Robert Dear, 67, died Nov. 22 at the U.S. Medical Center for Federal Prisoners in Springfield, Missouri. In addition to heart failure, Dear had too much fluid in his body and low oxygen levels in his blood, according to the Bureau of Prisons.

Dear was accused of attacking the Planned Parenthood clinic on Nov. 27, 2015. Authorities believed he intended to wage ā€œwarā€ on the clinic because the staff performed abortions. He arrived armed with four SKS rifles, five handguns, two more rifles, a shotgun and more than 500 rounds of ammunition, according to the U.S. Attorneyā€™s Office.

More than two dozen people who were inside the clinic at the time hid until they could be rescued by law enforcement, according to prosecutors. Dear fired 198 rounds in the attack and tried to blow up propane tanks to take out police vehicles during a five-hour standoff.

Those killed were Keā€™Arre Stewart, 29, Jennifer Markovsky, 36, and Garrett Swasey, 44, a campus police officer who responded to the clinic after hearing there was an active shooter.

Dear had been in state or federal custody since the 2015 attack and confessed to carrying out the mass shooting, but he was never convicted in the killings because he was always considered too mentally ill to go through the court process.

The federal case against him was dismissed after his death. The state case remained open Tuesday.

Robert Dear, 67, is accused of killing three people and wounding nine others at a Planned Parenthood clinic in Colorado Springs in 2015. He is charged with both state and federal crimes connected to the attack, but has long been considered too mentally ill to go through the court process — that is, he has been consistently found incompetent to stand trial.

On Wednesday, U.S. District Judge Robert Blackburn found Dear to be both incompetent and unlikely to be restored. The ruling, which was agreed to by the defense and prosecutors after a doctor’s opinion in August, starts a process in which Dear will be committed long-term to a mental health facility in Missouri.

Federal prosecutors stopped short of dismissing the charges against Dear, however, and instead asked that the case be set for a status conference as his treatment continues. Victims in the attack sought to offer comment in court Wednesday, but Blackburn denied their requests to be heard.

Dear appeared virtually from the facility in Missouri on Wednesday, resting his handcuffed hands on his stomach during the hearing. He did not speak.

Dear, who confessed to the mass shooting, was charged with murder in state court in 2015, and with federal crimes in 2019, after he was found incompetent in the state case. He has for years refused medication for his diagnosed mental illnesses.

In 2022, Blackburn ordered that Dear be medicated against his will. Federal prosecutors believed doing so would restore him to competency.

Dear, who called involuntary medication a “chemical lobotomy,” challenged that order all the way to the U.S. Supreme Court, which in February refused to take up the case. Blackburn then ordered that Dear’s treatment go forward, and the involuntary medication started in April.

A doctor who evaluated Dear in August found the treatment had not successfully restored Dear to competency.

A competency evaluation considers whether a criminal defendant is mentally ill or developmentally disabled, and whether that mental illness impedes the defendant¶¶Ņõap ability to understand the court process. Rooted in the constitutional rights to due process and a fair trial, competency centers on two prongs — whether defendants have a factual and rational understanding of the proceedings, and whether defendants are able to consult with their attorneys and assist in their own defenses.

Experts have previously testified that Dear understood the facts and circumstances of his case but was still incompetent to proceed because he could not assist in his own defense.

Competency refers only to a defendant¶¶Ņõap current mental capacity and is distinct from an insanity defense, which focuses on the defendant¶¶Ņõap mental state at the time of the alleged crime.

Dear is accused of attacking the Planned Parenthood clinic on Nov. 27, 2015. Authorities believe he intended to wage ā€œwarā€ on the clinic because the staff performed abortions. He arrived armed with four SKS rifles, five handguns, two more rifles, a shotgun and more than 500 rounds of ammunition, according to the U.S. Attorneyā€™s Office.

Authorities believe Dear first shot at people near his truck, then shot people in front of the clinic, then barged inside and continued shooting. Twenty-seven people who were inside the clinic at the time hid until they could be rescued by law enforcement, according to the office.

Dear fired 198 rounds in the attack and tried to blow up propane tanks in order to take out law enforcement vehicles during a five-hour standoff.

Those killed were Keā€™Arre Stewart, 29, Jennifer Markovsky, 36, and Garrett Swasey, 44, a campus police officer who responded to the clinic after hearing there was an active shooter.

The U.S. Court of Appeals for the 10th Circuit ruling upheld an order issued by a federal judge in 2022 allowing Robert Dear, 66, to be given medication for delusional disorder against his will to try to make him well enough to stand trial.

Dearā€™s federal public defenders challenged the involuntary medication order by U.S. District Judge Robert Blackburn in part because it allows force to also be potentially used to get Dear to take medication or undergo monitoring for any potential side effects to his physical health.

Dearā€™s lawyers have argued that forcing Dear to be treated for delusional disorder could aggravate conditions including untreated high blood pressure and high cholesterol. However, in their appeal, they said that Blackburnā€™s decision to give prison doctors the right to force treatment or monitoring for other ailments is ā€œmiles awayā€ from the limited uses for forced medication allowed by the U.S. Supreme Court.

The defense questioned why Blackburn did not explain why he discounted the opinions of its experts who testified during a hearing on whether Dear should be forcibly medicated in 2022. But a three-judge panel of the 10th Circuit said Blackburn sufficiently explained that he placed greater weight on the opinions of the government’s experts because of their experience with restoring defendants to competency and their personal experience working with Dear.

Dear has previously declared himself a ā€œwarrior for the babiesā€ and also expressed pride in the ā€œsuccessā€ of his attack on the clinic during one of many outbursts at the beginning of that hearing.

After Dearā€™s prosecution bogged down in state court because he was repeatedly found to be mentally incomptent to stand trial, he was charged in federal court in 2019 under the 1994 Freedom of Access to Clinic Entrances Act.

Two of the people killed in the attack were accompanying friends to the clinic — Keā€™Arre Stewart, 29, an Army veteran who served in Iraq and was a father of two, and Jennifer Markovsky, 36, a mother of two who grew up in Oahu, Hawaii. The third person killed was a campus police officer at a nearby college, Garrett Swasey, who responded to the clinic after hearing there was an active shooter.

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A husband promised carnage at his former place of worship.

A woman in east Denver vowed to open fire in a grocery store to make people listen to her.

An author published a book detailing gruesome killings.

A young person with bomb-making supplies pledged to be the next mass killer.

A Colorado Springs man threatened a mass shooting at a street fair.

In the last 15 months, three of those people acted on their threats. And 12 Coloradans died.

After those attacks, the three suspectsā€™ prior threats loomed large — missed warning signs of impending tragedy. A year before authorities say a 22-year-old killed five in a Colorado Springs LGBTQ nightclub, a judge said the suspect was clearly planning an attack and it would be ā€œso badā€ if the person did not get mental health treatment.

Before a man shot and killed five in a targeted spree across Denver and Lakewood, a reader tipped the FBI and Denver police that his murderous novels might be a manifesto.

And before a man attempted to bomb a Jehovah’s Witness hall in Thornton on Christmas Day — and fatally shot his wife and then himself — a family member became so worried about his escalating anti-social behavior she asked the police to intervene.

None of it was enough to prevent bloodshed.

The failings in those cases have been well-documented. But a review of red flag filings and interviews with law enforcement and mental health professionals by The Denver Post shows people across Colorado regularly make threats of mass violence, and the safety net intended to prevent such attacks is a complex, fragmented system that pits personal freedoms against public safety.

Patchwork funding means some communities are better equipped than others to investigate threats of mass violence and to get help for those who need mental health treatment. Assessing the credibility of threats is difficult, messy work, and state law can make it hard for bystanders, mental health professionals and police to intervene until a situation becomes dire. Mandatory holds for people experiencing dangerous mental health symptoms are short-lived and too often result in a person being released back into society with few resources.

“That grey area where there’s not necessarily criminal charges, but how do we make sure this person doesn’t do something in the future — that’s the tricky situation,ā€ said Denver police Cmdr. Paul Jimenez of the department’s strategic investigation bureau, which includes the counter-threat section.

Colorado doesn’t have a statewide, multidisciplinary threat assessment team, law enforcement and government officials told The Post. There is no overarching system to track a personā€™s threats or threatening behavior across jurisdictions and time — especially if that person is not charged with a crime.

Frustrated families are often left to advocate for a loved one, even as that loved one might pose a threat to them. And people fall through the cracks.

ā€œThis is one of the great challenges of our time,ā€ 18th Judicial District Attorney John Kellner said.

Mental illness and mass violence

By the time Denver police officers responded to reports of a man claiming to have a gun and pushing an empty wheelchair at Denver International Airport in September, that manā€™s family had been trying to get him help for five months.

They werenā€™t surprised to hear that officers took the man to a hospital for an involuntary mental health assessment after determining he was unarmed but ā€œacting highly erratic.ā€ They werenā€™t surprised when he was released from the hospital and was back at DIA the next day. It wasnā€™t a shock when the man then called his father from the airport and threatened to carry out a mass shooting, to hijack a plane.

ā€œThankfully he hasnā€™t gotten to where he has hurt anybody,ā€ the manā€™s sister said. ā€œBut it¶¶Ņõap just terrifying. When someone is this far gone, unless this trajectory can be stopped, where is this going to end? You just donā€™t know.ā€

The manā€™s sister spoke to The Post about her brotherā€™s long-term mental health issues with his permission, on the condition that neither sibling be named in order to protect the brotherā€™sĀ career. The 40-year-old man lives in rural Colorado and was diagnosed 20 years ago with bipolar schizoaffective disorder, which means he experiences episodes of mania — a high mood, with high energy and activity — coupled with delusions and a break from reality.

ā€œMy brother is a pretty normal person who is just plagued with his mind getting hijacked sometimes,ā€ his sister said.

People who are mentally ill are much more likely to be victims of crime than perpetrators, and the vast majority of people with mental illness do not carry out mass violence, experts told The Post. But mental illness does often play a role in mass violence.

A by the U.S. Secret Service that looked at perpetrators of 173 mass-violence attacks in public spaces between 2016 and 2020 found that the majority of attackers experienced mental health symptoms, including depression, paranoia or suicidal thoughts, prior to or during their attacks.

In Colorado, several suspects in mass shootings have had documented mental health conditions.

The suspect in the Nov. 19 attack at Club Q in Colorado Springs had been prescribed medications used to treat schizophrenia, mood disorders and depression. The man accused of carrying out a mass shooting at a Colorado Springs Planned Parenthood clinic in 2015 has been consistently found mentally incompetent to stand trial. And the man who killed 12 at an Aurora movie theater was diagnosed with schizophrenia, as was the man charged in a 2021 mass shooting at a Boulder King Soopers.

The Secret Service study found that effective mental health treatment is part of mass violence prevention and that communities should work to ensure people who are in a mental health crisis can get the help they need.

But that¶¶Ņõap easier said than done. People who need mental health care in Colorado must navigate a complex system that doesnā€™t easily share information between providers. And those who donā€™t want care — even though they need it — have to become a threat to their own safety or others before they can be helped against their will.

A disconnect between Coloradoā€™s court system and medical system means some people who need help are never connected to care, said Andrew Sylvester, a psychiatrist at UCHealth.

There are only a handful of mental health courts across the state — courtrooms that are focused on helping people with mental illness who are accused of crimes. There are five such courts serving 10 counties in Colorado, according to the Colorado Judicial Branch.

ā€œYou have a right to be mentally illā€

When the man who made threats at DIA is healthy, heā€™s a friendly, compassionate guy who is deeply dedicated to his family, his sister said. He holds down well-paying remote-work positions and keeps up romantic relationships. But when heā€™s sick, he becomes a different person: he uses a different name, changes his phone number to the 202 area code and dresses differently. Heā€™s rude and entitled, and he shuns his family in favor of spending time in bars with acquaintances.

Over the last two decades, heā€™s had regular episodes of mania and delusions that can last weeks or months, his sister said. Once, he went five years without having an episode, his longest healthy stretch. In early 2022, life was good for him: new job, likable colleagues, new girlfriend.

ā€œAnd then in May, he said to my aunt, ā€˜Something is wrong, my eyes donā€™t look right, Iā€™m afraid Iā€™m going manic,ā€™ā€ his sister said. ā€œAnd within days, he was no longer himself. And then it lasted for six months.ā€

When heā€™s delusional, her brother believes heā€™s part of some grand plan, she said. Heā€™s in the FBI, or he has to stop a global war, or he has a mission against looming dangers that he canā€™t quite articulate.

In 2011, he tried to break into the White House to personally warn the president of danger he perceived. “That did not go well,” his sister said with a laugh. Her brother was arrested and charged with assaulting a police officer.

The episode that hit him in May was the longest heā€™s ever experienced, his sister said. Over the years, heā€™s figured out how to recognize the signs of an episode early and get himself medical help. And he tried to last summer, she said.

He checked himself into the emergency room more than a dozen times, she said. Got inpatient help 10 times. But heā€™d often complain of something unrelated to his true problem once he got there, like foot pain, and heā€™d refuse antipsychotic medications — the only treatment that pulls him back to being healthy, she said. He always left the hospital as delusional as he was when he walked in, she said.

ā€œHe says it¶¶Ņõap like fighting with himself,ā€ she said. ā€œHeā€™s trying to get help, and then he arrives at the institution and the manic and delusional part of him takes over and heā€™s like, ā€˜No, no, no. Weā€™re not going to let them do that.ā€™ ā€¦ It¶¶Ņõap a battle. And it¶¶Ņõap a battle where the further he goes into the delusion it appears to be harder and harder to get help.ā€

Last summer, she watched her brother repeatedly refuse the only effective treatments for his illness, she said.

ā€œYou have a right to be mentally ill,ā€ his sister said.

Colorado law allows a person to be detained for 72 hours against their will in order to receive mental health care — what¶¶Ņõap known as an ā€œM1 holdā€ — but only if the person presents an imminent danger to themselves or others due to a mental disorder, or is so sick they canā€™t feed or care for themselves.

The patient must be evaluated within 72 hours. At the end of that time, the patient can either agree to receive ongoing voluntary care, be released with no further treatment or authorities can begin the court process of certification to force the person to undergo additional involuntary treatment, including involuntary medication. A person who has been certified can be held in a medical facility for care, or be released for court-ordered outpatient care, said Sylvester, the UCHealth psychiatrist.

In 2021, medical providers executed just under 36,700 72-hour M1 holds across Colorado, most for people who were considered a danger to themselves, according to statistics published by the Colorado Behavioral Health Administration. In about 1,450 of those holds, the person was considered a danger to others, according to the records. That same year, medical providers reported 4,500 certifications for longer-term court-ordered involuntary treatment.

ā€œThe standard to put someone on an M1 hold is very specific; Colorado wants to make sure peopleā€™s rights are not being violated,ā€ Sylvester said. ā€œ…There has to be a specific target with a specific timeline demonstrating imminent harm… Vague threats — ā€˜Iā€™m angry, I feel like hurting peopleā€™ — that is concerning. Very concerning. But without a specific threat, I canā€™t do anything about that.ā€

The laws around involuntary holds and certification , with phased changes set to take effect on July 1 and in 2025. The new laws will allow police officers to take a person to medical treatment instead of jail even if a warrant is out for the personā€™s arrest, increase the required paperwork around involuntary holds, and give the right to an attorney to people going through the court certification process, among numerous other procedural changes.

Lawmakers initially proposed allowing relatives to seek a court order for involuntary treatment for a family member, but that proposal was cut out of the final bill.

The sister of the man who made threats at DIA feels family members need better tools to help their loved one with mental illness.

ā€œIf the family could provide information that today he bought a gun, then he will be secured,ā€ she said. ā€œBut when we say, ā€˜He has this history and heā€™s in a delusional state,ā€™ they say, ā€˜Iā€™m sorry, there is nothing we can do.ā€™ …Youā€™re accepting a community threat and deferring to the rights of the mentally ill person to make decisions when theyā€™re not mentally well enough to make decisions. What can we do? Not to get all the way to involuntary commitment just willy-nilly, but the pendulum has swung too far right now for meaningful interventions by family or the medical community.ā€

She and her frustrated family members called hospitals, told them her brotherā€™s medical history, and explained what medication he needs, but the hospitals couldnā€™t act without her brotherā€™s consent. Sometimes medical staff assumed he was homeless, she said, or that he didnā€™t have family support.

For her brother, the right to be mentally ill meant he got sicker and sicker until he eventually made threats of mass violence.

ā€œWould he actually get on a plane and cause issues?ā€ she said. ā€œWould he actually bring a bomb? I donā€™t think so. I think of it as a plea for help. But you canā€™t know that as law enforcement. And I canā€™t know that, because heā€™s off in a different world.ā€

Early on in this summerā€™s episode, her brother ended up in Salida, and she convinced her father to pay for a hotel room out there for a few days, hoping it might help him to stabilize.

ā€œIt¶¶Ņõap like throwing spaghetti at a wall,ā€ she said. ā€œAt any moment, youā€™re like, ā€˜OK, what might work?ā€™ā€

A few days later, her mom drove out to pick her brother up.

ā€œAnd there he is with this crazy rifle, trying to get into the car, acting totally normal,ā€ she said. Their mother had him put the weapon in the trunk, and, later, they took the gun from him and realized it was an Airsoft gun, though it looked real.

At the time, there was nothing barring her brother from buying a real gun. Even when sick, he presents well to strangers and can pass as well, she said. After he made the threats at DIA, Denver police asked for and received a temporary extreme risk protection order under the state’s red flag law, which barred him from buying or possessing any guns for 10 days.

He wasn’t arrested for making threats, but was charged with petty theft for taking a limo to the airport and then refusing to pay, as well as trespassing. Both charges were later dismissed, court records show.

The threats at DIA were the beginning of the end of his manic and delusional episode. He eventually wasĀ connected to the Denver Police Department¶¶Ņõap co-responder team and to one of the stateā€™s 17 community mental health centers. Staff there went through the certification court process to medicate him against his will, and he was given an antipsychotic injection.

Within two weeks, the man was back to himself, his sister said. Then he had to deal with the aftermath of the crisis: the criminal charges, a lost job, damaged relationships, unpaid debts.

ā€œWhen he comes out of it he has inklings of what happened, but it¶¶Ņõap like someone waking up from a bad dream,ā€ his sister said. ā€œYou know some of these things happened, but you werenā€™t fully present for it.ā€

Once heā€™d been certified for involuntary treatment, he was barred from buying a gun under federal law, and Denver police did not pursue a permanent extreme risk protection order, which would have barred him from possessing guns for one year, on the grounds that it would be redundant.

Federal law prohibits anyone who has been involuntarily committed to a mental health facility from possessing a gun after being released. Most states also have similar or more restrictive laws on their books; Colorado is one of a handful of states that do not, instead relying on the federal statute, according to .

“A difficult line to walk” for law enforcement

Every day, law enforcement officials in Colorado triage reports of possible threats. With each report, they have to determine how credible the threat is and how many resources to devote to investigating it.

Few of those investigations lead to arrests, officials said.

“There are a lot of very hateful, nasty things that are said but are First Amendment-protected material,” said Ash Thorne, supervisory special agent over domestic terrorism and weapons of mass destruction at the FBIā€™s Denver field office.

When evaluating a threat, investigators consider the specificity of the threat, whether the personā€™s rhetoric has escalated over time, whether thereā€™s evidence that the person is making physical preparations to carry out their plan, and whether the person has a violent history.

But it¶¶Ņõap nearly impossible to know which of the hundreds of people who are reported will follow through. In the on mass shootings, U.S. Department of Homeland Security officials wrote that most people who exhibit behaviors connected to mass violence will not act at all. Law enforcement has to determine who will act.

“If there is a committed individual who has a plan and who isn’t communicating their plan to do something — that’s very challenging to stop,ā€ said Jimenez, of the Denver Police Department.

Investigators and prosecutors must prove that a threat is a ā€œtrue threatā€ to pursue criminal charges in a case, U.S. Attorney for Colorado Cole Finegan said. That means they need to prove the person was serious about their statement and that it would cause a reasonable person to be afraid. Prosecutors donā€™t have to prove the person intended to carry out the threat or had the means to do so, but they must prove the statement wasnā€™t a joke, idle talk or an exaggeration.

ā€œIt¶¶Ņõap really a difficult line to walk,ā€ Finegan said.

The standard of what constitutes a ā€œtrue threatā€ changes from state to state, with some states requiring judges and jurors to consider the speakerā€™s state of mind and intent when a threat was made. Other states — like Colorado — consider only the impact of the threat on a ā€œreasonable person,ā€ not the threat makerā€™s intent.

In a Colorado stalking case that¶¶Ņõap , the justices will consider how to define a ā€œtrue threat.ā€ The case stems from a man who sent unwelcome social media messages to a Colorado musician and implied he was watching the woman, was romantically interested in her and was frustrated when she ignored and blocked him.

Colorado courts found that the manā€™s messages were true threats. He was convicted of stalking and sentenced to 4.5 years in prison. But he appealed, arguing that his messages were protected by the First Amendment and that Coloradoā€™s laws should consider a personā€™s state of mind when evaluating the legality of speech. The U.S. Supreme Court agreed to take up the question after the Colorado Supreme Court declined.

Criminal prosecutions for threatening behavior can be difficult, said Denver District Attorney Beth McCann. But when prosecutors do bring charges, they can use the court system as a way to push a person into getting mental health treatment or complying with probation in order to have their record wiped clean, she said.

ā€œI prefer that kind of approach in these cases because if we have someone making that kind of threat, there most likely is some kind of mental health issue going on,ā€ she said. ā€œAnd sometimes it¶¶Ņõap really a cry for attention and a cry for help, and if we can get ahead of that and try to provide a way for that person to get counseling and treatment, we are better off in the long run.ā€

In Colorado, prosecutors can charge people with menacing ā€œif, by any threat or physical action, he or she knowingly places or attempts to place another person in fear of imminent serious bodily injury.ā€ Under federal law, prosecutors can pursue charges if they can prove a suspect communicated a threat across state lines.

Between 2020 and March 2023, prosecutors across Colorado filed about 49,000 counts of menacing across about 15,000 cases, according to data provided by the Colorado Judicial Branch.

About 44% of the menacing charges were ultimately dismissed by prosecutors, the data shows. Defendants were found guilty in 20% of the menacing charges, the data shows. In another 22% of charges, no disposition had been reached by March 2, according to the data.

Criminal charges mean that police, probation officers and other criminal justice workers can follow up with a person and make sure their behavior isnā€™t escalating, Jimenez said. Otherwise, officers have no legal reason to keep track of them.

Criminal charges also often mean a protection order is entered against the defendant that bans them from legally purchasing a gun, said Kellner, the district attorney.

Sometimes prosecutors may not be able to pursue threat charges but will prosecute a suspect for other crimes and use the personā€™s threatening behavior to get a stiffer sentence.

But even if they donā€™t make an arrest, law enforcement officials often will try to intervene in other ways. Prosecutors in Denver will try to warn named victims of threats even if thereā€™s not enough evidence to support a criminal prosecution, McCann said. Sometimes, the FBI will send agents to someoneā€™s door to explain to them the seriousness of making threats and the potential consequences should they continue, Thorne said.

ā€œPeople donā€™t have to go to jail for it to be a win,ā€ he said. ā€œThereā€™s no one-size-fits-all solution.ā€

It¶¶Ņõap impossible to quantify how many people would have acted had law enforcement not stepped in. Threats of mass violence prompted about 11% of all extreme risk protection orders filed statewide in 2022, a review by The Post found. Across 111 red-flag petitions, 12 involved threats of mass violence.

“Success for our section is when something doesn’t happen and nobody knows about it,ā€ Jimenez said.

Some thwarted plots do make the news. Finegan pointed to the case of a Colorado man who was investigated for a plot to blow up a synagogue in Pueblo. The 27-year-old white supremacist told undercover FBI agents that he planned to start a ā€œracial holy warā€ and purchased fake bombs from agents to blow up the temple. And in January, the FBI arrested an Evergreen man who threatened to commit a mass shooting at the FBI office as well as a local performing arts venue.

ā€œWhen I started this job in December 2021, after the first few weeks I was just struck by how much violence there is in the country,ā€ Finegan said. ā€œI thought I understood that, but when youā€™re involved in these cases dailyā€¦ the number of guns is astonishing. The crisis with drugs is terrifying. And just the amount of violent rhetoric that is in our state is really disturbing.ā€

ā€œRelentless follow-upā€ needed

Every week in northwest Oregon, mental health professionals, law enforcement officers, prosecutors, advocates and others gather in the same room to talk about people who recently made violent threats across the region.

The experts discuss each case in detail: a man who lost a job and made threats to his boss, or a husband targeting his wife, or a college counselor concerned about a particular student¶¶Ņõap behavior, said David Okada, a member of the team and president of the Association of Threat Assessment Professionals.

ā€œThe beauty of this system is that we are getting different perspectives,ā€ Okada said. ā€œ…the idea is problem-solving as a team. Coming up with things we can do to help keep somebody from doing any further attacks.ā€

Twenty-seven different public agencies are represented on the , including members from higher education, the juvenile justice system, veteransā€™ affairs, probation and parole. The group, which was established in 1998, serves a solely advisory role — any member can bring a case to the team, which then brainstorms ideas for de-escalation and makes suggestions to the originating agency.

It¶¶Ņõap not a law enforcement task force, and it¶¶Ņõap not led by mental health professionals or any one agency. It¶¶Ņõap a system-wide collaboration for the region, Okada said. Cases sometimes come to the team before a person has been arrested or charged.

ā€œOur leaders within our community have recognized our process as a good process to help solve problems,ā€ he said. ā€œSo maybe people donā€™t understand what they are seeing, or it¶¶Ņõap just kind of ominous. Theyā€™ll send that stuff to us.ā€

Multidisciplinary threat assessment teams are the gold standard for preventing mass violence, said John Hollywood, a senior researcher at the RAND Corporation who .

But Colorado has no such team.

While and have such teams and law enforcement agencies collaborate on such cases, there arenā€™t any multidisciplinary teams in the state that handle adult cases, law enforcement and state government officials said.

Hollywood reviewed more than 600 mass attacks — including more than 300 that were stopped — to find new prevention and intervention strategies. Multidisciplinary teams like the one in Oregon can follow peoplesā€™ trajectories over extended periods of time and check in on them as needed.

ā€œThere needs to be relentless follow-up,ā€ he said.

Arrest is almost never the next step and most incidents can be handled outside the justice system, he said. The Department of Homeland Security also as a way to intervene before threats become so dire they require a law enforcement response.

On the Oregon threat assessment team, members consider how to connect subjects to counseling, financial support, mental health services or some sort of continued supervision, either through a mental health case manager or, if someone has already been arrested, through probation or incarceration, Okada said.

Much of the team’s work focuses on intimate partner violence, he said. They also handle threats of mass violence, though less frequently, and can help agencies develop safety plans for potential targets. On weeks when the team has no new recent cases to consider, theyā€™ll either follow up on past cases or do training, Okada said.

In the absence of a formal multidisciplinary threat assessment team, professionals in law enforcement and mental health care should still build cross-disciplinary connections, Okada said.

One way that Colorado has created collaboration between law enforcement and mental health providers is through co-responder teams, which partner a mental health professional with police departments to handle police calls for service.

There are 27 co-responder programs across Colorado that are funded by the stateā€™s Behavioral Health Administration, according to the department, as well as other programs not funded by the agency. The BHA spends about $6.6 million on the programs, pulling money from marijuana tax revenue and the stateā€™s general fund.

The co-responder programs are located in 24 of the stateā€™s 64 counties. In the 2020-2021 fiscal year, co-responders made in 80 communities, according to the BHA. Most of those contacts were during active calls, but also include follow-up contacts and referrals for additional care.

The Denver Police Department added a mental health clinician to its counter-threats section about a year ago to help complete threat assessments and help detectives understand mental health concerns, Jimenez said. The clinician can help people connect with services if there isnā€™t an arrest.

Other proposed solutions in Colorado include changing two state laws — one governing M1 holds and another the stateā€™s red flag law — and increasing access to mental health hospital beds.

Thirty-eight days before the Aurora theater shooting in 2012, the shooterā€™s psychiatrist became so concerned by his homicidal thoughts that she alerted campus police at his school, the University of Colorado’s Anschutz Medical Campus, that he might be dangerous.

The psychiatrist didnā€™t, however, send the man for a 72-hour involuntary mental health hold — an M1 — because the law requires that professionals know about an ā€œimminentā€ threat to the safety of others or the safety of the patient, and she didnā€™t feel his general homicidal thoughts met that threshold.

The ā€œimminentā€ requirement in the law was scrutinized after the theater shooting, but ultimately not changed, said Frank Cornelia, deputy executive director at the Colorado Behavioral Healthcare Council.

ā€œSome of that came from a lot of pushback from consumers who felt threatened about expanding the ability to take somebodyā€™s civil liberties away,ā€ Cornelia said, adding that whether to order an involuntary hold can be a tough judgment call for mental health providers.

Some providers interpret imminent to mean a specific threat with a specific timeline, while others take the term more generally, said Jen Bock, chief clinical officer for AllHealth Network.

ā€œIt doesn’t have to mean, ā€˜I’m going to kill myself in five minutes,ā€™ right? It can mean, I want to die and Iā€™m intent on killing myself without a specific timeframe,ā€ she said.

McCann said the imminent danger standard makes it too difficult for mental health providers to order involuntary mental health holds.

ā€œI think the term ā€˜imminentā€™ should be removed and can be substituted with another kind of word, like ā€˜substantial,ā€™ā€ she said.

The 72-hour clock starts as soon as someone is ordered for an involuntary hold, Sylvester said, even if there are no hospital beds available.

ā€œPatients may sit in the ER for two or three days,ā€ he said.

In general, the state needs more effective mental health holds that ensure people in crisis are released into ongoing care after they become stable or the 72-hour period expires, Kellner said.

ā€œAs a society, we moved away from institutionalizing people because of widespread abuses and scandals, but that move away left a large gap that really hasnā€™t been filled,ā€ Kellner said.

State mental health hospitals are often overloaded and too full to accept new patients coming off 72-hour mental health holds, Sylvester said. Independent psychiatric hospitals usually have more open beds, but patients covered by Medicaid can be rushed out the door in those facilities because of the way the state insurance works: if a patient on Medicaid is held for more than 15 days in a calendar month, the state does not pay for any of their care, Sylvester said.

The idea behind the policy was to prevent private hospitals from keeping patients for longer than necessary, but it has created a situation in which hospitals must sometimes choose between discharging a patient prematurely or offering the care for free, Sylvester said.

ā€œThere is a push to make sure we are getting people out the door,ā€ he said.

The is driven by federal guidelines, said Marc Williams, spokesman for the Department of Health Care Policy and Financing. Inpatient stays of over 15 days make up just 2.7% of all stays in psychiatric hospitals, he said in a statement.

“HCPF has engaged providers to understand their concerns and provide suggestions for how to address the financial impact related to lengths of stay over 15 days,” he said in the statement.

Colorado lawmakers are also hoping to expand the stateā€™s red flag law. If is passed, licensed medical care providers, licensed mental health-care providers, licensed educators and district attorneys will be able to request that a judge take away someoneā€™s guns. Under current law, only family members and law enforcement may do so.

ā€œWe need to get better as a society, we need to get better working with law enforcement at identifying threats, taking them seriously and getting them referred to the right authorities,ā€ Colorado Attorney General Phil Weiser said, ā€œand then making sure authorities know about and are comfortable using tools — most notably the red flag law — to save lives.ā€

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The Eighth Judicial District, which includes Larimer and Jackson counties, created a special “competency court” — a central place where defendants facing mid-level felony charges are supported by a team of mental health professionals who work together with the judge, defense attorneys and prosecutors to reduce delays and restore defendants to competency.

The court does not accept misdemeanor cases unless the defendant is also facing felony charges, and does not accept the most serious felony cases, like homicide.

The program in Larimer County has been so successful in its first 18 months that courts in Denver and Pueblo launched similar efforts this year, and courts in Colorado Springs and Arapahoe County have plans underway to do so in the next two months, said Denise Cosgrove, who works on competency issues for theĀ state’s Office of Civil and Forensic Mental Health.

“I have really seen a reduction in the number of people who are just stuck in this process, and it¶¶Ņõap really increased their ability to be connected to community resources, which gives us better outcomes and greater community safety,” Cosgrove said.

In Colorado’s criminal courts, a defendant must be mentally competent — able to have a rational and factual understanding of the court proceedings and assist their attorneys with their own defense — in order for a case to proceed. When mental competency is in question, the criminal case is put on hold until defendants go through competency evaluations.

If they’re found to be competent, the cases go forward. If they’re found incompetent, defendants must go through a restoration process. Most defendants who are considered incompetent are restored to competency within a few months through mental health treatment, though a small percentage of defendants are restored more slowly or never at all.

The criminal cases against the suspects in the 2021 King Soopers mass shooting in Boulder and the 2015 Planned Parenthood shooting in Colorado Springs have both been stalled in competency proceedings since those attacks.

The competency process is notoriously slow, particularly because defendants who are considered too dangerous to be released into the community are often ordered to undergo an evaluation or treatment at the Colorado Mental Health Institute in Pueblo, which has long wait times. Such defendants are held in jail, often for months, awaiting further treatment.

Defendants can be released from jail and go to outpatient competency evaluations and treatment, though that presents its own challenges: judges must weigh whether the defendant poses a safety threat to the community, and defendants who are homeless or seriously mentally ill sometimes struggle to make their appointments and may end up in more trouble with the law.

Improving communication

That’s where Larimer County’s competency court comes in. Once the question of competency is raised in a case with qualifying felony charges, the case is moved to Chief Judge Susan Blanco’s competency docket, and a team of professionals from outside the court system takes on the defendant as a client, creating a plan so that the defendant, if released from jail, will have housing, transportation, medication, access to treatment and other supports.

“When the judge and district attorney feel like, ‘Hey, there is a team supporting this person in the community,’ theyā€™re more willing to try another option besides just leaving the client in custody,” Cosgrove said.

Ensuring everyone who can be evaluated outside of jail is evaluated outside of jail also frees up spots in Pueblo’s hospital for the most dangerous and seriously ill defendants, Cosgrove added, potentially reducing wait times there as well.

Consolidating competency cases under one judge — instead of having the relatively rare cases spread out among all judges — makes it possible for the team of experts to easily keep track of each defendant, said Gene Klivansky, head of Larimer County’s Competency Services Team.

Cases are heard at the same time and place every Thursday morning. The team, public defenders and prosecutors are all in the same room. If a defendant needs to connect with a particular service, a representative from that service can talk to them immediately, while court is ongoing.

It’s a totally different environment than when Klivansky tried to offer defendants similar support before the creation of competency court. Then, he spent most of his time running from courtroom to courtroom and talking with unfamiliar attorneys. Now, he sees the same attorneys, same experts, same judge, and everyone in the room has a solid grasp of competency procedure and law.

“Communication was a lot harder before than it is now,” Klivansky said.

The competency court team also arranged for a forensic evaluator — a person who performs competency evaluations — to be at the courthouse every Wednesday morning, which makes it easier for the court to schedule evaluations and is more convenient for defendants, who come to a familiar centralized place instead of being required to find their evaluator at other locations. About 90% of people show up for their evaluation appointments at the courthouse, Klivansky said.

The power of competency court is in how it brought together services and experts who already were at work in the community but had never been connected to the court process in a meaningful way, Blanco said.

“It¶¶Ņõap amazing how many resources were in our community,” she said. “There was already a group of people who were there to support individuals who are going through what these people are going through. It was worth the ask of, ‘Would you come to court and work with us?'”

Finding successes

Since launching in May 2021, Larimer and Jackson counties’ competency court has served 160 defendants. Ninety-eight of those defendants have left the court, and 62 cases are pending. Typically, a defendant is only seen in competency court while the case is awaiting resolution of competency. Once a defendant is found competent, the case is usually transferred back to its original courtroom and judge, where it proceeds normally through the court process, Blanco said.

Occasionally, a case may be resolved within the competency court docket, particularly if the person cannot be restored to competency and the charges are dismissed, or if the case is transferred to the judicial district’s court for severely mentally ill defendants, which Blanco also heads.

She said some successes in the program stand out, like one man who seriously assaulted a police officer. He was right on the brink of going to prison, she said.

“You are sitting on the bench and you have this important moment where it¶¶Ņõap like, ‘Should this person go to prison, or not?'” she said. “And you donā€™t want to be wrong either way. You donā€™t want to put someone in the community who isnā€™t safe, and you donā€™t want to put someone in prison that potentially you could have done something more to help them in the community, safely.”

This particular defendant had gone through competency court and he’d continued to be supported when he moved into Blanco’s mental health court. He was engaged with services and he wanted to be stable, she said. She ruled against prison.

Now, she said, “they have a job, they’re stable and have been for some time, and successful. …And for someone to be successful, it’s not a small task.”

Earlier this month, U.S. District Judge Robert Blackburn ruled that involuntary medication was the only realistic approach with a substantial chance of making Robert Dear, 64, competent to stand trial and was also in the best interest of his overall health, both mental and physical.

Dearā€™s attorneys appealed the order to the 10th U.S. Circuit Court of Appeals and on Monday Blackburn ruled that Dear would not be involuntarily medicated while the appeal is considered, which could take several months. Federal prosecutors did not object to the order being put on hold, according to court records.

Dearā€™s federal public defenders challenged the involuntary medication order in part because it allows force to also be potentially used to get Dear to take medication or undergo monitoring for any potential side effects to his physical health.

Dearā€™s lawyers have argued that forcing Dear to be treated for his delusional disorder could aggravate conditions including untreated high blood pressure and high cholesterol. However, in the appeal, they say that Blackburnā€™s decision to give prison doctors the right to force treatment or monitoring for other ailments is ā€œmiles awayā€ from the limited uses for forced medication allowed by the U.S. Supreme Court.

The appeal noted that the last forced medication order reviewed by the 10th Circuit took three months to resolve.

Dearā€™s prosecution has stalled, first in state court and then in federal court, because he has been repeatedly found mentally incompetent to stand trial since his arrest and he has refused to take medication.

During a three-day hearing this summer on whether he should be forcibly medicated, prosecutors argued that medication had a substantial likelihood, based on research and the experience of government experts, to make Dear well enough to meet the legal standard for mental competency — being able to understand proceedings and assist in his defense.

The prosecution of Robert Dear, 64, has stalled because he has been repeatedly found mentally incompetent since his arrest and he has refused to take anti-psychotic medication for delusional disorder.

During a three-day hearing this summer, prosecutors argued that medication had a substantial likelihood, based on research and the experience of government experts, to make Dear well enough to meet the legal standard for mental competency — being able to understand proceedings and assist in his defense.

Dearā€™s lawyers and experts, however, said the government¶¶Ņõap plan did not take into account Dearā€™s age and his health problems, including untreated high blood pressure and high cholesterol, which could be worsened as a result of the medicationā€™s side effects.

Dear, who has called himself a ā€œwarrior for the babies,ā€ intended to wage ā€œwarā€ against the clinic because it offered abortion services, arming himself with four semi-automatic rifles, five handguns, two other rifles, a shotgun, propane tanks and 500 rounds of ammunition, prosecutors have alleged. He began shooting outside the clinic before getting inside by shooting his way through a door, according to his federal indictment.

According to experts who testified and Dearā€™s lawyers, Dear has persecutory delusions that cause him to believe that the FBI is following him because he called a radio show in 1993 to criticize the agency over the law enforcement siege against the Branch Davidian compound in Waco, Texas. He also believes his lawyers are working for the FBI and the judge is also in on the arrangement.

Dear mentioned the radio call in one of many outbursts during the recent hearing, where he also claimed the shooting was a ā€œsuccessā€ and told the judge to go to hell because he did not get to testify. He largely remained quiet after Blackburn warned him that he would not tolerate any more disturbances. The judge said he concluded the outbursts were not the result of Dearā€™s mental illness but of ā€œselfish, childish and disaffected arrogance.ā€

After Dearā€™s prosecution bogged down in state court over the competency issue, Dear was charged in federal court in 2019 under the 1994 Freedom of Access to Clinic Entrances Act. Federal prosecutors have said they would not seek the death penalty against him if he is convicted, but life in prison instead.

Two of the people killed in the attack were accompanying friends to the clinic — Keā€™Arre Stewart, 29, an Army veteran who served in Iraq and was a father of two, and Jennifer Markovsky, 36, a mother of two who grew up in Oahu, Hawaii. The third person killed was a campus police officer at a nearby college, Garrett Swasey, who responded to the clinic after hearing there was an active shooter.

Dr. George Woods Jr., a California physician specializing in neuropsychiatry, testified during a hearing in federal court to determine whether Robert Dear, 64, who has been diagnosed with delusional disorder, could be injected with the drugs while restrained — either by handcuffs if he agrees to them or by a team of six prison guards.

While a psychiatrist and a psychologist who evaluated Dear at the federal prison hospital in Springfield, Missouri, testified Tuesday that there was a substantial likelihood he would be made well enough to be able to work with his lawyers, Woods disagreed. He said research shows the drugs are less effective in treating the disorder in older patients like Dear. He also said the drugs could also exacerbate Dearā€™s existing health problems like high blood pressure and lead to him to develop vascular dementia, brain damage caused by strokes.

He said the plan from a prison psychiatrist to medicate Dear did not take into account the complexity of Dearā€™s case.

ā€œIt¶¶Ņõap a standard template that doesnā€™t speak to the specific person Mr. Dear is,ā€ said Woods.

However, a cardiologist who works with psychiatrists to prevent patients with heart conditions from being harmed by anti-psychotic medication at Denver Health, the cityā€™s public hospital, testified Dearā€™s health conditions are not very unusual, noting that about half of adults in the United States have high blood pressure. If left untreated like Dearā€™s, Dr. Matthew Richard Holland acknowledged it can lead to congenital heart failure, strokes and kidney dysfunction.

Still, Holland said he doubted he would have been asked to consult on Dearā€™s case if he were a patient at his hospital.

According to his medical records, Dear reported having a heart attack but neither Holland nor Dr. Robert Sarrazin, the chief of psychiatry at the Springfield prison hospital, said they could find anything else in the records to back up that claim.

During the first day of the hearing Tuesday, Dear interrupted the proceedings multiple times with outbursts. On his way out of the hearing that day he shouted at Judge Robert Blackburn he shouted at the judge ā€œI had a right to take the stand, you bastard. Go to hell.ā€

On Wednesday, Blackburn said he initially tried to give Dear some leeway, assuming that his comments were related to his mental illness but said he now believes they are the result of ā€œselfish, childish and disaffected arrogance.ā€ Blackburn said Dearā€™s departing comments were the final straw and warned Dear he would immediately be removed if he continued to speak out during the proceedings

Dear, who was dressed in a khaki t-shirt and pants and not wearing any handcuffs, did not appear to react and looked down toward the defense table after testimony resumed following the warning. He did not say anything.

Robert Dear, 64, has repeatedly admitted to killing three people and wounding nine others during a mass shooting at a Planned Parenthood in Colorado Springs in 2015, but the criminal proceedings against him have been on hold for years as he continuallyĀ has been found mentally unable to stand trial.

Dear has steadfastly refused medication for his diagnosed mental illnesses, and he objected several times to forced medication during a hearing in U.S. District Court in Denver on Tuesday to determine whether he should be involuntarily medicated.

“It is chemical lobotomy,” Dear said. “That is what they are doing. Chemical lobotomy.”

Dear suffers from significant bizarre delusions that make it impossible for him to assist in his own legal defense, psychologist Lea Ann Preston Baecht testified during the hearing.

Dear believes he is being persecuted by the FBI, that former President Barack Obama is the anti-Christ and sent agents to kill Dear, that staff at the hospital where he is being held are witches and warlocks, and that Masons carried out the 2017 mass shooting in Las Vegas, she testified.

Baecht said Dear’s delusions impact his ability to participate in his own defense, and Dear is likely to remain mentally incompetent to proceed unless he is medicated. He has been diagnosed with delusional disorder and, in the past, schizophrenia, two closely related conditions, she testified.

Dear objected to her assessment of his ability to work with his defense attorneys.

“There is no defense,” he shouted in court. “I did it.”

Federal prosecutors brought 68 criminal counts against Dear in late 2019 in connection with the Planned Parenthood attack in an attempt to move forward with criminal proceedings after the case stalled in state court, but Dear was also found mentally incompetent by the federal courts, stalling those proceedings as well.

Dear’s defense attorneys argued Tuesday’s hearing should be closed to the public to protect Dear’s medical privacy, but Senior Judge Robert Blackburn dismissed that argument, finding the First Amendment right to public court access outweighed Dear’s privacy interests.

During the hearing, Dear’s defense attorneys emphasized the potential adverse side effects of the proposed medications and questioned whether the forced treatment would be effective in helping Dear recover.

Dear has consistently claimed he is not mentally ill in outbursts during court proceedings over the years, including on Tuesday, when he said he’d been declared incompetent as part of a scheme to keep him from firing his attorneys and representing himself.

In other outbursts, Dear applauded the recent U.S. Supreme Court decision to end constitutional protections for abortions and said he was “glad I did what I did” and that the attack was a “success.”

“Planned Parenthood? You lost at the Supreme Court,” he said.

A competency evaluation considers whether a criminal defendant is mentally ill or developmentally disabled, and whether that mental illness impedes the defendant¶¶Ņõap ability to understand the court process. It centers on two prongs — whether defendants have a factual and rational understanding of the proceedings, and whether defendants are able to consult with their attorneys and assist in their own defenses.

Competency refers only to a defendant¶¶Ņõap current mental capacity and is distinct from an insanity defense, which focuses on the defendant¶¶Ņõap mental state at the time of the alleged crime.

Baecht testified that her evaluation found Dear had a solid understanding of the facts and circumstances of his case, but was nevertheless incompetent because he could not assist in his own defense. She estimated his psychosis may have gone untreated for between 15 and 30 years.

Robert Sarrazin, a psychiatrist, testified that medication was the best course of treatment for Dear and that he was likely to be restored to competency if he was forced to be medicated.

The hearing is scheduled to last through Wednesday, after which Blackburn will issue a decision on whether Dear will be medicated against his will.

The six-person civil jury ruled Planned Parenthood could not be held civilly responsible for the attack, in which confessed shooter Robert Dear killed three people and wounded nine others during a violent rampage.

The lawsuit was brought by victims of the shooting, who argued that Planned Parenthood should have foreseen such an attack and taken better security measures to prevent it, in part because the clinic and others nationwide had been receiving escalating threats of violence at the time.

Attorneys for Planned Parenthood countered that no one could have stopped Dearā€™s ā€œfanatical rampageā€ and argued there were no reasonable security measures that could have deterred him.

The Colorado Supreme Court in June 2020 ruled in a split 4-3 decision that the issue of civil liability should be determined by a jury, rather than a judge, with the majority of justices finding it was possible a reasonable juror might find Planned Parenthood responsible to some degree for the attack.

The decision drew attention from land and business owners, who worried about shouldering liability in future mass-shooting attacks. The three dissenting justices in the state Supreme Court’s decision argued that by putting the decision in the hands of a jury, the ruling wrongly subjected landowners to liability for the “irrational actions of a mass murderer.”

A civil jury trial started in Denver on Oct. 11. The jury deliberated for about a day-and-a-half before finding entirely in favor of Planned Parenthood on Wednesday.

“Yesterday’s unanimous decision in Planned Parenthood of the Rocky Mountains’ favor, asserts that this act of violence on our Colorado Springs health center was neither foreseeable, nor preventable,” the organization’s spokeswoman, Whitney Phillips, said in a statement.

Planned Parenthood’s attorney, Kevin Taylor, said Thursday he was grateful the court ensured a fair and impartial trial.

ā€œPlanned Parenthood of the Rocky Mountains thinks today of all the victims of Robert Dearā€™s murderous rampage,ā€ he said. ā€œThe four plaintiffs suffered tremendously.ā€

An attorney for the shooting victims did not immediately respond to a request for comment.