ATLANTA – The Georgia sun scorched the slab of concrete beneath Juan Carlos Ramirez Bibiano’s body when nurses found him in a puddle of his own excrement, vomiting, according to a complaint.
Officers left Ramirez in an outdoor cell at Telfair State Prison on July 20, 2023, for five hours without water, shade or ice, even as the outside temperature climbed to 96 degrees by the afternoon, according to a lawsuit brought by his family. That evening, the complaint says, Ramirez died of heart and lung failure caused by heat exposure. He was 27.
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Ramirez’s family, including his mother, Norma Bibiano, announced a lawsuit against the Georgia Department of Corrections on Thursday, alleging that officers’ negligent performance of their duties caused his death. The warden directed officers to check on inmates, bring them water and ice and limit their time outside, the complaint says.
The Department of Corrections reported that Ramirez died of natural causes, Jeff Filipovits, one of Norma Bibiano’s attorneys, said at a news conference in Decatur, a suburb of Atlanta.
Georgia’s prisons are under nationwide scrutiny. In 2021, the U.S. Department of Justice opened a civil rights investigation, which is ongoing, into the state’s prisons following concerns about violence, understaffing and sexual abuse.
Outside of Georgia, the Federal Bureau of Prisons has faced complaints of widespread dysfunction. The Associated Press found rampant sexual abuse, criminal misconduct from staff, understaffing, inmate escapes, COVID outbreaks and crumbling infrastructure inside prisons across the country.
The findings led U.S. Sen. John Ossoff of Georgia to introduce bipartisan legislation in 2022 that would overhaul oversight of the agency and improve transparency. The bill passed unanimously in the Senate on July 10.
At an 8 a.m. daily meeting on the day of Ramirez’s death, Telfair State Prison Warden Andrew McFarlane ordered department heads to keep inmates hydrated, bring them ice and avoid leaving them outside for too long in the heat, according to the lawsuit.
A prison staff member brought Ramirez to an outdoor “rec cell” around 10 a.m., after his meeting with a mental health provider, the lawsuit says. The temperature had reached 86 degrees by then.
About 3 p.m., five on-site nurses rushed into the yard in response to an alert from security staff, according to the lawsuit. That is when the nurses found him lying naked on the concrete near his vomit and excrete, the lawsuit says.
Ramirez’s breathing was strained, and his heartbeat was irregular, the lawsuit says. A nurse said that Ramirez was blue and “hot to the touch,” according to the complaint. Nurses pressed cold water bottles onto his groin and under his arms.
Nurses then put an automated external defibrillator on Ramirez’s chest, but it did not deliver a shock. After some time passed, a doctor arrived to help the nurses administer cardiopulmonary resuscitation, the complaint says. He tried to insert tubes into Ramirez, who still had trouble breathing, seemingly because of his yellow stomach bile, according to the complaint.
Later, his internal body temperature was recorded at 107 degrees Fahrenheit (41.7 Celsius), the complaint says.
Around 3:35 p.m., Emergency Medical Services arrived and took Ramirez to a local hospital. He died at 8:25 p.m. from cardiopulmonary arrest brought by heat exposure, according to the complaint.
“The number of deaths that are occurring in custody is galling, and the absolute lawlessness inside of prisons is a humanitarian crisis,” Filipovits said at the news conference of Georgia’s prisons. “I don’t use those words lightly.”
Homicides inside Georgia’s prisons are rising, and the number is higher than in other states, the Atlanta Journal-Constitution reported. But the Journal-Constitution also reported that starting in March, the Department of Corrections stopped immediately reporting the causes of inmate deaths
The attorneys said they have minimal information about the events leading up to Ramirez’s death. For example, they aren’t sure whether officers brought Ramirez to an outdoor cell for routine or punitive purposes. They say they remain in the dark about which officers were directly in charge of taking care of Ramirez.
“A piece of my heart is gone,” Norma Bibiano said in Spanish at the news conference. Ramirez's brother sat by her side. Ramirez also left behind a son, and he was a father figure to his partner's son, the family said.
Bibiano recalled her son as loving, kind and intelligent. She said she always hoped her son would return home, and she misses hearing him say, “I love you, mama” over the phone.
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Charlotte Kramon is a corps member for The Associated Press/Report for America Statehouse News Initiative. Report for America is a nonprofit national service program that places journalists in local newsrooms to report on undercovered issues. Follow Kramon on the social platform X: @charlottekramon