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.
