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.
