A court

–

appointed monitor found that the death of a

8th

year-old girl in Border Patrol custody was preventable and was the result of a series of failures in the [Customs and Border Protection] medical and custodial systems for children, according to a

legal

submit

Tuesday

in federal court

on Tuesday

.

Anadith Danay Reyes Ivarez, who suffered from sickle cell and heart disease, died May 17 in U.S. custody. She was initially held at a border facility in Donna, Texas before being transferred to another in Harlingen, Texas.

Her fever had risen to 104.9 the day before she died. Her mother’s requests to send her to a hospital or for an ambulance to come to the border security facility in Harlingen were denied, according to a Homeland Security Department summary. The girl was eventually taken under custody to a hospital where she died.

The report was filed Tuesday as part of a long-running case over conditions for migrant children in custody. Monitor Paul H. Wise, a pediatrician and professor at Stanford University, made his assessment based on publicly available information and interviews, he wrote. He had previously briefly discussed the matter with the Associated Press.

Based on the information currently available, the death of [Anadith]

ADRA

was an avoidable tragedy that resulted from a series of failures in the [Customs and Border Protection]

CBP

medical and custodial systems for children, he wrote. The direct cause was poor clinical decision-making by the health care providers responsible for her care in Harlingen [Border Patrol]

bp

Station on the day of [Anadith’s]

ADRs

dead.

Wise said his report focused on the systemic failures that caused poor decision-making by several health care providers to result in the death of a child. systemic weaknesses that, if not corrected, are likely to lead to future harm to children in…

CBP

custody.

Wise noted that border police personnel were apparently unaware of the girl’s underlying medical issues and that it appeared that doctors or a local health center were not consulted about those conditions. He said what happened at the Harlingen facility raised a range of other serious concerns, not only about the immediate care she received, but also about the detention and medical systems that failed to prevent [Anadith’s]

ADRs

clinical deterioration and death.

Wise said it was not clear whether medical workers in Harlingen knew she had sickle cell disease

.

The judge monitor said he could not assess why health care providers in Harlingen were so reluctant to transfer Anadith to a hospital, but he interviewed health care providers in other areas.

Wise said this staff said Border Police officials have occasionally questioned a medical provider’s decision to transfer a patient to a local hospital, emphasizing the evacuation of [the agency’s]

bp

manpower associated with guiding families or children to outside facilities.

The Times previously revealed that an internal government report documented how officials at the detention center in Donna had complained about the overuse of hospital facilities.

Wisely, he emphasized that his report contained no information to indicate that those complaints had played a role in the girls’ case.

Border Patrol

bp

concerns about transferring people to local health facilities are understandable; but to confront medical personnel with these concerns when a transfer is being considered is both inappropriate and dangerous, he wrote. The decision to transfer an ill person to a local health center should be based solely on medical criteria, as determined by the appropriate medical staff.

Wisely recommended that the government take a series of steps including expediting the transfer of children from custody; working with a child counselor to monitor children in custody who have

underlying

medical conditions; and passing a statement to Border Patrol that only medical personnel should make decisions about transferring children to health facilities.

Neha Desai

senior director of immigration at the National Center for Youth Law, which is suing the government for caring for children in custody, said the report was enlightening.

“Dr. Wise’s report clearly establishes that Anadith’s tragic and preventable death was the result of serious systemic failures. These fundamental systemic failures were compounded by callous indifference to Anadith’s suffering,” she wrote in an email.

Border officials have said they are reviewing

for

detain medically vulnerable migrants and prioritize processing.

We continue to evaluate procedures, practices and equipment to ensure we protect those in our care, especially the most vulnerable, Troy Miller, Acting Chief of [Customs and Border Protection]

CBP

said in a statement in early June after the girl’s death.