EL PASO, Texas (Border Report) — An analysis of deaths at migrant detention facilities found significant violations of internal medical care standards.

Researchers at the University of Southern California examined the deaths of 55 people who died in U.S. Immigration and Customs Enforcement custody and found delayed or inappropriate care and/or inadequate or no response to abnormal vital signs.

The results were published JAMA Network Open.

Researchers also found that ICE violated its internal medical care standards in 78% of the 55 cases — which occurred between 2011 and 2018, primarily in relatively young and healthy men. In all, 71 individuals died while in ICE detention in that period.

“The ICE medical care team minimized or dismissed signs and symptoms of critical illness,” first author Molly Grassini, a physician in the Department of Emergency Medicine at the Keck School of Medicine of USC and Los Angeles County+USC Medical Center, said in a USC news release. “It is possible that these deaths might have been avoided if these concerns had been addressed.”

In multiple cases, researchers found, detention facility staff or other detainees raised concerns about a person’s health to a superior or staff member before that person’s death.

ICE has not responded to requests from Border Report for comment.

Researchers reported finding that 47 of the 55 deaths they analyzed were due to medical causes and eight due to suicide. The average age at death was 42.7 years, and the individuals (85.5% of whom were men) had lived in the U.S. an average of 15.8 years before spending a median of 39 days in custody before they died.

Medical staff often ignored vital signs, such as abnormal heart rates and blood pressure. According to one documented case in the report, a man with flu-like symptoms who grew increasingly ill was given supplemental oxygen only intermittently and not as directed by the advising physician. The death report also showed instances of oxygen levels not documented, nurses not notifying a physician of low oxygen levels, and oxygen levels not adequately monitored following administration of supplemental oxygen.

In their conclusion, researchers recommended that the Department of Homeland Security officials ensure timely, public, and transparent reporting, along with independent medical reviews, of all deaths in ICE detention facilities as well as those that occur within one week of release.

“Facilities with recurrent violations should undergo targeted rehabilitation and close monitoring. Those that are unable to meet predetermined benchmarks and fail to implement acceptable corrective action should be faced with penalties including possible closure,” senior and corresponding author Parveen Parmar, an associate professor of clinical emergency medicine at the Keck School of Medicine, said in a news release. “These processes are vital to ensuring that the dignity and health of the detained population are respected.”

As of July 8, ICE held 27,217 people in detention, according to Syracuse University’s Transactional Research Access Clearinghouse, which tracks immigration statistics. Of those, 79.6% have no criminal record.