IN A RECENT Boston Globe column, Marcela Garcia details the torturous history of a federal civil rights suit arising from the death of Terence Coleman, a mentally ill Black man who was killed by Boston Police in 2016. Coleman’s mother called for EMT’s to deal with her agitated son. She had called them many times before. This time, the  EMT’s, feeling threatened, summoned police assistance. The police, who claimed Coleman reached for a knife, shot him twice. He died hours later.  

Garcia’s column focused on the presiding federal judge’s exasperation with the city’s lawyers (there were 14 of them) and their failure to provide required discovery that would allow the case to move toward resolution.

Garcia’s piece came on the heels of a lengthy analysis in the New York Times Magazine of widespread  police resistance to releasing body camera footage in the aftermaths of officer-involved shootings.

It might seem that what we face here is a crowd of officials (with armies of lawyers) protecting the cops who pull the triggers.

That’s wrong. The officials aren’t protecting the cops; they are hiding behind them.

And it might seem that the criminal system is hiding the facts from the public.

That’s only partly true. The real scandal here is that we have a system hiding facts from itself. 

Look carefully at the long list of mentally ill people killed by police answering calls from families or attempting to deal with “suicide-by-cop” episodes and you realize that going “down and in” to focus on the last 20 seconds on the body camera video is inadequate if we are trying to prevent repetitions of these tragedies.  

The lesson from safety experts in aviation, medicine, and other dangerous fields is that we will also have to go “up and out” to understand the conditions and influences that shaped the actions of the cops at the scene. We need not only a performance review of the proximate cop, but a full event review that explains why the cop zigged when he could have zagged—and why the next cop might do the same if nothing changes. What we will find in these reviews is that often the cop has been set up to fail.

Every police “bad shoot” is a system failure.  It involves not just a “bad apple” cop but his hiring, training, dispatch, equipment, shift work, and the performance of adjacent agencies.  In cases involving the mentally ill, the “system” we confront includes medical decision-makers, ongoing care plans, EMTs and—the sad reality is—the families and neighbors of the patients, onto whom the professionals routinely off-load many of the decisions.

The Joint Commission, which accredits health care organizations, has recently expanded its requirement for “sentinel event” reporting and review of patients’ self-inflicted injurious behavior when it occurs while the patient is receiving treatment or within a week of discharge. The Joint Commission believes that its new framework “fosters a shared mental model among stakeholders throughout treatment; and highlights its continued responsibility of ongoing assessment throughout an individual’s treatment plan.”  

Recently, a number of cities, supported by technical assistance from the National Institute of Justice’s Sentinel Event Initiative have undertaken reviews of officer-involved fatalities on the same non-blaming, forward-looking, all-stakeholders model used in aviation and medicine—one that aims at learning and prevention not at simply blaming the last cop in line.  Tucson, for example, reviewed  two fatal encounters and generated 53 recommendations for system safety improvements. Within six months almost all of those reforms had been instituted.

The tragic death of Boston Globe health reporter Betsy Lehman after a chemotherapy overdose at the Dana-Farber Cancer Institute led to the founding of the state’s Betsy Lehman Patient Safety Center, which, among its other activities, promotes learning from error. (The center’s enabling legislation includes a “safe harbor” provision which renders its materials inadmissible in litigation.) That model can be mobilized here.

The “account” in “accountability” after these harrowing events refers to more than a debt to be paid for harm; it also includes a story to be told—a story about past harm and future safety. That story is about the safety of everyone, including patients, cops, and the community. 

We have to develop the capacity to get everyone to the table together—behavioral health providers, families, cops, EMT’s, communications experts—and to make learning from events a priority.  

And the taxpayers want to stop spending on lawyers who see their job as keeping cases away from juries of taxpayers, and to start spending instead on compensation and prevention. 

A century ago, confronting the challenges presented by rapidly accelerating industrial complexity, we developed a workers’ compensation system to replace our reliance on tort liability. Workers’ compensation was established by a coalition: it offered something for everyone. Workers, employers, and insurers all anticipated gains from replacing negligence liability. Employers wanted reduced uncertainty and administration costs. The average worker anticipated more certain and higher benefits after accidents. Insurers expected to expand their coverage of workplace accidents.

Cases like Terence Coleman’s show why it’s past time for a concerted effort to develop a comparable system for compensating ordinary people caught by chance in proximity to the complicated, fallible, machinery of public safety.  The safety of victims like Terence Coleman is at stake, but so is the safety of responding cops and EMTs, and the safety of their communities.

Yes, there are examples of police misconduct. And, yes, criminal prosecutions and punitive damage actions should still be available for those events. But error is part of the human condition; tragedies are going to happen even when they are “normal accidents” in complex systems under chaotic dynamic pressures.  

We should be treating them as moments for learning and restorative justice—facing them as problems in risk management, lowering overhead, and safety improvement, not as the sparks for grinding adversarial wars of attrition. We should be streamlining the path to restoration for the victims, not saddling them with the burden of demonizing cops and proving misconduct. 

We could recognize that—like a family—we all share a future. 

James Doyle is a Boston defense lawyer and author and formerly the head of the public defender division of the Committee for Public Counsel Services and director of the Center for Modern Forensic Practice at the John Jay College of Criminal Justice.