EPSTEIN
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IV.
Events of July 23 and the Placement of Epstein on Suicide Watch and Psychological Observation
from July 23 to July 30
V.
The Psychology Department's Post-July 23 Determination that Epstein Needed to Have an
Appropriate Cellmate
VI.
Selection of Epstein's Cellmate After Psychological Observation
VII.
Epstein's Cell Assignment from July 30 to August 10
VIII.
Psychological Evaluations of Epstein from July 6 to August 9
Chapter 5: The Events of August 8-10, 2019, and Epstein's Death
I.
Epstein Signs a New Last Will and Testament on August 8
II.
Court Order on August 9 Releasing Epstein-Related Documents in Pending Civil Litigation
III.
Transfer of Epstein's Cellmate on August 9 to Another Institution and Failure to Replace Him with
Another Inmate
A.
Notice on August 8 of the Impending Transfer of Epstein's Cellmate on August 9
B.
MCC New York Staff Reject Epstein Attorney's Request that Epstein be Housed Without a
Cellmate
C.
Removal on August 9 of Epstein's Cellmate from MCC New York
D.
Failure to Assign Epstein a New Cellmate on August 9
IV.
Epstein is Allowed to Make an Unmonitored Telephone Call on August 9
V.
Failure to Conduct SHU Inmate Counts and Staff Rounds on August 9--10
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A.
SHU Inmate Counts
B.
Staff Rounds in the SHU
VI.
Epstein's Death on August 10
A.
Discovery of Epstein Hanged in Cell and Emergency Response
B.
Items Found in Epstein's Cell on August 10 Following His Death
C.
Autopsy Results
Chapter 6: The Availability of Limited Recorded Video Evidence Due to the Security Camera
Recording System Failure
I.
Background on the Security Camera System at MCC New York
II.
Discovery of Security Camera System Recording Issues in August 2019
A.
Discovery on August 8 of the DVR 2 Failure that Occurred on July 29
B.
Response on August 8 and 9 to Discovery of the Recording Failure
C.
SHU Camera Locations and Operational Status on August 10
D.
FBI Forensic Analysis of the DVR System
Chapter 7: Conclusions and Recommendations
I.
Conclusions
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
B.
MCC New York Staff Failed to Conduct Mandatory Rounds and Inmate Counts Resulting in
Epstein Being Unobserved for Hours Before His Death
102
C.
MCC New York Staff Allowed Epstein to Place an Unmonitored Telephone Call on August 9 107
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
108
E.
MCC New York Staff Failed to Ensure that the Institution's Security Camera System was Fully
Functional Resulting in Limited Recorded Video Evidence
109
II.
Recommendations
110
Appendix A: The BOP's Response to the Draft Report
115
Appendix B: OM Analysis of the BOP's Response
118
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Chapter 1: Introduction
The Federal Bureau of Prisons (13OP) is a component of the Department of Justice (DOJ) that operates
122 institutions across the United States. According to its website, the BOP's current mission statement is
"Corrections professionals who foster a humane and secure environment and ensure public safety by
preparing individuals for successful reentry into our communities." However, the DOJ Office of the
Inspector General (OIG) has issued numerous reports over more than a decade identifying long-standing
operational challenges facing the BOP that have negatively affected its ability to operate its institutions
safely and securely. Those reports have contained dozens of recommendations to the BOP. As we detail in
this report, many of those same operational challenges and systemic issues, including significant staffing
shortages, providing appropriate custody and care of inmates at risk for suicide, the absence of functional
security camera systems, and management failures and widespread disregard of BOP policies and
procedures, were once again identified by the OIG during the course of this investigation and review into
the custody, care, and supervision of one of the SOP's most notorious inmates, Jeffrey Epstein. We
therefore make further recommendations to the BOP in the conclusion of this report to help it address
these recurring issues.
The OIG initiated this investigation upon the receipt of information from the BOP that on the morning of
August 10, 2019, in the Metropolitan Correctional Center located in New York, New York (MCC New York),
inmate Jeffery Epstein was found hanged in his assigned cell within the Special Housing Unit (SHU). The SHU
is a housing unit where inmates are securely separated from the general inmate population and kept locked
in their cells for approximately 23 hours a day, to ensure their own safety as well as the safety of staff and
other inmates. Epstein had been placed in the SHU on July 7, 2019, the day after his arrest, due to the
significant media coverage of his case and awareness of his notoriety among MCC New York inmates.