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The OIG investigation also found that during the next shift in the MCC New York SHU, both the Evening Watch SHU Officer in Charge and Noel became aware that Epstein was without a cellmate. The Evening Watch SHU Officer in Charge told the OIG that when he escorted Epstein back to his cell after Epstein’s telephone call, he saw that Inmate 3 was not there and then he, Noel, and the Material Handler discussed the need for Epstein to have a new cellmate. The Evening Watch SHU Officer in Charge also told the OIG that he notified an unspecified supervisor. However, other witnesses did not corroborate his account. Noel told the OIG that she was unaware both that Epstein needed to have a cellmate and that Inmate 3 had been removed from the institution. Noel also told the OIG that she went to Epstein’s cell at approximately 10 p.m.—a time of day when all inmates were secured in their cells—and may have plugged in Epstein’s medical device for him. The OIG did not credit Noel's statements that she did not know that Epstein needed a cellmate or that Inmate 3 had been removed from the SHU based on contradictory witness statements (including her own) regarding SHU staff's knowledge of Epstein’s cellmate requirement and Inmate 3’s transfer out of the SHU.® The OIG investigation concluded that on August 9, 2019, the Day Watch SHU Officer in Charge, the Evening Watch SHU Officer in Charge, and Noel failed to notify a supervisor as required after Epstein’s cellmate was permanently removed from the MCC New York SHU, which constituted a violation of BOP standards of conduct. Additionally, their inaction violated MCC New York SHU Post Orders because none of these individuals documented the fact the Epstein needed a new cellmate as required. Finally, all of these officers failed to exercise good judgment and common sense, as required by the SHU Post Orders, by not immediately undertaking steps through their chain-of-command to ensure that a high-profile inmate who had been released from suicide watch and psychological observation 10 days earlier had an appropriate cellmate. 2. Failure to Adequately Supervise SHU Staff The OIG also found that MCC New York supervisory personnel failed to effectively perform their duties, which contributed to the fact that Epstein was housed without a cellmate at the time of his death. Rather than passively relying on a notification from subordinates, supervisory personnel also had an obligation under federal regulations to “put forth honest effort in the performance of their duties,” which included supervision of SHU personnel.®” The OIG's investigation revealed that the Captain and the Day Watch Operations Lieutenant, the Day Watch Activities Lieutenant, the Evening Watch Operations Lieutenant, and the Morning Watch Operations Lieutenant, among other MCC New York staff, received an email from the U.S. Marshals Service (USMS) on August 8, 2019, notifying them that Inmate 3 was scheduled to be transferred to another facility the following day. If any of these supervisors had read the email attachment, they would have known of the need to assign Epstein a new cellmate. Instead, many of these individuals told the OIG that they believed that Inmate 3 had gone to court on August 9 and they were unaware that he would not return and Epstein needed a new cellmate. The SHU Lieutenant's shift on August 8 ended over an hour before the USMS sent the email notification and he was not working on August 9. In his absence, the Day Watch Operations Lieutenant, the Day Watch Activities Lieutenant, the Evening Watch Operations Lieutenant, and the Morning Watch Operations Lieutenant had oversight of the SHU during their respective 6 Noel reviewed a draft of the report and we considered her comments but made no changes as a result. 9? 5 C.F.R. 8 2635.101(b)(5); see also 5 C.F.R. 8 2635.705(a). 100 DOJ-OGR- 00023467