TY  - JOUR
TI  - Root Cause Analysis: A Tool to Promote Officer Safety and Reduce Officer Involved Shootings Over Time
AU  - Hollway, John
AU  - Smoot, Sean
AU  - Lee, Calvin
T2  - Villanova Law Review
AB  - To date, efforts to reduce OIS have taken two forms: improved training
protocols designed to improve officer decision-making, and a variety
of accountability mechanisms designed to deter officer misconduct (usually
defined as any departure from protocol, whether or not that departure
was intentional or whether the OIS itself was intentional).1 While
each approach seeks to reduce the incidence of OIS in its own way, it is not
clear that our systems for evaluating a past OIS through administrative reviews,
civilian oversight, or civil and criminal litigation are effective in understanding
how to learn from past OIS or how to prevent the next OIS from occurring.
In this Article, we propose a third form of evaluating OIS: Root Cause
Analysis (RCA). RCA is a method of problem solving designed to identify
core underlying factors, including environmental or systemic factors, that
contributed (along with individual decision-making) to generate an undesirable
outcome, organizational accident, or adverse event.2 Once these
core underlying causative factors have been identified, participants in the
system can fashion remedies that will reduce or remove them from the
system, thereby preventing future occurrences of the undesirable outcome
DA  - 2017///
PY  - 2017
VL  - 883
UR  - https://digitalcommons.law.villanova.edu/cgi/viewcontent.cgi?article=3362&context=vlr
ER  - 

TY  - JOUR
TI  - Reducing Fatal Police Shootings as System Crashes: Research, Theory, and Practice
AU  - Sherman, Lawrence W.
T2  - Annual Review of Criminology
AB  - Can fatal shootings by American police be reduced? If so, what theoretical framework would be most useful in saving more lives? What research agenda would that framework suggest? The purpose of this review is to answer those three questions. It applies the system-accident framework (Perrow 1984) as a pathway to help police agencies reduce fatal police shootings, adapting it as system-crash prevention to encompass a wider range of systemic causes of catastrophic events. In contrast to deterrence, the dominant policy perspective on reducing fatal shootings, a system-crash prevention approach applies lateral thinking (Johnson 2010) from lessons learned about airplane crashes, surgical errors, nuclear power plant meltdowns, and other rare events in complex systems. This framework spotlights the rare combinations of risk factors and errors that can produce fatal shootings, the prevention of which may need to vary widely between large and small communities. Of the 986 fatal police shootings reported nationally in 2015 (Wash. Post 2016), an estimated half occurred in cities with fewer than 50,000 residents; only a third occurred in cities over 250,000 residents (Sherman 2015), where the majority of all research on police shootings has been done. The system designs for fewer police killings in very large versus very small police agencies require a general framework for policy-relevant criminology. The framework suggested by Sampson et al. (2013) requires research to identify (a) causal mechanisms that may generally help to reduce fatal police shootings but may also have (b) heterogeneous effects that may work differently on different subpopulations or when their application is (c) contextualized in different social settings. Future research must therefore include very small communities in order to understand and help prevent the majority of all fatal police shootings.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/BQP0SWofKCM
DA  - 2018///
PY  - 2018
DO  - 10.1146/annurev-criminol-032317-092409
DP  - Annual Reviews
VL  - 1
IS  - 1
SP  - 421
EP  - 449
ST  - Reducing Fatal Police Shootings as System Crashes
UR  - https://doi.org/10.1146/annurev-criminol-032317-092409
Y2  - 2018/01/19/17:06:44
ER  - 

TY  - NEWS
TI  - City invests $400K to prevent Rikers Island suicides - NY Daily News
AU  - Tracy, Thomas
T2  - New York Daily News
AB  - The three-year study will be funded by a federal grant from the National Institute of Justice and conducted by the Department of Correction, the Department of Health and Mental Hygiene and the Vera Institute of Justice
DA  - 2014/10/28/
PY  - 2014
UR  - http://www.nydailynews.com/new-york/nyc-crime/city-invests-400k-prevent-rikers-island-suicides-article-1.1990213
Y2  - 2016/08/23/13:53:41
KW  - SEI Media Coverage
ER  - 

TY  - NEWS
TI  - Something To See Here: Don’t Move Along
AU  - Doyle, James M.
T2  - The Crime Report
AB  - The world of criminal justice and the media that monitor it act as if whenever there is no one to hang, there is nothing to learn. We think "accountability" is the same thing as punishment.
DA  - 2015/01/20/
PY  - 2015
ST  - Something To See Here
UR  - https://thecrimereport.org/2015/01/20/2015-01-something-to-see-here-dont-move-along/
Y2  - 2017/05/25/17:59:42
L2  - https://thecrimereport.org/2015/01/20/2015-01-something-to-see-here-dont-move-along/
L2  - https://thecrimereport.org/2015/01/20/2015-01-something-to-see-here-dont-move-along/
KW  - Doyle Article
ER  - 

TY  - RPRT
TI  - Conviction Review Units: A National Perspective
AU  - Hollway, John
AB  - As Conviction Review Units have emerged across the United States, community and other observers have sought to evaluate their impact and to identify those CRUs that are sincere about investigating and resolving credible allegations of factual innocence among closed convictions. A skepticism prevails that some CRUs are units conducting “Conviction Review In Name Only,” or “CRINOs.” This skepticism is fueled by CRUs that lack the independence, flexibility, and transparency that is described herein.
CY  - Penn Legal Scholarship Repository
DA  - 2016/04//
PY  - 2016
PB  - Quattrone Center for the Fair Administration of Justice
SN  - Paper 1614
UR  - http://scholarship.law.upenn.edu/cgi/viewcontent.cgi?article=2615&context=faculty_scholarship
Y2  - 2017/05/02/15:57:02
KW  - wrongful conviction
KW  - Conviction Integrity Units
ER  - 

TY  - ELEC
TI  - Feeling ‘Dirty’ About Sentencing
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Retired Federal Judge Schira Scheindlin has said mandatory-minimum requirements made her feel "dirty." Other judges have joined the chorus of justice reformers who complain rigorous sentencing guidelines are unfair. But are they addressing the wrong problem?

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/YuQ5Mc94wQo
DA  - 2017/03/07/
PY  - 2017
UR  - http://thecrimereport.org/2017/03/07/feeling-dirty-about-sentencing/
Y2  - 2017/03/13/
L2  - http://thecrimereport.org/2017/03/07/feeling-dirty-about-sentencing/
L2  - http://thecrimereport.org/2017/03/07/feeling-dirty-about-sentencing/
L2  - http://thecrimereport.org/2017/03/07/feeling-dirty-about-sentencing/
L2  - http://thecrimereport.org/2017/03/07/feeling-dirty-about-sentencing/
L2  - http://thecrimereport.org/2017/03/07/feeling-dirty-about-sentencing/
L2  - http://thecrimereport.org/2017/03/07/feeling-dirty-about-sentencing/
KW  - Doyle Article
ER  - 

TY  - ELEC
TI  - The Death Penalty’s ‘Normal Accidents’
AU  - Doyle, James M.
T2  - The Crime Report
AB  - In the final days of this year’s Supreme Court term, Justice Stephen Breyer unexpectedly launched a new offensive against the American system of capital punishment. The offensive was announced in his dissenting opinion in a case upholding the legality of Oklahoma’s lethal injection protocol. Some commentators believed that Breyer was training his artillery on one [...]
DA  - 2017/06/05/
PY  - 2017
UR  - https://thecrimereport.org/2015/07/16/2015-07-the-death-penaltys-normal-accidents/
Y2  - 2017/06/05/18:22:49
L2  - https://thecrimereport.org/2015/07/16/2015-07-the-death-penaltys-normal-accidents/
L2  - https://thecrimereport.org/2015/07/16/2015-07-the-death-penaltys-normal-accidents/
KW  - Doyle Article
ER  - 

TY  - NEWS
TI  - Why Journalists (and Prosecutors) Should Heed the Rolling Stone Lesson
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Criminal justice journalists need the public's trust as much as the criminal justice system operators they cover.
DA  - 2015/04/28/
PY  - 2015
UR  - https://thecrimereport.org/2015/04/28/2015-04-why-journalists-and-prosecutors-should-heed-the-roll/
Y2  - 2017/06/09/13:49:12
L2  - https://thecrimereport.org/2015/04/28/2015-04-why-journalists-and-prosecutors-should-heed-the-roll/
L2  - https://thecrimereport.org/2015/04/28/2015-04-why-journalists-and-prosecutors-should-heed-the-roll/
KW  - Doyle Article
ER  - 

TY  - BLOG
TI  - From the Senior Advisor: Systems, Errors, and Ethics
AU  - Feucht, Thomas
T2  - Police Chief Magazine
AB  - When something goes wrong, often our first instinct is to place blame. Whether the error occurs at our workplace, in our community, or in national affairs, we ask: Who is at fault? What rules were violated? Why did this slip through the cracks? Often these errors are not the fault of a single person or team, but of the entire system.

We all work within organizations and social “systems.” When bad things happen, we can quickly come to believe that a single individual—through ineptness, maliciousness, or just sloth—may be the prime cause of the error, the individual solely responsible. Our snap judgment is that someone didn’t do their job or didn’t do it well enough or zigged when they should have zagged. And, now, someone is going to get blamed.
DA  - 2015/12/01/
PY  - 2015
ST  - From the Senior Advisor
UR  - http://www.policechiefmagazine.org/from-the-senior-advisor-systems-errors-and-ethics/
Y2  - 2017/05/25/18:28:44
L2  - http://www.policechiefmagazine.org/from-the-senior-advisor-systems-errors-and-ethics/
L2  - http://www.policechiefmagazine.org/from-the-senior-advisor-systems-errors-and-ethics/
KW  - BLAME
KW  - SEI Publications
ER  - 

TY  - JOUR
TI  - Gun crime incident reviews as a strategy for enhancing problem solving and information sharing
AU  - Hipple, Natalie Kroovand
AU  - McGarrell, Edmund F.
AU  - O’Brien, Mallory
AU  - Huebner, Beth M.
T2  - Journal of Crime and Justice
AB  - Over the last several decades, police departments and other criminal justice agencies have seen a shift toward a proactive problem-solving response to crime problems. This problem-solving orientation has often included an emphasis on expanded partnerships across criminal justice agencies as well as with a variety of community stakeholders, including researchers. This manuscript uses the issue of gun violence as a lens through which to examine the organizational and inter-organizational changes necessary to apply a data-driven, proactive, and strategic policing-led response to gun homicides and non-fatal shootings in four Midwestern sites. Each site adapted a unique data collection process and incident review. The data collection, incident reviews, and the varying models developed across the four cities, provide a reflection on corresponding organizational and inter-organizational changes that illuminate the movement toward this proactive, data-driven, problem-solving model of criminal justice. Fulfilling the promise of the incident reviews, however, requires internal organizational and cross-agency inter-organizational collaboration to align people, systems, and resources with this proactive, problem-solving model. Additionally, effectively implementing these organizational and inter-organizational changes appears dependent on commitment and leadership, collaboration and partnerships, data quality and availability, and training and communication within and across organizational boundaries.
DA  - 2017/01/02/
PY  - 2017
DO  - 10.1080/0735648X.2016.1155303
DP  - Taylor and Francis+NEJM
VL  - 40
IS  - 1
SP  - 50
EP  - 67
SN  - 0735-648X
UR  - http://dx.doi.org/10.1080/0735648X.2016.1155303
KW  - Citing the SEI
KW  - Fatality Reviews
KW  - Homicide Reviews
KW  - Incident reviews
KW  - gun violence
KW  - non-fatal shootings
KW  - problem solving
ER  - 

TY  - RPRT
TI  - From Error Toward Quality: A Federal Role in Support of Criminal Process
AU  - Doyle, James M.
AB  - ACS is pleased to distribute From Error Toward Quality: A Federal Role in Support of Criminal Process, an Issue Brief by James M. Doyle. Mr. Doyle is a lawyer in private practice with the Boston law firm of Carney & Bassil and the former head of the Public Defender Division of the Massachusetts Committee for Public Counsel Services, which is the statewide public defender agency.
CY  - Washington,  D.C.
DA  - 2010/07/26/
PY  - 2010
M3  - ACS Issue Brief
PB  - American Constitution Society
ST  - From Error Toward Quality
UR  - https://www.acslaw.org/issue_brief/briefs-2007-2011/from-error-toward-quality-a-federal-role-in-support-of-criminal-process/
Y2  - 2017/05/19/17:13:33
L2  - https://www.acslaw.org/publications/issue-briefs/from-error-toward-quality-a-federal-role-in-support-of-criminal-process-0
L2  - https://www.acslaw.org/publications/issue-briefs/from-error-toward-quality-a-federal-role-in-support-of-criminal-process-0
KW  - Doyle Article
ER  - 

TY  - BLOG
TI  - Building Bottom-Up Review Into Criminal Justice
AU  - Doyle, James M.
T2  - American Constitution Society for Law and Policy
DA  - 2010///
PY  - 2010
UR  - http://www.acslaw.org/acsblog/building-bottom-up-review-into-criminal-justice
N1  - <p>August 17<br/>Building Bottom-Up Review Into Criminal Justice</p>
N1  - <p>August 17<br/>Building Bottom-Up Review Into Criminal Justice</p>
N1  - <p>August 17<br/>Building Bottom-Up Review Into Criminal Justice</p>
KW  - Doyle Article
KW  - Incident reviews
ER  - 

TY  - ELEC
TI  - The Dangerous Decline of the Jury Trial
AU  - Doyle, James M.
T2  - The Crime Report
AB  - “The wisdom of our sages and the blood of our heroes has been devoted to the attainment of trial by jury. It should be the creed of our political faith.” So said small- government apostle Thomas Jefferson in his First Inaugural Address in 1801. It may be our creed, but we exercise it only in [...]
DA  - 2015/05/21/
PY  - 2015
UR  - https://thecrimereport.org/2015/05/21/2015-05-the-dangerous-decline-of-the-jury-trial/
Y2  - 2017/06/08/19:14:17
L2  - https://thecrimereport.org/2015/05/21/2015-05-the-dangerous-decline-of-the-jury-trial/
L2  - https://thecrimereport.org/2015/05/21/2015-05-the-dangerous-decline-of-the-jury-trial/
KW  - Doyle Article
ER  - 

TY  - MGZN
TI  - NIJ's Sentinel Events Initiative: Looking Back to Look Forward
AU  - Doyle, James M.
T2  - Corrections.com
DA  - 2014/01/27/
PY  - 2014
UR  - http://www.corrections.com/news/article/35054-nij-s-sentinel-events-initiative-looking-back-to-look-forward-
Y2  - 2016/08/23/13:51:29
KW  - Doyle Article
ER  - 

TY  - CHAP
TI  - An Etiology of Wrongful Convictions: Error, Safety, and Forward-Looking Accountability in Criminal Justice
AU  - Doyle, James M.
T2  - Wrongful Conviction and Criminal Justice Reform: Making Justice.
A2  - Marvin Zalman and J. Carrano, eds
DA  - 2013///
PY  - 2013
N1  - <p>An Etiology of Wrongful Convictions: Error, Safety, and Forward-Looking Accountability in Criminal Justice.</p>
N1  - <p>An Etiology of Wrongful Convictions: Error, Safety, and Forward-Looking Accountability in Criminal Justice.</p>
KW  - wrongful conviction
KW  - Doyle Article
KW  - Conviction Integrity Units
ER  - 

TY  - MGZN
TI  - More Accountability for Prosecutors
AU  - Doyle, James M.
T2  - New York Times
AB  - Letter to the Editor  about June 6, 2016 NY Times editorial entitled To Stop Bad Prosecutors, Call the Feds.

"To address the recurrent problem of prosecutors withholding evidence that would show innocence or mitigate punishment, we need to develop — as aviation and medicine have — a way to understand why things went wrong. Why did a prosecutor zig when he or she should have zagged? What incentives in the environment made withholding evidence seem like the best (or least bad) idea at the time?

Efforts such as the National Institute of Justice’s Sentinel Event Initiative and the Task Force on 21st Century Policing’s call for all-stakeholder, forward-looking reviews of the “sentinel events” that signal system weaknesses — evaluations of mishaps aimed at cutting risk, not laying blame — offer a promising model.

JAMES M. DOYLE

Siasconset, Mass.

The writer, a defense lawyer in Boston, is a consultant to the National Institute of Justice’s Sentinel Events Initiative.
DA  - 2016/06/20/
PY  - 2016
UR  - https://www.nytimes.com/2016/06/20/opinion/more-accountability-for-prosecutors.html
Y2  - 2016/08/23/13:49:12
L2  - http://www.nytimes.com/2016/06/20/opinion/more-accountability-for-prosecutors.html?_r=0
KW  - Doyle Article
ER  - 

TY  - NEWS
TI  - Wrongful Convictions: How We Drift into Error
AU  - Doyle, James M.
T2  - The Crime Report
AB  - http://www.thecrimereport.org/viewpoints/2013-04-wrongful-convictions-how-we-drift-into-error
DA  - 2013///
PY  - 2013
N1  - <p>Date<br/>Wrongful Convictions: How We Drift into Error</p>
KW  - Doyle Article
ER  - 

TY  - JOUR
TI  - Criminal Injustice: A Cost Analysis of Wrongful Convictions, Errors, and Failed Prosecutions in California’s Criminal Justice System
AU  - Silbert, Rebecca Sullivan
AU  - Hollway, John
AU  - Larizadeh, Darya
T2  - Penn Legal Scholarship Repository
T3  - Faculty Scholarship
AB  - Mistakes, incompetence and malfeasance in our criminal justice system can have serious and lifelong consequences on the person prosecuted, and can compromise the public’s belief in the system. Although much has been examined regarding small sample sets of individuals for whom there is uniform agreement on innocence, thousands of other defendants are subjected to these flawed prosecutions. This report analyzes a dataset of 692 adult felony criminal cases in California, the majority from 2000 – 2012, wherein the defendant was convicted of felony or felonies, the convictions were reversed, and the charges were either dismissed or the defendant subsequently found not guilty on retrial. The individuals in the study endured hundreds of trials, mistrials, appeals, and habeas petitions and served more than two thousand years in prison and jail, at a total cost to California taxpayers of more than $282 million, adjusted for inflation. The document examines the types of cases susceptible to error, the types of error that exist, and the direct costs of incarceration, representation, and compensation attributable to these cases and their ultimate resolution. In the absence of data relating to the taxpayer costs for trial, the report suggest a methodology to estimate taxpayer costs for cases that proceed to trial and cases that settle prior to trial, grouped by type of crime.
DA  - 2016///
PY  - 2016
DP  - scholarship.law.upenn.edu
ST  - Criminal Injustice
UR  - http://scholarship.law.upenn.edu/faculty_scholarship/1635
Y2  - 2017/05/08/19:19:03
L2  - http://scholarship.law.upenn.edu/faculty_scholarship/1635/
L2  - http://scholarship.law.upenn.edu/faculty_scholarship/1635/
L2  - http://scholarship.law.upenn.edu/faculty_scholarship/1635/
L2  - http://scholarship.law.upenn.edu/faculty_scholarship/1635/
L4  - http://scholarship.law.upenn.edu/cgi/viewcontent.cgi?article=2636&context=faculty_scholarship
L4  - http://scholarship.law.upenn.edu/cgi/viewcontent.cgi?article=2636&context=faculty_scholarship
L4  - http://scholarship.law.upenn.edu/cgi/viewcontent.cgi?article=2636&context=faculty_scholarship
L4  - http://scholarship.law.upenn.edu/cgi/viewcontent.cgi?article=2636&context=faculty_scholarship
KW  - wrongful conviction
KW  - Conviction Integrity Units
KW  - Innocence Commissions
ER  - 

TY  - RPRT
TI  - Elephants in the Station House: Serial Crimes, Wrongful Convictions, and Expanding Wrongful Conviction Analysis to Include Police Investigation
AU  - Zalman, Marvin
AU  - Larson, Matthew
AB  - In this article we advocate that the study of miscarriages of justice be expanded to view the entirety of police crime investigation as a source of wrongful con
CY  - Rochester, NY
DA  - 2016/01/13/
PY  - 2016
DP  - papers.ssrn.com
M3  - SSRN Scholarly Paper
PB  - Social Science Research Network
SN  - ID 2716155
ST  - Elephants in the Station House
UR  - https://papers.ssrn.com/abstract=2716155
Y2  - 2017/03/13/
L2  - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2716155
L2  - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2716155
L2  - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2716155
L2  - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2716155
L2  - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2716155
L2  - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2716155
L4  - https://papers.ssrn.com/sol3/Delivery.cfm?abstractid=2716155
L4  - https://papers.ssrn.com/sol3/Delivery.cfm?abstractid=2716155
L4  - https://papers.ssrn.com/sol3/Delivery.cfm?abstractid=2716155
L4  - https://papers.ssrn.com/sol3/Delivery.cfm?abstractid=2716155
L4  - https://papers.ssrn.com/sol3/Delivery.cfm?abstractid=2716155
L4  - https://papers.ssrn.com/sol3/Delivery.cfm?abstractid=2716155
KW  - wrongful conviction
KW  - Innocence Commissions
KW  - Miscarriage of justice
KW  - actual innocence
KW  - legal causation
KW  - serial crime
ER  - 

TY  - ELEC
TI  - The Law Made Us Do It: 46 Times
AU  - Doyle, James M.
T2  - The Crime Report
AB  - The media have agreed that we face a catastrophic crisis in mass incarceration, andwe are being treated to a swelling chorus of ex-presidents, retired judges and remorseful prosecution agencies all agreeing that we have a disaster on our hands. Despite its diversity, the ensemble harmonizes flawlessly on the poignant motif: “The Law Made Us Do [...]
DA  - 2015/07/15/
PY  - 2015
ST  - The Law Made Us Do It
UR  - https://thecrimereport.org/2015/07/29/2015-07-the-law-made-us-do-it-46-times/
Y2  - 2017/05/25/18:11:50
L2  - https://thecrimereport.org/2015/07/29/2015-07-the-law-made-us-do-it-46-times/
L2  - https://thecrimereport.org/2015/07/29/2015-07-the-law-made-us-do-it-46-times/
KW  - Doyle Article
ER  - 

TY  - JOUR
TI  - Innocence, harmless error, and federal wrongful conviction law
AU  - Garrett, B.
T2  - Wisconsin Law Review
AB  - This Article examines the body of law emerging in cases brought by former criminal defendants once exonerated, often through DNA testing, which may fundamentally reshape our criminal justice system. Federal wrongful conviction actions share a novel construction - they rely on criminal procedure rights incorporated as an element in a civil rights lawsuit. During a criminal trial, remedies for violations of procedural rights are often seen as truth defeating, because they exclude evidence possibly probative of guilt. In a civil wrongful conviction action, that remedial paradigm is reversed. The exonerated defendant instead seeks to remedy government misconduct that was truth defeating and concealed evidence of innocence. This Article contends that in a civil case, the harmless error rules that limit remedies for violations of criminal procedure rights do not apply. Further, though not generally recognized as such, the Supreme Court has created internal harmless error rules to accompany each of the relevant fair trial claims: the Brady v. Maryland right to have exculpatory evidence disclosed; the right to effective assistance of counsel; the right to be free from suggestive eyewitness identification procedures; and the right not to be subject to a coerced confession. Civil claims suggest the transformative result that for each right, harmless error insulation is stripped away. This Article concludes by reflecting on how wrongful conviction suits may spearhead wide-ranging reform of our criminal justice system and renew substantive development of the constitutional right to a fair trial.
DA  - 2005///
PY  - 2005
VL  - 35
UR  - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=794792
N1  - <p>Innocence, harmless error, and federal wrongful conviction law</p>
N1  - <p>Innocence, harmless error, and federal wrongful conviction law</p>
KW  - Innocence Commissions
ER  - 

TY  - RPRT
TI  - Final Report of the President’s Task Force on 21st Century Policing
AU  - President’s Task Force on 21st Century Policing
AB  - Recommendation 2.3
 Law enforcement agencies are encouraged to
implement nonpunitive peer review of
critical incidents separate from criminal
and administrative investigations.
These reviews, sometimes known as “near miss”
or “sentinel event” reviews, focus on the improvement of practices and policy. Such reviews already exist in medicine, aviation, and other industries.

According to the National Institute of Justice (NIJ), a sentinel event in criminal justice would include wrongful convictions but also “near miss” acquittals and dismissals of cases that at earlier points
seemed solid; cold cases that stayed cold too long; wrongful releases of dangerous or factually guiltycriminals or of vulnerable arrestees with mental
disabilities; and failures to prevent domestic
violence within at-risk families.
Sentinel events can include episodes that are
within policy but disastrous in terms of community relations, whether or not everyone agrees that the event should be classified as an error. In
fact, anything that stakeholders agree can cause
widespread or viral attention could be considered
a sentinel event.38

38. James M. Doyle, “Learning from Error in the Criminal Justice System: Sentinel
Event Reviews,” Mending Justice: Sentinel Event Reviews (Special Report from the

National Institute of Justice, September 2014): 3–20.
What distinguishes sentinel event reviews from
other kinds of internal investigations of apparent
errors is that they are nonadversarial. As task force
member Sean Smoot has written,
For sentinel event reviews to be effective and
practical, they must be cooperative efforts that
afford the types of protections provided in the
medical context, where state and federal laws
protect the privacy of participants and prevent the
disclosure of information to anyone outside of the
sentinel event review . . . . Unless the sentinel event process is honest and trustworthy, with adequate
legal protections—including use immunity,
privacy, confidentiality, and nondisclosure, for
example—police officers, who have the very best
information about how things really work and what
really happened, will not be motivated to fully
participate. The sentinel event review approach will
have a better chance of success if departments can
abandon the process of adversarial/punitive-based
discipline, adopting instead “education-based”
disciplinary procedures and policies.39

39. Sean Smoot “Punishment-Based vs. Education-Based Discipline: A
Surmountable Challenge?” in Mending Justice: Sentinel Event Reviews (Special
Report from the National Institute of Justice, September 2014): 48–50.
DA  - 2015/07/28/
PY  - 2015
ST  - President’s Task Force on 21st Century Policing Recommendations
UR  - https://www.justice.gov/archives/opa/blog/president-s-task-force-21st-century-policing-recommendations-print-action
Y2  - 2017/06/13/19:08:31
KW  - Citing the SEI
ER  - 

TY  - CHAP
TI  - Sentinel Events (SE): Definitions,
AU  - Joint Commission
AB  - SMH Note: SE Definitions, Goals, Action Plan. Appendix. Accreditation RequirementsRelated to Sentinel Events.

The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals
that experience serious adverse events improve safety and learn from those sentinel
events. Careful investigation and analysis of patient safety events, as well as strong corrective actions that provide effective and sustained system improvement, is essential
to reduce risk and prevent patient harm. The Sentinel Event Policy explains how The Joint Commission partners with hospitals that have experienced a serious patient safety
event to protect the patient, improve systems, and prevent further harm.
DA  - 2017/01//
PY  - 2017
UR  - https://www.jointcommission.org/assets/1/6/se_2017_camh.pdf
ER  - 

TY  - ELEC
TI  - Sentinel Event Policy and Procedures
AU  - Joint Commission
AB  - The Joint Commission adopted a formal Sentinel Event Policy in 1996 to help hospitals that experience serious adverse events improve safety and learn from those sentinel events
DA  - 2017/06/29/
PY  - 2017
LA  - en
UR  - http://www.jointcommission.org/sentinel_event_policy_and_procedures/
Y2  - 2018/02/09/22:34:01
ER  - 

TY  - SOUND
TI  - The Sentinel Event
AB  - In law enforcement, as with other high-stress professions, tragedies happen. The question we should all be asking is, what is the department doing to make sure that it’s not repeating history...
DA  - 2019/03/04/
PY  - 2019
LA  - en-US
UR  - https://thecommandpost.org/the-sentinel-event/
Y2  - 2019/03/04/16:10:32
ER  - 

TY  - RPRT
TI  - Policing and Wrongful Convictions
AU  - Batts, Anthony W
AU  - deLone, Maddy
AU  - Stephens, Darrel W
T2  - New Perspectives in Policing
AB  - As experienced professionals from policing and legal advocacy, the authors of this paper have come together to call for the field of policing to take the lead in reviewing cases, learning lessons, and changing practice to prevent the innocent from becoming swept into the criminal justice system and eventually convicted of crimes they did not commit. D.P.A., Police Commissioner, Baltimore, Maryland and former Chief of Police of Long Beach and Oakland, California Anthony W. Batts; Executive Director, Maddy deLone of the Innocence Project, a nonprofit legal organization committed to exonerating the wrongfully convicted through use of DNA testing and criminal justice system reform; and Executive Director of the Major Cities Chiefs Association and retired Chief, Charlotte-Mecklenburg Police Department, Darrel W. Stephens examine the systematic causes of wrongful criminal convictions and potential solutions to benefit both law enforcement and communities in Policing and Wrongful Convictions.
DA  - 2014/08/19/
PY  - 2014
PB  - Harvard Kennedy Schools of Government
UR  - https://www.hks.harvard.edu/sites/default/files/centers/wiener/programs/pcj/files/PolicingWrongfulConvictions.pdf
Y2  - 2017/08/23/18:25:31
N1  - <p>Given their function as gatekeepers to the criminal justice system and as the initial point of contact with offenders, accused offenders, victims and ordinary citizens, police agencies are in the most advantageous position to conduct such an examination. This paper calls for strong leadership from police agencies to lead reviews of wrongful convictions that can be learning experiences for all components of the criminal justice system. The lessons learned from these reviews can lead to the implementation of changes in practice across criminal justice agencies that will improve justice without compromising safety</p>
<p> </p>
<p> </p>
<p>B. Learn From Error Using an Organizational Accident Model Implementing an organizational accident model allows police departments to review errors as systemwide weaknesses instead of single-cause mistakes.</p>
<p> </p>
<p>We recommend that police agencies develop a review system that avoids simply blaming individuals and concentrates on understanding the organizational factors that contribute to errors.</p>
ER  - 

TY  - BOOK
TI  - Rise of Big Data Policing
AU  - Ferguson, Andrew Guthrie
AB  - The consequences of big data and algorithm-driven policing and its impact on law enforcement

In a high-tech command center in downtown Los Angeles, a digital map lights up with 911 calls, television monitors track breaking news stories, surveillance cameras sweep the streets, and rows of networked computers link analysts and police officers to a wealth of law enforcement intelligence.

This is just a glimpse into a future where software predicts future crimes, algorithms generate virtual “most-wanted” lists, and databanks collect personal and biometric information.  The Rise of Big Data Policing introduces the cutting-edge technology that is changing how the police do their jobs and shows why it is more important than ever that citizens understand the far-reaching consequences of big data surveillance as a law enforcement tool.

Andrew Guthrie Ferguson reveals how these new technologies —viewed as race-neutral and objective—have been eagerly adopted by police departments hoping to distance themselves from claims of racial bias and unconstitutional practices.  After a series of high-profile police shootings and federal investigations into systemic police misconduct, and in an era of law enforcement budget cutbacks, data-driven policing has been billed as a way to “turn the page” on racial bias.

But behind the data are real people, and difficult questions remain about racial discrimination and the potential to distort constitutional protections.

In this first book on big data policing, Ferguson offers an examination of how new technologies will alter the who, where, when and how we police.  These new technologies also offer data-driven methods to improve police accountability and to remedy the underlying socio-economic risk factors that encourage crime.

The Rise of Big Data Policing is a must read for anyone concerned with how technology will revolutionize law enforcement and its potential threat to the security, privacy, and constitutional rights of citizens.
DA  - 2017///
PY  - 2017
PB  - NYU Press
UR  - http://nyupress.org/books/9781479892822/
ER  - 

TY  - JOUR
TI  - Novel Concepts for the Application of Rapid DNA Technology as a Sentinel Event Prophylactic in the Criminal Justice System
AU  - Adams, George W.
T2  - Journal of Forensic Research
AB  - Rapid DNA Technology (RDNA) holds the key to the elimination of a significant number of sentinel events. Sentinel events in the criminal justice system may best be explained through the Joint Commission on Accreditation of Health Care Organizations’ (JACHO) definition as “an unexpected occurrence involving death or severe physical or psychological injury, or the risk thereof”. The most notable sentinel event in the criminal justice system today is a wrongful conviction – which exposes all attendant parties to significant personal and institutional liabilities. The International Association of Chiefs of Police/U.S. Department of Justice released its August report on the Wrongful Convictions Summit. In the report, there were thirty recommendations to reduce sentinel events in the criminal justice system. Sentinel events are likely the result of compound errors. The recommendations of the Summit Advisory Group focused on preventing the compounding of errors (racial profiling, investigative biases, aggressive interviewing, faulty line-up protocols, false testimony and eyewitness errors) to which Doyle refers. Currently, the public safety community seems to be virtually silent on the use of RDNA as a sentinel event prophylactic in fulfilling the criminal justice system’s goal to protect the blameless while holding the blameworthy accountable. The injection of RDNA at the earliest opportunity in the pre-charging phase of the criminal process may provide relief from the seemingly endless rise of sentinel events in the criminal justice system.
DA  - 2015/03/27/
PY  - 2015
DO  - 10.4172/2157-7145.1000278
DP  - www.omicsonline.org
VL  - 6
IS  - 2
SP  - 1
EP  - 4
SN  - 2157-7145
UR  - https://www.omicsonline.org/open-access/novel-concepts-for-the-application-of-rapid-dna-technology-as-a-sentinel-event-prophylactic-in-the-criminal-justice-system-2157-7145-1000278.php?aid=40979
Y2  - 2017/06/13/17:02:29
KW  - Citing the SEI
ER  - 

TY  - RPRT
TI  - NATIONAL INSTITUTE OF JUSTICE  SENTINEL EVENTS INITIATIVE  ALL-STAKEHOLDER FORUM
AU  - National Institute of Justice
AB  - In June 2017, nearly 100 federal, state, and local criminal justice practitioners, researchers and academics, 
policymakers, crime survivors, community representatives,
and federal partners convened to discuss learning-from-error
mechanisms in criminal justice. The forum aimed to explore
the potential benefts of aiding state and local criminal justice
systems in developing the capacity for local sentinel event
reviews (SERs); discuss how lessons learned from instilling
sustainable cultures of safety in the medical and aviation
felds might be applied in criminal justice; explore existing
research in criminal justice and other related felds; identify
aspects of technical assistance (TA) necessary to support local
systemwide reviews; and create a shared understanding of
common goals and anticipated products from SERs that allow
for local variation.
CY  - Washington DC
DA  - 2017///
PY  - 2017
PB  - National Institute of Justice
UR  - https://www.ncjrs.gov/pdffiles1/nij/251239.pdf
ER  - 

TY  - RPRT
TI  - Sentinel Events Initiative All-Stakeholder Forum: Meeting Summary
AU  - National Institute of Justice
AB  - The following memo summarizes the key takeaways from the National Institute 
of Justice’s (NIJ) recent All-Stakeholder Forum in support of the Sentinel Events Initiative
(SEI). These lessons and insights will be integrated into program development as the
national demonstration project builds over the coming years.
DA  - 2017///
PY  - 2017
PB  - National Institute of Justice
UR  - https://www.nij.gov/topics/justice-system/Pages/sentinel-events-stakeholder-forum.aspx
ER  - 

TY  - JOUR
TI  - A Glimpse at Ongoing Research Projects
AU  - National Institute of Justice
T2  - NIJ Journal
AB  - As part of building the evidence base for bringing sentinel event reviews (SERs) into the justice system, NIJ is supporting four major research projects.
DA  - 2015/12/14/
PY  - 2015
IS  - 276
UR  - http://nij.gov:80/journals/276/Pages/sentinel-events-glimpse.aspx
Y2  - 2017/08/23/13:34:37
ER  - 

TY  - SOUND
TI  - "Sentinel Event" Review in the Criminal Justice System
A2  - Doyle, James M.
T3  - NIJ Audio
AB  - Listen to James Doyle discuss the basics of a "sentinel event" review in the criminal justice system. This learning-from-error approach borrows from principles that medicine, aviation and other high-risk enterprises have successfully used. Former NIJ Fellow Doyle offers the basics to understand this innovative idea that takes a system-wide perspective of error, bringing all stakeholders together in a non-blaming, forward-looking way after a bad outcome, such as a wrongful conviction, occurs.
​
CY  - National Institute of Justice
DA  - 2014/01//
PY  - 2014
ST  - Audio
UR  - http://nij.gov:80/multimedia/Pages/audio-doyle.aspx
ER  - 

TY  - NEWS
TI  - NYC launching system-wide review of jail suicides
AU  - Pearson, Jake
T2  - AP News
AB  - The review — dubbed the “sentinel event” approach — is a way to identify systemic breakdowns by investigating occurrences such as suicides and unravelling the chain of events that preceded them, but not for the purposes of punishment.
DA  - 2014/10/28/
PY  - 2014
UR  - https://apnews.com/a1b25f7163c64d56a3479da29372d9ca/nyc-launching-system-wide-review-jail-suicides
Y2  - 2017/06/13/16:47:00
KW  - SEI Media Coverage
ER  - 

TY  - SOUND
TI  - Milwaukee Joins Criminal Justice Research Project To Review Tragic Crime
AB  - Milwaukee is joining two other cities in a new criminal justice research project designed to pinpoint bad decisions by law enforcement agencies that led to tragic crimes.
Date: September 8, 2014
DA  - 2014/09/08/
PY  - 2014
PB  - WPR
UR  - http://www.wpr.org/milwaukee-joins-criminal-justice-research-project-review-tragic-crime
Y2  - 2017/06/14/21:10:06
KW  - SEI Media Coverage
ER  - 

TY  - ELEC
TI  - Kenosha mayor attends crime symposium in Washington
AU  - STAFF, KENOSHA NEWS
T2  - Kenosha News
AB  - Kenosha Mayor John Antaramian is wrapping up a visit to the nation’s capital this week.
DA  - 2017/06/20/
PY  - 2017
UR  - http://www.kenoshanews.com/news/local/kenosha-mayor-attends-crime-symposium-in-washington/article_9a6deeda-155d-5fef-b456-8f94f31d2876.html
Y2  - 2017/06/22/19:37:15
ER  - 

TY  - NEWS
TI  - Can We All Get Along?
AU  - Tabachnick
T2  - The Crime Report
AB  - Can we learn from our mistakes? America's system of justice may finally be ready to apply the same techniques for identifying crucial flaws that have been used or years in the medical and aviation worlds. At least that's the hope of a landmark pilot project now underway under the aegis of the National Institute of Justice (NIJ). The project, called “Sentinel Events” reviews focuses on three cities—Philadelphia, Milwaukee and Baltimore, where major justice stakeholders—such as police, court officials and probation [...]

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/lRY9lTHYlTo
DA  - 2014/09/02/
PY  - 2014
UR  - https://thecrimereport.org/2014/09/02/2014-09-can-we-all-get-along/
Y2  - 2017/06/27/17:15:32
ER  - 

TY  - JOUR
TI  - SUSTAINABILITY OF INNOCENCE REFORM
AU  - Zalman, Marvin
AU  - Carrano, Julia
T2  - Albany Law Review
AB  - SEI mentioned on p. 955
DA  - 2014/10/08/
PY  - 2014
VL  - 77
KW  - Citing the SEI
ER  - 

TY  - JOUR
TI  - Strengthening Justice in the U.S.: The Impact of Scientific Research
AU  - Rodriguez, Nancy
T2  - OHIO STATE JOURNAL OF CRIMINAL LAW
DA  - 2016///
PY  - 2016
VL  - 14
UR  - http://moritzlaw.osu.edu/students/groups/osjcl/files/2016/12/12-Rodriguez.pdf
KW  - Citing the SEI
ER  - 

TY  - BLOG
TI  - “Sentinel Events:” Learning From Mistakes/Errors
AU  - Couper, David
T2  - Improving Policing
AB  - A bright light for Police — Sentinel Events.   Listen to an audio presentation of the topic by NIJ Fellow James Doyle: What is a “Sentinel Event?” “When bad things happ...
DA  - 2016/09/14/
PY  - 2016
ST  - “Sentinel Events
UR  - https://improvingpolice.wordpress.com/2016/09/14/sentinel-events-learning-from-mistakeserrors/
Y2  - 2017/06/13/16:36:51
KW  - Citing the SEI
KW  - SEI Media Coverage
ER  - 

TY  - BOOK
TI  - Leadership and Management in Police Organizations
AU  - Giblin, Matthew J.
AB  - SEI mentioned on Page 287.

Built on a foundation of nearly 1,200 references,  Leadership and Management in Police Organizations is a highly readable text that shows how organizational theory and behavior can be applied to improve the operations, leadership, and management of law enforcement. Author Matthew J. Giblin emphasizes leadership and management as separate skills in successful police supervisors and executives, illustrating to students how the two skills combine to improve individual and organizational efficacy in policing. Readers will come away with a stronger understanding of why organizational decisions  matter and the impact research can have on police departments.
DA  - 2016/10/04/
PY  - 2016
DP  - Google Books
SP  - 449
LA  - en
PB  - SAGE Publications
SN  - 978-1-5063-5227-5
L2  - https://books.google.com/books?id=jVS0DAAAQBAJ
KW  - Citing the SEI
ER  - 

TY  - RPRT
TI  - Creating a Culture of Safety: Sentinel Event Reviews for Suicide and Self-Harm in Correctional Facilities
AU  - Pope, Leah
AU  - Duleney-Brumsey, Ayesha
AB  - Since 2011, the National Institute of Justice (NIJ), through its Sentinel Events Initiative, has been investigating the feasibility of using a sentinel events approach to review and learn from errors in the criminal justice system such as wrongful convictions, eyewitness misidentifications, or incidents of suicide and self-harm in custody. Recognizing that adverse situations are rarely caused by a single event or the actions of an individual person, NIJ defines a sentinel event as a significant negative outcome that: 1) signals underlying weaknesses in a system or process; 2) is likely the result of compound errors; and 3) may provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse events or outcomes. 
With funding from NIJ, the Vera Institute of Justice (Vera) has been examining the applicability and appropriateness of using sentinel event reviews for incidents of suicide and serious self-harm in detention. This report focuses on these incidents as prime opportunities to implement sentinel event reviews in the criminal justice context.
DA  - 2017/06/12/
PY  - 2017
LA  - en
PB  - Vera Institute of Justice
UR  - https://www.vera.org/publications/culture-of-safety-sentinel-event-suicide-self-harm-correctional-facilities
Y2  - 2017/06/13/16:39:39
KW  - Citing the SEI
ER  - 

TY  - JOUR
TI  - America's Guilt Mill
AU  - Krajicek, David
T2  - Prison Legal News
AB  - Vaughn’s analysis made the Challenger disaster seem inevitable—not aberrative. Boston’s Doyle calls it the “normalization of deviance.” In “Mending Justice,” a September 2014 publication that was part of the National Institute of Justice’s Sentinel Events Initiative, Doyle explained how certain events signal systemic problems in complicated bureaucracies like criminal justice.

A sentinel event in the criminal justice system warns us of threats to justice, and it calls us to act. It is a significant, unexpected negative outcome that signals a possible weakness in the system or process. Sentinel events are likely the result of compounded errors and — if properly analyzed and addressed — may provide important keys to strengthening the system and preventing future adverse events or outcomes. Sentinel errors leading to wrongful convictions have many facets, Doyle says.

“Most of the time you can’t blame it on a single cause,” he says. “When things go wrong, it’s an organizational accident. Criminal justice is this vast, fragmented, complex ecosystem, and everyone in the system feels the pressure to produce—cops, DAs, judges...And there’s fresh pressure every day. Cops have today’s cases to worry about, so they don’t have time to go back and look at the old ones for errors.”
DA  - 2017/03/28/
PY  - 2017
UR  - https://www.prisonlegalnews.org/news/2017/mar/28/americas-guilt-mill/
Y2  - 2017/06/14/22:00:00
KW  - Citing the SEI
KW  - SEI Media Coverage
ER  - 

TY  - NEWS
TI  - Justice Reform Under Trump: Some Good News?
AU  - Handelman, Stephen
T2  - The Crime Report
AB  - An experimental project aimed at helping local jurisdictions examine--and correct--mistakes in the justice system will soon be expanded to up to 25 cities and counties. The expansion of the Sentinel Events program amounts to an endorsement by the Justice Department of a major Obama-era reform initiative.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/l46EbMGPcps
DA  - 2017/06/28/
PY  - 2017
ST  - Justice Reform Under Trump
UR  - https://thecrimereport.org/2017/06/26/justice-reform-under-trump-some-good-news/
Y2  - 2017/06/26/16:53:18
ER  - 

TY  - NEWS
TI  - Do the ‘Right Thing’: Janet Reno’s Legacy for Trump’s Attorney General
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Whoever takes the helm of the Department of Justice next year will be overseeing a justice system profoundly transformed by the nation’s first female A-G.  One of her top priorities—addressing wrongful convictions—is now a hard-to-abandon centerpiece of American justice.
DA  - 2016///
PY  - 2016
ST  - Do the ‘Right Thing’
UR  - http://thecrimereport.org/2016/11/10/do-the-right-thing-janet-renos-legacy-for-trumps-attorney-general/
Y2  - 2017/02/13/19:58:14
L2  - http://thecrimereport.org/2016/11/10/do-the-right-thing-janet-renos-legacy-for-trumps-attorney-general/
ER  - 

TY  - NEWS
TI  - When Justice Fails, Here’s How to Begin the Healing
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Saying "I'm sorry" is a useful start.  But justice authorities could take a lesson from medicine by combining a genuine apology with a full disclosure of what went wrong.   In today's 24/7 media landscape that's an essential step to rebuilding trust and confidence.
DA  - 2016///
PY  - 2016
UR  - http://thecrimereport.org/2016/10/13/when-justice-fails-heres-how-to-begin-the-healing/
Y2  - 2017/02/13/19:58:50
L2  - http://thecrimereport.org/2016/10/13/when-justice-fails-heres-how-to-begin-the-healing/
ER  - 

TY  - NEWS
TI  - Portraits of Risk
AU  - Doyle, James M.
T2  - The Crime Report
DA  - 2016/07/26/
PY  - 2016
UR  - http://thecrimereport.org/2016/07/26/portraits-in-risk/
Y2  - 2016/08/22/14:57:30
ER  - 

TY  - JOUR
TI  - Op-Ed: A Systemwide Failure Led To Wrongful Convictions of Central Park 5
AU  - Doyle, James M.
T2  - National Law Journal
AB  - Claim that police, prosecutors acted reasonably doesn't account for grave mistakes.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/OP2Cht33RRA
DA  - 2014/09/29/
PY  - 2014
ST  - Op-Ed
UR  - http://www.nationallawjournal.com/id=1202671521752/OpEd-A-Systemwide-Failure-Led-To--Wrongful-Convictions-of-Central-Park-5
Y2  - 2017/06/27/16:33:01
ER  - 

TY  - JOUR
TI  - Research on “Sentinel Events” and Criminal Justice System Errors
AU  - National Institute of Justice
T2  - National Institute of Justice Request for Proposals
AB  - Request for Proposals
DA  - 2016///
PY  - 2016
UR  - https://www.ncjrs.gov/pdffiles1/nij/sl001132.pdf
Y2  - 2017/05/19/17:45:47
ER  - 

TY  - JOUR
TI  - Using Science to Advance the Police Profession
AU  - Spivak, Howard
AU  - McGough, Maureen
AU  - Rodriguez, Nancy
T2  - Southern Illinois University Law Journal
DA  - 2016///
PY  - 2016
VL  - 40
SP  - 457
EP  - 4 73
UR  - https://law.siu.edu/_common/documents/law-journal/articles-2016/spring-2016/11%20-%20Spivak%20-%20sm.pdf
KW  - Citing the SEI
KW  - SEI Publications
ER  - 

TY  - RPRT
TI  - Sentinel Events Roundtable Summary
AU  - National Institute of Justice
DA  - 2013///
PY  - 2013
PB  - National Institute of Justice
UR  - https://www.ncjrs.gov/pdffiles1/nij/243586.pdf
Y2  - 2017/05/19/17:21:39
KW  - SEI Publications
ER  - 

TY  - SLIDE
TI  - NIJ’s “Sentinel Events Initiative”
A2  - Feucht, Thomas
CY  - NIST International Forensics Symposium
DA  - 2015/07/21/
PY  - 2015
UR  - https://www.nist.gov/sites/default/files/documents/director/mending_justice_and_learning_from_error_NIJs_sentinel_events_initiative-feucht-crim1.pdf
KW  - SEI Publications
ER  - 

TY  - JOUR
TI  - FY 2017 BJA Sentinel Events Initiative  Demonstration Project: Technical Assistance Provider (Request for Proposals)
AU  - Bureau of Justice Assistance
AB  - Sentinel Events Initiative Technical Assistence provider RFP.
DA  - 2017/06//
PY  - 2017
UR  - https://www.bja.gov/funding/SEI17.pdf
ER  - 

TY  - JOUR
TI  - To Err is Human: Using Science to Reduce Mistaken Eyewitness Identifications Through Police Lineups
AU  - McGough, Maureen
T2  - National Institute of Justice
AB  - Researchers take police lineup studies from the laboratory to the field.
DA  - 2012/06/15/
PY  - 2012
VL  - 270
ST  - To Err is Human
UR  - http://www.nij.gov:80/journals/270/Pages/reduce-eyewitness-mistakes.aspx
Y2  - 2017/06/14/21:33:51
KW  - SEI Publications
ER  - 

TY  - SOUND
TI  - After DNA Exoneration, The Beatrice Six Share False Memories Of Murder
AU  - All Things Considered
AB  - DNA exonerated six people who had been convicted of killing an elderly woman in Nebraska in the 1980s. But several of the exonerees confessed to the crime and still recall details of the scene. NPR's Audie Cornish talks with Rachel Aviv of The New Yorker about her reporting on why the so-called Beatrice Six created false memories around the crime.
DA  - 2017/06/15/
PY  - 2017
PB  - NPR
UR  - http://www.npr.org/2017/06/15/533102554/after-dna-exoneration-the-beatrice-six-share-false-memories-of-murder
Y2  - 2017/06/19/12:04:04
ER  - 

TY  - JOUR
TI  - Learning from Error in American Criminal Justice
AU  - Doyle, James M.
T2  - Journal of Criminal Law and Criminology
DA  - 2010///
PY  - 2010
VL  - 100
IS  - 1
UR  - https://scholarlycommons.law.northwestern.edu/cgi/viewcontent.cgi?article=7346&context=jclc
N1  - <p>Learning from Error in American Criminal Justice</p>
ER  - 

TY  - NEWS
TI  - Widening the Lens on Blame
AU  - Dwyer, Jim
T2  - New York Times
AB  - Next week, the National Institute of Justice is expected to release a special report, “Mending Justice: Sentinel Event Reviews,” which concludes that the criminal justice system has a hard time squarely facing its mistakes. The report, by the research division of the Justice Department, urges all branches of criminal justice to consider adopting the approaches used in medicine and aviation to study — and reduce — errors.
DA  - 2014/09/02/
PY  - 2014
UR  - http://www.nytimes.com/2014/09/03/nyregion/widening-the-lens-on-blame.html
Y2  - 2016/08/23/13:55:25
ER  - 

TY  - JOUR
TI  - Ready for the Psychologists: Learning from Eyewitness Errors
AU  - Doyle, James M.
T2  - Court Review
DA  - 2012///
PY  - 2012
VL  - 48
SP  - 4
EP  - 48
UR  - https://pdfs.semanticscholar.org/6992/d934c0af8984d9d03c37d5262f9055f71602.pdf
N1  - <p>Ready for the Psychologists: Learning from Eyewitness Errors</p>
ER  - 

TY  - JOUR
TI  - CONTINUOUS QUALITY IMPROVEMENT: INCREASING CRIMINAL PROSECUTION RELIABILITY THROUGH STATEWIDE SYSTEMATIC IMPROVEMENT PROCEDURES
AU  - Cutino, Josh
T2  - Lewis and Clark Law Review
AB  - Several district attorney offices have established conviction integrity units
and instituted programmatic reform as a result of wrongful convictions.
However, reform only as a result of a wrongful conviction misses countless
opportunities to reduce errors, identify best practices, and improve
processes. This Comment explores various organizational models to reduce
error and capture best practices in an effort to assist district attorneys
in bolstering the effectiveness, efficiency, and reliability of criminal
prosecutions. Ultimately, district attorneys should establish systematic
procedures for assessing errors and improving internal processes. Part II
describes various conviction integrity unit models created by district attorneys.
Part III introduces the sentinel-event review process as a means
of reducing error. Part IV describes different organizational procedures
for institutionalizing and distributing best practices, such as the U.S.
Air Force and New York State’s criminal justice Best Practices Committee.
I conclude in Part V by arguing that district attorneys should learn
from these various programs, partner with police agencies and other
stakeholders, and establish statewide organizations to capture and disseminate
best practices.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/9B5T6q5Es6c
DA  - 2016/10/24/
PY  - 2016
VL  - 20
IS  - 3
SP  - 1066
EP  - 1091
UR  - http://law.lclark.edu/live/files/22773-lcb203art07cutinocompletepdf
Y2  - 2017/03/27/15:11:43
KW  - CRIMINAL convictions
KW  - wrongful conviction
ER  - 

TY  - NEWS
TI  - Learning How To Learn (Together) From Justice Errors
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Criminal justice reform is having its moment in the public square. The gatekeepers—editors, publishers, producers, bloggers, and the “most-followed” social media posters—have decided to grant criminal justice issues some attention. These media moments always fade. How can reformers exploit the opportunity this one presents? Can something useful be left behind? Since 2011, the National Institute [...]
DA  - 2015/11/10/
PY  - 2015
UR  - https://thecrimereport.org/2015/11/10/2015-11-learning-how-to-learn-together-from-justice-errors/
Y2  - 2017/05/26/16:41:29
L2  - https://thecrimereport.org/2015/11/10/2015-11-learning-how-to-learn-together-from-justice-errors/
ER  - 

TY  - NEWS
TI  - The Justice Dilemma: When the Cure is Worse Than the Disease
AU  - Doyle, James M.
T2  - The Crime Report
AB  - We’re now paying the price for simplistic assumptions that establishing “control” is a requisite for tackling the roots of criminal behavior. Could sensible, evidence-based approaches help make communities safer?

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/V7vWCmhZmYs
DA  - 2017/05/18/
PY  - 2017
ST  - The Justice Dilemma
UR  - https://thecrimereport.org/2017/05/18/the-justice-dilemma-when-the-cure-is-worse-than-the-disease/
Y2  - 2017/05/19/
L2  - https://thecrimereport.org/2017/05/18/the-justice-dilemma-when-the-cure-is-worse-than-the-disease/
ER  - 

TY  - MGZN
TI  - A New Way to Reform the Judicial System - The New Yorker
AU  - Starr, Douglass
T2  - The New Yorker
AB  - A series of experiments over the past year has aimed to build similar safeguards into the justice system. A veteran Boston defense attorney, James Doyle, observed the proliferation of exoneration cases in the post-DNA era and has worked on a number of reform efforts. “No one gets into this job to convict innocent people,” he told me. “The real problem is developing the capability for dealing with inevitable mistakes.” He wondered if “sentinel event analysis”— reviewing legal errors in a blame-free environment—could tease out the sequence of factors that might have contributed to a mistake and, perhaps, lead to a more accident-proof legal system.
DA  - 2015/03/31/
PY  - 2015
UR  - http://www.newyorker.com/news/news-desk/the-root-of-the-problem
Y2  - 2016/08/22/14:51:14
ER  - 

TY  - NEWS
TI  - Learning in Criminal Justice: Small Cases, Big Lessons
AU  - Doyle, James M.
T2  - The Crime Report
AB  - When criminal justice fails in a spectacular way—for example, in a wrongful conviction discovered after an innocent man has served 20 years—people find it easy to see the point of using the model employed by the National Transportation Safety Board: investigate the event and see if we can learn some lessons.
DA  - 2014/11/04/
PY  - 2014
ST  - Learning in Criminal Justice
UR  - http://thecrimereport.org/2014/11/04/2014-11-learning-in-criminal-justice-small-cases-big-lessons/
Y2  - 2016/08/22/14:45:02
L2  - http://thecrimereport.org/2014/03/04/2014-03-the-paradigm-shift-in-criminal-justice/
ER  - 

TY  - NEWS
TI  - Whose Justice Is It?
AU  - Doyle, James M.
T2  - The Crime Report
AB  - The phrase “criminal justice system” is everywhere, but no one working in—or writing about—the system day-to-day spends much time debating what sort of “system” this system might actually be. It is what it is. But a recent New York Times account of a startling amicus brief filed by former Justice Department dignitaries (including a former [...]
https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/juQ7DxYwasM
DA  - 2015/08/19/
PY  - 2015
UR  - https://thecrimereport.org/2015/08/19/2015-08-whose-justice-is-it/
Y2  - 2017/06/05/14:27:59
ER  - 

TY  - JOUR
TI  - Imagining Sentinel Event Reviews in the U.S. Probation and Pretrial Services System
AU  - Sheil, Janette
AU  - Doyle, James
AU  - Lowenkamp, Christopher T.
T2  - Federal Probation
AB  - https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/fUX6neGO6Ao
DA  - 2016/09//
PY  - 2016
VL  - 80
SP  - 33
J2  - Fed. Probation
UR  - http://www.uscourts.gov/sites/default/files/usct10024-fedprobation-sept2016_0.pdf
ER  - 

TY  - NEWS
TI  - In Criminal Justice, the “Simple” Solutions Are Usually Wrong
AU  - Ferguson, Andrew Guthrie
AU  - Doyle, James
T2  - The Crime Report
AB  - Innocent citizens who have experienced the violent impact of systemic failures in criminal justice deserve better than analyses that focus "blame" on individual players.  As the medical and aviation fields have long known,  "who" failed is less important than "why" things failed.
DA  - 2017/01/31/
PY  - 2017
UR  - http://thecrimereport.org/2017/01/31/in-criminal-justice-the-simple-solutions-are-usually-wrong/
Y2  - 2017/02/06/22:02:01
L2  - http://thecrimereport.org/2017/01/31/in-criminal-justice-the-simple-solutions-are-usually-wrong/
L2  - http://thecrimereport.org/2017/01/31/in-criminal-justice-the-simple-solutions-are-usually-wrong/
N1  - <p>Doyle:</p>
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<div dir="ltr" style="margin: 0px; padding: 0px; border: 0px;">A Crime Report piece by Professor Andrew Guthrie Ferguson and yours truly concerning a Washington Post presentation on failed Youth Act sentences:  <a style="margin: 0px; padding: 0px; border: 0px; text-decoration: none; color: #6611cc; cursor: pointer;" href="http://thecrimereport.org/2017/01/31/in-criminal-justice-the-simple-solutions-are-usually-wrong/" target="_blank" rel="nofollow noopener">http://thecrimereport.org/2017/01/31/in-criminal-justice-the-simple-solutions-are-usually-wrong/</a></div>
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ER  - 

TY  - NEWS
TI  - The Paradigm Shift in Criminal Justice
AU  - Doyle, James M.
T2  - The Crime Report
AB  - We may look back on 2014 as the year in which the criminal justice system finally agreed to see itself as a system.
DA  - 2014/03/04/
PY  - 2014
UR  - http://thecrimereport.org/2014/03/04/2014-03-the-paradigm-shift-in-criminal-justice/
Y2  - 2016/08/22/14:47:21
L2  - http://thecrimereport.org/2014/03/04/2014-03-the-paradigm-shift-in-criminal-justice/
ER  - 

TY  - MGZN
TI  - What Criminal Justice Can Learn From Its Bad Outcomes
AU  - Doyle, James M.
AU  - Starheim, Rianna
T2  - Governing
AB  - In Milwaukee, an offender committed murder while released on supervision. In Seattle, questions remained over how a deadly police encounter unfolded. In New York City, fatigued officers made questionable decisions during a routine traffic stop. We can agree that these scenarios reflect system failings. However, the criminal justice system lacks a mechanism to examine these events and effectively prevent their recurrence.
DA  - 2018/02/05/
PY  - 2018
UR  - http://www.governing.com/gov-institute/voices/col-criminal-justice-sentinel-events-risk-mitigation.html
Y2  - 2018/02/09/22:37:28
ER  - 

TY  - RPRT
TI  - Learning About Learning From Error
AU  - Doyle, James M.
T2  - Ideas in American Policing
AB  - If we can learn, as
medicine has learned, to
treat errors as sentinel
events to be studied rather
than embarrassments to be
buried, we can all do a
much better job.
DA  - 2012/05//
PY  - 2012
PB  - Police Foundation
SN  - 14
UR  - https://www.policefoundation.org/wp-content/uploads/2015/06/Doyle-2012-Learning-About-Learning-From-Error.pdf
Y2  - 2017/05/19/17:17:12
N1  - <p>Cites Learning From Error (Doyle, 2010)</p>
KW  - Doyle Article
ER  - 

TY  - RPRT
TI  - Mending Justice: Sentinel Event Reviews
AU  - National Institute of Justice
AB  - Mending Justice: Sentinel Event Reviews explores the potential to learn from errors in the criminal justice system by applying a sentinel event review approach.
The primary essay — written by James Doyle, a Visiting Fellow with NIJ for two years — discusses how principles used by aviation and medicine to improve outcomes could be adopted in criminal justice.
CY  - Washington,  D.C.
DA  - 2014/10//
PY  - 2014
SP  - 68
PB  - National Institute of Justice
UR  - https://www.ncjrs.gov/pdffiles1/nij/247141.pdf
Y2  - 2016/08/22/15:06:34
KW  - Doyle Article
KW  - SEI Publications
ER  - 

TY  - JOUR
TI  - A Systems Approach to Error Reduction in Criminal Justice
AU  - Hollway, John
T2  - Faculty Scholarship
AB  - The “systems approach” has been used, improved, and refined over time to improve safety and reduce errors in a variety of complex, high-risk industries, including health care, aviation, and manufacturing, among others. Such an approach targets the system for improvement rather than specific individuals within the system, and seeks to provide an environment that maximizes each participant’s ability to act safely and in a way that achieves the goals of the system. It prizes a non-punitive culture of disclosure to identify errors, gathers and applies data to understand the causes of the error, and tests systems changes to prevent future errors. This focus on system improvement, rather than on individual punishment or blame, unites all participants around objective criteria and allows each participant to do his or her job more efficiently, accurately and safely.
DA  - 2014/02/01/
PY  - 2014
UR  - http://scholarship.law.upenn.edu/faculty_scholarship/976
ER  - 

TY  - BLOG
TI  - Learning from Error in the Criminal Justice System
AU  - Mason, Carol
T2  - Office of Justice Programs Blog
AB  - The Office of Justice Programs (OJP) About Us page provides information about OJP and the OJP bureaus and offices, including mission statements, goals and priorities, contact information, and policy and guidance resources.
DA  - 2014/09/16/
PY  - 2014
UR  - https://ojp.gov/ojpblog/learningfromerror.htm
Y2  - 2017/06/27/16:45:50
ER  - 

TY  - JOUR
TI  - The Progressive Prosecutor’s Handbook
AU  - Sklansky, David Alan
T2  - UC Davis Law Review
AB  - Faced with the November election results and the initial steps taken
by the new Administration, many criminal justice reformers are turning
their eyes to state and county officials, especially to the growing
number of local prosecutors who have won office by promising a more
thoughtful and evenhanded application of criminal statutes. Suppose
you are one of those prosecutors. Imagine you defeated an incumbent
you successfully argued was too tied to the past — too much a
champion of harsh, racially disproportionate punishment, too heedless
of the risk of convicting innocent people, too protective of the police,
too lackadaisical in supervising his or her own staff. Since criminal
justice is mainly a state and local responsibility, your policies could
mean much more for the quality of justice in your jurisdiction than
anything that takes place in Washington.1 You swept to victory
promising reform. What do you do now?




https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/J5lHWtBdm6Y
DA  - 2017///
PY  - 2017
VL  - 50
IS  - 25
UR  - https://lawreview.law.ucdavis.edu/online/vol50/Sklansky.pdf
N1  - <p>Independent reviews of credible claims of wrongful conviction are<br />important not just to ensure that justice is done but also so that your<br />office can learn from its mistakes. An exoneration should be an occasion<br />for root cause analysis: what went wrong, and how can your office avoid<br />similar blunders in the future? That kind of analysis is common in many<br />fields: doctors have morbidity and mortality conferences; the military has<br />after-action reviews; the aviation industry studies near misses.<br />Prosecutors rarely engage in anything of the kind. Since 2011, the<br />National Institute of Justice has been exploring the use of “sentinel<br />event” analysis in the criminal justice; that initiative has produced<br />concrete guidelines for building systems that will allow your office, along<br />with the other agencies you regularly interact with, to learn from their<br />mistakes.19 The main idea is to conduct reviews that are routine and<br />ongoing, that are non-blaming, and that involve not just prosecutors but<br />also judges, defense attorneys, and law enforcement officers. You should<br />take the lead on bringing this kind of analysis to your jurisdiction, and<br />there is no reason to limit it to instances where a conviction has been set<br />aside. Mistakes that are caught earlier and do less damage can be<br />opportunities for learning, as well.</p>
ER  - 

TY  - JOUR
TI  - Are the crime lab scandals ‘Public Safety’s Chernobyl’?
AU  - Doyle, James M.
T2  - Massachusetts Lawyer Weekly
AB  - The chemotherapy dose required by the 1994 experimental breast cancer protocol was already high. Then the Dana-Faber Cancer Institute administered four times that dosage to Betsy Lehman, the health columnist for The Boston Globe. Lehman died within days. For two months the hospital didn’t realize that the overdose had caused her death.
DA  - 2018/02/15/
PY  - 2018
UR  - http://masslawyersweekly.com/2018/02/15/are-the-crime-lab-scandals-public-safetys-chernobyl/
ER  - 

TY  - NEWS
TI  - Who’s Really to Blame for Police ‘Testilying’?
AU  - Doyle, James M.
T2  - The Crime Report
AB  - The reflex reaction to cops caught lying on the witness stand is punishment. But if we really want to curb “testilying,” we need to look deeper at the systemic factors that make the practice all too common, says a Boston attorney.
DA  - 2018/03/29/
PY  - 2018
LA  - en-US
UR  - https://thecrimereport.org/2018/03/29/whos-really-to-blame-for-police-testilying/
Y2  - 2018/04/09/
ER  - 

TY  - JOUR
TI  - Systems Failures in Policing
AU  - Schwartz, Joanna C.
T2  - Suffolk University Law Review, Forthcoming
AB  - This Essay, an adaptation of my 2018 Donahue Lecture, argues that acts of police violence and overreach should be viewed as systems failures. Researchers who study error in aviation, medicine, and other complex organizations agree that errors are the product of human failings and poorly designed systems. When tragedies occur, human error almost always plays a role — people misperceive information, process it incorrectly, make careless mistakes, and sometimes act recklessly or maliciously. But faulty systems also play a role — technologies can be confusing, rigorous schedules can fatigue workers, organizational culture can stifle productive communication, and policies can put workers in situations where they have to make difficult decisions under conditions of high stress. A key insight of this body of research is that it is impossible to cure limitations of human perception, cognition, and decisionmaking. Instead of focusing exclusively on training people to change their behavior — and threatening them with criminal, civil, or department sanctions if they fail to do so — the systems approach adjusts equipment, schedules, protocols, and policies in ways that can make it harder for people to err and can reduce the impact of error when it inevitably occurs.A focus on systems contributors to error has been used for decades to improve the safety of aviation, nuclear power, and other complex industries. Over the past thirty or so years, medicine has adopted some of aviation’s strategies. It is time for law enforcement to embrace a systems approach. When a person is shot by the police we must still examine whether the shooting was justified, and officers should continue to be disciplined, sued, and prosecuted when they violate department policy or the law. But then conversation must turn to whether the shooting was preventable, and the ways in which technology, schedules, protocols, and policies could be adjusted to prevent another shooting in the future. The shift in perspective will likely be harder in policing than it has been in medicine or aviation, but is necessary if we want to make policing safer.
DA  - 2018/05/16/
PY  - 2018
DP  - papers.ssrn.com
LA  - en
UR  - https://papers.ssrn.com/abstract=3179889
Y2  - 2018/05/18/16:48:27
KW  - Policing
KW  - safety
ER  - 

TY  - SOUND
TI  - Sentinel Events: Justice System Disasters
AU  - Harris, David
AB  - The criminal justice system is designed to enforce accountability when bad things happen. But when it comes to preventing them from happening in the first place, courts and law enforcement agencies could learn a thing or two from the aviation and healthcare industries.
DA  - 2018/06/01/
PY  - 2018
LA  - en-US
ST  - #73 Sentinel Events
UR  - http://www.criminalinjusticepodcast.com/blog/2018/1/31/73-sentinel-events-justice-system-disasters
Y2  - 2018/06/01/
ER  - 

TY  - NEWS
TI  - Parkland Shooting Suspect Lost Special-Needs Help at School When He Needed It Most
AU  - Mazzei, Patricia
T2  - The New York Times
AB  - A report commissioned by the school district in Parkland, Fla., said Nikolas Cruz generally received the help he needed but lost access to it by mistake.
DA  - 2018/08/05/
PY  - 2018
DP  - NYTimes.com
LA  - en-US
SE  - U.S.
SN  - 0362-4331
UR  - https://www.nytimes.com/2018/08/04/us/parkland-florida-nikolas-cruz.html
Y2  - 2018/09/24/15:59:29
KW  - Mental Health and Disorders
KW  - Broward County (Fla)
KW  - Cruz, Nikolas
KW  - Marjory Stoneman Douglas High School (Parkland, Fla)
KW  - Parkland (Fla)
KW  - Parkland, Fla, Shooting (2018)
KW  - School Shootings and Armed Attacks
KW  - Special Education
ER  - 

TY  - NEWS
TI  - How the Justice System Can Learn From 'Frequent Fliers’
AU  - Doyle, James M.
T2  - The Crime Report
AB  - For some Americans, health care and criminal justice are not two separate systems, but components of one big system that too often fails them. Frustrated cops call them “frequent fliers” because they regularly cycle between jail and hospital, so why do we  think we can fix one without the other?
DA  - 2018/08/07/
PY  - 2018
LA  - en-US
UR  - https://thecrimereport.org/2018/08/07/how-the-justice-system-can-learn-from-frequent-flyers/
Y2  - 2018/09/24/16:05:32
ER  - 

TY  - JOUR
TI  - Essay: A 'Safety Model' Perspective Can Aid Diagnosis, Prevention, and Restoration after Criminal Justice Harms
AU  - Doyle, James M.
T2  - Santa Clara Law Review
AB  - An essay discussing an embryonic "Safety Model" derived from literature and practice mobilized in high risk industry, aviation, and medicine that promises to enhance criminal justice as public safety.
DA  - 2018/05/02/
PY  - 2018
DP  - papers.ssrn.com
VL  - Available on SSRN
IS  - Forthcoming
LA  - en
ST  - Essay
UR  - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3171542
Y2  - 2018/09/24/17:38:24
KW  - wrongful convictions
KW  - sentinel events
KW  - criminal justice error
KW  - learning reviews
KW  - public safety
KW  - restorative justice
KW  - system error in criminal justice
ER  - 

TY  - NEWS
TI  - Chicago Cops and Justice: Will the Past Cripple the Future?
AU  - Doyle, James M.
T2  - The Crime Report
AB  - A draft consent decree aimed at curbing abuse of force and racial bias in the Chicago police department is now circulating for comment. But it may not solve the underlying issues, writes a Boston attorney.
DA  - 2018/08/29/
PY  - 2018
LA  - en-US
ST  - Chicago Cops and Justice
UR  - https://thecrimereport.org/2018/08/29/chicago-justice-will-the-past-cripple-the-future/
Y2  - 2018/10/03/15:37:38
ER  - 

TY  - RPRT
TI  - Mondernizing Parole Statutes: Guidance from Evidence-Based Practice
AU  - McVey, Catherin
AU  - Rhine
AU  - Reynolds
AB  - The Parole Release and Revocation Project of the Robina Institute of Criminal Law and Criminal Justice
is committed to engaging releasing authorities in both indeterminate and determinate sentencing states
in examining all aspects of the discretionary parole release and post-release violations process. A central
goal of this project is to contribute to the enhancement of decision-making at every stage. To accomplish
this goal, the Parole Release and Revocation Project partners with select jurisdictions on issues related
to parole release decision-making; researches and publishes legal and statutory state parole profiles; and
publishes survey and other findings focusing on releasing authorities.



P. 18 Transparency also includes a thoughtful response to
a critical incident, typically when a person on parole
commits a high-visibility, violent crime. A formal review
of the critical incident to determine any system failing
is a longstanding, recognized practice in law enforcement
and institutional corrections. Paroling authorities
typically have not engaged in a formal critical incident
review process to analyze how and why the event
occurred and to determine if any corrective actions are
warranted. However, the National Institute of Justice
has been investigating the feasibility of using “sentinel
event reviews” since 2011 and has embarked on a project
called the “Sentinel Events Initiative”.
64
CY  - University of Minnisota
DA  - 2018///
PY  - 2018
PB  - Robina Institute of Criminal Law and Criminal Justice
UR  - http://www.apaintl.org/resources/documents/publications/modern_parole_statutes.pdf
Y2  - 2018/10/03/15:45:27
ER  - 

TY  - JOUR
TI  - BEYOND BAD APPLES:ADOPTING SENTINEL EVENT REVIEWS IN NEVADA’S CRIMINAL JUSTICE SYSTEM
AU  - Aguirre, Beatriz
T2  - University of Nevada Law Journal
AB  - I would also like to acknowledge
my internship supervisors at the U.S. Department of Justice’s Office for Access to Justice who exposed me to this topic and to Maureen McGough with the National Institute of Justice
for answering my questions about sentinel event reviews.
DA  - 2018///
PY  - 2018
VL  - 18
IS  - 3
SP  - 1059
EP  - 1089
UR  - https://scholars.law.unlv.edu/cgi/viewcontent.cgi?article=1756&context=nlj
ER  - 

TY  - NEWS
TI  - Scientifical Protocols for Fire Investigation
AU  - Lentini, John
T2  - Fire Scientist Newsletter
AB  - Scientific Protocols for Fire Investigation, Third Edition focuses on the practical application of fundamental scientific principles to determine the causes of fires. Originally published in 2006, the First Edition was very well received by fire investigators and those who work with them. Since fire investigation is a rapidly evolving field―driven by new discoveries about fire behavior―the Second Edition was published in late 2012.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/w3onzTAnlqA

John Lentini: The introduction to Chapter 9 does give a shout out to sentinel event reviews, but the individual case studies all focus on the sharp end operators who got the ball rolling. The introduction is attached in manuscript form.
DA  - 2018///
PY  - 2018
ET  - 3
UR  - http://www.firescientist.com/newsletter4.php
Y2  - 2018/10/12/16:58:14
ER  - 

TY  - BLOG
TI  - Wrongful Convictions as a Sentinel Event
AU  - Cleary, Patrick
T2  - The Constitution Project
AB  - Now, the Department of Justice is introducing a promising new test program that is designed to support systemic changes to the criminal justice system. Two years ago, the National Institute of Justice (NIJ), the research agency of the Department of Justice, began to examine how to develop a process that would analyze mistakes in the criminal justice system in a way to better prevent errors from occurring in the future. The NIJ observed that the similar errors were repeating across the country and that the current reforms were not adequately providing solutions. The NIJ hypothesized that the system’s inadequacies were not caused by structural defects but, rather, by the underlying cultural influences that pressure individuals into making a series of individual mistakes that collectively lead to organizational errors. The problem the NIJ discovered was that the criminal justice system does not lend itself to an honest self-evaluation, as the Attorney General notes, “Practitioners in an adversarial system that probes, refutes, and defends do not, in general, concede fault readily.” The NIJ’s challenge was to develop a blame-free process that would allow for open and honest evaluation of errors that would uncover the underlying precursors that cause the mistakes.
DA  - 2014/09/12/
PY  - 2014
M3  - The Constitution Project
UR  - https://constitutionproject.org/documents/wrongful-convictions-as-a-sentinel-event/
Y2  - 2018/10/12/17:31:46
ER  - 

TY  - JOUR
TI  - A Tale of Two Countries: Examining the Regulation of Prosecutorial Discretion and Misconduct in Canada and the United States by Stephen Wilks, Charles MacLean :: SSRN
AU  - Wilks, Stephen
AU  - Maclean, Charles
T2  - Ottawa Faculty of Law Working Paper
AB  - Note 123 Funding from the US Department of Justice, National Institute of Justice, Office of Justice Programs has
recently catalyzed research into sentinel events research. Borrowed from medical sentinel event research,
criminal justice sentinel events are clusters of cases betraying a systemic flaw. The sentinel event approach
allows public review of multiple related cases at once intending to identify root causes and generate
systemic solutions. For a brief overview, see National Institute of Justice, “The Sentinel Event Initiative:
Proceedings from an Expert Roundtable” (Roundtable at the National Institute of Justice, 21 May 2013)
DA  - 2013/12/04/
PY  - 2013
SP  - 38
UR  - https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2362928&download=yes
Y2  - 2018/10/12/
ER  - 

TY  - NEWS
TI  - Justice Systems Test "Sentinel Event Analysis" To Prevent Mistakes
AU  - Handelman, Stephen
T2  - The Crime Report
AB  - "Sentinel event analysis," a process traditionally not used in criminal justice but entrenched in the health-care and transportation industries, now is being tested to help prevent major justice errors,
DA  - 2015/04/02/
PY  - 2015
LA  - en-US
UR  - https://thecrimereport.org/2015/04/02/2015-04-nykr-on-cj-errors/
Y2  - 2018/11/05/16:11:25
ER  - 

TY  - ELEC
TI  - Learning from Error in Criminal Justice: A Sentinel Events Approach
AU  - McGough, Maureen
AU  - Doyle, James M.
T2  - Justice Clearinghouse
AB  - In criminal justice, a “sentinel event” is a bad outcome that might include a death in custody, routine police encounter that escalates to violence, mishandling of evidence, wrongful conviction, or “near miss,” in which a negative event is narrowly avoided. Too often, the criminal justice system fails to learn from these bad outcomes. Drawing inspiration from aviation, medicine, and other high-risk fields, the Sentinel Events Initiative (SEI) takes an alternative approach. SEI advocates for non-blaming, all-stakeholder, forward-looking reviews of sentinel events, to learn from these events in an effort to prevent their recurrence. 

This webinar:
• outlines the sentinel events approach,
• shares how criminal justice practitioners can implement sentinel event reviews in their jurisdictions,
• includes information about a National Demonstration Project being implemented across the country by the National Institute of Justice and the Bureau of Justice Assistance.
DA  - 2018/10/30/
PY  - 2018
UR  - https://justiceclearinghouse.com/resource/learning-from-error-in-criminal-justice-a-sentinel-events-approach/
ER  - 

TY  - RPRT
TI  - Implementing the Lessons from Wrongful Convictions: An Empirical Analysis of Eyewitness Identification Reform Strategies
AU  - Findley, Keith A.
AB  - Learning about the flaws in the criminal justice system that have produced wrongful convictions has progressed at a dramatic pace since the first innocent individuals were exonerated by postconviction DNA testing in 1989. Application of that knowledge to improving the criminal justice system, however, has lagged far behind the growth in knowledge. Likewise, while considerable scholarship has been devoted to identifying the factors that produce wrongful convictions, very little scholarly attention has been devoted to the processes through which knowledge about causes is translated into reform. Using eyewitness misidentification -- one of the leading contributors to wrongful convictions and the most thoroughly and scientifically studied of those contributors -- as the focus, this Article begins to fill that void by empirically analyzing a variety of approaches to eyewitness identification reform that have been attempted. This Article establishes a taxonomy of reform efforts ranging from top-down, command-and-control legislation, to entirely bottom-up, essentially laissez-faire approaches, to a hybrid that builds on emerging notions of democratic experimentalism -- a form of "new governance" -- to foster bottom-up experimentation by imposing obligations on police while giving them the freedom to develop their own locally tailored responses to the problem of eyewitness error. The bulk of the empirical analysis assesses the effects of the bottom-up experimentalist approaches to reform, as a contrast to command-and-control approaches. The analysis draws on previously collected national survey data as well as data from a few individual states, most prominently new data developed for this Article on the attempt to foster bottom-up eyewitness identification reform in Wisconsin. While more research is required before one can draw conclusions about which approach works best, the data suggest that the democratic experimentalist model shows promise for considerable, albeit imperfect, implementation of social-science-based eyewitness identification reforms.

From Page 380:
While the research has largely addressed these specific error
points, it has also approached the problem from a systems perspective, viewing error not just as, or even primarily, the result of individual and isolated human errors, but as the product of systemic and institutional arrangements that permit or create conditions for error.11
CY  - Rochester, NY
DA  - 2016/01/11/
PY  - 2016
DP  - papers.ssrn.com
LA  - en
M3  - SSRN Scholarly Paper
PB  - Social Science Research Network
SN  - ID 2713963
ST  - Implementing the Lessons from Wrongful Convictions
UR  - https://papers.ssrn.com/abstract=2713963
Y2  - 2018/11/05/19:07:44
KW  - wrongful conviction
KW  - criminal justice reform
KW  - innocence movement
KW  - democratic experimentalism
KW  - double-blind sequential
KW  - eyewitness identification
KW  - innocence
KW  - new governance
KW  - policing
ER  - 

TY  - CONF
TI  - If It is Broke[n], Fix It: Innovative Approaches to Diagnosing, Repairing, and Improving Systems
AU  - Doyle, James M.
AU  - O'Brien, Mallory
AU  - Ely, Amy
AU  - Smith, Jenniffer
T2  - National Association of Attorney Generals
AB  - The panelists will discuss their experiences with identifying, diagnosing, and addressing structural
challenges and problems. You will be introduced to the National Institute of Justice’s Sentinel Event Initiative; hear one approach to addressing the opioid epidemic; and learn how the Washington, D.C. crime lab went from shutting down DNA testing to eliminating its rape kit backlog in just two years.
DA  - 2018/06/21/
PY  - 2018
UR  - https://vimeo.com/276327926
ER  - 

TY  - SLIDE
TI  - Profiles in Innovation: The NIJ Sentinel Events Initiative
A2  - Spivak, Howard
CY  - Penn Quattrone Center
DA  - 2017/04/26/
PY  - 2017
ST  - Profiles in Innovation
UR  - https://www.youtube.com/watch?v=fAAO2XURlIw
Y2  - 2018/11/05/19:37:39
ER  - 

TY  - JOUR
TI  - Conviction Integrity Units, Innocence Commissions Tackle Wrongful Convictions, Prosecutorial Misconduct | Criminal Legal News
AU  - Horn, Steve
T2  - Criminal Legal News
AB  - In that vein, the U.S. Department of Justice’s National Institute of Justice – surprisingly under the presidency of Donald Trump – has launched Sentinel Events Initiative, which gave a $1.6 million grant to the University of Pennsylvania in 2017 to perform reviews along the lines presented in the paper by Gould and Leo, or what the DOJ has called technical assistance reviews.

“Through the Sentinel Events Initiative (SEI), we are focused on learning from system weaknesses in criminal justice and transforming the culture into one of safety, transparency, and commitment to continual improvement,” wrote Howard Spivak, then the acting director and now the deputy director of the National Institute of Justice, in a report done by the Justice Department about its Sentinel Events Initiative. “The SEI is supporting the development and broad adoption of a rigorous approach that not only reveals system weaknesses, but also identifies high-priority areas where further scientific exploration can support system improvements.”
DA  - 2018/11/05/
PY  - 2018
UR  - https://www.criminallegalnews.org/news/2018/oct/25/conviction-integrity-units-innocence-commissions-tackle-wrongful-convictions-prosecutorial-misconduct/
Y2  - 2018/11/05/19:47:16
ER  - 

TY  - SOUND
TI  - Kim Rossmo Discusses Investigative Failures
AU  - Ratcliffe, Jerry
AB  - Kim Rossmo discusses his latest work trying to better understand investigative failures and why solvable cases go cold.  Date: 11/2018
LA  - en
M1  - 2018
UR  - https://player.fm/series/reducing-crime/ep-04-kim-rossmo
Y2  - 2018/11/23/16:08:45
ER  - 

TY  - RPRT
TI  - Risk Management in Law Enforcement: Discussions on Identifying and Mitigating Risk for Officers, Departments, and the Public
AU  - Copple, Colleen K.
AU  - Copple, James E.
AB  - From the COPS [Community Oriented Policing Services] website: In the course of executing their duties, law enforcement agencies are vulnerable to costly lawsuits by officers and community members for claims of misconduct, harm, or violation of rights - lawsuits that can undermine not only the financial security of the agencies but also the well-being of the officers and the public they serve. To help law enforcement identify and minimize these risks, the COPS Office and Strategic Applications International (SAI) convened a forum that included representatives of labor unions, local government, law enforcement agencies, and the community. This report, which details the discussions of that forum, covers all aspects of this critical subject, including departmental leadership's role, recruitment policies, and police-community relations. Readers will also find tools for sharing risk management and a description of the roles and responsibilities of government, risk managers, insurers, unions, and the community in this effort. The appendices provide a summary of the forum's recommendations and a list of resources for risk management.
DA  - 2018///
PY  - 2018
DP  - www.hsdl.org
LA  - en
PB  - Office of Community Oriented Policing Services (COPS)
ST  - Risk Management in Law Enforcement
UR  - https://www.hsdl.org/?abstract&did=818145
Y2  - 2019/03/08/22:10:29
ER  - 

TY  - JOUR
TI  - Hitting (or missing) the mark: An examination of police shooting accuracy in officer-involved shooting incidents
AU  - Donner, Christopher M.
AU  - Popovich, Nicole
T2  - Policing: An International Journal
DA  - 2018/10/31/
PY  - 2018
DO  - 10.1108/PIJPSM-05-2018-0060
DP  - emeraldinsight.com (Atypon)
J2  - Policing: Int J.
SN  - 1363-951X
ST  - Hitting (or missing) the mark
UR  - https://www.emeraldinsight.com/doi/abs/10.1108/PIJPSM-05-2018-0060
Y2  - 2019/03/11/17:25:09
KW  - Hit rates
KW  - Police accountability
KW  - Police training
KW  - Police use of deadly force
ER  - 

TY  - MGZN
TI  - Police Misconduct Is Increasingly a Financial Issue
AU  - Farmer, Liz
AB  - Lawsuits are costing governments millions, and, in some cases, forcing them to shut down departments.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/UN7lAQ1bEyw
DA  - 2018/06/20/
PY  - 2018
LA  - en
UR  - https://www.governing.com/topics/finance/gov-police-misconduct-growing-financial-issue.html
Y2  - 2019/04/08/14:55:31
ER  - 

TY  - NEWS
TI  - Philly agencies grapple with a wrongful conviction. Can they learn from their mistakes?
AU  - Melamed, Samantha
T2  - Philadelphia Enquirer
AB  - In 2012, George Cortez was convicted of murdering Nasif Murray on a street in North Philadelphia, and sentenced to life in prison. Then, in 2016, after further investigation, he was exonerated.
...The Quattrone Center, part of Penn’s law school, is seeking to implement such reviews in jurisdictions across the country, and has received a $1.6 million grant, as part of a joint partnership from the National Institute of Justice and Bureau of Justice Assistance, to take the “Sentinel Event Review” model to between 12 and 20 more cities. Baltimore, Chicago, and Austin, Texas, have already signed on. The idea is to bring to criminal justice the approach long practiced in medicine, where post-mortem reviews examine where errors were introduced and how such failures can be prevented going forward.
DA  - 2019/04/09/
PY  - 2019
LA  - en-US
UR  - https://www.philly.com/news/philadelphia-wrongful-conviction-event-review-quattrone-center-penn-20190409.html
Y2  - 2019/04/10/13:48:23
ER  - 

TY  - ELEC
TI  - Sentinel Events Initiative (SEI)
AU  - Bureau of Justice Assistance
T2  - Bureau of Justice Assistance (BJA)
AB  - Learn about the Sentinel Events Initiative (SEI), a joint initiative of the Bureau of Justice Assistance and the National Institute of Justice.
LA  - en-us
UR  - https://www.bja.gov/sentinel-events-initiative/index.html
Y2  - 2019/04/10/21:46:12
L2  - https://www.bja.gov/sentinel-events-initiative/
ER  - 

TY  - ELEC
TI  - How Small Errors Combine to Send Innocent People to Prison
AU  - Staff
T2  - The Crime Report
AB  - A series of preventable mistakes sent George Cortez to prison for a murder he didn't commit. Philadelphia’s police, legal and judicial community used a groundbreaking DOJ initiative to come up with ways to make sure it never happens again.
DA  - 2019/04/11/T12:15:54+00:00
PY  - 2019
LA  - en-US
UR  - https://thecrimereport.org/2019/04/11/how-small-errors-combine-to-send-innocent-people-to-prison/
Y2  - 2019/04/11/20:56:07
ER  - 

TY  - RPRT
TI  - REPORT OF THE PHILADELPHIA EVENT REVIEW TEAM ON COMMONWEALTH V. GEORGE CORTEZ
AU  - Quattrone Center for Fair Administration of Justice
AB  - The Philadelphia Event Review Team (PERT) is a voluntary collaboration among the Philadelphia District Attorney’s Office, the Philadelphia Police Department, the First Judicial District Courts of Pennsylvania, and the Defender Association of Philadelphia, coordinated by the Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania Law School. The PERT is a first-of-its-kind initiative in the United States, dedicated to a culture of learning from error that is shared across all of the participating agencies. The project is supported by funding from the National Institute of Justice (NIJ), the research and development arm of the United States Department of Justice (DOJ). The stakeholders listed above decided to review the conviction and subsequent exoneration of George Cortez as its initial case for review. The PERT dedicated itself to the thorough review of the case using principles of root cause analysis (RCA) to conduct a “just culture event review.” For purposes of this process, we define a “just culture” as “a culture that recognizes that
competent professionals make mistakes and acknowledges that even competent professionals
will develop unhealthy norms (e.g., shortcuts, ‘routine rule violations’), but has zero tolerance
for reckless behavior.”1
 Thus, we designed our review to understand the events that
occurred in the George Cortez case, from arrest through appeal and ultimately
exoneration, and to generate precise recommendations with the goal of preventing the mistakes that occurred in that case from happening in the future. Our goal was not to punish or find blame with any individual or agency, but solely to understand how our system
could ultimately convict George Cortez and then conclude that the conviction was in error based
on the specifics of this case and its subsequent appeal.
DA  - 2019/04//
PY  - 2019
PB  - University of Pennsylvania
UR  - https://www.law.upenn.edu/live/files/9323-pertcortez
ER  - 

TY  - JOUR
TI  - A “SAFETY MODEL” PERSPECTIVE CAN AID DIAGNOSIS, PREVENTION, AND RESTORATION AFTER CRIMINAL JUSTICE HARMS
AU  - Doyle, James M.
T2  - Santa Clara Law Review
AB  - Criminal justice in the United States is primarily a state and local
enterprise and most (if not all) states and localities have experienced
some disturbing outcomes. Harris County, Texas, for example, has
experienced its own lab scandals.7
 Elsewhere, the innocent are wrongly 
convicted while the real perpetrators go free; dangerous prisoners are
mistakenly released and then kill again; avoidable “suicide-by-cop”
fatalities traumatize families and frontline police. Beneath these frontpage spectacles a submerged universe of coerced misdemeanor8
  pleabargains, protracted pretrial detentions, failed re-entry plans, fruitlessstreet stops, “near-misses,” declining “closure rates” and “high frequency, low impact” events of all kinds erode public security and trust in the law.
DA  - 2019///
PY  - 2019
VL  - 59
IS  - 11
UR  - https://digitalcommons.law.scu.edu/cgi/viewcontent.cgi?article=2869&context=lawreview
N1  - <p>Elsewhere, the innocent are wrongly convicted while the real perpetrators go free; dangerous prisoners are<br />mistakenly released and then kill again; avoidable “suicide-by-cop”<br />fatalities traumatize families and frontline police. Beneath these frontpage spectacles a submerged universe of coerced misdemeanor8<br />plea<br />bargains, protracted pretrial detentions, failed re-entry plans, fruitless<br />street stops, “near-misses,” declining “closure rates” and “high<br />frequency, low impact” events of all kinds erode public security and trust<br />in the law. </p>
<p> </p>
<p>Discussions of contemporary American criminal justice do not<br />suffer from any shortage of Models. Herbert Packer set the ball rolling<br />by describing his opposing Crime Control and Due Process Models.10</p>
<p>John Griffths deployed a Family Model to show that Packer’s two polar<br />ideologies are really variant versions of a single, unified Battle Model.11</p>
<p>In the aftermath of the DNA exoneration cases Innocence Movement<br />scholars such as Keith Findley and Marvin Zalman have attempted to<br />point out to partisans for one or the other of Packer’s Models that some<br />version of a Reliability Model12 or Integrated Justice Model,13 focusing<br />on factual accuracy, could present a win/win option that simultaneously<br />protects the innocent and targets the actually guilty, whom wrongful<br />convictions leave free to find further victims.</p>
N1  - <p>The last decade has seen a growing interest 14 in a criminal justice<br />orientation derived from a deep reservoir of literature and experience"<br />that high-risk fields such as aviation and medicine16 have tapped to<br />develop 'cultures of safety.17 T he fact that safety concepts are so easily<br />borrowed from other fields probably explains why there have been few<br />efforts to denominate an explicit 'Safety Model _ in criminal justice."<br />But by now it is easy to list books, articles, and compilations that<br />introduce the basic safety concepts to criminal justice practicecommunities. 19 The National Institute ofJ ustice (NIJ), has given this<br />interest practical form through its 'Sentinel Events Initiative- by<br />conducting a sustained investigation of the potential for mobilizing</p>
<p> </p>
<p>Scott Hertzberg a librarian at the National Criminal J ustice<br />Reference Service, has compiled a bibliography illuminating the extent of an interdisciplinary<br />literature that implicates the safety-oriented model. See Sentinel Events Initiative: A Corrpiled<br />Bibliography, NAT L INST. OF J UST., https:/iww.nij.gov/topics/ usticesystem/Pages/senti nel-events- bi bl iography.aspx</p>
N1  - <p>The safety at issue here is everyone's safety: the safety of crime<br />victims, defendants, and communities' even the safety of law<br />enforcement personnel 21 and legal system practitioners.22 This wider<br />safety perspective escapes the zero-sum i deol ogy of the C ri me Control<br />versus Due Process dialectic in which anything protecting an<br />individual -s rights automatically threatens potential crime victims to an<br />equal extent. It recognizes the impact of iatrogenic 23 ('from the<br />treatment-) injury inflicted by hyper-aggressive 'stop, question, and<br />frisk- programs, re-traumatizing victim interviews, mass incarceration,24<br />and other interventions, and requires that those harms be weighed in the<br />balance before making criminal justice choices, not deferred to be<br />deplored at some later date.25 It throws a new light on familiar<br />challenges; examining events in that light reveals opportunities.<br />Familiarity with an emerging Safety Model can improve practice, and<br />may fuel transformati on.</p>
ER  - 

TY  - MPCT
TI  - New Report Details Wrongful Conviction of Philadelphia Man
AU  - Conners, Rosemary
T2  - NBC 10 News
AB  - New details are emerging about how a man wrongfully accused of murder had his conviction overturned and was released from prison. Its part of an ongoing effort to reform the criminal justice system.
DA  - 2019/04/11/
PY  - 2019
PB  - NBC Philadelphia
UR  - https://www.nbcphiladelphia.com/news/local/New-Report-Details-Wrongful-Conviction-of-Philadelphia-Man_Philadelphia-508340842.html?platform=hootsuite
Y2  - 2019/04/12/20:48:30
ER  - 

TY  - RPRT
TI  - Police Shootings: Is Accountability the Enemy of Prevention?
AU  - Armacost, Barbara E.
AB  - Police officers shoot an unarmed man or woman. The victim’s family and community cry out for someone to be held accountable. In minority communities, where a disproportionate number of officer-involved shootings occur, residents suspect that racial animus and stereotypical assumptions about “dangerous black men” played a part. Citizens seek accountability by filing lawsuits and demanding criminal prosecutions. They are usually disappointed: The majority of police-involved shootings are deemed “justified” by police investigators and courts, and no criminal charges are brought. If so, this is the end of the inquiry under current legal standards and there is no accountability. There is also no legal reason to ask why the shooting occurred and how it could have been prevented. This article argues that the current accountability paradigm is hindering genuine progress in decreasing the number of police-involved shootings, including those motivated by racism. We need to look beyond the limited time-frame embraced by the current legal standard and view police-involved shootings as organizational accidents. Borrowing lessons learned from the aviation and healthcare fields, this article urges a prevention-first approach that applies systemic analysis to what are systems problems. In these sectors, investigations of tragic accidents employ Sentinel Event Review, a systems-oriented strategy that looks back to identify all the factors that contributed to the event and looks forward to identify systemic reforms that could mitigate the chance of recurrence. The goal is to create systemic barriers that make it more difficult for sharp-end actors to err or misbehave. I am not arguing that individual police officers should escape responsibility for their actions. But our cur-rent relentless focus on accountability – while an understandable human reaction – has become the enemy of prevention in the very communities that need it most.
https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/EYlPwxuAlpg
CY  - Rochester, NY
DA  - 2019/04/01/
PY  - 2019
DP  - papers.ssrn.com
LA  - en
M3  - SSRN Scholarly Paper
PB  - Social Science Research Network
SN  - ID 3363909
ST  - Police Shootings
UR  - https://papers.ssrn.com/abstract=3363909
Y2  - 2019/04/25/14:37:28
KW  - excessive force
KW  - policing
KW  - root cause analysis
KW  - accountability
KW  - justified shooting
KW  - police-involved shooting
KW  - prevention
KW  - racially motivated shooting
KW  - Sentinel Event Review
ER  - 

TY  - JOUR
TI  - Safety in Post-Conviction Proceedings
AU  - Sangero, Boaz
T2  - John Marshall Law Review
AB  - It is extremely difficult to correct an error after conviction.
Given the Hidden Accidents Principle in criminal law, it is very
hard to uncover mistakes and even harder to prove them. Time is
one of the greatest enemies of reconstructing the truth. Evidence
gets lost, potential witnesses forget, move away, or die. The legal
rules, including the finality of verdicts rule, hinder the rectification
of miscarriages of justice. Another factor is that once the indictment
has been made, the police usually close their investigation. Even
when the appellate court finds a defect in the original trial
proceedings, it will most likely be deemed “harmless error.” Thus,
the finality of proceedings rule in fact already applies with the
handing down of the verdict at trial, even before appeal. The main
procedural mechanism intended for correcting miscarriages of
justice is a motion for a new trial. But this mechanism is not
effective. Since safety theory and safety measures are not yet
developed in the criminal justice system, we have to learn it from
other areas, such as aviation, transportation and engineering. In
order to bring SAFETY to post-conviction proceedings, this essay
offers some safety measure

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/UMjoTsgCB9E
DA  - 2018///
PY  - 2018
VL  - 51
IS  - 4
UR  - https://repository.jmls.edu/cgi/viewcontent.cgi?article=2767&context=lawreview
ER  - 

TY  - VIDEO
TI  - The Quattrone Center's Systems Approach
AU  - Penn Law
AB  - John F. Hollway C'92, Executive Director of the Quattrone Center for the Fair Administration of Justice, discusses the Center's multi-disciplinary, data-driven approach and how it is instrumental in building a world class policy hub for researching and debating the system's most crucial problems, as well as in framing solutions to catalyze long-term structural improvements. 

By integrating world-class scholarship from across the University with the perspectives of nationally prominent practitioners, the Center will analyze and make recommendations that will shape public deliberations and improve the fairness of our legal system. Penn is the ideal host for the Center due to its outstanding overall academic credentials as well as its particular strengths in law, criminology, engineering, life sciences, medicine, public policy, social sciences and statistical analysis—all of which will come into play in advancing the justice system to the next level. The Center, and Penn as a whole, will inspire and support collaborative ventures that provide novel perspectives on our current practices, generating applied scholarship that enhances the efficacy, transparency, and accountability of the criminal justice system.
DA  - 2013/11/08/
PY  - 2013
DP  - YouTube
UR  - https://www.youtube.com/watch?v=sF-zq5RiQkY
Y2  - 2019/04/25/20:08:55
ER  - 

TY  - RPRT
TI  - REPORT OF THE BALTIMORE EVENT REVIEW TEAM On the State of Maryalnd V. Malcolm J. Bryant
AU  - Quattrone Center for Fair Administration of Justice
AB  - The Baltimore Event Review Team (BERT) is a voluntary collaboration among the Baltimore
City State’s Attorney’s Office (SAO), the Baltimore Police Department (BPD), the Maryland
Office of the Public Defender in Baltimore City (OPD), and the University of Baltimore
Innocence Project (UBIP), a collaborative effort of the Office of the Public Defender and the
University of Baltimore School of Law, coordinated by the Quattrone Center for the Fair
Administration of Justice at the University of Pennsylvania Law School.1
 The BERT is
dedicated to promoting a culture of learning from error across all of the participating agencies.
In 1999, Malcolm J. Bryant was convicted of the murder of Ms. Toni Bullock and sentenced to
life in prison. In 2015, after 16 years in prison, a DNA test conclusively proved Mr. Bryant’s
innocence of the crime for which he was convicted. While is it a given that no system is perfect,
and errors will occur, the members of the Baltimore Event Review Team (BERT) came together
to learn from this unfortunate and unwanted injustice to Mr. Bryant, and design improvements to
the Baltimore criminal justice system that will reduce the likelihood of such inaccurate
convictions occurring in the future.
DA  - 2018/11//
PY  - 2018
UR  - https://www.law.upenn.edu/live/files/8862-malcolm-bryant-exoneration
ER  - 

TY  - RPRT
TI  - REPORT OF THE PHILADELPHIA EVENT REVIEW TEAM ON THE LEX ST. MASSACRE: National Institute of Justice Sentinel Events Initiative Pilot Program
AU  - Quattrone Center for Fair Administration of Justice
AB  - In the spring of 2014, the Quattrone Center for the Fair Administration of Justice at the University of
Pennsylvania Law School, along with the Philadelphia Police Department, the Philadelphia District
Attorney’s Office, the Philadelphia Court of Common Pleas, two private defense counsel, and a former
reporter for the Philadelphia Daily News collaborated on a proposal to the National Institute of Justice
(NIJ), the research division of the United States Department of Justice, in response to a call for proposals
for Sentinel Event Reviews in criminal justice. The question posed by NIJ was whether a multi- stakeholder event review using “systems principles” of error reduction that had been proven effective in
other environments (e.g., healthcare, aviation, nuclear power management) could be deployed
effectively in criminal justice.
The stakeholders listed above decided to use the Lex St. Massacre, one of the most notorious crimes in
Philadelphia’s history, as the case for our review. Still the largest single mass murder in Philadelphia
history, it is a case that was successfully closed, with four men (Shihean Black, Dawud Faruqi, Khalid
Faruqi, and Bruce Veney) tried and convicted of seven murders and three attempted murders. At the
same time, the four men ultimately convicted of these heinous and tragic crimes were not the first four
men arrested, charged and incarcerated for them. Instead, through a combination of false confessions,
mistaken eyewitness identifications, and other mistakes and occurrences within the Philadelphia
criminal justice system, four other men (Jermel Lewis, Quiante Perrin, Hezekiah Thomas, and Sacon
Youk) were arrested, charged and incarcerated for almost 18 months for crimes they did not commit.
DA  - 2015/12/08/
PY  - 2015
PB  - Quattrone Center for the Fair Administration of Justice
UR  - https://www.law.upenn.edu/live/files/6850-lex-st-report
ER  - 

TY  - RPRT
TI  - Using Root Cause Analysis to Instill a Culture of Self-Improvement: Program Replication Materials
AU  - Quattrone Center for Fair Administration of Justice
AB  - This white paper describes an internal Root Cause Analysis (“RCA”) conducted by the Montgomery
County, PA District Attorney’s Office (“DA”) in partnership with the Quattrone Center for the Fair
Administration of Justice, an interdisciplinary research and policy center within the University of
Pennsylvania Law School (“Quattrone Center”). The Quattrone Center specializes in RCA
regarding errors within the criminal justice system. RCA has been used in complex and fragmented
industries (e.g., healthcare, aviation, nuclear power) to understand the various factors (direct and
environmental) that lead to both individual and systemic-based errors, and to provide interventions
that can effectively prevent future error.
CY  - Innovations in Criminal Justice Summit III
DA  - 2015/04/20/21
PY  - 2015
UR  - https://www.law.upenn.edu/live/files/4291-impact-report-root-cause-analysis
ER  - 

TY  - VIDEO
TI  - The Sentinel Events Initiative: Becoming a Demonstration Site
AU  - Bureau of Justice Assistance
AB  - The Sentinel Events Initiative (SEI) aims to empower jurisdictions by learning from negative outcomes in the criminal justice system and preventing their reoccurrence. Currently, the Bureau of Justice Assistance is seeking sites for the SEI National Demonstration Collaboration, in which jurisdictions across the country will receive technical assistance to conduct sentinel event reviews of outcomes such as wrongful releases, in-custody deaths, or fatal overdoses of justice-involved individuals. This webinar provided an overview of the sentinel events approach and an opportunity for interested applicants to ask questions about SEI.
DA  - 2019/04/31/
PY  - 2019
DP  - YouTube
ST  - The Sentinel Events Initiative
UR  - https://www.youtube.com/watch?v=QnvrWH5oFwQ&feature=youtu.be
Y2  - 2019/05/09/17:05:22
ER  - 

TY  - ELEC
TI  - Keeping the Wrong Secrets: The ‘Cone of Silence’ Around Exonerations | The Crime Report
AU  - Doyle, James M.
T2  - The Crime Report
AB  - In every criminal justice bureaucracy, there are layers of mid-level people who have been taught that their role is to help their department (or office, or agency, or court) keep its head down.  The rote demands for confidentiality orders and the refusal to admit wrongdoing in the Abernathy case were predictable, reflexive, part of a routine.
DA  - 2019/05/28/
PY  - 2019
UR  - https://thecrimereport.org/2019/05/28/keeping-the-wrong-secrets-the-cone-of-silence-around-exonerations/
Y2  - 2019/05/28/20:42:18
ER  - 

TY  - ELEC
TI  - ‘Confirmation Bias’ Called a Key Reason for Wrongful Convictions
AU  - Staff
T2  - The Crime Report
AB  - Why do innocent people go to jail? Two Texas State University professors argue that procedural mistakes like eyewitness misidentification and flawed forensic evidence are compounded by a common human failing: once we come to a conclusion about an issue, we rarely pay attention to evidence that might contradict it.
DA  - 2019/07/16/T11:45:53+00:00
PY  - 2019
LA  - en-US
UR  - https://thecrimereport.org/2019/07/16/confirmation-bias-called-a-key-reason-for-wrongful-convictions/
Y2  - 2019/07/18/19:07:35
ER  - 

TY  - ELEC
TI  - Beware the ‘Professional’ Reformer | The Crime Report
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Reform has professionalized, and the profession is organized around discrete tasks that can be expressed in grant announcements, awarded, completed, evaluated, and (when promising) publicized.

Has this process fostered a vision of criminal justice change no individual participant would completely endorse, and which many participants would repudiate? Will it take on a life of its own?
DA  - 2019/08/01/
PY  - 2019
UR  - https://thecrimereport.org/2019/08/01/beware-the-professional-reformer/
Y2  - 2019/08/01/21:06:05
ER  - 

TY  - NEWS
TI  - Madison City Council approve initial recommendations from police committee
AU  - Becker, Abigail
T2  - Madison Cap Times
AB  - On Tuesday, the Madison City Council signaled its support of pursuing civilian review mechanisms and a comprehensive internal review process of critical incidents.
DA  - 2019/08/07/
PY  - 2019
LA  - en
UR  - https://madison.com/news/local/govt-and-politics/madison-city-council-approve-initial-recommendations-from-police-committee/article_64b1b9d9-f18b-54c6-bde6-3cd76d8b78ef.html
Y2  - 2019/08/08/15:17:13
ER  - 

TY  - JOUR
TI  - Applying sentinel event reviews to policing
AU  - Hollway, John
AU  - Grunwald, Ben
T2  - Criminology & Public Policy
AB  - A sentinel event review (SER) is a system‐based, multistakeholder review of 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 American police department—the review of the Lex Street Massacre 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 identify new systemic reforms for participating police departments and other criminal justice agencies.
DA  - 2019/07/31/
PY  - 2019
DO  - https://doi.org/10.1111/1745-9133.12457
VL  - 18
IS  - 3
SP  - 705
EP  - 730
UR  - https://onlinelibrary.wiley.com/doi/full/10.1111/1745-9133.12457
Y2  - 2019/08/16/14:05:19
ER  - 

TY  - BOOK
TI  - Justice Series: Policing
AU  - Worrall
AU  - Schmalleger
AB  - Hollway and Grunwald (2019): "Another recent textbook devotes a quarter of a page to “sentinel event reviews” but does not indicate whether any police departments have implemented them (Worrall & Schmalleger, 2018)."
DA  - 2018///
PY  - 2018
ET  - 3rd
UR  - https://www.pearson.com/us/higher-education/program/Worrall-Policing-Justice-Series-3rd-Edition/PGM333509.html
Y2  - 2019/08/16/14:37:30
ER  - 

TY  - RPRT
TI  - Mending justice: Sentinel event reviews. In Learning from error in the criminal justice system: Sentinel event reviews
AU  - Doyle, J.M.
CY  - Washington
DA  - 2014///
PY  - 2014
LA  - en
PB  - U.S. Department of Justice
ER  - 

TY  - JOUR
TI  - How Sentinel Event Reviews May Help Prevent Suicides in Jails: Report
AU  - Helm, Angela
T2  - The Root
AB  - Despite the fact that suicides make up one-third of all deaths in jail custody, nearly 63 percent of jails in the United States don’t conduct reviews following a suicide, and few institutionalized responses exist to answer instances of self-harm. In its latest report, “Preventing Suicide and Self-Harm in Jails: A Sentinel Approach” the Vera Institute of Justice partnered with four diverse county jail systems to study how they review and respond to incidents of suicide and self-harm and how they might integrate sentinel event reviews into those jails’ regular practices.

“In layman’s terms, a sentinel event is a significant negative outcome that signals underlying system weaknesses,” says Leah Pope, Senior Research Fellow in Vera’s Center on Substance Use and Mental Health and lead author of the July 2019 study. “So, [it refers to] something that has happened that might look like one fatal error, but is really the result of a series of errors.”
DA  - 2019/08/20/
PY  - 2019
UR  - https://www.theroot.com/suicides-in-jails-are-preventable-how-a-unique-approac-1837371058
Y2  - 2019/08/21/15:41:26
ER  - 

TY  - RPRT
TI  - Preventing Suicide and Self-Harm in Jail: A Sentinel Events Approach
AU  - Pope, Leah
AU  - Tan de Bibiana, Jason
AU  - Todd, Therese
AB  - Vera’s first report provided practical guidance on how to conduct a sentinel event review—an all-stakeholder, nonblaming, and forward-looking examination of the error—in the aftermath of a suicide in custody. In this report, Vera shares lessons learned from an in-depth study of how four county jail systems review and respond to incidents of suicide and self-harm and the feasibility of integrating sentinel event reviews into those jails’ regular practices.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/_8x7e0m8Fko
DA  - 2019/07//
PY  - 2019
SP  - 43
PB  - Vera Institute of Justice
UR  - https://www.vera.org/publications/preventing-suicide-and-self-harm-in-jail
Y2  - 2019/08/21/15:46:37
ER  - 

TY  - ELEC
TI  - How Do Prosecutors (and the Rest of Us) Get Sentencing So Wrong?
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Some reformers suggest creating Sentence Review Units to reassess long prison terms that are no longer justified. While it’s a worthwhile idea, it still doesn’t address the bigger question, writes TCR’s legal columnist: how did those bad sentences happen in the first place?
DA  - 2019/08/21/T15:20:13+00:00
PY  - 2019
LA  - en-US
UR  - https://thecrimereport.org/2019/08/21/how-do-prosecutors-get-sentencing-so-wrong/
Y2  - 2019/08/23/14:32:19
ER  - 

TY  - ELEC
TI  - What Medicine Could Teach Our Flawed Justice System
AU  - Doyle, James M.
T2  - The Crime Report
AB  - A unique Massachusetts agency devoted to the analysis of medical errors, inspired by the 1995 death of award-winning Boston reporter Betsy Lehman,  could be a model for getting past the bitter debates about who to blame for miscarriages of justice.
DA  - 2017/04/11/T11:00:55+00:00
PY  - 2017
LA  - en-US
UR  - https://thecrimereport.org/2017/04/11/what-the-movement-for-patient-safety-could-teach-our-flawed-justice-system/
Y2  - 2019/08/23/16:16:42
ER  - 

TY  - JOUR
TI  - Building popular legitimacy with reconciliatory gestures and participation: A community-level model of authority
AU  - O'Brien, Thomas C.
AU  - Tyler, Tom R.
AU  - Meares, Tracey L.
T2  - Regulation & Governance
AB  - The research tests a model of reconciliation between authorities and communities. It expands past models of legitimacy to an intergroup dynamic model by identifying two community-level actions that legal authorities can undertake to build their popular legitimacy and promote cooperation. One type of action is a community-level reconciliatory gesture: an initiative that authorities make to communities to build trust by recognizing and trying to move beyond prior negative experiences. A second involves community-level opportunities for participating in decisions about how to manage social order. The results of this study with residents from a large metropolitan city suggest that both types of community-level gestures can make distinct contributions to building trust in and cooperation with the police.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/XK4nlwEZwqg
DA  - 2019///
PY  - 2019
DO  - 10.1111/rego.12264
DP  - Wiley Online Library
VL  - 0
IS  - 0
LA  - en
SN  - 1748-5991
ST  - Building popular legitimacy with reconciliatory gestures and participation
UR  - https://onlinelibrary.wiley.com/doi/abs/10.1111/rego.12264
Y2  - 2019/08/23/18:28:14
KW  - criminal justice reform
KW  - cooperation
KW  - intergroup relations
KW  - legitimacy
KW  - reconciliation
ER  - 

TY  - JOUR
TI  - Preface: THE INTEGRITY OF OUR CONVICTIONS:HOLDING STAKEHOLDERS ACCOUNTABLE IN AN ERA OF CRIMINAL J USTICE REFORM
AU  - Scheck, Barry
T2  - GEO.L.J. ANN.REV.CRIM.PROC
DA  - 2019///
PY  - 2019
VL  - 48
ER  - 

TY  - SOUND
TI  - Autopsy of a Wrongful Conviction
AU  - Rose, Julie
T2  - Top of Mind with Julie Rose
AB  - Guest: John Hollway, Associate Dean and Executive Director of the Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania Law School

2,482. That’s how many people over the last 30 years have spent time in prison–an average of 8 years –and then been exonerated of the crime because it turned out they were innocent. 2,482 people. How do mistakes like that happen? Or maybe it’s not mistakes –it’s outright misconduct on the part of cops or prosecutors? Increasingly, cities around the country are setting up task forces to uncover wrongful convictions –and in a few cases, when they do, another task force comes into figure out what went wrong.
CY  - BYU Radio
DA  - 2019/09/03/
PY  - 2019
UR  - http://www.byuradio.org/episode/23d7965e-0759-42fc-b9fb-dba76c87b1d0/top-of-mind-with-julie-rose-rural-politics-justice-system-senior-suicide?playhead=1114&autoplay=true
ER  - 

TY  - ELEC
TI  - Kamala Harris, Police Shootings and ‘Safety’
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Sen. Harris’ recent justice reform plan called for a federal board to review incidents involving police use-of-force against civilians and other "severe" misconduct. It’s a good idea, but the devil is in the details, warns TCR’s legal affairs columnist.

.....At this point it is possible to marshal a compelling literature that undertakes this work by applying modern Safety concepts to criminal justice.

A bibliography compiled for the National Institute of Justice for National Criminal Justice Reference Service librarian Scott Hertzberg is regularly updated to track safety materials with criminal justice cross-over potential.
DA  - 2019/09/18/T15:05:37+00:00
PY  - 2019
LA  - en-US
UR  - https://thecrimereport.org/2019/09/18/kamala-harris-police-shootings-and-safety/
Y2  - 2019/09/18/15:38:28
ER  - 

TY  - JOUR
TI  - Reliable Justice: Advancing the Two Fold Aim of Establishing Guilt and Protecting the Innocent
AU  - Acker, James R
T2  - Albany Law Review
AB  - Page 767:
6
 A decisional process resembling “sentinel event
review[s]” offers an attractive model.287
 As described in a National
Institute of Justice report, a sentinel event is “a bad outcome that no
one wants repeated and that signals the existence of underlying
weaknesses in the system.”288
 Sentinel event reviews have been
utilized in several contexts outside of criminal justice.289
 For example, when medical patients are mistreated or suffer harm while
undergoing hospital procedures, or when airplane accidents occur,
concerted efforts are made by investigative bodies to determine the
source of errors with a particular eye toward identifying potential
fundamental or root causes, in contrast to focusing on the mistakes
of individual actors or other idiosyncratic contributing factors.290
 The emphasis is on diagnosing and correcting deep-seated systemic flaws
to prevent recurrent mishaps, rather than ascribing case-specific
blame.2
Decision-makers intent on promoting reliable justice would have
no need to wait to react to specific cases of wrongful conviction or
other justice system errors to be faithful to the sentinel event review
model.292
 Indeed, “[s]entinels stand watch. They are the first to see
threats, and they sound a warning before those threats can do
harm.”293
 There is no shortage of warning signals regarding
miscarriages of justice, and there would be no shortage of agenda
items for discussion in criminal justice sentinel reviews. Reformers
have focused on sources of error that spawn wrongful convictions for
decades.294
 For example, Yale Law School Professor Edwin
Borchard’s seminal volume, Convicting the Innocent, which
highlighted many of the same concerns confronting criminal justice
today, was published in 1932.295
 Although many leading problems
that put innocents at risk are well known, effective systemic
responses too often have remained elusive.296 “The problem . . . is not
identifying which reforms are necessary, but rather getting system buy-in on their implementation.”297



https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/oOTujatZFI0
DA  - 2019///
PY  - 2019
VL  - 82
IS  - 3
UR  - http://www.albanylawreview.org/issues/pages/article-information.aspx?volume=82&issue=3&page=719
Y2  - 2019/09/19/20:44:03
ER  - 

TY  - ELEC
TI  - How Much Difference Does the Lawyer Make?
AU  - Anderson, James M.
AU  - Heaton, Paul
AB  - Describes the results of a study to examine the effect of defense counsel on outcomes in murder prosecutions in Philadelphia.
DA  - 2011///
PY  - 2011
LA  - en
M3  - Product Page
UR  - https://www.rand.org/pubs/working_papers/WR870.html
Y2  - 2019/10/02/19:51:49
ER  - 

TY  - JOUR
TI  - THE INTEGRITY OF OUR CONVICTIONS: HOLDING STAKEHOLDERS ACCOUNTABLE IN AN ERA OF CRIMINAL JUSTICE REFORM
AU  - Scheck, Barry
T2  - GEO.L.J. ANN.REV.CRIM.PROC
AB  - By its very nature, this is a “system” question involving multiple stakeholders that
intersects with complex ethical, legal, and scientific issues. In the last decade, drawing from a rich “safety” literature in the high-risk fields of medicine and aviation, an
interdisciplinary cadre of researchers and reformers have been seeking to translate
some of the successful models from aviation and medicine to the criminal justice
arena.2 A rich interdisciplinary “sentinel event” literature has developed3 involving
“safety experts,” psychologists, and criminal justice stakeholders from practice and
academia.
DA  - 2019///
PY  - 2019
VL  - 48
UR  - https://www.nacdl.org/getattachment/e8d57a4e-b5db-4bbf-9c2b-a203e681953c/barry-scheck-the-integrity-of-our-convictions-holding-stakeholders-accountable-in-an-era-of-criminal-justice-reform-georgetown-law-journal-scjn-conference-2019.pdf
ER  - 

TY  - JOUR
TI  - Safe Convictions
AU  - Sangero, Boaz
T2  - Criminal Law Forum
AB  - It is clear today that there is a significant phenomenon of wrongful convictions. Since safety theory and safety measures are not developed in the criminal justice system, we have to learn it from other areas, where modern safety is common practice, such as aviation, transportation and engineering. The article proposes some general principles for modern safety from false convictions, based on principles guiding other areas, as well as specific modern safety methods that can and should be applied in the criminal justice system, including: Establishing a “Safety in the Criminal Justice System Institute”; Enforcing accident (false convictions) and incident reporting duties; Developing education, training and a culture of safety; Applying “Identify-Analyze-Control” using the innovative STAMP safety model (“System-Theoretic Accident Model and Processes”); Creating redundancy; and Conducting an ongoing process of improvement. The high rate of false convictions is not an inevitable fate.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/Rlg--YYXm8M
DA  - 2019/11/12/
PY  - 2019
DO  - 10.1007/s10609-019-09379-5
DP  - Springer Link
J2  - Crim Law Forum
LA  - en
SN  - 1572-9850
UR  - https://doi.org/10.1007/s10609-019-09379-5
Y2  - 2019/11/15/21:05:12
N1  - <div data-schema-version="8"><p>Note 33 </p>
<p>33 For articles in this direction, see Mordechai Halpert & Boaz Sangero, From a Plane Crash to the Conviction of an Innocent Person: Why Forensic Science Evidence Should Be Inadmissible Unless It Has Been Developed as a Safety-Critical System, 32 HAMLINE L. REV. 65, (2009); James M. Doyle, Learning from Error in American Criminal Justice, 100 J. CRIM. L. & CRIMINOLOGY 109 (2010); Boaz Sangero & Mordechai Halpert, A Safety Doctrine for the Criminal Justice System, MICH. ST. L. REV. 1293 (2011); James M. Doyle, An Etiology of Wrongful Convictions: Error, Safety, and Forward-Looking Accountability in Criminal Justice. In M. Zalman & J. Carrano (Eds,), WRONGFUL CONVICTION AND CRIMINAL JUSTICE REFORM: MAKING JUSTICE 56 (2013); James M. Doyle, Learning from Error in the Criminal Justice System: Sentinel Event Reviews, in National Institute of Justice, Mending Justice: Sentinel Event Reviews (special report, 2014);</p>
</div>
KW  - CRIMINAL justice system -- United States
KW  - SAFETY
KW  - ACTUAL innocence
KW  - CRIMINAL law -- United States
KW  - INNOCENCE Project
ER  - 

TY  - ELEC
TI  - Can We Learn from Prosecutor Misconduct?
AU  - Doyle, James M.
T2  - The Crime Report
AB  - At least one federal judge has argued that violations of the Brady v. Maryland rule requiring prosecutors to disclose evidence favorable to the defense are “epidemic.”  But we should be thinking about how to prevent such miscarriages of justice, rather than just punishing them, writes TCR’s legal columnist.
DA  - 2019/12/09/T15:20:00+00:00
PY  - 2019
LA  - en-US
UR  - https://thecrimereport.org/2019/12/09/can-we-learn-from-prosecutor-misconduct/
Y2  - 2019/12/09/20:49:34
ER  - 

TY  - RPRT
TI  - A Sentinel Events Approach to Jail Suicide and Self-Harm: Final Summary Overview
AU  - Pope, Leah
AU  - Tan de Bibiana, Jason
AB  - The current study draws on research in four county jail systems to answer the following
research questions: (1) How do the selected jail systems currently review incidents of suicide and
self-harm? (2) What challenges and successes have they experienced in developing multistakeholder reviews and corrective action plans in response to incidents of suicide and selfharm? And (3) How does the legal and policy landscape in each jurisdiction impact the
feasibility of conducting sentinel event reviews in response to incidents of suicide and self-harm?
The findings presented below build the evidence base for the feasibility of sentinel event reviews
in the criminal justice system and also provide rich data on both why the problem of jail suicide
remains so intractable and how some jurisdictions are trying to innovate their responses.
CY  - 19
DA  - 2019/06//
PY  - 2019
PB  - Vera Institute of Justice
UR  - https://www.ncjrs.gov/pdffiles1/nij/grants/254365.pdf
ER  - 

TY  - ELEC
TI  - A Sentinel Review Process Could Help Washington D.C.
AU  - Johnson, Akhi
T2  - Vera Institute of Justice
AB  - When mistakes happen in the criminal justice system, we often seek to cast blame, quickly, on a single actor. But we can do better, collectively. I’d like to...

"In 2014, the National Institute of Justice (NIJ) — the research arm of the Department of Justice — successfully piloted sentinel reviews for justice errors in three jurisdictions. As a result, the NIJ is now encouraging others to do the same."
DA  - 2019/12/19/T22:21:00+0000
PY  - 2019
LA  - en
M3  - text/html
UR  - https://www.vera.org/blog/a-sentinel-review-process-could-help-washington-d-c
Y2  - 2019/12/26/17:00:40
ER  - 

TY  - JOUR
TI  - Dispatch Priming and the Police Decision to Use Deadly Force:
AU  - Taylor, Paul L.
T2  - Police Quarterly
AB  - Police shootings have become one of the most “visible and controversial” aspects of the criminal justice system . Yet, very little empirical effort has been devoted to understanding the underlying ...olicing scholars have routinely called for research on police decision-making within the context of deadly force (e.g., Alpert & Smith, 1994; Klinger & Brunson, 2009; Reiss, 1980; Shane & Swenson, 2018; Zimring, 2017). Yet, with a few exceptions (e.g., Correll, Hudson, Guillermo, & Ma, 2014; Fridell & Binder, 1992; James, James, & Vila, 2016; Klinger, 2004; Pickering, 2016), very little work has gone into unpacking how officers, situated in the moment, decide whether or not to pull the trigger. This is somewhat surprising given the focus and controversy surrounding police shootings (Klinger, Rosenfeld, Isom, & Deckard, 2015; Zimring, 2017) and the relatively advanced state of decision-making and error research in other high-risk endeavors. In fact, the systematic study of error has been used as a vehicle for understanding work place decision-making, professional reform, and improved outcomes in a number of other risk-laden occupational fields including medicine (Institute of Medicine, 2000), commercial aviation (Wiegmann et al., 2005), transportation (Green, 2017), and the military (Snook, 2002). James Doyle (2010) and a growing group of others (e.g., Hollway, 2014; Shane, 2013) have called for a similar lens to be  to various aspects of the U.S. criminal justice system including police use of deadly force (e.g., Pickering & Klinger, 2016; Sherman, 2018).
DA  - 2019/12/30/
PY  - 2019
DO  - 10.1177/1098611119896653
DP  - journals.sagepub.com
VL  - 12/30/19
LA  - en
ST  - Dispatch Priming and the Police Decision to Use Deadly Force
UR  - https://journals.sagepub.com/doi/10.1177/1098611119896653
AN  - Sage CA: Los Angeles, CA
Y2  - 2020/01/03/21:10:54
ER  - 

TY  - JOUR
TI  - Costs and Benefits of Implementing a Root Cause Analysis Framework into the Queensland Correctional Oversight System
AU  - Zhouand, Samay V.
AU  - Byrne, James M.
T2  - Federal Probation
DA  - 2017///
PY  - 2017
DP  - HeinOnline
IS  - 3
SP  - 3
EP  - 7
J2  - Fed. Probation
LA  - eng
UR  - https://heinonline.org/HOL/P?h=hein.journals/fedpro81&i=141
Y2  - 2020/01/09/17:41:47
ER  - 

TY  - JOUR
TI  - Tax Recovery Task Force Capitalizing on Collaborative Enforcement
AU  - Mandla, Vikram
AU  - Silva, Randy
T2  - CDAA Prosecutor’s Brief •
AB  - The National Institute of Justice (NIJ) established the Sentinel
Events Initiative in 2014 to promote sentinel event reviews
(SERs) of errors in the criminal justice system. Borrowed from
the healthcare industry, the term “sentinel event” is defined as
an unanticipated event that, in a
healthcare setting, results in a death or
serious injury not related to the natural
course of the patient’s illness. Sentinel
events are identified and reviewed to
help develop preventive measures.
The theory is that when a bad outcome
occurs in a complex social system, it
is rarely the result of just one person’s
mistake. Instead, a group of smaller
errors coalesce to create an underlying weakness in the system.14
The NIJ has tested the SER model in Milwaukee, Philadelphia, and
Baltimore criminal justice communities.15 The NIJ white paper,
Mending Justice: Sentinel Event Reviews, explores the potential
to learn from criminal justice system errors, including wrongful
convictions, by applying an SER model.16
DA  - 2016///Summer
PY  - 2016
VL  - 38
IS  - 4
UR  - http://1x937u16qcra1vnejt2hj4jl.wpengine.netdna-cdn.com/wp-content/uploads/Summer-2016-PBrief-CRU-article-1.pdf#page=52
ER  - 

TY  - VIDEO
TI  - How Justice Agencies Can Implement and Benefit from Sentinel Event Reviews
AU  - Hollway, John
AU  - O'Brien, Mallory
AB  - There is much to be learned from our mistakes and failures – and it is this concept that is the foundation of Sentinel Events. Different industries have employed this learning approach of reviewing and analyzing events that did not quite turn out as expected to improve policies and procedures. This approach has been proven to be effective in the area of law enforcement and criminal justice where public trust, safety, and human lives are at stake. To discuss the Sentinel Events approach and its intricacies are John Holloway and Dr. Mallory O’Brien. John is the Associate Dean and Executive Director
DA  - 2019/10/18/T08:00:14-06:00
PY  - 2019
LA  - en-US
UR  - https://justiceclearinghouse.com/resource/how-justice-agencies-can-implement-and-benefit-from-sentinel-event-reviews/
Y2  - 2020/01/17/18:36:14
ER  - 

TY  - ELEC
TI  - How Police Can Kill Fewer People: Numbers vs Narratives
AU  - Doyle, James M.
T2  - The Crime Report
AB  - A recent scholars’ debate over the impact of police shootings on African-Americans’ mental health misses the more important point, argues TCR’s legal columnist. What systemic flaws drove police actions to begin with?

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/0hgCfuEtn0o
DA  - 2020/01/15/T16:00:57+00:00
PY  - 2020
LA  - en-US
ST  - How Police Can Kill Fewer People
UR  - https://thecrimereport.org/2020/01/15/how-police-can-kill-fewer-people-numbers-vs-narratives/
Y2  - 2020/01/17/18:39:09
ER  - 

TY  - RPRT
TI  - From Funnels to Large-Scale Irrigation: Changing the Criminal Justice System Paradigm to Improve Public Health and Safety
AU  - Reed, Tom
AU  - Chrishom, John
T2  - Papers from the Executive Sessons on Community Corrections
AB  - In this paper Tom Reed and John Chisholm, a public defender and a prosecutor, argue that the criminal justice system needs a "paradigm shift." Using their own experiences in Milwaukee, they challenge all criminal justice stakeholders to undertake the collaborative efforts necessary to bring about reforms to the criminal justice system. They lay out this work in seven core ideas:
https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/97m17vv96RI

The third important area is what is often described as sentinel events, after-action reviews, or critical incident reviews (National Institute of Justice,
2014). These are common in medicine, air safety, and law enforcement. By looking back at cases
DA  - 2019/12//
PY  - 2019
LA  - en
PB  - Harvard Kennedy Schools of Government
ST  - From Funnels to Large-Scale Irrigation
UR  - https://www.hks.harvard.edu/centers/wiener/programs/criminaljustice/research-publications/executive-session-on-community-corrections/publications/changing-the-criminal-justice-system-paradigm
Y2  - 2020/01/17/18:44:24
N1  - <p>The third important area is what is often described<br />as sentinel events, after-action reviews, or critical<br />incident reviews (National Institute of Justice,<br />2014). These are common in medicine, air safety,<br />and law enforcement. By looking back at cases</p>
<p>that had bad outcomes, or were “near misses,”<br />with all system actors in a safe environment,<br />significant learning can occur. While contested<br />cases may not have an agreed outcome in<br />the same way that we wish to avoid airplane<br />disasters, there is a surprising opportunity to<br />look at hard cases—especially when root causes<br />of the underlying conduct are included in the<br />sentinel events analysis.26 The Homicide Review<br />Commission has proven a valuable platform for<br />this analysis (see Sidebar). Stated differently, the<br />criminal justice system is only a part of a larger<br />pattern of problems in the community that need<br />to be considered.</p>
ER  - 

TY  - ELEC
TI  - Sentinel Events Initiative:: Resources
AU  - Bureau of Justice Assistance
T2  - Bureau of Justice Assistance
AB  - Since it was established in 2011, the Sentinel Events Initiative (SEI) has conducted a number of forums and stakeholder meetings, research activities, and pilot implementation projects to test and report on the approach.
LA  - en
UR  - https://bja.ojp.gov/program/sentinel-events-initiative/resources
Y2  - 2020/01/17/21:51:22
ER  - 

TY  - JOUR
TI  - Preventing Violence: A Public Health Participatory Approach to Homicide Reviews
AU  - O'Malley, Teagen L.
AU  - Documét, Patricia I.
AU  - Burke, Jessica G.
AU  - Garland, Richard
AU  - Terry, Art
AU  - Slade Sr, Roland L.
AU  - Albert, Steven M.
T2  - Health Promotion Practice
AB  - Death review teams are a common method for assessing preventable deaths, yet they rarely review adult homicides and do not typically include community members. Academic-community partnerships can enhance public health research by encouraging translation of research into practice and support a data-driven approach to improve community health and well-being. We describe the Pittsburgh Homicide Review Group, a community-partnered initiative to prevent future homicides through data review and community dialogue. Group members reviewed all 42 Pittsburgh 2012 homicides informed by three primary data sources: publicly available data, local service databases, and community outreach resources. Thirty-two individuals representing relevant county agencies and community groups participated in eight reviews. Data sharing among partners resulted in a comprehensive understanding of the context of homicides. Review meetings supported a collective discussion around potential contributing factors to homicides, intervention implications, and recommendations. Academic-community homicide review partnerships are a productive approach to inform homicide prevention and interventions that are relevant to communities and should be implemented widely.
DA  - 2018///
PY  - 2018
DO  - 10.1177/1524839917697914
DP  - EBSCOhost
VL  - 19
IS  - 3
SP  - 427
EP  - 436
SN  - 15248399
UR  - http://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=129547467&site=ehost-live
AN  - 129547467
DB  - a9h
N1  - <p>O'Malley, Teagen L. 1 Documét, Patricia I. 1 Burke, Jessica G. 1 Garland, Richard 1 Terry, Art 2 Slade Sr., Roland L. 2 Albert, Steven M.; Email Address: tlo8@pitt.edu; Affiliation: 1: University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA 2: Kingsley Association, Pittsburgh, PA, USA; Source Info: May2018, Vol. 19 Issue 3, p427; Subject Term: HOMICIDE -- Prevention; Subject Term: COMMUNITY health services; Subject Term: INTERPROFESSIONAL relations; Subject Term: MEETINGS; Subject Term: PUBLIC health; Subject Term: PATIENT participation; Author-Supplied Keyword: community-based participatory research; Author-Supplied Keyword: health research; Author-Supplied Keyword: injury prevention/safety; Author-Supplied Keyword: partnerships/coalitions; Author-Supplied Keyword: violence prevention; NAICS/Industry Codes: 621494 Community health centres; NAICS/Industry Codes: 621498 All Other Outpatient Care Centers; NAICS/Industry Codes: 623220 Residential Mental Health and Substance Abuse Facilities; NAICS/Industry Codes: 624190 Other Individual and Family Services; NAICS/Industry Codes: 913910 Other local, municipal and regional public administration; NAICS/Industry Codes: 525120 Health and Welfare Funds; Number of Pages: 10p; Document Type: Article; Full Text Word Count: 6568</p>
KW  - COMMUNITY health services
KW  - PUBLIC health
KW  - violence prevention
KW  - INTERPROFESSIONAL relations
KW  - MEETINGS
KW  - community-based participatory research
KW  - health research
KW  - HOMICIDE -- Prevention
KW  - injury prevention/safety
KW  - partnerships/coalitions
KW  - PATIENT participation
ER  - 

TY  - ELEC
TI  - Why Holding Police ‘Accountable' Won’t Prevent Shootings of Civilians
AU  - TCR Staff
T2  - The Crime Report
AB  - The “relentless” focus on singling out individual police officers to blame for civilian shootings is understandable, but it has "become the enemy of prevention in the very communities that need it most," according to a study in the Ohio State Law Journal.
DA  - 2020/01/30/T16:00:10-05:00
PY  - 2020
LA  - en-US
UR  - https://thecrimereport.org/2020/01/30/why-holding-police-accountable-wont-prevent-shootings-of-civilians/
Y2  - 2020/02/20/17:11:19
ER  - 

TY  - ELEC
TI  - How Bloomberg Can Get Beyond Stop-and-Frisk
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Of all the presidential candidates, former NYC Mayor Mike Bloomberg is best placed to lead a pivot from sterile arguments over crime control vs due process toward a radical re-orientation aimed at safety. First,  he needs to go beyond atoning for stop-and-frisk, says TCR’s legal affairs columnist.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/oXI9SaGrkAc
DA  - 2020/02/14/T16:35:59-05:00
PY  - 2020
LA  - en-US
UR  - https://thecrimereport.org/2020/02/14/how-bloomberg-can-get-beyond-stop-and-frisk/
Y2  - 2020/02/20/17:54:35
ER  - 

TY  - JOUR
TI  - Evidence-Based Policing and Fatal Police Shootings: Promise, Problems, and Prospects
AU  - Sherman, Lawrence W.
T2  - The ANNALS of the American Academy of Political and Social Science
AB  - The promise of evidence-based policing is to reduce harm with better research for targeting, testing, and tracking police actions. The problems of using evidence-based policing to reduce harm are found in the emotional dimensions of ethics and risk. These problems are most pronounced with fatal police shootings, where the risks of injury to American police are often framed as a zero-sum choice in relation to the ethics of taking citizens’ lives. Yet evidence-based policing offers good prospects for reframing the debate over fatal police shootings, in ways that could reduce harm to both police and citizens. This volume offers substantial new evidence for initiatives at all levels of U.S. government that could help to save lives in police encounters with citizens. Putting that evidence to work remains the major challenge facing the American police.
DA  - 2020/01/01/
PY  - 2020
DO  - 10.1177/0002716220902073
DP  - SAGE Journals
VL  - 687
IS  - 1
SP  - 8
EP  - 26
J2  - The ANNALS of the American Academy of Political and Social Science
LA  - en
SN  - 0002-7162
ST  - Evidence-Based Policing and Fatal Police Shootings
UR  - https://doi.org/10.1177/0002716220902073
Y2  - 2020/02/20/18:03:47
ER  - 

TY  - JOUR
TI  - Organizational Accidents and Deadly Police-Involved Violence: Some Thoughts on Extending Theory, Expanding Research, and Improving Police Practice
AU  - Klinger, David
T2  - The ANNALS of the American Academy of Political and Social Science
AB  - In recent years, violence by and against the police has been examined from the perspective of organizational accident theory. This article extends that work by reviewing some key ideas, identifying some limitations of organizational accident theory for understanding police-involved violence, and detailing some specific research topics for future empirical exploration. It concludes by offering some specific policy and practice recommendations to reduce police-involved violence.

Conclusion: In the practitioner realm, police supervisors, managers, and policy-makers can look to the organizational accident literature for guidance about how to develop the individual, group, organizational, and institutional mindfulness that can lead to the safety culture that can enhance police performance and thereby reduce the level of deadly police-involved violence in the United States.

In sum, if academics and practitioners take seriously the calls that Doyle (2010), Sherman (2018), a few others (e.g., Pickering and Klinger 2016), and this article have made for viewing some bad policing outcomes as organizational accidents and work to reduce them, we may just be able to save a multitude of lives.

Doyle, James. 2010. Learning from error in American criminal justice. Journal of Criminal Law and
Criminology 100 (1): 109–48.
DA  - 2020/01/01/
PY  - 2020
DO  - 10.1177/0002716219892913
DP  - SAGE Journals
VL  - 687
IS  - 1
SP  - 28
EP  - 48
J2  - The ANNALS of the American Academy of Political and Social Science
LA  - en
SN  - 0002-7162
ST  - Organizational Accidents and Deadly Police-Involved Violence
UR  - https://doi.org/10.1177/0002716219892913
Y2  - 2020/02/20/18:03:48
ER  - 

TY  - JOUR
TI  - The Role of Individual Officer Characteristics in Police Shootings
AU  - Ridgeway, Greg
T2  - The ANNALS of the American Academy of Political and Social Science
AB  - Assessing whether individual characteristics of police officers such as age, race, and prior performance influence police behavior has been a long-standing topic of social science research. The effect of officer characteristics on their risk of shooting people is confounded by police assignments and by the environmental factors associated with those assignments. This article provides a method to separate out the influence of individual officer characteristics from environmental factors. Using data from the New York City Police Department (NYPD) and the Major Cities’ Chiefs Association (MCCA), the analysis finds that police officers who join the NYPD later in their careers have a lower shooting risk: for each additional year of their recruitment age, the odds of being shooters declines by 10 percent. Both officer race and prior problem behavior (e.g., losing a firearm, crashing a department vehicle) predict up to three times greater odds of shooting, yet officers who made numerous misdemeanor arrests were four times less likely to shoot.
DA  - 2020/01/01/
PY  - 2020
DO  - 10.1177/0002716219896553
DP  - SAGE Journals
VL  - 687
IS  - 1
SP  - 58
EP  - 66
J2  - The ANNALS of the American Academy of Political and Social Science
LA  - en
SN  - 0002-7162
UR  - https://doi.org/10.1177/0002716219896553
Y2  - 2020/02/20/18:03:49
ER  - 

TY  - JOUR
TI  - Social Interaction Training to Reduce Police Use of Force
AU  - Wolfe, Scott
AU  - Rojek, Jeff
AU  - McLean, Kyle
AU  - Alpert, Geoffrey
T2  - The ANNALS of the American Academy of Political and Social Science
AB  - Controversial incidents involving uses of force by police in recent years have led to calls for improving officers’ de-escalation skills. A more fruitful approach to police training reform may be a broader focus on improving officers’ social interaction skills. By viewing all police-citizen encounters as social interactions that can either escalate toward or de-escalate away from the use of force, police training can develop what other fields call a “deliberate, repetitive practice” framework. This article describes the implementation of a randomized trial that brought such training to two U.S. police agencies and yielded encouraging results. We conclude that the conceptual framework was generally well received but that results depended heavily on the selection and performance of each agency’s own trainers.
DA  - 2020/01/01/
PY  - 2020
DO  - 10.1177/0002716219887366
DP  - SAGE Journals
VL  - 687
IS  - 1
SP  - 124
EP  - 145
J2  - The ANNALS of the American Academy of Political and Social Science
LA  - en
SN  - 0002-7162
UR  - https://doi.org/10.1177/0002716219887366
Y2  - 2020/02/20/18:03:49
ER  - 

TY  - JOUR
TI  - Moving beyond “Best Practice”: Experiences in Police Reform and a Call for Evidence to Reduce Officer-Involved Shootings
AU  - Engel, Robin S.
AU  - McManus, Hannah D.
AU  - Isaza, Gabrielle T.
T2  - The ANNALS of the American Academy of Political and Social Science
AB  - In post-Ferguson America, police departments are being challenged to implement evidence-based changes in policies and training to reduce fatal police-citizen encounters. Of the litany of recommendations believed to reduce police shootings, five have garnered widespread support: body-worn cameras, de-escalation training, implicit bias training, early intervention systems, and civilian oversight. These highly endorsed interventions, however, are not supported by a strong body of empirical evidence that demonstrates their effectiveness. Guided by the available research on evidence-based policing and informed by the firsthand experience of one of the authors in implementing departmental reforms that followed the fatal shooting of a civilian by an officer, this article highlights promising reform strategies and opportunities to build the evidence base for effective use-of-force reforms. We call upon police executives to engage in evidence-based policing by scientifically testing interventions, and we call on academics to engage in rapid research responses for critical issues in policing.
DA  - 2020/01/01/
PY  - 2020
DO  - 10.1177/0002716219889328
DP  - SAGE Journals
VL  - 687
IS  - 1
SP  - 146
EP  - 165
J2  - The ANNALS of the American Academy of Political and Social Science
LA  - en
SN  - 0002-7162
ST  - Moving beyond “Best Practice”
UR  - https://doi.org/10.1177/0002716219889328
Y2  - 2020/02/20/18:03:50
ER  - 

TY  - JOUR
TI  - Reducing Violent Incidents between Police Officers and People with Psychiatric or Substance Use Disorders
AU  - Pollack, Harold A.
AU  - Humphreys, Keith
T2  - The ANNALS of the American Academy of Political and Social Science
AB  - This article describes evidence-based strategies designed to reduce the prevalence of police encounters with people in behavioral crisis (PBCs) and to make such encounters less dangerous for all parties when they do occur. Some of these strategies are implemented by law enforcement, including gun violence restraining orders and the training of officers to provide time, distance, and cover during encounters with PBCs. Other strategies involve broader systems of community care, including assertive community treatment for people with serious psychiatric disorders, and critical time interventions for individuals leaving incarceration or inpatient psychiatric care. Broader adoption of such strategies should both reduce the risk of police shootings of PBCs as well as improve the effectiveness and well-being of police officers.
DA  - 2020/01/01/
PY  - 2020
DO  - 10.1177/0002716219897057
DP  - SAGE Journals
VL  - 687
IS  - 1
SP  - 166
EP  - 184
J2  - The ANNALS of the American Academy of Political and Social Science
LA  - en
SN  - 0002-7162
UR  - https://doi.org/10.1177/0002716219897057
Y2  - 2020/02/20/18:03:51
ER  - 

TY  - JOUR
TI  - Five Years after Ferguson: Reflecting on Police Reform and What’s Ahead
AU  - Robinson, Laurie O.
T2  - The ANNALS of the American Academy of Political and Social Science
AB  - Policing in the United States is not the same profession it was before Michael Brown’s death on a street in Ferguson, Missouri, five years ago. Police use of lethal force has become central to the debate triggered by Ferguson. In this article, I review steps taken to implement policing reforms at local, state, and federal levels; note obstacles to reform; and speculate about which proposals advanced by authors in this volume might be implemented by policy-makers at different levels of government. I conclude by suggesting four areas where attention is needed if reform measures are going to be successfully institutionalized, and I comment on current bipartisan attention in Washington to criminal justice that offers the potential for federal action.
DA  - 2020/01/01/
PY  - 2020
DO  - 10.1177/0002716219887372
DP  - SAGE Journals
VL  - 687
IS  - 1
SP  - 228
EP  - 239
J2  - The ANNALS of the American Academy of Political and Social Science
LA  - en
SN  - 0002-7162
ST  - Five Years after Ferguson
UR  - https://doi.org/10.1177/0002716219887372
Y2  - 2020/02/20/18:03:52
ER  - 

TY  - JOUR
TI  - The Eric Garner Incident: Sentinel Calls for Greater Scholarly Support in Policymaking
AU  - Mazza, Joe
T2  - Jounal of Criminal Justice and Law
AB  - The Eric Garner incident serves as a sentinel event exposing weakness in our system of
policing low-level offenses. The New York Police Department policy at the center of this
encounter lacked a foundation of sound evidence. Administrative mandates forced officers
to make a custodial arrest instead of releasing a low-level offender in the field. Combined,
they created a condition ripe for tragic results. Custodial arrests should serve important
public interests, but none are apparent here. This incident presents a call for greater
scholarly partnerships with police and other stakeholders to provide studies with evidence
on which better public policy can be based.

Sentinel Events
When unexpected negative outcomes happen in complex systems, a single act is rarely
the cause. Such outcomes are sentinel events that may serve as indicators of system or
process weaknesses (National Institute of Justice, 2017). Thoughtful and considered
analysis of sentinel events can lead to change that strengthens systems and improves
performance for the benefit of everyone. The Garner incident was such an event, but with
media and political attention focusing almost exclusively on blame, society is being
deprived of an opportunity to learn and to improve its system of justice. The death of Eric
Garner demands a better review. 

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/M2cnf_9jOd8
DA  - 2018///
PY  - 2018
VL  - 2
IS  - 2
SP  - 136
EP  - 142
UR  - https://www.uhd.edu/academics/public-service/jcjl/Documents/Volume%202,%20Issue%202.pdf#page=57
ER  - 

TY  - CHAP
TI  - Improve Prevention of Police-Involved Harm through Sentinel Event Reviews, and Response Essay (Chief David W. McGill)
AU  - Scott, Michael
T2  - Transforming the Polie: Thirteen Key Reforms
AB  - https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/HYZ65Nb8sRI
DA  - 2020///
PY  - 2020
PB  - Waveland Press
UR  - https://www.waveland.com/browse.php?t=746&r=b%7Ct
Y2  - 2020/03/03/23:16:50
ER  - 

TY  - RPRT
TI  - Paving the Way Lessons Learned in Sentinel Event Reviews
AU  - Browning, Katharine
AU  - Feucht, Thomas
AU  - Ritter, Nancy
AU  - Schmitt, Katherine Darke
AU  - McGough, Maureen
AU  - Hertzberg, Scott
DA  - 2015/11//
PY  - 2015
PB  - National Institute of Justice
UR  - https://www.ncjrs.gov/pdffiles1/nij/249097.pdf
ER  - 

TY  - JOUR
TI  - The Milwaukee Homicide Review Commission: An interagency collaborative process to reduce homicide
AU  - O’Brien, M.
AU  - Cisler, R. A.
AU  - Woods W.
T2  - Wisconsin Medical Journal
AB  - The Milwaukee Hoimicide Review Commission (MHRC) is a multi-level, multi-disciplinary, and multiagency homicide review process aimed at reducing the occurrence of homicides in Milwaukee. Based on the public health approach to violence reduction, the MHRC has 3 goals: (1) to gain a better understanding of homicide through strategic problem analysis, (2) to develop innovative, effective responses, and (3) to focus limited enforcement and intervention activities on identifiable risks. The MHIRC creates an environment for many disciplines and agencies to share information and work collectively on violence prevention strategies. Since its inception, the MHRC has reviewed over 150 homicides and developed over 100 recommendations aimed at reducing homicide. These recommendations are based on themes that emerge from case reviews and focus on initiating change at system, agency/organization, and individual levels. The MHRC has many accomplishments to date, including improved communication between local, state, and federal criminal justice agencies; assistance in immediate investigations new strategic criminal justice activities; changes in ineffective agency practices; and new cooperative efforts between community service providers. Future plans include the continuation and expansion of initiatives including greater community impact and developinga Center of Excellence in community and public safety serving Milwaukee and the state of Wisconsin.
DA  - 2007///
PY  - 2007
VL  - 106, 385-388
N1  - <p>The Milwaukee Homicide Review Commission: An interagency collaborative process to reduce homicide</p>
KW  - Fatality Reviews
KW  - Homicide Reviews
KW  - Incident reviews
ER  - 

TY  - JOUR
TI  - The Learning Model of Use-of-Force Reviews
AU  - Thacher, David
T2  - Law & Social Inquiry
AB  - Since the 1970s, police departments have subjected the use of force by their officers to increasingly stringent oversight, but those efforts have struggled against the difficulty of codifying the complex and idiosyncratic judgments that police work requires. In response, some departments have developed new models of oversight that use routine incident reviews partly as a tool for learning in order to document the continually surprising circumstances that officers encounter in the field, to scrutinize existing responses, and to articulate alternatives. This article analyzes the logic of this emerging model through a case study of use-of-force reviews in the Portland Police Bureau. I argue that this emerging model relies on an approach to practical inquiry that has not been adequately understood in criminal justice scholarship and practice—one that uses the routine review of organizational experience to pursue normative progress as well as technical understanding and that makes it possible to adapt complex policing practices to the local environment in which they operate.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/ueDHo0lodTk

Cites:

Doyle, James. 2012. “Learning about Learning about Error in Policing.” In Ideas in American Policing, no. 14. Washington, DC: Police Foundation.Google Scholar
Doyle, James. 2014. “Learning from Error in the Criminal Justice System: Sentinel Event Reviews.” In Mending Justice, 3–19. Washington, DC: US Department of Justice.Google Scholar
Doyle, James. 2019. “Essay: A ‘Safety Model’ Perspective Can Aid Diagnosis, Prevention, and Resotration after Criminal Justice Harms.” Santa Clara Law Review 59: 107–34.Google Scholar
DA  - 2020///
PY  - 2020
DO  - 10.1017/lsi.2019.80
DP  - Cambridge Core
SP  - 1
EP  - 32
LA  - en
SN  - 0897-6546, 1747-4469
UR  - https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B
Y2  - 2020/04/20/17:38:31
N1  - <p class="p" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-weight: 400; font-stretch: inherit; line-height: 1.6; font-family: 'Noto Sans', sans-serif; font-size: 18px; vertical-align: baseline; text-rendering: optimizelegibility; word-break: break-word; hyphens: manual; widows: 2; orphans: 2; color: #333333; letter-spacing: normal; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">Hospitals learned years ago that it makes no sense to blame medication errors entirely on the nurse or anesthesiologist who administered the wrong dose; they should also investigate the overly complicated systems that contributed to such mistakes and figure out how to improve them (for example, by pre-dosing medication or redesigning confusing machines) (Schwartz<span> </span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r61"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Schwartz</span>2018</a>, 544). Similarly, avoidable use of force results not just from poor decisions made by the officer who actually used force but also from the organizational systems that influenced her actions (Doyle<span> </span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r17"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Doyle</span>2012</a>; Hollway, Lee, and Smoot<span> </span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r31"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Hollway, Lee and Smoot</span>2017</a>; Sherman<span> </span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r65"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Sherman</span>2018</a>). To reduce the use of force and other troubling outcomes in policing, agencies must engage in relentless self-scrutiny to spot and rectify these systemic flaws, just as aviation and medicine have done for years (Doyle<span> </span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r17"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Doyle</span>2012</a>,<span> </span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r18"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Doyle</span>2014</a>; Hollway, Lee, and Smoot<span> </span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r31"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Hollway, Lee and Smoot</span>2017</a>).</p>
<p class="p" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-weight: 400; font-stretch: inherit; line-height: 1.6; font-family: 'Noto Sans', sans-serif; font-size: 18px; vertical-align: baseline; text-rendering: optimizelegibility; word-break: break-word; hyphens: manual; widows: 2; orphans: 2; color: #333333; letter-spacing: normal; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">This “systems perspective” captures important features of the emerging practices of use-of-force review, but it does not yet encompass some of their most important components—in particular, their pursuit of normative inquiry as well as technical analysis, their attention to local context as well as generalized best practices, and their commitment to routine review of everyday incidents as well as occasional scrutiny of high-profile tragedies. These components of the learning model are not entirely absent from the fields where the systems perspective originated, but the distinctive nature of American policing makes them especially salient in that context.</p>
N1  - <p><span style="color: #333333; font-family: 'Noto Sans', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">The point of the learning model is precisely to transcend the limits of rule-based accountability. A newer and more apposite framework applies ideas about “organizational accidents,” “root cause analysis,” and “high-reliability organizations,” which were developed in fields like aviation and medicine, to policing, particularly to the police’s use of force (Pickering and Klinger<span> </span></span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-weight: 400; font-stretch: inherit; line-height: inherit; font-family: 'Noto Sans', sans-serif; font-size: 18px; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r46"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Pickering and Klinger</span>2016</a><span style="color: #333333; font-family: 'Noto Sans', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">; Hollway, Lee, and Smoot<span> </span></span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-weight: 400; font-stretch: inherit; line-height: inherit; font-family: 'Noto Sans', sans-serif; font-size: 18px; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r31"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Hollway, Lee and Smoot</span>2017</a><span style="color: #333333; font-family: 'Noto Sans', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">; Schwartz<span> </span></span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-weight: 400; font-stretch: inherit; line-height: inherit; font-family: 'Noto Sans', sans-serif; font-size: 18px; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r61"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Schwartz</span>2018</a><span style="color: #333333; font-family: 'Noto Sans', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">; Sherman<span> </span></span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-weight: 400; font-stretch: inherit; line-height: inherit; font-family: 'Noto Sans', sans-serif; font-size: 18px; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r65"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Sherman</span>2018</a><span style="color: #333333; font-family: 'Noto Sans', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">) and to wrongful arrests and convictions (Doyle<span> </span></span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-weight: 400; font-stretch: inherit; line-height: inherit; font-family: 'Noto Sans', sans-serif; font-size: 18px; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r17"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Doyle</span>2012</a><span style="color: #333333; font-family: 'Noto Sans', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">; Shane<span> </span></span><a class="xref bibr" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-weight: 400; font-stretch: inherit; line-height: inherit; font-family: 'Noto Sans', sans-serif; font-size: 18px; vertical-align: baseline; color: #006fca; text-decoration: none; transition: all 0.3s ease 0s; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff;" href="https://www.cambridge.org/core/journals/law-and-social-inquiry/article/learning-model-of-useofforce-reviews/B7E9FF03862C5D22F4C72FCEBABB300B#r64"><span class="show-for-sr" style="box-sizing: border-box; margin: -1px; padding: 0px; border: 0px; font: inherit; vertical-align: baseline; clip: rect(0px, 0px, 0px, 0px); height: 1px; overflow: hidden; width: 1px; position: absolute; white-space: nowrap;">Reference Shane</span>2013</a><span style="color: #333333; font-family: 'Noto Sans', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">).<span> </span></span></p>
ER  - 

TY  - ELEC
TI  - Public Health, Justice and COVID-19: A Tragedy Foretold
AU  - Doyle, James M.
T2  - The Crime Report
AB  - The pandemic is teaching us crucial lessons about the poverty of our criminal justice discourse— about our fixation on treating criminal offenders as if they are pathogens.  We ignore those lessons at our peril, warns TCR’s legal columnist.
DA  - 2020/04/08/T14:50:06-04:00
PY  - 2020
LA  - en-US
ST  - Public Health, Justice and COVID-19
UR  - https://thecrimereport.org/2020/04/08/public-health-justice-and-covid-19-a-tragedy-foretold/
Y2  - 2020/04/20/17:41:17
ER  - 

TY  - ELEC
TI  - How to Prevent the Justice ‘Meat-Grinder’ From Making Juries Extinct
AU  - Doyle, James M.
T2  - The Crime Report
AB  - The Supreme Court recently held that jury verdicts in state criminal cases must be unanimous.  The remarkable fact, argues TCR’s legal columnist, is not that unanimous juries are required; it is that virtually nothing is decided by jurors, unanimously or otherwise—and no one seems to care.
DA  - 2020/05/04/T15:00:40-04:00
PY  - 2020
LA  - en-US
UR  - https://thecrimereport.org/2020/05/04/how-to-prevent-the-justice-meat-grinder-from-making-juries-extinct/
Y2  - 2020/05/05/19:56:43
ER  - 

TY  - JOUR
TI  - Race and Reasonableness in Police Killings
AU  - Fagan, Jeffrey
AU  - Campbell, Alexis
T2  - Boston University Law Review, Vol. 100, p. 951, 2020; Columbia Public Law Research Paper No. 14-655
AB  - Police officers in the United States have killed over 1000 civilians each year since 2013. The constitutional landscape that regulates these encounters defaults to the judgments of the reasonable police officer at the time of a civilian encounter based on the officer’s assessment of whether threats to their safety or the safety of others requires deadly force. As many of these killings have begun to occur under similar circumstances, scholars have renewed a contentious debate on whether police disproportionately use deadly force against African Americans and other nonwhite civilians and whether such killings reflect racial bias. We analyze data on 3933 killings to examine this intersection of race and reasonableness in police killings. First, we describe the objective circumstances and interactions of police killings and map those event characteristics to the elements of reasonableness articulated in case law. Second, we assess whether inherently vague constitutional regulation of lethal force is applied differently by officers depending on the civilian’s race, giving rise to a disproportionate rate of deaths among racial and ethnic minority groups. We then assess the prospects for remediation of racialized police killings by testing the effects of an existing evidence-based training curricula designed to reduce police use of deadly force towards persons experiencing mental illness.

We find that, across several circumstances of police killings and their objective reasonableness, Black suspects are more than twice as likely to be killed by police than are persons of other racial or ethnic groups; even when there are no other obvious circumstances during the encounter that would make the use of deadly force reasonable. Police killings of Latinx civilians are higher compared to whites and other racial or ethnic groups in some but not all circumstances. We find no evidence that enhanced police training focused on mental health crises can reduce the incidence of fatal police shootings of persons in mental health crisis or racial and ethnic disparities generally in police killings. Our findings suggest that the standards in constitutional case law fail to anticipate the circumstances of fatal police shootings and are therefore seemingly irrelevant in preventing racial disparities in police fatal police shootings. In light of this constitutional landscape, we argue that the ineffectiveness of enhanced police training to reduce shootings overall and racial disparity within these shootings may reflect the absence of race-specific components in their curricula. We suggest that the addition of training components that specifically address the role of race in officers’ perceptions of risk and their decision-making in potentially dangerous interactions with citizens may remediate both the incidence of police shootings and their apparent racial and ethnic disparity.
https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/65GZM_4tfRw

Really cites John Hollway, Calvin Lee & Sean Smoot, Root Cause Analysis: A Tool to Promote
Officer Safety and Reduce Officer Involved Shootings over Time, 62 VILL. L. REV. 883, 912-
14 (2017) (explaining that root-cause analyses allow for implementation of reforms that will
improve safety, increase morale, and restore police legitimacy

 John Hollway, Calvin Lee & Sean Smoot, Root Cause Analysis: A Tool to Promote
Officer Safety and Reduce Officer Involved Shootings over Time, 62 VILL. L. REV. 883, 912-
14 (2017)
DA  - 2020/01/01/
PY  - 2020
UR  - https://scholarship.law.columbia.edu/cgi/viewcontent.cgi?article=3660&context=faculty_scholarship
ER  - 

TY  - NEWS
TI  - We Are All Complicit in George Floyd’s Death
AU  - Doyle
T2  - The Crime Report
AB  - All of us have collaborated in the social construction of a reality that led to an African-American man’s death under the knee of a white Minneapolis cop. We are as responsible as the three other policemen who watched without speaking up, writes TCR’s legal columnist.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/P9VoSzsV33c
DA  - 2020/06/01/T15:25:26+00:00
PY  - 2020
DP  - thecrimereport.org
LA  - en-US
UR  - https://thecrimereport.org/2020/06/01/we-are-all-complicit-in-george-floyds-death/
Y2  - 2020/07/10/19:23:23
ER  - 

TY  - BOOK
TI  - Killing Time: An 18-Year Odyssey from Death Row to Freedom
AU  - Hollway, John
AU  - Gauthier, Ronald M.
AB  - In 1984, John Thompson was convicted and sentenced to death for the murder of a prominent white man in New Orleans, Louisiana. He was sent to Angola Prison and confined to his cell for twenty-three hours a day. However, Thompson adamantly proclaimed his innocence and just needed lawyers who believed that his trial had been mishandled and would step up to the plate against the powerful DA’s office. But who would fight for Thompson’s innocence when he didn’t have an alibi for the night of the murder and there were two key witnesses to confirm his guilt?Killing Time is about the eighteen-year quest for Thompson’s freedom from a wrongful murder conviction. After Philadelphia lawyers Michael Banks and Gordon Cooney take on his case, they struggle to find areas of misconduct in his previous trials while grappling with their questions about Thompson’s innocence. John Hollway and Ronald M. Gauthier have interviewed Thompson and the lawyers, and paint a realistic and compelling portrait of life on death row and the corruption in the Louisiana police and DA’s office. When it is found that evidence was mishandled in a previous trial that led to his death sentence in the murder case, Thompson is finally on his road to freedom—a journey that continues with his suit against Harry Connick, Sr. and the New Orleans DA’s office to this day.
DA  - 2010/05/18/
PY  - 2010
DP  - Google Books
SP  - 497
LA  - en
PB  - Skyhorse Publishing Inc.
SN  - 978-1-60239-974-7
ST  - Killing Time
L2  - https://books.google.com/books?id=axj6Lze9XQUC
KW  - Social Science / Criminology
KW  - Social Science / Penology
KW  - Political Science / Law Enforcement
KW  - True Crime / General
KW  - True Crime / Murder / General
KW  - True Crime / Murder / Serial Killers
KW  - Law / Civil Rights
KW  - Law / Constitutional
ER  - 

TY  - ELEC
TI  - The Real Culprit in the Central Park 5 Convictions
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Before you join the chorus of outrage against the prosecutors in the Central Park jogger case, it’s worth thinking about the systemic flaws that led to the wrongful convictions—so we can prevent it from happening again, says TCR’s legal columnist.

https://groups.google.com/forum/#!topic/criminal-justice-sentinel-events/2qCg9Db8Qzc
DA  - 2019/07/08/
PY  - 2019
LA  - en-US
UR  - https://thecrimereport.org/2019/07/08/the-real-culprit-in-the-central-park-5-convictions/
Y2  - 2019/07/08/17:58:07
ER  - 

TY  - ELEC
TI  - How to Prevent the Next Wrongful Conviction
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Brooklyn, N.Y., DA Eric Gonzales has taken an important step with the publication of a report on 25 wrongful convictions uncovered by his Conviction Review Unit, the largest in the nation. But the deeper challenge remains preventing future miscarriages of justice, writes TCR’s legal affairs columnist.
DA  - 2020/07/21/T15:21:50+00:00
PY  - 2020
LA  - en-US
UR  - https://thecrimereport.org/2020/07/21/how-to-prevent-the-next-wrongful-conviction/
Y2  - 2020/07/21/17:14:22
ER  - 

TY  - ELEC
TI  - Can Jurors Save the Justice System?
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Jury trials have largely disappeared because courthouse insiders deploy an elaborate apparatus of carrots and sticks to make sure no defendant ever chooses one. Expanding the role and responsibilities of jurors could fix that, writes TCR’s legal affairs columnist.
DA  - 2020/08/04/T15:09:48+00:00
PY  - 2020
LA  - en-US
UR  - https://thecrimereport.org/2020/08/04/the-empowered-juror-a-proposal-to-save-the-justice-system/
Y2  - 2020/08/25/17:08:58
ER  - 

TY  - ELEC
TI  - The Missing Link in Police Reform: 911 Call-Takers
AU  - Gillooly, Jessica W.
T2  - The Crime Report
AB  - The wrongful arrest of Harvard Prof. Henry Louis Gates in 2009 started with a 911 call-taker who exaggerated the original complaint. Training on how to distinguish between high-risk and low-risk calls is a critical, but so far largely ignored, factor in determining police response, writes an NYU law scholar and former call-taker.

https://groups.google.com/g/criminal-justice-sentinel-events/c/9l_28MySKVs
DA  - 2020/07/27/T14:40:19+00:00
PY  - 2020
LA  - en-US
ST  - The Missing Link in Police Reform
UR  - https://thecrimereport.org/2020/07/27/the-missing-link-in-police-reform-911-call-takers/
Y2  - 2020/08/25/17:24:09
ER  - 

TY  - RPRT
TI  - Sentinel Event Review of Police Response to 2020 Protests in Seattle Wave 2: Downtown Protests June 2 - 7, 2020
AU  - Seattle Office of the Inspector General
AB  - The murder of George Floyd had a monumental impact around the world and engaged a wide segment
of the United States population in public dialogue about the role of race in every aspect of society. The
implications of this event are still being felt. Like other departments in cities around the country, the
Seattle Police Department (SPD) and the City of Seattle grappled with how to respond to ongoing
community protests about the institution of policing in a way that would not further erode public trust,
given concerns about the historical role of policing and centuries of abuse suffered by Black, Indigenous,
and other People of Color.
The process of Sentinel Event Review (SER) is a collaborative effort between community members, SPD,
and OIG to identify the causes and contributing factors of undesired incidents with the goal of
prevention (see principles and goals in Table 1 below). 1 SER is used extensively in other fields, including aviation, health care and manufacturing, among others, to identify root causes of tragedies and design
improvements that will prevent their recurrence. The focus of SER is on fixing the system, not on
assigning individual liability. To that end, Panelists participating in this SER made no attempt to assign individual accountability for acts taken during the incidents reviewed. The SER Panel considered data
collected by OIG and investigations conducted by SPD and the Office of Police Accountability (OPA) in its
review of the incidents and considered OPA’s assessments of misconduct or deviation from SPD policies and procedures. These discussions generated recommendations to improve SPD’s response to future protests and minimize uses of force, avoid harm to community, and mitigate acts of violence or destruction.


https://groups.google.com/g/criminal-justice-sentinel-events/c/PrBtPpoV9aAhttps://groups.google.com/g/criminal-justice-sentinel-events/c/PrBtPpoV9aA
DA  - 2022/03/14/
PY  - 2022
SP  - 73
UR  - https://seattle.gov/documents/Departments/OIG/Sentinel%20Event%20Review/SER%20Wave%20Two%20Draft%20Report%20Final%20Version%20%28V2%29.pdf
Y2  - 2020/08/25/17:27:11
N1  - <p>18</p>
<p>In addition to this special peacemaking circle, Panelist Dr. Karin Martin of the University of Washington<br />led the Panel in a conversation on systemic racism, where Panelists spoke about their own experiences<br />with race, revealing larger racial dynamics at play in society. Panelists reflected on definitions of<br />systemic racism, institutional racism, and other vocabulary, and discussing each Panelist’s first<br />awareness of race as a way of bringing to light each person's particular experience related to race, while<br />revealing racial dynamics in society that are larger than any given person. Panelists used<br />https://www.racialequitytools.org/glossary to standardize the group’s vocabulary.</p>
<p>These conversations were (and continue to be) extremely challenging. They created a substantial hurdle<br />to generating a shared understanding of the Incidents reviewed by the Panel – and therefore to the<br />drafting of consensus recommendations. The damage that has been done – the damage that caused<br />these protests in the first place, and the overall inability of SPD as a Department and the City of Seattle<br />to immediately craft particularized responses to the needs of peaceful protestors while addressing<br />threats to public order and safety – is deep and lasting. However, acknowledging the underlying<br />Contributing Factor of institutional and systemic racism was critical to being able to move forward as a<br />group.</p>
N1  - <p>In the past, it has been common for protest organizers to reach out to SPD and enlist its support in<br />planning and holding a safe protest. Such was not the case in the wake of George Floyd’s murder. First,<br />the protests were decentralized. Many appeared to grow organically, while others, such as the Westlake<br />Park demonstrations on May 30, included a variety of different groups with different messages and<br />perspectives. In a sign of the community’s current distrust of police and of SPD, many organizers refused<br />to communicate with SPD, viewing them as part of the problem rather than a possible partner in the<br />solution.<br />The absence of advance notice of protester intentions and goals forced SPD into a more reactive<br />approach to crowd management rather than a proactive conversation about protest facilitation. This,<br />coupled with the anti-police focus of the Events, created a “new normal” for protests that SPD was<br />reacting to for the first time, in real time.<br />In response, SPD fell back on its standard tactics and procedures for “crowd management,” defined as<br />“strategies and tactics that employ communication and dialogue with event leaders to obtain voluntary<br />compliance with lawful orders and allow for minimal enforcement action”23 and “crowd control and<br />dispersal.” While these policies have helped hundreds of protests and demonstrations per year occur in<br />Seattle without violence, the phrases “crowd management” and “crowd control” and the focus on<br />“compliance with lawful orders” and “minimal enforcement action” are telling.</p>
N1  - <p>Mayor Durkan announced a curfew for the city beginning at 5:00 p.m., and an executive order<br />prohibiting a range of weapons, including firearms, rocks, and flares. While the curfew made being on<br />the streets of downtown technically illegal, it was increasingly difficult for protestors to leave the city, as<br />the Westlake Metro station and Downtown sections of I-5 were temporarily closed, and King County<br />buses stopped operating in the Downtown core.<br />Looting, vandalism, and peaceful protests in defiance of the curfew and the police department<br />continued throughout the evening, leaving the City and SPD struggling to adapt their tactics for<br />facilitating protests motivated by anger at the police themselves</p>
N1  - <p>n part because of these the protests on May 30 – June 1 were of a volume and scope that was<br />unprecedented for SPD. As one SPD Panelist noted, “these protests were events that you’d usually take<br />six to eight months, maybe even a year, to prepare for. We had days.” Again, because police were the<br />focus of the protests, community/police communications regarding these events were reduced.<br />Moreover, images of confrontations and conflagrations during these days, in Seattle and elsewhere,<br />were broadcast widely through social media and traditional media, enhancing tensions among many<br />participants on a daily basis. Events like the burning of a Minneapolis police building on May 28<br />heightened police fears of organized violence and arson among protesters, and the destruction of<br />downtown Seattle buildings and SPD vehicles on May 29 and 30 upset and concerned community<br />members, business owners and SPD alike. SPD officers who responded with uses of force and<br />deployments of less-lethal munitions had a similarly galvanizing effect on protesters, who became more<br />determined to protest by the day. Each new “back and forth” of violence or destruction was easily<br />accessible and shareable on social media and broadcast by traditional media. Panelists described each<br />subsequent day of protests pitting increasingly scared, angry, and exhausted community members </p>
ER  - 

TY  - NEWS
TI  - TPD forms board to review 'critical' incidents
AU  - Conover, Christopher
T2  - Arizona Public Media
AB  - The new board will review the events that lead to the death of Carlos Ingram-Lopez in Tucson police custody in April.
LA  - en
UR  - https://news.azpm.org/p/news-splash/2020/7/7/176097-tpd-forms-board-to-review-critical-incidents/
Y2  - 2020/08/25/17:30:51
ER  - 

TY  - ELEC
TI  - Want to fix policing? Start with a better 911 system.
AU  - Karma, Roge
T2  - Vox
AB  - "911 call takers are gatekeepers for the entire criminal justice system. We need to start treating them that way."

https://groups.google.com/g/criminal-justice-sentinel-events/c/_g2w0EpUqdw
DA  - 2020/08/10/T07:50:00-04:00
PY  - 2020
LA  - en
ST  - Want to fix policing?
UR  - https://www.vox.com/2020/8/10/21340912/police-violence-911-emergency-call-tamir-rice-cahoots
Y2  - 2020/08/25/17:33:05
ER  - 

TY  - ELEC
TI  - 3 Ways Lack of Police Accountability Contributes to Wrongful Convictions
AU  - Rebecca Brown
T2  - Innocence Project
AB  - The current system offers more protections for guilty police officers than innocent citizens.

https://groups.google.com/g/criminal-justice-sentinel-events/c/9206CleOWRo
DA  - 2020/08/17/T21:55:27+00:00
PY  - 2020
LA  - en-US
UR  - https://www.innocenceproject.org/lack-of-police-accountability-contributes-to-wrongful-conviction/
Y2  - 2020/08/25/17:45:13
ER  - 

TY  - ELEC
TI  - Why Can't Reformers Speak the Same Language?
AU  - James M. Doyle
T2  - The Crime Report
AB  - Justice reformers like to use words like “safety,” “accountability” and “reform,” but too often they mean different things depending on who is using them. It would be better if we agreed on common definitions if we want to really change the system, writes TCR’s legal affairs columnist.
DA  - 2020/08/24/T15:02:15+00:00
PY  - 2020
LA  - en-US
UR  - https://thecrimereport.org/2020/08/24/why-cant-reformers-speak-the-same-language/
Y2  - 2020/08/25/19:05:37
ER  - 

TY  - BLOG
TI  - Another week in America, another police shooting
AU  - Ratcliffe, Jerry
T2  - Jerry Ratcliffe
AB  - A goal of zero police shootings is impossible in America for the foreseeable future. There are too many armed citizens, and some of them lik
DA  - 2020/08/27/T16:47:45.396Z
PY  - 2020
LA  - en
UR  - https://www.jratcliffe.net/post/another-week-in-america-another-police-shooting
Y2  - 2020/08/27/20:36:18
ER  - 

TY  - ELEC
TI  - Decolonizing Criminal Justice
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Few criminal justice reforms can be enacted, and none of them will be sustained, unless we discard an approach that systematically dehumanizes minority lives at both the individual and neighborhood levels. Reformers who neglect that work are building on sand, writes TCR’s legal affairs columnist.
DA  - 2020/11/17/T12:45:15+00:00
PY  - 2020
LA  - en-US
UR  - https://thecrimereport.org/2020/11/17/decolonizing-criminal-justice/
Y2  - 2020/11/17/18:50:35
ER  - 

TY  - RPRT
TI  - Probation and Parole in the United States, 2017-2018
AU  - Kaeble, Danielle
AB  - https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6986
p 25
Appendix Table 7
Adults exiting parole, by type of exit, 2018

Returned to incarceration revocation: 70,224
DA  - 2020/08/04/
PY  - 2020
PB  - Bureau of Justice Statistics
UR  - https://www.bjs.gov/index.cfm?ty=pbdetail&iid=6986
Y2  - 2020/12/03/18:27:40
ER  - 

TY  - RPRT
TI  - Prisoners in 2019
AU  - Carson,, E. Ann
AB  - https://www.bjs.gov/index.cfm?ty=pbdetail&iid=7106
Table 8
Admissions and releases of sentenced prisoners under the jurisdiction of state or federal correctional authorities, 2018
and 2019
DA  - 2020/10//
PY  - 2020
PB  - Bureau of Justice Statistics
UR  - https://www.bjs.gov/index.cfm?ty=pbdetail&iid=7106
Y2  - 2020/12/03/18:34:20
ER  - 

TY  - ELEC
TI  - The Prosecutor as Quiet Revolutionary
AU  - Doyle, James M.
T2  - The Crime Report
AB  - If you wanted to remake the fundamentals of the U.S. criminal justice system, you might start with the decisions by a growing number of prosecutors to establish Sentencing Review units, writes TCR’s legal affairs columnist. The latest to sign on are newly elected Los Angeles County DA George Gascón and Baltimore State’s Attorney Marilyn Mosby.
DA  - 2020/12/14/T16:41:02+00:00
PY  - 2020
LA  - en-US
UR  - https://thecrimereport.org/2020/12/14/the-prosecutor-as-quiet-revolutionary/
Y2  - 2020/12/15/23:20:09
ER  - 

TY  - RPRT
TI  - Report of the Tucson Sentinel Event Review Board (SERB) on the Deaths in Custody of Mr. Damien Alvarado and Mr. Carlos Adrian Ingram-Lopez
AU  - Sentinel Event Review Board
AB  - The deaths of Damien Alvarado and Carlos Adrian Ingram-Lopez are two of five in-custody
deaths over the past decade (one in 2010, two in 2012, and the recent two) that involved some
use of restraints imposed by the Tucson Police Department. TPD leadership believes that any
death in custody is a tragedy that should be carefully reviewed and understood, and
improvements to procedures implemented to reduce the chance that any such event can
happen in the future.
The SERB is a multi-stakeholder group, including representatives from TPD, the Tucson Fire
Department and its Emergency Medical Services (“TFD” or “EMS”), the Public Safety
Communications Department, staff from the offices of the Mayor and Councilmembers, the
Community Police Advisory Review Board (“CPARB”), and a diverse array of community
participants, including experts in critical care, the care of individuals with mental or behavioral
health issues, and experts in cultural literacy and racial justice.
Assisting the SERB were John Hollway, Executive Director of the Quattrone Center for the Fair
Administration of Justice from the University of Pennsylvania Carey Law School (“Quattrone
Center”) and Michael Scott, Clinical Professor and Director of the Center for Problem-Oriented
Policing at the Watts College of Public Service and Community Solutions at Arizona State
University. Mr. Hollway and Mr. Scott are experts in the conduct of sentinel event reviews.

Renee Koser comment on Google Forum about using the report as part of a training. https://groups.google.com/g/criminal-justice-sentinel-events/c/ArtDcs37MzU
DA  - 2020/09/18/
PY  - 2020
PB  - City of Tucson
UR  - https://www.tucsonaz.gov/files/police/SERB/In_Custody_SERB_Final_Report_Sept_2020.pdf
ER  - 

TY  - ELEC
TI  - Why Punishing Bad Prosecutors Won’t Fix the System
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Prosecutorial misconduct should be punished when it occurs, writes TCR’s legal affairs columnist. But it’s a bad place to stop if the goal is to make sure the misconduct isn’t repeated.
DA  - 2021/02/15/T12:30:25+00:00
PY  - 2021
LA  - en-US
UR  - https://thecrimereport.org/2021/02/15/why-punishing-bad-prosecutors-wont-fix-the-system/
Y2  - 2021/02/16/21:59:16
ER  - 

TY  - RPRT
TI  - Report to Strengthen UMPD Alignment with UMN Expectations
AU  - University of Minnesota
AU  - Alexander Consulting
AB  - 7.3 Recommendation: Develop a Critical Incident Review process similar to Sentinel Event Reviews conducted in transportation and medicine to identify systemic issues that need to
 be corrected to prevent similar future incidents.
7.3.1 Conduct critical incident (SER) reviews to learn from critical events such as Somali Night 2018 to
 identify and address systemic barriers to improve policing outcomes, prevent similar situations
 and improve community alignment.

https://groups.google.com/g/criminal-justice-sentinel-events/c/Ne0yZ3GqHBo
DA  - 2021/01//
PY  - 2021
UR  - https://president.umn.edu/dr-alexander-report
ER  - 

TY  - VIDEO
TI  - Rescuing 911: Opportunities for Reform in Police Dispatch
AU  - Quattrone Center for Fair Administration of Justice
AB  - Amid ongoing calls for reform to address systemic racism in our communities, our 911 operators continue to receive about 500,000 calls each day. These operators are the first of our first responders. The information they gather, what they transmit, and the way they transmit it can have a meaningful impact on how police respond to calls for help from our communities. And as the recent killing of Walter Wallace Jr. in Philadelphia shows, the manner in which police get dispatched to an encounter with a community member can critically shape how it ends.

Speakers:
Jerry L. Clayton, Sheriff, Washtenaw County (MI) Sheriff’s Office
Dr. Jessica W. Gillooly, Fellow, the Policing Project at NYU School of Law
John Hawkins, Assistant Chief Constable, Police Scotland

Moderator:
John Hollway, Quattrone Center
DA  - 2021/01/27/
PY  - 2021
DP  - YouTube
ST  - Rescuing 911
UR  - https://www.youtube.com/watch?v=ecNU5ISWEzU&feature=youtu.be
Y2  - 2021/02/17/16:48:42
ER  - 

TY  - NEWS
TI  - Legislative police reform package calls for creation of commission promoted by Michael Bell | Local News | kenoshanews.com
AU  - Smith, Deneen
T2  - Konosha News
AB  - The package also includes creation of a board Bell has been promoting, a first-in-the-nation board based on a National Transportation Safety Board model that would analyze “use of force” incidents and recommend ways of preventing death and serious injuries in similar circumstances.

https://groups.google.com/g/criminal-justice-sentinel-events/c/_d4UWvPxsDU
DA  - 2021/01/21/
PY  - 2021
UR  - https://www.kenoshanews.com/news/local/legislative-police-reform-package-calls-for-creation-of-commission-promoted-by-michael-bell/article_1403e035-352a-5d3d-a1e2-2788c96a58d8.html?utm_medium=social&utm_source=twitter&utm_campaign=user-share
Y2  - 2021/02/17/17:28:44
ER  - 

TY  - RPRT
TI  - A Blueprint for Change 2020
AU  - Wisconsin Professional Police Association
AB  - Page 8 cites SEI webpage. 

https://groups.google.com/g/criminal-justice-sentinel-events/c/_d4UWvPxsDU
DA  - 2020///
PY  - 2020
ST  - WPPA
UR  - https://wppa.com/wp-content/flowpaper/blueprint2020/WPPA-A-Blueprint-for-Change.html#page=1
Y2  - 2021/02/17/17:35:12
ER  - 

TY  - ELEC
TI  - Biden’s First Justice Duty: Commute All Federal Death Sentences
AU  - Doyle, James M.
T2  - The Crime Report
AB  - The “moral squalor” of the closing days of the current administration, when frenzied efforts to execute prisoners coincided with granting pardons to cronies, provides the incoming president with justification for taking steps that make clear the era of treating criminal justice challenges with futile anti-crime gestures is over, writes TCR’s legal affairs columnist.
DA  - 2020/12/28/T16:27:29+00:00
PY  - 2020
LA  - en-US
ST  - Biden’s First Justice Duty
UR  - https://thecrimereport.org/2020/12/28/bidens-first-justice-duty-commute-all-federal-death-sentences/
Y2  - 2021/02/17/19:48:26
ER  - 

TY  - CHAP
TI  - Sentinel Event Reviews in the United States and Canada: Enhancing Service Delivery to the Community
AU  - Parent, Richard B.
AU  - Parent, Catherine
T2  - Enhancing Police Service Delivery
A2  - Albrach, James F
A2  - Den Hayer, Garth
DA  - 2021///
PY  - 2021
DP  - Google Books
SP  - 125
EP  - 141
LA  - en
PB  - Springer Nature
SN  - 978-3-030-61452-2
L2  - https://books.google.com/books?id=tqQeEAAAQBAJ
L2  - https://books.google.com/books?id=tqQeEAAAQBAJ
ER  - 

TY  - JOUR
TI  - Social Science Research in Domestic Violence Law: A Proposal to Focus on Evidentiary Use Comment
AU  - Etlinger, Laura
T2  - Albany Law Review
DA  - 1994///1995
PY  - 1994
DP  - HeinOnline
VL  - 58
IS  - 4
SP  - 1259
EP  - 1308
J2  - Alb. L. Rev.
LA  - eng
ST  - Social Science Research in Domestic Violence Law
UR  - https://heinonline.org/HOL/P?h=hein.journals/albany58&i=1269
Y2  - 2021/03/01/22:05:24
ER  - 

TY  - JOUR
TI  - Sentinel event reviews in the criminal justice system: a review of the literature.
AU  - Friend, Karen B.
AU  - Gordon, Mary
AU  - Scarbrough, Bill
AU  - Collins, David
AU  - Fritz, Kyra
AU  - Smoot, Sean
AU  - Copple, James
AU  - Copple, Colleen
AU  - Joyce, Nola
T2  - Criminal Justice Studies
AB  - Trust between law enforcement officers and the communities they serve is essential to the safety of our citizens. Relationships between police and communities have, however, become increasingly strained, with reports of deadly events and wrongful convictions filling the television, newspapers, and the Internet. While the model of conducting internal investigations to determine blame and penalize the individuals involved has been used for years, a new paradigm to bring systemic change is increasingly being embraced by the criminal justice field. Historically used in other disciplines, sentinel event reviews have been employed to understand organizational failures. Multiple key community stakeholders gather to conduct a root cause analysis, which is an empirical approach that involves data collection to understand the systems-level causes of organizational events. The purpose of this paper is to examine the literature on sentinel event reviews in the criminal justice system, borrowing heavily from other disciplines where they are already well-established. We then examine the literature on organizational adoption, since the ultimate goal of sentinel event reviews is to lead to stronger systems that can learn from systemic mistakes and allow the dissemination of best practices to benefit both law enforcement and the individuals they serve. [ABSTRACT FROM AUTHOR]
DA  - 2020/12//
PY  - 2020
DP  - EBSCOhost
VL  - 33
IS  - 4
SP  - 337
EP  - 353
J2  - Criminal Justice Studies
SN  - 1478601X
UR  - https://d1wqtxts1xzle7.cloudfront.net/91822769/1478601x.2020.174122720221001-1-13f54pa-libre.pdf?1664637810=&response-content-disposition=inline%3B+filename%3DSentinel_event_reviews_in_the_criminal_j.pdf&Expires=1687281915&Signature=XUmVDsqXl~qLhxlsg792ZGoNT2L9L8PxNLpmZyphfUVp10sX0YEgrpFfVKOmycaqLO5LyZLot2piwTgRcjLH3MZbtNROTOmpwy8-2vSavKROKRJqxgF5OExNjXqPAv0Be7yeFe-O~N6mDZzzcWGa8NWQXwUscOzRZP~frrylrJSe35wQvg-4yXIlTHI~JdnQJFEMk1C8lUNkQo2tEd-IlIun-CgvzjifC8wYl47zBLHdzNDlBXt3-AIueX0LkQ6KIL8kLhkhQyhJbfs8Ph2ov2pNi-ceOAdLf2MEt27a4toP54ykuWiNCuWthvL5NIfZom5JiZVZLQo1CrcUSvWQXw__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA
DB  - Criminal Justice Abstracts with Full Text
N1  - <p>Accession Number: 147311245; Friend, Karen B. 1,2; Email Address: kfriend@pire.org; Gordon, Mary 1; Scarbrough, Bill 1; Collins, David 1; Fritz, Kyra 1; Smoot, Sean 3; Copple, James 4; Copple, Colleen 4; Joyce, Nola 5; Affiliations: 1 : Pacific Institute for Research and Evaluation, Beltsville, MD, USA; 2 : Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA; 3 : Police Benevolent and Protective Association of Illinois, Springfield, IL, USA; 4 : Strategic Applications International LLC, VA, USA; 5 : 21CP Solutions, Chicago, IL, USA;  Source Info: Dec2020, Vol. 33 Issue 4, p337; Subject Term: CRIMINAL justice system; Subject Term: LITERATURE reviews; Subject Term: POLICE; Subject Term: TRUSTS & trustees; Subject Term: ROOT cause analysis; Subject Term: POLICE attitudes; Author-Supplied Keyword: accountability; Author-Supplied Keyword: law enforcement; Author-Supplied Keyword: root cause analysis; Author-Supplied Keyword: Sentinel event review; Author-Supplied Keyword: systems approach; Author-Supplied Keyword: trust; Number of Pages: 17p; Document Type: Article; Full Text Word Count: 8759</p>
N1  - <p>Accession Number: 147311245; Friend, Karen B. 1,2; Email Address: kfriend@pire.org; Gordon, Mary 1; Scarbrough, Bill 1; Collins, David 1; Fritz, Kyra 1; Smoot, Sean 3; Copple, James 4; Copple, Colleen 4; Joyce, Nola 5; Affiliations: 1 : Pacific Institute for Research and Evaluation, Beltsville, MD, USA; 2 : Department of Psychiatry and Human Behavior, Brown University, Providence, RI, USA; 3 : Police Benevolent and Protective Association of Illinois, Springfield, IL, USA; 4 : Strategic Applications International LLC, VA, USA; 5 : 21CP Solutions, Chicago, IL, USA;  Source Info: Dec2020, Vol. 33 Issue 4, p337; Subject Term: CRIMINAL justice system; Subject Term: LITERATURE reviews; Subject Term: POLICE; Subject Term: TRUSTS & trustees; Subject Term: ROOT cause analysis; Subject Term: POLICE attitudes; Author-Supplied Keyword: accountability; Author-Supplied Keyword: law enforcement; Author-Supplied Keyword: root cause analysis; Author-Supplied Keyword: Sentinel event review; Author-Supplied Keyword: systems approach; Author-Supplied Keyword: trust; Number of Pages: 17p; Document Type: Article; Full Text Word Count: 8759</p>
KW  - POLICE
KW  - root cause analysis
KW  - accountability
KW  - CRIMINAL justice system
KW  - law enforcement
KW  - LITERATURE reviews
KW  - POLICE attitudes
KW  - ROOT cause analysis
KW  - Sentinel event review
KW  - systems approach
KW  - trust
KW  - TRUSTS & trustees
ER  - 

TY  - ELEC
TI  - The New Pioneers of Conviction Integrity
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Conviction Integrity Unit prosecutors would probably say they are just “trying to do justice.”  In fact, they are pioneers in mobilizing a modernized understanding of how things go wrong in criminal justice, writes TCR’s Legal Affairs columnist.
DA  - 2021/03/04/T15:50:27+00:00
PY  - 2021
LA  - en-US
UR  - https://thecrimereport.org/2021/03/04/the-new-pioneers-of-conviction-integrity/
Y2  - 2021/03/04/22:38:28
ER  - 

TY  - JOUR
TI  - Changing the Face of Police Lineups: Delivering More Information From Witnesses
AU  - Brewer, Neil
AU  - Doyle, James
T2  - Journal of Applied Research in Memory and Cognition
AB  - Police lineups are widely used despite evidence that eyewitnesses frequently err by failing to identify the culprit or mistakenly identifying innocent suspects or lineup fillers. We examine how police investigators, prosecutors, defense attorneys, and judges interpret the information witnesses provide when confronted with a traditional lineup and describe one alternative procedure that departs significantly from current practice. This alternative abandons the categorical witness decision, replacing it with confidence judgments about each lineup member’s match to memory for the culprit. Compared with the traditional lineup, this approach provides more nuanced information about suspect guilt. We challenge criminal justice researchers and professionals to examine the potential informational gains this approach offers—and to explore other genuine alternatives—rather than merely tinkering with the existing approach. Finally, we emphasize that a truly collaborative engagement with justice system professionals will be more productive than researchers being the sole arbiters of model practices.
DA  - 2021/02/13/
PY  - 2021
DO  - 10.1016/j.jarmac.2020.12.004
DP  - ScienceDirect
J2  - Journal of Applied Research in Memory and Cognition
LA  - en
SN  - 2211-3681
ST  - Changing the Face of Police Lineups
UR  - https://www.sciencedirect.com/science/article/pii/S2211368120301236
Y2  - 2021/03/12/16:52:30
KW  - Confidence
KW  - Eyewitness identification
KW  - Police lineups
KW  - Probability of guilt
ER  - 

TY  - ELEC
TI  - Ingram-Lopez death helps lead to police reform in Tucson
AU  - Mingura, Mark
DA  - 2021/04/21/
PY  - 2021
UR  - https://kvoa.com/news/2021/04/21/ingram-lopez-death-helps-lead-to-police-reform-in-tucson/
Y2  - 2021/05/05/20:29:09
ER  - 

TY  - JOUR
TI  - Systematic Case Review Strategies: An Application for Jail Population Reduction
AU  - Huebner, Beth M.
AU  - Lentz, Theodore S.
AU  - Gibson, Miranda
T2  - Justice Quarterly
AB  - Jails are a critical part of the criminal justice system but, until recently, have been omitted from discussions of reform. The goal of the current study is to describe and evaluate a collaborative, problem-solving initiative designed to reduce the jail population in St. Louis County, Missouri. The initiative was implemented as part of a research-practitioner partnership and is designed around a case review model, deemed the Population Review Team (PRT) commonly used in epidemiological analysis and problem-solving policing models. The outcome analysis suggests that the implementation of the PRT was associated with a significant decline in the total jail population, the number of individuals held on non-violent felonies, and those held for over 100 days. The collaborative project provides one model for criminal justice systems reform and a tool for decarceration.
DA  - 2020/11/09/
PY  - 2020
DO  - 10.1080/07418825.2020.1819384
DP  - Taylor and Francis+NEJM
VL  - 37
IS  - 7
SP  - 1261
EP  - 1276
SN  - 0741-8825
ST  - Systematic Case Review Strategies
UR  - https://doi.org/10.1080/07418825.2020.1819384
Y2  - 2021/05/05/20:40:30
KW  - Jail
KW  - pretrial release
KW  - COVID-19
KW  - policy reform
KW  - researcher-practitioner partnership
ER  - 

TY  - JOUR
TI  - Neutral Ground: Criminal Justice Safety Learning Centers Enabling Legislation
AU  - Doyle, James M.
AB  - An array of jurisdictions are doing the exploration of forward-looking, all-stakeholders, non-blaming “sentinel event” learning reviews supported by the National Institute of Justice and the Bureau of Justice Assistance. This essay presents for amendment and criticism a sketch of legislation that would sustain the learning review practice as an embedded cultural feature.
DA  - 2019/10/10/
PY  - 2019
DO  - 10.2139/ssrn.3467719
DP  - papers.ssrn.com
LA  - en
ST  - Neutral Ground
UR  - https://papers.ssrn.com/abstract=3467719
Y2  - 2021/05/05/20:43:13
KW  - sentinel events
KW  - criminal justice learning reviews
ER  - 

TY  - JOUR
TI  - Improving police effectiveness in ensuring justice
AU  - Braga, Anthony A
AU  - MacDonald, John
T2  - CRIMINOLOGY & PUBLIC POLICY
DA  - 2019///
PY  - 2019
SN  - 1538-6473
UR  - https://onlinelibrary.wiley.com/doi/full/10.1111/1745-9133.12458
N1  - <p>cites Mending Justice</p>
ER  - 

TY  - RPRT
TI  - Sentinel Event Review Board (SERB) Board: Six-month Review
AU  - Sentinel Event Review Board
AB  - "Sentinels stand watch," says James Doyle, founding Director of the Center for Modern Forensic Practice at John Jay College of Criminal Justice. "They detect the first signs of a looming threat and sound a warning that should not be ignored." When bad things happen in a complex system, such as the larger policing environment, the cause is rarely a single act or event. More often, bad outcomes are "sentinel events." Sentinel events are events with significant negative outcomes that: Signal underlying weaknesses in the system. Are likely the result of multiple or compound contributing factors.
DA  - 2021/04//
PY  - 2021
LA  - en
PB  - City of Tucson
UR  - https://www.tucsonaz.gov/files/police/SERB/Recommendation_Implementation_Report_April_2021.pdf
Y2  - 2021/05/06/15:08:48
ER  - 

TY  - ELEC
TI  - The Perils of Justice ‘Colonialism’
AU  - Doyle, James M.
T2  - The Crime Report
AB  - A recent account of life in a Washington, DC precinct uncomfortably reminds TCR’s legal columnist of the “adventure travel” books that once filled bookshelves about the British Raj. Purporting to be sympathetic to the plight of inhabitants, they were factual, without being quite true—and in our current age of reform there are many more like them.
DA  - 2021/06/17/T11:15:13+00:00
PY  - 2021
LA  - en-US
UR  - https://thecrimereport.org/2021/06/17/the-perils-of-justice-colonialism/
Y2  - 2021/06/17/14:35:29
ER  - 

TY  - JOUR
TI  - Do New Chiefs Mean Fresh Perspectives? The Institutionalization of the Police Executive Environment
AU  - Matusiak, Matthew C.
T2  - CRIMINAL JUSTICE AND BEHAVIOR
DA  - 2022/04//
PY  - 2022
DO  - 10.1177/00938548211006753
SN  - 0093-8548
ER  - 

TY  - JOUR
TI  - Policing's Information Problem
AU  - Friedman, Barry
AU  - Janszky, Elizabeth G.
T2  - TEXAS LAW REVIEW
AB  - 316. See NAT'L INST. OF JUSTICE, PAVING THE WAY: LESSONS LEARNED IN SENTINEL EVENT
REVIEWS 2 (Nov. 2015), https://www.ncjrs.gov/pdffilesl/nij/249097.pdf [https://perma.cc/GNB4-
9Q9H] (assessing the feasibility of implementing sentinel event reviews in the criminal justice
system because such reviews have been successfully employed, presumably system-wide, in
medicine and aviation).
DA  - 2020/11//
PY  - 2020
VL  - 99
IS  - 1
SP  - 1
EP  - 71
SN  - 0040-4411
ER  - 

TY  - JOUR
TI  - Police supervisor attitudes toward organizational change
AU  - Schafer, Joseph A.
AU  - Varano, Sean P.
AU  - Galli, Phillip M.
AU  - Ford, Teri
T2  - JOURNAL OF CRIME & JUSTICE
DA  - 2021/05/27/
PY  - 2021
DO  - 10.1080/0735648X.2020.1803952
VL  - 44
IS  - 3
SP  - 258
EP  - 274
SN  - 0735-648X
ER  - 

TY  - JOUR
TI  - Innocence and Prevention: Could we Build Justice Safety Centers?
AU  - Doyle, James
T2  - The Wrongful Conviction Law Review
AB  - Some contemporary writers argue that wrongful convictions represent system failures in a complex criminal justice system.  Currently explorations are underway into whether pursuit of non-blaming, all-stakeholders, forward-looking “sentinel event” reviews focused on lowering risk rather than laying blame can improve safety from wrongful convictions.  This article reviews the underlying theory of safety-based practices and sketches one model of how work on preventing wrongful convictions might be institutionalized:  made a part of a new culture of continuous improvement that lowers the risk of future wrongful convictions and offers a degree of restorative justice to the victims of errors.
DA  - 2020/09/15/
PY  - 2020
DO  - 10.29173/wclawr19
DP  - wclawr.org
VL  - 1
IS  - 2
SP  - 253
EP  - 269
J2  - Wrongful Conviction L Rev
LA  - en
SN  - 2563-2574
ST  - Innocence and Prevention
UR  - https://wclawr.org/index.php/wclr/article/view/19
Y2  - 2021/07/09/14:22:38
KW  - wrongful conviction
KW  - exoneration
KW  - safety
KW  - restorative justice
KW  - organizational accidents
KW  - system failure
ER  - 

TY  - ELEC
TI  - The Uncomfortable Truth About Wrongful Convictions
AU  - Doyle, James M.
T2  - The Crime Report
AB  - A New York Times journalist’s account of how she helped free a wrongfully convicted individual shines a spotlight on why so many innocent people still languish in a system that is incapable of discovering and rectifying errors, writes TCR’s legal affairs columnist.
DA  - 2021/07/12/T15:00:44+00:00
PY  - 2021
LA  - en-US
UR  - https://thecrimereport.org/2021/07/12/the-uncomfortable-truth-about-wrongful-convictions/
Y2  - 2021/07/12/17:01:21
ER  - 

TY  - RPRT
TI  - Tale of Four Cities: Improving our Understanding of Gun Violence, Draft Final Summary Overview | Office of Justice Programs
AU  - McGarrell, Edmund
AU  - Hipple, Natalie Kroovand
AU  - Huebner, Beth
AU  - O'Brien, Mallory
AB  - Data collection and analysis focused on Detroit, Indianapolis, Milwaukee, and St. Louis. The five goals of the project were 1) to create a better understanding of nonfatal shootings and how they relate to gun homicides; 2) to improve data systems on gun violence; 3) to increase understanding of the spatial and network dimensions of firearms violence; 4) to disseminate the data and findings; and 5) to expand the study from Detroit, Indianapolis, and Milwaukee to include St. Louis. The central issue in research methodology was the development of methods for obtaining data on nonfatal shootings, since police records management systems do not typically include a focus on nonfatal shootings. The method of data collection on nonfatal shootings developed for this project is described in this report. The database developed is organized by incident as well as by person (victim, offender). The cross-city database facilitates current and future firearm violence research and will be submitted to the NACJD. Spatial analyses will continue to be developed and will be improved by the common census data that have been integrated in the cross-city database. Conference presentations that use data from Detroit and Milwaukee have been used to examine the social network patterns of people involved in homicides and nonfatal shootings. A table of victim characteristics in homicides and nonfatal shooting incidents is provided. A listing of 19 scholarly conference presentations and 5 project publications
DA  - 2019/10//
PY  - 2019
UR  - https://www.ojp.gov/ncjrs/virtual-library/abstracts/tale-four-cities-improving-our-understanding-gun-violence-draft
Y2  - 2021/07/19/14:50:28
ER  - 

TY  - JOUR
TI  - Sentinel Events Preceding Youth Firearm Violence An Investigation of Administrative Data in Delaware
AU  - Sumner, SA
AU  - Maenner, MJ
AU  - Socias, CM
AU  - Mercy, JA
AU  - Silverman, P
AU  - Medinilla, SP
AU  - Martin, SS
AU  - Xu, LK
AU  - Hillis, SD
T2  - AMERICAN JOURNAL OF PREVENTIVE MEDICINE
AB  - Introduction: Accurately identifying youth at highest risk of firearm violence involvement could permit delivery of focused, comprehensive prevention services. This study explored whether readily available city and state administrative data covering life events before youth firearm violence could elucidate patterns preceding such violence.
Methods: Four hundred twenty-one individuals arrested for homicide, attempted homicide, aggravated assault, or robbery with a firearm committed in Wilmington, Delaware, from January 1, 2009 to May 21, 2014, were matched 1: 3 to 1,259 Wilmington resident controls on birth year and sex. In 2015, descriptive statistics and a conditional logistic regression model using Delaware healthcare, child welfare, juvenile services, labor, and education administrative data examined associations between preceding life events and subsequent firearm violence.
Results: In a multivariable adjusted model, experiencing a prior gunshot wound injury (AOR=11.4, 95% CI=2.7, 48.1) and being subject to community probation (AOR=13.2, 95% CI=5.7, 30.3) were associated with the highest risk of subsequent firearm violence perpetration, though multiple other sentinel events were informative. The mean number of sentinel events experienced by youth committing firearm violence was 13.0 versus 1.9 among controls (p<0.0001). Within the sample, 84.1% of youth experiencing a sentinel event in all five studied domains ultimately committed firearm violence.
Conclusions: Youth who commit firearm violence have preceding patterns of life events that markedly differ from youth not involved in firearm violence. This information is readily available from administrative data, demonstrating the potential of data sharing across city and state institutions to focus prevention strategies on those at greatest risk. Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine
DA  - 2016/11//undefined
PY  - 2016
DO  - 10.1016/j.amepre.2016.08.002
VL  - 51
IS  - 5
SP  - 647
EP  - 655
SN  - 0749-3797
AN  - WOS:000386785100007
ER  - 

TY  - RPRT
TI  - How Can We Achieve Accountability in Policing? The (Not-So-Secret) Ingredients to Effective Police Reform
AU  - White, Michael
AU  - Fradella, Henry
AU  - Flippin, Michaela
AB  - The summer of 2020 has been marked by a series of high-profile police killings of citizens, highlighting excessive force as the most pernicious form of racial injustice in American policing. The persistence of the excessive use of force problem over decades raises serious questions regarding what we know about police accountability, and has led some to argue for defunding or even abolishing the police. However, the roadmap to effective police accountability is tangible and known. In this Article, we delineate eight guiding principles and eight strategies that have emerged as reoccurring themes in the pursuit of police accountability and transparency. The principles and strategies of effective police accountability have proven difficult to implement and maintain, and we discuss the primary barriers to positive change. Despite these obstacles, we conclude with a sense of optimism about the potential for real police reform in the immediate to near future.
........ Sentinel events review is reflective of an overall emphasis on organizational learning through ...
including the opportunity costs of time that could have been more productively spent by police
and other criminal justice agencies Lack of trust leading to higher crime rates and ...
CY  - Rochester, NY
DA  - 2020/10/18/
PY  - 2020
DP  - papers.ssrn.com
LA  - en
M3  - SSRN Scholarly Paper
PB  - Social Science Research Network
SN  - ID 3720162
ST  - How Can We Achieve Accountability in Policing?
UR  - https://papers.ssrn.com/abstract=3720162
Y2  - 2021/07/22/13:32:19
N1  - <div data-schema-version="8"><p>cites </p>
<p>73 James M. Doyle, NIJ’s Sentinel Events Initiative: Looking Back to Look Forward, NIJ J. 10, 10 (2014), https://www.ncjrs.gov/pdffiles1/nij/244145.pdf.</p>
<p>74 NAT’L INST. OF JUST., SPECIAL REPORT: MENDING JUSTICE: SENTINEL EVENTS REVIEWS 1 (2014) [hereinafter “NIJ, MENDING JUSTICE”], https://www.ncjrs.gov/pdffiles1/nij/247141.pdf. 75 James M. Doyle, Learning from Errors in the Criminal Justice System: Sentinel Events Reviews, in NIJ, MENDING JUSTICE, supra note 74, at 3.</p>
</div>
KW  - police reform
KW  - police accountability
ER  - 

TY  - ELEC
TI  - Advancing a Coordinated Response to Intimate Partner Violence
AU  - Duane, Marina
AU  - Ervin, Storm
AU  - Nembhard, Susan
AU  - Taylor, Roderick
AU  - Bastomski, Sara
AU  - Tiry, Emily
T2  - Urban Institute
AB  - From June 2018 to December 2020, we conducted a systemwide assessment of the response of Allegheny County, Pennsylvania, to intimate partner violence with an eye toward solutions that can bring individual agencies together. Working with local partners, we identified three priority areas for the future: (1) encouraging county leaders to prioritize intimate partner violence for a defined period, (2) shifting the focus to the experiences of people involved, not only case outcomes or resolutions, and (3) reinstituting and sustaining fatality or near-fatality reviews. Further, partners can establish a specialized intimate partner violence unit in the Allegheny County Public Defender office, develop consistency in recording intimate partner violence rather than domestic violence, and finally, continue promoting treatment and interventions instead of punishment.
DA  - 2021/06/14/T15:51:51-04:00
PY  - 2021
LA  - en
UR  - https://www.urban.org/research/publication/advancing-coordinated-response-intimate-partner-violence
Y2  - 2021/07/22/13:41:17
ER  - 

TY  - BOOK
TI  - Policing and Mental Health
A3  - McDaniel,, John L.M.
A3  - Moss, Kate
A3  - Pease, Ken G.
AB  - This book explores the relationship between policing and mental health. Police services around the world are innovating at pace in order to develop solutions
DA  - 2019///
PY  - 2019
LA  - en
UR  - https://www.taylorfrancis.com/books/edit/10.4324/9780429470882/policing-mental-health-john-mcdaniel-kate-moss-ken-pease
Y2  - 2021/07/22/13:51:14
ER  - 

TY  - JOUR
TI  - Cognitive Biases in Criminal Case Evaluation: A Review of the Research
AU  - Meterko, Vanessa
AU  - Cooper, Glinda
T2  - Journal of Police and Criminal Psychology
AB  - Psychological heuristics are an adaptive part of human cognition, helping us operate efficiently in a world full of complex stimuli. However, these mental shortcuts also have the potential to undermine the search for truth in a criminal investigation. We reviewed 30 social science research papers on cognitive biases in criminal case evaluations (i.e., integrating and drawing conclusions based on the totality of the evidence in a criminal case), 18 of which were based on police participants or an examination of police documents. Only two of these police participant studies were done in the USA, with the remainder conducted in various European countries. The studies provide supporting evidence that lay people and law enforcement professionals alike are vulnerable to confirmation bias, and there are other environmental, individual, and case-specific factors that may exacerbate this risk. Six studies described or evaluated the efficacy of intervention strategies, with varying evidence of success. Further research, particularly in the USA, is needed to evaluate different approaches to protect criminal investigations from cognitive biases.

Cites: Doyle JM (2012) Learning about learning from error. Police Foundation 14:1–16

Doyle JM (2014) NIJ’s sentinel events initiative: looking back to look forward. National Institute of Justice Journal 273:10–14. https://www.ncjrs.gov/pdffiles1/nij/244144.pdf
DA  - 2021/06/23/
PY  - 2021
DO  - 10.1007/s11896-020-09425-8
DP  - Springer Link
J2  - J Police Crim Psych
LA  - en
SN  - 1936-6469
ST  - Cognitive Biases in Criminal Case Evaluation
UR  - https://doi.org/10.1007/s11896-020-09425-8
Y2  - 2021/07/22/14:00:35
ER  - 

TY  - JOUR
TI  - Thirty Years of Innocence: Wrongful Convictions and Exonerations in the United States, 1989-2018
AU  - Norris, Robert J.
AU  - Acker, James R.
AU  - Bonventre, Catherine L.
AU  - Redlich, Allison D.
T2  - Wrongful Conviction Law Review (WCLR)
DA  - 2020///
PY  - 2020
DP  - HeinOnline
VL  - 1
IS  - 1
SP  - 2
EP  - 58
J2  - Wrongful Conv. L. Rev.
LA  - eng
ST  - Thirty Years of Innocence
UR  - https://heinonline.org/HOL/P?h=hein.journals/wclr1&i=5
Y2  - 2021/07/22/14:05:18
KW  - criminal justice
ER  - 

TY  - JOUR
TI  - Notification for Victims of Assault (NoVA): A Guide for Communities with Untested Sexual Assault Kits
AU  - Busch-Armendariz, Noël
AU  - Sulley, Caitlin
AU  - Hoefer, Sharon
AU  - Backes, Bethany
AU  - Dempster, Mariel
AU  - Thompson, Jennifer
AB  - This document is a comprehensive guide about sexual assault kit (SAK) testing and the
resulting need for victim notification regarding the forensic results or details on the
progression of a case. This guide addresses the need for a coordinated community response
to re-engage victims after testing unrequested or untested SAKs using trauma-informed,
victim-centered protocols, and to build effective practices moving forward. The key to
creating this lasting change is to build multidisciplinary engagement and collaboration. This
resource is to be used in conjunction with state and federal statutes about confidentiality, as
well as other resources, to seek the most expedient justice in sexual assault cases. We have
distilled best practices and current science into a comprehensive guide and procedures called
the NoVA Change Process. The NoVA Change Process is empirically based and describes the
steps for victim notification to be undertaken through a coordinated community response.
DA  - 2019/08//
PY  - 2019
DO  - http://dx.doi.org/10.26153/tsw/3227
DP  - repositories.lib.utexas.edu
LA  - eng
ST  - Notification for Victims of Assault (NoVA)
UR  - https://repositories.lib.utexas.edu/handle/2152/76138
Y2  - 2021/07/22/14:47:42
ER  - 

TY  - NEWS
TI  - Wrongful Convictions: The Grisham Effect
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Novelist John Grisham is an outspoken critic of the miscarriages of justice that put innocent people in jail. But his most valuable contribution, from a reformer’s perspective, has been to show the connection between the mistakes made by individuals and the system that nurtures them, says our legal affairs columnist.
DA  - 2019/11/04/T13:00:59+00:00
PY  - 2019
LA  - en-US
ST  - Wrongful Convictions
UR  - https://thecrimereport.org/2019/11/04/wrongful-convictions-the-grisham-effect/
Y2  - 2021/07/22/18:22:14
ER  - 

TY  - JOUR
TI  - Toward a cost–benefit analysis of quality programs in digital forensic laboratories in the United States
AU  - Hughes, Nicolas
AU  - Ziemak, Erika
AU  - Martinez, Carisa
AU  - Stout, Peter
T2  - Wiley Interdisciplinary Reviews: Forensic Science
DA  - 2021///
PY  - 2021
SP  - e1422
J2  - Wiley Interdisciplinary Reviews: Forensic Science
SN  - 2573-9468
ER  - 

TY  - CHAP
TI  - Managing Violent Offenders in the Community
AU  - Serin, Ralph C.
AU  - Lowenkamp, Christopher T.
AU  - Lloyd, Caleb D.
T2  - The Wiley Handbook of What Works in Violence Risk Management
AB  - The community has substantial concerns regarding the risk posed by violent offenders, especially those recently released from prison. This chapter highlights recent work intended to refine risk assessment to include more acute dynamic risk factors to inform risk re-assessment and reviews case and risk management strategies specific to non-sexually violent offenders, with a view towards improved identification and management of violent offenders. It considers which offenders warrant more intensive community supervision, what appropriate strategies should be applied to mitigate risk of harm to the public, and when such strategies might be optimally applied. Case planning is often considered at the start of supervision. Commonly, a risk and need assessment is completed and the identification of criminogenic needs drives referrals for intervention. Essentially, the case plan is a roadmap designed to chart the expected path the offender will successfully navigate to exit the criminal justice system.
DA  - 2020///
PY  - 2020
DP  - Wiley Online Library
SP  - 543
EP  - 558
LA  - en
PB  - John Wiley & Sons, Ltd
SN  - 978-1-119-31593-3
UR  - https://onlinelibrary.wiley.com/doi/abs/10.1002/9781119315933.ch28
Y2  - 2021/08/20/14:21:05
KW  - community supervision
KW  - case plan
KW  - criminogenic need
KW  - non-sexually violent offenders management
KW  - risk assessment strategies
ER  - 

TY  - JOUR
TI  - Lessons Learned from a Decade of Reform and a Season of Protest: An Enterprise Risk Management Approach to Officer Wellness & Early Intervention
AU  - Boatright, Rebecca
AU  - Fisher, Christopher
AU  - Atherley, Loren
T2  - Criminology, Criminal Justice, Law & Society
AB  - It is unlikely the day-to-day response of a
functional ERM would have changed the events of
2020 without substantial enhancement beyond the
scope of this paper. The follow-up, modelled on an
evolved After Action Review type response (i.e.,
Sentinel Event Review), functions for strategic decision-making much the way ERM might guide
strategic development and continuous improvement.
DA  - 2021///
PY  - 2021
VL  - 22
IS  - 2
SP  - 50
EP  - 59
J2  - Criminology, Criminal Justice, Law & Society
ER  - 

TY  - CHAP
TI  - Wrongful Convictions and the Culture of Denial
AU  - Johnson, David T.
T2  - The Culture of Capital Punishment in Japan
A2  - Johnson, David T.
T3  - Palgrave Advances in Criminology and Criminal Justice in Asia
AB  - On the surface, it appears the United States has a more serious problem with wrongful convictions than Japan, for it has uncovered many more cases of this kind. Yet this gap is probably more apparent than real, for Japan does a poor job of discovering wrongful convictions. To reduce the problem of wrongful convictions in Japanese criminal justice and capital punishment, reformers must make structural reforms, but they must also confront a “culture of denial” (hitei no bunka) that makes it difficult to acknowledge mistakes.
CY  - Cham
DA  - 2020///
PY  - 2020
DP  - Springer Link
SP  - 61
EP  - 80
LA  - en
PB  - Springer International Publishing
SN  - 978-3-030-32086-7
UR  - https://doi.org/10.1007/978-3-030-32086-7_4
Y2  - 2021/08/20/15:23:56
KW  - Miscarriage of justice
KW  - Structural reform
KW  - Wrongful conviction
KW  - Culture of denial
KW  - Hakamada Iwao
ER  - 

TY  - JOUR
TI  - Body-worn cameras' effects on police officers and citizen behavior: A systematic review
AU  - Lum, Cynthia
AU  - Koper, Christopher S.
AU  - Wilson, David B.
AU  - Stoltz, Megan
AU  - Goodier, Michael
AU  - Eggins, Elizabeth
AU  - Higginson, Angela
AU  - Mazerolle, Lorraine
T2  - Campbell Systematic Reviews
AB  - Librarian note: Does not cite NIJ SEI, shares terminology.  
aw enforcement agencies have rapidly adopted BWCs in the last decade with the hope that they might improve police conduct, accountability, and transparency, especially regarding use of force. Overall, there remains substantial uncertainty about whether BWCs can reduce officer use of force, but the variation in effects suggests there may be conditions in which BWC could be effective. BWCs also do not seem to affect other police and citizen behaviors in a consistent manner, including officers’ self‐initiated activities or arrest behaviors, dispatched calls for service, or assaults and resistance against police officers. BWCs can reduce the number of citizen complaints against police officers, but it is unclear whether this finding signals an improvement in the quality of police–citizen interactions or a change in reporting. Research has not directly addressed whether BWCs can strengthen police accountability systems or police–citizen relationships.
DA  - 2020/09/01/
PY  - 2020
DP  - eprints.qut.edu.au
VL  - 16
IS  - 3
SP  - Article
EP  - number: e1112
LA  - en
SN  - 1891-1803
ST  - Body-worn cameras' effects on police officers and citizen behavior
UR  - https://eprints.qut.edu.au/205611/
Y2  - 2021/08/20/15:37:06
ER  - 

TY  - RPRT
TI  - Jail-Specific Data Analysis: Considerations for Jail Analysts
AU  - Chakraborty, Reena
AB  - ...If a jail wishes
to establish a routine program to examine
and learn from significant incidents and
near misses, often called sentinel event
reviews, regularly providing these data can
greatly facilitate the process.
CY  - Washington, DC
DA  - 2020/10//
PY  - 2020
PB  - National Institute of Justice
ER  - 

TY  - JOUR
TI  - The Prosecutor as a Final Safeguard Against False Convictions
AU  - Webster, Elizabeth H
T2  - Journal of Criminal Law and Criminology
AB  - Legal scholars have devoted significant scholarly attention to
explaining why prosecutors reject postconviction evidence of innocence.'
Indeed, some prosecutors have appealed postconviction defense motions
exhaustively-even in the face of forensic evidence of innocence-rather
than acknowledge a factual error.2 Yet, recent years have seen an undeniable
shift. Prosecutors have always had the authority, the ethical obligation, and
the investigative tools to identify false convictions. 3 Now it seems that some
have the political will to remedy them as well. As of 2018, the National Registry of Exonerations (NRE) reported that a total of 344 exonerations had
been achieved with the assistance of Conviction Integrity Unit prosecutors. 4
Conviction Integrity Units (CIUs), also commonly known as Conviction
Review Units (CRUs) among other titles, investigate claims of innocence and
wrongful conviction claims through a separate unit in the chief attorney's
office.5 The rapid emergence of CIUsj and the hundreds of exonerations
that have followed, demonstrate this shift.
DA  - 2020///
PY  - 2020
VL  - 110
IS  - 2
J2  - Journal of Criminal Law and Criminology
ER  - 

TY  - JOUR
TI  - Applying the STAMP Safety Model to Prevent False Convictions Based on Eyewitness Misidentifications
AU  - Sangero, Boaz
T2  - Alb. L. Rev.
AB  - In many criminal law systems, eyewitness identification of a
suspect is sufficient to establish that they are the perpetrator of the
crime in question, without any need for additional corroborating
evidence. But this lofty legal status stands in contrast to the
undisputed assertion in the professional literature that an
erroneous eyewitness identification is far from rare, with many
scholars holding it to be the most common cause of false convictions.
On this background, this Article offers ways of reducing the rate of
false convictions based on eyewitness misidentifications. The
Article argues for the creation and application of a safety theory in
the criminal justice system, specifically regarding eyewitness
identifications. Therefore, after the Article connects between the
modern theory of safety, which is well developed in other areas of
our life, and the new theory of safety from false convictions; and
after a deep discussion of one of the most serious hazards in
criminal law––the hazard of false convictions based on eyewitness
misidentifications––a specific safety model shall be developed,
based on these discussions and on the innovative STAMP safety
model. The substance of the suggested rules is based on both the
psychological research and the legal literature. The high rate of
false convictions is not an inevitable fate.
DA  - 2019///
PY  - 2019
VL  - 83
SP  - 931
J2  - Alb. L. Rev.
ER  - 

TY  - ELEC
TI  - Sentinel Events: A Sustainable Model for System Change
AU  - National Institute of Justice
T2  - National Institute of Justice
AB  - The proposed study seeks to implement sentinel review processes in three jurisdictions and to study the feasibility and utility of employing sentinel reviews in criminal justice settings. The study builds on review processes already in existence in three cities (Detroit, Indianapolis, and Milwaukee). Specifically, gun homicide (GH) and non-fatal shooting (NFS) reviews occur in these three cities with the goal of developing data-driven gun violence prevention and control strategies.
DA  - 2015///
PY  - 2015
LA  - en
ST  - Sentinel Events
UR  - https://nij.ojp.gov/funding/awards/2015-r2-cx-k041
Y2  - 2021/10/01/16:18:29
ER  - 

TY  - JOUR
TI  - The Case for Studying Criminal Nonfatal Shootings: Evidence from Four Midwest Cities
AU  - Hipple, Natalie Kroovand
AU  - Huebner, Beth M.
AU  - Lentz, Theodore S.
AU  - McGarrell, Edmund F.
AU  - O'Brien, Mallory
T2  - Justice Evaluation Journal
AB  - Using law enforcement data from four Midwest communities, we document the similarities and differences between criminal nonfatal and fatal shooting incidents, including the spatial dimensions of the events. We present a definition for a nonfatal shooting incident that guides our victim and incident characteristic comparisons. Our work suggests that law enforcement agencies should build capacity for standardized data collection surrounding gun violence to include nonfatal shootings especially for use in evaluations of gun violence prevention strategies.
DA  - 2020/01/02/
PY  - 2020
DO  - 10.1080/24751979.2019.1689152
DP  - Taylor and Francis+NEJM
VL  - 3
IS  - 1
SP  - 94
EP  - 113
SN  - 2475-1979
ST  - The Case for Studying Criminal Nonfatal Shootings
UR  - https://doi.org/10.1080/24751979.2019.1689152
Y2  - 2021/10/01/17:30:51
KW  - Gun violence
KW  - gun crime
KW  - community characteristics
KW  - nonfatal shootings
KW  - spatial data analysis
ER  - 

TY  - ELEC
TI  - #144 To Blame or to Learn? Sentinel Event Reviews of Police Action
AU  - Harris, David
T2  - Criminal Injustice
AB  - When something goes catastrophically wrong with a police action, we ask whose fault it was. Who made the mistake? Focusing on who’s to blame is a key question for justice. But what if we want to prevent similar errors going forward? How do we fix the system that allowed the mistake to happen?
DA  - 2021/10/05/
PY  - 2021
LA  - en-US
ST  - #144 To Blame or to Learn?
UR  - http://www.criminalinjusticepodcast.com/blog/2021/10/05/144-to-blame-or-to-learn
Y2  - 2021/10/05/18:34:25
ER  - 

TY  - ELEC
TI  - What Responsibility Do Courts Bear for the Crisis at Rikers Island? | The New Yorker
AU  - Doyle, James M.
T2  - The Crime Report
DA  - 2021/10/09/
PY  - 2021
UR  - https://www.newyorker.com/news/our-local-correspondents/what-responsibility-do-courts-bear-for-the-crisis-at-rikers-island
Y2  - 2021/10/12/15:06:54
ER  - 

TY  - RPRT
TI  - Madison Police Department Sentinel Event Review (SER) of the Department’s Responses to 2020 Protests of Police
AU  - Quattrone Center for Fair Administration of Justice
CY  - University of Pennslyvania
DA  - 2021/11//
PY  - 2021
SP  - 132
PB  - Quattrone Center for the Fair Administration of Justice
UR  - https://www.cityofmadison.com/police/documents/SentinelReport20211116.pdf
ER  - 

TY  - ELEC
TI  - Sentinel Event Review Board (SERB)
AU  - City of Tucson,
AB  - "Sentinels stand watch," says James Doyle, founding Director of the Center for Modern Forensic Practice at John Jay College of Criminal Justice. "They detect the first signs of a looming threat and sound a warning that should not be ignored." When bad things happen in a complex system, such as the larger policing environment, the cause is rarely a single act or event. More often, bad outcomes are "sentinel events." Sentinel events are events with significant negative outcomes that: Signal underlying weaknesses in the system. Are likely the result of multiple or compound contributing factors.
DA  - 2020/09/18/T15:12:01-07:00
PY  - 2020
LA  - en
UR  - https://www.tucsonaz.gov/police/critical-incident-review/sentinel-event-review-board-serb
Y2  - 2021/12/02/19:24:23
ER  - 

TY  - ELEC
TI  - Sentinel Event Review Board
AU  - Office of Inspector General
T2  - City of Seattle
AB  - entinel events can occur as result of Seattle Police Department (SPD) interactions with the public. Examples of SPD sentinel events include officer-involved shootings, mass use of chemical weapons during protests, fatal vehicle pursuits, and other incidents that negatively impact individual safety, community well-being, and public trust in SPD.

Our Sentinel Event Review (SER) is a community inclusive accountability program led by the Office of Inspector General (OIG). A SER panel will review "critical incidents," looking at SPD systems to determine how they can avoid future harmful outcomes and better serve the community. This work is different from that of the Office of Police Accountability, which investigates allegations of individual police employee misconduct. SER is not focused on individual actions or assigning blame, but strengthening system fail-safes to prevent harm. SER aims to identify the causes and contributing factors to these incidents with the goal of prevention. The principles and goals of these reviews are:
UR  - https://www.seattle.gov/oig/sentinel-event-review
Y2  - 2021/12/02/19:28:16
ER  - 

TY  - ELEC
TI  - Seattle Sentinel Event Review
AU  - Seattle Office of the Inspector General
AB  - What is the Seattle Sentinel Event Review?

Sentinel events can occur as result of Seattle Police Department (SPD) interactions with the public. Examples of SPD sentinel events include officer-involved shootings, mass use of chemical weapons during protests, fatal vehicle pursuits, and other incidents that negatively impact individual safety, community well-being, and public trust in SPD.

Our Sentinel Event Review (SER) is a community inclusive accountability program led by the Office of Inspector General (OIG). A SER panel will review "critical incidents," looking at SPD systems to determine how they can avoid future harmful outcomes and better serve the community. This work is different from that of the Office of Police Accountability, which investigates allegations of individual police employee misconduct. SER is not focused on individual actions or assigning blame, but strengthening system fail-safes to prevent harm. SER aims to identify the causes and contributing factors to these incidents with the goal of prevention. The principles and goals of these reviews are:
UR  - https://www.seattle.gov/oig/sentinel-event-review
Y2  - 2021/12/02/19:29:50
ER  - 

TY  - RPRT
TI  - Report on the conviction of Jeffrey Deskovic
AU  - Snyder, L., McQuillan, P., Murphy, J., and Joleson, R. (
CY  - Westchester, New York
DA  - 2007///
PY  - 2007
PB  - Westchester County District Attorney’s Office
UR  - https://antipolygraph.org/yabbfiles/Attachments/Jeffrey_Deskovic_Comm_Rpt.pdf
ER  - 

TY  - RPRT
TI  - “Comprehensive Operational Assessment, Criminal Investigative Unit, Sheriff’s Office, Will County, Illinoi
AU  - Andrews International Group
DA  - 2010///
PY  - 2010
LA  - en
UR  - https://www.scribd.com/doc/47496706/Andrews-Report
Y2  - 2021/12/02/21:48:22
ER  - 

TY  - RPRT
TI  - “Missed Opportunities, Shared Responsibilities: The Final Report of the Cambridge Review Commission
AU  - Cambridge Review Commission
CY  - Cambridge, MA
DA  - 2010///
PY  - 2010
PB  - Cambridge Review Commission
UR  - https://www2.cambridgema.gov/CityOfCambridge_Content/documents/Cambridge%20Review_FINAL.pdf
ER  - 

TY  - RPRT
TI  - How Case Reviews Transformed Allegheny County’s Criminal Justice System
AU  - Barron, Bruce
AB  - In retrospect, the idea of holding criminal justice case reviews may look like a stroke of
genius, but it started as an act of desperation proposed by Erin Dalton, Deputy Director
for Data Analysis, Research, and Evaluation at Allegheny County’s Department of Human
Services (DHS).
Allegheny County had been chosen as one of the first three U.S. counties in a “justice
reinvestment” project funded by the U.S. D epartment of Justice’s Bureau of Justice Assistance
and guided by the Urban Institute. The concept was to examine criminal justice processes
looking for ways to save money (for example, by shortening the time that defendants spend
2
in the county jail a waiting trial) that could then be reinvested in activities, like pre-discharge
counseling and community support, that reduce recidivism rates.
Unfortunately, the project wasn’t going very far, because of difficulties in interpreting the
available raw data so as to yield useful insights. Dalton could not come up with key figures
like the average length of time spent in jail before trial, or how probation detainers impact
the time to case disposition.
Lacking sufficiently useful quantitative data, Dalton proposed a qualitative alternative:
looking intensively at a small number of illustrative cases to see what they might tell
reviewers about the system’s operation and its weaknesses. DHS was already using this
approach to improve its child welfare services.
CY  - Pittsburgh, Pennsylvania
DA  - 2011/09/01/
PY  - 2011
PB  - Allegheny County Analytics
UR  - https://www.alleghenycountyanalytics.us/index.php/2011/09/01/how-case-reviews-transformed-allegheny-countys-criminal-justice-system/
ER  - 

TY  - RPRT
TI  - Developing the capacity to understand and prevent homicide: An evaluation of the Milwaukee Homicide Review Commission
AU  - Azrael, Deborah
AU  - Braga, AA
AU  - O’Brien, ME
AB  - A distinguishing feature of the MHRC is its inclusion of community agencies and leaders outside of the traditional criminal justice system. The evaluation examined MHRC's work from January 2005 through December 2007. Overall, the homicide review process found that homicide in the city's intervention districts were largely clustered in specific locations, such as in and around taverns, as well as in districts with concentrations of active offenders who had been involved in the criminal justice system. Homicides were often the outcome of persistent disputes between individuals and/or groups (usually gangs). Homicides were often committed to gain respect and status among peers who valued fearless displays of power and control over others, as well as to inflict retribution on those showing disrespect and confrontational interactions. Generally, the MHRC decisionmaking and actions produced a comprehensive set of actionable policy and practice recommendations whose implementation and effects were continuously monitored by the MHRC. MHRC actions were intended to better position criminal justice, social service, and community based organizations in addressing the violence-related factors in high-risk locations and high-risk individuals with a propensity for violence. The impact evaluation found that the implementation of the MHRC interventions was linked with a statistically significant 52-percent decrease in the monthly count of homicides in the treatment districts. In comparison, the control districts had a statistically insignificant 9.2- percent decrease in homicides, after controlling for the other covariates. Apparently, the MHRC's crafting of interventions designed to address underlying risks associated with homicides has had a significant impact in reducing incidents of lethal violence. 6 tables, 1 figure, 57 references, and appended evaluation instruments
DA  - 2019///
PY  - 2019
SP  - 95
PB  - National Institute of Justice Grant Report.
UR  - https://www.ojp.gov/pdffiles1/nij/grants/240814.pdf
ER  - 

TY  - CONF
TI  - Milwaukee Sexual Assault Review: A Public Health Approach to Sexual Assault Prevention in Milwaukee
AU  - Emer, Lindsay
AU  - O'Brien, Mallory
AU  - Jackson-Obregon, Aimee
T2  - APHA 2016 Annual Meeting & Expo (Oct. 29-Nov. 2, 2016)
AB  - Milwaukee has experienced a 33% increase in the number of reported rapes since 2010. In response to this
growing problem, Aurora Health Care and the Milwaukee Homicide Review Commission spearheaded a
multidisciplinary collaboration called the Milwaukee Sexual Assault Review (MSAR). This presentation shares
lessons learned from employing an innovative, evidence-based public health approach to sexual assault
prevention in Milwaukee from 2015 to present. Partners from law enforcement, state and local criminal justice
agencies, health care representatives and community service providers meet regularly to review sexual assault
cases, exchange information, and make actionable recommendations based on trends in sexual assault identified
in the review. The reviews are patterned after the Milwaukee Homicide Review, which was rated “Effective” for
homicide reduction by CrimeSolutions.Gov. MSAR is creating and advancing a broad spectrum of
recommendations that range from micro-level, case-specific strategies to macro-level, policy changes. In
collaboration with the Milwaukee Police Department, Milwaukee County District Attorney's Office and the Aurora
Health Care Sexual Assault Treatment Center, a multisector data collection and reporting system is being
developed to track sexual assaults and enable data-driven sexual assault prevention recommendations. Sexual
assault is one of the most underreported crimes, making prevention challenging. MSAR provides the opportunity
to build a multidisciplinary response aimed at preventing future sexual assaults from occurring, improving abuse
response services for victims, expediting sexual assault suspect arrests, and advancing the prosecution of sexual
assault offenders in Milwaukee.
DA  - 2016///
PY  - 2016
PB  - American Public Health Association
ER  - 

TY  - BOOK
TI  - Engaging communities in reducing gun violence
AU  - Bieler, Sam
AU  - Kijakazi, Kilolo
AU  - La Vigne, Nancy
AU  - Vinik, Nina
AU  - Overton, Spencer
AB  - In an effort to learn what could be done better, we decided to ask people from communities directly
impacted by gun violence. We convened more than 100 community members in three diverse American
cities—Richmond, Virginia, Milwaukee, Wisconsin, and Stockton, California. The convenings included
faith leaders, law enforcement, social service providers, formerly incarcerated individuals, elected
officials, and other community members. Our goal was to hear directly from communities about the
factors driving gun violence and about actionable policy strategies to make their neighborhoods safer.
We learned that gun violence is a multifaceted challenge that demands a holistic set of solutions. In
communities of color, gun violence is interconnected with issues of policing and prosecution,
disinvestment, and marginalization of community voices. Limiting access to deadly weapons must be
part of the solution, but it’s not the only part. Improving police-community relations and enhancing law
enforcement accountability, investing in community-based supports, and creating opportunities for the
community to engage in violence prevention are critical in a comprehensive approach to reducing gun
violence in communities of color.
DA  - 2016///
PY  - 2016
PB  - Washington, DC: Urban Institute
UR  - https://www.urban.org/research/publication/engaging-communities-reducing-gun-violence-road-map-safer-communities
ER  - 

TY  - ELEC
TI  - Let's Reopen America's Courts, But Send the Pundits Home
AU  - Doyle James M.
T2  - The Crime Report
AB  - The national discussion following two recent high-profile trials―the Kyle Rittenhouse and Ahmaud Arbery cases―was once again dominated by sound-byte commentary. It’s one reason Americans know very little about how the justice system operates. Much of what they think they know is wrong, says TCR's legal affairs columnist.
DA  - 2021/12/06/T12:30:46+00:00
PY  - 2021
LA  - en-US
UR  - https://thecrimereport.org/2021/12/06/lets-reopen-american-trials-but-send-the-pundits-home/
Y2  - 2021/12/06/19:29:55
ER  - 

TY  - ELEC
TI  - The Value of Sentinel Event Reviews in Police Use-of-Force Cases
AU  - ASU Criminal Justice News
T2  - Crime and Justice News
AB  - Thanks to the American Arbitration Association's (AAA) generous grant and partnership, Arizona State University (ASU) has the opportunity to put this process to the test. With the goal of nationwide SERs' incorporation into the justice system, the AAA has put faith in ASU. 

In the meantime, ASU has been focusing on bringing together statewide law enforcement bodies, including tribal police, to participate in the SERs.

The use of force reviews began by putting together n independent panel comprised of members of the community, specialists in relevant fields, and academics. ASU's Academ for Justice and the University of Pennsylvania's Quattrone Center have facilitated the process.

Finally, law enforcement officers with varied backgrounds and ranks come to the panel voluntarily with a good faith interest in better serving the community they risk their lives to protect.

This diverse team of people work together to solve the problems dividing our community and police force.

The key component of the SER system is forward thinking. Most participants agree that there is a time and place for discipline, and sometimes legal consequences for the actions
of parties involved. This is not that place.
DA  - 2021/12/08/T07:23:00-07:00
PY  - 2021
LA  - en
Y2  - 2021/12/09/15:34:14
ER  - 

TY  - RPRT
TI  - Detailing Overdose Fatality Reviews: A Coordinated, Multi-agency Response
AU  - Wisconsin Department of Health Services
AU  - Wisconsin Department of Justice
AB  - What are Overdose Fatality Reviews?
Overdose Fatality Review (OFR) is a locally-based, multi-disciplinary process for understanding
the risk factors and circumstances leading to fatal overdoses and identifying opportunities to
prevent future overdoses. The basis of OFR – like all fatality reviews – is that overdose fatalities
could have been prevented with the right action, timing, intervention, and/or response.
DA  - 2021/02//
PY  - 2021
UR  - https://www.dhs.wisconsin.gov/publications/p02550.pdf
ER  - 

TY  - RPRT
TI  - Annual Report 2020-2021
AU  - Winnebago County, Wisconsin Overdose Fatality Review
CY  - Winnebago County, Wisconsin
DA  - 2021///
PY  - 2021
PB  - Department of Health
UR  - https://www.co.winnebago.wi.us/sites/default/files/uploaded-files/2020_2021_winnebago_ofr_annual_report.pdf
Y2  - 2021/12/10/14:48:17
ER  - 

TY  - JOUR
TI  - Can we prevent deaths of homeless persons? Police led public health approach to prevent homeless deaths
AU  - Hipple, Natalie Kroovand
AU  - Shaefer, Sarah J. M.
AU  - Hipple, Robert F.
AU  - Ballew, Alfarena T.
T2  - Journal of Social Distress and the Homeless
AB  - Research on homeless populations demonstrates that homelessness in itself is an independent risk factor for death. However, there is a dearth of detailed data on homeless decedents and the situations surrounding their deaths. This lack of knowledge, a desire to understand how and why homeless individuals were dying, and a sentinel event death led the Indianapolis Metropolitan Police Department Homelessness and Panhandling Unit to partner with a local researcher and begin conducting homeless death reviews. The approach is modeled after the evidence-based, public health approach of the Fetal and Infant Mortality Review process (FIMR). The FIMR model is a systematic approach to understanding system gaps and obtaining insights into the factors that resulted in homelessness and ultimately death. This article reports on the process to develop this unique multi-agency, police-led review of homeless deaths in Indianapolis, Indiana and resulting recommendations for action to decrease these deaths.
DA  - 2016///
PY  - 2016
DO  - 10.1080/10530789.2016.1240950
DP  - Dimensions
VL  - 25
IS  - 2
SP  - 78
EP  - 85
ST  - Can we prevent deaths of homeless persons?
N1  - <p>https://scholarworks.iu.edu/dspace/bitstream/2022/21114/1/SDH%20128%20Manuscript_VoR_PostPrint.pdf</p>
ER  - 

TY  - NEWS
TI  - When it comes to bad-apple cops, look at the whole tree; It's not enough to release James Lucien from prison. We have to prevent more wrongful convictions like his. That means taking a big-picture approach. You're up, Mayor Wu.
AU  - Abrahams, Yvonne
T2  - Boston Globe
AB  - Veteran defense attorney James Doyle is an evangelist for this big-picture approach: "Even after you exorcise Jack Brazil or George Foley, you're still left with the conditions and influences that made them do what they did, which made sure nobody caught them," he said.

Preventing future disasters means not just looking back, but forward too. It's been more than two decades since these detectives did their worst, but we need to know how much has truly changed.

Doyle's proposal: What if we got all of the major players together — representatives of the police, prosecutors, the courts, defense attorneys, and the community, among others — and really looked at what went wrong in Lucien's case, and what they could change so that more future cases go right? By all means, let's identify the obvious villains. But so much more than Brazil had to go wrong here. His corruption had to be an open secret in the department. Why was he invincible for so long? Why did Foley's superiors give him the benefit of the doubt? Why did the prosecutors and judges make the decisions they did? Most importantly: Could this happen again?
DA  - 2021/12/12/
PY  - 2021
UR  - https://plus.lexis.com/document/?pdmfid=1530671&crid=fce46438-0e05-4a62-bd03-b716f83f6ba8&pddocfullpath=%2Fshared%2Fdocument%2Fnews%2Furn%3AcontentItem%3A648X-G4W1-F072-J00Y-00000-00&pdcontentcomponentid=8110&pdteaserkey=&pdislpamode=false&ecomp=tf4k&earg=sr0&prid=7fa96108-d8b8-4b5c-aac4-7451711c3714
Y2  - 2021/12/13/17:22:29
ER  - 

TY  - RPRT
TI  - Hidden Hazards: Prosecutorial Misconduct Claims in Pennsylvania, 2000 - 2016
AU  - Quattrone Center for Fair Administration of Justice
AB  - In an effort to learn more about allegations of prosecutorial
misconduct in Pennsylvania, the Quattrone Center sought
to collect and analyze all judicial opinions from federal and
state courts in Pennsylvania published between 2000 and
2016 in which either the phrase “prosecutorial misconduct”
or the citation “Brady v. Maryland” appeared. We identified
4,644 opinions in which allegations of misconduct were
raised. Each opinion was carefully read and analyzed to understand how many claims of prosecutorial misconduct
were raised, what types of misconduct were raised, how often courts decided them on their merits, and how often
misconduct was found.

Cites Mending Justice 

https://groups.google.com/d/msgid/criminal-justice-sentinel-events/be721db1-f9c6-4d64-9092-450516cce799n%40googlegroups.com
CY  - University of Pennslyvania
DA  - 2017///
PY  - 2017
SP  - 87
PB  - Quattrone Center for the Fair Administration of Justice
UR  - https://www.law.upenn.edu/institutes/quattronecenter/reports/hidden-hazards.php?fbclid=IwAR3Y-SlqebjSKzcOTFXzrTllogyEjGj22NRcd8Uo5IIs-nL5dBwI0ieRQcY
ER  - 

TY  - JOUR
TI  - Safety in Forensic Science
AU  - Sangero, Boaz
T2  - Ohio State Law Journal
AB  - Using DNA comparisons, the Innocence Project has shown that people
are occasionally convicted based on flawed forensic science evidence.
A National Academy of Sciences (NAS) report determined many areas
of forensic science lack sufficient scientific foundation, and the forensic
science system does not function properly and must undergo significant
changes. These changes should stem from interdisciplinary thinking, a
combination of current scientific knowledge, NAS recommendations,
and the law, together with advanced safety methods. To minimize the
injustice of false convictions based on flawed forensic science evidence,
this Article recommends applying the Systems-Theoretic Accident
Model and Process (STAMP) safety model to forensic science evidence and using it in the criminal justice system in general. The Article
provides detailed implementation suggestions.

visit https://groups.google.com/d/msgid/criminal-justice-sentinel-events/4aa684a4-1021-4fe4-9525-627c5e39f5b0n%40googlegroups.com
DA  - 2021///
PY  - 2021
VL  - 82
SP  - 221-
UR  - https://moritzlaw.osu.edu/sites/default/files/2021-12/Online%20Vol%2082%20-%20Sangero%20%20Final%20Format.pdf
ER  - 

TY  - RPRT
TI  - Sentinel Events: A Sustainable Model for System Change – Draft Final Summary Report Overview
AU  - MCGARRELL, EDMUND F.
AU  - Kroovand, Natalie
AU  - O'Brien, Mallory
AU  - Kostelac, Constance
AB  - The SE reviews occurred in distinctive but related processes in the Midwestern cities of Detroit, Indianapolis, and Milwaukee. In Detroit, the basis of the sentinel event (SE) reviews was weekly incident analysis of firearm crime incidents to inform the deterrence of violence. In Indianapolis, SE reviews focused on analyses of non-fatal shootings. In Milwaukee, SE reviews focused on homicides, non-fatal shootings, and incidents of domestic violence. In all three sites, the SE reviews were based on existing review processes that were extended into more in-depth reviews customized to each local circumstance. The study design of SE reviews was a participant-observer protocol whereby members of the research team facilitated the SE reviews through planning and consultation, problem-solving, analytical support, and observation of the reviews. Toward the end of the study, the research team conducted key informant interviews that focused on practitioner perceptions of the SE reviews. The challenges and obstacles to implementing SE reviews, their benefits, and the customization of the reviews to meet local needs were the issues addressed in the interviews. In all three cities, the systematic review of gun crimes resulted in the identification of issues for which a deeper analysis through SE reviews provided valuable information. Also, in all three sites, the reviews provided information and facilitated shared understanding of system and process failures. Further, in all three cities, examples of corrective action emerged. In addition to the benefits of SE reviews, the analysis also identified barriers and challenges to the effective implementation of SE reviews in a criminal justice context. These are outlined. A listing of scholarly products produced or in process is provided.
DA  - 2021/12//
PY  - 2021
PB  - Michigan State University Address
UR  - https://www.ojp.gov/pdffiles1/nij/grants/303608.pdf
ER  - 

TY  - ELEC
TI  - Why the Bill for Miscarriages of Justice Should be Shared by All of Us
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Some 99.98 percent of the money paid out for police misconduct in civil rights cases comes from public funds, not from the wallets of individual cops. It’s money well spent if it helps prevent future tragedies, writes TCR’s legal affairs columnist.
DA  - 2022/01/19/T12:30:20+00:00
PY  - 2022
LA  - en-US
UR  - https://thecrimereport.org/2022/01/19/why-the-bill-for-miscarriages-of-justice-should-be-shared-by-all-of-us/
Y2  - 2022/01/21/17:44:20
ER  - 

TY  - RPRT
TI  - PRECISION POLICING 2.0: A FRAMEWORK FOR THE FUTURE OF POLICING
AU  - Haberman, Cory
AU  - Bratton, William
AU  - Murad, Jon
AU  - Rawlins, Wayne
AB  - Sentinel Event Reviews
Sentinel event reviews (SER) are another useful way of thinking about how police departments can
improve transparency (Browning et al., 2015). But SER are not necessarily about accountability in a
traditional sense. SER start with the idea that sometimes complex events end with bad outcomes –
sentinel events. Bad outcomes are not always “somebody’s fault”, however, and may be just the result of
a series of unfortunate events within a flawed system. Now policing is high-stakes and high-risk work –
after all the job is to show up to some of the most serious and dangerous events in society – so bad
outcomes, like loss of life, should be taken very seriously but that does not mean somebody purposively
wanted a bad outcome to occur. As such, SER call for a working group to review what led to the bad
outcome, with a focus on system flaws, in order to learn from it and prevent it in the future. Reports from
SER can be used for continuous improvement and publishing SER reports is certainly an act of
transparency. Overall, the use of SER is a sign of a mature police agency that embodies continuous learning
by seeking to learn from past mistakes. 

https://groups.google.com/d/msgid/criminal-justice-sentinel-events/515cd681-addd-4922-a9b4-b05ab42b5a3bn%40googlegroups.com
CY  - University of Cincinnati
DA  - 2022///
PY  - 2022
SP  - 31
PB  - Institute of Crime Sciences
UR  - https://static1.squarespace.com/static/610d4c380caa60623d6cca72/t/61f7e6c7de9b6d39921e8c11/1643636424045/Precision+Policing+2.0+White+Paper.pdf
N1  - <p>Many U.S. cities have also used the offender-focused strategy “focused deterrence”, or what has been<br />recently rebranded as “group violence intervention” (GVI), but is probably best known as “Operation<br />CeaseFire” from its roots in Boston in the 1990s (Braga et al., 2001; Kennedy, 1997, 2011). </p>
<p> </p>
ER  - 

TY  - ELEC
TI  - Judge Jackson Can ‘Reset’ the Nation’s Conversation About Justice
AU  - Doyle, James M.
T2  - The Crime Report
AB  - If she is appointed to the Supreme Court, Ketanji Jackson Brown has the potential to challenge the sterile dialectic about the criminal legal system, writes TCR’s legal affairs columnist.
DA  - 2022/03/07/T12:30:14+00:00
PY  - 2022
LA  - en-US
UR  - https://thecrimereport.org/2022/03/07/judge-jackson-can-reset-the-nations-conversation-about-justice/
Y2  - 2022/03/07/16:53:20
ER  - 

TY  - NEWS
TI  - Opinion: Here’s why Biden should commute Dzhokhar Tsarnaev’s death sentence
AU  - Doyle James M.
T2  - Washington Post
DA  - 2022/03/08/
PY  - 2022
UR  - https://www.washingtonpost.com/opinions/2022/03/08/biden-commute-dzhokhar-tsarnaev-death-sentence/
ER  - 

TY  - JOUR
TI  - The Lawyers' Art: Representation in Capital Cases
AU  - Doyle, James M
T2  - Yale JL & Human.
DA  - 1996///
PY  - 1996
VL  - 8
SP  - 417
J2  - Yale JL & Human.
ER  - 

TY  - ELEC
TI  - The Unfinished Business of Felony Murder
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Eliminating the felony murder rule is only a first step in reforming a sentencing process that has destroyed hundreds of lives, says TCR’s legal affairs columnist.
...We need a functioning process not only for reviewing the cases of the “nearly two dozen” convicted first-degree felony murder prisoners cited by the Globe, but also for examining myriad sentences that were warped by the power imbalance created by simply charging felony murder.
DA  - 2022/04/06/T11:15:52+00:00
PY  - 2022
LA  - en-US
UR  - https://thecrimereport.org/2022/04/06/the-unfinished-business-of-felony-murder/
Y2  - 2022/04/06/15:40:34
ER  - 

TY  - RPRT
TI  - Guidelines for Collaboration and Engagement: Prosecutors and Defense Counsel Working Together in Joint Post-Conviction Investigations
AU  - Quattrone Center for Fair Administration of Justice
AB  - To try to provide some guidance to professionals
engaged in collaborative post-conviction investigations
the Quattrone Center gathered over 100 practitioners
together through four days of online meetings to produce
working guidelines. We met with defense counsel first,
and prosecutors second. We decided to hold separate
meetings to provide space where participants could
raise issues they felt could not be comfortably raised in
the presence of others. Defense lawyers were able to
frankly discuss their frustrations with prosecutors and
provide information they felt prosecutors need to know.
Prosecutors discussed their feelings of frustration and even
betrayed trust over past investigations that started out well
but turned sour. 

What emerged was a comprehensive set of Guidelines
for Collaboration and Engagement. Those who attended
the meetings were quick to point out that there is only so
far a nationally-aimed project like this can go; so much of
post-conviction investigation and litigation is driven by
local and state statutory or even ethics limitations. While
in some states, prosecutors can subpoena witnesses and
conduct depositions without pending active litigation, that
remains a pipe dream in others. Some states offer those
convicted of crimes they claim to have not committed
generous latitude to file petitions in court based upon
new evidence of innocence while others restrict the ability
to a single post-conviction petition


This project was supported by Grant No. 2018-FA-BX-K003 awarded by the Bureau of Justice Assistance. T
DA  - 2022/03//
PY  - 2022
SP  - 38
PB  - University of Pennsylvania
UR  - https://www.law.upenn.edu/live/files/12062-guidelines-for-collaboration-and-engagement
ER  - 

TY  - RPRT
TI  - Learning from Mistakes
AU  - Joe, Irene
AB  - Much of the attention following the reversal of a defendant’s wrongful conviction focuses on the role that police or prosecutors played in perpetuating the injustice. To the extent that a public defender’s role is considered, it is often limited to claims of ineffective assistance of counsel. This Article challenges the conventional wisdom that a public defender’s role in a wrongful conviction is limited to just their own ineffective practice during legal representation. It also interrogates the common understanding that the public defender’s duty to provide competent representation ends after a wrongfully convicted defendant is exonerated.Although every exoneration has its own unique facts and story, collectively they provide a lens in which to examine how public defenders reflect upon their own involvement in such miscarriages of justice. The medical, military, and aviation sectors have adopted sentinel event reviews to broadly examine the behaviors and actions that took part in any event that leads to loss of life or physical harm.  Perhaps due to its adversarial underpinnings, the criminal justice system has yet to adopt similar large-scale reviews. In the absence of an expansive review of how each component of the criminal process failed to uphold systemic integrity both separately and in concert, professional and ethical rules require the public defender to create one reviewing its own actions.The public defender assigned to a case has much to learn from a conviction’s reversal - whether the reversal occurred because a defense attorney fell short of their constitutional obligation, a prosecutor failed in their duty to perform as a minister of justice, or if unrealized evidence eventually shows that a defendant was convicted despite being factually innocent. After uncovering the inadequacy of the current methods public defenders rely on to identify and learn from these system failures, this project describes a more adequate reaction to these reversals.  This improved reaction would include more direct involvement by the trial attorneys in appellate work, greater action by public defender system leadership to address the official misconduct of other government actors, and a more formalized review by disciplinary boards of appellate reversals. By adopting such methods of review, the public defender would more clearly mirror other entities tasked with protecting the public from significant harm and reduce the systemic brittleness that permits repeat failures in the criminal justice system.
CY  - Rochester, NY
DA  - 2022/04/04/
PY  - 2022
DP  - papers.ssrn.com
LA  - en
M3  - SSRN Scholarly Paper
PB  - Social Science Research Network
SN  - ID 4075305
UR  - https://papers.ssrn.com/abstract=4075305
Y2  - 2022/04/15/19:41:50
KW  - criminal procedure
KW  - criminal law
KW  - legal ethics
KW  - poverty law
KW  - professional responsibility
ER  - 

TY  - ELEC
TI  - Who's to blame for wrongful convictions? Accountability demands more than finger-pointing.
AU  - Doyle, James M.
T2  - USA TODAY
AB  - Like a plane crash, a wrongful conviction is a system failure, an 'organizational accident.'
DA  - 2022/03/19/
PY  - 2022
LA  - en-US
ST  - Who's to blame for wrongful convictions?
UR  - https://www.usatoday.com/story/opinion/columnist/2022/03/19/wrongful-convictions-criminal-justice-accountability/7062303001/
Y2  - 2022/05/27/14:33:18
ER  - 

TY  - ELEC
TI  - The War On Innocence
AU  - Doyle, James M.
T2  - The Crime Report
AB  - In last week’s Shinn v Ramirez ruling, the Supreme Court dangerously accelerated the process of getting federal courts out of the business of enforcing rights, argues TCR’s legal columnist James Doyle.
DA  - 2022/05/31/T11:30:44+00:00
PY  - 2022
LA  - en-US
UR  - https://thecrimereport.org/2022/05/31/the-war-on-innocence/
Y2  - 2022/05/31/18:45:24
ER  - 

TY  - NEWS
TI  - Why We Need a National School Safety Board
AU  - Doyle, James M.
T2  - The Crime Report
AB  - The National Transportation Safety Board conducts a full investigation after every plane crash. It’s time to establish a similar body to explore school shooting tragedies and the lessons we should learn from them, writes TCR’s legal affairs columnist James Doyle.
DA  - 2022/06/02/T11:15:47+00:00
PY  - 2022
LA  - en-US
UR  - https://thecrimereport.org/2022/06/02/why-we-need-a-national-school-safety-board/
Y2  - 2022/06/02/15:37:06
ER  - 

TY  - ELEC
TI  - Decolonizing the Justice System
AU  - Doyle, James M.
T2  - The Crime Report
AB  - The reform question that never seems to be presented with any urgency is about whether the people most impacted by the criminal justice system’s operations will have any actual power over the choices, writes TCR legal affairs columnist James Doyle.
DA  - 2022/06/21/T12:00:16+00:00
PY  - 2022
LA  - en-US
UR  - https://thecrimereport.org/2022/06/21/de-colonizing-the-justice-system/
Y2  - 2022/06/21/13:40:48
ER  - 

TY  - RPRT
TI  - Medicolegal Death Investigation Partnerships on Overdose Fatality Reviews
AU  - Forensic Technology Center of Excellence
AB  - Drug overdoses are a leading cause of death in the United
States.1 In fact, based on recently released provisional data
from the Centers for Disease Control and Prevention (CDC),
there were an estimated 100,306 drug overdose deaths in the
United States from April 2020 to April 2021.2 This was an
increase of 28.5% from the same period the prior year.2 To
combat this epidemic and help prevent future overdoses,
states, counties, and municipalities have formed multidisciplinary teams to review overdose fatality cases. These
teams serve to identify system gaps and create innovative
community-specific overdose prevention and intervention
strategies.1

The makeup of the teams vary based on jurisdiction but are
typically made up of partnerships between health departments, law enforcement, social service providers, medical examiner and corner offices, and others. These groups are commonly referred to as Overdose Fatality Review
(OFR) teams.
DA  - 2022/07//
PY  - 2022
SP  - 9
PB  - RTI International
UR  - https://forensiccoe.org/private/62e0636932468
ER  - 

TY  - ELEC
TI  - Just Partnerships to Enhance Overdose Fatality Review
AU  - National Institute of Justice
AB  - This fifth episode in the National Institute of Justice's (NIJ's) Just Science podcast series is an interview with Dr. Mallory O'Brien, Assistant Professor at the Medical College of Wisconsin, who discusses how partnerships can improve Overdose Fatality Reviews. Dr. O'Brien has a PhD in Epidemiology and has been a researcher with public health, community, and criminal justice partners in Milwaukee for the past 14 years. She has led the development, implementation, and expansion of the Milwaukee Homicide Review Commission (MHRC) and DataShare. Background information for the interview notes that the national Violent Death Reporting System (NVDRS) is the only state-based reporting system for all types of violent deaths, including homicides and suicides. It pools just over 600 data elements from multiple sources into an anonymous, usable database. Dr. O'Brien has used her experience with NVDRS to improve the overdose fatality review (OFR) process. In the current interview, she discusses leveraging partnerships to improve overdose fatality reviews, their impact on communities with substance abuse problems, and the historical context that led to fatality reviews. The interview focuses on the reasons for an OFR and who should be included in providing input for the OFR report. OFR reports provide important input for communities that pertain to healthcare, drug treatment, drug prevention, family services, and drug law enforcement. The medical examiner, who determines cause of death, determines whether the death was caused by a drug overdose and the drug(s) that caused the death. Other disciplines represented in an OFR can provide background information on the decedent's recent behaviors, treatments received or not received, drug-use patterns, access to drugs, law enforcement contacts, and justice processing. The OFR report can be instrumental in preventing drug overdose fatalities through reforms in healthcare, legislation, criminal justice, drug abuse prevention, public education, and family services.
DA  - 2021/02/01/
PY  - 2021
LA  - English
M3  - Just Science Podcast
UR  - https://www.proquest.com/other-sources/just-science-podcast-partnerships-enhance/docview/2677043897/se-2?accountid=26333
L2  - https://forensiccoe.org/illicit-substance-episode5/
N1  - <p>Date revised - 2022-06-22</p>
N1  - <p>Last updated - 2022-06-22</p>
KW  - Forensic sciences
KW  - Drug overdose
KW  - Drugs
KW  - Multidisciplinary teams
KW  - National Institute of Justice (NIJ)
KW  - Drug abuse prevention and education
KW  - Drug prevention
KW  - Forensic Technology Center for Excellence
KW  - Multidisciplinary investigative teams
KW  - NIJ Grant-related Documents
ER  - 

TY  - RPRT
TI  - Overdose Fatality Review Data System Guidance Version 1.0
AU  - O'Brien, Mallory E
AU  - Heimen, Mellissa
AB  - This instructional material provides guidance on the types of data that are to be included in a drug overdose fatality review that is suitable for inclusion in the Overdose Fatality Review (OFR) Data System. The OFR Data System structure, variables, and responses were developed by the OFR Data Work Group topic leads and members. An OFR team collects information from partners across multiple agencies for the purpose of understanding the circumstances leading to an overdose fatality. The ability of the team to know whether an event or circumstance occurred is limited to the information and records available to the team. The guidance provided on collecting and reporting the data includes instructions intended to increase the reliability and comprehensiveness of the information. Instruction is provided for entering data in each item of the formatted database.
DA  - 2020///
PY  - 2020
SP  - 263
LA  - English
UR  - https://bja.ojp.gov/library/publications/overdose-fatality-review-data-system-guidance-version-10
AN  - 900614434; 255882
DB  - National Criminal Justice Reference Service (NCJRS) Abstracts Database
L2  - https://www.cossapresources.org/Content/Documents/Articles/OFR_Data_System_Guidance_Oct_2020.pdf
N1  - <p>Date revised - 2022-06-22</p>
N1  - <p>Last updated - 2022-06-22</p>
KW  - Drug overdose
KW  - Drugs
KW  - Data analysis
KW  - BJA Grant-related Documents
KW  - Data collections
KW  - Death investigations
KW  - Illegal substances
KW  - Legal substances
ER  - 

TY  - SLIDE
TI  - Understanding the Opioid Crisis Case-by-Case: Overdose Fatality Reviews in Wisconsin
A2  - O'Brien, Mallory
AB  - In this 4-minute video with accompanying transcript, Mallory O’Brien, an Assistant Professor at the Medical College of Wisconsin, discusses Wisconsin’s response to the opioid crisis through its Overdose Fatality Review (OFR) process. The OFR is a joint effort of the state’s Departments of Justice and Public Health. Under the OFR, all of the stakeholders in an overdose case share specific case information that can assist in understanding factors in the drug overdose fatality, including the events that contributed to it and actions that might have prevented it and similar cases. The focus of the reviews is missed opportunities for intervention and prevention. Reviews also are compared with a series of case reviews, so as to identify patterns and trends that should be taken into account in designing broad intervention and prevention efforts. Professor O’Brien outlines the steps a state should consider in developing a similar review process. The first step is to identify the stakeholders with responsibilities for preventing and responding to drug abuse that can lead to overdose fatalities. The second step is to bring together representatives from these stakeholder agencies to discuss the importance of cooperation and the nature and usefulness of a cooperative reviews of overdose fatality cases. Following an agreement to proceed with such an effort, the stakeholder should develop a confidentiality agreement in sharing information, protocols for selecting and reviewing cases, and a means of ensuring accountability for implementing policies and procedures agreed upon in responding to the opioid crisis in the state.
CY  - 2018 International Association of Chiefs of Police annual conference
DA  - 2018///
PY  - 2018
LA  - English
UR  - https://nij.ojp.gov/media/video/17576
L2  - https://nij.gov/multimedia/Pages/video-understanding-the-opioid-crisis-case-by-case-transcript.aspx%20https://nij.gov/publications/pages/publication-detail.aspx?ncjnumber=252934%20https://www.youtube.com/watch?v=Cp1YRrew61M
N1  - <p>Availability - National Institute of Justice (NIJ), Washington, DC 20531</p>
N1  - <p>Date revised - 2020-03-17</p>
N1  - <p>Last updated - 2020-03-17</p>
KW  - Interagency cooperation (04204)
KW  - NIJ Resources (60292)
KW  - Drug prevention programs (03714)
KW  - Opioids (01505)
KW  - Drug abuse (00355)
KW  - Wisconsin (55000)
KW  - Community Drug Prevention (60078)
KW  - Drug overdose (05116)
ER  - 

TY  - ELEC
TI  - Anatomy of a 'Split Second' Police Shooting
AU  - Doyle James M., T. C. R.
T2  - The Crime Report
AB  - Some fatal shootings have sometimes been justified because officers had only a “split second” to decide whether they faced a threat to their lives. But what was going on before that “split second”?
...Authorities on policing, including the University of Cambridge’s Lawrence Sherman, the University of Missouri at St. Louis’ David Klinger, and the University of Michigan’s David Thacher, join legal scholars such UCLA’s Joanna Schwartz and the University of Virginia’s Barbara Armacost in arguing that officer-involved shootings have to be understood as “system crashes” or “organizational accidents.”

They emerge from complex systems under acute stress, not as the isolated acts of the lone triggermen.
DA  - 2022/08/22/T11:15:28+00:00
PY  - 2022
LA  - en-US
UR  - https://thecrimereport.org/2022/08/22/anatomy-of-a-split-second-police-shooting/
Y2  - 2022/08/22/16:22:15
ER  - 

TY  - NEWS
TI  - Why 911 dispatch is critical to the Uvalde shooting investigation
AU  - Gillooly, Jessica
T2  - The Hill
AB  - The actions of 911 call-takers and dispatchers often are ignored in the aftermath of critical incidents yet impact entire incident trajectories.

https://groups.google.com/d/msgid/criminal-justice-sentinel-events/835d1313-3334-44c4-8231-f129c4fcfc7bn%40googlegroups.com.
DA  - 2022/06/04/T15:00:00+00:00
PY  - 2022
LA  - en-US
UR  - https://thehill.com/opinion/criminal-justice/3511188-why-911-dispatchers-are-critical-to-the-uvalde-shooting-investigation/
Y2  - 2022/09/07/15:41:10
ER  - 

TY  - NEWS
TI  - Making Sense Out of Justice Tragedies
AU  - Pupulidy, Ivan
T2  - The Crime Report
AB  - Can a process developed to analyze serious mishaps in the US Forest Service be applied to justice? Its creator believes that the “Learning Review,” now used in medicine and other fields to learn from accidents, incidents and normal work, without trying to affix blame, is ideally suited to criminal justice as well.
DA  - 2018/07/25/T15:02:18+00:00
PY  - 2018
LA  - en-US
UR  - https://thecrimereport.org/2018/07/25/making-sense-out-of-justice-mistakes/
Y2  - 2022/09/07/16:41:01
ER  - 

TY  - RPRT
TI  - Preventing Domestic Abuse Related Homicides and Suicides: Learning Lessons from ‘near-miss’ cases.
AU  - Monckton-Smith, Jane
AU  - Ash, Daniel P
AU  - Haile, Sue
AU  - Bellussi, Laura
AB  - The aim of this study was to engage with professionals involved in managing responses to domestic abuse in England and Wales to understand the steps that they took to prevent homicide and/or suicide in so-called ‘near-miss’ cases. Thirty professionals from police forces and domestic violence charities were interviewed, and each of them related the detail of approximately four near-miss cases (on average), which produced a total number of around one hundred and twenty cases for the study. It was found, through a thematic analysis, that there are key activities and approaches that are believed to promote a positive outcome and potentially prevent domestic abuse related homicide and/or suicide. Advocacy was the single most dominant theme, being cited in all interviews irrespective of the job role or agency. Advocacy is a specific activity that differs in critical ways from support, advisory, or investigative activities. Advocates may speak for someone, may fight for their rights or position, and may give an informed opinion. Advocacy was directly linked by interviewees to effective offender management, victim engagement, risk management, and positive outcomes. It was suggested that advocacy could help circumvent any problems with interpreting organisational policy, and promoted innovation. It was also linked to job satisfaction and learning. It was however, universally felt, that effective advocacy could only be achieved with support from line managers and supervisors who would encourage any challenges, and support any decisions to make a challenge. It was argued that without advocacy, victim engagement was more difficult, and without victim engagement, offender management was more difficult.  The importance of advocacy is previously acknowledged and led to the use of IDVAs. However, all our interviewees felt that advocacy was not defined by job role, and that any professional could be involved in advocating for victims to achieve positive outcomes.
DA  - 2022/07//
PY  - 2022
PB  - Home Office
UR  - https://www.researchgate.net/publication/362133998_Preventing_Domestic_Abuse_Related_Homicides_and_Suicides_Learning_Lessons_from_'near-miss'_cases
Y2  - 2022/09/12/19:41:07
N1  - <p style="text-align: justify; line-height: 150%; margin: 0in -30.95pt .0001pt -28.35pt;"><span><span style="font-size: 11.0pt; line-height: 150%; font-family: 'Calibri Light',sans-serif; color: black;">2005). ‘Sentinel events’ are events that could have caused death or serious harm, and in a criminal justice context include those events where there has been a wrongful conviction or the release of a dangerous individual into the community. In the United States, ‘sentinel event reviews’ were introduced in 2011 by the National Institute of Justice (Doyle, 2015; Ritter, 2015).</span></span></p>
<p style="text-align: justify; line-height: 150%; margin: 0in -30.95pt .0001pt -28.35pt;"> </p>
<p style="margin-left: 27.75pt; text-align: justify; text-indent: -27.75pt; vertical-align: baseline;"><span style="font-size: 10.0pt; font-family: 'Calibri Light',sans-serif; color: black;">Doyle, J. M. (2015). NIJ's Sentinel Events Initiative: Reducing Errors in the Criminal Justice System. Annotation.  </span></p>
<p style="text-align: justify; line-height: 150%; margin: 0in -30.95pt .0001pt -28.35pt;"> </p>
<p style="margin-left: 27.75pt; text-align: justify; text-indent: -27.75pt; vertical-align: baseline;"><span style="font-size: 10.0pt; font-family: 'Calibri Light',sans-serif; color: black;">Ritter, N. (2015). Testing a concept and beyond: Can the criminal justice system adopt a nonblaming practice? NIJ Journal, 276, 1-8.  </span></p>
<p style="text-align: justify; line-height: 150%; margin: 0in -30.95pt .0001pt -28.35pt;"> </p>
<p style="text-align: justify; line-height: 150%; margin: 0in -30.95pt .0001pt -28.35pt;"> </p>
ER  - 

TY  - JOUR
TI  - Reimagining the Use of Force by Police in a Post-Floyd Nation
AU  - Smith, Michael R
T2  - Police Quarterly
DA  - 2022///
PY  - 2022
VL  - 25
IS  - 2
SP  - 228
EP  - 251
J2  - Police Quarterly
SN  - 1098-6111
N1  - <p> <br />A few years later, Doyle (2010) applied the lessons from NAT and advances in how<br />the medical profession learned from aviation and other high-risk professions to urge the<br />adoption of post-hoc reviews of wrongful convictions based on a National Transportation Safety Board model that focuses on system errors rather than individual<br />failures. Modeled after NTSB investigations and medical board reviews that now<br />routinely review negative patient outcomes from a systems perspective (rather than<br />pointing fingers at the failures of individual health care professionals), Doyle urged the<br />formation of a process for tracking “helpful errors” in criminal justice case processing<br />identified by interdisciplinary clearinghouse teams charged with conducting case<br />studies of wrongful convictions and near-misses, collectively known as “sentinel<br />events.” The National Institute of Justice responded through its joint NIJ-BJA Sentinel<br />Events Initiative (NIJ, 2017), which offered funding to jumpstart sentinel event reviews<br />and demonstration projects across the criminal justice system (Ritter, 2015).</p>
ER  - 

TY  - CHAP
TI  - Accountability and Enhancement: The Dual Objectives of Use-of-Force Review
AU  - Stoughton, Seth W
T2  - Rethinking and Reforming American Policing
DA  - 2022///
PY  - 2022
SP  - 227
EP  - 257
PB  - Springer
N1  - <p><span style="color: #333333; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #fcfcfc; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">Ritter, N. (2015). Testing a concept and beyond: Can the criminal justice system adopt a nonblaming practice?<span> </span></span><em style="box-sizing: inherit; color: #333333; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 18px; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #fcfcfc; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">National Institute of Justice Journal,</em><span style="color: #333333; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #fcfcfc; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"><span> </span></span><em style="box-sizing: inherit; color: #333333; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 18px; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #fcfcfc; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">276</em><span style="color: #333333; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #fcfcfc; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">, 1–8.</span></p>
ER  - 

TY  - RPRT
TI  - Wethersfield Police Department Organizational Climate Study
AU  - Barao, Lisa
AU  - Farrell, Chelsea
AB  - This work is an independent organizational climate assessment of the Wethersfield Police
Department and was supported through project funds provided by the Town of Wethersfield.
We would like to express our gratitude to the police officers and civilian employees of the
Wethersfield Police Department, all of whom welcomed us openly into their department. We are additionally grateful to all officers and employees who took the time to provide us with their honest feedback and input via survey or interview in a collaborative effort to improve their
agency.
CY  - Wethersfield Police Department
DA  - 2022///
PY  - 2022
N1  - <p>This assessment is framed by the values guiding root cause analysis, which is undertaken<br />separate from any legal proceedings and does not intend to place blame on individuals or<br />agencies.<br />15 Instead, this assessment is intended to be supportive of officers, civilian personnel,<br />and police administrators in identifying problems and making meaningful changes to the<br />environment. This approach is necessary to create buy-in, identify the true root causes of<br />negative events and practices, and implement sustainable improvements. It is a forward-thinking<br />approach that avoids focusing on blame-placing and encourages other agencies to be similarly<br />proactive, rather than fearful, of critically assessing their own organizations.</p>
<p>15 Ritter, “Testing a Concept and Beyond: Can the Criminal Justice System Adopt a Nonblaming Practice?”; National Institute of Justice, Mending<br />Justice: Sentinel Events Reviews</p>
ER  - 

TY  - CHAP
TI  - Root Cause Analysis to Improve Care: Getting Past Blame
AU  - McCambell, Susan
T2  - Public Health Behind Bars
AB  - Correctional organizations are challenged to conduct thorough and objective reviews of critical events, but often stop short of identifying the real problem. Root cause analysis is not a part of their toolkits. While review of critical incidents may occur, the internal culture of many agencies rushes to find “blame” for an event, categorizing the symptoms of the dysfunction, rather than concluding the perhaps painful process of unearthing the core issues. As such, organizations seem to be confronted by a too familiar crisis, too often, with apparently no effective solution. After the blame, personnel actions, rewriting of policy, or retraining of employees is concluded, systemic solutions remain elusive. Root cause analysis combined with corrective action plans, carefully and objectively constructed, monitored, amended, and assessed provide an important means to improving operations. This new way of thinking can be used in advance of an anticipated crisis, meeting emerging challenges head-on. Staff need orientation, training, and leadership support for root cause analysis to become an ingrained part of an agency’s operations. There are internal obstacles to these in-depth reviews which need to be identified and strategies to address developed.
DA  - 2022///
PY  - 2022
SP  - pp
EP  - 209–218
UR  - https://link.springer.com/chapter/10.1007/978-1-0716-1807-3_13
Y2  - 2022/09/12/20:05:26
N1  - <ul class="c-article-references" style="box-sizing: inherit; margin-top: 0px; list-style: none; padding: 0px; color: #333333; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #fcfcfc; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;" data-track-component="outbound reference">
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<p id="ref-CR7" class="c-article-references__text" style="box-sizing: inherit; padding: 0px 0px 0px 8px; margin: 0px 0px 8px; overflow-wrap: break-word; word-break: break-word; line-height: 1.8; flex: 1 1 0%;">Doyle, J. M. (2010a). Leaning from error in American criminal justice.<span> </span><em style="box-sizing: inherit;">The Journal of Criminal Law and Criminology, 100</em>(1), 110.</p>
<p id="ref-CR7-links" class="c-article-references__links u-hide-print" style="box-sizing: inherit; padding: 0px; margin: 0px; overflow-wrap: break-word; word-break: break-word; display: flex; flex-basis: 100%; justify-content: flex-end; flex-wrap: wrap; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 1rem; font-weight: bold; list-style: none; line-height: 1.8;"><a style="box-sizing: inherit; text-decoration: underline 0.0625rem; text-decoration-skip-ink: auto; background-color: transparent; color: #004b83; overflow-wrap: break-word; word-break: break-word; text-underline-offset: 0.08em; padding-left: 0px;" rel="nofollow noopener" href="https://scholar.google.com/scholar_lookup?&title=Leaning%20from%20error%20in%20American%20criminal%20justice&journal=The%20Journal%20of%20Criminal%20Law%20and%20Criminology&volume=100&issue=1&publication_year=2010&author=Doyle%2CJM" data-track="click" data-track-action="google scholar reference" data-track-label="link" aria-label="Google Scholar reference 4">Google Scholar</a> </p>
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<p id="ref-CR8" class="c-article-references__text" style="box-sizing: inherit; padding: 0px 0px 0px 8px; margin: 0px 0px 8px; overflow-wrap: break-word; word-break: break-word; line-height: 1.8; flex: 1 1 0%;">Doyle, J. M. (2010b). Learning from error in American criminal justice.<span> </span><em style="box-sizing: inherit;">The Journal of Criminal Law and Criminology, 100</em>(1), 114.</p>
<p id="ref-CR8-links" class="c-article-references__links u-hide-print" style="box-sizing: inherit; padding: 0px; margin: 0px; overflow-wrap: break-word; word-break: break-word; display: flex; flex-basis: 100%; justify-content: flex-end; flex-wrap: wrap; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 1rem; font-weight: bold; list-style: none; line-height: 1.8;"><a style="box-sizing: inherit; text-decoration: underline 0.0625rem; text-decoration-skip-ink: auto; background-color: transparent; color: #004b83; overflow-wrap: break-word; word-break: break-word; text-underline-offset: 0.08em; padding-left: 0px;" rel="nofollow noopener" href="https://scholar.google.com/scholar_lookup?&title=Learning%20from%20error%20in%20American%20criminal%20justice&journal=The%20Journal%20of%20Criminal%20Law%20and%20Criminology&volume=100&issue=1&publication_year=2010&author=Doyle%2CJM" data-track="click" data-track-action="google scholar reference" data-track-label="link" aria-label="Google Scholar reference 5">Google Scholar</a> </p>
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<p id="ref-CR10" class="c-article-references__text" style="box-sizing: inherit; padding: 0px 0px 0px 8px; margin: 0px 0px 8px; overflow-wrap: break-word; word-break: break-word; line-height: 1.8; flex: 1 1 0%;">Doyle, J. M. (2014). NIJ's sentinel events initiative: Looking Back to look forward.<span> </span><em style="box-sizing: inherit;">NIJ Journal</em>, (273), 1.</p>
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</ul>
<p><span style="color: #333333; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #fcfcfc; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;">Ritter, N. (2015). Testing a concept and beyond: Can the criminal justice system adopt a nonblaming practice? NIJ Journal</span><em style="box-sizing: inherit; color: #333333; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 18px; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #fcfcfc; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">,</em><span style="color: #333333; font-family: -apple-system, BlinkMacSystemFont, 'Segoe UI', Roboto, Oxygen-Sans, Ubuntu, Cantarell, 'Helvetica Neue', sans-serif; font-size: 18px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: left; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #fcfcfc; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial; display: inline !important; float: none;"><span> </span>p. 5.</span></p>
ER  - 

TY  - RPRT
TI  - Hartford Police Department Organizational Climate Study
AU  - Barao, Lisa
AU  - Farrell, Chelsea
AB  - This work is an independent organizational climate assessment of the Hartford Police Department
and was supported through project funds provided by the City of Hartford. We would like to thank
Chief Jason Thody, Assistant Chief Rafael Medina, Deputy Chief Sonia Watson, and Sergeant
Lara Traczynski for their administrative and logistical support throughout the course of this study.
We would also like to express our gratitude to the police officers of the Hartford Police
Department, all of whom treated us with respect and welcomed us into their department. We are
additionally grateful to all officers who took the time to provide us with their honest feedback and
input via survey or interview in a collaborative effort to improve their workplace.
DA  - 2020/08/31/
PY  - 2020
SP  - 152
PB  - Hartford Police Departmen
UR  - https://www.hartfordct.gov/files/assets/public/mayors-office/mayors-office-documents/2020.08.31-hpd-climate-report.pdf
N1  - <p>Finally, and relatedly, this study examines organizational features that may set the stage<br />for occurrences of negative and harmful treatment of officers by their peers or supervisors.<br />Following instances of public criticism and negative media attention, organizations often seek to<br />immediately correct and remediate past wrongs but do little to correct ongoing processes that may<br />continue to lead to such “adverse outcomes.” Adverse outcomes rarely occur only once or by chance, and these events take place within a broader organizational context.<br />8 Negative events can<br />signal underlying systemic weaknesses, are likely the result of compound errors, and “may<br />provide, if properly analyzed, important keys to strengthening the system and preventing future<br />adverse events or outcomes.”9 This project aims to illuminate and address these potential systemic<br />weaknesses.</p>
<p>8 National Institute of Justice, Mending Justice: Sentinel Events Reviews. Washington, DC: U.S. Department of Justice,<br />Office of Justice Programs, 2014.<br />9 Nancy Ritter, "Testing a Concept and Beyond: Can the Criminal Justice System Adopt a Nonblaming Practice?,"<br />NIJ Journal 276 (2015).</p>
ER  - 

TY  - JOUR
TI  - Measuring Innocence: How to Think About the Rate of Wrongful Conviction
AU  - Zalman, Marvin
AU  - Norris, Robert J
T2  - New Criminal Law Review
DA  - 2021///
PY  - 2021
VL  - 24
IS  - 4
SP  - 601
EP  - 654
J2  - New Criminal Law Review
SN  - 1933-4192
N1  - <p>cites</p>
<h2 class="gs_rt" style="margin: 0px 100px 2px 0px; padding: 0px; border: 0px; position: relative; font-weight: normal; font-size: 17px; line-height: 19px; color: #222222; font-family: Arial, sans-serif; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;"><a style="color: #d14836; text-decoration: underline; outline: none;" href="https://scholar.google.com/scholar?cluster=2711782513260445282&hl=en&as_sdt=20005&sciodt=0,9&as_ylo=2021">Learning from error in American criminal justice</a></h2>
ER  - 

TY  - BOOK
TI  - WRONGFUL CONVICTION: From Prevention to the Reversal of Injustice
AU  - Humphrey, John A
AU  - Clarke, Kaitlyn M
DA  - 2018///
PY  - 2018
PB  - Charles C Thomas Publisher
SN  - 0-398-09206-0
N1  - <p>cites Mending Justice</p>
ER  - 

TY  - JOUR
TI  - The Justice Department's Pattern-or-Practice Police Reform Program, 1994–2017: Goals, Achievements, and Issues
AU  - Walker, Samuel
T2  - Annual Review of Criminology
AB  - The Department of Justice's pattern-or-practice police reform program has been an unprecedented event in American policing, intervening in local and state law enforcement agencies as never before and requiring a sweeping package of reforms. The program has reached reform settlements with forty agencies, including twenty with judicially enforced consent decrees. Academic research on the program, however, has been fairly modest. Social scientists have largely focused on a few selected issues. There is no study of the full impact of the program on one agency, and there is no comprehensive study of the impact of the program as a whole. Evaluations of individual agencies have been generally favorable, although with backsliding in some agencies. This review argues that the combination of several major goals and the various elements of specific consent decree reforms has created a web of accountability that is unmatched by any previous police reform effort.

Keywords
DA  - 2022///
PY  - 2022
VL  - 5
SP  - 21
EP  - 42
J2  - Annual Review of Criminology
SN  - 2572-4568
N1  - <p>Cites PavingtheWay</p>
ER  - 

TY  - JOUR
TI  - Testing a concept and beyond: Can the criminal justice system adopt a nonblaming practice
AU  - Ritter, Nancy
T2  - NIJ Journal
DA  - 2015///
PY  - 2015
VL  - 276
SP  - 1
EP  - 8
J2  - NIJ Journal
UR  - https://nij.ojp.gov/topics/articles/testing-concept-and-beyond-can-criminal-justice-system-adopt-nonblaming-practice
ER  - 

TY  - JOUR
TI  - What Are Victim Impact Statements for?
AU  - Bandes, Susan A
T2  - Brook. L. Rev.
DA  - 2021///
PY  - 2021
VL  - 87
SP  - 1253
J2  - Brook. L. Rev.
N1  - <p>Cites A Safety Model Perspective</p>
ER  - 

TY  - JOUR
TI  - SYMPOSIUM: THE ROLE OF THE" VICTIM" IN THE
AU  - Garvin, Margaret
AU  - Green, Bruce A
AU  - Ruben, Brandon P
AU  - Lave, Tamara Rice
AU  - Bandes, Susan A
AU  - Karteron, Alexis
AU  - Godsoe, Cynthia
T2  - LAW REVIEW
DA  - 2022///
PY  - 2022
VL  - 87
IS  - 4
J2  - LAW REVIEW
N1  - <p>cites</p>
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<li class="gs_ind" style="margin: 0px 0px 4px; padding: 0px 0px 0px 8px; border: 0px; text-indent: -8px;"><a style="color: #222222; text-decoration: none;" href="https://scholar.google.com/scholar?as_ylo=2022&hl=en&as_sdt=20005&sciodt=0,9&cites=7990426734155661430&scipsc="> </a><a id="gs_bdy_sb_ca" class="gs_btnM gs_in_ib" style="color: #222222; text-decoration: none; position: relative; display: inline-block; line-height: 16px; padding: 6px 0px 7px; user-select: none; margin-top: -6px;" href="https://scholar.google.com/scholar_alerts?view_op=create_alert_options&hl=en&alert_params=%3Fhl%3Den%26as_sdt%3D20005%26sciodt%3D0,9%26cites%3D7990426734155661430%26scipsc%3D"></a></li>
</ul>
</div>
</div>
</div>
<div id="gs_bdy_ccl" style="margin: 0px; padding: 0px 24px 0px 16px; border: 0px; display: table-cell; vertical-align: top; color: #222222; font-family: Arial, sans-serif; font-size: 13px; font-style: normal; font-variant-ligatures: normal; font-variant-caps: normal; font-weight: 400; letter-spacing: normal; orphans: 2; text-align: start; text-indent: 0px; text-transform: none; white-space: normal; widows: 2; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: #ffffff; text-decoration-thickness: initial; text-decoration-style: initial; text-decoration-color: initial;">
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<h2 class="gs_rt" style="margin: 0px 100px 2px 0px; padding: 0px; border: 0px; position: relative; font-weight: normal; font-size: 17px; line-height: 19px;"><a style="color: #d14836; text-decoration: underline; outline: none;" href="https://scholar.google.com/scholar?cluster=7990426734155661430&hl=en&as_sdt=20005&sciodt=0,9">A Safety Model Perspective Can Aid Diagnosis, Prevention,<span> </span></a></h2>
</div>
</div>
</div>
</div>
ER  - 

TY  - JOUR
TI  - Adrift in The Interstices of Law and Justice: Divining Right and Wrong in the Sad, Strange Case of People v. Schmidt
AU  - Acker, James R
T2  - Alb. L. Rev.
DA  - 2019///
PY  - 2019
VL  - 83
SP  - 697
J2  - Alb. L. Rev.
N1  - <p>Cites a Safety Model Perspective</p>
ER  - 

TY  - JOUR
TI  - The criminology of wrongful conviction: A decade later
AU  - Leo, Richard A
T2  - Journal of Contemporary Criminal Justice
AB  - This article reflects on the author’s 2005 article, “Rethinking the Study of Miscarriages of Justice,” which sought to describe what scholars empirically knew at that time about the phenomenon, causes, and consequences of wrongful convictions in America. The 2005 article argued that the study of wrongful convictions constituted a coherent academic field of study and set forth a vision for a more sophisticated, insightful, and generalizable criminology of wrongful conviction. In this current article, the author revisits the ideas first developed in “Rethinking the Study of Miscarriages of Justice” to evaluate what scholars have learned about wrongful convictions in the last decade, and what challenges lie ahead for developing a more robust criminology of wrongful conviction. The article concludes that there have been significant theoretical, methodological, and substantive advances in the last decade, but that a root cause analysis of wrongful convictions has yet to come to fruition and urges empirical scholars to begin to study other sources of error and inaccuracy in the criminal justice system. Scholars should develop a criminology of erroneous outcomes, not just of erroneous conviction. By studying both sets of outcomes, scholars can improve accuracy and reduce errors across the board.


Cites Orwell's Elephant (Doyle, 2015)
DA  - 2017///
PY  - 2017
VL  - 33
IS  - 1
SP  - 82
EP  - 106
J2  - Journal of Contemporary Criminal Justice
SN  - 1043-9862
ER  - 

TY  - JOUR
TI  - Taking stock of innocence: Movements, mountains, and wrongful convictions
AU  - Acker, James R
T2  - Journal of Contemporary Criminal Justice
AB  - This article offers a brief overview of the current state of the Innocence Movement. It begins by reviewing what we know, and do not know, about the incidence of wrongful convictions and their correlates and causes. It then explores select issues that should receive greater attention to help sustain the Innocence Movement and ensure its advancement. Acknowledging that much has been learned about wrongful convictions and that important reforms have been enacted, the article concludes by observing that significant challenges remain and must be addressed before efforts to guard against convicting the innocent are relaxed.



.....Prescriptions for identifying the diverse sources of justice system errors have invoked models from other fields, including medical board procedures for diagnosing hospital errors and the National Transportation Safety Board’s efforts to reconstruct airplane crashes. Such investigations demand a painstaking, comprehensive analysis of individual and systemic factors, including their interaction (Doyle, 2010; National Institute of Justice, 2013; Scheck & Neufeld, 2002). Rarely can hospital errors or plane crashes be attributed to the isolated miscue of a lone doctor or pilot, and the same is true regarding wrongful convictions: They almost always result from a complex web of interrelated actions occurring within and outside of the justice system.
DA  - 2017///
PY  - 2017
VL  - 33
IS  - 1
SP  - 8
EP  - 25
J2  - Journal of Contemporary Criminal Justice
SN  - 1043-9862
UR  - https://journals.sagepub.com/doi/full/10.1177/1043986216673008
ER  - 

TY  - JOUR
TI  - Elephants in the Courtroom: Examining Overlooked Issues in Wrongful Convictions Foreword
AU  - Acker, James R.
AU  - Redlich, Allison D.
AU  - Bonventre, Catherine L.
AU  - Norris, Robert J.
T2  - Albany Law Review
DA  - 2015///2016
PY  - 2015
DP  - HeinOnline
VL  - 79
IS  - 3
SP  - 705
EP  - 716
J2  - Alb. L. Rev.
LA  - eng
ST  - Elephants in the Courtroom
UR  - https://heinonline.org/HOL/P?h=hein.journals/albany79&i=721
Y2  - 2022/09/16/20:07:37
ER  - 

TY  - JOUR
TI  - Learning from Error in Violence Prevention: A School Shooting as an Organizational Accident
AU  - Goodrum, Sarah
AU  - Slepicka, Jessie
AU  - Woodward, William
AU  - Kingston, Beverly
T2  - Sociology of Education
AB  - This article argues that the organizational structure and culture of schools may impede the prevention of violence in America?s schools, specifically threat assessment and management for students of concern. The data come from a qualitative case study of a school shooting where two students died; the data include deposition testimony from 12 school officials and more than 4,000 pages of school and law enforcement records. The findings illustrate the way the school?s organizational structure and culture shaped and hindered violence prevention practices. The tightly coupled guidelines for threat assessment created an institutional myth of safety and a false sense of security for the school and district, and the loosely coupled structure of the organization led educators to modify guidelines and make decisions about the student?s behavior problems and discipline without consulting others. The school?s culture of autonomy for staff and fresh start mentality for students created unintentional secrets about the history of the student?s difficulties, which gave educators little context for understanding the problem behaviors they observed and inhibited the threat assessment team?s ability to adequately evaluate and monitor those behaviors. Recommendations for building organizational structures and cultures that support violence prevention in schools are discussed.
DA  - 2022/09/16/
PY  - 2022
DO  - 10.1177/00380407221120431
DP  - SAGE Journals
SP  - 00380407221120431
J2  - Sociol Educ
LA  - en
SN  - 0038-0407
ST  - Learning from Error in Violence Prevention
UR  - https://doi.org/10.1177/00380407221120431
Y2  - 2022/09/21/15:31:13
N1  - <p>Ciites Learning From Error (Doyle, 2010)</p>
ER  - 

TY  - ELEC
TI  - Why Homicide Counts Can Be Misleading
AU  - Doyle James M., T. C. R.
T2  - The Crime Report
AB  - Measuring the success or failure of justice reforms by statistics like the number of deaths is an example of the “myopic focus on data” that ignores the wider narrative about the drivers of crime in America, writes TCR commentator James Doyle.
...There are initiatives, such as the pioneering efforts of the Milwaukee Homicide Review Commission, that show us a way out: collaborative, all-stakeholders’ analyses of particular sentinel events that open up productive areas of inquiry and can address these questions.

These efforts will have to be data-informed. They will supply platforms for interrogating the data. They will include the people most affected. They will identify new areas where data must be harvested.
DA  - 2022/09/21/T11:30:41+00:00
PY  - 2022
LA  - en-US
UR  - https://thecrimereport.org/2022/09/21/why-homicide-counts-can-be-misleading/
Y2  - 2022/09/21/16:50:33
ER  - 

TY  - ELEC
TI  - City and SPD leadership failures amplified CHOP dangers, report says
AU  - Carter
T2  - The Seattle Times
AB  - The report is the third in a series of reviews of the Seattle Police Department's response to the racial unrest following George Floyd's murder in Minneapolis.
DA  - 2022/10/12/06:00:00
PY  - 2022
LA  - en-US
UR  - https://www.seattletimes.com/seattle-news/law-justice/city-and-spd-leadership-failures-amplified-chop-dangers-report-says/
Y2  - 2022/11/17/21:03:04
L2  - https://www.seattletimes.com/seattle-news/law-justice/city-and-spd-leadership-failures-amplified-chop-dangers-report-says/
ER  - 

TY  - RPRT
TI  - Sentinel Event Review of Police Response to 2020 Protests in Seattle  Wave 3: June 8 – July 1, 2020
AU  - Seattle Office of Inspector General
AB  - The May 2020 murder of George Floyd by Minneapolis police officers sparked an
unprecedented global response. Protestors gathered in cities across the United States to
express their collective concern and anger about institutionalized racism in policing, and the
number of unarmed Black men dying at the hands of police. Like cities across the United States, the City of Seattle and the Seattle Police Department (SPD) grappled with how to respond to
the protests and eroding public trust. The Office of Inspector General, in collaboration with
community members and SPD, conducted a series of Sentinel Event Reviews (SER) to identify
root causes of critical incidents in the 2020 protests.
1 This report is the third in the 2020 protest
series, centering on events that occurred between June 8 and July 1, 2020, during which SPD
vacated the East Precinct and the CHOP was established.2
The report presents the Panelists’ recommendations using insight from their diverse
experiences in the Seattle community. Panelists participating in this SER made no attempt to
assign individual accountability for acts taken during the incidents reviewed. Instead, Panelists
identified strategies to repair the public trust and safety compromised by SPD decisions
throughout Wave 3.
DA  - 2022/10/11/
PY  - 2022
SP  - 81
UR  - https://seattle.gov/documents/Departments/OIG/Sentinel%20Event%20Review/Wave3ReportFinal.pdf
ER  - 

TY  - RPRT
TI  - Sentinel Event Review of Police Response to 2020 Protests in Seattle Wave 1: Downtown Protests May 29 – June 1
AU  - Seattle Office of Inspector General
AB  - The murder of George Floyd had a monumental impact on this country and internationally, and engaged wide segments of America in public dialogue about the role of race in every aspect of society. The implications of this event are still being felt even as this report is released. Like other departments in cities around the country, the Seattle Police Department (SPD) faced a complex and difficult challenge in
the days after Mr. Floyd’s murder. Namely, the City grappled with how to respond to ongoing
community protests about the long history of abuse, excessive use of force, and deaths suffered byBlack, Indigenous, and other People of Color at the hands of police. These protests also served as an
urgent call for an examination of the institution of policing, to find a manner that would not furthererode public trust, given these longstanding problems and concerns.
Sentinel Event Review (SER) aims to identify the causes and contributing factors to undesired incidents with the goal of prevention (see principles and goals in Table 1 below).
1
SER has been used extensively
in aviation, health care, and manufacturing, among others, to identify root causes of tragedies and
design improvements that will prevent their recurrence. The focus of SER is on fixing the system, not on
assigning individual liability.
CY  - Seattle, WA
DA  - 2021/07/22/
PY  - 2021
SP  - 112
UR  - https://seattle.gov/documents/Departments/OIG/Policy/OIGSERWave1Report072221.pdf
ER  - 

TY  - ELEC
TI  - At The Criminal Justice Safety Office
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Columnist James M. Doyle imagines a system of 'Criminal Justice Safety Offices' that borrow lessons from workman's compensation and prioritize compensating victims of the public safety risks within the criminal justice system.
DA  - 2022/12/16/T12:30:58+00:00
PY  - 2022
LA  - en-US
UR  - https://thecrimereport.org/2022/12/16/at-the-criminal-justice-safety-office/
Y2  - 2022/12/16/17:27:46
L2  - https://thecrimereport.org/2022/12/16/at-the-criminal-justice-safety-office/
ER  - 

TY  - VIDEO
TI  - Tu5: Sentinel event review in criminal justice...
AU  - GLEPHA
DA  - 2021/06/12/
PY  - 2021
DP  - YouTube
ST  - Tu5
UR  - https://www.youtube.com/watch?v=PaNijdd7140
Y2  - 2023/01/26/18:59:14
ER  - 

TY  - CONF
TI  - Sentinel Event Review in Criminal Justice.
T2  - GLEPHA, Global Law Enforcement and Public Health
A4  - Hollway, John
A4  - Kasmer, Chad
A4  - Balfour, Margie
A4  - Shrozier, Tanya
AB  - Video Recording.

Sentinel event review in criminal justice: a case study of two deaths in custody with the Tucson Police Department, USA

https://groups.google.com/d/msgid/criminal-justice-sentinel-events/62bc7927-db5b-45e5-9d2c-7ae5fe7b2b40n%40googlegroups.com.
C1  - Philadelphia, PA
DA  - 2021/06/12/
PY  - 2021
UR  - https://www.youtube.com/watch?v=PaNijdd7140
ER  - 

TY  - NEWS
TI  - Reforming police culture
AU  - Harris, David
T2  - Pittsburgh Post-Gazette
AB  - The death of Tyre Nichols at the hands of police officers in Memphis brings us to a tragically familiar place. We feel pain, anger and deep frustration....

Sentinel event reviews. Every department must require command staff to confront incidents of serious misconduct in an open and frank way, to ask what went wrong and how to prevent it from happening again. Incidents within the department would always get this treatment, as would high profile incidents elsewhere, such as the Tyre Nichols killing.

This would not displace appropriate disciplinary processes where there has been misconduct. But the focus would be different: not about assigning personal blame, but figuring out how the system failed. This kind of process, called sentinel event review, has proven fundamental to improving safety in fields like aviation and medicine. With sentinel event review, practices are improved, flaws in systems are identified, and policy and training follow. All of this can lead to culture change.

https://groups.google.com/d/msgid/criminal-justice-sentinel-events/565fd2a2-3c1f-44ce-baba-f88a523ed12bn%40googlegroups.com.
DA  - 2023/02/12/
PY  - 2023
LA  - en
ST  - David A. Harris
UR  - https://www.post-gazette.com/opinion/insight/2023/02/12/tyre-nichols-police-violence-culture/stories/202302120044
Y2  - 2023/02/13/16:35:14
L2  - https://www.post-gazette.com/opinion/insight/2023/02/12/tyre-nichols-police-violence-culture/stories/202302120044--
N1  - <div data-schema-version="8"><p><em><span style="color: rgb(34, 34, 34)"><span style="background-color: rgb(255, 255, 255)">Sentinel event reviews.</span></span></em><span style="color: rgb(34, 34, 34)"><span style="background-color: rgb(255, 255, 255)"> Every department must require command staff to confront incidents of serious misconduct in an open and frank way, to ask what went wrong and how to prevent it from happening again. Incidents within the department would always get this treatment, as would high profile incidents elsewhere, such as the Tyre Nichols killing.</span></span></p>
<p><span style="color: rgb(34, 34, 34)"><span style="background-color: rgb(255, 255, 255)">This would not displace appropriate disciplinary processes where there has been misconduct. But the focus would be different: not about assigning personal blame, but figuring out how the system failed. This kind of process, called sentinel event review, has proven fundamental to improving safety in fields like aviation and medicine. With sentinel event review, practices are improved, flaws in systems are identified, and policy and training follow. All of this can lead to culture change.</span></span></p>
</div>
ER  - 

TY  - DICT
TI  - The problem isn't just a few bad apples
AU  - Doyle James M.
T2  - CommonWealth Magazine
AB  - Now we learn that  Inspector General Glen Cuhna, who once seemed ready to pin a massive state drug lab scandal on a lone chemist, Annie Dookhan, actually referred four other lab workers for prosecution.  Interesting. Still, counting the number of “bad apples” shouldn’t distract us from the reality that the Massachusetts lab scandals were not the work of(...)

When we discover one of these travesties of justice, we have to seize the opportunity that it offers to discover the myriad system weaknesses that still lie in wait for the next case that will come along—and it will come along.

Don’t look for three or four bad apples. Convene an all-stakeholders “sentinel event review” as a hospital would after a wrong patient surgery, or the NTSB would do after a plane crash.

Hold ourselves accountable for learning the lessons. Change what we can change. Build the capacity to keep doing it.
DA  - 2023/02/23/T01:45:54+00:00
PY  - 2023
LA  - en-US
UR  - https://commonwealthmagazine.org/criminal-justice/the-problem-isnt-just-a-few-bad-apples/
Y2  - 2023/02/27/17:15:30
L2  - https://commonwealthmagazine.org/criminal-justice/the-problem-isnt-just-a-few-bad-apples/
ER  - 

TY  - MGZN
TI  - For Any Good to Come of It, We Must Judge the Murder of Tyre Nichols in a Forgiving Spirit
AU  - Margulies, Joseph
T2  - The Verdict
AB  - In this fifth column in a series about the murder of Tyre Nichols by Memphis police officers, Cornell professor of government Joseph Margulies argues that, for any good to come of Nichols’s death, we...

....And if we really want some good to come from this horrible night, we must take the same approach with the City of Memphis and its Police Department. We must judge them, as we would the officers, in a spirit of forgiveness. As I indicated in my last essay, the murder of Tyre Nichols is an occasion for a Sentinel Event Review. A properly facilitated SER of the sort conducted by, for instance, the Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania Law School, takes the broadest view of an event to ask, as capaciously as possible, how it came to be and what might be done to prevent its recurrence. It brings together the widest range of stakeholders to examine all the biases, incentives, relationships, and norms employed by all the actors whose conduct made the outcome incrementally more likely. It undertakes this examination candidly and openly, without blame or recrimination, driven solely by a shared desire to see that nothing like this ever happens again. I am drawn to these reviews because they are the institutional equivalent of my desire for a forgiving society.

https://groups.google.com/d/msgid/criminal-justice-sentinel-events/375a0f52-b68a-4682-849c-4476ccef4368n%40googlegroups.com.
DA  - 2016/02/16/
PY  - 2016
LA  - en
UR  - https://verdict.justia.com/2023/02/16/for-any-good-to-come-of-it-we-must-judge-the-murder-of-tyre-nichols-in-a-forgiving-spirit
Y2  - 2023/02/27/17:27:36
L2  - https://verdict.justia.com/2023/02/16/for-any-good-to-come-of-it-we-must-judge-the-murder-of-tyre-nichols-in-a-forgiving-spirit
ER  - 

TY  - MGZN
TI  - The Wrong Epiphany
AU  - Margulies, Joseph
T2  - The Verdict
AB  - Cornell Law professor Joseph Margulies points out that the Memphis police officers who beat Tyre Nichols to death were doing exactly what the SCORPION unit of the department was supposed to do. Profes...
.....Along with the prosecution, this is an occasion for a Sentinel Event Review. We must ask, capaciously and compassionately, what happened? We must expand our lens to the very broadest limits of causation, going far beyond the narrow questions about the evening Tyre Nichols died, the training these officers received, or even why Chief Davis created the unit in the first place, even though she had to have known the violent history of comparable units across the country. We must even go beyond the pressures she faced from the mayor or other Memphis leaders. Answering these questions would shed light on the problem but would not solve it.

For behind all these questions lies a conception of “them.” The murder of Tyre Nichols calls on us to investigate, at the deepest, most painful level, the fraught complexity of us-and-them in Memphis. And do not suppose that because Memphis city leadership is largely Black, the criminal legal system in the city is untroubled by these divisions. If such a naïve notion could survive the complex racial history of punishment in the last half century, articulated so well by Yale law professor James Forman, it certainly should not survive a video of five Black officers beating to death a Black suspect.
DA  - 2023/02/10/
PY  - 2023
LA  - en
UR  - https://verdict.justia.com/2023/02/10/the-wrong-epiphany
Y2  - 2023/02/27/17:47:19
L2  - https://verdict.justia.com/2023/02/10/the-wrong-epiphany
ER  - 

TY  - MGZN
TI  - Imagine We Lived in a Different World
AU  - Margulies, Joseph
T2  - The Verdict
AB  - Cornell Law professor Joseph Margulies describes the crucial difference between a world where we ask, “What happened?” and one where we ask, “Who is to blame?” Professor Margulies explains that the fi...
....The effort to understand what happened, and to make sure it never happened again, is called a Sentinel Event Review. There is an entire literature behind it and I expect to write more about it more in the future. For now, it is enough to say that it has a place whenever mistakes happen that we don’t want to see repeated, from the meltdown at Southwest Airlines to classified documents ending up in the home of former presidents. And it has an obvious role in the criminal legal system, where miscarriages are legion. If an officer shoots an unarmed suspect or the police charge an innocent person, for instance, that’s an opportunity for a Sentinel Event Review, and in the best municipalities, that’s exactly what happens. And of course, there should always be a Sentinel Event Review every time a person takes his own life or withers to a shadow and dies in custody.
DA  - 2023/01/23/
PY  - 2023
LA  - en
UR  - https://verdict.justia.com/2023/01/23/imagine-we-lived-in-a-different-world
Y2  - 2023/02/27/17:50:56
L2  - https://verdict.justia.com/2023/01/23/imagine-we-lived-in-a-different-world
ER  - 

TY  - BLOG
TI  - In Shielded, Joanna Schwartz Dissects Policing’s Legal Environment
AU  - Doyle, James M.
T2  - The Crime Report
AB  - TCR Columnist James Doyle discusses a freshly-released book that, if it were in his power, he'd assign as required reading to all those engaged in the debate on police reform. Joanna Schwartz' "Shielded: How The Police Became Untouchable" releases Tuesday, February 14.
The contest here can seem to be one between the public’s safety and the officials’ impunity, and “Shielded” provides plenty of evidence showing that for now impunity is winning.

But Prof. Schwartz points out that even the current litigation landscape provides opportunities for learning from errors that we neglect. Data could be collected on the macro level and shared; tragedies could be scrutinized on the micro level; sentinel event reviews could reveal the organizational bridge between the two. 

Often, a frontline cop can be “set up to fail:” left with three bad choices. He can choose the least bad, and be protected, having made a “reasonable” choice. That “reasonable” choice might still kill a civilian victim whose actual contribution to the event—no matter what the cop reasonably perceived—was simply to be present.
DA  - 2023/02/14/T12:10:17+00:00
PY  - 2023
LA  - en-US
UR  - https://thecrimereport.org/2023/02/14/in-shielded-joanna-schwartz-dissects-policings-legal-environment/
Y2  - 2023/02/27/17:53:58
L2  - https://thecrimereport.org/2023/02/14/in-shielded-joanna-schwartz-dissects-policings-legal-environment/
ER  - 

TY  - JOUR
TI  - Sentinel event reviews: applications in criminal justice settings
AU  - McGarrell, Edmund F.
AU  - Hipple, Natalie Kroovand
AU  - O’Brien, Mallory
T2  - Journal of Crime and Justice
AB  - Sentinel event reviews were developed in the medical, military, and aviation fields and involve systematic assessment of the processes that resulted in a critical event such as an unexpected death of a patient or an airplane crash. The sentinel event review is intended to identify system weaknesses that resulted in the negative outcome and to inform corrective actions. Sentinel event reviews have rarely been used in the criminal justice system, although recent years have witnessed experimentation in the use of review processes to examine negative outcomes such as domestic violence homicides and drug overdoses. This study examined the development and implementation of sentinel event review processes in three midwestern cities. The sentinel event reviews built upon existing reviews of shooting incidents and extended those reviews through a systematic approach that involved deeper investigation into specific critical incidents. The research involved participant observation, review of the materials related to the sentinel event reviews, and a small number of key actor interviews. The results suggest that the reviews hold promise for informing decision makers on system weaknesses and for improving criminal justice practices. Yet, they also revealed obstacles to effective implementation and utilization of sentinel event reviews in criminal justice settings.
DA  - 2023/03/03/
PY  - 2023
DO  - 10.1080/0735648X.2023.2184412
DP  - Taylor and Francis+NEJM
VL  - 0
IS  - 0
SP  - 1
EP  - 16
SN  - 0735-648X
ST  - Sentinel event reviews
UR  - https://doi.org/10.1080/0735648X.2023.2184412
Y2  - 2023/03/07/17:12:56
KW  - fatality reviews
KW  - incident reviews
KW  - Sentinel events
ER  - 

TY  - ELEC
TI  - Sentinel Events Review
AU  - Florida State University College of Criminology & Criminal Justice
T2  - Community Safety Web Podcast
AB  - Today we will be discussing Sentinel Event Reviews in policing.  Sentinel events are incidents with undesirable outcomes that may signify underlying systemic weaknesses, likely the result of multiple contributing factors and may identify ways to strengthen the system or process and prevent future negative outcomes. A sentinel event review is an examination involving all stakeholders of the system in which the error occurred.  It aims to prevent similar errors in the future rather than assigning blame and punishing those making the error.

Sentinel event reviews have their roots in the manufacturing environment and have become widely used in other high-risk fields like aviation and health care. Over the past 10 years the police have begun to utilize the sentinel event review process.  Although not widespread, police departments in Seattle, Tucson, Madison, Milwaukee, New York, and Tempe have conducted sentinel event reviews.


We are pleased to have Michael Scott with us today.  He is a Clinical Professor and Director of the Center for Problem-Oriented Policing, School of Criminology & Criminal Justice (CCJ) at Arizona State University.  Mike began his career in policing as a police officer with the Madison, WI police department.  His career in policing has been both as a practitioner serving as a policer chief and special advisor to the chief in St. Louis and the NYPD Commissioner.  He was a Senior Researcher at PERF and clinical professor at the University of Wisconsin School of Law. He is a 1987 graduate of Harvard Law School where he received his Juris Doctorate.

Mike is also involved with a project at Arizona State University to explore the development of a statewide system for conducting sentinel event reviews of police use of force, particularly among vulnerable populations.
DA  - 2023/03/18/
PY  - 2023
UR  - https://criminology.fsu.edu/community-safety-web-podcast
Y2  - 2023/03/20/20:15:56
L2  - https://criminology.fsu.edu/center-for-criminology-and-public-policy-research/institutes/policing-security-technology-and-private-security-research-policy-institute
ER  - 

TY  - BLOG
TI  - We need to learn from criminal justice mistakes
AU  - Doyle, James
T2  - CommonWealth Magazine
AB  - OUR IDEA of safety is person-based. Whenever something goes tragically wrong in criminal justice our reflex is  to go “down and in” to find the malfunctioning human whose misconduct defeated our safe system and victimized a helpless citizen. We equate “accountability” with “punishment.” In the context of the police violence that is now a media preoccupation,(...)
DA  - 2023/03/22/T01:59:43+00:00
PY  - 2023
LA  - en-US
UR  - https://commonwealthmagazine.org/criminal-justice/we-need-to-learn-from-criminal-justice-mistakes/
Y2  - 2023/03/22/16:01:46
L2  - https://commonwealthmagazine.org/criminal-justice/we-need-to-learn-from-criminal-justice-mistakes/
ER  - 

TY  - JOUR
TI  - Wrongful convictions and claims of false or misleading forensic evidence
AU  - Morgan, John
T2  - Journal of Forensic Sciences
AB  - The results are reported of a study to examine case factors associated with 732 wrongful convictions classified by the National Registry of Exonerations as being associated with “False or Misleading Forensic Evidence.” A forensic error typology has been developed to provide a structure for the categorization and coding of factors relating to misstatements in forensic science reports; errors of individualization or classification; testimony errors; issues relating to trials and officers of the court; and evidence handling and reporting issues. This study, which included the analysis of 1391 forensic examinations, demonstrates that most errors related to forensic evidence are not identification or classification errors by forensic scientists. When such errors are made, they are frequently associated with incompetent or fraudulent examiners, disciplines with an inadequate scientific foundation, or organizational deficiencies in training, management, governance, or resources. More often, forensic reports or testimony miscommunicate results, do not conform to established standards, or fail to provide appropriate limiting information. Just as importantly, actors within the broader criminal justice system—but not under the purview of any forensic science organization—may contribute to errors that may be related to the forensic evidence. System issues include reliance on presumptive tests without confirmation by a forensic laboratory, use of independent experts outside the administrative control of public laboratories, inadequate defense, and suppression or misrepresentation of forensic evidence by investigators or prosecutors. In approximately half of wrongful convictions analyzed, improved technology, testimony standards, or practice standards may have prevented a wrongful conviction at the time of trial.
DA  - 2023/03/22/
PY  - 2023
DO  - 10.1111/1556-4029.15233
DP  - Wiley Online Library
VL  - n/a
IS  - n/a
LA  - en
SN  - 1556-4029
UR  - https://onlinelibrary.wiley.com/doi/abs/10.1111/1556-4029.15233
Y2  - 2023/03/31/15:06:52
L2  - https://onlinelibrary.wiley.com/doi/full/10.1111/1556-4029.15233
N1  - <div data-schema-version="8"><p><span style="color: rgb(28, 29, 30)"><span style="background-color: rgb(255, 255, 255)">Rigorous evaluation of wrongful convictions should reflect a methodology concordant with accident reconstruction or sentinel event analysis [</span></span><strong><u><span style="color: rgb(47, 123, 174) !important"><span style="background-color: transparent"><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1556-4029.15233#jfo15233-bib-0026" rel="noopener noreferrer nofollow">26</a></span></span></u></strong>, <strong><u><span style="color: rgb(47, 123, 174) !important"><span style="background-color: transparent"><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1556-4029.15233#jfo15233-bib-0027" rel="noopener noreferrer nofollow">27</a></span></span></u></strong><span style="color: rgb(28, 29, 30)"><span style="background-color: rgb(255, 255, 255)">]. Just as a pilot may make many good and bad decisions that relate to a plane crash, criminal justice practitioners may make many good and bad judgments along the way to wrongful conviction and exoneration. The exoneration may be associated with a forensic science error, but it may also be associated with forensic results that are valid and contradict the exoneration.</span></span></p>
<p></p>
<p><span style="color: rgb(28, 29, 30)"><span style="background-color: rgb(239, 239, 240)">26</span></span><em><span style="color: rgb(28, 29, 30)"><span style="background-color: rgb(239, 239, 240)">Hollway JF. Instilling a culture of continuous learning from criminal justice systems errors: a multi-stakeholder sentinel event review process in Philadelphia. Washington, DC: National Institute of Justice; 2021.</span></span></em></p>
<p></p>
<p><span style="color: rgb(28, 29, 30)"><span style="background-color: rgb(239, 239, 240)">27</span></span><em><span style="color: rgb(28, 29, 30)"><span style="background-color: rgb(239, 239, 240)">National Institute of Justice. Sentinel events Initiative. 2017 Available from: </span></span><span style="color: rgb(0, 82, 116)"><span style="background-color: transparent"><a href="https://nij.ojp.gov/topics/articles/sentinel-events-initiative" rel="noopener noreferrer nofollow">https://nij.ojp.gov/topics/articles/sentinel-events-initiative</a></span></span>. </em></p>
</div>
N1  - <div data-schema-version="8"><p><span style="color: rgb(28, 29, 30)"><span style="background-color: rgb(255, 255, 255)">The case review framework and coding typology developed for this study may also be a useful tool to inform sentinel event reviews that support the comprehensive analysis of wrongful conviction cases involving forensic evidence.</span></span></p>
</div>
KW  - wrongful conviction
KW  - exoneration
KW  - policy
KW  - cognitive bias
KW  - DNA
KW  - forensic science
KW  - forensic pathology
KW  - seized drugs
KW  - serology
KW  - toxicology
KW  - forensic medicine
KW  - ballistic evidence
KW  - bitemark
KW  - crime scene investigation
KW  - fire debris investigation
KW  - hair comparison
KW  - latent print
KW  - standards
ER  - 

TY  - BLOG
TI  - Do Appellate Courts Learn from Wrongful Convictions?
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Regular Columnist James M. Doyle highlights the recent exoneration of ten men in Massachusetts, most of whom were wrongfully convicted in Suffolk County and are Black. Doyle argues that wrongful convictions are not just caused by individual "bad apples," but by systemic failures at every level of the criminal justice system. Doyle questions whether state appellate courts, such as the Massachusetts Supreme Judicial Court, are interested in learning from these wrongful convictions, and argues that relying on end-of-process inspection for safety is doomed to failure.
DA  - 2023/04/12/T18:40:00+00:00
PY  - 2023
LA  - en-US
UR  - https://thecrimereport.org/2023/04/12/do-appellate-courts-learn-from-wrongful-convictions/
Y2  - 2023/04/13/13:28:31
ER  - 

TY  - BLOG
TI  - Executing Richard Glossip Will Show a Brittle, Unsafe System
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Veteran litigation lawyer and regular viewpoint series contributor James M. Doyle argues against the fetishizing of "finality" in the criminal justice system and points to the looming execution of Richard Glossip in Oklahoma, who has been tried, convicted, and sentenced to death twice for the murder of a motel manager in 1997. The author argues that the Oklahoma judiciary is proud of itself for forbidding adaptive reactions and enforcing brittleness, and that the looming execution shows how the legal system prioritizes the "finality of judgment" over ensuring that justice is served.
DA  - 2023/05/03/T19:07:39+00:00
PY  - 2023
LA  - en-US
UR  - https://thecrimereport.org/2023/05/03/executing-richard-glossip-will-show-a-brittle-unsafe-system/
Y2  - 2023/05/03/20:58:50
ER  - 

TY  - JOUR
TI  - Contexts shaping misdemeanor system interventions among people with mental illnesses: qualitative findings from a multi-site system mapping exercise
AU  - Wood, Jennifer D.
AU  - Watson, Amy C.
AU  - Pope, Leah
AU  - Warnock, Amanda
AU  - Nelson, Veronica
AU  - Gesser, Nili
AU  - Zern, Adria
AU  - Stagoff-Belfort, Aaron
AU  - de Bibiana, Jason Tan
AU  - Compton, Michael T.
T2  - Health & Justice
AB  - People with mental illnesses are disproportionately entangled in the criminal legal system. Historically, this involvement has resulted from minor offending, often accompanied by misdemeanor charges. In recent years, policymakers have worked to reduce the footprint of the criminal legal system. This paper seeks to better understand how misdemeanor systems intervene in the lives of people with mental illnesses.


https://groups.google.com/d/msgid/criminal-justice-sentinel-events/255d757e-d979-467d-bf78-91aed8e66ae3n%40googlegroups.com.
DA  - 2023/04/04/
PY  - 2023
DO  - 10.1186/s40352-023-00219-8
DP  - Springer Link
VL  - 11
IS  - 1
SP  - 20
J2  - Health Justice
LA  - en
SN  - 2194-7899
ST  - Contexts shaping misdemeanor system interventions among people with mental illnesses
UR  - https://doi.org/10.1186/s40352-023-00219-8
Y2  - 2023/05/15/15:17:00
N1  - <div data-schema-version="8"><p>Doyle </p>
<p>The de-institutionalization of the mentally ill and heightened barriers to coercive treatment have resulted in dumping the mentally ill into the criminal justice system.  This, in turn,  has led to extended "send the cops v. send the docs" debates generally conducted as if were possible to know in advance ("the work as imagined") what would actually be required on the scene.</p>
<p> </p>
<p>Here's a refreshing qualitative look at a number of efforts to wrestle with these issues in the misdemeanor systems in several cities.  I should emphasize <em>systems</em> here.  Everyone's role gets a look, and there's an unemphasized "historical ethnography" undertone reminiscent of Diane Vaughan's attention to "situated actions" etc.  </p>
<p> </p>
<p>Provides a recommendation for SE reviews in "high frequency / low impact" events---couple with the recognition that sometimes the impact (e.g., F Train stranglings) will be hight.  <a href="https://link.springer.com/article/10.1186/s40352-023-00219-8" rel="noopener noreferrer nofollow">https://link.springer.com/article/10.1186/s40352-023-00219-8</a></p>
<p> </p>
<p>Open access.</p>
<p>-- <br>You received this message because you are subscribed to the Google Groups "Criminal Justice Sentinel Events" group.<br>To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:criminal-justice-sentinel-events+unsubscribe@googlegroups.com" rel="noopener noreferrer nofollow">criminal-justice-sentinel-events+unsubscribe@googlegroups.com</a>.<br>To view this discussion on the web visit <a href="https://protect2.fireeye.com/v1/url?k=b454b0ed-ebcf8816-b4539408-ac1f6b0176a2-57d8e9782898c997&q=1&e=99e7fc08-08d0-4113-9926-d9a1a9f23a8a&u=https%3A%2F%2Fgroups.google.com%2Fd%2Fmsgid%2Fcriminal-justice-sentinel-events%2F255d757e-d979-467d-bf78-91aed8e66ae3n%2540googlegroups.com%3Futm_medium%3Demail%26utm_source%3Dfooter" rel="noopener noreferrer nofollow">https://groups.google.com/d/msgid/criminal-justice-sentinel-events/255d757e-d979-467d-bf78-91aed8e66ae3n%40googlegroups.com</a>.</p>
</div>
N1  - <div data-schema-version="8"><p><span style="color: rgb(51, 51, 51)"><span style="background-color: rgb(252, 252, 252)">Scenario-based, or case-based exercises might provide a concrete mechanism for criminal legal decision-makers to examine their shared decision-making contexts in depth, and to develop innovative ideas for improving those contexts. Such exercises might follow a modified version of the ‘Sentinel Event Review’ (SER) process which focuses on improving how whole systems function. The SER process was designed to diagnose system ‘errors’ or what Hollway and colleagues refer to as “any undesirable outcome in the criminal process” (Hollway & Grunwald, </span></span><span style="color: rgb(0, 75, 131)"><span style="background-color: rgb(252, 252, 252)"><a href="https://link.springer.com/article/10.1186/s40352-023-00219-8#ref-CR28" title="Hollway, J. F., & Grunwald, B. (2019). Applying sentinel event reviews to policing [https://doi.org/10.1111/1745-9133.12457]. Criminology & Public Policy, 18(3), 705–730. 
                  https://doi.org/10.1111/1745-9133.12457
                  
                " rel="noopener noreferrer nofollow">2019</a></span></span><span style="color: rgb(51, 51, 51)"><span style="background-color: rgb(252, 252, 252)">, p. 707). SERs traditionally focus on a case-based analysis of a ‘sentinel event’ where a significant error or harm occurred, or an event that was a ‘near miss’ took place. It is concerned with thoroughly diagnosing the root cause or causes of an error and identifying practical points of intervention to reduce the chances of the error happening in the future. The assumption is that errors can in some cases be caused by a series of small ‘mistakes’ that combine to produce a big mistake, or even a disaster (Doyle, </span></span><span style="color: rgb(0, 75, 131)"><span style="background-color: rgb(252, 252, 252)"><a href="https://link.springer.com/article/10.1186/s40352-023-00219-8#ref-CR20" title="Doyle, J. M. (2010, 2010 Winter). Learning from error in American criminal justice. Journal of Criminal Law and Criminology, 100(1), 109. 
                  https://link.gale.com/apps/doc/A227944259/ITOF?u=temple_main&sid=bookmark-ITOF&xid=2cc66b5d
                  
                " rel="noopener noreferrer nofollow">2010</a></span></span><span style="color: rgb(51, 51, 51)"><span style="background-color: rgb(252, 252, 252)">; see also Sherman, </span></span><span style="color: rgb(0, 75, 131)"><span style="background-color: rgb(252, 252, 252)"><a href="https://link.springer.com/article/10.1186/s40352-023-00219-8#ref-CR55" title="Sherman, L. W. (2018). Reducing fatal police shootings as system crashes: research, theory, and practice. Annual Review of Criminology, 1(1), 421–449. 
                  https://doi.org/10.1146/annurev-criminol-032317-092409
                  
                " rel="noopener noreferrer nofollow">2018</a></span></span><span style="color: rgb(51, 51, 51)"><span style="background-color: rgb(252, 252, 252)">). The approach has been used in a range of industries such as aviation and medicine (Liang, </span></span><span style="color: rgb(0, 75, 131)"><span style="background-color: rgb(252, 252, 252)"><a href="https://link.springer.com/article/10.1186/s40352-023-00219-8#ref-CR36" title="Liang, B. A. (2000). Risks of reporting sentinel events. Health Affairs, 19(5), 112–120." rel="noopener noreferrer nofollow">2000</a></span></span><span style="color: rgb(51, 51, 51)"><span style="background-color: rgb(252, 252, 252)">), and the case has been made to apply such reviews to policing and criminal justice (Doyle, </span></span><span style="color: rgb(0, 75, 131)"><span style="background-color: rgb(252, 252, 252)"><a href="https://link.springer.com/article/10.1186/s40352-023-00219-8#ref-CR21" title="Doyle, J. M. (2019). Essay: A “safety model” perspective can aid diagnosis, prevention, and restoration after criminal justice harms. Santa Clara Law Review, 59(1), 107–134." rel="noopener noreferrer nofollow">2019</a></span></span><span style="color: rgb(51, 51, 51)"><span style="background-color: rgb(252, 252, 252)">; Sheil et al., </span></span><span style="color: rgb(0, 75, 131)"><span style="background-color: rgb(252, 252, 252)"><a href="https://link.springer.com/article/10.1186/s40352-023-00219-8#ref-CR54" title="Sheil, J., Doyle, J., & Lowenkamp, C. T. (2016). Imagining sentinel event reviews in the U.S. probation and pretrial services system. Federal Probation, 80(2), 33–37, 66." rel="noopener noreferrer nofollow">2016</a></span></span><span style="color: rgb(51, 51, 51)"><span style="background-color: rgb(252, 252, 252)">), as has been done previously in Philadelphia (Hollway & Grunwald, </span></span><span style="color: rgb(0, 75, 131)"><span style="background-color: rgb(252, 252, 252)"><a href="https://link.springer.com/article/10.1186/s40352-023-00219-8#ref-CR28" title="Hollway, J. F., & Grunwald, B. (2019). Applying sentinel event reviews to policing [https://doi.org/10.1111/1745-9133.12457]. Criminology & Public Policy, 18(3), 705–730. 
                  https://doi.org/10.1111/1745-9133.12457
                  
                " rel="noopener noreferrer nofollow">2019</a></span></span><span style="color: rgb(51, 51, 51)"><span style="background-color: rgb(252, 252, 252)">) outside of a mental health context.</span></span></p>
</div>
KW  - Housing
KW  - Diversion
KW  - COVID-19
KW  - Misdemeanors
KW  - Criminal charges
KW  - Criminal legal system
KW  - Mental illnesses
KW  - System mapping
ER  - 

TY  - ELEC
TI  - Agenda - Innovations in Criminal Justice: The 2023 Quattrone Center Spring Symposium
AU  - Quattrone Center for Fair Administration of Justice
AB  - May 11: 
3:15 – 4:45 pm
Sentinel Event Reviews: What has worked and where do we go from here?

• Moderator: John Hollway, Quattrone Center, University of Pennsylvania Carey Law School
• Lisa Judge, City of Seattle (WA) Office of Inspector General
• Karin D. Martin, University of Washington
• Paige Valenta, City of Madison (WI) Police Department
DA  - 2023/05/10/12
PY  - 2023
UR  - https://web.cvent.com/event/aadf0660-96e1-4206-b963-e1750deec993/websitePage:ae1234dc-291e-4622-8d69-b39130b3479a
Y2  - 2023/05/15/15:52:13
L2  - https://web.cvent.com/event/aadf0660-96e1-4206-b963-e1750deec993/websitePage:ae1234dc-291e-4622-8d69-b39130b3479a
ER  - 

TY  - BLOG
TI  - Saul Kassin Probes Dangerous Practices in ‘Duped: Why Innocent People Confess—and Why We Believe Their Confessions’ (Book Review)
AU  - Doyle, James M.
T2  - The Crime Report
AB  - Do innocent people really confess to horrific crimes they did not commit?  Yes, they do. A masterful recent book from John Jay College of Criminal Justice Professor Saul Kassin, “Duped: Why Innocent People Confess—and Why We Believe Their Confessions,” proves it beyond any doubt.   And Dr. Kassin’s book goes further than that.  It shows how
DA  - 2023/04/24/T15:34:58+00:00
PY  - 2023
LA  - en-US
ST  - Saul Kassin Probes Dangerous Practices in ‘Duped
UR  - https://thecrimereport.org/2023/04/24/saul-kassin-probes-dangerous-practices-in-duped-why-innocent-people-confess-and-why-we-believe-their-confessions-book-review/
Y2  - 2023/05/15/16:24:24
L2  - https://thecrimereport.org/2023/04/24/saul-kassin-probes-dangerous-practices-in-duped-why-innocent-people-confess-and-why-we-believe-their-confessions-book-review/
N1  - <div data-schema-version="8"><p>Doyle email:</p>
<p>In the course of demolishing Hugo Munsterberg's early law/psychology efforts, John Henry Wigmore looked forward to the day when psychologists and lawyers could join together in a "friendly and energetic alliance in the noble cause of justice."  In this book Saul Kassin shows how that alliance could work and what an ally can contribute.  Highly recommended. <a href="https://protect2.fireeye.com/v1/url?k=b8304c17-e7ab74ce-b83768f2-ac1f6b01751a-8079e89dec5816db&q=1&e=65e300b8-157f-4985-8793-9a1cab53151a&u=https%3A%2F%2Fthecrimereport.org%2F2023%2F04%2F24%2Fsaul-kassin-probes-dangerous-practices-in-duped-why-innocent-people-confess-and-why-we-believe-their-confessions-book-review%2F" rel="noopener noreferrer nofollow">https://thecrimereport.org/2023/04/24/saul-kassin-probes-dangerous-practices-in-duped-why-innocent-people-confess-and-why-we-believe-their-confessions-book-review/</a></p>
<p>-- <br>You received this message because you are subscribed to the Google Groups "Criminal Justice Sentinel Events" group.<br>To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:criminal-justice-sentinel-events+unsubscribe@googlegroups.com" rel="noopener noreferrer nofollow">criminal-justice-sentinel-events+unsubscribe@googlegroups.com</a>.<br>To view this discussion on the web visit <a href="https://protect2.fireeye.com/v1/url?k=833d70f0-dca64829-833a5415-ac1f6b01751a-9c9dc0dda6267645&q=1&e=65e300b8-157f-4985-8793-9a1cab53151a&u=https%3A%2F%2Fgroups.google.com%2Fd%2Fmsgid%2Fcriminal-justice-sentinel-events%2F604f470b-aec6-4bcd-8633-e1bb0dd3ef38n%2540googlegroups.com%3Futm_medium%3Demail%26utm_source%3Dfooter" rel="noopener noreferrer nofollow">https://groups.google.com/d/msgid/criminal-justice-sentinel-events/604f470b-aec6-4bcd-8633-e1bb0dd3ef38n%40googlegroups.com</a></p>
</div>
ER  - 

TY  - ELEC
TI  - Leading the Process for Systemic Policing Change
AU  - Quattrone Center for Fair Administration of Justice
AB  - The Quattrone Center has released of the final set of recommendations from a Sentinel Event Review (SER) of incidents during protests following the murder...
DA  - 2023/04/19/
PY  - 2023
LA  - en
UR  - https://www.law.upenn.edu/live/news/15769-leading-the-process-for-systemic-policing-change
Y2  - 2023/05/15/16:46:46
L2  - https://www.law.upenn.edu/live/news/15769-identifying-opportunities-for-systemic-improvement
N1  - <div data-schema-version="8"><p>Doyle:</p>
<p>Seattle's Inspector General enlisted the Quattrone Center's SE expertise and has done all-stakeholders, forward-looking examinations of the waves of events following the George Floyd homicide.  Both involves the community and represents an effort to establish a permanent capability.   <a href="https://www.law.upenn.edu/live/news/15769-identifying-opportunities-for-systemic-improvement" rel="noopener noreferrer nofollow">https://www.law.upenn.edu/live/news/15769-identifying-opportunities-for-systemic-improvement</a></p>
<p> </p>
<p>This <em>will </em>be on the exam. </p>
<p>-- <br>You received this message because you are subscribed to the Google Groups "Criminal Justice Sentinel Events" group.<br>To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:criminal-justice-sentinel-events+unsubscribe@googlegroups.com" rel="noopener noreferrer nofollow">criminal-justice-sentinel-events+unsubscribe@googlegroups.com</a>.<br>To view this discussion on the web visit <a href="https://protect2.fireeye.com/v1/url?k=ed217e50-b2ba4701-ed265ab5-ac1f6b01770e-5a78da26a0300240&q=1&e=3e56bc93-5c6f-4b4f-b688-f05ebc755e93&u=https%3A%2F%2Fgroups.google.com%2Fd%2Fmsgid%2Fcriminal-justice-sentinel-events%2Ffb3f9517-16e1-493a-8a13-2207c13100c3n%2540googlegroups.com%3Futm_medium%3Demail%26utm_source%3Dfooter" rel="noopener noreferrer nofollow">https://groups.google.com/d/msgid/criminal-justice-sentinel-events/fb3f9517-16e1-493a-8a13-2207c13100c3n%40googlegroups.com</a>.</p>
<p>-- <br>You received this message because you are subscribed to the Google Groups "Criminal Justice Sentinel Events" group.<br>To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:criminal-justice-sentinel-events+unsubscribe@googlegroups.com" rel="noopener noreferrer nofollow">criminal-justice-sentinel-events+unsubscribe@googlegroups.com</a>.<br>To view this discussion on the web visit <a href="https://protect2.fireeye.com/v1/url?k=893df59f-d6a6ccce-893ad17a-ac1f6b01770e-2093cc68f008f8b3&q=1&e=3e56bc93-5c6f-4b4f-b688-f05ebc755e93&u=https%3A%2F%2Fgroups.google.com%2Fd%2Fmsgid%2Fcriminal-justice-sentinel-events%2FBL3PR01MB7010DB3083794E1630ED968296639%2540BL3PR01MB7010.prod.exchangelabs.com%3Futm_medium%3Demail%26utm_source%3Dfooter" rel="noopener noreferrer nofollow">https://groups.google.com/d/msgid/criminal-justice-sentinel-events/BL3PR01MB7010DB3083794E1630ED968296639%40BL3PR01MB7010.prod.exchangelabs.com</a>.</p>
</div>
ER  - 

TY  - RPRT
TI  - Sentinel Event Review of Police Response to 2020 Protests in Seattle Wave 4: July 2 – October 7, 2020
AU  - Seattle Office of Inspector General
AB  - This report is the culmination of an in-depth, community-centered review of the Seattle Police
Department (SPD) response to sustained protests in the wake of George Floyd’s murder.
Beginning in the Fall of 2020, the Office of Inspector General (OIG), in collaboration with
community members and SPD, conducted a series of Sentinel Event Reviews (SERs) to identify
contributing factors resulting in critical incidents causing community concern in the 2020
protests.1 This fourth and final report focuses on crowd management tactics utilized by SPD in
response to three significant protest events occurring between July and September.
DA  - 2023/04/18/
PY  - 2023
SP  - 45
UR  - https://seattle.gov/documents/Departments/OIG/Sentinel%20Event%20Review/FINALSERWave%204Report.pdf
ER  - 

TY  - BLOG
TI  - Announcement: Diane Vaughan’s “Dead Reckoning: Air Traffic Control, System Effects, and Risk” (Chicago, 2021) has been selected for the 2023 American Institute of Aeronautics and Astronautics Gardner-Lasser Aeronautics and Astronautics History Literature Award.
AU  - Eren, Dilan
T2  - Organizations, Occupations and Work
AB  - Dead Reckoning is an historical ethnography covering the life course of the air traffic control system from system emergence through 2017. Based on archival research and field work in four air...
DA  - 2022/11/10/T08:14:50+00:00
PY  - 2022
LA  - en
ST  - Announcement
UR  - https://oowsection.org/2022/11/10/announcement-diane-vaughans-dead-reckoning-air-traffic-control-system-effects-and-risk-chicago-2021-has-been-selected-for-the-2023-american-institute-of-aeronautics-and-astronau/
Y2  - 2023/05/15/17:06:08
L2  - https://oowsection.org/2022/11/10/announcement-diane-vaughans-dead-reckoning-air-traffic-control-system-effects-and-risk-chicago-2021-has-been-selected-for-the-2023-american-institute-of-aeronautics-and-astronau/
N1  - <div data-schema-version="8"><p>I'd like to be able to say that "I've read it so that you don't have to," but, alas, I'm only part way in.  That fraction, though is enough to get me to urge SE list members to take advantage of the U of Chicago Press free offer during April.</p>
<p> </p>
<p>Diane Vaughan approaches the air traffic control system as a question of historical ethnography and focuses on the "situated action" in an approach that takes account of institutional, organizational, and individual interactions in a hugely complex socio-technical system under constant pressure.  The timing of her project gave her an opportunity to evaluate the system's responses to 9/11.  No individual SE review could do what Vaughan does but the ambitions should be something like this.  And, of course, what is striking is that (as far as I know anyway) no one has ever done anything like this in criminal justice.  The only journalistic attempts I know of to understand the "situated action" of the myriad players are Jennifer Gonnerman's.  </p>
<p>On Tuesday, April 4, 2023 at 12:30:06 PM UTC-4 James Doyle wrote:</p>
<p>Not sure if this will work. I haven't played it though all the way myself.  But it appears that the University of Chicago Press is offering free e-book copies of Diane Vaughan't "Dead Reckoning."  <a href="https://press.uchicago.edu/books/freeEbook.html?utm_source=newsletter&utm_medium=email&utm_content=DOWNLOAD&utm_campaign=Free_e-book_April_2023" rel="noopener noreferrer nofollow">https://press.uchicago.edu/books/freeEbook.html?utm_source=newsletter&utm_medium=email&utm_content=DOWNLOAD&utm_campaign=Free_e-book_April_2023</a></p>
<p> </p>
<p>Most of you will remember that Vaughan's careful anatomy of the space shuttle, Challenger, launch decision was a paradigm shifting recognition that cause lay not in amoral calculators violation rules, but in "a mistake embedded in the banality of organizational life", that conformity, not violation was the issue.</p>
<p> </p>
<p>In the new book she turns her attention to air traffic control: to a system that works rather than to a disaster.   </p>
<p>-- <br>You received this message because you are subscribed to the Google Groups "Criminal Justice Sentinel Events" group.<br>To unsubscribe from this group and stop receiving emails from it, send an email to <a href="mailto:criminal-justice-sentinel-events+unsubscribe@googlegroups.com" rel="noopener noreferrer nofollow">criminal-justice-sentinel-events+unsubscribe@googlegroups.com</a>.<br>To view this discussion on the web visit <a href="https://protect2.fireeye.com/v1/url?k=7f3b4a61-20a073d2-7f3c6e84-0cc47adc5e1a-2ea4d1335281a1fc&q=1&e=e44f0651-d98f-464c-9eda-961f8b883115&u=https%3A%2F%2Fgroups.google.com%2Fd%2Fmsgid%2Fcriminal-justice-sentinel-events%2Fd9c0a8a4-e0d8-4b0e-ae9e-d4ec8133a913n%2540googlegroups.com%3Futm_medium%3Demail%26utm_source%3Dfooter" rel="noopener noreferrer nofollow">https://groups.google.com/d/msgid/criminal-justice-sentinel-events/d9c0a8a4-e0d8-4b0e-ae9e-d4ec8133a913n%40googlegroups.com</a>.</p>
</div>
ER  - 

TY  - BLOG
TI  - What if we treated wrongful convictions and bad police shootings the way we treat plane crashes?
AU  - Balko, Radley
T2  - The Watch
AB  - In a Q&A, Quattrone Center Executive Director John Hollway explains how "sentinel event reviews" can improve the criminal justice system
DA  - 2023/06/08/
PY  - 2023
M3  - Substack newsletter
UR  - https://radleybalko.substack.com/p/what-if-we-treated-wrongful-convictions
Y2  - 2023/06/08/15:21:52
L2  - https://radleybalko.substack.com/p/what-if-we-treated-wrongful-convictions
ER  - 

TY  - BLOG
TI  - Looking at 911 mental health calls in a new way
AU  - Doyle, James
T2  - CommonWealth Magazine
AB  - A SPOUSE,  A SISTER, or a brother suffers an acute mental health crisis. Family members call 911 as a last resort. A Boston Globe analysis reports that these calls—there are a lot of them—initiate chains of events that can (and, on an average of five times each year in Massachusetts, do) culminate in a fatal police(...)
DA  - 2023/06/19/T19:49:08+00:00
PY  - 2023
LA  - en-US
UR  - https://commonwealthmagazine.org/opinion/looking-at-911-mental-health-calls-in-a-new-way/
Y2  - 2023/06/20/20:19:58
L2  - https://commonwealthmagazine.org/opinion/looking-at-911-mental-health-calls-in-a-new-way/
N1  - <div data-schema-version="8"><p><span style="color: rgb(34, 34, 34)"><span style="background-color: rgb(255, 255, 255)">But aviation’s components have the advantage of functioning under the integrated federal umbrella managed by the Federal Aviation Administration.  Air traffic controllers work in scattered, individualized centers, towers, and other facilities, each with its own “personality,” but all received the same training and answer to the same agency.   The pilots, airlines, and manufacturers that the controllers are working to position are all included in careful </span></span><span style="color: rgb(160, 21, 37)"><span style="background-color: rgb(255, 255, 255)"><a href="https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.ntsb.gov%2Fsafety%2Fsafety-studies%2FDocuments%2FSR0601.pdf&data=05%7C01%7Cbmohl%40massinc.org%7Ce6ec3ec8a4294adc9a8708db6ce5a799%7C2e4281ac78ee4d85a6c5083153ea1b48%7C1%7C0%7C638223506303514355%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=kE79oV%2Fi9e10sLsAVNHlN50tFv%2BBR9BGjXAF428NBvg%3D&reserved=0" rel="noopener noreferrer nofollow">National Transportation Safety Board</a></span></span><span style="color: rgb(34, 34, 34)"><span style="background-color: rgb(255, 255, 255)"> reviews of serious accidents and in a confidential, voluntary, non-punitive </span></span><span style="color: rgb(160, 21, 37)"><span style="background-color: rgb(255, 255, 255)"><a href="https://nam11.safelinks.protection.outlook.com/?url=https%3A%2F%2Fasrs.arc.nasa.gov%2F&data=05%7C01%7Cbmohl%40massinc.org%7Ce6ec3ec8a4294adc9a8708db6ce5a799%7C2e4281ac78ee4d85a6c5083153ea1b48%7C1%7C0%7C638223506303514355%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C3000%7C%7C%7C&sdata=wtxLIogKBP%2BbJR%2BSZPd5sFQmTNZ09ldEsJeVxyaa%2Ftc%3D&reserved=0" rel="noopener noreferrer nofollow">Aviation Safety Reporting System</a></span></span><span style="color: rgb(34, 34, 34)"><span style="background-color: rgb(255, 255, 255)"> that analyzes “near miss” and “good catch” incidents. Lessons are learned, and the lessons are disseminated.  Bulletins are issued; training is modified</span></span></p>
</div>
ER  - 

TY  - RPRT
TI  - San Francisco Domestic Violence Death Review Team Pilot Report
AU  - City of San Franciso
AB  - This Domestic Violence Death Review Team (DVDRT) Pilot was jointly created by the San Francisco District Attorney’s Office (SFDA) and the Department on the Status of Women of the City and County of
San Francisco (DOSW) pursuant to the provisions of California Penal Code 11163.3.1
 The City and County of San Francisco have a long-established commitment to reviewing domestic violence-related
fatalities, to strengthen system policies and procedures and identify prevention strategies to reduce
future incidents of domestic violence-related injuries and deaths. San Francisco has an active Family
Violence Council that addresses systems response to domestic violence but has not had staffing for a
dedicated Death Review Team. The development of a Domestic Violence Death Review Team is a recurring recommendation from the Family Violence Council. In 2018 CCSF was able to secure additional
resources to reintroduce a DVDRT in the form of a pilot. The SFDA and DOSW began by reviewing a prior protocol for domestic violence, child and elder death case reviews conducted by system partners.
Prior DVDRT efforts were co-chaired by the San Francisco District Attorney’s Office and the Cooperative
Restraining Order Clinic (CROC), with the Department on the Status of Women providing staffing and
coordination. This prior experience laid a strong foundation for coordinating the relaunch named the
DVDRT Pilot. The SFDA and DOSW engaged the Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania Carey Law School (Quattrone Center or QC) to assist in coordinating
and moderating the DVDRT Pilot.
2
 The Quattrone Center is a national thought leader in sentinel event
reviews in criminal justice and has assisted jurisdictions across the country in the conduct of such reviews in a variety of different contexts within the criminal justice system.
DA  - 2023/05//
PY  - 2023
UR  - https://sf.gov/sites/default/files/2023-06/2023%20San%20Francisco%20Domestic%20Violence%20Death%20Review%20Team%20(DVDRT)%20Pilot%20Report.pdf
N1  - <div data-schema-version="8"><p>This research was supported by Grant No. 2017-MU-MU-K021 awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Department of Justice's Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office. Points of view or opinions in this document are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice.</p>
</div>
ER  - 

TY  - JOUR
TI  - The Impacts of Neighborhoods on Intergenerational Mobility I: Childhood Exposure Effects*
AU  - Chetty, Raj
AU  - Hendren, Nathaniel
T2  - The Quarterly Journal of Economics
AB  - We show that the neighborhoods in which children grow up shape their earnings, college attendance rates, and fertility and marriage patterns by studying more than 7 million families who move across commuting zones and counties in the United States. Exploiting variation in the age of children when families move, we find that neighborhoods have significant childhood exposure effects: the outcomes of children whose families move to a better neighborhood—as measured by the outcomes of children already living there—improve linearly in proportion to the amount of time they spend growing up in that area, at a rate of approximately 4% per year of exposure. We distinguish the causal effects of neighborhoods from confounding factors by comparing the outcomes of siblings within families, studying moves triggered by displacement shocks, and exploiting sharp variation in predicted place effects across birth cohorts, genders, and quantiles to implement overidentification tests. The findings show that neighborhoods affect intergenerational mobility primarily through childhood exposure, helping reconcile conflicting results in the prior literature.
DA  - 2018/08/01/
PY  - 2018
DO  - 10.1093/qje/qjy007
DP  - Silverchair
VL  - 133
IS  - 3
SP  - 1107
EP  - 1162
J2  - The Quarterly Journal of Economics
SN  - 0033-5533
ST  - The Impacts of Neighborhoods on Intergenerational Mobility I
UR  - https://doi.org/10.1093/qje/qjy007
Y2  - 2023/06/21/17:21:11
L2  - https://academic.oup.com/qje/article/133/3/1107/4850660
ER  - 

TY  - RPRT
TI  - REPORT 02 OF THE BOARD OF TRUSTEES (I-21) Policing Reform
AU  - American Medical Association
AB  - Frome Executive Summary 
There is a lack of evidence that abolishing qualified immunity, terminating the 1033 Program,
and/or establishing COBs would reduce police violence. Therefore, the AMA’s contribution to the
national conversation about policing would be better focused on a holistic approach to policing. In
particular, procedurally just policing models and greater community involvement in policing
policies and practices are promising, evidence-based means of decreasing use-of-force. In addition,
because of the similarities between medicine and law enforcement—professionals in both fields are
frequently placed in high-pressure situations in which they must make split second, life-or-death
decisions—it may benefit law enforcement to borrow some of the strategies and practices that the
medical profession uses to ensure that its members provide safe and effective care, such as
establishing evidence-based standards and practices, implementing sentinel event reviews
following an adverse event, and encouraging further research into the impact of law enforcement
practices and programs.

P. 6 

Furthermore, application of sentinel event reviews, like those conducted in health care and aviation
2 settings, following a negative event, such as a police shooting, provide a promising upstream
3 approach to reform. A sentinel event review focuses not on assigning blame but bringing together
4 key community stakeholders to conduct a root cause analysis of all factors that led to a negative
5 outcome and reforms that can strengthen the system to prevent recurrence. Like sentinel event
6 reviews in health care, the approach recognizes that failures are often system-wide and not the
7 result of a single individual’s actions. The goal, therefore, is to enable systems changes in practice
8 and culture. Sentinel event reviews are an emerging effort, though the U.S. Department of Justice
9 Sentinel Events Initiative has been encouraging and evaluating their adoption since 2014. One of
10 the first jurisdictions to adopt a sentinel event review board (Review Board) was the Tucson Police
Department, which convened in summer 2020 following two in-custody deaths of Latino men.21 11
12 The 15 members of the Review Board identified 32 contributing factors and agreed unanimously
13 on 53 recommendations for the Tucson Police Department, the Tucson Fire Department, and the
14 Tucson Public Safety Communications Department to prevent future in-custody deaths. An
15 implementation report produced six months later found that, as a result, of the review, agencies had
adopted new policies, procedures, and training to address prior failings.22
DA  - 2023///
PY  - 2023
SP  - 19
UR  - https://www.ama-assn.org/system/files/n21-bot02.pdf
ER  - 

TY  - ELEC
TI  - AMA Policy Policing Reform D-65.987
AU  - American Medical Association
AB  - Our AMA: (1) will advocate for efforts to implement evidence-based policing and the creation of evidence-based standards for law enforcement; (2) will advocate for sentinel event reviews in the criminal justice system following an adverse event, such as an in-custody death; (3) encourages further research by subject matter experts on the issues related to the transfer of military equipment to law enforcement agencies, including the impact on communities, particularly those in minoritized and marginalized communities; and (4) supports greater police accountability, procedurally just policing models, and greater community involvement in policing policies and practices.
DA  - 2021///
PY  - 2021
UR  - https://policysearch.ama-assn.org/policyfinder/detail/Sentinel%20event?uri=%2FAMADoc%2Fdirectives.xml-D-65.987.xml
Y2  - 2023/06/22/18:58:05
L2  - https://policysearch.ama-assn.org/policyfinder/detail/Sentinel%20event?uri=%2FAMADoc%2Fdirectives.xml-D-65.987.xml
ER  - 

TY  - ELEC
TI  - Sentinel Event Reviews: What Has Worked and Where Do We Go From Here?
AU  - Quattrone Center for Fair Administration of Justice
T2  - Innovations in Criminal Justice: The 2023 Quattrone Center Spring Symposium
AB  - 04:29:14 - Sentinel Event Reviews: What Has Worked and Where Do We Go From Here?y

Sentinel Event Reviews: What Has Worked and Where Do We Go From Here?
Moderator: John Hollway, Quattrone Center, University of Pennsylvania Carey Law School
Panelist: Lisa Judge, City of Seattle (WA) Office of Inspector General; Karin D. Martin, University of Washington; Paige Valenta, City of Madison (WI) Police Department
 
Field Drug Tests and Wrongful Convictions: What the Data Tells Us
Ross Miller, Quattrone Center, University of Pennsylvania Carey Law School
DA  - 2023/05/11/
PY  - 2023
ST  - Innovations in Criminal Justice
UR  - https://www.youtube.com/watch?v=aLFq_DqIZ28
Y2  - 2023/06/22/19:16:55
ER  - 

TY  - CHAP
TI  - Learning from Sentinel Events
AU  - Doyle, James
AU  - McGough, Maureen Q.
T2  - Transforming Criminal Justice
A2  - Gould, Jon B.
A2  - Metzger, Pamela R.
DA  - 2022/12/06/
PY  - 2022
DP  - www.degruyter.com
SP  - 321
EP  - 344
LA  - en
PB  - New York University Press
SN  - 978-1-4798-1883-9
UR  - https://www.degruyter.com/document/doi/10.18574/nyu/9781479818839.003.0016/pdf
Y2  - 2023/07/05/17:58:37
ER  - 

TY  - JOUR
TI  - “I am doing my part, you are doing your part”: the sworn-civilian divide in police dispatching
AU  - Orosco, Carlena
AU  - Gaub, Janne E.
T2  - Policing: An International Journal
AB  - Purpose While police culture typically refers to the culture among sworn police personnel, there are internal cultural differences between subgroups. This has been documented among sworn personnel, such as the difference between street cops and management cops (Reuss-Ianni, 1983). The divide between professional and sworn staff in a law enforcement context has also been discussed at length (Maguire, 1997; Reiss, 1992), specifically the “us versus them” mentality that stems from feelings of isolation among professional and sworn staff. The relationship between dispatchers and officers is vital to public and officer safety; it is imperative that cultural barriers preventing effective collaboration between two of the most critical components of policing are identified, and recommendations to bridge the gap are provided. Design/methodology/approach The authors use semi-structured interview data from a sample of peer-nominated top dispatch de-escalators (TDDs) considered highly skilled at de-escalation with callers and officers. Reflexive coding techniques were used to identify key themes in an area largely unexamined by research. Findings The authors find that the police culture creates friction between sworn officers and dispatchers in a number of contexts. This diminishes organizational commitment and increases burnout and frustration. Practical implications There are several policy recommendations for both communications centers and sworn staff to foster understanding and increase collaboration, all of which may result in improved outcomes for community members, dispatchers and officers. Originality/value The authors use qualitative methods to explore the implications of the sworn-civilian divide for police practice, such as more effective de-escalation and incident resolution, as well as the conceptualization of police culture writ large.
DA  - 2022/01/01/
PY  - 2022
DO  - 10.1108/PIJPSM-07-2022-0090
DP  - Emerald Insight
VL  - 46
IS  - 1
SP  - 164
EP  - 178
SN  - 1363-951X
ST  - “I am doing my part, you are doing your part”
UR  - https://doi.org/10.1108/PIJPSM-07-2022-0090
Y2  - 2023/07/05/18:33:47
L2  - https://www.emerald.com/insight/content/doi/10.1108/PIJPSM-07-2022-0090/full/html
KW  - Policing
KW  - Qualitative research
KW  - Police culture
KW  - Dispatch
ER  - 

TY  - JOUR
TI  - Cognitive biases in criminal case evaluation: a review of the research
AU  - Meterko, Vanessa
AU  - Cooper, Glinda
T2  - Journal of Police and Criminal Psychology
DA  - 2022///
PY  - 2022
VL  - 37
IS  - 1
SP  - 101
EP  - 122
J2  - Journal of Police and Criminal Psychology
SN  - 0882-0783
ER  - 

TY  - JOUR
TI  - Shrinking the police footprint
AU  - Thacher, David
T2  - Criminal Justice Ethics
DA  - 2022///
PY  - 2022
VL  - 41
IS  - 1
SP  - 62
EP  - 85
J2  - Criminal Justice Ethics
SN  - 0731-129X
ER  - 

TY  - JOUR
TI  - The learning model of use-of-force reviews
AU  - Thacher, David
T2  - Law & Social Inquiry
DA  - 2020///
PY  - 2020
VL  - 45
IS  - 3
SP  - 755
EP  - 786
J2  - Law & Social Inquiry
SN  - 0897-6546
ER  - 

TY  - JOUR
TI  - Two kinds of problem-solving
AU  - Thacher, David
T2  - Policing: A Journal of Policy and Practice
DA  - 2023///
PY  - 2023
VL  - 17
SP  - paac073
J2  - Policing: A Journal of Policy and Practice
SN  - 1752-4512
ER  - 

TY  - JOUR
TI  - Cognitive biases in criminal case evaluation: a review of the research
AU  - Meterko, Vanessa
AU  - Cooper, Glinda
T2  - Journal of Police and Criminal Psychology
DA  - 2022///
PY  - 2022
VL  - 37
IS  - 1
SP  - 101
EP  - 122
J2  - Journal of Police and Criminal Psychology
SN  - 0882-0783
ER  - 

TY  - THES
TI  - Human error in police involved shootings
AU  - Taylor, Paul L
AB  - Police use of deadly force has become one of the most contentious and controversial aspects of
the U.S. criminal justice system. Yet, the vast majority of police shootings never rise to the level
of public consciousness (Zimring, 2017). Instead, the public discourse and controversy tends to
center on a handful of cases that appear excessive and/or are difficult to understand (Pickering &
Klinger, 2016). As a result, these cases have a disproportionate impact on the public’s perception
of police legitimacy and competence, particularly when it comes to their use of deadly force
(Gua, 2014). The outcomes of many of these controversial cases meet the definition of and could
be classified as human error (Reason, 1990). Where we find error in the professional
environment, we find the opportunity to improve practice and future outcomes (Woods et al.,
2010). Indeed, research on human error has been used as vehicle for reform and improved
practice in a number of other high-risk occupations including aviation, medicine, the military,
and transportation. This dissertation examines human error within the context of the police
decision to discharge a firearm in the line of duty. The goal of the dissertation is to provide and
test a theoretical framework designed to facilitate more meaningful research, understanding,
prediction, and perhaps even the reduction of some of the most controversial police shootings.
DA  - 2019///
PY  - 2019
PB  - State University of New York at Albany
ER  - 

TY  - THES
TI  - Law Enforcement Officers' Perceptions of their Skill Development and Transfer of Learning Post-Training
AU  - Northup, Jane
AB  - This research examined how law enforcement officers who took a course in criminal investigative techniques developed their skill and transferred what was learned post-training. The data was collected using document reviews and interviews. The participants were ten law enforcement officers who expected to use their newly acquired skill after leaving a course in criminal investigations. As a result of the qualitative multiple case study data analysis, four constructs were revealed as aids to the participants in transferring what was learned in the course and further improving their skills. The constructs were supports, experience, reflection, and motivation. The constructs can serve as tools that help law enforcement agency leaders examine their existing practices and develop new ones.
DA  - 2019///
PY  - 2019
M3  - Open Access Dissertations. Paper 836.
UR  - https://digitalcommons.uri.edu/oa_diss/836
ER  - 

TY  - JOUR
TI  - Rethinking the Blackstone Ratio with Global Public Opinion: Crime Control and Due Process
AU  - Xiong, ML
T2  - CHINESE JOURNAL OF COMPARATIVE LAW
AB  - Both the Blackstone ratio and due process are cornerstones of classical philosophy in criminal law and justice around the world. However, less consideration has been paid to contemporary society and whether the public shares this theoretical approach. Using data from four waves of the International Social Survey Programme, examining public attitudes towards controlling habitual criminals and suspected terrorists across countries, I offer evidence for how preference towards authorities' reactions (a proxy of fear of crime) affects preferences about judicial errors. My analysis shows that (i) the public supports the authorities in taking action against criminals and terrorists without a court order, though in different proportions depending on the specific means at hand; (ii) the apparent paradox of public support for the elegance of due process and fear of crime can be explained by the difficult reality of controlling criminals; (iii) absolute proponents consider type one errors to be worse and thus will not support any measures being taken, while absolute proponents consider type two errors to be worse and steps therefore need to be taken to prevent communities from the risk from crime or terrorist attacks; (iv) members of the public who favour proactive policing are significantly less likely to consider type one errors to be worse than type two; and (v) citizens across countries share the above features in a longitudinal survey. Legislators, law professors, and criminologists in transitional risk societies around the world should reconsider their justification of anti-Blackstonian theory and the crime control model.
DA  - 2022/12/16/
PY  - 2022
DO  - 10.1093/cjcl/cxac026
VL  - 10
IS  - 3
SN  - 2050-4802
AN  - WOS:000847393400001
ER  - 

TY  - JOUR
TI  - Reimagining the Use of Force by Police in a Post-Floyd Nation
AU  - Smith, MR
T2  - POLICE QUARTERLY
AB  - At this important juncture in American policing, this essay sets forth a framework to encourage law enforcement leaders and scholars to reconceptualize the use of force from the ground up. It begins by outlining changes needed in police culture and how police view their mandate to use force in society. It next addresses use of force policy-making and synthesizes recent reviews of the policy landscape, including a recent analysis of the deadly force policy from one the nation's largest county police agencies. It then suggests ways that better training can improve decision-making and produce better outcomes when force must be used. The essay concludes with a challenge to law enforcement leaders and policy-makers to leverage momentum from the tragic death of George Floyd to make fundamental changes in how police in America think about, train for, use, and manage coercive force in society.
DA  - 2022/06//undefined
PY  - 2022
DO  - 10.1177/10986111211049372
VL  - 25
IS  - 2
SP  - 228
EP  - 251
SN  - 1098-6111
AN  - WOS:000750049800001
ER  - 

TY  - JOUR
TI  - Factors Contributing to Guilty Plea Wrongful Convictions: A Quantitative Analysis of Australian Appellate Court Judgments
AU  - Nash, C
AU  - Dioso-Villa, R
AU  - Porter, L
T2  - CRIME & DELINQUENCY
AB  - Criminal defendants can face significant pressures to plead guilty, but wrongful conviction scholarship has largely overlooked the study of guilty pleas. This study content analyzed 139 Australian appellate court judgments in which a guilty plea conviction was overturned, investigating the types of errors involved in these convictions, and the stage of the criminal justice process at which the errors occurred. The findings revealed that errors occurred during the police investigation, pretrial preparations, and formal court procedures, with the most frequent errors involving incorrect or inappropriate charges, inadequate legal representation, and the courts erroneously accepting a guilty plea. The findings raise important implications regarding the adequacy of safeguards to ensure guilty pleas are appropriate or factually and legally accurate.
DA  - 2021/11/05/
PY  - 2021
DO  - 10.1177/00111287211054723
SN  - 0011-1287
AN  - WOS:000715968500001
ER  - 

TY  - JOUR
TI  - Wrongful convictions and forensic science
AU  - Bonventre, CL
T2  - WILEY INTERDISCIPLINARY REVIEWS: FORENSIC SCIENCE
AB  - More than 2,600 exonerations have been documented in the United States since 1989. Forensic science-in the form of postconviction DNA testing-has played a critical role in the revelation that wrongful convictions are a problematic feature of criminal justice. Yet, forensic science is also among the many factors-including eyewitness misidentification, false confessions, informants, and more-that are correlates of wrongful convictions. Forensic science contributes to erroneous convictions when analysts provide invalid testimony at trial or when such evidence fails to correct false crime theories. Moreover, while intentional forensic misconduct certainly exists, the effects of confirmation biases may present a greater threat to forensic analyses. The preceding mechanisms and reform efforts are discussed. This article is categorized under: Jurisprudence and Regulatory Oversight > Expert Evidence and Narrative
DA  - 2021/07//undefined
PY  - 2021
DO  - 10.1002/wfs2.1406
VL  - 3
IS  - 4
SN  - 2573-9468
AN  - WOS:000904734600003
ER  - 

TY  - JOUR
TI  - Delivering More Information to and From Lineup Witnesses: Commentary on Brewer and Doyle
AU  - Rossmo, DK
T2  - JOURNAL OF APPLIED RESEARCH IN MEMORY AND COGNITION
DA  - 2021/06//undefined
PY  - 2021
VL  - 10
IS  - 2
SP  - 196
EP  - 199
SN  - 2211-3681
AN  - WOS:000683568300003
ER  - 

TY  - JOUR
TI  - Therapy with exonerated clients: review and recommendations
AU  - Heilbrun, K
AU  - Fishel, S
AU  - Lankford, C
AU  - Ratkalkar, M
T2  - JOURNAL OF FORENSIC PRACTICE
AB  - Purpose
The conviction of innocent individuals has emerged as an international concern, resulting in substantial attention to the legal needs that stem from exoneration. However, many other challenges can also arise in the aftermath of an exoneration, including financial, psychosocial and mental health needs. Relatively little has been written about the particular reentry needs of individuals who are exonerated of their charges, and even fewer studies have considered the effectiveness of various treatment approaches. The purpose of this paper is to reviews the available literature, identifies gaps and provides clinical recommendations for the development of treatment interventions for exonerees.
Design/methodology/approach
The research addressing the needs and challenges that arise in the aftermath of exoneration is reviewed and analysed for implications that can guide treatment-planning in this area.
Findings
This paper reviews key finds from the literature and provides recommendations for developing a semi-structured approach to treating exonerees.
Practical implications
Practical applications for the development of effective therapeutic interventions for exonerated individuals are identified and discussed.
Originality/value
Currently, there is very limited literature addressing the specific reentry needs and effective therapeutic interventions for exonerated individuals.
DA  - 2020/04/08/
PY  - 2020
DO  - 10.1108/JFP-02-2020-0004
VL  - 22
IS  - 2
SP  - 123
EP  - 135
SN  - 2050-8794
AN  - WOS:000527712400001
ER  - 

TY  - JOUR
TI  - Costs and Benefits of Implementing a Root Cause Analysis Framework into the Queensland Correctional Oversight System
AU  - Byrne, James M
T2  - Fed. Probation
DA  - 2017///
PY  - 2017
VL  - 81
SP  - 3
J2  - Fed. Probation
ER  -