ICE Review of Immigrant’s Suicide Finds Falsified Documents, Neglect, and Improper Confinement

An internal review of Efraín Romero de la Rosa's death in ICE custody found almost two dozen policy violations during his stint in detention.

In a still from closed-circuit video footage inside the facility, Efraín Romero is seen being escorted by a guard to the recreation area. Still: Stewart Detention Center

Medical and security staff at a U.S. Immigration and Customs Enforcement detention center violated numerous agency rules when dealing with a detainee with mental illness, according to an internal agency investigation. Efraín Romero de la Rosa, who had been diagnosed with schizophrenia, took his own life after 21 days in solitary confinement in Georgia’s Stewart Detention Center in July 2018.

Following Romero’s death, ICE’s External Reviews and Analysis Unit, a nominally impartial body within the agency, opened an investigation that found that staff had falsified documents; improperly dealt with Romero’s medication; neglected to follow proper procedures for his care; and improperly placed him in disciplinary solitary confinement — despite multiple warnings of Romero’s declining mental health.

“The real question is, why would the government imprison an individual with a documented mental health illness in a deadly detention center?”

“The real question is, why would the government imprison an individual with a documented mental health illness in a deadly detention center?” said Azadeh Shahshahani, legal and advocacy director of the Atlanta-based civil rights nonprofit Project South, after reviewing the report. “And why would they repeatedly subject him to solitary confinement instead of providing him with the mental health care that he desperately needed?”

The investigative unit’s Detainee Death Review, obtained through a Freedom of Information Act request by The Intercept, lists 22 separate violations of both ICE and Stewart Detention Center rules by staff during Romero’s four months in ICE detention. It also lists eight separate “areas of concern.” ICE did not respond to a request for comment.

Deadliest Immigration Jail

The Stewart Detention Center, owned and operated by private prison company CoreCivic, is one of the largest immigration jails in the country — and the deadliest. Since 2017, eight people detained at Stewart have died: four from complications with Covid-19 and two by suicide, including Romero. Two others died of pneumonia and a heart attack.

Romero had been diagnosed with schizophrenia prior to being detained by ICE. During his time at Stewart, he spent time in an external mental health facility for schizophrenic delusions. In 2019, The Intercept and WNYC’s The Takeaway released an investigation into Romero’s death demonstrating a stunning level of neglect toward Romero in the months leading up to his death. The newly revealed review document confirms our previous reporting and adds more detail to Romero’s time in ICE custody.


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The Detainee Death Review raises questions about the quality of care for people detained at Stewart. Two inspection reports by ICE’s Office of Detention Oversight earlier this year, although limited from constraints to the investigation due to the coronavirus pandemic, highlight some of the same concerns listed by the 2018 death review, including deficiencies in Stewart’s proper use of solitary confinement and incomplete records by medical and correctional staff. Both the oversight and review offices operate under ICE’s Office of Professional Responsibility.

The use of solitary confinement in ICE detention centers has been subject to extensive scrutiny. In 2019, the International Consortium of Investigative Journalists, The Intercept, and other news organizations published an investigation based on thousands of internal documents demonstrating the agency’s widespread use of solitary confinement. A watchdog report in 2019 found that some 40 percent of detainees in ICE solitary confinement had mental health issues.

Last week, the Department of Homeland Security’s Office of Inspector General published a report on ICE’s use of solitary confinement that said the agency did not have clear policies on the practice — and even when it did, ICE did not always comply with them. The report also said ICE did not comply with reporting and proper record-keeping practices, including the unlawful destruction of files.

In 2017, 14 months before Romero’s death, Jeancarlo Alfonso Jimenez-Joseph, a 27-year-old longtime U.S. resident, died in Stewart under similar conditions. Jimenez-Joseph also had diagnosed schizophrenia; he had expressed to staff that he was undergoing mental health crises and took his own life after spending 19 days in a solitary confinement cell.

Last year, Romero’s family filed a lawsuit against CoreCivic, claiming wrongful death and disability discrimination. “In this case, CoreCivic had the benefit of hindsight: The company knew everything about its operations that failed to save Jean’s life; but elected not to address those systemic failures because to do so would render its contract to operate the Stewart Detention Center financially unviable,” the lawsuit says. CoreCivic denied the lawsuit’s allegations in a court filing.

“The safety and well-being of the individuals entrusted to our care is our top priority,” a CoreCivic spokesperson told The Intercept in a statement. “We take seriously our obligation to adhere to federal Performance Based National Detention Standards in our ICE-contracted facilities, including the Stewart Detention Center (SDC). Our immigration facilities are monitored very closely by the government, and each and every one is required to undergo regular review and audit processes that include ensuring an appropriate standard of living for all detainees.”

Three Stints in Solitary

The ICE Detainee Death Review summarizes Romero’s time in the U.S. criminal justice system and in immigration detention. Romero crossed into the U.S. in 2000 and, starting in 2004, spent years in different carceral facilities following convictions on various charges including carjacking, possessing burglary tools, receiving stolen property, and driving under the influence. In 2013, the Virginia Department of Corrections transferred him to a mental health facility, where, due to his schizophrenia, Romero was “found to be mentally incompetent and was therefore unable to participate in his criminal proceedings,” according to the review.

Romero was released from the state-run mental health facility in 2017 and was rearrested in 2018 for larceny in Raleigh, North Carolina. It was in that jail that ICE took custody of Romero and sent him to the Stewart Detention Center in March 2018.

Throughout his time in ICE custody, staff members were aware of Romero’s diagnosis. Not only did staff have Romero’s health documentation, but he also spoke with them numerous times about it, discussed medications, and repeatedly expressed that he was experiencing auditory hallucinations. He also expressed his fixation on death, which worsened during his time in solitary confinement.

InGenesis, a health care company that contracts with the government to staff a variety of facilities nationwide, was helping provide care at Stewart at the time of Romero’s death. Health care at Stewart is now solely run by CoreCivic itself.

Romero was in solitary confinement three times during his stint at Stewart: the first time for “disciplinary segregation”; the second time for suicide watch; and the third time again for “disciplinary segregation.” For the two times he was sent to solitary on disciplinary bases — both times for making inappropriate sexual comments to staff — he was committed for 30 days.

The three stints in solitary were all marked by repeated failures to adhere to rules and standards around detention and, particularly, solitary confinement.

The three stints in solitary were all marked by repeated failures to adhere to rules and standards around detention and, particularly, solitary confinement. Romero spent his first 15 days in solitary without being taken by staff to shower, despite a rule requiring offers of at least three showers per week. In other cases, paperwork by staff went uncompleted. All the while, Romero’s mental health, particularly his delusions, continued and worsened.

At different periods during Romero’s time on suicide watch, until May 4, medical staff reported checking on him, but the ICE review unit investigation found that documentation was incomplete and that one nurse “did not sign her note until July 19, 2018” — nine days after Romero died.

From May 4 to June 12, he was taken to the Columbia Regional Care Center, a mental health facility, where he was given antipsychotic medications and regularly evaluated by a psychiatrist. The review said Romero continued to experience delusions and was fixated on death during his time at the facility.

The Last Three Weeks

After over a month at the mental health facility, Romero was set to be discharged, despite continuing delusions. The psychiatrist’s discharge summary said his “insight and judgment were chronically impaired.”

Despite his time at the mental health facility, and despite being previously placed in solitary confinement at Stewart, when he returned, security staff did not classify him during the intake process as someone with a “special vulnerability,” according to documents viewed by The Intercept in 2019.

After returning to Stewart, Romero was prescribed three medications but refused to take them, regularly telling staff they were not needed. The Detainee Death Review says there is no record that medical staff followed up to address the refusal.

A nurse practitioner at the facility was informed 17 times that Romero was refusing medication after his return from the mental health facility, but the nurse never saw Romero, citing “staffing issues” for numerous follow-up appointments being rescheduled.


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On June 19, Romero was placed in disciplinary solitary confinement after approaching a female guard, rubbing his foot on hers, and making inappropriate comments. A supervisor, identified by The Intercept in 2019, sent him to solitary confinement for 30 days without making note of his history of mental illness, as required by ICE standards.

During the disciplinary process, there was “no documentation that security staff consulted a mental health professional prior to disciplinary hearings on April 6 and June 21, 2018, or that the hearing officer considered the degree to which DE LA ROSA’s mental illness may have contributed to his behavior,” the review said. (ICE used the latter surname, de la Rosa, to identify Romero, while representatives for the family told The Intercept the former surname was preferred.)

Despite a social worker’s warnings about Romero’s “serious mental illness” the day after being placed in solitary, he remained there until he died 20 days later.

On June 22, after three days, an ICE agent completed a form requiring Romero to stay in solitary confinement. The review report says there was no note on the form or in Romero’s detention file that indicated that he had been interviewed. A higher level ICE official approved the continued confinement.

Five days later, Romero’s detention records note that a nurse administered night doses of his medication, but ICE investigators were unable to corroborate the account because InGenesis, the company helping provide healthcare at Stewart, had “separated her from service” at the detention facility. According to the review, InGenesis discovered she had falsified an entry on Romero’s medical records on July 10, 2018 — the day he died.  The document said that, given Romero’s refusals to take medication, it was “highly unlikely” that he was actually administered the doses recorded by the nurse.  The review found that medical staff, including workers operating under the aegis of InGenesis, had violated detention rules. (InGenesis did not respond to requests for comment.)

The review said that during his time in solitary confinement, nurses on rounds did not note any hallucinations by Romero but added that “all notes are virtually identical and did not include subjective information reflecting DE LA ROSA’s answers in response to queries.”

Romero, left, poses for a photo with his brother, Isaí.

Photo: Courtesy of Isaí Romero

The Final Neglect

The day Romero died, a social worker conducted a mental health assessment and once again documented that Romero met “serious mental illness” criteria. She noted that he “presented as pleasantly delusional.”

That night, correctional staff neglected to check on Romero from 8:40 p.m. to 10:33 p.m., despite ICE rules requiring checks every 30 minutes. For the three required cell checks during that time, the officer in the unit falsified a document, signing off as if he had looked inside Romero’s solitary confinement cell, according to the review as well as internal security videos obtained and published by The Intercept in 2019. CoreCivic told The Intercept in 2019 that the officer was fired after Romero’s death.

It was during this period that Romero took his own life. When another officer found Romero at 10:33 p.m., he called for a medical emergency. Other officers rushed to the solitary unit, moved Romero, and began performing CPR.

When nurses arrived five minutes later, they could not locate the automated external defibrillator. They also had a nonfunctioning oxygen tank.

Emergency services arrived, placed Romero on a gurney, and took him to the ambulance — all the while telling staff that he “was clinically dead” but that “they were going to do everything they could to reverse that,” according to the review. Emergency medical services took Romero to a hospital, where he was pronounced dead at 11:29 p.m.

The report ends, noting that with so many illegible signatures in Romero’s detention file, “there is no way to account for actions and decisions.”

“The system works like this because it’s designed and allowed to do so.”

Romero’s family’s lawsuit against CoreCivic is ongoing. Andrew Free, one of the attorneys representing Romero’s family, said that ICE’s death reviews often fail to hold broader policies and higher-ranking officials to account. “Accountability flows down the chain of command to the lowest paid, most vulnerable workers at the facility,” Free said, “while profit flows up in the billions to the private prison companies whose facilities keep breaking the rules and claiming human lives with impunity. The system works like this because it’s designed and allowed to do so.”

Stewart, for its part, is seeing an influx of new detainees. Though the facility has previously been used to house male immigration detainees, a number of women have been transferred to Stewart. Some of the women were sent to Stewart from another ICE detention center in Georgia, the privately run Irwin County Detention Center, following allegations of widespread medical misconduct at the facility.

With a rising number of women detainees being held at Stewart, advocates fear that more detainees will be mistreated at the facility.

“Instead of transferring additional people to Stewart,” said Shahshahani, of Project South, “the administration must immediately shut Stewart down before we witness even more tragedies.”

The National Suicide Prevention Lifeline offers 24-hour support for those experiencing difficulties or those close to them, by chat or by telephone at 1-800-273-8255.

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