Inmates placed bets on how long ‘Whitey’ Bulger would survive at prison. So why didn’t officials know of risk?

A booking photo provided by the Boston Police Department shows James "Whitey" Bulger after an arrest in Boston in 1953. A remarkable succession of administrative errors, gross incompetence and health system failures inside the federal prison system led to the bludgeoning death of Bulger hours after he was transferred to a West Virginia prison in 2018, the inspector general of the Justice Department has found.BOSTON POLICE DEPARTMENT/NYT

The inmates yelled “rat” for an hour after James “Whitey” Bulger arrived at the federal prison in West Virginia. Several of them had already placed bets on how long he would survive. One inmate later told investigators he assumed “multiple inmates would try to kill Bulger,” because of his notoriety as a former FBI informant, and a correctional officer allegedly predicted Bulger would not “last very long.”

“He was a rat,” an inmate told investigators. “What would you think would happen to him?”

The description of the prison scene before Bulger’s transfer to the US Penitentiary Hazelton in 2018, laid out this month in a Justice Department inspector general report, raises troubling questions about how Bureau of Prisons officials failed to recognize the dangers Bulger faced, when inmates knew very well that he would be a likely target, according to legal and criminal justice analysts who reviewed the report’s findings.

The inspector general described “serious deficiencies” by prisons officials that led to Bulger’s death, but the analysts placed greater blame on senior Bureau of Prisons officials who, according to the report, not only failed to protect Bulger but also made a series of missteps that allowed him to be transferred to Hazelton in the first place.

“This never should have happened,” said Zachary Hafer, a former federal prosecutor and member of the team that won Bulger’s conviction. “Even the worst human beings should be able to rely on the fact that the Bureau of Prisons will protect them when they are in custody.”

Bulger, who was sentenced to life in prison in 2013 for killing 11 people while running a sprawling criminal enterprise from the 1970s to the 1990s, was publicly identified in the late 1990s as a longtime FBI informant who provided information against local Mafiosi.

“He never should have been in general population, certainly not at Hazelton, given who was there,” Hafer said.

Bureau of Prisons officials did not respond to a Globe request for comment about the report findings, or say whether any employees have been disciplined for their involvement in Bulger’s transfer. He was beaten to death by fellow inmates on October 30, 2018 — less than 12 hours after he arrived at Hazelton.

Inspector General Michael Horowitz found that steps taken by prisons officials to assess whether Bulger faced harm from other inmates “were lacking.” Despite Bulger’s notoriety, for instance, prison policy didn’t require a specially trained senior intelligence officer to assess the risk at Hazelton.

But Horowitz concluded there was no “malicious intent” or evidence of any federal criminal violations by prison officials, even as he found bureaucratic “incompetence.” He provided his findings to the prisons agency with recommendations for improvements.

A lawsuit brought by Bulger’s family against the Bureau of Prisons was dismissed, though the family has appealed.

Meanwhile, in August, Fotios “Freddy” Geas, 55, a Mafia enforcer from West Springfield who is serving a life sentence for two gangland murders, and Paul J. DeCologero, 48, of Lowell, were charged with repeatedly striking Bulger in the head, causing his death. A third former inmate, Sean McKinnon, a Vermont native, was charged with serving as lookout during the brutal attack. All three men have pleaded not guilty to charges related to Bulger’s slaying and are awaiting trial.

The inspector general report detailed a months-long effort, riddled with confusion, by staff at Coleman penitentiary in Florida to get Bulger transferred to another prison after he was placed in the Special Housing Unit, or solitary confinement, in February 2018 for threatening a nurse. Bulger was in a wheelchair and receiving treatment for a chronic heart condition, but a senior prison official recommended lowering his medical classification, which would expand the number of facilities where Bulger could be transferred.

Another high-ranking official denied a request to lower Bulger’s classification, finding that he should remain at a Level 3 care facility — such as Coleman — because his heart condition required a higher level of care. But at least four Coleman officials filed false reports ignoring that finding and claiming that Bulger was no longer being treated for his chronic heart condition and should be transferred to a facility that provided a lower level of medical care, according to the report. As a result, prison officials changed his classification, paving the way for his transfer to Hazelton, which provided fewer medical services.

“I think they just wanted to get rid of him,” said Joe Rojas, president of Local 506, which represents prison workers at Coleman. “They’ll do whatever it takes to get rid of their troublemaker.”

Rojas said he believed criminal charges should be brought against those who orchestrated Bulger’s transfer by filing false reports and the “ultimate culprit” who approved placing him in general population at Hazelton.

“The reason they are not charged is because they are all executives,” Rojas said. “If it had been someone like me who made that mistake I would probably be in handcuffs doing time. The executives protect the executives.”

Rojas said Bulger should not have been kept in solitary confinement for eight months for what was a minor infraction.

“He was just a cranky old man; he was harmless,” Rojas said.

During a mental health screening the month before his transfer, Bulger said “he had lost the will to live” while in isolation, according to the report.

After arriving at Hazelton at about 6 p.m. on Oct. 29, 2018, Bulger denied during routine intake screening that he had been an informant and asked to be placed in general population, the report said. The IG found that officials who assessed Bulger’s security risk failed to consider his notoriety. One special investigative services technician said he treated Bulger “like any other inmate.”

Hafer said prison officials should not have given any weight to Bulger’s “self-serving” assertions that he wasn’t an informant.

“He doesn’t decide where he goes,” Hafer said. “You can imagine if you are the [Bureau of Prisons] trying to maintain the safety and security across the inmate population what a disaster it would be if the inmates themselves decided what their security classifications were and where they should go.”

Cameron Lindsay, a former warden at three federal facilities, said it was “a clear security failure” that prison staff talked openly around inmates about Bulger’s transfer to Hazelton before his arrival and “absolutely baffling” that he was placed in general population.

“This guy is going to come onto the compound and try to prove to the world he is still a tough guy at 89 years old and is not going to take protective custody,” Lindsay said. “This guy was arguably the Al Capone of our day. Why wouldn’t you know what was going on with him?”