Another death there soon spurred another inquiry, and another scathing report was issued about the care provided by the private company, the Corrections Corporation of America.
But the government scrutiny did not add up to much for Felix Franklin Rodriguez-Torres, 36, an Ecuadorean construction worker who wound up in Eloy that fall as an unauthorized immigrant after being jailed for petty larceny in New York City. By mid-December, a fellow detainee told the man's relatives, Mr. Rodriguez lay pleading for medical help on the floor of his cell, unable to move.
He died weeks later of testicular cancer, a typically fast-growing but treatable disease, which had gone undiagnosed and untreated during his two months at Eloy, which holds more than 1,500 detainees. And despite a discussion of his case among top federal immigration officials while he was dying -- captured in e-mail messages between Washington and Arizona -- his death on Jan. 18, 2007, was not listed on the roster of detention fatalities that the federal agency, Immigration and Customs Enforcement, produced under pressure last year and updated in April.
His death, and the damning reports that preceded it, are coming to light only through a Freedom of Information Act lawsuit by the American Civil Liberties Union.
On Monday, after inquiries about Mr. Rodriguez's death by The New York Times, the immigration agency added his name and nine others to the public roster -- including another unrecorded death at Eloy, in 2005.
The Rodriguez case echoes many others that have spurred demands for an overhaul of immigration detention. But in its details, it underscores the daunting challenge facing the Obama administration as it tries to improve detention conditions, starting with greater oversight of places like Eloy.
''The rampant problems of medical and mental health care aren't just going to go away if there's more oversight,'' said David Shapiro, a lawyer with the A.C.L.U.'s National Prison Project, which has called for legally binding rules on conditions in immigration detention. ''There have to be consequences.''
The Corrections Corporation of America referred questions about Mr. Rodriguez's case to the immigration agency, known as ICE, which is part of the Department of Homeland Security.
Matthew Chandler, a spokesman for the department, said the administration had taken its first steps ''to improve medical care, custodial conditions, fiscal prudence and ICE's critical oversight of the immigration detention system, and we will find out why this death wasn't reported properly.''
The administration's long-term goal is a vastly different detention system, no smaller in size, but less penal in character.
At the same time, however, Janet Napolitano, secretary of homeland security, is expanding immigration enforcement. And officials said they would rely on the same prison companies and county jails.
In some ways, Mr. Rodriguez's case fits a priority of Ms. Napolitano's: detaining people accused of immigration violations who are already in jail for a crime.
Records show that Mr. Rodriguez, who had entered the United States on a visitor's visa in 1998 to represent Ecuador in a karate tournament, was transferred to immigration authorities on Nov. 8, 2006, after serving five months at Rikers Island. He had been accused of helping rob an acquaintance after a Saturday of soccer and beer in Corona, Queens.
Though he pleaded guilty to petty larceny, he maintained his innocence even on his deathbed, said his father, Felix Rodriguez, a legal resident who has been a deliveryman for a Manhattan jewelry company for 15 years.
''I understand a prisoner shouldn't be on a golden bed, but a prisoner is a human being,'' the father said in Spanish. ''He at least deserves respect when he is so sick he can't even eat.''
By the time the ailing detainee was taken to Maricopa Medical Center in Phoenix, on Dec. 27, 2006, he had a mass in his neck that had ''tripled in size'' and obstructed his breathing, according to a government summary of his care. He was placed on life support, and died when it was disconnected.
While he was dying, a draft synopsis of his case was already circulating in Washington. It stated that he had been seen by the Eloy medical staff ''on numerous occasions,'' and first complained of a sore neck on Dec. 25. In their exchanges, officials did not question why the medical staff had failed to recognize symptoms of cancer.
Just weeks earlier, the agency's own investigations had linked two Eloy deaths to inadequate medical staffing by the Corrections Corporation, which was then reaping record profits from stepped-up immigration enforcement.
''Medical care in this facility does not meet ICE standards,'' the first investigating team wrote to John P. Torres, director of detention and removal operations, after the suicide of a 32-year-old Guatemalan detainee on Sept. 29, 2006. They noted that a sick call request from the Guatemalan, Jose Lopez-Gregario, had been ignored for a week, even though he was on suicide watch.
The medical staff -- ''overwhelmed due to a sudden loss of veteran staff'' -- apparently assumed he had already been deported. Cut off from care in an isolation cell and racked with guilt that he had left his family without enough food, he hanged himself.
A second team assessed Eloy again after a 27-year-old Colombian was found unconscious in an isolation cell there on Dec. 6, 2006; an ''unwitnessed seizure'' left him brain-dead.
''The facility has failed on multiple levels to perform basic supervision and provide for the safety and welfare of ICE detainees,'' the investigators wrote.
The Colombian, Mario Chavez-Torres, had shown symptoms of bleeding on the brain, and should have been sent for outside evaluation, the report said; a week after his written request for medical attention for ''headaches, dizziness and vomiting,'' he collapsed in the shower.
A call for medical help by a guard was answered an hour later by a vocational nurse who told him: ''I'm not qualified. To be honest, I'm just a pill-pusher.'' That lone night nurse was responsible for distributing medication to 300 chronically ill detainees among 1,500, the report said.
The first report had warned that most of the seasoned medical staff left Eloy that fall, months before a planned takeover of its medical unit by ICE's Division of Immigration Health in 2007. But authorities had continued to send detainees to Eloy, and Mr. Rodriguez was among them.
To his sister Janneth Montesdeoca, who lives in Ozone Park, Queens, Mr. Rodriguez seemed healthy until just before his transfer to immigration authorities. On her last visit to Rikers, she noticed that his head seemed swollen.
The swelling was most likely a sign that cancer was blocking his lymph system, said physicians consulted for this article, adding that it should have been caught in a full medical exam. Both reports had noted that though all immigration detainees are supposed to get a medical exam within 14 days of admission, timely exams were not performed at Eloy that fall.
Most testicular cancer is fast-growing, said Dr. David Weiner, a urologist at St. Luke's-Roosevelt Hospital Center in Manhattan, but even after spreading, ''it's a very treatable cancer in the vast majority of cases.''
In a phone call to his mother from Eloy on Dec. 18, 2006, Mr. Rodriguez said he had seen the doctor there many times, complaining of coughing and fever. When he stopped calling, his worried family repeatedly contacted his deportation officer, who kept assuring them that Mr. Rodriguez was fine, said his brother-in-law, Leonardo Montesdeoca, a United States citizen who works for the Metropolitan Transportation Authority.
The family says they learned the truth about a week after Mr. Rodriguez had been taken to the hospital, in a call from another detainee.
''He said Franklin was very, very sick,'' Mr. Montesdeoca said. ''They would call the attention of the guards and they would just ignore, they would look the other way.''
Records show that on Jan. 12, 2007, the hospital told the detention company that he had as little as a week to live. But his sister says the deportation officer would not tell them where Mr. Rodriguez had been hospitalized. Instead, relatives said, he offered to release the detainee to their care if they paid for a plane ticket to New York -- a plan derailed, apparently, because the patient was too sick to travel.
It was a phone call from Mr. Rodriguez that brought the family to his deathbed. Against the rules, a nurse had lent him her cellphone.
''If it wasn't for her, I wouldn't have known if my son was dead or alive,'' said his mother, Maria Torres, who lives in Queens.
His face lit up when he saw his parents arrive the next day, Mr. Montesdeoca said. They spoke for a few hours before the two guards at his bedside cut off the visit. The next morning, he was in a coma.
In the e-mail messages about his impending death, one official wrote from a BlackBerry, ''Thanks for the advance notice,'' after alerting Mr. Torres, the director of detention for the agency, and Gary E. Mead, the deputy.
Dr. Gene A. Migliaccio, director of the agency's Immigration Health Services at the time, was asked ''to reach out to Phoenix'' and ''to ensure that proper protocols are followed.'' One of his employees asked if anyone had the Eloy medical records: ''When this detainee is taken off life support, may I get a copy for my death chart?''
But there is no evidence that the medical records were ever collected. The death was automatically referred to the immigration agency's Office of Professional Responsibility in Washington, which simply sent it back to the Phoenix field office for an internal management review.
In March 2007, the matter was closed when the local office filed its terse conclusion: the detainee had died of aggressive cancer, and there was no evidence of negligence. The same month, a report by the Homeland Security Department's inspector general on the death of the Colombian detainee found no evidence of foul play or inadequate response.
But at least two more detainees died at Eloy in 2008 -- a 41-year-old Iraqi and a 52-year-old man from Ghana.
Mr. Rodriguez's ashes were mailed to his mother, and she carried them back to Ecuador for burial.
''I never want another immigrant to feel this pain,'' she said. ''Not knowing what to do, his suffering and no way of getting him help.''