U.S. Army commanders in Iraq had an advisory suicide prevention plan, but no mandatory steps to follow when dealing with at-risk soldiers like the one accused of killing five troops at a military mental health clinic last May, according to a review of military procedures.

Sgt. John Russell is accused of shooting and killing five soldiers after an altercation at a counseling center located on a U.S. base in Iraq five months ago.

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According to the Associated Press, the report found that no Army publication provides step-by-step details to a unit on how to implement a suicide watch and that security at the Combat Stress Clinic at Camp Liberty was “inadequate.”

“It paints a picture of soldier less than two months from the end of his third deployment who began to show obvious signs of unraveling weeks before the clinic shootings,” the AP noted. “The report describes a man whose problems were known and who received some counseling, yet at critical times did not appear to get the help he needed.”

Russell’s own unit was aware of his suicidal thoughts for at least three or four days before the tragedy, but there was no 24-hour suicide watch on him until the morning of the shooting. His fellow soldiers described him as saying he was “sick and tired of life and believed everyone hated him.”

A company commander told investigators that they did not have the personnel available to continuously monitor Russell, who was on his fourth visit to the mental health clinic the day the tragedy occurred.

The review says Russell’s clinic visit the morning of the shooting was cut short when he became “verbally non-compliant” with clinic staff, who called military police for help. The military police sent Russell back to his unit, but within an hour he took a loaded M-16 rifle from another soldier, stole an SUV and went back to the counseling facility where he is alleged to have killed the five troops.

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An Army Times article about the report says the investigation found that “many of the patients seen by the center’s staff are ‘potentially violent,'” and there are “inadequate locks'” on the clinic building’s exterior doors.

“Minor physical security improvements would have made the facility safer for the staff members and patients alike,” the report found.

The report also noted communication difficulties for military police; those officers had no policy about how to warn potential victims at the base of a credible threat and poor radio communication that forced them to meet in person to share information about the suspect.