Guards at an immigration detention center in El Paso, Texas, could see a detainee in his cell with one end of a bedsheet wrapped around his neck and the other tied to the door handle. If they opened the door, the sheet would tighten and strangle him.

The detainee, Geraldo Lunas Campos, had been in detention at Camp East Montana for a month by then. The facility itself was still relatively new and had been opened as part of the Trump administration’s plans to house and quickly deport thousands of immigrants at a time.

Almost immediately after being admitted, the 55-year-old Cuban immigrant began expressing frustration about his care, according to a nearly 300-page unpublished medical examiner’s investigative report.

If you or someone you know needs help, here are a few resources:

Call the National Suicide Prevention Lifeline: 988

Text the Crisis Text Line from anywhere in the U.S. to reach a crisis counselor: 741741

The report, reviewed by ProPublica and The Texas Tribune, includes dozens of notes that detail medical staff interactions with Lunas Campos, who had a history of mental illness and had been previously institutionalized in New York.

The report and the records it contains offer a rare and disturbing look at how immigrant detention facilities — erected rapidly and with little oversight — manage detainees with serious mental health needs. The records paint a portrait of a man in a crisis and a facility whose staff, on several occasions, discussed transferring him to a facility where he could get a higher level of care.

According to the records, he complained at least eight times to staff about skipped or late doses of antipsychotic drugs to treat his depression, anxiety and hallucinations. He “expressed frustration regarding his medication dosage,” says a Sept. 9 entry from medical staff.

They point to moments of exasperation that led to self-harm. He banged his head against the wall after he couldn’t afford to pay the charges to talk with his children in New York. That left him with a black eye. In response, staff simply noted that they spoke with him about “not hitting his head against the wall bc he must take care of his brain and his eyes.”

The incident with the noose and the doorknob came in early October. A mental health provider eventually coaxed him to untie it. Notes detailing the incident stated that Lunas Campos affirmed he wasn’t suicidal. The notes dismissed what occurred as a “suicidal gesture made to force security staff to release him” from the isolation room where he had been segregated from the rest of the detainees. Hospitalization, the notes stated, was “not clinically indicated at this time based on assessed risk and protective factors.”

Lunas Campos died in detention nearly three months later, after an altercation with guards over his medication. The Trump administration initially claimed that he had experienced medical distress, but a coroner later ruled his death a homicide.

The conflicting accounts over the cause of his death have drawn significant media attention and served to rally advocacy groups who have alleged that it is one of the more shocking pieces of evidence of the dangerous conditions endured by immigrants in federal detention facilities.

But little had been reported about Lunas Campos’ condition and treatment before that day. On Monday, Lunas Campos’ three children sued the companies running the facility at the time of his death. The lawsuit alleged that guards killed him and argued negligence, including missed medication doses and the improper use of force and restraint. The Washington Post on Thursday reported that Lunas Campos had repeatedly sought treatment for his mental illness, pointing to the medical examiner’s investigative report. The companies have not responded to the allegations in court filings and did not return emails and phone calls seeking comment.

ProPublica and the Tribune reviewed the contents of the report several weeks ago. Two doctors, who are experts on mental health and deaths in detention, also reviewed the report at the news organizations’ request. The takeaway was clear: The detainee asked for help, the facility staff failed to adequately respond.

The news organizations separately reviewed more than 160 emergency calls, as well as records 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 felt........

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