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 “war” 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. Attorney’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 Ke’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, died at 6:30 a.m. Saturday in the U.S. Medical Center for Federal Prisoners in Springfield, Missouri, Bureau of Prisons spokesperson Randilee Giamusso said. His death was “preliminarily linked to natural causes,” Giamusso said Tuesday, and prison officials followed advanced medical orders before he died.

Dear’s death ends a decade-long — and ultimately unsuccessful — effort to convict him of crimes connected to the mass shooting. Although Dear had been in state or federal custody since the 2015 attack and confessed to carrying out the mass shooting, he was never convicted because he was always considered to be too mentally ill to go through the court process — that is, he was consistently found incompetent to stand trial.

Fourth Judicial District Attorney Michael Allen said in a statement Tuesday that the victims of the shooting were denied justice in the “evil attack.”

“All three victims and this community deserved the full measure of justice in this case, but they are now denied that possibility,” Allen said. “Their family members and loved ones have endured this horror for far too long.”

The Bureau of Prisons declined to provide any additional information about Dear’s death and officials with the Greene County Medical Examiner’s Office did not immediately return requests for more information.

Dear’s attorneys did not respond to requests for comment Tuesday.

Dear was accused of attacking the Planned Parenthood clinic on Nov. 27, 2015. Authorities believe he intended to wage “war” 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. Attorney’s Office.

Twenty-seven 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 law enforcement vehicles during a five-hour standoff.

Those killed were��Ke’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. Another four police officers were wounded.

The issue of Dear’s competency stalled the state’s murder case against him in 2016. Federal prosecutors brought their own case alleging firearm and civil rights violations in 2019; those proceedings also stalled due to Dear’s compromised mental state.

A��competency evaluation��considers whether a criminal defendant is mentally ill or developmentally disabled, and whether that mental illness impedes the defendant����ap 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 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.

Dear was known for frequent outbursts in court. During a 2019 hearing, he declared himself to be a “religious zealot” who was being prosecuted in a “political kangaroo court.” In 2021, he insisted in federal court that he was competent to stand trial, shouting, “I’m not crazy.”

In September, a federal judge started the process for Dear to be committed long-term to the mental health facility in Missouri after finding he was unlikely to be restored to competency.

The decision came nearly three years after the judge ordered that Dear be medicated against his will in 2022. 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. The judge then ordered that Dear’s treatment go forward, and the involuntary medication started in April.

The medication did not restore him to competency, the judge found in September.

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����ap 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����ap current mental capacity and is distinct from an insanity defense, which focuses on the defendant����ap 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 “war” 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. Attorney’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 Ke’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.

U.S. District Judge Robert Blackburn ordered that Robert Dear be involuntarily medicated “as soon as practicable” in the Thursday order, which he issued after the U.S. Supreme Court on Monday declined to take up Dear’s case.

Dear, 66, has 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 has been consistently found to be too mentally ill to stand trial.

He faces both state and federal criminal charges in separate cases.

Dear has for years refused medication for his diagnosed mental illnesses, which prompted federal prosecutors in 2022 to seek a court order that he be medicated against his will. At the time, they said such medication was likely to improve Dear’s mental health to a point where the criminal cases against him could go forward.

Blackburn first ordered the forcible medication in September 2022. Dear then challenged the order all the way up to the U.S. Supreme Court, which declined to take up the case Monday.

The judge on Thursday re-ordered that the involuntary medication start as soon as practical, and ordered attorneys to update the court about Dear’s status on June 30. State experts will re-consider Dear’s competency after the new treatment.

A competency evaluation considers whether a criminal defendant is mentally ill or developmentally disabled, and whether that mental illness impedes the defendant����ap 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����ap current mental capacity and is distinct from an insanity defense, which focuses on the defendant����ap mental state at the time of the alleged crime.

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.

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.

Dear’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.

Dear’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 Blackburn’s decision to give prison doctors the right to force treatment or monitoring for other ailments is “miles away” 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 “warrior for the babies” and also expressed pride in the “success” of his attack on the clinic during one of many outbursts at the beginning of that hearing.

After Dear’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 — Ke’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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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 continually��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����ap 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����ap current mental capacity and is distinct from an insanity defense, which focuses on the defendant����ap 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 Dear’s “fanatical rampage” 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.

“Planned Parenthood of the Rocky Mountains thinks today of all the victims of Robert Dear’s murderous rampage,” he said. “The four plaintiffs suffered tremendously.”

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

Robert Dear, 63, has admitted to killing three people at the clinic, but the state’s case against him stalled beginning in 2016 after he repeatedly was found mentally incompetent to proceed — that is, he could not comprehend the criminal case against him or participate in his own defense.

Federal prosecutors brought 68 criminal counts against Dear in late 2019 in an attempt to move forward with criminal proceedings. While the standards for determining mental competency in federal court are nearly identical to Colorado’s standards, federal courts have a reputation for finding incompetency less frequently than state courts.

On Thursday, Senior Judge Robert Blackburn declared Dear incompetent in a brief hearing at the Alfred A. Arraj United States Courthouse in Denver. The finding of incompetency was not contested by the prosecution or defense, though Dear himself disagreed.

“I’m opposing it; I’m not crazy,” he shouted at one point, appearing via video feed from a mental health facility in Missouri with his attorney.

Blackburn ordered that Dear be committed for additional mental health care to “determine if there is a substantial probability that in the foreseeable future Mr. Dear will attain the capacity to permit the proceedings to go forward.”

Dear is accused of killing three people and wounding eight others during the Nov. 27, 2015, shooting rampage at the clinic.

Authorities believe he intended to wage “war” 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. Attorney’s Office.

Twenty-seven people who were inside the clinic at the time hid until they could be rescued by law enforcement, according to the U.S. Attorney’s 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, according to the office.

Four police officers were wounded and one was killed.

U.S. Attorney Jason Dunn submitted a one-sentence notice of the decision concerning Robert Dear that did not include any explanation of the reasons for it.

The move comes about a year after Dear was charged in federal court in the shooting after his prosecution in state court stalled. He had been repeatedly deemed incompetent to stand trial. Dear, however, has insisted he is competent.

During his initial appearance in federal court a year ago, he interrupted the proceedings to criticize evaluations at the state mental hospital in Pueblo, insisting the process is unnecessary and complaining that it was not videotaped.

Last month, a judge ordered Dear to undergo a federal competency examination once his lawyers and prosecutors worked out the details of where it would take place.

Dear is facing 68 counts in the federal case, including use of a firearm during a crime resulting in death and violating a law ensuring access to clinic entrances.

The court����ap 4-3 decision strives to avoid creating a hard-and-fast rule for all liability cases in which mass shooters attack businesses, but dissenting justices worry the ruling will put an undue burden on business owners.

A district judge previously found that Planned Parenthood of the Rocky Mountains couldn’t be held responsible for the shooting because the actions of confessed shooter, who is accused of killing three people and wounding nine others in the November 2015 shooting, were the overwhelming cause of the carnage.

But the state Supreme Court ruled Monday that the decisions should be made by a jury, not a judge. There is enough debate as to whether Planned Parenthood could have anticipated, prevented or lessened the severity of the attack through security measures that a jury should consider the evidence.

Justice Richard Gabriel wrote for the majority that it����ap possible a reasonable juror would find Planned Parenthood responsible to some degree for the attack — in part because the organization “had long been the subject of known threats of such violence, making the likelihood of an event like that which occurred less remote and arguably more foreseeable.”

Gabriel differentiated the Planned Parenthood attack from other mass shootings where the businesses were found not liable — like the 2012 attack at an Aurora movie theater — because of the ongoing and escalating threats to Planned Parenthood around the time of the shooting.

Justices Melissa Hart, Monica Marquez and Brian Boatright dissented, arguing that the court����ap decision wrongly shifts the risk posed by mass shooters from the attackers to landowners.

“The dangerous consequence of this move is to subject a landowner to liability for the irrational actions of a mass murderer, who has no concern about detection or death,” Hart wrote.

She argued that the decision may also place additional liability on businesses that are politically controversial versus those that are not, creating an environment in which controversial businesses are “uninsurable or require impossibly expensive fortifications.”

“After today’s decision, antisemitic fanatics can impose additional costs on synagogues, and White supremacists can inflict the same on Black churches or businesses,” she wrote. “Threats of violence often precede acts of violence at these locations, as they did at Planned Parenthood of the Rocky Mountains. I fear the consequences of today’s decision will be felt well beyond this litigation.”

Gabriel wrote that the court����ap decision should not be interpreted that way.

The majority’s ruling is not intended to “suggest either that different rules apply to what may be deemed ‘politically neutral’ sites, on the one hand, and potentially ‘incendiary’ sites such as a women’s health clinic, on the other,” he wrote, adding that mass shootings can happen virtually anywhere and potential targets do not need to build fortresses to protect against risk.

Rather, he wrote, the court����ap decision is tailored specifically to the case at hand.

Kirk McCormick, an attorney for the victims of the shooting, said Monday the court����ap decision is a “reaffirmation of longstanding Colorado law that preserves the place of jurors, of lay people, to make these determinations.”

“The jury will decide who caused our clients injuries and they’ll be able to decide in terms of a percentage out of 100% what percent should be charged to Robert Dear and what percentage to Planned Parenthood of the Rocky Mountains,” he said. “And then separately how much money should be awarded to our clients in order to compensate them for their injuries and damages.”

A date has not yet been set for that proceeding, he said.

Planned Parenthood of the Rocky Mountains and an attorney for the group did not return requests for comment Monday.