m.g
100 mg
100 rnl!
100ffin100 m.\!
100 me.
100 ffit!
100 ffiQ
100 rna
100 rna
100 ill\!
100 m.g
100 mg
100 mg
100 m\!
100 mg
100 mg
100 me.
lOa mg:
100 mg
100 mn100 mg
100 ml!
100 mg
100 mg
100 mg
100 mg
100 mg
100 mg
100 mg
100mg
100 m
100 m.!?
100 mg

Adminis!mrion lOS

lQ9 (LiSF8ES) 2 August 20121
(b)(7)(E).(b}(I}{F)
1From the entries on the Medication
Administration Record (MAR), it appears thut the Haldol was givcn via injection. This is consistent with swom
statcments indicating that a nurse administered emergenc), medications to ISN 156 following the incident. (Exhibits
11,17,99)
110 (U"T8U8) Likc virtually all entries on the PRN Medications Reports, the date is very difficult to read, and is in
fnct illegible, but appcMS to fall betwccn II and [4 March 2012 and 14 Mar 12. As discussed later in the report,
because of the way the PR.,"l Medications Reports are structured, it is extremely difficult to reconslruct a chronology
of when a particular medication was taken. These tables reflect the Investigative Team's effon to do so. (Exhibit
97)

33

 ::£CR£T:.?iC~2~:-·

Datc and Time of
1os
Administmt"ion
23 Aor 2012 0000
4 Mav 2012 2300
7 May20122109
JOMay20l22213
15 Jun 2012 0015
16 Jun 2012 0020
17Jun20120021
17 Jun 2012 2300
19 Jun 2012 0020
20 Jun 2012 0205
22 Jun 2012 0145
22 Jun 2012 2405
16 Jul2012 0000
18Jul20122200
26 Jul2012 2010
30 Jul2012 2020
3Aug20120155
13Aug20120155
25Aug20122105
27 Au' 2012 0005
28 AU1l2012 0550
30 AulZ, 2012 2345
31 Aug 2012 0508
I SeD 20120820
2 SeD 2012 0530
3 Scn 2012 ‫סס‬oo
3 Sep 2012 2115
4 SeD 2012 0945
4 SeD 2012 2240
5 Sep 2012 0940

Drug

Quantity

ScroQucl
Scroauel
ScroQucl
ScrOQucl
Scroaucl
Scroauel
Scroaucl
Serooucl
Scroaucl
Serooucl
SCfOQucl
Seroquel
ScrOQuel
Scrooucl
Seroouel

100 mg
100mt!:
100 mg
100 mg
100 m'
lOOml?
IOOmg
100 rnll
100ml!
100 mf!
looml!.
100 mg
100ml?
100 ml!
100mp
100 mg
100m'
100m·
100 mg
100ma
100 ml!.
100me
100ml!
100 me.
loa ml!
100 ml!
l00mg
100 me.
100ml!.
100 mt!:

So<

uel

Seroauel
Seroouel
Seroouel
SerOQucl
Seroauel
Seroouel
SerOQuel
Seroaucl
Seroaucl
Seroouel
Seroquel
Scroauel
Seroouel
Seroaucl

111 (iH/FOUO) The SOlan size of the boxes on the PRN Medications Reports sometimes makcs it difficult to discern
whether 11 d:l!e is for "Jan" or "Jun", or';Mar" or "'May". for example. (Exhibit 97)

34

 ::c::.::':: ?:OFQ :1?i
B, (U) Prescribed, Scheduled Medications
119. (L'/.TO'JO~ Table 4 reflccts prescribed, scheduled medications for ISNI S6 thai he was
prescribed at the time of his death on 8 Scptcmber 2012. t12

(U;rrOBO) Table 4 - Prescribed, Scheduled Medications for ISNlS6 (S -8 September
2012).1IJ

,

,

Prescribed
Start Dare
14Ju02012

14 Jun 2012

Dale and Time of
Administrnliontl~
5 Sep 2012 0430
5 Scp2012 2200
6 Scp 2012 0430
6 Sep 2012 2200
7 Sep 2012 2200
8Se020120430
5 Sep2012 0430
5 Sep 2012 2200
6 Sep 2012 0430
6 Sep 2012 2200
7 Sep 2012 2200
8 Seo 2012 0430

14 Jun 22012

NONE

14 Jun 2012
14 Jun 2012

6 SeD 2012 2200

14 Jun 2012

5Sep20122100
6Sep20122100
7Sco20122100
7 Sc 20122100

Drug

Dosage

Zantac

1 tab, by mouth, twice a day

Lidcx Cream

Apply to lesions. twice a day

Benzoyl Peroxide
Solution 10 %
Salicvlic Acid Wash
Calcium and Vitamin D

Use in s.hower daily

Apply to lees. twice a day
I tab. by mouth, every da)'

Glucosamine I

I tab. b mouth, everv day

Il~ (b"q:QtiQj As noted abo\'e, prcscribcd, scheduled mcdications are distinct from PM' medications. The
scheduled medicationS:lre olTercd to the detaim.'e at particular times each day based on the doctor's order. (Exhibit
99)
111 (b"<fQUQ) The information for Tablc 4 is compiled from the Medications Administration Records for ISNI56,
(Exhibit 99)
11. tHTee8) Because none orthe scheduled medications appeared on the "High-RiSk DEA Classified Drugs~ list
(see Table 3), Tablc 4 only reflects thc dates and timcs ofndministration going back three days from ISNI56's death
on 8 September 2012. As with lhc PRN Medications Records, -administration" is used as opposed to "ingCSlioo".
Based on testimony from guards and corpsmen.ISNl56 did not lake any medications aller 2200 hours 7 Seplcmber
2012, as he appeared. asleep the entire time. II appears the Medication Administration Record for 7 nnd 8 Seplember
2011 is improperly c-ompleted as it indicates thatlSNI56 accepted medications during that time. which is
inconsistent with the st:1temenlS and photographs. Based 00 the fuct that there .....ere medications in pill cups in the
splashbox oflSKI56 at the time of his death, it is possible that the MAR is reflecting whcn the medications were
offered to the detainee: (i.e.• were left in his splashbox). nol whcn ISNl56 accepted them. Those medications after
22007 Seplember 10 12 are included in Table 4 because the)' ....·cre disco\·ered in his splashbox following his de:uh.
(E.mibits I. 6, 8.9.10,23.99.129)
II' EU'.T8l'Q) ISNI56 refused certain scheduled drugs from 5 to 8 September 1012. In such cases. Table 4,
Column 2 reflects "NONE."

35
:::CFtET '::-:O~OR:-:

 S:CRE7,:?iOfS::,?:
Prescribed
Slart Date

Date and Time of
l14
Adminislmtion

19 Jun 2012

5 Scp 2012 0800

19Jun2012

19 JUIl 2012

19 Jun 2012

S Scp 2012 2100
6 Sep 2012 0800
6Sep20122100
7 Sep 2012 2100
8 SeD 2012 0800
5 Sep 2012 0800
5 Sep 2012 2100
6 Scp 2012 0800
6 Scp 2012 2100
7Scp20122100
8 SeD 2012 0800
5Sep20120430
5 Scp 2012 2200
6 Scp 2012 0430
6 Scp 2012 2200
7 Scp2012 2200
8 Seo 2012 2200 116
SSep20122100

Drug

Do"",.

chondroitin
Colace

100 mg, by mouth, twice a day

Hydrocortisone
suppository

Insert by rectum. lwice a day

Hydrocortisone 2.5%
Rectal Cream

Triamcinolone in
Oralbase Demal Paste
,
Remeron

2S Jul2012

5 Sep 2012 2200
6 Sep 2012 2200

27 Jul2012

6 Sep 2012 [no time]

Throalloz.enges

22 Aug2012

5Sep20120430
6 Scp20t2 0430
7 Sep 2012 0430

Invega

Each night (over lower lip)
15 mg. by mouth, each night, for
three months

7 SeD 2012 2200

Offer every 4 hOUlS, while awake,
for sore Ihroat
9 mg, 11& by mouth, every morning

8 Se.2012 0430

116 (C',T8tif)) II appe31'5 thaI the corpsm3Jl initialed in Ihe ....TOng box as ISN156 was no longer in his cell by 2200 8
September 2012.
lU fE'.TOlO) Remeron and Jnvega were the onl)'I",o scheduled. ps)'ehiatric medications that ISNI56 was taking al

the time of his death on SSeptember 2012. (Exhibit 24)
fndiC3ted thai starting 22 AuguS12012, the Invega dose w.lS made up of two ClIpsules-o.
one 3 mg capsule and one 6 mg capsule. (ExhibiI24)

M3f10USCI.I'..~t!&LeeO~-.
(t);.}lDX111ci

36

 ::::G:l£T::?i OreR?i

c. (0) Administration oflnvcga
120. (Uf,'fOUO) Table 5 reflects the administration times and dates of Invcga for ISNI56. which
prescribed start date was 21 August 2012. (Exhibit 99)

(UHFOU03 Table 5 -IJlvcga (21 August 2012 - 8 September 2012).119
(UJ.!P'OUO)
Prc..<;,cribed
Start Date
21 Aug
20 12'2~
22Aug2012

Date and Time of

Drug

Dosage

NUmber of Total

Adlllinistrntion
21 Aug20120430

[nvcga

6 mg

CSDsulcs in Dosapc
I

22Aug2012 0430
23 Aug2012 0430
24 Aug 2012 0430
25 Aug2012 0430
26 Aug 20[2 0430
27 Aug2012 0430
28 Aug 2012 0430
29Aug2012 0430
30Aug2012 0430
31 Aug 20120430
I Sep 20120430
2 Sep 20120430
3 Sep 20120430
4 Sep 20 12 0430
5 Sep20120430
6 Sep20120430
7 Sep 2012 0430 111
8 Sco2012 0430 ln

rnvega
Invcga
[nvcga
[nvega
Invega
Invega
Invega
Invcga
lnvega
Invega
Invega
Invega
Invega
Invega
Invega
Invega
Invcga
(nvc 'a

6mg
9mg

I

9mg

2
2
2
2
2
2
2

9mg

2

9mg
9mg
9mg

2
2
2

9mg

2
2
2

9mg

9mg
9mg
9mg
9mg

9mg
9mg
9mg
9mg

9 m.

2
2
2

119 (LY/rSliS) The information for Table 5 is compiled from the Medicalion Administration Records for ISNI 56.
(Exhibit 99)
110 P J'Qho r '0) There are two prescribed slart dales reflected for lnvega. On 21 August 20 12~ordt:rcd ...
. _ It:Oi lllVSC §\:;c~
(D~ltIOVSC_m~. _15"']5_6 on.J!..dQsc_o(6J1lg. _On22.Augusl: 2012J··~hangcd the Inve a. dose to 9 mg.~)
(DX6)(b){7XC)
(tmlli;axCl
121 (CTSb"8) The Mcdication Administration Record indic.ltes that !1~'1il~~!','Ml adminislcred thc daily l~
dose to ISNI56 at 0430 on 7 Septembcr 20 12. 'nmltime is inconsistcnt \\1t t e Information provided by
- - - " ;Ol(l).JRYSC§1l00
(o:O~lovsc§.l;ko--·
~n her st'l.temen~. in w.hich she indieilted thallSN IS6 initiallv
\0;
.!; ~os~ oflnvega \nat morning, ut t 1M
I01l61101l1:1C)
to~6).(o)7;(C)
she was able to convmce hun around 1100 or I J 30 to take them.
-,,- .. mdlcated that shc.watched lSNl~&
lb~3PD usc §13CD,
take the capsules, put them in his mouth. drink water, llnd swallow them. (E' libit 28)
ibi(6l.l0Xl)(C)
.- fdminislCred __ tbX!tloysqlJOl>.
1:2 (C:.'f9UO) The Medication Administration Record indicates that on 8 September 20J2~
9 mgofln....egll to fSNJ56. ItappcafS that ISN156 did not ingest the dose, as NCIS photos Ollhc cell and splashbox
(tX61,(bVXCI
indicate two C:lpsules oflnvcga (3 mg and 6 mg) in a pill eup in the splQshbox. NCIS arrived at the scene and took
the photogl1lphs at that time. (Exhibits 99,129)

37
SECR£T::?:orOR~i

 SECft£T,'/NOf6RN

In. (V) Cause of Death of ISN156:

121. tu/IfOUO~ The Armed Forces Medical Examiner (AFME) determined the cause of death
oflSNI56 to be suicide by paliperidone toxicity.123 The AFME noted that resuscitative efforts
were initiated at the scene and that ISNI56 was transported to the hospital,.where he was
pronounced deceased. The AFME review ofmedical records showed a history of multiple
psychiatric disorders, suicidal ideation with previous attempts~ intentional harm to others and
reported traumatic brain injury. The autopsy examination showed a fracture of a rib, compatible
with resuscitative efforts. An examination ofthe lungs showed acute bilateral pneumonia.
(Exhibits 130, 131)
122. flJ!JfQ~Q3 The toxicology examination revealed the presence ofpaliperidone (Invega),
codeine (Tylenol #3), oxycodone (Percocet), quetiapine (Seroquel), mirtazpine (Remeron), and
citalopram (Celexa) in the blood ofISN156. Morphine (by-product ofTylenol #3).
oxymorphone (active ingredient in Percocet), and lorazepam (Ativan) were present in the urine
without detectable blood levels. (Exhibit 131)
123. EtJI;LFQQQ) The AFME was not able to determine a precise time of death for ISN 156, 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)
124. EUJWQl::JQ) The AFME concluded that ISNI56 died ofpaliperidone toxicity resulting from
an overdose. The AFME determined that it is uncertain to what extent the. acute pneumonia
contn'buted to the death of ISN156. The AFME indicated that "no eviden~e was identified to
suggest that [ISNI 56's] actions were other than purposeful and self-inflicted." (Exhibits 130,
131)

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

125. Q' wEm 10) The commander of Joint Task Force - Guantanamo (JTF-GTMO) is Rear
Admiral John W. Smith. The deputy commander ofJTF-GTMO is Brigadier General James
Lenko. The chief-of-staffis Captain William Docherty. The mission statement for JTF-GTMO

\23 Paliperidone is the pharmacological name for the brand name drug Invega. The certificate ofdeath is in the
name oC"Ad-Rahman, Allal A:' The name that is attached to ISNI56 atJTF·GlMO is "Adnan Farhan Abd AI
Lalit" The AFME indicated that the Federal Bureau ofInvestigation (FBI) determined that the fingerprints on the
person ofISNI 56 matched an individual known as "Ad-Rahman, AUal A." An internet search reveals several
names very similar to Ad-Rahman as aliases for Adnan Farhan Abd Al Latif. (Exhibit 130)

38
SECRETNNOFORtI

 SECRET.'.'NOFORN

is 1) safe, humane, legal, and transparent care and custody of detainees; 2) intelligence
conection; and 3) commissions support. (Exhibit 69)124

v. (U) Joint Detention Group (JOG)
~

(U) Leadership and Command Structure

126. ~!;!IiQ{.J~ The commander ofthe IDG is COL John Bogdan. COL Bogdan arrived at
JTF-GTMO 29 May 2012, and took command on 7 June 2012. The JOG and the Joint Medical
Group (JMG) fall under the command and control of JTF-GTMO. 12S (Exhibits S, 69, 108)
127. f'::J!J.fQWg~ The JOG is composed ofa 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. EY!;l;Q~Q~ The 525th MP BN is ADCON to United States Anny South (ARSOUTH), and
TACON to JOG. (Exhibit 4)
129. @:J:("QUQ~ The commander of the 189th Military Police Company (189th MP CO) is

§1-'ibjl5),(b)

Il6:d)::~,~}~:go6'16l (ll)(3af~:l~:..g~~~OIl. is also the Camp V OIC. The 189th MP CO is an active duty unit

and provides the guard force for Camp V and Camp Echo. She arrived at JTF-GTMO December
2011, took over Camp V on 15 February 2012, and took command ofthe I 89th MP CO on 23
March 2012. She is currently the most senior OIC of the camps at GTMO. (Exhibit 16)
130. eu!i't'6U~ The 19300 MP CO is an active duty unit, and provides the guard force for
Camp V and Camp Echo. (Exhibit 4)

131. (Hj,~Q{.JQ~ The commander ofthe 314th Military Police Company (314th MP CO) is 'm~~~~~f

I(6j{9}J~(~~&}fJe) IThe 314th MP CO is a reserve unit out of Southern California. The 314th MP
CO provides the guard force for the BHU, DH, Cam I na, and Camp VI. (1lJ(?~lc~).~~:6~OIl. is
also the OIC ofthe BHU. DH, and Camp Iguana. (IIXC~)(~.~~;~~~all. arrived at JTF-GTMO 14
December 2011. At the time of the report, the 314th MP CO had redeployed. (Exhibit 18)

1%4 @iJ8;QUQ) CAPT Docherty provided the slides to the Investigative Team on 1I September 2012. The slides
themselves arc undated. One slide titled "Detention Conditions: Soft" lists as a bullet "Troops adhere to SOPs."
Adherence, and the lack. thereof, to SOPs is discussed at length below in this report. (Exhibit 69)
125 JDG Procedure 1#2, Command and Control establishes the procedures for Command and Control ofthe JOG.
Paragraph 2-4c, establishes a "Field-Grade-in-thc-Wire" Pro
to rovide leadership presence in the cam s
ni tl.
(b}(5)

39
HE'CRE'fHPi8F8fUi

 SECRET/mOPQR?:
132. €W/JfOHO~The 348th MP CO is a reserve unit out ofIowa, and provides the guard force
for Camp VI. (Exhibit 4)
133. flJ"q;QHQ~ The 755th MP CO is a National Guard unit out of Pueno 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. EY/~QYQ) Together, the 189th MP CO, the 193rd MP CO, the 314th MP CO, the 348th
MP CO, and the 755th MP CO fall under the command and control ofthe 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 V houses compliant and non-compliant detainees in single cells and communal
blocks. as well as a Drisoner DODulation in smele cells. l26 ,

(b)(1 ).(b}(3):1 0 USC 130b.(b}(6),(b}{7}{C)

I (Exhibit 16)

L-

.....

136.~ The BHUIDH

houses mentally and physically ill detainees. as well as long-tenn hunger
strikers, in single cells.J
(b}(1).(b}(3}:10 usc 130b.(b)(6),(b}(7}(C)

'-----------------------------~

1128

C. (U) Training

137. EU/~QUQ) Ultimately, the IDG is responsible for training camp guards. The 525th MP
BN, specifically, the 83 section, conducts the actual training over 12 days, with the final two
days being on-the-job training (OJT). (Exhibits 4, 70)

(Y/R!QWQ} Because ISNlS6 was housed at Camp Vat the time of his death and was transferred from the DH the
clay before, only the guard structures for Camp V and the BHUIDH are set forth in the report.
127 tul.q:e"S) Alpha (Upper) is empty. (Exhibit 16)
(D;o):10USC§13J1L.~~.6-!ttfl~ilelAllhouglulOtincJudedin-his statcmenf-- ._.
'provided the infonnalion during a telephone
CbX6}CbJ(7XCl
call with the Investigative Team on 12 October 2012.
126

40
SECRETNNOFOR?l

 SECUET/mSF6RN

138. ~U{;lr8UO' At the end ofthe 12 days, the guards must pass a Job Qualification
Requirement (JQR). The JQR 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 / work station duties. Fundamentals covers such items as block
cleanliness, rules for the use of force, and detainee discipline levels. 129 (Exhibits 4, 71, 72, 73,
74, 75, 76, 77, 78, 79, 80,81)
139. tuf,'FSU6) The 200 Section, Basic Knowledge, is designed to acquaint Soldiers with the
systems they will be required to operate at the guard post / 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. fY//#g\J~ The 300 Section, Guard Posts, is made up of tasks Soldiers are required to
satisfactorilyperfonn to pass the final JQR. Guard Posts includes sections on how to properly
conduct a cell search and open feed tray slots.J3° (Exhibits 4, 71, 72, 73, 74, 75, 76, 77, 78, 79,
80,81)

141. EU'/FOUO, Training for the BHU/ DHU BNCOs and DIMS operators is divided into four
sections. The 100 section, Prerequisites, is similar to the 100 section for the JOG Pod / Block
Guard JQRs, and cover SOPs and other directives necessary to understand the watch station.
(Exhibits 4, 82, 83)
142. flTAq:ggg) The 200 Section, Camp Specific Knowledge, includes sections on weight

refusal and hunger strIker protocols, detainee restraint levels, and priority offorce. (Exhibits 4,
81,82)
143. ~/,(fgUg) The 300 Section,lntroduction to Watch Standing is made up of tasks Soldiers
must satisfactorily perform to pass the fmal JQR. (Exhibits 4, 82, 83)131

(b)(3):10U~~130
(b)(61.lb)(7XC)

129 ttf(;¥8t;'8) While the front page and other parts of the training packets slightly vary between the JDG p~
Block Guard. the NCO, and the WC/AWC JQRs. the substance ofthe training is very similar. The training 0
.._-- ll.l(3l:.tll usc 5130b
fappears to have been conducted
by the NEGB on 2 August 2012 for duty at Camp Iguana. Again, althou
(b)(61.1bll7l1C)
., packcts sI'18btlYvary, th e substance 0 f t
h···
·
II'd . I
the IrOnt page and other parts ofthe traiJUng
e tralnmg
IS Vlrtua Y1 cntlC8
to the training for other camps.
130 ~Hi'9\;8~ Training on line of sight duty is not listed in any of the three sections. Also not listed is any training
by the JMG to provide an overview of the JMG operations and expectations ofthe guards with respect to JMG
0Rerations in the camps. This item addressed in the Recommendations ofthe report.
1 ~Ii'F9W9) The training for the JDG Camp Guard Force and the JOG BRUIDH Guard Force is very similar
except that the JOG BHUIDH Guard Force JQR includes two sections covering systems (Sections 200 and 300 one general and one specific to the BRUIDM) whereas the JDG Camp Guard Force JQR includes only one section
(Section 200).

J-.'

41

 144. fU/jq;OI:::lO~ The 400 Section, Watches, which is similar to the 300 Section ofthe JD.G
Camp Guard Force JQRs, is the validation section where the Soldier must complete the tasks
required to pass the final JQR. (Exhibits 4, 82, 83)
D. (U) JOG Standard Operating Procedures (SOPs)

145. Ell/WOVO) There are a total of90 JDG SOPs governing a wide range ofdetainee
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) JOG Procedure #27: General Guidelines for Camp Operations

146. fU/JfOlJO) JDG Procedure #27 addresses General Guidelines for Camp Operations. The
SOP notes that "fair, fum, and impartial enforcement ofrules and regulations facilitates the
control of detainees." The SOP also notes that "[c]ustodyand control measures maintain good
order and discipline and protect the welfare ofall camp personnel and detainees alike."
Specifically, security requires all personnel to "continually maintain an effective working
knowledge of rules, regulations, and special orders; maintain constant vigilance throughout their
daily duties; review/evaluate procedures.,,133· (Exhibit 40)
147. EY/.lPQ\JQ) Several guards and medical personnel indicated a lack of familiarity with
specific provisions of various SOPs. (Exhibits 9, 10, 14, 18,20,24,28)
148. (WIfOWO) Other guards and medical personnel indicated that although they were familiar
with specific provisions ofthe SOP and what the SOP required, they did not always follow the
SOPs. Indeed, guards indicated that enforcement ofthe SOPs is one ofthe biggest challenges
they face at JTF_GTMO. 134 (Exhibits 1,6,8, 18,25)

I

149. EU'J¥QgQ) The Camp V OIC (b'?J~:)~~J~~Ob. noted tha~
(b}(7}(E)
inconsistent application of SOPs to ISN156 caused "stress on the guard force" and also ISNI56.
(1l~lJ(1J'~~:~) b, dicated that she was frustrated that "consistency" was the "watchword" and yet,
132 tuJi'F8f:l8) Although the current SOP Version List goes to 9S. three ofthe SOPs are archived and two are not
used, for a total of90. The JDG 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 significant projects
since taking command has been to "update and synchronize the SOPs, to ensure that they are reflecting current
practice." Although some are entitled "JDG SOPs" and some are entitled "JDG Procedures" they are the same type
of document - a Standard Operating Procedure. (ExhibilS S, 39)
133 fW/;lF9\J9) Specific examples ofguards following. and in many cases not following, the SOPs are laid out later
in the repon. following the specific corresponding SOP, rather than here in the "General Guidelines" section•
•,. (UOF9lJ9) One guard noted that when the 314th MP Company took over, Sailors .from 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 I left seat handover and would state things like "be sure to tell the 3 14th how
to do it the right way." (Exhibit 17)

42
SE~'F:;'NOFOIlN

 B;;CIlE'Fl/NOFORPi

in her opinion~ ''there is not a consistent application ofthe SOPs." (1l~;:~~:)(~~~30Il. cited several
other examples of inconsistent application ofthe SOPs. 13S (Exhibit 16)

2. {tiWP8t18) JDG SOP #53: SaUy Port Operations

1SO. (W/1f91::JO~ JOG SOP#53 addresses Sally Port Operations. I
(b)(7}(E)

1(Exhibit 44)

-1

L...-

IS I. ~/~OUO~ On the day ISN156 was found unresponsive in his cell at Camp V, several
witnesses stated the ambulance arrived to Camp V ''very quickly," within minutes of having
been called. 136 The guards and medical personnel indicated they were not aware of any issues
with the SalIy Port when the ambulance left Camp V for the SHVIDH. Furthermore uards and
medical personnel indicated they arrived promptly at the BHUIDH, entering through (b)(7)(E)
~ The guards and medical personnel indicated they left the BHVIDH expeditiously, and
arrived at the NAVSTA Hospital I
(b)(7)(E)
p37 (Exhibits 10, 15, 23, 25~ 29, 30, 34)
152. f:UlJfOU9~ Having been identified by the Camp V Watch Commander~Camp V guards
aocompanied ISN156 from the time the ambulance departed Camp V, arrived at the BHUIDH,
departed the BHUIDH, and arrived at the NAVSTA Hospital, through the time the body of
ISN156 was transferred to the morgue. (Exhibits 13~ IS~ 29)
3. fE:"'1F8tiS, JDG Procedure #22: Wildlife and Pest Control

153. (U/IFOUO~ JOG Pl'Qcedure #22 addresses Wildlife and Pest Control. The Chief, Joint
Task Force (JTF) Preventive Medicine shall ensure that inspectors are trained and proficient 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 oftheir responsibilities with respect to wildlife and pest
contra!." (Exhibit 109)
154. fUh'fOUO) 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 hann an iguana." "At no time will a detainee be allowed to feed an
iguana." Similarly, noting that banana rats will bite iffed by guards or detainees, "at no time

(.-/JPQYQ) Those examples are addressed in twn throughout the report.
There is an unmanned ambulance pennanently stationed outside Camp V I VI. (Exhibit IS)
137 (HlJ't'8He) Immediately after the incident, several of the medical personnel created timelines ofthe events
surrounding ISNlS6's death. Copies ofthose hand-written timelines are attached as exhibits to the witness
statements. (Exhibits 13,30,22, 32, 33)
135

136 ttJiJfeHe)

43
SECRE1WP,O FOtUi

 SBCAE:JrNPi8F8R?i
will a banana rat be fed. ,,138 If a banana rat is found in a camp, the SOP directs the individualto
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)
ISS. EUJWQWQ) On numerous occasions, the Investigative Team observed stray cats. iguanas,
and pigeons lined up at the BHUIDH recreation yards.
156. ftJl~QYQl Several guards and medical personnel spoke of detainees regularly feeding
wildlife. A nurse at the BHUIDH IllWJ:I.~~lgoll., for example, noted that one ofthe things that
stuck out in her mind about ISN 156 was that he was allowed to leave food out for the iguanas at
the BHUIDH recreation yards. She noted that stray cats, iguanas, and banana rats sometimes line
up outside ofthc.recreation yards, waiting for food. She also noted that one detainee,fD){~Vej(l)1
has pigeons regularly come and sit on his shoulder. 139 (Exhibit 35)

I

I

157. flJJWQU~ The OIC for the BHUIDH and Camp Iguana (6)(3);10 ~1WJgO~(6}(6), indicated he
understood that althou
cnerally not allowed, certain detainees were al owe to· interact with
the wildlife. (b~:~~~~:~rOb. indicated thatl1D)ltifctKij ~ad
(b}(7)(E)
(b)(7)(E)
He also noted that ISNI56 was '"usually allowed to feed animals
on doctor's orders because it helped keep himcalm. nl4o (Exhibit 18)

I

I

158. tufIt'OUO' JOG and JMG leadership, however, had an understanding quite different from
that ofthe guards and medical personnel. The JOG 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. ttJs'.'i=gQ~ JDG Procedure #30: Detainee Camp Rules and Standards of Conduct

159. EU/JfOU8~ JOG 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 ofprivileges for failure to comply with the rules.
(Exhibit 41)

lU) Commonly referred to as "banana rats," hutias
ts found at OTMO.
~J';:Q\JQ~ Although not included in her statement, tbll~JJg)~~3lll>- ffered that she was concerned about the failure
to follow the SOP, and did Dot think that allowing de ees to
and inteta't with wildlife was a "good idea."
(Exhibit 35)
13&

139

140 f{;/;F~ije~

(b)(6),(b)(7)(C).(b)(7)(E)

....__ '-_..
There is nothing 18 these SOPs or medical records (lSN156) that indicates that either ISNIS6 0.1...:=:.1...1
(b)t6).(bl(7)(C1.ltillnEl
were actually authorized to feed or interact with the wildlife. (Exhibits 48, 48-A. 48-B. 48-C, 48-D)

44
6£CRETNN8r8RPi

 SECRETHN8f8RN

160. EU!JfOUO~ Detainees are classified in a "compliant" or "discipline" status. Detainees who
commit "serious offenses" may, at the discretion ofthe IDG Commander, be re~assigned to
Camp V. (Exhibit 41)
161. ~".WfOUO~ JOG Procedure #30 also establishes a matrix. for Basic Issue/Comfort (BIICI)
items for detainees. 141 Generally, items of BUCI may be exchanged on a one~for-one basis. 142
(Exhibit 41)
162. EU/JfOUO~ When a detainee commits a camp rules infraction or an offense listed in the
Detainee Offense Matrix
(b)(7){E)

The maximum recommendation for any single punishment,
guard force will inform the detainee he has been placed,L...(b;.;.;)(7~){E,;;,;,)
detainee will serve the discipline time in an assigned cell in Camp V

I

(b)(7){E)

I

~.=._
(b}(7){E)

163. fU/A60y.g~ According to the SOP, the JOG Commander has the authority to assign
detainees who have committed certain offenses to Camp V,
Those offenses include

164. fUl~Oy.g~ As discussed earlier in the report, ISN156 had a long history ofdisciplinary
events at JTF-GTMO. Several witnesses indicated that not aU of those disciplinary events were
1l
consistently addressed. The Camp V OICI lb)(S):1
X6>tbi Ifor example, indicated that she
was made aware of the fact that ISNI56 wasl
(b)(6)
Iduring

05%tJE6.t

141

(I WiO I !O~ A detainee may lose certain items if he is placed on self-bann precautions or on discipline status.

(Exhibit 4).
142 (WI/f9W9~ The 10 interviewed a noncommissioned officer watch commander who related anecdotally that
because the on~for-one exchange policy is sometimes violated by the orders ofthe medical team (eg., "give the
detainee extra blankets), some ofthe guard force feels compelled to take home and wash detainee items rather than
risk a detainee outburst upon only receiving one blanket in return from detainee laundry.
14) EU/;'f8~8' A GTMO Fonn 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
aEProval." (Exhibit 41 )
I ~ 1/'iO' q There are two detainee disci line levels
complete the specified time on
(b){1)(E)
·11 be c ange to~~~~,""",!",,,,,
time. Once both the
(b)(7}(E)
complet
be returned to com bant status. ExlubJt
145
r:-_':"':"'".....:;;~~
.retainees serve their

45
SECREl';'RfOfORl'i

 ~JS€RE'Fs'}~rQFOR?j

movements. 146 (b)(:~~~~18~J~Ob. 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. (b,?l,~m~~~~~Ob. indicated that she was not aware
ofthe previous command having done anything to "truly address the Soldiers' complaints about
ISNI56'~ (b)(6) ,,, (Exhibits 16. 51)
165. tu{woeo) Other guards reported that up through the days leading up to his death, ISN156
was engaging in indecent behavior. In fact, one guard understood th~ (b}(7)(E) lline of light
rotation policy stemmed from ISN156's behavior, and that camp leadership ""aia not want guards
to have to watch [the indecent behavior] for more than
(b)(7)(E)
t a time," Several guards
indicated that they had to watch ISN 156
(b)(6)
(b)(6)
"right up near the window," (Exhibits 6, 14.29)
166. (UJJfOUO~ Similarly, a nurse at the BHUIDH

(bl(~:1:)~~~b3Ob,

noted that ISN1S6 would
(b)(6)
!while on line ofsight and •
(b)(6)
t' IblC:;g~~~~~~OD, noted that it was
"very difficult for guards to watch" this behavior. There is nothing in the file ofISN156 to
indicate that any discipline time was imposed for this type of indecent behavior. 147 (Exhibit 35)

I

167. E-Ya'J¥QUQ) On I August 2012, ISN156 received a Detainee Report for throwing feces at a
nurse and guards from a cup in the BHUIDH recreation yard. As a result ofthe incident, ISN156
was given (b)(7)(E) discipline time. (Exhibits 17,35,56)

I

I

168. EUJ./fQWQ) On 2 August 2012,lSN156 also received 508 Detainee Reports for "Major
Damage to Property" and "Agvravated Assault on Staff,tt both reports stemming from~
(b)(7)(E),(b)(7)(F)
J.148 As a result ofthe incident, ISN156 was given a total o~
Ifbl(1)lE1 ~f discipline time ~ (b)(7)(E) Ifor the Major Damage to Property and (b)(7){E) ~for the
Aggravated Assault on Staffs not to exceed the
(b)(7)(E)
for a single event.) (Exhibits
54,55)

I

I

I

I

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

46

 SECllfSli'/N oro RN

170. EUNr9U9~ In fact. it was this type of"out of control" behavior that led the JOG
Commander to approach tl"/~){6l.lb)(71 the momingof 7 September 2012 and ask her whether there
was any medical reason that would prevent ISN 1S6 from serving his discipline time. 149 f\~~l(~l,(b)
(1):(3~IOUSC
d d th . h
.. thoIS was •very
•
' was I7JlC)
13llIld:~~)~bl spon e
at 10 er oplWon,
vo I"Itlon aI behavior" and that there
"no
psyc Iatric reason" to prevent ISNIS6 from serving his discipline time. The JDG Commander
indicated that based on that, he decided on 7 September to transfer ISNI56 to Camp V (b)(7)(E)
(b)(7)(E)
(Exhibits 5, 24)

I

I

I

5.

~'JF9,(;~

JDG Procedure #34: Search and Inspection

171. fUN+'9WQ) JDG Procedure #34 covers Search and Inspection. 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. I
(b)(7)(E)

"-----------_.....

l(Exhibit 43)

172•.•

(b)(7)(E)

1(Exhibit 43)

L . -_ _......

173. E\:IIJfQWQ)1
(b)(7)(E)

11-.

KEXhibit 43)

149 (f:JlWef:Je) It is unclear for which ofthe offenses lSN 156 was being sent to Camp V to serve discipline time.
What is clear is that because ofms behavior in the weeks leading up to his death, ISNIS6 had a large amount of
discipline time to serve.

(b)(7)(E)

ISO
(b)(7l(E)

The JOG Commander indicated that he is current! in the rocess of rcviewin the

47
g ECRF.T.\'Pj8f8RN

(b)(7)(E)

I

 6ECm:1YfPiOfe~:i

174. (U/ffOUO' The Camp V OIC (Dll:;'~:>.'i':~~~oo. indicated that she understands that her
s
are conducting
(b)(7)(E)
Noting that the most common thing guards fmd during searches are excess quantity items (such
as too many books), she aclmowledged that on other occasions, guards have discovered

I

(b)(7)(F)

Iand water flavoring bubbles in the cells.1S2 (Exhibit 16)

175. ~IfOU9) Several guards indicated they properly understood provisions ofthe search and
inspection SOP,
~--~-~-~.....,
One guard
noted that in his opinion (b}(1)(E)
]76. (U,'lFOUO) After ISNlS6 moved from the DH to Camp Von 7 September 2012, guards at
Camp V 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 ofhis
things, including a foam pillow and linens. IS3 (Exhibit 19)

6. fll/lf'el10~ JDG Procedure #56: Line of Sight
177. fUsC,q'OUO)
(b)(1)(E)

Detainees may be designated for line ofsight forf
~-"""'="'~-~~
I Detainees on line ofsight will bel

I
178. ~NrOUO)
(b)(1)(E)

L-_~~

~_~ _ _"""":,,,,~~~TheWC/AWCwillbrieftheguardson
line ofsight procedures prior to them assuming line ofsight duty,

E

U2 ttT/il1?9W9) DlI'~\f6ltb> I
noted the flavoring bubbles are distinct from the flavoring packets that detainees are
authorized eae n ay. it ~;I61 I suspects the source ofthe flavoring bubbles (contraband) to be certain guards,
but she has not been ab e 0 I en
Which uards are brin 'n in the flavorin bubbles. She indicated the
(b)(7)(F)
(Exhibit 16)
(I J(~Qtlg) Although ISNI S6 was authorized a mattress. he indicated that he only wanted the foam pillow.
Accordingly, when ISN IS6 was found unresponsive, he was lying directly on the cell floor, where he had appeared
to be asleep. (Exhibits IS, 19)

48

SEC!t£=F//NOFOR.?i

 s Ee~TNNOr()n?i

I

(b)(7)(E)
--_______________________1r
(Exhibit 45)
180. EU/WQljQ) The SOP states

(b)(7){E)
a detainee covers
or otherwise obstructs the view ofthe guards.
r--------I"-r:I~f-:th-e-re~is no response, the guard shall call r--.....;;.(b-}(7-)(E-).L---,or--~:-T"''"'T''Ilr'

(b)(7)(E,...--

181. tUllf8UO) Guards failed to require ISNI56 to uncover hisl (b}(7)(E) !after he covered it with
a food mixture the night of 7 September 2012. (Exhibit I)

182. EtJ/fFOUO) Several guards indicated that they were unfamiliar with what the line of sight
SOP required with respect to rotation times. (Exhibits 10, 14, 19, 20)
183. g JIIfQUO~ 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 1,6,8,
25)
184. EU/WQ~Q) Once it was determined on 7 September 20]2 that ISNI56 would be transferred
from the DH to Camp V, 1~1~1I6).lbli7j recommended ISNI56 be on line of sight. Although the
Camp V OIC asked whether it could be electronic line ofsight,I·-~ --Irecommended.direc.l ..._.lWllQJJSC§130b.
(physical) line of sight. ISS In the end, (b~~X~J1'b~:~~Ob. ordered that ISN156 be placed on electronic
(Ill(6Ub)l7)(C)
and direct line of sight. (Exhibits 16. 24)

----...I L ...§J.;;mn.:awllil..J

-.

r-~~~-t

self-harm in a articular location.

(blQ):10 USC.~

·-----iIl:l3J:.111.\.lSC §13Ob.
Ib)l6).(Il)l7~C)

-J-:

r~~~i!!!2U~~lb]ii]~~!!s!!5!.!!!!!!~C:;;;:===J(b~)(7~){E~)=======J[::-.~.

lbX6~(liX7J(C~I=-"'7'I'!':~~~------------....;..;,;:....;.;...;....-------------

49
SI5CRE:r/lN8F9UN

....

ll3);1D.VSC §130b.
(Il)(81lb)l7)1C)

 S£CUEl'/,,?iSf8RN

189. £o\1IJfggg) Generall •

5

understood that the
(b)(7){E)

so
8ECRE'FH?(QF9RN

 SECRETImOFOIU,
7. fQ/Jli:94JQ) JDG Procedure #66: Medication Pass (Moo Pass) Procedures

190. ~/,q:OUO~ JOG Procedure #66 governs Medication Pass (Med Pass) Procedures. IS9
Generall the SOP indicates that
(b)(7){E)

(b)(7}(E)

46)
191. ~U;'IfOUO) According to the SOP,
(b)(7){E)

....._------------'

(Exhibit 46)

192. etJ/IfOUO):

(b)(7)(E)

....._-----------_...I(Exhibit 46)

193. ~I IIQi'O~O) For "high risk" DEA-controlled drugs. the SOP establishes that

"I

(b)(7)(E)

JOG SOP notes tha

(b)(7)(E)

1S9 ~Nf8~8) There is an entirely sepllJ1lle JMO SOP that also governs medication administration procedures.
There is some overlap between the JOG iutd JMO SOPs governing medication administration. Where items are
solely addressed in the JMG SOP, those items arc discussed below in the corresponding JMG SOP discussion
sedion rather than here. (Exhibit SO)
160 EW/Jf9W) As noted below in the JMO SOP subsection in therenort. the NO SOP ..-ardinl! Med Pass differs
notably from the JOG SOP governing Med Pass. Significantly.1

(b)(7)(E)

161

l(Exhibits 28, SO)
(YllFQYQ) The provision requiring the BNCO to verify tbatJ
(b)(7){E)

/(Exhibit 46)
As discussed below, the specific drugs that qualify as high·risk DEA classified drugs are set forth in
the JMO SOP. (Exhibit SO)
_ I

51
SECR£TNf::8F8RN

 ~ ECR:ETI:'~i QFQRN

(b}(7}(E)

(Exhibit 46)
194. fUl/F9WQ~ Several co smen indicated that they are
(b){7)(E)

(Exhibits 21, 23)
195. f

Indeed, the JMG Training Officer,tb)(3ti~~~~~~r-(bt indicated thatt
(b}(3):10 usc §130b,(b)(6),(b)(1)(C),(b)(7)(E)

196. ~U/JfOUO~ Furthermore, a registered nurse assigned to the BHUIDH

b)(3';~~.~~br-lb)

noted

lb)l3):10 usc §130b,(b}(6),(b)(7}(C),(b)(7)(E)

163

•

(b}(7}(E)

~'tp9U~

Several corpsmen acknowledged that there
' for example, noted that because of the risk, he
does not ever leave medications in a detainee's splash x. ( I Its 6, 21)
16S (H/;Q;eW9lln addition to being the psychiatric mental health nurse at GTMO~
---~+H1so.the.dcsignat~d __ ." (Illl3t.lOMSC §130b,
Training Officer for the JMG, Unlike the lnG, who relies on the
~ to conduct the guard tralni
e
(b)(6Mb)(1l!C)
JMG is re uircd to conduct its own training. It is unclear whether
.•_.- s.referriDg._to...tb~JD.G..s.QP. _~)(ll!.E) •__•• (Ill{3):llLlISC §130b,
\---:""=",......~~E~),.,..,.......,..""""",,--1 or the JMG SOP
(b){7)(E)
(b1l61,(bl(711C)
(b)(7)(E)
(Exhibits 4, 28)
(GAtpQYQl Based on her experience as a registered nurse in civilian psychiatric hospitalJ
-----4uggestc;,L .ltlQ);!l!USC §IJOb.
a more robust medication administmtion program at JTF·GTMO than the Med Pass program currently oii'i1i.ned in
(b)(6),(b)(7)(C)
the 100 and JMG SOPs. (Exhibit 35)

was a real risk ofdetainees hoarding medications.

52
SECREli'lN8FORN

 (b)(3):10

usc §130b,(b)(6),(b)(7)(C),(b)(7)(E)

I(Exhibits 31,38)

L...-

.....

198. (~/jq;QUQ~I§f3JgJJ:~{~~}(~ndicated that the ~OliC: is a "significant change" since he took
command ofthe JMG on 21 May 2011. 168 I (W,(itb~~~!: lindicated that because a detainee had
just died by hanging on 18 May 2011, it was immediately clear to him that "the risk ofsuicide
was a very serious issue here." (ru~~h~/~t lindicated 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 overdosing.,,169 (Exhibit 31)

I

199. ~U/iq;gUg}

( :
130b

indicated that, consistent with the JOG and JMG SOP, he

.r';"~ Nonetheless, in contrast to the SOP and the understanding 0

200.

I

(b)(~X~.~~§1~Ob.

d

(bX3~::j~~~~~Ob.(b) none of the corpsmen interviewed by the Investigative Team indicated that

I170

(b)(7KE)

8.

flJ/w.g~g) JDG

Procedure #82: Detainee Death

201. (YfWQYQ) JDG Procedure #82 covers procedures in the event of a detainee death. In the

case of an unresponsive or dead detainee,l

167

(b)(7)(E)

t\}#f'8W8) Another example ofthe apparent d ons eetween the JMG leadership and the medical personnel

(b1l3):10uS5,L\11~~,j~ • .m~ted.by..the..comments.of..anight.corpsman;

.....
indicated "Since I began my duties here at Camp V
28APRI2, I do not recall ever being visited by anyone In my eadership chain. I have felt invisible with no one
seeming to even know I was workin here." xhibit 9-A)
168 tWNI=8WEij The statement of
". ,
indicates that he took commqd
on 27 May 2012 and that
a detainee died by hanging on 18 y 2 12 -these dates should read 201 1.
--.- .. '1>-0 e f _ . . . _.. _
unl_cd offieea II :-<":E0 who Iw been at GTMO fb, ov.... _ .
IUs
(b~3r.10U~,!:.§.tlOb. .Jw-.cleauvhetberj....--:
was Ye .
c IDG SOP or the JMG SOP
vemin medication administration.
(bJ(6),(b)(7)(C)
Furthermore. it IS une car w ether bJ(~~Jg~SCtl30b is aware that the JMG SOP
(b)(6Ub"lG)(C)

OftbrG

:~. ;;l ,~,.;:...

(b

(E

I It
1&9 (,=,..we,=,e~ The Cultural Advisor has been at JTF-GTMO sim:e 29 September 2005, and accordingly bas been
present for all nine detainee deaths that have occurred at JTF-GTMO to date (seven suicides and two natural deaths).
An interpreter refem:.d to a specific insumce orISN156 hoarding pills, noting that at one point in 2008, ISN 156 said
something like "here, I co£;Jse pills if! wanted to kill myselr and showed him and the guard a fist full of
fb)(3):1ou~nJl~~"_fJills.....·.~maybe~r~iIl .•.•••
dicated that the guard confiscated the pills from ISNI56. (Exhibits 2,12,31)
(b)(6l.fb
OJ
70 (tl//f'e~e~ Bealuse 0
g ofthe investigation, interviews. and the draftin~ofstatements, the statements
ofthe corpsmen do not reflect any specific information regarding thel (b)(1)(E)
ot being followed.

53
SECRET,I;?lElPOItN

~'ID10USC§13Ob.

."""",,,

 5ECRET/fNOr8IDi

(b)(7)(E)

----II~

"'""-

tCxnlDrt ] ] 1)

202.
(b)(7)(E)

(Exhibit Ill)
203. (\:WR'OUO) Once it was detennined that ISN156 was unresponsive and would be
transferred out of Camp V for emergency medical treatment. the Camp V Watch Commander,
(Il)(~;J:I~~:glb.
ked an NCO and a guard I
(b}(3):10 usc §130b,(b)(6),(b)(7}(C)
Ito
accompany N156. The guards remained with ISN 156 from Camp V to the DH, j n from the
DH to the NAVSTA Hospital, and from the NAVSTA Hospital to the mo~e. Canectl
~
. g that their orders were "to stay with the body the whole time: (IlK3I::~~:~~Ob.(b1 d
§1300.(bl(61.(b)(7) stayed with the body until it was brought into the morgue and the morgue door was
closed. (Exhibits 13, 29)
204.4+The Cultural Advisor I
(b)(1 ),(b)(3):10

IV:;XnJDlt
'----~

usc §130b,(b)(6),(b)(7)(C),Sec. 1.4(c)

1~)

VI. (U) JOINT MEDICAL GROUP (JMG)

A. (U) Leadership

205. fUJIfOUO) As noted above, theJMO falls under the command and control of JTF·GTMO.
The commander ofthe JMG is Captain Richard Stoltz. (Exhibit 69)

54
8rCAETNNQFQIlN

 SE€RE·YJ.'?18FOIUi

206. ~/fQYQ~ The JMG Headquarters element (HQ) is composed of the Joint Troop Clinic
(JTC). the Detainee Hospital (DH). and J-Smart. (Exhibit 69)
207. EU/WQYQ) The total number of detainees at JTF-GTMO under mental health services at
any given time is from (b)(7)(E),(b)(7}(F) Approximatel ~:\~~~~. fthose detainees see only the JMG
psychiatrist Ibll~:J~,~'(~ (detainees who only need medications and do not require I request
counseling) l:\\;~~~ nly see the JMG psychologist Ibl(~~;:~)=3OIl (detainees who only need
counseling but do not require I request medications), and the remainder see both the JMG
psychiatrist and psychologist. l73 (Exhibit 24)

B. (U) Training
208. EUI,q;Q~Q) The JMG is responsible for training the medical personnel providing detainee
medical care. The training consists of Skill Validation (RN and technicians), BHUIDH
Orientation, Camp VNI Orientation, Care of Detainees, Enteral Feed Orientation. and
Ambulance Operation. I?4 There is a specific block on medication preparation I Med Pass,
including "How to pass medications." (Exhibits 87. 88, 89, 90, 91, 92, 93, 94)
209. @:lU~OtJO~ There is a separate Medication Administration 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. 17S (Exhibits 87,88,89,90,91,92,93,94)

etainees who he has concerns about their Ion tenn care.

- - •. _. (b)(Il.lIlX3}:10USC

··"11Ob.lb1l6),lb)(71
(C),sec. 1.4jc)

(b)(7)(E)

(Exhibits 21, 23,28,31,87,88,89,90,91,92,93,94)
e
. . n Ad
. n e e ce indicate!! that the tmin
(b)(7)(E)

55
SEGRETH~iOFORPI

will be able to demonstrate a
d

 210. EU/,q:eue~ There is also a separate Medication Administration Understanding. signed by
the trainee. The Medication Administration Understandin2 indicates thad

(b)(7)(E)

---------------------_

l(Exhibits 87. 88, 89, 90. 91. 92, 93.

.......

94)

c. (U) JMG Standard Operating Procedures (SOPs)
211. fUI/POUO~ There are a total of79JMGSOPs governing a wide array of detainee
operations, ranging from Medical Management ofDetainees on Hunger Strike, In·Service

JMG sOP #I 117:' The trainee wilJ be able to:1
(b)(1)(E)

I In her statement.!lbitJJ;IOUliC IlJllb.l-dic:ated that she was told thepreVIous wave h8lftril!d .'" 1f",1

1'1\17111<1

1b)l1lIEI
(b)(7)(E)

I' ,

I:

....

plaincd that she rcgularly asksl (on") lfur c......._ 1a

(b)(1)(E)

56
SECRE1WN8F8R?i

a I~_".

 SECltET,'/NOPORf,

Training, Nursing Guidelines, Detainee Refusal of Care, and Phannacy, to Medication
Administration Policy. 177 (Exhibit 126)
1. fti/JF9{;,9) JTF-JMG #117: Medication Administration Policy
212. EU:'IfOUO~ JTF-JMG#117 covers the Medication Administration Policy.178

(b)(7)(EI

"----_..... (Exhibit 50)
213. ElJIIfOWO~ According to the SOPt
(b)(7)(E)

1.-

-.1'

(Exhibit 50)

214. fY/j!fOUO~
(b)(1)(E)

'--

~

(Exhibit 50)

215. (UNrOVe) After each medication pass,
Ib)(7)(E)
~-:-:':"":"""":"':"':----------~
---oI(Exhibit
50)

1.-

I7T

flSA'F9W9~ Although the current sopi

(b)(7)(E)

Ifur a

total of 79 active SOPs.
118 fl1iiftmPl As noted above. there
(b)(7)(E)
I
(b)(7)(E)
The JMG Commander (CAPT Stoltz indicated that shortly after he took command. he changed the
SOP specifically
(b)(1}(E)
, CAPT Stoltz indicated thc JMG is again re·

isl

I

examinin the M

Pass SOP as he i

57
SECUETN?'8FO RoN

 lSECIlETNl)IOFOR.'i

216. (T:Jt'JfQYQ~

I

(b)(7)(E)

II'"""(E-xh-j-bi-tS-O-)- - - - - - - -

I-

217. ~II¥Q~Q~I
(b)(7)(E)

I

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _II"7l(EI't"""T"'lt"'i6P."'i"l:r.= ) - - - - Xh

t

so

218. (a',q:ouo~·
(b}(7)(E)

~r(Exhibit

L...-

SO)

219. fU;'/fOU8)1
(b)(7}(E)

I

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _.....Il-(E-xh.,...i.,...bi-tS--O--}- - - - - - -

I
I
I
------------.....1
221. ~J¥QUQ~ Finally, the SOP indicates thatl
I
220. El'I1¥9WO~ The SOP establishes that
(b){7)(E) (Exhibit SO}

I

(b)(7)(E)

.

r

I

(b)(7)(E)

(b)(7)(E)

8S

(Exhibit 50)

arel

180 ~Wp9W9) High Risk DEA medications
(b)(7){E)
J Those medications that
ISNIS6 had been recently administered (Table 3 ofthis report) include Ativan, Percocet, Tylenol #3, Haldol, and
Seroquel. (Exhibit SO)
181·
•
The 49)
JMG SOpl
(b}(7){E)
(b)(7)(E) (Exhibit

,1-.

. .:; .: :. ;.:.:.; ;. . .

The JMG SOP

(b)(7)(E)

(Exhi.~bi;,;,,;t5.0",,)

(b)(7}(E)

The J

SOP
(b)(7)IE)

I

(UW8H8) The JOG SOP
(b)(7)(E)

(b)(7){E)

58
SECRiiTll?i8FORN

_I

I

-.

 SECRETNi'iSrSRN

222. ~tJ/:!I'Q~Q) As noted above,1
(b)(7)(E)

(Exhibit 46, 50)
223. fH';rOUO~ With'respect to the administration ofPRN medications, a review ofthe medical
records for ISN156 seems to indicate that the corpsmen are not properly annotating those
instances where the detainee requested a PRN medication more thanl
(b)(7)(E)
period. (Exhibit 97)
224. tV/WeDe, Regarding the locations of Med pass,l

I(Exhibits 9, 21, 23A).i86

(bXlXE)

225. t1=J(;reUO~ The IDG Commander, COL Bogdan, himself indicated that I
(b){7)(E)
(b){7)(E)
COL Bogdan indicated that he
.
(b)(7)(E)
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
l87
(b)(7)(E)
(Exhibit 5)

I

I

I

t

I

I

I

226. ~HfOUO~ One corpsman indicated that he
(b)(7)(E)
"during Ramadan, but not before or after."ISS Another corpsman indicated without reservation
(b)(7)(E)
(Exhibits 9, 21, 23A)
that

I

1

227. (':J/;~Ol:JQ) Not all corpsmen are complying with the SOP requirement
(b}(7 E

(b)(1):10 usc §13Ob,(b)(6),
(b)(7)(Cl

writln
ibits 24, 35, 48·8, 98)

11l:m10USC§!10P~_'T._rr,_:f~ijvi~!E'~eiwi8i1~~~~ id not indicate why he understood the Nics to be different during Ramadan. (Exhibit 9)
IbX6\fbJ(7XCI

....._--.11

S9
f

ECRETI/.j)rQ'FQR~T

I

 SECR£l'HNOFOftf4

I(Exhlblfs 9, 50)

.....

(blU}(E)

2. fWJP9'8~ JTF-JMG #60: Cardiac Arrest Procedures
228. flJl.'FQl:JO) JMG SOP #60, Cardiac Arrest Procedures, provides that in the event ofa
the following will apply...
b
E
(b

(U) Part 2: FINDINGS

1. EWmQg~ Finding: ISN1S6 bad an extensive history of disciplinary and self-barm
attempts while detained at JTF-GTMO. (Facts 19-64)
(U) Discussion:
a. fUNfQl:J~ Disciplinary events spanned from 2002 to 2012 and included assaults on
guard force, inappropriate use of bodily fluids, and possession ofcontraband. Self-barm events
spanned from 2003 to 2012, and included ingestion of inedible items, attempted hanging, and
cutting. ISN156 frequently expressed suicidal ideations, including writing dark poems, talking
about death, and making passive statements about suicide. At various times during his detention,
ISN1S6 was on hunger strike, and at certain points required enteral feeding.

b. EU"IfOUO~ There was also a significant spike in disciplinary issues in the several
weeks before his death. ISN 1S6 threw rocks, strikin the uard tower, the tower spotlight, and
two guards. Later that same day, while in
(b)(7)(E),(b)(7)(F)
,lSN1561
(b)(7)(E).(b)(7}(F)
(b)(7)(E),(b)(7)(F)
The night of 31 July 2012,
ISN1S6 began jumping around in his cell and refused to comply with an order to stop jumping.
The following morning, ISNlS6 threw a cocktail offeces and urine from 8 styrofoam cup at a
nurse and the
ds. striking them in the face and neck. Later that week, while at BHU
«
).(b}()
ISNI S6
(b ()o(
F)

r::-~----::~~~~:"":"":"'-~TI'Il'Ir.J'htrm:l!'l

m::-l!"Iln'rrt'-------------......I During a fit ofrage, ISN1S6 lunged a
\~(b~5Mb)

i 130ll.Ibl61.

d assaulted several guards. On 6 September 2012, while still at the DH, ISN156 began
spontaneously yelling and kicking, threw his urina~ and thereby splashed a guard.
2. (U/IP6Be, Finding: Because of his unique medical issues and temperament, ISN156 was
not treated like any otber detainee. This disparate ~eatment resulted in significant

deviations from SOPs and protocols and caused significant pressure on the guard force.
(Facts 22-27)
60
SEGRETNNOFOIDi

 ~li:cnET/;,NQFQRN

(U) Discussion:
a. EWAlQUQ) There were several instances where ISNI S6 was either not disciplined or
was not required to serve discipline time immediately (rock-throwing incident). ISN156 was
able to have a cup full of feces and urine at the recreation yard because of an order by (DX:~~~~=3Ob.
permitting ISNI S6 t<? 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. ISN156 frequently made
demands on the guard force (demanding the guards loca 51~~iD~61.lD) or a threat of"big
problemstt).
b. fl/J,cfOWO) Much ofthe guard force and medical personnel felt that ISN I S6 was not
subject to the same boundaries that other detainees were, and that certain provisions ofthe
general IDO and JMG SOPs did not apply to him. Other guards were unfamiliar with what the
specific SOP provisions required. Accordingly, guards and medical personnel frequently did not
enforce JOG and JMG SOPs with respect to ISNI56. Some guards expressed concerns
regarding reprisals from leadership if they were to exercise too much force with respect to
ISN156.
c. (lHKOUO) Over the course of his ten-and-a-half years ofdetention at JTF-GTMO,
ISNI56 moved from camp to camp over 67 times. He was variously housed at Camp X-Ray,
Camps I, II, III, V. VI. the BHU and the DH. Some ofthese moves did cause stress on the guard
force and ISN156, but nothing that was overly unusual. Although ISN156 had bad memories of
the cell where he was ultimately moved and at least one detainee stated that moving ISN 156 to
the cell would cause him to commit suicide, the moves themselves did not contribute to the
detainee's death.
3. fU/W9""9~ Finding: JDG leadenbip failed to take remedial action to address the

I

problems with the
(Facts 42-43, 54-64)

(b}(7}(E),(b)(7)(F)

ttl/IFODO) Discussion: Recognizing the potential dangers caused when ISN IS6
(b)(7)(E),(b)(7){F)

4. f\J/mOgoJ Finding: Despite the Force Protection report indicating that ISNlS6 may be
suicidal, COL Bogdan acted reasonably in ordering ISN156 to be moved to Camp V to
serve his disciplinary sentence. (Facts 73-91, 170; Exhibit 5)

61

 SECRE"",'f,8P8ft?if
EJJ/JPQ\JQ) 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 1~1~)j81.t~l(7 whether there was a medical or psychiatric
reason that ISN 156 could not serve his discipline time at Camp V. §13Qb~b)(6~(Il1 indicated that
ISNIS6's recent behavior, including his splashing the guard the day e ore, was entirely
(~;(3r.l0USC§rulll ••__ .•Y.01itionaLAccordingly-,I·---··_·
lindicated there was no reason that ISNIS6 could not serve his
(~1(6~(blf/J(Cl
d"
,..
C
ft th
...
.
Isclplme tIme at amp V. A er e deCISIon was made to move hIm,
(b}(6),(b)(7)(C),(b){7)(E)

receiving the infonnation, 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
ISNlS6 to Camp V, because ISNl56 was known to make "melodramatic" statements. In this
instance, COL Bogdan acted reasonably as he had to address the frequent misconduct by
ISNI56. On balance, the suicidal ideation did not stand out compared to any ofthe other
instances. Additionally, line of sight was ordered in an attempt to prevent any self-hann by
ISN156.
... Upon

a..-

5. Eti/JF969) 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. EUI/FSUS) Before giving ISNI56's belongings to him after he arrived from the DH,
Camp V guards searched them in accordance with the SOP. Guards removed certain
unauthorized items, such as extta towels and T-shirts, and ave the remainin ,authorized items
to ISN156.
(

r.:Th::::-:"is-c~i'ea--:-te-s-e-xtrao~-rd~lD-ary-o-p-p-o~rtun~i~ti:-es-fj~o-r-;d:-etai~·n-e-'es

~~~~~~~"I""""'I""'~~~~~'"

b. ~U/IfSUS) Additionally, lAW SOP, guards did not search ISN156's Koran. The
current version of the JDG SOP, only the Cultw'al Advisor or interpreters may search a Koran.
c. tlWIfSUS) ISNlS6 was able to successfully conceal contraband, specifically, 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 JMG SOPs are drafted created numerous 0fPortunitieS for ISNlS6 to conceal the
capsules. )(3):::I~~~b~(lb.(b) xpressed his concerns with the
(b)(7)(E)
(b)(7)(E)
He also noted that his staff is in the process of

I

62
5ECUET/s'?/SFSRN

 SECIlETNN8F8:RN

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. ('QA~Q'QQ) Finding: The JDG guard force failed to follow the JDG Line of Sight SOP,
violated the JDG and JMG Med Pass SOPs, and should have taken remedial measures
after ISN156 appeared to be sleeping an unusuallengtb of time. (Facts 90-106, 177-89, 190200, 212-27)
(U) Discussion.

a. (~/JiglJg) The failure of guards within the camps to follow thel (b)(1)(E) lline of
sight rotation time and the failure of the Ileadershi P - both officers and non-commissioned
officers - within Camp V to enforce the (b)(7)(E) 1line of sight rotation time increases the risk
that a line of sight guard, because of fatigue or distmction, 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.
b. fU/1F8U8~ When ISN 156 arrived at Camp V, he was on electronic and direct line of
sight. After he arrived, ISN156 covered hisl(b)(7)(E)lwith a food mixture. The guard monitoring
thel(b)(7)(E)lwas not able to continue to see what ISNl56 was doing. When this occurred, the
SOP requires the guard to knock loudly on the cell door and uncover thel(b)(1)(E) I Ifthe detainee
does not respond immediately, the guard is to call
(b)(7)(E)
Guards violated the SOP
when they failed to require ISN156 to uncover his (b)(7)(E) bile on line of sight, and failed to
call al
(b)(7)(E)
This failure may have contributed to the death of ISN 156 in that it
prevented the guard from being able to monitor ISN156 electronically, and from discovering
whether something was in fact wrong with ISN 156 during the time that the direct line ofsight
guards say ISN 156 was sleeping.

I

c. €U/~OUO) The line of sight guards on the night shift were rotating outl (b)(7)(E) ~o
(b)(7){E)
J The guards knew that the SOP required al (b)(1KE) rotation, but elected
not to follow it. On the day shift, seveml guards were either not familiar with the (b)(7~E)
rotation requirement set forth in the JDG SOP, or were familiar with the requirement an C ose
to disregard it. At the time that ISN 156 was found unresponsive, the day shift line ofsight guards
for ISNl56 were rotating out (b){7)(E) The AOIC of Camp V on duty knew that guards
usually rotated 0
(b)(7){E)
and did not know that the line of sight SOP specifically
addressed rotation times. The tier NCO that night was on his first duty as an NCO of lin~ of
sight, and did not know what the SOP required. He allowed the line ofsight guards to rotate out
(b)(7)(E) ~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 ofthe NCO to enforce the

I

I

I

63
SEC~Tf."10FOll"'i

I

hi

 t,ECRET/mOFORN

standards ofthe SOP, may have contributed to the death ofISNlS6 as the failures meant that the
guards were not as vigilant as the SOP required in their monitoring ofISN156.

.

,--",,=,=,,"~_ _~~

~_ _~_~~E:.-_.... The SOP does not allow for
medications to be distributed in any other way other than that authorized by the ~OP. This
particular failure to follow the SOP the morning of8 September 2012 did not contribute to the
death ofISNl 56. as the medications were still in the splashbox at the time that ISN 156 was
found unresponsive. However, similar failures by medical staff over time, to follow the SOP,
may have contributed to ISN156's ability to hoard medications, as discussed below.

e. EY/KOUO~ The IDO SOP governing line ofsight requires the Watch Commander to
check detainees placed on line of sight at a minimum o~
(b){7)(E)
land 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 ofISN156, the
lack ofentries did make it difficult after the fact to re-create the immediate events leading up to
the point that the guards found ISNlS6 unresponsive.
.
f. (U/;lfOUO~ 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 ISN1S6 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 1000-1200. The Watch Commander
recalled that the last time he saw ISNI 56 alive was around 1100. At that time, he checked on
ISNlS6 to see whether he wanted to go to recreation, but because ISNI S6 appeared to be asleep,
he did not disturb ISN156. Around 1200, ISN156 missed the noon call to prayer. At this point
ISN156 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.
7. fl"/lf'ef:Je~ Finding: There is inconsistency between the JDG SOP governing brevity
codes and the JDG SOP governing line of sight. This inconsistency did not contribute to
the death of ISNI56. The guard force overall performed admirably with respect to their
promptness in responding to the eode, their entry into the cell, and their lire-saving
attempts. (Facts 63, 106-14, 177-89, 201-03; Exhibits 45, 47)
(U) Discussion.

64
gKClYiiTI/:>rOIlQR?l

 fI3CR£Th?iOrORN
a. tu/IfOUO~

The IDG SOP governing brevity codes requires a guard to call al(b)(7)(E)1
~b)(7)(Elwhen a detainee is obviously not breathing, as indicated by unresponsiveness, lack of chest
movement, and discoloration ofthe face. The SOP governing brevity codes requires a (b)(7)(E)
(b)(7)(E) Iwhen a detainee is committing self-harm and a Code Yellow when there is a
potentially life-threatening medical condition requiring immediate response.

I

b. {UOf6U6) The JOG SOP governing line of sight does not address a

I

(b}(7)(E) lor a
Code Yellow, but does require a guard to call al
(b)(7)(E)
Iwhen a guard suspects a detainee
is not breathing or loses line ofsight and does not get a response from the detainee after
knocking on the cell door. The provisions in the two SOPs are inconsistent with respect to when
al
(bX7)(E)
Ishould be called. The inconsistent provisions lead to confusion as to when a
guard should call al
(b)(7)(E)
Ivice a (b}(7}(E)

I

I

c. (U/jq:OUO~ The day shift Watch Commander looked into the cell for ISNIS6 and
immediately determined that there was something wrong - ISN 156's eyes were open at the
point, staring blankly at the cell door and ISN156's skin color looked gray. At that point the
Watch Commander caned a Code Yellow. Based on his observations oflSNlS6, the Watch
Commander could have immediately called a (1l)(7)(E) ~r a
(b)(7)(E)
linstead 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
ISNlS6 could no longer be seen definitively breathing. The nurse arrived and upgraded the
situation to a (b)(7)(E) The Watch Commander's initial call of Code Yellow instead 0~(b)(7)(E) I
(b)(7XEJor a
(b)(7)(E)
~id not significantly affect the medical response to the incident nor did
the failure in any way contribute to the ultimate death of ISN156.

I

I

I

I

I

d. tu/IfOUO) Available guards and the corpsmen from Camp V responded immediately
to thel (b)(1)(E) ~ arriving to the cell shortly after 1400. The guard team donned th~ei~r::":'::':":":':':::~
protective
, entered the cell, secured ISN 156, and began basic life support, wi Ib~~.~~~~~Ob.
and (1l)«~~~),~b~~gOb. alternating 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. ~\JlmoU~ 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 DB on weekends. (Facts 111-13,
Exhibit 112)
EtJI.q:QYQ) Discussion. Around 1425, the ambulance arrived from Camp V to the DH.
The registered nurse on duty at the BHUIDHI (6)(3):~).~~md6.'61~assessed the situation, and based on
the condition ofISN156 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

65
SECftE'fS?QOFORN

 demonstrated quick thinking and sound decision-making based on the circumstances. The stop
at the DH did not contribute to ISN156's death but could waste time in other circumstances.
9. f(:JlW9Y9) Finding: Several factors contributed to the ability ofISN156 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 eases, failure to comply with Med Pass SOP
requirements. These failures contributed to the death of ISN156 in that they permitted
ISN156 to be able to hoard medications. (Facts 190-200,208..10,212-27)

(U) Discussion.
a. (H'/F8UO~ The JOG SOP and the JMG SOP governing Moo Pass are inconsistent
with resnect to key orovisions.l

(b){7)(E)

b.

The JOG and JMG SOPs reauirel
(b){7}(E)

IThe failure contributed to the ability ofISN156to conceal medications.
c.

'."'.. The JMG SOP Drohibitsl

(b}(7)(E)

rnte failure may have contributed to the ability of ISN156 to ultimately hoard the
L.p":"lilll'l""s~
thla~t -w-ere-' found in his stomach.
10. ~/W889} Finding: The JMG training procedures and record keeping are flawed.
This contributed to the Moo Pass SOP violations and to confusion of JMG personnel.
(Facts 208-27)

66
~ISCIHii+//pjOrQI11'i

 gECRET//?iOFOR?i
(U) Discussion.

fU/;/fOUO) The JMG does not have a training officer or section devoted solely to the
training ofJMG procedures. The JMG training officer is a psychiatric mental health nurse at the
BHUIDH. She is required to see detainees, administer medications, and also oversee other
aspects ofnursing 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 ofnurses and corpsmen are consistent and proper.
8.

b. fU'lfOUO) The training records for the JMG nurses, corpsmen, and other medical
personnel are in many cases missing, incomplete, and/or do not reflect what the trainees later
indicate they understood from the training. Several ofthe 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 ofthe
JMG training program. Ultimately, the JMG Commander is responsible for the JMG training
program itself. The Senior Nurse Executive acknowledged deficiencies in the maintenance of
the training records, and indicated he is working to prevent the problem from happening again.
c. fU/.q:OUO) There exist deficiencies 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 ofJMG operations, or are aware ofthe SOPs and are choosing not
to follow them.
d. E'Q'K'OUO) Finally, although the JMG training certificates provided indicate that
corpsmen and nurses are bein trained
(b)(7)(E)
several corpsmen noted that
they in fact were told not
(b}(7}(E)
because it would anger the detainees. The
JMG Training Officer herself indicated that as of February 2012, thel
(b)(7)(E)
(b)(7)(E)
~ The few complete training records that exist for the nurses and
corpsmen indicate that in May 2012, trainees were required to sign a
(b)(7)(E)

I

I

(b)(7}(E)

11. (,"'W9B9} Finding: The JDG training program is well-supported, in that there is an
entire battalion headquarters S~3 section (from the 52Stb MP Battalion) devoted'to
ensuring that, among other things, guards are properly trained. (Facts 137-44)
(U) Discussion.
a. fl,J/JfOWO) The battalion 53 conducts the training of the JOG guards. The JOG

training records were provided promptly to the Investigative Team and were very weJldocumented and maintained.

67

 SECRETh'P;OFOR1#

b. EtJ/.q:QYQ) However, the guards at the BHUIDH are not currently receiving training
on the unique challenges presented by detainees housed at the BOOIDH. While the
responsibility to provide medical and mental health care to the detainees ultimately rests with the
JMG. the BHUIDH guards would better be able to perfonn their guard functions ifthey were at
least familiar with certain aspects of how the JMG administers care to psychiatric detainees.
12. tyilFelie~ Finding: There are other SOP violations impacting the operations of tbe
Camps. (Facts 145, 147, 153-58, 159, 161; Exhibits 41,109)
(U) Discussion.
a. ~;'}fOUO~ 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
ISNIS6. Pennitting 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.

b. fU/IfQl:IQ~ The JOG 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 BHUIDH 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 official laundry channels will only be replaced by the set number of items
authorized. To avoid creating problems with the detainees, the guards at the BHUIDH 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 ofthe impact
that their decisions have on the guard force.
13. fU"W~~ The JDG and JMG leadership are not communicating sufficiently wit~ each
other to ensure that their respective detainee operations practices and policies are
consistent and synchronized. (Facts 125-26, 147-48, 158, 195-200,205-07)
(lHlfOUO) Discussion: The JOG 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 oCthe differences with brevity codes SOPs and Med
Pass SOP. Guards working at the BHUIDH 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
infonnation down to the guards at the BHUIDH.

68

SECIl£T,Y?iOr8RPi

 14. f8/IP080) Finding: The JMG would be better served by a command and stafTthat is
solely focused on JMG operations. (Facts 205-07; Exhibits 31, 38)

(U) Discussion.
a. fYNfOUO) The Joint Medical Group Commander also serves as the Commander of
the Guantanamo Bay Naval Station Hospital. As such (b)i3l::~.~~gOb.lbl is dual-hatted. Although
there is some degree ofoverlap 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 eUITent commands are structured, (b)m::I.~~~~~50b.lbJ is not able to devote
the time and attention that JMG medical operations require.
b. ~J'fg~g) 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 BHUIDH and the camps. For example, the JMG Commander and the Senior Nurse
Executive both understandr

I

(b){7)(E)

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

15. flI/W9~9) Finding: The deficiencies and failures identified at the JDG and the JMG
are not solely attributable to the short rotation times. (Facts 125-228)

(UNrOVO) Discussion: Many ofthe deficiencies and failures identified in this
investigation are due to a failure to synchronize JOG and JMG SOPs, a failure of the JMG to
properly train the material contained in the SOPs, and a failure of the IDG and JMG to enforce
the SOPs once trained. Ultimately. the JOG Commander and the JMG Commander are
responsible for the SOPs, and ITF-GTMO is responsible for ensuring the synchronization 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 Briefdoes not provide a sufficient forum for the
JOG and JMG Commanders to exchange information regarding systemic problems affecting
JTF-GTMO detention operations, the JOG and JMG Commanders should, at a minimum. meet
biweekly to address such systemic problems.

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6ECRETNNOFORN

 SECM'flRfOfOftIV

2. Recommendation: Tbe JDG and JMG sbould syncbronize JDG and JMG SOPs to
ensure tbat they are consistent.

Discussion: By synchronizing SOPs, the JOG and JMG will eliminate inconsistent
provisions that currently exist, for example with respect to Medication Administration ("Med
Pa.ss") and Brevity Codes and actions to be taken in cases ofdetainee emergency. The SOPs
should be revised to ensure that IDG and JMG pet"30nnel are able to execute their respective
missions while taking on only acceptable risk. The JOG and JMG Commanders should be the
ones ultimately responsible for their respective SOPs.
3. Recommendation: Once the JDG and JMG Commanders synchronize their SOPs, they
should ensure that changes and updates are passed down to the guard force aud medi~l
personnel.

Discussion: Where there are specific provisions in the IDG and JMG SOPs that affect or
assign responsibility to the guards or medical personnel, the IDG and JMG Commanders should
ensure that the infonnation is not just flowing vertically (from the Commander down to the
operator) but also horizontally between the JOG 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 BHUIDH, the JDG should incorporate a block of training for guards
that are assigued to the BHUIDIL

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 offamiliarization 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 S2Stb MP BN should continue with the current rigorous and
comprebensive training program and training records maintenance it currently bas in
place to train JDG guards.

70
SECiHS'F;';?iSFOUN

 CHCRU'F.1?fOPORN
8. Recommendation: The JMG should establish a training section, whose sole
responsibility and mission is planning, coordinating, executing, and documenting aU
training of JMG personnel.

Discussion: The training of JMG personnel should be reinvigorated and reinforced to
ensure that lMG 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 retrain 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 specific reference to how failures to follow the SOP regarding line
of sight may have contributed to the death ofISN156. JOG and lMG training should include a
specific block, to be certified on the training records by the training officer, regarding line of
sight lOG and JMG Commanders should also consider re-introducing a document to reflect a
detainee's actions at regular intervals ~
(b)(7}(E)
t during line ofsight.
10. Recommendation: JDG and JMG Commanden and leadership must re-enforce and
re-train all personnel with respect to SOP requirements for Medication Administration
("Med Pass").

.....

---.11

To emphasize the real-world importance of following the
SOPs, the Medication Administration training should include specific 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 synchronized and made consistent their SOPs regarding Medication
Administration.

11. Recommendation: In the process of synchronizing their respective SOPs, the JDG and
JMG Commanders must analyze the risks and benefits associated with either not
specifically
(b)(7)(E)
Once the JDG and JMG
Commanders have analyzed the matter from a risk I benefit standpoint, they should revise
and finalize their SOPs to clearly reflect their determination regarding whether (b)(7)(E)

I

-

I

-,I

(b)(7)(E)

I

I

I

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

71

I

 6£CRETh?iOra itt,

Discussion: Commanders should engage the Preventive Medicine section to ensure that
the Preventive Medicine section is aggressively addressing the issue ofwildlife in the camps.
13. Recommendation: The JDG Commander should revisit the issue of whether to
(b)(7)(E)

Discussion: In revisiting the issue, the JDG Commander should consider consulting with
the ]MG Commander as the matter relates directly to the opportunities for detainees (b)(7)(E)

I

(b)(7)(E)

I

I

I

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

Discussion: Because ofthe 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 NAVSTA
Hospital Commander. During this interim period, USSOUTHCOM should engage the Navy to
assess and detennine 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 deficiencies in detainee
operations at JTF-GTMO across a broad spectrum of operations, to include medical, legal,
and intelligence, and security.

Discussion: The inspection program should require checklists for each section to identify
specific deficiencies 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 JTF-GTMO is promptly and effectively correcting identified deficiencies. The
Field-Grade-in-the-Wire program should be entirely revamped and invigorated or eliminated
altogether, as it is currently not detecting critical deficiencies in detainee operations at JTFOTMO.
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
reeommendatioDS made here.18'

189 Many ofthe recommendations in the report mirror recommendations from earlier investigations, specifically
Recommendations S and 13 from tho investigation into the death ofISNI0028 (18 May 2011) and

72

6ECRE'TH?lOFOR;'i

 SECRi3'f/.?i Sye Wi

Discussion: JTF-GTMO has not implemented many of the required changes identified 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 JOG and JMG Commanders to provide him
information with respect to the specific recommendations that fall to the JOG and JMG
Commanders.
17. Recommendation: Commander, USSOUTHCOM, refer this investigation to
Commander, JTF-GTMO, for appropriate corrective and/or administrative action.

Discussion: As noted in the findings, many of the deficiencies and failures identified in
this investigation are due to a failure to synchronizc JOG and JMG SOPs, a failure of the JMG to
properly train the matcrial contained in the SOPs, and a failure of the IDG and JMG to enforce
the SOPs 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 synchronization of
the SOPs, both the current JOG and JTF-GTMO Commanders were in the first 90-days of
command at the time of ISN 156 deaths.

Recommendations 1,2,3,4,8, 11, 12, 13, 16, 18 from the investigation into the death ofISN782 (1 February 2011).
(Exhibits 124, 125)

73