The Army reservist who committed Maine’s deadliest mass shooting, killing 18 people, exhibited red flags for months before his shooting spree, but his leaders failed to act because of communication gaps between civilian and Army worlds, limited policy, and confusion over what Army authorities could legally do.
Sgt. First Class Robert Card attacked a bowling alley in Lewiston, Maine Oct. 25, 2023, opening fire on patrons. He then went to a bar in the town a few minutes later and continued firing. Card killed 18 people across the two locations and injured 13 others. His remains were found after a two-day manhunt at the recycling center where he had previously worked and was fired from. He died from a self-inflicted gunshot.
“Good leaders care about their soldiers and they make sure that their civilian life is proceeding as well as it can. Having those good contacts and knowing about your soldiers is what we can continue to emphasize and make sure that our leaders actually follow through and care for their soldiers,” Lt. Gen. Jody Daniels, Chief of the Army Reserve said.
Family members warned law enforcement officials that Card was deteriorating in the months before the killing. Notably, the report downplays suspicions by civilian doctors who examined Card’s brain that he suffered from the effects of traumatic brain injuries after years as a firearms and explosives instructor.
In November, both U.S. Senators from Maine sent a letter to the Army’s Inspector General to ask for a comprehensive review of the Army’s handling of Card in the months before the shooting. The Army Reserve’s 15-6, released Tuesday, found procedural breakdowns between the military and civilian health systems that Card interacted with, and that certain Army procedures weren’t followed or understood by his chain of command. The case also highlighted existing issues with the legal authority that the Army Reserve had over Card, a part-time soldier, the report said.
The case prompted a revision and review of several Army policies and administrative actions against three officers in Card’s chain of command for “dereliction of duty.”
At a press conference Monday on the Army’s 15-6 findings, Daniels said the actions “have the potential to prevent further military advancement of those officers” or they could face a show cause board which could lead to administrative separation. The Army would not release their names “because the officers are in the rank of colonel and below.”
In the report and at the Monday press conference, the Army distanced itself from local reporting on Card’s brain injuries due to military service and a Boston University research analysis of Card’s brain tissue. BU researchers found Card had “significant evidence of traumatic brain injuries” which they suggested could be from his exposure to “thousands of low-level blasts” as an Army instructor for a grenade training range.
The Army reported a 2008 incident where Card fell from a roof and broke his neck and noted Card “was not exposed” to combat environments. Daniels doubled down on this point, adding that his exposure to shock was “relatively minor.” She referred questions on his brain health to Walter Reed National Military Medical Center which is conducting a forensic autopsy.
“SFC Card’s death was preceded by a series of events beginning in the Fall of 2022, which likely exacerbated his mental health issues leading up to his suicide,” the report said.
Who was Robert Card?
Sgt. 1st Class Card was a Petroleum Supply Specialist in the Army Reserve who enlisted in December 2002. In his reserve duty, Card served as a senior trainer for firearm instruction at West Point with a focus on hand grenades and crew-served weapons. The report referred to Card’s 20-year military career as “unremarkable” and said he did not deploy or mobilize with the Army.
In 2017, Card was referred to a medical board during his retention review over his hearing issues which found him fit for duty. Card had become eligible to retire in March 2023, according to the Pentagon.
Fellow reservists described Card as “kind, friendly, calm, and generous,” the report said.
The report also looked into Card’s past. The report found Card dealt with anxiety and was described as sensitive and an introvert with a small group of friends as a child. He was not violent and “would often hide” when it was time to go hunting or a farm animal had to be euthanized. The report also said he experimented with drugs as a young adult and drank socially but “became emotional or angry if he drank too much.” Card’s autopsy did not find any substances in his system.
Behavioral health concerns grow
In the months before the mass shooting, family and friends reported Card’s changing behavior to Army officials which included his perception of others making derogatory statements about him, including the use of hearing aids, and conflicts with members of his Army reserve unit. At the same time, Card’s family reported their concerns over his “deteriorating mental state” and sought help from law enforcement in May 2023.
Card was ordered to attend annual Reserve training in July 2023 where he had a verbal altercation with other soldiers. As a result, he was ordered to undergo a Command Directed Behavioral Health Evaluation the next day. Army providers recommended Card be entered into the Disability Evaluation System and be discharged.
Army officials then ordered that Card go to Four Winds Hospital in Westchester, Katonah, New York for further evaluation and treatment. He was placed on medical leave at the hospital where he stayed for 19 days. The NY hospital reported his symptoms included psychosis, mood lability/aggression, homicidal ideation, paranoia, and auditory hallucinations.
On July 23, Card’s access to his assigned weapon was restricted. But Card’s family had previously reported to law enforcement that they believed he had 10-to-15 rifles or handguns at his residence.
Card was discharged Aug. 3 from Four Winds Hospital “under questionable circumstances, and released from his USAR orders with a diagnosis of ‘Brief Psychotic Disorder.’” Medical personnel recommended follow on treatment and psychiatric medication. A court hearing to involuntarily commit Card to Four Winds was canceled, and on August 3rd, Card was released to a soldier and friend from his unit. Daniels said this decision was made by medical personnel.
“This investigation was unable to determine the reason for SFC Card’s release due to the hospital staff declining to speak with the investigating officer,” the Army said.
When Card was released, his chain of command was not given any details on his diagnosis, prognosis or discharge instructions. After receiving Card’s discharge instructions (eight days after Card’s release), the nurse care manager did not upload documents into Card’s military medical record for another 10 days, nor did she closely review discharge instructions, “which would have revealed troubling information that could have been relayed to the chain of command,” the Army said.
“The failure was not generating a report to the Army within the Army channels to say, ‘I had a soldier who was hospitalized for more than 24 hours,’” Daniels said, which would’ve started the line of duty requirements to document Card’s current care and use it for potential follow-on care with the Department of Veterans Affairs.
When soldiers in Card’s chain of command were asked if they sought discharge or prognosis information from Four Winds, they told officials they believed it was covered under HIPAA protections. Daniels said there was a misunderstanding in what was covered and what could be exempt under command authority so the Army ordered
The Army recommended that the Department of Defense reconsider using Four Winds Hospital as an authorized treatment facility and terminate its contract with the company that provided case management services. The Army also requested that the Defense Health Administration and Army Surgeon General require written communication with a soldier’s chain of command at the lowest level and that medical agencies are properly trained on the basic nature of a reservist’s service for better monitoring and follow-on care.
Leaving the hospital
Aug. 3rd, 2023, was Card’s last day in a duty status with the Army Reserve. After his August discharge, Card complained to friends and family that he was upset about his hospital stay and he “began to communicate vague threats of violence.” Two days after leaving the hospital, Card tried to pick up a firearm silencer he ordered online a month earlier but store employees refused to sell it after he self-reported his psychiatric facility stay.
On Aug. 11, Card told a nurse care manager from Keller Army Hospital who contacted him that he stopped taking a prescribed medication “because it made him feel lazy.” That same day, he also told the U.S. Army Reserve Psychological Health Program that he was upset that his hospitalization limited his ability to purchase firearms.
Later that month, PHP closed Card’s case because he was unresponsive to efforts to contact him, which was in line with policy at the time. The Army has since revised its policy.
“Just because someone is non responsive doesn’t mean that we don’t need to have additional contact with them,” Daniels said. “We don’t want to close it just because they didn’t answer the phone. We’re making that change so that we continue to press to get a bit better resolution.”
The Army is also revising policies to make sure that Army Reserve leaders understand HIPAA requirements, resources for covering soldier health care costs and reservists’ personal weapons. Besides increasing training for leadership, Daniels noted the limitations of the Army Reserve’s authority on personal weapons.
“We can recommend that they lock them in a safe. We can provide all kinds of other safeguards and advice, but there’s nothing that we can actually compel them to do, unless there has been a medical determination and in this case, there was not because Sgt. Card was released by the Civilian providers to go home,” Daniels said.
Another failure occurred on Sept. 13, when Card told a fellow reservist that he “could take out 100 people with this expensive scope” and a list of places he could “shoot up.” This was reported to the chain of command and referred to local law enforcement who tried to contact him Sept 15 and 16.
“Despite SFC Card being inside his home on the 16th, local authorities did not force an interaction or attempt to employ the Maine Yellow Flag Law, which could have restricted SFC Card’s access to his privately owned firearms,” according to the report.
The report also highlighted the gap between Army authorities and law enforcement. Daniels said it’s hard to come up with an official way forward because each law enforcement jurisdiction is different.
“We have to be careful to balance protection of civil rights versus if we’re concerned about health safety concerns – then the commanders will obviously initiate an action, but each jurisdiction also varies as to how they will respond to those,” Daniels said. “There’s so much variance. I don’t know. Let’s see how we can proceed.”
The investigation was turned over to the Department of Forensic Psychology at the Walter Reed National Military Medical Center for review and analysis of whether Four Winds met the Standard of Care and whether Card’s condition was in the Line of Duty.
Maine’s state police and a state commission are conducting separate investigations.