The blame around the multiple system failures involved in the case of the Parkland school shooter is painful in hindsight. The educational system failed him, the social services system failed him and the mental health system failed him. The failures are astonishing by any measure. The most egregious failures in this situation seem to be those of the government systems and agencies who are supposed to help troubled youth.  Here are the top five systems that I think should have alerted any number of government bureaucrats that this young man was a ticking time bomb with a very short fuse.  Remember, I am not an attorney or a law enforcement professional, just a blogger with common sense and a good understanding of systems and organizations and the problems they can encounter in communication and coordination.

5. Florida Department of Children and Families (DCF): The shooter had a long history of mental health concerns which were well recorded in the local Department of Children and Families and law enforcement systems. As recently as September of 2016 the shooter made his intention to purchase a gun known to the Department of Children and Families DCF) social workers who visited his home and evaluated him. On these visits, they also noted that the shooter had been engaging in self harm-cutting to be specific-and talked about being depressed. Even though the investigator expressed concern about these issues, the case was closed without further action.

4. The Mental Health System: The mental health system in Broward County, like the law enforcement system, knew this young man and his case very well. His mother, Lydia Cruz who passed away last November, assured DCF that her son was being seen by a counselor at Henderson Behavioral Health in Broward County. He had been referred to the practice by his school after being involved in a fight with another student and cutting himself. In October of 2016, Henderson’s Mobile crisis unit had been called out to the school and determined that the shooter was not a risk to himself or others and therefore could not be committed under Florida’s Baker Act. This act allows families to have family members who pose a threat to themselves or others to be evaluated by a mental health professional. DCF could have easily referred him since the shooter had been practicing self-harm in the form of cutting. His mother could have also had him evaluated under the Baker Act based on his Instagram feed when considered along with his self-harming behavior. Antonio Sanchez, an adjunct professor at Miami-Dade College and former command officer for multiple police agencies in that area, has stated in recent interviews on the topic that the self-mutilation behavior alone was a frequent trigger for enacting the Baker Act. Had that happened he would have been prevented from buying a gun.

3. The Educational System: The shooter had a discipline record in school that stretched back to middle school and only intensified over the years. He had vocal outbursts, drew disturbing images of guns and wrote that President Obama should be “burned alive and eaten”. Say what you will about boys being boys but this last piece when considered with the prior issues should have been a huge tip that something was deeply off with this child. Teachers at his Middle School banned him from their classrooms because of his behavior. Security personnel at prior schools searched his person for weapons. Some teachers were so uncomfortable with him at that age that they refused to be alone with him in their classrooms. And still, he was allowed to return to Parkland’s Majorie Stoneman Douglas High School after being in a school for students with behavioral issues.

2. The local Law Enforcement System: Local law enforcement was very familiar with this individual since they had visited his home 39 times over the past seven years. According to records of the Broward County Sheriff’s Office, the nature of the calls included “mentally ill person”, “child/elderly abuse”, “domestic disturbance”, and “missing person”. Though it is impossible to determine if all of these involve the shooter directly when considered with the other evidence from the educational, mental health and DCF systems one would think that it would be a safe assumption that the likelihood of those calls involving the shooter would be high. According to one former classmate, Brody Speno, the police were called to the shooters home almost every other week. Having known the shooter since elementary school Speno described the shooter in an interview with CNN as  “an evil kid who was always getting into trouble”.

1. The Federal Bureau of Investigation (FBI): Possibly the most egregious red flag that was missed was a report to the FBI in January of this year when a person close to the troubled teen warned the FBI that he would “get into a school and shoot the place up” according to an FBI memo detailing the call. The caller also explained that the shooter had the “mental capacity of a 12 to 14-year-old” despite his chronological age being 19. She continued on to say that the shooter had previously been discussing his desire to kill himself and that he had recently started expressing a desire to kill other people on social media. The caller continued to detail the shooters past cruelty to animals, including the dismemberment of a bird that he “threw onto his mother’s kitchen counter and started cutting it up”. When his mother asked what he was doing the caller explained the shooter had replied: “I want to see what’s inside”. The caller expressed “that to me would be a red flag“.

According to a Wall Street Journal article on the lack of the FBI’s interest in following up on these tips, the FBI issued a statement explaining that failure to pass the call on to their field office in Miami for further investigation was a “failure of protocol”.

“Under established protocols, the information provided by the caller should have been assessed as a potential threat to life,” the FBI said. “The information then should have been forwarded to the FBI Miami field office, where appropriate investigative steps would have been taken.”

That is one very expensive violation of protocol folks. After all that violation of protocol cost seventeen souls. This one violation of protocol that none of these systems should ever end up repeating.