Deep in the backroads of central Florida, hidden between trees dripping with Spanish moss, sits the campus of an infamous center for the developmentally disabled. Its story shows what can happen when families have nowhere else to find care for their loved ones.

After years of complaints, Carlton Palms is finally being shut down. But its parent company, Bellwether Behavioral Health, is still running group homes across the country, where new allegations have arisen.  

WNYC reporter Audrey Quinn investigates the company and speaks to a family whose son was abused at two of Bellwether’s New Jersey facilities. She discovers that, with national spending on autism services expected to increase 70 percent by 2025, the company is owned by a private equity firm.

Then, reporter Elly Yu investigates the death of a DACA recipient while at an Immigration and Customs Enforcement detention center in rural Georgia.

Dig Deeper

  • Listen: Aftereffect
  • Read: Staff describe Georgia immigrant detention center as ‘ticking bomb’


Produced by Amy Walters. Edited by Deb George. Special thanks to WNYC Studio’s podcast, Aftereffect, and WABE in Atlanta.

Support for Reveal is provided by the Reva and David Logan Foundation, the Ford Foundation, the John D. and Catherine T. MacArthur Foundation, The John S. And James L. Knight Foundation, the Heising-Simons Foundation and the Ethics and Excellence in Journalism Foundation.

Reveal is a co-production of The Center for Investigative Reporting and PRX.


Reveal transcripts are produced by a third-party transcription service and may contain errors. Please be aware that the official record for Reveal’s radio stories is the audio.

 Section 1 of 3          [00:00:00 – 00:17:04]
(NOTE: speaker names may be different in each section)
Al Letson:From The Center for Investigative Reporting and PRX, this is “Reveal”. I’m Al Letson.
Deep in the back roads of Central Florida, hidden between trees dripping with Spanish moss, sits the campus of an institution called Carlton Palms. For over three decades, it’s been home to hundreds of developmentally disabled people, adults, kids, mostly on the autism spectrum. Every few years, new stories would seep out of the facility. Resident injuries, abuse, neglect. In 2016, the state vowed to finally crack down on Carlton Palms. It ordered more staff training and more surveillance, and the state said it would stop sending clients to the facility. They didn’t, and that’s where reporter Audrey Quinn, of WNYC in New York, comes in. She’s also the host of their podcast, Aftereffect. Hi, Audrey.
Audrey Quinn:Hey, Al.
Al Letson:What made you doubt that Florida was serious about closing Carlton Palms down?
Audrey Quinn:Florida had been sending about 30% of its developmentally disabled people, the ones with severe behavioral issues that really need residential care, to Carlton Palms, and they didn’t have a lot of other options set up. I started looking at their records from the last couple years, found that there had been more abuse allegations since the state said it was cracking down, not fewer. The Florida Agency for Persons with Disabilities, the state agency that’s supposed to be overseeing Carlton Palms, seemed hesitant to take any real action. For example, they threatened fines than settle for more staff training. Then, in the middle of my reporting, on March 1st of this year, another incident happened.
Speaker 1:911. Do you need police, fire, or ambulance?
Speaker 2:I need ambulance.
Audrey Quinn:This is a 911 call to the Lake County Sheriff’s Department from a Carlton Palms staff member.
Speaker 2:We are a residential facility that serves special needs individuals. One of our individuals was engaging in some self-injurious behavior by headbanging on the floor and the wall and other surfaces and has passed out from that.
Al Letson:So, who’s the individual they’re talking about?
Audrey Quinn:He’s a 26-year-old man named William Lamson. He went by Willy. He was autistic, had been at Carlton Palms for 13 years.
Speaker 1:Well, help is on the way as requested. If he gets worse in any way, call us back immediately for further instructions.
Speaker 2:All righty, thank you.


Speaker 1:You’re welcome. Bye-bye.


Speaker 2:Bye.


Audrey Quinn:Later that night, David Lamson-Keene got a call from his brother, Jamie Lamson. That’s Willy’s dad.


David L.-K.:I answered the phone. I said, “Jamie, we’re watching a movie. Is everything alright?” He was crying, “Dave, Willy’s dead.” I said, “What do you mean Willy’s dead?” He said, “He hit his head.” That’s when all the red flags began.


Al Letson:What does he mean by red flags?


Audrey Quinn:The family knew Willy had a habit of hitting his head with his hand, hard. It’s what’s called a self-stimulatory behavior, a form of repetitive movements, something a lot of people with autism do. In Willy’s case, it had led to a detached retina, so, for years, he had doctor’s orders to wear a padded helmet during all waking hours to keep him safe. He actually was pretty into the helmet, didn’t like taking it off. At night, he slept with it tucked under his arm. Right away, David starts to wonder how did his nephew Willy die from hitting his head during waking hours when he was medically required to have the helmet on.


Al Letson:What did David do?


Audrey Quinn:A couple days later, he goes down to Florida for Willy’s memorial. He hadn’t seen Willy for years, had never been to Carlton Palms, so he made a suggestion to his brother.


David L.-K.:I said to Jamie, “We’re making an unannounced visit to Carlton Palms.”


Audrey Quinn:They do it, just show up days after Willy’s death, surprise the executive they find in the back office.


David L.-K.:His eyes, they were like a deer in the headlights. He was very, very upset, visibly upset that we were there.


Audrey Quinn:What did you say to him?


David L.-K.:I was in shock to be honest. I just said, “Can you explain to us what happened?”


Audrey Quinn:David and Jamie hear the same story again.


David L.-K.:That Willy hit his head and that, when they went to resuscitate him, they could not resuscitate him.


Audrey Quinn:But there were cameras mounted in the common room and hallways of Carlton Palms, and according to state reports, they show something a little more complicated. A staff member rips the helmet off Willy’s head, taunts him with it, and Willy follows him into a bedroom where there were no cameras. 12 minutes later, the worker comes out, but no Willy. In the video, you can hear the caretaker then repeating his version of events over and over, before starting to alert other staff that Willy had hit his head on the floor, knocked himself out. David later got Willy’s autopsy report.


David L.-K.:Revealing that he died … That Willy was killed by traumatic asphyxiation.


Al Letson:What’s that mean, Audrey, traumatic asphyxiation?


Audrey Quinn:It means something, or someone, basically crushed his chest. The manner of the death, the report says, is homicide, caused by the actions of another person, not self-inflicted as Carlton Palms first reported. David found out that the worker, who was 44 pounds heavier than Willy, later admitted to laying on top of him.


David L.-K.:Which is heartbreaking because of the violence that must have been associated with his death.


Audrey Quinn:Was it surprising or did it feel like, “Oh, this is making sense now?”


David L.-K.:Well, sadly, it is making sense. You don’t want it to make sense, but it just starts falling apart. It’s so hard. It really is hard, because you think of this poor vulnerable soul, wishing you had been there, more involved, instead of assuming the care was all wonderful as the pictures show.


Audrey Quinn:We reached out to Carlton Palms and its parent company. They said they wouldn’t comment on individual cases. Willy’s uncle David has become the family’s spokesperson since Willy’s death. Then, there’s another thing he told me about the visit he and Willy’s dad made to Carlton Palms, about a whiteboard they noticed in the back of the manager’s office.


David L.-K.:On the whiteboard there are two comments, “settlement reached,” “settlement almost secure.”


Audrey Quinn:I had him draw the board for me on a piece of paper.


Al Letson:What did he put on it?


Audrey Quinn:There are two columns. The first was labeled “settlements reached.” The second says “settlements almost secure.” Then, in the columns are a list of dates of settlements, as in lawsuits settled.


David L.-K.:Then, there were bullet points, “Good job. Congratulations. Goals met,” almost as if it was like a sport, that they were achieving successive settlements that were keeping things quiet, but they were visibly on the whiteboard.


Audrey Quinn:David went back and did some research, found Willy was not the first death at Carlton Palms. In 1997, a teenage boy died after staff workers ignored his seizures. In 2013, it was a teenage girl who died from dehydration. There’d been other recent incidents, a resident burned by a staff member with scalding water, a child nearly strangled by a staff member. He also found out one very important thing. Carlton Palms is owned by a much bigger company called Bellwether Behavioral Health. Willy’s family is now suing the Carlton Palms staff and Bellwether Behavioral.


Al Letson:What about the criminal charges?


Audrey Quinn:The Florida State Attorney’s Office has acknowledged Willy’s death was a homicide, but they’re not pressing charges against Carlton Palms or its employees. They said they don’t think they can prove beyond a shadow of a doubt that what happened to Willy was culpable negligence, but the state is finally moving to close Carlton Palms.


What’s happened in Florida is just one chapter in Bellwether Behavioral Health’s story, the story of a company that knows how to survive bad press and lawsuits, how to lobby for laws in its favor, and how to milk state developmental disability agencies for hundreds of millions of dollars at the expense of disabled people’s lives.


Al Letson:That’s Audrey Quinn of WNYC in New York. Audrey kept digging around and found out that Bellwether has turned developed mental disability services into a lucrative business in several states.


Speaker 3:They told us that they had a program for him, for the behavior, they have a program that will fit his needs. He’s going to be placed in a group home and they’re going to be having a day program.


Al Letson:But that’s not what happened. Audrey comes back with the rest of the story after our break. This is “Reveal” from The Center for Investigative Reporting and PRX.


From The Center for Investigative Reporting and PRX, this is “Reveal”. I’m Al Letson.


Before the break, we heard how a 26-year-old man died in a Florida facility for people with developmental disabilities. Turns out, that company is owned by a larger corporation called Bellwether Behavioral Health. It operates in several states, including New Jersey, where it’s seen its strongest growth. In fact, Bellwether is the largest provider of residential care for developmentally disabled people in the state. Over 60 locations, mostly group homes, with almost 450 residents.


Audrey Quinn of WNYC in New York has been following Bellwether’s success. Audrey, what have you learned?


Audrey Quinn:This business that Bellwether has tapped into in New Jersey brings in nearly 67 million a year in Medicaid dollars, taxpayer money. That’s about $150,000 a year per disabled person it serves. It’s such a promising investment, Bellwether got picked up by a New York private equity firm, Wellspring Capital Management, in 2015. They bought it using one of their investment funds. The idea is Wellspring will make Bellwether even more profitable, then sell it for more money.


Al Letson:Audrey’s been following the story of one Bellwether client in New Jersey, a young man named Abdulaye Saccoh.


Abdulaye Saccoh:Hi.


Emma Abdullah:Hi, Du-Du.


Audrey Quinn:Du-Du, that’s the family’s nickname for Abdulaye, comes from the middle part of his name. He’s now 26. He first moved in to a Bellwether group home in 2012.


Abdulaye Saccoh:How’s it going?


Emma Abdullah:I’m doing good. How are you?


Abdulaye Saccoh:Good.


Audrey Quinn:Abdulaye talks with his mom, Emma Abdullah, just about every day on the phone.


Emma Abdullah:Okay. What are you going to do today?


Abdulaye Saccoh:We’re playing Legos. That’s good.


Emma Abdullah:Okay. You’re going to be in your room and play Legos?


Audrey Quinn:I met up with Emma in Trenton, New Jersey.


Emma Abdullah:My son is a big guy. I wish you seen him. He’s a tall, 6′ 4″, 6′ 5″ even, guy.


Fatou Saccoh:I mean, he’s a big guy, but he just is a big teddy bear.


Audrey Quinn:Emma was with her daughter, Fatou Saccoh. Growing up, Abdulaye was the youngest of eight kids. He’s autistic and intellectually disabled, so Emma says his siblings took a big role in helping him out.


Emma Abdullah:Everybody has a task for him, helping him in the morning, making his breakfast. She was tying his shoelaces. I mean, he had a routine.


Audrey Quinn:Seven helpers.


Emma Abdullah:Yes. Yes. They would take him to the park. He loved to go on the swing. He was a happy kid.


Audrey Quinn:He’d have tantrums sometime, sure, but Emma would just wait it out and they’d pass. He did better and better in school, was good at computers, would win races at the Special Olympics. Emma says all that ended one day when he was 18. Most of the older siblings had moved away, or were in college, and she was home alone with Abdulaye.


Emma Abdullah:Winter [we-in-can-ta 00:12:37], it was cold, snow on the ground, and he was expecting somebody to take him out. He act up but, this time, he attacked me, which he never did before.


Audrey Quinn:She saw him coming toward her, tried to redirect him, couldn’t.


Emma Abdullah:Then, I got scared, ran out of the house thinking that he’s going to forget, he’s not going to follow me, but he followed me outside, and outside he grabbed me.


Audrey Quinn:A neighbor saw the scuffle, called 911.


Emma Abdullah:Before I knew it, the police was at the door.


Audrey Quinn:The police brought Abdulaye to a psych ward. He was medicated there, locked in a room.


Emma Abdullah:From that day, he left home, he did not come back.


Audrey Quinn:The hospital kept him the psych ward for two months, said they needed to stabilize him. State officials then transferred him to a state run institution for developmentally disabled people. He was there two years, picked up more behavioral issues, got more aggressive.


Emma Abdullah:I didn’t see no hope. I didn’t see … What am I going to do now? He …


Fatou Saccoh:It’s okay, Mommy.


Audrey Quinn:Fatou walks into the kitchen, gets a paper towel, comes back and kneels next to her mom on the couch.


Fatou Saccoh:[inaudible 00:13:58].


Audrey Quinn:Dabs at her eyes.


Emma Abdullah:I’m sorry. How was that possible, that things would just turn so bad?


Audrey Quinn:Things turned bad, and they were about to get worse. One day, a salesperson contacted the family from Bellwether Behavioral Health. The company actually has recruiters, recruitment videos, even, with parent testimonials.


Speaker 4:When I take him out now, we walk amongst the crowds. He doesn’t touch anybody, he doesn’t walk fast, he doesn’t make noise. These people did all of that for him.


Emma Abdullah:They told us they have a program that will fit his needs. He’s going to be placed in a group home and they’re going to be having a day program.


Audrey Quinn:Emma says the family really pushed to make sure Abdulaye got into a Bellwether group home, really wanted that for him. He moved into one in August 2012 and, at first, it seemed great. Abdulaye was living with just a handful of other guys at a house in Branchburg, about an hour north of Trenton. Fatou said they were just glad to have him out of the institution.


Fatou Saccoh:We were like, “Finally, somewhere … It’s a beautiful house, it’s clean, look at the room. He’ll be comfortable here. We can come and see him when we want. He’s not home, but this can be his home.” Did we notice a few things here and there, maybe had a scratch or a bump, but we said, “He lives in the house with other individuals like him.”


Audrey Quinn:A little bit of conflict seemed inevitable. Abdulaye could be rough. The family was still focusing on the positive, on Abdulaye getting back into the community. Maybe Bellwether could teach him some job skills, better ways to handle frustration.


But Emma says that’s not what happened. He started acting more anxious, obsessive even.


Emma Abdullah:He was looking like somebody who was not eating. The face, the body, was just a big skeleton, standing there. We had no answer for that.


Audrey Quinn:Yeah, he’s a big guy, but, over a year, Emma says he lost 100 pounds. They showed me pictures. His cheeks were hollow. Fatou and Emma say Abdulaye wasn’t getting any kind of vocational training, either, no therapy. They start noticing more marks on his body.


Emma Abdullah:He had scratches, he had wounds that were not healing.


Fatou Saccoh:Open wounds.


Emma Abdullah:Open wounds.


Audrey Quinn:What would you say?


Emma Abdullah:We would ask, “What happened? Why anybody’s treating this?” “Oh, we didn’t see that.”


Fatou Saccoh:Yeah. That’s when I started saying, “Mom, I’m taking pictures. I’m writing notes.”


Audrey Quinn:At this point, Fatou is working with disabled adults herself at Rutgers University. She becomes the family’s main point person on Abdulaye. She opens up a folder on her phone to show me.


So your phone is just filled with documentation?


Fatou Saccoh:Yeah.


Emma Abdullah:Those … This is on his face.


Audrey Quinn:Oh, that …


 Section 1 of 3          [00:00:00 – 00:17:04]
 Section 2 of 3          [00:17:00 – 00:34:04]
(NOTE: speaker names may be different in each section)


Audrey Quinn:… Documentation.


Emma:Yeah, yeah. I mean, this is on his face.


Audrey Quinn:Like, no one saw it…


Audrey Quinn:They flip through years of pictures. A giant bump protruding on a [Abdulaye’s 00:17:12] shoulder. Scratches on his neck. An open wound on his face. You might be thinking, “Why didn’t they get him out of there?” They were trying. This whole time, the family is emailing Bellwether, saying, “What is happening?”, and not getting any response. But the thing you have to understand is how few options the family has.


The Medicaid money that covers Abdulaye’s placement gets handled by the state so for him to move to another group home, the state has to see verifiable abuse. They say they don’t.


I’m going to transfer you on to my kind of headset here so give me just one second.


Do I still have you?


I started reaching out to former employees to try to figure out what goes on inside Bellwether Group Homes.


Rebecca Keith started working for the company in early 2016. She was their director of operations in Virginia up until the end of last year. She’d been working in Disability Services for over 20 years, had never seen group homes run with such a corporate touch.


Rebecka Keith:Every group home you go into Bellwether, looks exactly like the last, every other group home. Bellwether has a policy of going in and sort of sterilizing the environment. They put TV’s up on the wall and then they cover them in plexiglass. They have wooden furniture with plastic coated cushions.


Audrey Quinn:Rebecca says they were getting Medicaid money to run a vocational program for residents, to give people job skills, experience in the community. One Virginia employee we talked to said he’d sometimes take residents on walks to the park. But Rebecca says workers would mainly just pile all the residents in the van, drive them around on errands.


Rebecka Keith:You know how in the circus when the clown, and then everybody just keeps coming out of the car? That’s what it reminded me of, clown cars.


Audrey Quinn:Rebecca says that other employees told her that the New Jersey homes, those were Bellwether’s cash cow. Staff told us that Bellwether cut costs by hiring fewer people with less experience at lower salaries. I talked with two other former Bellwether directors in New Jersey. They didn’t want to be named as they still work in the field.


They said Bellwether packs more clients into homes than any other provider and said staff were encouraged not to report incidents in the homes. So, I ordered police records from Bellwether facilities all across New Jersey, found homes all across the state where injuries like the one Abdulaye’s family reported, were weekly occurrences.


Then I drove out to Branchburg, where Abdulaye’s Bellwether home was.


So, this is the house that Abdulaye would have spent four years at.


The neighborhood is spread out. Quiet. I get out to look around. It’s a brick one-story. It’s a pretty home. I didn’t go in, but I talked to the Branchburg police. They tell me officers are at Bellwether facilities three to fur times a day. Basically providing backup because the homes don’t have enough staff to supervise clients. One Branchburg facility had 156 emergency squad visits in the last two years alone. Seven of those were for incidents where a staff member had allegedly assaulted a client. One of those incident reports is about Abdulaye. The police note his eye is swollen shut.


What first made you suspicious that abuse was also going on?


Emma:When one time we called and they said they had an issue. He had headbutt somebody and broke his nose.


Audrey Quinn:At one point, Abdulaye was beaten so badly he had to be hospitalized. A hospital social worker called the police to report abuse at the home. The state’s Division of Developmental Disabilities told the Branchburg Police they’d handle looking into the incident, but never followed up with the department and the abuse continued; even after Bellwether moved Abdulaye to another of their group homes. Finally, Emma gets the help of lawyers with the advocacy group Disability Rights New Jersey. They helped get Abdulaye into an emergency placement in December 2017.


Emma:You know that I love you right?




Emma:And who else loves you?


Abdulaye:Yeah, Mommy.


Emma:Okay daddy, have a nice day.


Audrey Quinn:Abdulaye’s still in a temporary group home now. Fatou says they’re trying to find a more permanent place that will take him.


What do you think would have happened if you had let him stay at Bellwether?


Fatou:I think we would have gotten a call that my brother was killed, or passed away with Bellwether. That is my honest feeling with them.


Audrey Quinn:Two other families with adults in Bellwether homes did get that call last year. Carlos Beltre died after what his family alleges was an accumulation of harm at the hands of staff. Susan Osborn died of choking after staff failed to follow her doctor’s orders for food preparation, neglected to monitor her eating. Bellwether won’t comment on individual cases, but they issued a statement, “When incidents inevitably occur, we strive to address them responsibly”.


Both families are now suing Bellwether Behavioral Health and its owner, The private equity group Wellspring Capital Management. You might be wondering why a private equity group would be in this type of business. It’s not that unusual. They see it as a growth industry, because national spending on Autism services is supposed to go up 70 percent by 2025.


Private equity funds buy companies like Bellwether with money from investors. The idea is they’ll be able to make the companies more lucrative, then sell them at a profit, giving their investors a good return on their money. It’s like flipping a house. By the way, those investors aren’t just rich people out to make a buck. Many of Wellspring investors are public employee retirement accounts, looking to grow their pension funds. Public employee retirement accounts from Oregon, Connecticut, Colorado, California, New York City, Arkansas and Florida. Which means, Bellwether Group Homes are funded by police officers, postal workers and school teachers.


Connie Albright:I think they would be mad if they knew that, I really do.


Audrey Quinn:Connie Albright worked in Orlando public schools for 40 years. She now lives near Carlton Palms, had hear about the abuse there, had no idea her retirement dollars were helping run its parent company.


Connie Albright:It’s sad because it’s counter productive to what we’ve done every day of our lives. You know, as a teacher you’re always striving to see improvement in your kids. Then you have this thing going on over here, where it’s detrimental to people’s welfare.


Audrey Quinn:The lawsuit Carlos Beltre’s family filed alleges Bellwether and its owner, Wellspring Capital, were using Medicaid money to “improperly and unjustly enrich the corporate defendants”. It also accuses them of using Medicaid money to fight off lawsuits.


Chris Gowen:This is tax payer dollars that clearly seem to be used in nefarious ways.


Audrey Quinn:I met up with one of the lawyers in the suits against Bellwether and Wellspring, Chris Gowen, at his Washington DC office. He had his 13 month old son James with him. Chris says they’ve gone over employee time sheets at several Bellwether homes.


Chris Gowen:We’ve been investigating the staffing and the staff ratios and there was several hours where there was either no staff or one staff. There was not the proper ratio.


Audrey Quinn:He says Bellwether provides as little services as they can get away with.


Chris Gowen:This is a place that makes all of their money off state and local governments. They make millions and millions of dollars. I think they exist solely to make money and not get sued.


Audrey Quinn:And it works. The people the care for often don’t even have the ability to speak up. On top of that, the states that contract with Bellwether often don’t have any other place to send people. Bellwethers’ built a niche by being the company that will take the most difficult clients. We called Wellspring Capital Management multiple times for comment. Even tried visiting their office. I wanted to ask if they knew what was going on in Bellwether homes, why they removed all mention of Bellwether Behavioral Health from their company website. They said I needed to talk to their General Council, who was out for the afternoon. When I finally reached her over the phone, she hung up when I said who I was.


Over the last year, the number of times New Jersey officials had to investigate abuse and neglect incidents at Bellwether homes was nearly six times the average rate of investigations per bed at other large New Jersey group home companies. I reached out to New Jersey’s Department of Human Services about the problems at Bellwether facilities. They sent a blanket statement saying they were keeping their eye on the company. Then I spoke with State Senator Thomas Kean. He sent a letter of concern to state officials.


After that happened, New Jersey’s Department of Human Services made an announcement. For now, the state is refusing to send new clients to Bellwether.


Al Letson:The moratorium started in July, but it leaves nearly 450 New Jersians’s still in Bellwether homes. Remember, it was after a state moratorium on admissions that Willie Lamson died at Bellwether’s facility in Florida. Our story was reported by Audrey Quinn of WNYC. Audrey has a whole podcast devoted to the story of one Autistic man, who passed through Carlton Palms, Arnaldo Rios Soto. The story takes you places you can’t even imagine and really gets at how America’s Developmental Disabilities services work. The podcast is called “After Effect”. All eight episodes are out now.


Group homes and residential treatment centers aren’t the only places where people receive around the clock care. Prisons, jails and immigration detention centers also take care of people with disabilities.


Karina:The Panamanian Embassy … They gave me a call. They were the ones to tell me that my brother had died in detention.


Al Letson:That story when we come back on Reveal from the Center for Investigative Reporting and PRX.


From the Center for Investigative Reporting and PRX, this is Reveal. I’m Al Letson. Today we’ve heard what can go wrong when a private company is responsible for taking care of your loved one. But what about when it’s the Federal Government that’s responsible? What can a family do to make sure their loved one is getting the care that they need behind bars? That’s what the Jimenez family was forced to deal with.


Jean Carlo:One, two, three. Here we go. “Happy Birthday to you”.


Al Letson:That’s the oldest son in the family, Jean Carlo. He pronounced the family name, Jimenez, because he wanted to sound American. He loved being with his family, dance, play drums for hours. He made sure to make people smile. He wasn’t afraid to break out into song, like in this video he made in 2013 for his sister’s birthday.


Jean Carlo:Oh grandmas singing.


Al Letson:Jean was a guy in his 20’s with a wide smile. His personal motto was “Too legit to quit”. His life wasn’t perfect. He had troubles with the law. But in 2017, things got a lot worse.


Jean Carlo:I only have a short amount of time to talk to you, so … What I really wanted to tell you was I was actually transferred to Stewart County jail in Lumpkin Georgia.


Al Letson:Stewart County Jail, but it’s not a jail. It’s an immigration detention center in rural Georgia. Over the next few weeks and months, Gene made calls out to his mom and sister almost every day.


Jean Carlo:I just wanted to let you know they’re treating me pretty well here. They’re feeding me three times a day. I get a chance to go out to the yard a couple of days ago and it was pretty nice. I can run. I can play basketball. I can do a lot of things if I want to.


Al Letson:Jean called lawyers too, looking for help, trying to get out.


Jean Carlo:Hi. Can I please speak to someone I can contact … I’m calling from Stewart Detention Center in Georgia. I am currently paying … I have a backup-


Al Letson:But he didn’t get out. About a month and a half after he made that call, Jen was dead. The guard found him in a solitary confinement cell, where he’s hung himself with sheet wrapped around his neck. What happened in those few short months Jean was in detention, Reveal Investigative Reporting fellow, Elly Yu, went looking for an answer.


Elly Yu:Jean and his family came to the US from Panama when he was 10 years old. They came on tourist Visa’s. When the Visa’s were up, they stayed on. Jean grew up for the most part in Kansas, where he went to school and a community college. Karina, his older sister, says people loved to be around him.


Karina:Always went out of his way to make new friends and to make people comfortable. He really cared about people. That is a characteristic that really made him special.


Elly Yu:Karina said he had big plans. He was a dreamer.


Karina:He dreamed of having his own architectural firm. He shared that vision with anyone and everyone in sight that would listen to him about it.


Elly Yu:In 2013, Jean became and actual Dreamer. He applied for and got DACA status. The program created by President Obama for young, undocumented people brought to the country as children. He moved to North Carolina with his mom and stepdad and brother. But as he got older, Jean started showing symptoms of what seemed like Schizophrenia. He was hearing voices. Once he was found hallucinating in a park. Jean was hospitalized at least three times for psychiatric care. Karina says his family tried to help, but Jean was in denial about his illness.


Karina:As a result, he got worse. He started making bad decisions that got him into trouble with the law.


Elly Yu:In October 2016, Jean was arrested at an auto parts store where he was working. A customer had taken her car in for some work.


Karina:When they were done, Jean took the car for a test, to test the work that had been done. He took longer than expected and the owner of the vehicle called the police and reported her car stolen.


Elly Yu:Police found the car and arrested Jean for larceny. He was released, but there were other misdemeanor offenses; begging and having marijuana paraphernalia. In January of 2017, President Trump had issued an Executive Order expanding the number of people targeted for deportation. ICE took custody of Jean and brought him to Stewart Detention Center. Jean was eight hours away from home, but he could phone his family. The calls from Stewart to his mom show he was optimistic at first.


Jean Carlo:So, it looks like my court case is going to go well, ’cause I got DACA. I don’t have any aggravated felonies and I’ve been in the United States for over 10 years. So, I got to find out how to get a record, got to call Turbo Tax to see if they can fax me my tax returns. Hey mom




 Section 2 of 3          [00:17:00 – 00:34:04]
 Section 3 of 3          [00:34:00 – 00:50:38]
(NOTE: speaker names may be different in each section)


Jean Carlo:My tax returns. Oh hold on. Hey mom, Corina.




Jean Carlo:I’m going to have to call you back because I’ve got to go take my psychotic medicines.


Elly Yu:He was taking medication for schizophrenia. He even thought his mental health issues might help him in front of a judge.


Jean Carlo:I’ve got to see about the mental hospital, to be able to get everything faxed to the jail detention center so I can have all the documents and stuff take to the judge.


Elly Yu:Jean was able to get pencils and sheets of paper. He was sketching pictures for other detainees in the common room and making friends, but as the days and months passed, he was realizing that getting released from detention wasn’t going to be as easy as he’d first thought.


Atty Mackenzie:This is attorney Patricia Mackenzie. How are you?


Jean Carlo:Pretty good. How are you?


Elly Yu:The attorneys he was hoping could get him out, were giving him some bad news.


Atty Mackenzie:It’s three misdemeanor convictions though. You’re not eligible for DACA anymore. So you’re subject to deportation and I don’t see any relief that you would be eligible for?


Jean Carlo:Okay.


Atty Mackenzie:Hello?


Jean Carlo:Yeah, I’m still here.


Elly Yu:Jean’s getting depressed and starts losing hope. He tells his family he should just self deport and go to Panama.


Jean Carlo:Really my only option right now is self deportation, voluntary departure. I don’t meet any of the requirements.


Elly Yu:Then he tells his family he’s gotten into trouble.


Jean Carlo:They put me in the segregation cell because somebody beat me up in one of the cells. The one [inaudible 00:35:33] is in.


Elly Yu:At some point in all of this, Jean begins chanting to himself.


Jean Carlo:Julius Caesar is [inaudible 00:35:41] for real.


Mom:[Spanish 00:35:42].


Jean Carlo:I am Julius Caesar, and I am for real.


Elly Yu:Others in the detention center start referring to him as Julius Caesar too.


April 27th, about two months into his detention, Jean jumps off a second story catwalk overlooking a common area. In video surveillance tape, you can see him behind the railing taking off his shirt and putting it back on.


He stretches and mouths something to himself. Then, he climbs over the railing and jumps. He manages to stumble to a landing on his feet. He keeps taking his clothes on and off. His behavior is clearly erratic, but no one seems to respond.


Jean Carlo:[Spanish 00:36:31].


Elly Yu:The next time Jean speaks to his family, he sounds different. Really different, and really sad.


Jean Carlo:[Spanish 00:36:40].


Elly Yu:I’m tired of life, he says. He’s speaking in Spanish to his mom, but his sentences don’t always make sense. He finally manages to explain his voice is so hoarse from all the screaming he’s been doing.


Jean Carlo:[Spanish 00:36:54].


Mom:[Spanish 00:36:56].


Jean Carlo:[Spanish 00:36:57].


Elly Yu:I threw myself from the balcony to the floor he says. His mom can’t believe what she’s hearing.


Jean Carlo:[Spanish 00:37:06].


Mom:[Spanish 00:37:08].


Elly Yu:She asks him, are you trying to kill yourself?


Jean Carlo:Si. [Spanish 00:37:12].


Elly Yu:Life is a lie, he says. Jean’s in the infirmary, and his mom asks to speak with the nurse who’s there. The nurse refuses Jean tells her.


Jean Carlo:[Spanish 00:37:24].


Elly Yu:After jumping off the walkway, Jean is put in solitary confinement known as disciplinary segregation.


The offense, an act that could endanger persons or property. He’s sent to solitary for 20 days. While he’s there, Jean keeps hearing voices.


Jean Carlo:I’ve been asking my psychiatrist to increase my dosage, and I’m supposed to be able to speak to him on Monday so that he could increase it, because I’m still hearing a lot of voices that are kinda tormenting me during the night.


Elly Yu:His mom tells him he has to pray.


Mom:Pray, pray to God.


Jean Carlo:Pray? Yeah, if these voices don’t haunt me and try to change-


Mom:You need to pray and shut that off.


Jean Carlo:I can’t pray, these voices are haunting me. They’re taunting me. They’re changing my thoughts and my prayers.


Elly Yu:It’s now May. On the 13th, Jean’s mom and Stepdad drive down from North Carolina to see him for the first time. His mother is worried and asks a local volunteer group to go check on him. It was the last time they spoke to Jean.


On Monday, Jean’s sister Corina got a call at work.


Corina:The Panamanian Embassy, they gave me a call. They were the ones to tell me that my brother had died in detention.


Elly Yu:She says three days later, she got an official letter from ICE in the mail.


Corina:Saying quote, unquote, they regretted to inform us that our brother had passed away in one of their detention facilities.


Elly Yu:The Stewart County Sheriff’s department called the Georgia Bureau of Investigation to look into Jean’s death.


Speaker 5:This investigation is just to determine whether any criminal laws have been violated that resulted in the death of a Jean [inaudible 00:39:22].


Elly Yu:These are recordings of interviews from the inquiry. We got them through an open records request.


Agent Justin Lowethorpe questions Freddy Wims, the Detention Officer on duty in the segregation unit that night. He describes going to look into Jean’s cell around 12:45 AM.


Freddy Wims:I looked in the door, and I didn’t see him. He wasn’t on his bed. I looked at the floor, threw the CCM on the floor and looked over there in the corner by the commode, and he was hanging by the sheet.


Elly Yu:Wims calls for backup. He announces over the radio that there’s a medical emergency. Another officer grabs a camera and starts recording. Several guards rush to Jean’s cell.


Speaker 6:I was a [inaudible 00:40:08] responding to a possible hanging. Instead of an Alpha.


Elly Yu:Staff members started administering CPR on Jean. About 15 minutes later, the EMT’s arrive. They put Jean on a Gurney and transport him out of the cell. Jean’s taken to a hospital about 30 miles away where he’s pronounced dead.


ICE has standards on suicide prevention, they include continuous one on one monitoring of suicidal detainees put in isolation, and making sure they’re in a room that’s suicide resistant. A room without anything that could be used in a suicide attempt.


But Jean didn’t get any of that because he wasn’t placed on suicide watch. Officer Wims, who was assigned to monitor one of the segregation units, told investigators he was busy. He had 29 people to monitor that night.


Freddy Wims:I was to make my rounds, get a guy to take showers that had got scabies. Get him showered, and sent him back to his unit, and do the paperwork.


Speaker 7:That you don’t have to do?


Freddy Wims:Yes, sir.


Elly Yu:Plus, the other detention officer with Wims that night was assigned to one on one monitoring of another detainee who was on suicide watch.


Officer Wims logged seven visits to Jean’s cell, but video footage from two cameras mounted outside the cells show he only made four. CoreCivic fired Wims a month after Jean’s death. Wims didn’t respond to our requests for comment. CoreCivic though, isn’t responsible for medical care at Stuart, ICE is.


In documents we obtained through the Freedom of Information Act, we found the center had no psychiatrist on staff. Employees there said there was under staffing to a point that it was a danger to detention officers and detainees.


I talked to ICE spokesman Brian Cox. He told me that Stewart Detention Center follows ICE’s staffing ratios.


Speaker 8:What is the minimal level of staff you need-


Brian Cox:Right, so shortages is a somewhat editorial term that is in the document. I don’t dispute that, but that is a somewhat opinion based statement. The opinion of a short staff is, is a non technical term.


Elly Yu:When I followed up with him about the staffing ratios by email, Cox wrote the staffing ratio is an internal policy that is not releasable.


Should the detention center staff have known that Jean was in danger of killing himself? This is what we know. Several days before he died, the nurse Chantelle Anderson told investigators she saw Jean standing on the toilet in his cell. He was banging on the mirror in front of it.


S Anderson:I went over there. I was like, are you okay? He said, these fucking voices, they won’t leave me the fuck alone!


Elly Yu:Anderson followed up. She asked him if the voices were telling him to hurt himself.


S Anderson:First, he said, no. He’s like, they’re just time to control me, they’re trying to control what I say, they try to control what I do. They’re trying to control my drawings.


I said, but they’re not telling you to harm yourself or anybody, right? He said, well yeah, they’re telling me to commit suicide because the people here are simple, but I don’t want to harm myself.


Elly Yu:That was when Jean asked to have his medication increased. Anderson called the facilities mental health counselor, Kimberly Calvary. She set up a tele video appointment with a psychiatrist for Monday morning. Five days from then, but by then Jean had died.


While Anderson, her Jean say voices for telling him to kill himself, that’s not what Calvary told the Georgia Bureau Investigator.


Speaker 9:Well, what can you tell me about him?


Speaker 10:He was in segregation for disciplinary issues. He was not endorsing any thoughts he wanted to hurt himself the last time I saw him.


Elly Yu:It’s clear that officials at Stuart Detention Center had a mixed view of Jean. While they acknowledged his mental illness, giving him access to his medications for example, they also saw them as a disciplinary problem.


Special Agent Danny Jackson was in charge of the inquiry into Jean’s death.


Danny Jackson:Stated that he was always clowning around and trying to get attention.


Elly Yu:When Jean jumped from the catwalk, they viewed it as a stunt.


Danny Jackson:They deemed that an incident that warranted placing him in solitary or isolation.


Elly Yu:But, in an ICE document about Jean’s disciplinary segregation, a detention officer wrote quote, detainee stated he was trying to hurt himself when he jumped.


Andres [inaudible 00:44:55] is a psychiatry professor at the University of Florida. He was one of the authors of a position statement on the treatment of detained immigrants with mental illness for the American Psychiatric Association. He says, someone like Jean should have gotten immediate attention.


Speaker 11:Someone who has made a suicide attempt, who is experiencing serious depression with psychotic features, who had command hallucinations telling him to commit suicide. In those instances that requires urgent response.


Elly Yu:He says someone with Jean’s symptoms should have been evaluated by a psychiatrist as soon as possible, and if he were determined to need more help, should have been taken to an emergency room or a psychiatric facility elsewhere.


He also says it’s against both clinical practice and national correctional standards to put someone with severe depression in solitary confinement.


Speaker 11:Solitary confinement aggravates depression, makes a person feel even more hopeless and desperate. As such, it likely lead to aggravation of the suicidal crisis.


Elly Yu:We asked ICE for Jean’s medical records while at Stewart Detention through the Freedom of Information Act. The agency denied our request, citing ongoing law enforcement investigations. Homeland Security is looking into Jean’s death, and ICE hasn’t finished its own detainee death review.


Jean’s family wants answers. They intend to file a lawsuit against ICE personnel for failing to give Jean the help he needed. Andrew Free is their attorney.


Speaker 12:We’re waiting for the government to finish its investigation into what happened in the days leading up to Jean’s death, and to publish its findings. In 14 months, the government hasn’t done that.


How much longer do we have to wait? How many more people have to die before the government provides a transparent and complete account of what happens in this facility that leads to these deaths?


Elly Yu:ICE says it has a good record of caring for detainees. They wouldn’t speak to me about Jean’s case. Here’s what the Atlanta Field Office Director Sean Gallagher said to public radio station WABE in March.


Speaker 13:ICE last year detained three hundred and twenty five thousand people in custody, and experienced 12 deaths in custody.


Statistically, that’s less than four deaths per hundred thousand detained. Which I would argue had far better care while in ICE custody than in the State, Local, or any other Federal system.


Elly Yu:Since Jean died in May 2017, there have been at least 14 deaths in ICE custody. That includes another person who died at Stewart Detention Center on July 10th.


Efrain De La Rosa was 40 years old. ICE says his death appears to be from quote, self-inflicted strangulation.


Al Letson:In May 2018, a year after Jean Jimenez’s death, his family and friends gathered at a church in Kansas City, Missouri to remember him.


Speaker 14:What happened to Jean should not happen to anyone else. No family should have to lose their son, brother, and no friends should have to lose their friend the way that we lost ours.


Al Letson:They’ve helped launch Illegal Defense Network, to help others who are detained. Our story was brought to you by LEU.


One of reveals investigative fellows. She worked on the story with NPR member station WABE, and she’s currently a reporter at WAMU in Washington DC.


Our Lead Producer for this week’s show is Amy Walters. Dev George edited the show. Thanks to Christopher Worth and our partners at WNYC for their work on Audrey Quinn story, including research help from Nikki Gotland. Be sure to check out their podcast After Effect, that goes even deeper into the story they brought us.


Thanks to our Editor Ziva Branstetter for her help on LEU story. Also, thanks to Susanna Kappaludo and John Haas at public radio station WABE, our partner on that story. Our production manager is [inaudible 00:49:33]. Original score and sound designed by the dynamic duo Jay Breezy, Mr Jim Briggs, and Fernando, my man Yoaruda. Our CEO is Christa Scharfenberg. Amy pyle is our Editor In Chief. Our Executive Producer is Kevin Sullivan. Our theme music is by Comorado Lightning.


Support for Reveal is provided by the Reva and David Logan Foundation, the John D and Catherine T Macarthur Foundation, the Jonathan Logan Family Foundation, The Ford Foundation, the Heising Simons Foundation, and the Ethics and Excellence in Journalism Foundation. Reveal is a co production of the Center for Investigative Reporting and PRX.


I’m Al Letson, and remember there is always more to the story.


 Section 3 of 3          [00:34:00 – 00:50:38]

Amy Walters is a reporter and producer for Reveal. She began her career as a broadcast journalist in the Middle East. In 2000, she moved to Washington, D.C., to work for NPR’s flagship shows, "Morning Edition" and "All Things Considered." A Southern Californian native, Walters returned to the Golden State as a field producer for NPR in 2003. Her work was honored with the Edward R. Murrow Award for investigative reporting, the Alfred I. DuPont-Columbia University Award, two Peabody Awards and two Robert F. Kennedy Awards. Throughout her career, Walters has continued to cover the world, including the U.S. war with Iraq in 2004, the 2010 earthquake in Haiti, the 2011 Arab Spring in Egypt and Libya, and the U.S. war with Afghanistan. She also has reported from Ethiopia, Kenya and Iran. In 2014, Walters was based in Doha, Qatar, as a producer for Al Jazeera English before returning to the United States. Walters is based in Reveal's Emeryville, California, office.

Deborah George is the senior radio editor for Reveal. She's also a contributing editor with the ""Radio Diaries"" series on NPR's ""All Things Considered."" George has worked in the U.S., Asia, Africa and Latin America, covering stories ranging from the Los Angeles riots to the Rwandan genocide. She's a two-time recipient of the George Foster Peabody Award and a six-time recipient of the Alfred I. duPont-Columbia Award (five silver batons and one gold baton).

Mwende Hinojosa is a former production manager for Reveal. Prior to joining Reveal, she was the training strategist and innovation manager for the Bay Area Video Coalition, a nonprofit media arts center in San Francisco. At BAVC, she provided resources and support to students training in video, motion graphics, web and graphic design and managed a community for creative freelancers called Gig Union. She has produced segments for public radio stations KUSP, KQED, KALW and KUOW; videos and short documentaries for nonprofits; interactive panel discussions; and immersive storytelling experiences for tech companies. .

Jim Briggs III is the senior sound designer, engineer and composer for Reveal. He supervises post-production and composes original music for the public radio show and podcast. He also leads Reveal's efforts in composition for data sonification and live performances.

Prior to joining Reveal in 2014, Briggs mixed and recorded for clients such as WNYC Studios, NPR, the CBC and American Public Media. Credits include “Marketplace,” “Selected Shorts,” “Death, Sex & Money,” “The Longest Shortest Time,” NPR’s “Ask Me Another,” “Radiolab,” “Freakonomics Radio” and “Soundcheck.” He also was the sound re-recording mixer and sound editor for several PBS television documentaries, including “American Experience: Walt Whitman,” the 2012 Tea Party documentary "Town Hall" and “The Supreme Court” miniseries. His music credits include albums by R.E.M., Paul Simon and Kelly Clarkson.

Briggs' work with Reveal has been recognized with an Emmy Award (2016) and two Alfred I. duPont-Columbia University Awards (2018, 2019). Previously, he was part of the team that won the Dart Award for Excellence in Coverage of Trauma for its work on WNYC’s hourlong documentary special “Living 9/11.” He has taught sound, radio and music production at The New School and Eugene Lang College and has a master's degree in media studies from The New School. Briggs is based in Reveal's Emeryville, California, office.

Fernando Arruda is a sound designer, engineer and composer for Reveal. As a multi-instrumentalist, he contributes to the original music, editing and mixing of the weekly public radio show and podcast. He has held four O-1 visas for individuals with extraordinary abilities. His work has been recognized with Peabody, duPont-Columbia, Edward R. Murrow, Gerald Loeb, Third Coast and Association of Music Producers awards, as well as Emmy and Pulitzer nominations. Prior to joining Reveal, Arruda toured as an international DJ and taught music technology at Dubspot and ESRA International Film School. He worked at Antfood, a creative audio studio for media and TV ads, and co-founded a film-scoring boutique called the Manhattan Composers Collective. He worked with clients such as Marvel, MasterClass and Samsung and ad agencies such as Framestore, Trollbäck+Company, BUCK and Vice. Arruda releases experimental music under the alias FJAZZ and has performed with many jazz, classical and pop ensembles, such as SFJAZZ Monday Night Band, Art&Sax quartet, Krychek, Dark Inc. and the New York Arabic Orchestra. His credits in the podcast and radio world include NPR’s “51 Percent,” WNYC’s “Bad Feminist Happy Hour” and its live broadcast of Orson Welles’ “The Hitchhiker,” Wondery’s “Detective Trapp,” MSNBC’s “Why Is This Happening?” and NBC’s “Born to Rule,” to name a few. Arruda also has a wide catalog of composed music for theatrical, orchestral and chamber music formats, some of which has premiered worldwide. He holds a master’s degree in film scoring and composition from NYU Steinhardt. The original music he makes with Jim Briggs for Reveal can be found on Bandcamp.