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An Antiguan immigrant who committed suicide in 2013 while detained in York County Prison received "woefully inadequate" mental health treatment, according to a Human Rights Watch report released Monday.

Tiombe Kimana Carlos was detained for 2 1/2years before hanging herself in her cell in October 2013.

A review by U.S. Immigration and Customs Enforcement found that Carlos, 34 at the time of her death, had been placed on suicide watch five times and attempted suicide once, about two months before successfully committing suicide.

ICE's Office of Detention Oversight noted that the prison violated federal standards by having "no overall treatment plan with measurable goals and objectives."

According to The Philadelphia Inquirer, Carlos was 4 when her family moved to New York City as legal permanent residents of the United States. She was diagnosed with schizophrenia when she was 14. She was 30 when her green card was revoked for petty crimes, probation violations and hitting a police officer who arrested her after a bar brawl.

Human Rights Watch is a nonprofit human rights organization with a mission to defend to rights of people worldwide, according to its website. The report was co-authored by California-based nonprofit Community Initiatives for Visiting Immigrants in Confinement.

Its 103-page report, titled "Systemic Indifference," provides medical experts' analysis for 18 detainee deaths, including Carlos', that occurred from 2012 to 2015.

Dr. Allen Keller, a New York-based expert in access to health care for prisoners, called the care Carlos received "woefully inadequate."

Dr. Marc Stern, a correctional health care physician in Olympia, Washington, said he was struck by the fact that the facility clearly knew Carlos had mental health issues and she continued to display problems, but the prison medical staff kept giving her the same treatment.

Carlos was receiving biweekly injections of Haldol, a psychotropic drug, according to ICE's review of the suicide.

Stern noted that the problems identified throughout the report are systemic around the country, and they will not be fixed simply by repairing the system at York County Prison.

CIVIC also filed a civil rights complaint last month over sexual-abuse-related complaints against ICE, alleging that at least 1,016 detainees in DHS custody have submitted sexual-abuse-related complaints to the Office of the Inspector General since May 2014, when the office began specifically categorizing such complaints.

That complaint documented 27 sexual-abuse-related allegations by ICE detainees, including one at York County Prison, saying there were inadequate investigations into such reports at U.S. immigration detention facilities.

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