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Assisting People & Organizations in Crisis
A company’s failure to communicate important information in the wake of deadly gunfire to survivors exacerbates a tragedy.
No One Here Gets Out Alive
All is not well in the home of Gretchen and Peter Mansfield.
Gretchen, 41 is a sales manager for Durham, N.C.-based
pharmaceutical manufacturer BioRealm. Her husband Peter, 44,
lost his sales job in mid-2015 and insecurity has been eating away
in the parking lot of the Durham location of BioRealm.
From the open windows of the car, Metallica’s “For Whom the
Bell Tolls” was blaring.
Peter wore a two-day beard, but there was nothing else in his
appearance to warrant alarm.
As he walked to the front door, carrying a large black gym bag
and a vinyl grocery bag, he caught the eye of Sandy Brick,
Gretchen’s friend and coworker, whom he’d known for years.
Sandy always liked Peter.
“Hey Sandy,” said Peter with a smile.
He was in sales for years. He can do this.
“Hey Peter, what brings you here?” said Sandy.
“Gretchen forgot her lunch bag and her gym bag,” said Peter
affably, smiling and holding up the gym bag as he did so.
A big part of Gretchen’s job is working with BioRealm’s SVP
for sales, Brian Hatch, 35. Fit, good looking and very well
compensated, Brian is Peter’s current nightmare.
He did this just as Sandy reached the front door. Not giving her
action a second thought, Sandy swiped her security card to open
the front door and allowed Peter in ahead of her.
“You know where Gretchen’s office is, right?” Sandy said.
Brian and Gretchen spend a lot of time traveling together,
sometimes staying in the same hotel for days at a time. Peter,
always the jealous sort, stole Gretchen’s work email password
long ago and has been following her every move.
“Sure I do,” said Peter with a smile that faded a little too quickly.
He’s read emails between Gretchen and Brian that left no doubt
in Peter’s mind they were having an affair.
Peter half-jogged to Brian’s office pulling a Glock 9 mm handgun
with a 12-round magazine from the grocery bag and an AK-101
with a 30-round clip from the gym bag.
But instead of heading toward Gretchen’s office, Peter made a
beeline for Brian’s office, in the opposite direction.
The last straw was when he picked up a voicemail from Brian that
went direct to Gretchen’s email. Hearing Brian describe what he’d
like to do with Gretchen the next time he saw her sent Peter over
Approaching Brian’s office, he heard his voice, that same
confident baritone that Peter last heard on Gretchen’s voicemail.
Peter’s rage went from burning red to white hot.
At 11:10 am on September 15, 2015, Peter parked his family’s SUV
Now running, Peter burst into Brian’s office and shot him three
times in the head with the Glock. Peter bit completely through his
lower lip as he shot Brian, so intense was his anger.
Not knowing exactly what they heard, BioRealm employees
turned their heads to see Peter, with blood running from his
mouth, leaving Brian’s office holding the handgun and the assault
rifle and heading toward Gretchen’s office.
Now it’s clear what’s happening. Screams begin to rise from the
Falling Short of Competence
BioRealm prided itself on having a state-of-the art emergency
response and security system. In the wake of numerous office
shootings throughout the country, the company installed swipe
card security six months before Peter Mansfield’s shooting
“He’s going for Gretchen!” a woman shouted.
Two men rushed Peter and he shot them down with a burst from
Gretchen poked her head out of her office at the sound of the
second round of shots. She saw Peter coming at her. But it wasn’t
like it was him at all.
His face was a grey mask and his pupils were pinpoints.
Gretchen’s right hand went up reflexively as Peter fired a 9 mm
bullet through her hand and into her temple. Peter fired again
and again, some of the bullets hitting Gretchen’s falling body and
some of them ricocheting off of office fixtures.
Within 10 minutes of the attack, a text alert was sent to all
BioRealm employees and their preferred emergency contacts
informing them of the incident.
In a half-jog, wiping spasmodically at his bleeding mouth, Peter
moved back to the front door.
The text informed BioRealm employees to punch in a code
number to let the system know they were safe and sound.
People attempting to flee the building scattered as he
approached. Peter fired with the AK-101 as he neared the
front door, striking at least half a dozen people as those more
fortunate fled in a different direction.
The text lacked specific detail, however, only informing
employees and next of kin that an incident had occurred at
the Durham campus and that BioRealm was working with local
authorities to resolve any issues.
The exit door was streaked with blood. A woman with sandy hair
was propped against the door, dead.
The texting system also failed to take into account any employees
that might have gone into hiding when Peter Mansfield first
Peter grabbed her by the hair and tossed her aside to clear his
exit. The door wouldn’t budge. So he shot the latch to pieces with
Peter shot Brian Hatch down at 11:12 am.
Peter walked out to the parking lot, placed the muzzle of the
Glock in his mouth and pulled the trigger. Blood splattered on
the BioRealm sign adjacent to the front door.
At 1:10 pm, Angela Brighton, an event planner who assisted the
BioRealm sales team, was still hunkered down in a utility closet on
the first floor of the Durham offices. When the shooting started,
Angela fled for cover, not having time to take her cell phone with
Peter Mansfield’s final visit to BioRealm lasted all of three minutes
and 25 seconds.
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In her haste to pull the closet door shut, Angela lacerated her
shin against the edge of a mop bucket. Traumatized and now
dehydrated, Angela finally burst out of the closet at 1:15 p.m.,
overcome by claustrophobia and pain and crying hysterically. The
building by then had been evacuated.
“Text them?” Blinton asked.
Angela suffered the surreal experience of walking thorough the
BioRealm offices, seemingly by herself. In her shock, she saw a
smear of blood on a corridor wall, and traced it with her finger, as
if to confirm for herself that it was real.
Blinton gave Galbreath a look and then turned away to start
The first person she encountered was a County Police Lieutenant,
who looked at her in shock when he saw her.
Social media was alive with cell-phone footage of Peter
Mansfield’s exit from the BioRealm offices, when he heartlessly
yanked a dead woman’s body from the door and shot his way out.
“Ma’am, have you been in here the whole time?” the Police
Lieutenant asked her.
“Nobody….nobody said anything,” Angela said, visibly
distraught. “Nobody came looking for me. It’s like I don’t exist,”
she said, clearly off-center.
Quickly, the Lieutenant got her a seat and ordered medical
attention for her via walkie-talkie. No sooner did he have her
seated when Gabe Crooks, an intern from Duke, walked up.
“I was in a second floor bathroom,” Crooks told the Lieutenant.
Crooks was less visibly shaken than Brighton, but he was clearly
“I’d like to go home now,” he told the Lieutenant.
In a nearby hotel conference room, BioRealm risk manager
Nathalie Galbreath, company CEO Keith Ryerson and chief
communications officer Roger Blinton were huddled over scratch
pads, cell phones and laptops.
“Yep. Do it. It’s the fastest way to get to them,” Ryerson said.
The swirl of events continued.
A gutsy BioRealm intern somehow managed to follow him to the
door, shooting video with her phone. She posted the video to
Facebook within ten minutes of Peter’s death.
BioRealm’s attempts to comfort bereaved families and provide
information to others continued to fall short.
Four hours after the incident, no BioRealm employee had
reached out to families in person to tell them what was going on.
Contrasting this failure was the excellent effort put out by local
emergency responders, who placed personal calls to the homes
of every dead or injured employee.
With frustration against BioRealm building to a peak, the grieving
sister of a slain employee became outraged when BioRealm
couldn’t give her a solid answer as to when she’d be able to enter
the building to collect his belongings.
“What do you mean you can’t answer that?” she screamed at
a BioRealm employee outside the Durham offices as television
cameras recorded the moment.
“How many are still unaccounted for?” Ryerson asked Galbreath.
“My latest information is five,” Galbreath said.
“That’s five employees that aren’t in the time and attendance
system as being on business travel or vacation and who haven’t
responded to the emergency text.”
“Dead and injured, again?” Ryerson asked Galbreath.
“Seven dead, four injured, one critically.”
“Text the families of the missing again,” Ryerson told Blinton. “Let
them know that we’re still working with authorities to find their
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“My brother is dead! Answer me!” she screamed as the
employee, rattled, turned his back on her and headed back into
the building, all the while on camera.
Television news producers edit the blood-spattered BioRealm
sign into their coverage.
It took BioRealm executives until noon the following day to
determine that their time and attendance system malfunctioned
and that the five “missing” employees were actually in the
building at the time the shooting occurred and had fled to their
None of the five ever came back to work for BioRealm.
No Quarter Asked or Given
BioRealm were prepared for an active shooter scenario, or so they
thought. There was the aforementioned addition of swipe card
security. The company was also banking on its text messaging
system to get crucial information out to friends and family in a
“Let me get this straight. Nobody made any attempt other than
a text message to reach you and no one came looking for you,”
one of the attorneys handling the lawsuit asked Brighton and
“No one,” Brighton said.
“No one, means no one,” said Brooks, whose usually sunny
disposition was under a very dark cloud.
“Who allows a non-employee to enter a supposedly secure
building carrying a heavy black bag?” another attorney
representing the employees in the lawsuit said to one of his
colleagues as they prepared their brief.
The reputational harm caused by social media sharing of the
Peter Mansfield shooting video, plus the images of a BioRealm
employee turning his back on a grieving family member also
wouldn’t go away.
The company had created an evacuation plan and an emergency
communications plan in case of an extreme weather event or
some other catastrophe. The actual event, someone’s spouse
entering the building and killing people, simply overwhelmed all
BioRealm’s risk management and emergency response
management failures would prove costly in human and financial
Keith Ryerson’s inability to realize the importance of speaking
directly to employees and their families on the most notorious
day in his company’s existence did not play well.
Coupled with the results of investigations that reported that
BioRealm failed to adhere to its own crisis response policies,
families that felt their loved ones were killed or injured due to
corporate security laxity filed suit.
Also filing suit were 25 BioRealm employees who left the
company after the shooting. They alleged that the company’s
emergency management training and security measures were
Included in that class of litigants were Angela Brighton and Gabe
Brooks, the two employees who were left behind the day of the
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“We’re going to have to up investments in security,” Nathalie
Galbreath told Keith Ryerson in a meeting two months after the
“I’m talking metal detectors on every door and armed security
guards. I think it’s the only way we’re going to get any sense of
stability in our workplace,” she added.
“Do you know what our legal bill is already from this?” Keith
Ryerson said to her.
“Um, no, I don’t know what it is,” Nathalie said, not feeling very
“How about $650,000 and we’re not even at trial with any one of
five lawsuits?” Keith said.
Keith Ryerson put his head in his hands.
“Go ahead,” he said.
“Go ahead what?” Nathalie said, sharing his exhaustion and
“Go ahead and order the metal detectors, order the guards,”
Keith said weakly.
Disclaimer: The events depicted in this scenario are fictitious. Any
similarity to any corporation or person, living or dead, is merely
Lessons Learned – Partner’s Content
Risk & Insurance® partnered with Black Swan Solutions to produce
this scenario. Below are Black Swan Solutions’ recommendations
on how to prevent the losses presented in the scenario. This
perspective is not an editorial opinion of Risk & Insurance®.
1. Crisis Response and Business Continuity plans must coordinate
with community police, fire and emergency medical agencies. In
addition, pre-establish coordination with a local chapter of the Red
Cross. All organizations rely on community responders to assist in
a crisis. Yet most never proactively involve these same agencies in
plan development and testing. If a crisis occurs, this can result in
significant challenges related to cooperation and coordination.
2. Have a plan for testing, shelter in place and evacuation processes
including a reliable means to account for every employee on
premise at the time of the event. This information will also be
invaluable for first responders involved in the search and rescue
3. Have a secure centralized database for up to date information.
This will allow for timely and accurate notifications to stakeholders.
4. Consider contracting with a specialized crisis call center to
ensure you have a plan in place to accommodate mass inquires
while providing a professional and compassionate response.
Families will expect your organization to provide timely information
and account for their loved ones who may have been affected by
the crisis. The volume of inquiries and requests for information will
often overwhelm your expectations and capabilities to respond.
5. Difficult news must be delivered personally. If the news is not
good, make the effort to say it either in person or on the telephone
– don’t text it. Realizing you have to use the tools and contact
information you have, do your best to connect on a personal level,
no matter how challenging, when you must deliver bad news.
6. Prior to a crisis, identify and train organizational personnel who
will interface with victims and families in a critical event. Understand
the importance of self-care for those involved in responding to
the incident and debrief them at the end of every shift. Consider
contracting with an organization to provide specialized training,
as well as to provide guidance and support to those employees
during the crisis.
7. Pre-consider strategies for establishing a family assistance center,
typically at a hotel, where victim families can gather to obtain
information and receive emotional support and psychological first
aid. Families also have an opportunity to obtain information from
WHAT ARE RISK SCENARIOS?
Created by Risk & Insurance® editors along with key industry thought
leaders, Risk Scenarios are hypothetical situations that showcase
emerging risks. Participants first consider how they would handle the
challenge before reviewing key risks, available solutions and related
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• Available Solutions: Products, services and companies that provide
risk mitigation solutions.
• Additional Scenarios: Read other risk scenarios on a variety of topics.
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Assisting People & Organizations in Crisis
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