Sentinel Event Review

View Sentinel Event Review Report Wave 1

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?

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 SPD and community stakeholders
  • Focus on community perspectives and concerns; define implementable recommendations for SPD change.
  • No assignation of individual blame
  • Identify root causes of negative outcomes.
  • Learn from mistakes and other best practices in other jurisdictions
  • Improve systems to reduce or prevent future negative outcomes or harm to community.
  • Support analysis with data and evidence
  • Increase legitimacy of government agencies and departments.
  • Take action to correct identified issues
  • Facilitate community healing and mutual understanding.

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

What are the steps of SER?

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

Reference Materials

OIG Protest-Related Reports

Resources

For more information or to provide comments:

Please email oig@seattle.gov. 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.