Mass Shootings at Virginia Tech

Home , Clery Act, Graduating Peter, Kevin Granata, Liviu Librescu, Lucinda Roy

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

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 ...... K-1 APPENDIX L – FATAL SCHOOL SHOOTINGS IN THE UNITED STATES: 1966–2007...... L-1 APPENDIX M – RED FLAGS, WARNING SIGNS AND INDICATORS...... M-1 APPENDIX N - A THEORETICAL PROFILE OF SEUNG HUI CHO ...... N-1

DEDICATION

The Virginia Tech Review Panel invited the families of the victims to lend their words as a dedication of this report. The panel is honored to share their words of love, remembrance, and strength.

* * *

We dedicate this report not solely to those who lost their lives at Virginia Tech on April 16, 2007, and to those physically and/or psychologically wounded on that dreadful morning, but also to every student, teacher, and institution of learning, that we may all safely fulfill our goals of learning, educating, and enriching humanity's stores of knowledge: the very arts and sciences that ennoble us.* "Love does not die, people do. So when all that is left of me is love… Give me away.…" – John Wayne Schlatter "This is the beginning of a new day. You have been given this day to use as you will. You can waste it or use it for good. What you do today is important because you are exchanging a day of your life for it. When tomorrow comes, this day will be gone forever; in its place is something that you have left behind…let it be something good." – Anonymous "We should consider every day lost on which we have not danced at least once. And we should call every truth false which was not accompanied by at least one laugh." – Friedrich Nietzsche "Unable are the loved to die, for Love is Immortality." – Emily Dickinson

32 candles burning bright for all to see, Lifting up the world for peace and harmony, Those of us who are drawn to the lights, enduringly embedded in our mind, indelibly ingrained on our heart, forever identifying our spirit, We call out your name: Erin, Ryan, Emily, Reema, Daniel, Matthew, Kevin, Brian, Jarrett, Austin, Henry, Liviu, Nicole, Julia, Lauren, Partahi, Jamie, Jeremy, Rachel, Caitlin, Maxine, Jocelyne, Leslie, Juan, Daniel, Ross, G.V., Mary, Matthew, Minal, Michael, Waleed, and, hold these truths ever so tight, your lives have great meaning, your lives have great power, your lives will never be forgotten, YOU will always be remembered, --never and always . . . – Pat Craig

*Neither this dedication nor the use herein of the victims' photos or bios represents an endorsement of the report by the victims' families.

Ross Abdullah Alameddine Brian Roy Bluhm Christopher James Bishop Hometown: Saugus, Massachusetts Hometown: Cedar Rapids, Iowa Residence in Blacksburg Sophomore, University Studies Masters student, Civil Engineering Instructor, Foreign Languages Student since fall 2005 Student since spring 2005 Joined Virginia Tech on Posthumous degree: Posthumous degree: August 10, 2005 Master of Science, Civil Engineering Bachelor of Arts, English

Austin Michelle Cloyd Kevin P. Granata Ryan Christopher Clark Hometown: Blacksburg, Virginia Residence in Blacksburg Hometown: Martinez, Georgia Sophomore, Honors Program, Professor, Engineering Science and Senior, Psychology International Studies Mechanics Student since fall 2002 Student since fall 2006 Joined Virginia Tech on Posthumous degrees: Posthumous degrees: January 10, 2003 Bachelor of Science, Biological Bachelor of Arts, Foreign

Sciences Languages/French Bachelor of Arts, English Bachelor of Arts, International Bachelor of Science, Psychology Studies

Caitlin Millar Hammaren Jeremy Michael Herbstritt Hometown: Blacksburg, Virginia Matthew Gregory Gwaltney Hometown: Westtown, New York Sophomore, International Studies Masters student, Civil Engineering Hometown: Chesterfield, Virginia Student since fall 2006 Masters student, Environmental Student since fall 2005 Engineering Posthumous degree: Posthumous degree: Student since fall 2001 Bachelor of Arts, International Master of Science, Civil Engineering Studies Posthumous degree: Master of Science, Environmental Engineering

Rachael Elizabeth Hill Emily Jane Hilscher Partahi Mamora Halomoan Hometown: Glen Allen, Virginia Hometown: Woodville, Virginia Lumbantoruan Freshman, University Studies Freshman, Animal and Poultry Hometown: Blacksburg, Virginia Student since fall 2006 Sciences (originally from Indonesia) Student since fall 2006 Posthumous degree: Ph.D. student, Civil Engineering Bachelor of Science, Biological Posthumous degree: Student since fall 2003 Sciences Bachelor of Science, Animal and Posthumous degree: Poultry Sciences Doctor of Philosophy, Civil Engineering

Henry J. Lee Matthew Joseph La Porte Jarrett Lee Lane Hometown: Roanoke, Virginia Hometown: Dumont, New Jersey Hometown: Narrows, Virginia Sophomore, Computer Engineering Sophomore, University Studies Senior, Civil Engineering Student since fall 2006 Student since fall 2003 Student since fall 2005 Posthumous degree: Posthumous degree: Posthumous degree: Bachelor of Science, Computer Bachelor of Arts, Political Science Bachelor of Science, Civil Engineering

Engineering

Lauren Ashley McCain Liviu Librescu G. V. Loganathan Hometown: Hampton, Virginia Residence in Blacksburg Residence in Blacksburg Freshman, International Studies Professor, Engineering Science and Professor, Civil and Environmental Student since fall 2006 Mechanics Engineering Posthumous degree: Joined Virginia Tech on Joined Virginia Tech on Bachelor of Arts, International Studies September 1, 1985 December 16, 1981

Jocelyne Couture-Nowak Daniel Patrick O’Neil Juan Ramon Ortiz-Ortiz Residence in Blacksburg Hometown: Lincoln, Rhode Island Hometown: Blacksburg, Virginia Adjunct Professor, Foreign Masters student, Environmental Masters student, Civil Engineering Languages Engineering Student since fall 2006 Joined Virginia Tech on Student since fall 2006 Posthumous degree: August 10, 2001 Master of Science, Civil Engineering Posthumous degree: Master of Science, Environmental Engineering

Minal Hiralal Panchal Daniel Alejandro Perez Erin Nicole Peterson Hometown: Mumbai, India Hometown: Woodbridge, Virginia Hometown: Centreville, Virginia Masters student, Architecture Sophomore, International Studies Freshman, International Studies Student since fall 2006 Student since summer 2006 Student since fall 2006 Posthumous degree: Posthumous degree: Posthumous degree: Master of Science, Architecture Bachelor of Arts, International Bachelor of Arts, International Studies Studies

Mary Karen Read Michael Steven Pohle, Jr. Julia Kathleen Pryde Hometown: Annandale, Virginia Hometown: Flemington, New Hometown: Blacksburg, Virginia Freshman, Interdisciplinary Studies Jersey Masters student, Biological Student since fall 2006 Senior, Biological Sciences Systems Engineering Posthumous degree: Student since fall 2002 Student since fall 2001 Bachelor of Arts, Interdisciplinary Posthumous degree: Posthumous degree: Studies Bachelor of Science, Biological Master of Science, Biological Sciences Systems Engineering

Reema Joseph Samaha Waleed Mohamed Shaalan Leslie Geraldine Sherman Hometown: Centreville, Virginia Hometown: Blacksburg, Virginia Hometown: Springfield, Virginia Freshman, University Studies (originally from Egypt) Junior, Honors Program, History Student since fall 2006 Ph.D. student, Civil Engineering Student since fall 2005 Student since fall 2006 Posthumous degrees: Posthumous degrees: Posthumous degree: Bachelor of Arts, History Bachelor of Arts, International Studies Bachelor of Arts, International Studies Bachelor of Arts, Public and Urban Doctor of Philosophy, Civil Affairs Engineering

Maxine Shelly Turner Nicole Regina White

Hometown: Vienna, Virginia Hometown: Smithfield, Virginia Senior, Honors Program, Chemical Sophomore, International Studies Engineering Student since fall 2004 Student since fall 2003 Posthumous degree: Bachelor of Arts, International Posthumous degree: Bachelor of Science, Chemical Engineering Studies

FOREWORD FROM TIMOTHY M. KAINE GOVERNOR, COMMONWEALTH OF VIRGINIA

On April 16, 2007, a tragic chapter was added to Virginia’s history when a disturbed young man at Virginia Tech took the lives of 32 students and faculty, wounded many others, and killed himself. In the midst of unspeakable grief, the Virginia Tech community stood together, with tremendous support from friends in all corners of the world, and made us proud to be Virginians.

Over time, the tragedy has been felt by all it touched, most deeply by the families of those who were killed and by the wounded survivors and their families. The impact has been felt as well by those who witnessed or responded to the shooting, the broad Virginia Tech community, and those who are near to Blacksburg geographically or in spirit.

In the days immediately after the shooting, I knew it was critical to seek answers to the many questions that would arise from the tragedy. I also felt that the questions should be addressed by people who possessed both the expertise and autonomy necessary to do a comprehensive review. Accordingly, I announced on April 19 the formation of the Virginia Tech Review Panel to perform a review independent of the Commonwealth’s own efforts to respond to the terrible events of April 16. The Panel members readily agreed to devote time, expertise, and emotional energy to this difficult task.

Those who agreed to serve were:

• Panel Chair Col. Gerald Massengill, a retired Virginia State Police Superintendent who led the Commonwealth’s law enforcement response to the September 11, 2001, attack on the Pentagon and the sniper attacks that affected the Commonwealth in 2002. • Panel Vice Chair Dr. Marcus L. Martin, Professor of Emergency Medicine, Assistant Dean of the School of Medicine and Associate Vice President for Diversity and Equity at the University of Virginia. • Gordon Davies, former Director of the State Council of Higher Education for Virginia (1977–1997) and President of the Kentucky Council on Postsecondary Education (1998–2002). • Dr. Roger L. Depue, a 20-year veteran of the FBI and the founder, past president and CEO of The Academy Group, Inc., a forensic behavioral sciences services company providing consultation, research, and investigation of aberrant and violent behavioral problems.

vii

FOREWORD FROM GOVERNOR KAINE

• Carroll Ann Ellis, MS, Director of the Fairfax County Police Department’s Victim Services Division, a faculty member at the National Victim Academy, and a member of the American Society of Victimology. • The Honorable Tom Ridge, former Governor of Pennsylvania (1995–2001) and Member of the U.S. House of Representatives (1983–1995) who was also the first U.S. Secretary of Homeland Security (2003–2005). • Dr. Aradhana A. “Bela” Sood, Professor of Psychiatry and Pediatrics, Chair of Child and Adolescent Psychiatry and Medical Director of the Virginia Treatment Center for Children at VCU Medical Center. • The Honorable Diane Strickland, former judge of the 23rd Judicial Circuit Court in Roanoke County (1989–2003) and co-chair of the Boyd-Graves Conference on issues surrounding involuntary mental commitment. These nationally recognized individuals brought expertise in many areas, including law enforcement, security, governmental management, mental health, emergency care, victims’ services, the Virginia court system, and higher education.

An assignment of this importance required expert technical assistance and this was provided by TriData, a division of System Planning Corporation. TriData has worked on numerous reports following disasters and tragedies, including a report on the 1999 shooting at Columbine High School. Phil Schaenman and Hollis Stambaugh led the TriData team.

The Panel also needed wise and dedicated legal counsel and that counsel was provided on a pro bono basis by the Washington, D.C., office of the law firm Skadden, Arps, Slate, Meagher & Flom, L.L.P. The Skadden Arps team was led by partners Richard Brusca and Amy Sabrin.

The level of personal commitment by the Panel members, staff and counsel throughout the process was extraordinary. This report is the product of intense work and deliberation and the Commonwealth stands indebted to all who worked on it.

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.

We must now challenge ourselves to study this report carefully and make changes that will reduce the risk of future violence on our campuses. If we act in that way, we will honor the lives and sacrifices of all who suffered on that terrible day and advance the notion of service that is Virginia Tech’s fundamental mission.

viii

ACKNOWLEDGEMENTS

he Virginia Tech Review Panel thanks the many persons who contributed to gathering Tinformation, provided facilities at which the panel held four public meetings around the state, and helped prepare this report. The administration and staff of Virginia Tech, George Mason University, and the University of Virginia hosted public meetings at which speakers presented background information and family members of the victims addressed the panel. The University of Virginia also provided facilities for the panel to meet in three sessions to discuss confidential material related to this report. The panel is grateful to more than 200 persons who were interviewed or who participated in discussion groups. They are identified in Appendix B. Finally, the panel is grateful for staff support and legal advice provided by TriData, a Division of System Planning Corporation, and Skadden, Arps, Slate, Meagher & Flom LLP.

TriData, a Division of System Planning Corporation • Philip Schaenman, panel staff • Paul Flippin director • Teresa Copping • Hollis Stambaugh, panel staff • Maria Argabright deputy director • Shania Flagg • Jim Kudla, panel public information officer • Lucius Lamar III • Dr. Harold Cohen • Rachel Mershon • Darryl Sensenig • Jim Gray Skadden, Arps, Slate, Meagher & Flom LLP • Richard Brusca • Brad Marcus • Amy Sabrin • Cory Black, Summer Associate • Michael Tierney • Ray McKenzie, Summer Associate • Michael Kelly • Colin Ram, Summer Associate • Ian Erickson

SUMMARY OF KEY FINDINGS

n April 16, 2007, Seung Hui Cho, an angry and disturbed student, shot to death 32 stu- Odents and faculty of Virginia Tech, wounded 17 more, and then killed himself. The incident horrified not only Virginians, but people across the United States and throughout the world. Tim Kaine, Governor of the Commonwealth of Virginia, immediately appointed a panel to review the events leading up to this tragedy; the handling of the incidents by public safety officials, emergency services providers, and the university; and the services subsequently provided to families, survivors, care-givers, and the community. The Virginia Tech Review Panel reviewed several separate but related issues in assessing events leading to the mass shootings and their aftermath: • The life and mental health history of Seung Hui Cho, from early childhood until the weeks before April 16. • Federal and state laws concerning the privacy of health and education records. • Cho's purchase of guns and related gun control issues. • The double homicide at West Ambler Johnston (WAJ) residence hall and the mass shootings at Norris Hall, including the responses of Virginia Tech leadership and the actions of law enforcement officers and emergency responders. • Emergency medical care immediately following the shootings, both onsite at Virginia Tech and in cooperating hospitals. • The work of the Office of the Chief Medical Examiner of Virginia. • The services provided for surviving victims of the shootings and others injured, the families and loved ones of those killed and injured, members of the university community, and caregivers. The panel conducted over 200 interviews and reviewed thousands of pages of records, and reports the following major findings: 1. Cho exhibited signs of mental health problems during his childhood. His middle and high schools responded well to these signs and, with his parents' involvement, provided services to address his issues. He also received private psychiatric treatment and counseling for selective mutism and depression. In 1999, after the Columbine shootings, Cho’s middle school teachers observed suicidal and homicidal ideations in his writings and recommended psychiatric counseling, which he received. It was at this point that he received medication for a short time. Although Cho’s parents were aware that he was troubled at this time, they state they did not specifically know that he thought about homicide shortly after the 1999 Columbine school shootings.

SUMMARY OF KEY FINDINGS

2. During Cho's junior year at Virginia Tech, numerous incidents occurred that were clear warnings of mental instability. Although various individuals and departments within the university knew about each of these incidents, the university did not intervene effectively. No one knew all the information and no one connected all the dots. 3. University officials in the office of Judicial Affairs, Cook Counseling Center, campus police, the Dean of Students, and others explained their failures to communicate with one another or with Cho’s parents by noting their belief that such communications are prohibited by the federal laws governing the privacy of health and education records. In reality, federal laws and their state counterparts afford ample leeway to share information in potentially dangerous situations. 4. The Cook Counseling Center and the university’s Care Team failed to provide needed support and services to Cho during a period in late 2005 and early 2006. The system failed for lack of resources, incorrect interpretation of privacy laws, and passivity. Records of Cho’s minimal treatment at Virginia Tech’s Cook Counseling Center are missing. 5. Virginia’s mental health laws are flawed and services for mental health users are inadequate. Lack of sufficient resources results in gaps in the mental health system including short term crisis stabilization and comprehensive outpatient services. The involuntary commitment process is challenged by unrealistic time constraints, lack of critical psychiatric data and collateral information, and barriers (perceived or real) to open communications among key professionals. 6. There is widespread confusion about what federal and state privacy laws allow. Also, the federal laws governing records of health care provided in educational settings are not entirely compatible with those governing other health records. 7. Cho purchased two guns in violation of federal law. The fact that in 2005 Cho had been judged to be a danger to himself and ordered to outpatient treatment made him ineligi- ble to purchase a gun under federal law. 8. Virginia is one of only 22 states that report any information about mental health to a federal database used to conduct background checks on would-be gun purchasers. But Virginia law did not clearly require that persons such as Cho—who had been ordered into out-patient treatment but not committed to an institution—be reported to the database. Governor Kaine’s executive order to report all persons involuntarily committed for outpatient treatment has temporarily addressed this ambiguity in state law. But a change is needed in the Code of Virginia as well. 9. Some Virginia colleges and universities are uncertain about what they are permitted to do regarding the possession of firearms on campus. 10. On April 16, 2007, the Virginia Tech and Blacksburg police departments responded quickly to the report of shootings at West Ambler Johnston residence hall, as did the Virginia Tech and Blacksburg rescue squads. Their responses were well coordinated. 11. The Virginia Tech police may have erred in prematurely concluding that their initial lead in the double homicide was a good one, or at least in conveying that impression to university officials while continuing their investigation. They did not take sufficient action to deal with what might happen if the initial lead proved erroneous. The police

SUMMARY OF KEY FINDINGS

reported to the university emergency Policy Group that the "person of interest" probably was no longer on campus. 12. The VTPD erred in not requesting that the Policy Group issue a campus-wide notification that two persons had been killed and that all students and staff should be cautious and alert. 13. Senior university administrators, acting as the emergency Policy Group, failed to issue an all-campus notification about the WAJ killings until almost 2 hours had elapsed. University practice may have conflicted with written policies. 14. The presence of large numbers of police at WAJ led to a rapid response to the first 9-1-1 call that shooting had begun at Norris Hall. 15. Cho’s motives for the WAJ or Norris Hall shootings are unknown to the police or the panel. Cho's writings and videotaped pronouncements do not explain why he struck when and where he did. 16. 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. 17. Emergency medical care immediately following the shootings was provided very effectively and timely both onsite and at the hospitals, although providers from different agencies had some difficulty communicating with one another. Communication of accurate information to hospitals standing by to receive the wounded and injured was somewhat deficient early on. An emergency operations center at Virginia Tech could have improved communications. 18. The Office of the Chief Medical Examiner properly discharged the technical aspects of its responsibility (primarily autopsies and identification of the deceased). Communica- tion with families was poorly handled. 19. State systems for rapidly deploying trained professional staff to help families get information, crisis intervention, and referrals to a wide range of resources did not work. 20. The university established a family assistance center at The Inn at Virginia Tech, but it fell short in helping families and others for two reasons: lack of leadership and lack of coordination among service providers. University volunteers stepped in but were not trained or able to answer many questions and guide families to the resources they needed. 21. 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. As reflected in the body of the report, the panel has made more than 70 recommendations directed to colleges, universities, mental health providers, law enforcement officials, emergency service providers, law makers, and other public officials in Virginia and elsewhere.

SUMMARY OF KEY FINDINGS

4 Chapter I BACKGROUND AND SCOPE

n April 16, 2007, one student, senior Seung panel and its work, and other issues. Their OHui Cho, murdered 32 and injured 17 stu- advice and counsel were invaluable. dents and faculty in two related incidents on the The governor requested a report be submitted in campus of Virginia Polytechnic Institute and August 2007. The panel devoted substantial time State University (“Virginia Tech”). Three days and effort from early May to late August to com- later, Virginia Governor Tim Kaine commis- pleting its review and preparing the report. All sioned a panel of experts to conduct an inde- panel members served pro bono. The panel rec- pendent, thorough, and objective review of the ognizes that some matters may need to be tragedy and to make recommendations regarding addressed more fully in later research. improvements to the Commonwealth’s laws, policies, procedures, systems and institutions, as SCOPE well as those of other governmental entities and private providers. On June 18, 2007, Governor he governor’s executive order directed the Kaine issued Executive Order 53 reaffirming the Tpanel to answer the following questions: establishment of the Virginia Tech Review Panel and clarifying the panel’s authority to obtain 1. “Conduct a review of how Seung Hui Cho documents and information necessary for its committed these 32 murders and multi- review. (See Executive Order 53 (2007), ple additional woundings, including Appendix A.) without limitation how he obtained his firearms and ammunition, and to learn Each member of the appointed panel had what can be learned about what caused expertise in areas relevant to its work, including him to commit these acts of violence. Virginia’s mental health system, university administration, public safety and security, law 2. “Conduct a review of Seung Hui Cho's enforcement, victim services, emergency medical psychological condition and behavioral services, and the justice system. The panel issues prior to and at the time of the members and their qualifications are specified in shootings, what behavioral aberrations the Foreword to this report. The panel was or potential warning signs were observed assisted in its research and logistics by the by students, faculty and/or staff at West- TriData Division of System Planning field High School and Virginia Tech. This Corporation (SPC). inquiry should include the response taken by Virginia Tech and others to In June, the governor appointed the law firm of note psychological and behavioral issues, Skadden, Arps, Slate, Meagher & Flom, LLP, as Seung Hui Cho's interaction with the independent legal counsel to the panel. A team of mental health delivery system, including their lawyers provided their services on a pro without limitation judicial intervention, bono basis. Their advice helped enormously as access to services, and communication they identified the authority needed to obtain between the mental health services sys- key information and guided the panel through tem and Virginia Tech. It should also many sensitive legal areas related to obtaining include a review of educational, medical and protecting information, public access to the and judicial records documenting his

CHAPTER I. BACKGROUND AND SCOPE

condition, the services rendered to him, measures that can be taken to improve and his commitment hearing. the laws, policies, procedures, systems and institutions of the Commonwealth 3. “Conduct a review of the timeline of and the operation of public safety events from the time that Seung Hui Cho agencies, medical facilities, local entered West Ambler Johnston dormitory agencies, private providers, universities, until his death in Norris Hall. Such and mental health services delivery review shall include an assessment of the system.” response to the first murders and efforts to stop the Norris Hall murders once In summary, the panel was tasked to review the they began. events, assess actions taken and not taken, identify lessons learned, and propose 4. “Conduct a review of the response of the alternatives for the future. Its assignment Commonwealth, all of its agencies, and included a review of Cho’s history and relevant local and private providers interaction with the mental health and legal following the death of Seung Hui Cho for systems and of his gun purchases. The panel was the purpose of providing recommendations also asked to review the emergency response by for the improvement of the all parties (law enforcement officials, university Commonwealth's response in similar officials, medical responders and hospital care emergency situations. Such review shall providers, and the Medical Examiner). Finally, include an assessment of the emergency the panel reviewed the aftermath—the medical response provided for the injured university’s approach to helping families, and wounded, the conduct of post-mortem survivors, students, and staff as they dealt with examinations and release of remains, on- the mental trauma and the approach to helping campus actions following the tragedy, and the university itself heal and function again. the services and counseling offered to the victims, the victims' families, and those METHODOLOGY affected by the incident. In so doing, the panel shall to the extent required by he panel used a variety of research and federal or state law: (i) protect the Tinvestigatory techniques and procedures, confidentiality of any individual's or with the goal of conducting its review in a family member's personal or health manner that was as open and transparent as information; and (ii) make public or possible, consistent with protecting individual publish information and findings only in privacy where appropriate and the summary or aggregate form without confidentiality of certain records where required identifying personal or health information to do so. related to any individual or family Much of the panel’s work was done in parallel by member unless authorization is obtained informal subgroups on topics such as mental from an individual or family member that health and legal issues, emergency medical specifically permits the panel to disclose services, law enforcement, and security. The that person's personal or health panel was supplemented by SPC/TriData and information. Skadden staff with expertise in these areas. 5. “Conduct other inquiries as may be Throughout the process, panel members appropriate in the panel's discretion identified documents to be obtained and people otherwise consistent with its mission and to be interviewed. The list of interview subjects authority as provided herein. continued to grow as the review led to new questions and as people came forth to give 6. “Based on these inquiries, make information and insights to the panel. recommendations on appropriate

CHAPTER I. BACKGROUND AND SCOPE

From the beginning, the concept was to structure summaries from law enforcement officials about the review according to the broad timeline their investigation rather than reviewing those pertinent to the incidents: pre-incident (Cho’s files directly. These included briefings by campus history and security status of the university); the police, Blacksburg Police, Montgomery County two shooting incidents and the emergency Police, Virginia State Police, FBI, and U.S. response to them; and the aftermath. This Bureau of Alcohol, Tobacco, Firearms and helped ensure that all issues were covered in a Explosives (ATF). The first two such briefings logical, systematic fashion. were conducted in private because they included protected criminal investigation information and Openness –The panel’s objective was to conduct some material that was deemed insensitive to air the review process as openly as possible while in public. Most of the information received in maintaining confidential aspects of the police confidence was subsequently released in public investigation, medical records, court records, briefings and through the media. Although the academic records, and information provided in panel did not have direct access to criminal confidence. The panel’s work was governed by investigation files and materials in their the Virginia Freedom of Information Act, and the entirety, the panel was able to validate the requirements of that act were adhered to strictly. information contained in these briefings from the Requests for Documents and records it did have access to from other sources Information – An essential aspect of the and from discussions with many of the same review was the cooperation the panel received witnesses who spoke to the criminal from many institutions and individuals, investigators. The panel believes that it has including the staff of Virginia Tech, Fairfax obtained an accurate picture of the police County Public School officials and employees, the response and investigation. families of shooting victims, survivors, the Cho Finally, with respect to Cho’s firearms pur- family, law enforcement agencies, mental health chases, the Virginia State Police, the ATF, and providers, the Virginia Medical Examiner, and the gun dealers each declined to provide the emergency medical responders, as well as panel with copies of the applications Cho com- numerous public agencies and private pleted when he bought his weapons or of other individuals who responded to the panel’s records relating to any background check that requests for documents and information. may have occurred in connection with those pur- Notwithstanding some difficulties at the outset, chases. The Virginia State Police, however, did the Executive Order of June 18, 2007, and the describe the contents of Cho’s gun purchase work of our outside counsel ultimately allowed applications to members of the panel and its the panel to obtain copies of, review, or be briefed staff. on all records germane to its review. In this Virginia Tech Cooperation – An essential regard, however, a few matters should be noted. aspect of the review was the cooperation of the First, as explained more fully in the body of the Virginia Tech administration and faculty. report, the university’s Cook Counseling Center Despite their having to deal with extraordinary advised the panel that it was missing certain problems, pressures, and demands, the records related to Cho that would be expected to university provided the panel with the records be in the center’s files. and information requested, except for a few that Second, due to the sensitive nature of portions of were missing. Some information was delayed the law enforcement investigatory record and until various privacy issues were resolved, but due to law enforcement’s concerns about not ultimately all records that were requested and setting a precedent with regard to the release of still existed were provided. University President raw information from investigation files, the Charles Steger appointed a liaison to the panel, panel received extensive briefings and Lenwood McCoy, a retired senior university

CHAPTER I. BACKGROUND AND SCOPE

official. Requests for meetings and information Interviews were conducted to understand Cho’s went to him. He helped identify the right people history, including his medical and mental health to provide the requested information or obtained treatment during his early school and university the information himself. The panel sometimes years, and his interactions with the mental requested to speak to specific individuals, and all health and legal systems. This included inter- were made available. Many of the exchanges views with the Cho family, Cho’s high school were monitored by the university’s attorney, who staff and faculty, staff and faculty at the univer- is a special assistant state attorney general. sity, many of those involved with the mental Overall, the university was extremely health treatment of Cho within and outside the cooperative with the panel, despite knowing that university (including the Cook Counseling Cen- the panel’s duty was to turn a critical eye on ter and his high school counseling), and members everything it did. of the legal community who had contact with him. The assistance of attorney Wade Smith of Interviews – Many interviews were conducted Raleigh, NC, was important in dealing with the by panel members and staff during the course of Cho family. He helped obtain signed releases this review—over 200. A list of persons inter- from the family and arranged an interview with viewed is included in Appendix B. A few inter- them. Various experts in mental health were viewees wanted to remain anonymous and are consulted on the problems with the mental not included. Panel members and staff held health and legal system within Virginia that numerous private meetings with family members dealt with Cho. They also provided insight on of victims and with survivors and their family ways to identify and help such individuals in members. other systems.

One group of interviews was to obtain first-hand In evaluating the aftermath—the attempt to information about the incidents from victims and mitigate the damage done to so many families, responders. This included surviving students and members of the university community, and the faculty, police, emergency medical personnel and university itself—many interviews were con- hospital emergency care providers, and coordina- ducted with family members of the victims, sur- tors. The police used hundreds of personnel from vivors and their families, people interacting with many law enforcement agencies for their investi- the families and survivors, and others. The fam- gation, and the panel did not have nor need the ily members were extended opportunities to resources to duplicate that effort. Rather, the speak to the panel in public or private sessions, panel obtained the benefit of much of the inves- as were the injured and some other survivors. tigative information from the law enforcement For these groups, everyone who requested an agencies. Interviews were conducted with survi- interview was given one. Not all wanted inter- vors, witnesses, and responders to validate the views. Some wanted group interviews. Some information received and to expand upon it. were ready to speak earlier or later than others. To further evaluate the actions taken by law To the best of the panel’s knowledge, and cer- enforcement, the university, and emergency tainly its intent, all were accommodated. The medical services against state and national stan- panel learned a great deal about the incident and dards and norms, panel members and staff also also confronted directly the indescribable grief conducted interviews with leaders in these fields and loss experienced by so many. From families outside the Virginia Tech community, from else- and survivors, the panel learned about the posi- where in Virginia and from other states. The tive aspects of the services provided after April panel also solicited their expert opinions on how 16 and also about the many perceived problems things might have been done better, and what with those services. The panel also considered things were done well that should be emulated. the many issues that the family members asked to be included in the investigation. This input

CHAPTER I. BACKGROUND AND SCOPE

was invaluable and substantially improved this In addition to the primary speakers, every public report. meeting included time for public comment. In some cases the people testifying were Most of the formal interviews were conducted by representatives of lobbying groups, one or two panel members, often with one or two organizations, and associations, but the panel TriData staff present. Some were conducted also heard from victims, family members of solely by staff. Generally, they were conducted in victims, independent experts, and concerned private. No recordings or written transcripts citizens. There was even one instance of a were made. All those interviewed were told that cameraman who put his camera down and the information they provided might be used in testified. Generally, the public presenters were the report but if they wished, they would not be expected to restrict themselves to a few minutes, quoted or identified. These steps were taken to and most did not abuse the opportunity. At one encourage candor and to protect remarks that meeting, more people wanted to speak than time were provided with the caveat that they not be available, even though the meeting was extended attributed to the speaker. The panel believes it an hour. Those not able to present information was able to obtain more candid and useful infor- still had the opportunity to submit it to the panel mation using this approach. Panel members and through letters, e-mails, or phone calls, and staff had many informal conversations with col- many did. leagues in their fields to obtain additional insights, generally not in formal settings. Web Site and Post Office Box – Shortly after the panel was formed, its staff created a – Especially toward the Literature Research web site that was used both to inform the public beginning of the review but continuing through- and to receive input from the public. It proved to out, much research was undertaken on various be very valuable. There was a minimum of spam topics through the Internet and through infor- or inappropriate inputs. The web site was used mation sources suggested by panel members and to post announcements of public meetings and to by individuals with whom the panel came into post presentations made or visual aids used at contact. Many useful references were submitted meetings. More than 400,000 “hits” were to the panel by the general public and experts. recorded, with 26,000 unique visitors. The web Public Meetings – A key part of the panel’s site also was advertised as a vehicle for anyone review process was a series of four public meet- to post information or opinions. As of August 9, ings held in different parts of the Commonwealth 2007, more than 2,000 comments were posted to accommodate those who wished to contribute from experts in various fields as well as the gen- information. The first meeting was held in Rich- eral public, victims, families of victims, and oth- mond at the state capitol complex, followed by ers as follows: meetings at Virginia Tech, George Mason Parents (self-identified) 251 University, and the University of Virginia. This General public 1,547 facilitated input from the public and officials of Educators 91 various universities on issues they all cared EMS 8 deeply about. Several other universities offered Students 48 facilities besides those chosen, including some Law enforcement officers 18 out of state. Each university site was fully sup- Family members of victims 12 ported by their leadership, public relations Health professionals 102 department, event planning staff, and campus Virginia Tech staff 2 police. The Virginia State Police provided added Total 2,079 protection at the meetings. (The agendas of the public meetings are given in Appendix C.) Most persons who submitted information to the web site appeared sincere about making a

CHAPTER I. BACKGROUND AND SCOPE

contribution. Some lobbying groups on issues dations regarding the methodology used by the such as gun control, carrying guns on campus, panel are presented in Appendix D; they were and the influence of video games on young people put in an appendix to avoid having the proce- clearly urged their members to post comments. dural issues distract the reader from the heart of the main issues. A post office box also was opened for the public to address comments directly to the panel. The The findings and related recommendations in number of letters received was much smaller this report are of two kinds. The first comes from than the number of e-mails but generally with a reviewing actions taken in a time of crisis: what high percentage of relevancy, especially from was done very well, and what could have been experts, families, and victims. done better. Almost any crisis actions can be improved, even if they were exemplary. Telephone Calls and E-Mails – Some information was received directly by panel mem- The second type of finding identifies major bers or staff through phone calls or e-mails. administrative or procedural failings leading up Much of this information was received by one to the events, such as failing to “connect the panel member or staff member and was shared dots” of Cho’s highly bizarre behavior; the miss- with others when thought important. ing records at Cook Counseling Center; insensitivity to survivors waiting to learn the fates of Panel Interactions – The members of the their children, siblings, or spouses; and fund- Virginia Tech Review Panel engaged on a per- raising that appeared opportunistic. sonal level, participating in the majority of interviews conducted and exchanging many e-mails To help in understanding the events, the report and phone calls among themselves and with the begins in Chapter II with a description of the panel staff. The panel was impeded by the FOIA setting of the Virginia Tech campus and its pre- rules that did not allow more than two members paredness for a disaster. In Chapter III, a to meet together or speak by phone without it detailed timeline serves as a reference through- being considered a public meeting. out the report—the succinct story of what happened, starting with Cho’s background, his FINDINGS AND RECOMMENDATIONS treatment, and then proceeding to the events of April 16 and its aftermath. The events are elabo- he panel’s findings and recommendations are rated in subsequent chapters. Tprovided throughout the report. Recommen-

Chapter II UNIVERSITY SETTING AND SECURITY

efore describing the details of the events, it CAMPUS POLICE AND OTHER LOCAL Bis necessary to understand the setting in LAW ENFORCEMENT which they took place, including the security situation at Virginia Tech at the time of the key element in the security of Virginia Tech shootings. This chapter focuses on the physical Ais its police department. It is considered security of the campus and its system for alert- among the leading campus police departments in ing the university community in an emergency. the state. While many campuses employ security It also gives a brief background on the campus guards, the Virginia Tech Police Department police department and the university’s Emer- (VTPD) is an accredited police force. Its officers gency Response Plan. The prevention aspect of are trained as a full-fledged police department security—including the identification of people with an emergency response team (ERT), which who pose safety threats—is discussed in Chapter is like a SWAT team. IV. The police chief reports to a university vice UNIVERSITY SETTING president.

irginia Tech occupies a beautiful, sprawling On April 16, the VTPD strength was 35 officers. Vcampus near the Blue Ridge Mountains in It had 41 positions authorized but 6 were vacant. southwest Virginia. It is a state school known for The day shift, which comes on duty at 7 a.m., has its engineering and science programs but with a 5 officers. Additionally, 9 officers work office wide range of other academic fields in the liberal hours, 8 a.m. to 5 p.m., including the chief, for a arts. total of 14 on a typical weekday morning. On April 16, approximately 34 of the officers came to The main campus has 131 major buildings work at some point during the day. spread over 2,600 acres. The campus is not enclosed; anyone can walk or drive onto it. There The campus police could not handle a major are no guarded roads or gateways. Cars can event by themselves with these numbers, and so enter on any of 16 road entrances, many of which they have entered into a mutual aid agreement are not in line of sight of each other. Pedestrians with the Blacksburg Police Department (BPD) can use sidewalks or simply walk across grassy for immediate response and assistance. They fre- areas to get onto the campus. Figure 1 shows quently train together, and had trained for an aerial views of the campus. There is a significant active shooter situation in a campus building amount of ongoing construction of new buildings before the incident. As will be seen, this prepara- and renovation of existing buildings, with associ- tion was critical. ated noise. The VT campus police also have excellent work- On April 16, the campus population was about ing relationships with the regional offices of the 34,500, as follows: state police, FBI, and ATF. The high level of cooperation was confirmed by each of the federal, 26,370 students (9,000 live in dorms) state, and local law enforcement agencies that 7,133 university employees (not were involved in the events on April 16, and by counting student employees) the rapidity of coordination of their response to 1,000 visitors, contractors, transit the incident and the investigation that followed. workers, etc. Training together, working cases together, and 34,503 Total

CHAPTER II. UNIVERSITY SETTING AND SECURITY

Figure 1. Aerial Views of Virginia Tech Campus

CHAPTER II. UNIVERSITY SETTING AND SECURITY

knowing each other on a first-name basis can be Many other school buildings are considered pub- critical when an emergency occurs and a highly lic spaces and are open 24 hours a day. The uni- coordinated effort is needed. versity encourages students to use the facilities for classwork, informal meetings, and officially The purpose of the Virginia Tech campus police sanctioned clubs and groups. is stated in the university’s Emergency Response Plan as follows: “The primary purpose Most classrooms, such as those in Norris Hall, of the VTPD is to support the academics have no locks. Staff offices generally do have through maintenance of a peaceful and orderly locks, including those in Norris Hall. community and through provision of needed There are no guards at campus buildings or general and emergency services.” Although some do not consider police department mission cameras at the entrances or in hallways of any statements of much importance versus how they buildings. Anyone can enter most buildings. It is actually operate, the mission statement may an open university. affect their role by indicating priorities. For Some buildings have loudspeaker systems example, it may influence a decision as to intended primarily for use of the fire depart- whether the university puts minimizing disrup- ment in an emergency. They were not envi- tion to the educational process first and acting sioned for use by police. They can only be used on the side of precaution second. There are by someone standing at a panel in each building many crimes and false alarms such as bomb and cannot be accessed for a campus-wide threats on campus, and it is often difficult to broadcast from a central location. make the decision on taking precautions that are disruptive. The police mission statement This level of security is quite typical of many also may affect availability of student informa- campuses across the nation in rural areas with tion. Explicitly including the police under the low crime rates. Some universities are partially umbrella of university officials may allow them or completely fenced, with guards at exterior to access student records under Family Educa- entrances; usually these are in urban areas. tional Rights and Privacy Act (FERPA) regula- Some universities have guards at the entrance tions. to each building and screen anyone coming in without student or staff identification, again Several leaders of the campus police chiefs of usually on urban campuses. Some universities Virginia commented that they do not always have locks on classroom doors, but they typically have adequate input into security planning and operate by key from the hallway. They are threat assessment or the authority to access intended to keep students and strangers out important information on students. when they are not in use and often cannot be locked from the inside. BUILDING SECURITY A few universities (e.g., Hofstra University in he residence halls on campus require plac- Nassau County, NY) now have the ability to Ting a student or staff keycard in an elec- lock the exterior doors of some or all buildings tronic card reader in order to enter between at the push of a button in a central security 10:00 p.m. and 10:00 a.m. A student access card office. Most require manual operation of locks. is valid only for his or her own dormitory and for Virginia Tech would have to call people in scores the mailbox area of another dormitory if one’s of buildings or send someone to the buildings to assigned mailbox is there. lock their outside doors (except for dormitories between 10 p.m. and 10 a.m. when they are locked automatically).

CHAPTER II. UNIVERSITY SETTING AND SECURITY

Many levels of campus security existed at col- Existing System – Virginia Tech had the capa- leges and universities across Virginia and the bility on April 16 to send messages to the stu- nation on April 16. A basic mission of institu- dent body, faculty, and other staff via a broad- tions of higher education is to provide a peace- cast e-mail system. The associate vice president ful, open campus setting that encourages free- for University Relations had the authority and dom of movement and expression. Different capability to send a message from anywhere institutions provide more or less security, often that was connected to the web. Almost every based on their locations (urban, suburban, or student and faculty member on campus has a rural), size and complexity (from research uni- computer and e-mail address (estimated at 96 versities to small private colleges), and percent by the university). Most but not all stu- resources. April 16 has become the 9/11 for col- dent computers are portable. Many are carried leges and universities. Most have reviewed their to classes. However, an e-mail message sent by security plans since then. The installation of the university may not get read by every user security systems already planned or in progress within minutes or even hours. The e-mail sys- has accelerated, including those at Virginia tem had 36,000 registered e-mail addresses. Tech. Distribution of an emergency message occurred at a rate of about 10,000 per minute. Although the 2004 General Assembly directed the Virginia State Crime Commission to study The university also has a web site that it uses to campus safety at Virginia’s institutions of post emergency warnings, mostly for weather higher education (HJR 122), the report issued events. The system has high-volume capacity. December 31, 2005, did not reflect the need for (As events unfolded on April 16, the VT web site urgent corrective actions. So far as the panel is was receiving 148,000 visits per hour.) An emer- aware, there was no outcry from parents, gency message can be put in a box on the web students, or faculty for improving VT campus site that anyone reaching the site would see no security prior to April 16. Most people liked the matter what they were looking for. relaxed and open atmosphere at Virginia Tech. The university also has contacts with every local There had been concern the previous August about an escaped convict and killer named radio and TV station. The Virginia Tech associ- William Morva whose escape in the VT vicinity ate vice president for University Relations has a code by which he can send emergency messages unnerved many people. Also, some campus assaults led some students to want to arm to the stations that could be played immedi- themselves. However, if the April 16 incident ately. This process could take 20 minutes or so because each station has its own code to vali- had not occurred, it is doubtful that security issues would be on the minds of parents and date the sender. The validation codes are neces- students more than at other universities, where sary because students or members of the public could send spoof messages to the media as a the most serious crimes tend to be rapes, assaults, and dangerous activity related to prank. The public media are used for the occa- alcohol or drug abuse by students. These issues sional weather emergencies, and the campus community is trained to tune in to get further were addressed by the State Crime Commission Report and were given an average level of information. attention at Virginia Tech. An estimated 96 percent of students at Virginia Tech carry cell phones according to the univer- CAMPUS ALERTING SYSTEMS sity. Most bring them to classes or wherever else they go. A text message to cell phones probably irginia Tech was in the process of upgrading its campus-wide alerting system in spring will reach more students faster than an e-mail V message because the devices are more portable 2007. and can be rung. But some are forgotten, turned

CHAPTER II. UNIVERSITY SETTING AND SECURITY

off, or intentionally not carried. The university was still in the process of installing a text messaging system on April 16 and had no way to send a message to all cell phones.

Personal digital assistants (or PDAs) such as Blackberries are used by fewer students and faculty than cell phones because they are more expensive and are not as capable as computers. They have the capacity to receive e-mails and would be treated either as a computer or as a phone or both, depending on how it is registered.

The university also has a broadcast phone-mail system that allows it to send a phone message to all phone numbers registered with its messaging system. VT used this system to send messages to all faculty offices and some students on April 16. Students and faculty must voluntarily register their phones with this system if they want to be notified. It takes time to reach all the phones; 11 separate actions are required to send a broadcast message to all reg- Figure 2. One of the Six Sirens Being istered numbers, said the associate vice presi- Installed on Virginia Tech Campus dent for University Relations. It is not a useful buildings to personally spread a warning. In approach when time is critical. Norris Hall, for example, the chairman of the A university switchboard with up to four opera- Engineering Mechanics Department, whose tors is working during normal business hours. It office was on the second floor, said he had been can handle hundreds of calls per hour. issued a bullhorn to make announcements and was instructed to rap on classroom and office To augment the range of messaging systems it doors to alert people if there was an emergency had available, the university was in the process and other notification systems failed, if a per- of installing six outdoor loudspeakers to make sonal approach was needed to convey safety emergency announcements. Some are mounted information, or if an evacuation or sheltering in on buildings and others on poles, as shown in place was required. Figure 2. They can be used for either a voice message or an audible alarm (such as a siren). New Unified Campus Alerting System – In Four had been installed and were used on April spring 2007, Virginia Tech was in the process of 16, but they did not play a significant role in installing a unified, multimedia messaging sys- this incident. (The announcement was made tem to be completed before the next semester. It after the 9:05 a.m. class period in which the would allow university officials to send an mass shooting had already started.) emergency message that would flow in parallel to computers, cell phones, PDAs, and tele- As part of its emergency planning, the univer- phones. The message could be sent by anyone sity has another system in place as a last-ditch who is registered in the system as having resort—using resident advisors in dorms and authority to send one, using a code word for floor wardens in some older classroom and office validation. The president of the university or associate vice president of University Relations

CHAPTER II. UNIVERSITY SETTING AND SECURITY

can be anywhere and send a message to every- students and staff quickly, but also planning one—all that is needed is an Internet connec- what to say and how quickly to say it. Pursuant tion. to its Emergency Response Plan in effect on April 16, the Virginia Tech Policy Group and the Students must be registered with the new sys- police chief could authorize sending an emer- tem to receive messages. A student can provide gency message to all students and staff. Typi- a mobile phone number, e-mail address(es), or cally, the police chief would make a decision instant messaging system to be contacted in an about the timing and content of a message after emergency. Parents’ numbers can be included. consultation with the Policy Group, which is All students and staff are encouraged but not comprised of the president and several other required to register with the new system. Each vice presidents and senior officials. This process user can set the priority order in which their of having the Policy Group decide on the mes- devices are to be called. The message will cas- sage was used during the April 16 incidents. cade through the hierarchy set by each user 1 However, while the Virginia Tech campus police until it gets answered. This system has the had the authority to send a message, they did enormous advantage of transmitting a message not have the technical means to do so. Only two to the entire university community in less than people, the associate vice president for Univer- a minute. sity Relations and the director of News and For the Virginia Tech community of about Information, had the codes to send a message. 35,000 users, the system will cost $33,000 a The police could not access the alerting system year to operate and no out-of-pocket expense to to send a message. . The police had to contact start. However, it takes considerable staff time the university leadership on the need and pro- to select a system and then oversee its startup. posed content of a message. As a matter of The operating cost is a function of the band- course, the police would usually be consulted if width used and the frequency of messages. The not directly involved in the decision regarding more people and devices on the system and the the sending of an alert for an emergency. more messages sent per year, the higher the There are no preset messages for different types cost. Initially, Virginia Tech is planning to use of emergencies, as some public agencies have in the system only for emergency messages. Other order to speed crafting of an emergency mes- schools have started using such systems for sage. All VT messages are developed for the par- more routine purposes such as sending informa- ticular incident. tion about special events on campus and administrative information, at an extra charge. The timing and content of the messages sent by Virginia Tech was willing to share the criteria it the university are one of the major controversies used in its selection of a messaging system concerning the events of April 16. (Chapter VIII (Appendix E). Several competing commercial addresses the double homicide at West Ambler options have excellent capabilities. Some are Johnston residence hall and the messaging deci- only suitable for small schools. Universities and sions that followed). colleges need to balance their needs and the system capability versus costs. EMERGENCY RESPONSE PLAN

Message Content and Authorization – A he university’s Emergency Response Plan critical part of security is not only having the Tdeals with preparedness and response to a technical communication capability of reaching variety of emergencies, but nothing specific to shootings. The version in effect on April 16 was

1 about 2 years old. Emergencies such as weather A system being developed sends a message to anyone within range of a tower or set of towers. It does not matter who you are or whether you have “registered”; if you have a cell phone and are in range, you get the message.

CHAPTER II. UNIVERSITY SETTING AND SECURITY

problems, fires, and terrorism were in the fore of gency response coordinator. The ERRG is sup- VT emergency planning pre-April 16.2 posed to meet at the EOC. Decisions made by these groups and their members on April 16 are The plan addresses different levels of emergen- addressed in the remainder of the report, as the cies, designated as levels 0, I, II, and III. The event is described. Norris Hall event was level III, the highest, based on the number of lives lost, the physical The VT Emergency Response Plan does not deal and psychological damage suffered by the with prevention of events, such as establishing a injured, and the psychological impact on a very threat assessment team to identify classes of large number of people. threats and to assess the risk of specific problems and specific individuals. There are threat The plan calls for an official to be designated as assessment models used elsewhere that have an emergency response coordinator (ERC) to proven successful. For example, at two college direct a response. It also calls for the establish- campuses in Virginia, the chief operating officer ment of an emergency operations center (EOC). receives daily reports of all incidents to which Satellite operations centers may be established law enforcement responded the previous day, to assist the ERC. As will be discussed in including violation of the student conduct code describing the response to the events, there up to criminal activity. This information is then were multiple coordinators and multiple opera- routinely shared with appropriate offices which tions centers but not a central EOC on April 16. are responsible for safety and health on campus. Two key decision groups are identified in the Emergency Response Plan: the Policy Group KEY FINDINGS and the Emergency Response Resources Group. he Emergency Response Plan of Virginia The Policy Group is comprised of nine vice presi- TTech was deficient in several respects. It did dents and support staff, chaired by the univer- not include provisions for a shooting scenario sity president. The Policy Group deals with pro- and did not place police high enough in the cedures to support emergency operations and to emergency decision-making hierarchy. It also determine recovery priorities. In the events of did not include a threat assessment team. And April 16, it also decided on the messages sent the plan was out of date on April 16; for exam- and the immediate actions taken by the univer- ple, it had the wrong name for the police chief sity after the first incident as well as the second and some other officials. mass shooting. The Policy Group sits above the emergency coordinator for an incident. It does The protocol for sending an emergency message not include a member of the campus police, but in use on April 16 was cumbersome, untimely, the campus police are usually asked to have a and problematic when a decision was needed as representative at its meetings. soon as possible. The police did not have the capability to send an emergency alert message The second key group, the Emergency Response on their own. The police had to await the delib- Resources Group (ERRG), includes a vice presi- erations of the Policy Group, of which they are dent designated to be in charge of an incident, not a member, even when minutes count. The police officials, and others depending on the Policy Group had to be convened to decide nature of the event. It is to ensure that the whether to send a message to the university resources needed to support the Policy Group community and to structure its content. and needs of the emergency are available. The ERRG is organized and directed by the emer- The training of staff and students for emergencies situations at Virginia Tech did not include 2 shooting incidents. A messaging system works Appendix F has an example of the “active shooter” part of the University of Virginia’s plan, and something similar more effectively if resident advisors in dormito- should be included in the Virginia Tech plan. ries, all faculty, and all other staff from janitors

CHAPTER II. UNIVERSITY SETTING AND SECURITY

to the president have instruction and training Virginia Tech did not have classroom door locks for coping with emergencies of all types. operable from the inside of the room. Whether to add such locks is controversial. They can block It would have been extremely difficult to “lock entry of an intruder and compartmentalize an down” Virginia Tech. The size of the police force attack. Locks can be simple manually operated and absence of a guard force, the lack of elec- devices or part of more sophisticated systems tronic controls on doors of most buildings other that use electromechanical locks operated from than residence halls, and the many unguarded a central security point in a building or even roadways pose special problems for a large rural university-wide. The locks must be easily or suburban university. The police and security opened from the inside to allow escape from a officials consulted in this review did not think fire or other emergency when that is the safer the concept of a lockdown, as envisioned for course of action. While adding locks to class- elementary or high schools, was feasible for an rooms may seem an obvious safety feature, some institution such as Virginia Tech. voiced concern that locks could facilitate rapes It is critical to alert the entire campus popula- or assaults in classrooms and increase univer- tion when there is an imminent danger. There sity liability. (An attacker could drag someone are information technologies available to rapidly inside a room at night and lock the door, block- send messages to a variety of personal commu- ing assistance.) On the other hand, a locked nication devices. Many colleges and universities, room can be a place of refuge when one is pur- including Virginia Tech, are installing such sued. On balance, the panel generally thought campus-wide alerting systems. Any purchased having locks on classroom doors was a good system must be thoroughly tested to ensure it idea. operates as specified in the purchase contract. Shootings at universities are rare events, an Some universities already have had problems average of about 16 a year across 4,000 institu- with systems purchased since April 16. tions. Bombings are rarer but still possible. An adjunct to a sophisticated communications Arson is more common and drunk driving inci- alert system is a siren or other audible warning dents more frequent yet. There are both simple device. It can give a quick warning that some- and sophisticated improvements to consider for thing is afoot. One can hear such alarms regard- improving security (besides upgrading the alert- less of whether electronics are carried, whether ing system). A risk analysis needs to be per- the electronics are turned off, or whether elec- formed and decisions made as to what risks to tric power (other than for the siren, which can protect against. be self-powered) is available. Upon sounding, There have been several excellent reviews of every individual is to immediately turn on some campus security by states and individual cam- communication device or call to receive further puses (for example, the states of Florida and instructions. Virginia Tech has installed a sys- Louisiana, the University of California, and the tem of six audible alerting devices of which four University of Maryland). The Commonwealth of were in place on April 16. Many other colleges Virginia held a conference on campus security and universities have done something similar. on August 13, 2007.

No security cameras were in the dorms or any- The VTPD and BPD were well-trained and had where else on campus on April 16. The outcome conducted practical exercises together. They had might have been different had the perpetrator of undergone active shooter training to prepare for the initial homicides been rapidly identified. the possibility of a multiple victim shooter. Cameras may be placed just at entrances to buildings or also in hallways. However, the The entire police patrol force must be trained in more cameras, the more intrusion on university the active shooter protocol, because any officer life. may be called upon to respond.

CHAPTER II. UNIVERSITY SETTING AND SECURITY

It was the strong opinion of groups of Virginia systems that will be used. An annual college and university presidents with whom the reminder provided as part of registration should panel met that the state should not impose be considered. required levels of security on all institutions, II-5 Universities and colleges must comply but rather let the institutions choose what they with the Clery Act, which requires timely think is appropriate. Parents and students can public warnings of imminent danger. and do consider security a factor in making a “Timely” should be defined clearly in the federal choice of where to go to school. law. Finally, the panel found that the VTPD statement of purpose in the Emergency Response CAMPUS ALERTING Plan does not reflect that law enforcement is the II-6 Campus emergency communications primary purpose of the police department. systems must have multiple means of sharing information. RECOMMENDATIONS II-7 In an emergency, immediate messages EMERGENCY PLANNING must be sent to the campus community that II-1 Universities should do a risk analysis provide clear information on the nature of (threat assessment) and then choose a level the emergency and actions to be taken The of security appropriate for their campus. nitial messages should be followed by update How far to go in safeguarding campuses, and messages as more information becomes known. from which threats, needs to be considered by II-8 Campus police as well as administra- each institution. Security requirements vary tion officials should have the authority and across universities, and each must do its own capability to send an emergency message. threat assessment to determine what security Schools without a police department or senior measures are appropriate. security official must designate someone able to II-2 Virginia Tech should update and make a quick decision without convening a enhance its Emergency Response Plan and committee. bring it into compliance with federal and POLICE ROLE AND TRAINING state guidelines. II-9 The head of campus police should be a II-3 Virginia Tech and other institutions of member of a threat assessment team as well higher learning should have a threat as the emergency response team for the assessment team that includes representa- university. In some cases where there is a tives from law enforcement, human security department but not a police depart- resources, student and academic affairs, ment, the security head may be appropriate. legal counsel, and mental health functions. The team should be empowered to take actions II-10 Campus police must report directly to such as additional investigation, gathering the senior operations officer responsible for background information, identification of addi- emergency decision making. They should be tional dangerous warning signs, establishing a part of the policy team deciding on emergency threat potential risk level (1 to 10) for a case, planning. preparing a case for hearings (for instance, commitment hearings), and disseminating II-11 Campus police must train for active warning information. shooters (as did the Virginia Tech Police Department). Experience has shown that wait- II-4 Students, faculty, and staff should be ing for a SWAT team often takes too long. The trained annually about responding to various emergencies and about the notification

CHAPTER II. UNIVERSITY SETTING AND SECURITY

best chance to save lives is often an immediate mindset, with the police yielding to academic assault by first responders. considerations when it comes time to make decisions on, say, whether to send out an alert to the II-12 The mission statement of campus students that may disrupt classes. On the other police should give primacy to their law hand, it is useful to identify the police as being enforcement and crime prevention role. involved in the education role in order for them They also must to be designated as having a to gain access to records under educational pri- function in education so as to be able to review vacy act provisions. records of students brought to the attention of the university as potential threats. The lack of Specific findings and recommendations on police emphasis on safety as the first responsibility of actions taken on April 16 are addressed in the the police department may create the wrong later chapters.

Chapter III TIMELINE OF EVENTS

he following timeline provides an overview of family. He has serious health problems from Tthe events leading up to the tragedy on April 9 months to 3 years old, is frail, and after 16, and then the actions taken on April 16. The unpleasant medical procedures does not time scale switches from years to months to days want to be touched. and even to minutes as appropriate. This infor- 1992 Cho’s family emigrates to Mary- mation is a reference source to use as one reads land when he is 8 years old. the chapters. 1993 The Cho family moves to Fairfax The information here was drawn from numerous County, Virginia, when he is 9 years old. interviews and written sources. The Cho family They work long hours in a dry-cleaning and Seung Hui Cho’s school administrators, business. counselors, teachers, and medical and school records are the prime sources for his history 1997 Seung Hui in the 6th grade con- prior to attending Virginia Tech. tinues to be very withdrawn. Teachers meet with his parents about this behavior. In the Information obtained on his university years summer before he enters 7th grade, he before the shootings came from interviews with begins receiving counseling at the Center for faculty, counselors, administrators, police, Multi-cultural Human Services to address courts, psychological evaluators, suitemates, and his shy, introverted others. The panel also had access to many uni- nature, which is diagnosed as “selective versity, medical, and court records and to e-mails mutism.” Parents try to socialize him more and other written materials involving Cho. by encouraging extracurricular activities The timeline for the events of April 16 relied pri- and friends, but he stays withdrawn. marily on state and campus police reports and 1999 During the 8th grade, suicidal interviews, supplemented by interviews with and homicidal ideations are identified by survivors, university officials, emergency medical Cho’s middle school teachers in his writing. responders, hospitals and others. It is connected to the Columbine shootings The information on the aftermath drew on medi- this year. (He references Columbine in cal examiner records, interviews with families, school writings.) The school requests that and other sources. his parents ask a counselor to intervene, which leads to a psychiatric evaluation at Each aspect of the timeline is discussed further the Multicultural Center for Human Ser- in the following chapters, with an evaluation as vices. He is prescribed antidepressant medi- well as narration of events. cation. He responds well and is taken off the medication approximately one year later. PRE-INCIDENTS: CHO’S HISTORY

2000–2003 (High School) 1986–2000 Fall 2000 Cho starts Westfield High School 1984 Seung Hui Cho is born to a in Fairfax County as a sophomore, after at- family living in a small two-room apartment tending another high school at Centreville in Seoul, South Korea. He is an inordinately for a year. After review by the “local screen- shy, quiet child, but no problem to his ing committee,” he is enrolled in an

CHAPTER III. TIMELINE OF EVENTS

Individual Educational Program (IEP) to 2005 (Virginia Tech) deal with his shyness and lack of respon- siveness in a classroom setting. Therapy Spring 2005 Cho requests a change of major to continues with the Multicultural Center for English. The idea for a book sent to a New Human Services through his junior year. He York publishing house is rejected. This has no behavior problems, keeps his ap- seems to depress him, according to his fam- pointments, and makes no threats. He gets ily. He still sees no counselor at school or good grades and adjusts reasonably to the home, and exhibits no behavioral problems school environment. Both the guidance other than his quietness. office in school and the therapist feel he was Fall 2005 Cho starts junior year and moves successful. back into the dorms. Serious problems begin June 2003 Cho graduates from Westfield to surface. His sister notes that he is writing High School with a 3.5 GPA in the Honors less at home, is less enthusiastic, and won- Program. He decides to attend Virginia Tech ders if the publisher’s rejection letter curbed against the advice of his parents and coun- his enthusiasm for writing and reversed his selors, who think that it is too large a school improving attitude. At school, Cho is taken for him and that he will not receive ade- to some parties by his suitemates at the quate individual attention. He is given the start of the fall semester. He stabs at the name of a contact at the high school if he carpet in a girl’s room with a knife in the needs help in college, but never avails him- presence of his suitemates. self of it. Professor Nikki Giovanni, Cho’s poetry professor, is concerned about violence in his 2003–2004 (Virginia Tech) writing. She also asks him to stop taking pictures of classmates from a camera held August 2003 Cho enters Virginia Tech as a under the desk. She offers to get him into business information systems major. Little another class and writes a letter to English attention is drawn to him during his fresh- Department Chair Lucinda Roy to create a man year. He has a difficult time with his record that could lead to removing Cho from roommate over neatness issues and changes her class. rooms. His parents make weekly trips to visit him. His grades are good. He does not Dr. Roy removes Cho from Professor see a counselor at school or home. He is Giovanni’s class and tutors him one-on-one excited about college. with assistance from Professor Frederick D’Aguiar. When Cho refuses to go to coun- Fall 2004 Cho begins his sophomore year. seling, Dr. Roy notifies the Division of Cho moves off campus to room with a senior Student Affairs, the Cook Counseling who is rarely at home. Cho complains of Center, the Schiffert Health Center, the mites in the apartment, but doctors tell him Virginia Tech police, and the College of it is acne and prescribe minocycline. He Liberal Arts and Human Sciences. Cho’s becomes interested in writing and decides to problems are discussed with the university’s switch his major to English beginning his Care Team that reviews students with junior year. He submits the paperwork late problems. that sophomore year. His sister notes a growing passion for writing over the sum- November 27 A female resident of WAJ files a mer break, though he is secretive about its report with the Virginia Tech Police content. Cho submits a book idea to a pub- Department (VTPD) indicating that Cho lishing house. had made “annoying” contact with her on the Internet, by phone, and in person. The

CHAPTER III. TIMELINE OF EVENTS

VTPD interviews Cho, but the female stu- Before 11 a.m. A staff psychiatrist at Carilion dent declines to press charges. The investi- evaluates Cho, concludes he is not a danger gating officer refers Cho to the school’s dis- to himself or others, and recommends outpa- ciplinary system, the Office of Judicial tient counseling. He gathers no collateral in- Affairs. formation.

November 30 Cho calls Cook Counseling Cen- 11-11:30 a.m. Special Justice Paul M. Barnett ter and is triaged (i.e., given a preliminary conducts Cho’s commitment hearing and screening) by phone at following his interac- rules in accordance with the independent tion with VTPD police. evaluator, but orders follow-up treatment as an outpatient. Cho then makes and keeps December 6 E-mails among resident advisors an appointment with the campus Cook (RAs) reflect complaints by a female resi- Counseling Center. dent in Cochrane residence hall regarding instant messages (IMs) from Cho sent under Noon The staff psychiatrist dictates in various strange aliases. E-mails also report his evaluation summary that “there is no that he went in disguise to a female stu- indication of psychosis, delusions, suicidal or dent’s room (the event of November 27). homicidal ideation.” The psychiatrist finds that “his insight and judgment are nor- December 12 A female student from Campbell mal.…Followup and aftercare to be Hall files a report with the VTPD complain- arranged with the counseling center at ing of “disturbing” IMs from Cho. She Virginia Tech; medications, none.” Cho is requests that Cho have no further contact released. with her. 3:00 p.m. Cho is triaged in person at the Cho does not keep a 2:00 p.m. appointment Cook Counseling Center for the third time at Cook Counseling Center but is triaged by in 15 days. them again by phone that afternoon.

December 13 VTPD notifies Cho that he is to 2006 have no further contact with the second female student who complained. After cam- January The Cook Counseling Center pus police leave, Cho’s suitemate receives an receives a psychiatric summary from St. IM from Cho stating, “I might as well kill Albans. No action is taken by Cook Counsel- myself now.” The suitemate alerts VTPD. ing Center or the Care Team to follow up on The police take Cho to the VTPD where a Cho. prescreener from the New River Valley April 17 Cho’s technical writing professor, Community Services Board evaluates him Carl Bean, suggests that Cho drop his class as “an imminent danger to self or others.” A after repeated efforts to address shortcom- magistrate issues a temporary detaining ings in class and inappropriate choice of order, and Cho is transported to Carilion St. writing assignments. Cho follows the profes- Albans Psychiatric Hospital for an overnight sor to his office, raises his voice angrily, and stay and mental evaluation. is asked to leave. Bean does not report this December 14 incident to university officials.

7 a.m. The person assigned as an inde- Spring Cho writes a paper for Professor pendent evaluator, psychologist Roy Crouse, Hicok’s creative writing class concerning a evaluates Cho and concludes that he does young man who hates the students at his not present an imminent danger to himself. school and plans to kill them and himself. The writing contains a number of parallels

CHAPTER III. TIMELINE OF EVENTS

to the events of April 16, 2007 and the re- March 23 Cho purchases three additional corded messages later sent to NBC. 10-round magazines from another eBay seller. September 6–12 Professor Lisa Norris, another of Cho’s writing professors, alerts the Associ- March 31 Cho purchases additional ammu- ate Dean of Liberal Arts and Human nition magazines, ammunition, and a hunt- Sciences, Mary Ann Lewis, about him, but ing knife from Wal-Mart and Dick’s Sport- the dean finds “no mention of mental health ing Goods. He buys chains from Home issues or police reports” on Cho. Professor Depot. Norris encourages Cho to go to counseling with her, but he declines. April 7 Cho purchases more ammunition. April 8 Cho spends the night at the Fall Professor Falco, another of Cho’s writing instructors, confers with Professors Hampton Inn in Christiansburg, Virginia, videotaping segments for his manifesto-like Roy and Norris, who tell him that Dr. Roy in Fall 2005 and Professor Norris in 2006 diatribe. He also buys more ammunition. alerted the Associate Dean of Students, April 13 Bomb threats are made to Mary Ann Lewis, about Cho. Torgersen, Durham, and Whittemore halls, in the form of an anonymous note. The 2007 threats are assessed by the VTPD; and the buildings evacuated. There is no lockdown February 2 Cho orders a .22 caliber Walther or cancellation of classes elsewhere on cam- P22 handgun online from TGSCOM, Inc. pus. In retrospect, no evidence is found link- ing these threats to Cho’s later bomb threat February 9 Cho picks up the handgun from in Norris Hall, based in part on handwriting J-N-D Pawnbrokers in Blacksburg, across analysis. the street from the university. April 14 An Asian male wearing a hooded March 12 Cho rents a van from Enterprise garment is seen by a faculty member in Rent-A-Car at the Roanoke Regional Air- Norris Hall. She later (after April 16) tells port, which he keeps for almost a month. police that one of her students had told her (Cho videotapes some of his subsequently the doors were chained. This may have been released diatribe in the van.) Cho practicing. Cho buys yet more ammuni- March 13 Cho purchases a 9mm Glock 19 tion. handgun and a box of 50 9mm full metal April 15 Cho places his weekly Sunday jacket practice rounds at Roanoke Firearms. night call to his family in Fairfax County. He has waited the 30 days between gun pur- They report the conversation as normal and chases as required in Virginia. The store ini- that Cho said nothing that caused them con- tiates the required background check by cern. police, who find no record of mental health issues. THE INCIDENTS March 22 Cho goes to PSS Range and Training, an indoor pistol range, and spends April 16, 2007 an hour practicing. 5:00 a.m. In Cho’s suite in Harper Hall March 22 Cho purchases two 10-round (2121), one of Cho’s suitemates notices Cho magazines for the Walther P22 on eBay. is awake and at his computer.

CHAPTER III. TIMELINE OF EVENTS

About 5:30 a.m. One of Cho’s other suitemates 7:26 a.m. VT Rescue Squad 3 arrives on- notices Cho clad in boxer shorts and a shirt scene outside WAJ. brushing his teeth and applying acne cream. Cho returns from the bathroom, gets 7:29 a.m. VT Rescue Squad 3 arrives at room 4040. dressed, and leaves. 7:30 a.m. Additional VTPD officers begin 6:47 a.m. Cho is spotted by a student waiting outside the West Ambler Johnston arriving at room 4040. They secure the (WAJ) residential hall entrance, where he crime scene and start preliminary investigation. Interviews of residents find them has his mailbox. unable to provide a suspect description. No 7:02 a.m. Emily Hilscher enters the dorm one on Hilscher’s floor in WAJ saw anyone after being dropped off by her boyfriend (the leave room 4040 after the initial noise was time is based on her swipe card record). heard.

About 7:15 a.m. Cho shoots Hilscher in her room 7:30–8:00 a.m. A friend of Hilscher’s arrives at (4040) at WAJ. He also shoots Ryan Chris- WAJ to join her for the walk to chemistry topher Clark, an RA. Clark, it is thought, class. She is questioned by detectives and most likely came to investigate noises in explains that on Monday mornings Hil- Hilscher’s room, which is next door to his. scher’s boyfriend would drop her off and go Both of the victims’ wounds prove to be back to Radford University where he was a fatal. student. She tells police that the boyfriend is an avid gun user and practices using the 7:17 a.m. Cho’s access card is swiped at gun. This leads the police to seek him as a Harper Hall (his residence hall). He goes to “person of interest” and potential suspect. his room to change out of his bloody clothes. 7:40 a.m. VTPD Chief Flinchum is notified 7:20 a.m. The VTPD receives a call on their by phone of the WAJ shootings. administrative telephone line advising that a female student in room 4040 of WAJ had 7:51 a.m. Chief Flinchum contacts the possibly fallen from her loft bed. The caller Blacksburg Police Department (BPD) and was given this information by another WAJ requests a BPD evidence technician and resident near room 4040 who heard the BPD detective to assist with the investiga- noise. tion.

7:21 a.m. The VTPD dispatcher notifies the 7:57 a.m. Chief Flinchum notifies the Virginia Tech Rescue Squad that a female Virginia Tech Office of the Executive Vice student had possibly fallen from her loft bed President of the shootings. This triggers a in WAJ. A VTPD officer is dispatched to meeting of the university’s Policy Group. room 4040 at WAJ to accompany the Vir- 8:00 a.m. Classes begin. Chief Flinchum ginia Tech Rescue Squad, which is also dis- arrives at WAJ and finds VTPD and BPD patched (per standard protocol). detectives on the scene and the investigation 7:24 a.m. The VTPD officer arrives at WAJ underway. A local special agent of the state room 4040, finds two people shot inside the police has been contacted and is responding room, and immediately requests additional to the scene. VTPD resources. 8:10 –9:25 a.m. Chief Flinchum provides updated 7:25 a.m. Cho accesses his university information via phone to the Virginia Tech e-mail account (based on computer records). Policy Group regarding progress made in He erases his files and the account.

CHAPTER III. TIMELINE OF EVENTS

the investigation. He informs them of a pos- 9:01 a.m. Cho mails a package from the sible suspect, who is probably off campus. Blacksburg post office to NBC News in New York that contains pictures of himself hold- 8:11 a.m. BPD Chief Kim Crannis arrives ing weapons, an 1,800-word rambling dia- on scene. tribe, and video clips in which he expresses 8:13 a.m. Chief Flinchum requests addi- rage, resentment, and a desire to get even tional VTPD and BPD officers to assist with with oppressors. He alludes to a coming securing WAJ entrances and with the inves- massacre. Cho prepared this material in the tigation. previous weeks. The videos are a performance of the enclosed writings. Cho also mails 8:15 a.m. Chief Flinchum requests the a letter to the English Department attack- VTPD Emergency Response Team (ERT) to ing Professor Carl Bean, with whom he pre- respond to the scene and then to stage in viously argued. Blacksburg in the event an arrest is needed or a search warrant is to be executed. 9:05 a.m. Classes begin for the second period in Norris Hall. 8:16–9:24 a.m. Officers search for Hilscher’s boyfriend. His vehicle is not found in campus 9:15 a.m. Both police ERTs are staged at parking lots, and officers become more con- the BPD in anticipation of executing search fident that he has left the campus. VTPD warrants or making an arrest. and BPD officers are sent to his home; he is 9:15–9:30 a.m. Cho is seen outside and then not found. A BOLO (be on the lookout) inside Norris Hall, an engineering building. report is issued to BPD and the Montgomery He chains the doors shut on the three main County Sheriff’s Office for his vehicle. entrances from the inside. No one reports Meanwhile, officers continue canvassing seeing him do this. WAJ for possible witnesses. VTPD, BPD, and the Virginia State Police (VSP) continue 9:24 a.m. A Montgomery County, Virginia processing the room 4040 crime scene and deputy sheriff initiates a traffic stop of gathering evidence. Investigators secure Hilsher’s boyfriend off campus in his pickup identification of the victims. truck. Detectives are sent to assist with the questioning. 8:19 a.m. Chief Crannis requests BPD ERT to respond for the same reason as the VTPD 9:25 a.m. A VTPD police captain joins the ERT. Virginia Tech Policy Group as police liaison and provides updates as information 8:20 a.m. A person fitting Cho’s description becomes available. is seen near the Duck Pond on campus. 9:26 a.m. Virginia Tech administration 8:25 a.m. The Virginia Tech Policy Group sends e-mail to campus staff, faculty, and meets to plan on how to notify students of students informing them of the dormitory the homicides. shooting. 8:52 a.m. Blacksburg public schools lock 9:31–9:48 a.m. A VSP trooper arrives at the traf- their outer doors upon hearing of the inci- fic stop of the boyfriend and helps question dent at WAJ from their security chief, who him. A gunpowder residue field test is per- had heard of the incident on police radio. formed on him and the result is negative. 9:00 a.m. The Policy Group is briefed on the latest events in the ongoing dormitory homicide investigation by the VTPD.

CHAPTER III. TIMELINE OF EVENTS

1 About 9:40 a.m. until about 9:51 a.m. Cho dispatcher initially has difficulty under- begins shooting in room 206 in Norris Hall, standing the location of the shooting. Once where a graduate engineering class in identified as being on campus, the call is Advanced Hydrology is underway. Cho kills transferred to VTPD. Professor G. V. Loganathan and other students in the class, killing 9 and wounding 3 9:42 a.m. The first 9-1-1 call reporting shots fired reaches the VTPD. A message is of the 13 students. sent to all county EMS units to staff and Cho goes across the hall from room 206 and respond. enters room 207, an Elementary German class. He shoots teacher Christopher James 9:45 a.m. The first police officers arrive at Bishop, then students near the front of the Norris Hall, a three-minute response time classroom and starts down the aisle shoot- from their receipt of the call. Hearing shots, ing others. Cho leaves the classroom to go they pause briefly to check whether they are back into the hall. being fired upon, then rush to one entrance, then another, and then a third but find all Students in room 205, attending Haiyan three chained shut. Attempts to shoot open Cheng’s class on Issues in Scientific Com- the locks fail. puting, hear Cho’s gunshots. (Cheng was a graduate assistant substituting for the pro- About 9:45 a.m. The police inform the admini- fessor that day.) The students barricade the stration that there has been another shoot- door and prevent Cho’s entry despite his firing. University President Steger hears ing at them through the door. sounds like gunshots, and sees police running toward Norris Hall. Meanwhile, in room 211 Madame Jocelyne Couture-Nowak is teaching French. She and Back in room 207, the German class, two her class hear the shots, and she asks stu- uninjured students and two injured student Colin Goddard to call 9-1-1. A student dents go to the door and hold it shut with tells the teacher to put the desk in front of their feet and hands, keeping their bodies the door, which is done but it is nudged open away. Within 2 minutes, Cho returns. He by Cho. Cho walks down the rows of desks beats on the door and opens it an inch and shooting people. Goddard is shot in the leg. fires shots around the door handle, then Student Emily Haas picks up the cell phone gives up trying to get in. Goddard dropped. She begs the police to Cho returns to room 211, the French class, hurry. Cho hears Haas and shoots her, graz- and goes up one aisle and down another, ing her twice in the head. She falls and shooting people again. Cho shoots Goddard plays dead, though keeping the phone cra- again twice more. dled under her head and the line open. Cho says nothing on entering the room or during A janitor sees Cho in the hall on the second the shooting. (Three students who pretend floor loading his gun; he flees downstairs. to be dead survive.) Cho tries to enter room 204 where engineer- 9:41 a.m. A BPD dispatcher receives a call ing professor Liviu Librescu is teaching regarding the shooting in Norris Hall. The Mechanics. Librescu braces his body against the door yelling for students to head for the window. He is shot through the door. Stu- 1The panel estimates that the shooting began at this time dents push out screens and jump or drop to based on the time it took for the students and faculty in the grass or bushes below the window. Ten room next door to recognize that the sounds being heard were gunshots, and then make the call to 9-1-1. students escape this way. The next two students trying to escape are shot. Cho

CHAPTER III. TIMELINE OF EVENTS

returns again to room 206 and shoots more • Police officials assign the additional students. responding law enforcement personnel.

9:50 a.m. Using a shotgun, police shoot At Norris Hall, the first team of officers open the ordinary key lock of a fourth begins— entrance to Norris Hall that goes to a • Securing the second floor. machine shop and that could not be chained. The police hear gunshots as they enter the • Triaging the 48 gunshot victims and building. They immediately follow the aiding survivors in multiple classrooms. sounds to the second floor. • Coordinating rescue efforts to remove Triage and rescue of victims begin. survivors from Norris Hall.

A second e-mail is sent by the administra- • Gathering preliminary suspect or gun- tion to all Virginia Tech e-mail addresses man descriptions. announcing that “A gunman is loose on campus. Stay in buildings until further • Determining if additional gunmen notice. Stay away from all windows.” Four exist. loudspeakers out of doors on poles broadcast 9:52 a.m. The police clear the second floor a similar message. of Norris Hall. Two tactical medics attached Virginia Tech and Blacksburg police ERTs to the ERTs, one medic from Virginia Tech arrive at Norris Hall, including one para- Rescue and one from Blacksburg Rescue, are medic with each team. allowed to enter to start their initial triage.

9:51 a.m. Cho shoots himself in the head 9:53 a.m. The 9:42 a.m. request for all EMS just as police reach the second floor. Investi- units is repeated. gators believe that the police shotgun blast 10:08 a.m. A deceased male student is dis- alerted Cho to the arrival of the police. Cho’s covered by police team and suspected to be shooting spree in Norris Hall lasted about the gunman: 11 minutes. He fired 174 rounds, and killed 30 people in Norris Hall plus himself, and • No identification is found on the body. wounded 17. • He appears to have a self-inflicted gun- While the shootings at Norris Hall were shot wound to the head. occurring, police were taking the following actions in connection with the shootings at • He is found among his victims in class- WAJ: room 211, the French class.

• Officers canvass WAJ for possible • Two weapons are found near the body. witnesses. 10:17 a.m. A third e-mail from Virginia Tech • VTPD, BPD, and VSP process the room administration cancels classes and advises 4040 crime scene and gather evidence. people to stay where they are.

• Officers search interior and exterior 10:51 a.m. All patients from Norris Hall waste containers and surrounding have been transported to a hospital or areas near WAJ for evidence. moved to a minor treatment unit.

• Officers canvass rescue squad 10:52 a.m. A fourth e-mail from Virginia personnel for additional evidence or Tech administration warns of “a multiple information. shooting with multiple victims in Norris

CHAPTER III. TIMELINE OF EVENTS

Hall,” saying the shooter has been arrested George W. Bush, Virginia Governor Tim and that police are hunting for a possible Kaine (who had returned from Japan), second shooter. Virginia Tech President Charles Steger, Virginia Tech Vice President for Student 10:57 a.m. A report of shots fired at the ten- Affairs Zenobia L. Hikes, local religious nis courts near Cassell Coliseum proves leaders (representing the Muslim, Buddhist, false. Jewish, and Christian communities), Pro- 12:42 p.m. University President Charles vost Dr. Mark G. McNamee, Dean of Stu- Steger announces that police are releasing dents Tom Brown, Counselor Dr. Christo- people from buildings and that counseling pher Flynn, and poet and Professor Nikki centers are being established. Giovanni.

1:35 p.m. A report of a possible gunshot 8:00 p.m. A candlelight vigil is held on the near Duck Pond proves to be another false Virginia Tech drill field. alarm. 11:30 p.m. The first autopsy is completed. 4:01 p.m. President George W. Bush speaks to the Nation from the White House regard- April 18, 2007 ing the shooting. 8:25 a.m. A SWAT team enters Burruss 5:00 p.m. The first deceased victim is Hall, a campus building next to Norris Hall, transported to the medical examiner’s office. responding to a “suspicious event”; this 8:45 p.m. The last deceased victim is proved to be a false alarm. transported to the medical examiner’s office. 4:37 p.m. Local police announce that NBC Evening A search warrant is served for News in New York received by mail this day the residence of the first victim’s boyfriend. a package containing images of Cho holding Investigators continue investigating weapons, his writings, and his video whether he is linked to the first crime; the recordings. NBC immediately submitted two crimes are not yet connected for certain. this information to the FBI. A fragment of the video and pictures are widely broadcast. POST-INCIDENT April 19, 2007 April 17, 2007 VT announces that all students who were 9:15 a.m. VTPD releases the name of the killed will be granted posthumous degrees shooter as Cho Seung Hui and confirms 33 in the fields in which they were studying. fatalities between the two incidents. (The degrees are subsequently awarded to the families at the regular commencement 9:30 a.m. VT announces classes will be exercises.) cancelled “for the remainder of the week to allow students the time they need to grieve Virginia Governor Kaine selects an inde- and seek assistance as needed.” pendent Virginia Tech Review Panel to detail the April 16 shootings. 11:00 a.m. A family assistance center is established at The Inn at Virginia Tech. Autopsies on all victims are completed by the medical examiner. The autopsy of Cho 2:00 p.m. A convocation ceremony is held found no gross brain function abnormalities for the university community at the Cassell Coliseum. Speakers include President

CHAPTER III. TIMELINE OF EVENTS

and no toxic substances, drugs, or alcohol April 20, 2007 that could explain the rampage. Governor Kaine declares a statewide day of mourning.

30 Chapter IV MENTAL HEALTH HISTORY OF SEUNG HUI CHO

This chapter is divided into two parts: Part A, the mental health history of Cho, and Part B, a discussion of Virginia’s mental health laws.

Part A – Mental Health History of Seung Hui Cho

Virginia Tech, and various medical offices and ne of the major charges Governor Kaine mental health treatment centers. Ogave to the panel was to develop a profile of Cho and his mental health history. In this • Interviews with high school staff and adminis- chapter, developmental periods of Cho’s life trators where Cho attended school, faculty are discussed, followed by an assessment and and staff at Virginia Tech, and several of recommendations to address policy gaps or Cho’s suitemates, roommates, and resident system flaws. The chapter details his involun- advisors in the dormitories. tary commitment for mental health treatment • Interviews with staff at the Center for Multi- while at Virginia Tech. It also examines the cultural Human Services, the Cook Counsel- particular warning signs during Cho’s junior ing Center, the Carilion Health System, spe- year at Virginia Tech and the university’s cial justices, and Virginia Tech police. ability to identify and respond appropriately • The tape and written records of Cho’s hearing to students who may present a danger to before special justice Barnett. themselves and others. • The report of the Inspector General for Mental Information was gleaned from many sources. Health, Mental Retardation and Substance One of the most significant was a 3-hour Abuse Services, Investigation of April 16, 2007 interview with Cho’s parents and sister. The Critical Incident at Virginia Tech. family stated that they were willing to help in any way with the panel’s work, and felt inca- EARLY YEARS pable of redressing the loss for other families. ho was born in Korea on January 18, 1984, They expressed heartfelt remorse, and they the second child of Sung-Tae Cho and Hyang apologized to the families whose spouse, son, C Im Cho. Both parents were raised in two-parent or daughter was murdered or injured. The families that included the paternal grandmother; Cho’s have said that they will mourn, until there was extended family support. The families the day they die, the deaths and injuries of did not encounter the level of deprivation that those who suffered at the hands of their son. many did in post-war Korea. The Chos recall that Cho’s sister, Sun, interpreted the answers to a paternal uncle in Korea committed suicide. every question posed to Mr. and Mrs. Cho. At Their first child, daughter Sun Kyung, was born 3 the end of the interview, they had portrayed years before Seung Hui. the person they knew as a son and brother, When he was 9 months old, Cho developed someone who was startlingly different from whooping cough, then pneumonia, and was the one who carried out premeditated murder. hospitalized. Doctors told the Chos that their son Other sources of information included: had a hole in his heart (some records say “heart murmur”). Two years later, doctors conducted • Hundreds of pages of transcripts and cardiac tests to better examine the inside of his records from Westfield High School, heart that included a procedure (probably an

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

echocardiograph or a cardiac catherization). Sun and her parents recall that Cho seemed to be This caused the 3-year-old emotional trauma. doing better. He was enrolled in a Tae Kwon Do From that point on, Cho did not like to be program for awhile, watched TV, and played video touched. He generally was perceived as games like Sonic the Hedgehog. None of the video medically frail. According to his mother, he games were war games or had violent themes. He cried a lot and was constantly sick. liked basketball and had a collection of figurines and remote controlled cars. Years later when he In Korea, Cho had a few friends that he would was in high school, Cho was asked to write about play with and who would come over to the his hobbies and interests. He wrote: house. He was extremely quiet but had a sweet nature. In Korea, quietness and calm- I like to listen to talk shows and alternative ness are desired attributes—characteristics stations, and I like action movies…My favorite movie is X-Men, favorite actor is Nicolas equated with scholarliness; even so, his intro- Cage, favorite book is Night Over Water, fa- verted personality was so extreme that his vorite band is U2, favorite sport is basketball, family was very concerned. favorite team is Portland Trailblazers, favorite food is pizza, and favorite color is green. In 1992, the family moved to the United States to pursue educational opportunities for Transportation to and from extracurricular activi- their children. They were encouraged by Mr. ties was a problem because both parents worked Cho’s sister who had immigrated before them. long hours trying to save money to buy a town- Mrs. Cho began working outside the home for house, which they accomplished a few years later. the first time in order to make ends meet. The The parents recalled that Cho had to wait for transition was difficult: none of the family transport back and forth all the time. spoke English. Both children felt isolated. The The parents reported no disciplinary problems parents began a long period of hard labor and with their son. He was quiet and gentle and did extended work hours at dry cleaning busi- not exhibit tantrums or angry outbursts. The fam- nesses. English was not required to do their ily never owned weapons or had any in the house. work, so both there and at home they spoke At one point after Cho was in college, his mother Korean. found a pocket knife in one of his drawers, and Sun stated that her brother seemed more she expressed her disapproval. He had few duties withdrawn and isolated in the United States or responsibilities at home, except to clean his than he had been in Korea. She recalled that room. He never had a job during summers or over at times they were “made fun of,” but she took school breaks, either in high school or in college. it in stride because she thought “this was just The biggest issue between Cho and his family was a given.” In about 2 years, the children began his poor communication, which was frustrating to understand, read, and write English at and worrisome to them. Over the years, Cho spoke school. Korean was spoken at home, but Cho very little to his parents and avoided eye contact. did not write or read Korean. According to one record the panel reviewed, Mrs. For the first 6 months in the United States, Cho would get so frustrated she would shake him the Chos lived with family members in Mary- sometimes. He would talk to his sister a little, but land. They moved to a townhouse for 1 year, avoided discussing his feelings and reactions to after which they relocated to Virginia, living things or sharing everyday thoughts on life, in an apartment for 3 years. The move to Vir- school, and events. If called upon to speak when a ginia occurred in the middle of third grade for visitor came to the home, he would develop sweaty Cho. He was 9 years old. Cho’s only known palms, become pale, freeze, and sometimes cry. friendship was with a boy next door with Frequently, he would only nod yes or no. whom he went swimming.

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

Mrs. Cho made a big effort to help Cho become • His parents worked very long hours and had better adjusted, and she would talk to him, financial difficulties. They worried about the urging him to open up, to “have more cour- effect of this on their children because they age.” The parents urged him to get involved in had less than optimum time to devote to par- activities and sports. They worried that he enting. was isolating himself and was lonely. Other • Medical records did not indicate a diagnosis of family members asked why he would not talk. mental illness prior to coming to the United He reportedly resented this pressure. Mr. Cho, States. having a quiet nature himself, was slightly more accepting of his son’s introspective and ELEMENTARY SCHOOL IN VIRGINIA withdrawn personality, but he was stern on matters of respect. Cho and his father would ho was enrolled in the English as a Second argue about this. According to one of the re- CLanguage (ESL) program in Virginia as soon cords reviewed, Cho’s father would not praise as he arrived in the middle of third grade. The his son. Where Cho’s later writings included a family at this time was living in a small apart- father-son relationship, the character of the ment. School teachers indicated that Cho would father was always negative. Cho never talked not “interact socially, communicate verbally, or about school and never shared much. His participate in group activities.” One teacher mother and sister would ask how he was doing reported that he did play with one student during in school, trying to explore the possibility of recess. “bullying.” His sister knew that when he Cho was referred to the school’s educational walked down school hallways a few students screening committee because teachers believed his sometimes would yell taunts at him. He did communication problems stemmed more from not talk about feelings or school at all. He emotional issues than from language barriers. would respond “okay” to all questions about When Cho was in sixth grade, his parents bought his well being. a townhouse next to the school so he could easily Cho, as a special needs child, generated a high commute to his classes. The school requested a level of stress within the family. Adaptation to parent–teacher conference because Cho was not cope with this stress can produce both positive answering any questions in class. Mrs. Cho took and negative results. The family dynamic an interpreter with her to the parent-teacher con- which evolved in the Chos’ to cope with this ference. She resolved to “find” friends for him and stress was that of “rescue” behavior and more encouraged both their children to go to the church coddling of Cho who seemed unreachable emo- she attended. Because the congregation was tionally. There was some friction between Cho small, however, there were few children, so both and his sister, however, nothing that appeared Cho and his sister lost interest and stopped going as other than normal sibling rivalry. In fact, to church. Sun was the one to whom Cho spoke the most. One of Mrs. Cho’s friends urged her to look into Key Findings of Early Years another church that reportedly had a minister who “could help people with problems like Cho’s.” • Cho’s early development was character- She occasionally attended that church over a 6- ized by physical illness and inordinate month period, but decided against reaching out to shyness. that pastor to work with her son. Several news- • Even as a young boy, Cho preferred not to paper articles that appeared after the shooting speak, a situation that worried and frus- reported that the pastor from that church had trated his parents. worked directly with Cho. According to Mrs. Cho, • He was ostracized by some peers, though those reports are untrue. Mrs. Cho did register he did not discuss this with his family. her son for a 1-week summer basketball camp

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

sponsored by that church, but she never addressing the emotional pain and psychological sought its help on personal matters. problems of clients. Typically, this form of therapy is used with younger children who do not have Mrs. Cho tried to be extra nurturing to Cho. sufficient language or cognitive skills to utilize He did not reject her attempts at socialization traditional “talk” therapy. Because Cho would not per se, but he disliked talking. Finally, Cho’s converse and uttered only a couple words in parents decided to “let him be the way he is” response to questions, art therapy was one way to and not force him to interact and talk with reach him. The specialist offered clay modeling, others. He never spoke of imaginary friends. painting, drawing, and a sand table at each ses- He did not seem to be involved in a fantasy sion. Cho would choose one of the options. As he world or to be preoccupied by themes in his worked, the therapist could ascertain how he was play or work that caused concern. He never feeling and what his creations might represent talked of a “twin brother.” The parents’ char- about his inner world. Then she talked to him acterization of him was a “very gentle, very about what his work indicated and hoped to help tender,” and “good person.” him progress in being more socially functional. He modeled houses out of clay, houses that had no MIDDLE SCHOOL YEARS windows or doors.

he summer before Cho started seventh Cho’s therapist noted that while explaining the Tgrade, his parents followed up on a rec- meaning of Cho’s artwork to him, his eyes some- ommendation from the elementary school that times filled with tears. She never saw anything they seek therapy for Cho. In July 1997, the that he wrote. Eventually, Cho began to make eye Cho’s took their son to the Center for Multi- contact. She saw this as a start toward becoming cultural Human Services (CMHS), a mental healthier. health services facility that offers mental health treatment and psychological evalua- Cho also had a psychiatrist who participated in tions and testing to low-income, English- the first meeting with Cho and his family and limited immigrant and refugee individuals. periodically over the next few years. He was diag- They told the specialists of their concern about nosed as having [severe] “social anxiety disorder.” Cho’s social isolation and unwillingness to dis- “It was painful to see,” recalled one of the psychia- cuss his thoughts or feelings. trists involved with Cho’s case. The parents were told that many of Cho’s problems were rooted in Mr. and Mrs. Cho overcame several obstacles acculturation challenges—not fitting in and diffi- to get their son the help he needed. In order culty with friends. Personnel at the center also for Cho to make his weekly appointments at noted in his chart that he had experienced medi- the center, they had to take turns leaving cal problems and that medical tests as an infant work early to drive him there. There were cul- and as a preschooler had caused emotional tural barriers as well. In the family’s native trauma. Records sent to Cho’s school at the time country, mental or emotional problems were (following a release signed by his parents) and the signs of shame and guilt. The stigmatization tests administered by mental health professionals of mental health problems remains a serious evaluated Cho to be a much younger person than roadblock in seeking treatment in the United his actual age, which indicated social immaturity, States too, but in Korea the issue is even more lack of verbal skills, but not retardation. His relevant. Getting help for such concerns is tested IQ was above average. only reluctantly acknowledged as necessary. Cho continued to isolate himself in middle school. After starting with a Korean counselor with He had no reported behavioral problems and did whom there was a poor fit, Cho began working not get into any fights. Then, in March 1999, with another specialist who had special train- when Cho was in the spring semester of eighth ing in art therapy as a way of diagnosing and

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

grade, his art therapist observed a change in was in the process of doing that at GWU Hospital his behavior. He began depicting tunnels and when he first met Cho. caves in his art. In and of themselves, those Mr. and Mrs. Cho explained to the psychiatrist symbols were not cause for alarm, but Cho that they were facing a family crisis since their also suddenly became more withdrawn and daughter would be leaving home in the fall to showed symptoms of depression. In that con- attend college and she was the family member text, the therapist felt that the tunnels and with whom Cho communicated, as limited as that caves were red flags. She was concerned and communication was. They feared that once their asked him whether he had any suicidal or daughter was no longer home, he would not com- homicidal thoughts. He denied having them, municate at all. The psychiatrist also was but she drew up a contract with him anyway, informed of the disturbing paper Cho had written. spelling out that he would do no harm to himself or to others, and she told him to commu- The doctor diagnosed Cho with “selective mutism” nicate with his parents or someone at school if and “major depression: single episode.” He pre- he did experience any ideas about violence. scribed the antidepressant Paroxetine 20 mg, That is just what he did, in the form of a which Cho took from June 1999 to July 2000. Cho paper he wrote in class. did quite well on this regimen; he seemed to be in a good mood, looked brighter, and smiled more. The following month, April 1999, the murders The doctor stopped the medication because Cho at Columbine High School occurred. Shortly improved and no longer needed the antidepres- thereafter, Cho wrote a disturbing paper in sant. English class that drew quick reaction from his teacher. Cho’s written words expressed Selective mutism is a type of an anxiety disorder generalized thoughts of suicide and homicide, that is characterized by a consistent failure to indicating that “he wanted to repeat Colum- speak in specific social situations where there is bine,” according to someone familiar with the an expectation of speaking. The unwillingness to situation. No one in particular was named or speak is not secondary to speech/communication targeted in the words he wrote. The school problems, but, rather, is based on painful shyness. contacted Cho’s sister since she spoke English Children with selective mutism are usually inhib- and explained what had happened. The family ited, withdrawn, and anxious with an obsessive fear of hearing their own voice. Sometimes they was urged to have Cho evaluated by a psy- show passive-aggressive, stubborn and controlling chiatrist. The sister relayed this information traits. The association between this disorder and to her parents who asked her to accompany autism is unclear. Cho to his next therapy appointment and report the incident, which she did. The thera- Major depression refers to a predominant mood of pist then contacted the psychiatrist for an sadness or irritability that lasts for a significant evaluation. period of time accompanied by sleep and appetite disturbances, concentration problems, suicidal Cho was evaluated in June 1999 by a psychia- ideations and pervasive lack of pleasure and trist at the Center for Multicultural Human energy. Major depression typically interferes with Services. There, psychiatric interns from The social, occupational and educational functioning. George Washington University Hospital pro- Effective treatments for depression and selective vide treatment one day a week supervised by mutism include psychotherapy and anti depres- other doctors at GWU. Cho was fortunate sants/anti-anxiety agents such as Selective Sero- because the intern who was his psychiatrist tonin Reuptake Inhibitors (SSRI’s). was actually an experienced child psychiatrist and family counselor who had practiced in It should be noted that when the subject of Cho’s South America prior to coming to the United eighth grade paper and subsequent evaluation States. He had to recertify in this country and was discussed with Mr. and Mrs. Cho and Cho’s

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

sister during the interview, they appeared mainstreamed in classrooms. Provisions are made shocked to learn that he had written about for special services or accommodations after a core violence toward others. They said they knew evaluation involving a battery of tests is given to he had hinted at ideas about suicide, but not diagnose the problems and to guide the school in about homicide. preparing an Individualized Education Plan (IEP). The high school conducted a special as- School records indicate that an interpreter sessment to rule out autism as an underlying fac- was provided (sometimes this was Cho’s sis- tor. Cho also was evaluated in the following ter) during meetings that involved the par- domains: ents, as is the policy and required by law. Psychological HIGH SCHOOL YEARS Sociocultural Educational n fall of 1999, Cho began high school at Speech/Language Centreville High School. The following year I Hearing Screening a new school, Westfield High School, opened to Medical accommodate the population growth in that Vision part of Fairfax County. Cho was assigned there for his remaining 3 years. About 1 As part of the assessment process, school person- month after classes began at Westfield, one of nel met with Cho’s parents to find out more about Cho’s teachers reported to the guidance office his history and to explain the assessment process. that Cho’s speech was barely audible and he Mrs. Cho expressed concern about how her son did not respond in complete sentences. The would fare later in college given the transition teacher wrote that he was not verbally inter- required and his poor social skills. She noted that active at all and was shy and shut down. her son was receiving counseling and gave per- There was practically no communication with mission for the school to contact her son’s thera- teachers or peers. Those failings aside, teach- pist. The therapist, in turn, was encouraged by ers also praised Cho for his qualities as a stu- the fact that the school would be tracking Cho’s dent. He achieved high grades, was always on progress. The committee determined that Cho was time for class, and was diligent in submitting eligible for the Special Education Program for well-done homework assignments. Other than Emotional Disabilities and Speech and Language. failing to speak, he did not exhibit any other Mr. and Mrs. Cho were receptive to receiving help unusual behaviors and did not cause prob- for him and so was his older sister who was in col- lems. When the teacher asked Cho if he would lege and with whom he had a good relationship. like help with communicating, he nodded yes. The parents and sister continued to be in contact with the school; Sun usually served as interpreter. The guidance counselors asked Cho whether he had ever received mental health or special Special accommodations were made to help Cho education assistance in middle school or in his succeed in class without frustration or intimida- freshman year (at the previous high school), tion. The school developed an IEP, as required by and he reportedly indicated (untruthfully) law, that was effective in January 2001. The IEP that he had not. listed two curriculum and classroom accommodations and modifications: modification for oral Cho’s situation was brought before Westfield’s presentations, as needed, and modified grading Screening Committee on October 25, 2000, for scale for oral or group participation. In-school lan- evaluation to determine if he required special guage therapy was recommended as well, but Cho education accommodations. Federal law only received that service once a month for 50 requires that schools receiving federal funding minutes. His art therapist, who reached out to a enable children with disabilities to learn in few teachers and others at the school with the least restrictive environment and to be

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

questions or concerns, said she asked why the school counselor could not say whether bullying language therapy was so limited. The school might have occurred before or after school, as responded that it was reluctant to pull him suggested by other unconfirmed sources. out of class for this special service because It would be reasonable, however, to assume that this would interrupt his academic work or Cho was a victim of some bullying, though to what negatively impact his grades. Besides, the extent and how much above the norm is not primary diagnosis was selective mutism, not known. His sister said that both of them were sub- problems with the mechanics of speaking or jected to a certain level of harassment when they an inability to function in English. first came to the United States and throughout Cho was encouraged to join a club and to stay their school years, but she indicated that it was after school for help from teachers. He was neither particularly threatening nor ongoing. permitted to eat lunch alone and to provide In the eleventh grade, Cho’s weekly sessions at verbal responses in private sessions with the mental health center came to an end because teachers rather than in front of the whole there was a gradual, if slight, improvement over class where his manner of speaking and the years and he resisted continuing, according to accent sometimes drew derision from peers. his parents and therapist “There is nothing wrong With this arrangement, Cho’s grades were with me. Why do I have to go?” he complained to excellent. He had advanced placement and his parents. Mr. and Mrs. Cho were not happy honors classes. However, his voice was liter- that their son chose to discontinue treatment, but ally inaudible in class, and he would only he was turning 18 the following month and legally whisper if pushed (an observation consistent he could make that decision. with his behavior later in college). In written Cho took upper level science and math courses responses, at times, his thinking appeared and spent 3 to 4 hours a day on homework. He confused and his sentence structure was not earned high marks and finished high school with fluent. Indeed, his guidance counselor raised a grade point average of 3.52 in an honors pro- the question to the panel: “Why did he change gram. That GPA, along with his SAT scores (540 his major to English at Tech?” Why did this for verbal and 620 for math registered in the 2002 student, whose forte appeared to be science testing year) were the basis for his acceptance at and math, switch to humanities? Virginia Tech. What the admission’s staff at Vir- After the Virginia Tech murders, some news- ginia Tech did not see were the special accommo- papers reported that Cho was the subject of dations that propped up Cho and his grades. bullying. The panel could not confirm whether Those scores reflected Cho’s knowledge and intel- or not he was bullied or threatened. His fam- ligence, but they did not reflect another compo- ily said that he never mentioned being the nent of grades: class participation. Since that target of threats or intimidating messages, aspect of grading was substantially modified for but then neither did he routinely discuss any Cho due to the legally mandated accommodations details about school or the events of his day. for his emotional disability, his grades appeared His guidance counselor had no records of bul- higher than they otherwise would have been. lying or harassment complaints. When his guidance counselor talked to Cho and Nearly all students experience some level of his family about college, she strongly recom- bullying in schools today. Much of this behav- mended they send him to a small school close to ior occurs behind the scenes or off school home where he could more easily make the transi- grounds—and often electronically, through tion to college life. She cautioned that Virginia instant messaging, communications on Tech was too large. However, Cho appeared very MySpace and, to a lesser extent, on Facebook, self-directed and independent in his decision. He a website used by older teenagers. Cho’s high

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

chose Virginia Tech, which had been his goal lems. Then, there is a subheading labeled “Special for some time. He applied and was accepted. Services Files” where six additional boxes are presented: Contract Services, ESL, 504 Plan, Gifted Virginia Tech does not require an essay or let- and Talented, Homebound, and Special Educa- ters of recommendation in the freshman tion. Only the ESL box is checked, even though application package and does not conduct per- Cho had special education services. The special sonal interviews. Acceptance decisions at Vir- education services box was not checked. ginia Tech are based primarily on grades and SAT scores, though demographics, interests, As the panel reviewed Cho’s mental health and some intangibles are also considered. An records and conducted interviews with persons essay about oneself is optional. Cho included a who had provided psychiatric and counseling ser- short writing about rock climbing in his appli- vices to Cho throughout his public school career, it cation, which was written in the first person became evident that critical records from one pub- and spoke about human potential that often lic institution are not necessarily transferred to cannot be achieved because of self-doubt. the next as a person matures and enters into new stages of development. What are the rules regard- Before Cho left high school, the guidance ing the release of special education records counselor made sure that Cho had the name between, for example, high schools and colleges? and contact information of a school district resource who Cho could call if he encountered It is common practice to require students entering problems at college. As is now known, Cho a new school, college, or university to present never sought that help while at Virginia Tech. records of immunization. Why not records of serious emotional or mental problem too? For that As Cho looked to the fall of 2003, he was pre- matter, why not records of all communicable dis- paring to leave home for the first time and eases? enter an environment where he knew no one. He was not on any medication for anxiety or The answer is obvious: personal privacy. And depression, had stopped counseling, and no while the panel respects this answer, it is impor- longer had special accommodations for his tant to examine the extent to which such informa- selective mutism. Neither Cho nor his high tion is altogether banned or could be released at school revealed that he had been receiving the institution’s discretion. No one wants to stig- special education services as an emotionally matize a person or deny her or him opportunities disabled student, so no one at the university because of mental or physical disability. Still, ever became aware of these pre-existing condi- there are issues of public safety. That is why tions. immunization records must be submitted to each new institution. But there are other significant There is a standard cover page that accompa- threats facing students beyond measles, mumps, nied Cho’s transcripts to Virginia Tech called or polio. “Pupil Permanent Record, Category 1”. The page lists all the types of student records, The panel asked its legal counsel to review the whether they include information from ele- laws pertaining to special education records and mentary, middle, or high school, and how long the release of that information, specifically as they are to be retained. The lower right corner addressed in FERPA and the Americans with Dis- of the page has a section marked “The Student abilities Act (ADA). Although FERPA generally Scholastic Record” under which are boxes to allows secondary schools to disclose educational be checked as they apply. The first six boxes records (including special education records) to a are Clinic, Cumulative, Discipline, Due Proc- university, federal disability law prohibits univer- ess, Law Enforcement, and Legal. Only the sities from making what is known as a ‘preadmis- first two were checked, indicating Cho had no sion inquiry” about an applicant’s disability records pertaining to discipline or legal prob- status. After admission, however, universities

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

may make inquiries on a confidential basis as well remain relevant. Maybe there really should to disabilities that may require accommoda- be some form of "permanent record." tion. Key Findings of Cho’s School Years It should be noted that the Department of • Both the family and the schools recognized Education’s March 2007 “Transition of Stu- that Cho’s problem was not merely introver- dents with Disabilities to Post Secondary Edu- sion and that Cho needed therapy to help with cation: A Guide for High School Educators” extreme social anxiety, as well as accultura- clarifies that a high school student has no tion and communication. obligation to inform an institution of post secondary education that he or she has a disabil- • A depressive phase in the second half of ity; however, if the student wants an academic eighth grade led to full blown depression and adjustment, the student must identify himself thoughts of suicide and homicide precipitated or herself as having a disability. Cho did not by the Columbine shooting. Cho received seek any accommodations from Virginia Tech. timely psychiatric assessment and interven- The disclosure of a disability is always volun- tion (prescription of Paroxetine and continued tary. therapy). This episode abated within a year, and medications were discontinued. It is a more subtle question whether Fairfax • Transportation problems interfered with Cho’s County Public Schools would have had to remove any indication of special education involvement with sports and extracurricular status or accommodation from Cho’s tran- activities, which may have increased his isola- script or grade reports as part of his college tion. application. • Intervention for a child suffering from mental Because this issue is of such great importance illness reduces the burden of illness as well as and because much more study is needed, the the risk for severe outcomes such as violence panel does not make a recommendation here. and suicide, as it did for Cho during his pre- But the panel hopes that this issue begins to college years. be debated fully in the public realm. Perhaps • During his high school years, Cho was identi- students should be required to submit records fied as having special educational needs. His of emotional or mental disturbance and any communicable diseases after they have been identification as a special education student admitted but before they enroll at a college or within the first 9 weeks of enrollment in a university, with assurance that the records new high school and the accommodations ac- will not be accessed unless the institution’s corded him as part of his Individualized Edu- threat assessment team (by whatever name it cational Plan led to a high degree of academic is known) judges a student to pose a potential success. Indeed, his high school guidance threat to self or others. counselor felt that his high school career was Or perhaps an institution whose threat a success. With regard to his social skills, assessment team determines that a student is however, his progress was minimal at best. a danger to self or others should promptly con- • Clearly, Cho appeared to be at high risk, as tact the student’s family or high school, inform withdrawn and inhibited behavior confers them of the assessment, and inquire as to a risk. This risk seemed mitigated by the inter- previous history of emotional or mental ventions and accommodations put in place by disturbance. the school. This risk also was reduced by in- This much is clear: information critical to pub- volved and concerned parents who were par- lic safety should not stay behind as a person ticular in following through with weekly ther- moves from school to school. Students may apy. This risk was further mitigated by effec- start fresh in college, but their history may tive therapy that allowed expression (through

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

art therapy) of underlying feelings of thing, including money. Mr. and Mrs. Cho said inadequacy. These factors as well as an that he never asked for extra money and would above-average performance in school (but- not accept any. He was very mindful of the fam- tressed by accommodations) lessened his ily’s financial situation and lived frugally. He frustration and anger. would not buy things even though his parents • The school that Cho attended played an encouraged him occasionally to purchase new important part in reducing the possibility clothes or other items. They reported that he did of severe regression in his functioning. not appear envious or angry about anything. The school worked closely with Cho’s par- During his freshman year, Cho took courses in ents and sister. There was coordination biology, math, communications, political science, between the school and the therapist and business information systems, and introduction to the psychiatrist who were treating Cho. poetry. His grades overall were good, and he These positive influences ended when Cho ended the year with a GPA of 3.00. graduated from high school. His multi- faceted support system then disappeared Cho’s sophomore year (2004–2005) brought some leaving a huge void. changes. Cho made arrangements to share the rent on a condominium with a senior at Virginia COLLEGE YEARS Tech who worked long hours and was rarely home. His courses that fall leaned more heavily n August of 2003, Cho began classes at toward science and math. His grades slipped that IVirginia Tech as a Business Information term. At the same time, he became enthusiastic Technology major. Mr. and Mrs. Cho were about writing and decided he would switch his concerned about his move away from home major to English beginning the fall semester of and the stress of the new environment, espe- 2005. It is unclear why he made this choice as he cially when they learned he was unhappy with disliked using words in school or at home. More- his roommate. His parents visited him every over, English had not been one of his strongest weekend on Sundays during that first semes- subjects in high school. ter, which was a major time commitment since they both worked the other 6 days of the week. The answer may be found in an exchange of They noted that the dorm room trash can was e-mails that Cho had with then-Chair of the Eng- full of beer cans (allegedly, from the interview lish Department, Dr. Lucinda Roy. Cho had taken with Cho’s parents, the roommate was drink- one of her poetry classes, a large group, entry- ing) and the room was quite dirty. Cho, in con- level course the previous semester. On Saturday, trast, had kept his room neat at home and had November 6, 2004, he wrote “I was in your poetry good hygiene. He requested a room change—a class last semester, and I remember you talking move that his parents and sister saw as a about the books you published. I’m looking for a positive sign that he was being proactive and publisher to submit my novel…I was just wonder- taking care of his own affairs. It seemed as ing if you know of a lot of publishers or agents or though college was working out for him if you have a good connection with them.” He went because he seemed excited about it. on, “My novel is relative[ly] short…sort of like Tom Sawyer except that it’s really silly and Cho settled in, got his room changed by the pathetic depending on how you look at it.…” Dr. beginning of the second semester, and seemed Roy’s first e-mail back said: “Could you send me to be adjusting. Parental visits became less your name? You forgot to sign your note.” “Seung frequent. According to a routine they estab- Cho,” he wrote. Dr. Roy then recommended two lished, every Sunday night he spoke with his resource books and gave him tips on finding liter- parents by telephone who always asked how ary agents. She also advised, “If you haven’t yet he was doing and whether he needed any-

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

taken a creative writing (fiction) course…you from a New York publishing house on Cho’s desk should consider doing so.” at home. He had submitted a topic for a book describing the book’s outline. She encouraged him University personnel explained to the panel to continue to write and learn saying that all that Virginia Tech’s process for changing writers have to work at their craft for a long time majors relies on “advisors” who serve to help before they are published and that he was just at ensure that students are taking the right the beginning and not to lose heart. number of credits and courses to meet the requirements of their major and to graduate. While living in the off-campus condominium, Cho They do not generally offer counsel on became convinced that he had mite bites (based whether a student is making a wise move or on searches he did on the Internet). He went to a examine the reasons behind their class local doctor who diagnosed it as severe acne and choices. In any given year at Virginia Tech, put him on medication. Other than followup many students change majors. Over 40 per- appointments for his acne at home and at the cent of the student body changes their major Shiffert Medical Center at Virginia Tech (he con- after the first year or two. Thus this change is tinued to believe mites were the problem), he did not abnormal and not a red flag. not have regular appointments with general practitioners, specialists, psychiatrists, or counselors Cho seemed to enjoy the idea of writing, espe- in his hometown during his entire college tenure. cially poetry. His sister noticed that he would His family reported that he came home for all his bring home stacks of books on literature and breaks and would spend the time writing, reading, poetry and books on how to become a writer. playing basketball, and riding his bike—alone. Writing seemed to have become a passion, and his family was thrilled that he found some- Storm Clouds Gathering, Fall 2005 – The fall thing he could be truly excited about. He semester of Cho’s junior year (2005) was a pivotal would spend hours at his computer writing, time. From that point forward, Cho would become but when his sister asked to see his work, he known to a growing number of students and fac- would refuse. On one rare occasion, she did ulty not only for his extremely withdrawn person- get to read a story he wrote about a boy and ality and complete lack of interest in responding his imaginary friend, which she thought was to others in and out of the classroom, but for hos- somewhat strange, but nothing too odd. tile, even violent writings along with threatening behavior. Cho’s parents never read his compositions, both because he did not offer to show them He registered for French and four English and because they did not read English, at courses, one of which was Creative Writing: least not well. Poetry, taught by Nikki Giovanni. It would seem he selected this course on the basis of Dr. Roy’s Cho took three English courses in the spring advice to him the previous fall. His sister began of 2005, plus an economics course, and an noticing some subtle changes: he was not writing introductory psychology course. He did not do as much in his junior year and he seemed more particularly well, especially in the literature withdrawn. The family wondered whether he was courses. One of his English professors gave getting anxious about the future and what he him a D-, another, a C+. He earned a B+ in would do after graduation. His father wanted him Introduction to Critical Reading, but also to go to graduate school, but Cho indicated he did withdrew from the economics class, thus earn- not want to continue with academics after he ing only 12 credits and registering a 2.32 for graduated. His parents then offered to help him the semester. find a job after graduation, but he refused.

Late that sophomore year, in his presence, Cho had moved back to the dormitories that Cho’s sister chanced upon a rejection letter semester. He had a roommate and two suitemates

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

who lived in another room connected by a bottle on his desk. He and the others in the suite bathroom—a typical layout in the residence looked it up online and found that it was a halls. The panel interviewed his roommate medication for “skin fungus.” and one suitemate who related some events Cho’s actions in the poetry class taught by Nikki from that year. They described Cho in the Giovanni that semester are widely known and same way as he is described throughout this documented. For the first 6 weeks of class, the report: very quiet, short responses to ques- professor put up with Cho’s lack of cooperation tions, and rarely initiating any communica- and disruptive behavior. He wore reflector glasses tion. At the beginning of the school year, the and a hat pulled down to obscure his face. roommate and the other suitemates took Cho Dr. Giovanni reported to the panel that she would to several parties. He would always end up have to take time away from teaching at the sitting in the corner by himself. One time they beginning of each class to ask him to please take all went back to a female student’s room. Cho off his hat and please take off his glasses. She took out a knife (“lock blade, not real large”) would have to stand beside his desk until he and started stabbing the carpet. They stopped complied. Then he started wearing a scarf taking him out with them after that incident. wrapped around his head, “Bedouin-style” The three suitemates would invite Cho to eat according to Professor Giovanni. She felt that he with them at the beginning of the year, but he was trying to bully her. would never talk so they stopped asking. They Cho also was uncooperative in presenting and observed him eating alone in the dining hall changing the pieces that he wrote. He would read or lounge. The roommate asked Cho who he from his desk in a voice that could not be heard. hung out with and Cho said “nobody.” He When Dr. Giovanni would ask him to make would see him sometimes at the gym playing changes, he would present the same thing the fol- basketball by himself or working out. lowing week. One of the papers he read aloud was Cho’s roommate never saw him play video very dark, with violent emotions. The paper was games. He would get movies from the library titled “So-Called Advanced Creative Writing – and watch them on his laptop. The roommate Poetry.” He was angry because the class had spent never saw what they were, but they always time talking about eating animals instead of seemed dark. Cho would listen to and down- about poetry, so his composition, which he would load heavy metal music. Someone wrote heavy later characterize as a satire, spoke of an “animal metal lyrics on the walls of their suite in the massacre butcher shop.” fall, and then in the halls in the spring. Sev- In the paper, Cho accused the other students in eral of the students believed Cho was respon- the class of eating animals, “I don’t know which sible because the words were similar to the uncouth, low-life planet you come from but you lyrics Cho posted on Facebook. disgust me. In fact, you all disgust me.” He made Several times when the suitemates came in up gruesome quotes from the classmates, then the room, it smelled as though Cho had been wrote, “You low-life barbarians make me sick to burning something. One time they found the stomach that I wanna barf over my new shoes. burnt pages under a sofa cushion. Cho would If you despicable human beings who are all dis- go to different lounges and call one of the graces to [the] human race keep this up, before suitemates on the phone. He would identify you know it you will turn into cannibals—eating himself as “question mark”—Cho’s twin little babies, your friends,. I hope y’all burn in hell brother—and ask to speak with Seung. He for mass murdering and eating all those little also posted messages to his roommate’s animals.” Facebook page, identifying himself as Cho’s Dr. Giovanni began noticing that fewer students twin. The roommate saw a prescription drug were attending class, which had never been a

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

problem for her before. She asked a student Dean Brown also said, “I talked with a coun- what was going on and he said, “It’s the selor…and shared the content of the ‘poem’… and boy…everyone’s afraid of him.” That was she did not pick up on a specific threat. She sug- when she learned that Cho also had been gested a referral to Cook during your meeting. I using his cell phone to take pictures of stu- also spoke with Frances Keene, Judicial Affairs dents without permission. director and she agrees with your plan.” He continued, “I would make it clear to him that any Dr. Giovanni talked to Cho, telling him, “I similar behavior in the future will be referred.” don’t think I’m the teacher for you,” and offered to get him into another class. He said Frances Keene noted in her response to Dean that he did not want to transfer, which sur- Brown and Dr. Roy that she was available if Cho prised her. She contacted the head of the Eng- had any further questions about how using his lish Department, Dr. Roy, about Cho and cell phone in class to take photographs could con- warned that if he were not removed from her stitute disorderly conduct. She also wrote, “I agree class, she would resign. He was not just a dif- that the content is inappropriate and alarming ficult student, she related, he was not working but doesn’t contain a threat to anyone’s immedi- at all. Dr. Giovanni was offered security, but ate safety (thus, not actionable under the abusive declined saying she did not want him back in conduct – threats section of the UPSL).” class, period. She saw him once on campus During an interview with the panel, Ms. Keene after that and he just stared at the ground. related that she would have needed something in Dr. Roy explained to the panel what her writing to initiate an investigation into the disor- actions were once Dr. Giovanni made her derly conduct violation, and reported that she aware of Cho’s upsetting behavior. She never received anything. The formal request remembered Cho from the previous semester would have come from the English Department. when he took that poetry class she taught (she Ms. Keene recalled that the concern about Cho had given him a B- in the course). Dr. Roy was brought before the university’s “Care Team,” contacted the Dean of Student Affairs, Tom of which she is a member, at their regular meet- Brown, the Cook Counseling Center, and the ing. The Care Team is comprised of the dean of College of Liberal Arts with regard to the Student Affairs, the director of Residence Life, the objectionable writing that Dr. Giovanni head of Judicial Affairs, Student Health, and legal showed Dr. Roy. She asked to have it evalu- counsel. Other agencies from the university are ated from a psychological point of view and occasionally asked to participate; including the inquired about whether the picture-taking Women’s Center, fraternities and sororities, the might have been against the code of student Disability Center, and campus police, though conduct. these agencies are not standing members of the Dean Brown sent an e-mail message to Dr. Team. Roy and advised “there is no specific policy At the Care Team meeting, members were advised related to cell phones in class. But, in Section of the situation with Cho and that Dr. Roy and Dr. 2 of the University Policy for Student Life, Giovanni wanted to proceed with a class change to item #6 speaks to disruption. This is the ‘dis- address the matter. The perception was that the orderly conduct’ section which reads: ‘Behav- situation was taken care of and Cho was not dis- ior that disrupts or interferes with the orderly cussed again by the Care Team. The team made function of the university, disturbs the peace, no referrals of Cho to the Cook Counseling Center. or interferes with the performance of the The Care Team did nothing. There were no refer- duties of university personnel.’ Clearly, the rals to the Care Team later that fall semester disruption he caused falls under this policy if when Resident Life, and later, VTPD became adjudicated.”

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

aware of Cho’s unwanted communications to he was “just joking” about the writing in female students and threatening behavior. Giovanni’s class, but agreed that it might have been perceived differently. Dr. Roy asked him if Frances Keene said that she received no com- he was offended by the class discussion on eating munications from the female students who animals and he said, “I wasn’t offended. I was just had registered complaints about Cho and that making fun of it…thought it was funny, thought she learned of those incidents only through I’d make fun of it.” He was asked if he was a vege- campus police incident reports. However, the tarian or had religious beliefs about eating meat assistant director of Judicial Affairs, Rohsaan or animals; he answered no to both questions. Settle, received an e-mail communication on December 6 advising her of Cho’s “odd behav- Ms. Ruggiero’s transcript mentions that Dr. Roy ior” and “stalking.” Ms. Keene indicated that “proposes alternative of working independently it is her office’s policy to contact students who with herself and Fred D’Aguiar.” The transcript have been threatened and advise them of their also notes that Cho “doesn’t want to lose cred- rights, but one of the students stated that she its…if not ‘kicked out’ will stay” [I (Ruggiero) was never contacted by Judicial Affairs, and noted some emotion on the words ‘kicked out,’ a there is no documentation that the others small spark of anger or resentment]. The tran- were contacted. Ms. Keene indicated that she script goes on to document that “Lucinda asked if would have discussed these incidents with the he would remove his sunglasses.” Cho takes a long Care Team at the time the incidents occurred time to respond, but he does remove them. “It is a had she known about them. very distressing sight, since his face seems very naked and blank without them. It’s a great relief Dr. Roy e-mailed Cho and asked him to con- to be able to read his face, though there isn’t much tact her for a meeting. He responded with an there.” Dr. Roy asks if taking off the sunglasses angry, two-page letter in which he harshly has been terrible for him…and says “he doesn’t criticized Dr. Giovanni and her teaching, say- seem like himself, like the student she knew in ing she would cancel class and would not the Intro to Poetry class, and she asks if anything really instruct, but just have students read terrible or bad has happened to him.” Eventually what they wrote and discuss the writings. He Cho answers “No.” agreed to meet with Dr. Roy and said “I know it’s all my fault because of my personal- Twice during the meeting with Cho, Dr. Roy ity…Being quiet, one would think, would repel asked him if he would talk to a counselor. She told attention but I seem to get more attention him she had the name of someone, and asked than I want (I can just tell by the way people again if he would consider going. He did not stare at me).” He said he imagined she was answer for a while, and then said vaguely, “sure.” going to “yell at me.” In her interview with the panel, Dr. Roy stated Dr. Roy asked a colleague, Cheryl Ruggiero, to that the university’s policy made the situation be present for the meeting with Cho. Ms. difficult. She was obligated to offer Cho an alter- Ruggiero took notes, the transcription of native that was equivalent to the instruction he which provided an exceptionally detailed would receive in Giovanni’s class. Thus, she account of that session with Cho as did offered to tutor him privately. He later agreed. e-mails from Dr. Roy to appropriate admini- She told Cho that he would have to meet four stration officials after the meeting. more times and do some writing. As he left the meeting, Dr. Roy gave him a copy of her book. He Cho arrived wearing dark sunglasses. He took it and “appeared to be crying,” she related. seemed depressed, lonely, and very troubled. Dr. Roy assured him she was not going to yell Throughout the deliberations about Cho’s writing at him, but discussed the seriousness of what and behavior and the available options, Dr. Roy he wrote and his other actions. He replied that communicated widely with all relevant university

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

officers and provided updates on meetings and For the remainder of the semester, Dr. Roy decisions. On October 19, 2005, Dr. Roy focused on William Butler Yeats and Emily Dick- e-mailed Zenobia Hikes, Tom Brown, George inson to help him develop empathy toward others Jackson, and Robert Miller with a report on and redirect his writing away from violent her meeting with Cho. themes. They worked on a poem together where she went over technical skills. She saw no overt Cheryl and I met with the student we spoke about today. We spoke about 30 threats in the writings he did for her. He was stiff, minutes. He was very quiet and it took sad, and seemed deliberately inarticulate, but him long time to respond to question; but gradually he opened up and wrote well. She I think he may be willing to work with repeatedly offered to take him to counseling. She me and with Professor Fred D’Aguiar eventually gave him an “A” for a grade. rather than continuing in Nikki's course…h e didn't seem to think that his Cho did not go home for Thanksgiving, according poem should have alarmed anyone… to his roommate and resident advisor, though he [But] he also said he understood why people assumed from the piece that he thought that Cho may have gone home for a few was angry with them. I strongly recom- days at Christmas. When Cho’s parents were mended that he see a counselor, and he asked about this they indicated that he came didn't commit to that one way or the home at every break, but that sometimes he other. …Both Cheryl and I are genuinely would have to wait a day or so until their day off concerned about him because he ap- work so they could come pick him up at school. peared to be very depressed—though of course only a professional could verify According a VTPD incident report, on Sunday, that. November 27, the police, following a complaint One month later, Dr. Roy wrote to Associate from a female student who lived on the fourth Dean Mary Ann Lewis, Liberal Arts & Human floor of West Ambler Johnston, came to Cho’s Sciences, who in turn shared it with the dean room to talk to him. The roommate went to the of Student Affairs and Ellen Plummer, lounge and then returned after the police left. Cho Assistant Provost and Director of the Women’s said “want to know why the police were here?” He Center. She wrote then related that “he had been text messaging a female student and thought it was a game”. He He is now meeting regularly with me and went to her room wearing sunglasses and a hat with Fred D’Aguiar rather than with Nikki. This has gone reasonably well, pulled down and said “I’m question mark.” He though all of his submissions so far have said that “the student freaked out,” and the resi- been about shooting or harming people dent advisor came out and called the police. because he’s angered by their authority According to the police record, the officer warned or by their behavior. We’re hoping he’ll Cho not to bother the female student anymore, be able to write inside a different kind of narrative in the future, and we’re and told him they would refer the case to Judicial encouraging him to do so…I have to ad- Affairs. mit that I’m still very worried about this student. He still insists on wearing The resident advisor told the panel about Cho, highly reflective sunglasses and some “He was strange and got stranger.” She said that responses take several minutes to elicit. Cho’s roommate and one of the other suitemates (I’m learning patience!) But I am also found a very large knife in Cho’s desk and dis- impressed by his writing skills, and by carded it. what he knows about poetry when he opens up a little. I know he is very angry, On Wednesday, November 30, at 9:45 am, Cho however, and I am encouraging him to called Cook Counseling Center and spoke with see a counselor––something he’s resisted so far. Please let me and Fred know if Maisha Smith, a licensed professional counselor. you see a problem with this approach. This is the first record of Cho’s acting upon professors’ advice to seek counseling, and it followed

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

the interaction he had had with campus police CHO’S HOSPITALIZATION AND three days before. She conducted a telephone COMMITMENT PROCEEDINGS triage to collect the necessary data to evaluate the level of intervention required. Ms. Smith (The law pertaining to these proceedings is discussed in has no independent recollection of Cho and Part B of this chapter.) her notes from the triage are missing from n December 12, 2005, the Virginia Tech Po- Cho’s file. A note attached to the electronic Olice Department (VTPD) received a complaint appointment indicates that Cho specifically from a female sophomore residing in the East requested an appointment with Cathye Betzel, Campbell residence hall regarding Cho. She knew a licensed clinical psychologist, and indicated Cho through his roommate and suitemate. The that his professor had spoken with Dr. Betzel. students had attended parties together at the The appointment was scheduled for December beginning of the semester and it was at this young 12 at 2:00 pm, but Cho failed to keep the woman’s room that Cho had produced a knife and appointment. However, he did call Cook stabbed the carpet. While the student no longer Counseling after 4:00 pm that same afternoon saw Cho socially, she had received instant mes- and was again scheduled for telephone triage. sages and postings to her Facebook page through- According to the Cook scheduling program out the semester that she believed were from him. documents, Cho was again triaged by tele- The messages were not threatening, but, rather, phone at 4:45 on December 12. This triage self-deprecating. She would write back in a posi- was conducted by Dr. Betzel who has no recol- tive tone and inquire if she were responding to lection of the specific content of the “brief tri- Cho. The reply would be “I do not know who I age appointment.” Written documentation am.” In early December, she found a quote from that would have typically been completed at Romeo and Juliet written on the white erase that time is missing. The “ticket” completed to board outside her dorm room. It read: indicate the type of contact indicates that the By a name telephone appointment was kept, that no I know not how to tell thee who I am diagnosis was made (consistent with Cook’s My name, dear saint is hateful to myself procedure to not make a diagnosis until a Because it is an enemy to thee clinical intake interview is completed) and Had I it written, I would tear the word that no referral was made for follow-up ser- The young woman shared with her father her con- vices either at Cook or elsewhere. Dr. Betzel cerns about the communications that she believed did recall at the time of her interview with the were from Cho. The father spoke with his friend, panel that she had a conversation with Dr. the chief of police for Christiansburg, who advised Roy concerning a student whose name she did that the campus police should be informed. not recall, however the details were so similar that she believes it was Cho. She recalls that The following day, December 13, a campus police Dr. Roy was concerned about disturbing writ- officer met with Cho and instructed him to have ings submitted by Cho in class, and that Dr. no further contact with the young woman. She did Roy detailed her plans to meet with the stu- not file criminal charges. No one spoke with her dent individually. The date of Dr. Betzel’s con- regarding her right to file a complaint with Judi- sultation with Dr. Roy is unknown and any cial Affairs. Records document that there were written documentation that would typically multiple e-mail communications regarding the have been associated with the consultation is incident among Virginia Tech residential staff, the missing from Cho’s file. residence life administrator on call, and the president’s & upper quad area coordinator, the director of Residence Life, and the assistant director of Judicial Affairs. The matter was not, however,

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

brought before the Virginia Tech multi- inquired about this, and checking the box for fire- disciplinary Care Team. arm access may have been an error.) He was on no medication at the time of admission, but Ativan Following the visit from the police, Cho sent was prescribed for anxiety, as needed. One milli- an instant message to one of his suitemates gram of Ativan was administered at 11:40 p.m. stating “I might as well kill myself.” The (The records do not show that he ever received suitemate reported the communication to the another dose.) Cho passed an uneventful night VTPD. according to the nursing notes.

Police officers returned around 7:00 p.m. that On the morning of December 14, at approximately same day to interview Cho again in his dorm 6:30 a.m., the Clinical Support Representative for room. The suitemate was not present, but they St. Albans met with Cho to give him information spoke to Cho’s roommate out of his presence. about the mental health hearing. Around 7:00 The officers took Cho to VTPD for assessment, a.m., the representative escorted Cho to meet with and a pre-screen evaluation was conducted a licensed clinical psychologist, who conducted an there at 8:15 p.m. by a licensed clinical social independent evaluation of Cho pursuant to worker for New River Valley Community Virginia law. Services Board (CSB). The pre-screener interviewed Cho and the police officer, and then The independent evaluator reported to the panel spoke with both Cho’s roommate and a suite- that he reviewed the prescreening report, but that mate by phone. She recorded her findings on a due to the early hour, there were no hospital five-page Uniform Pre-Admission Screening records available for his review. He did not speak Form, checking the findings boxes indicating with the designated attending psychiatrist who that Cho was mentally ill, was an imminent had not yet seen Cho. The evaluator has no spe- danger to self or others, and was not willing to cific recollection, but believes that the independ- be treated voluntarily. She recommended ent evaluation took approximately 15 minutes. involuntary hospitalization and indicated that The evaluator completed the evaluation form cer- the CSB could assist with treatment and dis- tifying his findings that Cho “is mentally ill; that charge planning. She located a psychiatric he does not present an imminent danger to bed, as required by state law at St. Albans (himself/others), or is not substantially unable to Behavioral Health Center of the Carilion New care for himself, as a result of mental illness; and River Valley Medical Center (St. Albans) and that he does not require involuntary hospitaliza- contacted the magistrate by phone to request tion.” The independent evaluator did not attend that a temporary detention order (TDO) be the commitment hearing; however, both counsel issued. for Cho and the special justice signed off on the The magistrate considered the pre-screen form certifying his findings. findings and issued a TDO at 10:12 p.m. Shortly before the commitment hearing, the at- Police officers transported Cho to St. Albans tending psychiatrist at St. Albans evaluated Cho. where he was admitted at 11:00 p.m. Cho did When he was interviewed by the panel, the psy- not speak at all with the officer during the trip chiatrist did not recall anything remarkable about to the hospital. He was noted to be cooperative Cho, other than that he was extremely quiet. The with the admitting process. The diagnosis on psychiatrist did not discern dangerousness in Cho, the admission orders was “Mood Disorder, and, as noted, his assessment did not differ from NOS” [non specific]. On the Carilion Health that of the independent evaluator—that Cho was Services screening form for the potential for not a danger to himself or others. He suggested violence, it was marked that Cho denied any that Cho be treated on an outpatient basis with prior history of violent behavior, but that he counseling. No medications were prescribed, and did have access to a firearm. (The panel no primary diagnosis was made.

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

The psychiatrist’s conclusion was based in after 11:00 a.m. on December 14. Neither Cho’s part on Cho’s denying any drug or alcohol suitemate nor his roommate nor the detaining problems or any previous mental health police officer nor the pre-screener nor the inde- treatment. The psychiatrist acknowledged pendent evaluator nor the attending psychiatrist that he did not gather any collateral informa- attended the hearing. The prescreening report tion or information to refute the data obtained was read into the record by Cho’s attorney. The by the pre-screener on the basis of which the special justice reviewed the independent evalua- commitment was obtained. He indicated that tion form completed by the independent evaluator this is standard practice and that privacy laws and the treating psychiatrist’s recommendation. impede the gathering of collateral informa- He heard evidence from Cho. The special justice tion. (Chapter V discusses these information ruled that Cho “presents an imminent danger to privacy laws in detail.) The psychiatrist also himself as a result of mental illness” and ordered said that the time it takes to gather collateral “O-P” (outpatient treatment) “—to follow all rec- information is prohibitive in terms of existing ommended treatments.” resources. The clinical support representative (CSR) con- Freer access to clinical information among tacted Cook Counseling Center at Virginia Tech to agencies is imperative so that a rational plan make an appointment for Cho. The Cook Counsel- for treatment can be developed. As for the ing Center required that Cho be put on the phone relationship between the independent evalua- (a practice begun shortly before this hearing tor and the staff psychiatrist, they rarely see according to the CSR) to make the appointment, each other and they function independently. which he did. The appointment was scheduled for The role of the independent evaluator is to 3:00 p.m. that afternoon, December 14. The CSR provide information to the court and the job of does not recall whether this phone call was made the attending psychiatrist is to provide clinical prior to or following the hearing. care for the patient. The clinical support representative recalls making As for counseling services at Virginia Tech his customary phone call to New River Valley CSB and the other area universities from which St. to advise them of the outcome of the morning’s Albans Hospital receives patients, according hearings. It was not the hospital’s practice at that to the psychiatrist they are all stretched for time to send copies of the orders from the com- mental health resources. The lack of outpa- mitment hearings. tient providers who can develop a post- Due to the rapidly approaching outpatient discharge treatment plan of substance is a appointment for Cho, the CSR urged the treating major flaw in the current system. The lack of psychiatrist to expedite the dictation and tran- services is common in both the public and the scription of his discharge summary. It was tran- private outpatient sectors. scribed shortly before noon and the physical The psychiatrist noted his recommendation evaluation findings and recommendation about an for outpatient counseling on the Initial Con- hour later. The clinical support representative sent Form for TDO Admissions. The clinical recalls faxing the records to Cook Counseling Cen- support representative then escorted Cho and ter, but he did not place a copy of the transmittal other TDO patients to meet with their attor- confirmation in the hospital records. Cook Coun- ney prior to their hearings. There were four seling Center, however, has no record of having hearings that morning, and the attorney has received any hospital records until January 2006. no specific recollection of Cho. The physical evaluation report indicated that Cho was to be treated by the psychiatrist at St. Albans A special justice designated by the Circuit “and hopefully have some intervention in therapy Court of Montgomery County presided over for treatment of his mood disorder.” The discharge the commitment hearing for Cho held shortly

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

summary, which was not part of the records ers and eventually, campus police. They were received by the panel from Cook Counseling unaware that their son had been committed for a Center, indicated “followup and aftercare to be time to St. Albans Hospital or that he had arranged with counseling center at Virginia appeared in court before a special justice. This is Tech. Medications none.” corroborated by documents and interviews relating that Cho refused to notify his parents when Cho was discharged from St. Albans at 2:00 campus police responded to his threat of suicide. p.m. on December 14. No one the panel inter- The university did not inform the parents either. viewed could say how Cho got back to campus. However, the electronic scheduling program at According to Virginia Tech records, there was a the Cook Counseling Center indicates that “home town” doctor or counselor who Cho could Cho kept his appointment that day at 3:00 see when he was home. The panel did not discover p.m. He was triaged again, this time face-to- what led to this assumption. However, it is known face, but no diagnosis was given. The triage that the university did not contact the family to report is missing (as well as those from his ascertain the veracity of home town followup for two prior phone triages), and the counselor counseling and medication management. who performed the triage has no independent recollection of Cho. It is her standard practice When Cho’s parents were asked what they would have done if they had heard from the college about to complete appropriate forms and write a note to document critical information, recom- the professors’, roommates, and female students’ complaints, their response was, “We would have mendations, and plans for followup. taken him home and made him miss a semester to It is unclear why Cho would have been triaged get this looked at …but we just did not know… for a third time rather than receiving a treat- about anything being wrong.” From their history ment session at his afternoon appointment during the high school years, we do know that following release from St. Albans. The Colle- they were dedicated to getting him to therapy giate Times had run an article at the begin- consistently and also consented to psychopharma- ning of the fall semester expressing “concern cology when the need arose. about the diminished services provided by the More Problems, Spring 2006 – The trend of dis- counseling center” and the temporary loss of turbing themes continued to be apparent in many its only psychiatrist. of Cho’s writings, along with his selective mutism. It was the policy of the Cook Counseling Cen- ter to allow patients to decide whether to Robert Hicok had Cho in his Fiction Workshop class that semester. Hicok described his class as a make a followup appointment. According to the existing Cook Counseling Center records, mid-level fiction course with about 20 students. none was ever scheduled by Cho. Because He told the panel that there was no participation from Cho and that Cho’s stories and work were Cook Counseling Center had accepted Cho as a voluntary patient, no notice was given to the violent. He said Cho was a very cogent writer, but CSB, the court, St. Albans, or Virginia Tech his creativity was not that good. Cho was open to suggestions and he made some edits, but he was officials that Cho never returned to Cook “not very unique” in his writing. The combination Counseling Center. of the content of Cho’s stories and his not talking AFTER HOSPITALIZATION raised red flags for Hicok. He consulted with Dr. Roy, but then decided to keep Cho in the class and ho’s family did not realize what was hap- just deal with him. Hicok scheduled two meetings Cpening with him at Blacksburg that fall with Cho, but he did not show up, and Hicok 2005 semester: his dark writings, stalking, never saw Cho again after the semester ended. and other odd and unsettling behavior that Cho received a D+ in this class. worried roommates, resident advisors, teach-

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

Professor Hicok shared none of Cho’s writings dents would allow him to get credit for group pro- with the panel. However, based on a question jects without having worked on them. Bean noted to a panel member by a reporter, further in- that Cho derived satisfaction from learning “how quiry was made as this report was about to go to play the game—do as little as he needed to do to press. Several writings by Cho in Hicok’s to get by.” This profile of Cho stands in contrast to class were produced, one of which is of par- the profile of a pitiable, emotionally disabled ticular significance. It tells the story of a young man, but it may in fact represent a true morning in the life of Bud “who gets out of bed picture of the other side of Cho—the one that unusually early…puts on his black jeans, a murdered 32 people. strappy black vest with many pockets, a black Bean allowed that Cho was very intelligent. He hat, a large dark sunglasses [sic] and a flimsy could write with technical proficiency and could jacket….” At school he observes “students read well. However, his creative writing skills strut inside smiling, laughing, embracing each were limited and his command of the English lan- other….A few eyes glance at Bud but without guage was “very impoverished.” He had trouble the glint of recognition. I hate this! I hate all with verb tenses and use of articles. On two or these frauds! I hate my life….This is it….This three occasions early in the semester, Bean had is when you damn people die with me.…” He spoken to Cho after class regarding the fact that enters the nearly empty halls “and goes to an he was not participating orally nor working col- arbitrary classroom….” Inside “(e)veryone is laboratively on group assignments. By late March smiling and laughing as if they’re in heaven- or early April, the class was given a writing on-earth, something magical and enchanting assignment to do a technical essay about a subject about all the people’s intrinsic nature that within their major. Cho suggested George Wash- Bud will never experience.” He breaks away ington and the American Revolution, but Bean and runs to the bathroom “I can’t do this.…I advised him that this was not within his major. have no moral right.…” The story continues by Cho next suggested the April 1960 revolution in relating that he is approached by a “gothic Korea—again rejected because the topic was not girl.” He tells her “I’m nothing. I’m a loser. I in his major. Cho then decided to write “an objec- can’t do anything. I was going to kill every god tive real-time” experience based on Macbeth and damn person in this damn school, swear to corresponding to serial killings. god I was, but I…couldn’t. I just couldn’t. Damn it I hate myself!” He and the “gothic On April 17, 2006, one school year prior to the girl” drive to her home in a stolen car. “If I get shooting to the day (because it was also a Mon- stopped by a cop my life will be forever over. A day), Bean asked Cho to stay after class again. stolen car, two hand guns, and a sawed off The professor explained to Cho that his work was shotgun.” At her house, she not satisfactory and that his topic was not accept- retrieves “a .8 caliber automatic rifle and a able. He recommended that Cho drop the class M16 machine gun.” The story concludes with and that he would recommend that a late drop be the line “You and me. We can fight to claim permitted. Cho never said a word, just stared at our deserving throne.” him. Then, without invitation, Cho followed Bean to his office. The professor offered for him to sit Cho encountered problems in another English down, but Cho refused and proceeded to argue class that semester, Technical Writing, taught loudly that he did not want to drop the class. Bean by Carl Bean. The professor told the panel was surprised because he had never heard Cho that Cho was always very quiet, always wore speak like that before nor engage in that type of his cap pulled down, and spoke extremely conduct. He asked Cho to leave his office and softly. Bean opined that “this was his power.” return when he had better control of himself. Cho By speaking so softly, he manipulated people left and subsequently sent an e-mail advising that into feeling sorry for him and his fellow stu- he had dropped the course.

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

Bean did not discuss the matter with Dr. Roy is reasonable and cogent. The professor awarded and he was not aware that Nikki Giovanni Cho a B for the course. had encountered problems with Cho the prior Cho’s senior year roommate explained to the semester. After the massacre of April 16, it panel that he tried speaking to Cho at the begin- was discovered that Cho had mailed a letter to ning of the semester, but Cho barely responded. “I the English Department on that same day. hardly knew the guy; we just slept in the same Bean stated he knew Cho was antisocial, room.” Cho went to bed early and got up early, so manipulative, and intelligent. Cho, he said, his roommate just left him alone and gave him his had obviously “researched” Bean after drop- space. The only activities Cho engaged in were ping Bean’s course, because in the April 16 studying, sleeping, and downloading music. He letter Cho wrote numerous times that Bean never saw him play a video game, which he “went holocaust on me.” Bean has a great thought strange since he and most other students interest in the Holocaust. play them. One of the suitemates mentioned that Fall 2006 – Cho enrolled in Professor Ed he saw Cho working out at McCommis Hall and Falco’s playwriting workshop in the fall saw him return to the room from time to time in semester. During the first class when each workout attire. Cho kept his side of the room very student was asked to introduce him/herself to neat. Nothing appeared to be abnormal—no the class, Cho got up and left before his turn. knives, guns, chains, etc. The only reading mate- When he returned for the second class, Profes- rial the roommate saw on Cho’s side was a paper- sor Falco informed him that he would have to back copy of the New Testament, which he participate; Cho did not respond. In his inter- thought may have been for a class. (Cho took a view with the panel, Professor Falco described course in the spring 2007 semester: The Bible as Cho’s writing as juvenile with some pieces Literature.) venting anger. The resident advisor for the section of Harper Hall Post April 16, 2007 students from this class where Cho resided had been forewarned by the were quoted in the campus newspaper as say- previous year’s RA that “there were issues” with ing that some classmembers had joked that Cho. She knew about his unwanted advances to- they were waiting for Cho to do something. ward female students and that he was suspected One student reportedly had told a friend that of writing violent song lyrics on the dorm walls Cho “was the kind of guy who might go on a that also were posted on his web site. However, rampage killing”. she did not encounter a single problem with him.

According to an article in the August 10, 2007 That fall semester, Cho enrolled in Professor edition of The Roanoke Times, Professor Falco, Norris’ Advanced Fiction Workshop—a small class director of Virginia Tech’s creative writing of only about 10 students. Cho had taken one of program, recently proposed and participated her classes the previous spring, on contemporary in the drafting of written guidelines for deal- fiction, so she knew how little he participated in ing with students who submit disturbing and class. Norris realized that the workshop class violent work. The guidelines suggest that fac- would be a problem for Cho because there would ulty concerned about a student’s writing pur- be discussions and readings. Cho appeared in sue a series of actions including speaking to class with a ball cap pulled low and making no eye the student, encouraging the student to seek contact. Norris checked with the dean’s office to counseling, and involving university adminis- see if it was safe—if Cho was okay—and she trators. asked to have someone intervene on his behalf.

Cho also took a class called “Contemporary The English Department did not know about Horror” in the fall of 2006. His final exam Cho’s dealings with campus police and the paper which appears to analyze a horror film

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

communications generated from Residence a night at St. Albans as a result of such detention Life about his stalking behavior. order. The Care Team did not know the details of all these occurrences. Norris told Cho that he had to come see her if he was going to able to make it through this Residence Life knew through their staff (two resi- particular class. She ascertained that Cho had dent advisors and their supervisor) that there trouble speaking in both English and Korean, were multiple reports and concerns expressed and she offered to connect him with the Dis- over Cho’s behavior in the dorm, but this was not ability Services Office. brought before the Care Team. The academic component of the university spoke up loudly about After meeting with Cho, she e-mailed him to a sullen, foreboding male student who refused to reiterate her offers to go with him for counsel- talk, frightened classmate and faculty with maca- ing or for other services. He did not pursue bre writings, and refused faculty exhortations to those offers. His written work was on time get counseling. However, after Judicial Affairs and he was on time for class, but he missed and the Cook Counseling Center opined that Cho’s the last 2 weeks of class. Cho earned a B+ in writings were not actionable threats, the Care Norris’s class that semester. Team’s one review of Cho resulted in their being satisfied that private tutoring would resolve the The following semester, spring 2007, Cho problem. No one sought to revisit Cho’s progress began to buy guns and ammunition. His class the following semester or inquire into whether he attendance began to fall off shortly before the had come to the attention of other stakeholders on assaults. There were no outward signs of his campus. deteriorating mental state. In their last phone call with him the night of April 15, 2007, Mr. The Care Team was hampered by overly strict Cho and Mrs. Cho had no inkling that any- interpretations of federal and state privacy laws thing was the matter. Cho had called per their (acknowledged as being overly complex), a decen- usual Sunday night arrangement. He tralized corporate university structure, and the appeared his “regular” self. He asked how his absence of someone on the team who was experi- parents were, and other standard responses: enced in threat assessment and knew to investi- “No I do not need any money.” His parents gate the situation more broadly, checking for col- said, “I love you.” lateral information that would help determine if this individual truly posed a risk or not. (The MISSING THE RED FLAGS interpretation of FERPA and HIPAA rules is discussed in a later chapter.) he Care Team at Virginia Tech was estab- Tlished as a means of identifying and work- There are particular behaviors and indicators of ing with students who have problems. That dangerous mental instability that threat assess- resource, however, was ineffective in connect- ment professionals have documented among mur- ing the dots or heeding the red flags that were derers. A list of red flags, warning signs and indi- so apparent with Cho. They failed for various cators has been compiled by a member of the reasons, both as a team and in some cases in panel and is included as Appendix M. the individual offices that make up the core of the team. KEY FINDINGS – CHO’S COLLEGE YEARS TO APRIL 15, 2007 Key agencies that should be regular members of such a team are instead second tier, non- permanent members. One of these, the VTPD, he lack of information sharing among aca- knew that Cho had been cautioned against Tdemic, administrative, and public safety enti- stalking—twice, that he had threatened sui- ties at Virginia Tech and the students who had cide, that a magistrate had issued a tempo- raised concerns about Cho contributed to the fail- rary detention order, and that Cho had spent ure to see the big picture. In the English Depart-

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

ment alone, many professors encountered undoubtedly clouded his ability to evaluate his similar difficulties with Cho—non- participa- own situation, he, ultimately, is the primary per- tion in class, limited responses to efforts to son responsible for April 16, 2007; to imply other- personally interact, dark writings, reflector wise would be wrong. glasses, hat pulled low over face. Although to any one professor these signs might not neces- RECOMMENDATIONS sarily raise red flags, the totality of the IV-1 Universities should recognize their reports would have and should have raised responsibility to a young, vulnerable alarms. population and promote the sharing of Cho’s aberrant behavior of pathological shy- information internally, and with parents, ness and isolation continued to manifest when significant circumstances pertaining to throughout his college years. He shared very health and safety arise. little of his college life with his family, had no IV-2 Institutions of higher learning should friends, and engaged in no activities outside of review and revise their current policies the home during breaks and summer vaca- related to— tions. While he was an adult, he was a mem- a) recognizing and assisting students in dis- ber of the household and receiving parental tress support, but he did not hold a job to help earn b) the student code of conduct, including en- money for college. Unusual by U.S. standards, forcement a high, sometimes exclusive focus on academics is common among parents from eastern c) judiciary proceedings for students, includ- cultures. ing enforcement d) university authority to appropriately in- Cho’s roommates and suitemates noted fre- tervene when it is believed a distressed stu- quent signs of aberrant behavior. Three dent poses a danger to himself or others female residents reported problems with unwanted attention from Cho (instant mes- IV-3 Universities must have a system that sages, text messages, Facebook postings, and links troubled students to appropriate medi- erase board messages). One of Cho’s suite- cal and counseling services either on or off mates combined many of these instances of campus, and to balance the individual’s concern into a report shared with the resi- rights with the rights of all others for safety. dence staff. The residence advisors reported IV-4 Incidents of aberrant, dangerous, or these matters to the hall director and the threatening behavior must be documented residence life administrator on call. These and reported immediately to a college’s individuals in turn, communicated by e-mail threat assessment group, and must be acted with the assistant director of Judicial Affairs. upon in a prompt and effective manner to protect the safety of the campus community. Notwithstanding the system failures and errors in judgment that contributed to Cho’s IV-5 Culturally competent mental health ser- worsening depression, Cho himself was the vices were provided to Cho at his school and biggest impediment to stabilizing his mental in his community. Adequate resources must health. He denied having previously received be allocated for systems of care in schools mental health services when he was evaluated and communities that provide culturally in the fall of 2005, so medical personnel competent services for children and adoles- believed that their interaction with him on cents to reduce mental-illness-related risk as that occasion was the first time he had occurred within this community. showed signs of mental illness. While Cho’s IV-6 Policies and procedures should be emotional and psychological disabilities implemented to require professors

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

encountering aberrant, dangerous, or ing center, and parents. All parties should be threatening behavior from a student to educated about the public safety exceptions to the report them to the dean. Guidelines should privacy laws which permit such reporting. be established to address when such reports IV-11 The college counseling center should should be communicated by the dean to a report all students who are in treatment pur- threat assessment group, and to the school’s suant to a court order to the threat assess- counseling center. ment team. A policy should be implemented to IV-7 Reporting requirements for aber- address what information can be shared with fam- rant, dangerous, or threatening behavior ily and roommates pursuant to the public safety and incidents for resident hall staff must exceptions to the privacy laws. be clearly established and reviewed dur- IV-12 The state should study what level of ing annual training. community outpatient service capacity will IV-8 Repeated incidents of aberrant, dan- be required to meet the needs of the common- gerous, or threatening behavior must be wealth and the related costs in order to ade- reported by Judicial Affairs to the threat quately and appropriately respond to both involuntary court-ordered and voluntary re- assessment group. The group must formu- ferrals for those services. Once this informa- late a plan to address the behavior that will tion is available it is recommended that out- both protect other students and provide the patient treatments services be expanded needed support for the troubled student. statewide. IV-9 Repeated incidents of aberrant, dan- The panel’s report deals with facts. Sometimes, gerous, or threatening behavior should be however, police investigation requires educated reported to the counseling center and guesses and speculation—such as in instances reported to parents. The troubled student where a “profile” of an unknown killer is gener- should be required to participate in counseling ated by FBI profilers, who are specially trained in as a condition of continued residence in cam- this area. Set forth in Appendix N is such a work, pus housing and enrollment in classes. written by panel member Dr. Roger Depue, who IV-10 The law enforcement agency at col- is, among many other qualifications, a former FBI leges should report all incidents of an is- profiler. While no member of the panel can defini- suance of temporary detention orders for tively ascertain what was in Cho’s mind, this pro- students (and staff) to Judicial Affairs, file offers one theory. the threat assessment team, the counsel-

Part B – Virginia Mental Health Law Issues

serve the needs of people with mental illness, The Commonwealth of Virginia Commission on while respecting the interests of their families Mental Health Law Reform was appointed in and communities.” October 2006, by Virginia Chief Justice Leroy R. Hassell, Sr. The 26-member commission, The commission has held four meetings with chaired by Professor Richard J. Bonnie, Director another scheduled for November 2007 and is of the Institute of Law, Psychiatry and Public working through five task forces with more than Policy at the University of Virginia, is charged 200 participants. The Task Force on Civil Com- to “conduct a comprehensive examination of mitment is addressing criteria for inpatient and Virginia’s mental health laws and services” and outpatient commitment, transportation, and the to “study ways to use the law more effectively to emergency evaluation process, procedures for

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY hearings, training, and compensation for par- cause. The concerns raised included that it is ticipants in the process, and oversight. often difficult to promptly secure qualified personnel to perform the prescreening evaluation The Task Force on Civil Commitment will sub- given staff resources and required travel time, mit its final report to the commission in Novem- particularly in rural jurisdictions. It is often ber 2007. The commission intends to prepare a even more difficult to locate the available bed preliminary report during the winter and to required for a temporary detention order (TDO) submit a final report by the fall of 2008 for con- to issue. Four hours do not allow sufficient time sideration by the 2009 General Assembly. to gather meaningful collateral information The discussion that follows constitutes an from family, friends, or other health care pro- abridged effort, due to constraints of time and viders nor to secure proper evaluations for manpower, to address some of the issues that medical clearance. Some noted, however, that will be dealt with by the commission in a far an extension of the 4-hour period may require more comprehensive manner. Many of the police departments to spend more time with a panel’s recommendations are framed in general person in emergency custody in those locales terms with the expectation that the commission where hospital security are unable to assume will formulate specific proposals. responsibility.

Throughout the panel’s work, there was close The American College of Emergency Physicians collaboration with Professor Bonnie and James (ACEP) has recommended that emergency Stewart, the Inspector General for the Depart- physicians trained in psychiatric evaluation be ment of Mental Health and Mental Retardation given more authority in the involuntary hold and Substance Abuse Services. The inspector process. Since emergency departments are 24- general released a report in June 2007 detailing hour facilities, resources are already in place. his findings concerning Cho’s interaction with Because the CSB serves an independent mental health services in Virginia. “gatekeeper” role under the Virginia TDO process, emergency physicians and CSB staff TIME CONSTRAINTS FOR are generally expected to work collaboratively in EVALUATION AND HEARING determining whether a TDO is needed for those patients screened in emergency departments. Va. Code 37.2-808 establishes the procedures for However, where CSB pre-screeners are not involuntary temporary detention of persons who immediately available, properly trained are mentally ill, present an imminent danger to emergency physicians can effectively screen self or others, and are in need of hospitalization patients under an emergency custody order and but unwilling or unable to volunteer for treat- communicate with the magistrate to obtain the ment. Subsection H provides that no person TDO when needed. If such a gate keeping shall remain in custody for longer than 4 hours responsibility were to be conferred on without a temporary detention order issued by a emergency physicians, further questions would magistrate. In Cho’s case, the New River Valley have to be addressed regarding the respective CSB was able to provide a pre-screener in a roles of the emergency physicians and the CSB timely manner, and she was able to conduct the staff in exploring alternatives to hospitalization screening and locate an available bed in order to and in participating in the commitment hearing. present the matter to the magistrate within the required 4-hour period. Under current Virginia law, the duration of temporary detention may not exceed 48 hours However, mental health service providers and prior to a hearing (or the next day that is not a special justices interviewed for this report set Saturday, Sunday, or legal holiday). The mental forth numerous arguments as to why this period health service providers in Cho’s case were able should be lengthened to either 6 hours or to to comply with the 48-hour requirement; permit one renewal of the 4-hour period for good however, the information available to the

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY special justice was extremely limited. There was involuntary admission. At the commitment no history regarding prior treatment; there were hearing, the special justice did find Cho to be an no lab or toxicology reports, nor the report imminent danger to himself; however, he agreed regarding access to a firearm. At the hearing, with the independent examiner and treating there were no witnesses present such as family, psychiatrist that a less restrictive alternative to roommate/suitemates, the CSB pre-screener, involuntary admission, outpatient treatment, the independent evaluator, or the treating was suitable. Perhaps Cho presented himself psychiatrist. differently at various stages of the commitment process or perhaps the professionals had differ- Mental health professionals interviewed ing evaluations of someone who did not speak reported that 48 hours is one of the shortest much or perhaps they had differing interpreta- detention periods in the nation and recom- tions of the standard set forth in the Virginia mended that it be lengthened. Reasons cited for Code. expanding this period included the need to contact family or friends and to explore the person’s Mental health professionals advised the panel prior history. Also cited was the need for a more that the standard “imminent danger to self or comprehensive independent evaluation and the others” is not clearly understood and is subject difficulty in securing a complete report of the to differing interpretations. They recommend treating psychiatrist in time for the hearing. It that the criteria for commitment be revised to was suggested that a psychiatric “workup” as achieve a more consistent application. Service well as a toxicology screen be available to the providers and special justices suggest that the independent examiner. A further concern was “imminent danger” criterion should be replaced that often psychiatric inpatient bed space is not by language requiring “a substantial likelihood” available within the 48 hours. As a financial or “significant risk” that the person will cause consideration, it was argued that a longer period serious injury to himself or others “in the near would allow patients an opportunity to stabilize future.” A few disagreed on the basis that per- or recognize the need for voluntary treatment, sonal rights of liberty should be paramount, and thereby reducing the number of commitment that changing the standard would lower the hearings and the costs associated with special threshold for admission. Proponents for modify- justices and appointed counsel. ing the criteria respond that Virginia’s commitment standard is one of the most restrictive of STANDARD FOR INVOLUNTARY all the states. They contend that the threshold COMMITMENT finding prevents intervention in cases of severe illness accompanied by substantial impairment The judge or special justice ordering commit- of cognition, emotional stability, or self-control. ment must find by clear and convincing evidence that the person presents (1) an imminent PSYCHIATRIC INFORMATION danger to himself or others or is substantially unable to care for himself, and (2) less restric- Many of those interviewed expressed serious tive alternatives to involuntary inpatient treat- concerns regarding the paucity of psychiatric ment have been investigated and are deemed information available to the independent unsuitable. Cho was found to be an imminent evaluator and judge/special justice. As noted danger to himself by the pre-screener who also above, the independent evaluator for Cho had found that he was “unable to come up with a only the report from the CSB pre-screener and safety plan to adequately ensure safety.” He was no collateral information or medical records. unwilling to contact his parents to pick him up. The independent evaluator plays a key role in However, Cho was found not to be an imminent the commitment process in many jurisdictions. danger to self or others by both the independent In Cho’s case, notwithstanding the finding from examiner and the treating psychiatrist at St. the independent evaluator that Cho did not pose Albans, and accordingly neither recommended an imminent threat, the special justice,

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY nevertheless convened the hearing and actually vacy (VaHRP) often make it difficult to acquire made a finding that differed from that of the background medical/psychiatric information on independent evaluator. He did, however, agree a patient previously treated elsewhere. Legal with the independent evaluator that inpatient experts from a research advisory group for the treatment was not required. The panel was Commission on Mental Health Law Reform par- advised that in many jurisdictions, absent a ticipated in the development of a questionnaire finding by the independent evaluator that an for judges and special justices to complete fol- individual poses an imminent danger or is lowing civil commitment hearings in the month substantially unable to care for himself, many of May 2007. More than 1400 questionnaires special justices will decline to hold a hearing. were returned. They reflected that approximately 60 percent of the May hearings lasted no It is unclear under existing law whether the in- more than 15 minutes and only 4 percent dependent evaluator is intended to serve as a required more than 30 minutes. gate keeper. If the opinion of the independent evaluator is to be given great weight, then it is Cho was the only person to testify at his com- critical that sufficient psychiatric information be mitment hearing, and he was not very commu- available upon which an informed judgment nicative. The pre-screener was not present nor may be made. Background information includ- was any representative from the CSB. The ing records from the current hospitalization independent evaluator was not present. The must be assembled for review. The Cho case officer who detained Cho was not present. Cho’s calls attention to the need to assure that the roommate, suitemates, and Cho’s family were independent evaluator has both sufficient time all absent. This apparently is not an unusual and information to conduct an adequate evalua- scenario for commitment hearings in Virginia. tion. Often the pre-screener is off duty by the time of the hearing. CSBs with limited staff frequently At Cho’s hearing, the only documents available do not send a substitute. (The commission’s sur- to the special justice were the Uniform Pre- vey reflected that the CSB representatives Admission Screening Form, a partially com- attended only half of the hearings held in May, pleted Proceedings for Certification form 2007). Independent evaluators, paid $75 per recording the findings of the independent commitment evaluation, often feel compelled to evaluator and a physician’s examination form return to their private practice rather than containing the findings of the treating psychia- waiting for hearings that may be held hours trist. No prior patient history was presented; no after the evaluation is complete. (The responses toxicology, lab results, or physical evaluation to the questionnaires indicated that the inde- from the treating psychiatrist were available. pendent evaluators were present at approxi- The admitting form indicating that Cho had mately two-thirds of Mays hearings.) Due to access to a firearm was not presented. time constraints and concerns regarding HIPAA Panel members have been advised by mental and VaHRP restrictions, friends and family are health providers and special justices from other often not notified. locales in Virginia that it is not unusual for the HIPAA and VaHRP generally require that no evidence presented at commitment hearings to health care entity disclose an individual’s health be minimal. Due to the time constraints and records or information. However, permitted limitations of resource personnel, the informa- exceptions are information necessary for the tion available to the judge/special justice is often care of a patient and information concerning a very limited. Witnesses cannot be located patient who may present a serious threat to quickly and hospital records have often not been public health or safety. Therefore, a treating transcribed. Additionally, conflicting interpreta- physician at the facility where a patient is tions of the constraints of the Health Insurance detained should be granted access to all prior Portability and Accountability Act (HIPAA) and psychiatric history. These exceptions, however Virginia Code 32.1-127.1:03 Health Records Pri-

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY do not clearly permit these records be shared for involuntary outpatient treatment and to with the judge or special justice at the commit- monitor compliance. However, the Code does not ment hearing. Although a person may consent specify how or by whom the CSB will be notified to the release of information to any person or that outpatient treatment has been ordered if a entity, detained individuals are often unable or representative is not present at the hearing. disinclined to do so. There exists a disagreement as to whether the CSB was advised of the entry of the outpatient Because interpretation of HIPAA and FERPA order in Cho’s case. The clinical support were key in stopping adequate exchange of in- representative for St. Albans advised that he formation concerning Cho, the panel requested always calls the CSB following commitment that its legal council research the interpretation hearings to report the results. The CSB reports and exceptions under these laws, which is pre- that they have no record of having been notified. sented in the next chapter. If the CSB is represented at the hearing, there INVOLUNTARY OUTPATIENT ORDERS can be no reason for confusion. However, if Virginia Code is not amended to require the In conducting the investigation, the panel presence in person or telephonically, it must be encountered many questions concerning invol- amended to designate who has responsibility for untary outpatient orders. What specificity certifying a copy of the outpatient order to the should be required of outpatient orders? To CSB. There should also be clear guidance whom should notice of outpatient orders be provided in the Virginia Code as to who has given? How should compliance with outpatient responsibility for notification if a private mental orders be monitored? What procedures should health practitioner is to provide the mandated be available to address noncompliance and what outpatient treatment. resources are needed? No notice of the hearing or the order issued by The special justice ordered that Cho receive the special justice was given to Cho’s family, his outpatient treatment; however, the order pro- roommate/suitemates, the VTPD, or the Vir- vided no information regarding the nature of the ginia Tech administration. The Code of Virginia treatment other than to state “to follow all rec- authorizes no such notice. The recordings of the ommended treatments.” The order did not spec- hearing must be kept confidential pursuant to ify who was to provide the outpatient treatment Va. Code 37.2-818(A). The records, reports and or who was to monitor the treatment. court documents pertaining to the hearing are kept confidential if so requested by the subject There was considerable support among those of the hearing under 37.2-818(B) and are not interviewed by panel members for greater guid- subject to the Virginia Freedom of Information ance in the Virginia Code regarding outpatient Act. HIPAA and VaHRP restrictions may fur- treatment orders. Some felt that the order ther limit dissemination of certain information should track recommendations from the treating as no person to whom health records are dis- physician as to the frequency and duration of closed may redisclose beyond the purpose for treatment and whether medication was which disclosure was made. Concerns were required. Others observed that often physician’s raised by many interviewees and speakers at evaluations and orders were not available and panel hearings that family members, those the special justice/substitute judge did not have residing with the subject of a commitment hear- the expertise to order specific treatment. How- ing, the police department and school officials ever, all agreed that more specificity in out- should all be notified of the hearing and its outpatient treatment orders is essential. come in the interest of public safety. New River Valley CSB did not have a In Cho’s case, there are conflicting reports re- representative at Cho’s hearing due to financial garding the issue of notice to the treatment pro- constraints. Va. Code 37.2-817(C) currently vider, Cook Counseling Center. An appointment requires the CSB to recommend a specific course

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY had been scheduled by Cho with the assistance On June 22, 2007, the Commission on Mental of the clinical support representative for St. Health Law Reform released the final report of Albans. The representative reports that he its study of the current commitment process. faxed a copy of the discharge summary to Cook. This study, undertaken for the commission by Cook, however, contends that they did not Dr. Elizabeth McGarvey of the University of receive any written documentation until Janu- Virginia School of Medicine, involved intensive ary, and even then it was the physical examina- interviews with 64 professional participants in tion which indicated that Cho would be treated the process, 60 family members of persons with by the St. Alban’s psychiatrist. Following Cho’s serious mental illness, and 86 people who have in-person triage appointment on December 14, had the experience of being committed. Accord- the Cook Counseling Center left it to Cho’s dis- ing to Dr. McGarvey’s report, professional par- cretion whether to return for follow up treat- ticipants and family stakeholders are uniformly ment. When he did not, it was not reported to frustrated by almost every aspect of the civil the special justice, St. Alban’s, or the CSB. The commitment process in Virginia. Among the Virginia Code imposes no legal obligation for most common complaints were a shortage of Cook Counseling Center to do so, and Cook beds in willing detention facilities, insufficient counselors question whether they have the right time for adequate evaluation, the high cost and to do so given the restrictions of HIPAA and inefficiency of transporting people for evalua- VaHRP. tion, inadequate compensation for professional participants in the process, inadequate reim- Furthermore, there exists the question of bursement for hospitals, inconsistent interpre- whether Cho was noncompliant given the gen- tation of the statute by different judges, and eral language of the involuntary treatment lack of central direction and oversight. order; and if Cho were considered noncompliant, how was that to be addressed. There is no con- CERTIFICATION OF ORDERS TO THE tempt provision in the Virginia Code for those CENTRAL CRIMINAL RECORDS noncompliant with involuntary outpatient EXCHANGE orders. There is no guidance as to the nature of the hearing to be held for noncompliance; nor is Va. Code 37.2-819 requires the clerk to certify, there a basis for compensating the special on a form provided, any order for involuntary justice/substitute judge or attorney for followup admission to the Central Criminal Records proceedings. Many questions are raised. If a Exchange. The section does not specify who form is created to report noncompliance, can a bears responsibility for completion of the form. treatment provider file the report without vio- The failure of Va. Code 37.2-819 to specify lating HIPAA and VaHRP? If the noncompli- responsibility for preparation of the order fur- ance report is filed, how does the special justice nished by the Central Criminal Records secure the presence of the individual for a fol- Exchange was noted to be a problem. It is lowup hearing? If the noncompliant individual reported that in some jurisdictions, if the clerk does not pose an imminent danger to himself or is not furnished the completed form, no form is others at the time of the followup hearing, an forwarded to the exchange. There is lack of con- emergency custody order cannot be issued; nor sistency throughout the Commonwealth regard- can the special justice order involuntary in- ing who prepares the forms. In some jurisdic- patient treatment. Should there be a Code pro- tions, the forms are completed by the special vision allowing for a short period of inpatient justice/substitute judge, in others by the clerk of treatment for those not compliant with the out- court, and reportedly in others, the forms are patient order yet not an “imminent danger” at often not completed at all. the time returned for noncompliance? Will commitment for noncompliance pose yet another Of further concern was the issue of under what burden on the already overcrowded inpatient circumstances the forms are to be completed. facilities? Mental health and legal professionals

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY interviewed by panel members felt that there order to the CSB resulted in an absence of over- was no reasonable distinction to be drawn sight for Cho’s outpatient treatment. between persons ordered for involuntary inpatient The lack of a requirement in the Virginia Code to certify outpatient commitment orders to the treatment and those ordered for involuntary out-patient treatment when a finding has been CCRE resulted in Cho’s name not being entered made that the individual poses an imminent in the database, which could have prevented his danger to self or others. If firearms restrictions purchase of firearms. apply, they should be based upon the fact that There was a lack of doctor-to-clinician contact an individual poses a danger, not on the basis of between St. Albans Hospital and the Cook the type of treatment ordered; therefore, both Counseling Center. involuntary inpatient and involuntary outpatient treatment orders should be certified. In the wake of the Virginia Tech tragedy, much While the governor has addressed this matter of the discussion regarding mental health ser- by executive order, it was felt that legislation vices has focused on the commitment process. should be enacted embodying the certification However, the mental health system has major requirement. Mental health and legal experts gaps in its entirety starting from the lack of also raised the question of whether persons short-term crisis stabilization units to the out- electing voluntary admission upon being patient services and the highly important case advised of their right to do so during the management function, which strings together commitment hearing should also be reported. the entire care for an individual to ensure suc- (The commission’s survey indicated that 30 cess. These gaps prevent individuals from get- percent of the commitment hearings in May ting the psychiatric help when they are getting resulted in voluntary admission.) ill, during the need for acute stabilization, and when they need therapy and medication man- It was also noted with concern by the mental agement during recovery. health and legal experts interviewed that the reporting requirement does not apply to orders RECOMMENDATIONS for juveniles found to pose an imminent danger, regardless of whether inpatient or outpatient IV-13 Va. Code 37.2-808 (H) and (I) and treatment was ordered. They further expressed 37.2-814 (A) should be amended to extend concern regarding the absence of any provision the time periods for temporary detention to in the Virginia Code requiring the clerk to cer- permit more thorough mental health tify orders pertaining to persons found not evaluations. guilty by reason of insanity. IV-14 Va. Code 37.2-809 should be amended to authorize magistrates to issue temporary KEY FINDINGS detention orders based upon evaluations Statutory time constraints for temporary deten- conducted by emergency physicians trained tion and involuntary commitment hearings sig- to perform emergency psychiatric evalua- nificantly impede the collection of vital psychi- tions. atric information required for risk assessment. IV-15 The criteria for involuntary The Virginia standard for involuntary commit- commitment in Va. Code 37.2-817(B) should ment is one of the most restrictive in the nation be modified in order to promote more and is not uniformly applied. consistent application of the standard and to The fact that a CSB representative did not allow involuntary treatment in a broader attend the commitment hearing and the failure range of cases involving severe mental to certify a copy of the outpatient commitment illness.

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

IV-16 The number and capacity of secure IV-22 Virginia Health Records Privacy and crisis stabilization units should be Va. Code 37.2-814 et seq. should be amended expanded where needed in Virginia to to ensure that all entities involved with ensure that individuals who are subject to treatment have full authority to share a temporary detention order do not need to records with each other and all persons in- wait for an available bed. An increase in volved in the involuntary commitment capacity also will address the use of inpatient process while providing the legal safe- beds for moderately to severely ill patients that guards needed to prevent unwarranted need longer periods of stabilization. breaches of confidentiality.

IV-17 The role and responsibilities of the IV-23 Virginia Code 37.2-817(C) should be independent evaluator in the commitment amended to clarify— process should be clarified and steps taken • the need for specificity in involuntary to assure that the necessary reports and outpatient orders. collateral information are assembled before the independent evaluator conducts • the appropriate recipients of certified the evaluation. copies of orders. • the party responsible for certifying cop- IV-18 The following documents should be ies of orders. presented at the commitment hearing: • the party responsible for reporting non- • The complete evaluation of the treating compliance with outpatient orders and physician, including collateral infor- to whom noncompliance is reported. mation. • the mechanism for returning the non- • Reports of any lab and toxicology tests compliant person to court. conducted. • the sanction(s) to be imposed on the no- • Reports of prior psychiatric history. compliant person who does not pose an • All admission forms and nurse’s notes. imminent danger to himself or others.

IV-19 The Virginia Code should be • the respective responsibilities of the amended to require the presence of the pre- detaining facility, the CSB, and the screener or other CSB representative at all outpatient treatment provider in assur- commitment hearings and to provide ing effective implementation of involun- adequate resources to facilitate CSB tary outpatient treatment orders. compliance. IV-24 The Virginia Health Records Privacy IV-20 The independent evaluator, if not statute should be clarified to expressly present in person, and treating physician authorize treatment providers to report should be available where possible if noncompliance with involuntary outpatient needed for questioning during the hearing. orders.

IV-21 The Virginia Health Records Privacy statute should be amended to provide a safe harbor provision which would protect health entities and providers from liability or loss of funding when they disclose information in connection with evaluations and commitment hearings conducted under Virginia Code 37.2-814 et seq.

CHAPTER IV. CHO’S MENTAL HEALTH HISTORY

IV-25 Virginia Code 37.2-819 should be IV-26 A comprehensive review of the amended to clarify that the clerk shall Virginia Code should be undertaken to immediately upon completion of a commit- determine whether there exist additional ment hearing complete and certify to the situations where court orders containing Central Criminal Records Exchange, a copy mental health findings should be certified of any order for involuntary admission or to the Central Criminal Records Exchange. involuntary outpatient treatment.

Chapter V INFORMATION PRIVACY LAWS

privacy law. A narrow interpretation of the hile Cho was a student at Virginia Tech, his law is the least risky course, notwithstanding Wprofessors, fellow students, campus police, the harm that may be done to others if infor- the Office of Judicial Affairs, the Care Team, and mation is not shared. the Cook Counseling Center all had dealings with him that raised questions about his mental stabil- Much of the frustration about privacy laws ity. There is no evidence that Cho's parents were stems from lack of understanding. When seen ever told of these contacts, and they say they were clearly, the privacy laws contain many provi- unaware of his problems at school. Most signifi- sions that allow for information sharing where cantly, there is no evidence that Cho's parents, his necessary. Also, FERPA and HIPAA are not suitemates, and their parents were ever informed consistent (Cook Counseling Center records that he had been temporarily detained, put come under FERPA, Carilion’s under HIPAA), through a commitment hearing for involuntary which causes difficulties, as explained below. admission, and found to be a danger to himself. This chapter addresses federal and state law Efforts to share this information was impeded by concerning four key categories of information laws about privacy of information, according to that may be useful in evaluating and respond- several university officials and the campus police. ing to a troubled student: Indeed, the university’s attorney, during one of the panel’s open hearings and in private meetings, Law enforcement records told the panel that the university could not share Court records this information due to privacy laws. Medical information and records Educational records. The panel's review of information privacy laws governing mental health, law enforcement, and The report also examines a Virginia law that educational records and information revealed regulates the process of disclosing informa- widespread lack of understanding, conflicting tion. These laws are discussed in the context practice, and laws that were poorly designed to of Cho's conduct leading to the shootings of accomplish their goals. Information privacy laws April 16. are intended to strike a balance between protecting privacy and allowing information sharing that Appendix G summarizes the privacy laws as is necessary or desirable. Because of this difficult background for this chapter, for those un- balance, the laws are often complex and hard to familiar with them. understand. LAW ENFORCEMENT RECORDS The widespread perception is that information privacy laws make it difficult to respond effec- aw enforcement agencies must disclose tively to troubled students. This perception is only Lcertain information to anyone who 1 partly correct. Privacy laws can block some requests it. They must disclose basic informa- attempts to share information, but even more of- tion about felony crimes: the date, location, ten may cause holders of such information to general description of the crime, and name of default to the nondisclosure option—even when the investigating officer. Law enforcement laws permit the option to disclose. Sometimes this agencies also have to release the name and is done out of ignorance of the law, and sometimes intentionally because it serves the purposes of the 1 individual or organization to hide behind the Va. Code § 2.2-3706

CHAPTER V. INFORMATION PRIVACY LAWS

address of anyone arrested and charged with any court proceedings do not fit the general rule: type of crime. All records about noncriminal inci- juvenile hearings and commitment hearings dents are available upon request. When they dis- for involuntary admission.7 close noncriminal incident records, law enforce- A commitment hearing for involuntary admis- ment agencies must withhold personally- identifying information, such as names, sion is a hearing where a judicial officer 2 makes a determination as to whether an indi- addresses, and social security numbers. vidual will be committed to a mental health Universities with campus police departments facility involuntarily. Records of these hear- have additional responsibilities. They are required ings, which consist of any medical records, to maintain a publicly available log that lists all reports of evaluations, and all court docu- crimes.3 The log must give the time, date, and ments, must be sealed when the subject of the location of each offense, as well as the disposition hearing requests it. Tape recordings are made of each case. Under Virginia law, campus police of the proceedings. The tapes are sealed and departments must also ensure that basic informa- held by court clerks. These records can only be tion about crimes is open to the public.4 This released by court order.8 includes the name and address of those arrested for felony crimes against people or property and Although their records are confidential, the hearings themselves must be open to the pub- misdemeanor crimes involving assault, battery, or 5 lic and certain information about the hearing moral turpitude. is, at least in theory, publicly available.9 This Most of the detailed information about criminal would include the name of the subject and the activity is contained in law enforcement investiga- time, date, and location of the hearing. Of tive files. Under Virginia's Freedom of Informa- course, there is no central location where this tion Act, law enforcement agencies are allowed to information is stored so, as a practical matter, keep these records confidential. The law also gives unless an interested party knew where the agencies the discretion to release the records.6 hearing was being held or who was presiding However, law enforcement agencies across the over it, that person would have a difficult state typically have a policy against disclosing time uncovering such information. For exam- such records. ple, Cho's commitment hearing occurred approximately 12 hours after he was detained. JUDICIAL RECORDS Logistical difficulties also make it difficult to visit psychiatric facilities, which are common s a general matter, court records are public locations for commitment hearings. The key, and can be widely disclosed. For the purposes A though, is that the information is public. In of responding to troubled students, two types of Cho's case, the Virginia Tech Police Depart- ment (VTPD) was aware that he had been de- 2 tained pending a commitment hearing. VTPD Law enforcement records regarding juveniles (persons under 18) have special restrictions regarding disclosure. Normally, could have shared this information with they can only be released to other parts of the juvenile justice system or to parents of an underaged suspect. However, Vir- 7 ginia law also authorizes, but does not require, law enforce- Va. Code § 17.1-208 (circuit court records open to the ment to share information with school principals about offend- public). Regarding juvenile court records: under Virginia ers who commit a serious felony, arson, or weapons offense. law, juvenile court records are even more tightly Police can tell principals when they believe a juvenile is a sus- restricted than juvenile law enforcement records. Court pect or when a juvenile is charged with an offense. After the records can only be used within the juvenile justice sys- case is finished, law enforcement officials can tell principals tem unless a judge orders the records released. Va. Code § the outcome. Va. Code § 16.1-301 16.1-305 3 8 20 U.S.C. § 1092(f)(4)(A) Va. Code § 37.2-818. Cho was the subject of a commit- 4 ment hearing for involuntary admission on December 14, Va. Code § 23-232.2(B) 5 2005. The panel obtained the tape recording and records Va. Code § 23-232.2(B) of this hearing through court order. 6 9 Va. Code § 2.2-3706 Va. Code § 37.2-820

CHAPTER V. INFORMATION PRIVACY LAWS

university administration or Cho's parents, disclose information to a family mem- though they did not. ber, the provider can do so in two ways. The provider can gain permis- MEDICAL INFORMATION sion from the patient. Or, in an emergency where the patient is unable to oth state and federal law govern privacy of make such a decision, the provider can medical information. The federal Health In- 11 B proceed without explicit permission. surance and Portability and Accountability Act of 1996 and regulations by the Secretary of Health • Situations where privacy is out- and Human Services establish the federal stan- weighed by certain other interests. For dards. Together, the law and regulations are example, providers may sometimes commonly known as “HIPAA.” Virginia law on disclose information about a person medical information privacy is found in the who presents an imminent threat to Virginia Health Records Privacy Act (VHRPA). the health and safety of individuals and the public.12 Providers can also HIPAA and Virginia law have similar standards. disclose information to law enforce- They both state that health information is private ment in order to locate a fugitive or and can only be disclosed for certain reasons. suspect.13 Providers also are author- When specific provisions conflict, HIPAA can pre- ized to disclose information when state empt a state law, making the state law ineffective. law requires it.14 Generally, this occurs when a state law attempts to be less protective of privacy than the federal Disclosure of information is required by state law or rules. law in some situations and is permissible by HIPAA. An example under Virginia state law Both laws apply to all medical providers and bill- is that Virginia health care providers must ing entities. They define “provider” broadly to report evidence of child abuse or neglect. include doctors, nurses, therapists, counselors, Another type of required disclosure is when social workers, and health organizations such as freedom of information laws require public HMOs and insurance companies, among others. agencies to disclose their records. If a freedom of information law requires a public hospital Three basic types of disclosures are permitted to disclose information, the disclosure is au- under these medical information privacy laws: thorized under HIPAA.15 • Requests made or approved by the person who is the subject of the records. These EDUCATIONAL RECORDS exceptions are based on the idea that the rivacy of educational records is primarily privacy laws are for the benefit of the per- governed by federal law, The Family son being treated. If the patient asks for P Educational Rights and Privacy Act of 1974 his or her records from a health care pro- and regulations issued by the Secretary of vider or provides written authorization, the provider must release them. 11 • Disclosure when information must be 45 C.F.R. § 164.510(b) 12 shared in order to make medical treat- 45 C.F.R. § 164.512(j) 13 ment effective. Medical privacy laws allow Va. Code § 32.1-127.1:03(D)(28) 14 providers to share information with each 45 C.F.R. § 164.512(a), (c) 15 other when necessary for treatment pur- If, however, a state law merely permits disclosure, 10 HIPAA usually will override state law and prevent dis- poses. If a medical provider needs to closure. For example, Virginia's Freedom of Information Act gives public agencies the discretion to release information, but does not require information to be released. 10 Because the decision is left to the discretion of the agency, 45 C.F.R. § 164.506(c)(2); Va. Code § 32.1-127.1:03(D)(7) HIPAA would prohibit disclosure.

CHAPTER V. INFORMATION PRIVACY LAWS

Education that interpret the law. This law and Health Records Privacy Act. It is important to the regulations are commonly known as “FERPA.” note that FERPA was drafted to apply to educational records, not medical records. Though FERPA applies to all educational institutions that it has a small number of provisions about accept federal funding. As a practical matter, this medical records, FERPA does not enumerate means almost all institutions of higher learning, the different types of disclosures authorized including Virginia Tech. It also includes public by HIPAA. elementary and secondary schools. Like HIPAA, FERPA’s basic rule favors privacy. Information FERPA also has a different scope than from educational records cannot be shared unless HIPAA. Medical privacy laws such as HIPAA authorized by law or with consent of a parent, or if apply to all information—written or oral— the student is enrolled in college or is 18 or older, gained in the course of treatment. FERPA ap- with that student's consent. plies only to information in student records. Personal observations and conversations with FERPA has special interactions for medical and a student fall outside FERPA. Thus, for law enforcement records. HIPAA also makes an 16 example, teachers or administrators who wit- exception for all records covered by FERPA. ness students acting strangely are not Therefore, records maintained by campus health 17 restricted by FERPA from telling anyone— clinics are not covered by HIPAA. Instead, school officials, law enforcement, parents, or FERPA and state law restrictions apply to these 20 18 any other person or organization. In this records. FERPA provides the basic requirements case, several of Cho's professors and the Resi- for disclosure of health care records at campus dence Life staff observed conduct by him that health clinics, and state law cannot require dis- 19 raised their concern. They would have been closure that is not authorized by FERPA. How- authorized to call Cho's parents to report the ever, if FERPA authorizes disclosure, a campus behavior they witnessed. health clinic would then have to look to state law to determine whether it could disclose records, Many records kept by university law enforce- including state laws on confidentiality of medical ment agencies also fall outside of FERPA. For records. example, it does not apply to records created and maintained by campus law enforcement For example, Virginia Tech's Cook Counseling for law enforcement purposes.21 If campus law Center holds records regarding Cho's mental enforcement officers share a record with the health treatment. On a request for those records, school, however, the copy that is shared the center must determine whether the disclosure becomes subject to FERPA. For example, in is authorized under both FERPA and the Virginia fall 2005, VTPD received complaints from female students about Cho's behavior. Their 16 45 C.F.R. § 160.103, definition of “protected health informa- records of investigation were created for the tion.” law enforcement purpose of investigating a 17 U.S. Department of Education, FERPA General Guidance potential crime. Accordingly, the police could for Parents, available at http://www.ed.gov/policy/gen/guid/fpco/ferpa/parents.html have told Cho's parents of the incident. When (attached as Appendix H) (“June 2007 ED Guidance”). the university’s Office of Judicial Affairs 18 The nature of FERPA's application to treatment records has requested the records, FERPA rules applied to not been uniformly interpreted (discussed in the “Recommen- dations” section). The analysis in this section is based in part the copies held in that office but not to any on an official letter sent to the University of New Mexico by record retained by the VTPD. the Family Policy Compliance Office (FPCO). The FPCO is the part of the Department of Education that officially interprets FERPA. The letter is included in Appendix G. 19 Letter from LeRoy S. Rooker, Director, Family Compliance Policy Office, U.S. Department of Education, to Melanie P. 20 June 2007 ED Guidance (Appendix H). Baise, Associate University Counsel, The University of New 21 Mexico, dated November 29, 2004 (enclosed as Appendix G). 20 U.S.C. § 1232g(a)(4)(B)(ii)

CHAPTER V. INFORMATION PRIVACY LAWS

Law enforcement performs various other func- potentially broad group of parties, the regulations that promote public order and safety. For tions specifically state that it is to be narrowly example, law enforcement officers are usually construed. HIPAA, too, contains exceptions responsible for transporting people who are under that allow disclosure in emergency situa- temporary detention orders to mental health fa- tions.28 For both laws, the exceptions have cilities. No privacy laws apply to this law been construed to be limited to circumstances enforcement function. In the Cho case, the VTPD involving imminent, specific threats to health was not prohibited from contacting the university or safety. Troubled students may present such administration or Cho's parents to inform them an emergency if their behavior indicates they that Cho was under a temporary detention order are a threat to themselves or others. The and had been transported to Carilion St. Albans Department of Education's Family Compli- Behavioral Health. ance Policy Office (FCPO) has advised that when a student makes suicidal comments, FERPA authorizes release of information to par- engages in unsafe conduct such as playing ents of students in several situations. First, it with knives or lighters, or makes threats authorizes disclosure of any record to parents who against another student, the student’s conduct claim adult students as dependents for tax pur- 22 can amount to an emergency (see letter in poses. 29 FERPA also authorizes release to parents Appendix G). However, the boundaries of the when the student has violated alcohol or drug 23 emergency exceptions have not been defined laws and is under 21. by privacy laws or cases, and these provisions FERPA generally authorizes the release of infor- may discourage disclosure in all but the most mation to school officials who have been deter- obvious cases. mined to have a legitimate educational interest in receiving the information.24 FERPA also author- GOVERNMENT DATA COLLECTION izes unlimited disclosure of the final result of a AND DISSEMINATION PRACTICES disciplinary proceeding that concludes a student ACT violated university rules for an incident involving ne other law on information disclosure a crime of violence (as defined under federal law) applies to most Virginia government or a sex offense.25 Finally, some FERPA excep- O agencies. The Government Data Collection tions regarding juveniles are governed by state and Dissemination Practices Act establishes law.26 rules for collection, maintenance, and dis- FERPA also contains an emergency exception. semination of individually-identifying data. Disclosure of information in educational records is The act does not apply to police departments authorized to any appropriate person in connec- or courts. Agencies that are bound by the act tion with an emergency “if the knowledge of such can only disclose information when permitted 30 information is necessary to protect the health or or required by law. The attorney general of safety of the student or other persons.”27 Although Virginia has interpreted “permitted by law” to this exception does authorize sharing to a include any official request made by a government agency for a lawful function of the 22 20 U.S.C. § 1232g(b)(1)(H); 34 C.F.R. § 99.31(a)(8) agency. An agency must inform people who 23 20 U.S.C. § 1232g(i) 24 20 U.S.C. § 1232g(b)(1)(A); 34 C.F.R. § 99.31(a)(1) 25 28 20 U.S.C. § 1232g(b)(6)(B) 45 C.F.R. § 164.512(j); Va. Code § 32.1-127.1:03(D)(19); 26 § 32.1-127.1:04; 20 U.S.C. § 1232g(b)(1)(I) 20 U.S.C. § 1232g(b)(1)(E); Va. Code § 22.1-287. Virginia 29 law authorizes disclosure to law enforcement officers seeking Letter from LeRoy S. Rooker, Director, Family Compli- information in the course of his or her duties, court services ance Policy Office, U.S. Department of Education, to units, mental health and medical health agencies, and state or Superintendent, New Bremen Local Schools, dated local children and family service agencies. September 24, 1994 (enclosed as Appendix G). 27 30 20 U.S.C. § 1232g(b)(1)(I) Va. Code § 2.2-3803(A)(1)

CHAPTER V. INFORMATION PRIVACY LAWS

give it personal information how it will ordinarily the application of information privacy use and share that information. An agency can laws to the behavior of troubled students. disclose personal information outside of these The lack of understanding of the laws is ordinary uses. When it does, however, it must give probably the most significant problem about notice to the people who provided the informa- information privacy. Accurate guidance from tion.31 This act was initially used as a reason for the state attorney general’s office can alleviate not providing information to the panel until its this problem. It may also help clarify which authenticity was strengthened by the governor’s differences in practices among schools are executive order. based on a lack of understanding and which are based on institutional policy. For example, KEY FINDINGS a representative of Virginia Tech told the panel that FERPA prohibits the university’s rganizations and individuals must be able to administrators from sharing disciplinary intervene in order to assist a troubled student O records with the campus police department. or protect the safety of other students. Informa- The panel also learned that the University of tion privacy laws that block information sharing Virginia has a policy of sharing such records may make intervention ineffective. because it classifies its chief of police as an At the same time, care must be taken not to official with an educational interest in such invade a student's privacy unless necessary. This records. means there are two goals for information privacy The development of accurate guidance that laws: they must allow enough information sharing signifies that law enforcement officials may to support effective intervention, and they must have an educational interest in disciplinary also maintain privacy whenever possible. records could help eliminate discrepancies in Effective intervention often requires participation the application of the law between two state of parents or other relatives, school officials, institutions. The guidance should clearly medical and mental health professionals, court explain what information can be shared by systems, and law enforcement. The problems pre- concerned organizations and individuals about sented by a seriously troubled student often troubled students. The guidance should be require a group effort. The current state of infor- prepared and widely distributed as quickly as mation privacy law and practice is inadequate to possible and written in plain English. Appen- accomplish this task. The first major problem is dix G provides a copy of guidance issued by the lack of understanding about the law. The next the Department of Education in June 2007, problem is inconsistent use of discretion under the which can serve as a model or starting point laws. Information privacy laws cannot help stu- for the development of clear, accurate dents if the law allows sharing but agency policy guidance. or practice forbids necessary sharing. The privacy V-2 Privacy laws should be revised to laws need amendment and clarification. The panel include “safe harbor” provisions. The pro- proposes the following recommendations to visions should insulate a person or organiza- address immediate problems and chart a course tion from liability (or loss of funding) for mak- for an effective information privacy system. ing a disclosure with a good faith belief that the disclosure was necessary to protect the RECOMMENDATIONS health, safety, or welfare of the person in- V-1 Accurate guidance should be developed volved or members of the general public. Laws by the attorney general of Virginia regarding protecting good-faith disclosure for health, safety, and welfare can help combat any bias toward nondisclosure. 31 Va. Code § 2.2-3806(A)(2)

CHAPTER V. INFORMATION PRIVACY LAWS

V-3 The following amendments to FERPA necessary to protect the health or safety of should be considered: either the student or other people. At first, this appears to be an exception well-suited to FERPA should explicitly explain how it sharing information about seriously troubled applies to medical records held for treat- students. However, FERPA regulations also ment purposes. Although the Department of state that this exception is to be strictly con- Education interprets FERPA as applying to all strued. The “strict construction” requirement such records,32 that interpretation has not been is unnecessary and unhelpful. The existing universally accepted. Also, FERPA does not limitations require that an emergency exists address the differences between medical records and that disclosure is necessary for health or and ordinary educational records such as grade safety. Further narrowing of the definition transcripts. It is not clear whether FERPA pre- does not help clarify when an emergency empts state law regarding medical records and exists. It merely feeds the perception that confidentiality of medical information or merely nondisclosure is always a safer choice. adds another requirement on top of these records. V-5 Schools should ensure that law FERPA should make explicit an exception enforcement and medical staff (and oth- regarding treatment records. Disclosure of ers as necessary) are designated as school treatment records from university clinics should officials with an educational interest in be available to any health care provider without school records. This FERPA-related change the student’s consent when the records are needed does not require amendment to law or regula- for medical treatment, as they would be if covered tion. Education requires effective intervention under HIPAA. As currently drafted, it is not clear in the lives of troubled students. Intervention whether off-campus providers may access the ensures that schools remain safe and students records or whether students must consent. With- healthy. University policy should recognize out clarification, medical providers treating the that law enforcement, medical providers, and same student may not have access to health others who assist troubled students have an information. For example, Cho had been triaged educational interest in sharing records. When twice by Cook Counseling Center before being confirmed by policy, FERPA should not pre- seen by a provider at Carilion St. Albans in consent a barrier to these entities sharing infor- nection with his commitment hearing. Later that mation with each other. day, he was again triaged by Cook. Carilion St. Albans’s records were governed by HIPAA. Under V-6 The Commonwealth of Virginia Com- HIPAA's treatment exception, Carilion St. Albans mission on Mental Health Reform should was authorized to share records with Cook. Cook’s study whether the result of a commitment records were governed by FERPA. Because hearing (whether the subject was volun- FERPA’s rules regarding sharing records for tarily committed, involuntarily commit- treatment are unclear about outside entities or ted, committed to outpatient therapy, or whether consent is necessary, Carilion St. Albans released) should also be publicly avail- could not be assured that Cook would share its able despite an individual’s request for records. This situation makes little sense. confidentiality. Although this information would be helpful in tracking people going V-4 The Department of Education should though the system, it may infringe too much allow more flexibility in FERPA’a “emer- on their privacy. gency” exception. As currently drafted, FERPA contains an exception that allows for release of As discussed in Chapter IV, and its recom- records in an emergency, when disclosure is mendations to revise Virginia law regarding the commitment process, the law governing 32 hearings should explicitly state that basic June 2007 ED Guidance (Appendix H).

CHAPTER V. INFORMATION PRIVACY LAWS

information regarding a commitment hearing (the The history of Seung Hui Cho shows the po- time, date, and location of the hearing and the tential danger of such an approach. During his name of the subject) is publicly available even formative years, Cho's parents worked with when a person requests that records remain con- Fairfax County school officials, counselors, fidential. This information is necessary to protect and outside mental health professionals to the public’s ability to attend commitment hear- respond to episodes of unusual behavior. Cho’s ings. parents told the panel that had they been aware of his behavioral problems and the con- V-7 The national higher education associa- cerns of Virginia Tech police and educators tions should develop best practice protocols about these problems, they would again have and associated training for information become involved in seeking treatment. The sharing. Among the associations that should people treating and evaluating Cho would provide guidance to the member institutions are: likely have learned something (but not all) of • American Council on Education (ACE) his prior mental health history and would have obtained a great deal of information • American Association of State Colleges and Universities (AASCU) germane to their evaluation and treatment of him. There is no evidence that officials at Vir- • American Association of Community Col- ginia Tech consciously decided not to inform leges (AACE) Cho's parents of his behavior; regardless of • National Association of State and Land intent, however, they did not do so. The ex- Grant Universities and Colleges ample demonstrates why it may be unwise for (NASLGUC) an institution to adopt a policy barring release • National Association of Independent Col- of information to parents. leges and Universities (NAICU) The shootings of April 16, 2007, have forced • Association of American Universities (AAU) all concerned organizations and individuals to reevaluate the best approach for handling • Association of Jesuit Colleges and Univer- troubled students. Some educational institu- sities tions in Virginia have taken the opportunity If the changes recommended above are imple- to examine the difficult choices involved in mented, it is possible that no further changes to attempts to share necessary information while privacy laws would be necessary, but guidance on still protecting privacy. Effort should be made their interpretation will be needed. The unknown to identify the best practices used by these variable is how entities will choose to exercise schools and to ensure that these best practices their discretion when the law gives them a choice are widely taught. All organizations and indi- on whether to share or withhold information. How viduals should be urged to employ their dis- an institution uses its discretion can be critically cretion in appropriate ways, consistent with important to whether it is effectively able to the best practices. Armed with accurate guid- intervene in the life of a troubled student. For ance, amended laws, and a new sense of direc- example, FERPA currently allows schools to tion, it is an ideal time to establish best prac- release information in their records to parents tices for intervening in the life of troubled who claim students as dependents. Schools are students. not, however, required to release that information. Yet, if a university adopts a policy against release to parents, it cuts off a vital source of information.

Chapter VI GUN PURCHASE AND CAMPUS POLICIES

On March 22, 2007, shortly after purchasing the n investigating the role firearms played in the Glock, Cho went to PSS Range and Training, an Ievents of April 16, 2007, the panel encoun- indoor pistol range in Roanoke. Cho practiced tered strong feelings and heated debate from the shooting for about an hour. public. The panel's investigation focused on two areas: Cho's purchase of firearms and ammuni- Cho was not legally authorized to purchase his tion, and campus policies toward firearms. The firearms, but was easily able to do so. Gun pur- panel recognizes the deep divisions in American chasers in Virginia must qualify to buy a firearm society regarding the ready availability of rapid under both federal and state law. Federal law fire weapons and high capacity magazines, but disqualified Cho from purchasing or possessing a this issue was beyond the scope of this review. firearm. The federal Gun Control Act, originally passed in 1968, prohibits gun purchases by any- FIREARMS PURCHASES one who has “has been adjudicated as a mental defective or who has been committed to a mental very person killed at Cho's hands on April 2 institution.” Federal regulations interpreting 16 was shot with one of two firearms, a E the act define “adjudicated as a mental defective” Glock 19 9mm pistol or a Walther P22 .22 caliber as “[a] determination by a court, board, commis- pistol. Both weapons are semiautomatic, which sion, or other lawful authority that a person, as a meant that once loaded, they fire a round with result of …mental illness …[i]s a danger to him- each pull of the trigger, rather than being able to 3 self or to others.” Cho was found to be a danger fire continuously by holding the trigger down. to himself by a special justice of the Montgomery Cho purchased the Walther P22 first—by placing County General District Court on December 14, an online order with the TGSCOM, Inc., a com- 2005. Therefore, under federal law, Cho could pany that sells firearms over the Internet. Cho not purchase any firearm. then picked up the pistol on February 9, 2007, at J-N-D Pawn-brokers in Blacksburg, which is The legal status of Cho's gun purchase under located just across Main Street from the Virginia Virginia law is less clear. Like federal law, Tech campus. Virginia law also prohibits persons who have been adjudged incompetent or committed to Cho purchased the Glock a month later, on 4 mental institutions from purchasing firearms. March 13, from Roanoke Firearms in Roanoke. However, Virginia law defines the terms differ- Virginia law limits handgun purchases to one ently. It defines incompetency by referring to the every 30 days, which he may have known judg- 1 section of Virginia Code for declaring a person ing by this spacing. Cho made his purchases 5 incapable of caring for himself or herself. It does using a credit card. Although his parents gave not specify that a person who had been found to him money to pay for his expenses, they said be a danger to self or others is “incompetent.” they did not receive his credit card bills and did Because he had not been declared unable to care not know what he purchased. They stated that for himself, it does not appear that Cho was dis- the only time they received an actual billing qualified under this provision of Virginia law. statement was after his death, and at that point the total bill was over $3,000. 2 18 U.S.C. § 922(g)(4) 3 27 C.F.R. § 478.11 4 Va. Code §§ 18.2-308.1:2 and 3 1 5 Va. Code § 18.1-308.2:2(P) Va. Code § 18.2-308.1:2, citing Va. Code 37.2-1000 et seq.

CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES

Virginia law also prohibits “any person who has the Virginia Firearms Transaction Record (SP been involuntarily committed pursuant to Article 65.) (Copies of the forms are provided in Appen- 5 (§ 37.2-814 et seq.) of Chapter 8 of Title 37.2” dix I.) The forms collect basic information about from purchasing or possessing a firearm.6 This the potential buyer, such as name, age, and section authorizes a court to order either in- social security number. Each form also asks patient or outpatient treatment. When a person questions to determine whether a buyer is eligi- is ordered into a hospital, the law is relatively ble to purchase a weapon. Form 4473 asks 11 straightforward—the person has been “involun- questions, such as whether the buyer has been tarily committed.” What is not clear from the convicted of a felony. SP 65 contains questions statute, however, is whether a person such as and information regarding Virginia law, such as Cho, who was found to be a danger to self or whether restraining orders were issued that dis- others and ordered to receive outpatient treat- qualify purchasers. Firearms dealers initiate the ment, qualifies as being involuntarily committed. background check by transmitting information Among the mental health community, “involun- from the forms to the state police’s Firearms tary outpatient commitment” is a recognized Transaction Program. term for an order for outpatient treatment. In Certain firearms transfers do not require back- practical terms, a person who is found to be an imminent danger to self or others and ordered ground checks at all. Virginia law does not into outpatient treatment is little different than require background checks for personal gifts or sales by private collectors, including transactions one ordered into inpatient treatment. However, the statute does not make clear whether out- by collectors that occur at gun shows. patient treatment is covered. Thus, Cho's right to In Virginia, the Central Criminal Records purchase firearms under Virginia law was not Exchange (CCRE), a division of the state police, clear. is tasked with gathering criminal records and This uncertainty in Virginia law carries over into other court information that is used for the back- the system for conducting a firearms background ground checks. Information on mental health commitment orders “for involuntary admission to check. In general, nationally, before purchasing a gun from a dealer a person must go through a a facility” is supposed to be sent to the CCRE by background check. A government agency runs court clerks, who must send all copies of the orders along with a copy of form SP 237 that pro- the name of the potential buyer through the vides basic information about the person who is databases of people who are disqualified from 7 purchasing guns. If the potential purchaser is in the subject of the order. As currently drafted, the database, the transaction is stopped. If not, the law only requires a clerk to certify a form, the dealer is instructed to proceed with the sale. and does not specify who should complete the The agency performing the check varies by state. form. Because of the lack of clarity, it was Some states rely on the federal government to reported to the panel that clerks in some juris- conduct the checks. In others, the state and the dictions do not send the information unless they federal government both do checks. In yet other receive a completed form. Recommendations to states, such as Virginia, the state conducts the improve this aspect of the law were given in check of both federal and state databases. In Chapter IV. Virginia the task is given to the state police. The meaning of the term “admission to a facility” Because purchasers have to be eligible under is less clear than it might seem. The law appears both state and federal law, potential buyers in on an initial reading to only include orders Virginia have to fill out two forms: the federal requiring a person to receive inpatient care. This “Firearms Transaction Record” (ATF 4473) and reading seems to have support from the Virginia

6 7 Va. Code § 18.2-308.1:3 Va. Code § 37.2-819

CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES

involuntary commitment statute. That law uses The FBI indicated in a press release dated April “admission to a facility” when describing in- 19, 2007, that just 22 states reported any mental patient treatment, not outpatient treatment.8 health information to the federal database. But the law is actually more complex. Laws Ironically, the FBI cited Virginia as the state about mental health commitment and sending that provided the most information on people orders to CCRE all appear in Title 37.2 of the disqualified due to mental deficiency.10 Virginia Code. The definitions for that title state In the days following the killings at Virginia that facility “means a state or licensed hospital, training center, psychiatric hospital, or other Tech, Governor Kaine moved to clarify the law type of residential or outpatient mental health or regarding inclusion of outpatient treatment into 9 the database. Executive Order 50 now requires mental retardation facility.” So while the most obvious reading of the law is that only inpatient executive branch employees, including the state orders should be sent to CCRE, the actual police, to collect information on outpatient orders and to treat such orders as disqualifications to requirement is unclear. owning a firearm. The state police revised SP At the time Cho purchased his weapons, the gen- 237 to ensure that they receive information eral understanding was that only inpatient regarding out-patient orders. Copies of the older orders had to be sent to CCRE. Probably due to and revised versions of SP 237 are presented in this understanding, the special justice’s Decem- Appendix J. As previously discussed in Chapter ber 14, 2005, order finding Cho to be a danger to IV, the panel recommends that the General himself was not reported to the firearms back- Assembly clarify the relevant laws in this regard ground check system. Although the law may to permanently reflect the interpretation of have been ambiguous, the checking process was Executive Order 50. not. Either you are or are not in the database It is not clear whether Cho knew that he was when a gun purchase request form is submitted, prohibited from purchasing firearms. ATF 4473 and Cho was not. asks each potential purchaser “[h]ave you ever There does not seem to have been an apprecia- been adjudicated mentally defective (which tion in setting up this process that the federal includes having been adjudicated incompetent to mental health standards were different than manage your own affairs) or have you ever been those of the state or that the practice deprived committed to a mental institution?” The state the federal database of information it needed in and federal forms that Cho filled out are cur- order to make the system effective. Thus on Feb- rently held by the Virginia state police in their ruary 9 and March 13, 2007, Cho, a person dis- case investigation file, but were destroyed in the qualified under federal law from purchasing a CCRE file, as required after 30 days. The state firearm, walked into two licensed firearms deal- police did not permit the panel to view copies of ers. He filled out the required forms. The dealers the forms in their investigation file but indicated entered his information into the background that Cho answered “no” to this question on both check system. Both checks told the dealers to forms. It is impossible to know whether Cho proceed with the transaction. Minutes after both understood that the proper response was “yes” checks, Cho left the stores in possession of semi- and whether his answers were mistakes or delib- automatic pistols. erate falsifications. In any event, the fact remains that Cho, a person disqualified from purchasing firearms, was readily able to obtain them. 8 Va. Code § 37.2-817. Paragraph B describes inpatient 10 orders and uses the term “admitted to a facility”; paragraph The panel notes that the federal law terminology referring C authorizes outpatient commitment but does not use the to mentally ill persons as “mentally defective” is outmoded term “admitted to a facility.” 9 based on current medical and societal understanding of men- Va. Code. § 37.2-100 tal health.

CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES

AMMUNITION PURCHASES GUNS ON CAMPUS

ho purchased ammunition on several occa- irginia Tech has one of the tougher policy Csions in the weeks and months leading up to Vconstraints of possessing guns on campus the shootings. On March 13, 2007, he purchased among schools in Virginia. However, there are no a $10 box of practice ammunition from Roanoke searches of bags or use of magnetometers on Firearms at the same time he bought his Glock campus like there are in government offices or 9mm pistol. On March 22 and 23, he purchased a airports. Cho carried his weapons in violation of total of five 10-round magazines for the Walther university rules, and probably knew that it was on the Internet auction site eBay. In addition, extremely unlikely that anyone would stop him Cho purchased several 15-round magazines to check his bag. He looked like many others. along with ammunition and a hunting knife on March 31 and April 1 at local Wal-Mart and Virginia universities and colleges do not seem to be adequately versed in what they can do about Dick's Sporting Goods stores. With these magazines loaded, Cho would be able to fire 15 rounds, banning guns on campus under existing inter- eject the magazine, and load a fresh one in a pretations of state laws. The governing board of colleges and universities can set policies on car- matter a moments. By the time he walked into Norris Hall, Cho had almost 400 bullets in maga- rying guns. Some said their understanding is that they must allow anyone with a permit to zines and loose ammunition. carry a concealed weapon on campus. Others Federal law prohibited Cho from purchasing said they thought guns can be banned from ammunition. Just as it prohibits anyone from buildings but not the grounds of the institution. purchasing a gun who has been found to be a Several major universities reported difficulty danger to self or others, it prohibits the same understanding the rules based on their lawyers’ individuals from buying ammunition.11 However, interpretation. Most believe they can set rules unlike firearms, there is no background check for students and staff but not the general public. associated with purchasing ammunition. Neither Virginia Tech, with approval of the state Attor- does Virginia law place any restrictions on who ney General’s Office, had banned guns from cam- can purchase ammunition. It does prohibit the pus altogether. use of some types of ammunition while commit- This issue came to a head at one of the panel’s ting a crime, but does not regulate the purchase 12 public meetings held at George Mason Univer- of such ammunition. Cho did not use any spe- sity. It was known that many advocates of the cial types of ammunition that are restricted by right to carry concealed weapons on campus were law. planning to attend the meeting carrying weapons The panel also considered whether the previous to make a point. GMU did not know they could federal Assault Weapons Act of 1994 that banned have established a policy to stop the weapons 15-round magazines would have made a differ- from being carried into their buildings. ence in the April 16 incidents. The law lapsed The Virginia Tech total gun ban policy was insti- after 10 years, in October 2004, and had banned tuted a few years ago when it was accidentally clips or magazines with over 10 rounds. The discovered that a student playing the role of a panel concluded that 10-round magazines that patient in a first aid drill was carrying a con- were legal would have not made much difference cealed weapon. That student, now a Virginia in the incident. Even pistols with rapid loaders Tech graduate with a master’s degree in engi- could have been about as deadly in this situation. neering, stated to the panel that he started carrying a weapon after witnessing assaults and hearing about other crimes on the Virginia Tech 11 18 U.S.C § 922(d)(4) campus. He and other students told the panel 12 Va. Code § 18.2-308.3

CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES

that they felt it was safer for responsible people Campus police chiefs in Virginia and many chief- to be armed so they could fight back in exactly level officers in the New York City region who the type of situation that occurred on April 16. were interviewed voiced concern that as the They might have been able to shoot back and number of weapons on campuses increase, sooner protect themselves and others from being injured or later there would be accidents or assaults or killed by Cho. The guns-on-campus advocates from people who are intoxicated or on drugs who cited statistics that overall there are fewer kill- either have a gun or interact with someone who ings in environments where people can carry does. They argued that having more guns on weapons for self-defense. Of course if numerous campus poses a risk of leading to a greater num- people had been rushing around with handguns ber of accidental and intentional shootings than outside Norris Hall on the morning of April 16, it does in averting some of the relatively rare the possibility of accidental or mistaken shoot- homicides. (See Appendix K for an article about ings would have increased significantly. The the recent discharge of a gun by someone intoxi- campus police said that the probability would cated in a fraternity house. Although a benign have been high that anyone emerging from a incident, it illustrates the concern.) classroom at Norris Hall holding a gun would The panel heard a presentation from Dr. Jerald have been shot. Kay, the chair of the committee on college men- Data on the effect of carrying guns on campus tal health of the American Psychiatric Associa- are incomplete and inconclusive. The panel is tion about the large percentage of college stu- unaware of any shootings on campus involving dents who binge drink each year (about 44 per- people carrying concealed weapons with permits cent), and the surprisingly large percentage of to do so. Likewise, the panel knows of no case in students who claim they thought about suicide which a shooter in campus homicides has been (10 percent). College years are full of academic shot or scared off by a student or faculty member stress and social stress. The probability of dying with a weapon. Written articles about a campus from a shooting on campus is smaller than the shooting rarely if ever comment on permits for probability of dying from auto accidents, falls, or concealed weapons, so this has been difficult to alcohol and drug overdoses. research. It may have happened, but the numbers of shootings on campuses are relatively KEY FINDINGS few—about 16 a year at approximately 4,000 col- ho was able to purchase guns and ammuni- leges and universities, according to the U.S. tion from two registered gun dealers with no Department of Education Campus Crime Statis- C problem, despite his mental history. tics for 2002–2004. It could be argued that if more people carried weapons with permits, the Cho was able to kill 31 people including himself few cases of shootings on campus might be at Norris Hall in about 10 minutes with the reduced further. semiautomatic handguns at his disposal. Having the ammunition in large capacity magazines On the other hand, some students said in their remarks to the panel that they would be uncom- facilitated his killing spree. fortable going to class with armed students sit- There is confusion on the part of universities as ting near them or with the professor having a to what their rights are for setting policy regard- gun. People may get angry even if they are sane, ing guns on campus. law-abiding citizens; for example, a number of police officers are arrested each year for assaults with weapons they carry off duty, as attested to by stories in daily newspapers and other media.

CHAPTER VI. GUN PURCHASE AND CAMPUS POLICIES

RECOMMENDATIONS does not appear on their records, and they are free to purchase guns. Some highly respected VI-1 All states should report information people knowledgeable about the interaction of necessary to conduct federal background mentally ill people with the mental health sys- checks on gun purchases. There should be tem are strongly opposed to requiring voluntary federal incentives to ensure compliance. This treatment to be entered on the record and be should apply to states whose requirements are sent to a state database. Their concern is that it different from federal law. States should become might reduce the incentive to seek treatment fully compliant with federal law that disqualifies voluntarily, which has many advantages to the persons from purchasing or possessing firearms individuals (e.g., less time in hospital, less who have been found by a court or other lawful stigma, less cost) and to the legal and medical authority to be a danger to themselves or others personnel involved (e.g., less time, less paper- as a result of mental illness. Reporting of such work, less cost). However, there still are powerful information should include not just those who incentives to take the voluntary path, such as a are disqualified because they have been found to shorter stay in a hospital and not having a re- be dangerous, but all other categories of disquali- cord of mandatory treatment. It does not seem fication as well. In a society divided on many gun logical to the panel to allow someone found to be control issues, laws that specify who is prohib- dangerous to be able to purchase a firearm. ited from owning a firearm stand as examples of broad agreement and should be enforced. VI-4 The existing attorney general’s opinion regarding the authority of universities and VI-2 Virginia should require background colleges to ban guns on campus should be checks for all firearms sales, including clarified immediately. The universities in Vir- those at gun shows. In an age of widespread ginia have received or developed various inter- information technology, it should not be too diffi- pretations of the law. The Commonwealth’s at- cult for anyone, including private sellers, to con- torney general has provided some guidance to tact the Virginia Firearms Transaction Program universities, but additional clarity is needed for a background check that usually only takes from the attorney general or from state legisla- minutes before transferring a firearm. The pro- tion regarding guns at universities and colleges. gram already processes transactions made by registered dealers at gun shows. The practice VI-5 The Virginia General Assembly should should be expanded to all sales. Virginia should adopt legislation in the 2008 session clearly also provide an enhanced penalty for guns sold establishing the right of every institution of without a background check and later used in a higher education in the Commonwealth to crime. regulate the possession of firearms on campus if it so desires. The panel recommends that VI-3 Anyone found to be a danger to them- guns be banned on campus grounds and in build- selves or others by a court-ordered review ings unless mandated by law. should be entered in the Central Criminal Records Exchange database regardless of VI-6 Universities and colleges should make whether they voluntarily agreed to treat- clear in their literature what their policy is ment. Some people examined for a mental illness regarding weapons on campus. Prospective and found to be a potential threat to themselves students and their parents, as well as university or others are given the choice of agreeing to men- staff, should know the policy related to concealed tal treatment voluntarily to avoid being ordered weapons so they can decide whether they prefer by the courts to be treated involuntarily. That an armed or arms-free learning environment.

Chapter VII DOUBLE MURDER AT WEST AMBLER JOHNSTON

his chapter discusses the double homicide at TWest Ambler Johnston (WAJ) residence hall and the police and university actions taken in response. It covers the events up to the shootings in Norris Hall, which are presented in the next chapter.

APPROACH AND ATTACK

ho left his dormitory early in the morning of CApril 16, 2007 and went to the WAJ, about a 2-minute walk. He was seen outside WAJ by a student about 6:45 a.m. Figure 3 shows the exterior of WAJ and Figure 4, a typical hallway inside WAJ.

Figure 4. Hallway Outside Dorm Rooms in West Ambler Johnston

She had just returned with her boyfriend, a student at Radford University who lived in Blacks- burg. He drove her back to her dorm, saw her enter, and drove away. She entered at 7:02 a.m., based on swipe card records, which also showed Figure 3. Exterior of West Ambler Johnston that she used a different entrance than Cho did. Because Cho’s student mailbox was located in Although it is known that Cho previously stalked the lobby of WAJ, he had access to that dormi- female students, including one in WAJ on her floor, the police have found no connection tory with his pass card, but only after 7:30 a.m. between Cho and Hilscher from any written Cho somehow gained entrance to the dormitory, materials, dorm mates, other friends of his or possibly when a student coming out let him in or hers, or any other source. by tailgating someone going in. (No one remem- bers having done so, or admits it.) As of this writing, the police still had found no motive for the slaying. Cho went to the fourth floor by either stairway or elevator to the room of student Emily Hilscher.

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

Figure 5. Typical Dorm Room in Ambler Johnston Hall

Not long after 7:15 a.m., noises emanating from she received care, and then transferred to Hilscher’s room were loud enough and of such a Carilion Roanoke Memorial Hospital where she disturbing nature that resident advisor Ryan died. Clark was treated en route to Montgomery Clark, who lived next door, checked to see what Regional Hospital, but could not be resuscitated was happening. The presumption is that he by the emergency medical technicians (EMTs) came to investigate, saw Cho, and was killed to and was pronounced dead shortly after arrival stop any interference with the shooter and his at the hospital. Their wounds were considered identification. Both Hilscher and Clark were nonsurvivable at the time and in retrospect. shot by Cho at close range. (Figure 5 shows a In the meantime, Cho somehow exited the build- typical dorm room in WAJ.) ing. No one reported seeing him leaving, accord- The sounds of the shots or bodies falling were ing to police interviews of people in the dorm at misinterpreted by nearby students as possibly the time. His clothes and shoes were bloodied, someone falling out of a loft bed, which had and he left bloody footprints in and coming out happened before. A student in a nearby room of the room. His clothes were found later in his called the Virginia Tech Police Department room. Students were getting ready for 8:00 a.m. (VTPD), which dispatched a police officer and an classes, but no one reported seeing Cho. Figure emergency medical service (EMS) team— 6 shows the door to Hilscher’s dorm room, with standard protocol for this type of call. The police a peephole typical of others on that floor. received the call at 7:20 a.m. and arrived outside at 7:24 a.m. (an EMS response under 5 When Chief Wendell Flinchum of the VTPD minutes for dispatch plus travel time is better learned of the incident at 7:40 a.m., he called for 1 additional resources from the Blacksburg Police than average, even in a city). The EMS team Department (BPD). A detective for investigation arrived on scene at 7:26 and at the dorm room and an evidence technician headed for the at 7:29. As soon as the police officer arrived and scene. Chief Flinchum notified the office of the saw the gunshot wounds, he called for addi- executive vice president at 7:57 a.m., after ob- tional police assistance. Hilscher was transported to Montgomery Regional Hospital where taining more information on what was found. Immediately after they arrived, police started

1 interviewing students in the rooms near This is based on data from 150 TriData studies of fire and EMS departments over 25 years. The National Fire Protec- Hilscher’s room, and essentially locked down the tion Association standard calls for a fire or EMS response in building, with police inside and outside. (The 5 minutes (1 minute turnout time, 4 minutes travel time) in 90 percent of calls, but few agencies meet that objective.

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

truck and searched for it in the campus parking lots but could not find it. This implied that the only known person of interest had likely left the campus. There were no other leads at that time.

The police had no evidence other than shell cas- ings in the room, the footprints, and the victims. The VTPD police chief said that this murder might have taken a long time to solve, if ever, for lack of evidence and witnesses. After the second incident occurred, the gun was identified by ATF as having been the same one used in the first shooting, but that was hindsight. If Cho had stopped after the first two shootings, he might well have never been caught.

PREMATURE CONCLUSION?

At this point, the police may have made an error in reaching a premature conclusion that their initial lead was a good one, or at least in conveying that impression to the Virginia Tech administration. While continuing their investigation, they did not take sufficient action to deal

Figure 6. Emily Hilscher’s Door With Peephole with what might happen if the initial lead proved false. They conveyed to the university exterior dorm doors were still locked from the Policy Group that they had a good lead and that usual nighttime routine.) A female friend of the person of interest was probably not on cam- Hilscher came to the dorm to accompany her to pus. (That is how the Policy Group understood class, as was their common practice, and she it, according to its chair and other members who was immediately questioned by the police. She were interviewed by the panel and who pre- reported that Hilscher had been visiting her sented information at one of its open hearings.) boyfriend, knew of no problems between them, After two people were shot dead, police needed and that Hilscher’s boyfriend owned a gun and to consider the possibility of a murderer loose on had been practicing on a target range with it. campus who did a double slaying for unknown She knew his name and the description of his reasons, even though a domestic disturbance vehicle and that he usually drove her back to was a likely possibility. The police did not urge the dorm. The boyfriend was immediately con- the Policy Group to take precautions, as best 2 sidered a “person of interest.” Because he had can be understood from the panel’s interviews. been the last known person to see her before the shooting, he was the natural starting point for It was reasonable albeit wrong that the VTPD an investigation. No one had seen him drop her thought this double murder was most likely the off. (The fact that he had dropped her off was result of a domestic argument , given the facts established more than an hour later, after he they had initially, including the knowledge that was questioned.) The police then sent out a the last person known to have been with the BOLO (be on the lookout) alert for his pickup female victim was her boyfriend who owned a gun and cared greatly for her, according to police interviews, plus the fact that she was shot 2 “Person of interest” means someone who might be a suspect or might have relevant information about a crime.

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

with a young man in her room under the cir- an interview with President Steger, members of cumstances found. the panel were told that the police reports to the Policy Group first described a possible “murder– There are very few murders each year on cam- suicide” and then a “domestic dispute,” and that puses—an average of about 16 across 4,000 uni- the police had identified a suspect. After the versities and colleges, as previously noted. The area parking lots had been searched, the police only college campus mass murder in the United reported the suspect probably had left the cam- States in the past 40 years was the University pus. of Texas tower sniper attack, though there have been occasional multiple murders. Based on The police did not tell the Policy Group that past history, the probability of more shootings there was a chance the gunman was loose on following a dormitory slaying was very low. The campus or advise the university of any immedi- panel researched reports of multiple shootings ate action that should be taken such as cancel- on campuses for the past 40 years, and no sce- ing classes or closing the university. Also, the nario was found in which the first murder was police did not give any direction as to an emer- followed by a second elsewhere on campus. (See gency message to be sent to the students. The Appendix L for a summary of the multiple police were very busy at WAJ investigating criminal shootings on campus.) The VTPD had what had happened, gathering evidence, and the probabilities correct, but needed to consider managing the scene. They were conveying in- the low-probability side as well as the most formation by phone to the Policy Group at this likely situation. point. Not until 9:25 a.m. did the police have a representative sitting with the Policy Group, a Both the VTPD and the BPD immediately put police captain. their emergency response teams (ERTs) (i.e., SWAT teams) on alert and staged them at loca- The VTPD has the authority under the Emer- tions from which they could respond rapidly to gency Response Plan and its interpretation in the campus or city. They also had police on practice to request that an emergency message campus looking for the gunman while they pur- be sent, but as related in Chapter II, the police sued the boyfriend. The ERTs were staged did not have the capability to send a message mainly in case they had to make an arrest of the themselves. That capability was in the hands of gunman or serve search warrants on the shoot- the associate vice president for University ing suspect. Affairs and one other official. As stated earlier, the VTPD is not a member of the Policy Group DELAYED ALERT TO UNIVERSITY but is often invited to attend Policy Group meet- COMMUNITY ings dealing with the handling of emergencies.

he VTPD chief and BPD chief both One of the factors prominent in the minds of the Tresponded to the murder scene in minutes. Policy Group, according to the university presi- Chief Flinchum of the VTPD arrived at 8:00 dent and others who were present that day, was a.m. and Chief Crannis of the BPD arrived at the experience gained the previous August when 8:13 a.m. As noted above, the VTPD chief had a convict named William Morva escaped from a notified the university administration of the nearby prison and killed a law enforcement offi- shootings at 7:57 a.m., just before he arrived at cer and a guard at a local hospital. Police the scene. reported he might be on the VT campus. The campus administration issued an alert that a Once informed, the university president almost murderer was on the loose in the vicinity of the immediately convened the emergency Policy campus. Then a female employee of the bank in Group to decide how to respond, including how the Squires Student Activities Center reportedly and when to notify the university community. In called her mother on a cell phone, and the

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

mother incorrectly inferred that people were Hall Boardroom and Dr. Steger convened being held hostage in the student center. The the meeting. I learned subsequently that as he awaited the arrival of other group mem- mother called the police, who responded with a bers, President Steger had been in regular SWAT team. News photos of the event show communication with the police, had given students rushing out of the building with their direction to have the governor's office noti- hands up while police with drawn automatic fied of the shooting, and had called the weapons and bulletproof vests were charging head of University Relations to his office to into the building, a potentially dangerous situa- begin planning to activate the emergency communication systems. tion. It was a false alarm. Morva was captured off campus, but this situation was fresh in the When he convened the meeting, President minds of the Policy Group as it met to decide Steger informed the Policy Group that what to do on the report of the double homicide Virginia Tech police had received a call at approximately 7:20 a.m. on April 16, 2007, at WAJ. It is questionable whether there was to investigate an incident in a residence any panic among the students in the Morva hall room in West Ambler Johnston. incident, as some reports had it, and how dan- Within minutes of the call, Virginia Tech gerous that situation really was, but the Policy police and Virginia Tech Rescue Squad Group remembered it as a highly charged and members responded to find two gunshot victims, a male and a female, inside a room dangerous situation. In the eyes of the Policy in the residence hall. Information contin- Group, including the university president, a ued to be received through frequent tele- dangerous situation had been created by their phone conversations with Virginia Tech warning in that August 2006 event coupled with police on the scene. The Policy Group was the subsequent spread of rumors and misinfor- informed that the residence hall was being mation. The Policy Group did not want to cause secured by Virginia Tech police, and students within the hall were notified and a repeat of that situation if the police had a sus- asked to remain in their rooms for their pect and he was thought to be off campus. safety. We were further informed that the room containing the gunshot victims was Even with the police conveying the impression immediately secured for evidence collec- to campus authorities that the probable perpe- tion, and Virginia Tech police began ques- trator of the dormitory killings had left campus tioning hall residents and identifying and with the recent past history of the “panic” potential witnesses. In the preliminary caused by the alert 9 months earlier, the uni- stages of the investigation, it appeared to be an isolated incident, possibly domestic versity Policy Group still made a questionable in nature. The Policy Group learned that decision. They sent out a carefully worded alert Blacksburg police and Virginia state police an hour and half after they heard that there had been notified and were also on the was a double homicide, which was now more scene. than 2 hours after the event. The Policy Group was further informed by the police that they were following up on Vice Provost of Student Affairs David Ford pre- leads concerning a person of interest in sented a statement to the panel on May 21, relation to the shooting. During this 30- 2007. He was a member of the university Policy minute period of time between 8:30 and Group that made the decisions on what to do 9:00 a.m., the Policy Group processed the after hearing about the shootings. factual information it had in the context of many questions we asked ourselves. For Shortly after 8:00 a.m. on Monday, April instance, what information do we release 16, I was informed that there had been a without causing a panic? We learned from shooting in West Ambler Johnston hall and the Morva incident last August that specu- that President Steger was assembling the lation and misinformation spread by indi- Policy Group immediately. By approxi- viduals who do not have the facts cause mately 8:30 a.m., I and the other members panic. Do we confine the information to of the group had arrived at the Burruss students in West Ambler Johnston since

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

the information we had focused on a single ulty saw the alert before the second event but incident in that building? Beyond the two many, if not most, did not see it, nor did most in gunshot victims found by police, was there Norris Hall classes. Those who had 9:05 a.m. a possibility that another person might be involved (i.e., a shooter), and if so, where is classes were already in them and would not that person, what does that person look have seen the message unless checking their like, and is that person armed? At that computers, phone, or Blackberries in class. If time of the morning, when thousands are the message had gone out earlier, between 8:00 in transit, what is the most effective and and 8:30 a.m., more people would have received efficient way to convey the information to all faculty, staff, and students? If we it before leaving for their 9:05 a.m. classes. If an decided to close the campus at that point, audible alert had been sounded, even more what would be the most effective process might have tuned in to check for an emergency given the openness of a campus the size of message. Virginia Tech? How much time do we have until the next class change? Few anywhere on campus seemed to have acted on the initial warning messages; no classes were And so with the information the Policy Group had at approximately 9 a.m., we canceled, and there was no unusual absentee- drafted and edited a communication to be ism. When the Norris Hall shooting started, few released to the university community via connected it to the first message. e-mail and to be placed on the university web site. We made the best decision we The university body was not put on high alert could based upon the information we had by the actions of the university administration at the time. Shortly before 9:30 a.m., the and was largely taken by surprise by the events Virginia Tech community—faculty, staff, that followed. Warning the students, faculty, and students—were notified by e-mail as follows: and staff might have made a difference. Putting more people on guard could have resulted in "A shooting incident occurred at West quicker recognition of a problem or suspicious Ambler Johnston earlier this morning. activity, quicker reporting to police, and quicker Police are on the scene and are investigating. The university community is urged to response of police. Nearly everyone at Virginia be cautious and are asked to contact Tech is adult and capable of making decisions Virginia Tech Police if you observe anything about potentially dangerous situations to safe- suspicious or with information on the case. guard themselves. So the earlier and clearer the Contact Virginia Tech Police at 231–6411. warning, the more chance an individual had of Stay tuned to the www.vt.edu. We will post as soon as we have more information” surviving. The Virginia Tech Emergency/Weather DECISION NOT TO CANCEL CLASSES Line recordings were also transmitted and OR LOCK DOWN a broadcast telephone message was made to campus phones. The Policy Group any people have raised the question of remained in session in order to receive whether the university should have been additional updates about the West Ambler M Johnston case and to consider further locked down. One needs to analyze the feasibil- actions if appropriate. ity of doing this for a campus of 35,000 people, and what the results would have been even if No mention was made in the initial message feasible. Most police chiefs consulted in this sent to the students and staff of a double mur- review believe that a lockdown was not feasible. der, just a shooting, which might have implied firing a gun and injuries, possibly accidental, When a murder takes place in a city of 35,000 rather than two murdered. Students and faculty population, the entire city is virtually never were advised to be alert. The message went out shut down. At most, some in the vicinity of the to e-mails and phones. Some students and fac- shooting might be alerted if it is thought that

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

the shooter is in the neighborhood. People might A message could theoretically be sent to all be advised by news broadcast or bullhorns to buildings on campus to lock their doors, but stay inside. A few blocks might be cordoned off, there was no efficient way to do this at Virginia but not a city of 35,000. A university, however, Tech. It would have required calls or e-mails to in some ways has more control than does the individuals who had the ability to lock the doors mayor or police of a city, so the analogy to a city for at least 131 buildings or sending people on is not entirely fitting. The university is also con- foot to each building. E-mails might have been sidered by many as playing a role in loco used, but one could not be sure they would be parentis for at least some of its students, even read promptly. Even if people in the buildings those who are legally adults, a view shared by received a message by phone or e-mail, the uni- several victims’ families. versity had no way of knowing who received the message without follow up calls or requesting President Steger noted that closing the univer- returned responses to the calls and e-mails. The sity in an emergency presents another problem, process was complicated and would have taken traffic congestion. In the Morva incident, when considerable time. the school was closed, it took over an hour and a half for the traffic to clear despite trying to Some university campuses, mostly urban ones, stage the evacuation. Numerous people also have guards at every entrance to their build- stood waiting for buses. Those evacuating were ings. Virginia Tech does not. It would take ap- very vulnerable in their cars and at bus stops. proximately 450–500 guards to post one at all entrances of all major buildings on the VT cam- Some people suggested that the university 3 pus. The VTPD at full strength has 41 officers, should have closed out of respect for the two of which only 14 are on-duty at 8:00 a.m. on a students who were killed. However, the general weekday, 5 on patrol and 9 in the office includ- practice at most large universities is not to close ing the chief. It is unlikely all VT buildings when a student dies, regardless of the cause could be guarded or closed within 1–2 hours af- (suicide, homicide, traffic accident, overdose, ter the first shooting. etc.). Universities and colleges need to make that decision based on individual criteria. Closing all of the roads into the school would also be a problem. The large campus includes 16 Feasibility – A building can be locked down in vehicle entrances separated in some cases by a the sense of locking the exterior doors, barring mile from each other. More police can be anyone from coming or going. Elementary brought in from Blacksburg and other areas. schools practice that regularly, and so do some Without a clear emergency, however, it is incon- intermediate and high schools. At least some ceivable that large numbers of police would rush schools in Blacksburg were locked down for a to the campus, leaving non-campus areas at risk while after the first shootings. Usually, a lock- from the same gunman and all other crimes down also implies locking individual classrooms. when it was not expected to be more than an Virginia Tech does not have locks on the inside isolated incident. of classroom doors, as is the case for most universities and many high schools. There are no barriers to pedestrians walking across lawns into the campus. It would have The analogy to elementary or high schools, how- taken hundreds of police, National Guard ever, is not very useful. The threat in elemen- troops, or others to truly close down the campus, tary schools usually is not from students, the and they could not have arrived in time. classrooms have locks, they have voice communication systems to teachers and students, and 3 the people at risk are in one building, not 131 There are about 30 dorm-type buildings with an average of about two entrances each, and 100 classroom/administration buildings. High schools usually have one build- buildings with an average of about four entrances each, for ing and some of the other characteristics too. an estimated total of about 460.

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

Messages might have been prioritized to reach was sent to the university community, and able the buildings with the most people and to guard to go anywhere that students were allowed to them first, but it still was impractical and not go. He would have received an alert, too. seriously considered. All police with whom the It might be argued that the total toll would have panel consulted felt that a lockdown for a campus like Virginia Tech was not feasible on the been less if the university had canceled classes and announced it was closed for business imme- morning of April 16. diately after the first shooting; or if the earlier More feasible would have been canceling classes alert message had been stronger and clearer. and asking everyone to stay home or stay Even with the messaging system that was in indoors until an all-clear was given, although place on April 16, many could have received even getting that message to everyone quickly messages before they left for class by e-mail or was problematical with the new emergency phone before 9 a.m., and the message probably alerting system not totally in place. Students would have quickly spread mouth to mouth as could have been asked to return to their dormi- well. Even if it only partially reduced the uni- tories or to housing off campus. However, many versity population on campus, it might have might have gone to other public buildings on done some good. It is the panel’s judgment that, campus unless those buildings also were all things considered, the toll could have been ordered to close. Canceling classes and getting a reduced had these actions been taken. But none message out to students off campus would have of these measures would likely have averted a stopped some from coming onto the campus. But mass shooting altogether. There is a possibility students still could congregate vulnerably in that the additional measures would have dis- dorms or other places. suaded Cho from acting further, but he had already killed two people and sent a tape to NBC Furthermore, the police and university did not that would arrive the following morning with all know whether the gunman was inside or outside but a confession. From what we know of his WAJ or other buildings. People not in buildings, mental state and commitment to action that typically numbering in the thousands outdoors day, it was likely that he would have acted out on the campus at a given time, may seek refuge his fantasy somewhere on campus or outside it in buildings in the face of an emergency. With- that same day. out knowing where the gunman is, one might be sending people into a building with the gunman, This was a single-shooter scenario; Columbine or sending them outside where a gunman is High School had two shooters, and that scenario waiting. The shooters at the Jonesboro Middle was quite different. Emergency planners have to School massacre in Arkansas in 1998 planned to anticipate various high-risk scenarios and how create an alarm inside their school building and to prepare for them. They must be aware that get students and faculty to go outside where the what happens will rarely be just like the sce- shooters were set up. nario planned for. The right thing for one scenario might be just the wrong thing to do for Cho, too, could have shot people in the open on another, such as whether to tell people to stay campus, after an alert went out, waiting for inside buildings or get outside. them outside. Although he was armed with only handguns, no one knew that at the time. The CONTINUING EVENTS Texas tower shooter sniped at people with a rifle outdoors. o continue the story of April 16, there was Tnot an event, a pause for 2 hours, and then Impact of Lockdown or Closedown – In this a second event. The notion that there was a 2- event, the shooter was a member of the campus hour gap as mentioned in some news stories and community, an insider with a pass card to get by many who sent questions to the panel is a into his dorm, able to receive whatever message

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

misconception. There was continuous action and proceeded to send out more alerts of the chang- deliberations from the first event until the sec- ing situation, but by then it was too late. ond, and they made a material difference in the Even after they realized he was not a likely sus- results of the second event. pect and had been traumatized by the news of Police Actions – The VTPD and the other law his girlfriend’s death, the police agencies enforcement agencies involved did a profes- involved in stopping and questioning Emily sional job in pursuing the investigation of the Hilscher’s boyfriend did not treat him sympa- WAJ incident with the one large and unfortu- thetically; he deserved better care. nate exception of having conveyed the impres- Cho’s Next Actions – After shooting the two sion to the university administration that they students in WAJ, Cho went back to his own probably had a solid suspect who probably had dormitory, arriving at 7:17 a.m. (based on the left the campus. These agencies did not know record of his swipe card). He changed out of his that with certainty. A stronger patrol of the blood-stained clothing, which was later found in campus and random checking of bags being car- his room. He accessed his university computer ried might have found Cho carrying guns. Cho, account at 7:25 a.m. and proceeded to delete his however, was one of tens of thousands of stu- e-mails and wipe out his account. He then re- dents on campus, did not stand out in appear- moved the hard drive of his computer and later ance, and carried his weapons in a backpack disposed of it and his cell phone. Cho apparently like many other backpacks. The police had no also had planned to dispose of his weapons after clues pointing to anyone other than the boy- using them in a different scenario because he friend, and it would not have been reasonable to had filed down the serial numbers on the guns.4 expect them to be able to check what each person on campus was carrying. Mentally disturbed killers often make one plan and then change it for some reason. The motiva- The VTPD and BPD mobilized their emergency tion may never be known for why he partially response teams after the first shooting. They did obscured his identity and did not carry any not know what the followup would bring, but identification into Norris Hall, but then sent his they wanted to be ready for whatever occurred. manifesto to a national news network with his The VTPD had not investigated a homicide in pictures. recent memory, and properly called on the resources of the BPD, state police, and ulti- Between 8:10 and 8:20 a.m., an Asian male mately ATF and FBI to assist in the investiga- thought now to be Cho was seen at the Duck tion. Pond. (The pond has been searched unsuccess- fully for the whereabouts of his phone and hard Boyfriend Questioning – At 9:30 a.m., the drive, which are still missing.) boyfriend of Emily Hilscher was stopped in his pickup truck on a road. He was cooperative and Before 9:00 a.m., Cho went to the Blacksburg shocked to hear that his girlfriend had just been post office off campus, where he was recognized killed. He passed a field test for the presence of by a professor who thought he looked frighten- gunpowder residue. While he remained a person ing. At 9:01 a.m., he mailed a package to NBC of interest, it appeared unlikely that he was the News in New York and a letter to the univer- shooter, with the implication that the real sity’s English Department. shooter was probably still at large. The police Diatribe – The panel was allowed to view the passed this information to the university lead- material Cho sent to NBC. The package was ership through the police captain who was in- signed “A. Ishmael,” similar to the “Ax Ishmael” teracting with the university staff.

4 This negative finding on the boyfriend raised The ATF laboratory was able to raise the numbers and the urgency of the situation, and the university identify the weapons collected after the shootings.

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

name he had written on his arm in ink at the tally, he even provided two takes of reading one time he committed suicide and also the name he portion of his written diatribe. used to sign some e-mails. The significance of this name remains to be explained, but it may After the mailings, Cho’s exact path is unknown tie to his self-view as a member of the until he gets to Norris Hall. oppressed. MOTIVATION FOR FIRST KILLINGS? Inside the package was a CD with a group of o one knows why Cho committed the first about 20 videos of himself presenting his killings in the dormitory. He ran a great extreme complaints against the world, two ram- N risk of being seen and having any of a number of bling, single-spaced letters with much the same things go wrong that could have thwarted his information that were used as the scripts for the larger plan. One line of speculation is that he videos, and pictures of himself with written cap- might have been practicing for the later killings, tions. The pictures showed him wielding weap- since he had never shot anyone before (some ons, showing his preparations for a mass mur- serial killers have been known to do this). He der, and railing against society that had ill- may have thought he would create a diversion to treated him. He seemed to be trying to look draw police away from where his main action powerful posing with weapons, the “avenger” for would later be, though in fact it worked the the mistreated and downtrodden of the world, opposite way. Many more police were on campus and even its “savior”, in his words. than would have been there without the first The videos and pictures in the package appear shootings, which allowed the response to the to have been taken at various times in a motel, second incident to be much faster and in greater a rented van, and possibly his dorm room over force. There is also a possibility that he consid- the previous weeks. It is likely that he alone ered attacking a woman as part of his revenge— took the photos; he can be seen adjusting the he was known to have stalked at least three camera. women in the previous year and had complaints registered against him, one from WAJ. Although His words to the camera were more than most there is a small possibility he knew the victim, people had ever heard from him. He wanted his no evidence of any connection has been found. In motivation to be known, though it comes across fact, he did not really know any of his victims as largely incoherent, and it is unclear as to ex- that day, not faculty, roommates, or classmates. actly why he felt such strong animosity. His dia- None of the speculative theories as to motive tribe is filled with biblical and literary refer- seem likely. The state and campus police have ences and references to international figures, not closed their cases yet, in part trying to but in a largely stream of consciousness man- determine his motives. ner. He mentions no one he knew in the videos. Rather, he portrays a grandiose fantasy of KEY FINDINGS becoming a significant figure through the mass killing, not unlike American assassins of presi- enerally the VTPD and BPD officers re- dents and public figures. The videos are a dra- Gsponded to and carried out their investiga- matic reading or “performance” of the writings tive duties in a professional manner in he enclosed. He read them several minutes at a time, then reached up to turn off the camera, is a balance between the public interest and the harm this changed the script he had mounted near the material can do to families of victims, the potential for giv- camera, and continued again. They clearly were ing incentive to future shooters, and the possibility of hidden not extemporaneous.5 Intentionally or acciden- messages triggering actions of others. NBC spent much time wrestling with what was the responsible thing to do journal- istically. It was a difficult set of decisions. They did not 5 NBC News in New York has the package Cho sent to them delay at all in getting the information package to the FBI and has released only a small amount of the material. There well before they released any of it.

CHAPTER VII. DOUBLE MURDER AT WEST AMBLER JOHNSTON

accordance with accepted police practices. How- to the double homicide that could have pre- ever, the police conveyed the wrong impression vented a tragedy of considerable magnitude on to the university Policy Group about the lead April 16. Cho had started on a mission of fulfill- they had and the likelihood that the suspect was ing a fantasy of revenge. He had mailed a pack- no longer on campus. age to NBC identifying himself and his rationale and so was committed to act that same day. He The police did not have the capability to use the could not wait beyond the end of the day or the university alerting system to send a warning to first classes in the morning. There were many the students, staff, and faculty. That is, they areas to which he could have gone to cause were not given the keyword to operate the alert- harm. ing system themselves, but rather they had to request a message be sent from the Policy RECOMMENDATIONS Group or at least the associate vice president for University Relations, who did have the key- VII-1 In the preliminary stages of an inves- word. The police did have the authority to tigation, the police should resist focusing request that a message be sent, but did not on a single theory and communicating that request that be done. They gave the university to decision makers. administration the information on the incident, VII-2 All key facts should be included in an and left it to the Policy Group to handle the alerting message, and it should be dissemi- messaging. nated as quickly as possible, with explicit The university administration failed to notify information. students and staff of a dangerous situation in a VII-3 Recipients of emergency messages timely manner. The first message sent by the should be urged to inform others. university to students could have been sent at least an hour earlier and been more specific. VII-4 Universities should have multiple The university could have notified the Virginia communication systems, including some Tech community that two homicides of students not dependent on high technology. Do not had occurred and that the shooter was unknown assume that 21st century communications may and still at large. The administration could have survive an attack or natural disaster or power advised students and staff to safeguard them- failure. selves by staying in residences or other safe places until further notice. They could have VII-5 Plans for canceling classes or closing advised those not en route to school to stay the campus should be included in the uni- home, though after 8 a.m. most employees versity’s emergency operations plan. It is not would have been en route to their campus jobs certain that canceling classes and stopping work and might not have received the messages in would have decreased the number of casualties time. at Virginia Tech on April 16, but those actions may have done so. Lockdowns or cancellation of Despite the above findings, there does not seem classes should be considered on campuses where to be a plausible scenario of university response it is feasible to do so rapidly.

87 Chapter VIII MASS MURDER AT NORRIS HALL

any police were on campus in the 2 hours Mfollowing the first incident, most at West Ambler Johnston residence hall but others at a command center established for the first incident. Two emergency response teams (ERTs) were positioned at the Blacksburg Police Department (BPD) headquarters, and a police captain was with the Virginia Tech Policy Group acting as liaison.

Cho left the post office about 9:01 a.m. (the time on his mailing receipt). He proceeded to Norris Hall wearing a backpack with his killing tools. He carried two handguns, almost 400 rounds of ammunition most of which were in rapid loading magazines, a knife, heavy chains, and a hammer. He wore a light coat to cover his shooting vest. He was not noticed as being a threat or peculiar enough for anyone to report him before the shooting started.

In Norris Hall, Cho chained shut the pair of doors at each of the three main entrances used by students. Figure 7 shows one such entrance. Figure 7. One of the Main Entrances to Norris Hall The chaining had the dual effect of delaying anyone from interrupting his plan and keeping vic- School dean’s office on the third floor. This was tims from escaping. After the Norris Hall inci- contrary to university instructions to immedi- dent, it was reported to police that an Asian male ately call the police when a bomb threat is found. wearing a hooded garment was seen in the vicin- A person in the dean’s office was about to call the ity of a chained door at Norris Hall 2 days before police about the bomb threat when the shooting the shootings, and it may well have been Cho started. A handwriting comparison revealed that practicing. Cho may have been influenced by the Cho wrote this note, but that he had not written two Columbine High School killers, whom he bomb threat notes found over the previous weeks mentioned in his ranting document sent to NBC in three other buildings. Those threats, which led News and previously in his middle school writ- to the evacuation of the three buildings, proved ings. He referred to them by their first names to be false. That may have contributed to the Cho and clearly was familiar with how they had car- note not being taken seriously, even though ried out their scheme. found on a chained door.

On the morning of April 16, Cho put a note on The usual VTPD protocol for a bomb threat that the inside of one set of chained doors warning is potentially real is to send officers to the threat- that a bomb would go off if anyone tried to ened building and evacuate it. Had the Cho bomb remove the chains. The note was seen by a fac- threat note been promptly reported prior to the ulty member, who carried it to the Engineering

CHAPTER VIII. MASS MURDER AT NORRIS HALL

start of the shooting, the police might have nothing. Even during this extreme situation at arrived at the building sooner than they did. the end of his life, he did not speak to anyone. Of 13 students present in the classroom, 9 were A female student trying to get into Norris Hall killed and 2 injured by shooting, and only 2 sur- shortly before the shooting started found the vived unharmed. No one in room 206 was able to entrance chained. She climbed through a window call the police. to get where she was going on the first floor. She did not report the chains, assuming they had Occupants of neighboring classrooms heard the something to do with ongoing construction. gunshots but did not immediately recognize Other students leaving early from an accounting them as gunfire. One student went into the hall- exam on the third floor also saw the doors way to investigate, saw what was happening, chained before the shooting started, but no one and returned to alert the class. called the police or reported it to the university. First Alarm to 9-1-1 – Cho started shooting at Prior to starting the shootings, Cho walked about 9:40 a.m. It took about a minute for stu- around in the hallway on the second floor poking dents and faculty in room 211, a French class, to his head into a few classrooms, some more than recognize that the sounds they heard in the once, according to interviews by the police and nearby room were gunshots. Then the instructor, panel. This struck some who saw him as odd Jocelyne Couture-Nowak, asked student Colin because it was late in the semester for a student Goddard to call 9-l-l. to be lost. But no one raised an alarm. Figure 8 shows the hallway in Norris Hall. Cell phone 9-1-1 calls are routed according to which tower receives them. Goddard’s call was routed to the Blacksburg police. Another call by cell phone from room 211 was routed first to the Montgomery County sheriff. The call-taker at the BPD received the call at 9:41 a.m. and was not familiar with campus building names. But it took less than a minute to sort out that the call was coming from Virginia Tech and it was then transferred to the Virginia Tech Police Depart- ment (VTPD).

At 9:42 a.m., the first call reached the Virginia Tech police that there was shooting in Norris Hall. Other calls later came from other classrooms and offices in Norris Hall and from other Figure 8. Hallway in Norris Hall buildings.

THE SHOOTINGS Students and faculty in other nearby rooms also heard the first shots, but no one immediately he occupants of the first classroom that Cho realized what they were. Some thought they attacked had little chance to call for help or T were construction noises. Others thought they take cover. After peering into several classrooms, could be the popping sounds sometimes heard Cho walked into the Advanced Hydrology engi- from chemistry lab experiments on the first floor. neering class of Professor G. V. Loganathan in One professor told his class to continue with the room 206, shot and killed the instructor, and lesson after some raised questions about the continued shooting, saying not a word. In fact, he noise. When the noise did not stop, some people never uttered a sound during his entire shooting went into the hallway to investigate. One stu- spree—no invectives, no rationale, no comments, dent from an engineering class was shot when he

CHAPTER VIII. MASS MURDER AT NORRIS HALL

entered the hallway. At that point, terror set in Students in room 205 attending a class in scien- among the persons in the classrooms who real- tific computing heard Cho’s gunshots and barri- ized that what they were hearing was gunfire. caded the door to prevent his entry, mainly with their bodies kept low, holding the door with their Continued Shooting – This section portrays feet. Cho never did succeed in getting into this the sense of the key action rather than trace the room though he pushed and fired through the exact path of Cho. It is based on police presenta- door several times. No one was injured by gun- tions to the panel, police news releases, and in- shot in this room. terviews conducted by the panel. Back in room 207, the German class, two un- After killing Professor Loganathan and several injured students and two injured students students in room 206, Cho went across the hall rushed to the door to hold it shut with their feet to room 207, a German class taught by Christo- and hands before Cho returned, keeping their pher James Bishop. Cho shot Professor Bishop bodies low and away from the center of the door. and several students near the door. He then Within 2 minutes, Cho returned and beat on the started down the aisle shooting others. Four stu- door. He opened it an inch and fired about five dents and Bishop ultimately died in this room, shots around the door handle, then gave up try- with another six wounded by gunshot. One stu- ing to reenter and left. dent tried to wrench free the podium that was fastened securely to the floor in order to build a Cho returned to room 211, the French class, and barricade at the door. She was unsuccessful and went around the room, up one aisle and down injured herself in the process. another, shooting students again. Cho shot Goddard two more times. Goddard lay still and As Goddard called 9-1-1 from classroom 211, played dead. This classroom received the most Couture-Nowak’s class tried to use the instruc- visits by Cho, who ultimately killed 11 students tor’s table to barricade the door, but Cho pushed and the instructor, and wounded another 6, the his way in, shot the professor, and walked down entire class. the aisle shooting students. Cho did not say anything. Goddard was among the first to be shot. A janitor saw Cho reloading his gun in the hall Another student, Emily Haas, picked up on the second floor and fled downstairs. Goddard’s cell phone after he was shot. She Cho tried to enter the classroom of engineering stayed on the line for the rest of the shooting professor Liviu Librescu (room 204), who was period. She was slightly wounded twice in the teaching solid mechanics. Librescu braced his head by bullets, spoke quietly as long as she body against the door and yelled for students to could to the dispatcher, heard that the police head for the window. Students pushed out the were responding, closed her eyes, and played screens and jumped or dropped onto bushes or dead. She said she did not open her eyes again the grassy ground below the window. Ten of the for over 10 minutes until the police arrived. Dur- 16 students escaped this way. The next two stu- ing her ordeal, she was concerned that the dents trying to leave through the window were shooter would hear the 9-1-1 dispatch operator shot. Librescu was fatally shot through the door over the cell phone. But by keeping the line open trying to hold it closed while his students she helped keep police apprised of the situation. escaped. A total of four students were shot in She kept the phone hidden by her head and hair this class, one fatally. so she could appear dead but not disconnect. Although the dispatcher at times asked her ques- Cho returned to most of the classrooms more tions and at other times told her to keep quiet, than once to continue shooting. He methodically she spoke only when Cho was out of the room, fired from inside the doorways of the classrooms, which she could tell by the proximity of the and sometimes walked around inside them. It shots. was very close range. Students had little place to

CHAPTER VIII. MASS MURDER AT NORRIS HALL

hide other than behind the desks. By taking a The massacre continued for 9 minutes after the few paces inside he could shoot almost anyone in first 9-1-1 call was received by the VTPD, and the classroom who was not behind a piece of about 10–12 minutes in total, including a minute overturned furniture. The classrooms were all for processing and transferring the call to VTPD, roughly square, with no obstructions. Figure 9 and the time to comprehend that shots were shows the interior of a typical classroom, seen being fired and to make the call. From the first from the corner furthest from the door. call, shots can be heard continuously on the dis- Table 1 shows the dimensions of the rooms with patch tapes, until they stopped with the suicide the shootings. shot.

Within that period, Cho murdered 25 students and 5 faculty of Virginia Tech at Norris Hall. Another 17 were shot and survived, and 6 were injured when they jumped from classroom windows to escape.

Cho expended at least 174 bullets from two semiautomatic guns, his 9mm Glock and .22 caliber Walther, firing often at point-blank range. The police found 17 empty magazines, each capable of holding 10–15 bullets. Ammunition recovered included 203 live cartridges,122 for the Glock and 81 for the Walther. The unexpended Figure 9: Interior of Typical Classroom ammunition included two loaded 9mm magazines with 15 cartridges each and many loose bullets. Table 1. Dimensions of the Classrooms Attacked Cho committed suicide by shooting himself in the Room # Dimensions head, probably because he saw and heard the 204 28’ x 25’ police closing in on him. With over 200 rounds 205 24’ x 25’ left, more than half his ammunition, he almost 206 22’ x 25’ surely would have continued to kill more of the 207 24’ x 25’ wounded as he had been doing, and possibly 211 22’ x 25’ others in the building had not the police arrived so quickly. Terrible as it was, the toll could have The rooms were furnished with lightweight been even higher. desk–chair combinations, single units combining both functions. Each instructor had a table desk DEFENSIVE ACTIONS and a podium, the latter bolted to the floor. The doors were not lockable from the inside. Unlike ccording to survivors, the first reaction of many lower grade schools and typical of most Athe students and faculty was disbelief, fol- colleges, the instructors had no university- lowed rapidly by many sensible and often heroic furnished messaging system for receiving or actions. One affirmative judgment in reflecting sending an alarm. Emergency communications on this event is that virtually no one acted irra- from classrooms were limited to any phone or tionally. People chose what they thought was the electronic devices carried by students or instruc- best option for their survival or to protect others, tors. The offices had standard telephones, but and many tried to prevent the shooter from gain- they were on the third floor. ing access to their room. Unfortunately, a shooter operating at point-blank range does not offer many options.

CHAPTER VIII. MASS MURDER AT NORRIS HALL

Escaping – Professor Librescu’s class was the only one where students escaped by jumping from windows. This classroom's windows face a grassy area. (Figure 10 is the view from outside and Figure 11 shows the structure of the windows. The view from inside looking out is shown in Figure 12.)

Figure 12. To Escape, They Had to Climb Over the Low Window

Figure 10. Norris Hall Classroom The window sills are 19 feet high from the Windows, Grassy Side ground, two stories up. In order to escape through the window, the first jumper, a male student, had to take down a screen, swing the upper window outward, climb over the lower portion of the window that opened into the classroom, and then jump. He tried to land on the bushes. Following his example, most of the rest of the class formed groups behind three windows and started jumping. All who jumped survived, some with broken bones, some uninjured except for scratches or bruises. Some survivors did the optimum window escape, lowering themselves from the window sill to drop to the ground, reducing the fall by their body length.

The other classes faced out onto concrete walks Figure 11. Typical Set of Windows in Norris Hall or yards, and jumping either did not seem a good idea or perhaps did not even enter their minds. No one attempted to jump from any other classroom.

CHAPTER VIII. MASS MURDER AT NORRIS HALL

Some attempts were made by a few students to Craig, and Brian Roe. More continued to arrive escape out of the classroom and down the hall in throughout the incident. the earliest stage of the incident. But after some people were shot in the hall, no one else tried By professional standards, this was an extra- ordinarily fast police response. The officers had that route. been near WAJ as part of the investigation and Attempting to Barricade – In three of the four security following the first incident, so they were classrooms that Cho invaded and one more that able to respond much faster than they otherwise resisted invasion, the instructor and students would have. The two police forces trusted each attempted to barricade the door against Cho en- other, had trained together, and did not have to tering either on his first attempt or on a later take time sorting out who would go from which try. They tried to use the few things available— organization in which car. They just went the teacher’s table, the desk–chair combinations, together as fast as they could. and their bodies. Some attempts to barricade The five officers immediately proceeded to succeeded and others did not. Cho pushed his implement their training for dealing with an way in or shot through some doors that were active shooter. The policy is to go to the gunfire being barricaded. In the German class, two as fast as possible, not in a careless headlong wounded students and two non-wounded stu- rush, but in a speedy but careful advance. The dents managed to hold the door closed against first arriving officers had to pause several sec- the return entry by Cho. They succeeded in stay- onds after exiting their cars to see where the ing out of the line of fire through the door. Two gunfire was coming from, especially whether it other rooms did the same. In one, Cho never did was being directed toward them. They quickly get in. At least one effort was made to use the figured out that the firing was inside the build- podium, but it failed (it was bolted to the floor). ing, not coming from the windows to the outside. Cho was not a strong person—his autopsy noted Because Cho was using two different caliber weak musculature—and these brave students weapons whose sounds are different, the and faculty helped reduce the toll. assumption had to be made that there was more Playing Dead – Several students, some of than one shooter. whom were injured and others not, successfully The officers tried the nearest entrance to Norris played dead amid the carnage around them, and Hall, found it chained, quickly proceeded to a survived. Generally, they fell to the ground as second and then a third entrance, both also shots were fired, and tried not to move, hoping chained. Attempts to shoot off the padlocks or Cho would not notice them. Cho had systemati- chains failed. They then moved rapidly to a cally shot several of his victims a second time fourth entrance—a maintenance shop door that when he saw them still alive on revisiting some was locked but not chained. They shot open the of the rooms, so the survivors tried to hold still conventional key lock with a shotgun. Five police and keep quiet. This worked for at least some officers entered and rapidly moved up the stairs students. toward the gunfire, not knowing who or how POLICE RESPONSE many gunmen were shooting.

ithin 3 minutes of the Virginia Tech police The first team of five officers to enter Norris Hall Wreceiving the 9-1-1 call, two officers arrived after the door lock was shot were: outside of Norris Hall by squad car. They were VT Officer H. Dean Lucas (patrol) Virginia Tech officer H. Dean Lucas and Blacks- Blacksburg Officer Greg Evans (patrol) burg Sgt. Anthony Wilson. A few seconds later, Blacksburg Officer Scott Craig (SWAT) three more officers arrived by car: Blacksburg Blacksburg Officer Brian Roe (SWAT) Police Department officers John Glass, Scott Blacksburg Officer Johnny Self (patrol)

CHAPTER VIII. MASS MURDER AT NORRIS HALL

They were followed seconds later by a second The auditorium connecting Norris Hall with Hol- team of seven officers: den Hall and shared by both could have been used as an entry path, but it would have taken VT Lt. Curtis Cook (SWAT) longer to get in by first running into Holden VT Sgt Tom Gallemore (SWAT) Hall, going through it, and then up the stairs to VT Sgt Sean Smith (SWAT) Norris Hall. The police ERT had the capability of VT Officer Larry Wooddell (SWAT) receiving plans of the buildings by radio from the VT Officer Keith Weaver (patrol) fire department, but that would have taken too VT Officer Daniel Hardy (SWAT) long and was not needed in the event. Blacksburg Officer Jeff Robinson (SWAT) During the shooting, a student took pictures Both teams had members from more than one from his cell phone that were soon broadcast on police department. The first police team got to television. They showed many police outside of the second floor hallway leading to the class- Norris Hall behind trees and cars, some with rooms as the shooting stopped. The second police guns drawn, not moving toward the gunfire. team that entered went upstairs to the opposite Most of them were part of a perimeter estab- end of the shooting hallway on the second floor. lished around the building after the first officers They saw the first team at the opposite end of on the scene made entry. The police were follow- the hall and held in place to avoid a crossfire ing standard procedure to surround the building should the shooter emerge from a room. They in case the shooter or shooters emerged firing or then went to clear the third floor. trying to escape. What was not apparent was The first team of officers arriving on the second that the first officers on the scene already were floor found it eerily quiet. They approached cau- inside. tiously in the direction from which the shots Once the shooting stopped, the first police on the were fired. They had to clear each classroom and scene switched modes and became a rescue team. office as they passed it lest they walk past the Four officers carried out a victim using a dia- shooter or shooters and get fired upon from the mond formation, two actually doing the carrying rear. They saw casualties in the hallway and a and two escorting with guns drawn. At this scene of mass carnage in the classrooms, with point, it still was not known whether there was a many still alive. Although the shooter was even- second shooter. The police carried several victims tually identified, he was not immediately appar- who were still alive to the lawn outside the build- ent, and they were not certain whether other ing, where they were turned over to a police- shooters lurked. This seemed a distinct possibil- driven SUV that took the first victims to emer- ity. As one police sergeant later reflected: “How gency medical treatment. (The emergency medi- could one person do all this damage alone with cal response is discussed in Chapter IX.) handguns?” A formal incident commander and emergency Some people have questioned why the police operations center was not set up until after the could not force entry into the building more shooting was over mainly because events quickly. First, most police units do not carry bolt unfolded very rapidly. A more formal process was cutters or other entry devices; such tools would used for the follow-up investigation. rarely be used by squad car officers. They usually are carried only in the vans of special police UNIVERSITY MESSAGES units. Second, the windows on the first floor are very narrow, as on all floors of Norris Hall. A hen university officials were apprised of thin student could climb through them; a heavily Wthe Norris Hall shootings, they were horri- armed officer wearing bulletproof vest could not. fied. Vice Provost Ford explained the events as Knocking down a door with a vehicle was not follows (continuing his statement presented to possible given the design and site of the building. the panel from the previous chapter):

CHAPTER VIII. MASS MURDER AT NORRIS HALL

At approximately 9:45 a.m., the Policy Group Group about what they had witnessed in the received word from the Virginia Tech police aftermath of the shootings in Norris Hall. of a shooting in Norris Hall. Within five minutes, a notification was issued by the Chief Flinchum reported that the scene was Policy Group and transmitted to the univer- bad; very bad. Virginia state police was han- sity community which read: dling the crime scene. Police had one shooter in custody and there was no evidence at the “A gunman is loose on campus. Stay in time to confirm or negate a second shooter, buildings until further notice. Stay away nor was there evidence at the time to link the from all windows.” shootings in West Ambler Johnston to those in Norris Hall. The police informed the Policy Also activated was the campus emergency Group that these initial observations were alert system. The voice message capability of ongoing investigations. that system was used to convey an emergency message throughout the campus. Based upon this information and acting upon Given the factual information available to the advice of the police, the Policy Group the Policy Group, the reasonable action was immediately issued a fourth transmittal to ask people to stay in place. The Policy which read: Group did not have evidence to ensure that a gunman was or was not on the loose, so every “In addition to an earlier shooting today in precaution had to be taken. The Virginia West Ambler Johnston, there has been a Tech campus contains 153 major buildings,1 multiple shooting with multiple victims in 19 miles of public roads, is located on 2,600 Norris Hall. Police and EMS are on the acres of land, and as many as 35,000 indi- scene. Police have one shooter in custody and viduals might be found on its grounds at any as part of routine police procedure, they con- one time on a typical day. Virginia Tech is tinue to search for a second shooter. very much like a small city. One does not en- “All people in university buildings are tirely close down a small city or a university required to stay inside until further notice. campus. All entrances to campus are closed.” Additionally, the Policy Group considered Information about the Norris Hall shootings that the university schedule has a class continued to come to the Policy Group from change between 9:55 a.m. and 10:10 a.m. on the scene. At approximately 11:30 [a.m.], the a MWF schedule. To ensure some sense of Policy Group issued a planned faculty–staff safety in an open campus environment, the evacuation via the Virginia Tech web site Policy Group decided that keeping people which read: inside existing buildings if they were on campus and away from campus if they had not “Faculty and staff located on the Burruss yet arrived was the right decision. Again, we Hall side of the drill field are asked to leave made the best decision we could based on the their office and go home immediately. Fac- information available. So at approximately ulty and staff located on the War Memorial/ 10:15 a.m. another message was transmitted Eggleston Hall side of the drill field are which read: asked to leave their offices and go home at 12:30 p.m.” “Virginia Tech has cancelled all classes. Those on campus are asked to remain where At approximately 12:15 p.m., the Policy they are, lock their doors, and stay away Group released yet another communication from windows. Persons off campus are asked via the Virginia Tech web site which further not to come to campus.” informed people as follows:

At approximately 10:50 a.m., Virginia Tech “Virginia Tech has closed today Monday, Police Chief Flinchum and Blacksburg Police April 16, 2007. On Tuesday, April 17, Chief Crannis arrived to inform the Policy classes will be cancelled. The university will remain open for administrative operations. There will be an additional university

1 statement presented today at noon. From another university source, we identified 131 major buildings and several more under construction. In any event, it is a large number of structures.

4 5

CHAPTER VIII. MASS MURDER AT NORRIS HALL

“All students, faculty and staff are required to stay where they are until police execute a OTHER ACTIONS ON THE SECOND planned evacuation. A phased closing will AND THIRD FLOORS be in effect today; further information will be forthcoming as soon as police secure the hile the shootings were taking place in campus. Wclassrooms on the second floor of Norris Hall, people on the other floors and in offices on “Tomorrow there will be a university con- the second floor tried to flee or take refuge—with vocation/ceremony at noon at Cassell Coli- seum. The Inn at Virginia Tech has been one exception. Professor Kevin Granata from the designated as the site for parents to gather third floor guided his students to safety in a and obtain information.” small room, locked the room and went to investigate the gunfire on the second floor. He was shot A press conference was held shortly after noon on April 16, 2007, and President and killed. People who did take refuge in locked Charles W. Steger issued a statement citing rooms were badly frightened by gunfire and the “A tragedy of monumental proportions.” general commotion, but all of them survived. Copies of that statement are available on request. In the first minutes after they arrived, the police could not be sure that all of the shooters were The Policy Group continued to meet and strategically plan for the events to follow. A dead. The police had to be careful in clearing all campus update on the shootings was issued rooms to ensure that there was not a second at another press conference at approxi- shooter mixed in with the others. In fact, perpe- mately 5:00 p.m. trators can often blend with their victims, Groups of police went through the building clear- It should be noted that the above messages were ing each office, lab, classroom, and closet. When sent after the full gravity of what happened at they encountered a group of people hiding in a Norris Hall had been made known to the Policy bathroom or locked office, they had to be wary. Group. They were too late to be of much value for The result was that many people were badly security. The messages still were less than full frightened a second time by the police clearing disclosure of the situation. There may well have actions. Some were sent downstairs accompanied been a second shooter, and the university com- by officers and others were left to make their munity should have been told to be on the look- own way out. Although quite a few officers were out for one, not that the continued search was in the building at this time, they still did not just “routine police procedure.” When almost 50 have sufficient members to clear all areas and people are shot, what follows is hardly “routine simultaneously escort out every survivor. It also police procedure.” The university appears to have appears that there was inadequate communica- tempered its messages to avoid panic and reduce tion between the police who were clearing the the shock and fright to the campus family. But a building and those outside guarding the exits. more straightforward description was needed. The messages still did not get across the enor- For example, one group of professors and staff mity of the event and the loss of life. By that was hiding behind the locked doors of the Engi- time, rumors were rife. The events were highly neering Department offices on the third floor. disturbing and there was no way to sugarcoat When they were cleared by police to evacuate, them. Straight facts were needed. they were directed down a staircase toward an exit where they found a chained door with police outside pointing guns at them. One of them remembered that there was an exit through the auditorium to Holden Hall and they left that way.

CHAPTER VIII. MASS MURDER AT NORRIS HALL

The group of students from Professor Granata’s Based on university records, 148 students were third-floor class that hid in a small locked office on the rolls of classes held at 9:05 a.m. in Norris were frightened by officers approaching with Hall on April 16. At least 31 and possibly a few guns at the ready, but then were escorted safely more missed classes or had classes cancelled that out of the building. day. So at least 100 students were in the building, possibly as many as 120, including a few not The police had their priorities straight. Although enrolled in the classes. (The statistics are inexact many survivors were frightened, the police because not all Norris Hall students responded understandably were focused on clearing the to a university survey of their whereabouts that building safely and quickly. Had there been a day.) Of the students present, 25 were killed, 17 second shooter not found quickly, the police were shot and survived, 6 were injured jumping would have wasted manpower escorting people from windows, and 4 were injured from other out instead of searching for and neutralizing the 2 causes. shooter. Room 211 suffered the most student casualties ACTION ON THE FIRST FLOOR (17). The other rooms with casualties were 207 (11), 206 (11), 204 (10), 205 (1), and 306 (1). ccording to VTPD Chief Flinchum: In addition to the classes, there were many other AWhen officers entered Norris Hall, two stayed on the first floor to secure it. One people in the building at the time of the shoot- officer said one or two people came out of ings, including staff of the dean’s office, other rooms and were evacuated. Officers on the faculty members with offices in the building, second floor took survivors down to the first other students, and janitorial staff. None of them floor on the Drillfield side of Norris, but was injured. they had to shoot the lock on the chained door to get out. When they did this, other When the shooting stopped, about 75 students officers entered Norris and began initial and faculty were uninjured, some still in class- clearing of the first floor while the other teams were clearing the third and second room settings and others in offices or hiding in floors. The first floor was cleared again by restrooms. With over 200 rounds left, the toll SWAT after the actions on the second floor could have been higher if the police had not were completed. arrived when they did, as noted earlier.

This all was appropriate, thorough police Table 2 and Table 3 at the end of this chapter procedure. show the numbers of students and faculty who were killed and injured, by room, based on the THE TOLL university’s research. n about 10 minutes, one shooter armed with Ihandguns shot 47 students and faculty, of KEY FINDINGS whom 30 died. The shooter’s self-inflicted wound verall, the police from Virginia Tech and made the toll 48. OBlacksburg did an outstanding job in Of the seven faculty conducting classes, five were responding quickly and using appropriate active- fatally shot. Three were standing in the front of shooter procedures to advance to the shooter’s their classrooms when the gunman walked in. location and to clear Norris Hall. One was shot barricading the door, and one shot while investigating the sounds after getting his class to safety on the third floor. They were brave 2 and vulnerable. There are small inconsistencies in the tallies of injuries among police, hospitals, and university because some students sought private treatment for minor injuries, and the definition of “injury” used.

CHAPTER VIII. MASS MURDER AT NORRIS HALL

The close relationship of the Virginia Tech Police being frightened is preferable to being injured by Department and Blacksburg Police Department a second shooter. The police had their priorities and their frequent joint training saved critical correct, but they might have handled the evacua- minutes. They had trained together for an active tion with more care. shooter incident in university buildings. There is little question their actions saved lives. Other RECOMMENDATIONS campus police and security departments should VIII-1 Campus police everywhere should make sure they have a mutual aid arrangement train with local police departments on as good as that of the Virginia Tech Police response to active shooters and other emer- Department. gencies. Police cannot wait for SWAT teams to arrive and VIII-2 Dispatchers should be cautious when assemble, but must attack an active shooter at giving advice or instructions by phone to once using the first officers arriving on the scene, people in a shooting or facing other threats which was done. The officers entering the build- without knowing the situation. This is a ing proceeded to the second floor just as the broad recommendation that stems from review- shooting stopped. The sound of the shotgun blast ing other U.S. shooting incidents as well, such as and their arrival on the second floor probably the Columbine High School shootings. For caused Cho to realize that attack by the police instance, telling someone to stay still when they was imminent and to take his own life. should flee or flee when they should stay still can Police did a highly commendable job in starting result in unnecessary deaths. When in doubt, to assist the wounded, and worked closely with dispatchers should just be reassuring. They the first EMTs on the scene to save lives. should be careful when asking people to talk into the phone when they may be overheard by a Several faculty members died heroically while gunman. Also, local law enforcement dispatchers trying to protect their students. Many brave stu- should become familiar with the major campus dents died or were wounded trying to keep the buildings of colleges and universities in their shooter from entering their classrooms. Some area. barricading doors kept their bodies low or to the side and out of the direct line of fire, which VIII-3 Police should escort survivors out of reduced casualties. buildings, where circumstances and manpower permit. Several quick-acting students jumped from the second floor windows to safety, and at least one VIII-4 Schools should check the hardware by dropping himself from the ledge, which on exterior doors to ensure that they are not reduced the distance to fall. Other students sur- subject to being chained shut. vived by feigning death as the killer searched for VIII-5 Take bomb threats seriously. Stu- victims. dents and staff should report them immedi- People were evacuated safely from Norris Hall, ately, even if most do turn out to be false but the evacuation was not well organized and alarms. was frightening to some survivors. However,

CHAPTER VIII. MASS MURDER AT NORRIS HALL

Table 2. Norris Hall Student Census for April 16, 2007 9:05 a.m. Classes

Total Students Accounted For: Used Windows To Killed or Not Physi- Did Not Status Students Escape Room Total Students Later cally In- Attend Not Injured** by Not No. on Class Roll Died Injured jured Class Verified Total Gunshot Injured* Injured* 200 14* 0 0 0 14** 0 14 0 204 23 1 9 6 5 2 23 3 6 4 205 14 0 1 8 3 2 14 0 206 14 9 2 2 1 0 14 2 207 15 4 7 1 3 0 15 6 211 22 11 6 0 4 1 22 6 306 37 0 1 20 1 15 37 0 Labs 9 0 0 9 0 0 9 0 Totals 148 25 26 46 31 20 148 17 6 4 * Included in "Total Students Accounted For" ** Class was cancelled that day

Table 3. Norris Hall Faculty Census

Total Total Faculty Accounted For Faculty Killed or Not Physi- Did Not At- Status Not Room # Scheduled Later Died Injured cally Injured tend Class Verified Total 200 1 0 0 0 1** 1 204 1 1 0 0 1 205 1 0 0 1 1 206 1 1 0 0 1 207 1 1 0 0 1 211 1 1 0 0 1 306 1 0 0 1 1 225/hallway 1 1 0 0 1 Totals 8 5 0 2 1 8 * Class was cancelled that day

These tables were provided by the Virginia Tech administration.

100 CHAPTER IX. EMS RESPONSE

Chapter IX EMERGENCY MEDICAL SERVICES RESPONSE

and training for mass casualty events, dedica- he tragic scenes that occurred at Virginia tion, and ability to perform at a high level in the TTech are the worst that most emergency face of the disaster that struck so many people. medical service (EMS) providers will ever see. Images of so many students and faculty mur- The Virginia Tech Rescue Squad and Blacksburg dered or seriously injured in such a violent man- Volunteer Rescue Squad were the primary agen- ner and the subsequent rescue efforts can only be cies responsible for incident command, triage, described by those who were there. This chapter treatment, and transportation. Many other discusses the emergency medical response on regional agencies responded and functioned April 16 to victims including their pre-hospital under the Incident Command System (ICS). The treatment, transport, and care in hospitals. Blacksburg Volunteer Rescue Squad (BVRS) personnel and equipment response was timely and Interviews were conducted with first responders, strong. Virginia Tech Rescue Squad (VTRS), the emergency managers, and hospital personnel lead EMS agency in this incident, is located on (physicians, nurses, and administrators) to the Virginia Tech campus and is the oldest colle- determine: giate rescue squad of its kind nationwide. It is a • The on-scene EMS response. volunteer, student-run organization with 38 members.1 Their actions on April 16 were heroic • Implementation of hospital multi- and demonstrated courage and fortitude. casualty plans and incident command systems. WEST AMBLER JOHNSTON INITIAL • Pre-hospital and in-hospital initial RESPONSE patient stabilization. he first EMS response was to the West • Compliance with the National Incident Ambler Johnston (WAJ) residence hall inci- Management System (NIMS). T dent. At 7:21 a.m., VTRS was dispatched to 4040 • Communications systems used. WAJ for the report of a patient who had fallen • Coordination of the emergency medical from a loft. In 3 minutes, at 7:24 a.m., VT Rescue care with police and EMS providers. 3 was en route. While en route, dispatch advised that a resident assistant reported a victim lying Evaluating patient care subsequent to the initial against a dormitory room door and that bloody pre-hospital and hospital interventions was footprints and a pool of blood were seen on the beyond the scope of this investigation. Fire floor. VT Rescue 3 arrived on scene at 7:26 a.m., department personnel were not interviewed 5 minutes from the time of dispatch. This because there were no reports of their involve- response time falls within the nationally ac- ment in patient care activities cepted range.2 Although there is always opportunity for improvement, the overall EMS response was 1 excellent and the lives of many were saved. The VTRS. (2007). April 16, 2007: EMS Response. Presentation challenges of systematic response, scene and to the Virginia Tech Review Panel. May 21, 2007, The Inn at Virginia Tech. provider safety, and on-scene and hospital 2 NFPA (2004). NFPA 1710: Standard for the Organization patient care were effectively met. Responders are and Deployment of Fire Suppression Operations, Emergency to be commended. The results in terms of patient Medical Operations, and Special Operations to the Public by Career Fire Departments. National Fire Protection Associa- care are a testimony to their medical education tion: Battery March Park, MA.

101

CHAPTER IX. EMS RESPONSE

At 7:29 a.m., Rescue 3 accessed the dorm room to Following CPR that occurred en route she was find two victims with gunshot wounds, both pronounced dead at CRMH.6 obviously in critical condition. At 7:31 a.m., it requested a second advanced life support (ALS) Based on the facts known, the triage, treatment, and transportation of both WAJ victims unit and ordered activation of the all-call tone requesting all available Virginia Tech rescue per- appeared appropriate. The availability of heli- sonnel to respond to the scene. The “all-call” copter transport likely would not have affected patient outcomes. Their injuries were incompati- request is a normal procedure for VTRS to respond to an incident with multiple patients. ble with survival. Personnel from BVRS responded to WAJ as well. NORRIS HALL INITIAL RESPONSE At 7:48 a.m., VT Rescue 3 requested that t 9:02 a.m., VT Rescue 3 returned to service Carilion Life-Guard helicopter be dispatched and following the WAJ incident. VT Rescue 2 was informed that its estimated time of arrival A continued equipment cleanup at MRH when the was 40 minutes. It was decided to dispatch the call for the Norris Hall shootings came in. At helicopter to Montgomery Regional Hospital approximately 9:42 a.m., VTRS personnel at (MRH). Carilion Life-Guard then advised that their station overheard a call on the police radio they were grounded due to weather and never advising of an active shooter at Norris Hall. began the mission. Many EMS providers were about to respond to One of the victims in 4040 WAJ was a 22-year- the worst mass shooting event on a United old male with a gunshot wound to the head. He States college campus. was in cardiopulmonary arrest. CPR was initi- Upon hearing the police dispatch of a shooting at ated, and he was immobilized using an extrica- Norris Hall, the VTRS officer serving as EMS tion collar and a long spine board. VT Rescue 3 commander immediately activated the VTRS transported him to MRH. During communica- Incident Action Plan and established an incident tions with the MRH online physician, CPR was command post at the VTRS building. VT Rescue ordered to be discontinued. He arrived at the 3 3, staffed with an ALS crew, stood by at their hospital DOA. station. At about 9:42 a.m., VTRS requested the The second victim was an 18-year-old female Montgomery County emergency services coordi- with a gunshot wound to the head. She was nator to place all county EMS units on standby treated with high-flow oxygen via mask, two IVs and for him to respond to the VTRS Command were established, and cardiac monitoring was Post. “Standby” means that all agency units initiated. She was immobilized with an extrica- should be staffed and ready to respond. Each tion collar and placed on a long spine board. At agency officer in charge is supposed to notify the 7:44 a.m., she was transported by VT Rescue 2 to appropriate dispatcher when the units are MRH. During transport, her level of conscious- staffed. ness began to deteriorate and her radial pulse 4 The Montgomery County Communications Cen- was no longer palpable. Upon arrival at MRH, ter immediately paged out an “all call” alert (9:42 endotracheal intubation was performed. At 8:30 a.m.) advising all units to respond to the scene at a.m., she was transferred by ground ALS unit to Norris Hall. Carilion Roanoke Memorial Hospital (CRMH), a 5 Level I trauma center in Roanoke, Virginia. The EMS responses to West Ambler Johnston and Norris halls occurred in a timely manner. 3 EMS Patient Care Report Q0669603. However, for the shootings at Norris Hall, all 4 EMS Patient Care Report Q0669604. EMS units were dispatched to respond to the 5 Turner, K. N., and Davis, J. (2007). Public Safety Timeline for April 16, 2007. Unpublished Report. Montgomery County 6 Department of Emergency Services, p. 4. EMS Patient Care Report Q0019057.

102

CHAPTER IX. EMS RESPONSE

scene at once contrary to the request. Sub- Overall, the structure of the EMS ICS was effec- sequently, the Montgomery County emergency tive. The ICS as implemented during the inci- services coordinator requested dispatch to correct dent is compared in Figure 13 and Figure 14 to the message in time to allow for most of the in- NIMS ICS guidelines. Figure 13 shows the coming squads to proceed to the secondary stag- Virginia Tech EMS ICS structure as imple- ing area at the BVRS station. mented in the incident.9 Although it did not strictly follow NIMS guidelines, it included most At 9:46 a.m., VTRS was dispatched by police to of the necessary organization. Figure 14 shows Norris Hall for multiple shootings—4 minutes the Model ICS structure based on the NIMS after VTRS monitored the incident (9:42 a.m.) on guidelines. the police radio. The VTRS EMS commander advised VT dispatch that the VTRS units would EMS Command – An EMS command post was stand by at the primary staging site until police established at VTRS. The BVRS officer-in-charge secured the shooting area. At 9:48 a.m., the EMS who arrived at Norris Hall reportedly was commander also requested the VT police dis- unable to determine if an EMS ICS was in place. patcher to notify all responding EMS units from Since each agency has its own radio frequency, outside Virginia Tech to proceed to the secondary the potential for miscommunication of critical staging area at BVRS instead of responding information regarding incident command is pos- directly to Norris Hall. sible. To enhance communications, EMS command reportedly switched from the VTRS to the The VTPD and the Montgomery County Com- BVRS radio frequency. In addition, to shift rou- munications Center issued separate dispatches tine communications from the main VT fre- for EMS units, which led to some confusion in quency, EMS command requested units to switch the EMS response. to alternate frequency, VTAC 1. Some units were confused by the term VTAC 1. Eventually, all EMS INCIDENT COMMAND SYSTEM units switched to the Montgomery County t the national level, Homeland Security Mutual Aid frequency. Presidential Directives (HSPDs) 5 and 8 A The fact that BVRS was initially unaware that require all federal, state, regional, local, and VTRS had already established an EMS command tribal governments, including EMS agencies, to post could have caused a duplication of efforts adopt the NIMS, including a uniform ICS.7 The and further organizational challenges. Partici- Incident Management System is defined by pants interviewed stated that once a BVRS offi- Western Virginia EMS Council in their Mass cer reported to the EMS command post, commu- Casualty Incident (MCI) Plan as: nications between EMS providers on the scene A written plan, adopted and utilized by all improved. The Montgomery County emergency participating emergency response agencies, management coordinator was on the scene and that helps control, direct and coordinate served as a liaison between the police tactical emergency personnel, equipment and other command post and the EMS incident command resources from the scene of an MCI or evacuation, to the transportation of patients post, which also helped with communications. to definitive care, to the conclusion of the 8 Because BVRS and VTRS are on separate pri- incident. mary radio frequencies, BVRS reportedly did not know where to stage their units. In addition, BVRS units reportedly did not know when the 7 police cleared the building for entry. Bush, G. W. (2003). December 17, 2003 Homeland Security Presidential Directive/HSPD–8. 8 9 WVEMS. (2006). Mass Casualty Incident Plan: EMS VTRS. (2007). April 16, 2007: EMS Response. Presentation Mutual Aid Response Guide: Western Virginia EMS Council, to the Virginia Tech Review Panel. May 21, 2007, The Inn at Section 2.1.7, p. 2. Virginia Tech.

103

CHAPTER IX. EMS RESPONSE

Virginia Tech Rescue Squad EMS Command

Montgomery County Virginia Tech Rescue ESC–Police Squad EMS Command Post Operations Chief Liaison

Triage Officer Staging Officer Treatment Officer

Primary Staging Triage Teams Tertiary Triage (on campus)

Primary Secondary Triage Staging (Station 1)

Secondary Triage

Figure 13. Virginia Tech EMS ICS as Implemented in the Incident

Another issue concerned the staging of units ing them out of the building. As victims exited and personnel. EMS command correctly advised the building, some walked and some were car- dispatch that assignments and staging would be ried out and transported by police SUV’s and handled by EMS command.10 other mobile units to the safer EMS treatment areas. Triage – The VTPD arrived at Norris Hall at 9:45 a.m. At 9:50 a.m., the VTPD and Blacks- The triage by ERT medics inside the Norris Hall burg police emergency response teams (ERTs) classrooms had two specific goals: first, to iden- arrived at Norris Hall, each with a tactical tify the total number of victims who were alive medic. At 9:50 a.m., two ERT medics entered or dead; and second, to move ambulatory vic- Norris Hall where they were held for about 2 tims to a safe area where further triage and minutes inside the stairwell before being al- treatment could begin. The tactical medics em- lowed to proceed. At 9:52 a.m., the two medics, ployed the START triage system (Simple Triage one from VTRS and one from BVRS, began tri- and Rapid Treatment) to quickly assess a victim age. Medics initially triaged those victims and determine the overall incident status. The brought to the stairwells while police were mov- START triage is a “method whereby patients in an MCI are assessed and evaluated on the basis 10 Turner, K.N., & Davis, J. (2007). Public Safety Timeline for April 16, 2007. Unpublished Report. Montgomery County Department of Emergency Services, p. 6.

104 CHAPTER IX. EMS RESPONSE

EMS Command VT Rescue VT Lieutenant Liaison Officer Safety Officer Norris Hall Norris Hall Montgomery Co. Blacksburg Lt. Coord.

PIO Police

Operations Chief Logistics Chief Planning Chief Finance/Admin VT Rescue VT Rescue VT EMS Command VT University Staff VT Lieutenant VT Lieutenant

Staging Manager Base VT Rescue Blacksburg Rescue

Triage Group Treatment Group Transportation Norris Hall Norris Hall Group VT Captain VT Lieutenant VT Rescue

Major Treatment Morgue Unit Unit Medical Norris Hall Norris Hall Communicator Blacksburg Lt. Lieutenant

Initial Triage Unit Delayed Norris Hall Treatment Unit Tactical Medics Barger Street

Minor Treatment Unit VT Rescue Squad

Patient Dispatch Manager VT Rescue Squad EMT

Figure 14. Model ICS Based on the NIMS Guidelines

of the severity of injuries and assigned to treat- Immediate ment priorities.”11 Patients are classified in one of four categories (Figure 15). Colored tags are Delayed affixed to patients corresponding to these catego- Minor ries. Deceased12 In an incident of this nature, the triage team Figure 15. START Triage Patient Classifications must concentrate on the overall situation instead

12 11 WVEMS. (2006). Mass Casualty Incident Plan: EMS Critical Illness and Trauma Foundation, Inc. (2001). Mutual Aid Response Guide: Western Virginia EMS Council, START—Simple Triage and Rapid Treatment. Section 2.1.8, p. 2. http://www.citmit.org/start/default.htm

105

CHAPTER IX. EMS RESPONSE

of focusing on individual patient care. Patient A decision was quickly made to treat a 22-year- care is limited to quick interventions that will old male victim who exhibited a profuse femoral make the difference between life and death. The artery bleed by applying a commercial-brand medics systematically approached the initial tri- tourniquet (Figure 17) to control the bleeding. age, with one assessing victims in the odd- The patient was transported to MRH, where sur- numbered rooms on the second floor of Norris gical repair was performed and he survived. The Hall while the other assessed victims in the application of a tourniquet was likely a lifesaving even-numbered rooms. The medics were able to event. quickly identify those victims who were without vital signs and would likely not benefit from medical care. This initial triage by the two tactical medics accompanying the police was appropriate in identifying patient viability. The medics reported “a tough time with radio communications traffic” while triaging in Norris Hall.

The triage medics identified several patients who required immediate interventions to save their lives. Some victims with chest wounds were treated with an Asherman Chest Seal (Figure 16). It functions with a flutter valve to prevent air from entering the chest cavity during inhala- 14 Figure 17 Tourniquet tion and permits air to leave the chest cavity during exhalation. This is a noninvasive tech- At approximately 10:09 a.m., VTPD dispatch nique that can be applied quickly with low risk. notified EMS command that the “shooter was It was reported that a female victim with chest down” and that EMS crews could enter Norris wounds benefited by the immediate application Hall. EMS command assigned a lieutenant from of the seal. Since the scene was not yet secured VTRS to become the triage unit leader. Triage at this point to allow other EMS providers to continued inside and in front of Norris Hall. enter, the tactical medics quickly instructed Some critical patients at the Drillfield side and some police officers how to use the seal. others at the secondary triage (critical treatment unit) Old Turner Street side of Norris Hall were placed in ambulances and transported directly to hospitals. Noncritical patients were moved to a treatment area at Stanger and Barger Streets.

A BVRS officer and crew arrived at Norris Hall and began to retriage victims. Their reassess- ment confirmed that 31 persons were dead. Based on the evidence available, the decision not to attempt resuscitation on those originally triaged as dead was appropriate. No one appeared to have been mistriaged. A medical director (emergency physician) for a Virginia State Police 13 Figure 16. Asherman Chest Seal Division SWAT team responded with his team to the scene. He was primarily staged at Burress Hall and was available to care for wounded 13 ACS (2007). Asherman Chest Seal. 14 http://www.compassadvisors.biz Medgadget (2007). http://www.medgadget.com

106

CHAPTER IX. EMS RESPONSE

officers if needed. There were no reports of injuries to police officers.

Interviews of prehospital and hospital personnel revealed that triage ribbons or tags were not consistently used on victims. The standard triage tags were used on some patients but not on all. These triage tags, shown in Figure 18, are part of the Western Virginia EMS Trauma Triage Protocol and can assist with record keeping and patient follow-up.15 Not using the tags may have led to some confusion regarding patient identification and classification upon arrival at hospitals.

Treatment – Patients were moved to the treatment units based on START guidelines. The treatment group was divided into three units: a critical treatment unit, a delayed treatment unit and a minor treatment unit. The critical treatment unit was located at the Old Turner Street Side of Norris Hall where patients with immediate medical care needs (red tag) received care. Patients who were classified as less critical (yel- low tag) were moved to the delayed treatment unit at Stanger and Barger Streets. Patients with minor injuries, including walking wounded/ worried well (green tag) were moved to a minor treatment unit at VTRS (Figure 19). “Worried well” are those who may not present with injuries but with psychological or safety issues.

Patients were moved to the treatment units in various ways. Some critical patients were carried out of Norris Hall by police and EMS personnel. Others were moved via vehicles, while those less critical walked to the delayed treatment or minor treatment units. EMS command assigned leaders to each of the units. Figure 18. Virginia Triage Tag The weather was a significant factor with wind set up or maintained. Large vehicles such as gusts of up to 60 mph grounding all aeromedical trailers and mobile homes, often used for tempo- services and hampering the use of EMS equip- rary shelter, had difficulty responding as high ment. This included tents, shelters, and treat- winds made interstate driving increasingly haz- ment area identification flags that could not be ardous. The incident site was close to ongoing construction. High winds blew debris, increasing danger to patients and providers and impeding 15 WVEMS. (2006). Mass Casualty Incident Plan: EMS patient care. To protect the walking wounded/ Mutual Aid Response Guide: Western Virginia EMS Council., worried well from the environment, patients Section 22.3, p. 13.

107

CHAPTER IX. EMS RESPONSE

A/B: Staging Areas B C C: Command Post D D: Treatment Area (Delayed and Minor A Treatment Units)

E: Secondary Triage (Critical Treatment Unit)

Figure 19. Initial Location of Treatment Units

were moved to the minor treatment unit at the was among the first in line at Norris Hall. CRS, VTRS building. BVRS, CPTS, and Longshop–McCoy Rescue Squad transported critical patients to area hos- Twelve EMS patient care reports (PCRs) were pitals. CPTS ambulances from Giles, Radford, available for review. In some cases PCRs were and Blacksburg as well as some of their not completed, and in other cases not provided Roanoke-based units, including Life-Guard upon request. In multiple casualty incident flight and ground critical care crews, responded situations, EMS providers can use standard tri- in mass to the incident either at Norris Hall or age tags in place of the traditional PCR; how- by interfacility transport of critical victims. By ever, no triage tag records were provided, as 10:51 a.m., all patients from Norris Hall were noted earlier. either transported to a hospital, or moved to the Based on the PCRs available and the interviews delayed or minor treatment units. In addition to of EMS and hospital personnel, it appears that VTRS, 14 agencies responded to the incident the patient care rendered to Norris Hall victims with 27 ALS ambulances and more than 120 was appropriate. EMS personnel (Table 4). Some agencies delayed routine interfacility patient transports Transportation – EMS command appointed a or “back filled” covering neighboring communi- transportation group leader who assigned ties through preset mutual aid agreements. patients to ambulances and specific hospital Agency supervisors and administrators were destinations. Christiansburg Rescue Squad working effectively behind the scenes procuring (CRS) responded with BLS and ALS units and

108

CHAPTER IX. EMS RESPONSE

Table 4. EMS Response EMS units from several companies would trans- 16 14 Assisting Agencies port the deceased to Roanoke. In general, front- line EMS units are not used to transport the Montgomery County Emergency Services deceased. In this instance, however, the use of Coordinator EMS units was acceptable because emergency Blacksburg Volunteer Rescue Squad coverage was not neglected and the rescuers felt Christiansburg Rescue Squad that the sight of a refrigeration truck and Shawsville Rescue Squad funeral coaches on campus would be undesir- Longshop-McCoy Rescue Squad able. Carilion Patient Transportation Services Salem Rescue Squad The decedents were placed two to a unit for Giles Rescue Squad transport. A serious concern raised by EMS pro- Newport Rescue Squad viders was an order given by an unidentified Lifeline Ambulance Service police official that the decedents be transported Roanoke City Fire and Rescue to Roanoke under emergency conditions (lights Vinton First Aid Crew and sirens). Due to safety considerations, EMS Radford University EMS command modified this order. City of Radford EMS The police order to transport the deceased under the necessary resources and supporting the emergency conditions from Norris Hall to the response of their EMS crews. These agencies medical examiners office in Roanoke was in- demonstrated an exceptional working relation- appropriate for several reasons: ship, likely an outcome of interagency training • It is not within law enforcement’s scope and drills. of practice to order emergency transport False Alarm Responses – At 10:58 a.m., EMS (red lights and siren) of the deceased. command was notified of a reported third shoot- • There was no benefit to anyone by ing incident at the tennis court area on Wash- transporting under emergency condi- ington Street that proved to be a false alarm. At tions. 11:18 a.m., EMS command was notified of a • A 30-minute or longer drive to Roanoke, bomb threat at Norris and Holden Halls that during bad weather, with winds gusting also proved to be false. Due to safety concerns, above 60 mph, exposes EMS personnel EMS command ordered the staging area moved to unnecessary risks. from Barger St. to Perry St. • Transporting under emergency condi- Post-Incident Transport of the Deceased – tions increases the possibility of vehicle At 4:03 p.m., the medical examiner authorized crashes with risk to civilians. removal of the deceased from Norris Hall to the medical examiner’s office in Roanoke. Due to Critical Incident Stress Management – another rescue incident in the Blacksburg area, Although no physical injuries were reported, units were not available until 5:15 p.m. to begin psychological and stress- related issues can sub- transport of the deceased. Several options were sequently manifest in EMS providers. Local and considered including use of a refrigeration regional EMS providers participated in critical truck, funeral coaches, or EMS units. EMS incident stress management activities such as command, in consultation with the medical defusings and debriefings immediately post- examiner’s representative, determined that incident.

16 VTRS. (2007). April 16, 2007: EMS Response. Presenta- tion to the Virginia Tech Review Panel. May 21, 2007, The Inn at Virginia Tech.

109

CHAPTER IX. EMS RESPONSE

HOSPITAL RESPONSE Montgomery Regional Hospital – The MRH emergency department, a Level III trauma cen- atients from Virginia Tech were treated at ter, received 17 patients from the Virginia Tech Pfive area hospitals: incident; two from West Ambler Johnston and • Montgomery Regional Hospital 15 from Norris Hall. The patients from WAJ arrived at 7:51 and 7:55 a.m. The first patient • Carilion New River Valley Hospital from WAJ was the 22-year-old male with a gun- • Lewis–Gale Medical Center shot wound to the head who was DOA. No fur- • Carilion Roanoke Memorial Hospital ther attempts at resuscitation were made in the emergency department. • Carilion Roanoke Community Hospital The second patient from WAJ was the 18-year- Twenty-seven patients are known to have been old female who arrived in critical condition with treated by local emergency departments. Some a gunshot wound to the head. Upon arrival to others who were in Norris Hall may have been the emergency department, she was unable to treated at other hospitals, medical clinics, or speak and her level of consciousness was dete- doctor’s offices including their own primary care riorating. Airway control via endotracheal intu- providers; but there are no known accounts. bation was achieved using rapid sequence in- Overall, the local and regional hospitals quickly duction. At 8:30 a.m., she was transported by implemented their hospital ICS and mobilized ALS ambulance to Carilion Roanoke Memorial resources. Aggressive measures were taken to Hospital, the Level I trauma center for the postpone noncritical procedures, shift essential region. She died shortly after arrival at CRMH. personnel to critical areas, reinforce physician HOSPITAL PREPAREDNESS: At 9:45 a.m., MRH was staffing, and prepare for patient surge. Three notified of shots fired somewhere on the hospitals initiated their hospital-wide emer- Virginia Tech campus. Because they were un- gency plans. One hospital, a designated Level I sure of the number of shooters or whether the trauma center, did not feel that a full-scale, incident was confined to campus, MRH initiated hospital-wide implementation of their emer- a lockdown procedure. Since the killing of a hos- gency plan was necessary. pital guard at MRH in August 2006 (the Morva The most significant challenge early on was the incident mentioned in Chapter VII), there has lack of credible information about the number of been heightened awareness at MRH regarding patients each expected to receive. The emer- security procedures. At 10:00 a.m., information gency departments did not have a single official became available confirming multiple gunshot information source about patient flow. Likely victims. A “code green” (disaster code) was initi- explanations for this were (1) an emergency ated and the following actions were taken: operations center (EOC) was not opened at the • The hospital incident command center university, and (2) the Regional Hospital Coor- was opened and preassigned personnel dinating Center did not receive complete infor- reported to command. mation that it should have under the MCI plan.17 • The hospital facility was placed on a controlled access plan (strict lockdown). Preparedness, patient care/patient flow, and Only personnel with appropriate identi- patient outcomes were reviewed for each of the fication (other than patients) could enter receiving hospitals. the hospital and then only through one entrance. • All elective surgical procedures were 17 Personal communications, Morris Reece, Near Southwest postponed. Preparedness Alliance, June 15, 2007.

110

CHAPTER IX. EMS RESPONSE

• Day surgery patients with early surgery At 10:30 a.m. as the above actions were being times were sent home as soon as possi- taken, four more gunshot victims arrived via ble. EMS transport from Norris Hall. Between 10:45 • The emergency department was placed and 10:55 a.m., five additional patients arrived on divert for all EMS units except those via EMS. Command designated a public infor- arriving from the Norris Hall incident. mation officer and, by 11:00 a.m., a base had The emergency department was staffed been established where staff and counselors at full capacity. A rapid emergency could assist family and friends of patients. department discharge plan was insti- By 11:15 a.m., MRH was still unclear about how tuted. Stable patients were transferred many additional patients to expect. (They had a from the emergency department to the total of 12 by this time.) The operations chief outpatient surgery suite. instructed an emergency administrator to At 10:05 a.m., the first patient from Norris Hall respond to the Virginia Tech incident as an on- arrived via self-transport. This patient was scene liaison to determine how many more injured escaping from Norris Hall. MRH was patients would be transported to MRH. At 11:20 unable to determine the extent of the Norris a.m., the emergency department administrator Hall incident based on the history and minor reported to the Virginia Tech command center. injuries of this patient. The Regional Hospital MRH said that the face-to-face communications Coordinating Center (RHCC) was notified of the were helpful in determining how many addi- incident and asked to open. Although the RHCC tional patients to expect. had early notification of the incident, they too At 11:40 a.m., MRH received its last gunshot were not able to ascertain the extent of the cri- victim from the incident. By 11:51 a.m., its on- sis initially. scene liaison confirmed that all patients had At 10:14 and 10:15 a.m., two EMS-transported been transported. At 12:12 p.m., the EMS divert patients from Norris Hall arrived. It was evi- was lifted. At 13:04 and 13:10 p.m., however, dent that MRH might continue to receive two additional patients from the incident expected and unexpected patients. In prepara- arrived by private vehicle. At 13:35 p.m., the tion for the surge, MRH took the following addi- code green was lifted. tional actions: PATIENT CARE/PATIENT FLOW/PATIENT OUTCOMES: In • The Red Cross was alerted and the blood all, 15 patients arrived at MRH from the Norris supply reevaluated. Hall incident (Table 5) and were managed well. • Additional pharmaceutical supplies and An emergency department (ED) nurse/EMT-C a pharmacist were sent to the emer- was assigned to online medical direction and gency department. assisted with directing patients to other hospi- • A runner was assigned to assist with tals. EMS was instructed to transport four bringing additional materials to and patients to Carilion New River Valley Hospital from the emergency department and the and five patients to Lewis–Gale Medical Center. pharmacy. One patient from the Norris Hall incident was transferred from MRH to CRMH in Roanoke. • Disaster supply carts were moved to the hallways between the emergency The hospital representatives reported that there department and outpatient surgery.18 were problems with patient identification and tracking. As noted earlier:

18 Montgomery Regional Hospital. (2007). Montgomery Regional Hospital VT Incident Debriefing. April 23, 2007, p. 1.

111

CHAPTER IX. EMS RESPONSE

Table 5. Norris Hall Victims Treated by friends to gather. Since Virginia Tech had not Montgomery Regional Hospital yet opened an EOC or family assistance center, some victims’ family and friends chose to pro- Injuries Disposition ceed to the closest hospital. Several family GSW left hand – fractured OR and admission members and friends of victims came to MRH 4th finger even though their loved ones were never trans- GSW to right chest – Chest tube in OR and hemothorax admission ported there. GSW to right flank OR and admission to A psychological crisis counseling team was ICU assembled at MRH to provide services to vic- GSW left elbow, right thigh Admitted tims, their families and loved ones, and hospital 19 GSW x 2 to left leg OR and admission staff. Virginia State Police troopers were assigned to the hospital and were helpful in GSW right bicep Treated and discharged maintaining security. GSW right arm, grazed chest Admitted wall; abrasion to left hand At 11:30 a.m., a surgeon arrived from Lewis– GSW right lower extremity; OR and ICU Gale Hospital and was emergently credentialed laceration to femoral artery by the medical staff office. This is notable as GSW right side abdomen OR and ICU Lewis–Gale and MRH are not affiliated. and buttock GSW right bicep Treated and discharged Police departments often rely on hospitals to GSW to face/head Intubated and trans- help preserve evidence and maintain a chain of ferred to CRMH custody. MRH was able to gather evidence in Asthma attack precipitated Treated and discharged the emergency department and operating by running from building rooms, including bullets, clothing, and patient Tib/fib fracture due to jump- OR and admission nd identification. At 1:45 p.m., the Virginia State ing from a 2 -story window Police notified the hospital that all bullets and First-degree burns to chest Treated and discharged wall fragments were to be considered evidence. Back pain due to jumping Treated and discharged Internal communications issues included: from a 2nd-story window • The Nextel system was overwhelmed. • An EOC was not activated at Virginia Clinical directors were too busy to Tech. Establishing an EOC can enhance retrieve and respond to messages. communications and information flow to • Monitoring EMS radio communications hospitals. was difficult due to noise and chatter. • Triage tags were not used for all • There was deficient communications patients. This would have provided a between the university and MRH. discrete number for identifying and tracking each patient. • An EOC could have been helpful with communications. MRH activated its ICS as shown in Figure 20.

ACCOMMODATIONS FOR PATIENTS’ FAMILIES AND FRIENDS: MRH accommodated families and friends of patients they treated in their emergency department. MRH was challenged by the need to provide assistance to those who were unsure of the status or location of persons they 19 were trying to find (possibly victims). An open Heil, J. et al. (2007). Psychological Intervention with the space on the first floor was used for family and Virginia Tech Mass Casualty: Lessons Learned in the Hospi- tal Setting. Report to the Virginia Tech Review Panel.

112 CHAPTER IX. EMS RESPONSE

Incident Commander

Safety Officer PIO Marketing Director Safety/Security

Biological/Infectious Disease Legal Affairs Liaison Officer Medical/Technical Chemical Risk Management Radiological Medical Staff Dir. Emergency Mgmt. Specialist(s) Clinic Administration Pediatric Care Hospital Administration Medical Ethicist

Operations Chief Planning Chief Logistics Chief Finance Section Chief CNO CEO/Director Emergency Mgmt. CEO CFO

Resources Leader Services Branch Staging Manager Time Unit Leader Director Material Mg. Director Personnel Staging Team Personnel Tracking Communications Unit Vehicle Staging Team Material Tracking IT/IS Unit Equipment/Supply Staging Team Staff Food & Water Unit Procurement Unit Medication Staging Team Leader Situation Unit Leader Medical Care Director Support Branch ED Director Patient Tracking Director Compensation/Claims Bed Tracking Triage Unit Leader Employee Health & Well-Being Unit Unit Leader (ED RN/Surgeon) Family Care Unit Immediate Care Unit Leader Supply Unit (ED Charge Nurse) Documentation Unit Facilities Unit Delayed/Minor Unit Leader Leader Transportation Unit Cost Unit Leader (ED RN/NP) Labor Pool & Credentialing Unit

Infrastructure Branch Demobilization Unit Director Leader Power/Lighting Unit Water/Sewer Unit HVAC Unit Building/Grounds Damage Unit Medical Gases Unit Medical Devices Unit Environmental Services Unit Food Services Unit

Hazmat Branch Director

Detection and Monitoring Unit Spill Response Unit Victim Decontamination Unit Facility/Equipment Decontamination Unit

Security Branch Director Access Control Unit Crowd Control Unit Traffic Control Unit Search Unit Law Enforcement Interface Unit

Business Continuity Branch Director Information Technology Unit Service Continuity Unit Records Preservation Unit Business Function Relocation Unit

Figure 20. Montgomery Regional Hospital ICS

113

CHAPTER IX. EMS RESPONSE

Carilion New River Valley Hospital – friends and assisting others who were looking CNRVH is a Level III trauma center that for their loved ones. received four patients with moderate to severe Table 6. Norris Hall Victims Treated by Carilion New injuries. River Valley Hospital HOSPITAL PREPAREDNESS: CNRVH initially heard Injuries Disposition unofficial reports of the WAJ shootings. They heard nothing further for over 2 hours until GSW to face, pre-auricular Surgical cricothyro- area, bleeding from external tomy they received a call from MRH and also from an auditory canal, GCS of 7, poor Transferred to CRMH RN/medic who was on scene. They were called airway, anesthesiologist rec- by critical care ALS again later by MRH and advised that they ommended surgical airway ambulance would be receiving patients with “extremity GSW to flank and right arm, Immediately taken to injuries.” They were also notified that MRH was hypotensive OR; small bowel on EMS divert. injury/resection GSW to posterior thorax (exit To OR for surgical While waiting for patients to arrive, the emer- right medial upper arm), addi- repair of left femur gency department (ED) physician medical direc- tional GSWs to right buttock, fracture and left lateral thigh tor assumed responsibility for the “regular” ED patients while the on-duty physicians were pre- GSW to right lateral thigh, exit Admitted in stable thru right medial thigh, lodged condition and paring to treat patients from Norris Hall. The in left medial thigh observed; no vascular on-duty hospitalist (a physician who is hired by injuries the hospital to manage in-patient care needs) reported to the ED to make rapid decisions on Lewis–Gale Medical Center – LGMC, a community hospital, received five patients from the whether current patients would be admitted or Norris Hall shootings. The ICS structure used discharged. and their emergency response to the incident The hospital declared a “code green” and their were appropriate. Multiple casualty incidents EOC was opened at 11:50 a.m. The incident and use of the ICS were not new to LGMC. commander was a social worker who had special Their ICS had been recently tested after an out- training in hospital ICS. Security surveyed all break of food poisoning at a local college. patients with a metal detection wand because HOSPITAL PREPAREDNESS: LGMC first became they were unsure who may be victims or perpe- trators. A SWAT team from Pulaski County aware of the Norris Hall incident when a call was received requesting a medical examiner. responded to assist with security. They were unable to fulfill the request. At 11:10 PATIENT CARE/PATIENT FLOW/PATIENT OUTCOMES: a.m., they received a call from Montgomery Four patients were transported by EMS to Regional Hospital advising them of the incident. CNRVH, each having significant injuries. The LGMC immediately declared a “code aster,” hospital managed the patients well and could which is their disaster plan. have handled more. Table 6 lists the patient The code aster was announced throughout the injuries and dispositions. hospital, the EOC was opened, and the ICS was ACCOMMODATIONS FOR PATIENTS’ FAMILIES AND initiated. At 11:16 a.m., they were notified that FRIENDS: The hospital received many phone calls MRH was on EMS diversion. At 11:32 a.m., they concerning the whereabouts of Virginia Tech were notified that they were receiving their first shooting victims. Communications issues, par- patient suffering from a gunshot wound. In ticularly the lack of accurate information, were addition to preparing for the patients to arrive a big concern for the hospital; while providing at their own hospital, LGMC sent a surgeon to accommodations for patients’ families and MRH to assist with the surge of surgical patients there.

114

CHAPTER IX. EMS RESPONSE

PATIENT CARE/PATIENT FLOW/PATIENT OUTCOMES: trauma fellow physician, one radiologist, one EMS transported five patients from the Norris anesthesiologist, and a lab technician. Hall shootings to LGMC. Table 7 lists the patient injuries and dispositions. These patients In addition to the patient transfers, CRMH received a trauma patient from another inci- were well managed. dent. The ED had three other emergency physi- Table 7. Norris Hall Victims Treated by cians physically present with others on standby. Lewis–Gale Medical Center A neurosurgeon was also in the ED awaiting the arrival of transfer patients. Injuries Disposition GSW grazed shoulder and Patient taken to sur- CRMH’s concerns echoed those of the other hos- lodged in occipital area, did gery by ENT for pitals who received patients from the Virginia not enter the brain debridement Tech incident, including lack of clarity as to GSW in back of right arm, Patient admitted for expected patient surge and the need for better bullet not removed observation regional coordination. It was suggested that the GSW to face, bullet fragment Treated in ED and in hair, likely secondary to released RHCC Mobile Communications Unit could have shrapnel spray been dispatched to the scene. Jumped from Norris Hall, 2nd Admitted, taken to sur- PATIENT CARE/PATIENT FLOW/PATIENT OUTCOMES: floor, shattered tib/fib gery the next day CRMH appropriately triaged and managed well Jumped from Norris Hall, 2nd Treated in ED and floor, soft tissue injuries, released the patients they received. Adequate staffing neck and back sprain, re- and operating rooms were immediately avail- portedly was holding hands able. Table 8 lists WAJ and Norris Hall victims with another jumper treated at CRMH.

ACCOMMODATION FOR PATIENTS’ FAMILY AND FRIENDS: Table 8. WAJ and Norris Hall Victims Treated by No specific information was obtained from Carilion Roanoke Memorial Hospital LGMC about accommodations for patients’ families and friends. However, the hospital’s needs Injuries Disposition for accurate information while accommodating Transfer from MRH, se- Pronounced dead in ED patient families’ and friends and assisting vere head injury others in attempting to locate loved ones are Transfer from MRH, head Patient taken to OR for similar for all emergency departments in times and significant facial/jaw surgery, subsequently injuries, subsequent oro- transferred to a facility of mass casualty incidents. tracheal intubation closer to home Carilion Roanoke Memorial Hospital – This Transfer from CNRVH, Patient taken to OR for GSW to face, subsequent surgery Level I trauma facility located in Roanoke cricothyrotomy received three critical patients transferred from local hospitals. Two patients were transported Carilion Roanoke Community Hospital – from MRH (one from the WAJ incident and one CRCH is a community hospital located near and from the Norris Hall incident). The third patient associated with CRMH. CRCH treated a self- was transferred from CNRVH (from the Norris transported student who was injured by jump- Hall incident). ing from Norris Hall. Table 9 lists the injuries and disposition of this patient. HOSPITAL PREPAREDNESS: CRMH did not initiate its hospital-wide disaster plan since standard Table 9. Norris Hall Victim Treated by Carilion procedures allowed for effective incident man- Roanoke Community Hospital agement with the relatively small number of Injuries Disposition patients received. They did initiate a “gold Ankle contusion and sprain Treated and released trauma alert” that brings to the ED three secondary to jumping nurses, one trauma attending physician, one

115

CHAPTER IX. EMS RESPONSE

EMERGENCY MANAGEMENT The Virginia Department of Health regional planning approach aligns hospitals with health ulticasualty incidents often require coor- department planning regions. In collaboration Mdination among state, regional, and local with the 88 acute care hospitals in the Com- authorities. This section reviews the inter- monwealth, six hospital and healthcare plan- relationships of these authorities. ning regions were established, closely corre- Virginia Department of Health – In 2002, sponding with five health department planning the Virginia Department of Health (VDH) was regions. Each of the six hospital planning awarded funding from the Health Resources and regions has a designated Regional Hospital Services Administration (HRSA) National Coordinating Center (RHCC) located at or near Bioterrorism Hospital Preparedness Program the Level I trauma facility in the region as well (NBHPP) for enhancement of the health and as a regional hospital coordinator funded medical response to bioterrorism and other through the HRSA cooperative agreement. emergency events. As part of this process, VDH Near Southwest Preparedness Alliance – developed a contract with the Virginia Hospital The Near Southwest Preparedness Alliance and Healthcare Association (VHHA) to manage (NSPA), which covers the Virginia Tech area, the distribution of funds from the HRSA grant was developed under the auspices of the West- to state acute care hospitals and other medical ern Virginia EMS Council pursuant to a memo- facilities and to monitor compliance. A small randum of understanding between the Virginia percentage of the HRSA funds were used within Department of Health, the Virginia Hospital VDH to fund a hospital coordinator position, as and Healthcare Association, and the NSPA. well as to partially fund a deputy commissioner NSPA is organized to facilitate the development and other administrative positions. Substan- of a regional healthcare emergency response tially more than 85 percent of this HRSA grant system and to support the development of a funding was distributed to hospitals or used for statewide healthcare emergency response sys- program enhancement, including development tem. Regional hospital preparedness and coor- of a web-based hospital status monitoring sys- dination will foster collaborative planning tem, multidisciplinary training activities, efforts between the several medical care facili- behavioral health services, and poison control ties and local emergency response agencies in centers. the established geographically and demographi- 21 At the same time, VDH received separate fund- cally diverse region. ing from the Centers for Disease Control and The “Near Southwest” region is defined as: Prevention (CDC) for the enhancement of public health response to bioterrorism and other emer- • 4th Planning District (New River area), gency events. The position of VDH Deputy which includes Floyd, Giles, Montgom- Commissioner for Emergency Preparedness and ery, and Pulaski counties and the City of Response was created, with responsibility for Radford. both CDC and HRSA emergency preparedness • 5th Planning District (Roanoke and funds. The physician in this position reports Alleghany area), which includes directly to the state health commissioner, who 20 Alleghany, Botetourt, Craig, and Roa- serves as the state health officer for Virginia. noke counties as well as the cities of Covington, Roanoke, and Salem. • 11th Planning District, which includes 20 Kaplowitz, L, Gilbert, C. M., Hershey, J. H., and Reece, Amherst, Appomattox, Bedford, and M. D. (2007). Health and Medical Response to Shooting Episode at Virginia Tech, April, 2007: A Successful Approach. Unpublished Manuscript. Virginia Department of 21 Health, p. 2. Ibid.

116

CHAPTER IX. EMS RESPONSE

Campbell counties; the cities of • Establish and manage WebEOC23 and Lynchburg and Bedford; and the towns communications systems for the dura- of Altavista, Amherst, Appomattox, and tion of the incident. Brookneal. • Serve as the single point of contact and • 12th Planning District (Piedmont area), collaboration point for Virginia fire/EMS which includes Franklin, Henry, Patrick agencies for the purposes of hospital di- and Pittsylvania counties and the cities version management, movement of of Danville and Martinsville patients from an incident scene to receiving hospitals, and input/guidance The region covers 7,798 square miles and with respect to hospital capabilities, houses a population of 910,900. It has 24 local available services, and medical trans- governments and 16 hospitals. port decisions. Regional Hospital Coordinating Center – • Coordinate interhospital patient move- At the regional level, hospital emergency ment, transfers, and tracking response coordination during exercises and • Provide primary resource management actual events is provided by RHCCs that have to hospitals for: been established to facilitate emergency Personnel response, communication, and resource alloca- Equipment tion within and among each of the six hospital Supplies regions. These centers serve as the contact Pharmaceuticals. among healthcare facilities within the region and with RHCCs in other state regions. RHCCs • Coordinate regional expenditures for are also linked to the statewide response system reimbursement. through the hospital representative seat at the • Coordinate regional medical treatment VDH Emergency Coordinating Center (ECC) in and infection control protocols during Richmond, Virginia. The hospital seat at the the incident as needed. ECC serves as the contact between the health- • Coordinate Virginia hospital requests care provider system and the statewide emer- for the Strategic National Stockpile gency response system. It provides a communi- through the local jurisdiction EOC. cation link to the Virginia Emergency Opera- tions Center (VEOC).22 The RHCC complements but does not replace the relationships and coordinating channels The primary responsibilities of the RHCC established between individual healthcare include: facilities and their local emergency operations • Provide a single point of contact between centers and health department officials. The hospitals in the region and the VDH regional structure is intended to enhance the ECC. communication and coordination of specific issues related to the healthcare component of • Collect and disseminate initial event no- the emergency response system at both regional tification to hospitals and public safety and state levels. partners. • Collect and disseminate ongoing situ- At 10:05 a.m. on April 16, MRH requested that ational awareness updates and warn- the RHCC be activated. At 10:19 a.m., it was ings, including the management of the activated under a standby status and signed on current bed availability in hospitals. 23 WebEOC is a web-based information management system

22 that provides a single access point for the collection and Ibid. dissemination of emergency or event-related information

117

CHAPTER IX. EMS RESPONSE

to WebEOC.24 By 10:25 a.m., the Virginia De- those in Patrick, Floyd, and Giles counties. The partment of Health also had signed on to region’s total population (based on 1998 esti- WebEOC and monitored the event. At 10:40 mates) is 661,200. The region encompasses a.m., the RHCC requested that all hospitals 9,643 square miles. provide an update of bed status and diversion status for their facility. By 10:49 a.m., LGMC The region encompasses the counties of was the only hospital that signed on to WebEOC Alleghany, Botetourt, Craig, Floyd, Franklin, Giles, Henry, Montgomery, Patrick, Pittsylva- of the hospitals that had received patients from 26 the Norris Hall incident. Pulaski County Hospi- nia, Pulaski, and Roanoke (Figure 21). tal also signed on and provided their status. At 11:49 a.m. (1 hour later), MRH signed on followed by CNRVH at 12:33 p.m.25

The WebEOC boards (the RHCC Events Board and the Near Southwest Region Events Board) were used for a variety of communications between the RHCC, hospitals, and other state agencies. Some hospitals spent considerable time attempting to post information on the WebEOC boards. None of the EMS jurisdictions signed on to either of the boards. Not all hospitals or EMS agencies are confident in using Figure 21. Map Showing Counties in the WebEOC and require regular training drills for 27 familiarity. Western Virginia EMS Region

The hospitals and public safety agencies should Multicasualty Incidents – The Western have used the RHCC and WebEOC expedi- Virginia EMS Mass Casualty Incident Plan tiously to gain better control of the situation. (WVEMS MCI) plan defines a multiple casualty Considering the many rumors and unconfirmed incident as “an event resulting from man-made reports concerning patient surge, the incident or natural causes which results in illness and/or could have been better coordinated. If the RHCC injuries that exceed the emergency medical services capabilities of a hospital, locality, jurisdic- was kept informed as per the MCI plan, it could 28 have acted as the one official voice for information and/or region.” Online medical direction is tion concerning patient status and hospital the responsibility of the MCI Medical Control, availability. defined as: That medical facility, designated by the Western Virginia EMS Mass Casualty Inci- hospital community, which provides remote dent Plan – The Western Virginia EMS region overall medical direction of the MCI or encompasses the 7 cities and 12 counties of evacuation scene according to predeter- Virginia Planning Districts 4, 5, and 12. The mined guidelines for the distribution of 29 region extends from the West Virginia border to patients throughout the community. the north and to the North Carolina border to the south. The region encompasses the urban and suburban areas of Roanoke and Danville, as 26 WVEMS. (2006). Trauma Triage Plan. Western Virginia well as many rural and remote areas such as EMS Council, Appendix E. 27 Ibid. 24 28 Baker, B. (2007). VA Tech 4-16-2007: RHCC Events WVEMS. (2006). Mass Casualty Incident Plan: EMS Board, p. 1. Mutual Aid Response Guide: Western Virginia EMS Council, 25 Section 2.1.1, p. 1. Baker, B. (2007). April 16, 2007: Near Southwest Region 29 Events Board, p. 1. Ibid., Section 2.1.4, p. 1.

118

CHAPTER IX. EMS RESPONSE

Access to online physician medical direction were unable to determine the appropri- should be available. In MCI situations, modern ate level of preparation. EMS systems rely more on standing orders and • In several instances, on-scene providers protocols and less on online medical direction. called hospitals or other resources Therefore, it may be more logical to have the directly instead of through the ICS. This RHCC coordinate these efforts, including patch- included relaying incorrect information ing in providers to online physician medical to hospitals. direction as needed. • Cell phones and blackberries worked The MCI plan identifies three levels of incidents intermittently and could not be relied based on the initial EMS assessment using the upon. Officials did not have time to Virginia START Triage System: return or retrieve messages left on cell phones. A mobile cell phone emergency

• Level 1 – Multiple-casualty situation operating system was not immediately resulting in less than 10 surviving vic- available to EMS providers. tims. • Level 2 – Multiple casualty situation Interviews with EMS and hospital personnel resulting in 10 to 25 surviving victims. reiterated a well-known fact: face-to-face communications, when practical, is the preferred Level 3 – Mass casualty situation result- • method. ing in more than 25 surviving victims.30 From a technological standpoint, the NIMS The Virginia Tech incident clearly fits into the requirement for interoperability is critical. Local definition of a Level 3 MCI, since at least 27 communities must settle historical issues and patients were treated in local emergency move forward toward an efficient communica- departments. tions system.

Frustrating communications issues and barriers Lack of a common communications system occurred during the incident. Every service between on-scene agencies creates confusion operated on different radio frequencies making and could have caused major safety issues for dispatch, interagency, and medical communica- responders. Each jurisdiction having its own tions difficult. These issues included both on- frequencies, radio types, dispatch centers, and scene and in-hospital situations that could be procedures is a sobering example of the lack of avoided. Specific communications challenges economies of scale for emergency services. Local included the following: political entities must get past their inability to • The radios used by responding agencies reach consensus and assure interoperability of consisted of VHF, UHF, and HEAR fre- their communications systems. In this case, the quencies. This led to on-scene communi- most reasonable and prudent action probably cations difficulties and the inability for would be to expand the Montgomery County EMS command or Virginia Tech dis- Communications System to handle all public patch to assure that all units were safety communications within the county. Coop- aware of important information. eration, consensus building, and the provision of adequate finances are required by emergency • Communications between the scene and service leaders and governmental entities. Fail- the hospitals were too infrequent. Hos- ure to accomplish this goal will leave the region pitals were unable to understand exactly vulnerable to a similar situation in the future what was going on at the scene. They with potentially tragic results.

Unified Command – There is little evidence 30 Ibid., Section 7, p. 4. that there was a unified command structure at

119

CHAPTER IX. EMS RESPONSE

the Virginia Tech incident. Command posts the BPD, a university official, a VT EMS officer, were established for EMS and law enforcement a BVRS EMS officer, the FBI special agent-in- at the Norris Hall scene and for law enforce- charge, the state police superintendent, and the ment at another location. Separate command ranking elected official for the City of Blacks- structures are traditional for public safety agen- burg. The operations section chief would have cies. The 9/11 attack in New York City exempli- received operational guidelines from the unified fied the need for public safety agencies to step command post and assured their implementa- back and reconsider these traditions. At Norris tion. Hall, a unified command structure could have The unified command team would be in direct led to less confusion, better use of resources, communications with the EOC and policymak- better direction of personnel, and a safer working group. Command and general staff members ing environment. Figure 22 depicts a proposed would have communicated with their counter- model unified command structure that could parts in the EOC. The policymaking group have been utilized. would have transmitted their requests to the The unified command post would be staffed by EOC and the unified command post. those having statutory authority. During the Virginia Tech incident, those personnel would likely have been the police chiefs for VTPD and

Unified Command*

Liaison Officer Safety Officer Montgomery County EMS or Fire Emergency Coord.

PIO Joint Information Center

Operations Planning Logistics Finance/ Section Chief Section Chief Section Chief Administration Virginia Tech or VT Police or VTRS Virginia Tech EMS Virginia Tech Univ. Blacksburg Police

Law Deputy Planning EMS Enforcement Section Chief Branch Branch FBI or ATF Assistant Special Agent In Charge (ASAIC) *For this incident, law enforcement would have been the lead agency. The unified command post would be staffed by those having statutory authority. During the Virginia Tech Incident, those personnel would likely have been the police chiefs for the VTPD and BPD, a university official, a VT EMS officer, the FBI special agent-in-charge, the Virginia State Police superintendent, and the ranking elected official for the City of Blacksburg.

Figure 22. Proposed Model Unified Command Structure for an April 16-Like Incident

120 CHAPTER IX. EMS RESPONSE

Emergency Operations Center – The lack of The application of a tourniquet to control a an EOC activated quickly as the incident un- severe femoral artery bleed was likely a life- folded led to much of the confusion experienced saving event. by hospitals and other resources within the Patients were correctly triaged and transported community. An EOC should have been activated at Virginia Tech. The EOC is usually located at to appropriate medical facilities. a pre-designated site that can be quickly acti- The incident was managed in a safe manner, vated. Its main goals are to support emergency with no rescuer injuries reported. responders and ensure the continuation of operations within the community. The EOC Local hospitals were ready for the patient surge does not become the incident commander but and employed their NIMS ICS plans and man- instead concentrates on assuring that necessary aged patients well. resources are available. All of the patients who were alive after the A policy-making group would function within Norris Hall shooting survived through discharge the EOC. Virginia Tech had assembled a policy from the hospitals. making group that functioned during the inci- Quick assessment by a hospitalist of emergency dent. department patients waiting for disposition Another responsibility of the EOC is the estab- helped with preparedness and patient flow at lishment of a joint information center (JIC) that one hospital. acts as the official voice for the situation at The overall EMS response was excellent, and hand. The JIC would coordinate the release of the lives of many were saved. all public information and the flow of information concerning the deceased, the survivors, EMS agencies demonstrated an exceptional locations of the sick and injured, and informa- working relationship, likely an outcome of tion for families of those displaced. By not im- interagency training and drills. mediately activating an EOC, hospitals or the RHCC did not receive appropriate or timely Areas for Improvement information and intelligence. There was also a All EMS units were initially dispatched by the delay in coordinating services for families and Montgomery County Communications Center to friends of victims who needed to be identified or respond to the scene; this was contrary to the located. Although Virginia Tech eventually set request. up a family assistance center, it was not done immediately. There was a 4-minute delay between VTRS monitoring the incident (9:42 a.m.) on the police KEY FINDINGS radio and its being dispatched by police (9:46 a.m.). Positive Lessons Virginia Tech police and the Montgomery The EMS responses to the West Ambler Johns- County Communications Center issued separate ton residence hall and Norris Hall occurred in a dispatches. This can lead to confusion in an timely manner. EMS response.

Initial triage by the two tactical medics accom- BVRS was initially unaware that VTRS had panying the police was appropriate in identify- already set up an EMS command post. This ing patient viability. could have caused a duplication of efforts and further organizational challenges. Participants interviewed noted that once a BVRS officer reported to the EMS command post, communi-

121

CHAPTER IX. EMS RESPONSE

cations between EMS providers on the scene National Incident Management System improved. Incident Command System model. For this incident, law enforcement would have been the Because BVRS and VTRS are on separate pri- lead agency. mary radio frequencies, BVRS reportedly did not know where to stage their units. In addition, IX-3 Emergency personnel should use the BVRS units were reportedly unaware of when National Incident Management System the police cleared the building for entry. procedures for nomenclature, resource typ- ing and utilization, communications, Standard triage tags were used on some interoperability, and unified command. patients but not on all. The tags are part of the Western Virginia EMS Trauma Triage Protocol. IX-4 An emergency operations center must Their use could have assisted the hospitals with be activated early during a mass casualty patient tracking and record management. Some incident. patients were identified by room number in the emergency department and their records IX-5 Regional disaster drills should be held on an annual basis. The drills should became difficult to track. include hospitals, the Regional Hospital Coordi- The police order to transport the deceased under nating Center, all appropriate public safety and emergency conditions from Norris Hall to the state agencies, and the medical examiner’s medical examiners office in Roanoke was office. They should be followed by a formal post- inappropriate. incident evaluation.

The lack of a local EOC and fully functioning IX-6 To improve multi-casualty incident RHCC may lead to communications and opera- management, the Western Virginia Emer- tional issues such as hospital liaisons being sent gency Medical Services Council should to the scene. If each hospital sent a liaison to review/revise the Multi-Casualty Incident the scene, the command post would have been Medical Control and the Regional Hospital overcrowded. Coordinating Center functions.

A unified command post should have been IX-7 Triage tags, patient care reports, or established and operated based on the NIMS standardized Incident Command System ICS model. forms must be completed accurately and retained after a multi-casualty incident. Failure to open an EOC immediately led to They are instrumental in evaluating each com- communications and coordination issues during ponent of a multi-casualty incident. the incident. IX-8 Hospitalists, when available, should Communications issues and barriers appeared assist with emergency department patient to be frustrating during the incident. dispositions in preparing for a multi- casualty incident patient surge. RECOMMENDATIONS IX-9 Under no circumstances should the IX-1 Montgomery County, VA should deceased be transported under emergency develop a countywide emergency medical conditions. It benefits no one and increases the services, fire, and law enforcement commu- likelihood of hurting others. nications center to address the issues of interoperability and economies of scale. IX-10 Critical incident stress management and psychological services should continue IX-2 A unified command post should be to be available to EMS providers as needed. established and operated based on the

122 Chapter X OFFICE OF THE CHIEF MEDICAL EXAMINER

On April 16, 2007, after the gunfire ceased on LEGAL MANDATES AND STANDARDS the Virginia Tech campus and the living had OF CARE been triaged, treated, and transported, the sad he Office of the Chief Medical Examiner job of identifying the deceased and conducting incorporates a statewide system with head- autopsies began. Since these were deaths asso- T quarters in Richmond and regional offices in ciated with a crime, autopsies were legally Fairfax, Norfolk, and Roanoke. Commonwealth required. The Office of the Chief Medical Exam- law requires the OCME to be notified and to iner (OCME) had to scientifically identify each 1 investigate deaths from violence. victim and conduct autopsies to determine with specificity the manner and cause of death. Au- Autopsies are used to collect and document evi- topsy reports help link the victim to the perpe- dence to link the accused with the victim of the trator and to a particular weapon. The OCME crime. In the Virginia Tech cases, this was bal- also has a role in providing information to vic- listic evidence—bullets and fragments of bullets. tims’ families. The autopsies provided scientific evidence on the types and numbers of bullets that caused To assess how these responsibilities were met, the fatal injuries. the panel interviewed: The OCME also must ensure that there is com- • The parents and family members of the plete, accurate identification of the human deceased victims remains presented for examination. When there • Dr. Marcella F. Fierro, Chief Medical are multiple fatalities, the possibility exists that Examiner and her staff there could be a misidentification, which would • Colonel Steven Flaherty, Superinten- result in the release of the wrong body to at dent of Virginia State Police least two families. Though a rare occurrence, there are examples of this type of error in recent • Mandie Patterson, Chief of the Victim history. The National Association of Medical Service Section, Virginia Department of Examiners (NAME) has adopted Forensic Criminal Justice Services Autopsy Performance Standards, which are con- • Jill Roark, Terrorism and Special Juris- sidered minimal consensus standards. The most diction, Victim Assistance Coordinator, recent version was approved in October 2006. Federal Bureau of Investigation Dr. Fierro is a member of the standards commit- • Mary Ware, Director of the Criminal tee of NAME. Injuries Compensation Fund The NAME standards require several proce- • Numerous victim service providers. dures to be performed if human remains are presented that are unidentified. A major issue The panel also reviewed the report issued by the with some of the families of those who were OCME on areas for improvement, lessons murdered, however, was that they felt they were learned, and recommendations. capable of identifying the body of their family member; in other words, from their viewpoint, the remains were not unidentifiable.

1 Sec. 32.1-283 Investigations of deaths. Section A, Code 1950

123

CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER

Family members of homicide victims are gener- deceased victims have a wide range of needs and ally unaware that the medical examiner is reactions to the sudden and untimely death of required to complete a thorough, scientific their loved ones. Consequently, the individuals investigation in order to identify a body, deter- who deliver the death notifications and the mine the cause of death, and collect evidence. manner in which they carry out this duty factor For the family members of victims, the experi- significantly in the trauma experienced by the ence is focused on immediacy. Is my loved one family. Death notifications must be delivered dead? When can I see my loved one? As hap- with accuracy, sensitivity, and respect for the pened at Virginia Tech, a difference in perspec- deceased and their families. Ideally, death noti- tives can cause deep hurt and misunderstand- fication should be delivered in private, in per- ing. A separate matter in some of the cases was son, and in keeping with a specific protocol whether it was advisable for a family to view adopted from one of the effective models. the remains. EVENTS The Virginia Tech incident presented the potential for misidentification. Bodies were presented Monday, April 16 – The closest OCME office to with either inconsistent identification or none at Virginia Tech is located in Roanoke. All remains all. This is not uncommon in mass fatality from the western part of the commonwealth scenes due to the amount of confusion that gen- that require an autopsy are taken there. In erally exists. In order to prevent misidentifica- addition to their full-time employees, the OCME tion, medical examiners have established a rig- has part-time and per-diem investigators to help orous set of practices based on national stan- conduct death investigations and refer cases to dards to ensure that identification is irrefutable. the regional offices. The Virginia OCME followed these standards as The first news about the Virginia Tech shoot- well as Commonwealth law in identifying the ings came to the OCME from the Blacksburg deceased. Police Department at 7:30 a.m. A police evi- DEATH NOTIFICATION dence technician there, who also is a per-diem employee for the ME, called to say he would not he death notification process is the opening be able to attend a scheduled postmortem exam Tportal to the long road of painful experi- (autopsy) because there had been a shooting at ences and varying reactions that follow in the the Virginia Tech campus. At this time, six wake of the life-altering news that a loved one cases were awaiting examination in the western has met with death due to homicide. This news regional office, an average caseload. that someone intentionally murdered a family By 11:30 a.m., another per-diem medical exam- member is the critical point of trauma and often iner, who was a member of a local rescue squad, inflicts its own wounds to the body, mind, and notified the regional OCME office of a multiple spirit of the survivors. From a psychological and fatality incident at Norris Hall with upwards of mental health perspective, trauma is an emo- 50 victims. It was at this time that one of the tional wounding that affects the will to live and decedents from West Ambler Johnston (WAJ) one’s beliefs, assumptions, and values. residence hall was transported to Carillion A homicide affects victims’ families differently Roanoke Memorial Hospital. The western office than other crimes due to its high-profile nature, notified the central office in Richmond that intent, and other factors. The act of informing additional assistance would be needed to handle family members of a homicidal death requires a the surge in caseload. responsible, well-trained, and sensitive individ- At 1:30 p.m., representatives from the Roanoke ual who can manage to cope with this mutually office arrived on campus and attended an inci- traumatizing experience. Family members of dent management team meeting with the public

124

CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER

safety agencies that had responded. OCME rep- • All victims were to be forensically resentatives attended the operations section identified prior to release. briefing. The activities in Norris Hall were • A second-shooter theory was still under organized by areas (classrooms and a stairway). consideration by law enforcement. As Investigation teams of law enforcement and such, all ballistic evidence had to be col- OCME employees were assigned specific tasks. lected and documented. The distribution The OCME requested resources from the north- of gunshot wounds was: ern regional office in Fairfax and the central – One victim with nine office in Richmond. They, along with Dr. Fierro, – One victim with seven departed for Blacksburg by 3:00 p.m. The west- – Five victims with six ern office had two vacancies in forensic patholo- – One victim with five gist positions, so additional staff clearly was – Five victims with four needed. The remainder of the victims had three or fewer The first autopsy, that of one of the dormitory gunshot wounds. The complexity of tracking victims, began at 3:15 p.m. No autopsy could bullet trajectories and retrieving fragments begin until after the crime scene had been thor- would be especially time consuming for the mul- oughly documented and investigated. As each tiple wounds. decedent was transported from campus, the It was decided to use fingerprints as the pri- Roanoke regional office was notified so that a mary identification method and dental records case number could be assigned. as the secondary. The reasons for this decision By 5:00 p.m., the first victim from Norris Hall were: had been transported to the Roanoke office. • Fingerprints were able to be taken from Volunteer rescue squads were transporting the all of the victims. victims from campus to the regional office, a 45- • Foreign students had prints on file with minute trip. Customs and Border Protection. At 6:30 p.m., Dr. Fierro and additional staff • There was an abundance of latent prints from Richmond arrived and met with represen- on personal effects in dorm rooms and tatives from state police and the Departments of apartments and on personal effects Health and Emergency Management. The recovered on site. methods for identification were discussed, as was the process of documenting personal effects. • The Department of Forensic Services The last victim was removed from Norris Hall had adequate staff available to assist in the collection and comparison of the fin- and transported to Roanoke by 8:45 p.m. By 11:30 p.m., the first autopsy was completed; gerprints. (The police reported that identification made, next of kin notified, and the nearly 100 law enforcement officers from local, state, and federal agencies volun- remains released to a funeral home. teered or were assigned to assist in Tuesday, April 17 – In the early morning gathering prints and other identifica- hours of the first day after the shooting, addition.) tional pathologists departed the Tidewater and The alternative method for identification, dental central regional offices for Roanoke. A staff examination, required the name of the dece- meeting was held at 7:00 a.m. to formulate the dent’s dentist to obtain dental records, and OCME portion of the incident action plan (IAP). families were asked to provide the contact Key points addressed for the morgue operations information in case that method was needed. sections included:

125

CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER

DNA was excluded as a means of identification and included in the file. Some state officials, because the collection and processing of samples seeing the VIP acronym, mistakenly concluded would have taken weeks. that OCME had designated some victims as “VIPs” (very important persons), singling them In addition to being short-staffed by two vacan- out for special consideration. As it happened, cies and one injured pathologist, the ME’s office several embassies did contact state officials to had to respond to the concerns and demands of a demand preferential treatment for their nation- religious group that contested one of the autop- als who were among the victims. However, the sies. By the end of the first day of operations, all OCME did not provide any preferential or “VIP” of the deceased, 33, had been transported to the treatment. western region office. Thirteen postmortem examinations had been completed, two positive MEDIA MISINFORMATION: Radio station K-92 identifications had been made, and two families announced that the “coroner” would be releasing were notified and the remains released and all of the human remains on Wednesday, April picked up by next of kin or their representative. 18. The origin of this incorrect report is unknown. Wednesday, April 18 – On the second day of morgue operations, the process of forensic iden- TRACKING INFORMATION: At the request of the gov- tification continued. Procedures began at 7:45 ernor’s office, a spreadsheet that detailed spe- a.m. and continued until 8:00 p.m. cific information for each victim was developed. During this process, members of the governor’s At 10:00 a.m., the chief medical examiner gave a staff became concerned that the OCME had pri- press conference where she discussed forensic oritized some cases. But in fact, cases were han- procedures and the methods employed. dled without a specific plan or intent to priori- At 11:00 a.m., a representative from OCME tize them. assisted in collecting antemortem data from the Staff members from the OCME went to the Inn families who had gathered at the family assis- to assist in the operation of the FAC. The tance center at The Inn at Virginia Tech. Virginia State Police and the OCME established

“VIP” AND MISUNDERSTANDINGS: The primary form a process and team to notify families that their OCME uses to collect antemortem data is called loved ones had been positively identified. a Victim Identification Protocol (VIP) form. This IDENTIFICATION AND VIEWING: Family members of form, used by many medical examiners and fed- the deceased victims were anxious for the for- eral response teams, documents information on mal identification and release of the bodies to be hair and eye color, medical history (such as an completed. In response to the concerns of family appendectomy), and other distinguishing marks members regarding the length of time involved such as scars or tattoos. During a postmortem in the identification process, some state officials examination, the pathologist conducting the au- suggested that the families should be permitted topsy comments on his or her findings and each to go to the morgue and identify the bodies if identifier and that information is entered into a they so chose. Though this would seem reason- case file. Forensic odontology (dental) and able, it conflicts with current practice. fingerprint findings may also be incorporated. Both profiles can be compared electronically and A public information officer at the FAC possible matches or exclusions made. The explained to families who were assembled there pathologist then reviews these findings as part what the OCME policy was regarding visible of the scientific identification. presumptive identification. Then the public information officer (PIO) unfortunately asked As case files were compiled, a designation was the families for a “show of hands” of those who made as to whether a VIP form was available

126

CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER

wanted to view the remains of their loved ones remains released to next of kin. Morgue opera- in case that could be arranged. tions were conducted from 7:00 a.m. to 8:00 p.m.

Viewing and identifying remains is a significant Thursday, April 19 – The third day of morgue issue for victim survivors. Even though identifi- operations began at 7:00 a.m. It was determined cation of the body by family members is not that the OCME would work around the clock if always considered scientifically reliable, for necessary to complete the identification process various reasons, victim survivors often want to this day. By this time, all of the antemortem make that decision for themselves. At Virginia records had arrived at the regional office. Tech, families were frustrated with the lack of information from OCME and why it was taking The media had gathered in the area of the so long to identify and release the victims’ morgue and was covering the activities of representatives of the families—usually funeral remains. Medical examiners must be sensitive to the waiting family members’ need to be kept homes—as they arrived to pick up the remains. informed when there are delays and when they Roanoke County law enforcement provided security. can expect a status update All of the remaining decedents were identified The remains of persons killed in a crime become part of the evidence of the crime scene, and are and released by 6:00 p.m. The last case was a legally under the jurisdiction of the OCME until special challenge as there were no fingerprints on file and the victim did not have a dentist of released. The OCME can set the conditions it thinks are appropriate for the situation. The record. The latent prints in the home were not standard of care does not include presumptive readable. The identification was completed through a process of exclusion and definition of identification using visual means. The public information officer who asked for a show of unique physical properties using the Victim Identification Protocol process. The Virginia hands should not have done so. OCME had completed 33 postmortem exams When the protocol and policies of the OCME and correctly made 33 positive legal identifica- were explained to the families, some of the ten- tions within 3 working days. sion seemed to abate. The confusion and misun- derstanding surrounding these issues involved Figure 23 summarizes the statistics for 3-day morgue operations. The figure shows that not misinformation, late information, no information, and the high emotional stress of the event. all of the remains were picked up by the end of Had a public information officer with a back- morgue operations because Cho’s family did not pick up his remains for several days after the ground in the operations of the OCME been available or a representative from the OCME operations were shut down. been present to answer these concerns, the con- troversy regarding this issue could have been ISSUES reduced or eliminated. hree major issues surfaced during panel Tinterviews and the collection of after-action IDENTIFICATION PROGRESS: The progress of the first reports in regards to the actions of the Virginia day continued on the second day of morgue OCME; these were primarily issues presented operations. The second-shooter theory had been by some families of the deceased: discounted after it was determined forensically that Cho used two different weapons. By the • Some felt the autopsy process took too end of the second day, another 20 autopsies had long. been completed, which meant that all 33 victims • Some felt families should have been had received a postmortem exam. At this point, allowed to go to the morgue and visibly there were 22 total identifications and 22 identify their family members.

127

Autopsies 13 20

Ante Records 4 19 8

ID by Prints 2 19 4 Day One

Dental IDs 1 4 Day Two

Other IDs 1 1 1 Day Three

Total IDs 4 21 9

Released 2 21 10

Picked Up 2 10 19

0 5 10 15 20 25 30 35 40 Source: Virginia Office of the Medical Examiner'

Figure 23. Progress and Activity of the OCME Over the 3-Day Period April 17–19, 2007

• Many felt the process of notifying the Medical System (NDMS) program. That pro- families and providing assistance to the gram can deploy a disaster mortuary opera- families was disjointed, unorganized, tional response team (DMORT) composed of fo- and in several cases insensitive. rensic specialists who can assist medical examiners in the event of mass fatality incidents. The Speed – There is no nationally accepted time DMORT system has three portable morgue standard for the performance of an autopsy. The units. DMORT resources (in this case, just per- NAME standards mentioned earlier do not set sonnel) could have been requested and probably time standards. been in place within 24 hours of mobilization.2 The average duration of the postmortem exams For example, a DMORT was used in the Station was just under 2 hours. Had the OCME office Nightclub fire in Rhode Island in February 2003 been fully staffed, it may have been able to per- to assist the Rhode Island medical examiner in form the identifications and examinations the identification of the victims of that fire. somewhat more rapidly. The OCME did have a Once antemortem information had been gath- disaster plan that it implemented upon notifica- ered, DMORT personnel could have worked a tion of the events. The plan called for staff from second shift and might have reduced the elapsed the regional and central offices to deploy to the time of morgue operations by 24 hours. Given regional office where the disaster occurred to the information regarding the performance of meet the surge in caseload, which was done.

The OCME did not call for federal assistance, 2 A member of TriData’s support staff to the panel is a which is available from the Department of member of a DMORT and provided first-hand information Health and Human Service’s National Disaster on its operation.

128

CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER

the family assistance center, which also was the The operative word in this method of iden- responsibility of OCME, this early collection tification is reliable [italics added]. Per- sonal recognition of visage or habitus, may or may not have occurred. The time delay under certain circumstances, is less reli- for identifications came from delays in gathering able than fingerprints, dental data, or antemortem information and then providing radiology. It (this method) relies on mem- that information to the OCME, a task outside ory and a rapid mental comparison of the control of the OCME. physical features under stressful conditions and often a damaged body.… Identification and Viewing – The second Another hazard in visual identification is issue was the insistence by the OCME to per- denial. The situation may be so stressful or form forensic identifications of the victims as the remains altered by age, injury, disease opposed to presumptive identifications. Forensic or changes in lifestyle that identification is identifications use methods such as fingerprint- denied even if later confirmed by finger- ing, dental records, DNA matches, or other sci- prints or dental examination.3 entific means for identification. Presumptive In Clinics in Laboratory Medicine, Victor Weedn identification includes photographs, driver’s writes: licenses, and visual recognition by family or friends. Visual recognition is among the least reliable forms of identification. Even brothers, Some of the families wanted to go to the sisters and mates have misidentified vic- regional office of the OCME to view the remains tims. …Family members may find it emotionally difficult and uncomfortable to care- and identify the victims. The OCME did not fully gaze at the dead body, particularly a permit this for several reasons. For one, the loved one. Identification requires a rapid regional office does not have an area large mental comparison under stressful condi- enough to display all the bodies for families to tions. The environment in which the identi- view each one to determine whether it is their fication is made and the appearance of the family member person at death are unnatural and strange….4 As noted earlier, the idea of families viewing Family Treatment – The third issue was the their loved one and making a legally binding treatment of the families of the decedents identification is not the current practice of the regarding official notification and support while OCME because it is not considered scientifically waiting for positive identification. Their treat- reliable. Nevertheless, it was emotionally ment was haphazard, inconsistent, and com- wrenching for families not to have a choice in pounded the pain and trauma of the event. this matter. Presumptive identification is acceptable in some communities under certain Victims of crime are afforded a number of conditions. OCME noted that several female rights, among them the right to be treated with victims had no personal effects such as a dignity and respect. The right of respect speaks driver’s license or student identity card when to victims being given honest and direct infor- they were transported to the hospital or morgue. mation free of any attempt to protect them from At the same time, some families told the medi- perceived emotional injury or their inability to cal examiner’s office about specific moles, scars, process information. Crime victims rights are or other distinguishing marks that were far protected by federal and state laws. Basic rights more reliable than a purse and could not be confused with another victim. 3 A textbook for students of forensic pathology Spitz and Fisher, Medicolegal Investigation of Death, 3rd edition, Edited by Werner U. Spitz. 1993, pages 77–78. discusses the identification of human remains. 4 Victor Weedn, “Postmortem Identification of Remains,” Regarding the topic of reliable visual identifica- Clinics in Laboratory Medicine, Volume 18, March 1998, tion: page 117.

129

CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER

for victim survivors generally include the right adequate. Many complaints were lodged by to be notified and heard, and to be informed. families regarding what they perceived as an insensitive attitude and manner of communica- In 1996, following several airline accidents, the tion from the medical examiner’s office. Some families of the victims felt the airline companies families also objected to the rigid application of and government officials did not address their the scientific identification process. Among the needs, desires, or expectations. In that year, complaints and questions relevant to the ME Congress passed the Aviation Disaster Family functions were the following: Assistance Act. This law holds airline companies and government officials, such as medical • Inadequate communication efforts (lack examiners and coroners, accountable to the of information). National Transportation Safety Board for com- • Lack of sensitivity to the emotions of passionate, considerate, and timely information survivors. regarding the disposition of their loved ones or Lack of a central point of contact for next of kin. • information for responders, victims, and The U.S. Department of Justice, through its family members. Office of Justice Programs, has an Office for • Lack of a security plan that resulted in Victims of Crime (OVC) that can provide an inability to distinguish personnel, support for victims of federal crimes such as responding service providers, and other terrorism. agents with authority to enter the FAC To this end, many medical examiners’ offices and surrounding areas. have developed plans for the establishment of • Confusion regarding the Victim Identifi- family assistance centers. A FAC serves several cation Profile form. purposes. First, it is the location where families • Confusion regarding the identification can receive timely, accurate, and compassionate process as to length and method used information from officials. Second, medical and its necessity. examiner’s office staff can collect vital antemortem information from families there to • Failure to provide adequate isolation for assist in the positive identification of the parents in receiving information. deceased. Third, it can be the location where • Location of the media relative to the private, compassionate notification of the posi- FAC; media management in general was tive identification of the deceased can be con- lacking. ducted with next of kin. • Issues surrounding the source and A FAC was established in Oklahoma City in responsibility for death notifications. April 1995 following the Murrah Building bomb- • Lack of personnel trained, skilled, and ing. Families were notified in private, before the prepared to assist victims upon receipt media was notified. This model for the compas- of death notification. sionate, accurate information exchange was • Concern that no one was addressing the 5 published by the federal OVC. needs of all family members, and awareness that some family members Although a FAC was established at The Inn at were having great difficulty in coping. Virginia Tech, reports received by the panel indicate that what was provided was not • No timely or consistent family briefings. • Confusion about who is responsible for 5 the death notifications and family OVC, “Providing Relief After a Mass Fatality, Role of the Medical Examiners Office and the Family Assistance Cen- assistance. ter,” Blakney, 2002

130

CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER

Some of these complaints are associated with Materials and Terrorism Consequence Man- the medical examiner’s office, but others are agement Plan,” part 14-D-2. not. In fact, no one individual agency or department of government is charged with the The OCME plan considers 12 or more fatalities in 1 day in one regional office to be the trigger responsibility of organizing and maintaining a fully operational family assistance center. This point for implementation of the emergency plan. is an oversight in federal and state policies. The plan calls for the establishment of both a family assistance center and a family victim Existing planning guidance, such as the National Response Plan, parcels out pieces of identification center. At this location, the OCME the FAC function to various lead agencies, but and law enforcement agencies would conduct interviews to gather antemortem information places no one agency in charge. The OCME is clearly identified as being responsible for fatal- and notify next of kin. The OCME, however, ity management, including death notifications; does not have sufficient personnel to perform this task, and its plan indicates as much (page also, the state plan calls for OCME to set up a family victim identification center within the 16). To their credit, the OCME has recruited a FAC. Who is supposed to run the FAC is not team of volunteers through the Virginia Funeral Directors Association to assist in the operation addressed. of a FAC. Funeral directors by training and dis- The university attempted to provide these ser- position have experience in interactions with vices. In the Virginia Tech Emergency Opera- bereaved families. This group is an ideal choice tions Plan, the Office of Student Programs is to provide assistance to the OCME. Unfortu- responsible to: nately, this team was not available for the Virginia Tech incident because the state Develop and maintain, in conjunction with the Schiffert Health Center, Cook Counsel- requires background checks and ID cards for ing Center, the University Registrar, and these teams and funding was not provided for Personnel Services, procedures for provid- them. ing mass care and sheltering for students, psychological and medical support services, What evolved by Wednesday, April 18, was an parental notification and other procedures uncoordinated system of providing family sup- 6 as necessary, port. It was too late and inadequate. A university the size of Virginia Tech must be prepared for more than emergencies of limited KEY FINDINGS size and scope. Universities need plans for Positive Lessons major operations. If the situation dictates the The part of the OCME disaster plan related to need for additional help from outside the uni- postmortem operations functioned as designed. versity, then all concerned must be prepared to The internal notification process as well as staff proceed in that direction. redeployments allowed the surge in caseload The university turned to the state for help on generated by the disaster to be handled appro- Wednesday, April 17. It should have done so priately as well as existing cases and other new earlier. The Commonwealth Emergency Opera- cases that were referred to the OCME from tions Plan in its “Emergency Support Function other events statewide. (ESF)” #8” addresses public health and fatality Thirty-three positive identifications were made issues. The Health Department is the lead in 3 days of intense morgue operations. agency for this ESF. The OCME mass fatality plan is found in Volume #4, “Hazardous The contention that the OCME was slow in completing the legally mandated tasks of inves- 6 “VA Tech Emergency Response Plan,” Appendix 10 to tigation is not valid. Functional Annex A, page 45.

131

CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER

Crime scene operations with law enforcement and misinformation, which caused additional were effective and expedient. stress to victims’ families.

Cooperation with the Department of No one was in charge of the family assistance Forensic Services for fingerprint and dental center operation. Confusion over that responsi- comparison was good. bility between state government and the university added to the problem. Under the current The OCME performed their technical duties state planning model, the Commonwealth’s well under the pressures of a high-profile event. Department of Social Services has part of the Areas for Improvement responsibility for family assistance centers. The university stepped in to establish the center and The public information side of the OCME was use the liaisons, but they were not knowledge- poor and not enough was done to bring outside able about how to manage such a delicate opera- help in quickly to cover this critical part of their tion. Moreover, the university itself was trau- duties. The OCME did not dedicate a person to matized. handle the inquiries and issues regarding the expectations of the families and other state offi- RECOMMENDATIONS cials. This failure resulted in the spread of misinformation, confusion for victim survivors, and he following recommendations reflect the frustrations for all concerned. Tresearch conducted by the panel, after- action reports from Commonwealth agencies, The inexperience of state officials charged with and other studies regarding fatality manage- managing a mass fatality event was evident. ment issues. This could be corrected if state officials include the OCME in disaster drills and exercises. X-1 The chief medical examiner should not be one of the staff performing the post- The process of notifying family members of the mortem exams in mass casualty events; the victims and the support needed for this popula- chief medical examiner should be manag- tion were ineffective and often insensitive. The ing the overall response. university and the OCME should have asked for outside assistance when faced with an event of X-2 The Office of the Chief Medical Exam- this size and scope. miner (OCME) should work along with law enforcement, Virginia Department of Training for identification personnel was inade- Criminal Justice Services( DCJS), chap- quate regarding acceptable scientific identifica- lains, Department of Homeland Security, tion methods. This includes FAC personnel; Vir- and other authorized entities in developing ginia funerals directors; behavioral health, law protocols and training to create a more enforcement, public health, and public informa- responsive family assistance center (FAC). tion officials; the Virginia Dental Association; and hospital staffs. X-3 The OCME and Virginia State Police in concert with FAC personnel should ensure Adequate training for PIOs on the methods and that family members of the deceased are operations of the OCME was lacking. This train- afforded prompt and sensitive notification ing had been given to two Health Department of the death of a family member when pos- public information officers prior to the shoot- sible and provide briefings regarding any ings. However, since neither was available, delays. information management in the hands of an inexperienced public information officer proved X-4 Training should be developed for FAC, disastrous. This in turn, allowed speculation law enforcement, OCME, medical and mental health professionals, and others

132

CHAPTER X. OFFICE OF THE CHIEF MEDICAL EXAMINER

regarding the impact of crime and appro- X-11 The Commonwealth should amend its priate intervention for victim survivors. Emergency Operations Plan to include an emergency support function for mass fatal- X-5 OCME and FAC personnel should ity operations and family assistance. The ensure that a media expert is available to new ESF should address roles and responsibili- manage media requests effectively and that ties of the state agencies. The topics of family victims are not inundated with intrusions assistance and notification are not adequately that may increase their stress. addressed in the National Response Plan (NRP) X-6 The Virginia Department of Criminal for the federal government and the state plan Justice Services should mandate training that mirrors the NRP also mirrors this weak- for law enforcement officers on death ness. Virginia has an opportunity to be a notifications. national leader by reforming their EOP to this effect. X-7 The OCME should participate in disaster or national security drills and exercises A FINAL WORD to plan and train for effects of a mass fatality situation on ME operations. The weaknesses and issues regarding the performance of the OCME and the family assis- X-8 The Virginia Department of Health tance process that came to light in the after- should continuously recruit board-certified math of the Virginia Tech homicides did not forensic pathologists and other specialty reveal new issues for this agency. In July 2003, positions to fill vacancies within the OCME. the Commonwealth published “Recommenda- Being understaffed is a liability for any agency tions for the Secure Commonwealth Panel.” Ap- and reduces its surge capability. pendix 1-3 of this report addressed mass fatality issues. Although the intent of the report was to X-9 The Virginia Department of Health assess the state of preparedness in Virginia for should have several public information terrorist attacks, many of the issues that arose officers trained and well versed in OCME following the Virginia Tech homicides were operations and in victims services. When identified in this report. Had the recommenda- needed, they should be made available to the tions in this report been implemented, many of OCME for the duration of the event. the problems cited above might have been X-10 Funding to train and credential vol- averted. unteer staff, such as the group from the Therefore, the panel also recommends that the Virginia Funeral Director’s Association, recommendations found in Appendices 1-3 of the should be made available in order to utilize Secure Commonwealth Panel from 2005 be their talents. Had this team been available, implemented. the family assistance center could have been more effectively organized.

133

Chapter XI IMMEDIATE AFTERMATH AND THE LONG ROAD TO HEALING

The people whose lives were directly affected n the hours, days, and weeks following Cho’s include: Icalculated assault on students and faculty at Virginia Tech, hundreds of individuals and doz- • Family members of the murdered vic- ens of agencies and organizations from Virginia tims, who are often called co-victims due Tech, local jurisdictions, state government, busi- to the tremendous impact of the crimes nesses, and private citizens mobilized to provide on their lives. assistance. Once again the nation witnessed the • Physically and emotionally wounded vic- sudden, unexpected horror of a large number of tims from Norris Hall and their family lives being intentionally destroyed in a fleeting members who, while grateful that they or moment. Only those caught up in the immediate their loved ones were spared death, face moments after the attacks can fully describe the injuries that may have a profound effect confusion, attempts to protect and save lives, and upon them for a lifetime. the heartbreaking struggle to recover the dead. • Witnesses and those within a physical Reeling from shock and outraged by the shoot- proximity to the event and their family ings, students and faculty who survived Norris members. Hall and law enforcement officers and emergency medical providers who arrived on the scene will • Law enforcement personnel who faced carry images with them that will be difficult to life-threatening conditions and were the deal with in the months and years ahead. first to respond to Norris Hall and among the first to respond to West Ambler Disaster response organizations including com- Johnston dormitory. They encountered a munity-based organizations, local, state and fed- scene few officers ever see. Their families eral agencies, and volunteers eager to help in are not sparred from the complicated any capacity flooded the campus. The media impact of the events. descended on the grounds of Virginia Tech with a • Emergency medical responders who large number of reporters and equipment, pursu- treated and transported the injured. ing anyone and everyone who was willing to talk Their family members also share in the in a quest for stories that they could broadcast complexity of reactions experienced by across the nation to feed the public’s interest in emergency medical responders. the shocking events. • Everyone from Virginia Tech who was The toll of April 16, 2007, assaults the senses: 32 part of the immediate response to the innocent victims of homicide, 26 physically two shooting incidents and the aftermath injured, and many others who carry deep emo- that followed. tional wounds. For each, there also are family • Mental health professionals. members and friends who were affected. Each of the 32 homicides represents an individual case • Funeral home personnel and hospital unto itself. The families of the deceased as well personnel, who, while accustomed to as each physically and emotionally wounded vic- traumatic events, are not necessarily tim have required support specific to their indi- spared the after-effects. vidual needs. Finding resolution, comfort, peace, • Volunteers and employees from sur- healing, and recovery is difficult to achieve and rounding jurisdictions and state agen- may take a lifetime for some. cies, and others who worked diligently to

135

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

provide support in the first hours and initial spontaneous responses helped to stabilize days. some of the impact of the devastation as it • The campus population of students, fac- unfolded. ulty, and staff and their families. Grief-stricken university leaders, faculty, staff, This chapter describes the major actions that and law enforcement worked together to monitor were taken in the aftermath of April 16... Many the rapidly changing situation and set up a loca- other spontaneous, informal activities took place tion where families could assemble. Some family as well, especially by students. For example, members arrived not knowing whether their members of the Hokie band went to the hospitals child, spouse, or sibling had been taken to a hos- and played for some injured students outside pital for treatment for their wounds, or to a their windows. The madrigal chorus from morgue. University officials designated The Inn Radford University sang at a memorial service at Virginia Tech as the main gathering place for for several students who had been killed. The families. private sector made donations and offered assistance. It is difficult to capture the true magni- ACTIONS BY VIRGINIA TECH tude of the heartfelt responses and the special he immediate tasks were to provide support kindnesses exhibited by thousands of people. Tto the families of Virginia Tech students and At the time of publication of this report, recovery particularly to the family members of the slain was only 4 months along in a process that will and injured. Countless responders including law continue much longer. The following sections dis- enforcement officers, concerned volunteers, gov- cuss the actions that key responders and entities ernment entities, community-based organiza- took in the immediate aftermath of the shootings tions, victim assistance providers, faculty, staff, and during the weeks that followed. and students worked diligently to lend assistance in this uncharted territory, the impact of a mass FIRST HOURS murder of this scale. Many aspects of the post- incident activities went well, especially consider- fter Cho committed suicide and the scene ing the circumstances; others were not well han- Awas finally cleared by the police to allow dled. EMS units to move in, the grim reports began to emerge. The numbers of dead and injured rose as The incident revealed certain inadequacies in each new report was issued. Parents, spouses, government emergency response plan guidelines faculty, students, and staff scrambled for infor- for family assistance at mass fatality incidents. mation that would confirm that their loved ones, Also, certain state assistance resources were not friends, or colleagues were safe. They attempted obligated quickly enough and arrived late. to contact the university, hospitals, local police Finally, the lack of an adequate university emer- departments, and media outlets, in an attempt to gency response plan to cover the operation of an obtain the latest information. onsite, post-emergency operations center (and most particularly a joint information center) and Chaos and confusion reigned throughout the a family assistance center hampered response campus in the immediate aftermath. Individuals efforts. and systems were caught unaware and reacted to the urgency of the moment and the enormity of A variety of formal and informal methods were the event. There was an outpouring of effort to used to assist surviving victims and families of help and to provide for the safety of everyone. deceased victims. Responders scrambled to offer solace to the University-Based Liaisons – The Division of despairing and to meet emergency needs for Student Affairs organized a group of family liai- medical care and comfort to the injured. These sons, individuals who were assigned to two or

136

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

more families for the purpose of providing direct with the aftermath of violent crime scenes and support to victim survivors. The liaison staff was were grappling with their own emotional comprised of individuals from the Division of responses to the deaths and injuries of the Student Affairs, the graduate school, and the students and faculty. Liaisons did not have Provost’s Office. They were tasked to track down adequate information on the network of services and provide information to families of those designed for victims of crime until at least 2 days killed and to victim survivors, to assist them later when most of the state’s victim assistance with the details of recovering personal belong- team arrived. ings and contacting funeral homes, and to act as In general, most families reported that their liai- an information link between families and the sons were wonderful and conscientious, and they university. Liaisons worked out the details on were grateful for the tremendous amount of time such matters as transportation, benefits from and effort put forth by them on their behalf. federal and state victim’s compensation funds (as that information became available), coordination State Victims Services and Compensation with the Red Cross, travel arrangements for out- Personnel – Assistance to survivor families and of-country relatives, and much more. They also families of the injured could have been far more helped arrange participation in commencement effective if executed from the beginning as a dual activities where deceased students received function between university-assigned liaisons posthumous degrees. and professional victim assistance providers working together to meet the ongoing needs of Interviews with victims’ families revealed that each family many of the liaisons were viewed as sensitive, knowledgeable, caring, and helpful. Originally Victim assistance programs throughout the set up as a temporary resource for the early days nation are supported by federal, state, and local and weeks following the shootings, the liaisons governments. Many victim assistance programs soon discovered that the overwhelming needs are community based and specific to domestic and expectations for their assistance would be violence and sexual assault crimes, while other ongoing. Many liaisons continued to help even as programs are system-based and operate out of the weeks stretched on, while others were not in police departments, prosecutor’s offices, the a position to continue on at such an intense level courts, and the department of corrections. These for an extended period of time. Still others were programs provide crisis intervention, counseling, not prepared to serve in the capacity of a liaison emotional support, help with court processes, and lacked training and skills needed to provide links to various resources, and financial assis- assistance to crime victims. tance to victims of crime. They represent a network of trained, skilled professionals accustomed There were a few reports of poor communication, to designing programs and strategies to meet the insensitivity, failure to follow-up, and specific needs of crime victims. Moreover, all misinformation, which added to the confusion states have a victim compensation program and frustration experienced by a number of charged with reimbursing crime victims for cer- families. Largely, these problems occurred tain out-of-pocket expenses resulting from crimi- because Liaisons were volunteers untrained in nal victimization. responding to victims in the aftermath of a major disaster. Nevertheless, they were willing and Patricia Snead, Emergency Planning Manager at available to fill an acute need while system based the Virginia Department of Social Services victim (DSS), alerted Mandie Patterson, Chief of the assistance providers awaited the required Commonwealth’s Victim Services Section (VSS) invitation before they were authorized to respond at the Department of Criminal Justice Services to Virginia Tech campus. The liaisons (DCJS), at 12:21 p.m. on April 16, and asked that themselves had little if any experience in dealing office to stand by for possible mobilization to

137

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

support the needs at Virginia Tech. At that expenses, funeral and burial costs, and a number point, it was unclear whether DCJS staff from of other out-of-pocket expenses associated with Richmond or local advocates would be needed to criminal victimization. At Virginia Tech, CICF staff a family assistance center and whether enabled the rapid provision of funds to cover fu- Virginia Tech would request assistance for these neral expenses, temporarily setting aside certain services per the state’s emergency management procedures until they could be processed at a procedures. According to those procedures, before later date. CICF staff and the team of victim ser- VSS staff can move forward, they must be vice providers orchestrated by DCJS arrived on authorized to do so from DSS. There was no fur- Wednesday morning and proceeded to help in ther instruction that day from DSS. various capacities.

The following day, April 17, the DCJS chief of The delay in the mobilization and arrival of the VSS sent a broadcast e-mail to the 106 victim victim service providers resulted in some fami- witness programs in Virginia to determine the lies working directly with the medical examiner availability of advocates with experience in regarding that office’s request for personal items working with victims of homicide. At 4:17 p.m. with fingerprints or DNA samples to help iden- that day, DSS sent a message to DCJS, VSS and tify the bodies. Though the university liaisons the victim advocates from local sister agencies were helping, a number of families did not have indicating that they were authorized to respond the benefit of a professional victim service pro- to the needs of victims on the campus. The team vider to support them in coping with the ME’s of victim service providers arrived on April 18, requests. Many families had scattered and begun 2 days after the massacre. Thus, even though the making arrangements with funeral homes, which Commonwealth’s emergency plan authorizes had a direct line to the ME’s office. Other non- immediate action, the process moved slowly—a governmental service providers—many without real problem given the substantial need for early identification or a security badge—appeared on intervention, crisis response, information and the scene without having been summoned to help in establishing the family assistance center. help. As a consequence, some families received According to Snead, time was lost while officials conflicting information about what the Red Cross from the state and the university worked would pay for, what the state would cover, and through the question of who was supposed to be what they would have to manage on their own. in charge of managing the emergency and its The victim assistance team comprised of the aftermath: the state university or the state gov- state’s two relevant agencies—DCJS and CICF— ernment. Reportedly, the university was guarded had difficulty locating and identifying victim and initially reluctant to accept help or relin- survivors. Victim Services and Crime Compensa- quish authority to the Commonwealth for man- tion staff became aware that the United Way aging resources and response. was fund-raising on campus and sought out Mary Ware, Director of the Department of Crimi- those individuals to ensure that there were no nal Injuries Compensation Fund (CICF), arrived conflicts or duplications of effort. The victim as- on Tuesday around midnight. Early on Wednes- sistance team provided assistance for family day morning, she began providing the services of members by informing them of their rights as her office and talked to two on-scene staff from crime victims and offering assistance in a num- the Montgomery County Victim Witness Pro- ber of areas to include help with making funeral gram. Kerry Owens, director of that program, arrangements, childcare in some instances, ar- told the panel, “You have never seen such pain, ranging for transportation, emotional support sorrow, and despair in one place, and you have and referral information. Unfortunately, when never seen so many people come together for a many of the family members returned home to common cause.” The CICF provides funds to help other states or other parts of Virginia, they were compensate victim survivors with medical not connected directly to available services in

138

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

their local jurisdictions. Because of the need to any materials, records, or items needed for con- respect privacy and confidentiality, victim assis- firmation of identification. tance providers in the victims’ hometowns had to A FAC also is supposed to serve as a safe haven, refrain from intruding and instead had to await a compassion center, and a private environment invitation or authorization by others to become created to allow victims and surviving family linked to the families. There was a gap in the members’ protection from any additional distress continuum of care as, in many cases, survivors brought about as a result of intrusive media. In returned home with little or no information re- addition to serving as an information exchange garding ongoing victim services in their jurisdic- mechanism, the FAC affords victims and family tions. To the extent the liaisons had sufficient member’s refreshments, access to telephones for information about victim’s assistance services to long-distance calls, and support from mental tell the families, they did. However, unless the health counselors and victims’ service providers. liaison or other responsible on-scene providers provided families and victims with specific in- Arriving media, unfortunately, were situated in formation regarding their local victim services a parking lot directly across from the inn. Fami- office, they did not know what services were lies had to traverse a labyrinth of cameras and available or how to access them. microphones to reach the front desk at the inn. The media were a constant presence because The Family Assistance Center – The Inn at they were stationed in the same area rather than Virginia Tech became the de facto information at a site farther away on Virginia Tech’s large center and gathering place where everyone con- campus. The impact of the media on victim sur- gregated to await news on the identification of vivors is enormous. In high-profile murder cases the wounded and deceased. It also was desig- the murderer instantaneously is linked to the nated as a family assistance center—a logical victims and together become household names. choice for families who needed lodging, informa- Some members of the press were appalled at the tion, and support. Accommodations at the inn tactics that some of their colleagues used to (rooms, food, and staff service) were well gather information on campus at the family received, and hotel staff offered special care to assistance center. the families who stayed there. However, the sheer magnitude of the immediate impact cou- There was little organization and almost no veri- pled with the failure to establish an organized, fiable information for many hours after the centralized point of information at the outset shooting ended. The operative phrase was “go to resulted in mass confusion and a communica- the inn” but once there, families struggled to tions nightmare that remained unabated know who was responsible for providing what throughout the week following the shootings. services and where to go for the latest news about identification of the dead victims. Some The official Virginia Tech FAC was set up in one unidentified people periodically asked families if of the ballrooms at Skelton Conference Center at they needed counseling. Those offers were pre- the Inn. Over the first 36 hours, 15 victim advo- mature in the midst of a crisis and information cates from several victim assistance programs was the most important thing that families arrived and formed a victim assistance team wanted at the time. comprised of seven staff from the Office of CICF and other service providers and counselors. Addi- Family members were terrified, anxious, and tionally, staff from the Office of the Chief Medi- frantic to learn what was happening. Who had cal Examiner (OCME) was assigned to supervise survived? Which hospital was caring for them? the family identification section (FIS) at the Where were the bodies of those who had perished FAC. The FIS, according to the OCME Fatality taken and how can one get there? There was no Plan “will receive inquiries on identification, identified focal point for information distribution prepare Victim Identification Profiles, and collect for family members or arriving support staff. For

139

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

decades, disaster plans have underscored the directors ideally accompany law enforcement importance of having a designated public during a death notification. Reports are that law information officer (PIO) who serves as the reli- enforcement, where involved, conducted sensitive able source of news during emergencies. The PIO and caring death notifications to family mem- serving at the FAC was inexperienced and over- bers. whelmed by the event. He was unable to ade- Virginia State Police officers, in some instances quately field inquires from victim survivors. Help with local law enforcement, personally carried from the state arrived later, but here again, the news no one wants to hear to victims’ homes repairing the damage caused by misinformation around Virginia late into the night of the 16th. or no information at all became all but impossi- Officers also coordinated with law enforcement ble. in other states who then notified the families in Guests at the inn, officials from state govern- those jurisdictions. Not all families, however, ment, and others reported a chaotic scene with were informed in that manner. One family no one apparently in charge. From time to time, learned their child was dead from a student. In small groups of families were pulled aside by law another case, a local clergy member took it upon enforcement officials or someone working in pub- himself to inform a family member that their lic information to hear the latest information, loved one was dead while they were on an eleva- leaving other families to wonder why they could tor at the Inn. The spouse of a murdered faculty not hear what was happening and what the member saw members of the press descend on information might mean for their own relative her home before his death had been confirmed. whose condition was in question. A number of The victims were known to faculty and friends victim families eventually gave up hope of learn- across campus. As a result, information circu- ing the status of their spouse, son, or daughter lated quickly through an informal network, and returned home. which allowed a few family members, who lived Without a formal public information center, ade- in the immediate area and who arrived quickly quately staffed, the ability to maintain a steady at the inn, to connect with those who were help- stream of updates, control rumors, and commu- ing to locate the missing. Families who lived out nicate messages to all the families at the same of the area had to rely on the telephone to obtain time was seriously hampered. Here is where information. Lines were busy and connections advance planning for major disasters provides were clogged. They were referred from one num- jurisdictions with a template and a fighting ber to another as they tried to track down infor- chance to appropriately manage the release of mation that would confirm or deny their worst information. fears.

The university did establish a 24-hour call center Until Friday, April 20, families reported that where volunteers from the university and staff they had to think of what questions to ask and from the Virginia Department of Emergency then try to locate the right person or office to Management responded to an enormous volume answer the question. The intensity of their pain of calls coming into the school. and confusion would have been diminished somewhat if they had received regular briefings Two of the most deeply disturbing situations with updates on the critical information sought were the dearth of information on the status and by all who were assembled at the inn. It would identification of Cho’s victims and the instances have helped if there had been a point person where protocol for death notifications was through whom questions were channeled. The breached. The authority and duty for this grim liaisons and the victim assistance team did the task falls usually to law enforcement, hospital best they could, but for the most part they were emergency room personnel, and medial examiner in the dark as well. offices. Victim advocates, clergy, or funeral

140

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

To make room for all the individuals who needed flexible options for completing the semester and to stay at the inn, many resource personnel like for grading. The college deans, the faculty, and Virginia State Police and others were housed in Student Affairs were helpful in advising students dormitories at nearby college campuses like and helping them complete the semester. Radford University. Academic suspensions and judicial cases were deferred. Counseling and Health Center Services – The university’s Cook Counseling Center quickly led Cranwell International Center provided compli- efforts to provide additional counseling resources mentary international telephone cards to stu- and provide expanded psychological assistance to dents who needed to contact their families students and others on campus. They extended abroad and assure them they were safe. Center their hours of operation and focused special staff called each Korean undergraduate and attention on individuals who lived at the West many Korean graduate students and, with the Ambler Johnston dormitory, surviving students, Asian American Student Union and Multi- who were in Norris Hall at the time of the inci- cultural Programs and Services, assured each dent, roommates of deceased students, and one of the university’s concern for their safety. classmates and faculty in the other classes where They especially addressed potential retaliation the victims were enrolled. The victims had par- and requests from the press. ticipated in various campus organizations, so Residence Life asked resident advisors to speak Cook Counseling reached out to them as well. personally with each resident on campus and Dozens of presentations on trauma, post-incident make sure they were aware of counseling ser- stress, and wellness were made to hundreds of vices as they grappled with lost friends or room- faculty, staff, and student groups. The center mates. Housing and Dining Services provided helped make referrals to other mental health complimentary on-campus meals for victims’ and medical support services. The center sent 50 families and friends at graduation. Several of the mental health professionals to the graduation victims were graduate students at Virginia Tech. ceremonies several weeks later, recognizing that The graduate school helped open the multipur- the commencement would be an exceptionally pose room in the Graduate Life Center as a place difficult time for many people. Resource informa- for graduate students to gather and receive tion on resilience and rebounding from trauma counseling services. They also aided graduate was developed and distributed, including posting assistants in continuing their teaching and on the Internet. research responsibilities. Schiffert Health Center at the university sent Hokies United is a student-driven volunteer medical personnel to the hospitals where injured effort that responds to local, national, and inter- victims were being treated to check on their well national tragedies. In addition to a candlelight being and reassure them of follow-up treatment vigil, this group organized several well-attended at Schiffert if needed. The medical personnel activities designed to bring the campus commu- included some psychological screening questions nity together. into their conversations with the injured students so that they could monitor the student’s Human Resources requested assistance from the psychological state as well. university’s employee assistance provider, which sent crisis counselors immediately. The counsel- Other University Assistance – The Services for ors worked with faculty and staff on issues of Students with Disabilities Office began investi- self-care, recovery, how to communicate the gating classroom accommodations that might be tragedy to their children, and other subjects. needed for injured students and planned for pos- After 4 weeks, more than 125 information ses- sible needs among students with psychological sions had been held and 800 individuals had disabilities. The Provost’s Office announced been individually counseled.

141

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

MEETINGS, VISITS, AND OTHER assistance and support they had received and for COMMUNICATIONS WITH FAMILIES the work of the panel. AND WITH THE INJURED Several families raised concerns about poor coor- resident Steger, Governor Kaine, and dination—what they saw as failings of the uni- PAttorney General McDonnell visited injured versity, of responders, of communicators, of vol- students in area hospitals to reassure them of unteers, of the panel and staff, and more. Some the university’s and the Commonwealth’s con- demanded financial restitution; most focused on cern for their recuperation. President Steger also relating what society had lost with those 32 lives, met with many families over the following who by all measures were outstanding individu- weeks. Governor Kaine held a private meeting als whose achievements and character were with families who were dealing with the death of making a difference in the world. The families their child, husband, or wife and another meet- asked the panel and the Commonwealth to find ing with injured students and their families. out what went wrong and change what needs to be changed so others might be spared this hor- On April 19 Governor Kaine appointed the ror. That has been the overriding concern of the Virginia Tech Review Panel to examine the facts governor and of the panel. surrounding April 16. After appointment, panel chairman Gerald Massengill sent a letter to all Family members of homicide victims of mass families of the deceased to express condolences fatalities tend to view their experiences and the and offer to meet with anyone who wished a pri- impact of the crime from the following perspec- vate audience with up to two members of the tives: panel. (As noted in Chapter I, FOIA rules require • The overwhelming event and the system that such meetings be public if more than two response to the scale of the event. Very members participate.) The letter also offered often, the victims become categorized as them the opportunity to speak at one of the four a group rather than as individuals (e.g., public meetings that were to be scheduled in dif- 9/11 and Oklahoma City victims). The ferent parts of the state. Several families took particular needs of each victim can be advantage of a special web site that was created overlooked as the public perceives them as a tool for collecting information and com- as a unit rather than as separate fami- ments. Others communicated their thoughts lies. Victims are attuned to whether they through letters. The chairman sent a similar let- received the information and care atten- ter to injured students. tion that they needed. Victim survivors Over the next several weeks, a number of fami- want to know what happened, how it lies communicated their desire to meet. Others happened, and why their loved was preferred their privacy, which of course was killed. They look for resources that can respected. Panel members and staff held at least adequately respond to their needs and 30 meetings (in individual and group sessions) answer their questions, though some with families of the murdered victims and with answers may never be found. injured students and their parents, and fielded • Death notifications have long-term more than 150 calls. The governor designated impact on victims. Survivors typically Carroll Ann Ellis as the panel’s special family remember the time, place, and manner in advocate. She spent many days initiating and which they first learned of the death of returning calls to provide information and to their loved ones. help families regarding their individual issues • Where is the justice? Victim survivors and concerns. Many with whom the panel met or look to the criminal justice system to talked with by phone noted appreciation for the hold the murderer accountable for the crime. Cho ended his life and denied the

142

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

criminal justice system and its partici- injury they already are experiencing. In these pants the justice that comes from a con- cases, accurate information in real time is viction and eventual sentencing. imperative if survivors are to develop a sense of trust in the very systems they now must count A homicide differs from other types of death on to explain what happened, and why it hap- because it— pened. When for a variety of reasons that does • Is intentional and violent. not occur, relatives of homicide victims can experience increased trauma. • Is sudden and unexpected. • Connects the innocent victim to the mur- Each family has its own particular way of proc- derer in a relationship that is disturbing essing the death of a loved one, because each life to family members of the dead victim. taken was unique. Several grievances, however, were shared widely among the victims’ families • Creates an aura of stigma that surviving as well as questions they wanted the panel’s family members often experience. investigation to address. Among the major con- • Is a criminal offense and as such is asso- cerns and questions were the following: ciated with the criminal justice system. • What are the facts and details of the first • It has the problematic overlap of symp- responder and university response to the toms created by the victim survivor’s first shooting, including the decision inability to move through the grief proc- process, timing, and wording of the first ess because of a preoccupation with the alert? trauma experience cause by a homicidal death. This completed grief reaction is • What were the assumptions regarding identified as traumatic grief. the relationship between the first two victims, and why were they made? • Is pursued by the media and is of interest to the public. • Did those assumptions affect the nature and timeliness of the subsequent first Meeting the overwhelming needs of the families alert? of homicide victims and fulfilling those expecta- • What are the facts and details of the first tions to a level each one finds acceptable is ex- responder and university response when tremely challenging when there is a mass mur- the shooting at Norris Hall began? der. So many people need the same information and services simultaneously. Systems are • With so many red flags flying about Cho severely tested because disasters cause the over a protracted period of time, how was breakdown of systems and create chaos. Without it that he was still living in the dorm and a well-defined plan, navigating through the af- allowed to continue as a student in good termath is an uphill struggle at best. Even when standing? Why were the dots not con- plans are in place, the quality and degree of nected? response to victims of disaster are often inconsis- • Was Cho’s family notified of any or all of tent. A small change in the initial conditions of a his interactions with campus police, the sensitive system can drastically affect the out- legal system, and the mental hospital? come. • Why was there no central point of contact All deaths generate feelings of anger, rage and or specific instructions for families of vic- resentment. In the case of a murder, and espe- tims at The Inn at Virginia Tech? cially when the shooter commits suicide, survi- • Why were identifications delayed when vors are denied their day in court and the oppor- wallet identifications, photos, and other tunity for the justice system to hold that person methods available would hasten the accountable. This adds insult to the terrible release of remains?

143

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

• Who was responsible for ensuring that CEREMONIES AND MEMORIAL the media was properly managed, and EVENTS who was supposed to be the authoritative source of information? eople seek ways to share their grief when tragic events occur. The university commu- • What is going to be done with the Hokie P nity came together in many ways, from small Fund and what about other crime com- prayer groups to formal ceremonies and candle- pensation funds? light vigils. Cassell Coliseum was the site of con- • What common sense practices regarding vocation on Tuesday, April 17. President George security and well being will be in place Bush, Governor Tim Kaine, University President before students return to campus? Charles Steger, noted author and Professor • What changes to policy and procedures Nikki Giovanni, and leaders from four major about warnings have been made at religions spoke to a worldwide television audi- Virginia Tech? ence and 35,000 people in attendance divided between the coliseum and Lane Stadium. Per- These and many other issues all have been ex- haps the most poignant event, however, was the amined by the panel and the results presented student-organized candlelight vigil later that throughout this report. evening. One by one, thousands of candles were With regard to the individuals who Cho lit in quiet testimony of the shared mourning injured— physically and emotionally—their that veiled every corner of the campus. Stones wounds may take a long time to heal if they ever were placed in a semicircle before the reviewing can heal completely. Many of the men and stand to honor the victims of the previous day’s women who were in the classrooms that Cho at- shooting. Mourners wrote condolences and tacked and who survived, bravely helped each expressed their grief on message boards that other to escape, called for help, and barricaded filled the area, while flowers, stuffed animals, doors. Others were too severely wounded to and other remembrances were left in honor of move. These men and women in Norris Hall not the professors and students who died in a dorm only witnessed the deaths of their colleagues and room and in classrooms. professors, but on a physical and emotional level also experienced their dying. The terror of those VOLUNTEERS AND ONLOOKERS who survived Cho’s attacks in the classrooms was increased by the silence of death as the liv- isasters draw an enormous response. At ing harbored somewhere between life and death. DVirginia Tech, hundreds of volunteers came Exposure to such an overwhelmingly stressful to offer their services; others arrived in unofficial event quite often leads to post traumatic stress capacities to promote a particular cause, and disorder (also known as critical incident stress) many drove to Virginia Tech to share the grief of represented by an array of symptoms that range from mild to severe and which are not always their friends and colleagues. As occurs during immediately apparent.. many disasters, some special interest groups with less than altruistic intentions arrived in The law enforcement officers and emergency numbers and simply took advantage of the situa- medical providers who were the first to witness tion to promote their particular cause. One group the carnage, rescue the living, and treat and wore T-shirts to give the impression they were transport the physically wounded were exposed to significant trauma. Their healing also is of bona fide counselors when their main goal was to concern. proselytize. Others wanted to make a statement for or against a particular political position.

Legitimate resources can be a great asset if they can be identified and directed appropriately. An emergency plan should define where volunteers

144

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

should report and spells out procedures for regis- DEPARTMENT OF PUBLIC SAFETY tration, identification, and credentialing. That way, available services can be matched to imme- any families interviewed by the panel diate needs for greater effectiveness. Mpraised Virginia Secretary of Public Safety John Marshall and the efforts of the Virginia COMMUNICATIONS WITH THE State Police during the days following the mur- MEDICAL EXAMINER’S OFFICE ders. Marshall’s leadership coalesced resources at the scene. The state police, with some help ith regard to identifying the victims, every- from campus police, mobilized to assist the medi- Wthing was done by the book and with care- cal examiner. They collected records and items ful attention to exactness as described in Chap- from homes to help confirm the identities of the ter X. Therein, however, lay the crux of a deceased and they carried official notification of wrenching problem for the families. From a clini- death to the families. State troopers also pro- cal perspective, the ME’s office can be credited vided security at The Inn at Virginia Tech to with unimpeachable results. From a communica- prevent public access to the FAC. tions and sensitivity perspective, they performed poorly. Finally, in the aftermath of April 16, the panel has discerned no coordinated, system-wide A death notification needs to be handled so that review of major security issues among Virginia’s families receive accurate information about their public universities. With the exception of the loved one in a sensitive manner and in private Virginia Community College System, which with due respect. The OCME should have taken immediately formed an Emergency Preparedness into consideration the wishes of the family and Task Force for its 23 institutions, the responses their care and safety once the news was deliv- of the state-supported colleges and universities ered. Counseling services need to be available to appear to be uncoordinated. families during the process of recovering the remains. The media needs to be managed with While Governor Kaine covered a large conference reference to families and their right to privacy, on campus security August 13, to the panel’s dignity, and respect. Finally, victims’ families knowledge, there have been no meetings of need to be given explanations for any delays in presidents and senior administrators to discuss official notifications and then be provided crisis such issues as guns on campus, privacy laws, support in the wake of receiving that news. admissions processes, and critical incident management plans. The independent colleges and For example, families needed to know what universities met collectively with members of the method was being used to identify their loved panel, and the community colleges have met one, and when and how the personal effects them twice. The presidents of the senior colleges would be retuned. Some families were told that and universities declined a request to meet with identification would take 5 days and were given members of the panel June 26, saying it was “not no explanation why. Some families did not untimely” to do so. derstand why autopsies had to be performed. Some wondered about getting copies of the ME’s KEY FINDINGS reports and how they could obtain those. The ME’s office attached this information to each Mass fatality events, especially where a crime is death certificate, but they concur this may not involved, present enormous challenges with have been sufficient. regard to public information, victim assistance, and medical examiner’s office operations. Time is critical in putting an effective response into motion.

145

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

Discussions with the family members of the with members of the panel June 26, saying it deceased victims and the survivors and their was “not timely” to do so. family members revealed how critical it is to address the needs of those most closely related to RECOMMENDATIONS victims with rapid and effective victim services he director of Criminal Injuries Compensa- and an organized family assistance center with tion Fund and the chief of the Victim Ser- carefully controlled information management T vices Section (Department of Criminal Justice) Family members of homicide victims struggle conducted internal after-action reviews and pre- with two distinct processes: the grief associated pared recommendations for the future based on with the loss of a loved one and the wounding of the lessons that were learned. The recommenda- the spirit created by the trauma. Together they tions with which the panel concurred are incor- impose the tremendous burden of a complicated porated into the following recommendations. grieving process. XI-1 Emergency management plans should Post traumatic stress is likely to have affected include a section on victim services that many dozens of individuals beginning with the addresses the significant impact of homi- men and women who were in the direct line of cide and other disaster-caused deaths on fire or elsewhere in Norris Hall and survived, survivors and the role of victim service pro- and the first responders to the scene who dealt viders in the overall plan. Victim service pro- with the horrific scene. fessionals should be included in the planning, While every injured victim and every family training, and execution of crisis response plans. members of a deceased victim is unique, much of Better guidelines need to be developed for federal what they reported about the confusion and dis- and state response and support to local govern- organization following the incident was similar ments during mass fatality events. in nature. XI-2 Universities and colleges should Numerous families reported frustration with ensure that they have adequate plans to poor communications and organization in the stand up a joint information center with a university’s outreach following the tragedy, public information officer and adequate including errors and omissions made at com- staff during major incidents on campus. The mencement proceedings. outside resources that are available (including those from the state) and the means for obtain- A coordinated system-wide response to public ing their assistance quickly should be listed in safety is lacking. With the exception of the the plan. Management of the media and of self- Virginia community College System, which im- directed volunteers should be included. mediately formed an Emergency Preparedness Task Force for its 23 institutions, the response of XI-3 When a family assistance center is cre- the state-supported colleges and universities has ated after a criminal mass casualty event, been uncoordinated. To the panel’s knowledge, victim advocates should be called immedi- there have been no meetings of presidents and ately to assist the victims and their families. senior administrators to discuss such issues as Ideally, a trained victim service provider should guns on campus, privacy laws, admissions proc- be assigned to serve as a liaison to each victim or esses, and critical incident management plans. victim’s family as soon as practical. The victim The independent colleges and universities met service should help victims navigate the agencies collectively with members of the panel, and the at the FAC. community colleges have met with panel mem- XI-4 Regularly scheduled briefings should bers two times. The presidents of the senior col- be provided to victims’ families as to the leges and universities declined a request to meet status of the investigation, the

146

CHAPTER XI. IMMEDIATE AFTERMATH AND LONG ROAD TO HEALING

identification process, and the procedures XI-8 It is important that the state’s Victims for retrieving the deceased. Local or state vic- Services Section work to ensure that the tim advocates should be present with the fami- injured victims are linked with local victim lies or on behalf of out-of-state families who are assistance professionals for ongoing help not present so that those families are provided related to their possible needs. the same up-to-date information. XI-9 Since all crime is local, the response to XI-5 Because of the extensive physical and emergencies caused by crime should start emotional impact of this incident, both with a local plan that is linked to the wider short- and long-term counseling should be community. Universities and colleges should made available to first responders, students, work with their local government partners staff, faculty members, university leaders, to improve plans for mutual aid in all areas and the staff of The Inn at Virginia Tech. of crisis response, including that of victim Federal funding is available from the Office for services. Victims of Crime for this purpose. XI-10 Universities and colleges should cre- XI-6 Training in crisis management is ate a victim assistance capability either in- needed at universities and colleges. Such house or through linkages to county-based training should involve university and area-wide professional victim assistance providers for disaster response agencies training together victims of all crime categories. A victim under a unified command structure. assistance office or designated campus victim advocate will ensure that victims of XI-7 Law enforcement agencies should crime are made aware of their rights as vic- ensure that they have a victim services sec- tims and have access to services. tion or identified individual trained and skilled to respond directly and immediately XI-11 In order to advance public safety and to the needs of victims of crime from within meet public needs, Virginia’s colleges and the department. Victims of crime are best universities need to work together as a served when they receive immediate support for coordinated system of state-supported insti- their needs. Law enforcement and victim ser- tutions. vices form a strong support system for provision of direct and early support.

147 Appendix A

EXECUTIVE ORDER 53 (2007)

OFFICE OF THE GOVERNOR COMMONWEALTH OF VIRGINIA

A–1 APPENDIX A. EXECUTIVE ORDER 53 (07)

A–2

APPENDIX A. EXECUTIVE ORDER 53 (07)

A–3 APPENDIX A. EXECUTIVE ORDER 53 (07)

A–4 APPENDIX A. EXECUTIVE ORDER 53 (07)

A–5

APPENDIX A. EXECUTIVE ORDER 53 (07)

A–6

APPENDIX A. EXECUTIVE ORDER 53 (07)

A–7

APPENDIX A. EXECUTIVE ORDER 53 (07)

A–8

APPENDIX A. EXECUTIVE ORDER 53 (07)

A–9 Appendix B

INDIVIDUALS INTERVIEWED BY RESEARCH PANEL

B–1

APPENDIX B. INTERVIEWEES

The Virginia Tech Review Panel conducted more than 200 interviews. The interviewees included family members of victims; injured victims; students; and individuals from universities, law enforcement, hospitals, mental health organizations, courts, and schools. During the course of the review, the interviews were conducted in person, through public meetings, by phone, and through group meetings. A number of people were interviewed multiple times.

The panel wishes to express its appreciation to everyone who graciously provided their time and comments to this undertaking.

Virginia Tech

Carl Bean English Department Faculty Cathy Griffin Betzel Cook Counseling Center Erv Blythe Vice President for Information Technology Tom Brown Dean of Students Sherry K. Lynch Conrad Cook Counseling Center Fred D’Aguilar English Department Faculty Ed Falco English Department Faculty Christopher Flynn, MD Director, Cook Counseling Center Davis R. Ford Vice Provost for Academic Affairs Nikki Giovanni English Department Faculty Kay Heidbreder University Counsel Bob Hicok English Department Faculty Zenobia Lawrence Hikes Vice President for Student Affairs Lawrence G. Hincker Associate Vice President for University Relations Maggie Holmes Manager, West Ambler Johnston Hall Jim Hyatt Vice President and Chief Operating Officer Frances Keene Director, Judicial Affairs Gail Kirby Faculty in Norris Hall Judy Lilly Associate Vice President Director of Administrative Operations, News and External Heidi McCoy Relations Jim McCoy Capital Design and Construction Lenwood McCoy Liaison of University President to Panel Jennifer Mooney Coordinator Undergraduate Counseling Jerome Niles Dean, College of Liberal Arts and Human Sciences Lisa Norris English Department Faculty Director, News and External Relations, College of Engineering Lynn Nystrom (faculty in Norris Hall) Ishwar Puri Chairman, Engineering Mechanics Dept. (faculty in Norris Hall) Kerry J. Redican President, Faculty Senate Lucinda Roy Past Chair, English Department Carolyn Rude Chair, English Department

B–2

APPENDIX B. INTERVIEWEES

Joe Schetz Aerospace and Ocean Engineering Faculty Maisha Marie Smith Cook Counseling Center Ed Spencer Faculty in Norris Hall Charles Steger President Other Universities and Colleges

Richard Alvarez Chief Financial Officer, Hollins University Grant Azdell College Chaplain, Lynchburg College Mary Ann Bergeron Virginia Community Services Board Walter Bortz President, Hampden-Sydney College William Brady, MD University of Virginia, Department of Emergency Medicine William Thomas Burnett, MD University of Virginia, Medical Director of the Virginia State Police Division 6 SWAT Team Valerie J. Cushman Athletic Director, Randolph College Susan Davis University of Virginia, Special Advisor/Liaison to the General Counsel, Office of the Vice President for Student Affairs Chris Domes Chief Admissions Officer, Marymount University Roy Ferguson Executive Assistant to the President, Bridgewater College Pamela Fox President, Mary Baldwin College Ken Garren President, Lynchburg College Nancy Gray President, Hollins University Robert B. Lambeth President, Council of Independent Colleges in Virginia Robert Lindgren President, Randolph-Macon College Greg McMillan Executive Assistant to President, Emory and Henry College Katherine M. Loring Vice President for Administration, Virginia Wesleyan College Courtney Penn Special Assistant to the President, Roanoke College Vice President for Business and Finance, University of Herb Peterson Richmond Richard Pfau President, Averett University Jeff Phillips Director of Administrative Services, Ferrum College Michael Puglisi President, Virginia Intermont College Robert Reiser, MD Department of Emergency Medicine, University of Virginia James C. Renick Senior Vice President, American Council on Education Robert Satcher President, Saint Paul’s College LeeAnn Shank General Counsel, Washington and Lee University Wesley Shinn Dean, Appalachian School of Law Douglas Southard Provost, Jefferson College of Health Sciences Phil Stone President, Bridgewater College Loren Swartzendruber President, Eastern Mennonite University Vice President of Student Affairs, Northeastern Illinois Melvin C. Terrell University Special Advisor/Liasion to the General Counsel and Chair, Madelyn Wessel Psychological Assessment Board, University of Virginia

B–3

APPENDIX B. INTERVIEWEES

William Woods, MD Department of Emergency Medicine, University of Virginia Andrea Zuschin Dean of Student Affairs, Ferrum College

National Higher Education Associations

Robert M. Berdahl President, Association of American Universities President and CEO, American Association of Community George R. Boggs Colleges Vice President for Communications, American Association of Susan Chilcott State Colleges and Universities Charles L. Currie President, Association of Jesuit Colleges and Universities Benjamin F. Quillian Senior Vice President, American Council on Education James C. Renick Senior Vice President, American Council on Education David Ward President, American Council on Education

Law Enforcement

Donald J. Ackerman Assistant Special Agent-in-Charge, FBI Criminal Division (NY) Joseph Alberts Captain, Virginia Tech Police Department Supervisory Special Agent for the FBI, (ret.), Academy Group Richard Ault Inc. Supervisory Special Agent for the FBI, U.S. Secret Service (ret.), Kenneth Baker Academy Group Inc., Manassas, VA Ed Bracht Director of Security, Hofstra University David Cardona Special Agent-in-Charge, FBI Criminal Division (NY) Counter-Terrorism Coordinator, Union County (NJ) Sheriff's Rick Cederquist Office Don Challis Chief, College of William and Mary Police Department Kim Crannis Chief, Blacksburg Police Department Lenny Depaul U.S. Marshal's Service (NY/NJ), Fugitive Task Force Chief, University of Richmond Police Department and President, Robert C. Dillard Virginia Association of Chiefs of Police Jonathan Duecker Assistant Commissioner, New York Police Department Chuck Eaton Special Agent, Salem, VA, Virginia State Police Samuel Feemster Supervisory Special Agent for the FBI, Behavioral Science Unit SES Resources International/ Special Agent-in-Charge (ret.) Martin D. Ficke Immigration and Customs Enforcement (NY) W. Steve Flaherty Superintendent, Virginia State Police Wendell Flinchum Chief, Virginia Tech Police Department Kevin Foust Supervisory Special Agent for the FBI, Roanoke, VA Vincent Giardani New York Police Department Counter-Terrorism Division Richard Gibson Chief, University of Virginia Police Department Christopher Giovino SES Resources/Dempsey Myers Co. SWAT Team Commander and Homicide Detective, Arlington Ray Harp County (VA) Police Department (ret.) Charles Kammerdener New York Police Department, Special Operations Division Lt. Col., Virginia State Police; Deputy Director, Bureau of Robert Kemmler Administration and Support Service

B–4

APPENDIX B. INTERVIEWEES

Kenneth Lanning Supervisory Special Agent for the FBI (ret.) Active Shooter Training Program, International Tactical Jeff Lee Officers Organization Supervisory Special Agent for the FBI (ret.), Academy Group Stephen Mardigian Inc. George Marshall New York State Police Raymond Martinez New York Police Department Counter-Terrorism Division Resident Agent-in-Charge, Bureau of Alcohol, Tobacco, Firearms Bart McEntire and Explosives, Roanoke, VA Special Agent-in-Charge, Bureau of Alcohol, Tobacco, Firearms William McMahon and Explosives, Roanoke, VA Ken Middleton High-Intensity Drug Traffic Agency (NY/NJ) Terrence Modglin Executive Director, College Crime Watch Andrew Mulrain Nassau County, New York Police Department. Eliud P. Pagan Office of Homeland Security, State of New York Chauncey Parker Director, High-Intensity Drug Traffic Agency (NY/NJ) Robert Patnaude Captain, New York State Police Alfred Perales Sergeant, University of Illinois Police Department, Chicago, IL Kevin Ponder Special Agent, FBI Criminal Division (NY) David Resch Chief, Behavioral Analysis Unit, FBI, Quantico, VA Anthony Rocco Nassau County, New York Police Department. Terrorism and Special Jurisdiction, Victim Assistance Jill Roark Coordinator, Federal Bureau of Investigation Bradley D. Schnur Esq. President, SES Resources International Inc. Dennis Schnur Chairman, Police Foundation of Nassau County Inc. Supervisory Special Agent for the FBI, Behavioral Analysis Andre Simons Unit, Quantico, VA Sergeant, Emergency Response Team Virginia Tech Police Sean Smith Department Philip C. Spinelli Union County, New Jersey Office of Counter-Terrorism Detective/Lt. Suffolk County, New York Police and Hostage Matt Sullivan Negotiation Team Lieutenant, Suffolk County, New York Police Emergency Bob Sweeney Services Bureau Thomas Turner Director of Security, Roanoke College Supervisory Special Agent for the FBI, Behavioral Analysis Shaun F. VanSlyke Unit, Quantico, VA Sergeant, Emergency Response Team, Blacksburg Police Anthony Wilson Department President, Active Shooter Training Program, International Jason Winkle Tactical Officers Organization Joan Yale Nassau County, New York Police Department

B–5

APPENDIX B. INTERVIEWEES

Families of Victims

Mrs. Alameddine Mother of Ross Alameddine Stephanie Hofer Wife of Christopher James Bishop Mr. and Mrs. Dennis Bluhm Parents of Brian Roy Bluhm Mr. and Ms. Cloyd Parents of Austin Michelle Cloyd Mrs. Patricia Craig Aunt to Ryan Christopher Clark Ms. Betty Cuevas Mother of Daniel Alejandro Perez Mrs. Linda Granata Wife of Kevin P. Granata Mr. Gregory Gwaltney Father of Matthew Gregory Gwaltney Ms. Lori Haas Mother of Emily Haas Marian Hammaren and Chris Poote Mother and Stepfather of Caitlin Millar Hammaren Mr.. John Hammaren Father of Caitlin Millar Hammaren Mr. Michael Herbstritt Father of Jeremy Michael Herbstritt Mr. and Mrs. Eric Hilscher Parents of Emily Jane Hilscher Mrs. Tracey Lane Mother of Jarret Lee Lane Mr. Jerzy Nowak Husband of Jocelyne Couture-Nowak Mr. William O’Neil Father of Daniel Patrick O’Neil Mrs. Celeste Peterson Mother of Erin Nicole Peterson Mr. and Mrs. Larry Pryde Parents of Julia Kathleen Pryde Mr. and Mrs. Peter Read Parents of Mary Karen Read Mr. and Mrs. Joseph Samaha Parents of Reema Joseph Samaha Mrs. Holly Adams-Sherman Mother of Leslie Geraldine Sherman Mr. Girish Suratkal Brother of Minal Hiralal Panchal Mr. and Mrs. Paul Turner Parents of Maxine Shelly Turner Ms. Liselle Vega-Coates Ortiz Wife of Juan Ramon Ortiz Mr. and Mrs. White Parents of Nicole Regina White

Cho Family

Mr. and Mrs. Cho Parents of Seung Hui Cho Sun Cho Sister of Seung Hui Cho Attorney at Law, Tharrington Smith, Raleigh, NC; Advisor, Wade Smith Friend to Cho Family Injured Victims and Their Families

Alec Calhoun Student, Virginia Tech Colin Goddard Student, Virginia Tech Suzanne Grimes Mother of Kevin Sterne Emily Haas Student, Virginia Tech Jeremy Kirkendall Virginia National Guard Mrs. Miller Mother of Heidi Miller

B–6

APPENDIX B. INTERVIEWEES

Erin Sheehan Student, Virginia Tech

Rescue Squads

Allan Belcher Carilion Patient Transportation Services Sidney Bingley Blacksburg Volunteer Rescue Squad William W. Booker IV Virginia Tech Rescue Squad Charles Coffelt Carilion Patient Transportation Services Paul Davenport Carilion Patient Transportation Services Jeremy Davis Virginia Tech Rescue Squad Jason Dominiczak Virginia Tech Rescue Squad Kevin Hamm Christiansburg Rescue Squad Matthew Johnson Captain, Virginia Tech Rescue Squad Tom Lovejoy Blacksburg Volunteer Rescue Squad Alisa Nussman Virginia Tech Rescue Squad John O’Shea Blacksburg Volunteer Rescue Squad Neil Turner Montgomery County EMS Coordinator Colin Whitmore Virginia Tech Rescue Squad

Hospitals

Carole Agee Legal Counsel, Carilion Hospital Deborah Akers Lewis-Gale Medical Center Pat Campbell Director of Nursing, New River Valley Medical Center Candice Carroll Chief Nursing Officer, Lewis–Gale Medical Center Loressa Cole Montgomery Regional Hospital Special Advisor/, Liaison to the General Counsel, Office of Susan Davis the Vice President for Student Affairs Michael Donato, MD Carilion Roanoke Memorial Hospital Emergency Room Robert Dowling, MD Lewis–Gale Medical Center Patrick Earnest Carilion New River Valley Medical Center Ted Georges, MD Carilion New River Valley Medical Center Carol Gilbert, MD EMS Regional Medical Director Mike Hill Director, Emergency Department, Montgomery Regional Hospital Scott Hill Chief Executive Officer, Montgomery Regional Hospital Anne Hutton Manager, CONNECT, Carilion Hospital

Judith M. Kirkendall Administrator, Criminal History Records, Richmond, VA David Linkous Director, Staff Development and Emergency Management, Montgomery Regional Hospital Rick McGraw Carilion Roanoke Memorial Hospital Emergency Room William Modzeleski Assistant Deputy Secretary, U.S. Department of Education Lieutenant and Cardiac Technician, Blacksburg Volunteer John O’Shea Rescue Squad Fred Rawlins, DO Carilion New River Valley Medical Center

B–7

APPENDIX B. INTERVIEWEES

Mike Turner Clinical Support Representative, Carilion St. Albans Holly Wheeling, MD Montgomery Regional Hospital

Federal, State, and Local Agencies

Marcella Fierro, MD Chief Medical Examiner, VA Director of Emergency Management, Rockbridge County, Robert Foresman VA Chief Victim Service Section, Department of Criminal Mandie Patterson Justice Services, VA Emergency Planning Manager, Virginia Department of Patricia Sneed Social Services Assistant Director, Victim Services, Montgomery County, Jessica Stallard Virginia Karen Thomas Virginia Department of Criminal Justice Services Mary Ware Director, Criminal Injuries Compensation Fund

Mental Health Professionals Director of Crisis and Intervention, New River Community Harvey Barker, MD Service Board Director, Institute of Law, Psychiatry and Public Policy, Richard Bonnie University of Virginia Director, Adult Clinical Services and Crisis Intervention, Gail Burruss Blue Ridge Behavioral Healthcare Pam Kestner Chappalear Executive Director, Council of Community Services Lin Chenault Executive Director, New River Community Service Board Katuko T. Coelho Center for Multicultural Human Services Roy Crouse Independent Evaluator for Commitment Joan M. Ridick Depue Clinical Psychologist, Pastoral Counseling, Culpeper, VA Director, Counseling and Psychological Services, University Russell Federman of Virginia New River Community Service Board, pre-screener for Kathy Godbey commitment James Griffith, MD Psychiatrist, Center for Multicultural Human Services Kathy Highfield Blue Ridge Behavioral Healthcare Executive Director, Center for Multicultural Human Dennis Hunt Services Clinical Psychologist and Executive Director, National D. J. Ida Asian American and Pacific Islander Mental Health Association Chair, College Mental Health Committee for the American Jerald Kay , MD Psychiatric Association, Chair of the Department. of Psychiatry, Wright State School of Medicine Wun Jung Kim, MD Psychiatrist and Professor, University of Pittsburgh Jeanne Kincaid ADA/OCR , Attorney with Drummond Woodson Chair, APA Council on Minority Mental Health and Health Francis Lu, MD Disparities, Professor of Clinical Psychiatry, UCSF Clinical Psychologist, Former NIMH Staff/School Violence James Madero Specialist, California School of Professional Psychologists at Alliant International University

B–8

APPENDIX B. INTERVIEWEES

Consultant Psychiatrist to the Office of the Inspector Kent McDaniel, MD General, VA Staff Psychiatrist, St Albans Medical Center, Carilion Jasdeep Migliani, MD Health System Frank Ochberg, MD Former Director of Michigan Department of Mental Health Carrie Owens Director of Victim Services, Montgomery County, VA Director, Division of National and Minority Affairs, Annelle Primm, MD American Psychiatric Association Chair of the Diversity Committee for the American Andres Pumariega, MD Psychiatric Association, Chair Department of Psychiatry, Reading Hospital, PA Commissioner, Virginia Department of Mental Health, James S. Reinhard Mental Retardation and Substance Abuse Services Executive Director, Critical Incident Analysis Group, Gregory B. Saathoff, MD University of Virginia Les Saltzberg Executive Director, New River Community Service Board Jim Sikkema Executive Director, Blue Ridge Behavioral Healthcare Bruce Smoller, MD President-elect, Medical Association of Maryland; HPC Inspector General, Virginia Department of Mental Health, James W. Stewart III Mental Retardation and Substance Abuse Services Terry Teel Attorney for Commitment Clavitis Washington-Brown Blue Ridge Behavioral Healthcare Psychologist, Research on Preventing Campus Mental Richard West Health-Related Incidents Courts/Hearing Officials

Paul Barnett Special Justice Donald J. Farber Attorney at Law, San Rafael, CA Lorin Costanzo Special Justice, Virginia John Molumphy Special Justice, Virginia Joseph Graham Painter Attorney, Former Special Justice

High School Staff Dede Bailer Director, Psychology and Preventative Services, Fairfax County Public Schools Rita Easley School Guidance Counselor, Westfield High School Frances Ivey Former Assistant Principal, Westfield High School

Students at Virginia Tech

Joseph Aust Cho Roommate Chandler Douglas Resident Advisor John Eide Cho Roommate Andy Koch Cho Suitemate Austin Morton Cho Resident Advisor Melissa Trotman Resident Advisor

Business

Kathleen Schmid Koltko-Rivera President, Professional Services Group, Winter Park, FL

B–9

APPENDIX B. INTERVIEWEES

Executive Vice President, Professional Services Group, Mark E. Koltko-Rivera Winter Park, FL

B–10

APPENDIX B. INTERVIEWEES

Other

Steve Capus President, NBC News Steven Erickson Father of Stalking Victim Mr. Gibson Father of Stalking Victim David McCormick Vice President, NBC News

Luke Van Heul Former Member, Delta Force

B–11

Appendix C

PUBLIC MEETING AGENDA

First Public Meeting of Governor Kaine’s Independent Virginia Tech Incident Review Panel Monday, May 10, 2007, General Assembly Building, Richmond

Second Public Meeting of Governor Kaine’s Independent Virginia Tech Incident Review Panel Monday, May 21, 2007, Virginia Tech, Blacksburg

Third Public Meeting of Governor Kaine’s Independent Virginia Tech Incident Review Panel Monday, June 11, 2007, George Mason University, Fairfax

Forth Public Meeting of Governor Kaine’s Independent Virginia Tech Incident Review Panel Wednesday, July 18, 2007, University of Virginia, Charlottesville

C–1

APPENDIX C. PUBLIC MEETING AGENDA

First Public Meeting of Governor Kaine’s Independent Virginia Tech Incident Review Panel House Room C, General Assembly Building 910 Capitol Street, Richmond, VA May 10, 2007

9:30 Panel Pre-Meeting Coffee Anteroom to House Room C (to the left of the dais)

10:30 Welcome and Charge to the Panel The Honorable Timothy Kaine, Governor of Virginia

10:45 Virginia Polytechnic Institute and State University Comments from Dr. Charles Steger, President

10:55 Introduction of Panel Members and SPC/TriData Project Leaders plus Guidance to the Panel Colonel Gerald Massengill, Chairman

11:15 Overview of SPC/TriData Support Philip Schaenman, Project Director

11:30 Panel Members: Initial Thoughts on Key Issues to be Considered

12:45 Lunch (Panel Meet in Anteroom)

1:30 Presentation: The Process for Obtaining a Weapon in the Commonwealth of Virginia Major Robert Kemmler, Virginia State Police, Deputy Director, Bureau of Administration and Support Services

2:15 Opportunity for Comments from the Public

2:45 Future Meetings and Next Steps

3:00 Adjourn

C–2

APPENDIX C. PUBLIC MEETING AGENDA

Second Public Meeting of Governor Kaine’s Independent Virginia Tech Incident Review Panel May 21, 2007

The Inn at Virginia Tech and Skelton Conference Center Latham Ballroom A&B 901 Prices Fork Road Blacksburg, VA 24061 540-231-8000 or 877-200-3360; Fax: 540-231-0146

7:30 a.m. Vote to be taken in accordance with Virginia Code Section 2.2-3712 to go into a closed meeting to review and discuss matters related to the ongoing criminal investigation and public safety. 10:30 a.m. Re-opening of Public Meeting Remarks by Colonel Gerald Massengill, Panel Chair 10:35 a.m. Virginia Tech Presentation: Dr. Charles Steger, President Mr. Jim McCoy, Capital Design & Construction Ms. Kay Heidbreder, University Counsel Dr. David Ford, Vice Provost, Academic Affairs Dr. Zenobia Hikes, Vice President, Student Affairs 11:50 a.m. Law Enforcement Presentation: Chief Wendell Flinchum, Virginia Tech Police Department Colonel W. Steven Flaherty, Superintendent, Virginia State Police 12:30 p.m. Lunch 1:30 p.m. Emergency Response Presentation: Richard Ferraro, Assistant Vice President, Student Affairs Matthew Johnson, Captain, Virginia Tech Rescue Squad Colin Whitmore, Lieutenant, Virginia Tech Rescue Squad Hospital Presentation: David Linkous, RN, BSN, MS Ed. Director of Staff Development and Emergency Management, Montgomery Regional Hospital Michael Hill, RN, BS, Director of Emergency Department, Montgomery Regional Hospital 3:00 p.m. Public Comments 4:00 p.m. Adjourn

C–3

APPENDIX C. PUBLIC MEETING AGENDA

Third Public Meeting of Governor Kaine’s Independent Virginia Tech Incident Review Panel Monday, June 11, 2007

Mason Hall (Meese Conference Room) George Mason University 4400 University Drive Fairfax, VA 22030

9:00 Opening remarks

h Colonel Gerald Massengill, Chair 9:05 Welcoming remarks h Dr. Alan G. Merten, President, George Mason University 9:15 Update from Panel Staff (SPC/TriData)

h Phil Schaenman h Hollis Stambaugh 9:30 Summary Report on the Investigation of Virginia’s Mental Health Services and Seung-Hui Cho

h James Stewart, Virginia Inspector General for Mental Health, Mental Retardation, and Substance Abuse Services. 10:45 Faculty Options for Dealing with Students at Virginia Tech

h Dr. Mark McNamee, Provost h Dr. Jerome (Jerry) Niles, Dean, College of Liberal Arts & Human Sciences h Dr. Christopher Flynn, Director of Thomas Cook Counseling Center h Dr. Kerry Redican, President of the Faculty Senate

C–4

APPENDIX C. PUBLIC MEETING AGENDA

11:30 Mental Health Issues at College Campuses

h Dr. Jerald Kay, Chair, College Mental Health Committee, American Psychiatric Association, and Chair, Department of Psychiatry, Wright State University School of Medicine 12:00 Lunch

h Panel will vote to go into a closed meeting over lunch (Pursuant to ¤ 2.2-3711.A.7, Virginia Code, the Panel will address with its legal advisors specific legal questions regarding its access to and use of information developed in connection with its investigation.) 1:00 Risk Assessment and Counseling at the High School Level

h Dr. Dede Bailer, Director, Psychology and Preventative Services, Fairfax County Public School (canceled - lack of time) 1:30 Status Report on the Panel’s Research into the Mental Health Issues of the Virginia Tech Tragedy (canceled-lack of time) h Dr. Bela Sood, Member of Panel and Chair, Division of Child and Adolescent Psychiatry, Virginia Commonwealth University, and Medical Director of the Virginia Treatment Center for Children, Virginia Commonwealth University Health Systems 2:00 Awareness and Strategies for Families and Survivors

h Carroll Ann Ellis, Member of Panel and Director, Victim Services Division, Fairfax County Police Department 2:30 Public Comments

h Persons desiring to speak are requested to sign up during the meeting

C–5

APPENDIX C. PUBLIC MEETING AGENDA

Fourth Public Meeting of Governor Kaine’s Independent Virginia Tech Incident Review Panel Wednesday, July 18, 2007

100 Darden Boulevard, Charlottesville, VA 22903 Abbott Center Auditorium at the Darden School (434) 924-3900

8:30 Abbott Center Doors Open

9:00 Opening Remarks Colonel Gerald Massengill, Chair

9:10 Welcome Dr. John T. Casteen III, President, University of Virginia

9:15 Update on Panel and Staff Activities

Phil Schaenman, Staff Director

9:30 Virginia Association of Campus Law Enforcement

h Chief Don Challis, President, VACLEA (Speaker) William and Mary Police Department h Michael Gibson, Chief of Police University of Virginia h Chief Robert Dillard University of Richmond Police Department h Thomas Turner, Director Roanoke College Campus Safety Department Added at Meeting: h Chief Mark Marshall, 4th VP, International Association of Chiefs of Police

C–6

APPENDIX C. PUBLIC MEETING AGENDA

h Mike Yost, Chief of Williamsburg, Virginia Police Department; President, Virginia Police Chiefs Association 10:15 Possible Civil Commitment Law Reform in Virginia

Richard Bonnie, Director, University of Virginia Institute of Law, Psychiatry and Public Policy and Chair, Commonwealth of Virginia Commission on Mental Health Law

11:15 Handling the Seriously Troubled Student – Legally Permissible Options and Strategies Available to Academic Institutions

h Dr. James Madero, San Francisco Campus, California School of Professional Psychology at Alliant International University h Dr. Russell Federman, Director Smith Memorial Center for Counseling and Psychological Services, University of Virginia h Richard Bonnie, University of Virginia 12:15 Lunch

There will be a closed session to consult with counsel and discuss matters and records which are required to be kept confidential

1:15 Mental Health Issues Dr. Bela Sood, Virginia Tech Review Panel Member

1:30 Public Comments

Persons desiring to address the panel may sign up at the meeting venue

3:30 Adjourn ÉÉÉÉÉÉÉÉÉÉÉÉÉÉ

Thursday, July 19, 2007

Darden Business School

Classroom 130

9:00 -12:00 Closed Panel Session

There will be a closed session to consult with counsel and discuss matters and records which are required to be kept confidential

C–7

Appendix D

RECOMMENDATIONS ON REVISED METHODOLOGY

D–1

APPENDIX D. RECOMMENDATION ON REVISED METHODOLOGY

RECOMMENDATIONS ON REVISED METHODOLOGY

The panel made the following recommendations related to its operations.

Establish the authority of a review panel from the outset. It was especially important to have the authority of the panel and the powers to collect confidential data spelled out in an executive order.

Appoint independent counsel to the panel from the outset. Having a noted law firm to interpret the various rules regarding privacy, record keeping, public vs. private meetings, and authority to obtain information expedited the work of the panel, and allowed it to move forward more confidently than if uncertain about the ground rules under which it operated. The governor’s office also suggested having independent counsel to avoid conflicts of interest.

As an investigating body, the panel should be expressly authorized to meet in closed sessions from the outset. It was the desire of the panel and the governor’s office to conduct a review as transparent and open to the public and media as possible. However, some discussion needs to be held in private while discussing and formulating opinions. The largest methodological problem faced by the panel probably was the limited ability to have multiparty conference calls or meetings in private with more than two panel members to discuss controversial issues.

D–2

Appendix E

VIRGINIA TECH GUIDELINES FOR CHOOSING ALERTING SYSTEM

E–1

APPENDIX E. GUIDELINES FOR CHOOSING ALERTING SYSTEM

VIRGINIA TECH GUIDELINES FOR CHOOSING ALERTING SYSTEM

The successful system would provide: • Multi-modal communications; o text messaging (preferably using true Short Message Service [SMS] protocol) o Instant Messaging (IM) o e-mail o web posting o voice communication to cellular or land line based extensions (including ability to fax) • Flexibility in “registering” or “subscribing” users; o ability to pre-load based on existing directory data with both APIs and online mechanisms for batch or manual updates • Robust, but distributed data centers, i.e. more than one location; ability to send alerts even if event impacts vendor’s facility • Robust, but dispersed messaging; concern is with saturation of communications channels (Part of “Lessons Learned” from 9/11 and previous incident in Blacksburg on first day of Fall Semester 2006; “too much, too soon” will quickly overwhelm cellular and land line telephony systems) • The vendor would have to be flexible in terms of contracting, and willing to collaborate on further developing the product’s features to meet specific needs identified by Virginia Tech.

E–2

Appendix F

ACTIVE SHOOTER EXCERPT FROM UNIVERSITY OF VIRGINIA EMERGENCY RESPONSE PLAN

F–1

APPENDIX F. ACTIVE SHOOTER EXCERPT

Excerpt from University of Virginia Emergency Response Plan, Annex K, “Critical Incidents and Response Strategies – Active Shooter or Violent Incident”

Violent incidents, including but not limited to: acts of terrorism, an active shooter, assaults, or other incidents of workplace violence can occur on the University Grounds or in close proximity with little or no warning. An “active shooter” is considered to be a suspect or assailant whose activity is immediately causing serious injury or death and has not been contained.

The UVA Police Department has adopted nationally accepted law enforcement response procedures to contain and terminate such threats, as quickly as possible. The following information regarding law enforcement response will enable you to take appropriate protective actions for yourself. Try to remain calm as your actions will influence others. The following instructions are intended for incidents that are of an emergent nature (i.e., imminent or in progress).

Immediate Action 1. Secure the immediate area. Whether a classroom, residence hall room, office, or restroom: • Lock or barricade the door, if able. Block the door using whatever is available – desks, tables, file cabinets, other furniture, books, etc. • After securing the door, stay behind solid objects away from the door as much as possible. • If the assailant enters your room and leaves, lock or barricade the door behind them. • If safe to do so, allow others to seek refuge with you. 2. Protective Actions. Take appropriate steps to reduce your vulnerability: • Close blinds. • Block windows. • Turn off radios and computer monitors. • Silence cell phones. • Place signs in interior doors and windows, but remember the assailant can see these as well. • Place signs in exterior windows to identify your location and the location of injured persons. • Keep people calm and quiet. • After securing the room, people should be positioned out of sight and behind items that might offer additional protection – walls, desks, file cabinets, bookshelves, etc. 3. Unsecured Areas: If you find yourself in an open area, immediately seek protection: • Put something between you and the assailant. • Consider trying to escape, if you know where the assailant is and there appears to be an escape route immediately available to you. • If in doubt, find the safest area available and secure it the best way that you can. 4. Call 911. Emergency situations should be reported to law enforcement by dialing 911. You may hear multiple rings – stay on the line until it is answered - do not hang up. Be prepared to provide the 911 operator with as much information as possible, such as the following:

F–2

APPENDIX F. ACTIVE SHOOTER EXCERPT

• What is happening. • Where you are located, including building name and room number. • Number of people at your specific location. • Injuries, if any, including the number of injured and types of injuries. • Your name and other information as requested. 5. Try to provide information in a calm clear manner so that the 911 operator quickly can relay your information to responding law enforcement and emergency personnel. 6. What to Report. Try to note as much as possible about the assailant, including: • Specific location and direction of the assailant. • Number of assailants. • Gender, race, and age of the assailant. • Language or commands used by the assailant. • Clothing color and style. • Physical features – e.g., height, weight, facial hair, glasses. • Type of weapons – e.g., handgun, rifle, shotgun, explosives. • Description of any backpack or bag. • Do you recognize the assailant? Do you know their name? • What exactly did you hear – e.g., explosions, gunshots, etc. 7. Treat the Injured. The 911 operator will notify law enforcement and other emergency service (EMS) agencies – fire and rescue. EMS will respond to the site, but will not be able to enter the area until it is secured by law enforcement. You may have to treat the injured as best you can until the area is secure. Remember basic first aid: • For bleeding apply pressure and elevate. Many items can be used for this purpose – e.g., clothing, paper towels, feminine hygiene products, newspapers, etc. • Reassure those in the area that help will arrive – try to stay quiet and calm. 8. Un-securing the Area • The assailant may not stop until his objectives have been met or until engaged and neutralized by law enforcement. • Always consider the risk exposure by opening the door for any reason. • Attempts to rescue people only should be made if it can be done without further endangering the persons inside of a secured area. • Be aware that the assailant may bang on the door, yell for help, or otherwise attempt to entice you to open the door of a secured area. • If there is any doubt about the safety of the individuals inside the room, the area needs to remain secured. Law Enforcement Response UVA Police will immediately respond to the area, assisted by other local law enforcement agencies, if necessary. Remember:

F–3

APPENDIX F. ACTIVE SHOOTER EXCERPT

1. Help is on the way. It is important for you to: • Remain inside the secure area. • Law enforcement will locate, contain, and stop the assailant. • The safest place for you to be is inside a secure room. • The assailant may not flee when law enforcement enters the building, but instead may target arriving officers. 2. Injured Persons. Initial responding officers will not treat the injured or begin evacuation until the threat is neutralized and the area is secure. • You may need to explain this to others in order to calm them. • Once the threat is neutralized, officers will begin treatment and evacuation. 3. Evacuation. Responding officers will establish safe corridors for persons to evacuate. • This may be time consuming. • Remain in secure areas until instructed otherwise. • You may be instructed to keep your hands on your head. • You may be searched. • You may be escorted out of the building by law enforcement personnel - follow their directions. • After evacuation you may be taken to a staging or holding area for medical care, interviewing, counseling, etc. • Once you have been evacuated you will not be permitted to retrieve items or access the area until law enforcement releases the crime scene. Decision Maker(s) Assistance from local and state law enforcement agencies will be provided under existing mutual aid agreements. The decision to call in outside supporting agencies or to close all or a portion of the Grounds will be made by the Chief of Police or designee in consultation with the Executive Vice President and Chief Operating Officer or designee and other appropriate individuals in University administration. Information will be released to the UVA community as quickly as circumstances permit.

Subsequent Procedures/Information We cannot predict the origin of the next threat; assailants in incidents across the nation have been students, employees, and non-students alike. In many cases there were no obvious specific targets and the victims were unaware that they were a target until attacked. Being aware of your surroundings, taking common sense precautions, and heeding any warning information can help protect you and other members of the community.

F–4

Appendix G

GUIDANCE LETTERS ON INTERPRETATION OF FERPA AND HIPAA RULES FROM U.S. DEPARTMENT OF EDUCATION

To University of New Mexico (2003)

To New Bremen Local Schools (1994)

G–1

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

Letter to University of New Mexico (November 2004)

G–2

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–3

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–4

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–5

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–6

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–7

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–8

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–9

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–10

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–11

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–12

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–13

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

Letter to New Bremen Local Schools (1994) [Letter starts on following page.]

G–14

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–15

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–16

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–17

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–18

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–19

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–20

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–21

APPENDIX G. FERPA/HIPAA GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

G–22

Appendix H

SUMMARY OF INFORMATION PRIVACY LAWS AND GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

H–1

APPENDIX H. SUMMARY OF INFORMATION PRIVACY LAWS

INFORMATION PRIVACY LAWS

[This summary was prepared by Skadden, Arps for the Virginia Tech Review Panel]

All Law Enforcement Agencies • Upon request, must disclose basic criminal incident information (such as a description of the crime and the date it occurred) about felony crimes.

• Upon request, must release the name and address of anyone arrested and charged with any crime.

• Upon request, must release all records about an incident that was not a crime. However, the agency must remove all personal information such as social security numbers.

• Upon request, may release information from investigative files. Law enforcement agencies typically adopt a policy against disclosure.

Universities and Campus Police Departments • Must keep a publicly-available log that lists all crimes. The log must give the time, date, and location of each offense, as well as the disposition of each case.

• Must disclose the name and address of people arrested for felonies and misdemeanors involving assault, battery, or "moral turpitude."

Juvenile Law Enforcement Records • Records restricted from disclosure. Agencies can release the records to other parts of the juvenile justice system or to parents.

• Officials may release to school principals information about certain offenders who commit serious felonies, arson, or weapons offenses.

Judicial Records • Generally, court records can be widely shared.

• Juvenile records are tightly restricted. They can only be disclosed outside the juvenile justice system with a court order.

• Records of commitment hearings must be sealed when the subject of the hearing requests it. If sealed, the records can only be accessed through court order.

H–2

APPENDIX H. SUMMARY OF INFORMATION PRIVACY LAWS

• Commitment hearings must be open to the public, so certain information is not required to be kept in confidence: name of the subject, and the time, date, and location of the hearing.

Medical Information • Governed by both state and federal law.

• Federal law is the Health Insurance and Portability and Accountability Act of 1996 and the regulations interpreting it. Virginia law is the Virginia Health Records Privacy Act.

• In most respects, the federal and state laws are similar and can be analyzed together.

• Both laws state that health information is private and can only be disclosed for certain reasons.

• HIPAA can pre-empt a state law, making the state law ineffective. This generally occurs when state law is less protective of privacy than federal law.

• The laws apply to all medical providers and billing entities. They define "provider" broadly: doctors, nurses, therapists, counselors, and social workers, as well as HMOs, insurers, and other health organizations are all included in the definition.

• Requires disclosure of records to patients who are the subject of the records.

• Allows disclosure to anyone when a patient fills out a written authorization.

• Allows sharing when it is necessary for treatment.

• Allows disclosure to relatives with permission or in emergency situations.

• Allows disclosure in situations where legislators and rule-makers have concluded that privacy is outweighed by other interests. For example, providers may disclose in certain situations when an individual presents an imminent threat to the health and safety of individuals and the public. Providers may also disclose information to law enforcement when necessary to locate a fugitive or suspect.

• Providers may disclose information when state law requires it, such as in mandated reports for domestic violence injuries. If the state law only permits disclosure and does not require it, federal law will invalidate the state law.

• Federal law does not apply to records held by school medical facilities. State law does apply.

H–3

APPENDIX H. SUMMARY OF INFORMATION PRIVACY LAWS

Educational Records • Privacy of educational records is primarily governed by federal law, the Family Educational Rights Privacy Act of 1974, as well as regulations that interpret the law.

• FERPA applies to all educational institutions that accept federal funding, whatever the level. As a practical matter, this means almost all institutions of higher learning as well as public elementary and secondary schools.

• FERPA states that information from educational records is private and can only be disclosed for certain reasons.

• FERPA has a different focus than HIPAA. HIPAA protects all medical information gained in the course of treatment, whether in oral or written form. FERPA applies only to information in student records. Personal observations, including information gained from a conversation with a student, fall outside FERPA.

• Applies to health records maintained at university health clinics. However, it was not drafted to address specific issues of medical information.

• State laws about health records also apply. Disclosure is not permitted when a state law is less protective of health records privacy than FERPA. However, state law can be more protective than FERPA. State law can restrict disclosure that FERPA authorizes.

• Records created and held by law enforcement agencies for law enforcement purposes fall outside of FERPA.

• If a law enforcement agency shares a record with the school, the record that is maintained by the school becomes subject to FERPA. The record kept by the law enforcement agency is not subject to FERPA.

• Authorizes disclosure of any record to parents who claim adult students as dependents for tax purposes.

• Authorizes release to parents when the student has violated alcohol or drug laws and is under 21.

• Authorizes use of information by all school officials designated to have a legitimate educational interest in receiving such information.

H–4

APPENDIX H. SUMMARY OF INFORMATION PRIVACY LAWS

• Authorizes disclosure of the final result of a disciplinary proceeding that held that a student violated school policy for an incident involving a crime of violence (as defined under federal law) or a sex offense.

• Allows state law to authorize certain uses in the juvenile justice system.

• Authorizes emergency disclosure to any appropriate person in connection with an emergency, “if the knowledge of such information is necessary to protect the health or safety of the student or other persons.”

• This exception is to be narrowly construed.

Government Data Collection and Dissemination Practices Act • Establishes rules for collection, maintenance, and dissemination of individually- identifying data.

• Does not apply to police departments or courts.

• Agencies that are bound by the Act may only disclose information when disclosure is permitted or required by law. "Permitted by law" to include any official request.

• If an agency requests data from another agency for a function it is legally authorized to perform, the request is official.

• The agency releasing the data must inform individuals when their data is disclosed.

H–5

APPENDIX H. SUMMARY OF INFORMATION PRIVACY LAWS

GUIDANCE FROM U.S. DEPARTMENT OF EDUCATION

Disclosure of Information from Education Records to Parents of Students Attending Postsecondary Institutions Recently many questions have arisen concerning the Family Educational Rights and Privacy Act (FERPA), the federal law that protects the privacy of students’ education records. The Department wishes to clarify what FERPA says about postsecondary institutions sharing information with parents.

What are parents’ and students’ rights under FERPA?

At the K-12 school level, FERPA provides parents with the right to inspect and review their children’s education records, the right to seek to amend information in the records they believe to be inaccurate, misleading, or an invasion of privacy, and the right to consent to the disclosure of personally identifiable information from their children’s education records. When a student turns 18 years old or enters a postsecondary institution at any age, these rights under FERPA transfer from the student’s parents to the student. Under FERPA, a student to whom the rights have transferred is known as an “eligible student.” Although the law does say that the parents’ rights afforded by FERPA transfer to the “eligible student,” FERPA clearly provides ways in which an institution can share education records on the student with his or her parents.

While concerns have been expressed about the limitations on the release of information, there are exceptions to FERPA’s general rule that educational agencies and institutions subject to FERPA may not have a policy or practice of disclosing “education records” without the written consent of the parent (at the K-12 level) or the “eligible student.”

When may a school disclose information to parents of dependent students?

Under FERPA, schools may release any and all information to parents, without the consent of the eligible student, if the student is a dependent for tax purposes under the IRS rules.

Can a school disclose information to parents in a health or safety emergency?

The Department interprets FERPA to permit schools to disclose information from education records to parents if a health or safety emergency involves their son or daughter.

Can parents be informed about students’ violation of alcohol and controlled substance rules?

H–6

APPENDIX H. SUMMARY OF INFORMATION PRIVACY LAWS

Another provision in FERPA permits a college or university to let parents of students under the age of 21 know when the student has violated any law or policy concerning the use or possession of alcohol or a controlled substance.

Can a school disclose law enforcement unit records to parents and the public?

Additionally, under FERPA, schools may disclose information from “law enforcement unit records” to anyone – including parents or federal, State, or local law enforcement authorities – without the consent of the eligible student. Many colleges and universities have their own campus security units. Records created and maintained by these units for law enforcement purposes are exempt from the privacy restrictions of FERPA and can be shared with anyone.

Can school officials share their observations of students with parents?

Nothing in FERPA prohibits a school official from sharing with parents information that is based on that official’s personal knowledge or observation and that is not based on information contained in an education record. Therefore, FERPA would not prohibit a teacher or other school official from letting a parent know of their concern about their son or daughter that is based on their personal knowledge or observation.

How does HIPAA apply to students’ education records?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a law passed by Congress intended to establish transaction, security, privacy, and other standards to address concerns about the electronic exchange of health information. However, the HIPAA Privacy Rule excludes from its coverage those records that are protected by FERPA at school districts and postsecondary institutions that provide health or medical services to students. This is because Congress specifically addressed how education records should be protected under FERPA. For this reason, records that are protected by FERPA are not subject to the HIPAA Privacy Rule and may be shared with parents under the circumstances described above.

In all of our programs here at the Department of Education, we consistently encourage parents’ involvement in their children’s education. FERPA is no exception. While the privacy rights of all parents and adult students are very important, there are clear and straightforward ways under FERPA that institutions can disclose information to parents and keep them involved in the lives of their sons and daughters at school.

H–7

Appendix I

FEDERAL AND VIRGINIA GUN PURCHASER FORMS

Federal Firearms Transaction Record (ATF–4473)

Virginia Firearms Transaction Record (SP–65)

I–1

APPENDIX I. FEDERAL/VIRGINIA GUN PURCHASER FORMS

Firearms Transaction Record (ATF 4473)

I–2

APPENDIX I. FEDERAL/VIRGINIA GUN PURCHASER FORMS

I–3

APPENDIX I. FEDERAL/VIRGINIA GUN PURCHASER FORMS

I–4

APPENDIX I. FEDERAL/VIRGINIA GUN PURCHASER FORMS

I–5

APPENDIX I. FEDERAL/VIRGINIA GUN PURCHASER FORMS

I–6

APPENDIX I. FEDERAL/VIRGINIA GUN PURCHASER FORMS

I–7

APPENDIX I. FEDERAL/VIRGINIA GUN PURCHASER FORMS Virginia Firearms Transaction Record (SP-65)

I–8

APPENDIX I. FEDERAL/VIRGINIA GUN PURCHASER FORMS

I–9

Appendix J

NOTIFICATION OF ADJUDICATION OF INVOLUNTARY COMMITMENT OR INCAPACITATION

J–1

APPENDIX J. VIRGINIA FORM FOR INVOLUNTARY COMMITMENT OR INCAPACITATION

SP-237, Revised 2006

J–2

APPENDIX J. VIRGINIA FORM FOR INVOLUNTARY COMMITMENT OR INCAPACITATION SP-237, Revised 2007

J–3

Appendix K

ARTICLES ON MIXTURE OF GUNS AND ALCOHOL ON CAMPUS

K–1

APPENDIX K. MIXTURE OF GUNS AND ALCOHOL ON CAMPUS

K–2

APPENDIX K. MIXTURE OF GUNS AND ALCOHOL ON CAMPUS

K–3

APPENDIX K. MIXTURE OF GUNS AND ALCOHOL ON CAMPUS

K–4

APPENDIX K. MIXTURE OF GUNS AND ALCOHOL ON CAMPUS

K–5

APPENDIX K. MIXTURE OF GUNS AND ALCOHOL ON CAMPUS

K–6

Appendix L

FATAL SCHOOL SHOOTINGS IN THE UNITED STATES: 1966–2007

[This compilation was prepared by Skadden, Arps for the Virginia Tech Review Panel]

L–1

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–2

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–3

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–4

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–5

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–6

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–7

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–8

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–9

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–10

APPENDIX L. FATAL SCHOOL SHOOTINGS: 1966–2007

L–11 Appendix M

RED FLAGS, WARNING SIGNS AND INDICATORS

M–1

APPENDIX M. RED FLAGS, WARNING SIGNS AND INDICATORS

RED FLAGS, WARNING SIGNS AND INDICATORS

By Roger Depue, Ph.D.

Experts who evaluate possible indicators that an individual is at risk of harming himself or others know to seek out many sources for clues, certain red flags that merit attention. A single warning sign by itself usually does not warrant overt action by a threat assessment specialist. It should, however, attract the attention of an assessor who has been sensitized to look for other possible warning signs. If additional warning signs are present then more fact-finding is warranted to determine if there is a likelihood of danger. Some warning signs carry more weight than others. For instance, a fascination with, and possession of, firearms are more significant than being a loner, because possession of firearms gives one the capacity to carry out an attack. But if a person simply possesses firearms and has no other warning signs, it is unlikely that he represents a significant risk of danger. When a cluster of indicators is present then the risk becomes more serious. Thus, a person who possesses firearms, is a loner, shows an interest in past shooting situations, writes stories about homicide and suicide, exhibits aberrant behavior, has talked about retribution against others, and has a history of mental illness and refuses counseling would obviously be considered a significant risk of becoming dangerous to himself or others. A school threat assessment team upon learning about such a list of warning signs would be in a position to take immediate action including: • Talking to the student and developing a treatment plan with conditions for remaining in school • Calling the parents or other guardians • Requesting permission to receive medical and educational records • Checking with law enforcement to ascertain whether there have been any interactions with police • Talking with roommates and faculty • Suspending the student until the student has been treated and doctors indicate the student is not a safety risk Following are some warning signs (indicators and red flags) associated with school shootings in the United States. Schools, places of employment, and other entities that are creating a threat assessment capability may want to be aware of these red flags: Violent fantasy content – Writings (Stories, essays, compositions), Drawings (Artwork depicting violence),

M–2

APPENDIX M. RED FLAGS, WARNING SIGNS AND INDICATORS

Reading and viewing materials (Preference for books, magazines, television, video tapes and discs, movies, music, websites, and chat rooms with violent themes and degrading subject matter), and role playing acts of violence and degradation. Anger problems – Difficulty controlling anger, loss of temper, impulsivity, Making threats Fascination with weapons and accoutrements – Especially those designed and most often used to kill people (such as machine guns, semiautomatic pistols, snub nose revolvers, stilettos, bayonets, daggers, brass knuckles, special ammunition and explosives) Boasting and practicing of fighting and combat proficiency – Military and sharpshooter training, martial arts, use of garrotes, and knife fighting Loner – Isolated and socially withdrawn, misfit, prefers own company to the company of others Suicidal ideation – Depressed and expresses hopelessness and despair Reveals suicidal preparatory behavior Homicidal ideation – Expresses contempt for other(s) Makes comments and/or gestures indicating violent aggression Stalking – Follows, harasses, surveils, attempts to contact regardless of the victim’s expressed annoyance and demands to cease and desist Non-compliance and disciplinary problems – Refusal to abide by written and/or verbal rules Imitation of other murderers – Appearance, dress, grooming, possessions like those of violent shooters in past episodes (e.g. long black trench coats) Interest in previous shooting situations – Drawn toward media, books, entertainment, conversations dealing with past murders

M–3

APPENDIX M. RED FLAGS, WARNING SIGNS AND INDICATORS

Victim/martyr self-concept – Fantasy that some day he will represent the oppressed and wreak vengeance on the oppressors Strangeness and aberrant behavior – Actions and words that cause people around him to become fearful and suspicious Paranoia – Belief that he is being singled out for unfair treatment and/or abuse; feeling persecuted Violence and cruelty – A history of using violence to solve problems (fighting, hitting, etc.), abusing animals or weaker individuals Inappropriate affect – Enjoying cruel behavior and/or being able to view cruelty without being disturbed Acting out – Expressing disproportionate anger or humor in situations not warranting it, attacking surrogate targets Police contact – A history of contact with police for anger, stalking, disorderly conduct; Past temporary restraining orders (or similar court orders), A jail/prison record for aggressive crimes Mental health history related to dangerousness – A history of referral or commitments to mental health facilities for aggressive/destructive behavior Expressionless face/anhedonia – An inability to express and/or experience joy and pleasure Unusual interest in police, military, terrorist activities and materials Vehicles resembling police cars, military vehicles, surveillance equipment, handcuffs, weapons, clothing (camouflage, ski masks, etc.) Use of alcohol/drugs – Alcohol/drugs are used to reduce inhibitions so that aggressive behaviors are more easily expressed

M–4 Appendix N

A THEORETICAL PROFILE OF SEUNG HUI CHO: From the Perspective of a Forensic Behavioral Scientist

N–1

APPENDIX N: A THEORITICAL PROFILE OF SEUNG HUI CHO

A THEORETICAL PROFILE OF SEUNG HUI CHO: From the Perspective of a Forensic Behavioral Scientist

By Roger L. Depue, Ph.D.

When a shocking and horrendous crime has been committed an immediate response is, “Why?” It is human nature to seek an answer to that question, some feasible explanation for the motivation behind the crime. We will never know for certain what motivated Seung Hui Cho to go on a murderous rampage on April 16, 2007. But professionals experienced in the study of multiple victim murderers have noted some patterns of personality and behavior that are pertinent here. As a result of 33 years of experience in the analysis of crimes of violence, including the study of violent fantasies, I have developed the following theory about what drove Cho to do what he did. I begin with a general observation. Most assassinations in the United States are not politically motivated. Instead they are often the work of inadequate persons who do not see any kind of meaningful life for them ahead. As a consequence of any of several types of mental disorders, they have come to the realization that they will never become important persons, such as significant contributors to their society and therefore, memorable persons in history. Some feel so poorly about themselves they do not believe they can even cope with the ordinary responsibilities of life. They feel powerless over their destinies and are helpless victims of their unfulfilled needs. They begin to build a fantasy where they can be achievers and persons who can change the course of history not in a beneficial way, but perhaps as an outcast. There is something significant they can do. These killers target a particular person or persons. They can do away with one of those very people who are functioning well, coping with life’s stresses and requirements all the while achieving success. They can kill one of those people who have risen to a position of accomplishment, influence and prominence. Then they will be forever recognized as the person who shot the president, the movie star, or the famous athlete. They begin to plan the event. They read books and magazines about assassinations of the past. Like John W. Hinkley, Jr., they have their photograph taken in front of Ford’s Theatre and the White House. They write of their plan in essays and journals. They want to make sure that history properly records their most significant event. And if they are killed in the assassination effort it will be worth it. It will be a sacrifice. They can go down in history as a great assassin. Their act will thus be two-fold: they will have a place in history as a major player (on the world scene) if the victim is important enough, and they will be killing that which they can not have for their own by virtue of ability, talent and achievement. Similarly, some multiple victim killers act out of a distorted sense of unfairness and disappointment stemming from their own actual inadequacies and unsatisfied needs

N–2

APPENDIX N: A THEORITICAL PROFILE OF SEUNG HUI CHO

for attention, adulation, power and control. Perhaps, such was the case of Seung Hui Cho. If one examines the life of Cho along the five dimensions of human growth and development, his inadequacies become apparent. Physically Cho was average to below average. He was frail and sick as an infant toddler. Even the autopsy report remarked about his lack of muscle for the body of a 23-year-old male. Emotionally, his growth was stunted as a result of his “selective mutism”. Spiritually, he showed little interest and dropped out of his church before experiencing a growth in faith. Socially, he could not function at all. He was virtually devoid of social skills due to his extreme social anxiety disorder. Intellectually, which was his strongest attribute, he was average to above average in his academic pursuits but even these afforded him little or no consistent or positive sense of achievement based on the feedback from his peers or others. Cho lived a life of quiet solitude, extreme quiet and solitude. For all of his 23 years of life the most frequent observation made by anyone about him was that Seung Hui Cho had absolutely no social life. During all of his school years he had no real friends. He had no interest in being with others. In fact, he shied away from other people and seemed to prefer his own company to the company of others. His few attempts to reach out to females at college were inappropriate and frightened them. Cho was quiet and uncommunicative even in his own family. This led his parents to repeatedly discuss this abnormal characteristic with extended family members, church leaders, schoolteachers, counselors and medical practitioners. It was all to no avail. It appeared this boy could not voluntarily participate in the social arena under any circumstances, regardless of any advice, threats or rewards. Not even the medication he took for a year or the several years of therapy seemed to correct this serious handicap. As a result of this condition of solitude, he grew into a joyless, socially invisible loner. But this condition in no way masked his desire to be somebody. He did well in school in spite of his lack of interaction. He was intelligent and worked hard to complete his assignments so that he could convince his teachers that he had a good grasp of the subject matter presented, even though he was orally mute. He simply did it all alone and with as little oral communication as was absolutely necessary. There are many problems that accompany such a lifestyle. One of the big problems with being a loner is that one does not get helpful reality checks from people who can challenge disordered thinking. Once a loner cuts off outsiders he automatically takes himself out of the game where he could grow, with help, out of his inadequacies. He inadvertently condemns himself to ongoing inadequacy and compensatory fantasies. It was in his second and third year of college that he began to find what he thought would be his niche, his special talent that would set him apart from the sea of other students at the university. He would become a great writer. He changed his major from computer technology to English. He began to write in earnest banging out composition after composition on his computer keyboard. He began seriously to believe that his original material and unique style were very good. He sent a book proposal to a pub-

N–3

APPENDIX N: A THEORITICAL PROFILE OF SEUNG HUI CHO

lisher with great expectations. When it was returned stamped “rejected” he probably was devastated. He internalized this rejection for months. His sister tried to console him and offered to edit his work, but he would not let her even see the document. He tried to impress his English professors with his writing assignments but only one or two saw any particular talent. In fact many of his professors as well as his fellow students reacted negatively to his stories that were often laden with horror and violence. Cho’s dream was slipping away because of people - people who could not see and appreciate his desperate need to be recognized as somebody of importance. Once again he could not function successfully in the real world of people and normal expectations. These rejections were devastating to him and he fantasized about getting revenge from a world he perceived as rejecting him, people who had not satisfied so many of his powerful needs. He felt this way despite the fact that many of his teachers, counselors, and family members had extended themselves to him out of a desire to help him succeed and be happy. At the same time, he realized that his parents had made great sacrifices for him so that he could attend college. He never asked them for anything yet they always asked him if he needed anything. They paid for his tuition, books, and expenses, and tried to give him whatever money he needed despite their own lack of education and low level of employment and earning potential. Perhaps he resented the fact that his parents worked and sacrificed so much and obtained so little in return. Meanwhile he was constantly aware of his classmates taking from their affluent parents and squandering their money on luxuries and alcohol. He perceived that these students had no appreciation for hard work and sacrifice. He saw them as spoiled and wasteful. They drove their BMW’s, dressed in stylish clothes and consumed the best food and drink. They had parties where sex and alcohol were plentiful. These students whom he once secretly wished to join were now considered evil and his peers were conspicuously privileged. They were engaging in “debauchery” and they needed to be taught a lesson. Cho began to fantasize about punishing the “haves” for their stupidity and insensitivity toward him and others like him – the “have nots”. He remembered how Eric and Dylan (in his fantasy he was on a first name basis with Harris and Klebold, the Columbine killers) had extracted their revenge while cheating society out of ever having the opportunity of arresting and punishing them by committing suicide at the end of their massacre. His fantasies began to come out in his writings as he authored plays about violence and revenge. Gradually, he realized he could extract a measure of revenge against the evil all around him. He began to plan. Simply by signing his name, he easily got a credit card to begin to make his purchases. He began to purchase the instruments and muni- tions he would need. He knew that he would never have to pay for these purchases because he would be dead. Like Eric and Dylan, he would kill as many of them as possible and then commit suicide. But his plan would be even better than theirs. He would plan a killing that would go down in history as the greatest school massacre ever. He

N–4

APPENDIX N: A THEORITICAL PROFILE OF SEUNG HUI CHO

would be remembered as the savior of the oppressed, the downtrodden, the poor, and the rejected. There was pleasure in planning such a grand demonstration of “justice.” He began to write about his plan and the rationale for it. He videotaped himself as he performed his role and read from the script he had written. He began to feel a power he had never felt before, and a freedom from his burden of inadequacy. He experienced a freedom to express the fantasies long held in abeyance. Whatever inhibitions he may have had against committing such an act were easily slipping away. He rented a vehicle. He purchased his weapons and ammunition, and began to practice for the big day. The ex- citement mounted as he moved closer to the day of reckoning. Graduation was only weeks away but for Cho it was not an occasion for joy. Rather it was a time of fear and dread. He had never held a job in his life, not even during summer vacations from school. He did not want to go to graduate school as his parents had urged. The educational institution did not appreciate him. He would soon be facing the job market as a mediocre English major whose ideas and compositions as a writer had been rejected, while all those around him were planning careers with enthusiasm and great expectations. What would he ever do once he was out of the intellectual environment of college where his brain had at least some success? He would be turned out into the world of work, finances, responsibilities, and a family. What a frightening prospect. As graduation loomed ahead he felt even more inadequate. There was the probability of only more rejection ahead. By this time Cho may have become submerged (immersed) into a state of self-pity and paranoia, and could not distinguish between constructive planning for the future and the need for destructive vengeance and retaliation. His thought processes were so distorted that he began arguing to himself that his evil plan was actually doing good. His destructive fantasy was now becoming an obsession. He had become a person driven by a need for vengeance and would now strike out against “injustice” and rejection. He would become the source of punishment, the avenger, against those he perceived as the insensitive hypocrites and cruel oppressors. He didn’t need specific targets. His mission was to destroy them all. In his distorted fantasy world, he himself had actually become that which he seemed to despise most. He had become the instrument for the destruc- tion of human dignity and precious potential.

N–5