If it’s true that only one of the two people guarding Jeffrey Epstein normally worked as a correctional officer, it’s not an excuse for his death.

I personally served as the lead person on the suicide watch team while housed in F.C.I. Fort Dix. The program consisted of approximately  12 inmates who were trained under the supervision of  Dr. Marcia Baruch who was the Chief Psychologist. We were taught cognitive behavioral therapy among other skills that would be necessary as members of the suicide watch team, anger management, and mentoring program facilitators in the federal prison.

It’s obvious that the mental health screening and suicide assessment tools and protocols were not followed in MCC Federal Prison in Manhattan.

It’s open to questions whether any risk evaluations were ever completed. It appears that the prison failed to justify the determinations of risk and had no adequate plan upon removing him from suicide watch. In so doing they completely relied on inconsistent or incomplete information about Mr. Epstein to determine his risk of committing suicide. That is likely a fragment of the serious issues that exist within the prison.

Inmates on suicide watch must be continuously observed and behaviors documented every 15 minutes.  The conditions would have required them to be moved to a special bare-bones cell where he would be outfitted in a tear-resistant one-piece smock and receive stepped-up observation from posted outside the cell. Everything he does during the fifteen-minute intervals are documented in a log with no spaces between the lines. There is a likelihood that no staff members on duty the night of Mr. Epstein’s death received proper training on documenting and making rounds on someone who was recently “taken off” suicide watch. Particularly since he was housed in a room alone. The question will be “Which high ranking member of the psychology department or upper management signed off on his release from suicide watch?” Those important questions will start with the Chief Psychologist and work its way down. The root cause analysis will be on full display in this case.

By performing faulty mental health evaluations, prison employees likely underestimated Mr. Epstein’s risk of suicide. An effective program would ensure that corrections officials take and pass stringent risk evaluation audits. Particularly new inmates who often have difficulties adjusting to prisons or inmates who have recently been released from the suicide watch program.

State and Federal Prisons must require Mental health staff to adequately complete all sections in any required suicide risk assessment to minimize any inmates risk of suicide.

Most federal prisons have hiring freezes and it’s possible that the officers on shift the night of Epstein’s death had worked overtime and fell asleep. Correctional officers are generally forced to work overtime 4 to 5 days straight. Inmates in most Federal Detention Centers are locked down 23 hours a day which may explain why no officer checked on Epstein for 7- hours. They were fatigued and likely sleeping in an empty office inside the prison. If a thorough investigation is conducted by the Department of Justice, cameras within the prison may show the whereabouts of the correctional officers during the 7-hours Epstein was left alone.

Effective suicide prevention programs in prisons “never” leave inmates without a cell mate if he has been recently released from suicide watch back into general population. It’s equally amazing that even if Epstein were removed from suicide watch, he could have been placed in a cell monitored by a camera 24-7.

Not since Jackie Smith’s dropped pass in Superbowl XIII have I seen a ball dropped this bad. William Barr is going to have a field day with this one.

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