Delay in Establishing Command Cited in Response Delays to Oxford, MI, School Shooting

The Oakland County Sheriff's Office failed to establish a timely incident command and was late to dispatch fire crews in response to the Oxford High School shooting, according to an independent investigative report released Monday.

The office did not create a formal incident command at Oxford High School until 25 minutes after a teenage gunman who went on a murderous rampage was in custody, according to an after-action review of the emergency response to the November 2021 school shooting.

The 275-page report by Guidepost Solutions found no evidence of neglect or dereliction of duty by individual responders, but noted that failing to quickly establish an initial command and promptly integrate with other public safety agencies can lead to severe consequences.

“Successful incident command operations in the first five minutes of a critical event often determine response success. These operations include not only ‘sizing up’ a scene, but also a brief description of initial actions, and instructions for additional responding personnel,” investigators wrote in the report's executive summary.

Nearly 560 emergency personnel responded to the scene from more than two dozen agencies. But poor communication and inadequate training hamstrung some EMS, police and fire workers, investigators found.

Survivor accounts from the attack revealed a chaotic scene in which nearly 1,600 students and dozens of staff were fleeing the sprawling school building while emergency responders tended to the wounded and dead and police searched for the student gunman.

Although multiple ranking sheriff's officers were present, the report said there was a 25-minute gap before a lieutenant assumed the role of incident commander.

"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," the report said. "Once command was established, law enforcement agencies were aligned with the roles needed to complete the building clears, secure the interior of the building, and create a perimeter around the outside of the building."

The release of the report follows a Detroit News investigation that revealed complaints from fire department officials that their crews were dispatched late to the attack. The News also reported that the Oakland County Sheriff's Office declined to participate in a third-party review of its department's response as recently as January 2024, a claim that Sheriff Michael Bouchard has denied.

Oakland County government officials approved $500,000 to hire a review firm three weeks after The News' report on response complaints. Guidepost was tasked with conducting a comprehensive report evaluating the multi-agency response to the shooting and the recovery effort that followed.

The shooter, Ethan Crumbley, a sophomore at the school at the time, fired his weapon 33 times in the attack and killed Hana St. Juliana, 14; Madisyn Baldwin, 17; Tate Myre, 16; and Justin Shilling, 17.

Report: Delay didn't doom victims

The report determined that, despite the misteps in response, the victims' injuries were "inherently fatal" and that a quicker emergency response could not have saved their lives. The conclusion was based on information from a medical examiner’s report and analysis by an independent medical expert.

"Our review determined that the nature and extent of Madisyn, Tate, and Justin’s single gunshot wounds to the head were inherently fatal," the report said. "Hana sustained multiple gunshot wounds, with resulting abdomen and chest injuries, which were collectively inherently fatal. Even with immediate medical intervention, the experts’ consensus is that the outcomes would not have changed."

Despite the shooter being apprehended just two minutes after the sheriff's office personnel arrived on scene, and Sheriff's Office ranking personnel arriving on scene within the first seven to nine minutes after the shooting began, the incident command was not formally created until Lt. Todd Hill arrived at 1:20 p.m. and initiated command at 1:25 p.m., the report found.

"This constitutes a time gap of approximately 27 minutes after the SRO (school resource officer) and OCSO Deputy 1 arrived on scene, approximately 25 minutes after the shooter was in custody, and approximately 24 minutes after OCSO dispatch confirmed the suspect’s arrest," the Guidepost Solutions report said. "Lieutenant Hill ultimately established incident command inside the lobby of OHS by a bench across from the administration offices."

Guidepost found breakdowns in communication regarding the locations of officers and victims early in the response. The first two officers to enter the schools, "while understandably focused on the apprehension of the shooter," did not provide updates on their movements, victim locations or their conditions via radio, the report says.

"Best practices suggest that, as the first responders on the scene, they are the 'de facto' command and should not only announce their entry point but also provide information about what they saw as they came upon the victims in the hallway. Also, due to a lack of effective communication, some efforts were duplicated. Injuries were reported multiple times and OHS surveillance depicted numerous deputies clearing the same hallways."

A lack of training, for both law enforcement and firefighters, was identified in the report as a challenge.

At the time of the shooting, sheriff's deputies and supervisors were not sufficiently trained in incident command and unified incident command, Guidepost found. The sheriff's office has since instituted programs on those concepts, the report said.

"During this review numerous fire department members indicated that, when on scene at OHS, they did not feel that they were adequately prepared to deal with the chaos and pressures of an active assailant situation," the report said.

"Departmental training was limited to mass casualty scenarios within EMS continuing education programs. There was insufficient or even non-existent training on the use of ballistic protective gear at the fire department, which was frequently stored away and never utilized by personnel," the report says. "For many OFD members, the day of the shooting was the first time they donned ballistic vests and helmets."

Guidepost recommended that fire department chiefs mandate bi-annual active assailant training with the sheriff's department.

Officials, families respond

Oakland County Executive David Coulter said he was briefed Monday morning by Guidepost officials and had not yet read the entire report.

“I appreciate the report. It is comprehensive. I think it's fair,” Coulter said. “We engaged with Guidepost because we're committed to taking an honest look at how we respond to these kinds of emergency, tragic events, and to see where there could be lessons that we can learn from them, and it certainly appears that there are areas that could be strengthened.”

The county executive said there was a very successful and courageous response by first responders and a lot of things were done right.

“And I continue to be proud of the people who responded on that horrible day,” Coulter said.

Oakland County Sheriff Mike Bouchard's office issued a statement late Monday disagreeing with several findings, including the 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. 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 statement said.

The statement noted that a key finding in the report found there was nothing in the department's emergency response that could have saved the lives of the four students. The report, they said, affirmed that deputies and first responders demonstrated courage and dedication under extreme conditions and further found no evidence of neglect or dereliction of duty on their part.

“We will be carefully reviewing the (report), which we just received today. We constantly seek ways to improve, and many of the training and protocol recommendations – including the expansion of our rescue task force – were already in progress prior to this report. To restate this clearly, we will take an honest look at this report to address any gaps we see in our response and look to be better trained and better prepared moving forward,” the statement says.

Steve St. Juliana, whose daughter, Hana, was killed in the shooting, said Monday he remains devoted to making the school district accountable, but that the after-action review of the emergency response was an absolutely necessary step toward overall lessons learned.

"I have appreciation for all of the cooperation from all of the agencies involved. I know this was difficult. This should have happened three and a half years ago. From what I have seen so far, it is highlighting a lot of systemic issues that hopefully the county and other agencies will take steps to address," St. Juliana said.

Communication and command were "just horrid," he said, adding that "Those are two items can directly be addressed and improved through training and education."

Dispatch delay found

In its report, Guidepost identified a delay in dispatching the Oxford Fire Department in response to early 9-1-1 calls that came in at 12:52:32 p.m. with a definitive report of injury.

At 2:19 minutes into the call, at 12:54:51, the caller confirmed a victim was shot, the report said. At 12:52:59, information regarding the shots fired was dispatched to all Sheriff's Office units. The Oxford Fire Department was not dispatched until 12:59:56, Guidepost said.

"Best practices suggest dispatch should be within 15-30 seconds of receipt of a call, and within no more than 60 seconds. The call data reviewed indicates that the call takers recognized this incident as a confirmed active shooter event well before the decision to dispatch the fire department," the report said.

"OCSO follows the practice of waiting to dispatch fire departments until confirmation of an injured party is established. Although OCSO asserts that this is based upon directions from fire departments, we suggest that in low occurrence-high threat events such as active shooter incidents, especially those at schools, it is logical that all necessary resources be dispatched even before confirmation of injuries."

The Guidepost report critiqued the response and offered recommendations to improve emergency preparedness and response to incidents, including a recommendation to Oakland County to ensure that a formal after-action review is conducted for all multi-agency critical events in the county.

In interviews with The News in 2024, Oxford Fire Chief Matthew Majestic and Addison Fire Chief Jerry Morawski said they dispatched their crews on their own when the high school came under attack.

While both chiefs said the dispatch delay did not affect their treatment of victims as fire and EMS crews staged outside the school until police worked to secure the scene, Majestic told The News then that the delay cost his department valuable time to develop a plan ahead of treating victims, four of whom died. It's an aspect of the tragedy he has struggled with for years.

"Had they toned us out, we could have been staging and ready and organized," Majestic told The News in 2024. "I know we would have reviewed the maps, probably made changes to who is responding and where. … We would have had more people on the scene. … We could have made a better-educated triage. … You took away that opportunity of building a plan."

Majestic was not immediately available Monday for comment.

Role of school resource officers

Guidepost, a New York-based investigations, regulatory compliance, monitoring and security consulting firm, found there was no protocol during the shooting for detailing responsibilities of the school resource officer in relation to non-police school security. School resource officers (SROs) are armed, certified police officers.

The issue stands out because the school resource officer at Oxford High School was not required to remain on campus and was not present at the time the shooting began, having left earlier for an investigation at Oxford Middle School and a stop at the substation. On the same day, the school security officer was absent on a pre-approved leave.

"Consequently, a part-time armed hall monitor was the sole armed individual at OHS. Going forward, expectations must be clearly delineated regarding SROs and school security," the report said. "There should be protocols in place between the district/school and OCSO about alternative security measures when school security is unavailable."

Investigators did 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."

Fire and emergency response

About the fire and emergency services' responses to the shooting, the report said both command and communications were "hindered" during the incident when fire command at the scene moved all fire communications to a different radio channel.

"This was intended to facilitate information-sharing among all responders. However, fire personnel within OHS 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."

Guidepost recommended that the dispatch be alert for misrouted communications and proactively redirect personnel to the correct channel, and that fire departments review and revise policies and practices of switching radio channels during critical incidents. The report added: "When a switch occurs, it should be announced by dispatch with a 'tone out' to alert all on the channel."

The report also found that in the absence of clear dispatch protocols, fire and EMS personnel were not informed when the shooter was in custody, delaying their entry into the high school by about four and a half minutes.

"The computer-aided dispatch (CAD) system did not utilize specific call types for active assailant incidents, and there was no county-wide operating procedure to guide a coordinated response. We recommend that pre-determined CAD call categories be implemented for active assailant events, not only to streamline dispatch practices but also to ensure that fire and EMS are made aware of developments as they occur," the report said.

Records from the Oakland County Sheriff's Office show Oxford EMS staging outside the high school at 1:00:53 p.m. and transporting the first victim out of the high school at 1:06:32 p.m., 15 minutes after the shooting began.

Guidepost investigators recommended that the fire departments reconsider their staging practices to provide "greater clarity and coordination" and move to a unified county-wide policy. At the time of the shooting, the policy of fire and EMS departments from both Oakland County and Oxford was to “stage” their response by waiting nearby until the scene is declared safe, the report says.

"This creates confusion for both personnel within the department as well as law enforcement, who remain unsure when firefighters and EMS members will enter a scene to render aid," the report said. "We recommend that Oxford Fire Department (OFD) as well as other departments across Oakland County reconsider staging practices. This requires agencies to evaluate best practice recommendations to forgo staging during active assailant events and clarify whether dispatch instructions to stage are mandatory or advisory."

Outdated dispatch system

Guidepost described the sheriff's office's Computer Aided Dispatch (CAD) system as outdated, saying it heavily relies on manual entry by dispatchers for the transfer of information. It recommended that CAD systems be updated to transition from manual to automated entry and that CAD should flag high-risk keywords such as “shot,” “injured,” “weapon,” “gun,” and “active shooter” to trigger response protocols.

On the day of the attack, 911 calls were rerouted from Oxford County to Lapeer County. A total of 248 emergency calls would flood the sheriff's dispatch in the first 60 minutes after the attack.

"For example, one call from OHS administration, which proved to be the most valuable for tracing the direction of the suspect, was rerouted to Lapeer. Active shooter incidents can often tax phone systems, as they were not designed for the volume that often occurs after a tragedy. We recommend that public safety organizations establish county-wide policies for handling misrouted 9-1-1 calls and build relationships with local phone service providers to understand how large-scale incidents affect call coverage and routing," the report said.

Reunification practices

The emergency operations plan for Oxford Community Schools had identified the Meijer store, a half mile from the school, as the reunification location. Hundreds of students fled there. The report said many Oxford High School families reported a positive experience with the reunification process, but the approach fell short in providing sufficient communication and emotional support to the families of the victims.

"The families of Madisyn, Tate, and Hana came to the reunification center with the expectation of reuniting with their children. However, after two hours and no more students arriving from the school, the parents were ushered into a store breakroom where they were informed that their children were killed," the report said.

Guidepost investigators wrote that in discussions with Madisyn's mother, Nicole Beausoleil, Buck Myre and Steven St. Juliana, the families did not approve of the manner or means by which the information was relayed.

"While they understood that there was no perfect way to convey this information, Nicole Beausoleil felt that the words were emotionally disconnected and significantly contributed to the continued trauma suffered. All agreed that OCSO’s delayed disclosure of their children’s passing, repetition of additional buses coming, and overall silence gave the impression that officers were not being forthcoming," the report said.

Guidepost suggested the reunification process could be improved by broader staff training and formalized protocols.

Others respond to report

Oakland County officials selected Guidepost in December from a group of consulting firms that had experience performing after-action reviews. The intent was to resolve questions raised by first responders and some victims' families about the emergency response and whether there were lessons that could be gleaned to improve the response in the future.

Oakland County commission board Chair David Woodward, D-Royal Oak, said Monday that he had read the executive summary and recommendations in the report Monday afternoon.

"This report did exactly what it was supposed to do: an objective recounting and examination of an event on the tragic day that identified deficiencies and made recommendations for how to improve," Woodward said.

Commissioners were all sent the report at 1 p.m. Monday when it was released, and Woodward said he expected a Board of Commissioners committee to have a presentation at the executive level this month.

The county is setting money aside to fund future after-action reports, and the matter will need to be formalized with a county resolution later this month, the board chair said.

"This is a roadmap for all communities across the county," Woodward said. "We think Oakland County could be a model for all agencies."

Andrew Arena, a former head of the Detroit FBI branch and current executive director of the Detroit Crime Commission, said he spent 25 years training in critical response management and was the incident commander at Metro Airport in 2009 when the underwear bomber, Umar Farouk Abdulmutallab, was taken into custody.

Arena said setting up incident command within five minutes is what is taught in training and a great idea — but not always realistic or a reality for law enforcement.

"That's all well and good and academically, that's a great idea if you can get it set up within five minutes," Arena said. "But then, there is reality. ... And you are dealing with what is right in front of you. You don't have time to stop and call a timeout and say, 'Hey, let's set up a command post.' The command post is sometimes where the commander is standing."

There is no federal or state law requiring an after-action review of a mass shooting. Elected officials and elected bodies in other states have initiated them.

Critical examinations of emergency responses were done for the school shooting in Uvalde, Texas, by the U.S. Justice Department. Attorney General Merrick Garland announced the review shortly after the tragedy on May 24, 2022.

After-action reviews were also done in Parkland, Florida, by the Marjory Stoneman Douglas High School Public Safety Commission, created by the Florida Legislature, and in Newtown, Connecticut, by the Sandy Hook Advisory Commission, created by Gov. Dannel Malloy.

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