Patrick Butler’s review of the BBC TV programme Baby P: the Untold Story is a must read, especially if you didn’t see the programme.
The documentary clearly established a number of important conclusions.
Firstly the failures that resulted in Peter Connelly’s death were widespread across agencies and professions. There were no examples of individual professionals committing gross errors or negligence. On the contrary the combination of lots of small failings together added up to cause the tragedy.
Secondly there were important structural problems. There were high workloads in Haringey Children’s Services and more or less a meltdown of paediatric assessment services at the St. Ann’s children’s hospital, with two out of four consultant posts unfilled.
Thirdly the culture of blame was pervasive. The unedifying scramble to finger scapegoats when the story broke in 2008 is perhaps the most sickening example of this, but the programme left no doubt that there were long established problems, such as the way in which staff who tried to signal concerns about safety at St Ann’s were dealt with. The author of the Serious Case Review report observed that agencies were defensive and were trying to point the finger of blame at others. She felt people were scared about their jobs.
The programme revealed the extent of the truly shocking behaviour of some members of the public who threatened and intimidated individuals involved in the case. It is hard to imagine that conduct of this sort could have occurred in a civilised society. The role of the tabloid press, especially the Sun, in stoking up an irrational and emotive public mood was clearly outlined. The craven response of some politicians to the public clamour was utterly dispiriting.
Then there was the issue of cover-up. Important information about the struggling services at St. Ann’s hospital appears to have been withheld from the Serious Case Review. There is no point at all in having a SCR if crucial information is withheld. The resulting report becomes part of the problem, not part of the solution.
The programme also explored the issue of why the Ofsted report, that was prepared after the scandal broke, differed so radically from the one that was prepared just before. This remains a bewildering puzzle that may never be resolved, not least because crucial Ofsted files appear to have been deleted. The programme quoted as anonymous Ofsted inspector as saying that they didn't know who had made the decision to delete the files, and that it was a cover-up. The inspector pointed out that removing that information resulted in removing accountability. I find it hard not to lapse into talking of ‘Ofstedgate’ at this point, because the whiff of obfuscation and conspiracy hangs heavily over the whole affair. And Ofsted’s senior management remains strangely silent on the issue, suggesting that it has little to say.
An interview with Edi Carmi, the author of the first Serious Case Review overview report, revealed two things that were very interesting to me. Firstly she described the way in which thinking about Peter’s bruising moved slowly from ‘non-accidental injury’ to ‘bruising as a consequence of neglect’ to the possibility of the child harming himself as a result of over-activity. There could be no clearer example of what Prof. Eileen Munro has called a ‘garden path error’. I like to use Prof. Charles Handy’s parable of the boiled frog in this context. In his 1989 book The Age of Unreason Handy tells us that if a frog is put in water that is slowly heated, the frog will eventually let itself be boiled to death. He uses this as an illustration of what happens to businesses that don’t respond to the way in which the world is changing around them. I think it is also a very good metaphor for what happens when professionals become too close to a family in which abuse and neglect is occurring. Cumulative small changes pass unnoticed so that thresholds are never crossed.
The other thing that Edi said, which seemed to me to be spot on, was her description of lots and lots of small mistakes made by every agency involved in Peter’s care. There wasn’t one big mistake, she said, but that it was just that lots of little mistakes happened at the same time. There could be no clearer example of Prof. Jim Reason’s Swiss Cheese model of organisational error – see http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html. Lots of small weaknesses in process and organisational design and working practices (holes in the cheese) line-up and allow the trajectory of the fatal error to pass unimpeded. That implies the need for a human factors approach to improving safety in child protection. Professionals with high workloads working in difficult conditions and dealing with complex problems need to be equipped with techniques to recognise, analyse and reduce or mitigate the errors they will inevitably make. That, to me, is the abiding message of the Baby Peter tragedy.