Perla Trevizo, The Texas Tribune

Guards at an immigration detention center in El Paso, Texas, could see a detainee in his cell with one end of a bedsheet wrapped around his neck and the other tied to the door handle. If they opened the door, the sheet would tighten and strangle him.

The detainee, Geraldo Lunas Campos, had been in detention at Camp East Montana for a month by then. The facility itself was still relatively new and had been opened as part of the Trump administration’s plans to house and quickly deport thousands of immigrants at a time.

Almost immediately after being admitted, the 55-year-old Cuban immigrant began expressing frustration about his care, according to a nearly 300-page unpublished medical examiner’s investigative report.

The report, reviewed by ProPublica and The Texas Tribune, includes dozens of notes that detail medical staff interactions with Lunas Campos, who had a history of mental illness and had been previously institutionalized in New York.

The report and the records it contains offer a rare and disturbing look at how immigrant detention facilities — erected rapidly and with little oversight — manage detainees with serious mental health needs. The records paint a portrait of a man in a crisis and a facility whose staff, on several occasions, discussed transferring him to a facility where he could get a higher level of care.

According to the records, he complained at least eight times to staff about skipped or late doses of antipsychotic drugs to treat his depression, anxiety and hallucinations. He “expressed frustration regarding his medication dosage,” says a Sept. 9 entry from medical staff.

They point to moments of exasperation that led to self-harm. He banged his head against the wall after he couldn’t afford to pay the charges to talk with his children in New York. That left him with a black eye. In response, staff simply noted that they spoke with him about “not hitting his head against the wall bc he must take care of his brain and his eyes.”

The incident with the noose and the doorknob came in early October. A mental health provider eventually coaxed him to untie it. Notes detailing the incident stated that Lunas Campos affirmed he wasn’t suicidal. The notes dismissed what occurred as a “suicidal gesture made to force security staff to release him” from the isolation room where he had been segregated from the rest of the detainees. Hospitalization, the notes stated, was “not clinically indicated at this time based on assessed risk and protective factors.”

Lunas Campos died in detention nearly three months later, after an altercation with guards over his medication. The Trump administration initially claimed that he had experienced medical distress, but a coroner later ruled his death a homicide.

The conflicting accounts over the cause of his death have drawn significant media attention and served to rally advocacy groups who have alleged that it is one of the more shocking pieces of evidence of the dangerous conditions endured by immigrants in federal detention facilities.

But little had been reported about Lunas Campos’ condition and treatment before that day. On Monday, Lunas Campos’ three children sued the companies running the facility at the time of his death. The lawsuit alleged that guards killed him and argued negligence, including missed medication doses and the improper use of force and restraint. The Washington Post on Thursday reported that Lunas Campos had repeatedly sought treatment for his mental illness, pointing to the medical examiner’s investigative report. The companies have not responded to the allegations in court filings and did not return emails and phone calls seeking comment.

ProPublica and the Tribune reviewed the contents of the report several weeks ago. Two doctors, who are experts on mental health and deaths in detention, also reviewed the report at the news organizations’ request. The takeaway was clear: The detainee asked for help, and the facility staff failed to adequately respond.

The news organizations separately reviewed more than 160 emergency calls, as well as records and interviews with staff and government officials familiar with the detention center. They show medical and mental health emergencies beyond those experienced by Lunas Campos, as well as staff indicating they felt ill-equipped to respond. Detainees had little access to recreational activities and time outside, which mental health experts say exacerbates their despair. Staff also ignored warning signs, such as detainees’ previous efforts to harm themselves.

“It’s civil detention,” said Will Horowitz, an attorney representing Lunas Campos’ adult children in the lawsuit. “They’re not in detention because they’ve committed a crime.”

The White House declined to comment. Immigration and Customs Enforcement didn’t respond to multiple requests for an interview and did not answer a list of written questions. The administration has previously dismissed detainee accounts of inadequate medical care and poor conditions at Camp East Montana and other detention centers as “false” and called them “fearmongering clickbait.” Federal officials have repeatedly said that for many immigrants, the medical care they receive in detention is the best in their lives.

In Lunas Campos’ case, officials from the Department of Homeland Security, which oversees ICE, initially minimized the incident that led to his death, pointing to his criminal history. Later, in response to news reports that the medical examiner planned to rule the death a homicide, a DHS spokesperson said guards had used force to keep him from killing himself.

Lunas Campos was sentenced to a year in jail after a 2003 conviction for sexual contact with a child under the age of 11, according to The Associated Press. The news organization also reported that he was convicted of attempting to sell a controlled substance and sentenced to five years in prison and three years of supervision in 2009.

Horowitz said Lunas Campos’ criminal history is irrelevant to his detention. Lunas Campos’ children declined to comment on the failures highlighted in the medical examiner’s report or on his criminal history, but, Horowitz said, “They want people to know that he was a person like anyone else and that he didn’t need to die.”

In a report issued after Lunas Campos’ death, DHS officials said he received regular medical and psychiatric evaluations, with staff adjusting his medication as needed. They also contended that he was monitored for suicidal ideation. Investigative records from the El Paso medical examiner show a period during which facility staff checked on him every 15 minutes following his suicide attempt, as required by the federal government.

But the medical examiner’s report also brings into focus a series of breakdowns in care, according to Dr. Sanjay Basu, an epidemiologist at the University of California, San Francisco. He said Lunas Campos’ case is a model of how such moments compound, creating crisis after crisis with dire outcomes.

“The clinical trajectory documented in his chart — escalating agitation, self-harm, pressured speech, repeated confrontations with staff over medication — is the predictable result of erratic psychotropic medication administration in a patient with serious mental illness,” Basu said.

He pointed to records that show staff didn’t transfer Lunas Campos to a facility that could better treat his mental health, even after noting that they were working to move him as early as Oct. 8. Lunas Campos was also repeatedly placed in segregation cells, separate from the rest of the camp population, which had little more than a bed in them. The government’s own detention standards say staff should generally make every effort to avoid placing detainees with a serious mental illness in segregation.

Most critically, instead of taking his previous suicide attempt seriously, staff interpreted it as an effort to manipulate them, Basu said.

The records, Basu said, clearly show “systemic neglect.”

A System Unraveling

Camp East Montana was supposed to be the model for how detention centers across the country would operate under President Donald Trump’s administration. It was near the U.S.-Mexico border and had easy access to a highway and an airfield to quickly transport and deport unauthorized immigrants. Its location on barren, massive Fort Bliss land also allowed for a space that could hold up to 10,000 unauthorized immigrants at a time, more than any other facility in the country.

Instead, the detention center became an example of what could go wrong.

Within months of the camp’s opening, the American Civil Liberties Union, which is now suing the federal government, published accounts from immigrants who said they were beaten by guards, denied lifesaving medication and kept in squalid conditions with sewage at times spilling into their eating areas. Detainees commonly caught measles or tuberculosis. The government hasn’t responded formally to the lawsuit, but in statements to the media a DHS spokesperson said claims of inhumane conditions and detainees being abused are “categorically false.”

The problems treating people with mental health challenges were not as visible but stacked up in ways that experts said added mental distress and could contribute to more suicide attempts. In the worst cases, they said, detainees unnecessarily died.

The facility was never set up to house detainees struggling with serious mental health conditions, a DHS official and a medical provider who worked there told ProPublica and the Tribune. They spoke on the condition of anonymity because the government did not authorize them to discuss conditions at the camp.

Several staffers told the news organizations that they had a lot of relevant information they could share, but they had signed nondisclosure agreements.

The DHS official said immigrants didn’t have adequate space to read, pray, write or get legal services. They were kept inside windowless cells with nothing to do. Detainees were also granted little time outside, partly because the facility’s outdoor space was not big enough for all of them, a government report later found. The federal government requires detention centers to provide detainees at least one hour of outdoor time per day, but many got only a couple of hours a week, detainees told ProPublica and the Tribune.

“Recreation and amenities, games, books, TVs, are all lifelines for people in detention,” the DHS official, who did not participate in the report, said.

Prolonged confinement made detainees more anxious and desperate, at times leading to hunger strikes and fights. Immigrants were only supposed to remain at Camp East Montana for a maximum of two weeks, according to contract documents and statements from federal officials. When Lunas Campos died, the typical detainee had spent 38 days in the facility, according to a ProPublica analysis of government data provided to the Deportation Data Project, which collects and posts immigration enforcement information. He had been there far longer, more than 100 days.

Dr. Katherine Peeler, a medical adviser for the advocacy group Physicians for Human Rights who has studied healthcare in immigration detention centers, said that the conditions reported at Camp East Montana signal that it is not a safe place for any detained individual.

“You’ve been detained. You don’t know what the process is going to be. You don’t know when you’re going to be released,” Peeler said. “It’s really hard to trust people who are in charge to give you accurate information and so, as a result, you’re going to have a lot more despair and a lot more kind of anguish.”

The situation is worse for people with a history of mental illness, Peeler said. Solitary confinement can cause post-traumatic stress disorder, self-harm and suicide risks, according to a 2024 report that Peeler co-authored with partners, including students and staff at Harvard University.

“We are creating a mental health crisis that does not need to be there,” Peeler said.

Some detainees at Camp East Montana who showed signs of potential self-harm were placed in isolation rooms that were not suicide-proof. They had doorknobs and mesh ceilings to which detainees who wanted to harm themselves could tie a bedsheet, the DHS official said.

National detention standards don’t specify the number of suicide-proof rooms needed in each facility but make clear that detainees who are suicidal should be placed in rooms “free of objects and structural elements that could facilitate a suicide attempt.”

“It’s insane,” said the medical provider who spoke to ProPublica and the Tribune. “If somebody wants to kill themselves, there’s nowhere to put them that’s actually safe.”

“They Just Didn’t Do It”

Lunas Campos was in such a room when he first tried to commit suicide. By then, staff had reported at least three other suicide attempts to 911.

There were the two calls in September, one about a detainee who lay on the floor holding his stomach in agony and unable to speak after swallowing an unknown object. The other about a man biting his arms and trying to cut his wrists with a piece of cardboard and a comb.

Another call came in October, the day before Lunas Campos was spotted with a sheet tied around his neck. A man being kept in a medical isolation room to rule out tuberculosis tried to hang himself, the caller told the 911 operator.

Suicide attempts are warning signs of a larger problem at a detention center, which could include inadequate strategies for observing or flagging self-harm or more general medical issues, said Claire Trickler-McNulty, a former senior official at ICE who served in the Obama, first Trump and Biden administrations.

Out of 53 deaths in ICE custody since Trump returned to the White House, at least 10 have been reported as presumed suicides. The United Nations High Commissioner for Human Rights has called for independent investigations into the ICE deaths and expressed alarm over the reported use of solitary confinement.

“You would hope that if you have a number of negative outcomes of problematic incidents like that, that they would do critical incident reviews, figure out what was going on and try to take corrective action,” Trickler-McNulty said.

Last week, DHS’s inspector general launched probes into detainee deaths and whether the department was following its own standards on the use of force, citing a rise in ICE custody fatalities since 2022.

Other problems were already identified in a report released last month by the Government Accountability Office. The GAO found millions of dollars had been wasted, pointed to gaps in medical care and noted unsanitary conditions at the El Paso facility. The report mentions that in October, ICE officials raised concerns with the contractors running the facility about the lack of windows on some doors in medical holding rooms, which prevented staff from easily seeing what was happening inside.

The DHS official flagged several other problems that the government could have worked to improve. It could have assigned more ICE agents to help with chronic staffing shortages, created more opportunities for recreational activities and built special tents with suicide-prevention rooms, the DHS official said.

“There was no lack of money or space and there was an obvious incentive to do it,” the official said, referring to the suicide attempts at the facility. “They just didn’t do it.”

There seemed to be a push-pull between career ICE staff and political appointees, the DHS official told the news organizations.

“The political side didn’t want to give the appearance that it was so chaotic, they wanted to pretend it wasn’t happening,” the official said.

Even without the proposed changes, staff at the detention center should have done more to treat Lunas Campos’ mental illness, said Joanne Ahola, a psychiatrist who has spent 17 years evaluating immigrants inside detention centers for Physicians for Human Rights’ volunteer Asylum Network. She also reviewed his records at the request of ProPublica and the Tribune.

Lunas Campos’ early pleas for help continued throughout his detention. Nearly two weeks after his suicide attempt, he again flagged that he wasn’t getting his medications.

“Pt reported being very frustrated and anxious because he had not received his medication for a couple of days,” a medical note from Oct. 19 read. It noted that Lunas Campos was visibly “irritated and yelling.”

Another note on Nov. 10, said Lunas Campos “had not gotten his medications since Nov. 6.”

And, on Nov. 11, more than a month after staff told Lunas Campos that they were working to move him to a facility with a higher level of care, shorthanded as HLOC, he was still waiting. “Continues to request transfer to HLOC stating conditions at current facility are adversely affecting his mental health,” according to a note from that date.

Lunas Campos was temporarily moved to another facility, but it was another detention center that experts say did not provide the higher level of care he needed.

On Jan. 2, a day before his death, he returned to Camp East Montana. A note from medical staff at 9:42 p.m. said they “provided emotional support,” “reviewed grounding and breathing techniques to manage anxiety,” encouraged him “to seek ongoing mental health support as needed,” and added his name to the medical sick call for a psychiatric evaluation.

“This is a man who needed regular medications, a full evaluation, mental health clinicians and, no doubt, re-hospitalization,” Ahola said.

“Instead, it almost seems like it was brushed off or brushed under the rug,” she added.

Less than two weeks after Lunas Campos’ death, the health administrator at Camp East Montana called 911 again.

Victor Manuel Díaz, a 36-year-old Nicaraguan native, was found in a cell with his pants tied around his neck. He was in a room with no windows.The staff found him as they were doing routine checks.

An ambulance was needed, the health administrator told the operator, explaining where emergency responders should go upon arrival at the facility. Without hesitation, he added, “They’ve been out here many times.”

Díaz, who cooked chicken and washed dishes at a Minneapolis Korean restaurant, had been picked up and flown to Camp East Montana a week earlier. The GAO noted that ICE itself later acknowledged in a report that staff had not properly followed procedures after he “exhibited risk factors for suicide.” Staff placed him in a medical holding room — not a suicide-resitant cell — and left him unattended for periods longer than 15 minutes, the GAO stated.

His autopsy, which was conducted by the military, has not been made public.