ST. LOUIS (AP) — A Mexican national accused of killing four people in Kansas and one in Missouri in 2016 died Tuesday after being found hanging from a light fixture in his St. Louis jail cell.

Pablo Serrano-Vitorino was found alone in his cell at 2:02 a.m. He was pronounced dead at a hospital about an hour later, said Koran Addo, spokesman for St. Louis Mayor Lyda Krewson.

Addo declined further comment but St. Louis Public Safety Director Jimmie Edwards said that Serrano-Vitorino hanged himself and left a note written in Spanish. Edwards was out of town and didn’t know if Serrano-Vitorino was on suicide watch or when jailers had last checked on him.

Serrano-Vitorino, 43, who was in the U.S. illegally, was accused of fatally shooting four men at a home in Kansas City, Kansas, on the night of March 7, 2016. He was arrested a day later and 170 miles away in Montgomery County, Missouri, where he was accused of killing Randy Nordman of New Florence. He was charged with first-degree murder in all five deaths.

He was being held in St. Louis awaiting an October trial in Nordman’s death on a change of venue. Missouri prosecutors were seeking the death penalty.

He had tried to take his own life before, with a safety razor, shortly after his arrest while jailed in Montgomery County. After a hospitalization he was returned to the jail.

Authorities say the shooting spree began when Serrano-Vitorino gunned down his Kansas City, Kansas, neighbor, 41-year-old Michael Capps, and three other men at Capps’ home — brothers Austin Harter, 29, and Clint Harter, 27, and 36-year-old Jeremy Waters. Before dying, one of the victims managed to call police.

Authorities have not disclosed a possible motive.

Serrano-Vitorino then allegedly fled in his pickup truck into Missouri. Authorities say he killed Nordman, 49, at Nordman’s rural home near Interstate 70 about 70 miles (113 kilometers) east of St. Louis. He was captured hiding face-down in a ditch a few miles from Nordman’s home, and had a rifle with him, the Missouri State Highway patrol said at the time.

A lawsuit filed in Kansas City, Kansas , by the father of one of the victims accused U.S. immigration officials of missing two chances to detain and deport Serrano-Vitorino.

Serrano-Vitorino was deported to Mexico after he was convicted of a felony in 2003 but illegally re-entered the U.S. He was arrested in 2014 and 2015.

After his 2014 arrest in Kansas for battery, Wyandotte County jail officials notified ICE he was in custody. But Serrano-Vitorino was released after the federal agency didn’t send an agent to the jail, according to the lawsuit.

Serrano-Vitorino was fingerprinted in Overland Park, Kansas, Municipal Court in September 2015 after he was cited for traffic infractions. ICE officials asked that he be held in custody but sent the paperwork to a different jail in Johnson County, Kansas, the lawsuit contends. He was once again released from custody.

WASHINGTON (AP) — Federal authorities said Tuesday they’ve broken up a $1.2 billion Medicare scam that peddled unneeded orthopedic braces to hundreds of thousands of seniors via foreign call centers.

The Justice Department announced charges against 24 people across the U.S., including doctors accused of writing bogus prescriptions for unneeded back, shoulder, wrist and knee braces. Others charged included owners of call centers, telemedicine firms and medical equipment companies.

The Health and Human Services inspector general’s office said the fast-moving scam morphed into multiple related schemes, fueled by kickbacks among the parties involved. The FBI, the IRS, and 17 U.S. attorney’s offices took part in the crackdown. Arrests were made Tuesday morning.

Medicare’s anti-fraud unit said it’s taking action against 130 medical equipment companies implicated. They billed the program a total of $1.7 billion, of which more than $900 million was paid out.

Telemarketers would reach out to seniors offering “free” orthopedic braces, also touted through television and radio ads. Beneficiaries who expressed interest would be patched through to call centers involved in the scheme. Officials described an “international telemarketing network” with call centers in the Philippines and throughout Latin America.

The call centers would verify seniors’ Medicare coverage and transfer them to telemedicine companies for consultations with doctors.

“The telemedicine we are talking about is basically a tele-scam,” said Gary Cantrell, who oversees fraud investigations for the HHS inspector general’s office. “We are not talking about the use of advanced technology to provide better access to care.”

The doctors would write prescriptions for orthopedic braces, regardless of whether the patients needed them or not. In some cases several braces were prescribed for the same patient.

The call centers would collect prescriptions and sell them to medical equipment companies, which would ship the braces to beneficiaries and bill Medicare. Medical equipment companies would get $500 to $900 per brace from Medicare and would pay kickbacks of nearly $300 per brace.

The scam was detected last summer, officials said. Complaints from beneficiaries were pouring in to the Medicare fraud hotline, and some consumer news organizations warned seniors. As the investigation progressed, Cantrell said, federal agents gained cooperation from people familiar with the various schemes.

Officials said it’s one of the biggest frauds the inspector general’s office has seen. Charges were being brought against defendants in California, Florida, New Jersey, Pennsylvania, South Carolina and Texas.

“The breadth of this nationwide conspiracy should be frightening to all who rely on some form of health care,” IRS criminal investigations chief Don Fort said in a statement. “The conspiracy…details broad corruption, massive amounts of greed and systemic flaws in our health care system that were exploited by the defendants.”

Health care fraud is a pervasive problem that costs taxpayers tens of billions of dollars a year. The true extent of it is unknown, and some cases involve gray areas of complex payment policies.

Experts say part of the problem is that Medicare is required to pay medical bills promptly, which means money often goes out before potential frauds get flagged. Investigators call that “pay and chase.”

In recent years, Medicare has tried to adapt techniques used by credit card companies to head off fraud. Law enforcement coordination has grown, with strike forces of federal prosecutors and agents, along with state counterparts, specializing in health care investigations.

The Medicare beneficiaries drawn into the orthopedic braces scam didn’t have to pay anything up front, but Cantrell said they have been harmed as well: A beneficiary’s private information, once in the hands of fraudsters, can be resold for many illegal purposes.

Additionally, if a beneficiary whose information was misused ever does need an orthopedic brace, he or she may encounter waiting periods from Medicare. The program limits how often it pays for certain supplies and equipment.

“It can be very attractive to receive equipment,” Cantrell said. “But after giving out your identifying information, it could be compromised to perpetuate additional fraud. There is no fraud without the ID number of a Medicare beneficiary.”

TOPEKA, Kan. (AP) — A captain in a Kansas National Guard brigade has resigned over what she says is a lack of concern from guard leadership over recent suicides.

Capt. Tara Fields is a behavioral health officer. She has served 12 years in military, eight on active duty. She said her resignation will be final by the end of April.

Kansas Guard Maj. Gen. Lee Tafanelli said the guard has had nine suicides in the last five years, with three in the past 18 months.

Fields says suicides of a civilian worker and a man who had just been discharged weren’t included in the guard’s official number.

Tafanelli said the guard is concerned about every death and offers several programs to help struggling members.

WASHINGTON (AP) — Outside allies of President Donald Trump have launched a public campaign urging him to nominate former Kansas Secretary of State Kris Kobach as his next secretary of Homeland Security.

That’s despite the uphill battle Kobach would likely face getting confirmed by the Senate.

NumbersUSA, a group that seeks to reduce immigration rates, released a statement Tuesday saying there is “no one more qualified” for the job and claiming Kobach has the support of Border Patrol and Immigration and Customs Enforcement officials.

They’re also rallying to defend Lee Francis Cissna, the director of United States Citizenship and Immigration Services, whose job is said to be in danger.

Kobach did not response to a request for comment Tuesday morning.

The White House declined to comment on the push.