The failures of the city's response to the protests and rioting that followed the death of Freddie Gray reflected "system-wide deficiencies of long standing," according to a review released Friday.
Among other problems, the report cited a lack of a strategy to address mass demonstrations, confused and overlapping chains of command, and poor communication internally and with the public.
It comes as the city braces for reaction as the trials of the six police officers charged in Gray's death from injuries sustained in custody unfold. Closing arguments in the trial of the first officer, William Porter, are expected to begin Monday.
The city has already started to incorporate many of the report's findings and is in a better position to respond to any future problems, officials said.
"As we have said since the time of the unrest, we were not going to wait until the after-action reports were completed to make the changes that needed to be made to improve our preparation and response plans," Mayor Stephanie Rawlings-Blake said in a statement. "I am confident that we have addressed, or are in the process of addressing, many of the recommendations in the report."
The 73-page report, which contained 33 recommendations, was prepared by the Johns Hopkins University Office of Critical Event Preparedness and Response. Jonathan Links, the office's deputy director, has worked with the city on emergency response since 2001, when the city asked him about reacting to potential terrorist threats after the Sept. 11 attacks.
The report, commissioned by the mayor, came to many of the same conclusions reached by two previous studies released since the riots — one by the police union and a second focused on the Police Department requested by then-Police Commissioner Anthony W. Batts. The report issued Friday, for which the city paid $50,000, was intended as a citywide analysis.
The Hopkins review found that the Baltimore Police Department, which led response to the April riots, was operating without any formal plan for handling mass demonstrations or protests. It also found that no statement was issued ahead of the protests telling officers not to engage the protesters.
It said the Police Department did not communicate well internally, with other city agencies or with the public.
Batts took on two roles — managing the citywide response, as well as directing police operations — but he did not appear to have the uncontested authority to lead, the report found.
A poor relationship between Rawlings-Blake and Gov. Larry Hogan also contributed to the appearance of disarray throughout the week, the report said.
There were also communication problems: Officers used cellphones and radio codes specific to the Police Department that led to "little or no" coordination with other agencies and inconsistent relay of information to the central command, the report found.
Even the number of fires was incorrectly reported — there were 33 building fires and 55 vehicle fires, according to the report. Previously, the Fire Department had said there were 61 structure fires and 144 vehicle fires.
Officials failed to disseminate information effectively after deciding to shut down regular bus service around Mondawmin Mall — a move some have said exacerbated an already volatile situation by stranding students and others in the area.
The report avoided pinning that decision on one person, saying it was made jointly in the incident command center at the Police Department headquarters, with involvement by the Baltimore City School Police and the Maryland Transit Authority. A 28-page timeline attached to the report attributes a request for buses to be diverted from Mondawmin to a school police officer.
On Friday, Baltimore City School Police Chief Marshall T. Goodwin reiterated the school system's stance, which has been consistent since April, that it was not consulted or aware of the MTA decision's about the Mondawmin buses that day.
"At no time was any member of the Baltimore City School Police in the decision-making process to close the Mondawmin hub," he said in an interview Friday, after reviewing the Hopkins report. "I was notified by my officers on the ground that the Mondawmin hub had closed. I was in total shock."
Links said the finding was based on a review of audio transmissions by the city's Office of Emergency Management, and he was not surprised to hear that some might not recall the day that way. The incident command center included all the agencies, he said.
"There was a lot going on that day, and unless you're going methodically through the transmissions and the other data, it's hard to remember exactly what did and didn't happen," said Links, adding that the report identified problems with how the situation was handled. "We framed this as a communication deficiency, rather than a decision-making deficiency, because we believe the correct multi-agency citywide incident command decision making process was used, but the communication both within the agencies and to the public was the primary deficiency."
The report also provided insight into the request for National Guard troops to assist the city, which some said took too long.
At 4:55 p.m. on Monday, April 27, Batts asked the emergency management office for an additional 600 officers from other police departments, a request relayed to the state. At 6:29 p.m., he asked Rawlings-Blake to request the National Guard troops. A minute later, the mayor declared a state of emergency.
Hogan issued an executive order around 7 p.m., authorizing the Guard's mobilization. The mayor's news conference, at which she announced the state of emergency and requested Guard troops, occurred just before 8 p.m.
The report offered some praise for the city, crediting the Police Department for taking an initially restrained approach to the use of force.
That attitude, it found, "likely prevented further escalation of crowd activity and damage to community, as well as preventing longer-term damage to BPD-community relationships, although it also put front-line officers at risk at times."
That conclusion appeared at odds with the analysis issued by the police union in July, which faulted Rawlings-Blake and Batts for taking what it called a passive approach, prioritizing image over safety in a way that allowed the situation to escalate.
Lt. Gene Ryan, president of the Fraternal Order of Police, did not respond Friday to a request for comment.
In other ways, the report incorporated findings from earlier reviews.
The report said the city should adopt an incident command system that clearly places a single agency in charge of responding to large incidents, recommending that the mayor's office and office of emergency management work with city departments to clarify their responsibilities when it comes to reporting to whichever is the lead agency.
The report also said the mayor's office should adopt a clear strategy for managing mass demonstrations. It said the Police Department should outline when using force — weapons such as tear gas — and making arrests is appropriate during mass demonstrations.
It is not clear if the Police Department has developed those guidelines. A police spokesman said he would not be able to reach the right people to answer the question Friday afternoon.
On many of the items, the city has made progress, spokesman Howard Libit said. It has developed plans for protecting important institutions, such as hospitals, implemented training, purchased new equipment and beefed up hires to staff 911 lines so that they are not overwhelmed by callers.
"You've seen some of the refined procedures, policies and tactics in some of the more recent demonstrations we've seen," Libit said. "I think things have generally gone pretty smoothly. People's rights to demonstrate and ensure their message is heard have been protected and the people demonstrating have been protected, but also we have worked to minimize disruptions.
"Our hope and our expectation is that whatever happens with the current trial and upcoming trials, that people will act responsibly," he added. "But we're prepared if the need arises."
Links said he is hopeful that some of the suggestions, such as extending "community policing culture and practices" throughout the Police Department will help the city on a regular basis, not just in emergency situations.
"The report's recommendations could be used on a daily basis by the Police Department, and in fact the city as a whole could use the recommendations for incidents that don't rise to the level of April's unrest/riots," he said.
Baltimore Sun reporter Erica Green contributed to this article.