At least 19 men and women have died since 2016 in tribal detention centers overseen by the Interior Department’s Bureau of Indian Affairs, including the Shiprock District Department of Corrections facility, according to an investigation by NPR and the Mountain West News Bureau.
Sharon Chischilly for NPR
This story was supported by the Pulitzer Center on Crisis Reporting.

When police took Carlos Yazzie to jail on the Navajo Nation in New Mexico after his arrest on a bench warrant in January 2017, he needed immediate medical attention. His foot was swollen and his blood alcohol content was nearly six times the legal limit.

But law enforcement decided that he was fine, jail records show. They put Yazzie in a cramped isolation cell at the Shiprock District Department of Corrections facility instead of taking him to a hospital and then left him unmonitored for six hours without periodic staff checks as required, according to an investigative report. When a guard handing out inmate jumpsuits the next morning stopped at Yazzie’s cell, the 44-year-old day laborer was dead. It would later be determined in an autopsy that he died from acute alcohol poisoning, which is easily treatable by medical professionals, experts said.

“These correctional officers are basically holding these lives in their hands with their decisions,” said Chris Yazzie, Carlos’ brother, who once worked as a correctional officer at the jail where his brother died but did not know the specific officers. “I don’t think these people are prepared.”

Carlos Yazzie (right) grills with his family. After he was arrested, he was left unmonitored for six hours and died of acute alcohol poisoning.
Yazzie family
Yazzie is one of at least 19 men and women who have died since 2016 in tribal detention centers overseen by the Interior Department’s Bureau of Indian Affairs (BIA), according to an investigation by NPR and the Mountain West News Bureau, a collaboration of NPR member stations. Several of them died after correctional officers failed to provide proper and timely medical care, records show. Many of the victims had been arrested for minor infractions, such as petty theft or violating open-container laws, and were awaiting trial. In some cases, BIA officials have not released details of inmate deaths, despite repeated written requests.

Federal officials have known about the mistreatment of inmates and other problems at the detention centers for nearly two decades. A 2004 federal investigation found widespread deaths, inmate abuse, attempted suicides, inhumane conditions and other issues in many of the more than 70 detention centers scattered throughout the U.S., including in Arizona, New Mexico, Montana, Wisconsin and Mississippi. The Interior Department’s inspector general told congressional lawmakers during a hearing on the matter then that the facilities were a “national disgrace.”

Seventeen years later, myriad problems remain, according to more than two dozen interviews with investigators, law enforcement, lawmakers and victims’ relatives, as well as a review of hundreds of pages of documents, including autopsy reports, jail logs, internal government reports and lawsuits.

Among the findings:

Poor staff training and neglect led to several inmate deaths that could have been prevented.
Correctional officers at several detention centers often violated federal policy and standards by not checking on inmates regularly or ensuring that they received medical care. In one instance, a 22-year-old man died in a holding cell, but his body wasn’t discovered for nearly three hours.
One in five correctional officers assigned to the detention centers as of April has not completed the required basic training, which includes CPR, first aid and suicide prevention.
Several of the detention centers have been in disrepair for years, with overflowing toilets, broken pipes and rust in the water. At least one facility lacked potable drinking water, forcing jail administrators to turn to charities for bottled drinking water.
Congress has chronically underfunded the detention centers, despite repeated investigations that found the facilities were short staffed and had problems.

A handprint remains on the window at the Shiprock District Department of Corrections facility.
Sharon Chischilly for NPR
Sen. Jon Tester, D-Mont., a member of the Senate Committee on Indian Affairs, said that an “immediate, transparent” investigation is warranted, calling the findings by NPR and the Mountain West News Bureau “deeply disturbing.”

“Any wrongdoing or negligence must be reported to Congress and the folks responsible must be held accountable,” he said in a written statement. “Where policies are found to have failed, we will work to fix them and ensure it does not happen again.”

Rep. Teresa Leger Fernandez, D-N.M., chair of the Subcommittee for Indigenous Peoples of the United States, said the problems at jails overseen by the BIA are “heartbreaking but, sadly, not new.” She said her goal is to significantly boost funding for the detention centers and eliminate an estimated $135 million budget shortfall.

Interior Secretary Deb Haaland declined a request for an interview.

A pattern of negligence

Joe Snell was 37 and broad shouldered. He loved shooting Nerf guns with his nieces and nephews and playing practical jokes on his older sister, Michelle.

“I used to tease him that he looked like a ninja turtle,” Michelle Snell recalled.

She knew Joe struggled with an addiction to prescription pills, methamphetamine and alcohol. But when he began serving a three-month sentence for a parole violation at a federally operated jail on the Spirit Lake Tribe Reservation in North Dakota, Michelle thought he could kick his addiction and get back on track. He was even taking classes during the five weeks he was there.

“We’d always thought he’d be safe there,” she said. “He’s good. He’s in jail.”

But shortly before 3:30 p.m. on March 26, 2020, Snell collapsed while exercising in the jail’s day room. He became unconscious before an ambulance arrived, but neither of the two correctional officers on duty, who the BIA said were certified in basic lifesaving techniques, performed CPR or used a defibrillator, also known as an AED, jail records show. The BIA declined to provide certification documents.

“That’s [AED] truly a lifesaving device,” said Ian Paul, a forensic pathologist at the New Mexico Office of the Medical Investigator, who specializes in emergency medicine. “When someone collapses like that, they really should go for an AED because that’s the lifesaving maneuver. As soon as they become unconscious, that’s when the AED should be applied.”

When the ambulance arrived, paramedics initiated CPR and tried unsuccessfully to save Joe Snell. Michelle Snell said her brother suffered a heart attack, but the North Dakota State Forensic Examiner’s Office declined to release Snell’s autopsy report, citing state confidentiality laws.

“Why are all these people working there?” Michelle Snell asked.

William McClure, the BIA special agent in charge of the district that oversees the jail on the Spirit Lake Tribe Reservation, declined to comment on Snell’s death.

Federal policy requires correctional officers to “initiate all available rescue options” when an inmate is in a life-threatening situation.

Interior Department spokesman Tyler Cherry said guards did not perform CPR or use an AED because Snell had a “pre-existing medical issue which needed to be addressed first by Emergency Medical Service personnel.” He declined to elaborate.

“There’s no medical condition that prevents one from initiating lifesaving maneuvers such as applying an AED and starting CPR,” Paul said.

Michelle Snell said she was unaware of her brother having a preexisting condition.

The incident at the Spirit Lake Tribe Reservation jail isn’t an anomaly. When Carlos Yazzie was booked into the Shiprock jail on the morning of Jan. 11, 2017, he was dangerously drunk. His blood alcohol content was about 0.461 — the legal limit is 0.08.