This June 23, 2011 booking photo provided by the US Marshals Service shows James "Whitey" Bulger.
Washington CNN  — 

The Justice Department’s Office of the Inspector General released a report on Wednesday outlining how a series of mistakes by the embattled Bureau of Prisons led to the beating death of imprisoned Boston gangster and convicted murderer James “Whitey” Bulger four years ago.

The report did not find any criminal acts by BOP employees. Instead, the report said that there were “serious job performance and management failures at multiple levels” within the bureau and found “confusing and insufficient BOP policies.”

Bulger was killed less than 12 hours after his transfer to the US Penitentiary Hazelton in West Virginia from another facility, according to the report. He was serving two life sentences for several crimes related to his reign over the South Boston criminal empire the Winter Hill Gang, including for the murders of 11 people.

Bulger had been placed in the general prison population, which gave inmates easy access to him. There, the mobster, known for his ruthless violence, was beaten by several men, one of whom was reportedly a hit man from Massachusetts.

The Justice Department has charged three inmates in connection to Bulger’s killing. They are charged with several crimes, including first degree murder by a federal prisoner serving a life sentence and false statements to a federal agent. They have pleaded not guilty.

The Inspector General’s office began their investigation into the circumstances around Bulger’s death after union leaders and correctional officers questioned the decision to transfer Bulger to the notoriously violent Hazelton facility, as well as the choice to place him in general population.

Critics have specifically pointed to the fact that Bulger – who was 89 and using a wheelchair when he was killed – had his level of medical care downgraded before transferring to Hazelton, despite earlier requests to transfer Bulger to a more intensive medical facility.

Bulger’s family sued prison employees after his death, alleging that prison wardens and other correctional officers were “intentional or deliberately indifferent” to the danger Bulger faced in prison, and that it appeared Bulger was “deliberately sent to his death.” A judge dismissed that lawsuit in January.

Based on their investigation, the Inspector General’s office suggested BOP make several policy changes, including suggestions to make medical paperwork consistent, modify guidelines about refusing medical care, streamline which staff members are made aware of inmate transfers, reassess which gangs are recognized by BOP and create specific procedures for unit assignments within facilities.

A BOP spokesperson said in a statement to CNN that the bureau has “initiated several improvements to its medical transfer system” since Bulger’s death, including enhanced communication between employees involved in the process and multiple trainings for personnel.

“The BOP appreciates the important work of the OIG and will be working closely with the office on future action and implementation efforts,” the statement said.

Medical mishandlings

According to the report, Bulger dealt with serious medical issues in the years before his death. Bulger was classified as what is called a “medical care level 3,” according to the report, meaning that he regularly sought treatment for a heart condition.

In 2018, Bulger allegedly threatened a nurse who was treating another patient at the facility, saying the nurse “gave me a heart attack due to yelling at me.” As a result of the threat, Bulger was moved to a special housing unit (SHU) and kept from other inmates as BOP staff attempted to transfer him to another facility.

It took the BOP eight months to finalize a transfer, according to the report. Officials initially attempted to move Bulger to another “level 3” facility but were unable to. Because the facility was desperate to offload him, the report says, individuals at the facility who were not intimately familiar with Bulger’s medical history used loopholes in their classifying guidelines to downgrade Bulger’s medical care level to “level 2,” noting that he had refused some treatments for his heart condition.

Bulger also appeared to suffer mental health problems from the eight months of isolation, according to the report. At one point during his isolation, Bulger told officials that he “had lost the will to live,” according to the report. The report does not indicate whether Bulger received any treatment for his declining mental health.

Rumors of his arrival

For several weeks before his arrival, rumors swirled about Bulger’s transfer to Hazelton.

According to the OIG report, “well over 100 BOP officials” were made aware that Bulger was being sent to Hazelton, including staff members at the facility who “spoke openly about Bulger’s upcoming arrival in the presence of Hazelton’s inmates.”

Inmates’ prior knowledge of his arrival, the report says, dramatically increased the likelihood Bulger faced imminent harm at Hazelton. Recorded phone calls and emails at the time included in the report show how inmates were prepared for what might happened when Bulger arrived.

One inmate interviewed by OIG said that because other inmates had a “beef” with Bulger and because he was viewed as a “rat” for working with the FBI, “both the inmates and the staff were speculating about – and inmates were betting money on – how long Bulger would stay alive at Hazelton.”

Gang affiliation and unit assignments

At the time of Bulger’s arrival, the manager of one of Hazelton’s housing units specifically requested that Bulger be assigned to his unit, the report says. The manager recognized Bulger from the FBI’s Most Wanted List, he told the OIG, and claimed to believe his staff was best suited to handle Bulger.

The manager chose where Bulger would stay based on several factors, he told the OIG, including his racial background, medical needs and gang affiliation. The manager claimed he was not a “gang expert” did not realize Bulger had “rivals” in the unit he was assigned to.

The manager’s request was approved, the report said, and did not require any “higher level” approval such as from the Warden.

Bulger arrived at Hazelton on October 29, 2018, according to the report, and underwent a normal intake procedure. According to his pre-screening forms and interviews with prison officials, Bulger claimed he had no conflicts with other gangs or groups and said that he had never assisted law enforcement – both of which were untrue.

Bulger told officials that he was a member of the Winter Hill Gang, according to the OIG report, but BOP guidelines did not officially recognize the Winter Hill Gang, one of the most notorious mobs in the Boston area, as an organized gang and no additional considerations were taken by prison officials to protect Bulger.

Officials told the OIG that Bulger was “really eager” to enter general population and stated during his intake screening that “I got two life sentences. I want to go to the yard.” When Bulger was being photographed during his intake, according to the report, he told an official “who knows, this might be my last picture.”

“Nine times out of ten if the inmate does not request [protective custody], we don’t usually make them take it,” one Hazelton employee told the OIG.

At least one employee pushed Bulger, asking the violent mobster and notorious snitch why he wouldn’t want additional protection.

“You sure to [sic] want to go to the yard, man?… I saw the movie,” the employee asked Bulger, appearing to reference either “The Departed” or “Black Mass,” both of which feature fictionalized depictions of Bulger and his rule over the Winter Hill Gang.

The employee said Bulger responded, “Don’t believe everything you see.”