How Solitary Confinement Kills: Torture and Stunning Neglect End in Suicide at Privately Run ICE Prison

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Efraín Romero de la Rosa would pace around his solitary confinement cell. He often paused to glance through the small window that looked out at the rest of the gray immigration jail unit. Standing at 5-foot-5, with a bushy black beard and receding hairline, Romero spent his 21st day in solitary battling the voices in his head.

Romero’s schizophrenic episodes had a particularly dark nature to them, frequently colored by his deep religious beliefs. Every voice that called him the “Antichrist” twisted the dagger of his anguish, and Romero sunk further into a state of depression. Confinement to his 13-by-7-foot concrete cell for 23 hours a day only worsened his condition.

Dressed in his red prison jumpsuit, the 40-year-old would push against the cell door. As he paced back and forth in his cell, he would sometimes weep. He occasionally passed the time by standing on the rim of his cell’s chrome toilet, only to step back down again. Step up, step down. Step up, step down.

Romero was being held at the Stewart Detention Center in rural Georgia, one of the largest U.S. Immigration and Customs Enforcement facilities in the country. The facility houses male migrants who are both requesting asylum and who are set to be deported. But ICE does not run the detention center: It is operated by the private prison company CoreCivic.

Romero wanted nothing more than to be deported to Mexico, a move that would mark an end to the excruciating months he had spent in ICE custody. Other men detained at Stewart saw Romero cry inside his cell and heard him yelling for his family. “He said that soon he wanted to see his dad and his mom,” one man detained in the same unit told a state investigator.

Before entering ICE custody, Romero had been diagnosed with schizophrenia and bipolar disorder. During his time in ICE detention, Romero’s mental health deteriorated; at one point, he told the detention center staff that he would suffer “three terrible deaths.”

Previously, while in ICE custody, Romero had been placed on suicide watch and, separately, assigned to a mental health institution. Officials had noted his fixation on death. And yet CoreCivic’s correctional staff sent Romero to solitary confinement for 30 days.

Nearing the end of his 21st day in solitary, Romero took his own life in the tiny cell.

Efraín Romero de la Rosa.

Documents obtained as part of a joint investigation by WNYC and PRX’s The Takeaway and The Intercept offer a look into Romero’s time in ICE custody, as well as his death. Hundreds of pages of documents collected in an investigation by the state of Georgia, and an internal CoreCivic investigation, along with records shared by Romero’s family attorney, show that CoreCivic staff at the Stewart Detention Center violated their own rules when dealing with the mentally ill detainee. From the intake process to the disciplinary process — and even on the night he killed himself — the CoreCivic staff neglected to properly care for the man in their custody who had been diagnosed with schizophrenia.

Romero’s case stands as a tragic exemplar of an immigration detention system gone off the rails. Solitary confinement is frequently used by corrections staff as a means to punish detainees; a Bangladeshi man told The Intercept in 2018 that guards at the CoreCivic-run Stewart Detention Center — the same facility where Romero was held — sent him to solitary confinement because of a dispute over $8 for prison labor.

The use of solitary confinement in immigration detention is growing and has, in tandem, become a political issue. An investigation by the International Consortium of Investigative Journalists and The Intercept, which included testimony from a whistleblower, found that the use of solitary was a go-to practice to discipline detainees and deal with troubled cases, rather than the last resort prescribed by detention standards. After the release of the investigation, Democratic presidential candidate Sen. Elizabeth Warren, D-Mass., condemned the use of solitary and Sen. Cory Booker, D-N.J., called for congressional hearings on the practice.

Cases of death in ICE custody are often shrouded in secrecy, with few details released to the public. The documents, photos, video, and audio obtained by The Takeaway and The Intercept offer a rare look at the specifics of an immigration detainee’s demise in custody.

Four Stewart Detention Center detainees have died since spring 2017. Romero is the second man detained at Stewart to die by suicide. There are striking similarities between Romero’s case and that of Jeancarlo Jimenez-Joseph, another ICE detainee at Stewart: Jimenez-Joseph had also been diagnosed with schizophrenia, taking his own life after 19 days in solitary confinement.

Both Romero and Jimenez-Joseph were held in solitary for weeks, a period of time widely agreed to constitute torture. In 2011, the U.N. said detention in solitary for more than 15 days should be prohibited — and that a ban should be placed on using solitary at all for detainees who, like Romero and Jimenez-Joseph, had been diagnosed with mental health conditions. Nonetheless, some 40 percent of ICE detainees held in solitary have diagnoses for mental illness, according to a report from the Project on Government Oversight.

Owing to the spate of migrant deaths in U.S. custody, the Department of Homeland Security, the parent agency of both ICE and Customs and Border Protection, has faced heightened scrutiny. Nonetheless, the numbers of people held by ICE continues to reach record levels: More than 55,000 migrants are in its custody — an all-time high. Of those, nearly 2,000 have a diagnosed mental illness.

As the Trump administration ramps up immigration detention, Romero’s story shines a light at an opaque immigration detention system, pulling back the curtain to reveal what happens behind the walls of one of the country’s largest immigration jails.

Inside Romero's solitary cell. Photos: GBI

The night of Efraín Romero de la Rosa’s death, the Stewart County Sheriff’s Department called on the Georgia Bureau of Investigation, a statewide law enforcement agency known by the initials GBI, to investigate. That night, GBI investigators descended on Stewart, interviewing medical staff, correctional staff, first responders, and other men held in the same solitary confinement cell block. The GBI’s conclusion was that Romero had, indeed, taken his own life. The records collected by GBI investigators would eventually reveal some of what Romero’s time in detention looked like.

At first, the GBI refused to release the case file and records from the investigation, citing a federal regulation granting the federal government control over information on immigration detainees. Emails obtained as part of an eventually successful public records request revealed that, in response to Romero’s death, a CoreCivic attorney pressured the GBI into barring the public release of the investigation records. But several news organizations and attorneys demanded the GBI turn over the records. New York Public Radio’s legal counsel crafted a pages-long appeal to the GBI, and in response, the state agency changed course and began releasing records, including the investigation summaries, photos, and 18 hours of security camera footage.

Photos taken by the GBI show the solitary cell Romero was held in. The underside of the cell’s top bunk bed was covered in pencil scribbles. Romero randomly wrote Mexican states, names, and random phrases. He etched the phrase “La Santa Muerte Lo La Cuida” on the wall; in English, the phrase means, “The Saint of Death protects him/her.” Below, in much darker letters, as if he traced over the words, Romero wrote: “CADA DIA ES MAS IMPORTANTE” — or, “EACH DAY IS MORE IMPORTANT.”

The cell bears a drab color scheme. The walls are off-white, and a white sheet is draped over a bed; its cream bunked frame has sporadic patches of blueish-gray paint. A seat and table protruding from the wall are beige. Even the pencil etchings evoke a grayscale palette. The bright orange socks stand out. Several of these socks are tied to one another and finally, with crude overhand knots, to the railing of the top bunk. The socks are what Romero used to hang himself while in the solitary cell.

The cut chain of socks hanging in Romero’s solitary cell.

Romero and his family are from the state of Puebla in central Mexico. “He was a very calm young man. He was a good person,” his brother Isaí Romero said, following Efraín’s death. Romero spent his days meticulously poring over the Bible. Isaí said, “He knew the Bible very well, and he wanted to go to Mexico — to be there with family and share with people what he knew about the word of God.”

The journey home was spurred — and eventually halted by a run-in with U.S. immigration authorities. Romero’s path to Stewart Detention Center came in fits and starts, amid run-ins with the U.S. justice system and, eventually, ICE.

Romero crossed the U.S.-Mexico border in the year 2000 through Arizona, when he was in his early 20s, according to a typo-laden ICE report on Romero’s case released by the agency in late 2018. Court records show he was charged with various crimes, including carjacking, possessing burglary tools, and driving under the influence. According to the ICE report, which is limited in scope, Romero was sentenced to eight years in prison in 2004 for charges related to carjacking and possession of burglary tools. None of the available records from Romero’s stints in the criminal or immigration detention systems indicate when or if he was ever freed from prison.

In April 2017, however, he arrived at the Marion Correctional Treatment Center, a mental health institution run by the state of Virginia. The following September, a medical discharge sheet indicates he had been diagnosed with schizophrenia. The staff at Marion prescribed five medications as a treatment. After his release from Marion, Romero went to North Carolina to live with his brother.

“I would see him shake sometimes,” Isaí Romero said. But the medications seemed to have an effect. “With time, that sort of went away. He was calmer. Sometimes these types of illnesses can make you scared.” Over time, Romero was integrated into his brother’s family. “While he was here — wow. My kids were so happy with him. We had birthday celebrations — just so happy,” Isaí said. “He would say, ‘I have that illness. But don’t worry, God has cured me.’”

Romero, left, poses for a photo with his brother, Isaí.

The time at his brother’s was brief. In February 2018, Romero was charged with larceny and taken to the Wake County Detention Center, a jail in Raleigh, North Carolina. That’s when ICE showed up — ensnaring Romero in the byzantine web of immigration detention. The goal was simple — the government wanted Romero deported — but the path there would take him to ICE’s privately run Stewart Detention Center in Georgia.

An ICE official who interviewed Romero at the jail noted that he refused to answer any questions about his health. But after reviewing Romero’s file, the official made a note of the schizophrenia diagnosis and added that a nurse told the agency Romero “gets a shot because of the shaking in prison.”

A little over a month later, Romero was taken to Stewart. During his intake screening, a registered nurse said Romero reported a history of schizophrenia, smoking cigarettes, using alcohol and drugs, and taking medication for his schizophrenia, according to ICE’s report. Romero also said he had auditory hallucinations.

Three days later during a mental health evaluation, according to the ICE report, Romero said, “God is talking to him and telling him what will happen in the future.” A psychologist, however, found Romero to be psychiatrically stable and released him to general population at Stewart.

ICE says that, as of March 2019, the agency is holding some 1,996 detainees with mental illnesses — nearly 4 percent of the estimated 55,000 people in ICE detention throughout the U.S.

Many people in ICE custody are waiting for their day in court: a chance to request asylum and, thereby, begin a legal fight to stay in the country. Others are simply waiting to be deported. Stewart holds both those seeking asylum as well as people waiting out deportation. The detention center has the capacity to hold nearly 2,000 detainees, according to the facility’s housing plans, more than any other immigration jail.

Over a nearly two-year period — from July 2017 to March 2019 — there were over 300 medical emergency calls from Stewart to the southern Georgia dispatch, according to 911 call records. The descriptions of the calls are succinct and do not offer much detail, but they include reports of many seizures, abdominal and chest pain, a report of an improperly inserted catheter, and even a detainee who was “Maced and now in distress.”

Among the 911 records, there are four clear instances of mental health emergencies in the calls. In one instance, clearly marked as a mental health emergency, a person in custody “ran into a wall and hit his head.” A call from January 2019 is recorded as an attempted suicide; a person in detention cut himself and was “bleeding badly.”

Alarms have long been sounded over conditions at Stewart, particularly for health-related care. In May 2017, the Atlanta-based social justice group Project South released a report highlighting the conditions, detailing “serious concerns” with the facility’s housing, medical care, food, hygiene, and mental health care.

It’s not only advocacy groups, however, that have raised concerns. A December 2017 report from the DHS Office of Inspector General documented multiple violations of national detention standards, including the misuse of “segregation,” or solitary confinement. The Inspector General’s report notes detainees were placed in solitary “for violations of minor rules” — without the required written notification for the reasons behind lockdown. As The Intercept previously reported, detainees at Stewart have been punished with solitary confinement for merely refusing to perform so-called voluntary labor.

ICE has established guidelines for detention at the federal level. Known as the Performance-Based National Detention Standards, it includes standards on detainee classification, transportation, and how to work with mentally ill detainees — as well as the use of solitary confinement.In Romero’s case, staffers at Stewart failed to follow ICE’s detention standards. They failed to properly classify him both on his reentry to the jail and on disciplinary forms as having been diagnosed with mental illness. Then guards did not check in on him at the prescribed intervals once he was placed in a solitary cell.

The door of Romero’s solitary cell, number 105 in Unit 7B.

On April 3, 2018, Romero would begin his first stint in solitary confinement while in Stewart. He had been in the detention center less than a month. Why, exactly, the CoreCivic staff placed Romero in isolation is unknown; ICE had marked the detainee’s disciplinary record as being “confidential,” said the GBI, which then declined to release the documents. (ICE denied FOIA requests from The Takeaway and The Intercept for records related to Romero’s time in custody, citing a pending investigation by ICE’s Office of Professional Responsibility.)

A nurse cleared Romero for placement in solitary confinement. Because the records are incomplete, however, it is unknown why the nurse cleared Romero despite his recorded diagnosis.

Romero was in solitary until April 18, which meant 15 days in a tiny cell. He was evaluated daily by staff at Stewart and given weekly mental health evaluations. A social worker noted Romero had been refusing to take medication.

Andrew Free, a Tennessee-based immigration attorney representing Romero’s family, along with other families of migrants who have died in government custody, said the stay in solitary marked a turning point: “You look at this 15-day stint for Efraín, and you see the beginning of a deterioration.”

Using solitary confinement can lead to prolonged effects and can often exacerbate already existing mental health conditions, according to mental health and criminal justice experts.

“The symptoms include massive anxiety, which may take the form of panic attacks; disordered thinking which may take the form of paranoia. They may become increasingly angry,” said Terry Kupers, a psychiatrist at the Wright Institute in Berkeley, California. “Despair is very prominent — people become very depressed, and that often leads to suicide. So it’s just a very miserable situation.”

In 2011, Juan E. Méndez, then the U.N. special rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, said solitary confinement for more than 15 days could be considered torture. ICE itself warned in a 2013 policy document that placing someone in solitary confinement could cause the “deterioration of the detainee’s medical or mental health.”

“The use of segregated housing radically increases the risk of suicide.”

“The use of segregated housing radically increases the risk of suicide,” said Ranjana Natarajan, director of the Civil Rights Clinic at the University of Texas School of Law. “People with very serious mental illnesses often do not need to be in ICE detention, especially because they’re going to end up in segregated housing for low-level disciplinary violations and then the risk of self-harm and suicide increases once they get into segregated housing.”

Six days after his release from solitary, on April 24, Romero was placed on one-on-one suicide watch in the Medical Housing Unit, the hospital ward of the detention center. What prompted Stewart staff to place him on suicide watch is not clear, because the GBI refused to release records from that day. (Citing its pending investigation, ICE denied a FOIA request.)

The ICE report, however, gives an indication of what may have occurred. Romero told a mental health practitioner that he was the “Antichrist” and that he would be “dead in three days,” according to the ICE report on his detention. The practitioner noted he did not have suicidal or homicidal ideations, but Romero himself said “there was a potential danger to himself or others in the dorm.”

The following day, Romero reported to a mental health physician that “God was trying to kill him,” according to the ICE report, and that he was experiencing auditory and visual hallucinations. The following week, social workers observed a clear deterioration in his condition. At one point, Romero told a social worker he was feeling “hopeless and helpless” and that he would “die three terrible deaths soon.” He would laugh at inappropriate times during evaluations and was obsessed with the concept of death. All the while, he continued to decline treatment and medication. A social worker decided Romero should be sent to a facility with a higher level of care in order to treat his mental health.

On May 4, Romero was taken to the Columbia Regional Care Center in South Carolina, a hospital specializing in mental health treatments that houses inmates and detainees from all over the rural south. Romero spent more than a month there.

A photograph of 27-year-old Jeancarlo Jimenez-Joseph is displayed during the Deportation Defense Legal Network Memorial Launch in Kansas City, Mo., on May 15, 2018. Jimenez-Joseph also hanged himself in his cell at the Stewart Detention Center during a prolonged period in solitary confinement.

In recent years, a spate of migrant deaths in government custody have made headlines. Stewart was among the detention centers where one such death occurred — and the similarities to Romero’s case are striking.

Jeancarlo Jimenez-Joseph was a 27 year old when he died in Stewart. He had been a beneficiary of the Deferred Action for Childhood Arrivals policy, an Obama-era program, since rolled back by the Trump administration, that allowed people brought to the U.S. as children to remain in the country. After suffering a traumatic brain injury that appeared to trigger psychological distress, Jimenez-Joseph was charged with stealing a car and subsequently stripped of his DACA status. Eventually, he came to be detained at Stewart. In the spring of 2017, a little over a year before Romero’s death, Jimenez-Joseph took his own life after spending 19 days in solitary confinement.

The GBI conducted an investigation into Jimenez-Joseph’s death, as did CoreCivic itself. Evidence unearthed by the probes, as well as news reports, catapulted the suicide into the limelight; Jimenez-Joseph’s suicide became one of the highest-profile examples of death in ICE custody. The GBI and CoreCivic probes concluded that his pleas for attention to his mental health went unheeded and, as in Romero’s case, prison staff violated guidelines for checking in on detainees in solitary.

The staff at Stewart were well-aware of Jimenez-Joseph’s schizophrenia diagnosis, according to reports. He had alerted officials that he was having suicidal thoughts, requested more medication, and even called the ICE national help line. And yet Jimenez-Joseph was placed in solitary twice; on the second occasion, he took his own life. That night, a detention officer neglected to check his cell during the 30-minute intervals required by ICE standards. And the correctional officer falsified his logs, lying about looking in Jimenez-Joseph’s cell. He was fired from the facility.

The deaths — not all related to mental health issues — continued coming at Stewart. In January 2018, Yulio Castro-Garrido, a 33-year-old father, died after being held in the facility. He had no health problems when he first entered Stewart but succumbed to pneumonia, a lung infection, and viral influenza. Castro-Garrido was working at the facility’s kitchen while waiting to be deported to Cuba.

“I believe the conditions inside have to be so bad that a flu can turn into pneumonia very quickly,” Frank Alain Suarez, Castro-Garrido’s brother, told The Intercept last year. “And I guess the medical care is so horrible, no one could catch it in time.”

In June, attorneys with Project South provided The Takeaway with a copy of ICE’s Detainee Death Review for Castro-Garrido’s case. According to the record, even after reporting his illness to staff, Castro-Garrido worked food service duties under CoreCivic supervision, potentially transmitting his illness to others. He even worked in the kitchen on the day he was taken from the facility in an ambulance. Eventually, Castro-Garrido had to be carried out by his roommate, another detained migrant, because he could barely walk.

This August, Pedro Arriago-Santoya died in ICE custody, after being taken to a hospital from Stewart. Little is known about the 44-year-old migrant’s death, other than that he died of a cardiopulmonary arrest.

At least 25 migrants have died in ICE detention during the past two years. Last summer, a report by Human Rights Watch documented systemic problems in the medical care provided at ICE detention facilities. In 14 of 15 detainee deaths analyzed for the report, Human Rights Watch’s experts found evidence of “subpar and dangerous practices” by medical staff. (The report mentions two deaths at Stewart, but they were not included in the analysis because little public information was available about those deaths at the time the report was being complied.)

Romero died just 20 days after the Human Rights Watch report was released.

A water tower welcomes visitors to Stewart Detention Center, just outside of Lumpkin, Ga.

Romero had been returned to Stewart after a month at the Columbia Regional Care Center. Thoughts of death still loomed over his psyche; he kept talking about dying three deaths. During his intake screening at Stewart, Romero told a nurse and social worker he was taking medication but that he would still “suffer three terrible deaths in the future but would never kill himself.”

According to an intake nurse interviewed by the GBI, Romero reported to her that God could control his mind and that — since childhood — they “always had conversations.”

But according to Romero’s ICE Custody Classification Worksheet, used to classify detainees into the proper housing units, Stewart correctional staff did not recognize his mental illness, despite having returned from a mental health hospital they had sent him to.

On the worksheet, CoreCivic correctional staff neglected to make note of the schizophrenia diagnosis. One question on the form read, “Does a Special Vulnerability Exist?” Correctional staff marked “No.” Yet schizophrenia, according to ICE’s detention standards, qualifies as a “special vulnerability.” The detention standards require staff to reference all documents available to them during the classification process, including medical information, to properly house detainees. The standards also encourage officers to “inquire about and remain alert to signs of any special vulnerability or management concern that may affect the custody determination.”

“He was literally coming back from a specialized psychiatric facility. And the form they signed — two different CoreCivic employees signed — said, ‘He’s fine, don’t worry about it.’”

Despite having been previously placed on suicide watch in the facility and returning from a mental health institution, a CoreCivic officer neglected to recognize Romero’s mental illness and placed him in a “high custody” housing assignment. According to ICE standards, “high custody” detainees are those with a history of violent charges, institutional misconduct, or those with gang affiliation. A supervisor — also a CoreCivic employee — approved the worksheet and signed off on the classification two days later.

“Two people — not just a one-off, but two people, the person who screened him first and the supervisor who reviewed it, both working for CoreCivic — looked at Efraín’s record, looked at the things we have in front of us, and said, ‘Nope, no mental health issues here,’” said Andrew Free, the attorney. “He was literally coming back from a specialized psychiatric facility, after being transferred out of Stewart because of his mental health issues. And the form they signed — two different CoreCivic employees signed — said, ‘He’s fine, don’t worry about it.’”

A CoreCivic spokesperson would not answer specific questions of Romero’s time at Stewart, citing the pending investigation. “What we can tell you is the safety and well-being of the individuals entrusted to our care is our top priority, and we take seriously our obligation to adhere to federal Performance Based National Detention Standards in our ICE-contracted facilities,” said the spokesperson.

At the time, the facility’s warden overseeing Stewart was Charlie Peterson, a longtime CoreCivic employee. According to the CoreCivic spokesperson, Peterson’s departure was unrelated to Romero’s death. When reached by phone, Peterson refused to answer any questions, saying he was not allowed to speak with the media.

On June 13, a day after his return to Stewart, an Advanced Practice Practitioner at the facility medically cleared Romero for deportation. In the days that followed, Romero refused his medication.

Six days later, on June 19, a social worker evaluated Romero for his medication refusals and noted his diagnosis “met the criteria for a serious mental illness,” according to the ICE report on his detention.

Later that day, Romero was placed in solitary confinement for the second — and final — time. At around 4:44 p.m., Romero approached a 20-year-old correctional officer in a hallway leading to Unit 5B, one of the “Medium-High/High” general population units. According to the disciplinary report, provided by Free, Romero spoke to the detention officer and rubbed his foot on hers. The detention officer later told the GBI, “He kept saying he liked me, I was beautiful and had a big butt, and tried to touch me.” She called two correctional officers, and they took Romero to an office.

Romero remained calm during the investigation of the incident, documents report. An officer referred disciplinary action to the Institution Disciplinary Panel, a body overseeing punishment for detainees who break rules, and a registered nurse cleared Romero for solitary confinement. He was moved to Unit 7B and locked away in a solitary cell.

A day later, a social worker evaluated Romero and documented a “limitation in mental functioning, his refusal of medication administration, and the potential of his behavior worsening.”

Two days after being placed in solitary, on June 21, Romero had his hearing before the disciplinary panel. He was the only witness called and admitted to doing what the correctional officer had accused him of.

The supervisor writing up the disciplinary panel report charged Romero with Violation 207: “Making Sexual Proposals.” His punishment: 30 days in solitary confinement — twice what the U.N. special rapporteur on torture says should be considered “torture.”

ICE standards require staff at detention facilities to consult with medical staff during the disciplinary process. They are required to evaluate a detainee’s mental and physical health during the disciplinary process. Yet none of the disciplinary records released by CoreCivic in response to courtroom discovery demands and provided by Free make mention of Romero’s worsening mental illness. (The Takeaway and The Intercept reached out to the shift supervisor, Latoya Gainer, who sent Romero to 30 days in solitary confinement. She never responded, but the current warden of the facility, Michael Donahue, sent a text message requesting that The Takeaway and The Intercept stop attempting to contact Gainer.)

“The use of that kind of discipline without regard to the person’s individual status and individual history is deeply problematic,” Natarajan, of the Civil Rights Clinic, said. Natarajan said the use of solitary in this context was particularly troubling: “When you place someone who has mental health needs, who perhaps hasn’t been taking their medication, has auditory hallucinations, has a history of self-harm, what you’re doing is radically increasing the risk of suicide — especially if you put them in a jail cell that also has protrusions that they can use to readily hang themselves.”

A view through the door of Romero’s solitary cell after his death.

The tiny solitary confinement cell — number 105 in Unit 7B — is where 40-year-old Romero spent his last days. The cell was sparsely accommodated; only a handful of items were present. Looking in from the door, a chrome toilet and sink sit to the left. On the right, a seat and a table protruding from the wall. And along the back of the cell, a bunk bed.

The bottom bed had a white sheet draped over it. The top bunk was without linens. That’s where Romero’s bent Spanish edition of the Bible sat next to some disciplinary records and court documents.

Despite being held in the beige-colored cell for 23 hours a day, Romero would smile and wave, Stewart staff told the GBI. They said he was quiet and reserved. The officer who eventually found Romero hanging, Jamorris McCoy, told the GBI the detainee had always been a nice person to detention staff and other detainees. According to McCoy, Romero would frequently jump around his cell, smile, and give a thumbs-up sign.

Romero continued to communicate with staff and other detainees through the typical means used by those in solitary: by yelling through the walls of the solitary unit or chatting during their one daily hour of recreation.

Despite his friendly disposition with staff and other detainees, Romero had dark moments in solitary. A detainee named Pedro Mejia-Soto told the GBI that Romero wanted to see his parents — something he said on the day he died.

Another detainee, Jorge Caballero-Ramos, told the GBI, “We saw him sad all the time, we saw him just walking around every night. He don’t talk with nobody, pushing the door sometimes. He always crying.” Caballero-Ramos went on, “He say, ‘Take me out, I don’t want to be here! My family!’ That’s all he talk, he just say that — loud.”

Jonathan Calix-Cruz, a detainee held in Cell 117, told the GBI that Romero was his friend and reported that the schizophrenic detainee also expressed troubling thoughts. Romero told Calix-Cruz that God forgave everybody — except for Romero.

Isaac Kargbo, who was held in the cell next to Romero’s, told the CoreCivic investigator during the company’s internal investigation that he was like Romero’s best friend. Romero would tell Kargbo he missed his family and hated being locked up.

“He really acted — he acted like he wasn’t normal,” Jose Ponce-Martinez, another detainee, said. “He would say things — like, that he was a prophet.”

Another detainee, Luis Alvarez-Pineda, told the CoreCivic investigator that Romero would sometimes talk about suicide, but that “no one took him seriously as he always said crazy things and never spoke coherently.” Alvarez-Pineda himself expressed regret in an interview with a CoreCivic investigator for failing to take Romero seriously. On the day Romero died, he reportedly told Alvarez-Pineda during their recreation hour that God had “told him to leave” — and that he was going to “leave the officers with a surprise.”

On June 27, after eight days in solitary, a Stewart Detention Center committee reviewed his case and recommended he remain in solitary confinement until July 18 — through the end of the imposed 30 days. It is not known whether a medical staff member was on the review committee, since those records were withheld from the release by the GBI.

Days later, on July 3, an immigration judge ordered Romero removed from the country.

Seven days after his deportation order came through, on July 10, 2018, Romero began his 21st day in solitary confinement.

At 8 a.m., correctional staff took detainees out of their cells for recreation time in the designated area; calling it a “yard” would be too generous. In Stewart, detained migrants in solitary exercise in one of a row of small, conjoined cages built of tall chain-link fences. Metal basketball hoops hang from the back wall of each enclosure, and a ball is provided.

Each detainee gets an hour of recreation. During his hour, Romero took his shirt off and began throwing the ball at the basket. From time to time, he paused and spoke to CoreCivic correctional officer Patrick Blue, who was keeping an eye on the recreation area. One of the pauses lasted for a while, with Romero leaning against the chain-link fencing, engaged in conversation.

Nothing seems out of the ordinary in the surveillance video footage of Romero; his body language is casual. There’s no audio, but Blue, in an interview with the CoreCivic investigator, said Romero “spoke about the Bible and that the Holy Spirit entered him through a woman.”

Later, according to the ICE report, a nurse evaluated Romero during rounds of the solitary units. According to the ICE report, he presented no distress during the check-in and denied any suicidal ideations. Romero “answered questions appropriately.”

The surveillance footage obtained through a public records request, however, raises questions about the evaluation. The 18 hours of video shows only one on-camera interaction with a nurse, taking place during the recreation hour. The nurse approaches Romero, placing a form through the slot in the fence and pointing at the paper for him to write on. She then stands back and watches. When he is finished, the nurse takes the paper, turns around, and walks away. Although there is no audio in the footage, the interaction between Romero and the nurse is very brief. It is unclear whether Romero expressed any mental health concerns. In response to a public records request, authorities declined to release the form passed between Romero and the nurse.

After his hour of recreation time, Romero was handcuffed and taken back to solitary confinement Cell 105. At around 11:30 a.m., Romero was handcuffed again, escorted out of the cell, scanned with a handheld metal detector, and placed in a wheelchair. A correctional officer wheeled him out of view of the camera.

According to the ICE report, Romero met with a social worker for a mental health evaluation. The social worker documented Romero saying “he was going to die” and, once again, that he did not need medication. At the end of the evaluation, the social worker said Romero “would benefit from a referral to a higher level of care mental health facility.” As Capital and Main reported, Romero did not receive the additional mental health care he needed.

For the rest of the day, Romero paced around his cell. He stood on top of the toilet or by the door, staring out at the unit. He sometimes pushed on the door or moved back toward the bunk bed — disappearing from view on the security footage. He seemed to be struggling to pass the time, to whittle away the long, arduous hours in solitary confinement.

Every 30 minutes, correctional officers are required to look in each individual cell to check on detainees’ well-being, according to ICE’s policy. The detention facility staff need to observe individuals for a long enough time to make sure there are no problems or emergency health situations. After watching each detainee, the staff are required to sign the log sheet on a clipboard by each cell door.

That was the job of Rodney Dent, a CoreCivic correctional officer: to do rounds of the solitary cells, including Romero’s, and sign the logs.

In a still from closed-circuit video footage inside the facility, Romero is seen being escorted by a guard to the recreation area.

On Romero’s 21st day in his small cell, Dent was responsible for rounds on the lower tier of Unit 7B, covering 17 detainees housed in cells 101 through 120. In the afternoon, Dent moved through the solitary unit, peeking in cells and signing the logs on the clipboards. At times, he sat at the desk in the center of the unit, looking through paperwork.

Inside Cell 105, the slow hours drudged on. Romero continued to pace back and forth, battling the voices in his head. At 8:04 p.m., he turned the lights off in the cell, something that struck another detainee as odd. “He turn the lights early,” Caballero-Ramos told the GBI. “And that’s not — that’s not normal.”

On one of his rounds, Dent can be seen in the surveillance footage passing by Caballero-Ramos’s cell. He stopped, and the pair chatted. There is no sound in the footage, so it is unknown what they discussed. But, according to Caballero-Ramos’s interview with the GBI, he tried to warn a corrections officer that something was off with Romero — and Dent was the only officer who stopped at his cell.

“We told him, ‘Can you check him?’ And they didn’t even care. You can see, they didn’t even care.”

“We told them, ‘Something is happening.’ We told him, he can tell you,” Caballero-Ramos told the GBI. “We told him, ‘Can you check him?’ And they didn’t even care. You can see, they didn’t even care.”

Dent walked by Romero’s cell, briefly peeked inside, and signed the clipboard. Then 30 minutes later, at 8:40 p.m., he did the same thing: walked up to the door, took a quick look inside the dark cell, and signed the clipboard. That 8:40 p.m. round was the last time Dent looked into Romero’s cell.

At 9:13 p.m., Dent spoke with the detainee in Cell 104. Then he stepped up to the clipboard outside Cell 105, with Romero inside, and signed it without peeking into the cell. At 9:39 p.m., Dent did the same thing: signed the clipboard and kept walking without looking in. And at 10:04 p.m. — Dent’s last round-count for that day’s shift — he approached Cell 104, spoke with the detainee, signed the clipboard on Romero’s cell, and walked away without looking inside. Dent’s falsification of the log was first reported by the Atlanta-Journal Constitution, based on the internal CoreCivic report.

Dent told a GBI investigator that he looked into the cell on each round. “He was by the side, looked at him in the corner with my peripheral vision. Just smiled and waving a bit,” Dent told the state-level investigator, when asked about the 10:04 p.m. round. “I just saw his silhouetted face and his gold tooth in his mouth when he smiled. And he was waving.”

Yet the surveillance footage contradicts this statement. From 9:13 p.m. to 10:04 p.m., over the course of three rounds of the unit, Dent hadn’t peered into Romero’s cell, despite what was recorded in his logs.

“If the guard or the officer never even looked into the cell to see what he was doing and if he was breathing, he wasn’t doing his rounds, that’s not doing an observation at all,” said Natarajan. “That’s a critical failure.”

CoreCivic’s internal investigation into Romero’s death found that the check-in logs had been falsified. According to a CoreCivic spokesperson, “Mr. Dent’s employment at Stewart Detention Center has been terminated.” When reached by phone, Dent said that what happened on that July night was an awful experience he was attempting to leave in the past. He hung up the phone, refusing to answer any questions.

In another still from closed-circuit video footage inside the facility, nurses can be seen rolling a gurney to Romero’s cell after he hanged himself, as guards stand by.

As Dent’s shift ended a little after 10 p.m., another correctional officer, Jamorris McCoy, relieved Dent. As McCoy’s shift began, he checked in on the cells in solitary unit 7B. At around 10:30 p.m., nearly two hours since anyone had checked on Romero, McCoy began his first round of checks, looking into each cell.

Security footage shows McCoy beginning to look into the cells at 10:34 p.m. He makes his way around the unit, looking into the cells through the small windows in the doors. He looked into Cell 101, Cell 102, Cell 103, and Cell 104. But when McCoy reached Cell 105, he paused.

“I looked, I wrote the time, but I looked. I hit the window, though I noticed he didn’t respond,” McCoy said. “I hit the window two times, but he didn’t respond so I called a medical emergency.”

In the two hours since someone had checked on him, Romero had fashioned his orange socks into a noose, attached them to the bunk bed’s railing, and hanged himself.

Correctional officer Patrick Blue, who was overseeing Unit 7A, was first to the scene after McCoy called him over. After reaching for his radio and calling for a medical emergency, McCoy rushed over to grab the “J-knife” — sometimes referred to as the “suicide knife” — used to cut down nooses. A supervisor, Lieutenant Jamal Williams, arrived and gave the two officers permission to enter the cell. The door swung open, and the three officers rushed to cut Romero down. Footage shows them struggling to place his body on the floor.

Detainees in the other solitary cells watched in horror. They began banging on the cell doors, yelling at correctional staff. Detainees described the scene unfolding before them, how correctional staff began giving CPR as nurses were called. Many thought he was already dead by the time staff found him.

The senior detention officer that night was assigned to the medical unit but did not hear the medical emergency call because her radio was dead. The correctional staff on the scene seemed unprepared for the medical emergency.

The CoreCivic report notes that the first oxygen tank medical staff brought to the scene was empty. The automated external defibrillator, or AED machine, was also nowhere to be found. Natarajan said, “It’s a critical failure if lifesaving devices like the AED and the oxygen tank are not available.”

CoreCivic staff began recording the events with a handheld camera for liability purposes; the resulting footage is difficult to watch. McCoy gives CPR to Romero as he lays on the floor of his cell, dressed in his red prison garb. Though the handheld recording has audio, the sound of detainees yelling drowns out much of what correctional staff are saying.

“Sons of bitches!” Some detainees can be heard yelling, amid the thunderous banging of the cell doors. “Murderers!”

The nurse who first arrived on scene seemed distressed in the video footage, frantically searching for the defibrillator and instructing the onlooking correctional staff to call an ambulance. “Call EMS now! Get the AED! AED!” the nurse yells. “No, where the hell’s my AED? I need it stat! Stat — I need the AED.”

As more Stewart staff gathered to watch, the nurse begins pleading to Romero. “Hey buddy, can you wake up for me? Hey! Hey! C’mon, buddy. C’mon. Hey! Hey! Wake up for me, c’mon please,” the nurse yells. She mumbles to herself, “I need an oxygen — dammit, there was nothing on my cart.”

Eleven minutes after Romero was found, Stewart County EMS arrived. Two minutes later, they entered the solitary unit and dragged Romero out of the cell. After continuing CPR and other procedures for 10 more minutes, they placed him on a stretcher and brought him outside of the unit and toward the ambulance.

“He’s clinically dead right now. He’s clinically dead,” one of the EMS first responders said. “We’re doing everything we can to reverse that.”

They loaded Romero into the ambulance and rushed him to a nearby hospital. A doctor pronounced him dead at 11:29 p.m.

The entrance to Stewart Detention Center on Feb. 21 , 2018.

The Takeaway and The Intercept sent a long list of detailed questions to ICE, highlighting findings of this investigation. An ICE spokesperson referred some of those questions to CoreCivic, saying the agency was unable to speak to the actions of CoreCivic employees.

“ICE is firmly committed to the health and welfare of all those in its custody and undertakes a comprehensive agency-wide review of every fatality that occurs in ICE custody,” the agency spokesperson said. “While any death in ICE custody is unfortunate, fatalities in ICE custody, statistically, are exceedingly rare. That reality, and the contextual data to follow, is in no way intended to diminish the significance of Mr. de la Rosa’s death; it is provided simply to illustrate just how exceptionally rare fatalities are in ICE custody and to explain the policies and procedures in place regarding ICE detention as a whole.”

According to the ICE spokesperson, fatalities in ICE custody occur at a rate approximately 100 times lower than other federal and state detained populations. The agency spokesperson said that ICE spends more than $250 million annually on comprehensive medical treatment for people in custody.

CoreCivic was not the only private company profiting off immigration detention during Romero’s time in ICE custody.

In the hundreds of pages of documents reviewed for this story, The Takeaway and The Intercept identified three companies contracted by ICE Health Service Corps to assist in providing health care-related services at Stewart, during the time that Castro-Garrido and Romero were detained: Maxim Healthcare, InGenesis, and STG International Incorporated.

Staff members for InGenesis and STG responded to the medical emergency call when Romero was found.

“InGenesis employed only a portion of the healthcare workers there, did not manage or maintain its medical records, and did not manage and direct its healthcare services program,” InGenesis’s chief strategy officer and general counsel Justin Harris said, in response to a request for comment. “InGenesis is committed to staffing trained and qualified personnel to support its clients’ healthcare practices.”

InGenesis nurses, however, were involved with Romero’s suicide watch and medication distribution, according to government records on his care. InGenesis did not respond to repeated inquiries on the company’s work at Stewart, how many InGenesis staff members were employed at the facility, or if the company trained staff on mental health and solitary confinement.

A spokesperson for Maxim said the company was not the primary health care staffing provider at Stewart. “According to our records, we placed a total of six health provider contractors over the 20-month time period in question,” a spokesperson said. “We are not presently aware that any of the staff members we placed had involvement in the cases you referenced.”

The nurse who first responded to the medical emergency call and made note that the emergency cart was bereft of supplies, was employed by STG, which did not respond to repeated requests for comment.

Last November, ICE ended the contracts with the three companies providing health care at Stewart, and ICE Health Service Corps is no longer in charge of care at the facility. According to an agency spokesperson, ICE headquarters contracted all medical and health care work to CoreCivic, which now controls the entire facility.

Family and friends march in Kansas City, Mo., to protest and attend a vigil for Jeancarlo Jimenez-Joseph on the one year anniversary of his death.

The 2017 death of Jimenez-Joseph brought waves of media attention to Stewart Detention Center. The similarities between his death and Romero’s, however, have led some critics to question whether any serious changes have been made.

“The fact that you see a suicide like Mr. de la Rosa’s about 14 months after another suicide, shows that perhaps there was not a thorough audit or review of the procedures used at Stewart,” Natarajan said. “I think it’s really important that ICE audit the particular suicides, but also audit to see what are the systemic failures at the facility that are causing suicides to happen over and over again. Because we shouldn’t be experiencing these kind of fatalities in immigration detention — period.”

Not only did Romero fall victim to an immigration enforcement system detaining people at unprecedented levels, but he was locked away in one of the most notorious detention facilities in the country. His mental illness only exacerbated his already precarious position. He had already served his time in jail for the laws he previously broke.

“ICE and CoreCivic failed Efraín de la Rosa at every step.”

ICE custody was not supposed to be a death sentence for crossing the border. On paper, it was a civil case, with deportation serving as punishment. But his time at Stewart was filled with anguish. Romero’s mental illness and his conditions swirled into a storm amid which he took his own life. Despite what an immigration judge had decided, Romero’s life came to a permanent end in what was supposed to be temporary detention.

“ICE and CoreCivic failed Efraín de la Rosa at every step,” Azadeh Shahshahani, a human rights attorney with Project South said, after being briefed on Romero’s case. “This horrific facility needs to be immediately shut down.”

There are impossible questions to answer about Romero’s case, questions about whether he would be alive if ICE, CoreCivic, and their staff at Stewart had followed their own procedures, had noted their own acceptance of a diagnosis, or had prepared to have the proper medical equipment to hand.

For attorney Andrew Free, the main question Romero’s death raises is one about how the U.S. organizes its immigration system. “It’s detention itself,” Free said. “When you have this bias towards putting people in cages, in order to get them through a civil immigration detention hearing without fighting, without having counsel, without having access to a lawyer or community advocate who can help with their case — because you want to up deportation numbers, because you want to racially profile and ethnically cleanse the United States of people you find undesirable — and you have this profit motive that fuels that. It is a system that sets people up to die.”

Romero’s brother Isaí, however, isn’t looking to place blame.

“I want there to be more noise, more anger,” Isaí Romero said. “So that this death won’t be in vain. If we can — with my brother’s death — I want other Hispanics to open their eyes, for there to be more unity among us, so we don’t fall and become accustomed to injustice. Because sometimes, if we are quiet, that’s why they do to us what they do. So that’s what I hope for — for there to be justice.”