EFTA00141175.pdf

Background Jeffrey Epstein was formally charged with Sex Trafficking Conspiracy in violation of 18 U.S.C. Section 371 and Sex Trafficking in violation of 18 U.S.0 Section 1591(a), (b) (2), 2 on July 2, 2019. Specifically, he was accused of sexually exploiting and abusing minor females over the course of several years. Charging documents allege that Epstein enticed and recruited minor females to engage in sexual activity. The minor females were reportedly compensated with case following the sexual encounters and some were encouraged to find other minor females to accompany them to Epstein's residences in New York and Florida. Epstein's incarceration with the Federal Bureau of Prisons The FBI arrested Jeffrey Epstein on the sex trafficking charges on Saturday, July 6, 2019. Epstein was arrested at Teterboro Airport in New Jersey upon his return from Paris, France. He was transported to the Federal Bureau of Prison (BOP) Metropolitan Correctional Center (MCC) located at 150 Park Row, New York, New York, and keyed into SENTRY at 9:24 p.m. that evening. The MCC, which housed approximately 750 inmates at any given time, assigned inmates to various housing units within the MCC. Epstein was initially assigned to a bed in the MCCs general population, but on July 7, 2019, at approximately 7:20 p.m., he was moved to the Special Housing Unit (SHU) pending reclassification due to the significant increase in media coverage and awareness of his notoriety among the inmate population. The SHU is a housing unit within the MCC where inmates are securely separated from the general population to ensure their own safety as well as the safety of staff and other inmates. The SHU is located on the ninth floor of the MCC, and access to that floor is controlled by a locked door that can be opened remotely only by an MCC staff member in the MCC's centralized control center, which is located on the first floor of the MCC. Access into the SHU is also controlled by a second locked door, to which only correctional officers assigned to the SHU have keys while on duty. Within the SHU, innates are assigned to six separate tiers, each of which can be accessed only via a single locked door, to which the correctional officers assigned to the SHU have keys while on duty. Each tier has eight cells, each of which can house either one or two prisoners, and each individual cell, which is made of cement and metal, is accessed only through a single locked door, to which only correctional officers assigned to the SHU have keys while on duty. Epstein was assigned to the SHU due to, among other things, risk factors for suicidality and safety concerns relating to housing him with the MCCs general population. According to former Warden the MCC typically houses inmates in the SHU with a cellmate. Upon Epstein's transfer to the SHU, he was assigned a cell with Inmate Nicholas Register Number 78514-054. He stated that he picked inmate Nicholas to be Epstein's cellmate because was a white male who could likely cope with Epstein. On July 8, 2019, Epstein underwent a psychological intake screening at the MCC. Epstein reported that he did not have thoughts of suicide, never attempted suicide, and told the psychologist that he was not receiving treatment related to his mental health. The MCCs chief psychologist, consulted with a psychiatrist from the BOP's Central Office, regarding Epstein. notes state that risk factors for suicidality were present in Epstein's situation. identified those risks as being: a high profile case with media attention, sex offense charges, pre-trial status, and a "court proceeding today which would potentially be giving him bad news regarding his legal situation." As a consequence, directed that Epstein be placed in psychological observation upon his return from court pending a mental health evaluation. During Epstein's period under suicide watch and psychological observation, "inmate companions" stayed with and continuously observed him. The inmate companions kept a log EFTA00141175 detailing Epstein's activities in 15-minute increments. The difference between suicide watch and psychological observation is the access to personal items while under observation and their clothing. During suicide watch, an inmate cannot have any clothing or personal items; whereas, during Psychological Observation, an inmate is permitted to have clothing and personal items that cannot be used to engage in self harm. On July 9, 2019, conducted a suicide risk assessment of Epstein. Epstein denied any suicidality and had no mental health or suicide history. According to notes, Epstein was "future-oriented and expressed a commitment to life and safety, agreeing to contact staff immediately should he experience suicidal ideation." The notes also show that Epstein said "being alive is fun." determined that Epstein's overall suicide risk was "low" and a "suicide watch [was] not warranted at this time," but psychology observation is continued "pending suitable housing placement." In addition, Health Services completed a History & Physical for Epstein. This assessment was done in lieu of an Intake Screening, which should have been conducted within 24-hours of Epstein's arrival (PS6031.04). A review of the BOP Electronic Medical Records (BEMR) indicate that Epstein was diagnosed with hyperlipidemia, sleep apnea, hypertension, constipation, prediabetes, neuralgia, and neuritis unspecified. He was prescribed the following medications: docusate sodium, milk of magnesia, omega 3, methylprednisone, and bisacodyl. Epstein was also prescribed insulin, and the prescription required him to go to the institution pharmacy for administration of this medication. However, the dates for which it was prescribed have a notation indicating "does not indicated," thus it does not appear insulin was routinely medically necessary. The rest of the medications prescribed were self-carry. On July 10, 2019, met with Epstein again. According to notes, Epstein again denied suicidality. also wrote that Epstein appeared "psychologically stable at this time and can be released from the psychological observation area." Epstein was taken off of psychological observation and returned to the SHU with documented recommendations for a cellmate and next-day contact by psychology. Epstein was placed in cell Z0S-124LAD, again with inmate On July 11, 2019, Epstein again met with while conducting a legal visit, because Epstein was spending an inordinate amount of day time hours with his attorneys. To avoid missing the completion of the follow-up visit, briefly interrupted the attorney visit and met with Epstein privately. According to notes, Epstein denied any suicidality. This visit recommended additional follow-up the next week. On July 16, 2019, Epstein is seen by psychology in the presence of his attorneys while conducting a legal visit. This visit recommended no follow-up. Per the BOP after action report, this visit was at the request of Epstein and was wholly inappropriate. Epstein's attempt to establish guidelines for communication and bring his attorneys into the fray regarding the mental health treatment being provided by the institution. It is not typical for the BOP to provide psychological intervention in the presence of others, nor is it appropriate for a BOP psychologist to meet with inmate attorneys. On July 23, 2019, at approximately 1:27 a.m., while Epstein was housed in the SHU, MCC correctional officers assigned to the SHU responded to noises coming from Epstein's cell. When the two SHU correctional officers responded, Epstein's cellmate, . told them that Epstein had attempted to hang himself. The correctional officers observed that Epstein had an "orange homemade rope" around his neck, which they removed. The correctional officers also observed that Epstein was breathing, but unresponsive. Epstein received medical treatment and, at approximately 1:40 am, was EFTA00141176 placed on suicide watch by Operations Lieutenants Inmates placed on suicide watch are housed in a cell on the hospital wing floor of the MCC, and are watched twenty-four hours a day by a staff member or a specially trained inmate companion. During the incident, there were reports that Tartgalione had attempted to harm Epstein. However, multiple witnesses, including told the OIG that Epstein was observed displaying behavior that was inconsistent with that allegation, and said that Epstein may have made the statement because he was attempting to be housed by himself. Special Investigative Services (SIS) staff opened an investigation to assess Epstein's safety and collect facts surrounding the episode. Despite this investigation, SIS investigators were unable to determine whether he was assaulted or engaged in self-directed violence. On the morning of July 24, 2019, Staff Psychologist Ph.D., conducted a "Post Suicide Attempt" interview of Epstein and directed that he be taken off of suicide watch. According to the notes, Epstein denied suicidality and stated, "I have no interest in killing myself" and that it "would be crazy" to take his life. He also said that he was "depressed" and "unhappy" about his current legal situation. The staff psychologist ended suicide watch and informed Epstein that he would remain in the same cell on psychological observation in the near term. Psychological observation is less restrictive than suicide watch, but inmates are still housed in the hospital wing of the MCC and watched twenty-four hours a day. Every day between July 25, 2019 and July 29, 2019, either Chief Psychologist or Staff Psychologist met with Epstein and conducted a clinical contact. In each instance, Epstein denied any suicidal ideation. According to notes, she met with Epstein on July 29, and at that meeting, Epstein asked to remain in the hospital for one more week. told Epstein that he would return to the SHU the next day. Daily psychology contact while on psychology observation indicated that Epstein would be moved to another cell due to toilet issues. This move is not shown by SENTRY to have occurred. A review of SENTRY indicates that he was transferred back to the SHU on July 29, 2019, whereas PDS-BEMR indicates that he was removed from Psychological Observation on July 30, 2019, at approximately 8:15 a.m. On July 30, 2019, Psychology observation status was discontinued with a recommendation for a cellmate while assigned to the SHU. Directive for Epstein to Have a Cellmate As detailed in the Psychology section of this report, prior to Epstein's removal from Psychological Observation on July 30, 2019, a determination was made by the MCC New York Psychology Department that Epstein be housed with a cellmate. To ensure Epstein's cellmate requirement was disseminated to MCC New York staff, on July 30, 2019, at 12:30 p.m., Dr. =, Psychology Department, sent a mass email to MCC staff members which read, "Inmate Epstein #76318-054 is being taken off Psych Observation and needs to be housed within an appropriate cellmate." A review of the email recipients showed that the email was sent to, among others, Warden AW Captain SHU Lt. SIS Lt. Lt. Lt. Lt. Lt. and who were all interviewed by the OIG. As a result of the requirement, Epstein was assigned to SHU cell Z04-206LAD with inmate =, Register Number . SENTRY is inaccurate regarding this move, as it shows to have occurred the previous day. A medical record note is completed stating that Epstein will be issued a Continuous Positive Air Pressure (CPAP) machine, which is typically used to treat sleep apnea. Per BEMR, Epstein was provided with his personal CPAP machine on July 30, 2019. Although EFTA00141177 there is no SENTRY transaction, Epstein and were moved to SHU cell 206-220. This move was done to accommodate the electrical needs of Epstein's assigned the CPAP machine. Epstein was also assigned to the cell closest to the correctional officers' desk in the common area of the SHU, which was approximately fifteen feet from his assigned cell. On July 30, 2019, the MCC psychologists determined that Epstein did not "appear to be an immediate danger to [himself]" and psychological observation was discontinued. Former MCC Warden N' Diaye stated that advised him that Epstein was not suicidal and was ready to return to the SHU. That same day, Staff Psychologist completed a "Post-Watch Report" which stated that the "SHU Lt. was informed that Mr. Epstein needs to be housed with an appropriate cellmate." SHU Lieutenant stated that a BOP psychologist said that Epstein must be housed with a cellmate when he returned to the SHU. also sent a group email to the MCCs leadership, including the Warden, Associate Wardens, the Captain, and all lieutenants, stating that Epstein was "being taken off of Psych Observation and needs to be housed with an appropriate cellmate." During interviews conducted by the 016 of AW =, Captain and SHU Lt. they each said that the verbally informed the SHU Staff of Epstein's cellmate requirement, and were confident that each staff who worked in the SHU on August 9 and 10, 2019, knew of Epstein's cellmate requirement. AW said that Captain was in charge of correctional services, and LT IN was the SHU LT. said that should have told M, and should have told the SHU staff. MI would be responsible for ensuring that everything was in compliance within the SHU. They should have provided it in writing via email and verbally. said the SHU staff did know that Epstein was required to have a cellmate, and said she personally heard it spoken about when she would visit the SHU on more than one occasion when doing rounds. Captain said that after the directive was issued, he spoke with SHU LT and directed him to ensure Epstein had a cellmate. LT said that he passed the directive down to the SHU staff. Additionally, SHU OIC said that he was aware of Epstein's cellmate requirement, and said that all SHU staff were also aware of the requirement. MCC New York Psychology Department personnel told the 016 that MCC personnel knew of Epstein's cellmate requirement because it was discussed during staff meetings, department head meetings, SHU meetings, morning meetings, and during required staff training. According to N' Diaye, when he spoke with regarding Epstein, said to get Epstein a cellmate. He added that typically the MCC will house an inmate who was previously on suicide watch with a cellmate. N' Diaye stated there was no BOP policy mandating that an inmate coming off of suicide watch have a cellmate, but that doing so was "sound correctional judgment." similarly told the 016 that it was "common practice" in the BOP for prisoners coming off of suicide watch to be assigned a cellmate. However, there is no BOP policy addressing the necessity of assigning cellmates to individuals coming off of suicide watch. Epstein's cellmate selection Captain told the OIG that on July 30, 2019, upon Epstein's removal from Psychological Observation, he was transferred to the SHU and inmate M, Register Number was assigned as his cellmate. Captain told the 016 that he compiled a list of potential cellmates for Epstein, but Epstein's ultimate cellmate selection was made by Warden and Regional Director Warden and Regional Director confirmed that they selected inmate was from a list of potential cellmates. Captain Warden and Regional Director told the 016 that if was removed as Epstein's cellmate, they would have to EFTA00141178 review a new list of potential cellmate candidates to ensure that Epstein was housed with an appropriate selection. and told the OIG if was removed from the MCC New York, SHU staff should have informed a Lieutenant on duty, who would in turn should have informed Captain who would have ensured that the process of selecting a new cellmate would begin. A review of financial transactions associated with Epstein's prison account revealed one of his attorneys was depositing funds into his commissary account for unknown reasons. Captain Jermain ME, who supervises all of the lieutenants and correctional officers working in the MCC, told the OIG that at direction, he compiled a list of possible cellmates for Epstein, vetted those inmates, and provided the list of names to stated that he identified three inmates to possibly house with Epstein and decided on . He further stated that he advised the BOP Director's Chief of Staff Regional Director and Associate Warden that Epstein needed to have a cellmate and provided them with the names of the three possible inmates that could fill that role and his decision to use . During re- interview, he said that the Warden contacted the Regional Director and the two of them made that decision. actually said that the Regional Director, was the one who made the ultimate selection. Typically, a lieutenant, in conjunction with the Officer in Charge and others can assign a cellmate to an inmate in the SHU. said that in regard to Epstein, if were to depart the MCC, the correctional officers were to notify the lieutenant of departure; the lieutenant was then to advise and would tell that Epstein did not have a cellmate. stated that he and his staff would then review the situation and determine which inmate would be Epstein's new cellmate. also said that there were no inmates pre-vetted to replace if he left the MCC. Aside from LT the LTs on August 9, 3019, knew that Epstein was required to have a cellmate and were aware that Epstein's cellmate was selected at a higher level due to his high profile status. said that he was off from work on August 9, 2019, and was unaware of transfer. also said that in the event Epstein was without a cellmate, the plan was to review the situation and decide with whom to replace M, but that no inmate in the SHU was preselected to replace if this event occurred. said that he directed to ensure that Epstein had a cellmate confirmed that directed him to ensure that Epstein had a cellmate. said that he orally informed his lieutenants that Epstein needed a cellmate at all times, and repeatedly directed to ensure Epstein had a cellmate. He said that he also visited the SHU on multiple occasions and directed his staff to be alert and attentive about Epstein's special needs. IM told the OIG that told him that Epstein was required to have a cellmate. MI also said that after the BOP staff psychologist directed that Epstein was to have a cellmate, he ensured that Epstein did so and advised his staff of the staff psychologist's directive. said that he did not work on August 9, 2019, and was unaware that Epstein was without a cellmate. Epstein's cellmate assignment According to a BOP report obtained under this investigation titled Institution Response dated May 14, 2020, a SENTRY quarters roster generated on August 10, 2019, at 12:51 a.m., there were three inmates EFTA00141179 assigned to Epstein's SHU cell, 204-206LAD, including him, at the time of his death. However, his SHU cell was only a double occupancy cell. Inmate =, Register Number inmate M, Register Number and Epstein were all assigned to the same cell. On August 13, 2019, at 12:06 p.m. and 12:08 p.m., a quarters history roster was generated for inmates and Mt respectively. Inmate cell assignment was 204-206LAD from August 5, 2019, until August 11, 2019, when he was moved to cell 104-212UAD. Inmate cell assignment was 204-206UAD from August 1, 2019, until August 11, 2019, when he was moved to cell 204-207LAD. A quarters history roster was generated for Epstein on August 13, 2019, at 9:07 a.m. His cell assignment was 204-206LAD from July 29, 2019, until August 10, 2019. The same BOP report indicates that on Monday, August 12, 2019, photographs of name tags on SHU cell doors and SHU locator forms were sent to the Correctional Service Department in the Northeast Region. The SHU locator form was dated August 9, 2019, and it shows inmate in cell 207L (Sentry states he was moved to this cell on August 11, 2019), inmate in cell 212U (SENTRY states he was moved to this cell on August 11, 2019), inmate Epstein in cell 220L (SENTRY never shows him in this cell) along with inmate =I, Register Number . The locator shows inmate Register Numbers and inmate Register Number in cell 206. The photo sheets show the cell being 220 with inmates Epstein and =' identification cards on the door. Inmate was in cell Z06-220U from August 5, 2019, to August 9, 2019. The OIG investigation has revealed that on July 30, 2019, at approximately XXXX, Epstein was placed into Special Housing Unit (SHU) cell number XXX with inmate . MCC staff entered Epstein's cell number in SENTRY to reflect Epstein's assignment. Following the placement, Epstein's CPAP machine did not reach the power cord. Therefore, Epstein and were physically moved to SHU cell number XXX. However, no one ever made the change in Sentry to reflect Epstein's move. (Check Quarters History). XXX was responsible for making the change within Sentry at the time of the move. According to staff interviews, it does not appear that there were any checks and balances to ensure that inmates were physically located within the cells that they were assigned within Sentry. AW told the OIG XXXX July 31, 2019 Although neither SENTRY nor the Lieutenant's Log reflect this event, Epstein attended a court hearing on July 31, 2019, and, upon his return at an unspecified time, the United States Marshals Service (USMS) provided paperwork to the MCC New York Receiving and Discharge (R&D) staff that noted "suicidal tendencies." August 1, 2019 Dr. =, Psychology, was notified of the form received from the USMS the previous day stating that Epstein had reported suicidal tendencies. She consulted with Dr. and then conducted a suicide risk assessment, noting watch was not indicated with a recommendation for follow-up in one week. According to the BOP After Action Review, the delay in conducting the assessment was not justified in the report. August 2, 2019 EFTA00141180 An SIS Investigation into the July 23, 2019, incident was completed. The investigation stated there was insufficient evidence to support either Epstein harmed himself or was harmed by his cellmate. August 8, 2019 On August 8, 2019, at 10:02 a.m., Psychology contact for suicide risk assessment follow-up was conducted. No concerns or follow-up noted. At 10:33 a.m., the United States Marshals Service (USMS) sent an email to MCC personnel assigned to the MCC Receiving and Discharge Department with the Subject, "Transfers of Prisoners from NYM to GEO." GEO is a Detention Facility located in Queens, New York. Within the body of the document, the text reads, "The following prisoners are to be transferred:" followed by two names and register numbers. The second name was listed as "=, ." Immediately below inmate name, it reads, "Please schedule the transfer for Friday 8/9/19. Please include 7 days mediation with the medical summary. Thank you." At 3:36 p.m., the USMS sent a second email to a number of MCC personnel assigned to the MCC Custody Department, with the Subject, "Prisoner Production 08-09-2019," which included two attachments. One of the attachments was listed as "NYM 08-09-2019." That attachment was the Prisoner Schedule Report for the MCC New York on August 9, 2019. On the first page of the attachment, it shows that inmate was scheduled be transferred from the MCC to GEO, on August 9, 2019. The document reflects the acronym WAB within the Destination/Description portion of the document, which all MCC staff members told the OIG means "With All Belongings." The MCC staff members told the OIG that WAB meant that was being permanently removed from the MCC on August 9, 2019. Among others, the email was sent to Captain Lt. IM=l, Lt. Lt. Lt. SHU Lt.= Stanley, SIS LT and AW who were all interviewed by the OIG. August 9 and 10, 2019 According to a BOP Memorandum for_, Regional Director, Northeast Region, on August 9, 2019, a federal court unsealed approximately 2,00 pages of documents in the public domain. These included allegations against Epstein. Included was a book order receipt for titles such as SM 101: A Realistic Introduction; SlaveCraft: Roadmaps for Erotic Servitude; and Training with Miss Abernathy: A Workbook for Erotic Slaves and Their Owners. Additional high profile public figures were also named in the released documents. The documents were part of a defamation lawsuit filed by a woman who alleged that Epstein had victimized her, against a British socialite, Ghislaine Maxwell, who was Epstein's ex-girlfriend, associate, and alleged to have assisted with his criminal activities. Day Watch on August 9, 2019 According to the MCC Daily Log (BOP Form PP38) and the Lieutenant's Log from August 9, 2019, at approximately 8:38 a.m., Epstein's cellmate, M, was "Pre-Removed" and transferred out of the MCC in a routine, pre-arranged transfer. A BOP Form PP38 tracks the daily inmate movements throughout the MCC, while the Lieutenant's Log is utilized by the Lieutenant's to document the daily activities that took place within the MCC. EFTA00141181 Supervisory Correctional Systems Specialist =, who was the supervisor of the Receiving and Discharge (R&D) department on August 9, 2019, and responsible for overseeing all movements in and out of the MCC, verified that the R&D Department would have utilized the USMS emails sent on August 8, 2019, to coordinate transfer from the MCC. said that since was listed as WAB on the USMS emails, that meant he was being transferred from the MCC and not coming back. explained that if was going to court, as many inmates at the MCC oftentimes do, the BOP Form PP38 entered by the R&D department would have been entered as court, rather than Pre-Remove. Since the BOP Form PP38 listed as Pre-Remove, the R&D Department personnel who entered the information knew that was being transferred from the MCC on the morning of August 9, 2019. said that it was not acceptable for SHU Staff to say that they thought an inmate may return to the SHU if the inmate left the housing unit as a WAB. said that if SHU staff have claimed that they did not know that was not coming back to the SHU, they probably would have called R&D during the 4 p.m. count to check on his status. said the R&D movement officer on August 9, 2019, was Corrections Systems Officer confirmed that the BOP Form PP38 documentation meant that was listed as Pre-Remove on August 9, 2019, at 08:38, because "Was being officially removed out of the institution, going to another destination." clarified by saying, "He was going to be transferred to another prison" and he was not going to return to the MCC. said that she was likely the BOP employee who created the inmate call out list that was disseminated throughout the MCC on August 9, 2019, and utilized by the SHU staff when escorting to the R&D for transfer. explained that R & D would have entered the information with regard to into Sentry, along with other inmates who would be leaving their housing units. R & D would then print out a call out lists, with all the inmate names and times they were to be moved, and the MCC internal officer would then take call out list to the various housing units within the MCC. The call out document created for August 9, 2019, would have listed WAB next to name, which meant that was departing from the MCC and not returning. said that the MCC does not maintain the call out lists that are printed and hand delivered to the housing units, and said that the lists are not emailed. also said that the inmate call out list is updated every 24 hours within an electronic document, so the call out lists are only maintained electronically for that 24-hour period, prior to it being update for the next day's list. MCC SW Lieutenant who was the supervisor of the SHU, told the OIG that he worked at the MCC on August 8, 2019, from approximately 6 a.m. until approximately 2 p.m., and was off on August 9, 2019. said that per Psychology, Epstein was required to have a cellmate. said that the Warden and Captain both told him of the requirement, and told the SHU Officer in Charge, of the requirement. said that everyone who regularly worked in the SHU also knew of the requirement. also said that all staff knew that if an inmate came from suicide watch, the inmate needed to be assigned a cellmate. explained that Psychology's policy says that if an inmate comes from suicide watch, they have to be assigned a cellmate. said that he learned of the requirement during training, and knew of the requirement from the first day he joined the BOP, as should all MCC staff members. said the requirement is clearly communicated during suicide watch training, posted throughout the SHU area, and is also institutional knowledge. said that he was not aware that was scheduled to be transferred from the MCC on August 9, 2019, and therefore did not make any notifications to his superior, Captain that Epstein would require a new cellmate. said that as soon as the SHU staff learned that was going to be transferred, they should have notified a lieutenant. said that if the SHU staff believed was at court, it should have been recognized that he was not coming back during the 4 p.m. count, when Epstein was returned to his cell, or during any one of the 30-minute rounds conducted in the SHU after Epstein was returned to his cell. EFTA00141182  said that it should have definitely been recognized by the 10 pm count. said that the SHU staff should have notified either the Operations or Activities Lieutenant, and that Epstein should have then either been reassigned a new cellmate or have been placed in a "hard cell." Captain told the 016 that due to absence, the Operations Lieutenant assigned to the various shifts throughout the day were responsible for overseeing the SHU. Operations Lieutenant had responsibility for the SHU on August 9, 2019, from approximately 6:00 a.m. until 2:00 p.m. told the OIG that he knew that Epstein was required to have a cellmate, but believed that was removed from his cell on August 9, 2019, for a court appearance, and was then unexpectedly released during the appearance after shift had ended. said that he did not inform his supervisor, Captain of departure from the MCC, or that Epstein was without a cellmate, because he did not know that was not going to return to the MCC. However, said that he should have known that was removed from the MCC based upon ' scheduled transfer from the MCC and his WAB status that would have been listed on the August 9, 2019, MCC inmate production list that would have been generated by the MCC R&D. said that no one informed him that left the MCC as a WAB. Captain told the OIG that he was not notified of departure, and did not know that Epstein was without a cellmate on August 9, 2019. said that since was transferred out of the MCC at approximately 8:38 a.m., it would likely have been the responsibility of to have notified him of departure. However, if believed that went to court and did not know that was not returning to the MCC, then the responsibility would fall to the SHU Officer in Charge (OIC) who did know that was leaving the MCC as a WAB. said that should have informed a Lieutenant during his shift. claimed that no one informed him of departure from the MCC, as they should have done, even though he worked until approximately 8 p.m. on August 9, 2019. advised that if he was informed, he would have taken immediate action to ensure that Epstein was either assigned a new cellmate, or was monitored until he was assigned a new cellmate. According to the Duty Roster from August 9, 2019, Activities Lieutenant was the other Lieutenant on duty during shift. confirmed to the OIG that he was the Day Watch Activities Lieutenant on August 9, 2019, from approximately 6:00 a.m. until 2 p.m. The August 9, 2019, 30-Minute Round Sheet shows that visited the SHU and conducted a Lieutenant Round at approximately 11:27 a.m. told the OIG that on August 9, 2019, he and were responsible for overseeing the SHU. said that he knew Epstein was required to have a cellmate, and said that he received the email from on July 30, 2019, documenting the requirement. He also said that all inmates in the SHU were required to have a cellmate, unless they had some special circumstance saying they should not have a cellmate. believed that on August 9, 2019, Epstein went to court and never came back to the MCC later that day because he was either released or transferred. said that he did not recall departing the MCC as a WAB, did not recall having any conversations with anyone with regard to being removed from the MCC, and did not know that Epstein was without a cellmate. said that he did not have any conversation with with regard to departing the MCC or Epstein needing a new cellmate. told the OIG that he was the MCC SHU OIC on August 9, 2019, from approximately 6 a.m. until 2 p.m. said that he last saw Epstein on the morning of August 9, 2019, and said that Epstein was EFTA00141183 in good spirits and they joked around. explained that at approximately 8:00 a.m., he escorted Epstein to the attorney conference room for Epstein's daily legal visit, along with MCC Internal Officer who escorted to the MCC Receiving and Discharge (R&D) Department. explained that the escorts occurred together. said that on the morning of August 9, 2019, the SHU staff received an inmate production document that listed as WAB. explained that WAB meant that was being discharged, or removed, from the MCC, and said that the document was utilized when escorting to the MCC R&D Department. and both told the OIG that was in fact escorted to R&D with all of his belongings, and both said that during the escort, informed Epstein that he (Epstein) would be assigned a new cellmate due to departure from the MCC, and Epstein's requirement to have a cellmate. According to the MCC PP38 Daily Log and the Daily Lieutenant's Log for August 9, 2019, was removed from the MCC at 8:38 a.m. told the OIG that he was aware that Epstein was required to have a cellmate, and said "We always practice, if somebody comes off suicide watch, they have to go with a cellmate until Psychology clears them to be alone." said that every inmate that is transferred from suicide watch and/or psychological observation to the SHU is placed with a cellmate, and also said the Lt. instructed him MI that Epstein was to be housed with a cellmate. said that between July 30, 2019, and August 9, 2019, he informed the other MCC staff members who worked in the SHU of the requirement, and added that everyone who worked in the SHU should have known that Epstein was required to have a cellmate due to their knowledge, training, and experience. said that he knew was WAB and expected him to depart from the MCC and not return to the SHU, but said there had been times that inmates had been escorted to R&D as an expected discharge, only to be returned to the SW later that same day, due to unforeseen circumstances. said that should have been replaced as soon as it was confirmed that he left the MCC building, and said that he did not select a new cellmate for Epstein because although he assumed that was not going to return to the SHU, he was not certain that had been discharged from the MCC. Rather, claimed that a at the end of his shift in the SHU, which ended at approximately 2 p.m., he informed SHU staff members and Senior Officer Shaadiq that Epstein would need a new cellmate upon Epstein's return from his attorney visit if did not return to the SHU. said that SHU staff should definitely have realized the was not returning to the SHU during the 4:00 p.m. SHU count, as well as when Epstein was returned to his cell from his attorney visit. said that Epstein was expected to be with his attorneys with an MCC attorney conference room until approximately 7 p.m., as was his daily routine, so the SHU staff had time to make a new cellmate assignment. believed that anyone assigned to the SHU could have replaced =I, as long as the inmate did not have a separation order on them, and said that it was all SHU staff members shared responsibility to replace =. However, said that due to Epstein's high profile, the SHU staff members should have asked a Lieutenant to contact Psychology to see who should be placed with Epstein. said that it was likely that he informed the Operations Lieutenant assigned to his shift, at some point during his shift, but he could not specifically recall if he informed him. said that when he escorted Epstein to his attorney visit and to R&D, Ops LT and Activities Lieutenant were physically present, and should have seen depart the MCC. swore under oath, that he was very confident that he told that Epstein would need a new cellmate if did not return to the SHU. He said he specifically recalled the conversation, and recalled being present during the conversation. said that after walked into the SHU, EFTA00141184  said, "Make sure this guy gets a Bunkie.," to which replied, "All right,." said that a new cellmate could have been reassigned prior to the 4:00 p.m. SHU count if it was known that was not coming back, but the SHU staff members had until Epstein returned from his Attorney visit to assign Epstein a new cellmate. AW =I said that on August 8, 9, and 10, 2019, she had oversight over MCC Correctional Services. AW reviewed the aforementioned USMS emails sent to MCC staff on August 8, 2019. =said the "court list" was attached to the emails, and said the destination on the court list attached to the USMS email says WAB, which means with all belongings. said that the USMS documents means that was transferring, and not going to court. Therefore, the MCC knew as of August 8, 2019, that was transferring. said that the MCC Custody Department received the court production list from the USMS as a courtesy, and there really is not anyone in the Custody Department that is required to review the document to vet it. =was asked who should made the appropriate notification about departure from the MCC due to his WAB status. said that even though was present, should have contacted the Operations Lieutenant since he was the SHU OIC. Because as the OIC, he had oversight of the SHU. As the OIC, who knew that Epstein was required to have a cellmate, and who knew the was listed as WAB, he would know that he should contact a supervisor and make them aware. Warden said that everyone who worked in the SHU at the time left WAB would be partly responsible for not replacing Epstein's cellmate. said that it was everyone's job to say that he needed a new cellmate, and anyone could have passed the information to a lieutenant. He said that holds true for every shift after departure. Regional Director served as the regional director with oversight over the northeast region from Sept 2018 until his retirement in December 2019. Had oversight of the MCC in August 2019, and the warden reported directly to him. said that the OIC of the SHU would be in charge of getting Epstein a new cellmate. "Whoever was in charge of the SHU at the time his cellmate was removed should be reviewing for, to find him a new cellmate." "Once he was removed from SHU, they knew he was removed and transferred, yeah, then someone should have started taking action at that point." If they knew that WAB meant that he wasn't going to return, then they should have started making plans for a new cellmate at that point. The OIC should have told the SHU LT. If the SHU LT was out, then he should have told the operations lieutenant, who would have been his direct supervisor. The activities lieutenant really would not be his direct supervisor. The Operations Lieutenant is responsible for the shift, and the Activities lieutenant is responsible for going around and reviewing documents, and policy, and making sure everyone is doing their job. If knew that was WAB, and Epstein had not received a new cellmate by the end of his shift, than he should have passed the information onto his relief. Night Watch on August 9, 2019 told the OIG that he was the SHU OIC on August 9, 2019, from approximately 2 p.m. until approximately 10 p.m. He said that on August 9, 2019, he relieved from his duties, and worked in the SHU with MIME, and Noel. said that when he began his shift, Epstein was visiting with his attorneys in the Attorney Conference Visiting Room. said he did not recall having a conversation with about Epstein needing a cellmate. When advised that was confident about their conversation, stated, "I don't necessarily want to call anyone a liar, per se, but I don't remember him speaking to me about this. So, maybe he spoke toI= (M), and EFTA00141185 maybe I was standing there, and he thought I heard him." said if left WAB, then someone should have replaced when he departed, because Epstein was required to have a cellmate. told the OIG that on August 9, 2019, he worked in the SHU from approximately 8:45 a.m. until approximately 4 p.m. said that Epstein was already with his attorneys when he arrived to the SHU, and Epstein did not return by the time left the SHU. said that was also gone from the SHU by the time he arrived, and did not return prior to his departure. said that he did not know was discharged from the MCC, and said that no one told him that Epstein would need a new cellmate, including or anyone from the Psychology Department. M, elaborated that never told him that was released from the MCC, or that Epstein required a new cellmate. No one else interviewed by the OIG had any knowledge of claim that he passed the information regarding Epstein's cellmate departure onto • or any else assigned to the next shift. However, the MCC staff members assigned to the SHU after shift did learn that Epstein was without a cellmate, as detailed later in this report. Supervisors of the Night Watch According to the Daily Roster from August 9, 2019, Lieutenant was the Operations Lieutenant, and Senior Officer Specialist (SOS) was the Activities Lieutenant. told the OIG that he was the Operations Lieutenant at the MCC on August 9, 2019, during the 2 p.m. to 10 p.m. shift, and was relieved between 9:50 and 9:55 p.m. said that he was aware that Epstein was required to have a cellmate due to a mass email that was sent to all of the MCC lieutenants. also said that Psychology generates a document called the "hot list" that was kept in the SHU, which identified all of the inmates that have psychological needs, and identifies the requirement to have a cellmate. believed that the SHU was the only place where the hot list was maintained, and said that it would have been located by the officers' station, and the officers assigned to the SHU were required to review the hot list. said that everyone who regularly worked in the SHU should have known that Epstein was required to have a cellmate. reviewed the Roster for August 9, 2019, and said the following should have known: on the Day watch; and and Noel on the Night Shift. said that would have known because he was the SHU OIC during his shift, and Noel would have known because the SHU was her quarterly post and she was required to review the hot list, because all SHU staff were required to know who their psychological inmates were, and be aware of their high profile and dangerous inmates. said that Epstein was on the hot list, especially after his first suicide attempt. believed that everyone in the MCC, and especially those who worked in the SHU, should have been aware that Epstein was required to have a cellmate due to his high profile. said that he was not aware that Epstein did not have a cellmate on August 9, 2019, and did not know had left the MCC earlier that day. said that when an inmate is transferred, the PP38 is updated in Sentry, and that information gets transferred over to the LT log, to monitor the inmate movements for the day, and to make sure the inmate numbers are correct at the end of each shift. said that once was removed, Epstein should have been assigned a new cellmate "as soon as humanly possible." said that WAB means that the inmate is not coming back. said there are occasions when they cancel the transport, and they do come back, but most of the time, when they go WAB, that means that they are gone from the MCC. said that if was transported to R&D as a WAB, and if the SHU LT was off, then an MCC supervisor should have been notified. If no one was notified, then no one would know. said EFTA00141186 that the SHU staff on his shift should have notified him that Epstein was without a cellmate, and said that he was not informed. said that acting Activities Lieutenant = conducted the Lieutenant round in the SHU on August 9, 2019. said that Activities LT = would probably only have known that Epstein was without a cellmate if someone from the SHU told her, or if she went down range during the round she conducted in the SHU. The SHU staff should have told