After the Webinar: How Justice Agencies Can Implement and Benefit from Sentinel Event Reviews. Q&A with the Presenters

Webinar presenters Dr. Mallory O’Brien and John Hollway answered a number of your questions after their presentation, How Justice Agencies Can Implement and Benefit from Sentinel Event Reviews.  Here are just a few of their responses.


Audience Question: Are you aware of any probational organizations that have been involved in this sentinel review process? 

Dr. Mallory O’Brien: I can speak to the experience that we had in Milwaukee and Minneapolis. Corrections are involved if If I’ve got the question right. Corrections are involved in both the Beta Site in Milwaukee at multiple levels and corrections have also involved in the Minneapolis review process.



Audience Question: If the Sentinel Events review process ends up identifying issues in how cases are investigated or prosecuted, do you know if any of the Sentinel Sites that you have been involved in will ultimately require to disclose this to defense attorneys? 

John Hollway: If you identify that there has been some sort of inappropriate activity in a case, the way we handle that within the Sentinel Event process, is to turn it over to the appropriate organizations within those agencies. So if we learn that a police officer or a prosecutor or somebody else has done something inappropriate, it is up to those agencies to then use their appropriate investigational process to pursue that and do it. So we separate these sentinel event reviews from any sort of investigational disclosure activity. We turn that back to the relevant agency to go to their normal process. And it’s very analogous to what the NTSB does if there is a transportation accident when the NTSB comes in, they’re the agency of record. If they find evidence that a crime has been committed, then they turn that over to the FBI who pursues it. But only at that point and the NTSB stays separate from that to preserve its role as a safety and quality organization.



Audience Question: Have those other industries that you mentioned such as aerospace or medicine, have they always been so receptive to doing peer reviews and event reviews? Do we have a sense of how they started on this process? 

John Hollway: So aviation’s been doing this for the past 50 years or so. I think what started it was they had too many planes that were falling out of the sky. I think what you’re seeing is 70 years of doing this and now you go from 30 crashes a year to 2 injuries per one million flights. Healthcare was a little bit later to the party. That To Err Is Human publication in 1998 was really looking back at aviation and saying what can we learn in healthcare, and criminal justice is now coming to it after those two industries and try to learn from both of them.



Audience Question: Do you recommend an outside facilitator when evaluating sentinel events or perhaps with just some types of cases? 

Dr. Mallory O’Brien: What I found over the years and I think John will echo this, is that it’s really important that you do find somebody who is external to the process to be facilitating the reviews and gathering information the way the Quattrone Center has. Because I’ve gone through these reviews where its been one of the agencies that’s part of the process leading the review. It’s just better for all parties if you’ve got a neutral person who can facilitate it. And another thing that we’ve learned over time too is that not everybody can facilitate a meeting. So it’s important that you not only find someone who’s neutral but someone who has strong facilitation skills.

John Hollway: I totally agree with that.  The thing that I would add just really quickly is, we have such a skeptical and cynical media and community presence that sometimes they are expecting that we’re trying to hide from one of these errors. But bringing in somebody from the outside is actually a useful communications tool to say to the community, “we’re not trying to do smoke and mirrors, this is a real investigation with an external organization helping us.”  Bringing that outside perspective helps get you credibility in the review.


Click Here to Watch a Recording of How Justice Agencies Can Implement and Benefit from Sentinel Event Reviews



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