Ben Zygier, the former Mossad operative known as “Prisoner X,” was seen crying and distraught following a visit from his wife and daughter just hours before he killed himself in 2010, according to a court document made public on Thursday.

The document also says that at the end of the hour-long meeting at Ayalon Prison, near Ramle, Zygier tried to pass his wife a note but was stopped by a prison official. Zygier then tore up the note in rage before his wife was allowed back into his cell to speak to him alone for a few minutes. After she left the cell, she was in tears, the document said, adding that it appeared that during the meeting Zygier had received a message that left him distraught.

That same day, wardens received what they considered an out-of-the-ordinary call from Zygier’s attorney Moshe Mazor, who asked if his client was doing all right and if he could speak to him.

They put the call through, and Mazor spoke to his client but did not update the Prisons Service officials about anything out of the ordinary after the call.

These revelations are part of a December 2012 report by Judge Daphne Blatman- Kadrai, president of the Rishon Lezion Magistrate’s Court, which placed blame for Zygier’s death directly on the Prisons Service, saying it had caused his death by failing to carry out its responsibilities to ensure he did not cause himself harm.

Though much of the document became public in February, the rest was cleared for publication only on Thursday.

The report – which is based mainly on testimony taken from Prisons Service officers, both senior and low-level – paints a picture of the 34- year-old Australian-born Zygier as a man whom Prisons Service officials knew full well was emotionally distraught and in danger of harming himself.

From the beginning, the service’s psychiatrists ruled that he was a prisoner in need of supervision level B, requiring that someone check up on him every 30 minutes.

Prisons Service officers testified that a social worker had visited Zygier 57 times during the time he was in Ayalon Prison between March and December 2010. The officers said they would call the social worker whenever they observed Zygier crying in his cell, and she would typically come and visit with him.

The document includes testimony from the social worker about a time when, during a visit, she noticed a cut on Zygier’s hand, which he told her he had made to relieve some of the stress he was under.

On December 15, the day Zygier was found dead in his cell, hanging from a bed sheet tied to his bathroom window, Prisons Service officers called the social worker to tell her about his distraught condition after the family visit. The court document says that “since it was not the first time that the deceased was disturbed and crying after a phone call or family visit, she didn’t see the emotional outburst as a special incident and didn’t give an instruction in kind.”

The document also states that on November 29, 2010, a doctor sent by the Prisons Service saw Zygier, ruling that the prisoner’s emotional state was in decline and that he posed a threat to himself. On December 5, Zygier saw a psychiatrist, whom he reportedly told that he had stopped taking the antidepressants he had been prescribed.

The psychiatrist ruled that Zygier’s situation hadn’t changed and that he wasn’t displaying suicidal tendencies.

Based on the testimony of 10 Prisons Service officials – including the head of Ayalon Prison at the time, “Commissioner A.B.S” – the document concludes that the Prisons Service failed to carry out guidelines that could have prevented Zygier’s suicide, and therefore bears direct responsibility for the tragedy.

The officers whom the court interviewed stated that they had been short on staff, with only four people instead of the usual five manning the operations room, which surveys footage from 330 cameras. The report goes into detail about the conduct of “M.A.,” an officer who was in charge of the control room – a separate command post that contains far fewer cameras. The document states that M.A. left the room shortly before Zygier committed suicide, and was in the operations room when it happened. The document says M.A. left his log notebook back in the control room and did not fill it in during the time he was absent.

In addition, it says that while the operations room did include the footage from the cameras in Zygier’s room, camera 116, which covered the center of his cell and part of his bathroom, was not connected to the screens in the operations room – a fact that the officers on duty beforehand had known.

According to the document, M.A. left the control room at 5:52 p.m. and went to the operations room, leaving behind his shift log. At 8 p.m., he felt something was amiss and sent an officer to check on Zygier by intercom. He then went himself to to the control room, at which point he saw Zygier hanging from the shower.

“At 6:54 p.m., Zygier went to the bathroom, and until he was found at 8:13 p.m., the situation was suspicious and should have drawn the attention of the supervising officers,” the court document reads.

Since there is no record in the log during this time, the document states that there is no way to prove that the officer even looked at footage of Zygier’s room at all from the time he left the control room until Zygier was found dead.

Besides this, the report states, the cell’s infrared camera, which would automatically turn on after the cell’s lights went out, was very old and provided “zero visibility” of what was going on in the cell. The report says officers had brought this up with one of their commanders, who told them that it would require a civilian contractor to come in for half a day to fix the camera. The commander told the two officers to write a letter to his commanders, which he would forward. However, he said he had never received a letter from the two officers.

The report also includes testimony from officers who said they had been told that there was no budget to fix the cameras.

In her conclusion, Blatman- Kadrai states that “during the time of the incident, the means needed to carry out the special supervision of the deceased were not followed: The control room was not occupied, the supervisors’ journal was not filled out every 30 minutes from 17:52 until the body was found, it was known that camera 116 from the cell was not transmitting footage to the operations room at the time and that the cameras’ ability to film in a dark room was insufficient.”

She ruled that while Zygier may have been determined to end his life no matter what, “defending the deceased from such possibilities is done through command procedures which were not carried out.”

Blatman-Kadrai added that since a prisoner with Zygier’s profile could be expected to try to end his life, a meticulous series of steps must be taken to ensure he does not do so, and that the failure to do so could have legal significance.

On Thursday, in the wake of the court’s decision to release the full content of the document, the Justice Ministry released what appears to be a decision taken beforehand, not to bring criminal charges against any of the Prisons Service personnel or other persons who had responsibility for Zygier’s safety.

In the wake of the Rishon Lezion Magistrate’s Court decision to release the report on the circumstances of Zygier’s death, the Justice Ministry on Thursday released what appears to be a decision taken beforehand, not to bring criminal charges against any of the Prisons Service personnel or other persons who had responsibility for Zygier’s safety.

The decision, signed by State Attorney Moshe Lador, said that despite “deficiencies” in how Zygier was handled, the issue would only be submitted to the Prisons Service itself to decide at its own discretion whether to take internal disciplinary measures.

Lador said that overall there was insufficient evidence to prove criminal charges to the standard of beyond a reasonable doubt.

He added that there is no legal precedent for bringing criminal action against prison personnel for negligence relating to a prisoner’s suicide such as occurred here.

More specifically, Lador cited information to the effect that in 14 visits from psychologists and 57 visits from sociologists during nine months prior to Zygier’s suicide, virtually all of the professionals said that he was not a suicide-risk, seemed to be improving and maybe could even have his prison conditions relaxed.

This opinion was reaffirmed by professionals who met with Zygier only days before he committed suicide.

Lador’s statement noted that despite some extreme indications of Zygier’s instability following a meeting he had with his family on the day he committed suicide, little could be inferred regarding any criminal culpability for Prisons Service personnel when not all of the facts of that day were known by them in real-time.

He also said that the expert reviewing Zygier’s hanging of himself said he likely died within minutes or shorter, whereas the standing order to check his status every 30 minutes was followed by the Prisons Service.

Essentially, Lador’s point was that even with strong evidence of negligence by the service, it was unlikely that they could have intervened in time to prevent Zygier’s suicide.

Lador noted the court’s complimenting the Prisons Service in recent years in its efforts to reduce the number of suicides, but also said that “the tragic suicide of the deceased strengthens the need to further address this complex issues [of prisoner suicide] and to do all we can to reduce this phenomenon.”

Responding to Lador’s statement, the service said that “in keeping with the publication of the ruling by the magistrate’s court on the cause of death and in light of the lessons that have already been implemented in regard to this incident, the IPS [Israel Prisons Service] will examine the state attorney’s findings on this matter.

The Prisons Service added that it “would like to emphasize the tremendous effort undertaken in recent years to reduce the number of suicides among those in its custody. In this matter, the figures indicate a dramatic drop in suicides.”

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