Niculas Fernando died at a Tokyo immigration detention center sometime between 9:33 a.m. and 10:44 a.m. on Nov. 22, 2014, according to the coroner.

But it wasn't until shortly after 1 p.m. that day that guards realized something was badly wrong — even though Fernando had been moved to an observation cell monitored via closed-circuit television after complaining of sharp chest pain.

An inmate had to alert the guards before they rushed into Fernando's cell and tried to revive him. They found him lying face down on a mattress stained with his urine. He was lifeless.