Sentinel Event Review Board (SERB)

"Sentinels stand watch," says James Doyle, founding Director of the Center for Modern Forensic Practice at John Jay College of Criminal Justice. "They detect the first signs of a looming threat and sound a warning that should not be ignored."

When bad things happen in a complex system, such as the larger policing environment, the cause is rarely a single act or event. More often, bad outcomes are "sentinel events."

Sentinel events are events with significant negative outcomes that:

  • Signal underlying weaknesses in the system.
  • Are likely the result of multiple or compound contributing factors.
  • May provide, if properly analyzed, ways to strengthen the system and prevent future negative outcomes.

Sentinel Event Review Boards (SERBs) have been an important safety and quality improvement process in the airline and healthcare industries for decades, and are in the early stages of being used in policing. TPD is one of the first departments in the country to convene a board of this kind. Board members include diverse members of the community and subject matter experts, as well as department members.

To view TPD'S first completed SERB report, click on the link below.

Report of the Tucson Sentinel Event Review Board (SERB) on the Deaths in Custody of Mr. Damien Alvarado and Mr. Carlos Adrian Ingram-Lopez

To view the 6-month report on implementations of SERB recommendations, click on the link below:

Sentinel Event Review Board (SERB) 6-month review