By Christopher Lee
Washington Post Staff Writer
Wednesday, July 26, 2006; A15
The failure of Bureau of Indian Affairs officials to act on long-standing safety concerns at an Indian boarding school in Oregon was a "significant factor" in the death of a 16-year-old student there, federal investigators said in a report made public last week.
Interior Department Inspector General Earl E. Devaney found that a "historical pattern of inaction and disregard for human health and safety" contributed to the death of Cindy Gilbert (also known as Cindy Gilbert Sohappy) in a detention cell at the Chemawa Indian School in Salem, Ore., on Dec. 6, 2003.
Devaney found that inaction by officials in BIA's Office of Indian Education Programs and Office of Law Enforcement Services "resulted in the failure to maintain a safe environment at the detention facility and, ultimately, became a significant factor in Gilbert's death," according to the report, obtained by The Washington Post through a Freedom of Information Act request.
Gilbert, a first-year student at the school, died of acute alcohol poisoning several hours after a staff member saw several students trying to help Gilbert walk near a campus dormitory, the report said. Gilbert had initially been taken to the student services center, where her blood-alcohol level registered 0.192 -- more than twice the state's standard for drunken driving. A security officer escorted her to a holding facility and placed her on a mattress.
A surveillance camera videotape showed that Gilbert -- who had been unsteady on her feet and who had slurred speech and bloodshot eyes -- stopped moving about an hour later, according to the report. Almost two more hours went by before a residential living assistant entered the cell to check on Gilbert and found that she was not breathing. Emergency personnel were summoned, but Gilbert was dead.
The inspector general found that the Chemawa school's staff had not received training for detaining students or monitoring intoxicated students. But the problems went beyond that. BIA officials had not acted on annual inspection reports by the Indian Health Service dating to 1996 that cited the need to develop emergency medical screening at the school, the IG report said. The report also warned that school officials were using the detention cells unlawfully and in violation of BIA policy by holding as many as 240 students a year without documenting charges, in some cases for the purpose of letting drunk students detoxify.
"BIA officials had long been alerted to the potential liabilities associated with the detention facility and were provided clear recommendations to correct the deficiencies," according to the report. "The recommendations, however, were never acted upon."
Shane Wolfe, an Interior spokesman, said in a statement that the IG report was "helpful" and had led to new training sessions for staff at BIA schools. "The Department and the Bureau of Indian Affairs (BIA) take very seriously the health and safety of the 48,000 students we educate in our 184 BIA-funded schools," Wolfe said.
Wolfe said he was unaware of deaths or other serious management and oversight problems at other BIA-funded schools.
The Chemawa school is the oldest continuously operated Indian boarding school and mostly serves tribes from the Northwest and Alaska. The BIA oversees 68 boarding schools, but only seven, including the Chemawa school, are not on Indian reservations. According to the Interior Department, about 80 percent of students who enroll in the schools are considered "at risk" -- because of factors such as behavioral problems, substance abuse and neglect -- and require specialized services.
The FBI investigated Gilbert's death, but in 2004 federal prosecutors in Oregon declined to charge school officials with involuntary manslaughter, saying there was not enough evidence. In December 2005, Gilbert's family filed a $24 million lawsuit in federal court in Eugene, Ore., against then-Interior Secretary Gale A. Norton, accusing government officials of negligence, torture, conspiracy, racial discrimination and deliberate indifference.
"She was rolling on the floor and had appeared to either throw up or urinate on herself or both, and they still denied any kind of attention, let alone human care or medical care," the family's attorney, Foster Glass, said yesterday.
In turning over his report to Interior officials in November, Devaney wrote that he hoped the department would pursue administrative sanctions against as many as eight BIA officials. "I feel very strongly that the inactions and indifference demonstrated by several Bureau of Indian Affairs (BIA) officials should not go unpunished," he wrote.
Wolfe said it "would be inappropriate" for him to comment on any personnel actions taken in the case.