Army investigation reveals series of failures ahead of Maine mass shooting carried out by reservist

(CNN) — A US Army investigation into Robert Card — the Army reservist who shot and killed 18 people in Lewiston, Maine, last year — found a series of failures and breakdowns in communication among Card’s military chain of command, civilian law enforcement and medical providers, occurred ahead of the mass shooting.

The investigation found communication failures “impacted [Sgt. 1st Class] Card’s continuity of care.” In one critical failure, military and civilian health facilities failed to upload Card’s discharge documents to the military medical system for more than two weeks after he left their care.

“The discharge summary included relevant and critical information which if it had been provided to the chain of command would have detailed the extent of SFC Card’s mental health issues,” the investigation report says. Among those details include that he “had homicidal ideations … appeared resistant to psychoeducation, and he blamed others for his behavior.”

The report also outlines several months of extremely troubling behavior by Card preceding the shooting, during which colleagues, friends, and family alike voiced concerns over his mental health and said they believed he was going to hurt others.

“I believe he’s going to snap and do a mass shooting,” Card’s best friend, whose name is redacted in the report, said in a text message to unit leadership in September 2023, a little over a month before Card would go on a shooting rampage, that also injured 13 people, at a local bowling alley and restaurant.

Card was found dead two days later with a self-inflicted gunshot wound.

In total, the investigating team interviewed 43 witnesses and gathered 445 exhibits of evidence. Chief of Army Reserve Lt. Gen. Jody Daniels told reporters Monday the team was made up of a senior military intelligence officer, a military judge advocate serving as a legal adviser, a nurse, and a criminal investigation division agent.

The investigation noted Card’s chain of command had “limited jurisdiction” over him given that Army Reservists are typically on duty in the military roughly 40 days a year.

Still, three people within Card’s chain of command have been punished, officials told reporters. It was unclear what exactly the punishment was; Daniels said she took “appropriate administrative action.” The investigation report said his leadership should not have ordered him to his annual training in July 2023 — during which he was hospitalized in a psychiatric facility — and that they failed to conduct a Line of Duty Investigation. The Line of Duty investigation would have “properly” documented his hospital stay and condition, the report said.

“Even though we are on a limited duty status, that doesn’t stop us from calling our soldiers and caring about them and checking in with them and seeing how they’re doing, and asking others to go and do those wellness checks,” Daniels said. “Good leaders care about their soldiers.”

Months of warnings

The breakdown in Card’s mental state is believed to have started in the fall of 2022, when he experienced “a series of emotional events and behavioral health challenges,” the report said, including auditory hallucinations, interpersonal conflicts, and beginning to use new hearing aids, the report said.

Card’s family first reported concerns over his mental health to law enforcement in May 2023, but prior to that, Card — an Army Reserve sergeant first class who worked as a truck driver in his civilian job — had no recorded history of suicide attempts or mental health issues.

Others in his unit “generally considered” Card to be “a steady, average performer, who was ‘solid and reliable,’” according to the investigation. Fellow service members described him as quiet, laid back, generous, and kind.

But in January 2023, his demeanor began to change. Card grew increasingly paranoid, not just of people in his unit but of total strangers, including a Dunkin’ Donuts employee he interacted with at a rest stop. 

Card’s family had reported at least four mental health incidents by May 2023 to a high school resource police officer, who referred the incidents to the local law enforcement agency, Sagadahoc County Sheriff’s Office. The report from Card’s family included that he was believed to have “10 to 15 rifles and/or handguns” at his home.

In July 2023, Card was ordered to attend annual training at the US Military Academy at West Point where he served as a weapons trainer for roughly two weeks every year between 2014 and 2022. Almost immediately upon arriving, Card remarked to colleagues that people were talking about him; within 24 hours of getting to New York for training, Card’s leadership ordered him to undergo a command directed behavioral health evaluation at an Army hospital.

At the Army hospital, officials believed Card needed a higher level of care, transferring him to a civilian hospital in the area, Four Winds, on July 16. The Army’s investigation said psychological testing at Four Winds revealed Card’s coping resources were “about as well-developed as those of most adults,” but that he exhibited narcissism, poor emotional controls, and an inconsistent coping style that they believed would impact the way he responded to things.

Card was ultimately discharged from Four Winds on August 3; the hospital’s discharge summary said he presented a “very low risk” of harming himself or others. But the individual who picked him up from the hospital told the Army investigating officer that Card told him he was “smarter than the Four Winds staff,” that he “flipped out” on a female patient who he believed was talking about him, and he was so angry about being in the hospital that “he placed his mattress against the wall and punched it until his hands become bloody.”

Despite Card being discharged on August 3, the investigation says Four Winds did not fax his discharge summary to the Army hospital until August 11, and it was not uploaded to the military medical system until August 21. It included details about his state including that he told providers he “decided to quit his job before he ended up killing someone” and that he had a “hit list.”

Card’s discharge from Four Winds also appeared to have impacted his unit’s ability to remove his personal firearms from his home.

Daniels said on Monday there were “multiple instances” of Army Reserve personnel requesting Card’s personal firearms be stored elsewhere, but that with private weapons, the Army Reserve “can request, we can ask, but we cannot compel that they store them anywhere … unless there’s been a medical determination, and in this case there was not because [SFC] Card was released by civilian providers to go home.”

Staff at Four Winds refused to participate in the Army’s investigation, the report says. The investigating officer recommended at the conclusion of the report that the Defense Health Agency should consider removing Four Winds as an authorized treatment facility.

Four Winds has not yet responded to CNN’s request for comment.

Between Card’s discharge from Four Winds and the mass shooting in October, the investigation outlined a number of other concerning incidents. Among them was a threat by Card to commit a mass shooting which was reported by his chain of command to local law enforcement. Law enforcement could not make contact with him at his home, and despite him being inside, the investigation says, law enforcement “did not force an interaction or attempt to employ the Maine Yellow Flag Law, which could have restricted SFC Card’s access to his privately owned firearms.”

Card’s family has since spoken out about their many concerns with his behavior. James Herling, his brother-in-law, told an independent commission investigating the shooting that we “can point fingers at who’s at fault, who has failed to make the ultimate contact, but in all reality, we all could have done better — from the sheriff’s office to the Army to the family.”

Footage from law enforcement released in December showed authorities speaking to an Army Reserve officer about Card and attempting to make contact with him at his home.

“They’re (Card’s family) worried about him doing a mass shooting,” a sheriff’s deputy is heard telling the captain in one of the videos from September, “and he’s having hallucinations, that he’d been institutionalized for a couple of weeks this past summer, and he’s not showing any signs of improvement.”

‘We’re doing the best we can’

In the days leading up to the shooting in Lewiston, the investigation said, Card “continued to withdraw from those around him,” accusing them of talking about him and ridiculing him despite continuous outreach from his family attempting to provide encouragement and support.

The Army Reserve Medical Management Center attempted to contact him in October to discuss follow-up treatment and check in on his wellbeing. The investigation says an individual attempted to contact him on October 17 and 19, but was unsuccessful in getting in touch.

On October 24, one day before the mass shooting, an individual called Card. A man answered the phone, but as soon as they asked to speak with Card, the person on the other end of the hung up.

On the evening of October 25, Card opened fire at Sparetime Recreation, a local bowling alley, and Schemengees Bar & Grille Restaurant. His body was located on October 27 in the back of a tractor trailer; the cause of death was noted as a “suicide (shot self with handgun).”

The Army’s investigation report said the service felt a “moral and ethical imperative” to investigate after the mass shooting.

Since October 2023, there has been speculation as to whether traumatic brain injury sustained during Card’s service may have contributed to his mental health decline. The investigation says Card did not deploy during his 22 years of service, and that while Card’s “Brief Psychotic Disorder” may have been “aggravated” by his military service and training during 2023, “this condition pre-dated SFC Card’s [annual training].”

The investigation also references a 2008 incident when Card fell off of his home’s roof and broke his neck — an incident that did not appear to be reported to the Army Reserve. Daniels said Monday Card’s fall is believed to have had a larger impact on his health than events during his service.

“SFC Card did not deploy or mobilize; therefore, he was not exposed to conditions found in a combat environment,” the investigation report said.

Ultimately, Daniels said going forward commanders and legal advisers will be re-trained on their authorities when it comes to private weapons and health privacy, and ensuring other service members who may have been impacted by the shooting had mental health resources available to them.

The Army Reserve is also undergoing a review of its behavioral health policies and standard operating procedures, and various issues have been reported up to broader agencies including the Defense Health Agency to improve case management procedures.

“My heart and soul goes out to all those families, the folks that were witnesses to what happened,” Daniels said on Monday. “We’re doing the best that we can in terms of understanding what did transpire and then make changes for the future.”

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