MassMass ShootingsShootings atat VirginiaVirginia TechTech AddendumAddendum toto thethe ReportReport ofof thethe ReviewReview PanelPanel PresentedPresented to:to: GovernorGovernor TimothyTimothy M.M. KaineKaine CommonwealthCommonwealth ofof VirginiaVirginia November 2009 Mass Shootings at Virginia Tech Addendum to the Report of the Review Panel Presented to: Governor Timothy M. Kaine Commonwealth of Virginia Presented by: TriData Division, System Planning Corporation 3601 Wilson Boulevard Arlington, VA 22201 November 2009 INTRODUCTION On April 16, 2007, Virginia Tech experienced one of the most horrific events in American uni- versity history—a double homicide followed by a mass shooting that left 32 students and fac- ulty killed, with many others injured, and many more scarred psychologically. Families of the slain and injured as well as the university community have suffered terribly. Immediately after the incident Virginia Governor Timothy M. Kaine created a blue ribbon Re- view Panel, referred to as the Virginia Tech Review Panel, which consisted of nine members selected for their expertise in the areas that were to be investigated. The Review Panel’s mis- sion was to assess the events leading to the shooting and how the incident was handled by the university and public safety agencies. Mental health services and privacy laws were examined as well. The Review Panel was to make recommendations that would help college campuses prevent or mitigate such incidents in the future. The Report of the Review Panel was presented to the Governor in late August 2007. It is referred to as the “Report” in this Addendum. SCOPE OF THIS REPORT: ADDITIONS AND CORRECTIONS In the two years since the Review Panel’s report was published, additional information has been placed in the public record, including Seung Hui Cho’s case file from the Cook Counseling Center and a recent report from the Commonwealth’s Inspector General concerning the Cook Counseling Center’s handling of Cho’s records. Briefings to the victims’ families by police and Virginia Tech officials provided additional details of the events In light of the new information presented to the families, and other information they found in the April 16 archive, several family members requested that additions and corrections be made to the Report. Some families had personal knowledge of the events that were not previously shared. Some families requested new interpretations of certain findings or revisions to some of the Review Panel’s recommendations in light of the new information. Virginia Tech officials also submitted comments requesting some corrections. Governor Kaine asked the victims’ families and Virginia Tech to submit any corrections or ad- ditions they thought important by the end of August, 2009. The time was extended into Sep- tember after discovery of Cho’s missing Cook Counseling Center records. This Addendum responds to the comments and questions received from the families and Vir- ginia Tech by correcting facts in the original report, including the timeline, and by adding addi- tional information about the events leading to the incidents, the response to the incidents, and the aftermath of April 16. The Addendum also includes corrections to names and titles of peo- ple cited in the Report or the list of interviewees. The Addendum does not address opinions or value judgments that were raised, but provides some additional background information that might help address the concerns raised. ADDENDUM PROCESS Governor Kaine engaged the TriData staff that supported the Review Panel to review the addi- tional information and the questions and comments about the Report. TriData was familiar with the research and details of the Report, the sources, and the deliberations behind the Re- port’s original findings and recommendations. All comments received by the Governor’s Office were forwarded to TriData for review. INTRODUCTION The focus of this Addendum is on correcting and adding to the pertinent facts. Many of the families as well as Virginia Tech submitted corrections or comments and added detailed refer- ences to documents now in the public record. After completing an initial review of the com- ments from all parties, TriData submitted a number of questions to Virginia Tech and also in- terviewed several family members for clarification of their comments, and to cross-check in- formation and corroborate facts. There are conflicting opinions on whether the Review Panel should have treated certain issues differently, reached stronger or different conclusions, placed blame on certain individuals, or interviewed additional people. The new and additional information has tended to reinforce the Review Panel’s original findings and recommendations. In several instances, emphasis was added to findings where strongly supported by the facts. While some of the findings have been modified slightly and one added, none of the new information merited changes to any of the recommendations in the original Report. A number of questions and corrections were raised about the timeline in the Report. The time- line was intended to provide an overview of the most important markers in the sequence of events to assist readers as a reference as they went through the details in the text. The Review Panel chose not to include many details in the timeline that were later discussed in the text. This Addendum contains an expanded timeline with virtually all of the additions suggested by the families. SCOPE OF ORIGINAL REVIEW PANEL REPORT As described in the Review Panel’s Report, Governor Kaine’s executive order directed the Re- view Panel to accomplish the following: 1. “Conduct a review of how Seung Hui Cho committed these 32 murders and multiple ad- ditional woundings, including without limitation how he obtained his firearms and am- munition, and to learn what can be learned about what caused him to commit these acts of violence.” 2. “Conduct a review of Seung Hui Cho's psychological condition and behavioral issues prior to and at the time of the shootings, what behavioral aberrations or potential warn- ing signs were observed by students, faculty and/or staff at Westfield High School and Virginia Tech. This inquiry should include the response taken by Virginia Tech and oth- ers to note psychological and behavioral issues, Seung Hui Cho's interaction with the mental health delivery system, including without limitation judicial intervention, access to services, and communication between the mental health services system and Virginia Tech. It should also include a review of educational, medical, and judicial records docu- menting his condition, the services rendered to him, and his commitment hearing.” 3. “Conduct a review of the timeline of events from the time that Seung Hui Cho entered West Ambler Johnston Dormitory until his death in Norris Hall. Such review shall in- clude an assessment of the response to the first murders and efforts to stop the Norris Hall murders once they began.” 4. “Conduct a review of the response of the Commonwealth, all of its agencies, and rele- vant local and private providers following the death of Seung Hui Cho for the purpose of providing recommendations for the improvement of the Commonwealth's response in similar emergency situations. Such review shall include an assessment of the emer- gency medical response provided for the injured and wounded, the conduct of post- INTRODUCTION mortem examinations and release of remains, on-campus actions following the tragedy, and the services and counseling offered to the victims, the victims' families, and those affected by the incident. In so doing, the Review Panel shall to the extent required by federal or state law: (i) protect the confidentiality of any individual's or family member's personal or health information; and (ii) make public or publish information and findings only in summary or aggregate form without identifying personal or health information related to any individual or family member unless authorization is obtained from an in- dividual or family member that specifically permits the Review Panel to disclose that person's personal or health information.” 5. “Conduct other inquiries as may be appropriate in the Review Panel's discretion other- wise consistent with its mission and authority as provided herein.” 6. “Based on these inquiries, make recommendations on appropriate measures that can be taken to improve the laws, policies, procedures, systems and institutions of the Com- monwealth and the operation of public safety agencies, medical facilities, local agencies, private providers, universities, and mental health services delivery system.” “In summary, the Review Panel was tasked to review the events, assess actions taken and not taken, identify lessons learned, and propose alternatives for the future. Included a review of Cho’s history and interaction with the mental health and legal systems and of his gun pur- chases. The Review Panel was also asked to review the emergency response by all parties (law enforcement officials, university officials, medical responders and hospital care providers, and the Medical Examiner). Finally, the Review Panel reviewed the aftermath—the university’s approach to helping families, survivors, students, and staff as they dealt with the mental trauma and the approach to helping the university heal itself and function again.” REVIEW PANEL AND STAFF The Review Panel consisted of nine highly distinguished members from a variety of relevant backgrounds. Members included a former