Guards at an immigration detention center in El Paso, Texas, were able to see a detainee in his cell with one end of a sheet wrapped around his neck and the other tied to the door handle. If they opened the door, the sheet would tighten and strangle her.
The inmate, Geraldo Lunas Campos, had been held at Camp East Montana for a month at the time. The facility itself was still relatively new and had been opened as part of the Trump administration’s plans to quickly house and deport thousands of immigrants at a time.
Almost immediately after his admission, the 55-year-old Cuban immigrant began expressing frustration with the care he received, according to a previously unpublished, nearly 300-page investigative report from the medical examiner.
The report, reviewed by ProPublica and The Texas Tribune, includes dozens of notes detailing medical staff’s interactions with Lunas Campos, who had a history of mental illness and had previously been institutionalized in New York.
The report and documents it contains offer a rare and disturbing look at how immigration detention centers — built quickly and with little oversight — handle detainees with serious mental health needs. The records paint a picture of a man in crisis and a facility whose staff repeatedly discussed transferring him to a facility where he could receive a higher level of care.
According to records, he complained to staff at least eight times about skipped or late doses of antipsychotic medications to treat his depression, anxiety and hallucinations. He “expressed his frustration regarding the dosage of his medications,” said a September 9 press release from medical staff.
They highlight moments of exasperation that led to self-harm. He banged his head against the wall because he couldn’t afford the fees to speak with his children in New York. It left him with a black eye. In response, staff simply indicated that they had talked to him about “not banging his head against the wall, because he needs to take care of his brain and his eyes.”
The noose and doorknob incident happened in early October. A mental health provider finally persuaded him to untie him. Notes detailing the incident indicated Lunas Campos claimed he was not suicidal. The notes dismiss what happened as a “suicidal move aimed at forcing security personnel to release him” from the isolation room where he had been separated from the rest of the inmates. Hospitalization, according to the notes, was “not clinically indicated at this time based on assessed risk and protective factors.”
Lunas Campos died in custody almost three months later, after an altercation with guards over his medication. The Trump administration initially claimed he had experienced medical difficulties, but a coroner later ruled his death a homicide.
The conflicting accounts about the cause of his death attracted media attention and served to rally advocacy groups who said it was some of the most shocking evidence of the dangerous conditions endured by immigrants in federal detention centers.
But little had been reported about Lunas Campos’ health and treatment before that day. On Monday, Lunas Campos’ three children sued the companies that operated the establishment at the time of his death. The lawsuit alleged the guards killed him and argued negligence, including missed medication doses and inappropriate use of force and restraint. The Washington Post reported Thursday that Lunas Campos had repeatedly sought treatment for his mental illness, showing the medical examiner’s investigation report. The companies did not respond to the allegations filed in court and did not respond to emails and phone calls seeking comment.
ProPublica and Tribune reviewed the contents of the report several weeks ago. Two doctors, experts in mental health and deaths in custody, also reviewed the report at the request of news agencies. The conclusion was clear: the inmate asked for help, but the facility staff did not respond adequately.
News organizations separately reviewed more than 160 emergency calls, as well as recordings 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 did not feel equipped to respond. Inmates had little access to recreational activities and time spent outside, which mental health experts say exacerbates their despair. Staff also ignored warning signs, such as inmates’ previous efforts to harm themselves.
“It’s a civil detention,” said Will Horowitz, an attorney representing Lunas Campos’ adult children in the lawsuit. “They are not detained because they committed a crime.”
The White House declined to comment. Immigration and Customs Enforcement did not respond to multiple interview requests and did not respond to a list of written questions. The administration has previously rejected inmate accounts inadequate medical care and poor conditions at Camp East Montana and other detention centers as “fake” and called them “fear-mongering.” Federal officials have repeatedly said that for many immigrants, the medical care they receive in detention is the best of their lives.
In Lunas Campos’ case, officials at the Department of Homeland Security, which oversees ICE, initially downplayed the incident that led to his death, emphasizing his criminal history. Later, in response to reports that the medical examiner planned to rule the death a homicide, a DHS spokesperson said. guards used force to prevent him from committing suicide.
Lunas Campos was sentenced to a year in prison after being convicted in 2003 of sexual contact with a child under 11, according to the Associated Press. The news agency also reported that he was convicted of attempted sale of a controlled substance and sentenced to five years in prison and three years of supervision in 2009.
Horowitz said Lunas Campos’ criminal history was unrelated to his detention. Lunas Campos’ children declined to comment on the failings 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 any other and that he didn’t need to die.”
In a report released after Lunas Campos’ death, DHS officials said he received regular medical and psychiatric evaluations, with staff adjusting his medications as necessary. They also said he had been monitored for suicidal ideation. Investigative records from the El Paso medical examiner show a period when facility staff examined him every 15 minutes after his suicide attempt, as required by the federal government.
But the medical examiner’s report also highlights a series of failures 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 escalate, creating crisis after crisis with disastrous consequences.
“The clinical trajectory documented in his file — increasing agitation, self-harm, pressured speech, repeated confrontations with staff over medications — is the predictable result of erratic administration of psychotropic medications in a patient with a serious mental illness,” Basu said.
He pointed to documents showing that staff did not move 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 solitary confinement cells, separated from the rest of the camp population, which contained little more than a bed. The government’s own detention standards state that staff should generally make every effort to avoid placing inmates with serious mental illness in solitary confinement.
More importantly, instead of taking his previous suicide attempt seriously, staff interpreted it as an attempt to manipulate them, Basu said.
The records, Basu said, clearly show “systemic negligence.”
A system in disarray
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 United States-Mexico border and had easy access to a highway and an airfield to quickly transport and deport illegal immigrants. Its location on the vast, barren lands of Fort Bliss also made it possible to create space for up to 10,000 illegal immigrants at a time, more than any other settlement in the country.
Instead, the detention center became an example of what could go wrong.
A few months after the camp opened, the American Civil Liberties Union, which is currently suing the federal government, testimonials published by immigrants who said they were beaten by guards, deprived of life-saving medicine and kept in squalid conditions, with sewage sometimes flowing into their dining rooms. Prisoners usually caught measles or tuberculosis. The government has not officially responded to the lawsuit, but in statements to the media u A DHS spokesperson said allegations of inhumane conditions and mistreatment of detainees were “categorically false.”
Problems with treating people with mental health problems weren’t as visible, but they accumulated in such a way that experts said they added to mental distress and could contribute to more suicide attempts. In the worst cases, they said, inmates died needlessly.
The facility was never designed to house detainees with serious mental health issues, a DHS official and a medical provider who worked there told ProPublica and the Tribune. They spoke on condition of anonymity because the government did not authorize them to discuss conditions in the camp.
Several staff members told news organizations they had plenty of relevant information to share but had signed nondisclosure agreements.
The DHS official said immigrants do not have enough space to read, pray, write or receive legal services. They were held in windowless cells, doing nothing. Inmates also had little time outside, in part because the facility’s outdoor space was not big enough for everyone, a government report later found. The federal government requires detention centers to provide inmates with at least an hour of outside time a day, but many get only a few hours a week, inmates told ProPublica and the Tribune.
“Hobbies and equipment, games, books, televisions, are all lifelines for people in detention,” said the DHS official, who was not involved in the report.
Prolonged detention has made detainees more anxious and desperate, sometimes leading to hunger strikes and fights. The immigrants were only supposed to stay at Camp East Montana for a maximum of two weeks, according to contract documents and statements from federal officials. Wh en Lunas Campos died, the typical inmate had spent 38 days in the facility, according to a ProPublica analysis of government data provided to the Deportation Data Projectwhich collects and publishes immigration enforcement information. He had been there much longer, over 100 days.
Dr. Katherine Peeler, a medical adviser to the advocacy group Physicians for Human Rights who has studied health care in immigration detention centers, said conditions reported at Camp East Montana indicate it is not a safe place for anyone detained.
“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 very difficult to trust officials to give you accurate information and, as a result, you’re going to feel a lot more despair and a lot more anxiety.”
The situation is worse for people with a history of mental illness, Peeler said. Solitary confinement can cause post-traumatic stress disorder, risk of self-harm and suicide, according to a 2024 report co-authored by Peeler with partners including students and staff at Harvard University.
“We’re creating a mental health crisis that doesn’t need to be there,” Peeler said.
Some inmates at Camp East Montana who showed signs of potential self-harm were placed in segregation rooms that were not suicide-proof. They were equipped with door handles and mesh ceilings to which detainees wishing to harm themselves could attach a sheet, the DHS official said.
National detention standards do not specify the number of suicide rooms required in each facility, but clearly state that suicidal inmates must be placed in rooms “free from 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 someone wants to commit suicide, there is no place to keep them safe.”
“They just didn’t do it.”
Lunas Campos was in such a room when he first attempted suicide. By then, staff had reported at least three other suicide attempts to 911.
There were two calls in September, one involving an inmate who was lying on the ground holding his stomach in agony and unable to speak after swallowing an unknown object. The other is about a man who bit his arms and tried to cut his wrists with a piece of cardboard and a comb.
Another call came in October, the day before Lunas Campos was seen with a sheet tied around his neck. A man placed 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 in a detention center, which could include inadequate strategies for observing or reporting self-harm or broader medical problems, said Claire Trickler-McNulty, a former senior ICE official who served in the Obama, Trump and Biden administrations.
Of the 53 deaths in ICE custody since Trump returned to the White House, at least 10 have been reported as suspected suicides. The United Nations High Commissioner for Human Rights called for independent investigations on ICE deaths and expressed concern over the reported use of solitary confinement.
“You hope that if you experience a number of negative outcomes from problematic incidents like that, that they will do critical incident reviews, understand what’s going on and try to take corrective action,” Trickler-McNulty said.
Last week, the DHS Inspector General launched investigation into the death of inmates and if the ministry followed its own standards on the use of forceciting an increase in deaths in ICE custody since 2022.
Other problems have already been identified in a report released last month by the Government Accountability Office. The GAO discovered that millions of dollars had been wastedhighlighted gaps in medical care and noted unsanitary conditions at El Paso facilities. The report mentions that in October, ICE officials raised concerns with contractors running the facility about the lack of windows on some doors to the medical detention rooms, which made it difficult for staff to easily see what was happening inside.
The DHS official pointed to several other problems that the government could have improved. He could have assigned more ICE agents to address chronic staffing shortages, created more opportunities for recreational activities and built special tents with suicide prevention rooms, the DHS official said.
“There was no shortage of money or space and there was a clear incentive to do this,” the official said, referring to suicide attempts at the facility. “They just didn’t.”
There appears to be tension between career ICE staff and political appointees, the DHS official told news organizations.
“The political side didn’t want to make it look like it was so chaotic, they wanted to act like nothing was happening,” the official said.
Even without the proposed changes, detention center staff should have done more to treat Lunas Campos’ mental illness, said Joanne Ahola, a psychiatrist who spent 17 years evaluating immigrants in detention centers for the voluntary asylum network Physicians for Human Rights. She also reviewed his records at the request of ProPublica and the Tribune.
Lunas Campos’ initial cries for help continued throughout his detention. Nearly two weeks after his suicide attempt, he again reported that he was not receiving his medication.
“Pt reported being very frustrated and anxious because he had not received his medications in a few days,” an Oct. 19 medical note read. He noted that Lunas Campos was visibly “irritated and yelling.”
Another note from November 10 stated that Lunas Campos “had not received his medication since November 6.”
And, on Nov. 11, more than a month after staff told Lunas Campos they were working to move him to a facility with a higher level of care, shorthanded under the name HLOC, he was still waiting. “He continues to request transfer to the HLOC, claiming that conditions at the current facility are harming his mental health,” according to a memo from that date.
Lunas Campos was temporarily moved to another facility, but it was another detention center that experts said did not provide the higher level of care he needed.
On January 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 him with emotional support,” “reviewed grounding and breathing techniques to manage anxiety,” encouraged him “to seek continued mental health support if necessary” and added his name to the medical call for psychiatric evaluation.
“This is a man who needed regular medication, a comprehensive evaluation, mental health clinicians and, without question, rehospitalization,” Ahola said.
“Instead, it almost seems like it’s been swept away or swept under the rug,” he said. -she added.
Less than two weeks after Lunas Campos’ death, Camp East Montana’s health administrator called 911 again.
Victor Manuel Díaz, a 36-year-old Nicaraguan, was found in a cell with his pants tied around his neck. He was in a windowless room. Staff found him while they were carrying out routine checks.
An ambulance was needed, the health administrator told the operator, explaining where emergency responders should go when they arrived at the facility. Without hesitation, he added: “They have been here many times. »
Diaz, who cooked chicken and washed dishes at a Korean restaurant in Minneapolis, 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 failed to properly follow procedures after he “exhibited suicide risk factors.” Staff placed him in a medical holding room — not a suicide cell — and left him unattended for more than 15 minutes, the GAO said.
His autopsy, carried out by the army, has not been made public.