Virginia Tech officials might have saved lives if they had given out information on the first two shootings on campus sooner, an investigating panel concluded.
The report into the April shootings that left 33 dead at the US university was released last night.
"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," said the report.
However, the report concluded that while alerts might have helped students and faculty to protect themselves or alert authorities of suspicious activity, a lockdown of the 131 buildings on campus was not feasible.
It would take 400-500 security officers to do the job, while only 14 of the school's 41 officers are on duty at 8am on a weekday, the report said.
Gunman Seung-Hui Cho was also an insider, a student with an ID card to access campus buildings and the ability to get the same messages as everyone else.
He could have gained access to a dormitory or begun shooting people in the open, the report said.
"From what we know of his mental state and commitment to action that day, it was likely that he would have acted out his fantasy somewhere on campus or outside it that same day," the report said.
The eight-member panel, appointed by Gov Timothy Kaine, spent four months investigating the worst mass shooting in modern US history.
Panel chairman Gerald Massengill declined to comment on the contents of the report when reached last night.
The report also concluded that while Cho had demonstrated numerous signs of mental instability, the university did not intervene effectively.
The governor's panel sharply critiqued the university's counselling centre, where Cho was referred for treatment in 2005 after a stretch of bizarre behaviour and concerns that he was suicidal.
The panel concluded that the counselling centre failed to provide needed support and services to Cho, due to a lack of resources, misinterpretation of privacy laws and passivity.
The report also noted that records of Cho's "minimal treatment" at the counselling centre are missing.
Cho showed signs of mental health problems as far back as middle school, the panel found.
His middle school teachers found suicidal and homicidal thoughts in his writings after the Columbine High School shootings in 1999.
He received psychiatric counselling and was on medication for a short time, the report said.
Individuals and departments at Tech were aware of incidents that warned of his mental instability in his junior year, but "did not intervene effectively. No one knew all the information and no one connected all the dots", the report said.
Cho killed the first two students just after 7am, more than two hours before his deadly rampage in classroom building across campus. It wasn't until 9.26am that the school sent the first e-mail to students and faculty.
The subject line read: "Shooting on campus." The message read: "The university community is urged to be cautious and are asked to contact Virginia Tech Police if you observe anything suspicious or with information on the case."
No further action was ordered. Cho began shooting inside Norris Hall about 20 minutes later. He later killed himself.
The protocol for sending an emergency message on April 16 was "cumbersome, untimely, and problematic when a decision was needed as soon as possible", the report said.
The first message sent by the university to students could have been sent at least an hour earlier and been more specific, but Cho likely would have found someone to kill that day, the report concluded.
"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," the report said. "Cho had started on a mission of fulfilling a fantasy of revenge."
The report said the university's emergency response plan was deficient in several respects: it did not include provisions for a shooting scenario and did not place police high enough in the emergency decision-making hierarchy. It also did not include a threat assessment team.
A university spokesman did not immediately return a call seeking comment.
Before the report was released to the public, injured students and deceased students' families received private briefings on the report's contents.
Some of the families of those killed and injured have demanded frank answers about how Cho was able to commit the shooting despite behaviour that had alarmed fellow students, faculty and police.
"My focus is why they didn't cancel the classes that day," said Suzanne Grimes, whose son Kevin Sterne was shot in the leg and survived.Reuse content