Virginia Tech was too slow to inform staff and students about a shooting incident in April that rapidly spiraled into the bloodiest campus massacre in US history, an investigation concluded.
The probe by the US state of Virginia pointed to errors by university police and officials in the immediate aftermath of an early morning shooting of two students on April 16 by mentally disturbed gunman Seung-Hui Cho.
Within hours of the first deadly shootings in the West Ambler Johnston residence hall, 23-year-old Cho went on to massacre 30 students and faculty inside another building before killing himself.
"Senior university administrators ... failed to issue an all-campus notification about the West Ambler Johnston killings until almost two hours had elapsed," the report said.
"The VTPD (Virginia Tech police department) erred in not requesting ... a campus-wide notification that two persons had been killed and that all students and staff should be cautious and alert."
Campus police initially pursued the boyfriend of the female student who was killed, believing the incident to be domestic in nature after an acquaintance said the boyfriend was fond of guns.
Meanwhile, Cho mailed a package containing video clips, photos and a handwritten manifesto to NBC News, then made his way to Norris Hall where he chained shut the doors to the building before shooting dead 30 people inside.
The first shooting incident occurred at about 7:15 am; the second began at 9:40 am. A campus email went out to students and staff at 9:26 am urging caution due to a "shooting on campus."
Some family members of those killed have demanded to know why the university did not issue a campus-wide lockdown after the first shootings.
"Warning the students, faculty and staff might have made a difference ... So the earlier and clearer the warning, the more chance an individual had of surviving," the report said.
However, it added that a lockdown was neither feasible or likely to have prevented the killings.
"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 added: "The events were highly disturbing and there was no way to sugarcoat them. Straight facts were needed."
Cho emigrated with his family from South Korea to the United States in 1992 when he was eight years old.
The 147-page report by an eight-member panel appointed by Virginia Governor Tim Kaine also found that signs of Cho's mental illness had not been properly handled by campus officials.
"During Cho's junior year at Virginia Tech, numerous incidents occurred that were clear warnings of mental instability," it said.
Among them were complaints by female students about "annoying" and "disturbing" instant messages and phone calls from Cho as well as his violent creative writing stories in which he detailed twisted plots to kill parents and teachers.
"Although various individuals and departments within the university knew about each of these incidents, the university did not intervene effectively. No one knew all the information and no one connected all the dots."
Cho was briefly admitted to a psychiatric hospital in 2005 but was deemed not a danger to himself or others. He was recommended for outpatient counseling, but campus counselors did not follow up for treatment.
In his package of clips, writings and photos, a rambling Cho compared himself to Jesus and to the high school killers Dylan Klebold and Eric Harris who killed 13 people in 1999 at Columbine High School before committing suicide.
The panel did not recommend any officials be dismissed as a result of the probe and stated that controversial issues such as the right to bear arms and gun control were beyond its scope.
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