AR 15-6 Investigation re: Death of a Detainee

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Army AR 15-6 investigation in to the death of a detainee at Camp Patriot; FOB Ironhorse. A detainee was brought to FOB Ironhorse for detention on February 5, 2004. He was complaining about being sick and an Army medic examined him on February 7, 2004. The medic failed to recognize the seriousness of the detainee's condition. On February 8, 2004 at approx. 7:00 am, the detainee was found dead in his cell. The inquiry determined it was natural causes and no foul play was involved.

Doc_type: 
Investigative File
Doc_date: 
Thursday, February 26, 2004
Doc_rel_date: 
Sunday, April 17, 2005
Doc_text: 

DEPARTMENT OF THE ARMY
HEADQUARTERS TASK FORCE IRONHORSE
OFFICE OF THE STAFF JUDGE ADVOCATE
TIKRIT, IRAQ

REPLY TO
ATTENTION OF:

AFYB-JA-AL 26 February 2004
MEMORANDUM FOR Commander, Task Force Ironhorse, Tikrit, Iraq
SUBJECT: AR 15-6 Investigation Legal Review

1. In accordance with AR 15-6, paragraph 2-3, I have reviewed the AR 15-6 investigation into the
circumstances surrounding the death of a detainee on 08 February 2004. I make the following
determinations:

a. The proceedings comply with the legal requirements.
b Errors in the proceedings, if any, do not have a material adverse effect on any individual's substantial rights.
c.
Sufficient evidence supports the findings.

d.
The recommendations are consistent with the findings.

2.
The investigation is legally sufficient.

3.
The point of contact is the undersigned at (DNVT11111111.1

CPT, JA Chief, Administrative Law
.67t,_-
6547
.1s
DEPARTMENT OF THE ARMY
HEADQUARTERS, 4TH INFANTRY DIVISION (MECHANIZED) REPLY TO TIKRIT, IRAQ, APO.,AE 09323 ATTENTION OF:
AFYB-SG 2 March 2004
MEMORANDUM for SJA, 4th Infantry Division (/vIech).
SUBJECT: AR 15-6 Investigation of the death detainee #11111 (b) Co-
After reviewing the findings, and statements from this investigation, r make the following
recommendations:
31
I. A Doctor or PA should review all intake medical screenings, and sign\date the form as reviewer. They
will personally examine detainees as indicated, based on the results of the screening form. This review(will occur after each transfer of an EPW as well as after the initial intake_
-2. A Doctor or PA. should conduct weekly rounds with MP medics.
3 - The intake medical assessment must be reviewed and,updated by the medic at the accepting facility:
The reviewer will sign .
the updated form_ All assessments will then bedeltVered-tae
0 tidte,te _ P v, 1 ,'rev
6548

REPORT OF PROCEEDINGS BY INVESTIGATING OFFICER/BOARD OF OFFICERS
For use of this form, see AR 15-6; the proponent agency is OTJAG. IF MORE SPACE IS REQUIRED IN
FIT.I ING OUT ANY PORTION OF THIS FORM, ATTACH ADDITIONAL SHEETS
SECTION I • APPOINTMENT

Appointed by C ro(no,r) 1 ()
(Appointing authority)
on 1 FES oLl
(Attach inclosure : Letter of appointment or summary of oral appointment data.) (See para 3-15, Al? 15-6.)
(Date)
SECTION II - SESSIONS
The (investigation) (board) commenced at co o O 5. £
at ia.on
(Place)
(Time)
on
(If
a formal board met for more than one session, check here
pax) D. Indicate in an inclosure the time each session began and
ended, the place, persons present and absent, and explanation of abSences, if any.) The folloviing persons
present: (members, respondents, c el) were
(After each name, indicate capacity, e.g., President, Recorder, Member, Legal ,4dvisor.)

The following persons
(members, respondents; counsel) were absent: (Include brief explanation of each absence.) (See paras 5-2 and 5-8a, AR 15-6.)
The .(investigating officer) (board)
finished gathering/hearing evidence at 153 6
(lInze)
and cornpleted findings and recommendations at
SECTION III - CHECKLIST FOR PROCEEDINGS
A. COMPLETE IN ALL CASES
1 Inclosures (para 3-15, AR 15-6)

Are the following inclosed and numbered consecutively with Roman numerals:
(Attached in order listed)
a.
The letter Of appOiniment or a summary of oral appointment data?
b.
Copy of notice to respondent, if any? (See item 9, below)

c.
Other cOrrespOndence-with respondent or counsel, if any?

ct.
All tither written communications to or from the appointing authority?
e. Privacy Act Stateinents
(CerOcate, if statement provided orally)?
f

Explanation by the investigating officer or board of any unusual delays, difficulties, irregularities, or other problems
encountered

(e.g„ absence of material Witnesses)?
g.. Information as to _sessions of a formal board-nOt included on page 1 of this report?

- .
h. Any"
other significant papers . (other than evidence) relating to administrative aspects of tbe investigation or board?

FOOTNOTES_
Exfiiciiii all negative answers on an attached sheet.
Use of the N/A column constitutes a positive representation

tebOarcl. that the circumstances described in the question did not occur in this investigation
DA FORM 1574, MAR 83
EDITION OF NOV 77 IS OBSOLETE.
Page 1 of 4 pages
SECTION VI-AUTHENTICATION (para 3-1Z AR 15-6)
THIS REPORT OF PROCEEDINGS IS COMPLETE AND ACCURATE.
below, indicate the reason in the space where his signature should appear.) (If any voting member or the recorder fails to sign here or in Section VII
blo Lf 6 7 c (71
(Recorder)
. (Member)
Wernher) (Member)
SECTION VU -.MINORITY-REPORT
(para 3-13, AR 15-6)
To the extent indicated in Inclosure the undersigned do(es) not concur in the fmdings and recomaiendations of the board.
(In the inclosure, identify by number each finding and/or recommendation in which the dissenting menzber(s) do(es) .not concur. State the
reasons for disagreement. Additional/substitute findings and/or recommendations may be included in the inclosure.)

(Member) (Member)
SECTION VIII -
ACTION BY APPOINTING AUTHORITY
Umra 2-3, A.A. 15-6)
The findingi and recommendations of the
(investigating Officer) .(bo.r4 are
substitutions). af felpfrFe429d) ,(dixapp-Feved). (approved with following exceptions/the appointing authority returns the proceedings to the investigating officer or board for further proceedings or
corrective action, attach that correspondence (or a summary, if oral) as a numbered-inclosure.)
1.
A doctor or physician's assistant should review all intake medical screenings, and sign/date the form as reviewed. They will personally examine detainees as indicated, based on the results of the screening form.This review will occur after each transfer of a detainee as well as after the initial intake
,.
2.
A doctor or physician's assistant should Conduct weekly rounds With military police medics.

3.
The intake Medical assessment must be reviewed and updated by the medic at the accepting facility.The reviewer Will sign and date the updated form. All assessments will then be delivered to the supervising

doctor or physician's assistant for review.
RAYMOND T. ODIERNO Major General, USA Commanding 7 MR: 2004,
.6550:Page 4 of 4 pages, DA Form 1574, Mar 83
USAPA V1.20 .
MEMO FOR. RECORD - EVIDENCE
On 04 Feb 2004, it was noticed by shift change that detainee1111111was
not moving. (exhibit G) After the medic summoned the physician on call,gaS G`•/

h 76
the EPW was onounced dead at 0730. (exhibit G) Prior to pronouncing he detainee,
had never seen, treated or been called to render advice
on the patient. (exhibit D) 6 loY b 7 c-V

Prior to arrival at FOB Ironhorse, the detainee was process_ ed at Brassfield Move FOB. (exhibit F) An intake physical done at that time by -2 c recorded ,that the patient had diabetes and anemia, as well as left fai ure. The diabetes notation was crossed off without explanation. (exhibit F) Of particular importance, it was noted that the detainee was urinating onl 1 oz.
daily. (exhibit F)
The detainee was,transported to Ironhorse on 5 Feb 2004. At the time of
reception, the detainee was noted to be frail appearing, weak, and required
assistance in dismounting the vehicle.(exhibit C) During the incarceration, the

,
detainee had two episodes of fainting or near fainting, one resultingin injury
requiring wound care. In addition, he was so weal that ha required assistancein
holding his head up for the photo ID'. (exhibit C)

of 7 Feb 2004, the detainee was seen by the-MP medic,
He stated that through an interpreter, the detainee
reported painful-unnation. No action was taken by the medic.texhibifl
'- - ,c:/ -, 74 q :64?ff::

s .
On the morning of 8 Feb 2004,, ,and: su mmonecit(:) the detainee's area becadse' he was not ritoVirt 4 e/ -6 7eci
-
check the detainee's pulSe and also noted that he vvas cold. (extil
detainee was last seen alive during,,the evening coffee andso up -"• adm

inistration..
• (exhibit A) Prior to the detainee'Sdemise, -the . patient was not interrogatedat FOB Iroot orse: (ekhibit-B)
FINDINGS:
1.
The medic at. FOB Ironhorse failed to recognize the seriousness of the
detainee's condition, did not read the intake physical and failed to contact
appropriate medical personnel for guidance and treatment.

2.

The medic at FOB Brassfield MAY not have recognized the seriousness of the
detainee's condition and may not have sought appropriate medical advice.

3. The medic at FOB Ironhorse appeared not to be aware of the detainee's
medical conditions and it appears that the intake sheet was not -available to the
medic.

6551
4. Although in hindsight, officer personnel at the detention center were aware of
the frail nature of the detainee, it appears that this was not communicated to the medic.
MEMO FOR RECORD - RECOMMENDATIONS

2 Exhibits (para 3-16, AR 15-6) 'a. Are all items offered (whether or not received)
or considered as evidence individually numbered or lettered asexhibits and attached to this report?
b.
Is an index of all exhibits offered to or considered by investigating officer or board attached before the first exhibit?
• c. Has the testimony/statement of each witness been recorded verbatim or been reduced to written form and attached as
an exhibit?
d. Are copies, descriptions, or depictions
(f substituted for real or documentary evidence)
properly authenticated and isthe location of the original evidence indicated?
YES N
matter to :be-investtgated , includings espOndent e name and ad de t s to be present W.as#he respondent provi there were elevan ass Ifl If anyespon en as design as hee-proper as record of pro
courts -ts a la check:h
unset present at all open sessions o unset was, regy,
Are all of the respondent's requests and objections which were denied indicated in the report of proceedings or in an
-enclosure or exhibit to it (paro 5-11, AR 15-6)?
FOOTNOTES.-II Explain all negative answers on an attached sheet. Use of the N/A colunin constitutes a positive representation that the circumstances described in the question did not occur in this investigation
board: Page 2 of 4 pages, DA Form 1574, Mar 83
LtSAPA V1.20 "
654

L_ SECTION. IV - FINDINGS (para 3-1q AR 15-6)The (investigating officer) (board), having carefully considered the evidence, finds:
_SEE AiTACHEb NClO
SECTION V- RECOMMENDATIONS
&Nora 3-11, AR 15-6)
In view of the above findings, the
(investigating officer) (board)
recommends:
56 A RcN b ME MO
Page 3 of 4 pages, DA Form 1574, Mar 83
1. A doctor or ph3rsician's assistant should review all intake medical screenings, andsip/datetheform asreviewed: They willpexsonally ex—
ainine 'detainees as indicated ; based on *.e-results offhe screening form.TI­
4§ review will occur4fter each tansfer of a detainee as well as aftere the initial Wake.
2.
A doctor or-physicain's assistant should conduct weekly rounds withrnilitarypolice medics.

3.
The intake thedical assessment,must be reviewed and updated by the:pw.clic at-the accepting facility. The reveiVver will sign and date the updated form. All assessments will then be deliVered to the supervisingdoctor or physician's assistant for review.

6556

SWORN STATEMENT
For use of this form, see AR 190-45; the proponent agency is =SOPS PRIVACY ACT STATEMENT
MITY:
Title 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397 dated November 22, 1943
ISSN).
IPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately identified.
NE USES: Your social security number is used as an additional/alternate means of identification to facilitate filing and retrieval.
3SURE:
Disclosure of your social security number is voluntary.
:ATION
2. DATE InTYMMODI 3. TIME
4. FILE NUMBER
711.Y CC 7/140 /h/rS' r'-ZaDC1 A.2 /.7 /ej SO
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1GANIZATION OR ADDRESS
(Typed Alathe.ol Person, Adntinistering Oath(
tGANIZATION PR ADDRESS • -
(Authority To Administer Oaths.)
For use of this form see a110143sgDSOPS
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3GANIZATION OR ADDRESS
(Typed Name of l'eaou Achniiristering (Jath/ RGANIZATION OR ADDRESS (Authority To Administer Oaths)
656 0

SWORN STATEMENT
For use of this thorn, see AR 190.45; the proponent agency is ODCSOpS
PRIVApy ACT STATEMENT

lRITY: Title 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397 dated November 22, 1943
ISTNI.
IPAL PURPOSE: To provide commanders and law enforcement officials with means by which information may be accurately identified.
NE USES: Your social security-number is used as an additional/altemate means of identification to , facilitate filing and retrieval.
OSURE: Disclosure of yourSocial sectirity number is voluntary.
:ATION
2. DATE tkritsfhibbi 3. TIME
;T NAMEA flPONAME,VitbOLNAMF__ 6 ,-Qty-4-irg R.fi# Illi z
3ANI2ATTElk 6 7 c

WANT TO MAKE THE FOLLEPNING STATEMENT tINDER DAM
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IGANI2ATION OR ADDRESS
(Typed Name ofPerstin Administering Oath)
1CANIZATION DR ADDRESS
(Authority To Administer Oaths)
SWORN STATEMENT
For use of this form, see AR 190-45; the proponent agency is 0DCSOPS
PRIVACY ACT STATEMENT AUTHORITY:
Title 10 USC Section 301; Title 5 USC Section 2951; E.O. 9397 dated November 22, 1943 (SSNJ. PRINCIPAL PURPOSE:
To provide commanders and law enforcement officials with means by which information may be accurately identified. ROUTINE USES:
Your social security number is used as an additionallalternate means of identification to facilitate filing and retrieval.
DISCLOSURE: Disclosure of your social security number is voluntary.
1. LOCATION
2. DATE (YYYI'MMDDJ 3. TIME 4. FILE NUMBER
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SWORN STATEMENT
For use of this form, see AR 190.45; the proponent agency is ODCSOPS
PRIVACY ACT STATEMENT
)RITY:

Title 10 USC Section 301; Title 5 USC Section 2951; E.D. 9397 dated November 22, 1943
(SSA9.
IPAL PURPOSE:
To provide commanders and law enforcement officials with means by which information may be accurately identified.
NE USES:

Your social security number is used as an additionallalternate means of identification to facilitate filing and retrieval.
OSURE:

Disclosure of your social security number is voluntary.
:ATION

2. DATE (YTTYAIMGOI 3. TIME
4. FILE NUMBER
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6585

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-_ HAVE READ OR HAVE HAD READ TO ME THIS STATEMENT400- 41:0*M-FULLY UpIDERSANDilt CONTENTS
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6566
DOD 002792
3
RD BCT EPW CAGE
NAM
SEXAi DOB: Ici H3
EPW NO.
CAGE I-4 DATE SCREENED: I F-­
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ASSESSMENT
MEDIC: —
GENERAL IMPRESSION:
GOOD/BAD ,
PHYSICALINJUR ES: 4 -(7ci
IP OLD HOW OLD:-.
BLEEDING PRESENT:

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MEDICATIONS ON RAND:

MEDICAL HI "STOR:Y/ChNDITIO1
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LUNGSSTROKE COPD
HOA.i:ZT:DISEASE:
BRONCHITIS'• DY.SAVTAMIAS TB
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PSYMI-4.TRIC
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LUNG SOUNDS: LIVE..DTSEASE
COUGHING? YIN
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At;LEIZGIES:: ti
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MEDICAL COMMENTS:

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AND TIMAtiWENT
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HOW OLD:
. : INFECTIONS: 6
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TEMPERATURE /CONDITION /APPEARANCE: :
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6567

/7 6-
INCIDENT REPORT FORM Type of Report: Initial Date/time of report: 080805February2004 Date/time of incident 080708February2004 Location -of incident: LD 80132903 (TF IH eCP-Tikrit Main Palace) Unit invoiVed in the indident: Platooh, 4th Military Police Company
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Name 6 senior person invo
64-76k. e
1 6 7 c 1
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Friendly Casua NfA
Enemy Casualties:N/A
s: Deceased of unknown causes
e and contact DNVT 6 7c- I

65es

EXHIBIT H
MEMO FOR RECORD 26 February 2004
On 20 Feb, ?()94 at approximately 1100 hrs, I conducted a phone inimie ,L lith :
assigned to Brassfield. Move FOB. b 6 (/ 12 7 c the 0 a i e mitiatiritake processing on the EPW named 6 ei Ahmed. The intake processing was, accomplished on 1 Feb 2004_
had no recollection of the above mentioned EPW or of the medical note written on that date (Exhibit F). He did say that,the note would have prompted a call to the p1-131 161an on duty butcan't recall if that call wasanade or if a physician was contactedk
6589

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66