The tragic case of Ayeeshia Jane Smith has received wide
coverage in the British press following the convictions of her mother and
stepfather in connection with her death.
Only limited information about the involvement of statutory
services is available at this stage, but the case appears to have all the
hallmarks of one in which there had been substantial involvement prior to the
child’s death. The child had been in care and then returned home; and she was
subject to a child protection plan. Inevitably the papers are asking the
question ‘why?’ and some are comparing the case to the Baby Peter tragedy.
An MP is calling for a public inquiry to be set up.
Until the Serious Case Review (SCR) report is published we
can only speculate about the extent and nature of statutory services’
involvement. However, I believe that we are unlikely to learn much new about
how to make services safer from either the SCR or from any form of inquiry. Almost
certainly the kind of mistakes that have happened in this case are comparable
to those that have happened in all the similar cases dating back to Maria
Colwell in the early 1970s and beyond. Professionals have lost situation
awareness, made poor decisions and become embroiled in communication foul-ups.
Simply recounting it all again will not make it less likely that they will
reoccur.
Instead of putting our faith in formal administrative
reviews or legalistic inquiries, it would be much better if we applied what we
know about the psychology of human error and addressed the questions of how
people working in child protection organisations make mistakes and how they can
work more safely. We need to address the question “why?” Why are ‘obvious’ signs of abuse and neglect missed? Why do individual practitioners and
groups of professionals sometimes become strongly attached to misperceptions
and misjudgements which seem to them at the time very sensible but which are
hard to justify with the benefit of hindsight? Why do communications become confused or obscured?
I am delighted to see that the British Department for Health
is now strongly embracing a human factors
approach to safety and I was impressed by a speech made by the Secretary of
Sate for Health, Jeremy Hunt, in which he argues is that patient safety is
compromised because there is more interest in blaming than in learning.
Quoting Matthew Syed’s book Black Box Thinking Hunt draws heavily on the experience of the
airline industry saying: “… the airline industry realised that if it was going
to reduce airline fatalities, it needed to change its culture. They realised
that ‘human factors’, rather than technical or equipment failure had been at
the heart of the problem.”
He goes on to argue that in order to improve safety in the
NHS there needs to be a cultural change involving two elements: (i) openness
and transparency about where problems exist and (ii) a true learning culture to
put them right. He explicitly draws on the experience of civil aviation in
developing human factors approaches
to safety, and announces a proposal to create an organisation modelled on the
Air Accident Investigation Branch to investigate accidents and safety concerns
in health care (something that I suggested for child protection in 2010 - http://chrismillsblog.blogspot.co.uk/2010/04/my-election-manifesto.html).
He stresses that: “Other industries – in particular the airline and nuclear
industries – have learned the importance of developing a learning culture and
not a blame culture if safety is to be improved.”
Hunt has told the House of Commons that the Government
proposes developing this type of safety culture in the British National Health
Service (NHS). That is a development greatly to be welcomed.
What is less welcome, however, is that there appears to be
little by way of parallel developments from the Department for Education, which
in England is responsible for children’s social care and child protection.
Indeed a significant disconnect appears to be emerging between the safety
approaches being developed in the NHS and attempts to improve safety in child protection
and children’s social care, which are still deeply rooted in old-fashioned
administrative approaches to human error and a thinly disguised blame culture.
Children’s sector leaders are by and large dismissive or
disinterested in human factors thinking.
There is no knowledge or interest within Ofsted about this type of approach.
Civil servants have told me and other campaigners that they believe human factors training is of marginal
value to child protection and that learning from error is adequately taken care
of by serious case reviews! Now, while closely linked services within the
purview of the Department of Health are to be taken down the fruitful path that
has been well trodden by the airline and nuclear industries and which is a
proven route to greater safety, it appears that children’s services are to be
allowed to languish in a safety time warp.
In my view officials from the Department for Education
should be meeting urgently with their counterparts in the Department for Health
and trying to go up the steep learning curve they need to climb to begin to
embrace the ideas that Jeremy Hunt has so clearly articulated.
