Girl tried twice to kill herself. They took her off suicide watch. It was a fatal error.

Alleny Carbone didn’t keep to herself her desire to die. A foster child facing months in custody on an escape charge, Alleny tried twice to strangle herself while in juvenile jail. She told youth workers she heard hallucinations telling her to “just do it.”

And she did, on June 10. Right in front of the people who were supposed to protect her.

Though Alleny’s mental health records at the Manatee Regional Juvenile Detention Center show the 15-year-old was a flashing neon sign for potential suicide, lockup mental health workers repeatedly removed her from suicide watch, and failed to provide her with treatment or therapy.

Following her second attempt to take her life, detention center staff removed sharp objects from her cell, but left her with everything she needed for a hanging — her preferred method.

When asked why she had failed to provide Alleny with treatment during the teen’s 17-day incarceration, a therapist insisted Alleny was too mentally ill to benefit from counseling — but well enough to be removed from suicide precautions.

The girl would tell her father, Victor Carbone, on the phone that she was being seen by mental health staff, but not getting actual counseling, he said.

“I would tell her, ‘Alleny, are you telling them your feelings?’ ” Carbone said. “And she would tell me, ‘Yes, Dad, but they don’t care.’ ”

Alleny Carbone was 15 when she took her own life. Facebook

Carbone said he tried to tell facility administrators his daughter was in danger, but his attempts, too, fell on deaf ears.

“I knew something was wrong, but I felt like the state was so powerful,” he said.

A Florida Department of Juvenile Justice Inspector General investigation into Alleny’s death concluded that two detention officers either violated an agency rule or failed to properly supervise the teen, while mental health counselor Chima Hope-Lubin, who worked for an agency contractor, also violated a rule or policy.

The IG report, released to McClatchy’s Florida newspapers, details a white-out blizzard of mistakes and failures that, taken as a whole, led to Alleny’s tragic death. She became the 13th youth to die in DJJ custody under questionable circumstances since 2000. The youths’ stories were recounted in a 2017 Miami Herald investigation, called Fight Club.

“First and foremost, it is heartbreaking that this young lady tragically died at such a young age,” said a DJJ spokeswoman, Amanda Slama. “We send our condolences and deepest sympathies to Alleny’s family and all those that cared for her.”

“DJJ is committed to the safety and security of all youth in our facilities. The Department is conducting a thorough review of facility operating procedures related to suicide prevention and mental health services,” Slama added.

Slama said one agency employee, detention supervisor Frisner Bien-Aime, no longer works at the Bradenton lockup, while another, detention officer Kacha Allen, is facing unspecified disciplinary action, “up to and including termination.” Allen is not allowed to have contact with detained youths while an investigation continues.

Hope-Lubin’s “employment at the facility has been terminated,” Slama said, and DJJ’s health services office is reviewing the report to decide whether the agency should report the therapist to the state’s health department, which regulates her industry.

Hope-Lubin, a licensed marriage and family therapist, claimed to have expertise in self-harm and suicide risk, as well as crisis intervention, when she applied for her job with Camelot Community Care, which contracts with DJJ.

She hung up on a reporter seeking comment.

The Manatee Regional Juvenile Detention Center in Bradenton where a girl was found unresponsive Sunday and later was pronounced dead at Manatee Memorial Hospital. Tiffany Tompkins ttompkins@bradenton.com

Hope-Lubin could have related to Alleny had she tried to counsel the teen. In a recent book, called “Hope Deferred: Radically Changed by the Love of Jesus Christ,” Hope-Lubin disclosed that she, too, had experienced child abuse or neglect. A short review says the book is a candid account of her time in foster care, and how she found purpose through faith.

The book was released in August in the midst of the investigation into Alleny’s death, and Hope-Lubin held a book release party at the Manatee County library in downtown Bradenton in late September. On the book’s back cover, Hope-Lubin touted her work in the juvenile detention center, saying she “stands as an advocate for the voiceless.”

The inspector general report suggests Alleny could have used an advocate.

State child welfare administrators took Alleny into foster care a few years ago, her father said, when he was incarcerated, and the Department of Children & Families alleged the girl’s mother both abused and neglected her. Her father said Alleny cycled from foster home to foster home.

DCF has declined to provide records explaining why Alleny was taken into state care. DJJ’s report says she had been diagnosed with a laundry list of mental and behavioral health problems, including bipolar disorder, anxiety disorder, intermittent explosive disorder and poly-substance abuse.

Alleny moved into the state’s delinquency system, as well, in the beginning of 2015, when she was charged with petit theft. More arrests followed later that year. She was charged again with theft in December, and then with probation violations in 2016. Alleny’s father said the teen would steal cars in an effort to see a boyfriend.

Though Alleny had faced battery charges, her record doesn’t suggest she was particularly violent. Most of her arrests were for marijuana possession, drug paraphernalia and car theft.

Alleny was booked into the Pinellas County lockup on April 26, and within 10 days she attempted suicide by wrapping a sheet around her neck. Alleny told authorities the detention center was making her feel suicidal, the report said, though she “later denied suicide ideation.” A mental health counselor thought it was appropriate to “step-down” Alleny from suicide watch to “close supervision.”

Alleny Carbone Facebook

On May 8, just two days after she attempted to hang herself, Alleny met with the mental health staff and all suicide precautions were lifted. And within six days of arriving at the St. Petersburg lockup, Alleny was transferred to the detention center in Bradenton on May 24, under precautionary observation.

In her first interview with Hope-Lubin, Alleny “denied any suicidal ideation,” and, the report said, presented “no other relevant elevated risk factors.” Four days later, though, on May 28, Alleny wrote a letter to someone in the lockup staff saying “she [had] been feeling very suicidal, but did not know how to cope with it,” the report said.

Hope-Lubin later told investigators she never saw the note.

Inexplicably, Hope-Lubin checked the “no” box in a May 29 evaluation of Alleny when asked if the teen had any “recent or current desire to die or harm [her]self.” The report says that, in a risk assessment just five days earlier, Alleny “told Hope-Lubin she tried” to kill herself by tying a shirt around her neck.

Alleny, the report said, did agree “to discuss any self-harm statements immediately with staff or mental health.” Lockup workers removed the teen from suicide precautions, even though just a day earlier Alleny acknowledged she was thinking of harming herself.

A psychiatrist increased Alleny’s dosage of Prozac “to help with her issues of depression” on May 30, and Alleny was “stepped down” again to “standard supervision” — meaning she would not be watched closely for suicide attempts.

The IG report includes no other mental health notations until June 3, a day after Alleny again tried to “strangle herself.”

Investigators appeared to be harshly critical of Hope-Lubin for failing to take meaningful action that day. Hope-Lubin said she recommended Bien-Aime, a supervisor, place Alleny under “secure observation,” or suicide watch, but Bien-Aime told her he couldn’t, as he lacked adequate staff. And when asked why she didn’t insist that Alleny be taken to a mental health crisis unit. Hope-Lubin said Alleny was “calm” and “fine” following the attempt on her life.

June 4: “Youth needs to present as stable for more than one day” before returning to general observation.

June 5: “Youth presented with happy affect as evidenced by smiling and laughing.” Alleny was removed from suicide precautions. This notation was written in her file an unspecified number of days later.

June 6: Youth “reported feeling depressed, and was crying in her room last night. Youth reported having difficulty being in a room by herself.”

June 7: “Affect was happy as evidenced by smiling and laughing. Youth currently denies any suicidal ideation or plans of suicidal ideation.” Alleny is once again returned to standard supervision.

“There was no further [documented] contact between the mental health staff” and Alleny after that, the report said — even though counselors were in the lockup every day.

She hanged herself three days later, on June 10.

The report called the mental health staff’s failure to provide Alleny treatment a “policy deficiency,” as agency rules don’t “specify a mandatory delivery schedule for necessary” mental health care.

When interviewed by an IG investigator, Hope-Lubin defended removing the suicide precautions, referring to a “step-down process to be followed.” Apparently, a day or two without a suicide attempt or threat was enough to be considered safe.

But she said Alleny’s fragile state made it impossible to do the kind of treatment that might have helped her.

“How could they do therapy with a youth who is in crisis at the moment?”

You can follow Carol Marbin Miller on Twitter @MarbinMiller. You can follow Jessica De Leon on Twitter @JDeLeon1012.