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Instilling a Culture of Continuous Learning from Criminal Justice Systems Errors: A Multi-Stakeholder Sentinel Event Review Process in Philadelphia

NCJ Number
Date Published
16 pages

This is a report on the development and assessment of the Philadelphia Event Review Team (PERT), which is an ongoing working group that identifies potential errors and miscarriages of justice in the Philadelphia criminal justice system and then conducts “sentinel event” reviews (SERs) to identify the nature, causes, and means of preventing their recurrence.


The PERT’s operation was examined over a period of 3 years. The SERs conducted by PERT met the definition of SER presented in the NIJ publication “Mending Justice: Sentinel Event Reviews.” SERs have a history in fields such as aviation, healthcare, and military operations as multi-stakeholder reviews of instances of error in complex human systems. SERs involve a formal procedure for identifying and reviewing errors in a non-blaming atmosphere, concluding with recommendations for avoiding such errors in the future. A SER in the criminal justice context involves reviewing a criminal investigation and prosecution deemed to have failed in achieving justice, as defined by the participants of the SER. The PERT determined that any wrongful conviction, cold case, officer-involved shooting, or death of an individual in the custody of the state is a case of error that requires an SER. The current assessment of PERT’s operation examined 1) how SERs are applied to the criminal justice system; 2) whether they reduce future errors; and 3) whether the approach is sustainable. Overall, the evaluation determined that the PERT achieved success, forming a group of criminal justice professionals across multiple agencies under an agreement to meet regularly and review cases that participants agreed had an undesired outcome. PERT has succeeded in creating evaluative tools within Root Cause Analysis to guide reforms in the criminal justice system.

Date Published: January 1, 2020