However, based on evidence in the case, the State Prosecutor's Office could not determine that members of the Prison Service caused Ben Zygier's death due to reckless behavior and therefore no indictments will be filed.
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Listing the faults leading to Zygier's suicide, the report focuses on the nearly two and a half hours when Zygier was left unattended, between 5:52 pm and 8:13 pm.
It was during that lapse that he hanged himself in the toilet using a bed sheet.
Detailing that day's failures, Judge Dafna Blatman-Kadrei described how the Ayalon Prison's command
center was manned by only four Israel Prison Service (IPS) officers instead of the regulation five, due to a
The failure was "particularly noteworthy" due to a drill being held that day, which "increased pressure on the command center."
Furthermore, instead of working from the supervisor's room, Sergeant Major M.A., the man who was supposed to supervise Zygier's wing, worked from the command center.
Though he was still able to see the camera feed from Zygier's cell, the judge said "it meant a decrease in the level of supervision."
According to psychiatrists and social workers' opinions, Zygier was meant to be checked in on every 30 minutes, with check ups entered in the journal.
But the journal itself stayed in the supervisor's room while the officer was in the command center. M.A. wrote in the journal at 5:52 pm.
"M.M.M left the wing after locking the cell. Nothing to report."
The next entry from 8:13 pm relates lack of communications from Zygier. At 8:19 pm his body was found.
According to camera footage, suspect activity can already be seen at 6:54 pm, when Zygier rose from his
bed, turned on the television and then went to the toilet where he hanged himself.
The judge said it's impossible to corroborate M.A's evidence that he watched Zygier every half hour since he did not write the required journal entries.
According to the report, the three cameras offered only impaired vision. Nevertheless, the judge described that by careful attention Zygier's upper body can be seen, unmoving, in the toilet.
The inquiry report lists a number of officials as responsible for the discovered faults.
According to the judge, Sergeant Major M.A (responsible for the journal at the day of the incident) did not write entries and failed to notice suspect occurrences.
Major A.D (in charge of operations in the command center) did not follow the supervision protocol, did not confirm journal entries were made and allowed for manpower shortage in the command center.
Deputy Warder N.A (Security officer) did not keep the cameras in order and did not confirm Zygier was supervised.
Senior Warden A.A and Senior Warden S.A did not act to repair surveillance.
Social worker L.S did not recognize Zygier's mental anguish as unusual.
Nevertheless, State Prosecutor Moshe Lador said Thursday that the State cannot determine based on evidence in the "Prisoner X" affair that members of the IPS or any other outside individuals caused Zygier's death due to reckless behavior and there will therefore be no indictments in the case.
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