CNN
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The U.S. Army investigation into Robert Card, an Army reservist who shot and killed 18 people in Lewiston, Maine, last year, has found a series of miscommunications and breakdowns in communication between Card’s military chain of command, civilian law enforcement and medical providers before the shooting.
The survey revealed that communication failures were [Sgt. 1st Class] “Continuity of Care for Mr. Card” In one significant failure, military and civilian medical facilities did not upload Mr. Card’s discharge paperwork into the military medical system until more than two weeks after he completed his treatment.
“The discharge summary contained relevant and significant information that, if provided up the chain of command, would have detailed the extent of SFC Card’s mental health issues,” the investigation report said. Among those details were that he “had homicidal thoughts…appeared to be resistant to psychoeducation and blamed others for his actions.”
The report also found that Card had been exhibiting extremely problematic behavior in the months leading up to the shooting, during which coworkers, friends and family had expressed concern about his mental state and said he would harm others.
“I think he’s going to lose his mind and go on a shooting spree,” a close friend of Card’s, whose name was redacted in the report, wrote in a text message to the unit’s commander in September 2023, a little more than a month before Card went on a shooting spree at a local bowling alley and restaurant, wounding 13 people.
Card was found dead two days later from a self-inflicted gunshot wound.
The investigative team interviewed a total of 43 witnesses and collected 445 pieces of evidence. Army Reserve Commander Lt. Gen. Jody Daniels told reporters on Monday that the team is made up of a senior military intelligence officer, a military judge serving as legal adviser, a nurse and an investigator from the Criminal Investigation Division.
The investigation said Card’s chain of command had only “limited jurisdiction” over him because Army reservists typically serve about 40 days a year.
Nonetheless, three members of Card’s chain of command were disciplined, officials told reporters. It was unclear what those disciplines were, but Daniels said “appropriate administrative action” had been taken. The investigation report said superiors should not have ordered him to his annual training in July 2023 (during which he was admitted to a psychiatric facility) and did not conduct a performance review, which would have “appropriately” documented his admission and condition.
“Even if the mission is limited, it doesn’t stop me from calling my Soldiers and caring, checking in, making sure they’re OK, asking other members for wellness checks,” Daniels said. “A good leader cares about their Soldiers.”
The report said Card’s mental breakdown is believed to have begun in the fall of 2022, when he experienced “a series of emotional events and behavioral health issues,” including auditory hallucinations, interpersonal conflicts and beginning to use new hearing aids.
Card’s family first reported concerns about his mental health to police in May 2023, but prior to that, Card, a sergeant first class in the Army Reserves who worked as a truck driver in a civilian job, had no record of suicide attempts or mental health issues.
Others in the unit “generally viewed Card as a reliable and dependable individual who demonstrated solid, average performance,” according to the investigation. Fellow soldiers described him as quiet, easygoing, generous and kind.
But in January 2023, his attitude began to change. Card became increasingly paranoid, not only about fellow unit members but also about complete strangers, including a Dunkin’ Donuts employee he met at a rest stop.
Card’s family reported at least four mental health incidents through May 2023 to the high school resource police officer, who reported the incidents to Sagadahoc, the local law enforcement agency. The sheriff’s office said a family member of Card said he believed there were “10 to 15 rifles and handguns” in the home.
In July 2023, Card was ordered to attend his annual training at the United States Military Academy at West Point. He served as a weapons trainee at the academy for approximately two weeks each year from 2014 to 2022. Shortly after arriving, Card told his colleagues that people were talking about him. Within 24 hours of arriving in New York for training, Card’s superiors ordered him to undergo a behavioral health evaluation by his commander at a military hospital.
Army hospital staff believed Card needed more intensive care and transferred him to a civilian hospital in the region, Four Winds, on July 16. A psychological evaluation at Four Winds found Card’s coping skills were “as developed as most adults,” but he exhibited narcissism, poor emotional control and an inconsistent coping style that may have affected how he responded to events, according to an Army study.
Card was eventually released from Four Winds on August 3. The hospital’s discharge report stated that Card was a “very low risk” of harming himself or others. However, the person who picked him up from the hospital told Army investigators that Card had said he was “smarter than the staff at Four Winds,” had become “enraged” at a female patient who believed Card was talking about her, and had been so angry about being admitted that he “pushed a mattress against the wall and punched himself until his hands were bloody.”
Card was discharged on Aug. 3, but the investigation found that Four Winds did not fax a discharge summary to an Army hospital until Aug. 11, and it wasn’t uploaded to the military medical system until Aug. 21. It included details about Card’s condition, including that he told medical personnel he “decided to quit my job before I killed someone” and that he had a “hit list.”
Card’s discharge from Four Winds also appears to have affected his unit’s ability to remove personal firearms from his home.
Daniels said Monday that there have been “multiple instances” in which the Army Reserve has requested that Card’s personal firearms be stored elsewhere, but that when it comes to personal weapons, the Army Reserve “can request, and they can ask, but they can’t force you to store them somewhere … unless there is a medical determination, which was not the case in this case.” [SFC] Card was released by a private donor and was able to return home.”
Four Winds officials declined to participate in the Army’s investigation, according to the report, which concluded that the Defense Health Agency should consider removing Four Winds as a licensed treatment facility.
Four Winds has not yet responded to CNN’s request for comment.
The investigation found several other concerning incidents between Card’s discharge from Four Winds and the October shooting, including one in which Card threatened to carry out a mass shooting that was reported by his chain of command to local police. Investigators were unable to reach him at his home, and even though he was present, investigators “did not attempt to enforce contact or enforce Maine’s Yellow Flag law, which would have restricted Private Card’s access to his personal firearm,” the investigation said.
Card’s family has since voiced a number of concerns about his actions. His brother-in-law, James Harling, told the independent commission investigating the shooting, “You can blame who was at fault, who didn’t make the final call, but the reality is we all could have done better, from the sheriff’s office to the Army to the family.”
Law enforcement footage released in December showed authorities speaking with an Army Reserve officer about Card and attempting to make contact with him at his home.
“They (Card’s family) are concerned he may become a mass shooter,” a sheriff’s deputy can be heard telling an inspector in one of the videos from September. “He’s been having hallucinations and was institutionalized for about two weeks this summer and shows no signs of improvement.”
Days before the Lewiston shooting, investigators, Card “withdrew from those around him” and accused them of talking about him and making fun of him, despite ongoing efforts by his family to offer encouragement and support.
The Army Reserve Medical Administration Center attempted to contact him in October to discuss further treatment and check on his health. An individual attempted to contact him on Oct. 17 and 19 but was unsuccessful, according to the investigation.
On Oct. 24, the day before the shooting, someone called Card and was met by a man who answered the phone, but when he said he wanted to speak to Card, the man on the other end was a man.
Card opened fire at a local bowling alley, Sparetime Recreation, and Schemengees Bar & Grille Restaurant on the evening of October 25. His body was found in the bed of a tractor-trailer on October 27, and the cause of death was listed as “suicide (self-shot with a handgun).”
The Army’s investigation report said the service felt a “moral and ethical obligation” to investigate the mass shooting.
Since October 2023, there has been speculation that a traumatic brain injury sustained by Col. Card during his service may have contributed to the deterioration of his mental condition. The investigation found that Col. Card had not deployed during his 22 years of service, and that while Col. Card’s “short-term psychosis” may have been “aggravated” by his service and training in 2023, “the condition was present prior to Col. Card’s entry into the military.” [annual training].”
The investigation also cited a 2008 incident in which Card fell from the roof of his home and broke his neck, an incident that did not appear to be reported to the Army Reserve. Daniels said Monday that Card’s fall appears to have had a greater impact on his health than any incidents that occurred while he was in the military.
“The SFC cards were not deployed or mobilized and therefore were not exposed to conditions found in a combat environment,” the investigation report states.
Finally, Daniels said going forward, commanders and legal advisers will need to be retrained on personal weapons and health privacy rights, and ensure mental health resources are available to other service members who may be affected by active shooter incidents.
The Army Reserve is also reviewing its behavioral health policies and standard operating procedures, with various issues being reported to broader agencies, including the Defense Health Agency, to improve case management procedures.
“My heart goes out to those who witnessed this incident and to the families of those affected,” Governor Daniels said Monday. “We are doing our best to understand what happened and make changes for the future.”
