An Army investigation into the October 2023 mass shooting committed by an Army Reserve soldier, Robert Card II, found that a number of factors contributed to the Army’s inaction as Mr. Card’s mental health careened toward violence, including procedural breakdowns, missteps by commanders and rules that restrict military authority over reserve soldiers when they are out of uniform.
But the report said the Army saw no link between his mental health problems and the years he spent working as a grenade instructor, repeatedly exposed to explosions on the practice range.
Every summer for eight years, Mr. Card taught cadets at the U.S. Military Academy at West Point to use heavy weapons, including machine guns and shoulder-fired anti-tank guns. For five of those years, he worked on the grenade range, where about 2,400 grenades exploded over a two-week period. By age 40, he wore hearing aids.
Last July, he was supposed to run machine-gun training for cadets, despite having missed a mandatory training session in the spring, the report said. But he was behaving so erratically in July that his Army Reserve commander had him hospitalized at a civilian psychiatric hospital in New York.
The hospital determined that Mr. Card was experiencing psychosis and homicidal thoughts and had a “hit list.” Doctors moved to commit the soldier involuntarily for treatment, but the effort was dropped by the hospital under what the Army report called “questionable circumstances,” and Mr. Card was released after 19 days.
His hospital records noted that his access to treatment after discharge was “poor” and that he had been discharged without follow-up appointments.
The civilian hospital did not notify Army commanders about Mr. Card’s discharge, his diagnosis or his homicidal thoughts, the report said. And his commanders, who, according to the report, had not completed training sessions covering their responsibilities when soldiers are hospitalized, did not think they had authority to ask about his medical status.
Four Army Reserve officers have been given administrative punishment for failing to follow procedures.
In the active-duty Army, soldiers can be restricted to quarters, assigned an escort and required to attend therapy. Army Reserve soldiers, however, usually spend only about a month out of every year in uniform, and when they are not on duty, the Army has little authority over them. The Army restricted Mr. Card’s access to Army weapons while he was on duty, but at home he still had full access to his civilian weapons.
Mr. Card ignored calls and emails about follow-up care from the civilian hospital, and he stopped taking the medication the hospital’s doctors had prescribed.
The Army Reserve’s health system was not tracking Mr. Card or following up on his care because he was not on active duty. His Reserve unit did not learn that he was home from the hospital until weeks after he had been released.
The report said that Army commanders should have filed paperwork that is required after an extended hospitalization, which could have kept Mr. Card on active duty and under their authority so that he could receive continuing medical care. They did not.
In the months after his release from the hospital, some soldiers in his Reserve unit became concerned that Mr. Card was dangerous. But with no authority to act on their own, they would have had to ask civilian law enforcement officials to intervene. They did not.
Mr. Card died by suicide after his shooting rampage in Lewiston, Maine, on Oct. 25, 2023, which left 18 people dead. Maine’s state medical examiner sent Mr. Card’s brain to be examined at Boston University’s brain lab, which found profound damage. The lab issued a report saying that the tissue damage resembled the characteristic pattern seen in the brains of combat veterans, as well as those of laboratory animals exposed to blasts.
The research team said it could not determine specifically what had caused the damage in Mr. Card’s brain, but it concluded that the damage “may be related to repetitive blast exposure.”
The Army’s investigation dismissed that possibility. On the last page of its 115-page report, it concluded that Boston University’s lack of definitive proof, combined with the absence of anything in Mr. Card’s Army medical record about a brain injury while on duty, meant that the damage to Mr. Card’s brain must have “occurred during a non-duty status, and not related to his military service.”
At a briefing for reporters on Monday, the chief of the Army Reserve, Lt. Gen. Jody J. Daniels, was asked if the Army believed there was no connection between the thousands of blasts Mr. Card had experienced and the condition of his brain. General Daniels responded, “Correct.”
She said the brain damage seen in Mr. Card could have come from an accident in 2008, when he fell from a roof, and she called the blasts he had been exposed to “relatively minor.”
Other soldiers who worked on the grenade range with Mr. Card disagree. One soldier said he had been experiencing chronic vertigo, sleeplessness and headaches — all of which can be symptoms of brain injury — and described the concussion from the grenade range as “brutal.”
In recent years, the Army has twice investigated other grenade ranges after instructors complained of concussion-like symptoms.
Mr. Card’s sister, Nicole Herling, said the Army’s reasoning didn’t make sense.
“If they can’t conclusively say it was the blasts, how can they conclusively say it wasn’t?” she said in an interview. “I think they don’t want to accept that it’s a possibility because the impact could be so big.”
The blast wave from an exploding grenade that is felt by soldiers on the practice range measures well below the Army’s current blast safety guidelines. If that level of exposure can, over time, cause the extensive damage that the lab found in Mr. Card’s brain, it would mean that there are significant risks for anyone who is repeatedly exposed to more powerful blasts, like those from firing heavy machine guns, mortars, artillery or shoulder-fired anti-tank weapons.
Similar patterns of damage have been found in the brains of career Navy SEALs who worked around explosions but were never wounded in combat.
General Daniels said that Army researchers at Walter Reed National Military Medical Center had received tissue samples from Mr. Card’s brain and were doing their own analysis, the results of which, the report said, are pending.
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