Learning from Error in Criminal Justice: A Sentinel Events Approach

Learning from Error in Criminal Justice: A Sentinel Events Approach
Duration: 60 Minutes
Module 1Resources
Recorded on: 2018-10-30
Unit 1Slide Deck: Learning from Error in Criminal Justice
Unit 2Recording: Learning From Error in Criminal Justice
Unit 3Workbook: Learning from Error in Criminal Justice

In life, there are no failures or mistakes, just lessons. The criminal justice field could take a hint or two from this wisdom. But too often, when law enforcement messes up, fingers are pointing blame across different directions. Failures, mistakes and bad outcomes are referred to as sentinel events. Examples of which in the criminal justice field include incidents that involve violence escalating, deaths, mistakes related to evidence handling, conviction, among others.

The National Institute of Justice (NIJ) – US-DOJ’s research and development arm, wants to maximize the learning criminal justice practitioners get out of sentinel events. Today’s guests spearhead the Sentinel Events Initiative (SEI) that aims to leverage failure and turn them into opportunities. Maureen McGough is the senior policy advisor of the NIJ, while James Doyle is the Senior Consultant for the NIJ’s Sentinel Events Initiative. Together, they work towards creating a mechanism to learn from mistakes and from there, improve the criminal justice system.

Maureen and James discuss the SEI, its goals, and methodology. Some of the specific areas they talk about include:

  • What sentinel events are, its roots from the field of medicine, and examples of sentinel events that may be encountered in the criminal justice system.
  • How criminal justice can take notes from best practices in the field of aviation and medicine in handling sentinel events.
  • The NIJ’s Sentinel Event Initiative that encourages agencies to experiment and innovate and it’s three characteristics.
    • The non-blaming approach that does not dwell on the failure or the blame game plus case studies of a wrong man event as it happened in the hospital and courtroom setting.
    • The all-stakeholder characteristic that stresses the importance of inter-agency contact such that personnel gets out of their silos, influence others, learn and benefit from the collaboration.
    • A forward-looking approach that analyzes where the misses happened and what can be done to prevent it or improve conditions moving forward.
  • The importance of learning from all types of incidents – even the low risk, high-frequency ones.
  • How the NIJ supports the SEI through information and intelligence gathering and fostering inter-agency and community relationships to better understand challenges, opportunities, and the people within and affected by the system.
  • The different activities that the SEI is involved in to raise awareness about the value in sentinel events and to get agencies involved.
  • The SEI National Demonstration Collaboration that tailor-fits engagement based on the jurisdiction’s realities, its goals, and progress.
  • Maureen and James addressed a lengthy Q&A segment that looks at:
    • Examining smaller individual variables leading to sentinel events
    • Initiating a review
    • The negative effects of decision making bias
    • Obstacles encountered by the pilot sites
    • Political and legal ramifications of conducting sentinel event reviews
    • Integrating root cause analysis with the all stakeholder approach
    • Using the sentinel event approach to other fields like wildlife conservation and child protection
    • The members of the sentinel events review team
    • The purpose of sentinel events initiatives


Additional Resources about the Sentinel Events Initiative:

  • Mending Justice outlines the sentinel events approach and includes essays by district attorneys, directors of criminal justice organizations, a victims advocate, judge, police officer, and others.
  • Paving the Way compiles lessons learned from pilot site reviews in Baltimore, Philadelphia, and Milwaukee.



Additional Resources
3 years ago
Implementing Evidence-Based Policing: Lessons from the LEADS Program
Evidence-based methods have been utilized in medicine and sciences for a significant time and it has […]
4 years ago
Evidence-Based Policing: A Practical Approach
Evidence-Based Policing (EBP) has been around for two decades but only has been getting a lot of tra […]
4 years ago
After the Webinar: Learning from Sentinel Events. Q&A with the Presenters
Webinar presenters Maureen McGough and Jim Doyle answered a number of your questions after their […]
5 years ago
Evidence Based Best Practices for Public Safety Agencies
Public Safety Agencies are faced with a myriad of issues daily. As part of their duty to serve and p […]