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 . Major areas of difficulty can arise where groups are involved in making joint decisions. Of particular importance are risky shift  and groupthink  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.
 Walters, A. Crew Resource Management is No Accident Wallingford: Aries, 2002
 Stoner, James "Risky and cautious shifts in group decisions: the influence of widely held values". J. Exp. Social Psychology 4: 442–459 (1968)
 Janis, I. L. Victims of Groupthink Boston: Houghton Mifflin, 1972