In a Q&A, Quattrone Center Executive Director John Hollway explains how "sentinel event reviews" can improve the criminal justice system
I wonder in your first paragraph, if you could also add police unions and their role in protecting officers who have been involved in shootings, or accused of misconduct.
The problem with looking at errors from a systemic point of view is that it assumes that the system actually views the events as errors, and I’m not sure that’s the case.
[quote]Every officer shooting, every death in custody, every wrongful conviction, every on-the-job police injury. Put personal accountability aside. These are not events we want to happen.[/quote]
Who is “we” here? Because even in the worst cases when a cop kills an unarmed man, there are a ton of apologists who pop out of the woodwork—not least among them police unions—who argue that, actually, everything is fine. The problem was the person who was killed. Move a step away from that to people who were shot by the cops who actually had a gun, and it’s extremely easy to find entrenched interests arguing that everything is working as intended. The system cares a lot more about cops disproportionate fears for their safety than it does a dead armed civilian with a rap sheet. As another example, the Federal Judiciary really doesn’t care about wrongful convictions.
I know Halloway gets into that a bit with the cops studying for a different test than how they’re judged by the community, but how does he grapple with dead civilians being, if not the system working as intended, then at least viewed as an acceptable cost of doing business?
From this interview at least, I’m not sure he’s willing to consider that maybe the system places a higher value on enforcing a certain social order than it does protecting people or even solving crimes. And I’m unconvinced that a voluntary, all-sides exercise is capable at delivering solutions that actually reprioritize system-wide priorities. And in that case it’s usefulness is reduced to the events the very few events the cops agree is a problem, and as, always it skips the “ruins the whole bunch” part of the “few bad apples” saying.
Sentinel event reviews are a great general tool. We use them in software engineering to maintain high reliability in critical systems like the Google search stack-- they're generally called "blameless postmortems" there. I wrote a piece awhile back about the lessons of the tech experience for other social applications of such reviews:
In particular, the requirement of a social consensus on what good and bad outcomes are-- which I call "supermajority shared values"-- may sadly not always hold in criminal justice, as commenter Jon points out downthread. Accountability for coverups and repeat offenders, another key pillar, is also often missing, as I've learned from reading your reporting over the years!
The Seattle Sentinel Event Review was a joke. It was another case of cops investigating themselves and finding they did nothing wrong. "Six out of 11 SER panelists were SPD employees, including Capt. John Brooks, the commander responsible for some of the most notorious events of 2020." https://twitter.com/DivestSPD/status/1648819203338809345
For what it's worth, the Madison, WI Quattrone report (I'm a local) was impressive in some areas and extremely underwhelming in others.
I was pretty disappointed that they didn't fully take into the context of the Floyd protests enough about the city's inaction about Matt Kenny, because that was a major undercurrent in the community; he had killed two people and was still on the force helping teach meditation or whatever.
Plus, the way the Quattrone report addressed CS gas usage seemed to be "well the problem was that the officers ran out of CS gas", when the real problem was they did NOT effectively warn people that the protest had been judged illegal (ha) and they were about to be gassed. (I wasn't there that late, but have talked to a number of friends who were, and one media person who got hit with a canister with no warning whatsoever.) Plus the report completely elided all the community members who complained about being gassed in their apartments, etc. that night. That was a definite harm that MPD seems to not give one single shit about, which is too bad.
To be fair, the worst part was reading the comments in the appendix and seeing all the community members who are pushing for MORE police violence.
I'm curious to see what comes out soon that he's hinting at, with the bureaucrats releasing some information about the changes they've made. To a close observer, I don't think they've made many inroads, and our police oversight board is still a powerless joke. We'll see. Maybe they bought more "less lethal" weapons for next time, though! Hooray!