Carlos Gregorio Hernandez Vasquez, a 16-year-old Guatemalan migrant, was seriously ill when immigration agents put him in a small South Texas holding cell with another sick boy on the afternoon of May 19.
A few hours earlier, a nurse practitioner at the Border Patrols dangerously overcrowded processing center in McAllen had diagnosed him with the flu and measured his fever at 103 degrees. She said that he should be checked again in two hours and taken to the emergency room if his condition worsened.
None of that happened. Worried that Carlos might infect other migrants in the teeming McAllen facility, officials moved him to a cell for quarantine at a Border Patrol station in nearby Weslaco. By the next morning, he was dead.
In a press release that day, Customs and Border Protections acting commissioner at the time, John Sanders, called Carlos death a tragic loss. The agency said that an agent had found Carlos unresponsive after checking in on him. Sanders said the Border Patrol was committed to the health, safety and humane treatment of those in our custody.
But the record shows that the Border Patrol fell far short of that standard with Carlos. ProPublica has obtained video that documents the 16-year-olds last hours, and it shows that Border Patrol agents and health care workers at the Weslaco holding facility missed increasingly obvious signs that his condition was perilous.
The cellblock video shows Carlos writhing for at least 25 minutes on the floor and a concrete bench. It shows him staggering to the toilet and collapsing on the floor, where he remained in the same position for the next four and a half hours.
According to a subject activity log maintained by the Border Patrol throughout Carlos custody, an agent checked on him three times during the early morning hours in which he slipped from unconsciousness to death, but reported nothing alarming about the boy.
The video shows the only way CBP officials could have missed Carlos crisis is that they werent looking. His agony was apparent, even in grainy black and white, making clear the agent charged with monitoring him failed to perform adequate checks, if he even checked at all. The coroner who performed an autopsy on Carlos said she was told the agent occasionally looked into the cell through the window.
The video makes clear that CBP, the Border Patrols parent agency, inaccurately described how Carlos body was discovered. Contrary to the agencys press release, it was Carlos cellmate who found him, not agents doing an early morning check. On the video, the cellmate can be seen waking up and groggily walking to the toilet, where Carlos was lying in a pool of blood on the floor. He gestures for help at the cell door. Only then do agents enter the cell and discover that Carlos had died during the night.
Officials with the Department of Homeland Security, which includes CBP, wouldnt say whether the scenes recorded by the camera during Carlos final hours were shown live on video monitors, as is the case in some Border Patrol facilities, and if they were, whether anyone had been assigned to watch the footage.
The video and other records reviewed by ProPublica document numerous missteps in the days leading up to Carlos final hours on the floor of Cell 199. Independent medical experts pointed in particular to the decision to send a 16-year-old suffering from the flu to a holding cell rather than a hospital as a pivotal mistake.
Why is a teenaged boy in a jail facility at all if he is sick with a transmissible illness? Why isnt he at a hospital or at a home or clinic where he can get a warm bed, fluids, supervised attention and medical care? He is not a criminal, said Dr. Judy Melinek, a San Francisco-based forensic pathologist who reviewed records of Carlos death at the request of ProPublica. No one should die this way: vomiting, with a fever and without the comfort of a caregiver.
A CBP spokesman declined to respond to a series of questions about Carlos death, citing an ongoing internal investigation. While we cannot discuss specific information or details of this investigation, we can tell you that the Department of Homeland Security and this agency are looking into all aspects of this case to ensure all procedures were followed, CBP spokesperson Matt Leas said.
CBP has refused to release the video and other records of Carlos death to the public or Congress, citing the ongoing internal investigation. But using Texas open records laws, ProPublica obtained material from the Weslaco Police Department, which briefly investigated his death. The records included surveillance video, detainee logs and health records turned over to police by Border Patrol.
Interviews and documents illustrate how immigration and child welfare agencies, while grappling with surging migrant numbers, were unable to meet their own guidelines for processing and caring for children. With holding tanks that were never equipped to house migrants for more than a few hours, the Border Patrol was inundated with families and children. Shelters for children, offering beds and medical care, were already packed.
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