USDOJ/OIG Special Report
SUMMARY OF THE OFFICE OF THE INSPECTOR GENERAL'S REPORT:
"A REVIEW OF THE JUSTICE DEPARTMENT'S HANDLING OF THE
DEATH OF KENNETH MICHAEL TRENTADUE AT THE BUREAU OF PRISONS'
FEDERAL TRANSFER CENTER IN OKLAHOMA CITY"
This investigation by the Department of Justice Office of the Inspector General (OIG) examined the death of Kenneth Michael Trentadue, an inmate who died in the Federal Transfer Center (FTC) on August 21, 1995. Located in Oklahoma City, the FTC is a Bureau of Prisons (BOP) facility that temporarily houses federal inmates who are in transit to other facilities or who are awaiting parole revocation hearings. According to FTC correctional officers, at approximately 3:00 a.m. on August 21, they found Trentadue hanging by a bed sheet around his neck from a grate in his cell. FTC staff treated Trentadues death as a suicide.
Later that day, Trentadues body was taken to the Oklahoma State Medical Examiners Office (MEO), where an autopsy was performed. Because of the condition of Trentadues body, which was bloody, bruised, and lacerated, the Medical Examiner was not convinced that his death was a suicide. The Medical Examiner initially ruled the manner of death as pending.
Also on August 21, the FTC notified the Oklahoma City FBI (FBI/OKC) about Trentadues death. FBI/OKC opened a criminal investigation into the death, but that investigation, particularly in the first several months, was minimal. Trentadues family and the MEO, suspicious of the way the federal government was handling the case, raised numerous questions and allegations about the manner of his death. The family maintained that FTC employees or inmates had beaten and murdered Trentadue, and that the federal government was covering up the true manner of his death. This case subsequently received significant public attention, both in Oklahoma City and nationally. Various newspaper, magazine, and television reports raised questions about the circumstances of Trentadues death and the governments response.
In early 1996, the Criminal Section of the Civil Rights Division (CRD) of the Department of Justice began supervising the investigation in an attempt to determine whether Trentadue had been beaten or murdered. After CRD presented extensive testimony to a federal grand jury, it declined prosecution of anyone. In a press release dated October 9, 1997, the Department of Justice reported CRDs conclusions that the investigation failed to establish credible evidence that any BOP personnel violated federal civil rights laws and did not establish evidence that was inconsistent with a conclusion that Trentadue committed suicide.
CRDs conclusions did not end the controversy about Trentadues death. Aside from the continuing questions about how Trentadue died, substantial questions remained about the actions of BOP employees in responding to Trentadues death and the actions of the FBI in investigating the death. As a result, in October 1997, after CRD had declined prosecution, the matter was referred to the OIG for further review of the BOPs and the FBIs actions in this case.
After our investigation started, the Oklahoma County District Attorneys Office also began its own criminal investigation into Trentadues death. In a report issued in July 1998, the District Attorney concluded that Trentadue had committed suicide. Also in July 1998, the Oklahoma Medical Examiner amended his findings and concluded that Trentadue had committed suicide.
The OIG continued this investigation because of the many allegations that persisted about Trentadues death and how it was handled. We primarily focused on the alleged deficiencies in the BOPs response to his death and how the FBI investigated it. However, to address these issues more fully, we also attempted to determine what happened to Trentadue when he came to the FTC, including how he died. We also investigated many allegations raised by Trentadues family about CRDs grand jury investigation into Trentadues death.
During our review, we interviewed more than 230 witnesses, many more than once. Among the persons we interviewed were FTC employees, including the correctional officers who responded to Trentadues death; BOP employees who conducted an inquiry into his death; numerous inmates who had been in the FTC when Trentadue died; Trentadues brother, Jesse Trentadue, who made numerous allegations relating to his brothers death; several of Trentadues friends regarding his background and state of mind; the Medical Examiner and personnel from the MEO; and the emergency personnel who went to the FTC the night Trentadue died. Also, we interviewed FBI employees who conducted and supervised the FBIs investigation into Trentadues death. In addition, we interviewed the CRD attorneys who led the grand jury investigation.
We reviewed thousands of pages of documents from various sources, including the BOP, FBI, and MEO. In addition, we obtained two court orders granting us access to the information that had been presented to the grand jury. We also reviewed the FBIs entire investigative file. We consulted with a variety of forensic experts regarding the cause and manner of Trentadues death. We independently examined many of the tests conducted by the FBI on the evidence, and we consulted with outside experts to review some of those tests.
As a result of our review, we concluded, like the Medical Examiner and the Oklahoma County District Attorney, that Trentadues death was a suicide and that he had not been beaten and murdered by correctional officers or inmates. We did not find that the BOP participated in any conspiracy to cover up his death, as some have alleged. But we did find that the BOPs response to his death was significantly flawed. FTC employees made various mistakes, including delaying their entry into Trentadues cell, attempting to videotape the scene rather than immediately providing medical attention to Trentadue, failing to assess Trentadues condition properly, failing to inform the FBI expeditiously and fully about the circumstances of his death, and rushing to clean the cell the day of his death.
Similarly, we did not find that the FBI attempted to cover up the circumstances of Trentadues death. But we did find significant deficiencies in the FBIs investigation and handling of evidence. The FBI devoted insufficient attention to the case for several months, and mishandled and misplaced several important pieces of evidence.
We also concluded that three BOP employees and one FBI employee made false statements about their actions to their supervisors, to various investigators, or to the OIG in this matter.
This Summary briefly presents the major findings of our investigation. Our full report, which is 206 pages long and includes 17 exhibits, contains grand jury information as well as information that may be protected by the Privacy Act or that otherwise implicates the privacy of individuals. In addition, the full report contains information concerning prison procedures that could compromise the security of a federal institution. Pursuant to an order from United States District Judge Tim Leonard, we provided our report to the litigants in a civil lawsuit relating to Trentadues death. We have also provided our report to the Deputy Attorney General, and, pursuant to an order from United States District Judge David Russell, to the FBI, the BOP, and CRD so that they may consider any discipline or other corrective actions that we have recommended or that may be appropriate.
On June 10, 1995, Trentadue was arrested for driving while intoxicated while returning to California from Mexico through the San Ysidro Port of Entry. A computer check revealed that he was wanted on an outstanding federal parole violator warrant. Trentadue had been convicted in 1982 for the armed robbery of a savings and loan institution and had been released from prison in 1987. After his release, he had violated his conditions of parole, which resulted in a warrant for his arrest.
Trentadue was detained at the Port of Entry and was eventually transferred to federal custody. On August 18, 1995, he was flown to the FTC in Oklahoma City, in order to have a parole revocation hearing before the United States Parole Commission. When Trentadue arrived at the FTC, he was processed in the normal fashion, which included a screening for social, psychological, or medical problems. FTC intake staff who screened him noted nothing unusual about him. On August 18, Trentadue was placed in a cell in the general population, in the FTCs Parole Violators Unit.
Trentadue began exhibiting strange behavior while in that unit. The OIG interviewed inmates who were housed in the Parole Violators Unit with Trentadue between August 18 and August 20. They described his behavior as paranoid, agitated, and weird. For example, Trentadues cellmate in the unit stated that he acted upset and paranoid, and he began talking to himself and laughing. Others observed him pacing the cellblock in an angry and agitated way. Another inmate described him as acting crazy. A few said that Trentadue appeared disturbed and upset and that he appeared to want to provoke a fight.
On Sunday, August 20, at approximately 7:45 a.m., Trentadue approached a correctional officer and asked to be taken out of the Parole Violators Unit and moved to protective custody. The correctional officer called the FTC lieutenant who was responsible for approving requests for protective custody, and that lieutenant came to the unit and spoke to Trentadue. The lieutenant remembered Trentadue telling her that since his arrival at the FTC he had a feeling that things arent quite right and that his problems might have resulted from a case of mistaken identity. He stated that he had stepped into some shit. He would not clarify what this meant, but again asked to be placed in protective custody.
The lieutenant approved Trentadues request and escorted him to the FTCs Special Housing Unit (SHU), a segregation unit in which inmates are more closely supervised and monitored. Entrance to and exit from the SHU are strictly controlled. The SHU is divided into three sections, called pods, which contain approximately 30 cells each. Four officers are on duty in the SHU on each shift.
When the lieutenant took Trentadue to the SHU, she completed an Administrative Detention Order that documented the reason for placing Trentadue in the SHU. The lieutenant wrote on the form: Inmate [Trentadue] requested admission to SHU for his own protection. Inmate [Trentadue] believes other inmates are out to get him. Trentadue signed the form. SHU officers on duty took custody of Trentadue and strip-searched him, in accord with the standard procedure when an inmate is transferred to the SHU. The officers said they observed nothing unusual about Trentadue and detected no injuries on him. Trentadue was then placed alone in SHU cell A709. The SHU officers on duty on August 20 said they observed Trentadue in his cell alone, with nothing noteworthy occurring in the cell.
Four correctional officers were on duty on the midnight to 8:00 a.m. shift on August 21. At irregular intervals, two of the officers are required to conduct rounds. During rounds they walk through the SHU and look inside each cell to confirm that every inmate is in his cell and that nothing out of the ordinary is occurring. The officers are required to document these rounds by swiping a card through a card reader located in the hallway of each pod. According to the SHU card reader records, SHU officers conducted rounds on August 21 at 12:26 a.m., 1:58 a.m., and 2:38 a.m. The officers also conducted a count which verifies that all inmates throughout the entire FTC are present and accounted for at 1:00 a.m. and 3:00 a.m. on August 21.
The two correctional officers who went on the 2:38 a.m. round said they saw Trentadue during this round in his bunk and noticed nothing to cause them any alarm. One said he saw Trentadue lying on the top of his blanket with his sheet over his body. The officer saw Trentadues head, and nothing seemed out of the ordinary.
Two SHU officers conducted the count at approximately 3:00 a.m. As one of the officers was passing Trentadues cell, he saw Trentadue in the cell hanging by a bed sheet from the vent above the sink. The officer said he immediately called on his radio for help, but the radio malfunctioned. The other SHU officer conducting the count then called on his radio that an inmate was hanging. A third SHU officer immediately came to the cell.
Yet, these SHU officers did not enter the cell and bring Trentadue down. We found differing versions as to why they did not do so. The first SHU officer said that when he reached the cell, he was about to open the cell door but he was told by another officer that the FTC Lieutenant on duty that morning had called and instructed them to wait for him before entering the cell. The Lieutenant and the other officers did not remember this instruction. The Lieutenant said that when he was in the FTCs Control Room monitoring operations throughout the FTC, he heard a radio transmission that an inmate was hanging in the SHU. He told Control Room staff to notify FTC executive staff and then went directly to Trentadues cell. While on his way to the cell, the Lieutenant radioed to SHU staff to get a video camera. The Lieutenant said that when he arrived at the cell, several correctional officers were standing outside the cell door. He said he then radioed for a FTC physician assistant to come to the cell. The Lieutenant said that at that time he looked through the cell door window and observed Trentadue hanging, with his head slumped down, his hands at his side, with no movement at all. The Lieutenant said he believed that Trentadue was dead and therefore decided to document the scene with the video camera before entering the cell.
A video camera was located and brought to Trentadues cell. As a correctional officer began filming the scene, the Lieutenant introduced himself on camera and gave a brief description of the situation, stating that they had an inmate hanging in the cell. After this introduction, which we were told took anywhere from twenty seconds to two minutes, the officers unlocked the cell door.
There is some disagreement about who went into the cell first. One officer said that the camera operator entered the cell first and filmed the inside of it. However, the majority of officers said that a physician assistant, who had arrived at the cell by this time, entered the cell first and examined Trentadue while he was still hanging. The physician assistant said that when he entered the cell, he checked Trentadues pulse while he was hanging and detected no pulse. The physician assistant then placed his stethoscope on Trentadues chest and did not hear any breathing or heart sounds. The physician assistant then pronounced Trentadue dead. Trentadue was cut down and placed on a gurney. The physician assistant again checked Trentadue for a pulse and used his stethoscope to check for breathing and heart sounds, but did not find any.
Trentadues body was taken to the FTC infirmary. An Emergency Medical Services Authority (EMSA) paramedic and driver arrived at the FTC at approximately 3:32 a.m. The paramedic spoke to the physician assistant, who said that Trentadue was dead and there was no reason to provide medical services. The physician assistant stated that Trentadue had hung himself and had lacerations to his neck. The paramedic asked whether the physician assistant was pronouncing the inmate dead, and the physician assistant responded yes. As a result, the EMSA employees left the FTC.
When the FTC Associate Warden arrived at the FTC at about 4:00 a.m., he directed that EMSA personnel be asked to return. The Associate Warden met the EMSA paramedic when he arrived at the FTC the second time and convinced him to examine Trentadue and pronounce him dead. The paramedic examined Trentadue and saw that his skin was gray and he was not breathing. The paramedic noted that Trentadues head was bloody, with trauma to his forehead. The paramedic placed a heart monitor on Trentadue and at 5:06 a.m. pronounced him dead. The EMSA personnel then left the FTC.
Because the EMSA personnel did not take Trentadues body, FTC staff called the MEO to ask it to pick up Trentadues body from the FTC. A MEO investigator arrived at the FTC and saw Trentadues body in the infirmary. The MEO investigator said that she had never seen a hanging accompanied by a cut neck and head trauma, and she became concerned about the cause of Trentadues death. She asked questions about how Trentadue was found and how his injuries were sustained. She also viewed Trentadues cell through the cell door window. At approximately 7:20 a.m., she left the FTC along with Trentadues body, and went to the MEO.
During the morning of August 21, the Acting Warden of the FTC notified Trentadues family about his death. The Acting Warden also spoke with the MEOs Chief Investigator about Trentadues death. Although their recollections differed, the Acting Warden asked the MEOs Chief Investigator if the MEO had received the FTCs request to perform an autopsy on Trentadues body. The Chief Investigator said that the MEO would conduct an autopsy, but he expressed his concern that the condition of Trentadues body indicated that he did not commit suicide. He suggested that the FBI be notified about the death.
At approximately 5:30 a.m., an FTC Lieutenant responsible for conducting internal investigations of alleged BOP and inmate misconduct arrived at the FTC. After he was briefed about the matter, he went to the infirmary and took photographs of Trentadues body. The Lieutenant then went to cell A709 and took photographs of it. He also took custody of the videotape of Trentadue and put it in his office.
At approximately 7:30 a.m., the Lieutenant first attempted to notify the FBI/OKC about Trentadues death. The Lieutenant did not reach the FBI agent he was calling at this time and did not leave a message on his voice mail. At approximately 9:00 a.m., the Lieutenant and a technician began processing cell A709 for evidence relating to Trentadues death. They collected various items from the cell such as the blood-stained sheet used as a noose, a blood-stained pillowcase, a plastic knife, a pencil, two blood-stained tubes of toothpaste, and Trentadues personal papers. After processing the cell for evidence, the Lieutenant and the technician went back to their office, where they documented what they had collected.
Later that morning, the Associate Warden decided that Trentadues cell should be cleaned. The Associate Warden told the OIG that when he asked the Lieutenant who had processed the cell for evidence during the morning of August 21 if the FBI had been notified, the Lieutenant told him that the FBI had been notified and had instructed the Lieutenant to send it a report about the incident. In addition, the Associate Warden said that he had been informed by FTC medical staff that Trentadues blood count indicated a high probability that he was HIV-positive. (In fact, Trentadue was not HIV-positive.) The Associate Warden said he thought that the cell should be cleaned promptly because of the potentially infectious blood. The Associate Warden said that when he saw the Lieutenant again at approximately 11:00 a.m., the Lieutenant told him he was finished processing the cell for evidence and that it could be released. The Associate Warden said he therefore instructed the FTC Health Unit to clean the cell.
However, the FBI agent whom the Lieutenant had called said he did not speak with the Lieutenant until approximately 11:30 a.m. The Lieutenant later admitted to the OIG that he had tried to contact an FBI agent early in the morning of August 21, but did not speak to anyone at the FBI about Trentadues death until after he had processed the cell for evidence.
Moreover, when the Lieutenant spoke to the FBI on August 21, he did not provide full details about Trentadues death. Although recollections of the conversation on August 21 differed, the Lieutenant said he told the FBI agent that FTC correctional officers had found Trentadue hanging in a secure cell, that Trentadue had committed suicide by hanging himself, and that there was a little bit of blood. The FBI agent said that he was not told about any blood or the extent of Trentadues injuries. They agreed that the FBI agent told the Lieutenant to submit a report describing what had happened.
At approximately 1:00 p.m., FTC medical staff and inmates cleaned Trentadues cell. Just before the cleaning, the Lieutenant took additional pictures of the cell, including photographs of words written on the wall of the cell that appeared to state, My Minds No Longer Its Friend, Love Ya Familia.
The MEO performed an autopsy on Trentadue during the morning of August 21. Concerned about the extent of Trentadues injuries, the MEO Chief Investigator called the FBI to express his suspicions about Trentadues death and to suggest that it might have been a homicide, not a suicide.
An FBI agent and an FBI photographer went to the MEO during the afternoon of August 21. They viewed Trentadues body, took photographs of it, and collected evidence from the MEO, including the bloody sheet that had covered Trentadues body during transport from the FTC to the MEO, fingernail clippings, and swabs. After returning to FBI/OKC with this evidence, the FBI agent reported that Trentadues death could have been a homicide, and he turned over the evidence he had collected to another agent. The FBI opened a criminal investigation into Trentadues death.
The BOP also initially investigated Trentadues death. Following inmate deaths that appear to be a suicide, the BOP normally sends a team of BOP psychologists to identify any problems with the BOPs actions related to the suicide. The BOP team that went to the FTC on August 21 had become concerned that the incident memoranda prepared by FTC employees contained little information about the death and the FTCs response. The BOP team also learned about the delay in entering Trentadues cell and responding to him. The team therefore had the matter referred to the BOP Office of Internal Affairs, and the BOP convened a Board of Inquiry (BOI) to investigate Trentadues death. The BOI interviewed some FTC staff, but decided to end its investigation after approximately two weeks because of the FBIs open criminal investigation.
For the first several months, the FBIs investigation was minimal. The FBI first went to the FTC regarding this case on August 24, three days after Trentadues death. An FBI agent spoke with several FTC officials and received copies of the Lieutenants photographs of Trentadues body and the cell, but the FBI conducted no interviews that day. The FBIs first interviews of twelve FTC staff were conducted on August 28. The FBI did not interview any inmates at that time, did not examine the cell, and did not collect any evidence. In September and October, the FBI/OKC did little additional investigation. It sent out some requests to other FBI offices asking them to locate and interview Trentadue family members and several inmates who had been in the FTC on August 21 but were no longer there.
Beginning in November 1995, FBI/OKC supervisors became concerned about the slow pace of the investigation and tried to ensure that the case became a priority. In late November, a key event in the investigation occurred the United States Attorneys Office for the Western District of Oklahoma (USAO) was notified about the case by a Department of Justice official who had received complaints from the Medical Examiner about the BOPs and FBIs response to Trentadues death. The USAO scheduled a meeting with the FBI/OKC. As a result of this meeting, the USAO believed that the FBI/OKC was not actively investigating the case. The USAO suggested that the FBI consult with the Oklahoma City Police Department (OCPD), which had extensive experience in homicide investigations, and the USAO contacted the Department of Justice Civil Rights Division (CRD), which conducts and oversees investigations of potential criminal violations implicating federal civil rights statutes.
In December 1995, the FBI assigned another agent to assist in the investigation, and the pace and thoroughness of the investigation increased dramatically. In early 1996, CRD began to supervise the investigation and decided that the matter warranted presentation to a federal grand jury. In conjunction with the grand jury investigation, the FBI conducted numerous interviews of relevant witnesses, and CRD began presenting the evidence to the grand jury.
On October 9, 1997, the Department of Justice issued a press release announcing that
CRD was concluding its investigation into Trentadues death. The press release stated
that the investigation did not establish credible evidence that any BOP personnel violated
federal civil rights laws and did not establish evidence that was inconsistent with a
conclusion that Trentadue had committed suicide. The press release announced that the
matter was being turned over to the OIG. We began our investigation in October 1997.
To determine whether BOP staff committed any misconduct in connection with Trentadues death, we believed it important to determine the cause and manner of Trentadues death. We reviewed the physical evidence, examined the reports of the MEO and the District Attorney which concluded that Trentadues death was a suicide, conducted interviews of numerous witnesses, consulted with various forensic experts about what the evidence and forensic tests showed, and performed tests of our own. While we cannot know with absolute certainty what happened in Trentadues cell the morning he died, we concluded that the available evidence and the expert analysis of it demonstrated that he committed suicide and that he was not beaten or killed by BOP staff or inmates.
We reached these conclusions for several reasons. First, the Medical Examiners autopsy report suggested that injuries to Trentadues body could have been self-inflicted. We also concluded that Trentadue could have caused his injuries with the items available to him in the cell. According to a forensic expert we consulted, some injuries on his neck were consistent with a hanging and other injuries on his neck could have been caused by Trentadue attempting to cut himself with the items in his cell. Our expert also noted that the autopsy report revealed no defensive wounds indicating that Trentadue had been involved in a fight.
Second, the autopsy report revealed that Trentadue was alive at the time of hanging, and toxicology tests performed by the MEO on his body showed no evidence of any incapacitating drugs in him.
Third, the OCPD bloodstain pattern expert who analyzed the patterns of blood shown in the photographs of Trentadues cell taken on August 21 concluded that they were consistent with self-inflicted wounds, not with a beating. The expert also described in detail his opinion as to the most probable sequence of events, based on the available tests, reports, photographs, physical evidence, and the bloodstain patterns. The expert concluded that Trentadue first attempted to hang himself, fell from the sink during this attempt, attempted to cut his throat with a toothpaste tube, then successfully hanged himself with a bed sheet he put around his neck and attached to the vent grate above the sink.
Fourth, the OIG conducted a weight support test on a grate that was similar to the one in Trentadues cell on August 21. When we formed a ligature from a sheet similar to the one in Trentadues cell and threaded the sheet through the grate, we found it could support Trentadues weight.
Fifth, FBI Laboratory tests did not find anyone elses blood on items taken from Trentadues cell.
Sixth, we found no credible witness testimony supporting the claim that Trentadue had been beaten or killed, either inside or outside his cell, by someone else. Access to the SHU is subject to strict controls, and several officers would have had to be involved in a conspiracy to kill Trentadue and cover it up. We found no evidence of such a conspiracy. In addition, the FTC officers who responded to Trentadues death did not act as if they were involved in such a conspiracy they immediately summoned help and rushed to his cell. We also found their denials of any such conspiracy to be credible. Moreover, SHU officers passed polygraphs on the issue of whether they helped beat or kill Trentadue. Inmates who were in the SHU on August 21 also told us they did not hear or see any officers enter Trentadues cell or beat him, and they heard no calls for help or sounds of an altercation at any time before Trentadues death.
Seventh, Trentadues state of mind was not inconsistent with suicide. After having been out of prison since 1987, Trentadue faced a potential prison sentence of between eighteen and twenty-eight months, and possibly longer, according to a lawyer at the U.S. Parole Commission. Inmates described him as exhibiting unusual behavior in the Parole Violators Unit. He later sought protective custody, suggesting without explanation that he thought that someone was out to get him.
Eighth, on the wall of his cell directly behind where Trentadue was hanging, was a note written in pencil that appeared to state, My Minds No Longer Its Friend, Love Ya Familia. An FBI document examiner was unable to determine whether Trentadue wrote this, partly because of the lack of detail in the photographs of the wall writing. The OIG submitted additional samples of Trentadues handwriting to an INS forensic document examiner. He concluded that Trentadue probably made the wall writing and that his handwriting was totally consistent in the significant habitual handwriting characteristics portrayed on the wall. The OIG also obtained handwriting exemplars from the eighteen inmates who occupied Trentadues cell since the FTC first opened in 1995, all SHU staff on the shift before Trentadue died and the shift during which he died, and key FTC employees. The INS document examiner concluded that none of them had written the note on the wall. The wall writing provides further evidence that Trentadues state of mind was consistent with his committing suicide.
In sum, we concluded, like the Medical Examiner and the District Attorney, that the allegation that Trentadue was beaten and killed by others, either inside or outside of his cell, was not supported. Rather, the evidence showed that Trentadue committed suicide.
Although we concluded that no one beat or killed Trentadue, many critical questions remained about the BOPs response to his death. Our review found serious deficiencies in that response.
The correctional officers who discovered Trentadue hanging in his cell responded in a timely fashion. Within seconds, several SHU officers arrived at his cell and were poised to enter. Unfortunately they did not do so. Instead, they waited outside the cell for a Lieutenant to arrive. When he arrived, he looked through the cell door window and, based upon Trentadues appearance, assumed that Trentadue was dead. We believe that this assumption was inappropriate. The Lieutenant was not qualified or trained to make such a determination. As a result of his assumption, the Lieutenant ordered the scene videotaped. This was also inappropriate, because it delayed what should have been the first priority providing medical attention to an inmate. We cannot say when Trentadue hanged himself closer to 2:38 a.m., when he was last seen alive during the correctional officers round or closer to 3:02 a.m., when the officers found him hanging. But it is clear that it took at least six minutes from the time he was discovered hanging and the time that the officers entered his cell, and at least two more minutes, and perhaps more, before the officers brought him down. This delay was inappropriate. FTC employees should have ensured that Trentadue received medical attention immediately, not that the scene was videotaped.
We also concluded that the physician assistant failed to respond to Trentadues death adequately. As the FTCs medical authority on the scene, he should have instructed the officers to bring Trentadue down immediately and then he should have examined Trentadue, attempted to revive him, or determined if he would respond. Instead, the physician assistant examined Trentadue while he was still hanging, which was an improper way to assess Trentadues condition. The physician assistant also pronounced Trentadue dead before determining whether life saving measures could have revived him. This pronouncement was premature and also not within his area of responsibility.
The Lieutenant who notified the FBI of the death told his supervisors, the FBI, and initially the OIG that he first spoke to the FBI early in the morning of August 21. He eventually admitted to the OIG that he did not speak to the FBI until after he had processed the cell for evidence. Also, when the Lieutenant first spoke to the FBI about the death, he did not provide sufficient detail about the circumstances of Trentadues death such as a description of Trentadues injuries and the extent of the blood in his cell. The Associate Warden ordered the cell cleaned based on this inaccurate representation that the FBI had already been notified.
Because FTC staff viewed the matter as a suicide rather than a possible crime, this led to other problems. For example, it caused the cell to be processed for evidence inadequately. The FTC did not collect the evidence properly, photograph the cell sufficiently, or describe the evidence he had collected accurately. Some of the evidence was moved before photographs were taken.
We also believe that the FTCs rush to clean the cell was inappropriate, especially in light of the suspicions expressed to the FTC by the MEO about the condition of Trentadues body and the possibility that he had been killed. The hurry to clean the cell because of the concern that Trentadues blood might be HIV-positive and could infect others was misplaced, since the cell could have been sealed off. This rush to clean the cell was misguided and eliminated important evidence.
Various technical or administrative failures in the BOPs response also contributed to the conspiracy theories that arose after Trentadues death. For example, when FTC employees attempted to view the videotape taken of Trentadue and the cell, none of the recording showed up on the tape. This gave rise to allegations that the BOP had tampered with or destroyed evidence. We investigated this possibility, consulting with four experts in videotape analysis. Although one experts opinion differed, three of the experts did not find that the videotape was tampered with or erased. We concluded that the camera operator unintentionally failed to record the scene and that no one tampered with the tape.
The FTC also misplaced evidence, such as the original Administrative Detention Order (ADO) signed by Trentadue when he requested transfer to the SHU. The original ADO was missing for almost two years before the FTC found it. In addition, the FTC failed to properly identify where a SHU inmate had been housed the morning Trentadue died, which caused confusion when the inmate made up claims about what he had allegedly witnessed the morning Trentadue died. The FTC issued a press release shortly after Trentadues death that inaccurately stated that Trentadues death had been ruled a suicide by the Medical Examiner when the death had not yet been ruled a suicide.
We also found that there had been significant confusion among the BOP, FBI, and state and local authorities as to who had jurisdiction to investigate possible crimes at the FTC. The FTC is located on land leased, not owned, by the federal government. This created uncertainty about the jurisdiction of these entities to respond to and investigate deaths there. Because the FTC only recently had opened, no memorandum of understanding between the state and federal authorities addressed these issues. This matter was eventually addressed by a memorandum of understanding in 1997 among the FBI, the BOP, and the MEO, which set forth their respective responsibilities in joint investigations of deaths at the FTC.
Finally, we did not substantiate various allegations made by Trentadues brother, Jesse Trentadue, about other BOP actions. For example, we did not find, as he alleged, that the photographs of Trentadues body and the cell were taken on different days or that a watch in one of the photographs of Trentadues body suggested that the photograph was taken before the time correctional officers said they discovered Trentadue hanging. We did not find that the FTC attempted to prevent an autopsy of Trentadue or that credible evidence supported the claim that specific correctional officers beat Trentadue and then covered up their actions.
We carefully examined the FBIs investigation into Trentadues death and did not find evidence that the FBI attempted to cover up the true circumstances of his death. We also believe that the FBI, along with CRD, reached the correct conclusion that the evidence did not establish that Trentadue was beaten and murdered. However, we found the FBIs investigation, particularly in the initial stages, to be significantly flawed.
After the FBI first learned about Trentadues death, it responded in a slow and haphazard fashion. The FBI was notified by the FTC about the death during the morning of August 21. Although the FBI did not receive a full briefing about the circumstances of the death, the FBI also failed to inquire adequately about the details of the death and simply told the Lieutenant to send a report.
The FBI also learned from the MEO and the FTC on August 21 about the MEOs suspicions that the death was a homicide. However, no one from the FBI went to the FTC until three days later. On August 24, the FBI paid a brief visit to the FTC and did not even examine Trentadues cell. No one from the FBI interviewed any witnesses until August 28, a week after Trentadues death, and no inmates were interviewed at that time. Over the next two months, in September and October, the FBI conducted little investigation. Given the concerns of the MEO and the suspicious injuries to Trentadues body, the FBIs initial efforts on this case were lacking.
We found that the FBIs case documentation was significantly deficient and significant events were never documented. For example, the FBI failed to document the initial call from the FTC notifying it about Trentadues death, which would have aided in determining when that call was made and what was said. Other calls as well as trips to the FTC were also not documented.
The FBI/OKC failed to submit important samples of Trentadues handwriting to the FBI document examiner for comparison with the handwritten note on the wall in Trentadues cell. The FBI/OKC submitted only two forms that Trentadue had signed at the FTC. Those forms contained minimal samples of his writing. Yet, the FBI had been given letters that Trentadue wrote to his family shortly before his death that contained extensive samples of his writing. The FBI never submitted these letters to the FBI document examiner for comparison.
The FBI/OKC also waited several months until November 15 to collect evidence the FTC had retained, such as the bloody linens from Trentadues cell, the toothpaste tubes, the pencil, the plastic knife, and Trentadue's personal papers that had been found in his cell. The FBI/OKC first submitted evidence to the FBI Laboratory for testing on November 30, more than three months after Trentadues death. This submission was mislabeled and did not accurately describe what had been submitted.
The FBI/OKC also failed to recognize that a SHU inmate who claimed to have witnessed events in Trentadues cell on August 21 could not have seen what the inmate claimed because of the location of the inmates cell.
The FBI/OKC mishandled various pieces of evidence. On August 21, the FBI received evidence from the MEO, which included the bloody sheet that had covered Trentadues body during transport from the FTC to the MEO, fingernail clippings, swabs, and other evidence. We concluded that this evidence was not turned in to an FBI evidence technician until September 8, several weeks later. Afterwards, the sheet was not dried and stored properly and by the time it was finally submitted to the FBI Laboratory for testing on November 30, the sheet had putrefied and become unsuitable for testing. Moreover, the FBI never determined where this sheet had originated, despite distinctive markings that showed the sheet had been placed on Trentadues body by the company that transported his body from the FTC to the MEO.
The FBI/OKC misplaced the negatives of FTC photographs taken of Trentadues body and the cell on the morning of August 21. The FBI/OKC did not document its receipt of these negatives, and the FBI could not find the negatives for several years. As a result, various investigators and forensic experts were unable to use the negatives to make enlargements or enhancements of these critical pictures of the cell and Trentadues body. In March 1999, when the FBI/OKC was moving offices, the negatives were found in a moving box. The FBI/OKC also did not document its receipt and handling of other photographs, such as Polaroid photographs taken by the FTC of Trentadues body in the infirmary on August 21. These photographs were also misplaced. Post-autopsy photographs taken by the FBI at the MEO on August 21 were also not properly documented and were temporarily misplaced.
We believe that FBI/OKC supervisors share some responsibility for the deficiencies in the investigation of this case. FBI supervisors took insufficient steps to address the problems in the case until several months into the investigation. In addition, the supervisors initially classified the FBIs case as a possible crime on a government reservation, even though the FTC was not on federal land. In addition, the supervisors initially failed to classify the case as a civil rights case and failed to promptly notify the Department of Justices CRD about the possible civil rights violation when the case was opened.
Based on our review, we became concerned about broader problems in the way the FBI/OKC handled evidence in this case, particularly in the way that it documented the chain of custody of evidence. After the evidence control technician received evidence from an agent, the technician would prepare a computer-generated evidence form, fill in the chain of custody form, then send the form back to the agent, who would list when the agent had collected the evidence. This out-of-sequence procedure permitted disputes to arise as to the chain of custody of evidence and how it was handled. Several such disputes occurred in this case.
We recognize that some of the problems in the FBIs investigation of this case can be explained by mitigating circumstances. The top management of the FBI/OKC changed during the first months of the Trentadue investigation. More significantly, the April 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City and the investigation of that bombing drained enormous resources from the FBI Oklahoma City office and required massive attention. Yet, the problems we saw in this investigation were too numerous and too fundamental to be solely explained by these circumstances. The FBI did not treat the Trentadue investigation seriously enough in its initial stages, the FBI made significant mistakes in investigating this case, and FBI supervisors did not adequately address these deficiencies until several months later.
Our report also discusses briefly the problems we encountered in obtaining evidence and cooperation from the FBI/OKC during our review. The OIG received full cooperation from the BOP as well as from personnel in FBI Headquarters in Washington, D.C. The FBI/OKCs lack of cooperation was in marked contrast. It attempted to discount the importance of aspects of our review, and its responses to OIG document and information requests were consistently late. The responses we received were often incomplete or inaccurate.
A significant example of FBI/OKCs lack of cooperation was its response to our request for an original evidence form, known as the green sheet, that an FBI agent completed before he turned in the evidence that had been collected from the MEO to the FBIs evidence control technician. This green sheet was critical to resolving a dispute about the date that the agent turned in this evidence. When the FBI/OKC ultimately found the original of the green sheet, we requested it immediately. Yet, the FBI/OKC refused to provide the original to us, despite our repeated requests. The FBI/OKC stated that all we needed was a copy and that the original would be safeguarded. Eventually the FBIs Office of General Counsel in Washington instructed FBI/OKC to provide us with the original document. However, the FBI/OKC then informed us that it had just discovered that the original had been inadvertently destroyed. We investigated this matter. Although we did not conclude that the destruction of the original was intentional, we believe this incident vividly demonstrated the difficulties we faced in obtaining information and cooperation from the FBI/OKC.
We concluded that three BOP employees and one FBI employee made false statements under oath to their supervisors, to various investigators, or to the OIG in this matter. We referred this matter to the Public Integrity Section of the Department of Justice. After its review, it declined prosecution because of lack of prosecutive merit. However, we believe these false statements constituted serious misconduct, and have referred the matter to the BOP and FBI for appropriate action.
Jesse Trentadue raised numerous allegations about the way that CRD attorneys handled the grand jury investigation of his brothers death. Some media reports raised similar allegations. These allegations included claims that CRD attorneys and the FBI deliberately ignored evidence that Trentadue was murdered to bolster the suicide theory, that CRD attorneys knowingly provided false testimony to the grand jury, or that the grand jury was a sham and a whitewash.
We obtained complete access to the full grand jury materials and interviewed various witnesses about these allegations, including the CRD attorneys who conducted the grand jury investigation as well as Jesse Trentadue. Based on our review of the grand jury materials, the evidence, and our interviews of witnesses, we did not substantiate any of these allegations against CRD attorneys. We concluded that CRD attorneys conducted a substantial, good faith investigation into the circumstances of Trentadues death. We did not find that any CRD attorneys committed misconduct during the investigation.
At the end of our report, we made a number of recommendations in response to the problems we found in this case. With regard to individuals, we concluded that the three BOP employees and the FBI employee who made false statements committed serious misconduct and should receive significant discipline.
We also make various systemic recommendations to address the problems we found in this
case. For example, with regard to the BOPs response to Trentadues death, our
With regard to the FBI, our recommendations include:
This report reflects the OIGs exhaustive efforts to examine the cause and manner of Trentadues death, the conduct of BOP personnel in responding to that death, and the conduct of FBI investigators and CRD attorneys in investigating that death. We believe that the evidence showed that Trentadue committed suicide, that BOP employees or inmates did not murder him, and that BOP and FBI employees did not conspire to cover up the true circumstances of his death.
We also concluded that the BOPs response to his death was seriously deficient in various ways. Although BOP employees responded to Trentadues cell in a timely fashion, they inappropriately delayed entry into his cell, did not examine him properly, and did not immediately provide medical attention to him. The BOPs notification to the FBI about his death was late and insufficient. The BOP inadequately processed the cell for evidence and inappropriately rushed to clean the cell.
The FBI did not investigate the case adequately, particularly in the early stages. The FBI mishandled evidence, failed to document the case adequately, and made various mistakes in its investigation. These mistakes fueled the allegations that Trentadue was murdered and the government was engaging in a cover-up. However, based on our extensive review, we concluded that these allegations were not supported.