EPSTEIN
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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 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
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moved by medical staff to the MCC New York Health Service Unit., The Clinical Nurse continuously
administered CPR until he was relieved by outside Emergency Medical Technicians (EMT) when they arrived
at the Health Services Area minutes later. The EMTs continued CPR, intubated Epstein, and administered
medication and fluids in their efforts to revive him. At approximately 7:10 a.m., Epstein was transported by
the EMTs in an ambulance to New York Presbyterian Lower Manhattan Hospital, where he was pronounced
dead by an emergency room physician at 7:36 a.m. On August 11, 2019, the Office of the Chief Medical
Examiner, City of New York, performed an autopsy on Epstein and determined that the 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