August 30, 2007
The toll in the April 16 massacre at Virginia Tech could have been lessened if authorities had canceled classes and promptly alerted students that a killer was on the loose, a panel appointed by Gov. Timothy M. Kaine says.
"But none of these measures would likely have averted a mass shooting altogether," a report released late Wednesday night on the governor's Web site concedes.
Virginia Tech should have notified students sooner of the first shootings on campus the day of the massacre and may have violated its own policies, the report says.
In perhaps the most damning conclusions, the report said police mistakenly thought the shooter was not on campus after the first two killings that morning and did not take correct action in dealing with the possibility they were wrong.
Tech's police department "erred in not requesting . . . a campuswide notification that two persons had been killed and that all students and staff should be cautious and alert," the report says.
Senior university administrators failed to issue an all-campus notification until almost two hours after the initial shootings, the report adds.
The document was released 135 days after a troubled Virginia Tech senior, Seung-Hui Cho, killed 27 students and five faculty members and then committed suicide. Seventeen others were wounded in the deadliest shooting rampage in U.S. history.
"There is a possibility that the additional measures would have dissuaded Cho from acting further," the panel's report says, "but he had already killed two people and sent a tape to NBC that would arrive the following morning with all but a confession.
"From what we know of his mental state and commitment to action that day, it was likely that he would have acted out his fantasy somewhere on campus or outside it that same day."
In all, the 260-page report contains more than 70 recommendations for colleges, mental-health providers, law-enforcement officials, emergency service workers, legislators and public officials.
In comments to reporters Wednesday before its release, Kaine said the report led him to conclude that neither Virginia Tech President Charles W. Steger nor campus police Chief Wendell Flinchum should resign.
He also said he was troubled that no one on the Tech campus knew of Cho's fascination with the Columbine High School killings, as detailed in the report.
Kaine's panel had no police powers and could neither order witnesses to appear nor demand documents from investigative agencies.
Kaine called the report "extremely thorough and fair" and said it will illustrate the many, many opportunities where Cho's deep problems could have been better served.
"I think there were a lot of instances where information was out there, or that different people had information where it needed to be put together, and I think obviously that is going to be a significant feature in the report," he said.
But Kaine stressed that the report's key objective is "accountability in the service of recommendations for improvement. And in that sense, the report does exactly what I asked."
Kaine dismissed speculation that newly discovered additional writings by Cho would have affected the panel's findings.
"Every next day or month or year might produce some other information," said Kaine, who added that the report's recommendations are "objective and fair."
The report points out that Cho, 23, of Centreville, exhibited signs of mental illness in his childhood and his middle and high schools "responded well to these signs and, with his parents' involvement, provided services to address his issues."
During his junior year at Tech, "numerous incidents occurred that were clear warning of mental instability," the report says, but "the university did not intervene effectively. No one knew all the information and no one connected all the dots."
Tech officials in various offices including counseling, campus police and the dean of students said they failed to communicate with each other or with Cho's parents because they believed this would violate federal privacy laws.
The study also says "Virginia's mental-health laws are flawed and services for mental-health users are inadequate." Also, there is "widespread confusion" over what state and federal privacy laws allowed, it says.
Cho bought two guns in violation of federal law, the report says.
Virginia law, it adds, does not clearly require that people like Cho, who had been ordered into out-patient treatment but not committed to a mental health institution, be reported to a federal database used to conduct background checks on gun purchasers.
The report points out that Tech and Blacksburg police and rescue squads responded quickly to the first shootings in West Ambler Johnston residence hall.
The presence of these officials there led them to rapidly respond to the first 9-1-1 calls about the shooting rampage two hours later at Norris Hall, the report says.
"The police response at Norris Hall was prompt and effective, as was triage and evacuation of the wounded. Evacuation of others in the building could have been implemented with more care," the report says.
It advises, "In order to advance public safety and meet public needs, Virginia's colleges and universities need to work together as a coordinated system of state-supported institutions."
State Sen. John S. Edwards, D-Roanoke, who is expected to be a point man in the General Assembly next year on legislative changes sparked by the shootings, said before the report was issued: "My sense is that it will be very factual but will leave people having to reach their own conclusions as to whether this was preventable or not."
From the beginning, the panel led by retired state police Superintendent W. Gerald Massengill was charged with producing a product that Kaine promised would be "independent and objective, and as public and transparent as possible."
But almost as quickly, issues emerged dealing with a tangle of federal, state and university-imposed privacy laws that inhibited or prevented communication about Cho's mental stability, about police investigative findings, and even the role of the Kaine panel itself.
At one point, the panel turned to private legal counsel, abandoning assistance by the state attorney general's office, when questions arose about the attorney general's simultaneous representation of Virginia Tech.
The eight-member panel, while holding multiple public sessions across the state, declined to release documents it had collected or often went into closed session, citing "an ongoing criminal investigation."
In the forward to the panel's report, Kaine made this observation:
"The magnitude of the losses suffered by victims and their families, the Virginia Tech community, and our Commonwealth is immeasurable. We have lost people of great character and intelligence who came to Virginia Tech from around our state, our nation and the world. While we can never know the full extent of the contributions they would have made had their lives not been cut short, we can say with confidence that they had already given much of themselves toward advancing knowledge and helping others."