Monday, 11 September 2017

Reflections on the Ayeeshia-Jayne Smith Serious Case Review

In the wake of the serious case review into the death of Ayeeshia-Jayne Smith, Joanna Nicholas (in the Guardian) wrestles with the problem of agencies appearing just to pay ‘lip service’ to the importance of learning from child protection tragedies. She concludes that we “… make all the right noises but then seem to carry on doing what we were doing before”.

Joanna points to two apparently obvious failings highlighted in the review: failure to follow-up a missed medical appointment of a child subject to a child protection plan and failure of medical staff to think about the possibility of abuse and neglect in framing their differential diagnosis. She despairs that what she calls these ‘simple aspects of practice’ were not followed in Ayeeshia’s case.

Sadly, except for a couple of concluding comments that there needs to be more research and clearer management direction, Joanna doesn’t provide us with a solution to the problem she outlines.

In contrast, I think that there is a solution. I think that what is needed is to create a responsive safety culture in child protection, just as they have done in other safety critical industries. We need to stop wagging the finger of blame and hoping to solve problems by top-down management fiat. Instead, we need to give people permission to learn and to put things right.

Unsafe practice persists not because child protection professionals are weak, ignorant, lazy or ill-informed, which, of course, by and large they are not. It persists because they are too often prevented from speaking openly and critically about what goes wrong routinely and analysing why it goes wrong.

Human error and organisational failings, just like Benjamin Franklin’s death and taxes, will always be with us. Rather than pretending that they can somehow be switched off at the click of a button, if only we could find it, we need to realise that the only solution is to improve continuously in small incremental steps. Building safer organisations and fostering safer practice is something that everybody involved in child protection needs to be involved in every day. They need to be permitted, encouraged and rewarded for learning from all the small and seemingly insignificant errors that are part of routine practice, but which one day may cumulate to cause a tragic death.

Professionals need to concentrate not so much on relatively rare tragedies. Rather, they need to focus on the mundane daily errors which we all make and look at ways in which better defences to them can be built and sustained.

Joanna Nicholas begins her article by asking: “when will we child protection professionals learn from child deaths?”

I would prefer to rephrase that question as follows: “when will we all (professionals, managers, policy makers, politicians, members of the public, journalists) realise that daily continuous learning is central to a safety critical activity like child protection? And when will we begin to put in place the conditions that are necessary to make that kind of learning flourish?”

Wednesday, 30 August 2017

Good news from Merton

There are so many words and phrases which tick all the right boxes in Ofsted’s report on children’s services in the London Borough of Merton, that I had to pinch myself to make sure it was not a dream.

I particularly liked the following: “a ‘flatter’ management structure”, “a 33% increase in frontline social workers”, “an extra £1 million pounds per year for the past three years”, “manageable caseloads”, “frequent supervision”, “a challenging and rewarding environment”, "frequent supervision" and “a strong culture of learning”.

You can read more about the inspection in Community Care.


Or if you have the time read the whole report yourself.


Closing Gaps

Peter Beresford in yesterday’s Guardian draws attention to what appears to me to be one of the most exciting and creative approaches to social work education to have emerged in recent years.


The new approach, apparently pioneered at Lund University in Sweden (which incidentally is also the home of a well-known department of risk management and societal safety - http://www.lunduniversity.lu.se/lucat/group/v1000224 ) involves educating trainee children’s social workers and care leavers together.

Referred to as ‘gap-mending’, the idea is to focus on how divisions between service users and social work students can be bridged, with an emphasis on understanding user perspectives and requirements.

I loved one of the quotations in Beresford’s piece. A care leaver is quoted as saying: “my bad experiences of homelessness are now valued as an asset in the education of future social workers”. Another spoke of helping to avoid “the same mistakes” in future. I love that expression ‘asset’ in this context. One of the best tricks is to turn liabilities (things not right) into assets (things of value).

This is exactly the approach we should be taking to learning in social work and child protection generally. We should listen carefully to those on the receiving end of services. We should look for service shortfalls and opportunities for improvement. We should work together to make lasting improvements.

Tuesday, 29 August 2017

Will ye no come back again?

The old Scottish ballad - Will ye no come back again?- is a pleasing melody. Likewise, the English Come Back to Social Work scheme sounds very easy on the ear. It is simply a good idea to offer social workers retraining and assistance to return to social work after a career break.
  
You can read more about the initiative in a recent article in Community Care.

One thing I don’t understand is why it is necessary to be so cautious about launching this scheme. For example, there are currently only 100 places available and only social workers who have left the profession in the last five years are eligible. Why?

Given that the shortage of experienced social workers is now reaching (or even exceeding) crisis point I can see no reason why the doors should not be flung open to returnees and every effort and resource put into re-recruiting as many as possible.

Fostering failures?

No doubt the account given in the Times (reported in The Guardian) of a small child who, it is alleged, was fostered by a family where, so it is said, no-one spoke her native language, English, will cause all sorts of hackles to rise across the media and beyond.

There is to be an investigation, so I’d counsel caution before comment until more is known. But what I would say is that, irrespective of what has happened in this case, the main problem with foster parents in Britain is that there aren’t enough of them to meet the continued high demand.

When services are under pressure, compromises are often made. The answer is not to leap up and down fulminating and calling for heads to roll, but to address the shortfalls by coming up with resources and strategies to ensure that every child who needs fostering has foster parents who can fully respond to her or his needs.

Thursday, 3 August 2017

Slow to blame and quick to learn

I recently wrote an article – published in the July/August edition of Professional Social Work - with Trevor Dale, a former British Airways pilot, about what social work can learn from civil aviation’s human factors approach to safety.
  
Regular readers of this blog will not be surprised to find that the article rehearses many of the arguments which I regularly put forward here. Just like civil aviation, child protection social work is a safety critical activity. Its practitioners require effective ways of learning from failures and mistakes so that they can slowly and progressively build safer services.

I was quite pleased with a little text box that the Professional Social Work editor suggested we include in the article and in particular with its first bullet point: 

“When things go wrong, be slow to blame and quick to learn”.

That could be a moral not just for social work and child protection but for life in general.

Wednesday, 2 August 2017

Smoke and mirrors

Ofsted has found that Reading Council’s children’s services continue to be ‘inadequate’.


Instead of trying to find out why Reading’s services are ‘inadequate’ – in other words doing some tough analysis to discover what needs to be put right - there now seems to be a preoccupation with outsourcing and revising governance structures.


I say this to Reading Council and their collaborators. You don’t make excellent services in committee rooms and board rooms and you don’t deliver high quality and safety by concentrating on who owns or controls what. You can only deliver excellent complex services by helping the people who deliver them to understand what they need to do to satisfy the needs of service users.

That involves moving the focus from the top of the organisation to the bottom, from the board room to the frontline. Forget the smoke and mirrors; concentrate on the knitting.