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Epstein was housed, from the common area of the SHU between approximately 10:40 p.m. on August 9 and approximately 6:30 a.m. on August 10. 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 cited to the absence of debris under Epstein’s fingernails, marks on his hands, contusions to his knuckles, or bruises on his body that evidenced Epstein had been in a struggle, which would be expected if Epstein’s death had been a homicide by strangulation. As discussed in greater detail in the Conclusions and Recommendations chapter of this report, 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. The OIG has investigated numerous allegations related to the falsification of official BOP documentation concerning inmate counts and rounds and has repeatedly found deficiencies with the BOP’s staffing levels, the custody and care of inmates at risk for suicide, and security camera systems at BOP institutions. The combination of negligence, misconduct, and outright job performance failures documented in this report all contributed to an environment in which arguably one of the most notorious inmates in BOP’s custody was provided with the opportunity to take his own life. The BOP’s failures are troubling not only because the BOP did not adequately safeguard an individual in its custody, but also because they led to questions about the circumstances surrounding Epstein’s death and effectively deprived Epstein’s numerous victims of the opportunity to seek justice through the criminal justice process. The fact that these failures have been recurring ones at the BOP does not excuse them and gives additional urgency to the need for DO) and BOP leadership to address the chronic problems plaguing the BOP. Unless otherwise noted, the OIG applies the preponderance of the evidence standard in determining whether DO] personnel have committed misconduct. The U.S. Merit Systems Protection Board applies this same standard when reviewing a federal agency's decision to take adverse action against an employee based on such misconduct. See 5 U.S.C. 8 7701(c)(1)(B) and 5 C.F.R. 8 1201.56(b)(1)(ii). In Chapter 2 of this report, we provide background information, including identification and a description of significant entities and individuals; a summary of our methodology; and the applicable laws, federal regulations, and BOP policies. In Chapter 3, we outline a timeline of key events. In Chapter 4, we set forth our findings of fact relating to the BOP’s custody and care of Epstein before his death. In Chapter 5, we set forth our findings of fact related to the events of August 8-10, 2019, including Epstein’s death. In Chapter 6, we set forth our findings of fact related to the BOP’s failure to ensure that there was a functional security camera system at MCC New York, which resulted in limited recorded video evidence relevant to Epstein’s death. Finally, Chapter 7 contains our conclusions and recommendations. DOJ-OGR- 00023371