The memorandum discusses the multi-level mortality review process conducted by the Bureau of Prisons' Office of Quality Management. It highlights the review of five mortality cases in the Northeast Region, including Jeffrey Epstein's death on 8/10/2019 at MCC New York. The review identified quality of care or risk management issues in Epstein's case, requiring a corrective action response. The document includes recommendations for improving AED monitoring and involving Health Services staff in suicide reconstruction reviews.
documents/EFTA00040957.pdf
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