It was a series of negligent unfortunate events and systemic failures that led to the death of gangster James “Whitey” Bulger in the hours after his transfer to a West Virginia prison in 2018, according to the oversight arm of the Department of Justice.

The Office of the Inspector General wrote in a new report released Wednesday that the prison transfer process Bulger went through was rife with issues and highly publicized — a break with protocol. Bulger also unusually received a new designation for a lower level of medical care when he was moved, despite no change in his medical condition, that would give the prison system more options for where to place him, according to the inspector general.

Three inmates have been charged with beating the 89-year-old to death with a heavy padlock while he sat in a wheelchair, less than 12 hours after arriving at the new prison.

No Bureau of Prisons inmate transfer should have been handled the way Bulger’s was, the watchdog said.

“The fact that the serious deficiencies we identified occurred in connection with a high-profile inmate like Bulger was especially concerning given that the BOP would presumably take particular care in handling such a high-profile inmate’s case,” the office wrote in its 99-page report.

Problems occurred “not because of a malicious intent or failure to comply with BOP policy, but rather because of staff and management performance failures; bureaucratic incompetence; and flawed, confusing, and insufficient policies and procedures,” the Inspector General’s office went on.

A prisoner ... said the "entire prison" knew of Bulger's arrival ahead of time, and that he heard officers talking about Bulger coming as if "they were talking about a football game."

Bulger gained notoriety for his criminal history as a violent organized crime leader in Massachusetts, and was on the FBI’s list of the 10 Most Wanted Fugitives for over a decade until his arrest in 2011. He was later convicted of several crimes in 2013.

He was recruited as an informant for the FBI in 1975 but continued his murdering spree.

The Office of the Inspector General called his death “suspicious” and raised a number of concerns.

For one, Bulger’s transfer to Hazelton was unusual due to his age, poor health and history as an FBI informant, along with the record of violence at the West Virginia facility, which should have raised red flags.

The decision to downgrade Bulger’s medical designation was a fatal one. Bulger developed a heart condition following his arrest and was ultimately classified as a medical care “level 3” inmate in January 2014 at an Arizona prison. He was moved to Coleman in Florida months later.

In April 2018, officials at the Florida prison submitted paperwork stating he needed to be transferred due to safety and disciplinary concerns, after he threatened a nurse. He was put in solitary confinement for eight months for the incident.

The watchdog said that it had concerns about the impact that Bulger’s lengthy stay in solitary had on his mental health.

“A September 2018 Psychology Services Suicide Risk Assessment that ’he had lost the will to live,’ and may have affected his persistence upon arriving at Hazelton that he wanted to be assigned to general population,” the report read.

When Coleman prison officials first sought a transfer, they requested another institution with the same level of medical care available. However, the Bureau of Prison’s regional director questioned whether he should be downgraded to expand the number of prisons he could be designated at. Coleman officials changed their request according to that recommendation.

Another Bureau of Prisons office raised concerns about the downgrade, but Coleman staff kept submitting requests for the lower level of care. The Bureau of Prisons designation office ended up choosing Hazelton for Bulger due to its proximity to Boston, where his family lives. The process violated its own internal policies.

A Hazelton official said the prison is able to “accommodate ‘medical cases’ because it is within ‘30 minutes’ of three hospitals, including a ’level one trauma center,’” according to the report.

Inmates and staff were acutely aware of Bulger’s impending arrival. His transfer was widely reported on before he arrived. Over 100 prison staffers knew about it from an email about incoming prisoners, and some were heard openly speaking about it, contrary to Bureau of Prisons policy.

A prisoner who spoke with the office said the “entire prison” knew of Bulger’s arrival ahead of time, and that he heard officers talking about Bulger coming as if “they were talking about a football game.” Inmates were betting money on how long Bulger could stay alive, he said.

The prisoner said that was because several inmates in Bulger’s soon-to-be home were part of the New York Genovese crime family, which had “beef” with Bulger’s Winter Hill Gang.

After Bulger arrived at Hazelton, he said, multiple inmates were “yelling” about Bulger being a “rat” for about an hour.

Bulger allegedly told supervisors he wanted to enter general population instead of being put in “SHU,” or solitary confinement, for his own protection.

“‘I don’t want to go to the SHU. I love everybody and I’m good with everybody. I don’t need the SHU. I just left the SHU,’” a member of Hazelton staff recalled Bulger telling her, per the Inspector General’s report. He was taken to a wheelchair-accessible cell in general population around 9 p.m.

Bulger’s cellmate exited the cell at 6:16 a.m, shortly after the cellblock was unlocked. The surveillance further showed that two individuals entered the cell housing Bulger at 6:19 a.m., closing the door behind them, and departed seven minutes later.

During rounds after later that morning, staff found Bulger unresponsive with visible injuries to his head and face. He was pronounced dead shortly after 9 a.m.

A Hazelton technician told the Inspector General’s office there were two “associates of organized crime families,” but none were from Massachusetts. One of those two, Fotios Geas, was ultimately one of the three individuals charged with first degree murder in connection to Bulger’s death.

The Office of the Inspector General said it didn’t find evidence of any federal criminal violations. It shared its report with the Bureau of Prisons to review the performance of the employees described for further action.

This story has been updated with further details about the Office of the Inspector General's report.