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Sentinel Event Review (SER)

Sentinel Event Review

A proven process to improve the quality, accuracy, safety, and fairness of the criminal justice system—and to heal the rifts between communities and criminal justice professionals in the wake of officer-involved shootings, deaths in custody, wrongful convictions, and other undesired and unintended errors in criminal justice.

The Statue of Justice - lady justice or Iustitia, Justitia the Roman goddess of Justice.

Officer-involved shootings. Deaths in custody. Wrongful convictions. Forensic errors. Uses of force during civil protests. Unsolved or “cold” cases. Each of these is an undesired and unintended outcome of our criminal justice system—an “error.” And while sometimes these “errors” happen due to deliberate actions, more often they happen because of existing systems, structures, and situations that combine to allow the errors despite the best efforts of our criminal justice professionals to avoid them.

Officials, community, and media often respond to these events by asking who made mistakes or deviated from policies or the law, seeking accountability through administrative reviews, internal investigations, or civil or criminal litigation. These evaluations of bad outcomes are important, but they have not reduced the frequency of the unwanted events in jurisdictions across the country. (Officer-involved shootings, for example, have hovered around 1,000 per year nationwide despite being the subject of intense local and national focus.)

By contrast, other human systems that, like criminal justice, operate in extremely dynamic environments involving complicated human interactions, imperfect data, and high-stress situations in which people’s lives are at stake (e.g., transportation and healthcare) have reduced the frequency of their errors and increased safety by conducting Sentinel Event Reviews in addition to existing accountability processes.

Read “The Case for Sentinel Event Reviews” with John Hollway and Radley Balko.


A Better Approach   

The Quattrone Center has developed a proven approach to conducting Sentinel Event Reviews (SER) in criminal justice, learning from errors including officer-involved shootings (OIS), deaths in custody (DIC), and wrongful convictions (WC) among other undesired outcomes.

SER is a voluntary, confidential process that applies principles of root cause analysis to identify the contributing factors underlying a significant negative outcome in the justice system. The Quattrone Center begins with a template that combines quality principles from healthcare and transportation with elements of procedural and restorative justice, and then customizes the template for each situation and jurisdiction.

Learn more about the benefits of conducting a Sentinel Event Review.


Benefits & Case Studies

Unlike the “retrospective accountability” of internal affairs investigations, municipal accountability boards, and civil litigation, the Quattrone Center’s SER process focuses on forward-looking organizational accountability—the obligation of every organization to learn from errors and improve over time. Our process generates implementable reforms designed by the agencies themselves that will help prevent the next tragic outcome, creating cycles of sustainable quality and safety improvement within the justice system (and reducing future liability risks in the tens of millions of dollars).

This forward-looking accountability, informed by community perceptions of the contributing factors to the underlying error and a consensus-driven approach to reform, bolsters the justice system’s integrity and legitimacy—which in turn leads to increased public trust, improved institutional pride, and continuous quality improvement.

Learn more about the Quattrone Center’s Sentinel Event Reviews, conducted with jurisdictions across the country.

How can the Quattrone Center help?

We are committed to helping jurisdictions eliminate errors and improve the quality of the justice system. 

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The Case for Sentinel Event Reviews

Quattrone Center Executive Director John F. Hollway C’92, MAPP’18 explains how SERs can improve the criminal justice system.

Crime scene

Driving Systemic Change to Prevent Domestic Violence Fatalities

The Quattrone Center and the City of San Francisco have released a report recommending policies and procedures to reduce domestic violence-related fatalities.

Leading the Process for Systemic Policing Change

The Quattrone Center has released of the final set of recommendations from a Sentinel Event Review (SER) of incidents during protests following the murder of George Floyd.

Quattrone Center

Improving Police Response to Protests

The Quattrone Center for the Fair Administration of Justice has released recommendations based on a Sentinel Event Review of the Seattle PD’s response to protests in 2020.