‘Several opportunities’ to prevent Maine mass shooting were missed, commission finds

An independent commission tasked with reviewing the shooting rampage in Lewiston, Maine, last October found the local sheriff’s office and leaders of the gunman’s Army Reserve Unit failed to take actions that might have prevented the shooting.

While Robert Card was “solely responsible” for the shootings – which left 18 people dead and 13 others wounded across two scenes – the commission’s final report found the Sagadahoc County Sheriff’s Office had probable cause to use Maine’s yellow flag law to begin the process of securing the gunman’s firearms in September 2023, the month prior to the shooting, but did not.

Additionally, the commission determined the leaders of Card’s Army Reserve Unit ignored recommendations by Card’s mental health providers to ensure weapons were removed from his home. The commanding officers also did not share with the sheriff’s office the totality of information about Card’s troubling behavior, which might have prompted them to change their approach, the report says.

“Although he might still have committed a mass shooting even if someone had managed to remove Card’s firearms before October 25, 2023,” the report says, “there were several opportunities that, if taken, might have changed the course of events.”

The Army Reserve conducted an investigation into Card earlier this year, spokesperson Bryce Dubee told CNN on Tuesday, which “found errors made by unit leadership, and recommended appropriate administrative action be taken against three officers in Card’s chain of command for dereliction of duty. This action has already been completed.”

Dubee added the investigation recommended updates to procedures and policies and the Army Reserve is also making changes to its psychological health program.

When asked about the commission’s findings that commanding officers ignored recommendations from Card’s mental health providers to ensure weapons were removed from his home, Dubee said the investigation noted “even if Card’s command had asked Card to store his weapons in a military facility, his commander had no authority to confiscate the weapons if SFC Card declined to surrender them.”

“We remain deeply saddened by these events and continue to mourn with the people of the State of Maine, the victims, and their families,” Dubee said.

CNN has reached out to the Sagadahoc County Sheriff’s Office for comment.

“All of us, and surely everyone here, wishes we could go back and change what happened in the months, weeks and days and minutes leading up to the tragedy on October 25th,” Daniel Wathen, the commission’s chairman, said in a news conference Tuesday. “We can’t. However, we can look forward.”

The report notes that the commission’s responsibility was not to suggest policy changes or amendments to state statutes, or propose operational changes for government agencies, but to follow the facts “so that the public, law enforcement, military leaders and elected and appointed officials can make informed decisions and reduce the risk of more such tragedies.”

“Our investigation and the information and findings set out in this final report are meant to bring truth to the victims’ families, to those who were injured and to the people of our state,” Wathen said. “We hope this truth will help the healing process while simultaneously enabling the public and policymakers to learn from mistakes.”

Gov. Janet Mills echoed that in a statement, saying Mainers’ ability to heal was “predicated on the ability to know and understand, to the greatest extent possible, the facts and circumstances surrounding the tragedy in Lewiston.”

“I look forward to closely reviewing the final report over the coming week,” Mills said, “and I will offer my views to the people of Maine after I have read and evaluated it.”

To reach their conclusions, the commission, which was granted subpoena power, interviewed witnesses, first responders and victims, according to the report. They reviewed thousands of pages of reports and records, hundreds of videos and photographs, maps, and hundreds more pages of text and email messages. Over the course of nine months, the commission held 16 public hearings, the commission reported.

“On behalf of the clients that we represent, this will be profoundly upsetting and saddening for them to learn that this could have and should have been prevented,” Travis Brennan, one of the attorneys representing victims’ families, said at a news conference Tuesday.

“People lost their husbands, people lost friends, people lost their fathers, and that can never be changed,” Brennan said. “But what we’ve heard repeatedly from our clients from the beginning is a desire to get all the facts and information about how this occurred.”

The report’s release comes on the heels of a separate review by the US Army released in July that said a series of failures and breakdowns in communication among Card’s military chain of command, civilian law enforcement and medical providers preceded the shooting. While noting Card’s commanders had “limited jurisdiction” over him – reservists are on duty an average of 40 days a year – three people in the gunman’s chain of command were punished, officials said at the time.

The commission’s findings released Tuesday echo an interim report released in March, which similarly said the sheriff’s office failed to invoke the state’s yellow flag law, which could have been used to disarm Card.

The law – a more relaxed version of the more widely known red flag laws in other states – was designed specifically for individuals like Card, who exhibited signs of a mental health crisis and demonstrated himself to be a threat, gun policy experts previously told CNN. But authorities instead relied on Card’s family to keep his guns from him after they tried unsuccessfully to speak with him, the interim report found.

Authorities say Card, using an assault rifle, went on a shooting rampage at a bowling alley and a bar on October 25, 2023, killing 18 people and wounding 13 others. Four of the people killed and some of the injured were deaf friends taking part in a cornhole tournament at the bar.

By analyzing security camera tapes at the bowling alley, the commission found Card fired 18 rounds in 45 seconds, killing eight people and wounding three others. At the bar, Card fired 36 rounds in 78 seconds, killing 10 people and wounding 10 others, according to the report.

A manhunt for Card ended two days later when he was found dead of a self-inflicted gunshot wound.

In the aftermath, the governor and Attorney General Aaron Frey announced the independent commission would review the shooting, including events that led up to it. Chief among them was a monthslong series of incidents that illustrated the reservist’s declining mental health and the mounting concerns of his family members, who repeatedly contacted authorities to voice concerns over his well-being and his access to firearms.

The report made the following findings:

Card’s 17-year-old son and his ex-wife first brought their concerns to law enforcement in May 2023, telling a school resource officer Card was hearing voices, exhibiting paranoid behavior and was having angry outbursts. The school resource officer reached out to the Sagadahoc County Sheriff’s Office, and a deputy contacted the senior non-commissioned officer in Card’s Army Reserve Unit.

Members of the unit had noticed behavioral changes in Card, the officer said, and told the deputy they would approach Card during an upcoming “battle assembly.” However, there’s no evidence that a conversation with Card was attempted.

In the meantime, Card’s sister also was seeking help. Between May and July, she left five voicemail messages at the Army Reserve unit to relay the family’s concerns. None of the messages was returned.

In July, getting in an argument with fellow reservists, Card was hospitalized at Keller Army Community Hospital in West Point, New York, where he was diagnosed with “unspecified psychosis.” The clinician recommended to Card’s commander that Card was unfit for duty, and that “measures be taken to safely remove all firearms and weapons.”

Card was then transferred to another hospital in Katonah, New York, where he was hospitalized for two weeks, the commission found. During that time, he acknowledged having a “hit list,” and upon his release in early August said he would participate in his treatment, take medicine and reach out to family and friends for help.

In September, a friend of Card’s informed his commanding officer that Card had assaulted him and threatened to “shoot up” his Army Reserve facility in Saco. The commanding officer, however, took no action and did not share the information with anyone else in the unit.

The report also details efforts by a Sagadahoc County Sheriff’s sergeant who made multiple unsuccessful attempts in mid-September to contact Card after concerns were raised by police in Ellsworth, Maine. However, the sergeant went on vacation after several days and considered the issue “resolved,” the report says. His supervisor deferred to the sergeant’s judgment.

The commission’s report found both the sheriff’s office and the leaders of the Army Reserve unit had multiple opportunities to “reduce the risk” of the tragedy that erupted on October 25.

The sheriff’s office could have sought an involuntary treatment order, and while it would not have prevented Card’s access to firearms, it could have bought them time, the report says. Additionally, the sheriff’s office had adequate information to leverage the yellow flag order – the information it had was “greater than the information forming the basis for many ‘yellow flag’ orders” Maine law enforcement had obtained prior to September 2023, the report says.

The commission also noted the sheriff’s office neglected to follow-up on the matter in October, when its new mental health liaison had been fully trained. The sheriff’s office would have learned, the report says, that Card’s mental health had not improved and that he still had access to weapons. If Card refused to cooperate with the liaison, the sheriff’s office would have had probable cause to take him into protective custody and initiate the yellow flag process.

Regarding the Army Reserve, the report pointed to the unit’s failure to sit down with Card in May and June 2023, its members’ failure to return voicemails from Card’s sister and the failure to follow up with Card after his hospitalization – which it described as “the appropriate first steps in getting Card evaluated and helped.”

Further, neither the Army Reserve Unit nor the sheriff’s office fully leveraged the breadth of mental health resources and assistance that were available, the report says.

The report also notes that medical personnel in New York could have filed a petition under the SAFE Act, which requires notification to county officials if a mental health professional believes a patient could cause harm to themself or others. That process can lead to the individual surrendering their firearms license and any weapons, or having them confiscated by police.

The commission, however, determined medical staff misunderstood the law, believing it applied only to New York residents. But the statute, the report notes, calls for the petition to be filed in the individual’s “county of residence,” and does not limit the action to New York.

This story has been updated with additional information.

CNN’s Amanda Musa, Rebekah Riess and Haley Britzky contributed to this report.