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.