Authorities failed to monitor a mentally ill detainee as often as they were required before he hanged himself with a pair of socks in an immigration detention center in southwest Georgia last year, according to documents obtained through Georgia’s Open Records Act.

This is not the first time this has happened at Stewart Detention Center, a sprawling federal complex located just outside the city of Lumpkin.

In July, Efrain De La Rosa, 40, became the second detainee to hang himself in his solitary confinement cell at Stewart in less than two years. In 2017, The Atlanta Journal-Constitution reported the staff at Stewart did not check on Jean Jimenez-Joseph, 27, as often as mandated before the Panamanian national was found hanging from a sheet in his cell that year.

More: ICE detainee wasn’t observed as required before he hanged himself

Jean Jimenez-Joseph hanged himself with a sheet in his solitary confinement cell in 2017 in U.S. Immigration and Customs Enforcement’s Stewart Detention Center in southwest Georgia. (photo provided by family)
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Both Jimenez and De La Rosa had been diagnosed with schizophrenia, institutionalized and kept on “suicide watch.” Federal standards say immigration detainees held in isolation must be “personally observed” at least every 30 minutes, though the rules require checks at 15-minute intervals, if they are suicidal.

But the staff at Stewart didn’t look into De La Rosa’s cell for nearly two hours before the Mexican national killed himself, according to a confidential investigative report by CoreCivic, the Nashville-based corrections company that operates Stewart through an agreement with U.S. Immigration and Customs Enforcement. That report includes a log of what happened based on surveillance video of De La Rosa’s cellblock.

CoreCivic declined to comment about what happened or say whether De La Rosa’s suicide could have been prevented. In a written statement, the company said it couldn’t comment because of an ongoing ICE investigation but that 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.”

Rodney Dent, the Stewart detention officer who was assigned to monitor De La Rosa the evening he died, could not be reached for comment. His “employment at Stewart Detention Center has been terminated,” according to CoreCivic.

Declining to comment, ICE referred to a statement it released about De La Rosa’s death in July, when it said it would review what happened to him and that it is “firmly committed to the health and welfare of all those in its custody.” ICE also said it is “exceedingly rare” for its detainees to die. In fiscal year 2016, nine out of 352,000 ICE detainees died. De La Rosa was the eighth person to die in ICE custody in fiscal year 2018, which ended in September.

The revelations about the latest lapses at Stewart come as the Trump administration is seeking to expand its detention capacity as part of its crackdown on illegal immigration. Meanwhile, the federal government remained in shutdown mode amid a stalemate between President Donald Trump and the Democratic-controlled House over Trump’s demand for $5 billion in border wall funding.

Despite an attempt by CoreCivic to limit their release, The Atlanta Journal-Constitution obtained voluminous records about De La Rosa’s death from the Georgia Bureau of Investigation. The GBI probed what happened to De La Rosa to determine whether any criminal laws were broken, finding he killed himself. On Oct. 1, Steve Curry, an attorney for CoreCivic, wrote the GBI, citing a federal regulation that restricts access to documents about ICE detainees. Curry said: “It would appear that only the federal government can make disclosure of such records to the public.”

“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,” Curry said, adding: “It is our request that there not be a release of information contrary to federal law.”

Initially last year, the GBI refused to release records about De La Rosa’s death to The Atlanta Journal-Constitution, citing the federal regulation Curry highlighted. The agency reversed itself in December and agreed to release some of the records after the AJC and New York Public Radio/WNYC persisted in their requests for them.

Critics reject CoreCivic’s interpretation of the federal regulation, arguing it should not preempt Georgia’s sunshine statutes and that it does not apply to deceased ICE detainees in any case. The 2002 regulation was promulgated in the wake of the Sept. 11 terrorist attacks as civil liberties advocates sued to learn the identities of hundreds of New York City-area immigration detainees who were being questioned by the federal authorities.

The documents the GBI eventually released provide a behind-the-scenes look at De La Rosa’s odyssey through the immigration detention system. ICE took custody of De La Rosa on March 11 in Wake County, N.C., after he racked up an extensive record of offenses. He was convicted of driving under the influence, possession of burglary tools, receiving stolen goods and carjacking, ICE records show.

As he was booked into Stewart, he told the medical staff he had schizophrenia, had been hospitalized for it, had experienced hallucinations, had talked to God, and that he was taking eight medications for his condition. The following month, he claimed he was “the Antichrist” and said he was going to die. Stewart placed him on “suicide watch.” After he refused to take his medication and as his delusions persisted, Stewart sent him to a separate mental healthcare facility for treatment. He stayed there for just over a month before returning to Stewart.

On June 19, a Stewart officer accused De La Rosa of “making sexual proposals” in an encounter with her. Two days later, the center ordered his punishment: 30 days in solitary confinement. During De La Rosa’s isolation, a federal Immigration Court judge ordered him deported.

On the day he killed himself, De La Rosa told a licensed clinical social worker at Stewart he didn’t want to take his medication and that he was going to die. The social worker concluded he “would benefit from a referral to a higher level of care (at a) mental health facility.”

That evening, Dent, the detention officer, looked into De La Rosa’s cell at 8:40 p.m. Dent told the CoreCivic investigator he saw De La Rosa sitting on his bed and smiling at him at 10:04 p.m. But CoreCivic’s investigative report contradicts Dent, saying he did not look inside De La Rosa’s cell at that time. At 10:32 p.m., another detention officer looked into the cell, noticed trouble and summoned help. De La Rosa had hanged himself with a pair of orange socks tied to the top bunkbed, nearly 5 feet high.

Stewart workers scrambled to cut him down with their “suicide knife” and resuscitate him. Realizing they had rushed in without an oxygen tank or an automated external defibrillator, they dispatched colleagues to retrieve those items. One of them found a tank but discovered it had no oxygen in it. At 11:03 p.m., De La Rosa was transported 22 miles to Southwest Georgia Regional Medical Center, where he was pronounced dead.

The GBI is still refusing to release to The AJC some of the documents about De La Rosa’s case. Among them is the “Suicide Observation Checklist” CoreCivic employees used to log the times they observed De La Rosa that evening. The GBI called it a “protected health record and a confidential federal record not subject to release under the Open Records Act.”

Andrew Free, the attorney representing De La Rosa’s and Jimenez’s families, said the federal standards for regularly monitoring such detainees are in place “to prevent tragedies like this from happening.”

“It is important. It is not optional,” he said. “And CoreCivic’s employees have treated it like it is optional.”

De La Rosa arrived in the United States 18 years ago, seeking a job, said his younger brother, Isai Romero of Raleigh, N.C. In a statement he released through Free, Romero said he wants Stewart closed. If it is not, Romero said, the detainees there should be treated humanely.

“I already had in my mind that there was a possibility they hadn’t been monitoring him,” Romero said. “Two hours is a really long time, and to know the reality of everything that he faced during that time is so hard.”

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Statement from CoreCivic 

CoreCivic, the Nashville-based corrections company that operates Stewart Detention Center through an agreement with U.S. Immigration and Customs Enforcement, issued the following statement in response to questions from The Atlanta Journal-Constitution about Efrain De La Rosa’s suicide:

“Since this is a pending claim and the ICE Office of Professional Responsibility’s investigation is ongoing, we cannot get into the details of Mr. De La Rosa’s death. 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.

The staff and leadership at Stewart Detention Facility fully cooperated with the Georgia Bureau of Investigation (GBI) as it conducted an investigation into this matter. We are likewise cooperating with ICE officials.”

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This article has been updated to clarify which news media organizations persisted in their requests for records from the Georgia Bureau of Investigation.