A Sentinel Review Process Could Help Washington D.C.

Akhi Johnson Former Director, Reshaping Prosecution
Dec 19, 2019

When mistakes happen in the criminal justice system, we often seek to cast blame, quickly, on a single actor. But we can do better, collectively.

I’d like to help establish a “sentinel review process” to assess failings in the criminal justice system from a systemic perspective in Washington D.C., where I served as a prosecutor for half a decade.

I was trained to do justice on a case by case basis. But when things go wrong we rarely, if ever, take the chance to step back and look at the system as a whole. And it’s a missed opportunity.

When you compare the criminal justice system to the medical world, or to aviation, right now, we’re far behind in the way we review our mistakes. When a plane overruns a runway, or doctors operate on the wrong person, for example, those systems do not simply look to cast blame on the pilot, or the doctor.

Instead, they conduct sentinel reviews to determine if an unexpected negative outcome is indicative of a systemic problem, without seeking to ascribe blame. Taking this approach means bringing together everybody, system-wide, to review what led up to the negative events, and to make changes to prevent them from reoccurring.

Even where there is a rare quintessential bad actor, a sentinel review pushes beyond merely blaming the bad apple to understanding contributory causes like how the person got hired, or why no one caught the errant decision before it was too late.

In 2014, the National Institute of Justice (NIJ) — the research arm of the Department of Justice — successfully piloted sentinel reviews for justice errors in three jurisdictions. As a result, the NIJ is now encouraging others to do the same.

D.C. should heed the NIJ’s guidance and create a sentinel review process, bringing together judges, prosecutors, public defenders, police officers, pre-trial services, probation, and the mayor’s office.

In order for a sentinel review process to work, we need everyone around the table so that there’s no finger-pointing at the end. Because it’s not about finding someone to pin the problem on, it’s about taking a collective step back to learn from our mistakes.

I’d been thinking about helping to create a sentinel review process in D.C., and then I read about a recent case, the wrongful arrest of Lamar Hicks.

Officers arrested Mr. Hicks for a murder he did not commit. He denied any involvement. But an eye witness identified him, video footage appeared to implicate him, and his “freakishly calm” demeanor compounded suspicions.

Lamar Hicks was arrested by police after surveillance footage captured him near a crime scene, but he was released after his legal team challenged the evidence. (Image courtesy D.C. Public Defender Service).

Prosecutors charged him with second degree murder, and a judge found that he was a danger to the community, denying his request for pretrial release. Mr. Hicks spent 13 days in jail before his defense team noted that the video actually depicted a different suspect, prompting prosecutors to dismiss the case.

Under the single cause-bad actor approach, we might simply blame law enforcement. But that would almost certainly obscure the full story.

As soon as you start to peel back the onion on a case like this, it’s readily apparent that this is an onion we need to peel back more often. So many different people touched Mr. Hicks’ life, and there were so many different opportunities to find the concerns with the case.

It’s only because Mr. Hicks had the benefit of one of the best public defender’s offices in the country that someone caught the mistake.

Another less-resourced attorney might have said, “look, they got you on video,” and there’s a decent chance Mr. Hicks might have taken a plea for something he didn’t do, and then we would not know his story.

We cannot know how many people like Mr. Hicks are in the D.C. system, or nationwide. But that’s why sentinel reviews are so important.

If we focus on learning lessons, instead of simply placing blame, we can work to prevent mistakes like these in the future. That Mr. Hicks was mistakenly identified, arrested, charged, and held in jail for 13 days are all system-wide failures.

For instance, it appears that the officers who initially viewed the video could have seen that the suspect wasn’t Mr. Hicks. Our current approach ascribes blame to the officers, where a sentinel review probes why they missed it. Perhaps they felt rushed by a mounting list of investigative tasks, which could caution the use of different investigative tactics moving forward.

Further, a sentinel review could highlight safeguards to catch similar errors after an arrest — like potentially including critical video screenshots in court documents, instead of relying on written summaries. These suggestions are speculative, but they highlight the potential value in adopting a new approach.

The system already failed Mr. Hicks, but we can use sentinel reviews to prevent it from failing others.

Akhi Johnson served for five years as an Assistant United States Attorney in Washington, D.C. before joining the Vera Institute of Justice in January 2019. At Vera, Akhi helps prosecutors around the country use data to better pursue public safety.