A Slap on the Wrist?

I’ve commented on Health and Care Professions Council (HCPC) decisions before - http://chrismillsblog.blogspot.co.uk/2013/06/name-shame-blame.html - in that case because I felt that discipline was an excessive response.

Now I am reacting to another case in the opposite direction - http://www.hpc-uk.org/mediaandevents/pressreleases/index.asp?id=658 

A panel of the HCPC Conduct and Competence Committee heard that a social worker was with others outside the victim’s house shouting abuse. Apparently she was heard to shout out threats to kill a victim inside the property. As a result she appeared in court and was convicted of a criminal offence.

One report states that she was heard to shout “baby murders” - http://www.dailymail.co.uk/news/article-2351562/Social-worker-suspended-12-months-screaming-baby-murderers-outside-couples-house-threatening-kill-them.html 

The HCPC panel concluded that the social worker’s behaviour was “wholly unacceptable, unprofessional and deplorable conduct and brings the profession into disrepute”. They can say that again!

The panel expressed the view that this type of bullying behaviour called into question her suitability to remain in social work, but then decided the most appropriate action was to suspend her from the Register for a period of twelve months!

Sorry, perhaps I didn’t hear that correctly. Twelve months = one year = 365 days = over in 2014 and back to work. Surely not!

Two horrific cases

Two horrific cases have recently hit the news. 

I predict that the tragic death of two-year-old Keanu Williams in Birmingham will result in an important Serious Case Review (SCR) Report

http://www.guardian.co.uk/uk/2013/jun/25/rebecca-shuttleworth-jailed-son-murder

The chair of Birmingham's safeguarding children board, Jane Held, has said: “It is clear from this trial that professionals in the different agencies involved missed a significant number of opportunities to intervene and take action."

Also we need to look out for the SCR Report on the death of Daniel Pelka in Coventry. http://www.coventrytelegraph.net/news/coventry-news/daniel-pelka-like-concentration-camp-4313168

This case has some eerie echoes of the Khyra Ishaq tragedy.

Anyone who tells you that the same mistakes don’t keep happening has got it wrong!!  

The Answer to Oxford

We will have to wait for the report of the Serious Case Review to get a clearer picture of what went wrong in the Oxford grooming sex case. http://www.bbc.co.uk/news/uk-england-oxfordshire-23079649 

I expect that there will be a lot of pundits calling for better information sharing and more integrated working, but the truth of the matter, I suspect, is that the cause of the tragedy was that the girls were not listened to when they should have been listened to.

I think the Children's Society’s Matthew Reed has it about right. He is quoted by the BBC as saying that professionals and agencies need to “… change their attitude to vulnerable, exploited teenage girls, who are being routinely dismissed as ‘troublesome’ or ‘promiscuous’ or as having made life style choices”.

We should all be thinking long and hard about how we can make it easier and safer for children and young people to report abuse and to seek help and support. And we should be asking children and young people to help us in designing services. Current bureaucratic approaches – ‘referrals’ and ‘investigations’ and ‘enquiries’ and ‘assessments’ – probably cut no ice with vulnerable young people. What they need is people they can trust to deliver appropriate help.

Some years ago I co-authored a report about ‘information sharing’. We titled it “I think it’s about trust … “ because that is what one of our respondents (a teenage girl who had suffered abuse) told us. [1]

We need to design services that children and young people trust more. That’s the answer to Oxford.

[1] Zoe Hilton and Chris Mills ‘I think it’s about trust’: the views of young people on information sharing. London: Office of the Children’s Commissioner, September 2006 – to download a pdf, Google ‘I think it’s about trust’ and follow the link.

Female Genital Mutilation

The NSPCC should be congratulated for launching a helpline to help protect girls from female genital mutilation (FMG). http://www.guardian.co.uk/society/2013/jun/24/nspcc-helpline-girls-female-genital-mutilation

The helpline will not only be of great value to victims and those trying to help and protect them, but it should be a valuable source of learning about the nature and extent of the problem, which has until now remained largely hidden from view.

I hope the NSPCC will be able to make this learning available to others so that awareness and understanding grows.

In favour of a Reporting Culture

Today the CQC whistle-blower, Kay Sheldon, writes a very good and informative article in the Daily Mail. She concludes by saying: “We need to change things so that not reporting concerns is seen as wrong, rather than the other way round. … this culture of fear has to be driven out and we all need to be much more open and honest in our day-to-day work”. [My emphasis]

She is absolutely right. Safety requires a reporting culture and so does quality. Unless people feel safe in bringing concerns about poor safety and poor quality to the attention of people who can bring about changes, then poor safety and poor quality will simply persist, unremarked until a tragedy or disaster occurs.

I listened to BBC Radio 4’s Any Questions yesterday. I was a bit surprised to hear contributors invoking the argument that people should not feel afraid in their jobs to justify not naming the managers at the CQC who are accused of orchestrating the cover-up.

I take a different view. Where there are allegations of bullying or suppressing the truth, to the detriment of safety, then I see no problems at all in uncovering what is going on and I have no problems with bullies being named and shamed.

A reporting culture should be a ‘just culture’ as Sidney Dekker [1] says. Serious wrong-doing should not be protected in a reporting culture; just as slips, lapses and honest mistakes should not result in blame and punishment.

[1] Dekker, S. Just Culture: Balancing Safety and Accountability, Ashgate, 2007

Whistle-blowing and the CQC

I’ve mentioned the Care Quality Commission (CQC) before. It’s the body that inspects health and adult social care in England. I have been quite impressed with their new management, under David Prior, who seems to be clearing up one hell of a mess, created by the former management team, who have now all ‘moved-on’.

None of that stopped me being shocked rigid by the revelations in today’s media (http://www.guardian.co.uk/society/2013/jun/19/met-nhs-regulator-morecambe-farron) that the CQC, under its former bosses, hushed up important reports concerning an under-performing maternity unit, which allowed the unit to continue unchecked with further infant deaths resulting.

And then there was the amazing revelation, covered at length in today’s Independent, (http://www.independent.co.uk/voices/comment/our-love-for-the-nhs-blinds-us-to-its-failures-morecambe-bay-is-yet-another-wake-up-call-8665269.html) that a member of the CQC’s Board Kay Sheldon, who tried to blow the whistle on this state of affairs, was branded as ‘mentally unstable’ by the then chairman, Dame Jo Williams. Taxpayers’ money was apparently used to pay a psychiatrist to prepare a report on Ms Sheldon, with a view to removing her from the Board.

This type of shenanigans has no place in a body charged with safety and quality improvement. Inspection may be at the best of times a blunt tool, but without openness it is no kind of tool at all. Just as I always wonder how a Soviet agent became the head of MI6 (could they have appointed a worse person for the job?) I am utterly gob-smacked that someone somewhere seems to have allowed a group of people who have no idea about quality and safety to become precisely those people who are placed in charge of an organisation charged to deliver quality and safety improvements.

If you wrote about it in a novel they would say it was incredible …

 

Ugh!! More from Ofsted

How depressing it is to read yet another glib document from Ofsted! 

I don’t know how many people will be fooled with this one, but it cuts no ice with me. I shall certainly be responding to the consultation and leaving them in no doubt what I think.

The headlines speak of plans for “tougher” child protection inspections.

But the main proposal seems to be just re-labelling a finding of ‘adequate’ as ‘requires improvement’. Thereafter the document weaves its merry way through bureaucratic gobbledegook that seems to me designed to lull the unwary into a false belief that there is some kinds of scientific basis for all this. Terms like ‘grade descriptors’ sound technical, but what they are in fact are just adjectives or, worse, the subjective judgements of inspectors.

But the worst thing about this document is the seemingly endless list of the characteristics of a ‘good’ service that become ever more convoluted and contrived.

For example we are told (page 8) that … “(c)hildren and young people … (should be) consistently seen and seen alone by social workers where statutory guidance requires that this should happen and it is professionally judged to be in the best interests of the child”. 

I think that all that this means is that children should be seen alone except where they shouldn’t be seen alone.

And what do you make of this entangled offering? 

“Children, young people and families are offered help when concerns are first identified and, as a consequence of the early help offered, children’s circumstances improve and, in some cases, the need for targeted services is lessened or avoided. The interface between early help and statutory child protection work is clearly and effectively differentiated.” (also page 8)

I wonder how many people would recognize that if they saw it in practice! Frankly it’s just empty words. 

I can heartily agree with Eleanor Schooling, the chair of the Association of Directors of Children's Services' Standards, Performance and Inspection Policy Committee, who is quoted by Children and Young People Now as saying that local authorities require more than “… a long, potentially highly aspirational, list of descriptors to assess whether or not a service is good” and that "(t)here has to be a more precise and definitive definition of what 'good' looks like to avoid a superficial tick box approach if we are to be confident that all children have access to high-quality provision and support."

The truth of the matter is that Ofsted approaches the inspection of child protection as a kind of bureaucratic game in which the regulator draws up contrived written hurdles over which the regulated have to jump. But how these relate to the experience of any child, or to the effectiveness, cost quality and safety of the service remains a mystery. Children deserve better than that.

An Interesting and Important Appointment

I am very pleased to see that Michael Gove has appointed an aviation safety expert to the panel of experts who will oversee Serious Case Reviews.

The press release says: “Nicholas Dann is Head of International Development at the Air Accidents Investigation Branch (AAIB), the government body charged with the investigation of accidents and serious incidents to aircraft. He has over 10 years’ experience as a senior inspector of air accidents during which time he has investigated a wide range of accidents, both in the UK and overseas.”

I hope that he will bring a much welcome new focus, with more emphasis of the ‘why’ issues and a human factors perspective, which is essential to understanding, correcting and mitigating error in the workplace.

The Limitations of Serious Case Reviews

There is no better illustration of the limitations of the Serious Case Review as a tool of learning than the coverage of the recent case of the fourteen-year-old girl who was forced by her mother to inseminate herself.

http://www.guardian.co.uk/uk/2013/jun/05/child-services-missed-chances-forced-pregnancy

For legal reasons, which are not explained, the name of the local authority where these events took place cannot be divulged. That makes it impossible for most professionals to access the report of the serious case review or the executive summary. Instead we have to rely on the press coverage which is, of necessity, somewhat abbreviated.

We are told that an unqualified member of children’s social care staff was ‘fobbed-off’ when s/he tried to investigate concerns about the mother’s care, but there are no details about exactly what happened or why.

In order to learn how to avoid mistakes and errors it is no use having only sketchy, high level summaries of what went wrong. That’s like saying that a plane has crashed because the pilots failed to keep it flying! We need to know what has happened, we need to know how it happened and we need to know why it happened.

And the answers to such questions need to be available nationally, not just to a small local elite.

We desperately need to re-examine the widespread assumption that the Serious Case Review is an adequate tool of learning from mistakes. It isn’t.

Name, Shame, Blame

I have severe reservations about bringing cases before the Health and Care Professions Council like the one described recently in Community Care 
http://www.communitycare.co.uk/articles/04/06/2013/119228/social-worker-cautioned-after-failing-to-properly-assess-childs-aunt-and-uncle.htm?cmpid=NLC|SC|SCNEW-20130605

The social worker concerned is acknowledged to have had a hitherto unblemished record and so far as I can see from the reports, and the full notice of the decision, her main offence is that she ignored procedures. http://www.hpc-uk.org/complaints/hearings/archive/index.asp?id=3553  

In my experience a very common reason for ignoring procedures is that it is the only way to get the job done – a ‘workaround’ in the jargon. We should not be naming, shaming and blaming people just because they find a difficult job sometimes too difficult. If people are dishonest, or worse, deliberately cause or allow harm to a child then discipline is the correct response. But not following the rules should prompt us to ask:  “Can the rules always be followed?”

And, of course, there is another reason why this kind of heavy-handed response is so wrong. It inhibits people who make mistakes from confessing them and helping to put matters right. We want people who stray from the rules, or who find themselves creating a mess, to be open and frank with management and colleagues about what went wrong. That’s the only way it will get put right.

Coming down heavily on people who are simply trying to get a job done is not only the wrong response, it is a dangerous response.