EFTA00039025.pdf

Investigation and Review of the Federal Bureau of Prisons' Custody, Care, and Supervision of Jeffrey Epstein at the Metropolitan Correctional Center in New York, New York * * * INVESTIGATIONS DIVISION 23-085 JUNE 2023 EFTA00039025  EXECUTIVE SUMMARY Investigation and Review of the Federal Bureau of Prisons' Custody, Care, and Supervision of Jeffrey Epstein at the Metropolitan Correctional Center in New York, New York Introduction and Background Epstein is Assigned to the SHU on July 7 According to its website, the Federal Bureau of Prisons Epstein was assigned to a cell in the SHU on July 7 due (BOPys current mission statement is "Corrections to media coverage of his case and inmate awareness of professionals who foster a humane and secure his notoriety. SHU inmates are securely separated environment and ensure public safety by preparing from general population inmates and kept locked in individuals for successful reentry into our their cells for approximately 23 hours a day. communities? However, the Department ofJustice (DOJ) Office of the Inspector General (OIG) has BOP policy requires SHU staff to observe all inmates at repeatedly identified long-standing operational least twice an hour and that Lieutenants conduct at challenges that negatively affect the BOP's ability to least one round in the SHU each shift. BOP policy also operate its institutions safely and securely. Many of requires multiple inmate counts during every 24-hour those same operational challenges, including staffing period. Among other things, inmate counts and rounds shortages, managing inmates at risk for suicide, enable BOP staff to observe inmates and ensure they functional security camera systems, and management are secure in their cells and in good health. Further, to failures and widespread disregard of BOP policies and eliminate safety hazards, MCC New York requires SHU procedures, were again identified by the OIG during staff to search SHU common areas and at least five cells this investigation and review into the custody, care, and daily, and to search the entire SHU every week. supervision of one of the BOP's most notorious inmates, Jeffrey Epstein. On July 18, the court refused to set bail for Epstein and ordered him detained pending trial on the The OIG initiated this investigation upon receipt of criminal charges. information from the BOP that on August 10, 2019, in the Metropolitan Correctional Center in New York, Incident Involving Epstein on July 23 New York (MCC New York), Epstein was found hanged While in MCC New York, Epstein was screened on in his assigned cell within the Special Housing Unit numerous occasions by psychological staff, including a (SHU). The Office of the Chief Medical Examiner, formal suicide assessment on July 9. In the evaluations City of New York, determined that Epstein had died he denied having thoughts or a history of attempted by suicide. suicide. Psychological staff determined Epstein did not meet the criteria for a psychological diagnosis. The OIG conducted this investigation jointly with the Federal Bureau of Investigation (FBI), with the OIG's On July 23, at 1:27 a.m., correctional officers (CO) investigative focus being the conduct of BOP personnel. responded to Epstein's SHU cell where they found Among other things, the FBI investigated the cause of Epstein with an orange cloth around his neck. Epstein's Epstein's death and determined there was no cellmate told officers Epstein tried to hang himself. criminality pertaining to how Epstein had died. Medical staff examined Epstein, observed friction marks and superficial reddening around his neck and This report concerns the OIG's findings regarding MCC on his knee, and placed him on suicide watch. BOP New York personnel's custody, care, and supervision of policy requires that inmates identified as suicide risks Epstein while detained at the facility from his arrest on federal sex trafficking charges on July 6, 2019, until his be placed on suicide watch until no longer at imminent risk. The BOP uses a less restrictive monitoring form, death on August 10. EFTA00039026 psychological observation, for Inmates who are Also on August 9, after meeting at the prison with his stabilizing but not yet ready to return to a housing unit. lawyers, MCC New York staff allowed Epstein to make, Epstein was removed from suicide watch on July 24 but in violation of BOP policy, an unrecorded, unmonitored remained under psychological observation until July 30. telephone call before he was returned to his SHU cell. Although Epstein said he was calling his mother, in Epstein first told MCC New York staff he thought his actuality he called someone with whom he allegedly cellmate had tried to kill him, but later said he did not had a personal relationship. know what occurred and did not want to talk about how he had sustained his injuries. Epstein also later At approximately 8 p.m. on August 9, SHU inmates asked if he could be housed with the same cellmate. were locked in their cells for the night, including Epstein Mother inmate housed on the same SHU tier told the who was without a cellmate. A search of Epstein's cell 016 that he heard Epstein's cellmate call for assistance, following his death revealed Epstein had excess prison and that Epstein's cellmate told him that Epstein tried blankets, linens, and clothing in his cell, and that some to hang himself from the bunkbed ladder. Disciplinary had been ripped to create nooses. Only one SHU cell charges against Epstein for alleged self-mutilation were search was documented on August 9, and it was not of not sustained due to insufficient evidence. Epstein's cell. BOP records did not Indicate when Epstein's cell was last searched. The 016 also found Following the July 23 incident, the Psychology that SHU staff did not conduct any 30-minute rounds Department determined Epstein needed to be housed after about 10:40 p.m. on August 9 and that none of the with an appropriate cellmate, and on July 30 it sent an required SHU Inmate counts were conducted after email to over 70 MCC New York employees informing 4 p.m. on August 9. Count slips and round sheets were them of this requirement. The Warden at the time told falsified to show that they had been performed. the OIG that he selected a new cellmate for Epstein in consultation with BOP executive leadership. That On August 10, at approximately 6:30 a.m., the two SHU inmate remained Epstein's cellmate until August 9. staff on duty, CO Tova Noel and Material Handler Michael Thomas, began delivering breakfast to SHU Events of August 8-10, 2019, and Inmates. Noel unlocked the door to Epstein's SHU tier. Epstein's Death When Thomas attempted to deliver breakfast to Epstein through the food slot in his locked cell door, On August 8, the U.S. Marshals Service sent two emails Epstein did not respond to Thomas's verbal commands. notifying numerous MCC New York staff that Epstein's Thomas unlocked the cell door and saw Epstein cellmate was being transferred to another facility on hanged. Thomas immediately yelled for Noel to get August 9. However, no action was taken to ensure help and call for a medical emergency. Epstein was assigned another cellmate. Thomas told the OIG that when he entered Epstein's Also on August 8, Epstein met with his attorneys at the cell, Epstein had an orange string, presumably from a prison, as he had on prior occasions, and signed a new sheet or a shirt, around his neck that was tied to the Last Will and Testament. MCC New York officials did top portion of the bunkbed. Epstein was suspended not learn about the new Will until after Epstein's death. from the top bunk in a near-seated position, with his buttocks approximately 1 inch to 1 inch and a half off The following day, August 9, Epstein's cellmate was the floor. Thomas said he immediately ripped the transferred to another facility and he was not assigned orange string from the bunkbed, and Epstein's buttocks a new cellmate. Additionally, on that date, the dropped to the ground. Thomas then lowered Epstein's U.S. Court of Appeals for the Second Circuit unsealed body to the floor and began chest compressions until approximately 2,000 pages of documents in civil responding MCC New York staff members arrived litigation involving Ghislaine Maxwell, who was later approximately 1 minute later. Shortly thereafter, convicted in December 2021 of conspiring with Epstein outside medical personnel arrived and took over the to sexually abuse minors over the course of a decade. emergency response, eventually removing Epstein to a The documents contain substantial derogatory local hospital where he was pronounced dead. Information about Epstein and there is extensive media coverage of information in the unsealed documents. On August 11, 2019, the Office of the Chief Medical Examiner performed an autopsy and determined the ii EFTA00039027 cause of death was hanging and the manner of death Epstein to make an unmonitored telephone call the was suicide. Blood toxicology tests did not reveal any evening before his death. Additionally, we found that medications or illegal substances in Epstein's system. staff failed to undertake required measures designed The Medical Examiner who performed the autopsy told to make sure that Epstein and other SHU inmates were the OIG that Epstein's injuries were consistent with accounted for and safe, such as conducting inmate suicide by hanging and that there was no evidence of counts and 30-minute rounds, searching inmate cells, defensive wounds that would be expected if his death and ensuring adequate supervision of the SHU and the had been a homicide. Epstein did not have marks on functionality of the video camera surveillance system. his hands, broken fingernails or debris under them, contusions to his knuckles that would have evidenced a The 016 also found that several staff falsified BOP fight, or, other than an abrasion on his arm likely due to records relating to inmate counts and rounds and convulsing from hanging, bruising on his body. lacked candor during their OIG Interviews. Two MCC New York employees, Noel and Thomas, were charged The Limited Available Video Evidence criminally with falsifying BOP records. The charges Recorded video evidence for August 9 and 10 for the were later dismissed after they successfully fulfilled SHU area where Epstein was housed was only available deferred prosecution agreements. The U.S. Attorneys from one prison security camera due to a malfunction Office for the Southern District of New York declined of MCC New York's Digital Video Recorder system that prosecution for other MCC New York employees who occurred on July 29, 2019. While the prison's cameras the OIG found created false documentation. continued to provide live video feeds, recordings were made for only about half the cameras. MCC New York The combination of these and other failures led to personnel discovered this failure on August 8, 2019, but Epstein being unmonitored and alone in his cell, which it was not repaired until after Epstein's death. As contained an excessive amount of bed linens, from detailed in this report, like many other BOP facilities, approximately 10:40 p.m. on August 9 until he was MCC New York had a history of security discovered hanged in his locked cell the following day. camera problems. While the 016 determined MCC New York staff engaged The available recorded video footage from the one SHU in significant misconduct, we did not uncover evidence camera captured a large pan of the common area of contradicting the FBI's determination regarding the the SHU and portions of the stairways leading to the absence of criminality in connection with how Epstein different SHU tiers, Including Epstein's cell tier. Thus, died. We did not find, for example, evidence that anyone entering or attempting to enter Epstein's SHU anyone was present in the SHU area where Epstein was tier from the SHU common area would have been housed during the relevant timeframe other than the picked up by that video camera. Epstein's cell door, Inmates who were locked in their assigned cells. The however, was not in the camera's field of view. The OIG SHU housing unit was securely separated from the reviewed the video and found that, between general inmate population and Inmates were kept approximately 10:40 p.m. on August 9 and about locked in their cells for approximately 23 hours a day. 6:30 a.m. on August 10, no one was seen entering Access to the SHU was controlled by multiple locked Epstein's cell tier from the SHU common area. The OIG doors. Within the SHU, the entrance to each tier could determined that movements captured on video before be accessed only via a single locked door at the top or and after those times were generally consistent with bottom of the staircase leading to the individual tier. employee actions as described by witnesses and Keys to open the locked tier doors were available to a documented in BOP records. limited number of COs while on duty. Each tier had eight cells and each individual cell, which was made of Results of the OIG's Investigation and Review cement and metal, could be accessed only through a The OIG's investigation and review identified numerous single locked door, to which a limited number of COs had keys while on duty. The SHU cell doors were made and serious failures by MCC New York staff, Including multiple violations of ma New York and BOP policies of solid metal with a small glass window and small and procedures. The OIG found that MCC New York locked slots that correctional staff used to handcuff Inmates and provide food and toiletries to inmates. As staff failed on August 9 to carry out the Psychology Department's directive that Epstein be assigned a a further security measure, during each shift a limited number of the COs had keys while on duty. cellmate, and that an MCC New York supervisor allowed iii EFTA00039028 SHU staff told the OIG that at approximately 8 p.m. on found in his cell on the morning of August 10; that no August 9, all SHU inmates, including Epstein, were weapons were recovered from his cell after his death; locked in their cells for the evening and we found no and that he signed a new Last Will and Testament on evidence to the contrary. The prison's recorded video August 8, 2 days before he died. We found that the did not identify any staff or other individuals staffs failure to assign Epstein a cellmate on August 9; approaching Epstein's SHU tier from the SHU common failure to conduct rounds and counts that evening; and area between approximately 10:40 p.m. on August 9 to allow him to have excess linens in his cell, left and about 6:30 a.m. on August 10. Additionally, the Epstein unmonitored and locked alone in his cell for O16 did not observe on the recorded video that Noel hours, which provided him an opportunity to and Thomas, who were seated at the desk at the SHU commit suicide. Officers' Station immediately outside the area where Epstein was housed, at any time during the time period Finally, the Medical Examiner who performed the rose from their seats or approached the cell block. We autopsy detailed for the O16 why Epstein's injuries were additionally found that Thomas's and Noel's reaction on more consistent with, and indicative of, a suicide by the morning of August 10 upon finding Epstein hanging hanging rather than a homicide by strangulation. The in his cell, as described to us by Thomas, Noel, the Medical Examiner also cited the absence of debris responding Lieutenant, and inmates, was consistent under Epstein's fingernails, marks on his hands, with their being unaware of any potential harm to contusions to his knuckles, or bruises on his body Epstein prior to Thomas entering Epstein's cell at about evidencing a struggle, which would be expected if 6:30 a.m. on August 10. Epstein's death had been a homicide by strangulation. None of the MCC New York staff members we Conclusion and Recommendations interviewed were aware of any information suggesting This is not the first time the O16 has found significant Epstein's cause of death was something other than Job performance and management failures on the part suicide. Additionally, none of the inmates we of BOP personnel and widespread disregard of BOP interviewed had any credible information suggesting policies that are designed to ensure that inmates are Epstein's cause of death was something other than safe, secure, and in good health. The combination of suicide. Further, the SHU staff and three interviewed negligence, misconduct, and outright job performance inmates with a direct line of sight to Epstein's cell door on the night of his death stated that no one entered or failures documented in this report all contributed to an environment in which arguably one of the BOP's most exited Epstein's cell after the SHU staff returned Epstein notorious inmates was provided with the opportunity to his cell on August 9. to take his own life, resulting in significant questions As noted, the surveillance camera in the SHU area being asked about the circumstances of his death, how it could have been allowed to happen, and most where Epstein was housed was live streaming movement in the hallway outside of Epstein's cell. importantly, depriving his numerous victims, many of Although the camera was not recording the captured whom were underage girls at the time of the alleged crimes, of their ability to seek Justice through the video, the camera was in plain view of the inmates and therefore inmates would have been aware that any criminal justice process. The fact that these failures hallway movements, including into or out of Epstein's have been recurring ones at the BOP does not excuse them and gives additional urgency to the need for DOJ cell, could be monitored by BOP staff, even if, unbeknownst to them, the DVR system was not and BOP leadership to address the chronic staffing, recording the live stream at that time. As the OIG has surveillance, safety and security, and related problems plaguing the BOP. noted in numerous prior reports, BOP staff and inmates are aware of where prison cameras are located and often engage in wrongdoing in locations where The O16 made eight recommendations to the BOP to address the numerous issues identified during our they know cameras are not located. Investigation and review. Finally, we recommended We noted as well that Epstein had previously been that the BOP review the conduct and performance of placed on suicide watch and psychological observation the BOP personnel as described in this report and determine whether discipline or other administrative due to the events of July 23, 2019; that numerous nooses made from the excess prison sheets were action with regard to each of them is appropriate. iv EFTA00039029  Table of Contents Chapter 1: Introduction 1 Chapter 2: Background 5 I. Significant Entities and Individuals 5 IL Methodology 6 III. Applicable Law, Regulations, and BOP Policies 7 A. Standards of Conduct 7 B. False Statements and Lack of Candor 8 C. Relevant BOP Policies Regarding the Operation of Correctional Facilities 8 Chapter 3: Timeline of Key Events 14 Chapter 4: Custody and Care of Epstein Prior to His Death 21 I. Epstein's Arrest and Detention on July 6 21 II. MCC New York's Special Housing Unit 22 III. Epstein's Initial Cell and Cellmate Assignment from July 7 to July 23 28 IV. Events of July 23 and the Placement of Epstein on Suicide Watch and Psychological Observation from July 23 to July 30 29 V. The Psychology Department's Post-July 23 Determination that Epstein Needed to Have an Appropriate Cellmate 32 VI. Selection of Epstein's Cellmate After Psychological Observation 33 VII. Epstein's Cell Assignment from July 30 to August 10 33 VIII. Psychological Evaluations of Epstein from July 6 to August 9 41 Chapter 5: The Events of August 8-10, 2019, and Epstein's Death 50 I. Epstein Signs a New Last Will and Testament on August 8 50 II. Court Order on August 9 Releasing Epstein-Related Documents in Pending Civil Litigation 50 III. Transfer of Epstein's Cellmate on August 9 to Another Institution and Failure to Replace Him with Another Inmate 51 A. Notice on August 8 of the Impending Transfer of Epstein's Cellmate on August 9 51 B. MCC New York Staff Reject Epstein Attorney's Request that Epstein be Housed Without a Cellmate 51 C. Removal on August 9 of Epstein's Cellmate from MCC New York 52 D. Failure to Assign Epstein a New Cellmate on August 9 53 IV. Epstein is Allowed to Make an Unmonitored Telephone Call on August 9 58 V. Failure to Conduct SHU Inmate Counts and Staff Rounds on August 9--10 61 EFTA00039030  A. SHU Inmate Counts 61 B. Staff Rounds in the SHU 67 VI. Epstein's Death on August 10 70 A. Discovery of Epstein Hanged in Cell and Emergency Response 70 B. Items Found in Epstein's Cell on August 10 Following His Death 76 C. Autopsy Results 79 Chapter 6: The Availability of Limited Recorded Video Evidence Due to the Security Camera Recording System Failure 81 I. Background on the Security Camera System at MCC New York 81 II. Discovery of Security Camera System Recording Issues in August 2019 82 A. Discovery on August 8 of the DVR 2 Failure that Occurred on July 29 82 B. Response on August 8 and 9 to Discovery of the Recording Failure 83 C. SHU Camera Locations and Operational Status on August 10 84 D. FBI Forensic Analysis of the DVR System 92 Chapter 7: Conclusions and Recommendations 94 I. Conclusions 94 A. MCC New York Staff Failed to Ensure that Epstein Had a Cellmate on August 9 as Instructed by the Psychology Department on July 30 98 B. MCC New York Staff Failed to Conduct Mandatory Rounds and Inmate Counts Resulting in Epstein Being Unobserved for Hours Before His Death 102 C. MCC New York Staff Allowed Epstein to Place an Unmonitored Telephone Call on August 9 107 D. MCC New York Staff Failed to Conduct and Document Cell Searches and Eliminate Safety Hazards in Epstein's Cell on August 9 Leaving Epstein with Excessive Linens in His Cell 108 E. MCC New York Staff Failed to Ensure that the Institution's Security Camera System was Fully Functional Resulting in Limited Recorded Video Evidence 109 II. Recommendations 110 Appendix A: The BOP's Response to the Draft Report 115 Appendix B: OM Analysis of the BOP's Response 118 EFTA00039031  Chapter 1: Introduction The Federal Bureau of Prisons (13OP) is a component of the Department of Justice (DOJ) that operates 122 institutions across the United States. According to its website, the BOP's current mission statement is "Corrections professionals who foster a humane and secure environment and ensure public safety by preparing individuals for successful reentry into our communities." However, the DOJ Office of the Inspector General (OIG) has issued numerous reports over more than a decade identifying long-standing operational challenges facing the BOP that have negatively affected its ability to operate its institutions safely and securely. Those reports have contained dozens of recommendations to the BOP. As we detail in this report, many of those same operational challenges and systemic issues, including significant staffing shortages, providing appropriate custody and care of inmates at risk for suicide, the absence of functional security camera systems, and management failures and widespread disregard of BOP policies and procedures, were once again identified by the OIG during the course of this investigation and review into the custody, care, and supervision of one of the SOP's most notorious inmates, Jeffrey Epstein. We therefore make further recommendations to the BOP in the conclusion of this report to help it address these recurring issues. The OIG initiated this investigation upon the receipt of information from the BOP that on the morning of August 10, 2019, in the Metropolitan Correctional Center located in New York, New York (MCC New York), inmate Jeffery Epstein was found hanged in his assigned cell within the Special Housing Unit (SHU). The SHU is a housing unit where inmates are securely separated from the general inmate population and kept locked in their cells for approximately 23 hours a day, to ensure their own safety as well as the safety of staff and other inmates. Epstein had been placed in the SHU on July 7, 2019, the day after his arrest, due to the significant media coverage of his case and awareness of his notoriety among MCC New York inmates. According to information obtained by the OIG during the investigation, at approximately 8 p.m. on August 9, all SHU inmates, including Epstein, were locked in their cells for the evening. Additionally, the six separate tiers or groups of cells within the SHU were also securely locked. At approximately 6:30 a.m. on August 10, 2019, SHU staff unlocked the door to the SHU tier in which Epstein's cell was located in order to deliver breakfast to inmates through the food slots in the locked cell doors. When SHU staff entered the tier to deliver breakfast to Epstein, SHU staff knocked on the locked door to Epstein's cell. Epstein, who was housed alone in the cell, did not respond to SHU staff. SHU staff unlocked the cell door and found Epstein hanged in his cell, with one end of a piece of orange cloth around his neck and the other end tied to the top portion of a bunkbed in Epstein's cell. Epstein was suspended from the top bunk in a near-seated position with his buttocks approximately 1 inch to 1 inch and a half off the floor and his legs extended straight out on the floor in front of him. Epstein's cell contained an excess amount of prison linens, as well as multiple nooses that had been made from torn prison linens. SHU staff immediately activated a body alarm, which notified all MCC New York staff of a medical emergency and prompted MCC New York staff assigned to the Control Center to call for 911 emergency services. SHU staff then ripped the orange cloth away from the bunkbed, which caused Epstein's buttocks to drop to the ground. SHU staff laid Epstein on the ground and immediately initiated cardiopulmonary resuscitation (CPR). At approximately 6:33 a.m., other MCC New York employees responded to the SHU. A responding MCC New York Lieutenant took over administering CPR and asked SHU staff to retrieve an automated external defibrillator and call for the duty nurse. A Clinical Nurse responded and continued to perform CPR on Epstein in the place of the Lieutenant. At approximately 6:39 a.m., Epstein was placed on a stretcher and 1 EFTA00039032 moved by medical staff to the MCC New York Health Service Unit., The Clinical Nurse continuously administered CPR until he was relieved by outside Emergency Medical Technicians (EMT) when they arrived at the Health Services Area minutes later. The EMTs continued CPR, intubated Epstein, and administered medication and fluids in their efforts to revive him. At approximately 7:10 a.m., Epstein was transported by the EMTs in an ambulance to New York Presbyterian Lower Manhattan Hospital, where he was pronounced dead by an emergency room physician at 7:36 a.m. On August 11, 2019, the Office of the Chief Medical Examiner, City of New York, performed an autopsy on Epstein and determined that the cause of death was hanging and the manner of death was suicide. The OIG conducted this investigation jointly with the Federal Bureau of Investigation (FBI), with the OIG's investigative focus being the conduct of BOP personnel. Among other things, the FBI investigated the cause of Epstein's death. The FBI determined that there was no criminality pertaining to how Epstein had died. This report concerns the OIG's findings regarding MCC New York personnel's custody, care, and supervision of Epstein during his detention at the facility from his arrest on July 6, 2019, until his death on August 10, 2019. The OIG investigation and review identified numerous and serious failures by MCC New York staff, as well as multiple violations of MCC New York and BOP policies and procedures. Among the most significant was the failure to assign Epstein a new cellmate on August 9, 2019, after Epstein's cellmate was transferred out of MCC New York that day. Epstein was required to have a cellmate at all times pursuant to a written direction that the MCC New York Psychology Department issued on July 30 after Epstein was removed from suicide watch and psychological observation following a possible attempted suicide by him on July 23. As a result of the failure to assign him a new cellmate, Epstein was housed alone in his cell from the night of August 9 until he was found hanged in his cell by SHU staff at approximately 6:30 a.m. the following morning. In addition, we determined that SHU staff failed to conduct required inmate counts and rounds, including overnight on August 9-10, and allowed Epstein to have an excess of blankets, linens, and clothing in his cell. These failures compromised Epstein's safety, the safety of other inmates, and the security of the institution, and provided Epstein an opportunity to commit suicide while locked alone in his cell on the morning of August 10 without having been subject to overnight observation or supervision by SHU staff. The OIG also found that an MCC New York supervisor had allowed Epstein, in violation of BOP policy, to make an unrecorded, unmonitored telephone call the evening before his death to an individual with whom he allegedly had a personal relationship. Further, 2 days before his death, during a meeting with his lawyers in a private room at the MCC New York, Epstein signed a new Last Will and Testament, which MCC New York officials did not learn about until after his death. Additionally, the OIG determined that MCC New York staff assigned to the SHU, including the two SHU staff on duty the night of August 9-10, 2019, who were stationed at a desk that was directly outside the SHU tier in which Epstein was housed and diagonally across from Epstein's cell, had falsified BOP records to claim Moving an inmate requiring outside emergency medical care to the Health Services Unit provides health care staff and Emergency Medical Technicians (EMT) with immediate access to any necessary medical equipment and supplies and allows EMTs faster access to the inmate when they arrive at MCC New York because Correctional Officers (CO) can directly escort EMTs to the Health Services Unit to begin emergency treatment immediately. If EMTs had to be escorted to the housing unit, they would first need to be thoroughly screened, which would delay medical attention. 2 EFTA00039033 that they had conducted all of the required counts of inmates and 30-minute rounds during their shifts within the SHU. As described in greater detail in Chapter 2, inmate counts and 30-minute rounds are two means by which the BOP accounts for inmates and assesses their safety, security, and well-being. BOP and MCC New York policies require that staff members count all inmates in each housing unit within the facility at designated times each day. Additionally, SOP and MCC New York policies require that a staff member observe all SHU inmates at least once during the first 30 minutes of each hour (e.g., 12 a.m. to 12:30 a.m.) and again during the second 30 minutes of the hour (e.g., 12:30 a.m. to 1 a.m.), thus ensuring that inmates are observed at least twice per hour. SOP staff are required to document inmate counts and 30-minute rounds on official BOP forms, which are often referred to as "count slips" and "round sheets."2 During the OIG's investigation, the OIG obtained information that the staff assigned to the MCC New York SHU did not conduct any counts of inmates within the SHU from August 9, 2019, at approximately 4 p.m., until Epstein was found hanged in his cell on the morning of August 10, 2019. However, in documentation completed by the SHU staff on duty during that period, staff members falsely certified in the count slips that they had conducted the required counts. Additionally, the OIG investigation revealed that the staff assigned to the MCC New York SHU did not conduct any required 30-minute rounds of inmates after approximately 10:40 p.m. on August 9, 2019. Again, however, SHU staff on duty during that period had falsely certified in the round sheet that the required rounds were conducted. The combination of these and other failures led to Epstein being unmonitored and locked alone in his cell, which the OIG found contained an excessive amount of bed linens, from approximately 10:40 p.m. on August 9 until he was discovered hanged in his cell at approximately 6:30 a.m. the following day. While the OIG determined that MCC New York staff committed significant violations of BOP and MCC New York policies and falsified records related to their conducting inmate counts and rounds, the OIG did not uncover evidence that contradicted the Fars determination regarding the absence of criminality in connection with how Epstein died. All MCC New York staff members who were interviewed by the OIG said they did not know of any information suggesting that Epstein's cause of death was something other than suicide. Additionally, none of the 15 inmates who agreed to be interviewed in connection with this investigation, 10 of whom were housed in the SHU on August 9 and 10, had any credible information suggesting that Epstein's cause of death was something other than suicide. Further, the SHU staff and the three interviewed inmates with a direct line of sight to the door of Epstein's cell from their cells stated that no one entered or exited Epstein's cell after the SHU staff returned Epstein to his cell on the evening of August 9, which is consistent with the security measures in place within the MCC New York SHU. SHU staff told the OIG that at approximately 8 p.m. on August 9, all SHU inmates were locked in their cells for the evening and that there was no indication that any of the other inmates could have gotten out of their cells. Additionally, the OIG analyzed the available recorded video of the SHU, which was limited to the common area of the SHU, including the SHU Officers' Station, due to the MCC New York security camera system's recording issues that we detail in this report.' The OIG's analysis of the recorded video did not identify any Correctional Officers (CO) or other individuals approaching any of the SHU tiers, including the L Tier where 2 These BOP forms are officially entitled "Official Count Slip" and "MCC New York, Special Housing Unit, 30 Minute Check Sheer For reasons we describe below, while the camera inside the L Tier was working and transmitting live video, the video was not being recorded. 3 EFTA00039034 Epstein was housed, from the common area of the SHU between approximately 10:40 p.m. on August 9 and approximately 6:30 a.m. on August 10. Finally, the Medical Examiner who performed the autopsy detailed for the OIG why Epstein's injuries were more consistent with, and indicative of, a suicide by hanging rather than a homicide by strangulation. The Medical Examiner also cited to the absence of debris under Epstein's fingernails, marks on his hands, contusions to his knuckles, or bruises on his body that evidenced Epstein had been in a struggle, which would be expected if Epstein's death had been a homicide by strangulation. As discussed in greater detail in the Conclusions and Recommendations chapter of this report, this is not the first time that the OIG has found significant job performance and management failures on the part of BOP personnel and widespread disregard of SOP policies that are designed to ensure that inmates are safe, secure, and in good health. The OIG has investigated numerous allegations related to the falsification of official SOP documentation concerning inmate counts and rounds and has repeatedly found deficiencies with the BOP's staffing levels, the custody and care of inmates at risk for suicide, and security camera systems at BOP institutions. The combination of negligence, misconduct, and outright job performance failures documented in this report all contributed to an environment in which arguably one of the most notorious inmates in BOP's custody was provided with the opportunity to take his own life. The BOP's failures are troubling not only because the BOP did not adequately safeguard an individual in its custody, but also because they led to questions about the circumstances surrounding Epstein's death and effectively deprived Epstein's numerous victims of the opportunity to seek justice through the criminal justice process. The fact that these failures have been recurring ones at the BOP does not excuse them and gives additional urgency to the need for DOJ and BOP leadership to address the chronic problems plaguing the BOP. Unless otherwise noted, the OIG applies the preponderance of the evidence standard in determining whether DOJ personnel have committed misconduct. The U.S. Merit Systems Protection Board applies this same standard when reviewing a federal agency's decision to take adverse action against an employee based on such misconduct. See 5 U.S.C. § 7701(cX1)(B) and 5 C.F.R. § 1201.56(bX1)(ii). In Chapter 2 of this report, we provide background information, including identification and a description of significant entities and individuals; a summary of our methodology; and the applicable laws, federal regulations, and BOP policies. In Chapter 3, we outline a timeline of key events. In Chapter 4, we set forth our findings of fact relating to the BOP's custody and care of Epstein before his death. In Chapter 5, we set forth our findings of fact related to the events of August 8-10, 2019, including Epstein's death. In Chapter 6, we set forth our findings of fact related to the BOP's failure to ensure that there was a functional security camera system at MCC New York, which resulted in limited recorded video evidence relevant to Epstein's death. Finally, Chapter 7 contains our conclusions and recommendations. 4 EFTA00039035  Chapter 2: Background I. Significant Entities and Individuals Jeffrey Epsteinwas born in 1953 and, prior to his arrest, worked at various jobs in the financial industry and ultimately developed considerable wealth. On July 2, 2019, a federal grand jury of the U.S. District Court for the Southern District of New York returned an indictment that charged Epstein with engaging in sex trafficking and a sex trafficking conspiracy, in violation of 18 U.S.C. 44 371, 1591(a), (b)(2), and 2. These charges were based on allegations that between 2002 and 2005, Epstein paid girls as young as 14 years old hundreds of dollars in cash each for engaging in sex acts with him at his Florida and New York residences. The indictment further alleged that Epstein also paid each of these minor victims hundreds of dollars in cash to recruit other girls to engage in sex acts with Epstein. On July 6, 2019, Epstein was arrested at Teterboro Airport in New Jersey upon his return to the United States from France and was transported to the Federal Bureau of Prisons' (BOP) Metropolitan Correctional Center, located at 150 Park Row in New York, New York (MCC New York). Following a detention hearing on July 15, 2019, the court ordered that Epstein be detained pending trial based on the court's finding that he was a danger to the community and a flight risk. MCC New York is a federal administrative detention facility operated by the BOP that primarily provides pretrial detention services for the U.S. District Courts for the Southern and Eastern Districts of New York. The BOP temporarily closed MCC New York in October 2021 due to substandard conditions that are unrelated to this investigation. When it was operational, MCC New York housed approximately 750 inmates at any given time. Prior to its closure, the majority of MCC New York's inmate residents were individuals with pending criminal charges (as opposed to individuals who had been convicted of offenses and were serving a sentence of imprisonme