Council discusses Sentinel Event Review process for serious incidents; direction for staff to develop details

The city attorney’s office presented a draft framework for a Sentinel Event Review (SER) process on Jan. 6, describing a non‑adversarial, multidisciplinary review intended to identify system‑level causes after serious incidents (for example, a death or major injury) rather than to assign criminal blame. The concept is modeled on health‑care and other industries’ after‑action reviews and was proposed after council requested a mechanism to examine high‑impact incidents following last year’s officer‑involved fatality reviews.

City Attorney Moses Brown and staff described what an SER could cover and the legal limits the city faces: state statutes restrict access to investigative records such as police reports, SBI reports and body‑worn camera footage in certain circumstances. Brown said the SER’s purpose would be systems review—policy, training and interagency coordination—rather than charging decisions, which remain the purview of the DA and state investigators.

Potential SER participants suggested in the staff memo included representatives from the city attorney’s office, the police department, the district attorney’s office, public defender’s office, public-health agencies, county social services, community partners and subject‑matter experts. Staff also proposed confidentiality protections, a written report focusing on recommendations and a defined scope to avoid interfering with active criminal or civil matters.

Council debate emphasized two recurring themes. Supporters—including Councilmember Benavente and others—said a multidisciplinary review could reveal system failures upstream of a crisis (for example, gaps in mental‑health follow‑up, housing or interagency coordination) and produce actionable recommendations for prevention. Opponents raised procedural and timing concerns: several council members said the city has ongoing after‑action and investigative reviews (internal affairs, SBI, DA and DOJ channels), that staff should not replicate those investigatory roles, and that county agencies (which operate many social‑service programs) should be engaged early because implementation of recommendations would likely require county or state action.

Councilmember Benavente moved that the city attorney’s office proceed to develop the Sentinel Event Review concept and return to council with a refined proposal identifying roles, confidentiality protections, triggers for review, and statutory limitations. The motion was seconded and prompted extended discussion about whether SERs should be standing committees or ad hoc panels convened per incident, how to protect employee due process rights, and how to coordinate with county partners. Several council members asked that staff bring back a clearer structure before formal adoption.

Staff recorded the discussion and said they would return with a more detailed proposal, including suggested membership, confidentiality rules, a sample scope and how the SER would coexist with statutory investigations and personnel protections. The transcript records a motion to develop the concept and directions for staff; council members asked for a follow‑up report and clearer structure before the council commits to implementation.