Regular readers of the blog will know that I am no great fan of Serious Case Reviews (SCRs). I was however pleased to see that a new publication from the NSPCC goes some considerable way to introducing safety systems thinking and a human factors approach into SCR practice.
On page 19 of the document the authors draw attention to the "... large body of safety management literature that addresses the same problems as child protection of understanding how poor outcomes arise and how they can be reduced". A key lesson, we are told, is that practitioner errors generally arise from the interaction of several areas of weakness in the system, and not from one major mistake by an individual. So the focus of investigations, it is argued, should be on exploring how systems function routinely and on general factors which predispose to error. The authors quote Professor Don Berwick, in his report on patient safety in the NHS, and Professor Sidney Dekker, who both argue that it is vitally important to distinguish clearly between wilful misconduct, on the one hand, and human error which is normal, and by definition unintended, on the other. Well-intentioned people who make errors at work or who are involved in systems failures need support not punishment. And unjust punishment inhibits people reporting their errors, or defects in systems, and so inhibits learning.
All this is excellent stuff. I don’t think this document will transform the Serious Case Review process into something truly useful, but I do think that it moves forward establishment thinking about how investigations into accidents and service failures in child protection investigations are undertaken and what conditions need to be in place to encourage reporting and so facilitate learning.
That could be the start of a journey towards developing approaches – such as critical incident reporting and human factors thinking - that will deliver better results than SCRs ever have.