a'l?w?o U.S. Department of Homeland Security

i Immigration and Customs Enforcement
9.5.. 5: Office of Professional Responsibility

44m) 3635 Washington, DC 20536

External Reviews and Analysis Unit
Detainee Death Review

Kamyar SAMIMI
Date of Death December 2, 2017
Denver Contract Detention Facility
Aurora, Colorado

 

 

JICMS Case 

 

 

 

FOR INTERNAL USE ONLY. This document may contain sensitive commercial, financial, law
enforcement, management, and employee information. It has been written for the express use of the
Department of Homeland Security to identify and correct management and operational deficiencies. In
reference to OPR Directive 08006.1, issued 092205; any disclosure, dissemination, or reproduction of
this document, or any segments thereof, is prohibited without the approval of the Director, Office of

Professional Responsibility.

D?ice of Professions! Responsibility
Department of Homeland Security
950 L1 Enfant Plaza SW

Washington, DC 20536

PL Th!?

-. US. Immigration
and Customs
- Enforcement

Jr

on 

q?fn i0 3'

no it as

MEMORANDUM FOR: Matthew Albence
Executive Associate Director

Enforcement and Remova Operations 
1?
THROUGH: Waldemar Rodriguez WM [4

Associate Director
FROM: Jennifer M. Fenton %7 5917 geek

Assistant Directo 

 
 

SUBJECT: Findings Death of ICE detainee Kamyar SAMIMI

moms-

The Of?ce of Professional Re5ponsibility, External Reviews and Analysis Unit (ERAU), has
completed its investigation into the death of US Immigration and Customs Enforcement (ICE)
detainee Kamyar SAMIMI who died on December 2, 2018, while in ICE custody, at the
University of Colorado Medical Center (UCMC) in Aurora, Colorado (CO). The Adams 
Bakers?eld County Coroner?s Autopsy Report documented cause of death as
undetermined but listed chronic obstructive pulmonary disease and gastrointestinal
bleeding as contributing factors.

On November 17, 2017, ERO arrested SAMIMI at his residence in Denver, CO and served him
with a Notice To Appear (N TA) charging him as removable under section 237(a)(2)(b) of the
Immigration and Naturalization Act (INA) as an alien convicted of a controlled substance
violation. BRO transferred SAMIMI to the Denver Contract Detention Facility in
Aurora, CO, that same day.

During his intake screening on November 17, 2017, SAMIMI reported taking between 150-
190mg of methadone daily and stated he was experiencing methadone withdrawal 
Given longuterm use of high?dose methadone, nursing staff received orders from
DCDF ?s physician to house the detainee in medical observation, complete laboratory work, take
vital signs every eight hours, and give medications as needed for anxiety, restlessness,
sleeplessness, nausea, and pain. The physician did not order monitoring of 
withdrawal using any standardized instrument.2

 

The facility is also referred to as the Aurora County Processing Center, but is used throughout this
memorandum and the Detainee Death Review report for consistency.

2 The Clinical Opiate Withdrawal Scale (COWS) is a widely-recognized and used instrument for monitoring opiate
withdrawal. GEO also has a limited monitoring instriunent entitled, ?AlcoholfDrug Withdrawal Monitoring Sheet.?

 remained in the medical unit for the duration of his 16 days in detention, and his
laboratory test results were within normal limits, with the exception of an abnormally high
thyroid hormone and a low hemoglobin level. In contravention of physician?s orders,
nurses took vital signs only twice daily, on average (rather than every eight hours). Although
observed condition indicated a need for withdrawal medicatiocs, nurses administered
less than half of the doses ordered. physician never physically examined the detainee.

Mental health professionals saw SAMIMI on three occasions. A staff conducted
the initial evaluation in?person on November 20, 2017, and conducted the second
and third evaluations via on November 29, and November 30, 2017, respectively.
During the second evaluation, following his attempted suicide, the directed that
suicide watch level be lowered, prescribed medication changes, and ordered
monitoring of his withdrawal using COWS. Medical staff never completed any
COWS. During his ?nal mental health encounter, two days before his death, SAMIMI stated he
was stressed, depressed, and wanted to die due to his of methadone withdrawal. The
continued SAMIMI on suicide watch and his medications.

All of?cers interviewed observed signi?cant deterioration in condition, especially
during the 48 hours prior to his death, and expressed concern about the care provided by nursing
staff during interviews. Nursing notes prepared during detention, cerroborated by
video surveillance footage, re?ect a progressive deterioration in health, starting on
November 22, 2017. They include the following observations regarding his condition: tremors,
pain and weakness, nausea and vomiting, refusing meals, inability wheelchair, incontinence and signs of dehydration. The majority of nurses interviewed stated
they believed SAMIMI was malingering and seeking drugs throughout his stay and did not see
an urgent need to notify the physician of his worsening condition.

condition started to rapidly deteriorate the night of December 1, 2017, when he
appeared to spit up blood, complained of stomach pains throughout the night, and vomited
frequently. The morning of December 2, 2017, while two officers and a nurse attempted to
move SAMIMI into a wheelchair, he exhibited of seizure. The officers returned him
to his mattress where they observed him vomit and urinate on himself. Over the following
approximately six minutes, an RN made several unsuccessful attempts to contact the physician
for guidance on managing SAMIMI. Meanwhile, the officers contacted their Lieutenant, who
directed that 911 be called immediately. Emergency Medical Services (EMS) arrived on the
scene approximately four minutes later. SAMIMI stopped breathing shortly after their arrival,
and paramedics performed CPR during the detainee?s transit to the Emergency Room (ER). ER
staff were unable to resuscitate SAMIMI, and an ER physician pronounced his death at 12:02
pm.

ERAU reviewed compliance with the ICE 2011 (revised 2016) as they relate to
medical care, safety and security, and found DCDF did not comply with the
standards detailed below. These de?ciencies are noted for informational purposes only, and
should not be construed as contributory to the detainee?s death.

. ICE 2011 (revised 2016), Medical Care, Section states ?All facilities
shall provide medical staff and suf?cient support personnel to meet these standards.? At
the time of detention, DCDF had vacancies in key medical personnel,
including a Director of Nursing and a midlevel provider, for longer than six months.

. ICE 2011 (revised 2016), Medical Care, Section states, ?Each
detention facility shall have and comply with written policy and procedures for the
management of include: (12) documentation of accountability for
administering or distributing medication in a timely manner, and according to licenses
provider orders.? In spite of frequent and progressive complaints related to
of withdrawal, nurses administered less than 50% of physician-ordered
withdrawal medications to be given on an as needed basis.

. ICE 2011 (revised 2016), ilat?ca'icarl Care, Section states, ?Where there is a
clinically signi?cant ?nding as a result of the initial screening, an immediate referral
shall be initiated and the detainee shall receive a health assessment no later than two
working days from the initial The intake nurse documentation of
possible early opioid withdrawal did not result in an initial provider
assessment within two working days of intake.

. 2011 (revised 2016), Medical Care, Section states, ?Detainees
experiencing severe or life-threatening intoxication or withdrawal shall be transferred
immediately to an emergency department for evaluation. Once evaluated, the detainee
will be referred to an appropriate facility quali?ed to provide treatment and monitoring
for withdrawal, or treated on-site if the facility is staffed with quali?ed personnel and
equipment to provide appropriate care.? DCDF medical staff failed to transfer SAMIMI
to an ER even though he exhibited life threatening withdrawal in the week
following his intake.

. ICE 2011 (revised 2016), Medicai Care, Section states, ?Each facility?s
health care provider shall conduct a comprehensive health assessment, including a
physical examination and mental health screening, on each detainee within 14 days of the
detainee?s arrival unless more immediate attention is required due to an acute or
identi?able chronic condition.? DCDF failed to complete an initial physical assessment
during the 15 days SAMIMI was housed at the facility, in part due to the absence of a
midlevel provider.

. ICE 2011 (revised 2016), Medical Care, Section states, ?Where a
detainee has a serious medical or mental health condition or otherwise requires special or
close medical care, medical staff shall complete a Alert form (IHSC-
834) or equivalent, and file the form in the detainee?s medical record.? Medical staff did
not complete a alert for SAMIMI.

. ICE 2011 (revised 2016), Medical Care, Section states, ?An initial
dental screening shall be performed within 14 days of the detainec?s arrival. The initial
dental screening may be performed by a dentist or a properly trained qualified health

provider.? Medical staff did not schedule SAMIMI for a dental screening examination.

8. ICE 2011 (revised 2016), Medical Care, Section states, ?An on-call
physician, dentist, and mental health professional or designee, are available 24 hours per
day.? Nurses reported dif?culty reaching Dr. outside of his work hours. On the
day of death, the physician did not answer or return two phone calls.

9. ICE 2011 (revised 2016), Medical Care, Section which states,
?Distribution of medication (including over the counter) shall be performed in
accordance with speci?c instructions and procedures established by the HSA, in
consultation with the CMA. Written records of all prescribed medication given to or
refused by detainees shall be maintained.? Nurses failed to document administration of
medications on numerous occasions.

10. ICE 2011 (revised 2016), Medical Care, Section which states, ?The
facility administration and clinical medical authority shall ensure that the Field Of?ce
Director is noti?ed as soon as practicable of any detainee housed at the facility who is
determined to have a serious physical or mental illness or to be pregnant, or have medical
complications related to advanced age, but no later than 72 hours after such
determination. The written noti?cation shall become part of the detainee?s health record
DCDF did not notify the Field Of?ce Director that SAMIMI was withdrawing from
methadone and that his condition deteriorated during the detention period.

11. 2011 (revised 2016), Medical Care, Section which states, ?Prior
to the administration of medication, a separate documented informed
consent, that includes a description of the medication?s side effects.? An informed
consent speci?c to the antidepressant/sedative Trazodone was not completed and signed
by the detainee.

12. 2011 (revised 2016), Signi?cant Self Harm and Suicide Prevention and
Intervention, Section (V which states, ?All suicidal detainees placed in an isolated
con?nement setting will receive continuous one?to-one monitoring, welfare checks at
least every 8 hours conducted by clinical staff, and daily mental health treatment by a
quali?ed clinician.? Nursing staff did not conduct a welfare check on SAMIMI during
the 14 hours between his placement on suicide watch and his evaluation via tele-



In addition to these ?ndings of non-compliance, ERAU identi?ed several areas of concern which
are discussed in the attached report.

If you have any questions, lease contact me or have a member of your staff contact Unit Chief,
(202)732 

Attachment

cc: Peter T. Edge

 

 



 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

SYNOPSIS

On December 2, 2017', Kamyar SAMIMI, a sixty-four year old citizen of Iran, died while in the
custody of US. Immigration and Customs Enforcement (ICE) at the University of Colorado
Medical Center (UCMC), in Aurora, Colorado (CO). The Adams Broom?eld County
Coroner?s Autopsy Report for Kamyar SAMIMI listed the cause of death as undetermined. The
report listed chronic obstructive pulmonary disease and gastrointestinal bleeding as
contributing factors.

SAMIMI was detained at Denver Contract Detention Facility in Aurora, CO, from
November 17', 2017, until his death. DCDF is privately-owned and operated by the GEO Group,
Inc. (GEO) and is required to comply with the ICE Performance Based National Detention
Standards 2011. Medical care at DCDF is provided by Correctional Care Solutions
(CCS). At the time of death, DCDF housed approximately 7?36 ICE detainees of all
classification levels for periods in excess of 72 hours.

DETAILS OF REVIEW

From January 9 to 11, 2017, ICE Of?ce of Professional Responsibility, External Reviews and
Analysis Unit (ERAU) staff visited DCDF to review the circumstances surrounding 
death. ERAU was assisted in its review by contract subject matter experts (SME) in correctional
healthcare and security.2 contract SMEs are employed by Creative Corrections, a
national management and consulting firm. As part of its review, ERAU examined immigration,
medical, and detention records pertaining to SAMIMI, in addition to conducting in-person
interviews of individuals employed by GEO, CCS, and the local ?eld office of Of?ce of
Enforcement and Removal Operations (ERO).

During the review, the ERAU team took note of any deficiencies observed in the detention
standards as they relate to the care and custody of the deceased detainee and documented those
deficiencies herein for informational purposes only. Their inclusion in this report should not be
construed in any way as indicating the de?ciencies identified contributed to the detainee?s death.
ERAU determined the following timeline of events, from the time of SAMIMI's apprehension
by ICE, through his detention at DCDF, and eventual death at UCMC3.

IMMIGRATION AND CRIMINAL HISTORY4
In 1976, the legacy Immigration and Naturalization Service (INS) admitted SAMIMI to the

United States (U.S.) through New York, NY, under an F?l non-immigrant student visa. In 1979,
SAMIMI adjusted his status to Lawful Permanent Resident (LPR) based on his marriage to a

 

1 The facility is also referred to as the Aurora County Processing Center, but is used throughout this report
and the accompanying memorandum for consistency.

2 See Exhibit 1: Creative Corrections Medical and Security Compliance Analysis.

3 Throughout the narrative, several event descriptions are supplemented by a description of the corresponding
Closed Captioned Television (CCTV) footage. Additionally, although referenced specifically on certain dates, the
entirety of the detainee?s vital signs and medication administrations are captured in tables found in Appendix 1, and

Appendix 2, respectively.
4 See Detainee Death Notice.

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

US. citizen. SAMMI applied for naturalization in 1985, and the INS denied his application in
198?}' for failure to submit the proper documentation.

On June 9, 2005, SAMIMI plead guilty to Possession of a Controlled Substance (Schedule 2)
and Possession of Drug Paraphernalia. He received a deferred sentence (2 years) and 64 days of
public service.

On November 17, 2017, ERO arrested SAMIMI at his residence in Denver, CO and served him
with a Notice To Appear (NTA) charging him as removable under 23T(a)(2)(b) of the
Immigration and Naturalization Act (INA) as an alien convicted of a controlled substance
violation. ERO transferred SAMIMI to the DCDF that same day.

NARRATIVE

On November 17, 2017, at 4:00 pm, SAMIMI arrived at DCDF. Security staff appropriately
classi?ed him as medium-low based on his criminal history and assigned him to a general
population housing unit.5 At approximately at 9:30 pm, prior to being housed, SAMIMI
received a medical intake screening by Licensed Practical Nurse LPN
noted that SAMIMI spoke English. vital signs were all within normal limits?



with the exception of an abnormally-elevated blood pressure of 14694. His height was five feet,
seven inches tall, and his weight was 135 pounds. LPN- documented that SAMIMI
reported taking 190 milligrams (mg) of methadone daily and that he was suffering withdrawal
though she did not specify how long he had taken methadone or the date of his last
use.3 The intake screening form prompts the user to document evident of withdrawal;
not include any for SAMIMI because, according to her, SAMIMI was stable and
steady on his feet and did not appear to have tremors or other withdrawal 

LPN *ecalled that the only SAMIMI reported was anxiety and that he

repeate stated he needed methadone for chronic back pain caused by a car accident. 10
SAMIMI reported sharp back pain at a level five on a scale of zero to ten? during screening.
5 reported substance abuse history included consumption of two to three beers
occasionally over the past thirty years, cocainet?crack one time weekly over the past twenty years,
marijuana once weekly and opium daily twenty years prior. He also reported smoking ten
cigarettes a day, his last having been ten hours earlier. '3

 

5 See ICE Custody Classi?cation Worksheet, dated November 201?.

?5 Normal temperature is 98.6; normal range for pole is 60 to 100 beats per minute; normal range for respirations is
12 to 20 breaths per minute; and, normal blood pressure is 120030, with 90f60 to 139E519 considered within normal
range. See Exhibit 1. 

I See Exhibit 2: GEO Medical Intake Screening by LPN dated November 201?.

ERAU Interview with LPNI- dated December 09, 201?.

9 Early signs of opiate withdrawal include running nose, sweating, tearing, yawning, dilated pupils, and increased
temperature. Later signs include loss of appetite, nausea, vomiting, diarrhea, goose flesh, increased blood pressure,
increased pulse, restlessness, and severe muscle and joint pain. See Exhibit 1.

ERAU Interview with LPN dated December 09, 2017.

The zero to ten scale is a standardized method ofdetermining patient pain presence and severity, allowing
practitioners to determine the need for and the effectiveness ofpain treatment. Zero indicates no pain, while a level
ten indicates the worst pain one has ever experienced. See Exhibit 1.

?3 See Exhibit 2: GEO Medical Intake Screening by LPN ted November 17, 201?.

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

LPN added SAMIMI to the ?blood pressure list?, which required medical staff to conduct
blood pressure checks three times weekly for two weeks and referral to a provider for elevated
blood pressure.? placement on the blood pressure list effectively identified him as a
chronic care patient. 14

LPN initially cleared SAMIMI for general population; '5 however, 

_directed security staff to bring him to the clinic before housing him after LPN
noti?ed her of his reported withdrawal. When RN spoke with SAMIMI, he stated
that he took 190 mg of methadone on a daily basis for detoxification from other drugs. ?5
SAMIMI signed a consent for medical, dental, and mental health services?r and an authorization
for DCDF to obtain his health information. ?1 A screening chest x-ray completed during
intake screening showed no acute cardiopulmonary disease or evidence of active
tuberculosis. 19

After evaluating SAMIMI, RN (bli?liiblmicl called Dr. (131151113117) to report the detainee?s
methadone use and documented receipt of the following telephone orders from Dr. 

1. Statl' laborator studies to include a com lete blood count,22 com rehensive metabolic

panel,23 thyroid stimulating hormone,24 and formal urine.25 RN (bll?lilblmicl drew the

blood samples and sent them for laboratory testingz?i'

2. Medications for withdrawal, to include:27

 

?Id.

?4 ERAU Interview with HSA dated December 09, 201?.

?5 ERAU Interview with LPN dated December 09, 201?.

ERAU Interview with RN dated December 09, 201?.

?7 See GEO Consent to Medical, Dental, Mental Health Services and Medical Interpretation, dated November 
201?.

See GEO Authorization to Disclosei'Obtain Protected Health Information, dated November 2017.

19 588 Paci?c Mobile Radiology Report, dated November 18, 2017.

3? RN did not document whether the orders were read back to verify accuracy, and Dr. did
not sign to authenticate his verbal orders. The Colorado Revised Statutes Title 25 Health 25?3?1 1 requires verbal
order authentication within 48 hours, unless a read?back and verify process is in place, in which case the
authentication must occur within 30 days.

21 Stat means immediate. See Exhibit 1.

22 A complete blood count is a test that provides information about the various cell concentration in a patient?s blood
to assist in disease diagnosis. See Exhibit 1.

23 A comprehensive metabolic panel is a test that provides information about the status of your metabolism,
including kidney and liver function, electrolyte balance, blood glucose, and blood proteins, in order to monitor such
conditions as hypertension and diabetes. See Exhibit 1.

2'4 A thyroid stimulating hormone (TSH) test is a blood test that measures the level of this hormone to determine if
the thyroid gland is functioning properly. See? Exhibit 1.

25 A formal urine, or urinalysis, is a test that analyzes the culture and contents of a urine sample. 3ch Exhibit 1.

2? ERAU Interview with RN dated December 09, 201?. According to RN she drew
blood samples and sent them to the laboratory that same night; however, the laboratory report documents their
receipt date as November 20, 2017.

37 Dr. ordered all withdrawal medications on an as needed basis. Per Creative Corrections, standard
nursing practice calls for assessment of patient prior to administration of as needed medications, and
documentation of the justi?cation for administration in a nursing note and recordation of the administration in both a

3

      
     

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

I Ativan28 1 mg intramuscularly up to three times daily as needed for 15 days.29
I Clonidine30 0.1 mg orally up to three times daily as needed for 15 days.

m: As noted by Creative Corrections, GEO Clinical Practice
Guidelines (CPG) for opiate withdrawal calls for giving clonidine in doses
of to 0.2 mg orally three to four times daily, as a means of controlling
hypertension and somnolence,? and suggests interval dosing at speci?c
times rather than on an as needed basis. Although Dr. ordered
administration as needed, the Medication Administration Records (MAR)
for both clonidine and Ativan set 9:00 am, 3:00 pm, and 9:00 pm, as
the times for administration. The MAR entries for all of 
ordered medications were inconsistent throughout the detention period,
with times not recorded at all or noted at times which did not align with
nursing notes. Regarding the irregular MAR entries, RN
stated that at least for clonidine, nurses selected whichever of the three set
times was closest to when they gave SAMIMI a dose. Per Creative
Corrections, by failing to document the actual time they gave clonidine,
Ativan, and other medications, the nurses risked administering those
medications either in a premature or delayed manner.

Additionally, the CPU states blood pressure and heart rate levels must be
obtained prior to each dose of clonidine, and that the medication should be
withheld if systolic blood pressure32 falls below 90. Dr. order
did not include this guidance. Because nurses documented taking
vital signs less than half the time ordered, and because they did
not consistently and accurately document the times they administered
clonidine and other medications, record does not demonstrate
whether his blood pressure was taken before he received clonidine. As
noted by Creative Corrections, and detailed in Appendix 1, 
blood pressure was in the normal range when taken, which suggests the
clonidine effectively controlled any hypertension caused by his
withdrawal.

- Cyclobenaaprine33 10 mg orally up to three times daily as needed for 15 days.
0 Ibuprofen??4 800 mg orally up to three times daily as needed for 15 days.
0 Phenergan35 25 mg orally up to three times daily as needed for 15 days.

 

nursing note and on the MAR. medical record re?ects that nurses did not consistently document
assessment of his to determine the need for medications, nor did they consistently document
administration in either a nursing note or on the MAR.

23 Ativan is a medication to treat anxiety. See Exhibit 1.

29? RN note documents 1mg of Ativan was administered intramuscularly in the right deltoid on this
date; additionally, the administration of the medication was not recorded on the MAR.

3? Clonidine is a medication with sedating properties, used to treat high blood pressure. See Exhibit 1.

3] Somnolence is a state of feeling drowsy, increasing risk of injury. See Exhibit 1.

Systolic blood pressure is reflected in the top number. See Exhibit 1.

Cyclobenzaprine is a muscle relaxant medication. See Exhibit 1.

Ibuprofen is a medication to treat pain. See Exhibit 1.

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

3. Hold (house) in medical.
4. Appointments with and physician.

- SAMIMI was seen by the on November 20, 201723?3 described
below, but nursing staff never added him to Dr. Provider Appointment
Log, despite the doctor?s order and the clinically-signi?cant findings identified
during the intake screening. 37

5. Increase and encourage ?uids.

6. Vital signs every eight hours until further notice.38

. Although RN created a MAR for vital signs which
speci?ed they be taken every eight hours, nurses did not make any notations on
the vital signs MAR throughout his detention. Nurses only documented vital
signs in their notes, and on three occasions (November 25, November 30, and
December 1, 2017) documented blood pressure readings on a separate Blood
Pressure Record. Further, nursing notes show vital signs were taken
only once or twice per day rather than every eight hours. Health Services
Administrator (HSA) stated nurses mistakenly understood that vital
signs were to be conducted once per shift, and because many worked 12 hour
shifts, vital signs were not taken every eight hours as orderedsl9 Additionally,
SAMIMI was not weighed again following intake, and his pulse oxygen
saturation was not consistently taken with vital signs. Dr. stated pulse
oxygen saturation and body weight should typically be taken when obtaining vital
signs.?

Dr. stated that his orders were based on CPG for opioid withdrawal.? Dr.
stated he opted not to order an EKG as recommended in the CPG because he thought it
more important to have the laboratory tests done. Dr. indicated that opioid withdrawal
assessment instruments provide guidance, but they ?are not really protocol." He added that
detainees typically finish withdrawing in three to four days, but because SAMIMI reported use
of high dose methadone over several years, his withdrawal was prolonged. Creative Corrections
notes that while the CPG does not address use of an assessment instrument, the National

 

35 Phenergan is a medication with sedating and pain control properties, used to treat nausea. See Exhibit 1.

3? Sea GEO Mental Health Evaluation, dated November 20, 2017.

37 SAMIMI was not physically examined by the physician during the detention period.

33 See Appendix 1: SAMIMI Vital Si_ns, for all vital signs recorded by medical staff through the detention period.
ERAU Interview with HSA dated December 09, 201?.

4? ERAU Interview with Dr. (bll?liibll dated December 10, 201?.

4] Dr. and HSA both noted the GEO CPG mirrors that of the Federal Bureau of Prisons.

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

Commission on Correctional Health Care mandates monitoring using validated
instruments.43

 

 

 

At approximately 10:30 RN conducted a nursing round during which
SAMIMI stated he felt terrible. vital signs were within normal limits with the
exception of a elevated blood pressure of 130r?94. He denied chest and abdominal pain
but complained of generalized level eight pain.44 RN _1oted SAMIMI reported
nausea and vomiting two hours earlier and described his emesisql5 as ?hardly anything" and
?greenish? in color. He reported he had a ?watery? bowel movement on November 20, 201146
oted tremors in his hands and an unsteady gait. Her nursing plan included
continued monitoring and encouraging ?uid intake.47

 

Security staff assigned SAMIMI to medical observation cell 537 per Dr. order, 43 and
at 11:14 pm. SAMIMI entered the cell unassisted and made his bed without difficulty.49 icer
was the assigned medical of?cer when SAMIMI arrived. Of?cer described
SAMIMI as very talkative and very thin. She recalled a nurse obtained a blood sample, but
SAMIMI was unable to provide a urine sample. SAMIMI asked for Gatorade, which Of?cer

btained from nurses in powdered version and provided to 


0)

 

 


Cl

 

 

 

On November 18, 2017, SAMIMI accepted all three meal trays but declined both recreation and

Wmted that when she collected the detainee?s breakfast tray, she noted

all items were consumed, but when she returned to duty for the evening shift, some of the dinner
meal remained on the tray}?2

 

42 DCDF was at the time of detention; the facility is due for re?accreditation in 2Ul8.
43 The Clinical Opiate Withdrawal Scale is the most widely?recognized and used instrument. Although
GEO has a limited instrument titled, ?AlcoholfDrug Withdrawal Monitoring Sheet," neither a COWS nor the GEO
instrument were completed during detention.
44 RN?did not document the location or nature of the pain.
45 Emesis is vomit, via the forceful expulsion of the contents of one's stomach through the mouth and sometimes the
nose. See Exhibit 1.
4? November 20, 2017. was three days after the date ofthis encounter. admitted the date recorded
was an error and could not recall the date SAMIMI reported.
47 see GEO Medical Observation Nursing Progress Record by dated November 17, 2017.
45 Cell 537 is accessed via an enclosed anteroom which includes a sink. The door to the cell has a window in the top
half, and to the left ofthe door is another large viewing window. The cell has a single bed on the left, a toilet behind
a half wall and a shower behind a full wall. A camera is in the upper left corner of the cell. A monitor on the

desk displays live video feed of the interior of all cells in the clinic.
49? Sec GEO e, dated November 17', 201?.
5? ERAU Interview with Officer dated December 10. 201?.
5] SAMIMI's Medical Unit Housing Record Log does not document that he ever accepted the opportunity to
shower. While officers would not necessarily have noticed and recorded his use of the shower within cell 537.
showering after placement on suicide watch would have necessitated release from the cell to do so and entry in the
log by the officer. No officer interviewed recalled SAMIMI ever showering.

53 ERAU Interview with Officer btiigi?f dated December It}, 201?.

 

 

 

 

 

 

 


0)

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

RN completed a GEO Alcohol Withdrawal Assessment and Treatment Flow Sheet
(Clinical Institute Withdrawal Assessment (CIWAD53 at 1:45 p.m.5?4 SAMIMI was given a
CFWA score of seven, indicating the level of alcohol withdrawal did not require medication
treatment. Creative Corrections notes that the CIWA is speci?c to alcohol withdrawal, and
although many of the same are experienced by persons withdrawing from cpioids,
there are clinical differences which are factored in scores on the respective assessment forms.
RN stated that she knows that alcohol and opioid withdrawal are clinically
different and that she inadvertently used the wrong form.?55

SAMIMI consumed an unspeci?ed amount of water at 4:40 p.m. and ate 40 percent of his dinner
at 4:50 pm. SAMIMI reported his last bowel movement was the previous day. His skin was
warm and ?ushed, and he complained of headache pain at a level sixf?6:00 pm. documented that SAMIMI was experiencing nausea. vital

signs were tormal limits. He denied all pain but appeared pale. With the exception of
nausea, did not document any signs or of withdrawal. SAMIMI reported
his last bowel movement was earlier in the day, and that he ate approximately 7'0 percent of his
evening meal.57

 

 

 

 

At approximately 10:00 SAMIMI spoke with LPV and indicated he had pain in
his back, that the back pain was due to a previous car accident, and that he took methadone for
pain. SAMIMI was alert and oriented with no shortness of breath or distress observed. He
complained of methadone withdrawal including a stomachache and shivering. LPN
(more: stated she informed RN of and believed RN-
consulted Dr. However, medical record contains no

documentation RN (13115111311010) contacted Dr. 113115111311??

 

On November 19, 2017, SAMIMI accepted all three meals and declined recreation and a
shower. The medical officer noted at 10:40 that SAMIMI said he was in a lot of pain. The
of?cer informed Nurs_at 10:42 and at 10:4?1r am. Nurs-gave
SAMIMI ibuprofensg Nurses did not create documentation of any nursing rounds or progress
notes in the medical record this date. HSA acknowledged during interview that nurses
should have documented all encounters with 

 

53 CIWA is a tool used to assign points speci?cally to of alcohol withdrawal, with total scores indicating
the severity of withdrawal. Per the CIWA, a score of 15 or higher indicates severe alcohol withdrawal. See Exhibit
1.

5'4 See GEO Alcohol Withdrawal Assessment and Treatment Flowsheet. dated November 18-26. 201?.

55 ERAU Interview with RN dated December 09, 201?.

5? See GEO Medical Observation Nursin Progress Record by dated November 18. 201?.

1? ERAU Interview with RN?dated December 11. 201?.

53 See GEO Medical Progress Note LPN ?ted November is, 2017. ERAU notes LPN (most
erroneously referred to RN as RN-in her note on this date.

59 See GEO Medical Housing Unit Lo_, dated November 19, 2017.
ERAU Interview with HSA dated December 09, 201?.

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

On November 20, 2017, SAMIMI accepted all three meals.? RN 111311511me} loomleted
a CIWA form, with a genre of 13, at 9:30 but did not initial or sign it.62 
recorded vital signs were within normal limits except for a elevated blood

pressure. She applied points on the CIWA for of nauseafvomiting, tremors, and
163

paroxysma sweating, and anxiety.? As noted by Creative Corrections, althouh the CIWA
was not the proper assessment instrument, the categories in which RN applied points

are of opioid withdrawal.

Dr.? conducted a mental health evaluation for SAMIMI at 1:15 pm.
SAMIMI denied a history of suicidal or homicidal intent, self-harm, alcohol use, domestic
violence, sexual assault, or violence toward self or others. SAMIMI reported he first used opium
in Iran when he was four years old, and explained that his grandfather, a doctor, administered the
narcotic to him for an earache. He said he made a decision to use opium recreationally at the age
of 14 while still in Iran. SAMIMI reported he migrated to methadone in 1991, at the
recommendation of a mental health professional, and has taken methadone daily since that time.
SAMIMI responded to questions logically and cooperatively, was fully oriented, exhibited no
signs of and denied delusions or hallucinations as part of withdrawal?5

 

 

 

At 7:00 SAMIMI spoke with RN SAMIMI denied pain or nausea, although
RN observed he had tremors and appeared anxious. RN did not
record vital signs during this encounter but gave SAMIMI an injection of Ativan, which she
administered in the right deltoid muscle. She did not record the dose of Ativan on the MARE

On November 21, 2017, SAMIMI accepted all three meals but declined recreation and a
shower.? Dr. received and signed the results of laboratory tests ordered on
November 17", 2017. All tests were within normal limits with the exception of a low
hemoglobin level and an elevated thyroid hormone level. During interview, Dr. called
the lab results ?excellent? overall and cited them as a reason he was not concerned about the
ability of DCDF to manage withdrawalbg At 6:30 SAMIMI spoke with RN
and denied pain but appeared anxious and was experiencing tremors. His vital
signs were within normal limits. RN ZMI gave SAMIMI Ativan, which she
administered in his right deltoid muscle, which she did not document on She
also encouraged the detainee to consume ?uids. Her nursing plan included continued
monitoring.

 

 

1? See GEO Medical Housin Unit Lo dated November 20, 201?.

?52 ERAU Interview with RNHdaled December 09, 2017. RN stated she is untrained in
opiate withdrawal monitoring and is therefore unfamiliar with an appropriate assessment instrument such as the
COWS or GED Form.

?3 A paroxysmal is a sudden recurrence or intensi?cation of See Exhibit 1.

Sea GEO Alcohol Withdrawal Assessment and Treatment Flowsheet, dated November 18-26, 201?.

See Mental Health Evaluation by dated November 20, 2017.

See GEO Medical Progress Note by RN dated November 20, 2017.

Sat? GEO Medical Housin_ Unit Lo_, dated November 21, 2017.

?g ERAU Interview with Demigdated December 10, 201?.

?g Sat? GEO Medical Progress Note by RN dated November 21, 2017'.

 

 


Cl

 

 

 
 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

On November 22, 2017, SAMIMI accepted all three meals but declined recreation and a
showerm At 6:00 SAMIMI Spoke with RN- who documented SAMIMI complained
of nausea and vomiting, generalized pain, tremors, and shivering related to methadone
withdrawal. vital signs were all within normal limits. SAMIMI reported his last
caloric intake was at 5:00 pm. at which time he ate 50 percent of his dinner, and he complained
of nausea after eating. RN- nursing plan included continued monitoring, administration
of medications, and increasing ?uids as tolerated.71

On November 23, 2017, SAMIMI accepted all three meals but declined recreation and a
shower.T2 At 11:15 am, RN observed that SAMIMI was alert and oriented,
with mild hand tremors and level four generalized pain. vital signs were all within
normal limits. RN- encouraged SAMIMI to increase his ?uid intake.B

At 1:30 RN-spoke with SAMIMI, who complained of pain and weakness and spent
most of the shift in bed. His vital signs were all within normal limits with the exception of a
mildly elevated blood pressure of 

On November 24, 2017, SAMIMI did not accept any of his three meals and declined recreation
and a shower. The medical of?cer noted that SAMIMI did not eat breakfast due to abdominal
pain and that he notified a nurse.TS

During the early morning hours (4:11 am. to 7:45 am), the medical officer logged that
SAMIMI had difficulty sleeping, asked for ice chips, and cried out for a nurse several times due
to abdominal pain. The officer logged notifying a nurse of 5 complaints and receiving
permission to give the detainee ice chips. The officer logged that a nurse did not assess SAMIMI
until 11:15 am, at which time the nurse administered medications and approved more ice chips.
The medical record contains no entries addressing these events.

At 1:45 pm, Of?cer?conducted a security round. SAMIMI approached his cell

door and told her he was having abdominal pain. She told him she would notify nursing staff,
but before she left to get a nurse, SAMIMI fell to the floor of his cell. Of?cer _called
for nursing assistance,? and RN Captain and other responders arrived.?

RN :tated that when he arrived, SAMIMI was unresponsive and lying on his back on the
floor. RN _applied a sternal rub, and SAMIMI began to regain consciousness. RN-
stated he assisted SAMIMI into a seated position, at which time the detainee made contact
and stated he had not eaten in four days. He then lost consciousness a second time. RN-
who also responded, performed a second sternal rub, SAMIMI regained consciousness, and the
nurses assisted him into a seated position on his bed. SAMIMI complained of nausea, vomiting,

 

See GEO Medical Housing Unit Log, dated November 22, 201?.

7] See GEO Medical Observation Nursing Progress Record by RN (filt?l?, dated November 22. 2017.
See GEO Medical Housing Unit Log, dated November 23, 201?.

1? See GEO Medical Progress Note by RN dated November 23, 201?.

edical Progress Note by RN lifllC} dated November 23. 2017.

75 Sec GEO Medical 0 dated November 24, 2017.

7" Sec GEO General Incident Report by Of 1cer dated November 24, 2017.

77 Sec GEO Medical Housing Unit Log, dated November 24, 2017.

 

 

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

and being unable to eat. He requested to lie down, and the nurses assisted him to the supine78

position. RN-conducted a nursing assessment and found pupils were equal,
round. and reactive to light. RN-did not assess SAMIMI for possible injuries resulting
from his fall. vital signs were within normal limits with the exception of an
abnormalli elevated pulse rate of 102, and an abnormally low oxygen saturation of 93 percent.
RN ?235,811?) documented the detainee was dehydrated, possibl dru-seeking. and noted the
nursing plan was to administer Ativan and Phenergan. RN-provided education on diet,
medications. and the imiortance of good nutrition and ?uid intake. and SAMIMI acknowledged

 

understanding.? RN did not document whether he contacted Dr. (ensues?) regarding
dehydration and withdrawal but stated during interview that Dr. (bll??liibll?)
is difficult to reach when not at the facility, and he may not have attempted to contact him on this
date.

DCDF CCTV footage documented the following sequence of events following fall: 8?

I At 1:50:39 pm, SAMIMI lay on his back on the floor, and Of?cer left to get
assistance.

0 At 1:50:52 pm, Officer returned to the cell and opened the cell door.

I At 1:51:51 pm, RN entered the cell, stepped over the detainee, donned gloves,
kneeled at the detainee? 5 side to check his pulse, and then performed a sternal rub.

. At 1:52:27 RN -pulled SAMIMI to a sitting position. As seen in the footage
head visibly lolls, and the detainee does not appear to be conscious.

I At 1:53:38 pm, RN -entered the cell, and RN repositioned so his
back faced the wall away from his bunk, and RN -appeared to check 
head.

. At 1:54:54 pm, RN-and RN -lifted SAMIMI and moved him to the bed.
SAMIMI appeared limp but was able to sit with support. RN- wheeled in the
mobile electronic vital signs monitor and applied the cuff to the left arm.
After removing the cuff, RN-left with the blood pressure machine.

0 At 1:58:04 pm, RN -eturned with a pulse oximeter which he placed on the
detainee?s ?nger.

I At 1:58:43 pm, SAMIMI motioned to RN-to bring him the wastebasket from the
corner of the room. RN-placed the wastebasket in front of him and 
vomited into it. He then placed both arms on the basket for support and placed his head
directly over the basket. After a minute, RN-pulled SAMIMI away from the
wastebasket. and the detainee sat up on the bunk unassisted. After another minute. RN

-left SAMIMI alone in the cell.

At 3: 12 pm, Office-ogged that SAMIMI appeared to be doing much better.

At 8:30 pm. RN -spoke with SAMIML and the detainee complained of nausea and
vomiting. vital signs were all within normal limits, with the exception of a 

 
    

   
    

 

75? The supine position means lying face up. See Exhibit 1.
79 See GEO Medical Progress Note by RN dated November 24, 2017.
8? See GEO CCTV footage, dated November 24, 2017.

10

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

elevated temperature of 98.8 si - nifying a slight fever. SAMIMI stated his last bowel movement
was the previous day. RN inoted dinner intake at 5:00 pm. was 50 percent.
RN {E?ifiilbl? oted SAMIMI had signs and of withdrawal, but no tremors or seizures.
RN nursing plan was to continue monitoring the detainee and encourage food and
nutritional intake.81

 

 

 

 

On November 25, 2017, SAMIMI refused all three meals and declined both recreation and a
shower.HE At an undocumented time, RN- spoke with SAMIMI, and he complained of
abdominal pain at a level six, with weakness, nausea, and vomiting. vital signs were
all within normal limits, with the exception of a mildly-elevated blood pressure. 
heart, lungs, and abdomen were normal, and he reported having his last bowel movement the

previous day.33 RN did not document whether he gave the detainee any medications.

At 6:30 RN noted that SAMIMI was lying in bed and stated he did not sleep
the previous night. SAMIMI's vital signs were all within normal limits with the exception of a
blood pressure.34 RN completed a CIWA which resulted in a
score of 17 based on nauseafvomiting, tremors, anxiety, and paroxysmal sweating.35
In her note, RN documented she gave the detainee Phenergan for complaint of
nausea and instructed SAMIMI to pick up his trash, clean his room and to stay up as much as
possible during the day. RN did not record administration of Phenergan on the


On November 26, 2017, SAMIMI refused all three meals and declined both recreation and a
shower.?

At 12:00 131.111., RN-- spoke with SAMIMI, and SAMIMI complained of having
pain all over but did not report a pain level. SAMIMI was alert and oriented, his lung sounds
were clear, and heart and abdominal assessments were normal. vital signs were
within normal limits with the exception of an abnormally-elevated pulse rate. RN Idid
not observe any vomiting. speech was slurred, and RN observed he
appeared unsteady but gained steadiness when she encouraged him to walk. SAMIMI did not
recall his last bowel movement and was uncertain of the last time he ate. RN nursing
assessment was ?possible withdrawal,? and her nursing plan included continuation with his plan
of care and monitoring his food intake.38

 

 

5] See GEO Medical Observation Nursing Progress Record by RN Muiru, dated November 24, 2017.

52 See GEO Medical Housing Unit Log, dated November 25, 201?.

53 See GEO Medical Observation Nursing Progress Record by RN Aboye, dated November 25, 2017.

8'4 See GEO Medical Progress Note by RN dated November 25, 2017.

85 Creative Corrections notes RN incorrectly calculated the CIWA score. The correct total was 13
which, according to the form, indicates moderate alcohol withdrawal. However, Creative Corrections also notes that
per the form, a score of 15 or higher indicates severe alcohol withdrawal, and even though the form, which does not
dictate a threshold for provider noti?cation, prudent nursing practice called for RN to contact Dr.

for the score she understood to be 

8" See GEO Medical Progress Note by RN dated November 25, 2017'.

87 See GEO Medical Housing Unit Log, dated November 26, 2017.

RE See GEO Medical Observation Nursing Progress Record by RN Aboye, dated November 26, 201?.

ll

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

At 6:40 RN completed a CIWA and took vital signs, which were
all within normal limits. The total score as tabulated by RN was 19 based on the
detainee?s level of anxiety, nausea and vomiting, tremors, and paroxysmal sweatsgg As noted
above, the threshold for severe alcohol withdrawal is RN did not notify Dr.
of the CIWA score.

During RN assessment, SAMIMI complained of feeling very weak, nauseated,
and the inability to eat. RN noted SAMIMI attempted to rise up on his knees
during the encounter but fell over because he was so weak. RN noted SAMIMI
had not eaten lunch or dinner, and that she told him that because he was so weak, he would only
receive Phenergan. She also told him that following medication pass, she would assess how he
was feeling. RN instructed the medical officer to take him to the TV room with
food and water??

OfficerleHElilbimlcl the medical officer, stated she convinced SAMIMI to go to the TV room after
telling him that RN IWI would not give him Ativan until he got up and moved around.
Of?cer _eft SAMIMI in the TV room for approximately 40 minutes during which time
she cleaned his cell. At approximately 8:45 Officer-found SAMIMI knocking on
the TV room window, urgently requesting to use the bathroom because he was sick. Of?cer
_unlocked and opened the door, and SAMIMI walked quickly back to this room.?92

 

After SAMIMI returned to his room, he rested for a few moments and then ate half a cookie and
half an orange at RN prompting. After he ate, she administered his medications.
She documented that his nursing plan was over?the?counter Pepto?Bismol93 30 mg at night for
three days and continued monitoring in medical observation}?4 At 9:28 pm, after returning to
the TV room, SAMIMI sat in a wheelchair at the rear of the room and had his feet up on the table
in front of him. At 9:30 pm, SAMIMI removed his feet from the table and slowly slid from the
wheelchair onto the ?oor. He then covered himself with a blanket. Officer -ntered the
room and turned the lights on. She spoke with SAMIMI, and he sat up, then stood and returned
to the wheelchair. He put both of his feet on the table as Of?cer eft, turning the light
off.95

On November 27, 2017, SAMIMI did not wake up to eat breakfast, did not eat lunch or dinner,
and declined recreation and a shower.?S

 

5" When scores applied were re?tabulated, Creative Corrections determined that the RN made an addition error. The
correct score was 16.

"0 Sea GEO Alcohol Withdrawal Assessment and Treatment Flowsheet, dated November 18-26, 201?.

See GEO Medical Progress Note by RN dated November 26, 2017.

"3 ERAU notes RN stated SAMIMI ?ran" back to his room which indicated less weakness and made
her suspect he may have been exaggerating his earlier 

"3 Pepto-Bismol is an over-the-eounter medication for loose stools. See Exhibit 1.

94 See GEO Medical Progress Note by RN dated November 26, 2017',

95 See GEO CCTV footage, dated November 26, 2017.

9" See GEO Medical Housing Unit Log, dated November 2017.

12

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

At 1:00 am, RN heard SAMIMI yelling for the nurse because he was unable to
relax. RN gave SAMIMI Ativan, which she administered intramuscularly to his
right gluteal muscle.W

As logged by the medical of?cer, at 6:59 pm, SAMIMI asked a nurse for ice, and the nurse
denied the request. At that same time, SAMIMI informed the medical of?cer that he was on a
hunger strike.93 GEO Policy 614, Hunger Strikes, states, ?Detainees declaring andi?or identified
as being on a Hunger Strike (missed 9 consecutive meals) will be monitored daily." 
record contains no documentation that either medical or security staff initiated daily monitoring
in accordance with the policy.

At 7:00 pm, LPN documented that SAMIMI refused to eat dinner and
requested stronger medications. vital signs were within normal limits. LPN

(13115111311010) -ncouraged SAMIMI to eat and drink.99

On November 28, 2017, accepted breakfast and lunch but refused dinner, recreation,
and a shower. Shortly after 11:00 am, SAMIMI collapsed in the hallway on his way to a

follow-up mental health appointment with (13115111311010)

DCDF CCTV footage documented the following sequence of events:

I At 11:13 am, as door opened and he approached the threshold with an
officer, a nurse with a pill cart stopped in front of the door blocking the line of sight to
SAMIMI and the officer. Once the nurse moved the pill cart, the camera showed
SAMIMI lying face down on the floor just inside his door.

I At 11:14 am, the nurse who was with the pill cart walked down the corridor toward the
camera and returned a few moments later with a mobile vital signs monitor. She leaned
down to assist SAMIMI who was still on the floor.

0 At 11:15 am, RN-walked down the corridor and leaned down toward SAMIMI.

. At 11:16 3.111., RN- pulled SAMIMI up to a standing position. knees
appeared to buckle, but he remained upright.

. At 11:17 SAMIMI, with an unidentified nurse holding his right arm and RN-
on his left, walked down the corridor toward the camera where they were met by Dr.
tho appeared to speak with SAMIMI. The nurses and SAMIMI then turned
around and headed back toward his room while Dr.-went into to Dr.

offi .

RN-documented SAMIMI sustained no injuries during this incident. He also noted that
SAMIMI reponed not having eaten regularly in eight days due to nausea and requested stronger
medications to combat his withdrawal vital signs were within normal
limits with the exception of an abnormally elevated pulse rate and very elevated blood

 

"1 ERAU Interview with RN dated December 09, 201?. RN erroneously documented
in her progress note that she administered the Ativan intramuscularly to the right coccyx.

95? See GEO Medical Housing Unit Log, dated November 2017.

99 See GEO Medical Progress Note by LPN-dated November 27, 2017'.

Set? GEO Medical Housing Unit Log, dated November 23, 201?.

 

 

pressure. SAMIMI denied any pain. RN nursing assessment included dehydration, and
the detainee nutritional needs not being met. The nursing plan was to continue to monitor and
administer medications as ordered. RN {bit?ltbl educated SAMIMI on the need to make an effort
to eat and drink. RN Walso wrote ?no matter his actions, stronger meds unavailable 1
RN -xplained that he included this notation to make the point to SAMIMI that he was not
helping himself by his actions (refusing meals and purposefully falling) and that he needed to
cooperate because he was not going to get methadone. '02

After fall, Dr.-liscussed state with Dr. and they agreed
that SAMIMI was not stable enough to proceed with his mental health follow-up appointment
that day. Dr. assured Dr._that medical was monitoring vital signs
and that SAMIMI had experienced a few good days and that his laboratory results looked good.
Dr. stated SAMIMI would remain in medical observation as he underwent withdrawal,
and when he stabilized enough to have a coherent conversation, he would return to the mental
health clinic. 103

 

Suicide Attempt

 




 

 

 

At approximately 8:45 Officer- the medical officer on duty. entered the
anteroom of cell to perform a security round. When she looked through the ow.
she observed SAMIMI with a dark blue sheet tied around his neck. 10" Of?cer reached for
the radio on her duty belt so she could call an emergency. Discovering the radio was dead, she
hurried to the officer?s station and used the telephone to call central control for assistance. She
returned to the cell, alerting nursing staff along the way that there was an emergency. Officer
_opened the cell door, and the responding medical and security staff removed the sheet
from around the neck, despite some resistance from him in the process. Officer
_tated she heard someone say SAMIMI would be placed on suicide watch, so she left to
make preparations. Her preparations included setting up the officer?s table and constant watch
logbook outside the suicide prevention cell, and retrieving a suicide resistant smock and blanket

for issuance to the detainee. '05 Lieutenant bif?iilbiml onfirrned that Dr. {bli?liiblm placed SAMIMI
on constant suicide watch which was ?started immediately.? ?if?

DCDF CCTV footage documents the following sequence of events:

 

99mm)? 0 At 8:44:58 pm, SAMIMI, who was sitting cross legged on his bed. took a blue sheet

from his bed and placed it around his neck from behind. He then crossed each end over
the htened the sheet by pulling with each arm.

I At 8:46: 16 pm, Officer entered the camera?s view at the end of the hallway and
entered the outer door into the anteroom outside cell.

 

 

 

 

 

 

(bit??bimt
C)

 

 

 

10' See GEO Medical Progress- Note by RN biibjil dated November 28. 2017'.
. I erview with RN _Ut?libt dated December 09 201?

. General Incident Re dated November 28 201??
?15 ERAU Interview w1t .- I dated December 1 201?.
Set? GEO General Incident Report (Supervisor?s Notes) by Of?cer dated November 28, 2017.


 
 


0)

 

 

 

 

 

 

 

l4

 

 

(1311511131101
0)

 

 


C)

 

 

 

(1311511131101
0)

 

 

 


C)

 

 

 

   
 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

{bil?liibil

 

 

 

I At 8:46:33 Of?cer W3) exited the outer door into the corridor and walked to the
nurses? station approximately ten feet away. She motioned to the nurse to come to the

 

door. opened the door at 8:46:54 pm.

I At 8:47:25 Officer alked back to the of?cer?s station, approximately 10 feet
from the nurses? station, holding her radio in her left hand. She looked at the monitor on
her des camera views of the cells and picked up the phone.

I At 8:48: 14 Of?cer ung up the phone, returned to cell and

opened the outer door at 8:48:32.

I At Nurse Aboye and an unidentified of?cer entered the cell.

 

133593;th and Officer

RN 

entered behind them. Nurse and the first of?cer

removed the sheet from around neck as he struggled brie?y and tried to push
them away. Several more officers arrived. SAMIMI spoke with the staff as his property
and linens were removed from the cell. He was seated on the bed, cross-legged and

leaned forward with his hands on his forehead.

I At 8:51:18 RN picked up Styrofoam meal container, which

appeared to contain a full meal, and looked inside.

I At 8:51:25 an officer removed property bin from the room, and RN

(11311531111311 upened the meal container and showed it to the detainee.

I At 8:51:41 SAMIMI shook his head no, and RN- set the container on the
floor at the end of the bed. RN-then departed, leaving SAMIMI alone with the cell
door left open. SAMIMI remained seated cross-legged on the bed, leaning forward with

 

his hands on his forehead.
I At 8:55:29 Lieutenant

(bll?lle?r?li

 

 



 

entered the cell. SAMIMI spoke to the Lieutenant

in an animated way, gesturing with his arms and hands, pointing at his head and throwing

 

his arms wide open.
I At 8:58:28 Lieutenant

(DHEHDHW

.9

left the cell.

 

 

 

I At 9:01:49 an officer entered the cell and spoke to SAMIMI.

I At 9:02:30 SAMIMI swung his legs onto the ?oor and sat up. The officer then

assis
I At 9:03:08 Of lcer

M1 to his feet and held his left arm as they walked out of the cell.
re-entered the cell and placed the property bin back into

the empty cell. She then removed what appeared to be a pillow case or cloth from behind

the bed. 107

RN called Dr. to notify him of the incident. Dr. gave seven verbal
orders: 

1. Suicide level 1 with one-on-one monitoring;

2. Suicide gown, suicide blanket, suicide pillow;

3. Finger foods with paper spork;

4. Ten sheets of toilet paper at a time;

5. One small book or Bible;

6. No underwear, no bed sheet;

7. Mental health appointment.

 

Sec GEO CCTV footage, dated November 28, 201?.

?13 Sac GEO Medical Progress Note by RN 1322921 dated November 28, 201?.



15

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

Security staff placed SAMIMI on level 1 suicide watch with constant, one-on-one monitoring.
Medical and security staff took SAMIMI to cell 527 which is the designated suicide watch cell
and has a motion-activated camera installed that only records when there is movement inside the
cell. '09 The door has a window in the top half and a pipe sensor in the middle. To the right of
the door is a large viewing window. Bolted to the center of the ?oor inside the cell is a concrete
bed slab. A stainless steel toilet and sink combination ?xture is in the back left corner of the
cell. A camera is mounted at the back of the cell near the ceiling and shows a view of the bed,
toilet and cell door and window.

The desk for the officer assigned to constant watch was positioned immediately outside the large
viewing window and can be seen from the camera inside the cell. The of?cer was required to
log the activity of the detainee every ?ve minutes in the Constant Watch Logbook (separate from
the Medical Unit Logbook) and not allowed to leave the post without being properly relieved.
Per the ICE 2011(revised 2016), detainees placed on suicide watch are to receive eight-
hour checks by clinical staff and daily mental health treatment by a qualified clinician.

However, there were no medical record entries documenting any encounters with a health care
professional between the time SAMIMI was placed on suicide watch and 11:00 am. the next
morning. Nurset?clinician welfare checks were not conducted every eight hours as required by
the ICE 

On November 29, 201?, an officer notated SAMIMI accepted his breakfast tray but did not
make notations regarding lunch or dinner, or whether he refused or accepted a shower or
recreation. At 10: 58 a. ERO Deportation Ientered the Medical Unit to
conduct staff-detainee communication. ?0 At 11: 00 a. Dr. 
completed an initial evaluation with SAMIMI via tele- W51 (WW0) I
documented that SAMIMI complained of inability to sleep, constant vomiting, sweating, and
shaking. He denied other opiate of yawning, tears, and diarrhea. He also denied
suicidal intent.

Dr._bserved that CIWA score consistently increased over time and noted
that medical staff reported SAMIMI had tremors and frequently requested stronger medication.

Dr._listed what to expect with opiate withdrawal, including a notation that it is
generally not life-threatening, although dehydration is possible. She also addressed the
unsuitability of using the CIWA instead of an opiate withdrawal instrument. Her findings
included orientation to person, place, time, and situation; appropriateness of rapport; disheveled
appearance with poor grooming, dress, and body odor;] anxious, irritable mood; expansive
affect; and coherent, appropriate speech. ?3

 

Dr. discussed and treatment of mental illness, the frequency of follow-up,
prescribed medications and potential side effects, and explained access to mental

 

 

(bll?lilb
109 ERAU Interview with Security dated December 11, 2017.

1111 See GEO Medical Housing Unit Log, dated November 29, 201?.

11' Dr_description of the detainees body odor was likely reported to her by RN {bll?lilbl
?2 Sec GEO Initial Evaluation by Dr_ated November 29, 201?.

 

 

 

16

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

health services. She also documented medication consent forms were reviewed and signed.?3

Dr (13115111311013) entered nine orders: ?4

1. Push ?uids for 15 days;

2. Discontinue Ativan;

3. Clonidine 0.1 mg orally three times daily for four days, then clonidine 0.1 mg twice daily
for four days, then 0.1 mg every night for four days, then stop;

4. HydroxyaineI '5 50 mg three times daily as needed for anxiety for 15 days.

5. Imodium] 1?5 2 mg after each loose stool, total daily dose not to exceed 16 mg as needed

for three days;

6. Trazodone' '7 100 mg orally every night as needed for sleep for 15 days, then decrease to
50 mg every night for 15 days, then stop;

7. Offer Ensure with each meal for seven days;

8. COWS monitoring for ten days;] 18

9. Level 2 suicide watch.

 

RN-- noted Dr. Chambless? orders that same ay and accurately transcribed the
medications to MAR. At 11:20 am, RN conducted a nursing round during
which SAMIMI complained of nausea. SAMIMI's vital signs were within normal limits, with
the exception of an elevated heart rate. RN -did not document administration of anti-
nausea medication. ERAU notes this was the first documented nursing round after 
suicide attempt, more than 14 hours prior.

 

 

 

At 2: 18 pm, the medical of?cer documented SAMIMI was transitioned to level 2 suicide watch
which required monitoring checks with corresponding notations to the Constant Watch Logbook
every 15 minutes. The logged 15 minute checks through the remainder of the day primarily
documented that SAMIMI was sleeping or lying on his bed. However, the officer logged at
10:15 pm, 10:30 pm, and 11:00 pm, that SAMIMI requested ice water, but was told by RN
that he should get water from the sink in his cell.

On November 30, 2017, SAMIMI did not accept any meals and did not shower or go to
recreation.? At 1:00 am, RN documented that SAMIMI had blood on his nose,
the sleeve of his right arm, and in his mouth, which he spit onto the Officers and
medical staff cleaned SAMIMI and the cell. She completed a full nursing assessment, during
which she noted the blood appeared to be coming from nose. After he was cleaned
up and provided new clothes, his vital signs were repeated and were within normal limits. RN

 

?3 medical record did not contain a signed consent form for use ofthe medications,
Trazadone.

?4 See GEO Medical Progress Note by dated November 29, 201?.

?5 Hydroxizine is a medication used to treat anxiety, nausea and vomiting. See Exhibit 1.

Immodium is a medication to treat loose stools or diarrhea. See Exhibit 1.

?7 Trazodone is a medication used to treat anxiety, depression, and sleeplessness. See Exhibit 1.

?3 No COWS was ever completed after ordered b_

?9 Sec GEO Medical Housing Unit Log, dated November 30, 201?.

Sec GEO Medical Progress Note by RN dated November 30, 2017'.

Sec GEO Constant Watch Log, dated November 30, 2017'.

17

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

{1311511131th nursing plan included offering SAMIMI water every two hours while awake,
continuing to monitor him, and notifying the morning staff of the nursing plan.122

At 2:00 am, RN documented that SAMIMI rested off and on, and that he
occasionally screamed, ?Nurse, nurse,? before falling back asleep. SAMIMI's vital signs were
all within normal limits. An officer assigned to SAMIMI's suicide watch logged that SAMIMI
screamed from 4:30 am. to 5:15 am, and again at 6:57 am. when he asked for ice water. The
officer noted that a nurse (identity unknown) denied SAMIMI ice water and stated he could
drink water [from the sink] like everyone else. '23

According to a progress note by refused to allow her to take his vital
signs at 9:22 am, and at 9:25 am. refused to cooperate with a nursing assessment. At 11:57r

SAMIMI was evaluated by Dr.  in a encounter.
SAMIMI complained of feeling stressed and depressed and stated that he would rather die than
stay in the facility due to needing methadone which he was on for 28 years. Dr.
reminded SAMIMI mood were normal during withdrawal and that he would feel
better over time. No was identi?ed. Dr. plan was to continue SAMIMI on
level 2 suicide watch, continue the medication protocol ordered by Dr._and evaluate
SAMIMI again in one day. '24

 

 

At 5:37 SAMIMI had a legal call which ended at 6:15 pm.125 According to HSA
GEO transferred the call to the medical officer's desk, but neither the officer nor
medical staff documented the call. HSA stated he overheard SAMIMI converse on the

telephone, and the detainee answered questions quickly and coherently. After the call, RN
observed that SAMIMI appeared more upbeat. 

On December 1, 2017', SAMIMI did not accept breakfast or lunch but accepted dinner. He did
not shower or attend recreation.'3" At 4:00 am, RN logged an interaction with
SAMIMI from earlier that morning. She documented SAMIMI slept through the night until 3:30
am. when he was observed talking to himself, trying to drink from toilet, falling to the floor, and
rolling on the ground. She wrote that the medical of?cer accompanied her into the cell to
prevent injury and offer water. As noted, a few minutes later SAMIMI was asleep. Her nursing
plan was to continue to monitor SAMIMI every 15 minutes. vital signs were all
within normal limits. '29 ERAU notes of?cers did not log the incident in either the Medical Unit
or Constant Watch Logbook, nor did they write incident reports.

 

123 sea GEO Medical Progress Note by RN dated November 30, 201?.

See GEO Constant Watch Log, dated November 30, 2017.

'34 See GEO Medical Progress Note by Dr. dated November 30, 2017'.

'35 See GEO Constant Watch Lo_, dated November 30, 2017.

11* ERAU Interview with HSA dated December 09, 2017. HSA also stated that the lucidness
with which SAMIMI spoke on the phone led him to believe the detainee was exaggerating the severity of his
withdrawal 

ERAU Interview with RN dated December 09, 2017.

'33 Set? GEO Medical Housing Unit Log, dated December 1, 2017'.

'39 Set? GEO Medical Progress Note by RN dated December 1, 2017'.

18

 

 

(blt??blmi
0)

 

 

   
 

 


C)

 

   

 

 

(blt??blmi
0)

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

DCDF CCTV footage documents the following sequence of events: ?0

I At 3:17 SAMIMI lay on his mattress on the floor of his cell (he moved the mattress
to the floor from the bed slab at an unknown time).

I At 3:21 SAMIMI unsteadily sat up, took his cup and reached for the sink above the
toilet. Before reaching the sink, he collapsed to the floor on his side. As he collapsed,
arm hit the toilet and his cup fell out of his hand and into the toilet. He
retrieved the cup, lifted it up to the sink, and then brought it toward his mouth. Before
reaching his mouth, the cup fell out of his hand and back into the toilet. SAMIMI
slumped beside the toilet, with his hand in the toilet, as he tried to fish the cup out a
second time. After approximately one minute, SAMIMI pulled his hand out of the toilet,
wiped it on his blanket, and continued to lay slumped next to the toilet.

I At 3:23 SAMIMI attempted to pull himself into a sitting position but quickly fell
back to the floor, and did not appear to have the strength to sit. An officer entered the
cell and assisted SAMIMI into a sitting position, but SAMIMI toppled over to his right
side, and narrowly missed hitting his head on the concrete wall. After falling over,
SAMIMI positioned himself on his back, and the officer motioned with his hand toward
the door.

I At 3:26 the officer exited the cell but returned at 3:28 am. with a cup of water
which he placed on the concrete bed slab before exiting the cell again.

I At 3:30 SAMIMI pulled himself into a sitting position, took the cup of water from
the bed slap, sipped it, and set it on the floor before slumping back to the floor.

I At 3:31 RN entered the cell with a cup, and SAMIMI sat up resting

his head on the bed slab. RN rubbed head, held the em out to

him, but before taking the cup, SAMIMI fell back to the floor. RN moved
to temporarily blocking the camera?s view of the detainee.

I At 3:32 Officer entered the cell with another officer. The two officers and
RN I grabbed ahold of legs and arms and slid him onto the
mattress away from the toilet.

I At 3:33 Officer removed a Styrofoam meal container and returned to stand
by the toilet.

I At 3. .34 am, re? ?entered the cell with the mobile blood pressure
mac - . ulaced the cuff on the detainee arm.

I At 3:35 Officer?handed the detainee a cup of water.

I At 3:39 RN removed the blood pressure cuff from the detainee?s arm
an the blood pressure machine out of the cell.

I At 3:40 Officer and RN re-entered the cell and the nurse
placed an additional blanket over SAMIMI.

I At 3:41 all staff left the cell.

 

 

 

 

 

 

 
 
   

 

RN stated during interview that she was very concerned about SAMIMI after this
incidentseen by a physician and was very weak. She stated that when
SAMIMI asked for more medications during the prior days, it led her to believe he was drug-
seeking, but she noted he was never belligerent when asking for medications. She also stated

 

See GEO CCTV footage, dated December 1, 2017.
19

 

 


C)

 

 

  

 

 


C)

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

that because his vital signs were consistently normal, she did not believe a visit to the hospital
was justi?able, but noted that in retrospect, she should have sent him to the hospital. ERAU
notes other nurses interviewed, as well as Dr. cited normal vital signs as a
reason they did not believe his condition was critical or requiring notification to Dr.
Creative Corrections advises that the clonidine may have been responsible for controlling
blood pressure.

After this encounter, RN did not make a referral to Dr.

At 8:50 am, Supervisory Detention and Deportation Officer lentered
the medical unit to conduct staff-detainee communication. 131 lstated he did not
speak with SAMIMI during this visit because the detainee was on suicide watch and was
sleeping. He stated that although he never met the detainee. he recalled DCDF reporting at a
weekly meeting that SAMIMI was a methadone user and was on suicide watch. '32

At 9:15 am, was escorting SAMIMI to the office when,


according to RN (bll?ii?ibllf '33 SAMIMI threw himself out of the wheelchair and landed on the
near face first. 134 SAMIMI sustained a nosebleed and urinated on himself. RN applied
pressure tc nose with gauze until the bleedin stepped. RN took 
vital signs which were within normal limits. RN IEBEEWH i stated he was unable to obtain a blood
pressure reading because SAMIMI would not stay still. RN Itbll?iitbll I also stated SAMIMI was
uncooperative, attempted to grab RN with his bloody hands, and was spitting. Officer

who was present during this incident, stated SAMIMI asked RN for

- - - heelchair, but RN declined and told SAMIMI he could get
into the wheelchair on his own. Ot ice tated SAMIMI lowered himself slowly into
the wheelchair, but fell out of it on the way to the appointment. Officer noted SAMIMI
did not attempt to break his fall.

 

 

 

 

 

Dr. approached SAMIMI shortly after his fall from the wheelchair and ordered that
SAMIMI be placed back into the suicide watch cell. 135 Dr. con?rmed that he did not
witness the incident but based on what was described by RN he believed SAMIMI
intentionally threw himself to the floor. He stated he returned SAMIMI to level 1 suicide watch
because the action could be interpreted as a suicidal gesture. SAMIMI did not have his tele-
appointment that day, but medical staff scheduled an appointment with 
for the following day. 

 

 

 

 

 

{bit?lit
At 9:44 pm, Officer blft'HC the constant watch officer, documented that with his Lieutenant?s

permission, he Opened door to give the detainee water. His entries thereafter

 

 

 

 

  

See Medica ook, dated December 1, 201?.
?3 ERAU Interview with SDD dated December 10, 201?.
?3 See GEO Medical Progress Note by dated December 1, 201?.

Neither the Medical Unit nor the Constant Watch Lo book documents this incident.

sec GEO Medical Progress by dated December 1, 2017.

'36 ERAU Interview with Dr. dated December 10, 2017. However, the Constant Watch Logbook does not
include an entry documenting SAMIMFs change in status to level 1 suicide watch. However. monitoring entries in
the Constant Watch Logbook do switch from every 15 minutes to every five tninutes at 10:00 am, consistent with

level 1 procedures.

in Set? GEO Medical Progress Note by RN {blt?litbitmci dated December I, 201?.
20

 

 


C)

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

documen I yelling intermittently, and at 10:29 pm, he logged that SAMIMI appeared

 

 


C)

 

 

(anatomy: At 11: . . Of?cer bit?itbitntci relieved Of?cer WW3


informed Of?cer that SAMIMI refused his meals and did not sleep much during his shift.

 

to Spit up blood. Office noti?ed the medical officer who noti?ed a nurse. 
medical record does not show a related nursing encounter on this time and date.

 

(W511

 

 

. During shift change, Office DHEIIMIHC)

 

At 11:34 pm, logged that SAMIMI complained of stomach pain and that nurses
ed that RN visited SAMIMI,

were not available. At 11:44 Of?cer
took his vital signs, and gave him medications.

 

 

In an incident report, '38 Officer THC)

 

 


C)



 

 

 

 

 

 


CI

 

 

{bil?litbilflt


 

 

 

 

documented that throughout his shi' got up
every few minutes complaining of stomach pains. Of?cer
six different occasions that SAMIMI was in pain and was requesting more medication, though

noted he alerted medical staff

he did no hether medical staff responded on any of these occasions. At one point,
SAMIMI asked Of?cer to bring his medicine and then vomited into the toilet. Officer
_stated he noti?ed the medical of?cer to alert nursing staff, and that the nurse who came to
check on SAMIMI noticed the detainee was incontinent of urine. Officers removed 

 

wet mattress from the cell and Of?cer

bil?litbil

 

IHC)

cleaned the cell with the assistance of another

 

 

officer. '39

LieutenantleHelile?Hlol the supervisor on duty the night of December 1, 2017?, recalled Officer
{Maximum Icontacting him regarding SAMIMI, and reporting to the medical unit to check on the
detainee himself. Lieutenant-reported to a nurse that officers were concerned about
SAMIMI, speci?cally that the detainee was suffering, and the nurse stated Dr. was
aware of status and planned to see the detainee. Lieutenant-stated that he
decided not to call 911 for SAMIMI when he learned Dr. was informed of the

detainee?s state. 

In a progress note completed at 5:00 am. on December 2, 2017', RN noted that
during the prior evening, SAMIMI screamed for nurses and complained of abdominal pain. At
an undocumented time, she took his vital signs which were within normal limits with the
exception of a lowered oxygen level. She did not obtain pain level. 
lungs were clear, and his bowel sounds were normal. She noted that several times during the
night, SAMIMI screamed that he was unable to breathe, and that nurses gave him a re-

breather, which he pulled off and went back to sleep. At 3:30 am, SAMIMI woke up a third
time screaming for Zantac and an injection for nausea. She took vital signs again and
all were within normal limits. '42 RN gave SAMIMI 4 mg of Zofran for nausea

 

bil?lib

 


C)

 

 

 

 

 

 

that he wrote or submitted it.

?3 See Of?cer Incident Report, signed January 5, 2018. Of?cer
stated during intervlew that he completed it in mid-December ofhis own volition, though he did not remember the

 

(DKEIID

 

?9 See GEO Gene Report by 

 

 

14? ERAU Interview with Lieutenan

?42 A body temperature was not obtained.

 

 

 

{bit?litbi 
d1d not date 1nc1dent report, but

 

 

reviewed by his supervisor January 5, 2018.

dated December 11, 201?.

A rebreather is a mask with an attached reservoir bag that saves one third of a person?s exhaled air, while the rest
of the air gets pushed out through side ports covered with a one-way valve. This allows the person to rebreathe
some of the carbon dioxide exhaled, which acts as a way to stimulate breathing. See Exhibit 1.

21

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

intramuscularly, per verbal order of Dr. (13115111311010) RN (13101113101101 noted that SAMIMI did
not receive his nighttime dose of Trazodone. 144

December 2, 2017 Day of Death

SAMIMI ate half his breakfast at approximately 5:27 am. '45 At 7:06 am, Officer-
assumed the Constant Watch Of?cer post. He logged that SAMIMI ate some food at 10:15 am,
but at 10:35 am. screamed that he had stomach pain and was vomiting. At 10:50 am, when

 

 

 

(131(51113'1011
Cl

 

SAMIMI continued to scream, Officer 99011131011 called Lt. '46

 

 

 

 

 

 

 

 


C1

 

reported by both Officer? at approximately 1100 a a nurse asked Officer
13115111311?) SAMIMI to an appointment with Dr_ The medical
officer and Officer efused, and told the nurse SAMIMI was too
unsta le to move, and he did not want to risk moving the detainee on his own. Officer
_stated during interview that SAMIMI had noticeably declined from the previous day
and that be continually checked to make sure the detainee was still breathing. Officer?
asked a nurse to hel move SAMIMI and RNW _arrived with a wheelchair. Officer
_arid Rleifted SAMIMI into the wheelchair but she
stiffened and slid out of the wheelchair. Oftlcer an RNW _moved SAMIMI ba
to the mattress laid him on his back and SAMIMI pulled his blanket ove
(13115111310110 remained at cell while Of?cer the scene to wash his arm of a
substance from face which brushed against him during the maneuvers. 143

 

Of?cer-stated she called for RNEQQIW arid reentered cell at 11:02 am.

when she heard the detainee make a choking sound. '49 When RN 1011511101 returned, he turned
SAMIMI on his side, and the detainee vomited. Officer 13115103110101 ubserved ood clots in
the vomit, which she pointed out to RN 131133311311 and then told the nurse to call Dr. 

Of?cer x-ited the cell and contacted Lieutenant glossary 152 and requested the
Lieutenant come to medical. '53

 

 

 

 

 

 

 

 

 

 

 


C1

?3 Althouih 5 7' documented the verbal order in her progress note, the order was never authenticated by

 


C1

 

Dr. Additionally, the order, as documented, was incomplete, as it did not specify whether it was a stat, as?
ed, or regularly?scheduled dose.

dical Progress Note by RN 03115103117113) dated December 2, 2017.

 


C1

 
 

 

 

 


C1

 
  

stated he was assigned to constant watch the previous day and was aware ofthc incident where
et water and appeared be drinking from the toilet, as well as the incident when SAMIMI fell

 

SAMIMI strugg

 

Of?cer

 

03115111311711
C1

from his wheelchair.

 

    

GEO CCTV foota '3 date shows the detainee in a very weak condition, resting in a kneeling position with his

 

 

03115111311711
C1

 

on his mattress until Office and RN moved him, stumbling as he moved to the door and then
collapsing before

 and 131111131151 l?alas-sits?tim him into the wheelchair

dated December 09 2017.
14" ERAU Interview with Officer my ?017.

 

 

 

 

 

{b11511bltf1l
C1

 

Interview withR 519,19,le dated December 11 201?.
dated December 09 2011'.

ERAU Interview with Officer
'52 Lieutenant was the Watc ?or ander for the 7:00 am. to 3:00 pm.
da December 09, 2011'.

'53 ERAU lntervie iv with Of?cer germane
03115111311111
C1

 

 

 

 

 

 

 

 

22

 


C1

 

 

 

 
   
  

 


C1

 

 


C1

 

 

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

RN stated that he returned to cell after of?cers informed him SAMIMI was
vomiting, repositioned SAMIMI on his side as the detainee vomited, and then instructed the
officers to clean the vomit and keep their on detainee. 15? RN stated the vomit
consisted of stomach contents only and that there was no blood. After leaving the cell, RN
stated he decided to call Dr. to recommend that SAMIMI be transferred to a
hospital where his needs would be better managed. RN .stated he did not consider calling
911 as he did not deem the situation an emergency. RN stated he left messages on Dr.
home and mobile phones asking for a return call. ?55 Dr. stated during
interview that he did not receive the messages. '56

(DHEIIDHTH

At 11:06 am, Lieutenant arrived, accompanied by Officer (?11513113101101 Lieutenant
13115111319113) ooked in the cell and observed SAMIMI lying on his right side on a mattress on the

floor. He noted eyes were open, and he looked pale. The Lieutenant stated it was
obvious SAMIMI was in crisis and noted there was vomit on the side of 5 face, and the
detainee had urinated and was breathing heavily. The Lieutenant told the officers SAMIMI

ed an ambulance and then proceeded to the nurses? station and t; SAMIMI
needed an a The RN replied that he left messages for Dr. and was trying to
reach the HSA. Lieutenant

 



 

 

 

 

(13115111311111
0)

 

 

 

 
 
 

then used another phone in medical to call Central Control,

 

 

 

 

 

 

 

and at 11:10 am, directed the control officer, to call 911. '53 Officer .
mot-(metre) - - - 159 
_left the area to prepare for He: hospital transport. (3)
. . . In 5:13 
After the Central Control thcer to call 911, Lteutenantc?) returned to 1311 11 )1

 

 

 

 

 

 

5 cell and told SAMIMI that an ambulance was on the way. Lieutenantl lstate
he observed vomit on and near face and a substance that looked like blood
?oor. The Lieutenant then went to the armory to issue weapons to Officers andlt 131(5) {133111113} I

whom he assigned to accompany SAMIMI to the hospital. Lieutenant a551gned 

perimeter patrol Officer 13115111319110} to report to the perimeter gate to escort the paramedics

   
   

 

 

 

 

 

into the facility.
gymnast

 

 

 

1.6 a the Aurora Fire Department (AFD) dispatched a team consisting of two
Emergency 'cian (EMT) paramedics and two EMT basic responders, who arrived
at the facility at 11:18 am. ?5'0 Of?cer opened the perimeter gates for the EMS
responders and escorted them through the intake area and into medical. 

 

 

15" See GEO Medical Progress Note by RN {b??litb dated December 2, 2017.
ERAU Interview with RN {131151113 dated December 11, 201?.

 

 

 

 

 

 

 

 

 

 

 

 

15?" ERAU Interview with Dr. dated December 10, 201?. {13115111311711
15? GEO CCTV footage shows Lieutenant and Of?cer (b11511 arriving on scene and looking in the cell at C)

11:07 a.m. b39110

?3 RN {b16311 documented that he then called HSA {bl(51:1b1( who ordered that 911 be called. at after

speaking with HSA (13115111311 he went back to the cell area and found Lieutenant was there. He told the

 

(13115111311111 lieutenant that he received the order for SAMIMI to go to the hospital, whereupon the lieutenant asked if the
'31 detainee could ?support his own weight. When told he could not the lieutenant called 91 1 for him. RN {bl(51:1b1(

 

 

 

 
     
 

events leading to calling for an ambulance ts inconsistent with Lieutenant . and not supported
by any other evi or reported. {0 1
'59 ERAU Interview with Lieutenant dated December 09, 2017.

See Aurora Fire Department EMS Patient Care Report, dated December 2, 201?.

ERAU Interview with dated December 09, 2017'.

 

 

 

 

 

 

 

 

 

(blt??blmt
C)

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

According to the AFD report, the EMTs found SAMIMI ?lying prone in the holding cell with
emesis on the mattress.? He was unresponsive and pulseless with no obvious signs of trauma.
The EMTs gave SAMIMI cardiopulmonary resuscitation (CPR) and put a Basic Life Support
airwayl62 in place. SAMIMI had ?coffee ground type emesis? in his airway, and the EMTs
continuously suctioned to clear the airway. The EMTs administered epinephrine and continued
CPR, which was momentarily delayed when they moved SAMIMI from the floor onto a gumey
and out to the ambulance. The EMTs reported SAMIMI had agonal '54 respirations at a rate of
two per minute, and their monitor showed him to be in asystole. '65 They gave SAMIMI a total
of nine rounds of CPR, and he remained in asystole until the eighth round, when he transitioned
to ventricular ?brillation?f?? The EMTs shocked SAMIMI once, but at the next heart 
check, he was back in asystole. ?57

tenant C) escorted the EMS responders to the ambulance, and the ambulance left the
facility at . . for the emergency room at the University of Colorado Health Medical
Center (UCMC). Office rode in the ambulance in the front passenger seat and Officer

 

 

 

 

bil?lilbim?icl followed in a chase vehicle. The ambulance arrived at the University of Colorado

Medical Center at 11:45 am. Upon arrival at the UCMC Emergency Room (ER), 
had fixed pupils and was in asystole. The ER physician?s preliminary diagnosis was cardiac
arrest. ER personnel noted SAMIMI had black vomit on his face and in his airway suggestive of
a possible gastro-intestinal bleed. ?3

At 12:02 pm, was pronounced dead by UCMC physician Dr. I171 At 2:32

pm, hospital staff moved body to the morgue, and Officers baggy and returned
to the facility. ?2 e)

 

 

 

 

 

 

 

Post-Death Events

On December 6, 2017', at approximately 10:00 pm, an autopsy was performed on SAMIMI by
Dr. _of the Adams Broomfield County Coroner?s Office. Dr. Cina recorded
SAMIMI's cause of death as undetermined, but documented SAMIMI had chronic obstructive
pulmonary disease and gastrointestinal bleeding, which likely contributed to his
death. Dr. documented he could not rule out methadone withdrawal as the cause of death,

 

Basic Life Support airway is an instrument inserted through the mouth. extending into the airway. to keep the
airway open. See Exhibit 1.

Sea Aurora Fire Department EMS Patient Care Report, dated December 2, 201?.

Agonal breathing refers to labored breathing, characterized by gasping. See Exhibit 1.

Asystole, also known as cardiac [lat line, is the absence of heart contractions. See Exhibit 1.

Ventricular ?brillation is a life-threatening heart that results in a rapid, inadequate heartbeat. See Exhibit
1.

See Falk Rocky Mountain Emergency Medical Services (EMS) Patient Care Report, dated December 2, 2017.
The Falk Rocky Mountain EMS also reported to DCDF and documented events reported by the ADF EMTs.

See GEO Medical Transport Log, dated December 2, 201?.

See GEO Medical Transport Log, dated December 2, 201?.

See UC HealthIAMC Emergency Report, dated December 2, 201'?

See GEO Medical Progress Note by RN dated December 2, 201?.

?2 See GEO Medical Transport Log, dated December 2, 201?.

24

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

but noted that deaths due to methadone withdrawal are rare. He noted SAMIMI had no injuries
and no evidence of dehydration. '73

Following death, DCDF's Warden, Johnny Choate, personally met with each
member of security staff who interacted with SAMIMI and provided information on employee
assistance services. However, Warden Choate only met informally with nursing staff and did not
refer them to employee assistance.

ERO sent a letter to next-of?kin on December 11, 2017, notifying her of his death.

DCDF reviewed SAMIMI's death on December 6, 2017', at a Safety Committee
Meeting.?4 CCTV footage was not reviewed for this review. The resulting report stated that
both medical and security staff acted properly and in accordance with policy and procedures on
December 2, 2017. ?5

On December 18, 2017, a committee composed of Warden Choate, Dr. HSA
RN and a GEO quality assurance representative- completed a
Multi-Level Mortality Review of death. No security or ERO staff participated in the
review, and the committee did not review any CCTV footage as part of the review. The
committee?s ?ndings are purportedly based on the detainee?s medical record and reports from
medical staff; however, the report contains many statements that are inconsistent with the
medical record, and findings that are unsupported by the medical record, which are examined in
detail by Creative Corrections. The Mortality Review resulted in one recommendation: ?Re?
emphasize to all nursing staff, use your clinical judgment and call 911 when presented with a life
or death situation.? The committee also identified as strength: ?Quick initiation of withdrawal
protocol. Monitoring of detainee while on withdrawal protocol.? 

MEDICAL CARE AND SECURITY REVIEW

ERAU reviewed the medical care SAMIMI was provided at DCDF, as well as the facility?s
efforts to ensure that he was safe and secure while detained at the facility. ERAU found

deficiencies in DCDF's compliance with certain requirements of the ICE 2011 (revised
2016).

1. ICE 2011 (revised 2016), Medical Care, Section which states, ?All facilities
shall provide medical staff and sufficient support personnel to meet these standards.?

II At the time of detention, DCDF had vacancies in key medical personnel,
including a Director of Nursing and a midlevel provider, for longer than six months.

 

in See Exhibit 3: Adams 82: Broom?eld County Autopsy Report by Dr. (131(5)? dated December 6, 201?.

17? Key Safety Committee participants include the Warden, Associate Warden, Chief of Security, Training
Administrator, Maintenance Supervisor, HSA, Food Service Manager.

?5 Sec GEO Safety Committee Meeting Minutes by Safety Manager_ dated December 6, 2017'.
176 Sec GEO Multi-Level Mortality Review, dated December 13, 201?.

25

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

. ICE 2011 (revised 2016), Medical Care, Section which states, ?Each

detention facility shall have and comply with written policy and procedures for the
management of pharmaceuticals, to include. 2) documentation of accountability for
administering or distributing medication in a timely manner, and according to licenses
provider orders.?

I physician wrote prescription orders for treatment of withdrawal, for up to
three times daily, as needed, for anxiety, restlessness, sleeplessness, nausea, and pain.
In spite of frequent and progressive complaints of these the Medication
Administration Record (MAR) shows nurses administered only ?ve of 42 doses for
anxiety, 2] of 42 doses for 17' of 42 doses for pain, and
only four of 42 doses for nausea and vomiting.

I Neither nursing notes nor the MAR consistently document times nurses administered
medications to SAMIMI, making it difficult for nurses on subsequent shifts to know
when SAMIMI was due for his next dose.

. ICE 2011 (revised 2016), Medical Care, Section which states, ?Where there

is a clinically signi?cant finding as a result of the initial screening, an immediate referral
shall be initiated and the detainee shall receive a health assessment no later than two working
days from the initial screening.?

I The intake nurse?s documentation of possible early opioid withdrawal did
not result in an initial provider assessment within two working days of intake.

. ICE 2011 (revised 2016), Medical Care, Section which states, ?Detainees

experiencing severe or life-threatening intoxication or withdrawal shall be transferred
immediately to an emergency department for evaluation. Once evaluated, the detainee will
be referred to an appropriate facility quali?ed to provide treatment and monitoring for
withdrawal, or treated on-site if the facility is staffed with qualified personnel and equipment
to provide appropriate care.?

I DCDF medical staff failed to transfer SAMIMI to an ER even though he exhibited
life-threatening withdrawal during the week following his intake.

. ICE 2011 {revised 2016), Medical Care, Section which states, ?Each

facility?s health care provider shall conduct a comprehensive health assessment, including a
physical examination and mental health screening, on each detainee within 14 days of the
detainee?s arrival unless more immediate attention is required due to an acute or identi?able
chronic condition.?

I DCDF failed to complete an initial physical assessment during the 15 days SAMIMI
was housed at the facility, in part due to the absence of a midlevel provider.

. ICE 2011 {revised 2016), Medical Care, Section which states, ?Where a

detainee has a serious medical or mental health condition or otherwise requires special or

26

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

10.

close medical care, medical staff shall complete a Alert form (IHSC-
834) or equivalent, and file the form in the detainee?s medical record.?

0 Medical staff did not complete a alert for SAMIMI.

ICE 2011 {revised 2016), Medical Care, Section which states, ?An initial
dental screening shall be performed within 14 days of the detainee?s arrival. The initial
dental screening may be performed by a dentist or a properly trained qualified health
provider.?

a Medical staff did not schedule SAMIMI for a dental screening examination.

ICE 2011 (revised 2016), Medical Care, Section which states, ?An can-call
physician, dentist, and mental health professional or designee, are available 24 hours per
day-5!

II Nurses reported difficulty reaching Dr. outside of his working hours. On the
day of death, the physician did not answer or return two phone calls.

ICE 2011 {revised 2016), Medical Care, Section which states, ?Distribution
of medication {including over the counter) shall be performed in accordance with speci?c
instructions and procedures established by the HSA, in consultation with the CMA. Written
records of all prescribed medication given to or refused by detainees shall be maintained.?

0 A nurse who administered Phenergan on November 25, 2017, did not document it on
the MAR.

- Nurses documented administration of Ativan in nursing notes on November 17, 20,
21, and 27, but did not make corresponding notations on the MAR.

II A nurse did not document refusal of clonidine on December 1, 2017, in
the nursing notes, and did not complete a refusal form.

I A nurse did not notate an administration of clonidine on December 2, 2017, on the
MAR.

ICE 2011 (revised 2016), Medical Care, Section (VXX), which states, ?The facility
administration and clinical medical authority shall ensure that the Field Office Director is
notified as soon as practicable of any detainee housed at the facility who is determined to
have a serious physical or mental illness or to be pregnant, or have medical complications
related to advanced age, but no later than 72 hours after such determination. The written
notification shall become part of the detainee's health record file.?

I DCDF did not notify the Field Office Director that SAMIMI was withdrawing from
methadone and that his condition was deteriorating.

27

 

ll.

12.

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

0 Had ERO field office personnel been noti?ed and engaged early into his treatment by
medical personnel, a critical opportunity to engage with security and medical staff
concerning SAMIMI's treatment could have been leveraged. Prompt engagement of
the local ?eld office would likely help to ensure a comprehensive and adequate
review of events and assist in identifying areas needing both immediate andior long-
term corrective action, before response becomes critical.

ICE 2011 {revised 2016), Medical Care, Section (VXAA), which states, ?Prior to the
administration of medication, a separate documented informed consent, that
includes a description of the medication's side effects.?

a An informed consent speci?c to the anti-depressantisedative Trazodone was not
completed and signed by the detainee.

ICE 201 1 (revised 2016), Significant SeifHarm and Suicide Prevention and
Inrewenrion, Section (VHF), which states, ?All suicidal detainees placed in an isolated
confinement setting will receive continuous one-to-one monitoring, welfare checks at least
every 8 hours conducted by clinical staff, and daily mental health treatment by a qualified
clinician.?

I Nursing staff did not conduct a welfare check on SAMIMI during the 14 hours
between his placement on suicide watch and his evaluation via The
next nursing round occurred 15 hours later.

AREAS OF CONCERN

Although not re?ective of any violation of the requirements of the detention standards, ERAU
noted the following violations of GEO policy related to medical care.

QOS-A, i?Mediu::val Observation, which states, Nursing personnel will complete the
Medical Observation Nursing Progress Record, form 142.6, upon entry to the observation
area; 2) Subsequent assessments will be documented on each shift; 3) A patient status note
and vital signs will be performed and documented every two hours unless directed
otherwise by the physicianidesignee and will be entered into a progress note; 4) Detainees
admitted for 24 hour observation may, but are not required to, receive skilled nursing
intervention; 5) The responsible clinicianidesignee will write a daily note for each detainee
on medical observation for more than 24 hours.?

Nurses did not consistently perforrn nursing assessments each shift.

0 Nurses did not take vital signs every eight hours, as ordered by the
physician.

The clinician or designee did not write daily notes.

28

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

I 905-A, Medical Observation, which states, ?Detainees will not be housed in the medical
observation area for more than 24 hours without a physician?sfdesignee' 5 order, Medical
observation may be continued for three consecutive 24-hour periods (up to 72 hours).
Each renewal of medical observation after 24 hours must be approved through notification
of the responsible physicianfdesignee. Medical observation may not be continued beyond
72 hours. After 72 hours the detainee must be admitted as an infirmary patient in an
institution with an in?rmary, discharged to the general population, or transferred to a
higher level of care.?

0 Dr. did not renew his orders for SAMIMI's placement in medical
housing.

0 902, Alcohol and Drag Assessment and Treatment, which states, ?Detainees at risk for
progression to more severe levels of intoxication or withdrawal will be kept under constant
observation in the in?rmaryfmedical observation area by health care staff, and whenever
detainee are observed, a physician will be consulted Detainees
experiencing severe, life?threatening intoxication or withdrawal will be immediately
transferred to an acute care facility."

0 On at least two occasions, November 30 and December 1, 2017, the night
nurse failed to call the physician, despite her observation of 
serious clinical 

ERAU identi?ed the following violations of GEO post orders.

0 Medical Utility Of?cer Post Order, section General Ditties, which states,
?All necessary documentation shall be completed prior to the end of your work period
and forwarded to your immediate supervisor.?



OfficerT)(C) not complete an incident report documenting significant
events prior to the end of his shift.

 

 

 

 

0 Medical Utility Of?cer Post Order, section Level I One-on-One Obsenration,
which states, ?The detainee will be given appropriate suicide preventative clothing. All
non-suicide preventative articles of clothing will be removed from the detainee. This
will include the detainee?s undergarments.?

When placed again on Level 1 observationlsuicide watch on December 1,
2017, security staff allowed SAMIMI to retain his detention uniform.

0 Medical Utility Of?cer Post Order, section Level 1 One-on-One Obsenwtion,
which states, ?The Cell door will not be opened under any circumstances without two
officers being present and the on duty Shift Supervisor being noti?ed of the need to open
the cell.?

29

 

 


0)

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

On several occasions, officers opened the cell door when SAMIMI was on
Level 1 suicide watch without another of?cer present or without any
documentation a shift supervisor was noti?ed and gave approval.

ERAU identified the following violations of GEO policy concerning safety and security.

DCDF Policy 11.2.31, Permanent Logs and Reports, sections (A) and (H), which state
respectively, ?Logs will be maintained to re?ect the activities of each post or other area
on a shift-by-shift basis and to document emergency situations, unusual incidents, and
other pertinent information regarding detainees and activities on the post?; and ?Make
written and oral reports as necessary."

(bll?lIbHTli
0 Officer did not log in the Constant Watch Logbook move

from Level 2 to Level suicide watch.

 

 

 

 

The GEO Suicide Watch Log and Notes, Form lists Level 1 suicide
watch as ?Constant Observation,? while the DCDF post orders for the Medical
Utility Officer refer to Level 1 suicide watch as ?Continual Observation.?
The GEO Suicide Watch Log and Notes, Form lists Level 2 suicide
watch as ?Fifteen Minute Checks? while the DCDF post orders for the
Medical Utility Officer refer to Level 2 suicide watch as ?Constant
Observation? requiring 15 minute checks. Per Creative Corrections, ensuring
consistency among the forms and post orders will help avoid staff confusion.

?n his shift from 11:00 pm. on December 1, to 100 am. on December 2,
2017', Officer did not document in the Constant Watch Logbook all

pertinent information that occurred on the shift.

I The GEO Track system also erroneously documented the date and time of the
detainee?s placement on suicide watch.

DCDF Policy 17.1.2, Sanitation Procedures, section (I), Blood or Other Body Fluid,
which states, ?Following any incident where there is spillage of blood or other body
?uids the area shall be sanitized immediately by a member of the health service staff. . ..
Medical staff will utilize ?Clean-Up Kits? to clean up any blood and body fluids as well
as decontaminate the area." Security staff is responsible for ensuring the area is secure
and that all persons entering the area are donning appropriate personal protective
equipment.

DCDF currently requires security personnel to clean up bodily fluids such as
urine, feces and vomit. Medical personnel only clean spills that contain
blood. While the Security Chief believes medical staff should clean any spills
in accordance with the policy, the HSA believes that medical staff should only
clean spills containing blood. As result of internal disagreement between the
Security Chief and the HSA, despite the language of the written policy, the

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

two disciplines appear to be operating in a tense environment which could
adversely affect their communication and responsiveness.

GEO Policy 614, Hunger Strikes, which states, ?Detainees declaring andfor identified as
being on a Hunger Strike (missed 9 consecutive meals) will be monitored daily.?

On November 27', 2017, at 6:59 the medical officer logged that SAMIMI

declared he was on a hunger strike. A supervisor reviewed and signed off on
the medical officer?s logbook entries approximately eight hours later.
Although the log entry indicates security staff were aware of SAMIMI's
declared hunger strike, neither security nor medical documentation indicate
staff initiated monitoring of SAMIMI pursuant to the policy.

ERAU also identified the following area of concerns regarding implementation of opiate
withdrawal protocols.

DCDF holds current accreditation but failed to comply with standard 
G-UT, which states: ?Detoxification and withdrawal are best managed by a physician or
other medical professional with appropriate training and experience. As a precaution,
severe withdrawal must never be managed outside of a hospital. Deaths from
acute intoxication or severe withdrawal have occurred in correctional institutions. In
deciding the level of that can be managed safety at the facility, the responsible
physician must take into account the level of medical supervision that is available at all
times. Clinical management should also include the use of validated withdrawal
assessment instruments, such as the Clinical Opiate Withdrawal Scale or the Objective
Opiate Withdrawal Scale in case of opiate withdrawal, and the Clinical Institute
Withdrawal Assessment of Alcohol Scale, Revised, in the ease of alcohol withdrawal.?

Nurses reported they were unfamiliar with the COWS instrument, and were

never trained in opioid withdrawal. Nurses? actions demonstrated a lack of
understanding of Opioid withdrawal including that drug seeking
behaviors are expected. Nurses also failed to properly monitor SAMIMI as he
withdrew from opioids and to recognize his related life-threatening 

Nurses did not fulfill the November 29, 2017 order to complete
a daily COWS for SAMIMI.

ERAU identified the following concerns related to administration of medications:

Nursing notes did not consistently document justification for administration of as needed
medications, or an assessment of need for medications.

Nurses sometimes refused medications until the detainee ate, rather than provide anti-
nausea medication to enhance his appetite.

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

0 Nurses often failed to document the time of medication administration. Per Creative
Corrections, absent documentation of times medications were given, nurses on later shifts
could not know when another dose was or was not due. Although speculative, the poor
documentation on MARs may have contributed to SAMIMI less than 50 percent of
possible doses of medications as needed for anxiety, restlessness, sleeplessness, nausea
and pain.

I Nurses erroneously recorded administration of medications on MAR after he
was transported to the hospital.

ERAU identified the following concerns regarding nursing care.

- intake screening did not address current of withdrawal as called for
on the screening form.

0 After intake, nurses did not take weight again to determine rate of weight
loss, which Creative Corrections advises was particularly important given 
refusal of meals and inability to keep food down.

0 Nurses did not make any entries to medical record on November 19, 2017'.

0 Nurses did not maintain safety through fall prevention. Video showed
incidents in which SAMIMI appeared to hit his head or come close to doing so on the
floor or against the wall.

0 On November 24, 2017', nurses failed to complete a full injury assessment after SAMIMI
fainted.

0 Although, both medical and security staff described him as disheveled and having a
strong body odor during their interviews, the nurses stated they did not encourage
SAMIMI to shower.

0 Dr. {Mis?ttbitntc verbal orders for medications issued November 17, 2017, were not
authenticated.

- Nursing notes were brief and inadequate, particularly with respect to subjective
information.

I Nurses did not write progress notes in SOAPE format. '77

 

SDAPE charting, a nursing standard ofcare which provides organized information to other healthcare personnel,
addresses subjective information (what the detainee said], ob i ective information (relevant physical examination),
assessment nursing diagnosis based on both subjective and objective information, {efforts to resolve, report, or
monitor), and education (teaching, directing, and ensuring the patient?s full understanding). See Exhibit 1.

 

32

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

0 Nurses did not consistently document encounter times.

0 Nursing assessments did not consistently document pain levels.

I Nurses did not consistently document the justification for giving as-needed medications.
- Nurses incorrectly documented verbalftelephone orders.

0 Nurses did not document completion of assessments for dehydration.

ERAU identi?ed the following concerns related to security documentation.

While security staff routinely documented that the detainee was not eating meals, it is unclear
whether security staff communicated this to medical staff. On six occasions, officers did not
make entries to the Medical Housing Unit Log documenting acceptance or refusal
of showers, recreation, and meals. Missed meal entries include both lunch and dinner on
November 29, 2017', which, if refused, total seven consecutive meals SAMIMI refused.

The majority of signatures made by security supervisors and medical staff on the Medical
Unit Housing Log forms are illegible. Creative Corrections advises that ensuring the staff
documenting rounds are easily identi?able ensures accountability.

ERAU identified the following concerns related to after-action reviews of death.

Following death, facility staff including the Warden, Medical Director, HSA,
Quality Assurance Manager, and an RN, discussed the events surrounding the detainee?s
death at a routine safety meeting and during a facility mortality review. Neither review
included viewing of video surveillance footage of the detainee. As a result, conclusions
reached during both reviews were based, in part, on incomplete information.

ERAU identified the following concern related to maintenance of security equipment.

The medical of?cer had a non-functioning radio when she made a round on November 28,
2017 and encountered SAMIMI. Security equipment should be regularly checked to ensure
its operability in the event of an emergency.

Lad
L1.)

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

APPENDIX 1
SAMIMI VITAL SIGNS

The table below shows vital signs listed in nursing notes, and blood pressure readings
documented in the Blood Pressure Record. Missing readings indicate a nurse did not notate a
reading on that date anywhere in medical record.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE TEMPERATURE PULSE RESPIRATIONS BLOOD PRESSURE OXYGEN

1171772017 97.9 75 21 146794

1171772017 98.2 94 16 130794 100
1171772017

1171872017 97.1 75 16 104767 95
1171872017 98.0 65 19 110774

1171872017

1171972017

1171972017

1171972017

1172072017 106776

1172072017 94 16 130794 100
1172072017

1172172017 97.6 87 16 118776 95
1172172017

1172172017

1172272017 98.2 82 17 108774 99
1172272017

1172272017

1172372017 98.1 82 16 107774 97
1172372017 97.8 76 16 134793 98
1172372017

1172472017 98.2 102 18 128783 93
1172472017 98.8 77 18 129785 96
1172472017

1172572017 97.8 76 16 134793 98
1172572017 91 16 127793 96
1172572017 117788

1172672017 98 111 16 107781 99
1172672017 97.6 71 16 125785 96
1172672017 92 16 126778 96
1172772017 98 12 124780 95
1172772017

1172772017

1172872017 98.] 107 18 124791 95
1172872017

1172872017

 

 

 

 

 

 

 

 

34

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1172972017 97.7 120 16 108782 100
1172972017

1172972107

1173072017 97.6 88 16 100770 95
1173072017 97.8 100 15 101770 99
1173072017 100776

1270172017 84 16 101764 96
1270172017 94 18

1270172017 112768

1270272017 982 92 17 113768 94
1270272017 100 17 92768 95

 

 

 

 

 

35

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

APPENDIX 2

SAMIMI MAR DOCUMENTATION

The table below shows medication administrations as documented on his MAR.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodnne
9:00 1. . Given
IS- 9:00 (Jiven once; time None lwrce; Not Nol Not
Nov am. not recorded times not Prescribed Prescribed Prescribed
9:00 pm. recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
. . Given
Refused 9.00 am. (33:12:23? None twice; Not Not Not
Nov limes not Prescribed Prescribed Prescribed
9300 pm. recor recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
9:00 am; 1.
second Given twiee? Given
20? 1 t' twice; Not Not Not
Nov one $233]; one limes not Prescribed Prescribed Prescribed
recorded
recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
Given
None 9.00 :1 Given once; lime None once; lime Not Nol Not
Nov not recorded not Prescribed Prescribed Prescribed
recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodnne
9:00 a.m. . . . . Given Given
22? 9:00 once: time once; time Not Not Not
Nov p.111. 9:00 pm. recor de not not Prescribed Prescribed Prescribed
recorded recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
9:00 a.m. . - . Given
23? 9 :00 Non: once; time Not Not Not
Nov pm. 9:00 p. m. recor de not Prescribed Prescribed Prescribed
recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
C?iven twice? Given Given
24? 9:00 9:00 am" ltimes not once; time once; time Not Not Not
Nov p.m. rem} de not not Prescribed Prescribed Prescribed
9:00 p. m. recorded recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
9:00 am. - . . 
25? None None once; time Not Not Not
Nov 900 recorded not Prescribed Prescribed Prescribed
recorded

 

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
Given
26? None 9' 00 :1 Given once: time None once: time Not Not Not
Nov not recorded not Prescribed Prescribed Prescribed
recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxvzine Immodium Trazodone
Given
None 900 Given once; Iime None once; time Not Not Not
Nov p. not recorded not Prescribed Prescribed Prescribed
recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
Given Given
23? None 900 a Given once: time once: time once: time Not Not Not
Nov not recorded not not Prescribed Prescribed Pres-:cribed
recorded recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
Not 
Prescrib 9:00 pm. None None None None None
Nov ed not
recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
9:00 run. Given
10? Nm Given once- time twice"
Nov Prejjrib 3:00 pm. not recorded None times not None None 9:00 pm.
9:00 pm. recorded
Date Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen Hydroxyzine Immodium Trazodone
9:00 am.
1? Not
Dec Pres-acrib 3:00 11m. 9:00 am. 3:00 pm. 9:00 am. 9:00 am. None None
ed
9:00 pm.

 

 

 

 

 

 

 

 

 

 

DETAINEE DEATH REVIEW Kamyar SAMIMI, IICMS 

 

EXHIBITS

1. Creative Corrections Medical and Security Compliance Analysis
2. GEO Medical Intake Screening by LPN dated November 17, 2017.
3. Adams Broomfield County Autopsy Report by Dr.? dated December 6, 2017.

Detainee Death Review: Kamyar SAMIMI, A #22732918
Healthcare and Security Compliance Analysis

Denver Contract Detention Facility

Aurora, Colorado

As requested by the ICE Office of Professional Responsibility (OPR), External Reviews and
Analysis Unit (ERAU), Creative Corrections participated in a review of the death of detainee
Kamyar SAMIMI while in the custody of the Denver Contract Detention Facility (DCDF). A

site visit was conducted January 9 through 11, 2018 by {momentum ERAU Unit Chief, momentum
. ERAU Inspection and Compliance Specialist and team leader; and Creative Corrections

contract personnel I DHEIIDHIHCJ Program Manager_ Security Subject Matter
Expert; I Registered Nurse, Medical Subject Matter Expert. Contractor
participation was requested to determine compliance with the ICE 2011 Performance Based
National Detention Standards 2016 revision, governing medical care and security
operations.

 

Included in this report is a case synopsis, description of the facility and its medical services,
detention summary, a narrative description of events, and conclusions. The information and
findings herein are based on analysis of detainee medical record and detention ?le,
tour of the intake and medical areas, interviews of staff, and review of policy, video surveillance
recordings, and available incident related documentation.

SYNOPSIS

Kamyar SAMIMI was 64 years old when admitted to DCDF on November 17', 2017. He died
shortly after transfer to the hospital on December 2, 2017.

During intake screening, SAMIMI reported taking high-dose methadone on a daily basis since
sustaining an injury to his back more than 20 years ago. The physician was contacted and
ordered housing in medical observation, laboratory testing, vital signs every eight hours, and
medications as needed for anxiety, restlessness, sleeplessness, nausea, and pain. The detainee
remained in medical housing over the course of the 16-day detention period. The laboratory tests
were completed and determined by the physician to be essentially within normal limits. Vital
signs, typically taken twice a day during nursing encounters, were also generally within normal
limits over the detention period. An assessment instrument for monitoring withdrawal 
was not used, and SAMIMI was never evaluated by the physician or other medical provider.
Evaluations by mental health providers identified no mental health diagnosis. Nurses
administered less than half the as-needed medications ordered.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 1
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanve_
I 

Starting November 24, 2017, there were multiple incidents suggesting withdrawal
were worsening and his condition was deteriorating, although medical staff
questioned their legitimacy based on their observations and his vital signs. The incidents
included SAMIMI appearing to faint while at the door of his cell, collapsing in the hallway while
being escorted to a mental health appointment, suicide attempt, and report that he was drinking
from the toilet. Video taken in the last 48 hours of detention shows he was in an
extremely weakened condition, unable to stand or sit up, and incontinent of bowel and urine.

On the day of death, an unsuccessful attempt was made to move SAMIMI to a
wheelchair for a mental health appointment. Finding he was too ill, the nurse and of?cers
returned him to his cell. As the nurse attempted contact with the physician by telephone, a
lieutenant arrived and directed that an ambulance be called. Emergency Medical Services
responders arrived within approximately four minutes and SAMIMI stopped breathing very
quickly thereafter. Cardiopulmonary resuscitation was started and continued through his
placement in the ambulance and arrival at the emergency room. Resuscitation efforts were
unsuccessful, and death was pronounced at 12:02.

The autopsy report documents the cause and manner of death were undetermined.

FACILITY DESCRIPTION

DCDF is privately owned and operated by the GEO Group, Inc. (GEO) of Boca Raton, Florida.
The facility holds detainees for ICE and the United States Marshal Service. On the day of
detainee death, the total population of 808 includedg 7'3 United States Marshal
Service detainees and 735 ICE detainees.

 



 

 

 

According to Majo- Security Chief, of?cers attend a two week on-site academy and
complete one week of on-the-job training before assuming a post alone. A watch commander,
typically a lieutenant, is responsible for supervising officers and managing shift operations.
During day shift on Fridays and Saturdays, the administrative captain serves as watch
commander.

DCDF has maintained accreditation by the American Correctional Association since 1989 and
by the National Commission on Correctional Health Care since 2003. According to
the Health Services Administrator (HSA), the next survey is scheduled for May 2018.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 2
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


reanve_
I 

HEALTH CARE SERVICES

Health care is provided by GEO, supported on a limited basis by subcontractors. The HSA,
is a foreign medical graduate who retired from the Federal Bureau of Prisons as
a physician assistant. Mr. Eli?iilbiml I was hired as HSA for DCDF in March 2016. The Clinical
Medical Authority, Dr. I provides clinical services and oversight under
subcontract with Correctional Care Solutions (CCS). Dr. provides on-site services 40
hours per week and on?call services 24 hours per day, seven days per week. The staffing plan

includes one half?time midlevel provider; however, the position has been vacant since July 2017.
HSA reported the vacancy has recently been ?lled.

 

 

All nurses are GEO employees. Authorized nursing positions include a full time Director of
Nurses (DON), eight full-time and five part?time registered nurses (RN), and seven full-time
licensed practical nurses (LPN). The HSA reported the DON position has been vacant for a
period of time due to recruitment challenges. Additional nursing vacancies at the time of
the site visit included two LPNs and an RN with designated responsibility for chronic care
patients. Nurses work both eight and 12 hour shifts, providing coverage by two nurses at all
times. Additional positions authorized by the GEO staf?ng plan include a registered health
information administrator, three medical records clerks, a part-time dental assistant, a full-time
x-ray technician, and an administrative assistant. The administrative assistant position was
vacant at the time of the site visit.

Mental health services are provided by two part-time and four as?needed tele?
The provide services under contract with Registry of Physician
Specialists the four provide services under three contracts, one with
RPS, two with Family Guidance Center, and one with Mind Care Solutions. Dental services are
provided by one part-time CCS dentist and the afore-referenced GEO dental assistant.

The DCDF clinic is spacious and well maintained. It has two examination rooms, an urgent care
room, pharmacy, laboratory, x-ray area, two-chair dental suite, enclosed nurses? station, medical
records office, room, biohazard and supply storage closets, and various offices
for mental health and administrative staff. There are ?ve observation cells with anterooms, each
equipped with negative pressure for respiratory isolation, and one cell designated for suicide
watch. The cells have stationary security cameras, footage from which is monitored by the
assigned medical of?cer.

DCDF does not have an electronic medical record system. Nursing encounters are documented
on GEO Progress Notes and for patients housed in medical, GEO Medical Observation Nursing
Progress Record forms. The standard SOAPE1 format is used only on the latter.

 

SDAPE charting, a nursing standard of care which provides organized information to other healthcare personnel,
addresses subiective information (what the detainee said}, obiective information (relevant physical examination),


DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 3
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


reanve_
I 

A review of credential files found all professional licenses and certifications were current and
primary source verified.

SUMMARY OF EVENTS

Friday, November 17, 2017

Detainee SAMIMI was transported to DCDF from the ERO office by GEO officers. There is no
time stamp on video surveillance footage of the intake area so the exact time of arrival could not
be determined; however, the Emergency Noti?cation and Property Disposition Form documents
arrival at 4:00 p.m. Form 1?213, Record of Deportablei?lnadmissible Alien, noted, ?The subject
claims good health. Subject takes methadone for back pain." The video shows detainee
SAMIMI arrived with four others and was placed in a holding cell where he remained for
approximately ?ve hours. According to the intake of?cer, fbil?iilbi?iici the delay in
initiation of processing was caused by the volume of admissions and releases. Review of video
confirmed a high level of activity in the area. Officer-tated SAMIMI was let out of
the hold room to see a nurse because an of?cer or another detainee reported he was ill. The
video shows him walking without assistance to the medical screening room.

 

 

LPN completed the medical and mental health intake screening at 9:30 p.m. She
documented and con?rmed during interview that SAMIMI spoke English. Staff interviewed
during the site visit consistently reported SAMIMI spoke English fluently. vital
signs were all within normal limits with the exception of an abnormally elevated blood pressure
of 146094. His height was five feet, seven inches tall and his weight was 135 pounds.

Note: 135 pounds is underweight for a man of SAMIMI's height. Arresting Deportation
Officer ERO Fugitive Operations, stated during interview that the
detainee appeared very thin, especially compared to a past photograph. Medical and
security staff also observed that SAMIMI was very thin when admitted.

LPN documented that SAMIMI reported taking 190 milligrams (mg) of methadone daily
and that he was suffering withdrawal She did not specify how long he had taken
methadone and last use. In addition, she did not complete section 17 of the screening form
calling for specifying of withdrawal?

 

assessment (nursing diagnosis based on both subjective and objective information, pl? {efforts to resolve, report,
or monitor], and education (teaching, directing, and ensuring the oatient?s full understanding].

22 Earlyr signs of opiate withdrawal include running nose, sweating, tearing, yawning, dilated pupils, and increased
temperature. Later signs include loss of appetite, nausea, vomiting, diarrhea, goose flesh, increased blood
pressure, increased pulse, restlessness, and severe muscle and joint pain.

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 4
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanve_
I 

 

. . . 
Note: No methadone was received with detainee SAMIMI. DO C) informed the

review team that when he arrested SAMIMI at his residence, the detainee was walking to
his car and reported he was on his way to his methadone clinic.

 

 

 

During interview of LPN she stated she observed no tremors or other withdrawal
and that SAMIMI was stable and steady on his feet. She recalled that the only
SAMIMI reported was anxiety, and that he repeatedly stated he needed methadone for
chronic back pain caused by a car accident. LPN documented he reported sharp back
pain of level five3 during screening. substance abuse history included two to three
beers occasionally over the past thirty years, cocainefcrack one time weekly over the past twenty
years, marijuana once weekly and opium daily twenty years ago. He also reported smoking ten

cigarettes a day, his last having been ten hours earlier. In the dental section of the form, LPN
documented SAMIMI lost his front teeth in the car accident.

Note: There was no further dental screening or examination during the detention period.

The nursing plan of care directed the detainee?s placement on the ?blood pressure list? and
completion of blood pressure checks three times weekly for two weeks, with urovicler referral in
the event his blood pressure was elevated. As explained by HSA ?placement on the
blood pressure list effectively referred SAMIMI for chronic care evaluation following the period
of blood pressure monitoring. LPN cleared SAMIMI for general population; however,
RN I reported that she directed that he ?rst be brought to the clinic due to
his reported withdrawal. RN stated that when she spoke with detainee SAMIMI,
he informed her he was taking 190 mg of methadone on a daily basis for detoxification from
other drugs, leading her to telephone Dr. for orders (see below).

 

Note: The reported methadone dosage of 190 mg daily is consistent with information
reported to LPN however, LPN documented SAMIMI said methadone
was used to address chronic back pain. RN I did not document her
discussion with therefore, it cannot be determined whether he gave discrepant
information, or if the recollection was inaccurate.

As part of the intake process, SAMIMI signed consent for medical, dental, and mental health
services and authorization to obtain health information. In addition, a screening chest x-ray
showed no acute cardiopulmonary disease or evidence of active tuberculosis.

Of?cer reported that she expedited intake processing when informed he
was to go to the clinic. She said he was offered a shower, changed into facility clothing, and his
property was inventoried. The inventory form lists a belt and hat, two pair of pants, five pair of

 

3 Patient report of pain level is based on a standardized scale of zero to ten, with zero signifying no pain
and ten signifying the worst pain ever experienced.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 5
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanve_
I 

socks, one shirt, two t-shirts, two pair of underwear, one pair of shoes, two sweaters and one
wallet. He also had $22 in U.S. currency. The funds were placed into an account for purchase of
phone time and commissary. SAMIMI signed receipts for the funds, facility clothing and
hygiene supplies. He gave consent to have mail delivered to him at the facility and named-

(bil?lilblmici as his emergency contact.

A PREA Risk Assessment form was signed by the detainee and a staff member whose signature
is not legible. Risk factor checkboxes were left blank in both the yes and no columns, and no
score was applied. SAMIMI also signed a form acknowledging that he was apprised of PREA
reporting information and received the ICE Sexual Abuse and Assault Awareness Pamphlet.

Detainee SAMIMI was classified medium low using the ICE Custody Classi?cation Worksheet.
The rating was approved by a supervisor on November 21, 2017'.

RN documented receipt of telephone orders from Dr. (bil??litbim at 10:30 p.m.
Note: RN did not document whether the orders were read back to verify
accuracy, and Dr. did not sign to authenticate his verbal orders as required by
Colorado law?.

The orders were as follows:

1. Stat?3 laboratory studies to include a complete blood count?, comprehensive metabolic
panel7, thyroid stimulating hormone?, and formal urine";

Note: During interview, RN said she drew the blood samples and sent
them for laboratory testing the same night. According to the LabCorp report, they were
not received until November 20, 2017.

2. Medications, to include:

 

4 Colorado Revised Statutes Title 25 Health 25?3?111 requires verbal order authentication within 48 hours, unless
a read-back and verify process is in place, in which case the authentication must occur within 30 days.

5 Stat means immediate.

5 A complete blood count is a test that provides information about the various cell concentration in a patient?s
blood to assist in disease diagnosis.

7 A comprehensive metabolic panel is a test that provides information about the status of your metabolism,
including kidney and liver function, electrolyte balance, blood glucose, and blood proteins, in order to monitor
such conditions as hypertension and diabetes.

8 A thyroid stimulating hormone test is a blood test that measures the level of this hormone to determine if
the thyroid gland is functioning properly.

9 A formal urine, or urinalysis, is a test that analyzes the culture and contents of a urine sample.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 6
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


i: reanve_
I 

- Ativan?l 1 mg intramuscularly up to three times daily as needed for 15 days.

Note: RN 5 note documents Ativan 1 mg was administered
intramuscularly in the right deltoid. Administration of the medication was not recorded
on the Medication Administration Record (MAR).

Clonidine]1 0.1 mg orally up to three times daily as needed for 15 days.
Cyclobenaaprine'2 10 mg orally up to three times daily as needed for 15 days.
Ibuprofen13 800 mg orally up to three times daily as needed for 15 days.
Phenergan '4 25 mg orally up to three times daily as needed for 15 days.

Hold in medical.
Appointments with and physician.

Note: As described below, SAMIMI was seen by the on November 20,
201?. However, he was not added to Dr. Provider Appointment Log despite
the verbal order and clinically signi?cant ?ndings identi?ed during the intake screening.
In fact, SAMIMI was not physically examined by the physician during the detention
period. During interview of Dr. he shared that initial assessments of detainees
with abnormal intake screening findings were completed by the midlevel provider in the
past. He said that since the midlevel urovider became vacant, RNs have performed all
physical examinations. HSA confirmed Dr. does not conduct initial
physical examinations and remarked it is likely there were other detainees with
signi?cant medical problems whose initial examinations were conducted by RNs.

Increase and encourage ?uids.
Vital signs every eight hours until further notice.

Note: A MAR for vital signs was created specifying they were to be taken every eight
hours; however, it remained blank throughout the detention period. RN
stated that she noted the vital signs order on the MAR as a reminder to nursing staff.
Nurses documented vital signs in their notes and on three occasions (November 25,
November 30, and December 1, 2017), recorded blood pressure readings on the Blood
Pressure Record. As re?ected below and in Appendix 1, nurses took vital signs once or

 

10 Ativan is a medication to treat anxiety.

ll Clonidine is a medication with sedating properties. used to treat high blood pressure.

12 Cyclobenzaprine is a muscle relaxant medication.

13 Ibuprofen is a medication to treat pain.

14 Phenergan is a medication with sedating and pain control properties, used to treat nausea.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 7?
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


reanve_
I 

twice per day rather than every eight hours. HSA stated during interview that
nurses mistakenly understood that vital signs were to be conducted once per shift.
Because many worked 12 hour shifts, vital signs were not taken every eight hours as
ordered.

Note: SAMIMI was not weighed again following intake, and pulse oxygen saturation
was not consistently taken with vital signs. During interview, Dr. stated pulse
oxygen saturation and body weight should typically be taken when obtaining vital signs;
however, because the laboratory results were normal (see below), he did not believe it
was ?truly necessary? for nurses to do so in case. He also shared his opinion
that there is risk involved in having patients whose gait is unsteady walk down the hall
and step on a scale.

During discussion of his orders, Dr. stated they were based on Clinical Practice
Guideline (CPG) for opioid withdrawal. He and HSA both noted the GEO CPG
mirrors that of the Federal Bureau of Prisons. Dr. stated he opted not to order an EKG
as recommended in the CPG because he thought it more important to have the laboratory tests
done. He also opted not to order an HIV test because SAMIMI did not report use of injectable
drugs or other high risk behaviors. Asked whether he considered ordering nurse monitoring
using an opioid withdrawal assessment instrument, he remarked that such instruments provide
guidance but they ?are not really protocol.? He added that detainees are typically finished
withdrawing in three to four days but because SAMIMI reported use of high dose methadone
over several years, his withdrawal was prolonged.

Note: The CPG does not address use of an assessment instrument; however, 
mandates monitoring using validated instruments. The reviewer notes the Clinical Opiate
Withdrawal Scale is most widely recognized and used, although GEO has a
limited instrument titled, ?Alcoholi?Drug Withdrawal Monitoring Sheet?. Instructions on
the AlcoholfDrug Withdrawal Monitoring Sheet direct completion at least twice daily for
a minimum of three days. If signi?cant issues are found, the nurse is to notify a clinician
and document in the health record. Review of the GEO form found it does not mirror
the COWS. Regardless, neither a COWS nor the GEO instrument were completed during
detention. As discussed below, on four occasions nurses used an instrument
speci?c to alcohol withdrawal.

Note: Nurses reported they have not been trained in opiate withdrawal, although HSA
stated opiate withdrawal has been discussed at meetings. No documentation of
training in the subject was available, and Dr. stated it is assumed nurses receive
adequate training in nursing school.

 

15 COWS is a tool used to assign points specificallyf to of opiate withdrawal, with total scores indicating
the severityr of withdrawal. It is not compatible with alcohol withdrawal instruments 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 8
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


i: reanve_
I 

Note: The CPG calls for giving clonidine in doses of 0.1 to 0.2 mg orally three to four
times daily as a means of controlling hypertension and somnolence'f', suggesting interval
dosing at specific times rather than as needed. Although Dr. ordered
administration as needed, the MARs for both clonidine and Ativan set 9:00 am, 3:00
and 9:00 p.m. as the times for administration. As identified below, MAR entries for
ordered medications were found by the reviewer to be inconsistent, with times not
recorded at all or noted at times which did not align with nursing notes. Asked about the
process followed for making MAR entries, RN stated that at least for
clonidine, nurses selected whichever of the three set times (9:00 am, 3:00 pm, and 9:00
pm.) was closest to when they gave SAMIMI a dose. Failure to document the actual
time clonidine, Ativan, and other medications are given may result in administration of
medication before or after another dose is clinically apprOpriate.

In addition to addressing dosage and frequency, the CFO states blood pressure and heart
rate levels must be obtained prior to each dose of clonidine. The CPG also states the
medication is to be withheld if systolic blood pressure? falls below 90. Dr.
order did not include this guidance. Because nurses took vital signs less than half the
time ordered, and because they did not consistently and accurately document the time
clonidine and other medications were given, the reviewer was unable to verify whether
blood pressure was checked before giving clonidine. As identified below and
in Appendix 1, the detainee?s blood pressure was in the normal range when taken,
suggesting the clonidine effectively controlled any hypertension that may have been
caused by withdrawal.

Note: Standard nursing practice calls for assessment of patient prior to
administration of as-needed medications. In addition, justi?cation must be documented
in a nursing note, and administration must be documented in both the note and on the
MAR. As noted below, nurses did not consistently document assessment of to
determine the need for medications, and did not consistently document administration on
both the MAR and in a nursing note.

Written in the margin of RN ?s note documenting Dr. orders was ART
Innovative Recovery Clinic, 2925 East Colfax Avenue, Denver, Colorado, with two telephone
numbers. RN stated during interview that SAMIMI said he was a methadone
patient at this clinic. She wrote the name and address of the clinic in the event Dr.
decided to seek records. As discussed below, Dr. reported to the review
team that he attempted to verify the detainee was a patient at the clinic.

 

1'5 Somnolence is a state of feeling drowsy, increasing risk of injury.
1? Systolic blood pressure is reflected in the top number.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 9
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


i: reanve_
I 

The first nursing round was documented by RNl?lffjile llibli?liiblillicl I at 10:30 p.m. Asked about
the expected frequency of rounds, HSA stated it was implied in Dr. order
for vital signs every eight hours that nurses were expected to perform assessments at the same
time. Standard nursing practice requires that assessments include documentation of subjective?:
and objectivelg ?ndings and administration of medications as needed, to manage identi?ed


Note: As detailed below, nurses documented encounters with only once or
twice per day and did not consistently document subjective and objective ?ndings.

On a Medical Observation Nursing Progress Record, RN documented that SAMIMI
stated, feel terrible.? His vital signs were within normal limits with the exception of a 
elevated blood pressure of 13094. He denied chest and abdominal pain but complained of level
eight pain.

Note: RN (bll?lilblm?icl did not document the location or nature of the pain.

RN wrote that SAMIMI reported nausea and vomiting two hours earlier and
described his emesis as, ?hardly anything? and ?greenish" in color. He reported he had a
?watery? bowel movement on November 20, 2017, which the reviewer notes was three days after
the date of this encounter. RN admitted the date recorded was an error and could not
recall the date SAMIMI reported. The assessment noted tremors to his hands and an unsteady
gait. The nursing plan was to continue monitoring and encourage ?uid intake.

Note: Neither the MAR nor the note documents whether SAMIMI was given medication
for his reported level eight pain.

The GEO track form2U shows detainee SAMIMI was placed in medical observation cell 537' at
11:14 p.m. Video surveillance footage of detainee entry to the cell shows he walked
in unassisted and made his bed without difficulty. The Medical Logbook documents 
assignment at 11:19 p.m. and that his placement made the total unit count four. The Medical
Logbook is bound, with numbered pages on which officers sequentially record events on the post
and any noteworthy information pertaining to detainees assigned to the unit. Cell 537 is entered
through an enclosed anteroom which includes a sink. The door to the cell has a window in the
top half, and to the left of the door is another large viewing window. The cell has a single bed on
the left, a toilet behind a half wall and a shower behind a full wall. A camera is in the upper left
corner of the cell. A monitor on the of?cer?s desk displays live video feed of the interior of all
cells in the clinic. Activities are documented in a Medical Unit Housing Record Log specific to

 

18 In the standard SOAP note charting method, subjective information refers to what the patient reports.

19 Objective information refers to physical assessment findings.
2? The GED track form shows the time and location of detainee housing assignments.

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 10
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


reanve_
I 

each detainee. On this form, officers enter yes, no or refused for acceptance of a meal,
recreation, and shower, and medical staff and security supervisors document rounds. Recreation
in the medical unit consists of time outside the cell, including use of the Room? equipped
with a wall-mounted television, table and chair. Entries to detainee SAMIMI's Medical Unit
Housing Record are summarized in Appendix 2.

Note: As re?ected below and in Appendix 2, Medical Unit Housing Record
Log does not document that he ever accepted the opportunity to shower. While officers
would not necessarily have noticed and recorded his use of the shower within cell 537?,
showering after placement on suicide watch would have necessitated release from the cell
to do so and entry in the log by the officer. No officer interviewed recalled SAMIMI
ever showering.

Note: Logging yes with respect to a meal signi?es acceptance of a tray. Officers do not
record whether a detainee consumes all or part of the meal. As noted below and in
Appendix 2, acceptance of meal trays became sporadic starting November 24,
201?. Other documentation indicates that he frequently did not consume meals in whole
or in part.

Note: HSA stated he expects nurses to sign the log each day. During interview
of RN ?e stated that the log sheets are on the officer?s desk and nurses may
miss making entries. In addition, RN stated it is not clear which nurse is
responsible to sign the log, the nurse assigned to the area or the nurse who delivers

medication. As re?ected below and in Appendix 3, nurses made daily entries on the log

 

on all but two occasions. Although the log entries were missed, the medical record

E'b 
documents contact with the SAMIMI. 

 

 

 

Officer?tarted detainee Medical Housing Unit Log a' the
post for the 11:00 pm. to 7:00 am. shift. On interview, Of?cer escribed SAMIMI as

very talkative and very thin. She recalled the nurse obtained a blood sample but SAMIMI was
unable to provide a urine sample. He asked for Gatorade, which Officer obtained from
nurses in powdered version and provided to SAMIMI.

 

 

 

 

Saturday, November 18, 2017

Medical Housing Unit Log

SAMIMI accepted all three meal trays this date and declined recreation and a shower. Officer
-tated that when she collected the detainee?s breakfast tray, she noted all items were

consumed but when she returned to duty for the evening shift, some of the dinner meal remained

on the tray. Medical staff signed the leg as did a security supervisor. All signatures are

illegible.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 11
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


reanare_
I 

MAR

 

 

 

 

 

 

 

Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
9:00 am. 9:00 am. Given once; time Not given Given twice; times not
9:00 pm. not documented documented

 

 

Note: Administration of Ativan was not documented in a nursing note.

Note: Ibuprofen may have been given due to complaints of pain during nursing
encounters discussed below. The nursing notes for the encounters do not document
whether the medication was given, and do not document the justification for giving
cyclobenzaprine. The basis for giving clonidine is also not documented as required for
as-needed medication; however, the fact that SAMIMI was experiencing of
withdrawal justifies administration of the medication on this and subsequent dates. The
con?ict is that Dr. ordered clonidine as needed rather than on a scheduled basis.
As noted above, the reviewer cannot verify whether SAMIMI's blood pressure was
checked before he was given clonidine due to the inconsistent and possibly inaccurate
timing of MAR entries.

 

 

 

 

 

 

 

 

 

 

 

 

Vital Signs
Temperature Pulse Respirations Blood Pressure Oxygen Weight
97.1 75 16 104f67 95 Not taken
98.0 65 17 1 10f74 Not taken Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
Medical Record

A GEO Alcohol Withdrawal Assessment and Treatment Flow Sheet (Clinical Institute
Withdrawal Assessment or was completed at 1:45 p.m. RN stated during
interview that she completed the form but acknowledged she did not enter her initials where
required. Vital signs {see the first row of the above table) were within normal limits. A score of
seven was determined, indicating the level of alcohol withdrawal did not require medication
treatment.

Note: The CIWA is speci?c to alcohol withdrawal. Although many of the same
are experienced by persons withdrawing from opioids, there are clinical
differences which are factored in scores on the respective assessment forms. RN
stated during interview that she knows that alcohol and opioid withdrawal are
clinically different and that she ?must have grabbed the wrong form.?

 

21 CIWA is a tool used to assign points specifically to of alcohol withdrawal, with total scores indicating
the severityr of withdrawal. It is not compatible with opiate withdrawal instruments leg. 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 12
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


i: reanare_
I 

 completed a Medical Observation Nursing Progress Record. He did not
record the time. During interview, RN guessed that the encounter occurred about 11:00
am; however, his documentation includes reference to times later in the day. Specifically, RN
wrote that SAMIMI consumed an unspecified amount of water at 4:40 p.m. and ate 40
percent of his dinner at 4:50 p.m. Vital signs exactly matched those documented on the CIWA,
suggesting the same set was used. SAMIMI reported his last bowel movement was the previous
day. His skin was warm and flushed, and he complained of headache pain at a level six.

Note: RN note does not document whether pain medication was given.

At 6:00 completed a Medical Observation Nursing Progress Record. He

wrote that SAMIMI reported taking methadone over the past 20 years and that he was
experiencing nausea at the time. Vital signs (see second row of the above table) were within
normal limits. He denied all pain but appeared pale. With the exception of nausea, no signs or
of withdrawal were noted. SAMIMI reported his last bowel movement was earlier in
the day, and that he ate approximately 70 percent of his evening meal. The nursing plan was to
continue monitoring.

Note: There is no documentation Phenergan was given to relieve nausea.

Note: RN entry documents SAMIMI consumed 40 percent of the evening meal;
RN Muiru entry documents he ate 70 percent. The inconsistency cannot be explained,
although it is possible the detainee gave different reports.

A 10:00 p.m. progress note written by LPN documents SAMIMI stated, have pain on
my hand and on my back, including my spinal from long time car accident? and that he takes
methadone for pain. He was alert and oriented with no shortness of breath or distress observed.
He complained of methadone withdrawal symtoms, stating, stomach hurts, I am
shivering.? LPN wrote, ?Pass to nurse . and nursed contact Dr.
During interview, LPN stated RN was the nurse referred to in her note, and
that she believed Dr. had been noti?ed.

 
    
   
   

 

Note: The medical record documents no contact or attempted contact with Dr. 
this date.

Note: LPN note does not document whether SAMIMI was given any
medication.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 13
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?

.
reanve_
I 

Sunday, November 19, 2017

Medical Unit Housing Record
SAMIMI accepted all three meals and declined recreation and a shower. Medical staff signed
the log as did a security supervisor. All signatures are illegible.

Medical Unit Logbook
A 7:38 a.m. entry documents, SAMIMI ?x-Ray, withdraw?.

Note: The medical record includes no x-ray report corresponding to this logbook entry.

A 10:40 a.m. entry documents detainee SAMIMI said he was in a lot of pain and nurses are
aware. Nurse was informed at 10:42 am. and at 10:47' am, reported to the cell and gave
medication.

Note: There were no medical record entries this date to corroborate the of?cer?s entries,
although the MAR documents SAMIMI was given pain medication at an unspeci?ed
time.

The Telmate Phone Record Report documents that at 6:13 detainee SAMIMI made a free
?ve minute phone call. Reviewers listened to the recording of the call, which was made to an
unidenti?ed person. SAMIMI stated he is ?dying here? and asked the call recipient to notify his
sister so she could post his bond. He also asked what day it was and how long he had been
detained. He was told it was Sunday and that he had been there three days. Detainee SAMIMI
stated, ?I?m a legal resident? and at the end of the call, stated he was housed in medical and that
he was ?sicker than hell."

 

 

MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
Refused 9:00 am. Given twice; times None Given twice;
9:00 pm. not documented documented times not
documented

 

 

 

 

 

 

 

Note: There were no medical record entries documenting the justi?cation for giving
medications.

Vital Signs
No vital signs were documented this date.

Medical Record
There were no nursing rounds or progress notes in the medical record this date. HS A (DHEMDHW
could not explain why encounters were not documented.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 14
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

i 
rea:uve_
I 

Monday, November 20, 2017

Medical Unit Housing Record

SAMIMI accepted all three meals. There was no entry documenting whether a shower or
recreation was offered and accepted or declined, although the Telmate Phone Record report
documents that at 4:49 pm, attempted a phone call to the same number called on
November 19, 2017. There was no answer. The fact that he attempted a call suggests he
accepted the offer of his recreation period. Medical staff signed the log as did a security
supervisor for each shift. All signatures are illegible.

Note: There is no record of any other non?attorney phone calls attempted or completed
by the detainee. Both the logbook and staff recollections confirm he had telephone
communications with his attorney. Since attorney calls are not monitored and recorded,
they are not placed through the Telmate phone system used for personal calls. Instead,
attorney calls are placed on facility phones with staff assistance, and no record is

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

maintained.
MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
None 9:00 am; second dose Given twice; None Given twice; times
documented at time not documented times not documented not documented
documented.
Note: As noted below, RN documented in her note that she gave an
injection of Ativan that is not documented on the MAR. The basis for as-needed
administration of cyclobenzaprine and ibuprofen is not re?ected in nursing notes.
Vital Signs
Temperature Pulse Respirations Blood Pressure Oxygen Weight
Not taken Not taken Not taken 106f7?6 Not taken Not taken
Not taken 94 16 13094 Not taken Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
Medical Record

A CIWA form was completed at 9:30 a.m. The form was not initialed or signed, but RN
acknowledged completing it. When asked about use of the CIWA, she said she has
not been trained in opiate withdrawal monitoring and therefore, is unfamiliar with an appropriate
assessment instrument such as the COWS or the GEO form. RN _recorded vital signs
within normal limits except for a elevated blood pressure (see second row of the above
table) and applied points for of nauseafvomiting, tremors, and paroxysmal sweating,
and anxiety.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 15
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

i 
rea:uve_
I 

Note: Although the CIWA was not the proper assessment instrument, the categories in
which RN applied points are of opioid withdrawal. Her
application of points documents SAMIMI was experiencing withdrawal in the
referenced categories.

Dr. conducted a mental health evaluation from 1:15 to 1:40 p.m.
Dr. wrote that SAMIMI denied a history of suicidal or homicidal intent, self-harm,
alcohol use, domestic violence, sexual assault, or violence toward self or others. SAMIMI said
he came to the U.S. when he was 20 years old and attended universities in Colorado and
Wisconsin. Prior to detention, he was self-employed as an auto technician. He reported an
arrest for cocaine possession 15 years ago and that he ?met all requirements.?

Dr. documented SAMIMI reported ?rst use of opium in Iran when he was four years
old, explaining that his grandfather, a doctor, administered the narcotic to him for an earache.
He said he made a decision to use opium recreationally at the age of 14 while still in Iran.
SAMIMI reported he migrated to methadone in 1991 upon recommendation of a mental health
professional. He has been taking methadone daily since that time; most recently, five days prior
to arrival at DCDF. SAMIMI said his daily dose was 150 mg.

Note: As noted above, documentation by LPN and RN indicates
SAMIMI previously reported he was taking 190 mg daily.

Dr. noted SAMIMI was in active withdrawal, complaining of chills, nausea, stomach
pain, headache, and body aches. He responded to questions logically and cooperatively. He was
fully oriented, exhibited no signs of and denied delusions or hallucinations as part of
withdrawal. Dr. plan was to continue housing in the medical observation
unit for continued monitoring of vital signs. He was to return in one week for follow up of his
withdrawal status, assess his adjustment to detention, and identify any potential mental health
concerns underlying or resulting from the opiate addiction.

During interview, Dr. shared that she is a certified Addictions Specialist She offered
that her specific knowledge in methadone use and withdrawal is limited, but she readily
identified SAMIMI as a patient in opioid withdrawal. She said she did not discuss her
observations of withdrawal with medical staff. Asked for other
observations, she said she found SAMIMI, ?very bright, well-spoken and cooperative," and that
she observed nothing to suggest he was being ?dodgy" or manipulative.

A 7:00 p.m. progress note by RN documented SAMIMI denied pain or nausea,
although tremors were observed and he appeared anxious. Vital signs were not recorded during
this encounter. He was given an injection of Ativan, administered in the right deltoid muscle.

Note: The dose of Ativan was not recorded on the MAR.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 16
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


reanare_
I 

In addition to documented entries in the medical record, Dr. reported during interview
that he contacted named methadone clinic upon arrival at work this date. He was
told SAMIMI was ?not in the system." Dr. also stated he accessed the University of
Colorado EpiLink database in an attempt to obtain more medical history. He said it listed visits
for opioid withdrawal, ?some stomach stuff,? and a fall, with no recent contact. Dr.
speculated SAMIMI may have used an alias to seek services.

Note: Dr. contact with the clinic and accessing of the EpiLink database was
not documented in the medical record, although a printout of the latter was provided to
reviewers. The printout was dated nine days later, November 29, 2017' and as reported by
Dr. lists multiple visits for opioid withdrawal and no recent contact. No visits
related to abdominal complaints were identified.

Tuesday, November 21, 2017
Medical Unit Housing Record

SAMIMI accepted all three meals but declined recreation and a shower. Again, medical staff
signed the log as did a security supervisor for each shift. All signatures are illegible.

 

 

MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
None documented 9:00 a.m. Given once; time None documented Given once; time
not documented not documented

 

 

 

 

 

 

 

Note: Administration of as-needed medications is not addressed in nursing notes.

Vital Signs

 

 

 

 

 

 

 

 

 

 

 

 

Temperature Pulse Respirations Blood Pressure Oxygen Weight
97.6 87 16 18f76 95 Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
Medical Record

Results of the laboratory tests ordered on November 17, 2017' were received and signed by Dr.
All tests were within normal limits with the exception of a low hemoglobin
level and an elevated thyroid hormone level. During interview, Dr. called the lab
results ?excellent? overall and cited them as a reason he was not concerned about the ability of
DCDF to manage withdrawal.

In the only nursing entry this date. RN {overcame} documented in a 6:30 p.m. progress note
that SAMIMI denied pain but appeared anxious, with tremors. Vital signs were within normal

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 1?
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanva_
I 

limits (see ?rst row of the above table). She noted he was given Ativan, administered in the right
deltoid muscle. Fluids were encouraged, and the nursing plan was to continue monitoring.

Note: The dose of Ativan was not documented on the MAR.

Wednesday, November 22, 2017

Medical Unit Housing Record

SAMIMI accepted all three meals but declined recreation and a shower. Again, medical staff
signed the log as did a securitv supervisor for each shift. All signatures are illegible with the
exception of Lieutenant who signed for second shift.

 

 

 

 

 

 

 

 

 

 

MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
9:00 pm. 9:00 am. Given twice; times Given once; time not Given once; time
9:00 pm. not documented documented not documented.

 

 

 

Note: Administration of as-needed medications is not addressed in nursing notes.

Vital Signs

 

 

 

 

 

 

 

 

 

 

 

 

Temperature Pulse Respirations Blood Pressure Oxygen Weight
98.2 82 17 108f74 99 Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
ikl'edicmI Record

 

 

 

There was only one nursing entry this date. At 6:00 RN Eglfg?g?b} completed a Medical
Observation Nursing Progress Record documenting SAMIMI complained of nausea and
vomiting, generalized pain, tremors. and shivering related to methadone withdrawal. Vital signs
were all within normal limits (see first row of above table). He reported his last caloric intake
was at 5:00 pm. at which time he ate 50 percent of his dinner. He complained of nausea after
eating. The plan was to continue monitoring and administration of medication and increase
?uids as tolerated.

 

Note: The RN did not document whether Phenergan was given for nausea, although the
MAR documents a dose was administered at some point during the day.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 18
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?

i 
rea:uve_
I 

Thursday, November 23, 2017

Medical Unit Housing Record
SAMIMI accepted all three meals but declined recreation and a shower. Again, medical staff

signed the log as did a securit supervisor for each shift. All signatures are illegible with the
exception of Lieutenan ,(blt?ublt?t who signed for second shift.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
9:00 pm. 9:00 am. Given twice; None documented Given once; time
9:00 pm. times not not documented
documented
Note: Administration of as-needed medications is not addressed in nursing notes.
Vital Signs
Temperature Pulse Respirations Blood Pressure Oxygen Weight
98.1 82 16 107174 97 Not taken
97 .8 76 16 134/93 98 Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
Medical Record
At 11:15 I- documented SAMIMI was alert and oriented, with

 

mild hand tremors and level four generalized pain. Vital signs were all within normal limits {see
?rst row of above table). He was encouraged to increase his fluid intake.

Note: RN did not document whether any medications were given.
At 1:30 RN (bli?lilbl wrote in a progress note that SAMIMI complained of pain and
weakness and spent most of the shift in bed. Vital signs were all within normal limits with the

exception of a mildly elevated blood pressure of l34f93 (see second row of above table).

Note: RN {bli?liibl did not document whether any medications were given.

Friday, November 24, 2017

Medical Unit Housing Record
SAMIMI did not accept any of the three meals and declined recreation and a shower. The officer
noted that the detainee did not eat breakfast due to abdominal pain and the nurse was noti?ed.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 19
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


reanve_
I 

Medical staff signed the log as did a security supervisor for each shift. Again, all signatures are
illegible with the exception of Lieutenant grammar who signed for second shift.

 

 

 

 

 

 

 

 

Medical Unit Logbook
The of?cer made the following entries during the morning hours:
Time Event
4:11 am. SAMIMI requested ice chips; nurse approved.
5:00 am. SAMIMI was having a hard time falling asleep and he was tossing and turning.
A cup of ice chips were given.
6:32 am. SAMIMI was screaming out for a nurse stating that he has abdominal pain.

Nurses were notified.

 

7:45 am. ?Detainee SAMIMI keeps on screaming."

 

11:15 am. The RN was in the cell with detainee SAMIMI, gave him meds and approved
more ice chips.

 

 

 

11:59 am. Captain notified detainee SAMIMI ?not wanting to eat?.

 

 

Note: There are no medical record entries addressing these events and response by

 

 

 

 

 

 

 

 

 

 

 

 

 

nurses.
MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
9:00 p.m. 9:00 am. Given twice; Given once; time Given once; time
9:00 p.m. times not not documented not documented
documented
Note: The Administration of the as?needed medications is not addressed in nursing
notes. Following the fainting incident (see below), the nursing plan was to administer
both Ativan and Phenergan; however, the administration of Ativan was not documented
until 9:00 over six hours later, and the time Phenergan was given is not noted.
Vital Signs
Temperature Pulse Respirations Blood Pressure Oxygen Weight
98.2 102 18 128/83 93 Not taken
98.8 77' 18 12985 96 Not taken
Not taken Not taken Not taken Not taken Not taken Not taken

 

 

 

 

 

 

 

 

The ?rst noteworthy incident of detention period occurred during the afternoon hours
this date. Officer?was the medical officer for the 7:00 am. to 3:00 pm. shift.
According her incident report, she was conducting a security round at 1:45 p.m. when detainee
SAMIMI approached the door and told her he was having abdominal pain. She told him she
would notify nursing staff. As the detainee got closer to the door, he ?slowly fell down.? She
then called for nursing staff. In the Medical Logbook, Officer _wrote that RN

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 20
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

 

 

(bil??bilfil
0)

 

 

Captain bh?ttbhiitm and other responders arrived, and, ?detainee being treated, unable to

eat for the past 3 days, detainee looked confused, and sweaty, detainee was choking, detainee sat
wn by nurse to stop the choking. Detainee states that he has been ?ushing food can't stand

smell. incident report, Officer {blistibiti?HC} also documented SAMIMI said he had been
vomiting. Captain documented on the bottom of the incident report that he observed the

detainee vomit into the trash can while he was sitting on his bunk and that Nurse (131151113) was
evaluating the detainee.

Video surveillance footage of these events taken from the camera inside the cell was viewed.
The video starts at 1:49 p.m. with detainee SAMIMI laying on his bunk under a blanket. At
1:50 p.m. he stands up and walks to the cell door. He leans on the window and appears to speak
with Of?cer- He then turns to his right away from the door and slowly slides to the
floor, ending up spread-eagle on his back. Subsequent events shown on the video are as follows:

 

Time Event

 

1:50:39 pm. Detainee laying on his back on the ?oor. The feet of the officer are visible
through the window moving away from the door to get assistance.

 

1:50:52 pm. The officer returns to the cell and opens the cell door.

 

1:51:51 pm. RN enters the cell. He steps over the detainee, dons gloves, then kneels
at the detainee?s side and appears to check his pulse. He then performs a
sternal22 rub.

 

 

1:52:27 pm. RN tries to pull the detainee up to a sitting position. The detainee?s
head can be seen lolling. The view of the detainee is now blocked by the
nurse.

 

 

1:53:38 pm. RN libii?iilbil enters. RN (bil?iilb repositions the detainee so his back faces the
wall away from his bunk. The nurse appears to check the detainee?s head.

 

 

1:54:54 pm. RNs and  ib1151iibi  lift the detainee and move him to the bed. SAMIMI
appears limp. He is now sitting up, with support, and RN wheels in the
mobile electronic vital signs monitor. RN applies the cuff to the
detainee?s left arm. The cuff is removed and the detainee appears to speak to
RN RN loiteribil leaves with the blood pressure machine.

 

1:58:04 pm. RN IlEll?iglbil returns with a ulse oximeter on the detainee's finger.

 

 

 

1:58:43 pm. SAMIMI motions to RN to bring him the wastebasket from the comer
of the room. When the wastebasket was placed in front of him, detainee
SAMIMI appears to vomit in it. He then places both arms on the basket for
support and places his head directly over the basket. After a minute, RN
pulls the detainee away from the wastebasket and the detainee sits up
on the bunk unassisted. After another minute the detainee is left alone in the

 

 

 

 

 

22 A sternal rub is the application of painful stimuli with the knuckles of a closed fist to the center chest of a
patient who is not alert and does not respond to verbal stimuli. Response to the stimulus is used to make
assumptions about the integrity of the brain and its function.

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 21
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


reanare_
I 

 

cell.

 

2:02:55 pm. SAMIMI appears to vomit again in the wastebasket.

 

2:05:22 p.m. SAMIMI lays down on the bed and covers himself with a blanket. The video
ends.

 

 

 

 

RN medical record progress note documenting this event is timed 2:30 pm. He wrote
that the medical of?cer alerted nursing staff that ?she witnessed detainee faint in cell.? On
arrival, SAMIMI was found on his back, lying on the ?oor, unresponsive. Attempts to rouse him
verbally and physically were unsuccessful. On applying a sternal rub, SAMIMI began to regain
consciousness. He was assisted to a sitting position, at which time he gave contact and
stated he had not eaten in four days. He then lost consciousness a second time. Another nurse
also attempted to perform a sternal rub, at which time SAMIMI regained consciousness. He was
assisted onto the bed in a sitting position. He complained of nausea and vomiting and being
unable to eat. On his request to lie down, he was assisted to the supine23 position. His pupils
were equal, round, reactive to light, and accommodative (PERRLA). Vitals signs (see ?rst row
of the above table) were within normal limits with the exception of an abnormally elevated pulse
rate of 102 and an abnormally low oxygen saturation of 93 percent. The nursing assessment was
dehydration and ?possible drug-seeking behavior?, and the plan was to administer Ativan and
Phenergan. Education was provided on diet, medications, and importance of good nutrition and
?uid intake, for which he verbalized understanding.

Note: The injury assessment addressed only PERRLA and did not include assessment
for other possible injuries. There is no documentation Dr. was contacted for
possible follow-up orders despite RN assessment of dehydration and ongoing
withdrawal According to medical record documentation, a follow-up nursing
assessment did not occur until six hours later.

Note: The MAR does not document administration of Ativan until 9:00 pm. The time
Phenergan was given is not documented.

Both RN and RN were interviewed regarding this incident. RN did not
recall any involvement but when shown the video, confirmed he was the second nurse. He
maintained he had no recollection of the event after viewing the full video, but stated it appeared
clear SAMIMI was not faking. RN gave an account that stands in contrast to what he
documented and what is seen on the video. He said that Officer _came to get him after
SAMIMI supposedly fainted while she was performing a round. He said that when he got to the
cell, SAMIMI started what he believed to be a feigned seizure, moving and making sounds like
none he has observed in his experience. RN commented that SAMIMI was not
disoriented when he came out of the seizure and, looking right at him, said he had not had a
seizure in ten days. Asked for other observations of detainee SAMIMI, RN stated that in

 

23 The supine position means lying face up.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 22
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


reanve_
I 

general, detainee SAMIMI was the same on most days, resting, not saying much and not eating
much. He commented that the detainee?s actions got ?more dramatic? as time went on; also,
that ?it became clear he was trying to sabotage his care.? When asked for examples, RN
replied that SAMIMI made ?grand gestures? like throwing his food down the toilet and that the
detainee threw himself on the ?oor. The latter example refers to an incident discussed later in
this report. When asked how often the detainee threw food down his toilet, RN stated he
knew of one time for certain.

Note: An incident report by Officer- summarized above, documents SAMIMI
reported flushing his food because he could not tolerate the smell. Sensitivity to food
aromas is common with nausea; therefore, the suggestion that SAMIMI flushed his food
as a grand gesture is questionable.

Nurse could not recall if he considered informing Dr. that the detainee was
dehydrated. He commented Dr. can be difficult to reach when he is not in the office,
estimating the physician does not answer two out of every five calls placed. According to RN
voicemail is not set up on Dr. cell phone and that he returns missed calls only
50 percent of the time. Nurse stated he has never been able to reach Dr. on his
home phone.

At 3:12 Of?cer noted in the Medical Logbook that detainee SAMIMI ?is doing
much better.?

 

 

 

At 8:30 p.m. RN ??ifg??im" ompleted a Medical Observation Nursing Progress Record. He wrote
that SAMIMI complained of nausea and vomiting ?unobserved by staff.? Vital signs (see second
row of the above table) were all within normal limits, with the exception of a elevated
temperature of 98.8 signifying a slight fever. last bowel movement was the previous
day, and his dinner intake at 5:00 pm. was 50 percent. The assessment findings included, ?Signs
and of withdrawal, no tremors, no seizures?. The nursing plan was to continue
monitoring and encourage food and nutritional intake.

 

Note: November 24, 2017'r was the seventh day of detainee housing in
medical. There is no renewal of housing orders for continuation of this status as required
by GEO policy 905-A, Medical Observation.

Saturday, November 25, 201 7

Medical Unit Housing Record
SAMIMI refused all three meals and declined recreation and a shower. Again, medical staff

signed the log as did a security supervisor for each shift. All signatures are illegible with the
exception of Lieutenant who signed for both first and second shift.

   

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 23
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanare_
I 

 radical Unit Logbook

 

Time Event

 

1:35 pm. SAMIMI missed his third meal.

 

4:00 pm. A nurse took SAMIMI's vital signs.

 

7:20 pm. SAMIMI refused supper after repeated offers. The tray was thrown out at his

 

 

 

 

 

 

request.
MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
None 9:00 am. Given twice; None documented Given once; time
documented 9:00 pm. times not not documented
documented

 

 

 

 

 

 

 

Note: The basis for administration of as-needed medications is not addressed in nursing
notes. In her 6:30 pm. progress note, RN {momentum documented she gave Phenergan
not recorded on the MAR.

Vital Signs

 

 

 

 

 

 

 

 

 

 

 

 

Temperature Pulse Respirations Blood Pressure Oxygen Weight
97.8 76 16 134/93 98 Not taken
Not taken 91 16 127193 96 Not taken
Not taken Not taken Not taken 1 17f88 Not taken Not taken
Medical Record

RN completed a Medical Observation Nursing Progress Record, again failing to
document the time. He wrote that SAMIMI complained of abdominal pain at a level six, with
weakness, nausea, and vomiting. Vital signs (see ?rst row of the above chart) were all within
normal limits, with the exception of a mildly elevated blood pressure. Assessment of SAMIMI's
heart, lungs, and abdomen were normal, and he reported having his last bowel movement the
previous day. It was noted he ate 30 percent of his lunch at 11:30 am. and consumed water at
12:30 pm.

Note: RN (9)1510} did not document whether he gave any medications.

At 6:30 RN documented in a progress note that SAMIMI was lying in bed
and reported he did not sleep the previous night. Vital signs {see second row of the above table)
were all within normal limits with the exception of a elevated blood pressure. The same
vital signs were recorded on a CIWA completed by RN during the same encounter.
The ?ow sheet score was 17' based on nauseafvomiting, tremors, anxiety, and paroxysmal
sweating, although the reviewer determined the scores were incorrectly added. The correct total
was 13 which according to the form, indicates moderate alcohol withdrawal.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 24
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


i: reanve_
I 

Note: Although the CIWA was not the proper monitoring instrument and the score of 17
tabulated by RN was incorrect, the score she determined exceeds the
threshold of 15 identified on the form as indicative of severe alcohol withdrawal.
Although the form does not dictate provider notification, and there were no orders so
requiring, prudent nursing practice called for contacting Dr. 

In her note, RN (DHEWIWCJ documented she gave Phenergan for complaint of nausea, and
instructed SAMIMI to pick up his trash, clean his room, and to stay up as much as possible
during the day.

Note: RN Hormone) did not document administration of Phenergan on the MAR.

Sunday, November 26, 201' 7

Medical Unit Housing Record
SAMIMI refused all three meals and he declined recreation and a shower. Medical staff signed
the log as did a security supervisor for each shift. All signatures are illegible.

Medical Unit Logbook

 

Time Event

 

2:03 pm. SAMIMI was eating ?small portions of food like oranges, cookies, a little bit of
milk water.?

 

 

3:00 pm. Of?cer told by the off-going shift to keep an on detainee
SAMIMI ?as he has not been eating?.

 

5:10 pm. SAMIMI refused his dinner and requested that the tray be removed from his cell.
Ice chips were provided to him per his request.

 

 

 

 

 

 

 

 

 

MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
None 9:00 am. Given once; time None documented Given once; time
documented not documented not documented

 

 

 

 

Note: Administration of cyclobenzaprine and ibuprofen was not addressed in nursing
notes. Although referenced in a 6:40 pm. nursing note, administration of Phenergan was
not documented on the MAR.

Vital Signs

 

 

 

 

 

 

 

 

 

 

 

 

Temperature Pulse Respirations Blood Pressure Oxygen Weight
98 1 ll 16 107781 99 Not taken
97.6 71 16 125;?85 96-97r Not taken
Not taken 92 16 12608 96 Not taken
DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 25

Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?

i 
rea:uve_
I 

 

Medical Record

RN-- completed a Medical Observation Nursing Progress Record at 12:00 p.m.
She documented that SAMIMI complained of having pain all over but did not document a pain
level. SAMIMI was alert and oriented, his lung sounds were clear, and heart and abdomen
assessments were normal. Vital signs (see first row of the above table) were within normal
limits with the exception of an abnormally elevated pulse rate.

RN wrote that vomiting was not observed. speech was slurred and he was
?unsteady until encouraged to walk, then walked good.? He did not recall his last bowel
movement and was uncertain of the last time he ate. RN noted his accounts varied. The
nursing assessment was ?possible withdrawal?, and the plan was to continue with the plan of
care and monitor his food intake.

Note: RN {133115111311 did not document whether medication was given.

The second medical record entry was timed 6:40 pm. when RN completed a
CIWA. vital signs (see second row of the above table) were all within normal limits.
The total score as tabulated by RN was 19 based on the detainee?s level of anxiety,
nausea and vomiting, tremors, and paroxysmal sweats. When scores applied were re?tabulated,
the reviewer discovered that for the third time, the RN made an addition error. The correct score
was 16. As noted above, the threshold for severe alcohol withdrawal is 15.

Note: Again, although assessment instruments for alcohol and opiate withdrawal differ,
both factor the identified by RN (13115111310110) as continuing and increasing.
AS before, RN twosome) did not notify D11 

An accompanying progress note by RN also timed 6:40 documents
complaints of feeling very weak, nauseated, and unable to eat. She noted that he
?raised up on knees and fell over to buttocks?, adding, ?He did this because he is so weak.? RN
wrote that the officer reported SAMIMI had not eaten lunch or dinner, and that she
told him that because he was so weak, he would only receive Phenergan. She also told him that
following medication pass, she would assess how he was feeling. Vital signs documented on
CIWA were repeated in the note. RN instructed the medical officer to take him to
the TV room with food and water.

In a subsequent note timed 8:45 RN wrote that the medical officer reported
that SAMIMI was in the TV room for 40 minutes and then knocked on the window, urgently
requesting to use the bathroom. She wrote that on exiting he ?ran from TV room to 539.
Appears to have less weakness.? RN documented that she explained that he would
have to eat before taking medications. SAMIMI consumed a half cookie and half an orange,
after which the remainder of medication was administered. The nursing plan was to give over-

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 26
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanare_
I 

 

 

(DHEHDHW
C)

 

 

the-counter Pepto-Bismol24 30 mg at night for three days and to continue to monitor in medical
observation.

Note: The room number documented by RN 539, is incorrect.
cell was 53?.

Note: RN {overcame} does not specify the remaining medications referenced in her
note.

Officer- summarized this incident in an untimed entry to the Medical Unit Housing
Record. She wrote that SAMIMI refused dinner but asked for ice. In an addendum, she wrote
he was, ?complaining he is very sick to his stomach. Refused to eat dinner and asked that I
remove it, along wf his lunch, from his room as the smell was bothering him. Agreed to go to
the TV room for 40 mins. Left due to upset stomach and needing to use the restroom. Have
observed him eat a few pieces of orange and drink milk. Back to TV room at 9:10 pm."

As she documented, Officer _recalled on interview that SAMIMI did not want to eat

asked that trays be removed from his cell as the smell of the food was making him ill. She
asked ['11 wanted to shower, suggesting it might make him feel better, but he declined.
According to Of?cer she convinced SAMIMI to go to the television room because RN
told him she would not give him Ativan until he got up and moved around. He
was able to get up and sit in the wheelchair and was wheeled to the television room. Officer

said that while he was there, she cleaned his cell and got clean bed linens so the

detainee would feel a little better when he returned. When she went to check on him, he was
frantically knocking on the window and said he needed to use the bathroom. She let him out of
the room and he did a ?fast walk? back to his cell. She stated RN asked her to
document that he moved quickly and without dif?culty. She recalled the RN shared that Dr.
was thinking about discharging SAMIMI from the medical unit and to avoid going to
general population, the detainee was faking. Of?cer _said this was not the ?rst
occasion medical staff voiced their opinion that SAMIMI was faking his In the
opinion of the of?cer, he was not faking and he did, in fact, look worse than when she conducted
his intake.

According to SAMIMI asked to rest for a while after he returned to his cell.
After RN IWI gave him a medication, SAMIMI wanted to return to the TV room and
was taken by wheelchair. Video surveillance footage from the camera inside the TV room shows
the following:

 

 

24 Pepto?Bismol is an over?the?counter medication for loose stools.

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 2?
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


i: reanve_
I liarreclunls

 

Time Event

 

9:28 pm. SAMIMI is seated in a wheelchair at the rear of the room with his back to the
camera. His feet, in socks, are up on the table in front of him.

 

9:30 pm. SAMIMI removes his feet from the table and slowly slides from the wheelchair
onto the ?oor. He then covers himself with a blanket. Note: The move to the
?oor appears parpose?rl and because it was very slow, does not appear to be a

fan.

 

 

9:34 pm. Officer the room and turns on the light on. She speaks with the
detainee, he sits up, then stands and returns to the wheelchair. He puts both of his
feet on the table as the of?cer leaves, turning the light off.

 

9:35 pm. Detainee SAMIMI moves his feet from the table to a chair in front of him. The
video ends.

 

 

 

 

RN documented in a 9:00 pm. progress note that the of?cer reported SAMIMI slid
out of his wheelchair while in the television room, but he was able to get back into the chair by
himself. No injury was noted, and he returned to his cell ?to relax?. Vital signs (see third row of
above table) were within normal limits.

Monday, November 27, 201 7

Medical Unit Housing Record

SAMIMI did not wake up to eat breakfast, did not eat lunch or dinner and declined recreation
and a shower. No medical staff signed the log. A security supervisor signed for each shift
although the signatures are illegible. A notation for ?rst shift documented, ?Did not eat lunch
only ate ice.? A notation for third shift noted, ?Did eat.?

Medical Unit Logbook

 

Time Event

 

11:05 am. SAMIMI did not eat breakfast and when provided his lunch tray stated he only
wanted ice. He was given two cups of ice.

 

5:30 pm. SAMIMI still had not eaten his dinner.

 

6:59 pm. ?Samimi informed me that hes [sic] on a hunger strike wants ice Nurse said no

9!

ICE .

 

8:41 pm. ?Samimi finally got up for water?

 

 

 

8:54 pm. Nurse in the cell giving SAMIMI medication and water.

 

 

Note: GEO Policy 614, Hunger Strikes, states, ?Detainees declaring andfor identified as
being on a Hunger Strike (missed 9 consecutive meals) will be monitored daily.? Despite
the detainee declaring he was on a hunger strike, there was no clear documentation
medical was notified or that daily monitoring was initiated. The requirement to initiate
monitoring upon declaration of a hunger strike exceeds the 2011, Hunger Strike,

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 28
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


i: reanve_
I liorreclunls

2016 revision. The standard states detainees who have not eaten for 72 hours are to be
considered on hunger strike. The de?nition of hunger strike was not met during
detention.

 

 

 

 

 

 

MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
None 9:00 pm. Given once; time None documented Given once; time
documented not documented not documented

 

 

 

Note: Although not documented on the MAR, RN documented in a 1:00
am. nursing note that she gave an injection of Ativan.

Note: Administration of clonidine, cyclobenzaprine and ibuprofen was the first in 36

 

 

 

 

 

 

 

 

 

 

 

 

hours.
Vital Signs
Temperature Pulse Respirations Blood Pressure Oxygen Weight
Not taken 98 12 124f80 95 Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
edica! Record

A 1:00 a.m. progress note by RN documents SAMIMI was yelling for the nurse
because he was unable to relax. She wrote that Ativan was administered intramuscularly to right
During interview, RN acknowledged reference to the coccyx was
incorrect. The injection was administered to the gluteal muscle.

Note: Administration of Ativan was not recorded in the MAR.

Note: The next nursing assessment was conducted more than 17 hours later.

LPN?completed a progress note at 7:00 p.m. documenting SAMIMI refused to

eat dinner and requested stronger medications. Recorded vital signs (see first row of the above
chart) were within normal limits. He was encouraged to eat and drink.

 

25 The coccvx is the final segment of the vertebral column, also known as the tail bone.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 29
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


reaal-re_
I 

Tuesday, November 28, 2017

Medical Unit Housing Record

SAMIMI accepted breakfast and lunch trays and refused dinner, recreation, and shower. No
medical staff signed the log. An unknown security supervisor signed for first shift and noted,
?Did eat?. Lieutenant gi?lilblilli signed for second shift. No security supervisor signed off
on third shift.

 

 

 

 

 

 

 

 

 

 

MAR
Ativan Clonidine Cyclobenzaprine Phenergan Ibuprofen
None 9:00 a.m. Given once; time Given once; time Given once; time
documented not documented not documented not documented

 

 

 

Note: Administration of the as-needed medications was not addressed in the nursing
notes.

Vital Signs

 

 

 

 

 

Temperature Pulse Respirati ons Blood Pressure Oxygen Weight
98.1 107 18 12491 95 Not taken
97.? 120 16 108f82 100 Not taken
Not taken Not taken Not taken Not taken Not taken Not taken

 

 

 

 

 

 

 

There were two noteworthy events this date. Shortly after 11:00 SAMIMI collapsed in the
hallway on his way to a follow up mental health appointment with Dr. Video from the
surveillance camera covering the medical unit corridor shows the following:

 

Time Event

 

11:13 a.m. A pill cart is seen at the door. As the door opens, and an officer are seen
moving in the direction of the cart. The pill cart blocks the view, but as it is
moved aside, SAMIMI is seen lying face down on the ?oor just inside the door.

 

11:14 a.m. The nurse who was with the pill cart walks down the corridor toward the camera,
leaving the detainee laying on the ?oor. The nurse returns with a mobile vital
signs monitor and leans down to assist the detainee.

 

 

11:15 a.m. RN libll?liibl walks down the corridor and leans down to check on the detainee.

 

 

11:16 a.m. RN WI pulls the detainee up to a standing position. knees appeared
to buckle but he remains upright.

 

11:17 a.m. SAMIMI, with an unidentified nurse holding his right arm and RN on his
left, walk down the corridor toward the camera. They are met in the hallway by
Dr. who appears to speak with SAMIMI. The nurses and the detainee
then turn around and head back toward the door while Dr. goes to Dr.
office. SAMIMI then leaves with the unidentified nurse.

 

 

 

 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 30
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


reanve_
I 

The medical record progress note documenting this incident was entered by RN at 11:50
a.m. RN wrote that no injuries were noted. SAMIMI reported not having eaten in eight
days due to nausea and requested stronger medications to combat his withdrawal 
Vital signs (see first line of above table) were within normal limits with the exception of an
abnormally elevated pulse rate and very elevated blood pressure.

Note: An elevated pulse rate is a common sign of dehydration. RN {bll?iilb did not
document skin turgor testingz? to assess loss of ?uid in the body.

SAMIMI denied pain. The nursing assessment was ?Dehydration, nutritional needs not met.?
The plan was to continue to monitor and administer medications as ordered, and the detainee was
educated on the need to make an effort to eat and drink. RN wrote, ?no matter his actions,
stronger meds unavailable.? Questioned about this statement, RN explained he was trying
to make the point to the detainee that he was not helping himself by doing the things he was
doing and that he needed to cooperate because he was not going to get methadone.

Note: In spite of the nursing assessment of dehydration, likely worsening due to
vomiting, sweating, and inadequate fluid intake, Dr. was not informed. Given
the totality of the circumstances, notification of a provider would have been proper
nursing practice.

In a progress note timed 11:16 Dr. documented SAMIMI collapsed when leaving
his cell in medical and was observed lying in the hallway with two nurses rendering care. She
described him as pasty in appearance, confused, wobbly, and disheveled. In discussing the
matter with Dr. they agreed that the detainee was not stable enough to proceed with his
mental health follow up appointment. According to Dr. note, Dr. said
medical was monitoring his vital signs and stated ?He had a few good days. Other than some
thyroid that we will need to supplement, his labs look good." The plan was to keep SAMIMI in
medical observation as he undergoes withdrawal. When stable enough to have a coherent
conversation with ability to engage and to understand and comurehend the content, he would
return to the mental health clinic. During interview, Dr. _Pcon?rmed the information and
observations in her note, adding that it was clear SAMIMI was ?really ill." Contrary to what is
shown in the video, she also stated she did not approach after witnessing the detainee lying in the
hallway.

According to the Visitor Log, detainee SAMIMI had a one hour visit with _at 5:12
p.m. The relationship is not noted on the log.

 

26 Skin turgor testing involves grasping the skin on the lower forearm between two fingers. The skin is held for a
few seconds then released. Skin with normal turgor snaps rapidly back to its normal position.

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 31
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


reanve_
I 

 

 

(manner
0)

 

 

 

 

(oeuvres
Cl

 

 

 

 

(oeuvres
Cl

 

The second noteworthy incident of the day was suicide attempt at approximately
8:45 p.m. According to her incident report, Officer _went into the anteroom of 
537' to perform a security round. When she looked through the window, she ob AMIMI
with a dark blue sheet tied around his neck. On interview, Officer stated she reached for
her radio on her duty belt so she could call an emergency. Discovering the radio was dead, she

"ed to the officer?s station and used the telephone to call central control for assistance. She
returned to erting nursing staff along the way that there was an emergency. Onc
other staff were present, Officer opened the cell door and responding medical ficer
staff forcibly removed the sheet from around the detainee?s neck. Officer stated she heard
someone say SAMIMI would be placed on suicide watch so she left to make preparations. Her
preparations included setting up the of?cer?s table and constant watch logbook outside the
suicide prevention cell, and retrieving a suicide resistant smock and blanket for issuance to the
detainee.

 

 

Lieuten responded to the emergency call and noted in a Supervisor Supplemental
Report that Officer?reported she witnessed the detainee with a shirt around his head and
his arms wrapped around the neck. He also noted that first responders were already in the cell

and the shirt was taken off his head. Lieutenant ocumented Dr. (blt?lilbl?l placed the

detainee on constant suicide watch which was ?started immediately.?

Note: As indicated below, reviewers con?rmed SAMIMI used a sheet, not a shirt, in the
suicide attempt.

Video from the camera in cell and the camera in the medical unit hallway was
reviewed to determine the timing of events. The camera in the hallway shows the officer?s
station on the left, the enclosed nurses? station on the right, and cell 537? directly ahead at the end
of the hallway. The following events are shown:

 

(bll?libllf?


 

 

 

 

 

 

 

?ute Event Camera
SAW SAMIMI sits u: in bed with his back against the wall. Cell
8:44:52 pm. Officerl: takes the electronic pipe and keys and leaves the Hall

 

officer?s station to conduct a round. When she reaches the end of
the corridor, she turns right out of the camera?s view.

 

 

 

(DHEHDHW
Cl

 

 

8:44:58 pm. SAMIMI takes the blue sheet from his bed and places it around his Cell
neck from behind. He then crosses each end over the other and
tightens the sheet by pulling with each arm. Note: It not possible
to gauge the amount of tension placed on the sheet and now much it

tightened around the detainee ?s neck. The detainee remained
seated on the bunk as he tightened the sheet.

 

 

8:46:16 pm. Officerl:  re-enters the camera?s view at the end of the hallway Hall

 

 

and enters the outer door into the anteroom outside cell.

 

 

 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 32
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


i: reanare_
I 

 

 

(bll?libllf?


 

 

 

 



 

 

 


C)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 




 

 

 

 

 

 

 

 

 

 

 

 

 


0)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8:46:33 p.m. Of?cer WHO) exits the outer door and is back in the corridor. She Hall
walks to the nurses station (enclosed) approximately ten feet away
and motions to the nurse to come to the door. The nurse opens the

door at 8:46:54 p.m.

8:47:25 p.m. Officer1: lwalks back to the officer?s station, approximately 10 Hall
feet from the nurses station, holding her radio in her left hand. She
looks at the monitor on her desk displaying camera views of the
cells.

8:41:25 p.m. Officer icks up the phone. Hall

8:48:14 p.m. Officer hangs up the phone, returns to cell and Hall
opens the outer door at 8:48:32.

8:48:40 p.m. The light in the cell is turned on. Cell?r??e

8:49:12 p.m. Nurse IEEHEUWI and an unidenti?ed officer enter the mg Cell
gloves. RN land Officer 
Nurse and the first of?cer remove the sheet from around
neck as he struggles brie?y and tries to push them
away. Several more of?cers arrive. SAMIMI speaks with staff as
his property and linens were removed from the cell. The detainee
is seated on the bed, cross-legged, and leans forward with his hands
on his forehead.

8:50:46 p.m. the cell, looks at the detainee?s ID Cell
badge and leaves.

8:51:18 p.m. 1?.le picks up the Styrofoam meal container and looks inside. Cell
It appears to contain a full meal.

8:51:25 p.m. The property bin is removed. opens the meal container Cell
and shows it to the detainee.

8:51:41 p.m. SAMIMI shakes his head no, and RN WI sets the container on Cell
the floor at the end of the bed. The RN departs, leaving the
detainee alone with the cell door left open. The detainee remains
seated cross-legged on the bed, leaning forward with his hands on
his forehead.

8:52:17 p.m. An of?cer enters and removes the wastebasket. Cell

48:52:39 p.m. SAMIMI appears to say something to someone outside the cell. Cell
removes his hands from his head and sits upright. Cell

8:55:29 p.m. Lieutenantl lre-enters the cell. For the next three minutes, Cell
SAMIMI speaks to the Lieutenant in an animated way, gesturing
with his arms and hands, pointing at his head and throwing his arms
Wide ?Pen-rbvormmt

8:58:28 p.m. Lieutenant 0) leaves the cell. Cell

8:59:14 p.m. SAMIMI looks toward the cell window. Cell

8:59:55 p.m. SAMIMI lays down on his bed on his left side with his arms Cell
covering his face.

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 33

Medical and Secu

rity Compliance Analysis

March 6, 2018, revised March 14, 201?

 

 

 

(DHEHDHW
C)

 

 

 

9:01:49 p.m. An officer enters the cell, squats down at the head of the bed and Cell
speaks to the detainee.

 

9:02:30 p.m. SAMIMI swings his legs over the side of the bed onto the ?oor and Cell
sits up. The officer then assists him to his feet and they walk out of
the cell with the of?cer holding the detainee?s left arm.

 

 

9:03:08 p.m. Officerl:  re-enters the cell and places the property bin back Cell
into the empty cell. She then removes what appeared to be a pillow
case or cloth from behind the bed.

 

 

 

 

 

 

. . {blf?lifblf
Note: More than two minutes elapsed between the time Of?cer mo) appears to have

first observed SAMIMI with the sheet around this neck and when she returned to the cell.

 

 

 

The medical record entry documenting this incident was entered at 8:45 p.m. by RN He
wrote that the medical officer called, ?All response team to medical.? Responding nurses found
SAMIMI sitting on his bed, ?legs closed with a tight bed sheet around his neck and pulling
strong on both ends of the sheet with his arms." He noted that the response team ?forcefully
removed the bed sheet around his neck." SAMIMI was described as alert, disheveled, and able
to make needs known. He stated, haven?t slept in 14 days. I want medication to help me
sleep.? A call was made to Dr. notifying him of the incident, and the following verbal
orders were obtained:

1. Suicide Level one with one-on-one monitoring;
2. Suicide gown, suicide blanket, suicide pillow;
3. Finger foods with paper spork;

4. Ten sheets of toilet paper at a time;

5. One small book or Bible;

6. No underwear, no bed sheet;

Mental health appointment.

RN (bli?lilb documented the orders in his nursing note and in the Special Instructions section of
the Suicide Alert Level 1 form.

Note: Dr. {bli?liibliil did not document authentication of his verbal orders.

The Medical Unit Logbook documents the detainee was placed on constant suicide watch in cell
527' at 8:53 p.m.

Note: The GEO track system erroneously documents the date and time of placement as
November 29, 2017 at 9:33 am.

Cell 527 is the designated suicide watch cell. The door has a window in the top half and a pipe
sensor in the middle. To the right of the door is a large viewing window. Bolted to the center of

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 34
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?

the floor inside the cell is a concrete bed slab. A stainless steel toilet and sink combination
fixture is in the back left corner of the cell. A camera is mounted at the back of the cell near the
ceiling and shows a view of the bed, toilet and cell door and window. Per Security Chief?
this camera is motion-activated and only records when there is movement.

As noted, SAMIMI was placed on Level one suicide watch with constant, one-on-one
monitoring. The desk for the officer assigned to constant watch is positioned immediately
outside the large viewing window and can be seen from the camera inside the cell. The officer is
required to log the activity of the detainee every five minutes in the Constant Watch Logbook
(separate from the Medical Unit Logbook) and is not allowed to leave the post without being
properly relieved. Per the ICE 2016 revision, detainees placed on suicide watch are to
receive eight?hour checks by clinical staff and daily mental health treatment by a quali?ed
clinician.

Note: There were no medical record entries documenting any encounters with a health
care professional between the time SAMIMI was placed on suicide watch and 11:00 am.
the next morning. As discussed below, nursefclinician welfare checks were not
conducted every eight hours as required by the ICE 

Entries to the Constant Watch Logbook for this date documented SAMIMI mainly slept or laid
down on the bed. He complained twice of being too cold.

Wednesday, November 29, 2017

Medical Unit Housing Record

SAMIMI accepted a breakfast tray but there are no notations regarding lunch or dinner or
whether he refused or accepted a shower or recreation. Medical staff signed the log as did a
security supervisor for each shift. All signatures are illegible.

Medical Unit Logbook
At 12:15 a.m. nurses were notified that detainee SAMIMI had blood on his arm.

Note: The officer assigned to the constant watch did not document this information in
the Constant Watch Logbook.

Note: There were no corresponding documentation in the medical record.

At 10:58 a.m. ERO officer (?115111311053 initialed the Medical Unit Logbook documenting she
was present for communication.?

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 35
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

i 
[E?il'll'E_
I ?Enrrecl 

Constant Watch Logbook
Entries from midnight until 10:55 am. primarily documented SAMIMI was sleeping or laying
on his bed. Other entries were as follows:

 

 

 

 

 

 

 

 

 

 

 

 

 

Time Event

1:40 am. to 2:20 am. SAMIMI intermittently ?banging on his bunk?.

2:30 am. Detainee asked to speak to a nurse.

2:35 am. Detainee seen by a nurse

4:45 am. Breakfast served; detainee ate.

6:50 am. Detainee stated he was cold and wanted clothes.

8:10 am. Detainee spoke with Nurse Ilbli?lilbl and was given antacids.

9:55 a.m. Nurse was notified the detainee was sweating.

10:05 am. Detainee was yelling.

10:55 am. to 11:00 am. Detainee met with the returning to cell at 11:05
am.

 

 

MAR (Re?ects medication changes following ?:00 ans. encounter)

 

 

Clonidine Hydroxyzine Immodium Trazodone Cyclo- Phenergan Ibuprofen
benzaprine
9:00 pm. None None None None Given once; None
documented documented documented documented time not documented
documented

 

 

 

 

 

 

 

 

 

Note: Administration of as-needed Phenergan was not addressed in a nursing note.

 

 

 

 

 

 

 

 

 

 

 

Vital Signs
Temperature Pulse Respirations Blood Pressure Oxygen Weight
97.7 120 16 108l82 100 Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
Not taken Not taken Not taken Not taken Not taken Not taken
Medical Record

At 11:00 an initial evaluation was completed via with Dr.

libll??lib?l?HC)

Note:

IMD.

This was 14 hours after the suicide attempt, with no nursing rounds in between.

The subjective section noted, ?He clearly stated after emergency team responded that what he
would like was medication for sleep."

Note: In the subjective section or elsewhere, there is no documentation was asked
why he attempted suicide.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

"i -
Hazing:

E-
I 

Page 3 6

 

Dr. documented detainee SAMIMI complained of inability to sleep, constant
vomiting, sweating, and shaking. He denied other opiate of yawning, tears, and
diarrhea. He also denied suicidal intent. Regarding the CIWA scores, Dr-
documented, score consistently increasing over time. Patient has been noted to have
tremors and to be requesting ?stronger medication? frequently.? Detainee SAMIMI Dr.
note listed what to expect with opiate withdrawal, stating, ?It is generally not life
threatening, although dehydration can occur,? and she addressed the unsuitability of using the
CIWA instead of an opiate withdrawal instrument. Findings included orientation to person,
place, time, and situation; appropriateness of rapport; disheveled appearance with poor
grooming, dress, and body odor; anxious, irritable mood; expansive affect; and coherent,
appropriate speech.

 

Note: Dr. description of the detainee?s body odor is assumed to have been
reported to her by RN 

 

 

 

The plan included:

0 Push ?uids for 15 days;

0 Discontinue Ativan;

Clonidine 0.1 mg orally three times daily for four days, then clonidine 0.1 mg twice daily
for four days, then 0.1 mg every night for four days, then stop;

- Hydroxyzine? 50 mg three times daily as needed for anxiety for 15 days.

0 Immodium28 2 mg after each loose stool, total daily dose not to exceed 16 mg as needed
for three days;

- Trazodone29 100 mg orally every night as needed for sleep for 15 days, then decrease to
50 mg every night for 15 days, then stop;

I Offer Ensure with each meal for seven days;

- COWS monitoring for ten days;

0 Level 2 suicide watch.

The Special Instructions form for Suicide Alert Level 2, signed by Dr. at 2:15 
authorizes, ?May have toilet paper. May have shower, soap and comb, toothbrush, underwear
OK. May have regular diet and spork. May have reading material. May have GEO uniform.
Suicide mattress and pillow.?

Dr. documented she discussed and treatment of mental illness and
frequency of follow-up, prescribed medications and potential side effects, and explanation of
access to mental health services. She also documented medication consent forms were reviewed
and signed.

 

2? Hydroxizine is a medication used to treat anxiety, nausea and vomiting.
23 Immodium is a medication to treat loose stools or diarrhea.
29 Trazodone is a medication used to treat anxiety, depression, and sleeplessness.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 3?
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


reanare_
I 

Dr. mammogram orders were noted by RN John the same day, and the medications were
accurately transferred to the MAR. Consent for Mental Health Services and Consent for
medication hydroxyzine were signed by detainee.

Note: Consent for use of medication Trazodone was not included in the
medical record.

Note: Although the order for Ensure was noted on the MAR, there is no documentation
it was offered with every meal as prescribed.

Note: Subsequent nursing documentation does not include inquiry into recurrent loose
stools.

A blank COWS form was found in the medical record. During interview of RN {bli?liiblif he
stated Dr. mentioned she was surprised no COWS assessments had been completed.
He added that he had to research the instrument and printed the form from the internet following

the encounter with Dr. {blt?liblt?tcl
Note: No COWS was ever completed after ordered by Dr. 

At 11:20 a.m. RN documented a Medical Observation Nursing Progress Record, at which
time SAMIMI complained of nausea. His vital signs (see first row of the above table) were all
within normal limits with the exception of the abnormally elevated heart rate.

Note: There is no indication this ?nding was reported to the provider, nor does the MAR
show that anti-nausea medication was administered.

An entry in the Medical Housing Unit Log timed 2:18 p.m. documents SAMIMI was moved to
Level Two suicide watch. At this point, monitoring checks and notations in the Constant Watch
Logbook were required every 15 minutes. Except for the following, entries to the logbook
following the evaluation on this date primarily documented SAMIMI slept or laid
in his bed.

 

 

 

 

 

 

 

 

 

 

 

Time Event

5:01 p.m. Dinner was served; detainee ?ate just a little bit" but was eating and
drinking again at 5:24 p.m.

7:45 p.m. Detainee provided with a uniform ?approved on special instructions
for detainee.?

10: 15 p.m. Detainee requested ice water

10:30 p.m. Detainee again requested ice water. Per Nurse Ross he should ?get
it from the sink? in his cell.

11:00 p.m. Detainee continued to request ice water.

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 38

Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

i 
rea:uve_
I ?Enrrecl 

Note: As noted above, the special instructions form stating SAMIMI was to be allowed a

uniform and setting other conditions for level 2 suicide watch was signed by Dr.
{133315111337in at 2: 15 pm. The five hour, 30 minute delay is unexplained.

Thursday, November 30, 2017

Medical Unit Housing Record

SAMIMI did not accept any meals and did not shower or go to recreation. Again, medical staff
signed the log, as did a security supervisor for first and third shift. No security supervisor signed
for second shift. All signatures are illegible.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAR
Clonidine Hydroxyzine Immodium Trazodone Cyclo- Phenergan Ibuprofen
benzaprine
9:00 a.m. 9:00  a.m. None 9:00 p.111. Given once; None Given twice;
3:00 p.m. 3:00 p.m. documented time not documented times not
9:00 pm. 9:00 pm. documented documented
Note: Administration of as-needed Phenergan and Trazodone were not addressed in a
nursing note.
Vital Signs
Temperature Pulse Respirations Blood Pressure Oxygen Weight
97.6 88 16 100770 95 Not taken
97.8 100 15 101770 97.8 Not taken
Not taken Not taken Not taken Not taken Not taken Not taken

 

 

 

 

 

 

 

 

The Constant Watch Logbook noted the detainee had a nose bleed at 12:30 a.m. and the officers
and nurses cleaned the detainee and the cell. In a 2:00 a.m. progress note, RN
documented ?Detainee on suicide level two. Resting off and on. Screams, ?Nurse, nurse,? then
he is asleep.? Vital signs {see the top row of the above table) were all within normal limits. RN
wrote that at 1:00 am. he was observed to have blood on his nose, the sleeve of his
right arm, and in his month, which he spit onto the ?oor. Following a full nursing assessment,
RN noted the blood appeared to be coming from his nose, although during
interview, she stated she could not recall how she reached the conclusion that he was bleeding
from his nose as opposed to his mouth. After he was cleaned up and provided new clothes, vital
signs were repeated and were within normal limits (see second row of above chart). The nursing
plan included offering water every two hours while awake, continue to monitor, and notify the
morning staff.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 2017


reanve_
I liorreclunls

Page 39

Note: RN did not notify Dr. SAMIMI was bleeding through his

nose for no apparent reason, which was significant given his compromised condition.

The Constant Watch Logbook documents SAMIMI was screaming from 4:30 a.m. to 5:15 a.m.
He screamed off and on until 6:57 a.m. when the of?cer documented an unnamed nurse denied
ice water again and stated the detainee ?will drink water like everyone.? At 7:08 a.m. it was
logged the detainee refused to eat.

Security shift change occurred at 7:10 a.m. The oncoming officer logged receipt of pass-down
information that SAMIMI was not eating. He drank ?uids at 8:45 a.m. and refused the nurse?s
request to take his vital signs at 9:22 a.m. A medical record progress note by RN
corroborates this information. At 9:25 she documented refusal to get up for
his nursing assessment, describing him as ?irate.? When asked about his speci?c behavior
during interview, RN stated only that he called her names.

At 11:57 a.m. the log documents a nurse took SAMIMI to the room; however, a
12:00 p.m. entry documents the detainee was lying down and quiet. Per entry to the medical
record timed 11:00 SAMIMI was, in fact, evaluated by in a tele-
encounter. The note documented he complained of feeling ?stressed and depressed?
and stated, want to die and not be here because of my methadone. I was on high doses for 28
years.? He was reminded mood were to be expected during withdrawal and that he
would feel better over time. No was identi?ed. The ulan was to continue suicide level
two, continue the medication protocol ordered by Dr. and return to the clinic in one
day. Asked for his theory on why an antidepressant medication was not prescribed by either
Dr. said that though not contraindicated, SAMIMI had no history of

depression and adding another medication could aggravate stomach problems.

 

Per the Constant Watch Logbook, at 4:45 p.m. the nurse checked his vital signs.

Note: The medical record does not document vital signs were taken at this time. Vital
signs were next recorded at 4:00 am. on December 1, 2017.

At 5:37 p.m. the Constant Watch Logbook documents SAMIMI had a legal call which ended at
6:15 p.m. The start time of the call was ?ve minutes earlier per the Medical Unit Logbook.

The review team was informed by HSA {bll?iilbl?inl the call was transferred to the officer?s desk;


therefore, there is no record of it. HSA stated he overheard SAMIMI converse and
answer questions immediately and with specificity. He believed that supported the theory that
the detainee was faking the seriousness of his RN stated that after the
call, she asked SAMIMI if it ?went ok". He smiled and said it had, and was ?more upbeat".

The Constant Watch Logbook documents vital signs were taken at 6:30 p.m.

Note: there is no corresponding documentation in the medical record.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 40
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 2017

.
roan-ire_
I 

The Constant Watch Logbook documents the detainee slept the rest of the evening.

Friday, December I, 2017

Medical Unit Housing Record

SAMIMI did not accept breakfast or lunch but accepted dinner. He did not shower or attend
recreation. Medical staff signed the log although the signature is illegible. No security
supervisors signed the log for any shift this date.

 

 

MAR
Clonidine Hydroxyzine Immodium Trazodone Cyclo- Phenergan Ibuprofen
benzaprine
9:00 am. 9:00 a.m. None None 9:00 am. 3:00 p.m. 9:00 am.
3:00 p.m. documented documented
9:00 p.m.

 

 

 

 

 

 

 

 

 

Note: The MAR established for December improperly sets 9:00 am, 2:00 p.m. and 9:00
p.m. as the administration times for as-needed medications hydroxyzine, Trazodone,
cyclobenzaprine, and ibuprofen. The basis for administration of hydrosyzine,
cyclobenzaprine, Phenergan, and ibuprofen is not reflected in the nursing notes.

Note: According to the MAR. the 9:00 p.m. dose of clonidine was refused. There is no
reference to refusal in the nursing notes, nor is there a refusal form.

Vital Signs

 

 

 

 

 

 

 

 

 

 

Temperature Pulse Respirations Blood Pressure Oxygen Weight
Not taken 84 16 101f64 96 Not taken
Not taken 94 18 Not taken Not taken Not taken
Not taken Not taken Not taken 1 le68 Not taken Not taken

 

 

By way of a 4:00 am. medical record entry discussed in entirety below. reviewers learned of an
incident not logged in either the Medical Unit or Constant Watch Logbooks, nor did officers
write incident reports. The incident as referenced by RN involved SAMIMI
?trying to drink from toilet,? falling to the floor, and ?rolling on the ground.? The following
summarizes video from the camera inside the cell immediately preceding and following the
incident.

At 3:17 detainee SAMIMI is seen laying on a mattress on the ?oor with his head by the
door. At 3:21 a.m. he unsteadily sits up, takes his cup and reaches for the sink above the toilet.
He then collapses to the ?oor onto his side. In so doing, his arm hit the toilet and his hand

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


i: reanve_
I 

Page 41

dropped into the toilet water. He tries again to reach for the sink to get water. He brings the cup
down from the sink then up to his mouth but the cup falls from his hand and into the toilet. He
tries to ?sh the cup out of the toilet but again, falls back to the ?oor. A minute later, he pulls his
hand out of the toilet and wipes it on his blanket. He was still on the ?oor with his head by the
toilet.

At 3:23 the detainee again pulls himself into a sitting position but does not appear to have
the strength to hold himself up. He falls back to a prone position. An officerg?U enters the cell.
The of?cer goes to SAMIMI and from behind, assists him into a sitting position. The detainee
then topples over onto his right side, narrowly missing the concrete wall with his head. The
of?cer again assists SAMIMI into a sitting position and appears to motion to the detainee that he
should slide towards the door and away from the toilet. SAMIMI instead lays back down. The
of?cer then motions to someone outside the cell, presumably to get assistance. At 3:26 a.m. the
officer walks to the door and stands in the doorway, then leaves the cell. At 3:28 a.m. the officer
returns with a cup of water, sets it on the concrete bed slab and leaves the cell. At 3:30 am. the
detainee again pulls himself up and tries to reach the sink. He then takes the cup from the bed
slab, takes a sip, sets the cup on the floor and collapses to the ?oor. At 3:31 RN Ross-
Pearson enters with a cup. SAMIMI sits up but rests his head on the bed slab. RN
rubs his head and holds out the cup. SAMIMI then falls backward onto the floor. RN Ross?
Pearson moves to assist, taking a position inadvertently blocking view of the detainee.
Subsequent actions were as follows:

 

 

Time Event {meson

 

 

 


C)

 

 

 

 

 

3:32 am. Officer WC) enters the cell. The two of?cers and I grab hold of
legs and arms and slide him down toward the door of the cell so his
head was away from the toilet. Note: O?icer was the Medical Of?cer

during the shift. 

 

 

 

 

 

 

 

 


G)

3:33 am. Of?cer emoves the Styrofoam meal container and returns to stand by
the toilet.

 

 

 

 

RN Ilbll?lilbllilici Ire-enters the cell with the mobile blood pressure machine and

aplaces the cuff on the detainee's arm while he is on his side.

 

 

 

 

 

 

 

 

 

 

3:35 am. Of?cer ands the detainee a cup of water. The view is blocked;
therefore, it is unknown if he drank any water.

3:39 am. RN Iremoves the blood pressure cuff from the detainee?s arm and
wheels the blood pressure machine out of the cell.

3:40 am. Of?cedtbit?ltbimt  and RN IWI re?enter the cell and the nurse places an
additional blanket over SAMIMI.

3:41 am. Staff leave the cell.

{blf?iilbl
3? The Constant Watch documents the assigned officer was First name is unknown.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 42
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


i: roan-?L
I liarreclunls

 

 


Officer HG) was asked for an account of these events during interview. She said she was

checking the monitor showing live-feed footage of the cells when she observed detainee
SAMIMI urinating so she turned her head away. When she turned back, she observed him grab
the toilet. She called for the Constant Watch officer to stop SAMIMI
from drinking out of the toilet, and went to the nurses station to report the information to RN
She recalled the nurse replied, ?Oh good thing he urinated.?

instructions, the officer took ice chips to SAMIMI but he refused them. Officer

 

 

 

  
 
   

arrived with the mobile vital signs monitor. Officer ?aid that when the nurse lifted
arm to take his blood pressure, he screamed, whereupon RN told him
to stop being difficult. Officer gaggiibli reported that he screamed, ?It hurts so fucking bad. I just
want to die?.

 

 

 

 

Note: The Constant Watch Logbook documents only that at 3:30 a.m. SAMIMI was
laying by the toilet ?mumbling?, and that the nurse checked his blood pressure and
provided him with ice water and an additional blanket

RN 4:00 am. progress note was the first of two medical record entries this date.
She ?rst addressed phone call with his attorney, indicating the detainee appeared
pleased. As noted previously, the call occurred the evening before. RN (bii?lilbiif?ci Iwrote that
SAMIMI slept through the night until 3:30 am. after which time he was observed talking to
himself, trying to drink from toilet, falling to the ?oor, and rolling on the ground. She wrote that
the medical of?cer accompanied her into the cell to prevent injury and offer water. A few
minutes later he was asleep. When asked if he had a nightmare, he replied he did. The nursing
plan was to continue to monitor every 15 minutes. Vital signs (see first row of the above chart)
were all within normal limits.

 

During interview, RN said she was very concerned by this point because SAMIMI
was very weak and he had yet to see the physician. She said that leading up to this night, the
detainee?s increasing demands for ?more, more, more? led her to conclude that he was drug?
seeking, despite her best efforts to explain that medications may cause further stomach upset.
She recalled that even when demanding more medication, he was never mean or belligerent. RN
?said, ?Do I wish I had sent him out? Yes. Ihaven?t slept since.? She added that
her primary consideration in not doing so was the fact that vital signs were good, so
feared being criticized if she sent him to the emergency room.

Note: Other nurses cited normal vital signs to support their decisions
throughout the detention period. Dr. also cited normal vital signs as evidence
there was no clear cause that he should have been contacted following the incidents
described above. As noted, clonidine may be responsible for having controlled
blood pressure.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 43
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanare_
I 

 

{bil?litbiml


 

 

 

 

{bil?litbiml


 

 

 

 


0)

 

 

      
 

 



By e-mail timed 8:01 Lieutenant bil?liibimicl noti?ed Security Chief that

MIMI was offered and refused the breakfast meal, marking the third straight meal missed.
Assocl arde replied at 8:07 am. with the question, ?Does ICE know this yetSecurity Chief a responded, No they were not notified. Assoc1ate Warden ini??: reply
states, would make sure they are right after lunch so in the event he doesn?t eat ey re not

blindsided over the weekend. We?ll see if he eats lunch today. Thanks.?

At 8:50 Supervisory Detention and Deportation Officer (SDDO)?signed

the Medical Unit logbook noting, ?All secure.?

 

 

 

Note: SDDO _stated during interview that he did not speak with SAMIMI
because he was on suicide watch and sleeping. He said he never met the detainee, but
recalled he was discussed at the weekly meeting of department heads on November 29,
201?. It was reported at the meeting that he was on suicide watch and a life-long drug
abuser.

In a 9:29 a.m. progress note, documented SAMIMI was on his way to the tele-
of?ce when he ?threw himself out of the wheelchair, landing on the floor face first.?
He sustained a nosebleed and urinated on himself. Pressure was applied to his nose with gauze
until the bleeding stopped. According to the note, a blood pressure reading was not obtained
because SAMIMI would not stay still. Other vital signs (see second row of above table) were
within normal limits. RN ?rote that SAMIMI attempted to grab him with his bloody
hands and was spitting. Dr. arrived on the scene and ordered that SAMIMI be placed
back into the suicide watch cell. The appointment was cancelled, and an

appointment was scheduled with for the following day.

RN was asked for his verbal account of this incident. He indicated that when he arrived
at cell to take him to the appointment, the detainee requested
assistance in getting into the wheelchair. RN indicated he declined to assist because he
had a knee injury. He stated the detainee was able to get into the wheelchair without difficulty
but moved slowly. Officer?stated during interview that he was present and
witnessed SAMIMI ask for assistance getting in the wheelchair. He said RN told him no
and that he could do so by his own power. The officer confirmed SAMIMI moved slowly into
the wheelchair, but fell out on the way to the appointment. As described by RN
SAMIMI lunged out of the wheelchair, falling on the ?oor. Questioned about this, he said the
detainee ?de?nitely lunged? because he landed at a distance which the RN believed required
some effort. He said SAMIMI did not attempt to break his fall. RN said the detainee
urinated on himself and started bleeding from the nose, adding when asked that there were no
other injuries such as a cut lip. He donned gloves and put gauze on nose, and another
nurse arrived to assist because the detainee was ?rolling around.? RN said that when
arm hit the bill of his cap, he no longer felt safe because the detainee?s hands were
bloody and he could have poked him in the eye. According to RN Dr. arrived

 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 44
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanva_
I 

 

 


C)

 

 

  

and ordered return to his cell and to level one suicide watch. RN stated Dr.
(enema?) neither assessed nor spoke with the detainee at this time.

During interview of Dr. he confirmed he did not witness the incident but based on what
was described by the RN. he was confident SAMIMI intentionally threw himself to the ?oor. He
returned the detainee to level one suicide watch because the action could be interpreted as a
suicidal gesture. Dr. said that when he arrived on the scene, SAMIMI was ?just laying
there" looking at them.

The Medical Unit Logbook documents SAMIMI was returned to level one suicide watch per Dr.
at 10:00 a.m.

There were no entries documenting the precipitating incident in either the Medical Unit or the
Constant Watch Logbooks, and the latter does not include an entry documenting the change in
status. Monitoring entries in the Constant Watch Logbook do. however, switch from every 15
minutes to every ?ve minutes at 10:00 am, consistent with Constant Watch procedures. The
log documents the detainee slept throughout the day until 3:35 p.m. when the of?cer
documented a nurse was talking with SAMIMI and provided Ensure at 3:40 p.m. The of?cer
noted the detainee took two drinks and spit the rest out.

Note: No corresponding nursing encounter is documented in the medical record.

At 3:55 p.m. the detainee took one drink of Ensure and spit the rest out. At 4:40 p.m. a meal
was offered and refused. At 5:05 p.m. a nurse spoke with SAMIMI and he took medication at
5:10 p.m.

Note: The medical record does not document an encounter with administration of a
medication and as noted, MAR documentation does not allow determination of what
medication was given at this time.

- logged that he assumed the Constant Watch post at 7:06 p.m. At 7:37
Office logged he noted SAMIMI was still wearing his full uniform whe
removed the blanket. HSA was consulted and informed the offic er the doctor,
the detainee was only supposed to have underwear. Of?cer
at 8:35 pm. they entered SAMIMI's cell together and removed the uniform. A suicide smock
was issued.

   

HSA 03(01le completed a Suicide Alert Level 1 form documenting special instructions to
include:

1) Suicide smock;
2) Suicide pillow. gown, blanket;

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 45
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?

.
reanva_
I 

 


0)

 

 

    
 

otified Lieutenant Salk 1'

 

 

(bll??blmf


 

 

 

3) Finger foods only;

4) Orange: cup;

5) One paperback book or Bible no metal;
6) Ten sheets of toilet paper at a time; and,
7) No lethal items.

He also noted Dr. Wilson, was to assess SAMIMI on December 2, 2017.
(bll?llb . . . -
At 9:44 p.m. Officer documented that w1th the lieutenant?s permission, he opened the door

to give the detainee water. Entries thereafter documented SAMIMI was yelling intermittently

then at 10:29 it was observed he appeared to be spitting up blood. Officer
documented he notified the medical officer and stated on interview that the of?cer noti?ed the
nurse. The nurse reportedly said she would see the detainee.

 

 

 

 

 

 

a . .
Note: The medical record does not document a related nursmg encounter.

 

 

 

 

 

 

(W?w
At 1 . Officer We} was relieved by Officer ?as the Constant Watch
Officer. Officer documented in the logbook that at 11:34 p.m. SAMIMI was

complaining of stomach pain and ?nurses not available." At 11:44 RN (bli?lileTliC)
responded to the cell, checked the detainee?s vital signs and gave him medication.

Note: RN did not respond for 7'5 minutes after SAMIMI was observed
spitting up blood.

Note: RN did not document her encounter with SAMIMI until 5:00 21.111.
the next day.
Saturday, December 2, 201 7

This was the day of death.

 

 

. . . {blt?litblt . . . .
c) An incident report written by Of?cer documents events which occurred during his shift.

 

 

 

 

noted above, he was the Constant Watch Officer for the shift starting 11:00 pm. on
December The date the incident report was written and submitted is not documented.

 

 

. . . . 
ct During interview, Officer stated that because he had never seen a detainee as sick as

 

 

 

AMIMI, and because of what happened during the shift, he wrote an account in case it was
nee ter. The account was not documented in an incident report, but was turned in to
Lieutenant after Of?cer earned of SAMIMI's death sometime in mid-December.
He transferred the information to an 1 cident report when requested, but as noted, did not record
the date or document in the report tha it was written based on notes made after his shift on

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI {attendant Page 46
Medical and Security Compliance Analysis 
March 6, 2018, revised March 14, 201?

.
rea:uve_
I 

 

 

 

December 2, 2017.
201?.

The reviewing supervisor did not sign the incident report until January 5,

 


Officer report documents that he was told by the of?cer he relieved that SAMIMI had

been refusing meals and not sleeping very much. He wrote, ?From the moment I assumed the

 



 

 

post, there was a strange odor emanating from his room which I assumed was vomit.? Of?ce
rote that when SAMIMI requested to see a nurse, RN came his
stated in his

vital signs and commented, ?It smells like he has liver failure.? Officer

report that he figured that if that was the case, the detainee should be taken to the hospital. The
nurse was unable to get a proper reading of the detainee?s vital signs because he was unable to 1?
still. The detainee was given medications but the detainee was only able to sw
remaining pills were left in a cup on the mattress. Officer contacted the Watch
Commander, Lieutenant- who instructed that he be kept informed and to let him know
if the detainee eats breakfast.

 

 

 


0)

 



 

 

Officer

 

 

 

 


Cl

medica on six different occasions that SAMIMI was in pain and requested more
medication. Officer ocumented that RN told the detainee she could not
give him additional medication until he consumed some food. She was able to check his vital
signs and they were all normal. According to the report, the nurse stated the detainee was
?dehydrated and hungry.?



 

 

 


0)

 

 

 

 

wrote that later in his shift, the detainee dragged himself to the toilet but he could
not see a inee was doing. SAMIMI asked him to bring his medicine and then
vomited into the toilet. Of?cer notified the medical of?cer to alert nursing staff. When

 

 

 

 


Cl

 

ey came to check on him ?for a third time?, they noticed SAMIMI had been incontin
oor was mopped
ocumented that when nursing staff left
the detainee?s cell, the other officer asked LPN  what is wron w'
detainee to which she replied, ?He?s dying.? The officer then

    

 

   
   

 

 

 

to eat his breakfast? and drank a little bit of water. This information was reported to Lieutenant


Note: In an email to facility leadership at 5:27' am, Lieutenant-documented
SAMIMI ate ?half of his breakfast this date.?

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
roan-rm
I 

Page 4?

 


0)

 

 

 

 




 

 

 

 




 

 

 

incident report goes on to document that throughout the shift, de MIMI
up every few minutes complaining of stomach pains. Of?cer rote that he alerted

 




 

 
 

 




 

 

 

 

 

(bil?libilili
Cl

 

 

 

 

{bli?libli bll?lLiblli?ll
Of?cer MC) ended his Incident Report by noting he informed his relief, Of?cer of

?everything that occurred during my shift? and told the officer to ?keep a good eye? on SAMIMI
because he had missed four meals and was vomiting.

 

 

 

 

?3

 

 

Lieutenant (bit?iibitiitcl was interviewed concerning his recollection of events shift. He
said he recalled being asked to come to the post by Officer and that the of?cer was ?very

concerned.? Lieutenant-also recalled seeing the medications on the bed and spoke
with the nurse. He asked what was going on because the of?cers were saying the detainee was
suffering. He was told Dr. was aware of the situation and planned to see SAMIMI.
Lieutenant {bli?libliiltci ?aid that in retrospect, he wished he had called 911 himself but did not
because he was told Dr. was fully informed. He commented he has ?had battles with
Dr. in the past" and has lost; consequently, he knows his ?boundaries."

The revie also interviewed LPN concerning her involvement in the events
documented by Of?cer She recalled nursing staff were handling a very heavy volume of

 

admissions that night and that RN {bli?iilblifilci said she would come to intake assist; however,
she was delayed because ?Mr. Samimi was having problems.? When the

 

 


Cl

 

opportunity, she went to medical to ?see what was going on.? She remembered 

calling for a nurse and that she and RN (bil?lilbilillcl went to the cell. The RN said, ?let?s get

him up on the bed," then the noticed the ?oor was wet and she stepped in the liquid, asking,
?What?s that?? LPN ?said SAMIMI ?didn?t look good?, was very agitated, and did not

want the nurses there. When apprised of the comment, ?He?s dying? attributed to her by Of?cer

LPN Numongo replied, ?Oh my goodness! Did I say that?? She noted that sometimes in

a stressful situation people will say inappropriate things and offered that it was certainly an
inappropriate, very regrettable comment.

RN documented the events of the night in a 5:00 a.m. progress note. She wrote
that SAMIMI screamed for nurses and complained of abdominal pain. Pain level was not
obtained. Vital signs were recorded as follows: temperature 98.2, pulse 92, respirations 17,
blood pressure ll3i?68, and oxygen saturation 94 percent, all within normal limits with the
exception of a lowered oxygen level. lungs were clear to auscultation, and bowel
sounds were present in all four quadrants.

Note: RN {bll?lilbllillcl did not document the time this assessment was conducted.

The note goes on to state that several times during the night SAMIMI screamed that he was
unable to breath, for which a re-breather? was provided. He pulled it off and went back to sleep.
At 3:30 am. he woke up a third time screaming for Zantac and an injection for nausea. His vital

 

31 A rehreather is a mask with an attached reservoir bag that saves one third of a person?s exhaled air, while the
rest of the air gets pushed out through side ports covered with a one-way valve. This allows the person to
rebreathe some of the carbon dioxide exhaled, which acts as a way to stimulate breathing.

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 48
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanare_
I 

 

signs at were recorded as follows: pulse 100, respirations 17, blood pressure 92168, and oxygen
saturation 95 percent, all within normal limits. A body temperature was not obtained. He was
given Zofran for nausea 4 mg intramuscularly per verbal order of Dr. to treat the
nausea, as he was unable to swallow the Phenergan. RN documented the verbal
order by 

Note: The order was never authenticated by Dr. (W?liib?f? and the prescription is
incomplete as it does not indicate if this was a stat, as-needed, or regularly scheduled
dose.

RN noted that SAMIMI did not receive his nighttime dose of Trazodone.
. . .
Of?cer entrles to the Constant Watch Log for the remalnder of his sh1ft documented
that at 6:16 SAMIMI was vomiting in the toilet and stopped after one minute. The nurse
was noti?ed. At 6:44 Officer $323}?le documented the detainee was vomiting again and that
the nurse was notified.

 

CI

 

 

 

 

 

 

 

 

. 
The Constant Watch log documents Of?cer C) assumed the post at 7:06 am. He logged

SAMIMI was eating at 10:15 a.m. At 10:35 am. his entry documents, ?Yelling and screaming
of tummy pain, I notified the nurse The 10:40 a.m. entry documents SAMIMI was

 

 

 

 

?Yelling and screaming for nurse, nurse noti?ed?; at 10:45 ?Yelling and screaming for
nurser?called Lt. 9916111211011: and at 10:50 ?Yelling and screaming for nurse?.

 

(bil?libiml


 

 

 

 

 

 

   
   

According to medical record entries (detailed below) and written an ports of Officer
and Medical Officer Of?cer was asked to take SAMIMI to an
11:00 am. appointment with Dr. I Both officers stated Of?cer

 

. . . . . 
Irefused because he belreved SAMIMI was too unstable to move. Dur1ng intervtew, 53H 

 

 

 

that he was the Constant Watch officer the previous day and was at: _f
aware of the incident where it was believed SAMIMI was drinking from the toinn? 
said

return to Level one suicide watch after falling from his wheelchair. Officer

 

(bil?libiml


observed SAMIMI was in an extremely weakened condition and reported his ation to

 

 

 

- . 13 am 
?kept looking at him? to make sure the detainee was breathing. Of?cer did not want to 

 

 

 

 
   

incur the risk of moving SAMIMI on his own, so he asked for the assistance of a nur -

 

 

 

?3%th Of?cer {b31010} report, she documented that she notified RN (WW - e- a wheelchair
e) and they both went to cell. OfficerEeca led that when the nurse arrived, he

 

 

 

SAMIMI he had an appointment and that they woulc put him in a wheelchair. Both officers
reponed a ainee was moved to the wheelchair, but then stiffened. He was moved back
to the mattress. Officer stated there was a substance of some sort on his forearm
because face brushed it as they moved him into the wheelchair. Of?cer-

remained at the cell while Of?cer left the scene to wash it off.

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 49
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

'i

reaai-re_
I 

 

 

 

 


C)

 

 

Video from inside the cell starting at 10:51 a.m. was viewed to corroborate the officers?
accounts of these and subsequent events. At the time the video starts, SAMIMI is sitting on a
mattress on the floor with his head resting on a second mattress on top of the bed. He was
wearing socks and underwear. The following events occurred:

 

 

 

 

 

Time Event

10:52 am. Detainee lays down on the mattress on ?oor, grabbing a blanket to cover
himself.

10:53 am. The officer opens the cell door, closes it, and re-opens it.

10:55 am. RN  lblt?lilbl  enters and hands SAMIMI a small cup. SAMIMI sits up, takes the

cup, and appears to ingest the contents. He lays back down. Note: per the
logbook, the cup contained medication.

 

 

10:56 am. RN (bll?lilbl stands in the doorway and motions for SAMIMI to get up. RN
pulls the blanket off him. SAMIMI moves to his knees and appears to

speak to the nurse.

 

 

 

 

10:57 am. RN libll??liibll leaves the cell. SAMIMI remains in a kneeling position with his
head on the mattress.
10:58 am. RN  tbll5litbl  returns with suicide smock. SAMIMI stands, stumbles and

reaches out to the nurse for support, grabbing the nurse?s arm. He then
collapses to the floor in the doorway and is assisted to his feet by Of?cers
lonesome land land RN They move him to the wheelchair
outside the cell door.

 

 

 

10:59 am. is helped to a sitting position in the wheelchair. His head then rolls
back and his leg stiffen and appear to shake. He then slides out of the
wheelchair, feet first. He is caught by the staff before reaching the ?oor, then
is carried back into the cell and placed on the mattress on the floor. RN
picks up the medication cup that had been left on the bed and covers
with a blanket. SAMIMI moves the blanket up over his head,
concealing his face. His right arm and both legs are still visible and

movement of the limbs is seen.

 

 

11:00 am. Officer   removes a Styrofoam food container and a cup from the cell.
The cell door is closed, then re-opened as RN stands in the doorway
looking into the cell. Of?cer is seen on camera pointing at his own
arm and then walks away.

 

 

 

 

 

 

 

 

RN medical record entry addressing these and subsequent events is timed 12:30 pm.
He documents that he and the officers ?tried to assist to transfer detainee from the floor where he
was sleeping on the mattress to the wheelchair. The detainee was very weak. The nurse told the
officers to leave detainee on the mattress on the floor." During interview of RN about
events to this point, he confirmed Officer-asked for his assistance in getting SAMIMI
to his appointment with indicating the detainee could not walk. RN indicated

 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 50
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

i 
rea:uve_
I ?Enrrecl 

 


C)

 

he did not know the detainee could not walk, so he went to the cell with Officer He
said they attempted to place SAMIMI in the wheelchair but could not move him from the ?oor
because he became stiff. When shown the video of placement in the wheelchair,
immediately followed by his stiffening and appearing to shake, RN acknowledged his
recollection was incorrect. Asked about the possibility that SAMIMI experienced a seizure, RN
said he had not considered it because the detainee had no known seizure history.

The next events as shown on the video were as follows:

 

Time Event

 

11:01 am. Officer {13115111311010} land RN re?enter the cell. RN Ilbll?lilbll grabs the
detainee?s arm and lifts him to move him onto his right side, then leaves the

cell.

 

 

 


C)

 

 

 

(1311511131011
0)

 

 

 

     

 

11:02 am. Officer {13315111331010} Ileans down and appears to speak to the detainee.

 

{1311511131101


 

 

 

 

11:03 am. Officer a keturns to the cell and stands in the Jen doorway.

 

11:04 am.

 

Ilbll??lilbll returns to the cell door and hands Officer lseveral cloths.
Officerl 

bends down and begins to clean the detainee's head, face and
mattress. As this occurs, RN {1311511131 stands in the hallway, brie?y watches as
the officer cleans SAMIMI, then he walks away.

 



 

 

11:05 am.

 

 

RN Ilbll?lilbll returns to the cell doorway and Officer) points to a dark
spot on the detainee?s suicide smock. The nurse picks up the smock, which
appears to have a large wet spot on it, then moves SAMIMI by the arm so his
face could be seen. RN uses a cloth to wipe mouth area
and leaves the cell.

 

 

 

 

 

11:06 am.

 

 

 

Officer cleans hand with a cloth.

 

 

 

During interview of Officer about these events, she said she heard a choking sound
immediately after they left the cell and called for RN to return. RN said he was
turning to his office when called back to the scene. SAMIMI was turned on his side and
vomite.. 'cer stated she observed blood clots in the vomit and pointed this out to
RN Of?cer: stated that he returned to the cell after SAMIMI was moved to his
side and observed vomit on his face. According to both of?cers, Officer told . -
nurse he should call the doctor. RN agreed and left to do so. 9 er
informed the review team that she contacted Lieutenant=at this point to request that he
come to medical, although her written report suggests the contact was made after SAMIMI was
?rst returned to the cell. Lieutenant was the Watch Commander for the 7:3:00 pm. shift date.

     
   

 

 

 

 

In his 12:30 pm. medical record entry, RN addresses these events by stating that around
11:08 am, the officer reported SAMIMI was vomiting. He and the of?cer repositioned the

detainee to his side and he instructed the of?cers to clean the vomit and keep their on
detainee. During interview, RN {131151113} stated he was called back into the cell after leaving for

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

Page 51

.
reanare_
I 

 

(bil?lilbilfll
0)

 

 

 
 

 

 

 

 

(DHEHDHW
C)

 

 

   

 

(DHEHDHW
C)

 

 

 

(bll??blmf
C)

 

 

his office upon report SAMIMI was vomiting. He said the vomitus consisted of stomach
contents only and that there was no blood. RN said he decided to call Dr. at this
point, indicating he did not call 911 because the situation was not a ?super emergency." His
intent in calling Dr. was to notify him that alternative placement should be sought for
SAMIMI because his needs exceeded capability to handle.

Officer documented in the medical unit log that at 11:05 a.m. Dr- was
informed the detainee is not stable enough to see him as he was unable to sit in the wheelchair.
In Dr.-nedical record entry, he wrote that when ?rst informed of the attempt to place
SAMIMI in a wheelchair, he said he would go to the cell to conduct the evaluation. However,
shortly thereafter, security advised him that he was lying on the ?oor vomiting up blood, with
nursing staff tending to him and attempting to contact the doctor.

(bll??blmf .
At 11:06 Of?cer logged that L1eutenant C) arrived. The lieutenant
confirmed during interview and documented in his written report that Officer {bll?liiblmicl

 

 

 

 

 




 

 

contacted him by radio and asked him to report to medical. He was in his office at th and
was able to respond immediately. While en route to medical, Lieutenant ?red
Of?cer?who was also on his way to medical. Of?cer on interview that
- was in the control center when the officer watching the camera monitors questioned aloud

at the

 

he was

 

 

 

to medical to inform the of?cer this was imnnroer. According to Officer 552onme 
cleaning face as directed by RN 

operator

   
 
  
   

 

 

. . .
and Of?cer arr1v1ng on scene and looking in the cell

and  are seen speaking to the lieutenant, then Of?cer
ell and removes the blanket from SAMIMI who remained on his right side.
During interview, Of?cer commented that he was concerned there could be a security
issue, so he entered the cell to look for anything that could be used as a weapon. Lieutenant

 

 

 

 

 

informed the review team and documented in his written statement that when he looked

in the cell SAMIMI was lying on his right side on a mattress on the floor. He noted the
detainee?s eyes were open and he looked pale. The lieutenant stated to the review team that ?the
guy was clearly in crisis,? noting there was vomit on the side of the detainee?s face, he had
urinated, and was breathing heavily. The lieutenant reported that he said, ?We need an
ambulance? and asked the officers where the nurse was. They replied that he had gone to 

     

the doctor, whereupon the lieutenant proceeded to the nurses station and said to 
?What are you doing? We need an ambulance.? The RN said he had -- .ages for Dr

and was trying to reach the HSA. Lieutenant stated that an ambulance was

 

 

{broom
0)

 

 


0)

 

 

 

 

 




 

 

needed and went to another phone in medical to direct Central Control to call 911. 

left to prepare for the hospital detail.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

'i

reaai-re_
I 

Page 52

 

 

(1311511131101
C)

 

 

(1311511131101
0)

 

 

 

 
    
 

 


C1

 

 

 

(1311511131101
C)

 

 

 
  
 

According to RN 12:30 pm. progress note, he left messages on Dr. home
and mobile phones asking for a return call. Dr. stated during interview that he did not
receive the messages. documented that he then called HSA who ordered
that 911 be called. RN informed the review team that after speaking with HSA 
he went back to the cell area and found as there. He told the lieutenant that
he received the order for SAMIMI to go to the hospital, whereupon the lieutenant asked if the
detainee could ?support his own weight." When told he could not, the lieutenant called 911 for
him. Reviewers note RN account of events leading to calling for an ambulance is
inconsistent with Lieutenant {1311511le131, and not supported by any other evidence, written or
reported.

 

 

 

 

 

ltb} We} lwas the Central Control Officer. He con?rmed that on camera, he obs ed
touching SAMIMI about the head. He stated that when Officer eft to
investigate, 'nued to watch events in the cell on the monitor. Based on what he observed,
he knew when Lieutenant alled that it was about SAMIMI. Per Of?cer
logbook entry and incident report, he received the instruction to call 911 at 11:10 am. He
reported the intake area was subsequently locked down so he could override the gates and let
Emergency Medical Services (EMS) responders in quickly.

{1311511131011

 

 

 

 

9

Lieutenant reported that after he instructed the control officer to call 911, he returned to
cell 527? where he observed detainee SAMIMI was breathing. He said he observed vomit on and
near his face, and that there may have been blood on the ?oor. He told the detainee to lie still as

 

 

(mascara


 

 

 

 

(mascara


 

 

an ulance was on the way. The Lieutenant then went to the armory to issue weapon
Officers  would be accompanying the detainee to i a one in
ambulance and the other in the chase vehicle. Lieutenant lso assigned perimeter

   
 

 

 

 
 

patrol to report to the perimeter gate to escort the paramedics into the
facility. Officer: stated on interview that he opened the perimeter gates for the EMS

responders and escorted them through the intake area and into medical.

 

 




 

The report of the Aurora Fire Department documents a team consisting of two Em
Medical Technician (EMT) paramedics and two EMT basic res 1spatched at 11:16
am, arriving on scene at 11:18 am. Of?cer ocumented the same time of arrival in
the Central Control logbook. The in-cell video shows the following events prior to and upon
EMS arrival.

 
   
 

 

Time Event

11:09?1 1:15 SAMIMI moves his arms and legs and rolls from his side to his back, then to
am. his stomach.

11:15-11:18 is on his stomach. Very little movement is observed.

a.m.
11:18:03 am. RN  lbll?lilbl  enters the cell, pulls arm to turn him He looks
at the detainee?s face then releases the arm.

 

 

 

 

 

 

 

 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 53
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

'i

reaai-re_
I 

 

 

 

11:18:35 a.m. head moves 

11:18:51 a.m. An EMT enters the cell and shakes the detainee by the shoulder. He then
turns SAMIMI onto his back and checks for a pulse. A second EMT enters.
The ?rst EMT then pulls the detainee by his arms out into the hallway.
11:19:48 a.m. EMTs started chest compressions and administer medications in the hallway.

 

 

 

 

 

 

The Aurora Fire Department (AFD) report documents that upon arrival on scene, the EMTs
found SAMIMI ?lying prone in the holding cell with emesis on the mattress.? He was
unresponsive and pulseless with no obvious signs of trauma. SAMIMI was given
cardiopulmonary resuscitation (CPR) and a Basic Life Support airway was put in place. It was
noted SAMIMI had ?coffee ground type emesis? and he was continuously suctioned to clear the
airway. Epinephrine was given and CPR was continued with a delay when the detainee was
moved from the floor onto a pram and out to the ambulance. The provider?s impression was
noted in the report as cardiac arrest. The in-cell video shows he was out of camera range at
11:32 a.m.

The Falk Rocky Mountain EMS also responded. According to the responders? report, detainee
SAMIMI was lying supine on the ground with CPR in progress by AFD personnel on their
arrival. AFD reported the detainee had agonal32 respirations at a rate of two per minute, and the
monitor showed him to be in asystole33. He received a total of nine rounds of CPR, remaining in
asystole until the eighth round, at which time he was in ventricular ?brillation?. He was
shocked once and upon the next check, he was back in asystole. He was transported to
the emergency room at the University of Colorado Health Medical Center.

Video footage from the camera in the Medical West Hallway shows EMS responders working on
SAMIMI outside the cell. At 11:27 a.m. two additional responders arrive. At 11:29 a.m. the
Aurora Police Of?cer motions for Of?cer-to meet him at the end of the corridor.
Officer-is seen speaking with the officer and showing him the logbook and the
detainee?s identification information. The two speak for approximately six minutes while rescue

 

 

a .
13f efforts continued behind them.

 

 

 

At 11:33 a.m. inee is lifted in the pram onto the gumey and the gumey is wheeled off the
unit. At 11:34 Officers  speak to each other and Officer?

 

makes entries in the logbook. An unidentified nurse approaches them and the of?cers appear to
re-enact the incident when the detainee stiffened as he was being placed into the wheelchair. At

11:38 RN approaches the two officers and he and Officer-hug. The

video ends at 11:39 a.m.

 

3'2 Agonal breathing refers to labored breathing, characterized by gasping.
33 Asvstole, also known as cardiac flat line, is the absence of heart contractions.
3'4 Ventricular fibrillation is a life-threatening heart that results in a rapid, inadequate heartbeat.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 54
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
ll: reanve_
I 

 

 


Cl

 

 

  
 
 

Lieutenant I-eorted EMS responders were performing CPR when he returned to
medical. He asked Officer what ha nened and was told SAMIMI was breathing but
stopped when the paramedics arrived. RN 12:30 p.m. progress note also documents
SAMIMI was breathing when the paramedics arrived but then stopped. Lieutenant?
notified the Warden, Associate Warden and Security Chief by telephone and then escorted the
EMS responders to the ambulance. According to the DCDF transport log. the ambulance left the
facility at 11:40 a.m.

(b10311
rode in the ambulance. She reported on interview that she sat in the front passenger
seat because the EMS responders needed available space in the back area to continue working on
SAMIMI. She recalled the ambulance activated lights but no siren en route to the hospital. The
transport log documents they arrived at the University of Colorado Medical Center (UCMC) at
11:45 a.m.

 

 

 

 

According to the emergency room record, EMS responders reported the patient was breathing
roughly two times a minute and they immediately started CPR, continuing for 19 minutes. On
arrival at the emergency room he had fixed pupils and was in asystole. His preliminary
diagnosis was cardiac arrest. The emergency room record states black vomitus noted on his face
and in his airway suggested a possible gastro-intestinal bleed.

At 12:02 p.m. detainee SAMIMI was pronounced dead. According to RN 12:30 p.m.
progress note, notification of death was provided by UCMC physician Dr.? At 2:32
p.m. the detainee was taken to the morgue by hospital staff and the assigned officers returned to

the facility.

Note: The DCDF MAR documents SAMIMI was given a dose of ibuprofen at 2:00 p.m.
and clonidine at 3:00 p.m. As noted, he left the facility at 11:40 a.m. and death was
pronounced at 12:02 p.m.

Post-Death Events

. . . . a . . .
I Lieutenant collected Incident reports from all officers involved in events leadmg

to medical emergency and wrote his own.

 

 

 

 

0 A letter was sent to sister on December 11, 2017, notifying her of his death.

Per the Resident Account report 2018 a check for $22.00 was sent to_n

January 4, 2018.

0 Warden Johnny Choate personally met with each member of involved security staff and
provided information on available employee assistance services. He did not, however,
meet with nursing staff. HSA (bil??liibilfli said he spoke with certain nurses who were

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 55
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?


reanare_
I 

impacted by the death but the discussions were ?more informal? and did not include
referral to employee assistance services. Warden Choate acknowledged he should have
spoken with nursing staff as well as officers.

0 The facility conducted two after action reviews. Video surveillance footage was not
reviewed for either. The first, dated December 6, 2017, was conducted at the 
Safety Committee Meeting. This report found, ?Medical and security staff acted properly
as directed by policy and procedures. Several Department Heads at the facility were
unaware of the incident until later in the week.? Noted remedial action was for the
Warden to notify all department heads by email of any future serious incidents.

I The second report, dated December 18, 2017, is titled Multi- Level Mortality Review.
The report wa committee members Warden Choate, Dr. HSA
I 33(5) I and ?33(5) {leC} I, identified 1n the signature block as
responsible for quality assurance. The report was directed to the GEO Chief Medical
Of?cer and the Executive Vice President of Health Services. No security or ERO
personnel were involved in this review. The report is based on documented information

in the medical record and medical staff report, although the basis for some of what is
documented is unclear or not supported.

 

 

The report lists the presumptive cause of death as, Secondary to
Broncho Aspiration of Gastric Contents?. The cause of death is not attributed on
the document, although Dr. acknowledged on interview that it was his
based solely on observations reported by staff.

Methamphetamine use is referenced in the admitting diagnosis section of the
report and included in specific information relevant to death. Nowhere in the
medical record is it documented SAMIMI used methamphetamines.

?Specific information as relevant to death? includes the statement, ?Presented to
this facility experiencing acute withdrawal of blu1red vision, shaking
extremities, nausea and vomiting." Reviewers note that although of
withdrawal were observed within hours of arrival at DCDF and
progressed thereafter, documentation and verbal statements do not support that he
was experiencing blurred vision, shaking extremities, nausea and vomiting when
he arrived at the facility or during intake screening.

The document states, ?Appeared to progress well with withdrawal protocol, began
demanding stronger medications?. Reviewers note that the basis for the
statement that he appeared to progress well is not supported by the medical
record. Although not clearly addressed in the medical record, security and video
documentation suggest withdrawal progressively worsened.

The document states, ?Sporadic ingestion of food and drink, appeared unable to
cooperate with and evaluations, but able to sit and speak
with attorney." Reviewers note that SAMIMI fully cooperated with Dr.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 56
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

?1

i: reaai-re_
I 

during his initial mental health examination on November 20, 2017. While en
route to his follow up appointment on November 28, 2017, SAMIMI collapsed
and was determined too unstable to proceed with the evaluation by the
with concurrence by the physician. The next mental health
appointment was completed via on November 29, 2017 following
the detainee?s suicide attempt. The medical record documents 
cooperation. Likewise, the record documents his cooperation with the next
mental health appointment on November 30, 2017. While on route to the final
mental health appointment on December 1, 2017, SAMIMI fell from his
wheelchair. The nurse?s observation was that he ?lunged?, suggesting the fall was
not for medical reasons. Whether it was or was not cannot be determined,
although events during the preceding hours suggest he was very ill. The
reviewers conclude that the statement in Multi-Level Mortality Review that the
detainee ?appeared unable to cooperate with and 
evaluations? is not supported by the medical record.

Regarding events on December 2, 2017, the document describes events in a
manner inconsistent with information reported by officers and RN It
states, ?Samimi was being prepared for a evaluation. Nursing staff
and detention officers attempted to move him from his bedding he had placed on
the floor into a wheelchair; Samimi was unable to sit in the wheelchair and was
returned to the mattress. The volunteered to conduct the evaluation
in the cell. Noting Samimi?s condition the nurse went to call the physician for
orders, he was summoned by the detention officers who informed him Samimi
had vomited. The nurse returned to the cell, repositioned Samimi on his side and
removed the vomitus from his mouth, and asked the detention officers to watch
him and returned to the phone. The HSA was contacted and gave instructions to
send Samimi out. The Shift Commander called control and instructed the control
officers to call 911.? Based on documented and reported information, RN
did not attempt contact with the physician until after he returned to the cell and
SAMIMI was found to have vomited. While accurate that the Shift Commander
instructed calling 911, evidence indicates he did so prior to the receiving
authorization from the HSA as implied in the Mortality Review.

In the section, ?Institution Medical Care Review?, ?poor? is marked for prognosis
with treatment. Whereas the physician did not evaluate SAMIMI, and nothing in
the medical record suggests nursing staff assessed the detainee?s prognosis as
poor and made appropriate referrals, the documentation on the Mortality Review
is unexplained.

In the section, ?Any complications adversely affecting outcomes?, ?yes? is
marked with the description, ?After withdrawal completed began demanding
medications. Made suicidal gesture.? The medical record does not document or
support that withdrawal was ever completed; in fact, Dr. stated during
interview that SAMIMI was still in withdrawal on the day he died. Also, the

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 57
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 2017


reanve_
I 

medical record does not document determination that actions on
November 30, 2017 were a suicidal gesture versus a suicide attempt.

0 Entries in the section, ?Review of Emergency Medical Care" appear non-
responsive or unclear. Yes is checked for CPR, although no DCDF personnel
administered CPR. Yes is checked for ?Problems encountered during medical
emergency, equipment, communications, and transportation?? with the
description, team reported presence of ?vomitus? in airway during
resuscitation effort." Based on all available information, CPR was not initiated by
DCDF personnel because SAMIMI was reportedly breathing when EMS arrived,
and no problems with equipment, communications, or transportation were
identi?ed.

The Mortality Review inaccurately documents SAMIMI became unresponsive
after he was placed on the EMS gurney. In fact, he became unresponsive before
he was moved to the EMS gurney.

The Mortality Review findings identified as the sole strength, ?Quick initiation of
withdrawal protocol. Monitoring of detainee while on withdrawal protocol.? The ERAU
review team concurs that the physician was contacted and a withdrawal protocol was
initiated quickly. However, as identified above and discussed below, the physician did
not fully follow the CPG protocol and nursing monitoring was inadequate.

The Mortality Review includes one recommendation: ?Re-emphasize to all nursing staff,
use your clinical judgment and call 911 when presented with a life or death situation."

Dr. and HSA (bll?liibllf? stated they did not review any video footage prior to or
following completion of the Mortality Review.

Staff Comments

Reviewers found comments made by both medical and security personnel provided instructive
context for events described above. Highlights include the following:

SAMIMI was overwhelmingly described as cooperative, respectful and pleasant. The
few exceptions were occasions when he demanded medical attention to address
withdrawal 

Although Dr. never examined SAMIMI, he said he had casual contact with the
detainee almost every day, speaking to him through the glass window of the cell or in the
hallway. He said nurses kept him informed of progress and actions and that
based on what he was told, he believed the detainee engaged in ?behavior to get what he
wanted.? Dr. said the two fainting spells were ?not legitimate?, referring to the

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 58
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?

i 
rea:uve_
I ?Enrrecl 

November 24, 2017 incident when SAMIMI was observed by the officer and on video
sliding to the floor in his cell, and the incident on December 1, 2017? when he ?threw
himself? out of the wheelchair. Dr. said he repeatedly heard from nurses and
SAMIMI that he wanted methadone. He indicated he considered but dismissed the idea
of a methadone detoxification regimen because of the dose SAMIMI reported taking and
because he was unable to verify the detainee was getting it legitimately. He believed
SAMIMI was progressing through withdrawal well despite his demand for stronger
medications and he had no reason to believe nursing staff were not administering the
medications he ordered. Dr. remarked, ?Maybe in the last 48 hours a nurse
should have called him.? but SAMIMI was doing pretty well when he left the facility on
Friday.

I HSA said he was also the recipient of information from nurses which led him to
believe SAMIMI ?did a bit of acting.? He said that at one point, he observed that the
detainee seemed to look around to see who was watching, then acted disoriented. He
believed that what he observed and overheard when SAMIMI spoke with his attorney on
November 30, 2017 supported the prevailin ouinion that some of the detainee?s actions
were exaggerated and manipulative. HSA indicated SAMIMI was withdrawing
?pretty effectively". then deteriorated.

I Dr. and HSA both emphasized that clinical services provided at
DCDF are ambulatory and that the medical housing unit is not an infirmary. Dr.
also stressed that they are not set up to handle patients with health care needs requiring
housing in medical for inde?nite periods of time. For that reason, and because he
believed SAMIMI was progressing well, he considered discharging him from the medical
housing unit. He did not do so because he was concerned about the tremors nurses
observed.

I Dr. and HSA expressed overall con?dence in the nursing staff,
although they noted work volume sometimes stretches resources. They said turnover is
higher than desirable and that the process for completing background investigations is
slow. Due to the long term vacancy in the Director of Nurses position, all nurses answer
directly to HSA on administrative matters and to Dr. on clinical

matters.

I Nurses were asked how they know when administration of as?needed medications is or is
not appropriate given the lack of documentation on MARs. RNs {bli?liibl (bli?lilbl and
mammogram stated communications on matters related to patient care are made at shift
change.

 

(momma 
I Of?cers  and 3'33} did not share the opinion

voiced to them by nurses that SAMIMI was faking his Of?cers

 

 

 

 

 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 59
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?

.
reanve_
I 

 

 


C)

 

 

   
 

 


land were assigned to medical more than once during

detention, and all stated his condition clearly deteriorated over time. As time
progressed, they observed he was often in pain and was not tolerating food. They
brought him ice and Officer brought him oranges from the kitchen, peeling
them for him in the hopes he would be more likely to eat them. Concerning meal trays,
they said SAMIMI ate what he could, when he could. They did not share the opinion of
some nurses that refusal of trays or flushing food items down the toilet was an act of
defiance; rather, they believe the smell of food increased his nausea. All officers were
troubled by what they perceived was a lack of concern and care for SAMIMI.

 

 

 

 

 

- Interviews with of?cers and Lieutenant-pointed to tension between security
and health care staff. The officers reported that when they bring detainee medical issues
to nurses? attention, they are typically told to tell the detainee to submit a ?kite?, referring
to a written request. Lieutenant _stated he has been frustrated with
medicali?security relations ?for a long time.? He shared that he gets a call from an officer
almost every night stating a detainee needs to be seen but medical will not come to the
unit. Consistent with the officers? statements, the lieutenant said the response from
medical staff is to tell the detainee to send a kite.

During interview of Dr. he offered his own opinion on what he called animosity
between of?cers and nurses. He said officers think nurses are not responsive when in
fact, they are just over-worked and cannot respond to every complaint officers convey.

I Disagreement over who is responsible for cleaning up bodily ?uid spills feeds the tension
between security and health care staff. Although GEO policy states medical staff are
responsi e, directed to clean up body ?uids unless blood is involved.
he stated HSA does not agree with
the policy and has instructed nurses they are not to clean spills. He indicated that unless
or until facility leadership decides whether the policy is to be followed as written, this
particular source of tension between security and health care staff will remain.

CONCLUSIONS

Medical

(bH?l'tbimtc .g intake screening on November 17, 2017, LPN (bil?lilbi appropriately notified 

that detainee SAMIMI reported he was withdrawing from high dose methadone, and RN
I appropriately followed up by having him brought to the clinic. After speaking
with SAMIMI and confirming information reported to her by the LPN, RN
contacted Dr. for orders. In partial adherence to the CFO, he ordered housing in

 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 60
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanve_
I 

medical observation, laboratory testing, vital signs every eight hours, scheduling of physician
and appointments, and medications for anxiety, restlessness, sleeplessness, nausea,
and pain. All medications, including clonidine, were ordered for administration as needed. Dr.
opted not to order an EKG or HIV test and did not order scheduled dosing of clonidine
as called for in the CPG. He also did not order monitoring of withdrawal using a
standardized instrument such as the COWS.

Per Dr. orders, the lab tests were completed with results essentially normal. However,
vital signs were typically taken twice a day rather than every eight hours as ordered. Recorded
vital signs were generally in normal limits, including blood pressure, possibly attributable to
administration of clonidine at least once a day. Although ordered as needed, administration of
both clonidine and Ativan was scheduled on the MAR for three set times per day. Nurses? MAR
entries were inconsistent, with times of administration not recorded at all or documented at times
which did not align with nursing notes. In their notes, nurses did not consistently document
when medications were given based on assessment findings, or assessment findings justifying
the need for medications documented on the MAR. Administration of Ativan, a controlled
substance, was documented in nursing notes but not on the MAR on four occasions.

SAMIMI remained in medical housing over the course of the 16 day detention period. Although
ordered by Dr. and called for in the ICE Medical Care detention standard, SAMIMI was
not scheduled for an appointment with a provider. In fact, the detainee was never examined by
the physician. Dr. reported having routine, casual contact with SAMIMI and receiving
information on the detainee's condition and behaviors, but at no point following his initial
telephone order did he direct that SAMIMI be scheduled for examination.

SAMIMI was seen by mental health arofessionals on three occasions. The first was for initial
evaluation by M1 on November 20, 2017. Witnessing the detainee's
collapse in the corridor on route to his follow up appointment on November 28, 2017', Dr.
consulted Dr. and based on her observations, they collaboratively determined
SAMIMI was too unstable to proceed. The next two mental health encounters were via tele-
The ?rst occurred November 29, 2017, 14 hours after the detainee was placed on
Level 1 suicide watch. The ordered lowering of the suicide watch level, medication
changes, and monitoring of withdrawal using COWS. No COWs was ever completed.
The medication changes included discontinuation of as-needed Ativan in favor of as-needed
Hydoxyzine; discontinuation of clonidine as needed in favor of three times daily; and 
medication Trazodone and immodium, both as needed. Consent for Trazodone, administered
only once the same day ordered, was not obtained. Documentation indicating SAMIMI was
asked why he attempted suicide is not included in the encounter notes. For reasons not
supported in the medical record, the attempt was called a gesture in the Mortality Review. The
next and final mental health encounter, conducted via on November 30, 2017',
resulted in continuation of Level 2 suicide watch and medications as ordered. The note for the
encounter documented SAMIMI stated he was ?stressed and depressed? and that he wanted ?to

 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 61
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


i: reanve_
I 

die here and not be here because of my methadone.? On December 1, 2017, Level 1 suicide
watch was reinstated by Dr. (bll?lilblm based on information the detainee threw himself from his
wheelchair while being taken to a follow up mental health appointment.

Although nursing notes were very limited in content and inadequately documented subjective
information, they reflect a progressive deterioration in health starting November 22,
2017. Tremors, pain and weakness, nausea and vomiting, refusal to eat, inability to sit up in
bed, and signs of dehydration were documented, as was the November 24 fainting incident and
November 28 incident where SAMIMI collapsed en route to the mental health appointment and
later attempted suicide. Thereafter, the only nursing note for November 29, 201?? includes an
abnormally elevated heart rate; a nursing note for November 30, 2017' documents unexplained
bleeding, apparently from the detainee's nose. The note and security documentation indicate he
screamed for the nurse throughout the early morning hours. At approximately 5:30 pm. this
date, SAMIMI had a legal call which, according to the RN and HSA, appeared to please him.
HSA referenced what he observed and overheard to support his impression that SAMIMI ?did a
bit of acting? while in medical observation. Consistent with this comment, nursing staff
suggested during interviews that they believed SAMIMI was malingering and drug seeking, and
Dr. stated he engaged in behavior ?to get what he wanted.?

During the early morning hours of December 1, 2017, approximately nine hours after the legal
call, video shows SAMIMI in an extremely weakened condition, dropping his cup in the toilet
after unsuccessfully trying to reach up to the sink for water. He appears unable to sit up and falls
over more than once. The nurse who responded, RN documented that SAMIMI
was offered water and when asked, said he had a nightmare. His vital signs were normal. The
note does not address the level of apparent weakness as shown on the video.
Approximately six hours later, RN declined to honor the detainee?s request for
assistance moving to a wheelchair for transport to a mental health appointment. According to
the RN, SAMIMI threw himself from the wheelchair while en route, sustaining a nosebleed and
urinating on himself. The appointment was cancelled, and no further nursing encounters were
documented this date.

Security documentation re?ects condition deteriorated starting at approximately
10:30 pm. on December 1, 2017? when he appeared to spit up blood. RN
responded 75 minutes later. Overnight, the detainee complained of stomach pains and was
observed frequently vomiting in the toilet, and nurses were called for multiple times. He was
also found to have urinated on himself. The nursing note addressing overnight events
documents SAMIMI screamed for nurses, complaining of abdominal pain and inability to

breathe. He was given but removed a re-breather mask, and an injection of Zofran was given for
nausea per verbal order of Dr. {blt?liblt?t

 

(blf?llbl?lt
At 10: 15 am. on December 2, 2017, Officer 1' documented SAMIMI was eating. Twenty

minutes later, at 10:35 am, the detainee was vomiting and screaming of stomach pain. RN

0

 

 

 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 62
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


reanve_
I 

 

 


0)

 

 

was noti?ed and over the course of the next ?fteen minutes, was noti?ed two additional
times as SAMIMI continued to yell and scream. The instruction from RN was that
SAMIMI be taken to the mental health of?ce for an 11:00 am. appointment. When the officer

sed without the presence of medical staff, RN responded and gave the detainee

medication. - si ns were not taken. When it became evident he could not ambulate on his
own, the RN and Of?cers and moved him into a wheelchair. The video

shows SAMIMI immediately stiffens, appears to shake, and is caught before sliding from the
wheelchair onto the ?oor. He is lifted back to his mattress in the cell and shortly thereafter,
vomits. RN stated he decided to contact the physician to suggest alternative placement
rather than calling 911 himself because the situation was not a ?true emergency.? Unable to
reach Dr. on his cell or home phones, the RN called the HSA and received authorization
to send SAMIMI to the hospital. In the meantime, Officer _contacted Lieutenant

who, upon arriving on scene, determined 911 should be called. EMS arrived within

four minutes. SAMIMI stopped breathing very quickly thereafter and the paramedics started and
continued CPR through his placement in the ambulance and transfer to hospital emergency room
personnel.

Compliance Findings

Creative Corrections cites the following de?ciencies in the ICE 2011, revised 2016:

Medical Care, Section which states, ?All facilities shall provide medical staff and
sufficient support personnel to meet these standards.?

0 Positions for key personnel, including the sole midlevel provider and Director of Nursing,
were vacant for longer than six months. According to Dr. and HSA
the midlevel provider was responsible for conducting initial health appraisals for
detainees with chronic conditions. Since the position became vacant, RNs have routinely
conducted these initial health appraisals. SAMIMI did not receive a health appraisal by
either the physician or an RN. In addition, absent a Director of Nursing or other nurse
supervisor between nursing staff and Dr. clinical supervision was inadequate to
assure adherence to provider orders and necessary and appropriate care.

Medical Care, Section which states, ?Each detention facility shall have and comply
with written policy and procedures for the management of pharmaceuticals, to include:

12) documentation of accountability for administering or distributing medication in a timely
manner, and according to licenses provider orders.?

I Prescription orders for treatment withdrawal were written for up to three times daily, as
needed, for anxiety, restlessness, sleeplessness, nausea, and pain. In spite of frequent and

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 63
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
rcanve_
I 

progressive complaints of these the MAR and nursing notes show SAMIMI
was given fewer than half of the allowed doses.

I Neither nursing notes nor the MAR consistently document times medications were
administered, making it dif?cult, if not impossible, for nurses on subsequent shifts to
know when SAMIMI was due for his next dose.

Medical Care, Section which states, ?Where there is a clinically signi?cant finding as a
result of the initial screening, an immediate referral shall be initiated and the detainee shall
receive a health assessment no later than two working days from the initial screening.?

I The identification of early opioid withdrawal did not result in referral for
initial provider assessment within two working days following intake screening.

Medical Care, Section which states, ?Detainees experiencing severe or life-threatening
intoxication or withdrawal shall be transferred immediately to an emergency department for
evaluation. Once evaluated, the detainee will be referred to an facility qualified to
provide treatment and monitoring for withdrawal, or treated on?site if the facility is staffed with
qualified personnel and equipment to provide appropriate care."

I SAMIMI exhibited progressive of withdrawal over the detention period,
becoming pronounced and life threatening during the last 48 hours. He was not
transferred to the emergency room until within an hour of his death.

Medical Care, Section which states, ?Each facility's health care provider shall conduct
a comprehensive health assessment, including a physical examination and mental health
screening, on each detainee within 14 days of the detainee?s arrival unless more immediate
attention is required due to an acute or identifiable chronic condition.?

I An initial physical assessment was never completed during the 15 day detention period.

Medical Care, Section which states, ?Where a detainee has a serious medical or mental
health condition or otherwise requires special or close medical care, medical staff shall complete
a Alert form (IHSC-834) or equivalent, and ?le the form in the detainee?s
medical record.?

I There was no alert in the medical record.
Medical Care, Section which states, ?An initial dental screening shall be performed

within 14 days of the detainee's arrival. The initial dental screening may be performed by a
dentist or a properly trained qualified health provider.?

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 64
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


reanve_
I liarreclunls

I There is no documentation SAMIMI was scheduled for or received a dental screening
examination.

Medical Care, Section which states, ?An on-call physician, dentist, and mental health
professional or designee, are available 24 hours per day.?

I RNs reported difficulty reaching the physician after hours. On the day of 
death, the physician did not answer or return two phone calls.

Medical Care, Section which states, ?Distribution of medication (including over the
counter) shall be performed in accordance with specific instructions and procedures established
by the HSA, in consultation with the CMA. Written records of all prescribed medication given
to or refused by detainees shall be maintained."

I Phenergan given on November 25, 2017 was not documented on the MAR.

I Administration of Ativan, a controlled medication, was documented in nursing notes on
November 17', 20, 21 and 27' but was not documented on the MAR.

I A refused dose of clonidine on December 1, 2017 was not addressed in the nursing notes,
not was a refusal form completed.

I The MAR did not document administration of clonidine on December 2, 2017, at 9:00
am.

Medical Care, Section which states, ?The facility administration and clinical medical
authority shall ensure that the Field Office Director is notified as soon as practicable of any
detainee housed at the facility who is determined to have a serious physical or mental illness or
to be pregnant, or have medical complications related to advanced age, but no later than 72 hours
after such determination. The written notification shall become part of the detainee?s health
record file.?

I The Field Office Director was not notified SAMIMI was withdrawing from methadone
and that his condition was deteriorating.

Medical Care, Section which states, ?Prior to the administration of 
medication, a separate documented informed consent, that includes a description of the
medication?s side effects.?

I An informed consent specific to the anti-depressantfsedative Trazodone was not
completed and signed by the detainee.

Significant Self Harm and Suicide Prevention and Intervention, Section (VHF), which
states, ?All suicidal detainees placed in an isolated confinement setting will receive continuous

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 65
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


i: reanve_
I 

one-to-one monitoring, welfare checks at least every 8 hours conducted by clinical staff, and
daily mental health treatment by a quali?ed clinician.?

No welfare checks by clinical staff were completed during the 14 hours between
placement on suicide watch and evaluation via Thereafter, the next
nursing round was 15 hours later.

In addition, the following violations of GEO policy are cited:

905-A, Medical Observation, which states, 1) Nursing personnel will complete the Medical
Observation Nursing Progress Record, form 1426, upon entry to the observation area; 2)
Subsequent assessments will be documented on each shift; 3) A patient status note and vital
signs will be performed and documented every two hours unless directed otherwise by the
physicianfdesignee and will be entered into a progress note; 4) Detainees admitted for 24 hour
observation may, but are not required to, receive skilled nursing intervention; 5) The responsible
clinicianr?designee will write a daily note for each detainee on medical observation for more than
24 hours.?

I Nursing assessments were not performed on each shift;
I Vitals signs were not taken every eight hours as ordered by the physician;
0 Daily notes were not written by the clinician or designee.

?Time Limits: Detainees will not be housed in the medical observation area for more than 24
hours without a physician?sfdesignee's order, Medical observation may be continued for three
(3) consecutive 24-hour periods (up to 7'2 hours). Each renewal of medical observation after 24
hours must be approved through noti?cation of the responsible physicianfdesignee. Medical
observation may not be continued beyond 72 hours. After 72 hours the detainee must be
admitted as an in?rmary patient in an institution with an in?rmary, discharged to the general
population, or transferred to a higher level of care.?

I Dr. (bll?liiblm did not renew his orders for placement in medical housing.

902, Alcohol and Drug Assessment and Treatment, which states, ?Detainees at risk for
progression to more severe levels of intoxication or withdrawal will be kept under constant
observation in the infirmaryfmedical observation area by health care staff, and whenever
detainee are observed, a physician will be consulted Detainees experiencing
severe, life-threatening intoxication or withdrawal will be immediately transferred to an acute
care facility.?

I On at least two occasions, November 30 and December 1, 2017, the night nurse failed
to call the physician despite her observation of serious clinical 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 66
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


reaalve_
I 

Areas of Note

DCDF holds current accreditation; however, the medical department failed to
comply with standard which states: ?Detoxification and withdrawal are
best managed by a physician or other medical professional with appropriate training and
experience. As a precaution, severe withdrawal must never be managed
outside of a hospital. Deaths from acute intoxication or severe withdrawal have occurred
in correctional institutions. In deciding the level of that can be managed safety
at the facility, the responsible physician must take into account the level of medical
supervision that is available at all times. Clinical management should also include the use
of validated withdrawal assessment instruments, such as the Clinical Opiate Withdrawal
Scale or the Objective Opiate Withdrawal Scale in case of opiate withdrawal, and the
Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised, in the case of
alcohol withdrawal.?

Nurses reported they were unfamiliar with the COWS and that they were never trained in
opioid withdrawal. Through their actions, nurses demonstrated a lack of understanding of
opioid withdrawal including that drug seeking is to be expected. They also
demonstrated inability to properly monitor a patient withdrawing from opioids and to
recognize related life-threatening Given the nation?s current opioid epidemic,
staff preparedness is fundamental to assuring patients are provided with appropriate care.

Related to the above, nurses did not fulfill the November 29, 2017 order to
complete a COWS on a daily basis.

Dr. based his orders on the CPG governing opioid withdrawal, but opted not to
follow it in total. In so doing, he exercised provider judgment. He did not order an EKG
and HIV test, ordered clonidine as needed instead of three to four times daily, and did not
order nurses to ensure blood pressure was not below a set threshold before
giving clonidine.

As noted in above compliance ?ndings, Dr. never conducted an examination of
detainee SAMIMI. Although a nurse erred by not adding the detainee to the physician?s
schedule originally, at no point during the detention period did Dr. follow up
and direct scheduling of an appointment. His reported casual contacts with SAMIMI and
his acknowledged familiarity with events as they occurred support that it was reasonable
for him to do so.

The following concerns related to administration of medications are noted:

Despite frequent and progressive complaints of restlessness, sleeplessness, nausea
and pain, SAMIMI was given less than half the possible doses of as-needed

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 6?
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


i: reanva_
I 

medications ordered by Dr. to treat these The MAR shows
only ?ve of 42 doses were given for anxiety, 2] of 42 doses were given for
17 of 42 doses were given for pain, and only four of 42
doses were given for nausea and vomiting.

0 Nursing notes did not consistently document justi?cation for administration of as
needed medications, or assessment of need.

Administration of medications documented in nursing notes was not recorded on
MARS on five occasions.

Nurses sometimes refused medications until the detainee ate, rather than provide
anti-nausea medication to enhance his appetite.

0 Nurses often failed to document the time of medication administration. Absent
documentation of times medications were given, nurses on later shifts could not
know when another dose was or was not due. The poor documentation on MARs
may have contributed to SAMIMI receiving well under 50 percent of possible
doses of medications as needed for anxiety, restlessness, sleeplessness, nausea
and pain.

0 The MAR documents administration of two medications after SAMIMI was
transported to the hospital.

0 The manifestation of severe withdrawal did not result in prompt transfer to the

hospital. The direction to call 911 on December 2, 2017 was given by a lieutenant while
the nurse attempted to reach the physician and HSA.

- The intake screening did not address current of withdrawal as called for on the
screening form.

0 Vital signs were not obtained every eight hours as ordered by the physician.

- Weights were not obtained to determine rate of weight loss, particularly important given
refusal of meals and inability to keep food down.

0 There were no medical record entries on November 19, 2017.
0 Patient safety through fall prevention was not maintained. Video showed incidents in

which SAMIMI appeared to hit his head or come close to doing so on the ?oor or against
the wall.

0 The following concerns related to medical record chaning were identified:

0 Nursing notes were brief and inadequate, particularly with respect to subjective
information.
Progress notes were not written in SOAPE format.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 68
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

'i


'rE_


m-I

 Encounter times were not always noted.

Nursing assessments did not consistently document pain levels.

0 Nurses did not consistently document the justification for giving as-needed
medications.

Verbah?telephone orders were incorrectly documented.

Complete assessments for dehydration were not documented.

I On Friday, November 24, 2017?, a full injury assessment was not completed after
SAMIMI fainted.

- Nurses did not encourage SAMIMI to shower. He was described as disheveled and
having a strong body odor.

Physician?s verbal orders for medications issued November 17, 2017 were not
authenticated.

- Entries in the Constant Watch Logbook document that security staff notified nurses on
multiple occasions that detainee SAMIMI required medical attention. Based on medical
record entries, response was delayed.

 

{blimiblff'HC

 

 

 

0 Leading up to the medical emergency, Officer} exercised sound judgment by
refusing to move SAMIMI to the mental health office without medical personnel pres
Likewise, Officer bll?lilblm?icl took appropriate action by notifying Lieutenan 

events surrounding the attempt to place SAMIMI in the wheelchair, and Lieutenant

?Iecision to call 911 was unquestionably proper. The degree to which doubts
about the legitimacy of actions during withdrawal had a bearing on nurses?
failure to call 911 cannot be determined.

Safety and Security

Security staff did not make all required log entries documenting whether SAMIMI accepted or
refused meals and shower and recreation privileges. Most critically given his condition, officers
did not make entries documenting whether he accepted the lunch and dinner meals on November
29, 2017. Log entries over the detention period re?ect that SAMIMI declined all offered
opportunities to shower and went to the TV room only once, and refused 17' meals. Between
November 24 and the last tray offered on December 2, 2017, the detainee accepted only six
meals. Although SAMIMI did not miss nine consecutive meals which would have triggered a
review under the facility?s hunger strike protocols, on November 17', 2017, an of?cer
documented that the detainee declared he was on a hunger strike. According to GEO policy, this
declaration should have triggered daily monitoring in accordance with GEO policy. There is no
documentation any action was taken. Despite log entries and events pointing to 

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 69
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?


i: reanare_
I 

 

 

(bil?libilf?


 

 

deteriorating condition over the detention period, this case was not elevated by security
supervisors or medical staff for multidisciplinary review until November 29, 2017. On that
date, SAMIMI was discussed at a routine weekly meeting per mandate to review detainees on
suicide watch. The SDDO recalled it was reported the detainee was a long-time drug user, but
nothing further concerning his withdrawal status and duration in medical housing was discussed.

Important events were not documented in the log, including events surrounding 
reportedly ?drinking from the toilet? and lowering of suicide watch status from Level 2 to Level
1. Also, his uniform was not confiscated as required by post orders. On multiple occasions,
officers opened cell door without another of?cer present and without documenting
notification of the shift supervisor. Medical Utility Officer Post Orders require that two officers
be present and notification of the shift supervisor prior to opening the cell door. Given the
detainee?s condition as shown in video footage, reviewers recognize officers were acting in what
they believed was in the best interest of the detainee and that no security risk was evident.

Security staff demonstrated compassion and concern for detainee SAMIMI. They reported
medical staff were notified of the detainee?s requests and complaints; obtained food items from
the kitchen; encouraged him to eat, drink and shower; provided clean linens and clothing; and
cleaned his cell and his person, including vomit, urine and feces. Although current policy states
a health services staff member will clean any spill of blood or other body fluids, current practice
is for spills to be handled by security staff unless blood is present. Security personnel hold the
policy should be maintained and followed; the HSA holds health care staff should not be
required to clean body ?uid spills.

In the course of the medical emergency, the officer appropriately requested that the lieutenant
report to medical due to her concerns about the unfolding events. The lieutenant arrived quickly
and directed that 911 be called. Without the intervention of security staff, the medical
emergency would have escalated prior to arrival of EMS.

Officers made appropriate entries to the hospital log and remained with SAMIMI following his
death until authorized to return to DCDF. The officers at the hospital at the time of death and all
staff who responded to the medical emergency completed incident reports. However, the officer
on duty during the shift preceding the medical emergency did not submit a report documenting
events on his shift until an unknown date following the death. Officers involved in the medical
emergency were offered supportive counseling; nurses involved in 5 care were not. All
necessary video footage was retained, though none was viewed by personnel participating in two
separate after action reviews. As a result, conclusions were reached during those reviews based
on incomplete or inaccurate information.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 70
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?

i 
rea:uve_
I ?Enrrecl 

Compliance Findings

Creative Corrections identified no deficiencies in the applicable ICE 2011, 2016
revisions.

The following violations of facility policies and post orders were identified.

Medical Utility Officer Post Order, section which states, ?All necessary
documentation shall be completed prior to the end of your work period and forwarded to your
immediate supervisor.

 


0 Of?cerl'CC} did not complete an incident report documenting signi?cant events prior

to the end of his shift.

 

 

 

Medical Utility Officer Post Order, section Level 1 One-on-One Observation
which states, ?The detainee will be given appropriate suicide preventative clothing. All non-
suicide preventative articles of clothing will be removed from the detainee. This will include
the detainee? undergarments."

0 When placed again on Level 1 observationfsuicide watch on December 1, 2017?, the
detainee was allowed to retain his detention uniform.

Medical Utility Officer Post Order, section Level 1 One-on-One Observation
which states, ?The Cell door will not be Opened under any circumstances without two of?cers
being present and the on duty Shift Supervisor being noti?ed of the need to open the cell.?

0 On several occasions, officers opened the cell door when detainee SAMIMI was on Level
1 suicide watch without another officer present or without any documentation a shift
supervisor was notified and gave approval.

DCDF Policy 11.2.31, Permanent Logs and Reports, sections (A) and (H), which state
respectively, ?Logs will be maintained to re?ect the activities of each post or other area on a
shift-by-shift basis and to document emergency situations, unusual incidents, and other pertinent
information regarding detainees and activities on the post?; and ?Make written and oral reports
as necessary?.

 


0 Officer 0) did not log in the Constant Watch Logbook when SAMIMI was moved

from Level 2 to Level 1 suicide watch.

 

 

 

0 During his shift from 11:00 pm. on December 1 to 7:00 am. on December 2, 2017,
Of?cer-id not document in the Constant Watch Logbook all pertinent
information that occurred on the shift.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 71
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

.
reanve_
I 

These lapses also violate the Medical Officer Utility Post Orders which require the officer to
document ?any unusual occurrences?.

DCDF Policy 17.1.2 Sanitation Procedures, section (I), Blood or other body fluid, which
states, ?Following any incident where there is spillage of blood or other body ?uids the area shall
be sanitized immediately by a member of the health service staff. ?Medical staff will utilize
?Clean-Up Kits? to clean up any blood and body ?uids as well as decontaminate the area?.?
Security staff are responsible to ensure the area is secure and that all persons entering the area

are donning appropriate personal protective equipment.

0 Security personnel are being required to clean up bodily ?uids such as urine, feces and
vomit. Medical personnel are only cleaning spills that contain blood. The Security Chief
believes medical staff should clean any Spills in accordance with the policy. The HSA
believes that medical staff should only clean spills containing blood. The lack of
adherence to the policy and the disagreement between the Security Chief and HSA has
contributed to the tension between the two disciplines. The policy needs to be followed
or amended.

GEO Policy 614, Hunger Strikes, which states, ?Detainees declaring andz?or identified as being
on a Hunger Strike (missed 9 consecutive meals) will be monitored daily.?

I At 6:59 pm. on November 27, 2017, the assigned medical officer documented in the
logbook that SAMIMI informed the officer he was ?on a hunger strike." There is no
further documentation in the logbook. This notification by the detainee should have
triggered daily monitoring. A supervisor next reviewed the logbook at 3:20 am. and
supervisors are required to ?review and sign the log" in accordance with the Permanent
Logs and Reports policy noted above. No action taken as a result of this statement is
documented.

Areas of No he

I On six occasions, officers did not make entries to the Medical Housing Unit Log
documenting acceptance or refusal of showers, recreation, and meals. Missed meal
entries include lunch and dinner on November 29, 2017. If refused, SAMIMI did not
accept seven consecutive meals.

0 Most signatures of security supervisors and medical staff on the Medical Unit Housing
Log forms were illegible. Ensuring staff documenting rounds are easily identifiable

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 72
Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 201?

i 
rea:uve_
I 

ensures accountability and that the proper staff can be contacted when additional
information is needed at a later date.

0 While security staff routinely documented that the detainee was not eating meals, it is
unclear how this information was communicated, if at all. to medical staff.

a The medical officer had a non-functioning radio when she made a round on November
28, 2017 and discovered SAMIMI with a sheet around his neck. Equipment should be
regularly checked to ensure its operability in the event of an emergency.

0 The GEO track system erroneously documented the date and time of the detainee?s
placement on suicide watch.

I The GEO Suicide Watch Log and Notes form lists Level 1 as ?Constant
Observation? while the DCDF post orders for the Medical Utility Of?cer refer to Level 1
as ?Continual Observation". The GEO Suicide Watch Log and Notes form lists
Level 2 as ?Fifteen Minute Checks" while the DCDF post orders for the Medical Utility
Officer refer to Level 2 as ?Constant Observation? requiring 15 minute checks. The
forms and post orders should consistently de?ne the two levels to avoid staff confusion.

 

DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 73
Medical and Security Compliance Analysis
March 6, 2018, revised March 14. 201?

"i 


APPENDIX 1
SAMIMI VITAL SIGNS

Dr. ordered that vital signs be taken every eight hours. The below table lists vital signs
documented in nursing notes and blood pressure documented on the Blood Pressure Record on
November 25, 30 and December 1, 2017. Shaded areas indicate missing vital signs.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE TEMPERATURE PULSE RESPIRATIONS BLOOD PRESSURE OXYGEN

1171772017 97.9 75 21 146794

1171772017 98.2 94 16 130794 100
1171772017

1171872017 97.1 75 16 104767 95
1171872017 98.0 65 17 110774

1171872017

1171972017

1171972017

1171972017

1172072017 106776

1172072017 94 16 130794 100
1172072017

1172172017 97.6 87 16 118776 95
1172172017

1172172017

1172272017 98.2 82 17 108774 99
1172272017

1172272017

1172372017 98.1 82 16 107774 97
1172372017 97.8 76 16 134793 98
1172372017

1172472017 98.2 102 18 128783 93
1172472017 98.8 77 18 129785 96
1172472017

1172572017 97.8 76 16 134793 98
1172572017 91 16 127793 96
1172572017 117788

1172672017 98 111 16 107781 99
1172672017 97.6 71 16 125785 96
1172672017 92 16 126778 96

DETAINEE DEATH Kamyar SAMIMI Page 74

Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 2017

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11/27/2017 98 12 124/80 95

11/27/2017

11/27/2017

11/28/2017 98.1 107 18 124/91 95

11/28/2017

11/28/2017

11/29/2017 97.7 120 16 108/82 100

11/29/2017

11/29/2107

11/30/2017 97.6 88 16 100/70 95

11/30/2017 97.8 100 15 101/70 99

11/30/2017 100/76

12/01/2017 84 16 101/64 96

12/01/2017 94 18

12/01/2017 112/68

12/02/2017 98.2 92 17 113/68 94

12/02/2017 100 17 92/68 95
DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 75

Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 2017



I lcurreclunls

APPENDIX 2
SAMIMI MEDICAL HOUSING LOG

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE MEALS SHOWER RECREATION MEDICAL SUPERVISOR
ROUND ROUNDS
11/18f2017 3 No No Yes Yes
11f19f2017 3 No No Yes Yes
11f20f2017 3 No entry No entry Yes Yes
11f21f2017 3 No No Yes Yes
11(22f2017 3 No No Yes Yes
11.1,23f2017 3 No No Yes Yes
11f24f2017 0 No No Yes Yes
11(25f2017 0 No No Yes Yes
11f26f2017 1 (breakfast) No Yes Yes Yes
11(2772017 0 No No No entry Yes
11(28f2017 2 (breakfast, lunch} No N0 No entry 15? and 2??1 shift
?lly/29,1001? 1 {breakfast}; no No entry No entry Yes Yes
entries for lunch
and dinner

11(30f2017 0 No No Yes 15t and 3id shift
12f1/2017' 1 (dinner) No No Yes No entries
DETAINEE DEATH REVIEW: Kamyar SAMIMI Page 76

Medical and Security Compliance Analysis
March 6, 2018, revised March 14, 2017

"h .


 

 
 
 
 

     
   

       

 
     

 

 

 

 

maroon-en
?2732913
INTAKE SCREENING . . -.
SAMIMI, KAMYAR UDIP. ll: Center
DOB: ?ll3l'1953 Nation: IRAN 
Arrival Date: 11l1Tl2017 16:00 What langua will speak? htterpreterName and-?01?:
i Emm? 0am

 

 

. 
Ef?gy unconscious or have obvious pain, bleeding, injut?fes. or Other suggesting need for emergency medtcal referral
No

El Yes it'yes.explain'.

 

 

morn was identi?ed by {source}: a to Card Picmrc/O/Vcrhally :3 Arm band Other (Explain):
was transferred from another facility, did a medical transfer sun-Jittery accompany the [3 Yes El WA

afoot]: transferred from another facility.did the trout arrive with medications? ,ra/?o I: Yes liyes. explain:

 

Medical Screening -
l'Tl-low do you feel today? (Explain in hislher own words): ?fl 5" r, 

2. Have you fainted or have you ever had a had injury with loss of consciousness? 21/ No CI Yes If yes. explainhave you been treated by a doctor within the lost 5 for a medical condition, including hospitalizations? ?/No El Yes If yes, explain:
El Diabetes 13 Seizure El Ulcer El HTN Cl Heart condition Ell Kidney Disease CI Liver Dis-use El Other

Whatsurgerieshaveyouhadyou have a history of or current communicable illness: YD. Syphillis. Hepatitis or C, El Yes If yes. explain.

 

 

 

6. Have you ever had a TB skin test? El Yes Results:

Have you ever had Yes If yes, your of infection: {diff where? ?y 

 

 

 

 

 

 

 

 

 

  
 
  
   

 
     

 

     

 

 

 

 

 

 

Haye you ever been in contact with anyone who had El Yes {if
Have you ever been treated for Yes If yes. when? where? ?i
Last chest X-ray: {date} Results of chest X-ray: hi
7. 1n the last year, have you had a persistent and productive cough for more than three weeW?t pain, coughed up blood, had a fever, [15,
night sweats, unexplained loss of appetite or weight loss, back pain, blood in your urine? Yes If yes1 explain:
8. Do you take any medications on regular basis, including over-the-countcr El No ,B/Yts 1" lit-?5. the medications-
Matthew lotto W19
Does the Horn identify as transgendcr'? ME 0 You? What gender dogs the riots relate to? We
History of trensgendcr related health care? No Yes
9. Do you have any allergies to medication. food or latex'w'?o El Yes If yes, explain:
10. Are you on a special diet prescribed by a doctor'z? No El Yes If yes, explain:
A 
ll. Females Only: Date oflast menstmal period: . El Yes lfyes, have you 5 No El Yes
Recent abortion or delivery El Yes Ifyes, dat i No El NM Method:
Last Pap test date: El Nonnul t] Abra. fe 1c 
12. Do you have any signi?cant medical problems we have not discussed? Cl Yes li? yes, explain:
13. Is there any signi?cant family medical history-W El Yes If yes, explain:
UsefA
14. Have you ever smoked cigarettesfcigars'? No cs 11? yes, how long have you smoked?
l-low man ci ?7 When last smoke?
15. Do use smokeless tobacco Yes If how did last use smokeless
l6. Do now or have ever used alcohol or No es If details below and ii 
Substance Use of Last Often
A o. r? 3

Methamphetamine
A Other:

17. Have you ever suffered withdrawal from No if explain:

8. Have you ever been treated or alcohol prob] No es if circle all


 

apply and pro further explanation 

15? Page H5453

 i

4-

t?

Mental Health Screen'gg
l9, Have you ever received counseling for mental health dif?cultiesyEt?lzo El Yes if yes, explain:

 

 

20. Have you ever been hospitalized for mental health dif?culties? l3 Yes If yes. explain:

 

2i, Have you ever received medication for mental health di?ieulties?lla/No Yes if yes, explain:

 

22. Do you have any learning disabilities? No Yes If yesT explain:

23. Were you in any special education classcs?lu?' No Yes If yes, explain:

24. Do you now or have you ever has oices that other people don?t hear; seen things or people that others don't see: or fell others tvere trying to harm you [or
no logical or apparent reasonLEyl?Zx Yes If yes. explain:

 

 

if

25. Have you ever tried to kill Warsaw Yes How many times? if yes, when did the Suicide attempts occur? I: ?a

Method: El Gun El Hanging Cutting Skin El Pills El OtheglExplain}:
26. Arc you currently thinking about killing or banning yourself? ?ta/No Cl Yes if yes, make referral immediately and ensme safety.

 

 

 

21. Have you ever been a victim of physical or sexual abuse?? Ef?e-? El Yes if yes, explain:

 

28. Do you have a history ofserrual aggression or sexual assault? ME El Yes If yes, explain:

 

29. Do you feel that you are currently in danger of being physically or sexually assaultedlw El Yes If yes, explain:

 

 

39. Do you have a history of assaulting or attacking others, or have you ever been locked up for ?ghting while in jail or prison? Yes

 

 

 

 

 

 

 

 

 

 

 

 

 

3t. Do you lorow of someone in this facility whom you wish to attack? Me Yes if yes. who is this person? Uf?

If yes. inform security immediately. . 
32. Do you know of someone in this facility who wishes to harm [1 Yes if yes. who is this person? ?a

if yes. infonn security immediately. I 

21/ Pain Assessment
33. Are you currently having any rain? No Yes if yes, complete pain assessment below:
Character of Pain: Location: Duration: Intensity: {ti-to pain scale) What relieves your pain or make it won c?
5 W47 back CW 571 0 Milk
Oral Screening . 

 

34. Do you have any dental problems? El No ?21, Yes If yes, explain: 
Visualizethe mouth,teethaodgum] mom any dental problems noted? a rte/?es lfyes,cxplain: Log-yr 

Summary Question

 

 

 

 

35. Do you have any medical, dental, or mental health issues we have not discussed? No Yes it" yes, explain:
Instructions in oral hygiene and preventive oral education given? I: No Yes
0: Screener'is Observation
MR is oriented to person. place. and time El lv'DfR is not oriented 10?. Person Place Time 

 

UDIR appears to have nonml physical appearance, emotional characteristics, and no barriers to corrurruoication El No Mos
EDIE appears to present with a low level of intellectual functioning based on history andlor- current presentatiorr/Eriio El Yes

 

 

Does 1!ka behavior or physical appearance suggest the risk of sui cide or assault on staff or other inmates??rl?lo El Yes

 

 

 

 

   
   

  
 

 

Check the appropriate boxes for your observations [Explain any checked boxes under None of the following observed
Intoxication or withdrawal from drugsfalcoltol El Bizarre or abnormal behavior El Inability to foeusr'concentratc or agitation
Cl Excessive sweating {fever} El Malnourished appearance Shaking?remors
Cl Skin: 13 Skin: Cuts, bruises, signs of trauma El Skin: Tattoos, needlemarks, tracks. jaundice
Developmental disabilities El Mobility restricted in any way Cl Body deformity
Aids (hearing aids. glass-I. cleanups] El Physical aids (cane, crutch, brace) El Other
CommentsVital Signs: 'r "fr?PL 25: Remixwr. i235
If applicabl . . . - . i If patientis diabetic, record glucose linger-stick:

A: Initial Health Screening Completed: 342; No
P: DispositiorE??G-?I-tcral Population Refennl for immediate medical,mental health, or dental care El Isolation untilmcdically evaluated
Education: Mscnening explained to 1!le

?ows to medicaUdentaUmental healthcare. grievance process explained to 
given medical orientation and health information handouts in UDIR language SAMIMI. KAMYAR
was given written orientation materials ENCHOT translations in HDIRs own language DOE: ?311953 Nation;
at literacy problem exists, screener assisted the in understanding education handouts. Arrival Date: 11f17i?291? 15:0!0

IR verbaliaed understanding ofany teaching or instruction and was asked if he or she had

Care?nterven?onJFollow?Up: The lowing was given during this Take screening:

'Wasi cm giro liar?, roller; 

 

(bli?llbliflicl libli?iiblii?iic) 1 

Datefl'lme

    

Hi;

 

 

 

Page 2 of 2 H's-168

 

.. Referrals made: 13 [Physician NPIPA El Dmtist Cl Mental Health Dental/Dannie care Sick call 332 ii 30

OFFICE OF THE CORONER

Adams 8: Broomfield Counties
Monica Broncucia?Iordan

 

 


Name: SAMIMI, Kamyar Case Number: 
Date of birth: January 3, 1953 Age: 64 years

Date and time pronounced deceased: December 2, 2017; 1202 Hours
Death Investigator:?mmHmUMH 

Prosector:?W?HWUW? 

Autopsy Technician:?mm?m?m? 

 

 

 

OPINION

The cause and manner of death opinion is based on the scene
investigation, examination findings, and history available at
this time.

Cause of Death: Undetermined

Contributing Factors: Chronic Obstructive Pulmonary Disease
and Gastrointestinal
Bleeding

Manner of Death: Undetermined

(j 4/75) A 

Mdnica Brow ordan, Chief/ oroner
f/

- 

330 N. 19TH AVE. BRIGHTON, CO 80601 303.659.1027 303.659.4?18

AUTOPSY RE PORT

 

NAME: KAMYAR SAMIMI 
DATE AND TIME PRONOUNCED DEAD: December 2, 2017 1202 Hours

DATE AND TIME OF AUTOPSY: December 6, 201? 1000 Hours

Ch
ub-

AGE: RAGE: White GENDER: Male

CIRCUMSTANCES OF DEATH

This 64?year?old male was transported emergently to University
of Colorado Hospital on December 2, 2017. He was reportedly in
the custody of ICE officers at the immigration detention center
in Aurora at the time of his medical incident. He had been in
the facility for two weeks prior to the incident and was under a
direct supervision suicide watch when he was observed to be
?spitting up blood". Apparently he had been suffering from
gastrointestinal bleeding in the past. His social history
included opium addiction at the age of six and addiction to
methadone since 1990. He had been ?clean? for two weeks in the
ICE facility and was being watched for withdrawal, dehydration,
nausea and vomiting.

IDENTIFICATION

The decedent was identified by ICE officers. This was confirmed
by fingerprints.

CIRCUMSTANCES 0F POSTMORTEM EXAMINATION

The autopsy was authorized by the Coroner of Adams County,
Colorado. Prosecting was Dr. Stephen J. Gina and assisting were
autopsy technicians Simpson, Morales and Hermosillo. The
autopsy was performed at the Adams County Coroner's Office.

CLOTHING AND PERSONAL EFFECTS

The decedent was clad in white socks and cutaway white boxer
shorts.

 A17-03073 KAMYAR SAMIMI
EXTERNAL EXAMINATION

The body was that of a thin, White male. An appropriate
identification tag was on the left great toe and hospital
identification tags were on the left ankle and left great toe.
The body weighed 141 pounds, was 68 l/2?inches in height and
appeared compatible with the reported age of 64 years.

The body was cool. Full rigor mortis was present to an equal
degree in all extremities. Mild, fixed, purple lividity was
distributed over the posterior surfaces of the body, except in
areas exposed to pressure.

The scalp hair was receding, lack with gray and 2 l/Z-inches in
length. Facial hair consisted of a black with gray beard and
mustache. The irides were brown, the corneae were clear, the
sclerae were white, and the conjunctivae were pink/tan and free
of peLechiae. Bloody black fluid flowed from the mouth and
nose. The earlobes were not pierced. There were moderate
transverse creases of the lower pinnae. The nasal skeleton was
palpably intact. The lips were without evidence of injury. The
lower teeth were in poor condition and the upper jaw was
edentulous.

Examination of the neck revealed no evidence of injury.
Perimortem injuries to the chest will be described below. The
abdomen was flat and there was a possible 1?inch scar at the
right anterior costal margin.

The extremities showed no gross bony deformities or pitting
edema. There was a 3/4?inch scar on the right second finger and
a 3/l6?inch scabbed abrasion at the tip of the left second
finger. The fingernails were intact. Tattoos were not noted.
Needle tracks were not observed.

The external genitalia were those of a circumcised adult male.
The posterior torso was essentially without note. The anus was

atraumatic.

EVIDENCE OF THERAPY

 

Evidence of medical intervention consisted of bilateral tibial
intraosseous lines; an endotracheal tube; two defibrillator pads
on the chest; intravenous catheters in the right antecubital

 A1 103073 KAMYAR 

fossa and dorsal left hand; and venipuncture sites covered by
dressings on the loft forearm and in the left antocubital fossa.

EVIDENCE OF INJURI

A l/4-inch abrasion was on the right side of the bridge of the
nose. A 5/8?inch abrasion was on the lateral right zygomatic
region.

There were vaguely rectangular yellow abrasions overlying the
sternum. Right ribs 3 7 and left ribs 2 6 were fractured
anterolaterally. There was minimal associated internal
bleeding.

INTERNAL EXAMINATION
Body Cavities:

The body was opened by the usual thoracoabdominal incision and
the chest plate was removed. No adhesions or abnormal
collections of fluid were present in any of the body cavities.
All body organs were present in the normal anatomical positions.
The subcutaneous fat layer of the abdominal wall was 1.2 cm
thick.

Head: (Central Nervous System}

The scalp was reflected. The calvarium of the skull was
removed. The dura mater and falx cerebri were intact. There
was no subdural or epidural hemorrhage. The leptomeninges were
thin and delicate. The cerebral hemispheres were symmetrical.
The structures at the base of the brain, including the cranial
nerves and blood vessels, were intact. Coronal sections through
the cerebral hemispheres revealed no focal lesions. Transverse
sections through the brainstem and cerebellum were unremarkable.
The brain weighed 1,450 grams. The spinal cord was not
examined.

Neck:
Examination of the soft tissues of the neck, including the strap

muscles and large vessels, revealed no abnormalities. The hyoid
bone and larynx were intact.

 2117-03073 KAMYAR SAMIMI

Cardiovascular System:

The pericardial surfaces were smooth, glistening, and
unremarkable; the pericardial sac was free of significant fluid
or adhesions. The coronary arteries arose normally, followed
the usual distribution, and were widely patent with no evidence
of significant atherosclerosis or thrombosis. The cardiac
valves were unremarkable. The chambers and valves exhibited the
usual size-position relationships.

The myocardium was red/brown and firm with no focal lesions; the
atrial and ventricular septa were intact. The aorta and its
major branches arose normally, followed the usual course, and
were widely patent. The vena caves and their major tributaries
were returned to the heart in the usual distribution and were
free of thrombi. The heart weighed 300 grams.

Respiratory System:

 

The upper airway was clear of debris and foreign material;

the mucosal surfaces were smooth, yellow/tan and unremarkable.
The pleural surfaces were smooth and glistening with no focal
lesions. The pulmonary was purple/tan with diffuse
changes and bullae at the apices. The 
exuded a mild amount of foamy fluid upon sectioning. There was
marked anthracosis. No mass lesions were noted. The pulmonary
arteries were normally developed, patent, and without thrombus
or embolus. The right lung weighed 480 grams; the left lung
weighed 450 grams.

Liver and Biliary System:

 

The hepatic capsule was smooth, glistening and intact covering
uniformly brown No mass lesions were noted. The
gallbladder contained 4 mL of viscous, green/brown bile; the
mucosa was velvety and unremarkable. The extrahepatic biliary
tree was patent, without evidence of calculi. The liver weighed
1,500 grams.

Alimentary System:

 

The tongue exhibited no evidence of recent injury. The
esophagus was lined by gray/white, smooth mucosa. The gastric
mucosa was autolyzed and the lumen contained 10 mL of
bloody fluid. The small and large bowels were unremarkable.

4

 KAMYAR SAMIMI

The ilium contained approximately 100 mL of partially digested
blood and firm, black stool resided within the colon. No
specific site of bleeding could be identified. The pancreas had
a normal gray/white, lobulated appearance and the ducts were
clear. The appendix was present.

Genitourinary System:

 

The renal capsules were smooth and thin, semitransparent, and
stripped with ease from the underlying smooth, red/brown
cortical surfaces. The cortices were sharply delineated from
the medullary pyramids which were purple/tan and unremarkable.
The calyces, pelves, and ureters were without note. The urinary
bladder was empty; the mucosa was gray/tan and wrinkled. The
right kidney weighed 110 grams; the left kidney weighed

130 grams. The prostate gland was unremarkable.

Reticuloendothelial System:

 

The spleen had a smooth, intact capsule covering redfpurple,
moderately firm the follicles were
unremarkable. The regional nodes appeared normal.

The spleen weighed 120 grams.

Endocrine System:

 

The thyroid and adrenal glands were unremarkable.
Musouloskeletal System:

Muscle development was normal. There was moderate degenerative
joint disease of the thoracolumbar vertebral column. No
nontraumatic bone or joint abnormalities were noted.

OBTAINED

Samples of peripheral blood, heart blood, cavity blood, gastric
conLents, and vitreous fluid were obtained for toxicology.

A DNA card was retained for the file.

Samples of the major organs were submitted for stock in
formalin.

Two cassettes were submitted for histologic analysis.
5

Mm: Ali?03073 KAMYAR SAMIMI

MICROSCOPIC DESCRIPTION

 

A Left lung: disrupted septae; atelectasis; anthracosis;
edema; bacteria without inflammation; interstitial chronic
inflammation

Liver: moderate steatosis

Left ventricle: unremarkable

Right lung:disrupted septae; atelectasis; anthracosis;

edema; bacteria and intrabronchial gastric contents without
inflammation; interstitial chronic inflammation

PATHOLOGIC DIAGNOSES

 

I. Chronic obstructive pulmonary disease with
marked anthracosis and Lerminal aspiration

II. Lower gastrointestinal hemorrhage
Thoracolumbar degenerative joint disease
IV. CPR?related injuries
V. Minor abrasions of face
VI. Moderate hepatic steatosis
VII. Toxicology Labs 17380380, peripheral blood}: Negative
humor, chemistry studies:

A.elevated glucose {183 mg/dL}

B.Mild renal dysfunction

l.Urea nitrogen mg/dL

2.Creatinine 1.9 mg/dL
evidence of dehydration

 A17-03073 KAMYAR SAMIMI
OPINION

This 6??year?old, White male, Kamyar Samimi, died of
undetermined causes. Chronic obstructive pulmonary disease
and gastrointestinal bleeding likely contributed to
death. Methadone withdrawal cannot be ruled out as the cause of
death, however, deaths due to methadone withdrawal are rare.
There were no injuries to explain death nor was there evidence
of dehydration.

 

in?rm I. am, MD, FCAP, D-ABMDI
Forensic Pathology Consultant

January 30, 2018

 

Date

Dictated: 136301?
Received for transcription: 12f6f2017

'l?ranscri bod: 12f6z?2 017