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Chapter 7: Conclusions and Recommendations l. Conclusions Our investigation and review of the Federal Bureau of Prisons’ (BOP) custody, care, and supervision of Jeffrey Epstein identified numerous and serious failures by employees of the Metropolitan Correctional Center located in New York, New York (MCC New York), including falsifying BOP records relating to inmate counts and rounds and multiple violations of MCC New York and BOP policies and procedures, which compromised Epstein’s safety, the safety of other inmates, and the security of the institution. Specifically, we found that MCC New York staff failed to undertake required measures designed to make sure that, among other things, Epstein and other inmates were accounted for and safe, such as conducting inmate counts and 30-minute rounds, searching inmate cells, and ensuring adequate supervision of the Special Housing Unit (SHU) and the functionality of MCC New York's security camera system. We further found that multiple BOP employees submitted false documents claiming that they had performed the required counts and rounds and that several MCC New York staff members lacked candor when questioned by the Office of the Inspector General (OIG) about their actions. Two MCC New York employees, Tova Noel and Michael Thomas, were charged criminally with falsifying BOP records relating to their conducting inmate counts and rounds. The U.S. Attorney's Office for the Southern District of New York subsequently entered into deferred prosecution agreements with Noel and Thomas and the court dismissed all charges against them after Noel and Thomas successfully fulfilled the terms of their agreements. Prosecution was declined by the U.S. Attorney's Office for the Southern District of New York for other MCC New York employees assigned to the SHU on August 9-10, 2019, who the OIG found also created, certified, and submitted false documentation regarding inmate counts and rounds on the day before and the day of Epstein’s death. The OIG also found that the MCC New York staff failed to carry out the Psychology Department's directive that Epstein be assigned a cellmate and that an MCC New York supervisor allowed Epstein to make an unmonitored telephone call the evening before his death. The OIG determined that the combination of these and other failures led to Epstein being alone and unmonitored in his cell, with an excessive amount of bed linens, from approximately 10:40 p.m. on August 9, until he was discovered hanged in his cell at approximately 6:30 a.m. the following day. Additionally, the OIG found that staffing shortages, a persistent issue for the BOP, compromised the ability of MCC New York staff to adequately supervise inmates. As detailed below, we make a number of recommendations to the BOP to address the serious issues we identified during our investigation and review. While the OIG determined that MCC New York staff committed significant violations of BOP and MCC New York policies and falsified records relating to their conducting inmate counts and rounds, the OIG did not uncover evidence that contradicted the Federal Bureau of Investigation’s (FBI) determination regarding the absence of criminality in connection with how Epstein died. All MCC New York staff members who were interviewed by the OIG said they did not know of any information suggesting that Epstein’s cause of death was something other than suicide. Likewise, none of the interviewed inmates provided any credible information that Epstein’s cause of death was something other than suicide. 94 DOJ-OGR- 00023461