DOJ OIG report chapter on the events before Epstein's death, August 8–10, 2019

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

I. Epstein Signs a New Last Will and Testament on August 8¶

In the weeks following Epstein’s death, multiple media outlets reported that Epstein signed a new Last Will and Testament on August 8, 2019. At least one media organization published a copy of the notarized document showing that it was signed by Epstein and two of his attorneys and notarized on August 8, 2019. Attorney visitor logs from the Metropolitan Correctional Center in New York, New York (MCC New York) confirmed that those attorneys and the notary public visited Epstein on that date. The OIG confirmed via court records that the August 8, 2019 will and other probate-related documents were filed in the Superior Court of the Virgin Islands on August 15, 2019. Among the court filings was an affidavit from another attorney who stated that she received the August 8, 2019 will from Epstein. The OIG confirmed via attorney visitor logs that this attorney also visited Epstein at MCC New York on August 8, 2019. The OIG’s investigation and review revealed that MCC New York personnel were unaware that Epstein had changed his will 2 days before he died.¶

The Chief Psychologist said she had heard that Epstein had changed his will from media reporting following his death. The Chief Psychologist did not know if the media reporting was accurate, but she thought that if it were true, it would have been useful information to know because it would have been a red flag. The Staff Psychologist and the Chief Psychologist told the OIG that if Epstein’s attorneys had notified them or the Psychology Department that Epstein had changed his will, such information would have been a factor warranting a review of Epstein’s mental state and Epstein probably would have been placed back on suicide watch or some type of observation.¶

II. Court Order on August 9 Releasing Epstein-Related Documents in Pending Civil Litigation¶

On August 9, 2019, the U.S. Court of Appeals for the Second Circuit ordered the unsealing of the summary judgment filings from a defamation lawsuit filed by a woman who alleged that Epstein had victimized her when she was a teenager, against Ghislaine Maxwell. $ ^{28} $ As a result of the court’s order, that same day approximately 2,000 pages of documents were released into the public domain, some of which contained information that may have related to the criminal charges pending against Epstein. Additional high-profile public figures were also named in the released documents. There was significant media coverage of information contained within the unsealed court filings.¶

III. Transfer of Epstein’s Cellmate on August 9 to Another Institution and Failure to Replace Him with Another Inmate¶

A. Notice on August 8 of the Impending Transfer of Epstein’s Cellmate on August 9¶

As noted above, since July 30, consistent with the Psychology Department’s determination that Epstein needed to have a cellmate, Epstein had been housed with Inmate 3, whom the Warden and the Federal Bureau of Prisons (BOP) executive leadership had selected as an appropriate cellmate. At 10:33 a.m. on¶

28 Maxwell was subsequently indicted and, in December 2021, convicted of conspiring with Epstein to sexually abuse minors.¶

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August 8, 2019, the U.S. Marshals Service (USMS) sent an email to MCC New York personnel assigned to Receiving and Discharge, the area within the Correctional Services Department that is responsible for processing inmates who enter or leave the facility, with the subject “Transfer of Prisoners from NYM [MCC New York] to GEO.” $^{29}$ The body of the email identified Inmate 3 as one of the prisoners to be transferred and further stated, “Please schedule the transfer for Friday 8/9/19.”¶

At 3:36 p.m. on the same day, the USMS sent a second email to a number of MCC New York personnel, including Associate Warden 2, the Captain, the SHU Lieutenant, the Day Watch Operations Lieutenant, the Day Watch Activities Lieutenant, the Evening Watch Operations Lieutenant, another Lieutenant, and the SIS Lieutenant, with the subject “Prisoner Production 08-09-2019.” This email contained two attachments, one of which was the Prisoner Schedule Report for MCC New York for August 9, 2019. The first page of this attachment reflects that Inmate 3 was scheduled to be transferred from MCC New York to GEO (Queens Detention Facility) on August 9, 2019. This attachment also includes the acronym “WAB” within the Destination/Description portion of the document, which MCC New York personnel told the OIG means “with all belongings.” During their OIG interviews, MCC New York staff members further explained that the “WAB” notation meant that Inmate 3 was being permanently removed from MCC New York on August 9, 2019. Notwithstanding this email, as detailed below, several of the email recipients identified above, including the Captain, the Day Watch Operations Lieutenant, and the Day Watch Activities Lieutenant told the OIG that they believed Inmate 3 had gone to court on August 9, and they did not know he had been transferred to another facility.¶

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

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 explained to the attorney that because Epstein was housed in the SHU and he was a sex offender, he needed to have a cellmate.¶

Additionally, the OIG investigation revealed that on the day of Epstein’s death, a Supervisory Staff Attorney with the BOP’s Consolidated Legal Center for New York, sent an email to the Warden to inform him that on the previous day (August 9, 2019), two of Epstein’s attorneys separately contacted him. One of the attorneys asked for Epstein to be moved to a different, specific housing unit within MCC New York; the other attorney asked for Epstein to be housed without a cellmate in the SHU. The Supervisory Staff Attorney said he informed the first attorney that the suggested housing unit was not available for pretrial detainees such as Epstein, and he said he told the second attorney that Epstein could not be housed without a cellmate because of his prior suicide attempt.¶

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

According to MCC New York reports, including the Daily Log and the Lieutenant’s Log, on August 9, 2019, at approximately 8:38 a.m., Epstein’s cellmate, Inmate 3, was “pre-removed” and transferred out of MCC New York in a routine, pre-arranged transfer. The Daily Log tracks inmate movements throughout MCC New York each day, while MCC New York lieutenants utilize the Lieutenant’s Log to document the daily activities¶

29 GEO refers to the Queens Detention Facility, a contract detention facility located in Queens, New York, that is managed by The GEO Group, Inc.¶

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that took place within the institution during their respective shifts.¶

The Supervisory Correctional Systems Specialist was the supervisor of Receiving and Discharge on August 9, 2019, and was responsible for overseeing all inmate movements in and out of the institution that day. The Supervisory Correctional Systems Specialist verified that Receiving and Discharge would have used the USMS emails sent on August 8, 2019, to coordinate Inmate 3’s transfer out MCC New York, and since Inmate 3 was listed as “WAB” on the USMS emails, that meant he was being transferred from the facility and not coming back. She explained to the OIG that if Inmate 3 had been going to court, as many pretrial inmates held at MCC New York often did, the Daily Log would have reflected “court,” rather than “pre-remove.” Since the Daily Log listed Inmate 3 as “pre-remove,” the Receiving and Discharge personnel who entered the information into the report were made aware that Inmate 3 was being transferred from MCC New York on or before the morning of August 9, 2019. The Supervisory Correctional Systems Specialist told the OIG that the language in the USMS emails (“WAB,” i.e., “with all belongings”) and MCC New York reports (“pre-removed”) made it clear that Inmate 3 would not be returning to the SHU or MCC New York.¶

The OIG also interviewed the Correctional Systems Officer, who was the Receiving and Discharge officer who handled inmate movement in and out of MCC New York on August 9, 2019. The Correctional Systems Officer confirmed that the Daily Log reflected that Inmate 3 was “pre-removed” on August 9, 2019, at 8:38 a.m., because he was being officially moved from the institution to another prison. She explained to the OIG that the ordinary process was that Receiving and Discharge personnel would enter the information regarding Inmate 3 into SENTRY, along with information pertaining to other inmates who would be leaving their MCC New York housing units. Receiving and Discharge used this information to create the daily call out list, which had all of the inmates’ names and times that they were to be moved. The Correctional Systems Officer told the OIG that the call out list from August 9, 2019, was no longer available because the call out lists were printed and hand-delivered to the housing units each day, and then discarded by the units at the end of the day. She also said each day’s call out list was only maintained electronically for a 24-hour period, and then it was updated (overwritten) with the next day’s list. In her OIG interview, the Correctional Systems Officer explained what would have occurred on this date based on her experience. Receiving and Discharge personnel would have printed copies of the call out list for August 9, 2019, which the MCC New York internal officer would distribute to the various housing units within the facility. Based on the other records reflecting Inmate 3’s transfer, the Correctional Systems Officer said the call out list created for August 9, 2019, would have listed “WAB” next to Inmate 3’s name, which meant that he was departing from the institution and not returning.¶

Correctional Officer 1 told the OIG that on the morning of August 9, 2019, he and Day Watch SHU Officer in Charge escorted Inmate 3 to Receiving and Discharge and Epstein to his legal visit.¶

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

1. Day Watch Staff Actions on August 9¶

The SHU Lieutenant told the OIG that he worked at MCC New York on August 8, 2019, from approximately 6:00 a.m. until approximately 2:00 p.m., and that he was off on August 9, 2019. The SHU Lieutenant, whose shift ended over an hour before the USMS sent the second email regarding Inmate 3’s impending transfer, told the OIG he was not aware that Inmate 3 was scheduled to be transferred out of MCC New York, and therefore he did not notify the Captain that Epstein would require a new cellmate. According to the SHU Lieutenant, as soon as the SHU staff learned that Inmate 3 would be transferred, they should have notified a¶

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Lieutenant on duty. The Day Watch Operations Lieutenant and the Day Watch Activities Lieutenant told the OIG that on August 9, 2019, they had oversight of the SHU from approximately 6:00 a.m. until 2:00 p.m. due to their position descriptions and because of the SHU Lieutenant’s absence.¶

According to the MCC New York Staff Roster, on August 9, 2019, SHU Officer #1 was listed as Senior Officer Specialist 5. Although SHU Officer #1 is typically the Officer in Charge, another Senior Officer Specialist told the OIG that, in actuality, he was the Day Watch SHU Officer in Charge on August 9 from approximately 6:00 a.m. until 2:00 p.m. The Day Watch SHU Officer in Charge said that since he had the most experience and seniority, he was considered by everyone to be the SHU Officer in Charge, which the SHU Lieutenant confirmed. The Day Watch SHU Officer in Charge told the OIG that he knew that Epstein had to have a cellmate. He said that, as a general practice, every inmate who is transferred from suicide watch and/or psychological observation to the SHU is placed with a cellmate. He also confirmed that the SHU Lieutenant had instructed him that Epstein was to be housed with a cellmate at all times. According to the Day Watch SHU Officer in Charge, between July 30 and August 9, 2019, he told all other MCC New York staff members who worked in the SHU of Epstein’s cellmate requirement and further stated that everyone who worked in the SHU should have known that Epstein was required to have a cellmate due to their knowledge, training, and experience.¶

The Day Watch SHU Officer in Charge confirmed that on the morning of August 9, 2019, the SHU staff received an inmate call out list that listed Inmate 3 as “WAB,” which he explained meant that Inmate 3 was being removed from MCC New York. He told the OIG that sometime between 8:00 a.m. and 9:00 a.m., he escorted Epstein from the SHU to the attorney conference room for Epstein’s daily legal visit, during which time Epstein joked around with him. The Day Watch SHU Officer in Charge said that he and Epstein were accompanied by Correctional Officer 1, who was escorting Inmate 3 to Receiving and Discharge. The Day Watch SHU Officer in Charge and Correctional Officer 1 both told the OIG that Inmate 3 was escorted to Receiving and Discharge with all of his belongings, and both said that during the escort the Day Watch SHU Officer in Charge informed Epstein that he would be assigned a new cellmate due to Inmate 3’s departure and the requirement that Epstein have a cellmate. In his interview with the OIG, Correctional Officer 1 confirmed this conversation between the Day Watch SHU Officer in Charge and Epstein, but he did not provide any additional information regarding notifications made either by him or the Day Watch SHU Officer in Charge. The Day Watch SHU Officer in Charge told the OIG that when he and Correctional Officer 1 left the SHU with Epstein and Inmate 3, both the Day Watch Operations Lieutenant and the Day Watch Activities Lieutenant should have been physically present in the Lieutenants’ Office and should have seen that Inmate 3 was departing the institution when they passed the office.¶

The Day Watch SHU Officer in Charge said that while he did not expect Inmate 3 to return to MCC New York, there had been times when inmates had been escorted to Receiving and Discharge as an expected removal, only to be returned to the SHU later that same day due to unforeseen circumstances. According to the Day Watch SHU Officer in Charge, he did not select a new cellmate for Epstein because he was not certain that Inmate 3 had been discharged from the institution, although he assumed that Inmate 3 would not return to the SHU. The Day Watch SHU Officer in Charge told the OIG that when his shift ended at approximately 2:00 p.m., he informed the Evening Watch SHU Officer in Charge and Senior Officer Specialist 5 that, if Inmate 3 did not return to the SHU, Epstein would need a new cellmate upon Epstein’s return from his attorney visit. The Day Watch SHU Officer in Charge said he specifically recalled telling the Evening Watch SHU Officer in Charge, in the presence of Senior Officer Specialist 5, “Make sure this guy gets a bunkie,” to which the Evening Watch SHU Officer in Charge replied, “All right.” The Day Watch SHU Officer in Charge said that, at¶

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some point that day, it was likely that he also informed the Day Watch Operations Lieutenant, but he could not specifically recall if he had done so.¶

The Day Watch SHU Officer in Charge told the OIG that a replacement cellmate should have been identified as soon as it was confirmed that Inmate 3 had left the institution. He said a new cellmate could have been reassigned before the 4:00 p.m. SHU count if it was known that Inmate 3 was not coming back, but the SHU staff members had until Epstein returned from his attorney visit to assign Epstein a new cellmate. According to the Day Watch SHU Officer in Charge, SHU staff definitely should have realized that Inmate 3 was not returning both during the 4:00 p.m. count and when Epstein returned from his attorney visit later that evening. The Day Watch SHU Officer in Charge told the OIG that Epstein’s daily routine was that he would be with his attorneys in the attorney conference room until approximately 8:00 p.m., so SHU personnel had time to make a new cellmate assignment. He said all SHU staff members shared the responsibility to find a replacement cellmate and that anyone assigned to the SHU could have found another inmate to replace Inmate 3. However, he also said that due to Epstein’s high profile, the SHU personnel should have asked a lieutenant to contact the Psychology Department to see which inmate should be placed with Epstein.¶

On August 12, 2019, following Epstein’s death, the Day Watch SHU Officer in Charge wrote a memorandum to the Warden stating, “On Friday August 9, 2019 at approximately 1:50 p.m., I S/O/S [the Day Watch SHU Officer in Charge] passed on to oncoming staff member [the Evening Watch SHU Officer in Charge] and present shift staff [Senior Officer Specialist 5] and [Correctional Officer 2] that Inmate [3] was going WAB [i.e., with all of his belongings] and possibly may not return. Also that Inmate Epstein #76318-054 will be needing a cell mate upon arrival from his attorney visit.” The Day Watch SHU Officer in Charge departed the SHU at approximately 2:00 p.m. and worked an overtime shift as a driver for MCC New York. He stated that he did not follow up with the SHU staff to verify that Epstein had been assigned another cellmate.¶

MCC New York staff with responsibility for oversight and staffing of the SHU during the Day Watch, including the Warden, Associate Warden 1, the Captain, the SHU Lieutenant, the Day Watch Operations Lieutenant, the Day Watch Activities Lieutenant, and the Day Watch SHU Officer in Charge, told the OIG that they all knew Epstein was required to have a cellmate pursuant to the Psychology Department’s determination. They also confirmed that everyone who regularly worked in the SHU knew of this requirement, and that it was the responsibility of all SHU staff to notify a supervisor upon learning that Epstein needed to be assigned a new cellmate due to Inmate 3’s transfer to another prison. The Day Watch SHU Officer in Charge and Correctional Officer 1, however, were the only two MCC New York staff members working the Day Watch on August 9, 2019, who told the OIG that they were aware of Inmate 3’s transfer and the need to assign Epstein a new cellmate. Correctional Officer 1’s immediate superior (the Day Watch SHU Officer in Charge) was already aware of the need to assign Epstein a new cellmate. While the Day Watch SHU Officer in Charge told the OIG that he made a number of notifications, other witnesses could not confirm that he had passed on information regarding Epstein’s need for a new cellmate.¶

The Day Watch Operations Lieutenant and the Day Watch Activities Lieutenant both told the OIG that they did not know Inmate 3 had been transferred out of the facility, despite the fact that both were recipients of the second email USMS sent on August 8 that included the information about Inmate 3’s impending transfer out of MCC New York on August 9. Rather, the Day Watch Operations Lieutenant and the Day Watch Activities Lieutenant told the OIG that they believed Inmate 3 had been removed from MCC New York for a court appearance.¶

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The Day Watch Activities Lieutenant did not recall Inmate 3 departing the institution with all of his belongings or having any conversations with the Day Watch SHU Officer in Charge or anyone else regarding Inmate 3’s departure from MCC New York. According to the Day Watch Activities Lieutenant, he did not know that Epstein was without a cellmate. Other senior officials, including the Warden, Associate Warden 1, and the Captain, were also unaware of Inmate 3’s transfer and the need to assign Epstein a new cellmate. These officials concurred that while all SHU staff and supervisors were responsible for notifying a supervisor in the chain-of-command of the need to assign Epstein a new cellmate, the Day Watch SHU Officer in Charge bore primary responsibility for the notification because he was the SHU Officer in Charge and one of two people who saw Inmate 3 leave the facility with all of his belongings. The Captain told the OIG that since Epstein was in the attorney conference room all day, no one may have even thought about it, and may have only become aware when they put Epstein back in his cell after his attorney visit that evening. The Captain said as soon as the SHU staff became aware that Epstein was without a cellmate, they should have notified the Evening Watch Operations Lieutenant. The Captain said that if he had been informed, he would have taken immediate action to ensure that Epstein was either assigned a new cellmate or monitored until that assignment occurred. The Captain, however, was one of the recipients of the USMS August 8 email that notified members of MCC New York supervisory staff of Inmate 3’s transfer to another facility. The Warden and Associate Warden 1 did not receive this email.¶

The Warden told the OIG that he was off duty on August 9, 2019. The Warden said that in the event Epstein was without a cellmate, the plan was to review the situation and decide who should replace Inmate 3, but that no inmate in the SHU was preselected to replace Inmate 3 if this event occurred.¶

2. Evening Watch Staff Actions on August 9¶

The Evening Watch SHU Officer in Charge told the OIG that he was the SHU Officer in Charge on August 9 from approximately 2:00 p.m. until 10:00 p.m. The Evening Watch SHU Officer in Charge said he relieved the Day Watch SHU Officer in Charge from his duties and worked in the SHU with Senior Officer Specialist 5, a Material Handler, Correctional Officer 2, and Correctional Officer Tova Noel. The Evening Watch SHU Officer in Charge stated that when he began his shift, Epstein was visiting with his attorneys in the attorney conference room. The Evening Watch SHU Officer in Charge told the OIG that he did not recall having a conversation with the Day Watch SHU Officer in Charge about Epstein needing a cellmate. When advised that the Day Watch SHU Officer in Charge was confident about their conversation, the Evening Watch SHU Officer in Charge stated, “I don’t necessarily want to call anyone a liar[] per se, but I don’t remember him speaking to me about this. So, maybe he spoke to [Senior Officer Specialist 5], and maybe I was standing there, and he thought I heard him.” The Evening Watch SHU Officer in Charge said if Inmate 3 had left MCC New York with all of his belongings, then someone should have found another inmate to replace him because Epstein was required to have a cellmate.¶

The Evening Watch SHU Officer in Charge told the OIG that he eventually learned later that evening that Epstein did not have a cellmate. According to the Evening Watch SHU Officer in Charge, after Epstein returned from his attorney visit and placed a telephone call, he escorted Epstein to his cell and saw that Inmate 3 was not there. According to the Evening Watch SHU Officer in Charge, after he realized that Epstein did not have a cellmate, he, Noel, and the Material Handler, all of whom were working in the SHU that evening, talked about Epstein needing a new cellmate. The Evening Watch SHU Officer in Charge said SHU staff could not just put anyone in the cell with Epstein. In his interview with the OIG, the Evening Watch SHU Officer in Charge stated that he called someone (he could not recall who) and notified that person that Epstein did not have a cellmate. OIG interviews did not identify an individual who received such a call or¶

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who witnessed the Evening Watch SHU Officer in Charge making it.¶

Senior Officer Specialist 5 told the OIG that on August 9, he worked in the SHU from approximately 8:45 a.m. until 4:00 p.m. Senior Officer Specialist 5 said when he reported for duty, Epstein was already with his attorneys, Inmate 3 had already left the SHU, and neither inmate returned to the SHU prior to his departure. Senior Officer Specialist 5 told the OIG that he did not know Inmate 3 had been released from MCC New York and that no one told him Epstein would need a new cellmate, including the Day Watch SHU Officer in Charge, the Captain, the SHU Lieutenant, or anyone from the Psychology Department.¶

Correctional Officer 2 told the OIG that on August 9, he worked in the SHU from 8:00 a.m. until 4:00 p.m. Correctional Officer 2 said he did not recall Inmate 3 departing the SHU that day, and that he was unaware that Epstein needed a new cellmate.¶

The Evening Watch Operations Lieutenant told the OIG that he was the Operations Lieutenant at the MCC on August 9 from approximately 2:00 p.m. until 10:00 p.m. The Evening Watch Operations Lieutenant said he was aware that Epstein was required to have a cellmate due to a mass email that was sent to all of the MCC New York Lieutenants. According to the Evening Watch Operations Lieutenant, everyone who regularly worked in the SHU should have known that Epstein was required to have a cellmate. The Evening Watch Operations Lieutenant told the OIG that he did not know Inmate 3 had left MCC New York earlier that day and was unaware that Epstein did not have a cellmate. He said that if Inmate 3 had been transported to Receiving and Discharge as “WAB” and the SHU Lieutenant was off, then another supervisor should have been notified. The Evening Watch Operations Lieutenant told the OIG that SHU personnel assigned to his shift should have notified him that Epstein was without a cellmate, but he had not been informed. The OIG’s investigation revealed, however, that the Evening Watch Operations Lieutenant was one of the recipients of the USMS email notifying MCC New York supervisory staff of Inmate 3’s scheduled transfer out of MCC New York on August 9. According to the Evening Watch Operations Lieutenant, the Acting Evening Watch Activities Lieutenant conducted the lieutenant round in the SHU on August 9, and she only would have known that Epstein was without a cellmate if someone from the SHU told her or if she walked through the SHU tiers during the round. The Evening Watch Operations Lieutenant said he believed that if the Evening Watch Acting Activities Lieutenant knew that Epstein did not have a cellmate, she would have notified him.¶

Both the Acting Evening Watch Activities Lieutenant and the Morning Watch Operations Lieutenant told the OIG that they were unaware that Epstein needed to have a cellmate. The Acting Evening Watch Activities Lieutenant, who was serving in this position on August 9 from approximately 4:00 p.m. until 10:00 p.m., told the OIG that because her ordinary position was a Senior Officer Specialist, she was not aware that Epstein was required to have a cellmate. The Acting Evening Watch Activities Lieutenant recalled hearing that Epstein had been placed on suicide watch, but said she never received specific instructions regarding Epstein. She said the SHU staff did not tell her about the requirement that Epstein have a cellmate or that his cellmate had left MCC New York. The Acting Evening Watch Activities Lieutenant did not receive the August 8 USMS email regarding Inmate 3’s transfer. The Morning Watch Operations Lieutenant, who was the Operations Lieutenant from approximately 10:00 p.m. on August 9 until 6:00 a.m. on August 10, told the OIG that she did not know that Epstein was required to have a cellmate, and that the Captain never spoke with her about this issue. The Captain confirmed that he did not specifically tell the Morning Watch Operations Lieutenant that Epstein needed a cellmate; however, the Captain said he believed that the Morning Watch Operations Lieutenant should have known of the requirement, and she was one of the recipients of the email from the Psychology Department on July 30, 2019, that informed MCC New York staff¶

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that Epstein needed to have an appropriate cellmate. The Morning Watch Operations Lieutenant also received the August 8 USMS email notifying MCC New York supervisory staff of Inmate 3’s scheduled transfer out of MCC New York. The Morning Watch Operations Lieutenant told the OIG that if SHU staff knew that Epstein required a cellmate and did not have one, they should have informed her when she visited the SHU at approximately 4:00 a.m. on August 10, as part of her lieutenant rounds.¶

The Material Handler said the SHU was not his regular post and he had not attended SHU training, but he had worked in the SHU approximately 10 to 20 times. According to the Material Handler, on August 9 he reported for a voluntary overtime shift from 12:00 a.m. to 8:00 a.m. and then worked his regular 8:00 a.m. to 4:00 p.m. shift in the warehouse. At some point during the day shift, the Day Watch Operations Lieutenant called and asked the Material Handler if he could work overtime in the SHU, and he agreed. The Material Handler said he worked the 4:00 p.m. to 12:00 a.m. shift in the SHU with the Evening Watch SHU Officer in Charge and Noel. The Material Handler told the OIG that he felt pressured to work the third shift, which resulted in him working 24 hours straight, from 12:00 a.m. on August 9 through 12:00 a.m. on August 10. After the Evening Watch SHU Officer in Charge left at 10:00 p.m., the Material Handler and Noel were the only employees working in the SHU from 10:00 p.m. to 12:00 a.m. The Material Handler recalled that Epstein came back to the SHU from meeting with his attorneys at approximately 8:00 p.m., which was later than the rest of the inmates, and was returned to his cell on L Tier. After the Material Handler and Noel gave Epstein his food, the Material Handler said they left the L Tier area. The Material Handler said Epstein was alone in his cell, but he was unaware that Epstein needed a cellmate.¶

Noel told the OIG that she worked in the SHU from approximately 4:00 p.m. on August 9 until 8:00 a.m. on August 10, which was a double shift of 16 hours. Noel said the SHU was her regular post during the time that Epstein was housed within the SHU. According to Noel, inmates housed within the MCC New York SHU were typically assigned cellmates, but she did not know if they were required to have cellmates. Noel said Epstein was assigned a cellmate while he was housed within the SHU but said that no one spoke with her about a requirement that Epstein have a cellmate. Noel said she did not know that Inmate 3 had been removed from MCC New York on August 9, and stated she was not aware that Epstein should have been assigned a new cellmate if Inmate 3 had been removed from MCC New York.¶

Material Handler Michael Thomas told the OIG that he worked a shift in the SHU on August 10 from 12:00 a.m. until 8:00 a.m. Thomas said the SHU was not his normal post, but he had worked in the SHU on numerous previous occasions and was familiar with the SHU protocols and procedures. Thomas said he knew that if an inmate came off suicide watch or psychological observation, they should be assigned a cellmate, and said he was aware that Epstein had previously been on suicide watch and psychological observation. Therefore, Thomas assumed that Epstein was required to have a cellmate, but said no one had spoken with him about that requirement. Thomas said the SHU staff should have notified the Operations Lieutenant as soon as they knew that Epstein’s cellmate had departed MCC New York on August 9. However, Thomas said he did not know that Inmate 3 was removed from MCC New York on August 9, and that Epstein was without a cellmate during his shift on August 10.¶

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

For safety and security reasons, BOP policy requires that all inmate telephone calls be made through the Inmate Telephone System. BOP records reflect that Epstein placed an unrecorded, unmonitored telephone call to a telephone number in the local 646 area code using a non-Inmate Telephone System line on August¶

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9, 2019, from 6:58 p.m. to 7:19 p.m. No other BOP records exist regarding the unmonitored call, including identity of the person called or a summary of the conversation. The OIG found no evidence that Epstein signed an Acknowledgement of Inmate form, as required by BOP policy and necessary for him to use a non-Inmate Telephone System line. The Acknowledgement of Inmate form provides, among other things, that the BOP reserves the authority to monitor and record non-attorney conversations on any telephone located within the institution to preserve the security and orderly management of the institution and to protect the public. The OIG did not find that any notification was made to the MCC New York’s Special Investigative Services (SIS) staff advising the telephone call had been made, the date and time of the telephone call, the name of the person being called, Epstein’s name and register number, or a brief statement explaining the purpose of Epstein’s telephone call, as BOP policy requires.¶

The Evening Watch Operations Lieutenant told the OIG that when he was preparing to escort Epstein back to the SHU from the attorney conference room on August 9, 2019, a Unit Manager said to the Evening Watch Operations Lieutenant that he was going to escort Epstein so he could provide Epstein with the opportunity to place a telephone call using an unrecorded legal telephone line that is utilized by inmates to call their attorneys. The Unit Manager was the Institutional Duty Officer the week of Epstein’s death. The Northeast Regional Director told the OIG that an Institutional Duty Officer is a supervisor who monitors the facility on non-duty hours on behalf of the Warden when the Warden is not present.¶

The Captain told the OIG that he had authorized the Unit Manager to provide Epstein with a telephone call from the SHU on August 9, 2019, because he wanted to accommodate Epstein’s request for a telephone call since Epstein was assigned to the SHU and had limited ability to place telephone calls. The Captain explained that when the Unit Manager was escorting Epstein from his attorney visit back to the SHU, he told the Unit Manager in the elevator that Epstein could place a telephone call from the SHU, but it had to be monitored and logged.¶

The Unit Manager told the OIG that he worked on August 9 from approximately 11:00 a.m. to 7:00 p.m. The Unit Manager explained that on August 9, Epstein asked to call his mother and that it was his understanding that Epstein had not been able to obtain the necessary documentation to use the Inmate Telephone System for various reasons, including the fact that Epstein was with his attorneys during normal working hours. As described below, Epstein had, in fact, completed the requisite BOP paperwork that allowed him to place calls through the Inmate Telephone System. The Unit Manager said the decision to allow Epstein to place the call was his alone as the Unit Manager and because, as the Institutional Duty Officer, he was representing the Warden who was not physically within MCC New York at that time. The Unit Manager said he did not recall having a conversation with the Captain about permitting Epstein to make the call, and he would have allowed the call even if the Captain did not want him to, given it was his decision to make as the Unit Manager. The Unit Manager explained that he viewed ensuring that inmates had family socialization as a part of his job, and he would allow inmates to place telephone calls if they were unable to make calls under ordinary circumstances.¶

The Unit Manager told the OIG that at approximately 6:45 p.m., he and Senior Officer Specialist 1 escorted Epstein from the attorney conference room to the SHU so that Epstein could place a telephone call. The Unit Manager said he put Epstein in the shower area to make the telephone call because correctional officers were present in that area. The Unit Manager explained that he also chose the shower area because that location ensured Epstein would not be able to pull the phone cord into his cell and use it to harm himself. The Unit Manager said he plugged the telephone line into the legal line, which was not recorded,¶

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and dialed the telephone number that Epstein provided. As noted above, the number that was dialed was in the local 646 area code. The Unit Manager said he allowed Epstein to place the telephone call on the unrecorded legal line because he believed that Epstein had not set up his Inmate Telephone System account that would have allowed him to call on the institutions recorded lines. According to the Unit Manager, a male answered, and the Unit Manager handed the receiver to Epstein. Bullock heard Epstein say, “Hey, how are you doing? How’s everything?” The Unit Manager admitted that he should have verified who was on the line, as Epstein had requested to make a telephone call to speak with his mother, and it was a male who answered the phone. The Unit Manager said he could not verify the phone number because he believed that Epstein did not have his Inmate Telephone System account set up, and he did not have any phone numbers associated with his account. The Unit Manager told the OIG that after he handed the telephone to Epstein, his shift ended so he left the SHU and left MCC New York for the day.¶

The Unit Manager said that when he left the SHU, Epstein was still on the call and the Evening Watch SHU Officer in Charge and Noel were at the officers’ desk, and that Senior Officer Specialist 1 was also present. According to the Unit Manager, when he was leaving, he told the officers, “Hey, make sure he gets his 15 minutes, and after that, he’s done.” The Unit Manager said he did not provide the SHU staff with instructions to monitor the call. He said that after he left, he contacted Noel on the SHU telephone and asked her to make sure that Epstein’s call had ended because his time was up.¶

The Unit Manager acknowledged that he did not stay and monitor the call as he should have done. The Unit Manager said the proper way to have an inmate place a telephone call on an unmonitored line would be to bring the inmate out and place him in a belly chain because then he would be handcuffed in the front. The Unit Manager said he should have provided Epstein with the phone, with a counselor or unit team member present, and placed the call on speaker so the call was monitored.¶

The OIG investigation determined that Epstein did not, in fact, speak with his mother, who, according to public records, died in 2004. The OIG found that Epstein actually spoke with Individual 1, who declined to be interviewed by the OIG. $ ^{30} $ Individual 1’s lawyer told the U.S. Attorney’s Office for the Southern District of New York during an attorney proffer that Individual 1 spoke with Epstein on August 9, 2019, at about 7:00 p.m., for approximately 20 minutes. Individual 1’s attorney proffer was that Individual 1 was in the country of Belarus at the time of the call. $ ^{31} $ Individual 1’s attorney told the U.S. Attorney’s Office that during the telephone call, Epstein told Individual 1 that the press had gotten crazy, and they discussed personal things such as books, music, and hygiene while incarcerated. According to the representations by Individual 1’s counsel, Epstein told Individual 1, “They are trying to keep me safe,” and that his case would take a little longer that he originally thought. He told Individual 1 he loved her, to be strong, and that he would not be able to call her again for another month.¶

Senior Officer Specialist 1 told the OIG that he was not a witness to Epstein’s August 9 call, but he had previously discussed telephone calls with Epstein and knew that Epstein had the requisite paperwork that allowed him to place calls through the Inmate Telephone System. Senior Officer Specialist 1 told the OIG¶

30 The OIG does not have the authority to compel or subpoena testimony from individuals who are not Department employees.¶

31 The OIG did not investigate the factual accuracy of this proffer. We note that there are methods by which a call to the 646 area code could connect to a telephone in Belarus.¶

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that Epstein was issued the necessary documentation to make telephone calls when Inmate 1 was his cellmate. Senior Officer Specialist 1 also advised the OIG about an interaction that he had with one of Epstein’s attorneys prior to August 9 when he was on an elevator with Epstein and the attorney. According to Senior Officer Specialist 1, Epstein’s attorney asked him about getting Epstein the necessary documentation to make calls. Senior Officer Specialist 1 said he then verified that Epstein was able to make calls through the Inmate Telephone System. When Senior Officer Specialist 1 asked Epstein why he had said he was unable to make calls, Epstein responded, “[T]hey said they monitor those phone calls.” Senior Officer Specialist 1 said that in a subsequent conversation with Epstein’s attorney, the attorney asked how Epstein could get an unmonitored call. Senior Officer Specialist 1 told Epstein’s attorney that decision had to be made by a lieutenant or unit Manager.¶

Noel told the OIG that after Epstein’s attorney conference on August 9, the Unit Manager plugged a telephone line in the legal line, and placed Epstein in a shower area within the SHU where he was afforded a telephone call. The OIG investigation determined that the legal line is an unrecorded telephone line outside of the Inmate Telephone System, which is designed for inmates to use when speaking with their counsel and therefore is not recorded. Noel said that after the Unit Manager set Epstein up with the call, he left the SHU and did not instruct Noel, or anyone else to Noel’s knowledge, to monitor Epstein’s call. According to Noel, the call was not monitored or logged. Noel said that approximately 15 to 20 minutes later, while Epstein was still using the telephone, the Unit Manager called the SHU staff via telephone, told Noel that Epstein’s time was up, and asked that Noel retrieve the telephone from Epstein. Noel estimated that Epstein’s call lasted for 20 minutes and said the Evening Watch SHU Officer in Charge and the Material Handler were also present in the SHU during Epstein’s phone call. Noel reported that she took the phone back from Epstein, left Epstein alone in the shower, and went to use the bathroom on 10 South. Noel said that upon her return, Epstein was already placed back in his cell.¶

The Evening Watch SHU Officer in Charge told the OIG that he was present in the SHU on August 9 during the time of Epstein’s telephone call but did not overhear Epstein’s conversation. The Evening Watch SHU Officer in Charge also said that while Epstein was having his telephone call, the officers were distracted by the actions of another inmate. The Material Handler said he did not recall seeing the Unit Manager or Epstein in the shower area on the night of August 9, and did not have any knowledge or information regarding a phone call made by Epstein that night.¶

The Northeast Regional Director told the OIG that if Epstein’s call was authorized by an MCC New York official, then it should have been done on a speaker phone while being monitored by a staff member, and the call should have been logged and a record of the call should have been created. The Northeast Regional Director said Epstein’s unmonitored telephone call was extremely concerning because “[w]e don’t know what happened on that phone call. It could have potentially led to the incident [Epstein’s death], but we don’t, we will never know.”¶

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

A. SHU Inmate Counts¶

As detailed in the BOP policies section of Chapter 2, the BOP requires correctional officers assigned to guard inmates to conduct institution-wide counts of inmates at regularly scheduled intervals each day to ensure that all inmates are present and accounted for at the appropriate location within the facility. Performing an¶

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institutional count is one of the basic and essential aspects of a correctional officer’s job, and the count was one of the basic and essential components of the daily operation of MCC New York. The Captain told the OIG that counts are a core responsibility of correctional officers and ensure accountability of the inmates. The Evening Watch Operations Lieutenant said that it is very important that the institutional count is accurate because that is how staff members know if all inmates are present and if anyone has escaped.¶

On weekdays, MCC New York conducted institutional counts at 12:00 a.m., 3:00 a.m., 5:00 a.m., 4:00 p.m., and 10:00 p.m. The 10:00 p.m. count was a stand-up count, which meant that inmates were required to stand when they were counted. Pursuant to BOP policy and MCC New York SHU Post Orders, two correctional officers were required to perform the institutional count for each housing unit, including the SHU. To perform the institutional count in the SHU, BOP policy and MCC New York SHU Post Orders required two officers to walk from tier to tier to observe and count each individual inmate. During each count, one correctional officer would count the inmates while the other officer observed the inmates. The two officers would then switch roles and compare the count numbers. If the totals did not match, then the officers had to conduct another count in the same manner. Correctional officers had to document their performance of inmate counts on an official MCC New York form often referred to as a count slip. $ ^{32} $¶

On the count slip, correctional officers were required to fill in the date and time the count had been performed, write the total number of inmates physically present in the unit counted, and then both correctional officers printed their name and signed the count slip. Once the correctional officers had completed and signed the count slip, the count slips were then collected and delivered to the Control Center. Officers assigned to the Control Center were responsible for comparing the count slips from each housing unit to the institution’s inmate roster to ensure that each inmate was accounted for. Only after all the count slips had been collected from each housing unit, and the numbers on the slips had been matched to the institution’s inmate roster, could the institutional count be deemed “cleared” or completed. If a housing unit’s count slip was incomplete or did not match the number of inmates that were supposed to be in the unit, then the count had to be redone in that housing unit via a more intensive version of the institutional count, called a bed-book count, which is when inmates are counted using their picture cards. Records of each institutional count, including the count slips, were provided to a supervising official and retained by MCC New York.¶

The OIG’s investigation found that none of the required SHU inmate counts were conducted from 4:00 p.m. on August 9, 2019, until Epstein was discovered hanged in his cell at approximately 6:30 a.m. on August 10, 2019. Further, the OIG determined that SHU staff did not conduct any 30-minute rounds after approximately 10:40 p.m. on August 9, and that the count slips and round sheets had been falsified. As a result, many SHU staff and supervisors were unaware that Epstein did not have a cellmate as the Psychology Department had determined was necessary, and Epstein was alone and unobserved in his cell for an extended period of time.¶

1. The 4:00 p.m. SHU Count on August 9¶

The OIG’s investigation determined that the 4:00 p.m. SHU inmate count on August 9, 2019, was inaccurate because SHU staff did not physically count the inmates as required by BOP policy and instead relied upon a predetermined number of inmates believed to be in the SHU at that time. However, Epstein, who was in the¶

32 This BOP forms is officially entitled “Metropolitan Correctional Center; New York, New York; Official Count Slip.”¶

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SHU attorney visitation room, was correctly accounted for during the 4:00 p.m. and subsequent SHU counts. The OIG determined that the error in the 4:00 p.m. SHU count was carried over into the next inmate count at 10:00 p.m. that counted an inmate who had been transferred out of the SHU. The SHU inmate count was not corrected until 12:00 a.m. when the Morning Watch Operations Lieutenant reviewed the master institutional count and housing unit count slips and informed SHU staff of the correct number of inmates in the SHU at that time.¶

Senior Officer Specialist 5 told the OIG that prior to his departure from the SHU at approximately 4:00 p.m., he told the Evening Watch SHU Officer in Charge what the SHU count should be. In addition, the Day Watch SHU Officer in Charge told the OIG that SHU staff maintain a “cheat sheet,” which lists the number of inmates believed to be in the SHU at any given time.¶

When interviewed by the OIG, the Day Watch SHU Officer in Charge reviewed the 4:00 p.m. SHU count slip from August 9, 2019, which was signed by the Evening Watch SHU Officer in Charge and Correctional Officer Noel. Based on his review, the Day Watch SHU Officer in Charge told the OIG that the Evening Watch SHU Officer in Charge and Noel probably did not count the inmates in the SHU. He said they likely wrote down the numbers they thought should have been entered for the count because the count slip inaccurately included an inmate (Inmate 4) among the number of inmates in the SHU after that inmate had been transferred to another housing unit. According to what he told the OIG and wrote in an email on August 9, earlier that afternoon the Day Watch SHU Officer in Charge observed Inmate 4 attempt to retrieve an unknown item from his visitor in the MCC New York SHU visiting room. The Lieutenant’s Log from August 9, 2019, reflected that following this incident, Inmate 4 was removed from the SHU at 3:15 p.m. and transferred to the Receiving and Discharge dry cell, which is a secure location where inmates are taken for observation when they are believed to have ingested or secreted contraband on their person. According to the Day Watch SHU Officer in Charge, the inaccurate 4:00 p.m. count slip told him “that the count was not done and they just assumed and went by the cheat sheet because the body wasn’t even there,” referring to Inmate 4, who was transferred from the SHU to Receiving and Discharge. The Day Watch SHU Officer in Charge told the OIG that if the 4:00 p.m. SHU count had been accurately conducted, then the Evening Watch SHU Officer in Charge and the SHU staff should have realized that Inmate 4 was no longer in the SHU.¶

In his interview with the OIG, the Evening Watch SHU Officer in Charge acknowledged that neither he nor any other SHU staff member conducted the 4:00 p.m. SHU count on August 9. The Evening Watch SHU Officer in Charge verified that it was his handwriting and signature on the 4:00 p.m. SHU count slip and said he had prepared the count slip ahead of time because “[t]here was so much going on” in the SHU that day. The Evening Watch SHU Officer in Charge confirmed that Noel’s name and signature also appeared on the 4:00 p.m. count slip. $ ^{33} $ During his OIG interview, the Evening Watch SHU Officer in Charge reviewed BOP documents regarding the inmate’s transfer from the SHU and acknowledged further that based on that transfer, the number of inmates listed on the SHU count slip he and Noel submitted for the 4:00 p.m. count, the count slip was incorrect.¶

Noel admitted in the deferred prosecution agreement she entered into with the U.S. Attorney’s Office for the Southern District of New York that she completed false count slips on August 9 and 10. Noel initially told the OIG that she did not conduct the 4:00 p.m. count on August 9, but after acknowledging that she signed¶

33 Prosecution was declined for BOP employees (other than Noel and Thomas) who falsely certified inmate counts and rounds on the day before and the day of Epstein’s death.¶

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the 4:00 pm SHU count slip, Noel said she did not recall if she conducted the count. According to Noel, she and other SHU staff filled out the count slip before conducting the counts because they knew the number of inmates they were supposed to report.¶

2. The 10:00 p.m. SHU Count on August 9¶

At the time of the 10:00 p.m. count, all inmates in the MCC New York SHU, including Epstein, were locked in their cells for the night. At or around that time, the two officers assigned to the SHU were responsible for conducting the 10:00 p.m. stand up count. At 10:00 p.m. on August 9, the two assigned SHU officers were Noel and the Material Handler. Through review and analysis of the SHU security camera video, witness statements, and BOP records, the OIG determined that MCC New York staff did not perform the 10:00 p.m. count in the SHU. $ ^{34} $ Nonetheless, Noel and the Material Handler completed and signed the 10:00 p.m. SHU count slip. The 10:00 p.m. SHU count slip listed the total number of inmates as “73+1.” According to the MCC New York master count sheet for the 10:00 p.m. count on August 9, 2019, all units had verbally reported their inmate counts to the Control Center by 10:30 p.m. $ ^{35} $ At approximately 10:36 p.m., the Control Center completed all paperwork and officially cleared the 10:00 p.m. institutional count.¶

The Material Handler said he was present at the time of the 10:00 p.m. count, but that the count was not conducted because everyone was tired. The Material Handler noted that on August 9, he had worked an overtime shift from 12:00 a.m. until 8:00 a.m., his regular shift from 8:00 a.m. to 4:00 p.m., followed by his SHU overtime shift from 4:00 p.m. to midnight. Thus, at the time of the 10:00 p.m. count, he had worked 22 consecutive hours at MCC New York. The Material Handler verified that he and Noel signed the 10:00 p.m. count slip, and believed that Noel called the Control Center with their count numbers. He did not know why the count slip listed “73+1”.¶

Noel told the OIG that she had conducted the SHU count alone at 10:00 p.m. and that the Material Handler signed the count slip even though he did not conduct the count with her. However, the OIG’s review and analysis of the SHU security camera video conflicts with Noel’s statement that she conducted the 10:00 p.m. count. Specifically, the video reflects that it was not until between 10:29 p.m. and 10:36 p.m. when Noel walked to different tiers inside the SHU. Yet, as described above, MCC New York records reflect that counts from all MCC New York housing units were reported to the Control Center by 10:30 p.m., as the count documentation shows the count was verbally cleared by the Control Center at 10:30 p.m. It therefore appears that the video depicts Noel conducting a later round in the SHU, as she was required to do every 30 minutes during her shift, and not the 10:00 p.m. SHU count.¶

Noel said she wrote the 73 on the count slip but she did not remember if she or someone else had written “+1” on the count slip and she did not know why “+1” was on the count slip. Noel claimed that, unlike the 4:00 p.m. count slip, which the Evening Watch Officer in Charge pre-filled, she did not prepare the 10:00 p.m. count slip in advance of the count. Noel said she did not know that the 10:00 p.m. SHU count slip, which listed 73 inmates, was inaccurate, and she could not explain why the 12:00 a.m. count also inaccurately listed that 73 inmates were physically present in the SHU, whereas the 3:00 a.m. and 5:00 a.m.¶

34 The quality of the SHU video footage was poor. Therefore, in conjunction with reviewing the video, the OIG analyzed witness statements and BOP records to better determine what the video depicted.¶

35 The official name for the document used to record an institutional count is “Bureau of Prisons Count Sheet.”¶

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counts slips accurately listed 72 inmates in the SHU.¶

Senior Officer Specialist 6 told the OIG that on August 9, 2019, he worked in the Control Center from approximately 4:00 p.m. until 12:00 a.m., and then he worked as an Internal Officer from 12:00 a.m. until 8:00 a.m. on August 10. According to Senior Officer Specialist 6, he took the August 9 10:00 p.m. institutional count by himself in the Control Center, and assisted with the 12:00 a.m., 3:00 a.m., and 5:00 a.m. counts on August 10 as an internal officer. Senior Officer Specialist 6 confirmed to the OIG, as MCC New York records reflect, that he had received verbal counts from all units by 10:30 p.m., and further stated that he had cleared the institutional count at 10:36 p.m., which was when paperwork was complete and the count was officially complete.¶

Senior Officer Specialist 6 reviewed the MCC New York 10:00 p.m. institutional count, which showed that the SHU had 73 inmates assigned, whereas the Receiving and Discharge Department had zero inmates assigned to the unit. When questioned by the OIG about the 10:00 p.m. SHU count slip that listed “73 + 1” inmates and was signed by the Material Handler and Noel, Senior Officer Specialist 6 told the OIG that he believed that the “+ 1” on the count slip was in his handwriting. Senior Officer Specialist 6 also reviewed the 10:00 p.m. Receiving and Discharge count slip, which listed “9S + 1” on the count slip, and told the OIG that it was his handwriting. $ ^{36} $ Senior Officer Specialist 6 explained that the “9S + 1” on the SHU count slip meant that he was “ghost counting” the inmate (Inmate 4) who had been moved from the SHU, located in the 9 South area, to the Receiving and Discharge area earlier that day. Senior Officer Specialist 6 said that because there were, in actuality, only 72 inmates in the SHU during the 10:00 p.m. count, he should have written “73 - 1” on the SHU count slip rather than “73 + 1”.¶

Figure 5.1: 10:00 p.m. Count Slips from the SHU and Receiving and Delivery on August 9¶

Senior Officer Specialist 6 did not recall if he wrote on the count slips at the time of the 10:00 p.m. count or during the 12:00 a.m. count when Inmate 4 was transferred in SENTRY from the SHU to Receiving and Discharge. Senior Officer Specialist 6 told the OIG that if he had made the notations at the time of the 10:00 p.m. count, he should not have cleared the count. Instead, he should have created a new master count sheet and requested that the SHU staff conduct a new count, provide a new count slip, and discard the inaccurate SHU count slip. Senior Officer Specialist 6 told the OIG that an Operations Lieutenant would have¶

36 According to BOP records and witness interviews, “9S” refers to the SHU, which was located in 9th Floor South section of MCC New York.¶

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needed to authorize him to do the “ghost count” and write on the count slips, although he could not recall precisely who gave him the authorization or when he had done so. The OIG investigation and review determined that the only Operations Lieutenant on duty at the time was the Morning Watch Operations Lieutenant, who started her shift at 10:00 p.m. on August 9. When questioned by the OIG, the Morning Watch Operations Lieutenant adamantly denied having authorized a “ghost count” and the OIG identified no record or witness (other than Senior Officer Specialist 6) to indicate that she had done so. The OIG interviewed other MCC New York personnel, who said “ghost counting” was not permitted, and stressed the importance of an accurate physical count of inmates.¶

3. The 12:00 a.m., 3:00 a.m., and 5:00 a.m. SHU Counts on August 10¶

The Morning Watch Operations Lieutenant told the OIG that she supervised the August 10 12:00 a.m. institutional count from the Control Center. During the count, the Morning Watch Operations Lieutenant said she identified the issue with the inaccuracy of the SHU count slip because it counted Inmate 4 as present in the SHU, when in actuality he had been removed from the SHU and placed in the Receiving and Discharge dry cell the previous day (August 9, 2019). The Morning Watch Operations Lieutenant said that after learning of the discrepancy, she made the appropriate update reflecting the inmate transfer in SENTRY. This update is reflected in Inmate 4’s Inmate History Quarters, which states that Inmate 4 was transferred out of the SHU into a different housing unit on August 10, 2019, at 12:35 a.m. The Morning Watch Operations Lieutenant told the OIG that she believed she told the SHU staff to conduct a new count and create a new count slip, but she did not know if they had actually done so.¶

During his interview with the OIG, Senior Officer Specialist 6 reviewed BOP records relating to the inmate transfer, the 12:00 a.m. institutional count, and the housing unit count slips. Based on his review of this material, Senior Officer Specialist 6 said the 12:00 a.m. SHU count slip was inaccurate because it continued to list 73 inmates instead of the 72 inmates who were physically present in the SHU at that time. Senior Officer Specialist 6 reviewed the institutional counts and SHU count slips for the 3:00 a.m. and 5:00 a.m. counts and told the OIG that they were accurate because they listed the SHU as having 72 inmates.¶

At approximately 12:00 a.m. on August 10, 2019, Material Handler Thomas replaced the other Material Handler, and he and Noel were the only two staff members on duty in the SHU. Noel and Thomas were responsible for conducting the 12:00 a.m., 3:00 a.m., and 5:00 a.m. counts in the SHU. Through review and analysis of the SHU security camera video, witness statements, and BOP records, the OIG determined that Noel and Thomas did not perform any of these counts. Nonetheless, Noel and Thomas completed and signed SHU count slips for each of the three counts, and in reliance on the count slips, the Control Center cleared the 12:00 a.m., 3:00 a.m., and 5:00 a.m. institutional counts at approximately 12:49 a.m., 3:24 a.m., and 5:30 a.m., respectively. Noel and Thomas both admitted to the OIG that they did not conduct the 12:00 a.m., 3:00 a.m., and 5:00 a.m. counts on August 10, and that they had falsified the respective count slips.¶

Noel told the OIG that she signed the August 10 12:00 a.m., 3:00 a.m., and 5:00 a.m. count slips that Thomas had prefilled. Noel said she did not know why the 12:00 a.m. count slip documented that there were 73 inmates in the SHU, whereas the 3:00 a.m. and 5:00 a.m. slips documented there were only 72 inmates. Noel recalled that Thomas had spoken with someone and then they changed the count slips.¶

Noel told the OIG that she and Correctional Officer 3 conducted the 3:00 a.m. and 5:00 a.m. counts in MCC New York’s 10 South Unit, which is the single-celled secure unit adjacent to the SHU. Noel said that when¶

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she left the SHU to assist Correctional Officer 3, she took the SHU keys with her and that no one could have accessed the SHU while she was gone because she had to physically open the door for anyone who came into the SHU. Noel also told the OIG that when the Morning Watch Operations Lieutenant arrived to conduct a round at approximately 4:00 a.m., Noel let her into the SHU. The OIG’s review and analysis of the SHU video shows that the Morning Watch Operations Lieutenant arrived in the SHU at approximately 4:00 a.m., visited the 10 South Unit at 4:04 a.m., returned to SHU at 4:11 a.m., and left the SHU at 4:14 a.m. According to Noel, no one other than the Morning Watch Operations Lieutenant and Correctional Officer 3, as detailed later below, entered the SHU during her shift.¶

Thomas told the OIG that since he had begun working with the BOP in 2007, he had worked in the SHU fairly regularly and he was familiar with how to work in the SHU and how the SHU operated. Thomas described his responsibilities while working in the SHU as to maintain the count of inmates, make sure the inmates are fed, and, depending on the shift, make sure they get their showers. Thomas’s Overtime Schedule showed that he worked 21 shifts in the SHU during morning watch from May through August 2019. The overtime schedule also showed that Thomas worked 12 overtime shifts in the SHU when Epstein was assigned to the SHU in July and August 2019.¶

Thomas acknowledged that neither he nor Noel conducted any rounds or counts in the SHU during their shift between approximately 12:00 a.m. and approximately 6:30 a.m. Thomas said the August 10, 2019 round sheets were signed, but the rounds were not conducted because he was tired that day. Thomas recalled “dozing off from here and there” during his shift, but he did not know if Noel slept.¶

Thomas did not recall having a conversation with anyone concerning the discrepancy between the 12:00 a.m. SHU count slip, which listed 73 inmates, and the institutional count, which listed 72 inmates in the SHU. Thomas said he had filled out and signed the 3:00 a.m. SHU count slip, which listed 72 inmates in the SHU. Thomas did not know why the number of inmates was different on the 12:00 a.m. and 3:00 a.m. count slips and did not recall speaking with the Morning Watch Operations Lieutenant about the 12:00 a.m. count. Thomas told the OIG that he knew he was falsely certifying the count slips when he signed them on August 10, 2019.¶

B. Staff Rounds in the SHU¶

1. Correctional Officer Rounds¶

As detailed in the BOP Policies section of Chapter 2, in addition to inmate counts, BOP policy and MCC New York SHU Post Orders required that correctional officers assigned to the SHU conduct rounds to observe all inmates at least twice an hour. As part of their assigned duties, MCC New York SHU officers had to walk each of the tiers of the SHU twice an hour on an irregular schedule, once during the first 30 minutes and again during the second 30 minutes, with both rounds occurring no more than 40 minutes apart. Correctional officers working in the SHU were required to complete and initial an official MCC New York form, often referred to as a “round sheet,” which was reviewed and signed by a supervisor, documenting the date and time of each 30-minute round in each tier of the SHU. $ ^{37} $¶

The Day Watch SHU Officer in Charge told the OIG that SHU staff spoke about conducting rounds on Epstein¶

37 This BOP form is officially entitled “MCC New York, Special Housing Unit, 30 Minute Check Sheet.”¶

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every day. He said that the Warden, lieutenants, and other MCC New York staff members frequently told the SHU staff to conduct rounds and to keep an eye on Epstein. To reinforce this message, the Day Watch SHU Officer in Charge created a sign on orange paper that he hung on a computer in the SHU officer’s area that said, “MANADATORY [sic] ROUNDS MUST BE CONDUCTED EVERY 30 MINUTES ON EPSTEIN # 76318-054 AS PER GOD!!!!” The Day Watch SHU Officer in Charge said the sign was hanging on the computer on August 9 and 10, 2019, and it was clearly visible to everyone who worked in the SHU. The Acting Evening Watch Activities Lieutenant confirmed that written instructions to conduct rounds on Epstein were posted on the SHU computer.¶

Figure 5.2: Sign Created by the Day Watch SHU Officer in Charge¶

MANADATORY ROUNDS MUST BE CONDUCTED EVERY 30 MINUTES ON EPSTEIN #76318-054 AS PER GOD!!!¶

The Evening Watch SHU Officer in Charge told the OIG that Noel filled out the round sheet on behalf of everyone who was working in the SHU during his shift. The Evening Watch SHU Officer in Charge was not certain if all of the rounds were actually conducted. The Material Handler said he believed the rounds listed on the round sheet as having occurred between 4:01 p.m. to 7:36 p.m. probably had been done, but he was uncertain about the remaining rounds. The Material Handler said he had seen officers “blow off” 30-minute rounds in the past. Noel told the OIG that, as a general practice, when the correctional officers went to the various SHU tiers to distribute¶

food or supplies, they counted that as a round. Noel said she was aware that she was supposed to conduct two rounds every hour during their shift, but that she had never actually completed rounds every 30 minutes while working in the SHU. When asked which rounds she conducted on August 9, 2019, Noel responded, “That’s hard for me to tell because I didn’t conduct it every 30 minutes. It was give out food, pick up the trays, give out toilet paper, go down. So those were the rounds I conducted.” Noel verified that her initials were on the round sheets for August 9 and 10, 2019, and said, consistent with her usual practice, she filled out the round sheets and initialed the round sheets at the start of the 4:00 p.m. and the 12:00 a.m. shifts.¶

Noel and Thomas both admitted to the OIG that they did not conduct any of the rounds reflected on the SHU Round Sheet on August 10, 2019, from 12:00 a.m. until Epstein was found hanged in his cell at approximately 6:30 a.m. Nonetheless, Noel completed and signed more than 75 separate 30-minute entries stating that she and Thomas had, in fact, conducted such rounds. $ ^{38} $ Through review and analysis of the SHU video footage, witness statements, and BOP records, the OIG determined that Noel and Thomas did not enter the tiers in the SHU to conduct any of the rounds and counts between 12:00 a.m. and approximately 6:30 a.m. on August 10. Noel and Thomas can be seen at the SHU Officers’ Station, moving in the SHU common area, and the SHU laundry and entrance/exit area throughout the morning of August 10. Additionally, from approximately 1:00 a.m. to 3:00 a.m., Noel and Thomas were seated at the SHU Officers’ Station without moving and appeared to be sleeping. OIG analysis of the activity on the SHU computers revealed that Noel used the computer periodically throughout the night, including to search the internet for furniture sales and benefit websites and to read a news article about Epstein. Thomas used the computer¶

38 Each of the 6 tiers in the SHU had a separate round sheet, each of which had 13 entries reflecting 30-minute rounds were conducted, when they were not, in fact, completed.¶

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briefly around 1:00 a.m. and 6:00 a.m. to search for motorcycle sales and sports news.¶

Noel told the OIG that she went through each tier in the SHU at approximately 10:00 p.m., and at the time she went to Epstein’s cell and saw him laying on a mattress on the floor, which she said was typical for him. Epstein asked Noel for his medical device, so she plugged it in for him. Noel saw that Epstein was in the cell by himself and without a cellmate, but she maintained that she did not know that Epstein was required to have a cellmate. Noel told the OIG that Epstein’s cell was approximately 15 feet away from the SHU Officers’ Station. Noel said that during her shift on August 10, 2019, no one went to Epstein’s cell and no one other than the Morning Watch Operations Lieutenant and Correctional Officer 3 came into the SHU.¶

Through review and analysis of the SHU video footage, witness statements, and BOP records, the OIG determined that at approximately 10:40 p.m. a correctional officer, believed to be Noel, carried linen or inmate clothing up to the L Tier, which was the last time any correctional officer approached the only entrance to the SHU tier in which Epstein was housed.¶

2. Lieutenant Rounds¶

BOP policy requires that a lieutenant visit the SHU during each shift to ensure that all procedures are being followed. BOP training for new lieutenants instructs that the Operations Lieutenant must visit the SHU at least once per shift and “[t]his visit will be substantially more than just entering the unit, signing the log book, and talking with staff.” Additionally, when the SHU Lieutenant is unavailable, the Operations Lieutenant should make rounds in the SHU on each shift. The training instructs that while in the SHU the Operations Lieutenant must walk each range (tier), inspect logs and records, observe activities, and periodically observe SHU inmate counts. The training further outlines that the SHU Lieutenant is responsible for the direct supervision of the unit, including enforcement of rules, review of paperwork, coordination of activities, movement of inmates, and cell searches. The SHU Lieutenant should make rounds on the ranges (tiers) each day.¶

The statements of multiple witnesses were consistent with BOP training materials. The Northeast Regional Director, the Warden, Associate Warden 1, the Captain, and the Day Watch SHU Officer in Charge all told the OIG that lieutenants should have walked down all of the SHU tiers when conducting a lieutenant round in the SHU. Noel said the SHU Lieutenant walked the tiers all the time, however, other lieutenants did not always walk down the tiers. Multiple witnesses also told the OIG that it was standard practice for the BOP to store the SHU round sheets at the end of each tier in the SHU. This practice was designed to ensure that the assigned correctional officers and lieutenants walked down each tier when conducting rounds to observe every cell and inmate during the round before initialing the round sheet. On August 9 and 10, 2019, however, the MCC New York SHU round sheets were kept at the SHU Officers’ Station in the common area of the SHU rather than at the end of each tier.¶

None of the lieutenant rounds conducted on August 9 and 10 alerted the supervisory staff to the fact that Epstein lacked a cellmate. According to MCC New York records, the Day Watch Activities Lieutenant conducted a round in the SHU at 11:27 a.m. on August 9. The Day Watch Activities Lieutenant said he did not specifically recall if he conducted a round in the SHU, but he believed that he did conduct the round. As discussed in greater detail above, the Day Watch Activities Lieutenant told the OIG that he did not know that Epstein’s cellmate had been removed from MCC New York or that Epstein was without a cellmate during his shift on August 9. The Acting Evening Watch Activities Lieutenant told the OIG that she conducted a¶

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lieutenant round in the SHU on August 9 sometime between 5:00 p.m. and 8:00 p.m. The Acting Evening Watch Activities Lieutenant told the OIG that she did not know that that Epstein’s cellmate had departed from MCC New York or that Epstein required a cellmate because she was only the Acting Activities Lieutenant and had not attended SHU or department head meetings. The Evening Watch Operations Lieutenant reviewed the August 9 round sheets and said that although his signature is on one of the forms as if he conducted a round in the SHU, it was actually the Acting Evening Watch Activities Lieutenant who had conducted the round. The Evening Watch Operations Lieutenant said he did not know why his signature was on the form because he did not conduct any rounds within the SHU on August 9 and he did not recall signing the form. The Morning Watch Operations Lieutenant confirmed that she conducted her round in the SHU at approximately 4:00 a.m. on August 10. The Morning Watch Operations Lieutenant said she went up to the 10 South Unit and then back down to the SHU because she needed to sign the round sheets. Contrary to BOP training for new lieutenants, which she attended in 2011, the Morning Watch Operations Lieutenant told the OIG, “We are not required to go to each individual cell and look at the inmates. When we make rounds, we get with the officers.” The Morning Watch Operations Lieutenant said she did not conduct a round to observe the inmates when she visited the SHU. Noel confirmed that the Morning Watch Operations Lieutenant visited the SHU but did not walk down the tiers.¶

Through review and analysis of the SHU security camera video, witness statements, and BOP records, the OIG determined that at approximately 4:00 a.m. on August 10, 2019, the Morning Watch Operations Lieutenant briefly visited the SHU as part of her supervisory duties and conferred with Noel and Thomas, who were seated at and around the SHU Officers’ Station in the common area of the SHU. Noel told the OIG that at approximately 5:30 a.m., Thomas went to the 10 South Unit, which was adjacent to the SHU, to relieve Correctional Officer 3, and that Correctional Officer 3 briefly walked through the SHU common area as he left and returned from his break. The OIG’s review and analysis of the video footage revealed that, aside from those two officers, no one entered the SHU and no one conducted any counts or rounds.¶

VI. Epstein’s Death on August 10¶

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

On August 10, 2019, shortly after 6:00 a.m., the doorbell to the SHU rang, indicating that a delivery of breakfast carts had arrived at the SHU. Noel and Thomas retrieved the breakfast carts from the double-locked entrance to the SHU and brought them inside the SHU. At the time, Thomas and Noel were the only officers in the SHU. At approximately 6:30 a.m., MCC New York security camera video recordings show Noel and Thomas walking toward the L Tier. Noel and Thomas told the OIG that at this time they were entering the L Tier, in which Epstein was housed, to deliver breakfast to the inmates. As discussed previously, between approximately 10:40 p.m. on August 9 and approximately 6:30 a.m. on August 10, the OIG did not observe on the available recorded video any correctional officers or other individuals approach the L Tier where Epstein was housed from the common area of the SHU.¶

Noel told the OIG that she unlocked the door to the L Tier so Thomas could deliver the breakfast trays. Thomas told the OIG that he knocked on Epstein’s cell door, saw a portion of Epstein through the window but could not make out what he saw, so he said to Epstein, “Come to the door, come to the door.” Thomas said he did not observe any movement or hear a response, so he unlocked the cell door, entered the cell, and saw Epstein hanged as described further below. Thomas said he immediately yelled for Noel to get help, and that Noel activated a body alarm, signaling a medical emergency, and began taking the steps described below.¶

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Figure 5.3: Photograph of a Piece of Orange Cloth Hanging from the Bunkbed in Epstein’s Cell Following His Death¶

Thomas explained that when he first entered Epstein’s cell, Epstein had an orange string, presumably from a sheet or a shirt, around his neck. The end of the string 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 and his legs extended out straight on the floor. Thomas said Epstein did not look discolored or very different from when he last saw Epstein alive. Thomas said he immediately ripped the orange sheet or shirt away from the bunkbed, and Epstein’s buttocks dropped approximately 1 inch to 1 inch and a half to the ground. Thomas then lowered Epstein’s entire body to the floor and, because he did not believe Epstein was breathing, Thomas immediately began providing chest compressions until responding MCC New York staff members arrived approximately 1 minute later. Thomas said he did not provide rescue breaths and was unaware if Epstein was dead or alive because he never checked for a pulse before initiating chest compressions. Thomas said medical personnel took over the emergency response, including chest compressions¶

and use of an automated external defibrillator (AED), when they arrived. Thomas said he assisted with bringing Epstein down to the Health Services Unit on the second floor, and that he left MCC New York at approximately 8:00 a.m. Thomas said he had received cardiopulmonary resuscitation (CPR) training during MCC New York annual refresher training and had responded to medical emergencies in the past, but this was the first time he was the first responder.¶

Thomas said he was present in the SHU for his entire shift on August 10, 2019, from 12:00 a.m. until the time he attempted to deliver breakfast to Epstein at approximately 6:30 a.m., and did not see anyone go inside Epstein’s cell during his shift. Thomas said that he would have known if someone went in or out of Epstein’s cell, and said no one did. Thomas told the OIG that he could see Epstein’s cell door from the SHU Officers’ Station, but he could not see inside the cell from that vantage point. Thomas said that it was not possible for anyone to have entered the SHU without his knowledge because he or Noel would have had to open the SHU door for anyone to gain entry. The only other key to the SHU was located in the Control Center; no other MCC New York staff members had the keys required to gain access to the SHU. Moreover, Thomas said that anyone attempting to access the L Tier where Epstein was located would have had to walk directly in front of the SHU Officers’ Station where Thomas was seated, and no one did. Thomas denied that he or Noel had any role in Epstein’s death.¶

Noel told the OIG that on the morning on August 10, when it was time to deliver food to the inmates, she unlocked the door to the L Tier and stood by it while Thomas took the food to the inmates. Noel said that when Thomas knocked on Epstein’s door, there was no response. Noel said Epstein’s cell door was locked, so Thomas used a key to open it and went inside. Noel heard Thomas call out for her to retrieve the cutter and then she heard Thomas rip something. Noel said she observed Thomas lifting Epstein from under his¶

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arms and dragging him back out of the corner of the cell and laid him down on the ground to perform CPR. According to Noel, within seconds of Thomas calling out for the cutter she hit the body alarm, which is a button on an MCC staff member’s radio that is used to signal distress or an emergency. Noel recalled hearing Thomas say, “Breathe, Epstein, breathe,” and“We’re going to be in so much trouble.” Noel said she stood at the door about a foot away from Epstein’s cell and never went in. Noel said Thomas only performed chest compressions and said she did not see Thomas checking for breath or pulse. Noel said that when she saw Epstein, he looked blue and did not have a shirt on or anything around his neck. Noel said she did not get the cutter because Thomas did not need it based upon the ripping sound she heard.¶

Noel said an MCC New York Lieutenant who responded to the alarm asked her what happened, and before she got the chance to answer, Thomas stated, “Oh, it’s not her fault, we fucked up.” Noel did not recall making any comments or statements to the Lieutenant. Other than the Lieutenant, Noel did not recall which correctional officers responded to the alarm and she did not know what happened in the cell after MCC New York staff arrived because she was waiting at the bottom of the steps outside the L Tier. Noel said she was alone in the SHU for 20 minutes after they left with Epstein and she kept calling the Control Center to get status updates.¶

Noel told the OIG that Epstein’s cell was approximately 15 feet from the SHU Officers’ Station. Noel said she would have known if someone went in or out of Epstein’s cell overnight and no one did. She also said that there was no indication that any of the inmates could have gotten out of their cells. Noel said she never slept during her shift on August 9-10, 2019. Noel said that when she is seen on the camera at the desk not moving, she was on the computer. Noel then clarified by saying that she worked 5 days of overtime leading up to her shift, so she would begin to doze off; however, she caught herself and never slept.¶

The Lieutenant told the OIG that he was the Operations Lieutenant who relieved the Morning Watch Operations Lieutenant on August 10, 2019, at approximately 5:30 a.m. The Lieutenant said that at approximately 6:33 a.m., he heard a call for a medical emergency in the SHU and immediately responded to the alarm. When he arrived, Noel told him, “Epstein hung himself.” Once inside, the Lieutenant observed that Thomas was performing CPR on Epstein. The Lieutenant stated that he asked, “Where’s his bunkie at?” and that Noel responded, in substance, that Epstein did not have a cellmate. Noel also told the Lieutenant, “We didn’t do rounds at 3:00 a.m. and 5:00 a.m.” Thomas stated, “We didn’t do the rounds. We messed up.” The Lieutenant took over administering CPR and asked SHU staff to retrieve an automated external defibrillator (AED) and call for the duty nurse.¶

The MCC New York Electronics Technician told the OIG that he responded to the emergency call at 6:33 a.m. When the Electronics Technician first arrived in the SHU, Thomas and other MCC New York staff members were picking Epstein up and placing him on a stretcher. The Electronics Technician said he and Senior Officer Specialist 6 performed chest compressions on Epstein while he was on the stretcher and being transported to the Health Services Unit on the second floor. $ ^{39} $ The Electronics Technician stated that he then returned to the SHU and worked there for approximately 1 hour, along with the Morning Watch¶

39 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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Operations Lieutenant and Noel. The Electronics Technician believed he was in the SHU prior to 7:00 a.m. and until approximately 8:00 a.m., but was not positive with regard to the times. The Electronics Technician said he delivered food to the inmates on one tier while the Morning Watch Operations Lieutenant did the same on another tier while Noel unlocked the doors outside of the tiers for the Electronics Technician and the Morning Watch Operations Lieutenant. The Electronics Technician said that when they were delivering food to the inmates, he heard the inmates saying, “You killed him. You weren’t making rounds. You killed him.” The Electronics Technician told the OIG that the inmates also said Thomas and Noel just sat at the SHU Officers’ Station and never checked on the inmates. The Electronics Technician told the OIG he understood the inmates to be saying that Thomas and Noel were responsible for Epstein’s death because they had not conducted rounds during their shift. The Electronics Technician said he believed that Epstein took his own life and said he had no reason to believe otherwise.¶

Senior Officer Specialist 6 said he responded to the emergency call at 6:33 a.m. and when he arrived, staff members were already performing CPR on Epstein. Senior Officer Specialist 6 said he assisted with transporting Epstein to the Health Services Unit, taking Epstein to the ambulance, and then followed the ambulance to the hospital in another vehicle, and stayed at the hospital until he was relieved from duty.¶

The OIG also reviewed photographs that were taken in the MCC New York Health Services Unit of EMTs attempting to resuscitate Epstein. The photographs show, among other things, Epstein on his back with an intravenous line in his arm, his orange BOP-issued shirt ripped open and laying around his arms, and him wearing orange BOP-issued boxer shorts. None of the photographs taken at MCC New York show Epstein in a hospital gown; although the OIG did review photographs taken at New York Presbyterian Lower Manhattan Hospital which show Epstein in a hospital gown.¶

Additionally, the OIG participated in interviews of three inmates assigned to the same SHU tier as Epstein at the time of his death and who were housed in cells opposite Epstein’s cell and therefore had a direct line of sight to Epstein’s cell.40 One such inmate was Inmate 5, who was assigned to a cell directly across from Epstein’s cell on the left side of the tier and who told the OIG that he could see all the cells on the right side of L Tier, where Epstein was housed. Inmate 5 believed a count was last conducted within the SHU on August 9, 2019, a little before 12:00 a.m., and said that no additional count was conducted after that time. Inmate 5 did not see anyone, or hear anyone, go into Epstein’s cell on the night of August 9 or the morning of August 10 prior to a male correctional officer discovering Epstein on the morning of August 10. Inmate 5 said the male correctional officer knocked on Epstein’s assigned cell, looked in, and then opened the door. Inmate 5 could only see Epstein’s legs from the knee down, but could tell that Epstein was laying down on his back because his feet were pointed upward. The male correctional officer bent down to shake Epstein and was saying, “Epstein, Epstein.” The male correctional officer then tried to pick up Epstein from behind, with his arms wrapped around Epstein. Inmate 5 said both the officer and Epstein fell back to the floor, with Epstein falling to the side of the officer. Inmate 5 said that once the two fell, he could then see that it was Epstein. The correctional officer then started giving Epstein chest compressions and mouth-to-mouth resuscitation. At this point, the officer said, “Fuck!” and asked the female correctional officer, who was standing near the L Tier gate, if she has pressed the button. The female officer said, “Yeah, a long time ago.” A lieutenant then arrived at Epstein’s cell along with a male nurse who tried to revive Epstein. Epstein was not responsive. Inmate 5 said Epstein looked dead when the male correctional officer tried to pick him up¶

40 As noted previously, the U.S. Attorney’s Office for the Southern District of New York sought interviews from all of the inmates housed in the L Tier of the SHU on the night that Epstein died.¶

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and they both fell. Inmate 5 said officers had trouble getting Epstein onto the stretcher because Epstein was basically dead weight. When the officers did get Epstein on the stretcher, Epstein still had on headphones. $ ^{41} $ Inmate 5 did not see any marks around Epstein’s neck, and he did not see a rope around Epstein’s neck. However, Inmate 5 saw a male correctional officer come out of Epstein’s cell with a sheet that had a loop and knot.¶

Figure 5.4: Location of the Cells Assigned to Inmates 5-7 in Relation to Epstein’s Cell in the L Tier¶

Inmate 6 told the OIG that on August 9 and 10, 2019, he was housed within the SHU on L Tier in a cell directly across from Epstein’s cell. Inmate 6 last saw Epstein’s cellmate, Inmate 3, on August 9 when Inmate 3 said, “See you later. I’m going to court.” Inmate 6 said Inmate 3 did not return that night, and said the SHU officers never conducted their required 30-minute rounds. Inmate 6 believed the correctional officers last checked on the inmates in the SHU on August 10 between 12:30 a.m. and 1:00 a.m. Inmate 6 did not observe anyone entering Epstein’s cell after Epstein returned from his legal visit on August 9, 2019, did not hear noise that night, and said Epstein’s door was not opened during the night. Inmate 6 said a male officer discovered Epstein dead during breakfast delivery on August 10. Inmate 6 said he observed the male correctional officer entered Epstein’s cell and began performing CPR, while the female correctional officer, who appeared panicked, stayed outside of the cell. Inmate 6 said he observed Epstein on the floor, but did not see a rope over Epstein’s head. However, when Epstein was removed from his cell, Inmate 6 observed the correctional officers holding a rope and a defibrillator. Inmate 6 did not see marks on Epstein’s neck but did see bruising on his face and observed earphones that were still in place on Epstein’s ears.¶

Inmate 7, who was two cells down from Epstein’s cell and on the other side of the tier, told the OIG that he could not see into Epstein’s cell but he could see the cell door. Inmate 7 said that after dinner was brought¶

41 An MP3 player with headphones was obtained as evidence by the FBI.¶

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to Epstein’s cell on the evening of August 9, 2019, Inmate 7 did not recall seeing anyone going in or out of Epstein’s cell until the following morning at around 6:00 a.m. He further stated that he did not hear any door “pop open” that evening. Inmate 7 said he remembered waking up around 6:00 a.m. on August 10, 2019, and hearing a voice, possibly male, saying “Breathe.” Inmate 7 said he saw Epstein removed from his cell on a stretcher.¶

In addition, the OIG and the FBI interviewed seven inmates assigned to other tiers in the SHU, none of whom had any direct knowledge of how Epstein died. These inmates consistently reported that the SHU officers did not systematically conduct the counts and rounds as required on the evening Epstein died and that the last round was either between 9:30-10:00 p.m. or 12:30-1:00 a.m. Several inmates told the OIG that before Epstein died the SHU staff never conducted rounds at night.¶

According to the BOP Form 583 Report of Incident, on August 10, 2019, at approximately 6:33 a.m., while delivering the breakfast meal, Epstein was found unresponsive in his cell. Consistent with the required response to a suspected suicide outlined in the MCC New York General Housing Unit Post Orders that are described in Chapter 2, staff called for assistance and began life-saving measures. $ ^{42} $ At 6:39 a.m., Epstein was taken to the MCC New York Health Services Unit, and Emergency Medical Services (EMS) arrived to MCC New York at 6:43 a.m. Epstein was transported to the local hospital, New York Presbyterian Lower Manhattan Hospital, at 7:10 a.m., and was pronounced deceased at 7:36 a.m.¶

According to a memorandum attached to the Form 583 from the Clinical Nurse dated August 10, 2019, when the medical emergency involving Epstein was called over the radio, the Clinical Nurse immediately responded to the call and upon arrival, saw Epstein on the floor within his cell unresponsive with CPR in progress by Correctional Officers. The Clinical Nurse’s memorandum reads that Epstein was cold, with circumferential bruising around his neck and posterior mottling, pupils fixes and dilatated, and no palpable pulses were felt. According to the memorandum, at 6:35 a.m., a call was placed for EMS, CPR continued, and an AED was utilized and indicated “No Shock Advised,” so CPR continued. Epstein was then transported to the MCC New York Health Services Unit treatment room with CPR in progress. Upon arrival, Epstein’s pulse was checked, and the AED indicated “No Shock Advised.” EMS and paramedics arrived on the scene, intubated Epstein, and gave him medications and fluids. $ ^{43} $ Epstein was transported to the local emergency room with CPR in progress at approximately 7:10 a.m.¶

According to a memorandum attached to the Form 583 from the Correctional Systems Officer dated August 10,2019, after Noel called the medical emergency, the Correctional Systems Officer received a call from staff in the SHU instructing her to call 911 for an ambulance. The Correctional Systems Officer notified the New York Police Department (NYPD) via the MCC New York institutional NYPD telephone. The Correctional Systems Officer then informed NYPD that MCC New York needed an ambulance and medical assistance for one of the inmates. The New York City Fire Department and EMS arrived at MCC New York at 6:43 a.m. and¶

42 As noted in Chapter 2, BOP policy provides that the need to immediately attend to an apparent suicide victim, undertake lifesaving measures, and ensure inmate and staff safety take precedence over efforts to preserve a crime scene.¶

43 The EMS arrival time on the Clinical Nurse’s memorandum is listed as 6:56 a.m. Based on the OIG’s review of other documentation and interviews, we believe the arrival time reflected on those other documents (6:43 a.m.) is more likely the time of EMS’s arrival. We noted that the Clinical Nurse, at the time of EMS’s arrival, was actively engaged in administering CRP to Epstein and responding to the health emergency.¶

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were escorted to the second-floor medical area. EMS departed MCC New York with Epstein and a BOP escort via ambulance and chase car to the local hospital at 7:10 a.m.¶

The Morning Watch Operations Lieutenant told the OIG that she was relieved as the Operations Lieutenant prior to 6:00 a.m. on August 10, 2019, but was still working on things like the Daily Activity Reports and Lieutenant Logs that she did not get to finish during her shift. At some point, the Morning Watch Operations Lieutenant heard that there was a medical emergency in SHU, so she went to assist because she knew that inmates would need to be given food and other things would need to be done. The Morning Watch Operations Lieutenant estimated that she went to the SHU around 7:00 a.m. to help with the inmate meals, and believed the Electronics Technician was also helping out. Noel was there, but she was not helping with delivering food to the inmates. The Morning Watch Operations Lieutenant said that after the meals were delivered, she finished up and went home.¶

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, no inmate provided the OIG with information suggesting that anyone assisted Epstein with taking his own life, or had any credible information suggesting that Epstein’s cause of death was something other than suicide. Some MCC New York staff told the OIG that Epstein’s death could have been prevented if, among other things, Epstein had been assigned a new cellmate after Inmate 3’s departure and rounds and counts had been conducted in the SHU as required. Some witnesses also faulted MCC New York staffing shortages, which resulted in excessive overtime and meant that MCC New York staff members were often overtired during their shifts. Other MCC New York staff members told the OIG that even if inmate safety and accountability measures had been property executed, an inmate who wanted to take his life would have found a way to do so.¶

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

Following Epstein’s death, the BOP and FBI collected many of the items found inside Epstein’s cell. The FBI inspected the cell and retrieved what it believed to be relevant to its investigation into the cause of Epstein’s death, which included one torn sheet, miscellaneous papers, and an MP3 player. The FBI did not recover any weapons inside of the cell. After the FBI’s inspection, the BOP recycled the linens from Epstein’s cell and collected the remaining items, which included various over-the-counter medications, books (including religious books), BOP pamphlets, toiletries, batteries, headphones, glasses, mail and envelopes, a brown paper bag, an orange homemade rope, AED pads, and a medical device.¶

The photographs of Epstein’s cell on August 10, 2019, show an excess of blankets, linens, and clothing. Some of the linens had been ripped into thin strips, which were tied to the desk and bunkbed inside the cell. Some of the strips were tied like a noose. When shown a picture of Epstein’s cell, Noel verified that it contained a lot of linen and extra clothing. Noel said the mattress on the floor was Epstein’s, as he always slept on the mattress on the floor. As detailed in the BOP policies section of Chapter 2, MCC New York SHU Post Orders required that correctional officers assigned to the SHU during the daytime tours of duty conduct at least five cell searches each day, and that the entire SHU, including all common areas and cells, be searched every week. The OIG investigation revealed, however, that on August 9, 2019, the SHU staff¶

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logged only one cell search in TRUSCOPE, and the search was not of Epstein’s cell. $ ^{44} $ BOP records did not indicate when Epstein’s cell was last searched.¶

The Day Watch SHU Officer in Charge told the OIG that at least five cell searches should be conducted on the day and night watch shifts within the SHU, and that cell searches are conducted in cells every time the inmate departs the cell. He said the SHU Officer in Charge was responsible for making sure the searches were conducted and logged into the BOP TRUSCOPE database. The Day Watch SHU Officer in Charge said that only one cell search was entered into TRUSCOPE on August 9, 2019, because cell searches were tedious to enter, and he was busy. He did not believe that it was a problem that only one cell search was logged on August 9, because he said the SHU staff would have gone into every cell when the inmates took their showers. He said that during the period of Epstein’s custody, SHU inmates showered on Mondays, Wednesdays, and Fridays. The Day Watch SHU Officer in Charge said that during showers, SHU staff searched every cell. He explained that all of the SHU cells should have been searched on Friday, August 9 because it was a shower day. He said SHU staff should also conduct cell searches when inmates go to the recreation area or for attorney visits. According to the Day Watch SHU Officer in Charge, Epstein’s cell should have been searched because both Epstein and Inmate 3 left the cell on the morning of August 9. He further stated that he believed that the majority of cells in the SHU were searched although, as noted above, the SHU staff logged only one cell search in TRUSCOPE on August 9 and the search was not of Epstein’s cell.¶

Figure 5.5: Photograph of Epstein’s Cell After His Death¶

The Day Watch SHU Officer in Charge told the OIG that in August 2019, each inmate would have been authorized to have two sheets and one blanket. He said that in the winter, inmates are allowed to have an additional blanket. When interviewed by the OIG, the Day Watch SHU Officer in Charge reviewed a picture of Epstein’s cell from August 10, 2019, after Epstein had been removed from the cell. The Day Watch SHU Officer in Charge said there appeared to be an excess number of linens and blankets in the cell, which he believed were for both Epstein and Inmate 3, and that there were possibly a couple of extra sheets as well. He noted that there were two mattresses in the cell and deduced that Inmate 3’s assigned items had not yet been removed even though he had departed MCC New York earlier that day. According to the Day Watch SHU Officer in Charge, Inmate 3’s items should have been removed as soon as the SHU staff knew Inmate 3 was not returning. He told the OIG that any extra linens or blankets should be removed when the inmates take showers and their cells are searched. He told the OIG that he believed the purpose of limiting the linens provided to the inmates was to ensure¶

there was enough to go around and that it was more of an administrative matter rather than a security¶

44 TRUSCOPE is a BOP database that provides institution staff with detailed inmate and institution security-related information and provides unit officers an electronic event log.¶

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matter.¶

Figure 5.6: Photograph of a Piece of Orange Cloth Tied into a Noose Recovered from Epstein’s Cell After His Death $ ^{45} $¶

The Captain also reviewed the picture of Epstein’s cell from August 10, 2019, when interviewed by the OIG. He said Epstein had too many linens, t-shirts, and blankets in his cell. The Captain said the SHU staff were responsible for removing those items because they did not want to hear the other inmates complain that they were not issued the same number of items. The Captain stated that it is also a security issue because it “gives the inmates the materials to be able to make homemade fashioned and improvised nooses” or “use it as escape paraphernalia,” such as a rope that inmates had used to escape from another facility in Chicago.¶

Inmate 3 told the OIG that Epstein was allowed to sleep on the floor, which he said was unusual for the SHU where that was not normally allowed. Inmate 3 said Epstein also had two extra blankets, which no other inmate had, as well as two pens, which inmates were not allowed to have. Epstein would ask for things, and if the correctional officers said no, Epstein would tell them he was writing down their name and providing the information to his lawyer. According to Inmate 3, the correctional officers were on “eggsshells” around Epstein. Inmate 3 said that when he left the SHU on August 9, 2019, there was an orange cloth twisted around the ladder, strings on the side of the ladder, and a string tied across the bed. Inmate 3 explained that the string tied across the bed served as a clothesline, and that the strings were part of a sheet they had ripped. According to Inmate 3, one night he woke up, saw Epstein fidgeting with the clothesline, and asked Epstein what he was doing. Epstein said he was trying to fix the clothesline, but Inmate 3 told him no and flushed the clothesline down the toilet. As discussed in Chapter 4, when Inmate 3 and Epstein first became cellmates upon Epstein’s return to the SHU following suicide watch and psychological observation, Inmate 3 asked Epstein not to kill himself while Inmate 3 was his cellmate because Inmate 3 had a chance to go home soon. In response, Epstein told Inmate 3 not to worry and that he was not going to cause him any trouble.¶

When Inmate 3 left on August 9 he told Epstein that he would leave the clothesline in the cell so that Epstein could wash his clothes. Inmate 3 did not say anything about a noose having been in the cell, but he said there were five blankets in their cell when he left.¶

C. Autopsy Results¶

On August 11, 2019, the Office of the Chief Medical Examiner, City of New York, performed an autopsy on Epstein and determined that the cause of death was hanging and the manner of death a suicide. One of the¶

45 As noted previously, Epstein’s cell contained an excessive amount of linens, some of which had been ripped into thin strips and tied like a noose. Figure 6.5 depicts one such noose, which is illustrative of the types of linens found in Epstein’s cell; the noose depicted is not the ligature Epstein used to kill himself.¶

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office’s Medical Examiners performed the autopsy, and the autopsy report was reviewed by the First Deputy Chief Medical Examiner. In connection with this investigation, the OIG interviewed the Medical Examiner who performed the Epstein autopsy (hereinafter the “Medical Examiner”). The Medical Examiner told the OIG that the pattern of Epstein’s neck bone fractures was consistent with a hanging. The Medical Examiner explained that a different fracture pattern is present if there has been a manual compression of the neck versus a sustained pressure like in a hanging, and the pattern of Epstein’s neck fractures was that of a hanging. The Medical Examiner also said Epstein had petechial hemorrhages, which are pinpoint bleeds in skin, on his face and mouth. These hemorrhages are caused when the blood flow is obstructed and the small skin capillaries burst. The Medical Examiner additionally identified plethora, which is purple discoloration of the skin, and stated that both petechial hemorrhages and plethora are consistent with suicide by hanging. The Medical Examiner stated that Epstein’s petechia and plethora were identified from his neck up. In homicidal strangulations, according to the Medical Examiner, these conditions are normally found only in the eyes and mouth, and in a different pattern. Epstein also had, the Medical Examiner explained, a marked and obvious ligature furrow that peaked upward which is consistent with suicide as opposed to a ligature strangulation.¶

The Medical Examiner further stated that there was no evidence of defensive wounds consistent with what is seen in victims of strangulation. The Medical Examiner told the OIG that in strangulation cases there is invariably some signs of a struggle, even if the victim is impaired. The Medical Examiner noted that the autopsy did not identify any signs of a struggle. Epstein did not have any marks on his hands, no broken fingernails, no debris under the fingernails, no contusions to his knuckles that would have evidenced a fight, and, other than an abrasion on his arm likely due to convulsing from hanging, no bruising on his body. We also were told by the Medical Examiner that Epstein did not have strap muscle hemorrhages of the neck, which is bleeding in the lung muscles in the front of your neck. Nor did he have, the Medical Examiner told the OIG, hemorrhaging in the muscles in the back of his neck. The Medical Examiner explained that you would expect to see that hemorrhaging when there has been an incomplete compression as opposed to a sustained compression like a hanging.¶

In addition, the Medical Examiner determined that the cloth material of the ligature (noose) found in Epstein’s cell could have caused the fractures and superficial injuries the Medical Examiner identified during the autopsy. The Medical Examiner also told the OIG that the ligature furrow was too broad to have been caused by the electrical cord of the medical device in Epstein’s cell. The Medical Examiner said blood toxicology tests were conducted and no medications or illegal substances were identified in Epstein’s system. The Medical Examiner stated that the ruling of Epstein’s death a suicide was the Medical Examiner’s independent medical judgment, and that the Medical Examiner was not pressured or otherwise subjected to any attempt to influence her ruling.¶

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

In August 2019, the Metropolitan Correctional Center located in New York, New York (MCC New York) had approximately 150 video security cameras (no audio) placed throughout the institution. The OIG found that approximately 11 cameras were located in and around the Special Housing Unit (SHU) where Epstein was confined at the time of his death on August 10, 2019, including one at the end of the L Tier where Epstein was housed that showed any movement in or out of inmate cells and in the Tier’s hallway. In addition to broadcasting live video, MCC New York had a system that recorded the live video feeds. Following Epstein’s death, MCC New York officials and FBI investigators attempted to review video recordings related to the incident and discovered that, although the security cameras were working and transmitting live video, recorded video from most of the cameras in the SHU area was not available due to a malfunction of the video recording system that had occurred on July 29, 2019, including video from the camera at the end of the L Tier. As a result, while the L Tier video camera was transmitting a live video feed on the night of August 9, 2019, and morning of August 10, 2019, the video was not being recorded. One of the cameras that had available recordings from August 9 and 10 was a camera located outside a housing unit adjacent to the SHU. That camera captured video of a large part of the common area of the SHU, including the SHU Officers’ Station and portions of the stairways leading to the different SHU tiers, including the L Tier. Thus, anyone entering or attempting to enter the L Tier from the common area of the SHU, including on August 9 and 10, would have been picked up by the video recorded by that camera. In addition, the recordings showed the SHU Officers’ Station where the two SHU staff were seated at a desk immediately outside the entrance to the L Tier and diagonally across from Epstein’s cell, which was the first cell on the righthand side of the L Tier.¶

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

All video surveillance from MCC New York’s cameras was connected to a Digital Video Recorder (DVR) system. The DVR system had two data storage systems that were labeled “DVR 1” and “DVR 2,” and each consisted of 16 hard drives used for storing digital recordings. Roughly half of MCC New York’s security cameras were assigned to record to DVR 1, and the other half were assigned to record to DVR 2. Cameras assigned to DVR 1 only recorded to the DVR 1 hard drives, and cameras assigned to DVR 2 only recorded to the DVR 2 hard drives. Therefore, if DVR 2 crashed, no video from the DVR 2-assigned cameras could be retrieved from DVR 1, and vice versa.¶

The OIG’s investigation revealed a history of camera problems at MCC New York. In August 2019, the Electronics Technician was the only such technician at MCC New York. The Electronics Technician told the OIG that when he began work at MCC New York in 2016, he found that the facility’s security camera system needed to be upgraded. According to the Electronics Technician, the system had not been properly maintained prior to his arrival, the hard drives in the DVRs frequently malfunctioned and needed to be replaced, and the overall system was outdated, in part because the cameras were analog and not digital. The Electronics Technician told the OIG that, throughout his tenure at MCC New York, the camera system¶

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was subject to frequently recurring failures, particularly with respect to the DVR hard drives. 46¶

The Warden, who assumed his responsibilities at MCC New York in May 2018, told the OIG he was generally aware that there were problems with the security camera system throughout the institution. He further stated that efforts were undertaken to determine which cameras were working and which needed to be fixed, and that MCC New York officials intended to ultimately seek funding to replace the entire system. BOP records reflect that on September 6, 2018, the Warden submitted a memorandum to the Federal Bureau of Prisons’ (BOP) Northeast Regional Director to request $800,000 in funding to replace the entire camera system. The memorandum identified an estimated project start date of December 1, 2018, and an estimated completion date of February 9, 2019. The BOP approved the funding request, and on September 21, 2018, a contract in the amount of $698,108.99 was awarded to Company 1 to provide various equipment for the project and associated labor. On September 24, 2018, a separate contract in the amount of $34,089.28 was awarded to Company 2 to provide assorted networking equipment and wiring needed to install the camera system.¶

As the camera upgrade project was beginning, BOP officials recognized that MCC New York’s mechanical, electrical, and plumbing systems were also in need of major repairs. MCC New York did not have enough qualified technicians on staff to complete both the camera installation and other repairs needed at the facility, so beginning the week of March 17, 2019, the BOP’s Northeast Regional Office arranged for technicians from other BOP institutions to conduct temporary duty (TDY) assignments at MCC New York to perform the work. During the course of the TDY rotations, work was not consistently conducted on the camera upgrade because sometimes TDY staff assigned to the project were used to cover shortages at MCC New York’s custody posts, and sometimes there were not enough TDY volunteers who possessed the skills required to do the camera work.¶

At the time of Epstein’s death on August 10, 2019, the camera system upgrade had not been completed. Immediately following Epstein’s death, Company 1 officials arrived at MCC New York and installed the new recording system within a couple of days, and recording functionality was restored using the existing cameras. The majority of the new cameras did not arrive at the facility until October 2019, and they were installed in stages as the wiring work was conducted. According to the Electronics Technician, as of August 2021, when the MCC closed, the wiring work had still not been fully completed.¶

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

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

According to forensic analysis conducted by the FBI after Epstein’s death, disk failures occurred in MCC New York’s DVR 2 system on July 29, 2019, which resulted in the system being unable to record. According to BOP records and OIG interviews, the BOP did not learn about the failure until August 8, 2019, when the Special Investigative Services (SIS) Lieutenant and Associate Warden 1 attempted to review recorded surveillance video for a matter unrelated to Epstein. The SIS Lieutenant told the OIG she discovered that no recorded video was available for several of the institution’s cameras, so she reported the matter to the¶

46 The Electronics Technician provided the OIG with copies of email messages and work orders that documented nine instances between June 2017 and July 2019, in which actions were taken to address a problem with either the MCC New York’s cameras or the hard drives used to record video from the cameras.¶

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Communications Office, and the Electronics Technician arrived to assess the problem sometime before his shift was scheduled to end. The Electronics Technician told the OIG that he found that roughly half of the institution’s approximately 150 cameras, which were assigned to record to DVR 2, were displaying a live video feed but were not recording.¶

The Electronics Technician told the OIG that, before Epstein’s death, no one was specifically tasked with ensuring that video from the cameras was being recorded. The Electronics Technician said he therefore did not perform any daily checks to ensure that video was being recorded. The Warden indicated that SIS staff are usually responsible for checking the system for recording functionality and reporting any problems to the Communications Office. However, the SIS Lieutenant told the OIG that it was her belief that the Electronics Technician should have been checking the system daily to ensure it was recording. The OIG found that there are no BOP policies that require institutional staff to perform periodic checks to ensure the camera system is fully functional or that security camera systems have the capacity to record. The Facility Manager told the OIG that since Epstein’s death, he now checks to ensure that all cameras and the recording system are working on a daily basis, and he subsequently provides a report about the status of the system to the facility’s executive staff, the SIS, and the electronics technicians.¶

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

On August 8, following discovery of the recording failure, Company 1 service request records reflect that the Electronics Technician contacted a Company 1 technical support representative, who ultimately determined that two hard drives within DVR 2 had failed. According to the Electronics Technician and the Company 1 service request record, the Company 1 representative informed the Electronics Technician that the two drives needed to be replaced and DVR 2 needed to be rebuilt in order for the cameras to record again. The Electronics Technician told the OIG that he informed a Company 1 Technician that he had to obtain the drives from MCC New York’s Computer Services Manager. The Electronics Technician further stated that he left the institution at the end of his shift and did not obtain the hard drives and did not continue to work on the matter. The Electronics Technician told the OIG he had “no idea” why he did not stay at the facility to resolve the problem that day, but he noted for the OIG that he had not historically been required to stay after his shift ended to work on such matters, and even if he had begun working on the DVR that day, he would not have completed the work on August 8 due to the time the rebuilding process takes.47¶

The OIG found that the Electronics Technician’s immediate supervisor, the Facility Manager, was on leave that week and therefore was not told on August 8 about the DVR recording failure. The Facility Manager confirmed that he did not learn about the camera problem until days after Epstein’s death. The Electronics Technician told the OIG that he did not report the problem to the Lock and Security Supervisor, who was the Acting Facility Manager in the Facility Manager’s absence. The SIS Lieutenant told the OIG that after the Electronics Technician had examined the system on August 8, the Electronics Technician informed her that cameras were not recording and said, “I’m going to stay and do overtime tonight.” Based on his comment, the SIS Lieutenant assumed that the Electronics Technician would remain at the institution after his shift ended that day to correct the issue. The Electronics Technician told the OIG there must have been some miscommunication because he did not say he was going to work overtime and resolve the problem that same evening since he knew the problem could not be fixed in one evening. The Electronics Technician told¶

47 According to open source information on digital data storage system rebuilds, the rebuilding process can take up to several days to complete depending on the number of hard drives that were damaged and the storage capacity of each.¶

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the OIG that, in hindsight, he should have stayed at the institution to begin work on the problem that same day.¶

The SIS Lieutenant told the OIG that she verbally informed the Captain on August 8 that the cameras were down, but BOP records reflect that the Captain left the institution before the malfunction was discovered. The Captain told the OIG that he did not learn about the DVR recording issue until after Epstein’s death on August 10 when he asked to see video related to the Epstein incident. Associate Warden 1 confirmed she was with the SIS Lieutenant on August 8 when the camera problem was discovered, but she told the OIG she only knew video could not be replayed. She did not know the recording system for certain cameras was down. She could see live video from the cameras on that date, and therefore assumed they were recording.¶

According to the Electronics Technician, after he reported to work on August 9, 2019, and attended to other matters throughout the day, the Electronics Technician obtained the replacement hard drives and attempted to perform the repair sometime late in the day. However, the Electronics Technician told the OIG that no SIS staff were present at that time to give him access to the room in which the DVR room was located, so he requested access from the only other individual who had a key to the space, Correctional Officer 4. $ ^{48} $ According to the Electronics Technician, Correctional Officer 4 denied him access to the room because Correctional Officer 4’s shift was ending at 4:00 p.m., and Correctional Officer 4 was unable to stay and accompany him in the space while the Electronics Technician performed the work. According to the Electronics Technician, Correctional Officer 4 said he would be at the institution the following day to provide the Electronics Technician access to the room, so the Electronics Technician decided to postpone the repair until the following day. The Electronics Technician said his decision was influenced by the fact that he had historically been told by MCC New York supervisors that such matters did not have to be attended to until the following day, and even if he had replaced the hard drives that day, the rebuilding process would have taken 24 hours to complete and would therefore not have finished until the following day anyway.¶

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

The Electronics Technician arrived at the institution around 6:00 a.m. on August 10, 2019, and shortly thereafter, before he could begin working on the DVR system, he heard the staff body alarm sound and he reported to the SHU to assist. Later that day he was asked to pull potential video from cameras located in and around the SHU. The Electronics Technician eventually determined that most of the cameras in the SHU area were assigned to record to DVR 2. While the cameras assigned to DVR 2 were providing live video streams on August 9 and 10, 2019, no recordings from those cameras were available due to the DVR 2 hard drive issue, which the FBI later determined had occurred on July 29, 2019. Among the cameras whose video was not recorded was the camera at the end of L Tier, the SHU tier in which Epstein was housed.¶

Only two cameras in the vicinity of the SHU area were recording to DVR 1 at the time of Epstein’s death. $ ^{49} $ One camera was located on the upper-level entrance to the 10 South Unit, a housing unit adjacent to the SHU, near the door MCC New York staff referred to as the “46 door.” That camera captured video of a large part of the common area of the SHU, including the SHU Officers’ Station and portions of the stairways¶

48 The DVR system was located in a locked room, and access to the room was limited to the institution’s SIS unit, staff assigned to inmate phone monitoring, and the Electronics Technicians.¶

49 One additional camera located at the 10 South Officers’ Station was recording on August 10, 2019. That camera is not depicted in Figure 4.12 because neither the SHU nor the SHU entrances were within the field of view of that camera.¶

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leading to the different SHU tiers, including the tier containing Epstein’s cell. Thus, anyone entering or attempting to enter the L Tier from the common area of the SHU on August 9 and 10 would have been picked up by the video recorded by that camera. Epstein’s cell door, however, was not in that camera’s field of view. The other camera that was recording was located in one of the ninth floor’s two elevator bays and provided video of the ninth-floor fire exit and two of the floor’s four elevators.¶

The available video showed that at approximately 7:49 p.m. on August 9, Epstein was escorted toward the L Tier stairway by an individual believed to be the Evening Watch SHU Officer in Charge. At approximately 10:39 p.m., an unidentified Correctional Officer appeared to walk up the L Tier stairway, and then reappeared within view of the camera at 10:41 p.m. This is believed to be the last time anyone entered L Tier before approximately 6:30 a.m. on August 10. Between approximately 10:40 p.m. on August 9 and just before 6:30 a.m. on August 10, the OIG did not observe on the recorded video any Correctional Officer or other individual enter any of the SHU tiers, which is consistent with Correctional Officer Tova Noel and Material Handler Michael Thomas’ admissions to the OIG that the SHU rounds and counts were not conducted during that time frame. At approximately 6:28 a.m., an unidentified officer was observed on the L Tier stairway, presumably to deliver breakfast food trays. Between 6:28 a.m. and 6:32 a.m., an unidentified officer, believed to be Noel, moved back and forth several times between the L Tier stairway and the SHU Officers’ Station. At approximately 6:33 a.m., additional officers entered the SHU and ascended the L Tier stairway, presumably after Noel activated her body alarm when Epstein was discovered hanged in his cell.¶

As noted above, the camera at the end of the L Tier was providing a live video feed at the time of Epstein’s death but the video was not being recorded. The Electronics Technician told the OIG that certain MCC New York personnel, including the Control Center, SIS personnel, the Warden, most lieutenants, and the Electronics Technician, had access to the live video feed of the institution’s security cameras. He explained that to view the live feed of a particular camera, including the SHU L Tier camera, an employee with access would need to key in the specific camera into the security camera system to call up the live feed. The Correctional Systems Officer, who was working in the Control Center on August 10 from 12:00 a.m. to 8:00 a.m., and the Morning Watch Operations Lieutenant both told the OIG that the only live feed from the SHU on their screens was video from the camera showing the SHU common area, and they did not perceive a need to take the necessary steps to see the live feed from the SHU L Tier from either of their duty stations on the evening Epstein died.¶

The OIG found the video captured by the camera at the entrance to the 10 South Unit to be of low quality. Due to the video’s low quality and the distance between the camera and the SHU common area, the OIG was able to observe movement of individuals within the SHU but was not always able to conclusively identify the individuals. The OIG was also not always able to determine the specific destinations of the individuals seen in the video given that the camera only captured partial views of the stairways to the various SHU tiers. The OIG found that movements captured on the video were generally consistent with employee actions described by multiple witnesses and certain actions documented in BOP records.¶

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Figure 6.1: SHU Camera Locations and Recording Status on August 10, 2019¶

Figure 6.2: Location of Recording SHU Camera at 10th Floor-South entrance¶

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Figure 6.3: Field of View of the SHU Camera at 10th Floor-South Entrance¶

Figure 6.4: Partial View of L Tier Stairway, from the SHU Camera at 10th Floor-South Entrance¶

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Figure 6.5: View of SHU Officers’ Station from the SHU Camera at 10th Floor-South Entrance¶

Figure 6.6: Field of View of the Recording 9th Floor Elevator Bay Camera¶

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Figure 6.7: Location of Non-Recording Camera in the L Tier of the SHU¶

The Warden, who was not scheduled to work on August 10, 2019, arrived at the institution later that morning after being notified of Epstein’s death, and was informed that most of the cameras in the SHU were not recording. He told the OIG that when the SIS Lieutenant arrived at the facility that morning, he informed her that the SHU cameras had not been recording, and the SIS Lieutenant explained that the hard drive issue had been detected on August 8. He told the OIG that prior to August 10, he was unaware that the DVR 2 issue had been detected on August 8, and that approximately half of the facility’s cameras, and in particular the cameras in the SHU, were found to not be recording on that date.¶

The Electronics Technician told the OIG that the Warden had instructed Electronics Technician to try and recover any potential SHU video that may have been recorded by the cameras assigned to the malfunctioning DVR 2 system, but the Electronics Technician was unable to find anything. The Electronics Technician further said that the Warden wanted to have all the facility’s cameras recording again as soon as possible, so he instructed the Electronics Technician to begin repairing DVR 2.¶

D. FBI Forensic Analysis of the DVR System¶

FBI evidence documents revealed that on August 10, 2019, the FBI seized all hard drives contained within the DVR 2 system. On August 14, 2019, the FBI returned to MCC New York and seized additional DVR 2 components. On August 15, 2019, the FBI seized the entire DVR 1 system.¶

The FBI’s Digital Forensics Analysis Unit in Quantico, Virginia, received MCC New York’s DVR system on August 16, 2019, and began to conduct a forensic analysis of the system. According to FBI forensic reports, DVR 2 did not start successfully. The Digital Forensics Analysis Unit found that the system contained three faulty hard drives. The FBI forensic reports state that the three drives were repaired by an FBI Advanced¶

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Data Recovery Specialist, but the DVR was never able to be assembled successfully. The forensic reports further state that an FBI computer scientist and the Company 1 Technician reviewed the DVR 2 controller logs and found that there had previously been “catastrophic disk failures,” and no recordings would have been available after July 29, 2019.¶

When the OIG asked the Electronics Technician about this finding by the FBI, he told the OIG he was unaware that cameras were not recording to DVR 2 between July 29 and August 8, 2019. Neither the Warden nor the SIS Lieutenant was aware the cameras assigned to DVR 2 had not been recording since July 29, 2019. The Company 1 Technician could not recall working with the Electronics Technician on any DVR issues prior to August 8, 2019, but he said that if the entire DVR 2 server went down on July 29, 2019, no video would have been able to have been retrieved from that point forward from any of the cameras recording to DVR 2.¶

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