OIG_Report_24-041_BOP_Inmate_Deaths.pdf

"the suicide of Jeffrey Epstein in 2019, brought national focus to the BOP’s operational and management challenges"

"the homicide of James “Whitey” Bulger in 2018"

"OIG investigations of these deaths identified serious BOP job performance and management failures."

"inmate homicides at U.S. Penitentiary (USP) Hazelton"

"USP Thomson"

"custody, care, and supervision of Epstein, which identified numerous and serious failures by Metropolitan Correctional Center New York staff"

"In June 2023, the OIG issued an investigative report on the custody, care, and supervision of Epstein"

"the then BOP Director and other Department leaders received a congressional inquiry regarding concerns about BOP inmate suicide prevention and protoco"

"U.S. Department of Justice (DOJ or Department) Office of the Inspector General (OIG)"

"two OIG reports published in 2022 and 2023 specifically examined the circumstances surrounding the deaths of inmates Bulger and Epstein while they wer"

"Federal Prison Suicides Were Quietly Rising Before Jeffrey Epstein’s Death in a New York Detention Center"

"Michael E. Horowitz, Inspector General, U.S. Department of Justice"

"two OIG reports published in 2022 and 2023 specifically examined the circumstances surrounding the deaths of inmates Bulger and Epstein"

"we found from BOP reports and our investigation of the custody, care, and supervision of Epstein that a combination of recurring policy violations and"

"investigation of the custody, care, and supervision of Epstein"

"the BOP subsequently reported to the OIG that it suspended the SMU program in February 2023"

"inmates were housed at the BOP’s Special Management Unit (SMU)"

"OIG analysis of BOP data"

"the BOP’s SENTRY inmate management system"

"the BOP utilizes an MHCL designation system to manage inmates’ mental healthcare"

"The OIG’s June 2023 report related to the death of Jeffrey Epstein identified numerous and serious failures"

"Investigation and Review of the Federal Bureau of Prisons’ Custody, Care, and Supervision of Jeffrey Epstein"

"DOJ OIG, Custody, Care, and Supervision of Jeffrey Epstein, Recommendations 1 and 2."

"in May 2021 it established a Single Cell Task Force to review single-celling practices and inmate suicides"

"the SHU cell where he was housed"

"the OIG’s June 2023 report on MCC New York staff’s custody, care, and supervision of Epstein"

"In November 2017, Health Services staff saw an inmate after the inmate reported that he had swallowed razor blades."

"The inmate later got into an altercation with another inmate, which resulted in the first inmate’s placement in a SHU."

"The Psychological Reconstruction Report noted that, had increased collaboration and coordination taken place between Psychology Services and Correctio"

"Psychology Services staff told us that they believed that suicides are preventable if all staff follow policy"

"Correctional Services staff told us that they did not believe that there was any measure that the staff or the institutions could have implemented to "

"Health Services staff saw an inmate after the inmate reported that he had swallowed razor blades."

"the inmate subsequently requested to be placed in a single cell in a SHU, where he died by suicide"

"significant delay in notifying Central Office’s Psychology Services Branch of the inmate’s suicide"

"address our 2023 Epstein report recommendations"

"Source: OIG analysis of BOP data"

"clarify SHU supervisory staff’s round duties"

"an ERT collaborates with the Federal Bureau of Investigation, the regional U.S. Attorney’s Office, and other law enforcement agencies to pursue the su"

"One SIS staff member from FTC Oklahoma City told us that the ERT had not received the required quarterly ERT training"

"institution personnel (Mortality Review Committee members) complete an MLMR within 30 days of any inmate death and submit their report to the Office o"

"ERTs, composed of a minimum of eight BOP staff members, are described in BOP policy as part of the agency’s multi-pronged strategy"

"the BOP recommended that staff receive training to properly secure and document evidence, especially those staff in ERT and Special Investigative Serv"

"USP Atlanta, which had the most inmate deaths during the years of our evaluation scope"

"The BOP further stated that the PSB presents lessons learned during annual staff training... it disseminates guidance and talking points for Wardens."

"submit their resulting report to Central Office, specifically the OQM within the HSD"

"it is at the discretion of the Regional Director to decide whether the institution where the homicide occurred should respond"

"Central Office OQM"

"we reviewed as an example the available MLMR, ECR, and After Action Reports resulting from inmate deaths that occurred at one of the institutions we v"

"a total of five inmate deaths occurred at this institution: one homicide in FY 2020"

"two homicides and two suicides in FY 2021"