Sgt. John M. Russell is accused of shooting and killing five soldiers at a military counseling center at a U.S. base last May in the deadliest case of U.S. soldier-on-soldier violence of the six-year Iraq war.
The shooting deaths drew attention to the issues of combat stress and morale as troops have to increasingly serve multiple combat tours because the nation's volunteer army is stretched thin by two long-running wars.
The extensive 325-page report (PDF), issued Friday and obtained by The Associated Press Tuesday, included detailed witness statements describing the events leading up to the shootings. It paints a picture of soldier less than two months from the end of his third deployment who began to show obvious signs of unraveling weeks before the clinic shootings.
The report offered a detailed step-by-step accounting of Russell's behavior and actions at Baghdad's Camp Liberty on May 11 in the hours leading up to the shootings.
But even as the report laid bare many facts in the case, it also seemed to raise more questions as dozens of pages were redacted including key materials such as the criminal investigation report, the military police report, and the report's recommendations.
The report describes a man whose problems were known and who received some counseling, yet at critical times did not appear to get the help he needed.
Russell, who faces charges of murder and aggravated assault, was on his fourth visit to a mental health clinic in Iraq when the appointment was cut short because he became "verbally noncompliant," the report stated. Clinic personnel then called the military police, who declined to arrest him and just ordered him returned to his unit.
Less than an hour later, Russell managed to grab a loaded M-16 rifle from a fellow soldier and steal a white Ford Explorer SUV. He then went back into the counseling facility and shot and killed four soldiers and one sailor.
The report describes how soldiers in other rooms in the building dropped to the floor when they heard the loud "pop" of repeated gunshots, and then scrambled out the window to safety.
In the days leading up to the incident, many of Russell's fellow soldiers had noticed that his behavior appeared to be "deteriorating," the report stated.
His fellow soldiers described him as "unpredictable and prone to anger" and sometimes evidencing "paranoia." According to one statement, Russell, who spent one of his tours in the western city of Ramadi during the height of the conflict there, said he was "sick and tired of life and believed everyone hated him."
On the morning of May 11, Russell was taken by a member of his worried unit to the clinic after being "irritable" and telling other members of his unit to "get away from me," according to the report.
The report said although the unit knew of Russell's suicidal thoughts at least 3-4 days prior to the incident, little appeared to have been done to effectively monitor him.
"There is no clear procedure or established training guidelines in any of the references for managing soldiers identified as 'at risk' for suicide or the proper way to conduct suicide watch," the report stated.
According to the statement of one of the military police officers involved in the incident, he asked Russell's company commander whether the sergeant had been on "unit watch" and what that meant.
The company commander said Russell's roommate would keep an eye on him when he was around, but that they didn't have a 24-hour watch on him until the morning of the shootings.
"I asked him why he had not been on 24 hour a day watch since he first communicated his suicidal thoughts and he replied: 'I know this sounds bad but we don't have the personnel available,"' the statement read.
A breakdown in communication also contributed to the deadly series of events. One section of the report describes how units responding after Russell stole the weapon, instead of reacting immediately, had to meet up in person to coordinate their actions because radio communication was poor.
Additionally, nobody alerted the counseling clinic that Russell had stolen a weapon and a vehicle, the report said.
Although Russell told several people he was contemplating suicide including a chaplain, and a worker at the counseling clinic, others appeared to have doubts about the seriousness of the situation.
The report also was critical of the military police who responded to the incident, saying that their policies and procedures were not sufficient.
Military police did not have enough policies to "warn and protect possible victims when informed of a credible threat," the report stated.
The U.S. military in Iraq said the "candid review" is one of the tools used by the military to prevent such incidents in the future.
"Multi-National Corps-Iraq has already implemented several of the investigation's recommendations to include a command-wide review of behavioral health care services, updates to all suicide-prevention programs, training and appointing two behavioral health advocates per battalion, and executing new procedures for dealing with servicemembers attempting and/or threatening suicide," said Lt. Col. David Patterson said in a statement e-mailed to the AP.
The U.S. military has become increasingly concerned about mental health in the ranks following a steady rise in suicides - which the Army says have increased worldwide from at least 102 in 2006 to 140 last year. As of April, the Army had reported at least 48 suicides.
Thousands of other veterans are believed to suffer flashbacks, nightmares or fits of anger as they attempt to readjust to civilian life.
On the Web:
Full Report of Clinic Deaths (PDF)