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The OIG Report Into Jeffrey Epstein's Death: Introduction (Chapter 1) · The Vault: The Epstein Files

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Speaker 1: What's up, everyone, and welcome back to the Epstein Chronicles.
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The Inspector General drop their report this week, and that
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report is now what we would call the official narrative.
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So what we're going to do is we're going to
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go through the whole entire Inspector General Report, chapter by chapter,
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and we're going to get the official narrative added to
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the catalog without any commentary from me. That way, you
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have the unadulterated version of what the government says happened here,
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and then you can make up your own mind. So,
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each one of these episodes that we do about this
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Inspector General report will be one chapter. Now, if there
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are some exceptionally long chapters, what we'll do is we'll
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add two parts to that chapter, but the general format
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will be one chapter, one episode until we get through
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all one hundred and twenty eight pages. So let's just
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dive in, and we're going to start with chapter one,
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the introduction. There's a table of contents previously, and when
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you click on the link, you'll be able to check
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that out for yourself, but we're not going to add
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that here. We're just going to add what the Inspector
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General found and that starts with Chapter one, the introduction.
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The Federal Bureau of Prisons BOP is a component of
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the Department of Justice that operates one hundred and twenty
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two institutions across the United States. According to its website,
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the BOP's current mission statement is corrections professionals who foster
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a humane and secure environment to ensure public safety by
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preparing individuals for successful re entry into our communities. However,
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the DOJ Office of the Inspector General has issued numerous
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reports over more than a decade identifying long standing operational
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challenges facing the BOP that have negatively effect its ability
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to operate its institutions safely and securely. Those reports have
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contained dozens of recommendations to BOP. As we detail in
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this report, many of those same operational challenges and systemic issues,
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including significant staffing shortages providing appropriate custody and cara of
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inmates at risk for suicide, the absence of functional security
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camera systems and management failures, and widespread disregard of BOP
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policies and procedures, were once again identified by the OIG
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during the course of this investigation and review into the custody,
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care and supervision of one of the Goop's most notorious inmates,
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Jeffrey Epstein. We therefore make further recommendations to the BP
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in the conclusion of this report to help it address
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these reoccurring issues. The OIG initiated this investigation upon the
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receipt of information from the BP that the morning of
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August tenth, twenty nineteen, in the Metropolitan Correctional Center located
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in New York, New York MCC New York, inmate Jeffrey
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Epstein was found hanged in his assigned cell within the
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Special Housing Unit, or the SHOE. The SHOE is a
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housing unit where inmates are securely separated from the general
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inmate population and kep locked in their cells for approximately
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twenty three hours a day to ensure their own safety
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as well as the safety of the staff and other inmates.
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Epstein had been placed in the Shoe on July seven,
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twenty nineteen, the day after his arrest, due to the
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significant media coverage of his case and awareness of his
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notoriety among MCC New York inmates. According to information obtained
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by the OIG during the investigation, at approximately eight p m.
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On August ninth, all SHOE inmates, including Epstein were locked
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in their cell for the evening. Additionally, the six separate
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teers or groups of cells within the shoe were also
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securely locked. At approximately six thirty a m. On August tenth,
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twenty nineteen, shoe staff unlocked the door to the shoe
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tier in which Epstein's cell was located in order to
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deliver breakfast to inmates through the food slots in the
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locked cell doors. When shoe staff entered the tier to
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deliver breakfast to Epstein, Shoe staff knocked on the locked
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door to Epstein's cell. Epstein, who was housed alone in
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his cell, did not respond to shoe staff. Shoe staff
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unlocked the cell door and found Epstein hanged in a
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cell with one end of a piece of an orange
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cloth around his neck and the the other end tied
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to the top portion of a bunk bed. In Epstein's cell,
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Epstein was suspended from the top bunk in a near
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seated position, with his buttocks approximately one inch to one
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inch and a half off the floor and his legs
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extended straight out on the floor in front of him.
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Epstein's cell contained an excess amount of prison linens, as
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well as multiple nooses that had been made from torn
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prison linens. Shoe staff immediately activated a body alarm, which
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notified all mcc new York staff of a medical emergency
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and prompted mcc new York staff assigned to the control
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center to call nine to one one emergency Services. Shoe
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staff then ripped the orange cloth away from the bunk bed,
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which caused Epstein's buttocks to drop to the ground. Shoe
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staff laid Epstein on the ground and immediately initiated CPR.
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At approximately six thirty three am, other mcc new York
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employees responded to the shoe. A responding mcc new York
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lieutenant took over administering CPR and asked shoe staff to
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retrieve an automated external defibrillator and called for the duty nurse.
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A clinical nurse responded and continued to perform CPR on
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Epstein in place of the lieutenant. At approximately six thirty
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nine am, Epstein was placed on a stretcher and moved
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by medical staff to the mcc new York Health Service Unit.
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The clinical nurse continuously administered CPR until he was relieved
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by outside emergency medical technicians when they arrived at the
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Health Services area. Minutes later, the EMTs continued CPR, innovated Epstein,
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and administered medication and fluids in their efforts to revive them.
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At approximately seven ten am, Epstein was transported by EMTs
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in an ambulance to New York Presbyterian Lower Manhattan Hospital,
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where he was pronounced dead by an emergency room physician
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at seven thirty six am on August eleventh, twenty nineteen.
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The Office of the Chief Medical Examiner, City of New
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York performed an autopsy on Epstein and determined that the
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cause of death was hanging and the manner of death
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was suicide. The OIG conducted this investigation jointly with the
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Federal Bureau of Investigation, with the OIG's investigative focus being
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the conduct of BOP personnel, among other things. The FBI
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investigated the cause of Epstein's death. The FBI determined that
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there was no criminality pertaining to al Epstein had died.
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This report concerns the OIG's findings regarding mcc new York personnels, custody, care,
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and supervision of Epstein during his detention at the facility
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from his arrest on July sixth, twenty nineteen, until his
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death on August tenth of twenty nineteen. The OIG investigation
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and review identified numerous and serious failures by MCC New
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York staff, as well as multiple violations of MCC New
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York NBOP policies and procedures. Among the most significant was
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the failure to assigned Epstein a new cellmate on August ninth,
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twenty nineteen, after Epstein's cellmate was transferred out of New York.
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MCC that day. Epstein was required to have assellmate at
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all times, pursued into a written direction that the MCC
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New York Psychology Department issued on July thirtieth, after Epstein
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was removed from suicide watch and psychological observation following a
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possible attempted suicide biome on July twenty third. As a
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result of the failure to assign him a new cell mate,
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Epstein was housed alone in his cell from the night
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of August ninth until he was found hanged in his
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cell by SHOE staff at approximately six thirty a m.
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The following morning. In addition, we determined that SHOE staff
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failed to conduct or required inmate counts and rounds, including
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overnight on August ninth, and tenth, and allowed Epstein to
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have an excess of blankets, linens, and clothing in his cell.
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These failures compromised Epstein's safety, the safety of other inmates,
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and the security of the institution, and provided Epstein with
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an opportunity to commit suicide while locked alone in his
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cell on the morning of August tenth, without having been
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subject to overnight observation or supervision by SHOE staff. The
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OIG also found that an mcc new York supervisor had
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a allout Epstein, in violation of BOP policy, to make
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an unrecorded, unmonitored telephone call the evening before his death
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to an individual with whom he allegedly had a personal relationship. Further,
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two days before his death, during a meeting with his
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lawyers in a private room at the mcc new York,
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Epstein signed a new last will and testament, which mcc
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new York officials did not learn about until after his death. Additionally,
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the OIG determined that mcc new York staff assigned to
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the Shoe, including the two Shoe staff on duty the
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night of August ninth and tenth of twenty nineteen, who
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were stationed at a desk that was directly outside the
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shoe tier in which Epstein was housed and diagonally across
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from Epstein's cell, had falsified BOP records to claim that
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they had conducted all of the required counts of inmates
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and thirty minute rounds during their shifts within the Shoe.
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As described in greater detail in Chapter two. Inmate counts
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and thirty minute rounds are the means by which the
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BOP accounts for inmates and assesses their safety, security, and
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well being. BOP and MCC New York policies require the
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staff members count all inmates in each housing unit within
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the facility at designated times each day. Additionally, BOP MCC
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New York policies require that a staff member observe all
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Shoe inmates at least once during the first thirty minutes
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of each hour, for example, twelve am to twelve thirty AM,
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and again during the second thirty minutes of the hour, eg.
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Twelve thirty to one AM, thus ensuring that inmates are
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observed at least twice per hour. BOP staff are required
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to document inmate counts and thirty minute rounds on a
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official GOP forms, which are often referred to as count
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slips and round sheets. During the OIG's investigation, the OIG
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obtained information that the staff assigned to MCC New York
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Shoe did not conduct any counts of inmates within the
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shoe from August ninth, twenty nineteen, at approximately four pm
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until Epstein was found hanged in his cell on the
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morning of August tenth, twenty nineteen. However, in documentation completed
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by the shoe staff on duty during that period, staff
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members falsely certified in the count slips that they had
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conducted the required counts. Additionally, the OIG investigation revealed that
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the staff assigned to the MCC New York Shoe did
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not conduct any required thirty minute rounds of inmates after
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approximately ten forty pm on August ninth, twenty nineteen. Again, however,
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shoe's staff on duty during that period had falsely certified
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in the round sheet that the required rounds were conducted.
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The combination of these and other failures led to Epstein
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being unmonitored and locked alone in his cell, which the
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OIG found contained an excessive amount of bed linens, from
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approximately ten forty pm on August ninth until he was
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discovered hanged in his cell at approximately six point thirty
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am the following day. While the OIG determined that mcc
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new York staff committed significant violations of BOP and mcc
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new York policies and falsified records related to their conducting
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inmate counts and rounds, the OIG did not cover any
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evidence that contradicted the FBI's determination regarding the absence of
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criminality in connection with how Epstein died. All mcc new
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York staff members who were interviewed by the OIG said
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they did not know of any information suggesting that Epstein's
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cause of death was something other than suicide. Additionally, none
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of the other fifteen inmates who agreed to be interviewed
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in connection with this investigation, ten of whom were housed
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in the Shoe on August ninth and tenth, had any
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credible information suggesting Epstein's cause of death was something other
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than suicide. Further, the Shoe staff and the three interviewed
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inmates with a direct line of sight to the door
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of Epstein's cell from their cells stated that no one
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entered or exited Epstein's cell. After the Shoe staff returned
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Epstein to a cell on the evening of August ninth,
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which is consistent with the security measures in place within
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the MCC New York Shoe. Shoe staff told the OIG
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that at approximately eight pm on August ninth, all Shoe
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inmates were locked in their cells for the evening and
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d and that there was no indication that any of
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the other inmates could have gotten out of their cells. Additionally,
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the OIG analyzed the available recorded video of the shoe,
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which was limited to the common area of the shoe,
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including the shoe's officer station. Due to the MCC New
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York security camera systems recording issues that we detail in
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this report, the OIG analysis of the recorded video did
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not identify any correctional officer or other individuals approaching any
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shoe tier, including the L tier where Epstein was housed,
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from the common area of the shoe, between approximately ten
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forty pm on August ninth and approximately six thirty am
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on August tenth. Finally, the medical examiner who performed the
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autopsy detailed for the OIG why Epstein's injuries were more
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consistent with and indicative of suicide by hanging rather than
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a homicide by strangulation. The medical examiner also cited to
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the absence of debris under Epstein's fingernails, marks on his hands,
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contusions to his knuckles, or bruises on his body that
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evidenced Epstein had been a struggle, which would be expected
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if Epstein's death had been a homicide by strangulation, as
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discussed in greater detail in the Conclusions and Recommendations chapter
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of this report. This is not the first time that
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the OIG has found significant job performance and management failures
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on the part of the BOP personnel, and widespread disregard
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of BOP policies that are designed to ensure that inmates
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are safe, secure, and in good health. The OIG has
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investigated numerous allegations related to the falsification of official BOP
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documentation concerning inmate counts and rounds, and has repeatedly found
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deficiencies with a BOP's staffing levels, the custody and CARA
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of inmates at risk for suicide, and security camera systems
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at BP institutions. The combination of negligence, misconduct and outright
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job performance failures documented in this report all contributed to
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an environment which arguably one of the most notorious inmates
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in BOP's custody was provided the opportunity to take his
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own life. The BP's failures are troubling not only because
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BOP did not adequately safeguard an individual in its custody,
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but also because they led to questions about the circumstances
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surrounding Epstein's death and effectively deprived Epstein's numerous victims of
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the opportunity to seek justice through the criminal justice process.
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The fact that these failures have been reoccurring ones at
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the GOP does not excuse them and gives additional urgency
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to the need for the BOP leadership to address the
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chronic price problems plaguing the BOP. Unless otherwise noted, the
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OIG applies the preponderance of the evidence standard in determining
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whether DOJ personnel have committed misconduct. The US Merit Systems
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Protection Board applies this same standard when reviewing a federal
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agency's decision to take adverse action against an employee based
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on such misconduct. C US Code seven seven zero one
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C one B and five CFR Section twelve oh one
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dot fifty six B one, Section two. In Chapter two
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of this report, we provide background information, including identification and
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a description of significant entities and individuals, a summary of
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our methodology and the applicable laws, federal regulations, and BOP policies.
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In chapter three, we outline a timeline of key events.
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In chapter four, we say forth our findings of fact
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relating to the BOP's custody and care of Epstein before
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his death. In chapter five, we set forth our findings
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of fact related to the events of August eighth through tenth,
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twenty nineteen, including Epstein's death. In chapter six, we set
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forth our findings of fact related to the BOP's failure
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to ensure that there was a functional security camera system
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at mcc New York, which resulted in limited recorded video
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evidence relevant to Epstein's death. Finally, chapter seven contains our
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conclusions and recommendations. All right, folks, so there it is
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chapter one to get things started with the Inspector General's
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report into the circumstances surrounding Jeffrey Epstein's death while in custody.
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All of the information that goes with the episode can
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be found in the description box.