Widespread Breakdown of Safeguards at Gitmo

Military Inquiry finds systemic failure contributed to Guantanamo Prisoner’s tragic end.

Adnan Latif


On more than a dozen occasions over the course of eight years, Adnan Latif complained to his attorney that his American captors forced him to take medications that left him feeling like “a zombie.”

The 36-year-old Guantanamo prisoner, who died there last year in a high-security cell, claimed he was injected with unknown substances while he slept and plied with pills whenever the guards deemed him to be unruly, which appeared to be often.

The military repeatedly dismissed Latif’s allegations as the paranoid ramblings of a difficult and brain-damaged terror suspect. But it turns out his story was true – and only the tip of a still-submerged iceberg.

Latif’s tale of forced drugging, and other aspects of what has emerged as a torturous decade of indefinite detention at Gitmo, is laid bare in a military report released Friday in response to a Freedom of Information Act (FOIA) request filed by this reporter last year following the young Yemeni’s mysterious and solitary death.

The declassified 79-page report details the US military’s investigation into Latif’s reported suicide, found that Guantanamo guards contributed to his death by failing to follow numerous protocols set forth in the facility’s Standard Operating Procedures (SOPs); yet no one has been held accountable or faced disciplinary action in the case.

Nor does the report explain how the frail youngest son of a Yemeni merchant ended up on an autopsy table, his body laced with a mind-boggling pharmaceutical cocktail of undetermined origin.

Prophecy fulfilled?   

Latif, who suffered from a traumatic brain injury incurred decades before, believed the guard force was trying to kill him. According to unclassified notes taken in May 2012 by David Remes, his Washington D.C.-based attourney, Latif said he sometimes removed psychiatric medications from his mouth “because I don’t want to […] here.” A word in Remes’ notes is missing.  He said it might be “die.”

Remes also wrote that Latif was being medicated with “sedatives and psychotropics [and] painkillers,” and noted that his client said he was sometimes given the wrong dosage and the wrong medication.

After Latif was found unresponsive in his cell last September, an autopsy report concluded he committed suicide by hoarding and ingesting two-dozen doses of Invega, prescribed a month earlier to treat schizophrenia. 

The report does not mention Latif by name. Rather, it refers to him by his internment number, ISN156 – identification marks that were on his body bag when he was finally returned home to Yemen last December.

US military investigation finds that Guantanamo prison guards contributed to the death of detainee Adnan Latif. [US Military] 

In addition to Invega, the drug used to treat schizophrenia, a previously classified toxicology report made public last week reveals the presence of other anti-psychotics and painkillers in Latif’s system, including codeine, Percocet, Seroquel, Ativan, Celexa, morphine and Remeron – medications that can result in severe side effects if taken in combination, according to a redacted copy of the newly released report.

To top it off, Latif, who was a frequent hunger striker, also suffered from acute pneumonia that went undetected prior to his death. The report blames Latif, himself, for the institutional failures that led to his death, saying he was “an exceptionally challenging detainee.”

Remes calls the report “a whitewash,” adding that Latif’s death is an “indirect result of [President Barack] Obama’s failure to transfer Yemenis back to Yemen.”

Two presidential administrations over the course of a decade concluded Latif did not belong at Guantanamo and had cleared him for release, but he and other detainees continued to languish there, without being charged and without hope of a path to freedom.

Legal proceedings and other documentation over the years indicate Latif was seeking medical assistance for the crippling mental and physical damage sustained in a car crash when he was swept up in a post-9/11 dragnet for terrorists near the Afghan-Pakistan border. He was sold to the Northern Alliance for a $5,000 bounty and arrived at the US Naval Base at Guantanamo Bay as one of the prison’s first detainees.

“Everyone is to blame and no one is to blame,” Remes said of the report. “They turned him into a human pharmacy and then blame him for being challenging.”

Reports confirmed

The military report, issued by United States Southern Command (SOUTHCOM), confirms the details contained in a series of investigative stories this reporter published between September 2012 and January of this year into the circumstances behind Latif’s death.

A separate investigation into Latif’s death by the Naval Criminal Investigative Service (NCIS) is ongoing.

The report says Guantanamo doctors diagnosed Latif, who was “almost completely blind in his left eye,” with “Bipolar Disorder and Borderline Personality Disorder with antisocial traits,” and characterized one of his mental breakdowns “as manic with psychotic features, possibly affected by Traumatic Brain Injury (TBI).

“In layman’s terms, all of these diagnoses translate into an individual that would be unstable in mood, personality and relationships,” the report said. “The diagnosis also means that the individual would be difficult to live or work with and would be prone to impulsivity and to harm self or others, generally living life from one crisis to another.”

A footnote in the report adds that Latif’s “diagnoses evolved over the course of his detention at” Guantanamo, suggesting that his indefinite detention may have contributed to the deterioration of his mental health.

Widespread breakdown

Retired Army Brig. Gen. Stephen Xenakis, a psychiatrist who has consulted on numerous Guantanamo prisoner cases, including providing a sworn deposition in 2010 about Latif’s physical and mental condition, questioned why Latif was prescribed certain medications and not given others.

“They say he has bipolar disorder and he’s not prescribed mood stabilizers that typically are prescribed for people with bipolar disorder,” said Xenakis, who reviewed a copy of the report. “That’s missing in his medication list. I’m really surprised.”

Xenakis said the report’s conclusions undercut assertions by Guantanamo officials that prisoners are receiving quality medical care.

“Quality care means having a trained staff and having a staff that has worked in a particular setting for years,” he added. “It’s not just following algorithms or rules. It’s subtle and it has to do with the art of the medical practice and familiarity, in this case, with a particular population. And you have people who have not often worked with this kind of population under these conditions…”

The absence of qualifications extends far beyond the medical staff to the highest ranks of leadership. 

Col. John Bogdan, the warden at Guantanamo, has testified in recent proceedings that he has no prior experience running a prison operation. 

The report details a widespread breakdown of safeguards and procedures at the prison facility, where even prohibitions against feeding wildlife were not followed.

“Guards and medical personnel repeatedly violate various … Standard Operating Procedures (SOPs),” the report said.  “In some cases, the guards and medical personnel are unfamiliar with the SOPs. In other cases, the guards and medical personnel are familiar with the requirements but for various reasons, fail to follow them.”

Moreover, with nearly 200 procedures in place at Guantanamo – 79 of which apply to medical circumstances – “guards indicated that enforcement of the SOPs is one of the biggest challenges they face.”

Following Latif’s death, military officials told this reporter that guards checked on prisoners every one to three minutes and that medical staff and corpsmen were diligent when medication was administered. The military investigation found this was not the case, according to the report.

There were also training shortcomings and violations in the way in which medications were administered by Navy corpsmen who are supposed to follow a stringent protocol to ensure prisoners swallow the drugs.

One night shift corpsman told investigators he did not recall ever having been visited by anyone in his leadership chain. “I have felt invisible, with no one seeming to even know I was working here.”

In Latif’s case, a day before his death, a corpsman simply dropped medication off in a box in his cell door and never checked to see if Latif, who was sleeping at the time, had taken it, the report said.

Medical training procedures and record-keeping were also flawed, contributing to “violations and to confusion of … personnel.” The Joint Medical Group commander and senior leadership, including the Senior Nurse Executive, “appear largely removed from several aspects of what is going on at the tactical level” at the hospital, the psychiatric unit and the detention camps.

These failures, the report states, contributed to Latif’s death. Although deviating from the SOPs is considered to be an Article 92 violation – failure to obey an order or regulation – under the Uniform Code of Military Justice, no one was held accountable for the widespread procedural breakdown that resulted in the death of Latif, the ninth detainee in 11 years to leave Guantanamo in a body bag.

Furthermore, the report noted that Guantanamo leadership failed to implement certain safeguards designed to protect prisoners following a previous suicide in May 2011, in which another prisoner who suffered from mental health problems was able to walk into the recreation yard in the dead of night with a bed sheet and, undetected, tie it to a pole and hang himself.

This reporter’s FOIA request for a copy of the commander’s inquiry into the death of that prisoner, Hajji Nassim, has not yet been received.

Unintended consequences

According to the report, “Many of the recommendations in this investigation have been made in previous investigations,” but have not been implemented.

SOUTHCOM officials now say they’ve implemented a comprehensive program to address the issues raised in the report.

“We’ve also added additional training for the guards before and during deployment,” Col. Greg Julian told Al Jazeera. “We’re making sure the SOPs are followed.”

However, the report’s conclusions and recommendations may be directly linked to new aggressive procedures and policies implemented earlier this year that gave rise to a mass hunger strike that is now entering its fifth month at Guantanamo.

The report does not explicitly state how Latif was able to hoard the medications that killed him. However, a source close to the investigation told this reporter that a redacted section suggests he may have hidden the capsules in his Koran and/or his genital area, which were not searched by guards.

Since his death, the military has reintroduced a policy requiring Korans to be searched, and another that calls for prisoners’ genitals to be searched whenever they leave and return to their cells. The former policy is what led more than 100 of Guantanamo’s 166 prisoners to launch a massive hunger strike in March.

In May, more than a dozen military attorneys sent a letter to US Secretary of Defense Chuck Hagel asking him to examine whether Bogdan is fit for command due in part to the protocols he put into place that sparked the hunger strike.

Death wish

By all accounts, Latif was a difficult prisoner. According to the military report: “Self-harm events began in 2003 with two head-banging incidents, followed by three wrist-cutting events in 2006, and a spike of 19 self-harm events, involving choking, ingestion of indelible items, hanging, head-banging and cutting.”

The report also said Latif “frequently made passive statements” to [redacted] “asking to die, such as ‘I wish I could die here,’ and, ‘You could find meds that could kill me.’”

At one point Latif asked to be prescribed a “suicide pill.”

Apparently, in 2008, underscoring the guard force’s ongoing failure to follow prison procedures, there was an instance when Latif showed an interpreter a “fist full” of medications and said, “I could eat these pills if I wanted to kill myself.” The medications were then confiscated by a guard.

Latif splashed guards with bodily waste and was routinely placed in solitary confinement. The report said he was moved from camp to camp 67 times during his more than decade-long detention at Guantanamo.

There was also a childlike innocence to his behavior, although some of it was attributed to Latif being manic. One guard recounted how Latif would wrap a bed sheet around his neck, pretend it was a cape and do back flips off of the wall in his cell. Another member of the military said Latif had written a “love letter” he wanted her to deliver to another guard; yet another guard recounted how, in the weeks leading up to his death, Latif was in the recreation yard, singing and dancing and kicking a soccer ball.

Latif appeared to be an accomplished poet, although many of his writings contained “dark themes” about suicide. He wrote numerous letters to his family as well as “long letters to the Joint Detention Group (JDG) leadership with quality of life complaints.”

He also talked about his son, Ezzi Dean, who was a toddler when Latif left Yemen, and he held out hope that he would see him again.

‘Pushed Toward Death’

Perhaps as telling as what is in the report is what is missing from it.

The military report does not contain any of the stories Latif told Remes, his pro bono lawyer, about the physical abuse he said he suffered at the hands of his captors, nor does it explain the bodily injuries Remes said he observed on Latif when he began visiting him more than eight years ago.

In a letter sent to Remes and another attorney on May 28, 2010, the Yemeni detainee claimed he was given “contraband” items, such as a spoon and a “big pair of scissors … by the person responsible for Camp 5,” where uncooperative prisoners are sent.

“I am being pushed toward death every moment,” Latif wrote to Remes and human rights attorney Marc Falkoff.

“The way they deal with me proves to me that they want to get rid of me, but in a way that they cannot be accused of causing it,” Latif wrote.

To the contrary, the military report said Latif enjoyed luxuries and “special treatment” that other prisoners did not, such as unlimited television, the ability to move from camp to camp, and an OK by doctors to feed wildlife and even banana rats, because it kept him calm – a violation of prison policy.

“According to [redacted], the SOPs were ‘definitely not consistently followed’ with respect to” Latif, the report said.

“[Redacted] indicated that television helped distract [Latif] and ‘re-focus on other things,’” a footnote in the report added.

Beginning of the end

The report released by the military says Latif’s “downward spiral” began in June of 2012, after Remes spoke to him on the telephone and informed him that the US Supreme Court declined to review his habeas corpus petition.

Latif had been cleared for transfer back to his homeland at least three times over the past decade by both the Bush and Obama administrations. Yet the US government refused to repatriate him, and – for reasons unknown – filed legal challenges to keep him locked away at Guantanamo. This reporter has filed a FOIA request with the US Justice Department for internal documents that may shed light on the matter.

According to the report, Latif was devastated by his lawyer’s news and “came back furious and really started saying crazy stuff.” He was “voluntarily” admitted to the Behavioural Health Unit for about a week-and-a-half.

One witness recalled Latif talking about his 10-year-old son in Yemen and his hopes to see him again, “which she took as a good sign as it demonstrated a future orientation,” the report said.

“During the same time, however, [redacted] also reported that [Latif] engaged in lots of talk regarding death, which for [Latif] was fairly common behaviour.”

It is not entirely clear in the report, but it appears that Latif was either already on a hunger strike or launched one after he received the news from Remes. The report notes that Latif was force-fed.

End of days

The report goes on to document the last three months of Latif’s life: how he was shuffled back and forth from the two prison camps, back to the psych ward, to the detention hospital, and, finally, to a specific cell in a punishment wing in Camp 5, Alpha block – a cell that he insisted would kill him.

Toward the end of July, Latif was involved in “multiple incidents” of aggression: a “rock throwing incident, a splashing incident with urine and feces” and another unspecified behavior that was redacted. The report blamed Latif’s refusal to take medications during his fast for Ramadan for precipitating the events. 

Around this time, he was taking three powerful anti-psychotic medications: Celexa and Remeron, which he had just been prescribed, for depression – and Zyprexa to control “impulsivity.” This apparently was injected in an attempt to get him to stop “jumping around in the cell [at the psychiatric unit], from bed, to the table to the sink to the toilet.”

Latif was required to sit in a restraint chair to receive the injection. But he fought it and said he would agree only if he could inject himself, leading a [redacted] to say to him that he “would take the medication, one way or another, either by injection or mouth.” He refused both and the report does not indicate how it was eventually administered.

An incident in early August at the Behavioral Health Unit (BHU) recreation yard resulted in a visit from the brutal Quick Reaction Force (QRF) riot team, the administration of three emergency injections, and, eventually, a visit to the disciplinary wing of Camp 5.

On August 21, 2012 Latif was prescribed Invega, which is used to treat schizophrenia.

“[Redacted] intended to increase the Invega and titrate [Latif] off the Zyprexa, his earlier prescribed anti-psychotic medication,” the report said. A footnote in the report indicates that a medical ethics committee was approached about the ethics of administering Invega “against [Latif’s] will,” which the committee agreed to and noted that an “ethical basis existed” to undertake the measure.

The “plan,” according to the report, was to transition Latif from taking oral doses of the Invega medication to monthly injections. He died before the plan came to fruition.

But it appears that Latif may have had some reservations. On September 7, 2012, a day before he died, Latif wrote a letter to Remes, according to the report, asking whether he thought he should take the injection. Remes told Al Jazeera the letter Latif sent is classified and he is unable to discuss it.

Rushing towards death

The report said that Latif’s mood seemed “much improved” during the first few days of September while in the detention hospital and when he was told on September 6 that he would eventually be moved to a communal part of Camp 5, which houses noncompliant prisoners, he seemed “happy” and even asked about other prisoners who were being held there.

Later that day, the report said, Latif had a “spontaneous” outburst and began “yelling and kicking, and threw his portable urinal, thereby splashing a guard.”

“Another detainee … attempted to intervene and asked [redacted] not to request discipline for [Latif’s] infraction,” the report said. Latif took his night dose of Remeron (anti-depressant) that night.”

At around 10 pm, Latif demanded his urinal back, sprayed several guards with urine from “flip-top water bottles” and threatened to keep splashing if he didn’t get his urinal back. He eventually calmed down several hours later.

The next morning, September 7, 2012, Latif refused his morning dose of Invega, which came in two capsules. A psychiatric mental health nurse spoke with him and offered it to him again and this time Latif accepted. The nurse told investigators she watched Latif “take the capsules, put them in his mouth, drink water, and swallow them.”

“Also that morning, [Latif] handed a note to the Watch Commander, telling him to give the note to [Guantanamo warden] Col. Bogdan,” the report said. “In the note, [Latif] claimed that [redacted] was ‘rushing him towards death’ and that she was the ‘cause of the problems in the detainee hospital.’”

“Later that morning, on 7 September 2012, [redacted] asked the Senior Medical Officer [redacted] and [redacted] whether there was a medical or psychiatric reason that [Latif] could not serve his discipline time” for the splashing and other incidents,” the report said. “[Redacted] indicated to [redacted] that she viewed [Latif’s] behavior as willful, and that there was no medical or psychiatric reason that [Latif] could not serve his discipline.”

Apparently, the medical staff was unaware that Latif had acute pneumonia.

Based on the assessment by medical personnel, Bogdan decided to send Latif to solitary confinement in Camp 5 for discipline.

Latif appeared concerned and asked the guards “what specific tier” at Camp 5. The guard said he did not have that information. Latif packed his belongings and took them with him to Camp 5; these apparently included two dozen capsules hidden someplace the guard force at the camp never saw.

A footnote in the report suggests that another prisoner who had “become a close friend” of Latif’s “and one of the few people who could calm him” was present when Latif was told he was going to be transferred.

That may have been Shaker Aamer, a high-profile prisoner who occupied a neighboring cell. Aamer told Remes, the lawyer they shared, that Latif had “fought and fought” his transfer to a particular cell in Camp 5 because of the constant buzzing noise from a generator located behind a wall.

The report confirms Aamer’s account, although it doesn’t mention the generator specifically.

“Although [Latif] had bad memories of the cell where he was ultimately moved and at least one detainee stated that moving [Latif] to the cell would cause him to commit suicide, the moves themselves did not contribute to” Latif’s death, the report said.

Perhaps Latif knew his fate. He looked at [redacted] “and said something along the lines of ‘when I die, it will be on you’ and ‘you know that you have killed me sending me to [Camp 5].’”

The report said during this time medical staffers were still trying to convince Latif to take the injection of Invega.

The report documents numerous communications between personnel at Guantanamo suggesting that Latif was suicidal and planned to kill himself. One such alert was a “high priority email” sent to “Zak,” Guantanamo’s Muslim cultural advisor.  He, in turn, forwarded it to warden Bogdan and other senior prison officials, noting that “pushing [Latif] to the corner never works to our advantage.”

Bogdan, according to the report, did not receive the email until the following day – the day Latif died. He said that even if he had received it earlier he still would have sent Latif to the feared cell in Camp 5 because he knew Latif “to make melodramatic statements.”

The report said, “Bogdan acted reasonably” and that Latif’s “suicidal ideation did not stand out compared to any of the other instances.”

Still, the directive to the guard force was to watch Latif around the clock.

“At some point, the night corpsman … came to deliver [Latif] his prescribed medications,” the report said. The corpsman recalled leaving the medications in the splash box, but “did not recall [Latif] taking the medications that night.”

That’s because when Latif eventually fell asleep shortly before midnight, he never woke up. His last meal was rice, beef, shrimp, soup and apple juice, some of which he apparently used to cover the surveillance camera in his cell.

At around 5 am on September 8, a guard banged on Latif’s cell door to wake him for call to prayer and breakfast but he didn’t answer. Other prisoners called out Latif’s name and grew angry when he did not answer.

“At some point, [redacted] mentioned to [redacted] that [Latif] had been sleeping for ‘quite a while,’” the report said.

Guards who were interviewed by military investigators said they did not see Latif ingest any pills and they “did not leave their duty, and did not look away from [Latif] for more than two to five seconds while they were on line of sight of duty.”

Fourteen hours had passed and, through several shift changes, guards believed Latif was sleeping, even though he was known not to be a sound sleeper. Finally, during a tier check a guard knocked on the glass of Latif’s cell door. When he didn’t respond the guard called a “Code Yellow,” defined as a “potentially life-threatening condition requiring an immediate response.”

When guards entered Latif’s cell his right arm contained vomit and when his head was moved a guard told investigators she saw a “large quantity of yellowish bloody goo.”

Attempts to revive Latif failed. He was pronounced dead at 2:48 pm.

Guards violated the SOP when they failed to require Latif to uncover his surveillance camera while on line of sight, the report said. “This failure may have contributed to the death of [Latif] in that it prevented the guard force from being able to monitor [Latif] electronically, and from discovering whether something was in fact wrong with [Latif] during the time that the direct line of sight guards say [Latif] was sleeping,” according to the report.”

The report notes that the Medication Administration Record for September 7 and September 8 is “improperly completed” and was wrongly entered into a government database that contains information about all of the Guantanamo prisoners.

The autopsy report said the medical examiner was unable to pinpoint when Latif ingested the two-dozen capsules of Invega that were found in his stomach – medication that he was first prescribed 17 days before his death.

For the next three months, Latif’s body was stored at Ramstein Air Base in German because Yemeni government officials initially refused to accept it. Finally, he was returned home to his family for burial.

Al Jazeera spoke with Zak, the Muslim cultural advisor, during a visit to Guantanamo in May. Although he refused to discuss specific prisoners, Zak did agree to talk about Latif.

“We did our best for that gentleman,” he said.

Source: Al Jazeera