EFTA00139151.pdf

U. S. Department of Justice Federal Bureau of Prisons Metropolitan Correctional Center New York, New York For Immediate Release Contact: Lee Plourde August 10, 2019 Public Information Officer (646) 836-6300 Inmate Death at the MCC New York New York, NY: On Saturday, August 10, 2019, at approximately 6:30 a.m., inmate Jeffrey Edward Epstein was found unresponsive in his cell in the Special Housing Unit from an apparent suicide at the Metropolitan Correctional Center (MCC) in New York, New York. Life-saving measures were initiated immediately by responding staff. Staff requested emergency medical services (EMS) and life-saving efforts continued. Mr. Epstein was transported by EMS to a local hospital for treatment of life-threatening injuries, and subsequently pronounced dead by hospital staff. The FBI is investigating the incident. Mr. Epstein was a 66-year-old male who arrived at MCC New York on July 6.2019 under pretrial status after being indicted for sex trafficking of minors and conspiracy. MCC New York is an Administrative security facility that currently houses 763 male offenders in New York, New York. Additional information about the Federal Bureau of Prisons can be found at www.bop.gov. ### SDNY_00017560 EFTA00139151  MCC NEW YORK UPDATES Correctional Services Inmate Accountability: SHU • A whiteboard has been installed in the Special Housing Unit identifying the cell assignment of each inmate and pertinent information of each inmate which aids in accountability. This assists in correcting cell assignment discrepancies and aid in identifying programing needs (3 man hold, razor restriction, etc.). • TDY Staff have been assisting Correctional Services with vacant positions; Correctional Officers, Lieutenant's and Deputy Captain. • Addition to the Captains 2 hour SHU video review, IDO's are reviewing 6 hours of SHU video encompassing all three shift weekly. • IDO's are conduction Bed book counts on weekends during the 10:00 am count. • Single cell report emailed to the Warden each shift and receives approval memorandum for each. • Morning Watch Lieutenant supervises one count in SHU and is documented in the LT's Log. Psychology • Running Hospital Rosters Every Morning to see if inmates on SW are in the proper cells according to their Sentry assignments. Inconsistencies are reported the Associate Warden of Programs. Further, C&A is contacted to make appropriate corrections on the roster. • Court rosters are reviewed every day to see if any Psy Alerts are going out to court so that we can check in with them upon their return. • PSY ALERT inmate assignments are considered for inmates with ongoing risk factors associated with suicidality (e.g., sex offender status, high profile) even regardless of whether they exhibit substantial acute mental health symptoms. ■ The Chief Psychologist has written a new procedural Memorandum for Psy Alert inmates which is undergoing review in Central Office. ■ Psychology has been routing Hot List via e-mail to Lieutenant's and Executive Staff each time new inmates are added to the hot list. SDNY_00017561 EFTA00139152  MCC NEW YORK UPDATES ■ Psychology has been providing feedback at Executive Staff Meetings regarding inmates at-risk for suicidality and discussing cellmate placement (both GP and SHU) for inmates with significant mental health issues and suicide risk factors. • When inmates are added and released from Suicide Watch, an email and a phone call is made to Warden and the Operations Lieutenant notifying them of the addition or termination of the watch as well as their need for cellmates. This recommendation is also placed in the Post Suicide Watch Report in PDS and the psychologist indicates exactly who they contacted about the inmate's need for a cellmate in the recommendation section of the report. ■ Suicide Watch Books are reviewed daily by a psychologist and audited to see if the Unit Officer and Lieutenant make appropriate rounds and signed the log books each shift (MW, DW, and EW). Inconsistencies are sent to the Captain and Associate Warden of Programs. Correctional Systems ■ Since September 9, 2019, inmates have been tracked when released from court by utilizing the PP63 Sentry function as opposed to tracking by out count. There has been no issues to date utilizing this procedure. • All releases are being reviewed by a higher authority other than the CSO/SCSS. Typically reviewed by the Case Management Coordinator. Correctional Programs Inmate Accountability: • New bed books have been provided to each unit. A daily schedule of bed book counts has been established to ensure appropriate accountability of all inmates. Bed book counts are notated in the Daily Lieutenant Logs for Executive Staff review. Additionally, an Executive Staff member is present each evening to monitor this process and identify discrepancies. All discrepancies are typically corrected immediately. SDNY_00017562 EFTA00139153  MCC NEW YORK UPDATES ■ Daily Camera status reports of the status of high priority areas; SHU, 10 South, Suicided Watch, Female unit and 3 Sally. Facilities Cameras: ■ The FBI removed the previous camera system (DVR) and the new system (NVR) has been installed and is operational. 13 Additional cameras have been added in SHU which are digital. Within the next 6 months additional cameras will be added to the system with a target completion date of April 2020. • MCC has a total of 142 cameras. Currently, 141 cameras are connected to the NICE DVR System and are operational and recording. The 1 camera is inoperable and in the process of being replaced (bad camera). The anticipated date of completion is within the next two weeks. ■ The new NVR has the capability to monitor and record 350 cameras. The following locations have been identified as needing coverage: elevators, receiving and discharge, all inmate housing units, sallyports, and outside perimeter. Summary • To date all information requested by OIG and FBI has been provided. ■ Health Services has received the autopsy results from the NY Medical Examiner's office on inmate Epstein and is secured ■ TDY staff assigned to NYM have all been hard working and team players. ■ Staff morale at MCC New York is average in light of the most recent event; however, they are resilient and working hard as a team to move forward. They have embraced the TDY staff that have arrived and have been extremely courteous and receptive to ensure everyone works together. SDNY_00017563 EFTA00139154  MCC NEW YORK UPDATES Current Assessment: Some of the issues identified are due to seriously reduced staffing levels, improper or lack of training, and follow up and oversight. Since January 1, 2019, MCC New York has hired 18 staff and lost 33 staff to retirement, and transfers within the BOP and other agencies. To date approximately approximately 148 staff from multiple regions assisted NYM which we are very grateful for their assistance. All subject matter TDY staff are required to provide a report to the Warden prior to their departure. This report is similar to a Program Review report and includes areas of concern, tasks done well and recommendations. These reports will be shared with the Associate Wardens and Department Heads for guidance. Further, to ensure the training and efforts that will occur is sustainable, there will need to be continuous oversight by leadership. Therefore, several positions will need to be added to the staff compliment, such as an Associate Warden over Correctional Services, a Deputy Captain, and an Assistant Case Management Coordinator, Assistant Food Services Administrator, to name a few. SDNY_00017564 EFTA00139155  U.S. Department of Justice Federal Bureau of Prisons Office of the Warden Metropolitan Correctional Center 150 Past Row New York. New York 10007 (646)836-6300. (646) 836-7551 (Fax) August 10, 2019 Mark Epstein 301 E. 66 Street New York, NY, 10065 Dear Mr. Epstein: I am writing to express my condolences to you regarding the passing of your brother, Jeffrey Edward Epstein, who passed away Saturday, August 10, 2019. On August 10. 2019. Jeffrey Edward Epstein was pronounced deceased at the New York Presbyterian-Lower Manhattan Hospital in New York, New York. At this time, although there are no preliminary reports identifying the exact cause of death, it appears to be the result of suicide. Although I realize that words alone cannot lessen your sorrow, I hope that my thoughts and sincerest sympathy will be of some comfort to you. Sincerely, Warden MCC New York SDNY_00017565 EFTA00139156  U.S. Department of Justice Federal Bureau of Prisons Office of the Warden Metropolitan Correctional Center 150 Park Row New York. New York l(M07 (646) 836-6300. (646) 836.7551 (Fax) August 10, 2019 SENT VIA EMAIL The Honorable Colleen McMahon. Chief Judge The Honorable Richard M. Berman. District Judge Daniel Patrick Moynihan United States Courthouse 500 Pearl Street New York, New York 10007-1312 Dear Mr. Epstein: I am writing to express my condolences to you regarding the death of your brother, Jeffrey Edward Epstein. who passed away Saturday, August 10, 2019. On August 10, 2019, Jeffrey Edward Epstein was pronounced dead at the New York Presbyterian-Lower Manhattan Hospital in New York, New York. At this time, although there are no preliminary reports identifying the exact cause of death, it appears to be the result of suicide. Although I realize that words alone cannot lessen your sorrow, I hope that my thoughts and sincerest sympathy will be of some comfort to you. Sincerely, Warden MCC New York SDNY_00017666 EFTA00139157  U.S. Department of Justice Federal Bureau of Prisons Metropolitan Correctional Center ISO Park Row Ncw York. New York 10007 Office of the Warden January 27, 2020 MEMORANDUM FOR HUGH'. HURWITZ, ASSISISTANT DIRECTOR, REENTRY SERVICES DIVISION FROM: M. Licon-Vitale. Warden, MCC New York SUBJECT: Institution Response to Psychological Reconstruction Inmate Epstein, Jeffrey (76318-054) This is the response to the psychological reconstruction of inmate Epstein, Jeffrey (76318-054) dated December 27, 2019. 2. 30 Minute Rounds The substance of the two hour Captain video review and six hour IDO video review is unclear. Please clarify the requirement for the Captain and 1DO. Additionally, please identify the documentation used to maintain accountability of the reviews. Institution Response: Video review requirements have been instituted by NERO. Specifically, on Tuesday of each week, the institution is notified by NERO of the date, time, and SHU range in which to download video. The video is a two hour block. The video is to be reviewed by the Captain. During the reviews the Captain is looking for strict adherence to the requirements that rounds be conducted at least once during every 30-minute period, not to exceed 40 minutes between rounds and that all scheduled counts are being conducted in the SHU. The Captain will then submit an assurance memo to the institutional executive staff and Correctional Services Administrator (CSA) indicating the designated video footage was reviewed, and corrective actions which were taken for any deficiencies noted. This memorandum will be submitted to the Regional Office by COB on Friday of that same week. Institutional Duty Officers (IDOs) are required to review 6 hours of SHU video. The surveillance footage is downloaded by the institutional SIA and a compact disk is provided to the IDOs for review. The IDOs are reviewing the video for accuracy of the 30 minute rounds. All reviews are documented in the weekly IDO Report. 1 SDNY_00017587 EFTA00139158 3. Cellmate Assignments Documentation exists reflecting the role of the local Psychology Services department in communicating the importance of Mr. Epstein's status as a sex offender with specific needs to the Associate Warden. This includes consultation with the Psychology Services Branch in Central Office. The communication chain and decision making of Executive Staff lacks transparency as there is no documentation of the process or staff members present when decisions were made about the housing of Mr. Epstein. After the fact explanations may not accurately reflect what occurred. Institution Response: As was noted, there was no documentation indicating Psychology Services was present when housing decisions were made regarding Mr. Epstein. Psychology services is present at the weekly SHU meeting, Executive Staff meetings, and weekly Opening and Close-Out meetings. During these meetings, the Chief Psychologist or Acting Chief Psychologist are present to provide recommendations and feedback to the Executive Staff on housing concerns regarding inmates with mental health issues or risk factors for suicidality. When an inmate presents with unique risk factors associated with individuals who have been charged with and/or convicted of a sex offense, careful evaluation is made with regard to housing these inmates with appropriate cellmates. Moving forward, a plan has been established to have a sign-in sheet and checklist at these meetings where housing issues are addressed, indicating who was present and what the housing plan is for these inmates with psychological concerns. These checklists will be maintained in a binder by the Associate Warden of Programs. Please see the attached checklist. 4. Documentation Accuracy Professional responsibility requires taking into account multiple descriptions of an incident as noted in your response. However, when discrepancies exist these should be compiled and noted in documentation to decrease the likelihood of conflicting conclusions. As noted in the reconstruction report, an incident report must be written within 24 hours of having the information that an inmate likely violated BOP rules. An incident report was written for Mr. Epstein prior to a determination of whether he engaged in self-directed violence or was assaulted on July 23, 2019. Staff had ample time to wait for the outcome of the SIS investigation of this incident. The incident report presumed self-directed violence, although SIS was not able to determine whether this incident was self-directed violence or an assault. Generating the incident report for self-directed violence is evidence of a local bias about the July 23, 2019, incident that still exists amongst some staff at MCC New York. Preconceived notions challenge the ability to remain open about alternative explanations, and subsequent systemic changes may be needed. Please develop and provide local training for all staff that at a minimum reviews the time frame for writing incident reports and offers guidance when there is not clear evidence of an infraction. Include an outline of the training and evidence of staff who attended the training. Institution Response: Additional information (slides) has been included in our Annual Training presentations for Report Writing. In addition to the established training, the slides further differentiate and provide guidance to staff regarding when it is appropriate to write an Incident Report and when, in cases of a lack of evidence, a memorandum is more appropriate. The additional information is being provided to all staff as a part of Annual Training. Annual Training began the week of January 6, 2020, and will continue through the week of March 8, 2020. 2 SDNY_00017568 EFTA00139159 5. Telephone Calls As noted in the response, there is a lack of documentation to substantiate that a lieutenant facilitated two telephone calls to Mr. Epstein. However, this does not address the report of two telephone calls being provided. This response implies that the reporting of two staff members is inaccurate. The response neglects the documented telephone call to Mr. Epstein's deceased mother. Institution Response: On August 29, 2019, Warden'. Petrucci, signed a referral related to failure to follow policy in allowing Epstein to complete an unmonitored phone call. The referral was submitted to the Office of Internal Affairs on that same date and is pending further action at this time. 7. Follow-Up Please provide documentation for the follow-up training provided to staff detailing the content of the training and to whom it was provided. Institution Response: As recommended by Central Office, the Chief Psychologist has conducted suicide prevention trainings during Department Head Meetings, e-mail correspondence, SHU Staff Trainings, and Lieutenant's Trainings. The follow-up training sign-in sheets, Department Head Meeting Minutes, and e-mails provided by psychology staff regarding PSY ALERT Inmates are attached for your review. 8. Inmate Accountability and Assignment Accuracy Periodic and unannounced checks are now conducted in SHU to determine pp30 assignments and actual inmate placement match. Please provide an operational definition of periodic. Please do the same for routine, as it relates Executive Staff bed book counts in all units. Where will the periodic and routine reviews be documented and will they include the identity (e.g., name and title) of staff who complete them? Institution Response: An Executive Staff and Duty Officer schedule has been implemented to conduct daily 4 P.M. and 10 A.M. weekend bed book counts. Any discrepancies noted are documented and sent via email to Unit Mangers and Captain at the conclusion of each count for corrective action. Please see the attached schedule. 9. Attorney Log Books Please provide a copy of the log book audit. Institution Response: The audit revealed the Random Visitor Log Book did not reflect visitor pat searches after May 19, 2019. In addition, the log book does not offer a column to annotate a staff witness. The Contractor/Volunteer Log Book was not always filled in properly. The Law Enforcement Log Book was up to date; however, the time of departure was not always documented. The Attorney Log was missing inmate register numbers and more often than not was legible. There was no Visitor Denial Log created. The audit conducted on September 25, 2019, is attached for your review. 3 SDNY_00017569 EFTA00139160 Additional corrective measures will now include the Activities Lieutenant checking all Front Lobby log books. The Captain will ensure these checks are included in the Lieutenant's Daily Log for Day Watch and Evening Watch. In addition, the Activities Lieutenant will address any discrepancies immediately through on the spot training and/or performance log entries. 13. Sex Offense Risk Factors Psychologists are subject matter experts in sex offender risk factors and they play a crucial role in sharing this knowledge through traditional settings such as ICT, AT, and institutional meetings. However, Executive Staff play a pivotal role in establishing and addressing institutional culture and promoting and participating in training. A lack of a broad understanding of sex offender specific risk factors requires an intentional training approach led by Executive Staff. They must be out front talking about inmates with a sex offense, expressing an understanding of sex offender dynamics, modeling agency condoned expectations for the understanding and treatment of inmates with a sex offenses, and assisting with institutional trainings. These practices encourage a broader acceptance by line staff. Institution Response: The MCC New York Executive Staff are out front talking about inmates with sex offenses, and expressing an understanding of sex offender dynamics, modeling agency expectations for the understanding and treatment of inmates with sex offenses. This is done through departmental meetings, trainings, staff recalls and walking and talking throughout the institution. ATTACHED DOCUMENTS: Institution Duty Officer Report Cellmate Review Report Writing "Back to Basics Training" SHU Suicide Prevention Training Department Head Meeting minutes PSY ALERT inmates Bed Book Count Schedule (Exec Staff/IDO) Bed Book Audit (emails) Log Book Audit Executive Staff List 4 SDNY_00017570 EFTA00139161 Suicide Timeline: RE: Epstein, Jeffrey Edward, Reg. No. 76318-054 Friday, August 9, 2019 8:00 am: inmate Reyes Efrain, Reg. No. 85993-054 departs for court (WAB-USMS-SDNY). Reyes is Epstein's cellmate. 8:30 am: inmate Epstein arrives in Attorney Conference. He is visited by several attorneys throughout the day. 6:45 pm: inmate Epstein departs attorney conference and returns to SHU. 7:00 pm: inmate Epstein provided a social call by IDO. IDO reports inmate Epstein was in good spirits, nothing unusual. Saturday, August 10, 2019 6:33 am: Body alarm activated in SHU. Staff found inmate Epstein unresponsive in cell. Staff reported to bedside of inmate and attempted to wake him. Control announced medical emergency. CPR initiated 6:35 am: Medical staff (on duty PA) on site, CPR already in progress medical staff continues CPR and AED applied on inmate. Control called for ambulance 6:40 am: S. , AW notified 6:45 am: EMS arrives, paramedics continue CPR. Inmate Epstein remains unresponsive. Inmate Epstein is intubated, given three rounds of Epinephrine, IV access started, IO initiated. No pulse found, no shock advised, inmate prepared for transport to local hospital. 7:00 am: Institution placed on modified operations 7:10 am: EMS departs institution enroute to Beekman Hospital. 7:19 am: USMS notified of incident. smcoommn EFTA00139162 7:20 am: SIS Lt notified. 7:30 am: L. , Warden arrives at institution. , AW notified. 7:32 am: PIO notified of incident by the Warden. 7:36 am: Official time of death reported by ER physician. 7:40 am: Acting Chief Psychologist notified. 8:00 am: , AW and I. , Captain arrives at institution. 8:10 am: SIS Lt arrives at institution. 8:10 am: CMC and SCSS notified. 8:34 am: FBI notified. 9:00 am: AUSA notified. 9:00 am: C. arrives at institution. Cont. Saturday, August 10, 2019 9:00 am: SIS Lt. Reports to SHU. Interviews will be conducted with inmates assigned to tier. 9:15 am: CMC arrives at institution. 9:30 am: Acting Chief Psychologist arrived to the institution. 9:50 am: SCSS arrives at institution. 9:55 am: CMC and IDO depart institution enroute to Beekman Hospital. 10:00 am: CMC and IDO arrive at Beekman Hospital, fingerprints and photographs taken of inmate Epstein. Inmate clothing secured and brought back to institution. 10:00 am: Judge Berman notified. 10:15 am: CMC returns to institution. SDNY_00017572 EFTA00139163 Cont. Saturday, August 10, 2019 10:45 am: PIO arrived to the institution. 11:00 am: Next of kin (brother) notified by Case Management Coordinator. 11:12 am: Press Release released to media. 11:15 am: Press Release provided to Judge Berman. 11:15 am: Crisis Support Team activated. 12:15 pm: Body released to Medical Examiner (ME) for autopsy 12:19 pm: FBI arrives. 1:35 pm: FBI arrives in Special Housing Unit. 1:40 pm: OIG notified by the Warden and they will be sending an Agent to NYM. 2:15 pm: Crisis Support Team debrief conducted. 2:45 pm: OIG arrived in Special Housing Unit (SHU) 3:45 pm: OIG and FBI departed from SHU. 5:05 pm: OIG/FBI departed MCC New York. 5:30 pm: CST departed MCC New York. 10:15 pm: Computer Services Manager arrives at institution to remove hard drives (Computers) from SHU. And replaced with new ones. Sunday, August 11, 2019 8:00 am: Resumed normal operations. Attorney conference visits and social visits (Unit 3) resume. 12:15 am: Computer Services Manager departs the institution. SDNY_00017573 EFTA00139164 Cont. Sunday, August 11, 2019 10:40 am: DIG Agent and Agent arrives at institution. 11:15 am: DIG Agent , departs institution with two computers FPS 021407270 and FPS 0214207268. 2:00 pm: DIG Agent departs the institution. Monday, August 12, 2019 1:00 pm: Staff recall conducted 3:14 pm: FBI arrives 7:56 pm: FBI departs 9:45 pm: FBI returns 10:30 pm: FBI departs Tuesday August 13, 2019 7:15 am: Mr. , NER Correctional Services Administrator arrives to the institution 7:25 am: Dr. National suicide prevention coordinator, and Dr. , National Sex offender program coordinator arrives to the institution. 8:40 am: Northeast Regional Director arrives to the institution. SDNY_00017574 EFTA00139165 Wednesday August 14, 2019 11:30 am: FBI Agents arrive to work in communication room advised they will work through the night until next morning. NYM Facilities staff working in room also. Thursday August 15, 2019 5:24 am: FBI agent departs communication room and secured the door with evidence tape. 8:30 am: NER Regional Director arrives to the institution. 9:30 am: ODAG arrives to the institution. 9:40 am: AUSA/FBI/OIG arrives to the institution. 11:30 am: FBI arrives to work in communication room. 12:00 am: AUSA/FBI/OIG departed the institution. 12:30 am: ODAG departs the institution. 4:52 pm: FBI Agents departs with all computer software from communication room new system running. 5:37 pm: Gave Facilities Manager receipt from FBI for computer system. SDNY_00017575 EFTA00139166  U.S. Department of Justice Federal Bureau of Prisons Metropolitan Correctional Center ISO Park Row New York. New York 10007 Office of the Warden January 14, 2020 MEMORANDUM FOR HUGH I. HURWITZ, ASSISISTANT DIRECTOR, REENTRY SERVICES DIVISION FROM: M. Licon-Vitale, Warden, MCC New York SUBJECT: Institution Response to Psychological Reconstruction Inmate Epstein, Jeffrey (76318-054) This is the response to the psychological reconstruction of inmate Epstein, Jeffrey (76318-054) dated December 27, 2019. 2. Rounds: 30-minute rounds are required by P5500.14, Correctional Services Procedures Manual. Institution Response: 2. Rounds: SHU training is conducted quarterly in which emphasis will be placed on the importance of diligent rounds within the policy guided timeframes. In addition, the SHU Lieutenant will review documentation (SHU Round Sheets) on a daily basis and provide the Captain with an assurance memorandum of their completion weekly. SHU Rounds sheets will be maintained on the specified range to ensure officers are completing required rounds. A staff member must observe all inmates confined in continuous locked down status, such as administrative detention or disciplinary segregation, at least once in the first 30 minute period of the hour, followed by another round in the second 30 minute period of the same hour, thus ensuring an inmate is observed at least twice per hour. These rounds are to be conducted on an irregular schedule and no more than 40 minutes apart. All observations must be documented. Closer observation may be required for an inmate who is mentally ill, or who demonstrates unusual or bizarre behavior. These inmates have been identified with an orange photographic door tag to ensure staff are aware to take more security pit-cautions in dealing with this inmate. Two hour Captain video review and six hour IDO video review are being conducted. The substance of the weekly video reviews by the Captain and IDO consists of a general review of randomly designated ranges and times, covering all three primary shifts, to ensure all SHU policies and procedures are being followed. Additionally, the reviews will ensure strict adherence to the requirements that rounds be conducted at least once during every 30-minute 1 SDNY_00017576 EFTA00139167 period, not to exceed 40 minutes between rounds and that all scheduled counts are being conducted in the SHU. The Captain's reviews are documented in a memorandum that is submitted to institutional executive staff as well as the NERO Correctional Services Administrator. The IDO reviews are documented in their weekly report, with any misconduct being reported in a separate memorandum to the Warden and/or SIA. The requirement is that the Captain will view two hours of Special Housing Unit archived video footage selected by the NERO. The surveillance footage is downloaded by the institutional SIA and a compact disk is provided to the Captain for review. The footage is reviewed for any discrepancies and/or egregious security violations, which will be immediately addressed. On Tuesday of each week, institutions will be notified of the date, time, and range in which to download SHU video. The video is to be reviewed by the Captain. Each Captain will submit an assurance memo to the CSA indicating the designated video footage was reviewed, and corrective actions were taken for any deficiencies noted. This memorandum will be submitted to the Regional Office by COB on Friday of that same week. If an institution does not have inmates on the specified range, then video will be downloaded from the next highest/lowest range. References to highest/lowest and even/odd ranges are the SENTRY designations. (i.e. ZO1, Z03, Z05, etc. are odd ranges and Z02, Z04, Z06, etc. are even) Institutional Duty Officers (IDO's) are required to review 6 hours of SHU video to review the accuracy of SHU 30 Min Rounds. All reviews are documented in a memorandum to the Warden for review. 3.Cellmate Assignments: When Mr. Epstein was placed in MU on July 7, 2019, Executive Staff decided Mr. Tartaglione would be his cellmate. As explained by Dr. , input was not sought from Psychology Services and it is not clear if or how sex offender-specific needs and associated risk were incorporated into the housing plan. Mr. Tartaglione was also a high profile inmate-an ex-police officer charged in multiple murders. However, he and Mr. Epstein did not share the risk associated with being a sex offender and their pairing may have aggravated Mr. Epstein's risk for self-directed violence. In an effort to treat Mr. Epstein the same as other inmates, a statement repeated by multiple staff, Executive Staff may have inadvertently overlooked the need to consider unique risk factors associated with individuals who have been charged with and convicted of a sex offense. On July 25, 2019. Dr. sent an e-mail to , Associate Warden explaining a consultation between Dr. and Dr. , National Suicide Prevention Coordinator. In the e-mail, Dr. Reviewed the consult and recommendation from the Psychology Services Branch, Central Office that Mr. Epstein be housed with another inmate who had also been accused of committing a sex offense. There is no evidence this information was considered beyond this e-mail, and Mr. Epstein was never housed with another inmate charged or convicted of a sexual offense. It is recommended Executive Staff and Correctional Services staff include a psychologist in decisions about cellmates as a means of incorporating expertise about suicide risk, mental health needs, and interventions for psychological stability. Institution Response: 3. Cellmate Assignments: Inmates with serious mental illness and those at-risk for suicidality are discussed during staff meetings, department head meetings, SHU meetings, morning meetings. and close out meetings. The Captain. Associate Wardens. 2 SDNY_00017577 EFTA00139168 Warden and Psychology Services discuss the inmate's needs. The Legal Department also assists when the inmate's attorney or court are concerned about an inmate's mental health. Psychology Services are involved in making recommendations regarding the types of cellmates with whom inmates at-risk for suicidality should celled. Psychology Services takes into consideration the suicide risk factors involved with a particular inmate and shares their knowledge with Executive Staff. The psychological reconstruction team suggests MCC New York Executive Staff did not take into account Mr. Epstein's sex offender-specific needs in assigning him a cellmate in SHU. However, that is not correct. MCC New York Executive Staff considered a variety of factors in determining the most appropriate cellmate for Mr. Epstein, including but not limited to history of sex offenses, nature of the inmate, cooperation status, etc. MCC New York administrators initially housed Mr. Epstein with Mr. Tartaglione as both had high profile cases. Mr. Tartaglione is also a certified death penalty eligible inmate and, thus, based on correctional judgment, less likely to assault or otherwise try to harm Mr. Epstein. Indeed, Mr. Tartaglione notified staff immediately when he realized Mr. Epstein first made a possible suicide attempt/gesture on July 23, 2019. Prior to Mr. Epstein being taken off suicide watch, MCC New York Executive Staff, with input from Psychology staff, assessed all the inmates in SHU at that time and narrowed the list down to the most appropriate candidates. Mr. Tartaglione was not chosen as the investigation at the time had not yet cleared him of any wrongdoing. Most of the other inmates in SHU at the time were there for disciplinary reasons and were otherwise not appropriate to be housed with Mr. Epstein. The other notable inmate in SHU with a history of sex offenses, Mr. Hoyt, was deemed dangerous to Mr. Epstein due to his threatening nature. Accordingly, MCC New York Executive Staff narrowed the possibilities to cooperators. Specifically. Efrain Reyes, Register Number 85993-054. was placed in SHU for claims he was being threatened and extorted on his unit, and he was confirmed as proffering with the U.S. Attorney's Office. As both he and Mr. Epstein were in SHU for safety reasons, Mr. Reyes was deemed an appropriate cellmate. Based on the above, consideration was made for Mr. Epstein's sex-offender-specific needs in choosing his cellmate in SHU. His charged crime was just one of the factors reviewed in making the determination. MCC New York Executive Staff also considered high publicity inmates with ample reasons not to hurt Mr. Epstein, and cooperators who are not only vulnerable themselves, but also had a lot to lose should they harm Mr. Epstein. NYM Executive Staff conduct bed book audits Monday through Friday and the IDO conduct them on Weekends and Holidays. All discrepancies are noted and corrected ordinarily on the spot and or the next buisness day. 4. Documentation Accuracy: On July 23, 2019, Mr. Epstein was found unresponsive in his cell. He had abrasions on his neck and knee. There are inconsistencies between documents describing the circumstances of the scene. In a General Administrative Note in PDS-BEMR, Dr. documented information received from Operations Lieutenant that Mr. Epstein, "was found with a string loosely hanging around his neck." In contrast, Officer Wilson Silva, who responded to this emergency, wrote a memorandum dated July 23, 2019. In that memorandum, wrote he saw Mr. Epstein "laying down near his bunk with what appeared to be a piece of handmade orange cloth around his neck." It is critical that all descriptions of the incident accurately reflect objective evidence. Officer wrote Mr. Epstein an incident report for Self-Mutilation on July 23, 2019, after he was found unresponsive in his cell but prior to having the necessary facts to determine whether he likely engaged in a Bureau violation. BOP Policy expects staff to write an incident report within 24 hours ofhaving the information that an inmate likely violated BOP rules but without making a presumptive decision about guilt. A Special Investigative Services Threat Assessment was completed August 2, 2019, but results were inconclusive as to whether Mr. Epstein engaged in self- directed violence, willingly fought with his cellmate, or was assaulted by his cellmate. It is 3 SDNY_00017578 EFTA00139169 recommended that staff remain open to all reasonable explanations for a behavior and take the appropriate actions when a final determination is made. Although the incident report was later expunged, inmates frequently experience significant stress when they contemplate the potential consequences associated with findings of guilt. Dr. entered a Psychology Services Intake Screening into PDS-BEMR on July 8, 2010. The document has three typographical errors. She selected the No Sexual Offense Convictions check box when, in fact, Mr. Epstein was previously convicted of Solicitation of Prostitution and Procuring a Person Under the Age of 18 for Prostitution. Second, Mr. Epstein was erroneously identified as a Black male in this document. Finally, there is one instance where he was mistakenly referred to as Mr. Brown. Dr. completed a Risk of Sexual Abusiveness document on July 8, 2019. She marked "History of prior prison sexual predation" in the affirmative. This is not accurate. Mid-Level Practitioner, completed a History and Physical on July 9, 2019. An Intake Screening should have been conducted within 24 hours of his entry into Bureau custody which was on July 6, 2019, according to P6031.04, Patient Care. Officer was responsible for observing Mr. Epstein and documenting his behavior while on suicide watch on July 23, 2019. mistakenly used a Suicide Watch Log Book intended for inmate companion documentation between 1:40 a.m. and 6:00 a.m. on July 23, 2019, when he should have been using the Staff Suicide Watch Log Book. Ms. , Drug Treatment Specialist, reportedly noticed this error and subsequently hand copied all of entries from 1:40 a.m. to 6:00 a.m. into a Staff Suicide Watch Log Book. She then initialed these entries, and this makes it ap ar as if she was the one conducting the watch. This information was discovered and conve ed in an e-mail from Associate Warden to Dr. with a carbon copy to Warden on August 12, 2019. Of note did not make an entry explaining why she was making the log book changes. Additionally, then wrote entries for 6:15, 6:30 6:45 and 7:00 a.m. in the Staff Suicide Watch Log Book. These were not a part of the original entries made by nor was III assn ned to work the Suicide Watch st. Due to the inability to interview staff at this time, it is unknown why attempted to correct error, or made any of the subsequent log entries. It is recommended that if a staff member makes an entry error (e.g., writes in the incorrect suicide watch log book), the staff member should describe the error in the correct log book, to include indicating when they became aware of the error. The staff member should then notify the Chief Psychologist. A review of Special Housing Unit Records (BP-A0292) revealed a number of incomplete entries. This document is used to monitor provision and receipt of basic services such as recreation, medical rounds, showers, meal consumption, etc. The Officer in Charge signature is missing on 10 occasions and a medical provider's signature is missing in seven instances. There are six instances in which it is not clear if Mr. Epstein ate his meal. There are nine instances in which it is not clear if Mr. Epstein took a shower. There are ten instances in which it is not clear if Mr. Epstein was offered recreation. P5500.15, Correctional Services Manual requires accurate and complete information on the BP-A0292. A review of Psychology Observation Log Books revealed significant discrepancies from the approved Psychological Observation Procedural Memorandum, dated April 15, 2019. A Correctional Officer is required to complete hourly rounds and sign the log book. 179 out of 183 round signatures were missing. The lieutenant is required to sign the log book one time per shift and signatures were missing in 10 of 23 instances. A Physician Assistant is required to sign one time per shift and 16 of 16 instances were missing. It is recommended that a further review of Psychological Observation procedures be conducted. 4 SDNY_00017579 EFTA00139170 Institution Response: 4. Documentation Accuracy: The Reconstruction team indicates it is critical that all descriptions of the incident accurately reflect objective evidence, and references Psychology staffs reliance on differing statements from two different staff regarding the July 23, 2019 incident. Psychology staff considers the information from more than one source when making decisions about suicide watch placement. Clinical judgment is used to make determinations taking into consideration each person's self-report of a situation as they may be perceived differently. In reference to typographical errors noted in PDS/BEMR notes, the ChiefPsychologist has spoken to all psychology staff members concerning proof reading all documents entered to reduce typos and to improve information accuracy. Additionally, there is a second Staff Psychologist in the department which helps reduce the workload on current psychologists, allowing more time for documentation review. Regarding the Reconstruction team's concerns in reference to Mr. Epstein's expunged incident report, Special Investigative Services staff will conduct all investigations in matters of attempted suicide and make a determination as to whether an incident report is warranted. The Reconstruction team stated medical staff conducted Inmate Epstein's Intake Screening late. SENTRY records reflect Inmate Epstein arrived in MCC New York's Receiving and Discharge (R&D) area on July 6, 2019, at approximately 9:24 .m. His medical Intake Screening was conducted at approximately 9:38 p.m., by Physician Assistant (PA) on the same night and approximately 14 minutes after his arrival in R&D. On July 9, 2019, he was placed on Psychological Observation and at approximately 12:38 p.m., he was escorted from Psychological Observation to Health Services for a Medical Assessment and a History and Physical, which was performed by PA within three (3) days of his arrival. According to Program Statement 6031.04, Patient Care, a provider must perform a History and Physical within 14 days of the inmate arriving at BOP facility. The History and Physical and Intake Screening were conducted timely and in accordance to policy. Regarding use of the incorrect Suicide Watch Log and the re-creation thereof, the Chief Psychologist and Drug Abuse Coordinator counseled the Drug Treatment Specialist (DTS) concerning her documentation in the suicide watch log book. There was no ill-intent on the part of the DTS as all log books were maintained; the original log book written by the officer and the one documented by the DTS. The DTS indicated a desire to assist the officer as he had written in the wrong log book. Specifically, he wrote in the inmate companion log book rather than the staff log book. However, she was informed that this is not her role and she is not to document in a log book for anyone else observing an inmate on suicide watch. In the future, only the staff member watching the inmate on suicide watch and Operation