DOJ Inspector General draft report on Epstein's custody at MCC New York, March 2023

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DRAFT¶

Investigation and Review of the Federal Bureau of Prisons’ Custody, Care, and Supervision of Jeffrey Epstein at the Metropolitan Correctional Center in New York, New York¶

March 2023¶

Notice: This Draft Is Restricted to Limited Official Use.¶

This document is a WORKING DRAFT prepared by the U.S. Department of Justice Office of the Inspector General. It has not been fully reviewed within the Department and is, therefore, subject to revision. This report may contain sensitive law-enforcement or privacy-protected information and is for authorized recipients only. Recipients of this draft must not, under any circumstances, show or release its contents for purposes other than official review and comment. It must be safeguarded in accordance with Department of Justice Order 2620.7 to prevent publication or other improper disclosure of the information it contains.¶

If you have received this draft report in error, please contact (202) 768-2643 to arrange its return.¶

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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¶

The Department of Justice (DOJ) Office of the Inspector General (OIG) initiated this investigation upon receipt of information from the Federal Bureau of Prisons (BOP) that on August 10, 2019, in the Metropolitan Correctional Center 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 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 was assigned to 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.¶

While in MCC New York, Epstein was screened on numerous occasions by psychological staff and in all of the evaluations he denied having thoughts or a history of suicide. Psychological staff determined Epstein did not meet the criteria for a psychological diagnosis.¶

Relevant BOP Policies¶

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. For inmates identified as suicide risks, the BOP requires they be placed on suicide watch until no longer at imminent risk. A less restrictive monitoring form, psychological observation, is used for inmates who are stabilizing but not yet ready to return to a housing unit.¶

Additionally, BOP policy requires that all inmate telephone calls be made through BOP’s Inmate Telephone System. On rare occasions, BOP policy permits inmates to make a call outside of this system, but the call must be recorded and documented.¶

Incident Involving Epstein on July 23, 2019¶

On July 23 at 1:27 a.m., correctional officers responded to Epstein’s SHU cell where they found Epstein with a handmade 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. 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. Another inmate housed on the same SHU tier told the OIG 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¶

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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. Also on August 9, after meeting at the prison with his lawyers, staff allowed Epstein to make an unrecorded, unmonitored telephone call before he was returned to his SHU cell. Although Epstein said he was calling his mother, he actually called an individual with whom he allegedly had a personal relationship.¶

At approximately 8:00 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 OIG 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 4:00 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, Correctional Officer Tova Noel and Material Handler Michael Thomas, began delivering breakfast to SHU inmates. Tova 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 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. $ ^{1} $¶

1 As detailed in the report, MCC New York had a history¶

of security camera problems.¶

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The available video from the one SHU camera captured a large part 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 MCC 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 OIG 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. Attorney’s 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 OIG 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. SHU staff told the OIG that at approximately 8:00 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. Further, 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.¶

We further noted 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; and that he signed a new Last Will and Testament on August 8, 2 days before he died. We found that the staff’s failure to assign Epstein a cellmate on August 9, 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 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 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.¶

The OIG made nine recommendations to the BOP to address the numerous issues identified during our investigation and review. Finally, we recommend 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.¶

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Table of Contents

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Chapter 1: Introduction … 1¶

Chapter 2: Background … 5¶

I. Significant Entities and Individuals … 5 II. Methodology … 6 III. Applicable Law, Regulations, and BOP Policies … 7 A. Standards of Conduct … 7 B. False Statements and Lack of Candor … 8 C. Relevant BOP Policies Regarding the Operation of Correctional Facilities … 8¶

1. Special Housing Units … 8
2. Inmate Accountability … 9
3. Psychological Screening … 10
4. Suicide Response … 11
5. Inmate Discipline … 12
6. Conditions of Confinement … 12

Chapter 3: Timeline of Key Events … 14¶

Chapter 4: Custody and Care of Epstein Prior to His Death … 21¶

I. Epstein’s Arrest and Detention on July 6 … 21 II. MCC New York’s Special Housing Unit (SHU) … 22 III. Epstein’s Initial Cell and Cellmate Assignment from July 7 to July 23 … 26 IV. Events of July 23 and the Placement of Epstein on Suicide Watch and Psychological Observation from July 23 to July 30 … 26 V. The Psychology Department’s Post-July 23 Determination that Epstein Needed to Have an Appropriate Cellmate … 30 VI. Selection of Epstein’s Cellmate After Psychological Observation … 31 VII. Epstein’s Cell Assignment from July 30 to August 10 … 31 VIII. Psychological Evaluations of Epstein from July 6 to August 9 … 37¶

Chapter 5: The Events of August 8-10, 2019, and Epstein’s Death … 45¶

I. Epstein Signs a New Last Will and Testament on August 8 … 45 II. Court Order on August 9 Releasing Epstein-Related Documents in Pending Civil Litigation … 45 III. Transfer of Epstein’s Cellmate on August 9 to Another Institution and Failure to Replace Him with Another Inmate … 45 A. Notice on August 8 of the Impending Transfer of Epstein’s Cellmate on August 9 … 45¶

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B. MCC New York Staff Reject Epstein Attorney’s Request that Epstein be Housed Without a Cellmate … 46¶

C. Removal on August 9 of Epstein’s Cellmate from MCC New York … 46¶

D. Failure to Assign Epstein a New Cellmate on August 9 … 47¶

1. Day Watch Staff Actions on August 9 … 47
2. Evening Watch Staff Actions on August 9 … 50

IV. Epstein is Allowed to Make an Unmonitored Telephone Call on August 9 … 52¶

V. Failure to Conduct SHU Inmate Counts and Staff Rounds on August 9-10 … 55¶

A. SHU Inmate Counts … 55¶

1. The 4:00 p.m. SHU Count on August 9 … 56
2. The 10:00 p.m. SHU Count on August 9 … 58
3. The 12:00 a.m., 3:00 a.m., and 5:00 a.m. SHU Counts on August 10 … 60

B. Staff Rounds in the SHU … 61¶

1. Correctional Officer Rounds … 61
2. Lieutenant Rounds … 63

VI. Epstein’s Death on August 10 … 64¶

A. Discovery of Epstein Hanged in Cell and Emergency Response … 64¶

B. Items Found in Epstein’s Cell on August 10 Following His Death … 70¶

C. Autopsy Results … 72¶

Chapter 6: The Availability of Limited Recorded Video Evidence Due to the Security Camera Recording System Failure … 74¶

I. Background on the Security Camera System at MCC New York … 74¶

II. Discovery of Security Camera System Recording Issues in August 2019 … 75¶

A. Discovery on August 8 of the DVR 2 Failure that Occurred on July 29 … 75¶

B. Response on August 8 and 9 to Discovery of the Recording Failure … 76¶

C. SHU Camera Locations and Operational Status on August 10 … 77¶

D. FBI Forensic Analysis of the DVR System … 82¶

Chapter 7: Conclusions and Recommendations … 84¶

I. Conclusions … 84¶

A. MCC New York Staff Failed to Ensure that Epstein Had a Cellmate on August 9 as Instructed by the Psychology Department on July 30 … 88¶

1. Failure to Make Required Notifications Regarding the Need to Assign Epstein a New Cellmate … 88
2. Failure to Adequately Supervise SHU Staff … 90

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3.	Failure to Have a Contingency Plan for Assigning Epstein a Cellmate	91
4.	Lack of Candor	91
B. MCC New York Staff Failed to Conduct Mandatory Rounds and Inmate Counts Resulting in Epstein Being Unobserved for Hours Before His Death
1.	Failure to Conduct Rounds and Inmate Counts in the SHU	92
2.	False Statements and Lack of Candor	93
3.	Poor Judgment Regarding the Use of Overtime	94
4.	Clearing the 10:00 p.m. Institutional Count Knowing that It Was Inaccurate	95
5.	Failure to Adequately Supervise SHU Staff and Conduct Lieutenant Rounds	96
C. MCC New York Staff Allowed Epstein to Place an Unmonitored Telephone Call on August 9.. 97
D. MCC New York Staff Failed to Conduct and Document Cell Searches and Eliminate Safety Hazards in Epstein's Cell on August 9 Leaving Epstein with Excessive Linens in His Cell
E. MCC New York Staff Failed to Ensure that the Institution's Security Camera System was Fully Functional Resulting in Limited Recorded Video Evidence
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Chapter 1: Introduction¶

The Department of Justice (DOJ) Office of the Inspector General (OIG) initiated this investigation upon the receipt of information from the Federal Bureau of Prisons (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 8:00 p.m. on August 9, all SHU inmates, including Epstein, were locked in their cells for the evening. Additionally, the six separate tiers or groups of cells within the SHU were also securely locked. At approximately 6:30 a.m. on August 10, 2019, SHU staff unlocked the door to the SHU tier in which Epstein’s cell was located in order to deliver breakfast to inmates through the food slots in the locked cell doors. When SHU staff entered the tier to deliver breakfast to Epstein, SHU staff knocked on the locked door to Epstein’s cell. Epstein, who was housed alone in the cell, did not respond to SHU staff. SHU staff unlocked the cell door and found Epstein hanged in his cell, with one end of a piece of orange cloth around his neck and the other end tied to the top portion of a bunkbed in Epstein’s cell. Epstein was suspended from the top bunk in a near-seated position with his buttocks approximately 1 inch to 1 inch and a half off the floor and his legs extended straight out on the floor in front of him. Epstein’s cell contained an excess amount of prison linens, as well as multiple nooses that had been made from torn prison linens.¶

SHU staff immediately activated a body alarm, which notified all MCC New York staff of a medical emergency and prompted MCC New York staff assigned to the Control Center to call for 911 emergency services. SHU staff then ripped the orange cloth away from the bunkbed, which caused Epstein’s buttocks to drop to the ground. SHU staff laid Epstein on the ground and immediately initiated cardiopulmonary resuscitation (CPR). At approximately 6:33 a.m., other MCC New York employees responded to the SHU. A responding MCC New York Lieutenant took over administering CPR and asked SHU staff to retrieve an automated external defibrillator and call for the duty nurse. A Clinical Nurse responded and continued to perform CPR on Epstein in the place of the Lieutenant. At approximately 6:39 a.m., Epstein was placed on a stretcher and moved by medical staff to the MCC New York Health Service Unit.$^2$ The Clinical Nurse continuously administered CPR until he was relieved by outside Emergency Medical Technicians (EMTs) when they arrived at the Health Services Area minutes later. The EMTs continued CPR, 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¶

2. Moving an inmate requiring outside emergency medical care to the Health Services Unit provides health care staff and Emergency Medical Technicians (EMTs) with immediate access to any necessary medical equipment and supplies, and allows EMTs faster access to the inmate when they arrive at MCC New York because correctional officers can directly escort EMTs to the Health Services Unit to begin emergency treatment immediately. If EMTs had to be escorted to the housing unit, they would first need to be thoroughly screened, which would delay medical attention.

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cause of death was hanging and the manner of death was suicide.¶

The OIG conducted this investigation jointly with the Federal Bureau of Investigation (FBI), with the OIG’s investigative focus being the conduct of BOP personnel. Among other things, the FBI investigated the cause of Epstein’s death. The FBI determined that there was no criminality pertaining to how Epstein had died. This report concerns the OIG’s findings regarding MCC New York personnel’s custody, care, and supervision of Epstein during his detention at the facility from his arrest on July 6, 2019, until his death on August 10, 2019.¶

The OIG investigation and review identified numerous and serious failures by MCC New York staff, as well as multiple violations of MCC New York and BOP policies and procedures. Among the most significant was the failure to assign Epstein a new cellmate on August 9, 2019, after Epstein’s cellmate was transferred out of MCC New York that day. Epstein was required to have a cellmate at all times pursuant to a written direction that the MCC New York Psychology Department issued on July 30 after Epstein was removed from suicide watch and psychological observation following a possible attempted suicide by him on July 23. As a result of the failure to assign him a new cellmate, Epstein was housed alone in his cell from the night of August 9 until he was found hanged in his cell by SHU staff at approximately 6:30 a.m. the following morning. In addition, we determined that SHU staff failed to conduct required inmate counts and rounds, including overnight on August 9-10, and allowed Epstein to have an excess of blankets, linens, and clothing in his cell. These failures compromised Epstein’s safety, the safety of other inmates, and the security of the institution, and provided Epstein an opportunity to commit suicide while locked alone in his cell on the morning of August 10 without having been subject to overnight observation or supervision by SHU staff.¶

The OIG also found that an MCC New York supervisor had allowed Epstein, in violation of BOP policy, to make an unrecorded, unmonitored telephone call the evening before his death to an individual with whom he allegedly had a personal relationship. Further, 2 days before his death, during a meeting with his lawyers in a private room at the MCC New York, Epstein signed a new Last Will and Testament, which MCC New York officials did not learn about until after his death.¶

Additionally, the OIG determined that MCC New York staff assigned to the SHU, including the two SHU staff on duty the night of August 9-10, 2019, who were stationed at a desk that was directly outside the SHU tier in which Epstein was housed and diagonally across from Epstein’s cell, had falsified BOP records to claim that they had conducted all of the required counts of inmates and 30-minute rounds during their shifts within the SHU. As described in greater detail in Chapter 2, inmate counts and 30-minute rounds are two means by which the BOP accounts for inmates and assesses their safety, security, and well-being. BOP and MCC New York policies require that staff members count all inmates in each housing unit within the facility at designated times each day. Additionally, BOP and MCC New York policies require that a staff member observe all SHU inmates at least once during the first 30 minutes of each hour (e.g., 12:00 a.m. to 12:30 a.m.) and again during the second 30 minutes of the hour (e.g., 12:30 a.m. to 1:00 a.m.), thus ensuring that inmates are observed at least twice per hour. BOP staff are required to document inmate counts and 30-minute rounds on official BOP forms, which are often referred to as “count slips” and “round sheets.”¶

$ ^{3} $ These BOP forms are officially entitled “Official Count Slip” and “MCC New York, Special Housing Unit, 30 Minute Check Sheet.”¶

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During the OIG’s investigation, the OIG obtained information that the staff assigned to the MCC New York SHU did not conduct any counts of inmates within the SHU from August 9, 2019, at approximately 4:00 p.m., until Epstein was found hanged in his cell on the morning of August 10, 2019. However, in documentation completed by the SHU staff on duty during that period, staff members falsely certified in the count slips that they had conducted the required counts. Additionally, the OIG investigation revealed that the staff assigned to the MCC New York SHU did not conduct any required 30-minute rounds of inmates after approximately 10:40 p.m. on August 9, 2019. Again, however, SHU staff on duty during that period had falsely certified in the round sheet that the required rounds were conducted. The combination of these and other failures led to Epstein being unmonitored and locked alone in his cell, which the OIG found contained an excessive amount of bed linens, from approximately 10:40 p.m. on August 9 until he was discovered hanged in his cell at approximately 6:30 a.m. the following day.¶

While the OIG determined that MCC New York staff committed significant 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 FBI’s 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 8:00 p.m. on August 9, all SHU inmates were locked in their cells for the evening and that there was no indication that any of the other inmates could have gotten out of their cells. Additionally, the OIG analyzed the available recorded video of the SHU, which was limited to the common area of the SHU, including the SHU Officers’ Station, due to the MCC New York security camera system’s recording issues that we detail in this report.$^4$ The OIG’s analysis of the recorded video did not identify any correctional officers or other individuals approaching any of the SHU tiers, including the L Tier where Epstein was housed, from the common area of the SHU between approximately 10:40 p.m. on August 9 and approximately 6:30 a.m. on August 10.¶

Finally, the Medical Examiner who performed the autopsy detailed for the OIG why Epstein’s injuries were more consistent with, and indicative of, a suicide by hanging rather than a homicide by strangulation. The Medical Examiner also cited to the absence of debris under Epstein’s fingernails, marks on his hands, contusions to his knuckles, or bruises on his body that evidenced Epstein had been in a struggle, which would be expected if Epstein’s death had been a homicide by strangulation.¶

As discussed in greater detail in Conclusions and Recommendations chapter of this report, this is not the first time that the OIG has found significant job performance and management failures on the part of BOP personnel and widespread disregard of BOP 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 BOP documentation concerning inmate counts and rounds, and has repeatedly found deficiencies¶

4 For reasons we describe below, while the camera inside the L Tier was working and transmitting live video, the video was not being recorded.¶

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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(c)(1)(B) and 5 C.F.R. § 1201.56(b)(1)(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.¶

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Chapter 2: Background¶

I. Significant Entities and Individuals¶

Jeffrey Epstein was born in 1953 and, prior to his arrest, worked at various jobs in the financial industry and ultimately developed considerable wealth. On July 2, 2019, a federal grand jury of the U.S. District Court for the Southern District of New York returned an indictment that charged Epstein with engaging in sex trafficking and a sex trafficking conspiracy, in violation of 18 U.S.C. §§ 371, 1591(a),(b)(2), and 2. These charges were based on allegations that between 2002 and 2005, Epstein paid girls as young as 14 years old hundreds of dollars in cash each for engaging in sex acts with him at his Florida and New York residences. The indictment further alleged that Epstein also paid each of these minor victims hundreds of dollars in cash to recruit other girls to engage in sex acts with Epstein.¶

On July 6, 2019, Epstein was arrested at Teterboro Airport in New Jersey upon his return to the United States from France and was transported to the Federal Bureau of Prisons’ (BOP) Metropolitan Correctional Center, located at 150 Park Row in New York, New York (MCC New York). Following a detention hearing on July 15, 2019, the court ordered that Epstein be detained pending trial based on the court’s finding that he was a danger to the community and a flight risk.¶

MCC New York is a federal administrative detention facility operated by the BOP that primarily provides pretrial detention services for the U.S. District Courts for the Southern and Eastern Districts of New York. The BOP temporarily closed MCC New York in October 2021 due to substandard conditions that are unrelated to this investigation. When it was operational, MCC New York housed approximately 750 inmates at any given time. Prior to its closure, the majority of MCC New York’s inmate residents were individuals with pending criminal charges (as opposed to individuals who had been convicted of offenses and were serving a sentence of imprisonment), 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 Tova Noel and Material Handler Michael Thomas began working together in MCC New York SHU at 12:00 a.m. on August 10, 2019. $ ^{5} $ 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 referred to as a “round sheet”) falsely stating that she and Thomas had conducted such rounds when. in¶

5 Noel worked her regular shift in the SHU from 4:00 p.m. to 12:00 a.m. on August 9,2019,followed by an overtime shift in the SHU from 12:00 a.m. to 8:00 a.m. on August 10,2019. Thomas did not work his regular 4:00 p.m. to 12:00 a.m. shift as a Material Handler in a different location of MCC New York and instead worked an overtime shift in the SHU from 12:00 a.m. to 8:00 a.m. on August 10,2019.

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fact, they had not.⁶¶

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. §§ 371, 1001(a)(3), and 2. The indictment alleged that on August 9, 2019, Noel failed to conduct the mandatory 4:00 p.m. and 10:00 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 12:00 a.m., 3:00 a.m., and 5:00 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 correctional officer 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 contacted the OIG through his attorney and requested to provide information. The BOP employees and contractors we interviewed included employees involved in various aspects of the emergency response, who worked at¶

6 These BOP forms are officially entitled “ Official Count Slip” and “MCC New York, Special Housing Unit, 30 Minute Check Sheet.” Each of the six 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.¶

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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. $ ^{7} $ 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 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-302s), 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.¶

III. 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 in an honest effort to perform official duties.” $ ^{9} $ The ethical regulations also mandate that federal employees not use federal property “for other than authorized activities.” $ ^{10} $¶

BOP policy (Program Statement 3420.11, Standards of Employee Conduct) imposes several additional standards of conduct on its employees. At all times BOP employees must “[c]onduct themselves in a manner that fosters respect for the Bureau of Prisons, the Department of Justice, and the U.S. Government.” Because “[i]nattention to duty in a correctional environment can result in escapes, assaults, and other incidents,” BOP employees “are required to remain fully alert and attentive during duty hours.” BOP policy¶

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 Department employees.¶

$$\textcircled{8} \ 5 \ C.F.R. \ $ 2635.101(a).$$¶

$$\textcircled{9} \ 5 \ C.F.R. \ $2635.705(a); \text{ see also } 5 \ C.F.R. \ $2635.101(b)(5).$$¶

$$\textcircled{10}$$ 5 C.F.R. § 2635.101(b)(9); see also 5 C.F.R. § 2635.704(a).¶

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provides that employees can use government property for authorized purposes only, and further specifies that personal use of government office equipment, such as computers, “will not take place during official working hours.” BOP policy requires that employees “obey the orders of their superiors at all times.”¶

B. False Statements and Lack of Candor¶

Under federal law, “whoever, in any matter within the jurisdiction of the executive…branch of the Government of the United States, knowingly and willfully…makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry” has violated 18 U.S.C. § 1001(a)(3). The terms “knowingly and willfully” mean that the subject acted with knowledge that the conduct was, in a general sense, prohibited by law. It is not required that the subject was aware of the existence of Section 1001.¶

Under BOP standards of conduct discussed above, employees are required to cooperate fully with official investigations, which includes providing “all pertinent information they may have” and “truthfully responding to questions.”¶

C. Relevant BOP Policies Regarding the Operation of Correctional Facilities¶

1. Special Housing Units¶

Special Housing Units within BOP facilities are governed by federal regulations, 28 C.F.R. §§ 541.21-541.33. These regulations provide that the BOP may establish Special Housing Units (SHU) “where inmates are securely separated from the general inmate population.” These regulations and BOP policy (Program Statement 5270.11, Special Housing Units) explain that inmates in the SHU are either on administrative detention or disciplinary segregation status. Administrative segregation status is a non-punitive designation that removes an inmate “from the general population when necessary to ensure the safety, security, and orderly operation of correctional facilities, or protect the public.” There are several reasons an inmate can be placed in administrative detention status, including when an inmate’s presence in the general inmate population presents a threat to self or others, or when administrative detention status is necessary for the protection of the inmate. Assignment to the SHU for protection reasons can be based on being a victim of an assault, acting (or being perceived) as an informant, refusing to enter general population, or because of staff concerns about the inmate’s safety.¶

Inmates in the SHU are securely separated from general population inmates and are kept locked in their cell when in their assigned tier within the SHU. As discussed in greater detail in Chapter 4, witnesses told the OIG that SHU inmates are locked in their cells for approximately 23 hours a day. BOP policy provides that, weather and resources permitting, SHU inmates will have the opportunity to exercise outside their quarters 5 hours per calendar week. Under federal regulations and BOP policy, SHU inmates ordinarily have the opportunity to shower at least three times a week, typically on different days in 1-hour periods. SHU inmates may also be escorted from their cells by MCC New York staff for visits, including legal visits, court appearances, medical and psychological attention. The MCC New York SHU Post Orders require that all visitors to the SHU be documented in a visitor log, and that any inmate visiting the SHU, such as inmates on work details, be searched visually and with a hand-held metal detector, without exception. The MCC New York SHU Post Orders also require that food carts be searched inside and out before being brought into a SHU cellblock and that all meals be delivered to each inmate’s cell through the food slot in the inmate’s locked cell door.¶

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BOP policy provides that inmates housed in the SHU for 30 continuous calendar days are to be examined and interviewed by a mental health staff member to assess the inmate’s adjustment and the threat presented to self or others.¶

BOP policy also requires that all staff assigned to the SHU participate in quarterly training on, among other things, orderly supervision, suicide prevention, and security procedures relating to the unit. When a staff member is assigned to the SHU at the last-minute and has not completed the quarterly training, the staff member must be advised of the general requirements of a SHU post and be permitted to ask questions about the duties.¶

2. Inmate Accountability$$^{11}$$¶

a. Counts¶

Inmate counts serve an important security function, as they enable correctional officials to ensure that all inmates are accounted for and present at the appropriate location within the facility. BOP policy requires that each institution “conduct, at a minimum, five official inmate counts during every 24-hour period,” and that on “weekends and holidays an additional count will be conducted at 10:00 a.m.” At least one count a day during the week and two counts a day on weekends and holidays must be “stand-up counts,” which means that inmates are required to stand when they are counted. MCC New York SHU Post Orders designate that counts must occur at 12:00 a.m., 3:00 a.m., 5:00 a.m., 4:00 p.m., and that stand-up counts are to be conducted at 10:00 p.m. daily and also at 10:00 a.m. on weekends and federal holidays.¶

The BOP requires that each count be conducted by at least two officers, one of whom will count the inmates while the other observes the unit for any unauthorized movement from the end of the tier. This requirement is also set out in the MCC New York SHU Post Orders. The two officers will then switch roles and compare the count numbers. If the totals do not match, then the officers must conduct another count in the same manner. When conducting the count, officers are required to observe each inmate’s body and not rely solely on movement or sound. Officers conducting the count relay the count verbally to the Control Center, which maintains the master count of all inmates, and then remain in the unit until the Control Center accepts the count. If a count reported verbally does not match the master count, then the Control Center must notify the Operations Lieutenant and the staff members must recount the inmates. If the second count does not match the master count, then the Operations Lieutenant will order a bed-book count, that is, when inmates are counted using their picture cards, which are on file in the Control Center. A lieutenant must conduct at least one count in the morning and one in the evening.¶

Correctional staff prepare count slips for each count, which must be prepared in ink, signed by both officers, and retained for 30 days. Count slips may not be altered. BOP policy provides that the “official count will not be cleared until all count slips are received and verified in the Control Center.”¶

b. 30-Minute Rounds¶

The BOP uses additional accountability measures for inmates who are in administrative detention or¶

11 This section describes inmate accountability measures that are most relevant to this investigation and review. The BOP utilizes a variety of other security and inmate accountability tools in addition to those discussed in this section, which are described in BOP Program Statement 5500.14, Correctional Services Procedures Manual.¶

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disciplinary segregation, i.e., for those detained in a SHU. In such cases, a correctional staff member must observe all inmates at least twice an hour, once during the first 30 minutes (e.g., 12:00 a.m. to 12:30 a.m.) and again during the second 30 minutes (e.g., 12:30 a.m. to 1:00 a.m.). BOP policy provides that these “rounds are to be conducted on an irregular schedule and no more than 40 minutes apart.” These same requirements for rounds are also described in the Post Orders for the MCC New York’s SHU.¶

c. Documentation Regarding Inmate Status and Confinement¶

BOP policy also provides that each institution must prepare a daily change/transfer sheet, which indicates changes to an inmate’s status, including housing and job assignments and medical convalescence. The MCC New York SHU Post Orders require that correctional staff assigned to the SHU create a SHU file for each inmate housed in that unit and that morning watch officers audit the inmate files every night. The MCC New York SHU Post Orders further specify that all pertinent information about an inmate’s confinement should be noted on a Special Housing Unit Record Form (BP-292), and that SHU officers must maintain a log of pertinent information regarding inmate activity and enter such information into the BOP computer system TRUSCOPE, which provides institution staff with detailed inmate and institution security-related information and provides unit officers an electronic event log.¶

d. Cell Searches¶

BOP policy requires that BOP staff routinely and irregularly search housing units to, among other things, maintain sanitary standards and eliminate safety hazards. $ ^{12} $ The MCC New York SHU Post Orders require that officers assigned to the SHU conduct searches of the SHU common areas and cells. During the morning watch (12:00 a.m. to 8:00 a.m.), SHU staff are required to search the common areas; during the day watch (8:00 a.m. to 4:00 p.m.), SHU staff are required to search every inmate’s cell who attends recreation; and during the evening watch (4:00 p.m. to 12:00 a.m.), SHU staff are required to conduct at least five cell searches. The Post Orders further require that the entire SHU be searched every week. BOP policy and MCC New York SHU Post Orders require written documentation of each housing unit search.¶

3. Psychological Screening¶

a. Initial Screening¶

Pursuant to BOP policy governing inmates in pretrial detention status (Program Statement 7331.04, Pretrial Inmates), all pretrial inmates must have an initial risk/needs assessment screening within 48 hours of admission to the institution. The goal of this screening is to determine “the inmate’s security, medical, psychological, and/or other special needs.” The BOP also requires that institutions screen pretrial inmates “returning from court, as events at court may alter the inmate’s separation and/or security needs.” BOP policy further recognizes that there are often “high security, high profile inmates” who may present a significant threat to themselves or others, and that the “need to identify and monitor these inmates regularly is paramount.”¶

b. Suicide Prevention¶

The BOP’s suicide prevention program is governed by federal regulations, 28 C.F.R. §§ 552.40-552.42, which require the BOP to establish a suicide prevention program to identify and manage potentially suicidal inmates. Pursuant to these regulations, when an inmate is identified as being at-risk for committing suicide,¶

12 BOP Program Statement 5521.06, Searches of Housing Units, Inmates, and Inmate Work Areas.¶

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BOP staff must place the inmate on suicide watch until the inmate is no longer an imminent risk.¶

BOP policy (Program Statement 5324.08, Suicide Prevention Program) requires that medical staff screen all new inmates, ordinarily within 24 hours, for signs of suicidality. However, at MCCs, among other facilities with high rates of admissions and short lengths of stays, “comprehensive psychological intake conducted by Psychology Services ordinarily will be performed only on inmates who are suspected of being suicidal or appear psychologically unstable.” Inmates in the SHU are monitored more closely, and inmates exhibiting signs of potential suicide risk are referred to the shift lieutenant. BOP policy recognizes that inmates who are placed in the SHU due to a request for protective custody are at greater risk of committing suicide and should therefore be screened for suicidal ideation within 72 hours of arriving in the SHU. BOP policy explicitly states that “staff must never take lightly any inmate suicide threats.” Any staff member who has reason to believe that an inmate may be suicidal should “ordinarily maintain the inmate under direct, continuous observation.”¶

Every BOP institution must have one or more rooms, ordinarily in the health services area, dedicated to inmates placed on suicide watch. Suicide watch may be conducted by specially trained staff or inmates. For inmates placed on suicide watch, the specially trained staff or inmate maintains continuous observation of the inmate believed to be at risk of committing suicide. Following suicide watch and based on clinical findings following a face-to-face evaluation, the inmate will be removed from suicide watch or transferred to a medical referral or health care facility. Psychological observation is a less restrictive form of individual monitoring that is used for inmates who are stabilizing and not yet prepared for placement in general population or restrictive housing. While on suicide watch, the inmate is normally required to wear a suicide watch gown and will be allowed a suicide watch blanket.¶

As discussed in greater detail in Chapter 4, witnesses told the OIG that an inmate is placed on suicide watch when the inmate is believed to be imminently suicidal. During suicide watch, the inmate is under constant observation by staff; the cell lights are on 24 hours a day; and the inmate is given a special mattress, blanket, and smock to wear. Although psychological observation is a lower classification, witnesses told the OIG that at MCC New York the psychological observations was the same as suicide watch except that inmates were allowed to have their clothing and some materials, such as books, as determined by the Psychology Department. At MCC New York, psychological observation was used to see how an inmate was doing before releasing the inmate to a housing unit.¶

Suicide Response¶

Recognizing that failure to appropriately respond to an emergency can jeopardize the safety of staff and inmates and the security of the institution, the BOP’s Standards of Employee Conduct require that “employees respond immediately, effectively, and appropriately during all emergency situations.” The MCC New York General Housing Unit Post Orders outline the required response to a suspected inmate suicide. These orders require that MCC New York staff notify the Operations Lieutenant and Control Center of the situation. The orders further provide that, once there is adequate staff present, immediate action must be taken to open the inmate’s airway and initiate cardiopulmonary resuscitation, even if MCC New York staff believe that that the inmate “has been dead for a period of time.” MCC New York staff are to continue cardiopulmonary resuscitation until they are relieved by medical staff or another rescuer. The BOP policy governing crime scenes and the collection of evidence provides that the need to immediately attend to an apparent suicide victim, undertake lifesaving measures, and ensure inmate and staff safety take precedence¶

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over efforts to preserve a crime scene.$^{13}$¶

5. Inmate Discipline¶

Federal regulations, 28 C.F.R. §§ 541.1-541.8, and BOP policy (Program Statement 5270.09, Inmate Discipline Program) establish an inmate discipline program, which is designed to ensure the safety, security, and orderly operation of correctional facilities, as well as the protection of the public. The inmate discipline program applies to all inmates in BOP custody, including inmates with pending criminal charges. One of the guiding principles of this program is that BOP staff are to take disciplinary action when and to such a degree as necessary to regulate the behavior of inmates to promote a safe and orderly institution. “Tattooing or self-mutilation” is among the prohibited acts sanctioned through the inmate discipline program. This prohibited act falls within the second most severe category of offenses on a 4-tier scale. The BOP defines “tattooing or self-mutilation” as “[t]o put indelible patterns on the skin; to injure, disfigure or make imperfect by removing or irreparably damaging parts of the body (wrist cutting falls within this offense).” $ ^{14} $ The definition does not make an explicit reference to suicide attempts other than inclusion of “wrist cutting.”¶

Among other things, BOP policy addressing the inmate discipline program identifies the prohibited acts, describes the process for adjudicating violations, and lists applicable penalties for each category of offense. As relevant to this matter, the discipline process begins when a staff member observes an inmate commit a prohibited act and issues a report documenting the incident. A BOP supervisor then investigates the alleged inmate misconduct, which includes taking a statement from the inmate regarding the incident. If an inmate appears to be mentally ill at any stage of the disciplinary process, a mental health staff member will examine the inmate and assess the inmate’s competency to participate in the disciplinary process. If the inmate is found to be competent and the prohibited act falls into the first or second most severe category, the matter is referred to a discipline hearing officer, who will hold a hearing and make a determination as to whether the inmate committed the prohibited act and, if so, impose any of the sanctions that correspond to the severity of the prohibited act. At the hearing, the inmate is advised of his or her rights and permitted to choose a staff representative, make a statement, and call witnesses. The inmate is also allowed to appeal the outcome through the BOP’s administrative remedy program.¶

6. Conditions of Confinement¶

a. Telephone Calls¶

The federal regulations, 28 C.F.R. §§ 540.100-540.106, that govern telephone calls for inmates require that the Warden of each BOP institution establish procedures to monitor inmate telephone conversations, which is “done to preserve the security and orderly management of the institution and to protect the public.” For safety and security reasons, BOP policy (Program Statement P5264.08, Inmate Telephone Regulations) requires that all inmate telephone calls be made through the Inmate Telephone System. BOP policy recognizes that “on rare occasion, during times of crisis,” inmates may be permitted to make a telephone call outside of the Inmate Telephone System. In such circumstances, the telephone “must be placed in a secure area (e.g., a locked office),” and “must be set to record telephone calls.” Additionally, the staff member coordinating the call must notify the BOP’s Special Investigative Services via email, providing the inmate’s name and register number, the date and time of the call, the number and name of the individual¶

13 BOP Program Statement 5510.14, Crime Scene Management and Evidence Control, is a restricted policy that is not released to the public in its entirety.¶

14 BOP Elements of Prohibited Acts.¶

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called, and the reason for the call. The Special Investigative Services must enter this information into the telephone recording system within 7 days.¶

b. Personal Effects, Medication, and Linens¶

Federal regulations governing BOP Special Housing Units provide that inmates in administrative detention status ordinarily may have a reasonable amount of personal property. Under BOP policy regarding Special Housing Units, the personal property of SHU inmates “may be limited or withheld for reasons of security, fire safety, or housekeeping.” The BOP Chief Pharmacist issues medication each workday for inmates in the SHU. Restricted medications are administered to inmates during daily SHU rounds. Each institution determines “the medication(s) and amount (number of days) an inmate in SHU may maintain in their cell.” Inmates may also purchase pre-approved over-the-counter medications at the commissary. MCC New York General Housing Units Post Orders provide that when an inmate is released or transferred out of a housing unit, the inmate will remove all limited and government-issued clothing from the cell in which the inmate was previously housed. These Post Orders further specify that all cells are to be cleaned daily by inmates occupying the cell, and that blankets, towels, and other linens will not be used as rugs or hung over inmate bunk beds at any time. Pursuant to these Post Orders, MCC New York housing unit officers on all three shifts are responsible for maintaining “a high level of sanitation” and a “safe and clean environment.”¶

$$\textcircled{15}$$ 28 C.F.R. § 541.31(h)(1).¶

16 BOP Program Statement 5270.11, Special Housing Units.¶

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Chapter 3: Timeline of Key Events¶

Except as otherwise noted, the following information is derived from the Federal Bureau of Prisons (BOP) records and OIG interviews.¶

September 21-24,2018

The BOP awards contracts to two companies(Company 1 and 2) to upgrade the security camera system at Metropolitan Correctional Center in New York,New York(MCC New York). At the time,images from the MCC New York's analog video cameras are recorded to a Digital Video Recorder(DVR)system,which is divided into two DVR systems.Cameras assigned to the DVR1 system record only to the DVR1 hard drives,and cameras assigned to DVR2 system record only to the DVR2 hard drives.

March 17,2019

In connection with MCC New York's upgrade of its security camera system,the BOP's Northeast Regional Office begins arranging for technicians from other BOP institutions to perform temporary duty(TDY) assignments to MCC New York to perform necessary mechanical, electrical, plumbing,and wiring work.However,during the course of the TDY rotations,work is not consistently conducted on the camera upgrade because sometimes TDY staff are used to cover shortages at MCC New York's custody posts.

July 2, 2019 According to court records, a federal grand jury of the U.S. District Court for the Southern District of New York returns an indictment charging Epstein with sex trafficking and conspiracy to commit sex trafficking.¶

July 6, 2019 Epstein is arrested at an airport in New Jersey and is transported for detention pending his initial court appearance to the MCC New York as a pretrial detainee. Epstein is placed in the general inmate population and medically screened.¶

July 7, 2019¶

An MCC New York Facilities Assistant asks the Psychology Department to evaluate Epstein because he appears “distraught, sad, and a little confused.” Epstein is assigned to the MCC New York’s Special Housing Unit (SHU) because of significant media attention and his notoriety among other MCC New York inmates. $ ^{17} $¶

17 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 a day, to ensure their own safety as well as the safety of staff and other inmates.¶

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July 8, 2019	According to court records, Epstein is arraigned in federal court and enters a plea of not guilty to all charges. The court sets a detention hearing for July 15, 2019.
	MCC New York staff conducts a routine intake screening of Epstein, the records of which indicate that Epstein denies a history of any mental health problems. After the Chief Psychologist consults with the National Suicide Prevention Coordinator from BOP's Central Office, the Psychology Department conducts a further evaluation of Epstein after his return from court. Records show that Epstein denies any suicidal thoughts but was placed on psychological observation due to the presence of risk factors (high-profile case, nature of the charges, pre-trial status, and ongoing proceedings).
July 9, 2019	The Psychology Department administers a formal, in-person suicide risk assessment for Epstein. The Psychology Department continues psychological observation for another day pending a suitable housing placement.
July 10, 2019	The Psychology Department removes Epstein from psychological observation and returns him to the SHU with a recommendation that he have a cellmate. Epstein is housed with another inmate (Inmate 1).
July 11, 2019	An MCC New York psychologist meets with Epstein briefly and recommends an additional follow-up visit the following week.
July 15, 2019	According to court records, Epstein appears in court for his detention hearing.
July 16, 2019	At Epstein's request, an MCC New York psychologist meets with him during a legal visit.
July 18, 2019	According to court records, Epstein appears in court for a ruling on the issue of detention. The court orders that Epstein be detained pending trial because he presents a danger to the community and he is a flight risk.
	The Psychology Department conducts 30-day psychology reviews for the entire SHU population. Epstein is not in the SHU at the time and therefore is not reviewed.

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July 22, 2019 According to court records, Epstein files an appeal of the court’s order denying Epstein pretrial release.¶

July 23, 2019 At approximately 1:27 a.m., SHU staff hears noises coming from Epstein’s cell. Epstein’s cellmate (Inmate 1) says that Epstein has attempted to hang himself. SHU staff observes Epstein lying on the floor with a piece of orange cloth around his neck. Epstein initially tells MCC New York staff that his cellmate tried to kill him. Epstein’s cellmate (Inmate 1) tells MCC New York staff that while he was asleep, he felt something hit his legs and when he turned on the light, he saw Epstein with a string around his neck and called the guards. $ ^{18} $¶

Epstein is transferred out of the SHU and placed on suicide watch.¶

Later that morning, Health Services Unit personnel conduct a medical assessment and observes that Epstein has a red mark two-thirds of the way around the front and sides of his neck. The BOP assesses Epstein for risk of suicide and determines that he should remain on suicide watch.¶

July 24, 2019 At approximately 8:45 a.m., Epstein is removed from suicide watch but remains in the same cell and is under psychological observation. Medical staff examines Epstein at 1:08 p.m. and Psychological Services staff completes a Post Suicide Watch Report. In contrast to his statement the previous day, Epstein says he does not remember how he sustained the injuries to his neck.¶

July 25-29,2019

Epstein is seen by the Psychology Department daily and on each date adamantly denies suicidality or having any memory of what occurred on July 23,2019.

July 29, 2019¶

Psychology Department staff determined that Epstein may be released from psychological observation and return to the SHU. $ ^{19} $¶

Disk failures occur in DVR 2 of MCC New York’s security camera system,¶

18 When interviewed by the OIG, another inmate housed in the same SHU tier (Inmate 2) at the time of the July 23 incident said he heard Inmate 1 call for assistance, and that Inmate 1 later told him that Epstein had tried to kill himself by hanging himself from the bunkbed ladder.¶

19 The investigation revealed that Epstein was originally scheduled to return to the SHU on July 29, 2019, but at his request he remained on psychological observation until July 30, 2019. The BOP’s SENTRY database, which is a BOP database that contains information relating to the care, classification, subsistence, protection, discipline, and programs of federal inmates, was not updated to reflect this change because it indicated that Epstein was transferred back to the SHU on July 29, 2019.¶

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which results in the system being unable to record, although the cameras continue to work and broadcast live video feed. MCC New York personnel do not learn of the DVR 2 recording failure until August 8, 2 days before Epstein’s death. Roughly half of MCC New York’s security cameras, including those located in the SHU, are assigned to record to the DVR 2 system.¶

July 30, 2019 Epstein is transferred back to the SHU.²⁰¶

An MCC New York Staff Psychologist from the Psychology Department sends an email to over 70 BOP staff members stating that Epstein “needs to be housed with an appropriate cellmate.” Epstein and his new cellmate (Inmate 3) are placed in a cell within the SHU that can accommodate the electrical needs of Epstein’s medical device.¶

MCC New York conducts disciplinary proceedings against Epstein for alleged self-mutilation and ultimately concludes that there is insufficient evidence to find that Epstein engaged in a prohibited act. $ ^{21} $ When Epstein is psychologically evaluated in connection with the disciplinary proceedings, he says he does not remember how he sustained the marks around his neck.¶

MCC New York personnel attempt to obtain an estimate from Company 1 to run the wiring and conduit for the new camera system, which would eliminate the need for BOP technicians to perform the work.¶

July 31, 2019¶

According to court records, Epstein appears in court for a status conference, at which time the court sets deadlines for motions and responses. Upon his return to MCC New York, the U.S. Marshals Service provide paperwork to BOP that indicates Epstein had “suicidal tendencies.”¶

The Psychology Department conducts a clinical visit with Epstein, who denies any suicidal ideation.¶

August 1, 2019¶

MCC New York Receiving and Discharge staff notify the Psychology Department of the notation of “suicidal tendencies” on U.S. Marshals¶

20 The OIG’s investigation revealed that at some point after he returned to the SHU from suicide watch and psychological observation, Epstein asked two different MCC New York staff members if he can be housed with the same cellmate Epstein initially said tried to kill him.¶

21. The BOP’s inmate discipline program and the offense with which Epstein was charged is further described in Chapter 2.

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Service paperwork relating to Epstein. The Psychology Department conducts a suicide risk assessment of Epstein, who denies that he is suicidal, and determines that suicide watch is not warranted. Follow-up is recommended in 1 week.¶

August 2, 2019¶

2, 2019 MCC New York Special Investigative Services complete its investigation into the incident on July 23, 2019, and finds that there is insufficient evidence to determine that Epstein harmed himself or that he was harmed by his cellmate.¶

August 8, 2019 Epstein is seen by the Psychology Department and denies suicidal ideation, intention, or plan.¶

Epstein meets with his attorneys and, unbeknownst to MCC New York personnel, changes his Last Will and Testament during the meeting.¶

MCC New York staff receive notice that Epstein’s cellmate will be transferred out of the institution the following day, August 9.¶

MCC New York staff discover the disk failures that occurred in the DVR 2 system on July 29 and that resulted in approximately one half of the institution’s security cameras not recording, although the cameras continued to broadcast a live video feed. MCC New York staff do not perform the work necessary to restore recording functionality of the DVR 2 system or address long-standing performance failures with the institution’s camera system.¶

August 9, 2019¶

At approximately 8:30 a.m., Epstein’s cellmate (Inmate 3) is transferred out of MCC New York. Two MCC New York SHU staff members said they notified supervisory staff of Epstein’s cellmate’s transfer and Epstein’s need for a new cellmate. Other witnesses did not corroborate these statements. Epstein is not assigned a new cellmate as required by the Psychology Department.¶

Sometime between 8:00 a.m. and 9:00 a.m., Epstein meets with his attorneys in the attorney conference room. Epstein’s attorneys ask MCC New York staff members if Epstein could be moved to a different housing unit or housed without a cellmate.¶

MCC New York staff obtain the replacement hard drives to repair the institution’s security camera system but do not complete the repairs necessary to restore recording functionality and address long-standing¶

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performance failures with the institution’s DVR 2 system.¶

The U.S. Court of Appeals for the Second Circuit unseals approximately 2,000 pages of documents in civil litigation involving Ghislaine Maxwell, who is later convicted in December 2021 of conspiring with Epstein to sexually abuse minors over the course of a decade. Some of these documents contain information that may relate to the criminal charges pending against Epstein. There is extensive media coverage of information in the unsealed documents.¶

At approximately 6:45 p.m., Epstein leaves the attorney conference room.¶

At approximately 7:00 p.m., contrary to BOP policy but with the permission of a Unit Manager, Epstein is permitted to place an unmonitored telephone call to a number in the New York City area, purportedly to speak with his mother. In actuality, Epstein speaks with someone with whom he allegedly has a personal relationship. After the call, Epstein is returned to his cell, where he remains without a cellmate.¶

MCC New York SHU staff members do not conduct the 4:00 p.m. or 10:00 p.m. inmate counts. After approximately 10:40 p.m., SHU staff members do not conduct the required 30-minute rounds.¶

August 10, 2019¶

MCC New York SHU staff members do not conduct the 12:00 a.m., 3:00 a.m., or 5:00 a.m. inmate counts or any of the 30-minute rounds from 12:00 a.m. until approximately 6:30 a.m.¶

At approximately 6:30 a.m., SHU staff begin to deliver breakfast to inmates in the SHU through the food slots in the locked cell doors. When SHU staff attempt to deliver breakfast to Epstein, SHU staff unlock the door to the tier in which Epstein’s cell was located and then knock on the door to Epstein’s cell. Epstein, who is housed alone in the cell, does not respond to SHU staff. SHU staff unlock the cell door and find 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 is 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.¶

SHU staff immediately activate a body alarm, which notifies all MCC New York staff of a medical emergency and prompts MCC New York staff in the Control Center to call for 911 emergency services. SHU staff then rip the orange cloth away from the bunkbed, which causes Epstein’s buttocks to drop to the ground. SHU staff lay Epstein on the ground and immediately¶

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initiate cardiopulmonary resuscitation (CPR). At approximately 6:33 a.m., BOP medical staff respond to the SHU, continue CPR, apply the automated external defibrillator, and move Epstein to MCC New York’s Health Services Unit. Minutes after arriving in the Health Services Unit, an ambulance arrives and paramedics continue CPR, intubate Epstein, and administer medications and fluids. At approximately 7:10 a.m., the ambulance takes Epstein to New York Presbyterian Lower Manhattan Hospital, where he is pronounced dead at 7:36 a.m. by the emergency room physician.¶

MCC New York staff unsuccessfully attempts to recover video from the DVR 2 system of the SHU and the FBI seizes all hard drives contained in the DVR 2 system as evidence. The BOP begins repairing the DVR 2 system.¶

The Office of the Chief Medical Examiner, City of New York, performs an autopsy on Epstein.¶

August 14-15,2019 The FBI returns to MCC New York and seizes additional components of the DVR 2 system and the entire DVR 1 system. The FBI’s Digital Forensics Analysis Unit in Quantico, Virginia, subsequently begins to conduct a forensic analysis of MCC New York’s DVR systems and determines that there was catastrophic disk failures in the DVR 2 system disk array, and no recordings were available on the DVR 2 system after July 29,2019.¶

August 16, 2019 The Office of the Chief Medical Examiner, City of New York, releases its findings publicly that the cause of death was hanging and that the manner of death was suicide.¶

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Chapter 4: Custody and Care of Epstein Prior to His Death¶

I. Epstein’s Arrest and Detention on July 6¶

On July 2, 2019, a grand jury of the U.S. District Court for the Southern District of New York returned a two-count indictment that charged Epstein with committing sex trafficking and a sex trafficking conspiracy, in violation of 18 U.S.C. §§ 371, 1591(a), (b)(2), and 2, based on allegations that he sexually exploited and abused dozens of minor girls, some as young as 14 years old, at his homes in New York and Florida. The indictment alleged that from at least 2002 through 2005, Epstein enticed and recruited girls, many of whom he knew were underage, to visit his homes and perform sex acts in exchange for paying each girl hundreds of dollars in cash. The indictment further alleged that Epstein, working with employees and associates, created a vast network of underage victims to sexually exploit in New York and Florida by paying some victims hundreds of dollars in cash each to recruit other minor girls to be similarly abused by Epstein. In addition to the two criminal charges, the indictment also contained forfeiture allegations, which sought to forfeit to the United States any property that was either used to commit or was a proceed of the charged sex trafficking offense, including Epstein’s New York residence.¶

On Saturday, July 6, 2019, Epstein was arrested at Teterboro Airport in New Jersey upon his return to the United States from France. He was transported to the Metropolitan Correctional Center located in New York, New York (MCC New York), where he was initially placed in the general inmate population. MCC New York is a federal administrative detention facility operated by the Federal Bureau of Prisons (BOP). 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 primarily pretrial detainees who had not yet been convicted of any offense, 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. Due to the significant media attention surrounding his arrest and his notoriety among other MCC New York inmates, the following day Epstein was moved to MCC New York’s Special Housing Unit (SHU), a housing until 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. On Monday, July 8, 2019, Epstein appeared in federal court and pleaded not guilty to the charges. The court ordered that Epstein remain in custody pending a detention hearing scheduled for July 15, 2019.¶

At the detention hearing, Epstein sought to be placed in home detention at his New York residence with electronic monitoring and other conditions. The prosecutors sought to have Epstein detained at MCC New York pending trial. The court reviewed the parties’ filings and heard argument on the matter of pre-trial release on July 15, 2019. On July 18, 2019, the court ordered that Epstein be detained pending trial. In its ruling, the court noted that because Epstein had been indicted for a violation of the federal sex trafficking statute that involved minor victims, there was a presumption in favor of detention under federal law. The court found that the United States had shown by clear and convincing evidence that Epstein threatened the safety of another person and of the community based on testimony from two victims, the allegations of repeated sexual abuse of minors, and the lewd photographs of young-looking women or girls that were found during an authorized search of Epstein’s New York residence in July 2019. The court also relied on the recommendation of U.S. Pretrial Services, the seriousness of the offenses with which Epstein had been charged, evidence reflecting Epstein’s harassment and intimidation of and tampering with witnesses involved in a prior Florida state criminal investigation, and Epstein’s lack of compliance with his legal¶

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obligations as a registered sex offender. The court found that the United States had also shown by a preponderance of the evidence that Epstein was a flight risk based on the severity of the criminal charges and severity of the potential punishment; the strength of the evidence against Epstein; and Epstein’s criminal history, sex offender registration, vast wealth and substantial liquid assets, multiple residences, a foreign residence, limited family ties in the United States, private plane(s), extensive overseas travel, and possession of a foreign passport bearing Epstein’s photograph but not his name. Finally, the court found that Epstein’s pretrial release proposal was inadequate because, among other things, it did not contain sworn, accurate, or comprehensive financial statements; it required excessive court involvement in routine aspects of the proposed home confinement; the proposed consent to extradition was unenforceable; and the proposed appointment of a trustee to monitor Epstein’s compliance with release conditions was unacceptably vague and problematic due to the potential conflict of interest presented by monitoring the conduct of a person who paid the trustee’s salary, and allegations that Epstein engaged in unlawful acts with his employees during the sex trafficking conspiracy. Epstein appealed the court’s order on July 22, 2019. This appeal remained pending at the time of Epstein’s death.¶

II. MCC New York’s Special Housing Unit (SHU)¶

Epstein was initially assigned to MCC New York’s general inmate population, but on July 7, 2019, at approximately 7:20 p.m., he was moved to the SHU pending reclassification due to the significant increase in media coverage and awareness of his notoriety among other MCC New York inmate residents. 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 a day, to ensure their own safety as well as the safety of staff and other inmates. Inmates in the SHU are either on administrative detention or disciplinary segregation status. Administrative segregation status is a non-punitive designation that removes an inmate from the general population when it is necessary to do so to ensure the safety, security, and orderly operation of the correctional facility or to protect the public. The MCC New York employee who was the Acting Evening Watch Activities Lieutenant on August 9, 2019, told the OIG that most inmates housed in the SHU are “locked down” in their cells for most of the day. Other witnesses told the OIG that SHU inmates are locked in their cells for approximately 23 hours a day. The Warden of MCC New York during Epstein’s period of detention at that facility, along with Associate Warden 1 and the Acting Evening Watch Activities Lieutenant, explained that this was one of the reasons that conducting rounds in the SHU was so important. Unlike inmates in general population housing, SHU inmates could not physically approach a staff member; therefore, the staff member had to go to each inmate’s cell.¶

Witnesses told the OIG that Epstein’s daily routine in the SHU was to meet with his attorneys in the attorney conference room all day until approximately 8:00 p.m. $ ^{22} $ MCC New York attorney logs confirmed that Epstein had daily visits with attorneys from several different law practices throughout the period of his detention at MCC New York. This is consistent with the information available in SENTRY, a BOP database that contains information relating to the care, classification, subsistence, protection, discipline, and programs of federal inmates, which indicates that Epstein had 1-2 attorney visits on all but 1 day he was detained at MCC New York. BOP emails reflect that other attorneys expressed frustration to a Supervisory Staff Attorney with the BOP’s Consolidated Legal Center for New York because attorneys had to wait hours or were unable to meet with their clients because Epstein and his attorneys were occupying the attorney¶

22 As discussed in Chapter 1, BOP policy provides that SHU inmates may be escorted from their cells by MCC New York staff for visits, including legal visits, court appearances, medical and psychological attention, showers, and recreation.¶

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conference room, even at times when Epstein had to leave the conference room for a medical visit.¶

At MCC New York, the SHU was located on the south side of the institution’s ninth floor and was often referred to as “9 South.” Primary access to the SHU was controlled by a locked door adjacent to the elevator bay on the north side of the floor (Main Exterior Entry Door). That door was opened remotely by a staff member in MCC New York’s centralized Control Center, which is located on the first floor of the institution. Access into the SHU from the primary elevator bay was further controlled by a second locked door (Main Interior Entry Door), to which only one of the correctional officers assigned to the SHU had keys, while on duty.¶

Secondary access to the SHU was controlled by a locked door adjacent to the elevator bay on the south side of the floor. That door was opened remotely by a staff member in the centralized Control Center. Access into the SHU from the secondary elevator bay was further controlled by three additional locked doors, to which only one of the correctional officers assigned to the SHU had keys, while on duty. The secondary elevators and access doors were used only by staff when facilitating visits between the SHU inmates and their outside visitors.¶

Within the SHU, inmates were assigned to six separate tiers or groups of cells, three of which were accessible via stairs leading up from the common area on the ninth floor (Upper Tiers—G, J, and L Tiers) and three of which were accessible via stairs leading down from the common area on the ninth floor (Lower Tiers—H, K, and M Tiers). 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 only to one of the correctional officers assigned to the SHU, while on duty. Each tier had eight cells, each of which could house either one or two inmates. Each individual cell, which was made of cement and metal, could be accessed only through a single locked door, to which only one of the correctional officers assigned to the SHU 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 or toiletries to inmates. As a further security measure, during each shift the keys to the SHU tier doors and SHU cell doors were carried by different officers assigned to the SHU.¶

As noted above, inmates in the SHU are securely separated from the general inmate population and are kept locked in their cell when in their assigned tier within the SHU. Witnesses told the OIG that SHU inmates are locked in their cells for approximately 23 hours a day. BOP policy provides that, weather and resources permitting, SHU inmates will have the opportunity to exercise outside of their quarters 5 hours per calendar week. Under federal regulations and BOP policy, SHU inmates ordinarily have the opportunity to shower at least three times a week, typically on different days in 1-hour periods. SHU inmates may also be escorted from their cells by MCC New York staff for visits, including legal visits, court appearances, medical and psychological attention. The MCC New York SHU Post Orders require that all visitors to the SHU be documented in the SHU visitor log, and that any inmate visiting the SHU, such as inmates on work details, be searched visually and with a hand-held metal detector, without exception. The MCC New York SHU Post Orders also require that food carts be searched inside and out before being brought into a SHU cellblock and that all meals be delivered through the cell door food slot of the locked cell door.¶

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Figure 4.1: Primary SHU Entrance (Ninth Floor)¶

Figure 4.2: Secondary SHU Entrance (Ninth Floor)¶

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Figure 4.3: Tiered Structure of SHU (2-Dimensional)¶

Figure 4.4: Tiered Structure of SHU (3-Dimensional)¶

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Figure 4.5: Stairways Leading to SHU Upper and Lower Tiers¶

III. Epstein’s Initial Cell and Cellmate Assignment from July 7 to July 23¶

According to the Warden, MCC New York typically housed inmates in the SHU with a cellmate. Upon Epstein’s initial transfer to the SHU on July 7, 2019, he was assigned a cell in the M Tier of the SHU with Inmate 1. The Warden explained that Epstein was a high-profile inmate and that he initially selected Inmate 1 to be Epstein’s cellmate because Inmate 1 was another high-profile inmate, and the Warden believed Inmate 1 to be the least likely SHU inmate to harm Epstein. $ ^{23} $ Epstein and Inmate 1 were housed together in cell Z05-124.¶

IV. Events of July 23 and the Placement of Epstein on Suicide Watch and Psychological Observation from July 23 to July 30¶

According to BOP documents, at approximately 1:27 a.m. on July 23, 2019, Senior Officer Specialists 1 and 2 heard noise coming from the M Tier in the SHU, the tier where Epstein was housed. Senior Officer Specialist 2 documented in a BOP report that upon checking cell Z05-124, he saw Epstein laying down near his bunk with “a piece of handmade orange cloth” around his neck, and Senior Officer Specialist 1 wrote in a BOP report that Epstein’s cellmate (Inmate 1) said Epstein had attempted to hang himself. In his interview with the OIG, Senior Officer Specialist 1 said that Inmate 1, who appeared shaken up, told him that he had been¶

23 In 2008, Epstein pleaded guilty in a Florida state court to a felony charge of procurement of minors to engage in prostitution in violation of Florida Statute § 796.03. As a result of this conviction, Epstein was required to register as a sex offender.¶

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asleep on the floor of the cell and was awoken when he felt Epstein land on him. Senior Officer Specialist 2 reported that after he had been alerted by the noise, he grabbed the door keys, called the Control Center for assistance, and then he and Senior Officer Specialist 1 entered the cell, where they secured and removed Epstein’s cellmate. Senior Officer Specialist 1 reported that he then reentered the cell, placed Epstein on his side, and removed “an orange homemade rope” from his neck. In his interview with the OIG, Senior Officer Specialist 1 said Epstein had a sheet around his neck, which was attached to the bunkbed ladder in the cell. Senior Officer Specialist 1 said that Epstein was sitting on the floor of the cell with his back against the bunkbed ladder. Senior Officer Specialist 1’s report said that Epstein was breathing, but unresponsive, so he began chest compressions, at which time the Morning Watch Operations Lieutenant and other staff arrived. Senior Officer Specialist 1 confirmed in his OIG interview that they started cardiopulmonary resuscitation but stopped when they realized that Epstein was already breathing. The Morning Watch Operations Lieutenant documented in a BOP report that when she arrived at the SHU, she saw Epstein lying in the fetal position in his cell, breathing heavily and snoring, wearing only a t-shirt and boxers. The Morning Watch Operations Lieutenant observed that Epstein’s neck was red, but she saw no further injuries. She called out to Epstein, who flickered his eyes and continued snoring. The correctional officers unsuccessfully tried to get Epstein to stand on his own, and then placed him on a stretcher and took him to the Health Services Unit.¶

According to BOP records, at approximately 1:40 a.m., Epstein was transferred out of the SHU and placed on suicide watch. As previously noted in Chapter 2, inmates on suicide watch are housed in a dedicated room, typically in the health services area, where they are continuously monitored by specially trained staff or inmates.¶

Senior Officer Specialist 3 documented in a BOP report that when he and others responded to the call for assistance and gained access to the SHU, he saw Epstein lying on the floor of his cell snoring. He and the other officers verbally instructed Epstein to stand up, but Epstein did not. He and other officers then lifted Epstein onto a stretcher to remove him from the cell.¶

Senior Officer Specialist 4 wrote in a BOP report that he responded to a body alarm in the SHU and helped remove Epstein from his cell, placed him on a stretcher, and took him to the second floor for a medical assessment. Senior Officer Specialist 4 further reported that, while he was observing Epstein in the Health Services Unit, Epstein told Senior Officer Specialist 4 that he thought his cellmate had tried to kill him. Epstein further stated that his cellmate had tried to extort him, and that for the last week his cellmate had threatened to beat him if he did not pay him. Epstein told Senior Officer Specialist 4 he had not reported this to MCC New York staff, but that he had told his lawyers.¶

The Morning Watch Operations Lieutenant documented in a BOP report that when she returned to the Health Services Unit, Senior Officer Specialist 4 informed her that Epstein had said that his cellmate had tried to kill Epstein and had been harassing him. The Morning Watch Operations Lieutenant then spoke with the cellmate (Inmate 1), who said he was wearing headphones and was asleep when he felt something hit his legs. Inmate 1 said he called out to Epstein and when Epstein did not answer, he got up, turned on the light, and saw Epstein sitting on the floor, leaning to the side with a string around his neck. Inmate 1 told the Morning Watch Operations Lieutenant that he then called the guards. Inmate 1 provided a similar statement to BOP officials at approximately 2:50 p.m. on July 23, 2019.¶

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The Morning Watch Operations Lieutenant’s report notes that she also spoke with Epstein, who told her that he had returned to his cell after an attorney visit at approximately 8:00 p.m. the previous day, at which time his cellmate was reading the Daily News newspaper. Epstein’s said his cellmate turned to a page of the newspaper that had Epstein’s picture and reported that Epstein was worth $77 million. Epstein told the Morning Watch Operations Lieutenant that he looked at his picture, balled it up, and threw it in the garbage. Epstein further stated that he woke up at approximately 1:00 a.m. to get a drink of water, returned to his bunk, and the next thing he remembered was that he was snoring and MCC New York staff were inside his cell. When asked about the allegations against his cellmate, Epstein said he had been told that if his cellmate hurt him, MCC New York staff would not care.¶

Inmate 2, who was housed in the same SHU tier as Epstein on July 23, told the FBI about an incident that occurred in the SHU around 1:20 a.m. to 1:30 a.m. on unspecified date. Inmate 2 said he was reading a book when he heard an inmate scream and bang on the cell door to get the SHU officers’ attention. Inmate 2 said he could only see the cell door and not inside. According to Inmate 2, Senior Officer Specialist 2 responded to the cell and then left and returned with additional officers. The FBI was further told by Inmate 2 that the officers opened the cell door, removed an inmate, placed the inmate in handcuffs, and put the inmate in the shower area. Inmate 2 stated that the officers reentered the cell and Inmate 2 heard a thump as if something had hit the floor. The officers then pulled the other inmate out of the cell, placed him on a stretcher, and took him away. Inmate 2 also told the FBI that, later in the evening, around 2:10 a.m. to 2:15 a.m., the correctional officers returned to the cell where the incident had occurred earlier. He said he further observed the officers clean out the cell and use a video camera to record the inside of the cell. Inmate 2 said he saw the officers remove from the cell orange clothing items that had been tied together. Inmate 2 also said that the first inmate to be removed from the cell later told Inmate 2 that he was sleeping when his cellmate had tried to kill himself by hanging himself from the ladder of the bed.¶

According to BOP records, medical staff evaluated Epstein at approximately 6:20 a.m. on July 23, 2019, and observed friction marks and superficial reddening of his neck and one knee. The red mark spanned two-thirds of Epstein’s neck (front and sides) and was 2 inches wide. Epstein told the medical staff that he did not know what had caused his injuries, and that he went to drink a little water and woke up snoring.¶

Later that morning, the MCC New York Staff Psychologist conducted a suicide risk assessment and determined that Epstein should remain on suicide watch. During the assessment, Epstein denied any knowledge of how he sustained the marks on his neck. The Staff Psychologist noted in the assessment report that it was unclear whether Epstein had placed the string around his neck or if someone else did. Medical staff examined Epstein at approximately 1:08 p.m. the following day, July 24, 2019, and observed that the central part of the red mark on Epstein’s neck had some abrasion. According to BOP records, Epstein told the medical staff that he still did not want to talk about how he sustained his injuries, but he believed that his cellmate had something to do with it. BOP’s Special Investigative Services (SIS) opened an investigation into this incident but was unable to determine whether Epstein harmed himself or had been assaulted.¶

On July 24, 2019, at approximately 8:45 a.m., Epstein was removed from suicide watch. However, Epstein remained in the same cell that he was placed in the previous day and was under psychological observation¶

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until July 30, 2019.$^{24}$¶

The MCC New York Chief Psychologist told the OIG that an inmate is placed on suicide watch when the inmate is believed to be imminently suicidal. During suicide watch, the inmate is under constant observation by staff; the cell lights are on 24 hours a day; and the inmate is given a special mattress, blanket, and smock to wear. The Chief Psychologist explained that although psychological observation is a lower classification, at MCC New York the psychological observations was the same as suicide watch except that inmates were allowed to have their clothing and some materials, such as books, as determined by Psychology Department. At MCC New York, psychological observation was used to see how an inmate was doing before releasing the inmate to a housing unit.¶

The Chief Psychologist told the OIG that the Psychology Department independently makes the decision who goes on and off suicide watch. The Chief Psychologist also stated that the Psychology Department makes recommendations to the institution’s management about where inmates are housed when they come off of suicide watch. According to her, the Psychology Department always recommends that inmates coming off of suicide watch be housed with other inmates; however, she said the recommendations cannot always be carried out due to other security factors. When that occurs, the Psychology Department recommends conducting increased rounds and keeping an eye on those inmates.¶

The Chief Psychologist further told the OIG that, based on a conversation with the Psychiatrist with the BOP’s Central Office who was the BOP’s National Suicide Prevention Coordinator, she passed along to the MCC New York executive staff the recommendation that Epstein be housed with an alleged sex offender in the SHU. $ ^{25} $ The Chief Psychologist stated that the MCC New York Warden and Associate Wardens decided who Epstein would be housed with and the Psychology Department was not involved in that decision.¶

According to BOP records, as a result of the July 23 incident, MCC New York subsequently conducted disciplinary proceedings against Epstein for alleged self-mutilation, but ultimately found that there was insufficient evidence to find that Epstein engaged in a prohibited act. When Epstein was psychologically evaluated on July 30, 2019, in connection with disciplinary proceedings, Epstein said he did not remember how he obtained the marks around his neck. On August 2, 2019, the SIS investigation into the July 23, 2019, incident was completed and found insufficient evidence to support either that Epstein had harmed himself or that he had been harmed by his cellmate.¶

Senior Officer Specialist 1 told the OIG that after Epstein came off of suicide watch, Epstein asked if he could be paired up with Inmate 1 again. Senior Officer Specialist 1 told Epstein that his request was something he would need to raise with the Operations Lieutenant. Senior Officer Specialist 1 told the OIG that Epstein replied, “Yeah, but I don’t understand, you know, we were bunkies, everything was cool.” The Chief Psychologist also told the OIG that Epstein mentioned to her that he wanted Inmate 1 to continue to be his cellmate.¶

24 Epstein’s BOP medical records reflect that he was removed from psychological observation and returned to the SHU on July 30, 2019.¶

25 Neither of Epstein’s cellmates at MCC New York were alleged to be sex offenders.¶

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V. The Psychology Department’s Post-July 23 Determination that Epstein Needed to Have an Appropriate Cellmate¶

Following the events of July 23, the MCC New York Psychology Department determined that Epstein needed to be housed with an appropriate cellmate. To ensure Epstein’s cellmate requirement was disseminated to MCC New York staff, on July 30, 2019, at 12:30 p.m., the Staff Psychologist sent an email to over 70 MCC New York staff members which read, “Inmate Epstein #76318-054 is being taken off Psych Observation and needs to be housed with an appropriate cellmate.” A review of the email recipients showed that the email was sent to, among others, the Warden, Associate Warden 2, the Captain, the SHU Lieutenant, the SIS Lieutenant, the Day Watch Operations Lieutenant, the Evening Watch Operations Lieutenant, the Morning Watch Operations Lieutenant, the Day Watch Activities Lieutenant, and Correctional Officer 1. The Staff Psychologist also completed a “Post-Watch Report,” which stated that the “SHU L[ieutenant] informed inmate Epstein needs to be housed with an appropriate cellmate.”¶

The Warden told the OIG that the Chief Psychologist had advised him that Epstein was not suicidal and was ready to return to the SHU. According to the Warden, when he spoke with the Chief Psychologist regarding Epstein, she told him to assign Epstein a cellmate. He added that MCC New York would typically house an inmate who was previously on suicide watch with a cellmate. The Warden stated there was no BOP policy mandating that an inmate coming off of suicide watch have a cellmate, but they usually housed such an inmate with a cellmate.¶

During their interviews with the OIG, Associate Warden 1, the Captain, and the SHU Lieutenant each said they had verbally informed the SHU staff of Epstein’s cellmate requirement and were confident that all SHU staff members knew of Epstein’s cellmate requirement. Additionally, the Captain said he visited the SHU on multiple occasions and directed his staff to be alert and attentive about Epstein’s special needs.¶

According to Associate Warden 1, the Captain was in charge of correctional services, including the SHU. Associate Warden 1 said the Captain should have told the SHU Lieutenant, and that the SHU Lieutenant should have told the SHU staff about the cellmate requirement. Associate Warden 1 further told the OIG that the SHU Lieutenant was responsible for ensuring that everything within the SHU was in compliance. Associate Warden 1 told the OIG that the SHU staff knew that Epstein was required to have a cellmate, and said she personally heard it being discussed on more than one occasion when she would visit the SHU while performing her rounds.¶

The Captain, who supervised all of the lieutenants and correctional officers working in MCC New York, said that after the cellmate requirement was issued for Epstein, he spoke with the SHU Lieutenant and directed him to ensure that Epstein had a cellmate. Similar to the Warden, the SHU Lieutenant told the OIG that while there is no BOP policy addressing the necessity of assigning cellmates to individuals coming off of suicide watch, it was common practice in the BOP for prisoners coming off of suicide watch to be assigned a cellmate. The SHU Lieutenant confirmed that a BOP psychologist told him that Epstein had to be housed with a cellmate when Epstein returned to the SHU, and said that he passed the directive down to the SHU staff.¶

Additionally, the Day Watch SHU Officer in Charge on August 9, 2019, said he and all other SHU staff were aware of Epstein’s cellmate requirement. MCC New York Psychology Department personnel told the OIG¶

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that MCC New York staff members knew of Epstein’s cellmate requirement because it was discussed during staff meetings, department head meetings, SHU meetings, morning meetings, and during required staff training.¶

Forensic Psychologist 1 told the OIG that on August 9, 2019, she was present during a meeting in which one of Epstein’s attorneys opposed Epstein having a cellmate. Forensic Psychologist 1 said she explained to the attorney that Epstein needed to have a cellmate because he was housed in the SHU and he was a sex offender.¶

VI. Selection of Epstein’s Cellmate After Psychological Observation¶

The Captain told the OIG that he compiled a list of possible cellmates for Epstein, vetted those inmates, and provided the list of names to the MCC New York Warden. The Warden told the OIG that he identified two potential cellmates and tentatively decided on Inmate 3. The Warden said he passed this information on to the BOP Director’s Chief of Staff and later received word that he should assign Inmate 3 to be Epstein’s cellmate.¶

The Warden told the OIG that no inmates were pre-vetted to replace Inmate 3 if he left MCC New York. The Warden and the Captain told the OIG that if Inmate 3 had been removed as Epstein’s cellmate, they would have had to review a new list of potential cellmate candidates to ensure that Epstein was housed with an appropriate inmate. According to the Warden and the Captain, if Inmate 3 were no longer detained at MCC New York, SHU staff should have informed a lieutenant on duty, who should have informed the Captain, who would have ensured that the process of selecting a new cellmate for Epstein would begin.¶

VII. Epstein’s Cell Assignment from July 30 to August 10¶

As a result of Epstein’s cellmate requirement, on July 30, 2019, following his release from psychological observation, Epstein was initially assigned to cell Z04-206 with Inmate 3 in the J Tier of the SHU. $ ^{26} $ A BOP medical record note reflected that, on this same date, Epstein was provided with his personally-owned¶

26 SENTRY, which is BOP’s database of information relating to the care, classification, subsistence, protection, discipline, and programs of inmates, inaccurately reflected that this move from his psychological observation cell to the SHU occurred the previous day (July 29, 2019). The investigation revealed that Epstein was originally scheduled to return to the SHU on July 29, 2019, but, at his request, he remained on psychological observation until July 30, 2019.¶

SENTRY was not updated to reflect either the actual date of Epstein’s transfer back into the SHU or the cell to which he and Inmate 3 were assigned after the initial cell change necessitated by the electrical needs of Epstein’s medical device. The administrative error in BOP’s SENTRY records regarding Epstein’s cell assignment had no effect on the events the OIG investigated and reviewed.¶

According to OIG interviews with MCC New York staff members, it does not appear that there were any checks to ensure that inmates were physically located in the cells to which they were assigned in SENTRY. Associate Warden 1 told the OIG that the error would have been identified if SHU staff members had conducted a bed-book count, but there was no requirement to do a bed-book count every certain number of days. Associate Warden 1 explained that during a bed-book count, the staff members have a roster with them while conducting the count of inmates assigned to their housing unit to ensure all inmates are accounted for and in their assigned cells. The OIG’s investigation revealed that these and other cell assignment and recordkeeping errors would have been uncovered had MCC New York SHU staff been undertaking inmate accountability measures, such as rounds, counts, census checks, and bed-book checks.¶

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medical device. BOP witnesses told the OIG that on that same date, Epstein and Inmate 3 were moved to cell Z06-220 in the L Tier of the SHU to accommodate the electrical needs of Epstein’s medical device. Of all the cells in the SHU, cell Z06-220 was the closest cell with a direct line of sight to the SHU Officers’ Station in the common area of the SHU, which was approximately 15 feet away.¶

Inmate 3 told the OIG that when he and Epstein were first assigned as cellmates in cell Z06-220 in the L Tier, the Day Watch Operations Lieutenant told Inmate 3 that he had a “cool bunkie” for him, an “old guy” who would not bother Inmate 3. Inmate 3 said he told the Day Watch Operations Lieutenant that he slept on the bottom bunk, and the Day Watch Operations Lieutenant said that would not be a problem because his new cellmate slept on the floor. Inmate 3 said he was surprised by this response because he understood that sleeping on the floor was not allowed and he had previously been disciplined for doing so.¶

When Epstein arrived in the cell, Inmate 3 recognized him and said he (Inmate 3) told the Day Watch Operations Lieutenant that the Day Watch Operations Lieutenant had “jammed up” Inmate 3. Inmate 3 said he knew Epstein had tried to hang himself and had just come from suicide watch. According to Inmate 3, the Day Watch Operations Lieutenant told Inmate 3 not to worry, that Epstein was okay, and that Inmate 3 should keep an eye on him. Inmate 3 asked the Day Watch Operations Lieutenant if he was supposed to serve as a suicide prevention advocate, that is, an inmate who is assigned to the suicide watch area. Inmate 3 said the Day Watch Operations Lieutenant laughed and brushed off Inmate 3’s comment.¶

According to Inmate 3, correctional officers brought two mattresses to the cell for Epstein and placed them on the floor. Epstein put the mattresses on the right side of the cell, which is only partially visible through the cell door window when the cell door is closed. Inmate 3 noted that Epstein also had two extra blankets, which Inmate 3 said was also unusual because none of the inmates had extra blankets.¶

Inmate 3 said he asked Epstein to please not kill himself or hang himself while Inmate 3 was his cellmate because Inmate 3 had a chance to go home soon. Epstein told Inmate 3 not to worry and that he was not going to cause Inmate 3 any trouble.¶

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Figure 4.6: SHU L Tier¶

Figure 4.7: Exterior Views of Epstein’s Cell¶

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Figure 4.8: The Door to the Cell Occupied by Epstein and Inmate 3 from July 30 to August 9¶

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Figure 4.9: View of Epstein’s Empty Cell from Cell Door Window¶

Figure 4.10: Interior View of Epstein’s Empty Cell from Just Inside the Cell Door¶

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Figure 4.11: View of Epstein’s Cell Door from the SHU Officers’ Station¶

Figure 4.12: View of the SHU Officers’ Station from Epstein’s cell¶

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VIII. Psychological Evaluations of Epstein from July 6 to August 9¶

During Epstein’s detention at MCC New York, a variety of medical professionals, including a Medical Doctor, a Clinical Nurse, and Physician Assistant 1, who is a Mid-Level Practitioner, conducted multiple medical appointments with Epstein, and Epstein was prescribed a variety of medications for various ailments and health needs. Epstein was also given an eye and dental exam, as well as a blood panel screening. This section details Epstein’s psychological evaluations while he was in MCC New York custody prior to his death.¶

On Saturday, July 6, 2019, at 9:38 p.m., upon Epstein’s intake into MCC New York, he was medically screened by Physician Assistant 2. The screening included taking vital signs and asking various medical history questions, including questions related to Epstein’s mental health. Among other things, Physician Assistant 2 annotated that Epstein did not have current suicidal ideation and had denied having a history of suicide attempts. Physician Assistant 2 instructed Epstein how he could obtain medical, dental, and mental health care.¶

At 2:58 a.m. on Sunday, July 7, 2019, a Facilities Assistant emailed the Psychology Department asking that someone evaluate Epstein because he appeared “distraught, sad, and a little confused.”¶

On July 8, 2019, Forensic Psychologist 1 of the Psychology Department conducted an Intake Screening of Epstein that included a self-report, staff observation, and a review of information in SENTRY. Forensic Psychologist 1 noted that during Physician Assistant 1’s initial intake evaluation, on the intake questionnaire, Epstein denied having a history of mental health treatment and any history of mental health symptoms. Additionally, Forensic Psychologist 1 noted no suicidal ideations, attempts, or self-harm; no history of substance abuse or treatment; and no sexual offense convictions.¶

During the evaluation, Epstein stated he had been previously incarcerated for 3 months for “prostitution,” and that he was currently charged with sex trafficking. Epstein denied recent or present morbid thoughts and denied passive or active suicidal ideation. It was noted in BOP records that Epstein’s verbalizations were future-oriented and did not have indications of helpless or hopeless thinking.¶

According to Forensic Psychologist 1, Epstein did not meet the criteria for any psychological diagnosis and was designated as Mental Health Care Code 1. This is indicative of an inmate who does not show any significant level of functional impairment associated with a mental illness and does not demonstrate a need for regular mental health intervention. Epstein was educated on emergency procedures for contacting the Psychology Department staff, and Epstein agreed to contact staff if he needed Psychology Department services in the future.¶

The MCC New York Chief Psychologist told the OIG that based on the Psychological Services Intake Questionnaire, inmates have four different Care Code ratings. Code 1 means there are no concerns about the inmate’s mental health status; they have no needs and will not be followed up with unless requested by staff or the inmates. Code 2 means there is some history of mental health issues, but the inmate has them under control and the Psychology Department will follow up monthly. Code 3 is more severe, requiring weekly visits by the Psychology Department to ensure the inmate is stable and if unstable would be moved to observation. Code 4 inmates are seen daily by the Psychology Department and are under constant psychological observation. The Chief Psychologist stated that a Code 1 inmate can be on suicide watch.¶

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Suicide watch is for inmates who are showing immediate and exigent signs of being suicidal.¶

Subsequent to the intake screening, on July 8, 2019, the Chief Psychologist consulted with the Psychiatrist who was the National Suicide Prevention Coordinator from the BOP’s Central Office, regarding the various risk factors associated with Epstein for suicidality. These risk factors were that Epstein was involved in a high-profile case with media attention, had been charged with sex offenses, was on pretrial status, and there was the potential for bad news from a court proceeding that day. A determination was made that upon Epstein’s return from court, staff were to notify the psychologist and place Epstein on a “watch status” until a thorough suicide risk assessment could be conducted.¶

When Epstein returned from court on July 8, 2019, it was after duty hours and MCC New York staff contacted the Psychology Department and informed them that Epstein denied suicidality. However, for precautionary reasons, Epstein was placed on psychological observation status until Psychology Department staff could conduct a suicide risk assessment the following day. During Epstein’s period of psychological observation, inmate companions continuously observed him and kept a log that detailed Epstein’s activities in 15-minute increments. Under BOP policy, on a case-by-case basis, the Warden may authorize such an inmate companion program at an institution to utilize inmate observers, who are selected, trained, and supervised by the institution’s Suicide Prevention Program Coordinator.¶

On July 9, 2019, the Chief Psychologist conducted a suicide assessment of Epstein. She reviewed Epstein’s medical record and interviewed him, which revealed that he possessed some risk factors for suicidality. Epstein denied having any past or present suicidal ideation, intention, or plan, and also denied having any history of mental health treatment or any current mental health symptoms. The Chief Psychologist’s assessment was that Epstein had “protective” factors present that could decrease his risk of suicide. The Chief Psychologist assessed factors that included his willingness to engage in treatment, view of death as negative, future orientation, and the fact that he adamantly denied any suicidal ideation, intention, or plan. The Chief Psychologist’s assessment was that Epstein had numerous protective factors that outweighed his risk factors for suicidality and that he had a positive outlook regarding his legal case. Epstein remained on psychological observation pending a suitable cell assignment, and the Chief Psychologist noted that a suicide watch was not warranted at the time of her report.¶

On July 10, 2019, the Chief Psychologist met with Epstein for a psychological observation and noted that, according to the psychological observation logbook, Epstein had been eating his meals, sleeping, and interacting with other inmates. During this meeting with the Chief Psychologist, Epstein voiced concerns over being housed in the SHU. Epstein asked the Chief Psychologist to be “single-celled” if he were to be housed in the SHU and had also requested a shower, his property, pen, and paper. The Chief Psychologist stated Epstein had been provided a shower on this date. She provided Epstein with coping skills strategies, to which he was receptive. Epstein continued to deny any suicidal ideation, intention, or plan; and Epstein stated he was looking forward to his upcoming court hearing regarding pretrial release. The Chief Psychologist’s assessment was that Epstein was psychologically stable at the time and that he could be released from the psychological observation area. She noted that Epstein would be housed in the SHU with a cellmate and would be seen the following morning to evaluate his mental status and stability. Following this July 10 assessment, Epstein was taken off of psychological observation and returned to the SHU with documented recommendations for a cellmate and next-day contact by the Psychology Department.¶

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The following day, July 11, 2019, the Staff Psychologist attempted to see Epstein in the morning and afternoon, but he was meeting with his attorneys. Since the Staff Psychologist was unable to meet with Epstein, the Chief Psychologist met with Epstein in the attorney conference area for a psychological observation follow-up. During this meeting, Epstein expressed concerns about a number of issues, including not yet receiving his property, not having enough water during his attorney conference, and a desire to attend recreation. Epstein was upset about having to wear an orange uniform and the Chief Psychologist explained the orange uniform was because he was being housed in the SHU. During this clinical contact, the Chief Psychologist provided Epstein with additional coping strategies, to which he was receptive. Additionally, Epstein was educated about routine and emergency procedures for contacting the Psychology Department staff and reminded of self-help books/audiotapes available through the Psychology Department. Epstein continued to deny any suicidal ideation, intention, or plan and was scheduled to be seen again the following week. The Chief Psychologist told the OIG that Epstein and his attorney mocked her for thinking Epstein was suicidal.¶

On July 16, 2019, at Epstein’s request, the Chief Psychologist met with Epstein during his attorney conference. The Chief Psychologist noted that Epstein did not have any psychological concerns and denied suicidality. The Chief Psychologist noted that she provided Epstein with psychoeducation regarding additional coping strategies. Epstein was educated about routine and emergency procedures to contact Psychology Department staff and reminded of self-help books and audiotapes that are available to him. The Chief Psychologist noted in her clinical contact report that there was no need for follow-up and that Epstein would be seen in the SHU for rounds and monthly SHU reviews.¶

According to the BOP After Action Review submitted by the Southeast Regional Director, the Chief Psychologist’s meeting with Epstein on July 16, 2019, at Epstein’s request during his attorney conference was inappropriate. The Southeast Regional Director wrote in the report that Epstein attempted to “bring his attorneys into the fray regarding the mental health treatment being provided by the institution.” In the After Action Review, the Southeast Regional Director wrote that it was not typical for the BOP to provide psychological intervention in the presence of others, nor was it appropriate for a BOP psychologist to meet with an inmate’s attorney. When asked by the OIG about these findings, the Chief Psychologist stated that the intention was to check on Epstein, not to breach any security.¶

On July 18, 2019, the Chief Psychologist conducted a monthly SHU review and noted that Epstein was unavailable due to a meeting with his legal team and that she would attempt to interview Epstein in the near future to complete his monthly review.¶

As noted previously, at approximately 1:27 a.m. on July 23, 2019, Epstein was found lying on the floor of his cell with a piece of homemade orange cloth around his neck. The Chief Psychologist made a general administrative note in Epstein’s file that she was contacted by the Operations Lieutenant at approximately 2:00 a.m., and informed that Epstein was being placed on suicide watch after he was found with a string loosely hanging around his neck. That morning, Physician Assistant 1 assessed Epstein for injuries and noted in BOP records that Epstein was cooperative, alert, and oriented. According to BOP’s medical records, Epstein did not appear distressed and was smiling during the clinical assessment. Epstein said he did not know what had happened and could not explain the mark on his neck. Physician Assistant 1 noted that Epstein had a circular line of erythema, i.e., superficial redness on the skin, that was 2 inches wide and spanned two-thirds of the way around the front and sides of the base of his neck. According to the BOP report, one section of the erythema (or redness) in the front of his neck had marks of friction, and there was¶

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no inflammation, deformities, hematomas, lacerations, or tenderness. The BOP report stated that Epstein was able to move his neck without any restriction and denied having any pain, discomfort, or respiratory problems. Physician Assistant 1 further noted there was another small erythema (or redness) on Epstein’s left knee about 2 centimeters in diameter, which was noted as mild. Physician Assistant 1’s assessment was that the injury was unspecified and was self-inflicted.¶

Also on July 23, 2019, the Staff Psychologist conducted a suicide risk assessment that included a clinical interview of Epstein and a review of Epstein’s medical record, the psychology data system, and a review of the SENTRY database. According to the Staff Psychologist’s report, Epstein denied knowing why he was placed on suicide watch. BOP records state that Epstein recalled getting a drink of water the night prior and then went back to bed. Epstein’s next recollection was hearing himself snoring. The BOP assessment records reflect that Epstein wanted to know why he was on suicide watch and he was informed that he had been found with a string on his neck. The Staff Psychologist noted that it was unclear whether Epstein had placed the string around his neck or if someone else did. Epstein denied current suicidal or self-harm thoughts or ever having these thoughts; denied a history of self-harm and suicide attempts; and denied feeling hopeless and fearing for his safety. Epstein told the Staff Psychologist that he lived to enjoy life and that his future plans included fighting his criminal case and getting back to his normal life. The Staff Psychologist noted that Epstein was to remain on suicide watch for further observation. The Staff Psychologist told the OIG she had advised BOP staff that Epstein would need a cellmate.¶

The Chief Psychologist said she considered three possibilities to explain the July 23 incident: (1) Epstein and/or Inmate 1 were gaming the system to get something they wanted that they were not getting; (2) Epstein, who really was suicidal, had conducted a rehearsal; (3) Inmate 1 had assaulted Epstein. The Chief Psychologist told the OIG that after Epstein told her he wanted to be housed with the same cellmate he originally said had assaulted him, she began to think that the third possibility (assault by Inmate 1) was less plausible than the other two possibilities, although she did not know for certain.¶

The following day, July 24, medical staff examined Epstein at approximately 1:08 p.m., and observed that the central part of the red mark on Epstein’s neck had some abrasion. Epstein told the medical staff that he still did not want to talk about how he sustained his injuries, but he believed that his cellmate had something to do with it. BOP’s Special Investigative Services (SIS) opened an investigation into this incident but was unable to determine whether Epstein had harmed himself or had been assaulted.¶

On July 24, 2019, after 31 hours and 5 minutes, Epstein was removed from suicide watch. Epstein remained in the same cell that he was in under suicide watch and was under psychological observation until July 30, 2019. $ ^{27} $ Also on July 24, 2019, Forensic Psychologist 2 completed a Post Suicide Watch Report. According to Forensic Psychologist 2’s report, Epstein continued to claim a lack of memory regarding how he sustained the scar around his neck. The BOP report further stated that Epstein adamantly denied suicidal ideation, intentions, and plans, that Epstein identified reasons to live and was future-oriented, and that Epstein was assessed for a willingness to engage in treatment. The BOP report reflected that Forensic Psychologist 2 inquired further if Epstein could recall the previous day’s incident and Epstein stated that he had been trying to remember. Forensic Psychologist 2 asked Epstein why he told another inmate that Epstein’s cellmate had tried to kill him but was now claiming he has no memory of the incident. Epstein told Forensic Psychologist¶

27 Epstein’s BOP medical records reflect that he was removed from psychological observation and returned to the SHU on July 30, 2019; however, SENTRY inaccurately reflects that Epstein was transferred back to the SHU on July 29, 2019.¶

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2 that he did not recall himself or his cellmate tying a string or rope around his neck.¶

Following Forensic Psychologist 2’s examination of Epstein, she determined that he should be removed from suicide watch. Forensic Psychologist 2 told the FBI that she discussed the decision to step Epstein down to psychological observation from suicide watch with the Chief Psychologist and Associate Warden 2, who both concurred with her determination. Epstein was therefore taken off suicide watch and placed on psychological observation, during which time BOP records reflect that he was continuously observed by inmate companions and seen daily by Psychology Department staff. Forensic Psychologist 2 annotated in the Post Suicide Watch Report that the reason for removing Epstein from suicide watch was due to Epstein stating he had no interest in killing himself; he had described having a wonderful life; and Epstein had said it would be crazy to take his own life and he would not do that to himself. Forensic Psychologist 2 told the FBI that following her clinical visit with Epstein on July 24, 2019, she was cautious with Epstein’s case and his self-reporting of what had occurred the previous day. Forensic Psychologist 2 stated that she observed signs of positivity and that Epstein “adamantly denied suicide.” Nevertheless, she was not comfortable taking Epstein off suicide watch and instead opted to place Epstein on psychological observation, which was a step down from suicide watch. Forensic Psychologist 2 told the FBI that “I made the decision with the consent” of the Chief Psychologist and Associate Warden 2, with whom she had consulted. Forensic Psychologist 2 told the FBI that placing Epstein on psychological observation allowed him to possess hygiene products, two novels, attend legal visits, and take showers. It also allowed him to have standard inmate clothing, a flex pen, a toothbrush and toothpaste, soap, and deodorant. However, Forensic Psychologist 2 explained that it was not healthy for inmates to stay on suicide watch for extended periods of time and they are re-evaluated on a day-to-day basis.¶

According to Forensic Psychologist 2’s Post Suicide Watch Report, Epstein expressed a feeling of safety being housed in the psychological observation area rather than the SHU and asked if there was a safer unit for him to be housed. Forensic Psychologist 2 informed Epstein that he would remain on psychological observation for the near future, but his long-term housing would need to be revisited because it is not ideal to remain in psychological observation for extended periods of time. The BOP report states that Epstein was again educated on routine and emergency procedures for contacting Psychology Department staff.¶

According to BOP records, between July 25-29, 2019, Epstein was seen daily by the Chief Psychologist or the Staff Psychologist while he was on psychological observation. On each of these dates, according to BOP reports, Epstein adamantly denied any suicidality and denied having any memory of what occurred on July 23, 2019, which resulted in him being placed on suicide watch. Additionally, on each date, Epstein was provided with supportive and coping skill interventions to which he was receptive. BOP records state that Epstein expressed concerns about being housed again in the SHU because he felt it was dangerous; he could not sleep well due to noise from other inmates; and it was difficult for him to work on his legal case. The Chief Psychologist told the FBI and OIG that she met with Epstein on July 25, 2019, and he was in good spirits. She said that during this clinical visit, Epstein said he was baffled over the July 23, 2019 incident and asked the Chief Psychologist to give him some cues to help him remember. The Chief Psychologist told the OIG that she kept Epstein on psychological observation because he had not answered her questions regarding the possible suicide attempt. The Chief Psychologist told the OIG that she coordinated with the BOP’s National Suicide Prevention Coordinator, who recommended that Epstein be housed with a sex offender in the SHU. The Chief Psychologist notified Associate Warden 2 of this recommendation via email. BOP records further reflect that, during his clinical visit on July 28, 2019, Epstein told the Staff Psychologist that he was agitated for hours the previous night because of a non-stop toilet flushing and that the noise¶

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was similar to when he was housed in the SHU. The Staff Psychologist informed Epstein that he would be moving to a different cell.¶

On July 29, 2019, according to BOP records, Epstein reported to the Chief Psychologist that his memory of the July 23, 2019 incident may be impaired because of his sleep apnea. On this date, Epstein was to receive his personally owned medical device. BOP records state that Epstein was aware he would be returning to the SHU but reported that he did not feel well due to lack of sleep and other medical concerns. Epstein asked to stay on psychological observation, where he felt safe, for one more night to get some sleep and then return to the SHU with a cellmate the following day. According to BOP records, the Chief Psychologist informed Epstein that he could stay 1 more night and explained that there were no mental health issues precluding him from returning to the SHU the following day. The Chief Psychologist explained to Epstein that he would be placed in a safe situation in the SHU. Epstein again was provided supportive interventions and psychoeducation regarding additional coping strategies. BOP records state that Epstein was somewhat receptive but more concerned with getting phone calls, recreation, and housing placement concerns.¶

On July 30, 2019, according to BOP records, Epstein reported to the Staff Psychologist that he had not slept well, and Epstein discussed how he did not think he would be able to sleep well in the SHU because of the noise. The Staff Psychologist annotated in the clinical contact summary that documentation revealed Epstein had eaten and taken a shower the day prior (July 29) and also had eaten breakfast on July 30. The Staff Psychologist annotated, Epstein did not display indications of disturbed thought process or content and denied current suicidal or self-harm ideation. BOP records further stated that Epstein agreed to immediately report to staff if he began to have suicidal or self-harm thoughts, and that Epstein was future-oriented and did not appear to be a danger to himself. The Staff Psychologist noted in her clinical contact report that she had consulted with the Chief Psychologist and that psychological observation of Epstein would be discontinued. According to her clinical contact report, the Staff Psychologist educated Epstein about routine and emergency procedures for contacting Psychology Department staff and noted that Epstein would be seen the following day. The Staff Psychologist also noted in her report that the SHU lieutenant was informed that Epstein needed to be housed with an appropriate cellmate.¶

Also on July 30, 2019, the Staff Psychologist completed an evaluation of competency related to Epstein being able to proceed with the disciplinary process. Epstein had been charged by BOP with a prohibited act, specifically tattooing or self-mutilation, for the incident that occurred on July 23, 2019. In conducting the evaluation of competency, the Staff Psychologist reviewed the suicide risk assessment completed by the Chief Psychologist on July 9, 2019, in which Epstein had denied a history of mental health treatment and having any past or present suicidal ideation, intention, or plan. The Staff Psychologist also reviewed the suicide risk assessment that she herself completed, dated July 23, 2019, which stated that it was unclear at the time if Epstein had placed the string around his neck or if it was done by someone else. According to the Staff Psychologist’s notes from her competency evaluation on July 30, the determination of an inmate’s competency to proceed with the disciplinary process was based on a clinical assessment of the inmate’s ability to understand the nature of the proceedings and his or her ability to assist in his or her own defense. After a review of available psychological and psychiatric records and information related to the offense, the Staff Psychologist found that Epstein was competent to proceed with the disciplinary process.¶

That same day, July 30, Epstein was removed from psychological observation and transferred back to the SHU, consistent with what he had been told by the Chief Psychologist the prior day.¶

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On July 31, 2019, according to BOP records, Forensic Psychologist 3 conducted a clinical visit with Epstein and noted that he was in a pleasant mood, generally slept well, and was getting readjusted to being in the SHU. Epstein told Forensic Psychologist 3 that he was getting along with his cellmate. According to her report, Epstein explicitly denied recent and current suicidal ideation or intent and denied having thoughts of harming others. Epstein also agreed to contact staff immediately if he experienced any suicidal thoughts or psychological distress. Forensic Psychologist 3’s report further stated that Epstein was receptive to her utilization of cognitive behavioral therapeutic techniques. She wrote that there did not appear to be a need for follow-up at the time and Epstein expressed a willingness to self-refer to Psychology Department staff if needed. According to the report, Epstein would continue to be seen during routine SHU rounds and SHU reviews.¶

On August 1, 2019, according to BOP records, BOP Receiving and Discharge staff, who are responsible for processing inmates who enter or leave the facility, notified the Staff Psychologist that the previous day when the U.S. Marshals Service (USMS) had brought Epstein back to MCC New York from court, they had provided a form on which it was noted that Epstein had “suicidal tendencies.” The OIG reviewed the USMS Prisoner Schedule Report for July 31, 2019, as well as the USMS Prisoner Custody Alert Notice that had annotated in the remarks that Epstein had “Mental Concerns: Suicidal Tendencies”. The Chief Psychologist told the OIG that the USMS annotates suicidal tendencies for many inmates if the USMS was aware the inmate was previously on suicide watch. Therefore, the Chief Psychologist said the annotation was not abnormal since Epstein had just come off suicide watch and Epstein may have told the USMS that he had been on suicide watch.¶

Following receipt of this information from the Receiving and Discharge staff, the Staff Psychologist conducted a suicide risk assessment on August 1 that included a review of Epstein’s previous clinical encounters, medical records, and data in the Psychology Department and SENTRY systems. According to the Staff Psychologist’s assessment, Epstein denied stating he was suicidal and was surprised that the form noted that he had suicidal tendencies. The Staff Psychologist said that Epstein told her that the incident report he received for the marks on his neck arising from the July 23 event had been expunged. The OIG confirmed that the incident report was expunged. Epstein also said his cellmate talked at night and kept Epstein awake but that Epstein wanted to give it 3 to 4 more days before determining if he wanted another cellmate. The Staff Psychologist concluded in her report that Epstein did not appear to be a danger to himself and denied current suicidal or self-harm ideation and agreed to immediately inform staff if he had any of these thoughts. Epstein told her that he had social supports in the community and that he had reasons to live and positive future plans. The Staff Psychologist noted that Epstein was currently psychologically stable, and that suicide watch was not indicated at the time. The Staff Psychologist concluded that Epstein’s overall acute suicide risk was low, and the overall chronic suicide risk was absent. Epstein was again provided supportive and educative interventions and educated about routine and emergency procedures for contacting Psychology Department staff. The Staff Psychologist’s report noted that Epstein would continue to be seen during routine SHU rounds and SHU reviews.¶

On August 8, 2019, the Chief Psychologist conducted a clinical follow-up session with Epstein. According to her report, Epstein described his sleep as fair and requested that he be placed in general population. The report further stated that Epstein denied feelings of depression, anxiety, and any suicidal ideation, intention, or plan. Epstein told the Chief Psychologist that he received the necessary documentation to make phone calls and asked if his previous phone calls over the speaker phone counted as his monthly phone contact. The Chief Psychologist stated in her report that Epstein had no mental health concerns and did not appear¶

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to be in any distress. The Chief Psychologist wrote that SHU staff had not reported any unusual behaviors related to Epstein. She provided Epstein with supportive interventions and psychoeducation regarding additional coping strategies, to which Epstein was receptive. Epstein was educated on routine and emergency procedures for contacting Psychology Department staff and also reminded of self-help books and audiotapes that are available to him. The Chief Psychologist wrote that Epstein would be seen in weekly SHU rounds and monthly for SHU reviews. The Chief Psychologist told the OIG that the fact that Epstein underwent three suicide risk assessments was unusual.¶

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