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DEPARTMENT OF HOMELAND SECURITY

Immigration and Customs Enforcement

Office of Professional Responsibility

REPORT OF INVESTIGATION
H8420041

Ng. HluluilUnknawnllncldent CrIticellSlgnlllcantlCENTRAL FALLS. PROVIDENCE, AI

RESOLUTION

7. RELATED

Conclusion of Investigation: Hiu lui Ng

On August e, 2008. the Joint Intake Center (JIC). Washtnglon. D.C •• received Infonnation reporting
the death of U.S. Immigration Enforcement (ICE). Dellntlon and Removal (ORO)
detainee. named H1u L.ul Ng Mr. Ng was hospitalized In Rhode Island on August 1.
2008. when he was Slage center. On August 6, 2008, Mr. Ng passed
away at the Rhode Island Hospital Cenler, Providence, RI, while stUl detaIned by the Donald Wyatt
Detention Facility (WDF) In Central Falls. RI.

The ICE. Offtce of Professional Responsibility (OPR), ResIdent Agent In Charge (RAe).
Portsmouth. New Hampshire was assigned 10 Inveatlgall the conditions of delantlon end
circumstances preceding Mr. Ng's death.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF lNVESTlGAnoN
CONTINUAnoN
... <IlIIIO-01

BACKGROUND:

On February 6, 1992. Mr. Ng entered the United Sletes at New York 88 8 nonImmIgra~t with
authorization to remain in the United Sletes unUl February 5. 1993. Mr. Ng remained Ul the U.S.
beyond his period of authorized stay.

MR. NG's IMMIGRATION HISTORY:

On November 2.2000. Mr. Ng was issued a Notice to Appear (NTA) Form 1-862. to appear before
an Immigration judge In New York City. On February 2. 2001, Mr. Ng did not appear for his
removal hesring and a removal order to China was issued In absentia.

On April 20. 2001. the INS' Vermont Service Center In St. Albans. VT. recelved a
Rellillvil!t, FIIane8le. or Orphan) on bahalf of Mr. Ng. from

on December 13. 2006. Mr. Ng applied to register for Permanent Residence/AdJustment of Status
to the uldellnes required during the adjustment
via Form 1-485. On February 11. 2007, PUfSU8l1iit
of status process, Mr. Ng was examined by Dr. Medical Doctor (MO). AcconI/ng to
the Form 1-693 (Medial ExaminaUon of Aliens USlment of Status). Mr. Ng hed no
apparent defects. disease. or dlsabllilles.

on June 28. 2007. a tettar addressed to Mr. Ng was sent to his address of record from U.S.
CItiZenShIp and ImmlgraUon Services (CIS). to appear on July 19. 2007, in New York City for an
adjustment of steluelntervlew. On July 19, 2007. Mr. No attended the IId1eduted appointment at
the CIS NYC. at which lime his appMcelIon waa denied 88 the ImmigreUon Judge ordered him
removed on February 2. 2001. Also on July 19. 2OO7,ICE ORO was contacted and Mr. Ng waa
arrested based upon the Immigration Judge's removal older. Mr. No was transported to the-!CE's
Varick Street facility. In older to be PltlCesssd for removal. AcconIlng to the ICE ORO booking
records, form 1-203. no health conditions were listed. Mr. No was held at the ICE ORO
Varlck Street """nltv
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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
CONTINUATION
HB420lWll
10. NARRATIVE
On August 27, 2007, Mr. Ng's motion to reopen his removal hearing was denied by the Immigration
judge who ruled thai Mr. Ng fated to artlcutete sufficfent justification 10 excuse his failure to appaar
al his Fabruary 2, 2001. removal hearing.

On August 31,2007, an appeal of Iha immigration judge's danlal to reopen Mr. Ng's case was
appealed to the Board of Immigration Appeals (BIA).

On 0cI0bar 3, 2007, a Stey of Removal for Mr. Ng was granted by Iha Board of Immigration
Appeals.

On October 18, 2007, the BIA dlsmiued Mr. Ng's appeal and rescinded the stey of removal.

On October 19, 2007, Mr. Ng wea advised by ICE ORO thellhay were In possession of a travel
document to faciHtete his removal to the People's Republic of China. Mr. Ng was also advised that
his removal would occur someUme In November 2007. Subsequently, Mr. Ng's removal was
scheduled for Novembar 16, 2007.

On November 7, 2007, a petition for review (PFR) was flied on Mr. Ng's behalf with the U.S. Court
of Appeals for the Second Circuli, requesting that the Court raview the BlA's decision affirming the
immlgraUon judge's danial of Mr. Ng's MoHon to Reopen. In addiUon, a Slay of Removal was also
requesled. The Second Circuli granted a stay of removal while Iha court consldared the maills of
Mr. Ng's petition for review.

On the same dale, e Petillon for Wril of Habeas Corpus with Emergency Order \0 Show cause
wilhln Ihreii!!Eda
s uant to 28 U.S.C. § 2241 erseq., was also flied on Mr. Ng's behalf by
Altomeys and _ In this petition, It Is also claimed that Mr. Ng was denied medical
treatment an access to counsel.

Mr. Ng's Stay at the Wyatt Detention Facllty (July 20.2007 - January 10. 2008)

On Mr. Ng was to Iha Donald W. Wyatt Delentlon

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
CONTINUATION
HB4:zoo.o1

Central Falls. RI. Mr. Ng remained detained at the WDF until January 10. 2008.

On the same dale, Mr. Ng was proceued Into the WDF. Upon his admission to WDF, he received
a standard medical evaluatIOn and mental health screening. Mr. Ng's initial medical evaluation did
nol reveal any health Issues. His mental health evaluation, however, noted that Mr. Ng exhibited
signs of depression. During the medical evaluation, Mr. Ng was lestad for tuben:ulosls with a
standard skin Iell. On July 23, 2007, Mr. Ng was examined via chest X-ray to determine if he was
Infected with tubefculosis. According to the records, the chest X-ray was reed on July 23, 2007, by
D r . _ , MO. The X-ray was reported es negaUve for signs of tuberculosis.

On October 9, 2007, while detained at the WDF. 8 WOF Incident

report regarding Mr. Ng from Shift Commander, According to the report,
Mr. Ng was ordered to dress for e scheduled proceedings.
Captain _stated that Mr. Ng was noncompliant when directed to dress In proper attire for
transPort out of the facility.
Captain_report related \hat Mr. Ng advised him \hat ha wee In fear of deportation;
therefore~ wanl to be transported to his appointment Next, Mr. Ng removed his shirt
and tied It loosely around his neck. To ensure his safety, Mr. Ng was In a
cell. Mr. Ng was Immediately evaluatad by Ucensed Prectical Nurse 10
Identify any potential Injuries stemming from him being restrained. No were
noted. Mr. Ng eventually became compllanl and was transportad 10 his scheduled appointment.
Upon return, Mr. Ng was placed In edminlstrative detention, to await e decision on disciplinary
sancllon resulting from his non-compnanl behavior earlier \hat morning.

Until Mr. Ng's transfer from the WDF on January 10. 2008, no other Incidents were reported. Mr.
Ng never requeslsd special attention or advised of any medical needs, with the exception of
blisters on his raet and his need for cleaning aolulion for his c:onlact lenses.

Mr. Ng's Stay at the Franklin County House of CorrecUons (January 10, 2008 - April 17. 2008)
On January 10, 2008, Mr. Ng was transferred to Franklin County House of Corrections (FCHC) In
Greenflald, Massachusetts, In order to maintain detention equilibrium within the Jurl8dlctlon of the
Hartford, DRO offlce. Mr. Ng's Intake Mental Heallh Screening and Assessment Form rrorn his
admission to FCHC reflects no report or detection of menial or medical Issues, with the
exception of a positive Purified Protein Oerlvatlve test reaction. for which Mr. Ng was
Isoniazid and 8-6 vitamins for a of e months. As of the standard
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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
CONTINUATION
H8 4~1 (371. SpecIaIAg.nIHoml_

10.
procedure for medical evaluations at the FCHC, a blood specimen was taken from Mr. Ng on
January 1. 2008. According to the laboratory report, the results of the tests were within the normal
range.
~ 2008, Mr. Ng was givan a physicel assassment by Family Nurse Practitioner
_ According to his medical records, Mr. Ng did not advisa Nurse_ of any
medlcellssues.

Mr. Ng's Stay at the Franklin County Jail (April 17, 2008· July 3,2008)

On April 17, 2008, Mr. Ng was transferred from the FCHC In Greenfield, MA,to the Franklin
County Jail (FCJ) in St. Albans, Vermont, In order to maintain detention equilibrium within the
jurisdiction of the Hartford ORO offica. Upon his arrival to the FCJ, Mr. Ng wes processed through
Ihe standard Intake procedures, Including a medical evaluation. Mr. Ng advised that he did not
have eny existing medical conditions, only that he had an allergy to some clothes and hed dry skin.

On June 11, 2008, Mr. Ng filed a grievance form Indicating that he wished to sae e nursa to
evaluate his skin condition.

On June 12,2008, Mr. Ng was seen Registered Nurse (RN). R N _

prescribed an anti-ltch cream, and she ad1#1seld that If the rash developed further, she would
reevaluate him.

Mr. Ng filed an additional grievance form during his stay at the FCJ. The form Is undated, thus, It Is
unclear whether this grlevanca was Died before or after the June 12th grievance. On his undated
grievance form, Mr. Ng explained that he needed to see a doctor for his skin problem. Mr. Ng
further advised that he believed that something was wrong with his body, resulting in his skin
problem. Mr. Ng asked that If the FCJ did not have the power to arrange an examination by a
doctor. he requested that ICE be notified. Mr. Ng's medical records provide no documentary
evidence that Mr. Ng wes saen by a doctor or that ICE was contacted.

On June 27, 2008, In a letter to ICE authored by Mr. Ng's Mr. Ng a stated
that he was suffering from chronic back pain and akin Irritation. claimed that Mr.
Ng made many requests, but arrangements had not been made for Mr. Ng to sae a doctor. While
addressed to ICE, tha leHer was Instead maUed \0 the Frenklln County Jail, 30 Uncoln Ave., St
Albans. VT. ICE does not melntaln an office at the FCJ. Is believed that the leller was not
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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVE8T1GAnoN
CONnNUAnON
H84200-01

received by ICE unlll several weeks after Mr. Ng was lransferred back to Ihe WOF.)

On July 2. 2008. Mr. Ng was afforded the opportunity to lransfer to a facility with outdoor
recreation. Mr. Ng accepted and signed the form tilled "Waiver Form eo Day Transfer OpUon
Request· The form II dated July 2. 2008 and signed by Mr. Ng.

Mr. Ng's Stey atlhe Wyatt Detention Facility (July 3. 2008 - August 6. 2008)

On July 3. 2008. Mr. Ng retumed to the WOF In Central Falls. RI. Upon his atrivalto the WOF. Mr.
Ng was processed through the standard intake procedures Including a medical evaluation. A
medical history and screening was conduclad by L P N _ and signed by Mr. Ng. According
to the WOF medical records. currant medical conclUons and medical hIstory ware negallve. with
the excepUon of the rash on his body. and prior treatment for TB from July 22,2007. In the IniUal
evaluaUon Mr. Ng reeponds "yes· when asked if there are any medical problems the facility should
know about The medical condition II noted as "resh - all ovar: There Is no wrillen indication that
Mr. Ng reported any back problems. In addition to SCl8enlng. a mental health
evaluation was also conducted. According to LPN no mental health problems were
reported or observed. Mr. Ng was also given a screening. which also appeared to ba
normal. Mr. Ng was approved for housing within WDPs general population. Mr. Ng was
prescribed Benadryl for his skIn condlilon. An X-ray of Mr. Ng's chest was taken to datermlne
whethar he was Infected with TB.

On July 5. 2008. Mr. Ng filled out a WOF Heath SarvIcas Request Form. On that form. Mr. Ng
adVised that he was experiencing a rash aD ovar his body for two months. Mr. Ng staled thai the
facility that he was detained at prtor to tha WDF had no medical cara. Mr. Ng also advised that he
was expertancing back peln, which had started a wask prtor. WOF medical records indicate that
par WOF protocol. Mr. Ng was prescribed 600 mI~ for a five Mr. Ng's
comptalnt appaere to have baen reviewed by RN _ _ _ and Dr. MD.

On Jut 6. 2008. the X-nlY taken to verll'y whelher Mr. Ng was Infecled with TB was reviewed by
Dr. MD, and Indicated no active disease.
On July 7. 2008. Mr. Ng was evaluated by Dr MD. regarding his comptalnts of a skin
condilion and low back pain. AI this Ime. MD. praecrlbad Betamethaaone cream
and Benadryl for Mr. NO's rash and NO'S beck pain. On the same data.
Heath Services Administrator ravieWed Mr. NO'S medical records for qualHy
assurence. to his MD. statad that tha "normal practice for iniUeI
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DEPARTMENT OF HOMELAND SECURnY 1. CASE NUMBeR

REPORT OF INVEsnGATION
CONTINUAOON
HB 4200-01 (371. SpecIII AgIIII"_
10. NARRAnVE
back pain" Is to presc:l1be pain medications. possible muscle relaxers. and heat to the back. Upon
reviewing his notes. Dr. _ . MD. stated that Mr. Ng's back pain was "not severe enough for
Motrln. which I cancelled and prescribed Tylenol."

On July 8. 2008. Mr. Ng requested to see a doctor, advising that he had not slapt for two nlghls
bacauH of back psIn. HIs Tylenol prescripUon remained In effect for back pain.

On July 10. 2008. Mr. Ng again requested to sea a doctor for back pain relief. His Tylenol
prescription remained In effect. In his request Mr. Ng states "Please arrange doctor visit for me
when he comes to facility next Ume.·

~08. WDF Warden Wayne Sansbury received an email from _

_ of Mr. Ng. In tha eman, Mr._advised that slnceil!r. N i"iiTIVida'i'ie WDF. he
repeatedly asked for medical attention. specifically his back pain. Mr. statad that the medical
staff did not care about his health problems or his back pain. Mr. advised Warden Salisbury
that Mr. Ng nlHlCHd immediate attention.

July 14. 2008:

was forwarded to the Director of Nursing

advised Warden Salisbury that Mr. Ng hed
was pniSiilIiid "heavy-duty" narcotic analgesics, as well as muscle relaxers.
acMsad Warden Salisbury thai he would advise If any addiUonal medical slips ware racllived.

records Indicate that Mr. Nil was examined by Dr. _ . MD. on the 88me date.
MD. prescribed F1exalil (a muscle relaxant) and Vlcodln (painkiller) for two weeks.
MD, recommended lhat Mr. Nil should be moved to a bottom bunk in his cell to
;;;;irA. for Mr. Ng to get Into his bed.

_ July 11. 2008. amall to Wartlen SaUsbury. ON

he could not provIda much datal! due 10 pallentidalalnae privacy
~!!::~ that the prescribed medications and treatment was the
recomrnendel:l IF for chronic back pain. ON _rurther advised that every detainee
In cuslody at tha WDF was treated with a high leval ~professional care.

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REPORT OF INVESTIGATION
CONTINUATION
H84zoo,ol r.m. ....... AGanlH_

July 17. 2008:

Mr. Ng lilled out a WDF Heath SeIViceS Request Fonn. In which he aclYlsed that he needed an
X-ray of his back and requested a cane because he could not walk. WDF medical reCOlUs IndiCate
Ihatthe request was received on July 18. 2008. by LPN_. and was triaged to a medlcel
doctor.

July 18. 2008:

Mr. Ng was examined by Dr. MD. D r . _ MO, ordered an X-ray of Mr.

Ng'lI spine and right hlp. Dr. also authorized the use of a cane for Mr. Ng for s
period of two waeks. (The ~scril,tIol18 Flexatil and Vicodin continued).

July 20. 2008:

An X-ray of Mr. Ng's right hlp and lumbar spine was reviewed by Dr. _ _, MD. Dr.
_ . MD. Is a radlofoglst with Mobilex USA. The right hlp X·ray ~mbar spine
x:rayTndicated slight sccHOlIls. but was otherwise unremalt<sble.

July 22. 2008:

ON _recalved an email response rrorn Mr_. In this emal Mr._Slated thaI he

eppreciated thetthe WDF~rovIded reasonable care to Mr. Ng. Howaver;1..'f.' Ng's condition
continued tOWOl88n. Mr._steted thet he visited Mr. Ng on July 17th and July 20th. to see Mr.
Ng's condlUon pellOnstly. Mr. _advised thet Mr. Ng told him the following things: he was
experlancing diflictJlty getting out of bed; his right leg lost sensitivity; he experienced 4;OId sweats
during the night; he had diflIculty walking even after he was given a cane to walk with; and he was
un~ to sleep due to the medication. Mr• • asked that lhe medical department expedite Mr.
Ng's medical dlegnosUc procedures.

That same day, ON _ w r o t e Warden Salisbury, via emall.lndlcaUng that ha would nol
respond to Mr.~ fieRlceived dlrecUon fnlm his superiors.

Associate Warden (AW) authorized an activity watch for Mr. Ng.

July 23, 2008:

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DEPARTMENT OF HOMeLANDSECURnY 1. CASE NUMBER

REPORT OF INVESnGAnON
CONnNUAOON
He 42(JO.Q1 (3n

A physical examlnallon of Mr. Ng was conducted by an unknown person, beHaved to be from !he
WDF medical staff. WhIle It occurred on the 20th day of his stay at WDF, It appeara this
examination may have been the 14-day physical examination as required by the ICE NOS. The
notes on !he form tilled "Physical Asseasment· notes that Mr. Ng's back pain had not Improved,
and he was unable to stand or put pressura on his right leg. It Is also noted !het Mr. Ng hes •
p08IUve pain while voiding since back~ Is mede for a CT scan. At this time, It
appaara that Nuraa PracUlioner (NP)_advIsed O r . - . MO,that a CT scan
was needed to help determine the cause of Mr. Ng's pain.

July 24, 2008:

A Health Services Request form was received by LPN _ ; from Mr. Ng advising that he could
not walk with a cane and requested a Wheelchair or something he could use to help him welk.

Dr. _ MD, submitled a consultation request for a CT seen of Mr. Ng'8 right hip and lower
spine, indicating that Mr. Ng had peln and weakness and wes unable to stand or walk. ThIs
consultetion request resulted from the physical evaluation findings on July 23, 2008. There Is no
chart entry recording any further evaluation on this date.

AW _ requested ICE, ORO, Supervisory Detention

and 15ijiOriation Officer CT. At this lime, S O D a _
advised that she would have the requ~dlted through the Department of Health and Human
Service's Public Health Service. AW_furlher advised ICE ORO that Mr. Ng was raquesllng
that he be moved into segregation so that he could have his medication brought to his cell.

AW_alsorequested ON regarding Mr. Ng's medical

aasessment and his transfer to ON replied that the treelmant for muscle
strain was exaclly what had been prescribed. However, Mr. Ng advised that he had no
improvement. additional taaIlng was necessary to confirm Mr. Ng's diegnosls.

authored by Mr. Ng'8 a t t o m a y _ , to Deportation Officer

Hartford, CT, ORO, 450 Main St. ~rtford, CT, Mr• •
Mr. ~ufl'erlng serious and rapidly deteriorating health
adviised DO _ t h a t It that Mr. Ng ba raJeaaed from
custody to adequate medical traalment. that Mr. denied
medical treatment. According to her aftldavlt. DO Ng
had been admitted to the and, therefore.
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REPORT OF INVESTIGATION
CONTINUATION
H8 4200.01 (37).

letter.

July 25. 2008:

ON _ advised that the CT acan was approved by ICE and was acheduJed for July 29.
2008, at Rhode Islend Medlcallrnaglng.
Reid 011108 Director lAFIODl was oontacled that same day by
en attom~enung his client be examined by a
I)rivI.!lte pt!ySlc:lan, AFOO _ advised WDF medical staff detetmlnes
~Ical treatment for its inform WDF ataff of his concerns. AFOO
_ d/scuSsed the conversation with advised that she was aware of the
slluaUon and "was being addressed. PiO'~ldetdAFOO _ with updates on
Mr. Ng's status, Including that he was scheduled

July 26, 2008:

Mr. Ng was scheduled to have his attomey. According to an email message

from Shift Commander Captain to his superiorS, Including Warden Salisbury and
AW_, Mr. Ng refused to his attorney unless he was brought to the
meating space by wheelchair. that he advised ~he hed been
Issued a cane and would not be given • According to Captain _ . Mr. Ng
refused to attend the appointment and Mr. Ng'a attomey was noUfied that Mr. Ng declined the visit.
According to the recorda. this incident occurred between approximately 15:00-18:00 hours.

Captain _ further advised thetlaler that same day. at approximately 17: 10 hours, Mr. Ng
was obsiiVid"b"Yen olllcar having dllllculty getting up from his call floor. According 10 the ofIIoer.
Mr. Ng required the asslatanoe of another datalnee 10 11ft Mr. Ng Inlo a seaL Captaln_
stated that he advised the medical staff of the situation. At this Ume, Mr. Ng was evaluatad by AN
_ . After Mr. Ng fell to the floor when he demptad to stand up with the usa of his cane. It
was determined that he would need to be sent 10 Memorial Hospital In Pawtucket. RI. In order 10 be
evaluated further. Captain _advised that Mr. Ng was removed from the call area via
wheelchair and eacorted 10 the Health Servlcas Unit (HSU).

Mr. Ng was brought 10 the Memorial Hospital of Rhode Island. According 10 the hospital recorda,
Mr. Ng arrived at 20:15 hours on July 26. and was admitted 10 a room at 20:18 hours. According to
the incident WOF staff utitlzed a wheelchair to move Mr. Ng to the van for
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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

-
REPORT OF INVESTIGATION
CONTINUATION

ll'ansportallon to the hospital. Mr. Ng was examined by MO. In the

emergency room (ER). Mr. Ng advised that ha recently of his hips and beck and that ha
was experiencing leg pain for several days and was unable to bear walght on his lags. According
the hospital records. Mr. Ng denied having any direct trauma to the area. but advised that the pain
bagan several weeks age and became worse In the last week.

with Sclallca (low back pain) and prescribed Ibuprofen. Valium. and
MD. advised that Mr. Ng should have his physician schadula an MRI fer
July 28. to evaluate whether Mr. Ng had any disc problems In his Jowar back er if ha
had any problems. Further. after the MRI was complete. sha advised that Mr. Ng should
be seen by a Neurcstlrgacn. In addition. Dr. _ . MD. advised that If poulble. Mr. Ng should
be receiving pain medlcatJcns for his oondilion.

Mr. Ng was discharged from Memorial Hospital and returned to the WDF HSU. As part of the
discharge precess. Mr. Ng was provided paperwcrll ragardlng his diagnoses and treatment fer
Lumbar Redlculcpathy Scialica (low back pain). The fonn tetter provided to Mr. Ng fisted a number
of treatmant cptJcns for individuals who hava been diagnosed with sciatica. The treatment optJcns
noted on the form renge from encouraging patJanls partJclpate In acUve exercise to recommending
slerold Injecllons or surgerY. The medical dlrecUcns are general medical advice provided In a letter
formal. The above direcUons were provided to Mr. Ng at the hospital and ware addad to Mr. Ng's
medical records at the WOF.

July 27. 2008:

Mr. Ng was asslIISed by RN _ . RN _ advised that Mr. Ng appeared to be stable.

bul needed 10 follow-up with a doclor.

On the same data. according to the medical records Mr. Ng was offered all of his prescribed
medlcatJcn. bul rafused to get out of bed. According to LPN _ . Mr. Ng was spckan 10 al
tangth regarding his back pain and his noncomplisnce with the prescribed treatment. Mr. Ng
Rlfused to come to IhB cell door to racelve his medlcatJcn. Acc;ording to IhB WDF medical racon:Is,
Mr. Ng was dlspenlied his preSCribed rnsdlcatJcn Istar that same evening and through the fo~owing
day.

July 28. 2008:

advlsedAW Mr. Ng had been with low back and It was

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REPORT OF INVESTIGATION
CONTINUATION

recommended that further testing should conUnue. D N _ further advIsad thai a CT scan
was already scheduled for July 29. 2008.

July 29. 2008:

Mr. Ng was scheduled for a CT scan al Rhodel&land Imaging. According to WOF records, the
WOF staff describes Mr. Ng as having "refusad" to attend his CT scan.

a
According to WDF incident report by Sergeant (Sgl)..-on July 29,2008, he was
a&8lgned to escort Mr. Ng to a scheduled medical appotntmenlearliar thet day. Upon arriving 10
Mr. Ng's cell in the HSU, he noticed Mr. Ng slldng on the bed, crying and smUng that ha could not
move. Sgl_staled that he advised Mr. Ng that by attending the medical appointment. it
would a&8lst In determining the nature of his Sgt. _ advised Mr. Ng had a walking cane
near his bedside that could be used 10 In walking, and that tha medicIII staff determined
.!I!!!..!f did not need a wheelchair. Sgt. that he dld.!!.91!W!mpt 10 move Mr. Ng. Sgl
_further staled thai he nodlled ON Captain _ and the appalntment was
cancaned.

Sgt. _ advised his supervisors that ICE ORO, ImmigmUon Enforcement Agent (IEA)_
~rtford. CT, was notified that~d·1o attend his scheduled CT scan earlier thai
morn!!!En
. l ter that seme day, Major_advised Warden Salisbury, AW_and
AW thet Mr. Ng had been scheduled to ~e ICE ORO office In Hartford. CT, 10
meet with lEA . Accordlng to Major_ IEA_ advised that a meellng between Mr.
Ng and his attorney would also be facIIltaIed.

AW _ senl an emaU to Warden Salisbury asking whal the plan would ba if Mr. Ng stated that
he could not move and "refused" to go. Later Ihat evening, In msponse to amalls sent 88r11ar that
day. Warden SalISbury replied, "VIdeotape the movement and place him on the vant Gendy of
course.· In his affidavit 10 OPR for this Invasllgsl/on, Warden Salisbury slated that he "did not
know at that dm. that he (Ng) was physically unable 10 attend his appointment as It was reported to
me In the emaD as a 'refusar. Warden SaBsbury &Iso stated that the reason for sending the email
ft

about videotaping was 10 "make sura the enUre Incident Is videotaped per poUcy as I considered it
to be a polandel U.e of Force. I did nol know at lIlelime ha was physlcaUy unabla 10 attend his
appointment as It was reported 10 me In the email as a 'rafusar.·

Later lha\ same evening, Mr. Ng was examined by Or MO. O r . _ M D ,

advlsad In his notas that Mr. had was unable 10 stand and
OFFICIAL use ONLY seNSITIVE
OFFICIAL USE ONLY SENSITIVE Pagl13 of33

DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

-
REPORT OF INVESnGATION
CONnNUAnON
H8 420~t 1371.
10.
was constipated. Dr. _ . he explained to Mr. Ng that a CT scan needed
10 be done as soon as poSSIble. Dr. MD, edvlsed that Mr.
with lransportation and authorized the usea wheelchair at that time.
completed an Interagency Health Cara raquast for a CT scan for Mr. Ng.

An activity watch remained in effect for Mr. Ng while In the HSU. Severallnddent reports wars
generated on July 29. 2008. with moslly However. according to a WOF
Incident raport by Corrections Officer (CO) Mr. Ng. stated 10 her that no one
bellaved that he could not walk.

July 30. 2008:

At approximately 06:00 hours. officers from the WOF attempted to facilitate lransportatfon from the
WOF to the ICE ORO office In Hartford. CT. The movement was videotaped by overhead mountad
surveillance cameras and by hand held camcorder. The ovelf1ead mounted cameras ramain
constant and view the entira movement However. Happears obvious that the hand held
cemcorder Is shul on and off several times.

The video begins by showing Captain _ Ng that he had been Issued a

cane. and would not be given a wiheelchalr. Captain further edvIsed Mr. Ng that he
move on hts own. Mr. Ng edvIsed the could not walk. CaptaIn
10 Mr. Ng that he had been sean by a doctor and that he was fine. captain
edvIsed Mr. Ng to stand Mr. Ng was visibly crying and appeared to have
this lime. appears 10 signal 10 the offfcer holding tha
IdeIll/INK! as CO slop recording.

r. N then ettampled to put his shoes on. Mr. Ng advised that he could not walk. Caplaln
_ advised Mr. that he needed 10 walk to the Receiving and Discharge (R&D) unit. Mr.
9 rapaa that walk. Captain_directed Mr. Ng 10 pili hil8hoes on. Mr.
Ng asked to believe him that ha could not move his legs. Mr. Ng continued to
Mr. Ng appeared 10 be In pain at that tIn1e. After a short Ume.
advised Mr. Ng to get his shoes on mora quickly. that he needed to get to the
go court. Mr. Ng statad that he did not want to go 10 court. It Is notad that Mr. Ng
did not have a 8dladuled court appearanca; rather he was scheduled for an Intarvlew at the
Hartford ORO off1ce.

For a short Ume. continued 10 ..y,..,"" ..... words. Mr. advised

OFFICIAL U810NLY 8ENSmYE
OFFICIAL USE ONLY SENSITIVE Page 14of33

DEPARTMENT OF HOMaAND SeCURITY 1. CASe NUMBER

REPORT OF INVesTIGATION
CONTINUATION
H84200-01

caplain _ that he could not move. caplaln _ repled that the doctor Iold him that
he was okay 10 move. Mr. Ng continued 10 appear a"ilTiii'Was unable or unwilling 10 move. At
this tlma, Caplain _ auisted Mr. Ng with placing his shoes on his feel Mr. Ng appeared
10 be experiencing soma level of discomfort at this time. Mr. Ng explained that he wanted 10 lake
care of his Injury end aee a doctor. Mr. Ng continued 10 advise Caplain _ that he could
not walk.

At Ihls lima, Ceptaln_ and the assisting oftIcer (Jatar Idantlfled

~ his bed, 'Urid8r"iliSshoulders in the
_lifted Mr. Ng. he began 10 scream loudly. Capltain
proceeded to carry Mr. Ng down the hallway, face folWSrd. allOllYing feet to dreg on the ground.
Mr. Ng continued to scream as he was being canied.

A short l i e
m . 'the video shows Mr. Ng now lying on the ground In another area of the WDF.
Isler
Captain advised Mr. Ng that to be moved to a sllUng position. Mr. Ng
advisad t e could not move. Caplaln Mr. Ng that his cane was ava.able so
that he could help himself up. Mr. Ng cane did not wort. Duri1l9 tha next few
momenls. Mr. Ng asked for tha aeslsblnca of a wheelchair. Captain _ advised Mr. Ng that
he could walk on his own, and he was then moved from the floor and positioned against tha walt.
Mr. Ng continued to explain to Captain_that he could not walk. Mr. Ng was than placed
in transport mlralnls for movement to ~ ORO office.

As Mr. Ng was restraints, that the madlcal staff be

contacted. Mr. Ng the nurse check him before he
was placed on the statad that he could not go. At this time. the video depicls Mr. Ng
being moved against the wall. Ng screamed In peln and advised th~e going to break
his leg. Mr. Ng advised that he could not make the Irip. which Captain _replied that he
had to. Mr. Ng again advised that he was in pain.

At this Uma, LPN restlonded to Mr. Ng's location. Mr. Ng advised L P N _

that he was unatlki advised Mr. Ng that he hed been sent out for a tast and
that the CT scan. Mr. Ng replied that he could nol walk.
LPN wanted his madk:allon. Mr. Ng repUed thet he did and the
the WDF madical records Mr. Ng was given 100mg of
edvlisad Mr. Ng that he needed to go to court. Mr. Ng
slaled that he could go; he was just refusing 10 go.

Ol'l'1C1AL use ONLY SENSITIVE

 PIIlIe150U3
OFFICIAL USE ON!.Y

DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
CONTINUATION
H1142QO.01

Mr. Ng advised thai his legs were """""in,,,. and that ha wanled 10 take the test. but no one
would give him a wheelchair. stsllild thai she was to through the S8me
conversaUon with Mr. Ng. Captain LPN to
he was
have left the area. In her partlng ~~~~~~:~I
able to be transported. but refusas to go. would asslsl
him onto the bus.

A short time laler. Captain _ advised Mr. Ng that he would nol be given a wheelchair. At
this lime. four otIIcers, picked up Mr. Ng and brought him to the bus welting In the sally port area of
the WOF. As Mr. Ng WEll being lifted. he made slmMar crias of pain thel he had made earlier. After
a short time. Mr. Ng was carried onto the bus and transported 10 the Ice ORO Hartford. CT offica.

II ia noted that the hendheld video camera was tumed on end off approxlmalely nina times during
the approxlmataty 40 mlnule movement of Mr. Ng from his cell In the HSU to the bus In the outdoor
seRy port area. (EN 1)

On the same data. Captain _ provided a report of the Incldent involvtng Mr. Ng. Captain
_ advised that he was assigned to assist in the escort of Mr. Ng to the R&D unit in
praparation for court that day. captain _ raported that Mr. Ng was ~iant with his
inslrUctlons and needed to be ~I;ii'iiiliiiifto the R&D unit Captain _ reported that
Mr. Ng was assessed by LPN _ to ensure that he was not injured whHe being assiated.

Captain _further reported that aftar the conclusion of Mr. Ng's medical assessment, he
was provided his prescnbed medication and placed In transportation reslralnts. Captaln_
reported thai Mr. Ng was physically Ufted under his arms and by his feel. and placed on en
awaiting bus for IransportaUon 10 court . .£!i!!!!II_further raported that the escort was
video taped per Instructions rrom Major_

prelparEKI a WDF Incident raport explaining hia involvement with the Trensport of
reported that he was Instructed by the Shift Commander to assist in moving
R&D unit and then 10 en awaiting bus. 6 g 1 . _ reported that he was
Ng because he was unable to walk on his own.

a WDF Incident report explalnlng his Involvement with the

M",f>rtold that he was assigned 10 8ssial In escorting a
thet Mr. Ng advised thai he could nol walk. Officer
carried Mr. his arms and onto en
OFI'JCJAL USE ON!.Y 8ENSITMl
OFFICIAL USE ONLY SENSITIVE Page 16 of 33

DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
CONTINUATION
HB 42QO.()! (37). $petia) Agenl Handboo'

10.

CO pre:palred a WDF incident report explaining his involvement with the transport of
Mr. reported Ihal he was assigned to move Mr. Ng from the R&D uoillo an awaiting
bus. SUI leu Ihal he carried Mr. Ng by his len arm.

DfllDa,red a WDF Incidenl report explaining her Involvemenl with Ihe transport
advised Ihal she was inslructed 10 video lape the movement of Mr. Ng on
July 30. that she was instructed by Calpta,in
recording the movement • Ng. in order to deescalate Mr. Ng's bellaviar.
reported that while recording. it was determined Ihat Mr. Ng's behavior escalated.
further reported that once Mr. Ng was secured in a cell and the door was closed. the camera was
shut off and turned over to Captain_

CO or~!oa.reda WDF incidenl report explaining his involvemenl with the Transport of
Mr. r"nnr".nlhal he was assigned to escort Mr. Ng from Ihe R&D un II 10 an
awaiting bus. teDOm!O Ihat Mr. Ng was noncomplianl and was carried oul by his arms
and legs. (EN 2)

'ri~~~~~e~a WDF Incidenl report explaining his involvemenl with Ihe Tralns~'ort
Mr. Ng. • Ihal he was assigned 10 escort Mr. Ng to the R&D
reported Ihal Mr. was several orders to stand and PUI his shoes on.
that Mr. Ng failed to inslructtons. slaling that he could not move.
thaI he and Caplain Mr. Ng in pulling on his shoes and then moving
him 10 lhe R&D unit. Ihal the detainee decided not to use the muscles in his
legs and was carried arms to the R&D unit.

Mr. Ng arrived at the Hartford ORO office and was carried off the bus by Hartford ORO officers and
placed inlo a wheelchair and brought to the ORO offICe on Ihe 5th Roor. AI the office. Mr. Ng met
wilh I~ Mr. Ng was interviewed as to why he did not attend his scheduled CT scan
on July 29. 2008. Mr. Ng was afforded Ihe opportunily 10 make numerous phone calls 10 his family
and his attorney. It was noled thai while althe Hartford ORO office. Mr. Ng did not appear to be in
pain. Mr. Ng was released back to the cuslody of lhe WOF officer without incident.

Mr. Ng arrived back to the WDF at approximately 17:30 hours. Mr. Ng waS again carried by
several officers from the transport van to his cell in the HSU. There is a videotape of the
movement of Mr. Ng from Ihe transport van 10 his cell. This is video from stationary cameras in
WOF and Ihere is no sound. On Ihe video. Mr. Ng is shown being carried stomach down by four
(4) WOF guards. One guard is holding each arm and leg. Mr. Ng has restraints on his hands and
OffiCIAL USE ONLY SENSITIVe
OFFICIAl. USE ONLY Page 17 of 33

DEPARTMENT OF HOMeLAND Sl!CURITY 1. CAS!! NUMBER

REPORT OF INVESnGAnON
CONTINUAnON
HB 42lIII-01

feet. The WDF guards place Mr. Ng on his bed faee-down. The reslnlints are removed from his
feet and hands. The guards tum Mr. Ng over 80 he Is laying on his back and a medical slaff; It
appears to be a doctor, kneels down by Mr. Ng and appears to be evaluating him. No wheelchair
was provided for his movement.

P~I~~liia~W~D~F incident report explaining his involvement when Mr. Ng

returned to the IF CO reported thet upon the arnval of the transport van. he opened
the rear door and observed Mr. Ng sitting upright. CO _ reported that Mr. Ng would not get
out of the van. CO _
earned to !he medlcsl unit. CO
while lying on his bunk.
_reported
repQrIed thai supervisors were on the scene and Mr. Ng was then
thet he observed Mr. Ng hed urinated on himself

Incident report explelnlng his Involvement when Mr. Ng

reported thai he assislad In moving Mr. Ng from the InInaport
van securing Mr. Ng'sleft ann asslsled him to the medical unit. CO _reported thet he
provided Mr. Ng with his dinner and a second rnsttraas par medical ardara.

CO
_reported
a WDF Incidenl report elq:.'alrling his Involvement whBI1 Mr. Ng

standup and walk by himself Inlo the facility. CO

to the WDF, Mr. Ng rel'used to
reported that he and three other officers
were dlrecled by a supervisor to pickUp Mr. Ng by hI1I anns and legs to the HSU for
evaluation.

CO incident report explaining his Involvement when Mr. Ng

returned to the reported thet upon erT1val to the WDF, Mr. Ng refused to walk
by himself. CO he and three othar officers earned Mr. Ng from the InInsport
van to !he HSU.

CO Incident report explaining his involvement when Mr. Ng

returned to !he theI ~ the activity watch for Mr. Ng thai evening, he
obServed Mr. Ng lying on his back asleep. CO _ further reported thai Mr. Ng received his
dinner without any Issues.

The CO incident reports were reviewed by their supervisors thet same day. Despite their
knowledge that Mr. Ng hes complained about back pain and his requests for a wheelchair, the
WDF Suparvlsotl characterize Mr. Ng'S behavior as "non-compliant" and a "distraction.'
the raUOnale for shutting off the numerous Urnes the move of
OFFICIAL USE ONLY SENSITIve
OFF1CIAl. USE ONLV SENsmVE Page 1. of 33

DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESnGAlION
CONTINUAnON
lIB &20041 (37). $llllClllAelnt_

Mr. Ng from his room \0 the traMpart van was \0 "de-escalate the situation"; however, there Is no
evidence of what behavior Mr. Ng was exhlbiling that would necessitate any sort of de-escalation.
(EN 3)

July 31, 2008:

CO prepared a WDF Incident report explaining his involvement afler Mr. Ng was
retumed \0 the HSU. CO_reported that he did nol nolice Mr. Ng performing any type of
acttvity between 23:00 hours, on July 30, 2008, until 08:00 hours on July 31, 2008. He stated that
Mr. Ng appeared \0 be sleeping on his back and his right side during the night.

At approximately 08:00 hours, CO _ prspared a WDF report explaining his

Involvement eller Mr. Ng returned to the WDF on that date. CO reported that he did not
witness Mr. Ng perfonning any activities during the aCtivity watch 23:00 hours, on July 30,
2008, until 06:00 hours, on July 31, 2008.
PAlIP81'E1d a WDF incident rep01l explaining his Involvement with Mr. Ng in the
reporleld that he witnessed Mr. Ng eat his breakfast lind lunch, and that he
on his bunk and storege bin.

Mr. Ng was scheduled for a visit with his attorney. ~ this time, Mr, Ng was transferred from the
HSU \0 the contaet visitation sscUon of the WDF. The movement was recorded via hand held
camcorder. During the movement. Mr. Ng did no! appear to be In any pein end appeared to
cooperate with ollieara and medical staff. Mr. Ng did no! display any discomfort In his movements.

The video eteerly shows Mr. Ng being transported vie wheelchair to his appointment at
approximately 16:50 hours. At approximately 19:45 hours. Mr. Ng's visit with his allomey
concluded. and he was transported back to the HSU vie wheelchair. Mr. Ng did nol display eny
signs of discomfort or pain during this movement.

CO _ _ prepared e WDF Incident report explaining his Invotvament with Mr. Ng. CO
~t he observed Mr. Ng lilting on hie storage bin In his cell. CO _reported
that Mr. Ng hed be~n a change of clothes and was put In a wheelchair, In order to attend an
attomey visit. CO _stated that Mr. Ng was given his dinner tray without any Issues.
a WDF incident his Involvement with Mr. CO
OFF1CIAL USE ONLY 8ENSITM!
OFFICIAL USE ONLY 8EN81TNE P881110'"

DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
CONTINUATION
H84200-01

_reported that he observed Mr. NO after he attended his visit with his attemev. CO_
reported that Mr. NO was escorted, via wheelchair, to his HSU. CO reported that he
helped Mr. NO out of the wheelchair with the help of m.ne reported that the
enUre Incident was reClOl'ded on video by Shift Commander UB!Jle~lanl

prepared a WDF Incidant report explaining his Involvement

reportEld thaI Mr. N~ from a wheelchair 10 his bed after
relurnlng from a visit attorney. MY _report did not Identify any speallc Issues
regarding Mr. Ng'l condition.

August 1. 2008:

prelparEld a WOF ~ort expleining his lnvoIvement with Mr. NO

HSU. CO_reported that Mr. Ng.lay In hie bed throughout
reported thaI Mr. Ng urinated and defecated on himself. CO
medical staff and other officers cleaned Mr. Ng.

Dr. _ MD, scheduled an emergency CT scan for Mr. Ng at the Memorial Hospital In
PawtuckaI. RI. At approximately 14:50 hours, Mr. NO was transported to MemOllal Hospital In
Pawtucket, Rhode lsIand by members of the Central Falls. RI, Rescue Squed. The movement was
videotaped by WDF ofllcers. At the time of the movement, Mr. Ng appeared 10 be calm and not

_If
experlenang any discomfort.

In the video. the voice of one of the Rescue Squad omcers clearly asked the nurse on duty (later
IdenURed as LPN Mr. Ng could walk. The nurse repned thet Mr. Ng could not walk, but
that he could cry end whine. At this time. the Rescue omcer advised Mr. NO that they were going
to bring him 10 the hospital. At this time, Mr. Ng was placed on a whealed gumey without Incident.

While lying in the gurney, one of the Rescue omcars observed bruising on Mr. Ng's arm, and asked
how he received those bruises. Mr. Ng replied that he was dragged through the hanway. At this
Ume, Mr. Ng wal placed In transport restralnls without Incident. During this movement. Mr. Ng did
not appear to be experiencing any discomfort. Mr. Ng was moved out of the HSU wlthoullncldent.

thaiDr._
A WDF Incident report was prepered by H S A _ . HSA_ repened that Mr. NO wes
unable ~t on his legs and was periodically Incontinent. HSA
MO. ordered an emergeney CT acen and Mr. NO was
In Pawtucket, RI.
OFFICIAL USE ONLY SEN8ITIVE
further reported
10 MemOl'iaI
OFFICIAL USE ONLY SI!NSlnve ' ... 2Oof33

DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
CONTINUATION
H842QO.111

Another Incidenl report '!!!!.I!!!pared by regarding his contact with Mr. Ng al

Memorial Hospilal. CO _ reported thai to him that "Whatever Captain dragged
me In R&D on Wednesday Is going to should just sign the house over to my wife, go
back to Hong Kong and kll myself." reported that after Mr. Ng made the comments
regarding suicide, he advised Mr. Ng that he needed 10 remain posillve and consider his family.

CO further reported that he was present while the Doctor explained the resulls of his MRI.
CO that the Doctor edvlsed Mr. Ng that his injuries were praexJstlng. Mr. Ng told
the that they happened while in the faeRlly. The Doctor then notad the bruising on Mr. Ng's
arms. Mr. Ng edvlsed thai they were a result of being dragged from the facIHIy and the courthouse.
CO _ fur!l!!!!:.!:!Por thai the Doctor advised thai it may be something for social services 10
look into. CO _ reported thai the Information was passed on to his supervisor.

1'II1hll'1I19:52 hours, MaJor_edlllsed,lIla emall.WardenSallsbury.AW_and

Mr. Ng was admitted to the hOSPItal and that an MRI revealed potantlaillertebrae
problems and a possible tumor In his liver.

hours. Captain_advised, via email. the HSU, Warden Salisbury.

and MaJo~a to the results of Mr. Ng's MRI. II wes necessary
the hospital for further observation.

AW _that
At a~mately 21:30 hours, MeJor_advised, via emall, Warden Salisbury, AW _
Mr. Ng was golng 10 be moved to
neurological bad. At approximately 23:41 hours,
10 be pieced in a
and

edvlsed thai Mr. Ng was moved to

Rhode Island HOSPItal.

ICE ORO was notified that M:.~m the WOF 10 Rhode Island Hospital, 2 Dudlay
Street. ProIIldence. RI. ( S I R " - -

Augusl 2, 2008:

Beginning on this dille, email correspondence between Warden Salisbury and other WOF staff
mambers. Indicated that necessary arrangements were made to facilitate family and legel counsel
IIlslts at the Rhoda Island Hospital.

Augusl4. 2008:

OfFICIAL USE ONLY 8EH81T1VE

OFFICIAl. USE ONLY 8EH81T1VE PageZ1of33

DEPARTMENT OF HOMELAND SECURITY 1. CASE! NUMBER

REPORT OF INVCSnOAnON
CONnNUAnON
HlI42IJO.01 (37). S;oodaI

In a letter 10 WDF Security Staff, Warden Salisbury informed officers that Mr. Ng was 10 remain
resIraIned (soft reslnllnts) and under dose observatlon. Further. an unarmed oftIcer was 10 remain
In \he room with Mr. Ng at aD Umes. Telephone calIS and television ware authorized and needed 10
be documented In the log book. Femlly and attomey visits were authorized. Wardan SalisbUry
advised that theee dlrecUves ware a deviation of normal policy and only pertained 10 Mr. Ng.

August 5, 2008:

Multiple relellves ware scheduled 10 visit Mr. Ng In the hospital. At approximately 20:01 hours,
Major_ advised \het Mr. Ng's family had visited him and lhen left the hospltel without
Incident.

AugustS, 2008:

ICE ORO SDDO~as notified by WDF AW _lh!rt~r.tm had passed away al \he
Rhode Island Hospltel al approximately 01:22 hoUIS. ~immediately advised ORO
~SIIUallon and a Significant Event Notillcetlon was created. (SIR

INITIATION OF THE INVESTIGATION:

On August 19, 2008, the Investigation was assigned 10 the ICE, Office of Professional
~~ (CPR). Rellidenl Agent In Charge (RAC). Portsmouth. NH ofllce under file

On December 11, 2008,ICe received the Autopsy Report from the Rhode IsIend Department of
Health. In this report, \he Chief Medical examiner concluded that Mr. Ng cause of death was
complication of metastatic hepatooellular carcinoma and the manner of death was nalurel.

During the course of Its InvasligaUon, OPR interviewed a loIal of 158 Individuals 10 Include: ICE
ORO Hllltford. CT employees; personnel and detalneas al the Franklin County Jail In St. Albans,
VT; the Franklin County House of CorrecUons In Greenfield, MA; and the Wyatt Delention Faclnty
In Cenlnll Falls, RI. In eddltlon 10 the Interviews conducted. CPR was able to review and obtain
documentary Information at each locallon 10 Include: medical records. detainee files. facUlty
policies and reports, video surveDlance tapes and Intamal correspondence.
ISSUE ONE: Danlal of Medical Care
OFFICIAL USE ONLY IBNsmvE
OFFICIAL US! ONLY SENSITIVE Page 22 of 33

DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIOAnoN
CONTINUATION
HB4:zoo.o,

findings:
The Investlgal/on revealed that In accordance with tha ICE National Oelanl/on Slandards (NOS).
Mr. Ng was given I medical evaluation and mental health screening upon entering WOF (July 20.
2001 - January 10. 2008). Franklin County House of Corrections In Greenfield. MA (January 10.
2008 - April 11. 2008). and the Franklin County JaD In SI. Albans. VT (April 11. 2008 - July 3,
2008). Howaver. upon hili relum 10 the WOP (EN 4) (July 3, 2008 - AugustS. 2008). we found that
he was nol given a follow-up medical examlnal/on within 14 days of admission 10 a facility as Is
required by the NOS. (EN 5)Thls represents a failure of the ICE National Detention Slendard
requirement that detainees be provided a 14 day physical. On July 1. 2008. HSA _ performed
a medical record quality assurance check list and noted that all referrals had bean medEI. The 14
day physical was not naiad. HSA_ may not have considered the 14 day physical 10 be a
referral or she may have overiooked the failUre. The HSA Is accountable for making sure that the
14 day physical Is performed In a timely mamer.

ThlslnvesUgallon also revealed that on July 21 and July 29. 2008, Mr. Ng was denied access 10
approprlala medical care.

On July 21. acoordlng 10 the madlcal records. Mr. Ng was ·offered" all of his prescribed medication
on this date. but he "refusad"to get out of bad and come 10 the cell door 10 recaive his medication.
(EN 6)

The WOF medical records reflact that Mr. Ng was dispensed his prescribed medication later thai
same evening and through the foRowlng day.

The appficable policy In effect at the \lme (Policy #406 - PharmaceuUeals). provided as follows:

All detainees scheduled 10 receive medication at I partk;ular medlcaUon line must report 10 receive
the prescribed medlcal/on. In the evenlthay refuse 10 do so or faR to do so, tha HSU wlR be
responsible 10 liking appropriate subsequent action. Including but not limiled 10, subsequenl
counseling of the Impact of nal taking prescribed medications as directed or terminaUon of the
prescripl/on.

The policy then In effect did not speclflcaPy require medical personnel to administer the medication
if refused by the detalnae. (EN 1)
In fact. bssad on the severity and extent of Mr. Ng's physical condll/on. It Is evident that Mr. Ng did
no\ "refuse" his medications, bul rather was physically unable 10 himself out of bad end 10 Ihe
OFFICIAL US! ONLY SENSITIVE
OFFICIAL US! ONLY SEN8lnv! Peg.nofl3

DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
CONTINUATION
H94~t

cell door wIIhout proper assistance. By failing to lake appropriale action bringing the presc:r1bed
medlcetion direclly to Mr. Ng, the facility had ~enled Mr. Ng his medication. (EN 8) This
represents leilure to perform on the pert or LPN _ . If Mr. Ng stated !hat he couldn't come to
the door for his medicallons. il was her duty to either ensure that he rec:elvas his medication or to
obtain a signed medical refusal from the detainee and 10 report this to a medical authority. Withoul
a signed refUsal It Is noIln 8 nurse's scope of precUca to withhold rnadlc:atlon ordered by a
physician. DoIng so represents medical dac:isIon·mak~nd her aulhorlty Ell an LPN. There
Is no record In the medical chart to indicalethal LPN _Informed 8 medical provider of this
incidenl nor Is there 8 medical refusal form In Mr. Ng's file.

The second specific denial occurred on July 29, 2008. Mr. Ng was schsduled for a CT scan al
Rhode Island Imaging on thai date. Mr. Ng requesled a whselc~er to attend this scan.
According 10 facility records, the wheelchair was denied by ON _ because Ihsre was no
standing order In placa at that time for Mr. Ng to utilize a wheelchair. (EN 9)

The WOF recorda describe this as a "refusal" by Mr. Ng: however, there is nothing In the WOF
records thai indicates Ihst Mr. Ng actually "refused" 10 attend Ihs appointment Relhsr he
Indicaled thai he was unable 10 move without the assistance of a wheelchair or oIhsr mobllty
device. WOPs denial of Mr. Ng's request for a wheelchair constructively denied Mr. Ng access to
the presaibed scheduled CT scan. (EN 10)

In addillon 10 the denials of access to approprlale medical care on July 27 and July 29, It is unclear
from the records whether a WDF doctor properiy evaluated Mr. Ng after his trip 10 the Pawluclcst
Hospital emergency room on July 26. The medical progress notes dated July 26, stale that Mr. Ng
was unable 10 walk or bear welghl on his legs and he WEll &enllo the hospital for an evaJualion.
He was sent back 10 WDF with discharge papers and three (3) presc:r1ptions. The only note In the
file aflar he was released from the Pawtuckel Hospital on July 26 is dated July 27 stating that Mr.
Ng returned 10 WOF, appears stable, and Dr. _ MD, was aware of Mr. Ng's "situation.·
While Mr. Ng was seen by RN _ o n the July 27. there Is no Indical/on thai a doctor met
with or evalualed Mr. Ng after his retum from the hospital. There is no Indicallon thel a doctor
evaluated Mr. Ng'8 emergency room dlecharge papers 10 determine a course of treatment. In fact.
according 10 the medical records Ills not untIl July 29lhst Mr. Ng Is 8981n seen by a doctor. (EN
11)

This is a failure on the pert of RN _ t o alther properly inform the physician of Ihs ER
evaluaUon or 10 sutllclenUy docuni8riiihli1O the medical record. The ER documents have clear
orders and InstruClions thaI were neither translated to the WDF medical record nor shown to have
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DEPARTMENT OF HOMELAND SECURITY 1. CAse NUMBER

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CONTINUATION
H84~1

been evaluated and dismissed by a WDF provider. This constitutes medical decision-making on
the part of the RN and Is beyond her scope of practice or authority.

ISSUE TWO: Denial of Access to Counsel

Findings:
The Investlgallon revealed that while detained et the Frankftn County Sheriff's OffIce In Greenfield.
MA. and Franklin County Jail In St. Albans. VT. there was never any Indlcetion that Mr. Ng was
denied acce.. to his altomey. However. our invesUgation revealed that on July 26. 200B. whOe
detained at the WOF. Mr. Ng was constructively denied access to his attorney.

The InvestigaUon revealed that Mr. Ng did not meet with his attorney on July 26, 2008 because a
not provided to take him to this scheduled meeting. Through the on-site CO.
Captaln_ Informed Mr. Ng that he would not be allowed use of a
Instead ~ulred to walk to the attorney visitation room. (EN 12)

According to Captain _ . that decision came from Malor_. the on-duty supervisor at

0,._
the facility. Based on this denial. Mr. No decfmed the altomey visit. Mr. Ng's ~s
Informed that Mr. Ng had declined the visit by the on-duty supervisor Captaln_

Given that on July 24th. just two days prior. MO. hed submitted a consultation
request for a CT seen for Mr. Ng. noting that Mr. Ng was suffering from pain and weakness and
was unable 10 stand or walk. It Is clear that he was not "refusing" to meet with his altomey on July
26th as notad In the facility reports. A mora apt description Is that he was physlcaDy unable to do
so by walldng under his own strength or with the use of the prescribed cane. In fad. the amcer
attending to Mr. Ng at the time of this requested a wheelchair for Mr. Ng
relaying to his commanding oflk:er. Captain Mr. Ng was "In need of a wheelchair
and wasn' actually refusing his attorney It Is evident that at the time, officials
at Wyatt were viewing Mr. Ng as being purposefully "non-complalnt" and classified this incident as
a "rafusal" to cooperata. Given Mr. Ng's condition as documentad In his medical reports, end tha
circumstances of the Incident as repoded by the CO who was physicaDy present with Mr. Ng and In
the bast poslUon at the lime 10 essess his behavior and needs, by denying Mr. Ng a wheelchair or
like mObility devica, the facility conslrUclively denied him access to his attorney. Further, It was
medically epproprlate to accommodate Mr. Ng's reported pain and inabUIty to ambulate with the
use of the cane. This should have been determined by a medical provider and not by Captain
- . a non-medical officer. (EN 13) This represents a failure to provide orf8clNtate edequate
~ care or accommodaUon.
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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
CONTINUATION
HI 421JO.01 (31~

ISSUE THREE: Inappropriate Denial of Use of Whaalchalr

Findings:
The Invesllgallon revealed that Mr. Ng requested and was specllically denied use of a wheelchair
on July 26. 29. and 30.

As detailed above, on July 26 Mr. N~ed a wheelchair to facilitate his attomey client visit.
His request was denied by Captain _ and Mr. Ng was unable to meet with his attomey at
Jhat tima. At Jhe Ume of the denlel, no medical personnel were consulted end the on-duty
supervisor denied the request at approximately 16:00 hours.

Less Jhen two hours later, Mr. Ng was evaluated by RN _ w h o mede the determination that
Mr. Ng could not walk and was In need of a wheelchair and made the request that he be sent to a
local hospital for fUrther evaluation. (EN 14) Mr. Ng was given a wheelchair and transported to the
hOSpital where he was examined by a doctor and diagnosed with sciatica (lower beck pain). The
doctor slated Mr. Ng should receive pain medlcaUons for his condition and that Mr. Ng be
schacllied for en MRlto further evaluate his condition.

On July 29. Mr. Ng requested In order 10 attend his scheduled CT scan. SOt.-
notified his supervisor Caplain and department. AccordIng to fsclllty
records, the wheelchair was the DN because there was no standing order In
place at that time for Mr. Ng to utilize a wheelchair. Due to the denial, the on..<futy Supervisor,
Caplaln _ made the decision not to move Mr. Ng and the medical appolnlment was
cancelled. According to medical stafl'. It Is not uncommon for detainees to decline their
appointments for various reasons; therefore. the medical staff with the
~~!IlfI!1. Only after the CT scan was cancelled did the ON with Dr.
MD. regarding use of a wheelchair for transport. MD, wrote an order,
29. authorizing use of a wheelchair for Mr. Ng during tr8IlSp,ort.

On tha evening of July 29. It was reported to Warden Salisbury that Mr. Ng "refused" to attend his
CT scan and facility staff expressed concem over being able to transport Mr. Ng to his scheduled
appointment with the Hartford DRO office the next dey. While Warden Salisbury was apparently
unaware of the standing order for a wheelchair given by Dr. _ . MD. thai same evening.
he was on notice the Mr. Ng had a medical condition requiring repeated traatment and evaluation.
He nonelhelesa ordered. without addilionallnqulry, that Mr. Ng be "placed In the vanl Gently of
course" and thai the transport be videotaped In accordance with WDF policies. In his affldevlt, the
Wardan slated that he ordered the transport to be laped as he vieWed it as a potentlel use of force.
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DEPARTMENT OF HOMELAND seCURrrY 1. CASE NUMBER

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He further slated thai he did nol know althallime lIat Mr. Ng was ·physlcally unable" to attend his
appointment because his staff reported tha incident as Mr. Ng "refusing" his medical treatment.

On July 30, Mr. Ng was scheduled 10 attend an appolntmenl at the Hartford ORO office. As no
wheelchair was provided for the trensport, Ills apparent that either Or. _ MO's, Slandlng
order authorizing I wheelchair for transport that was contained In Mr. Ng's medleal records was
either nol known 10 facility slaff conducting the transport or was Ignored.

Mr. Ng's transport to Hartford was videotaped per the Warden's order. The videotape clearly
shows that:

1. Mr. Ng requested a wheelchair and that request was denied by Captaln_

2. The camere wes repaatedly shul off and tumed beck on altha request of Captaln_ In
direct vlolaDon of WOF Policy Number 206(K) and the Warden's order; and

3. The on-duty nurse, LPN was presenl during the transport and by slaOng that
Mr. Ng was In fact able to an Inappropriate medical assessment outside the aoope of
her authority with regard 10 the medleal sllueUon. This assessment directly contributed 10 the
su~ctIvIty by the detention steff In moving Mr. Ng without the aid of a wheelchair. Had
LPN _ performed her duty and contacted a medical provider, the physician notes end order
for a wheelchair given the previous day would have been discovered;
After revlewI~ videotape of Mr. ~'s trensport of July 30, the Warden verbaUy instructed AWs
_and _and Major_ to ensure that Mr. Ng ulillzed a wheelchair for all movement
within the facility and that those movements be videotaped. It appears those Instructions ware
followed when Mr. Ng was videotaped being transported to visit with his attorney on July 31.

Accordingly, the faclnty Inapproprialely denied whselchair 8CC8$S to Mr. Ng on July 26, July 29,
and July 30. Any argumenllhal a wheelchelr may be provided with a specific medical
aulhorizaUon Is undermined by the fact that on at least one occasion (the evening of July 26), a
whee/cheir was used without eny specific medical authorization form. The failure to provide Mr. Ng
with a wheelchair constructively denied Mr. Ng access to both his attorney and medical care, as
explained above.

ISSUE FOUR: VloisUon of Use of Force Policy

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVeSTIGATION
CONTINUATION
"42G041 (31). 8pecilllAII'.U_
10.
Findings:
WDF staff vlolated applicable Use of Force policies during July 30 transport of Mr. Ng.

It is apparent that Mr. Ng did not "rafuse"10 meet with lEA_In Hartford. CT. on July 30 (EN
15); rather he was physically unable to do so by walking under his own strength or with the use of
the prescribed cane. Fully appreciating thai Mr. Ng's phyalcal condition and associaled physical

Dr._.
pain progressively worsened over a very short period of time. he had cleady bean diagnosed with
severe back pain by July 14. 2008. at which point
or
MD. prescribed the drugs Flexerl
and Vicodln, and also recommended accommodation his physical condition by moving him to a
bottom bunk to make It easier to get into his bed.

Between July 14. 2008. and 30,2008. the record Is repleta with Incidents where both Wyatt
medical steff on notice that Mr. NO suffers from back pain. On July 16, DN
Informed Mr. was being treated for chronic back pain
DI'II!l:lIerilbAd medications. auIhoI1zes use of a cane due to
back pain and difficulty walking. On July 22. ON notified by Mr. Ng's
thai Mr. Ng's condltlon continues to worsen. On Ng Is examined end the recc)rds
Indicate that his back I!!!!:!..!!!s not Improved and he una\)le to stand or put pressure on his right
leg. AccordIngly, AW _ requests from ICE, and recaJves, approval for an expedlled CT scan.

On July 26, Mr. Ng Is observed by a WDF officer hsvlng dlmcully getting up from his calilloor and.
according to Captain _ , required the another detainee to 11ft Mr. Ng Into a
seat. That same day he Is also observed by RN falUng to the floor when he attempted to
stand up with the use of his cane. On July 29, a report by Sergeent (Sgt.) _
_ Indlcetes thai Mr. Ng Is observed silting on his bed, crying and stating thel he could not
move and Is unable to attend his medical appointment. Latar that same evening, Mr. Ng was
examined by D r . _ MD, who advised In his prog~aI Mr. Ng had weakness in
his right leg. was una\)le to stand and was constlpaled. Dr. _ MD, edvlsed thai he
explained to Mr. Ng that a CT seen needed to be done as soon as possible. D r . _ MD,
advised that Mr. Ng may need asSistance wHh trensponaUon end aulhDrized the use of a
wheek:hslr at thet time.

Over approximately the same period or time, Mr. Ng was placed under an "activity walch" to
determine the veracity of his medical complaints. That acllvlty watch, however, apparenlly found
litUe or note as the relevant ac\lvIty reports offer nothing or note.

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGAnON
CONnNUATION
H84200001

Simply stated, we lind no evidence supporting Ihe Isseltlon lhet Mr. Ng was In fact being·
non-compliant" In any wilIng sense, or that It was reasonable 10 view his as rafUslng or being
non-complaint during the operative time frame. Moreover, there are no IndrcaUons or allegations
for that matter that he waa In anyway offering resistance 10 guards or medical staff at Wyatt. Use
of force In this context Is in complete violation of thl ICE National OetenUon Slandard (NOS) on
Use of Force. whk:h prohibits use of force against I detainee offering no raslstance. Even If he
was viewed as non-compliant. there Is absolutely no IndlcaUon that Mr. Ng offered any resistance.

Even assuming, however. that Ng could reasonably be viewed as "non-compltant" and that the use
of force was appropriate. Warden SaUsbury concedes that Wyatt officers then violated their own
use of force policies during thalr contact with Mr. Ng on July 30, 2008.

According to WOF Policy Number 206. Section K. the Shift Commander will designate a slaff
member qualified to operate the video recorder to record the movement Each video recorded
Incident waJ be InlUated verbaUy on tape by Ihe assigned recorder with the follOWing InfonnaUon:

1. Current data and Ume;

2. Neme and tlUe of person operaUng the video recorder;
3. General and spedllc location where Incident Is being recorded:
4. Names and tiUes of staff members Involved In Ihe use of forca;
5. Name and tiUe of on-scene Commander;
6. Namas and titles of s1Bff members ancllor visitors wllnsssing the incident: and
7. Name of dalalnee(s) Involved In the incident
All incldenls are to be recorded In their enUrety. If there Is an equipment failure during the
recorcrll1g of Ihe incident, a full written report will be submitted by tha assigned operator.

Upon review of Ihe vldeolape and reports, Warden Salisbury Identifies numerous direct violations
of the WOF policy and his eman directive of July 29. Based on the WOF poncy, the videotape
failed to Include Ihe title of person operating the video recorder; location of the incident being
recorded; name and title of staff Involved; neme and title of the on-scane Commander; name and
uue of staff anellor visitors witnessing the incident. Additionally, the Warden noted that !hera wens
12 breaks In the taping. which Is another violation ofWOF policy. The Werdan commented In his
affidavit that the vldeolaplng slopped after "a wink of Ihe eye" fron1 captain _ the
supervising officar.

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CONTINUATION
HS42QO.Ot

In addition, WDF PoDcy Number 206, VIII. Po. 3. specifies that "In every case, only the minimum
force necessary shaD be uaed.· As Is made dear from the videotape and reports of the July 30,
incident. Wyatt olflclals look Mr. Ng by his upper extremities and dmgged him from his cell to the
R&D unit and Inlo the awaiting van. Wardan Salisbury offers that policy and procedure In such
circumstance dictate that oftlcers use a wheelchair or gurney 10 effectuate a transport. By
dragging him Instead, Wyatt ofllcars did not UBe the mtnlmum force necessary and violated
eslabUshed usa offorce policy.

Warden's affidavit. AW _After

AW _also reviewed the videotape and Incident reports of July 30, 2008. In addHlon 10 the
Action Report supporls our ftndlngs thet the WDF staff did not
follow Its estabUshad policy and procedures and there was an overall fallum 10 exercise good
jUdgment in tha transport of Mr. Ng from his room 10 tha transport ven. (EN 16)

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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
ExhlbltUat
H84200001

ENDNOTES

1.) A count by_Inspector, Professional Standards Unil. WOF, revealed that the
camera was s~alotal of 13 tlmas. The breaks in taping range from a few seconds to
a few minutes.
to Warden Salisbury. after reviewing omcer _ _ ortginal report. Captain
dullmUlod thai raport and ordered Officer _~raport. While Captain
was Offlcer_ oriOlnal report 10 be illegible, aCCOrding to the
iiiii1iiiI'sed..!!2!!!.!!lclude that Mr. Ng wal being •
non-compuanL· nor Captain_agreed 10 be Interviewed by OPR for
purposes of this Investigation.

3.) Major _ and Associate Warden a WOF Incident report.

dated Au~bssed upon review of an submitted end videotapes of the July 30
incident. The report summery findings are as follows:

a. Captain _ w a l the senior officer in charge overseeing Mr. Ng's move for transport 10
and from w"'Y8R"OiiTuly 30.

b. Captaln_falted to exercise good judgment in violating established polley by direcllng

and signaling the video operator 10 tum off the video camera no less than 9 tlmas.

c. Captain _ f e l l e d to Utilize proper transport options (wheelchair and gurney). Inslead

forcibly ca~dregglng Mr. Ng from the Health Sarvlcas Unll to Receiving and DIscharge.
This Is spscified a. a violation of established policy and procadura.

d. Captain _exhibited Iotal disregard for staff and detainee safely by transporting Mr. Ng
In a mannerciiif1Y'UnauthOrized by polley and procadure.

e. Captain _BlChlblled cond~1 unbecoming a senior officer by telling Mr. Ng to stop

whlnlngan~hlm8 _ _ idIof". \!JOrd ~(l(kd b-.j ?fO:pC.m v\
f. Captain _ l a c k of Judgment and failure to adhere to established policy and procedure
subjected iheTaCiiiiYTo federal and clv" lawsulta.

The report wall received by the Warden's office on August 7. 2008.

Du.in" the 16-18.2008. revlaw Creative Correcllons of America,

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DEPARTMENT OF HOMELAND SECURITY CAse NUMBER

REPORT OF INVESTIGATION
Exhibit List

was found not to be In compliance with the NOS requlremenlthal all detainees receive a medical
examlnaUon within 14 days of admission to a lacnlty. Wyatt hes been working with ORO on
corrective actions to address this.

5.) The file reflects thai Mr. Ng was given a 14-dayexam; however, the exam occurred on 7123. 20
days after his arrival at WOF. Also. Ills unclear If the exam was done because of NOS or because
of his repealed sick allps.

6.) According to C O _ Incidenl Report of thai day, at approximately 1:03p.m, nurses

entared Mr. Ng. room to distribute medicine but when Mr. Ng "would not gel up to receive medicine
therefore he refused to take medicine.. If unable to move to receive his medlcatton. this should not
be charecterized .. 8 "refusal" to take his pf88Crlbed madlclne. DlII:!!:Jl..!!!!evening Mr. Ng again
stated ha could not get off the bed. Al dinnertime, according to CO _Ineldant Report. when
Mr. Ng staled he could nolgel oul orbed to receive his dinner lood tray, CO_"wan1 over
and handed delalnee Ng his trey."

7.) WOF polley has subsequently been changed. As 01 November 5,2008.11 the delalnee cannot
attend the Medication Une, medical personnel wnl respond 10 tha delalnee's call or Iocatton to
administer the medication.

8.) Affidavits of Wyatt employees. MT _ RN _ and others. Indlcale that leading up to

Dr._.
this Urneframe. it was a common theme of discussion that Ng was having difficulty coming to the
madlcatton line and using the assistance of other detainees and a chair to get his med'lC8tton.

9.) II was not until later that evening that Mr. Ng was evaluated by MO. who
approved an order for the use 01 a wheelchair.

10.) AddlUonally. on July 8. 2008. Mr. Ng requesled to see a doctor. advising that he had not slept

Dr._
for two nights because of back pain. Again. on July 10. 2008. Mr. NO again requested to see a
doctor for beck pain relief. In his requesl Mr. Ng sliltes "[PJIease arrange doctor visit for me when
he comes to facility next time.· The WDF medical records It was not unlll July 14,
2008. that Mr. No was examined by MD. MD. then prescribed Flexeril
(a muscle relaxant) and Vicodln (palnldlliijlO'i"iWO waek8. MD. rurthal'
recommended thai Mr. Ng should be moved to 8 bottom bunk make It easier for Mr.
Ng to get Into his bed.

11.) Although not seen by a doctor. on July 27 LPN _ "Instructed" Mr. Ng to start "back
exerciaes." The medical file does not indicate any madleel order that Mr. Ng do Iny 801'\ of "back
exercises' and there Is no Indicalion that Mr. was advised 01 particular exatd... or tha
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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

REPORT OF INVESTIGATION
exhibit List

0'
duration exercISes for his condltlon. Additionally,
resistant to an insIJUction and refused to stand and come
characterizes Mr. Ng as "very
for mads." Again, the
circumstances support a finding that Mr. Ng was very likely unable to walk and his actions were not
a "refusal" but an lnablilly to move.

12.) Wyalt employee CO that on July 26, 2008, Mr. Ng was In

need of a wheelchair to also noted that a nurse hed
commented that he, Ng, needed a whl,elchalr could not adequalely care for Ng's
needs.

13.) In addition, whUalt Is not claar exac~MaJor_ told Captain _ regarding

_to
the wheelchair and to what extent Major_ was aware of Mr. NO'S medlcai history at Wyalt, at
a minimum there should have been further inquiry Rlgardlng the true nature of Mr. Ng's condltlon.

14.) RN _ hed been called by Captain alSess whether Mr. ~Ie to

ambulate after he had declined his attorney visit. WhHe evaluating Mr. Ng, Nurse_request
that Mr. Ng stand up by using his cane. Whle attempting to foUow the Nurse's orders, Mr. Ng
coIlapsad to the floor. Nurse _ then recolI"lIended that Mr. Ng be sent to the Memorial
Hospital in Pawtucket, RI, for further evaluation as she was concerned that he may have hurt
himself when he fell.

15.) Warden Salisbury Identifies numerous other vlolalions of pOlicy or his spsclfic instructions:

a. Medlcai start Is not visible nor are they making medical decision during movemant from the
Health Services UnIt;

b. Mr. Ng is "dragged" In contravention of policy for movement of detainees;

c. Mr. Ng is placed on the floor for severel mInutes with no medical attention (Instead she (the
attending nurse) yans at Mr. NO from outside the cameras view); and

d. The supervising officer, Captain _ does not accurately report the Incident es per
required poUcy.

In add~rtiCIJlarly
Offlcer_ to
rewrlle the report. WhIle
to be to
that
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DEPARTMENT OF HOMELAND SECURITY 1. CASE NUMBER

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REPORT OF INVESTlGAnON
ExhlbltU.t

16.) As Identlfted by the Warden, that Captain violated established

policy and procedures· by .~ the video oIf the video camera
a number of limes. Captaln_ was found to have faled to utilize "proper and available
lransport options (wheelchair and gurney)· and "elected" for "forcibly carry" Mr. Ng from his room to
the transport Braa.

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