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.
