Blame and compensation

The BBC reports that the former Director of Children’s Services at Haringey Council, Sharon Shoesmith, is to be paid a six-figure sum in compensation for wrongful dismissal following the Baby Peter tragedy in 2008. This news follows a court ruling in 2011 that she was unfairly sacked.

http://www.bbc.co.uk/news/uk-24715666

Add that sum to all the legal fees that will have been incurred and add that to the costs of the sackings of other Haringey employees following Peter’s death. We are talking millions.

A rush to point the finger of blame following the death of Baby Peter Connelly has now cost the taxpayer a fortune and nothing has been achieved. No child is safer as a result.

Rushing to blame people is always negative. If all the money spent on disciplining employees had been spent on improving services and enhancing safety, the outcome would have been constructive. As it is, lots of time and money have been expended, with the main result being that a culture of blame is propagated and reinforced.

That makes professionals more defensive. Not unreasonably they will look to protecting their own backs, not to being open and constructive about service failures. That makes it even more difficult for organisations to deliver safe children’s services in Britain.

Shocking Stats

I have been wrestling with the Ofsted Social Care Report 2012-2013 (http://www.ofsted.gov.uk/resources/social-care-annual-report-201213) that was published last week. I will complete my post on it shortly, but I have stayed my hand and not rushed to judgement. So please watch this space.

One thing I can address now is some interesting information arranged on page 9 of the report. Extracted from government statistics the volumes of children’s social care work in 2012 are compared with those in 2008. In the table below I reproduce these together with a % change column that does not occur in Ofsted’s table.

Some of the figures are quite shocking. Although there has only been a modest increase in referrals and the number of children looked after, initial assessments were up by more than 40% over the four year period; Section 47 Enquiries were up by more than 60%; Core Assessments were up by 110% and the number of children made subject to Child Protection Plans were up by nearly 50%.

No wonder services are experiencing strains and stresses!

Sadly I can find no accurate estimates for changes in the size of the children’s social care workforce during the period. If anybody knows where this data might be found, please email me on chris-mills-child-protection-blog@gmx.co.uk

Volumes of children’s social care work in 2012 compared with those in 2008, adapted from Ofsted Social Care Report 2012-2013, page 9
	2008	2012	% Change
Referrals	538,500	605,100	12.4
Initial Assessment completed	319,900	451,500	41.1
S.47 started	76,800	124,590	62.2
Core Assessment completed	105,100	220,670	110.0
Children made subject to CP Plans	29,200	42,850	47.0
Children looked after on 31/3	59,500	67,050	12.7

Thinking about alternative ways to protect children?

Kate Morris, Brid Featherstone and Sue White are right to suggest that we need to question the ways in which we protect children. And they are right to consider alternative approaches. In their Guardian article today they make some telling points.

http://www.theguardian.com/social-care-network/2013/oct/22/think-again-how-protect-children

I was particularly struck by their account of contemporary practice reality for child protection social workers: dashing from family to family, visit to visit, completing forms, directing parents to change their behaviour or to expel abusive partners immediately or by next week at the latest. It is a grim vision, but it has the ring of truth.

However, I do not think that in the end they deal satisfactorily with the inherent contradictions with which we are all faced. They write:

“However tempting it looks in the face of another tragedy, there is no easy moral mandate to rescue more and more children from impoverished families and communities. We need to understand and work with the relational ties of blood, kin, friendship, place and community. These are the primary contexts for the resolution of children's needs.”

Progressive as this argument sounds it does not deal effectively with the dilemma that confronts every social worker in every encounter that she or he has with abused and neglected children and their carers. In an ideal world ‘ties of blood, kin, friendship, place and community’ would be capable of being woven to prevent the catastrophic breakdown of care. But in the real world brutal and unrelenting social forces often result in these ties being irretrievably severed. The hopelessly addicted mother of Hamzah Khan or the viciously sadistic carers of Daniel Pelka are not easily seen as candidates for rehabilitation and support, no matter how optimistic the observer. And false optimism blinds us to the terrible dangers they pose. So for a particular child on a particular day there may be no meaningful choice between kinship and community on the one hand and state intervention on the other. The only choice may be that between the child facing continuing maltreatment in the home or being rescued and protected.

Sadly there is a stark analogy. We cannot transfer resources from the emergency ambulance service before road safety campaigns have been effective in reducing the number of accidents; at least not unless we are prepared to leave victims to die by the roadside.

Yes, it is about trust

Some interesting and useful research funded by the Children’s Commissioner for England has been published this week. 

‘It takes a lot to build trust’ Recognition and Telling: Developing earlier routes to help for children and young people (http://www.childrenscommissioner.gov.uk/content/publications/content_733) reports on work undertaken by researchers at the University of East Anglia and Anglia Ruskin University.

The central message of the research is that children and young people facing abuse and neglect “… most often come to the attention of services through their behaviour and demeanour rather than through explicitly disclosing abuse.”

The researchers conclude: 

“Of central importance is the fact that young people’s past experiences of professionals, as well as their experiences within the family and in the community, will influence how comfortable they feel about talking and their willingness to trust and talk to practitioners.” 

That shouldn’t surprise anybody. It is commonsense. Sadly it is commonsense which is often forgotten. These researchers should be congratulated for reasserting an important message. 

Some research I was involved in a few years ago came to some similar conclusions.

“Minds are like parachutes; they work best when open.” [T. Dewar]

I was pleased to read in Children and Young People Now that Children’s Minister, Edward Timpson, has announced an innovation programme for children’s services.

He is reported as saying that he wants people to come forward with ‘adventurous’ ideas and that he wants to 'confront head-on' the barriers to innovation in the sector.

“It is a call to frontline staff and experts in the field to develop better ways of constructing and managing services,” he said. He offered those who were experiencing difficulty in getting an idea off the ground help in taking it forward.

I think this is a really promising initiative. I hope that it will be responded to widely. After years of stultifying top-down poorly thought-out change, the sector is crying out from some bottom-up, innovative thought, built on experience of actually delivering services.

“If you always do what you always did, you will always get what you always got,” said Albert Einstein. 

My advice to those who respond is that the best ideas will be modest proposals, capable of being trialed or tested and based on experience of successful implementation elsewhere. 

Let's see what happens.

After the tragedies, a hike in referrals

It will come as no surprise to anybody that in the wake of publicity surrounding the tragedies of Daniel Pelka, Keanu Williams and Hamzah Khan, there has been a big jump in calls to the NSPCC’s Helpline from members of the public. 

http://www.bbc.co.uk/news/uk-24602910 

Many of these calls will be passed through to the statutory agencies which in turn are probably experiencing more direct referrals.

I say it will have come as no surprise to anybody, but in most places no more resources will have been made available to cope with the increased volume of work. The likelihood is that triage will be more tightly applied (or ‘thresholds’ raised, if you like to put it that way).

The more pressure there is on resources the greater the likelihood of a high-risk case falling by the wayside and creating the conditions in which another tragedy might occur.

Why do I constantly get the feeling that we shouldn’t be starting from here!!

The Negative Consequences of Disciplinary Action

There are important negative consequences of local authorities in England taking cases, like the recent one of a social worker in London, to the Health and Care Professions Council. 

(http://www.hpc-uk.org/complaints/hearings/index.asp?id=3467)

Apparently the person in question had recently come to the UK from East Africa. It is not hard to see from a quick reading of the evidence that the she was:

·       Inexperienced

·       Unfamiliar with child protection work in Britain

·       Felt herself to be under pressure and overworked

·       Felt intimidated by her managers

·       Felt unwell

Clearly her work fell short of accepted good practice, but there seems to be no suggestion that she acted maliciously or willfully. It appears that she just didn’t do her job very well.   

Is discipline the right response to this sort of case? My argument is that discipline in the workplace is required only where people act dishonestly, corruptly or deliberately dangerously.

When people screw up or just fail to live up to expectations they should be re-trained and supported in their improvement. That is the humane and constructive response so far as the individual is concerned.

More importantly a rush to disciplinary procedures nurtures a blame culture and that contributes to undermining safety in the organisation. Resorting to discipline in the case of an individual has important consequences for how other employees will behave.

We know that when people fear admitting their mistakes that they will cover them up. The consequence is that management remains in ignorance of day-to-day failings at the front line and, as a result, the organisation becomes even more unsafe.

Let's have som e simple statistics on SCRs

Having a national research database of all child deaths seems to be such a good idea that it is difficult to know why it has not been done already, especially when the data is collected by local Child Death Overview Panels which were set up to investigate the circumstances surrounding child deaths in each local authority area. http://www.cypnow.co.uk/cyp/news/1119106/national-child-death-database-mooted

It also seems bizarre, given the importance attached by the authorities to Serious Case Reviews (SCRs), that there is no routine national collection of statistical information about them. There have been research exercises and some lengthy research reports from academics, and, of course, Ofsted produced some work which sadly failed to inform a great deal. (http://chrismillsblog.blogspot.co.uk/2011/10/is-ofsted-learning-from-serious-case.html)

But what I am talking about are some simple statistics every six months. How many serious case reviews have been completed in the period, how long did they take to prepare, how many are currently being completed, which local authorities are involved, what are their cumulative totals of reports since the monitoring started, what are the ages of the children involved, what type of maltreatment was involved, did the child die etc etc.?

Asking the author of the overview report to fill out a short questionnaire on completion of the report could also provide more information. What factors were involved in the case, what was the family status, in what systems (health, social care, law enforcement etc.) where failings identified?

These are just some examples of what data could be collected. Simple stuff but it would be informative.

The wrong approach?

In the wake of the Daniel Pelka tragedy Coventry Council has announced that it is to appoint a retired high court judge to advise it on child protection. http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-24487953

I do not know the judge in question, but clearly what went wrong in Daniel’s case was not of a legal nature. It was much more about how to spot children who are in difficulty as a result of abuse and neglect at the earliest possible opportunity. That seems to me to imply that the kind of help most required is either of a technical working-with-and-listening-to-children type or of a more general organisational safety type.

So I am not sure how the judge is going to help.

It is also reported that Coventry councillors have decided to ask a House of Commons select committee to look at safeguarding children issues. I don’t think that that is the right approach. It is not so long since the Education Select Committee looked at child protection and seemed to wander all over the place, including a lengthy un-productive discussion about the definition of neglect. http://chrismillsblog.blogspot.co.uk/2012/01/definition-of-neglect.html

I don’t think that child protection will ever improve if it is left to councillors and judges and MPs to come up with ‘bright ideas’ about how to reform systems.

Responsibility for improvement has to be located at the ‘coalface’ with those who do the work and who understand how business and professional processes operate. Such people also need to understand how active errors occur during the course of practice and how latent conditions contribute to failures in systems. So there is scope for input from people who understand organisational safety in other industries to become involved.

We need to create the conditions for improvement, not create the opportunity for yet another poorly focused public debate. The role of Government, both central and local, is not to get involved in the detail of service provision. It is to set the broad objectives, to resource services adequately and to hold those delivering services to account – not for being right all the time, but for ensuring continuous improvement in quality and safety.  

Assessments in a jiffy

Professor Harry Fergusson makes some important points in his article in the Guardian last week.

http://www.theguardian.com/society/2013/sep/24/why-social-workers-become-helpless 

There is no substitute for reading the whole of this excellent article, but I was particularly struck by one of Harry’s observations from his own research. 

He found that heavy social worker workloads and high levels of bureaucracy resulted in reduced time devoted to effective child protection interventions and that “… working conditions led to assessments being made after a matter of minutes spent alone with children”.

Harry is absolutely right to conclude that the resources must be made available for those safeguarding and protecting children to have sufficient time to conduct assessments properly.

The Judgements of Ofsted

I do not find it surprising that the school attended by Daniel Pelka - at which teachers and other staff did not suspect neglect as Daniel starved to death - had been described in a recent Ofsted inspection as having ‘robust’ arrangements for child safeguarding and protection. http://www.coventrytelegraph.net/news/coventry-news/ofsted-criticised-describing-safeguarding-daniel-6160992 

The problem is not with the school so much as with Ofsted. The spot-check inspection approach favoured by Ofsted is unlikely to be reliable (or ‘robust’ for that matter). A few questions will have been asked and a few boxes will have been ticked and, hey presto, we don’t have to worry too much until the next formulaic inspection. What a relief!

The inspection judgement sends the wrong message, to staff and to parents, and it lets down children because a safe school is not one in which a few neatly typed documents are available to the inspectors. It’s one where members of staff have the right state of mind; where they understand human error and how it can and does occur; and where they remain creatively anxious about the possibility of failure. It's a school where everybody takes a part in improving services and systems to make them safer.

I wonder how much the inspector who wrote that clean bill of health knew about organisational safety?

Keanu Williams - some reflections on the Serious Case Review

Coverage of the Keanu Williams Serious Case Review report has focused on the problems being experienced by the Birmingham Children’s Services Department. The BBC highlights the rapid changes in senior managers in the department, with the interesting, if possibly irrelevant, detail that one was paid £1,000 per day! http://www.bbc.co.uk/news/uk-england-birmingham-24332978

There seems to be a sense of despair. Birmingham, Europe’s largest local authority, seems to be lumbering towards yet more child protection disasters.

http://www.bbc.co.uk/news/uk-england-birmingham-24305689

There are high sickness absence rates among staff (http://www.bbc.co.uk/news/uk-england-birmingham-21352709) and a staggeringly large number of serious case reviews have been necessary in Birmingham in recent years, estimated to be as high as 23 since 2006. (http://www.bbc.co.uk/news/uk-24384977).

It almost goes without saying that there is a chronic tendency to fail Ofsted inspections. http://www.ofsted.gov.uk/local-authorities/birmingham

None of this comes as news to anyone who has been watching Birmingham even casually for the last few years. As long ago as 2009 I reported in this blog that an audit of case files in Birmingham found that child care planning and practice was "unacceptably poor" in 53% of cases, "acceptable" in 39% and "good" in only 7%. Services for children in need were said to be “sparse”. http://chrismillsblog.blogspot.co.uk/2009/10/more-detail-on-birmingham-scrutiny.html

These considerations make it all the more surprising that Jane Held of the Birmingham Safeguarding Children Board – and I suspect many other senior people connected with child protection in Birmingham – chose to respond to the serious case review with such an old-fashioned rotten-apples-have-been-rooted-out approach. Not for her any consideration of the fact that Birmingham Children’s Services is a failing, and probably toxic, organisation. Rather her press release states:

“Keanu died because people missed opportunity after opportunity to intervene, and do something decisive to ensure he was safe and properly cared for. Some staff did their best for Keanu but some staff did not comply with required practice, processes and procedures. Those staff have already been held to account for this by individual agencies.”

So mostly it is individuals who are to blame and had people followed ‘required practice, processes and procedures’ the tragedy may never have happened: I don’t think so!

Another paragraph in this press release also annoyed me. Jane said:

“It is absolutely clear that if everyone had known what others knew there may have been a very different outcome. Children are best protected when there are local networks of competent confident professionals working together to share information. This enables them to build relationships, share responsibility for the situation, critically challenge, assess the information they have and to plan action collectively to support children, young people and their families. When there is a risk of significant harm, they would then be able to act decisively.”

I wonder if Jane has ever heard of hindsight bias (http://en.wikipedia.org/wiki/Hindsight_bias) and I wonder if she understands the nature and extent of those problems in the Children’s Department that her Board is supposed to hold to account? I found myself agreeing with the frustration of Jackie Long who – writing about the Hamzah Khan tragedy in her Channel 4 News Blog - said:

'By now we can all close our eyes and take a guess at what serious case reviews will say. There needs to be “more communication”, a “multi agency approach” and – I almost scream as I write – “better sharing of information.”'

http://blogs.channel4.com/jackie-long-on-social-affairs/amanda-hutton-guilty-starving-child/916

I found the Keanu Williams Serious Case Review report itself (http://www.lscbbirmingham.org.uk/) very frustrating. It was full of information but I struggled to be informed. There seem to be two big unexplained ‘whys’. Why did a child protection conference not put Keanu on a Child Protection Plan when there was ample evidence that he was at risk of significant harm? There is no explanation in the SCR report although some of the events surrounding the decision are described.

The second ‘why’ is why didn't the nursery staff refer Keanu to Children's Social Care when they observed suspicious bruising? We are just told they accepted mother's explanations. Maybe there was a history of problems in making referrals to Children's Social Care, or maybe there were conflicts between different people in the nursery, or maybe training had been poor. Perhaps there was a management system that made referral difficult and stressful. Who knows, because the Serious Case Review does not tell us?

Like the Daniel Pelka report, this report – although containing sections headed ‘analysis’ and ‘lessons learned’ – does not aspire to the systems model proposed by Eileen Munro and SCIE (http://www.scie.org.uk/publications/ataglance/ataglance01.asp) . It never seems to get behind mounds of detail to identify causal factors or even to explore possibilities.

It all seems very frustrating. Two more children – Daniel and Keanu - seem to have died needlessly and we seem to have advanced our state of knowledge of how to avoid a repeat performance by not one jot. It is difficult not to despair.

For me hope comes from trying to think laterally. We need to reverse the assumption that we need to wait for disaster before we start learning. We need to create the conditions so that we learn much more - and much more quickly - earlier. And we need to realise that the people who need to learn are the people who do the work.

In other words the best way forward from this juncture is to change the culture, not the procedures or the personnel or the computer systems or the law. For an authority like Birmingham, I think this does presuppose some immediate triage work to remedy the staff shortages and high turnovers and to stabilise the lurching services and haemorrhaging resources. But thereafter I see the solution as being one of opening minds, including those at the top, to new ways of thinking. Improvement will come not from kicking people out or revising the rulebook. It will come from an increasing awareness of how human factors interact with organisational safety.

The day that people working in Birmingham, and elsewhere, begin not to think about watching their backs, and begin to think about what improvements they can make today and tomorrow to make the service they offer safer and more effective, will be the day things turn around.

Keanu Williams - First Reactions

I noted two important comments on the Serious Case Review this morning. 

The first was from Bridget Robb, the Chief Executive of the British Association of Social Workers, who was quoted in the Daily Mail as saying that Birmingham Council has an old fashioned, hierarchical culture and that members of staff there are afraid to discuss their mistakes.

Then, in confirmation, I read in a BBC report that Jane Held, of the Birmingham Local Safeguarding Board, had said that there had been 'double-figure' sackings in Birmingham since Keanu's death.

Sadly many newspapers, and many members of the public, will think that a blame culture is justified in the wake of the failings that resulted in the tragedy. The truth is the exact opposite. Make people afraid and the first casualty is safety. Bridget Robb is absolutely right when she calls for Birmingham to support front line staff in making improvements, rather than conducting a 'witch-hunt' when things go wrong.

(Apologies for lack of links - written on my iPad on a Portuguese beach)