The family of Nestor Garay, a federal prisoner, filed a wrongful death lawsuit on March 4 alleging that private prison operators negligently left inmates in the care of underqualified medical workers who failed to respond properly to a medical emergency.

Garay was 41 when he died on June 28, 2014, shackled to his bed in Midland Memorial Hospital in Midland, Texas. The cause, according to the neurologist who examined him there, was a stroke he’d suffered two days earlier and 40 miles away, in Big Spring Correctional Center. The facility is operated by the Geo Group and its medical subcontractor, Correct Care Solutions (CCS).

Garay’s story was the subject of a Nation investigation on medical neglect in federal contract prisons, reported in partnership with the Investigative Fund and Reveal News.

Garay suffered the stroke in a 10-man cell in the 3,500-bed prison, one of 11 federal facilities that house only noncitizens. His cellmates were startled awake at around 1:30 a.m. on June 26 by the sounds of his pained moans. When they found Garay unresponsive, nearly falling off of his top bunk, and covered in sweat and urine, they called for help. But the only medical staff member on duty that night was a licensed vocational nurse, or LVN, whose licensure required only one year of training. In most settings, LVNs typically serve as support staff for more highly trained registered nurses or medical doctors.

The LVN phoned a physician’s assistant who was on call for a consult; rather than order Garay to be delivered to an emergency room, the PA ordered a dose of antiseizure meds and had Garay returned to his cell until morning.

When the morning nurse found Garay on a mattress on the floor of a cell at 6:15 a.m., his face was drooping and his right arm was contracted. It was only then, roughly five hours after Garay’s cellmates first reported the stroke, that he was ordered to an ER. It took another hour before Garay was finally on the way to the hospital. The Midland neurologist said that for ischemic strokes, the window for intervention is typically three hours; after the long delay, he said, treatment “was pretty futile.”

In the family’s lawsuit, Garay’s parents, Indalecio and Alvara Garay, who have lived for decades in California’s Napa Valley, allege that their son’s “life threatening conditions were left untreated.”

“The nurses on staff were severely undertrained and were not equipped to recognize, diagnose, or treat patients with serious illnesses or conditions,” the complaint reads.

Geo Group and CCS said they would not comment on pending litigation. But Big Spring’s own mortality review faulted both the LVN and the PA for failing to alert the clinical director when Garay’s condition did not improve. The review found that the PA “did not respond correctly to the initial report from nursing describing new onset of presumed seizure of a previously healthy 41 year old male.” It also found that neither diagnosis nor treatment was “appropriate and timely.”

Big Spring, like the other 10 contract prisons that the Federal Bureau of Prisons uses to hold noncitizens, is not an immigration detention center, but a federal prison for low-security inmates. The segregated, private prisons operate under less strenuous rules than the rest of the bureau’s facilities.

Garay is one of at least 137 men who have died while incarcerated in privately run Bureau of Prisons facilities. Medical records obtained through a federal open-records lawsuit revealed systemic shortcomings in their medical care. Doctors who reviewed 103 of the medical files agreed that in 25 cases, including Garay’s, substandard medical care likely contributed to prisoners’ premature deaths.

The reviewers repeatedly found evidence that the private contractors operating these facilities—Geo Group, Corrections Corporation of America, and Management and Training Corporation—and medical subcontractors have used low-trained medical workers like LVNs to fill positions that in Bureau of Prisons–operated facilities would be staffed by more highly trained registered nurses. The prison contractors are not bound by the bureau’s staffing plans.

Garay had been sentenced to a five-year term for selling drugs near his parents’ home in Napa. Like nearly every other prisoner held in Big Spring, he probably would have faced deportation to Mexico after completing his sentence. But he died just one year into his sentence.

“We don’t want prisoners who are still in the prison to be mistreated anymore,” Indalecio Garay said after filing the lawsuit. “We don’t want others to suffer. We want them to pay for the damage they’ve done.”