An Iraqi national, 56-year-old male, died while in custody at FOB Ironhorse on August 13, 2003 due to cardiopulmonary arrest; no autopsy was performed; no foul play or abuse suspected. Detainee had been ill and received medical attention. The detainee complained throughout the day of physical aliment and after resting the detainee became unresponsive without spontaneous respirations or a pulse. CPR was initiated; IV access was obtained; and the detainee was intubated. Cardiac monitoring revealed ventricular tachycardia without a pulse. The detainee was pronounced dead. Medical care was appropriate and met all standards for medical care given in the field.
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 FILLING OUT ANY PORTION OF THIS FORM, ATTACH ADDITIONAL SHEETS
SECTION I - APPOINTMENT
)
Appointed by_COLONEL_ ( 6)(6 ) 7--
(Appointing authority)
on 15 August 2003_
(Attach inclosure 1: Letter of appointment or summary of oral appointment data.) (See para 3-15, AR 15-6.)(Date)
SECTION II - SESSIONS
The (investigation) (board) commenced at_21st CSH, LSA Anaconda, Balad, Iraq_ at_1000 hours
(Place) (Tinze)
on_16 August 2003_
(If a formal board met for more than one session, check here ¦ . Indicate in an inclosure the time each session began and
(Dae)
ended, the place, pes-sons 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 offices) (board) finished gathering/hearing evidence at _ 1330 hours_on_16 August 2003
(Time) (Date) ..
and completed findings and recommendations at _ 1800 hours_ on_24 August 2003
(Time) (Date)
SECTION III - CHECKLIST FOR PROCEEDINGS
A. COMPLETE IN ALL CASES YES NO 1/ NA
1 Inclosures_, , -t-0 "''
(para 3-15, AR 15-6) "n ._ft' Are the following inclosed and numbered consecutively with Roman numerals: _(Attached in order listed)
11 4 ; '
a. The letter of appointment or a summary of oral appointment data?
X_-..-A1
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? I X
Privacy Act Statements _(Certificate, if statement provided orally)?
X I
‘planation by the investigating officer or board of any unusual delays, difficulties, irregularities, or other problems X
..:ncountered_(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?
1r c,.,,,.. .., ....... ,, : .... ___. n 2 65'0 1
Formumwc •n .,...., .., .,.
4nn. .n •• .
.21 Use of the NM column constitutes a positive represencarion chat: the circumstances described in the question did not occur in this investigation
or board.
DA FORM 1574, MAR 83 EDITION OF NOV 77 IS OBSOLETE. Page I of 4 pages USAPA V1.20
. .
SECTION VI - AUTHENTICATION
(para 3-17, 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
E '
(Recorder) SS/1/1-'_:2; CC, 1 ZOir_c.7_7.7¦46-
1fgebartrillyAln e st ig a ting Officer) (President)
(Member) (Member)
(Member) (Member)
SECTION VII - MINORITY REPORT
(para 3-13, AR 15 -6)
To the extent indicated in jnclosure
_
, the undersigned do(es) not concur in the finding's and recommendations of the board.
(In the inclosure, identify by number each finding and/or recommendation in which the disseruing 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 APPO
ITY (para 2-3, AR 15-6)
slings and recommendations of the
(investigating officer) (b. •rd) are (approved) (di approved) (approved with following exceptions/
suv3titutions). (If the appointing authority returns the proceedings t• • • es o cer or board for further proceedings orcorrective action, attach thbt correspondence (or a summary, if oral) as a numbered inclosure.)
RAYMOND T. ODIERNO fl -9 SEP 20:0.3 Major General, USA Commanding
020502
'age 4 of 4. pages, DA Form 1574, Mar 83
USAPA V1.20
DEPARTMENT OF THE ARMY
C CO, 64 FORWARD SUPPORT BATALLION
3 BRIGADE COMBAT TEAM, 4 INFANTRY DIVISION (M)
BALAD, IRAQ APO-AE 09323
AFCZ-FC-C_ 24 August 2003
MEMORANDUM FOR Commander, Task Force Ironhorse, ATTN: Chief of Staff,
Headquarters, Task Force Ironhorse, Tikrit, Iraq
SUBJECT: Findings and Recommendations of Informal Investigation of death of Iraqi
detainee
1. FINDINGS
to;(0Lp
a. On 13 August 2003, Iraqi detainee # _was declared dead due to
cardiopulmonary arrest by CPT _
E Co, 204 FSB, 2 BCT. The ailment(s)
and medical conditions that led to the ca diopulmonary arrest are unknown as no autopsy
was performed._ (b)(Ce)-2—
(W6e
b. Detainee #1111111Pas a 56-year-old male that was apprehended on 3 August
2003. He was brought to the detainee center at Camp Warhorse on the same day and
Coalition Provisional Authority Forces Apprehension Form was completed.
The 4th MP
Co and E Co 204 th FSB report that each new detainee undergoes a medical screening
within 24 hours of arriving at the camp which includes listing chronic medications, a
brief physical examination, and treating any significant injuries/ailments.
The medical
information is placed in the detainee's file. "Sick call" is provided daily by E Co 204
FSB and all detainees have access to this service. "Sick call" encounters were not
documented until 11 August 2003 when CP_equired written documentation tobe performed. Detainee_
had no documentati9f a medical screening or "sick
call" encounters in his file._-10)((c.)
(0)((o)1_
(601_.N
c. SSG_
reports that detainee ijallitomplained of being hot on the evening of 12 August 2003 and was let out of his cell to cool down. The detainee was given water to drink and water was poured on him by SSG
_The detainee was
placed back into his cell due to mortar fire and SSG )eing more from him
that evening._ (6)(4)(
d. On the 13 th of August, detainee #ralirvas lying on the concrete outside of his
cell. MAJ_
CRNA, was the medical officer tending to the detainees. She asked the MPs wh was wrong and they informed her that the detainee had beenfeeling ill from the nigh nor. SSG
_reports that the detainee told him that he had stomach problems and co dn't eat meat nd wanted milk. She informed the MPs that she wanted to see him after valuating t e new detainees. MAJ 1111111h -eports that
020503
AFZC-FC-C
SUBJECT: Findings and Recommendations of Informal Investigation of death of Iraqi
detainee lafirML X6) )
the detainee was able to walk without assistance an _ough another detainee that spokeEnglish; she was able to determine that detainee 14 complained of his nose
hurting. She obtained vital signs and examined his nose and found nothing to be
abnormal. She instructed the MPs to send him to E Co 204 FSB if he worsened. SSG
eports that MAJAIMnstructed the MPs to give the detainee extra water and two airy shakes in the morning and evening. She reports that she documented her encounter and the MPs assisting her confirm she wrote a medical note but the note was
not found during this investigation. (ON) LI
e. At approximately 1600 the same day, detainee_as let out of cell as hecomplained of being hot per SSG _SPC_
laims that the detainee ain. The detainee was placed in t e s ade and given water. Within
0J't(t) q_30 minutes, detainee_as omiting. SPC (4th MP medic) was summoned but was not in the ea. E Co 204 FSB was called and SPC~came to the detainee camp. SP 11111111
_saw he detainee and decided to go to the aid station to ask the medical officers or further guidance. He arrived and was informed to give intravenous fluids and phenergan. Once he returned to the detainee camp, the detainee was noted to be unconscious without respirations or pulse. SPC
___confirmed thatthe detainee had no pulse and went to ;he aid station to get help. SSG _ad initiated
CPR once the detainee became unresponsive. CPR was continued unti the detainee wastransported to E Co 204 FSB.
bjel)
f. CPT.
was the m cal officer in charge of running the code. Upon
presentation, detainee _
as unresponsive without "spontaneous respirations or a pulse. CPR was resume , IV access was obtained, and the detainee was intubated. Cardiac monitoring revealed ventricular tachycardia without a pulse. The detainee received defibrillation of 200-300-360 joules, followed by epinephrine and lidocaine and repeat defibrillation of 360 joules. No change in cardiac conversion was noted. Blood work revealed a glucose of 293, BUN 22, Sodium 140, potassium 3.8, hematocrit 29, pH 7.152, bicarbonate 9, and base excess of-20. An axial temperature was noted to be
104.0 F. On obtaining a rectal temperature, bowel function was noted to be lost. CPR was.terminated and CPT _
declared the time of death at 1719. Medical care was
appropriate and met the iia.77a7d.
g. The conditions of the detainee camp are adequate. The detainees are given 5-6 bottles of water a day and can have more if they ask for it. All of the detainees have a rug or mat to sit or lie on. They are released from their cells to use the restroom and to walk in the courtyard at scheduled times but can also leave their cell if they request. The camp consists of two large cells that are designed to hold 30-35 adults each. There are two smaller cells that are used to separate detainees with tribal conflict or those that hold titles or power within the country. The MPs report that there are usually more detainees than they have room for so overcrowding has been an issue. The facility is clean without evidence of garbage or trash. There is no air conditioning or fans that circulate air. The cells are warm and the air is stagnant within them. Detainees are
020504
AFZC-FC-C
SUBJECT: Findin s and Recommendations of Informal Investigation of death of Iraqi
detainee
()(G/ )
given three MREs a day but the MPs report that most of the detainees don't eat them as
they complain of the smell and taste.
h. An interpreter from the MI BN is available on occasion but most of the time the MPs and medical personnel rely on other detainees to helpwith the language barrier. The ajzzMI interpreter claims that he had talked with detainee
_n the past but not during
this incident and has no knowledge of any medical history on theaFairree,--_4(4 4 ) 1/4
1
i. The medical officers of E Co 204 FSB and the 1982 FST. Physicians, physician's
assistants, nurse anesthetists, and registered nurses perform the medical evaluations and
sick call duties at the detainee camp. Physicians and physician's assistants have
credentials to provide this type of medical care, however, nurse anesthetists and
registered nurses due not have the same practicing privileges. Individual's credential
packets were not available for review.
2. RECOMMENDATIONS
a.
All medical information and encounters should be documented. A paper trail becomes significant and is standard of care throughout the world. Documentation provides better care and protects those providing the care. Recommend that the initial medical screening and all medical encounters and interventions be documented and placed in the detainee's file.
b.
Ensure all providers providing medical care have the appropriate credentials and " skills. Many nurses have learned through their experiences how to care for individuals but they do not have the authority to examine, diagnose, and treat medical conditions. With that said, they may not have the knowledge base to recognize a problem that needs further attention. Recommend that nurses and nurse anesthetists provide care within the scope of their credentials. If nurses continue to provide care, recommend that the supervising physician provide a guideline for them to follow and list the conditions/procedures that they can perform autonomously and those conditions that need to be referred to a physician or physician assistant. Also recommend that all documentation be reviewed and signed by a physician with the appropriate credentials.
c.
Interpreters are a must. It is apparent that many individuals had differing opinions as to what detainee 11 was complaining of and the designated interpreter was not involved in any aspect of this case. Without the use of an interpreter and relying on
V6)
another detainee to bridge the language gap, it becomes a guessing game as to what an
individual is saying. If detainee I.chest pain the night prior to his death, no one was aware of it and that may be due to the language barrier. If this was known, his death may have been prevented. Recommend that an interpreter be readily available in all detainee camps, especially for the initial medical interview and during sick call.
020505
AFZC-FC-C SUBJECTiiiitis and Recommendations of Informal Investigation of death of Iraqi
detainee #
d. Autopsy. To give a definitive cause of death, an auto sy is required. Without an autopsy I can not comment on whether or not detainee # _s death was related to big living conditions, heat, medical carc (or lack of), of uiideilyiug ailments. Recommend that future deaths of Iraqi detainees undergo autopsy so more can be learned about the causative factors and can possibly help with future operations and care.
3. The POC is the undersigned (DNVT 534 (6)() 7--
MAJ, MC BN Surgeon, 64 FSB
020506