An internal investigation by the U.S. Army found multiple communication and procedural failures allowed one of its reservists to evade psychiatric treatment after he was released from a private psychiatric hospital less than three months before he committed the worst mass shooting in Maine history last October.
At the same time, Army investigators were unable to solve an enduring mystery about Robert Card, the gunman and Army reservist who was abruptly discharged from the New York hospital despite the hospital acknowledging in its discharge summary that Card expressed “homicidal ideations” and was resistant to treatment during his 19-day stay there. Specifically, Card told his providers that he had a "hit list," although it was the hospital's determination at the time of discharge that "he did not demonstrate a risk of harm to self or others."
The 115-page Army report is based on 3,300 pages of documents, as well as interviews with more than 40 witnesses. However, Army investigators found that not all potential witnesses were cooperative, specifically officials at Four Winds Hospital in Katonah, New York, where Card was hospitalized last summer. The report says hospital officials declined to speak with investigators, leaving longstanding questions about why Card was released from its care.
Overall, the report paints a portrait of a soldier displaying increasingly troubling and violent behavior, but who somehow managed to slip through the Army’s disjointed mental health system rife with communication failures. At one point, an Army investigator wrote that it was unclear whether Card’s release from Four Winds was because his command directive to seek treatment was set to expire, or if it was allowed to expire because he had been released by the hospital. The report also notes that Card's ability to access treatment after discharge whether "poor" and that he was released without any follow-up appointments — just "referrals pending."
The report echoes claims by Card’s Army supervisors during testimony to a state commission investigating the shootings that they have limited authority over its soldiers when they’re off duty. However, the report also found that the “preponderance of the evidence shows SFC Card was not properly released from his orders.” Such orders would have ensured that he stayed under commanders’ supervision and potentially lead to further treatment. It could also have limited his access to firearms. Card killed 18 people and injured more than a dozen others.
The report reveals for the first time that three of Card’s commanders have been disciplined for “dereliction of duty” and will no longer be able to receive promotions. The supervisors were not named in the report.
The report states that “unit leadership took several consistent and sustained actions to address SFC Card’s deteriorating mental state. However, there were also a series of failures within the unit leadership.”
Head of the U.S. Army Reserves Lt. Gen. Jody Daniels told reporters during a news conference that there were “communication breakdowns” among Card’s commanders that affected his continuity of care after he was discharged from Four Winds. Daniels was apparently referencing instructions to Card’s commanders that they take steps to follow his treatment plan from Four Winds, make efforts to remove guns from his home and begin a medical evaluation process that could lead to his discharge from the Army.
Commanders from Card’s unit have acknowledged to the state shooting commission that they did not take any of those steps.
The report also dives into the aftermath of Card’s unexpected release from Four Winds, surprising his family and fellow soldiers who had sounded the alarm about his increasing paranoia and violent behavior. While Four Winds notified Keller Army Health Clinic that it intended to release Card from its care on Aug. 3, the report says the private hospital did not send discharge instructions until eight days after he returned to Maine.
Additionally, the nurse at Keller who was responsible for uploading Card’s care instructions into his military record did not do so for an additional 10 days. Nor did she pass them along to his commanders. The report says the delays deprived Army leaders of learning “troubling information” about one of their soldiers.
Investigators also found procedures in some Army Reserve programs were not followed, including its Psychological Health Program, or PHP. They found that the PHP “did not adequately review” Card’s medical records before it closed his case. Instead, case managers closed his file based on a protocol that allows them to do so if a soldier is unresponsive to five attempts to reach him over a three-week period.
The report details attempts to reach Card and continue his behavioral treatment program. Card was either unresponsive or resistant, at one point accusing a case manager of posting derogatory statements about him on Facebook. On Oct. 23, Card was notified that his case had been reassigned. The new case supervisor tried to call Card on Oct. 24, the day before he carried out the mass shootings in Lewiston. According to the report, a male individual answered the phone, but immediately hung up.
Members of Maine's congressional delegation called for an independent review of the Army's handling of Robert Card. In a lengthy statement, U.S. Sen. Susan Collins said that investigations by the Army Reserves and the Army Inspector General have answered some important questions and raised others.
She pointed to what the report described as "multiple errors made by unit leadership, medical professionals and law enforcement" in the months before the shootings. Specifically, she said, the investigations show that more could have been done to trigger Maine's yellow flag law, a process that allows police to remove weapons from someone in a mental health crisis who may pose a threat to themselves or others.
And she said there were significant breakdowns in Card's medical care including with the Army's Psychological Health Program which Collins said had "inadequate procedures for following up with soldiers with mental illness." The PHP, for example, closed Card's case when he failed to respond to follow-up calls. Collins said that should have been considered "a warning sign that his mental health was deteriorating."
But some of the biggest remaining questions are about how and why Card was released from Four Winds, the civilian hospital in Katonah, New York. Card was transferred there on July 16 after undergoing a command directed behavioral health examination at the Keller Army Community Hospital.
According to the reports, Four Winds took steps to have Card involuntarily committed when he sought release. A court hearing was scheduled for Aug. 2, but Collins, who was briefed by Army Reserve leadership and the Army Inspector General, said Card dropped his request to leave and the court hearing was canceled. Yet, the very next day he was released.
"It is unclear why he was released and whether the hospital provided adequate care," Collins said. "That facility did not fully cooperate with the Army Reserve's or the Army Inspector General's investigations, so these key questions remain unresolved."
Collins said she will be tracking implementation of the recommendations contained in the reports, including a review of existing behavioral health policies and procedures, updating Army leadership training and expansion of the scope of the Army's suicide prevention program.
Meanwhile, the Army's investigation has been turned over to the Department of Forensic Psychology at the Walter Reed National Military Medical Center for review and analysis about whether Robert Card's care at Four Winds met the established Standard of Care. According the report, the results of that examination are pending.
