Tuesday, 17 September 2013

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.