Instilling a Culture of Continuous Learning From Criminal Justice System Errors: A Multi-Stakeholder Sentinel Event Review of Process in Philadelphia, Pennsylvania, 2006-2016 (ICPSR 38188)
In January 2016, the Quattrone Center for the Fair Administration of Justice at the University of Pennsylvania Law School was awarded grant 2015-R2-CX-K040 for a proposal entitled "Instilling a Culture of Continuous Learning from Criminal Justice System Errors: A Multi-Stakeholder Sentinel Events Review of Process in Philadelphia." The work performed under the grant built upon a successful pilot program supported by NIJ, in which a group of criminal justice professionals in Philadelphia, PA conducted a multi-stakeholder sentinel event review (SER) of a criminal case in the United States. The Quattrone Center proposed to build upon the pilot project by implementing the Philadelphia Event Review Team (PERT) as a more permanent working group to identify cases of error in the Philadelphia criminal justice system and conduct sentinel event reviews of those cases over the three-year period of performance for the grant.
The PERT formed a group of dedicated criminal justice professionals across multiple agencies - the Philadelphia District Attorney's Office, the Philadelphia Police Department, the Defender Association of Philadelphia, the 1st Circuit Court of Common Pleas of Pennsylvania, and others - who agreed to meet regularly and review cases where all of the participants felt an undesired outcome had occurred.
The process for conducting the second SER was lengthy and circuitous, and was slowed by a number of factors: the churn of elected and appointed personnel in the participating agencies, the overhang of potential impending litigation on cases being reviewed for possible selection, and in one instance, the inability to waive attorney/client privilege for a defendant whose treatment by the system was viewed as suboptimal by the PERT. Both the successes and the challenges of SERs in criminal justice as experienced by the PERT are set forth below.
The SERs conducted as part of this project followed the definition of SER set forth in the NIJ publication Mending Justice: Sentinel Event Reviews. Sentinel events, which have a history of successful application in fields as diverse as aviation, healthcare, and military operations, are multi-stakeholder reviews of instances of error in complex human systems that seek to reveal and understand the root cause(s) of such "never events" as plane crashes, surgical errors, and other accidents. They involve a formal procedure to review errors in a non-blaming atmosphere and determine ways to avoid such errors in the future.
Applying the methodology of Sentinel Event Reviews (SER) to the criminal justice system involves reviewing a criminal investigation and prosecution that demonstrated some "error," as defined by the participants of the SER. The PERT took the position that any wrongful conviction, cold case, officer-involved shooting, or death of an individual in the custody of the state was by definition a case of error; this definition is completely separate from an assessment of blame and simply held that any instance of these outcomes was per se unwanted, even if such an outcome may have resulted by good faith professionals acting within established training and protocols. The PERT attempted to conduct SERs of selected cases in the criminal justice system using principles of "just culture review," defined as "a culture that recognizes that competent professionals make mistakes and acknowledges that even competent professionals will develop unhealthy norms (shortcuts, "routine rule violations"), but has zero tolerance for reckless behavior." (Agency for Healthcare Research and Quality Glossary)
A substantial question regarding the application of SERs to criminal justice was whether the adversarial nature of the criminal justice system, which is different than the structure of the systems in which SERs were originally developed, would be a barrier to their successful application in criminal justice. The adversarial culture unique to the criminal justice process creates additional challenges, including the complexity of gaining consensus from cross-agency participants on the definition or occurrence of errors, the ability to define shared goals within a system, and the ability to implement reforms that require changes in agencies other than one's own. Within that context, the work performed under this grant provides additional information to help answer the questions posed by, and the methodology outlined in, Mending Justice--namely, (1) how might SERs be applied to the criminal justice system; (2) can they effectively reduce future errors; and (3) is this approach sustainable?
The datasets are the result of two data requests. The first data request asked for appeals court cases for the Philadelphia County Court of Common Pleas involving criminal cases with an appeal filed from 1/1/2011 through 12/31/2015 as recorded in the Pennsylvania Appellate Court Management System (PACMS). The second data request asked for data on case level data related to the criminal cases disposed in the Philadelphia County Court of Common Pleas from 11/17/2006 through 11/17/2016 with one of the following final case dispositions: dismissed, judgement of acquittal, mistrial, nolle prossed, nolle prossed (case dismissed), quashed, demurrer sustained, or withdrawn. For each kind of data (cases, case dispositions, offenses, offense dispositions, docket entries) there are two files, one for each of the data requests. The two files for each type of data share the same structure and fields.