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The Justice Department’s inspector general identified a series of “management and performance failures” among Bureau of Prison (BOP) employees that preceded the 2018 death of infamous mobster James “Whitey” Bulger in a West Virginia prison.

Three men were charged with conspiracy to commit first degree murder over Bulger’s killing, which occurred in October 2018 just hours after he was transferred to the Hazleton facility.

Bulger, an organized crime leader in Massachusetts, was on the FBI’s most wanted list for years prior to his 2011 arrest. He was convicted in 2013 on numerous charges, including his role in the murders of 11 people, and received two life sentences.

The inspector general’s report, released on Wednesday, did not find evidence of any federal criminal violations, but it scorches BOP’s downgrading of Bulger’s medical care level that led to his transfer and inmates’ prior knowledge of his arrival.

“In our view, no BOP inmate’s transfer, whether they are a notorious gangster or a non-violent offender, should be handled like Bulger’s transfer was handled in this instance,” the inspector general’s report reads.

Donald Murphy, a BOP spokesperson, indicated the bureau received the report.

“Subsequent to the events described in the [inspector general’s] report, BOP initiated several improvements to its medical transfer system including enhanced communication between employees involved in the process, multiple trainings for personnel, and technological advancements,” he said. “The BOP appreciates the important work of the [inspector general] and will be working closely with the office on future action and implementation efforts.”

Following his arrest, Bulger developed atrial fibrillation and began using a wheelchair as doctors frequently recommended him for hospitalization.

Bulger’s transfer came after BOP employees downgraded the level of medical care he needed, making Hazleton a compliant facility for his medical needs, according to the inspector general’s report.

The report details that the bureau’s chief of health programs had determined a downgrade was not appropriate, but employees at the Coleman prison in Florida where Bulger was housed at the time moved ahead anyway.

“Bulger’s transfer to Hazelton and placement in the general population appeared unusual in view of his age, his health, his notoriety and history as an FBI informant, and the record of violence among inmates at that facility,” the report reads. “His violent death less than 12 hours after arriving at Hazelton highlighted these concerns.”

The report also criticizes how multiple inmates became aware of Bulger’s impending arrival in West Virginia. The inspector general indicated well over 100 BOP employees knew about the transfer, and some spoke openly about it in front of the inmates.

“The transfer specifically to Hazelton raised additional questions because of the record of violence among inmates at Hazelton, which housed gang members and inmates with connections to organized crime,” it states. “Based on our review of incident records, Coleman was a safer facility.”