Officials' slow action likely cost lives of students and staff ahead of the bloodiest campus massacre in US history, an investigation into the April shooting at Virginia Tech University concluded Wednesday.
The probe by the US state of Virginia noted crucial errors by university police and officials following the early morning shooting of two students on April 16 by mentally disturbed gunman Seung-Hui Cho.
Within hours of the first deadly shootings in the West Ambler Johnston residence hall, 23-year-old Cho went on to massacre 30 students and faculty inside another building before turning his gun on himself.
"It might be argued that the total toll would have been less if the university had canceled classes and announced it was closed for business immediately after the first shooting; or if the earlier alert message had been stronger and clearer," the report said.
Particularly, the report pointed to "senior university administrators ... (who) failed to issue an all-campus notification about the West Ambler Johnston killings until almost two hours had elapsed."
In addition, the Virginia Tech police department "erred in not requesting ... a campus-wide notification that two persons had been killed and that all students and staff should be cautious and alert."
Campus police initially pursued the boyfriend of the female student who was killed, believing the incident to be domestic in nature after an acquaintance said the boyfriend was fond of guns.
Meanwhile, Cho mailed a package containing video clips, photos and a handwritten manifesto to NBC News, then made his way to Norris Hall where he chained shut the doors to the building before shooting dead 30 people inside.
The first shooting incident occurred at about 7:15 am; the second began at 9:40 am. A campus email was not sent out to students and staff until 9:26 am urging caution due to a "shooting on campus."
Some family members of those killed have demanded to know why the university did not issue a campus-wide lockdown after the first shootings.
"Warning the students, faculty and staff might have made a difference ... So the earlier and clearer the warning, the more chance an individual had of surviving," the report said.
However, it added that a lockdown was neither feasible nor was it likely to have prevented the killings.
"There does not seem to be a plausible scenario of a university response to the double homicide that could have prevented the tragedy of considerable magnitude on April 16."
Cho, who emigrated with his family from South Korea to the United States in 1992 when he was eight years old, was "on a mission of fulfilling a fantasy of revenge," it said.
Virginia Governor Tim Kaine, who appointed the eight-member panel that drafted the report, said the 147-page document provides a blueprint for Virginia and campuses nationwide to prevent similar tragedies.
"This is not a situation where you're dealing with a university that has been insensitive," Kaine told CNN.
"There's intense pain on this campus that remains five months later, and it will remain for a long time," he said. "And I think the university is very committed to making the necessary fixes. I know the state is as well."
The report also found that signs of Cho's mental illness had not been properly handled by campus officials.
"During Cho's junior year at Virginia Tech, numerous incidents occurred that were clear warnings of mental instability," it said.
Among them were complaints by female students about "annoying" and "disturbing" instant messages and phone calls from Cho as well as his violent creative writing stories in which he spun twisted plots of killing parents and teachers.
"Although various individuals and departments within the university knew about each of these incidents, the university did not intervene effectively. No one knew all the information and no one connected all the dots," it said.
Cho was briefly admitted to a psychiatric hospital in 2005 but was deemed not a danger to himself or others. He was recommended for outpatient counseling but campus counselors did not follow up for treatment.
"There's a lot of food for thought in here," Kaine told CNN.