The chain of command above the Army Reservist who committed the worst mass shooting in Maine history “neglected” to use tools at their disposal and “downplayed” the severity of threats that the reservist made in the weeks before. The conclusions were reached by an independent commission launched by Maine Gov. Janet Mills last year, which was separate from an Army-led investigation of the mass shooting that killed 18 and injured 13 in October 2023.
In their final report, the Maine commission more directly faulted the leadership of Sgt. First Class Robert Card’s Army Reserve unit more than the Army’s 15-6 investigation. The Maine review found leaders in Card’s 304th Infantry Regiment “neglected to use the tools available to them” and cited two specific Army Reserve officials’ for not initiating a Line of Duty investigation after Card was hospitalized following erratic behavior, including during reserve training with live weapons. The Maine investigators included several civilian attorneys, a forensic psychologist, and a psychiatrist.
“The Army Reserve unit also missed several opportunities that might have reduced the risk of this tragedy occurring,” the commission said.
In July, the Army Reserve released its own review of the events which found that officials missed signs leading up to the shooting.The report concluded that Card’s leaders failed to act because of communication gaps between civilian and Army worlds, limited authority over part-time soldiers and confusion with Army policies. The Maine commission pushed back.
“The AR leadership did not try any of these options. Card was left to continue his isolation, disengaged from other unit members or other sources of support,” the commission said.
The Army’s report prompted Reserve officials to take administrative action against three officers in Card’s chain of command for “dereliction of duty” which could prevent further promotions or lead to a show cause board for potential administrative separation. Bryce Dubee, a spokesperson for the Army said in a statement that administrative actions against the officers have “already been completed.”
“The Army Reserve is instituting policy changes to its Psychological Health Program and is communicating changes and lessons learned to Pre-Command Courses and Army Reserve Senior Leader Orientation,” Dubee said. “Army leadership is committed to reviewing the findings and implementing sound changes to prevent tragedies like this from recurring.”
The Reserve investigation had not included the officer’s names because their ranks were below colonel but the Maine report did not hold back and listed numerous individual failings by Card’s unit leaders.
Mental health treatment, discharge
In July 2023, Card attended Army Reserve training at the Military Academy at West Point in New York where fellow soldiers noticed his increasing paranoia and reported their “concerns for the safety of the cadets and soldiers if Card were to react violently during the training.” Card was brought to Keller Army Community Hospital for a command-directed behavioral health evaluation directed by Capt. Jeremy Reamer, Card’s direct commander.
The Reserve 15-6 report said that Army providers who conducted the command-directed evaluation said Card did not meet medical retention standards and that he be entered into the Disability Evaluation System which would facilitate his service discharge. Psychiatric nurse practitioner Capt. Mathew Dickison told Reamer to “include medical” to start the medical board process. However, the Maine commission found no paperwork indicating a pending retirement application or that Reamer initiated a medical board review or forced medical discharge.
During his stay at Keller, Dickison diagnosed Card with “unspecified psychosis not due to a substance or psychological condition” and recommended he be transferred to another hospital for a “higher level of care.”
Card agreed to be transferred to Four Winds Hospital in New York which he stayed at for evaluation and treatment between July 16 and Aug. 3, 2023. The Reserve’s investigation found that he was discharged “under questionable circumstances” and released to a soldier and friend from his unit. Reserve investigators said they were unable to determine the reason for his discharge due to the hospital staff declining to speak with them.
Army Reserve Chief Lt. Gen. Jody Daniels said the discharge decision was made by medical personnel. Card’s psychiatrist told the Maine commission that his treatment progress, agreement to continue medication and therapy, and current stabilization led her to believe that the hospital would be unsuccessful in pursuing additional court-mandated treatment. At the time of his discharge, the doctor said it was her opinion that Card was “safe to be released.”
When Card was released, his chain of command was not given any details on his diagnosis or discharge instructions, the Army said in its investigation. Daniels said there was no report to the Army that would’ve acknowledged a soldier hospitalized for more than 24 hours 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.
However, Dickison, the nurse practitioner, told the Maine commission he verbally made several recommendations to Reamer that he failed to follow. This included ensuring Card attended follow-up appointments and increasing supervisory support to keep him engaged with the unit and other Army resources.
Dickison said that Reamer left him with the impression that he would carry out the recommendations. Instead, the commission found, Reamer neglected to follow any of Dickison’s suggestions.
“In fact, he ignored them,” the report said.
After the U.S. Army Reserve Psychological Health Program tried to contact Card over email and phone to no avail, officials closed his case “due to his noncompliance,” the commission said. The decision to close his case was in line with policy at the time but the Army said it has since revised it.
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Lt. Col. Ryan Vazquez who took over Card’s battalion in June 2023 testified to the commission that he discussed Card’s psychosis diagnosis and hospitalization with Reamer but the commission found that “it does not appear” Vazquez provided Reamer with any “meaningful advice, guidance or direction about Card.”
The commission acknowledged that “Reamer had inadequate support in a difficult situation,” but called out his lack of initiative to use Reserve policies and procedures to help Card and alleviate the situation.
Access to firearms
The Army said Card’s access to his assigned weapon was restricted on July 23 but Card’s family previously reported to law enforcement that they believed he had other rifles or handguns at home.
One of Dickison’s other recommendations to Reamer was that he encourage Card to temporarily secure his personal weapons in the Reserve unit’s arm rooms or another safe spot. “I was all about making sure the service member did not have access to weapons,” Dickison told the commission.
However, Vazquez told the commission that the Reserve “strongly discouraged the storage” of soldiers’ personal weapons. He said that it was “very challenging” and “without certain permissions, it would have been impossible.” He promised the commission a memo that dictated this policy but the Reserve never produced it, the report said.
Meanwhile, in a report for Card’s medical status evaluation, Dickison checked a box on the preprinted Army form for recommending safe storage.
“It is implausible that the Army’s own preprinted form would present an option that is impermissible for AR commanders to follow,” the report said. The commission also included the specific Army regulation that spells out the possibility to store personal firearms.
According to the commission, Reamer also “inexplicably” left the task of trying to get Card to store his weapon to Card’s friend Sean Hodgson “who had no authority over Card” and who was personally prohibited from possessing firearms during the summer and fall 2023. Reamer testified that he expected the family to take them.
“Downplayed’ the situation
After a September 2023 incident where Card drove erratically and punched him, Hodgson reported his behavior to Reamer who took no action. Hodgson texted Reamer asking to change the unit gate passcode and said he was concerned that he still had access to weapons.
“I believe he is going to snap and do a mass shooting,” Hodgson wrote. Reamer asked the local sheriff to conduct a wellness check on Card. With Card’s threat to his unit, Ellsworth police prepared a narrative that would help the sheriff secure a yellow flag order which allows police to potentially take someone with weapon access into protective custody for mental health evaluations and apply for a court order to remove guns if someone is in a psychiatric crisis.
When Reamer was contacted by the local sheriff’s office, the commission said he “downplayed the severity of the threat relayed by Hodgson” despite Card’s hospitalization and concerns from other soldiers in Card’s unit.
Reamer also did not suggest a risk assessment despite telling officials, “I don’t think this is gonna get any better.”
When officials with a Reserve medical management center tried to contact Card several times over email, they included Reamer on them but he did not respond. Despite being his commanding officer, Reamer did not follow up with Card about the emails and told the commission that his emails were “down” and did not explain why “he did not read them until after the shooting,” the report said.
Brain trauma
Card joined the Reserve in 2003 and initially served as a petroleum supply specialist. In 2013, he became a trainer at West Point, teaching cadets how to throw live hand grenades. During his career, Card was present when thousands of grenades were thrown each year.
The Maine commission reviewed a Boston University analysis of Card’s brain tissue which found Card had “significant evidence of traumatic brain injuries” which they suggested could be from his exposure to “thousands of low-level blasts” in his position as an Army instructor. However, the Maine commission did not address Card’s brain health – a point of contention that bubbled up during the Reserve’s review.
The 15-6 investigation included a 2008 incident where Card fell from a roof and broke his neck and noted Card “was not exposed” to combat environments. At a press conference after the Reserve released its review, officials doubled down, adding that his exposure to shock was “relatively minor.”
Army Reserve Officials referred questions on his brain health to Walter Reed National Military Medical Center which is conducting a forensic autopsy. Walter Reed did not respond to inquiries about the timeline for their review release.
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