Jeffrey Epstein And The Psychological Reconstruction Of The Events Leading To His Death (Part 3) (3/12/26)

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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, inmate accountability and assignment accuracy.

According to a century quarters roster generated

on August 10th, 2019 at 12.51 AM,

there were three inmates assigned to Mr. Epstein's

Schussel, Z04, dash 206, LAD,

including him at the time of his death.

However, his Schussel was only a double occupancy cell

inmate Patrick Avila,

inmate Gregory Ferrer and Mr. Epstein were all assigned

to the same cell.

On August 13th, 2019 at 12.06 PM and 12.08 PM,

a quarters history roster was generated

for inmate Avila and Ferrer, respectively.

Inmate Avila's self-assignment was Z04, dash 206, LAD,

from August 5th, 2019 until August 11th, 2019,

when he was moved to a cell, Z04, dash 212, UAD.

Inmate Ferrer's self-assignment was Z04, dash 206,

UAD from August 1st, 2019

until August 11th, 2019, when he was moved to cell, Z04,

207, LAD, a quarters history roster was generated

for Mr. Epstein on August 13th, 2019 at 907 AM.

His self-assignment was Z04, dash 206, LAD,

from July 29th, 2019 until August 10th, 2019.

On Monday, August 12th, 2019, photographs of name tags

on Schu cell doors and Schu locator forms were sent

to correctional service department in the Northeast region.

The Schu locator form is dated August 9th, 2019.

It shows inmate Ferrer in cell 207, L,

sentry states that he was moved to the cell on August 11th, 2019.

Inmate Avila in cell to 12u, sentry states

that he was moved to this cell on August 11th, 2019, Epstein,

in cell to 20l, sentry never shows him in a cell,

along with inmate Reyes.

The locator shows inmate Copper and inmate Dockery in cell 206.

The photo sheets show the cell being to 20 withinmate's

Epstein and Reyes identification cards on the door, inmate Reyes,

Efrin, regulation number 85993-054 was in cell Z06 to 20u from August 5th, 2019,

to August 9th, 2019.

MCC New York has four suicide watch cells and each is for single occupancy use.

The suicide watch cells are located and health services.

Each cell is abbreviated with the unit code,

H01 in sentry followed by a 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 H01-00IL according to sentry,

but the suicide watch logbooks indicate he was in cell four.

A second review was conducted on August 13th, 2019,

while there were four inmates in these cells.

Sentry showed two inmates assigned to H01-0021 and the fourth inmate,

assigned to a general population housing unit.

Through physical observation of the dedicated suicide watch cells,

there were four H01 cells, however a review of BOP where inmate housing format only shows three cells.

Inmate movement and assignments are not accurately reflected,

and sentry is required by p5500.14 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 sentry 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 sentry 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 sentry assignments of H01-001L

through H01-004L. 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 to Sally Port and unit to 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-30 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 keying of suicide watch bed assignments

after hours. The lieutenants were instructed that upon placing an inmate on suicide watch,

they are responsible for contacting CNA and providing the cell assignment. Additionally,

the lieutenant will run PP-30 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 bed 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 cell inside the special

housing unit, periodic and unannounced checks are conducted. Specifically, Century roster PP-30

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 and accounting for inmates and cell assignments. A unit accountability board along

with Century PP-30 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 to officer will be responsible for making rounds,

serving meals, collecting trash in the area and performing the count with the internal one

or internal to 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, lieutenant will reinforce the message through conference calls with staff.

Roll call notes will be placed on true scope to notify staff of which inmates are currently

on suicide watch. 9. Attorney Logbooks

Four logbooks were not secured following Mr. Epstein's death, specifically,

three attorney logbooks located in the attorney visiting and 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. P5-324.08 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.

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This policy further states all possible evidence and 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 concurrently 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 cannot 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

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 10, 2019,

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 was conducted to ensure accuracy of the documentation and compliance with policy.

Measures were being taken to ensure in the future that all relevant logbooks 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 defibrillators report presented by

Great Lakes Biomedical Service, dated July 22, 2019, 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 2018.

Medical staff provides training and conducts monthly inspections of all AEDs in the institution.

Great Lakes Biomedical Services and outside contractor

conducts a biannual inspection and provides a report. Procedures on inspecting all AEDs in the

institution have been prepared and are awaiting approval. These procedures are attached to

11 post-orders and shoe training. Shoe post-orders sign-in sheets were reviewed.

For the third quarter, spanning June 9, 2019 to September 7, 2019, Officer Elle Gray

felt the sign post-orders for shoe number three post. Quarterly shoe training sign-in sheets

were reviewed. The 2019 third quarter shoe training was conducted on June 6, 2019.

Three staff assigned to the third quarter shoe roster in Shoe did not attend or receive

shoe training. Officer David Dubenzic, Officer Miguel Mangay, and Officer Robert Grovala,

institution response 11 post-orders and shoe training.

The Suicide Watch post-orders are located in the Lieutenant's office and Shoe with a quarterly

sign-in 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.

Attach please find a copy of the narrow waiver permitting staff monitor 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 was 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,

the shoe training on Bob Learn will be completed by all staff assigned to the shoe

that day of training. Shoe staff will be a lot of 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 Watch shall maintain a chronological

log of the inmates' behavior. Blank log books 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 log book prior to initiating the watch.

Different log books will be used for each inmate on Suicide Watch. Each log book 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 log book and at the top of each page in the log book

in which entries are made. During some Suicide Watch's staff observers may cover some shifts

and inmate companions may cover others. In the instance, two separate log books 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 log books are used,

staff must sign the inmates companion log book every 60 minutes. Lights will remain on inside

the cell 24 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 curse research. No food items,

trays, eating utensils, mill 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, MP3 players,

magazines, books, or anything that would distract them from maintaining constant supervision.

Inmate 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 1 of

staff re-alignment during fiscal year 2018 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

12 staffing

The drug abuse coordinator position is currently a shared 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 psychologist to perform critical clinical service.

At the current time, the position is pending selection. We are currently in the process

of requesting the higher-estaff psychologist position to provide additional psychological

services to inmates in the shoe. Including therapy sessions with PsyAlert, CC2, MH, and CC3,

MH inmates who are currently house there. An additional psychologist 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 intervention and suicide risk assessments, 13 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 designate, continues to present at all executive staff meetings, department head meetings,

and shoe meetings. During these meetings, the chief psychologist 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 offender 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.

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