(WWJ) A new report on the mass shooting at Oxford High School says the four students who died wouldn't have survived if help had arrived earlier.
The 275-page After Action report released by Guidepost Solutions Monday afternoon says none of the gunshots to Hana St. Juliana, Tate Myre, Madison Baldwin or Justin Shilling were surviveable.
A summary of the report says the "review found no evidence of neglect or dereliction of duty by those individual responders. It did, however, identify certain breakdowns in command, coordination, communication, and training, which demonstrate the need for improved rapid response protocols, rescue task force (RTF) training, and enhanced tactical medical readiness."
Among the deficiencies in the response was a delay in establishing a formal incident command at the scene of the shooting.
The report says although multiple ranking officers were present, there was an approximately 25-minute gap before a lieutenant assumed the role of incident commander.
The report says during this 25-minute period, although critical objectives were met and the shooter was apprehended, there was some confusion about where resources should be directed and coordination with public safety officials such as fire/EMS was disjointed.
Recommendations listed at the end of the report include:
For Oxford High School and the Oxford Community School District:
• School districts should develop a recovery plan for an active assailant event. This plan should address renovations/demolition, return to school, memorials, and more. (Tier 1)
• All school districts that have armed staff in the school should clearly define the staff member’s responsibilities and duties during a violent event. All armed staff members should receive, at a minimum, quarterly training specific to their duties and responsibilities when armed. (Tier 1)
• Training for ALICE Alerts should involve clarifications so as not to confuse participants when an actual incident occurs. There should be clear protocols in place and language to assist in differentiating between drills and real-life situations such as announcements stating “This is a drill, this is a drill, this is a drill” when a drill occurs. Lockdown announcements should not use code words or code names. Announce, “Lockdown, lockdown, lockdown.” (Tier 1)
• Training in the use of surveillance video systems within a school should not rest solely within the security officials. Administrative staff within range of camera access should all be trained in the technology. (Tier 1)
• All Oakland County schools should notify local law enforcement, OCSO, and the local fire department if they have installed any type of door barricade device. These agencies should all have a high degree of familiarity with the locking device. A cautionary note should be placed in CAD so responders are aware of the device. (Tier 1)
• Oakland County school districts should reevaluate the use of the Nightlock device and consider alternative lockdown options. (Tier 2)
• Schools should carefully consider their communication practices with the community. They should prioritize transparency and understand the implications of silence on students, parents, and those in the community. (Tier 3)
For Oakland County, the recommendation is for a county-wide active assailant plan:
• Establish a county-wide integrated active assailant response plan that incorporates law enforcement, fire, EMS, 9-1-1, and emergency management. Include clearly written policies and procedures for law enforcement, fire, EMS, and emergency management’s strategic and tactical priorities at active assailant events. (Tier 2).
• Clearly identify in the plan each public safety discipline’s equity at active assailant events. (Tier 2)
• Create active assailant checklists for law enforcement, fire, EMS, 9-1-1, and emergency management supervisors and command staff. (Tier 2) 2. Incident Command
• Embrace incident command in all operations. (Tier 1)
• Establish incident command training in the academy and continue incident command coursework as a requisite for promotion, including training about active assailant incident command. (Tier 1)
• Dispatch should prompt on-scene units to establish command if they have not done so in a multi-agency critical event. (Tier 1)
• Establish rapid unified incident command at the initiation of all multi-agency critical events, incorporating fire and EMS. (Tier 1)
• OCSO should establish and record critical command benchmarks over the radio and in CAD, to include at a minimum: (1) suspect down or suspect in custody, (2) location of the unified command post, and (3) location of known or suspected explosive devices. These critical response benchmarks should be rebroadcast on all channels with an alert tone. (Tier 2) 237 | P a g e
• All Oakland County public safety agencies should address area command and NIMS complex management structures in policy and training. (Tier 2)
• Adopt the “Fifth Officer Rule” where, barring exigent circumstances, the fifth law enforcement officer on scene at critical events regardless of rank is the incident commander until relieved by the next arriving ranking officer or if command was previously established by arriving officers. This ensures that the role of incident commander is established early and that critical directions are relayed to dispatch and responding units. (Tier 3). • Establish a rapid notification process for OCSO command staff and Special Operations units to be used at critical events. This process should include a command CAD page or other rapid notification system. Utilization of a phone tree is not acceptable. (Tier 1)
• Chief officers should take charge at critical events. Even if they do not take command, the highest-ranking person is still ultimately responsible for operations. Agency policy should clearly address this expectation.
In response to the report, Oakland County Executive Dave Coulter issued a statement saying the county is committed to taking an open and honest look at how we respond to emergency events, including active assailant incidents like the Oxford High School shooting.
"The county has held a robust schedule of training for our thousands of first responders during the last 15 years, but we know that there are always lessons to be learned and ways to strengthen our response to prevent and address these tragedies," Coulter said in a statement. "We saw on that day how our first responders reacted with dedication and courage in the face of horrifying violence, and this report reinforces their immense bravery. It also includes important insights that will help us build on the comprehensive strategies we already have in place, and we hope it will provide some long-awaited answers for the families and community.”
The shooter, Ethan Crumbley, pleaded guilty to all charges and is serving a life sentence. His parents, James and Jennifer, were convicted of involuntary manslaughter.