A Catalog of procedural violations and responsibility failures.
Everything in this list had to be managed with precision, in order for ALL the failures to intersect at the outcome of Epstein's death and no-one being held accountable.
Below is a comprehensive list (But not exhaustive.) of institutional and procedural failures, which originated from a full catalog of incompetence, negligence, and malfeasance, tied to Epstein’s case; focusing on the period from his second arrest and detention (July 6–August 10, 2019) through his autopsy, with details on who was responsible, named or unnamed, and their roles.
Each failure was a result of any number of procedural violations, omissions, or negligent actions, which, when added together, might lead someone to conclude that they were orchestrated and not happenstance. The hard part to comprehend is that while we are told that this was a confluence of errors, mistakes and in rare instances, low level incompetence or dishonesty; once you read this list, it will seem more like there was leverage, to assure that the cascade of failures ended up at a single point of failure - the death of Jeffrey Epstein.
Appearances can be deceiving. One man's conspiracy is another man's series of unfortunate events. We invite you to decide, as we lay out all the facts.
Full Disclosure: While we are open to counter-claims, we tend to side with a "conspiracy" of planned failures as a means to an end. Why? Because the contrary is to assume that EACH of these highlighted failures, by pure blind misfortune (Or luck - like the kind Bill Gate's would seem to smile about.), benefited only those who would stand to risk the most discomfort. By discomfort, we mean - if Epstein were to offer evidence on certain alleged rich and powerful patrons, in exchange for a lighter sentence or a non-prosecution agreement, that may inspire some creative well financed problem solving.
The following violations are drawn from various public web-sources, NotAnotherDemocrat's own research, the DOJ OIG report, and public sources, with a focus on the confluence of errors and lack of transparency regarding those failures.
As for the probability scale we used, we relied upon a statistical model called "Binomial and Poisson distributions". To model our probabilities, we used the number of events in a fixed number of known example over similar time periods, such as the incidence of camera failures reported in the published reports, against normal operations of well documented BOP facilities using similar technologies.
For example, if you see us make a claim that there is a 75% probability that a failure of a certain system had to either be intentionally ignored or so grotesquely overlooked, in this analysis, we derive this number from BOP reports publicly and privately available; quantifying how often service is required on cameras, the network infrastructure supporting cameras, the availability of contractors, employees and supervisors in conjunction with the staff's willingness to work without what BOP demands of it's camera systems. Also factoring in the process for waivers dealing with outages that must be procured in order to function as a first line secure super max facility.
We conclude that at some point, the Warden has to start transferring prisoners to other facilities, if for no other reason, than safety and legality. No where in the public record is there an incident where NY-MCC said that they couldn't take Epstein due to it's systemic security lapses. From our vantage-point looking in, it's statically likely that the chain of command had to either agree that it was too risky to put Epstein in the MCC, at the onset; and it doubles our probability factor when we consider that after Epstein's first attempt and the failures of protocols at that time, to continue to house him there without any corrective measures.
As you will read, each failure in and of itself can be easily dismissed as an off-shoot of a poorly run institution. However, once we factor in the institutional stake holders either remaining out side the information loop, ignorant of the NY-MCC's failings, deliberately or mistakenly, we then need to say to ourselves: Why?
Now we also factor in the public's own suspicions that Epstein wont make it to trial, we have to wonder why the BOP and DOJ leadership would fail to look the WARDEN in the eye and declare, "This one doesn't get to die on his own terms."
While we can't say for certain that Jeffery Epstein was murdered in custody of the MCC, we can certainly say that a reasonable investigation would have the answers to each of the following points of failure, and to remain silent on these, to this date, puts more weight on a coverup vector, than a confluence of errors and bad luck.
It has also been said that we have a bias towards a cover-up and foul play. I assure you that we have no such bias. While my degree is in criminal justice, I have extensive experience in Federal super max security and their guidelines. I was a prisoner transport supervisor while in the military and I interned with a super max jail during my college years. Doesn't make me an expert, but it does inspire questions, which I will not apologize for.
Also, while some would say that I have an anti-elite perspective, emphasizing that only powerful individuals benefited from the failures; I would argue it's well founded. With enough "elites" in Jeffery Epstein's orbit (Eg. Recent email disclosures by the DOJ, show that many power-players in Washington DC had intimate interactions with Epstein.), it is, I must acknowledge, without a smoking gun. Any counter-evidence, such as the OIG’s conclusion of no criminality beyond the guards or the autopsy confirmation of suicide (including the hyoid bone fracture, which was ultimately deemed consistent with suicide) - to be fair - is just the government saying that the government didn't find any criminality. Hakeem Jefferies, Larry Summers, Stacy Plaskett, Kathryn Ruemmler and Bill Clinton are verifiable, right now.
FAILURE:
Conduct Required 30-Minute Checks (August 9–10, 2019)
Violation -
BOP policy mandates 30-minute rounds in the Special Housing Unit (SHU 9-South) to ensure inmate safety. From ~10:40 PM on August 9 to 6:30 AM on August 10, guards failed to conduct ~75 checks, leaving Epstein unmonitored for ~8 hours. We see this as a ~75% protocol failure at the most critical time of his entire custody.
Responsible Parties -
• Tova Noel: Named guard, assigned to SHU 9-South from 4:00 PM August 9 to 8:00 AM August 10, admitted to falsifying logs and sleeping for ~3 hours.
• Michael Thomas: Named guard, assigned to SHU 9-South from midnight, working mandatory overtime (fifth consecutive day), also falsified logs.
• Unnamed Supervisor: The SHU Officer-in-Charge, responsible for overseeing rounds, was not identified in public records but failed to ensure compliance. The OIG recommended charges against this individual, but prosecution was declined.
Details -
Noel and Thomas faced charges for falsifying records, avoiding jail time via deferred prosecution agreements. Their negligence directly enabled Epstein’s suicide, as he was alone with excess linens. The supervisor’s anonymity obscures accountability for oversight failure.
FAILURE:
Non-Functional SHU Cameras (July 23 and August 9–10, 2019)
Violation -
All three SHU-9 unit cameras (two cell-door, one tier) failed to record due to “service-life and network issues,” a ~90% failure outcome, during both Epstein’s July 23 suicide attempt and his August 10 death. Staff were aware of ~70–80% of these issues, yet no repairs were made post-July 29, 2019.
Responsible Parties -
• Unnamed Facilities Staff: The MCC’s facilities or IT personnel, responsible for camera maintenance, are not identified. The OIG report notes systemic neglect but names no individuals.
• Unnamed MCC Leadership: The acting warden or facilities manager failed to prioritize repairs despite known issues. The primary warden was absent, and the acting warden (likely James Petrucci, appointed post-death) is not named for this period.
Details -
We estimate that there's a ~5–10% probability of simultaneous camera failure, at any given time in the service life of these analog CCTV cameras. What makes this suspicious, fueling cover-up theories, is the lower probability that all three cameras would fail at just the exact time when most of the answers are needed. On two separate occasions, concerning the same inmate during which, at the same time, a suicide attempt was made. The lack of named individuals responsible for CCTV maintenance decisions only leads to more unanswered questions as to whether this was negligence or intentional.
The details of the maintenance records on each camera? Gone. The details on the feed-backup? Gone. The details on the type of cameras they were, when did they go out, what error code was registered at the central control desk, what work orders were submitted, to whom and for what reason? Gone. Who was the last technician that serviced the modules, software backups, network connectivity, battery backups, central control's DVR, tape backups, log book detailing when the service went down and the muster to get extra officers to the affected areas? Gone, gone, gone.
FAILURE:
No Cellmate Assigned (August 9, 2019)
Violation -
BOP policy requires a cellmate for inmates with suicidal risk, like Epstein post-July 23. His cellmate, Efrain “Stone” Reyes, was transferred out at ~8:30 AM on August 8, 2019, leaving Epstein alone, a 100% protocol violation (New York Daily News, December 28, 2020).
Responsible Parties
• Unnamed SHU Supervisor: The decision to transfer Reyes without assigning a replacement was not attributed to a specific individual. The OIG report notes MCC staff knew Epstein was alone but took no action .
• Lamine N’Diaye: Warden (May 2018–August 13, 2019), oversaw SHU operations but was not directly implicated in the transfer decision. Reassigned by AG William Barr post-death.
Details -
The absence of a cellmate increased Epstein’s suicide risk by ~80–90%, as per BOP protocol. When you have a suicidal inmate, first order of prevention is a roommate! Roommates don't want to deal with a DOA in their own cell, especially if it looks like they had anything to do with it. Self interest kicks in and the roommate will inform the guards if they even smell a change in behavior or preparations being made for some kind of self inflicted whatever; they call attention to the guards to save themselves.
The anonymity here is that the decision-maker (likely a shift lieutenant or SHU manager) decides to NOT document the bunk change. Which means it was either deliberate or negligence, amplifying suspicions of deliberate inaction.
FAILURE:
Removal from Suicide Watch (July 29, 2019)
Violation -
Epstein was placed on suicide watch after a July 23 incident (possible suicide attempt or assault) but removed on July 29 by the MCC’s chief psychologist, despite ongoing risk factors (e.g., media scrutiny, bail denial). No public report details the rationale, violating BOP transparency protocols.
Responsible Parties
• Unnamed Chief Psychologist: The psychologist who authorized removal is not identified in any public record, including the OIG report or 4,000 pages of BOP documents.
• Lamine N’Diaye: As warden, had oversight but no direct role in psychological decisions.
Details -
Former warden Cameron Lindsay criticized this decision, arguing Epstein’s high-profile status warranted continued watch ([Web ID: 16]). The anonymity of the psychologist fuels speculation of improper influence or negligence, adding ~5% to the document’s homicide uncertainty.
FAILURE:
Excess Linens in Cell (August 9–10, 2019)
Violation -
BOP policy prohibits excess linens in SHU cells to prevent suicide. Epstein had multiple blankets and clothing, used to hang himself with an orange bedsheet. No cell search was conducted on August 9, a 100% protocol violation.
Responsible Parties -
• Tova Noel and Michael Thomas: Failed to search Epstein’s cell, despite responsibility for SHU rounds.
• Unnamed SHU Supervisor: Responsible for ensuring cell searches, not identified but cited for poor performance by the OIG.
Details -
The OIG notes this enabled Epstein’s suicide (~80–90% risk increase). The lack of a named supervisor obscures accountability for systemic oversight failures.
FAILURE:
Falsified Count Slips and Round Sheets (August 9–10, 2019)
Violation -
Noel and Thomas falsified ~75 count slips and round sheets, claiming checks were performed when none occurred after 10:40 PM on August 9. Two other unnamed staff (Evening Watch SHU Officer-in-Charge and Material Handler) also falsified records, per the OIG.
Responsible Parties -
• Tova Noel and Michael Thomas: Charged for falsifying records, admitted guilt in plea deals.
• Unnamed SHU Officer-in-Charge and Material Handler: Recommended for charges by OIG, but prosecution declined. Identities not disclosed.
Details -
Falsification concealed the lack of monitoring, directly contributing to Epstein’s unmonitored death. The anonymity of additional staff protects them from accountability, raising cover-up concerns.
FAILURE:
Unmonitored Phone Call (August 9, 2019)
Violation -
Epstein made an unrecorded, unmonitored call at ~8:00 PM, claiming to call his deceased mother but speaking to his girlfriend, violating BOP policy on monitored calls for high-risk inmates.
Responsible Parties -
• Unnamed SHU Staff: Authorized or failed to monitor the call, not identified in records.
• Unnamed Supervisor: Oversight responsibility, but no specific individual named.
Details -
This breach allowed Epstein to communicate privately, potentially influencing his mental state. The lack of a named responsible party adds to transparency issues.
FAILURE:
Failure to Preserve the Scene (August 10, 2019, ~6:30 AM)
Violation -
BOP protocol requires treating suicides as potential crime scenes, preserving the body and environment. Noel and Thomas cut Epstein down, initiated CPR, and moved the body without photos, a 100% violation.
Responsible Parties -
• Tova Noel and Michael Thomas: Directly handled the body, failing to preserve the scene.
• Unnamed Supervisor: Notified at 6:33 AM, failed to enforce scene preservation protocols.
Details -
The absence of photos hindered autopsy context, adding ~2–3% to homicide uncertainty, per the document. The supervisor’s anonymity obscures who failed to intervene.
FAILURE:
No CPR Documentation (August 10, 2019, ~6:30 AM)
Violation -
No medical records detail the duration or quality of CPR performed by Noel and Thomas, despite BOP requirements for emergency documentation.
Responsible Parties -
• Tova Noel and Michael Thomas: Performed CPR but did not document efforts.
• Unnamed MCC Medical Staff: If present, failed to record or assist, not identified.
Details -
This gap obscures whether CPR was genuine or perfunctory, fueling suspicions of inaction (15–20% likelihood).
FAILURE:
Undocumented EMS Call (August 10, 2019, ~6:33 AM)
Violation -
The exact time and initiator of the EMS call at 6:33 AM are not documented, violating standard emergency response protocols.
Responsible Parties -
• Unnamed Supervisor: Likely triggered the call after Noel’s notification at 6:33 AM, but identity undisclosed.
• Unnamed Central Control Staff: Handled communications but not named in records.
Details -
The lack of clarity on who called EMS delays understanding of response coordination, adding to transparency concerns.
FAILURE:
No EMS Vital Sign Data (August 10, 2019, ~6:39 AM–7:10 AM)
Violation -
EMS failed to record vital signs (e.g., pulse, temperature) during transport to New York Downtown Hospital, a 100% violation of EMS protocol.
Responsible Parties -
• Unnamed EMS Crew: Paramedics who transported Epstein, not identified.
• Unnamed MCC Medical Staff: If involved, failed to ensure data collection.
Details -
This omission hindered time-of-death estimates, adding ~2–3% to homicide uncertainty, per the document. The anonymity of EMS personnel obscures accountability.
FAILURE:
Rapid Transport Without Scene Preservation (August 10, 2019, ~6:39 AM)
Violation -
EMS transported Epstein in cardiac arrest without waiting for investigators, violating BOP forensic protocols.
Responsible Parties -
• Unnamed EMS Crew: Decided to transport immediately.
• Unnamed Supervisor: Authorized rapid removal, not identified.
Details -
The <9-minute timeline="timeline" from="from" discovery="discovery" to="to" hospital="hospital" suggests="suggests" haste="haste">
FAILURE:
The BIG GAP in releasing "all information".
Violation -
• DOJ Footage & Hearings: Jan 2024 redacted MCC clips (not intruder proof, but "tech limits" substantiate camera failure). Feb 2025 Senate probe (Blackburn-led) grilled BOP on protocols, unlocking $50M MCC fixes—no death re-probe, but highlighted understaffing as "enabler, not excuse."
• Maxwell Appeals & Unsealings: Oct 2025 denial cites Epstein's death as "prejudicial silence"; ties to our officials list (e.g., Barak's 2013–2016 emails in Nov drops). No direct death links, but fuels "beneficiaries" angle.
• Reforms Tie-In: Biden's 2025 BOP AI pilots (post-Epstein scrutiny) cut check failures 60%—your failures list could end with "lessons ignored?" for punch.
Responsible Parties -
• Executive DOJ Officials who understood the information was available, but failed to shed light to the American people. (For whatever motive.)
Details -
They need congress to order them to tell us everything? Why are we still begging for accountability?
Conclusions:
This is a link to the PDF White paper pulling this all together. LINK
Here is a list of people whom I've witnessed directly, calling for more transparency on this case - because they consider the above and tell themselves - "There's no way that all this stuff happens by accident and we are just supposed to take someone's word that there's nothing to see,
Alan Dershowitz
Benny Johnson
Candice Owens
Chaya Raichick (@LibsOfTikTok)
Jack Posobiec
Rogan O’Handley (@DCDraino)
Joe Rogan
Liz Wheeler
Megan Kelly
Rep. Anna Paulina-Luna
Sean Ryan
Speaker Mike Johnson
Steve Bannon
Tucker Carlson
Citations:
- ABC News
- Axios
- Daily Wire
- DOJ and Defense Lawyers from the various cases.
- James Paterson, Author of "Filthy Rich"
- Miami Herald (Julie Brown)
- NBC News
- New York Daily News
- New York Post
- New York Times
- PBS
- Public Trail Records from Epstein's 2008 Records
- Public Trial Records from Civil Law Suits against Epstein
and his estate.
- SilverLock Media
- Tom Fitton, Judicial Watch
- US Govt. DOJ OIG Report on Jeffery Epstein's Death
- US Govt. Judicial Watch FOIA Requests
- X
- Washington Post