It is clear that at the heart of the failure to protect seventeen
year-old Georgia Williams from Jamie Reynolds, who murdered her by hanging her,
there is a catalogue of poor decision-making.
Reynolds was treated as low risk when in fact there was
plenty of information available to the main agencies dealing with him, especially
the police, to indicate that he posed a high risk, not just to Georigia but to
other young women as well. But, for reasons that still remain unclear, it was
decided only to caution him for a similar previous offence, leaving him at
large and unsupervised at the time of his attack on Georgia. And it was decided
not to warn some of those whose images he had in his position and which he had
doctored in an alarming way.
In addition to a Serious Case Review report there is also said to be a report by the Devon and Cornwall
police force into the handling of the case by West Mercia police. This has not
so far been released to the public, although it has apparently been shown to
some journalists.
I found the Serious Case Review report hard going. It seemed
to be endless detail and not much analysis. There seemed to be more references
to poor ‘information sharing’ than to poor ‘decision-making’. Perhaps that was
what sparked off the memorable radio interview on the Today programme on Radio 4 this morning where a representative of
the Police Superintendents’ Association stuck rigidly to his contention that
poor information sharing was to blame, while the incredulous interviewer kept
pointing out that the police were in possession of all the crucial information
at the time it was decided to treat Reynolds as low risk.
I regret to say that the phrase ‘poor information sharing’
has become on a par with the mantra of ‘lessons will be learned’ when it comes
to reflecting on this kind of tragedy. It seems to be wheeled out as a
general-purpose explanation and goes hand-in-hand with a general-purpose
solution – everybody promises to share more information next time. The
consequence that professionals and practitioners are in danger of information
overload, and likely to become unable to see the wood because of the trees, appears to be
recognised by few.
I would like to see attention in this and similar cases
focused on the question of why poor decisions were made. I don’t want to focus
on blaming those who made them, because I expect that they were made
professionally and in good faith; despite the fact that they turned out to be
tragically wrong. But there are well known ‘error traps’ facing decision-makers
that are listed in the human factors
literature, including jumping to solutions, being unwilling to challenge those
seen as ‘experts’, assuming that there is insufficient time to make a full
assessment, failing to consult other people and, probably most importantly,
failure to review a decision and amend it if necessary [1]. Major areas of
difficulty can arise where groups are involved in making joint decisions. Of
particular importance are risky shift
[2] and groupthink [3] in which
groups have been seen to take riskier decisions than would individually be
taken by each of their members. Groupthink is often credited with being a significant
factor in the Bay of Pigs fiasco in 1961.
Safer decision-making practice comes from being aware of
these error-traps, of being able to recognise them and in knowing how and when
to take action to avoid them.
Endnotes
[1] Walters, A. Crew Resource
Management is No Accident Wallingford: Aries, 2002
[2] Stoner, James "Risky and cautious shifts in group
decisions: the influence of widely held values". J. Exp. Social Psychology
4: 442–459 (1968)
[3] Janis, I. L. Victims
of Groupthink Boston: Houghton Mifflin, 1972
