Skip to main content

The Case for Sentinel Event Reviews

July 06, 2023

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

Radley Balko, Journalism Fellow at the Quattrone Center for the Fair Administration of Justice, recently spoke with the Center’s Executive Director, John F. Hollway C’92, MAPP’18, about how the sentinel event review (SER) process can improve the criminal justice system.

Radley Balko, Quattrone Center Journalism Fellow Radley Balko, Quattrone Center Journalism FellowThe Quattrone Center is a nonpartisan, national research and policy hub at the University of Pennsylvania Carey Law School, producing and disseminating research designed to prevent errors in the criminal justice system. The Center takes an interdisciplinary, data-driven, “systems approach” to identifying and analyzing the most crucial problems in the justice system, and proposing solutions that improve its fairness for the benefit of society.

Over the past decade, the Quattrone Center has facilitated several SERs that have generated clear, actionable recommendations toward systemic improvement, including for the Lex St. Massacre case, the wrongful conviction of Malcolm J. Bryant, the police department and city responses to protests after the murder of George Floyd in Seattle and Madison, and, most recently, for a domestic violence fatality that took place in October 2014 in San Francisco.

The following is an excerpt from the interview:

RB: The inspiration for sentinel event review comes from fields like aviation and medicine, where you have these all-hands investigations of plane crashes and medical errors. But law enforcement — and policing in particular — tends to be a psychologically isolated profession that’s incredibly suspicious of critiques from outsiders. How can a SER board get past that skepticism and persuade law enforcement officials to cooperate?

JH: I think I’d start by asking if the isolation you’re talking about is cause or effect. Perhaps one reason people are suspicious of critiques because the critiques are focused solely on blame, often by people who haven’t walked in the shoes of the actors in question, and have not been focused on the systemic factors that contribute to undesired or unintended outcomes. What aviation and healthcare show us is that starting from a perspective that is less blame-focused, and more system-focused leads to asking different questions, and generates different answers about how to prevent the recurrence of bad outcomes. And those systems share a lot with criminal justice. If I were to tell you our goal is to improve a system that’s operating in a hyper dynamic environment with lots of different human interactions, imperfect data, things that are changing moment to moment, all in a high-stress environment where people’s lives are at risk, would you tell me I’m talking about health, care, transportation, or policing?

The answer is yes. All three fit that description. The other thing that’s true in all three professions — and lots of others — is that people don’t like to have their work second-guessed. They get worried and defensive when they think someone is accusing them of making a mistake.

So I think healthcare and and transportation point to the ability to be successful with these reviews — that you can get past the isolation and unwillingness to revisit a bad outcome out of the fear that you are personally going to be held responsible.

They’ve been doing this in transportation for 70 years. They’ve been doing it in healthcare for 40. We just haven’t been doing it in criminal justice, but all the necessary precursors are there for this to be successful. We just have to convince people to make it part of the culture. It’s now just accepted that after a plane crash, the NTSB will be doing a review. It’s just accepted that after a botched surgery or a bad clinical outcome, we’re going to do a morbidity and mortality review.

That’s where we need to get in the criminal justice system… . 

Read the full interview at Balko’s “The Watch.”