The U.S. Army has disciplined several of those in the Lewiston gunman’s chain of command for “dereliction of duty” after a series of administrative failures, but investigators said they still cannot determine why the soldier was released from a psychiatric hospital last summer.

The long-awaited report from the Army’s internal investigation into its handling of Robert Card, a reservist from Bowdoin who went on to kill 18 people in Lewiston on Oct. 25, was released to the public Tuesday.

But while the report highlights mistakes made by Army case managers and Card’s commanders, three of whom have been disciplined, it does not explain why the soldier was released from a New York hospital last August despite displaying paranoia, psychosis and homicidal ideation.

His discharge came a day after he was scheduled to appear in court to consider an involuntary commitment, but that hearing was canceled at the last minute after Card rescinded his request to leave.

The Army investigator, whose identity was redacted, noted several times in the report that they still don’t understand that decision because hospital staff refused to cooperate with the probe. The Army is now asking other federal offices to investigate Four Winds Hospital and whether it is meeting the standard of care.

“This investigation identified multiple errors made by unit leadership, medical professionals and local law enforcement,” the report states. “I recommend holding unit leaders accountable and making systemic adjustments to improve oversight and care of Army Reserve soldiers in the future.”

The report also reveals a series of attempts the Army made to reach Card in the days before the shooting, as late as Oct. 24, in order to complete his behavioral health profile. Card answered the phone that day, but quickly hung up.

The Army launched its probe into the handling of the reservist days after the shooting. While the small team of investigators worked behind closed doors, specific details about the case slowly trickled out to the public during hearings hosted by the Maine commission investigating the shooting.

Tuesday’s report is one of several investigations into the shooting that are expected to wrap up in the coming weeks. The Army Inspector General also published her evaluation of the independent Army report Tuesday, saying Card is “singularly responsible” for the mass shooting. And the Maine commission is expected to release its final report later this summer.

‘LAST, BEST CHANCE’

Much of the Army’s 115-page report revisits familiar pieces of the timeline of the shooter’s declining mental health, from the first reports of paranoia last January to his aggression and hospitalization last July to his threats against his unit’s Saco base in September. But the document draws new conclusions about the mistakes that led to the shooting – only some of which it attributes to Army personnel and policies.

The reservist’s commanders failed to file incident reports and other paperwork they should have submitted at several points, investigators found. They also misunderstood what medical records from Four Winds Hospital they were entitled to under a military exemption to health privacy laws.

The civilian case managers assigned to track the reservist’s care didn’t closely review his medical records when he refused to engage with follow-up care, the report found, so they closed his file at the end of August in accordance with the flawed (and since amended) policy of the Army’s Psychological Health Program.

The report also calls for several changes to Army training practices and policies – including that those working in the psychological health program be required to report to command anytime they cannot contact the soldier – and for discipline for the three unnamed soldiers, who could be denied future promotion or could even be discharged as a result.

Yet the Army shifts blame when it comes to the “questionable” decision to release the reservist from the hospital last year, a choice made by hospital staff unaffiliated with the Army, the report states.

The investigator seems to hint that the brain damage linked to Card’s paranoid behavior may have actually been related to a bad fall from a ladder in 2008, not the annual hand grenade training he led during his 20 years with the Army. In a press briefing Monday, Lt. Gen. Jody Daniels, the head of the Army Reserve, said that she doesn’t believe there was any connection between the blasts and the brain damage.

And they found that ultimate responsibility for preventing the shooting lay with the Sagadahoc County Sheriff’s Office, which never managed to confront the reservist directly after he made threats last September.

“I find (Sagadahoc) had the last, best, chance of impacting SFC Card’s actions,” the report states. “Any reliance on the military to handle this matter was also unreasonable because the Army did not have jurisdiction nor authority over SFC Card in his civilian capacity.”

ADMINISTRATIVE ERRORS

Starting as early as May 2023, when local police passed along concerns about Card’s aggression and paranoia, his commanders appeared not to follow through with steps they said they’d take to monitor him, like meeting to discuss his mental health at the unit’s May drill weekend.

The Army’s investigation found commanders were aware of multiple reports of the reservist’s strange behavior before the unit’s annual training mission to New York in July, but they did not think the incidents warranted placing him on active orders so they could order him to get medical attention.

One commander told investigators that he did not remove Card from the mission to New York, where he would be helping run a machine gun range for West Point cadets, because his mental health problems were not “a detriment to his military job.”

Though public hearings have revealed that Capt. Jeremy Reamer and Sgt. Kelvin Mote were the two soldiers who most directly responded to the growing concerns, redactions in the Army report make it impossible to know with certainty who exactly is being interviewed or referred to in any specific section.

Investigators also took issue with the administrative response to the reservist’s hospitalization in July after he tried to fight a fellow soldier who he wrongly believed was insulting him.

After Card was quickly moved from Keller Army Community Hospital to Four Winds for a more comprehensive psychological evaluation and treatment and then abruptly released on Aug. 3, his commanders should have conducted a “line of duty investigation” – the process of determining and documenting whether the reservist’s service aggravated his health issues and therefore entitled him to benefits.

The commanders also should have extended his active duty orders and returned him to Keller for a medical evaluation following his discharge from Four Winds, the report states.

Instead, he was allowed to leave directly from the hospital with few if any discharge instructions and drive home with a friend.

But even if the commanders had done everything right, investigators concluded, local law enforcement had the best chance of preventing the shooting because of the Army’s limited power over reservists.

Like Mote and Reamer, who testified before the commission investigating the shooting, the Army report concluded that deputies should have been able to use Maine’s yellow flag law to confiscate Card’s weapons – a claim deputy Aaron Skolfield has fiercely disputed.

While Skolfield has said Reamer and Mote downplayed the threats Card made, the Army’s report takes particular issue with the deputy’s dismissal.

“They wrote a report saying they were going to, essentially, ignore a letter from a fellow law enforcement officer that delivered information about an eyewitness account of a threat to commit a mass shooting,” the report states.

DISCHARGE DILEMMA

Recent commission meetings have illustrated how a tangled web of contracted medical providers, Army programs and privacy laws have made it difficult for investigators to pin down exactly what happened during the reservist’s hospitalization in New York last summer.

The release of the report Tuesday raised new questions about Four Winds’ relationship with the Army, but offered few answers.

On June 26, Card underwent psychological testing at Four Winds. Evaluators found he had poor emotional controls and an “inconsistent coping style,” which together could make him less predictable than most people. They found his lifetime risk for violence “may be somewhat higher than most people” and “may increase sharply at times when he is paranoid and emotionally overwrought.”

On July 27, 11 days after commanders first ordered Card to go to the hospital, he asked staff at Four Winds to release him, according to the report. Doctors did not believe he was ready to be released and took steps to involuntarily commit him under New York State law. A hearing was scheduled for Aug. 2.

The reservist then rescinded his request, and for some reason, the hospital changed tack and released him on Aug. 3 without a court hearing.

Hospital staff told investigators that they could not legally answer questions about why they decided to release him because they had not received a court order or a waiver from the reservist’s estate.

“We don’t have the authority to compel them to participate,” said Daniels, the head of the Army Reserve. She said she could not answer questions about the Army’s exact relationship with Four Winds.

After the reservist’s discharge, several parties that should have been tracking his case failed to adequately share information with one another, the report states.

“It appears that Four Winds’ discharge of SFC Card was lacking any follow-through regarding medication management or adequate arrangements for SFC Card’s follow-on care,” the report reads. “Four Winds believed (Keller) would follow up. (Keller) was not tracking SFC Card’s care because he was not on orders for more than 30 days. As a result, no one adequately followed up on SFC Card’s discharge care.”

He had been prescribed the anti-psychotic olanzapine, according to the report, though soon after his release he told friends and an Army case manager that he had stopped taking the drug because he didn’t like how it made him feel. He never followed through with setting up therapy appointments and hardly answered the phone when case managers called.

The report says there is evidence Four Winds should not have released the reservist, who was not responding to treatment or medication. But rather than make a definitive conclusion, investigators have asked the Department of Forensic Psychology at Walter Reed National Military Medical Center to analyze whether Four Winds met the established standard of care. Walter Reed also will perform a forensic autopsy.

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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