Jeffrey Epstein was left alone in his jail cell with a surplus of bed linens the night he killed himself. Nearly all the surveillance cameras on his unit didn't record.
One worker was on duty for 24 hours straight. And, despite his high profile and a suicide attempt two weeks earlier, he wasn't checked on regularly as required.
On Tuesday (early Wednesday AEST), the Justice Department's watchdog said a "combination of negligence, misconduct and outright job performance failures" by the federal Bureau of Prisons and workers at the New York City jail enabled the wealthy financier to take his own life in August 2019, finding no evidence of foul play.
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Crisis support is available from Lifeline on 13 11 14.
Inspector General Michael Horowitz blamed numerous factors for Epstein's death, including the jail's failure to assign him a cellmate and overworked guards who lied on logs after failing to make regular checks. Had the guards done so, Horowitz said, they would've found Epstein had excess linens.
The failures are deeply troubling not only because they allowed Epstein's suicide 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", Horowitz said in a video statement.
Horowitz's investigation, the last of several official inquiries into Epstein's death, echoed previous findings that some members of the jail staff involved in guarding Epstein were overworked.
He identified 13 employees with performance failures and recommended possible criminal charges against four workers. Only the two workers assigned to guard Epstein the night he died were charged, avoiding jail time in a plea deal after admitting to falsifying logs.
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Horowitz's report also revealed new details about Epstein's behaviour in the days before his death, including that he signed a new last will and testament while meeting with his lawyers two days before he was found unresponsive in his cell the morning of August 10, 2019.
Jail officials did not know about the new will until after Epstein's death, Horowitz said.
Few of the cameras in the area where Epstein was housed were making recordings of the images they captured due to a mechanical failure on July 29.
The prison had contracted for a camera system upgrade three years before his death, but it had not been completed, in part due to serious staffing shortages.
Meanwhile, Epstein was alone the night of his death, even though the prison's psychology department had informed 70 employees that he needed to be with a cellmate after his previous suicide attempt in July.
His cellmate was nevertheless transferred on August 9, with no action taken to replace him. Epstein was also allowed an unmonitored personal phone call the night before he was found dead, a violation of BOP policy.
Horowitz's report highlighted some of the many problems plaguing the Bureau of Prisons, many of which have been exposed by The Associated Press.
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The agency, the Justice Department's largest with more than 30,000 employees, 158,000 inmates and an annual budget of about $US8 billion ($12 billion), is plagued by severe staffing shortages, staff sexual abuse and criminal conduct, among other issues.
The Bureau of Prisons said it has accepted all eight of Horowitz's recommendations, has updated its suicide watch process and will apply other lessons learned "to the broader BOP correctional landscape."
The agency said it will review video to ensure correctional officers are making the proper rounds in restrictive housing and will require more paperwork when prisoners are kept alone in cells.
A warden must now be notified when someone is placed on suicide watch, the agency said. It is also requiring specialised training on suicide prevention.
"We make every effort to create a controlled environment within our facilities that is both secure and humane, prioritising the physical and emotional well-being of those in our care and custody," the Bureau of Prisons said in a statement.
Horowitz's report comes nearly four years after Epstein took his own life at the Metropolitan Correctional Centre in Manhattan while awaiting trial on sex trafficking and conspiracy charges.
It also comes weeks after the AP obtained thousands of pages of records detailing the wealthy financier's detention and death and its chaotic aftermath.
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Horowitz's investigators found no evidence to suggest anything other than suicide, echoing the findings of New York City's medical examiner's office, which determined Epstein killed himself, and a separate FBI investigation that found no crimes directly associated with the death.
No physical evidence supported any of the many conspiracy theories surrounding Epstein's death, Horowitz concluded, and none of the video captured from the cameras that were recording showed any indication of anyone else in the cell. Investigators probed for possible money changing hands involving guards but found no evidence of that, either.
The workers assigned to guard Epstein were sleeping and shopping online instead of checking on him every 30 minutes as required, prosecutors said.
Nova Noel and Michael Thomas admitted lying on prison records to make it seem as though they had made the checks but avoided prison time under a deal with prosecutors. They left the Bureau of Prisons in April 2022, agency spokesperson Benjamin O'Cone said.
It's the second time in six months that Horowitz has blamed a high-profile inmate's death on the Bureau of Prisons' failings.
In December, the inspector general found that management failures, flawed policies and widespread incompetence were factors in notorious gangster James "Whitey" Bulger's 2018 beating death at a troubled West Virginia prison.
The AP obtained more than 4000 pages of documents related to Epstein's death from the federal Bureau of Prisons under the Freedom of Information Act.
The documents, including a reconstruction of events leading to Epstein's suicide, internal reports, emails, memos and other records, underscored how short staffing and corner-cutting contributed to Epstein's death.
Epstein spent 36 days at the now-shuttered Metropolitan Correctional Centre. Two weeks before his death, he was placed on suicide watch for 31 hours after what jail officials said was a suicide attempt that left his neck bruised and scraped.
The workers tasked with guarding Epstein the night he died were working overtime. One of them, not normally assigned to guard prisoners, was working a fifth straight day of overtime. The other was working mandatory overtime, which meant a second eight-hour shift in one day.
Crisis support is available from Lifeline on 13 11 14.
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