On the last day of his life, Efrain de la Rosa, a 40-year old Mexican citizen detained as an undocumented immigrant, told a social worker he didn’t need medication for his schizophrenia. He would die soon, he said. Later that day, De la Rosa knotted together his prison-issue orange socks, fashioned them into a noose, and hanged himself from the top bunk in his solitary confinement cell at Georgia’s Stewart Detention Center.
De la Rosa spent four months at Stewart, which is operated by the private prison firm CoreCivic. While incarcerated, he repeatedly predicted his own death, reported hearing voices, and refused medication. He was briefly placed on suicide watch and was sent to an outside mental health facility for five weeks. Upon his return to Stewart, he continued to refuse medication and to dwell on death in his conversations with healthcare staff and detainees.
Stewart is indistinguishable from a prison even though the detainees are held only to compel their attendance at immigration hearings or to await deportation there, and not as punishment. At the time of his July 10, 2018, death, De la Rosa had been alone in a 13-by-6-foot cell 23 hours a day for three weeks. It was his second stint in solitary confinement.
De la Rosa’s suicide came just 14 months after that of JeanCarlo Jimenez Joseph, a 27-year-old man who was also mentally ill and hanged himself after 19 days in solitary confinement. He was the 184th detainee to die in the custody of U.S. Immigration and Customs Enforcement since 2003, and the third to die at Stewart since May 2017.
The Georgia Bureau of Investigation found no criminal wrongdoing in De la Rosa’s death, but its report, which includes findings from the detention center’s internal investigation, along with ICE’s detention death report, shows that Stewart Detention Center staff made a series of mistakes in De la Rosa’s care, beginning with his placement in solitary confinement and ending with a chaotic emergency response when he was found unresponsive in his cell.
The report shows that detention center staff repeated some of the same errors in De la Rosa’s care that they made in Jimenez Joseph’s. The failure to correct such mistakes–which can prove fatal to vulnerable detainees–is common in ICE detention centers, concluded a Department of Homeland Security Office of Inspector General report entitled, “ICE’s Inspections and Monitoring of Detention Facilities Do Not Lead to Sustained Compliance.” “ICE does not adequately follow up on identified deficiencies or consistently hold facilities accountable,” inspectors found.
Private prison firm sought to suppress the report
In De la Rosa’s case, CoreCivic made an attempt to suppress the release of the Georgia Bureau of Investigation (GBI) report, which exposes some of those errors, arguing that making it available to the public would violate federal law.
“We had another death at the facility last year where the GBI released records and video to the public as part of OR [open records] requests,” wrote Stephen Curry, a CoreCivic attorney. “It is our request that there not be a release of information contrary to federal law.”
The GBI initially acquiesced, but last month largely reversed course and released a first batch of documents after attorneys and media outlets, including Capital & Main, challenged its decision. The agency plans to redact audio and video evidence before making it available to the public, beginning at the end of January. The GBI continues to refuse to release some solitary confinement records and other information that it maintains are federal documents.
In both De la Rosa’s and Jimenez Joseph’s suicides, the reports show:
- Both men were in prolonged solitary confinement, despite their serious mental illnesses.
- Healthcare professionals recommended both men receive additional mental healthcare, but both died before it could be provided.
- Detention officers failed to perform every-half-hour checks in the hours before each man died to ensure their well-being.
- Both men’s cells contained suicide hazards, including a bunk bed in De la Rosa’s one-person cell.
Ignoring advice to take him out of solitary
The social worker who met with de la Rosa on the day that he died had noted he “would benefit from a referral to a higher level of care mental health facility” after he once again refused medication and predicted he would die. Terry Kupers, a psychiatrist who has written extensively about prison mental health care, suggested that was a mistake.
“One would think provisions would be made to immediately place him in some form of observation in a safe place awaiting transfer to the location of that higher level of care,” Kupers wrote in an email.
De la Rosa, however, remained in isolation.
Moreover, detention officers failed to look in on De la Rosa for nearly two hours before finding him unresponsive in his cell later that evening.
Stewart officials found that detention officer Rodney Dent falsified records to cover for his failure to check on De la Rosa, and he was fired.
Dent had falsely claimed he looked in on De la Rosa at 10:04 p.m. before he finished his shift. Security cameras showed that his relief, Officer Jamorris McCoy, was doing rounds when he found De la Rosa unresponsive and hanging from the top bunk in his cell at 10:34 p.m.
Dent, however, may not have been the only officer who was negligent on the night of De la Rosa’s death.
Detainee Eduardo Corado Martinez, who was also in segregation when De la Rosa died, told a GBI agent that he tried to alert guards that something was wrong in De la Rosa’s cell when he heard noises that night. But he said they didn’t immediately respond. Jorge Caballero Ramos, who was also in a neighboring cell, told the GBI that he woke up to the sound of Corado Martinez pushing on his own door to get the guards’ attention, but he said they didn’t act until it was too late.
CoreCivic spokeswoman Amanda Gilchrist said in an email that she could not reveal details of De la Rosa’s death, including why the detention center’s investigation didn’t include statements by Corado Martinez and Caballero Ramos, because of a “pending claim” and an ongoing ICE investigation.
“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,” Gilchrist wrote.
At the time of this story’s deadline, ICE public affairs staff were unavailable to comment on the lapses the reports showed because of the government shutdown.
Out of step with “clear evidence” about risks
However, it appears that the Stewart Detention Center and ICE are out of step with a trend in corrections to keep seriously mentally ill people out of solitary confinement. Kupers said that prisons are moving away from the practice “because of the high risk of suicide and in even larger part because we have such clear evidence from much research that solitary confinement exacerbates serious mental illness.”
He cited state laws in New York and Maine that prohibit solitary confinement for people who are seriously mentally ill, and federal court orders in at least three states that require more stringent screening for inmate placement in solitary.
The reports also describe a haphazard emergency response on the night De la Rosa was found unresponsive in his cell.
Two nurses who rushed to help discovered that their medical bag was missing a defibrillator and working oxygen tank, slowing the attempt to revive him. The detention officer assigned to the medical unit didn’t hear the emergency call for medical assistance. Another officer had to alert them several minutes after the initial radio call.
The lack of adequate lifesaving equipment at Stewart is puzzling given CoreCivic’s healthy bottom line. In the third quarter of last year, the company’s revenues were up 4.5% from the year before, and it netted $41 million for the quarter.
ICE is also better funded than ever before, with a $4.1 billion congressional appropriation for its Enforcement and Removal Operation, but it is unclear whether it is taking steps to hold detention centers more accountable. The agency is scheduled to report to the inspector general on its progress by June 2019.
Lucille Roybal Allard (D-CA), newly appointed chair of the House Homeland Security Subcommittee on Appropriations, said in a call with reporters last month that she would demand greater accountability from ICE and its contractors for detention conditions.
De la Rosa’s family and his attorneys have not filed a lawsuit, but say they are exploring their legal options.
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