Monday, 23 May 2016

Preparing for Ofsted?

I am torn between disbelief and despair by an article in the Evesham Journal about Worcestershire County Council’s Children’s Services.
Has somebody misunderstood what is going on or are council chiefs (as the headline proclaims) really planning to stage “a series of mock inspections” of Worcestershire's child protection services in order to prepare for an upcoming visit from Ofsted?

I don’t know specifically what is happening in Worcestershire. But generally it seems to me that there is a fundamental problem with the impact of the Ofsted regime; with its judgemental approach and its narrowly graded outcomes. A good result in an inspection can become more important than actually providing a good service. Improving appearances can become more important than improving service quality. Pleasing the inspectors can become more important than meeting children’s needs.

It all adds up to just more and more pressure on services that are already pressured as a result of tight financial constraints, increasing demands and a longstanding and unremitting shortage of suitably trained and experienced staff.

To my mind it’s all part of a name and blame and shame culture. It isn’t a recipe for improvement, it’s a recipe for knocking the stuffing out of services and the people who deliver them.

Unnecessary criminalisation must stop

A new report from the Prison Reform Trust prepared by a group chaired by Lord Laming comes to eminently sensible conclusions. The Guardian reports that the main findings are that children in care are six times more likely to be cautioned or convicted of a crime than other young people and that half the children in youth custody have been in care. The main recommendation is that great care needs to be taken not unnecessarily criminalise children who are in care.

The report points to the shocking phenomenon of children who are in care being dealt by the police in trivial situations that would normally be dealt with by parents, for example when a child “steals” food from a kitchen of a care home or when a teenager trashes his own room. Lord Laming is quoted as saying: “Most families deal with this sort of challenging behaviour within the family. Once the police are called, it becomes theft or criminal damage and it goes on the child’s record.”

In recent times I have reported in this blog on two other similar reports. 

In August 2015 I drew attention to an excellent report by the Northern Ireland Human Rights Commission examining the rights of children in care. This says (page 158) that some young people in residential care are “… being penalised for offences in a way that they would not if they resided with their parents”. Police, it is said, are called out to deal with incidents that occur within residential homes, in circumstances which would never result in police action if the children were living with their parents. The report concludes that “… the practice of police involvement and potential subsequent engagement with the youth justice system (have) profound negative implications for young people’s subsequent life chances”.

Another report which I commented on in July 2015 points to similar practices occurring in England. The police regulator, Her Majesty’s Inspectorate of Constabulary, produced a report (In Harm’s Way) which concludes: “We were surprised to find examples of children who had been accused of offences such as pushing a sibling, criminal damage in their (own) children’s home, or for wasting police time by running away from home. Sometimes, children were accused of lying or perverting the course of justice when their accounts of offences against them were disbelieved.” (Page 11)

In my view the Government needs to get a grip on this issue and provide clear and unambiguous guidance to police and care agencies that the criminal law is not to be used as an easy alternative to dealing constructively with challenging behaviour. Unnecessary criminalisation of children and young people is a form of abuse; it must stop.

Sunday, 15 May 2016

Thinking about Serious Case Reviews

Regular readers of the blog will know that I am no great fan of Serious Case Reviews (SCRs). I was however pleased to see that a new publication from the NSPCC goes some considerable way to introducing safety systems thinking and a human factors approach into SCR practice.

On page 19 of the document the authors draw attention to the "... large body of safety management literature that addresses the same problems as child protection of understanding how poor outcomes arise and how they can be reduced". A key lesson, we are told, is that practitioner errors generally arise from the interaction of several areas of weakness in the system, and not from one major mistake by an individual. So the focus of investigations, it is argued, should be on exploring how systems function routinely and on general factors which predispose to error.  The authors quote Professor Don Berwick, in his report on patient safety in the NHS, and Professor Sidney Dekker, who both argue that it is vitally important to distinguish clearly between wilful misconduct, on the one hand, and human error which is normal, and by definition unintended, on the other. Well-intentioned people who make errors at work or who are involved in systems failures need support not punishment. And unjust punishment inhibits people reporting their errors, or defects in systems, and so inhibits learning.

All this is excellent stuff. I don’t think this document will transform the Serious Case Review process into something truly useful, but I do think that it moves forward establishment thinking about how investigations into accidents and service failures in child protection investigations are undertaken and what conditions need to be in place to encourage reporting and so facilitate learning.

That could be the start of a journey towards developing approaches – such as critical incident reporting and human factors thinking - that will deliver better results than SCRs ever have.

Thursday, 28 April 2016


The revelations of a toxic culture of cover up and denial and blame in the South Yorkshire police force, which are now revealed following the Hillsborough inquests, contribute greatly to our understanding of what went wrong in Rotherham, a town served by that same police force, where young people were ruthlessly sexually exploited without effective action by the police and other agencies to protect them.

Clearly on that fateful day in 1989 terrible mistakes – errors of judgement - were made in the policing of the football match. If only the reaction of the police had been to be immediately open and frank about the disaster, to be honest about what may have gone wrong and to look for safety lessons, not scapegoats, it could all have been so different. A great deal of needless unbearable pain and suffering could have been avoided.

Whether it be football crowd control or responding to child abuse and neglect, the message from recent events is clear. There are no greater enemies of public safety than secrecy, fear, blame, denial, conspiracy and self-protection.

Wednesday, 27 April 2016

Human factors thinking in child protection - cheaper and quicker than blue skies research

NSPCC Scotland’s Matt Forde, writing in The Herald, makes the astute observation that if inquiries into child protection failures worked, the problem of preventing child abuse and neglect would have been solved by now. He says: “Dozens of cases, over more than four decades, cite familiar problems – professionals not talking to each other, not putting the picture together and missing opportunities to act.”

Matt goes on to recommended increased spending on research into the causes and consequences of abuse and neglect – undoubtedly a very worthy cause – but my conclusion from his premise is somewhat different. 

If inquiries into the causes of disasters have not worked, we need to think of better ways of gaining an understanding of why things go wrong. That’s exactly what they realised in civil aviation in the 1980s and since then they have practiced human factors thinking [*] which helps all kinds of employees – not just pilots – to recognise how and why mistakes happen in the workplace and what can be done to put them right.

Human factors thinking is not about blue skies research. It is based on a number of simple skills, stemming from the insights of the psychology of human error, which are practiced daily by everybody involved in a safety critical activity, like child protection. 

It ain’t rocket science and it’s a lot cheaper and quicker than conducting huge studies into the causes and effects of abuse. And we could all be doing it, as they do in other industries, if only the leaders of the children’s sector and their political rulers would open their minds and see the sense of it.

* See Flin et al Safety at the Sharp End: a guide to non-technical skills Farnham, Ashgate, 2008 - for a very readable introduction.

Tuesday, 26 April 2016

Child Refugees

James Brokenshire MP, a Home Office minister, is reported in the Guardian as saying in the recent House of Commons debate that for Britain to accept refugee children already in Europe would “…. inadvertently create a situation in which families see an advantage in sending children alone, ahead and in the hands of traffickers, putting their lives at risk by attempting treacherous sea crossings to Europe which would be the worst of all outcomes”.

That’s a bit like saying that we shouldn’t provide medical care to the victims of motor accidents because to do so might encourage people to drive less safely!

The Shadow Immigration Minister, Keir Starmer MP has my support. He is reported as saying that Brokenshire is arguing that we must abandon these children to their fate. I’m glad that Starmer and many other Parliamentarians, such as Alf Dubbs and Yvette Cooper,  are standing up to this indefensible and cruel policy adopted by the British government.

Sunday, 24 April 2016

Education Committee - written evidence from the Safer Safeguarding Group

The Safer Safeguarding Group’s written evidence to the House of Commons Education Committee enquiry into the reform of children’s social work can be found on the Committee’s website.

The group concludes that the Government lacks a clear focus on safety in children’s services and fails to take account of a human factors approach to making children’s social work safer. On a number of important issues – training, recruitment and retention, learning – the Government fails to provide a clear analysis of the problems and any clear vision of how safer and higher quality children’s social work can be brought about.

The Safer Safeguarding Group’s evidence stresses the need for cultural change and the importance of helping children’s social workers talk more freely and openly about the errors they make so that they can learn more readily from then and discover the error traps that lurk within their organisations.

The group commends to the Committee inexpensive and evidence-based approaches to learning that have found favour in other safety critical industries – human factors training (mandatory in civil aviation) and Near Miss Reporting, which has played a significant role in exposing error traps in fields such as civil aviation and anaesthesia. 

Because the protection and safeguarding of children is a multi-agency activity, involving the practice of many different types of professionals and agencies, the group believes that a learning culture based on an understanding of human factors and near-miss reporting should be incorporated into multi-agency training and management of cross-agency work, not just social work training.