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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, resulting in significant questions being asked about the circumstances of his death, how it could have been allowed to have happen, and most importantly, depriving his numerous victims, many of whom were underage girls at the time of the alleged crimes, of their ability 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 Department of Justice (DOJ) and BOP leadership to address the chronic staffing, surveillance, security, and related problems plaguing the BOP. The OIG has completed its investigation and is providing this report to the BOP for appropriate action. Unless otherwise noted, the OIG applies the preponderance of the evidence standard in determining whether DOJ 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. § 7701(c)(1)(B) and 5 C.F.R. 8 1201.56(b)(1)(ii). A. MCC New York Staff Failed to Ensure that Epstein Had a Cellmate on August 9 as Instructed by the Psychology Department on July 30 On July 30, 2019, the MCC New York Psychology Department sent an email to over 70 BOP staff members stating that Epstein “needs to be housed with an appropriate cellmate.” The Psychology Department's directive that Epstein have an appropriate cellmate arose out of the events that occurred on July 23, 2019, when Epstein was found lying on the floor of his cell with a piece of orange cloth around his neck. Epstein’s cellmate at the time (Inmate 1) told MCC New York staff that Epstein had tried to hang himself, and another inmate housed on the same SHU tier at the time (Inmate 2) corroborated several aspects of Inmate 1's account. Epstein’s accounts of what had occurred varied. Epstein initially told MCC New York staff that he thought his cellmate had tried to kill him, but thereafter he repeatedly said he did not know what had occurred. Epstein later asked two different MCC New York staff members if he could be housed with the same cellmate Epstein initially accused of having tried to harm him. As a result of this incident, Epstein was placed on suicide watch and then psychological observation. Consistent with the Psychology Department's directive, the Captain and the SHU Lieutenant each told the OIG that they verbally informed SHU staff of Epstein’s cellmate requirement. These and other witnesses said staff members regularly assigned to the SHU knew that Epstein needed to have a cellmate. However, despite the Psychology Department's widely disseminated July 30 email instruction and the subsequent verbal direction provided by the Captain and the SHU Lieutenant, Epstein was left without a cellmate on August 9 and, less than 24 hours later, Epstein died by suicide. 1. Failure to Make Required Notifications Regarding the Need to Assign Epstein a New Cellmate The OIG's investigation and review revealed that on August 9, 2019, MCC New York staff assigned to the SHU failed to notify their superiors that Epstein’s cellmate, Inmate 3, had been transferred out of MCC New York and therefore Epstein needed to be assigned a new cellmate. The failure to make these required notifications—and the supervisors’ failure to properly supervise the SHU staff, discussed further below— 98 DOJ-OGR-00023465