Eight years after the death of sixteen-month-old Kyle Keen, from a brain haemorrhage after being shaken by his stepfather, the Walsall Healthcare NHS Trust has published the report of an independent investigation, which concludes that there is “…a significant probability that this death could have been avoided if the staff at Walsall Manor Hospital had referred Baby K to social services … and action had been taken to intervene”.
The critical mistake appears to have occurred when the
concerns of nursing staff and junior doctors about bruising to Kyle were
overruled by a consultant paediatrician. As a consequence no referral to
children’s social care was made and the baby was returned to the care of his
mother and stepfather.
In human factors terms this looks to be very much a case in
which the authority of a senior person was not challenged, despite junior staff
having strong and valid concerns. It seems very like the terrible tragedy at Tenerife North Airport in 1977,
in which the very senior and highly respected captain of a jumbo jet began to take off without permission
and was not appropriately challenged by his co-pilot or the flight engineer. In
the resulting collision more than 500 people were killed.
In civil aviation the Tenerife crash resulted in less
experienced flight crew members being trained and encouraged to challenge their
captains when they believe something is not correct. Captains are also trained
to listen to their crews and evaluate all decisions in the light of crews’
concerns. This concept was developed as Crew Resource Management (CRM) or human
factors training and is now mandatory for all European and US airlines.
Sadly that sort of training is still not available for
most child protection professionals. If it had been in Walsall perhaps this tragic
death would not have occurred.