RICHMOND, Va. – Virginia Tech officials may have been able to save lives if the campus warning system had been implemented more quickly, a panel said in a report issued Thursday.
But the panel also found that the failure of the state's mental health system and the school's lack of information about the shooter's mental health also played a role.
"The dots were not connected, the signals were missed at Virginia Tech," said Gov. Timothy M. Kaine at a press conference Thursday.
It took administrators more than two hours to get out an e-mail warning students and staff to be cautious. The shooter had time to leave the dormitory where the first two victims were killed, mail a letter, and then enter a classroom building, chain the doors shut and kill 31 more people, including himself.
Click here to read the key findings of the report (pdf).
Even before the killings, the university had failed to properly care for the mentally troubled student gunman, Seung-Hui Cho, the panel found.
"The mental health system failed in that instance because there was a court order for treatment that we now know was not complied with," he said.
One victim's mother on Thursday urged Gov. Timothy M. Kaine to "show some leadership" and fire the university's president and campus police chief for their lack of action during the April 16 attack. Others demanded accountability for errors that were made.
Kaine, however, told The Associated Press the school's officials had suffered enough without losing their jobs.
"This is not something where the university officials, faculty, administrators have just been very blithe. There has been deep grieving about this, and it's torn the campus up," Kaine said. "If I thought firings would be the way to do that, then that would be what I would focus on."
Kaine said he wanted to focus instead on fixing the problem. After formally accepting the report, he said parents of troubled children who are starting college should alert university officials, and those officials should "pick up the phone and call the parent" if they become aware of unusual behavior.
"The information needs to flow both ways," the governor said.
An eight-member panel appointed by Kaine spent four months investigating the worst mass shooting in modern U.S. history and issued its report late Wednesday.
"Warning the students, faculty and staff might have made a difference," the panel. "So the earlier and clearer the warning, the more chance an individual had of surviving."
The first victims were shot shortly after 7 a.m. It wasn't until 9:26 a.m. that the school sent an e-mail to students and faculty warning: "Shooting on campus. The university community is urged to be cautious and are asked to contact Virginia Tech Police if you observe anything suspicious or with information on the case." Cho opened fire inside Norris Hall about 20 minutes later.
Derek O'Dell, who was shot in the arm at Norris Hall, said he probably wouldn't have gone to class that morning if he knew there was a killer on the loose.
"I don't think anybody would have," he said.
"The alert should have been issued and classes should have been closed," the panel's chairman, Gerald Massengill, told the AP Thursday.
But the panel also concluded that a lockdown of the 131 buildings on campus would not have been feasible. And while the first message sent by the university could have gone out at least an hour earlier and been more specific, Cho likely still would have found more people to kill, it said.
"There does not seem to be a plausible scenario of a university response to the double homicide that could have prevented the tragedy of considerable magnitude on April 16," the report said. "Cho had started on a mission of fulfilling a fantasy of revenge."
The report detailed a breakdown in communication about the gunman, who had shown signs of mental health problems for years.
His middle school teachers had found signs of suicidal and homicidal thoughts in his writings after the Columbine High School shootings in 1999. He received psychiatric counseling and was on medication for a short time. In 2006, he wrote a paper for his Virginia Tech creative writing class about a young man who hates students at his school and plans to kill them and himself, the report said.
The university's counseling center failed to give Cho the support he needed despite the warnings, including his referral to the center in 2005 because of bizarre behavior and concerns he was suicidal, the panel said. It blamed a lack of resources, misinterpretation of privacy laws and passivity.
Individuals and departments at Virginia Tech were aware of incidents that suggested his mental instability, but "did not intervene effectively. No one knew all the information and no one connected all the dots," the report said.
The report said the response by university and Blacksburg police to the dormitory shootings was well coordinated, and said the police response at Norris Hall was "prompt and effective," as was triage and evacuation of the wounded. But it also noted university police may have erred in prematurely concluding that the first two shootings were the result of a domestic dispute.
"As you read the report, it's clear that so many of the mistakes that were made result from a failure of leadership at the very top levels of the university," said Cathy Read, stepmother of slain freshman Mary Karen Read
Celeste Peterson, whose freshman daughter Erin was killed, said the governor should act forcefully and fire university President Charles Steger and campus police Chief Wendell Flinchum.
"I love Virginia Tech, too. My daughter loved Virginia Tech," the grieving mother said. "We have to separate Virginia Tech brick and mortar from the administration, which is inept."
This is Kaine's "opportunity to step up and do the right thing," she said Thursday. In Virginia, university presidents serve at the pleasure of the Board of Visitors, which is appointed by the governor. Campus police chiefs are accountable to the university president.
William O'Neil, father of slain graduate student Daniel O'Neil, called it outrageous that no one had been held accountable. "With the exception, of course, of Cho, no one from the university is held accountable," he said.
Diane Strollo, whose daughter Hilary was shot and survived, said she was thankful the panel recognized that an earlier warning could have derailed Cho's plans for Norris Hall.
"Had some or all of the student body been notified that 2 students were gunned down that morning, they may have had heightened sensitivity to the sound of gunshots and other suspicious activity," Strollo wrote in an e-mail to the AP. "One or two minutes of notice may have been critical in saving more lives in Norris Hall."
The Associated Press contributed to this report.