The 'Toll Would Have Been Less'
Panel Details Problems That Could Take Years to Fix

By Tim Craig and Sandhya Somashekhar
Washington Post Staff Writers
Friday, August 31, 2007

RICHMOND, Aug. 30 -- The communications breakdowns, gaps in the mental health system and confusion over student privacy laws that were identified as problems by the panel that investigated the massacre at Virginia Tech might take years to correct and require action by the federal government, panel members said Thursday.

The long-awaited panel report, released late Wednesday, concluded that Virginia Tech officials could have saved lives by warning students earlier that two students had been shot and that the killer had not been caught. It also said that a judge ordered Seung Hui Cho to be treated for mental health issues but that he never received it.

A large segment of the report focuses on federal privacy laws designed to protect sensitive information about students. Mental health officials are so worried about following those laws that they often withhold information that can legally be shared with others, the panel concluded. Even the doctors treating killer Cho's mental illness didn't have all the facts about him.

"Many people became aware of Cho's difficulties: students, parents, resident assistants, teachers, administrators, the Tech police department and counselors," Gov. Timothy M. Kaine (D) said of Cho, who killed 32 people and himself April 16. "But there was not an effective mechanism for compiling information and taking action, either to intervene in an effective way or even to contact Cho's family." Kaine appointed the panel and asked for the review.

Cho's rampage -- the worst mass shooting by an individual in U.S. history -- was probably unavoidable, the panel concluded. But government agencies and other institutions should have done more to respond to his illness and rage, the report said.

Virginia's mental health system was ill-equipped, the report said, to treat Cho, a loner who as a toddler didn't like to talk or be touched.

The eight-member panel, which included former U.S. homeland security secretary Tom Ridge, was backed by a team of investigators who fanned out across the country to gather information related to the massacre over the past four months. The report outlined 13 recommendations for reforming the state's mental health system, including changing the criteria for involuntary commitments and increasing the number of beds available to patients at crisis stabilization centers.

The report did not estimate how much money would be needed to improve mental health services in Virginia, but W. Gerald Massengill, chairman of the panel, said the state does not have the money to "get the job done."

"I think the one thing that caught the panel by surprise was the magnitude of the problems today in our mental health system," Massengill said in an interview. "This is an issue that has national implications, because this is not a problem unique to Virginia."

The report outlined almost a dozen examples in which better communication might have averted some bloodshed. Communication lapses existed between Cho's high school and college officials, his doctors and Virginia Tech officials, and the students and faculty members on campus the morning of the shootings. Cho attended Westfield High School in Chantilly.

Kaine, who commissioned the panel three days after Cho's rampage, said Thursday that the report should be a wake-up call for governments and colleges across the country. Kaine vowed to spend his remaining 2 1/2 years in office "fixing problems" instead of "assessing blame."

But Kaine will probably continued to be dogged with questions about whether Virginia Tech President Charles W. Steger or other university officials should be fired.

The report concluded that "one could argue the total toll would have been less" had Steger and administrators alerted students and faculty members sooner after Cho shot and killed two people about 7:20 a.m. in West Ambler Johnston Hall. Two-and-a-half hours later, Cho killed 30 people in Norris Hall before taking his own life.

One victim's mother, Celeste Peterson, has called for Steger's firing. Another, Suzanne Grimes, mother of wounded student Kevin Sterne, said: "I can't understand why the alarm to students wasn't sent out at 7:20. The president of the college still states that there is a misconception about the two-hour gap. I'm not sure what planet the president is on. There was a two-hour gap. If there's any misconception, it's in the president's own mind. . . . He still hasn't acknowledged responsibility for what happened, and that's why we're so angry."

Peter Read's daughter Mary, an Annandale High graduate, was killed in Norris Hall. "It's hard for us to believe that anybody could . . . read this report and not believe that key people should be held accountable," he said.

Read stopped short of calling for the ouster of the university's president.

At a news conference at Virginia Tech on Thursday, Steger defended his actions and said he wouldn't resign. "We believe that our people acted quickly and to the best of our abilities, based on what we knew at the time," he said. Steger said the school administration did not have all the facts about the first shooting and did not want to spread partial or incorrect information to students.

Kaine said: "I want to fix this problem so I can reduce the chance of anything like this ever happening again. If I thought firings would be the way to do that, then that would be what I would focus on."

Cho, the report said, was to blame for the rampage. He was on "a mission of fulfilling a fantasy of revenge."

The report cited a major breakdown in communication and treatment in 2005 after a judge ordered Cho to receive outpatient care. He was suicidal after police interviewed him when female students complained that he was stalking them, according to the report.

The judge ordered Cho to go to the university's Cook Counseling Center, but health-care professionals there never treated him, and the center lost many of his records. The school never told Cho's parents in Centreville about his condition.

Roger L. Depue, a panel member and former FBI profiler, said there were lots of "warning signs, red flags and indicators" that Cho was in trouble.

But "it takes people who are trained to pick up on it," Depue said, and that became difficult once Cho was in college because Virginia Tech officials didn't know about his history of mental health problems as a student in Fairfax County schools.

"All those people who tried to help him earlier in life, now they were gone, and he began to degenerate," Depue said. "No one was putting it all together."

The report concluded that confusion over state and federal privacy laws was a major factor contributing to Cho's problems going undetected.

"The widespread perception is that information privacy laws make it difficult to respond effectively to troubled students," the report stated. "This perception is only partly correct."

Often, the report said, people and organizations in possession of privileged information do not share it with others, even though the law permits them to do so.

Under a 1974 federal law, education records are private and can be released only for specific reasons. But the law applies to information about student academic records. At Virginia Tech, police and university officials sometimes wrongly believed the law prevented them from sharing mental health information with Cho's parents.

Virginia Tech Provost Mark G. McNamee said the university will push for changes in the privacy laws that prevented Fairfax schools from relaying anything about Cho's mental state to the college.

When the university accepted Cho, officials knew little more about him than his grade point average and SAT scores, he said.

"I think we are moving into a new era, a new national dialogue" about how individual privacy rights are weighed against public safety, McNamee said. "Safety has clearly risen to a higher profile."

Staff writers Amy Gardner, Annie Gowen, Sari Horwitz and Brigid Schulte contributed to this report. Somashekhar reported from Blacksburg.

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