When bad things happen in a complex system, such as the larger policing environment, the cause is rarely a single act, event, or slip-up. More often, bad outcomes are "sentinel events."
A sentinel event is a significant negative outcome that:
- Signals underlying weaknesses in the system or process.
- Is likely the result of multiple or compound errors.
- May provide, if properly analyzed and addressed, important keys to strengthening the system and preventing future adverse events or outcomes.
Examples of sentinel events that involve policing could include:
- Police shootings;
- Wrongful convictions;
- Police pursuits with serious injury/death;
- Failure to prevent a death or injury, such in a child abuse or DV case;
- Controversial events/activities that cause potential loss of public confidence in the police;
- "Near miss" situations.
Underlying principles of the TPD Critical Incident Review Board:
- Involve all stakeholders, including those outside of the police department.
- Lean forward; learn from the past to achieve better outcomes in the future.
- Focus on broader issues of policy, training, supervision, and needed resources, as opposed to investigating individual misconduct or violations of policy (which remains the responsibility of the department’s Office of Professional Standards).
That said, it is impossible to conduct a meaningful review of certain police sentinel events without considering the decisions and behavior of individual department members. Because the department is accountable to the public, it may be necessary and appropriate in some cases for the CIRB to make evaluative findings associated with individual actions.
"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."
To view the Operations Pamphlet, click here. To view a completed CIRB Report, click on the name of the incident.