Nine months after a former member of the U.S. Army Reserve killed 18 people in two linked massacres that became the deadliest shootings in Maine’s history, a special commission tasked with investigating what happened, and whether it could have been prevented, released a final report Tuesday detailing missed opportunities to potentially stop the rampage.

The report pointed to failures on the parts of both the Army Reserves and local law enforcement to intervene in the gunman’s psychiatric crisis, creating an image of a spiraling reservist whose weapons should have been seized before he had a chance to carry out the attacks.

The independent commission — which held more than a dozen public meetings, heard from scores of witnesses and reviewed thousands of pages of evidence — cited shortcomings by police for failing to take the gunman’s weapons and by the Army Reserves for failing to provide proper care for the 40-year-old gunman, Robert Card.

The commission, created by Gov. Janet Mills, a Democrat, announced its conclusions at Lewiston City Hall, less than 3 miles from the two sites where the shootings took place on Oct. 25, 2023.

The 215-page report reiterated the panel’s conclusion from an interim finding in March that law enforcement had authority under the state’s yellow flag law to seize the shooter’s guns and put him in protective custody weeks before the shootings. But it also said the Army Reserves also should have done more, as well, to ensure care and deal with the weapons.

While the commission noted near the beginning of the report that the gunman “is solely responsible for his own conduct,” and may have committed a mass shooting even if his weapons had been taken from him prior to Oct. 25, it highlighted opportunities to intervene “that, if taken, might have changed the course of events.”  

In the case of the “yellow flag” order, commissioners found that the local sheriff could have pursued one against Card in September of 2023, not long before the shootings. 

“Based on the information available to the Sheriff’s Office from Card’s family members and colleagues in the [Army Reserves], 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,” the report said.

Daniel Wathen, chair of the commission, started his remarks by acknowledging the victims. “None of us can begin to imagine the pain you people have experienced on that terrible day,” he said.

He said it’s impossible to know if the tragedy would have happened if police and the Army had done a better job. He also said police did their best to respond to the tragedy but noted that there was “utter chaos” when hundreds of police officers poured into the region.

In a letter addressed to Gov. Mills that introduced Tuesday’s report, Wathen also recognized some of the broader consequences of the shooting.

“Every Mainer was touched by what occurred on October 25, 2023. The acts of violence ended and upended our lives, forever changed our communities, and damaged a sense of safety and tranquility that defines what it means to live in Maine,” he wrote. “Our investigation and the information and findings set out in this final report are meant to bring truth to the victims’ families, to those who were injured, and to the people of our state and nation.”

Wathen closed the letter by saying, on behalf of the commission, that he hopes their findings “will help the healing process” while, at the same time, “enabling the public and policymakers to learn from mistakes.”

The commission began its work a month after the mass shooting by Card, an Army reservist who killed 18 people at a bowling alley and a bar in Lewiston and then took his own life. Over nine months, there has been emotional testimony from family members and survivors of the shooting, law enforcement officials and U.S. Army Reserves personnel, and others.

The commission’s public hearings revealed the swift response by police to the shootings, but also the ensuing chaos during the intensive search for the gunman. Card’s sister testified at a hearing, her hand resting on his military helmet as she spoke. Kathleen Walker, whose husband, Jason, was killed while rushing at Card to try to stop him, said: “The system failed, and we can’t allow this to happen again.”

Family members and fellow reservists said Card had exhibited delusional and paranoid behavior months before the shootings. He was hospitalized by the Army during training in July 2023, but a commanding officer acknowledged to the commission that he didn’t check on Card’s compliance on follow-up care.

The starkest warning came in September when a fellow reservist texted an Army supervisor, saying, “I believe he’s going to snap and do a mass shooting.” Card was found dead by his own hand after the search that followed the shootings.

Army officials conducted their own investigation after the shootings that Lt. Gen. Jody Daniels, then the chief of the Army Reserves, said found “a series of failures by unit leadership.” Three Army Reserve leaders were disciplined for dereliction of duty, according to the report, which noted communication failures within the chain of command and between military and civilian hospitals.

Maine’s legislature passed new guns laws for the state, which has a tradition of hunting and firearms ownership, after the shootings. A three-day waiting period for gun purchases went into effect this month.

Wathen is a former chief justice of Maine’s highest court. The seven-member commission also included two former federal prosecutors, two additional former judges, the state’s former chief forensic psychologist, and a private psychiatrist who’s an executive at a psychiatric hospital.