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the L Tier during that timeframe other than the inmates who were locked in their assigned cells on that tier of the SHU.
We also noted that the surveillance camera in the L Tier, as shown in the photograph in Figure 6.7, was in plain view of the inmates and therefore inmates would have been aware that any hallway movements, including into or out of Epstein's cell, were being live streamed and could be monitored, even if, unbeknownst to them, the Digital Video Recorder (DVR) system was not recording the live stream at that time. As the OIG has noted in numerous prior reports regarding the BOP's camera system, BOP staff and inmates are aware of where prison cameras are located and often engage in wrongdoing in locations where they know cameras are not located.56 Additionally, the OIG did not observe on the recorded video of the SHU common area that Noel and Thomas, who were seated at the desk at the SHU Officers' Station immediately outside the L tier during that time period, at any time rose from their seats or approached the L Tier. We additionally found that Thomas's and Noel's reaction on the morning of August 10 upon finding Epstein hanging in his cell, as described to us by Thomas, Noel, the responding Lieutenant, and inmates, was consistent with their being unaware of any potential harm to Epstein prior to Thomas entering Epstein's cell at about 6:30 a.m. on August 10.
We further noted that Epstein had previously been placed on suicide watch and psychological observation due to the events of July 23, 2019; that numerous nooses made from prison bed sheets were found in his cell on the morning of August 10; and that he had signed a new Last Will and Testament on August 8, 2 days before he died. No weapons were recovered from Epstein's cell after his death. Additionally, the inmates who were interviewed consistently reported that on the evening Epstein died the SHU staff did not systematically conduct the required rounds and counts, which was one of the primary mechanisms for the SHU staff to ensure the safety and security of inmates housed in the SHU. As a result, Epstein was unmonitored and locked alone in his cell for hours with an excess amount of linens, which provided an opportunity for him to commit suicide.
Finally, the Medical Examiner who performed the autopsy detailed for the OIG why Epstein's injuries were more consistent with, and indicative of, a suicide by hanging rather than a homicide by strangulation. The Medical Examiner also told the OIG that the ligature furrow was too broad to have been caused by the electrical cord of the medical device in Epstein's cell and that blood toxicology tests revealed no medications or illegal substances were in Epstein's system. The Medical Examiner also noted the absence of debris under Epstein's fingernails, marks on his hands, contusions to his knuckles, or bruises on his body that would have indicated Epstein had been a struggle, which would be expected if Epstein's death had been a homicide by strangulation.
This is not the first time that the OIG has found significant job performance and management failures on the part of BOP personnel and widespread disregard of BOP policies that are designed to ensure that inmates are safe, secure, and in good health. For instance, the OIG's December 2022 investigation and review of the BOP's handling of the transfer of James "Whitey" Bulger identified serious job performance and
56 U.S. Department of Justice (DOJ) OIG, Notification of Needed Upgrades to the Federal Bureau of Prisons' Security Camera System, Management Advisory Memorandum 22-001 (October 2021); U.S. DOJ OIG, Audit of the Federal Bureau of Prisons' Management and Oversight of its Chaplaincy Services Program, 21-091 (July 2021); U.S. DOJ OIG, Review of the Federal Bureau of Prisons' Contraband Interdiction Efforts, Evaluation and Inspections Report 16-05 (June 2016).