Monday, 5 August 2013

Daniel Pelka and Keanu Williams - a systems approach to discovering what went wrong?

It is puzzling why so much less has been written about the tragic death of Keanu Williams, than about the murder of Daniel Pelka.

Both cases are, of course, horrific. Both appear to have involved similar failings. As we wait for the report of the Serious Case Review concerning Daniel, we must also expect the equivalent report concerning Keanu.

We certainly need to understand what has happened in both these cases. I hope the reports will result in some important learning, although I am becoming increasingly pessimistic about the ability of Serious Case Reviews to generate useful information. Just pointing out what went wrong is not enough. The reports need to be analytic. They need to go beyond simple descriptions of what went wrong and to try to answer the question of why things went wrong.

I hope the authors of the reports are adopting the systems approach to conducting a serious case review, advocated by Eileen Munro and SCIE ( The ‘systems’ model focuses on those factors in the working environment that support good practice, and those which result in unsafe working practices and systems. The idea is to produce organisational learning that provides an explanation that moves beyond the basic facts of a case and to identify underlying causes of what has gone wrong.