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‘Signals were missed’

August 31, 2007

By Pamela StallSmith & Bill McKelway

A blistering assessment of mental-health and campus security issues released yesterday as part of the Virginia Tech massacre report could spur profound changes in Virginia and across the nation.

From security devices to a deeper knowledge of an incoming college student's personal background to simple word changes in state laws, Gov. Timothy M. Kaine yesterday promised a vigorous review on multiple fronts.

"As we move forward in the coming weeks, we will closely review all of the recommendations in the report to determine what will be required to implement them," Kaine said on national television yesterday from Capitol Square in Richmond.

Kaine said a report that took more than four months to assemble, covers 321 pages, and lays out 91 recommendations focuses on a basic failure to communicate on many fronts.

"Dots were not connected and signals were missed," the governor said, describing systemic failures to address gunman Seung-Hui Cho's mental problems and Virginia Tech's failure to promptly alert students to the severity of danger on the campus April 16.

The report called the tragic day "the 9/11 for colleges and universities" and gives an unvarnished assessment of the school's and state mental-health system's failure to address gunman Cho's many problems.

Firm and unbending in his promise to present an objective report that he said followed the truth, Kaine said "a fair reading of this report will demonstrate there is accountability here."

The report lauds heroic attempts by medical and law-enforcement responders to save the lives of Cho's more than four-dozen victims. It tracks Cho's life and a bloody death that was hastened by failed communication, a broken mental-health system and contrary responses to danger signs by Tech teachers and counselors.

Reaction was mixed among the families of victims; defensive from Virginia Tech officials; and supportive from mental-health advocates, who view the report as a call for overdue reform.

"I know the families don't believe there is accountability," said Greg Gwaltney, a Chesterfield resident whose son Matthew died in the attack. "The families expected specific names named."

Holly Sherman, whose daughter died, told CBS News last night that Tech still is not facing up to its liability.

In Blacksburg, school officials said they didn't do anything wrong on April 16 and did the best they could with the information available at the time.

"The focus of the report is to fix any problems identified so we can avoid this happening in the future," Kaine told reporters, declining to address the potential for litigation from the attack or calls from some people for the resignation of Tech President Charles W. Steger.

"If I felt those fixes demanded personnel changes, I wouldn't hesitate to suggest them," Kaine said.

Some family members criticized the report, saying it didn't go far enough laying the blame in the right place.

"You don't want the police to be the scapegoat here," said New Jersey security specialist Vincent Bove, who represents about a half-dozen families of those killed or wounded by Cho. "Someone should be held accountable."

The report raises sharp criticisms of the Virginia Tech police force for not adequately warning students and teachers about two homicides at a Virginia Tech dormitory, West Ambler Johnston Hall. Those shootings preceded Cho's subsequent, unimpeded rampage about two hours later at Norris Hall less than a mile away.

A failure by university officials, mental-health counselors and campus police to communicate with one another, as well as with Cho's parents, could have made a difference, Kaine said.

"There were enough red flags [about Cho's deterioration] that should have been heeded . . . at least to the point of alerting Cho's family."

Kaine said that one of the greatest failings was the fact that Virginia Tech administrators did not have access to Cho's high school records showing the effort it took to keep the emotionally troubled, behaviorally impaired student on a positive academic track.

The governor said one solution might be as simple as asking families to release full academic records to a university after a student is admitted

That way, there would be no impression that a student's mental condition affected admission, but mental issues could still be addressed.

When Virginia Tech police relied too much on their belief that an initial suspect was no longer on campus, they "did not take sufficient action to deal with what might happen if [their] initial lead proved erroneous," the report states.

While Cho mailed a package of tapes to the news media about his killings and readied himself for his attack on Norris, police spent almost two hours tracking down a possible suspect, a boyfriend of Cho's first victim, Emily Hilscher.

The emergency Policy Group of Tech administrators huddled throughout that time period but authorized only a vague warning to students about two deaths on campus.

Virginia Tech police "erred in not requesting that the Policy Group issue a campuswide notification that two persons had been killed and that all students and staff should be cautious and alert," according to the report.

While a more specific warning may have made students more cautious that morning, the report says that "there does not seem to be a plausible scenario of university response to the double homicide that could have prevented a tragedy of considerable magnitude.

"Cho had started on a mission of fulfilling a fantasy of revenge."

The report's recommendations will be a focus at next year's General Assembly session, according to legislators reached yesterday.

"I think the General Assembly will take this report very seriously and place it as a high priority to act upon," said state Sen. John S. Edwards, D-Roanoke, whose district includes Tech. "It's got to be taken seriously."

Edwards said he doesn't fault the Tech administration for the tragedy.

"They handled an extraordinarily difficult situation as well as they could under the circumstances," he said. "It's easy to be a Monday-morning quarterback."

The report lays out a biting assessment of the state's mental-health system, which judged Cho mentally ill and a danger to himself in December 2005 but never made good on a court order demanding care.

In tracking down reports that inexplicably turned out to be missing key documents, panel members could unearth only a single session at a Tech counseling center that Cho was ordered to visit.

The mandatory visit, which resulted in no treatment plan, was not followed up by health-care providers or by Cho, who was allowed to decide for himself if he wanted further attention.

Nor was the court ever informed that no care was being provided. Cho's parents, who emigrated from South Korea to the United States and barely speak English, were never told by Virginia Tech, the courts, or Cho's court-appointed lawyer that Cho was declared mentally ill.

Del. David A. Nutter, R-Montgomery, who works at Virginia Tech, called it a "somber report" that will take time to digest.

"I hope this report is taken in the context of how do we move forward, how do we make our systems better, and not one of blame," he said.

Contact Pamela Stallsmith at (804) 649-6746 or pstallsmith@timesdispatch.com.

Contact Bill McKelway at (804) 649-6601 or bmckelway@timesdispatch.com.

Staff writer Rex Bowman contributed to this report.