More than three weeks before Lauren McCluskey was killed on campus by an older man she had dated, two of her friends told staff at University of Utah dorms that they were scared about the man’s control over her, how he talked about guns and often stayed in her room.

That Sept. 30 report, and other information learned by housing officials in days that followed, was not passed to university police or campus safety advocates who may have intervened.

McCluskey began reporting her own concerns to campus officers on Oct. 12. But a formal case was not opened until Oct. 19 — and in that weeklong gap, McCluskey twice called Salt Lake City police’s dispatch line looking for more help. And even after campus police opened their case, no work happened because the assigned detective was off, and she did not return to the investigation until after McCluskey was killed.

The man who killed McCluskey on Oct. 22 was on parole, and some of her allegations — and the report to housing officials that he might have had a gun — could have led to his arrest for violations of the terms of his release. But an independent review released Wednesday found: “There was never an attempt by any of the officers involved to check his ‘offender status.’ Further, there were no policies or procedures that required such checks.”

These missed opportunities were among the shortcomings detailed in the review, ordered by U. President Ruth Watkins after McCluskey, a 21-year-old track athlete, was shot to death outside her dorm by registered sex offender Melvin S. Rowland, 37, who later died by suicide.

At a new conference Wednesday, Watkins said the report “does not offer any reason to believe” that McCluskey’s slaying could have been prevented. “Instead, the report offers weaknesses, identifies issues and provides us with a road map for strengthening security on our campus,” she said.

Former Utah Department of Public Safety Commissioner John T. Nielsen, who led the review, then specified multiple missteps the investigative team found, including the handling of reports by McCluskey’s concerned friends.

And the report described an unaccredited police force that was not trained to recognize or respond to possible interpersonal violence; didn’t know how and wasn’t expected to check on a suspect’s parole status; leaned toward communicating with victims by email or text rather than in person; conducted victim and witness interviews in its lobby; and didn’t ensure important information was followed up on when assigned officers were off duty.

Nielsen recommended that the U.’s police department hire more officers and a victim advocate; develop a working relationship with existing victim advocates elsewhere on campus; train all police staff about interpersonal violence issues and adopt a lethality assessment already used by many other Utah law enforcement agencies in such cases. The review also urged changing some basic practices — such as interviewing victims and witnesses in person, in private. Fear and anxiety are more apparent with personal contact, Nielsen said.

Watkins pledged to put the recommendations in place, including asking the Utah Legislature for funding for five new police staff, including a victim advocate.

She said campus police Chief Dale Brophy “has my full confidence,” and added he “has the ability, the talent and the commitment to lead these changes going forward.” No officers will be disciplined.

McCluskey’s parents, Jill and Matthew, did not comment Wednesday. But on Thursday, they issued a statement disputing the U.'s assertion that her murder could not have been prevented — and said they want university staff disciplined.

A halted intervention

When McCluskey’s friends reported their concerns to housing staff, it appears to have been the university’s first opportunity to step in. Housing officials are often the first to discover a student is in trouble, the review said — but in McCluskey’s case, the early attempt to intervene was blocked.

The two friends told a resident assistant that McCluskey was in an unhealthy relationship with a man who talked about bringing a firearm to campus. One of them expressed fear that McCluskey might get seriously hurt. Both said Rowland had been “practically living with her” at the dorms.

The housing coordinator responded by saying she would talk to McCluskey about the guest policy.

The next day, housing officials agreed a report should be filed with the campus safety team, but nothing ever was because the computerized system was down. As housing officials continued to talk with each other about McCluskey’s situation, they focused on whether housing rules were being broken rather than assessing her safety.

They decided “not to ‘overstep,’” the report noted, because she was an adult “in an apparently consensual relationship.” They did not contact campus police or the behavioral intervention team on campus tasked with responding to cases of abuse.

Tapping the expertise of victim advocates might have influenced their focus; the report said housing officials should involve advocates when they learn of potential interpersonal violence.

The reviewers saw a similar gap in the police department’s response.

‘Evidence of possible dangers’

McCluskey contacted campus dispatch first on Oct. 12 to report her concerns with Rowland. Days earlier, she had ended their month-long relationship after learning he had lied to her about his name and age and not disclosed that he was a registered sex offender on parole.

She said she had been getting harassing messages from Rowland, or possibly his friends, since Oct. 9, including one that told her to kill herself and another that said Rowland was dead. McCluskey was able to tell from Rowland’s recent posts on social media that wasn’t true, but campus police said there wasn’t much they could do.

On Oct. 13, McCluskey called police again to say that she received emails and texts threatening to release “compromising pictures” of her if she didn’t send an account $1,000; she said she had sent the money. She contacted police several times that day, sharing copies of messages.

U. police did not open a formal investigation until six days later. The report criticized the department for not recognizing that McCluskey was at risk based on the messages, which should have been viewed as “evidence of possible dangers” of interpersonal violence, not just extortion.

The report said the detective assigned to the case was “placed in a position for which she lacked the expertise to recognize subtle indicators of domestic violence cases.”

Because of that, it said, she never connected McCluskey to the university's two victim advocates in the wellness center. “Victim advocates should have been engaged very early on," Nielsen said.

“As we examined the totality of this troubling event,” the report said, “we discovered that there were several indications that Lauren McCluskey was in trouble. Had victim advocates been engaged, Lauren might not have been left to assess the dangerousness of her situation on her own.”

Jenn Oxborrow, executive director of the Utah Domestic Violence Coalition and one of 30 people interviewed for the university’s report, said there were red flags that were missed with Rowland’s behavior. She noted three specific things — Rowland’s stalking, the threat to release illicit photos, and his access to a firearm — that are among the top 10 risk factors experts see in domestic and dating violence cases.

Those signs are more easily spotted by people who have trained in the coalition’s “lethality assessment protocol,” Oxborrow said. Since McCluskey’s murder, five university police officers have taken that training; she hopes everyone in the department will, and that’s what investigators have recommended.

‘Make things better’

The report also outlined a number of mistakes made by the detective, who has worked for university police since March 2016, and other shortcomings in policy:

• The detective “should have ascertained [Rowland’s] parole status when she had evidence that he was a convicted felon and [McCluskey] identified Rowland as a suspect.” In fact, investigators found that no officer on the force had ever run such a check and all were unfamiliar with the process to do so. Such checks should become routine in all but minor cases, the report notes.

• She never talked to McCluskey in person, only through texts, emails and calls. And she never explained to McCluskey why there was a delay. At first, the detective was busy responding to other calls. During that time, McCluskey called Salt Lake City police’s dispatch twice because she was "very concerned" that she had not heard back from the campus department. And after the case was formally opened on Oct. 19, the detective was scheduled for three days off.

• No other officer was assigned to keep an eye on McCluskey’s case in the detective’s absence, which the review cited as an issue that needs to be immediately addressed. The detective, for instance, received “an important email” about the case on one of her days off and did not open it until after McCluskey was killed. The review recommends that detectives brief each other on their cases so someone can respond when an officer is out of the office.

The reviewers also determined the department is understaffed, and Brophy agreed he could use more officers. The chief did not participate in Wednesday’s news conference.

The criminal investigation into McCluskey’s case is still ongoing, university spokesman Chris Nelson said, but should be wrapped up in the next few weeks. He would not describe what is being investigated: the only assailant, Rowland, is dead and police have said it’s unlikely the man who gave him the gun will be charged. (As a felon, Rowland could not possess a gun.)

Watkins characterized Rowland on Wednesday as “a manipulative, evil criminal” who exploited vulnerabilities. “I think as we consider this terrible tragedy, the individual responsible is Melvin Shawn Rowland.”

A related inquiry into overall campus safety is to be finished in the spring.

The independent review team included Nielsen, who served as commissioner of the Utah Department of Public Safety from 1985 through 1988 and also is an attorney; and Keith Squires, who retired as commissioner in August.

Former University of Wisconsin-Madison Police Chief Sue Riseling was selected as the third member of the team. She is now executive director of the International Association of Campus Law Enforcement Administrators.

“You can only hope that at the end of this that something good will come that will make things better for the future,” Squires said.

A second review

Utah Gov. Gary Herbert had also called for investigations into how the Utah Department of Corrections and the Board of Pardons and Parole handled Rowland’s cases, and that report was also released Wednesday.

On Oct. 16, in the lag between McCluskey’s initial call to campus police and the department opening a formal case, an Adult Probation and Parole agent talked to Rowland. But the agent did not know about McCluskey’s allegations because university police had not communicated with the agency.

The review said investigators will never know whether McCluskey’s slaying could have been prevented by university police contacting parole agents.

In May, Rowland’s parole officer had given him a verbal warning about exchanging text messages with women he met on a dating site. Rowland said he hadn’t thought that dating sites were included in his ban from social media; the officer said they were. Text messaging was allowed.

In August, Rowland tested positive for marijuana — his first drug offense since getting out of prison. He got another verbal warning from a parole officer, who had the discretion to act more harshly.

McCluskey told campus police that Rowland was using social media, but his parole officer reported having never found any of those pages, which were set up under different aliases. “It is speculative, but possible Rowland maintained a ‘clean’ phone for use, contact and inspection with AP&P,” the report said.

Only after Rowland’s death did university police determine Rowland had sent McCluskey texts and extortion messages that purported to be from others, the state report said.

Utah Department of Public Safety Commissioner Jess L. Anderson also cited three reasons that university police didn’t know about Rowland’s parole status — in addition to the fact that officers were not trained to check.

• The Department of Corrections’ system for offender tracking, called O-Track, had Rowland’s parole ID number but not his driver’s license.

• The state’s Public Safety Alert Notification system, or PSAN, which pings every time a law enforcement agency asks about an offender, is overloaded, averaging 25,000 queries a month.

• Since May, Utah criminal history records no longer note whether an offender is out on probation or parole, after a 2015 FBI audit found the practice “out of compliance” because that custody data was not also shared with federal officials.

The report recommends the state return to listing an offender’s parole or probation status on his or her criminal history, by sharing such information with the FBI. The report also suggests updates to the PSAN system to handle the volume of background requests sent to it, and that law enforcement officers be better trained in using O-Track. Finally, the report urges more money for the agency, to bolster its outreach to local law enforcement.

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If you or someone you know is experiencing domestic violence, please call the 24-hour Utah domestic violence hotline at 1-800-897-5465.