EFTA00172546.pdf

LIMITED OFFICIAL USE The attached information must be protected and not released to unauthorized individuals. Use of this cover sheet is in accordance with the Department of Justice regulation on the control of Limited Official Use information. EFTA00172546  LIMITED OFFICIAL USE ONLY-NOT FOR PUBLIC RELEASE IN SPEC DRAFT 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 * * March 202:-; Notice: This Draft Is Restricted to Limited Official Use. This document is a WORKING DRAFT prepared by the U.S. Department of Justice Office of the Inspector General. It has not been fully reviewed within the Department and is, therefore, subject to revision. This report may contain sensitive law-enforcement or privacy-protected information and is for authorized recipients only. Recipients of this draft must not, under any circumstances, show or release its contents for purposes other than official review and comment. It must be safeguarded in accordance with Department of Justice Order 2620.7 to prevent publication or other improper disclosure of the information it contains. If you have received this draft report in error, please contact (202) 768-2643 to arrange its return. LIMITED OFFICIAL USE ONLY —NOT FOR PUBLIC RELEASE EFTA00172547  Limited Official Use Only—Not for Public Release 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 enable BOP staff to observe inmates and ensure they are secure in their cells and in good health. Further, to The Department of Justice (OOJ) Office of the Inspector eliminate safety hazards, MCC New York requires SHU General (OIG) initiated this investigation upon receipt of staff to search SHU common areas and at least five information from the Federal Bureau of Prisons (BOP) cells daily, and to search the entire SHU every week. that on August 10, 2019, in the Metropolitan For inmates identified as suicide risks, the BOP requires Correctional Center in New York, New York (MCC New they be placed on suicide watch until no longer at York), inmate Jeffery Epstein was found hanged in his imminent risk. A less restrictive monitoring form, assigned cell within the Special Housing Unit (SHU). psychological observation, is used for inmates who are The Office of the Chief Medical Examiner, City of New stabilizing but not yet ready to return to a housing unit. York, determined that Epstein had died by suicide. Additionally, BOP policy requires that all inmate The OIG conducted this investigation jointly with the telephone calls be made through BOP's Inmate Federal Bureau of Investigation (FBI), with the OIG's Telephone System. On rare occasions, BOP policy investigative focus being the conduct of BOP personnel. permits inmates to make a call outside of this system, Among other things, the FBI investigated the cause of but the call must be recorded and documented. Epstein's death and determined there was no criminality pertaining to how Epstein had died. Incident Involving Epstein on July 23, 2019 This report concerns the OIG's findings regarding MCC On July 23 at 1:27 a.m., correctional officers responded New York personnel's custody, care, and supervision of to Epstein's SHU cell where they found Epstein with a Epstein while detained at the facility from his arrest on handmade orange cloth around his neck. Epstein's federal sex trafficking charges on July 6, 2019, until his cellmate told officers Epstein tried to hang himself. death on August 10. Epstein was assigned to the SHU Medical staff examined Epstein, observed friction on July 7 due to media coverage of his case and inmate marks and superficial reddening around his neck and awareness of his notoriety. SHU inmates are securely on his knee, and placed him on suicide watch. Epstein separated from general population inmates and kept was removed from suicide watch on July 24 but locked in their cells for approximately 23 hours a day. remained under psychological observation until July 30. While in MCC New York, Epstein was screened on Epstein first told MCC New York staff he thought his numerous occasions by psychological staff and in all of cellmate had tried to kill him, but later said he did not the evaluations he denied having thoughts or a history know what occurred and did not want to talk about of suicide. Psychological staff determined Epstein did how he had sustained his injuries. Epstein also later not meet the criteria for a psychological diagnosis. asked if he could be housed with the same cellmate. Another inmate housed on the same SHU tier told the Relevant BOP Policies OIG that he heard Epstein's cellmate call for assistance, and that Epstein's cellmate told him that Epstein tried BOP policy requires SHU staff to observe all inmates at to hang himself from the bunkbed ladder. Disciplinary least twice an hour and that lieutenants conduct at charges against Epstein for alleged self-mutilation were least one round in the SHU each shift. BOP policy also not sustained due to insufficient evidence. requires multiple inmate counts during every 24-hour period. Among other things, inmate counts and rounds Following the July 23 incident, the Psychology Limited Official Use Only—Not for Public Release EFTA00172548  Limited Official Use Only—Not for Public Release Department determined Epstein needed to be housed breakfast to Epstein through the food slot in his locked with an appropriate cellmate, and on July 30 it sent an cell door, Epstein did not respond to Thomas's verbal email to over 70 MCC New York employees informing commands. Thomas unlocked the cell door and saw them of this requirement. The Warden at the time told Epstein hanged. Thomas immediately yelled for Noel the OIG that he selected a new cellmate for Epstein in to get help and call for a medical emergency. consultation with BOP executive leadership. That inmate remained Epstein's cellmate until August 9. Thomas told the OIG that when he entered Epstein's cell, Epstein had an orange string, presumably from a Events of August 8-10, 2019, and Epstein's Death sheet or a shirt, around his neck that was tied to the top portion of the bunkbed. Epstein was suspended On August 8, the U.S. Marshals Service sent two emails from the top bunk in a near-seated position, with his notifying numerous MCC New York staff that Epstein's buttocks approximately 1 inch to 1 inch and a half off cellmate was being transferred to another facility on the floor. Thomas said he immediately ripped the August 9. However, no action was taken to ensure orange string from the bunkbed, and Epstein's buttocks Epstein was assigned another cellmate. dropped to the ground. Thomas then lowered Epstein's body to the floor and began chest compressions until Also on August 8, Epstein met with his attorneys at the responding MCC New York staff members arrived prison, as he had on prior occasions, and signed a new approximately 1 minute later. Shortly thereafter, Last Will and Testament. MCC New York officials did outside medical personnel arrived and took over the not learn about the new Will until after Epstein's death. emergency response, eventually removing Epstein to a local hospital where he was pronounced dead. The following day, August 9, Epstein's cellmate was transferred to another facility and he was not assigned - On August 11, 2019, the Office of the Chief Medical a new cellmate. Also on August 9, after meeting at the Examiner performed an autopsy and determined the prison with his lawyers, staff allowed Epstein to make cause of death was hanging and the manner of death an unrecorded, unmonitored telephone call before he was suicide. Blood toxicology tests did not reveal any was returned to his SHU cell. Although Epstein said he medications or illegal substances in Epstein's system. was calling his mother, he actually called an individual The Medical Examiner who performed the autopsy told with whom he allegedly had a personal relationship. the OIG that Epstein's injuries were consistent with suicide by hanging and that there was no evidence of At approximately 8:00 p.m. on August 9, SHU inmates defensive wounds that would be expected if his death were locked in their cells for the night, including Epstein had been a homicide. Epstein did not have marks on who was without a cellmate. A search of Epstein's cell his hands, broken fingernails or debris under them, following his death revealed Epstein had excess prison contusions to his knuckles that would have evidenced a blankets, linens, and clothing in his cell, and that some fight, or, other than an abrasion on his arm likely due to had been ripped to create nooses. Only one SHU cell convulsing from hanging, bruising on his body. search was documented on August 9, and it was not of Epstein's cell. BOP records did not indicate when Epstein's cell was last searched. The OIG also found The Limited Available Video Evidence that SHU staff did not conduct any 30-minute rounds Recorded video evidence for August 9 and 10 for the after about 10:40 p.m. on August 9 and that none of the SHU area where Epstein was housed was only available required SHU inmate counts were conducted after 4:00 from one prison security camera due to a malfunction p.m. on August 9. Count slips and round sheets were of MCC New York's Digital Video Recorder system that falsified to show that they had been performed. occurred on July 29, 2019. While the prison's cameras continued to provide live video feeds, recordings were On August 10, at approximately 6:30 a.m., the two SHU made for only about half the cameras. MCC New York staff on duty, Correctional Officer Tova Noel and personnel discovered this failure on August 8, 2019, but Material Handler Michael Thomas, began delivering it was not repaired until after Epstein's death.' breakfast to SHU inmates. Tova unlocked the door to Epsteln's SHU tier. When Thomas attempted to deliver I As detailed in the report, MCC New York had a history of security camera problems. ii Limited Official Use Only—Not for Public Release EFTA00172549  Limited Official Use Only—Not for Public Release The available video from the one SHU camera captured contradicting the FBI's determination regarding the a large part of the common area of the SHU and absence of criminality in connection with how Epstein portions of the stairways leading to the different SHU died. SHU staff told the OIG that at approximately 8:00 tiers, including Epstein's cell tier. Thus, anyone entering p.m. on August 9, all SHU inmates, including Epstein, or attempting to enter Epstein's SHU tier from the SHU were locked in their cells for the evening and we found common area would have been picked up by that video no evidence to the contrary. The prison's recorded camera. Epstein's cell door, however, was not in the video did not identify any staff or other individuals camera's field of view. The OIG reviewed the video and approaching Epstein's SHU tier from the SHU common found that, between approximately 10:40 p.m. on area between approximately 10:40 p.m. on August 9 August 9 and about 6:30 a.m. on August 10, no one was and about 6:30 a.m. on August 10. Further, none of the seen entering Epstein's cell tier from the SHU common MCC New York staff members we interviewed were area. The OIG determined that movements captured aware of any information suggesting Epstein's cause of on video before and after those times were generally death was something other than suicide. Additionally, consistent with employee actions as described by none of the inmates we interviewed had any credible witnesses and documented in BOP records. information suggesting Epstein's cause of death was something other than suicide. Further, the SHU staff Results of the OIG's Investigation and Review and three interviewed inmates with a direct line of sight to Epstein's cell door on the night of his death stated The OIG's investigation and review identified numerous that no one entered or exited Epstein's cell after the and serious failures by MCC New York staff, including SHU staff returned Epstein to his cell on August 9. multiple violations of MCC New York and BOP policies and procedures. The 016 found that MCC New York We further noted that Epstein had previously been staff failed on August 9 to carry out the Psychology placed on suicide watch and psychological observation Departments directive that Epstein be assigned a due to the events of July 23, 2019; that numerous cellmate, and that an MCC New York supervisor allowed nooses made from the excess prison sheets were Epstein to make an unmonitored telephone call the found in his cell on the morning of August 10; and that evening before his death. Additionally, we found that he signed a new Last Will and Testament on August 8, 2 staff failed to undertake required measures designed days before he died. We found that the staffs failure to to make sure that Epstein and other SHU inmates were assign Epstein a cellmate on August 9, to conduct accounted for and safe, such as conducting inmate rounds and counts that evening, and to allow him to counts and 30-minute rounds, searching inmate cells, have excess linens in his cell, left Epstein unmonitored and ensuring adequate supervision of the SHU and the and locked alone in his cell for hours, which provided functionality of the video camera surveillance system. him an opportunity to commit suicide. The OIG also found that several staff falsified BOP Finally, the Medical Examiner who performed the records relating to inmate counts and rounds and autopsy detailed for the 016 why Epstein's injuries were lacked candor during their OIG interviews. Two MCC more consistent with, and indicative of, a suicide by New York employees, Noel and Thomas, were charged hanging rather than a homicide by strangulation. The criminally with falsifying BOP records. The charges Medical Examiner also cited the absence of debris were later dismissed after they successfully fulfilled under Epstein's fingernails, marks on his hands, deferred prosecution agreements. The U.S. Attorney's contusions to his knuckles, or bruises on his body Office for the Southern District of New York declined evidencing a struggle, which would be expected if prosecution for other MCC New York employees who Epstein's death had been a homicide by strangulation. the OIG found created false documentation. The OIG made nine recommendations to the BOP to The combination of these and other failures led to address the numerous issues identified during our Epstein being unmonitored and alone in his cell, which investigation and review. Finally, we recommend that contained an excessive amount of bed linens, from the BOP review the conduct and performance of the approximately 10:40 p.m. on August 9 until he was BOP personnel as described in this report and discovered hanged in his locked cell the following day. determine whether discipline or other administrative action with regard to each of them is appropriate. While the 016 determined MCC New York staff engaged in significant misconduct, we did not uncover evidence iii Limited Official Use Only—Not for Public Release EFTA00172550  Limited Official Use Only—Not for Public Release Table of Contents Chapter 1: Introduction 1 Chapter 2: Background 5 I. Significant Entities and Individuals 5 II. 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 1. Special Housing Units 8 2. Inmate Accountability 9 3. Psychological Screening 10 4. Suicide Response 11 5. Inmate Discipline 12 6. Conditions of Confinement 12 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 (SHU) 22 III. Epstein's Initial Cell and Cellmate Assignment from July 7 to July 23 26 IV. Events of July 23 and the Placement of Epstein on Suicide Watch and Psychological Observation from July 23 to July 30 26 V. The Psychology Department's Post-July 23 Determination that Epstein Needed to Have an Appropriate Cellmate 30 VI. Selection of Epstein's Cellmate After Psychological Observation 31 VII. Epstein's Cell Assignment from July 30 to August 10 31 VIII. Psychological Evaluations of Epstein from July 6 to August 9 37 Chapter 5: The Events of August 8-10, 2019, and Epstein's Death 45 I. Epstein Signs a New Last Will and Testament on August 8 45 II. Court Order on August 9 Releasing Epstein-Related Documents in Pending Civil Litigation 45 III. Transfer of Epstein's Cellmate on August 9 to Another Institution and Failure to Replace Him with Another Inmate 45 A. Notice on August 8 of the Impending Transfer of Epstein's Cellmate on August 9 45 Limited Official Use Only—Not for Public Release EFTA00172551  Limited Official Use Only—Not for Public Release B. MCC New York Staff Reject Epstein Attorney's Request that Epstein be Housed Without a Cellmate 46 C. Removal on August 9 of Epstein's Cellmate from MCC New York 46 D. Failure to Assign Epstein a New Cellmate on August 9 47 1. Day Watch Staff Actions on August 9 47 2. Evening Watch Staff Actions on August 9 50 IV. Epstein is Allowed to Make an Unmonitored Telephone Call on August 9 52 V. Failure to Conduct SHU Inmate Counts and Staff Rounds on August 9-10 55 A. SHU Inmate Counts 55 1. The 4:00 p.m. SHU Count on August 9 56 2. The 10:00 p.m. SHU Count on August 9 58 3. The 12:00 a.m., 3:00 a.m., and 5:00 a.m. SHU Counts on August 10 60 B. Staff Rounds in the SHU 61 1. Correctional Officer Rounds 61 2. Lieutenant Rounds 63 VI. Epstein's Death on August 10 64 A. Discovery of Epstein Hanged in Cell and Emergency Response 64 B. Items Found in Epstein's Cell on August 10 Following His Death 70 C. Autopsy Results 72 Chapter 6: The Availability of Limited Recorded Video Evidence Due to the Security Camera Recording System Failure 74 I. Background on the Security Camera System at MCC New York 74 II. Discovery of Security Camera System Recording Issues in August 2019 75 A. Discovery on August 8 of the DVR 2 Failure that Occurred on July 29 75 B. Response on August 8 and 9 to Discovery of the Recording Failure 76 C. SHU Camera Locations and Operational Status on August 10 77 D. FBI Forensic Analysis of the DVR System 82 Chapter 7: Conclusions and Recommendations 84 I. Conclusions 84 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 88 1. Failure to Make Required Notifications Regarding the Need to Assign Epstein a New Cellmate 88 2. Failure to Adequately Supervise SHU Staff 90 Limited Official Use Only—Not for Public Release EFTA00172552  Limited Official Use Only—Not for Public Release 3. Failure to Have a Contingency Plan for Assigning Epstein a Cellmate 91 4. Lack of Candor 91 B. MCC New York Staff Failed to Conduct Mandatory Rounds and Inmate Counts Resulting in Epstein Being Unobserved for Hours Before His Death 92 1. Failure to Conduct Rounds and Inmate Counts in the SHU 92 2. False Statements and Lack of Candor 93 3. Poor Judgment Regarding the Use of Overtime 94 4. Clearing the 10:00 p.m. Institutional Count Knowing that It Was Inaccurate 95 5. Failure to Adequately Supervise SHU Staff and Conduct Lieutenant Rounds 96 C. MCC New York Staff Allowed Epstein to Place an Unmonitored Telephone Call on August 9 97 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 98 E. MCC New York Staff Failed to Ensure that the Institution's Security Camera System was Fully Functional Resulting in Limited Recorded Video Evidence 99 II. Recommendations 100 Limited Official Use Only—Not for Public Release EFTA00172553  Limited Official Use Only—Not for Public Release Chapter 1: Introduction The Department of Justice (DOJ) Office of the Inspector General (OIG) initiated this investigation upon the receipt of information from the Federal Bureau of Prisons (SOP) 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 8:00 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 moved by medical staff to the MCC New York Health Service Unit.2 The Clinical Nurse continuously administered CPR until he was relieved by outside Emergency Medical Technicians (EMTs) when they arrived at the Health Services Area minutes later. The EMTs continued CPR, incubated 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 2 Moving an inmate requiring outside emergency medical care to the Health Services Unit provides health care staff and Emergency Medical Technicians (EMTs) 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 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. 1 Limited Official Use Only—Not for Public Release EFTA00172554  Limited Official Use Only—Not for Public Release 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 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., 12:00 a.m. to 12:30 a.m.) and again during the second 30 minutes of the hour (e.g., 12:30 a.m. to 1:00 a.m.), thus ensuring that inmates are observed at least twice per hour. BOP 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."3 3 These BOP forms are officially entitled "Official Count Slip" and "MCC New York, Special Housing Unit, 30 Minute Check Sheet." 2 Limited Official Use Only—Not for Public Release EFTA00172555  Limited Official Use Only—Not for Public Release 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 4:00 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 violatio OP and MCC New York policies and falsified records related to their conducting inmate counts and rou e OIG did not uncover evidence that contradicted the FBI's determination regarding the absence of cr ity in connection with how Epstein died. All MCC New York staff members who were interviewe 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 8:00 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.4 The OIG's analysis of the recorded video did not identify any correctional officers or other individuals approaching any of the SHU tiers, including the L Tier where 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 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 4For reasons we describe below, while the camera inside the L Tier was working and transmitting live video, the video was not being recorded. 3 Limited Official Use Only—Not for Public Release EFTA00172556  Limited Official Use Only—Not for Public Release 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 SON 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 SOP does not excuse them, and gives additional urgency to the need for DOJ and BOP leadership to address the chronic problerlaguing the SOP. 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(c)(1)(8) and 5 C.F.R. § 1201.56(b)(1)(ii). 11 In Chapter 2 of this report, we provide background information, including identification an 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 SON 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 Limited Official Use Only—Not for Public Release EFTA00172557  Limited Official Use Only—Not for Public Release 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. §§ 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 imprisonment), b