The report from Interior Department Inspector General Earl Devaney, dated Nov. 1, said inaction on the part of BIA officials resulted in ''the failure to maintain a safe environment'' at a detention facility in the Chemawa Indian Boarding School where Cindy Gilbert Sohappy died of alcohol poisoning in 2003.

Devaney said the inaction was a significant factor in the death of the 16-year-old from Warm Springs in a cell. Investigators found that nobody had checked on her for more than two hours, even though a video monitor recorded her convulsions and death. Devaney said 90 minutes elapsed between her last movement and the next time someone checked on her.

A medical examiner reported her blood alcohol level at 0.37 percent, more than four times the legal limit in Oregon for driving.

''I feel very strongly that the inactions and indifference demonstrated by several Bureau of Indian Affairs officials should not go unpunished,'' Devaney said.

Devaney said BIA officials knew of the problems involving the holding cells and how to fix them.

''The recommendations, however, were never acted upon,'' Devaney said. ''An argument between the law enforcement and education programs ensued, concerning who within BIA 'owned' the problem.''

The two offices, he said, ''became embroiled in what essentially became a turf war.''

Devaney had been critical previously about the death.

He told a Senate committee in 2004 that school and BIA administrators were warned about the risks to students in holding cells years before the Sohappy death, and cited the teenager's death in a report that called such detention facilities a ''national disgrace.''

In his November report, Devaney said that beyond a bureaucratic disagreement, ''we believe the evidence reflects negligence and mismanagement in the oversight of the detention facility.''

He said employees overseeing the detention center weren't trained, that up to 240 students a year were put in the cells and that up to 30 students at a time were in the four cells.

The FBI conducted an investigation, and federal prosecutors declined to file criminal charges against the personnel on duty the night Sohappy died, Devaney said, noting that the FBI ''did not address the conduct of upper-level BIA officials.''

Nedra Darling, a spokeswoman for the bureau, said that because a lawsuit is pending, she couldn't comment on what action, including discipline, it had taken as a result of Devaney's report. Sohappy's family filed a $24 million lawsuit last year.

The Washington Post filed a request for Devaney's report under the Freedom of Information Act, and reported on it Wednesday.