Portland's police bureau has failed to learn from past shootings to prevent tactical and accountability errors, according to a report by outside consultants released by the city Wednesday.

The 132-page report, completed by California-based OIR Group, looked at six officer-involved shootings and one in custody death from 2005 through 2010. The report looked at the March 2006 in-custody death of Timothy Grant and six officer-involved shootings: Marcello Vaida in October 2005; Dennis Young in January 2006; Scott Suran in August 2006; David Hughes in November 2006; Osmar Lovaina-Bermudez in August 2009; and Keaton Otis in May 2010.

The review went through all seven deaths and recommended 31 policy changes. In its report, the OIR Group highlighted Taser use (already a big issue for the bureau in its recent Department of Justice settlement), which officers deployed in four of the seven deaths. It also dinged the bureau for unsafe foot pursuits and poor tactics in removing uncooperative suspects from cars.

The most critiqued shooting was the 2006 death of Dennis Young, who was killed by Lt. Jeff Kaer. Kaer responded to his sister's home, where there was a report of a man in a suspicious vehicle.

Kaer, without waiting for backup, attempted to wake Young, who then tried to drive off, the report says. The two struggled as a backup officer arrived. Young accelerated and hit a tree, then began to reverse toward Kaer, who fired twice. Young died at the scene. The backup officer then Tased Young, who was declared dead on scene by paramedics.

Removing suspects from cars has cropped up as a repeated issue, from Young's death in 2006, to the 2010 shooting of Keaton Otis and the incendiary death of Kendra James in 2003.

The review pointed out that then-Mayor Tom Potter tried to fire Kaer for the shooting, going against the recommendation of the then police chief. An arbitrator overturned Potter's termination. But, instead of studying why the arbitrator overturned the city's firing, the bureau changed little, the report says.

"Unfortunately, the Bureau did not use this decision as a learning opportunity and did not consider or change any practices as the result of the arbitration decision," the report reads.

The report praised PPB for being open to review, but it cautioned that internal review processes "must be accompanied by efforts to make substantive modifications in the way officers act and make decisions in the field. Otherwise, review efforts remain hollow and invisible to the community."

In a response also attached to the report, Police Chief Mike Reese agreed with nearly all of the 31 policy changes, and said some had already been made. He disagreed with changes the group recommended he make in foot pursuit and the use of the "box in maneuver" in high risk vehicle stops of armed suspects.

The group, hired by City Auditor Lavonne Griffin-Valade in March 2011, has been charged with reviewing and making policy recommendations on 17 police-involved deaths. One report focused on the controversial killing of James Chasse in 2006; a second report, released in 2012, looked at seven other officer-involved shootings.

"This report builds on prior reports OIR has done," says Constantin Severe, director of the Independent Police Review division in the Auditor's office. "It allows us to map the way the bureau has evolved over time and the steps we need to make."

Severe says a number of city code changes—including increasing the amount of information available to the public and strenghtening the authority of the IPR to interview officers directly during investigations—will need to go on a city ballot soon. "This will be one of the fundamental documents we use," Severe says.

OIR Group representatives will go over the report with the City Council on July 17.