The Tragedy of Daniel Pelka

Apparently the Serious Case Review into the death of Daniel Pelka will not be available until September. http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-23349527

Nobody should be in any doubt that this is an extremely worrying case. Early indications are that the school, health and other professionals were involved, but there is no mention of child protection enquiries having been initiated, even though the child is described as looking terrible and searching bins for food.

There are echos of Khyra Ishaq’s tragic death, another child about whom the school had serious concerns and who was being starved at home. http://news.bbc.co.uk/1/hi/england/west_midlands/8512503.stm  

I think having to wait until September for an SCR is an unacceptable option. I have for a long time been in favour of having an inspectorate (not Ofsted) which is capable of moving rapidly into a local authority in circumstances like these and finding out without delay the early indications of what has gone wrong.

That’s what happens when the Air Accident Investigation Branch deals with an air crash. Their staff members are on site as soon as it is safe to begin an examination of the wreckage. And anything they learn which needs to be communicated to make other planes safe is disclosed at the earliest possible moment.

I have a dreadful sinking feeling about this terrible tragedy of Daniel Pelka. It has all the hallmarks of a case in which dreadful failures have occurred.

Jones on SCRs

I am pleased to see Prof. Roy Jones in The Guardian (http://www.theguardian.com/social-care-network/2013/jul/25/serious-case-reviews-costly-complex) arguing that Serious Case Reviews (SCRs) have important limitations, which mean that we need to reconsider how and when we use them.

His argument is that SCRs must help, not hinder, child protection. Costly, time-consuming and disruptive reviews that undermine, rather than inform, practice are a bad idea in anybody’s book.

More Work in Manchester

The Manchester Evening News reports that there has been a rise of 23% in the past year in the numbers of children and young people subject to child protection plans. http://www.manchestereveningnews.co.uk/news/greater-manchester-news/rise-manchester-kids-abuse-risk-5379095 

This is said to accompany a steep increase in the numbers of referrals to Manchester’s Children’s Social Care teams.

No service can cope well with fluctuations of this kind. It is extremely difficult to scale up staffing and facilities to handle this sort of increase and major problems - including redundancy- are encountered if subsequently activities return to previous levels. Inevitably front line staff will feel the brunt of the extra work and the pressure of unforeseen changes.

This is all part of a national trend. There has been a steady rise in child protection work in England since 2008. This may now be tailing off, with the increase from 2011 to 2012 being much less dramatic than in previous years. However the 2012 figure is 47% up on the 2008 figure, an alarming rise. 

Children and young people subject of a Child Protection Plan, England 2008-11

Type of abuse	2008	2009	2010	2011	2012
Neglect	13,400	15,800	17,300	18,600	18,220
Physical abuse	3,400	4,400	5,000	4,800	4,690
Sexual abuse	2,000	2,000	2,300	2,400	2,220
Emotional abuse	7,900	9,100	10,800	11,400	12,330
Multiple	2,500	2,900	3,700	5,500	5,390
Total	29,200	34,100	39,100	42,700	42,850

Source: Department for Education (2012) Characteristics of children in need in England, 2011-12. http://www.education.gov.uk/rsgateway/DB/SFR/s001095/index.shtml 


Surprise, surprise - there is no national strategy to deal with this situation. It looks like ministers are just hoping that it will go away. 

The ‘Bane’ of ICS

Having just written a post about computer problems in child protection in British Columbia, my attention has been drawn to an interesting post in the Community Care Social Work Blog at the end of last year that I had missed.

A social worker called ‘Frank’ describes the Integrated Children’s System (ICS) used in England as “… the bane of my life …”

Frank says that the system is very time consuming and difficult to work with. He says he feels as though he is being forced to follow the computer rather than using his professional judgement about children and families.

I strongly recommend reading the whole of his post: http://www.communitycare.co.uk/blogs/social-work-blog/2012/11/ics-is-the-bane-of-my-life-2/ 

It is little short of mind-bending that somehow leaders of children’s services in the UK have agreed to the development and implementation of systems of this type; and that systems of this type are still in use.

Urgent action is required to move to systems which support, not frustrate, effective practice.

Computer Problems

It is interesting to see that having problems with IT systems in child protection is not just a British disease. Apparently child protection workers in British Columbia, Canada, are struggling with similar issues to those experienced with the ill-fated Integrated Children’s System in England [1]. The Times Colonist reports that Canadian social workers find the new IT system too complicated. It is said to make it difficult to access important information.

http://www.timescolonist.com/computer-system-for-social-workers-can-be-fixed-minister-says-1.560326 

Earlier this year a watchdog accused the British Columbia government of wasting time and money on the system at the expense of vulnerable children. 
http://www.timescolonist.com/news/local/children-s-watchdog-says-computer-system-for-social-workers-a-colossal-failure-1.56291 

Given that the costs of systems of this type run into hundreds of millions, and given that the requirements are not that different in different places, I can’t see why we are not having a proper worldwide discussion about what systems of this type should look like and how they should function. Perhaps some sort of conference would be a good idea?

My own view is that simple robust systems which seek to reduce the administrative burden and support workers by taking away unproductive bureaucratic tasks, or making them simpler, are the best. What we don’t want are systems that seek to drive practice or to ‘take’ decisions or set priorities. Computers are good at processing, not making complex judgements.

End Note

[1]  see  Darrel Ince, The Re-development of a Problem System, Technical Report no. 2010/ 0417, May, 2010, Department of Computing, Faculty of Mathematics, Computing and Technology, The Open University

http://computing-reports.open.ac.uk/2010/TR2010-04.pdf

Mandatory Reporting

It is difficult not to have some sympathy with the campaign to introduce mandatory reporting in England. http://www.childabuselawyers.com/2013/news/mandatory-reporting-press-release-launched-surivor-charites/ 

The long history of failures to report institutional abuse in some churches and residential homes certainly leads to a lot of frustration and a feeling that the criminal law should be used to force people to report.

Sadly it isn’t that easy. The criminal law is usually a blunt instrument and there is a real danger that fear of prosecution will result in some professionals reporting unnecessarily just to be sure. That would put pressure on children’s social care services, which might result in children actually receiving a worse service.

Then there is the question of to whom any new law should apply. The Association of Child Abuse Lawyers press release says:

“The law would make failure to report suspected or known child abuse in ‘Regulated Activities’ a criminal offence. Regulated Activities include schools, sports clubs linked to national sports bodies, children’s homes and faith organisations.”

But could anybody ‘fail to report’ or only ‘professionals’ and ‘practitioners’? If it is only some people and not others, how will the line be drawn? If the law covers everybody, and people like plumbers or the electricians or neighbours are required to report, then what about family members or a child’s friends or brothers or sisters? There are dangers that a poorly drafted law could even be used against people who are the victims of abuse themselves or their close friends.

By and large people report abuse and neglect because they trust the people to whom they report it to deliver appropriate help to the victim. And they expect that they will be protected as the person reporting the abuse. Rather than negatively focusing on the threat of criminal sanction for failure to report, we should be positively focusing on ways to make it easier and safer for people who have genuine concerns to discuss them with somebody they can trust to do the right thing.

Doncaster

It is difficult to know what effect stripping Doncaster Council of its children social care responsibilities for up to ten years will have.  

Children and Young People Now also reports that Michael Gove’s decision to have the troubled department run by an independent trust will bring to a very premature end the Council’s contract with consultants Impower, who had been chosen in a £1.8 million deal to help the Council reinvigorate its failing children’s social care services. http://www.cypnow.co.uk/cyp/news/1077535/doncaster-brings-impower-fix-childrens-services 

Ripping it all up and starting again seldom turns out to be the right decision. On the other hand, outsourcing the service can also result in outsourcing its problems. Certainly I can’t see how Doncaster Council will ever be in a position to take the service back in-house, especially if it loses as much as ten years experience while the service is run by another organisation.

A great deal turns on how ‘independent’ and how ‘accountable’ the new trust will be. These are complex issues that are discussed, in my view inconclusively, in the report recommending this solution. http://www.education.gov.uk/childrenandyoungpeople/safeguardingchildren/a00223342/improving-childrens-care-doncaster 

Existing staff and systems will be transferred to the new organisation, but they will work to a new board comprising some representation from both the Council and central government.  Will that work satisfactorily? Who knows? 

My view is that these are uncharted waters. While it will be interesting to see what happens in Doncaster, it will inevitably be an uncertain and risky future. Let’s just hope that children and young people benefit rapidly from the changes and do not suffer as a result of them.

Jillings – at last

It is truly shameful that it has taken twenty years to publish the Jillings Report into institutional child abuse in North Wales.

http://www.guardian.co.uk/uk-news/2013/jul/08/jillings-report-north-wales-child-abuse

Some of the abuse that the report details dates back nearly forty years.

Of course there are all kinds of human tragedies that lie behind the words of the report. And no doubt justice has been denied to many. But my main concern is what appears to have been an endemic knee-jerk response from all sorts of agencies and individuals; namely that when things go wrong, ranks are closed and the truth is brushed under the carpet.

Can you imagine us tolerating the same sort of thing happening after an air crash? What would the public reaction be if we were told that a report on the safety of a particular plane or airport was not going to be published, for legal reasons. It would sound like something out of the old Soviet Union. It would be intolerable.

We should all be intolerant of secrecy and obfuscation about child protection failings. Without an open culture in which things going wrong, or appearing to go wrong, are reported and investigated, failings in systems will never become public and solutions will never emerge.

Of course that does not mean that individuals have to be identified. There are any number of ways in which individuals can be protected, if the need arises, and people wishing to report institutional abuse, especially the victims, need to know that they will protected personally if that is required.  

Inspection, inspection ....

There has been a lot of comment on inspection this week.

I was very pleased to hear the head of Ofsted, former head teacher Sir Michael Wilshaw, finally agree to multi-agency child protection inspection. I expect he has come under pressure to change his mind, with virtually everybody else thinking it is a good idea. Why we have to wait for them until 2015 is beyond me!

http://www.communitycare.co.uk/articles/05/07/2013/119309/multi-agency-child-protection-inspections-to-start-in.htm

Then there was what seemed to me an interesting and useful suggestion from Andrew Webb, the President of the Association of Directors of Children’s Services. Rather than giving one word, headline-grabbing judgements, Webb suggested that Ofsted inspections of child protection should give ‘a narrative verdict’. This would, he argued, reflect the complexity of the safeguarding system.

http://www.communitycare.co.uk/articles/05/07/2013/119307/one-word-ofsted-judgements-ludicrous-says-top-childrens-director.htm

I think that idea is simple and sensible – so it probably will never be put into practice!!

Neglecting neglect - in Ireland

The report of an independent review of the management of child neglect case in three parts of the Republic of Ireland has reached some uncomfortable conclusions, according to the Irish Times.

http://www.irishtimes.com/news/report-criticises-hse-child-protection-services-1.1449718

Most worryingly the review found that some social workers “… lacked understanding of the deep and long-lasting impact of neglect, while some seemed fixated on keeping children in families where neglect was occurring”.

I have to say that I personally don’t know many social workers who are unaware of the consequences of severe neglect. But what may be happening in Ireland, and elsewhere, is that the priorities of agencies and the operation of the legal system shape workers’ perceptions and responses.

If you believe that you are not going to get the necessary resources from your bosses to deal with a particular case, or if you believe that the courts will not make orders in certain situations, then it would not be surprising if you ended up tolerating behaviour that should not be tolerated.

I believe that the neglect of neglect will not be addressed simply by providing additional training for social workers. A strategic cross cutting approach is required, targeting not only front-line service providers, but, among others, members of higher management, legal staff and judges.

To SCR or not to SCR, that is the question??

I’m sure I can’t be the only person to be thinking that process seems to be triumphing over purpose.

According to Children and Young People Now heads of local safeguarding children boards (LSCBs) have been instructed to inform the new panel of experts if they decide not to conduct a full serious case review (SCR) following a serious incident. It seems that the experts will ask for details and may overturn the decision.

Let’s just hope that all this doesn’t become some centre versus periphery bureaucratic tiff, with regulations being waved and procedures cited.

The PURPOSE should be learning to make children and young people safer, not producing more reports. Simply producing a Serious Case Review report in itself does nothing. It’s the thinking and the understanding and the sharing that result in learning. These are things not well covered by regulations.