Thursday, 1 August 2013

The death of Daniel Pelka - early reactions

Ray Jones makes some telling points against knee-jerk reactions to the tragic death of Daniel Pelka. In particular he is right to draw attention to the increased workload that has afflicted child protection services in Britain since the death of baby Peter Connelly.|SCCC|SC019-2013-0108#.UfpWTFPUCUc 

Ray is also right to caution against the blame culture. However, he does not, to my mind, make strongly enough the important point that blame inhibits learning and that it is only through sustained and serious learning that we can hope to avoid similar tragedies. [1]

Having a model of how serious mistakes come about is absolutely essential. Most people go to work anxious to do a good job. The last thing they want to see is a tragic outcome. But individual and organisational defences against error are always imperfect. We, and the organisations we work in, are error prone, and it is only by having multiple layers of defences that most of the time things do not result in bad outcomes. [2] 

Safety is only improved by constant improvements in organisational defences and by gaining ever greater insight and understanding of our own propensities to make mistakes. We need to understand how we lose situational awareness or make bad decisions or fail to communicate effectively or respond in appropriately to authority or challenge or provide poor leadership and contribute to poor teamwork.

A Human Factors perspective [] is not just a novel or interesting approach to error in child protection. It is an essential precondition of learning how to make children safer.

[1] See Dekker, S. Just Culture: Balancing Safety and Accountability, Ashgate, 2000

[2] See Reason, J. “Human error: models and management.”  British Medical Journal 2000; 320:768-770 (18 March)