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Chapter I


O n April 16, 2007, one student, senior Seung panel and its work, and other issues. Their
Hui Cho, murdered 32 and injured 17 stu- advice and counsel were invaluable.
dents and faculty in two related incidents on the
The governor requested a report be submitted in
campus of Virginia Polytechnic Institute and
August 2007. The panel devoted substantial time
State University (“Virginia Tech”). Three days
and effort from early May to late August to com-
later, Virginia Governor Tim Kaine commis-
pleting its review and preparing the report. All
sioned a panel of experts to conduct an inde-
panel members served pro bono. The panel rec-
pendent, thorough, and objective review of the
ognizes that some matters may need to be
tragedy and to make recommendations regarding
addressed more fully in later research.
improvements to the Commonwealth’s laws, poli-
cies, procedures, systems and institutions, as
well as those of other governmental entities and
private providers. On June 18, 2007, Governor
Kaine issued Executive Order 53 reaffirming the
establishment of the Virginia Tech Review Panel
T he governor’s executive order directed the
panel to answer the following questions:

and clarifying the panel’s authority to obtain 1. “Conduct a review of how Seung Hui Cho
documents and information necessary for its committed these 32 murders and multi-
review. (See Executive Order 53 (2007), ple additional woundings, including
Appendix A.) without limitation how he obtained his
firearms and ammunition, and to learn
Each member of the appointed panel had what can be learned about what caused
expertise in areas relevant to its work, including him to commit these acts of violence.
Virginia’s mental health system, university
administration, public safety and security, law 2. “Conduct a review of Seung Hui Cho's
enforcement, victim services, emergency medical psychological condition and behavioral
services, and the justice system. The panel issues prior to and at the time of the
members and their qualifications are specified in shootings, what behavioral aberrations
the Foreword to this report. The panel was or potential warning signs were observed
assisted in its research and logistics by the by students, faculty and/or staff at West-
TriData Division of System Planning field High School and Virginia Tech. This
Corporation (SPC). inquiry should include the response
taken by Virginia Tech and others to
In June, the governor appointed the law firm of note psychological and behavioral issues,
Skadden, Arps, Slate, Meagher & Flom, LLP, as Seung Hui Cho's interaction with the
independent legal counsel to the panel. A team of mental health delivery system, including
their lawyers provided their services on a pro without limitation judicial intervention,
bono basis. Their advice helped enormously as access to services, and communication
they identified the authority needed to obtain between the mental health services sys-
key information and guided the panel through tem and Virginia Tech. It should also
many sensitive legal areas related to obtaining include a review of educational, medical
and protecting information, public access to the and judicial records documenting his


condition, the services rendered to him, measures that can be taken to improve
and his commitment hearing. the laws, policies, procedures, systems
and institutions of the Commonwealth
3. “Conduct a review of the timeline of and the operation of public safety
events from the time that Seung Hui Cho
agencies, medical facilities, local
entered West Ambler Johnston dormitory agencies, private providers, universities,
until his death in Norris Hall. Such and mental health services delivery
review shall include an assessment of the
response to the first murders and efforts
to stop the Norris Hall murders once In summary, the panel was tasked to review the
they began. events, assess actions taken and not taken,
identify lessons learned, and propose
4. “Conduct a review of the response of the
alternatives for the future. Its assignment
Commonwealth, all of its agencies, and included a review of Cho’s history and
relevant local and private providers interaction with the mental health and legal
following the death of Seung Hui Cho for
systems and of his gun purchases. The panel was
the purpose of providing recommendations also asked to review the emergency response by
for the improvement of the all parties (law enforcement officials, university
Commonwealth's response in similar
officials, medical responders and hospital care
emergency situations. Such review shall providers, and the Medical Examiner). Finally,
include an assessment of the emergency the panel reviewed the aftermath—the
medical response provided for the injured
university’s approach to helping families,
and wounded, the conduct of post-mortem survivors, students, and staff as they dealt with
examinations and release of remains, on- the mental trauma and the approach to helping
campus actions following the tragedy, and
the university itself heal and function again.
the services and counseling offered to the
victims, the victims' families, and those METHODOLOGY
affected by the incident. In so doing, the
panel shall to the extent required by
federal or state law: (i) protect the
confidentiality of any individual's or
T he panel used a variety of research and
investigatory techniques and procedures,
with the goal of conducting its review in a
family member's personal or health manner that was as open and transparent as
information; and (ii) make public or possible, consistent with protecting individual
publish information and findings only in privacy where appropriate and the
summary or aggregate form without confidentiality of certain records where required
identifying personal or health information to do so.
related to any individual or family
Much of the panel’s work was done in parallel by
member unless authorization is obtained
informal subgroups on topics such as mental
from an individual or family member that
health and legal issues, emergency medical
specifically permits the panel to disclose
services, law enforcement, and security. The
that person's personal or health
panel was supplemented by SPC/TriData and
Skadden staff with expertise in these areas.
5. “Conduct other inquiries as may be Throughout the process, panel members
appropriate in the panel's discretion identified documents to be obtained and people
otherwise consistent with its mission and to be interviewed. The list of interview subjects
authority as provided herein. continued to grow as the review led to new
questions and as people came forth to give
6. “Based on these inquiries, make information and insights to the panel.
recommendations on appropriate


From the beginning, the concept was to structure summaries from law enforcement officials about
the review according to the broad timeline their investigation rather than reviewing those
pertinent to the incidents: pre-incident (Cho’s files directly. These included briefings by campus
history and security status of the university); the police, Blacksburg Police, Montgomery County
two shooting incidents and the emergency Police, Virginia State Police, FBI, and U.S.
response to them; and the aftermath. This Bureau of Alcohol, Tobacco, Firearms and
helped ensure that all issues were covered in a Explosives (ATF). The first two such briefings
logical, systematic fashion. were conducted in private because they included
protected criminal investigation information and
Openness –The panel’s objective was to conduct some material that was deemed insensitive to air
the review process as openly as possible while
in public. Most of the information received in
maintaining confidential aspects of the police confidence was subsequently released in public
investigation, medical records, court records, briefings and through the media. Although the
academic records, and information provided in
panel did not have direct access to criminal
confidence. The panel’s work was governed by investigation files and materials in their
the Virginia Freedom of Information Act, and the entirety, the panel was able to validate the
requirements of that act were adhered to strictly. information contained in these briefings from the
Requests for Documents and records it did have access to from other sources
Information – An essential aspect of the and from discussions with many of the same
review was the cooperation the panel received witnesses who spoke to the criminal
from many institutions and individuals, investigators. The panel believes that it has
including the staff of Virginia Tech, Fairfax obtained an accurate picture of the police
County Public School officials and employees, the response and investigation.
families of shooting victims, survivors, the Cho
Finally, with respect to Cho’s firearms pur-
family, law enforcement agencies, mental health chases, the Virginia State Police, the ATF, and
providers, the Virginia Medical Examiner, and the gun dealers each declined to provide the
emergency medical responders, as well as
panel with copies of the applications Cho com-
numerous public agencies and private pleted when he bought his weapons or of other
individuals who responded to the panel’s records relating to any background check that
requests for documents and information. may have occurred in connection with those pur-
Notwithstanding some difficulties at the outset, chases. The Virginia State Police, however, did
the Executive Order of June 18, 2007, and the describe the contents of Cho’s gun purchase
work of our outside counsel ultimately allowed applications to members of the panel and its
the panel to obtain copies of, review, or be briefed staff.
on all records germane to its review. In this Virginia Tech Cooperation – An essential
regard, however, a few matters should be noted. aspect of the review was the cooperation of the
First, as explained more fully in the body of the
Virginia Tech administration and faculty.
report, the university’s Cook Counseling Center Despite their having to deal with extraordinary
advised the panel that it was missing certain problems, pressures, and demands, the
records related to Cho that would be expected to
university provided the panel with the records
be in the center’s files. and information requested, except for a few that
Second, due to the sensitive nature of portions of were missing. Some information was delayed
the law enforcement investigatory record and until various privacy issues were resolved, but
due to law enforcement’s concerns about not ultimately all records that were requested and
setting a precedent with regard to the release of still existed were provided. University President
raw information from investigation files, the Charles Steger appointed a liaison to the panel,
panel received extensive briefings and Lenwood McCoy, a retired senior university


official. Requests for meetings and information Interviews were conducted to understand Cho’s
went to him. He helped identify the right people history, including his medical and mental health
to provide the requested information or obtained treatment during his early school and university
the information himself. The panel sometimes years, and his interactions with the mental
requested to speak to specific individuals, and all health and legal systems. This included inter-
were made available. Many of the exchanges views with the Cho family, Cho’s high school
were monitored by the university’s attorney, who staff and faculty, staff and faculty at the univer-
is a special assistant state attorney general. sity, many of those involved with the mental
Overall, the university was extremely health treatment of Cho within and outside the
cooperative with the panel, despite knowing that university (including the Cook Counseling Cen-
the panel’s duty was to turn a critical eye on ter and his high school counseling), and members
everything it did. of the legal community who had contact with
him. The assistance of attorney Wade Smith of
Interviews – Many interviews were conducted Raleigh, NC, was important in dealing with the
by panel members and staff during the course of Cho family. He helped obtain signed releases
this review—over 200. A list of persons inter- from the family and arranged an interview with
viewed is included in Appendix B. A few inter-
them. Various experts in mental health were
viewees wanted to remain anonymous and are consulted on the problems with the mental
not included. Panel members and staff held health and legal system within Virginia that
numerous private meetings with family members
dealt with Cho. They also provided insight on
of victims and with survivors and their family ways to identify and help such individuals in
members. other systems.
One group of interviews was to obtain first-hand In evaluating the aftermath—the attempt to
information about the incidents from victims and
mitigate the damage done to so many families,
responders. This included surviving students and members of the university community, and the
faculty, police, emergency medical personnel and university itself—many interviews were con-
hospital emergency care providers, and coordina-
ducted with family members of the victims, sur-
tors. The police used hundreds of personnel from vivors and their families, people interacting with
many law enforcement agencies for their investi- the families and survivors, and others. The fam-
gation, and the panel did not have nor need the
ily members were extended opportunities to
resources to duplicate that effort. Rather, the speak to the panel in public or private sessions,
panel obtained the benefit of much of the inves- as were the injured and some other survivors.
tigative information from the law enforcement
For these groups, everyone who requested an
agencies. Interviews were conducted with survi- interview was given one. Not all wanted inter-
vors, witnesses, and responders to validate the views. Some wanted group interviews. Some
information received and to expand upon it. were ready to speak earlier or later than others.
To further evaluate the actions taken by law To the best of the panel’s knowledge, and cer-
enforcement, the university, and emergency tainly its intent, all were accommodated. The
medical services against state and national stan- panel learned a great deal about the incident and
dards and norms, panel members and staff also also confronted directly the indescribable grief
conducted interviews with leaders in these fields and loss experienced by so many. From families
outside the Virginia Tech community, from else- and survivors, the panel learned about the posi-
where in Virginia and from other states. The tive aspects of the services provided after April
panel also solicited their expert opinions on how 16 and also about the many perceived problems
things might have been done better, and what with those services. The panel also considered
things were done well that should be emulated. the many issues that the family members asked
to be included in the investigation. This input


was invaluable and substantially improved this In addition to the primary speakers, every public
report. meeting included time for public comment. In
some cases the people testifying were
Most of the formal interviews were conducted by representatives of lobbying groups,
one or two panel members, often with one or two
organizations, and associations, but the panel
TriData staff present. Some were conducted also heard from victims, family members of
solely by staff. Generally, they were conducted in victims, independent experts, and concerned
private. No recordings or written transcripts
citizens. There was even one instance of a
were made. All those interviewed were told that cameraman who put his camera down and
the information they provided might be used in testified. Generally, the public presenters were
the report but if they wished, they would not be
expected to restrict themselves to a few minutes,
quoted or identified. These steps were taken to and most did not abuse the opportunity. At one
encourage candor and to protect remarks that meeting, more people wanted to speak than time
were provided with the caveat that they not be
available, even though the meeting was extended
attributed to the speaker. The panel believes it an hour. Those not able to present information
was able to obtain more candid and useful infor- still had the opportunity to submit it to the panel
mation using this approach. Panel members and
through letters, e-mails, or phone calls, and
staff had many informal conversations with col-
many did.
leagues in their fields to obtain additional
insights, generally not in formal settings. Web Site and Post Office Box – Shortly
after the panel was formed, its staff created a
Literature Research – Especially toward the web site that was used both to inform the public
beginning of the review but continuing through- and to receive input from the public. It proved to
out, much research was undertaken on various be very valuable. There was a minimum of spam
topics through the Internet and through infor-
or inappropriate inputs. The web site was used
mation sources suggested by panel members and to post announcements of public meetings and to
by individuals with whom the panel came into post presentations made or visual aids used at
contact. Many useful references were submitted
meetings. More than 400,000 “hits” were
to the panel by the general public and experts. recorded, with 26,000 unique visitors. The web
Public Meetings – A key part of the panel’s site also was advertised as a vehicle for anyone
review process was a series of four public meet- to post information or opinions. As of August 9,
ings held in different parts of the Commonwealth 2007, more than 2,000 comments were posted
to accommodate those who wished to contribute from experts in various fields as well as the gen-
information. The first meeting was held in Rich- eral public, victims, families of victims, and oth-
mond at the state capitol complex, followed by ers as follows:
meetings at Virginia Tech, George Mason Parents (self-identified) 251
University, and the University of Virginia. This General public 1,547
facilitated input from the public and officials of Educators 91
various universities on issues they all cared EMS 8
deeply about. Several other universities offered Students 48
facilities besides those chosen, including some Law enforcement officers 18
out of state. Each university site was fully sup- Family members of victims 12
ported by their leadership, public relations Health professionals 102
department, event planning staff, and campus Virginia Tech staff 2
police. The Virginia State Police provided added Total 2,079
protection at the meetings. (The agendas of the
public meetings are given in Appendix C.) Most persons who submitted information to the
web site appeared sincere about making a


contribution. Some lobbying groups on issues dations regarding the methodology used by the
such as gun control, carrying guns on campus, panel are presented in Appendix D; they were
and the influence of video games on young people put in an appendix to avoid having the proce-
clearly urged their members to post comments. dural issues distract the reader from the heart of
the main issues.
A post office box also was opened for the public to
address comments directly to the panel. The The findings and related recommendations in
number of letters received was much smaller this report are of two kinds. The first comes from
than the number of e-mails but generally with a reviewing actions taken in a time of crisis: what
high percentage of relevancy, especially from was done very well, and what could have been
experts, families, and victims. done better. Almost any crisis actions can be
improved, even if they were exemplary.
Telephone Calls and E-Mails – Some
information was received directly by panel mem- The second type of finding identifies major
bers or staff through phone calls or e-mails. administrative or procedural failings leading up
Much of this information was received by one to the events, such as failing to “connect the
panel member or staff member and was shared dots” of Cho’s highly bizarre behavior; the miss-
with others when thought important. ing records at Cook Counseling Center; insensi-
tivity to survivors waiting to learn the fates of
Panel Interactions – The members of the their children, siblings, or spouses; and fund-
Virginia Tech Review Panel engaged on a per-
raising that appeared opportunistic.
sonal level, participating in the majority of inter-
views conducted and exchanging many e-mails To help in understanding the events, the report
and phone calls among themselves and with the begins in Chapter II with a description of the
panel staff. The panel was impeded by the FOIA setting of the Virginia Tech campus and its pre-
rules that did not allow more than two members paredness for a disaster. In Chapter III, a
to meet together or speak by phone without it detailed timeline serves as a reference through-
being considered a public meeting. out the report—the succinct story of what hap-
pened, starting with Cho’s background, his
FINDINGS AND RECOMMENDATIONS treatment, and then proceeding to the events of
April 16 and its aftermath. The events are elabo-

T he panel’s findings and recommendations are

provided throughout the report. Recommen-
rated in subsequent chapters.