Two years ago, Tiombe Kimana Carlos, an immigrant facing deportation, twisted a bedsheet into a noose and hanged herself at York County Prison.
The Oct. 23, 2013, suicide of the native of Antigua and Barbuda, who was 14 when diagnosed with chronic schizophrenia and 34 when she died, threw a spotlight on a dark corner of the immigration system, which critics say lacks the ability to safely incarcerate the mentally ill. The prison had no articulated mental health treatment plan for Carlos.
On Wednesday, her mother, father, and teenage daughter filed a wrongful-death suit in federal court in Harrisburg, alleging that York County, its prison guards, and medical subcontractor PrimeCare Medical of Harrisburg were "negligent" and "deliberately indifferent" in failing to protect Carlos from self-harm, even after she tried to kill herself in their custody two months before her suicide.
"A lot of times people think that if someone wants to kill herself, she will," said the family's lawyer, Jonathan Feinberg, of Kairys, Rudovsky, Messing & Feinberg, a Philadelphia firm. "But that's not entirely true. A woman who tries to kill herself [in prison] and doesn't succeed shouldn't be allowed to kill herself two months later."
The suit seeks compensatory and punitive damages and any other relief the court deems appropriate.
"Somebody has to be accountable for what happened to my child," said Carlos' mother, Angela Carlos of Bensalem. "She didn't intentionally kill herself. She was so messed up, with what they had her on, or didn't have her on."
The suit alleges that Carlos did not have the proper amount of the prescribed antipsychotic drug Haldol in her system because she had missed at least two biweekly injections in the two months before her death. Apparently for administrative reasons, guards nonetheless transferred her to a "non-suicide resistant" cell, the suit says.
PrimeCare Medical's vice president of operations, Todd Haskins, declined comment on behalf of the company and the PrimeCare-employed psychiatrist and mental health counselor named as defendants. Carl Lindquist, a spokesman for York County, said the county had not yet been served with the complaint and could not comment on its allegations.
York County Prison holds immigrants under a contract with U.S. Immigration and Customs Enforcement (ICE). The agency is mentioned in the suit but is not a defendant.
Carlos' detention and death, which was chronicled that fall by The Inquirer, sparked an ICE inquiry and report that cited medical and custodial deficiencies in the handling of her case. The report also called for a "corrective action plan."
On Thursday, Philadelphia-ICE spokeswoman Sarah Maxwell could not provide specifics of any actions taken to date. She also said the agency does not comment on litigation.
Angela Carlos said her granddaughter, Natalla, 16, Tiombe's only child, "has not been the same" since her mother died. Carlos' father, Hueth Carlos, "breaks down in tears" each time he passes her picture on their living-room table, said his wife. The family has been making installment payments so it can buy a headstone.
"Thirty-seven dollars more and they will make it," Angela said. "I want it to be there when we visit the grave on [Tiombe's] birthday" Nov. 21.
The suit cites "extensive efforts" by Tiombe Carlos' immigration lawyer, Thomas Griffin of Philadelphia, to get ICE to release Carlos to a community-based mental health facility, which, he contended, was better suited to address her psychiatric condition.
"They were well aware she was severely mentally ill, and supremely aware she was suicidal" after she tried to kill herself in August and "they had to cut her down," Griffin said.
Liability law tends to target "day-to-day caregivers," such as the medical personnel, which is why they and not ICE are defendants, Griffin said.
But ICE, he said, "has a duty" to conduct "a real vetting of who is giving the services. . . . It's unfortunate that ICE gets to write it off when they were fully aware."
After the August 2013 suicide attempt, Carlos was put in the prison's Intensive Custody Unit, a punitive segregation area, where she was housed in a suicide-resistant cell on one pod for several weeks before being moved to a non-suicide-resistant cell - one with linens and bars on the windows - on another pod, according to the suit.
Two days later, she killed herself in that cell.