Victoria Snelgrove died because of a series of failures by the Boston Police Department, including poor planning at headquarters, a breakdown of command outside Fenway Park, and ''serious errors in judgment" by individual officers at the scene of her shooting, an independent panel has concluded.
The department ignored lessons learned months earlier in the death of a Super Bowl reveler, who was hit by a car after the Patriots' victory, and during the Democratic National Convention, according to the panel's findings released yesterday.
''We have concluded that the death of Victoria Snelgrove is a tragedy that never should have happened," said Donald K. Stern, a former US attorney who led the panel.
Police Commissioner Kathleen M. O'Toole said yesterday that five officers, including the commander in charge of planning and another in charge of operations on Lansdowne Street that night, are facing discipline on department charges, including inappropriate use of force, poor planning, and bad judgment. The officers could be fired, O'Toole said, but the process could take weeks or months.
Snelgrove, 21, was shot, and two others were injured Oct. 21 by pepper pellets fired by officers trying to control crowds celebrating the Red Sox pennant victory.
The panel's 50-page report is harshly critical of officers on Lansdowne Street that night, saying they fired FN303 pepper-pellet guns ''indiscriminately."
Lawyers for the officers said yesterday that the patrolmen were following orders and reacting to threats. A lawyer for the on-scene commander, Robert E. O'Toole, maintained that he acted properly and based on his experience. The commander in charge of planning, Superintendent James Claiborne, did not return calls for comment.
The police commissioner said yesterday that she has appointed a committee to ensure that the panel's recommendations are carried out, including formation of a police-civilian review board to examine officer and public injuries, and improved weapons training and events planning.
''While it will provide little comfort to Victoria Snelgrove's family and friends," the commissioner said, ''I hope this effort will be a substantial contribution to public safety in preventing similar tragedies in the future."
Patrick T. Jones, the Snelgrove family's lawyer, said ''the commission's findings are broadly consistent with conclusions reached by the family's legal counsel and investigative team."
Earlier this month, the city said it will pay $5 million to the Snelgrove family in its largest-ever wrongful-death settlement.
Stern's panel, convened by the police commissioner shortly after Snelgrove's death, also recommended that national testing and standards be established on the use of all ''less lethal" weapons, including the FN303, the weapon used to shoot Snelgrove. The panel did not find any evidence that the guns, which fire pepper-spray pellets, malfunctioned that night, but said testing of the weapons is needed to conclusively determine whether they worked properly.
The seven-member panel relied on reports from Boston police internal-affairs and homicide investigators, including transcripts of 111 interviews, reviews of 140 training records, 65 after-action reports, and 22 operational plans. In addition, the panel reviewed video and photographic accounts.
The panel included Raymond L. Downs, a retired deputy director at the National Institute of Justice's Office of Science and Technology; Robert P. Gittens, vice president of public affairs at Northeastern University; Christopher E. Stone, a criminal justice professor at Harvard University; Janice W. Howe, a product-liability lawyer and former assistant district attorney; Major Steven Ijames of the Springfield, Mo., police, a specialist in less-lethal weapons; and Patrick J. King, a retired Massachusetts trial judge.
The failures that led to Snelgrove's death began with planning. Claiborne and his team did not examine possible scenarios for the night or issue guidelines for the use of force when preparing for the event, the Stern panel said. Both were recommended after James Grabowski was killed during the 2004 Super Bowl celebrations and for the Democratic National Convention.
The planning team also ignored advance intelligence that revelers would probably gather on Lansdowne Street and did not place specially trained riot police there, instead stationing them at Kenmore Square and near Northeastern University.
When Lansdowne Street flooded ''wall to wall" with celebrants after the game ended about midnight, officers not adequately trained in crowd control became ''outnumbered and outflanked," the report said. The commander in charge of police operations around the ballpark, Deputy Superintendent O'Toole, then incorrectly issued pepper-pellet guns to officers he knew were not certified to use the gun and took one himself, even though he, too, was not certified, the report said.
O'Toole, no relation to the commissioner; Patrolman Samil Silta, and Officer Rochefort Milien, the only officer certified to use the gun, started firing at fans on the back of the Green Monster.
The report cites one witness account that Robert O'Toole fired as if hoping the pellets hit intended targets. The two other officers fired their weapons indiscriminately, continuing even as people were climbing down.
Two people were shot in the face, 24-year-old Cambridge resident Paul Gately and Boston College student Kapila Bhamidipati. The injuries were not reported to headquarters, which could have alerted police to problems with the FN303, the report says.
Robert O'Toole, meanwhile, tried to hand his gun to Officer Steven Gil, saying, ''Stevie, are you certified on this?" Gil said no and refused to take the weapon. The commander then gave the gun to another officer, who said he was also uncertified. O'Toole replied, ''Just pull the trigger," the report said. That officer did not fire the weapon and is not facing discipline.
A short time later, after officers had cleared much of the crowd from a section of Lansdowne Street, Milien fired two quick shots at a man he said had been throwing bottles. One of the pellets struck Snelgrove in the eye. The panel concluded that Milien fired so quickly he probably did not have time to aim properly.
An officer at the weapons supply truck on Brookline Avenue, Patrolman Thomas Gallagher, failed to treat the returned weapons as evidence, not tracking who had fired which weapon.
Claiborne, Robert O'Toole, Silta, Milien, and Gallagher were recommended for disciplinary action yesterday by police Internal Affairs Unit. Suffolk District Attorney Daniel F. Conley has not decided whether to bring criminal charges, a spokesman said.
Thomas Drechsler -- a lawyer for Silta, Milien, and Gallagher -- called the commission's criticism of the officers ''terribly disappointing and unfair."
''Anything that those three officers did was under the direct supervision and control of their supervisor," he said.
The lawyer representing Robert O'Toole said the commander did not have enough officers and denied he fired haphazardly. ''If that was the case, there certainly would have been more injuries," lawyer Timothy Burke said.
In February, the commissioner transferred Claiborne from supervision of all uniformed officers to managing department training.
She said she did not sign off on Claiborne's operations plan, which was not completed until the night of the Red Sox game. She appointed the panel after the Super Bowl death that recommended better planning for all major events.
Mayor Thomas M. Menino said yesterday that he has ''full confidence" in the police commissioner. ''Anyone who second-guesses her," he said, ''doesn't understand the quality of this individual."
Shelley Murphy, Suzanne Smalley, and Andrea Estes of the Globe staff and Globe correspondent Cyra K. Master contributed to this report. Donovan Slack can be reached at firstname.lastname@example.org.