The State Prosecutor’s Office on Thursday released for publication previously embargoed materials from the investigation into the cause of death of alleged Mossad agent Ben Zygier, also known as Prisoner X.
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Along with the release of the materials, the Prosecutor's Office announced that it would not serve any indictments against Prison Service personnel involved in guarding Zygier prior to his death while in detention at Ayalon Prison.
The materials in question deal with responsibility of prison personnel charged with guarding Zygier while he was jailed. The Prosecutor’s Office had asked the court to keep the material confidential until it had formulated its decision as to indictments. The change in policy regarding publication was made following requests by Haaretz and Channels 10 and 2.
Among the information revealed in the newly released investigation materials is the fact that Zygier had a history of unstable mental health and that he posed a danger to himself. The investigation materials also reveal events from the day of Zygier's death, including an encounter with his wife that left him in tears.
According to the investigation materials, Zygier himself reported that he had tried to commit suicide twice in the past. Despite this history, a psychiatrist told the Prisons Service that Zygier did not seem to be at risk of committing suicide.
Nevertheless, the materials indicate that both medical and security officials warned that Zygier must be kept under constant supervision.
"The deceased was held in secret conditions of isolation and compartmentalization, under an alias, in a separate wing comprised of a cell with toilet facilities, a shower, and an exit to a separate courtyard [wing 15], and under special supervision orders. The orders for isolation and compartmentalization were made in consideration of orders given by security personnel, who strictly dictated maintaining the utmost level of secrecy, and in consideration of the orders given by the doctor and social worker who examined the deceased's mental and physical condition and determined the constant supervision needed for him," the materials reveal.
The main details of a court decision following the investigation were released for publication in February, but without the clauses pertaining to the involvement of the Prisons Service personnel.
Rishon Letzion magistrate's court president, Judge Daphna Blatman Kedrai, ruled following the investigation that Zygier had taken his own life and that prima facie evidence had been found of Prison Service negligence in guarding him. The judge ordered the Prosecutor’s Office to consider filing indictments against members of the Prison Service, including high-level officials.
It was revealed in February that during the summations of the investigation process in court, the prosecution had argued that the case be closed since it did not involve any allegations of criminal activity. “At most,” argued the prosecution, “the investigation materials indicate flaws in the conduct of the Prison Service with regard to the guarding conditions and physical supervision of the deceased.”
Zygier’s family objected to the prosecution’s position and argued that a series of inadequacies had accumulated, causing death through negligence. The judge accepted their opinion and ruled that the state should reconsider its position.
According to the decision, “special supervision orders for preventing suicide risks were issued, and these were known to the people in charge of supervision and surveillance. These supervision orders were not carried out." Thus, a "suicidal window of opportunity" developed.
“Due to the sensitive security matter regarding the deceased, personnel members who took care of his incarceration were exposed only to the parts of information relevant to their work,” the judge wrote. Intelligence officer "A.A." served as the liaison between the security personnel and the Prison Service, and the social workers were responsible for the supervision orders to prevent suicide.
The decision reveals that upon Zygier’s incarceration, the intelligence officer issued orders by email to the prison commander and the Operations Branch officer. The email described Zygier as “a prisoner in isolation and distress” who should be under supervision 24 hours a day. After examination by a doctor and a social worker Zygier was classified as “a prisoner in level B psychological distress” – indicating the third of three levels of supervision, whereby intentional self-inflicted harm was a threat. Therefore the staff determined he needed special inspection every half hour.
According to the decision, for security reasons these instructions were not documented in the list of prisoners under supervision because of risk of self-inflicted harm.
During the period of his detention Zygier was under medical, psychiatric and social work supervision. He was examined by three different psychiatrists, he met with social workers and he was examined medically by general practitioners.
On March 7, 2010, a social worker administered a test that anticipates suicidal tendencies, in which Zygier reported suicidal thoughts and anxieties as well as psychiatric treatment he had received in the past. An external psychiatrist recommended drug treatment to calm him and improve his sleep and noted that during the examination he formed the impression that Zygier did not present a risk of suicide.
In a psychiatric examination on November 14, 2010, Zygier reported two previous suicide attempts and that he had been diagnosed as suffering from anxiety disorder. In the summary of his examination the psychiatrist noted: “There is no need for supervision in a psychiatric context,” and wrote that there was a need for a follow-up in two weeks.
On November 29, 2010, the chief medical officer of the Prison Service examined Zygier. She diagnosed that his mental state was low and that he was a danger to himself. He told her he was not taking the medications that had been prescribed for him. She contacted the security people and Zygier was examined by another psychiatrist. In the last examination on December 5, 2010, by yet another psychiatrist, it was found that there was no change in his mental and anxiety state, but it was determined that his behavior was not out of the ordinary and he was not having suicidal thoughts.
One of the social workers related that the wardens would contact her whenever they noticed that Zygier was crying or upset and she would meet with him or see to it that he be examined by a psychiatrist. On one of her visits she noticed a superficial cut on his arm and Zygier told her he had done this because of the pressure he was under and in order to calm down, but denied any suicidal intention.
According to the decision, “nearly all the wardens and professional personnel involved raised in their investigation a complaint about the implications of the compartmentalization on the absence of comprehensive knowledge about the deceased and his circumstances.” The judge wrote that there is scope for examining whether the compartmentalization “created obstacles relevant to the causation of his death."
Upsetting family visit
The decision includes an account of the events of the day of Zygier’s death: At 11:10 in the morning his wife and his small daughter entered the cell. At 12:05 in the afternoon they ended the visit and the non-commissioned intelligence officer who accompanied them out of the cell said he had noticed that Zygier was “crying, edgy and upset.”
The judge wrote, “The deceased asked to give his wife a note he was holding but the intelligence NCO refused and in resposne to this the deceased tore up the note and expressed anger. The wife of the deceased asked to allow her to enter the deceased’s cell again in order to try to soothe him and the intelligence NCO allowed this, in an exceptional manner.”
Zygier’s wife entered the cell again for a few minutes and when she came out the NCO saw that Zygier was crying.
The judge wrote that it emerged from the testimonies concerning the meeting between Zygier and his wife that she gave him some “bad news.” The judge did not specify the content of the news in her decision because there was no testimony that any of the prison personnel were exposed to its contents that day.
The NCO reported on the events to another intelligence officer, who in turn reported it to a social worker who instructed the jailers to devote special attention to Zygier. The social worker related that this was not the first time Zygier was found to be crying and upset after telephone conversations and visits from his family and therefore she did not see this incident as unusual.
Camera malfunction and manpower shortage
One of the prison wardens testified that on the day of his death, Zygier had also received an unusual phone call from his lawyer, Moshe Mazor. Mazor wanted to check if Zygier was all right in his cell and demanded to speak to him. The warden woke Zygier up and received permission from the assistant intelligence officer to connect the call. The conversation was not reported, nor was it properly documented.
That same day, according to the decision, a drill was held at the prison and the facility's control center was manned by four wardens rather than five due to a manpower shortage. As result, the supervisor of the isolated cells was dispatched from the supervision room, where he monitored Zygier, to the control center. He left the supervision room after documenting Zygier at 5:52 P.M., without taking the log of the wing along with him.
During questioning, the supervisor said he continued to observe Zygier from time to time by means of the control center cameras, but noted that he did not remember the exact times and did not record these instances in the log. According to him, he did not notice any unusual activity on Zygier’s part until just before 8:00 P.M., when he perceived something was not right. He then sent a guard to make contact with Zygier over the intercom. When Zygier did not answer, he went to the supervision room himself and discovered Zygier hanging in the shower.
According to the decision, the screens at the control center are linked to 300 cameras, making supervision of Zygier's wing less efficient. Furthermore, the footage from the camera documenting the shower in Zygier's cell wasn't streamed at the control center due to a malfunction. In fact, a review of the shower camera footage showed suspicious indications as early as 7:00 P.M.
“In the absence of a notation, it is impossible to confirm the claim that M.A. [the supervisor] observed the deceased every half hour. It is a fact that he was observing him when his suspicion was aroused. It is a fact that he did not see [Zygier’s] exit to the bathroom and that his suspicion was not aroused prior to the time indicated, despite there having been no change in the suspicious signs for over an hour,” the findings read.
At the end of her decision the judge wrote: “The obligations incumbent on the Prison Service are many and difficult to carry out. The obligations incumbent on Prison Service personnel in the matter of the deceased are especially difficult and complex in light of the layers of secrecy, compartmentalization, gaps in information and partial compartmentalization in the supervision orders themselves.”
“The evidentiary material shows that all prison service personnel who were on duty at the time of the suicide were working with the full intention to carry out their tasks, but tasks of supervising the deceased in accordance with the known instructions were not carried out,” the judge added.