On April 28, 2009, Officer Richard DeCoatsworth shot a mentally ill man named Anthony Temple in the hip during a confrontation in Logan.
Temple was trying to grab DeCoatsworth's 9mm service weapon, the officer said. DeCoatsworth was able to backpedal, draw his gun, and empty a round into Temple. Then a backup officer fired another bullet that killed the disturbed 28-year-old at Lindley Avenue and Warnock Street.
When Internal Affairs investigators probed the shooting, they found that DeCoatsworth may have violated the department's policy on deadly force - officers are instructed to shoot only if they are in fear that they or someone else will be seriously hurt or killed.
It took more than two years, but he eventually appeared before the police trial board that decides whether to mete out discipline against officers involved in shootings.
Between 2007 and 2013, he was one of 88 such Philadelphia police officers who appeared before the board over shootings. Each already had been found by department brass to have violated policy.
The next step was to appear before a second group of officers - the trial board known as the Police Board of Inquiry, which would hear arguments from both sides and decide on the officers' guilt and, if necessary, punishment. Typically, the board deals with the most serious shootings.
Nearly half of the accused would return to the street without formal discipline.
DeCoatsworth, who was found not guilty of violating policy, was one of them.
The officer, who had survived a 2007 shotgun blast and was hailed as a hero, would, just months later, resign from the department on disability. He had, by then, shot another man and would be involved in a series of violent events: He spent 10 months in prison in 2013 over an armed standoff with police and was sentenced to 18 months' probation earlier this year on a simple-assault charge involving his live-in girlfriend.
But at the time, he emerged unscathed from a labyrinthine process singled out for criticism by the Justice Department in a report released last week on Philadelphia officers' use of force.
The federal reviewers said the process was laced with "inherent conflict." And they said it frequently invalidated the department's own findings in police-involved shootings.
"This sends a mixed message to members of the department," the report found, "and causes unnecessary internal strife."
Whenever a police officer fires a weapon in Philadelphia, the department's Internal Affairs unit opens an investigation.
In DeCoatsworth's case, Internal Affairs investigators concluded that he was the only officer who should be cited for a violation in the shooting - the officer who fired the fatal shot, James Kelly, was found to be in compliance with department rules.
But investigators said that, because DeCoatsworth had time to backpedal, escaping from Temple, he may have violated the rule that police can shoot only if they believe they face "imminent danger of death or serious bodily injury."
After internal investigations, the department's Use of Force Review Board - four deputy commissioners, some of the highest-ranking police officials in the city - review case files and determine whether the officers involved have, indeed, violated policy. If that's the case, those findings are sent to the department's charging unit.
Should the charging unit agree with the UFRB, the matter is forwarded to the three members of the Police Board of Inquiry - a captain, a lieutenant, and one of the officer's peers.
Those three PBI members hear witnesses from both sides and decide whether the officer was guilty of the policy violation.
DeCoatsworth appeared before the PBI in May 2011 - more than two years after the shooting itself.
Forty-eight percent of the time, those who came before the PBI between 2007 and 2013 received either a not-guilty verdict, like DeCoatsworth, or an order to undergo additional training - in other words, the report concluded, no formal discipline.
"Based on our review of PBI outcomes," the federal report read, the department's original findings were "essentially invalidated nearly half the time."
Of the 88 officers who appeared before the board, 16 were found not guilty; 27 were found in need of training and counseling; and 21 received an "official reprimand." An additional 18 were suspended, for terms of one to 30 days. One retired.
Only five were fired from the department.
None of the officers' names was included in the Justice Department report, nor were descriptions of the shootings they had been involved in.
There's an "inherent conflict" in the way Philadelphia police hold officers accountable for their involvement in shootings, the federal report concluded.
The report said the two-board system was confusing and contradictory - considering that by the time officers appear before the PBI to defend themselves, the department's higher-ups have already indicated, in writing, that their actions were not in accordance with department policy.
And should a civil suit be filed in an officer-involved shooting, the conclusions of both boards would end up in court records.
That's how, for example, Officer Stephen Szczepkowski, who in 2007 killed an unarmed 21-year-old while responding to New Year's Day gunfire in Overbrook, ended up with a line like this in a lawsuit against him:
"The PPD's Firearms Discharge Review Board [an arm of the UFRB] . . . found that PO Szczepkowski did not discharge his firearm according to departmental policy."
And one paragraph later: "After a hearing before the PPD Police Board of Inquiry, the PBI unanimously found PO Szczepkowski not guilty of violating the PPD Disciplinary Code."
Reached last week, Szczepkowski noted that police recovered numerous guns from the area near where the shooting occurred, and arrested several people. Court records show those charges were dropped due to the difficulty of determining who might have fired on police and who was simply firing guns into the air.
The family of the 21-year-old who was killed, Bryan Jones, eventually received a $1.2 million settlement from the city.
The Justice Department offered a simple fix to the two-board problem: Consolidate them into one that, like the UFRB, includes high-ranking department officials, and, like the PBI, includes a peer officer and an officer one rank higher than the officer involved - and allow officers to appear before the board with representation.
It should also, the report said, include at least one civilian with ruling power.
Police Commissioner Charles H. Ramsey, who commissioned the Department of Justice report in 2013, said that he supported an overhaul of the current disciplinary system surrounding shootings.
"What we have to do is something where we take into account the rights of citizens," he said, "but we also have to make sure that we don't infringe upon the rights of officers."
Ramsey wants to institute an independent entity to investigate such shootings - a recommendation that was also made by the 21st Century Policing Task Force and drafted by a committee chaired by Ramsey.
John McNesby, the head of the Fraternal Order of Police Lodge 5, said he also disliked the current disciplinary system.
"We don't want to rush to judgment to hang a guy," he said. "We have great investigators that are up in Internal Affairs. They know what they're doing, they're highly trained, they're professional. I would like to get them more involved in the decision-making."
The low share of officers that the PBI decides to fire is not necessarily cause for concern, Ramsey said, and should be viewed in the context of a city still plagued by homicides and violent crime, where nine officers have been killed since 2007.
"You can't just look at numbers and say something is not right," Ramsey said. "You have to look at each individual case and see whether or not something has risen to the level of actual discipline being imposed."
That said, "one shooting that's inappropriate or is not justified is one too many," he added. "It should be zero."