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defibrillator. Inmate 6 did not see marks on Epstein’s neck but did see bruising on his face and observed earphones that were still in place on Epstein’s ears. Inmate 7, who was two cells down from Epstein’s cell and on the other side of the tier, told the OIG that he could not see into Epstein’s cell but he could see the cell door. Inmate 7 said that after dinner was brought to Epstein’s cell on the evening of August 9, 2019, Inmate 7 did not recall seeing anyone going in or out of Epstein’s cell until the following morning at around 6 a.m. He further stated that he did not hear any door “pop open” that evening. Inmate 7 said he remembered waking up around 6 a.m. on August 10, 2019, and hearing a voice, possibly male, saying “Breathe.” Inmate 7 said he saw Epstein removed from his cell on a stretcher. In addition, the OIG and the Federal Bureau of Investigation (FBI) interviewed seven inmates assigned to other tiers in the SHU, none of whom had any direct knowledge of how Epstein died. These inmates consistently reported that the SHU officers did not systematically conduct the counts and rounds as required on the evening Epstein died and that the last round was either between 9:30-10 p.m. or 12:30- 1a.m. Several inmates told the OIG that before Epstein died the SHU staff never conducted rounds at night. According to the BOP Form 583 Report of Incident, on August 10, 2019, at approximately 6:33 a.m., while delivering the breakfast meal, Epstein was found unresponsive in his cell. Consistent with the required response to a suspected suicide outlined in the MCC New York General Housing Unit Post Orders that are described in Chapter 2, staff called for assistance and began life-saving measures.® At 6:39 a.m., Epstein was taken to the MCC New York Health Services Unit, and Emergency Medical Services (EMS) arrived to MCC New York at 6:43 a.m. Epstein was transported to the local hospital, New York Presbyterian Lower Manhattan Hospital, at 7:10 a.m., and was pronounced deceased at 7:36 a.m. According to a memorandum attached to the Form 583 from the Clinical Nurse dated August 10, 2019, when the medical emergency involving Epstein was called over the radio, the Clinical Nurse immediately responded to the call and upon arrival, saw Epstein on the floor within his cell unresponsive with CPR in progress by COs. The Clinical Nurse’s memorandum reads that Epstein was cold, with circumferential bruising around his neck and posterior mottling, pupils fixes and dilatated, and no palpable pulses were felt. According to the memorandum, at 6:35 a.m., a call was placed for EMS, CPR continued, and an AED was utilized and indicated “No Shock Advised,” so CPR continued. Epstein was then transported to the MCC New York Health Services Unit treatment room with CPR in progress. Upon arrival, Epstein’s pulse was checked, and the AED indicated “No Shock Advised.” EMS and paramedics arrived on the scene, intubated Epstein, and gave him medications and fluids.*® Epstein was transported to the local emergency room with CPR in progress at approximately 7:10 a.m. 45 As noted in Chapter 2, BOP policy provides that the need to immediately attend to an apparent suicide victim, undertake lifesaving measures, and ensure inmate and staff safety take precedence over efforts to preserve a crime scene. 4 The EMS arrival time on the Clinical Nurse’s memorandum is listed as 6:56 a.m. Based on the OIG’s review of other documentation and interviews, we believe the arrival time reflected on those other documents (6:43 a.m.) is more likely the time of EMS's arrival. We noted that the Clinical Nurse, at the time of EMS's arrival, was actively engaged in administering CPR to Epstein and responding to the health emergency. 75 DOJ-OGR- 00023442