DEPARTMENT OF THE ARMY

HEADQUARTERS, UNITED STATES ARMY RESERVE COMMAND

4710 KNOX STREET
FORT LIBERTY 28310-5010

AFRC-OPI (800B-15-6b2) 7 March 2024

MEMORANDUM FOR Commanding General, United States Army Reserve Command,

Fort Liberty, North Carolina 2831 O

SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation

into the Suspected Suicide of SFC Robert R. Card 11

1. Executive Summary.

a. BLUF. On 25 October 2023, SFC Robert R. Card II, B Company, 3d Battalion,

304th Infantry Regiment, 2d Brigade, 104th Tra ining Division, 108th Train ing Command,
killed 18 civilians and wounded 13 others in Lewiston, Maine. Maine law enforcement
officials found SFC Card's body two days later at the Maine Recycling Company, SFC
Card's former employer. SFC Card committed suicide by a self-inflicted gunshot wound
. . . . .. This investigation identified multiple errors made by unit leadership,
'iriecJicaT"'pfessionals, and local law enforcement. For example, SFC Card's unit should
not have ordered SFC Card to Annual Train ing and should have conducted a Line of
Duty Investigation when he was hospitalized in July 2023. Keller Army Community
Hospital (KACH ) and the chain of command should have kept SFC Card on Active-Duty
orders for a Line of Duty determination and Medical Evaluation Board . I was unable to
determine whether SFC Card received signed discharge instructions from Four Winds
Hospital , the day after a court hearing should have taken place in New York State Court.
Local law enforcement authorities in Maine could have conducted a more extensive
welfare check and follow-through in September 2023 and better employed the Maine
Yellow Flag law to prevent harm. Given the nature of the United States Army Reserve
(USAR), with only 38 duty days per year, the USAR had limited jurisdiction over SFC
Card during non-duty periods. 1 I recommend holding unit leaders accountable and
making systemic adjustments to improve oversight and care of Army Reserve Soldiers
in the future .

1 In accordance with 10 USC 10147, members of the Ready Reserve, including the Troop Program Unit
(TPU), are expected to participate in 48 Multiple Unit Training Assemblies (MUTAs) for a total of 24 days
and at least 14 active duty (AT) days a year, for a total of 38 duty days. A standard drill weekend consists
of4 MUTAs.

Encl. Page 0025

AFRG-OPI '(800B-15-6b2)
SUBJIECT: Findings and Reeorn1mern1ations, Army Regulatiorn (AR) 15-6 Investigation
1into ~he Sus:pected Suicide of S.FC R,obert R. Ca1rd II

b. Findings. The fihtilngs of ~ms investigatic,h are based 1C)lil a preponderance of thij
evidenee.1
1(1) SFC Card enlisted in the United States Army Reserve on 14 December 2002.
·and his Military Occurpational Speciality {MOS) was 92F1 Petrole:um Siuppl:y Specialist
with an Additional Ski111 Identifier EH7, Enliisted Petroleum Vehicle Operator. At the time
of lhis ertli'stment1 SFC CarrdJ had h o ide:ntified mehtal health iS$U~s requiring a m~dical
waiverto jorirn. Atcon:Jing to all repom,, SFC card lilad an unrremarkable military ,career
spanning tvventy-years. SFC Carrd did not deploy or mobmize: therefore, he was not
exposed to cohdfltions found irn a combat environment
1

(2) SFG Card's death was preceded lby a rseries of events beginning in the FalUof
1

2oi2, which likely exacerbated his mental health issues leading up to his suicide, ihe$e
events included his pemepUo:n r0f others making derogatory
statements about him, beginning the use of hearing aids, arnd eonfllets with -
, and with his fellow lJSAR urnlt members. Family members
became concerned with SFC Card's ,deterioratirng mental .state and reported their
concerns, seelking assistance from local law enforcement authorities for ~he first time.,
on 3 May 2023,

(3) Despite not attendililQ the unit validation exericise in 1Aprn .2023, SFG Gard was
ordered to lilis Fiscal Year Annual naining (AT) from 15 - 28 July 2023. Afte'r engaging
rir, ,a veJibal altercation wit/lit unit mem!Jer.s on 15 July 20.23. SFC carrd was oraerea by
3d Batta~io:n, 304tfh l nfantry Regime'.nt
(3-304th), to undergo a Command Directed Behavioral Health Evajuaition (CD'BHE) on
16 July 2023. While 1umdergo,in9 this eval UJatio:n, medical officials at Keller Army
Commun'ity Hospital (KACH), West Poirrlt,, NJY,, assessed SFC Card''s ~ondltion to be
signifiO"anit enough to o:rder his t1ospitalizatioo at a civilian mental health fadllity, the Fol!lr
'Wi1t11ds Hospital - Westchester. Katonah, NY, for ·further evaluation and treatment At the
eonolusion of ~is AT orders, 3-304th placea SFC cara on a medical Active Duty
Operatiornal S1upport-Reserve Component (ADOS-RC) duty order for six-days to
facmtate his stay in the !hospital. SFC Card's reported! symptoms included psychos_is~
mood lability/aggressio:n, lhomilcidal idleations, [Parainoia, arnd a1Udtitory hallucinations,
according the Four Winds dijscharge summary.

2 Army Regulati<1n 15-6 (1 Apr,ii 2016) defines [l)repo:niderance of the ev,idence as Evidence which is ,of
greate:r weight or more convincing tharn the ,evidence which is offered in oppO'sitiron to it; that is, evide:oce
which as a w hole shows that the 'fact sought to be proved 1is more probable t'harn not. Preponderance of
the ev,i dence may not be determined by ~he number of witnesses, but by the ,greater we,ight of all
·evidence..

!End Page 0026

AFRC-'OPI (800B-15-6b2)
SUBJIECT: Findings and Recom1mendations. Army Regu latiorn (AR) 15-6 l1rwestigation
Iinto the Sus:pected Suicide of SFC R,oberi: R. Ca rd H 1

{4) llhe Army metllCal provide:r who conduttijd the COBHIE icondluded SFC Card
did not meet the Armts meaieal retention standards and recommended to SFC Card's
chain of command th,at SIFC Ca rd r15e entered into the Disability Evaluation System,
1

whicfh would fadmate his disdia1rge firom the military. 3 SFC Card's access to his
assigned {military ,owned) weapon was re:stricted on 20 Jiuly 202,3. SFG Gard was
eventually d'ischarged from Four Wirntls H(ospital o:n 3 August 2023 under questionable
circumstarnC'"esi and rtlea$ed ~rorn lhis USAR orde-rs, after 20 days with a dia9't:1o~is of
"Brief Psychotic Discm:1~r and rncommendea sttleduling of ftillow--0n treatment ~ntJ
prescribed psycniatric rrH:iditatio'.ns.

(5) After SFC Card's release in ea1rly August 2023, StFC Caird's unit diid not
conduct a reqruired Line of Duty lnvesti,gatio.n to propetily document SFC Ca1rd':$
,oondmon and hospital stay which would allow the ,government to pay for treatment of his
·condition, nor did the unit initiate disabmty processing. 4 Upon SFC Card's release 1from
Four 'Winds Hospital on 3 Augrust 2023, SFC card's chain or command was not
providea with any ijnformation regarding SFC Cardls diag111osis1 prog nosis,, or dischat1ge
1

instructions. SIFC Cardi,s discharge instructions were eventua~ly sent to KACH on 11

August 2023, but were inot rel,ayed to SIFC Card's chain of command,,

(6) qn .13 September 2023, SFC Card told h i s - and feUow urnit
membeir,l he "could itake out 100 people with this (exipensive scope"
he had just bought followed by a list o-f dlfferrernt [places rne cou~d 4ishoot up." Ill'
- reported SFC Gard's trtnreats to commit a mass s11ooting to tri~ chain of
command who ~hen referred the thire,ats t,o local law enforcemernt Law ,enforcement
attempted t,o establish contact w ith SIFC Card on 15 and 16 September 2023. Despit~
SFC Card being inside his home on tihe 16th, lo-cal aiuthorities did llilOt force an
int,eract'ion or attempt to employ the Maine Yelllow Flag Law, which could lhave restricted
SFC Card's access to his prlvately owned flirearms.

(7) on 25 October 2023, SFC Card was identified as me lone snooter, kimin,g 18
people, a'nd wounding ain additional 13 in L,ewiston, Maine, After a two-day manhunt,
SFC Card's body was dis·covered, The Oilflce of Chief Medical Examiner, State of

3 The Disability Evaluation System is the Army",s mechanism for determinililQ whether ,a 'Se:rviciemember
will re~um to duty, medically separate, or imedicalty reti're due to disability, The Dis:abil'ity Ev,aluation
System, also r,eferred to .as ibhe lrntegra'tec!l Disability Ev,aluation Sy.stem {1DIES}, consists of a Medical
lEvaluation Board and a Physical Evaluation Board. The applicable Army Regulatio:ns are Army
Regulation 40-501 ·(Standards of Medial Fitness) and Army Regulation 63-5-40 (Disability Evaluation for
Retentio'.ft, Retirement, or Separation).
4 A line of !Duty determirnation is an administrative tool for determinil'itg a Soldier's duty stat,us at the time
of injury, illness, disability,, or death, USAR Soldiers are generally on1y in the lirne of Duty while in a duty
status, See Army Regulatio:n 600--8-4 (lirne of Duty Policy, Procedures, arnd lnvesti,gations},

End Hage 0027

AFRCJOPI (800B-15-8b2)
1

SUBJECT: Fitildings and Recommendations, Army R·egulahorn (AR) f5-6 Investigation

1into the Sus'pected Suicide of :SFC Rob'ert R Gard fl

Maine, found that SFt C:ard dled due to a single perforating s~lf;inflleted 1gunshot
w o u n d -. At the time of his death, SFC Card nac1 no intoxicating drugs,
including alcohol, in r111is system.

c. Recommendatiorns.

(1) Ref~r thi$ irtveistigation to the Director, D~fEJn$e li~ami Agency (DHA), to
evaluate whetherr Four Winds Hospital imet the stand~ra of ca1 re. arnd if rnotl consider
r emoving Four Winds as ·am authorized treatment facility, In accordance with Title 32 to
the Code of Federal Regulations. Additionany, consider terminating fne contract of
Spectrum Services Group, Inc., whb provided nurse case management servic:es w ithin
KACH .

(2) Reqt1<:!$t DHA an~ the Army Surg·eon General update procedures of Army
med Ital agencies to ireqUiire written communication witn a Soldier's chain of command
at 1he lowest level at every stage of a So'ldler;s case.. Also tiequest Army medica1
ag·encies are trained on the basic nature of Reserve personnel's service tio better
communicate with iunit and civilian agencies when ther.e is a requirement for monitoring
t?:ind follow-on ca1re.

(3) Take appropriate administrative action against SFC Card's

d. Tlhis irnvestigatilon has been iturned over, in its entirety; to the De.partment of
Fo:rens ic Psychology at the Walter Reed National Mmitary Medical Center for review and
1

expert analysis of wfllether SFC Card 's care at FoU'r Windls met the establ~slhed
Standard of Care and! whe~her SFC Card's rcondition requiring hospitalization in July-
A1.1tgutst 20.2 3 wa:s in the Line of Duty. Walter Reed wiill :also prov~de a Rodt Gause
Analysis an:d a Forensic Autopsy. 5 The a-esullts of Walter Reed's examirnat~on are
pe:nding.

5Root cause analysis (RCA) is a -structured method used to analyze serious adverse events. lnitiallly
developed to analyze !industrial accidents. RCA is now widely deployed as an e:rror anatysis tool in lheralth
care. A centra1I tenet of RCA is to ndentrfy underlying problems that increase the lik,elihood of errors while
avoflding the trap of focusing on mistakes by individuals. RCA thus uses the systems approach to identify
both active errors (errors occurring at the 1point of interface between !humans -and a complex system)
and latent erroirs (the hidden probllems within health care systems that contribute to adverse events). It is
one of the most widely used re1rospective methods for detecting safety hazards. See

IEnc'I. Page 0028

AFRC-'OPI (c800B-15-6b2)
1

SUBJIECT: Findings and Recommendations. Army Regulatiorn (AR) 15-6 lnvestigati-on

Iinto the Sus:pected Suicide of SFC R,obert R. Ca1rd II

a. On '.2 November 2023. I was appointed by the Deputy Commandi1ng Gene:ral,

Unilted States Army Resefrve Command (USA RC), Major Gen'eral Eu.gene J. LeBoeuf, to
serve as ~he l1rwestig,ating Office:r to determine the facts and c1
i:rc:umstances surrounding
the suspe'ct,ed stiicide of Sergeant !First c 1ass {SFC) Robert Russell Card II, B
1

Company, 3d !Battalion, 304th Infantry Regiment1 2d Brigade, 104th Training Divlsitm,

108th Training command located in Saco, Maine.

were assi ned as m Assistant Investigating Officers (AIO).

, USARC, was assigned as my Legal
Advisor. The purpose of the investigation w,as "to ident1ify the circumstances. methods,
and contributing factors surrounding the suspected suidde.'" Specificall)\ I was directed
t,o "e;;;:amine tlile Soldie(s !behavior before the event; actions by ~he chain of command;
anci potential improvements to tlile unit's, lnstalllations·, antl/ior Army s suicide iprevention
rprogram." I was di:reeted to uprovide clear, relevant, and practical recommendation(s) to
[prevent futuire suicides. 6 jj

b. As part of th is investigation1 my team and I inteirviewed 43 witnesses. 7 I gathered

4-45 exhibits, including photogu1iphsr videos, tilocumentsj text messages1 e-mails,
medicafl recot1ds, public records, police reports1 search warr.ants and afidaviits j military
rrecords, witness statemerntsypoj!eies, regulations, ·standard operating proc:eaures,
open-source media reports, alfila autopsy results. t visited mu1trip1e sites of interest
pertine:111t to lthe investigaU0111 or to co'ndtud iinterviews, including: Camp Smith, New York;
Kene:r Army Community Hospital (KACH), West Point, New York; Range 1 at W~st
Point, New York,; the West Point Office :o f the Department of the Army's Criminal
l nvestigatkm Division (CIID); the C.W. Bill Young Anmeg Forces Reseirve Center amt!
Army R·eserve Medical Management Oernter (ARMMC) in Pinellas ParK, Florida;
Schemengees Bar a1nd Grille IRestaurnnt, Lewiston Maiine; .Just-rln-Time Recreation
rce:nter, Lewiston, Maine; Maine Recyding and Annex, liSbon Falls, Maine; lisbolii Falls,

https:J/psinet ahrq.govfprimer/foot-cause-analysis. A forensic autopsy is an examination ,t onducted

postmortem to addre.ss medk:olegal objectives. A forernsic al!Itopsy is a/st> called a medicolegal autopsy,
The performance of a forensic ial!ltopsy follows instructions from the oonce:med legal authority responsible
for the medicolegal inves\tigation of :sudde1n, iunexpeeted, suspidous, mysterious, unwJtrnessed, obscurre.
unexplaiined, or litigious deaths, criminal deaths, industrial deaths, and deaths associated with medical ar
surgical treatment Vvtiere medical negligeince is alleged or anesthetic deaths. In lbnief, all deaths of
unnatural! (homicide, suicide, accident) manner. suspicious deaths, and urnexpected deaths necessitate a
legal investigation, which includes an a1uto11sy as ,a portion of the evidernce-gathering 1Prooess. See
https:HVv'Ww.,ncbi.nlm.ni1h.gov/booksfNBK539901/.
6 Ernclosl!lre 1.
7 A list of the individuals interv1ewed, as well as those I was unable to irnterview for a variety of reasons, tis
attached hereto, E~hib:Jt A.

!Encl Page 0029

AFRC-OPI (800B-15~6b2)
SUBJIECT: Fil'ildihgs and Recommendations, Army Regulatit)n (AR) 15-6 Investigation
~nto the Sus:pected Suicide of SFC Robert R. Ca1rd II

Main~ ooat ramp; the UJn1ited States Attorney's Offite for Vhe District of Maine,, P,ortland.,
Maine; tne LTC Charles L. Butler U.S. Army Reserve Center irn Saco, Maine; ,and SFC
'Card;s and SFC Card's . Maine,

c. On 14 February 2024i this investigation w,as informally presented to the

Commanding General; USARC, for an informal review and ru1 rther :guidanice. On 20
Fe!bruary 2024, I received! atkHtitin~I rtrquesls for irtfotn1atiort, anti recerved ~n exteh~ion
rl!lntil 20 Mar-ch 2.02·4 .

d. Unfortunately, tlhere are several u1

nresolved iss ues. Despite multiple requests, i
1

was unab 1e to speak to several key witnesses. including the

1
at
Keller Army C)ommunity Hlospita~1 a contract employee. Add itional witnesses include
civilian co~workers a:nd managers, and key ),
and SFC Card's . I was unable to speak to hospital staff at
Four ·winds Hospital to determine why SFC card was released on 3 August 2023. I
rrequested multiple times but never received the Maine State Po1Uce reports, which
1included ihterviews with olther witnesses ~ needed to interview and other forensic
1information about tlhe last days of SFC Card's life. I requested expert assiistance from
the Chief of Forensic Psychology at the Walter Reed National Military Medical Center,
Specificallly, I requested a Root 'Cause Analysis and Fon.msicAutopsy. I made a
supplemental request to Walter Reed t,o detenmine if 8 FC Gard's oorndition was
1

ex,aeeroated by serv,iee in Jru1y 2023 for tne pl!irposes of a Line of Duty 1determination
and wtiletner Four Winds complied wittil tne stan:dard of care in its treatment of SFC
Card.

3. Facts.

a. Family and Childhood.

in Brunswick, Maine, to
8

(3) SFC Card grew up on his in Bowdoin, Maine. At the time

of lhis aeath, he re.sided at , Bowdoin, Maine 04287. 10

a Exhibits H2. D.
9 Exhibit B21:
rn Exhibits B21, G54-56, J1-J 2.

iEnd. P,age 0030

AFRG.:OPI (8008-15-6b2)
SUBJIECT: Findings anti Recommendations, Army Regulation (AR) 15-6 Investigation
1into ~he Suspected Suicide of SFC Robert R. Catrd H

(4) During his childhood, SFC Card's

(5) SFC Card dealt with anxiety iand was described a:s "sensitive"' and "cam
1introvert." While SFC card 1reportedly lived with lhe~ring issue~ since childhood, 'th~re ie
1no intom,atiorn that he saw a medical pnifessional Tor h~s 1diminishea heanng until he
was ;an adu~t SFC Card was ~eportedly refused [hearing aids lby a doetor later in life,
1

because his heating was too fair gone to benefit.1113 A review of SFC Card s enlistment
11 1

report of medical! e.xamihation (DD F,orm 2808) ilndicated re:durced hearing in his left ear
but not at the level requiring a waiver to enllist in the USAR The - suspected
his long-term hearing issues were a - "lharden~ng of the ear canal," likely

(6) .As a child, and ~ater a:s an adult1 SFC Card h·ad a small group offrlends. 15 He
was close with h~s- aind generally had good relationships with
Tluougho1utl l l childhrood, SFG Card and . . routinely competed .
while SIFC Card w~s tech savvy.16

(7) SFC Gard was inot violelfilt as a child. He ''never wa111ted to kin anything" and
would often hide with - when it was time to go nuntrng with
- or if a fam, animal had to be euthan~zoo. SIFC Card aid not kill his first deer until
he was an adult. 17

(9) As an adolescent, SFC Carel was c:tescrilbed as "straight edge," despite

experimenting with drugs briefly as a young adult. 19 SFC Card drank socially but "d idn't
handle alcohdl welll. He became emotional ror angry if he drank too much."20

11 Exhibit 13'21.
12 Id,
13 Exhibits 821, K42.
u Jd,
lS Id,
i6 Id.
17 Exhibit B21.
l8 Id.
n9 /d.

!Encl P.age OD~ 1

AFRC.!O Pl (800B-15--6b2)
SUBJECT: Findings and Recommendations. Army Regulation (AR) f5-6 linve$tigation
1into the Suspected Suicide of SFC R•ober1 R Gard II

1(1 o) SFC Gard possessed a strong work ethic, whith hislllll ,credited to lhis
desire to 11get away from doing worrk on the _ _21 ,ij

(11) SFC Card attended colllege lbut did not graduate.22

b. Eintry into the Army/Family:

(1) SFC Cara enlisted rn the U.S. Army Reserve on 14 December 2002.. At the
time, SFC Card's

i{2) SFC Card's Military Occupational Specialty (MOS) was -92.F, Petroleum
Supply Specialist1 with an Additional Skill Identifier {ASI) EH7, Ernlisted Petroleum
Veihicle oiperato-r.2"

I II - •11-

(5) In September 2006, SFC Card, then-SPC Card met

SFC Card an • •
•• • ~' 1

20 Id,
21 Id.
22 Exhibit D.
23 Exhibit B21.
24 Exhibit N79.
25 Exhibit B39.
26 Exhibit N69.
27 Exhibit B21.
28 Exhibit B21.
29 Exhibit B36.

!Encl Page 0032

AFRC-'OPI {800B-15-6b2)
SUBJIECT: findings an-d Recommendations, Army Regulatiol'il (AR) 15-6 Investigation
Iinto the Sus;pected Suicide of SiFC Robert R. Card II

(6) In Aprn 2007, SFC Carrd was arre$t~d fo:r, and stJlbseqruert~ly eor1vlcted ofl
30

{9) In :was, S1 FC Card fell f1rom the roof of his home and broke his neck,35 There
is no evidence that SIFC Card re1po'li ed this accide:nt to the USAR and ~here are no
notes in hiis military medical file documenting the accident.

(10) SFC card join~d B company, 3d Battalion, 304th Infantry Regime:n t 2,ct
Brigade, 104tn Traintng DMsion,, 108th Trairning Command, on 9Aprll 2014.36

(11 ) While assigned to B Company, SFC Cardi served primarily as a "senior

trainer," trailfiling West Po·int cadets irn a variety of firearms instruction with a particular
focus as ;, a "pit NCO" i nstructor on the hand grcenade 1 range and "iane NCO" for crew~
se1rved weapons. 37

i(1 2) 1111 2017 1 SFC Card was referred to an MOS Adminilstrative IRete:ntion Review
to determine if he shoulld be referred to a Medical Evaluation Board due to his persistent
!hearing issues. Otil 1.2 July 2017, SFC Card was found fit for duty and given a
fpemum~nt H3 profile with a Woode. This profiile and cod.e Iindiicated that although SFC
Card had a permanent iprofile, he shoulltl be retaiined and returned to duty. 38

(13) Urnit members desrcribed SFC Card as kind, friendly, calm , and genemus. 39
Accordirng tio his SFC Catd lilad no
pteviol!Jsly reported performance or conduct issues prior to the Spring of 2023.40

30 Exhibit J4.
31 Exhibits H2, N70, N71.
32 Exhibit 836.
33 Exhibit B21.
34 Exhibits B2t, 839.
35 Exhibit B21.
:35 Exhibit N79.
37 Exhibits H2, 85, 810, B42, R13,
38 Exhibit E7.
39 Exhlbits 81 0, 842, 836, B39.
1

End P,age OOS3

AF RC-'OPI (8008-15-6b2)
1

SUBJECT: Findings and Recommendations. Army Regulatiorn (AR) 15-6 lnvestigati·On

1into the Suspected Suicide of SFC Rrobert R. Card II

1(14) sFC Card worked primarily as a true!< drTver in nls civllh:m capacity. and al
the time of his death was emp~oyed as a bread de~ivery driver for First Fleet, Inc. in
Lewiston. Maine.41 SFC Card also worked as a truck driver fo'r Maine Recycling
1

,corporation in Lisbon Fallls; Maine, ftrom 2021 until early Jully 2023. 42 SFC Gaird
previotisly wo:rked at Pine State Beverage distribution in Gardiner1 Maine, Kris~Way
Truck Leasing in Auburn, Maine, and Bsaxtet Brewing company in ILeWi$tdn, Maine,
accordirng to 43

(15) observed SFC Card daily in the

Spring of 2022. reported SFC Card was financially responsible. SFC
Card reportedly made $50,000 in three mon'ths in ~he stock market in 2021 and
afterNa1rds took a break ~rom working. According to SFC Card returned
t,o work purely out of lboretlom. 4 -"

(16) !Between .2007 a1

nd the Fall of 2022,

( 17) Until early 2023, SFG Card and . 45 - ·

SFC Card would regularly go

fishing, bowling, out to restaurants, and attend "cornhole" nights at Schemengees Bar
,iiind Grille, a bar and rec11eation facility located in Lewisto:n, Maine. 47

c. Fall 2022,

40 Exhibit B3,
4•1 Exhibits D, 836, B21 ,
42 Exhibit B21.
43 Exhibit K41.
44 Exhibit B36.
45 Id.
46 Exhibits 838, 821 .
47 Exhibits 838, G48-53.
48 Exhibit 838.

10

!Encl. P.oge 0054

AFRC-OPI (8008-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(4) Members of SFC Card 's unit and his

d. December 2022/January 2023.

(1) SFC Card reached 20 years of service in the U.S. Army Reserve on 14
December 2022. In early 2023, SFC Card received his 20-year letter memorializing the
same.56

(2) In January 2023, SFC Card bought hearing aids online from Aud icus
(www.audicus.com), receiving them on 2 March 2023. 57

(3) In or about January 2023,

noticed SFC Card 's mental health began to decline.

49 Id.
50 Exhibit 836.
51 Id.
52 Exhibits 836, 81 0, 821.
53 Exhibit 838.
54 Id.
55 Exhibit 836.
56 Exhibits N77, 836, 810.
57 Exhibit 821.
58 Exhibits 836, 838.

11

Encl. Page 0035

AFRC..:OPI (8008-15-6b2)
SUBJIECT: findings an'a Recommendations, Army Regulation (AR) 15.,6 lnvestigation
1into ~he Sus'pected Suicide of SFC Robert R. Ga:rd II

(4) Among the m:erntai hlealtih iS$Ue$ observed wrc1s Sif t card rte[po rting that he
1

was ne11ring voices. There are no reports of SFC Card hearing voices prior to January
2023. The first time SFC Card complained about hearing people talking arDout him
[befhind his back occurred in January 2023 when he was with at
Schemengees Bar and Grille.59

(5) w~re out iin public p'laces SFC

1

Card would claim that people around him were talking 1clbout hint 60 SFC Card told _
he .believ,ed that people nearby were saying derogatory things, such as calling him a
1
" pedophile ."
61

came to tihe conclusion that SFC Card was "hearing voices" and that he was "starting to
experience paranoia." 62 - desrcribad SFC Card as "acting angry and parano'id,"63

e. Marc hi 2023.

(1) Upon receiving his r111earing aids o:n 2 March 2023, SFC Card texteci 1111
stating, "Got my hear,Jng aids today got llfly night ear perfect but left is
about where my hearing 1in my r1ight ear was about 4'0 percent hea1ring 1-oss lbut they may
lbe able to adjust it to get it a little better or I'll have to srend these back and lhea(jj to the
1

doctors and s:pend 8 to 10 grand to get it better (sic).'164

(2} In Marcri 2023, SFC car,cJ and - went to the Gowell's Shop n Save 1

grocery store 1in 1Litch1fiela, Maiine.65 SFC ~ he "heard" an olcter couplle 50-
100 feet away in the store talking about him, and he told - they were calling him a
"pedophile."66 - told SFC Card that he did not hear the older couple say anything
abouit him, but SIFC Card insisted they were talkring about him.67 SFC Caird did not
'Confront the older couple.'68

(3) Also in or about Mar,ch 2023, SFC Card told - ·that there was
"somettling online·· about tnim being a pedophile.69 - refrfevecl an online pnotograpln

r,9 Exhibit B38.

60 Exhibits J1 tpg, 3, 838.
61 Id,
62 Jd,
63 Jd.
64 Exhibit C29.
65 Exhibit B38.
66 /d.
67 Id.
&s Id.
69 Exhibit B38.

12

IEnd P,age 0036

AFRC-'OPI (:800B-15-6b2)
SUBJIECT: fitildings and Recommendations, Army Regulatiorn (AR) 15-6 Investigation
Iinto the SusIpected Suicide of S FC Rrobert R. Card II

but SFC Card insisted there had to be something else out there pertaining to
him. SFC Card ~hen became very upset, accusing
derro:gatory !information >about him that - h,ad see:n on the internet.

f. April 2:023.

(1) Between Marrch and April 2023., SFC Carrd ofte:n cal l e d -. one of
SFC Card's closest Mends in the 31304th. to comp!lain that tpeople in the unit were
callling him "gay." When - asked for specmc names of the people camng him
"gay,'' SFC Card dud not respond . Instead, SFC Caird indicated that it was people 'Who
·sat at the front of tjhe room in the group of classrooms. An estimate of the amouint of unit
memlbers and the distance rt,etween SFC Cara and the ameged people taI11<ing atJout him
i's at least tnirty 1
people sitting ,about 30-401eet away. 73

(2) On 11 April 2023,

for 31304th !infantry Regiment informed the
that he received a call from regarding rumors that SFC Card
was gay and/or a pedophile.74

(3) - responaea by contacting aina asking him to

investigate IPOterntial ha1ra;ssment of SFC Card. instructed to
keep up with SFC Card and to investigate the matter further. 76

(4)A!lso in April 2023, the 3/304th conducted a unit anrmal tra1iniIng validation
event at Jloint fBase McGuire-Dix~LaKehurst in New Jersey, to determine trainers for the
upcomirng summer Annual Training at West Point. 77 SFG Card did not attend the
valiclation exercise.78

10 Exhibits 838, J·13.

71 Exhibit 838,
72 Jd,
73 Exhibit 810.
7-4 Exhibits 822, C19.
75 Exhibit 822.

7 6 Exhibits 822, G19.

77 Acoording to 2d 8rnigade, 104th Training Division, validation in this context
is a term the DivisiO'n lhas borrowed from U.S. Army Cadet Comm:and (USACC) since the majority of the
!Division's Battalions (8 of 9) sl!lpport US Army Cadet Command (USACC). At USACC. "validation" rrefers
to the time period (usl!lally late May) before Cadet Sl!lmmer Trainillg i(CST) where the C'ST Commandant
will ensure each tra1ni1ng lane, of which the 104th !Division has several participants in. meets ~he

13

Encl. P:age 0037

AFRC-OPI (8008-15~b2)
SUBJECT: Firndings and Recommendations, Army Regulatiorn (AR) 15-6 Investigation
1into the Sus:p ected Suicide of S FC R•obefit R Gard II

(5) 17he tnitd ineklent observed b y - occurred in April 2023 When Ihle
and SFC Carcj were shopping at a Lowe's Hardware St1ore. According t10 -. there
was ,a couple ta'lking to a !Lowe's employee about electlical work in their garage.79 SFC
Card tol d - h e believed the couple was calling him a pedophile,00 -said he to11d
- he did not lh ear the co·uple say anything othe:r than ask q11Jestions raboUJt
electrical work.81

(7) From April '.2023 to Jurne 2023,

standards set forth by ithe USACC G37. The 104th T,raining Divtsioo'-s battalions generally run internal
training events called "validations" during an FTX or Battle Assembly in the April or May timeframe. E:adh
battalion ~validlation• is tailored to the battalicn's mission to support UJ$AC.C ot the United States Military
Academy (IJSMA), The "validation" 1is not Soldier validation or qualificatiorn. nor is 1it an externally
evaluated training event, bl!lt rather ,a battalion internal collective training e:vent or rehearsal focused on
the irequireme111ts, running various ranges, of th~ customer unit {USMA). lihus. 3-304's validation event
consisted of mnnang various ranges and the ba'ttallioro h:ad ernough leaders wfllh the proper training it> be
rar11ge ·OJC-s/NCOICs and that they aire [Prepared to conduct fheir respedtlve range 1AW USMA's
requi11emen1s. Upon the battalion''s arrival at USMA. USMA's Department of Military !instruction assess the
vanl'OUS trai.nin9 lanes a few days pnior to the execution of IUSMA's summer tr:airning missiorns. According
t,o _ _ it was not uncommorn for Soldiers to still be assigned to AT despite not attending the
" v ~ e n l t because there are always duties that don't requiire specific requiiremerits at the various
summer training events. for ,examjple vehicle drive:rs or ammunitkm detaiL
78 Exh.ibit 838.
79 Id,
so Id.
s1 Id,
82 /d,
83 Exhibits 838, 821 ,

14

1Encl. Page 0038

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations. Army Regulation (AR) 15-6 lrrwestigation
1into tlhe Sus:pected Suicide of SFC Robert R. Gard II

g. May 2023,

(1) After the incident at SFO Card's house in late April 2023,

i(2) On ,o r about 3 May 2023, reported their co:ncerns

about SFC Card's mental health to the (Topsham Police
Officer

(3) The Topsham Ponce Officer referred the matter to tlile Sagadahoc County
Sheriff's Office, responsible for Bowdoin, Maine, the town where SFC Card lived .86 The
Sagadahoc County Sheriiff's Office (SC.SO) assigned to
investigate the mattet 87

r(4) On 3 May 2023, prepared a police re;port memoriaHZiing his

1
intetviews with reported the four alarming incidents
evidencing deteriorating mental state. 88 expressed concern that■
- had access to weapons. telling that SFC Caiid had weapons
locked in his bedroom and poss ibly in his vehicle.
1

~ Exhibit B38.
85 Exhibits B38, H6.
86 Exhibits J1. IH6.
87 EKhibit J1 pg. 1.
68 Exhibit B38.
tr9 Id.

15

IEnd Hage 0039

AFR:C-OPI (8008-15~b2)
SUBJECT: !Findings and Recommendations, Army Regulation (AR) i 5-6 Investigation
1into the Suspected Suicide of 'S
. FC Robert R Ca:rc!I II

(5) - informed that SFd Can!! was an Am1y Res,ervist

assigned to a training uinit in Saco, Maine. also expressed concern about
SFC Card's access to weapons. was not aware of
any specific threats SFC Card had made involving a weapon but was genenallly
concerned because SFC Card h:ad access to weapons, heaving 1reoently retnieved 10-15
lrifle·s and/or handguns 1previously stored at home.90

(6} - also told tnat SFC Card's·

deterio:rating mental state and that she was working with SFC Card's to get him
91
the help he ineeded. However, SFC Card refused any ass isbmce aind deni1ed anything
1

was wrorng. 9'i

(7) they -did not want SFC

Gard to know they had gone to law enforcement, fearing that it would aggravate the
situation with SFC card.93 was simply trying to avoid
contact with s FC Carrd. 94

1(8) Based on 'a lack of any specific threat, ,explained that their
95
options were limited, Nevertheless, discussed several options with
including how to approach SFC Card. 96 They all agreed tihe
best course of action was to oormect with SFC Card's command irn the U.S. Army
Reserve.97 that ne would contact SFC Card's
• • • •

(9} In addition to cirmtacting Sf'C Card's U.S. Army Reserve unit ~he Sagadahoc
County Sherri'ff's Office a s k e d - if he would be willing to speak to ■
-- further stated tllat when :said he would
:spealk t,o SFC C:ard , the Sagadahoc Sherirfff's Office considered the matter closed,. 101

90 Exhibit H6.
91 Exhibits H6, J1' 839.
92 Id.
93 Exhibit J 1 pg, 3.
~ Exhibit:s J1 IPQ. 3, 839.
95 Exhibit J'1 pg. 3.
96 Jd,
97 Id,
98 Exhibit J1 ,
99 Id.
noo IExihibits 821, B39, iH6, J1.
10' IE~'hibit 821.

16

iEnd Page 0040

AFRC-'OPI {800B-15-6b2)
SUBJIECT: firndings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Ga:rd II

i(1 o} After interviewing

the Anny Reserve Center in ,
• with the
d that b
-:re Ipolice officers. 10
recently been t ohsidf?rable tom;;~ ··
105
left a voice m-aH m:essage with -

(11) While awaiting a return phone call from

contacted to update her with his findings. relayed that she lhad
spoken to , who stated ~t the time that he "didn't realize that Robert was
becoming paranoid or hearing v,oioes."1O1 Walso reported to
that - allegedly made a reference to SIFC Card's heavy drinking, during which
"he has made angry rants about navirng to shoot someone,"108 - then told
that - was allegedly going to check in with Robert later that
day and was "much in favor" of involving SFC Card 1s comma111ding officer to seelk
help.109

(12) them spoke with on 3 May 2023, and they

discussed SFC Card's situation "at length." 11 that SIFC
Garra had accusea other SOidiers of calling him a sex offender, which coincided wiijh the
report that - lnad rgivern about- .r 11

(13) acknowledged that he had no nde3 ·that SFC Card's problem was
as serious as was des~ribing. - also thanked for
making him awarre of the extent of SFC Card's mental health decline, since the unit was
planning an upcoming training exerrdse involving crewQserved weapons and
grenades. 112 that lhe would contact and

rn2 IEx'thibit J1 pg. 4.

rn3 JrJ.
HM :ld.
105 Jd.
106 /<J.
107 !Exhibit J1 pg. 4.
108 J<J.
f 09 J<J.
110 !Exhibits B7.. J1.
111 !Exhibit J1 pg. 4.
i1 2 Id.

17

Encl. P:oge 0041

AF'RC.:OPI (8008-15-6b2)
SUBJIECT: findihgs ,and Recom1rnendations, Army Regu lation (AR) 15-6 Investigation
1into ~he Sus'pected Suicide of SFC Robert R. Gard II

<lstatt to figurre o'L!lt ,options to get Robert help." 113 a.greed

to Keep each other u,pd·ated with any etumges. 11
1

(14)Afterspeaking with spoke with _ , who

reported that he was not aware SFC Card had picked Yp ,gwns frrom his house, which
,caused ham great 1ooncem, 115 - also exp~ained that he belie'Ved SFC card's
pa1ranoia and anger started around the time that SIFC Card -received heariing aid$ for th~
first time iln or isoout March 2023.116

,{15) performed some online research .and found that "hearing

1(:'.)ss-inclurced mental mness" is a documented condition that ,can project itse~f in paranoid
lbelhavior. 117 that he had :spoken with SFC Ca1rd's
command in the U.S. Army Reserve and that they discussed strategies for ap;proaching
SFG Card directed at getting 1t11im help. 118

told him he thought the presence of a police officer might

agreed to keep posted on any
developments, and reiterated that should meet with SFC Card
and detem1i111e he is a danger to himself or others, to call him (law enforcement)
rimrnectiately. 119

(17) Later that evenirng, on 3 May 2023 , went to

trailer. SFC Card answered the door holding a gun because "he was
worried about people ooming to lk:ill him. He immediately hid the 91.m when he let in ■
120 SFC Carra made comments aboUJt ~plflnchring people in the face,"

with regard to the people fhe believed were talking about him, although he did not
menti1on anyone specifically. 121 SFC Card was "in denial ithat tihe voices werern't real." 122
Durirn.g their visit, noticed tnat sometimes SFC Card would ''have to tal<e

113/d.
114 Jd.
115 Id.
~16 EJiOhibit J1 pg. 4.
111 c/d.
11B ,/cf.
n19 Id.
r20 IExi'hibit B21.,
121 ,l ei.
n22 Jd.

18

!Encl P:oge 0042

AFRG-OPI '(800B-15-6b2)
SUBJIECT: IFirndings and Recommendations, Army Regulatiorn (AR) 15-6 Investigation
into the Suspected Suicide of S.FC Robert R. Caircj II

the h~aring aids ol!Jt becaus~ it would b"e ov~rstiml!Jlatinig in a ltJud t:!t11Virorm1ent." 123 SFC
Card refused to stop usirtg tine hea1
r lfilg aids but did agree to go to the doctor beca~se
h i s - expressed conc:•em about SFC Card's weight l oss. 124

{18) Orn 3 May 2023,

ir~ported to the , Topsham Police Officer
125
- about SFC Card's deteriorating mental condition. - explained thllit
rne Sagadahoc County Sheriff's Office (SCSO) tnad ihe matiter (because SFC Cara 11vee1
in tneir.juwis1diction). Aceording to only relayed that SFC Card
had be·en iIwolv'8d in an ilf\cident at a Home Depot reported as Lowe's)
where .someone was 'talking about SFC Card behind his back. "126
- agreed they would 'taU< to .SFC ca11d at ~he June ,2 0:2 3 Battle Assembly ,and
figure out a way forvvard ~hen; des1pite tjhe fact the urniit lhad a Battle Assembly scheduled
frnm 6-7 IM ay 2G23. 1.17

(19) On 3 May 2023, asking if he was available

for an update on SFC Card.
1
presumably had a phone
discussion about speaking with SFC Card during the June Battle Assembly (BA), but
- does not recall if relayed the specifics of the early May unciaent
involving SFC Car.d. 129 When asked why he did 1not calll SFC Card to fdllow~up ilf'il May
2023,

(20) On 4 May 2023, 1efit a voicemail for - stating tnat

,SFC Card'~-had intervened and that SFC Card agreed to seek medical
treatment ur - -

(21) Orn 4 May 2023, regardlrng-

- voicemail. 132 Neither srpoke direct~y to SFC Gard
tro check on him thlroughout the month of May 2023.

d23Jd.
Jd.
,124
125 iE~hibits 83, B38, J1.
126 IExihibit 83.
t121.Jd.
n2s IExrhibits B3, C.20.
129 IE,ohibit B.22.
no ,E~'hibit B3.
rn IE,ohibits J 1, C15, B7.
132 IE,ohibit H12,
m IE~hibits H12, B7, 83.

19
AFRC-'OPI {800B-15-6b2)
1

SUBJIECT: Findings and Recommendations, Army Regulatiorn (AR) 15-6 Investigation

1into the Sus:peded Suicide of S.FC Robert R. Card II

(22) 10rn 4 May 2023, called again to determirne if she

rnad an update. - explained that had met with
SFC Card ctn 3 May 2023. - communicated that SFC Card answered the door
with a gun becal!Jse he heard people talking outsid·e his house, 134 - told _
had relayed to lher tihat his conversation with SFC Card went "very
well" and that he had agreed to .go see a doctor abol!Jt the paranoia and tjhe voices he
had be~n heanng. 135

(23) - asked to tdllow-rup with SFC Ca1rd js eommaind in

the U.S. Army Reserve. and relay that she wanted 'thern to approach SFC Card but to
out of the process. - reiterated that - did not want
SFC Card to know that the 1init!a~phone call to the police had come from
136
. Aocordling to
were going to make sure that SFC Card got to the doctor. 37

{24) Ofil 4 May 2023, texted SFC Card to follow-up on their v,isit
from the prior evening. She wrote, Please keep me posted on the
!recordings and please make a physicians appointme1nt TODAY i(sic). It is so important to
1mle out and (sic) physical health problems. We are alll 1unique ,arnd have strengths and
weaknesses. It's important to lknow l:Jotih ~o navigate thirouglh life. You arre not alone.
Keep irn touch. " 138 However. wlhen- called SfC Card later that day to
ehec'k on lhim, SFC card had ehanged his mifild aoout seeing a <doetor.

spoke a second time on 4 May 2023.

with respect to what !he hacll leanned from hiis irecent
conversations - cexiplained that the comma nd1s
plan was lo sit down with SFC Card in the "near future" and see if they ~ould get hiim to
op,en=~rp t!~out what had been going on. specifically warned:l illlll
that - had told him that SFC Card answered his door with a gun in his tnand
,and was ta.lking ,about people routsiae "casing" t,1is lh0'uSe. 139 Neither
kinewthat at the time ,of their discrussion, SFC Caird had decided he was
1

not willing to see a doctor,

u 4 :Exhibit J1 pg. 4.
n3S Id.
n'36 /d. at pg. 5.
m.1d.
~38 IE~'hibit 821 .
n39 Id. at pgs, 4-5.

20

!Encl. Poge 0044

AF RG..:OPI (8008-15--6b2)
1

SUBJIECT: Findings and Reeomirnendations, Army Regulation (AR) 15-6 Investigation

~nto ~he Suspected Suicide of SFC Robert R. Card II

(26) "13 Company, 31304th lhe?ld its Battle Assembly (BA) o:n 6-7 May 2023. SIFG
Carel attended this BA. 140 Despite what he had told ,about speaking to
SFC Card - saw SFC Card at BA but did not approach or speak to him
lbec.ausre he thought he should "let the dodors deall with the situation.!1141 However:. SF:C
Catrd had told - two days earlier tlhat would not see a <doctor.

tlid not attend the Battlie Att,semlbly (BA)

The company's
served as for the May 2023 Battle
Assembly. was "nervous that SFC Card was ,a th1rieat." so she released
the unit early on 7 May 202'.3, ''perhaps right after 11unch ."144 However,. . stated
"I do not recall any time we 1released early based on concerns wJth SFC Caird." 45 -
- "followed up to make sure were aware of the
situation."14 confirmed with that SFC Card's - was alsro
147
aware of lhis mental health .•

i(28) lhe unit5s sigrn-in roste:r did not indicate a1n ea1rly release on 7 May 2023. 148
Other unit membe1rs interviewed could not recall en eanly irelease.149 ~ did
not recall being 1notifi-ed abo'ut ;an early re!lease between March and June.

(29) !Later in May 2023, - told that SFC card said he !had
nired tnree attorrneys because he was hearing people talk about him. 151 -
mentioned tnat SFC Card's attorrneys did not believe h1Jm either. 152 ~ old ~
~hat SFC Card even [bought a recorder to prove that people were talking about him.

a40 IExlhibit L1 pg. 17.

u 1 !Exlhibit hl12.
u42 IExihibits B3, L.4.
n.t3 Exihibit 841 .
14'1 :Exlhibits B41, L1.
nt5 [Exlhibit 87.
146 iExlhibit B41 .
m:1d.
U 8 !Exlhibit L1.
U 9 IExihibits L1, B3, B7.
w50 !Exlhibit 83.
m !Exihibit B21.
d52 Id.
t 53 !Exhibit B21.

21

!Encl. Roge 0045

AFRC-'OPI (800B-15--6b2)
SUBJIE'CT: Findings and Recommendations, Army Regulatiorn (AR) 15-6 Investigation
1into the Sus:pected Suicide of SFC Robert R. Ca1rd II

1(30) As of May 2023, SFC Card's assumed that people really we,re
talking :about SFC Caret However,
1511 . 'explained to - c
- that tll~ voices SFC Card was hearing were not real .1

,(31) At some point in the spring of 2023, called ''to

relay that S!FC Card was saying that people are calling him a pedophile at the unit." 156
told that he ne~d~d to speak with SFC Card regard ing this
issue and that SFC Card needed to {;alll him. SFC Card and rnever callled
back. called later to discuss a separate
matter asked about SFC Card and told that
"81FC Card did not want to pursue it ~urther and that he was only upset and
trustr;ated.1' 157

i{1) SFC Card .attended th~ unit's Battle Assemb1y on 3-4 Jurne 2023. 1511!111
saw SFC Card at Bame Assembly and recalled that SFC Card seemed normal. 159
did not speak: to SFC Card at the Jurne 2023 Battle Assembly because he
believed he should let the doctors lhaindle the situation.160

{2) - claimed lhe assumed that

SFC card and had inquir1ed Into his wellbeing. However, aid not attend
tne June 2023 Battle Assembly and dia not speak with SFC Card in June 2023. 162
1

(3) In early June 2023, ~ checked in with SFC Card, iinquiring as to

Wh;etjher he had sought medical treatment. SFC Card became upset when asked
about medical treatment, ~ut as of 5 Jurne 2023 SFC Card oonfirmed with - that he
was ,okay. 1~

nS4 Jd.
nss 1d.
156 IE~hibits B3, B36.
157 IExihibit B3.
158 Elll'hibit L1.
~59 !Exhibits H1-2, L1, B7.
~60 IElllhibit H12,
f 61 IElll'hibit t-fl12,
162 IElll'hibits 83, L1.
m IE~hibit C8.
, ~ IElll'hibits CS. C9.

22

!Encl Hage 0046

AFRC-()Pl (800B-15--6b2)
1

SUBJECT: Findings and Recommendations, Atrny Regulation (AR) i 5-6 Investigation

1into the Susi1,ected Suicide of SFC Robert R. Gani II

(4) Betweel'il on ,or Iibout 6 June 2023 and on ,or ·about 7 June 2023,
stopped by SFC Car~'s house to drop off
was also present. During the conversation, relayed that
' rn kill . _"165
(5)
Despite the tense interactions between them in April 2023, invited SFC Card t,o
the - reportedly observed a mass it,n SFC Card'·s
head when she briefly stood next to him at the e1
n(j of the - -·~57

(6) In Jtune 2023, both an~ were uncter the mistak::en

impression that SFC Card was seeking treatment and that everything wa:s going we IL1'69
tfid mot have any contact with SFC Cardi from 3 May 2023 (i.e. , the date
on which he teceiv~d the initial report) iuntil 16 July 2023. 169

(7) 0 111 24 June 2023, of the 31304th

170 did not discuss SFC Card's previous incidents with
during handover. 171 - !believed th'e
previous incidents involving SFC Card were not .a "high enough issue,• despite !having
previol!rsly assisted other Soldiers with lbehavioral health issues lby placing them on
orders, 172

i. July 2023.

1) Despite his we1ll-known, orngoing belhavioral health issues, SF C Card received

1(

orders for Anniual Training (AT) in Ju~y 20'.23 and - made that
decision "ibecause everyone needs to do Annual Training." 173 OTnof~ did
not factor in SFC Carrd's mental health issues, by not cancelling SFC Card's AT orders,
dated 5 AprU2023, because "it wasn't a detriment to his military jo!b."174 SFC Card was
i1nma11y scheduled to serve as a lane NCO for a crew-served WE:rapon.s 1ra111ge, Ill'
- also did not factor in SFC C-ard;s abserrrce from the valldatio:n exercise in April

~65 IExihibit 838.

166 i~ hibits B3'8, 839,
m IEX:hibit B39.
168 IEX:hibit hl12,
' 69 IEX:hibitB3.
HO IEX:hibit 86.
m IExrhibit B22..
112fcJ.
m IEX:'hibit B3.
n74 'E~hibits B3, J'1 pg. 4.

23

!Encl. Page 0047

AFiRC-'OPI (8008-15-6b2)
SUBJIECT: Findings and Recommendations, Atmy Regulatiorn (AR) i 5"'6 Investigation
Iinto ~he Sus:pected Suicide of SFC Robert R. Caird II

2023. Ofthe 148 fk>ldiers who c:c>nducted Annual Training at West Point iIn July 2023,
32 did not attend 1rne Arpril 2023 11validation" event. 175

(2) According to "SFC Ca1rd did not want t,o be at AT this year, He
just wanted to retire but was ordered to go to AT." 176 maintained that SFC
Card firs·t mentioned this desire to iretire to him in September 2023, but as of the Spring
of '20.23 SIFC Card had lhdt indicated to that he dUd not Wa'f'it to attend
AT.177

(3) On the morrfrng of 15 July 2023, SFC Card picked up a rental van from the
Anmy Reserve Centeir in Saco, Maine. The
- 1lefd: the velhicle k1eys and a tue~ card for SFC Card. SFC Card left his personally
owned vehicle; a Subaru 0 1!Jtback, at the Army Reserve Center. SFC Card departed
1

Sa-co, Maine for Camp Smith, New York, 'fior fourteen days of Annual Training at Wesft
Point. NY ending on 28 Jlllly 2023. '178

(4) SFC Card arrived late on the afternoon of 15 July 2023. 179 At that time, other
training NCOs, including

in the pool at Camp Smith lodging.

(5) ~ asked SFC Gani to drop his luggage off in his room and jo'in the
otners at the pool. SFC Cara droppea tlis luggage cfff and aIpproxirnately t\,vtHilty
minutes later joined the oithers in the pool. lmmedlately upcm getting into the pool, SFC
Card began complaining that the "lady at the fro:nt desk" at the Camp Smi•th lodging
office who was checking him into his room was "talking a!bout me."182 - aind
the other NCOS expressed ske·pticism at SFC Card's aHegation, suggestirng to him that
he may have misheard the '"lady at the 1front desk."183

(6) FolloWing this conversatiorn, SFC Cata appeared quiet aincl witnc:Jrew from the
group cornversaUon,184 SFC Card retunrned to ~he group conversation a;pp:roximatelly

m IExihiblt K38.
176 l~ hibits836, B1'1>.
m IExihibit 83.
i11a E~hibit N132.
n 9 IE~hibit B10.
1~ IE~'hibits B10, B2, BS, B4. B16., G5-Gi9..
m 1Ell1'hibit B10.
Jd.
182
/d.
f 83
'164 IEXl'hibits 10, 85.

24

!Encl Page 00l!l8

AFRC-'OPI '(800B-15-6b2)
SUBJIECT: !Findings and Recommendations, Army Regulatiorn (AR) 15-6 Investigation
Iinto ~he Susrpected Suicide of SFC ~obert R. :Card H

twenty minl[tes later, t:omplainlng that wMle travelirng to Camp Smith a lady wor1Klng at a
Dunkin Donuts, ~ocated at a hlghw~y rest stop in Massachusetts h-alfway down from
Maine 1 lhad been talking about him as welf.185 - questioned SFC Card about
this statement, explaining that the Dunkin Donutrs lady pro~bly sees hundreds ;o f
people every day, that she didl not know lilirn 1 and tlhell"efore it was unlikely she was
· •
talkmg ·
about·• · him.
• 100

,(1) Later that afte moott, tne group ordered ·ptzz:a for 1dinner: SFC Card, Ill'
went to a convenience store located neaiF Camp Smith to
purrchase beerr arnd thlern pick up the pizza at the restaurrant w.ext door.1sr On me way to
1
the convenience st,ore, S FC Card, while seated in the back of the truck, stated, "I can't
1

believe you're talking about me too, - rntalke care of it," or words to that effect 186
At that point, fell SFC Carn::f''.$ demeaInor change 1(180 degrees." 189
- then aske rf the had said anything, to which
replied he had not.

(8)Acoording to SFC Card was "mad dogging" at him (which lhe

defined as looking menacingly) eind grirtding his teeth ~he entire way to the convenience
store. 191 SFC Card was still observed a:s angry when the group anriived at the
conveniienc,e store. Hie was 'the first to open th·e vehicle door, slamming it and walking
Iinto the convenience store. SFC Card then jerked the beer cooler door open, stomped
lrnis way to tne elerK t\o pay for the beer, ~rrnd then left trle store rretumirng to the tmclt 19'2
A11riving at tne trucK, SFC Card charged a Wi'rno was standing nearr trne front
of lhe vehicle, and then cirded the truck to avoid contact with SFC Card.193 Arter SFC
Catrd calmed down , ~nd SFC Card entered the truck and
returned to Camp Smith . During the return trip, SFC Card was observed staring
blankly out the window.'195

1(9) Upon return ing to Camp Smith, SIFC Carrd exited the truck without speaking to
anyone., grabbea mis beer, and weInt directly to lilis room .·196 - ltold me otliler

U85 [Exihibits 82, BS, B 10.

Hl6 Exhibit BHl
m :Exihibits Brn, B2, G20-23,
188 IE,dhibit B10.
189 ,l d.
,1!Kl E~hibits Brn, B2.
~91 IE.Xlhibit B10.
~92 Id.
n93 Id.
194 Id.
~95 Jd.
11
96 fEXl'hibits B10, B2. 85.

25

IEncl Hage 0Cl49

AFRC.:OPI '(800B-15~6b2)
SUBJIECT: Firndihgs and Recomirnendations, Army R'egulatiorn (AR) 15-6 Investigation
Iinto the Sus:pected Suicide of SFC Robert R. Gard II

NCO$ abtHJ~ SFC Card's strange arnd threatening !behavior, recommending th·ey m~k~
the raw.are of the situatrion. -
also described SFC Card's behavior as "paranoia." 197

(10) Observing SFC Card's agitated mental state,_ was ,concerned

~bol!lt his handling crew~servetl weapons near IJnited States Military Ac:ad·emy (USMA)
Cadets, 19 told Utal ~©methirng was wrong with SFC
199
Caret SFC Card's w~s initially skeptical of the notion
that SFC Card was exhibiting paranoid behavior, given his prior interactions working
with him.200 Howeve:r. once he per.scmally observed SFC Cart!. - - agreed that
SFC Card was exhiibiiting paranoid chla1r.ac;terislic$. 201 tlhen rconnecterd witli
- and[- expllaining to them what lhe had! observed, as welll f1i!S his
1

belief that SFC Calf'd shoUJld not lbe around liveQfire weapons trainirog.202

(11) contacted on the evening of 1'5 July 2023,

explaining to him SFC Card's stri~mge behavior since arriving at Camp Smith, including
~hat SFC Card was "trying to pick fights with everybody. "203 told
1111 that he did not believe SFC Card's lbehavior was alcohol related.
lthen immediately called - to exp!lain the situation.205

(12} St.ay,ing at another locatton at the time,- then traveled to Camp

206
s mitt\ ,arrMrng at approximate1y 2130 on 15 July 2023. - and 15 other
Solld!·ers were !otigect at camp f-JJatrural Bridge, a billeting location in closer proximity to
West Poi1rnt om the west side of tlhe Hudson River. With command approval, -
and seve:ral other NCOs elected to stay at Camp Smith for an out-of-pocket cost of
$30/night because of its bettetr faciUties. Upon arrival- spoke with
alborut SFC Card's behavior. They
explained SFC Card's paranoia at the swimming pool and threatening behavior at the
·convenaence store.207 - a~so spoke with - and expressed concern
r egardilflg SFC Card's access to crew~served weapons_-ioa- and

m IExihibit B16.
n9l! Exihibit B1 Cl.
us!l iExihibits B2, B5.
21t> IE~hibit B4.
201 .Id.
202 JcJ.
2ro iExihibits B1, 82.
204 IElll'hibit 82.
205 IElll'hibits B1, 87.
206 Elll'hibit B7.
101 IE~'hibits B7. 8'2. BS. 8'10.
168 IE~'hibits B7, 81:

26

!Encl. P,age 0050

APRC-OPI (8008-15-6b2}
SUBJECT: Findings and Recommendations, Army Regulation (AR) f5-6 Investigation
1into the Suspected Suicide of SFC Robert R Ca:rt!l JI

went to 8FC cara·s room attempti1ng to s:peak with t11mj !Jut his door was locked, an~ he
1
lnitially refused to answer.

<(13) SFC Card eventuailly answered the door. - coula smell alcohol
emanating from Inside and assL!lmed SFC Cara had been drinking. SFG Caird said thiat
Ihle wanted to lbe left alone and to go to lbed, and th:en arttem1Pt ~d to close lhis door. 209
1

5tucK his foot into th~ door well. SFC Card told - that "he wanted
people to stop talking about him," to which~ reiterated that ever;one there was
·a friend and that no one was talking about him. SFC Card did not say mucn, if
anything, in response, but was observed having a ''-lhous'i:i!nd-ya1rd stare" as he
sucoessfully closed fhe door on them. 211 A short time l~teir, - retirieved a
"imasteir key" and enter,ed SFC Card's room, At ~hat point, SIFC Caird was in ihis bed,
retri,eveci SFC card',s rental van keys while - ,u1rv~yed the room
for weapons arr1d ammunition but f.ound none. 112 SFC Card told them he just wanted to
sleep, anca.111111 planned to reengage SFC card agatn in the moming.113
(1 4) then called on the way back to his lodging site.2~4
- told what had happened wrnh SFC Card as we!II as his plan to
ireengage the next morning. 15 wa.s not on AT ,o rders and not physically at
West Poi1nt at this time

. They made a command decision to stagger their AT

days for the two-week crew-served weapons larnes training period in July 2023, so one
of them would be on the ground at all times.

(15) On the morning of 16 July 2023, returned to Camp Smith at 0700,

217
w11ere he first met wit~ then went to SFC
Gaird's room. SFC Card answered the door, telling them to leave him alone wilth the
same "thousand-yara stare" as naa been observed tne niglilt prior.213 -
1

'Scanned SFC Card's room 1and noticed that o:nly two beers were missitig tom the

2~ IExlhibit B7.
210 IExlhibrt J2 pg. 4.
211 IE~hibit B7.
2121d.
213 /d.
214 IE~hiblts B7, B3.
2·1s Id.
216 E~'hibit B3, K39.
217 IE~'hibits B7. B1.
218 IE~'hibits B2, B7.

27

!Encl. Page 0051

AFRC-'OPI (800B-15-6b2)
SUBJIECT: findings and Recom1mendations, Army Regulation (AR) 15-6 Investigation
Iinto the Sus:pected Suicide of SFC Robert R 'Gard II

twelve~:p atk SFG Card had purclhased the day before. 219 This led - to ~llev~
SFC Card's behavior was r,-ot ahx,ht>I related and that he 1
needed to go to the
hospital. 220

(16) - then contacted Gamp Smith Security which informed him that
because Camp Smith was a New Yo'rk Army Nait.'iona! Guard installl:ation, this matter
would be within the j'l!Jtisdictiorn of New York State? Polic~.~ 1 lll'ile New York State Pt,l1
ite
responded to the scene and mterviewe-c:f SFC caret m According to the New York State
Poriiee, unit members reported that SFC Card was drunk and threatening them ~ne night
before.223

1(17) SFC Card told the New York State Police he "was fed up with hearing others
talk behind lhis back. He further told the police that his unit is afraid that he "will do
something and tjha't (he) is cap,able."2i 4 However, me <confirmed tjhat me did rn,ot desire to
harrm h11mse!f or e,tners.125

(18) SFC Card was not taken ~nto custody. The rNew York State Poflice advised
- that it had insufficieint cause to place SFC Card in protectJive custody. The
New York State Police also refused to transport SFC Card to Keneir Army Oommunity
Hospital (IKACH) at West Point 226 However, the !New York State ~olice d1id rag1ree to
es-co:rt a personally owned ve'hlide from camp Smith to KACH. 227

(19) ~ men called , informing Mm tnat SFC Card remained

uncooperative. Thereafter, orderred SFC Card to uindergo a Command
Directed Behavioral IHealth Evaluation (COB HE) IAW MEIDCOM Po licy 17-031 and AR
40=68. 'll. then departed New Hampshire at 1100 on 16 July
2023, enrowte to KACHj West Point, New York, arriving therre at 1500.2~
was 1111either paid base pay nor travel pay for this o:ne;day round tri[P to \Nest Point and
back

219 IE~hibit B7.

220 Jd.
221 IE:xlhibits H12, B7.
222 iExlhibit J3,
223 /rJ. However, based on statements from Exhibits B1. 62, 85. B7, !810, all stated that alcohol was not a
:contributing factor.
224 iEx1 hibit J.3 pg . .2.
225 /rJ.
126 IExihibit 87.
217 !Exhibit J3 pg. 2
228 IExihibit B7.
229 IExihibit 83. 187, E1 pg. 42.
130 IExihibit 83.

28

End Page 0052

AFRG.:OPI '(800B-15-6b2)
SUBJIECT: !Findings anti Recommendations. Army Regulatiorn (AR) 15"'6 Investigation
Iinto ~he Sws pected Suicide of SFC Robert R. Caird II
1

- - - - - - - - -
(20) transported SFC card to KACH. 231
SFC Card did not speak during the trip but was observed sheddil'lg tears silently at one
point for about five minutes during the hour-~ong ride.232 - rep~etedly
,attempted! t,o speak with SFC Card duriIng the ride, explaining that th~y would not be
taking lhim to KACH if they did not care for him,233

(21) The ·group arrived at KACH at approximately 1250 on 16 July '.2023. SFC
Carrd was evalluated tit the Emergency IDep-anment 234 He was admitted for behavioral
health reasons with directions for 1:1 observation.235 arranged for -
to serve as

(22) The medijcal provide:rs at KACH coded th·e visit as 1{Primary; R45.850
homicidal ideations, Secondary~urnspeemect psycnosis not due to a substarnee or
know11 physiological ieondition. n2'a7 Medlcar Re,cords Mst the provider as
1
238

(23} SFC Card was obseirved as allert arnd responsive upon arriving at KACH .•
in KAC H's Emergency Deparrtme:nt.,
noted that SFC Card denied having suicidal ideations but exp:ressed that peqple were
talKing about rnim bernin{j lhis track, wnieh angered lnin't~ 9

(24) assessed that SFC Card was experiencing a

"stress reaction causing mixed disturbance ,o f emotion and conduct, urnspecified
psychosis n,o tdue to substance or knowrn physiological comfition: '240 - noted
~hat SFC Card was a,ccompanied by- - - aI1so documented veiled
threats made lby SfC Card, incll1d1ing that he ''will take carre of th is." 242

23, Jd.
232 E~ibits 85, B10. C32.
213 IE-Xihibit 81 C
t
234 IExihibit E1 pg.72.
235 /cl. at pg. 75.
2!16 iE,ohibits E1 pgs. 88-90, 87, 810 pg. 3.
237 :E,ohibit E1 pg. 73.
238 /d. at pgs. 74-75..
239 J<J. at pg. 77.
240 .Jd. at pg. 78.
241
Id. at pg. 78.
242 iE~hibit E1 pg. 79, B10 pg. 3.

29

!End P,ege 0053

AFRC-'OPI (8008-15-6b2)
1

SUBJIE'CT: Findings and Recom1mendations, Army Regulatiorn (AR) 15-6 Investigation

into ~he Sus:pected Suicide of SFC R,oberl: R. Card II

(25) calle while enroute to West Point, New York, to

rinform him that he was traveling to West Point to order 'al Command Directed Behavioral
Health Evaluation (CDBHE). 243 arrived at KACH at 1500 ,on 16 July 2023.
Upon arrival, met with KACH 's on-call
tol it was a good thing that SFC
expressed eoncern that SFC card had
privately owned weapons. 246 did not irecommend at that point ,or any other
time that SFC Card's firearms or ammunition be voh.mtarilly stored -at the unit, or anotlher
DoD~tontro!lled 1ocatkm approved 1or the $torage of firearms, Regardless,
had mo authority to compel SFC card to store his privately owned weapmi s at a DoD-
rontrolled facility.

(26 then completed the paperwork necess-ary to effec~uate SFC

Carrd's CDBHE. did not obtain any other information beyond the
riniormation contained on the DA Form 3822 Report of Mental Slatus 1::var1uation
completed by- - ,departed West Point at 1600 on 16 July
1

2023, after staying approximately one hour, returning to New Hampshire.249

(27) SFC Card's GDBHE was ,completed ,on 16 Jully 20:23.250 The ev~lu~tion
noted that SFC Card failed to meet medical retentij on stand:ards ~AW .AR 40-501, mad
reached the medical retention determililation poiint. and that a Disability Evafluation
System refenal was required. 251 llhe evar1uation sighed by further noted
u,at SFC Card t'lad perce[Ption a1t11a cognitive impairment but that the risk ,o f narming
himself or others was low ait that time. 252

(28) In the oomment sectiion of the DA 3822 (Report of Mental Status Evaluati-0n),
recommended that, upon SFC Card's discharrge. his dha'in of ·comm~ntl
remain engaged with hiis care, the Brigade Medica~Officer foflow-l!lp with him
,concerning 1case management, and the Comma1nd initiate the Medical Ew1luatio:n Board

243 IExihibits 83, 86.

2M Exhibits 83, B15.

X I its
246 Id.
241 :Exihibit 83.
24s :Id.
249 fd.
250 iElll'hibit E1 pgs. 38-39.
251 :Id. at pg. 33.
252 /d.

30

!Encl P:oge 005'1

AF1RC-'OPI (800B-15-6b2)
SUBJIECT: Findings and Recommendations, Army Regulatiorn (AR) l 5-6 Investigation
1into ~he .suspected Suicide of SFC R,obert R. Caird H

process. 253 allso re◊on1urnt1:mdea llfhlat measures be taken to safely rremove

all fireairms arnd weapons from s·Fc Card~s home of recora.•;,~s-i

(29) - completed the Medical Necessity Certification Statement for Non-

Eme:rgency Ambulance Services, noting the medical condition necessitating transport
was upsychosij;s/harm to olhers." 255 noted that SFC C,ard coUJld not be safely
t,ran$1po1rted by car or wheelchair; due to representing a '1danger t◊ selftoth~r
and need. or possible need for restraints."
,(30) SFC Card called after completing his Command Directed
Behavioral Health Evaluation on 16 July 2023. 257 SFC Card told that he
was "pissed off that everyone was running their mouthslf and he was angry that lhe was
st1J1ck in the hos,pital.258 SFC Caird told he did not think he needed hel[p;
lhe did not think' there was anything wrong with him, that he wanted to defend himself,
and that he \,v,anted lo see the ''Videos_"w9
(31) submitted to the chaih of a command ,a Commander's
Cri·ltical In'Wormatiot11 Requiirement {CCI R) ,and a CCIIR Update on 17 July 2023 rand 18
July 2023 detailing information provided b ~ in connection with SFC Card's
erratic behaviors and ultimate hospitali.zatioin, respectively. The CC1R and CCIIR Update
were routed to l!ISARC by re July 2023.260

j. Four Winds Hlospital - Westcne1ster.

(1 )At approXimately 2120 on 16 Jl!lly 2023, SFC Card was trainsferred from
KACH to Four Winds Hospital - W~stchester in IKato:nah, New York.2'61 He was liisted in
stable concHtion.2 62 Tlhe Four Winds admission note ireads '1reason for hospitalization. 40
y/o male reports he doesn't need to lbe here as 1111e doesn't believe lhe is Schizophreniic
or hearing voices/263 Additiornal ireasons for SFC Gard's admissil on we:re t1ue to reports

253 Jd. ,at pg, 40.

254 :Id. at pg. 40,
2s.s 1E~hibit E1 pg. 84,
256 Exihibit E1 pg. 91,
257 E~hibit B36.
258 Jd.
259 J<J.
260 E~'hibit B7. 1 R4,
261 IE~'hibit E1 pg. 79.
262 J<J.
263 E~'hibit B36 pg. 35.

31

!Encl P,age 0055

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

of psychosis, mood lability/aggression, homicidal ideations, the patient endorsing having

a “hit list”, paranoia, and AH (auditory hallucinations). 264

(2) SFC Card told Four Winds staff about the “rumors” going around that he was
a pedophile or gay, telling them that “everyone” or “just about everyone” – to include
those at his civilian and military jobs, a coffee shop, and the hospital – was spreading
these rumors. 265 SFC Card told them the rumors began at a local bar where he plays
cornhole and that the rumors quickly spread to his job. SFC Card also said people were
threatening to hurt him because they think he is a “bad ass.” 266 He admitted that
thinking about all these rumors had become a big distraction for him while at work. SFC
Card referenced a rumor going around about him at work that he had a small penis, to
which he responded by showing a coworker a picture of his penis, resulting in SFC Card
receiving a written warning.267 SFC Card told them he ultimately decided to quit his job
before he got fired or before he “ended up killing someone.” 268 SFC Card denied any
AHs or VHs (visual hallucinations). 269

(3) SFC Card told Four Winds staff that in his 20s he used to get into physical
fights with others, but he had not fought since then. 270 He denied any history of prior
suicidal ideations or suicidal attempts.271 SFC Card also told them he recently changed
his truck driving schedule to nights so that he would avoid seeing people during the
day.272 He acknowledged sleeping only about 3-4 hours during the day. 273 He denied
any recent changes in appetite. He had stopped drinking soda, resulting in the loss of
approximately 40-50 pounds within a month’s time back in December but had since
gained back 20 pounds. 274 He acknowledged being angry and frustrated at being
admitted to Four Winds because he did not need to be there, but he understood that if
he left, his commander would just send him right back. 275 He told them he might be
agreeable to taking medication if someone could give him a good sales pitch. 276

264 Exhibit E1 pg. 5.

265 Id.
266 Exhibit E1 pg. 5.
267 Id.
268 Id.
269 Id.
270 Id.
271 Exhibit E1 pg. 5.
272 Id.
273 Id.
274 Id.
275 Id.
276 Exhibit E1 pg. 5.

32

Encl. Page 0056

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(4) SFC Card denied any history of depression, but acknowledged having social
anxiety, not liking large crowds, and drinking "to loosen up" in social settings. 2n He told
Four Winds staff he had mostly acquaintances and not any close friends.278 With
respect to his dating history, SFC Card identified as a male attracted to females only,
confirmed that he was not currently dating anyone, but that he had previously dated an
individual back in December, and then again in February for a period of two weeks, and
that he lost this relationship over all these rumors.279 He denied feeling hopeless or
helpless as well as any history of mania or hypomania.280 SFC Card told Four Winds
staff that he shared and that he was very active in -
- SFC Card became "irritable and agitated" after the Four Winds intake team
began discussing guns at his residence.282

(5) SFC Card participated in individual support, medication management, and

family support sessions with staff while being treated at Four Winds. 283 He resisted most
group therapy, despite encouragement from staff. 284

(6) SFC Card was able to report feelings and symptoms during treatment
targeting Psychosis and Thought Disorders.28.5 Over time, SFC Card engaged in limited,
but mostly positive, interactions with his treatment group, whereas he often appeared
more guarded and resistant to treatment when interacting with Four Winds staff.286
However, he appeared able to comply with program expectations with staff support and
encouragement.287

(7) Four Winds staff experienced difficulties engaging with SFC Card's -
during his hospitalization, as - did not answer the phone during most
288
attempted calls. After numerous attempts, Four Winds staff established contact with
, and discussed SFC Card's ongoing treatment, safety, and
told them that SFC Card "could not return to •

m 1d.
21s 1d.
219 1d.
200 Id.
281
Exhibit E1 pg. 5.
Id.
282
283
Id.
™ Id.
285 Jd .
286 Exhibit E1 pg. 5.
287 Id. at pg. 6.
2es 1d.
289 Id.

33

End. Page 0057

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

Four 290 A

Winds therapist provided supportive therapy to and SFC Card, which included
safety planning and SFC Card's treatment throughout his stay.291

(8) , coordinated with the KACH team

throughout SFC Card's hospitalization due to his ongoing concerns over SFC Card's
presentation, coordination and continuity of care, and his access to firearms. 29W '
Ill noted that he spoke with SFC Card's after admission and relayed his
concerns about SFC Card's access to firearms at his home; however,
stated he never spoke with anyone at Four Winds.293 - further noted that SFC
Card's command was looking into having firearms removed from his home.294 He also
noted that he had been told b~ that SFC Card had previously removed
firearms from his home once for an unknown reason .295 also toldJ I I I I
that the majority of SFC Card's firearms were stored in gun safe. 2

(9) On 20 July 2023, based on the CCIR submitted by on 17 July,

at the Army Reserve Medical
Management Center (ARMMC), was assigned to SFC Card's case and created a
MEDCHART 297 case for SFC Card.298 The medical diagnosis used in MEDCHART was
"F329, Major Depressive Disorder, Single Episode, Unspecified." 299 The medical
records from KACH and Four Winds do not support this medical diagnosis.300

(HJ) The MEDCHART case was then tasked to

at ARMMC , who completed a 90-day profile for SFC Card.
noted, "Please touch base with command to ascertain SM status. Continue to
maintain contact so we can also know the status of the SM." The case was then
returned to for assignment to a Nurse Case Reviewer (NCR). At
ARMMC , the NCRs manage temporary profiles {up to 365 days, unless changed to a

290 Id.
291 Exhibit E1 pg. 6.
292 Id.
293 Id.
294 Id.
295 Id.
296 Exhibit E1 pg. 6-7.
297 MEDCHART is The Medical Electronic Data (for) Care History and Readiness Tracking system and is
a customizable, centralized approach to managing all aspects of a Soldier's medical readiness and care
history. From routine s-ervices, dental treatments, and medical record imaging to full case management
capabilities, MEDCHART aims to provide better care and readiness tracking for military Soldiers.
298 Exhibit E1 pg. 4.
299 Id.
300 Exhibit E1.

34

End . Page 0058

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

permanent profile sooner) and Nurse Case Managers (NCM) manage pennanent
profiles. At times, ARMMC leadership will switch roles based on experience and
skillsets. 301

( 11) On 20 July 2023, SFC Card's case was then transferred to

302
As part of her review, - noted that SFC Card belonged to the
108th Training Command, had a profile based on suicidal ideations and psychosis as
noted on the CCIR, and that he had not had any previous behavioral health profiles. 303
then transferred the case to
on 20 July 2023.304

(12) - began his initial case review on 20 July 2023.305 - noted

the following: "Soldier is displaying s/s of psychosis and sent to Hospital for further
evaluation .. .reviewed information in his online military records (IWS) which included
information that his expiration of tenn of service was 20430430. Soldier has 19 years,
00 months, and 00 days. His last PHA was completed 20230102. HRR notes that the
PHAon 20230102 had no PCL-C or PHQ-8 scores resu lts. AHLTA/JLV reflected the
Soldier has received care at the VA/MTF. In the JLV system it shows that the Soldier
has a VA rating of 0%. JLV-Federal EHR/MHS GENESIS-BEH Psychiatrist OP initial
visit note shows on 20230716, Soldier being transferred to Four Winds Hospital for
further psych care/eval. There is no DD214 found in system."306

(13) On 20 July 2023, _ then contacted and informed him of

the behavioral health profile created for SFC Card fol lowing receipt of the CCI R. 307 llf
- told tri~t SFC Card remained at Four Winds and his discharge date
was unknown. • told - he planned on going to the hospital during
the upcoming weekend to receive a further status update on SFC Card. 309 ~
indicated that he would email SFC Card regarding his behavioral health profile.

301 Exhibit K40.

302 Id.
303 Exhibit E1 pg. 4.
304 Id.
305 Id.
306 Id.
307 Id.
308 Exhibit E1 pg. 4.
309 Id.
310 Id.

35

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(14) On 20 July 2023, _ emailed SFC Card and ~ , notifying

them of SFC Card's behavioral health profile and follow-up instructions. Despite also
speaking with - on 20 July 2023, stated that he "missed the email
on 20 July 2023," did not see it "until after October 26," and "did not recall" what SFC
Card's profile stated. 312

(15) On 21 July 2023, U.S. Army Reserve

Psychological Health Program (PHP), was assigned SFC Card's case.313 She reviewed
the CCIR and noted the elevated risk level. 314 texted
informing him that she planned to speak with SFC Card when discharged and to let her
know if she could be of any further assistance. 315 acknowledged receipt
and informed her he had no additional updates.31

(16)
- During this time, did not visit, or attempt to visit, SFC Card, while
he remained hospitalized at Four Winds.318 Further, did not attempt to
discuss a treatment plan or way forward with medical providers at KACH or Four Winds
while on the ground

(17) On 23 July 2023, prepared a DA Form 3822, Report of Mental

Status Evaluation, pertaining to SFC Card. noted that SFC Card failed to
meet medical retention standards and recommended that Case Management and the
Brigade Surgeon follow-up. The completed DA 3822 was placed in SFC Card's medical
record and those with permissions for MHS Genesis or JLV would have been able to
access his records. Behavioral Health records have an added level of security and
those attempting to view the record in MHS Genesis or JLV would have to note why
they requested access. also sent the DA 3822 to via DOD
Safe. was unable to download the document due to difficulties with his

..
email. Therefore,
-

311
left a hard copy DA 3822 in an envelope fol l l l
at KACH, which he picked up a few days later

Exhibit E1 pg. 3.
-

3 12 Exhibit B3.
313 Exhibit E1 pg. 6.
31-' Exhibits E1 pg. 5, 831 .
315 Exhibit E1 pg. 5.
31& Id.
317 Exhibit B3.
31e Id.
31s 1d.

36

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AFRC-OPI (8008-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(18) On 24 July 2023, entered a nurse

case management note into the KACH medical documentation system, noting that
Nurse Management had started and assigning as the
medical provider.320 However, while was assigned by -
as the provider, he never saw SFC Card in person or reviewed his medical chart until
after SFC Card's suicide, when directed to review SFC Card's medical file by the KACH

(19) While at Four Winds, on 26 July 2023, SFC Card received psychological
testing to assist in differential diagnosis and treatment planning.321 SFC Card did not
participate in psychological testing after 26 July 2023. Four Winds staff faxed this
information to - at KACH on 28 July 2023.322

(20) Four Winds used the following psychological testing methods: Wechsler
Adult Intelligence Scale, 4th Edition (Wais-IV); WAIS-IV Advanced Clinical Solutions:
Test of Premorbid Functioning (TOPF); Wechsler Memory Scales, 4th Edition (WMS-
IV)-Nonverbal Working Memory; California Verbal Learning Test, Third Edition (CVLT-3);
Wide Range Achievement Test-Revision 5 (WRAT-5); Wisconsin Card Sorting Test
(WCST); Four Winds Continuous Performance Task (FWCPT); Delis-Kaplan Executive
Functioning System (D-KEFS); Minnesota Multiphasic Personality Inventory-Revision 2
(MMPl-2); Personality Assessment Inventory (PAI); Beck Hopelessness Scale (BHS);
Suicide Probability Scale (SPS); Adult Suicidal Ideation Questionnaire (ASIQ); Firestone
Assessment of Violent Thoughts (FAVT); Classification of Violence Risk (COVR);
Rorschach (Comprehensive System )323 ; and Hopkins Psychiatric Rating Scale
(HPRS).324

(21 ) The Four Winds staff assessed SFC Card's

personality using questionnaire ,instruments and performance-based measures, as
listed in paragraph 20, above. 325 During testing, - indicated that SFC Card
was "guarded and skeptical" when discussing the test's validity. 326 The diagnosis under

320 Id. at pg. 16.

321 Id. at pgs. 54-71.
322 Exhibit E1 pg. 53.
323 Exhibit JLV pg. 55. The Rorschach test is a projective psychological test in which subjects' perceptions
of inkblots are recorded and then analyzed using psychological interpretation, complex algorithms, or
both. Some psychologists use this test to examine a person's personality characteristics and emotional
functioning.
324 Id. at pg. 54.
325 Id. at pg. 55.
326 Id.

37

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

primary consideration as part of the psychological testing was an "unspecified

schizophrenia spectrum or other psychotic disorder'' and information was requested
"concerning Mr. Card's risk for homicidal and assaultive behaviors at the present
time."327

(22) - observed that SFC Card responded to the testing in a thoughtful

and consistent manner, and there was no indication of any effort to exaggerate or deny
psychological problems or personal shortcomings.328 SFC Card's responses were
sufficient in number and complexity to serve as a reliable basis for inferences likely to
provide an accurate picture of his personality organization and current psychological
functioning. 329

(23- determined that SFC Card's coping resources were about as well-
developed as those of most adults, and he was no more likely to be overwhelmed,
disorganized, or lose control in the face of the ordinary demands of daily life than others
his age. 330 According to _ , this "does not mean that his behavior is always
effective, appropriate, or admirable," only that SFC Card 's actions are typically the result
of his decisions, beliefs, preferences, and general predilections and rarely the result of
overwhelming stress of symptoms of some abnormal state.331 However, - did
note there were three aspects of Mr. Card's personality that were likely to contribute to a
pervasive and recurring effect on his judgement and behavior: inconsistent coping style,
poor emotional controls, and narcissism.332

(24 )- further stated that people lacking consistent coping styles make
them less efficient in their approach to the world and more likely to reverse direction or
change course which lends an unstable and unpredictable quality to their behavior.333
Other things being equal, these individuals tend to make more errors, experience
greater stress, and appear more mercurial to the people around them. According to ■.
- "[SFC] Card appears to be one such individual and for that reason he may be
less predictable-both to himself and to those around him." 334

(25) - observed SFC Card to have very limited emotional controls, and
for that reason "it is difficult to know when [SFC] Card will react in this volatile and

327 Id. at pg. 54.

328 Exhibit E1 pg. 54.
329 Id.
330 Id. at pg. 57.
331 Id.
332 Id.
333 Exhibit E1 pg. 57.
334 Id.

38

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

extreme fashion. There will be times when he has intense and volatile reactions that
sometimes dominate his psychological functioning, but there will be other times when
his reactions seem moderate, appropriate, and well-integrated into his decision-making
activities."335

(26)According to _ , SFC Card was "likely to be particularly reactive to

anything that he perceives as somehow related to his self-concept or his self-worth.
This is because [SFC] Card's approach to life is based on a fundamental belief in his
own uniqueness and superiority."336 - opined that "[SFC] Card is likely to
experience an extreme emotional reaction that clouds or distorts his perceptions, biases
his thinking, and drives his actions." 337

(27) Taken together, - interpreted the data as suggesting that SFC

Card's "lifetime risk for violence may be somewhat higher than most people and his risk
may increase sharply at times when he is paranoid and emotionally overwrought.
However, they do not suggest that he is high risk for violence at this moment," but "his
risk for violence is likely to fluctuate with this level of emotional arousal and the extent to
which he has suffered some acute narcissistic injury." 338

(28) - interpreted the data as suggesting that SFC Card was "a man of
average intellectual abilities. His mental abilities appear to be evenly developed and the
only neuropsychologically based cognitive impairment suggested by his test
performance was some difficulty sustaining focus when tracking auditory stimuli."339

(29) Based on the data,_ found SFC Card "extremely paranoid." Given
his observed erratic coping style, poor emotional controls, and unusual levels of
narcissism, - noted SFC Card's actions would be difficult to predict. 340

(30) - concluded that SFC Card's central problems stemmed from SFC
Card's personality rather than symptoms of some psychiatric condition and as a result
the benefits derived from psychotropic medications may be somewhat limited. 341
Nevertheless, noted SFC Card may derive some benefit from neuroleptic
medications. considered SFC Card a poor candidate for psychotherapy

335 Id.
336 Id. at pg. 58.
337 Exhibit E1 pg. 58.
338 Id. at pgs. 59--60.
339 Id. at pg. 60.
340 Id.
341 Id.
342 Id.

39

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

because SFC Card previously indicated on questionnaires that he found such therapy
disconcerting and unappealing. 343

(31) On 26 July 2023, the emailed SFC Card,

introducing herself, thellll and offering resources and support. 344 Due to his in-patient
status, SFC Card would not have had access to retrieve this email until 3 August 2023.

(32) On 27 July 2023, the KACH spoke to ■

- - - reported that Four Winds had previously submitted an application for
a court-ordered retention. SFC Card was served accordingly on 26 July 2023 and a
hearing was to occur in five days. - advised - that he was calling SFC
Card's command to have all firearms removed from SFC Card's home.346 However,
neither nor- ever spoke to anyone at Four Winds about SFC
Card's treatment.

(33) Also on 27 July 2023, KACH personnel coordinated with ~

telephonically to discuss the admissions process and discharge planning. Based on
information received from KACH, the 31304th extended SFC Card's orders keeping him
in a duty status until he was released from Four Winds. 349

(34) On 28 July 2023, KACH and Four Winds conducted a weekly meeting. 350
During this meeting, Four Winds reported that "SFC Card is taking Zyprexa
(Olanzapine) 5mg AM and 7.5mg PM."351 SFC Card reported that he would refuse to
take his medication ''tomorrow. "352 Four Winds staff observed he "continues to be
paranoid" and that Four Winds would fax psychological testing results to (KACH)
behavioral health "today. [SFC Card's] Court Hearing is Wednesday 02 August. No
discharge information at this time."353

(35) was "not provided much information" about SFC Card during
his hospitalization at Four Winds.354 was told SFC Card was not accepting

343 Exhibit E1 pg. 60.

344 Id. at pg.5.
345 Id. at pg.15.
346 Id.
347 Exhibits B7, B3, E1.
348 Exhibits B3, B1 2.
349 Exhibit E 1.
350 Id. at pg.15.
351 Id.
352 Id.
353 Id.
354 Exhibit B3.

40

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

visitors and he thought "he would not have access to health information due to HIPPA
(sic)." 355 claims that Four Winds did not provide him with SFC Card's
discharge instructions. 356 However, also did not seek information from
Four Winds concerning SFC Card's prognosis, discharge instructions, or his follow-on
care requirements. 357

(36) Neither command team maintained any contact with

KACH following SFC Card's discharge from Four Winds.358 was also
unaware of the relationship between KACH and Four Winds pertaining to the sharing of
medical information.359

(37) understood that KACH and Four Winds held weekly

meetings.3 indicated the only update he received from a female
representative at KACH regarding SFC Card's care was that SFC Card was still at Four
Winds on or around 25 or 26 July 2023. 361

(38) did not request additional information from KACH or Four

Winds concerning SFC Card because he ''thought [SFC Card] was at the best place he
could be, which was at the hospital. After speaking with _ , SFC Card was not
only at the Army hospital, but he was also at a next level up of higher care at Four
Winds being seen by professionals. SFC Card didn't want to see anyone, but he was in
a safe spot, and he was getting professional help." 362

k. August 2023.

(1) On 1 August 2023, _ noted that "SM appears to still be admitted to

BH facility. We will monitor and reach out after discharged."363

(2) On 2 August 2023, - spoke to at Four Winds.364 -

learned that SFC Card rescinded his 72 hours request for discharge and that his court

355 Id. Additionally, informed his chain of command - to include battalion, brigade, and
division command teams - of his understanding with respect to obtaining SFC Card's health information.
356 Id.
357 Id.
358 Id.
359 Exhibit B3.
360 Id.
361 Id.
362 Id.
363 Exhibit E1.
~Id.at pg.17.

41

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

appearance was cancelled.365 She noted that SFC Card was to be discharged at 1100
on 3 August 2023. 366 "The discharge plan is to have Telemynd for psychiatry and
psychology."367

(3) On or about 2 August 2023, SFC Card called , explaining that

he was about to be released from Four Winds and asked him to drive down from Maine
to pick him up the next day. 368 SFC Card called again on the morning of
3 August 2023 to "make sure he was coming" to Four Winds to pick him up.369 1111'
- then called on his drive down and informed him that he was
going to retrieve SFC Card from the hospital. 370 did not ask
to tum around and not pick up SFC Card. Additionally, did not make
alternative arraignments for the military to return SFC Card to Saco, Maine.

(4) On 3 August 2023, Four Winds discharged SFC Card and

retrieved him from the hospital that day. 371 When arrived, SFC Card saw
him through the window and SFC Card walked out of the hospital under his own
volition.372 never saw any discharge instructions and he did not speak to
anyone at Four Winds about SFC Card's follow-on care requirements .373

(5) then told SFC Card he was , and so he

gave SFC Card the keys and asked him to drive them back to the unit in Saco,
Maine.374 On the drive back asked SFC Card how things went for him in
the hospital, to which SFC Card replied that the hospital had misdiagnosed him and that
he was smarter than the Four Winds staff. 375

(6) SFC Card stated that he "flipped out" on a female patient at Four Winds who
he claimed was talking about him.376 SFC Card told that he was really
angry about being committed to the hospital, so angry that he placed his mattress

365 /d.
366 Jd.
367 Telemynd is an online service that provides mental health services. Telemynd partners with TRICARE
to provide beneficiaries with therapy and psychiatry.
368 Exhibit B36.
369 Jd.
370 Exhibits B36, B3.
371 Exhibit B36.
3n /d.
373 /d.
31-' Jd.
375 /d.
376 Exhibit B36.

42

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

against the wall and punched it until his hands became blood y. 3n SFC Card further
explained that he did not want to be in the hospital and that he did not like that the
medications made him feel "lazy."378 Eventually, SFC Card stopped taking his
medication altogether. 379 When SFC Card and arrived at the Butler Army
Reserve Center in Saco, SFC Card was "really angry that his (car] doors were
unlocked." stated "I believe he had weapons in his car, specifically a
rifle."380

(7) The Four Winds Discharge Summary, dated 7 August 2023, noted the
following: "SFC Card received Individual, Group, Art, Family and Recreation Therapies.
The discharge diagnosis was noted as "F23 Brief Psychotic Disorder''. His abilities to
attend to activities of daily living, day to day ability to attend work/school and family/peer
interaction are noted as fair. His ability to access treatment after discharge is noted as
poor. He was discharged without appointments, with a note of referrals pending." 381

(8) Additionally, the Four Winds discharge summary noted that SFC Card
"appeared to be resistant to psychoeducation throughout treatment when discussing
presentation of symptoms. SFC Card acknowledged to providers at Four Winds that he
had a 'hit list.' He often appeared to place blame on others for his behaviors, stating that
'they were messing with me.' At the time of discharge, he denied any auditory or visual
hallucinations. However, at the time of discharge, he did not demonstrate a risk of harm
to self or others."382

(9) SFC Card was not formally evaluated for a Medical Evaluation Board, and his
unit did not conduct a formal Line of Duty Investigation, following SFC Card's discharge
from Four Winds.383

(10) On 3 August 2023, SFC Card's duty status terminated (for the last time)
when his AT orders and medical ADOS orders ended. 384 was not aware of
the Army Reserve Psychological Health Program at the time SFC Card's AT and
medical ADOS orders ended.385 The only action ~ ~ took upon SFC Card's

m Id.
31s 1d.
379 Id.
380 Exhibit B36.
381 Exhibit E1 pg. 4.
38 2 Id. at pg. 7.
383 Exhibit B3.
384 Exhibits N32, R6, B3, L 1.
385 Exhibit B3.

43

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

discharge was to update 386 The unit did not submit a CCIR update to the

18 July 2023 CCIR, upon SFC Card's release from Four Winds.

(11) On 5 August 2023, two days following his discharge from Four Winds, SFC
Card went to a gun shop in Auburn , Maine, to pick up a suppressor he had ordered
online.387 SFC Card ordered the suppressor before he departed for Annual Training on
15 July 2023, but intended to pick it up after Annual Training, according to llll
. . .8

(12) Upon arrival at the gun shop, SFC Card completed the required ATF Form
4473 in order to complete the transfer and take possession of the suppressor. 389 One of
the questions on that form asked if the purchaser had ever been committed to a
psychiatric facility.390 SFC Card answered in the affirmative, and the store employees
told him they could not sell him the suppressor. 391 According to the store owner, SFC
Card was polite, but said he would return after consulting a lawyer. 392 SFC Card
apparently never returned to the store.393

(13) On 6 August 2023, texted SFC Card following his discharge,

texting that she was "happy to hear you are home safely. I would love to hear about
your experience if you ever want to talk.

( 14) The Four Winds Hospital discharge summary was completed on 7 August
2023. 395 ~ made a chart entry on 7 August 2023 noting Case Management visit
type as continued. 6

(15) On 8 August 2023, - made a Case Manager entry, noting that she
left voicemails for SFC Card on 7 August 2023 and 8 August 2023, respectively, but that

386 Id.
387 Exhibit T6.
388 Exhibit C29.
389 Exhibit T6.
390 Id.
391 Jd.
392 Jd.
393 /d.
394 Exhibit C9.
395 Exhibit E1 pgs. 2-14.
396 Id. at pg. 18.

44

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

she had not received any return calls as of the time of her entry. 397 The noted provider
was 398

(16) The Four Winds Discharge Summary was faxed to KACH at 1432 on 11
August 2023. 399 This document was not uploaded into the military medical system until
21 August 2023.400 The discharge summary included relevant and critical information
which if it had been provided to the chain of command would have detailed the extent of
SFC Card's mental health issues. The summary provided the following functional
assessment. SFC Card's "ability to access treatment after discharge was noted as poor,
referrals were pending, and patient discharged without appointment at the time of
discharge." According to the Discharge Summary, SFC Card told providers at Four
Winds that he "decided to quit his job before he ended up killing someone," that he was
"sleeping 3-4 hours during the day", he "had a history of social anxiety" and that "he
usually drinks to loosen up in social situations." The discharge summary indicated SFC
Card had homicidal ideations (pt endorsed having a "hit list"), he appeared resistant to
psychoeducation, and he blamed others for his behavior. The therapist and treatment
team had difficulty engaging with - throughout the hospitalization and further
noted that SFC Card's - confirmed that the majority of the firearms were stored in
- gun safe.

(17) The telephoned SFC Card on 11 August 2023. 401

SFC Card told her he had been frustrated since being discharged due to limitations with
respect to his weapons.402 He reported problems with anxiety but not with respect to
anger or safety. 403 He denied any SI/HI. 404 SFC Card indicated that a Nurse Case
Manager had contacted him about starting virtual therapy. 405 He indicated he planned to
start therapy soon but did not have any dates.406 and SFC Card discussed
phone applications he can use at home as well as his behavioral health profile.407 •
- emailed SFC Card with phone applications for military Soldiers as well as
contact info for the ARM MC NCR. 408

397 Id. at pg. 20.

398 Id.
399 Id. at pg. 1.
400 Exhibit E1.
401 Id.
402 Id.
403 /d.
404 Id.
405 Exhibit E1.
406 Id.
407 Id.
408 Id.

45

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(18) On 25August2023, theARMMC emailed SFC Card's

personal and military email addresses, cc'ing - was conducting
a routine monthly follow-up concerning SFC Card's behavioral health profile. 410 ■
11111 inquired as to whether any updates to the profile were requested as well as
reminding SFC Card and about the process for modifying profiles.411

(19) attempted to call SFC Card on 28 August 2023 to follow-up and

provide support with follow up care.412 She left a voicemail requesting a return call. 413
also sent a text message.414

(20) As of 31 August 2023,~ had not received any response from SFC
Card.415 PHP subsequently closed his case. SFC Card's case was closed based on
the PHP standard operating procedure (SOP or handbook) in use at the time. Based on
that SOP, PHP staff were required to reach out to SFC Card via email, phone, and/or
text, weekly until contact had been established or until the individual failed to respond to
at least five PHP documented contact attempts over a three-week period. PHP closed
this case based on the non-response by SFC Card.417

I. September 2023.

(1) On 13 September 2023, SFC Card and ~ went to the Oxford

Casino located in Oxford, Maine, to gamble and drink. While driving home from the
casino, SFC Card "started talking about guns and how he could take out 100 people
with this expensive scope he had just bought." 419 SFC Card then told
about the various places he could "shoot up."420

409 Id.
410 Exhibit E1.
411 Id.
412 Id.
41l Id.
41.t Id.
415 Id.
41& Id.
417 Exhibit E1 .
418 Exhibits B10, 836.
419 later recalled this
Id. This statement was made by SFC Card to - .
information to- -.
420 Exhibit B10.

46

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(2)Also, on the ride home from the casino, SFC Card began repeating that "they
are ruining my life," and became very angry. 421 SFC Card described "places" where he
believed that people were talking about him and became angry about those as well. 422

(3) SFC Card complained to that the reason he could not buy
guns presently was due to his being committed to a mental hospital. 423

(4) Shortly thereafter, SFC Card began accusing of talking about

him and then began punching the steering wheel, shouting "Shut the fuck up!"424 SFC
Card punched -- • •• . in the face while driving the car.425 At that point, ~
- b e g a n "to put two and two together," regarding SFC Card's deteriorating
mental health.426

(5) Needing an excuse to get out of the car, told SFC Card he
wanted to get a pack of cigarettes and asked him to pull over at a nearby gas station. 427
When exited the car, SFC Card told . he was "done with"
him and left him at the gas station.428

(6) Shocked and concerned by the interaction,

at 0204 on 14 September 2023. texted the
following: "You up i have something to report. Change the passcode at the unit gate and
be armed if sfc (sic) card does arrive. Please. I believe he's messed up in the head. And
threaten the unit and other places. but I do not know how to help him,
and he refuses to get help or continue help. I'm afraid he's going to fuccck (sic) up his
life from hearing things he thinks he heard. When i dropped him off he was concerned
his weapons were still in the car. I beleive (sic) they were at the unit. And no one
searched his vehicle on federal property. And yes he still has all of his weapons.. . .
. I believe he's going to snap and do a mass shooting." • •

(7) then called at approximately 0400 on 14

September 2023, informing him of their physical altercation.430 told 1111

421 Exhibit B36.

422 Jd.
423 Exhibit J2 pg. 4.
424 Exhibit B36.
425 Jd.
426 Jd.
427 Jd.
426 Jd.
429 Exhibits 836, C24, J2.
430 Exhibit 83.

47

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

- that "SFC Card starting yelling at him, saying 'I can't believe you're talking
behind my back' and was punched by SFC Card."431 told
he got out of the vehicle at a gas station and found his own way home. 43
did not personally contact law enforcement or submit a CCIR following his conversation
43
with directed - to contact the Sagadahoc
County Sherriffs Office (SCSO) and request that it conduct a health and welfare check
on SFC Card. 434 Despite not submitting a CCIR, maintains he informed
~ of his plan and that approved his intended course of
action.

(8) - called , who at the time was unable to give

additional specifics about the threat SFC Card posed.436

(9) ~ called SFC Card at 0800 on 15 September 2023, leaving a

voicemail message. SFC Card returned call at 1400, telling him that
he was angry about how everything went down during AT, that he wanted to punctllll
Ill, that he would not be attending Battle Assembly, and that he had received his 20-
year letter and wanted to retire.438 responded telling SFC Card he "would
coordinate with to send him retirement information."
Whilel did direct to send SFC Card retirement information, he
also coded SFC Card as a "U" (i.e., unexcused absence) for the September and
October 2023 Battle Assemblies. 439

(10) On or about 15 September 2023, at the

Ellsworth Police Department, Ellsworth, Maine, , making him aware of SFC
Card's history.440 In an effort to maintain objectivity and create a degree of separation
for between and as a
directed to have a
detective from the Ellsworth Police Department request assistance from the Sagadahoc
County Sheriff's Office (SCSO). The assistance request from Ellsworth Police
Department to the SCSO was for a well-being check on SFC Card because that was the

431 Id.
432 Id.
433 Exhibit B3.
434 Exhibits B7, J2.
435 Exhibit B3.
436 Id.
437 Exhibits B3, L2, L3.
438 Id.
439 Id.
440 Exhibit J2 pg. 4.

48

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

law enforcement agency with jurisdiction over SFC Card. 44. , _ formally
requested assistance from the Ellsworth Police Department as directed.44•2

(11) On 15 September 2023, Ellsworth Police Department

- wrote to Sagadahoc County Sheriff's
for his assistance with the well-being check request.

(12) In order to assist the Ellsworth Police Department in its request for
assistance, - wrote a letter describing SFC Card's recent mental health history
over the_preceding nine months, describing SFC Card's physical altercation with .
• fear that SFC Card would commit a mass shooting.
I

also provided a copy of the text message he received from on

14 September 2023. - 445 described SFC Card as "one of my senior firearms
instructors in Bravo Company, 31304TH Infantry Regiment (USMA)."446 - also
informed the detective that SFC Card had spent fourteen (sic) days in the hospital, had
been released, and that to his knowledge SFC Card had not received any subsequent
treatment. 447

(13) - formally requested , on the order of that the

"Sagadahoc County conduct a well-being check on Card at his residence,
- Bowdoin, Maine, to gauge his mental health and determine if he is a threat to
himself and/or others."448 - also attached a photograph of SFC Card to his
letter.449 - concluded his letter by stating that he "would rather err on the side
of caution with regards to Card since he is a capable marksman and, if he should set his
mind to carry out the threats made t • • he would be able to do it."450
{14) of the Sagadahoc County Sheriff's Office
received the request for assistance from at 1447 on 15
September 2023, along with letter and accompanying photograph and

4
'° Id.
442 Id.
44 l Id.
44A Id. at pgs. 3-4, 9-10.
44 5 Exhibit J2 pgs. 3-4, 9-10.
44 6Id. at pg. 3.
447 Id. at pg. 4.
448 Id. I I
mistakenly provided an incorrect address for SFC Card in his request. The address-
- provided to the SCSO was for SFC Card's I and located approximately eight miles away.
SFC Card used th address on his official military documents. However, it appears
Sagadahoc County Sheriffs Office deputies did respond to SFC Card's residence, which was the white
trailer located at Bowdoin, Maine 04287.
449 Id. at pg. 4.
450 Exhibit J2 pg. 4.

49

End. Page 0073

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regu lation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

text.451 then traveled to SFC Card's residence at

- Bowdoin, Maine, arriving at 1504.452 Upon arrival,
a motorcycle with license number- under the garage overhang.4 He completed
a vehicle registration inquiry on the motorcycle and confirmed it was registered to
Robert Card, although the registered address was SFC Card's located at
454
Bowdoin, Maine. However, determined that
SFC Card lived in the trailer adjacent to the garage a . 455 However,
~ was unable to locate SFC Card during h·is visit to the property on
15 September 2023. 56

(15) Although report indicates he was going to request

the evening shift check on SFC Card, it is unknown as to whether anyone from the
Sagadahoc County Sheriff's Office checked on him on the evening of 15 September
~023. 457 requested that a "file 6" be sent out. 458 In his report,
misidentified the complaint as emanating from the Maine National
Guard, stating that "it has come to the Guard's attention that Card is having psychotic
episodes where he is hearing voices that are insulting him calling him a pedophile. Card
is also making threats to shoot up the Saco National Guard facility. He had been
committed over the summer for a couple of weeks due to his altered mental state but
has since been released." 459 stated that he had been asked by
the National Guard "to identify any specific individuals who were concerned for card
whereas he may focus his altered aggression toward them as he has already
demonstrated."460 He also noted that "Card is a firearms instructor with the Guard so
utmost caution should be utilized."461

(16) returned to SFC Card's residence at approximately

0845 the following day, 16 September 2023. 462 Upon arrival,
noticed that a white Subaru Outback was now parked in the yard, causing him to
request backup from another unit. 463 About 45 minutes later, of

451 Id. at pg. 3.

4s2 1d.
453 Id.
4~ Id.
455 Exhibit J2 pg. 3.
456 Id.
457 Id. No supplemental report was attached to incident report #23-015694.
458 Id.
459 Id.
460 Exhibit J2 pg. 3.
461 Id.
462 Id. at pg. 4.
463 Id.

50

End. Page 0074

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

the Kennebec County Sheriff's Office arrived to assist. 464 Both deputies then attempted
to contact SFC Card.465 The deputies could hear SFC Card moving around inside his
trailer, but he would not answer the door.Ml6 The deputies ultimately decided to leave the
property "due to being in a very disadvantageous position."467

(17) after departing the property.468

According t told him that SFC Card "no longer had
any weapons from the reserve unit" and that they "had made arrangements with Card's
who retrieved the personal weapons belonging to Card.n469

(18) never spoke directly with - about SFC Card's

weapons or any other matter.470 had spoken with about
SFC Card's weapons and "was under the assumption" that he had planned with . .
- to retrieve the weapons, although did not follow-up .471

(19) told that he had tried to make physical

contact with SFC Card, but that he would not answer the door. 472 According to -
, told him that this was something SFC Card had done in the
past and that after he "keeps to himself for a while he will come back out."473

(20) indicated that he informed thal l l l

- was the source of the alleged threat emanating from SFC Card, but he
downplayed and stated he was a " who would
as based

~Id.
465 Exhibit J2 pg. 4.
466 Jd.
467 Id.
468 /d.
469 Exhibits J2 pg. 4, C24. The information
weapons differs greatly fro
believed that SFC Card still
470 Exhibit B3.
4n Id.
m Exhibit J2 pg. 5.
473 Id.
474 Exhibit B3.

51

End. Page 0075

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(21) informed that "the Guard (sic) is in the

process of trying to get Card to retire from the Guard with conditions that he get some
mental health treatment."475 concluded
was of the opinion that forcing a contact with Card
was [sic] necessary or advantageous. He thought it best to let Card have some time to
himself for a bit."476

spoke with on 17 September 2023. 477

confirmed that was "able to confirm that he was able
478
guns." However, also told the
guns "were in a gun safe that the ' has access to at th '' and that he
to get the guns moved somewhere else ." further
informed that he would "try and work with Robert to make sure he
does not have any other firearms ."480 then told - it was
"our intention to make sure Robert does not do anything to hurt himself or others," but
told - to "make his own judgment" as to whether SFC Card needed an
eval~ warned that "when Robert answers the
door at his trailer, in the past he usually does so with a handgun in hand out of view
from the person inside." 482

(23) " at an unidentified date

and time and told that "between they would work to
ensure that Robert does not have any access to any firearms. They have a way to
secure his weapons."483

(24) According to attempted to retrieve and secure SFC

Card's weapons on 23 September 2023. maintains that SFC Card
called- - and threw off his property. 485

(25) SFC Card texted on 23 September 2023, stating that he was

475 Exhibit J2 pg. 5.

476 Id.
m Id.
478 Id.
479 Id.
400 Exhibit J2 pg. 5.
481 Id.
482 Id.
483 Id.
484 Exhibit B23.
485 Exhibit J2 pg. 5.

52

End. Page 0076

AFRC-OPI (8008-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

"U)ust sitting here going insane like the plan is no one will tell me we're this shit being
said turned and my friends against me, so their plan is working." 486
responded , texting "I can't imagine how difficult this is for you. I don't
understand why this would be happening to you. It has to be for a purpose greater than
we can know and see. I think your and friends love you and don't know how
to help. It is fear of hurting you.

(26) Following the 23 September 2023 incident, reported that

·~ asked for help from law enforcement to take Robbie's weapons because Robbie
kept kicking us off his property."488

(27) On 26 September 2023, - attempted to contact SFC Card to

determine if an extension of his behavioral health profile was necessary and requested
that SFC Card call him back.489

(28) Unit members and SFC Card's

Card following the incident in which SFC Card punched •in the face .
"could tell that he was declining fast after 9/23/23 and 10/13/23."490 She
indicated that had texted her, explaining that SFC Card "thought we were all
against him and this was the first time he accused - of being in on the
conspiracy too. by his accusations."491 - "attempted
to reach out via text, but he accused me of being part of the conspiracy. I knew he was
really hurt and angry, but I didn't know how else to help.

(29) Likewise, had irregular contact with SFC Card after 13

September 2023. He indicated that he occasionally saw SFC Card at
passing, but they did not speak to each other.49 asked his at

486 Exhibit C 10.

487 Exhibits C10, C11.
488 Exhibits B21 , E1 .
489 Exhibit E 1 .
490 Exhibit B21 .
491 Id.
492 /d.
493 Exhibit B36.

53

End. Page 0077

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

the ~ to arrange his work schedule so he would have no contact with

SFC Card.

(30) - final interaction with SFC Card occurred on or about 14

September 2023. SFC Card called and yelled at him for uposting stuff
on Facebook," eventually hanging up on him. • claimed he had not
posted anything on Facebook in years, and "certainly not about SFC Card."497
According to ~ , SFC Card called him again on 22 September 2023, but he
did not answer.

(31 ) According te>_ _ , at some point in late September 2023, he

contacted SFC Card'~ and asked him to remove all the weapons from SFC
Card's home. 499

m. October 2023.

(1) Despite several attempts, was unable to reach SFC Card

between 23 September 2023 and 13 October 2023.500
Card occurred on 13 October 2023, texting
501 SFC Card responded , asking her to "tell me

where this fucking shit online is" never heard from SFC Card again.503
This is the last known interaction betvveen SFC Card and - .

(2) Despite not hearing from SFC Card, - contacted on 17

October 2023, requesting his behavioral health profile be extended and allowing SFC
Card additional time to obtain and submit documentation.504 As the designated ARMMC
approved a 90-day Temporary Profile extension that
same day. instructed- to utilize the command if SFC Card
remained unresponsive.

4~ Id.
495 fd.
496 Jd.
497 Id.
498 Exhibit B36.
499 Jd.
soo Exhibit C12.
501 Id.
502 /d.
503 Exhibit B21 .
504 Exhibit E1.
505 /d.
506 Jd.

54

End . Page 0078

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(3) On 19 October 2023,_ again unsuccessfully attempted to contact

SFC Card. 507 - then emailed SFC Card and 508

(4) According to open-source media, SFC Card was in Hudson, New Hampshire,
on 19 October 2023, making a delivery to a Country Kitchen Bakery Outlet. 509 Bakery
outlet employees said SFC Card accused them of talking about him.510 Before he left,
SFC Card reportedly told employees, "Maybe you will be the ones I snap on."511

(5) On 23 October 2023, emailed SFC Card, informing him his case
had been reassigned to a new and reminding him that he needed to update his
behavioral health information.5 SFC Card's case was transferred because -
duties were changing to become alll.
(6) On 24 October 2023, the new attempted to contact
SFC Card by phone. 513 - previously served as a but switched roles with
- in mid-October 2023. A male answered the phone, asked to speak
with SFC Card, and the male on the other end of the line then hung up.514 - .
tried the number again, but the call went to voicemail, and she left a message.5 '15 •
Ill then emailed SFC Card, cc'ing 515

n. Mass Shooting and Suicide.

(1 ) On 25 October 2023, national media outlets reported a mass casualty

shooting event in Lewiston, Maine.517 That evening, the media showed a photograph of
the shooter from security footage taken from Just-in-Time Recreation, a family bowling
center located in Lewiston, Maine.518

507 Id.
soa 1d.
509 Exhibit T 1.
510 Id.
511 Id.
512 Exhibit E1 pg. 1.
51l Id.
514 Id.
515 Id.
516 Id.
517 Exhibit T1 .
51s Exhibits G24-G29.

55

End. Page 0079

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(2) That evening, to

inform him of the shooting. identtfied SFC Card as the shooter after
reviewing photographs from other law enforcement departments.520
a police officer in
Rockland, Maine, also identified SFC Card after running his reg istration plate through
Mobile Data Terminal. 521

(3) As events progressed, additional reports suggested the shooter had moved to
Schemengees Bar and Grille.522
, was one of
the officers called to respond to the active shooter event that evening. After
responding to several unconfirmed reports pertaining to SFC Card's whereabouts, Ill
- identified SFC Card's vehicle at the Lisbon Falls boat ramp .524

(4) gave his name and phone number to the on-scene commander
that evening, but no one followed up with him before SFC Card 's suicide. 525 Police were
unable to locate SFC Card after they found his vehicle at the boat ramp that evening. 526
A manhunt then ensued.

(5) SFC Card killed 18 people and wounded an additional 13 people.527

(6) At approximately 1945 on 27 October 2023, SFC Card's body was located at
Maine Recycling, 36 Capital Avenue , Lisbon, Maine 04252.528 SFC Card's body was
discovered in the back of a tractor trailer parked on a Maine Recycling annex storage
lot. 529 The cause of death was listed as "gunshot wound - " and the manner of
530
death was listed as "suicide (shot self with handgun)." The toxicology report did not
reveal any findings of toxicological significance other than the presence of caffeine and
nicotine in SFC Card's system.531

519 Exhibits B1, B43.

520 Id.
521 Id.
522 Exhibits G48-G53.
523 Exhibit B5.
524 Exhibits B5, G34-39.
525 Exhibits B1, B43.
526 Jd.
s21 Exhibits J10, T1-T3.
528 Exhibit E2.
529 Id.
530 Exhibits D, E2.
531 Exhibit E2.

56

End . Page 0080

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(7) The 3/304th submitted both a CCIR for the mass shooting on 25 October
2023 and a separate CCIR for SFC Card’s suicide on 27 October 2023.

4. Findings: I make the following findings by a preponderance of the evidence:

a. Military History.

(1) Provide a complete accounting of SFC Card’s military history. Include any
periods of Active-Duty Service, Mobilization, Deployments, Inactive Duty Training, etc.
Include promotions, reductions, transfers, awards, Uniform Code of Military Justice
violations, unfavorable personnel actions, etc.

(a) SFC Card enlisted in the United States Army Reserve on 14 December 2002,
and his Military Occupational Specialty (MOS) was 92F, Petroleum Supply Specialist
with an Additional Skill Identifier EH7, Enlisted Petroleum vehicle operator. SFC Card
completed Basic Training (Initial Entry Training) in 2003 and completed at least the
minimum-required statutory Inactive Duty Training and Annual Trainings every year
through 2023 in the U.S. Army Reserve. He never served on active duty in the Regular
Army or in the Army National Guard and he never mobilized or deployed to a CONUS
(Continental U.S.) or OCONUS (Outside Continental U.S.) location. In addition to his AT
periods, he completed multiple active-duty periods consistent with a full career,
including Professional Military Education (Initial Entry Training, Advanced Individual
Training, Warrior Leader Course, Advanced Leader Course) and additional skills training
(Unit Prevention Leader, Advanced Marksmanship Training, CBRN Defense Course).
His promotions, unit assignments, and awards are listed below. SFC Card received no
unfavorable actions during his career as indicated in his official military file, to include
Uniform Code of Military Justice violations or unfavorable personnel actions. 532

(b) Promotions (Date of Rank)

14 DEC 2002 E2
14 DEC 2003 E3
22 MAR 2004 E4
01 JAN 2008 E5
01 MAR 2016 E6
02 JUL 2020 E7

(c) Assignment and Enlistment Orders

14 DEC 2002 Initial Enlistment/Assignment to 947 QM CO

532 Exhibits H2, N79.

57

Encl. Page 0081

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

16 APR 2006 Transfer order to 439 QM (Quartermaster) CO 3 PLT

28 MAR 2008 MOS order 92F2OH7OO (Petroleum Vehicle Operations)
31 DEC 2013 Reenlistment - Six Years
09 APR 2014 Transfer order 304 REGT 3 BN
31 JUL 2020 Reenlistment – Indefinite

(d) Additional Active-Duty Training

20 MAR 2003 Initial Entry Training (Basic Training)
6 JUN 2003 Advanced Individual Training (92F-Petroleum Supply)
12 MAY 2006 Warrior Leader Training
06 MAR 2009 CBRN Defense Course
26 SEP 2012 Petroleum Supply Specialist, Advanced Leader Course

(e) Awards
06 MAR 2009 Commandant's List CBRN Defense Course
06 APR 2009 Army Reserve Components Achievement Medal
19 JUN 2009 Army Achievement Medal
28 JUN 2013 Certificate of Appreciation
05 MAY 2018 Army Reserve Components Achievement Medal
14 SEP 2020 Humanitarian Service Medal

(f) Assignments
14 DEC 2002 947 QM CO (PETRL SPT)
01 JAN 2008 439 QM CO (PETRL SPT)
09 APR 2014 B Company, 3d Battalion, 304th Infantry Regiment

(g) Deployments/Mobilizations
None

(2) Did SFC Card require any waivers to join the Army?

No. Despite his reported hearing issues, SFC Card did not require any waivers to
join the Army. 533

(3) Was SFC Card hospitalized during periods of Active-Duty service? If so, was
he properly discharged? If on active-duty orders, was he properly released from his
orders?

533 Exhibit N25.

58

Encl. Page 0082

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(a) SFC Card was hospitalized while on AT orders dated 15 July 2023 through 28
July 2023. His orders were extended on a different type of order for six days to facilitate
his stay in the hospital. 534 SFC Card was not hospitalized while in a duty status prior to
July 2023. SFC Card was hospitalized at KACH on 16 July 2023 and then transferred to
Four Winds.535 KACH was unable to provide the required level of treatment as they do
not have an inpatient behavior health facility, so they requested a transfer to Four Winds
on 16 July 2023. His admission to Four Winds was due to reports of psychosis, mood
!ability/aggression, homicidal ideations (having a "Hit list"), paranoia, and auditory
hallucinations.536 He was rated a "very low risk" of committing harm against himself or
others at Four Winds, after a full psychological evaluation
approximately 10 days after entry into the hospital and after he started psychiatric
medication. SFC Card was eventually discharged with a diagnosis of "Brief Psychotic
Disorder'' and scheduled for follow-on treatment and orders to continue to take
prescription medication.537

(b) I defer findings on whether SFC Card was property discharged from the Four
Winds Hospital to the experts at the Walter Reed Department of Forensic Psychology. I
am unable to conclusively determine if SFC Card received discharge instructions from
Four Winds when discharged on 3 August 2023. The discharge summary with
information related to appointments, medication, and care received was not signed by
Four Winds providers until 7 August 2023, 8 August 2023, 10 August 2023, and 11
August 2023.538 On the surface, SFC Card was permitted to leave the hospital and may
have had information on what to do next. However, according to .
"When I got there, he was immediately released and they let him out right away, no one
needed to talk to me first, and I never saw the discharge instructions." 539 The official
documents, which were not signed until at least four to eight days after SFC Card was
already released, indicate SFC Card was discharged by Four Winds under guidance
from and SFC Card received follow-up care instructions and medication.
SFC Card arranged on his own to have come pick him up from the
hospital. at KACH, wrote a medical note: "Call placed to SM [on 11
August 2023] .... Educated him on the services provided by Telemynd which he was
referred to by Four Winds. Services which include medication management and
therapy. Instructed him to go to their website to apply for an appointment. ... " 540 The
standard of care requires a patient to have a discharge order, therapy follow up, and

534 Exhibits R3, R6.

535 Exhibits B7, B3, B6, N32, R6, E 1.
536 Exhibit E 1 pgs. 3-5.
537 Id. at pgs. 14, 54-71.
538 Id. at pg. 12.
539 Exhibit B36.
540 Exhibit E 1 pgs. 17, 22.

59

End . Page 0083

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

medication follow up at the time of discharge. The documents I received as part of my

investigation show none of these items were completed until four to eight days after
SFC Card was already released. However, I defer to Walter Reed to opine on whether it
is customary or within the standard of care for a patient to receive unsigned discharge
instructions.

(c) A preponderance of the evidence shows SFC Card was not properly released
from his orders. Because SFC Card was hospitalized for over 24 hours during his
service on active duty, SFC Card’s unit should have initiated a Line of Duty Investigation
(LODI) while SFC Card was still in the hospital or immediately after his discharge. He
should have been continued on active-duty orders until the LODI was completed to
determine if his condition was aggravated by his service and if he was entitled to follow-
on medical care at the government’s expense, either on or off active-duty orders.

(1) Rules/Law. Per AR 600-8-4, paragraph 2-2, a LODI should be initiated on any
Soldier that experiences a loss of duty time for a period of more than 24 hours and the
injury, illness, or disease is of lasting significance or may require follow-on care for
Reserve members on duty for less than 30 days. Additionally, per paragraph 2-2d, a
formal LODI must be conducted when an injury, illness, or death occurs under strange
or doubtful circumstances or when a member of the USAR becomes disabled due to
that injury, illness, or death (emphasis added). Per paragraph 5-3 of that same
regulation, Commanders, medical officers, S1s, Staff Judge Advocates, unit
administrators, noncommissioned officers, and Reserve Component Soldiers who learn
of a Soldier’s injury, illness, disease, or death that occurred under circumstances that
might warrant a Line of Duty Investigation/Determination must take an active role in
ensuring that an investigation/determination is initiated and completed. Per AR 135-181,
paragraph 2-8c, Soldiers serving on active duty for 30 days or less may be continued on
active duty after their orders expire to continue health care treatment for the “in the line
of duty” (ILD) condition. Finally, per 10 United States Code (USC) § 12322, a member
may be continued on active duty for a period of more than 30 days while the member is
being treated for (or recovering from) an injury, illness or disease incurred or aggravated
in the line of duty.

(2) Application. While on active-duty orders, SFC Card was admitted to KACH for
psychiatric evaluation due to reports of erratic and concerning behavior. When KACH
determined they lacked the resources to treat SFC Card’s condition, they referred him
to Four Winds. SFC Card stayed at Four Winds from 16 July 2023 to 3 August 2023,
including the entire two-week active-duty training time. 541 SFC Card was on AT orders

541 Exhibit E1.

60

Encl. Page 0084

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regu lation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

from 15-28 July 2023 and then extended on Active Duty utilizing medical ADOS orders
from 29 July - 3 August 2023 for a total of 20 Active-Duty days and 19 spent receiving
treatment. This means SFC Card missed at least 10 duty days. Additionally, on-call
, determined SFC Card was not fit for
military service (did not meet medical retention standards). SFC Card's mental condition
could be considered "strange" under AR 600-8-4, which would require a Line of Duty
determination.

(3) The medical professionals at KACH and Four Winds documented that SFC
Card would require follow-on care, and completed a DA Form 3822,
Report of Mental Status Evaluation, stating SFC Card did not meet medical retention
standards. recommended SFC Card be entered into the Disability
Evaluation System and be evaluated for behavioral health medical readiness due to
"unspecified psychosis."

(4) Because SFC Card missed more than 24 hours of duty, the circumstances
were strange, he was likely to be determined medically unfit for military service, and his
condition required follow-on care, the requirement to initiate a LODI under AR 600-8-4
was met. The command should have initiated a LODI while SFC Card was still in the
hospital or immediately after his release.

(5) Additional good cause for extension on active-duty orders is because SFC
Card was found to need follow-on care to a condition discovered and treated during his
time on active duty. To receive that follow-on care at government expense, a LODI
would be necessary to determine if the condition was caused or aggravated by military
service. Because the follow-on care for SFC Card needed to occur immediately, the unit
should have continued SFC Card on medical ADOS orders, per AR 600-8-4, AR 135-
381 , and 10 USC§ 12322.

(6) The need for a LODI to determine service connection is further bolstered by
the statements of two providers, one reviewing the file near in time to the inciden --
KACH
one reviewing the fi le after SFC Card's death
These providers have differing opinions on whether this condition
was fully service aggravated, with - believing it was "exacerbated while on AT"
and believing it was not at all military-service aggravated.542 An
investigation should have been conducted to conclusively determine if the condition for
which SFC Card was treated in July 2023 was service aggravated or if it existed prior to

542 Exhibits 830, B34

61

End . Page 0085

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

service and was not affected by military service. I defer findings on whether SFC Card's
condition in July - August 2023 should be considered in the Line of Duty.

(7) Because SFC Card needed immediate follow-on care, and because his
condition may have been aggravated by his military service, he should have been
extended on active-duty orders, and a LODI should have been conducted to determine
his entitlement to medical care before he was released from his orders. Additionally, AR
40-400, paragraph 5-9 states that Reserve Component members on active-duty orders
for 30 days or less will be evaluated for an MEB (Medical Evaluation Board) upon
completion of hospitalization before release from the Military Treatment Facility (MTF).
Upon release from Four Winds, SFC Card should have been returned to KACH for an
MEB rather than released of his own accord. Because he was released without a LODI
and MEB, a preponderance of the evidence shows SFC Card was improperly released
from his active-duty orders.

(d) A preponderance of the evidence shows the unit did not properly release SFC
Card from his orders because the unit did not ensure SF C Card was properly returned
to the Reserve Center in Saco, Maine (where SFC Card's AT began).

Regardless,
should have been placed in a duty status to accomplish this task. Although
- was later paid (on 26 October 2023) for his time using a DA Form 1380, he
was not paid for associated costs such as mileage.

(4) How long had SFC Card been in his current unit? Had he properly been in-
processed and counseled IAW Army regulations?

62

End. Page 0086

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(a) SFC Card joined B Company, 3d Battalion, 304th Infantry Regiment (United
States Military Academy) (31304th), 104th Train ing Division, 108th Training Command,
on 9 April 2014 when he was a SGT.543

(b) B Company, 31304th was unable to provide any in-processing or counseling

documents.

(5) What were SFC Card's assigned duties?

(a) SFC Card was assigned as a "Senior Trainer" of USMA Cadets.

(b) SFC Card provided a variety of firearms instruction, with a particular focus as
a "grenade pit safety NCO" on the hand grenade range and a lane instructor for crew-
served weapons. Army Training Circular 3-23.30 doctrinally defines a safety NCO and
weapons instructor as having responsibility for the instruction and safety during live
hand grenade training and weapons training. 544

(6) What type of suicide or resiliency training did SFC Card participate in, and in
what time frame? When did SFC Card last complete a suicide stand-down/training?

(7) What was SFC Card's reputation at the unit? What ratings had he received on
his NCOERS in his current unit?

(a) SFC Card was generally considered a steady, average performer, who was
"solid and reliable ."546 He was described as a follower who would rather execute the
mission than lead other Soldiers. He was also described as kind , friendly, calm, and
generous.547 SFC Card's ~ reported no previous performance or
conduct issues prior to the Spring of 2023.

54 3 Exhibit H2.
s.u Exhibits H2, 85, 810, 87, 84, B42, R13.
545 Exhibit R-14.
546 Exhibit B18.
54 7 Exhibits B10, B42, 816, B36.
548 Exhibit B3.

63

End. Page 0087

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regu lation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(b) During SFC Card's last eight NCO ER ratings, he received a mix of average
(met standard) and above average (exceeded standard) ratings. 549

(8) Had SFC Card been singled out or harassed in any way by unit members or
leadership?

(a) There was no evidence of actual harassment, bullying, or hazing. However,

SFC Card believed that unit members were talking behind his back, claiming he was
either gay, a pedophile, or that he had a small penis. Nevertheless, according to at least
one unit member shared intimate details about SFC Card during
the June 2023 Battle Assembly. shared the intimate details (i.e. , possible
sexually transmitted disease, discussion of pedophile, and small penis, etc.) witttlllll
- in his position as SFC Card's and as a basis for why the unit
needed to watch SFC Card. sharing of the above information with 1111
in this context would not be considered harassment. It is unknown whetfierllllll
shared these details with other unit members beyond

(b) Due to his deteriorating mental state, it is likely SFC Card attributed potential
harassment occurring at his civilian job at Maine Recycling to his fellow military service
members.550

(9) When was the last time SFC Card qualified on his assigned weapon? What
was his level of proficiency?

(a) SFC Card last qualified on his assigned weapon on 23 October 2021 .

(b) SFC Card qualified as an Expert Marksman (40/40).

(10) Did SFC Card make any protected communications to the IG, Command,
Congressional, etc.? If so, what was the result of those communications?

SFC Card did not make any protected communications to the IG, the command,
or Congress during his tenure at the 31304th from 2014 to 2023.551

( 11) Did SFC Card develop an injury, illness, or disease during a period where he
was in a duty status? If so, were there any Line of Duty Investigations conducted into
any injuries, illnesses, or diseases obtained by SFC Card? If not, why not? Did military

54 9Exhibits N9-N18.
550 Exhibit B10.
ss1 Exhibits K35, K36.

64

End . Page 0088

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regu lation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

service aggravate any medical or mental conditions SFC Card may have had? Should a
formal Line of Duty Investigation be conducted IAW AR 600-8-4?

(a) Yes. SFC Card required treatment for a "Brief Psychotic Disorder" while on
active-duty orders in July 2023. SFC Card's mental health issues likely manifested in
January 2023, or earlier, while in a non-duty status. 552 His condition may have been
aggravated by subsequent military service during IDT periods in Spring 2023 or during
his AT in July 2023 noted, "My opinion is that SFC Card's preexisting
condition was exacerbated while on AT, but this condition pre-dated SFC Card 's AT."
However, opined that SFC Card's condition was not service
connected/aggravated, stating: "I don't believe records reflect that [this was service
aggravated]. He believed that he was hearing voices. I don't believe that this is military
service aggravated."553

(b)A LODI was not conducted for SFC Card. ~ stated that the unit
did not consider conducting a LODI a requirement at the time. As discussed above,
the unit erred in not initiating a formal LODI based on SFC Card's hospitalization in July
2023.

(c) At present, there are conflicting opinions whether military service aggravated
any medical or mental conditions SFC Card may have had. This reinforces the
necessity of a LODI. As stated previously, SFC Card's mental health issues may have
been exacerbated because he may not have wanted to be atAT. 555 When he
experienced his mental health episode during the first two days of AT in July 2023,
fellow unit members who SFC Card considered as peers and trusted colleagues
recognized his symptoms and reported their concerns to the command. SFC Card was
then taken to KACH, and later Four Winds, for evaluation and treatment. 556

(d) A formal LODI should be conducted IAW AR 600-8-4, focusing on SFC Card's
July 2023 admission to KACH and Four Winds as well as his condition prior to
discharge on 3 August 2023. The threshold question of whether his psychosis was
service connected, or service aggravated must be determined before any findings can
be made regarding SFC Card's suicide. As noted above, it is possible, military duties
exacerbated SFC Card's condition in July 2023, but
- opinions differ on this issue. A LODI should have been conducted in July

552 Exhibit B38.

553 Exhibits B34 pg. 2, B30 pg. 2.
554 Exhibits 63, P5 pg. 6, 66.
555 Exhibit B36.
556 Exhibits E1 , B5, 610, 62.

65

End. Page 0089

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

2023 to make a finding as to service connection. As such, I defer findings on whether

SFC Card's suicide occurred in the line of duty pending the results of an expert medical
opinion from the Walter Reed National Military Medical Center on SFC Card's mental
health condition as of July 2023.557 I acknowledge that, as a general rule, a LODI would
not be required for SFC Card's suicide because he was not in a duty status at the time
of his death in October 2023. However, should the results of the initial LODI reflect that
SFC Card's mental condition was exacerbated by his service and therefore in the line of
duty, then a follow-on LODI should be conducted to determine if that same condition
resulted in his suicide. 558

b. Personality, Lifestyle and Medical History.

(1) What was SFC Card's basic personality (relaxed, intense, jovial, gregarious,
withdrawn, outgoing, morose, bitter, suspicious, angry, hostile, combative, other)?

(a) According to numerous members of his unit and SFC Card

was quiet and laid back for most of the time they knew him. He spok·e with a slow
drawl. 559 He was also described as friendly, kind, and generous.1
mentioned that he was "grumpy and cynical towards the military," but "his attitude was
the same as the rest of us as we end our careers." 560

described him as "angry.11561- -

- described as "aggressive. and he would yell a lot" and that "he never had
anything nice to say'' about

(2) Was SFC Card's personality and demeanor before the suspected suicide
different from his normal behavior?

(a) In the months leading up to his suicide, beginning in or about January 2023,
SFC Card became increasingly paranoid that others were talking about him behind his
back, claiming he was a pedophile, gay, or had a small penis. When discussing these
matters, SFC Card would become easily agitated if anyone doubted his claims. 562

557 Exhibits B3, D, P6.

558 Exhibits B3, D.
559 Exhibits B10, B21 , B5, B4.
560 Exhibit 642.
561 Exhibit B39.
562 Exhibit B38.

66

End. Page 0090

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(b) As a result of his paranoia, SFC Card engaged in altercations with

and strangers at local retail establishments, including with
in September 2023. 563

(3) Explain any recent change(s), if any, in mood or symptoms of mental illness.

(a) SFC Card's paranoia was indicative of his mental illness. His repeated
mentioning of hearing people talk about him could be attributed to feeling anxious or
worried.

(b) Other noted symptoms of mental illness can be emotional outbursts to include
changes in mood, extreme distress, anger, or the feeling that people are out to get
them.

(4) Explain any recent change(s) if any, in behavior, such as eating, sleeping,
social relationship, drinking, or drugs.

(a) SFC Card had reduced his alcohol intake.

(b) Additionally, SFC Card lost a considerable amount of weight, which he

attributed to eliminating soda from his diet. SFC Card had increased his exercise. 564 His
weight loss was so extreme tha became concerned and on 3 May 2023
asked him to see a doctor. She later tried to follow up to make sure that he saw
someone. 565

(c)SFC Card also self-reported to Four Winds that he was sleeping about 3-4
hours a day. 566

(5) Describe SFC Card's friendship group. Were there many, few, casual, or
intense friendships?

(a) SFC Card had a very small group of friends.

described himself as SFC Card 's -

56 3Exhibits B21 , B10, B36, J1 .

564 Exhibit B10.
565 Exhibit B21.
566 Exhibit E1.

67

End. Page 0091

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regu lation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(c) - and SFC Card attended many Army training events together and
looked forward to seeing each other at drill weekends. 569

(6) Explain any recent withdrawal from any friend(s) or acting out, such as
gambling, overspending, or fighting .

(a) SFC Card routinely went to the casino with but was not known
to have a gambling addiction.

(b) SFC Card had an altercation with on 15 July 2023 during his AT at
Camp Smith, New York. SFC Card charged , stating "I can't believe you're
talking about me like that," referring to rumors about him being a pedophile and gay.
- denied saying anything negative about SFC Card, but SFC Card then
threatened to fight _ _s10

(c) On 13 September 2023, SFC Card got into an altercation with

after leaving the Oxford Casino. SFC Card became agitated and was making threats of
violence towards others. SFC Card then accused of talking about him
behind his back before punching him in the face. SFC Card then told he
was done with him. 571

(7) Explain how SFC card spent his free time.

(a) According to : SfC Card spent a fairly large time in the outdoors
fishing and hunting with

(b) SFC Card would gamble at casinos, participate in horseshoe and corn hole
leagues and tournaments, and was a regular member of a bowling league "throughout
the years."

(c) There were no reports that SFC Card developed any friendships with any
participants while conducting these activities. On the contrary, SFC Card was reportedly
more of a loner with only a few close relationships such as with
and

567 Exhibit B36.

568 Exhibits B10, B36.
569 Exhibit B10.
570 Exhibit B10.
571 Exhibit B36.

68

End. Page 0092

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(d) In addition, he collected various types of firearms and accessories and would
sometimes show scopes and other accessories to his fellow unit members. He was also
interested in investing in the stock market and would frequently discuss his
investments. 572

(8) Provide an accounting of SFC Card's civilian employment experience. Identify

any periods of unemployment.

(a) SFC Card worked at Friendly's Restaurant in 2001 for an undetermined

amount of time. 573

(b) SFC Card attended University of Maine from the Fall of 2001 until the Spring
of 2003. There was no record of civilian employment obtained for this time period. 574

(c) There were no records of SFC Card's employment history from 2003 through
2009.575

(d) SFC Card began working for Baxter Brewing Company as a delivery truck
driver in or around 2009 or 2010. 576

(e) There were no records available to determine SFC Card's employment history
from 2010 through 2023; however, - reported he
worked for several other companies, including Baxter Brewing Company, Pine State
Beverage, and Kris-Way Truck Leasing.

(f) SFC Card began working at Maine Recycling in the Spring of 2023. SFC Card
worked at Maine Recycling until he left in July 2023 following an incident with a 1111
- regarding the size of SFC Card's penis. 577

(g) SFC Card then started working for First Fleet as a bread truck delivery driver
in the summer of 2023.578

sn Exhibits B21 , B10, B5, B36, B38, K42.

573 Exhibits B39, B21 .
s7.c Exhibit N74.
575 I did not attempt to obtain tax records through the Internal Revenue Service.
576 Exhibit B18.
m Exhibits B10, B21, B36.
578 Exhibit B36.

69

End. Page 0093

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(9) Did SFC Card experience a recent loss (death, breakup of a relationship)? If
so, explain.

(10) Did SFC Card have any significant financial issue(s) or problem(s)? If so,
describe the nature of the problem(s).

(a) No. SFC Card did not have any significant financial issues.

(b) SFC Card was reportedly skilled at investing in day-trading stocks and crypto
currency. - - - reported that SFC Card made over $50,000 in profit between
2021-202~

(c) SFC Card was very interested in financial topics and education as evidenced
by the 16 Army electronic learning (distance learning) finance and accounting courses
he completed in and about 2011-2012. These courses included, Basic Accounting
Principles and Framework, The Balance Sheet, The Cash Flow Statement, and The
Value of Money and Investments for Non-Financial Personnel. 581

(11 ) Did SFC Card have a significant health problem(s)? If so, describe the
nature and treatment of the problem(s).

(a) No. However, SFC Card dealt with hearing loss. In 2017, SFC Card had
surgery on his ears, but the surgery was not completely successful. After he was
retained by the MOS Administrative Retention Review (MAR2), SFC Card purchased
commercial hearing aids and received them on approximately 2 March 2023.582

(b) Further, in 2008, according to SFC Card's _ , he fell from the roof of his
home and reportedly broke his neck, possibly leading to a traumatic brain injury.583 I

579 Exhibit 838, 810, 821 .

560 Exhibit 836, 810, 838.
581 Exhibit N80.
582 Exhibits B10, B21.
583 When the neck snaps around rapidly, the force can place enough stress on the brain to cause
damage. This often results in a concussion, the most common type of traumatic brain injury.

70

End. Page 0094

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

was unable to obtain SFC Card's civilian medical records to confirm his reported
cervical fracture. Additionally, I defer to Walter Reed to opine on the impact of SFC
Card's broken neck in relation to his mental health in the months leading to his death in
2023.

(12) Is there any indication that SFC Card was experiencing difficulties in a
relationship with a spouse, partner, parents, or children?

~ anuary 2023, SFC Card was

(b) In April 2023, SFC Card was involved in a verbal altercation with -
This incident, together with other observed paranoid behavior, caused
to report to law enforcement and to reduce the amount of contact and
visits he had with 584

(c) On 23 September 2023, when

home attempting to safely remove his firearms, SFC Card called
and kicked them both off his property.585

(d) attempted to reach out to -

-
went to SFC Card's

after this incident and

explain that the voices he was hearing were not real. On 23 September 2023, SFC Card
texted that he was: "just sitting here going insane like the plan is no one will tell me
we're this shit being said turned and my friends against me, so their
plan is working".586 When texted him on 13 October 2023 to tell him that
, SFC Card responded : "well tell me where
this fucking shit online is." When explained that there was nothing online
and that his delusions were not real , she never heard from SFC Card again.587

(13) Had SFC Card ever been arrested? If so, what were the charges and the
disposition of those charges?

564 Exhibit B38.

585 Exhibit B21 .
586 Exhibits C10, J4.
587 Exhibit C12.
588 Exhibit B39.

71

End. Page 0095

AFRC-OPI (8008-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(a) SFC Card was arrested for and convicted of 'misdemeanor operating under
the influence' on 14 April 2007 in Topsham, Maine.

(b) SFC Card was found guilty on 15 May 2007, fined $500.00, incarcerated for
48 hours, and his license was suspended for 90 days. 589

(14) Did SFC Card have a history of illegal drug use or prescription medication
abuse? If so, explain.

According to , SFC Card "always been straight edge but

experimented with drugs when he was younger like a lot of people."590

(15) Did SFC Card have any recent communication(s) on the internet (that is,
with social networking sites)? If so describe or include these communications.

During this investigation, I discovered that SFC Card's social media sites were
either deleted or locked. However confirmed that SFC Card had used
Facebook.591

(16) Did SFC Card contact Army OneSource? Is so, about what issue?

Military One Source did not reply to my inquiry dated 8 January 2024.592

(17) Was SFC Card prescribed any prescription drug(s) at the time of his death?
If so, list the prescription drugs and for what the drugs were prescribed. When were the
drugs prescribed? Who prescribed the medications(s) and what type of provider was
he/she (i.e., Civilian doctor, Veteran's Affairs , Military Treatment facility)?

(a) SFC Card was prescribed the anti-psychotic, Olanzapine, during his hospital
stay and at the time of his discharge from Four Winds on 3 August 2023. 593 Four Winds
also recommended SFC Card take the following medications upon discharge: Omega-3
Fatty acid 1 gram daily, Melatonin 3mg daily at bedtime, and Vitamin 03 1000 units
daily.594

589 Exhibit J4.

590 Exhibit B21 .
59 t Exhibit B36.
592 Enclosure 6F.
593 Jd.
5~Exhibit E 1. Olanzapine is a second-generation (atypical) antipsychotic medication. The FDA has
approved this medication for schizophrenia if the patient is over the age of 13 and bipolar disorder,

72

End. Page 0096

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(b), From the onset, SFC Card did not want to take this medicine because how it
made him feel. On 28 July 2023, noted in the medical
record that SFC Card stated to the Four Winds treatment team, that "tomorrow he will
refuse to take his medication."

(c) During her 11 August 2023 follow up call with SFC Card after his release, SFC
Card told - · he (SFC Card) "stopped taking his medications because he did
not like how they made him feel." Finally, SFC Card told on their drive
back to Maine on 3 August 2023 that, "he didn't like how the medications made him feel,
it made him feel 'lazy'."

(18) What was SFC Card's religion and was SFC Card active in any religious
programs? If so, when was the last time he saw a religious professional? Did SFC Card
ever seek out a chaplain or was he ever command referred to a chaplain during military
service?

(a) SFC Card's listed religion is Baptist Churches; Other595

(b) There was insufficient information to determine the last time SFC Card saw a
religious professional or if SFC Card was referred to a command chaplain.

(19) Did SFC Card communicate a threat of suicide or homicide? If yes, then
answer the following: (a) To whom did SFC Card communicate the threat? (b) When
and where did he communicate the threat? (c) Was/were the communication(s) written ,
spoken, or nonverbal? (d) Was the chain of command aware of the suicide and
homicide threats? If yes: How did the command react to the threats (referral to law
enforcement, chaplain, combat stress team, mental health provider, other)? (e) What
was the diagnosis or opinion of these professionals if SFC Card was referred to a
medical health provider?

(a) Yes. SFC Card communicated threats, explicit and implicit, multiple times
between January 2023 and October 2023. In July 2023, SFC Card told - he
would ''take care of it" after accusing - of talking about him.

including mixed or manic episodes. Olanzapine helps to manage symptoms of mental health conditions
such as: seeing, hearing, feeling, or believing things that others do not, feeling unusually suspicious or
having muddled thoughts (schizophrenia) feeling agitated or hyperactive, very excited, elated, or
impulsive (mania symptoms of bipolar disorder).
595 Exhibit N79.

73

End. Page 0097

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(b) While a patient at Four Winds, SFC Card conveyed mood !ability/aggression,
homicidal ideations, and admitted he had a "hit list."596

(c) SFC Card did not directly communicate a threat to however,

SFC Card did tell on the way home from the Oxford Casino on 13
September 2023 that he could take out 100 people with this expensive scope he had
just bought followed by different places he could shoot up.597 Based upon this
discussion, was concerned SFC Card was going to commit a mass
shooting. Between January 2023 and October 2023, SFC Card made comments about
wanting to punch several people. He made these comments to
Additionally, in June 2023, SFC Card told
hurt him emotionally, he would kil

(d) The chain of command was aware of the threats, and they referred the threat
in September 2023 to local law enforcement in the form of letter to the
Sagadahoc County Sheriffs Office.599 - concluded his letter by saying that he
''would rather err on the side of caution with regards to Card since he is a capable
marksman and, if he should set his mind to carry out the threats made t~ he
would be able to do it."600 The chain of command did not confer with PHP which would
have revealed SFC Card was non-compliant with pursuing treatment or available
resources.

(e) Referral was made to law enforcement, not a medical health provider. SFC
Card's medical diagnosis remained unchanged after he was discharged from Four
Winds.

(20) Had SFC Card previously attempted suicide? If so, provide a history of the
attempt(s) and responses(s), indicate what circumstances led to those previous
attempts.

There is no record of any previous suicide attempts by SFC Card. He had

previously denied having attempted suicide or having suicidal ideations.601

596 Exhibit E1 pg. 5.

597 Exhibit B10. This specific information was not included on warning of a shooting to the
Chain of Command.
596 Exhibits 836, 838.
599 Exhibits 83, B7.
600 Exhibit J2.
601 Exhibits E1 , B15 pg. 2, 830 pg. 2.

74

End. Page 0098

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(21) Provide a complete accounting of SFC Card's medical and behavioral health
interactions dating back to 1 January 2020.

(a) SFC Card completed his Periodic Health Assessment (PHA) on 16 November
201 9, 15 January 2021 , 19 October 2021 , and 2 January 2023.602

(b) There is no mention of any additional medical or mental health care sought,
planned, or completed until his Emergency Department visit to KACH and transfer to
Four Winds on 16 July 2023 after being ordered to undergo a Command Directed
Behavioral Health Evaluation.603

c. Prior to the Incident.

(1) From 15-28 July 2023, SFC card was ordered to perform AT at Camp Smith,
New York. While at AT, when did SFC Card begin showing signs of mental distress?
What did the command do in response? Please be as detailed as possible.

(a) SFC Card began showing signs of mental distress immediately upon arriving
at Camp Smith. The command allowed SFC Card to sleep overnight and reengaged
him in the morning.

(b) The ultimately ordered a Command Directed

Behavioral Health Evaluation. See Section 3.i. July 2023.

(2) On or about 15 July, SFC Card received care for his mental distress at Keller
Army Community Hospital (KACH), West Point, NY. (a) What was his diagnosis? (b)
What information did KACH give to SFC Card's Chain of Command regarding his
condition? (c) What information did KACH provide to the civilian mental health facility,
Four Winds Hospital?

(a) The medical providers at KACH coded the visit as "Primary- R45.850
homicidal ideations, Secondary-unspecified psychosis not due to a substance or known
physiological condition." Medical records list the provider at KACH as
Keller Army Community Hospital confirmed that
. This diagnosis of homicidal ideations on 16 July
2023 was the first time any medical professional formally documented that SFC Robert
Card was noted as potentially homicidal.

602 Exhibits E6 - E9
603 Exhibits 815, E1 , 83.

75

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(b) completed a request for a Command Directed Behavioral Health

Evaluation (CDBHE). KACH only provided with a copy of the DA 3822. 604

(c) KACH provided Four Winds with the following documents: Consent to
Transfer; DA Form 4700, lnterhospital Patient Transfer Form; EKG; 002870,
Authorization of Disclosure of Medical or Dental Information; and the Sitter Brief,
Medical Necessity Certification Statement for Non-Emergency Ambulance Services.605

(3) When was SFC Card admitted to Four Winds? (a) What medical diagnosis
did SFC Card receive at Four Winds? (b) How long was this care provided? (c) How
much information about this care did Four Winds provide with SFC Card's chain of
command?

(a) SFC Card was transferred from KACH and admitted to Four Winds on 16 July
2023. 606 SFC Card received care from Four Winds from 16 July 2023 to 3 August 2023
for a total of 19 days.607

(b) SFC Card received Individual Therapy, Group Therapy, Medication, Art
Therapy, Family Therapy, and Recreation Therapy. He also received psychological
testing.608

(c) After he was transferred to Four Winds, SFC Card was diagnosed with Brief
Psychotic Disorder, with no secondary diagnosis listed. The diagnosis from Four Winds
was based on the results of psychological testing, and therapy. At discharge from Four
Winds, SFC Card was diagnosed with "Brief psychotic disorder" by •
-- - - - - - - -- - -
and
- - -
- -
receiving care as a patient at Four Winds, SFC Card was also referred for psychological
testing to assist in differential diagnosis and treatment planning. At that time, the
diagnosis under primary consideration was "unspecified schizophrenia spectrum or
other psychotic disorder."610

(d) Four Winds did not provide with any information regarding SFC
Card's diagnosis, prognosis, or discharge instructions. Compounding matters, neither
nor- maintained any contact with KACH following SFC Card's

604 Exhibit B3.

605 Exhibit E1 pgs. 84-89.
606 Exhibit B3.
60 7 Exhibit E1.
608 Id. at pgs. 3, 54-71.
609 Id. at pg. 3.
610 Id. at pg. 54.

76

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AFRC-OPI (8008-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

discharge from Four Winds. ~ believed llllwould not "be given any
information due to HIPPA (sic). "

(4) Was Four Winds providing updates to KACH on SFC Card's care? If so, how
often and to whom? If so, was KACH providing this information to SFC Card's Chain of
Command?

(a) Four Winds provided updates to KACH. indicated

"KACH and Four Winds met every Friday to discuss patients and meetings were held on
7/21 and 7/28." also indicated that participated
on behalf of KACH and participated on behalf of Four Winds. According
to keeps tabs on the meeting and patients."612

(b) indicated the only update received from KACH regarding SFC
Card's care was that SFC Card was still at Four Winds around 25 or 26 July 2023.613
said "during that week someone from Keller contacted - on
approximately 25/26 July. I can't recall the name, but it was a female representative.
She told me that SFC Card was still at Four Winds Hospital and Keller and Four Winds
were communicating during a weekly meeting they have for referred patients."614

(5) What actions did SFC Card's Chain of Command take while he was
hospitalized?

(a) On 17 July 2023, •

- 104th Training Division, received the CCIR related to SFC Card's
hospitalization and forwarded it to
- 108th Training Command.

(b) On 27 July 2023, the 31304th placed SFC Card on a medical ADOS-RC order.
did not visit SFC Card at Four Winds
was told SFC Card was not
accepting visitors and thought not have access to health information due to
HIPPA (sic)."616

611 Exhibit B3.

612 Exhibit B30.
613 Exhibit B3.
6U Id.
615- -
616 ~

77

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(c) assumption was incorrect. DoD Instruction 6490.08 was

enacted to balance patient confidentiality rights with the commander's need to make
informed operational and risk management decisions within the Military Healthcare
system. Authorized activities for which Protected Health Information (PHI) may be
disclosed to a commander include, but are not limited to, fitness for duty determinations,
fitness to perform a particular assignment, or the service member's ability to carry out
any other activity essential for the military mission. Accordingly, would
have been able to receive information from KACH that was received from Four Winds
during their weekly meetings.

(d) This information was available to because mental health

services were obtained because of a Command Directed Behavioral Health Evaluation.
gave a valid military order for SFC Card to undergo the evaluation.
Conversely, Four Winds considered SFC Card's hospitalization to be voluntary, because
involuntary hospitalization typically requires a court order. The military and civilian
constructs are incongruent. Therefore, had the ability to request and
receive PHI related to SFC Card's mental health treatment that was sent to KACH from
Four Winds as well as be involved with and receive updates from the KACH behavioral
health provider. Further, DoDI 6490.08, paragraph 3.3 directs that "the commander
should aim to interact and cooperate with the provider in a manner that does not breach
confidentiality as described in this instruction. This interaction should occur with the
intent of building partnerships, enabling, and encouraging Service Members to feel
comfortable in obtaining care via self or medical referrals while furthering the successful
accomplishment of the military mission." While Four Winds may not have disclosed
information directly to , they certainly provided information to KACH for the
purposes of treatment, and billing/reimbursement
- - ----
from TRI CARE. KACH in turn would
have provided that information to

(e) - called Four Winds a_sking to visit SFC Card but was told that SFC
Card was not accepting visitors. gained contact information for SFC Card's
~re~~ )
and passed that Information to asked the
care team if SFC Card needed anything, to which they replied he needed pants, a
hearing aid charger, and shoes. • subsequently voluntarily delivered
these items. 617 never followed up with

617 Exhibits 87, 842.

78

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(f) instituted a no-alcohol policy upon first

learning of the incident involving SFC Card and - because he mistakenly
believed SFC Card 's aggression was caused by excessive alcohol. 618 Further, he "relied
on. : and the NCOs to handle it as he was 300 miles away."6 19

(g) On 3 August 2023, notified - (104th Training Division

Suicide Prevention ) of SFC Card's discharge from Four Winds. They
did not discuss a treatment plan .

(6) When did SFC Card's command depart West Point at the end of its annual
training?

Based on mission requirements, there were staggered orders for different groups
of Soldiers. 021

(7) Was SFC Card's AT order extended to provide him additional care? Was this
the proper mechanism to obtain treatment for SFC Card beyond his initial annual
training period?

(a) On 27 July 2023, IAW 10 U.S.C. § 12301(d), the 81st Readiness Division
placed SFC Card on Active Duty Operational Support-Reserve Component (ADOS-RC)
orders for an additional six days for "MEDICAL APPTS -ADOS HOSPITAL STAY."623
The 81 st Readiness Division's issuance of these extension orders do not appear
inconsistent with the USARC G-1 Standard Operating Procedure for Active Duty
Medical Care, dated 30 December 2022.624

(b) I was unable to determine why SFC Card's orders were only extended for six
days; whether the unit issued orders based off Four Winds release date, or whether
Four Winds discharged SFC Card based off the date his orders were ending.

(8) What were the discharge instructions by Four Winds for SFC Card? Did they
provide these instructions to SFC Card's chain of command or KACH? If not, did the

6 18Exhibit B6.
619 /d.
620 Exhibit B14.
621 Exhibit B3.
622 Exhibit B7.
623 Exhibits R15, B12. 10 U.S.C. § 12301(d) provides that a member of a reserve component may, with

the consent of that member, be ordered or retained on active duty.

624 Exhibit 036.

79

End. Page 0 103

AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

Chain of command or KACH seek information from Four Winds on SFC Card's
discharge instructions, prognosis, need for follow on care etc.?

(a) SFC Card was discharged from Four Winds at 1355 on 3August 2023. The
Discharge Summary indicated that "SFC Card received Individual, Group, Art, Family
and Recreation Therapies. The discharge diagnosis was noted as "F23 Brief Psychotic
Disorder." His abilities to attend to activities of daily living, day to day ability to attend
work/school and family/peer interaction are noted as "fair." His ability to access
treatment after discharge is noted as "poor". He was discharged without appointments,
with a note of "referrals pending."625

(b) The Discharge Summary further noted that SFC Card "appeared to be
resistant to psychoeducation throughout treatment when discussing presentation of
symptoms. He often appeared to place blame on others for his behaviors, stating that
'they were messing with me."' At the time of discharge, he denied any auditory or visual
hallucinations. At the time of discharge, he did not demonstrate a "risk of harm to self or
others. "626

(c) Four Winds did not share the discharge instructions with SFC Card's chain of
command which was customary based on the referral relationship through TRICARE.
Instead, Four Winds faxed the Discharge Summary to KACH on 11 August 2023, eight
days after SFC Card was released.627 This document was not uploaded by KACH into
the military medical system until 21 August 2023.628

(d) did not seek information from Four Winds after

SFC Card was discharged.629

(9) Did SFC Card's chain of command maintain contact with KACH following
SFC Card's discharge from Four Winds? If not, why not?

(a) command team did not maintain contact with KACH

following SFC Card 's discharge from Four Winds.

(b) did not follow up with KACH after SFC Card's discharge
because he "did not think that he would be given any information due to HIPPA (sic)"630

625 Exhibit E1 pg. 4.

626 Id. at pg. 7.
627 Id. at pg. 2.
628 Exhibit E1.
629 Exhibit B3.

80

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

( 10) What other agencies / commands with the Army Reserve were monitoring
his care and communicating with SFC Card? Please provide the 5Ws for every
communication. What did these agencies do after SFC Card was discharged from Four
Winds?

(a) Aside from the chain of command, the other agencies that were monitoring
SFC Card's care were KACH, the ARMMC ,631 and the PHP.632 The following is a
summary of their activities:

(b) On 20 July 2023, was assigned the case and issued

a 90-day Behavioral Health profile for SFC Card, restricting his access to his assigned
weapon.633 instructed to touch base with the command to
determine SFC Card's status. 634 sent an email informing him
that SFC Card was issued a profile and followed up the email with a phone call. Despite
the indication that spoke directly with that day, in our interview
with him, told us that he "missed the e-mail on 20 July 2023" and that he

630 Exhibit B3.

631 ARMCC provides case management for Soldiers with a deployment-limiting medical condition.
ARMMC tracks and manages all USAR P3/P4 profiles using a team of providers, team leads, nurse case
managers, and patient administrative assistants working with individual Soldiers and units.
ARMMC's Mission Statement and Scope: Supports United States Army Reserve (USAR) commands and
provide case management for Soldiers with a deployment limiting medical condition. Centralized
management and tracking of all profiles received from Army Reserve Soldier's or Logistics Health
Incorporated (LHI}. Centralized location for MEB/NDPEB/MAR2 packet building and submission into the
Disability Evaluation System (DES} and the Major Subordinated Commands (MSC). Centralized location
for review of USAR SRU packets./ The case management team consists of Providers, Team Leads,
Nurse Case Managers, Patient Administrative Assistants, the Soldier, and the Soldier's Command/Unit.
The AR-MMC staff tracks and manages all USAR (TPU/} P3/P4 profiles. The case management team
works collaboratively with the Soldier, the Commander, the Psychological Health Program (PHP),
Deployment Health Assessment Program (DHAP}, the Health Services Branch representative (HSB), and
other internal and external stakeholders to ensure the highest quality of service is provided to the Soldier.

632 PHP is an Army Reserve-specific program designed to facilitate behavioral health services for Soldiers
and family members who need them. PHP Mission Statement: To achieve and sustain the most resilient
and mentally fit Reserve force in the Nation. We will accomplish this by facilitating behavioral health
services for Soldiers and family members who need them. Assist operational leadership through
Command consultation, preserving unit cohesion through traumatic event management, and developing
enduring partnerships with sister organizations.

633 Exhibit E1 pg. 4.

634 Id.

81

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

did not see it "until after October 26."635 then stated he "did not recall"
what the profile stated. 636

(c) On 7 August 2023, (KACH) entered a note into SFC Card's military
medical record. Specifically, noted SFC Card's care as "continued ."637

(d) On 7 and 8 August 2023, unsuccessfully attempted to reach SFC

Card by phone. On 8 August 2023, assigned as
SFC Card's provider.638

(e) On 11 August 2023, Four Winds finally faxed SFC Card's discharge summary
to KACH. This document was not uploaded into the military medical system until 21
August 2023.

(f) On 11 August 2023, (PHP) spoke to SFC Card by phone. SFC

Card expressed his frustration since being discharged due to limitations on his ability to
purchase new weapons. SFC Card admitted problems with anxiety but no anger
problems or safety issues. SFC Card denied any suicidal or homicidal ideations. SFC
Card reported a NCM contacted him about starting his virtual therapy which he planned
to start soon. and SFC Card discussed phone applications he could use at
home and his behavioral health profile.

(g) On 25 August 2023, - (ARMMC) emailed SFC Card, cc'ing 1111

- asking SFC Card for a status report to update SFC Card's profile. SFC Card
did not respond.

(h) On 28 August 2023, unsuccessfully attempted to call SFC Card

to follow-up and provide support. noted in the record that if SFC Card did
not respond by 31 August 2023 his case managemenVcare with PHP would be
terminated in accordance with PHP standard operating procedures.

(i) On 31 August 2023, - - - closed SFC Card's case. PHP would reopen
the case if SFC Card e s t a b l i s ~39

635 Id.
636 Id.
637 Id. at pg. 18.
638 Id. at pg. 20.
639 Exhibit E1.

82

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

0) On 26 September 2023, - again emailed SFC Card, cc'ing Ill

- asking SFC Card for a status report to update a SFC Card's profile. SFC Card
did not respond _64o

(k) On 17 October 2023, - contacted and requested a

profile extension for SFC Card of his own accord (without having heard back from SFC
Card). - requested the profile extension to allow SFC Card more time to
obtain/submit BH documentation.641

(I) On 17 October 2023, extended SFC Card's behavioral health

profile for an additional 90 days. directed to encourage SFC
Card to seek care if he was not already doing so. also directed _
to seek assistance from SFC Card's chain of command if SFC Card continued to be
unresponsive.642

(m) On 19 October 2023, - unsuccessfully attempted to reach SFC Card

by phone to inform him his profile had been extended. - followed up with an
email to SFC Card, again cc'ing .643

(n) On 23 October 2023, - sent an email to SFC Card, again cc'ing Ila
- notifying SFC Card that his case had been reassigned to a new NCR. 644

(o) On 24 October 2023, (ARMMC) contacted SFC Card by phone.

SFC Card hung up the phone after identified herself and asked to speak with
SFC Card. - called SFC Card again, but SFC Card sent the call to voicemail.
- left a message to return her call. 645 - followed up with an email to
SFC Card, again cc'ing , notifying him that she was his newllll'.646 She
also unsuccessfully attempted to call ' to seek his assistance with SFC
Card. - concluded her review of SFC Card's records on 24 October 2023.647

(11 ) Was SFC Card entitled to follow-on care following his release from Four
Winds? If so, did he receive follow-on care? Did these agencies provide any information
regarding SFC Card's care or communications following his discharge to SFC Card's

640 Id.
64 1 Id. at pg. 2.
642 Id.
643 Id.
64-4 Exhibit E1 pg. 1.
645 Id.
646 Id.
647 Id.

83

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AFRC-OPI (800B-15-6b2}
SUBJECT: Findings and Recommendations, Army Regulation (AR} 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

chain of command. If not, why not? What entities within the Army were responsible for
providing follow-on-care and monitoring SFC Card following his release? Were
appropriate procedures followed in regard to follow-on-care?

(a) SFC Card was entitled to follow-on care after his discharge from Four Winds.
On 2 August 2023, - documented that she spoke to at Four
Winds. 648 She noted that SFC Card withdrew his 72 hour request for discharge and that
his court appearance was cancelled. - documented that SFC Card would be
discharged at 1100 on 3 August 2023 with the discharge plan to have Telemynd for
psychiatry and psychology."649

(b) SFC Card did not receive follow-on care. According to Four Winds personnel,
at the time of discharge, they reached out to Telemynd for the status of SFC Card's
referral. Telemynd explained that patient appointments were still pending. They were
informed that an appointment can be given, and that the patient has been given all of
the necessary information to schedule a follow up appointment. Four Winds personnel
were subsequently informed by Telemynd that SFC Card had not set up an appointment
and had not checked his email which contained instructions on how to create an
account and to schedule an appointment. Four Winds personnel continued attempting
to connect Telemynd and SFC Card for a conference call to arrange for follow-on
care.650

(c} None of these communication failures were conveyed to SFC Card's chain of
command. Based upon statement, KACH does not admit or track Soldiers
who are on orders for 30 days or less. 651 Therefore, KACH was not following up on SFC
Card's care. Furthermore, Four Winds noted that the medication card for SFC Card
would be completed by West Point Behavioral Health.652 Follow-up appointments were
not completed by Four Winds upon SFC Card's discharge. It appears that Four Winds'
discharge of SFC Card was lacking any follow through regarding medication
management or adequate arrangements for SFC Card's follow-on care. Four Winds
believed KACH would follow up. KACH was not tracking SFC Card's care because he
was not on orders for more than 30 days. As a result, no one adequately followed up on
SFC Card's discharge care. Although Four Winds indicated that they had spoken to
SFC Card's- regarding discharge,
- SFCCard's

648 Jd. at pg.17.

649 Jd.
650 Exhibit E1 pg. 5.
651 Exhibit B34.

652 Exhibit E1 pg. 12.

84

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

1. SFC Card's
was concerned about his becoming aggressive when he consum~s alcohol. -
also told Four Winds personnel that and that SFC Card could not
return to . 653 SFC Card's -
however, Four Wfnds released SFC Card
anyway.

(d) During SFC Card's stay at Four Winds, - noted that he was admitted
to Four Winds Hospital due to reports of psychosis, mood !ability/aggression, HI
(homicidal ideations), patient endorses having a "hit list", paranoia and AH (auditory
hallucinations).654 Despite the disturbing information regarding a "hit list," Four Winds
discharged SFC Card without an adequate plan for follow-on care or notification to the
chain of command or proper authorities regarding the potential danger SFC Card
posed. I defer to Walter Reed on whether Four Winds met the standard of care.

(e) I cannot emphasize strongly enough the results of testing noting

that "psychotropic medication use may be somewhat limited," that SFC Card is "unlikely
to see himself as having any problems for which psychotherapy would be appropriate,"
and his "prognosis for significant change must be considered guarded."655 -
also noted that according to his test results, SFC Card "does appear to be at greater
risk for violence throughout the course of his lifetime."656 I defer to Walter Reed on
whether the results of this testing should have resulted in continued in-patient treatment,
transfer to long-term treatment, and urgent notification directly to SFC Card's chain of
command.

(f) I was unable to conclude by a preponderance of the evidence that Four Winds
attempted to invoke New York's Safe Act or if it reported to New York state officials that
SFC Card was "likely to engage in conduct that could seriously harm the patient himself
or others." Regardless, SFC Card was a transient and not a resident of the state.
Nonetheless, the facts surrounding SFC Card's discharge are suspect.

(g) SFC Card requested release from Four Winds on or about 26 July 2023, and
a court hearing was scheduled in accordance with New York state law for 2 August
2023. However, SFC Card rescinded his request, and the court hearing was cancelled.
Nevertheless, Four Winds released SFC Card anyway, without utilizing the court

65 3 Id. atpg. 6.
654 Id. at pg. 5.
655 Id. at pg. 60.
656 Id. at pg. 60.

85

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

hearing procedures. This suggests Four Winds may not have followed the appropriate
procedures.

(h)ARMMC and PHP provided information to . On 21 July 2023 , ■

. In addition to the initial 20 July 2023 email,
.
emailed or copied on 25 August 2023, 26 September 2023, 17
October 2023, 19 October 2023, and 23 October 2023. On 24 October 2023 ,
called and emailed ,
otherwise, he would have seen SFC Card was not cooperating or receiving treatment.

(i) Although received or was copied on emails to SFC Card multiple

times, he claims he did not see any of the emails until after 26 October 2023.657 111
command team did not maintain any contact with KACH following SFC
Card's discharge from Four Winds. claims his only update regarding SFC
Card's care was that SFC Card was still at Four Winds around 25 or ~6 ~uly 2023.658 It
appears that is referring to the 21 July 2023 text from . He

-
does not acknowledge any of the other communications from ARM MC,

(j) KACH was responsible for providing an adequate hand-off to SFC Card's
chain of command for his follow-on care and monitoring. KACH BH failed to properly
close out the case with SFC Card's military leadership. The Four Winds discharge
summary clearly noted that the West Point Behavioral Health department was
responsible for the medication follow up.659 Four Winds also noted a referral to therapy
would be provided through Telemynd, a virtual provider.660

(k) Appropriate procedures were not followed regarding SFC Card's follow-on
care. Four Winds did not appropriately note KACH's role in SFC Card's follow-on care,
as KACH would not be responsible for managing SFC Card's medications. Although
KACH technically followed its procedures for not providing follow-on care for Soldiers on
orders for 30 days or less, we recommend that those procedures be modified to
incorporate continuous follow-on care for Reserve Component Soldiers until a hand-off
with the command is completed.

(I) It appears that ARMMC followed their procedures. Despite PH P's procedures
proving to be inadequate, the members of the PHP followed the procedures that were in

657 Exhibit B3.

658 Jd.
659 Exhibit E1 pg. 12.
660 Id.

86

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

place at the time. While ARMMC and PHP are not explicitly required to provide care,
only give a status on profiles, or provide resource recommendations for care,
respectively, both organizations also failed to make adequate attempts to advise SFC
Card's chain of command of the serious diagnoses and warning signs in his medical
chart. This is of grave concern given ARMMC's and PHP's unrestricted access to SFC
Card's medical files. Both programs lacked an enforcement mechanism beyond
informing of SFC Card's non-compliance.

(12) What were the circumstances surrounding the physical altercation between
and SFC Card on 13 September 2023? Please provide the 5Ws.

(a) On 13 September 2023, SFC Card and ~ decided to go to the

Oxford Casino located in Oxford, Maine, to gamble and drink. During the ride home
from the casino, SFC Card began to repeat "they are ruining my life" and started to get
very angry. He also described "places" where he believed that people were talking
about him and got angry about those as well. 662

(b) Shortly thereafter, SFC Card began to accuse of talking about

him, and then he began to punch the steering wheel and shouted, "Shut the fuck up!"
SFC Card then punched in the face.

(c) At that point, began "to put two and two together" regarding
SFC Card's deteriorating mental health.663 As an excuse to get out of the car, llr
- told SFC Card that he wanted to get a pack of cigarettes and asked him to pull
over at a nearby gas station. When got out of the car, SFC Card said he
was "done with" , and left him at the gas station. 664

(13) On 15 September 2023, sent a text message to

indicating SFC Card threatened a mass shooting at the unit's Reserve Center. (a) What
exactly did the message say? (b) What actions did the command take in response? (c)
Were CID or the Insider Threat Hub notified once the command received a potential
threat to the organization/installation? If not, why not? (d) Were these actions
appropriate considering the threat and mental health history of SFC Card?

(a)At 0204 on Thursday, 14 September 2023, texted -

and : "You up i have something to report. Change the passcode at the unit

661 Exhibit B36.

662 /d.
663 /d.
~ Id.

87

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

gate and be armed if sfc (sic) card does arrive. Please. I believe he's messed up in the
head. And threaten the unit and other places. but I do not know how to
help him, and he refuses to get help or continue help. I'm afraid he's going to fuccck
(sic) up his life from hearing things he thinks he heard. When i dropped him off he was
concerned his weapons were still in the car. I beleive (sic) they were at the unit. And no
one searched his vehicle on federal property. And yes, he still has all of his weapons .
. I believe he's going to snap and do a mass

(b) directed - to request the Sagadahoc County Sheriff's

Office conduct a well-being check on SFC Card to gauge his mental health and decide
whether he was a threat to himself and/or others.666

(c) did not contact either CID or the Insider Threat Hub667 because
he "did not think of it at the time."668

( given the nature of the alleged

verbal t and SFC Card were described as -
- . Based on the length and
scope of their friendship, was the person best equipped to provide an
accurate warning about SFC Card. However, downplayed
warning about the mass shooting, informing the Sagadahoc County Sheriff's Office that

mid-September warnings, given the pattern and

lengthy reporting of SFC Card's dangerous threats.669
-
. While lllf

665 Exhibits B36, J2.

666 Exhibits B7, J2.
667 The Army Insider Threat Program is outlined in Army Regulation 600-20, Army Command Policy,
paragraph 5-18. It requires commanders to ensure compliance with reporting requirements for information
related to insider threats.
668 Exhibit B3.
669 Exhibit K39.

88

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(14) Was SFC Card absent from battle assembly for September and October of
2023? If so, what did his unit do in response? Was SFC Card coded as U- unexcused
for the IDT periods? Did the chain of command attempt to contact him?

(a) SFC Card was coded as unexcused absence (U) for the September and
October 2023 Battle Assemblies.

(b) SFC Card was angry about the circumstances of his hospitalization during AT
in July 2023. He relayed to that he had his 20-year letter and wanted to
retire .

did provide retirement information to SFC Card through

the , coded SFC Card as a "U" for both the September
and October Battle Assembljes. did not attempt to reach SFC Card for
the October Battle Assembly but did speak with him briefly on the phone the day prior to
the September Battle Assembly.

(15) Did SFC Card receive a profile for his mental health issues? If so, for how
long and by whom? If so, was the fact that he was the subject of a profile ever
communicated to SFC Card or his unit? If so, was this profile ever extended? If so,
why? Obtain a copy of the profile if one exits.

(a) SFC Card received a profile for his mental health issues on 20 July 2023 for
90 days.

(b) On 20 July 2023- emailed SFC Card and informing

them that ARM MC created a profile for SFC Card. We have no indication SFC Card
confirmed receipt of his profile.

(c) In addition to the email sent to SFC Card and spoke

to on the phone and informed him of the profile on 20 July 2023.

(d) On 17 October 2023, , extended

671
the profile for 90 days. Based on the Army Reserve Medical Management Center
(ARMMC) Behavior Health SOP criteria for profiles, the Nurse Case Manager shall
ensure the Soldier and Commander understand that the profile will be automatically

670 Exhibits B3, L2, L3.

671 Exhibits ES, B25.

89

End.Page0113
AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

extended up to one year at which point a Medical Evaluation Board or Non-Duty

Physical Evaluation Board process may start. ARMMC did not receive any information
related to SFC Card's behavioral health status and because there was no contact
between ARMMC and or SFC Card, extended the profile.

(16) Did the chain of command have any communication with local law
enforcement regarding SFC Card? If so, provide the 5Ws on each communication.

The chain of command had communications with law enforcement on the

following days; descriptions of these incidents are discussed at length above: 672

3 May 2023 - Sagadahoc County Sheriff's Office

4 May 2023 - Sagadahoc County Sheriff's Office
16 July 2023 - New York State Police
14 September 2023 - Ellsworth Police Department
15 September 2023 - Sagadahoc County Sheriff's Office
25 October 2023 - Various Entities - Identified SFC Card as the Shooter

d. The Incident.

(1 ) What was SFC Card's duty status from 24 October 2023 to 28 October 2023?

(a) SFC Card was not in a duty status from 24-28 October 2023.

(b) SFC Card's last day in a duty status was his last day of active-duty orders
(ADOS-RC) on 3 August 2023, the day he was discharged from Four Winds. The unit
did not have a Battle Assembly in August 2023. SFC Card did not attend the September
or October 2023 Battle Assemblies.673

(2) How, when, and where did SFC Card die?

(a) The Office of Chief Medical Examiner of the State of Maine determined that
SFC Card's death be ruled a suicide which took place on 27 October 2023. The exact
time is unknown. His body was found at 1945 by law enforcement at the Maine
Recycling Corporation (trailer storage annex), Lisbon Falls, Maine.

672 Exhibits B7, H12.

673 Exhibits l3, N32.

90

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(b)According to the medical examiner, SFC Card died due to a single perforating
self-inflicted gunshot wound- .674 The toxicology report did not reveal any
findings of toxicological significance other than the presence of caffeine and nicotine.675

(3) Where and when did SFC Card get the weapon(s) used to carry out his
apparent suicide? What weapons were used?

(a) There is no database in the State of Maine for privately owned weapons. It
would difficult to track down each individual firearm purchase from licensed (03FFL)
firearms dealers and private purchases/transfers. However, open-source media reports
indicate SFC card legally purchased the three weapons (two rifles, one handgun) to
conduct the mass shooting and commit suicide at a Cabela's and two local gun shops in
2012, 2018, and July 2023_a16

(b) Two weapons were found with SFC Card's body; a Smith and Wesson M&P
.40 caliber handgun, located to the right of the body, and a Smith and Wesson M&P AR-
15 style rifle, found under the body, with the muzzle visible to the left side of the body.6n
An AR-10 style Ruger SFAR .308 rifle was found in his abandoned Subaru Outback at
the Lisbon Falls boat ramp.678 Multiple reports indicate he owned a large number of
weapons ( 10-15) and was identified as a collector of various types of firearms.679
Accord ing to , the Maine State Police confiscated all weapons from SFC
Card's house and at the scene of the crime. 680

(4) Who were the last people to speak with SFC Card before the suspected
suicide ? (a) What was discussed? (b) What did that person observe or hear, what did
that person think or perceive about SFC Card, and what actions did that person take?
(c) Did his family and/or friends report his behavior prior to the suicide? If so, for what
reason? To whom? What was the response?

(a) was the last known person to have any communication with
SFC Card via text message. last contact with SFC Card occurred on 13
October 2023. She texted him, '
681
SFC Card responded , "Well tell me where this fucking shit

674 Exhibit E2.

675 Jd.
676 Exhibit TT.
677 Id.
678 Exhibit T1, T6.

679 Exhibits B36, 838, H6.

680 Exhibit K43.
681 Exhibit C 10.

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AFRC-OPI (800B-15-6b2}
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

online is."682 She never heard from him again. 683 told us she believed that
SFC Card's mental health was declining fast. She responded to SFC Card by telling him
that he was "experiencing delusions to make you think it is real. Please trust me when I
say it is not real."684

(b) On 27 February 2024 and 15 March 2024, (Maine

State Police) confirmed that a forensic audit (Cellebrite), was conducted on SFC Card 's
cellphone, but he was unwilling to provide me with a copy of the examination results
until completion of their investigation and with permission from state authorities.685
These results will provide greater understanding of who SFC Card spoke with during the
last two weeks of his life.

5. Regulatory Requirements: Did commanders at echelon adhere to the requirements

of AR 600-92 (Army Suicide Prevention Program)?

a. A preponderance of the evidence indicates the Army took prudent actions

regarding suicide prevention and monitoring based on the evidence available prior to
SFC Card's death. Additionally, the Army responded appropriately to the report of SFC
Card's death by initiating this investigation into his suspected suicide in accordance with
the requirements of AR 600-92.

b. The key piece of information to remember when evaluating the actions of the unit
and the Army in retrospect is that both KACH medical professionals and Four Winds
medical professionals wrote in their paperwork that SFC Card had no history of suicidal
ideations, nor did he have any current intent to harm himself or others. He was rated a
"very low risk" for such behaviors.

c. Army Regulation 600-92 (Army Suicide Prevention Program) became effective on

8 September 2023. Before that, Department of the Army Pamphlet (DA Pam) 600-24,
(Health Promotion, Risk Reduction, and Suicide Prevention) and Army Directive (AD}
2023-12 (Ask, Care, Escort (ACE] Suicide Prevention Program) guided the Army's

682 /d.
68 3
Exhibit B21 .
684Exhibits B21 , C10.
685A Cellebrite extraction reviews and analyzes the digital data on a cellphone. - - - only
verified that a forensic audit was conducted and did not offer to share the r e s u l t ~ a v e
confirmed if- was indeed the last person to communicate with SFC Card. There is no information
which confirms whether SFC Card had contact with others after 13 October 2023. An interview with his
employer at the time (First Fleet Inc.) may have provided additional context on SFC interactions with
others during the last two weeks of his life.

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

suicide prevention and response efforts. Each of these documents were considered
during the course of this investigation.

d. Generally, Reserve Components (RC) only have access to/authority over their
non-mobilized Soldiers for about 38 calendar days of military service per fiscal year,
compared to year-round access for the Active Army. The applicable law which covers
the jurisdiction of RC commanders over assigned Soldiers is 10 U.S. Code§ 802 - Art.
2. 686 It states "Reservists: A member of the Reserves is subject to the UCMJ while
performing Inactive Duty for Training (IDT), Active Duty for Training (ADT), or active
duty. Accordingly, all offenses committed by a reservist while on active duty, IDT, or ADT
may subject the reservist to discipline, including NJP. Personal jurisdiction over
reservists performing IDT includes travel to and from their IDT training site, intervals
between consecutive periods of IDT on the same day, and intervals between IDT on
consecutive days." The above 1 January 2019 amendment to the Uniform Code of
Military Justice primarily closes the gap in authority or jurisdiction a RC commander has
when a Soldier travels to and from a home of record and a duty location or the time
1
between consecutive Battle Assemblies (drill days). In effect, would have
had command authority over SFC Card only until he arrived at his home of record at
, Bowdoin, Maine on the evening of 3 August 2023. - would
have only had command authority over SFC Card during IDT periods such as the
September and October 2023 Battle Assemblies.

e. This results in a lack of jurisdiction for periods when Reserve Soldiers are in a
non-duty status. Therefore, we considered command and leadership regulations to
guide evaluation of the gap in access to Soldiers between the Active and Reserve
Components. Because Army Reserve commanders do not have year-round access to
their Soldiers, their ability to fully "encourage Soldiers to seek assistance if they are
experiencing challenges or mental health issues" (AR 600-92, 1-33) or facilitate the
"safe storage of lethal means" (AR 600-92, 1-33) is limited.

f. DA PAM 600-24 and AR 600-92 sugges

, their jurisdiction over SFC Card was

limited to the monthly Battle Assembly. An Active-Duty commander would have had
many tools at their disposal to accomplish these goals, from providing escorts,

686 See 10 USC 802.

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regu lation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

scheduling medical appointments, and even requiring SFC Card to move onto a military
reservation and surrender his weapons to a unit arms room.

g. However, a different standard applies to the USAR. SFC Card was a civilian and
the USAR did not have jurisdiction nor authority over him in that capacity. Ill
- jurisdiction over SFC Card was limited to periods of Active Duty, or Inactive
Duty Training (IDT). Additionally, the USAR has to articulate a legitimate military
purpose in order to order a Soldier onto active duty, as such, the ability to order SFC
Card onto a military reservation was limited. There is no authority to order him to
surrender his weapons.

they were limited by

authority and access. SFC Card was command directed to undergo a behavioral health
evaluation. He was then committed to a civilian hospital for 19 days and given
medication to aid him in his condition. Following his discharge, members of his unit
made sure he got home, and they stayed in touch with him to see how he was doing.
called, called called and visited,
from KACH called him about follow-up treatment, and from the
Reserve Psychological Health Program called and informed him of the resources
available to him. SFC Card failed to respond or turned down almost every offer of
assistance or care, as was his right as a civilian. Multiple members of the unit reached
out to SFC Card's to try and deliver support as well. Ultimately,. .
- was limited to AT and IDT periods (38 statutorily required calendar days per
year) to compel attendance for Behavioral Health treatment.

(2) According to AR 600-92, could have formally requested SFC

Card voluntarily store his weapons in a safe location (possibly the Saco USAR Center).
- ask SFC Card to voluntarily store his privately owned weapons.
Ralhe~ stated: "I did not talk to him under assumption that
made arrangements with SFC Card's to get the weapons and
safeguard them. I don't know if it was or someone else who would remove the
weapons. I did not personally talk to , and I did not follow up on it."687 -
- is mitigated, however, because even if he did ask SFC Card
to store his weapons and SFC Card said no , would not have had the
authority to confiscate the weapons nor order SFC Card to reside on a military
reservation to control his access to weapons.

687 Exhibit B3 pg. 6.

94

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AFRC-OPI (8008-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

g. The 104th Training Division, a higher unit in charge of SFC Card's unit, had a
current policy on suicide prevention from February 2023. 688 However, this policy was
not renewed between the time AR 600-92 became effective and SFC Card's death, a
period of approximately one month. As such, a new requirement in AR 600-92, which is
the Suicide Prevention Liaison, was not yet implemented, which may have aided
communication between the various entities involved in SFC Card's care. This is not
unusual due to the short time between the events under investigation and the publishing
of the new regulation , and it should not reflect negatively on the unit or the unit
leadership.

h. A unit in the Army is not just one person, it is a team. That team is usually led by a
command team, and there are levels of hierarchy between Soldiers and their command
teams. As mentioned earlier, multiple individuals in the unit attempted to stay in contact
with SFC Card, or to inquire after his wellbeing , after he departed Four Winds Hospital
and returned to his civilian life. Members of the unit were in contact with SFC Card's
- because SFC Card had proven so difficult to reach. regularly spoke
with SFC Card's , and he even reached out to SFC Card's ~ oJry to
determine if SFC Card's behavior in July 2023 was normal, but SFC Card's- would
not talk with him nor anyone in the unit.

j. Further, refer to Additional Finding 2, below, which describes in detail actions taken
by the unit and actions that local law enforcement failed to take which may have
prevented SFC Card from doing what he did.

k. Finally, according to , the Suicide Prevention

, would come to the unit and give suicide prevention/awareness
classes. SFC Card was at most of these.689

688 Exhibit 06.

689 Exhibit B8.

95

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

I. Overall, SFC Card 's unit was in the difficult position of having no authority over a
non-cooperative Soldier, and their actions were compliant with AR 600-92. The unit was
under the impression that SFC Card was acting strangely, but medical professionals
had determined that SFC Card was a "very low risk" of harm to himself or others, and
the actions undertaken by unit personnel were, based on the information available at
the time, prudent. When information came to the unit's attention that indicated
immediate action needed to be taken, members of the unit reached out to local law
enforcement with all the information they had to try to get the entity with actual
jurisdiction to handle the problems identified.

6. Additional Findings.

a. Additional Finding 1. I am unable to determine, by a preponderance of the

evidence, what caused SFC Card to commit the mass shooting and suicide. As such, I
have requested assistance from Walter Reed National Military Medical Center. The
assistance will help determine what mental condition, disease, or defect caused SFC
Card to act as he did. Additionally, an expert may help determine if there is a nexus
between SFC Card's paranoia and auditory hallucinations and his hearing aids, the
purported mass on his head, or the concussive force of yearly training (annual two-week
AT periods} on the grenade range.

b. Additional Finding 2 . I find by a preponderance of the evidence that if Sagadahoc

County Sheriff's Office (SCSO) had fully executed their health and welfare check on
SFC Card in September 2023, then the mass shooting and suicide may have been
avoided. Courts have, in the past, refused to find that law enforcement's failure to police
would lead to a shooting.690 Therefore, I cannot apply a traditional proximate cause
analysis to determine who bears responsibility for SFC Card's criminal actions.691
Regardless, I find SCSO had the last, best, chance of impacting SFC Card's actions.
scso was the law enforcement agency with jurisdiction over SFC Card.
(1 reported SFC Card's behavior to Maine law enforcement in
May 2023, which was documented by of the SCSO in Deputy
Report for Incident 23-006566. 692 That report resulted in action by the SCSO to meet
with SFC Card's to discuss the situation and formulate a plan for how to

690 https:l/www.americanbar.org/groups/tort_trial_insurance_practice/publications/the_brief/2019-
20/winter/liability-mass-shootings-are-we-a-tuming-point/
691 Proximate cause is defined as "a cause that directly produces an event and without which the event
would not have occurred." See Black's Law Dictionary 91 (3d ed. 2006).
692 Exhibit J1.

96

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

address the - concerns about SFC Card. The information delivered to SCSO,
among other things, was that SFC Card began hearing voices and exhibiting paranoia
in approximately January 2023. Additionally, SFC Card had exhibited what appeared to
be deteriorating mental conditions and had recently picked up 10-15 handguns/rifles
that had previously been stored at SFC Card's - house.
took this information and reached out to - ·v,a·voicemai
called back, he and discussed the situation regarding SFC Card at
length, and • concluded the call stating he would immediately reach out to ~
- to figure out options to get SFC Card help.693

(2)Additionally, called _ , SFC Card's - and they

discussed the situation at length. stated he was not aware that SFC Card had
retrieved his weapons, but that SFC Card's paranoia/anger started around the same
time he got his hearing aids .. . also said that SFC Card had messaged him that day
stating he was going to get a lawyer to deal with the people accusing him of being a
pedophile. followed up by leaving a voicemail for _ _

noted that he followed up with the - on 4 May

2023, and the reported that when they visited SFC Card, he answered the door
with a gun, talking about people outside casing his house. also
delivered this informationi to - via voicemail, and later that day called
him back. noted their plan was to sit down with SFC Card to figure out what
was goi informed - that SFC Card had answered the
with a gun, and the call ended. However, while - told
the USAR would work with SFC Card to get him help, the SCSO had
legal jurisdiction over SFC Card and should have continued to determine a reasonable
course of action to mitigate the threat during the spring and early summer 2023. And
while there is no indication that any of SFC Card's leadership,
, discussed the jurisdiction issue with law enforcement, the SCSO
should have been aware the USAR did not have legal authority over SFC Card when he
was in a non-duty status.

(4) On or about 15 September 2023, approximately four months later. -

received a report from , one of SFC Card's only friends, that SFC Card
had punched him and that SFC Card said he was going to commit a mass shooting.
- then reported SFC Card's July 2023 hospitallzatlon and
warning of SFC Card's threat to the SCSO. was so concerned, he went
through official channels Ellsworth Police Department. Not onty did
- seek guidance from , an unbiased individual, he explained his

693 Exhibit J1 , B7.

97

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

concerns in a letter that was reviewed and validated by the Ellsworth Police Department
prior to requesting formal assistance from the SCSO. Based on the report in May, SFC
Card's admission to a psychiatric hospital in July, and this new threat reported byl l l
- SCSO may have had enough information to take SFC Card into protective
custody and implement the next step in Maine's ''Yellow Flag Law. n However, I defer to
legal experts on Maine law to opine definitively on whether SCSO had probable cause
to employ the Maine Yellow Flag Law. However, scso failed to meaningfully confront
SFC Card about the recent and ve detailed information the received from

in requesting formal assistance from the SCSO. Further

SFC Card's actions to SCSO failing to conduct a meaningful welfare check.

(5) , in response to report, unsuccessfully

attempted to contact SFC Card on 15 September 2023. returned
on 16 September 2023 at about 0845 hours and discovered SFC Card was home.
requested backup and 45 minutes later
of the Kennebec County Sheriff's Office arrived to assist. 695 Both deputies then
attempted to contact SFC Card. 696 The deputies could hear SFC Card moving around
inside his trailer, but he would not answer the door. 697 The deputies ultimately decided
to leave the property "due to being in a very disadvantageous position." 698 Based on the
deputies' actions, they were clearly fearful, perceived SFC Card to be a threat, and
should have requested additional backup. Had they taken SFC Card into custody that
day, they likely would have been able to invoke Maine's "Yellow Flag Law" and apply for
a court order to get SFC Card's firearms temporarily taken away. Instead, the SCSO
and KCSO officers departed the scene, and after a discussion with , did
not confront SFC Card. They wrote a report saying they were going to, essentially,
ignore a letter from a fellow law enforcement officer that delivered information about an
eye-witness account of a threat to commit a mass shooting. Further, given SFC Card's
adversarial response to New York State Police questions on 16 July 2023, stating,
"they're scared I'm going to do something, because I am capable," it is highly likely that
if SCSO forced an interaction with a larger police presence in mid-September, SFC
Gard likely would have responded in a similar confrontational manner, resulting in his
arrest.699

694 Exhibit K39.

695 Exhibit J2 pg. 4.
696 Jd.
697 Id.
698 Jd.
699 Exhibit TT.

98

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regu lation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

(6) It was unreasonable for to believe and the

USAR exercised dominion and control over SFC Card such that their actions would
supplant a need for local law enforcement. It was also unreasonable to believe that SFC
Card had been divested of all weapons, regardless of what told him. The
report made by - clearly indicated that SFC Card was a danger to others, and
that he had, as recently as 48 hours before, expressed to at least one other person that
he had his guns and was going to shoot up the drill center at Saco and other places.
This information was conveyed by - ~ ~ SCSO via letter, documented in
Deputy Report for Incident 23-015694. - 700 included that had
been assaulted by SFC Card the night prior and was the one that had warned him SFC
Card was going to commit a mass shooting.

(7) Maine law enforcement's failure to take substantive action on

report was unreasonable.- attempted to do the right thing. Any reliance on the
military to handle this matter was also unreasonable because the Army did not have
jurisdiction nor authority over SFC Card in his civilian capacity. - was directed
by the Ellsworth Police Department to keep his professional distance from SFC Card
and allow the SCSO to handle interactions with SFC Card.

c. Additional Finding 3. I find , by a preponderance of the evidence, Four Winds

released SFC Card under questionable circumstances; however, I defer findings to
Walter Reed on whether SFC Card's treatment or discharge from Four Winds were
within the standard of care.

(1 ) There are conflicting reports resulting from the testing and the provider's
observations on whether SFC Card required continued care, either at Four Winds or a
higher-level facility. I am unable to determine exactly why SFC Card was released on 3
August 2023. SFC Card was command directed to Four Winds; however, Four Winds
considered SFC Card's hospitalization as voluntary. While hospitalized and under the
influence of medication, SFC Card informed Four Winds he wanted to leave the facility
because he believed there was nothing wrong with him. However, the facts indicate that
based on observation and testing, Four Winds believed SFC Card should remain
hospitalized and scheduled a court date in order to receive a court-ordered hold of SFC
Card. SFC Card rescinded his request to leave the facility. Nevertheless, Four Winds
released SFC Card anyway, despite noting SFC Card likely needed continued care,
including possibly, a higher level of care. It is unclear whether SFC Card was released
on 3 August 2023 because his orders were terminating, or if any attempt was made to
extend SFC Card's orders for the purposes of treatment, as there was no evidence that

7()() Exhibit J2.

99

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 AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

Four Winds queried KACH about extending the orders. It is unclear why SFC Card's
orders were only extended for six days; whether the unit issued orders based off Four
Winds release date, or whether Four Winds discharged SFC Card based off the date his
orders were ending. As discussed above, SFC Card was possibly released without the
required discharge instructions.

(2) KACH Behavioral Health (BH) Department bears culpability as well. KACH
BH's standard procedures do not include the case management of Reserve Component
Soldiers on orders for less than 30 days_Nevertheless,
became aware of SFC Card's

d. Additional Finding 4. I find by a preponderance of the evidence that even ifl l l

- had done everything correctly, the USAR wou ld have had limited jurisdiction
over SFC Card, and he would have remained under the jurisdiction of the local
authorities.

( 1) It is clear the actions of the chain of command were lacking in April - June
2023. For the sake of argument, if had sent a CCIR for the May 2023
incident, SFC Card likely would not have been placed on AT orders. If SFC Card was
not required to conduct an AT in July 2023, he would not have been hospitalized at Four
Winds_A Line of Duty Investigation would not have been required . SFC Card could have
retired from the USAR based on his twenty-years of service and would have been the
responsibility of the local authorities.

(2) If SFC Card had received a Line of Duty determination in July/August 2023
and a Medical Evaluation Board, he may have been extended on Active Duty. Absent
indefinite hospitalization, I cannot conclude that he would have responded to treatment.
At some point in time, SFC Card would have been released and wou ld have either
voluntarily or medically retired. SFC Card could have also refused disability processing
in lieu of his twenty-year retirement. In this scenario, SFC Card would still have been
the responsibility of the local authorities.

(3) If had submitted a CCIR or called the Insider Threat Hub in

September 2023, the USAR still had no enforcement mechanism and limited jurisdiction
over SFC Card. could have ordered SFC Card to attend behavioral health
treatment during Battle Assembly; however, options were limited during
periods where SFC Card was voluntarily absent from BA, such as in September and

701 Exhibit E1.

100

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AFRC-OPI (8008-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

October 2023. Again, SFC Card would have been the responsibility of the local
authorities.

e. Additional Finding 5. I find by a preponderance of the evidence that Army Reserve

Medical Management Command (ARMMC) staff was derelict in their duties. AR MMC
created the initial profile and extension of that profile for SFC Card. ARM MC -
- accessed the discharge summary portion of SFC Card's record in the medical
system on 22 and 25 August, 22 and 26 September, and 17 and 19 October 2023.
Given

f. Additional Finding 6. I find by a preponderance of the evidence that the

Psychological Health Program's (PHP) standard operating procedures were inadequate.

( 1) SFC Card's case should not have been closed due to unresponsiveness. We
recommend that their procedures be modified so that PHP is required to report to the
command any time they are unable to contact the Soldier before terminating behavioral
health facilitation. We further recommend that before services are terminated, the
command acknowledges, in writing, understanding of their responsibilities and the
process.

(2) had the opportunity to review SFC Card's discharge summary for
approximately seven days {21 - 28 August 2023) from the day it was uploaded to JLV
until the day she closed the case in MEDCHART. However, she did not access JLV after
11 August. She spoke to SFC Card on 11 August. He reported some frustration based
on limitations with his weapons, but no anger. She attempted contact again on 28
August with no response. Based on the PHP SOP, by not having any response from
SFC Card, she closed the case without notification to SFC Card's command leadership.
Our finding is the PHP SOP does not sufficiently support effective communication nor
provide adequate emphasis to a Soldier's command leadership.

7. Recommendations.

a. Strategic/Long Term.

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AFRC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

( 1) I recommend you forward this investigation to the Director, Defense Health

Agency: 702

(a) Pending the expert opinion of Walter Reed on whether Four Winds met the
standard of care, I recommend DHA consider removing Four Winds as an authorized
treatment facility, in accordance with Title 32 to the Code of Federal Regulations Part
199 (32 CFR 199).703 If the Director, DHA, determines a provider committed fraud or
abuse as defined in this part, the provider shall be excluded or suspended from
CHAM PUS/TRI CARE for a period of time determined by the Director. Abuse can include
care of an inferior quality. For example, consistently furnishing medical or mental health
services that do not meet accepted standards of care. In this case, Four Winds appears
to have conducted testing of SFC Card beyond the typical standard of care. However, if
Walter Reed determines Four Winds treatment did not meet accepted standards of care
based on the manner SFC Card was discharged, then there would be a basis for the
Director of DHA to remove them as an authorized facility. It is unclear why Four Winds
released SFC Card on 3 August 2023. SFC Card requested discharge on or about 27
July 2023. Four Winds scheduled a court hearing to keep him hospitalized which was
scheduled for 2 August 2023. SFC Card rescinded his request for release.
Nevertheless, Four Winds released SFC Card the day after the cancelled court hearing.
Overall, the manner in which SFC Card was released causes significant concern
regarding Four Winds adhering to the standard of care.

(b) I recommend DHA consider terminaUng the contract of Spectrum Services

Group, Inc. for cause.

The stopped the

crttical information fliow to other KACH team members and all levels of SFC Card's
chain of command. The critical information included SFC Card's resistance to
psychoeducation. SFC Card's - told Four Winds when they called her during her

702 The Defense Health Agency manages authority, direction, and oontrol of military hospitals and clinics
worldwide. DHA also manages the DoD health plan - TRICARE. The Director organizes, directs, and
manages the OHA and all assigned resources, including the administration of all OoO medical programs.
OoDD 5136.13, Defense Health Agency, 30 Sept 2013.
703 The Code of Federal Regulations (CFR) is a codification of the general and permanent rules published
in the Federal Register by the Executive departments and agencies of the Federal Government, including
policies and procedures published by the Defense Health Agency (DHA) on the delivery of health care.
Title 32 is for National Defense. Part 199 covers the Civilian Health and Medical Program of the
Uniformed Services (CHAMPUS).

102

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AF RC-OPI (800B-15-6b2)
SUBJECT: Findings and Recommendations, Army Regulation (AR) 15-6 Investigation
into the Suspected Suicide of SFC Robert R. Card II

stay, that "he could not return to

She also stated that the majority of his firearms were
stored in gun safe. Th [s statement would point to the fact that some of the
guns were still in his possession or at an unknown location. SFC Card was discharged
without a scheduled follow up plan for behavioral health or medication management
appointments.- noted that she spoke to SFC Card on 11 August 2023. Her
note indicated progression of aggressive tendencies. He reported no follow up care at
this time. This information is not noted to be forwarded to SFC Card's chain of
command. There was a ten-day delay from Four Winds faxing the document on 11
August 2023 until it was entered into the military medical record system on 21 August
2023. On 30 January 2023, I requested assistance from the Keller Army
Health Hospital, Specifically, I requested all Quality Assurance
inquiries conducted by the hospital or by the Defense Health Agency regarding its care
of SFC Card. Additionally, I asked for the Quality Assurance Surveillance Plan (QASP)
for- and Spectrum Services Group, Inc. On 2 February 2024,
provided a QASP for "the month SFC Card was treated at facility."7
However, the note from
11 August 2023 combined with the information included in the discharge summary dated
11 August 2023 is a critical oversite in coordination of care and monitoring.
did not agree to or partidpate in the interview process. I find that

(c) I recommend requesting the Director, DHA, provide a copy of this

investigation to the Reserve Affairs Office at DHA for lessons learned and how to
strengthen case management of USAR Soldiers.

7~ Exhibit K3 7.
705Additionally, although not rising to the level of obstruction, thEalllllllllll. KACH, surreptitiously
requested an attorney from DHA travel to West Point for our i n t e ~ C H staff. To avoid a direct
confrontation in front of witnesses, I allowed the civilian DHA counsel to sit in on one interview. However,
due to what I perceived to be a chilling effect on the witness's forthrightness, I instructed the civilian
counsel to leave the room.

706The DHA Medical Q-coded Services Task Order Performance Work Statement for Registered Nurse-
Behavioral Health Case management dated 07 JUN 2022 contains the following requirements:
Provide nursing expertise about 1he CM process, including assessment, planning, implementation,
coordination, and monitoring. Identify opportunities for CM and identify and integrate local CM processes.
Maintain liaison with appropriate community agencies and organizations. Establish mechanisms to
ensure proper implementation of patient treatment plan and follow-up post discharge in ambulatory and
community health care settings. Provide appropriate health care instruction to patient and/or caregivers
based on identified learning needs.

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(2) I recommend that you direct USARC Force Management to lead a working
group to assess whether the current USAR Warrior Transition Support Program (WTSP)
adequately supports the Army Reserve. The WTSP currently provides continued
collaboration of efforts with the Army Recovery Care Program (ARCP), MEDCOM,
Mobilization Force Generation Installations (MFGI) and USARC that focuses
involvement throughout the process of addressing and resolving issues encountered by
USAR Soldiers as they navigate through their comprehensive recovery plans. The
WTSP currently has Soldier Readiness Unit (SRU) coordinators and MFGI coordinators
that are USAR Soldiers on ADOS orders. The working group should determine if the
WTSP functions primarily in an administrative nature and if so, should it transition to an
operational role, directly supporting units and their Soldiers during a mental health
crisis. I recommend the working group considers the addition of 28 personnel (14x
03/04 67D (Psychologist) or 73A (Licensed Clinical Social Worker) and 14x E7/E8 68X
Behavioral Health Specialists) to the program. The shift to an operational focus by the
WTSP and the addition of clinical providers allows for enhanced coordination between
the treatment locations and better support to USAR Soldiers and their commands.

(3) I recommend you direct USARC Force Management to conduct an analysis of

the impact of establishing a USAR Behavioral Health Liaison, geographically/regionally
based to manage multiple MTFs and SR Us. Liaisons may remain members of their
parent unit while performing collateral duties for USAR commanders, and supporting
Soldiers dealing with mental health issues or may be a full-time AGR/ADOS.

(4) I recommend you direct the USARC Deputy Chief of Staff for Operations (G-
3/5/7) to lead a working group consisting of the G-1 , G-33, and Surgeon to assess
whether the current USA RC Serious Incident Reports (SIR) and Commanders Critical
Information Requirements (CCIR) listing (OPORD 23-032, Annex B, (Feb 20241)
provides sufficient consideration for mental health/behavioral health issues, which could
lead to acts of self-harm or violence against others. Of the twenty-three (23) SI Rs and
thirty-one (31) CCIRs, no single reportable incident allows commanders/leaders to
inform senior USAR leadership of a mental health issue for a TPU Soldier in a non-duty
status, not requiring hospitalization. Given the prevalence of mental health issues
throughout the military and the likelihood these issues will not abate over time, a
specific incident tailored to a mental health criteria or event could provide early warning
of possible mental health-related threats. In SFC Card's case, a CCIR for the 3 May
2023 event in whictalllllll reported to law enforcement - delusions and
threats of violence may have provided more visibility and opportunity for the chain of
command to direct an appropriate response sooner.

b. Operational/Short Term.

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into the Suspected Suicide of SFC Robert R. Card II

(1) The USAR averaged 44 suicides over the past four calendar years, which
necessitates a better response to mental health. 707 Therefore, I recommend you direct
USARC Force Management to lead a working group to assess courses of action for
establishing Behavioral Health sections (Behavioral Health Officer-67D, Army Social
Worker-73A and BH Specialist- 68X) down to the Brigade level across all USARC Major
Subordinate Commands (MSCs}. Currently, the USARC only authorizes 67D/68X for
select operating force MSCs (MIRC, 200th MP Command, Engineers, Chemical etc.) at
Brigade and higher and Army Reserve Medical Command (ARMEDCOM) units at
Detachments and higher. I recommend behavioral health sections be considered at
generating force MSCs as well. Specific roles and responsibilities would be defined by
the working group analysis but should include management of all mental health related
CCIRs in their commands. This provides oversite and tracking, inter and intra-unit action
lanes and situational awareness capabilities in medical and mental health related
CCIRs. In concert with a recommendation to reform the USAR Warrior Transition
Support Program, a more comprehensive system will be in place to support Soldiers
with behavioral health conditions and provide better tools and guidance for their
respective chains of command.

(2) I recommend you direct a working group (G-3/7, ARRTC) be created to

assess whether the current USAR CCFSC and BBPCC attendance policies place
sufficient emphasis on completion and define consequences (possible removal from
command, etc.) for failure to complete. Further, recommend the working group assess
whether any current iteration of the pre-command training (USAR and Active Duty
provide sufficient blocks of instruction on behavioral health and mental health, as well
as associated issues, including HIPAA responsibilities, commanders' legal authorities for
TPU Soldiers at civilian treatment centers, commanders' legal authorities during
Command Directed Behavioral Health Evaluations and during a mental health crisis in a
non-duty status.

c. Tactical/Near-term.

(1) I recommend you take appropriate administrative action

767In Calendar Year (CY) 20 - 42 suicides, CY 21 -46, CY 22 - 38, CY 23 - 48, CY 24 YTD - 9.

708After in-depth consultation with my legal counsel, prior to conducting any witness interviews, I
determined I would not provide rights warnings under Article 31, Uniform Code of Military Justice, to any
witness. At the time, I did not suspect • ■ any- -witnes.s of
committing any misconduct. Even after my initial interviews. I did not suspect misconduct. Upon
completion of my in1,1estigation, reviewing a totality of the circumstances.

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See Manual for Courts-Martial, United States (2019 ed.) [MCM], pt. IV, ,r 18.c.(3).
710 Exhibit 83.

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112 Id.
713 Exhibits B36, J2.
714 Exhibit E1 , p. 32.

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715 Exhibit 836.

716 Exhibit K42.

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(3) I recommend you take appropriate administrative action

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(4) I recommend you take appropriate administrative action

719 Exhibits B8, B22.

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into the Suspected Suicide of SFC Robert R. Card II

(5) I recommend you thoroughly review the actions of the chain

of command, specifically, , the 104th
Training Division Commander, BG Kristina Green, and the 108th Training Command
Commander, MG William Dyer. I recommend you consider whether their actions
constituted the appropriate level of oversight of SFC Card's hospitalization and release
in July/August 2023, with the understanding the level did not
report the May 2023 incident, update the July 2023 CCIR upon SFC Card's release in
August, or report the September 2023 incident. When I asked - if she or her
command team sought information from Four Winds on SFC Card's discharge
instruction, prognosis, or need for follow on care,
reported to me that they believed they were not
privileged to this medical information due to HIPPA (sic) and SFC Card not signing a
release of of (sic) information for them." There are no indications the chain of command
sought guidance from their serving Legal Advisor or Command Surgeons. Nevertheless,
and MG Dyer are attorneys. 721 At the very least, some members of the
chain of command should have known of the command exception to HIPAA and the
command's authority to request PHI from KACH as part of the Command Directed

720 Exhibit B36.

MG Dyer attend Samford University. Cumberland School of Law and has been a Judge Advocate fn the
United States Army Reserve since 1992. Under command, all four of his battalion
commanders have attended the PCC.

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AFRC-OPI (800B-15-6b2}
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into the Suspected Suicide of SFC Robert R. Card II

Behavioral Health Evaluation. If you determine the command's actions were not
appropriate given the circumstances, then consider taking administrative action. 722

(6) I recommend you direct mandatory refresher training for all Command Teams
and Legal Advisors for the entire 108th Training Command on HIPAA. Commanders at
echelon and their Judge Advocate Legal Advisors may have a misunderstanding of
information they are authorized to receive under the command exception to HIPAA.
Commanders should receive more training that what is provided at the BBPCC.

(7) I recommend you direct the USARC Surgeon to update the current
Psychological Health Program (PHP} Standard Operating Procedures to close out the
Soldier's file (case) by providing a final out brief to unit commanders at the lowest level
and ensuring battalion or higher commanders receive a copy of the out brief. This would
apply to all PHP cases (Soldier discharge, ETS, transfer to IRR, IMA, and/or veteran
status). In SFC Card's case, the case was closed due to SFC Card's failure to make
contact with the PHP.

(8) I recommend you direct the Army Reserve Medical Management Command
(ARMMC) update its current Standard Operating Procedures to close out the Soldier file
(case) by providing a final out brief to unit commanders at the lowest level and ensuring
battalion or higher commanders receive a copy of the out brief. This would apply to all
ARMMC cases (Soldier discharge, ETS, transfer to IRR, IMA, and/or veteran status)

(10) I recommend USARC policy for the submission of CCIRs/SIRs be updated

such that if a CCIR/SIR is submitted for a behavioral health issue it should trigger an
immediate Command Directed Behavioral Health Evaluation (Unless ETP is written and
approved) and a Line of Duty Evaluation (as needed) is initiated. And the MSC surgeon
and lowest unit surgeon or behavioral health officer at echelon should follow the CCIR
through close out.

8. Additional considerations. Based on time constraints, willingness to participate in

the investigation, or other factors, the following are outstanding/unresolved issues:

a. Understanding - has no regulatory or contractual obligation to participate

in this investigation, I requested the Contracting Officer who manages the contract for

722 I do not conclude the chain of command's actions constitute dereliction of duty; therefore, I defer
findings on whether their actions qualify as adverse information as defined in AR 15-6 Section II Terms.
As such, I am not referring this investigation tol I, BG Green, or MG Dyer for a response for the
purposes of the Army Adverse Information Program referenced in AR 15-6 or Army Directive 2023-03. If
you, as the Approving Authority determines that- . BG Green, and/or MG Dyer were derelict in
their duties, I recommend notifying them of their due process rights outlined in AR 15-6.

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into the Suspected Suicide of SFC Robert R. Card II

DHA to request a contract modification with Spectrum Services Group, Inc. to require
- to participate in our investigation. The Contracting Officer declined to make
the req uested modification.

b. On multiple occasions, I requested but never received the Maine State Police
reports, which included interviews with other witnesses we needed to interview and
other forensic information about the last days of SFC Card 's life.

c. Interviews with witnesses:

(1) Individuals at Maine Recycling Corporation. Of interest would have been SFC
Card's harassment claims of Maine Recycling employees calling him a pedophile or that
he had a small penis. In general, I would have asked the Maine Recycling
whether SFC Card potentially experienced any significant harassment
that would have exacerbated his mental health issues.

(2) First Fleet Trucking, Inc. Of interest would have been his work schedule
during September and October. SFC Card worked at First Fleet, Inc. -
- I would have asked management about any potential work-related issues
SFC Card may have experienced that would have exacerbated his mental health
issues.

(5) Four Winds Hospital. I attempted to arrange interviews w ith

employees at Four Winds Hospital,
Katonah, NY. , at Four Winds responded to our
request and explained that absent a "proper waiver from whoever owns Mr. Card's

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into the Suspected Suicide of SFC Robert R. Card II

rights (presumably, an estate) or a court order, [Four Winds) are by law not permitted to
disclose any more information than we already have, which is the discharge summary
that Four Winds provided to the referent, Keller Army Community Hospital."n3 These
medical professionals are most familiarized with physical and mental care SFC Card
received and could provide a situational understanding with information surrounding
these incidents. I would have also asked Four Winds why they released SFC Card on 3
August 2023. SFC Card requested discharge. Four Winds scheduled a court hearing to
keep him hospitalized which was scheduled for 2 August 2023. SFC Card rescinded his
request for release. Nevertheless, Four Winds released SFC Card the day after the
cancelled court hearing.

d. On 12 January 2024, I requested the expert assistance of

- Forensic Psychology at the Walter Reed National Military Medical Center.

(1) I provided him with our preliminary exhibits on 19 January 2024. Upon
completion of our investigation, I submitted all exhibits to for his expert
opinion on a Root Cause Analysis and Forensic Autopsy.

(2) In addition, I made a supplemental request to for his expert

opinion for SFC Card's Line of Duty determination and to determine if SFC Card's
condition was exacerbated by his military service in July 2023.

(3) I defer findings, pending the results of Walter Reed 's evaluation, on whether
Four Winds met the standard of care, or whether mental health treatment could have
prevented the mass shooting and/or suicide. Based on the testing administered by Four
Winds, I believe SFC Gard should have remained hospitalized in July/August 2023
rather than being released after a brief 19 days; however, I defer to the expert medical
opinion of providers at Walter Reed. Although he was unresponsive to treatment
(therapy and medication) during his hospitalization, I cannot predict how SFC Card
would have responded to continued treatment. Additionally, I acknow1edge that anything
short of indefinite hospitalization would have still exposed the public to SFC Card at
some point in time. Again , I defer to the experts at Walter Reed to provide an opinion on
whether SFC Card's mass shooting and suicide could have been prevented.

f. Boston University. On 6 March 2024, the Card Family released the results of
Boston University's study of SFC Card's brain. 724 The Boston University Chronic
Traumatic Encephalopathy (CTE) Center determined SFC Card's brain showed
degeneration in the nerve fibers that allow for communication between different areas of

723 Exhibits E, I.
72-' Exhibit TS.

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into the Suspected Suicide of SFC Robert R. Card II

the brain, inflammation, and small blood vessel injury. Boston University could not
conclude whether SFC Card's exposure to concussive forces as a grenade range
instructor caused his injury. SFC Card's records do not indicate any significant brain
trauma occurred while in a duty status, indicating SFC Card's injury occurred during a
non-duty status, and not related to his military service. I defer to the experts at Walter
Reed on whether they can draw a connection to SFC Card's brain study and his
potential exposure to concussive forces.

8. The point of contact for th is memorandum is the undersigned at

Investigating Officer

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