Page 0895 # PSYCHOLOGICAL RECONSTRUCTION OF INMATE DEATH
Name:Jeffrey Epstein
Register Number:76318-054
Date of Death: 08-10-2019 Prepared by: National Suicide Prevention Coordinator, Psychology Services Branch, Central Office ## BACKGROUND INFORMATION Mr. Jeffrey Epstein was a 66-year-old, White male who died on August 10, 2019, while housed at the Metropolitan Correctional Complex (MCC), New York, in New York, New York. former Acting Assistant Director, Reentry Services Division, appointed a team to conduct a psychological reconstruction. The team consisted of National Suicide Prevention Coordinator, Central Office; Sex Offender Treatment Programs Coordinator, Central Office; Mental Health Treatment Coordinator, Central Office; and Correctional Services Administrator, Northeast Regional Office. This reconstruction was established in accordance with Bureau of Prisons' (BOP) Program Statement 5324.08, Suicide Prevention Program. Formal interviews were not conducted as a part of this reconstruction at the direction of the Department of Justice. A copy of the video is normally made following a significant incident, but there was no such video in this case since the original video was confiscated by the Federal Bureau of Investigation (FBI) prior to the beginning of this reconstruction. The absence of these two areas of inquiry severely limited the ability to establish accurate timelines, confirm subjective reports, establish converging and diverging lines of facts, or discover new areas of inquiry. As a result, information typically gathered, reviewed and consolidated during a reconstruction to support actionable findings and recommendations is limited. Social History: Mr. Epstein did not have a Pre-Sentence Report (PSR) available at the time of the reconstruction; therefore, no official information regarding social history was accessible. The following was gathered from publicly available documents. Mr. Epstein was born in 1953 and grew up in a middle-class family in the neighborhood of Sea Gate on Coney Island, Brooklyn, New York with one brother. After early promotion in two grades, Mr. Epstein graduated from Lafayette High School in 1969, at the age of 16. He attended Cooper Union and New York University but did not graduate from either. Mr. Epstein taught at the Dalton School, a private school on the Upper East Side of Manhattan from September 1974 until he was dismissed in June 1976 for inadequate development as a teacher. Following that, he held a number of positions in the financial industry to include a position as a limited partner at Bear Stearns until he was dismissed for unknown policy violations in 1981. He also worked as a financial consultant and founded at least two separate companies. Mr. Epstein had two significant periods of employment. The first of these was his position as a consultant with Steven Jude Hoffenberg in the late 1980s. Mr. Hoffenberg was described as his first mentor. Mr. Hoffenberg was later convicted and incarcerated for running a large Ponzi scheme. He implicated Mr. Epstein in fraudulently diverting company funds for his own EFTA00105651 Page 0896 personal use. Years later, Leslie Wexner, Mr. Epstein’s sole client at J. Epstein and Company, granted him power of attorney over his affairs. Despite also being identified as Mr. Wexner's mentee, Mr. Epstein was again accused of misappropriating funds—more than 46 million dollars. These large sums are believed to be the seed money Mr. Epstein used to establish his considerable fortune. These events are indicative of Mr. Epstein’s highly-regarded intelligence and charismatic personality. Legal History: Mr. Epstein had a history of adult criminal charges and convictions. In June 2008, he entered into a non-prosecution agreement and pleaded guilty to one count Solicitation of Prostitution and one count Procuring a Person Under the Age of 18 for Prostitution in the state of Florida. He was sentenced to 30 months: 18 months of incarceration and 12 months of probation. He was also mandated to register as a sex offender under the National Sex Offender Registration and Notification Act. Mr. Epstein served 13 of his 18-month incarceration and then successfully completed 12 months of probation. It is unclear whether he followed the sex offender registration guidelines in each place he owned a residence. In regard to pending charges, Mr. Epstein was formally charged with Sex Trafficking Conspiracy in violation of 18 U.S.C. § 371 and Sex Trafficking in violation of 18 U.S.C. § 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 Mr. Epstein enticed and recruited minor females to engage in sexual activity. The minor females were reportedly compensated with cash following the sexual encounters and some were encouraged to find other minor females to accompany them to Mr. Epstein’s residences in New York or Florida. He pleaded not guilty to these charges and was pretrial at the time of his death. In a 37-page Decision & Order Remanding the Defendant, signed by Judge Richard M. Berman on July 18, 2019, 18 pages were dedicated to detailing the danger Mr. Epstein posed to others and the community. The document also alleged he was a flight risk. As a result, Mr. Epstein’s proposed bail package was determined to be inadequate. He was denied pretrial release and held on remand. This was likely significant to Mr. Epstein as he would lose the physical and financial comfort to which he had become accustomed. Furthermore, his ability to mount a defense would be limited to the parameters of legal visits and legal work that could be accomplished in jail. These restrictions and the abundance of witnesses, victims and negative public attention were likely a considerable burden on Mr. Epstein. Institutional History: On July 6, 2019, Mr. Epstein was arrested at Teterboro Airport in New Jersey upon his return from Paris, France. It is unknown whether he was anticipating this arrest. He was transported to MCC New York and keyed into SENTRY at 9:24 p.m. that evening. Mr. Epstein was placed in a general population housing unit for approximately 22 hours. 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. With regard to his adjustment to a correctional setting, Mr. Epstein received one incident report while in BOP custody for Self-Mutilation on July 23, 2019. As of August 15, 2019, the incident report had been expunged but it is unclear why it had been expunged and whether Mr. Epstein knew this. Also, a review of financial transactions associated with Mr. Epstein’s prison account revealed one of his attorneys was depositing funds into his cellmate’s (inmate Reyes) commissary account for unknown reasons. EFTA00105652 Page 0897 ## HEALTH CARE AND PERSONALITY DESCRIPTION BOP Electronic Medical Records (BEMR) indicate Mr. Epstein was diagnosed with hyperlipidemia, sleep apnea, hypertension, constipation, prediabetes, neuralgia, and neuritis unspecified. He was prescribed the following mediations: docusate sodium, milk of magnesia, omega 3, methylprednisone, and bisacodyl. Mr. 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 “dose not indicated,” thus it does not appear insulin was routinely medically necessary. The rest of the medications prescribed were self-carry. He also had a continuous positive airway pressure (CPAP) machine which is typically used to treat sleep apnea. Mr. Epstein was provided with his personal CPAP machine on July 30, 2019, per BEMR. In regard to mental health history and treatment, there are no known available records. Certainly there were records kept on Mr. Epstein’s incarceration in Florida. However, these records were not available for review as of the date of this report. With regard to Psychology Data System records in BEMR (PDS-BEMR), Dr. Kari Forensic Psychologist at MCC New York completed a routine Intake Screening on July 8, 2019. During this screening, Mr. Epstein denied any history of mental health problems, substance abuse, and treatment. No symptoms of mental illness were observed. He was classified as Mental Health Care Level 1 and was not diagnosed with a mental illness. Following a consultation with Dr. , National Suicide Prevention Coordinator on July 8, 2019, Dr. , Chief Psychologist at MCC New York determined Mr. Epstein should be pre-emptively evaluated for suicide risk upon his return from court. Primary consideration was given to his various risk factors for suicide such as his being a high profile case with media attention, his pending sex offense charges, pre-trial status, and an ongoing court proceeding. Mr. Epstein returned from court on July 8, 2019, after normal business hours. He denied suicidal thoughts at that time, but due to the potential for other risk factors listed above, the on-call psychologist placed Mr. Epstein on Psychological Observation in one of the suicide watch cells until he could be assessed in person by a BOP psychologist. On July 9, 2019, Mr. Epstein underwent a formal, in-person suicide risk assessment with Dr. . She determined that, while suicide watch was not warranted at that time, Mr. Epstein should remain on Psychological Observation status out of an abundance of caution. He was removed from Psychological Observation on July 10, 2019. On July 23, 2019, Dr. , the on-call psychologist was notified Mr. Epstein had been found in his cell with a piece of orange cloth around his neck. Reportedly, he was observed lying in the fetal position on the floor with a noose around his neck. Medical staff evaluated Mr. Epstein and found friction marks and superficial reddening of the neck skin and one knee. He was placed on suicide watch by the Operations Lieutenant at approximately 1:40 a.m. pending a formal in-person suicide risk assessment. Dr. , Staff Psychologist at MCC New York assessed Mr. Epstein for risk of suicide later in the morning of July 23, 2019, and determined he should remain on suicide watch. Mr. Epstein denied any knowledge of how he received marks on his neck and initially informed staff he believed his cellmate had attempted to kill him. Special Investigative Services (SIS) staff opened an investigation to assess Mr. Epstein’s safety and collect facts surrounding the episode. Despite this investigation, staff were unable to determine whether he was assaulted or engaged in self-directed violence. Mr. Epstein was removed from suicide watch on July 24, 2019, after 31 hours and 5 minutes. Thereafter, he EFTA00105653 Page 0898 remained in the suicide watch cell and was placed on Psychological Observation, where he remained housed until July 30, 2019, according to PDS-BEMR records. A discrepancy exists regarding when he was removed from Psychological Observation. His cell assignment, per SENTRY, indicates he was transferred back to the Special Housing Unit (SHU) on July 29, 2019, whereas PDS-BEMR indicates he was removed from Psychological Observation on July 30, 2019, at approximately 8:15 a.m. Mr. Epstein attended a court hearing on July 31, 2019, and, upon his return, the United States Marshals Service (USMS) provided paperwork to Receiving and Discharge (R&D) staff that noted "suicidal tendencies." Dr. was notified on August 1, 2019, about this paperwork. She consulted with Dr. and then met with Mr. Epstein to conduct a suicide risk assessment. She determined suicide watch was not warranted at that time. Mr. Epstein remained classified as a Mental Health Care Level 1 throughout his time at MCC New York. During his contacts with psychologists, Mr. Epstein routinely denied current mental health symptoms to include suicidal ideation, and he did not exhibit symptoms of a serious mental illness. His most frequent complaint was difficulty sleeping. He did not have access to his CPAP machine until it was reportedly provided to him on July 30, 2019. Mr. Epstein also reported he was bothered by noise in the SHU. At times, he noted concerns related to his safety in SHU or on a general population housing unit. On two occasions, July 26, 2019, and July 27, 2019, he described himself as a coward and as someone who does not like pain. On July 28, 2019, he told Dr. the toilet in his cell would not stop flushing for an extended period of time, and he then took to sitting in the corner with his hands over his ears. Mr. Epstein indicated he was agitated following this incident and was unable to sleep that night. ## ANTECEDENT CIRCUMSTANCES Mr. Epstein entered BOP custody on July 6, 2019, with a history of convictions for sexual offenses and allegations comprised of more serious charges. The current indictment alleged sexual crimes against minors, and he was facing up to 45 years in prison. On July 18, 2019, Mr. Epstein’s request for bail and pretrial release was denied. On July 23, 2019, Mr. Epstein was found unresponsive in his cell. The motivation and context were never fully determined. After 31 hours and 5 minutes on Suicide Watch, he was then placed on Psychological Observation. On July 30, 2019, Mr. Epstein was removed from Psychological Observation. Dr. sent an e-mail reporting Mr. Epstein had been removed from Psychological Observation and needed to be housed with an appropriate cellmate. This e-mail was sent to 71 MCC New York staff and, as of August 13, 2019, only 27 staff members had opened the message. On August 9, 2019, a federal court unsealed approximately 2,000 pages of documents into the public domain. These included graphic allegations against Mr. 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. The documents were part of a defamation lawsuit filed by , a woman who alleged Mr. Epstein had victimized her, against a British socialite, Ghislaine Maxwell, who was Mr. Epstein’s ex-girlfriend, associate, and alleged Madame. With the release of this information, it became increasingly clear that Mr. Epstein’s chances of avoiding a lengthy period of incarceration and a broader public understanding of his private life were inevitable. EFTA00105654 Page 0899 Mr. Epstein was afforded telephone calls on two different days. No records of the calls exist and it is not known with whom he was speaking. One occurred on or around July 16, 2019, and the other on August 9, 2019. Given the limited information known about Mr. Epstein, knowledge of the content of the calls would have been crucial to helping staff work with him. Following his final telephone call on the evening of August 9, 2019, Mr. Epstein was moved into his SHU cell. He was single-celled at that time because his cellmate (Efrain Reyes #85993-054) did not return from court. The need for a cellmate was communicated between Day Watch (DW) and Evening Watch (EW) shifts in the SHU, but no cellmate was placed with him by the EW staff. BOP staff knew Mr. Epstein’s cellmate had not returned from court as early as 1:50 p.m. that day. A review of the 30-minute Rounds forms indicate unit rounds were completed for the entire MW shift on August 10, 2019. However, a memorandum from Lieutenant Stanley Jean indicates Officer Tova Noel and Material Handler Supervisor Michael Thomas made a statement after Mr. Epstein’s death that they did not complete proper 30-minute rounds at 3:00 a.m. or 5:00 a.m. DESCRIPTION OF SCENE A detailed description of the scene was unavailable because the officers who discovered Mr. Epstein did not write memorandums and could not be interviewed. According to the Report of Incident, on August 10, 2019, at approximately 6:33 a.m., while serving the breakfast meal in the SHU, Range 9 South, Mr. Epstein was found unresponsive in his cell. Staff reportedly called for medical assistance, activated the body alarm, and began life-saving measures. Arriving staff alleged they brought an automated external defibrillator (AED) and stretcher. Cardiopulmonary resuscitation (CPR) reportedly continued while the AED was placed on Mr. Epstein. The AED reportedly indicated no shock advised and CPR was continued. Mr. Epstein was escorted to Health Services at approximately 6:39 a.m., and Emergency Medical Services (EMS) arrived at 6:43 a.m. He was transported to the local hospital at approximately 7:10 a.m. Mr. Epstein was pronounced deceased at 7:36 am. It was not possible to confirm this timeline without viewing video footage. ## CONCLUSIONS/RECOMMENDATIONS A general appreciation of risk factors for suicide with sex offenders is necessary when reviewing Mr. Epstein’s death. These factors, as well as more general risk factors for suicide, were likely present. There are several common factors that increase risk for suicide in individuals with a history of a sexual offense. These include stigma due to the nature of sexually-based crimes (both within society and the prison system), a disruption of the ability to utilize sex as a coping mechanism (which can lead to increased levels of distress and negative affect), and grief about loss experienced in regards to arrest. This grief may be secondary to the loss of former lifestyle, loss of physical items or collections related to sexual offenses, and/or the loss of perceived relationships with victims. Other factors that may increase risk for suicide among individuals accused of a sex offense include safety concerns, potentially long sentences, and lack of skills necessary to navigate social relationships in prison. Mr. Epstein was a high-profile, pretrial detainee awaiting trial on sex trafficking offenses. He had been a successful, wealthy businessman with a number of high-profile acquaintances that he accumulated through a combination of charisma, charm, and intelligence. Despite his many associates, he had limited significant or deep interpersonal ties. Although Mr. Epstein appeared EFTA00105655 Page 0900 to cultivate a large social and professional network, he was estranged from his only brother. Indeed, his identity appeared to be based on his wealth, power, and association with other high-profile individuals. Approximately two-and-a-half weeks before his death, Mr. Epstein appeared to attempt suicide, but ultimately denied it was a suicide attempt. He was convincing in his denial. At that time, he was saved because his cellmate notified BOP staff. In the weeks before his death, he made statements that he was “a coward” and was having difficulty adapting to his diminished circumstances. He also frequently referenced poor sleep and an inability to tolerate the noise of prison. On the day before his death, a number of documents in his case were unsealed, further eroding his previously-enjoyed elevated status and potentially implicating some of his associates. Given his lack of significant interpersonal connections, coupled with a complete loss of his status in both the community and among associates, the idea of potentially spending his life in prison was likely intolerable. 1. Single Ceiling: It is recommended that all inmates be double-celled unless safety concerns or an odd number of inmates precludes this. Priority should be given to inmates with a history of mental illness, self-directed violence, recent stressors (e.g., losses, newly sentenced, etc.) It is recommended that a system of control be implemented explaining who will be notified when a Suicide Watch or Psychological Observation ends and how that communication will take place. Because this is a life safety issue, the system of control, once approved by Executive Staff, should be reviewed in formal meetings such staff recalls, department head meetings, and lieutenants meetings. 2. Rounds: 30-minute rounds are required by P5500.14, Correctional Services Procedures Manual. 3. Cellmate Assignments: When Mr. Epstein was placed in SHU on July 7, 2019, Executive Staff decided Mr. Tartaglione would be his cellmate. As explained by Dr. , input was not sought from Psychology Services and it is not clear if or how sex offender-specific needs and associated risk were incorporated. Mr. Tartaglione was also a high profile inmate—an ex-police officer charged in multiple murders. However, he and Mr. Epstein did not share the risk associated with being a sex offender and their pairing may have aggravated Mr. Epstein’s risk for self-directed violence. In an effort to treat Mr. Epstein the same as other inmates, a statement repeated by multiple staff, Executive Staff may have inadvertently overlooked the need to consider significant unique risk factors associated with individuals who have been charged with and convicted of a sex offense. On July 25, 2019, Dr. sent an e-mail to Associate Warden explaining a consultation between Dr. and Dr. National Suicide Prevention Coordinator. In the e-mail, Dr. reviewed the consult and recommendation from the Psychology Services Branch, Central Office that Mr. Epstein be housed with another inmate who had also been accused of committing a sex offense. There is no evidence this information was considered beyond this e-mail, and Mr. Epstein was never housed with another sex offending inmate. It is recommended Executive Staff and Correctional Services staff include a psychologist in decisions about cellmates as a means of incorporating expertise about suicide risk, mental health needs, and interventions for psychological stability. EFTA00105656 Page 0901 4. Documentation Accuracy: On July 23, 2019, Mr. Epstein was found unresponsive in his cell. He had abrasions on his neck and knee. There are inconsistencies between documents describing the circumstances of the scene. In a General Administrative Note in PDS-BEMR, Dr. documented information received from Operations Lieutenant that Mr. Epstein, “was found with a string loosely hanging around his neck.” In contrast, Officer Wilson Silva, who responded to this emergency, wrote a memorandum dated July 23, 2019. In that memorandum, Officer Silva wrote he saw Mr. Epstein “laying down near his bunk with what appeared to be a piece of handmade orange cloth around his neck.” It is critical that all descriptions of the incident accurately reflect objective evidence. Officer wrote Mr. Epstein an incident report for Self-Mutilation on July 23, 2019, after he was found unresponsive in his cell. A Special Investigative Services Threat Assessment was completed August 2, 2019, but results were inconclusive as to whether Mr. Epstein engaged in self-directed violence, willingly fought with his cellmate, or was assaulted by his cellmate. Although the incident report was written in a timely manner, it presumed he engaged in self-directed violence and neglected to consider the other options of fighting and assault. Since it was unclear what had taken place in Mr. Epstein’s cell there should have been three incident reports written: one alleging Mr. Epstein engaged in Self-Mutilation, one alleging Mr. Epstein participated in a Fight or Assault without Injury, and a third alleging Mr. Tartaglione participated in a Fight or Assault with Injury. It is recommended that staff remain open to all reasonable explanations for a behavior and take the appropriate actions for all of those possibilities until a final determination is made. Dr. entered a Psychology Services Intake Screening into PDS-BEMR on July 8, 2010. The document has three typographical errors. She selected the No Sexual Offense Convictions check box when, in fact, Mr. Epstein was previously convicted of Solicitation of Prostitution and Procuring a Person Under the Age of 18 for Prostitution. Second, Mr. Epstein was erroneously identified as a Black male in this document. Finally, there is one instance where he was mistakenly referred to as Mr. Brown. Dr. completed a Risk of Sexual Abusiveness document on July 8, 2019. She marked “History of prior prison sexual predation” in the affirmative. This is not accurate. Mid-Level Practitioner, completed a History and Physical on July 9, 2019. An Intake Screening should have been conducted within 24 hours of his entry into Bureau custody, according to P6031.04, Patient Care. Officer was responsible for observing Mr. Epstein and documenting his behavior while on suicide watch on July 23, 2019. Officer mistakenly used an Inmate Suicide Watch Log Book between 1:40 a.m. and 6:00 a.m. on July 23, 2019, when he should have been using the Staff Suicide Watch Log Book. Inexplicably, Ms. , Drug Treatment Specialist, reportedly noticed this error and subsequently hand copied all of Officer entries from 1:40 a.m. to 6:00 a.m. into the Staff Suicide Watch Log Book. She then initialed these entries, and this makes it appear as if she was the one conducting the watch. This information was discovered and conveyed in an e-mail from Ms. Associate Warden to Dr. EFTA00105657 Page 0902 with a carbon copy to Warden on August 12, 2019. Of note, Ms. did not make an entry explaining why she was making the log book changes. Additionally, Ms. then wrote entries for 6:15, 6:30, 6:45 and 7:00 a.m. in the Staff Suicide Watch Log Book. These were not a part of the original entries made by Officer nor was Ms. assigned to work the Suicide Watch post. It is recommended that if a staff member makes an entry error (e.g., writes in the incorrect suicide watch log book), the staff member should describe the error in the correct log book, to include indicating when they become aware of the error. The staff member should then notify the Chief Psychologist. A review of Special Housing Unit Records (BP-A0292) revealed a number of incomplete entries. This document is used to monitor provision and receipt of basic services such as recreation, medical rounds, showers, meal consumption, etc. The Officer in Charge signature is missing on 10 occasions and a medical provider’s signature is missing in seven instances. There are six instances in which it is not clear if Mr. Epstein ate his meal. There are nine instances in which it is not clear if Mr. Epstein took a shower. There are ten instances in which it is not clear if Mr. Epstein was offered recreation. P5500.15, Corrective Services Manual requires accurate and complete information on the BP-A0292. A review of Psychology Observation Log Books revealed significant discrepancies from the approved Psychological Observation Procedural Memorandum, dated April 15, 2019. A Correctional Officer is required to complete hourly rounds and sign the log book; 179 out of 183 round signatures were missing. The lieutenant is required to sign the log book one time per shift and signatures were missing in 10 of 23 instances. A Physician Assistant is required to sign one time per shift and 16 of 16 instances were missing. It is recommended that a review of Psychological Observation procedures be conducted, and, if it can no longer be effectively implemented, the program should be discontinued. 5. Telephone Calls: In a PDS-BEMR note written by Dr. on July 16, 2019, she was informed by an unnamed staff member that a lieutenant facilitated two telephone calls for Mr. Epstein. It is unknown to whom these calls were placed and no evidence that they took place on a monitored telephone. According to a memorandum from Unit Manager on August 10,2019 Mr. Epstein terminated his legal visit early on August 9,2019,in order to place a telephone call to his family. Mr. Bullock (who was the Institutional Duty Officer that week) escorted Mr. Epstein to SHU around 7:00 p.m. that evening and he was placed in the shower area on G tier. While there,he was provided the telephone to make a call. Since Mr. Epstein reportedly did not have his PAC or PIN number,which is required to use the inmate telephone system,the Unit Manager placed the call,dialing a number that reportedly started with area code 347. Mr. Epstein told Mr. Bullock he was calling his mother who, according to public records,has been deceased since 2004. It is recommended that all telephone calls be made on monitored lines to be available for post-call review or on a speaker phone so staff can monitor what is discussed. 6. Direct Observation: Mr. Epstein was on suicide watch from July 23, 2019, until July 24, 2019. While on suicide watch on July 23, 2019, Mr. Epstein attended an attorney visit EFTA00105658 Page 0903 from approximately 12:40 p.m. until 7:15 p.m. During this time, he was without “direct, continuous observation” by a dedicated BOP staff member as required by P5324.08. While on Psychological Observation, he attended attorney visits on July 24, 2019, for 11.25 hours; on July 25, 2019, for 11.25 hours; on July 26, 2019, for 9.25 hours; on July 27, 2019, for 11.33 hours; on July 28, 2019, for 10.5 hours; and on July 29, 2019, for 8 hours. On July 30, 2019, Psychology Observation was terminated. During these visits, continuous observation by a dedicated BOP staff member was not maintained as required by MCC New York’s Procedural Memorandum for Psychological Observation. 7. Follow-Up: Mr. Epstein arrived at MCC New York on Saturday, July 6, 2019. While conducting the 10:00 p.m. institution count that evening, Facilities Assistant reported she observed Mr. Epstein in his cell. In an e-mail she sent to Drs. and Lieutenant later that evening, she described Mr. Epstein as “distraught, sad and a little confused.” She said she then asked Mr. Epstein if he was okay, and he reportedly said he was. However, she noted in her e-mail she was not convinced of this, adding, “He seems dazed and withdrawn.” She went on to say, “So just to be on the safe side and prevent any suicidal thoughts can someone from Psychology come and talk with him.” Despite the fact that Lieutenant opened the e-mail there is no evidence that he contacted the on-call psychologist as is required by P5324.08, Suicide Prevention Program. Additionally, if Ms. was concerned about suicide risk, P5324.08 Suicide Prevention Program, requires her to maintain direct, continuous observation of Mr. Epstein. When Dr. opened the e-mail the following Monday morning, Mr. Epstein was evaluated by Dr. at approximately 9:30 a.m. Mr. Epstein was denied bail on Thursday, July 18, 2019. This was a significant disappointment for Mr. Epstein and likely challenged his ability and willingness to adapt to incarceration. Given the potential impact of the judge’s decision, a psychologist should have assessed Mr. Epstein’s mental status upon his return to the institution. The BOP developed a SENTRY assignment of PSY ALERT for purposes such as this. Specifically PSY ALERT is used “to ensure, if movement occurs, that all staff consider the special psychological and management-related risks associated with the inmate.” Furthermore, P5324.07. SENTRY Psychology Alert Function states, “When a decision to move [any PSY ALERT] inmate occurs, any special psychological needs of the inmate are reviewed and considered by Psychology Services staff [and] any safety and security concerns are highlighted for non-Psychology Services staff.” Psychologists should use the PSY ALERT assignment more frequently with high profile cases and with inmates who have a history or charge of sex offense. Both of these groups of inmates are susceptible to exaggerated or unrealistic fears about correctional settings and experience stress associated during movement and periods of transition (e.g., cell/unit changes, movement to and from court, institutional movement, and release of information through the media). Mr. Epstein was reportedly in court on July 31, 2019. It is unknown what time he returned to MCC New York because this information was not entered in SENTRY. Regardless, upon his return, the United States Marshals Service (USMS) provided R&D staff with a Prisoner Custody Alert Notice regarding Mr. Epstein. The notice indicated Mr. Epstein had “MTL Mental Concerns Suicidal Tendencies.” The USMS requested R&D staff sign the form, and they then departed with the signed copy. On EFTA00105659 Page 0904 August 1, 2019, at 8:46 a.m., Dr. sent Dr. an e-mail reporting she had just become aware of the above information. In the absence of additional information about this notation, this should have been considered a referral to Psychology Services about a potentially suicidal inmate and procedures should have been followed as outlined in P5324.08, Suicide Prevention Program. Specifically, when a staff member becomes aware an inmate may be thinking about suicide during normal working hours, that staff member must contact Psychology Services and maintain the inmate under direct, continuous observation until he is placed on Suicide Watch or seen by a psychologist. There is no evidence Mr. Epstein was monitored under these conditions from the time he returned from court until he was seen by Dr. for a suicide risk assessment on August 1, 2019, at approximately 1:30 p.m. 8. Inmate Accountability and Assignment Accuracy: According to a SENTRY quarters roster generated on August 10, 2019, at 12:51 a.m., there were three inmates assigned to Mr. Epstein’s SHU cell, Z04-206LAD, including him, at the time of his death. However, his SHU cell was only a double occupancy cell. Inmate Patrick Avila (#86710-054), inmate Gregory Ferrer (#79793-054), and Mr. Epstein were all assigned to the same cell. On August 13, 2019, at 12:06 p.m. and 12:08 p.m., we generated a quarters history roster for inmate Avila and Ferrer, respectively. Inmate Avila’s cell assignment was Z04-206LAD from August 5, 2019, until August 11, 2019, when he was moved to cell Z04-212UAD. Inmate Ferrer’s cell assignment was Z04-206UAD from August 1, 2019, until August 11, 2019, when he was moved to cell Z04-207LAD. We then generated a quarters history roster for Mr. Epstein on August 13, 2019, at 9:07 a.m. His cell assignment was Z04-206LAD from July 29, 2019, until August 10, 2019. On Monday, August 12, 2019, photographs of nametags on SHU cell doors and SHU locator forms were sent to the Correctional Service Department in the Northeast Region. The SHU locator form is dated August 9, 2019. It shows inmate Ferrer in cell 207L (SENTRY states he was moved to this cell on August 11, 2019), inmate Avila 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 Reyes (#85993-054). The locator shows inmate Copper (#92299-054) and inmate Dockery (#60685-050) in cell 206. The photo sheets show the cell being 220 with inmates Epstein and Reyes’ identification cards on the door. Inmate Reyes, Efrain, Reg. No. 85993-054 was in cell Z06-220U from August 5, 2019 to August 9, 2019. MCC New York has four suicide watch cells and each is for single occupancy use. The suicide watch cells are located in Health Services. Each cell is abbreviated with the unit code H01 in SENTRY followed by the four-digit cell number. The doors are identified by a painted number from one to four. Two reviews were conducted. The first revealed Mr. Epstein was in H01-001L according to SENTRY but the Suicide Watch Log Books indicate he was in cell 4. A second review was conducted on April 13, 2019, while there were four inmates on in these cells. SENTRY showed two inmates assigned to HO1- 001L, one assigned to H01-002L, and the fourth inmate assigned to a general population housing unit. Through physical observationof the dedicated suicide watch cells there were four H01 cells, however a review of the BOPWARE Inmate Housing Format, only shows three cells. EFTA00105660 Page 0905 Inmate movement and assignments are not accurately reflected in SENTRY as required by P5500.14, Correctional Service Procedures Manual. 9. Attorney Log Books: Four log books were not secured following Mr. Epstein’s death. Specifically, three Attorney Log Books located in the Attorney Visiting and Front Lobby areas and an Inmate Search Log Book located in the Attorney Visiting area were not secured. All four books were still in use at the outset of the reconstruction and after the reconstruction team advised staff to secure them. P5324.08 states, “In the event of a suicide, institution staff, particularly Correctional Services staff, and other law enforcement personnel, will handle the site with the same level of protection as any crime scene in which a death has occurred.” This policy further states, “All possible evidence and documentation will be preserved to provide data and support for subsequent investigators doing a psychological reconstruction.” Further, a review of the attorney log books identified many errors and signify a systemic concern. For example, there were two concurrently open attorney log books in the Attorney Visiting area. Further, the different purposes of the two attorney log books, one in the Attorney Visit area and one in the Front Lobby, could not be explained. BOP staff were unable to articulate a system of control for the log books, and during the reconstruction, some of the log books could not be accounted for. Within the log books, entries were made out of chronological order, attorneys did not consistently sign in and out, significant information was illegible or missing, columns were not consistently labeled, log book opening and closing dates were inconsistent, and the cover had been torn off of several books. At the current time, these log books are not functioning as an adequate system of control and monitoring. 10. Automatic External Defibrillators: A review of available AEDs in the institution revealed that the list used for accountability and inspection purposes was inaccurate and incomplete. 11. Post Orders & SHU Training: SHU Post Orders Sign-In Sheets were reviewed for the 3rd Quarter, spanning June 9, 2019, to September 7, 2019. Officer L. Grey failed to sign post orders for SHU #3 post. Quarterly SHU Training Sign-In Sheets were reviewed. The 2019 3rd Quarter SHU Training was conducted on June 6, 2019. Three staff assigned to the 3rd Quarter SHU Roster in SHU did not attend or receive the SHU Training: Officer , Officer , and Officer . 12. Staffing: The Drug Abuse Program Coordinator positon at MCC New York was abolished during Phase I of the staff realignment during fiscal year 2018. Re-establishing the Drug Abuse Program Coordinator position would provide the institution with an additional supervisory psychologist to provide critical clinical services. Staffing in the Correctional Services department is relevant to the reconstruction. However, the details about this topic are provided in an After Action Review completed separately from this report. EFTA00105661 Page 0906 13. Case Conceptualization: A broad understanding of risk factors associated with sex offenders by staff at MCC New York did not appear to be present but was vital to his adjustment and safety in prison. There is limited time for psychologists to dedicate extended periods conceptualizing cases. However, it is recommended in particularly complex and high profile cases in order to provide effective psychological interventions and maximize support for Executive Staff management of inmates. ## DOCUMENTS EXAMINED TRU-INTEL Download Report of Incident (583), 586, & Global Report TRUVIEW – Money Exchanged; Phone, Email, & Visitor Lists; Calls; Messages; Visits; TRU-SCOPE – Logs, High Risk Inmates, Inmates Lists, etc.
Staff E-Mail
Photographs of Scene; Deceased, Autopsy
Video Showing Scene and Staff Response
Sentry Documentation
SIS Case File Index
Psychology File PDS-BEMR
Psychological Observation Procedural Memorandum
Post Orders
Lieutenant Logs
Attorney Logs
Staff Roster
Medical Information/Records(BEMR)
BOP Twenty-Four Hour Death Report
Pre-Sentence Report
Note(s) Left Behind by Deceased
Time Line
Autopsy Request&Report
Inmate Central File
Court Return Screening Form
Prisoner Remand Form(If applicable)
USM 129 Individual Custody/Detention Report(If applicable)
Prisoner Custody Alert Notice
Staff Sign-In Log1 Week Prior to Suicide(If applicable)
Detention Orders(If applicable)
30 minute SHU rounds
BP 292's&295's
BP 292's & 295's EFTA00105662