Investigation Finds Gross ‘Incompetence’ Led to Whitey Bulger’s Death

WASHINGTON — A remarkable succession of administrative errors, gross incompetence and health system failures inside the federal prison system led to the bludgeoning death of James (Whitey) Bulger hours after he was transferred to a West Virginia prison in 2018, the inspector general of the Justice Department has found.

The inspector general determined that officials in the federal Bureau of Prisons approved the downgrading of Mr. Bulger’s medical condition — even though they had determined he suffered from a life-threatening cardiac condition — for the sole purpose of moving him out of a secure unit in a Florida prison to the Hazelton federal penitentiary after he threatened a nurse.

They took minimal security precautions even though Mr. Bulger, 89, was widely known to have been a federal informant, which put him at heightened risk; they subsequently allowed word of his arrival to spread to hundreds of prison staff and eventually to the inmates who have been charged with beating him to death with a heavy padlock as he sat defenseless in his wheelchair, the report found.

Mr. Bulger’s death was preventable and resulted from “staff and management performance failures; bureaucratic incompetence; and flawed, confusing, and insufficient policies and procedures,” the Justice Department’s inspector general, Michael E. Horowitz, concluded in the damning 65-page report.

“In our view, no B.O.P. inmate’s transfer, whether they are a notorious offender or a non-violent offender, should be handled like Bulger’s transfer was handled,” he added.

The report into Mr. Bulger’s death did not uncover any specific indication that Bureau of Prisons employees acted with “malicious intent.” But investigators emphasized that the ongoing criminal probe by the Federal Bureau of Investigation and federal prosecutors could uncover any criminal wrongdoing that was beyond the scope of their efforts, which were aimed at identifying any needed changes in prison procedures.

While the report provides an exhaustive timeline of the bureaucratic failures that led to Mr. Bulger’s death, it is likely to raise as many questions as it answers about the underlying circumstances of the murder and the possible motives of three inmates charged in his death over the summer.

Mr. Horowitz is recommending the department discipline more than a half-dozen prison officials, and the report sheds new light on the actions of the unit manager at the Hazelton facility who volunteered to take the notorious Boston-area gang leader, citing previous experience in dealing with well-known criminals.

In August, three men were indicted for the killing, four years after Mr. Bulger died. Fotios Geas, Paul J. DeCologero and Sean McKinnon were charged with conspiracy to commit first-degree murder by the U.S. Attorney’s Office for the Northern District of West Virginia.

All three men were incarcerated with Mr. Bulger at Hazelton in Bruceton Mills, W.Va., where Mr. Bulger had been transferred to serve out two life terms for his role in 11 murders committed when he controlled Boston’s underworld for several decades.

Mr. Geas, 55, who is known as Freddy, and Mr. DeCologero, 48, known as Pauly, were also charged with aiding and abetting first-degree murder, as well as assault resulting in serious bodily injury. Mr. Geas faces an additional charge for murder by a federal inmate serving a life sentence.

On Oct. 30, 2018, less than 12 hours after Mr. Bulger was transferred to Hazelton from another prison, security camera footage showed at least two inmates rolling Mr. Bulger, who was in a wheelchair, out of view into a corner of a room. There, law enforcement officials said, he was beaten with a padlock stuffed inside a sock.

When guards found him — more than an hour after the attack took place, according to the new report — Mr. Bulger had been attacked so severely that he was “unrecognizable,” one law enforcement official said at the time.

Guards undertook lifesaving measures but Mr. Bulger was pronounced dead.