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  4. Corrective action implemented for tracking transportation of migrants at Carrizo Springs Station following death of ill migrant

Corrective action implemented for tracking transportation of migrants at Carrizo Springs Station following death of ill migrant

Release Date
Wed, 10/19/2022

On August 24, 2022, at approximately 1:40 p.m., Border Patrol agents assigned to the Carrizo Springs Border Patrol Station apprehended three undocumented migrants from Mexico. The group was apprehended approximately 1.25 miles east of the Carrizo Springs Border Patrol Station along Texas Highway 85.  Border Patrol agents transported the migrants to the Carrizo Springs Border Patrol Station, arriving at approximately 2:10 p.m. 

Following biometric processing, two of the migrants were determined to be amenable to Title 42 expulsion and were subsequently returned to Mexico via the Eagle Pass, Texas Port of Entry. The third migrant, a citizen of Mexico, was also determined to be amenable to Title 42 expulsion; however, he was suspected of involvement with a human smuggling organization and was held in custody pending an interview by Homeland Security Investigations.

Agents contacted an HSI special agent who requested assistance from Border Patrol Intelligence agents in conducting an interview of the man. Two Border Patrol Intelligence agents interviewed the man and conducted a consensual search of his cellular phone at approximately 3:00 p.m. Once completed, the Intelligence agents returned the man to a holding room. One of the intelligence agents sent an email message to several agents indicating the interview was completed at approximately 3:50 p.m.; however, the message was not relayed to Border Patrol personnel working in the holding facility and the man continued to be held in custody.

On August 25, 2022, between 6:00 a.m. and 7:00 a.m., the man reported leg pain to a Border Patrol agent who was conducting a welfare check.  The agent reportedly notified CBP-contracted medical personnel and the man was provided with acetaminophen for the pain; however, Customs and Border Protection’s Office of Professional Responsibility was unable to locate any record of a medical assessment or administration of medication consistent with this report. Border Patrol agents checked on the man’s status several times throughout the 6 a.m. to 2 p.m. day shift, and the man indicated the pain was diminishing.

A Supervisory Border Patrol agent also assigned to the day shift noticed that the man was still being held in the facility. The supervisory agent attempted to contact an HSI special agent but was unable to reach the agent until the afternoon. The HSI special agent confirmed that Border Patrol Intelligence agents already interviewed the man and he no longer needed to be held in custody. The supervisory agent indicated he advised the supervisory agent for the oncoming 2 p.m. to 10 p.m. evening shift that the man needed to be returned to Mexico; however, the evening shift supervisor stated to OPR that he was not informed. 

At approximately 9:00 p.m., the man indicated that he felt his diabetes was out of control and requested medical assistance. Border Patrol agents immediately referred the man to on-site CBP-contracted medical personnel who performed a medical evaluation. At the time, the man was running a fever and a physician’s assistant provided ibuprofen. The physician’s assistant tested the man’s glucose level, which was elevated, but did not suspect diabetic ketoacidosis. The man also had a large pink welt on his left leg which he indicated was the result of cactus spines. No puncture sites were located, and the wound was not draining.

The physician’s assistant reassessed the man’s condition at approximately 11:30 p.m. and discovered that his temperature improved but was still elevated. The man consumed an electrolyte replacement beverage and his overall appearance improved. The physician’s assistant administered acetaminophen for his elevated temperature. 

The physician’s assistant evaluated the man a third time on August 26 at approximately 3 a.m. The man’s vitals were virtually unchanged at that point, apart from an elevated heart rate. Medical personnel observed the welt on his leg was gone while evaluating the wound, but the area changed to a light shade of red. The physician’s assistant determined the man should be transported to the hospital for additional care and notified Border Patrol personnel.

A Border Patrol agent transported the man to the Dimmit Regional Hospital at approximately 3:50 a.m. and arrived at approximately 4:09 a.m. The man was admitted and received medical treatment while under hospital watch by CBP. The man’s condition worsened, and he was diagnosed with severe sepsis with shock. The man was transferred to the Methodist Hospital Stone Oak in San Antonio, Texas, at approximately 12:35 p.m., where he was admitted at approximately 3:32 p.m.  The man was processed in accordance with CBP guidelines and released from CBP custody at approximately 6:18 p.m. The man remained hospitalized in critical condition.

The man succumbed to his ailments and was pronounced deceased by medical personnel on August 28, 2022 at approximately 7:04 p.m.  

CBP Office of Professional Responsibility special agents interviewed multiple CBP employees and contracted personnel who had contact with the man while he was in CBP custody. One of the Border Patrol intelligence agents who interviewed the man on August 24 indicated he behaved in a calm manner during the interview and did not express any medical issues. The intelligence agent indicated he did not believe the man was being held specifically for the interview and did not advise anyone working in the holding facility when the interview was completed.

OPR special agents were unable to recover recorded video footage from the Carrizo Springs Border Patrol Station. CBP-contracted technicians determined a hard drive in the DVR system was likely damaged from a power outage caused by a thunderstorm. Although the damaged hard drive was replaced, and the video system’s operation was restored, video footage recorded from August 15 through September 1 was unrecoverable. Carrizo Springs Station management indicated they were unaware the DVR system was not recording until video was requested by OPR special agents, as live streaming video was still operational. 

OPR’s review of this incident revealed that the Carrizo Springs Station was not effectively tracking the transportation of migrants identified and expelled via Title 42 from the Carrizo Springs Station to the Eagle Pass, Texas, Port of Entry due to the short time in custody. Immediate corrective action was implemented, and the Carrizo Springs Station has added a “Time of Release” column to the Intake Sheet for the individuals identified and removed via Title 42.

CBP’s OPR is reviewing this incident and the Department of Homeland Security’s Office of Inspector General was also notified. Additionally, CBP’s Office of the Chief Medical Officer and an independent clinician will be conducting a mortality review of this incident, as required by agency policy.

Last Modified: Jan 04, 2024