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LIMITED OFFICIAL USE The attached information must be protected and not released to unauthorized individuals. Use of this cover sheet is in accordance with the Department of Justice regulation on the control of Limited Official Use information. EFTA00172546 LIMITED OFFICIAL USE ONLY-NOT FOR PUBLIC RELEASE IN SPEC DRAFT Investigation and Review of the Federal Bureau of Prisons' Custody, Care, and Supervision of Jeffrey Epstein at the Metropolitan Correctional Center in New York, New York * * March 202-:; Notice: This Draft Is Restricted to Limited Official Use. This document is a WORKING DRAFT prepared by the U.S. Department of Justice Office of the Inspector General. It has not been fully reviewed within the Department and is, therefore, subject to revision. This report may contain sensitive law-enforcement or privacy-protected information and is for authorized recipients only. Recipients of this draft must not, under any circumstances, show or release its contents for purposes other than official review and comment. It must be safeguarded in accordance with Department of Justice Order 2620.7 to prevent publication or other improper disclosure of the information it contains. If you have received this draft report in error, please contact (202) 768-2643 to arrange its return. LIMITED OFFICIAL USE ONLY—NOT FOR PUBLIC RELEASE EFTA00172547 Limited Official Use Only—Not for Public Release EXECUTIVE SUMMARY Investigation and Review of the Federal Bureau of Prisons' Custody, Care, and Supervision of Jeffrey Epstein at the Metropolitan Correctional Center in New York, New York Introduction and Background The Department of Justice (OOJ) Office of the Inspector General (OIG) initiated this investigation upon receipt of information from the Federal Bureau of Prisons (BOP) that on August 10, 2019, in the Metropolitan Correctional Center in New York, New York (MCC New York), inmate Jeffery Epstein was found hanged in his assigned cell within the Special Housing Unit (SHU). The Office of the Chief Medical Examiner, City of New York, determined that Epstein had died by suicide. The OIG conducted this investigation jointly with the Federal Bureau of Investigation (FBI), with the OIG's investigative focus being the conduct of BOP personnel. Among other things, the FBI investigated the cause of Epstein's death and determined there was no criminality pertaining to how Epstein had died. This report concerns the OIG's findings regarding MCC New York personnel's custody, care, and supervision of Epstein while detained at the facility from his arrest on federal sex trafficking charges on July 6, 2019, until his death on August 10. Epstein was assigned to the SHU on July 7 due to media coverage of his case and inmate awareness of his notoriety. SHU inmates are securely separated from general population inmates and kept locked in their cells for approximately 23 hours a day. While in MCC New York, Epstein was screened on numerous occasions by psychological staff and in all of the evaluations he denied having thoughts or a history of suicide. Psychological staff determined Epstein did not meet the criteria for a psychological diagnosis. Relevant BOP Policies BOP policy requires SHU staff to observe all inmates at least twice an hour and that lieutenants conduct at least one round in the SHU each shift. BOP policy also requires multiple inmate counts during every 24-hour period. Among other things, inmate counts and rounds enable BOP staff to observe inmates and ensure they are secure in their cells and in good health. Further, to eliminate safety hazards, MCC New York requires SHU staff to search SHU common areas and at least five cells daily, and to search the entire SHU every week. For inmates identified as suicide risks, the BOP requires they be placed on suicide watch until no longer at imminent risk. A less restrictive monitoring form, psychological observation, is used for inmates who are stabilizing but not yet ready to return to a housing unit. Additionally, BOP policy requires that all inmate telephone calls be made through BOP's Inmate Telephone System. On rare occasions, BOP policy permits inmates to make a call outside of this system, but the call must be recorded and documented. Incident Involving Epstein on July 23, 2019 On July 23 at 1:27 a.m., correctional officers responded to Epstein's SHU cell where they found Epstein with a handmade orange cloth around his neck. Epstein's cellmate told officers Epstein tried to hang himself. Medical staff examined Epstein, observed friction marks and superficial reddening around his neck and on his knee, and placed him on suicide watch. Epstein was removed from suicide watch on July 24 but remained under psychological observation until July 30. Epstein first told MCC New York staff he thought his cellmate had tried to kill him, but later said he did not know what occurred and did not want to talk about how he had sustained his injuries. Epstein also later asked if he could be housed with the same cellmate. Another inmate housed on the same SHU tier told the OIG that he heard Epstein's cellmate call for assistance, and that Epstein's cellmate told him that Epstein tried to hang himself from the bunkbed ladder. Disciplinary charges against Epstein for alleged self-mutilation were not sustained due to insufficient evidence. Following the July 23 incident, the Psychology Limited Official Use Only—Not for Public Release EFTA00172548 Limited Official Use Only—Not for Public Release Department determined Epstein needed to be housed with an appropriate cellmate, and on July 30 it sent an email to over 70 MCC New York employees informing them of this requirement. The Warden at the time told the OIG that he selected a new cellmate for Epstein in consultation with BOP executive leadership. That inmate remained Epstein's cellmate until August 9. Events of August 8-10, 2019, and Epstein's Death On August 8, the U.S. Marshals Service sent two emails notifying numerous MCC New York staff that Epstein's cellmate was being transferred to another facility on August 9. However, no action was taken to ensure Epstein was assigned another cellmate. Also on August 8, Epstein met with his attorneys at the prison, as he had on prior occasions, and signed a new Last Will and Testament. MCC New York officials did not learn about the new Will until after Epstein's death. The following day, August 9, Epstein's cellmate was transferred to another facility and he was not assigned - a new cellmate. Also on August 9, after meeting at the prison with his lawyers, staff allowed Epstein to make an unrecorded, unmonitored telephone call before he was returned to his SHU cell. Although Epstein said he was calling his mother, he actually called an individual with whom he allegedly had a personal relationship. At approximately 8:00 p.m. on August 9, SHU inmates were locked in their cells for the night, including Epstein who was without a cellmate. A search of Epstein's cell following his death revealed Epstein had excess prison blankets, linens, and clothing in his cell, and that some had been ripped to create nooses. Only one SHU cell search was documented on August 9, and it was not of Epstein's cell. BOP records did not indicate when Epstein's cell was last searched. The OIG also found that SHU staff did not conduct any 30-minute rounds after about 10:40 p.m. on August 9 and that none of the required SHU inmate counts were conducted after 4:00 p.m. on August 9. Count slips and round sheets were falsified to show that they had been performed. On August 10, at approximately 6:30 a.m., the two SHU staff on duty, Correctional Officer Tova Noel and Material Handler Michael Thomas, began delivering breakfast to SHU inmates. Tova unlocked the door to Epsteln's SHU tier. When Thomas attempted to deliver I As detailed in the report, MCC New York had a history breakfast to Epstein through the food slot in his locked cell door, Epstein did not respond to Thomas's verbal commands. Thomas unlocked the cell door and saw Epstein hanged. Thomas immediately yelled for Noel to get help and call for a medical emergency. Thomas told the OIG that when he entered Epstein's cell, Epstein had an orange string, presumably from a sheet or a shirt, around his neck that was tied to the top portion of the bunkbed. Epstein was suspended from the top bunk in a near-seated position, with his buttocks approximately 1 inch to 1 inch and a half off the floor. Thomas said he immediately ripped the orange string from the bunkbed, and Epstein's buttocks dropped to the ground. Thomas then lowered Epstein's body to the floor and began chest compressions until responding MCC New York staff members arrived approximately 1 minute later. Shortly thereafter, outside medical personnel arrived and took over the emergency response, eventually removing Epstein to a local hospital where he was pronounced dead. On August 11, 2019, the Office of the Chief Medical Examiner performed an autopsy and determined the cause of death was hanging and the manner of death was suicide. Blood toxicology tests did not reveal any medications or illegal substances in Epstein's system. The Medical Examiner who performed the autopsy told the OIG that Epstein's injuries were consistent with suicide by hanging and that there was no evidence of defensive wounds that would be expected if his death had been a homicide. Epstein did not have marks on his hands, broken fingernails or debris under them, contusions to his knuckles that would have evidenced a fight, or, other than an abrasion on his arm likely due to convulsing from hanging, bruising on his body. The Limited Available Video Evidence Recorded video evidence for August 9 and 10 for the SHU area where Epstein was housed was only available from one prison security camera due to a malfunction of MCC New York's Digital Video Recorder system that occurred on July 29, 2019. While the prison's cameras continued to provide live video feeds, recordings were made for only about half the cameras. MCC New York personnel discovered this failure on August 8, 2019, but it was not repaired until after Epstein's death.' of security camera problems. ii Limited Official Use Only—Not for Public Release EFTA00172549 Limited Official Use Only—Not for Public Release The available video from the one SHU camera captured a large part of the common area of the SHU and portions of the stairways leading to the different SHU tiers, including Epstein's cell tier. Thus, anyone entering or attempting to enter Epstein's SHU tier from the SHU common area would have been picked up by that video camera. Epstein's cell door, however, was not in the camera's field of view. The OIG reviewed the video and found that, between approximately 10:40 p.m. on August 9 and about 6:30 a.m. on August 10, no one was seen entering Epstein's cell tier from the SHU common area. The OIG determined that movements captured on video before and after those times were generally consistent with employee actions as described by witnesses and documented in BOP records. Results of the OIG's Investigation and Review The OIG's investigation and review identified numerous and serious failures by MCC New York staff, including multiple violations of MCC New York and BOP policies and procedures. The 016 found that MCC New York staff failed on August 9 to carry out the Psychology Departments directive that Epstein be assigned a cellmate, and that an MCC New York supervisor allowed Epstein to make an unmonitored telephone call the evening before his death. Additionally, we found that staff failed to undertake required measures designed to make sure that Epstein and other SHU inmates were accounted for and safe, such as conducting inmate counts and 30-minute rounds, searching inmate cells, and ensuring adequate supervision of the SHU and the functionality of the video camera surveillance system. The OIG also found that several staff falsified BOP records relating to inmate counts and rounds and lacked candor during their OIG interviews. Two MCC New York employees, Noel and Thomas, were charged criminally with falsifying BOP records. The charges were later dismissed after they successfully fulfilled deferred prosecution agreements. The U.S. Attorney's Office for the Southern District of New York declined prosecution for other MCC New York employees who the OIG found created false documentation. The combination of these and other failures led to Epstein being unmonitored and alone in his cell, which contained an excessive amount of bed linens, from approximately 10:40 p.m. on August 9 until he was discovered hanged in his locked cell the following day. While the 016 determined MCC New York staff engaged in significant misconduct, we did not uncover evidence contradicting the FBI's determination regarding the absence of criminality in connection with how Epstein died. SHU staff told the OIG that at approximately 8:00 p.m. on August 9, all SHU inmates, including Epstein, were locked in their cells for the evening and we found no evidence to the contrary. The prison's recorded video did not identify any staff or other individuals approaching Epstein's SHU tier from the SHU common area between approximately 10:40 p.m. on August 9 and about 6:30 a.m. on August 10. Further, none of the MCC New York staff members we interviewed were aware of any information suggesting Epstein's cause of death was something other than suicide. Additionally, none of the inmates we interviewed had any credible information suggesting Epstein's cause of death was something other than suicide. Further, the SHU staff and three interviewed inmates with a direct line of sight to Epstein's cell door on the night of his death stated that no one entered or exited Epstein's cell after the SHU staff returned Epstein to his cell on August 9. We further noted that Epstein had previously been placed on suicide watch and psychological observation due to the events of July 23, 2019; that numerous nooses made from the excess prison sheets were found in his cell on the morning of August 10; and that he signed a new Last Will and Testament on August 8, 2 days before he died. We found that the staffs failure to assign Epstein a cellmate on August 9, to conduct rounds and counts that evening, and to allow him to have excess linens in his cell, left Epstein unmonitored and locked alone in his cell for hours, which provided him an opportunity to commit suicide. Finally, the Medical Examiner who performed the autopsy detailed for the 016 why Epstein's injuries were more consistent with, and indicative of, a suicide by hanging rather than a homicide by strangulation. The Medical Examiner also cited the absence of debris under Epstein's fingernails, marks on his hands, contusions to his knuckles, or bruises on his body evidencing a struggle, which would be expected if Epstein's death had been a homicide by strangulation. The OIG made nine recommendations to the BOP to address the numerous issues identified during our investigation and review. Finally, we recommend that the BOP review the conduct and performance of the BOP personnel as described in this report and determine whether discipline or other administrative action with regard to each of them is appropriate. iii Limited Official Use Only—Not for Public Release EFTA00172550 Limited Official Use Only—Not for Public Release Table of Contents Chapter 1: Introduction 1 Chapter 2: Background 5 I. Significant Entities and Individuals 5 II. Methodology 6 III. Applicable Law, Regulations, and BOP Policies 7 A. Standards of Conduct 7 B. False Statements and Lack of Candor 8 C. Relevant BOP Policies Regarding the Operation of Correctional Facilities 8 1. Special Housing Units 8 2. Inmate Accountability 9 3. Psychological Screening 10 4. Suicide Response 11 5. Inmate Discipline 12 6. Conditions of Confinement 12 Chapter 3: Timeline of Key Events 14 Chapter 4: Custody and Care of Epstein Prior to His Death 21 I. Epstein's Arrest and Detention on July 6 21 II. MCC New York's Special Housing Unit (SHU) 22 III. Epstein's Initial Cell and Cellmate Assignment from July 7 to July 23 26 IV. Events of July 23 and the Placement of Epstein on Suicide Watch and Psychological Observation from July 23 to July 30 26 V. The Psychology Department's Post-July 23 Determination that Epstein Needed to Have an Appropriate Cellmate 30 VI. Selection of Epstein's Cellmate After Psychological Observation 31 VII. Epstein's Cell Assignment from July 30 to August 10 31 VIII. Psychological Evaluations of Epstein from July 6 to August 9 37 Chapter 5: The Events of August 8-10, 2019, and Epstein's Death 45 I. Epstein Signs a New Last Will and Testament on August 8 45 II. Court Order on August 9 Releasing Epstein-Related Documents in Pending Civil Litigation 45 III. Transfer of Epstein's Cellmate on August 9 to Another Institution and Failure to Replace Him with Another Inmate 45 A. Notice on August 8 of the Impending Transfer of Epstein's Cellmate on August 9 45 Limited Official Use Only—Not for Public Release EFTA00172551 Limited Official Use Only—Not for Public Release B. MCC New York Staff Reject Epstein Attorney's Request that Epstein be Housed Without a Cellmate 46 C. Removal on August 9 of Epstein's Cellmate from MCC New York 46 D. Failure to Assign Epstein a New Cellmate on August 9 47 1. Day Watch Staff Actions on August 9 47 2. Evening Watch Staff Actions on August 9 50 IV. Epstein is Allowed to Make an Unmonitored Telephone Call on August 9 52 V. Failure to Conduct SHU Inmate Counts and Staff Rounds on August 9-10 55 A. SHU Inmate Counts 55 1. The 4:00 p.m. SHU Count on August 9 56 2. The 10:00 p.m. SHU Count on August 9 58 3. The 12:00 a.m., 3:00 a.m., and 5:00 a.m. SHU Counts on August 10 60 B. Staff Rounds in the SHU 61 1. Correctional Officer Rounds 61 2. Lieutenant Rounds 63 VI. Epstein's Death on August 10 64 A. Discovery of Epstein Hanged in Cell and Emergency Response 64 B. Items Found in Epstein's Cell on August 10 Following His Death 70 C. Autopsy Results 72 Chapter 6: The Availability of Limited Recorded Video Evidence Due to the Security Camera Recording System Failure 74 I. Background on the Security Camera System at MCC New York 74 II. Discovery of Security Camera System Recording Issues in August 2019 75 A. Discovery on August 8 of the DVR 2 Failure that Occurred on July 29 75 B. Response on August 8 and 9 to Discovery of the Recording Failure 76 C. SHU Camera Locations and Operational Status on August 10 77 D. FBI Forensic Analysis of the DVR System 82 Chapter 7: Conclusions and Recommendations 84 I. Conclusions 84 A. MCC New York Staff Failed to Ensure that Epstein Had a Cellmate on August 9 as Instructed by the Psychology Department on July 30 88 1. Failure to Make Required Notifications Regarding the Need to Assign Epstein a New Cellmate 88 2. Failure to Adequately Supervise SHU Staff 90 Limited Official Use Only—Not for Public Release EFTA00172552 Limited Official Use Only—Not for Public Release 3. Failure to Have a Contingency Plan for Assigning Epstein a Cellmate 91 4. Lack of Candor 91 B. MCC New York Staff Failed to Conduct Mandatory Rounds and Inmate Counts Resulting in Epstein Being Unobserved for Hours Before His Death 92 1. Failure to Conduct Rounds and Inmate Counts in the SHU 92 2. False Statements and Lack of Candor 93 3. Poor Judgment Regarding the Use of Overtime 94 4. Clearing the 10:00 p.m. Institutional Count Knowing that It Was Inaccurate 95 5. Failure to Adequately Supervise SHU Staff and Conduct Lieutenant Rounds 96 C. MCC New York Staff Allowed Epstein to Place an Unmonitored Telephone Call on August 9 97 D. MCC New York Staff Failed to Conduct and Document Cell Searches and Eliminate Safety Hazards in Epstein's Cell on August 9 Leaving Epstein with Excessive Linens in His Cell 98 E. MCC New York Staff Failed to Ensure that the Institution's Security Camera System was Fully Functional Resulting in Limited Recorded Video Evidence 99 II. Recommendations 100 Limited Official Use Only—Not for Public Release EFTA00172553 Limited Official Use Only—Not for Public Release Chapter 1: Introduction The Department of Justice (DOJ) Office of the Inspector General (OIG) initiated this investigation upon the receipt of information from the Federal Bureau of Prisons (SOP) that on the morning of August 10, 2019, in the Metropolitan Correctional Center located in New York, New York (MCC New York), inmate Jeffery Epstein was found hanged in his assigned cell within the Special Housing Unit (SHU). The SHU is a housing unit where inmates are securely separated from the general inmate population and kept locked in their cells for approximately 23 hours a day, to ensure their own safety as well as the safety of staff and other inmates. Epstein had been placed in the SHU on July 7, 2019, the day after his arrest, due to the significant media coverage of his case and awareness of his notoriety among MCC New York inmates. According to information obtained by the OIG during the investigation, at approximately 8:00 p.m. on August 9, all SHU inmates, including Epstein, were locked in their cells for the evening. Additionally, the six separate tiers or groups of cells within the SHU were also securely locked. At approximately 6:30 a.m. on August 10, 2019, SHU staff unlocked the door to the SHU tier in which Epstein's cell was located in order to deliver breakfast to inmates through the food slots in the locked cell doors. When SHU staff entered the tier to deliver breakfast to Epstein, SHU staff knocked on the locked door to Epstein's cell. Epstein, who was housed alone in the cell, did not respond to SHU staff. SHU staff unlocked the cell door and found Epstein hanged in his cell, with one end of a piece of orange cloth around his neck and the other end tied to the top portion of a bunkbed in Epstein's cell. Epstein was suspended from the top bunk in a near-seated position with his buttocks approximately 1 inch to 1 inch and a half off the floor and his legs extended straight out on the floor in front of him. Epstein's cell contained an excess amount of prison linens, as well as multiple nooses that had been made from torn prison linens. SHU staff immediately activated a body alarm, which notified all MCC New York staff of a medical emergency and prompted MCC New York staff assigned to the Control Center to call for 911 emergency services. SHU staff then ripped the orange cloth away from the bunkbed, which caused Epstein's buttocks to drop to the ground. SHU staff laid Epstein on the ground and immediately initiated cardiopulmonary resuscitation (CPR). At approximately 6:33 a.m., other MCC New York employees responded to the SHU. A responding MCC New York Lieutenant took over administering CPR and asked SHU staff to retrieve an automated external defibrillator and call for the duty nurse. A Clinical Nurse responded and continued to perform CPR on Epstein in the place of the Lieutenant. At approximately 6:39 a.m., Epstein was placed on a stretcher and moved by medical staff to the MCC New York Health Service Unit.2 The Clinical Nurse continuously administered CPR until he was relieved by outside Emergency Medical Technicians (EMTs) when they arrived at the Health Services Area minutes later. The EMTs continued CPR, incubated Epstein, and administered medication and fluids in their efforts to revive him. At approximately 7:10 a.m., Epstein was transported by the EMTs in an ambulance to New York Presbyterian Lower Manhattan Hospital, where he was pronounced dead by an emergency room physician at 7:36 a.m. On August 11, 2019, the Office of the Chief Medical Examiner, City of New York, performed an autopsy on Epstein and determined that the 2 Moving an inmate requiring outside emergency medical care to the Health Services Unit provides health care staff and Emergency Medical Technicians (EMTs) with immediate access to any necessary medical equipment and supplies, and allows EMTs faster access to the inmate when they arrive at MCC New York because correctional officers can directly escort EMTs to the Health Services Unit to begin emergency treatment immediately. If EMTs had to be escorted to the housing unit, they would first need to be thoroughly screened, which would delay medical attention. 1 Limited Official Use Only—Not for Public Release EFTA00172554 Limited Official Use Only—Not for Public Release cause of death was hanging and the manner of death was suicide. The OIG conducted this investigation jointly with the Federal Bureau of Investigation (FBI), with the OIG's investigative focus being the conduct of BOP personnel. Among other things, the FBI investigated the cause of Epstein's death. The FBI determined that there was no criminality pertaining to how Epstein had died. This report concerns the OIG's findings regarding MCC New York personnel's custody, care, and supervision of Epstein during his detention at the facility from his arrest on July 6, 2019, until his death on August 10, 2019. The OIG investigation and review identified numerous and serious failures by MCC New York staff, as well as multiple violations of MCC New York and BOP policies and procedures. Among the most significant was the failure to assign Epstein a new cellmate on August 9, 2019, after Epstein's cellmate was transferred out of MCC New York that day. Epstein was required to have a cellmate at all times pursuant to a written direction that the MCC New York Psychology Department issued on July 30 after Epstein was removed from suicide watch and psychological observation following a possible attempted suicide by him on July 23. As a result of the failure to assign him a new cellmate, Epstein was housed alone in his cell from the night of August 9 until he was found hanged in his cell by SHU staff at approximately 6:30 a.m. the following morning. In addition, we determined that SHU staff failed to conduct required inmate counts and rounds, including overnight on August 9-10, and allowed Epstein to have an excess of blankets, linens, and clothing in his cell. These failures compromised Epstein's safety, the safety of other inmates, and the security of the institution, and provided Epstein an opportunity to commit suicide while locked alone in his cell on the morning of August 10 without having been subject to overnight observation or supervision by SHU staff. The OIG also found that an MCC New York supervisor had allowed Epstein, in violation of BOP policy, to make an unrecorded, unmonitored telephone call the evening before his death to an individual with whom he allegedly had a personal relationship. Further, 2 days before his death, during a meeting with his lawyers in a private room at the MCC New York, Epstein signed a new Last Will and Testament, which MCC New York officials did not learn about until after his death. Additionally, the OIG determined that MCC New York staff assigned to the SHU, including the two SHU staff on duty the night of August 9-10, 2019, who were stationed at a desk that was directly outside the SHU tier in which Epstein was housed and diagonally across from Epstein's cell, had falsified BOP records to claim that they had conducted all of the required counts of inmates and 30-minute rounds during their shifts within the SHU. As described in greater detail in Chapter 2, inmate counts and 30-minute rounds are two means by which the BOP accounts for inmates and assesses their safety, security, and well-being. BOP and MCC New York policies require that staff members count all inmates in each housing unit within the facility at designated times each day. Additionally, SOP and MCC New York policies require that a staff member observe all SHU inmates at least once during the first 30 minutes of each hour (e.g., 12:00 a.m. to 12:30 a.m.) and again during the second 30 minutes of the hour (e.g., 12:30 a.m. to 1:00 a.m.), thus ensuring that inmates are observed at least twice per hour. BOP staff are required to document inmate counts and 30- minute rounds on official BOP forms, which are often referred to as "count slips" and "round sheets."3 3 These BOP forms are officially entitled "Official Count Slip" and "MCC New York, Special Housing Unit, 30 Minute Check Sheet." 2 Limited Official Use Only—Not for Public Release EFTA00172555 Limited Official Use Only—Not for Public Release During the OIG's investigation, the OIG obtained information that the staff assigned to the MCC New York SHU did not conduct any counts of inmates within the SHU from August 9, 2019, at approximately 4:00 p.m., until Epstein was found hanged in his cell on the morning of August 10, 2019. However, in documentation completed by the SHU staff on duty during that period, staff members falsely certified in the count slips that they had conducted the required counts. Additionally, the OIG investigation revealed that the staff assigned to the MCC New York SHU did not conduct any required 30-minute rounds of inmates after approximately 10:40 p.m. on August 9, 2019. Again, however, SHU staff on duty during that period had falsely certified in the round sheet that the required rounds were conducted. The combination of these and other failures led to Epstein being unmonitored and locked alone in his cell, which the OIG found contained an excessive amount of bed linens, from approximately 10:40 p.m. on August 9 until he was discovered hanged in his cell at approximately 6:30 a.m. the following day. While the OIG determined that MCC New York staff committed significant violatio York policies and falsified records related to their conducting inmate counts and rou uncover evidence that contradicted the FBI's determination regarding the absence of cr connection with how Epstein died. All MCC New York staff members who were interviewe they did not know of any information suggesting that Epstein's cause of death was something other than suicide. Additionally, none of the 15 inmates who agreed to be interviewed in connection with this investigation, 10 of whom were housed in the SHU on August 9 and 10, had any credible information suggesting that Epstein's cause of death was something other than suicide. Further, the SHU staff and the three interviewed inmates with a direct line of sight to the door of Epstein's cell from their cells stated that no one entered or exited Epstein's cell after the SHU staff returned Epstein to his cell on the evening of August 9, which is consistent with the security measures in place within the MCC New York SHU. SHU staff told the OIG that at approximately 8:00 p.m. on August 9, all SHU inmates were locked in their cells for the evening and that there was no indication that any of the other inmates could have gotten out of their cells. Additionally, the OIG analyzed the available recorded video of the SHU, which was limited to the common area of the SHU, including the SHU Officers' Station, due to the MCC New York security camera system's recording issues that we detail in this report.4 The OIG's analysis of the recorded video did not identify any correctional officers or other individuals approaching any of the SHU tiers, including the L Tier where Epstein was housed, from the common area of the SHU between approximately 10:40 p.m. on August 9 and approximately 6:30 a.m. on August 10. OP and MCC New e OIG did not ity in the OIG said Finally, the Medical Examiner who performed the autopsy detailed for the OIG why Epstein's injuries were more consistent with, and indicative of, a suicide by hanging rather than a homicide by strangulation. The Medical Examiner also cited to the absence of debris under Epstein's fingernails, marks on his hands, contusions to his knuckles, or bruises on his body that evidenced Epstein had been in a struggle, which would be expected if Epstein's death had been a homicide by strangulation. As discussed in greater detail in Conclusions and Recommendations chapter of this report, this is not the first time that the OIG has found significant job performance and management failures on the part of BOP personnel and widespread disregard of SOP policies that are designed to ensure that inmates are safe, secure, and in good health. The OIG has investigated numerous allegations related to the falsification of official SOP documentation concerning inmate counts and rounds, and has repeatedly found deficiencies 4 For reasons we describe below, while the camera inside the L Tier was working and transmitting live video, the video was not being recorded. 3 Limited Official Use Only—Not for Public Release EFTA00172556 Limited Official Use Only—Not for Public Release with the BOP's staffing levels, the custody and care of inmates at risk for suicide, and security camera systems at BOP institutions. The combination of negligence, misconduct, and outright job performance failures documented in this report all contributed to an environment in which arguably one of the most notorious inmates in SON custody was provided with the opportunity to take his own life. The BOP's failures are troubling not only because the BOP did not adequately safeguard an individual in its custody, but also because they led to questions about the circumstances surrounding Epstein's death and effectively deprived Epstein's numerous victims of the opportunity to seek justice through the criminal justice process. The fact that these failures have been recurring ones at the SOP does not excuse them, and gives additional urgency to the need for DOJ and BOP leadership to address the chronic problerlaguing the SOP. Unless otherwise noted, the OIG applies the preponderance of the evidence standard in determining whether DOJ personnel have committed misconduct. The U.S. Merit Systems Protection Board applies this same standard when reviewing a federal agency's decision to take adverse action against an employee based on such misconduct. See 5 U.S.C. § 7701(c)(1)(8) and 5 C.F.R. § 1201.56(b)(1)(ii). 11 In Chapter 2 of this report, we provide background information, including identification an description of significant entities and individuals; a summary of our methodology; and the applicable laws, federal regulations, and BOP policies. In Chapter 3, we outline a timeline of key events. In Chapter 4, we set forth our findings of fact relating to the SON custody and care of Epstein before his death. In Chapter 5, we set forth our findings of fact related to the events of August 8-10, 2019, including Epstein's death. In Chapter 6, we set forth our findings of fact related to the BOP's failure to ensure that there was a functional security camera system at MCC New York, which resulted in limited recorded video evidence relevant to Epstein's death. Finally, Chapter 7 contains our conclusions and recommendations. 4 Limited Official Use Only—Not for Public Release EFTA00172557 Limited Official Use Only—Not for Public Release Chapter 2: Background I. Significant Entities and Individuals Jeffrey Epsteinwas born in 1953 and, prior to his arrest, worked at various jobs in the financial industry and ultimately developed considerable wealth. On July 2, 2019, a federal grand jury of the U.S. District Court for the Southern District of New York returned an indictment that charged Epstein with engaging in sex trafficking and a sex trafficking conspiracy, in violation of 18 U.S.C. §§ 371, 1591(a), (b)(2), and 2. These charges were based on allegations that between 2002 and 2005, Epstein paid girls as young as 14 years old hundreds of dollars in cash each for engaging in sex acts with him at his Florida and New York residences. The indictment further alleged that Epstein also paid each of these minor victims hundreds of dollars in cash to recruit other girls to engage in sex acts with Epstein. On July 6, 2019, Epstein was arrested at Teterboro Airport in New jersey upon his return to the United States from France and was transported to the Federal Bureau of Prisons' (BOP) Metropolitan Correctional Center, located at 150 Park Row in New York, New York (MCC New York). Following a detention hearing on July 15, 2019, the court ordered that Epstein be detained pending trial based on the court's finding that he was a danger to the community and a flight risk. MCC New York is a federal administrative detention facility operated by the BOP that primarily provides pretrial detention services for the U.S. District Courts for the Southern and Eastern Districts of New York. The BOP temporarily closed MCC New York in October 2021 due to substandard conditions that are unrelated to this investigation. When it was operational, MCC New York housed approximately 750 inmates at any given time. Prior to its closure, the majority of MCC New York's inmate residents were individuals with pending criminal charges (as opposed to individuals who had been convicted of offenses and were serving a sentence of imprisonment), but whom the court had determined under applicable law should remain in custody pending trial either because they represent a danger to the community, a substantial flight risk, or both. MCC New York has several different housing units. Epstein was initially assigned to MCC New York's general inmate population, but on July 7, 2019, he was moved to the Special Housing Unit (SHU) pending reclassification due to the significant increase in media coverage and awareness of his notoriety among the other inmates. The SHU is a housing unit within MCC New York where inmates are securely separated from the general inmate population, and kept locked in their cells for approximately 23 hours per day, to ensure their own safety as well as the safety of staff and other inmates. Correctional Officer Tova Noel and Material Handler Michael Thomas began working together in MCC New York SHU at 12:00 a.m. on August 10, 2019.5 During their shift, they each created and submitted falsified official BOP forms documenting inmate counts (often referred to as "count slips"), and Noel completed and signed more than 75 separate entries on an official BOP form documenting 30-minute rounds (often referred to as a "round sheet") falsely stating that she and Thomas had conducted such rounds when, in 5 Noel worked her regular shift in the SHU from 4:00 p.m. to 12:00 a.m. on August 9, 2019, followed by an overtime shift in the SHU from 12:00 a.m. to 8:00 a.m. on August 10, 2019. Thomas did not work his regular 4:00 p.m. to 12: 00 a.m. shift as a Material Handler in a different location of MCC New York and instead worked an overtime shift in the SHU from 12:00 a.m. to 8:00 a.m. on August 10, 2019. 5 Limited Official Use Only—Not for Public Release EFTA00172558 Limited Official Use Only—Not for Public Release fact, they had not.6 On November 19, 2019, a federal grand jury of the U.S. District Court for the Southern District of New York returned an indictment that charged Noel and Thomas with one count each of conspiracy and multiple counts each of falsification of records, in violation of 18 U.S.C. §§ 371, 1001(a)(3), and 2. The indictment alleged that on August 9, 2019, Noel failed to conduct the mandatory 4:00 p.m. and 10:00 p.m. counts of inmates in the MCC New York SHU, and that on August 10, 2019, both she and Thomas failed to conduct the mandatory 12:00 a.m., 3:00 a.m., and 5:00 a.m. counts and mandatory 30-minute rounds within the MCC New York SHU. The indictment further alleged that Noel and Thomas created, certified, and submitted false documentation indicating that the counts and rounds had been done as required to conceal their failure to perform their assigned duties. As a result, it appeared from documentation that prisoners in the SHU, including Epstein, were being regularly monitored when, in fact, no correctional officer had checked on Epstein from approximately 10:40 p.m. on August 9, 2019, until approximately 6:30 a.m. on August 10, 2019, when Epstein was found hanged in his cell. On May 25, 2021, the U.S. Attorney's Office for the Southern District of New York entered into deferred prosecution agreements with Noel and Thomas. Their respective agreements, which are part of the court record in their cases, included admissions by Noel and Thomas that they falsely certified that they had conducted counts and rounds. The agreements also required each of them to truthfully and completely disclose all information related to their activities and employment with the BOP; be interviewed by the U.S. Attorney's Office of the Southern District of New York, the FBI, and the OIG; complete 100 hours of community service; refrain from violating the law; and fulfill other conditions related to pretrial supervision and their establishment of good behavior. On December 13, 2021, after Noel and Thomas successfully fulfilled the terms of their deferred prosecution agreements as determined by the prosecutors, the U.S. District Court for the Southern District of New York entered a nolle prosequi order and dismissed all charges pending against them. Prosecution was declined by the U.S. Attorney's Office for the Southern District of New York for other BOP employees assigned to the SHU who also falsely certified inmate count slips and round sheets on the day before and the day of Epstein's death. As discussed in greater detail in Chapter 7 of this report, the OIG found that, in addition to Noel and Thomas, many other MCC New York staff members engaged in administrative misconduct, exercised poor judgment, and/or failed to adequately perform their assigned duties. II. Methodology During the course of this investigation, the OIG interviewed 54 witnesses, several on more than one occasion. The witnesses interviewed included Noel, Thomas, and other MCC New York staff assigned to the SHU on August 9-10, 2019; MCC New York supervisors at the time of Epstein's death, including the Warden, Associate Wardens, Captain, and Lieutenants; medical staff; staff members responsible for the MCC New York security camera system; other BOP staff and contractors; and a relative of Epstein, who contacted the OIG through his attorney and requested to provide information. The BOP employees and contractors we interviewed included employees involved in various aspects of the emergency response, who worked at 6 These SOP forms are officially entitled " Official Count Slip" and "MCC New York, Special Housing Unit, 30 Minute Check Sheet: Each of the six tiers in the SHU had a separate round sheet, each of which had 13 entries reflecting 30- minute rounds were conducted, when they were not, in fact, completed. 6 Limited Official Use Only—Not for Public Release EFTA00172559 Limited Official Use Only—Not for Public Release MCC New York in the days leading up to the response and following the response, as well as other individuals with information pertinent to our investigation. Additionally, the OIG participated in interviews of 15 inmates who had been housed at MCC New York during time periods relevant to our investigation, including three who were housed in the L Tier of the SHU on the day Epstein died.' Those three L-Tier inmates were housed in cells opposite Epstein's cell and therefore had a direct line of sight to Epstein's cell on the night of August 9-10. The OIG also reached out to one of Epstein's attorneys to discuss the possibility of providing information, but ultimately the attorney declined to be interviewed, citing attorney-client privilege and issues related to ongoing litigation involving Epstein's estate. The OIG also collected over 127,000 documents, as well as MCC New York video and photographs. Among these were BOP documents, including staff rosters; daily logs and reports; investigative and incident reports; documentation regarding inmate counts and 30-minute rounds; inmate housing assignment documentation; inmate transfer documents; Psychology Department reports and medical records relating to Epstein; Epstein's institutional phone call records; MCC New York records of Epstein's visits with his attorneys; electronic communications, including text messages and emails of BOP employees and contractors; MCC New York security camera surveillance video; records from contractors regarding the MCC New York security camera system; service records for MCC New York's security camera system; MCC New York photographs, including photographs taken of efforts to revive Epstein on the morning of August 10, 2019; BOP policies and program statements; MCC New York Post Orders; and financial records. The OIG also conducted forensic analysis of the computers located in the SHU and BOP cellular telephones. In addition, the OIG reviewed FBI investigative records, including interview reports (FD-3025), notes from witness interviews and other meetings, and electronic communications. The OIG also reviewed Epstein's autopsy report and interviewed the Medical Examiner who performed the autopsy on Epstein. Ill. Applicable Law, Regulations, and BOP Policies A. Standards of Conduct I The Standards of Ethical Conduct for Employees of the Executive Branch sets out general principles that are designed to "ensure that every citizen can have complete confidence in the integrity of the Federal Government."8 Among other things, these standards require that every federal employee "use official time in an honest effort to perform official duties."9 The ethical regulations also mandate that federal employees not use federal property "for other than authorized activities."10 BOP policy (Program Statement 3420.11, Standards of Employee Conduct) imposes several additional standards of conduct on its employees. At all times BOP employees must "[Conduct themselves in a manner that fosters respect for the Bureau of Prisons, the Department of Justice, and the U.S. Government." Because "Mnattention to duty in a correctional environment can result in escapes, assaults, and other incidents," BOP employees "are required to remain fully alert and attentive during duty hours." BOP policy The U.S. Attorneys Office for the Southern District of New York sought Interviews from inmates housed in the L Tier of the SHU on the night that Epstein died, each of whom was represented by counsel. Three inmates agreed to be Interviewed. The OIG does not have the authority to compel or subpoena testimony from individuals who are not Department employees. a 5 C.F.R. § 2635.101(a). g 5 C.F.R. § 2635.705(a); see also 5 C.F.R. § 2635.101(b)(5). 70 5 C.F.R. § 2635.101(b)(9); see also 5 C.F.R. § 2635.704(a). 7 Limited Official Use Only—Not for Public Release EFTA00172560 Limited Official Use Only—Not for Public Release provides that employees can use government property for authorized purposes only, and further specifies that personal use of government office equipment, such as computers, "will not take place during official working hours." BOP policy requires that employees "obey the orders of their superiors at all times." B. False Statements and Lack of Candor Under federal law, "whoever, in any matter within the jurisdiction of the executive...branch of the Government of the United States, knowingly and willfully...makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry" has violated 18 U.S.C. § 1001(a)(3). The terms "knowingly and willfully' mean that the subject acted with knowledge that the conduct was, in a general sense, prohibited by law. It is not required that the subject was aware of the existence of Section 1001. Under BOP standards of conduct discussed above, employees are required to cooperate fully with official investigations, which includes providing "all pertinent information they may have" and "truthfully responding to questions." C. Relevant BOP Policies Regarding the Operation of Correctional Facilities 1. Special Housing Units Special Housing Units within BOP facilities are governed by federal regulations, 28 C.F.R. §§ 541.21-541.33. These regulations provide that the BOP may establish Special Housing Units (SHU) "where inmates are securely separated from the general inmate population." These regulations and BOP policy (Program Statement 5270.11, Special Housing Units) explain that inmates in the SHU are either on administrative detention or disciplinary segregation status. Administrative segregation status is a non-punitive designation that removes an inmate "from the general population when necessary to ensure the safety, security, and orderly operation of correctional facilities, or protect the public." There are several reasons an inmate can be placed in administrative detention status, including when an inmate's presence in the general inmate population presents a threat to self or others, or when administrative detention status is necessary for the protection of the inmate. Assignment to the SHU for protection reasons can be based on being a victim of an assault, acting (or being perceived) as an informant, refusing to enter general population, or because of staff concerns about the inmate's safety. Inmates in the SHU are securely separated from general population inmates and are kept locked in their cell when in their assigned tier within the SHU. As discussed in greater detail in Chapter 4, witnesses told the OIG that SHU inmates are locked in their cells for approximately 23 hours a day. BOP policy provides that, weather and resources permitting, SHU inmates will have the opportunity to exercise outside their quarters 5 hours per calendar week. Under federal regulations and BOP policy, SHU inmates ordinarily have the opportunity to shower at least three times a week, typically on different days in 1-hour periods. SHU inmates may also be escorted from their cells by MCC New York staff for visits, including legal visits, court appearances, medical and psychological attention. The MCC New York SHU Post Orders require that all visitors to the SHU be documented in a visitor log, and that any inmate visiting the SHU, such as inmates on work details, be searched visually and with a hand-held metal detector, without exception. The MCC New York SHU Post Orders also require that food carts be searched inside and out before being brought into a SHU cellblock and that all meals be delivered to each inmate's cell through the food slot in the inmate's locked cell door. 8 Limited Official Use Only—Not for Public Release EFTA00172561 Limited Official Use Only—Not for Public Release BOP policy provides that inmates housed in the SHU for 30 continuous calendar days are to be examined and interviewed by a mental health staff member to assess the inmate's adjustment and the threat presented to self or others. BOP policy also requires that all staff assigned to the SHU participate in quarterly training on, among other things, orderly supervision, suicide prevention, and security procedures relating to the unit. When a staff member is assigned to the SHU at the last-minute and has not completed the quarterly training, the staff member must be advised of the general requirements of a SHU post and be permitted to ask questions about the duties. 2. Inmate Accountabilityll a. Counts Inmate counts serve an important security function, as they enable correctional officials to ensure that all inmates are accounted for and present at the appropriate location within the facility. BOP policy requires that each institution "conduct, at a minimum, five official inmate counts during every 24-hour period," and that on "weekends and holidays an additional count will be conducted at 10:00 a.m." At least one count a day during the week and two counts a day on weekends and holidays must be "stand-up counts," which means that inmates are required to stand when they are counted. MCC New York SHU Post Orders designate that counts must occur at 12:00 a.m., 3:00 a.m., 5:00 a.m., 4:00 p.m., and that stand-up counts are to be conducted at 10:00 p.m. daily and also at 10:00 a.m. on weekends and federal holidays. The BOP requires that each count be conducted by at least two officers, one of whom will count the inmates while the other observes the unit for any unauthorized movement from the end of the tier. This requirement is also set out in the MCC New York SHU Post Orders. The two officers will then switch roles and compare the count numbers. If the totals do not match, then the officers must conduct another count in the same manner. When conducting the count, officers are required to observe each inmate's body and not rely solely on movement or sound. Officers conducting the count relay the count verbally to the Control Center, which maintains the master count of all inmates, and then remain in the unit until the Control Center accepts the count. If a count reported verbally does not match the master count, then the Control Center must notify the Operations Lieutenant and the staff members must recount the inmates. If the second count does not match the master count, then the Operations Lieutenant will order a bed-book count, that is, when inmates are counted using their picture cards, which are on file in the Control Center. A lieutenant must conduct at least one count in the morning and one in the evening. Correctional staff prepare count slips for each count, which must be prepared in ink, signed by both officers, and retained for 30 days. Count slips may not be altered. BOP policy provides that the "official count will not be cleared until all count slips are received and verified in the Control Center." b. 30-Minute Rounds The BOP uses additional accountability measures for inmates who are in administrative detention or 11 This section describes inmate accountability measures that are most relevant to this investigation and review. The BOP utilizes a variety of other security and inmate accountability tools in addition to those discussed in this section, which are described in BOP Program Statement 5500.14, Correctional Services Procedures Manual. 9 Limited Official Use Only—Not for Public Release EFTA00172562 Limited Official Use Only—Not for Public Release disciplinary segregation, i.e., for those detained in a SHU. In such cases, a correctional staff member must observe all inmates at least twice an hour, once during the first 30 minutes (e.g., 12:00 a.m. to 12:30 a.m.) and again during the second 30 minutes (e.g., 12:30 a.m. to 1:00 a.m.). BOP policy provides that these "rounds are to be conducted on an irregular schedule and no more than 40 minutes apart." These same requirements for rounds are also described in the Post Orders for the MCC New York's SHU. c. Documentation Regarding Inmate Status and Confinement BOP policy also provides that each institution must prepare a daily change/transfer sheet, which indicates changes to an inmate's status, including housing and job assignments and medical convalescence. The MCC New York SHU Post Orders require that correctional staff assigned to the SHU create a SHU file for each inmate housed in that unit and that morning watch officers audit the inmate files every night. The MCC New York SHU Post Orders further specify that all pertinent information about an inmate's confinement should be noted on a Special Housing Unit Record Form (BP-292), and that SHU officers must maintain a log of pertinent information regarding inmate activity and enter such information into the BOP computer system TRUSCOPE, which provides institution staff with detailed inmate and institution security-related information and provides unit officers an electronic event log. d. Cell Searches BOP policy requires that BOP staff routinely and irregularly search housing units to, among other things, maintain sanitary standards and eliminate safety hazards.12 The MCC New York SHU Post Orders require that officers assigned to the SHU conduct searches of the SHU common areas and cells. During the morning watch (12:00 a.m. to 8:00 a.m.), SHU staff are required to search the common areas; during the day watch (8:00 a.m. to 4:00 p.m.), SHU staff are required to search every inmate's cell who attends recreation; and during the evening watch (4:00 p.m. to 12:00 a.m.), SHU staff are required to conduct at least five cell searches. The Post Orders further require that the entire SHU be searched every week. BOP policy and MCC New York SHU Post Orders require written documentation of each housing unit search. 3. Psychological Screening a. Initial Screening Pursuant to BOP policy governing inmates in pretrial detention status (Program Statement 7331.04, Pretrial Inmates), all pretrial inmates must have an initial risk/needs assessment screening within 48 hours of admission to the institution. The goal of this screening is to determine "the inmate's security, medical, psychological, and/or other special needs." The BOP also requires that institutions screen pretrial inmates "returning from court, as events at court may alter the inmate's separation and/or security needs." BOP policy further recognizes that there are often "high security, high profile inmates" who may present a significant threat to themselves or others, and that the "need to identify and monitor these inmates regularly is paramount." b. Suicide Prevention The BOP's suicide prevention program is governed by federal regulations, 28 C.F.R. §§ 552.40-552.42, which require the BOP to establish a suicide prevention program to identify and manage potentially suicidal inmates. Pursuant to these regulations, when an inmate is identified as being at-risk for committing suicide, 12 BOP Program Statement 5521.06, Searches of Housing Units, Inmates, and Inmate Work Areas. 10 Limited Official Use Only—Not for Public Release EFTA00172563 Limited Official Use Only—Not for Public Release BOP staff must place the inmate on suicide watch until the inmate is no longer an imminent risk. BOP policy (Program Statement 5324.08, Suicide Prevention Program) requires that medical staff screen all new inmates, ordinarily within 24 hours, for signs of suicidality. However, at MCCs, among other facilities with high rates of admissions and short lengths of stays, "comprehensive psychological intake conducted by Psychology Services ordinarily will be performed only on inmates who are suspected of being suicidal or appear psychologically unstable." Inmates in the SHU are monitored more closely, and inmates exhibiting signs of potential suicide risk are referred to the shift lieutenant. BOP policy recognizes that inmates who are placed in the SHU due to a request for protective custody are at greater risk of committing suicide and should therefore be screened for suicidal ideation within 72 hours of arriving in the SHU. SOP policy explicitly states that "staff must never take lightly any inmate suicide threats." Any staff member who has reason to believe that an inmate may be suicidal should "ordinarily maintain the inmate under direct, continuous observation." Every SOP institution must have one or more rooms, ordinarily in the health services area, dedicated to inmates placed on suicide watch. Suicide watch may be conducted by specially trained staff or inmates. For inmates placed on suicide watch, the specially trained staff or inmate maintains continuous observation of the inmate believed to be at risk of committing suicide. Following suicide watch and based on clinical findings following a face-to-face evaluation, the inmate will be removed from suicide watch or transferred to a medical referral or health care facility. Psychological observation is a less restrictive form of individual monitoring that is used for inmates who are stabilizing and not yet prepared for placement in general population or restrictive housing. While on suicide watch, the inmate is normally required to wear a suicide watch gown and will be allowed a suicide watch blanket. As discussed in greater detail in Chapter 4, witnesses told the OIG that an inmate is placed on suicide watch when the inmate is believed to be imminently suicidal. During suicide watch, the inmate is under constant observation by staff; the cell lights are on 24 hours a day; and the inmate is given a special mattress, blanket, and smock to wear. Although psychological observation is a lower classification, witnesses told the OIG that at MCC New York the psychological observations was the same as suicide watch except that inmates were allowed to have their clothing and some materials, such as books, as determined by the Psychology Department. At MCC New York, psychological observation was used to see how an inmate was doing before releasing the inmate to a housing unit 4. Suicide Response Recognizing that failure to appropriately respond to an emergency can jeopardize the safety of staff and inmates and the security of the institution, the BON Standards of Employee Conduct require that "employees respond immediately, effectively, and appropriately during all emergency situations." The MCC New York General Housing Unit Post Orders outline the required response to a suspected inmate suicide. These orders require that MCC New York staff notify the Operations Lieutenant and Control Center of the situation. The orders further provide that, once there is adequate staff present, immediate action must be taken to open the inmate's airway and initiate cardiopulmonary resuscitation, even if MCC New York staff believe that that the inmate "has been dead for a period of time." MCC New York staff are to continue cardiopulmonary resuscitation until they are relieved by medical staff or another rescuer. The SOP policy governing crime scenes and the collection of evidence provides that the need to immediately attend to an apparent suicide victim, undertake lifesaving measures, and ensure inmate and staff safety take precedence 11 Limited Official Use Only—Not for Public Release EFTA00172564 Limited Official Use Only—Not for Public Release over efforts to preserve a crime scene.13 5. Inmate Discipline Federal regulations, 28 C.F.R. §§ 541.1-541.8, and BOP policy (Program Statement 5270.09, Inmate Discipline Program) establish an inmate discipline program, which is designed to ensure the safety, security, and orderly operation of correctional facilities, as well as the protection of the public. The inmate discipline program applies to all inmates in BOP custody, including inmates with pending criminal charges. One of the guiding principles of this program is that BOP staff are to take disciplinary action when and to such a degree as necessary to regulate the behavior of inmates to promote a safe and orderly institution. "Tattooing or self-mutilation" is among the prohibited acts sanctioned through the inmate discipline program. This prohibited act falls within the second most severe category of offenses on a 4-tier scale. The SOP defines "tattooing or self-mutilation" as "No put indelible patterns on the skin; to injure, disfigure or make imperfect by removing or irreparably damaging parts of the body (wrist cutting falls within this offense)."16 The definition does not make an explicit reference to suicide attempts other than inclusion of "wrist cutting." Among other things, BOP policy addressing the inmate discipline program identifies the prohibited acts, describes the process for adjudicating violations, and lists applicable penalties for each category of offense. As relevant to this matter, the discipline process begins when a staff member observes an inmate commit a prohibited act and issues a report documenting the incident. A BOP supervisor then investigates the alleged inmate misconduct, which includes taking a statement from the inmate regarding the incident. If an inmate appears to be mentally ill at any stage of the disciplinary process, a mental health staff member will examine the inmate and assess the inmate's competency to participate in the disciplinary process. If the inmate is found to be competent and the prohibited act falls into the first or second most severe category, the matter is referred to a discipline hearing officer, who will hold a hearing and make a determination as to whether the inmate committed the prohibited act and, if so, impose any of the sanctions that correspond to the severity of the prohibited act. At the hearing, the inmate is advised of his or her rights and permitted to choose a staff representative, make a statement, and call witnesses. The inmate is also allowed to appeal the outcome through the BOP's administrative remedy program. 6. Conditions of Confinement a. Telephone Calls The federal regulations, 28 G.F.R. §§ 54O.1OO-54O.1O6, that govern telephone calls for inmates require that the Warden of each BOP institution establish procedures to monitor inmate telephone conversations, which is "done to preserve the security and orderly management of the institution and to protect the public." For safety and security reasons, BOP policy (Program Statement P5264.O8, Inmate Telephone Regulations) requires that all inmate telephone calls be made through the Inmate Telephone System. BOP policy recognizes that "on rare occasion, during times of crisis," inmates may be permitted to make a telephone call outside of the Inmate Telephone System. In such circumstances, the telephone "must be placed in a secure area (e.g., a locked office)," and "must be set to record telephone calls." Additionally, the staff member coordinating the call must notify the BOP's Special Investigative Services via email, providing the inmate's name and register number, the date and time of the call, the number and name of the individual 13 BOP Program Statement 551O.14, Crime Scene Management and Evidence Control, is a restricted policy that is not released to the public in its entirety. 74 BOP Elements of Prohibited Acts. 12 Limited Official Use Only—Not for Public Release EFTA00172565 Limited Official Use Only—Not for Public Release called, and the reason for the call. The Special Investigative Services must enter this information into the telephone recording system within 7 days. b. Personal Effects, Medication, and Linens Federal regulations governing BOP Special Housing Units provide that inmates in administrative detention status ordinarily may have a reasonable amount of personal property.15 Under SOP policy regarding Special Housing Units, the personal property of SHU inmates "may be limited or withheld for reasons of security, fire safety, or housekeeping."16 The SOP Chief Pharmacist issues medication each workday for inmates in the SHU. Restricted medications are administered to inmates during daily SHU rounds. Each institution determines "the medication(s) and amount (number of days) an inmate in SHU may maintain in their cell." Inmates may also purchase pre-approved over-the-counter medications at the commissary. MCC New York General Housing Units Post Orders provide that when an inmate is released or transferred out of a housing unit, the inmate will remove all limited and government-issued clothing from the cell in which the inmate was previously housed. These Post Orders further specify that all cells are to be cleaned daily by inmates occupying the cell, and that blankets, towels, and other linens will not be used as rugs or hung over inmate bunk beds at any time. Pursuant to these Post Orders, MCC New York housing unit officers on all three shifts are responsible for maintaining "a high level of sanitation" and a "safe and clean environment" O is 28 C.F.R. § S41.31(hX1). 76 BOP Program Statement 5270.11, Special Housing Units. 13 Limited Official Use Only—Not for Public Release EFTA00172566 Limited Official Use Only—Not for Public Release Chapter 3: Timeline of Key Events Except as otherwise noted, the following information is derived from the Federal Bureau of Prisons (SOP) records and OIG interviews. September 21-24, The BOP awards contracts to two companies (Company 1 and 2) to 2018 upgrade the security camera system at Metropolitan Correctional Center in New York, New York (MCC New York). At the time, images from the MCC New York's analog video cameras are recorded to a Digital Video Recorder (DVR) system, which is divided into two DVR systems. Cameras assigned to the DVR 1 system record only to the DVR 1 hard drives, and cameras assigned to DVR 2 system record onIC the DVR 2 hard drives. March 17, 2019 In connection with MCC New York's upgrade of its security ca system, the BOP's Northeast Regional Office begins arranging fo technicians from other BOP institutions to perform temporary duty (TDY) assignments to MCC New York to perform necessary mechanical, electrical, plumbing, and wiring work. However, during the course of the TDY rotations, work is not consistently conducted on the camera upgrade because sometimes TDY staff are used to cover shortages at MCC New York's custody posts. S July 2, 2019 According to court records, a federal grand jury of the U.S. District Court for the Southern District of New York returns an indictment charging Epstein with sex trafficking and conspiracy to commit sex trafficking. July 6, 2019 Epstein is arrested at an airport in New Jersey and is transported for detention pending his initial court appearance to the MCC New York as a pretrial detainee. Epstein is placed in the general inmate population and medically screened. July 7, 2019 An MCC New York Facilities Assistant asks the Psychology Department to evaluate Epstein because he appears "distraught, sad, and a little confused." Epstein is assigned to the MCC New York's Special Housing Unit (SHU) because of significant media attention and his notoriety among other MCC New York inmates." 77 The SHU is a housing unit within MCC New York where inmates are securely separated from the general inmate population and kept locked in their cells for approximately 23 hours a day, to ensure their own safety as well as the safety of staff and other inmates. 14 Limited Official Use Only—Not for Public Release EFTA00172567 Limited Official Use Only—Not for Public Release July 8, 2019 According to court records, Epstein is arraigned in federal court and enters a plea of not guilty to all charges. The court sets a detention hearing for July 15, 2019. MCC New York staff conducts a routine intake screening of Epstein, the records of which indicate that Epstein denies a history of any mental health problems. After the Chief Psychologist consults with the National Suicide Prevention Coordinator from BOP's Central Office, the Psychology Department conducts a further evaluation of Epstein after his return from court. Records show that Epstein denies any suicidal thoughts but was placed on psychological observation due to the presence of risk factors (high-profile case, nature of the charges, pre-trial status, and ongoing proceedings). July 9, 2019 The Psychology Department administers a formal, in-person suicide risk assessment for Epstein. The Psychology Department continues psychological observation for another day pending a suitable housing placement. July 10, 2019 July 11, 2019 July 15, 2019 July 16, 2019 July 18, 2019 The Psychology Department removes Epstein from psychological observation and returns him to the SHU with a recommendation that he have a cellmate. Epstein is housed with another inmate (Inmate 1). An MCC New York psychologist meets with Epstein briefly and recommends an additional follow-up visit the following week. According to court records, Epstein appears in court for his detention hearing. At Epstein's request, an MCC New York psychologist meets with him during a legal visit. According to court records, Epstein appears in court for a ruling on the issue of detention. The court orders that Epstein be detained pending trial because he presents a danger to the community and he is a flight risk. The Psychology Department conducts 30-day psychology reviews for the entire SHU population. Epstein is not in the SHU at the time and therefore is not reviewed. 15 Limited Official Use Only—Not for Public Release EFTA00172568 Limited Official Use Only—Not for Public Release July 22, 2019 According to court records, Epstein files an appeal of the courts order denying Epstein pretrial release. July 23, 2019 July 24, 2019 July 25-29, 2019 At approximately 1:27 a.m., SHU staff hears noises coming from Epstein's cell. Epstein's cellmate (Inmate 1) says that Epstein has attempted to hang himself. SHU staff observes Epstein lying on the floor with a piece of orange cloth around his neck. Epstein initially tells MCC New York staff that his cellmate tried to kill him. Epstein's cellmate (Inmate 1) tells MCC New York staff that while he was asleep, he felt something hit his legs and when he turned on the light, he saw Epstein with a string around his neck and called the guards.16 Epstein is transferred out of the SHU and placed on suicide watch. Later that morning, Health Services Unit personnel conduct a medical assessment and observes that Epstein has a red mark two-thirds of the way around the front and sides of his neck. The BOP assesses Epstein for risk of suicide and determines that he should remain on suicide watch. At approximately 8:45 a.m., Epstein is removed from suicide watch but remains in the same cell and is under psychological observation. Medical staff examines Epstein at 1:08 p.m. and Psychological Services staff completes a Post Suicide Watch Report. In contrast to his statement the previous day, Epstein says he does not remember how he sustained the injuries to his neck. Epstein is seen by the Psychology Department daily and on each date adamantly denies suicidality or having any memory of what occurred on July 23, 2019. July 29, 2019 Psychology Department staff determined that Epstein may be released from psychological observation and return to the SHU.19 Disk failures occur in DVR 2 of MCC New York's security camera system, la When interviewed by the OIG, another inmate housed in the same SHU tier (Inmate 2) at the time of the July 23 incident said he heard Inmate 1 call for assistance, and that Inmate 1 later told him that Epstein had tried to kill himself by hanging himself from the bunkbed ladder. 19 The investigation revealed that Epstein was originally scheduled to return to the SHU on July 29, 2019, but at his request he remained on psychological observation until July 30, 2019. The GOP's SENTRY database, which is a BOP database that contains information relating to the care, classification, subsistence, protection, discipline, and programs of federal inmates, was not updated to reflect this change because it indicated that Epstein was transferred back to the SHU on July 29, 2019. 16 Limited Official Use Only—Not for Public Release EFTA00172569 Limited Official Use Only—Not for Public Release which results in the system being unable to record, although the cameras continue to work and broadcast live video feed. MCC New York personnel do not learn of the DVR 2 recording failure until August 8, 2 days before Epstein's death. Roughly half of MCC New York's security cameras, including those located in the SHU, are assigned to record to the DVR 2 system. July 30, 2019 Epstein is transferred back to the SHU.20 An MCC New York Staff Psychologist from the Psychology Department sends an email to over 70 BOP staff members stating that Epstein "needs to be housed with an appropriate cellmate." Epstein and his new cellmate (Inmate 3) are placed in a cell within the SHU that can accommodate the electrical needs of Epstein's medical device. MCC New York conducts disciplinary proceedings against Epstein for alleged self-mutilation and ultimately concludes that there is insufficient evidence to find that Epstein engaged in a prohibited act.21 When Epstein is psychologically evaluated in connection with the disciplinary proceedings, he says he does not remember how he sustained the marks around his neck. MCC New York personnel attempt to obtain an estimate from Company 1 to run the wiring and conduit for the new camera system, which would eliminate the need for BOP technicians to perform the work. July 31, 2019 According to court records, Epstein appears in court for a status conference, at which time the court sets deadlines for motions and responses. Upon his return to MCC New York, the U.S. Marshals Service provide paperwork to BOP that indicates Epstein had "suicidal tendencies." The Psychology Department conducts a clinical visit with Epstein, who denies any suicidal ideation. August 1, 2019 MCC New York Receiving and Discharge staff notify the Psychology Department of the notation of "suicidal tendencies" on U.S. Marshals 20 The OIG's investigation revealed that at some point after he returned to the SHU from suicide watch and psychological observation, Epstein asked two different MCC New York staff members if he can be housed with the same cellmate Epstein initially said tried to kill him. 21 The SOP's inmate discipline program and the offense with which Epstein was charged is further described in Chapter 2. 17 Limited Official Use Only—Not for Public Release EFTA00172570 Limited Official Use Only—Not for Public Release Service paperwork relating to Epstein. The Psychology Department conducts a suicide risk assessment of Epstein, who denies that he is suicidal, and determines that suicide watch is not warranted. Follow-up is recommended in 1 week. August 2, 2019 MCC New York Special Investigative Services complete its investigation into the incident on July 23, 2019, and finds that there is insufficient evidence to determine that Epstein harmed himself or that he was harmed by his cellmate. August 8, 2019 Epstein is seen by the Psychology Department and denies suicidal ideation, intention, or plan. August 9, 2019 Epstein meets with his attorneys and, unbeknownst to MCC New York personnel, changes his Last Will and Testament during the meeting. MCC New York staff receive notice that Epstein's cellmate will be transferred out of the institution the following day, August 9. MCC New York staff discover the disk failures that occurred in the DVR 2 system on July 29 and that resulted in approximately one half of the institution's security cameras not recording, although the cameras continued to broadcast a live video feed. MCC New York staff do not perform the work necessary to restore recording functionality of the DVR 2 system or address long-standing performance failures with the institution's camera system. At approximately 8:30 a.m., Epstein's cellmate (Inmate 3) is transferred out of MCC New York. Two MCC New York SHU staff members said they notified supervisory staff of Epstein's cellmate's transfer and Epstein's need for a new cellmate. Other witnesses did not corroborate these statements. Epstein is not assigned a new cellmate as required by the Psychology Department. Sometime between 8:00 a.m. and 9:00 a.m., Epstein meets with his attorneys in the attorney conference room. Epstein's attorneys ask MCC New York staff members if Epstein could be moved to a different housing unit or housed without a cellmate. MCC New York staff obtain the replacement hard drives to repair the institution's security camera system but do not complete the repairs necessary to restore recording functionality and address long-standing 18 Limited Official Use Only—Not for Public Release EFTA00172571 Limited Official Use Only—Not for Public Release performance failures with the institution's DVR 2 system. The U.S. Court of Appeals for the Second Circuit unseals approximately 2,000 pages of documents in civil litigation involving Ghislaine Maxwell, who is later convicted in December 2021 of conspiring with Epstein to sexually abuse minors over the course of a decade. Some of these documents contain information that may relate to the criminal charges pending against Epstein. There is extensive media coverage of information in the unsealed documents. At approximately 6:45 p.m., Epstein leaves the attorney conference room. At approximately 7:00 p.m., contrary to BOP policy but with the permission of a Unit Manager, Epstein is permitted to place an unmonitored telephone call to a number in the New York City area, purportedly to speak with his mother. In actuality, Epstein speaks with someone with whom he allegedly has a personal relationship. After the call, Epstein is returned to his cell, where he remains without a cellmate. MCC New York SHU staff members do not conduct the 4:00 p.m. or 10:00 p.m. inmate counts. After approximately 10:40 p.m., SHU staff members do not conduct the required 30-minute rounds. August 10, 2019 MCC New York SHU staff members do not conduct the 12:00 a.m., 3:00 a.m., or 5:00 a.m. inmate counts or any of the 30-minute rounds from 12:00 a.m. until approximately 6:30 a.m. At approximately 6:30 a.m., SHU staff begin to deliver breakfast to inmates in the SHU through the food slots in the locked cell doors. When SHU staff attempt to deliver breakfast to Epstein, SHU staff unlock the door to the tier in which Epstein's cell was located and then knock on the door to Epstein's cell. Epstein, who is housed alone in the cell, does not respond to SHU staff. SHU staff unlock the cell door and find Epstein hanged in his cell, with one end of a piece of orange cloth around his neck and the other end tied to the top portion of a bunkbed in Epstein's cell. Epstein is suspended from the top bunk in a near-seated position with his buttocks approximately 1 inch to 1 inch and a half off the floor and his legs extended straight out on the floor in front of him. SHU staff immediately activate a body alarm, which notifies all MCC New York staff of a medical emergency and prompts MCC New York staff in the Control Center to call for 911 emergency services. SHU staff then rip the orange cloth away from the bunkbed, which causes Epstein's buttocks to drop to the ground. SHU staff lay Epstein on the ground and immediately 19 Limited Official Use Only—Not for Public Release EFTA00172572 Limited Official Use Only—Not for Public Release initiate cardiopulmonary resuscitation (CPR). At approximately 6:33 a.m., BOP medical staff respond to the SHU, continue CPR, apply the automated external defibrillator, and move Epstein to MCC New York's Health Services Unit. Minutes after arriving in the Health Services Unit, an ambulance arrives and paramedics continue CPR, incubate Epstein, and administer medications and fluids. At approximately 7:10 a.m., the ambulance takes Epstein to New York Presbyterian Lower Manhattan Hospital, where he is pronounced dead at 7:36 a.m. by the emergency room physician. MCC New York staff unsuccessfully attempts to recover video from the DVR 2 system of the SHU and the FBI seizes all hard drives contained in the DVR 2 system as evidence. The BOP begins repairing the DVR 2 system. August 11, 2019 The Office of the Chief Medical Examiner, City of New York, performs an autopsy on Epstein. August 14-15, 2019 August 16, 2019 The FBI returns to MCC New York and seizes additional components of the DVR 2 system and the entire DVR 1 system. The FBI's Digital Forensics Analysis Unit in Quantico, Virginia, subsequently begins to conduct a forensic analysis of MCC New York's DVR systems and determines that there was catastrophic disk failures in the DVR 2 system disk array, and no recordings were available on the DVR 2 system after July 29, 2019. The Office of the Chief Medical Examiner, City of New York, releases its findings publicly that the cause of death was hanging and that the manner of death was suicide. 20 Limited Official Use Only—Not for Public Release EFTA00172573 Limited Official Use Only—Not for Public Release Chapter 4: Custody and Care of Epstein Prior to His Death I. Epstein's Arrest and Detention on July 6 On July 2, 2019, a grand jury of the U.S. District Court for the Southern District of New York returned a two- count indictment that charged Epstein with committing sex trafficking and a sex trafficking conspiracy, in violation of 18 U.S.C. §§ 371, 1591(a), (b)(2), and 2, based on allegations that he sexually exploited and abused dozens of minor girls, some as young as 14 years old, at his homes in New York and Florida. The indictment alleged that from at least 2002 through 2005, Epstein enticed and recruited girls, many of whom he knew were underage, to visit his homes and perform sex acts in exchange for paying each girl hundreds of dollars in cash. The indictment further alleged that Epstein, working with employees and associates, created a vast network of underage victims to sexually exploit in New York and Florida by paying some victims hundreds of dollars in cash each to recruit other minor girls to be similarly abused by Epstein. In addition to the two criminal charges, the indictment also contained forfeiture allegations, which sought to forfeit to the United States any property that was either used to commit or was a proceed of the charged sex trafficking offense, including Epstein's New York residence. On Saturday, July 6, 2019, Epstein was arrested at Teterboro Airport in New Jersey upon his return to the United States from France. He was transported to the Metropolitan Correctional Center located in New York, New York (MCC New York), where he was initially placed in the general inmate population. MCC New York is a federal administrative detention facility operated by the Federal Bureau of Prisons (BOP). The BOP temporarily closed MCC New York in October 2021 due to substandard conditions that are unrelated to this investigation. When it was operational, MCC New York housed primarily pretrial detainees who had not yet been convicted of any offense, but whom the court had determined under applicable law should remain in custody pending trial either because they represent a danger to the community, a substantial flight risk, or both. Due to the significant media attention surrounding his arrest and his notoriety among other MCC New York inmates, the following day Epstein was moved to MCC New York's Special Housing Unit (SHU), a housing until within MCC New York where inmates are securely separated from the general inmate population, and kept locked in their cells for approximately 23 hours per day, to ensure their own safety as well as the safety of staff and other inmates. On Monday, July 8, 2019, Epstein appeared in federal court and pleaded not guilty to the charges. The court ordered that Epstein remain in custody pending a detention hearing scheduled for July 15, 2019. At the detention hearing, Epstein sought to be placed in home detention at his New York residence with electronic monitoring and other conditions. The prosecutors sought to have Epstein detained at MCC New York pending trial. The court reviewed the parties' filings and heard argument on the matter of pre-trial release on July 15, 2019. On July 18, 2019, the court ordered that Epstein be detained pending trial. In its ruling, the court noted that because Epstein had been indicted for a violation of the federal sex trafficking statute that involved minor victims, there was a presumption in favor of detention under federal law. The court found that the United States had shown by clear and convincing evidence that Epstein threatened the safety of another person and of the community based on testimony from two victims, the allegations of repeated sexual abuse of minors, and the lewd photographs of young-looking women or girls that were found during an authorized search of Epstein's New York residence in July 2019. The court also relied on the recommendation of U.S. Pretrial Services, the seriousness of the offenses with which Epstein had been charged, evidence reflecting Epstein's harassment and intimidation of and tampering with witnesses involved in a prior Florida state criminal investigation, and Epstein's lack of compliance with his legal 21 Limited Official Use Only—Not for Public Release EFTA00172574 Limited Official Use Only—Not for Public Release obligations as a registered sex offender. The court found that the United States had also shown by a preponderance of the evidence that Epstein was a flight risk based on the severity of the criminal charges and severity of the potential punishment the strength of the evidence against Epstein; and Epstein's criminal history, sex offender registration, vast wealth and substantial liquid assets, multiple residences, a foreign residence, limited family ties in the United States, private plane(s), extensive overseas travel, and possession of a foreign passport bearing Epstein's photograph but not his name. Finally, the court found that Epstein's pretrial release proposal was inadequate because, among other things, it did not contain sworn, accurate, or comprehensive financial statements; it required excessive court involvement in routine aspects of the proposed home confinement the proposed consent to extradition was unenforceable; and the proposed appointment of a trustee to monitor Epstein's compliance with release conditions was unacceptably vague and problematic due to the potential conflict of interest presented by monitoring the conduct of a person who paid the trustee's salary, and allegations that Epstein engaged in unlawful acts with his employees during the sex trafficking conspiracy. Epstein appealed the court's order on July 22, 2019. This appeal remained pending at the time of Epstein's death. II. MCC New York's Special Housing Unit (SHU) ‘Nk Epstein was initially assigned to MCC New York's general inmate population, but on July 7, 2019, at approximately 7:20 p.m., he was moved to the SHU pending reclassification due to the significant increase in media coverage and awareness of his notoriety among other MCC New York inmate residents. The SHU is a housing unit within MCC New York where inmates are securely separated from the general inmate population, and kept locked in their cells for approximately 23 hours a day, to ensure their own safety as well as the safety of staff and other inmates. Inmates in the SHU are either on administrative detention or disciplinary segregation status. Administrative segregation status is a non-punitive designation that removes an inmate from the general population when it is necessary to do so to ensure the safety, security, and orderly operation of the correctional facility or to protect the public. The MCC New York employee who was the Acting Evening Watch Activities Lieutenant on August 9, 2019, told the OIG that most inmates housed in the SHU are "locked down" in their cells for most of the day. Other witnesses told the GIG that SHU inmates are locked in their cells for approximately 23 hours a day. The Warden of MCC New York during Epstein's period of detention at that facility, along with Associate Warden 1 and the Acting Evening Watch Activities Lieutenant, explained that this was one of the reasons that conducting rounds in the SHU was so important. Unlike inmates in general population housing, SHU inmates could not physically approach a staff member; therefore, the staff member had to go to each inmate's cell. Witnesses told the OIG that Epstein's daily routine in the SHU was to meet with his attorneys in the attorney conference room all day until approximately 8:00 p.m.22 MCC New York attorney logs confirmed that Epstein had daily visits with attorneys from several different law practices throughout the period of his detention at MCC New York. This is consistent with the information available in SENTRY, a BOP database that contains information relating to the care, classification, subsistence, protection, discipline, and programs of federal inmates, which indicates that Epstein had 1-2 attorney visits on all but 1 day he was detained at MCC New York. SOP emails reflect that other attorneys expressed frustration to a Supervisory Staff Attorney with the BOP's Consolidated Legal Center for New York because attorneys had to wait hours or were unable to meet with their clients because Epstein and his attorneys were occupying the attorney 22 As discussed in Chapter 1, BOP policy provides that SHU inmates may be escorted from their cells by MCC New York staff for visits, including legal visits, court appearances, medical and psychological attention, showers, and recreation. 22 Limited Official Use Only—Not for Public Release EFTA00172575 Limited Official Use Only—Not for Public Release conference room, even at times when Epstein had to leave the conference room for a medical visit At MCC New York, the SHU was located on the south side of the institution's ninth floor and was often referred to as "9 South." Primary access to the SHU was controlled by a locked door adjacent to the elevator bay on the north side of the floor (Main Exterior Entry Door). That door was opened remotely by a staff member in MCC New York's centralized Control Center, which is located on the first floor of the institution. Access into the SHU from the primary elevator bay was further controlled by a second locked door (Main Interior Entry Door), to which only one of the correctional officers assigned to the SHU had keys, while on duty. Ax. Secondary access to the SHU was controlled by a locked door adjacent to the elevator bay on the south side of the floor. That door was opened remotely by a staff member in the centralized Control Center. Access into the SHU from the secondary elevator bay was further controlled by three additional locked doors, to which only one of the correctional officers assigned to the SHU had keys, while on duty. The secondary elevators and access doors were used only by staff when facilitating visits between the SHU inmates and their outside visitors. 4IL. Within the SHU, inmates were assigned to six separate tiers or groups of cells, three of which were accessible via stairs leading up from the common area on the ninth floor (Upper Tiers—G, J, and L Tiers) and three of which were accessible via stairs leading down from the common area on the ninth floor (Lower Tiers—H, K, and M Tiers). The entrance to each tier could be accessed only via a single locked door at the top or bottom of the staircase leading to the individual tier. Keys to open the locked tier doors were available only to one of the correctional officers assigned to the SHU, while on duty. Each tier had eight cells, each of which could house either one or two inmates. Each individual cell, which was made of cement and metal, could be accessed only through a single locked door, to which only one of the correctional officers assigned to the SHU had keys, while on duty. The SHU cell doors were made of solid metal with a small glass window and small locked slots that correctional staff used to handcuff inmates and provide food or toiletries to inmates. As a further security measure, during each shift the keys to the SHU tier doors and SHU cell doors were carried by different officers assigned to the SHU. As noted above, inmates in the SHU are securely separated from the general inmate population and are kept locked in their cell when in their assigned tier within the SHU. Witnesses told the OIG that SHU inmates are locked in their cells for approximately 23 hours a day. SOP policy provides that, weather and resources permitting, SHU inmates will have the opportunity to exercise outside of their quarters 5 hours per calendar week. Under federal regulations and BOP policy, SHU inmates ordinarily have the opportunity to shower at least three times a week, typically on different days in 1-hour periods. SHU inmates may also be escorted from their cells by MCC New York staff for visits, including legal visits, court appearances, medical and psychological attention. The MCC New York SHU Post Orders require that all visitors to the SHU be documented in the SHU visitor log, and that any inmate visiting the SHU, such as inmates on work details, be searched visually and with a hand-held metal detector, without exception. The MCC New York SHU Post Orders also require that food carts be searched inside and out before being brought into a SHU cellblock and that all meals be delivered through the cell door food slot of the locked cell door. 23 Limited Official Use Only—Not for Public Release EFTA00172576 Limited Official Use Only—Not for Public Release Figure 4.1: Primary SHU Entrance (Ninth Floor) Main Interior Entry Door Figure 4.2: Secondary SHU Entrance (Ninth Floor) South Elevato, I i i ej -1 _ I / Ie e Main Entry Door (not pictured) 24 Limited Official Use Only—Not for Public Release EFTA00172577 Limited Official Use Only—Not for Public Release Figure 4.3: Tiered Structure of SHU (2-Dimensional) Upper Tiers Figure 4.4: Tiered Structure of SHU (3-Dimensional) 25 Limited Official Use Only—Not for Public Release EFTA00172578 Limited Official Use Only—Not for Public Release Figure 4.5: Stairways Leading to SHU Upper and Lower Tiers Ill. Epstein's Initial Cell and Cellmate Assignment from July 7 to July 23 According to the Warden, MCC New York typically housed inmates in the SHU with a cellmate. Upon Epstein's initial transfer to the SHU on July 7, 2019, he was assigned a cell in the M Tier of the SHU with Inmate 1. The Warden explained that Epstein was a high-profile inmate and that he initially selected Inmate 1 to be Epstein's cellmate because Inmate 1 was another high-profile inmate, and the Warden believed Inmate 1 to be the least likely SHU inmate to harm Epstein.23 Epstein and Inmate 1 were housed together in cell Z05-124. IV. Events of July 23 and the Placement of Epstein on Suicide Watch and Psychological Observation from July 23 to July 30 According to BOP documents, at approximately 1:27 a.m. on July 23, 2019, Senior Officer Specialists 1 and 2 heard noise coming from the M Tier in the SHU, the tier where Epstein was housed. Senior Officer Specialist 2 documented in a BOP report that upon checking cell Z05-124, he saw Epstein laying down near his bunk with 'a piece of handmade orange cloth" around his neck, and Senior Officer Specialist 1 wrote in a BOP report that Epstein's cellmate (Inmate 1) said Epstein had attempted to hang himself. In his interview with the OIG, Senior Officer Specialist 1 said that Inmate 1, who appeared shaken up, told him that he had been 23 In 2008, Epstein pleaded guilty in a Florida state court to a felony charge of procurement of minors to engage in prostitution in violation of Florida Statute § 796.03. As a result of this conviction, Epstein was required to register as a sex offender. 26 Limited Official Use Only—Not f