Overview of the Investigation Ordered by the Commander of United States Army Reserve

Command Following the Mass Shooting in Lewiston, Maine.

On October 25th, 2023, Robert R. Card II, a Sergeant First Class in the United States Army
Reserve, carried out a mass shooting in Lewiston, Maine, killing 18 and wounding 13. Two days
later, local authorities found SFC Card deceased from a self-inflicted gunshot wound. This tragic
act of violence has forever impacted people in the State of Maine and across the country. At the
time of the mass shooting and suicide, SFC Card was not on duty nor under the direct control of
the U.S. Army. He was a civilian who also happened to be in the U.S. Army Reserve.
SFC Robert R. Card enlisted in the U.S. Army Reserve in December of 2002 as a Petroleum
Supply Specialist. For approximately two weeks a year, from 2014-2022, SFC Card served as a
combat weapons trainer at the United States Military Academy (USMA) at West Point, New
York. He never deployed to combat. In the fall of 2022, SFC Card began to experience a series
of emotional events and behavioral health challenges, including auditory hallucinations, the use
of new hearing aids and interpersonal conflicts with others, including fellow USAR unit
members.
In May 2023, SFC Card’s family reported his deteriorating mental health to local law
enforcement. In July 2023, SFC Card reported to his Annual Training event at West Point where
he displayed troubling signs of mental instability and was quickly ordered to complete a
Command Directed Behavioral Health Evaluation.

The behavioral health evaluation identified the need for more advanced follow-on care at Four
Winds Hospital, a civilian facility in Katonah, New York. SFC Card received in-patient care for
19 days between July 16th and August 3rd, 2023. During that time, he was diagnosed with a
“Brief Psychotic Disorder” and medical providers prescribed psychiatric medication and
recommended follow-on treatment. A court hearing to involuntarily commit SFC Card to Four
Winds was cancelled, and on August 3rd, Card was released. 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.

Shortly after his release from the hospital, SFC Card effectively ceased communication with
medical personnel. He also withdrew from his social circles and had few communications with
family, friends, coworkers, or his chain of command.

On October 25th, SFC Card committed the worst mass shooting in Maine’s history and two days
later Card was found dead.

On November 2nd, 2023, in accordance with Army Regulation 15-6, the Commander of United
States Army Reserve Command (USARC) ordered a thorough investigation into SFC Card’s
suicide, including his on and off duty conduct in the months leading up to the mass shooting. It is
important to note that the U.S. Army did not have the legal authority to serve as the sole
investigator into the mass shooting; however, Army leadership felt there was a moral and ethical

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imperative to investigate all actions and events leading to SFC Card’s suicide, including the mass
shooting in Lewiston, Maine.

The investigation also reviewed the actions of SFC Card’s chain of command and relevant
military medical commands. The Army’s investigation was conducted by a senior Military
Intelligence Officer, and supported by a Judge Advocate, a Nurse, and an Army Criminal
Investigation Division (CID) Agent. These investigators interviewed 43 witnesses, collected over
3,300 pages of documentation, and requested expert assistance from the Department of Forensic
Psychology at the Walter Reed National Military Medical Center.

The USARC investigation identified multiple communication failures between military and
civilian hospitals, as well as with SFC Card’s chain of command. These communication failures
impacted SFC Card’s continuity of care. The investigation recommended adverse administrative
action be taken against three officers in SFC Card’s chain of command for dereliction of duty.
The adverse actions have been completed. The nature of the adverse administrative action can
effectively preclude further military advancement for these officers. In accordance with policy,
the Army will not release the names or further details of the disciplinary action taken because the
officers are in the rank of colonel and below.
Finally, the investigation also recommended updates to standard operating procedures,
retraining, and new policies to better handle the complexities of behavior health care for our
USAR soldiers. The Army remains committed to working with stakeholders to improve key
areas of concern.
1. What Happened
SFC Card joined the U.S. Army Reserve on December 14, 2002, as a Petroleum Supply
Specialist. He did not deploy or mobilize while in the U.S. Army Reserve. As a Reserve Soldier,
SFC Card would serve in an active, or “duty”, status for approximately 38 days per year and he
was a civilian for the remainder of the year. During his mandatory Annual Training from 2014 –
2022, he trained USMA cadets on hand grenade and heavy weapon ranges. SFC Card served on
the hand grenade range during his two weeks of Annual Training for five years of the eight-year
span.
Until the final months before his death, SFC Card’s military record did not have any reports of
disciplinary action or major injuries. The investigation revealed that in 2008, while in a civilian
status, he fell from a roof and broke his neck. SFC Card also had persistent hearing issues which
seemed to be worsening.
Unit members described him as kind, calm, friendly, and generous. In his civilian capacity, SFC
Card was a truck driver.
In January 2023, around the same time that friends and family reported a decline in his mental
health, SFC Card received new hearing aids.
The investigation determined that SFC Card’s family, friends, and coworkers all began noticing
a decline in SFC Card’s mental health beginning in January of 2023. Witnesses testified that SFC

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Card began to hear voices of people, often strangers, but sometimes friends, family, and
coworkers, that he believed were ridiculing him behind his back, on social media, and directly in
his presence. While everyone he accused vehemently denied these allegations, even when
multiple witnesses were present, SFC Card nonetheless seemed to believe that most of his
friends, family, and coworkers had turned against him in a cruel and unexplained manner.
In the early months of 2023, these auditory hallucinations were mostly reported to family and
close friends who tried to reassure SFC Card that he was not being ridiculed nor was there a
conspiracy to spread malicious rumors about him. These auditory hallucinations persisted
through March and April of 2023, SFC Card did not attend his Annual Training validation
exercise in April 2023.
By May of 2023, SFC Card’s family reported at least four alarming mental health incidents to a
high school resource police officer, who then referred the matter to the Sagadahoc County
Sheriff’s Office, the law enforcement agency with criminal jurisdiction over SFC Card. This
information included the fact that they believed SFC Card had 10 to15 rifles and/or handguns at
his residence. At this time, SFC Card continued to refuse any assistance and he remained upset
and frustrated by the auditory hallucinations he believed were real. On May 3rd, local law
enforcement officers informed SFC Card’s chain of command about the situation and his
deteriorating mental health. In June, SFC Card attended his mandatory U.S. Army Reserve Battle
Assembly (sometimes referred to as “weekend drill”) but no one in his chain of command
discussed his mental health challenges with him and unit members reported that he seemed
normal.
SFC Card was ordered to attend his July 2023 Annual Training event because his unit leadership
believed the training was mandatory and that his mental health challenges weren’t a detriment to
his military job. When ordering SFC Card to attend his Annual Training amidst his mental health
challenges, the unit leadership did not consider the fact that he missed the unit validation
exercise or that SFC Card was scheduled to serve as an instructor for a machine gun range.
Within 24 hours of reporting to his Annual Training, SFC Card demonstrated signs of a
deteriorating mental state and was ordered by his command to undergo a Behavioral Health
Evaluation at Keller Army Community Hospital (KACH), a military hospital, at USMA. After an
initial screening at KACH, the medical professionals determined that he needed higher level care
and transported him to Four Winds Hospital, also in New York.
On July 20th, four days after he was checked into Four Winds hospital, the Army Reserve
Medical Management Center (ARMMC) placed SFC Card on a 90-day behavioral health profile,
which restricted SFC Card’s access to military issued weapons. Medical professionals at Four
Winds also recommended removing SFC Card’s access to personally owned weapons. SFC
Card’s chain of command attempted to coordinate the removal of Card’s weapons from his
home, but they lacked the authority to legally compel the removal of any firearms or weapons.

SFC Card was hospitalized at Four Winds Hospital for a total of 19 days from July 16th to
August 3rd and was diagnosed with a “Brief Psychotic Disorder.” The medical professionals at
Four Winds prescribed psychiatric medications and follow-on treatments. On July 27th, SFC
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Card requested release from Four Winds and the hospital initiated steps under New York state
law to involuntarily commit SFC Card for continued care. To involuntarily commit SFC Card, a
court hearing was scheduled for August 2nd, but SFC Card rescinded his request to leave, and the
court hearing was cancelled. Four Winds Hospital nevertheless released SFC Card on August 3rd,
to a Soldier and friend from his unit. 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.

August 3rd, 2023, was the last day SFC Card was in a duty status with the U.S. Army Reserve.
After his August 3rd discharge from Four Winds Hospital, SFC Card complained to friends and
family that he was very upset about being sent to the hospital and he began to communicate
vague threats of violence. Two days after his discharge from the hospital, he tried to pick up a
firearm silencer he had ordered online a month earlier. The store employees refused to sell SFC
Card the silencer after he self-reported that he was just released from a psychiatric facility.
On August 11th, SFC Card stated to a nurse care manager from Keller Army Hospital who had
contacted him that he stopped taking his prescribed medication because it made him feel lazy.
Also on August 11th, the U.S. Army Reserve Psychological Health Program (PHP) contacted
SFC Card and Card expressed his displeasure with the fact that his hospitalization was limiting
his ability to purchase firearms. He also reported he had not yet started prescribed therapy. This
conversation on August 11th, eight days after his release from Four Winds Hospital, was when
SFC Card ceased communication with medical professionals. The PHP closed SFC Card’s case
at the end of August because he was unresponsive to their efforts to contact him, which was the
standard policy at the time.
In August and September of 2023, SFC Card communicated increasingly violent, yet vague,
threats and rhetoric to friends and family. He often described how many people he could hurt
with his weapons or what locations he could “shoot up.” By September 14th, SFC Card’s
auditory hallucinations appeared to further impact his mental health, so much so that SFC Card
violently assaulted his best friend, who was in his reserve unit. Realizing just how bad things had
gotten, SFC Card’s best friend contacted the unit chain of command and told them he was
concerned that SFC Card would conduct a mass shooting at his unit or somewhere else. Within
24 hours of hearing from Card’s best friend, SFC Card’s leadership informed local law
enforcement of the threats. SFC Card’s chain of command conducted these notifications in their
civilian capacity because they were not on reserve duty at the time. Local law enforcement
attempted to conduct two wellness checks on SFC Card but failed to engage with him.
The investigation revealed that nearly everyone who knew SFC Card acknowledged how quickly
his mental health declined from September through October of 2023 - to the point that he was
accusing new, formerly trusted people, as part of his auditory hallucinations. SFC Card
continued to withdraw from those around him and had irregular contact with family and friends
during this time, other than a few select instances when he aggressively accused them of
continuing to ridicule him. Even when he became virtually unreachable, family members
continued to engage SFC Card, offering encouragement and support through text messages and
voicemails.

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In October 2023, ARMMC (the Army Reserve Medical Management Center) again attempted to
contact SFC Card to follow-up with him about his treatment and wellbeing. Although ARMMC
was unable to contact Card, they extended his behavioral health profile for another 90 days on
October 17th, 2023.
On October 25th, 2023, Robert Card conducted a mass shooting in Lewiston, Maine, killing 18
people and wounding another 13. Robert Card was found two days later with a self-inflicted
gunshot wound. The toxicology report did not reveal any findings of toxicological significance
other than caffeine and nicotine in his system.
2. Findings and Recommendations
It is important to note that while the Army’s investigation was exhaustive and judicious, the
investing officer and his team were unable to interview several key witnesses from Four Winds
Hospital, SFC Card’s family, and State of Maine law enforcement personnel. Because these
individuals are not in the U.S. Army, the investigating officer had no legal authority to compel
them to provide testimony, which they chose not to provide. Regardless, this investigation made
several findings and subsequent recommendations in four categories.
First, unit leadership took several consistent and sustained actions to address SFC Card’s
deteriorating mental state. However, there were also a series of failures within the unit
leadership. Members of the unit leadership were held accountable through appropriate adverse
administrative actions taken against the officers found derelict in their duties. These adverse
administrative actions can preclude further military advancement for those officers.
Second, the report identified procedural breakdowns in SFC Card’s medical care, from the
military hospital to the civilian hospital where he was committed. Four Winds informed Keller
Army Health Clinic of its intent to release SFC Card on August 3rd; however, a KACH
contracted nurse care manager did not inform unit leadership of SFC Card’s release date. The
nurse care manager also did not meaningfully communicate with unit leadership. In addition to
the unresolved circumstances surrounding SFC Card’s release, the investigation was unable to
confirm if SFC Card received discharge instructions from Four Winds on August 3rd. Four
Winds did not send signed discharge instructions to KACH until August 11th, 8 days after SFC
Card’s release. After receiving SFC Card’s discharge instructions, the nurse care manager did
not upload the documents into SFC Card’s military medical record for another 10 days after
receipt, or closely review the discharge instructions, which would have revealed troubling
information that could have been relayed to the chain of command. These procedural
breakdowns have been reported to the Defense Health Agency and the Army Surgeon General,
and the Army is updating the procedures for case management of U.S. Army Reserve component
Soldiers.
Third, the investigation found that several U.S. Army Reserve programs were insufficiently
followed. For instance, procedures for serious incident reports were not followed. Next, the
Psychological Health Program office did not adequately review SFC Card’s medical records
prior to closing his case due to unresponsiveness. The investigation determined the chain of
command had an incorrect understanding of their authorities under the Health Insurance

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Portability and Accountability Act (HIPAA). The USARC Commander has ordered updates and
reviews of those programs, as well as retraining of HIPAA and the Military Command Exception
for all commanders and legal advisors in the 108th Training Command, the parent organization
to which SFC Card was assigned.
Fourth, to better handle the complexities of behavior health care for our USAR Soldiers the
investigation also recommended updates to policies and standard operating procedures, a review
of the U.S. Army Reserve’s behavioral health force structure, and comprehensive behavioral
health retraining across the U.S. Army Reserve.
The investigation, and its subsequent findings, also highlight the limited legal authority that SFC
Card’s U.S. Army Reserve chain of command had over him and his actions. A U.S. Army
Reserve Soldier is typically in a duty status for approximately 38 days per year. This is an
important way for Soldiers to balance their Army service with their civilian life and profession,
but there are legal limitations.
When a Reserve Soldier is not in a duty status, their chain of command has no legal authority to
compel them to undergo medical treatment, follow-on care, or surrender personally owned
weapons, regardless of the circumstances. All of these actions must be done in a civilian
capacity, which is why SFC Card’s chain of command as well as his family and friends,
repeatedly worked with local law enforcement throughout this ordeal. This remains a unique
challenge for U.S. Army Reserve leadership and encourages strong relationships with local
governments and law enforcement personnel to handle difficult situations.
3. Way Ahead
The Army is committed to working with Congress, local and federal governments, and all
stakeholders to prevent tragedies like this from recurring. It is important to note that the U.S.
Army Reserve Command’s investigation and the independent Army Inspector General’s case
review are not the only ongoing investigations. The entirety of this investigation was provided to
the Department of Forensic Psychology at Walter Reed for a medical review and expert analysis.
While the Army has no jurisdiction over them, both the Maine State Police and the Maine
Commission are conducting separate investigations.
It is Army leadership’s sincere hope that these medical reviews and expert analysis, improved
procedures and policies, updated training and information sessions, and adverse administrative
action against those who were derelict in their duties, will help us determine how these events
happened, and help prevent similar tragedies in the future.

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