After Action Review MCC New York - Admin August 10, 2019 Page 4 of 18 yor24 PM - Inmate Epstein is SHESEER) into SENTRY as 4=eaWanQ@NAENMCG! New York as a pre-trial inmate. (PESENEM - Inmate Epstein SISSEEMNNGEnerallpopuletion cell E06- 5470. 2019 (7220) PM /- Inmate Epstein was placed sy: Z02-201LAD with s Inmate Nicholas Tartaglione, ter Number 78514-054. 9:24 AM - Psychology intake screening conducted with a risk of sexual abusiveness documented. No mental health concerns reported by staff. (GOSAMNAM -the chief Psychologist consulted with the Suicide Prevention Coordinator, Central Office. The decision was made to place Inmate Epstein on upon his return from court pending a mental health evaluation. 3:49 Pw Inmate Epstein returns from court. 5:49 PM - SENTRY shows a cell change transaction from Z02-201LAD to the same cell. There is no documented explanation for this peculiar change. 6:03 PM - Inmate Epstein is placed on SSYGHONSGYNSBSEEVaEHOR in cell H0O1-O0iL. July 9, 2019 7:30 aM - Psychology conducts a suicide risk assessment indicating suicide watch was not indicated, but fe) ending suitable housing placement. 10:13 AM -Psychology develops a diagnostic and care level formulation assigning “no diagnosis” and CARE 1 Mental Health. 12:35 PM -Health Services completes a History & Physical for Inmate Epstein. This assessment was done in lieu of an LIMITED OFFICIAL USE EFTA00036082

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After Action Review MCC New York - Admin August 10, 2019 Page 5 of 18 | which shoud" Rave been ‘conducted / Ww s of arrival (PS6031.04). Psychology conducts a Psycholo ends observation. Inmate Observation contact and and next-day gy. Inmate placed in cell Z05- 124LAD, again with Inmate Tartaglione. or Inmate Epstein is seen by Sea Uonitel Sey in the presence of his attorneys w e conducting a legal visit. This visit recommended follow-up the following week. (24 NEMPESt nmate Epstein is SE EaaNOLesy/ 1” the presence of his attorneys while conducting a legal visit. This visit was at the request of Inmate Epstein. This visit recommended no follow-up. population. attorney visit. The Inmate EE coins cell 205-124. Upon arrival sta observed Inmate Tartaglione, standing at the door of the cell stating Inmate Epstein attempted to hang himself. Staff observed Inmate Epstein lying on the floor near his bunk with what appeared to be a piece of homemade orange cloth around his neck. Inmate Epstein was removed from the cell and placed on suicide watch by the Operations Lieutenant and the on-call Psychologist was notified. Health Services conducted a t of Inmate Epstein. The following injuries were reported: “circular line of erythema at the base of neck reaching 2/3 of the LIMITED OFFICIAL USE EFTA00036083

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After Action Review MCC New York - Admin August 10, 2019 Page 6 of 18 neck circumference, 2 inches wide, sparing the back of the neck. Has one section of this erythema in the front with marks of friction. Small erythema on left knee about 2cm in diameter (mild).” Medical record note a 7:56 AM - Psychology administrative note opened and later completed on July 24, 2019. 9:10 AM - Psychology began a suicide risk assessment note. SEMSPAMIR Psychology for Inmate Epstein. 2019 8:33 AM - Daily psychology contact while on psychology observation indicated Inmate Epstein would be moved to another cell due to toilet issues. T to have occurred. July 29, 2019 10:01 AM -SSSMYEBEYSHOUSGYNESHESS’ while on psychology observation. A2sOUEM -DELLYEPSYEHOLSGYFESHEBEL white on psychology observation. Psychology observation status discontinued Inmate Epstein was placed in Cell Z04-206LAD with nmate Efrain Reyes, Register Number 85993-054. LIMITED OFFICIAL USE EFTA00036084

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After Action Review MCC New York - Admin August 10, 2019 Page 7 of 18 3:58 PM - A medical record note is completed stating Inmate Epstein will be issued a Continuous Positive Air Pressure (CPAP) machine. July 31, 2019 10:35 AM -Psychology contact completed for post removal from psychology observation. Prisoner custody documentation shows Inmate August 1, 2019 8:30 AM - Psychology documented they were notified by Correctional Systems of a form received from the United States Marshals Service (USMS) the previous day stating Inmate Epstein had reported suicidal tendencies. 1:00 PM - Psychology conducts a suicide risk assessment noting watch is not indicated with a recommendation for follow- up in one week. The delay in conducting this assessment is not justified in the report. August 2, 2019 11:34 AM -An SIS Investigation into the July 23, 2019 incident was completed. The investigation stated there is insufficient evidence to support either Inmate Epstein harmed himself or was harmed by his cellmate. August 8, 2019 10:02 AM -Psychology contact for suicide risk assessment follow- up conducted. No concerns or follow-up noted. INCIDENT LIMITED OFFICIAL USE EFTA00036085

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After Action Review MCC New York - Admin August 10, 2019 Page 8 of 18 to meet with several attorneys throughout the day. Inmate Epstein remains in the cell alone until the time of the incident. Epstein was . This call was done on an unmonitored line. It is extremely concerning why this call would have been placed and why it would be done on an unmonitored line. (GESSTAM- » BEUYNSUAERYSyRCHAVAEELY in the Special Housing Unit (SHU). SHU sta reported Inmate ° a entere e cell and attempted to wake Inmate Epstein. Control Center announced a medical emergency and Cardiopulmonary Resuscitation 6:35 AM - The in SHU and continues CPR and applies an Automated External Defibrillator (AED). (6:40 AM - Associate Warden notified. (GMISAMIS Emergency Medical Services (ENB dazelyep and continues CPR. Inmate Epstein is intubated, given three rounds of Epinephrine, Intravenous (IV) access established, Intraosseous (IO) initiated. The AED indicated there was no pulse found and no shock advised. Inmate Epstein is prepared for medical transport. [S2ONAME, Temate SPSESIRUSEDAES|EnSHINSEREUEKOR) for transport to Beekman Hospital. (7:20 AM - Special Investigative Supervisor (SIs) Lieutenant LIMITED OFFICIAL USE EFTA00036086

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7:30 AM - 1336000 - 8:10 AM - 8:10 AM - 9:30 AM - 9:50 AM - 9:55 AM 10:00 AM (10:00 aM 10:15 AM 10:45 AM 11:15 AM 11:15 AM After Action Review MCC New York - Admin August 10, 2019 Page 9 of 18 Warden arrives at the intuition. Inmate Epstein pronounced dead by the emergency room physician. Associate Warden of Programs and Captain arrive at the institution. Case Management Coordinator (CMC) and Supervisory Correctional Systems Specialist (SCSS) notified. Federal Bureau of Investigation (®BI)—NOeieiedy Assistant United States Attorney (AUSA) notified. Associate Warden of Operations and SIS Lieutenant arrive at the institution. CMC arrives at the institution. Acting Chief Psychologist arrives at the institution. SCSS arrives at the institution. CMC and IDO depart to Beekman Hospital. -CMC and IDO arrive at Beekman Hospital. Inmate Epstein is fingerprinted, photographed, and his clothing is secured. GBB xscnara M. Beerman is notified. -CMC returns to the institution. -Public Information Officer (PIO) arrives at the intuition. -CMC notifies Inmate Epstein’s brother as next of kin. -Press celease is tested co the media. -Press release is provided to Judge Beerman. -Crisis Support Team (csT) is activated. LIMITED OFFICIAL USE EFTA00036087

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After Action Review MCC New York - Admin August 10, 2019 Page 10 of 18 1 gxqiSTIBM | Inmate Epstein’s HOEY! lis released to the medical examiner for autopsy. PM - Office of the Inspector General ‘gaa cieatethe, Weeder| and advises an agent is being dispatched to the stitution. 3210 PM - em escorted to SHU. eaeS0EM - 4 to Office of Internal Affairs Regional Director (RD), and Office of General Counsel (OGC). ANALYSIS OF EVENTS PBI arrives at the institution. Inmate Epstein arrived at MCC New York on July 6, 2019, trial commit. It appears the as a pre- The following day he was placed , reportedly at the direction of the Warden. It is unclear how his cellmate was chosen or what method was used to determine appropriateness. A review of the assigned cellmate raises questions concerning the selection process. From his initial placement in SHU, until the date of the incident, Inmate Epstein was outside the institution on four occasions to attend court appearances and spent a considerable amount of time in attorney visitation. His interactions with the various departments was considered ordinary, although Inmate Epstein had many interactions with the Psychology Department. On July 23, 2019, Inmate Epstein was found in a state of unresponsiveness within his SHU cell. The investigation into this incident was inconclusive to determine if the cellmate was involved, if Inmate Epstein had made a suicide attempt or gesture, or if he was feigning the incident in an attempt to gain single cell status. Following the July 23, 2019 incident, supervision. LIMITED OFFICIAL USE EFTA00036088

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After Action Review MCC New York - Admin August 10, 2019 Page 11 of 18 when r to SHU. , by email from a staff psychologist, through individual conversations by the Captain to his Lieutenants, and verbally between SHU Officers, On August 10, 2019, the two assigned morning watch SHU Officers failed to make their designated rounds or count the SHU inmates for two counts. At 6:33 am, upon finding Inmate Epstein unresponsive in his cell, with a torn bedsheet around his neck, staff utilized a body alarm to initiate a call for assistance. The medical response to the incident was timely, efficient, and exhaustive. Staff utilized an AED, as well as continuous CPR until care was assumed by EMS personnel. OTHER FACTORS (Directly Related to the Incident) —————— rp Although it is well documented Inmate Epstein was housed with two other inmates during his assignment in icy SENTRY dove not reflect this information accurately. Innate Epstein was found within cell 220, yet SE never reflects him being housed within that cell at any time. SENTRY does not reflect Inmate Epstein being escorted from the institution by the USMS on July 31, 2019, although a signed Prisoner Remand form is documented receiving him from the USMS. SHU has multiple cells equipped with video recording capability. Inmate Epstein was not housed in one of these cells and there and subsequently available for SHU Officers oO reference. An outside person sent $200 each to Inmate Epstein and his cellmate Inmate Reyes. The outside person appears to be Inmate Epstein’s attorney. The purpose of this transaction is undetermined at this point. In an email to the Warden, dated post incident, the Supervisory Staff Attorney reported details of a conversation with Inmate LIMITED OFFICIAL USE EFTA00036089

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After Action Review MCC New York - Admin August 10, 2019 Page 12 of 18 Epstein’s attorneys. Inmate Epstein’s attorneys requested he be housed in a single cell, the staff attorney stated Inmate Epstein could not be housed alone due to previous suicide attempt/gesture. During the immediate response to the incident is umente y € eutenant. In an email to the Warden, the Orrectiona ervices supervisors and line staff during the week of July 31, 2019. Additionally, the Captain states he spoke with the SHU Lieutenant concerning the need to house Inmate Epstein with a cellmate. The Inmate Epstein is referred to as a ack inmate and a ifferent inmate name is used within the report. such as referencing an inaccurate program statement and noting a history of prior prison sexual predation. On July 16, 2019, a psychologist met with Inmate Epstein in the presence of his attorneys. This was done at the request of Inmate Epstein and appears to have been for the purpose of airing grievances with conditions of confinement. The Suicide Risk Assessment dated July 23, 2019, refers to the ligature as a “string” when in fact it was a sizable portion of torn bed sheet. On August 1, 2019, Correctional Systems staff reported the USMS concerns from the previous day regarding Inmate Epstein’s suicidal tendencies to Psychology staff. On August 9, 2019, during a shift change in SHU, the SHU #3 6:00 am-2:00 pm officer briefed his 2:00 pm-10:00 pm relief and the other two 8:00 am-4:00 pm officers of the likelihood Inmate LIMITED OFFICIAL USE EFTA00036090

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After Action Review MCC New York - Admin August 10, 2019 Page 13 of 18 Reyes, Register Number 85993-054 would not be returning and Inmate Epstein would require a cellmate upon returning from an attorney visit. Inmate Epstein was not placed with a cellmate upon his return to SHU. SHU 30-minunte check documentation shows @ trend of missing rounds / and rounds which extend beyond the -minute mit. Official count CagUERUPRE kenyehentennllsconntaiuers ieaneiets as scheduled, but based on e s of the responsible officers, this appearsiitolbeminaccurateyfor at least the 3:00 am and 5:00 am counts. The initial Upon further review it appears this On July 6, 2019, Health Services notes Inmate Epstein has no know allergies. On July 30, 2019, a i All psychologists at the institution are state licensed clinicians. Psychology Observation procedures dictate a Physielan SNASSastanty fe is clearly not possible based on , which #@@uairey A review of inmates housed within th uring the period of this review, revealed the Institution Duty Officers (SDO)NASUHOENEOUEINEIYEVISTENSHY cach day as required by the Institution Supplement (1IS5502.11). Additionally, the IDO reports consistently documents the condition of SHU as “satisfactory”, when observations have shown the SHU to be less than satisfactory. It is The Correctional Services roster requires a complete review to best utilize staffing resources. Currently, the roster appears to — LIMITED OFFICIAL USE EFTA00036091

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After Action Review MCC New York - Admin August 10, 2019 Page 14 of 18 A review of discontinued suicide watches for the past 30-days shows a history of placing inmates returned to SHU with a cellmate on each occasion. OTHER FACTORS (Not Directly Related to the Incident) Staffing Staffing changes within the Correctional Services department have changed significantly over the past several years. In May of 2018, during pay period 5, the institution lost 21 positions as a result of phase 1 and 2 reductions. These positions consisted of 19 correctional officers, 1 lieutenant and 1 SIS technician. The current complement for Correctional Services is 135 authorized, with 117 filled. Staffing levels at pay period 26 for previous Year 2015 2016 2017 2018 (No staffing report available. 153 128 Numbers are based on December 23, 2017.) July 26, 2019 July 25, 2019 July 24, 2019 July 23, 2019 July 22, 2019 July 21, 2019 [260 i280 Overtime The two morning watch SHU staff did not work an unusual amount of overtime leading up to the incident. The SHU #1 was assigned to SHU on mandatory overtime during the incident. This staff member does not typically work a large quantity of overtime. The SHU #2 was assigned to SHU on voluntary overtime. This staff member typically works a high volume of overtime on a volunteer basis. LIMITED OFFICIAL USE EFTA00036092

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After Action Review MCC New York - Admin August 10, 2019 Page 15 of 18 Overtime hours for the August 10, 2019 morning watch SHU Officers fT C~—“C SHCA SH Voluntary OT | Mandatory OT | Voluntary OT August [24 isd| 8 [July | 24 | [June | CdS (;$NNSCOO~S | SO CCU [May | Oo | oOo [184 0 {7 od Correctional Services overtime (8-Hour occurrences) by pay period based on the pay rate for a GL-8/5 PP 10 [pp 20, [17.1 [pp 21/20 PP 22 (19.4 ppp 23, [23 pp 24 [21 'PP 26 |Incl. PP 1 CONCLUSION After a thorough review of all ava ble evidence concluded there was a the review team Inmate Epstein was an inmate who fell within multiple suicide risk groups. He was also an inmate who had risk factors for assault by other inmates and did require careful selection for appropriate cellmates. Although these issues were noted, well documented, and communicated, a Although feasible for an inmate to effectuate suicide w e housed with a cellmate, the odds of this eccurring are significantly lowered when housed with another inmate. Without the use of compelled interviews, it is not possible to determine the true root of the communication breakdown. Concerning deficiencies were note institution. It appears a in common functions within the e review team observed significant LIMITED OFFICIAL USE EFTA00036093

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After Action Review MCC New York - Admin August 10, 2019 Page 16 of 18 Although inmate suicides do occur, the Bureau of Prisons has developed substantial training resources and processes to mitigate an environment leading to a suicide. While many correctional professionals completed their responsibilities within these processes, the failure to carry out all aspects of the suicide prevention process laid the groundwork for an environment vulnerable to suicide. At the core of this event was eir of correctional tasks should be viewed as the Had they performed the asic task of counting and viewing inmates within their assigned area, it is possible this suicide could have been detected or a minimum, responded to the event quicker. RECOMMENDATIONS | feb th igeetie’to Stemi soxteaiah wd e to provide a direct contact to field staff. * The Institution Supplement on Suicide Prevention’ is not required and occasionally not followed. oe el e Currently the Drug Abuse Prevention Coordinator (DAPC) has responsibilities between MCC New York and MDC Brooklyn. It is recommended this be reviewed to determine if the responsibilities are appropriately distributed or if they would be better served with an independent DAPC./ * A single post should be designated to document all movement ea aan This should include internal, court, releases, etc. e The od A Deputy Captain should be considered to provide additional higher level supervision. LIMITED OFFICIAL USE EFTA00036094

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After Action Review MCC New York - Admin August 10, 2019 Page 17 of 18 . should be reviewed to ¢ (BROGESUFEs should be established on wHSHl/—HalReWyEKS|VideDy COST/IMPACT STATEMENT Correctional Services Overtime (Estimate 16-Hrs) $741.60 Health Services Overtime $0.00 Medical Expenses (Historical Estimate) $10000.00 Death Related Expenses (Not Yet Released) $0.00 TOTAL: $10741.60 LIMITED OFFICIAL USE EFTA00036095

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After Action Review MCC New York - Admin August 10, 2019 Page 18 of 18 ATTACHMENTS Attachment 1: Inmate Involvement Listing LIMITED OFFICIAL USE EFTA00036096