Officials investigating how a college student was left for days in a windowless Drug Enforcement Administration holding cell found safety measures and procedures were either non-existent or ignored by federal agents.
Daniel Chong was discovered incoherent and suffering from kidney failure after spending five days handcuffed in a holding cell without food or water in April 2012.
Under a legal settlement the U.S. government paid $4.1 million to Chong who would later tell NBC 7 that he was forced to drink his own urine hoping it would help him stay alive.
“I had to do what I had to do to survive,” Chong said after the incident. “It’s so inconceivable. You keep doubting they would forget you."
Eventually Chong was discovered and the Office of the Inspector General (OIG) launched an investigation into how a detainee could be "forgotten about" by agents.
The OIG found that four agents reported seeing or hearing Chong while he was in custody for several days. They not only failed to act but told investigators they didn't think anything unusual about his presence there.
"They assumed that whoever had placed Chong in the cell would return shortly to process him," the report states.
"Someone Would Be Right Back"
Chong, then a student at UC San Diego, was at a friend’s house in University City celebrating 4/20. It's a day many marijuana users set aside to smoke.
After agents came inside and raided the residence, Chong was taken to the DEA office in Kearny Mesa.
He was questioned and it was decided he would be released.
San Diego Police Department officer Darin Reis, who was working as part of a DEA task force of local and federal law enforcement officers, told Chong that someone would be right back to get him.
Five days later, Chong was eventually found and rushed to the hospital where he spent three days in the ICU.
He has since been diagnosed with post-traumatic stress disorder and consults with a doctor who normally treats veterans who have returned from battle.
Investigators with the OIG say they found evidence that Chong discovered methamphetamine in the holding cell while he was detained and ingested it.
He also used the broken glass from his eyeglasses to injure himself, officials said.
As part of the report, OIG officials state that DEA management in the field and at headquarters violated policy by trying to investigate the incident on their own. Under protocol, OIG should have been notified immediately, officials said.
In addition, two of the employees responsible for the incident were involved in the initial investigation.
No Official Policy or Training
Any system for tracking detainees in the holding cells used by the San Diego Field Division was non-existent, according to the summarized report.
There were no video cameras inside the individual cells nor was there a system for agents to log in and out when entering and exiting.
The one camera covering the holding cell area was monitored by an employee with "many other responsibilities" according to investigators.
Investigators also found the door's locking mechanism was not working properly so there were no electronic records showing time in/time out for the days Chong was held.
Also, agents using the holding cells were not required to check at the end of the day to make sure all detainees had either been processed or released.
Investigators said they found "no official DEA policy or training regarding the operation of the holding cell area."
While the report states a DEA supervisor, two task force officers and a DEA employee are responsible for leaving Chong in custody for days, investigators agreed with the District Attorney's decision not to press criminal charges against the officers.
“All case evaluations and charging decisions in the United States Attorney’s Office are based on a thorough review of the evidence. In this instance that review led to our decision that no further action was warranted and the criminal investigation was closed. The OIG report issued today affirms our decision not to prosecute,” U.S. Attorney Laura E. Duffy said Tuesday.
As a result of its investigation, the OIG has offered recommendations to the DEA on procedures that investigators feel should be put in place to avoid another incident in the future.
A DEA spokesperson confirmed to NBC 7 that immediately following Chong's case, the agency initiated new procedures including routinely inspecting holding cells, assigning someome to monitor the holding area and maintaining an occupancy ledger for detainees.
Still, Chong’s attorney, Gene Iredale and the American Civil Liberties Union (ACLU) believe the summarized report released Tuesday is simply not enough, saying the public deserves to know more about how agents could possibly leave Chong in that cell for five days.
“What were the roles of each of the three case agents who were responsible for what happened? Who were the four DEA employees that actually heard Daniel in the cell during this time but didn’t think anything was unusual?” Iredale told NBC 7. “Why wasn’t the entire report released?”
“Did somebody lose a couple weeks pay? Did someone get at least a week on the beach?” he added.
Iredale said his client couldn't go on camera because he's in the middle of midterms and is busy studying. Chong is still finishing his degree at UC San Diego.