Speaker 1: What's up everyone, and welcome to another episode of the
Epstein Chronicles. In this episode, we're going to pick up
where we left off with the psychiatric breakdown and recreation
of Jeffrey Epstein's death Number eight It made accountability and
assignment accuracy. According to a Century Quarters roster generated on
August tenth, twenty nineteen, at twelve fifty one am, there
were three inmates assigned to mister Epstein's shoe cell Z
zero four dash two zero six LAD, including him at
the time of his death. However, his shoe cell was
only a double occupancy cell. Inmate Patrick Avila, it made,
Gregory Ferrer, and mister Epstein were all assigned to the
same cell. On August thirteenth, twenty nineteen, at twelve oh
six pm and twelve oh eight pm. A Quarter's History
roster was generated for inmate of Villa and Ferr, respectively,
and made a Villa cell assignment was Z zero zero
four dash two six la D from August fifth, twenty
nineteen until August eleventh, twenty nineteen, when he was moved
to sell Z zero four dash two one two ua
D and made. Farreer cell assignment was Z zero four
dash two O six UA D from August first, twenty
nineteen until August eleventh, twenty nineteen, when he was moved
to sell Z zero four to zero seven LAD. A
quarter's history roster was generated for mister Epstein on August thirteenth,
twenty nineteen at nine oh seven am. His cell assignment
was Z zero four DASH two zero six LA D
from July twenty ninth, twenty nineteen until August tenth, twenty nineteen.
On Monday, August twelfth, twenty nineteen, photographs of name tags
on shoe cell doors and shoe lokeader forms were sent
to Correctional Service Department in the North East region. The
shoe locator form is dated August ninth, twenty nineteen. It
shows inmate Ferror in cell two O seven L century
states that he was moved to this cell on August eleventh,
twenty nineteen. In mat of Vila in cell to twelve
U century states that he was moved to this cell
on August eleventh, twenty nineteen. Epstein in cell to twenty
L century never shows them in a cell along with
inmate reyes. The locator shows inmate copper and inmate dockery
in Cell two O six. The photo sheets show the
cell being two twenty with inmates Epstein and Reys identification
cards on the door. Inmate Reyes ephrin regulation number eight
five nine nine three DASH zero five four was in
cell Z zero six to twenty U from August fifth,
twenty nineteen to August ninth, twenty nineteen. 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 one
in Century, followed by four digit cell number. The doors
are identified by a painted number from one to four.
Two reviews were conducted. The first revealed mister Epstein was
in H zero one zero zero IL according to Century,
but the suicide Watch logbooks indicate he was in cell four.
A second review was conducted on August thirteenth, twenty nineteen.
While there were four inmates in these cells, Century showed
two inmates assigned to ho I zero zero IL, one
assigned to HO one DASH zero zero two one, and
the fourth inmate assigned to a general population housing unit.
Through physical observation of the dedicated suicide watch cells, there
were four HO one cells. However, a review of bop
ware inmate housing format only shows three cells. Inmate movement
and assignments are not accurately reflected in Century is required
by P five five zero zero dot one four Correctional
Service Procedure Manual Institutional Response eight Inmate Accountability and assignment accuracy.
With regard to accuracy and accountability of inmates placed on
suicide watch status in the hospital area, Psychology Services now
runs a daily Century roster of all inmates on suicide
watch in that area. The roster is examined to ensure
that the inmates placed on suicide watch in a suicide
watch cell are keyed into centry with the correct cell
assignment noted. The associate warden programs is notified if there
are any inconsistencies. Moreover, the four suicide watch cells now
all have Century assignments of H zero one zero zero
one L through H zero one dash zero zero five. Further,
Psychology Service Department reviews suicide watch logbooks on a daily
basis to assess whether the lieutenants have conducted rounds during
each shift and whether the Unit two sally Port and
Unit two officers are conducting hourly rounds. Any inconsistencies noted
in the logbooks by psychology staff will be reported immediately
to the Captain and Associate Warden over programs to address appropriately.
The Operations Lieutenant will physically check the PP thirty cell
assignment roster when inmates are quartered on Suicide Watch. The
lieutenant will ensure the counts and assignments officer key cell
assignments correctly and annotate any errors in the daily log
and contact the Captain immediately. Guidance was sent to the
lieutenants regarding king of Suicide Watch BET assignments after hours.
The lieutenants were instructed that upon placing an inmate on
Suicide Watch, they're responsible for contacting CNA and providing the
cell assignment. Additionally, the lieutenant will run PP thirty with
the selection category for Suicide Watch. The Operations Lieutenant will
email the roster to the Captain, as he will be
responsible for verifying that each inmate is in an appropriate cell.
This verification process will ensure inmates placed on Suicide Watch
are keyed into accurate BET assignments and will eliminate inmates
being keyed into the same cell. Additionally, the lieutenants were
instructed to contact the captain and on call psychology staff
by telephone when the need for suicide watch placement is
determined after hours. Psychology staff have been instructed to contact
the warden upon receiving said notification. After consultation with the warden,
Psychology staff will designate whether a staff or inmate companion
will be assigned. Psychology staff will in turn inform the
shift lieutenant of this determination. To ensure that inmates are
assigned to the correct sell Inside the Special Housing unit,
periodic and unannounced checks are conducted specifically Century Roster PP
thirty Quarters assignment are audited daily by the Shoe Lieutenant.
Executive staff also conduct routine bed book counts and all
units any and all discrepancies identified or addressed results will
be maintained by correctional services in the Lieutenant's log. The
morning watch lieutenant is responsible for observing one count during
his or her shift in the Shoe, which is documented
daily in the Lieutenant's log. In order to properly account
for inmates in the unit, staff have been informed not
to use the inmate locator form due to the form
being unreliable in accounting for inmates and sell assignments. A
Unit Accountability Board along with century PP thirty quarters Roster
have been placed in the unit to establish better oversight
over inmate accountability. Correctional staff are required to perform routine
rounds on the second floor suicide watch area every hour
on day watch Monday through Friday. The two sally officers
are required to perform rounds on suicide Watch inmates as
prescribed by the captain. After hours, the Unit two officer
will be responsible for making rounds, serving mules, collecting trash
in the area, and performing the count with the Internal
one or Internal two officer assisting with duties as assigned
by the captain to ensure that staff are informed of
the importance of suicide prevention and responsibilities. When one occurs,
lieutenants will reinforce the message through conference calls with staff.
Roll call notes will be placed on truscope to notify
staff of which inmates are currently on suicide watch. Nine
attorney logbooks four logbooks were not secured following mister Epstein's death. Specifically,
three attorney logbooks located in the attorney visiting in front
lobby areas and an inmate search logbook 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. P.
Five three two four dot zero eight states in the
event of a suicide, institution staff, particularly correction 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 in documentation will be preserved to provide data and
support for subsequent investigators doing psychological reconstruction. Further, a review
of the attorney logbooks identified many errors and signify a
systemic concern. For example, there were two can currently open
attorney logbooks in the attorney visiting area. Further, the different
purposes of the two attorney logbooks, one in the attorney
visit area and one in the front lobby, cannot be explained.
BOP staff were unable to articulate a system of control
for the logbooks, and during the reconstruction some of the
logbooks could not be accounted for. With the logbooks, 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, logbook opening and closing dates were inconsistent,
and the cover had been torn off several books. At
the current time, these logbooks are not functioning as an
adequate system of control and monitoring. Institution Response number nine
Attorney logbooks. On August tenth, twenty nineteen, logbooks deemed relevant
to the investigation were removed from various locations throughout the facility.
The reconstruction team did not identify pertinent logbooks that had
been secured. At this time. All relevant logbooks have been
removed and replaced. In addition, a logbook audit will conducted
to ensure accuracy of the documentation and compliance with policy.
Measures are being taken to ensure in the future that
all relevant log books are identified, secured immediately and replaced
with new ones to ensure the institution can continue to
run efficiently. Ten Automatic external defibrillators. A review of available
AEDs in the institution revealed that the list used for
accountability and inspection purposes was inaccurate and complete. Institution Response
ten Automatic external defibrillators. A review of the automatic external
defibilators report presented by Great Lakes Biomedical Service dated July
twenty second, twenty nineteen, revealed that all AEDs were accounted
for and were placed in correct respective areas. The report
was accurate and complete. New AEDs have been purchased and
will be inspected Great Lakes Biomedical Services upon their arrival.
The list reviewed by the reconstruction team was an old
and outdated list from January of twenty eighteen. Medical staff
provides training and conducts monthly inspections of all AEDs in
the institution Great Lakes Biomedical Services. An outside contractor conducts
a bi annual inspection and provides a report. Procedures on
inspecting all AEDs in the institution have been prepared and
are awaiting approval. These procedures are attached here. Two eleven
post orders and shoe training. Shoe post orders sign in
sheets were reviewed for the third quarter spanning June ninth,
twenty nineteen to September seventh, twenty nineteen. Officer L. Gray
failed to sign post orders for shoe number three post
Quarterly shoe training sign in sheets were reviewed the twenty
nineteen third quarter. Shoe training was conducted on June sixth,
twenty nineteen. Three staff assigned to the third order, Shoe
Roster and Shoe did not attend or receive Shoe training
Officer David to Benzig, Officer Miguel Mongey, and Officer Robert
Gravalla Institution Response eleven post orders and Shoe training. The
suicide watch post orders are located in the Lieutenant's office
and Shoe with a quarterly sign and sheet. A copy
of the suicide watch post orders will also be placed
in secure container outside of suicide watch cells on Tier
H and Shoe. This container will also hold signature sheets
and additional staff suicide watch logbooks. All staff members assigned
to a suicide watch post are responsible for signing the
post orders prior to performing the staff suicide watch. Attached,
please find a copy of the narrow waiver permitting staff
monitored suicide watches in the Shoe. With regard to Shoe
suicide prevention training, this continues to be conducted on a
quarterly basis. However, the sign in sheets for this training
are now to be examined by the Shoe lieutenant for accuracy.
If a staff member who is assigned to the Shoe
misses the training, the sign in sheet will be routed
to the captain who will coordinate with the chief Psychologist
and schedule a time to receive a makeup session for
the shoe suicide prevention training. Shoe training is conducted quarterly.
Two weeks from the beginning of a new quarter, a
representative from Psychology will provide the required suicide prevention training
in addition to shoe training on bob learn will be
completed by all staff assigned to the shoe that day
of training. Shoe staff will be allotted time during the
data complete the prescribed web based training as identified on
the agenda. Staff who are assigned to the shoe but
have not received the mandatory training before assuming the post
will be roster adjusted to attend another training day as
assigned by the Captain. Staff assigned to Suicide Walde shall
maintain a chronological log of the inmate's behavior. Blank logbooks
will be maintained in the Lieutenant's office and on the
second floor. A chronological record of events will commence immediately
upon the initiation of watch. It's the responsibility of the
staff member initiating the watch to obtain a blank logbook
prior to initiating the watch. Different logbooks will be used
for each inmate on Suicide watch. Each logbook will contain
entries for one suicide watch only. The name and register
number of the inmate on watch shall be clearly printed
on the front cover of the logbook and at the
top of each page in the logbook in which entries
are made. During some suicide watches, staff observers may cover
some shifts and inmate companions may cover others. In the instance,
two separate logbooks must be used, one of the shifts
or one for the shifts excuse me during which staff
are maintaining constant visual observation blue, and another for shifts
during which inmate companions are providing constant visual observation yellow.
When separate inmate companion logbooks are used, staff must sign
the inmate's companion logbook every sixty minutes. Lights will remain
on inside the cell twenty four hours a day to
ensure the inmate on watch can be seen. A lieutenant
will make rounds every shift and remove the inmate from
the cell and perform a cursor research. No food items, trays,
eating utensils, milk cartons, toilet paper, plastic bags, reading materials, pens, pencils,
or anything else not prescribed by psychology. Staff should be
in the cell. The inmate will be outfitted in a
suicide preventive smock, suicide preventive blanket, suicide preventive mattress, and,
if necessary, a suicide preventive helmet. Inmate companions will be
searched prior to assuming duties. Inmate companions are not allowed
to have radios, NP three players, magazines, books, or anything
that would distract them from maintaining constant supervision. In may
companions will not have direct or physical contact with inmates
on suicide watch staffing. The drug Abuse Program Coordinator position
at mcc New York was abolished during phase one of
staff realignment during fiscal year twenty eighteen. Re Establishing 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. Institutional Response twelve staffing.
The drug Abuse Coordinator position is currently a share position.
A warden has re established the Drug Abuse Coordinator position
as a full time position to provide the psychology department
with an additional supervisory psychologists to perform critical clinical service.
At the current time, the position is pending selection. We
are currently in the process of requesting to hire a
staff psychologists position to provide additional psychological services to inmates
in the Shoe, including therapy sessions with sy alert CC
two MH and CC three MH inmates who are currently
housed there. An additional psychologists could also monitor hot list
inmates arriving to the Shoe and ensure that they're housed
with appropriate cellmates. This psychologist could conduct daily rounds to
look for signs of psychological distress and address the concerns
of our long term Shoe inmates. Finally, an additional staff
psychologist could assist with our daily crisis and revention and
suicide risk assessments. Thirteen Sex offense risk factors a broad
understanding of risk factors associated with sex offenders by staff
at MCC New York did not appear to be present
in all staff, but was vital to his adjustment and
safety in prison. A more focused management strategy is recommended,
particularly in complex and high profile cases. Supplemental training on
sex offender specific risk factors is recommended for all staff
and should be provided by executive staff and Psychology Services
institutional response. The chief psychologist is a member of the
executive staff. The chief Psychologist or her designee continues to
present at all executive staff meetings, department head meetings, and
shoe meetings. During these meetings, the chief psychologists offers feedback
regarding the treatment and management of sex offender inmates. Additionally,
the chief psychologist continues to educate all staff during introduction
to correctional techniques and annual training about the sex offenders,
specific risk factors and suicide risk. All right, folks, Well
there you have it, the psychological reconstruction of what went
down leading up to and on the night of Jeffrey
Epstein's death. All the information that goes with this episode
can be found in the description box.