The Bureau of Indian Affairs knew about, but failed to correct, problems at a boarding school in Oregon where a 16-year-old student died after being placed in a detention cell, according to a scathing investigation made public on Wednesday.

Citing a "historical pattern of inaction and disregard for human health and safety," the Interior Department's Inspector General Earl E. Devaney called for the punishment of several top BIA employees. "These officials failed to take action that may have prevented the untimely death of Cindy Gilbert and endangered countless other students," the report said.

In a November 2005 letter delivered to former Interior secretary Gale Norton, Devaney expressed frustration that federal prosecutors declined to bring criminal charges not just once but twice. He said BIA education and law enforcement officials engaged in a "turf war" that could have prevented Gilbert's death on December 6, 2003, at the Chemawa Indian School.

"Evidence developed indicates that inaction on the part of senior officials within BIA OIEP and OLES resulted in the failure to maintain a safe environment at the detention facility and, ultimately, became a factor in Gilbert's death," Devaney wrote, referring to the Office of Indian Education Programs and the Office of Law Enforcement Services.

Despite the tragic death of Gilbert, a young member of the Warm Springs Tribes of Oregon who was also known as Cindy Sohappy, most of the people Devaney implicated continue to work for the agency. According to the report, the officials include Ed Parisian, the former director of OIEP, and Robert Ecoffey, the former director of OLES.

Parisian isn't identified by name but the report makes several references to the director of OIEP during the time period in question. A handwritten note on an e-mail sent just months before Gilbert's death referred to "Ed."

Parisian, a member of Montana's Chippewa Cree Tribe, stepped down as OIEP director but he held the "acting" position for more than a year while a replacement search was conducted. He now serves as deputy director and is the second in charge of the BIA's school system.

Ecoffey, a member of the Oglala Sioux Tribe of South Dakota, is mentioned by name in the report. He left his position as OLES director in June 2004 and now works for the BIA as one of the top officials for the Great Plains region.

At the time, Ecoffey said he was changing jobs in order to move back home. No public explanation has been given for Parisian's change in status. A new OIEP director was hired in May 2006.

It was Ecoffey's note on the February 2003 e-mail that showed both he and Parisian knew about long-standing problems at Chemawa. At issue were the holding cells being used at the school to detain intoxicated, unruly and other troublesome students.

Gilbert had only been at Chemawa since August 2003 before she was placed in a holding cell the evening of December 6, 2003. She was "considerably intoxicated" and had trouble sitting and standing up, the report said.

Within an hour, Gilbert stopped moving, according to a videotape from the school's holding facility. But it took nearly two hours before someone checked on her -- for the first time since she entered the cell that night -- the report said.

"At approximately 11:45 p.m., [emergency medical services personnel from the Salem fire department] informed the BIA police officer that Gilbert was dead and nothing further could be done for her," the report said.

An autopsy determined that Gilbert died of complications from "acute" alcohol poisoning. Her blood alcohol level was 0.73 and her urine alcohol level was 0.43, far above the state intoxication. limit of 0.08 for an adult.

Sohappy's family has since filed a $24 million lawsuit against the Interior Department. It accuses officials of torture and conspiracy.

The BIA has stopped using holding cells at Chemawa but there have been ongoing problems with the agency's management of jails and detention centers. In 2004, a 17-year-old male attempted suicide at a BIA detention facility in Washington.

Several months before Gilbert's death, a 15-year-old girl committed suicide at a BIA detention center in New Mexico.

In 2004, youth on the Blackfeet Nation in Montana complained of abuse and mistreatment at a BIA facility.

A separate investigation by the Inspector General found nearly 50 deaths, suicides, attempted suicides and prisoner escapes at BIA detention centers, the majority of which were never reported or documented. Devaney called the jail system a "disgrace."

The Washington Post first reported the results of the Cindy Gilbert investigation on Wednesday. The paper said it obtained a copy through a Freedom of Information Act request. The Office of Inspector General later posted the report on its website.

Cindy Gilbert Report:
Report on Child�s Death at Chemawa Indian Boarding School

Detention Facility Reports:
Final | Interim

Oregonian Special Series:
Warm Springs - A Place Where Children Die

Relevant Links:
Chemawa Indian School - http://www.chemawa.bia.edu