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because he did not conduct any rounds within the SHU on August 9 and he did not recall signing the form. The Morning Watch Operations Lieutenant confirmed that she conducted her round in the SHU at approximately 4 a.m. on August 10. The Morning Watch Operations Lieutenant said she went up to the 10 South Unit and then back down to the SHU because she needed to sign the round sheets. Contrary to BOP training for new Lieutenants, which she attended in 2011, the Morning Watch Operations Lieutenant told the OIG, “We are not required to go to each individual cell and look at the inmates. When we make rounds, we get with the officers.” The Morning Watch Operations Lieutenant said she did not conduct a round to observe the inmates when she visited the SHU. Noel confirmed that the Morning Watch Operations Lieutenant visited the SHU but did not walk down the tiers. Through review and analysis of the SHU security camera video, witness statements, and BOP records, the OIG determined that at approximately 4 a.m. on August 10, 2019, the Morning Watch Operations Lieutenant briefly visited the SHU as part of her supervisory duties and conferred with Noel and Thomas, who were seated at and around the SHU Officers’ Station in the common area of the SHU. Noel told the OIG that at approximately 5:30 a.m., Thomas went to the 10 South Unit, which was adjacent to the SHU, to relieve CO 3, and that CO 3 briefly walked through the SHU common area as he left and returned from his break. The OIG's review and analysis of the video footage revealed that, aside from those two officers, no one entered the SHU and no one conducted any counts or rounds. VI. Epstein’s Death on August 10 A. Discovery of Epstein Hanged in Cell and Emergency Response On August 10, 2019, shortly after 6 a.m., the doorbell to the SHU rang, indicating that a delivery of breakfast carts had arrived at the SHU. Noel and Thomas retrieved the breakfast carts from the double-locked entrance to the SHU and brought them inside the SHU. At the time, Thomas and Noel were the only officers in the SHU. At approximately 6:30 a.m., MCC New York security camera video recordings show Noel and Thomas walking toward the L Tier. Noel and Thomas told the OIG that at this time they were entering the L Tier, in which Epstein was housed, to deliver breakfast to the inmates. As discussed previously, between approximately 10:40 p.m. on August 9 and approximately 6:30 a.m. on August 10, the OIG did not observe on the available recorded video any COs or other individuals approach the L Tier where Epstein was housed from the common area of the SHU. Noel told the OIG that she unlocked the door to the L Tier so Thomas could deliver the breakfast trays. Thomas told the OIG that he knocked on Epstein’s cell door, saw a portion of Epstein through the window but could not make out what he saw, so he said to Epstein, “Come to the door, come to the door.” Thomas said he did not observe any movement or hear a response, so he unlocked the cell door, entered the cell, and saw Epstein hanged as described further below. Thomas said he immediately yelled for Noel to get help, and that Noel activated a body alarm, signaling a medical emergency, and began taking the steps described below. 70 DOJ-OGR- 00023437