After nine months of tense and tearful public hearings and closed-door interviews, the commission investigating the Lewiston mass shooting finally shared its conclusions Tuesday about the failures that led to the massacre of 18 Mainers last October.

While the group’s 45-page report takes aim at how local police and the Army handled warnings about shooter Robert Card’s increasingly troubling behavior, it offers little analysis or criticism of how New York doctors handled his treatment last summer, and it does not include specific policy recommendations.

The commission, a panel of seven legal and medical experts handpicked by Gov. Janet Mills, affirmed its finding that the Sagadahoc County Sheriff’s Office should have done more to take the Army reservist into protective custody and confiscate his firearms under Maine’s yellow flag law a month before he opened fire in two Lewiston businesses.

The report also criticized the shooter’s Army commanders, particularly Capt. Jeremy Reamer, for failing to take steps to reduce the threat Card posed to the public, despite being “well aware of his auditory hallucinations, increasingly aggressive behavior, collection of guns and ominous comments about his intentions.”

“Although he might still have committed a mass shooting even if someone had managed to remove Card’s firearms before Oct. 25, 2023, there were several opportunities that, if taken, might have changed the course of events,” Chairman Dan Wathen said at a news conference Tuesday morning inside Lewiston City Hall.

The document also includes some new details about his time in two New York hospitals last summer and his discharge back into the community he would attack just two months later. His attending psychiatrist told the commission in a private meeting this month that Four Winds hospital reversed its initial decision to try to involuntarily commit him because doctors doubted whether their petition would be successful in court.

Yet while the report criticizes Sagadahoc County and Army leaders, it includes essentially no analysis or second-guessing of the hospital’s role in Card’s case, even though Wathen acknowledged Tuesday that he expected it would be the subject of future civil litigation. Nor does it include any policy recommendations aimed at preventing future mass shootings.

That decision, Wathen said, was made by Mills and Attorney General Aaron Frey when they first put the commission together last fall and tasked it only with determining the facts surrounding the shooting.

“Those (policymaking) responsibilities properly rest with elected and appointed officials,” he said. “We really want the report to speak for itself.”

HOSPITAL TESTIMONY

Because exemptions to Maine and federal freedom of information laws have prevented the public from accessing many of the police, Army and medical records that detail the gunman’s declining mental health, the story of the shooting has come to light piece by piece mainly through the commission’s 16 public hearings.

Much of the report restates familiar pieces of that timeline, beginning when Card’s family first reported his increasingly paranoid and aggressive behavior to police in spring 2023 and ending shortly after a tactical team discovered his body on Oct. 27 following a two-day manhunt.

It offers fewer details about the case’s last and greatest mysteries: the brain injury that might have been at the root of the reservist’s declining mental health, and the hospitalization that could have been his best chance at real intervention.

Recent public hearings focused on those questions, but those meetings also highlighted the difficulty of uncovering what exactly happened during his time at Four Winds. Tuesday’s report makes clear that the commission finally got some of those answers when members met behind closed doors with the psychiatrist who treated Card at Four Winds.

That doctor, Sarah Klagsbrun – who, according to the report, could not speak publicly due to concerns about New York privacy laws – said she considered six factors when determining whether Card was safe for discharge: his aggression risk, his homicidal risk, his suicidal risk, his behavior in the hospital, his protective factors versus risk factors, and his medication compliance. When Card, who on July 16 had told doctors that he had a “hit list,” filed a petition for release with a New York court in late July, the hospital filed a petition to involuntarily commit him.

But no commitment hearing ever took place. Card had initially resisted group therapy, Klagsbrun said, but he consistently took his medication and showed improvements. She determined that he could be safely released, which meant a court would likely not agree to hold him against his will.

Card told his doctors that he would take his medication (a prescription for the antipsychotic Olanzapine), engage in treatment and reach out to his family members for support – promises that he promptly broke upon his Aug. 3 release. When police searched the shooter’s home the day after the shooting, they found 53 pills remaining from the bottle of 60 that he had been sent home with.

Even though she had decided the reservist should be released, Klagsbrun also felt that prohibiting him from being around guns using New York’s SAFE Act was “a very important safety concern,” according to the report. She said she spoke to a doctor from Keller Army hospital about enacting the law, who thought that process was initiated, but no one ever actually took that step.

The commission’s report does not take a position on whether anyone at either hospital should have tried to use New York’s separate red flag law to confiscate the shooter’s weapons, though it questions whether that action would have been enforceable in Maine.

They did take time, however, to reinforce a stance included in the interim report that Sagadahoc Sgt. Aaron Skolfield should have used Maine’s yellow flag law to remove Card’s weapons – a point the deputy still strongly disputes.

“I did the right thing with the information that I had,” he said Tuesday. “I’m not looking to shirk responsibility in any way, shape or form. I’m looking at it through the lens of what I had known at the time.”

‘THE LONG ROAD TO HEALING’

Mills, who just weeks after the shooting gave the commission its mission to “determine the facts” of the case, said in a statement Tuesday that she will review the final report over the next week and then offer her views.

“Our ability to heal – as a people and as a state – is predicated on the ability to know and understand, to the greatest extent possible, the facts and circumstances surrounding the tragedy in Lewiston,” she said. “The release of the Independent Commission’s final report marks another step forward on the long road to healing.”

Frey also released a statement thanking members of the commission and said “their thorough, thoughtful and transparent investigation is invaluable in helping Maine move forward from this tragedy.”

“The commission has clearly met its mission: to conduct a full investigation of the events of Oct. 25 and determine the relevant facts,” he said. “Now, every Maine official should review this investigation, consider the commission’s findings, and evaluate the role they have to protect against such tragedy from occurring in the future.”

Members of Maine’s congressional delegation, who have pushed the Department of Defense to adapt its safety policies in the wake of new research linking soldiers’ exposure to explosive blasts with traumatic brain injuries, also released statements saying they are looking forward to using the commission’s factual findings to push for systemic change.

“I want to express my gratitude to the Lewiston Commission for their painstaking review of the timeline and missteps surrounding the shooting, and commend them for their contribution to helping us avoid a nightmare like this in the future,” Sen. Angus King, I-Maine, said in a statement. “As we move forward, these contributions will be invaluable to public safety and the peace of mind of our community.”

Rep. Chellie Pingree, D-1st District, said the moment “calls for action, not just reflection.”

“While the report rightfully holds the shooter accountable, it also underscores the need for better coordination between military and civilian authorities, particularly when it comes to managing reservists’ health,” Pingree said in a statement. “We must ensure that the recommendations from this report lead to real change – both in how we address mental health within our non-active military and in our broader efforts to combat gun violence.”

Attorneys for the victims of the families said Tuesday that the report once against underscores several systemic failures, particularly within the Army, that need to be addressed.

“The warning signs were so apparent,” attorney Travis Brennan said at a news conference outside Lewiston City Hall. “This could have and should have been prevented.”

But while lawyers and legislators are looking toward next steps, those personally touched by the shooting continue to struggle to adjust to their new present. For Megan Vozzella, whose husband Stephen was killed, every day since Oct. 25 has been a journey.

“There’s no way to just move on quickly,” Vozzella said, speaking in American Sign Language through an interpreter.

“We’ve gone through a lot of broken pieces. It’s like we’re walking through the shards.”

Press Herald Staff Writer Gillian Graham and Sun Journal Staff Writer Steve Collins contributed to this report. 

This story is part of an ongoing collaboration with FRONTLINE (PBS) and Maine Public that includes an upcoming documentary. It is supported through FRONTLINE’s Local Journalism Initiative, which is funded by the John S. and James L. Knight Foundation.

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