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management failures at multiple levels within the BOP.*” Similar to the Bulger report, the numerous and serious transgressions that occurred in this matter came to light largely because they involved a high-profile inmate. The fact that serious deficiencies occurred in connection with high-profile inmates like Epstein and Bulger is especially concerning given that the BOP would presumably take particular care in handling the custody and care of such inmates. Regrettably, the OIG has encountered similar issues on many other occasions. For example, the OIG has investigated numerous allegations related to the falsification of official BOP documentation concerning inmate counts and rounds, several of which have resulted in criminal prosecution. The OIG currently has two open investigations into allegations of falsified inmate count and round documentation, each involving an inmate death (by suicide and homicide) or escape from a BOP facility. This investigation and review also revealed the direct impact of insufficient staffing levels on inmate safety. Witnesses repeatedly told the OIG that counts, rounds, cell searches, and other methods of inmate accountability were not undertaken because correctional staff were working multiple shifts—including one staff member who worked 24-hours straight—and were tired and overwhelmed with other duties. As discussed in greater detail in our recommendations, the OIG has repeatedly found the need for BOP to address staffing shortages. Most recently, in March 2023, the OIG found that the coronavirus disease 2019 (COVID-19) pandemic exacerbated the effects of preexisting BOP medical and nonmedical staffing shortages, an issue the OIG has identified as a concern for the BOP since at least 2015.°° Further, the OIG has repeatedly found that BOP personnel have not consistently been attentive to the needs of inmates at risk for suicide. In this investigation, that inattention manifested in the failure of MCC New York staff and supervisors to ensure that Epstein was assigned a cellmate as required by the MCC New York Psychology Department directive issued after the July 23, 2019 incident in which Epstein was discovered in his cell with an orange cloth around his neck. In a March 2023 report, the OIG found that BOP psychology staff did not assess the suitability of single-cell assignments for five of the seven inmates who died by suicide while in COVID-19 quarantine units between March 2020 and April 2021.°? The OIG’s 2017 report on the BOP’s use of restrictive housing for inmates with mental illness also noted that single-celling may present risks to inmate mental health, and both of the recommendations from that report regarding the use and oversight of single-celling remain open as of March 2023. Lastly, as discussed in greater detail in the conclusions and recommendations that follow, the persistent deficiencies of the BOP’s security camera systems are well documented and long-standing. 57 U.S. DOJ OIG, Investigation and Review of the Federal Bureau of Prisons’ Handling of the Transfer of Inmate James “Whitey” Bulger, 23-007 (December 2022). 58 U.S. DOJ OIG, Capstone Review of the Federal Bureau of Prisons’ Response to the Coronavirus Disease 2019 Pandemic, Evaluation and Inspections Division A-2020-011 (March 2023) (Capstone Report). 59 Capstone Report. 6 U.S. DOJ OIG, Review of the Federal Bureau of Prisons‘ Use of Restrictive Housing for Inmates with Mental IlIness, Evaluation and Inspections Report 17-05 (July 2017). 97 DOJ-OGR- 00023464