Daniel Pelka - supplementary report

There is an interesting article in the Coventry Observer that says that the second report into the death of Daniel Pelka from the Coventry Safeguarding Children Board will be available within the next two weeks.

http://www.coventryobserver.co.uk/2013/09/27/news-Daniel-Pelka-failures-review-could-become-%27gruesome-charade%27-85373.html

The article also quotes the leader of Coventry City Council, Councillor Ann Lucas, as calling for a political debate on mandatory reporting.

I wonder where all this mandatory reporting stuff is coming from. Rather than clutching at the first idea that some group has conjured up, let’s wait for the report. Then let’s consider the evidence and only think about new laws when there is an overwhelming case for one and no alternative.

Discipline and the culture of blame

I can't help feeling that it is inappropriate to bring cases like the one recently described on the Health and Care Professions Council website. 

The social worker concerned had probably not practiced safely, and it seems likely that her work was under par, but surely this is a matter for retraining and closer supervision, not being struck-off.

This social worker is said to have failed to take a child protection referral properly and said to have failed to conduct an assessment properly. We are not told why. Taking her to a disciplinary panel only serves to stoke up the culture of blame. 

Stoking up the culture of blame results in making children less safe, not more safe. That is because people who have made errors of judgement, or failed to live up to best practice standards, will seek to hide their failings and not openly report them. And that results in not learning from errors.

Sixteen principles - one summary

Here is the summary of the sixteen principles for better and safer child protection practice:

1. Proceed with caution
2. No more grand-scale top-down quick fixes
3. Create a learning culture
4. Drive out fear and develop a just culture
5. Have the correct attitude to human error
6. Give people space to learn and reward them for doing so
7. Give people the tools with which they can learn and improve
8. Listen to and learn from children and young people
9. Communicate learning
10. Stop pretending that inspectors know best
11. Get rid of targets and target driven management
12. Help managers to become supportive rather than directive
13. Learn from elsewhere – indeed anywhere and everywhere
14. Make learning incremental and cumulative
15. Recruit and RETAIN people who can and will learn
16. Minimise distractions, especially unnecessary bureaucracy and administration

Sixteen principles for better and safer practice [1]

Sometimes it seems that there is something about child protection that defies all attempts at improvement. The case of Daniel Pelka, and the uninspiring report into his tragic death, only serves to deepen frustrations. In the wake of the tragedy it is not surprising if people are asking yet again: what do we need to do to improve the child protection system?

The short answer is that I don’t know and neither does anyone else. There are lots of suggestions: mandatory reporting, more information sharing, computer systems, surveillance of children and their families, early intervention, named-persons, lead professionals, more training, different recruitment initiatives, assessment frameworks, harsher punishments for perpetrators, public education…. The list just goes on and on.

And it is so easy to lapse into an argument for or against making this particular change or that. I do it myself….

But the bottom line is that in September 2013 we really do not have the information that would allow us, with any degree of confidence, to make the improvements necessary to reduce the probability of another child dying like Daniela Pelka did. In many ways we are just as ignorant now as we were when we all agonised about Maria Colwell’s death in the 1970s.

History is littered with examples of how people in England have tried to improve the system only to be faced with yet another tragedy a few years later. Child protection procedures were introduced in the 1970s and 1980s, to be followed by assessment frameworks in the 1990s and 2000s. In the 1990s attempts were made to re-focus practice on need rather than simply looking at the question of whether or not abuse had occurred. The benefits of information sharing and the contribution of IT were endlessly and uncritically touted in the early 2000s. The Common Assessment Framework (http://www.education.gov.uk/childrenandyoungpeople/strategy/integratedworking/caf) was also introduced, amid unrealistic claims about what it could achieve.

And, of course there were still unacceptable failures. Some children who should have been protected died and many more have suffered re-abuse. 

I believe that we need to approach this problem in a different way. Rather than concentrating on specific suggestions for change we should instead focus on helping people who are responsible for safeguarding and protecting children to learn more in general about how to improve their practice and how to improve the organisations in which they work. 

That would not result in any quick fixes but, if we were able to make the organisations that safeguard and protect children better at learning and improving, then in the long run the quality and safety of services would get better and progressively fewer children would die or suffer continued abuse and neglect.

Below I sketch out some of the principles [2] that I believe should be applied by organisations that protect and safeguard children and that want to improve. The list in not exhaustive, but it is a start.

The first principle is proceed with caution. Primum non nocere – ‘the first thing is to do no harm’ - is a principle of medical ethics. It states that before doing anything we need to be sure that we are not risking causing more harm by acting, than we would be by doing nothing.

In the world of developing services it may not always be possible to apply such a principle rigorously – because the effect of changes may be unpredictable – but we can minimise the possibility of harm flowing from change by trying to ensure that change is modest and reversible. We should be most sceptical about grand scale changes which are irreversible or difficult to reverse.

 Application of this precautionary principle suggests that many improvements will have to be small scale; they will be cautious. This does not mean that their cumulative impact will be small. That is a point to which I will return below.

The second principle flows from the first. There must be no more grand-scale top-down quick fixes. Politicians, civil servants, ‘experts’, policy wonks, management consultants, newspaper editors and interest groups must not be allowed to railroad change top-down. Politicians and civil servants in particular need to understand that their primary responsibility is to ensure that organisations are focused on broad goals and are learning how to achieve them. They should not tell them in detail what to do or what they should learn. Organisations and professional groups should be held accountable for achieving the broad goals and for creating and sustaining learning and improvement in their organisations and in their practice.

More of the impetus for change needs to come from those who deliver the services and from those who receive them and from objective evidence about what changes will be most effective. We must never again experience the irrational dash for change driven from ‘the top’ that was so evident in the Every Child Matters agenda [3].

The third principle of improvement is to create a learning culture. No sensible change can occur unless we make learning and improvement the priority - not rule-following or slavish adherence to ‘big’ policies and shiny initiatives or to mundane procedures and regulations.

Associated with that is the fourth principle which is about removing barriers to learning. We need to drive out fear and develop a just culture [4], in which people are empowered to learn from their errors instead of being forced by fear of disapproval, discipline or other sanction to conceal them.

That leads on to my fifth principle; that is to have the correct attitude to human error. We need to accept that errors are inevitable and to be expected. Error is an opportunity for learning if we deal with it correctly. Discipline, rather than retraining, is only required where established safety rules and procedures have been deliberately flouted for the wrong reasons, such as personal gain.

We need to have an appropriate model of how organisational accidents occur. The best available model is Reason’s Swiss Cheese model [5] and Reason’s BMJ article [6] provides an excellent summary of this approach.

The sixth principle is to give people space to learn and to reward them for doing so. There is no point exhorting people to understand the consequences of their actions and then give them no time in which to reflect. Surprisingly the amount of time required is not great. A few minutes everyday, in which people reflect on what has gone well and what has gone wrong; and why. A short formal de-briefing, at the end of a significant piece of work, is often sufficient to produce useful information that can be taken forward to make practice safer.

It is vitally important to realise that people who are overworked find it difficult to be reflective learners. The idea that people are only working properly if they are staggering under the weight of unmanageable caseloads is part of the fallacy of work-hard-not-smart. Overburdened employees seldom produce work of high quality and often do not work safely. Interestingly they are not more productive, because frequently re-work is necessary to correct mistakes and quality shortfalls. A vicious spiral can occur in which overwork results in poor quality which results in rework which results in more overwork which results in poor quality etc etc. When such spirals occur they have to be disrupted by management action.

When I say to we should reward people for learning, I do not mean ‘financial reward’. Rather I am thinking of recognising and congratulating people who think constructively about error and improvement and valuing and using their contributions.

The seventh principle is to give people the tools with which they can learn and improve. They need to understand the business and professional processes that deliver the service and their effects. An analytical approach is required. We need to ask why we are doing things in a particular way and whether we could do them better. Management needs to carry out research to understand the resource requirements of business and professional processes and their effects. Could we be doing this at lower cost or at higher quality or both?

People need to understand how they do things well and how they screw-up. A Human Factors approach [7] gives practitioners and managers an intelligent perspective on human error in the workplace and how it can be avoided, reduced or mitigated. Learning how to de-brief following a significant piece of work can be a very effective way of capturing what went right and what went wrong.

Once members of a team understand Human Factors they can be ‘consciously competent. In other words they will be right by design not by luck. They can self-debrief and move towards error-proofing from within the team. 

Confidential Critical Incident (or Near Miss) Reporting [8] helps everyone in the organisation understand more about what happens when things go wrong, but not disastrously so. It is a way of gaining ‘free-lessons’ about how to practice more safely. 

Continuous Improvement Systems (Kaizen) [9] are ways in which the suggestions for improvement made by front-line practitioners can be turned into practical developments. They are a way of capturing the experience and expertise of those who actually deliver the service.

The eighth principle is to listen to and learn from children and young people, especially those who have suffered abuse and neglect and who have received safeguarding/protection services.  Conducting panels, surveys and focus groups requires special skills and can be expensive, so perhaps it needs to be done centrally at national level. It needs to be done by people who know how to engage with and listen to children.

Children and young people should be asked about their experience of services and they should be asked for their suggestions about how the quality and safety of services can be improved.

The ninth principle is to communicate learning. Textbooks and academic articles and research reports are often a slow and cumbersome way to spread knowledge. Brief simple electronic reports can be made available more frequently and cheaply with much wider circulation.

The tenth principle is to stop pretending that inspectors know best – they don’t. We need gradually to reduce reliance on inspection. We need to design quality and safety in, through progressive improvement in the design of services, rather than hoping to inspect it in. A positive learning culture works best when nobody is looking, or indeed needs to look.

The eleventh principle is to get rid of targets and target driven management. We need to measure the right things, not just those that are easy, convenient or politically expedient to measure. For example re-abuse following intervention is an absolutely vital measure which is not routinely collected, while at the same time fat statistical reports detail a great deal of data of questionable relevance. We need to use realistic outcome measures to understand the impact of professional and business processes – not proxy measures. Data needs to be used to understand and improve services, not to drive them.

The twelfth principle is to help managers to become supportive rather than directive. The focus of management should be on promoting learning not on telling people how to do the job. A complex professional service cannot be managed like a fast food restaurant. Managers have to listen to and support those people who actually do the work.

The thirteenth principle is to learn from elsewhere – indeed anywhere and everywhere - especially from other safety critical industries. Child protection professionals need to think laterally about how to improve the services they deliver. The defensive this-is-the-way-we-do-it-here stance is the kiss of death. We should be able to learn from pilots and surgeons and nuclear power station technicians and from bomb-disposal experts. There should be no horizons or limits. Protecting children successfully is too important for professional or occupational boundaries and rivalries.

The fourteenth principle is that of incremental and cumulative learning. When I outlined Principle 1 I said that improvements need to be cautious, but this does not mean that their cumulative impact will be small. Making lots of small improvements all the time can have huge cumulative impact. One improvement every working day amounts to more than 200 a year or 2,000 in ten years. And that may be what we could expect from a single team! Where continuous improvement has been introduced into manufacturing businesses it has made a huge cumulative impact.

The fifteenth principle is to recruit and RETAIN people who can and will learn. The ability to learn and receptiveness to new ideas should be necessary requirements of everybody who wants to work in a role in which they will have responsibilities for safeguarding and protecting children.

The sixteenth, and last, principle is to minimise distractions, especially unnecessary bureaucracy and administration. We must try to ensure that most of the scarce resources go to the most essential parts of the process – protecting children from abuse and neglect and learning how to do it more effectively. 

Notes 

[1] I am grateful to Trevor Dale for his helpful comments on an earlier version of this article. The remaining mistakes are all mine!

[2] These principles are by no means original and have been distilled from a variety of sources. In particular I have always been greatly impressed by the fourteen principles for quality improvement that were outlined by the American engineer and statistician, Dr. W. Edwards Deming, in his 1950 lectures at the Mount Hakone Conference Centre in Japan.

See - http://en.wikipedia.org/wiki/W._Edwards_Deming.

The lectures were attended by some of Japan’s leading industrialists at the time and are often credited with kick-starting the Japanese industrial revolution. Obviously the sixteen principles outlined in this paper lack the originality of Deming’s principles! Indeed, some of mine are directly inspired by his, for example my fourth (which resembles Deming’s eighth) and my tenth (which resembles Deming’s third).

[3] https://www.education.gov.uk/consultations/downloadableDocs/EveryChildMatters.pdf 

[4] See Dekker, S.  Just Culture: Balancing Safety and Accountability, Farnham: Ashgate 2007.

[5] http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html 

[6] Reason, J. “Human error: models and management” British Medical Journal 2000; 320:768 http://www.bmj.com/content/320/7237/768 

[7] See Flin, R et al Safety at the Sharp End: a guide to non-technical skills Farnham: Ashgate 2008

[8] See Mills, C. and Vine, P. “Critical Incident Reporting - an Approach to Reviewing the Investigation and Management of Child Abuse” 

Br. J. Social Wk. (1990) 20, 215-220 - http://bjsw.oxfordjournals.org/content/20/3/215.citation 

[9] http://en.wikipedia.org/wiki/Kaizen

Overwork and Performance

In a generally thoughtful article, but one with which I had a number of disagreements, Annie Hudson, chief executive of the College of Social Work, examines some of the implications of the Daniel Pelka tragedy.

My most fundamental difference of opinion with her concerns her comment:

“… the SCR pointed to workload and resource pressures across different children's services. These are part of the context, though they cannot excuse poor practice. However, we ignore them at our peril” (my emphasis).

We do ignore them at our peril and sadly they are part of the context and, in my view, workload and resource pressures often do excuse poor practice.

People who are over burdened are likely to make more mistakes. Research [1] and commonsense tell us that people whose workloads are excessive will not perform to the appropriate standards. Overwork results in undue stress and undue stress degrades performance. Would you want to fly on an airline where the pilots were chronically overworked?

The elephant in the room in many serious case reviews is that the organisations providing the services were experiencing a variety of problems resulting in overworked and stressed people delivering services as well as they could, but at an unacceptably low standard.

None of us should be giving policy makers any more excuses for not resourcing child protection well. Adequate resourcing is a necessary, if not sufficient, condition of a safe service.

Note

[1] See for example Morgan, B. and Bowers, C. (1995) “Teamwork stress: implications for team decision making”. In Guzzo and Salas (eds) Team Effectiveness and Decision Making in Organizations Sanfrancisco: Jossey Bass.

Daniel Pelka - a simple lesson from the tragedy?

There is a simple lesson from the Daniel Pelka tragedy that I do not think anyone else has yet drawn.

Those of you who read my response to the Working Together consultation may remember that one of the things I criticised about this government guidance for child protection in England was that it seems to fight shy of clearly defining, or even mentioning, child abuse and neglect.

Indeed the definition of abuse and neglect is relegated to a glossary. The document does not offer any guidance or direction on the issue of recognising abuse and neglect, nor on the related issue of when to make a referral or how to seek advice.

I am the first person to complain about mountains of unnecessary guidance, but I do think that a clear and simple account of the ways to recognise abuse and neglect, and of what to do next, should be an overwhelming priority in drafting guidance for all children’s practitioners.

In the past policy-makers have mistakenly muddied the waters by talking more about ‘safeguarding’ than ‘protection’ and by emphasising words like ‘outcomes’, ‘welfare’ and ‘well-being’ rather than concentrating on the concepts of ‘abuse’, ‘neglect’ or ‘maltreatment’.

A low cost initiative would be for government to commission a small expert group (*) to write a one-page guide to recognising abuse and neglect and what to do if you are not sure. Having something like that in the school might not have saved Daniel Pelka, but it might have reduced the probability that his perilous situation would have been so disastrously overlooked.

Note

(*) I mean that the members of the group should be ‘expert’ not ‘influential’ or ‘important’ or ‘well-connected’. A paediatrician, a child psychologist, a child protection social worker, someone from the police, a human factors expert and somebody who knows how to write very clear and unambiguous documents (probably NOT a civil servant) would be my choice. 

Munro on the Daniel Pelka SCR report

There were some wise words from Eileen Munro in the interview on the Daniel Pelka tragedy that she gave to the BBC Today programme  – see Community Care for a summary.

Munro told the BBC that she found the serious case review report “very frustrating”. She pointed out that it failed to explain why practitioners acted as they did. It was written completely with the benefit of hindsight. “I feel this report just describes what was done and the actual workers are invisible and their voice isn’t heard,” she said.

She's absolutely right.

Daniel Pelka, the aftermath

I recommend reading Diane Abbott’s piece in the Guardian:

http://www.theguardian.com/commentisfree/2013/sep/18/daniel-pelka-death-buck-passing

Then read the little story in the Belfast Telegraph:

http://www.belfasttelegraph.co.uk/news/local-national/uk/new-job-affront-to-public-opinion-29590744.html

It’s a strange world.

Named Persons

Here we go again. I was interested to read that the Scottish charity, Children 1st, sees the Daniel Pelka case as providing evidence for the proposed role of ‘named person’, currently being debated in the Scottish Parliament. The idea is that every child in Scotland would be provided with a named person, who might be a teacher or a health visitor or a social worker. 

http://www.heraldscotland.com/news/home-news/charity-calls-for-named-person-for-every-child-after-review-into-death.22174443 

Anne Houston, chief executive of Children 1st, is quoted in The Herald as saying that the lessons of Daniel’s tragedy support the principles underlying the named person idea. She believes the measure will prevent children ‘slipping through the net’. She argued that the named person would act as first point of contact for a child and all the professionals coming into contact with him or her. The named professional, she said, would collate and have access to all the information about the child. Presumably that means in some cases that (say) teachers who are named persons will have access to the whole of a child's health record and to police reports about the child and family members.

This idea reminds me of ContactPoint (http://en.wikipedia.org/wiki/ContactPoint) but substituting a person for the computer. I have to say that I can see absolutely no evidence either that it is practicable or that it would achieve its objectives.

We only have to consider what happened to Daniel in order to understand this. It was not as if people were not involved with him, they were. Teachers and other school staff were worried about his condition. They knew about his bruises and his previously broken arm. The error occurred not as a result of an absence of information, but as result of not interpreting the available information as indicating abuse and neglect. The failures were due mostly to poor situation awareness and poor decision-making. And some of the most important communication failures were not between professionals and agencies but with the child himself.

So yet again the wrong conclusions are being drawn from what happened to Daniel, just as they were from what happened to Victoria Climbié when the then Government argued that the ContactPoint computer system was a necessity in order to prevent a reoccurrence of what happened to her.

And once again ill-considered deductions from a child protection tragedy are being used to bolster policies that seem to run contrary to the rights of children and their families to privacy and family life. I believe that avoiding failures in child protection is most likely to be achieved by improving the quality of services, not by a crude policies which require public officials to try to regulate family life.

So I agree very much with the concerns expressed by Scotland’s Faculty of Advocates. The ‘named person’ idea cannot be justified as a necessary interference with basic human rights.

http://news.stv.tv/politics/236021-lawyers-slam-insidious-plans-to-give-every-child-a-named-person/

‘Inadequate’ and not getting better?

On the day following the publication of the Daniel Pelka Serious Case Review, the BBC reports that Ofsted has revisited councils previously judged by inspectors to have child protection weaknesses and has found that one third are still failing to meet minimum requirements. http://www.bbc.co.uk/news/uk-24139462

I was struck by the comments attributed to Andrew Webb, chairman of the Association of Directors of Children's Services. He is quoted as saying that he agreed the system was creaking, but he expressed concern about the way in which Ofsted rates councils.

He argued that Ofsted “… have a way of looking at systems and services which is designed to find fault."

What I find most alarming is that there seems to be no clear summary of information and analysis from Ofsted detailing and examining the likely causes of the ‘inadequacy’ and pointing to ways of correcting it.

Ofsted appears to be jumping up and down telling councils that their services are poor, but not doing much to give them the tools to achieve improvement.

But then, maybe it’s not about quality but about politics?

Daniel Pelka - WHY not WHAT

The Children’s Minister, Edward Timpson, is very right to challenge the report of the Daniel Pelka Serious Case Review, as reported in Children and Young People Now. 

The report does NOT answer many why questions, if any. Why did the professionals remain attached to the view that Daniel’s problems stemmed from organic causes in the light of evidence to the contrary? What factors impeded the sharing of information and the keeping and use of accurate records? Why did assessments fail to reveal the problems in the family? Why was the serious issue of domestic violence (between the adults) not given more weight in assessments? 

Timpson is right to complain that the report stops short of explaining how problems in management, systems and processes, which are briefly referred to, impacted on the case. Also the report mentions issues of training and workload that are not explored. These all sound like ‘latent factors’ to me: weaknesses that lurk beneath the surface of the organisation and which predispose to error. Knowing more about them is key to building a safer organisation.

The Daniel Pelka Serious Case Review has reported

I have to say that I saw little evidence in the report that the authors had adopted the ‘systems approach’, as recommended by Eileen Munro and SCIE, which they had said they would do (http://chrismillsblog.blogspot.co.uk/2013/08/systems-approach-to-daniel-pelka.html ). However, the report’s main author, Ron Lock, did say on the BBC Breakfast show that he considered that high workloads may have been a factor. That would be what Reason calls ‘a latent condition’. Not much, however, is said about it in the report itself.

The report paints a bleak picture. The child was marginalised, ‘almost invisible’ at times. Teachers, doctors and other professionals did not try ‘sufficiently hard’ to talk to him or to see issues from his perspective.

For me the huge puzzle that remains, even when you have read the report and digested its contents, is the issue of why staff in the school and a paediatrician did not consider abuse and neglect as a possible cause of Daniel’s weight problems. Possibly the fact that his two siblings did not demonstrate the same symptoms was a factor.

In human factors terms we are talking here about loss of situation awareness. Almost certainly those people dealing with Daniel at the time saw a very different picture to the one that we now see with the benefit of hindsight. The mother may have been very adept at manipulating people.

Confirmation bias was also a factor. Those dealing with Daniel appear to have formed an early hypothesis that they were not dealing with abuse and neglect and held on to that in the face of mounting evidence to the contrary.

It is all more evidence, in my view, for the importance of training people who have responsibilities for protecting and safeguarding children in human factors skills. If you know the clues to loss of situation awareness, or if you are aware of the phenomenon of confirmation bias and how it can distort perspectives, you are more likely to think laterally and to question critically some of the assumptions with which you are working.

Moving to a related issue, I am really quite disappointed by the way in which the campaign for mandatory reporting – ‘Daniel’s law’ as the Aljazeera website calls it  - appears to be being pushed in the media as if it were some sort of solution to the type of situation leading to Daniel’s death. The whole point is that the professionals concerned with Daniel did not believe he was being abused and neglected, so they would have done no different if a law of this type had been in force.

In any case, current government guidance already enjoins all professionals to report abuse, so the proposed change in the law is really one of introducing some sort of criminal sanction. Doing that, it seems to me, would have unpredictable consequences and seems likely to stoke up a culture of blame. Blame is always an impediment to safety. If professionals are fearful that they could go to prison for not reporting abuse, they will certainly be very circumspect about discussing it with anybody or learning lessons from near misses and critical incidents.

In short, I think mandatory reporting is a bad idea and I hope that the government will have the courage not to be swept into an ill-considered policy response, by populist arguments that lack rigour and validity.

Daniel Pelka SCR report - next week

The Coventry Telegraph reports that the report of the Serious Case Review (SCR) into the death of Daniel Pelka will be published next Tuesday, 17^th September 2013.

http://www.coventrytelegraph.net/news/coventry-news/daniel-pelka-council-admit-lessons-5908061

Daniel Pelka - more information from Coventry LSCB

I have just discovered that the Coventry Local Safeguarding Children Board (LSCB) has published some information about the Daniel Pelka tragedy in advance of the publication of the Serious Case Review (SCR) report.

It can be found at: http://www.coventrylscb.org.uk/dpelka.html

The brief outline of the facts of the case provided at this site makes it clear that Daniel was not referred to Children’s Social Care when concerns about his weight emerged or when subsequent bruising was noted.

The document makes clear that:

• When teachers became worried about Daniel’s low weight and his scavenging for food the school nurse, the GP and the community paediatrician became involved. Daniel’s behaviour and low weight were linked to a possible medical condition.
• When Daniel came to school with bruises and unexplained marks on him, different members of school staff saw these. However the injuries were not recorded nor were they linked to Daniel’s weight loss or to his scavenging for food.
• No referrals were made to Children’s Social Care as a result of these injuries or other concerns at this time.
• When Daniel’s school attendance became poor, an education welfare officer became involved.

There is no explanation at this stage of why no referral was made to Children’s Social Care. That seems to me to be the crucial question that I hope the SCR report will address.

Knees jerking in the September sun

In Britain we often talk about August as being the ‘silly season’. It is the time that everyone is on holiday and journalists have to devise innovative stories to fill the column centimetres.

It looks like this year the unusually warn summer has extended the silly season into September – at least as far as child protection is concerned.

There seem to be people popping up all over the media who have the solution to the Daniel Pelka tragedy. I’ve already mentioned a group campaigning for mandatory reporting – before, I might add, we even know how often Daniel’s case was drawn to the attention of Coventry’s Children’s Social Care.

Then there are a lot of ‘experts’ quoted in Community Care this week. 

A representative of the College of Social Work tells us that “… closer working between teachers and social workers is needed, such as shadowing days and more observations in schools”. That sounds like a lot of work to organise without any clear or definable benefit. And we don’t yet know how much (or how little) ‘co-operation’ there was between the school and social workers in Daniel’s case.

Then a representative of the teachers’ union NASUWT waxes lyrical about the doomed computer system ContactPoint. He is quoted as saying: “The seeds of good partnership working were there with children’s trusts and the ContactPoint database, which had real potential to be built upon. But this government has smashed it to pieces.”

At this point I begin to wish it was the middle of winter – the sensible season. However little we know about Daniel’s tragic death it takes a particular kind of mind to see it as being linked to the abolition of a piece of ill-conceived IT.

Let’s be sensible and wait for the Serious Case Review report. It might not explain what happened but it will describe the events and provide a chronology.

And let’s stop all those knees jerking in the late summer sunshine.

A child protection inspector calls…

It is now well known that Ofsted is getting ‘tough’.

In May 2012 the inspectorate introduced a new framework of unannounced local authority child protection inspections. According to statistics recently released, by 31^st May 2013 forty-five such inspections had been conducted. No authority was rated “outstanding” and only four authorities (9%) were rated ‘good’. A further 58% were rated ‘adequate’. In a third (33% or fifteen cases) the inspectors rated the overall effectiveness of the authority ‘inadequate’. 

Surprisingly these results do not seem to be causing the alarm and distress that might be expected. Of course there are ramifications for individual authorities, with some directors of children’s services throwing in the towel and resigning. Some authorities are in special measures and one, Doncaster, has had to surrender its child protection services to an independent trust. But there is no national outcry. Ministers and opposition spokespeople are, by and large, keeping mum.

If one third of aeroplanes or one third of surgical procedures or one third of car brake systems was rated ‘inadequate’ there would be a public uproar. But it seems things are different when it comes to child protection services. Even Ofsted makes little of its own aggregate findings, relegating the publication of them to an obscure statistical document.

So what is going on? One explanation might be that policy makers quietly welcome Ofsted waiving the big stick but don’t really believe the inspectorate’s verdicts. That is not as silly as it sounds, especially when careful reading of reports of child protection inspections reveals both a dearth of detail and a surfeit of judgemental pronouncements that are frequently not supported by hard evidence of poor performance. Inspectors list perceived failings, and make one-dimensional recommendations of the this-is-wrong-put-it-right variety, but they do not look at the underlying causes. And, without looking at the causes, real improvements in quality and safety will never occur. 

The main problem is that Oftsed lacks an analytical framework for conducting inspections of child protection. The approach seems to be simply to turn up and observe and judge. Yet there is an analytical framework available, which is well understood and widely adopted in other safety critical fields such as aviation and medicine; and which the Munro Review has commended to the child protection sector. This is the model of organisational safety devised by the psychologist, Professor James Reason.

According to Reason organisational safety depends on building layers of defences against catastrophic or unwanted outcomes. These layers – such things as procedures, training courses, professional standards, recruitment practices, information systems, supervision etc. – are themselves imperfect. They are full of weaknesses, which Reason famously compares to the holes in slices of Swiss cheese. Most of the time the holes in successive slices do not line up, so errors are trapped and safety is maintained. In rare circumstances, however, the holes in all the slices align and the result is a bad outcome or a serious accident. 

The Swiss cheese model has important implications for inspection. Simply looking for bad outcomes or perceived failings – and demanding that they be avoided in future - will not result in lasting safety and quality improvements. What is required of inspection is a study of the organisation’s defences and how they can be improved. Put another way the task is to find the holes in the cheese and identify ways to block them up or reduce their number. Doing that would mean a more positive and creative approach to inspection. Instead of finding fault, inspectors would be helping to identify opportunities for improvement. 

The present regime of unannounced Ofsted inspections can be compared to a lottery. If the inspectors turn-up on a day when some holes in some of the defences have by chance lined up, they are likely to observe failings or partial failings and so will incline to rate the authority ‘inadequate’.  That could happen even if the authority has better defences with fewer or smaller holes than an authority that was inspected on a ‘good day’ last week (when few holes were lining up) and so found to be ‘adequate’ or ‘good’.

In terms of waiving the big stick, that makes no difference, but in terms of creating higher quality and safer services it represents a significant failure of regulation. It does not serve abused and neglected children and young people well.

Rise in the numbers of Care Orders

According to the Lord Chief Justice’s Report 2013 , the number of children involved in public law applications made by local authorities in England and Wales increased in 2009 (following the Baby Peter case) from approximately 20,000 per year to almost 26,000 per year.

Since 2011 the figures are said to have stabilised at around 30,000 per year.

In the first quarter of 2013, there were just under 9,800 children involved in public law orders, a 19% increase from the same period of 2011. The annual rate of increase from 2011 to 2012 was 22 per cent.   

The most common type of public law order applied for is the Care Order  (69% of children involved in applications). 

Source: The Lord Chief Justice’s Report 2013 page 41 http://www.judiciary.gov.uk/Resources/JCO/Documents/Reports/lcj_report_2013.pdf