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U.S. Department of Justice Federal Bureau of Prisons¶
Metropolitan Correctional Center 150 Park Row New York, New York 10007¶
Office of the Warden¶
January 20, 2020¶
MEMORANDUM FOR HUGH . HURWITZ, ASSISTANT DIRECTOR, REENTRY SERVICES DIVISION¶
FROM:¶
M. Licon-Vitale, Warden, MCC New York¶
SUBJECT:¶
Institution Response to Psychological Reconstruction Inmate Epstein, Jeffrey (76318-054)¶
This is the response to the psychological reconstruction of inmate Epstein, Jeffrey (76318-054) dated December 27, 2019.¶
- Rounds: 30-minute rounds are required by P5500.14, Correctional Services Procedures Manual.
Institution Response:¶
Video review requirements have been instituted by NERO. Specifically, on Tuesday of each week, the institution is notified by NERO of the date, time, and SHU range in which to download video. The video is a two hour block. The video is to be reviewed by the Captain. During the reviews the Captain is looking for strict adherence to the requirements that rounds be conducted at least once during every 30-minute period, not to exceed 40 minutes between rounds and that all scheduled counts are being conducted in the SHU. The Captain will then submit an assurance memo to the institutional executive staff and Correctional Services Administrator (CSA) indicating the designated video footage was reviewed, and corrective actions which were taken for any deficiencies noted. This memorandum will be submitted to the Regional Office by COB on Friday of that same week.¶
Institutional Duty Officers (IDO’s) are required to review 6 hours of SHU video to review. The surveillance footage is downloaded by the institutional SIA and a compact disk is provided to the IDO’s for review. The IDOs are reviewing the video for accuracy of the 30 minute reviews. All reviews are documented in a memorandum to the Warden for review.¶
- 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
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it is not clear if or how sex offender-specific needs and associated risk were incorporated into the housing plan. 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 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 inmate charged or convicted of a sexual offense.¶
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.¶
Institution Response:¶
Psychology Services: As was noted, there was no documentation indicating Psychology Services, was present when housing decisions were made regarding Mr. Epstein. Psychology services is present at the weekly SHU meeting, Executive Staff meetings, and weekly Opening and Close-Out meetings. During these meetings, the Chief Psychologist and/or Acting Chief psychologist are present to give feedback to the Executive Staff on housing concerns regarding inmates with mental health issues or risk factors for suicidality. When an inmate presents with unique risk factors associated with individuals who have been charged with and/or convicted of a sex offense, careful evaluation is made with regard to housing these inmates with appropriate cellmates. Moving forward, a plan has been established to have a sign-in sheet and checklist at these meetings where housing issues are addressed, indicating who was present and what the housing plan is for these inmates with psychological concerns. These checklists will be maintained in a binder by the Associate Warden of Programs.¶
- 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, 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 but prior to having the necessary facts to determine whether he likely engaged in a Bureau violation. BOP Policy expects staff to write an incident report within 24 hours of having the information that an inmate likely violated BOP rules but without making a presumptive decision about guilt. 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. It is recommended that staff remain open to all reasonable explanations for a behavior and take the appropriate actions when a final determination is made. Although the incident report was later expunged, inmates frequently experience¶
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significant stress when they contemplate the potential consequences associated with findings of guilt.¶
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 which was on July 6, 2019, 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. mistakenly used a Suicide Watch Log Book intended for inmate companion documentation 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. Ms. Drug Treatment Specialist, reportedly noticed this error and subsequently hand copied all of entries from 1:40 a.m. to 6:00 a.m. into a 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 Associate Warden to Dr. with a carbon copy to Warden on August 12, 2019. Of note, did not make an entry explaining why she was making the log book changes. Additionally, 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 nor was¶
assigned to work the Suicide Watch post. Due to the inability to interview staff at this time, it is unknown why attempted to correct error, or made any of the subsequent log entries. 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 became 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, Correctional 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 further review of Psychological Observation procedures be conducted.¶
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Institution Response:¶
Two slides (slide numbers 23-24) have been added to the Annual Training slide show for the Report Writing class. In addition to the established training, the slides further differentiate and provide guidance to staff regarding when it is appropriate to write an Incident Report and when, in cases of a lack of evidence, a memorandum is more appropriate. The additional information is being provided to all staff as a part of Annual Training that is already in progress.¶
- 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 when and 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. （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 began with area code 347. Mr. Epstein told Mr. he was calling his mother who, according to public records, has been deceased since 2004.¶
It is recommended that all telephone calls, other than legal 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.¶
Institution Response:¶
On August 29, 2019, Warden Petrucci, signed a referral related to failure to follow policy in allowing Epstein to complete an unmonitored phone call. The referral was submitted to the Office of Internal Affairs on that same date and is pending further action at this time.¶
- 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 Imeri 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, Ms. 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 Medina 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¶
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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 departed or 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 August 1, 2019, at 8:46 a.m., sent Dr. an email 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 for a suicide risk assessment on August 1, 2019, at approximately 1:30 p.m.¶
- Inmate Accountability and Assignment Accuracy: According to a SENTRY quarter’s 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., a quarter’s history roster was generated 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. A quarter’s history roster was generated 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 HO1 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 H0l-00lL according to SENTRY but the Suicide Watch Log Books indicate he was in cell 4. A second review was conducted on August 13, 2019, while there were four inmates on in these cells. SENTRY showed two inmates assigned to HO1-00lL, one assigned to H01-002L, and the fourth inmate assigned to a general population housing unit. Through physical observation of the dedicated suicide watch cells there were four¶
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H0l cells, however a review of the BOPWARE Inmate Housing Format, only shows three cells.¶
Inmate movement and assignments are not accurately reflected in SENTRY as required by P5500.14, Correctional Service Procedures Manual.¶
Institution Response:¶
Psychology Services: Attached please find the follow-up training sign-in sheets, Department Head Meeting Minutes, and e-mails provided by psychology staff regarding Psy Alert Inmates. As recommended by Central Office, the Chief Psychologist has conducted suicide prevention trainings during Department Head Meetings, through e-mail correspondence, during SHU Staff Trainings, and during Lieutenant’s Trainings.¶
- 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 tom off of several books. At the current time, these log books are not functioning as an adequate system of control and monitoring.¶
Institution Response:¶
Please see the attached audit which was conducted on September 25, 2019.¶
- Sex Offense Risk Factors: A broad understanding of risk factors associated with sex offenders, by staff at MCC New York, did not appear to be present in all staff but was vital to his adjustment and safety in prison. A more focused management strategy is recommended, particularly in complex and high profile cases. Supplemental training on sex-offender specific risk factors is recommended for all staff and should be provided by Executive Staff and Psychology Services.
Institution Response:¶
The PREA Compliance Manager whom is an Associate Warden has been delegated the instructor for Sex offender specific dynamics and addressing inmate sexual misconduct.¶
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DOCUMENTS EXAMINED¶
Psy Alert inmates¶
Department Head meeting Minutes¶
SHU Suicide Prevention Training¶
Report Writing “Back to Basics training”¶
Bed book count Schedule¶
Bed Book audit Log Book Audit¶
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