The capsules below contain summaries of various chapters within the Virginia Tech Incident Review Panel report. They are presented in order of the chapters in the report. Check back for updates throughout the day.

University setting and security
While Tech police did have the equivalent of a SWAT team, the university did not have provisions for a shooting scenario in its emergency response plan and put police too low in the decision making hierarchy on when to send emergency alerts.

Police were authorized to send alerts but lacked the technical means to do so because only Associate Vice President for University Relations Larry Hincker and Director of News and Information Mark Owczarski had the codes needed to send emergency messages. Typical practice was for Tech police to consult a university policy group, which included the university president and other officials, before sending an emergency message. This was also done April 16. The panel called the structure of Tech’s emergency alert system “cumbersome, untimely, and problematic when a decision was needed as soon as possible.”

But that situation may not be unique to Tech. According to the panel, “several leaders of the campus police chiefs of Virginia” indicated they have too little input into security planning and threat assessment, as well as too little access to student information.

“April 16 has become the 9/11 for colleges and universities. Most have reviewed their security plans since then. The installation of security systems already planned or in progress has accelerated, including those at Virginia Tech.”

The panel said presidents of the state’s colleges and universities oppose mandatory levels of security at all institutions and want schools to be able to decide what measures to take.

Tech’s level of building security on April 16 was typical of rural campuses in low-crime areas but less than at some universities, particularly urban ones.

“[I]f the April 16 incident had not occurred, it is doubtful that security issues would be on the minds of parents and students [at Tech] more than at other universities, where the most serious crimes tend to be rapes, assaults , and dangerous activity related to alcohol or drug abuse by students. These issues … were given an average level of attention at Virginia Tech.”

Tech had no security cameras and “the outcome might have been different had the perpetrator of the initial homicides been rapidly identified.”

The panel said the mission statement of Tech’s police force “does not reflect that law enforcement is the primary purpose,” instead stressing the “maintenance of a peaceful and orderly community.” Such an emphasis, according to the report, “may influence a decision as to whether the university puts minimizing disruption to the educational process first and acting on the side of precaution second.”

That language is likely to bolster critics of the university’s failure to issue an alert for about two hours after the 7:15 a.m. shooting of students Emily Hilscher and Ryan Clark in the West Ambler Johnston dorm. The first university-wide email about that double homicide came at 9:26 a.m. Authorities were questioning Hilscher’s boyfriend around that time, just as Cho was chaining doors shut in Norris Hall before his attack on it.

-- Albert Raboteau

University response
The report of a state panel investigating the Virginia Tech shootings is critical of the Tech police department and university officials for not getting word out about the initial shootings in West Ambler Johnston dormitory sooner.

While the report concludes that the police department's reaction to pursue the boyfriend of Emily Hilscher was the right decision based on the evidence at the time, they should have also planned for other possibilities and instructed the university to send out an alert earlier.

"After two people were shot dead, police needed to consider the possibility of a murderer loose on campus ... even though a domestic disturbance was a likely possibility," the report said.

Tech police did not have the ability to send out emergency messages via e-mail and Tech's web site, but did have the authority to order such messages be sent, the report said. But based on interviews of the university policy group that met that day, they did not make such an order.

Tech sent a message out at 9:26 a.m. about the West AJ shootings and encouraging people on campus to be cautious. But most people on campus likely didn't get that message when Cho began the second round of shootings about 15 minutes later.

"If the message had gone out earlier, between 8:00 and 8:30 a.m., more people would have received it before leaving for their 9:05 a.m. classes. If an audible alert had been sounded, even more might have tuned in to check for an emergency message ... Nearly everyone at Virginia Tech is adult and capable of making decisions about potentially dangerous situations to safeguard themselves. So the earlier and cleqarer the warning, the more chance an individual had of surviving."

The report does note that a campus-wide lockdown was impractical because of the university's size and the lack of knowledge at the time about the shooter's identity and whereabouts. But if notifications even partly reduced the population on campus, lives could've been saved.

"It is the panel's judgment that, all things considered, the toll could h ave been reduced had these actions been taken," the report states.

-- Greg Esposito

Mental health
Virginia Tech’s “Care Team,” established to identify and intervene with troubled students, missed a host of red flags – including concerns raised by professors – that should have alerted them and others on campus that Seung-Hui Cho might pose a threat to the university, according to a panel report released late Wednesday.

The Care Team’s failure was attributed to numerous gaps in communication among campus agencies.

That is one conclusion from a report section focused on Cho’s mental health history. As has been widely reported, Cho exhibited symptoms at an early age of psychological and emotional distress. He was withdrawn and silent in many settings, especially in school, and isolated elsewhere.

At Virginia Tech, after switching majors to English for the fall semester, Cho’s disturbing writings and behaviors attracted official attention.

The report observed, “The academic component of the university spoke up loudly about a sullen, foreboding male student who refused to talk, frightened classmates and faculty with macabre writings, and refused faculty exhortations to get counseling.”

But after the university’s Cook Counseling Center and Judicial Affairs concluded that Cho’s writings “were not actionable threats,” the Care Team decided private tutoring would resolve his problems, the panel wrote.

-- Duncan Adams

Privacy law
Seung-Hui Cho’s parents told the governor’s investigative panel that they would have helped their son seek treatment had they known about his troubling behavior at Virginia Tech.

If Cho’s parents had become involved, the people treating him probably would have learned something about his prior mental health history and obtained information crucial to their evaluation and treatment of him, the gubernatorial panel’s report concluded.

“There is no evidence that officials at Virginia Tech consciously decided not to inform Cho’s parents of his behavior; regardless of intent, however, they did not do so,” the report says.

Although information privacy law can block some information sharing among various agencies, officials often err on the side of nondisclosure even when the law does not require it, the report says.

“Sometimes this is done out of ignorance of the law, and sometimes intentionally because it serves the purposes of the individual or organization to hide behind the privacy law,” the report says.

Information privacy law should be amended and clarified to ensure that school officials, law enforcement officers, mental health professionals and others share vital information about troubled students, the panel’s report concludes.

Virginia Tech police could have contacted Cho’s parents after they received complaints from female students about Cho’s behavior in the fall of 2005, the report said.

Police also could have informed Cho’s parents when he was taken to a mental health facility in December of that year. Cho was held overnight in the mental hospital after his roommate reported that he might be suicidal. A special justice released him the next day on orders to receive outpatient treatment.

-- Reed Williams

Gun control
Allowing students to carry guns on campus might have increased the death toll of April 16, the panel said in recommending that Tech and other schools maintain their bans on guns.

Gun advocates have argued that Tech’s ban contributed to the carnage by prohibiting students and staff from shooting back when Seung-Hui Cho opened fire in Norris Hall.

However, the panel’s report stated that "if numerous people had been rushing around with handguns outside Norris Hall...the possibility of accidental or mistaken shootings would have increased significantly."

In fact, campus police told the panel there was a "high probability" they would have shot anyone seen coming from a classroom with a gun in their hand.

Some have argued that in light of the Tech shootings, the General Assembly should reconsider a previously unsuccessful bill that would prevent colleges from banning firearms.

The panel, however, took the opposite tack — recommending that the legislature pass a law "clearly establishing" the right of colleges to regulate gun possession on their campuses if they choose to.

-- Laurence Hammack

Norris Hall
The report compliments the response by police to the Norris Hall shootings, as officers from the Virginia Tech Police Department and Blacksburg Police Department responded quickly thanks to joint training, saving lives. Two officers, Virginia Tech officer H. Dean Lucas and Blacksburg Sgt. Anthony Wilson. reached Norris within three minutes of receiving the call about shootings there. After unsuccessful attempts to open three doors chained shut, they entered through a maintenance shop door by shooting the lock. The report said Cho probably decided to take his own life when he heard the police entering.

"With over 200 rounds left, more than half his ammunition, he almost surely would have continued to kill more wounded as he had been doing, and possibly others in the building had not the police arrived so quickly. Terrible as it was, the toll could have been even higher."

-- Greg Esposito

Emergency response
The 15 emergency medical organizations that responded to the shootings were commended by the panel. The Virginia Tech Rescue Squad was singled out for praise. The report called the student-run and student-staffed squad “heroic.” The committee said the squad’s work on April 16 “demonstrated courage and fortitude.”

Virtually all of the shortcomings the committee found in the emergency response section of the report had to do with communications. “Communications issues and barriers appeared to be frustrating during the incident,” the report concluded.

Four minutes passed between the time members of the Virginia Tech Rescue Squad heard the shootings at Norris Hall on the police radio and the police call for the squad to respond. Initially, rescue units were dispatched to Norris Hall, when they should have been sent to staging areas. Virginia Tech police and Montgomery County issued separate dispatches, which could have been confusing. The Tech squad and Blacksburg Volunteer Rescue Squad use different radio frequencies, which made communications difficult and made the Blacksburg squad initially unaware the Tech squad had set up a command post.

Responders overcame all that, the committee concluded. Their response “was excellent and the lives of many were saved. … Responders are to be commended.”

The hospitals were praised, too. The committee noted their cooperation, even when they owned by competing companies. There were some issues of communication between the hospitals and emergency crews and between the hospitals and Virginia Tech, but every victim who was alive when the shooting stopped at Norris Hall survived – even those with serious and multiple gunshot wounds.

-- Tim Thornton

Office of the Chief Medical Examiner

The committee said the treatment victims’ families received was “haphazard, inconsistent, and compounded the pain and trauma of the event.”

The report was critical of Virginia Tech, the medical examiner’s office and law enforcement for their handling of the families and the way families were notified of their loved ones’ deaths.

“Information management in the hands of an inexperienced public information officer proved disastrous. This in turn, allowed speculation and misinformation, which caused additional stress to victims’ families,” the committee declared. “The process of notifying family members of the victims and the support needed for this population were ineffective and often insensitive.”

Families seeking information and support often found confusion and tactlessness instead.

“No one was in charge of the family assistance center operation,” the report said. “Confusion over that responsibility between state government and the university added to the problem.”

Tech was unprepared for a large emergency and slow to ask for assistance, according to the committee.

The weakness of the family assistance process is not news, the committee said. The state government published recommendations for preparing for mass casualty events in 2003.

-- Tim Thornton

Immediate aftermath and the long road to healing
While the report acknowledges “uncharted territory” and an environment of “chaos and confusion,” it finds a number of problems in the way the university, state victims services and compensation personnel and the medical examiner’s office organized their efforts and communicated with families in the aftermath of the shooting.

“The incident revealed certain inadequacies in government emergency response plan guidelines for family assistance at mass fatality incidents,” the report says. “Also, certain state assistance resources were not obligated quickly enough and arrived late. Finally, the lack of an adequate university emergency response plan to cover the operation of an onsite, post-emergency operations center (and most particularly a joint information center) and a family assistance center hampered response efforts.”

The report finds that Tech’s university-based liaisons, assigned to deal with surviving victims and families of deceased victims soon after the shootings, “were willing and available to fill an acute need” but were hindered by a lack of training and inadequate information on the network of services available to victims.

A team of victim service providers – representing trained, skilled professionals “accustomed to designing programs and strategies to meet the specific needs of crime victims” did not arrive until April 18 – two days after the massacre.

“Thus, even though the Commonwealth’s emergency plan authorizes immediate action, the process moved slowly– a real problem given the substantial need for early intervention, crisis response, information and help in establishing the family assistance center,” the report says.

Problems also surfaced at the Family Assistance Center established at the Inn at Virginia Tech.

“The sheer magnitude of the immediate impact coupled with the failure to establish an organized, centralized point of information at the outset resulted in mass confusion and a communications nightmare that remained unabated throughout the week following the shootings,” the report says.

And, as a result, “families struggled to know who was responsible for providing what service and where to go for the latest news about identification of the dead victims.”

“Two of the most deeply disturbing situations,” the report continues, “were the dearth of information on the status and identification of Cho’s victims and the instances where protocol for death notifications was breached.”

While some families were notified of loved ones’ deaths at their homes by Virginia State Police officers, one family was notified by a student, one by a local clergy member and another by the arrival of members of the press at their home.

“From a clinical perspective, the ME (Medical Examiner)’s office can be credited with unimpeachable results,” the report says. “From a communications and sensitivity perspective, they performed poorly.”

In addition to outlining shortcomings in the handling of the immediate aftermath of the shooting, the report details a number of services that continue to respond to the university community, as well as eleven recommendations for the future.

In its list of recommendations, the panel calls for emergency management plans that include a section on victim services; regularly scheduled briefings to victims’ families; and training in crisis management at universities and colleges.

-- Angela Manese-Lee