Downtown Seattle on May 30,2021 for multiple protests, over the killing of George Floyd

Weekend Long Reads: What Is The Sentinel Event Review?

by Kevin Schofield


This weekend’s “long read” is about a new report from Seattle’s Office of the Inspector General for Public Safety (OIG) on its investigation into last summer’s protests using a process called a “Sentinel Event Review.”

You may be asking, “What is a Sentinel Event Review?” Here’s the description from the report:

Sentinel Event Review (SER) aims to identify the causes and contributing factors to undesired incidents with the goal of prevention.  SER has been used extensively in aviation, health care, and manufacturing, among others, to identify root causes of tragedies and design improvements that will prevent their recurrence. The focus of SER is on fixing the system, not on assigning individual liability.

OIG assembled a 12-person panel, including “community members representing different lived experiences of Seattle and Seattle Police Department (SPD) officers at various command levels.” The panel was supported by a variety of data analysts and subject-matter experts in crowd psychology, trauma stewardship, police crowd facilitation techniques, and civil rights law.

After looking at the incidents of use of force by SPD last summer, OIG and the panel decided to break up its analysis into five “waves” of incidents over time, potentially representing changing phases of the confrontations and the police department’s response to them. The report issued this week is the panel’s analysis of the first wave, covering May 29 through June 1, 2020: from the day that George Floyd was murdered through the first weekend of protests. According to OIG, those four days saw two-thirds of  SPD’s uses of force, 71% of the total arrests, 85% of the injuries, and a majority of the complaints filed against SPD. They then focused down on five specific incidents that occurred during those four days, including a child being pepper-sprayed, SPD vehicles being lit on fire and rifles being stolen from an SPD vehicle, an SPD officer using a neck restraint, and the “pink umbrella” incident.

OIG Wave Report 

According to the report, the panel had a lot of work to do at the beginning to get on the same page on the impact of policing on BIPOC communities, in order to build sufficient trust and channels of communication to get their work done. From the report:

Bringing together police and members of the community that were affected by police actions to develop solutions both find agreeable is inherently difficult and has the potential to bring up difficult emotions and traumatic memories. Panelists regularly engaged in challenging conversations and reviewed a considerable amount of sensitive and traumatizing material. 

To help navigate these difficult conversations, OIG established peacemaking as a core component of SER. The peacemaking circle process is a framework for facilitating a supportive environment and encouraging open-mindedness. The process interrupts old patterns and assumptions that can block communication to create an opportunity for understanding, connection, and collaboration. 

The Panel dedicated a portion of each working session to peacemaking circle activities. The first sessions focused on SER panelists getting acquainted, understanding each other’s values, and creating shared principles to facilitate communication and collaboration. As the group moved forward, the peacemaking circle focused on deepening relationships, developing empathy, and building trust. 

The Panel began with an 8-hour session devoted to peacemaking, followed by over 18 hours dedicated to peacemaking during its first 13 meetings. It was important for each person to express how they were present in the room and to share their history, vulnerabilities, and expectations to engage on inherently divisive topics that were foundational to many in the room. 

The peacemaking process has provided a positive example for future trust-building and healing processes between the community and SPD. OIG will continue to use the peacemaking circle framework in future SER work.

In reviewing the five incidents, the panel identified 53 “contributing factors” that led to the incidents, and made 54 separate recommendations for SPD on how it can improve its response to protests.

The report has an interesting discussion of the circumstances that led to misinterpretations — and often escalation —by both protesters and police officers. It noted that the curfew that the Mayor imposed was interpreted by some as an authoritarian attempt to stifle free speech, while the defensive measure and “personal protective equipment” (including umbrellas) that protesters donned to shield themselves from pepper spray and tear gas were seen by officers as preparations for aggression. A particularly insightful section discusses the “content neutrality” policy that SPD officers must follow that prevents them from supporting or opposing viewpoints being expressed by protesters; most officers interpreted that as forbidding them from expressing solidarity with the protesters and outrage at the murder of George Floyd; and some protesters, in turn, interpreted the officers’ “content neutrality” as either indifference or disagreement with the outrage being expressed by protesters. There was a strong recommendation by the panel that SPD look harder at how it might change the “content neutrality” policy to bridge that gap.

The 110-page report is full of detailed information, and new insights and perspectives, on some of the worst of last summer’s conflicts between SPD and protesters. The Sentinel Event Review Panel still has much work ahead of it as it dives into the other four “waves,” but it is certainly adding an important dimension to our collective conversation.

 Sentinel Event Review of Police Response to 2020 Protests in Seattle, Wave 1

Disclosure: I have a family member who contributed to the generation of this report, though we have not discussed his work.


Kevin Schofield is a freelance writer and the founder of Seattle City Council Insight, a website providing independent news and analysis of the Seattle City Council and City Hall. He also co-hosts the “Seattle News, Views and Brews” podcast with Brian Callanan, and appears from time to time on Converge Media and KUOW’s Week in Review.

📸 Featured Image: Hundreds of people filled the streets of Downtown Seattle on May 30,2021 for multiple protests, over the killing of George Floyd by the Minneapolis Police Department on May 24, 2021. (Photo: Susan Fried)

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