Sunday, 5 April 2015

The wrong approach to misjudgements in child protection

You may not have time to read the whole the report of the hearing of the Health and Care Professions Council into the conduct of two Lancashire social workers, one of whom, a team manager, has been suspended for one year.

You can however find a good summary of the case in Community Care.

We are told that the social worker failed to visit a family where an allegation of serious child sexual abuse had been made and that the manager failed to ensure that the social worker undertook the necessary assessment.

I fully accept that children may have been put at serious risk as a result of misjudgements in this case, but that is what they were – genuine misjudgements. There is no evidence in the report of the hearing of any kind of deliberate wrongdoing, only of making mistakes that could have had serious consequences.

I believe that suspending the team manager, who it is said had an exemplary work record prior to these events, is a highly punitive sanction, which is likely to have negative consequences not only for the profession but also for the safety of children and young people. Let me explain.

Making decisions in child protection work is always fraught with difficulty. The quality of information is often uncertain, not least because there are frequently conflicting findings and opinions. Add to that the fact that decisions are often made under great pressure of time and serious shortfalls of resources. So the potential for misjudgement is readily apparent.

Then remember all we know from the study of organisational safety. Psychologists like Professor James Reason tell us that complex decision-making is an error prone process and that we need to focus continuously on improving organisational defences, not dwelling on issues of who is to blame for particular errors.

Another psychologist, Professor Sidney Dekker, has detailed how looking for ‘bad apples’ actually results in decreased safety. That is because the pursuit of people who make professional errors results in reducing the willingness of other professionals to be open and honest about their mistakes. A defensive blame culture results in obfuscation and concealment. It results in knowing less about the errors that actually occur and so results in organisations becoming less safe.

If the Health and Care Professions Council is confronted with cases where professionals have engaged in deliberate wrongdoing then I have no problem at all in it imposing punitive sanctions. Or if there is evidence of somebody who regularly and systematically makes dangerous decisions, then suspension is probably necessary to protect members of the public.

But this case appears to be one of a single, admittedly serious, misjudgement that we are told was very much out of character. The correct response should not be to blame anybody. The safety of children and young people is much better assured by creating the conditions in which the reasons for the error are explored and understood. The individual concerned should be offered any necessary support and re-training to try to reduce the probability of the error being repeated; not plunged into disciplinary proceedings.