Lessons For Analyzing Justice System Weaknesses


The National Institute of Justice (NIJ) today released a report detailing the lessons learned from studying three criminal justice system incidents with negative outcomes, or “sentinel events.” The report, titled “Paving the Way:Lessons Learned in Sentinel Event Reviews” outlines the best procedures and next steps for conducting future reviews of sentinel events that often signal an underlying weakness in the system,. Among other recommendations that emerged from reviews conducted in Milwaukee, Philadelphia and Baltimore, team members stressed the importance of researching the jurisdiction where the review will take place (such as determining if a homicide review unit is already in place), selecting team members with varied perspectives and hands-on experience and establishing what “a non-blaming review” actually means. The teams participating in the review process were promised anonymity in exchange for sharing information with NIJ, and as a result no details of specific sentinel events are included in the report. But participants' opinion of the review process appears positive, with one responding anonymously: “It is very hard to step back and take a 30,000-foot view, but incredibly important that we do so.” A copy of the report is available here.

The report is the outgrowth of the so-called “systems approach” to reform developed by some criminologists as a way of analyzing why often tragic errors in the criminal justice system arise from what appear to be small oversights or a lack of communication between police, courts, and other components of the system. In a related development, one of the main groups exploring this approach, the Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania Law School, has received a $350,000 grant from the NIJ to create a multijurisdictional team to study botched criminal cases in Philadelphia. Called the Philadelphia Event Review Team, it will include members from the Quattrone Center, the Philadelphia Police Department, the District Attorney’s Office, the Defender Association of Philadelphia, the Court of Common Pleas, the Mayor’s Office and the County Criminal Justice Advisory Board.

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