The state agency that investigates inmate deaths is out with scathing findings in the death of India Cummings, the 27-year-old Lackawanna woman who died in the custody of the Erie County Holding Center in February 2016.
The Commission of Correction Medical Review Board found "that the medical and mental health care provided to Cummings by Erie County during her course of incarceration - and her care, custody and safekeeping by Erie County Sheriff deputies was so grossly incompetent and inadequate as to shock the conscience."
Katrina Martin-Bordeax, a critical care registered nurse and Black Lives Matter organizer of protests about the death, told WBFO she was not surprised the state found rhabomyolosis - a serious syndrome developed by people who have sustained a fall or other injury - and renal failure among the diagnoses.
"What I was surprised about is that she actually had someone watching her - on the 24-hour watch - and no one intervened," she said. "That was most surprising to me is that, reports of her being naked, laying on the floor, not knowing if the floor still had urine or feces on it, those things were just completely inhumane."
The report found that Cummings ultimately died of acute renal failure at Buffalo General Hospital after suffering cardiac arrest in her Holding Center cell. She had been released from custody at the hospital, the report stated. However, due to her "continued neglect during incarceration, her death should be ruled a homicide due to medical neglect."
The report recalled that Cummings was originally arrested by Lackawanna Police in response to a mental health call for a disorderly person and was transferred to the Holding Center after her arraignment and bail set at $15,000.
Martin-Bordeax said that was the beginning of the end.
"I would strongly urge that we strongly look at our bail situation," she said. " We clearly know that people who have means, regardless of what crime they are potentially charged with, that they can often and usually make bail - and this is a disparity issue amongst those who are poor, that they don't have the money to make bail - especially someone like India that did not have a prior criminal irecord. She should not have been held as long as she was."
The Medical Review Board also said Cummings' "obvious mental status and lack of cooperation in the screening process" should have resulted in a referal to the Erie County Medical Center. However, it also faulted Lackawanna Police for not fully informing the Erie County Holding Center of the physical altercations Cummings had experienced with officers and others during her arrest, as well as ECMC for failing to provide appropriately in-depth medical treatement for her.
Martin-Bordeax wants accountability.
"So they do this investigation, they have this information and then what? Who is responsible and who is accountable?" Martin-Bordeax asked. "It can't just be where, 'Oh, we made a mistake and now let's see what it is we can do to make things better.' There has to be some type of retribution, some type of accountability, some type of compensation for this lady's family for her loss. This woman was 27 years old...27 years old. Somebody has to answer for that."
She wants an independent citizens advisory panel to be appointed to help provide oversight, transparency and advocacy into conditions and inmates at the Holding Center. Martin-Bordeax said it is up to the public to demand it.
WBFO reached out to the Erie County Sheriff's Office for a response, but was told no comment was possible because the issue is in litigation.