Analysis by MC4EI of Final Report Conclusions- Part 1

Co-Authored by Becky Behrends, M.D. and Joe Brandis

Michigan residents were stunned when a shooting tragedy occurred at Oxford High School (OHS) on Nov 30, 2021.  The shooter was a 15 yr old student at the school.  He shot and killed four students, and shot six other students and a teacher, all of whom survived. A year long independent investigation by Guidepost Solutions has resulted in the recent release of an in-depth final report.

These results are chilling and disturbing, revealing serious gaps and lapses in safety and security preparedness at the high school.  

What happened and what went wrong?  What can be learned that will propel other school districts to be transparent about the policies and guidelines they have in place?  

The report noted that “in certain areas, individuals at every level of the School District, from the Board to the Superintendent and his cabinet to the OHS administration and staff, failed to provide a safe and secure environment.”

Here are some of the most notable failures and red flags that should have triggered timely action:

  • On Nov. 29, a day before the shooting, a teacher alerted the administration that the shooter was seen looking at an image of bullets in class.
  • The Dean of Students and the shooter’s counselor believed the boy’s story that he had gone to a shooting range with his mother recently and that this was a family hobby.  He was told not to look at any material relating to guns or shooting while in school.  The parents were notified.
  • Later in the day, this same teacher sent to the administrators an index card upon which the shooter had drawn a picture of a person holding a gun, with the gun erased but still visible.  The Principal was not notified.
  • On Nov 30, the shooter was caught watching a violent video in his first class of the day, despite the warning he had been given the day before.  His teacher, again, notified administration.
  • Even more concerning was the shooter’s behavior in his second class.  His teacher there noted he had written “the thoughts won’t stop” and “help me” on his math assignment as well as “blood everywhere”, “my life is useless: and “the world is dead”. The teacher took a picture of this and walked to the administration office to alert them.  
  • The boy’s counselor went to bring him to the front office for a meeting.  The boy had crossed out most of the concerning statements and had written, “I love my life” and “OHS Rocks”.
  • The shooter denied to the counselor that he was a threat to himself. The counselor called his parents and asked them to come to the school.
  • The counselor asked the parents to take their son for mental health treatment that day.  The parents said they could not as they needed to get back to work.
  • The shooters backpack was retrieved from the classroom and brought to him in front administration office. This is when school officials could have asked the parents or shooter for consent to search the backpack, but they didn’t.
  • After the backpack was obtained the shooter said later to the defense psychologist, that for the first time in his life, he felt relieved. He just knew that the sheriffs were going to burst into the office and arrest him, because there was no way after all that they witnessed that they were not going to search the backpack. 
  • The counselor and Dean of Students never asked the parents if their son had access to a firearm.  
  • The counselor concluded that it would be okay to send the shooter back to class as it was a “controlled, supervised setting”.  
  • Again, the Principal was not notified -who had the authority to conduct a threat assessment and search the Shooter’s backpack.  
  • Had the backpack been examined, they would have found a gun and ammunition which was used to gun down students in the hallways of the high school later that day.
  • Had a threat assessment been done, the shooter’s social media would have been searched and they would have found that he had posted a picture of a 9mm handgun with the caption, “just got my new beauty today.”

The shooter should never have been allowed to return to class. His counselor later testified that he thought the boy was a threat to himself.  District policy was not followed as if there is a risk of suicide, the parents must come and retrieve their student immediately.  The Principal should have been notified and the backpack searched. 

Here are other glaring problems:

  • There were two security staff members.  But they were not required to be present at OHS at all times.  On the day of the shooting, the armed security guard had the day off and the other one (SRO or school resource officer) was  off site also at another school.
  • 177 surveillance video cameras were present at the school but the armed security guard who would normally monitor them had, as mentioned, the day off. So, no one else was monitoring the cameras.
  • The surveillance cameras showed in real time where the shooter was and this would have been critical information to inform the students and teachers which hallways NOT to go into and where to evacuate to.
  • The ALICE alert system was used via the PA system. (Alert, Lockdown, Inform, Counter, Evacuate). But no one was assigned to provide updated INFORM messages or situational awareness via the public address (PA) system.
  • The PA system was inadequate for emergency communications.  Communications were garbled and hard to hear and did not function in certain locations.
  • Inability to lockdown the bathrooms and courtyard created a dangerous situation for students. Also, the bathrooms did not have speakers and the speakers in the courtyards were not consistently audible.  One of the students who was shot and killed was in the bathroom. Another student who was killed had just come in from the courtyard- right into the hallway where the shooter was.
  • It is common practice not to provide lockdown devices for bathrooms because of concern for self-harm, assaults and drug use which would isolate students and prevent staff from entering.
  • However, panic (duress) buttons in bathrooms or Nightlock barricading devices with an overriding device placed near the bathrooms would have compensated for this. 

This tragic shooting may well have been avoided.  The ultimate responsibility lies with the shooter.  However, the school district has an obligation not only to educate students but to provide a secure and safe environment for them as well.

“If you’re proactive, you focus on preparing. If you’re reactive, you end up focusing on repairing.”

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In Part 2, we will address additional measures to be employed to minimize and avoid shooting occurrences at schools and to limit fatalities and injuries if shooting does happen.


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