A rare look inside immigration detention

This security camera footage, released by the Georgia Bureau of Investigation, gives a rare glimpse of daily life inside Stewart Detention Center, one of the largest immigrant detention facilities in the US.

Posted: Aug 26, 2018 5:51 PM
Updated: Aug 26, 2018 6:02 PM

Miguel Montilla was in the law library when the banging started.

Over and over he heard it -- the sound of a man screaming as he pounded the wall of the cell next door.

When a guard came by, Montilla listened. The man in Cell 102 said he was suffering from psychosis.

"I hear voices talking to me," he said. "And they're bothering the shit out of me."

Montilla climbed on a toilet and spoke through a vent. He wanted to offer some words of comfort to a fellow detainee -- to tell him things were going to get better.

"Hey, man. You OK, man? Calm down. Don't worry about it. You're gonna be out of here soon."

But things got worse for the man in Cell 102.

Two weeks later, Montilla heard a jarring noise again -- the sound of a man ramming into the wall of his cell.

Boom.

This time, there would be no words of comfort.

Jeancarlo Alfonso Jimenez Joseph, the 27-year-old who'd been locked inside Cell 102 for 18 days, hadn't just banged into the wall of his cell. He'd tied one end of a white bed sheet around a sprinkler head and the other end around his neck.

***

The night he died in May 2017, Jimenez was one of more than two dozen people in solitary at the Stewart Detention Center, a hulking complex just outside Lumpkin, Georgia, that can house nearly 2,000 immigrants.

He was the fourth detainee to die in Immigration and Customs Enforcement custody in 2017 and the 170th since the agency began in 2003.

After his death, headlines in English and Spanish flashed across websites around the globe. Some summed up what had happened. Others offered ominous warnings.

Immigrant detainee dies by suicide in ICE custody in Georgia

7 people in ICE custody have died since October

Donald Trump's immigration crackdown will be deadly

Immigrant rights activists quickly rallied around the case, noting that Jimenez had been held for more than two weeks in solitary confinement -- a disciplinary approach that's long drawn criticism from human rights groups.

Activists weren't the only ones interested in what happened in Cell 102.

Special agents from the Georgia Bureau of Investigation spent months interviewing witnesses, combing over documents, sifting through surveillance footage and listening to audio recordings after Jimenez's death.

The conclusion they reached: Suicide. There was no foul play.

But even though their case is closed, the records GBI investigators unearthed could provide crucial information as a federal inquiry continues, Jimenez's family pushes for answers and authorities investigate another apparent suicide in solitary at Stewart.

The photos, files and recordings from the state investigation into Jimenez's death offer a rare public window into life behind bars in the largest immigrant detention center in the Southeast. They reveal key details about events preceding Jimenez's death. And they raise larger questions about the quality of medical and mental health care the tens of thousands of people in ICE custody receive, at a time when the administration has vowed to increase the number of undocumented immigrants it detains and deports.

Jimenez's family alleges that staff at Stewart knew he needed better mental health care but punished him instead of treating him.

"Though Mr. Jimenez was immediately identified ... as a suicide risk during his arrival and booking, and despite their knowledge of his documented history of schizophrenia, suicidal ideation, and multiple involuntary commitments ... officials repeatedly subjected Mr. Jimenez to solitary confinement and denied him access to necessary mental health treatment and intervention," the family said in a lawsuit filed this year.

Jimenez ended up in solitary twice at Stewart. The first time broke his spirit, his family says. The second time, they argue, the consequences were fatal.

With ICE's investigation into Jimenez's death ongoing, federal authorities have been tight-lipped about the case.

But documents obtained by CNN show that well before Jimenez died, medical staff at Stewart had records from his previous commitments and knew he was schizophrenic, took anti-psychotic medication and had previously attempted suicide.

While many of the details surrounding his death remain a mystery, this much is clear: In the 70 days Jimenez spent at Stewart, authorities evaluated and reevaluated his case multiple times -- when he first entered the facility, when he was sent to solitary and when he spoke with nurses and guards inside the unit. And each time, they could have changed course -- but didn't.

The details that have emerged so far are damning, says Dr. Terry Allen Kupers, a forensic psychiatrist who's spent decades studying how solitary confinement affects mental health.

"This," Kupers said, "is absolutely the worst-case scenario."

Jimenez's death highlights widespread concerns about conditions in immigrant detention centers, which are often privately run in remote locations far from public view, says Mary Small, policy director of Detention Watch Network.

"Should we be concerned, based on what this administration has already done, that situations like this will become more common or worse? The answer to that," she says, "is an unequivocal yes."

***

In announcing Jimenez's death, ICE officials noted it had been more than eight years since a detainee at Stewart had died. Fatalities in ICE custody, they said, are "exceedingly rare," occurring far less frequently than deaths in other US prisons and jails. And, they pointed out, Jimenez was in custody because of a run-in with the law.

Asked about the case more than a year later, ICE spokesman Bryan Cox said he couldn't comment on specifics because of the ongoing investigation. The agency also has denied CNN's Freedom of Information Act request for records related to the case, citing the investigation.

"ICE holds its personnel and contractors to the highest standards of professional and ethical behavior, and the agency takes all allegations of misconduct seriously," Cox said. "ICE will continue to monitor the situation and respond appropriately based on the outcome of the investigative findings."

He noted that out of 324,000 people in ICE custody during the last fiscal year, 12 detainees died.

"That works out to approximately 3.7 per 100,000 detainees -- roughly 1.3% of the national average for detained populations," Cox said. "That context is not intended to diminish the significance of any specific incident; I provide it simply for important context about how exceptionally rare fatalities are in ICE custody."

CoreCivic, the private company that owns and operates the detention center, says it's cooperating with investigators.

"The safety and well-being of the individuals entrusted to our care is our top priority," CoreCivic spokeswoman Amanda Gilchrist said.

She said questions about medical or mental health services at Stewart should be directed to ICE.

"Because CoreCivic is not the healthcare provider at this facility," Gilchrist said, "we also do not have access to medical-specific information about detainees."

***

Before the 10 weeks he spent at Stewart, before the 18 days he spent in Cell 102, before the 90 minutes rescuers spent trying to revive him, Jeancarlo Alfonso Jimenez Joseph had lived in the United States for 16 years.

His mom brought him here from Panama on a tourist visa just before his 11th birthday. Eventually, he saw himself as American. English was the language he felt most comfortable speaking. His friends and family called him Jean.

He went to middle school and high school in Kansas. He became a star of his wrestling team. He was an artist with a sharp attention to detail, an amateur musician who loved playing the drums, a snappy dresser who knew how to pose for the camera.

He overstayed his visa and lived for years as an undocumented immigrant. Then in 2012, the Deferred Action for Childhood Arrivals program gave him a chance to live and work legally in the United States without fear of deportation.

He studied architecture at a community college and dreamed of running his own firm.

These details weren't in ICE's announcement of his death. The agency's news release included only one sentence about Jimenez's background before he ended up at Stewart: that he'd entered ICE custody after he was found guilty of felony motor vehicle larceny.

That isn't true. In the six months before he ended up at Stewart, police in Raleigh, North Carolina, arrested Jimenez at least five times, and he was found guilty of a string of misdemeanor offenses. But according to court records, the district attorney there dismissed the felony charge and several others.

To law enforcement, Jimenez was a man with a growing rap sheet who couldn't seem to stay out of trouble.

To friends and family, he was a kind and brilliant soul with a mental illness who needed medical attention but instead got what they say amounted to a death sentence.

Jimenez's family hasn't been trying to hide his arrest record. To them, the string of arrests was among the first signs of a system that failed.

To anyone who's seen friends or family members in the throes of a psychiatric crisis, Jimenez's last days as a free man sound hauntingly familiar.

Clashes with family. Run-ins with the law. Homelessness. Multiple stays at mental health facilities.

His mother, Nerina Joseph, says she can't stop asking herself where things went wrong. When did everything turn?

She started noticing changes in her son several years ago, she says. He lost interest in his studies. He seemed increasingly distant and detached. The man she knew as fun-loving and joyful became angry and despondent. Sometimes she felt frightened when he was alone with her. He'd explode, she says, when she'd tell him he needed professional help.

Time and again, she tried to find treatment, driving him to mental health facilities.

But his stays would only last for a day or two. Officials would tell her they couldn't hold him any longer against his will. Because he was an adult, they couldn't tell her his diagnosis -- and neither would he. But she knew something was seriously wrong.

"This wasn't my son. He needed to be helped. But the system didn't help me," she says. "The system is broken. It isn't designed for the needs of a human being."

Eventually, Jimenez ended up behind bars, in the custody of the Wake County Sheriff's Office in Raleigh.

A nurse there petitioned a court to involuntarily commit Jimenez in October 2016 after he appeared anxious and depressed, admitted to being psychotic and stated he was hearing voices that were making him "so angry," according to records CNN obtained from the family attorney. A magistrate found Jimenez was "mentally ill and in need of treatment." He was committed for about a week, then released.

A few months later, he was committed once again -- this time for nearly two weeks after his mother took him to a mental health crisis clinic. As soon as they arrived, he shouted he was going to kill himself.

All of this, according to Jimenez's family, should have been known by guards and medical staff at Stewart Detention Center the moment Jimenez walked through the door.

"They put him there. They knew that he was not well. But when he landed in Stewart, we couldn't talk with anyone," Nerina Joseph says. "That was his cemetery."

***

Jimenez wasn't the first person to face a mental health crisis behind bars. And he won't be the last.

Study after study shows that America's prisons and jails have become homes for the mentally ill at an alarming rate. During a mental health crisis, experts say, you're much more likely to encounter police than get psychological care. According to the National Sheriffs' Association, there are three times more seriously mentally ill people in jails and prisons than in hospitals.

The problem has become so acute that jails and prisons are now known as the "new asylums," says Dr. Marc Stern, an assistant professor of health services at the University of Washington's School of Public Health.

"The bulk of people in the country who have serious mental illness requiring hospitalization are currently today in a correctional institution," Stern says.

The nonprofit Treatment Advocacy Center estimates that as of 2016, there were more than 383,000 inmates with mental illness in jails and prisons -- a figure close to the total population of Cleveland.

The entire number of detainees in ICE custody is far smaller -- an average of 38,105 daily during the 2017 fiscal year. But it's projected to grow. And about 15% of people in ICE custody suffer from mental illness, according to a 2010 analysis in The Journal of the American Academy of Psychiatry and the Law.

***

Jimenez walked through the razor wire gates of the Stewart Detention Center on March 7, 2017, about a month before his 27th birthday. He entered Stewart with the sinking fear many undocumented immigrants face: that he could soon be deported to a country he barely remembered.

But the anxiety of an uncertain future wasn't the only thing weighing on his mind. Jimenez heard voices. He took anti-psychotic medication. And he'd been committed twice. Just a few months earlier, a psychologist in North Carolina reported he was at "acutely elevated risk of harm to self/others," according to records provided by the family's attorney.

Exactly how much did officials at Stewart know about Jimenez's psychological history when he first walked through the detention center's gates?

That depends on whom you ask.

It's not clear what physical or mental health records were in Jimenez's file when he arrived at Stewart.

ICE has denied CNN's requests for information on Jimenez's medical and mental health treatment, citing its pending investigation. But the agency has released some records to Jimenez's family members, who filed a federal lawsuit earlier this year accusing the agency of violating the Freedom of Information Act. Those records and the GBI file paint a contradictory picture of what officials knew that first day.

Bill Spivey, the detention center's warden at the time and a psychologist himself, told the GBI there "were no issues or disturbances initially reported" when Jimenez first arrived at Stewart on March 7, 2017. But the GBI's case file also includes a copy of an intake screening, paperwork completed for each detainee who enters ICE custody. The screening describes Jimenez as "displaying erratic behavior" and says, "subject does not claim good health."

As a nurse examined him on that first day, Jimenez said he wanted to hurt himself, according to an internal memo from ICE medical staff released to Jimenez's family in response to a public records request. The nurse also noted that he had a history of psychosis and suicide attempts. Officials placed him on one-on-one observation that day and gave him a suicide smock, according to the memo. And a doctor diagnosed him with suicidal ideations the next day.

ICE has not responded to a request for comment on the memo, which was provided to CNN by the family's attorney. By March 9, according to the document, Jimenez had been cleared for release into the detention center's general population.

Less than 70 days later, he was dead.

***

The series of events that sent Jimenez into solitary unfolded in a matter of minutes on April 27, 2017.

It began as a typical afternoon in the dayroom of Unit 4 Bravo. The large open space, surrounded on three sides by two stories of cells, was bustling with activity.

Several dozen men were scattered throughout the dayroom, playing checkers and watching TV. They sat in small groups, clustered around octagon-shaped tables bolted to the floor.

Jimenez stood alone beside one table covered with papers, his artwork spread out around him, just the way he liked it.

Then he darted away, heading up one of two staircases leading to the second floor.

Surveillance footage shows him pacing back and forth on the second-tier walkway overlooking the tables.

He stopped for a moment, set his hand on the metal railing at the edge of the walkway and looked down at the dayroom.

No one seemed to notice.

A few minutes later, Jimenez caught their attention.

He walked, skipped and hopped as he headed past a bathroom, past one cell door, then another. He slipped into a cell, then stepped back out. He took his shirt off, then put it back on. He grabbed onto the railing again. But this time, he flung himself over the side.

It was about a 10-foot drop to the concrete floor.

Jimenez dangled from the railing, then let go, ending up on two feet like a gymnast sticking a landing.

Less than 30 minutes later, three guards escorted Jimenez to Stewart's segregation unit and locked him inside Cell 102. His sentence for committing a disciplinary infraction: 20 days in isolation.

The reason, according to paperwork officials completed at the time: violation code #223, "an act that could endanger person(s) and/or property."

According to a guard's interview with the GBI, Jimenez gave no explanation that day other than repeating, "I am Julius Caesar."

Jimenez later told his family he had one goal in mind when he threw himself over the railing: ending his life.

***

Did staff at Stewart fear Jimenez was suicidal when they sent him to solitary?

Cox, the ICE spokesman, said last year that officials would have followed a particular protocol if they did.

"Had he expressed any kind of suicidal ideation," Cox told the Atlanta Journal-Constitution, "there would have been a specific medical reaction to that."

A mental health counselor at the facility told the GBI that Jimenez had a "suicidal past" but had never shown any suicidal tendencies at Stewart.

"He was in segregation for disciplinary issues," Kimberly Calvery said. "Pleasant, was not endorsing any thoughts of wanting to hurt himself the last time I saw him."

But records indicate that officials had more reasons to be concerned than they were letting on.

Documents obtained by CNN show that Stewart received a faxed copy of Jimenez's psychiatric records on April 12, 2017 -- two weeks before the dayroom incident. Jimenez had requested copies of the paperwork, according to his family. The documents, left behind in Jimenez's cell after he died and later released to his family, detail the symptoms he exhibited leading up to his commitments in North Carolina -- including hallucinations, delusional speech and suicidal ideation. They also reference several past suicide attempts.

Calvery's signature appears on every page, beside a stamp and a note that says, "reviewed April 14." Calvery could not be reached for comment.

Another document released in the GBI file shows there was paperwork on file at Stewart labeled with an alert about Jimenez's mental health.

The inmate information sheet describes Jimenez as a "suicide risk" with "medical issues." It's dated April 19, 2017, less than a week before Jimenez jumped off the walkway and ended up in solitary, and less than a month before he ended his life.

***

According to ICE policies, this is what is supposed to happen when someone with a mental illness or deemed a suicide risk lands in solitary:

The facility must notify the field office director within 72 hours.

The field office must then alert officials in Washington and notify the detainee's legal representative.

Then ICE's Health Service Corps, charged with handling the health care of detainees in agency custody, will evaluate the case.

"Such detainees shall be removed from segregation if the IHSC determines that the segregation placement has resulted in deterioration of the detainee's medical or mental health, and an appropriate alternative is available," the policy states.

The policies were part of an effort by the Obama administration to limit the use of solitary and increase oversight of the practice. Stewart's warden sent out a memo in 2016 noting the facility's compliance with the directive.

"Every effort shall be made to place detainees with serious mental illness in a setting in or outside of the facility in which appropriate treatment can be provided rather than in segregation, if separation from the general population is necessary," Stewart's policy states.

Since ICE has refused to release its records connected to the case, it's unclear whether Stewart administrators and ICE officials made such an effort when they sent Jimenez to Cell 102.

Records in the GBI file indicate Jimenez was screened by the Health Service Corps before entering solitary. A form signed at the time says, "cleared for special housing unit." Under comments, a series of numbers that appear to be vital signs are listed, but there's no mention of Jimenez's mental health. He wasn't placed on suicide watch.

Immigrant rights advocates say there's no doubt the case should have been handled differently. In a letter to lawmakers last year signed by some 70 groups, they pointed to Jimenez's death as a stark example of the need for more oversight and investigation at Stewart.

"He should have been receiving treatment, not been isolated and forgotten in solitary," the letter said. "This tragedy raises the question—how often are these standards being ignored?"

***

Cell 102 in Segregation Unit 7A was 13.5 feet long by 7 feet wide. The cement block walls were painted white.

There were two windows in the locked steel door that separated Jimenez from the guards who watched him. Jimenez could see out. They could see in.

There was a metal bed with a mattress pad on it. A metal toilet and sink. And a metal mirror. Bolts held each piece of furniture in place.

A sprinkler head jutted out from the wall above the toilet, more than 7 feet off the floor.

For one hour daily, Jimenez was escorted outside for the required hour of rec time, where detainees in solitary are locked in separate cages with basketball hoops.

But Cell 102 is where Jean Jimenez Joseph spent roughly 23 hours every day, for 18 days, until paramedics wheeled him out on a stretcher.

***

Jimenez was one of 27 people held in Segregation Unit 7A the day he died. A detention center log contained in the GBI report includes a list of reasons why each detainee ended up there. Among them: fighting, assault, refusing to obey, and medical observation. Three people had been there for more than two months.

It's common for corrections facilities to have restrictive areas where they separate detainees from the general population as punishment, says Luis Soto, a retired major from New Jersey's state prison system who now teaches criminal justice at Rutgers University. Students who haven't worked at a prison, he says, often have a hard time understanding why there'd be a "jail within a jail." Soto describes it as an essential tool.

"It helps to ensure that the population understands that there are some repercussions for their bad behavior," Soto says.

When US prisons started using solitary confinement in the 18th century, it was an experiment advocated as a more humane approach than flogging or executions. But now, Soto says, it's fallen out of favor among many corrections experts. And a growing number of US states are moving away from the practice, with some facilities moving toward alternatives such as holding people in restrictive areas with cellmates.

"We've debated the fact that (solitary is) not good for anyone. It's not good for the individual, and it's not good for the management of someone. You're in a cell, and there's nothing for you to do, other than count the cinderblocks on the wall or count the paint chips," Soto says. "What do you do? It's like you're a caged individual, and there's nothing that can benefit you mentally or physically."

ICE and its contractors don't use the term "solitary confinement" to describe the practice of pulling detainees out of the general population and putting them into isolation cells. They use terms like "restricted housing," "segregation" and "special management units." And they've argued that it's not the same as solitary, since detainees still interact with guards and have access to certain services, like a law library and barber shop.

Activists say the term used to describe the practice isn't what really matters.

The issue, they say, is what happens inside the mind of someone who's isolated for hours, days, weeks, or even months at a time.

Juan Mendez knows what it's like. And not just because of the stories he heard as the United Nations' special rapporteur on torture.

But because he lived it.

It was just for three days, but he still remembers the experience decades later.

How minutes seemed like hours, how he stared at a wall in his cell, unable to see beyond the darkness.

He was a human rights lawyer being held as a political prisoner in Argentina during the country's "dirty war." Now he's a professor at American University's Washington College of Law.

And these days, his words about solitary confinement come up in just about every human rights group's statement decrying the practice.

In 2011, Mendez called for an end to solitary confinement in most cases, saying it can amount to cruel and inhuman treatment -- and that in some cases it's tantamount to torture.

Stints in solitary lasting more than 15 days, he says, should be banned altogether.

"The science is quite clear. There's no question that the harm is real, the suffering," he says. "Any period of more than 15 days, your mind starts working differently."

***

On May 2, his 6th day in solitary, Jimenez exposed himself to two nurses who'd come by Cell 102. He was told to stop but continued, according to a report.

The result: another charge in Stewart's internal discipline system, this time for indecent exposure. His sentence: three more days in solitary.

According to the ICE medical memo released to Jimenez's family, that wasn't the only thing that happened in Jimenez's cell that day. Jimenez also told staff that he wanted to cut himself and told a counselor that voices were tormenting him.

On May 10, his 14th day in solitary, Jimenez was standing on top of a toilet, banging on the mirror above his vanity, when nurse Shuntelle Anderson stopped by Cell 102 to give him his daily dose of medication.

"Are you OK?" Anderson asked.

"These f---ing voices. They won't leave me the f--- alone," Jimenez said.

Anderson asked what the voices were saying. "Are they telling you to harm yourself or anybody?"

At first, Jimenez skirted the question, Anderson told investigators, saying the voices were just trying to control his drawings and actions.

"Then he said, 'Well, yeah, they're telling me to commit suicide, because the people here are simple. But I don't want to harm myself.'"

Jimenez said he wanted his medication increased.

Anderson tried to reassure him. She told him she'd speak with Stewart's mental health counselor about that. Later, the counselor, Calvery, told Anderson she'd scheduled an appointment with a psychiatrist based in North Carolina who saw patients at Stewart remotely.

On May 12, his 16th day in solitary, Jimenez seemed like he was in a better mood, Anderson said. And on the 17th day, too.

He'd been staring at the mirror, putting the finishing touches on a self-portrait he was sketching on a sheet of paper.

"Look, I finished it," he told her on the 18th day. "Does it look like me?"

"I said, 'Yeah, it looks like you, but you look older in the picture than you do in person.'"

Jimenez smiled. Anderson told him to have a good night.

In the end, Jimenez looked older in the drawing than he would ever become.

The next time Anderson saw him, he was lying on the floor of his cell, his toes already blue. She began pumping his chest and tried to find the hint of a pulse.

***

Even prisoners who go into solitary confinement without mental health problems often develop them in isolation, says Kupers, the psychiatrist and author of "Solitary: The Inside Story of Supermax Isolation and How We Can Abolish It."

"Relatively stable people," he says, "have long-lasting damage from this."

Kupers, who's interviewed more than 500 people in solitary confinement as part of his research, says regularly reported symptoms include massive anxiety, panic attacks, disordered thinking, problems with concentration and memory, despair, rage and suicidal ruminations.

That's one reason the practice has fallen increasingly out of favor in recent years, Kupers says, with some states, like Colorado, deciding to end the use of solitary altogether.

In 2015, experts estimated there were between 80,000 and 100,000 people held in isolation daily in the United States alone.

ICE did not respond to requests for information on how many people are in solitary in their immigrant detention facilities on an average day. But a 2013 New York Times report citing federal data said there were about 300 people in solitary on any given day at the 50 largest ICE detention centers.

Detainees with mental illness are at a far greater risk of harming themselves when they're in isolation, Kupers says. Often, he says, they end up in solitary as a disciplinary measure rather than getting the mental health care they need.

"Putting someone who's prone to mental illness in solitary is just an invitation to exacerbate the mental illness, and especially when it comes to suicide," he says. "It's like putting someone with asthma in a situation where there's fire and ashes."

Experts generally advise getting rid of sprinkler heads and vents in solitary cells to make them "suicide resistant." When Jimenez died, records show that officials at Stewart had plans in place to renovate medical facilities to add so-called "mental health/suicide cells" with sprinkler fixtures designed to prevent people from hanging themselves.

But really, Kupers says, there's no such thing as a suicide-proof cell.

"The main thing that has to happen is a screening process where the mental health staff is repeatedly assessing the risk of suicide over and over again," he says. "That's the way to prevent suicide. Anyone who has any significant risk of suicide should be removed from solitary confinement immediately."

And in this case, Kupers says, it's clear that didn't happen.

"They were basically setting him up to kill himself," he says.

***

Nerina Joseph hadn't seen her son in months when she walked through the doors of the Stewart Detention Center on May 13, 2017. It was his 17th day of isolation.

She waited for what seemed like an eternity to have the chance. Officials told her since her son was in solitary, she'd have to wait until other visits for the day were done. They couldn't bring him into the visiting area while other detainees were present.

"I didn't understand why they were acting like he was a murderer," she says.

But she waited.

Mother and son had been talking on the phone for weeks. Sometimes he sounded so despondent it terrified her. She'd put other family members on the line to offer him encouraging words.

But she felt relieved once they were face to face.

Jean seemed to be in good spirits.

He lifted up his shirt and showed her his muscles. Even in his cell, he told her, he'd found ways to work out. Sometimes he used his bed sheet as a jump rope.

They prayed together, and even sang. Guards gave them more time to talk than she expected -- so much time that they said good-bye over and over, thinking their visit was about to end.

Joseph had to head back to North Carolina. But before she left, she made one more stop in Stewart County: El Refugio, a nearby shelter for families visiting loved ones at Stewart that also hosts volunteers who regularly go to see detainees.

Once Jean was out of her sight, all her fears returned. She was terrified her son, if left alone, would try to harm himself.

"She was just begging someone to see him the next day because she was so worried about his mental state," recalls Marilyn McGinnis, the volunteer coordinator who was working at El Refugio that day.

McGinnis promised she would.

The next day, she tried. But a guard turned her away, telling her something she'd never heard in years of visiting detainees at Stewart: Because Jimenez was in segregation, the guard said, he could only have one visitor per month.

Jimenez wouldn't be allowed to have any more visitors until his stint in solitary was up.

"It was a matter of holding on for another five days," McGinnis said.

***

That night -- May 14, Jimenez's 18th day in solitary -- Freddy Wims made his first rounds in Segregation Unit 7A around 10 p.m.

Jimenez showed the guard his self-portrait -- the one he'd been working on for days as he peered into the metal mirror.

Wims was supposed to check Jimenez's cell every 30 minutes that night. And his official log indicates he did. But surveillance footage contained in the GBI report shows three of the cell checks in the log never happened.

When Wims walked by Cell 102 around 12:40 a.m. he realized something was terribly wrong.

"I looked in the door and I didn't see him. He wasn't on his bed. I looked on the floor and I didn't see him on the floor," Wims later told the GBI. "I looked over there in the corner by the commode, and he was in there hanging on a sheet."

Wims radioed for help -- "Medical emergency" -- then went to get a knife from the control room.

"I called his name, but he wasn't moving."

Wims and another guard cut the noose, laid Jimenez on the floor and started CPR. Two detention center nurses, including Anderson, took over a few minutes later.

***

Abel Blanco-Ramirez looked out the door of his solitary cell, horrified by what he saw.

On the other side of the unit, guards and paramedics were swarming. A body was on the ground.

The night had already been rough for Blanco. He'd been in solitary a few days -- placed there, he says, because his anxiety seemed to be spiraling out of control. He tried reading psalms to calm himself but felt his despair growing exponentially. Two fears raced through his mind: that he'd be murdered if he were deported to El Salvador, and that his infant son in North Carolina would never remember him.

It wasn't his first stint in solitary, and it wouldn't be his last. He rarely learned the names of people in solitary with him. But he knew their cell numbers, and their antics. The Asian man who bangs on the door in Cell 201. The naked man who doesn't know how to speak in Cell 110.

Blanco had seen the man in Cell 102 during rec time. He'd seemed perfectly normal then, shooting hoops shirtless in a nearby cage. Now he lay motionless. Another guard came. Then another. They tried to revive him. So did nurses and paramedics. Then they carted him away on a stretcher.

Blanco cried. He was afraid the same thing would happen to him -- that he, too, would somehow end up hurting himself and lying dead on the cold, hard prison floor.

Blanco has a young face, round cheeks and spiky hair. He wears a beaded crucifix and an orange bracelet that says, "Dios me ama." God loves me.

He already feels like he's become a different person since his time at Stewart began. He gets angry easily. He struggles to sleep. He felt terrible before he ended up in solitary. Now he feels far worse.

"Segregation," he says, "is the ugliest thing that there is here."

He was already inside Segregation Unit 7A for medical observation. After seeing what happened to Jimenez, he ended up on suicide watch.

***

It took 13 minutes for paramedics to arrive the night Jimenez died, and more than 20 minutes for the ambulance to leave.

Lumpkin's fire chief drove it to the nearest hospital, 35 miles away.

Doctors at Phoebe Sumter Medical Center in Americus, Georgia, pronounced Jimenez dead in less than 15 minutes.

The hospital released paperwork to the family that listed the medications he was taking, including risperidone, an antipsychotic drug. Jimenez never got a chance to increase his dosage. His appointment with the psychiatrist had been scheduled for May 15 -- the day he died.

Hours after his death, investigators from the GBI went to Stewart at the county sheriff's request. While one interviewed witnesses, another went to photograph Jimenez's cell.

On one wall, Jimenez left behind a haunting message, scrawled in black ink: "Hallelujah, the Grave Has Cometh."

On a shelf, atop a stack of papers, was Jimenez's self-portrait, still locked inside Cell 102.

***

Wims, the guard who was watching over the solitary unit that night, no longer works at Stewart.

His employment was terminated in June 2017, CoreCivic said.

Asked whether his firing had anything to do with Jimenez's death, Gilchrist, the company spokeswoman, declined to comment. "To preserve the integrity of the investigation," she said, "we will defer further comment on this matter until ICE's investigation is complete."

Reached via phone, Wims told CNN he didn't know anything about the case and hung up. He has not responded to subsequent requests for comment.

Spivey, the warden who ran the detention center when Jimenez died, also no longer works at the facility. Asked whether Jimenez's death had anything to do with his departure, CoreCivic said in a statement that Spivey chose to retire in October 2017 after 20 years with the company and had served with distinction in leadership roles at a number of CoreCivic's facilities. He could not be reached for comment.

***

Two days after Jimenez's death, an internal ICE medical memo noted that "limited availability" of tele-psychiatry services had forced officials to reschedule a follow-up appointment for him. The memo also cited "missed opportunities to possibly provide additional intervention" on the days when Jimenez had expressed a desire to harm himself in solitary.

"However," the memo concluded, "even if interventions were taken on these dates they may or may not have altered the outcome."

Four months after Jimenez's death, the Department of Homeland Security's own inspector general warned that officials weren't doing enough to track the cases of mentally ill detainees in ICE custody who ended up in solitary.

Seven months after Jimenez's death, investigators from the office singled out Stewart and several other detention facilities, noting problems with long waits for medical care and concerns that officials sent people to solitary confinement too readily.

Documents from their inspection of Stewart, first obtained by Atlanta NPR station WABE in response to a public records request, reveal serious concerns shared by a number of CoreCivic and federal officials at Stewart during interviews with investigators in 2017.

Officials told investigators that when Stewart takes custody of detainees from other facilities, there's often a lag before their files arrive. That delay, one official said, makes the facility a "ticking bomb" because staff aren't able to classify detainees appropriately.

Officials described Stewart as chronically short-staffed, noting that its remote location makes it difficult to hire and keep employees. One official said access to outside medical care -- particularly mental health care -- is difficult to find anywhere near the detention center. That official also noted that Stewart doesn't have a psychiatrist on site. When investigators visited the facility just a few months before Jimenez's death, officials there were trying to fill more than a dozen medical vacancies.

The week Jimenez died, only one of the three mental health providers in the detention center's staffing plan was working, according to the ICE memo. One social worker was on maternity leave and another position was vacant, the memo said. A psychiatrist position also hadn't been filled.

Andrew Free, an attorney representing Jimenez's family, describes the staffing shortage as "failure, pure and simple."

Since last year, Stewart has beefed up its medical staffing.

"There is no shortage of medical staff at the facility," Cox, the ICE spokesman, told CNN in July. As of June, he said, a psychiatry nurse practitioner had been hired, and the facility had 25 registered nurses, 13 licensed practical nurses, two licensed clinical social workers and two medical doctors on staff.

"As for claims (that) access to outside care is not available near the facility," Cox said, "I'd simply say 'near' is a relative term and point to the map -- the facility is approximately 35 miles from Columbus, which is Georgia's third-largest city."

Since May 2017, Stewart has been inspected twice by an independent third-party contractor as part of what Cox describes as an "aggressive inspections program."

Those inspections occurred the month Jimenez died and a year after his death. Inspectors found Stewart to be fully compliant with the agency's standards in every category they reviewed, Cox said.

Just last month -- 14 months after Jimenez's death -- guards at Stewart found another detainee unresponsive in a solitary cell. Efrain Romero De La Rosa was pronounced dead at a hospital less than an hour later. The preliminary cause of death listed in an autopsy report: suicide by hanging.

Citing a pending investigation, ICE declined to comment on why Romero, 40, had been held in isolation. A GBI investigation into the case has just begun.

Romero had been diagnosed with bipolar disorder and schizophrenia, according to his brother. And his family fears he wasn't getting the treatment he needed at Stewart.

***

Karina Kelly marches down Main Street in Kansas City, Missouri, holding a megaphone to her mouth.

"Immigrant lives matter," she shouts.

Behind her, a crowd of dozens repeats the chant.

A year ago, more than 800 miles away, inside a solitary cell in the Deep South at the Stewart Detention Center, her brother took his last breath.

But here in the Midwest is where Jean Jimenez Joseph spent his teenage years, where he prayed in church, where he'd go running in the rain to train before wrestling meets.

His family is still fighting in court to get answers about his last days at Stewart. Today, they're taking it to the streets.

Friends, families and strangers have convened in a lush, green park to honor Jimenez's memory.

They sing about Jesus, redemption and justice.

The air is muggy. Dark grey clouds hang in the sky. Soon it will rain.

Kelly and other speakers stand in front of an empty fountain, between two easels holding smiling photos of Jean from happier times.

Wind gusts keep blowing the pictures to the ground.

Each time, someone from the crowd rushes forward to prop them up again.

"He should have been a star," a former roommate says. "His potential was limitless, but unfortunately, our system is not."

Free, the family's attorney, says he keeps Jimenez's self-portrait on his desk.

"I often think ... about the last night of his life, and how I would do anything that I could to get this person I've never met the help that he was begging for," he says.

Free says the portrait reminds him of what Jimenez's mother, Nerina Joseph, has told him time and again -- that her fight for answers isn't just about her son. It's about thousands of others in ICE custody.

"We're here," Free says, "to help them."

Joseph looks on, but she doesn't speak at the memorial. The wounds of the past year are still too fresh.

She wears a silver bracelet on each wrist as a tribute to the child she lost. On one, a dangling charm says "J," for Jean. On the other, a pendant says, "a piece of my heart is in heaven."

She carries her son's picture in one hand and a Panamanian flag in the other.

She uses the flag to wipe her tears.

As the memorial draws to a close, Jimenez's family gives white balloons to everyone in the crowd.

Kelly leads them in prayer.

"For all those that died a premature and unjust death in ICE custody -- a brother, a son, a spouse, a sister," she says, "we are here to tell you that you are not alone and that your loved one did not die alone, and they will never be forgotten."

For a minute, the crowd is silent. Then they release the balloons.

With nothing to hold them back, the wind quickly pulls them high into the sky.

They stand out, even from a distance -- bright spots against the dark clouds, flying free.

More from 'Inside America's Hidden Border'

Two lawyers. One court. And their fight against the odds.

Their loved ones are behind bars. Their lives are on hold. This house gives them hope.

In one of America's poorest places, detaining immigrants is a big business

About this series

CNN reported the stories in this series over the course of more than a year, conducting dozens of interviews and making multiple visits to the privately run, all-male Stewart Detention Center -- one of more than 200 facilities across the United States where immigrants facing deportation are held. The facility has the capacity to house nearly 2,000 detainees. Some have significant criminal histories. Others ended up in the crosshairs of immigration authorities when they were pulled over for traffic offenses. And some are seeking asylum after recently crossing the border.

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