A serious case review which is reported in Community Care (http://www.communitycare.co.uk/2016/03/21/lack-reflective-supervision-hindered-action-baby-death-case/?cmpid=NLC%7CSCSC%7CSCNEW-2016-0323) draws two important conclusions which appear to be based on a human factors approach to safety in child protection. The review concludes:
“One of the most persistent and problematic tendencies in human cognition is a reluctance to revise an initial assessment of a situation."
“Reflective supervision is crucial when addressing cognitive issues. These types of erroneous thinking and decision making are unlikely to be recognised by the individuals themselves.”
Confirmation Bias is the tendency we all have to resist revising our assessments of situations. It is a form of Loss of Situation Awareness in which new information which disconfirms an initial hypothesis is ignored or degraded to preserve the status quo. The author of the SCR is also correct to note that Confirmation Bias can be difficult to detect, especially by individuals working alone. Good supervision is one factor in helping people recover from loss of situation awareness. By so is good team work in which colleagues feel free to challenge peers and especially superiors.
A major factor in the world's worst aviation disaster (at Tenerife North Airport) in 1977, was a mistaken decision to take off by a pilot who thought he had permission to do so, when he didn't. He was the airline's most senior captain, which may have been a factor which inhibited his two flight deck colleagues from confidently challenging what must have seemed to them to be an unaccountable and fatal decision.
