Jimenez’s fall sounded like a sledgehammer blow, said 20-year-old Abel Ramirez Blanco, who was also in segregation at Stewart that night. Another detainee, Miguel Montilla, had peered through the metal grate on his door and saw guard Freddy Wims frantically knocking at Jimenez’s cell door. “He got on the walkie-talkie and started screaming,” Montilla said.

“I looked in the door and I didn’t see him,” Wims would later remember. Wims scanned the small cell until, he said, “I looked over in the corner by the commode and he was hanging there by the sheet.”

Within hours, Georgia Bureau of Investigation agents descended on Stewart, about 140 miles south of Atlanta, to find out if foul play had been involved in Jimenez’s death. It wasn’t. But the investigation, which generated audio interviews of Stewart staff and detainees, along with recordings of Jimenez’s personal phone calls and official documents, revealed that CoreCivic, the for-profit prison company that operates Stewart for ICE, and ICE Health Services Corps, which provides health care at Stewart, cut corners and skirted federal detention rules. The organizations’ missteps and errors have led to concerns about the safety of immigrant detainees with mental health issues.

Items belonging to 27-year-old JeanCarlo Jimenez Joseph after his death in his cell. Credit: Georgia Bureau of Investigation

The probe disclosed that Jimenez repeatedly displayed suicidal behavior, but never got the mental health care he needed. He was also placed in a cell that contained a known suicide hazard, a ceiling sprinkler head, upon which he affixed his makeshift noose. Freddy Wims was assigned to check Jimenez’s cell every half hour, but didn’t do so. Instead, he falsified his logs to make it appear he had, and he was later fired. Stewart’s warden, Bill Spivey, retired after Jimenez’s death; a CoreCivic spokesman told The Atlanta Journal-Constitution that the two events were unrelated. Spivey couldn’t be reached for comment for this article.

CoreCivic’s spokesman, Jonathan Burns, didn’t respond to questions about Jimenez’s death and detention. Instead, he wrote in an email, “CoreCivic is deeply committed to providing a safe, humane and appropriate environment for those entrusted to our care, while also delivering cost-effective solutions to the challenges our government partners face.” ICE spokeswoman Tamara Spicer wrote in an email that she couldn’t answer questions about the case because it is “still undergoing a comprehensive review that has not been released.”

Jimenez had been in solitary for 19 days at the time of his death — punishment for what his sister would tell investigators was an earlier suicide attempt. He had leapt from a second-floor walkway in his dormitory, and later repeatedly told detention center personnel, “I am Julius Caesar for real.” He was physically unhurt, but Stewart staff were aware he was suffering from mental illness and had a history of suicide attempts, documents show. Still, after his jump, Jimenez saw a nurse who quickly cleared him for placement in a 13-by-7-foot segregation cell alone for 23 hours a day. After that, his suffering seemed to intensify.

“Placing a suicidal prisoner in segregation is like placing someone with bad asthma in a burning building,” Terry Kupers, a Bay Area psychiatrist who has studied solitary confinement and who reviewed some of the documents in Jimenez’s case, noted in an email. He added that half of successful prison suicides occur among the three to eight percent of prisoners in solitary confinement.

The noose JeanCarlo Jimenez Joseph fashioned from a bed sheet and hanged himself in his solitary confinement cell at the Stewart Detention Center. Credit: Georgia Bureau of Investigation

Jimenez wasn’t put on suicide watch, or even ordered monitored more frequently than the normal half-hour checks. He continued to display alarming behavior. Montilla told the GBI that he and a guard had heard Jimenez screaming and banging on his cell wall two weeks before his death. “Man, I’m suffering from psychosis and I hear voices talking to me and they’re bothering the shit out of me,” Montilla recalled Jimenez saying.

Registered Nurse Shuntelle Anderson told a GBI agent that some five days before his death, she saw Jimenez banging the metal mirror in his cell. He told her, “These fucking voices, they won’t leave me the fuck alone … They’re telling me to commit suicide … but I don’t want to harm myself.”

Jimenez asked Anderson for a higher dose of the anti-psychotic drug Risperidone, which he’d previously been prescribed at a North Carolina mental health facility. It was at least the second such request he’d made at Stewart — where he received only a fourth of his normal dosage.

Anderson told investigators she left a note for the facility’s behavioral health counselor, Kimberly Calvery, saying that Jimenez wanted more medication. Calvery arranged for him to speak with the detention center’s psychiatrist but Jimenez didn’t live long enough to keep the appointment, which was scheduled later in the morning he died. Calvery later told investigators that Jimenez “never showed any suicidal tendencies at the Stewart Detention Center.”

“He was such a good kid,” Anderson told investigators in the hours after Jimenez’s death. Earlier that night, she’d given him medication and he’d shared a self-portrait he’d been working on. “It was very nice, very detailed and last night, when I went down there, he said, ‘Look, I finished it.’” Anderson said. Guards and detainees also described Jimenez as mostly lucid and friendly, despite his occasional outbursts, quirky comments and a propensity to call himself Julius Caesar.

In a December 2017 report, “Concerns about ICE Detainee Treatment and Care at Detention Facilities,” the Homeland Security inspector general wrote that at Stewart and three other facilities (which are operated by county governments), “We identified problems that undermine the protection of detainees’ rights, their humane treatment, and the provision of a safe and healthy environment.” The IG’s staff wrote that immigration detention isn’t supposed to be punitive, and noted that at three of the facilities, including Stewart, segregation or solitary confinement appeared to be sometimes used to punish trivial offenses. At Stewart, the inspectors also found that showers were moldy and lacked cold water in some cases, and some bathrooms had no hot water, and that medical care, even for painful conditions, had been delayed for detainees.

Additionally, despite Jimenez’s nonviolent crimes, he was classified as a high-risk detainee. He had been convicted of marijuana possession, petty theft and an assault charge that arose from an unwanted hug he gave a woman in Raleigh, North Carolina. He was issued a red jumpsuit to signal his danger level and housed with others who were similarly classified. The inspector general’s report flagged misclassification of detainees as a problem at Stewart. While there, Jimenez wavered between wanting to wage a court battle to stay in the US, and paying for his own return to Panama through a process called voluntary departure. But, before he could take the first steps to fight his case, he ran into roadblocks, including the failure of the detention center to send a set of documents that Jimenez’s attorney had requested.

Like Jimenez, they’ve been dropped into a ballooning system whose rapid growth and diffuse nature would make it hard for the government to closely monitor, even if it attempted to do so.

ICE had fewer than 7,500 detention beds in 1995. Now the system is 500 percent bigger, with nearly 40,000 beds nationwide in 200 facilities that operate under three different sets of government standards. The Trump administration plans to add 12,000 more beds this year alone even as vulnerable detainees currently fall through the cracks.

Federal officials largely maintain a hands-off approach, leaving it to private prison companies like CoreCivic and the GEO Group to run day-to-day affairs. The companies tend to run them like prisons and not as the civil detention facilities that the law says they are.

CoreCivic, the for-profit prison company operates Stewart Dentention Center for ICE, and ICE Health Services Corps, which provides health care at Stewart, cut corners and skirted federal detention rules. Credit: Robin Urevich/Capital and Main

“Contractors operating facilities for ICE typically have backgrounds in corrections, and this shapes how they administer their ICE detention facilities,” said Kevin Landy, who led the Obama administration’s immigration detention reform efforts as the head of ICE’s Office of Detention Policy and Planning.

“Problems such as medical care, the way disciplinary proceedings are administered, the lack of sensitivity to detainee needs, and conditions generally reflect the problems writ large in our correctional system,” Landy said.

At Stewart, these problems have been particularly acute, said attorney Azadeh Shahshahani, whose group, Project South, monitors conditions at Stewart. “The facility needs to be shut down. It’s beyond redemption.”

Jimenez had come to the United States from Panama when he was 10, graduated from high school in Kansas, and considered himself American, even though he lived in the US without documents most of his life. Public records show he even registered to vote in North Carolina — as a Republican.

“When I heard what happened, it blew my mind,” said Matt Schott, who was about four years older than Jean Jimenez and now works for an oil and gas exploration company in Kansas. Jimenez was 19 when he and his sister, Karina Kelly, came to Matt’s church, and they became friends 12 years ago. “He brought a lot of laughter to everybody,” Schott said, recalling Jean’s huge open smile. In photos, he’s beaming, showing a mouthful of teeth and wearing a big afro.

“Jean would just show up at the house. We’d play Christian worship music, and be up till 3 or 4 in the morning. We would get a bunch of food and go to a park,” Schott remembered. A video on Jean’s Facebook page shows him executing expert dance moves as friends play instruments outdoors.

Schott said when they began to share more of their lives, Jean tearfully told Matt he was undocumented and had to hide in plain sight. “He had big dreams. He wanted to start an architecture firm and had already named it — Eyes Design.”

Except for a few Facebook messages they exchanged, Schott lost track of Jimenez after the latter moved to North Carolina with his mother and stepfather about eight years ago. While there, Jimenez had obtained protection from deportation through the Obama administration’s DACA or Deferred Action for Childhood Arrivals program.

But, in the six months before he was detained, his mental health declined. He was hospitalized twice for psychotic episodes and lost his DACA status. Jimenez also had the misfortune of being arrested just as President Trump took office. The new administration had declared that anyone in the country illegally was fair game for immigration enforcement, even if they’d committed no crime or if their crimes were as minor as Jimenez’s. He was transferred to ICE custody.

For Jimenez the prospect of deportation to Panama, a country he had left behind as a child, was scary, his sister Karina wrote in a chronology of conversations with her brother that she sent to the family’s attorney. “Game is over,” Kelly recalled Jimenez saying. But before being shipped to Panama, he would be held at Stewart, arguably one of the most troubled detention centers in the country.

About six weeks into his detention a fellow detainee punched Jimenez in the groin and busted his lip. Jimenez was punished with his first stint in solitary — even though he was the victim in the attack and the detention center’s camera shows he didn’t fight back.

“I’m tired of this life,” Jimenez told his stepfather Gilberto Rodriguez in a recorded phone call soon after, his voice sounding uncharacteristically weary.

“Don’t give up, you can start over,” Rodriguez counseled. “In God’s name you’re getting out … we have to do this together.”

Just two days before his death, Jimenez’s mother, Nerina Joseph, and Rodriguez made the trip from Raleigh, North Carolina, to visit him. “She reported that he was so happy to see them, and they had the best 60 minutes a mother in her shoes could ever ask for,” Karina Kelly wrote.

Still, Jimenez’s mother was concerned about his well-being, and stopped by El Refugio, a hospitality center in Lumpkin, Georgia, where detention center visitors can find a meal and place to sleep. El Refugio volunteers also visit detainees, and Joseph requested that someone check on Jimenez. A volunteer attempted to see him the next day, but was turned away because Stewart personnel mistakenly said Jimenez couldn’t receive visitors. Records show there were no such restrictions on Jimenez’s visits.

Later that night, Jimenez completed his self-portrait, and tied knots in a white bed sheet to shorten it. A guard even observed him jumping rope with the sheet a few hours before he died and asked him about it. Jimenez replied he was staying in shape and the guard took no further action.

Ten days after Jimenez’s suicide, a fellow detainee, Abel Ramirez Blanco, told GBI investigator Justin Lowthorpe that he had listened in his cell as guards, nurses and finally paramedics labored over Jimenez’s lifeless body, and an automatic defibrillator blared robotic CPR instructions.

A videotape of the scene inside Jimenez’s cell shows nurses Shuntelle Anderson and Davis English desperately trying to resuscitate Jimenez. Anderson yells for guards to call 911. “I’m calling an ambulance,” a voice answers. Records from a regional 911 center show paramedics were called six minutes after Wims radioed a medical emergency, and arrived in Jimenez’s cell some seven minutes after they were called.

ICE inspectors haven’t yet weighed in on Jimenez’s case. But in studying a 2013 suicide, ICE reviewers criticized staff at a Pennsylvania facility for waiting four minutes to call 911, writing that the Mayo Clinic and the American Heart Association recommend calling 911 before beginning CPR.

Jimenez was eventually taken to a hospital where he was pronounced dead less than 15 minutes after his arrival.

Red caution tape was placed in the shape of a large X on Jimenez’s cell door. Inside the cell, steel shelves held his art supplies, his artwork and a plastic instant-noodle soup bowl with some of the broth still in it. On his wall Jimenez had written, “The grave cometh. Halleluyah.”

Sometime after midnight in mid-May of 2017, 27-year-old JeanCarlo Jimenez Joseph fashioned a noose from a bed sheet and hanged himself in his solitary confinement cell at the Stewart Detention Center. Credit: Georgia Bureau of Investigation

A death like Jimenez’s “could have happened to me,” Ramirez told GBI agent Lowthorpe, because of his own anxiety and depression. Ramirez said Stewart staff didn’t help him when he reported those symptoms. Instead, he was thrown in segregation where he witnessed Jimenez’s suicide, and began to feel even more desperate.

Matt Schott struggled to reconcile his friend’s death with his Christian faith. “People believe you commit suicide and you go to hell,” Schott said. “I can’t believe that about Jean because I knew who he really was. I love the guy and I believe one day I’ll see him again.”

This piece was originally co-published by Capital and Main and International Business Times.