Investigation and Review of the Federal Bureau of

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 According to its website, the Federal Bureau of Prisons (BOPys 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 Department ofJustice (DOJ) Office of the Inspector General (OIG) has repeatedly identified long-standing operational challenges that negatively affect the BOP's ability to operate its institutions safely and securely. Many of those same operational challenges, including staffing shortages, managing inmates at risk for suicide, functional security camera systems, and management failures and widespread disregard of BOP policies and procedures, were again identified by the OIG during this investigation and review into the custody, care, and supervision of one of the BOP's most notorious inmates, Jeffrey Epstein. The OIG initiated this investigation upon receipt of information from the BOP that on August 10, 2019, in the Metropolitan Correctional Center in New York, New York (MCC New York), Epstein was found hanged in his assigned cell within the Special Housing Unit (SHU). The Office of the Chief Medical Examiner, City of New York, determined that Epstein had died by 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 and determined 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 while detained at the facility from his arrest on federal sex trafficking charges on July 6, 2019, until his death on August 10. Epstein is Assigned to the SHU on July 7 Epstein was assigned to a cell in the SHU on July 7 due to media coverage of his case and inmate awareness of his notoriety. SHU inmates are securely separated from general population inmates and kept locked in their cells for approximately 23 hours a day. BOP policy requires SHU staff to observe all inmates at least twice an hour and that Lieutenants conduct at least one round in the SHU each shift. BOP policy also requires multiple inmate counts during every 24-hour period. Among other things, inmate counts and rounds enable BOP staff to observe inmates and ensure they are secure in their cells and in good health. Further, to eliminate safety hazards, MCC New York requires SHU staff to search SHU common areas and at least five cells daily, and to search the entire SHU every week. On July 18, the court refused to set bail for Epstein and ordered him detained pending trial on the criminal charges. Incident Involving Epstein on July 23 While in MCC New York, Epstein was screened on numerous occasions by psychological staff, including a formal suicide assessment on July 9. In the evaluations he denied having thoughts or a history of attempted suicide. Psychological staff determined Epstein did not meet the criteria for a psychological diagnosis. On July 23, at 1:27 a.m., correctional officers (CO) responded to Epstein's SHU cell where they found Epstein with an orange cloth around his neck. Epstein's cellmate told officers Epstein tried to hang himself. Medical staff examined Epstein, observed friction marks and superficial reddening around his neck and on his knee, and placed him on suicide watch. BOP policy requires that inmates identified as suicide risks be placed on suicide watch until no longer at imminent risk. The BOP uses a less restrictive monitoring form, EFTA00039026 psychological observation, for Inmates who are stabilizing but not yet ready to return to a housing unit. Epstein was removed from suicide watch on July 24 but remained under psychological observation until July 30. Epstein first told MCC New York staff he thought his cellmate had tried to kill him, but later said he did not know what occurred and did not want to talk about how he had sustained his injuries. Epstein also later asked if he could be housed with the same cellmate. Mother inmate housed on the same SHU tier told the 016 that he heard Epstein's cellmate call for assistance, and that Epstein's cellmate told him that Epstein tried to hang himself from the bunkbed ladder. Disciplinary charges against Epstein for alleged self-mutilation were not sustained due to insufficient evidence. Following the July 23 incident, the Psychology Department determined Epstein needed to be housed with an appropriate cellmate, and on July 30 it sent an email to over 70 MCC New York employees informing them of this requirement. The Warden at the time told the OIG that he selected a new cellmate for Epstein in consultation with BOP executive leadership. That inmate remained Epstein's cellmate until August 9. Events of August 8-10, 2019, and Epstein's Death On August 8, the U.S. Marshals Service sent two emails notifying numerous MCC New York staff that Epstein's cellmate was being transferred to another facility on August 9. However, no action was taken to ensure Epstein was assigned another cellmate. Also on August 8, Epstein met with his attorneys at the prison, as he had on prior occasions, and signed a new Last Will and Testament. MCC New York officials did not learn about the new Will until after Epstein's death. The following day, August 9, Epstein's cellmate was transferred to another facility and he was not assigned a new cellmate. Additionally, on that date, the U.S. Court of Appeals for the Second Circuit unsealed approximately 2,000 pages of documents in civil litigation involving Ghislaine Maxwell, who was later convicted in December 2021 of conspiring with Epstein to sexually abuse minors over the course of a decade. The documents contain substantial derogatory Information about Epstein and there is extensive media coverage of information in the unsealed documents. Also on August 9, after meeting at the prison with his lawyers, MCC New York staff allowed Epstein to make, in violation of BOP policy, an unrecorded, unmonitored telephone call before he was returned to his SHU cell. Although Epstein said he was calling his mother, in actuality he called someone with whom he allegedly had a personal relationship. At approximately 8 p.m. on August 9, SHU inmates were locked in their cells for the night, including Epstein who was without a cellmate. A search of Epstein's cell following his death revealed Epstein had excess prison blankets, linens, and clothing in his cell, and that some had been ripped to create nooses. Only one SHU cell 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 016 also found that SHU staff did not conduct any 30-minute rounds after about 10:40 p.m. on August 9 and that none of the required SHU Inmate counts were conducted after 4 p.m. on August 9. Count slips and round sheets were falsified to show that they had been performed. On August 10, at approximately 6:30 a.m., the two SHU staff on duty, CO Tova Noel and Material Handler Michael Thomas, began delivering breakfast to SHU Inmates. Noel unlocked the door to Epstein's SHU tier. When Thomas attempted to deliver breakfast to Epstein through the food slot in his locked cell door, Epstein did not respond to Thomas's verbal commands. Thomas unlocked the cell door and saw Epstein hanged. Thomas immediately yelled for Noel to get help and call for a medical emergency. Thomas told the OIG that when he entered Epstein's cell, Epstein had an orange string, presumably from a sheet or a shirt, around his neck that was tied to the top portion of the bunkbed. 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. Thomas said he immediately ripped the orange string from the bunkbed, and Epstein's buttocks dropped to the ground. Thomas then lowered Epstein's body to the floor and began chest compressions until responding MCC New York staff members arrived approximately 1 minute later. Shortly thereafter, outside medical personnel arrived and took over the emergency response, eventually removing Epstein to a local hospital where he was pronounced dead. 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 was suicide. Blood toxicology tests did not reveal any medications or illegal substances in Epstein's system. The Medical Examiner who performed the autopsy told the OIG that Epstein's injuries were consistent with suicide by hanging and that there was no evidence of defensive wounds that would be expected if his death had been a homicide. Epstein did not have marks on his hands, broken fingernails or debris under them, contusions to his knuckles that would have evidenced a fight, or, other than an abrasion on his arm likely due to convulsing from hanging, bruising on his body. The Limited Available Video Evidence Recorded video evidence for August 9 and 10 for the SHU area where Epstein was housed was only available from one prison security camera due to a malfunction of MCC New York's Digital Video Recorder system that occurred on July 29, 2019. While the prison's cameras continued to provide live video feeds, recordings were made for only about half the cameras. MCC New York personnel discovered this failure on August 8, 2019, but it was not repaired until after Epstein's death. As detailed in this report, like many other BOP facilities, MCC New York had a history of security camera problems. The available recorded video footage from the one SHU camera captured a large pan of the common area of the SHU and portions of the stairways leading to the different SHU tiers, Including Epstein's cell tier. Thus, anyone entering or attempting to enter Epstein's SHU tier from the SHU common area would have been picked up by that video camera. Epstein's cell door, however, was not in the camera's field of view. The OIG reviewed the video and found that, between approximately 10:40 p.m. on August 9 and about 6:30 a.m. on August 10, no one was seen entering Epstein's cell tier from the SHU common area. The OIG determined that movements captured on video before and after those times were generally consistent with employee actions as described by witnesses and documented in BOP records. Results of the OIG's Investigation and Review The OIG's investigation and review identified numerous and serious failures by MCC New York staff, Including multiple violations of ma New York and BOP policies and procedures. The OIG found that MCC New York staff failed on August 9 to carry out the Psychology Department's directive that Epstein be assigned a cellmate, and that an MCC New York supervisor allowed Epstein to make an unmonitored telephone call the evening before his death. Additionally, we found that staff failed to undertake required measures designed to make sure that Epstein and other SHU inmates were accounted for and safe, such as conducting inmate counts and 30-minute rounds, searching inmate cells, and ensuring adequate supervision of the SHU and the functionality of the video camera surveillance system. The 016 also found that several staff falsified BOP records relating to inmate counts and rounds and lacked candor during their OIG Interviews. Two MCC New York employees, Noel and Thomas, were charged criminally with falsifying BOP records. The charges were later dismissed after they successfully fulfilled deferred prosecution agreements. The U.S. Attorneys Office for the Southern District of New York declined prosecution for other MCC New York employees who the OIG found created false documentation. The combination of these and other failures led to Epstein being unmonitored and alone in his cell, which contained an excessive amount of bed linens, from approximately 10:40 p.m. on August 9 until he was discovered hanged in his locked cell the following day. While the 016 determined MCC New York staff engaged in significant misconduct, we did not uncover evidence contradicting the FBI's determination regarding the absence of criminality in connection with how Epstein died. We did not find, for example, evidence that anyone was present in the SHU area where Epstein was housed during the relevant timeframe other than the Inmates who were locked in their assigned cells. The SHU housing unit was securely separated from the general inmate population and Inmates were kept locked in their cells for approximately 23 hours a day. Access to the SHU was controlled by multiple locked doors. Within the SHU, the entrance to each tier could be accessed only via a single locked door at the top or bottom of the staircase leading to the individual tier. Keys to open the locked tier doors were available to a limited number of COs while on duty. Each tier had eight cells and each individual cell, which was made of cement and metal, could be accessed only through a single locked door, to which a limited number of COs had keys while on duty. The SHU cell doors were made of solid metal with a small glass window and small locked slots that correctional staff used to handcuff Inmates and provide food and toiletries to inmates. As a further security measure, during each shift a limited number of the COs had keys while on duty. iii EFTA00039028 SHU staff told the OIG that at approximately 8 p.m. on August 9, all SHU inmates, including Epstein, were locked in their cells for the evening and we found no evidence to the contrary. The prison's recorded video did not identify any staff or other individuals approaching Epstein's SHU tier from the SHU common area between approximately 10:40 p.m. on August 9 and about 6:30 a.m. on August 10. Additionally, the O16 did not observe on the recorded video that Noel and Thomas, who were seated at the desk at the SHU Officers' Station immediately outside the area where Epstein was housed, at any time during the time period rose from their seats or approached the cell block. We additionally found that Thomas's and Noel's reaction on the morning of August 10 upon finding Epstein hanging in his cell, as described to us by Thomas, Noel, the responding Lieutenant, and inmates, was consistent with their being unaware of any potential harm to Epstein prior to Thomas entering Epstein's cell at about 6:30 a.m. on August 10. None of the MCC New York staff members we interviewed were aware of any information suggesting Epstein's cause of death was something other than suicide. Additionally, none of the inmates we interviewed had any credible information suggesting Epstein's cause of death was something other than suicide. Further, the SHU staff and three interviewed inmates with a direct line of sight to Epstein's cell door on the night of his death stated that no one entered or exited Epstein's cell after the SHU staff returned Epstein to his cell on August 9. As noted, the surveillance camera in the SHU area where Epstein was housed was live streaming movement in the hallway outside of Epstein's cell. Although the camera was not recording the captured video, the camera was in plain view of the inmates and therefore inmates would have been aware that any hallway movements, including into or out of Epstein's cell, could be monitored by BOP staff, even if, unbeknownst to them, the DVR system was not recording the live stream at that time. As the OIG has 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 they know cameras are not located. We noted as well that Epstein had previously been placed on suicide watch and psychological observation due to the events of July 23, 2019; that numerous nooses made from the excess prison sheets were found in his cell on the morning of August 10; that no weapons were recovered from his cell after his death; and that he signed a new Last Will and Testament on August 8, 2 days before he died. We found that the staffs failure to assign Epstein a cellmate on August 9; failure to conduct rounds and counts that evening; and to allow him to have excess linens in his cell, left Epstein unmonitored and locked alone in his cell for hours, which provided him an opportunity to commit suicide. Finally, the Medical Examiner who performed the autopsy detailed for the O16 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 the absence of debris under Epstein's fingernails, marks on his hands, contusions to his knuckles, or bruises on his body evidencing a struggle, which would be expected if Epstein's death had been a homicide by strangulation. Conclusion and Recommendations This is not the first time the O16 has found significant Job performance and management failures on the part of BOP personnel and widespread disregard of BOP policies that are designed to ensure that inmates are safe, secure, and in good health. 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 BOP's most notorious inmates was provided with the opportunity to take his own life, resulting in significant questions being asked about the circumstances of his death, how it could have been allowed to happen, and most importantly, depriving his numerous victims, many of whom were underage girls at the time of the alleged crimes, of their ability 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 staffing, surveillance, safety and security, and related problems plaguing the BOP. The O16 made eight recommendations to the BOP to address the numerous issues identified during our Investigation and review. Finally, we recommended that the BOP review the conduct and performance of the BOP personnel as described in this report and determine whether discipline or other administrative 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 imprisonment), but whom the court had determined under applicable law should remain in custody pending trial either because they represent a danger to the community, a substantial flight risk, or both. MCC New York has several different housing units. Epstein was initially assigned to MCC New York's general inmate population, but on July 7, 2019, 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 other inmates. The SHU is a housing unit within MCC New York where inmates are securely separated from the general inmate population and kept locked in their cells for approximately 23 hours per day, to ensure their own safety as well as the safety of staff and other inmates. Correctional Officer (CO) Tova Noel and Material Handler Michael Thomas began working together in MCC New York SHU at 12 a.m. on August 10, 2019.4 During their shift, they each created and submitted falsified official BOP forms documenting inmate counts (often referred to as 'count slips"), and Noel completed and signed more than 75 separate entries on an official BOP form documenting 30-minute rounds (often 4 Noel worked her regular shift in the SHU from 4 p.m. to 12 a.m. on August 9, 2019, followed by an overtime shift in the SHU from 12 a.m. to 8 a.m. on August 10, 2019. Thomas did not work his regular shift as a Material Handler in a different location of MCC New York and instead worked an overtime shift in the SHU from 12 a.m. to 8 a.m. on August 10, 2019. S EFTA00039036 referred to as a "round sheet") falsely stating that she and Thomas had conducted such rounds when, in fact, they had not.5 On November 19, 2019, a federal grand jury of the U.S. District Court for the Southern District of New York returned an indictment that charged Noel and Thomas with one count each of conspiracy and multiple counts each of falsification of records, in violation of 18 U.S.C. 4§ 371, 1001(a)(3), and 2. The indictment alleged that on August 9, 2019, Noel failed to conduct the mandatory 4 p.m. and 10 p.m. counts of inmates in the MCC New York SHU, and that on August 10, 2019, both she and Thomas failed to conduct the mandatory 12 a.m., 3 a.m., and 5 a.m. counts and mandatory 30-minute rounds within the MCC New York SHU. The indictment further alleged that Noel and Thomas created, certified, and submitted false documentation indicating that the counts and rounds had been done as required to conceal their failure to perform their assigned duties. As a result, it appeared from documentation that prisoners in the SHU, including Epstein, were being regularly monitored when, in fact, no CO had checked on Epstein from approximately 10:40 p.m. on August 9, 2019, until approximately 6:30 a.m. on August 10, 2019, when Epstein was found hanged in his cell. On May 25, 2021, the U.S. Attorney's Office for the Southern District of New York entered into deferred prosecution agreements with Noel and Thomas. Their respective agreements, which are part of the court record in their cases, included admissions by Noel and Thomas that they falsely certified that they had conducted counts and rounds. The agreements also required each of them to truthfully and completely disclose all information related to their activities and employment with the BOP; be interviewed by the U.S. Attorney's Office of the Southern District of New York, the FBI, and the OIG; complete 100 hours of community service; refrain from violating the law; and fulfill other conditions related to pretrial supervision and their establishment of good behavior. On December 13, 2021, after Noel and Thomas successfully fulfilled the terms of their deferred prosecution agreements as determined by the prosecutors, the U.S. District Court for the Southern District of New York entered a nolle prosequi order and dismissed all charges pending against them. Prosecution was declined by the U.S. Attorney's Office for the Southern District of New York for other BOP employees assigned to the SHU who also falsely certified inmate count slips and round sheets on the day before and the day of Epstein's death. As discussed in greater detail in Chapter 7 of this report, the OIG found that, in addition to Noel and Thomas, many other MCC New York staff members engaged in administrative misconduct, exercised poor judgment, and/or failed to adequately perform their assigned duties. II. Methodology During the course of this investigation, the OIG interviewed 54 witnesses, several on more than one occasion. The witnesses interviewed included Noel, Thomas, and other MCC New York staff assigned to the SHU on August 9-10, 2019; MCC New York supervisors at the time of Epstein's death, including the Warden, Associate Wardens, Captain, and Lieutenants; medical staff; staff members responsible for the MCC New York security camera system; other BOP staff and contractors; and a relative of Epstein, who had 5 These BOP forms are officially entitled "Official Count Slip" and "MCC New York, Special Housing Unit, 30 Minute Check Sheet." Each of the 6 tiers in the SHU had a separate round sheet, each of which had 13 entries reflecting 30-minute rounds were conducted, when they were not, in fact, completed. 6 EFTA00039037 requested to provide information.' The BOP employees and contractors we interviewed included employees involved in various aspects of the emergency response, who worked at MCC New York in the days leading up to the response and following the response, as well as other individuals with information pertinent to our investigation. Additionally, the OIG participated in interviews of 15 inmates who had been housed at MCC New York during time periods relevant to our investigation, including three who were housed in the L Tier of the SHU on the day Epstein died.' Those three L-Tier inmates were housed in cells opposite Epstein's cell and therefore had a direct line of sight to Epstein's cell on the night of August 9-10. The OIG also reached out to one of Epstein's attorneys to discuss the possibility of providing information, but ultimately the attorney declined to be interviewed, citing attorney-client privilege (the attorney-client privilege survives a client's death) and issues related to ongoing litigation involving Epstein's estate. The OIG also collected over 127,000 documents, as well as MCC New York video and photographs. Among these were BOP documents, including staff rosters; daily logs and reports; investigative and incident reports; documentation regarding inmate counts and 30-minute rounds; inmate housing assignment documentation; inmate transfer documents; Psychology Department reports and medical records relating to Epstein; Epstein's institutional phone call records; MCC New York records of Epstein's visits with his attorneys; electronic communications, including text messages and emails of BOP employees and contractors; MCC New York security camera surveillance video; records from contractors regarding the MCC New York security camera system; service records for MCC New York's security camera system; MCC New York photographs, including photographs taken of efforts to revive Epstein on the morning of August 10, 2019; BOP policies and program statements; MCC New York Post Orders; and financial records. The OIG also conducted forensic analysis of the computers located in the SHU and BOP cellular telephones. In addition, the OIG reviewed FBI investigative records, including interview reports (FD-302), notes from witness interviews and other meetings, and electronic communications. The OIG also reviewed Epstein's autopsy report and interviewed the Medical Examiner who performed the autopsy on Epstein. Ill. Applicable Law, Regulations, and BOP Policies A. Standards of Conduct The Standards of Ethical Conduct for Employees of the Executive Branch sets out general principles that are designed to "ensure that every citizen can have complete confidence in the integrity of the Federal Government." 8 Among other things, these standards require that every federal employee "use official time ' On a separate occasion, the relative contacted the OIG to say that the relative had "photographic proof' that the door to Epstein's cell was left open the night Epstein died. When the OIG followed up with the relative to request copies of the photographs and any information regarding this allegation, the relative stated that upon further review, the photographs did not show what the relative previously communicated to the OIG. / The U.S. Attorney's Office for the Southern District of New York sought interviews from inmates housed in the L Tier of the SHU on the night that Epstein died, each of whom was represented by counsel. Three inmates agreed to be interviewed. The OIG does not have the authority to compel or subpoena testimony from individuals who are not DOJ employees. 8 C.F.R. § 2635.101(a). 7 EFTA00039038 in an honest effort to perform official duties.", The ethical regulations also mandate that federal employees not use federal property "for other than authorized activities." , BOP policy (Program Statement 3420.11, Standards of Employee Conduct) imposes several additional standards of conduct on its employees. At