The independent commission investigating the mass shootings in Lewiston faulted local sheriff’s deputies and Army reserve officials for not taking all available steps to potentially thwart the gunman in the months before the tragedy.

After hearing from dozens of witnesses in public and private meetings and reviewing thousands of pages of documents, the commission concluded its work without making any formal policy recommendations.

Those are being left to elected and appointed officials to decide, commission chairman Daniel Wathen said during a Tuesday morning press conference. But in their final report released Tuesday, the seven commissioners say they hope the facts they’ve uncovered will help prevent a similar tragedy in the future.

“We will never know if he might still have committed a mass shooting even if someone had managed to remove Card’s firearms before Oct. 25,” said Wathen, a former chief justice of the Maine Supreme Judicial Court. “But the Commission unanimously finds that there were several opportunities that, if taken, might have changed the course of events.”

As they did in their interim report, the commission finds fault with the Sagadahoc County Sheriff’s Office for failing to take the gunman, Robert Card, into protective custody and trying to take away his firearms under Maine’s yellow flag law. That 2019 law allows police to seek a court order to temporarily seize the weapons on individuals considered to a pose a threat to themselves or others.

“Based on the information available to the Sheriff’s Office from Card’s family members and colleagues in the AR [Army Reserve], as well as the historical information available within its own files, the Sheriff’s Office had probable cause to believe that Card was mentally ill and that due to that illness, he posed a likelihood of serious harm,” reads the report. “Indeed, the available information concerning Card’s declining mental health and threats of violence was greater than the information forming the basis for many ‘yellow flag’ orders obtained by law enforcement officers in Maine before September of 2023.”

They also criticized leaders of Card’s Saco-based Army Reserve unit. Those commanders ordered Card to receive a psychiatric evaluation in July 2023 after he was behaving erratically — accusing other reservists of calling him a pedophile and then trying to fight others during a training mission to West Point, New York.

“Card’s commanding officers knew of his auditory hallucinations, increasingly aggressive behavior, collection of guns, and ominous comments about his intentions,” Wathen said. “Despite their knowledge, they ignored the strong recommendations of Card’s mental health providers to stay engaged with his care and take steps to remove weapons from his home.”

The commission also said that the Army neglected to share all the information relating to Card’s threatening behavior with the Sagadahoc County Sheriff’s Office and discounted warning from Card’s friends that he might “snap” and commit a mass shooting.

“Had members of Card’s Army Reserve unit presented a full and complete accounting of the facts, the Sheriff’s Office might have acted more assertively in September,” Wathen said.

The report does not, however, devote much time to Card’s time at the private psychiatric facility in New York, Four Winds Hospital, where he was treated for roughly two weeks after that initial psychiatric evaluation.

Card was released a day after a court hearing to consider his involuntary commitment was abruptly canceled. According to the report, Card was progressing in treatment, had agreed to continue taking his medications and participate in therapy and his treating psychiatrist “did not feel that the hospital would be successful in court.”

Eighteen people were killed and 13 injured as they bowled, played cornhole and relaxed with their family and friends at Just in Time Recreation and Schemengees Bar and Grille.

And while no one but Card is ultimately responsible for their deaths, the report finds that there were multiple ways the tragedy might have been prevented beginning in May, 2023. That’s when Card’s ex-wife and teenage son alerted the Sagadahoc County Sheriff’s Office that he was having delusions, becoming more aggressive and had access to an arsenal of weapons.

Card’s command in the Army Reserves were also aware of his increasing paranoia at least six months before the Oct. 25 shootings. Card had accused friends, family and total strangers of calling him a pedophile behind his back. But the situation escalated in July. While his unit was in New York to train West Point cadets in firearms and explosives, Card got into a fight with some fellow reservists. He was ordered to undergo a psychiatric evaluation and spent 19 days in a private mental health hospital where he was diagnosed with psychosis.

According to an Army investigation, Card had a “hit list” and was having homicidal ideations at the time of his hospitalization. It remains unclear why the private Four Winds Hospital released Card. The commission report as well as the separate Army report faulted Card’s Reserve commanders for not keeping him on “active duty” status after his release because they lost much of their authority over him once he returned to civilian life.

Attorneys representing victims and survivors of the shootings say they appreciate the facts gathered by the commission. What’s clear, says attorney Ben Gideon, is that someone with a diagnosed psychoses who also possesses numerous assault weapons requires action.

“There’s not much of a debate in this country about whether folks who have diagnosed mental health illness and have expressed the desire to commit violence should continue to possess weapons of warfare as occurred here. That shouldn’t happen. It shouldn’t have happened here and it should never be allowed to happen again,” he says.

Gideon pointed to other missed opportunities for action, including efforts by Card’s sister who repeatedly tried to speak to his Army Reserve leaders and never got a return phone call in April and May; her conversation with a VA crisis worker who told her that her brother’s delusions of being called a pedophile could harm his career; and her ongoing frustration in finding ways to help him.

“The next step in this process needs to be real accountability and that’s where we come in. And in the next few months you will be hearing about what that plan entails in terms of the civil lawsuits and cases we will be pursuing on behalf of all of our clients,” he says.

Speaking through an interpreter, Megan Vozzella, whose husband, Steve, was killed in the shootings, says more accountability is needed including better communication access for the deaf community. Four of the people killed were deaf. Their friends and family members struggled to get information that night.

“I want to see policies for police departments about communication access. I want the military to improve their access needs for mental health. And I think it’s really important for their health needs. People are crying out for help and they’re not getting it and the result is they harm innocent people in innocent communities,” she says.

One specific suggestion included in the report is that Maine State Police undergo an independent, after-action review about its massive response to the mass shootings, described as “utter chaos” in the first hours after hundreds of law enforcement officers descended on Lewiston. Wathen says that will allow for policy, protocol and other policing improvements.

The seven commissioners, who were selected by Gov. Janet Mills, included several retired judges, a former U.S attorney, a former chief forensic psychologist and a psychiatrist.

Mills helped author Maine’s yellow flag law in collaboration with a gun rights group, the Sportsman’s Alliance of Maine in 2019. That law came into play during commission hearings because it sets up a process for taking someone considered a threat to themselves or others into protective custody and then petitioning a judge to remove their firearms. In their interim and final reports, commissioners were highly critical of Sagadahoc County Sheriff’s deputy Aaron Skolfield who was asked to do a welfare check on Robert Card six weeks before the mass shooting but who they said made only half-hearted attempts to meet with Card face to face and left his family in charge of removing his weapons.

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