This may be one of the most important conclusions in a review of Aurora's response to the July 2012 theater shooting: "No one died who could have been saved."
However, the report does point out that several aspects of the police, fire, paramedic and public information response were problematic or could have been handled better. Among the biggest: Communication between the police and fire department command staff was inadequate. For example, fire personnel didn't know that a suspect had been arrested
Continue for a summary of the key points, as well as the full report.
The interior of the Aurora Century 16, where the shooting took place.
The shooting occurred on July 20, 2012, when a gunman opened fire inside the Century 16 theater in Aurora during a midnight showing of The Dark Knight Rises. Twelve people were killed and seventy more were wounded (though the report puts the number of wounded at 82). Suspect James Holmes was arrested at the scene.
The review was commissioned by the city of Aurora and conducted by TriData of Virginia, a public-safety consulting firm that has reviewed more than fifty such incidents, including the Columbine and Virginia Tech shootings. It was completed in April but released publicly today after the City of Aurora sought a judge's guidance on whether to do so.
TriData reviewed police reports, dispatch recordings and news stories, as well as conducted interviews with more than 180 people involved, including first responders, city leaders, hospital personnel and a handful of victims and their family members.
The review includes key findings and a total of 84 recommendations. It concludes that Aurora "should be proud of its response to the largest civilian shooting in U.S. history.... The outcome could not have been better in terms of lives saved and a rapid arrest."
Aurora Mayor Steve Hogan released a statement about the review and the actions the city has taken since the tragedy: "The important thing to remember is that we got the bad guy, and all victims with survivable injuries were saved. If you read the 170-page report, it is very clear that our responders carried out many remarkable actions that night....
"Every organization that has had to respond to an unprecedented tragedy of this magnitude knows there will be lessons to be learned, and we began making changes in programs and tactics two years ago, rather than waiting for this report."
Governor John Hickenlooper at a press conference following the shooting.
"There probably could not have been much better deployment and results than the Aurora police achieved. They deployed on the fly, with self-deployments initially, then gradually implementing more formal incident command."
The timing and location of the incident were fortuitous: It occurred during a shift change, which meant there were more officers on duty than usual, and it happened on a weeknight when there was little other police or fire activity in the city. The location was also close to a police station and to several major hospitals.
Police and fire commanders didn't establish a unified command right away and didn't effectively communicate during the first crucial minutes of the response. In addition, police and fire commanders didn't meet face-to-face to discuss what was going on.
Ambulances couldn't get to injured victims because the parking lot was full of police cars and the cars of theatergoers. Police officers couldn't move other officers' cars because the Aurora police don't use a "universal key" system.
Police officers were besieged by victims needing medical attention, but most officers "had not been trained beyond basic first aid." Several officers said they called dispatch for help in dealing with the injured victims but got no response.
The decision by police officers to transport victims to the hospital in their police cars rather than wait for ambulances to navigate the maze of the parking lot likely saved lives. Of the sixty patients transported to hospitals, 27 went in police cars.
"Police-fire personnel relations suffered for months after the incident. Some police officers openly criticized the fire department for not responding adequately to calls for rescue during the incident, without realizing the communications problem and that police did not escort fire personnel nor help fire personnel figure out how to get through the maze of vehicles (including parked police vehicles). On the other hand, the fire department did not take the initiative to adequately scout the situation and solve the access problem."
Paramedics did not use a "ribbon system" to designate which victims were deceased, which were severely injured and which had only minor injuries. This made it difficult to prioritize victims for transport to area hospitals.
The scene from James Holmes's apartment complex. He lived in the top left corner apartment.
The response to the discovery of explosive devices at Holmes's Aurora apartment was "exemplary," with the police evacuating the building's other residents and the fire department working with other agencies, including a local bomb squad and the FBI, to assess the risk and then render the devices safe.
Aurora's 911 dispatchers "successfully handled a huge volume of calls." However, some less experienced dispatchers went "by the book," asking callers the standard list of questions instead of telling them that help was on the way and moving on to the next call.
Senior management in the communications department, which handles the 911 calls, "did not comprehend the magnitude of the incident and did not come in until the following morning." This caused them to be ill-prepared to make command decisions the next day and fostered resentment among the staff, who felt that while they had "worked hard under great stress to handle the crisis, the senior managers slept through it."
The police department's media relations officers "effectively managed" the process of disseminating information to the press, setting up several timely press conferences and broadcasting the latest updates via social media.
Aurora's handling of the aftermath of the incident was "exemplary." Victim advocates set up a Family Reunification Center and the public information officers made a PIO available to every family of a deceased victim. However, it was against best practices when advocates from the district attorney's office suggested to victims that they stop working with the advocates assigned to them by the police department and work with them instead. (The review notes that the district attorney's office disagrees with this finding.)
The families of the deceased victims were frustrated by how long it took to identify their loved ones, even though the coroner took fingerprints from the victims in the theater in an attempt to ID them quicker using their driver's license records.
Aurora police chief Dan Oates addresses the media several hours after the shooting.
In the future, police and fire personnel should quickly establish an incident commander, who should announce his or her status and location on all radio channels.
The police and fire departments should practice a "unified command" system for complex incidents. That training should include procedures to ensure face-to-face contact between police and fire commanders. The report notes that Aurora has already done this.
The fire and police departments should train more officers as SWAT paramedics and dispatch them to active-shooter incidents where victims may be in the "hot zone." Luckily, in this incident, a SWAT paramedic was among the first responders to enter the theater and was able to triage some of the most critically wounded and deceased victims. Aurora reports that since the shooting, it has added two fire paramedics to the SWAT team.
Police and fire should develop procedures to keep paths open for ambulances. These could include towing civilian vehicles out of the way, having a police vehicle escort ambulances to victims, or e-mailing or texting maps of clear paths to ambulance drivers.
Police officers should be given more paramedic training, especially for gunshot wounds. In addition, they should carry more advanced first-aid kits that may include things like emergency bandages and tourniquets. The report notes that since the shooting, "a medical kit has been developed for Aurora officers."
During an incident with mass casualties, commanders should announce when the scene is safe for paramedics to proceed. If ambulances aren't available, police officers should transport victims to the hospital in their own cars, which proved life-saving in this case.
A helicopter flies over the scene several hours after the shooting.
Aurora should consider buying a drone to provide airborne monitoring of incidents such as this one. The report says some models cost less than $5,000 and "can be operated with no more skill than needed for a model airplane."
Police and fire personnel should be given more time to rest after responding to a critical incident, including allowing them to defer writing their reports.
Responders should set up a "decontamination and hydration" station for officers at critical incidents that would provide them clean water for drinking and washing, especially if they're dealing with victims who may be covered in blood.
When evacuating people from an area, such as an apartment building, have a plan for communicating with people who don't speak English. The report suggests smart phone apps that allow for quick translation and interpretation.
911 dispatchers should be empowered to "suspend the usual protocols when they are inefficient or troublesome." And procedures should be put in place to divert non-emergency calls elsewhere, such as to a city or police spokesperson.
Aurora should consider installing both police and fire radios in police and fire command vehicles to allow "continuous monitoring of each other's activities." The city should also consider buying a few satellite phones in case cell phones don't work. The report notes that after the shooting, Aurora set up a 1-800 number "to facilitate public contact with the city for inquiries after a major incident."
Public information officers should establish a "public information command post" in an area away from the crime scene and provide media with the ability to photograph police activities from a distance. Preference should be given to the local media, who have "more of a vested interest and will be covering the story for a long time."
When dealing with victims in the wake of such an incident, a single advocate should be assigned to each victim or family. That advocate should continue to work with the victim to provide continuity of care, even if other advocates join the case.
Don't allow "good-hearted volunteers without family assistance training" easy access to victims and family members. If clergy want to respond, designate an area where they can be available if victims choose to seek them out.
The city should plan for a way to receive and distribute monetary donations.
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