FINAL REPORT OF THE SANDY HOOK ADVISORY COMMISSION Presented to Governor Dannel P. Malloy State of Connecticut March 6, 2015 DJK/80178/1001/1273016v9 03/03/15-HRT/DJK “[W]e would often hear people say, I can’t imagine what you’re going through. I can’t imagine how hard it must be. I can’t imagine losing your child. And while we appreciated the sentiment, the fact was that they were imagining it. They were putting themselves into our shoes, for at least a second. And as hard and as horrible as it sounds, we need people to imagine what it is like. We need to empathize with each other, to walk a mile in each other’s shoes. Without that imagination, we’ll never change.” –Jeremy Richman, father of Avielle Richman DJK/80178/1001/1273016v9 03/03/15-HRT/DJK DEDICATION The Sandy Hook Advisory Commission dedicates this report to the twenty-six victims who were killed at Sandy Hook Elementary School in Newtown, Connecticut on December 14, 2012, to their families, the Newtown community, and to all those that have come face-to-face with the devastating effects of violence. The families of the twenty children and six educators killed have created a website in an effort to honor and remember the lives and legacies of each victim. The Commission could think of no better way to honor these individuals than to direct our readers to this site. Here you will learn more about the memorials created for each child and educator killed. www.MySandyHookFamily.org * * * The Children (name/age) Charlotte Helen Bacon (6) Daniel Barden (7) Olivia Rose Engel (6) Josephine Gay (7) Ana Grace Márquez-Greene (6) i DJK/80178/1001/1273016v9 03/03/15-HRT/DJK Dylan Christopher Hockley (6) Madeleine Hsu (6) Catherine Hubbard (6) Chase Michael Anthony Kowalski (7) Jesse McCord Lewis (6) James Radley Mattioli (6) Grace Audrey McDonnell (7) Emilie Parker (6) Jack Armistead Pinto (6) Noah Pozner (6) Caroline Previdi (6) Jessica Adrienne Rekos (6) Avielle Rose Richman (6) Benjamin Andrew Wheeler (6) Allison Wyatt (6) The Adults Rachel D’Avino (29) Dawn Hochsprung (47) Anne Marie Murphy (52) Lauren Gabrielle Rousseau (30) Mary Sherlach (56) Victoria Leigh Soto (27) ii DJK/80178/1001/1273016v9 03/03/15-HRT/DJK TABLE OF CONTENTS DEDICATION ................................................................................................... i FOREWORD.................................................................................................... x I. PREFACE .............................................................................................. x II. GOVERNOR DANNEL P. MALLOY’S CHARGE TO THE SANDY HOOK ADVISORY COMMISSION (PRESENTED ON JANUARY 24, 2013) ......... xii III. MEMBERSHIP OF THE SANDY HOOK ADVISORY COMMISSION ......... xiv ACKNOWLEDGMENTS .................................................................................. xvi EXECUTIVE SUMMARY .................................................................................. 1 I. THE SUBSTANTIVE COMPONENTS OF THE FINAL REPORT ................. 4 A. Safe School Design And Operation ...................................................... 4 B. Law Enforcement, Public Safety And Emergency Response ................. 5 C. Mental and Behavioral Health ............................................................. 7 OVERVIEW OF MASS SHOOTINGS AT SANDY HOOK ELEMENTARY SCHOOL ON DECEMBER 14, 2012 ............................................................... 10 PART ONE FINDINGS AND RECOMMENDATIONS OF THE SAFE SCHOOL DESIGN AND OPERATIONS WRITING GROUP, AS ADOPTED AND APPROVED BY THE FULL COMMISSION ...................................................................................... 14 I. PRELIMINARY STATEMENT ................................................................. 14 A. Contents Of Safe School Design And Operations Writing Group Report. ............................................................................................. 15 B. Who Should Read This Report? ......................................................... 16 C. Why The Commission’s Recommendations Should Be Credited. ........ 17 II. GUIDING PRINCIPLES OF SAFE SCHOOL DESIGN AND OPERATION RECOMMENDATIONS. ........................................................................ 20 iii DJK/80178/1001/1273016v9 03/03/15-HRT/DJK A. The “All Hazards” Approach To Safe School Design And Operation. ... 20 B. The Commission Based Its Recommendations On Their Perceived Efficacy, Not Their Anticipated Cost. ................................................. 23 C. Safe School Design and Operation Strategies Can And Should Enhance, Not Diminish, Students’ Educational Experience. .............. 24 D. The Importance Of “Situational Awareness.” ..................................... 25 E. The Importance Of Creating A Safe School Climate. .......................... 27 F. Safe School Design and Operations Strategies Must Be Tailored To The Needs Of Particular Communities And Specific Schools. ............. 29 G. Safe School Design And Operation Standards Are Not Static. They Must Be Reviewed And Updated On A Regular Basis. ........................ 31 H. Successful Implementation Of Safe School Design And Operation Strategies Requires “Local Champions.” ............................................ 31 III. RECOMMENDATIONS ......................................................................... 32 IV. ENDORSEMENTS AND COMMENTS .................................................... 38 A. Endorsement of Public Act 13-3. ....................................................... 38 B. Endorsement of School Safety Infrastructure Council Report and School Security and Safety Plan Standards. ...................................... 40 V. KEY SAFE SCHOOL INFRASTRUCTURE COUNCIL STANDARDS ......... 45 PART TWO FINDINGS AND RECOMMENDATIONS OF THE LAW ENFORCEMENT WRITING GROUP, AS ADOPTED AND APPROVED BY THE FULL COMMISSION ........... 61 I. INTRODUCTION .................................................................................. 61 II. INTERIM REPORT RECOMMENDATIONS ............................................ 63 A. Firearm Permitting And Registration ................................................. 64 B. High-Capacity Firearms, Magazine Capacity, And Ammunition ......... 65 C. Assault Weapons .............................................................................. 67 iv DJK/80178/1001/1273016v9 03/03/15-HRT/DJK D. Firearm Storage And Security ........................................................... 67 E. Additional Recommendations Re: Firearms And Ammunition ............ 68 III. FINAL REPORT RECOMMENDATIONS ................................................ 69 A. Firearms/Ammunition ...................................................................... 69 B. Best Practices/Protocols ................................................................... 71 C. Gun Violence Reduction Strategies ................................................... 77 PART THREE FINDINGS AND RECOMMENDATIONS OF THE MENTAL HEALTH WRITING GROUP, AS ADOPTED AND APPROVED BY THE FULL COMMISSION ........... 79 I. INTRODUCTION .................................................................................. 79 II. MODELS OF CARE .............................................................................. 85 A. Analysis: Reforming The System ....................................................... 85 1. Laying the groundwork for lifelong mental health .......................... 87 2. Treating the whole person and the whole family ............................. 89 3. Family-centered care ..................................................................... 94 4. Places of care: schools and communities ....................................... 99 5. Social isolation ............................................................................ 105 6. Concluding thoughts ................................................................... 108 B. Recommendations .......................................................................... 109 III. BARRIERS TO ACCESS: INSURANCE AND FUNDING ISSUES ........... 113 A. Analysis: System Fragmentation As A Barrier To Effective Care....... 113 1. Improving access to effective services in the public system........... 116 2. Elevating reimbursement rates to meet the costs of care .............. 117 3. Improving access to effective services in the private system.......... 119 v DJK/80178/1001/1273016v9 03/03/15-HRT/DJK 4. Expanding an overtaxed workforce .............................................. 124 5. Concluding thoughts: Toward a more integrated system of care ... 126 B. Key Findings And Recommendations .............................................. 127 IV. BARRIERS TO ACCESS: STIGMA AND DISCRIMINATION .................. 130 A. Analysis: Confronting Mental Health Stigma ................................... 130 1. Defining stigma ........................................................................... 131 2. The pervasiveness of stigma ........................................................ 134 3. Stigma deters access to care ........................................................ 136 4. Stigma impacts what care is available.......................................... 138 5. Internalized stigma ...................................................................... 140 6. The media’s role in perpetuating stigma ....................................... 142 7. Effectively combating stigma........................................................ 143 8. Concluding thoughts ................................................................... 149 B. Key Findings And