Can We All Get Along?


Can we learn from our mistakes? America's system of justice may finally be ready to apply the same techniques for identifying crucial flaws that have been used or years in the medical and aviation worlds.

At least that's the hope of a landmark pilot project now underway under the aegis of the National Institute of Justice (NIJ). The project, called “Sentinel Events” reviews focuses on three cities—Philadelphia, Milwaukee and Baltimore, where major justice stakeholders—such as police, court officials and probation authorities—will examine together a case or incident that went wrong (e.g., a wrongful conviction) and try to identify the glitches or wrong turns—the 'sentinel events'—that might have allowed them to catch mistakes before they ballooned into an injustice or egregious harm to public safety.

Next week, the NIJ will introduce the concept to the public for the first time, in a collection of essays written by some of the nation's leading criminologists and justice practitioners. The volume, called Mending Justice, is intended to jumpstart a national debate about radically transforming the current system of “silos” in which each component—from courts to law enforcement—operates with little regard to what the others are doing.

It will be available in hard copy and online September 8.

In an exclusive to The Crime Report, Milwaukee DA John Chisholm, one of the essayists (and a participant in the Sentinel Event pilot), discusses why he supports the concept, why he believes it should be a key tool for U.S. cities—and why its implementation might have prevented the tragic events in Ferguson MO last month—with Cara Tabachnick, managing editor of TCR.

The Crime Report: Why did Milwaukee decide to participate in the “Sentinel Events” project?

John Chisholm: As a jurisdiction, we've been committed to working not only among ourselves to try and improve the quality of our justice system, but we've recognized in order to do that most effectively we need to bring people in from the outside, in particular people who have the mix between academic experience and practical application. One of the processes we have been engaged in [over] the last couple of years is working with the National Institute of Corrections (NIC) and their evidence-based decision-making framework. The premise behind that is you actually can improve your systems by working collaboratively, by identifying points in the system of what actually works and doesn't work.

The NIC project has focused on four major areas: reducing the number of individuals with mental health issues in the system, looking at risk factors in people entering criminal justice system, expanding our actions beyond the traditional 'charge/ don't charge [approach], and early intervention. We are also working with the Department of Corrections to develop ways of reducing failures with individuals who are placed on supervision. But the one thing we realized is that you still have significant system failures in different areas, and when those events occur we rarely take the time to focus on those failures.

We don't determine what happened, why it happened, how it could have been prevented, and in some way that it could have been addressed in a much more effective way had we different process systems or players. Sometimes it's as simple as people having better information.

TCR: What would you define as a significant event?

JC: When the National Institute of Justice suggested this they really had broad parameters of what a significant event can be. They left it to the jurisdictions to identify. Some of the obvious would be wrongful convictions or significant numbers of people who are detained in early stages of review for longer periods than are necessary or appropriate, or significant delays in the system that can cause you to lose victims, so they are no longer available as witnesses.

TCR: Was there something in particular in Milwaukee that needed to be fixed?

JC: One of our advantages, we have had a community justice council for the past eight years. We sat down with the council and asked each of our key players to come up with an event that they thought was significant and should be addressed. The courts had a focus, prosecutors and defense attorneys had their focus, the police department had their focus, and as we were discussing it and laying out the different options, what we found was that the one area we all kind of agreed hasn't been looked at hard enough is the juvenile justice system.

We have something of a bifurcated system here in Milwaukee. Our juvenile system is on a different campus than our adult system, but we've come to realize that there are a lot of intersections between the two systems.

Fresh on everyone's minds was a case when a man under correctional supervision—who had significant contact with the juvenile system—went out and committed a homicide. This case [allows the system] players who normally don't get to talk to each other to sit down and map out exactly what happened.

TCR: What did you find?

JC: We are in that process right now. We are meeting regularly and establishing a timeline—looking at everything from when this kid was born to the time he committed his offense. It's a pretty fascinating stuff, I can tell you so far, We are looking at it from perspectives that normally wouldn't be done. For example, [we're examining] his public health background and trying to figure out if this kid was exposed to high lead levels. What kind of health interventions did he experience early on? How soon was he brought to the attention of the child welfare system? What were his parenting interactions?

We know they were extremely challenging, both his parents were deeply crime-involved and he was one of seven or eight kids from multiple fathers. At a very early age we know he was engaging in violent behavior. These are all things that are coming out in this process.

TCR: Should the criminal justice system be tracking challenging cases like this? Is this criminalizing youth without cause?

JC: There are a number of structural and legal obstacles that need to be addressed. For example, any time you try and collect information not just on an individual's background but a population's background, ideally you would need access to all databases that had contact with the individual. We have already started that process with Dr. Mallory O'Brien (an epidemiologist that works with the DA's office). She is working on building a data hub that would merge the data systems from about 7-8 different systems.

If you link all these systems and hide their identity on an individual basis –using a code in each system—and then link them that way you would be able to look across the population and identify high-risk kids. For example, if you have kids that have high exposure to lead and you can track them through the juvenile court system, then through the public school system, then the welfare or foster care system or involvement with law enforcement, you can actually create a profile of what are the risk factors that really stand out and how they are linked. It could be poor performance in the public school system or low reading scores, which is a huge red flag or behavioral disorders showing up early. Then we can check to see if they are in the child welfare system, and then we can see them show up very early at 16 or 17 years old into the criminal justice system.

TCR: So how would you address these types of cases now?

JC: Hopefully through this process we'll identify what really works. What has been eye-opening for a lot of criminal justice professionals, in particular prosecutors and police, is that most of us have grown up in a system that believes you charge a criminal offense because there is a necessity for accountability and punishment; but that there is also a belief that by doing so you are deterring the behavior in the future. We are coming to understand that while that may be true, there are sometimes much more effective ways of deterring behavior [rather than making young people] wards of the system for a long time.

If you intervene in a different way early on, often through extensive wrap-around services that address the behavioral needs, you can stop an individual from entering the criminal justice system. For a very small percentage of individuals who have a large number of these red flags, you need to do the intensive work, and make sure that they are properly supervised and getting the type of [help] that will be shown to prevent behaviors that result in tragedies.

TCR: Do you think this type of system could have prevented the tragedy of Michael Brown's death and aftermath in Ferguson, MO?

JC: What is unfolding now is part of the explanation why systems don't engage in this process. When a terrible event happens everybody descends upon it and has their own take on what is really going on. And what is absolutely [missing], as far as I can tell right now, are any actual facts.

Everybody has his r own perspective on what happened, but there isn't any space [for analysis]. Everyone demands a response from the system based on their preconceived idea of what should happen on the case; but it's all done in a complete vacuum of facts. And until those facts are developed and the system is allowed to do that in a professional, thorough and independent way, you really can't comment. That is the potential advantage of doing retrospective analysis: you 've got the time and space to get people to open up about what they did do and what they didn't do, but you often can't do that doing exigent circumstances. So a lot of times people just don't do it. In fact most of us just don't do it; we just don't take the time to go back and look. We should be looking not just at Ferguson, but police-related shooting cases as a whole.

TCR: Can these ideas expand to other cities?

JC: People think of the criminal justice system in the United States as a monolithic system, but in reality it's not. there are 3,200 or even more counties, and the counties are generally the organizational structure for most criminal justice systems. Even though they all operate generally under state and federal laws, even within the states themselves those laws change. And at the local level, the ordinance and local laws are different from jurisdiction to jurisdiction. The number of social services or the size of police forces also differ.

Milwaukee is in the top ten when it comes to the most challenging demographics and poverty and a host of other significant challenges—but that doesn't make it any different than any other jurisdictions. The challenges are the same, just different magnitudes. The benefit of this process right here is that it could be used and adapted to any size jurisdiction at the local level. They just need to work with one another in an open and honest way, and there should be no pointing blame during these reviews, which are aimed at achieving some level of clarity and honesty, and (ultimately) a commitment to change. There isn't any system in the United States that is perfect, there just isn't.

TCR: What should other jurisdictions be reviewing in their own system?

JC: Do they talk to each other on a regular basis? That would be the first question I would ask. They need to talk to each other in some type of structured way on a regular basis. It is an essential thing that should exist at each county level. There needs to be a commitment from system actors that they sit down on a regular basis and examine their system, and to be open to bringing other people in to review.

If you don't do that, then you get what you usually see, which is different parts of the system pointing fingers at other parts of the system. Police pointing fingers at social workers not doing their job; the court saying that prosecutors and defense aren't doing their job. It's a vicious circle. That's the game that is played constantly, fingers are pointed, and everyone says 'that is not my responsibility; I'm doing my job.' As long as you are locked in that paradigm you are not going to get any change.

Cara Tabachnick is managing editor of The Crime Report. She welcomes comments from readers.

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