IT WAS THE BLOOD—so much of it, too much of it. That was the giveaway.

Officer Dane Reister was kneeling on the shoulder of the 20-year-old he'd just hit with his bright orange "beanbag" shotgun, and he couldn't stop looking at the blood.

It just kept gushing, from holes across both of William Kyle Monroe's legs, onto the grass below, pulling all the pink from the agitated young man's face.

It was gushing so heavily, another cop huddling over Monroe couldn't resist poking one of the wounds.

Beanbag rounds are supposed to leave bruises, not holes. And while they've been known, in rare cases, to bite through skin and make a mess ("over-penetrate," in the sterile jargon of police work), it's not supposed to look like this. There was just too much blood. Something was wrong.

Reister called for a medic. And then he stood up.

"I'm like, I, what's going on here?" Reister would later tell detectives, investigating him just like any cop in Portland who uses deadly force. "My mind is just sp- sp- spinning, and I walk down the hill to where I believe I was standing, and I see a spent 12-gauge lethal round. And my heart sinks.

"And it makes sense," he continued. "And my feelings of... uh... relief that it was over, that it had, that we had safely... uh... stopped this guy before harming somebody went from relief to, 'Oh my god, what just happened?' A horrible mistake has been made."

How "horrible" would remain to be seen.

AFTERMATH OF A TRAGEDY

Monroe, a well-loved young man in a mental health crisis when he was shot the morning of June 30, 2011, was left with permanent and debilitating injuries. The buckshot that tore through his legs caused nerve damage so severe he'll never walk normally again. And in the months since he was shot, Monroe endured a series of painful complications and operations—some affecting his digestive tract.

Reister's "mistake," meanwhile, would lead to a lawsuit and a record settlement for a local police shooting: $2.3 million. It brought criminal charges of negligence—a first for a Portland cop's use of force in the course of duty. It drove some modest changes in training, and an apology from Chief Mike Reese. It also cost Reister his job, in early October, more than two years later.

But even worse? It might never have had to happen.

Internal documents released in the wake of Reister's dismissal—including training and investigative records requested exclusively by the Mercury and made public over the city's strong objections—revealed that Reister was never certified to use a beanbag gun in the first place.

In fact, he was among a handful of cops who'd spent years using one, despite his lack of proper credentials—exposing deep, structural flaws in how the police bureau monitors and teaches its officers.

This also wasn't his first lapse. Reister's letter of termination, jointly requested by the Mercury and the Oregonian, confirms he once injured a fellow cop in a training exercise by mistakenly firing a live smoke round from a riot-suppression launcher. He'd also been written up for other accidents and slipups involving police property.

But while the documents also provide, for the first time in public, what was going through the minds of Reister and other cops before and after Monroe's tragic shooting, they still don't answer the most important question: How did Reister manage to stuff live ammunition into a shotgun marked for beanbag rounds?

Asked by an internal affairs investigator if he had a "specific memory" of what went wrong, Reister could only answer, "No, sir, I do not."

A MAN IN A PARK

Kawika Bernal could tell something was off about the man he and his mother were watching in Lair Hill Park. They were running a Hawaiian-themed camp for kindergartners attending a nearby Waldorf school, and they had the kids outside on a pleasant day, making flower leis.

And this young guy, dressed in black with white tennis shoes, was making them nervous.

The man, later identified as Monroe, gave off a "weird vibe," Bernal told police investigators, like maybe he was under the influence. He was plucking flower stems from the garbage can and throwing them on the ground.

Bernal's mother, Sacha Etzel, remembers Monroe asking to hang out with her. She could see he was in distress, but she told him no all the same—because she had so many kids to mind. But Monroe didn't take her answer very well. He clenched his fists and started accusing Bernal of looking for a fight.

Etzel was frightened, and scared that Monroe might have a weapon. But still, somehow, she managed to persuade him to leave the park.

"I didn't want to freak the guy out, because I knew he would attack me," she told investigators.

That's when Bernal first called 911, hoping a cop would check things out. The dispatcher told him to call again if Monroe came back. And a few minutes later, he did.

That time, the dispatcher heeded Bernal's request for an officer. Dean Halley was on his way.

What no one knew was that Monroe, diagnosed as bipolar, was deep in a mental health crisis. He wasn't drunk. He wasn't high. And had never meant to set foot in Lair Hill Park or any other park.

He was trying to visit his mother.

According to court papers, Monroe had left his home in Hillsboro the afternoon before, starting out on the long drive to see her in Bremerton, Washington. But he wasn't feeling good. He parked in Southwest Portland and started walking.

Then, disoriented and drifting away, Monroe forgot where he parked. He walked all night looking for his car, ending up in Lair Hill Park exhausted, sleep deprived, and agitated.

Soon after, David DeMarkey placed what would be the third and final 911 call about Monroe.

DeMarkey, an administrator at the Waldorf school, had heard all about the confrontation in the park and was checking to see if Monroe had left. He saw him nearby on SW Barbur and went up to speak to him. He thought he'd made peace with Monroe, persuading him to leave because he was scaring people. As he tried to seal the bargain with a handshake, he saw what was in Monroe's right hand: a small pocketknife, with the blade extended.

"That certainly got me thinking," DeMarkey told investigators, "all right, you know, what's the best thing to do about this individual."

Halley was already on the way when 911 radioed out about the knife—just a few seconds away, in fact. He agreed with the dispatcher that it might make sense to send one more car for cover.

Officer Reister, driving nearby, heard the chatter play out. No one asked him to show up, but he radioed in all the same, asking a few questions about what to expect if he did join in—a man with a "pocketknife" who "appeared drunk" and who "has been hassling kids at a camp."

A little more than two minutes later, Reister was back on the radio saying he had his orange shotgun out and was after a young man who wouldn't do what he was asked.

THE SHOOTING

Reister, in fact, was the first officer to come across Monroe. Monroe, Reister told detectives, had walked down near SW Naito and Curry and was staring at a woman on a nearby back porch, looking like he was high or delirious. Reister didn't know which.

Reister got out of his car and tried to talk to Monroe calmly, drawing on his crisis intervention team training. Reister, according to documents obtained by the Mercury, would often volunteer for shifts with the bureau's Service Coordination Team in Old Town. It's work that frequently puts cops in contact with people in crisis.

First, Reister tried getting Monroe to sit down or show his hands. But Monroe, still manic and paranoid, wouldn't listen. He just kept gritting his teeth and tensing up his body.

Reister decided to show a little bit of muscle. He quickly grabbed his orange shotgun from the car—he'd already loaded it before starting his shift—and racked a round into the chamber. By this point, Reister said, he'd already seen Monroe with a knife in his hands, and that he'd been fumbling with it.

It was "very clear," he told investigators, "it was a knife."

But Monroe was even quicker. He started emptying his pockets. And then he sprinted several feet away before turning around and slowly walking backward.

Reister thought about firing as he tried to close the distance, figuring Monroe was maybe only a few feet past the shotgun's "effective range"—worth the risk. Reister told investigators he was desperately afraid that Monroe, even more agitated, might have headed back to the camp or into a neighborhood.

Reister never got the chance, because one of the other officers who'd showed up, Stu Palmiter, had run between Monroe and his gun. They chased Monroe up against a hill near the Caro Amico Italian restaurant. Slowly, Reister inched back into shotgun range.

Palmiter, next to Reister again, had pulled out his Taser. He later remembered Reister telling Monroe he wanted to talk and Monroe agreeing that would be okay. He also remembered Reister warning Monroe not to put his hands back in his pockets, or else he'd be shot.

Reister said he shouted "so many commands" at Monroe and warned him not to move. He told investigators he "couldn't believe it" when Monroe tensed up, one last time, and made like he was maybe ready to run off again.

Reister opened fire. First the right thigh. Then the left. The shots sent Monroe running.

"No effect," Reister told detectives. "He stayed on his feet."

He fired twice more, still at the thighs, and Monroe finally toppled with cries of pain that civilian witnesses said they could hear from nearby apartments and homes.

Ironically, Reister said, "I know not to shoot at the same spot every time, because it can cause over-penetration. Um, and serious physical injury."

He and Palmiter handcuffed Monroe, both stunned by the blood. Monroe, if he hadn't been so close to a hospital—Oregon Health and Science University—probably would have bled to death. His right thigh had only been grazed, but one round had punctured his right buttock, with two others spreading pellets into the back of his left thigh.

Palmiter went to find the various bits Monroe had been tossing away. The knife was among them. Police supervisors and training instructors found no fault with Reister's decision to shoot.

Palmiter also noticed, just like Reister, the telltale color of the shells on the ground.

Non-lethal shells are yellow. Live shells are red.

Four empty red shells sat scattered in the grass. One live beanbag round joined them, somehow ejected from the chamber during the flurry.

"I looked at it, and it was red," Palmiter told investigators, "and it was like, 'Oh, shit.'"

MISSING MEMORIES

Reister's shift on June 30, 2011, he told investigators, started like any other.

And even months later, he would say, he couldn't fathom any earthly reason for how or why he put lethal shotgun bullets into a less-lethal shotgun.

After roll call, he walked from Central Precinct over to his cruiser, parked in the basement of a city garage at SW 1st and Jefferson. He had two long-range weapons with him—one of them deadly (his AR-15 sniper rifle) and the other one presumably not (his unloaded orange beanbag shotgun). He stowed the guns, once inside the car, putting the shotgun in its designated rack.

But not everything that morning was the same.

He was missing his "duty bag"—the special sack that officers use to hold their gear, including ammunition. He'd left it in the basement of the Justice Center after his previous shift four days before—an overtime gig patrolling Old Town until 4 am on June 26.

That was his second off-hours overtime shift that week, according to documents obtained by the Mercury. And it was especially notable, because he'd deviated from his usual routine that night, he told investigators. Instead of taking his AR-15, Reister had grabbed a regular shotgun as his long-range lethal weapon. He hadn't done so, he said, in several years.

That should have given him pause the next time he was working. But asked if he remembered looking at the rounds he was loading into his orange shotgun on June 30, he said he did not.

"No, I don't," he told detectives. "It was just part of my routine."

Reister insisted he had a system. He would keep both kinds of rounds in his duty bag, but separated by binoculars and in different containers: less-lethal rounds in plastic bags, lethal rounds in the manufacturer's box. If he emptied a plastic bag, he'd stow it on the visor in his patrol car. If he emptied a box, he'd leave the box in his car or duty bag.

But that system clearly failed him.

Detectives, after the Monroe shooting, would find two plastic bags full of less-lethal rounds among Reister's possessions. They also found an empty plastic bag.

Investigators then went looking for an empty box of lethal shells—figuring the box would settle things.

It did not, however. Because they couldn't find it.

The bureau's training report took a dim view of Reister's hazy memories. It blasted him for not, apparently, looking over the bullets he was loading. It also rapped him for failing to recognize the difference, as he was firing his gun, between the volume and kick of a lethal round and a beanbag round.

Despite primarily blaming Reister for the mistake, the bureau still made one major change in the months after the shooting. Since October 2011, orange shotguns are affixed with special ammunition carriers. At the time of the shooting, an expert on less-lethal munitions told the Mercury the bureau had been playing with fire by waiting so long.

That didn't mean that bigger problems with training weren't still lurking.

LESSONS LEARNED?

If the Mercury hadn't thought to ask for the release of two key documents in the Monroe shooting—the bureau's training review and internal affairs investigation—two of the most surprising findings in the case might never have become public.

Reister had never been formally certified to carry the weapon on patrol, despite thinking he'd received that permission almost 10 years before he shot Monroe. Worse, he's not the only cop the bureau turned up in that strange position.

Reister, it turned out, had never attended what was supposed to be a mandatory two-day training class on the less-lethal shotgun. Those classes are required before a cop is allowed to carry a given weapon on patrol. It's presumably where issues like sound and recoil would be discussed. Rather, in 2002, Reister had attended a separate less-lethal training class for members of the bureau's crowd-control squad—and thought that had qualified him for the beanbag gun instead. Since then, Reister had been a regular at the shooting range. He also used the gun several times while on patrol.

"After [a] review of Officer Reister's training record, it shows that he did not ever attend [the] designated less-lethal 12-gauge [shotgun] certification course," the training analysis says. "Officer Reister does not have a less-lethal certification entry on his training record."

But the investigation kept turning up troubling details. That 2002 less-lethal class apparently did not include any hands-on training with less-lethal shotguns. It focused on smoke grenade launchers.

Reister admitted never laying hands on a shotgun during the class. And, yet, he also had no compunction about signing a qualification form saying he was certified.

He and other officers in similar straits told investigators they were told it was okay by their instructors. But the instructor Reister named, Steve Buchtel, said he didn't remember telling anyone they were certified to use the shotgun.

The discrepancy led to another startling discovery. Several lesson plans for the bureau's riot squad and other units appear to be missing. Having those lesson plans on hand would have made it perfectly clear whether beanbag guns were covered in the 2002 class or not.

Those missing files defy bureau policy, which calls for training division instructors to review each lesson plan before it's taught. Those lapses also raise serious questions about one of the underpinnings of good police work and careful discipline: how well officers are trained, and whether they can be punished for failing to live up to that training.

"If this policy is not enforced bureau-wide," the analysis says, "this will continue to plague the bureau as we move forward with trying to decipher which officers received exactly what training and what was taught at the training."

THE TERMINATION

The Portland Police Association has filed a grievance over Reister's dismissal.

Chief Reese, in weighing all of the documents, had nevertheless found a surprisingly simple argument for his decision. Reister had made too many mistakes earlier in his career—with Monroe left to pay the price.

In 2006, Reese noted in his letter of termination, Reister fouled up during a training session by hitting another cop with a live smoke round he'd forgotten was still in his weapon.

He got a letter of reprimand that time. Twice, and Reese decided he could no longer risk his trust.

"There is not an excuse sufficient enough to relieve you of responsibility for not knowing what rounds you loaded in a weapon before firing it," Reese wrote, "particularly when that weapon is fired at another person with serious—and potentially deadly—consequences."