U.S. flag

An official website of the United States government, Department of Justice.

Sentinel Events: A Sustainable Model for System Change – Draft Final Summary Report Overview

NCJ Number
Date Published
16 pages

This study examined the implementation of sentinel-event (SE) review processes in three jurisdictions to determine the feasibility and utility of using SE reviews in criminal justice settings.


The SE reviews occurred in distinctive but related processes in the Midwestern cities of Detroit, Indianapolis, and Milwaukee. In Detroit, the basis of the sentinel event (SE) reviews was weekly incident analysis of firearm crime incidents to inform the deterrence of violence. In Indianapolis, SE reviews focused on analyses of non-fatal shootings. In Milwaukee, SE reviews focused on homicides, non-fatal shootings, and incidents of domestic violence. In all three sites, the SE reviews were based on existing review processes that were extended into more in-depth reviews customized to each local circumstance. The study design of SE reviews was a participant-observer protocol whereby members of the research team facilitated the SE reviews through planning and consultation, problem-solving, analytical support, and observation of the reviews. Toward the end of the study, the research team conducted key informant interviews that focused on practitioner perceptions of the SE reviews. The challenges and obstacles to implementing SE reviews, their benefits, and the customization of the reviews to meet local needs were the issues addressed in the interviews. In all three cities, the systematic review of gun crimes resulted in the identification of issues for which a deeper analysis through SE reviews provided valuable information. Also, in all three sites, the reviews provided information and facilitated shared understanding of system and process failures. Further, in all three cities, examples of corrective action emerged. In addition to the benefits of SE reviews, the analysis also identified barriers and challenges to the effective implementation of SE reviews in a criminal justice context. These are outlined. A listing of scholarly products produced or in process is provided.

Date Published: January 1, 2021