An Army investigation found “multiple communication failures” regarding warning signs in the months leading up to reservist Robert Card committing the worst mass shooting in Maine’s history before killing himself in October.
Card shot and killed 18 people at a bowling alley and a nearby restaurant in Lewiston after a series of communication breakdowns among his military chain of command, civilian law enforcement and civilian hospitals treating him for mental health concerns, according to the investigation, publicly released on Tuesday.
In one instance, Four Winds, a hospital treating Card, found him to be at a “very low risk” of committing harm against himself or others despite his being admitted due to reports of psychosis, aggression and “homicidal ideations” such as having a “hit list.” He also “appeared resistant to psychoeducation, and he blamed others for his behavior.” He was discharged in August 2023 for unknown reasons.
Another communication failure came when Four Winds did not send discharge documents to the military medical system for eight days after Card’s release. Once received, the documents were not uploaded into Card’s medical record for another 10 days nor closely reviewed, “which would have revealed troubling information that could have been relayed to the chain of command.”
The Army Reserve has taken “adverse administrative action” against three officers in Card’s chain of command for “dereliction of duty,” a summary of the report states.
In total, the investigating team of a senior military intelligence officer, a military judge advocate, a nurse and an Army Criminal Investigation Division agent interviewed 43 witnesses and collected over 3,300 pages of documentation.
The report lays out a troubling series of events around Card, who served as a combat weapons trainer at the United States Military Academy at West Point, N.Y., for about two weeks a year, from 2014 to 2022. He was mainly an instructor on the hand grenade range and was never deployed or saw combat.
Card, who worked as a truck driver in his civilian job, had no recorded history of mental health issues and those in his unit considered him to be “a steady, average performer, who was ‘solid and reliable.’” He was also described as “kind, friendly, calm, and generous,” according to the investigation.
But in January 2023, family, friends and coworkers of Card noticed his mental health was beginning to decline when he “began to hear voices of people, often strangers, but sometimes friends, family, and coworkers, that he believed were ridiculing him behind his back, on social media, and directly in his presence,” according to the investigation.
Family and close friends tried to reassure Card that he was not being made fun of, but the “auditory hallucinations” persisted through March and April of 2023. By May 2023, his family reported at least four mental health incidents to a school resource police officer, and that he was believed to have “10 to 15 rifles and/or handguns” at his home.
Those reports were referred to local law enforcement, the Sagadahoc County Sheriff’s Office, who reported it to his chain of command in the Reserve. Card was still ordered to come to mandatory annual training in July as officials believed “his mental health challenges weren’t a detriment to his military job.”
Within 24 hours of reporting to annual training, however, Card showed signs of a “deteriorating mental state,” and his command ordered a behavioral health evaluation at the nearby Keller Army Community Hospital. An initial screening determined Card needed a higher level of care, and he was transported to the civilian hospital, Four Winds, on July 16.
The investigation later found his leadership should not have ordered him to the annual training and that they failed to conduct a line-of-duty investigation, which would have properly documented his hospital stay and condition, according to the report.
Card stayed at Four Winds for 19 days, was diagnosed with a “brief psychotic disorder” and prescribed psychiatric medications and follow-on treatments.
While at the hospital, Card’s chain of command attempted to coordinate the removal of guns from his home, “but they lacked the authority to legally compel the removal of any firearms or weapons.”
Card was released from Four Winds on Aug. 3 to a friend from his unit. The investigation was unable to determine why he was released as the hospital staff refused to speak with the investigating officer. That officer recommended in the report that the Defense Health Agency should consider removing the hospital as an authorized treatment facility.
On top of his discharge documents not being uploaded to the military medical system until Aug. 21, more than two weeks after he was let out, neither the civilian or military hospitals told Card’s chain of command of his discharge or follow-on care.
The documents included details about his mental state, including that he told medical providers he “decided to quit his job before he ended up killing someone,” that he was “sleeping 3-4 hours during the day.”
After his Aug. 3 release, Card, who was not in a duty status, “communicated increasingly violent, yet vague, threats and rhetoric to friends and family,” often describing how many people he could hurt with his weapons or what locations he could “shoot up.”
By Sept. 14, the voices Card heard impacted his mental health so much so that he violently assaulted his best friend who was in his reserve unit.
Realizing how bad things had gotten, the friend, whose name is redacted in the report, contacted the unit chain of command and relayed he was concerned Card would “snap and do a mass shooting,” according to a text message to the leadership.
Within 24 hours of that message, Card’s leadership informed local law enforcement of the threats as they were not on reserve duty at the time. Law enforcement then attempted to conduct two wellness checks on Card but failed to engage with him.
And on Oct. 17 and 19, the Army Reserve Medical Management Center attempted to contact Card to follow-up with him about his treatment and wellbeing but was unable to reach him.
Card eventually killed 18 people and injured 13 others on Oct. 25. He was found dead two days later from a self-inflicted gunshot wound.