Despite repeatedly placing her on suicide watch, the York County (Pa.) Prison failed to properly monitor an Antiguan immigrant with chronic schizophrenia who managed to hang herself in her cell 15 months ago, according to federal investigators.
The review - obtained last week by The Inquirer - also points to the shared responsibility of U.S. Immigration and Customs Enforcement in managing care for Tiombe Kimana Carlos.
It states that just days before Carlos' death in October 2013 - and two months after the 34-year-old had made another bid to hang herself in a cell - a deputy prison warden had asked ICE to consider placing her in a psychiatric facility. The local ICE office said an appropriate alternative to incarceration was unavailable.
The review by ICE's offices of professional responsibility and detention oversight also found multiple deficiencies in her care and in prison operations.
Though it stopped short of assigning blame for her death and takes no position on whether the suicide was preventable, the 32-page report paints a picture of a seriously disturbed woman whose transfers among prison units were supposed to be guided by "a psychiatric alert, requiring clearance by medical staff ... but none was ever generated."
Under an intergovernmental services agreement, the 2,500-inmate county prison in south central Pennsylvania houses immigrant detainees arrested by the Philadelphia-area field office of ICE.
Carlos' detention and death were chronicled by The Inquirer in November 2013. The ICE review into her death was completed last summer, but ICE only released it last week to The Inquirer after the newspaper sought comment for an article about the probe's delay.
Carlos' immigration lawyer, Thomas Griffin of Philadelphia, said he was unaware of the findings until shown them by The Inquirer. He said the report shows that officials knew the severity of his client's mental illness and did not address it adequately.
"They admit that professional treatment was nothing more than a regular injection of [the psychotropic drug] Haldol to keep her mummified," Griffin said. "It's inexcusable that it had to end with her death, rather than release to ... psychiatric care."
Among the report's findings:
Five times from 2011 through 2013, Carlos was put on suicide watch.
Despite getting biweekly injections of Haldol, she never had a treatment plan "with measurable goals ... to guide mental health interventions."
When Carlos acted out, guards soaked her with pepper spray. After an episode in 2012, she did not get routine follow-up at the infirmary for chemical decontamination and was told to wash with plain water from her cell's tap - a weak remedy, according to spray manufacturers.
In 2011, a guard zapped Carlos' left inner thigh with an electronic stun gun, leaving a mark, even though ICE's contract with York "prohibits the use of electronic devices on immigrant detainees." A note in the file says the guard "was unaware" she was an ICE detainee.
"Tiombe was sick, but she wasn't stupid," said Griffin. "Suicide was her way out of hopelessness."
When ICE investigators examined the cell block where Carlos killed herself, they observed three regular cells and three suicide-prevention cells.
The report appears to indicate that Carlos was in a regular cell. Investigators noted that a window with two horizontal bars is at the back of each regular cell, with Plexiglas panels over the windows and bars to prevent attaching anything there. Further investigation revealed that the panels were installed about one month after Carlos killed herself.
While the report's authors documented the deficiencies, they took pains to say they were for "information only" and "should not be construed in any way as meaning the deficiency contributed to the death of the detainee."
The next step is for ICE's Office of Detention Oversight to work with the field office and the prison on a "corrective action plan," said an ICE spokeswoman, who did not elaborate.
Carl Lindquist, a spokesman for York County, declined to comment regarding Carlos but said all suicides are investigated.
"In addition to any external review that may be conducted," he said, "the prison ... conducts an internal review. ... Any deficiencies identified are corrected."
Of nearly 140,000 inmates and detainees held at the prison since January 2008, he said, five have committed suicide.
The federal review also notes that ICE had been trying since July 2012 to obtain travel documents from the consulate of Antigua and Barbuda to carry out Carlos' removal from the United States. In an interview after the suicide, a consular official said Carlos' mental illness, and ongoing litigation, were reasons not to issue the document.
Investigators visited the prison from Dec. 10 through 12, 2013, and delivered their report to ICE top management in July.
It noted that Carlos was born in the Caribbean nation in 1978, and was 4 when her family moved to New York City as legal permanent residents of the United States. She was 14 the first time her schizophrenia was diagnosed. She was 30 when her green card was revoked for petty crimes, probation violations, and hitting a police officer who arrested her after a bar brawl. She was a month from her 35th birthday when she died.
Survivors include her mother, father, sister, brother, and 16-year-old daughter.
For the Carlos family, represented by attorney Jonathan Feinberg of Kairys, Rudovsky, Messing & Feinberg, a civil rights firm in Philadelphia, the official silence after ICE's public promise 15 months ago to investigate left an impression the case was languishing. On June 20, Feinberg filed a Freedom of Information Act request and has yet to get a reply.
"The report appears to show some serious deficiencies," Feinberg said after reviewing The Inquirer's copy. "We are continuing to investigate the circumstances that led to Tiombe's death and will decide whether to proceed with litigation soon."
Last November, on what would have been Carlos' 36th birthday, members of her family brought flowers to her grave at Merion Memorial Park in Bala Cynwyd.
Then they made a down payment on her headstone.