I have been reading the British Government’s latest document
about children’s social work in England - Children’s social care reform: a vision for change
I should say that there is quite a lot I don’t like in this
document, so my spirits picked up when I noticed what promised to be an
encouraging paragraph on page 7. Talking of practice and systems it says:
“Learn when things go wrong. The system is still too often
characterised by repeating the same mistakes. We need a deeper and more
sophisticated understanding of why mistakes occur and how the system can learn
to avoid them. This requires overhauling the serious case review process.”
There is so much to agree with in this paragraph other than
its conclusion! We must learn from things going wrong, the same mistakes do
keep happening and we need a better understanding of how they happen and how to
avoid and mitigate them. But we don’t want to spend a lot of time reforming the
serious case review process. There are better ways.
I have held forth before about serious case reviews and I
have now come to the view that they cannot be made to work. They are costly,
time consuming and disruptive. They are often very slow to report. They are
nearly always descriptive rather than being analytical. They are
unrepresentative, because they concern mostly fatal or near fatal incidents.
And they don’t get at the truth, often because the people involved in the
incident have something to gain by not being open with those conducting the
review. In short there is so much wrong with serious case reviews that the
prospect of an overhaul is not just daunting, it is overwhelmingly dispiriting.
Instead what we should be doing is building a just and
responsive reporting culture, in
which everybody, but perhaps most importantly those that work on the front line,
feel confident about reporting, discussing and analysing what goes wrong in
everyday practice and how to put it right. Such a reporting culture would be
based on a widespread understanding of human factors in the workplace,
supported by systems which encourage openness and reporting, such as
confidential near miss reporting, and underpinned by an ethic which values,
respects and protects those who raise safety concerns.
