Tuesday, 4 March 2014

The legacy of the tragedy of Daniel Pelka?

The BBC has a report [1] from Coventry about the continuing impact on the city’s children’s services of the death of Daniel Pelka. A social worker tells the BBC that he and his colleagues:  

·       Take the tragedy “really personally”

·       Feel responsible

·       Acknowledge that they have “collectively failed"

·       Understand that the social workers involved in the case lacked both “support from partner agencies” and relevant information

The social worker concludes by saying that they have all read the serious case review report and that they all know Daniel’s case “inside and out”.
Some might be tempted to think that the serious case review process has had a significant impact. But I am sceptical. Over the years I have become less and less enamoured with serious case reviews. Time and time again these reviews seem to identify the same sort of factors  - especially inter-agency co-operation and information sharing – and time and time again, despite everybody claiming to have learned the lessons, another child dies somewhere else in very similar circumstances, occasioning yet another serious case review.

And I wonder to what extent the kind of self-flagellation that they seem to be going through in Coventry contributes to greater safety. Perhaps it just distracts from the crucial issues?

In a very interesting and important paper published last year [2], Andrew Turnell, Eileen Munro and Terry Murphy argue that child death inquiries “ … repeatedly manufacture the notion that the cause of the fatality can be isolated, those culpable identified, and then new procedures can be put in place to make sure the tragedy will never happen again”. They suggest that what they call this “linear approach” has resulted in little improvement.

I heartily agree. Serious case reviews focus on cases which are unrepresentative of normal practice – usually cases in which a child has died – and generally they describe what has happened but fail to explain why. They take a simple, mechanical view of causation – information wasn’t shared or agencies didn’t co-operate, therefore lack of information sharing or inter-agency co-operation was the cause of the tragedy – and they seldom if ever reveal the kind of ‘error traps’ [3] that we know lurk beneath the surface of all business and professional processes. They continue to assume that human error is a rare aberration rather than a normal part of everyday practice. Often their authors seem to believe that error can be eliminated by the adoption of simple bureaucratic rules and procedures.

If that wasn’t bad enough serious case review reports take a long time to prepare and circulate. They are often long and difficult to read. They make numerous and often puzzling recommendations and they contribute to a continuing culture of blame by suggesting that the actions of individuals or groups specifically ‘caused’ the tragedy. They operate with lashings of hindsight bias and more than just a smidgen of holier-than-thou.

I don’t think the answer to these problems lies in reforming the serious case review process, although I do not think that fatal incident inquiries should be abolished altogether. The priority, I believe, is to recognise that the primary approaches to learning are to be found in other places.

I know of two methods that offer a fresh and different approach to learning about how to provide safer child protection services. They are similar to each other. 

The first is Confidential Critical Incident Reporting [4] (sometimes called Confidential Near Miss Reporting) which offers practitioners a safe and supportive means of reporting their mistakes in such a way that others can learn from them – before a tragedy occurs. Confidential Critical Incident Reporting has been widely adopted in transport industries [5] [6] and some branches of medicine [7] [8] [9]. It has even been used to understand failures in marketing [10]. It provides a means of achieving what James Reason tells us is a precondition of safer organisations: a reporting culture. He writes:

‘Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we have no way of uncovering recurrent error traps or of knowing where the “edge” is until we fall over it.’ [11]

The second method has its origins in manufacturing. Kaizen [12] (the Japanese word for ‘improvement’) is the idea that all employees should be involved on a daily basis in a constant and continuous quest for information about the causes of quality defects and about ways in which small but significant improvements can be made to improve business processes. Lots of small changes add up to something significant, even momentous - as they found out at Toyota in the 1950s-1960s when they introduced Kaizen. They collected thousands and thousands of suggestions from their workers on a daily basis, all for making small changes to improve quality, to make processes run more smoothly or to eliminate waste and delay. Within ten years they moved from being a very inefficient producer, with low quality products, to being one of the most efficient with very high quality – a world-beater in fact.

Unlike serious case reviews, which tend to be bureaucratic exercises, neither Critical Incident Reporting nor Kaizen are just methods. They are philosophies or cultures of practice. They are about management realising that business and professional processes are best understood by those who deliver them (not by supervisors or 'experts' or consultants) and that the role of management is not to implement change top-down, but rather to facilitate improvements suggested from the 'front-line'. In this way all the little things that many managers do not even know about that result in poor quality or unsafe practices are revealed and addressed.

That’s the way to make child protection services safer and to offer children and young people higher quality services. It would be good if it were to become the legacy of the tragic death of Daniel Pelka, rather than a long, puzzling and, I believe, not very informative report! 


[1] http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-26359754 

[2] Andrew Turnell, Eileen Munro and Terry Murphy: “Soft is Hardest: Leading for Learning in Child Protection Services Following a Child Fatality” Child Welfare, Vol. 92, No. 2, 2013. There is a brief journalistic summary of this article at:


[3] See Reason, J. “Human error: models and management.” British Medical Journal 2000; 320:768

[4] Flanagan, J.C. (1954) ‘The Critical Incident Technique', Psychology Bulletin, 51, pp.327-58

[5] http://www.chirp.co.uk/information-about.asp 

[6] Edvardsson, B (1992) “Service Breakdowns: A Study of Critical Incidents in an Airline,” International Journal of Service Industry Management, 3 (4), 17-29

[7] Williamson, J. (1988) 'Critical Incident Reporting in Anaesthesia - Monitoring and Patient Safety', Anaesthesia and Intensive Care, 16, pp. 101-03.

[8] Mahajan, R. P. “Critical incident reporting and learning” Br. J. Anaesthesia (2010) 105 (1): 69-75

[9] S. Reed, D. Arnal, O. Frank, J. I. Gomez-Arnau, J. Hansen, O. Lester, K. L. Mikkelsen, T. Rhaiem, P. H. Rosenberg, M. St. Pierre, A. Schleppers, S. Staender and A. F. Smith, “National critical incident reporting systems relevant to anaesthesia: a European survey.”

British Journal of Anaesthesia 112 (3): 546–55 (2014)

[10] Gremler, D.D. The Critical Incident Technique in Service Research, Journal of Service Research, Volume 7, No. 1, August 2004 65-89 

[11] Reason, J op. cit 

[12] Imai, M. (1986). Kaizen: The Key to Japan's Competitive Success. New York: Random House