Lessons From Another Needless Death

America recently had yet another tragedy of a police officer shooting someone in her own home by mistake, in an incident fraught with questions about racism and overzealous policing. Compliance officers should study this case because it offers some important lessons about risk management.

You might already know the story by now. Atatiana Jefferson, a 28-year-old black woman living in Fort Worth, Texas, was playing video games at home with her 8-year-old nephew in the early hours of Saturday, Oct. 12. A neighbor called the non-emergency number of the Fort Worth police to report that the doors to Jefferson’s home were open and the lights were on, and perhaps officers should do a welfare check.

Fort Worth PD dispatched two officers to the house to investigate what’s known as an open structure call — and note the change in language from what the neighbor suggested; that’s important. One of the officers who responded was patrolman Aaron Dean, 34 and white. Dean had been a police officer for only six months. 

Dean and his colleague parked their patrol car down the street, flashing lights off. They scouted the perimeter of the house. They saw Jefferson’s car, parked in  her driveway. Dean came to Jefferson’s bedroom window, where she and her nephew were playing inside.


As we can see from the bodycam footage Fort Worth police has since released, Dean shouted through the window, “Put your hands up! Show me your hands!” and then immediately fired one shot. Roughly two seconds elapsed from when Dean began shouting to when he fired his gun. The bullet struck Jefferson in the chest and killed her. Police later found that Jefferson had been holding a handgun, which she was properly licensed to own and carry. Her nephew said she picked up the gun when she heard noises outside the house.

That all happened at 2:30 a.m. on Saturday. Dean resigned the following Monday morning before police could interview him as part of an internal investigation. Fort Worth police chief Ed Kraus said he intended to fire Dean that day, but Dean quit first. Dean was charged on one count of murder that afternoon, and was released  on $200,000 bail that evening. 

Jefferson’s shooting happened just days after former Dallas police officer Amber Guyger, who is white, was convicted of murder for shooting Botham Jean, who was black, in 2018. Jefferson was the sixth person shot and killed by Fort Worth police since June 1. 

Failures in Communication

Above all, the Fort Worth police had a failure in communicating the risk. The neighbor, James Smith, called the non-emergency number for the police. He asked for a welfare check, which assumes the resident is home. Typically police will knock on the door, which by definition means the officers are making their presence known. 

Yet Dean and his fellow officer were told to respond to an open structure call, and a police call sheet even shows the incident defined as “burglary.” That is a categorically different type of issue, where police have much more discretion to park further away, creep onto the premises, not identify themselves, and approach with weapons drawn. 

Consider all this at a more abstract level. The neighbor Smith reported the possibility of Situation A (welfare check), where officers normally follow one set of procedures to mitigate one type of risk. But the officers were told to watch for Situation B (open structure), which directs them to follow a different set of procedures to mitigate a different risk. 

That’s a failure of information and communication. Fort Worth police communicated the wrong issue to Dean and the other officers, so they followed the wrong set of procedures, because they were trying to mitigate a different risk. That’s the mistake compliance officers want to avoid. 

This isn’t just fodder for a compliance post without any steps compliance officers could follow. The COSO Internal Control Framework devotes a whole section to information and communication. Principle 13 states: “The organization obtains or generates and uses relevant, quality information to support the functioning of internal control.” That principle then includes a supporting point that’s worth quoting in full:

Maintains quality throughout processing: information systems produce information that is timely, current, accurate, complete, accessible, protected, and verifiable and maintained. Information is reviewed to assess its relevance in supporting the internal control components. 

Dean’s information was not accurate. Because the information wasn’t accurate, it couldn’t support other internal control components like Dean’s training and common sense (or the lack thereof, which we’ll explore momentarily). The information system produced information that wasn’t accurate. Period.

Failures in Control Environment

We could also consider how the Fort Worth police came up short in its control environment. The control environment is a somewhat hazy concept, but it includes the tone of executive leadership, the organization’s culture and ethical values, and the commitment to developing competent employees who believe in those standards of ethics, integrity, and high performance. 

Well, circle back to the statistic that Fort Worth police have shot and killed six people in four months. I don’t know whether that number actually is high, but it certainly seems so to me. Fort Worth has a population of 895,000. In comparison, New York City is nearly 10 times larger (8.23 million), but has had only seven fatal police shootings all year. Boston, with 695,000 people, has had only two this year. 

Moreover, the problem of white police officers shooting black persons for no valid reason has seared itself into public consciousness in recent years. All police departments in large, diverse cities should have been aware of this problem for quite some time. That’s especially true in Fort Worth, which watched the Botham Jean tragedy unfold literally next door in Dallas. 

Something was wrong in the control environment at the Fort Worth police, because the department was not responding to its environment quickly enough. It was not taking external events into account and translating them into changes in policy, procedure, tone at the top, or personnel

That’s a failure of senior leadership. Even if their hearts were in the right place, their execution of risk assessment and internal control adjustment wasn’t.

Failures in the Person

None of this excuses Dean’s conduct. On the contrary, it shows how one failure compounded other failures — all leading to tragic result. 


I don’t know whether Dean is racist. I suspect that like most people, he lapses into implicit bias from time to time, probably without even realizing it. Maybe he saw the figure of someone holding a gun, panicked at the thought of losing his own life, and fired. Maybe he saw the figure of a black person and panicked; where he would have paused for a few precious moments if he’d seen the figure of a white person. 

Maybe this will all be determined in the investigations to follow. We should hope so, because Jefferson and her family deserve to know how this awful thing happened. Right now, however, we don’t know.

I will simply say that at best, Dean was insufficiently trained for the immensely stressful job that he had. And because of that insufficient training, whatever lapses he had in his thinking — implicit bias or outright racism — became magnified, and increased the chance of him reacting the wrong way to whatever situation confronted him. Then came the bad information from police dispatch, putting Dean in the wrong frame of mind, so his risk assessment was almost destined to be wrong. 

Atatiana Jefferson paid the price for those mistakes. We all owe it to her to draw as many lessons as we can from her death, a loss that never should have happened. 

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