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The OIG Report Into Jeffrey Epstein's Death: Conclusions And Recommendations (Chapter 7) (Part 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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We're going to pick right back up with that OIG report,
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and in this episode we're going to start looking at
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Chapter seven Conclusions and Recommendations, Part one Conclusions. Our investigation
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and review of the Federal Bureau of Prisons custody care
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and supervision of Jeffrey Epstein identified numerous and serious failures
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by employees of the Metropolitan Correctional Center located in New York,
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New York MCC New York, including falsifying BOP records relating
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to inmate counts, en rounds, and multiple violations of MCC
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New York and BOP policies and procedures which compromised Epstein's safety,
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the safety of other inmates, and the security of the institution. Specifically,
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we found that MCC New York staff failed to undertake
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the row quai fired measures designed to make sure that,
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among other things, Epstein and other inmates were accounted for
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and safe, such as conducting inmate counts and thirty minute rounds,
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searching inmate cells, and ensuring adequate supervision of the Special
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Housing unit, and the functionality of MCC New York's security
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camera system. We further found that multiple BOP employees submitted
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false documents claiming that they had performed the required counts
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en rounds, and that several MCC New York staff members
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lacked candor when questioned by the Office of the Inspector
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General about their actions. Two MCC New York employees, Touvin
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Owell and Michael Thomas, were charged criminally with falsifying BOP
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records relating to their conducting inmate counts and rounds. The
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US Attorney's Office for the Southern District of New York
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subsequently entered into deferred prosecution agreements with Noel and Thomas,
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and the court dismissed all charges against them. After Noel
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and Thomas successfully fulfilled the terms of their agreements. Prosecution
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was declined by the US Attorney's Office for the Southern
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District of New York for other MCC New York employees
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assigned to the Shoe on August nineth and tenth, twenty nineteen,
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who the OIG found also created, certified, and submitted false
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documentation regarding inmate counts and rounds on the day before
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and the day of Epstein's death. The OIG also found
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that the MCC New York staff failed to carry out
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the Psychology departments directive that Epstein be assigned to cellmate,
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and that an mcc new York supervisor allowed Epstein to
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make an unmonitored phone call the evening before his death.
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The OIG determined that the combination of these and other
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failures led to Epstein being alone and unmonitored in his
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cell with an excessive amount of bed linens from approximately
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ten pm on August ninth until he was discovered hanged
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in his cell at approximately six thirty am the following day. Additionally,
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the OIG found that staffing shortages, a persistent issue for
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the BOP, compromised the ability of mcc new York staff
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to adequately supervise inmates, as detailed below. We make a
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number of recommendations to the BOP to address the serious
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issues we identified during our investigation and review. While the
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OIG determined that mcc new York staff committed significant violations
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of BOP and MCC new York policies and falsified records
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relating to their conducting inmate counts and rounds, the OIG
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did not uncover evidence that contradicted the FBI's determination regarding
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the absence of criminality in connection with how Epstein died.
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All MCC New York staff members who were inner viewed
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by the OIG said that they did not know of
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any information suggesting that Epstein's cause of death was something
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other than suicide. Likewise, none of the interviewed inmates provided
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any credible information that Epstein's cause of death was something
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other than suicide. As detailed in Chapter four of this report,
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the Shoe was a housing unit within the MCC New
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York where inmates were securely separated from the general inmate
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population and kept locked in their cells for approximately twenty
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three hours a day to ensure their own safety as
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well as the safety of staff and other inmates. Access
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to the Shoe was controlled by multiple locked doors. The
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primary entrance to the Shoe, main exterior entry door, was
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opened remotely by a staff member in mcc new York
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Centralized Control Center. Additionally, there was a second locked door
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at the main entrance main interior entry door, which could
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be opened only with the key held by a limited
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nun number of correctional officers while on duty. Within the Shoe,
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the entrance to each tier could be accessed only via
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a single locked door at the top or bottom of
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the staircase leading to the individual tier. Keys to open
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the locked tier doors were available only to a limited
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number of cos while on duty. Each tier had eight cells,
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each of which could house either one or two inmates.
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Each individual cell, which was made of cement and metal,
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could be accessed only through a single locked door, to
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which only a limited number of cos had keys while
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on duty. The Shoe cell doors were made of solid
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metal with a small glass window and small locked slots
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that correctional staff used to handcuff inmates and provide food
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and toilet trees two inmates as a further security measure.
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During each shift, a limited number of the coos had
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keys while on duty. While BOP policy in practice require
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that all shoe inmates be locked in their cells overnight,
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the OIG found no evidence indicating that the door to
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Epstein's cell, or any other cell in the shoe tier
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in which Epstein was housed, was unlocked on the evening
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of August ninth and tenth, twenty nineteen, after Shoe staff
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locked Epstein in his cell at approximately eight pm. Shoe
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staff told the OIG that at approximately eight pm on
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August ninth, all Shoe inmates were locked in their cells
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for the evening, and that there was no indication that
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any of the other inmates could have gotten out of
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their cells. Epstein did not have a cell mate after
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inmate Ireie was transferred out of mcc New York on
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August ninth, and therefore Epstein was alone in his cell
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the evening of August ninth and tenth. The door to
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Epstein's cell was visible from the shoe officer's station, and
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co toven Noel and material handler Michael Thomas told the
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OIG that no one entered or exited epstein cell during
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their shift on August tenth. Both of them further described
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delivering breakfast to the el tier at about six thirty
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am on August tenth, and al Noel unlocked the door
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to the el tier. Thomas entered the el tier and
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called for Epstein, and then Thomas unlocked a cell door
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when Epstein failed to respond. Additionally, the three inmates who
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were housed in the same Shoe tier as Epstein on
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August ninth and tenth, who had a direct line of
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sight to the door of epstein cell from their cells,
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stated that no one entered or exited epstein cell after
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the shoe staff returned Epstein to is cell on the
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evening of August ninth, which is consistent with the security
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measures in place within the MCC New York Shoe. Further,
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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 officer's station. Due to the mcc new
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York security camera systems video recording issues that we detailed
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in chapter six. The OIG's analysis of the recorded video
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did not identify any CEOs other than those assigned to
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the shoe during that time frame or had a specific
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reason for visiting the shoe, or other individuals present in
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the common area of the shoe approach any of the
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shoe tiers, including the L tier where Epstein was housed,
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between approximately ten forty pm on August ninth and approximately
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six thirty am on August tenth. In some the OIG's
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investigation did not find any evidence that anyone was present
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in the L Tier during that time frame other than
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the inmates who were locked in their assigned cells on
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that tier of the shoe. We also noted that the
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surveillance cameras in the L tier, as shown in the
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photograph in figure sixt seven, was in plain view of
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the inmates, and therefore the inmates would have been aware
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that any hallway movements, including into or out of Epstein's cell,
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were being live streamed and could be monitored, even if
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unbeknownst to them, the digital video recording system was not
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recording the live stream at the time. As the OIG
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is noted in numerous prior reports regarding the BOP's camera system,
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BOP staff and inmates are aware of where prison cameras
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are located and often engage in wrongdoing in locations where
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they know cameras are not located. Additionally, the OIG did
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not observe on the recorded video of the Shoe common
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area that Noel and Thomas, who were seated at the
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desk at the Shoe Officer's station immediately outside the L
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tier during that time period, at any time, rose from
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their seats or approached the L tier. We additionally found
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that Thomas and Noel's reaction on the morning of August tenth,
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upon finding Epstein hanging in his cell, as described to
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us by Thomas, Noel, the responding lieutenant, and inmates, was
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consistent with their being unaware of any ctential harm to
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Epstein prior to Thomas entering Epstein's cell at about six
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thirty am on August tenth. We further noted that Epstein
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had previously been placed on suicide watch and psychological observation
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due to the events of July twenty third, twenty nineteen,
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that numerous newses made from prison bed sheets were found
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in his cell on the morning of August tenth, and
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that he had signed a new last will and testament
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on August eighth, two days before he died. No weapons
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were recovered from Epstein's cell after his death. Additionally, the
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inmates who were interviewed consistently reported that on the evening
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Epstein died, the Shoe staff did not systematically conduct or
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required rounds and counts, which was one of the primary
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mechanisms for the Shoe staff to ensure the safety and
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security of inmates housed in the Shoe. As a result,
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Epstein was unmonitored and locked alone in his cell for
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hours with an excess amount of linens, which proved an
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opportunity for him to commit suicide. Finally, the medical examiner
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who performed the autopsy detailed for the OIG why Epstein's
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injuries were more consistent with and indicative of a suicide
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by hanging rather than homicide by strangulation. The medical examiner
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also told the OIG that the ligature furrow was too
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broad to have been caused by electrical cord of the
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medical device in Epstein's cell, and the blood toxicology tests
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revealed no medications or legal substances were in Epstein's system.
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The medical examiner also noted the absence of debris under
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Epstein's fingernails, marks on his hands, contusions to his knuckles,
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or bruises on his body that would have indicated Epstein
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had been in a struggle, which would have been expected
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if Epstein's death had been a homicide by strangulation. This
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is not the first time that the OIG has found
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significant job performance and management failures on the part of
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BOP personnel and widespread disregard of BOP policies that are
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designed to ensure that inmates are safe, secure, and in
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good health. For instance, the OIG's December twenty twenty two
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investigation and review of the BOP's handling of the transfer
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of James Whitey Bulger identified serious job performance and management
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failures at multiple levels within the BOP. Similar to the
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Bulger report, the numerous and serious transgressions that occurred in
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this matter came to light largely because they involved a
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high profile inmate. The fact that serious deficiencies occurred in
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connection with high profile inmates like Epstein and Bulger is
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especially concerning given that the BOP would presumably take particular
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care in handling the custody in care of such inmates. Regrettably,
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the OIG has encountered similar issues on many other occasions.
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For example, theg IS investigated numerous allegations related to the
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falsification of a official GOP documentation concerning inmate counts and rounds,
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several of which have resulted in criminal prosecution. The OIG
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currently has two open investigations into allegations of falsified inmate
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count and round documentation, each involving an inmate death by
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suicide and homicide or escape from a BOP facility. This
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investigation and review also revealed the direct impact of insufficient
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staffing levels on inmate safety. Witnesses repeatedly told the OIG
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that counts, round cell searches, and other methods of inmate
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accountability were not undertaken because correctional staff were working multiple shifts,
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including one staff member who worked twenty four hours straight,
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and were tired and overwhelmed with the duties. As discussed
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in greater detail in our recommendations, the OIG is repeatedly
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found the need for BOP to address staffing shortages. Most recently,
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in March of twenty twenty three, the OIG found that
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the coronavirus disease twenty nineteen pandemic accelerated the effects of
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pre existing BOP medical and non medical staffing shortages and
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issue the OIG as identified as a concern for the
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BOP since at least twenty fifteen. Further, the OIG has
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repeedily found that BOP personnel have not consistently been attentive
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to the needs of inmates at risk for suicide. In
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this investigation, that inattention manifested in the failure of mcc
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New York staff and supervisors to ensure that Epstein was
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assigned to cellmate as required by mcc new York Psychology
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Department directive issued after July twenty three, twenty nineteen, in
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which Epstein was discovered in his cell with an orange
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cloth around his neck. In March twenty twenty three's report,
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the OIG found that BOP psychology staff did not assess
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the suitability of a single cell assignment for five of
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the seven inmates who died by suicide while in COVID
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quarantine units between March twentieth and April twenty twenty one.
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The OIG's twenty seventeen report on the BOP's use of
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restrictive housing for inmates with mental illness also noted that
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single selling may present risk to inmate mental health, and
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both the recommendations from that report regarding the use of
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oversight of single selling remain open as of March of
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twenty twenty three. Lastly, as discussed in greater detail in
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the conclusions and recommendations that follow, the persistent deficiencies of
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the BOP security camera systems are well documented in long standing.
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The combination of negligence, misconduct, and outright job performance failure
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documented in this report all contributed to an environment in
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which arguably one of the most notorious inmates and BOP's
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custody was provided the opportunity to take his own life,
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resulting in significant questions being asked about the circumstances of
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his death, how it could have been allowed to happen,
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and most importantly, depriving his numerous victims, many of whom
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were under age girls at the time of the alleged crimes,
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of their ability to seek justice through the criminal justice process.
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The fact that these failures have been reoccurring once at
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the BP does not excuse them and gives additional urgency
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to the need for the Department of Justice and BOP
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leadership to address the chronic staffing, surveillance, security, and related
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problems plaguing the BP. The OIG is completed its investigation
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and is providing this report to the GOP for appropriate action.
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Unless otherwise noted. The OIG applies the preponderance of evidence
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standard in determining whether DOGA personnel have committed misconduct. The
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US Merit System Protection Board applies the same standard when
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reviewing a federal agency's decision to take adverse action against
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an employee based on such misconduct. C five USC Section
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seventy seven oh one C one B and five CFR
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Section twelve oh one dot fifty six B one Section two.
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All Right, folks, that's going to wrap up this episode here,
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and in the next episode, we're going to pick up
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on the recommendations. All of the information that goes with
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the episode can be found in the description box.