Applying sentinel event reviews to policing

• Author: Ben Grunwald,John F. Hollway
• DOI: http://doi.org/10.1111/1745-9133.12457
• Date: 01 August 2019
• Published date: 01 August 2019

DOI: 10.1111/1745-9133.12457

RESEARCH ARTICLE

SENTINEL EVENT REVIEWS

Applying sentinel event reviews to policing

John F. Hollway1Ben Grunwald2

1University of PennsylvaniaLaw School

2Duke University School of Law

Correspondence

JohnF. Hollway,University of Pennsylvania

LawSchool, 3501 Sansom Street, Philadelphia,

PA19104.

Email:jhollway@law.upenn.edu

Research Summary: A sentinel event review (SER) is a

system-based, multistakeholder reviewof an organizational

error. The goal of an SER is to prevent similar errors from

recurring in the future rather than identifying and punishing

the responsible parties. In this article, we provide a detailed

description of one of the first SERs conducted in an Amer-

ican police department—the review of the Lex Street Mas-

sacre investigation and prosecution, which resulted in the

wrongful incarceration of four innocent men for 18 months.

The results of the review suggest that SERs may help iden-

tify new systemic reforms for participating police depart-

ments and other criminal justice agencies.

Policy Implications: Police departments and other crim-

inal justice agencies should begin implementing SERs to

review a wide range of organizational errors and “near

misses.” We offer guiding principles about the kinds of

errors that may be more or less susceptible to fruit-

ful review. Congress, state legislatures, and municipal-

ities should also enact policies—such as safe harbor

provisions—to encourage agencies to conduct SERs.

KEYWORDS

policing, procedural justice, quality improvement, root cause analysis,

sentinel event review

When something goes wrong in the criminal justice system, the public debate, the courts, and the media

tend to focus on a series of questions related to individual fault. Who committed the error? Was their

judgment reasonable? Was it improperly influenced by legally suspect considerations like race, class,

or a conflict of interest? And will they be punished for the error? This kind of response is often called

the person-based approach to error (Reason, 1990).

Criminology & Public Policy. 2019;18:705–730. wileyonlinelibrary.com/journal/capp © 2019 American Society of Criminology 705

706 HOLLWAY AND GRUNWALD

Focusing on individual fault makes sense, at least to some extent. Criminal justice officials hold

massive powers over the lives of American citizens (Bittner, 1970; Lipsky, 2010; NAS, 2004). When

they wield that power inappropriately, one correct response may be to retrain, discipline, or fire them

(Kane & White, 2013).

But individual actions are just one part of a larger and more complicated puzzle about errors in

complex human systems (Dekker, 2016; Reason, 1990; Van Dyck, Baer, Frese, & Sonnentag, 2005).

Organizational management scholars haveargued for decades that rather than investigating and punish-

ing the faults of the individual actor alone, organizations should also focus on preventingsimilar er rors

from recurring in the future. To do so, they should expand their attention to flaws in the wider system

in which individual actors operate. This is the system-based approach to error (Reason, 1997). It has

been adopted in many professional fields—like aviation, energy, and medicine—in which individuals

in rapidly changing circumstances must make split-second decisions based on imperfect information.

One core tool in the system-based approach to error is the sentinel event review (SER). A sentinel

event is a high-profile error—an undesired outcome that results in significant damage to the system

and its credibility. An SER is a voluntary, multistakeholder, nonpunitive review of such an undesired

outcome. Its primary goal is to apply a root cause analysis (RCA) to identify, assess, and respond to the

contributing causes—the underlying acts, omissions, or environmental factors—that led to the error,

as well as to devise solutions to minimize such errors in the future (Carroll, Rudolph, & Hatakenaka,

2002; Doyle, 2014, 2018).

From decades of experience, we know that the system-based approach in general, and SERs in

particular, have helped reduce errors in other fields (Reason, 2000). And, in the last four years, the

SER has received significant support from both the National Institute of Justice and the President’s

Task Fo rce on 21st Century Policing (2015). In this article, we seek to assess the potential contributions

of SERs to policing and other criminal justice agencies.

We begin by arguing that SERs may provide at least three primary benefits to police departments.

First, as in other fields (Bagian et al., 2002; Carroll et al., 2002; Knudsen, Herborg, Mortensen,

Knudsen, & Hellebek, 2007), they may generate novel institutional reforms that, over time, promote a

department’s effectiveness by reducing errors. As one example, SERs might improve a department’s

investigative practices, thus, helping it arrest more offenders and fewer innocents. Second, SERs

may build institutional buy-in to implement both well-known best practices as well as new reform

proposals generated by the SER. And finally, SERs may help improve public perceptions of the

legitimacy of a participating criminal justice agency, not only by reducing its errors over time but also

by demonstrating to the public that the agency takes its errors seriously and is committed to learning

from them (Tyler, Goff, & MacCoun, 2015).

Unfortunately, there is little data available to assess how successful an SER might be in practice

because the idea is relatively new to the criminal justice system. Indeed, criminal justice agencies are

often reluctant to open themselves up to close public scrutiny. Perhaps more important, there are real

implementation obstacles, even in departments that are open to system-based review.In the absence of

any legislative safe harbor (Nijm,2003), police agencies and their employees may worry that informa-

tion collected during an SER may be disclosed in civil discovery and used against them in court. As a

result, we have little data about how an SER might work in practice in a police department.

In this article, we begin to address that problem by providing the first detailed description of an

SER in an American police department—one that circumvented the obstacles described above by

examining an error 13 years after the events occurred, long after legal liabilities were settled through

litigation. In 2000, four men killed seven occupants of a row house in West Philadelphia and severely

wounded three more. The attack, called the “Lex Street Massacre” by the media, was the largest mass

murder in Philadelphia history (Jones, 2001). Based on a confession and eyewitness identification, the