HARTFORD, Conn. — The Justice Department’s inspector general has concluded that it wasn’t “malicious intent,” but rather “bureaucratic incompetence” that was responsible for mob boss James “Whitey” Bulger’s brutal beating death when prison officials transferred him to a violent West Virginia prison and housed him with rival gangsters in 2018.
The long-awaited report by Inspector General Michael Horowitz found that months of “staff and management performance failures; bureaucratic incompetence; and flawed, confusing, and insufficient policies and procedures” led to the decision to move the frail, wheelchair-using 89-year-old gangster to the notorious federal penitentiary at Hazelton where he was discovered dead in his cell less than 12 hours after arriving.
By the time Bulger was moved to West Virginia from a Florida prison better able to care for his cardiac condition — against medical advice — far more than 100 federal bureau prison employees were aware of the move and prison staff at Hazelton had made the inmate population aware, a violation of U.S. Bureau of Prisons policy, according to the report.
Because news of Bulger’s transfer was so widespread, it is not possible to learn who leaked the information to the inmates, the report said.
Three Hazelton inmates — including a mob hit man from Springfield, Massachusetts — were charged in August in connection with Bulger’s death.
The report questions whether Bulger should even have been considered for transfer to Hazelton because of his medical history. In 2011, after his arrest in California after years on the run, he was diagnosed with a cardiac condition that led doctors to frequently recommend hospitalization and surgery.
In 2018, months before his transfer and death, Bulger was locked up at a federal prison in Florida where the report said he could receive adequate care. But in February of that year, he was punished for a rules infraction and threatening a prison nurse, by being removed from the general prison population and placed in a special housing unit. The punishment coincided with an eight-month-long effort by authorities at the Florida prison to transfer Bulger somewhere else, the report said.
The justification for the transfer was “safety and disciplinary concerns” and it recommended he be moved to a prison offering equivalent medical care.
The transfer request was the subject of discussion for months, with much of the talk centered on Bulger’s medical history and requirements, according to the report. Ultimately, staff at the Florida prison “did not follow” medical advice and filed another request to move Bulger to an institution with what the Bureau of Prisons calls Level 2 rather than Level 3 or 4 medical care. Level 4 is the highest level of care.
“The new request did not reference the ... determination that Bulger should be housed in a medical care Level 3 or 4 facility. It also did not mention the numerous additional cardiac and other medical incidents that Bulger had since February while housed in the Special Housing Unit,” the report said.
The BOP’s final decision was to move Bulger to the Level 2 Hazelton penitentiary, in part because it was closer than comparable institutions to his family in Boston.
While Bulger sat in a single punishment cell during the months administrators were deciding what to do with him, he reported on a 2018 prison system Psychology Services Suicide Risk Assessment that “he had lost the will to live” because of the isolation, according to the report.
The IG report goes on to suggest that Bulger’s loss of will may have contributed to his death, as demonstrated by his “persistence upon arriving at Hazelton that he wanted to be assigned to the general population” among rival New England gangsters with a motive to kill him.
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