Police Practice and Research

An International Journal

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Case rethinking: a protocol for reviewing criminal

investigations

D. Kim Rossmo

To cite this article: D. Kim Rossmo (2016) Case rethinking: a protocol for reviewing criminal
investigations, Police Practice and Research, 17:3, 212-228, DOI: 10.1080/15614263.2014.978320

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Police Practice and Research, 2016
Vol. 17, No. 3, 212228, http://dx.doi.org/10.1080/15614263.2014.978320

RESEARCH ARTICLE
Case rethinking: a protocol for reviewing criminal investigations
D. Kim Rossmo*

Center for Geospatial Intelligence and Investigation, School of Criminal Justice, Texas State
University, San Marcos, TX, USA

Mistakes in decision-making have been identied as the most common type of error
in police investigations. Consequently, wrongful convictions and other types of crimi-
nal investigative failure may require a complete case rethinking, particularly when
new evidence disrupts the existing theory. A rush to judgment resulting in a prema-
ture shift from an evidence-based to a suspect-based investigation can produce a
number of problematic thinking errors. Faulty assumptions, tunnel vision, groupthink,
and other cognitive biases and organizational traps hinder evidentiary interpretation
and evaluation. This article outlines a protocol for reviewing evidence and rethinking
a wrongful conviction or unsolved crime when the existing investigative theory
appears to be incorrect. The protocol involves four stages: (1) evidence; (2) interpre-
tation; (3) patterns; and (4) analysis.
Keywords: criminal investigation; police detectives; criminal investigative failures;
cold cases; wrongful convictions

Introduction
Police agencies increasingly use sophisticated forensic techniques and powerful
computers in their response to major crimes. What can sometimes be forgotten in this
emphasis on technology, however, is the need to properly think about the information
produced by these and other approaches. Police investigations require rational analysis
and logical thinking. When cognitive biases and organizational traps distort the
process, wrongful convictions and other types of criminal investigative failure can
result.
This article presents a case rethinking protocol that has been successfully used on
unsolved crimes and wrongful convictions. The focus is on inquiries of crimes, such as
murder, where what happened remains unknown. Reviewing a case often involves the
effort to discover new evidence; however, this method is concerned with rethinking
existing evidence. Aspects of the protocol may also be helpful in guiding new investiga-
tions.
The types and causes of thinking errors that can obstruct a criminal investigation are
rst discussed. A protocol for the systematic review of a wrongful conviction or
unsolved case in which the existing investigative theory appears incorrect is then out-
lined. The protocol involves four stages: (1) evidence; (2) interpretation; (3) patterns;
and (4) analysis.

*Email: kr13@txstate.edu

2014 Taylor & Francis

 Police Practice and Research: An International Journal 213

Criminal investigative failures

A criminal investigative failure is dened as an unsolved crime that should have
been solved or a crime that was incorrectly solved (i.e., a wrongful conviction).
Many people tend to believe the criminal justice system is fair and competent, with
police, prosecutors, and jurors logically basing their decisions on reliable evidence.
Unfortunately, as The Innocence Project and similar groups have shown, innocent
people are sometimes prosecuted and convicted. The reality is the system makes
mistakes. It is difcult to determine how often such errors happen, but estimates of
the frequency of wrongful convictions range from 0.5% (all felonies; Huff, Rattner,
& Sagarin, 1996), to 4.1% (death row inmates; Gross, OBrien, Hu, & Kennedy,
2014), to 5% and higher (murder and sexual assaults; Roman, Walsh, Lachman, &
Yahner, 2012).
Eyewitness misidentications, improper forensic science, and false confessions are
the major causes of wrongful convictions (Innocence Project, 2013). However, investiga-
tive thinking errors often underlie these direct causes. Mistakes in decision-making have
been identied as the most common type of error in police investigations (Irvine &
Dunningham, 1993). Problems can arise when police rush to judgment during the early
stages of a case and prematurely shift the investigation from evidence-based to
suspect-based. If this occurs before all the evidence has been collected and analyzed,
there is a signicant risk of tunnel vision.
Human beliefs are the product of expectations, desires, and evidence; the more
ambiguous the last, the stronger the inuence of expectations and desires (Snook,
2000). There can be little doubt that our beliefs inuence the processes by which we
seek out, store, and interpret relevant information (Ross & Anderson, 1982, p. 149). It
is therefore important to collect as much evidence as possible before theorizing about
the crime and suspects; once that has happened, expectations and desires start inuenc-
ing the thinking process.
The need for an alternative approach may become evident if DNA reveals a wrong-
ful conviction or disrupts the dominant theory, or a crime is still unsolved after a
lengthy period. However, rethinking an investigation can be extremely difcult and
challenging. Cognitive biases and organizational traps may exist that hinder evidence
interpretation and evaluation. As Heuer (1999, p. 125) warns, once information rings a
bell, the bell cannot be unrung.

Thinking errors

When my information changes, I alter my conclusions. What do you do, sir? (John
Maynard Keynes)

In an ideal world, we would make the best possible decisions after a careful evalua-
tion of all available evidence. In reality, our thinking is frequently impaired by cognitive
biases. Within the context of a criminal investigation, such systematic errors in thinking
can result in an unsolved crime or a wrongful conviction (Jones, Grieve, & Milne,
2008a; Rossmo, 2009). Tunnel vision and conrmation bias are amongst the most prob-
lematic thinking errors that can be made by detectives. Faulty assumptions, probability
errors, and groupthink sometimes play supporting roles.
214 D.K. Rossmo

The initiating problem is often a rush to judgment reaching a conclusion before all
the evidence has been considered. A premature judgment can lead to tunnel vision and
conrmation bias, prevent subsequent evidence from being properly evaluated, and
result in a criminal investigative failure. These errors and the aggravating role of
groupthink are discussed below.

Premature judgment
For many reasons, detectives may jump to conclusions before an investigation is com-
plete. Community fear, media and political pressure, organizational stresses, personal
ego, and a compelling desire to apprehend a dangerous offender can all result in a pre-
mature arrest. The pressures are exacerbated if the crime is particularly heinous or the
victim is a young child.
An overreliance on intuition can lock in a premature judgment. Humans have both
intuitive and rational decision-making processes (Kahneman, 2003); while most people
are familiar with the former, the latter is often misunderstood. Intuition (sometimes
mistakenly referred to as gut instinct) operates at a below-consciousness level and is
automatic, fast, and powerful (Myers, 2002). It is learned slowly and typically involves
the use of heuristics. Because of its implicit nature, intuition is difcult to control and is
prone to error; it exists because it helps promote survival, not because of its accuracy.
Different situations require different types of judgment and when a decision has to be
made quickly under conditions of uncertainty, intuition can be useful (Wright, 2013).
But when we have reliable data and adequate time, reasoning is the better option; com-
plex tasks, such as major crime investigations, require analysis and logic (Jones et al.,
2008a).
Investigators need not be especially sure that they have the right person to sway
their investigation toward an early suspect (OBrien, 2009, p. 328). When that happens,
police prematurely move from an evidence-based to a suspect-based investigation
(Rossmo, 2009). In the former mode, detectives have not yet determined who the offen-
der is; they are still searching for and gathering information and evidence to determine
what happened during the crime and who might be a suspect. In the latter mode, detec-
tives have decided they know who the guilty person is, and their investigation shifts to
preparing for prosecution.
The central problem therefore originates from judgments based on only subsets
rather than the totality of evidence. Evidence discovered post-judgment is then less
likely to be evaluated in an unbiased manner, and relevant evidence that fails to support
the investigative conclusion may not be collected or properly analyzed; in some
instances, it may not even be recognized as evidence.
If a awed forensic test is done early in an investigation, it can have a powerful
effect because of the authority given to science (Garrett & Neufeld, 2009). However,
forensic science is not always very scientic, and some forensic analyses are more
subjective than objective. There have been a number of wrongful convictions attrib-
uted to bad forensic science (National Research Council, 2009). The uncritical accep-
tance of awed forensic results at the beginning of a case can result in premature
judgment and poor investigative decision-making, including the dismissal of important
evidence later discovered simply because it conicts with the forensic ndings. Inves-
tigations have been sent down the wrongful conviction road by several types of
unsound forensic analyses, including time of death estimates (Michael Morton, Texas),
 Police Practice and Research: An International Journal 215

sexual assault examinations (David Camm, Indiana), blood testing (Greg Taylor, North
Carolina), bite mark comparisons (Willie Jackson, Louisiana), and arson indicators
(Cameron Todd Willingham, Texas).

Faulty assumptions
Assumptions are often necessary in a criminal investigation, especially during its early
stages when information tends to be limited. As evidence is collected, however, it is
important to reevaluate all investigative assumptions and discard those no longer valid.
Unfortunately, this does not always happen. Given enough time, it is even possible
for an unsubstantiated assumption to reify and harden into fact. If investigators
working from a faulty assumption develop tunnel vision, they are unlikely to later
detect the underlying error. During the DC Sniper case, the assumption that the killers
were driving a white van evolved into a near-certainty during the early days of the
investigation (Horwitz & Ruane, 2003). However, this white van in fact, originally
reported as a white box truck did not exist; the killers were driving a blue Caprice
sedan.

Probability errors
A detective may have to estimate the probability of a particular event in order to
decide if it is signicant to the investigation or merely coincidence. However,
humans tend to have a poor understanding of probability, particularly at the intuitive
level (Gigerenzer, 2002). As a result, probability mistakes commonly occur; in the
context of a criminal investigation, these mistakes can create tunnel vision and
sustain conrmation bias. Several cases have been sabotaged by probability errors
originating from the awed estimates of investigators, forensic scientists, medical
pathologists, prolers, and prosecutors. Problem areas include violating the laws of
probability, ignoring base rates, using vague language (common, rare, risky),
and failing to understand the nature of randomness in large investigations involving
many suspects (Rossmo, 2009).
The tragic case of British solicitor Sally Clark is an infamous example of injustice
caused by a probability error. Clark was convicted of murdering her two sons who
died from sudden infant death syndrome (SIDS). The only evidence against her was
the assertion that the occurrence of two SIDS deaths in a single family was highly
improbable, an estimate calculated by a pediatrician, Roy Meadow. Unfortunately, he
made several errors in his analysis: he ignored genetic effects and incorrectly assumed
SIDS cases are independent within families; he committed an ecological fallacy by
equating individual-level risk to overall population risk; and he failed to realize that
SIDS is common enough on a national level that a recurrence happens to some unfor-
tunate family in England about once every 18 months (Hall, 1999). The Royal Statisti-
cal Society publically criticized Dr Meadows estimate and Clarks conviction was
eventually quashed on appeal, but only after she had spent more than three years in
prison.
216 D.K. Rossmo

Tunnel vision
Tunnel vision (also called incrementalism) results from a narrow focus on a limited
range of alternatives.

Tunnel vision is insidious . It results in the [police] ofcer becoming so focussed upon
an individual or incident that no other person or incident registers in the ofcers thoughts.
Thus, tunnel vision can result in the elimination of other suspects who should be investi-
gated. (Cory, 2001, p. 37)

Tunnel vision can be a product of satiscing, or the selection of the rst identied
alternative that appears good enough (Findley & Scott, 2006; Simon, 1956). Arrest-
ing the rst likely suspect, then closing the investigation off to alternative theories, is
a recipe for disaster. Not surprisingly, tunnel vision has been identied as a major
cause of wrongful convictions (FPT Heads of Prosecutions Committee Working
Group, 2004).
Gould, Carrano, Leo, and Young (2013) link tunnel vision to the broader issue of
systemic failure in wrongful convictions: tunnel vision helps explain how one error
often leads to additional errors in an erroneous conviction. It contributes and facilitates
system breakdown because it dismantles the rigorous testing of evidence that makes the
investigative and adversarial processes function effectively (p. xxi). They also connect
tunnel vision to the concept of escalation of commitment (also known as sunk costs;
Brockner, 1992; Coleman, 2010; Staw, 1981) to explain why entrenchment of beliefs
occur even when strong contradictory evidence has emerged:

As more resources money, time, and emotions are placed into a narrative involving a
suspect, the actors involved are less willing or able to process negative feedback that
refutes their conclusions. Instead, actors want to devote additional resources in order to
recoup their original investment. As a result, evidence that points away from a suspect is
ignored or devalued, and latent errors are overlooked. At this point, the police are working
to rule in rather than rule out the suspect, and prosecutors have moved from inspection
mode to selling mode.1 Escalation of commitment contributes and facilitates system
breakdown because it dismantles the rigorous testing of evidence that makes the adversarial
process function effectively. (pp. 8687)

Conrmation bias
Conrmation bias (also called verication bias) is a type of selective thinking. Once a
hypothesis has been formed, our inclination is to conrm rather than refute we tend to
look for supporting information, interpret ambiguous information as consistent with our
hypothesis, and minimize any inconsistent evidence (Koehler, 1991). Types of conrma-
tion bias include biased search for evidence, biased interpretation of information, and
biased memory (selective recall).2
Conrmation bias can cause a detective to focus on evidence conrming the investi-
gative theory, while ignoring or refusing to look for contradicting evidence (Stelfox &
Pease, 2005). Existing evidence is interpreted in a biased manner; evidence that
supports the investigative theory is taken at face value, while contradicting evidence3
is skeptically scrutinized (Ross & Anderson, 1982). Research has shown experienced
police investigators consider witnesses less credible if they exonerate a preferred
suspect than if they help conrm guilt (Ask & Granhag, 2007). Other manifestations
of conrmation bias include the failure to search for evidence that might prove a
 Police Practice and Research: An International Journal 217

suspects alibi, not utilizing such evidence if found, and refusing to consider alternative
hypotheses.
While the recording and documenting functions integral to a professional criminal
investigation minimize the risk of biased memory, there have been some instances of
detectives forgetting to document important evidence. There have also been several
cases where a prosecutor decided exculpatory evidence was not relevant to the case
and failed to share it with defense counsel. It is difcult to say whether such actions
are the result of rationalizations fed by conrmation bias or the product of outright
unethical behavior. In the wrongful conviction of Michael Morton for his wifes
murder, Ken Anderson, the district attorney of Williamson County, Texas, failed to
inform Mortons defense counsel of key physical and witness evidence that
eventually identied the real killer (Colloff, 2012). Anderson was eventually
sentenced to a jail term after being found in contempt of court and disbarred (he
had become a judge).
Conrmation bias can be detected in a criminal investigation by identifying:

 evidence missed post-judgment (ignored leads, unexplored lines of inquiry, lost

evidence, unanalyzed evidence); and
 biased treatment of post-judgment evidence (disregarded, downplayed, or distorted
evidence, illogically considered evidentiary implications).

Conrmation bias can be tested for by considering what would happen if the order
of evidential discovery was changed. The conclusions reached by detectives should not
depend on the particular sequence in which the evidence was discovered. If altering the
evidential order changes the case conclusion, there is likely a problem with the investi-
gative logic.
The strength and perseverance of conrmation bias is dramatically illustrated by the
convoluted theories put forth by those prosecutors and police who never can admit a
mistake. Prosecutors are normally thankful for DNA evidence in a criminal case;
however, their reaction can be quite different if the DNA establishes the innocence of
someone they originally believed guilty. After the bodies of two little girls were found
in a remote wooded area in Zion, Illinois, police arrested and charged the father of one
of the victims with murder. When sperm recovered from the girls vagina, mouth, and
anus was tested and found not to match her fathers DNA, the prosecutor dismissed the
laboratory results, suggesting the victim contacted the sperm while playing in the woods
where couples met to have sex (Martin, 2011). Later, after the DNA was matched to a
convicted violent serial rapist who was a friend of the victims brother, the prosecutor
again argued the sperm was unrelated to the crime. This time, he theorized the rapist
masturbated while sleeping over at the house of the victims brother. Later, while the
victim was watching a movie from the same bed, she touched his sperm and
subsequently transferred it to her other body parts (i.e., the inside of her vagina, mouth,
and anus).
In another example, from a Canadian case, DNA testing of sperm found on the
victims clothing matched a convicted rapist from her own neighborhood, not the
man who spent 23 years in prison for her murder. Rather than acknowledging
the failure, some police ofcers tried to explain away the DNA by suggesting the
convicted man had actually killed her. Then, after he left her body in a back alley,
the rapist came along and had sex with her frozen corpse before it was discovered
(Boyd & Rossmo, 1994).
218 D.K. Rossmo

Ross and Anderson (1982) observed:

it is clear that beliefs can survive potent logical or empirical challenges. They can survive
and even be bolstered by evidence that most uncommitted observers would agree logically
demands some weakening of such beliefs. They can even survive the total destruction of
their original evidential bases. (p. 149)

Stubborn and irrational belief perseverance by the state in the face of signicant
conicting new evidence is inconsistent with both justice and reality.

Groupthink
Within organizations with strong subcultures like the police, groupthink can enable and
exacerbate conrmation bias. Groupthink is the reluctance to think critically and chal-
lenge the dominant theory. It occurs in highly cohesive groups under pressure to make
important decisions. The main symptoms include (Janis, 1982):

(1) Power overestimation

(a) belief in the groups invulnerability, resulting in unwarranted optimism and
risk taking; and
(b) ignoring the ethical consequences of decisions because of a belief in the
morality of the groups purpose.
(2) Close-mindedness
(a) group rationalizations and the discrediting of warning signs; and
(b) negative stereotyping of the groups opponents (they are regarded as evil,
stupid).
(3) Uniformity pressures
(a) conformity pressures (those who disagree with the dominant views or
decisions are seen as disloyal);
(b) self-censorship (the withholding of dissenting views and counterarguments);
(c) shared illusion of unanimity (silence is perceived as consent, and there is an
unsubstantiated belief everyone agrees with the groups decision); and
(d) self-appointed mindguards (group members shield each other from conict-
ing information).

Groupthink has several negative outcomes (FPT Heads of Prosecutions Committee

Working Group, 2004). Aficted groups selectively gather information and fail to seek
expert opinions. They neglect to critically assess their ideas, examine few alternatives,
and fail to develop contingency plans. Groupthink in a major crime investigation perpet-
uates conrmation bias and preserves awed decisions.

Case rethinking protocol

The following protocol has been designed for the systematic review of a case in which
the investigative theory appears to be wrong.4 Such a realization may follow the discov-
ery of signicant new evidence that disrupts the existing theory, but it can also emerge
after a case has remained unsolved for an extended period of time. Rethinking an
 Police Practice and Research: An International Journal 219

investigation rst requires a detective to unravel the case wipe the slate clean, unlearn
what is believed, and abandon existing theories and suspects.
Crimes are solved by information derived from evidence (Willmer, 1970). The
purpose of the protocol is to create a focus on the evidence, its strengths and
weaknesses, and the overall evidentiary pattern. Facts must be distinguished from
beliefs, certainties from suspicions, and probabilities from possibilities. An investiga-
tor must be able to answer the question, How do you know what you think you
know?
The protocol involves four stages: (1) evidence; (2) interpretation; (3) patterns; and
(4) analysis. Each stage is explained in detail below, and then briey illustrated in a text
box using a short example based on an evidence item the written statement of an eye-
witness from a sexual murder case.

Evidence

Man prefers to believe what he prefers to be true. (Francis Bacon)

The rst step in rethinking a case is to identify the evidence5 in the investigation and
assess its reliability. Evidence is a tangible and recorded fact relevant to the crime. In
some situations, the absence of something can be considered evidence. Theories,
assumptions, and inferences are not evidence.
It is essential to identify the origin of each item of evidence, whether it is a police
report, crime scene photograph, witness statement, or laboratory analysis. Nothing
should be taken for granted. Rumors emerge in large investigations that can solidify into
facts after sufcient retelling; creeping credibility can turn a hypothesis into received
knowledge over time. If a record cannot be found, then there is no evidence. Identifying
the evidence and its supporting documentation establishes the facts of the case and the
information content of the investigation.
There are only three ways to solve a crime: a witness; a confession; or physical
evidence (Klockars & Mastrofski, 1991). Detectives typically have a good
understanding of the technical nature of these evidence types, including their benets
and problems. However, they do not always fully understand the probative value of
evidence (Robertson & Vignaux, 1995). Evidence has both signicance and reliability
(Grifth & Tversky, 2004). People tend to place more importance on signicant
evidence even if its reliability6 (the probability of its truthfulness) is low. All evidence
has an error rate eyewitnesses make misidentications, suspects give false confessions,
and scientic tests produce false positives. The possibility of mistakes and human error
always exists. It is therefore necessary to estimate the reliability of an item of evidence
in order to determine how much weight it should be given. Source reliability, forensic
test error rates, research on evidentiary consistency/trustworthiness, and any other
known issues should be considered. While it is usually impossible to assign exact
probabilities, investigators can roughly evaluate evidence on an ordinal scale from low
to high reliability. Evidence should not be considered more reliable because the
investigator wants it to be, and it should not be deemed unreliable simply because it is
inconsistent with the prevailing investigative theory.
220 D.K. Rossmo

Evidence
The evidence item used to illustrate the protocol is a written statement from an
eyewitness in a sexual murder that occurred in Saskatoon, Saskatchewan. The victim
was Gail Miller, a nursing assistant who was attacked while walking to the bus stop
on her way to work on an icy January morning. She was raped and stabbed; her
body was later found lying in the snow in a back alley a block from her home
(Boyd & Rossmo, 1994).
The witness, Nichol John, was one of three Regina teenagers, along with David
Milgaard and Ron Wilson, who set out on a road trip to buy drugs. They drove to
Saskatoon to pick up another friend (who had money), but ended up lost before they
found his house and got stuck in the snow. It was very cold, so John stayed in the
car while Milgaard and Wilson went for help. John told police she then saw Milg-
aard attack a woman on the street.
Written statement from witness Nichol John:
After we got to Saskatoon we drove around for about 10 or 15 minutes. Then
we talked to this girl. This was in the area where Sgt. Mackie drove me around.
Ron was driving the car at this time. He drove to the curb where Dave spoke to
this girl.
Dave was on the outside passenger side of the front seat. Dave opened the door
to talk to this girl as she approached along the sidewalk.
Dave asked this girl for directions to either down town or Pleasant Hill. He
offered to give her a ride to where ever she was going. She refused the ride.
Dave closed the door and said The stupid bitch.
We started to drive away and only went about half a block when we got stuck.
We ended up stuck at the entrance to the alley behind the funeral home.
Ron and Dave got out and they tried to push the car. They couldnt get it out.
I recall Dave going back in the direction we had spoke to the girl. Ron went the
other way past the funeral home.
The next thing I recall is seeing Dave in the alley on the right side of the car.
He had a hold of the same girl we spoke to a minute before. I saw him grab her
purse. I saw her grab for her purse again. Dave reached into one of his pockets and
pulled out the knife. I dont know which pocket he got the knife from. The knife
was in his right hand. I dont know if Dave had a hold of this girl or not at this
time. All I recall seeing is him stabbing her with the knife.
The next I recall is him taking her around the corner of the alley. I think I ran
after that. I think I ran in the direction Ron had gone. I recall running down the
street. I dont recall seeing anyone. The next thing I knew I was sitting in the car
again. I dont know how I got back to the car.

Reliability assessment: uncertain. It is unlikely Nichol John is mistaken in her

identication of the killer, as she knows Milgaard and was apparently situated near
him when the attack occurred. However, John may be deceitful. She is a 16-year-old
street girl who uses drugs. This statement is inconsistent with her rst statement to
the police. She was under pressure by detectives to talk about the Miller case; the
day before she gave this statement she was arrested and spent the night in jail. She
continued to travel with Milgaard after the murder. She now claims she cannot
remember anything about the crime.
 Police Practice and Research: An International Journal 221

Interpretation
Evidence must be explained and interpreted to give it meaning. Potential inferences
from the evidence and its context are identied in the protocols second stage. These are
reasonable deductions that can be based on the evidence. An inference can be thought
of as the extrapolation from the core facts of an item of evidence to its logical, proba-
ble, or (reasonably) possible conclusions, not all of which will necessarily be correct.
For example, DNA recovered from the vaginal vault of the victim in a child sex murder
leads to a strong inference it was left by the killer. However, that inference is not as
strong if the victim was a sex trade worker.
A likely inference from an unreliable item of evidence is still not probable; similarly,
an unlikely inference from a reliable item of evidence is also improbable. While infer-
ences are related to theories, they are distinct; the former is an extension from a single
item of evidence, while the latter is built up from the totality of evidence in an investi-
gation.
The explanation for an item of evidence the theory of its cause is an important
inference. While there can be a tendency to focus on the most obvious explanation, full
consideration should be given to all feasible options. Possible explanations can be
ranked by likelihood; as this assessment might change once an item of evidence is con-
sidered in relationship to the other evidence in the case, it is important not to prema-
turely eliminate possibilities (existing biases become most treacherous at this point).

Interpretation
Johns statement is signicant and highly probative. If accurate, it identies
Milgaard as Millers murderer. The following high probability inferences can be
made from this item of evidence (lower probability inferences are not listed in this
example):

(1) Nichol Johns statement provides an exact location for the stabbing (a loca-
tion different from where Millers body was found), suggesting there should
be blood and perhaps other physical evidence at the site.
(2) The location of the attack indicates the likely route walked by Miller to her
bus stop the morning of the murder.
(3) As described, the attack dictates Miller should have stab wounds and a
matching pattern of cuts in the clothing she was wearing (winter coat and
nursing uniform).

Patterns
The evidence in an investigation is simply a collection of facts. To understand what
happened in a crime, potential causes and inferences from the evidence have to be con-
nected and understood as a narrative or story. The third stage of the protocol involves
looking for patterns that can be derived from the constellation of evidence, and deter-
mining connections (inuences between items of evidence) and sequences (what ows
from what). It is also important at this point to analyze consistencies among inferences
as these suggest reliable narratives.
222 D.K. Rossmo

In many cases, the pattern will be patchy and incomplete. In such instances, it is
important to refrain from lling in the blanks beyond what can be supported by the
available evidence. In other cases, multiple competing patterns of varying probabilities
will emerge. Despite the human tendency to avoid uncertainty, it is necessary to con-
sider all viable options; this often requires consideration of contradictory possibilities.

Patterns
Part of Nichol Johns statement is consistent with the statement of her friend,
Ron Wilson, who also said he saw Milgaard with a knife.
However, Johns description of the location of the attack is not consistent with
the route the victim typically took to the bus stop. Miller usually followed the short-
est path, a three-minute trip. On the morning of her murder, she left her home ve
minutes before the bus was due (the temperature was 42 F), and it is unlikely she
would have been at the spot where John said the attack occurred.
Johns statement is also inconsistent with some of the physical evidence. No
blood was found near the place where she claimed the attack happened. (It is possi-
ble she was mistaken about the location, but no blood was found anywhere other
than by Millers body.) Furthermore, while the pattern of cuts in Millers winter coat
matched the pattern of her stab wounds, there were no cuts in her nursing uniform.
This meant that, at some point, Millers coat was taken off, her uniform was pulled
down, and her coat was put back on again none of which was described by John.

Analysis
Up to this point the focus has been on the case evidence. In the analysis stage, evi-
dence patterns are now used to generate and assess investigative theories or hypothe-
ses (see Jones et al., 2008a). It is best to start with broad comprehensive categories,
drilling down and becoming more specic as evidence permits. Not all the evidence
may be helpful in this process. Caution is needed when working with ambiguous evi-
dence, which is more vulnerable to expectations, desires, and other biases (Snook,
2000). When the evidence is ambiguous, subtle inuences on how an investigator
sees it could affect the outcome. A weak case can start to look strong when the inves-
tigator overlooks potentially fruitful leads in another direction (OBrien, 2009,
p. 329). To avoid this trap, it is important to consider the diagnosticity of an item of
evidence.7 Diagnosticity originally referred to the ability of a medical test to identify
a patients disease. In the context of a criminal investigation, the diagnosticity of an
item of evidence is a function of its ability to distinguish between different hypothe-
ses, such as a suspects guilt or innocence.
When developing case theories, investigators should remember Occams razor, the
Principle of Parsimony if more than one explanation for the evidence is possible, it is
preferable to start with the simplest (the one with the fewest assumptions). The narrative
of the crime should not be any more complicated than necessary to properly explain the
evidence. An important principle in the physical sciences, Occams razor can also be a
helpful investigative concept. While many things are possible in a crime, only some are
probable.
 Police Practice and Research: An International Journal 223

In the special case of only two competing theories, the available evidence can be
used to determine which is the most likely. The probability of an item of evidence given
the rst theory is compared to the probability of the evidence given the second theory.8
This process is then repeated for all items of evidence and the results combined. The
nal product indicates which theory is the more likely based on the totality of the evi-
dence (Blair & Rossmo, 2010).
The last step involves determining how particular suspects t into the various crime
theories and identifying any suspect-related information that might link back to the
crime, such as a relationship with the victim or prior criminal history. It should be
remembered, however, that a suspects bad character is not direct evidence of a crime,
absent information that provides a connecting link (e.g., a motive).
If it becomes necessary to use assumptions at this point, they should be written
down and all the conclusions derived from them so identied. To avoid tunnel vision,
the alternatives to an assumption (i.e., competing assumptions) must also be identied
and considered.

Analysis
There are signicant inconsistencies between Nichol Johns statement and other
reliable evidence in the case. Consequently, the reliability of her statement should be
reduced to low. John most likely lied in order to get the police to leave her alone.
Her statement should not be relied upon for theory generation or suspect prioritiza-
tion.
Unfortunately, considerable weight was given to Johns statement during the ori-
ginal investigation and trial, even though she continued to claim she could not
remember anything. Milgaard was convicted of Millers murder and spent over two
decades in prison. DNA testing eventually identied the real killer, a man who used
the same bus stop as the victim every morning (Commission of Inquiry Into the
Wrongful Conviction of David Milgaard, 2005).

Visualization
It is important to be thorough when rethinking a case and the results for each stage of
the protocol should be comprehensively recorded. It can be helpful to graphically depict
the evidence in a diagram. Figure 1 shows an example of such a diagram based on a tri-
ple murder case in Indiana. The wife and two children of David Camm, a former Indi-
ana State Police trooper, were shot in the garage of their home. Despite having an alibi,
David Camm was tried and convicted of their murders, the case relying heavily on
blood spatter evidence. Following a successful appeal, DNA found on a sweatshirt
recovered from the crime scene was linked to Charles Boney, a violent felon with multi-
ple convictions for attacks against women. His palm print was also found on the side of
the victims vehicle. Boney gave various conicting explanations for his presence at the
Camm house, the sixth and nal version of which had him there to sell David Camm a
handgun. The district attorney pursued murder charges against Boney, but he also chose
to retry Camm. Figure 1 shows a simplied version of the evidentiary support for each
of the three theories of the case: (1) David Camm did the murders alone, the rst
prosecution theory; (2) David Camm and Charles Boney did the murders together, the
224 D.K. Rossmo

Figure 1. Case evidence pattern in the Camm triple murder investigation.

second prosecution theory; and (3) Charles Boney did the murders alone, the defense
theory. Key evidence items are shown in small boxes situated under the particular the-
ory they support (interpretations are not shown); the stronger the reliability of the evi-
dence, the heavier the outline of the square. Clusters of consistent evidence are circled.
The third theory won out in court in separate trials, juries found Boney guilty and
David Camm not guilty.

Discussion
It is easy for detectives to become overwhelmed by the details in a major crime investi-
gation. The signal-to-noise ratio is often low and larger patterns can be missed because
of a focus on minutiae. There is a tendency to use cognitive heuristics (mental short-
cuts) under such conditions, even though these can lead to cognitive biases and then to
errors. One need look no further than conspiracy theorists to nd examples of how
biases can cause individuals to interpret and distort evidence to support the most amaz-
ing conclusions.
The purpose of this protocol is to assist investigators rethink a case when the exist-
ing theory appears incorrect. It requires a detective to start over by reexamining the
structure of the case, beginning with its foundation the evidence. Investigative hypoth-
eses are generated only after the evidence has been inventoried and assessed, explained
and interpreted, and connections and patterns identied. By focusing on and working
from the evidence, the investigation becomes grounded in reality instead of being based
 Police Practice and Research: An International Journal 225

on beliefs, hunches, or biases. This method can help correct thinking errors resulting
from a rush to judgment, tunnel vision, conrmation bias, and similar cognitive and
organizational traps.
The rethinking approach requires an investigator to abandon the existing theory and
adopt a completely open mind. However, this is much easier said than done. Research
has shown that awareness of cognitive bias does not make it easier to avoid (Heuer,
1999). Consequently, rethinking a case is more difcult for those detectives with prior
involvement in the investigation. The protocol works best when followed by someone
with no previous connection to the crime, ideally, an investigator from an outside
agency. This is the policy in England; unsolved murders are reviewed at prescribed time
periods (e.g., 28 days, 12 months) by a senior investigating ofcer (SIO) who is not
involved in the case. In high prole, complex, or sensitive investigations, it is recom-
mended the SIO be from another police force (ACPO, 2006). External peer reviewers,
for all the psychological and organizational reasons discussed above, are more apt to
notice mistakes and omissions and much more likely to point them out.

Conclusion
The purpose of the case rethinking protocol is to shift the focus of an investigation from
the prevailing theory/suspect to the evidence. Existing theories and assumptions can cre-
ate cognitive traps that prevent a crime from being solved. There is a tendency to
explain away inconsistent evidence discovered post-theory, rather than letting it con-
tribute to the development and prioritization of investigative hypotheses. This is conr-
mation bias.
The protocol does not provide a magic equation for the right answer; it is nothing
more than a systematic thinking tool, an analytic framework to help investigators objec-
tively rethink a case. It is still up to the detective to solve the crime. However, pilots
and surgeons have found the use of checklists to be helpful in minimizing mistakes
and their subsequent tragedies (Gawande, 2011). Criminal investigative failures that
result in innocent people being convicted or guilty parties going free are no less tragic.
Following this protocol can help reduce the number of such outcomes through a system-
atic and evidence-based approach to case rethinking.

Acknowledgements
I wish to thank Dr David Stubbins, Central Intelligence Agency (ret.), Deputy Chief Constable
Doug LePard, Vancouver Police Department, Detective James Trainum, DC Metropolitan Police
Department (ret.), Special Agent Gregg McCrary, Federal Bureau of Investigation (ret.), and the
anonymous reviewers for their helpful comments and suggestions.

Notes
1. This is similar to moving from an evidence-based to a suspect-based investigation (Rossmo,
2009), or from information generation to case building (Stelfox & Pease, 2005).
2. A study on bias in criminal investigations found participants who were asked to identify a
suspect early in the process showed a greater tendency to conrm that hypothesis, and later
remembered the case evidence as being consistent with their particular suspects guilt
(OBrien, 2009).
3. Police investigators rarely test their theories by searching for disconrming evidence even
though it is more probative than conrmative evidence (e.g., exclusionary DNA). Once a
narrative of the crime has been adopted, police tend to focus only on gathering conrmatory
evidence (Stubbins & Stubbins, 2009).
226 D.K. Rossmo

4. Templates for reviewing major crimes and evaluating cold cases have been previously
proposed (e.g., Adcock & Stein, 2013; Jones, Grieve, & Milne, 2008b). The present protocol
differs from these tools in its focus on how to rethink a case.
5. It may not be feasible to reanalyze every item of evidence in an investigation. The goal is to
list all the nontrivial items that might have an inuence on the theory of the crime and its
suspects. Trivial, however, does not mean inconsistent or contradictory.
6. Reliability is used here to refer to the accuracy or truthfulness of evidence, consistent with
most of the legal literature. However, the correct scientic term is validity.
7. Heuers (1999) analysis of competing hypotheses matrix can be a useful tool here.
8. The probability of evidence given a theory is not equal to the probability of the theory given
the evidence; confusing cause given effect with effect given cause is known as the prosecu-
tors fallacy (Robertson & Vignaux, 1995). Bayes theorem provides the mathematical rela-
tionship between the two probabilities (Taroni, Aitken, Garbolino, & Biedermann, 2006).

Notes on contributor
D. Kim Rossmo is the University Endowed Chair in Criminology and the director of the Center
for Geospatial Intelligence and Investigation in the School of Criminal Justice at Texas State
University. He has researched and published in the areas of environmental criminology, the
geography of crime, and criminal investigations. He is a member of the International Association
of Chiefs of Police Advisory Committee for Police Investigative Operations and is a full fellow of
the International Criminal Investigative Analysis Fellowship. He has written books on criminal
investigative failures and geographic proling.

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