AR 15-6 Investigation: Report of Proceedings re: Death of Detainee While in Custody

Form for AR 15-6 proceedings. Appointed by MG Raymond Odierno. A detainee died while in custody at the DCCP. The deceased was seen by a cardiologist at the 28th CSH and diagnosed with coronary artery disease, angina and type II diabetes. He died of apparent natural causes. No abuse was suspected.

Doc_type: 
Investigative File
Doc_date: 
Monday, August 4, 2003
Doc_rel_date: 
Tuesday, November 29, 2005
Doc_text: 

IF MORE SPACE IS REQUIRED IN FILLING OUT ANY PORTION OF THIS FORM, ATTACH ADDITIONAL SHEETS
SECTION I - APPOINTMENT
_
Appointed by i\il Ei I /t\-:\/ M 0 0 0 OPil-1-1\16
(Appointing authority)

2 6-i) L-1. 0 3
on (Attach inclosure 1: Letter of appointment or summary of oral appointment data.) (See para 3-15, AR 15-6.)
(Date)

SECTION II - SESSIONS
1 1 OA- • at I 2 00
The (investigation) (board) commenced at --ri 1Z-.(2-1 -1­(Place) (Time)

on (If a formal board met for more than one session, check here . . Indicate in an inclosure the tine each session began and (Dare)
ended, the place, persons present and absent, and explanation of absences, if any.) The following persons (members, respondents, counsel) were
present: (After each name, indicate capacity, e.g., President, Recorder, Member, Legal Advisor.)

. .
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 (Time) on (Date)
and completed findings and recommendations at (Time) on (Date)
SECTION III - CHECKLIST FOR PROCEEDINGS
A. COMPLETE IN ALL CASES YES NOS NA.
1 Inclosures (para 3-15, AR 15-6) -,-4., -5- - z.

•r..•.-,-r
Are the following inclosed and numbered consecutively with Roman numerals: (Attached in order listed) ''... 72--e
a.
The letter of appointment or a summary of oral appointment data? X I 4,

b.
Copy of notice to respondent, if any? (See item 9, below) X

c.
Other correspondence with respondent or counsel, if any?

X
d. All other written communications to or from the appointing authority?
X ^rivacy Act Statements (Certificate, if statement provided orally)?
X
-lanation by the investigating officer or board of any unusual delays, difficulties, irregularities, or other problems
X
,:ricountered (e.g., absence of material witnesses)?
g. Information as to sessions of a formal board not included on page 1 of this report?
X
h. Any other significant papers (other than evidence) relating to administrative aspects of the investigation or board?
FOOTNOTES: P Explain all negative answers on an attached sheet. &050 7 Z1Use of the P1/A column constitutes a positive representation that the circumstances described in the question did not occur in this investigation or board.
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DA FORM '1574, MAR 83 EDITION OF NOV 77 IS OBSOLETE.
DOD-043587

SECTION IV - FINDINGS.(para 3-10, AR 15-o)
The (investigating officer) (board), having carefully con id e4 th evidence, finds:
died at approximately 0445D on 22 July 2003 at the TFCCP. According to
par s e ecease had een elpe to e atrine for nausea by two other prisoners just prio is death. fter leaving the
1a,_ —, the deceased lost conciousness and was carried back to his tent. The prisoners then alerted SP PV ho checked
on th • ner. The prisoner wasitious with what was felt to be a weak pulse. SPIgnotifie o instructed
PFC o get a medic. SGT , . sen , was notified and
4th MP medic, responded and did not feel a pu fi
..4,
w ith CPT WM LEL Liu aid . Thu pi /JUIICL Lic..au cu. v-r-r...).
The deceased had been held at the DCCP since 27 June 2003. During this time he had sought medical attention from MP medics on
multiple occasions. According to the MP daily log, the deceased had been seen on 02 July for chest pain. The deceased was taken to the
aid station and eventually to the 28th CSH for treatment. The deceased was seen by a cardiologist at the 28th CSH and diagnosed with
coronary artery disease, angina and type II diabetes. The prisoner was discharged back to the DCCP with medications. Prisoner /IMP
stated that he had taken care of the deceased since his arrival at the DCCP. He further stated that the deceased had advanced coronary
artery disease and had some sort of procedure done last year (presumably angioplasty since there was no chest scar indicating bypass
surgery ) and was allegedly scheduled to have a second procedure done in April of this year. The deceased had recieved his medications
regularly during his stay in the DCCP. The deceased had also been seen on 03 July for vomitting, was treated and released by the MP
tseen 16 July for passing out, treated and released by MP medics, and 19 July for dehydration, treated and released by MP medics.
maili ated that the deceased had not been feeling well for the last 4-5 days and had been feeling weaker and was unable to eat. The
evening before his death, the deceased had complained of abdominal pain. # ated he told the gaurd, and the deceased was given an
aspirin. Several MP's verified that the deceased had not been eating well for t e past one to two weeks. The MP's also verified that the
deceased had to have help going to the latrine during the last 2-3 day s.
b
()c0
An autopsy was performed on the deceased by Dr. chief o forensics for Salah-al-din province. The autopsy did not reveal
any external or internal signs of trauma. The cause of ea was listed as congestive heart failure. This was most likely secondary to a
myocardial infarction (heart attack).

The MP medics are utilized for sick call and treating the EPW's within the DCCP, although this is not their primary responsibility. They
have very limited assets for patient care. All EPW's with medical complaints are screened by MP Medics. The medics then decide who
should be seen at the aid station or whether a higher medical personell should be consulted.

EPW's are nOt screened for medical problems when they are placed in the DCCP and there was no medical record keeping prior to the
de2" ')f this prisoner.

F. The deceased prisoner more than likely suffered a myocardial infarction and developed congestive heart failure which reached a critical point prior to' his death. (C) The patient had a known history of coronalry artery disease.(M, L) His last contact with the MP medics was on 19 July, 3 days prior, for dehydration. The prisoner also allegedly complained of abdominal pain with nausea and vomitting during the days proceeding his death, which are symptoms consistent with his disease.(M) According to the autopsy report there was no evidence of foul play or traumatic injury.(C) The MP medics are ill suited to handle complex medical patients and provide sick call to the EPW's as well as carry out their primary mission of supporting the MP unit.(P)
SECTION V - RECOMMENDATIONS (pdra 3-11, AR 15-6)
In view of the above findings, the (investigating officer) (board) recommends: There should be no disciplinary action taken against the MP medics or other. The MP medics should not be used as the primary care giver for the EPW's
A. physicians assistant or other higher medical authority should be assigned to provide sick call and medical care for the prisoners at the DCCP. This will allow the MP medics to accomplish their mission of providing support for their unit and remove them bieng the primary care giver of the EPW's. If providing a Physicians assistant is not possible, a formal Standard operating procedure should be established for the MP medics to operate under in providing care for the EPWs with direct oversight by physicians assistant or other higher medical authority. In addition a system to identify complex medical patients, medical screening of patients and tracking of medical problems should be instituted for the DCCP. This would however place even more of a burden on the MP medics and keep them from accomplishing their primary mission of medical support for the MP unit.
kz4-e,fi ODy6
020508

Page 3 of 4 pages, DA Form 1574, Mar 83 USAPA V1.20
DOD-043588

THIS REPORT OF PROCEEDINGS IS COMPLETE AND ACCURATE. (If any voting member or the recorder fails to sign here or in Section VII below, indicate the reason in the space where his signature should appear.)
(Recorder) nvestigating Officer) (President)
(Member) (Member)
(Member) (Member)
SECTION VII - MINORITY REPORT (para 3-13, AR 15-6)
To the extent indicated in Inclosure , the undersigned do(es) not concur in the findings and recommendations of the board.
(In the inclosure, identify by number each finding and/or recommendation in which the dissenting member(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 (para 2-3, AR 15-6)
The,,,idings and recommendations of the (investigating officer) .(boeirri} ar (c2T7ro17edaAraraued) (approved with following exceptions/ substitutions). (If 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.)
0 2 5 (19

Page 4 of 4 pages, DA Form 1574, Mar 83 USAPA V1.20
DOD-043589

Doc_nid: 
4071
Doc_type_num: 
66