An independent investigation into the emergency response to the 2021 mass shooting at Oxford High School has found “no evidence of neglect or dereliction of duty” by emergency responders.
The report issued Monday by Guidepost Solutions does, however, “identify … breakdowns in command, coordination, communication, and training.”
Those breakdowns demonstrate a need for improved protocols for the county’s rapid response to a crisis, and training on providing medical care in a mass casualty event, the report found.
Four students were killed and seven people – six students and a teacher – were injured in the shooting. The killer is serving a sentence of life without parole.
Oakland County contracted with Guidepost Solutions last year to evaluate the response to the shooting by law enforcement, fire departments, and other emergency crews.
The company said the responding agencies were “transparent and cooperative” and provided access to internal reviews and dispatch records.
“There is no doubt that the first responders demonstrated courage and dedication under extreme conditions,” the report said.
Still, it identified several “deficiencies.”
Investigators found despite multiple ranking officers arriving quickly at the scene, there was a 25-minute stretch before someone assumed the role of incident commander.
That led to “confusion about where resources should be directed,” and “disjointed” coordination with fire and medical services.
The two officers who were first on the scene did not follow best practices to provide updates on their movements, the locations of victims, or threat conditions, the investigators found – though the report noted that those officers were “understandably focused on the apprehension of the shooter.”
The breakdown in communication resulted in efforts being duplicated, the report said, including “numerous deputies clearing the same hallways.”
Emergency responses were also hindered, the report found, when the Oxford Fire Department – in an effort to “facilitate information sharing among all responders” – moved all its communications to a new channel.
Fire personnel “were unaware that the radio channel was changed and repeatedly called command on the wrong channel, receiving no response,” the report said. “Dispatch did not intervene to redirect units to the correct channel or have command switch channels.”
The communications and dispatch problems meant that “fire and EMS personnel were not informed when the shooter was in custody, delaying their entry into OHS by approximately four and a half minutes.”
A faster medical response would not have saved the students who died, though, according to the investigators. They consulted with Dr. Steven Shelton, a South Carolina physician who the report said specializes in tactical emergency medical response and mass casualty care, and found than in each case, the injury was “not survivable.”
In the aftermath of the shooting, the report praised the emergency responders who helped students reunite with their families despite lacking formal training in best practices. Nonetheless, the families of the students who were killed had to wait two hours, while other children reunited with loved ones, before being told their children had died.
The report lays out several recommendations for each responding agency. It also makes two recommendations that apply to every public safety agency in Oakland County: establish a county-wide active assailant plan, and formalize procedures for setting up an on-site command in a critical event.
Oakland County Executive Dan Coulter said in a statement Monday that the report will strengthen the county’s response to emergencies.
“Oakland 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,” Coulter said.
The county sheriff’s office took issue with several of the report’s findings.
In a statement issued Monday evening, Undersheriff Timothy Willis, who was the officer in charge of the criminal cases involving the shooter and his parents, said the sheriff’s office had not yet reviewed the entire report, but “we have noticed, and we strongly disagree with several conclusions that either omit critical facts or are simply incorrect.”
“The report suggested there was a delay in establishing an incident commander. In reality, a ‘hall boss’ assumed command immediately as the first command officer on scene, later transitioning to a lieutenant as incident commander,” Willis said.
“The report also cited a delay in fire dispatch, when in fact the fire department was dispatched precisely according to its established protocols – protocols they still use today,” the undersheriff said.
“Our response time was less than half the national average, and our entry into the building was also less than half the national average,” Willis said.
“Within two minutes and 20 seconds of arrival, our deputies confronted the suspect and took him into custody while he still had 18 rounds of ammunition. We firmly believe lives were saved that day because of our team’s rapid and decisive actions.”
Guidepost has previously issued two other reports into the school district’s response to the shooting, one focusing on the school’s threat assessment protocols that were in place at the time of the shooting, and one on the procedures the district adopted after the shooting.
