How do ICE’s detainee death review processes and ODO inspections work and what reforms have been proposed?
Executive summary
ICE’s detainee death reviews are governed by internal directives and a 2021 notification policy that require rapid reporting, internal investigations by the Office of Professional Responsibility (OPR)/Office of Detention Oversight (ODO), and separate clinical mortality reviews by IHSC, but critics say those reviews are opaque and inconsistently applied [1] [2] [3]. ODO inspections—created in 2009 to provide independent facility oversight and evaluate “core” detention standards—are intended to catch systemic problems before deaths occur, but multiple reports find inspections often superficial, uneven, and declining in frequency even as detainee populations and deaths rise, prompting a slate of reform proposals from advocates and oversight groups [4] [5] [6].
1. How the death-notification and review system is supposed to work
ICE policy requires field offices to report a detainee death within hours and to trigger a series of reviews: OPR/ODO investigations, internal management reviews, and a clinical mortality review by ICE’s Health Service Corps (IHSC), and ICE posts death reports for recent fiscal years as part of its transparency obligations [2] [3] [1]. Directive 11003.5 and the 2021 Notification, Review, and Reporting Requirements frame a multi-layered process intended to collect autopsy, forensic, and contract-review material so the agency can determine whether standards were followed [1] [3].
2. What ODO inspections are designed to do—and their limits
ODO inspections were created as an “independent” second set of inspections to review facilities that hold detainees over 72 hours and with average daily populations above ten, focusing on a set of core standards tied to life, health and safety; ERO also contracts third‑party inspections (Nakamoto) to evaluate compliance using checklists like Form G-324A [4]. In practice, inspections can be scheduled in advance, emphasize whether written policies exist over how they are implemented, and historically have treated detainee interviews as peripheral, undermining their ability to document lived conditions that contribute to deaths [4] [6].
3. Evidence of failures and declining oversight
Investigations and advocacy reports document discrepancies: facilities that later saw deaths often had passing inspection reports immediately before and after those deaths, and watchdogs say ODO and contractor inspections have been too forgiving or perfunctory—echoed by a 2019 OIG finding that contractor inspections were “very, very, very difficult to fail” and that inspection scope and guidance were inadequate [7] [4] [8]. Meanwhile, Project on Government Oversight reported a 36.25% drop in ODO inspection reports in 2025 amid a surge in detention and deaths, raising concern that oversight capacity is shrinking when it is most needed [5].
4. Critiques about transparency, accountability, and conflicts
Advocates and oversight groups argue ICE’s death reviews omit facts, release incomplete reports, and sometimes fail to interview detained eyewitnesses—practices that can shield facilities and contractors from consequences and reduce public accountability [3] [9]. There is an implicit institutional agenda in preserving contractual relationships and operational capacity: ERO’s long-standing contracts with private contractors like Nakamoto and reliance on periodic, contractor-led inspections create incentives to avoid harsh findings that would trigger funding or contract consequences [4] [8].
5. Proposed reforms from advocates and oversight bodies
Reform proposals range from procedural fixes—requiring ICE inspectors to read all death-review documents and for ODO reports, OPR death reviews, and IHSC mortality reviews to be published within 30 or 90 days—to structural changes such as monthly public reporting on medical staffing vacancies and response times, independent external mortality reviews, and statutory consequences for failing facilities [7] [3] [9]. Some watchdogs also urge reinstating twice‑yearly inspections mandated by Congress and reversing inspection declines to ensure inspections align with detainee population trends [5] [4].
6. Where disagreements remain and the political stakes
ICE and agency defenders emphasize that detainee health is a priority and point to existing policies and reporting as evidence of oversight, while critics counter that internal controls have repeatedly failed to prevent avoidable deaths and that transparency is insufficient to restore trust [5] [2] [10]. Reform advocates frame changes as necessary to prevent further preventable deaths and to break a pattern where inspection paperwork and contractor reports mask on-the-ground neglect; ICE and some congressional actors may resist reforms that imply systemic culpability or require greater resources and independent oversight [3] [6].