LIMITED OFFICIAL USE The attached information must be protected and not released to unauthorized individuals. Use of this cover sheet is in accordance with the Department of Justice regulation on the control of Limited Official Use information. EFTA00035986

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LIMITED C€ Investigation and Review of the Federal Bureau of Prisons’ Custody, Care, and Supervision of Jeffrey Epstein at the Metropolitan Correctional Center in New York, New York Notice: This Draft Is Restricted to Limited Official Use. This document is a WORKING DRAFT prepared by the U.S. Department of Justice Office of the Inspector General. It has not been fully reviewed within the Department and is, therefore, subject to revision. This report may contain sensitive law-enforcement or privacy-protected information and is for authorized recipients only. Recipients of this draft must not, under any circumstances, show or release its contents for purposes other than official review and comment. It must be safeguarded in accordance with Department of Justice Order 2620.7 to prevent publication or other improper disclosure of the information it contains. If you have received this draft report in error, please contact (202) 768-2643 to arrange its return. LIMITED OFFICIAL USE ONLY—NOT FOR PUBLIC RELEASE EFTA00035987

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Limited Official Use Only—Not for Public Release breakfast to Epstein through the food slot in his locked cell door, Epstein did not respond to Thomas's verbal commands. Thomas unlocked the cell door and saw Epstein hanged. Thomas immediately yelled for Noel to get help and call for a medical emergency. Thomas told the OIG that when he entered Epstein’s cell, Epstein had an orange string, presumably from a sheet or a shirt, around his neck that was tied to the top portion of the bunkbed. Epstein was suspended from the top bunk in a mear-seated position, with his buttocks approximately 1 inch to 1 inch and a half off the floor. Thomas said he immediately ripped the orange string from the bunkbed, and Epstein’s buttocks dropped to the ground. Thomas then lowered Epstein’s body to the floor and began chest\compressions until responding MCC New York staff members arrived approximately 1 minute later. Shortly thereafter, outside medical personnel arrived and took over the emergency response, eventually removing Epstein to a local hospital where he was pronounced dead. | On August 11, 2019, the Office of the Chief Medical _ Examiner performed an autopsy and determined the ~ causé of death was hanging and the manner of death was suicide. Blood toxicology tests did not reveal any medications or illegal substances in Epstein’s system. _ The Medical Examiner who performed the autopsy told the OIG that Epstein’s injuries were consistent with suicide by hanging and that there was no evidence of defensive wounds that would be expected if his death » had been a homicide. Epstein did not have marks on his hands, broken fingernails or debris under them, contusions to his knuckles that would have evidenced a fight, or, other than an abrasion on his arm likely due to convulsing from hanging, bruising on his body. On August 10, at approximately 6:30 a.m., the two SHU sof on yan Material Handler Michael Thomas, began delivering breakfast to SHU inmates. Tova unlocked the door to Epstein’s SHU tier. When Thomas attempted to deliver ' As detailed in the report, MCC New York had a history of security camera problems. ii Limited Official Use Only—Not for Public Release EFTA00035988

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Limited Official Use Only—Not for Public Release lacked candor during their OIG Piliews Two)MCC New York employees|fgmpnd Thomas, were charged criminally ‘anys BOP recor iii Limited Official Use Only—Not for Public Release EFTA00035989

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Limited Official Use Only—Not for Public Release Chapter 2: Background Significant Entities and Individuals nc Material Handler Michael Thomas began working together in MCC New York SHU at 12:00 a.m, on August 10, 2019.5 During their shift, they each created and submitted falsified official BOP forms documenting inmate counts (often referred to as “count slips”), Thomas did not work his regular 4:00 p.m. to 12: 00 a.m. shift as a Material Handler in a different location of MCC New York and instead worked an overtime shift in the SHU from 12:00 a.m. to 8:00 a.m. on August 10, 2019. 5 Limited Official Use Only—Not for Public Release EFTA00035990

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Limited Official Use Onty—Not for Public Release On November 19, 2019, a federal grand jury of the U.S. District Court for the Southern District of New York returned an indictment that charge! ind Thomas with one count each of conspiracy and multiple counts each of falsification of records, in violation of 18 U.S.C. 88 371, 1001(a)(3), and 2. The indictment alleged that on August 9, 2019, and that on August 10, 2019, both she and Thomas failed to conduct the mandatory 12:00 a.m., 3:00 a.m., and 5:00 a.m. counts and mandatory 30-minute rounds within the MCC New York SHU. The indictment further alleged that[jjgjand Thomas created, certified, and submitted false documentation indicating that the counts and rounds had been done as required to conceal their failure to perform their assigned duties. As a result, it appeared from documentation that prisoners in the SHU, including Epstein, were being regularly monitored when, in fact, no correctional officer had checked on Epstein from approximately 10:40 p.m. on August 9, 2019, until approximately 6:30 a.m. on August 10, 2019, when Epstein was found hanged in his cell. On May 25, 2021, the U.S. Attorney's Office for the Southern District of New York entered into deferred prosecution agreements with nd Thomas. Their respective agreements, which are part of the court record in their cases, included admissions ind Thomas that they falsely certified that they had conducted counts and rounds. The agreements also required each of them to truthfully and completely disclose all information related to their activities and.employment with the BOP; be interviewed by the U.S. Attorney's Office of the Southern District of New York, the FBI, and the O|G; complete 100 hours of community service; refrain from violating the law; and fulfill other conditions related to pretrial supervision and their establishment of good behavior. On December 13, 2021, after [iijpnd Thomas successfully fulfilled the terms of their deferred prosecution agreements as determined by the prosecutors, the U.S. District Court for the Southern District of New York entered a nolle prosequi order and dismissed all charges pending against them. Prosecution was declined by the U.S. Attorney's Office for the Southern District of New York for other BOP employees assigned to the SHU who also falsely certified inmate count slips and round sheets on the day before.and the day of Epstein’s death. As discussed in greater detail in Chapter 7 of this report, the OIG found that, in addition to[[jand Thomas, many other MCC New York staff members engaged in administrative misconduct, exercised poor judgment, and/or failed to adequately perform their assigned duties. Il. Methodology During the course of this investigation, the OIG interviewed 54 witnesses, several on more than one occasion. The witnesses ppprviewed included[ina] Thomas, and other as New York staff assigned to the ® These BOP forms are officially entitled “ Official Count Slip" and “MCC New York, Special Housing Unit, 30 Minute Check Sheet.” Each of the six tiers in the SHU had a separate round sheet, each of which had 13 entries reflecting 30- minute rounds were conducted, when they were not, in fact, completed. 6 Limited Official Use Only—Not for Public Release EFTA00035991

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Limited Official Use Only—Not for Public Release Material Handler Michael Thomas told the OIG that he worked a shift in the SHU on August 10 from 12:00 a.m. until 8:00 a.m. Thomas said the SHU was not his normal post, but he had worked in the SHU on numerous previous occasions and was familiar with the SHU protocols and procedures. Thomas said he knew that if an inmate came off suicide watch or psychological observation, they should be assigned a cellmate, and said he was aware that Epstein had previously been on suicide watch and psychological observation. Therefore, Thomas assumed that Epstein was required to have a cellmate, but said no one had spoken with him about that requirement. Thomas said the SHU staff should have notified the Operations Lieutenant as soon as they knew that Epstein’s cellmate had departed MCC New York on August 9. However, Thomas said he did not know that Inmate 3 was removed from MCC New York on August 9, and that Epstein was without a cellmate during his shift on August 10. 52 Limited Official Use Only—Not for Public Release EFTA00035992

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Limited Official Use Only—Not for Public Release At approximately 12:00.4.m. on August 10, 2019, Material Handler Thomas replaced the other Material Handler, and vefitlin the only two staff members on duty in the SHU. (jana Thomas were responsible for conducting the 12:00 a.m.,3:00 a.m., and 5:00 a.m. counts in the SHU. Through review and analysis of the SHU security camera video, witness statements, and BOP records, the OIG determined that Gmc Thomas did not perform any of these counts. Nonetheless [iiiimland Thomas completed and signed SHU count slips for each of the three counts, and in reliance on the count slips, the Control Center cleared the 12:00 a.m,, 3:00 a,m., and 5:00 a.m. institutional counts at approximately 12:49 a.m., 3:24 a.m., and 5:30 a.m., respectively ind Thomas both admitted to the OIG that they did not conduct the 12:00 a.m., 3:00 a.m., and 5:00 a.m. counts on August 10, and that they had falsified the respective count slips. 60 Limited Official Use Only—Not for Public Release EFTA00035993

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Limited Official Use Only—Not for Public Release Thomas told the OIG that since he had begun working with the BOP in 2007, he had worked in the SHU fairly regularly and he was familiar with how to work in the SHU and how the SHU operated. Thomas described his responsibilities while working in the SHU as to maintain the count of inmates, make sure the inmates are fed, and, depending on the shift, make sure they get their showers. Thomas's Overtime Schedule showed that he worked 21 shifts in the SHU during morning watch from May through August 2019. The overtime schedule also showed that Thomas worked 12 overtime shifts a SHU when Epstein was gssiened to the SHU in July and August 2019. Thomas acknowledged that neither he nor Noel conducted any rounds or counts in the SHU during their shift between approximately 12:00 a.m. and approximately 6:30 a.m. Thomas said the August 10, 2019 round sheets were signed, but the rounds were not conducted because he was tired that day. Thomas recalled “dozing off from here and there” during his shift, but he did not know if Noel slept. Thomas did not recall having a conversation with anyone concerning the discrepancy between the 12:00 a.m. SHU count slip, which listed 73,inmates, and the institutional count, which listed 72 inmates in the SHU. Thomas said he had filled out and signed the 3:00 a.m. SHU count slip, which listed 72 inmates in the SHU. Thomas did not know why the number of inmates was different on the 12:00 a.m. and 3:00 a.m. count slips and did not recall speaking with the Morning Watch Operations Lieutenant about the 12:00 a.m. count. Thomas told the OIG that hey he was falsely certifying the count slips when he signed them on August 10, 2019. 37 This BOP form is officially entitled “MCC New York, Special Housing Unit, 30 Minute Check Sheet.” 61 Limited Official Use Only—Not for Public Release EFTA00035994

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Limited Official Use Only—Not for Public Release and Thomas both admitted to the OIG that they did not conduct any of the rounds reflected on the SHU Round Sheet on August 10, 2019, from 12:00 a.m. until Epstein was found hanged in his cell at %® Through review and analysis of the SHU video footage, witness statements, and BOP records, the OIG determined that [Jjpnd Thomas did not enter the tiers in the SHU to conduct any of the rounds and counts between 12:00 a.m. and approximately 6:30 a.m. on August ee Thomas can be seen at the SHU Officers’ Station, moving in the SHU common area, and the SHU laundry and entrance/exit area throughout the morning of August 10. Additionally, from approximately 1:00 a.m. to 3:00 a.m. [ibn Thomas were seated at the SHU Officers’ Station without moving and appeared to be sleeping. Thomas used the computer 38 Each of the 6 tiers in the SHU had a separate round sheet, each of which had 13 entries reflecting 30-minute rounds were conducted, when they were not, in fact, completed. 62 Limited Official Use Only—Not for Public Release EFTA00035995

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Limited Official Use Only—Not for Public Release briefly around 1:00 a.m. and 6:00 a.m. to search for motorcycle sales and sports news. 63 Limited Official Use Only—Not for Public Release EFTA00035996

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Limited Official Use Only—Not for Public Release VI. Epstein's Death on August 10 A. Discovery of Epstein Hanged in Cell and Emergency Response On August 10, 2019, shortly after 6:00a.m., the doorbell to the SHU rang, indicating that a delivery of breakfast carts had arrived at the SHU ind Thomas retrieved the breakfast carts fi e double- locked entrance to the SHU and brought them inside the SHU. At the time, Thomas and ere the only officers in the SHU. At approximately 6:30 a.m., MCC New York security camera video recordings show Ey and Thomas walking toward the L Tier. (bra Thomas told the OIG that at this time they were entering the L Tier, in which Epstein was housed, to deliver breakfast to the inmates. As discussed previously, between approximately 10:40 p.m. on August 9 and approximately 6:30 a.m. on August 10, the OIG did not observe on the available recorded video any correctional officers or other individuals approach the L Tier where Epstein was housed from the common area of the SHU. Thomas told the OIG that he knocked on Epstein’s cell door, saw a portion of Epstein through the window but could not make out what he saw, so he said to Epstein, “Come to the door, come to the door.” Thomas said he did not observe any movement or hear a response, so he unlocked the cell door, entered the cell, and saw Epstein hanged as described further below. Thomas said he immediately yelled for Noel to get help, and that Noel activated a body alarm, signaling a medical emergency, and began taking the steps described below. 64 Limited Official Use Only—Not for Public Release EFTA00035997

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Limited Official Use Only—Not for Public Release Figure 5.3: Photograph of a Piece of Orange Cloth Hanging from the Bunkbed in Epstein’s Cell Following His Death Thomas explained that when he first entered Epstein’s cell, Epstein had an orange string, presumably from a sheet or a shirt, around his neck. The end of the string was tied to the top portion of the bunkbed. Epstein was suspended from the top bunk in a near-seated position, with his buttocks approximately 1 inch to 1 inch and a half off the floor and his legs extended out straight on the floor. Thomas said Epstein did not look discolored or very different from when he last saw Epstein alive. Thomas said he immediately ripped the orange sheet or shirt away from the bunkbed, and Epstein’s buttocks dropped approximately 1 inch to 1.inch and a half to the ground. Thomas then lowered Epstein’s entire body to the floor and, because he did not believe Epstein was breathing, Thomas immediately began providing chest compressions untilresponding MCC New York staff members arrived approximately 1 minute later. Thomas said he did not provide rescue breaths and was unaware if Epstein was dead or alive because he never checked for a pulse before initiating chest compressions. Thomas said medical personnel took over the emergency response, including chest compressions and use of an automated external defibrillator (AED), when they arrived. Thomas said he assisted with bringing Epstein down to the Health Services Unit on the second floor, and that he left MCC New York at approximately 8:00 a.m. Thomas said he had received cardiopulmonary resuscitation (CPR) training during MCC New York annual refresher training and had responded to medical emergencies in the past, but this was the first time he was the first responder. Thomas said he was present in the SHU for his entire shift on August 10, 2019, from 12:00 a.m. until the time he attempted to deliver breakfast to Epstein at approximately 6:30 a.m., and did not see anyone go inside Epstein’s cell during his shift. Thomas said that he would have known if someone went in or out of Epstein’s cell, and said no one did. Thomas told the OIG that he could see Epstein’‘s cell door from the SHU Officers’ Station, but he could not see inside the cell from that vantage point. Thomas said that it was not possible for anyone to have entered the SHU without his knowledge because he or Noel would have had to open the SHU door for anyone to gain entry. The only other key to the SHU was located in the Control Center; no other MCC New York staff members had the keys required to gain access to the SHU. Moreover, Thomas said that anyone attempting to access the L Tier where Epstein was located would have had to walk directly in front of the SHU Officers’ Station where Thomas was seated, and no one did. Thomas denied that he or Noel had any role in Epstein’s death. 65 Limited Official Use Only—Not for Public Release EFTA00035998

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Limited Official Use Only—Not for Public Release Between approximately 10:40 p.m. on August 9 and just before 6:30 a.m. on August 10, the OIG did not observe on the recorded video any Correctional Officer or other individual enter any of the SHU tiers, which is consistent es Material Handler Michael Thomas’ admissions to the OIG that the 78 Limited Official Use Only—Not for Public Release EFTA00035999

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Limited Official Use Only—Not for Public Release Chapter 7: Conclusions and Recommendations Conclusions 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 NewYork Te entered into deferred prosecution agreements wit sed a and Thomas successfully fulfilled the terms of thelt agreements. 84 Limited Official Use Only—Not for Public Release EFTA00036000

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Limited Official Use Only—Not for Public Release The door to Epstein’s cell was visible from the SHU Officers’ Station, an Material Handler Michael Thomas, told the Ric that no Thomas entered the L Tier and called for een and failed to respond. 5) The primary entrance doors to the MCC New York SHU are shown in Figure 4.1. Access to the secondary entrance to the SHU, which was adjacent to the elevator bay on the south side of the floor, was also controlled by an exterior entry door opened by the Control Center and an interior door opened only with a key held by one of the correctional officers assigned to the SHU, while on duty. The secondary entrance doors to the SHU are shown in Figure 4.2. 85 Limited Official Use Only—Not for Public Release EFTA00036001

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Limited Official Use Only—Not for Public Release 2 Additionally, the OIG did not observe on the recorded video of the SHU common area that and Thomas, who were seated at the desk at the SHU Officers’ Station immediately outside the L tier during that time period, at any time rose from their seats or approached the L Tier. additionally found that Thomas’ and [jj reaction on the morning of August 10 upon finding n hanging in his cell, as described to us by Thomas, was consistent with their being unaware of any potential harm to Epstein prior to Thomas entering Epstein’s cell at about 6:30 a.m. on August 10. » Management Advisory Memorandum 22-001 1 (October 2021); U.S. DOJ OIG, Audit of the Federal Bureau of Prisons’ i services Program, 21-091 (July 2021); U.S. DOJ OIG, Review of the Federal! ‘Bureau of Prisons’ Contraband interdiction Efforts Evaluation and Inspections Report 16-05 (June 2016). 86 Limited Official Use Only—Not for Public Release EFTA00036002

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Limited Official Use Only—Not for Public Release | Handler Michael Thomas each admitted that they did not conduct all of the mandatory rounds and inmate counts in the SHU on the evening of August 9 and the morning of August 10.) 92 Limited Official Use Only—Not for Public Release EFTA00036003

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Limited Official Use Onty—Not for Public Release Instead of performing the required duties to account for inmate whereabouts and wellbeing, the OIG found that officers assigned to the SHU on August 9 and 10, including and Thomas, primarily remained seated in the SHU Officers’ Station—sometimes without moving for a period of time, suggesting that they were asleep—and conducted a variety of internet searches on MCC New York computers. Thomas also admitted to the OIG that he “dozed off” for periods of time during his shift. The OIG's analysis of the SHU security camera video revealed that after approximately 10:40 p.m., no (abe Thomas Correctional Officer entered Epstein’s tier in the SHU until just before 6:30 a.m. when began to serve breakfast to the inmates. eae Ri aussietion and review concluded I and Thomas failed to conduct the mandatory rounds and inmate counts during their respective shifts in the MCC New York SHU on August 9 and 10,2019, and that their actions constituted violations of 5 C.F.R. 8§ 2635.101(b)(5) and 2635.705(a), BOP Program Statements 3420.11 and 5500.14, and MCC New York SHU Post Orders. 2. False Statements and Lack of Candor The OIG's — and review found that on August 9 and 10, 2019 [i ind Thomas made false statements when they falsified BOP records by attesting that they had completed the mandatory rounds and inmate counts when, in fact, they had not. Federal law provides that “whoever, in any matter within the jurisdiction of the executive...branch of the Government of the United States, knowingly and willfully...makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry” has violated 18 U.S.C. § 1001(a)(3): As discussed above, the OIG found tha (and Thomas failed to conduct all of the mandatory rounds and inmate counts. As part of each institutional inmate count, BOP policy and MCC New York SHU Post Orders require two correctional officers to conduct each count and memorialize the number of inmates in the SHU on an official MCC New York form, often called a count slip."’ On the count slip, both correctional officers are required to fill in the date and time the count had been performed, write the total number of inmates physically present in the unit counted, and then sign the count slip. Once the correctional officers complete and sign the count slips, the count slips are then collected and delivered to the MCC New York Control Center. Officers assigned to the Control Center are responsible for comparing the count slips from each housing unit to the institution’s overall inmate count sheet to ensure that each inmate was accounted for.”° Only after all the count slips have been collected from each housing unit, and the numbers on the count slips had been matched to the ® This BOP form is officially entitled “Metropolitan Correctional Center; New York, New York; Official Count Slip.” 7° The official name for the document used to record an institutional count is “Bureau of Prisons Count Sheet.” 93 Limited Official Use Only—Not for Public Release EFTA00036004

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Limited Official Use Only—Not for Public Release institution’s overall inmate count sheet, could the institutional count be deemed “cleared” or completed. and Thomas each prepared and/or signed a false count slip to create the impression that they had fulfilled their inmate accountability responsibilities when, in fact, they had not.”' These individuals admitted to the OIG that instead of performing their assigned duties, they pre-filled the count slips with the number of inmates they believed were in the SHU based on what officers from the previous shift had told them and signed off on the documents knowing that they falsely attested to having completed the counts. ana Thomas were indicted by a grand jury for their false certifications of having conducted counts and rounds. Subsequently, each entered into a deferred prosecution agreement with the U,S. Attorney's Office for the Southern District of New York. The OIG investigation has found tha’ and Thomas knowingly and willingly falsified BOP records in violation of federal law by attesting that they had completed the mandatory rounds and inmate counts on the evening of August 9, 2019, and morning of August 10, 2019. ind Thomas signed the 12:00 a.m., 3:00 a.m., and 5:00 a.m. count slips. ”2 This BOP form is officially entitled “MCC New York, Special Housing Unit, 30 Minute Check Sheet.” 73 BOP and Council of Prison Locals, Master Agreement, July 21, 2014-July 20, 2021 (extended until 2026). 94 Limited Official Use Only—Not for Public Release EFTA00036005