Not Learning Lessons

It comes as no surprise to me that a report by management consultants for the NHS in Scotland has found that information from Serious Case Reviews is not properly disseminated, hampering learning and improvement.

The press report in The Herald does not really go into the causes of this failing, but I expect these are many and various. Often the recommendations of Serious Case Reviews are complex, detailed and sometimes puzzling. The reports only become available after a considerable time delay and sadly it is often the case that they are strong on detail but weak on analysis.

National arrangements for 'sharing the learning' are haphazard.

It is also important to understand that the ‘lessons’ to be learned from child protection tragedies are usually not simple, obvious things that can be universally applied. That’s because child protection is a complex and demanding professional activity. In order to learn effectively practitioners need to understand the context in which errors arose. If safer child protection was simply a matter of learning simple obvious things then we would not have the continuing catastrophic errors which result in children dying or being re-abused.

The Herald quotes Dr Kim Holt, the paediatrician who blew the whistle on unsafe practices in the NHS contributing to the Baby Peter scandal. She said that NHS organisations often fail to learn from mistakes or share information because staff feared the consequences of owning up to errors.

That’s the message that every manager and every professional in every corner of every organisation dealing with child maltreatment needs to learn. The blame culture inhibits learning. Making professionals afraid silences them. Mistakes are covered up. Nobody is willing to own an error. No progress is made in making practice safer. Children continue to suffer.

Something Odd ...

The wonders of technology! Something strange appears to have happened and a post has suddenly changed its position in time. I published "Human Factors and Child Protection 1: Loss of Situation Awareness" in January and it has now appeared as having been published today!

I can't say what is going on. Apologies to anybody who has had trouble finding it. It is still worth a read, even if it is now out of sequence.

Human Factors and Child Protection 1: Loss of Situation Awareness

This is the first in a series of posts looking at how knowledge of human factors can inform safer working in child protection. It concerns the important concept of situation awareness.

By situation awareness we mean the ability to know, through attention and perception, what is happening in a particular environment. Having situation awareness means having a true perception and a true interpretation of the environment in which you are working.

In the old days one way in which pilots used to lose situation awareness was by making navigational errors which meant that they were not were they thought they were. Nowadays, with satellite navigation, loss of situation awareness on the flight deck is more likely to arise as a result of misinterpreting computerised displays or being by being overwhelmed by too much information.

Doctors can lose situation awareness by misinterpreting symptoms, ambiguous test results or by clinging to a false diagnosis. All sorts of professionals can be distracted by irrelevant or misleading information.

In child protection, loss of situation awareness often involves failing to perceive correctly the child’s situation, the family’s circumstances or the role and involvement of other agencies and professionals. Professionals can be 'led up the garden path' by manipulative families or have their attention misdirected to the wrong issues. Sometimes professionals become so familiar with a family's circumstances that they fail to notice subtle, but important changes. Sometimes they are just deceived.

Distraction can result from battling bureaucracy or trying to obtain resources. Sometimes parents add to distraction by creating issues and problems.

Many of the most well known child protection tragedies have involved loss of situation awareness on the part of the professionals involved. Victoria Climbié's social worker did not know the child's real name, thought that her great aunt was her mother and generally saw Victoria's carers as being needy rather than cruel. In the case of Baby Peter Connelly, professionals did not know that two men were living at the child's home. Mother hid bruising from the social worker by smearing the child's face with chocolate. There was a misperception that mother needed support and was basically caring. In the case of Khyra Ishaq mother succeeded in distracting professionals by making accusations of racism against them. In the recent case of Daniel Pelka school staff accepted mother's account that Daniel was suffering from an eating disorder, when in fact he was being starved.

An important cause of loss of situation awareness in child protection is confirmation bias. This term [1] refers to the phenomenon of selectively seeking evidence that confirms what we already think. We construct a hypothesis and confirm it, but we bend the facts to fit the theory. At the same time we ignore disconfirming evidence.

We all have this tendency. Receiving negative feedback is often not very pleasant. We all prefer to receive positive feedback. And we want to have faith in our own judgements. So having our initial assessments confirmed as being correct is satisfying. We were right all along.

Eileen Munro, in a study of 45 reports of inquiries, found that reluctance to revise initial assessments was a frequent cause of disaster in child protection. She writes:

“ … social workers are slow to revise their judgements…. misjudgements about clients that may have been unavoidable on the limited knowledge available when they were made continue to be accepted despite a growing body of evidence against them.”[2]

There are some important clues to loss of situation awareness. One is where there is a lot of professional disagreement. That suggests that different people are assessing the situation differently or are in possession of different information. Rather than trying to defend corners, the correct response is to try to understand why others' perceptions vary.

Feelings of information overload or disorientation are often clues to loss of situation awareness. Rather than being seen as individual professional failings, these should be seen as the tell-tale signs of having lost a true perception of the situation.

Perhaps the most important response to confirmation bias is to recognise that it can and will happen and that we have to be prepared to accept that an assessment may be wrong. As Munro concludes: “To change your mind in the light of new information is a sign of good practice, a sign of strength not weakness.” [3]

A fresh pair of eyes focused on a case from time to time is a good, but not infallible, safeguard against loss of situation awareness. The reviewer should be tasked to explore and challenge the status quo and workers need to be trained and encouraged to welcome challenge constructively. It may be that the dominant hypothesis passes the test and stands its ground. On the other hand testing it may reveal important weaknesses or omissions.

Of course time and resources need to be created for this type of review to take place.

There are also defences against distraction. A simple precaution is to make sure that when there are lots of distracting issues at least one person's attention remains focused exclusively on the needs and circumstances of the child.


Notes

[1] Wason, Peter C. (1960), "On the failure to eliminate hypotheses in a conceptual task", Quarterly Journal of Experimental Psychology, 12 (3): 129–140
[2] Munro, E. (1996) “Avoidable and unavoidable mistakes in child protection work”, British Journal of Social Work 26 (6) pp. 793-808
[3] ibid.

‘Daniel’s Law’ – a bad idea

I am really sorry to read in the Coventry Telegraph that 97,000 people have now signed a petition calling for it to be made a criminal offence for adults who work with children to fail to report any suspicions of abuse and neglect. http://www.coventrytelegraph.net/news/coventry-news/nearly-97000-sign-up-call-6733598 

I’m sure that most of the people who signed the petition are well meaning, and I’m sure that the organisers think that they are doing the right thing. But I believe that a so-called ‘Daniel’s Law’ is likely to have the opposite to the intended effect.

With such a law children are more likely to be unsafe because adults working with them will be constantly covering their backs fearing the possibility of conviction or even imprisonment if they make mistakes and fail to spot abuse at an early stage.

A culture of blame inhibits safety. We do not need the criminal law here. What we require is better training for all adults working with children to help them to recognise the signs of abuse and neglect, which often are not obvious. 

I wish 97,000 people would sign a petition asking for that.

Slough

Children and Young People Now’s report of the ‘inadequate’ rating achieved by Slough local authority in a recent Ofsted inspection of child protection services, actually made me warm a little to Ofsted, or at least to their inspector.

It is reported that Slough was continuing to experience difficulties recruiting enough qualified and experienced permanent social workers, with an "over-reliance on temporary staff". That certainly sounds like the real world of the organisations I used to work in.

It was further reported that this situation results in a great deal of re-work, resulting in "delays and drift in many children's cases". Again, that sounds like the places I used to work

Then there is the issue of “excessively high caseloads", resulting in social workers not having “sufficient time to spend with individual children to learn about their lives”. That sounds only too familiar. 

The inspector is said to conclude that this results in poor quality assessments, plans and outcomes for children. That sounds like a sensible deduction to me. 

Could Ofsted be getting the message? I hope so. 

Poor old Slough - this is not just their problem but an national one.

Prevention and Cure

I have been reading the World Health Authority's European report on preventing child maltreatment [1]. As the title suggests it advocates prevention. It is very hard to argue against that. Everybody knows that prevention is better than cure. The report takes a public health perspective on child abuse and neglect and examines several types of preventative measures.

It was interesting to note that the report finds that overall 'selective programmes', as opposed to 'universal programmes', were judged more likely to be effective or found to be supported by a well-designed research study. Among those selective programmes which were judged to be best evidenced were home visiting (health visiting) and parenting programmes. However one well-designed research study provided evidence for the effectiveness of a universal programme: educating new parents about how to avoid traumatic head injury.

There is certainly food for thought here and I agree strongly with the report that effective prevention would be cost-effective. Child abuse is not only a moral evil, it is a costly one, especially in its long-term consequences which run into billions of euros or pounds or dollars every year.

The report rightly stresses the need for an evidence-based approach. I believe we also have to be crystal clear in our thinking about prevention. We need to beware of fuzzy ideas or half-baked initiatives. We need to shun the work of spin-doctors and policy wonks and charlatans. It is only too easy to dress up a bright idea as a scientific innovation.

Effective child maltreatment prevention programmes are not a simple alternative to reactive protection and rescue services, just as road safety education is not a simple alternative to the ambulance service! Reactive services can only be scaled down as effective preventative services reduce demand. What is very wrong, and what has happened in the British context in the past with programmes such as Every Child Matters, is the kind of policy initiative that suggests that somehow poorly evidenced preventative measures can be widely introduced without significant new resources and simply substitute for reactive services. That will never work.

We need to move forward step by step - not in huge leaps of ill-placed faith. We need to amass evidence about which preventative approaches are effective and which are not, and we need to be clear about what we are talking about. The notion that bright ideas for early intervention, such as 'common assessment' or 'information sharing' or 'team around the child', should be widely introduced without proper evaluation is not only wrong, but dangerous. Such an approach diverts resources and shifts the focus of attention to activities of unproven worth. Prevention may be better than cure, but cure will continue to be required until truly effective prevention programmes have been developed and successfully deployed.

I am shocked by how often in Britain debate seems to assume that prevention amounts to some sort of 'early intervention' which is ill-defined or even not defined at all. Let's all intervene early and it will all be OK. Such thinking often amounts to putting pressure on people like teachers or nursery workers or police officers to do things that they are not particularly well-equipped or well-resourced to do. A child in the class has been abused. The cry goes up that the teachers should have intervened earlier. But what were they supposed to do and how well have they been trained to do it and how do we know that what they might do would have been effective? We simply don't know.

Preventative services are not just an extension of reactive ones. They have a different legal basis, a different focus and different processes. In health, preventative measures, such as sewers or clean water or mass vaccination, are often quite different in their technology, design and mode of operation from treatments, such as surgery or drug therapies or intensive care. Similarly with child maltreatment we should not expect that preventative services will look similar to reactive ones. They are likely to involve different processes, different people, different focuses and different ways of thinking.
In democracies intervention in family life can only take place against the wishes of the parents where there are justifiable concerns for the safety of their children, not where there are just 'risk factors' or ill-defined 'concerns'. That means that preventative services need to engage with parents and their children by offering something which is attractive to them, something which they value. So the design of preventative services has to be different from the design of reactive services. The latter have to be rigorous, thorough and, as far as possible fail-safe. The former have to be be engaging and attractive to people. If they are stigmatising or condescending or authoritarian there will be no buy-in, no engagement and, as a result, no prevention.

Notes

[1] Sethi, D. et al (Eds.) European report on preventing child maltreatment, World Health Organisation: Copenhagen 2013.