An independent investigation of the response to the deadly shooting at Oxford High School in November 2021 found several communication breakdowns by first responders.

The 275-page report from Guidepost Solutions, released Monday, offers an analysis of the multi-agency response and recovery during and after the deadly shooting on Nov. 30, 2021, that claimed the lives of Justin Shilling, 17, Madisyn Baldwin, 17, Tate Myre, 16, and Hana St. Juliana, 14, and injured seven others.

The shooter, Ethan Crumbley, was sentenced in December 2023 to life without the possibility of parole. The shooter's parents, Jennifer and James Crumbley, were convicted in February and March 2024, respectively, of four counts of involuntary manslaughter in connection with the mass shooting carried out by their son. The two were sentenced in April to 10-15 years in prison, and are the first parents in the U.S. to be held responsible for a school shooting committed by their child.   

Response by Oakland County Sheriff's Office

Guidepost Solutions says that while it did not find evidence of "neglect or dereliction" by first responders, it did find breakdowns by the Oakland County Sheriff's Office in establishing a unified command, communicating practices upon entering an active shooter scene, protocols related to the division of responsibilities between school security and the school resource officer, as well as training. 

The report found that there was a 25-minute gap before a lieutenant assumed the role of incident commander. 

"During this 25-minute period, although critical objectives were met and the shooter was apprehended, there was some confusion about where resources should be directed and coordination with public safety officials such as fire/EMS was disjointed. Once command was established, law enforcement agencies were aligned with the roles needed to complete the building clears, secure the interior of the building, and create a perimeter around the outside of the building," the report noted.  

Response by fire and emergency services

The investigation found command and communications by fire and emergency services were "hindered during the incident when Oxford Fire Department fire command moved all fire communications to a different radio channel," leaving fire crews near Oxford High School unaware that the radio channel had changed and "repeatedly called command on the wrong channel, receiving no response."

Reunification process 

The report also detailed the reunification process, which took place at a local Meijer store. It was there in a store breakroom where parents were notified that their children had been killed. 

One parent interviewed felt that the "words were emotionally disconnected and significantly contributed to the continued trauma suffered," and all families interviewed said the "delayed disclosure of their children's passing, repetition of additional buses coming, and overall silence gave the impression that officers were not being forthcoming."

Guidepost Solutions also found that following the shooting, Oakland County's recovery framework was "notably underresourced and lacked structure."

Read the full report below:

Recommendations moving forward

There are 12 pages of recommendations in the report, with specific instructions for law enforcement, dispatchers, fire and EMS, school officials and the emergency management operations staff who are involved in an "active assailant" situation in Oakland County.  

Among those details: 

• Create a county-wide plan that includes clearly written policies and procedures for each local agency, and provides checklists for their teams to follow. This includes guidelines for when fire and EMS should "stage," as in wait for law enforcement directions before entering a location. 
• Understand the circumstances under which a dispatcher can declare that an "active assailant" response is needed. The conditions include three or more people shot or stabbed in a public location, with the attacker still on scene.  
• Create a policy called the "Fifth Officer Rule," spelling out that the fifth law enforcement officer to arrive at a scene is automatically the designated incident commander until otherwise relieved. An incident commander has specific duties, including reporting to dispatchers every 10 minutes on the status of the scene. 
• Ensure that school employees and law enforcement are trained on what to expect in the process of getting students reunited with families and the procedures that will be followed. 
• Ensure that alerts use clear and consistent language rather than code words during announcements, so that all those on site know whether a response is a drill or a lockdown. 
• Record critical steps in the response over the radio and in computer records, to include verbal announcements of suspect down, suspect in custody, location of command post, and location of known or suspected explosives. 
• Host a formal training session for the Oakland County Sheriff's Office and other agencies every two years to work through and discuss what to do in such instances. 

Oakland County Executive's statement on report

Oakland County Executive Dave Coulter issued the following statement regarding the after-action report: 

"Oakland County is committed to taking an open and honest look at how we respond to emergency events, including active assailant incidents like the Oxford High School shooting. The county has held a robust schedule of training for our thousands of first responders during the last 15 years, but we know that there are always lessons to be learned and ways to strengthen our response to prevent and address these tragedies. We saw on that day how our first responders reacted with dedication and courage in the face of horrifying violence, and this report reinforces their immense bravery. It also includes important insights that will help us build on the comprehensive strategies we already have in place, and we hope it will provide some long-awaited answers for the families and community."   

The report was commissioned by Oakland County and analyzes the effectiveness of first responders and the command and coordination of the response, as well as the recovery efforts for the community and the mental health of first responders. Guidepost Solutions also identified the strengths and weaknesses of existing protocols and training and provided a series of recommendations.

As part of its investigation, Guidepost Solutions reviewed 4,800 pages of documents, 450 audio and video files, as well as school and aerial footage. The group also conducted interviews with victims, survivors and their families, parents of former students, current and former faculty and staff, the Oakland County Prosecutor's Office, current and former law enforcement and fire responders, emergency management officials, mental health professionals and members of Oxford and surrounding communities, as well as a tour of the high school. 

In October 2023, Guidepost Solutions released a 572-page investigation report into Oxford Community Schools. That report found that the school district bears responsibility and failed to provide a safe environment for students.