Washington — Systemic negligence, misconduct, and overall under-resourcing among federal corrections facility staff and facilities contributed to the conditions that enabled financier Jeffrey Epstein to die by suicide in his cell, the Justice Department’s inspector general concluded in a report released Tuesday.
The 66-year-old financier was found dead in his New York cell in 2019 a little over a month after federal authorities took him into custody for the alleged sex trafficking of minors. He was accused of exploiting and abusing dozens of underage girls and utilizing a network of employees to ensure continued access to victims, according to prosecutors.
A medical examiner ruled Epstein died by suicide on Aug. 10, 2019, from an apparent hanging and the inspector general’s report found no evidence inconsistent with that determination. An FBI investigation into the matter also found that there was no criminality directly tied to Esptein’s death.
Detention center staff misconduct gave Epstein opportunity to kill himself
While not unique to Epstein’s case, the federal watchdog’s investigation found “numerous and serious” instances of misconduct among corrections staff — some criminal — that gave him the opportunity to kill himself. In all, 13 individuals are identified as having committed performance failures between August 9 and 10, 2019, ranging from mere instances of indifference to potentially illegal acts.
Four Bureau of Prison employees were identified by the inspector general as having committed potential crimes, accused of either falsifying records or lying to investigators. Two were declined for prosecution by federal authorities. Tova Noel and Michael Thomas entered into a deferred prosecution agreement with federal prosecutors. Investigators alleged they altered records to make it appear as though they had performed proper checks on Epstein when in reality, they did not adequately supervise him. The charges were dropped by a federal judge after the former guards agreed to the deal with the Justice Department last year.
The report, the second in the last year that investigated a high-profile correction facility death, points to widespread problems across the Bureau of Prison and presents federal detention facilities as understaffed and lacking in supervision.
According to the report, Epstein’s death came just weeks after he was found injured in a cell and placed on suicide watch inside the Metropolitan Correctional Center (MCC) in Lower Manhattan. Prison staff found him with an orange cloth around his neck and his cellmate at the time told officials he had tried to hang himself.
Days later, the prison’s Psychology Department sent a notification to over 70 MCC employees notifying them that because of his condition, Epstein had to be housed with an appropriate cellmate for supervision. But on August 9, 2019, his cellmate was transferred to another corrections facility, and employees at the MCC failed to find Epstein another cellmate, according to the report.
After dozens of interviews with prison staff and inmates, the watchdog found, “A combination of negligence, misconduct, and outright job performance failures…all contributed to an environment in which arguable one of the most notorious inmates in BOP’s custody was provided with the opportunity to take his own life.”
Systemic understaffing
According to the report, there was also systemic understaffing in the prison, a failure to follow proper inmate check-in protocols by guards. They also gave Epstein access to excess bedding and other materials, the watchdog found.
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Thomas, Noel, and two supervisors only identified by their titles in the report knowingly and willfully falsified BOP records to show that they completed their mandatory rounds in inmate locations between Aug. 9 and 10 when they had not done so, the findings said. Regulations required inmates to be checked twice per hour and the report concluded Epstein and his fellow inmates in the MCC’s special housing unit were left unmonitored for hours overnight, during which time Epstein died by suicide.
It was not until Thomas — who told investigators he had “dozed off” overnight — performed his morning rounds that he found Epstein unresponsive in his cell.
Guards walked on “eggshells” around Epstein
Notably, a fellow inmate told investigators that guards walked on “eggshells” around Epstein and the inspector general’s report identified a series of irregularities in treatment, including hours-long attorney meetings, unrecorded phone calls and the excess bedding materials, which he ultimately used to hang himself.
In one instance, on the night before he died, staff allowed Epstein to place an unrecorded phone call after he asked to call his mother. Rules required such calls to be placed on a recorded and monitored line and investigators later established Epstein’s mother was deceased at the time. Still, a unit manager said he escorted Epstein to a phone and dialed a number for him. After a male answered, according to the report, the manager handed the phone to Epstein and left “because his shift had ended.”
The federal watchdog found numerous failures in the facility’s infrastructure also contributed to the conditions that led to Epstein’s death, including security cameras that functioned in a live capacity but failed to record any video.
A review of the security procedures around the time of Epstein’s conduct, however, found no evidence that anyone had entered his unit or cell and no indication of any foul play. And in interviews with inmates, none indicated they saw anyone enter their unit on the night Epstein died and none of the MCC staff told investigators they had any information “suggesting Epstein’s cause of death was something other than suicide.”
“In sum, the OIG’s investigation did not find any evidence that anyone was present in [the unit] during that timeframe other than the inmates who were locked in their assigned cells on that tier” of the special housing unit, the report concluded.
As part of the report, the inspector general provided eight recommendations to the Bureau of Prisons, all of which were accepted, including increased measures for suicide prevention. “Regrettably, the OIG has encountered similar issues on many other occasions,” the report said, adding, “the OIG has repeatedly found that BOP personnel have not consistently been attentive to the needs of inmates at risk of suicide.”
“While this misconduct described in this report is troubling,” the letter continued, “those who took part in it represent a very small percentage of the approximately 35,000 employees across more than 120 institutions who continue to strive for correctional excellence every day.”
“To further reinforce our commitment to the safety of individuals in our custody, all employees receive annual training in suicide prevention. Additionally, those who work closely with high-risk populations, particularly in restrictive housing, undergo enhanced specialized training. This training focuses on identifying signs of suicidal tendencies, making appropriate referrals, and responding effectively to emergencies,” a Bureau of Prison spokesperson said in a statement after the report’s release. “The BOP takes seriously our ability to protect and secure individuals in our custody while ensuring the safety of our correctional employees and the surrounding community.”
After Epstein’s death
Following Epstein’s death, then-Attorney General William Barr said he was “appalled” by the circumstances of his death in federal custody, which he said raised “serious questions that must be answered.” In addition to an FBI investigation into the matter, Barr directed the department’s inspector general to conduct an independent review.
The MCC was shuttered and the acting head of the Bureau of Prisons at the time, Hugh Hurwitz, was reassigned in the weeks that followed Epstein’s death. The more than 200 inmates who once inhabited the federal prison were transferred and, according to the Justice Department, the facility remains closed after numerous reports of faulty infrastructure.
More than a decade before he faced charges in New York, Epstein — who courted the world’s rich and powerful including Britain’s Prince Edward and former Presidents Bill Clinton and Donald Trump — pleaded guilty to charges in Florida and admitted he had solicited minors for prostitution. He was sentenced to 13 months in prison as part of the deal. Court documents revealed dozens of girls were brought to his Florida mansion and homes on his private Caribbean island and in New York and New Mexico.
According to court documents, authorities say at least 40 underage girls were brought into Epstein’s Palm Beach mansion for what turned into sexual encounters after female fixers looked for suitable girls locally, in Eastern Europe and other parts of the world.
His long-time associate and former girlfriend — Ghislane Maxwell — was convicted of five sex trafficking charges after prosecutors alleged she recruited and groomed Esptein’s victims. A judge in New York sentenced her to 20 years in prison last year. “My greatest regret in life is that I ever met Jeffrey Epstein,” she said at the time.
If you or someone you know is in emotional distress or a suicidal crisis, you can reach the 988 Suicide & Crisis Lifeline by calling or texting 988. You can also chat with the 988 Suicide & Crisis Lifeline here.
