Jeffrey Epstein suicide blamed on 'chronic problems' within Bureau of Prisons. What we know

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If you or someone you know may be struggling with suicidal thoughts, you can call or text the U.S. National Suicide Prevention Lifeline at 988 any time day or night, or chat online at Additional mental health resources can be found at the end of this article.

WASHINGTON – The suicide of disgraced financier Jeffrey Epstein was facilitated by the Federal Bureau of Prisons' failure to address "chronic problems" within the agency, according to a watchdog report released Tuesday.

"The BOP's failures are troubling not only because the BOP did not adequately safeguard an individual in its custody, but also because they led to questions about the circumstances surrounding Epstein's death and effectively deprived Epstein's numerous victims of the opportunity to seek justice through the criminal justice system," Michael Horowitz, the Justice Department’s inspector general, said in a statement released with the report.

Epstein died at the Metropolitan Correctional Center in New York in August 2019 while charged with sex trafficking.

Horowitz found that job performance and functional failures, amplified by staffing shortages and a "widespread disregard" for Bureau of Prisons policies and procedures, made Epstein's death possible. The report also said the inspector general found no evidence contradicting the FBI's determination that there was no criminality associated with Epstein's death.

Epstein’s case was sensational because he was an investment banker who counted among his powerful connections former Presidents Bill Clinton and Donald Trump and Prince Andrew of the United Kingdom. He had pleaded not guilty to charges of drug trafficking and sexually abusing dozens of underage girls in New York and Florida.

Epstein’s death had already triggered a series of investigations and reforms:

The Bureau of Prisons said in a statement that enhanced practices – like video footage review to ensure staff rounds are conducted promptly and properly – have already begun. Employees will also receive annual training in suicide prevention, and people working closely with inmates at high risk for mental health crises will undergo specialized training.

The agency "takes seriously our ability to protect and secure individuals in our custody while ensuring the safety of our correctional employees and the surrounding community,” the statement reads. “We make every effort to create a controlled environment within our facilities that is both secure and humane, prioritizing the physical and emotional well-being of those in our care and custody.”

Here is what we know about the inspector general’s report:

Policies ignored and special treatment

Misconduct and negligence by Metropolitan Correctional Center staff who treated Epstein differently from other inmates contributed to the circumstances that made it possible for Epstein to die by suicide, according to the report.

The inspector general's office found that staff in the Special Housing Unit (SHU), where Epstein was housed, falsified count slips and round sheets to show they had been done when they had not. SHU staff did not conduct any 30-minute rounds after 10:40 p.m. on Aug. 9, 2019.

After meeting with his lawyers at the prison, Epstein was allowed to make an unrecorded, unmonitored phone call – a violation of Bureau of Prisons policy. The call was made to a number with a local New York area code.

In his room, he had access to extra linens other inmates didn't have and was allowed to sleep on the floor. When Epstein was found dead, the linens had been tied into multiple nooses, according to the report.

Failure to address mental health

Epstein's first suicide attempt occurred on July 23, 2019, less than a month before his death. He was found lying on the floor of his cell with a piece of orange cloth around his neck, and his cellmate at the time said he tried to hang himself.

As a result of the attempt, he was placed on suicide watch for a day and psychological observation until July 30. The psychology department at the Metropolitan Correctional Center in New York sent an email to more than 70 Bureau of Prisons staff members a week later saying Epstein "needs to be housed with an appropriate cell mate."

Despite that instruction and verbal direction from high-ranking prison officials, Epstein was left without a cellmate on Aug. 9. Less than 24 hours later, he was dead.

"As a result, Epstein was unmonitored and locked alone in his cell for hours with an excess amount of linens, which provided opportunity for him to commit suicide," the report reads.

No evidence of criminality in Epstein's death, report says

After Epstein's untimely death, conspiracy theories about how − and even if − the disgraced financier died ran rampant on social media. But the Justice Department inspector general's report indicates no foul play was at hand.

"We did not uncover evidence contradicting the FBI's determination regarding the absence of criminality in connection with how Epstein died," the report reads.

Epstein's death was consistent with suicide, not strangulation, the report says; there was no evidence of defensive wounds, such as broken fingernails or contusions to his knuckles, that would be expected in a homicide. Epstein's ultimate death also showed parallels to his earlier suicide attempt, according to the report.

Only one prison security camera was available in the SHU where Epstein was housed because of a malfunction that occurred July 29, 2019 and was not repaired until after Epstein's death, a detail that led to unfounded speculation about his death.

But the camera that did record the area showed no one entering his cell tier between 10:40 p.m. on Aug. 9 and 6:30 a.m. on Aug. 10, the time during which he died. The SHU staff and three interviewed inmates who could see Epstein's cell door on the night of his death said no one entered or exited Epstein's cell after he was locked up for the evening.

Horowitz: 'Chronic problems and failures' must be addressed

Horowitz made eight recommendations based on shortcomings detailed in the report, mainly focused on establishing processes that better protect inmates with mental health struggles to prevent future incidents.

The report recommends that the Bureau of Prisons implement a process for assigning and retaining cellmates after an inmate has been placed on suicide watch or psychological observation, including establishing contingency plans in case cellmates are reassigned. The bureau also should reevaluate its process for documenting social or legal visits while an inmate is under observation related to mental health, the report said.

Policies on conducting rounds, accounting for inmates, searching cells, and security systems – plus persistent staffing shortages – also should be addressed, according to the report.

"The fact that these chronic problems and failures have been recurring ones does not excuse them and gives additional urgency to the need for BOP and DOJ leadership to address them," Horowitz said in the statement.

Mental health resources:

  • If you or someone you know may be struggling with suicidal thoughts, you can call or text the U.S. National Suicide Prevention Lifeline at 988 any time day or night, or chat online at

  • National Domestic Violence Hotline: 1-800-799-7233 or text LOVEIS to 22522.

  • Trans Lifeline: 1-877-565-8860 (para español presiona el 2).

  • Veteran’s Crisis Line: 988, then select 1, or text: 838255.

  • Support Line for Physicians: 1-888-409-0141 –

  • Help for Native American people: StrongHearts Native Helpline: 1-844-7NATIVE (762-8483) or chat online.

  • Resources for Black people:

  • Ayuda en español:

  • Find treatment:

This article originally appeared on USA TODAY: Jeffrey Epstein report: Prison negligence led to his suicide