Five takeaways from the final report on Lewiston mass shooting

See the Globe’s complete coverage of the Lewiston shootings.

Ten months after Robert R. Card II carried out the worst mass shooting in Maine’s history, the commission investigating the tragedy released its final report Tuesday.

The 215-page report focuses on the timeline leading up to, during, and immediately after Card, a 40-year-old Army Reservist, killed 18 and wounded more than a dozen more at a bar and a bowling alley in Lewiston on Oct. 25.

Here are some key takeaways:

Missed chances to intervene

The commission stated multiple times that Card alone was at fault for the tragedy. But it faulted both the Sagadahoc County Sheriff’s office and the Army Reserve for failing to take action.

“Although he might still have committed a mass shooting even if someone had managed to remove Card’s firearms before October 25, 2023, there were several opportunities that, if taken, might have changed the course of events,” the commission wrote.

The Army Reserve should have further engaged with Card’s care, followed up on him, and shared more information about his aggressive behavior and threats with local law enforcement, the commission found.

It also said a Sagadahoc sheriff’s deputy could have taken Card into custody and moved to take his weapons during a wellness check on Card a month before the shooting, reaffirming its earlier finding. The deputy backed off after a conversation with Card’s Reserve superior and Card’s family.

Many details, few recommendations

The report is the most comprehensive to date about Card’s descent into psychosis, his hospitalization three months before the shooting, his encounters with law enforcement, and the immediate aftermath of the tragedy.

But aside from a recommendation that Maine State Police undertake a further after-action review, the report is short on concrete recommendations about how to stop similar tragedies. Daniel E. Wathen, the chair of the commission, said that wasn’t the body’s charge; rather, he said, their duty was to create a definitive body of facts that can “guide the decisions” of Maine authorities and the impending civil litigation.

Card’s release from the mental health facility in New York

Last July, three months before the shooting, Card’s Army Reserve squad mates became so concerned about his erratic and threatening behavior at a training event in New York that they reported it to the authorities, leading Card to be brought to a private hospital. The hospital at one point sought for Card to be involuntarily committed, but then canceled a required court hearing after staff saw improvements in his condition and he complied with medication orders.

When he was released, the hospital psychiatrist talked about “the need to see that the firearms were removed from Card’s home.” She called a doctor who’d dealt with him at an Army hospital and asked him to make sure to file a petition to have his weapons removed under a New York state law.

None was ever filed, the report found, because local authorities believed the New York law could not apply to the Maine resident. That, the report found, was a misunderstanding of the law.

Last phone call to Card

The last phone call Card received was from the Army Reserve’s Psychological Health Program, one day before the shooting. PHP, which attempts to connect reservists with behavioral-health services, had tried to contact Card multiple times between his hospitalization and the shooting. But for the most part, the commission wrote, Card did not acknowledge or return messages.

And that final call was little different.

“When the caller identified herself, Card hung up,” the report said.

Praise but caution for police response

The commission and Wathen praised the bravery of police officers during and after the shootings, saying they hustled to the scene and put themselves in harm’s way as the horror unfolded.

But Wathen said the “self-dispatching” of officers just showing up unannounced caused “utter chaos.”