While a motive for the shooting remains unclear, Nashville Police Chief John Drake said investigators believed Hale, who police identified as transgender, may have harboured “some resentment” for having attended school as a child.

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He also told reporters that Hale was under medical care for an “emotional disorder” but managed to buy seven firearms legally – all of which were hidden from her parents.

But while the school was singled out for the attack, police reiterated that the individual victims were targeted at random.

Those victims were identified as Evelyn Dieckhaus, Hallie Scruggs, and William Kinney - all aged 9 - as well as Katherine Koonce, 60, the head of school; Mike Hill, 61, a school custodian; and Cynthia Peak, 61, a substitute teacher.

The bloody episode marked the 130th mass shooting this year, according to the Gun Violence Archive, which defines a mass shooting as four or more people shot or killed, not including the shooter.

And like the Uvalde massacre in Texas last year - which killed 19 children and two teachers - the incident has shattered yet another school community and reignited the vexed debate over the right to bear arms in America.

On his way to North Carolina, President Joe Biden once again pleaded with Congress to pass stronger gun safety laws, including a ban on assault weapons, noting he had already used “the full extent of my executive authority” to tighten the system.

“I can’t do anything except plead with the Congress to act reasonably,” he told reporters before departing the White House. “The majority of the American people think having assault weapons is bizarre; it’s a crazy idea. They’re against that. And so, I think the Congress should be passing the assault weapons ban.”

The shooting took place on Monday morning, US time. The Metropolitan Nashville Police Department began receiving calls about a shooter at 10.13am, with the suspect was pronounced dead by 10.27am. Patton told NBC that she saw the messages Hale sent at 9.57am. She said she called the suicide prevention hotline, which instructed her to contact the Davidson County Sheriff’s Office. The office, in turn, directed her to a non-emergency hotline.

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Footage released by police showed how Hale shot through the doors of the school and ducked through broken glass before wandering around the corridor holding a gun with a long barrel. At one point Hale walked into a room labelled “church office” before coming back out. The shooter could later be seen walking down another long corridor with the gun drawn.

According to police chief Drake, Hale conducted surveillance of the school building before carrying out the massacre, prepared a detailed map with potential entry points, and even planned out the clothes worn that day.

Hale also left behind a “manifesto” and other writings that investigators were examining, Drake told reporters.

The shooting has put the spotlight on the Tennessee legislature, where politicians are currently working to loosen gun control laws, including lowering the minimum age for carrying guns from 21 to 18. In 2021, the state passed a bill allowing people aged 21 and older to carry loaded handguns in public - openly or concealed - without requiring a permit.

“The cold horror of this attack is unthinkable,” said Dr Katrina Green, an emergency physician practicing in Nashville.

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“Our state leaders need to take a hard look at their values. Our children deserve to grow up in safe and healthy communities, free from the fear of gun violence. The right of our children to live should trump anyone’s right to own an assault weapon.”