Report of the Virginia Tech Review Panel

Mass Shootings at Virginia Tech April 16, 2007 Report of the Review Panel Presented to Governor Kaine Commonwealth of Virginia AUGUST 2007 MASS SHOOTINGS AT VIRGINIA TECH APRIL 16, 2007 Report of the Virginia Tech Review Panel Presented to Timothy M. Kaine, Governor Commonwealth of Virginia August 2007 CONTENTS FOREWORD...................................................................................................................... vii ACKNOWLEDGEMENTS ................................................................................................ ix SUMMARY OF FINDINGS .............................................................................................. 1 CHAPTER I. BACKGROUND AND SCOPE................................................................... 5 Scope……………………………………………………………………… .......................... 5 Methodology………………………………………………………………. ........................ 6 Findings and Recommendations…………………………………………… .................. 10 CHAPTER II. UNIVERSITY SETTING AND SECURITY............................................. 11 University Setting………………………………………………………….. ..................... 11 Campus Police and Other Local Law Enforcement.................................................. 11 Building Security…………………………………………………………......................... 13 Campus Alerting Systems………………………………………………… ..................... 14 Emergency Response Plan…………………………………………………..................... 15 Key Findings……………………………………………………………… ........................ 16 Recommendations………………………………………………………… ....................... 17 CHAPTER III. TIMELINE OF EVENTS………………………………………................... 21 Pre-Incidents: Cho’s History...................................................................................... 21 The Incidents.............................................................................................................. 24 Post-Incidents............................................................................................................. 29 CHAPTER IV. MENTAL HEALTH HISTORY OF SEUNG HUI CHO......................... 31 PART A – MENTAL HEALTH HISTORY ................................................................ 31 Early Years………………………………………………………………… ....................... 31 Elementary School in Virginia…………………………………………….. ................... 33 Middle School Years................................................................................................... 34 High School Years…………………………………………………………. ...................... 36 College Years………………………………………………………………........................ 40 Cho’s Hospitalization and Commitment Proceedings .............................................. 46 After Hospitalization……………………………………………………….. .................... 49 Missing the Red Flags................................................................................................ 52 Key Findings…………………………………………..…………………… ...................... 52 Recommendations…………………………………………………………. ...................... 53 PART B – VIRGINIA MENTAL HEALTH LAW ISSUES....................................... 54 Time Constraints for Evaluation and Hearing......................................................... 55 Standard for Involuntary Commitment .................................................................... 56 Psychiatric Information............................................................................................. 56 Involuntary Outpatient Orders ................................................................................. 58 Certification of Orders to the Central Criminal Records Exchange........................ 59 Key Findings............................................................................................................... 60 Recommendations ...................................................................................................... 60 iii CHAPTER V. INFORMATION PRICACY LAWS………………………………................ 63 Law Enforcement Records…………………………………………………..................... 63 Judicial Records……………………………………………………………....................... 64 Medical Information................................................................................................... 65 Educational Records................................................................................................... 65 Government Data Collection and Dissemination Practices Act…………… ............ 67 Key Findings…………………………........................................................................... 68 Recommendations…………………………………………………………. ...................... 68 CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES………………….. ........... 71 Firearms Purchases………………………………………………………… .................... 71 Ammunition Purchases……………………………………………………...................... 74 Guns on Campus ........................................................................................................ 74 Key Findings……………………………………………………………….. ...................... 75 Recommendations………………………………………………………….. ..................... 76 CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON………. .......... 77 Approach and Attack………………………………………………………. ..................... 77 Premature Conclusion?.................................................................................. ............ 79 Delayed Alert to University Community………………………………….................... 80 Decision not to Cancel Classes or Lock Down…………………………. ..................... 82 Continuing Events…………………………………………………………. ..................... 84 Motivation for First Killings?........................................................................ ............ 86 Key Findings……………………………………………………………….. ...................... 86 Recommendations………………………………………………………….. ..................... 87 CHAPTER VIII. MASS MURDER AT NORRIS HALL…………………………. ............. 89 The Shootings………………………………………………………………....................... 90 Defensive Actions…………………………………………………………. ....................... 92 Police Response……………………………………………………………........................ 94 University Messages………………………………………………………....................... 95 Other Actions on the Second and Third Floor……………………………................... 97 Action on the First Floor…………………………………………………….................... 98 The Toll…………………………………………………………………….. ....................... 98 Key Findings............................................................................................................... 98 Recommendations………………………………………………………….. ..................... 99 CHAPTER IX. EMERGENCY MEDICAL SERVICES RESPONSE… ......................... 101 West Ambler Johnston Initial Response…………………………………… ................ 101 Norris Hall Initial Response……………………………………………….. ................... 102 EMS Incident Command System…………………………………………..................... 103 Hospital Response…………………………………………………………....................... 110 Emergency Management…………………………………………………....................... 116 Key Findings……………………………………………………………….. ...................... 121 Recommendations………………………………………………………….. ..................... 122 iv CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER………………............ 123 Legal Mandates and Standards of Care……………………………………. ................ 123 Death Notification…………………………………………………………....................... 124 Events………………………………………………………………………. ....................... 124 Issues……………………………………………………………………… ......................... 127 Key Findings……………………………………………………………….. ...................... 131 Recommendations………………………………………………………….. ..................... 132 A Final Word .............................................................................................................. 133 CHAPTER XI. IMMEDIATE AFTERMATH AND THE LONG ROAD TO HEALING 135 First Hours…………………………………………………………………........................ 136 Actions by Virginia Tech…………………………………………………… .................... 136 Meetings, Visits, and Other Communications with Families and with the Injured...................................................................................................... 142 Ceremonies and Memorial Events………………………………………………............ 144 Volunteers and Onlookers……………………………………………………….. ............ 144 Communications with the Medical Examiner’s Office………………………….. ....... 145 Department of Public Safety……………………………………………………… .......... 145 Key Findings............................................................................................................... 145 Recommendations…………………………………………………………………............. 146 APPENDIX A – EXECUTIVE ORDER 53 (2007)............................................................ A-1 APPENDIX B – INDIVIDUALS INTERVIEWED BY RESEACH PANEL ................... B-1 APPENDIX C – PUBLIC MEETING AGENDA.............................................................. C-1 APPENDIX D – RECOMMENDATIONS ON REVIEW METHODOLOGY .................. D-1 APPENDIX E – VIRGINIA TECH GUIDELINES FOR CHOOSING ALERTING SYSTEM ............................................................................ E-1 APPENDIX F – ACTIVE SHOOTER EXCERPT FROM UNIVERSITY OF VIRGINIA EMERGENCY RESPONSE PLAN..................................... F-1 APPENDIX G – GUIDANCE LETTERS ON INTERPRETATION OF FERPA AND HIPAA RULES FROM U.S. DEPARTMENT OF EDUCATION........ G-1 APPENDIX H – EXPLANATION OF FIRPA AND HIPAA LAWS................................ H-1 APPENDIX I – FEDERAL AND VIRGINIA GUN PURCHASER FORMS .................. I-1 APPENDIX J – VIRGINIA FORM FOR INVOLUNTARY COMMITMENT OR INCAPACITATION ........................................................................ J-1 APPENDIX K – ARTICLES ON MIXTURE OF GUNS AND ALCOHOL ON CAMPUS ........................................................................................

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