Pages)

U.S. Department of Justice

Federal Bureau of Prisons
Reentry Services Division
Washington, DC 20534
SEP 37 7018

MEMORANDUM FOR J. RAY ORMOND, REGIONAL DIRECTOR

NORTHEAST REGION

FROM: h J. furdtz, Assistant Director

Reentry-Services Division
SUBJECT: Psychological Reconstruction
Inmate Epstein, Jeffrey (76318-054)
Inmate Jeffrey Epstein (76318-054) died by suicide on
August 10, 2019, while housed at the Metropolitan Correctional
Center (MCC) in New York. The attached psychological reconstruction
was completed byDrs [7577| National Suicide Prevention
Coordinator "TT Sex Offender Treatment Programs
Coordinator; Mental Health Treatment Coordinator and
Mx [FTE] correctional Services Administrator,
Northeast Regional Office. A summary review of these and other
recent reconstruction findings is forthcoming. Distribution of this
report is limited to staff named in this memorandum.
Recommendations at the conclusion of the report should prove
beneficial to staff at the facility and will be used to inform our
national suicide prevention program. Within sixty days of receipt
of this memorandum and report, please provide me with a written
response which outlines corrective actions as well as a plan for
implementation, based on recommendations contained within. The
institution response should be routed by the Warden through the
Regional Director to the Assistant Director, Reentry Services
Division.
If you have questions or concerns regarding this request, please
contact me at (202)LL iil
cc: M.D. Carvajal, Assistant Director, CPD
D. Shinn, Assistant Director, PRD
N. C. English, Assistant Director, HSD
J. Petrucci, Acting Warden, MCC New York
Page 2682

PSYCHOLOGICAL RECONSTRUCTION OF INMATE DEATH

This is an interim report, du to an inability to gather all necessary data. Formal interviews were
not conducted as a partof this reconstruction to avoid interference with pending investigations
by other Departmentof Justice components. A copy of the video is normally made by Special
Investigative Staff following a significant incident, but there was no such video in this case since
the original video was confiscated by the Federal Bureau of Investigation (FBI) prior to the
beginning ofthis reconstruction. The absenceofthese two sources of information severely
limited the ability to establish accurate timelines, confirm subjective reports, establish
convergingand diverging linesoffacts, or discover new areas of inquiry. ASa result,
information typically gathered, reviewed and consolidated during a reconstruction to Support
actionable findings and recommendations is limited.
Name: Jeffiey Epstein
Register Number: 6318-054
Date of Death: 08-10-2019
Prepared by: National Suicide Prevention Coordinator,
Psychology Services Branch, Central Office

BACKGROUND INFORMATION
Mr. Jeffrey Epstein was a 66-year-old, White male who died on August 10, 2019, while housed
at the Metropolitan Correctional Complex (MCC), in New York, New York. James C. Wills,
former Acting Assistant Director, Reentry Services Division, appointed a team to conduct a
psychological reconstruction. The team consisted National Suicide Prevention
Coordinator, CentralOffice: "| Sex Offender Treatment Programs Coordinator,
Central Office! "Mental Health Treatment Coordinator, Central Office; and
Correctional Services Administrator, Northeast Regional Office. This
Teconsiruction was established in accordance with BureauofPrisons’ (BOP) Program Statement
5324.08, Suicide Prevention Program.
Social History: Mr. Epstein did not have a Pre-Sentence Report (PSR) available at the time of
the reconstruction; therefore, no official information regarding social history was accessible.
“The following was gathered from publicly available documents. Mr. Epstein was born in 1953
and grew up in a middle-class family in the neighborhoodof Sea Gate on Coney Island,
Brooklyn, New York, with one brother. Afier early promotion in two grades, Mr. Epstein
graduated from Lafayette High School in 1969, at the age of 16. He attended Cooper Union and
New York University but did not graduate from either. Mr. Epstein taught at the Dalton School,
a private school on the Upper East Sideof Manhattan from September 1974 until he was

1
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dismissed in June 1976 for inadequate developmentas a teacher. Following that, he held a
‘numberofpositions in the financial industry to include a position as a limited partner at
Bear Stearns until he was dismissed for unknown policy violations in 1981. He also worked as a
financial consultant and founded at least two separate companies.
Mr. Epstein had two significant periods of employment. The firstofthese was his position as a
consuant wil nt ae 1980. described ay is
first mentor. [777 was ater convicted and incarcerated for running a large Ponzi
heme. He pCa ME Epstein in haudulenly divering company funds for his ov
personal use. Years. ep Epstein’s sole client at J. Epstein and Company,
ranted Him power of atomey over Bais. Despite als being dented
‘mentee, Mr. Epstein was again accused ofmisappropriating funds—more than 46 million
dollars. These large sums are believed to be the seed money Mr. Epstein used to establish his
considerable fortune. These events are indicativeofMr. Epstein’s highly-regarded intelligence
and charismatic personality.
Legal History: Mr. Epstein had a historyof adult criminal charges and convictions. In
June 2008, he entered into a non-prosecution agreement and pleaded guilty to one count
Solicitation of Prostitution and one count Procuring
a Person Under the Age of 18 for
Prostitutioninthe state of Florida. He was sentenced to 30 months: 18 months of incarceration
and 12 monthsof probation. He was also mandated to register as a sex offender under the
National Sex Offender Registration and Notification Act. Mr. Epstein served 13ofhis 18-month
incarceration and then successfully completed 12 monthsofprobation. It is unclear whether he
followed the sex offender registration guidelines in each place he owned a residence.
In regard to pending charges, Mr. Epstein was formally charged with Sex Trafficking Conspiracy
in violation of 18 U.S.C. § 371 and Sex Trafficking in violation of 18 U.S.C. § 1591(a), (b) (2), 2
on July 2, 2019. Specifically, he was accused of sexually exploiting and abusing minor females
over the course of several years. Charging documents allege Mr. Epstein enticed and recruited
‘minor females to engage in sexual activity. The minor females were reportedly compensated
with cash following the sexual encounters and some were encouraged to find other minor
females to accompany them to Mr. Epstein’s residences in New York or Florida. He pleaded not
guiltyto these charges and was in pretrial status at the timeofhis death.

In a 37-page Decision& Order Remanding the Defendant, signed by Judge Richard M. Berman
on July 18, 2019, 18 pages were dedicated to detailing the danger Mr. Epstein posed 10 others
and the community. The document also alleged he was a flight risk. As a result, Mr. Epstein’s
proposed bail package was determined to be inadequate. He was denied pretrial release and held
on remand.

2
Page2s4

Institutional History: On July 6, 2019, Mr. Epstein was arrested at Teterboro Airport in
New Jersey upon his return from Paris, France. It is unknown whether he was anticipating this
arrest. He was transported to MCC New York and keyed into SENTRY at 9:24 pam. that
evening. Mr. Epstein was placed in a general population housing unit for approximately 22
ours. On July 7, 2019, at approximately 7:20 p.m. he was moved to the Special Housing Unit
(SHU) pending reclassification due to the significant increase in media coverage and awareness
ofhis notoriety among the inmate population.
With regard to his adjustment to a correctional setting, Mr. Epstein received one incident report
while in BOP custody forSelf:Mutilation on July 23, 2019. As ofAugust 15, 2019, the incident
report had been expunged though it is unclear wh it had been expunged and whether
Mr. Epstein knew this. Also,a review of financial transactions associated with Mr. Epstein’
prison account revealed one ofhs attorneys was depositing funds into hiscellmate’s (inmate
Reyes) commissary account for unknown reasons.
HEALTH CARE AND PERSONALITY DESCRIPTION
BOP Electronic Medical Records (BEMR) indicate Mr. Epstcin was diagnosed with
hyperlipidemia, sleep apnea, hypertension, constipation, prediabetes, neuralgia, and neuritis
unspecified. He was prescribed the following mediations: docusate sodium, milk ofmagnesia,
omega 3, methylprednisone, and bisacodyl. Mr. Epstein was also prescribed insulin, and the
prescription required him to g0 to the institution pharmacy for administrationof this medication.
However, the dates for which it was prescribed have a notation indicating “dose not indicated,”
thus it does not appear insulin was routinely medically necessary. The restofthe medications
prescribed were self-carry. He also had a continuous positive airway pressure (CPAP) machine
whichis typically used to trat sleep apnea. Mr. Epstein was provided with his personal CPAP
machine on July 30, 2019, per BEMR.
In regard to mental health history and treatment, there are no known available records. Any
records that may have been maintained relating to Mr. Epstein’s incarceration in Florida were
not available for review as ofthe date of this report. With regard to Psychology Data System
records in BEMR oR Psychologist at
MCC New York completed aroutine Tntake Screening on July 8, 2019. During this screening,
Mr. Epstein denied any historyof mental health problems, substance abuse, and treatment. No
symptoms ofmental illness were observed. He was classified as Mental Health Care Level 1 and
was not diagnosed with a mental illness.
Following a consultation with” ~~] National Suicide Prevention Coordinator on
July$,2019("Thief Psychologist at MCC New York determined Mr. Epstein
Should be pre-empveTy evaluated for suicide risk upon his retum from court. Primary
consideration was given to his various risk factors for suicide such as his high profile case and
‘media attention, pending sex offense charges, pre-trial status, and an ongoing court proceeding.
Mr. Epstein retumed from court on July 8, 2019, after normal business hours. He denied suicidal
3
Page 28s

thoughts at that time, but due to the potential for other risk factors listed above, the on-call
psychologist placed Mr. Epstein on Psychological Observation in oneofthe suicide watch cells
unl he could be assessed in person by a BOP psychologist. Psychological Observation is a
formofindividual monitoring that is fess restrictive than Suicide Watch. Itis used for inmates
who are stabilizing and not yet prepared for placement in general population or restrictive
housing. Its often used to transition inmates offof Suicide Watch in order to monitor their
transition and safety after an acute suicidal crisis. On July 9, 2019, Mr. Epstein underwent a
Tor poo ede km pam She detemined tha, whik side
watch was not warranted at that time, Mr. Epstein should remain on Psychological Observation
status out ofanabundance ofcaution. He was removed from Psychological Observation on
July 10,2019.

He was placed on
Suicide waich by the Operations Lieutenant at approximately 1:40 am. pending a formal in-
person suicide risk PA WS Psychologist at MCC New York,
assessed Mr. Epstein for riskof suicide later in the morningof July 23, 2019, and determined he

Fo
Mir. Epstein was removed from suicide waich on July 24, 2019, after 31 hours and minutes.
Thereafter, he remained in the suicide watch cell and was placed on Psychological Observation,
where he remained housed until July 30, 2019, according to PDS-BEMR records. A discrepancy
exists regarding when he was removed from Psychological Observation. His cell assignment,
per SENTRY, indicates he was transferred back to the Special Housing Unit (SHU) on
July 29, 2019, whereas PDS-BEMR indicates he was removed from Psychological Observation
on July 30, 2019, at approximately 8:15 a.m.
Mr. Epstein attended a court hearing on July 31, 2019, and, upon his return, the United States
Marshals Service (USMS) provided paperwork to Receiving and Discharge (R&D)staffthat
noted “suicidal es notified on August 1, 2019, about this paperwork.
She consulted with" ~~ Jand then met with Mr. Epstein to conducta suicide risk
assessment. She determined suicide watch was not warranted at that time.
Mr. Epstein remained classified as a Mental Health Care Level 1 throughout his time at
MCC New York. During his contacts with psychologists, Mr. Epstein routinely denied current
‘mental health symptoms to include suicidal ideation, and he did not exhibit symptoms ofa
serious mental illness. However, there was evidence Mr. Epstein was experiencing challenges
4
Page 286

adjusting to his environment and changes in his lifestyle. He reported frequent complaints of
difficulty sleeping. He did not have access to his CPAP machine until it was reportedly provided
10 him on July 30, 2019. Mr. Epstein also reported he was bothered by noise in the SHU. At
times, he noted concerns related to his safety in SHU or on a general population housing unit.
On two occasions, July 26, 2019, and July 27, 2019, he described himself as acoward and as
someone who does not like pain. On July 28, 2019, he aL the toilet inhiscell would
mot stop flushing foranextended periodoftime, and he then 100K 0 sitting in the comer with his
hands over his cars. Mr. Epstein indicated he was agitated following this incident and was
unable to sleep that night.
ANTECEDENT CIRCUMSTANCES
Mr. Epstein entered BOP custody on July 6, 2019, with a history ofconvictions for sexual
offenses and allegations comprised of more serious charges. The current indictment alleged
sexual crimes against minors, and he was facing up to 45 years in prison. On July 18, 2019,
Mr. Epstein’s request for bail and pretrial release was denied.

—“After 31 hours and 5 minutes on Suicide Watch, he was then

placed on Psychological Observation. On July 30, 2019, Mr. Epstein was removed from
Psychological Observation. [~~ Jsent an e-mail reporting Mr. Epstein had been removed
from Psychological Observation and needed to be housed with an appropriate cellmate. This
e-mail was sent to 71 MCC New Yorkstaff and, as of August 13, 2019, only 27staffmembers
had opened the message.
On August 9, 2019, a federal court unsealed approximately 2,000 pagesof documents into the
public domain. These included graphic allegations against Mr. Epstein. Included was a book
order receipt for titles such as SM 101: A Realistic Introduction; SlaveCrafi: Roadmapsfor
Erotic Servitude; and Training with Miss Abernathy: A Workbookfor Eratic Slaves and Their
Owners. Additional high profile public figures were also named in the released documents. The
‘documents were part ofa defamation lawsuit filed by Virginia Roberts Giuffre, a woman who
alleged Mr. Epstein had victimized her, against a British socialite, Ghislaine Maxwell, who was
Mr.Epstein’sex-girlfriend, associate, and alleged to have assisted with his criminal activities.
According to staff report, Mr. Epstein was afforded telephone calls on two different days
although it is unknown whether they were legal or social calls. No recordingofthe calls exist
and itis not known with whom he was speaking. One occurred on or around July 16, 2019, and
the other on August 9, 2019. Legal calls are not monitored, and would not be recorded. A
social call would be recorded; given the limited information known about Mr. Epstein,
Knowledge of the content of any social calls would have been crucial to helpingstaffwork with
him.
Following his final telephone call on the eveningof August 9, 2019, Mr. Epstein was moved into
his SHU cell. He was single-celled at that time because his céllmate (Efrain Reyes #85993-054)
5
Page 267

did not retum from court. The need fora cellmate was communicated between Day Watch
(DW) and Evening Watch (EW) shifts in the SHU, but no cellmate was placed with him by the
EW staff. According to a memorandum from Senior Officer Specialise ST RU
Staffwere informed at approximately 1:50 p.m. that Mr. Epstein’scellmat would likely not
return from court. Furthermore, Office oe Mr. Epstein would need a cellmate upon
arrival from his attomey visit.
A reviewof the 30-minute rounds forms indicate unit rounds were completed for theentire MW
shift on August 10, 2019. However, a memorandum fromLieutenan|~~ jndicates
Officer nd Material Handler Supervisor ade a statement after
Mr. Epstein’s death that they did not complete proper 30-minute rounds at 3:00 a.m. or 5:00 am.
DESCRIPTION OF SCENE
‘A detailed descriptionof the scene was unavailable because the officers who discovered
Mr. Epstein did not write memorandums and could not be interviewed. According to the Report
of Incident, on August 10, 2019, at approximately 6:33 a.m, while serving the breakfast meal in
the SHU, Range 9 South, Mr. Epstein was found unresponsive in hs cell. Staff reportedly called
for medical assistance, activated the” ~~ _]and began life-saving measures. Arriving staff
stated they brought an automated external defibrillator (AED) and stretcher. Cardiopulmonary
resuscitation (CPR) reportedly continued while the AED was placed on Mr. Epstein. The AED
reportedly indicated no shock advised and CPR was continued. Mr. Epstein was escorted to
Health Services at approximately 6:39 am., and Emergency Medical Services (EMS) arrived at
6:43 a.m. He was transported to the local hospital at approximately 7:10 a.m. Mr. Epstein was
pronounced deceased at 7:36 am. It was not possibleto confirm this timeline without viewing
video footage.
CONCLUSIONS/RECOMMENDATIONS
'A general appreciationofrisk factors for suicide specific to sex offenders is necessary when
reviewing Mr. Epstein’s death. These factors, as well as more general risk factors for suicide,
were likely present. There are several common factors that increase risk for suicide in
individuals with a history ofa sexual offense. These include stigma due to the nature of
sexually-based crimes (both within society and the prison system), a disruptionofthe ability to
utilize sex as a coping mechanism (which can lead to increased levelsofdistress and negative
affect), and grief about loss experienced in regards to arrest. Thisgrief may be secondary to the
ossofformer lifestyle, lossofphysical items or collections related to sexual offenses, and/or the
lossofperceived relationships with victims. Other factors that may increase risk for suicide
among individuals aceusedof a sex offense include safety concerns, potentially long sentences,
and lackof skills necessary to navigate social relationships in prison.
Mr. Epstein was a high-profile, pretrial detainee awaiting trial on sex trafficking offenses. He
had been a successful, wealthy businessman with a number of high-profile acquaintances that he
accumulated through a combinationofcharisma, charm, and intelligence. Despite his many
associates, he had limited significant or deep interpersonal tes. Although Mr. Epstein appeared
6
Page 288

to cultivate a large social and professional network, he was estranged from his only brother.
Indeed, hisidentity appeared to be based on h h. power, and association with other hich.
profile individuals.
1
Tn the weeks
before fis death, he made statements that he was “a coward” and was having difficulty adapting
to his diminished circumstances. He also frequently referenced poor sleep and an inability to
tolerate the noiseofprison. On the day before his death, a number ofdocuments in his case were
unsealed, further eroding his previously-enjoyed elevated status and potentially implicating some
of his associates. “The lackof significant interpersonal connections, a complete lossofhis status
in both the community and among associates, and the idea ofpotentially spending his life in
prison were likely factors contributing to Mr. Epstein’s suicide.
The following recommendations concern institution operations:
I SingeCeingf™ 0000000000000]

2. Rounds: 30-minute rounds are required by P5500.14, Correctional Services Procedures

Manual,
3. Cellmate Assignments: WhenMr. Epstein was placed in SHU on 019

i]
Tn an effort to treat Mir. Epstein the same as other inmates, a statement repeated
by multiple staff, ExecutiveStaff may have inadvertently overlooked the need to consider
unique risk factors associated with individuals who have been charged with and
convicted ofa sex offense. On July 25,2019"
sentan e-mail to
Shirley Skipper-Scott, Associate Warden explaining aconsultation between ~~|
an National Suicide Prevention Coordinator. In the e-mail,

7
Page 289

reviewedtheconsult and recommendation from the Psychology Services Branch, Central

Office that Mr. Epstein be housed with another inmate who had also been accused of
committing a sex offense. There is no evidence this information was considered beyond
this e-mail, and Mr. Epstein was never housed with another inmate charged or convicted
ofa sexual offense,

4. Documentation Accuracy: 1]

Tis critical that al descriptionsofthe incident accurately

Tellect objeciive evidence.

re JAlthoughtheincident
Teport was later expunged, inmates frequently experience significant siress when they
contemplate the potential consequences associated with findings of guilt.
a a Psychology Services Intake Screening into PDS-BEMR on
July 8, 2010. The document has three typographical errors. She selected the No Sexual
Offense Convictions check box when, in fact, Mr. Epstein was previously convicted of
SolicitationofProstitution and Procuring a Person Under the Age of 18 for Prostitution.
Second, Mr. Epstein was erroneously identified as a Black male in this document,
Finally, thereis one instance where he was mistakenly referred toas["=]

8
Page 200

Ce eed aRisk of Sexual Abusiveness document on July 8, 2019. She.

arked “History of prior prison sexual predation” in the affirmative. This is not accurate.
rae Practitioner, completed a History and Physical on
uly 9, 2079. An Intake Screening should have been conducted within 24 hoursofhis
entry into Bureau custody which was on July 6, 2019, according to P6031.04, Patient
Care.
Office”“vas responsible for observing Mr. Epstein and documenting his
behavior while on suicide watch on July 23, 2019. Officer| BE nimakenty used a
Suicide Watch Log Book intended for inmate companion documentation between
1:40 am. and 6:00 a.m. on July 23, 2019, when he should have been using the Staff
Suicide Watch Log Book Eo hs Treatment Specials reporedly
noticed this error and subsequently hand copied all of Office buries from 1:40
am. 10 6:00 a.m. into a Staff Suicide Watch Log Book. She then initialed these entries,
and this makes it appear asifshe was the one conducting the watch. This information
was discovered and conveyed in an e-mail from Ms. Charisma Edge, Associate Warden
td" "7 with a carbon copy to Warden N'Diaye on August 12, 2019. Of note,
£7 idiot make an entry explaining why she was making the log book changes.
Additionally, 1"
Jhen wrote entries for 6:15, 6:30, 6:45 and 7:00 a.m. in the
Stalf Suicide Watch Log Book. These were not a partofthe original eniries made by
Officer” “Jnor was{~~ hssigned to work the Suicide Watch post. Due to the
inability 10 interviewstaffat this time, it is unknown why Bp 10 correct
OMe en or made anyofthe subsequent log entries. It is recommended that
ifastaffmember makes an entry error (e.g., writes in the incorrect suicide watch log
book), the staff member should describe the error in the correct log book, o include
indicating when they became aware of the error. Thestaffmember should then notify the
Chief Psychologist
A review of Special Housing Unit Records (BP-A0292) revealed a number of incomplete:
entries. This document is used to monitor provision and receiptofbasic services such as
recreation, medical rounds, showers, meal consumption, etc. The Officer in Charge
signature is missing on 10 occasions and a medical provider's signature is missing in
seven instances. There are six instances in which it is not clear if Mr. Epstein atc his
meal. There are nine instances in which it is not clear if Mr. Epstein took a shower.
‘There are ten instances in which it is not clear if Mr. Epstein was offered recreation.
P5500.15, Correctional Services Manual requires accurate and complete information on
the BP-A0292.
A reviewof Psychology Observation Log Books revealed significant discrepancies from
the approved Psychological Observation Procedural Memorandum, dated April 15, 2019.
A Correctional Officer is required to complete hourly rounds and sign the log book; 179
9
Page 201

out of 183 round signatures were missing. The lieutenant is required to sign the log book
one timepershift and signatures were missing in 10of23 instances. A Physician

=]
5. Telephone Calls: Ina PDS-BEMR note written b{™“Jon July 16, 2019, she was
informed by an unnamed staff member that a lieutenant facilitated two telephone calls for
Mr. Epstein. Its unknown when and to whom these calls were placed and no evidence
that they took place on a monitored telephone.
According
to a memorandum from UnitManage August 10,2019,
Mr. Epstein terminated his legal visit early on August 9; 2019, i order to place a
telephone call to his pet was the Institutional Duty Officer that
week) escorted Mr. Epstein to SHU around 7:00 p.m. that evening and he was placed in
the shower area on G tier. While there, he was provided the telephone to make a call.
Since Mr. Epstein reportedly did not have his PAC or PIN number, which is required to
use the inmate telephone system, the Unit Manager placed the cal, dialing a number that
reportedly began with area code 347. Mr. Epstein pal was calling his
mother who, according to public records, has been deceased since 2004

6. Direct Observation: Mr. Epstein was on suicide watch from July 23, 2019, until
July 24,2019. While on suicide watch on July 23, 2019, Mr. Epstein attended an
attomey visit from approximately 12:40 p.m. until 7:15 p.m. During this time, he was
without “direct, continuous observation’ by a dedicated BOP staffmember as required by
PS324.08. While on Psychological Observation, he attended attorney visits on
July 24,2019, for 11.25 hours; on July 25, 2019, for 11.25 hours; on July 26, 2019, for
9.25 hours; on July 27, 2019, for 11.33 hours; on July 28, 2019, for 10.5 hours; and on
July 29,2019, for 8 hours. On July 30, 2019, Psychology Observation was terminated.
During these visits, continuous observation by a dedicated BOPstaffmember was not
maintained as required by MCC New York's Procedural Memorandum for Psychological
Observation.
7. Follow-Up: Mr. Epstein arrived at MCC New York on Saturday. July 6, 2019. While
conducting the 10:0 p.m. institution count that evening Flies Assistant
reported she observed Mr. Epstein in his cell. In an e-mail she sent to Drs. [22.«_land
EndLieutenant ima later that evening, she described Mr. Epstein as
“distraught, sad and a Title confused.” She said she then asked Mr. Epsteinifhe was
10
Page 202

okay, and he reportedly said he was.bi SI in her e-mail she was

not convinced ofthis, adding, “He seems dazed and withdrawn.” She went on to say, “So
just1o be on the safe side and prevent any suicidal thoughts can someone from
Psychology come and talk with him.” Despite the fact that Lieutenan ~~~ )pened
the e-mail there is no evidence that he contacted the on-call psychologist as is required by
P5324.08, Suicide Prevention Program. Additionally, a in concerned about
suicide risk, P5324.08, Suicide Prevention Program, requires her o maintaindirect,
continuous observation of Mr. Epstein. Wher" "pened the e-mail the following
Monday moming, Mr. Epstein was evaluated by[ "ht approximately
9:30am.
Mr. Epstein was denied bail on Thursday, July 18, 2019. Thiswas a significant
disappointment for Mr. Epstein and likely challenged his ability and willingness to adapt
incarceration. Given the potential impactofthe judge’s decision,a psychologist
should have assessed Mr. Epstein’s mental status upon his return to the institution. The
BOP developed a SENTRY assignment of PSY ALERT for purposes such as this.
Specifically PSY ALERT is used “to ensure, ifmovement occurs, that all staff consider
the special psychological and management-related risks associated with the inmate.”
Furthermore, P5324.07. SENTRY Psychology Alert Function states, “When adecision to
move (any PSY ALERT] inmate occurs, any special psychological needs of the inmate
are reviewed and considered by Psychology Services staff [and] any safety and security
concerns are highlighted for non-Psychology Services staff.”
BR
Bothofthese groups of inmatesare
susceptible to exaggerated or unrealistic fears about correctional settings and experience
stress associated during movement and periods of transition (c.g. cell/unt changes,
movement to and from court, institutional movement, and release of information through
the media).
Mr. Epstein was reportedly in courton July 31,2019. It is unknown what time he
departed or returned to MCC New York because this information was not entered in
SENTRY. Regardless, upon his return, the United States Marshals Service (USMS)
provided R&Dstaffwith a Prisoner Custody Alert Notice regarding Mr. Epstcin. The
notice indicated Mr. Epstein had “MTL Mental Concerns Suicidal Tendencies.” The
USMS requested R&Dstaffsign the form, and they then departed with th signed copy.
On August 1, 2019, at 8:46 am.|" sen"“Jan e-mail reporting she had
just become aware of the above information. In the absenceofadditional information
about this notation, this should have been considered a referral to Psychology Services
abouta potentially suicidal inmate and procedures should have been followed as outlined
in P5324.08, Suicide Prevention Program. Specifically, when a staffmember becomes
aware an inmate may be thinking about suicide during normal working hours, that staff
‘member must contact Psychology Services and maintain the inmate under direct,
n
Page 29%

continuous observation until he is placed on Suicide Watch or seen by apsychologist.

‘There is no evidence Mr. Epstein was monitored under these conditions from the time he
returned from court until he was seenby"=" Jfor a suicide risk assessment on
August 1, 2019, at approximately 1:30 p.m.
8. Inmate Accountability and Assignment Accuracy: According to a SENTRY quarters
roster generated on August 10, 2019, at 12:51 a.m., there were three inmates assigned to
Mr. Epstein’s SHU cell, Z04-206LAD, including him, at the timeofhis death. However.

fm nd TTT
his SHU cell was only a double occupancy cell. Inmate["™ =

On August T3, 2019, at 12:06 p.m. and 12:08 p.m., a quarters history roster was
generated for fat 2respectively. ict assignment was
Z04-206LAD from August 5, 2019, until August 11, 2019, when ie was moved to cell
704-212UAD. ie assignment was Z04-206UAD from August 1, 2019,
until August 11, 2019, when he was movedtocell Z04-207LAD. A quarters history
roster was generated for Mr. Epstein on August 13, 2019, at 9:07 am. His cell
assignment was Z04-206LAD from July 29, 2019, until August 10, 2019.

On Monday, August 12, 2019, photographs of nametags on SHU cell doors and SHU
locator forms were sent to the Correctional Service Department in the Northeast Region.
“The SHU locator form is dated August 9, 2019. It shows inmatdZ7 Jin cell 207L
(SENTRY states he was moved to this cell on August 11,2019), inmatd"" Jin cell
212U (SENTRY states he was moved to this cell on August 11,2019), inmate Epstein in
cell 220L (SENTRY never shows him in this cell) along with inmate Reyes (#85993
50, Teorshorn
in cell 206. The photo sheets show
la]
the cell being 220 with inmates Epsicin and Reyes
identification cards on the door. Inmate Reyes, Efrain, Reg. No. 85993-054 was in cell
206-220U from August 5, 2019 to August 9, 2019.

MCC New York has four suicide watch cells and each is for single occupancy use. The
suicide watch cells are located in Health Services. Each cell is abbreviated with the unit
code HO1 in SENTRY followed by the four-digit cell number. The doors are identified
by a painted number from one to four. Two reviews were conducted. The first revealed
Mr. Epstein was in HO1-001L according to SENTRY but the Suicide Watch Log Books
indicate he was in cell 4. A second review was conducted on August 13, 2019, while
there were four inmates on in these cells. SENTRY showed two inmates assigned to
HOI-001L, one assigned to HO1-002L, and the fourth inmate assigned to a general
population housing unit. Through physical observation ofthe dedicated suicide watch
cells there were four HOI cells, however a reviewof the BOPWARE Inmate Housing
Format, only shows three cells.

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Inmate movement and assignmentsarenot accurately reflected in SENTRY as required

by 5500.14, Correctional Service Procedures Mana
9. Attomey Log Books: Four log books were not secured following Mr. Epstein’s death.
Specifically, three Attorney Log Books located in the Attorney Visiting and Front Lobby
areas and an Inmate Search Log Book located in the Atiomey Visiting arca were not
secured. All four books were sil in use at the outsetofthe reconstruction and after the
reconstruction team advisedstaff to secure them. P5324.08 states, “In the event ofa
suicide, institution staff, particularly Correctional Services staff, and other law
enforcement personnel, will handle the ite with the same levelofprotection as any crime
scene in which a death has occurred.” This policy further states, “All possible evidence
and documentation will be preserved to provide data and support for subsequent
investigators doing a psychological reconstruction.”
Further, a reviewof the attomey log books identified many errors and signify a systemic
concen. For example, there were two concurrently open attomey log books in the
Atiomey Visiting area. Further, the different purposes of the two attomey log books, one
inthe Attorney Visit area and one in the Front Lobby, could not be explained. BOP staff
were unable to articulate a system of control for the log books, and during the
reconstruction, someof the log books could not be accounted for. Within the log books,
entries were made outofchronological order, attorneys did not consistently sign in and
out, significant information was illegible or missing, columns were not consistently
labeled, log bookopeningand closing dates were inconsistent, and the cover had been
tomoffofseveral books. At the current time, these log books are not functioning as an
adequate systemofcontrol and monitoring.
10. Automatic External Defibrillators: A reviewofavailable AEDs in the institution
revealed that the list used for accountability and inspection purposes was inaccurate and
incomplete.
11. Post Orders & SHU Training: SHU Post Orders Sign-In Sheets were reviewed for the 3°
‘Quarter, spanning June 9, 2019, to September 7, 2019. Office”"failed to sign post
orders for SHU #3 post
Quarterly SHU Training Sign-In Sheets were reviewed. The 2019 3* Quarter SHU
Training was conducted on June 6, 2019. Threestaffassigned to the 3" Quarter SHU
Roster in SHU did not attend or receive the SHU Training:Officer ==]
Oe ge
12. Staffing: The Drug Abuse Program Coordinator positon at MCC New York was
abolished during Phase I ofthe staffrealignment during fiscal year 2018. Re-establishing

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the Drug Abuse Program Coordinator position would provide the institution with an
additional supervisory psychologist to provide critical clinical services.
Staffing in the Correctional Services department is relevant to the reconstruction.
However, the details about this topic are provided in an Afler Action Review completed
separately from this report.
13. Sex Offense Risk Factors: A broad understandingofrisk factors associated with sex
offenders, bystaff at MCC New York, did not appear to be present in allstaffbut was
vital to his adjustment and safety in prison.

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DOCUMENTS EXAMINED
TRU-INTEL Download Report of Incident (583), 586, &[|
TRUVIEW — Money Exchanged; Phone, Email, & Visitor Lists; Calls; Messages; Visits;
Timeline
TRU-SCOPE — Logs, High Risk Inmates, Inmates Lists, etc
Staff Memorandums
Staff E-Mail
Photographs of Scene; Deceased, Autopsy
Video Showing Scene andStaffResponse
Sentry Documentation
SIS Case File Index.
Psychology File PDS-BEMR
Psychological Observation Procedural Memorandum
Post Orders
Lieutenant Logs
Attomey Logs
StaffRoster
Medical Information/Records (BEMR)
BOP Twenty-Four Hour Death Report
Pre-Sentence Report
Note(s) Left Behind by Deceased
Time Line
Autopsy Request & Report
Inmate Central File
Court Return Screening Form
Prisoner Remand Form(If applicablc)
USM 129 Individual Custody/Detention Report (Ifapplicable)
Prisoner Custody Alert Notice
Staff Sign-In Log | Week Prior to Suicide (If applicable)
Detention Orders(Ifapplicable)
30 minute SHU rounds
BP292’s & 205s

is