The First Incident
On July 23, 2019, Jeffrey Epstein was found on the floor of his cell at MCC with marks on his neck. He was placed on suicide watch the standard BOP protocol requiring constant monitoring and removal of items that could be used for self-harm.
The Removal Decision
Approximately six days later, on July 29, Epstein was removed from suicide watch. He was placed in a special housing unit with a cellmate a former police officer who was later transferred away as a lesser protective measure called ‘psychological observation.‘
Who Made the Decision
The BOP investigation pointed to a psychological staff member who made the medical determination that Epstein no longer met the criteria for suicide watch. The Bureau of Prisons declined to name the individual publicly in its initial reports.
The Inadequate Replacement Measure
The replacement measure placement with a cellmate and twice-daily rounds was significantly less protective than suicide watch. Standard BOP protocol after a suicide watch incident typically includes more extended monitoring.
The Consequence
On August 9-10, 2019, Epstein was found unresponsive in his cell without a cellmate (his cellmate having been transferred) and with no guard having checked on him for hours due to documented overtime staffing failures.