A woman who hanged herself in immigrant detention at York County Prison in 2013 was the victim of "dangerously subpar medical care" that contributed to her death, says a Human Rights Watch report scheduled for release Monday.

The suicide of Tiombe Kimana Carlos, who was born in the Caribbean nation Antigua-Barbuda, and was 34 when she killed herself with a noose made from a bed sheet, was the subject of an Inquirer special report and follow-up. 

Established in 1978, Human Rights Watch (HRW) is a nonprofit group that presses governments to adopt policies that promote human rights. The 103-page report was produced in collaboration with Community Initiatives for Visiting Immigrants in Confinement (CIVIC), a San Francisco nonprofit.

"Systemic Indifference: Dangerous & Substandard Medical Care in Immigration Detention" is based on three medical experts' analyses of public records from internal investigations by U.S. Immigration and Customs Enforcement (ICE) into 18 deaths in detention from 2012 to 2015.

The report cites "systemic failures," including unreasonable delays in care, and unqualified medical staff, and states that inferior care contributed to seven of the 18 deaths, including Carlos'.

Carlos was 14 and living in New York when she was first diagnosed with chronic schizophrenia. Her family later moved to the Philadelphia area.

After she was arrested following a 2004 bar fight in which she also fought with police, her legal permanent residency was revoked and she faced deportation. Under a contract with ICE, York is where she was incarcerated for 2-and-a-half years, while her attorney, Thomas Griffin of Philadelphia, sought to have her placed under ICE supervision in a community mental health facility.

"Staff knew she had a mental health condition requiring substantial support," the report states, "but failed to create a mental health treatment plan."  One doctor, an expert on prison medicine, called the mental health care Carlos received "woefully inadequate." The records say Carlos was put on suicide watch five times, and attempted suicide once, before finally killing herself on Oct. 23, 2013.

A counselor at the prison told ICE investigators that the first attempt was a "gesture," not a suicide attempt, "because she waited for officers to enter her cell before dropping from the stool."

According to HRW, the internal investigation by ICE's Office of Detention Oversight (ODO) concluded that York had violated ICE standards by having no "overall treatment plan with measurable goals and objectives." Instead, Carlos was periodically injected with anti-psychotic medication, which she sometimes refused, and was held in isolation for nine months over "behavioral issues and associated mental health concerns."

Among its recommendations, the report asks the Department of Homeland Security, which oversees ICE, to "expand the use of community-based alternatives to detention," and "refrain from detaining individuals [whose] serious medical and mental health needs" cannot be fully addressed in a prison setting.

Carlos' parents, represented by Philadelphia lawyer Jonathan Feinberg, have filed a federal wrongful death lawsuit, which is pending in the Middle District of Pennsylvania.

To read the full HRW report go to https://www.hrw.org/node/302935/