Security personnel at an immigration holding site in El Paso, Texas, observed a person inside his room with one portion of a sheet looped around his throat and the opposite end fastened to the entry knob. Opening the door would have caused the fabric to constrict and choke him.

The individual, Geraldo Lunas Campos, had spent roughly thirty days at Camp East Montana by that point. The location was fairly recent and had been established under the prior administration to accommodate and swiftly remove large numbers of migrants.

Soon after arrival, the fifty-five-year-old Cuban national started voicing dissatisfaction with his treatment, based on an extensive unpublished coroner investigation file spanning nearly three hundred pages.

The file, examined by ProPublica and The Texas Tribune, contains numerous entries describing medical team contacts with Lunas Campos, who possessed a background of psychological conditions and prior institutionalization in New York.

The file and enclosed documents provide an uncommon and troubling view into how migrant holding sites - built quickly with minimal supervision - handle individuals requiring substantial mental health support. The materials depict a person experiencing acute distress and a location where employees discussed moving him multiple times to a setting offering more intensive assistance.

Records indicate he raised medication concerns at least eight times, noting missed or delayed antipsychotic prescriptions for his depression, worry, and visions. A September 9 staff note mentions he voiced irritation about his prescription amounts.

These entries highlight episodes of frustration that prompted self-injury. He struck his head on the wall after lacking funds for calls to his children in New York, resulting in a bruised eye. Staff responded by recording a conversation about avoiding such actions to protect his mind and vision.

The noose incident occurred in early October. A mental health specialist persuaded him to loosen the sheet. Documentation described the event as a non-suicidal act intended to compel release from isolation. Transfer to a hospital was deemed unnecessary given evaluated risks and safeguards.

Lunas Campos passed away in custody nearly three months afterward, following a confrontation with guards concerning his prescriptions. Initial statements from the prior administration described medical distress, yet a coroner determined the death resulted from homicide.

Differing explanations of the fatality attracted considerable coverage and mobilized advocacy organizations alleging it exemplified hazardous conditions in federal migrant facilities.

However, scant details emerged previously about his state and handling before that event. On Monday, his three offspring initiated legal action against the operators of the site at the time. The complaint claimed guards caused his death and cited lapses such as overlooked doses along with improper restraint methods. The Washington Post reported Thursday that Lunas Campos had sought repeated aid for his condition, referencing the coroner file. The firms have not addressed the claims in filings and did not reply to inquiries.

ProPublica and the Tribune assessed the file contents weeks earlier. Two specialists in mental health and custody deaths also examined it at the outlets request. The conclusion was evident: the detainee sought assistance, yet staff did not respond adequately.

The outlets additionally examined over one hundred sixty emergency dispatches, plus documents and discussions with employees and officials connected to the site. These reveal medical and psychological crises beyond Lunas Campos case, with personnel expressing insufficient preparation. Detainees faced limited recreation and outdoor access, which experts note heightens hopelessness. Staff overlooked indicators like prior self-harm attempts.

It constitutes civil holding, noted Will Horowitz, counsel for the adult children in the suit. They face detention absent any criminal offense.

The White House offered no comment. Immigration and Customs Enforcement did not reply to interview requests or written queries. The administration has labeled accounts of deficient care and poor conditions at Camp East Montana and similar sites as inaccurate and sensationalist. Officials have often stated that many migrants receive superior medical attention in custody than elsewhere.

In Lunas Campos situation, Homeland Security officials initially downplayed the event leading to his death by referencing his legal record. Later, amid reports of a homicide ruling, a spokesperson asserted guards applied force to prevent self-inflicted harm.

Lunas Campos received a one-year sentence following a 2003 conviction involving improper contact with a minor, per The Associated Press. The outlet also noted a 2009 conviction for attempting to distribute a controlled substance, resulting in five years imprisonment and three years oversight.

Horowitz stated the prior convictions hold no bearing on the detention matter. Lunas Campos children declined to address the care lapses in the coroner file or his record, though Horowitz added they wish to convey he was an ordinary individual who should not have perished.

A post-death review by Homeland Security indicated he underwent routine medical and psychiatric checks, with adjustments to prescriptions as required. It also asserted monitoring for suicidal thoughts. Coroner investigative materials show staff conducted fifteen-minute checks after the self-harm event, per federal rules.

Yet the coroner file underscores multiple care failures, according to Dr. Sanjay Basu, an epidemiologist at the University of California, San Francisco. He described the case as illustrative of how such lapses accumulate into repeated crises with severe results.

The documented progression in his records - rising agitation, self-injury, rapid speech, repeated medication disputes - represents the expected outcome of inconsistent medication delivery for someone with significant mental illness, Basu observed.

He highlighted entries showing no transfer occurred to a better-equipped site, despite discussions beginning October 8. Lunas Campos was also placed repeatedly in isolation units containing little beyond a bed. Federal standards advise avoiding such placement for those with serious mental conditions whenever possible.

Most importantly, staff treated the prior self-harm attempt as manipulative rather than genuine, Basu noted.

The materials demonstrate systemic disregard, Basu concluded.

A System Breaking Down

Camp East Montana was intended as a prototype for nationwide facilities under the Trump administration. Positioned near the border with highway and airfield access, it aimed to enable rapid movement and removal of unauthorized migrants. Its placement on expansive Fort Bliss property permitted capacity for up to ten thousand at once, exceeding any other site.

Instead, it illustrated potential failures.

Months after opening, the American Civil Liberties Union, now pursuing federal litigation, shared accounts from migrants describing guard assaults, denial of essential medication, and filthy surroundings with waste occasionally entering dining zones. Measles and tuberculosis outbreaks were common. The government has not formally answered the suit, but a Homeland Security spokesperson has called claims of abuse and inhumane treatment categorically untrue.

Challenges addressing mental health needs were less apparent yet built in ways experts said increased distress and could lead to further self-harm attempts. In severe instances, they said, unnecessary deaths occurred.

The site was never equipped for individuals with serious psychological conditions, a Homeland Security official and a medical worker there told ProPublica and the Tribune. They requested anonymity as they lacked authorization to discuss operations.

Multiple employees indicated they possessed relevant details but were bound by confidentiality agreements.

The Homeland Security official noted migrants lacked sufficient areas for reading, prayer, writing, or legal aid. They remained in windowless rooms with minimal activity. Outdoor time was restricted, partly due to insufficient space, as a later government assessment confirmed. Federal rules mandate at least one hour daily outdoors, yet many received only a few hours weekly, per detainee accounts.

Recreation options, reading materials, and entertainment serve as essential supports for those in custody, the official said.

Extended isolation heightened anxiety and desperation, sometimes resulting in hunger strikes and conflicts. Migrants were meant to stay no longer than two weeks per contracts and official statements. When Lunas Campos died, average stays reached thirty-eight days per a ProPublica review of government data from the Deportation Data Project. He had remained far longer, exceeding one hundred days.

Dr. Katherine Peeler, a medical adviser with Physicians for Human Rights who has examined care in migrant facilities, stated the reported conditions indicate the site was unsafe for any detainee.

Detention creates uncertainty about procedures and release timing, Peeler said. It becomes difficult to trust those in authority for accurate details, leading to increased despair and distress.

The impact intensifies for those with mental health histories, Peeler added. Isolation can trigger trauma responses, self-injury, and elevated suicide risks, according to a 2024 study she co-authored with Harvard affiliates.