Page 970 Fwd: Psychological Reconstruction - Epstein #76318-054 From Michael Carvajal To Ray Ormond Date 2019/09/17 16:09 Subject: Fwd: Psychological Reconstruction - Epstein #76318-054 Attachments: TEXT.htm, Fwd: Psychological Reconstruction - Epstein #76318- 054 Sent from my Verizon, Samsung Galaxy smartphone -------- Original message -------- From: BOP-CPD/Assistant Director~ Date: 9/17/19 2:15 PM (GMT-06:00) To: Andre Matevousiatj(b)(5):(b)(?)(c> @bop.gov>, Michael Carvajal[b)(s>;(bh7 )ccJ Subject: Fwd: Psychological Reconstruction - Epstein #76318-054 @bop.gov> Page 2189

Page 971 Fwd: Psychological Reconstruction - Epstein #76318-054 From BOP-CPD/ Assistant Director~ To Date Subject: Attachments: Andre Matevousian, Michael Carvajal 2019/09/17 15:15 Fwd: Psychological Reconstruction - Epstein #76318-054 TEXT.htm, Psych Reconst - Epstein #76318-054.pdf > > > BOP-RSD/ Assistant Director~ 9/17/2019 3:03 PM > > > Please see attached. Page 2193

Page 972 Mail Attachment Psych Reconst - Epstein #76318-054.pdf Page 2197

Page 973 U.S. Department of Justice Federal Bureau of Prisons Reentry Services Division Washington, DC 20534 fo/ SP' J 1 7019 MEMORANDUM FOR FROM: Reentr Division SUBJECT: Psychological Reconstruction Inmate Epstein, Jeffrey (76318-054) Inmate Jeffrey Epstein (76318 - 054) died by suicide on August 10, 2019, while housed at the Metropolitan Correctional Center (MCC) in New York. The attached psychological reconstruction was completed b ,b)(5>; (b)(7)(C> National Suicide Prevention Coordinator, b)(G); (b)(7)(c> Sex Offender Treatment Programs ibl( 5 > (bi< 7 >cc > Mental Heal th Treatment Coordinator and Correctional Services Administrator, Regional Office. A summary review of these and other recent reconstruction findings is forthcoming. Distribution of this report is limited to staff named in this memorandum. Recommendations at the conclusion of the report should prove beneficial to staff at the facility and will be used to inform our national suicide prevention program. Within sixty days of receipt of this memorandum and report, please provide me with a written response which outlines corrective actions as well as a plan for implementation, based on recommendations contained within. The institution response should be routed by the Warden through the Regional Director to the Assistant Director, Reentry Services Division. If you have questions or concerns regarding this request, please contact me at (202) 514 .bXG>; (b)C7>(c i cc: M. D. Carvajal , Assistant Director, CPD D. Shinn, Assistant Director, PRD N. C. English, Assistant Director, HSD J. Petrucci, Acting Warden, MCC New York

Page 974 PSYCHOLOGICAL RECONSTRUCTION OF INMATE DEATH This is an interim report, due to an inability to gather all necessary data. Formal interviews were not conducted as a part of this reconstruction to avoid interference with pending investigations by other Department of Justice components. A copy of the video is normally made by Special Investigative Staff following a significant incident, but there was no such video in this case since the original video was confiscated by the Federal Bureau of Investigation (FBI) prior to the beginning of this reconstruction. The absence of these two sources of information severely limited the ability to establish accurate timelines, confirm subjective reports, establish converging and diverging lines of facts, or discover new areas of inquiry. As a result, information typically gathered, reviewed and consolidated during a reconstruction to support actionable findings and recommendations is limited. Name: Register Number: Date of Death: Prepared by: Jeffrey Epstein 76318-054 08-10-2019 f b)(6); (b)(7)(C ) IN . al s . 'd p . C d' .._ ____ ~ at10n mc1 e revent10n oor mator, Psychology Services Branch, Central Office BACKGROUND INFORMATION Mr. Jeffrey Epstein was a 66-year-old, White male who died on August 10, 2019, while housed at the Metropolitan Correctional Complex (MCC), in New York, New York. James C. Wills, former Acting Assistant Director, Reentry Services Division, appointed a team to conduct a psychological reconstruction. The team consisted o lb)(6); (b)(7 l(Cl National Suicide Prevention Coordinator, Central Offic bH5>; <b)C?i(CJ Sex Of en er reatment Programs Coordinator, Central Office ,bl{ 5 >; (b)( 7Jcci enta eat Treatment Coordinator, Central Office; and b)( 5 >;(b)(7)(c> Correctional Services Administrator, Northeast Regional Office. This reconstruction was established in accordance with Bureau of Prisons' (BOP) Program Statement 5324.08, Suicide Prevention Program. Social History: Mr. Epstein did not have a Pre-Sentence Report (PSR) available at the time of the reconstruction; therefore, no official inforrnation regarding social history was accessible. The following was gathered from publicly available documents. Mr. Epstein was born in 1953 and grew up in a middle-class family in the neighborhood of Sea Gate on Coney Island, Brooklyn, New York, with one brother. After early promotion in two grades, Mr. Epstein graduated from Lafayette High School in 1969, at the age of 16. He attended Cooper Union and New York University but did not graduate from either. Mr. Epstein taught at the Dalton School, a private school on the Upper East Side of Manhattan from September 1974 until he was 1

Page 975 dismissed in June 1976 for inadequate development as a teacher. Following that, he held a number of positions in the financial industry to include a position as a limited partner at Bear Stearns until he was dismissed for unlmown policy violations in 1981. He also worked as a financial consultant and founded at least two separate companies. Mr. Epstein had two si nificant eriods of employment. The first of these was his position as a consultant with b)(6 ); (b)(?)(C) in the late 1980s. r b i(5 ); (b)(7)(C) lwas described as his first mentor. b)(5>: (b!(7Jcc> was later convicted and incarcerated for running a large Ponzi scheme. He implicated Mr. E stein in fraudulently diverting company funds for his own personal use. Years late b)(G>;(b)(7)(c> Mr. Epstein's sole client at J. Epstein and Company, granted him power of attorney over his affairs. Despite also being identified asl(biC5>; (b>mcc> I mentee, Mr. ~pstein was again accused of misappropriating funds-more than 46 million dollars. These large sums are believed to be the seed money Mr. Epstein used to establish his considerable fortune. These events are indicative of Mr. Epstein's highly-regarded intelligence and charismatic personality. Legal History: Mr. Epstein had a history of adult criminal charges and convictions. In June 2008, he entered into a non-prosecution agreement and pleaded guilty to one count Solicitation of Prostitution and one count Procuring a Person Under the Age of 18 for Prostitution in the state of Florida. He was sentenced to 30 months: 18 months of incarceration and 12 months of probation. He was also mandated to register as a sex offender under the National Sex Offender Registration and Notification Act. Mr. Epstein served 13 of his 18-month incarceration and then successfully completed 12 months of probation. It is unclear whether he followed the sex offender registration guidelines in each place he owned a residence. In regard to pending charges, Mr. Epstein was formally charged with Sex Trafficking Conspiracy in violation of 18 U.S.C. § 371 and Sex Trafficking in violation of 18 U.S.C. § 1591(a), (b) (2), 2 on July 2, 2019. Specifically, he was accused of sexually exploiting and abusing minor females over the course of several years. Charging documents allege Mr. Epstein enticed and recruited minor females to engage in sexual activity. The minor females were reportedly compensated with cash following the sexual encounters and some were encouraged to find other minor females to accompany them to Mr. Epstein's residences in New York or Florida. He pleaded not guilty to these charges and was in pretrial status at the time of his death. In a 37-page Decision & Order Remanding the Defendant, signed by Judge Richard M. Berman on July 18, 2019, 18 pages were dedicated to detailing the danger Mr. Epstein posed to others and the community. The document also alleged he was a flight risk. As a result, Mr. Epstein's proposed bail package was determined to be inadequate. He was denied pretrial release and held on remand. 2

Page 976 Institutional History: On July 6, 2019, Mr. Epstein was arrested at Teterboro Airport in New Jersey upon his return from Paris, France. It is unknown whether he was anticipating this arrest. He was transported to MCC New York and keyed into SENTRY at 9:24 p.m. that evening. Mr. Epstein was placed in a general population housing unit for approximately 22 hours. On July 7, 2019, at approximately 7:20 p.m. he was moved to the Special Housing Unit (SHU) pending reclassification due to the significant increase in media coverage and awareness of his notoriety among the inmate population. With regard to his adjustment to a correctional setting, Mr. Epstein received one incident report while in BOP custody for Self-Mutilation on July 23, 2019. As of August 15, 2019, the incident report had been expunged though it is unclear why it had been expunged and whether Mr. Epstein knew this. Also, a review of financial transactions associated with Mr. Epstein's prison account revealed one of his attorneys was depositing funds into his cellmate's (inmate Reyes) commissary account for unknown reasons. HEALTH CARE AND PERSONALITY DESCRIPTION BOP Electronic Medical Records (BEMR) indicate Mr. Epstein was diagnosed with hyperlipidemia, sleep apnea, hypertension, constipation, prediabetes, neuralgia, and neuritis -unspecified. He was prescribed the following mediations: docusate sodium, milk of magnesia, omega 3, methylprednisone, and bisacodyl. Mr. Epstein was also prescribed insulin, and the prescription required him to go to the institution pharmacy for administration of this medication. However, the dates for which it was prescribed have a notation indicating "dose not indicated," thus it does not appear insulin was routinely medically necessary. The rest of the medications prescribed were self-carry. He also had a continuous positive airway pressure (CPAP) machine which is typically used to treat sleep apnea. Mr. Epstein was provided with his personal CPAP machine on July 30, 2019, per BEMR. In regard to mental health history and treatment, there are no known available records. Any records that may have been maintained relating to Mr. Epstein's incarceration in Florida were not available for review as of the date of this report. With regard to Psychology Data System records in BEMR (PDS-BEMR)r )(B);(b)(])(C) !Forensic Psychologist at MCC New York completed a routine Intake Screening on July 8, 2019. During this screening, Mr. Epstein denied any history of mental health problems, substance abuse, and treatment. No symptoms of mental illness were observed. He was classified as Mental Health Care Level 1 and was not diagnosed with a mental illness. Following a , • bK5>: lb)(7)rc> National Suicide Prevention Coordinator on July 8, 2019 1 b)( 6 >: (o)(7J(c) Chief Psychologist at MCC New York determined Mr. Epstein should be pre-emptive y eva uated for suicide risk upon his return from court. Primary consideration was given to his various risk factors for suicide such as his high profile case and media attention, pending sex offense charges, pre-trial status, and an ongoing court proceeding. Mr. Epstein returned from court on July 8, 2019, after normal business hours. He denied suicidal 3

Page 977 thoughts at that time, but due to the potential for other risk factors listed above, the on-call psychologist placed Mr. Epstein on Psychological Observation in one of the suicide watch cells W1til he could be assessed in person by a BOP psychologist. Psychological Observation is a form of individual monitoring that is less restrictive than Suicide Watch. It is used for inmates who are stabilizing and not yet prepared for placement in general population or restrictive housing. It is often used to transition inmates off of Suicide Watch in order to monitor their transition and safety after an acute suicidal crisis. On Jul 9, 2019, Mr. Epstein underwent a formal, in-person suicide risk assessment wit (bK5J: (bl(l)(c) She determined that, while suicide watch was not warranted at that time, Mr. Epstein should remain on Psychological Observation status out of an abundance of caution. He was removed from Psychological Observation on July 10, 2019. (bj(7)(A) bX 7l<A1 e was p ace on smc1 y t e perat1ons 1eutenant at approximate y : a.m. pen mg a formal in- person suicide risk assessment. lCb)(5,:<b)(7)cc> !Staff Psychologist at MCC New York, assessed Mr. Epstein for risk of suicide later in the morning of July 23, 2019, and determined he should remain on suicide watch.fb>C7XA) (b)(7)(A) Mr. Epstein was removed from suicide watch on July 24, 2019, after 31 hours and 5 minutes. Thereafter, he remained in the suicide watch cell and was placed on Psychological Observation, where he remained housed until July 30, 2019, according to PDS-BEMR records. A discrepancy exists regarding when he was removed from Psychological Observation. His cell assignment, per SENTRY, indicates he was transferred back to the Special Housing Unit (SHU) on July 29, 2019, whereas PDS-BEMR indicates he was removed from Psychological Observation on July 30, 2019, at approximately 8: 15 a.m. Mr. Epstein attended a court hearing on July 31, 2019, and, upon his return, the United States Marshals Service (USMS) P.rovided a erwork to Receiving and Discharge (R&D) staff that noted "suicidal tendencies.' (bi( 6 ) (b)(7)(c> as notified on August 1, 2019, about this paperwork. She consulted wit <b>C5l: (bi(l)(c> d then met with Mr. Epstein to conduct a suicide risk assessment. She determined suicide watch was not warranted at that time. Mr. Epstein remained classified as a Mental Health Care Level l throughout his time at MCC New York. During his contacts with psychologists, Mr. Epstein routinely denied current mental health symptoms to include suicidal ideation, and he did not exhibit symptoms of a serious mental illness. However, there was evidence Mr. Epstein was experiencing challenges 4

Page 978 adjusting to his environment and changes in his lifestyle. He reported frequent complaints of difficulty sleeping. He did not have access to his CP AP machine until it was reportedly provided to him on July 30, 2019. Mr. Epstein also reported he was bothered by noise in the SHU. At times, he noted concerns related to his safety in SHU or on a general population housing unit. On two occasions, July 26, 2019, and July 27, 2019, he described himself as a coward and as someone who does not like pain. On July 28, 2019, he toldfb1<5>: Cbi(7iccJ ~he toilet in his cell would not stop flushing for an extended period of time, and he then took to sitting in the corner with his hands over his ears. Mr. Epstein indicated he was agitated following this incident and was unable to sleep that night. ANTECEDENT CIRCUMSTANCES Mr. Epstein entered BOP custody on July 6, 2019, with a history of convictions for sexual offenses and allegations comprised of more serious charges. The current indictment alleged se:x.'Ual crimes against minors, and he was facing up to 45 years in prison. On July 18, 2019, Mr. Epstein's request for bail and pretrial release was denied. (b)(?)(A) (t>>c7 >CA) After 31 ours an 5 mmutes on Suicide Watch, he was then placed on Psychological Observation. On July 30, 2019, Mr. Epstein was removed from Psychological Observation (b)(GJ;<biaicc> ent an e-mail reporting Mr. Epstein had been removed from Psychological Observa 10n an needed to be housed with an appropriate cellmate. This e-mail was sent to 71 MCC New York staff and, as of August 13, 2019, only 27 staff members had opened the message. On August 9, 2019, a federal court unsealed approximately 2,000 pages of documents into the public domain. These included graphic allegations against Mr. Epstein. Included was a book order receipt for titles such as SM I OJ: A Realistic Introduction; SlaveCraft: Roadmaps for Erotic Servitude; and Training with Miss Abernathy: A Workbook for Erotic Slaves and Their Owners. Additional high profile public figures were also named in the released documents. The documents were part of a defamation lawsuit filed by Virginia Roberts Giuffre, a woman who alleged Mr. Epstein had victimized her, against a British socialite, Ghislaine Maxwell, who was Mr. Epstein's ex-girlfriend, associate, and alleged to have assisted with his criminal activities. According to staff report, Mr. Epstein was afforded telephone calls on two different days although it is unknown whether they were legal or social calls. No recording of the calls exist and it is not known with whom he was speaking. One occurred on or around July 16, 2019, and the other on August 9, 2019. Legal calls are not monitored, and would not be recorded. A social call would be recorded; given the limited information known about Mr. Epstein, knowledge of the content of any social calls would have been crucial to helping staff work with him. Following his final telephone call on the evening of August 9, 2019, Mr. Epstein was moved into his SHU cell. He was single-celled at that time because his cellmate (Efrain Reyes #85993-054) 5

Page 979 . did not return from court. The need for a cellmate was communicated between Day Watch (DW) and Evening Watch (EW) shifts in the SHU, but no cellmate was placed with him by the EW staff. According to a memorandum from Senior Officer Special is tbl(5>; lb)C?>cc ; SHU staff were informed at approximately 1 :50 p.m. that Mr. Epstein's cellmat wou 1 e y not return from court. Furthermore, Office (b)(S>; tbiC7>ic ) oted Mr. Epstein would need a cellmate upon arrival from his attorney visit. A review of the 30-minute rounds forms indicate unit rounds were com leted for the entire MW shift on Au ust 10 2019. However, a memorandum from Lieutenan b)(5i: (b)(7>ic ) ndicates Offi b)(6) (b)(7)(C) • s , (b)(6): (b)(7)(C) ice • nd Material Handler uperv1so .__,......,...-,------' a e a statement after Mr. Epstein's death that they did not complete proper 30-minute rounds at 3:00 a.m. or 5:00 a.m. DESCRIPTION OF SCENE A detalied description of the scene was unavailable because the officers who discovered Mr. Epstein did not write memorandun1s and could not be interviewed. According to the Report of Incident, on August 10, 2019, at approximately 6:33 a.m., while serving the breakfast meal in the SHU, Range 9 South, Mr. Epstein was found unresponsive in his cell. Staff reportedly called for medical assistance, activated the r )(7)(E) I and began life-saving measures. Arriving staff stated they brought an automated external defibrillator (AED) and stretcher. Cardiopulmonary resuscitation (CPR) reportedly continued while the AED was placed on Mr. Epstein. The AED reportedly indicated no shock advised and CPR was continued. Mr. Epstein was escorted to Health Services at approximately 6:39 a.m., and Emergency Medical Services (EMS) arrived at 6:43 a.m. He was transported to the local hospital at approximately 7:10 a.m. Mr. Epstein was pronounced deceased at 7:36 am. It was not possible to confirm this timeline without viewing video footage. CONCLUSIONS/RECOMMENDATIONS A general appreciation of risk factors for suicide specific to sex offenders is necessary when reviewing Mr. Epstein's death. These factors, as well as more general risk factors for suicide, were likely present. There are several common factors that increase risk for suicide in individuals with a history of a sexual offense. These include stigma due to the nature of sexually-based crimes (both within society and the prison system), a disruption of the ability to utilize sex as a coping mechanism (which can lead to increased levels of distress and negative affect), and grief about loss experienced in regards to arrest. This grief may be secondary to the loss of former lifestyle, loss of physical items or collections related to sexual offenses, and/or the loss of perceived relationships with victims. Other factors that may increase risk for suicide among individuals accused of a sex offense include safety concerns, potentially long sentences, and lack of skills necessary to navigate social relationships in prison. Mr. Epstein was a high-profile, pretrial detainee awaiting trial on sex trafficking offenses. He had been a successful, wealthy businessman with a nun1ber of high-profile acquaintances that he accumulated through a combination of charisma, charm, and intelligence. Despite his many associates, he had limited significant or deep interpersonal ties. Although Mr. Epstein appeared 6

Page 980 to cultivate a large social and professional network, he was estranged from his only brother. Indeed, his identity a eared to be based on his wealth ower and association with other hi h- profile individuals. b)Cl )(AJ In the weeks L-------------------------------' before his death, he made statements that he was "a coward" and was having difficulty adapting to his diminished circumstances. He also frequently referenced poor sleep and an inability to tolerate the noise of prison. On the day before his death, a number of documents in his case were unsealed, further eroding his previously-enjoyed elevated status and potentially implicating some of his associates. The lack of significant interpersonal connections, a complete loss of his status in both the community and among associates, and the idea of potentially spending his life in prison were likely factors contributing to Mr. Epstein's suicide. The following recommendations concern institution operations: (b)(5) 1. Single Celling: r b)(S) 2. Rounds: 30-minute rounds are required by P5500.14, Correctional Services Procedures Manual. 3. Cellrnate Assi nments: When Mr. E b)(7)(A) l(b)(6); (b)(7)(C) Cbl(7}CA> n an e ort to treat r. pstem t e same as ot er inmates, a statement repeated by multiple staff, Executive Staff may have inadvertently overlooked the need to consider unique risk factors associated with individuals who have been charged with and convicted of a sex offense. On July 25, 2019r ( 6 );(b)(?)(Ci bent an e-mail to ~-. ~~--, Shirle Ski er-Scott, Associate Warden explaining a consultation bet Cb)C 61 (b)(7XC) N • al s . "d p . C di In h ·1 :b)(6); (b)(7)(C) at10n u1c1 e revent1on oor nator. t e e-mai , 7

Page 981 reviewed the consult and recommendation from the Psychology Services Branch, Central Office that Mr. Epstein be housed with another inmate who had also been accused of committing a sex offense. There is no evidence this information was considered beyond this e-mail, and Mr. Epstein was never housed with another inmate charged or convicted of a sexual offense. 4 D . A [-b)[7)(A) . ocumentat10n ccuracv:.1 b)[7XA) [ It is critical that all descriptions of the incident accurately '-----....,.....,--,------,-,,----~ b)[7)(A) reflect objective evidence. (b)(7)(A) r□x,i; (Di(/ 11" 1 I Although the incident report was later expunged, inmates frequently experience significant stress when they contemplate the potential consequences associated with findings of guilt. r b)(6); (b)\7)(C) I ~------~entered a Psychology Services Intake Screening into PDS-BEMR on July 8, 2010. The document has three typographical errors. She selected the No Sexual Offense Convictions check box when, in fact, Mr. Epstein was previously convicted of Solicitation of Prostitution and Procuring a Person Under the Age of 18 for Prostitution. Second, Mr. Epstein was erroneously identified as a Black male in this document. F• 11 h • • h h • k nl C d } b)(G):(b)(7)(C) I ma y, t ere 1s one mstance w ere e was m1sta e y re1erre to a1~----~ 8. I

Page 982 r )(6); (b)(7)(C) 1 1 d R. k f s I b · d 1 1 s ._ _____ ___.compete a IS o exua A us1veness ocument on u y 8, 2019. he marked "History of prior prison sexual predation" in the affirmative. This is not accurate. (b)(6); (b)(7)(C) Mid-Level Practitioner, completed a History and Physical on '---...-u_,.y--,.,,...., .,....,......,....--,A,---Jn Intake Screening should have been conducted within 24 hours of his entry into Bureau custody which was on July 6, 2019, according to P6031.04, Patient Care. Officer b)( 5 l: (b)(7)(CJ as responsible for observing Mr. E stein and documenting his behavior w I eon smcide watch on July 23, 2019. Officer b)(5): (b)(7J(CJ istakenly used a Suicide Watch Log Book intended for inmate companion documentation between l :40 a.m. and 6:00 a.m. on Jul 23 2019 when he should have been using the Staff Suicide Watch Log Book. 'b)(5 >; (b)(7)(CJ Drug Treatment Specialist, reportedly noticed this error and subsequently hand copied all of Officer (b)(5): (blmcc > entries from 1 :40 a.m. to 6:00 a.m. into a Staff Suicide Watch Log Book. She then initialed these entries, and this makes it appear as if she was the one conducting the watch. This information was discovered and conveyed in an e-mail from Ms. Charisma Edge, Associate· Warden t (b>( 5 l: (o)c?xc> ith a carbon copy to Warden N' Dia ye on August 12, 2019. Of note, (b)( 6 >; (b)(7Jcc> i not make an entry explaining why she was making the log book changes. Additionally, l(oX5l:(b)(7 >(CJ ~hen wrote entries for 6:15, 6:30, 6:45 and 7:00 a.m. in the Staff Suicide Watch Lo Book. These were not a part of the original entries made by Offi b- 6)· b" 7)(C' (b)(5); (b)(7)(C) • d k h s · ·d w h n h cer - i( , l " 1 or was • ss1gne to wor t e UICI e ate post. ue to t e inabilit to mterview sta at t IS time, it is unknown why (bl(5>:(b)(?)cc > attempted to correct Office bl( 5 >; (b)(? J<c > rror, or made any of the subsequent log entries. It is recommended that if a staff member makes an entry error (e.g., writes in the incorrect suicide watch log book), the staff member should describe the error in the correct log book, to include indicating when they became aware of the error. The staff member should then notify the Chief Psychologist. A review of Special Housing Unit Records (BP-A0292) revealed a number of incomplete entries. This document is used to monitor provision and receipt of basic services such as recreation, medical rounds, showers, meal consumption, etc. The Officer in Charge signature is missing on 10 occasions and a medical provider's signature is missing in seven instances. There are six instances in which it is not clear if Mr. Epstein ate his meal. There are nine instances in which it is not clear if Mr. Epstein took a shower. There are ten instances in which it is not clear if Mr. Epstein was offered recreation. P5500.15, Correctional Services Manual requires accurate and complete information on the BP-A0292. • A review of Psychology Observation Log Books revealed significant discrepancies from the approved Psychological Observation Procedural Memorandum, dated April 15, 2019. A Correctional Officer is required to complete hourly rounds and sign the log book; 179 9

Page 983 . out of 183 round signatures were missing. The lieutenant is required to sign the log book one time per shift and signatures were missing in 10 of 23 instances. A Physician Assistant .is re uired to si n one time e • • 'b)(5i :b)(5) 5. Telephone Calls: In a PDS-BEMR note written byl(b)(G);(b)(7)(c> ~n July 16, 2019, she was informed by an unnamed staff member that a lieutenant facilitated two telephone calls for Mr. Epstein. It is unknown when and to whom these calls were placed and no evidence that they took place on a monitored telephone. According to a memorandum from Unit Manage~(b)(6J;(b)(?)(c) Ion August 10, 2019, Mr. Epstein terminated his le al visit earl on August 9, 2019, in order to place a telephone call to his family. (bX5l:(bl<7l(C> (who was the Institutional Duty Officer that week) escorted Mr. Epstein to SHU around 7:00 p.m. that evening and he was placed in the shower area on G tier. While there, he was provided the telephone to make a call. Since Mr. Epstein reportedly did not have his PAC or PIN number, which is required to use the inmate telephone system, the Unit Manager placed the call, dialing a number that reportedly began with area code 347. Mr. Epstein toldfb}(G);(b)C7>(C) lhe was calling his mother who, according to public records, has been deceased since 2004. 'b)(5) 6. Direct Observation: Mr. Epstein was on suicide watch from July 23, 2019, until July 24, 2019. While on suicide watch on July 23, 2019, Mr. Epstein attended an attorney visit from approximately 12:40 p.m. until 7: 15 p.m. During this time, he was without "direct, continuous observation" by a dedicated BOP staff member as required by P5324.08. While on Psychological Observation, he attended attorney visits on July 24, 2019, for 11.25 hours; on July 25, 2019, for 11.25 hours; on July 26, 2019, for 9.25 hours; on July 27, 2019, for 11.33 hours; on July 28, 2019, for 10.5 hours; and on July 29, 2019, for 8 hours. On July 30, 2019, Psychology Observation was ternlinated. During these visits, continuous observation by a dedicated BOP staff member was not maintained as required by MCC New York's Procedural Memorandum for Psychological Observation. 7. Follow-Up: Mr. Epstein arrived at MCC New York on Saturda Jul 6, 2019. While conducting the I 0:00 p.m. institution count that evening lb)(G); (b)(?)(c) Facilities Assistant re orted she observed Mr. E stein in his cell. In an e-ml-<n-=...,.,,~~ Drs. ~~Ii"' and -~l~ltc) d Lieutenant b)(s );<b:C7)<c) later that evening, she described Mr. Epstein as "distraught, sad and a 1 e co She said she then asked Mr. Epstein if he was

Page 984 okay, and he reportedly said he was. However,fbl(5);(b)<n<c> poted in her e-mail she was not convinced of this, adding, "He seems dazed and withdrawn." She went on to say, "So just to be on the safe side and prevent any suicidal thoughts can some Psychology come and talk with him." Despite the fact that Lieutenan""b""'i1"'" 6>; ..... (b..,,)(l~)<c!',,> pened the e-mail there is no evidence that he contacted the on-call s cholog1st as is required by P5324.08, Suicide Prevention Program. Additionally, i iblC5>;(bi(7)(c> was concerned about suicide risk, P5324.08, Suicide Prevention Pro r ·res her to maintain direct, . b . f Mr E . Wh b)(6l; (b)(7)(C) contmuous o servat10n o . pstem. e • pened the e-mail the following Monday morning, Mr. Epstein was evaluated ,__ ____ __, t approximately 9:30 a.m. Mr. Epstein was denied bail on Thursday, July 18, 2019. This was a significant disappointment for Mr. Epstein and likely challenged his ability and willingness to adapt to incarceration. Given the potential impact of the judge's decision, a psychologist should have assessed Mr. Epstein's mental status upon his return to the institution. The BOP developed a SENTRY assignment of PSY ALERT for purposes such as this. Specifically PS Y ALERT is used "to ensure, if movement occurs, that all staff consider the special psychological and management-related risks associated with the inmate." Furtht:rmore, P5324.07. SENTRY Psychology Alert Function states, "When a decision to move [any PSY ALERT] inmate occurs, any special psychological needs of the inmate are reviewed and considered by Psychology Services staff [and an safet and securit concerns are hi hli hted for non-P ch • " b><5J ·b)(5) bl(5> Both of these groups of inmates are susceptible to exaggerated or unrealistic fears about correctional settings and experience stress associated during movement and periods of transition (e.g., cell/unit changes, movement to and from court, institutional movement, and release of information through the media). Mr. Epstein was reportedly in court on July 31, 2019. It is unknown what time he departed or returned to MCC New York because this information was not entered in SENTRY. Regardless, upon his return, the United States Marshals Service (USMS) provided R&D staff with a Prisoner Custody Alert Notice regarding Mr. Epstein. The notice indicated Mr. Epstein had "MTL Mental Concerns Suicidal Tendencies." The USMS requested R&D staff sign the form and the then eparted with the signed copy . • b)(6 )· (b)(7)(C ) b)(6); (b)(7)(C) • 1 . d On August l , 2019, at 8:46 a.m. • en '--:---,---'an e-mai reportmg she ha just become aware of the above information. In the absence of additional information about this notation, this should have been considered a referral to Psychology Services about a potentially suicidal inmate and procedures should have been followed as outlined in P5324.08, Suicide Prevention Program. Specifically, when a staff member becomes aware an inmate may be thinking about suicide during normal working hours, that staff member must contact Psychology Services and maintain the inmate under direct, 11

Page 985 continuous observation until he is placed on Suicide Watch or seen by a psychologist. There is no evidence Mr. Epstein was monitored under these conditions from the time he returned from court until he was seen by b)r 6> (b)C7>cci for a suicide risk assessment on August 1, 2019, at approximately 1:30 p. . 8. Inmate Accountability and Assignment Accuracy: According to a SENTRY quarters roster generated on August 10, 2019, at 12:51 a.m., there were three inmates assigned to Mr. Epstein's SHU cell, Z04-206LAD, including him, at the time of his death. However, his SHU cell was only a double occupancy cell. Inmatefb>r5>: (b)(7xci I inmatejcbJ15>: lb)mrc) I and Mr. Epstein were all assigned to the same cell. On August 13, 2019, at 12:06 p.m. and 12:08 p.m., a quarters history roster was d C • (b'(6) d b'(6) . 1 I (b)(6) 11 . generate 1or mmate 1b\mici an h(mrr., respective y. nmate /h \f7\fr \ ce assignment was Z04-206LAD from Au ust 5 2019, until August 11, 2019, when he was moved to cell Z04-212UAD. Inmat lb)(6l:(b)(7)(cJ cell assignment was Z04-206UAD from August 1, 2019, until August 11, 2019, when he was moved to cell Z04-207LAD. A quarters history roster was generated for Mr. Epstein on August 13, 2019, at 9:07 a.m. His cell assignment was Z04-206LAD from July 29, 2019, until August 10, 2019. On Monday, August 12, 2019, photographs of nametags on SHU cell doors and SHU locator forms were sent to the Correctional Service Department in the Northeast Region. The SHU locator form is dated August 9, 2019. It shows inmate ,g~b in cell 207L (SENTRY states he was moved to this cell on August 11, 2019), inrnat ~\[~(b in cell 212U (SENTRY states he was moved to this cell on August 11, 2019), inmate Epstein in cell 220L (SENTRY never shows him in this cell) along with inmate Reyes (#85993- 054). The locator shows inmatej'bl(5l:(bl(7)cc> land inmat (b)(5> (bl<7,rc> in cell 206. The photo sheets show the cell being 220 with inmateLs~ p-st-e~m- an - ......... -ey_e_s..---' identification cards on the door. Inmate Reyes, Efrain, Reg. No. 85993-054 was in cell Z06-220U from August 5, 2019 to August 9, 2019. MCC New York has four suicide watch cells and each is for single occupancy use. The suicide watch cells are located in Health Services. Each cell is abbreviated with the unit code HO 1 in SENTRY followed by the four-digit cell number. The doors are identified by a painted number from one to four. Two reviews were conducted. The first revealed Mr. Epstein was in H0l-00lL according to SENTRY but the Suicide Watch Log Books indicate he was in cell 4. A second review was conducted on August 13, 2019, while there were four inmates on in these cells. SENTRY showed two inmates assigned to HO 1-001 L, one assigned to HO 1-002L, and the fourth inmate assigned to a general population housing unit. Through physical observation of the dedicated suicide watch cells there were four HO! cells, however a review of the BOPWARE Inmate Housing Format, only shows three cells. 12

Page 986 Inmate movement and assignments are not accurately reflected in SENTRY as required by PSS00.14, Correctional Service Procedures Manual. 9. Attorney Log Books: Four log books were not secured following Mr. Epstein's death. Specifically, three Attorney Log Books located in the Attorney Visiting and Front Lobby areas and an Inmate Search Log Book located in the Attorney Visiting area were not secured. All four books were still in use at the outset of the reconstruction and after the reconstruction team advised staff to secure them. P5324.08 states, "In the event of a suicide, institution staff, particularly Correctional Services staff, and other law enforcement personnel, will handle the site with the same level of protection as any crime scene in which a death has occurred." This policy further states, "All possible evidence and documentation will be preserved to provide data and support for subsequent inves\igators doing a psychological reconstruction." Further, a review of the attorney log books identified many errors and signify a systemic concern. For example, there were two concurrently open attorney log books in the Attorney Visiting area. Further, the different purposes of the two attorney log books, one in the Attorney Visit area and one in the Front Lobby, could not be explained. BOP staff were unable to articulate a system of control for the log books, and during the reconstruction, some of the log books could not be accounted for. Within the log books, entries were made out of chronological order, attorneys did not consistently sign in and out, significant information was illegible or missing, columns were not consistently labeled, log book opening and closing dates were inconsistent, and the cover had been tom off of several books. At the current time, these log books are not functioning as an adequate system of control and monitoring. 10. Automatic External Defibrillators: A review of available AEDs in the institution revealed that the list used for accountability and inspection purposes was inaccurate and incomplete. 11. Post Orders & SHU Training: SHU Post Orders Sign-In Sheets were reviewed for the }rd Quarter, spanning June 9, 2019, to September 7, 2019. Office (b)CB);(b)(?)(c) failed to sign post orders for SHU #3 post. Quarterly SHU Training Sign-In Sheets were reviewed. The 2019 }rd Quarter SHU Training was conducted on June 6, 2019. 'Three staff assigned to the 3rd uarter SHU Roster in SHU did not attend or receive the SHU Training: Office lb>C5>: (b)C7)tc> Officerfb)(6); (b)(7)(C) I and Officerr )(6); (b)(7)(C) I 12. Staffing: The Drug Abuse Program Coordinator positon at MCC New York was abolished during Phase I of the staff realignment during fiscal year 2018. Re-establishing 13

Page 987 the Drug Abuse Program Coordinator position would provide the institution with an additional supervisory psychologist to provide critical clinical services. Staffing in the Correctional Services department is relevant to the reconstruction. However, the details about this topic are provided in an After Action Review completed separately from this report. 13. Sex Offense Risk Factors: A broad understanding of risk factors associated with sex offenders, by staff at MCC New York, did not a ear to be resent in vital to his ad·ustment and safet in rison. tbl( 5 > b)(5) 14

Page 988 DOCUMENTS EXAMINED 0 j b){7'(E) TRU-INTEL Download Report of Incident (583), 586, oq.__' ____ _. TRUVIEW - Money Exchanged; Phone, Email, & Visitor Lists; Calls; Messages; Visits; Timeline TRU-SCOPE - Logs, High Risk Inmates, Inmates Lists, etc. Staff Memorandums Staff E-Mail Photographs of Scene; Deceased, Autopsy Video Showing Scene and Staff Response Sentry Documentation SIS Case File Index Psychology File PDS-BEMR Psychological Observation Procedural Memorandum Post Orders Lieutenant Logs Attorney Logs Staff Roster Medical Information/Records (BEMR) BOP Twenty-Four Hour Death Report Pre-Sentence Report Note(s) Left Behind by Deceased Time Line Autopsy Request & Report Inmate Central File Court Return Screening Form Prisoner Remand Form (If applicable) USM 129 Individual Custody/Detention Report (If applicable) Prisoner Custody Alert Notice Staff Sign-In Log 1 Week Prior to Suicide (If applicable) Detention Orders (If applicable) 30 minute SHU rounds BP 292's & 295's 15

Page 989 From To Date Subject: Ray Ormond 2019/07/24 11 :08 Re: Epstein Update Attachments: TEXT.htm Can you call when you break free for a moment. Thanks. > > > Ray Ormond 7/24/2019 10:56 AM > > > Inmate Epstein #76318-054 was removed from Suicide Watch and stepped down to Psychological Observation. He was just escorted to Health Services for a follow-up assessment/evaluation. Once completed, he will be escorted to Attorney Conference to meet with his Attorney. He has a pending incident report for Self-Mutilation and therefore, he will return to the Special Housin Unit S and will be celled with inmate 'b)<5>; (b)(7)(Ci (b)(6); (b)(l)(C) 'b)(6}; (b)(7)(C) he requested Protective Custody. J. Ray Ormond Regional Director Northeast Re ion 215-521 (b){G) (b)(l )(C) ecause Page 2214

Page 990 Re: Epstein #76318-054 From l(b)(6>: (b)(7)(c> ~. ,,,.-,.,,,-,....,,-..,.,,-,,,..,,-~---_-_-_-_-_~---, To (b)(6): (b)(7)(C ) Date 2019 07 24 12:00 Subject: Re: Epstein #76318-054 Attachments: TEXT.htm Page 2218

Page 991 AW SS just called regarding his competency .... I said yes, do you agree? l (b)(6); (b)(7)(Ci I ~- ----~Psy.D. Chief Psychologist U.S. Department of Justice/ Federal Bureau of Prisons Metropolitan Correctional Center 150 Park Row NewYork, New York 10007 Office: (646) 836 b)(G); CbK7)<c ) Fax: (646) 836-7712 E-mail r (6); (b)(? )(C ) r bop.goy > > 1 b)(6); (b)(7)(C) SIS, f/24/201911:41 AM>> > b)(7)(A) Very respectfully, l(b)(6); (b)(7)(C) I l (b)(6); (b)(7)(C) I h ~- ----~ p .D. Forensic Psychologist LT, U.S. Public Health Service U.S. Department of Justice Federal Bureau of Prisons Metropolitan Correctional Center 150 Park Row NewYork, New York 10007 Office: 646.83 ig~!tq Fax: 646.836.7 E-mailr G);(b)(7i(C) bop.gov l(b)(6); (b)(7)(C) "This message is intended for official use and may contain SENSITIVE information. If this message contains SENSITIVE information, it should be properly delivered, labeled, stored, and disposed of according to policy." Page 2219