Sentinel Event Review

What is a Sentinel Event?

A sentinel event is a significant negative outcome, such as a death or serious injury, that acts as a signal that problems within a system exist and may lead to similar bad results if the system is not examined to find root causes and proper remedies. Industries like airlines and health care providers have developed and used "sentinel event review" processes to thoroughly examine these types of incidents, identify what caused them, and use those lessons to prevent them in the future. 

What is the Seattle Sentinel Event Review (SER)?

Sentinel events can occur as result of Seattle Police Department (SPD) interactions with the public. Examples of SPD sentinel events include officer-involved shootings, mass use of chemical weapons during protests, fatal vehicle pursuits, and other incidents that negatively impact individual safety, community well-being, and public trust in SPD.

Our Sentinel Event Review (SER) is a community inclusive accountability program led by the Office of Inspector General (OIG). A SER panel will review "critical incidents," looking at SPD systems to determine how they can avoid future harmful outcomes and better serve the community. This work is different from that of the Office of Police Accountability, which investigates allegations of individual police employee misconduct. SER is not focused on individual actions or assigning blame, but strengthening system fail-safes to prevent harm. SER aims to identify the causes and contributing factors to these incidents with the goal of prevention. The principles and goals of these reviews are:

Principles Goals
  • Include community stakeholders
  • Focus on community perspectives and concerns.
  • Not to assign individual blame
  • Identify root causes of negative outcomes.
  • Learn from mistakes and other best practices
  • Improve systems to minimize the likelihood of future tragedies or harm to community
  • Take action to correct identified issues
  • Reduce future risk

These fundamentals are a blend of "just culture" models from health care and aerospace sentinel events and those from the National Institute of Justice applicable to criminal justice sentinel event reviews. NIJ Sentinel Event Review fundamental principals are: non-blaming, forward-looking, all-stakeholder.

Why is OIG conducting a Sentinel Event Review (SER)?

This is an opportunity to create a community-centered process to address the concerns being expressed by community members about use of force by SPD. The SER can be used as a framework for community-centered review of other SPD actions and practices that may be of concern to the Seattle community.

Who are the SER stakeholders and what is their role?

Community: Contributes their concerns and perspectives in meetings, surveys, and other engagements. Community will be represented on the SER panel.

CPC: Facilitates and provides technical assistance for outreach to solicit community concerns and gather community's perspectives about SPD policies and practices. Seattle Police Department: Provides information and technical assistance for any incident under review, including access to policies, training, SPD personnel, or other information needed to assess sentinel events. Use the recommendations from Sentinel Event Review to modify SPD policies, training, and data collection. Increase transparency of data, policies, and procedures.

What is the role of OIG?

We will engage with community and stakeholders to gather community input, hear community concerns, and ensure inclusion of various perspectives about the issues under review using meetings, surveys, and other communication methods. This will include working with the CPC, and other stakeholders to create opportunities for the community to give their input. OIG will work with stakeholders to incorporate the issues and concerns into the review process.

With members of the community, subject matter experts, and academic professionals, OIG will conduct a thorough review of a sentinel event, from start to finish, including review of any aspects of the system that could have contributed to, or been impacted by, a sentinel event. In this first case, the events leading up to, during, and in the aftermath of the Black Lives Matter protests after the murder of George Floyd. After the review process, OIG will carry out additional audit work and provide recommendation that target the root causes of the sentinel events. The goal is to improve SPD systems and reduce the risk of future incidents. According to the U.S Department of Justice in their October 27, 2015 briefing on the Guidebook on 21st Century Policing, these are ways in which stakeholders could implement the task force's recommendations.

What are the steps of Sentinel Event Review (SER)?

This SER will take place in three phases:  Phase 1 - Gathering community input and perspectives, Phase 2 - SER panel analysis and findings, Phase 3 - Audit and further systems review of issues identified by SER.

Image describing phases of the Sentinel Event Review Process.

What are some sources with more information on sentinel event review and OIG's authority?



  • 3.29.200.H  OIG shall have the authority to review and audit policies and practices of other City departments and offices in areas related to policing and criminal justice matters.
  • 3.29.200.J  OIG shall be responsive to community needs and concerns through means including, but not limited to, the following:
    • 1. Obtaining information about community perspectives and concerns germane to OIG's oversight responsibilities, including using the expertise of CPC.

How can I get more information or provide comments?

Please email Note that emails sent to OIG are subject to disclosure under the Public Records Act, RCW 42.56, and any allegations about individual officer misconduct are forwarded to the Office of Police Accountability to address.