Introduction
What’s below is a summation of the Justice Department’s Incident review of the active shooter incident at the Robb Elementary School in Uvalde, Texas.
It is entirely composed of materials from the US Department of Justice. It’s offered as a service to readers. Pagination is mine. You are encouraged to read the executive summary and full report at the link provided.
A summation of two federal reports on mass shooters is available at Recognizing Mass Shooters And Potential Attacks In Public Places-Federal Research.
My only concern with the report, after spending 35 years in media and public relations for police, research, and criminal justice agencies, is that their recommendations for public affairs officers are unrealistic. It would take an extraordinary lead PIO with considerable powers to force the coordination and cooperation of all participating agencies and speak with one voice, and practice scenarios four times a year. It would require a vast team of public affairs specialists to verify all known information before release through a separate command and control structure (as recommended by FEMA). Few have that power. Few have that time.
Author
Leonard Adam Sipes, Jr.
Thirty-five years of explaining crime data while directing multi-award-winning public relations for national and state criminal justice agencies.Retired federal senior spokesperson. Interviewed multiple times by every national news outlet.
Former Senior Specialist for Crime Prevention for the Department of Justice’s clearinghouse. Former Director of Information Services, National Crime Prevention Council. Former Adjunct Associate Professor of Criminology and Public Affairs-University of Maryland, University College.
Former advisor to presidential and gubernatorial campaigns. Former advisor to the “McGruff-Take a Bite Out of Crime” national media campaign. Certificate of Advanced Study-Johns Hopkins University. Former police officer.
Author of ”Success With The Media: Everything You Need To Survive Reporters and Your Organization” available at Amazon and additional booksellers.
Partial Press Release
The Justice Department announced the release of a report on its critical incident review of the law enforcement response to the tragic school shooting at Robb Elementary School. Attorney General Merrick B. Garland announced the review shortly after the tragedy on May 24, 2022, in which 19 children and two teachers died at Robb Elementary School in Uvalde, Texas. The report provides a thorough description of the critical incident review that has taken place over the past 20 months.
The report is intended to provide the most comprehensive assessment available of the law enforcement response to the horrific incident on May 24, 2022, as well as the emergency medical response, communications, and trauma services in the wake of the tragedy. It begins with a minute-by-minute timeline reconstructing key events before, during, and immediately following the shooting. The report addresses many previously unanswered questions, builds on the existing knowledge base for responding to incidents of mass violence, and identifies generally accepted practices for effective law enforcement responses. In doing so, this report endeavors to honor the victims and survivors of this tragedy, as well as offer recommendations to improve future responses in other communities.
“The victims and survivors of the mass shooting at Robb Elementary School deserved better,” said Attorney General Garland. “The law enforcement response at Robb Elementary on May 24th, 2022 — and the response by officials in the hours and days after — was a failure. As a consequence of failed leadership, training, and policies, 33 students and three of their teachers — many of whom had been shot — were trapped in a room with an active shooter for over an hour as law enforcement officials remained outside. We hope to honor the victims and survivors by working together to try to prevent anything like this from happening again, here or anywhere.”
The report examines the multiple failures in the response to the tragedy, including the breakdowns in leadership, decision-making, tactics, policy, and training that contributed to those failures. It describes the responding officers’ most significant failure as not treating the incident throughout as an active shooter situation and using the available and sufficient resources and equipment to push forward immediately and continuously to eliminate the threat. Although several of the first officers on the scene initially acted consistent with generally accepted practices to try to engage the subject, once they retreated after being met with gunfire, the law enforcement responders began treating the incident as a barricaded subject scenario rather than as an active shooter situation. In all, there was a 77-minute gap between when officers first arrived on the scene and when they finally confronted and killed the subject.
The report also examines the communications challenges during and after the shooting, including the inaccurate narrative that was initially delivered. It also documents the trauma and support services that were provided, as well as those that were not provided, to victims, survivors, family members, and responders.
The critical incident review was led by the COPS Office, with the support of leading subject matter experts with a wide variety of relevant experience. The team established the following areas of focus: (1) incident timeline reconstruction; (2) tactics and equipment; (3) leadership, incident command, and coordination; (4) post-incident response and investigation; (5) public communications during and following the crisis; (6) trauma and support services; (7) school safety and security; and (8) pre-incident planning and preparation.
The report, in both English and Spanish, as well as profiles of the victims and additional resources, is available on the COPS Office website at cops.usdoj.gov/uvalde.
Overview of CIR Factual Observations
At 11:33 a.m. on the morning of May 24, 2022, the subject entered Robb Elementary School equipped with a high-powered AR-15 rifle. He immediately started shooting and within a minute entered classrooms 111 and 112, which were connected via an interior door.
Within 3 minutes of the subject’s entry into the school, 11 law enforcement officers from the Uvalde Consolidated Independent School District (UCISD) and Uvalde Police Departments (UPD), including supervisors, arrived inside the school. Hearing continued gunfire, five of the responding first on scene (FOS) law enforcement ran toward classrooms 111/112. The other six FOS did not advance down the hallway, including UPD Acting Chief Mariano Pargas, who was in the best position to start taking command and control, and to start coordinating with approaching personnel.
One of the officers said to “line up to make entry” and within seconds shots were fired from inside one of the rooms. Two officers were hit with shrapnel, and all responders retreated to positions of cover. After three attempts to approach the classrooms, the focus of the responders shifted from entering classrooms 111/112 and stopping the shooting to evacuating other classrooms, attempting to negotiate with the subject, and requesting additional responders and equipment.
With this shift from an active shooter to a barricaded subject approach, some responders repeatedly described the subject over the radio as “barricaded” or “contained.” Yet within four minutes from FOS arrival, 911 dispatch confirmed that class was in session and reported that they had received calls from victims.
Chief Pete Arredondo of the UCISD Police Department (UCISD PD) directed officers at several points to delay making entry into classrooms 111/112 in favor of searching for keys and clearing other classrooms. Occupants of other classrooms were at risk of further injury as a result of the high-powered nature of the shooter’s AR-15 style rifle and from possible crossfire once classrooms 111 and 112 were entered.
At several points, UCISD PD Chief Arredondo also attempted to negotiate with the subject. Others called out over the radio for additional resources and indicated that they were waiting for a tactical team to arrive, such as Uvalde special weapons and tactics (SWAT), the Texas Department of Public Safety (TXDPS), and the U.S. Border Patrol Tactical Unit (BORTAC).
Chief Arredondo, who became the de facto on-scene commander, was without his radios, having discarded them during his arrival, and communicated to others either verbally or via cell phone throughout the response. Over the course of the incident, overwhelming numbers of law enforcement personnel from different agencies self-deployed to the school. Leadership on scene, however, had not established command and control, to include an incident command post (ICP), staging area, or clear perimeter around the hallway or the school. Thus, arriving personnel did not receive accurate updates on the situation or direction for how to support the response efforts.
Many arriving officers—based on inaccurate information on the scene and shared over the radio or from observing the lack of urgency toward entering classrooms 111/112—incorrectly believed that the subject had already been killed or that UCISD PD Chief Arredondo was in the room with the subject.
As leaders from additional law enforcement agencies arrived, including Uvalde County Sheriff Ruben Nolasco, the lack of clear communication and command structure made coordination difficult. Emergency medical responders faced similar challenges as they deployed. They struggled to identify who was in charge, and ambulances encountered streets blocked by law enforcement vehicles. Concerned families were also arriving at the school. They likewise had difficulty obtaining information about their loved ones’ status. Incorrect and conflicting information was also being shared on social media with the UCISD posting that all students and staff were safe in the building and later posting messages about reunification that conflicted with the UPD posts.
At 12:21 p.m., 48 minutes after the subject entered the school, the subject fired four additional shots inside classrooms 111/112. Officers moved forward into formation outside the classroom doors but did not make entry. Instead, presuming the classroom doors were locked, the officers tested a set of keys on the door of a janitor’s closet next to room 112. When the keys did not work, the responders began searching for additional keys and breaching tools.
UCISD PD Chief Arredondo continued to attempt to communicate with the subject, while UPD Acting Chief Pargas continued to provide no direction, command, or control to personnel. After another 15 minutes, officers found a second set of keys and used them to successfully open the janitor’s closet. With working keys in hand, the officers then waited to determine whether a sniper and a drone could obtain sight of and eliminate the subject through the window. Those efforts were unsuccessful.
At 12:48 p.m., 27 minutes after hearing multiple gunshots inside classrooms 111 and 112, and 75 minutes after first responders first entered Robb Elementary, officers opened the door to room 111. A team composed of BORTAC members, a member of the U.S. Border Patrol Search, Trauma, and Rescue Unit (BORSTAR), and deputies from two local sheriffs’ offices entered the rooms, and officers killed the subject when he emerged shooting from a closet. The subject was killed at approximately 12:50 p.m., 77 minutes after the first officers entered the school and after 45 rounds were fired by the shooter in the presence of officers.
There were 587 children and many other teachers and staff members present at Robb Elementary School that fateful day. In the end, 19 children and two staff were killed, with at least 17 survivors physically injured. Since not all the children and staff present at Robb Elementary at the time of the shooting were brought to the hospital or otherwise assessed for any medical concerns, it is unknown how many in total sustained physical injuries as a result of this incident. Wounded and deceased victims were transported to Uvalde Memorial Hospital, while the majority of other victims were transported to the Uvalde Civic Center, where the Reunification Center was eventually established.
At the hospital and the center, some families were reunited with their children. But other families received incorrect information suggesting their family members had survived when they had not. And others were notified of the deaths of their family members by personnel untrained in delivering such painful news.
In the days, weeks, and months following the tragedy, survivors, families, and responders received varying levels of support services. Many organizations arrived in Uvalde in the days that followed to assist survivors and families in accessing mental health and other victim support resources. But since then, difficulties with tracking victims and transitioning service providers have meant that some victims, family members, and community members have not received services.
Public communications challenges continued throughout the response and in the aftermath of the tragedy. Both impromptu and scheduled news conferences and media engagements contained inaccurate and incomplete information.
Victims, families, and community members struggled to receive timely and accurate information about what occurred on May 24. And although government officials and school administrators hosted several family briefings and school board meetings over the weeks and months after the shooting, those events offered limited information and few substantive responses from officials and, in some cases, exacerbated the distress of the families.
Overview of CIR Team Analysis Based on these facts, the CIR team identified several critical failures and other breakdowns prior to, during, and after the Robb Elementary School response and analyzed the cascading failures of leadership, decision-making, tactics, policy, and training that contributed to those failures and breakdowns.
From the facts and analysis, the CIR team has been able to identify generally accepted practices for an effective law enforcement response to similar mass shootings and offer recommendations in hopes that in the future, law enforcement would be able to act quickly, save lives, and prevent injuries to the greatest extent possible.
The most significant failure was that responding officers should have immediately recognized the incident as an active shooter situation, using the resources and equipment that were sufficient to push forward immediately and continuously toward the threat until entry was made into classrooms 111/112 and the threat was eliminated.
Since the tragic shooting at Columbine High School in 1999, a fundamental precept in active shooter response and the generally accepted practice is that the first priority must be to immediately neutralize the subject; everything else, including officer safety, is subordinate to that objective. Accordingly, when a subject has already shot numerous victims and is in a room with additional victims, efforts first must be dedicated to making entry into the room, stopping the subject, and rendering aid to victims.
These efforts must be undertaken regardless of the equipment and personnel available to those first on the scene. This did not occur during the Robb Elementary shooting response, where there was a 77-minute gap between when officers first arrived on the scene and when they finally confronted and killed the subject.
Several of the first officers on scene initially acted consistent with generally accepted practices to try to engage the subject, and they moved quickly toward classrooms 111/112 within minutes of arriving. But once they retreated after being met with gunfire, the law enforcement responders, including UCISD PD Chief Pete Arredondo—who we conclude was the de facto on-scene incident commander—began treating the incident as a barricaded subject scenario and not as an active shooter situation.
As more law enforcement resources arrived, first responders on the scene, including those with specific leadership responsibilities, did not coordinate immediate entry into the classrooms, running counter to generally accepted practices for active shooter response to immediately engage the subject to further save lives.
Instead, law enforcement focused on calls for additional SWAT equipment (which should not delay the response to an active shooter), requests for delivery of classroom keys and breaching tools (which may not have been necessary to gain entry), and orders to evacuate surrounding classrooms prior to making entry into classrooms 111/112.
In addition to the overall failure to appreciate the active shooter nature of the situation, responders also failed to act promptly even after hearing gunshots around 12:21 p.m., which should have spurred greater urgency to confront the subject but instead set off a renewed search for keys.
There were also failures in leadership, command, and coordination. None of the law enforcement leaders at the scene established an incident command structure to provide timely direction, control, and coordination to the overwhelming number of responders who arrived on the scene.
This lack of structure contributed to confusion among responders about who was in charge of the response and how they could assist. Communications difficulties exacerbated these problems. Per UCISD policies, Chief Arredondo was the on-scene incident commander, but he lacked a radio, having discarded his radios during his arrival thinking they were unnecessary. And although he attempted to communicate with officers in other parts of the hallway via phone, unfortunately, on multiple occasions, he directed officers intending to gain entry into the classrooms to stop, because he appeared to determine that other victims should first be removed from nearby classrooms to prevent further injury.
These failures may have been influenced by policy and training deficiencies. For example, recent training that UCISD PD provided seemed to suggest, inappropriately, that an active shooter situation can transition into a hostage or barricaded subject situation. And while many of the FOS had sufficient active shooter and incident command training, other key FOS responders lacked any active shooter training or incident command training.
The vast majority of the officers from different law enforcement agencies had never trained together, contributing to difficulties in coordination and communication on the day of the incident. The lack of pre-planning hampered even well-prepared agencies from functioning at their best.
As noted above, the CIR team organized the review of the Robb Elementary School response by focusing on particular topics. A summary of the CIR team’s observations and recommendations for each of these chapters is provided below.
Chapter 1. Incident Timeline Reconstruction This chapter provides an authoritative account of pertinent facts leading up to, during, and immediately following the tragic mass shooting.
Chapter 2. Tactics and Equipment Police active shooter response tactics have undergone significant changes and evolution over the years. Throughout most of history, the police response to an active shooter incident was to secure a perimeter and call out a SWAT team and, in some cases, negotiators. Most officers lacked specialized, advanced training and preparation to handle such situations. The watershed moment in tactical changes occurred following the Columbine massacre in 1999. Following Columbine, law enforcement expert tacticians and associations testified that the new paradigm for responding to crises like Columbine is rapid deployment. Rapid emergency deployment puts significant responsibility on the first responding officers, who may not be fully equipped or trained as a SWAT team member. First responders are instructed to go toward the violent offender, if necessary, bypassing injured victims and placing themselves in harm’s way. “
Chapter 2. Tactics and Equipment” examines the tactics and pieces of equipment that were contemplated, sought, and deployed over the course of the incident response at Robb Elementary School, beginning with the initial officers’ approach from outside the school and ending approximately 77 minutes later when the medical triage of victims inside classrooms 111/112 began.
The first officers on scene immediately moved toward the sound of gunfire and into the West Building of Robb Elementary to stop the shooter, which was in adherence to active shooter response generally accepted practices. Once inside the building, five of the first officers on scene continued to press down the hallway and toward a barrage of gunfire erupting inside of rooms 111/112.
After officers suffered graze wounds from shrapnel, the first officers on scene did not penetrate the doors to rooms 111/112 and repositioned to a barricaded subject situation. This mindset permeated throughout much of the incident response, even impacting many of the later responding officers. Despite their training and despite multiple events indicating the subject continued to pose an active threat to students and staff in the building, including the likelihood Critical Incident Review: and then confirmation of victims inside the room, officers on scene did not attempt to enter the room and stop the shooter for over an hour after they entered the building.
The shooter was not killed until approximately 77 minutes after law enforcement first arrived. (Observation 3)
The effort to clear and evacuate the entire West Building was intentional and directed by Chief Arredondo, to preserve and protect the lives of the children and teachers who remained in the hot zone, while the shooter remained an active threat with multiple victims in rooms 111/112. This was a major contributing factor in the delay to making entry into rooms 111/112.
The time it took to evacuate the entire building was 43 minutes, beginning at around 11:38 a.m., when Chief Arredondo realized there were occupants in room 109 that he could not access, and ending at 12:21 p.m., when four shots were fired, and that same room was finally evacuated through the windows. During this time and prior to 12:21 p.m., there were multiple stimuli indicating that there was an active threat in classrooms 111/112—including: the barrage of gunfire during the initial response; the children and teachers observed when evacuating the classrooms; the single shot fired at 11:44 a.m.; the notification that class was in session; the notification from an officer on scene that his wife, a teacher, was inside classrooms 111/112 and shot; and multiple radio broadcasts of a 911 call from a student inside the classroom. (Observation 6)
Some officers on scene believed that they were waiting for more assets to arrive, such as shields and a specialized tactical team, to make entry. (Observation 7) Selected Recommendations To see the full list of Recommendations, see “Chapter 2. Tactics and Equipment.”
Officers responding to an active shooter incident must continually seek to eliminate the threat and enable victim response. The shooter’s immediate past actions and likely future actions serve as “triggering points” that indicate the appropriate response should be in line with active shooter response protocols.2 2 IACP (International Association of Chiefs of Police), Model Policy on Active Shooter (Alexandria, VA: International Association of Chiefs of Police, 2018), https://www.theiacp.org/resources/policy-center-resource/active-shooter. An active shooter with access to victims should never be considered and treated as a barricaded subject. (Recommendation 3.1)
Law enforcement training academies and providers should ensure that active shooter training modules include the factors in determining active shooter versus barricaded subject situations. (Recommendation 3.3)
Officers responding to an active shooter incident must first and foremost drive toward the threat to eliminate it. In the event there are resources available and an opportunity to evacuate bystanders and victims from the hot zone, officers must balance the risk posed by evacuation versus the risk posed by remaining in lockdown and potentially in the crossfire. Evacuations in such circumstances must be conducted in the most expeditious manner, limited to those immediately in harm’s way, and not at the expense of the priority to eliminate the threat. In the case of Robb Elementary, the CIR team concludes that the effort to evacuate was protracted and should not have caused such significant delay in the eventual entry into rooms 111/112. (Recommendation 6.1)
Officers responding to an active shooter incident must be prepared to approach the threat and breach or enter a room using just the tools they have with them, which is often a standard-issue firearm/service weapon. (Recommendation 7.1)
Chapter 3. Leadership, Incident Command, and Coordination Leadership in law enforcement is absolutely critical, especially in moments of a dire challenge, such as the active shooter incident at Robb Elementary School. It requires courageous action and steadiness in a chaotic environment. Leadership can arise regardless of rank or title. Such moments require steady and commanding actions and based on facts gathered for this report, this leadership was absent for too long in the Robb Elementary School law enforcement response. “Chapter 3. Leadership, Incident Command, and Coordination” describes key principles related to leadership in an active shooter incident, including the need to direct an immediate response to the active shooter threat and to establish a coordinated and collaborative command and control system. The chapter analyzes the actions of leaders from several law enforcement agencies, including UPD, UCISD PD, UCSO, TXDPS, and CBP in responding to the shooting at Robb Elementary School. The chapter discusses incident command and management; coordination with other law enforcement agencies, including mutual aid; self-deployment by other local, state, and federal law enforcement personnel; and emergency medical services/fire medical response. Selected Observations To see the full list of Observations, see “Chapter 3. Leadership, Incident Command, and Coordination.”
Leadership from UPD, UCISD PD, UCSO, and TXDPS demonstrated no urgency for establishing a command and control structure, which led to challenges related to information sharing, lack of situational statuses, and limited-to-no direction for personnel in the hallway or on the perimeter. (Observation 4)
Failure to establish a unified command led to limited multiagency coordination. (Observation 5)
There was no uniformly recognized incident commander on the scene throughout the incident. (Observation 8) Critical Incident Review: Active Shooter at Robb Elementary School | Executive Summary 9
UCISD PD Chief Arredondo was the de facto incident commander on the day of the incident. Chief Arredondo had the necessary authority, training, and tools. He did not provide appropriate leadership, command, and control, including not establishing an incident command structure nor directing entry into classrooms 111 and 112. (Observation 9)
On the day of the incident, no leader effectively questioned the decisions and lack of urgency of UCISD PD Chief Arredondo and UPD Acting Chief Pargas toward entering classrooms 111/112, including within their respective agencies and agencies with concurrent/overlapping jurisdiction (e.g., Uvalde County Sheriff Nolasco, Uvalde County Constable Zamora, Uvalde County Constable Field, TX Ranger 1). (Observation 12) Selected Recommendations To see the full list of Recommendations, see “Chapter 3. Leadership, Incident Command, and Coordination.”
Agency leaders must immediately determine incident status and the appropriate command structure for the event. Leadership must continually assess and adjust as the threat and incident evolve. (Recommendation 4.1)
As soon as possible and practical, the lead agency should establish a unified command that includes a representative from each primary first responder agency to facilitate communication, situational awareness, operational coordination, and allocation and delivery of resources. (Recommendation 5.1)
The ICP should provide timely direction, control, and coordination to the agency leadership, other agencies, and other critical stakeholders before, during, and after an event or upon notification of a credible threat. The ICP must also serve as an intelligence collection and dissemination node. (Recommendation 7.4)
Agencies should create and train on a policy, and set an expectation that leaders will act in a manner consistent with that policy during critical incidents. (Recommendation 12.1)
A memorandum of understanding (MOU) or memorandum of agreement (MOA) needs to be developed among agencies within a county or region that provides clarity on who is in command, taking into consideration an agency’s training, experience, equipment, and capacity to take the lead during a multiagency response to a critical incident. (Recommendation 12.2)
Agencies should use the Incident Command System (ICS) for more than large-scale tactical events. They should incorporate as many of the ICS principles as possible in response to varying levels of emergencies or planned events, so ICS becomes a regular component of the agency’s culture. (Recommendation 13.1)
Post-Incident Response and Investigation Establishing investigative command after a multiagency response to a mass casualty incident is critical to ensuring effective control and coordination of the scene and responsive resources, assignment of investigative assets, collection of information and intelligence, and external and internal communication. In the wake of a critical incident involving a law enforcement response, multiple investigations and reviews will often occur.
In addition to a criminal investigation of the subject, critical incidents often result in one or more administrative investigations of officer conduct during the incident. The “Post-Incident Response and Investigation” chapter centers around criminal and administrative investigations and associated activities and processes that took place at Robb Elementary School, such as management of the crime scene, evidence collection, and interagency coordination in such efforts. Additionally, it describes several critical incident reviews that were initiated following the tragedy. Selected Observations To see the full list of Observations, see “Chapter 4. Post-Incident Response and Investigation.”
The involvement of local agencies in the hallway during the incident led the district attorney, in consultation with the TXDPS, to assign Texas Rangers to solely investigate the incident. (Observation 1)
Body-worn camera (BWC) video captures officers walking into the crime scene without an investigative purpose or responsibility in the immediate aftermath of the incident. Furthermore, in the days that followed, crime scene preservation was compromised, and the crime scene team had to continually stop and start their important work when non-investigatory personnel entered the hallway and classrooms 111/112 for the purpose of viewing the scene. (Observation 4)
The Texas Rangers Crime Scene Team processed and exhaustively documented an incredibly challenging crime scene that put their training, policies, and procedures to the test. The team conducted an after-action review to examine their efforts and learn as an organization. (Observation 9)
Among the agencies with the most involved personnel, most have not completed administrative investigations into their officers’ actions on May 24. (Observation 11) Selected Recommendations To see the full list of Recommendations, see “Chapter 4. Post-Incident Response and Investigation.”
Agencies should have a formal agreement or understanding on investigative command after a multiagency response. (Recommendation 1.1)
Leaders must respect the integrity of the crime scene and only access it with a declared and documented legitimate purpose. Crime scenes need to be held without contamination until completed. The crime scene team should be permitted to do their methodical work without continuous interruptions by VIPs who want to enter the crime scene but have no probative need to do so. (Recommendation 4.1)
Agencies in regional proximity to each other should conduct multiagency tabletop exercises for complex investigations that may necessitate mutual aid and support from each other. Doing so will build greater interagency coordination in activities like evidence collection as well as understanding of jurisdictional boundaries, capabilities, processes, and expectations among partner agencies. The tabletop exercises should include local, state, and federal agencies, as appropriate, and be designed to exploit weaknesses, uncover strengths, and develop solutions. (Recommendation 7.1)
Agencies should adopt parallel investigations policy for criminal and administrative investigations, including for major incidents, while taking diligent steps to ensure that information derived from compelled administrative interviews are completely walled off from any criminal investigation into the officer’s or agent’s actions. (Recommendation 11.1)
Agencies that engage in after action/critical incident reviews should adequately resource the effort to ensure high-quality and timely reports of lessons learned and areas for organizational improvement. (Recommendation 12.1)
Chapter 5. Public Communications During and Following the Crisis Public communications during and after a disaster, emergency, or mass violence event is itself an intervention that can help victims and community members prepare and respond effectively. Communications from trusted leaders who exude a sense of calmness, competency, control, and compassion that integrate trauma-informed information can also help those impacted manage their stress and distress reactions to these events. Thus, both internal and external communications are vitally important in every disaster, emergency, and mass violence incident. These communications must be timely and accurate and provide as much information as appropriate at any given time, providing the community with a sense of trust and confidence during a time in which many are learning the most devastating news that anyone can receive.
The “Public Communications During and Following the Crisis” chapter describes critical components for coordinated communication during and after a tragedy, including the identification of a public information officer (PIO) and the establishment of a Joint Information System (JIS), housed by a Joint Information Center (JIC). The chapter canvasses the public communications in the days, weeks, and months following the shooting at Robb Elementary School and describes how inaccurate and untimely information combined with inconsistent messaging created confusion and added to the victims’ suffering.
Selected Observations To see the full list of Observations, see “Chapter 5. Public Communications During and Following the Crisis.”
Inaccurate information combined with inconsistent messaging created confusion and added to the victims’ suffering, both on the day of the incident and in the days after the mass shooting. (Observation 1)
Family members encountered many obstacles to locating their loved ones, getting access to the hospital, and getting information from leadership, law enforcement, and hospital staff in a timely manner. This includes initial information posted by UCISD on the reunification site followed by a series of contradictory posts between UPD and UCISD on reunification. This added to the confusion, pain, and frustration. (Observation 5)
Spokespersons for UCISD and TXDPS, the only agencies speaking publicly, did not coordinate their messaging during the afternoon of the incident. Some conflicting information was shared by the two agencies. (Observation 11)
All social media public messaging was posted only in English. The one exception to this was the FBI San Antonio Field Office’s messaging starting on May 25. (Observation 15)
The extent of misinformation, misguided and misleading narratives, leaks, and lack of communication about what happened on May 24 is unprecedented and has had an extensive, negative impact on the mental health and recovery of the family members and other victims, as well as the entire community of Uvalde. (Observation 18) Selected Recommendations To see the full list of Recommendations, see “Chapter 5. Public Communications During and Following the Crisis.”
To establish leadership and a sense of order, the lead agency must be swift, proactive, accurate, and transparent in its messaging. Relevant information that is not law enforcement-sensitive should typically be released as soon as it is confirmed. However, speed must be balanced with the need for accuracy. It is critical that information is verified before it is released even when there is tremendous pressure to release information quickly. (Recommendation 4.3)
When reunification is complete and the victims’ families have been notified, the lead agency should release that information to the community. This is a crucial step in unifying the community to start the healing process. (Recommendation 6.2)
The lead agency should institute incident command and establish a JIC for coordinating the release of all public information, including victim information from all medical facilities that can be incorporated into coordinated news briefings. (Recommendation 7.1)
When an organization recognizes that an error has occurred, it should admit the mistake and share what actions it is taking to rectify the problem and prevent it from happening again. Even when the mistake is egregious, an agency can maintain or seek to regain public trust by being open and holding itself accountable to the community. In these moments, a law enforcement agency can build community trust by holding itself to the highest possible standard. (Recommendation 13.1)
In a community with a large population with limited English proficiency, officials should post emergency information in English and in other predominant languages. This inclusive approach will help ensure that critical public safety messages reach a larger audience and will help boost trust. (Recommendation 15.1)
Intentional transparency is needed for the victims, survivors, and loved ones who are seeking answers about what happened; however, authorities need to provide information in a traumainformed, victim-centered, and culturally sensitive manner. (Recommendation 24.1)
Chapter 6. Trauma and Support Services Support services for individuals who are exposed to tragedies like a mass casualty incident, including victims, family members, the broader community, and responders, are essential. Helping those affected understand that they can access crisis counseling, learn good coping skills, reach out to social supports, and access their innate strengths to build their resilience, can protect against people developing a mental illness as a result of their exposure to a traumatic event and its aftermath. Adequate support, services, and resources all contribute to recovery and healing.
“Chapter 6. Trauma and Support Services” assesses the support and resources provided to survivors, victims, responders, and others involved in the shooting at Robb Elementary School. This chapter describes the acute services provided in the first 24–72 hours following the shooting, including during the evacuation process and the establishment of the Reunification Center for families and survivors. It also describes intermediate and long-term survivor and victim family support; support services for law enforcement and other responders; and management of emotional/trauma support for the broader Uvalde community following the tragic incident at Robb Elementary School. Selected Observations To see the full list of Observations, see “Chapter 6. Trauma and Support Services.”
Once the children and adults were rescued from their classrooms during the evacuation process, they received limited instruction and direction on where to proceed. Due to the chaotic nature of the evacuation, children and school personnel were not adequately evaluated medically prior to being transported to the Reunification Center. As such, injured victims had delayed medical care and were at risk of further injury. (Observation 1)
The establishment of a Reunification Center was delayed and chaotic. Families and next of kin received conflicting instructions on the location of the center. (Observation 6)
The death notification process was disorganized, chaotic, and at times not conducted in a trauma-informed manner. (Observation 9)
Responders were not provided timely, immediate access to trauma and support services, and many reported feeling abandoned and unsupported in the weeks and months following the critical incident. Others reported being aware of the services but electing not to use them. (Observation 14)
Shared trauma is a concern for the Uvalde community due to compounding factors, including the size of the community and its interrelatedness. For the hundreds of law enforcement, medical, behavioral health, and government personnel who responded to this incident, shared trauma can make what happened even more overwhelming. Law enforcement’s trauma is also exacerbated by the backlash from the community–as the community’s trauma is exacerbated by the lack of an adequate response from law enforcement. (Observation 16)
The Uvalde community continues to need support and guidance as it struggles with the negative impacts of the failed response, a lack of accountability for those implicated in this failure, and remaining gaps in the information about what happened to their loved ones. (Observation 43) Selected Recommendations To see the full list of Recommendations, see “Chapter 6. Trauma and Support Services.”
Officials should ensure all victims of a mass violence incident are screened medically and assessed for mental health concerns soon after evacuation and no later than 24-48 hours postincident. (Recommendation 2.1)
In the weeks and months following an incident, victims and family members should receive follow-up or continued monitoring to ensure they are receiving the necessary mental health care and other services. (Recommendation 2.2)
Victim advocates should be assigned to communicate with and assist families. Each family member of a deceased person and each injured victim should be assigned a victim advocate who works with that family/victim consistently throughout the treatment and recovery period, having frequent communications to ensure the family/victim is aware of and able to access needed services and supports. (Recommendation 9.4)
Local officials engaging in trauma and death notifications should consult national resources and ensure best practices are followed when providing these notifications. Preparedness and planning can help a locality identify areas where they have fewer trained or experienced staff, thus the areas where they need mutual aid supports. (Recommendation 11.1)
Leaders from responder agencies need to provide services to all personnel involved in a mass casualty incident (MCI), which for some agencies means everyone on their staff. These services should include resources on post-disaster behavioral health and secondary traumatic stress, referrals to health care providers, and peer support. (Recommendation 14.5)
As part of disaster preparedness planning, communities—including law enforcement—need to plan for the aftermath of a critical incident. This planning should include generally accepted practice processes, education and training, support, and resources. A trauma-informed, culturally sensitive approach should be applied to the victims, survivors, and impacted community members, as well as responders and their families. (Recommendation 16.3)
A family assistance center(FAC) should be established within 24 hours of an incident with a security plan that includes external law enforcement presence and a process for internal vetting of providers and those seeking services. (Recommendation 18.1)
The definition of responders should be expanded, consistent with generally accepted practices, to include disciplines other than law enforcement, fire, and rescue staff, such as dispatchers, EMTs, health care providers, ambulance drivers, behavioral health providers, and faith-based leaders. This should be reflected in all support services provided by resiliency centers, nongovernmental and governmental entities, and other support service providers. (Recommendation 31.2)
Chapter 7. School Safety and Security While the primary goal of school districts across the United States is to educate, they must also prepare for myriad threats to school safety and security, ranging widely in scale and seriousness.
In addition to certain safety functions maintained at the school district administration level, such as threat assessment teams, school safety committees, student counseling services, and physical security maintenance and upgrades, many school districts throughout the nation partner with local law enforcement agencies to establish school resource officer programs, and some create their own police departments.
Among the 1,207 independent school districts in Texas, 309 (about 26 percent) have their own police department, including the UCISD. “Chapter 7. School Safety and Security” reviews the safety and security apparatus of UCISD on May 24, 2022, including UCISD policies and procedures on active shooter response and incident command and their policies on locked doors, use of an emergency alert system, history of drills and exercises, establishment of its police department, and district-wide and campus planning processes around school safety.
Selected Observations To see the full list of Observations, see “Chapter 7. School Safety and Security.”
UCISD’s campus safety teams met infrequently, and annual safety plans were based largely on templated information that was, at times, inaccurate. (Observation 5)
UCISD had a culture of complacency regarding locked-door policies. Both exterior and interior doors were routinely left unlocked, and there was no enforced system of accountability for these policies. Door audits were conducted, but not done systematically, nor were they documented. On May 24, all of the exterior doors and at least eight interior doors of the West Building, where the incident took place, were unlocked. (Observation 8)
Law enforcement arriving on scene searched for keys to open interior doors for more than 40 minutes. This was partly the cause of the significant delay in entering to eliminate the threat and stop the killing and dying inside classrooms 111 and 112. (Observation 10)
Four years into its existence, the UCISD PD was functioning without any standard operating procedures. A range of UCISD employees, including administrators, faculty, support staff, and police officers, told the CIR team they had no knowledge of, nor had they been informed about, their school police department’s policies and procedures. The UCISD PD has recently drafted standard operating procedures. (Observation 18) Selected Recommendations To see the full list of Recommendations, see “Chapter 7. School Safety and Security.”
School district police departments should enter into MOUs that establish mutually agreed upon clear jurisdictional responsibilities with other neighboring agencies that are likely to respond to a critical incident on school property. The MOUs should account for not only routine criminal activity, but also critical incidents. The MOU should address the issue of unified command, in addition to incident command, and account for the capacity and capabilities of the respective agencies. (Recommendation 2.1)
Law enforcement, first responders, emergency management, and other municipal government agencies should coordinate with school districts to conduct multiagency preparedness exercises on at least an annual basis. Exercises should operate in accordance with the state and local regulations regarding active threat exercises. The exercises should be incorporated into the emergency operations plans and Campus Safety Plans. (Recommendation 3.1)
Communities should adopt a multidisciplinary approach to school safety that includes school police, law enforcement, school officials, mental health professionals, and other community stakeholders. It is especially important that all voices in the school community be heard, including faculty, staff, administrators, counselors, nurses, resource officers, parents, and students. Every stakeholder must feel empowered to play a role in reducing fear and raising the level of safety in and around schools. Each campus should establish and train school safety committees that will meet at least monthly for this purpose. (Recommendation 4.2)
School districts should invest in upgrading or replacing all doors (or locks) throughout its campuses to remedy this issue, so that doors can be locked from the inside. (Recommendation 9.1)
School districts should implement universal access boxes. A universal access box refers to a locked box that contains master keys, located near the entry points of school buildings, that can be accessed by authorized emergency first responders and school district staff. (Recommendation 10.1)
School districts should ensure that emergency alert systems are well-understood by all staff. In the case of UCISD, district leadership should issue a district-wide clarification on the use of PA systems in conjunction with Raptor emergency alerts. (Recommendation 11.1)
Chapter 8. Pre-Incident Planning and Preparation Pre-incident planning is crucial in preparing for and responding to mass violence incidents, as it enables agencies and organizations to develop strategies and procedures to respond quickly and effectively to such incidents.
The planning process involves identifying potential risks and hazards, assessing the likelihood and potential impact of incidents, and creating plans and procedures to respond to them. When a mass violence incident occurs, a community’s response is not limited to one agency, but falls to multidisciplinary stakeholders, including law enforcement, fire, emergency medical services, hospitals, victim service providers, prosecutors, emergency management, government and civic leaders, media, businesses, and individual community members. The planning process—coordinating routinely among all relevant stakeholders, developing agreements, and conducting multidisciplinary trainings, exercises, and drills—is foundational, as are relationship- and trust-building. Most failures in response can be traced back to failures in pre-incident planning and preparation, and this is true of the mass casualty incident at Robb Elementary School.
“Chapter 8. Pre-Incident Planning and Preparation” describes the policies and procedures, training, mutual aid agreements, and other formal coordination efforts in Uvalde prior to May 24, 2022, and explains how those pre-incident processes impacted the response at Robb Elementary School. Selected Observations To see the full list of Observations, see “Chapter 8. Pre-Incident Planning and Preparation.”
Responding agencies lacked adequate related policies and, in most cases, any policy on responding to active attackers. (Observation 1)
The Uvalde emergency operations center (EOC) developed an adequate emergency management plan. However, not all the relevant agencies and organizations actively participated in the process, drills, and exercises which ultimately contributed to a failed emergency response on May 24, 2022. (Observation 2)
The MOU between UPD and UCISD PD that was active the day of the incident failed to adequately outline the expectations and authorities for a response to a mass violence event. The agencies failed to exercise the MOU, nor cross-train in preparation for a critical incident. (Observation 3)
Responding agencies had minimal exposure to incident command system (ICS)/National Incident Management Systems (NIMS). Of those serving in top leadership positions within the primary responding agencies, only UCISD PD Chief Arredondo and the TXDPS regional director had taken training in ICS/NIMS. (Observation 6)
Responding officers had levels of active shooter training that varied in terms of their length of time and quality, leading to failures in operationalizing the training. (Observation 7)
Personnel from responding agencies rarely trained and exercised in a multiagency environment.
(Observation 8) Selected Recommendations To see the full list of Recommendations, see “Chapter 8. Pre-Incident Planning and Preparation.”
Every agency must have a clear and concise policy on responding to active attacker situations. (Recommendation 1.1)
Agencies should regularly review after-action reviews (AAR) with other regional agencies to plan as a region for a coordinated and collaborative response to possible similar events. (Recommendation 1.2)
Agencies should consider obtaining state- or national-level accreditation to adopt and maintain standardized policies and procedures. This process also ensures accountability and transparency that can enhance confidence and trust in law enforcement among the communities they serve. (Recommendation 1.3)
Regional public safety partners should plan, train, and exercise unified command for complex incidents. This includes federal, state, and local law enforcement, fire, EMS, and emergency management as well as other governmental and non-governmental agencies that would respond to a critical incident. (Recommendation 2.9)
Elected officials should establish a Multi-Agency Coordination (MAC) Group to provide policy guidance to incident personnel and support resource prioritization and allocation. Typically, these groups are made up of government agency or private sector executives and administrators whose organizations are either impacted by, or provide resources to, an incident. MAC Groups enable decision-making among senior officials and executives, and delegate command authority to the incident commander to cooperatively define the response and recovery mission and strategic direction. Additionally, MAC Groups identify operational priorities and communicate those objectives to the Emergency Operations Center and the pertinent functions of the Incident command system and the joint information center. (Recommendation 2.11)
Interagency training, drills, and exercises help to build relationships at the front-line officer level and, if attended by law enforcement supervisors, can further strengthen relationships and the efficacy of a multiagency response to a mass casualty incident. Though policies may differ slightly among agencies, overarching commonalities are the same in an active attacker incident. (Recommendation 8.1)
Each PIO should draft a crisis communication plan and practice it at least four times a year with smaller events. This will help identify problem areas and solutions and ensure everyone is familiar with the plan and knows their role instead of trying to figure that out during a crisis. (Recommendation 12.2)
We hope the observations and recommendations in this report will improve the preparation and response by those law enforcement agencies assessed during this review, as well as other law enforcement agencies throughout the country. We also provide this independent review of what transpired as a measure of dedication not only to those who lost their lives on May 24, but also to the surviving victims, family members, and others deeply and forever affected by this tragedy.
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