Illustration by Jenna Lechner

THREE TIMES since 2012, the city auditor's office has released an outside watchdog's dense, detailed deconstruction of Portland police shootings stretching back a decade. Twice, the police bureau has issued a self-congratulatory news release welcoming the scrutiny—while also highlighting the kinder findings tucked inside.

Not this year. The third such report (pdf) by the Los Angeles-based Office of Independent Review (OIR Group) went public on Monday, November 24, and it came with nary a trumpet blare from police brass. Instead, behind the scenes, revision-seeking officials and city attorneys pushed back harder than ever before.

And maybe that's because—after three studies probing lessons either learned or lost after 23 shootings and in-custody deaths, including nine in the latest report—the consultants have finally hit a particularly sensitive nerve.

Despite notable lapses leading up to the use of deadly force—including flawed or nonexistent planning, tactical mistakes, and fraught communication gaffes—few officers ever seem to face discipline for their bad decision-making. Worse, the consultants found, sometimes those missteps aren't even examined by the internal investigators and trainers the bureau relies on to keep its performance sharp.

"Some law enforcement agencies rigorously examine the performance of involved officers and supervisors," the consultants wrote more than 100 pages into their report, later making clear that "this is consistent with the broadly accepted understanding that tactical decisions and judgments have consequences in the field and will often determine the need or perceived need to use force."

But in Portland?

"In our previous reports, we have identified occasions when these issues may or may not have been identified," the consultants write before coming to a devastating point: "But rarely in Portland have such decisions led to either discipline or other targeted corrective action."

In all, the OIR Group submitted 21 fresh recommendations for policy changes after examining one in-custody death (Darris Johnson, 2011) and eight more police shootings (Dupree Carter in 2006; Steven Bolen, 2007; Jeffrey Turpin, 2007; Derek Coady, 2008; Craig Boehler, 2010; Darryel Dwayne Ferguson, 2010; Marcus Lagozzino, 2010; and Ralph Turner, 2011).

The consultants fretted over lengthy administrative investigations, some of which stretched beyond two years. (That's something the city's recently approved settlement agreement with the US Department of Justice is supposed to solve.) They renewed a call, first made in their 2012 report, that the city do away with a union-bargained rule giving cops 48 hours after a deadly force incident before they have to explain what happened ["Will They Ever Learn?" News, June 7, 2012].

They also noted unheeded exhortations to produce training videos and memos after shootings that happened in part because of bad planning. And they emphatically called for the bureau's Police Review Board—made up of police leadership, peer cops, supervising officers, civilians, and an Independent Police Review representative—to play a stronger role both in poking holes in investigations and tracking the progress of policy changes.

But much of the report revolves around fine-toothed reviews of the nine cases selected for study—with the consultants matching the concerns they'd flagged directly against their demands for change. For instance:

• In examining the in-custody death of Johnson—which followed a 4 am traffic stop and foot chase that left him out of breath before he died in the back of a police car—the report pointedly called out officers' decision not to call for paramedics at the first hint the 26-year-old was in trouble ["When Should Cops Call for Help?" News, July 14, 2011].

Officers Justin Thurman and Zach Zelinka said they thought Johnson's troubles were a predictable result of the chase—only to realize they weren't routine after he stopped breathing in the backseat on the way to East Precinct. (Johnson, it turned out, had meth in his system, and also an enlarged heart.)

But the consultants said no one questioned some telling details that might have undercut the officers' assertion that no paramedics were required: namely, that 20 minutes had elapsed between the moment Johnson took off running and his arrest, and that the running itself lasted only about a minute.

Given that the officers had "fully recovered" from the chase, the consultants wrote, their outright dismissal of Johnson's ongoing breathing difficulties could have been seen as "less reasonable."

Earlier, they found "there was no discussion" in the bureau's investigation of whether Thurman and Zelinka violated a policy that clearly lists "respiratory difficulty" among prescribed reasons for seeking medical help. And they called on the bureau to add a policy encouraging officers to "err on the side" of calling paramedics.

• In the 2010 shooting of Boehler, who died in a house fire that he set after taking shots at several tactical and plainclothes officers in a standoff, the consultants wondered why investigators never questioned a glaring inconsistency in the decision-making of the cop who fired at Boehler, Peter McConnell.

McConnell said at one point that he thought officers would be safe from Boehler's bullets because they were inside an armored vehicle or behind cover. But he also said he shot Boehler, when given the chance, because he feared for those same officers' lives.

"Officer McConnell's independent decision to shoot in order to stop Mr. Boehler was in contrast to the discipline exercised by the rest of the team," the report says. "For that reason, it falls to the bureau to ask if there was an actual exigency that made the use of deadly force necessary at that moment....

"The investigation and review did not explore these questions."

• The report noted that six of the eight shootings involved confrontations "at or near a doorway of a residential dwelling"—and that poor planning often marred those rushed encounters, with few lessons actually gleaned from these mistakes.

In the Bolen shooting, officers burst into his home without waiting for tactical officers after hearing from neighbors (but never verifying) that Bolen was beating his girlfriend. A review board's urging that trainers produce a video based on the Bolen case slipped through the cracks.

When two officers knocked on Ferguson's door, stepping into a dispute Ferguson was having with a neighbor, they never announced themselves or thought to craft a plan based on an earlier report Ferguson might have had a gun. (He had a fake gun, which he waved when opening the door, not knowing it was cops who were knocking.) Investigators gave the officers a pass on both.

In the Turner shooting, cops were shot at as soon as they knocked on the door—something admittedly difficult to prepare for. And what was supposed to be a welfare check spiraled into a shootout that saw an officer hit in the stomach. All the same, the consultants said, poor communication in the wake of the chaos resulted in sergeants being pinned down as targets instead of taking the lead as supervisors. They also said the bureau's emotional response to the incident may have clouded its willingness to look for tactical mistakes.

In documents attached to the report, and in footnotes sprinkled throughout, bureau officials quibbled with some of OIR Group's findings and rebuffed a handful of recommendations outright. Often, they pointed to reforms initiated after 2012, beyond the time period examined in the report, as part of the city's reform deal with the US Department of Justice.

They also directly rejected a suggestion that officers ask the medical examiner to evaluate whether a shooting victim's wounds might have been survivable if medical attention was provided sooner. The report cites delays in rendering aid as an ongoing challenge.

In one case, when the bureau said it agreed with a recommendation, it did so without actually addressing what was being demanded. The consultants suggested the bureau combat fatigue by putting limits on officers' extra-duty work on specialty units, like the tactical squad. The bureau said that was its "current practice," but described a discretionary system in which supervisors "evaluate" cops' capacities, with no firm limits ever actually in play.

Mike Reese, the soon-to-retire chief of police, was as tart as ever about the OIR Group's work in a letter that came just before the bureau's detailed response.

"Many of the [reviewed] shootings occurred under very challenging circumstances and include one where officers were shot and others where officers and the community were at grave risk," he wrote. "During these rapidly unfolding events, officers performed commendably and relied on the high caliber of training they have received. While we agree with the majority of the recommendations, we have concerns with some of the tactical analysis and conclusions drawn in this report."

Reese will have a chance to say more in a few days. The report is scheduled for a Portland City Council hearing on December 3.