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Mega Edition: The Psychological Reconstruction Of The Events Leading To The Death of Epstein (6/2/26) · The Vault: The Epstein Files

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Speaker 1: What's up, everyone, and welcome to another episode of the
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Epstein Chronicles. In this episode, we're going to continue talking
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about the death of Jeffrey Epstein and the circumstances surrounding it,
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and to do that, we're going to start taking a
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look at the psychological response to the reconstruction of inmate
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Jeffrey Epstein. November thirteenth, twenty nineteen from Jay Petrucci, Warden
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mcc New York. This is a response to the psychological
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reconstruction of inmate Jeffrey Epstein, dated September seventeenth, twenty nineteen.
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One single ceiling. It's recommended that all inmates be double celled,
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unless safety concerns for an odd number of inmates precludes this.
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Priorities should be given to inmates with history of mental illness,
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self directed violence, recent stressors, eg losses, newly s ins, etc.
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It's recommended that a system of control be implemented, explaining
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who will be notified when a suicide watch or a
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psychological observation ends and how that communication will take place.
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Because this is a life safety issue, the system of control,
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once approved by the warden, should be reviewed in formal
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meetings such as staff recalls, department head meetings and lieutenant meetings,
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Institution response one single cell placement. A system has been
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put in place to ensure inmates are not single celled.
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A single cell report is completed during each shift by
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the Shoe Lieutenant during day watch and the Operations Lieutenant
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during the morning watch and evening watch. Notifications are made
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to the institution, Duty Officer, IDO and executive staff. Psychology
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discusses the status of inmates who are at risk for suicidality,
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their housing needs, as well as their needs for cellmates
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during staff meeting, the apartment head meetings, shoe meetings, morning meetings,
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and close out meetings. When inmates are placed on and
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off suicide watch, the warden is notified verbally regardless of
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the time of day. The warden then determines which suicide
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watch area a suicidal inmate will be housed and if
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they will be observed with an inmate companion or a
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staff member. Psychology verbally notifies the Operations Lieutenant when inmates
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are removed from suicide Watch and that they will need
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to be placed with the cell mat. Cell mats are
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recommended not only for Shoe inmates being removed from suicide Watch,
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but also for inmates returning to the general population setting.
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The CNA officer is responsible for entering the proper assignment.
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Once an inmate is removed from Suicide Watch, Psychology staff
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sends an email to the executive staff IDEO and lieutenants
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informing them that the inmate is being removed from Suicide
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Watch and can return to a cell with a cell mate.
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The email contains the name of the staff member whose
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psychology verbally spoke with This recommendation for a cellmate and
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conversation with the lieutenant is also documented in the post
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Suicide Watch report and placed in bee mr slash PDS.
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Psychology Services has eliminated the use of psychological observation to
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avoid any confusion as to the needs of inmates on
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watch status. Section two rounds thirty minute rounds are acquired
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by P five five zero zero dot one four Correctional
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Services Procedures Manual institution Response two rounds. Shoe training is
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conducted quarterly in which emphasis is placed on the importance
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of diligent rounds within the policy guided timeframes. In addition,
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the shoe lieutenant will review documentation shoe round sheets on
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a daily basis and provide the captain with an assurance
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memorandum of their completion. Weekly Shoe round sheets will be
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maintained on the specified range. To insure officers or completing
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required rounds, a staff member must observe all inmates confined
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in continuous lockdown status such as administrative detention or disciplinary
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segregation at least once in the first thirty minute period
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of the hour, followed by another round in the second
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thirty minute period of the same hour, thus ensuring an
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inmate is observed at least twice per hour. These rounds
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are to be conducted on an irregular schedule and no
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more than forty minutes apart. All observations must be documented.
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Closer observation may be required for an inmate who is
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mentally ill or who demonstrates unusual or bizarre behavior. These
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inmates have been identified with an orange photographic door tag
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to ensure a staff are aware to take more security
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precautions in dealing with this inmate. Two hour captain VIE
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review and six hour IDEO video review are being conducted.
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Number three cell made assignments. When mister Epstein was placed
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in Shoe on July seventh, twenty nineteen, the executive staff
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decided mister Tartaglioni would be a cellmate. As explained by
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doctor Miller, input was not sought from Psychology Services, and
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it's not clear if for how sex offender specific needs
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and associated risk were incorporated into the housing plan. Mister
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Tartaglioni was also a high profile inmate, an ex police
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officer charged in multiple murders. However, he and mister Apstein
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did not share the risk associated with being a sex offender,
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and the repairing may have aggravated mister Epstein's risk for
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self directed violence. In an effort to treat mister Epstein
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the same as other inmates, a statement repeated by multiple staff,
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executive staff may have inadvertently overlooked the need to consider
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a unique risk factors associated with the individuals who have
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been charged with and convicted of sex offense. On July
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twenty fifth, twenty nineteen, doctor Miller sent an email to
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Shirley Skipper Scott Associate Warden explaining a consultation between doctor
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Miller and doctor Nagel, National Suicide Prevention Coordinator. In the email,
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doctor Miller reviewed the consult and recommendation from the Psychology
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Services Branch Central Office that mister Epstein be housed with
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another inmate who had been accused of committing a sex offense.
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There is no evidence this information was considered beyond the email,
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and mister Epstein was never housed with another inmate charged
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or convicted of sexual offense. It's recommended executive staff and
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correctional service staff include a psychologist in decisions about cellmates
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as a means of incorporating expertise about suicide risk, mental
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health needs, and interventions for psychological stability institution response three
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cellmate assignments. Inmates with serious mental illness and those at
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risk for suicidality are discussed during staff meetings, the apartment
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head meetings, shoe meetings, morning meetings, and close out meetings.
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The Captain, Associate Wardens, Warden and Psychology Service discussed the
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inmates needs. The legal department also assists when the inmates,
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attorney or a court are concerned about an inmate's mental health.
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Psychology Services are involved in making recommendations regarding the type
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of cellmate with whom inmates at risk for suicide should
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be seld. Psychology Services takes into consideration the suicide risk
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factors involved with a particular inmate and shares their knowledge
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with executive staff. The psychological Reconstruction team suggests mcc new
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York executive staff did not take into account mister Epstein's
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sex offender specific needs in assigning a cellmate in the shoe. However,
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that is not correct. Mcc new York executive staff considered
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a variety of factors in determining the most appropriate cellmate
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for mister Epstein, including but not limited to history of
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sex offenses, nature of the inmate, cooperation status, etc. Mcc
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new York administrators initially housed mister Epstein with mister Tartaglioni,
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has both had high profile cases. Mister Tartaglioni is also
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a certified death penalty eligible inmate and thus, based on
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correctional judgment, less likely to assault or otherwise try to
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harm mister Epstein. Indeed, mister Tartaglioni notified staff immediately when
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he realized mister Epstein first made a possible suicide attempt
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gesture on July twenty three, twenty nineteen. Now, mind you
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just to interrupt here. They're basing this all on Tartaglioni's word.
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That's it. So you're going to take the word of
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a four time murderer okay I guess. Prior to mister
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Epstein being taken off suicide watch, mcc new York executive staff,
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with input from psychology staff, assessed all the inmates in
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Chue at the time and narrowed the list down to
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the most appropriate candidates. Mister Tartaglioni was not chosen as
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the investigation at the time had not yet cleared him
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of any wrongdoing. Most of the other inmates in Choe
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at the time were there for disciplinary reasons and were
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otherwise not appropriate to be housed with mister Epstein. The
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other notable inmate in Shoe with the history of sex offenses,
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mister Hoyt, was deemed dangerous to mister Epstein due to
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his threatening nature. Accordingly, mcc new York executive staff now
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of the possibilities to cooperators, specifically, ephrin Reis Register number
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eight five nine nine to three DASH zero five to
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four was placed in Schue for he claims he was
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being threatened and extorted on his UNI and he was
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confirmed as proffering with the US Attorney's Office as both
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he and f ex Stein were in Schoe for safety reasons.
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Mister Rayis was deemed an appropriate cellmate based on the above.
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Consideration was made for mister Epstein's sex offender specific needs
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in choosing his cellmate in the shoe. His charge crime
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was just one of the factors reviewed in making the determination.
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Mcc new York executive staff also considered high publicity, inmates
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with ample reasons not to hurt mister Epstein, and cooperators
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who are not vulnerable themselves, but also had a lot
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to lose should they harm mister Epstein. Number four Documentation accuracy.
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On July twenty three, twenty nineteen, mister Epstein was found
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on a responsive in his cell. He had abrasions on
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his neck and knee. There are inconsistencies between documents describing
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the circumstances of the scene. In a general administrative note
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in PDSBE, Mr Doctor Miller documented information received from Operations
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Lieutenant Glenn to Anderson that mister Epstein was found with
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a string loosely hanging around his neck. In contrast, Officer
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Wilson Silva, who responded to the emergency, wrote a memorandum
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dated July twenty third, twenty nineteen. In that memorandum, Officer
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Silva wrote that mister Epstein laying down near his bunk
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and what appeared to be a piece of handmade orange
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cloth around his neck. It's critical that all description of
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the incident accurately reflect objective evidence. Officer Joseph Massulo wrote
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that mister Epstein an incident report for self mutilation on
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July twenty third, twenty nineteen, after he was found on
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responsive in his cell, but prior to having necessary facts
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to determine whether he likely engaged in bureau violation. BOP
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policy expects staff to write an incident report within twenty
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four hours of having the information that an inmate likely
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violated BOP rules, without making a presumptive decision about guilt.
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A Special Investigative Service had a special threat assessment that
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was completed on August two, twenty nineteen, but the results
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were inconclusive as to whether mister Epstein engaged in self
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directed violence, willingly fought with the cell mat, or was
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assaulted by a cell mat. It's recommended that staff remain
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open to all reasonable explanations for a behavior and take
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the appropriate actions when a final determinations made. Although the
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incident report was later expunged, inmates frequently experienced significant stress
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when they contemplate the potential consequences associated with findings of guilt.
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Doctor Schlessinger entered a Psychology Service intake screening into PDS
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B E MR on July eighth, twenty ten. The document
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has three typographical errors. She selected no sexual offense conviction
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checkbox when in fact, mister Epstein was previously convicted of
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solicitation of prostitution and procuring a person under the age
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of eighteen for prostitution. Second, mister Epstein was erroneously identified
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as a blackmail in this document. Finally, there's one instance
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where he is mistakenly referred to as mister Brown. Doctor
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Schlessinger completed a risk of sexual abusiveness document on July eighth,
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twenty nineteen. She marked history of prior prison sexual predation
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in the affirmative. This is not accurate. Ismal Joaquin mid
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level practitioner completed a history and physical on July ninth,
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twenty nineteen. An intake screening should have been conducted within
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twenty four hours of his entry into bureau custody, which
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was on July sixth, twenty nineteen. According to P six
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zero three one dot zero four. Patient care Officer Alwyn
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Thomas was responsible for observing mister Epstein and documenting his
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behavior on suicide Watch. On July twenty third, twenty nineteen,
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Officer Thomas mistakenly used a suicide watch logbook intended for
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inmate companion documentation between one forty am and six am
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on July twenty three, twenty nineteen, when he should have
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been using the Staff Suicide Watch logbook. Miss Kenya Coates,
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drug treatment specialist, reportedly noticed this error and subsequently hand
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copied all of Officer thomas entries from one forty am
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to six am into a staff Suicide Watch logbook. She
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then initialed these entries, and this makes it appear as
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if she's the one conducting the watch. This information was
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discovered and conveyed in an email from Miss Charisma Edge
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Associate Warden to doctor Slesinger with a carbon copied of
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Warden and Die on August twelfth, twenty nineteen. Of note,
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Miss Coates did not make an entry explaining why she
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was making the logbook changes. Additionally, Miss Coats then wrote
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entries for six fifteen, six thirty, six forty five and
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seven am in the Staff Suicide Watch logbook. These were
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not part of the original entries. Made by Officer Thomas.
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Nor was Miss Coates assigned to work suicide Watch post
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due to the inability to interview staff at this time,
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It's unknown why Miss Coats attempted to correct Officer Thomas's
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error or made any of the subsequent log entries. It's
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recommended that if a staff member makes an entry error
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eg writes the incorrect Suicide Watch logbook, the staff member
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should describe the error in the correct logbook, to include
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indicating when they became aware of the error. The staff
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member should then notify the chief Psychologists. A review of
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Special Housing Unit records BP dash A zero two nine
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two reveal a number of incomplete entries. The document is
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used to monitor provision and receipt of basic services such
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as recreation, medical showers, meal consumption, et cetera. The officer
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in charge signature is missing in ten occasions, and a
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medical provider's signature is missing in seven instances. There are
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six instances in which it's not clear if mister Epstein
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ate his meal. There are nine instances in which it's
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not clear if mister Epstein took a shower. There are
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ten instances in which it's not clear if mister epstein
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was offered recreation P five five zero zero dot one
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five Correctional Services Manual requires accurate and complete information on
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the VP dash A zero two nine two. A review
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of psychology observation logbooks revealed significant discrepancies from the approved
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Psychological Observation Procedural Memorandum dated April fifteenth, twenty nineteen. A
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correctional officer is required to complete hourly rounds and sign
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the logbook one hundred and seventy nine out of one
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hundred and eighty three rounds, six signatures were missing. The
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lieutenant is required to sign the logbook one time per
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shift and signatures were missing, and ten of twenty three instances,
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a physician assistant is required to sign one time per
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shift and sixteen of sixteen instances were missing. It's recommended
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that a further review of psychological observation procedures be conducted.
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The institution response documentation accuracy the reconstruction team indicates it's
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critical that all descriptions of the incident accurately reflect objective
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evidence and references psychology staff's reliance on differing statements from
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two different staffs regarding the July twenty three, twenty nineteen incident.
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Psychology staff considers the information from more than one source
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when making decisions about suicide watch placement. Clinical judgment is
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used to make determinations, taking into a consideration each person's
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self report of a situation, as they may perceive differently.
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In reference to typographical errors noted in pdspe MR notes
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the Chief Psychologists has spoken to all psychology staff members
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concerning proofreading all documents entered to reduce typos and to
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improve information accuracy. Additionally, there is a second staff psychologist
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in the department which helps reduce the workload on current psychologists,
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allowing more time for a documentation review. Regarding the reconstruction
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Team's concern in reference to mister Epstein's expunged incident report,
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Special Investigative Services staff will conduct all investigation in matters
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of attempted suicide and make a determination as to whether
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an incident report is warranted. The reconstruction team stated medical
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staff conducted inmate Epstein's intake screening. Late century records reflected
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Mate Epstein arrived in mcc New York's Receiving and Discharge
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area on July six, twenty nineteen, at approximately nine twenty
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four pm. His medical intake screening was conducted at approximately
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nine thirty eight pm by Physician Assistant PA Kang on
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the same night and approximately fourteen minutes after his arrival
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in r and D on July ninth, twenty nineteen, he
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was placed on psychological observation and approximately twelve thirty eight
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pm he was escorted from psychological observation the Health Services
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for a medical assessment and a history in physical, which
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was performed by PA Joaquin within three days of the arrival.
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According to Program Statement six zero three dot zero four
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Patient Care, a provider must perform a history and physical
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within fourteen days of the inmate arriving at a GOP facility.
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The history and physical and intake screening were conducted timely
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and in accordance with policy regarding use of the incorrect
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suicide watchlogs and the recreation thereof The Chief Psychologist and
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Drug Abuse Coordinator counseled the Drug Treatment Specialists concerning her
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documentation in the Suicide watchlogbook. There was no ill intent
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on the part of the DTS, as all logbooks were maintained,
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the original logbook written by the officer and the one
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documented by DTS. The DTS indicated a desire to assist
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the officer as he had written in the wrong logbook. Specifically,
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he wrote that the inmate companion logbook rather the staff logbook. However,
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she was informed that this is not a role and
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she is not a document in a logbook for anyone
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else observing an inmate on suicide watch. In the future,
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only staff members watching the inmate on suicide watch and
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operation lieutenants document in the suicide watch logbook. Logbooks are
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now being closely monitored on a daily basis by Chief Psychologist.
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Incomplete entries were noted in the BP two two. Shoe
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training is conducted quarterly in which emphasis will be placed
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on the importance of proper two ninety two documentation. In addition,
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the Shoe Lieutenant will receive two ninety twos on a
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daily basis and provide the Captain with an assurance memorandum.
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Two ninety twos will be printed for the previous week.
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Every Sunday. The Shoe Lieutenant will acquire any needed signatures
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from the respective oics in a handwritten manner. The reconstruction
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team findings noted discrepancies and the procedures approved for psychological observation.
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The Psychology Department has eliminated psychology observation at mcc New York.
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Both staff and lieutenants received additional training on when they're
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required to complete rounds and sign Suicide Watch logbooks. With
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regard to Suicide Watch logbook signatures, correctional staff are required
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to perform routine rounds every hour. The two sally officer
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on Monday through Friday during day watch is required to
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perform rounds on Suicide Watch inmates as prescribed by the captain.
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After hours, the unit to officer will be responsible for
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making rounds, serving meals, collecting trash in the area, and
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performing the count with the internal one or Internal two
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assisting with duties as assigned by the captain. Additionally, psychology
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staff check the Suicide Watch logs daily when they interview
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the inmates on Suicide Watch. If it's noted hourly rounds
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are not being conducted by the unit officer and or
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the lieutenants are not rounding and signing the books each shift,
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the Associate warden over programs and the captain are notified
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immediately and enforce accountability. All right, folks, we're going to
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wrap up right here, and in the next episode we're
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going to pick up where we left off. All the
22:52
information that goes with this episode can be found in
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the description box. What's up, everyone, and welcome to another
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episode of the Epstein Chronicles. In this episode, we're going
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to pick up where we left off with the psychological
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reconstruction of the circumstances surrounding Jeffrey Epstein's death. Number five
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telephone calls. In a PDS dash pe mr note written
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by doctor Miller on July sixteenth, twenty nineteen, she was
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informed by an unnamed staff member that a lieutenant facilitated
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to telephone calls for mister Epstein. It's unknown when into
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whom those calls were placed and no evidence that they
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took place on monitor telephones. According to a memorandum from
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unit manager Nathaniel Bullock on August tenth, twenty nineteen, mister
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Epstein terminated his legal visit early on August ninth, twenty nineteen,
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in order to place a telephone call to his family.
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Mister Bullock, who was the institutional duty officer that week,
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escorted mister Epstein to the Shoe around seven pm that evening,
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and he was placed in the shower area on g Tier.
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While there, he was provided the telephone to make a
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phone call. Since mister Epstein reportedly did not have his
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PAC or a PIN number, which is required to use
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inmate telephone system, the unit manager placed the call, dialing
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a number that reportedly began with the area code three
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four seven. Mister Epstein told mister Bullock he was calling
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his mother, who, according to public records, has been deceased
24:30
since two thousand and four. It's recommended that all telephone
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calls other than legal calls be made on monitored lines
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to be available for post call review, or on a
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speaker phone so staff can monitor what's being discussed. Institution
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Response Number five telephone calls. There's no documentation to substantiate
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that Lieutenant facilitated two telephone calls to mister Epstein. However,
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there is documented evidence that Unit managed proto provided a
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call to mister Epstein on July thirtieth, twenty nineteen, at
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five fifteen pm to Karina Shuliac friend on a monitor
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telephone speaker phone. The call was documented in a log
25:14
that's maintained in the Correctional Systems department. Mister Epstein was
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provided a call because he had not been able to
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conduct voice recording on the Inmate telephone. This is standard
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procedure by the unit team at MCC New York to
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occasionally provide a call to new arrivals when necessary. Number
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six Direct observation. Mister Epstein was on suicide watch from
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July twenty third, twenty nineteen until July twenty fourth, twenty nineteen.
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While on suicide watch, on July twenty third, twenty nineteen,
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mister Epstein attended an attorney visit from approximately twelve forty
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pm until seven to fifteen pm. During this time, he
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was without direct continuous observation by a dedicated BOP staff
25:59
member as required by P. Five three two four dot
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zero eight. While on psychological observation, he attended attorney visits
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on July twenty fourth, twenty nineteen, for eleven and a
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half hours, on July twenty fifth, twenty nineteen, for eleven
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point twenty five hours, on July twenty six, twenty nineteen,
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for nine point two five hours, and on July twenty seventh,
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twenty nineteen, for eleven point thirty three hours. On July
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twenty eight, twenty nineteen, for ten and a half hours,
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and on July twenty ninth, twenty nineteen, for eight hours.
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On July twenty three, twenty nineteen. Psychology observation was terminated
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during these visits. Continuous observation by a dedicated BOP staff
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member was not maintained as required by MCC New York
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Procedural Memorandum for Psychological Observation Institution Response number six Direct Observation.
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The Psychology Department has eliminated psychology observation at MCC new
27:05
York inmates on suicide Watch or only provided legal visits
27:09
under special circumstances as deemed by the court. Seven follow up.
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Mister Epstein arrived at MCC New York on Saturday, July sixth,
27:19
twenty nineteen. While conducting the ten pm institution count that evening,
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Albatore's facility's assistant reported she observed mister Epstein in his cell.
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In an email she sent to doctor Miller and to
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Mary and Lieutenant David Medina later that evening, she described
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mister Epstein as distraught, sad, and a little confused. She
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said that she then asked mister Epstein if he was okay,
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and he reportedly said he was. However, Miss Torres noted
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in her email she was not convinced of this, adding
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he seems dazed and withdrawn. She went on to say, so,
27:56
just to be on the safe side and prevent any
27:58
suicidal thoughts, can someone from psychology come and talk with them.
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Despite the fact that Lieutenant Medina opened the email, there's
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no evidence that he contacted the on call psychologist as
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is required by P. Five three two four dot zero
28:14
eight Suicide Prevention Program. Additionally, if Miss Torres was concerned
28:19
about suicide risk, P. Five three two four dot zero
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eight Suicide Prevention Program requires her to maintain direct continuous
28:28
observation of mister Epstein. When doctor Miller opened the email.
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The following Monday morning, mister Epstein was evaluated by doctor
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Slessinger at approximately nine thirty am. Mister Epstein was denied
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bail on Thursday July eighteenth, twenty nineteen. This was a
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significant disappointment for mister Epstein and likely challenged his ability
28:51
and willingness to adapt to incarceration. Given the potential impact
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of the judge's decision, a psychologist should have assessed mister
28:59
apple Spstein's mental status upon his return to the institution.
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The BOP developed a century assignment of sy Alert for
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purposes such as this. Specifically, cy alert is used to
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ensure if movement occurs, that all staff consider the special
29:16
psychological and management related risk associated with the inmate. Furthermore, p.
29:23
Five three two four do zero seven Century psychology alert
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function states when a decision to move any SY alert
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inmate occurs, any special psychological needs of the inmate are
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reviewed and considered by psychology services staff, and any safety
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and security concerns are highlighted for non psychology services staff.
29:44
Psychologists should use the SY alert assignment more frequently with
29:48
high profile cases and with inmates who have a history
29:52
or charge of sex offense. Both of these groups of
29:55
inmates are susceptible to exaggerated or unrealistic fears about directional
30:00
settings and experienced stress associated during movement and periods of
30:05
transition eg. Sell unit changes, movement to and from court,
30:09
institutional movement, and release of information through the media. Mister
30:14
Epstein was reportedly in court on July thirty one, twenty nineteen.
30:20
It's unknown what time he departed or returned to mcc
30:23
New York, because this information was not entered in century.
30:28
Regardless upon his return, the United States Marshals Service provided
30:32
R and D staff with a prisoner custody Alert notice
30:35
regarding mister Epstein. The notice indicated mister Epstein had MTL
30:40
mental concerns suicidal tendencies. The us MS requested R and
30:45
D staff signed the form, and they then departed with
30:49
the signed copy. On August first, twenty nineteen, at eight
30:52
forty six am, Doctor and Mary sent Doctor Miller an
30:56
email reporting that she had just become aware of the
30:59
above information. In the absence of additional information about this notation,
31:04
this should have been considered a referral to psychology Services
31:08
about a potentially suicidal inmate, and procedures should have been
31:11
followed as outlined in p. Five three two four DO
31:15
zero eight Suicide Prevention Program. Specifically, when a staff member
31:20
becomes aware an inmate may be thinking about suicide during
31:24
normal working hours, the staff member must contact psychology Services
31:28
and maintain the inmate under direct continuous observation until he's
31:33
placed on suicide watch or seen by a psychologist. There
31:37
is no evidence mister Epstein was monitored under these conditions
31:42
from the time he returned from court until he was
31:44
seen by doctor Amery for a suicide risk assessment on
31:48
August first, twenty nineteen at approximately one thirty pm. Institution
31:54
response seven. Follow up staff have been trained that it's
31:59
required that they make verbal contact with either a psychology
32:02
staff or a lieutenant when they have concerns for an
32:05
inmate's mental health. If psychology staff is not in the institution,
32:10
an inmate is placed on suicide watch and the on
32:13
call psychologist and warden are notified. As part of their
32:18
signature block, All psychology staff have added the following. If
32:23
you're emailing about an inmate that may be at risk
32:25
for suicide or self harm, this is an emergency situation.
32:30
Please make sure that you contact verbally the psychology staff
32:35
and the on call psychologist. Please ensure to maintain constant
32:39
visual observation of the inmate until formal steps can be
32:43
taken to ensure his or her safety pending a formal
32:46
assessment by a psychologist. The Psychology Department uses SI alert
32:51
codes more frequently with high profile cases and with inmates
32:55
with a history of a charge of a sex offense.
32:58
The SI alert code is a play immediately on classification
33:02
and loor identification, and not just when an inmate is
33:05
about to leave the institution. If an inmate is moved
33:09
in and out of an institution for court, etc. The
33:12
inmate is assessed immediately prior to being released to a unit.
33:17
R and D staff have reminded of the US Marshal
33:20
and Court alert process. Psychology staff are notified immediately if
33:24
there are suicidal concerns noted by the court. If psychology
33:28
staff is not in the institution, an inmate that enters
33:32
the institution with an alert notice is placed on suicide
33:35
watch and the on call psychologist and warden are notified.
33:40
These inmates receive a suicide risk assessment by a psychologist
33:44
before being released to general population. R and D will
33:48
review the PP forty four code and intake screeners will
33:52
utilize the PP sixty four to determine if inmates entering
33:56
the facility have a SI alert assignment. If there is
33:59
no a psychologist in the building. When a S inmate
34:04
is identified and or if it's during non duty hours,
34:08
the Operations Lieutenant will immediately be notified and will contact
34:12
the on call psychologist. The on call psychologist will come
34:16
in after hours to screen the inmate in R and
34:19
D and determine their appropriateness for a general population, as
34:24
well as any other pertinent housing considerations. Prior to the
34:28
inmates released to general population, inmates may also be assigned
34:32
to SIE alert function by a psychologist while housed at
34:36
the institution. Psychologists will consider not only inmates with substantial
34:41
mental health concerns for a SI alert assignment, but will
34:44
use sy alert codes frequently with high profile cases and
34:49
with inmates with a history or charge of a sex offense.
34:52
The sy alert code is applied immediately and not just
34:55
when an inmate is about to leave the institution. Attached
35:00
Institutional Procedural Memorandum has been reviewed by Central Office Psychology
35:05
Service and implemented by mcc New York Psychology Service to
35:09
outline the follow up procedures when existing SI alert inmates
35:12
return from trips such as court proceedings and hospital trips.
35:16
If any movement occurs with an existing SI alert inmate,
35:20
psychology must be verbally notified immediately when the inmate returns
35:24
back to the institution. This would include movement from court,
35:28
institutional movement, or hospital trips. The Psychology department will also
35:33
notify of a SIE alert inmate movement prior to the
35:36
inmate leaving. The Psychology department will be provided with the
35:42
court list as well as prisoner schedule report on a
35:45
daily basis. These reports will be reviewed daily by members
35:50
of the Psychology Department to assess whether a sire alert
35:53
inmate is scheduled to go out to court the following day.
35:57
When an existing SI alert inmate who is all right
36:00
already been initially screened by the Psychology Department returns from
36:03
court with a notice from the judge or a Marshal's
36:06
office indicating imminent mental health concerns or concerns related to suicide,
36:11
the SIE alert inmate will be seen by the psychologist
36:15
immediately and prior to their return to general population. A
36:19
psychologist will determine at that time if a SI alert
36:23
inmate is ready to return to general population, their psychological stability,
36:28
and their treatment needs. If the inmate returns after hours
36:32
and there's no psychologist in the institution, the SI alert
36:35
inmate will be placed on suicide watch pending a suicide
36:39
risk assessment by a psychologist. When an existing SI alert
36:45
inmate who has already been initially screened by the Psychology
36:48
Department returns from court routinely and without a notice from
36:52
the judge or Marshal's office, they will be screened by
36:55
a member of Psychology Department within twenty four hours to
36:59
assess if they're experiencing any significant distress regarding their court
37:04
proceeding that may be exasperating their mental health difficulties and
37:08
or risk factors. Per guidance from Central Office Psychology Division,
37:13
the Psychology Department will conduct a training with R and
37:16
D staff to help train them about sy alert inmates
37:19
and to recognize signs of psychological distress and suicide. Suicide
37:24
prevention in SI alert training have recently been conducted by
37:28
the Psychology Services Department with lieutenants and during a recent
37:32
department head meeting. Further, an email regarding sy alert procedure
37:37
was sent to all lieutenants, receiving and discharge psychology and
37:42
all Health and Services staff eight it made accountability and
37:47
assignment accuracy. According to a Century Quarter's roster generated on
37:51
August tenth, twenty nineteen, at twelve fifty one am, there
37:55
were three inmates assigned to mister Epstein's shoe sell Z
37:59
zero five four DASH two zero six la D, including
38:04
him at the time of his death. However, his shoe
38:07
cell was only a double occupantcy cell and made Patrick Avila,
38:12
it made, Gregory Ferrer, and mister Epstein were all assigned
38:15
to the same cell. On August thirteenth, twenty nineteen, at
38:19
twelve oh six pm and twelve oh eight PM. A
38:22
quarter's history roster was generated for inmate of Villa and Ferr, respectively,
38:28
and made a Villa cell assignment was Z zero four
38:32
dash two six la D from August fifth, twenty nineteen,
38:36
until August eleventh, twenty nineteen, when he was moved to
38:40
sell Z zero four dash two one two ua D,
38:46
and made ferr cell assignment was Z zero four dash
38:49
two O six ua D from August first, twenty nineteen
38:54
until August eleventh, twenty nineteen, when he was moved to
38:57
sell Z zero four to zero seven LAD. A quarter's
39:02
history roster was generated for mister Epstein on August thirteenth,
39:06
twenty nineteen at nine oh seven am. His cell assignment
39:10
was Z zero four dash to zero six LAD from
39:15
July twenty ninth, twenty nineteen until August tenth, twenty nineteen.
39:20
On Monday, August twelfth, twenty nineteen, photographs of name tags
39:25
on shoe cell doors and shoe locator forms were sent
39:28
to Correctional Service Department in the Northeast region. The shoe
39:32
locator form is dated August ninth, twenty nineteen. It shows
39:37
inmate error in cell two O seven. L Century states
39:41
that he was moved to this cell on August eleventh,
39:44
twenty nineteen. In made Vila in cell to twelve U
39:48
Century states that he was moved to this cell on
39:50
August eleventh, twenty nineteen. Epstein in cell to twenty L
39:56
Century never shows them in a cell along with inmate Reyes.
40:01
The locator shows inmate Copper and in may Dockery in
40:04
cell two O six. The photo sheets show the cell
40:08
being two twenty withinmates Epstein and Reyes. Identification cards on
40:12
the door. Inmate Reyes E fhrin regulation number eight five
40:17
nine nine three DASH zero five four was in cell
40:21
Z zero six to twenty U from August fifth, twenty
40:24
nineteen to August ninth, twenty nineteen. MCC New York has
40:30
four suicide watch cells and each is for single occupancy use.
40:35
The suicide watch cells are located in health services. Each
40:39
cell is abbreviated with the unit code h O one
40:43
in Century, followed by four digit cell number. The doors
40:47
are identified by a painted number from one to four.
40:50
Two reviews were conducted. The first revealed mister Epstein was
40:54
in H zero one zero zero IL according to Century,
40:58
but the Suicide Watch lockbook syndicate he was in cell four.
41:02
A second review was conducted on August thirteenth, twenty nineteen.
41:06
While there were four inmates in these cells, Century show
41:10
two inmates assigned to ho I zero zero IL, one
41:15
assigned to HO one DASH zero zero two one, and
41:19
the fourth inmate assigned to a general population housing unit.
41:23
Through physical observation of the dedicated suicide watch cells, there
41:27
were four HO one cells. However, a review of bop
41:31
ware inmate housing format only shows three cells. Inmate movement
41:36
and assignments are not accurately reflected in Century is required
41:40
by P five five zero zero dot one four Correctional
41:44
Service Procedure Manual Institutional Response eight. Inmate Accountability and assignment accuracy.
41:52
With regard to accuracy and accountability of inmates placed on
41:56
suicide watch status in the hospital area, Psychology Service now
42:00
runs a daily centry roster of all inmates on suicide
42:03
watch in that area. The roster is examined to ensure
42:07
that the inmates placed on suicide watch in a suicide
42:10
watch cell are keyed into centry with the correct cell
42:13
assignment noted, the Associate warden programs is notified if there
42:18
are any inconsistencies. Moreover, the four suicide Watch cells now
42:23
all have century assignments of H zero one zero zero
42:27
one L through H zero one dash zero zero four L. Further,
42:33
Psychology Service Department reviews Suicide Watch logbooks on a daily
42:37
basis to assess whether the lieutenants have conducted rounds during
42:42
each shift and whether the Unit two sally Port and
42:45
Unit two officers are conducting hourly rounds. Any inconsistencies noted
42:50
in the logbooks by Psychology staff will be reported immediately
42:54
to the Captain and Associate Warden over programs to address appropriately.
43:00
The operations lieutenant will physically check the PP thirty cell
43:03
assignment roster when inmates are quartered on Suicide Watch. The
43:07
lieutenant will ensure the counts and assignments officer key cell
43:11
assignments correctly and annotate any errors in the DELI log
43:16
and contact the captain immediately. Guidance was sent to the
43:20
lieutenants regarding keying of Suicide Watch bet assignments after hours.
43:24
The lieutenants were instructed that upon placing an inmate on
43:27
suicide Watch, they're responsible for contacting CNA and providing the
43:32
cell assignment. Additionally, the lieutenant will run PP thirty with
43:38
the selection category for Suicide Watch. The Operations Lieutenant will
43:42
email the roster to the Captain, as he will be
43:45
responsible for verifying that each inmate is in an appropriate cell.
43:49
This verification process will ensure inmates placed on Suicide Watch
43:53
are keyed into accurate BET assignments and will eliminate inmates
43:57
being keyed into the same cell. Additionally, the lieutenants were
44:02
instructed to contact the Captain and on call psychology staff
44:06
by telephone when the need for suicide Watch placement is
44:10
determined after hours. Psychology staff have been instructed to contact
44:14
the warden upon receiving said notification. After consultation with the warden,
44:20
Psychology staff will designate whether a staff or inmate companion
44:24
will be assigned. Psychology staff will in turn inform the
44:28
shift lieutenant of this determination to ensure that inmates are
44:32
assigned to the correct cell. Inside the special housing unit,
44:35
Periodic and unannounced checks are conducted specifically century roster PP
44:40
thirty quarters assignment, or audited daily by the Shoe Lieutenant.
44:45
Executive staff also conduct routine bedbook counts and all units.
44:50
Any and all discrepancies identified or addressed results will be
44:54
maintained by correctional services. In the Lieutenant's log. The morning
44:58
watch lieutenant is a re responsible for observing one count
45:02
during his or her shift in the shoe, which is
45:04
documented daily in the Lieutenant's log. In order to properly
45:08
account for inmates in the unit, staff have been informed
45:11
not to use the inmate located reform due to the
45:14
form being unreliable in accounting for inmates and sell assignments.
45:19
A Unit Accountability Board along with century PP thirty Quarters
45:23
Roster have been placed in the unit to establish better
45:26
oversight over inmate accountability. Correctional staff are required to perform
45:31
routine rounds on the second floor suicide Watch area every
45:35
hour on day watch Monday through Friday. The two sally
45:39
officers are required to perform rounds on suicide Watch inmates
45:43
as prescribed by the captain. After hours, the Unit two
45:46
officer will be responsible for making rounds, serving mules, collecting
45:50
trash in the area, and performing the count, with the
45:53
Internal one or Internal two officer assisting with duties as
45:56
assigned by the captain To ensure that staff are in
45:59
fur formed of the importance of suicide prevention and responsibilities.
46:03
When one occurs. Lieutenants will reinforce the message through conference
46:08
calls with staff. Roll call notes will be placed on
46:11
truscope to notify staff of which inmates are currently on
46:15
suicide watch. Nine Attorney logbooks. Four logbooks were not secured
46:20
following mister Epstein's death. Specifically, three attorney logbooks located in
46:26
the attorney visiting in front lobby areas and an inmate
46:29
search logbook located in the attorney visiting area were not secured.
46:34
All four books were still in use at the outset
46:36
of the reconstruction and after the reconstruction team advised staff
46:40
to secure them. P. Five three two four dot zero
46:45
eight states in the event of a suicide, institution staff,
46:49
particularly correction staff and other law enforcement personnel, will handle
46:53
the site with the same level of protection as any
46:56
crime scene in which a death has occurred. This policy
47:01
further states all possible evidence in documentation will be preserved
47:05
to provide data and support for subsequent investigators doing psychological reconstruction. Further,
47:12
a review of the attorney logbooks identified many errors and
47:16
signify a systemic concern. For example, there were two can
47:19
currently open attorney logbooks in the attorney visiting area. Further,
47:23
the different purposes of the two attorney logbooks, one in
47:26
the attorney visit area and one in the front lobby,
47:29
cannot be explained. BOP staff were unable to articulate a
47:33
system of control for the logbooks, and during the reconstruction
47:37
some of the logbooks cannot be accounted for. With the logbooks,
47:41
entries were made out of chronological order, Attorneys did not
47:45
consistently sign in and out, significant information was illegible or missing.
47:52
Columns were not consistently labeled. Logbook opening and closing dates
47:56
were inconsistent, and the cover had been torn several books.
48:01
At the current time, these logbooks are not functioning as
48:03
an adequate system of control and monitoring. Institution Response number
48:09
nine Attorney Logbooks. On August tenth, twenty nineteen, logbooks deemed
48:13
relevant to the investigation were removed from various locations throughout
48:18
the facility. The reconstruction team did not identify pertinent logbooks
48:23
that had been secured. At this time, all relevant logbooks
48:27
have been removed and replaced. In addition, a logbook audit
48:31
was conducted to ensure accuracy of the documentation and compliance
48:35
with policy. Measures are being taken to ensure in the
48:39
future that all relevant logbooks are identified, secured immediately and
48:43
replaced with new ones to ensure the institution can continue
48:47
to run efficiently. Ten automatic external defibrillators. A review of
48:53
available AEDs in the institution revealed that the list used
48:56
for accountability and inspection purposes was an act, curate and
49:00
complete institution response. Ten automatic external defibrillators. A review of
49:07
the automatic external Defibillators report presented by Great Lakes Biomedical
49:12
Service dated July twenty second, twenty nineteen, revealed that all
49:16
AEDs were accounted for and were placed in correct respective areas.
49:22
The report was accurate and complete. New ads have been
49:25
purchased and will be inspected Great Lakes Biomedical Services upon
49:30
their arrival. The list reviewed by the reconstruction team was
49:33
an old and outdated list from January of twenty eighteen.
49:38
Medical staff provides training and conducts monthly inspections of all
49:42
AEDs in the institution. Great Lakes Biomedical Services, an outside
49:47
contractor conducts a bi annual inspection and provides a report.
49:51
Procedures on inspecting all AEDs in the institution have been
49:56
prepared and are awaiting approval. These procedures are attached Heer
50:00
two eleven post orders and shoe training. Shoe post orders
50:05
sign in sheets were reviewed for the third quarter spanning
50:09
June ninth, twenty nineteen to September seventh, twenty nineteen. Officer L.
50:15
Gray failed to sign post orders for shoe number three
50:17
post Quarterly shoe training sign in sheets were reviewed the
50:22
twenty nineteen third quarter. Shoe training was conducted on June sixth,
50:27
twenty nineteen. Three staff assigned to the third quarter shoe
50:31
roster and shoe did not attend or receive shoe training.
50:35
Officer David du Benzig, Officer Miguel Mongey, and Officer Robert
50:41
Gravala Institution Response eleven post orders and shoe training. The
50:47
suicide Watch post orders are located in the Lieutenant's office
50:51
and shoe with a quarterly sign in sheet. A copy
50:55
of the suicide Watch post orders will also be placed
50:58
in secure container outside of suw sidewatch cells on Tier
51:01
H and shoe. This container will also hold signature sheets
51:06
and additional staff suicide watch logbooks. All staff members assigned
51:10
to a suicide watch post are responsible for signing the
51:14
post orders prior to performing the staff suicide watch. Attached,
51:18
please find a copy of the narrow waiver permitting staff
51:22
monitored suicide watches in the shoe. With regard to shoe
51:26
suicide prevention training, this continues to be conducted on a
51:30
quarterly basis. However, the sign in sheets for this training
51:34
are now to be examined by the shoe lieutenant for accuracy.
51:37
If a staff member who is assigned to the shoe
51:40
misses the training, the signing sheet will be routed to
51:43
the Captain, who will coordinate with the Chief Psychologist and
51:46
schedule a time to receive a makeup session for the
51:49
shoe suicide prevention training. Shoe training is conducted quarterly. Two
51:55
weeks from the beginning of a new quarter, a representative
51:58
from Psychology will by the required suicide prevention training in
52:03
addition to shoe training on bob learn will be completed
52:07
by all staff assigned to the shoe that day of training.
52:11
Shoe staff will be allotted time during the data complete
52:14
the prescribed web based training as identified on the agenda.
52:19
Staff who are assigned to the shoe but have not
52:21
received the mandatory training before assuming the post will be
52:25
roster adjusted to attend another training day as assigned by
52:28
the captain. Staff assigned to suicide Watch shall maintain a
52:32
chronological log of the inmates behavior. Blank logbooks will be
52:36
maintained in the Lieutenant's office and on the second floor.
52:40
A chronological record of events will commence immediately upon the
52:44
initiation of watch. It's the responsibility of the staff member
52:48
initiating the watch to obtain a blank logbook prior to
52:52
initiating the watch. Different logbooks will be used for each
52:55
inmate on suicide watch. Each logbook will contain entries for
53:00
one suicide watch only. The name and register number of
53:03
the inmate on watch shall be clearly printed on the
53:06
front cover of the logbook and at the top of
53:09
each page in the logbook in which entries are made.
53:14
During some suicide watches, staff observers may cover some shifts
53:18
and inmate companions may cover others. In the instance, two
53:22
separate logbooks must be used, one of the shifts or
53:25
one for the shifts excuse me, during which staff are
53:28
maintaining constant visual observation blue, and another for shifts during
53:33
which inmate companions are providing constant visual observation yellow. When
53:38
separate inmate companion logbooks are used. Staff must sign the
53:42
inmate's companion log book every sixty minutes. Lights will remain
53:46
on inside the cell twenty four hours a day to
53:49
ensure the inmate on watch can be seen. A lieutenant
53:52
will make rounds every shift and remove the inmate from
53:55
the cell and perform a curse research. No food items, trays,
53:59
it being utensils, milk cartons, toilet paper, plastic bags, reading materials, pens, pencils,
54:06
or anything else not prescribed by psychology staff should be
54:09
in the cell. The inmate will be outfitted in a
54:12
suicide preventive smock, suicide preventive blanket, suicide preventive mattress, and,
54:17
if necessary, a suicide preventive helmet. In May, companions will
54:22
be searched prior to assuming duties. In May, companions are
54:26
not allowed to have radios, MP three players, magazines, books,
54:31
or anything that would distract them from maintaining constant supervision.
54:36
In May, companions will not have direct or physical contact
54:39
with inmates on suicide watch staffing. The Drug Abuse Program
54:45
Coordinator position at mcc New York was abolished during phase
54:49
one of staff realignment during fiscal year twenty eighteen. Re
54:53
Establishing the Drug Abuse Program Coordinator position would provide the
54:57
institution with an additional supervised psychologists to provide critical clinical services.
55:04
Staffing in the Correctional Services Department is relevant to the reconstruction. However,
55:09
the details about this topic are provided in an after
55:12
action review completed separately from this report. Institutional Response twelve staffing.
55:19
The Drug Abuse Coordinator position is currently a share position.
55:22
A warden has re established the Drug Abuse Coordinator position
55:26
as a full time position to provide the Psychology Department
55:30
with an additional supervisory psychologist to perform critical clinical service.
55:34
At the current time, the position is pending selection. We
55:38
are currently in the process of requesting to hire a
55:41
staff psychologist position to provide additional psychological services to inmates
55:46
in the Shoe, including therapy sessions with sy alert CC
55:50
two MH and CC three MH inmates who are currently
55:54
hous there. An additional psychologist could also monitor hot list
55:58
inmates arriving to the Shoe and ensure that they're housed
56:01
with appropriate cellmates. This psychologist could conduct Deli rounds to
56:06
look for signs of psychological distress and address the concerns
56:09
of our long term shoe inmates. Finally, an additional staff
56:13
psychologist could assist with our daily crisis and revention and
56:18
suicide risk assessments. Thirteen Sex offense Risk factors, A broad
56:23
understanding of risk factors associated with sex offenders by staff
56:26
at mcc New York did not appear to be present
56:30
in all staff, but was vital to his adjustment and
56:33
safety in prison. A more focused management strategy is recommended,
56:37
particularly in complex and high profile cases. Supplemental training on
56:42
sex offender specific risk factors is recommended for all staff
56:46
and should be provided by executive staff and psychology services
56:51
institutional response. The chief Psychologist is a member of the
56:55
executive staff. The chief Psychologist or her designee continues to
57:00
present at all executive staff meetings, department head meetings, and
57:05
shoe meetings. During these meetings, the chief psychologists offers feedback
57:09
regarding the treatment and management of sex offender inmates. Additionally,
57:14
the chief psychologist continues to educate all staff during introduction
57:18
to correctional techniques and annual training about the sex offenders
57:23
specific risk factors and suicide risk. All right, folks, Well
57:27
there you have it. The psychological reconstruction of what went
57:31
down leading up to and on the night of Jeffrey
57:35
Epstein's death. All the information that goes with this episode
57:39
can be found in the description box.