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did not return from court. The need for a cellmate was communicated between Day Watch (DW) and Evening Watch (EW) shifts in the SHU, but no cellmate was placed with him by the EW staff. According to a memorandum from Senior Officer Specialist [Redacted - (b)(6); (b)(7)(C)] SHU staff were informed at approximately 1:50 p.m. that Mr. Epstein’s cellmat would likely not return from court. Furthermore, Officer [Redacted - (b)(6); (b)(7)(C)] noted Mr. Epstein would need a cellmate upon arrival from his attorney visit.

A review of the 30-minute rounds forms indicate unit rounds were completed for the entire MW shift on August 10, 2019. However, a memorandum from Lieutenant [Redacted - (b)(6); (b)(7)(C)] indicates Officer [Redacted - (b)(6); (b)(7)(C)] and Material Handler Supervisor [Redacted - (b)(6); (b)(7)(C)] made a statement after Mr. Epstein’s death that they did not complete proper 30-minute rounds at 3:00 a.m. or 5:00 a.m.

DESCRIPTION OF SCENE
A detailed description of the scene was unavailable because the officers who discovered Mr. Epstein did not write memorandums and could not be interviewed. According to the Report of Incident, on August 10, 2019, at approximately 6:33 a.m., while serving the breakfast meal in the SHU, Range 9 South, Mr. Epstein was found unresponsive in his cell. Staff reportedly called for medical assistance, activated the [Redacted - (b)(7)(E)] and began life-saving measures. Arriving staff stated they brought an automated external defibrillator (AED) and stretcher. Cardiopulmonary resuscitation (CPR) reportedly continued while the AED was placed on Mr. Epstein. The AED reportedly indicated no shock advised and CPR was continued. Mr. Epstein was escorted to Health Services at approximately 6:39 a.m., and Emergency Medical Services (EMS) arrived at 6:43 a.m. He was transported to the local hospital at approximately 7:10 a.m. Mr. Epstein was pronounced deceased at 7:36 am. It was not possible to confirm this timeline without viewing video footage.

CONCLUSIONS/RECOMMENDATIONS
A general appreciation of risk factors for suicide specific to sex offenders is necessary when reviewing Mr. Epstein’s death. These factors, as well as more general risk factors for suicide, were likely present. There are several common factors that increase risk for suicide in individuals with a history of a sexual offense. These include stigma due to the nature of sexually-based crimes (both within society and the prison system), a disruption of the ability to utilize sex as a coping mechanism (which can lead to increased levels of distress and negative affect), and grief about loss experienced in regards to arrest. This grief may be secondary to the loss of former lifestyle, loss of physical items or collections related to sexual offenses, and/or the loss of perceived relationships with victims. Other factors that may increase risk for suicide among individuals accused of a sex offense include safety concerns, potentially long sentences, and lack of skills necessary to navigate social relationships in prison.

Mr. Epstein was a high-profile, pretrial detainee awaiting trial on sex trafficking offenses. He had been a successful, wealthy businessman with a number of high-profile acquaintances that he accumulated through a combination of charisma, charm, and intelligence. Despite his many associates, he had limited significant or deep interpersonal ties. Although Mr. Epstein appeared

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