Cornwall gets a 'good'

Over the years I’ve not had many good words to say about Ofsted. I don’t go back on what I’ve said. I still believe Ofsted’s inspection model is the wrong one for children’s services and child protection.

But I have to say that their recent report on Cornwall Children’s Services did have some sensible things in it.

  

Finding the overall quality of services ‘good’, the report says that the senior management team:

“….. demonstrates a good understanding of services, is committed to continual improvement and responds swiftly to meet the changing needs and demands for services

“(has) created a culture of learning, support and challenge in a professional environment that has enabled social work to flourish

“(has continued) investment in high quality training and support (resulting) in a stable

and skilled workforce.”

There is absolutely no doubt that those are things that any successful organisation delivering complex services needs to do. In particular, I liked the use in the report of the following words/phrases: ‘continual improvement’, ‘culture of learning’, ‘challenge’.

A while ago I posted something about Ofsted’s use of the word ‘robust’, concluding that over-use of this word was, in my view, associated with “…cultures that inhibit improvement and prevent people learning from mistakes. They come from the knee-jerk response of pointing the finger of blame at the usual suspects whenever things go wrong. They come from fear and despair”.

  

It seems as if Ofsted may be moving forward, if slowly.

With the benefit of hindsight …

With the benefit of the hindsight there can be little doubt that the ruling by a highly experienced judge in the case of six-year-old Ellie Butler that she should live with her father, Ben Butler, was a catastrophic error. As we now know Ellie’s father subsequently beat her to death.

https://www.theguardian.com/uk-news/2016/jun/22/ellie-butler-judge-took-unwarranted-steps-to-reunite-her-with-violent-parents

The phrase “with the benefit of hindsight” is one that we often hear in these circumstances. It belies the fact that we never take decisions with the luxury of knowing for sure what the outcome will be. Indeed, we only experience the ‘benefits’ of hindsight when it is already too late. Parading the view from hindsight as a counsel of perfection is seldom, if ever, helpful. “So-and-so ought to have done X” is often just a statement of the blindingly obvious. It does not help us to understand how to make practice and systems safer in the future.

For all our attempts to learn from forensic and microscopic examination of child protection tragedies, by means of public enquiries and Serious Case Reviews, we have not learnt enough to prevent similar tragedies occurring with sickening regularity. We probably haven’t even learnt enough to make their occurrence less likely. We continue to be shocked by some new and hitherto unthinkable way in which the best laid plans, and the most developed systems, seem to be riddled with holes through which the trajectory of errors pass untroubled. For all our best endeavours things keep going wrong in surprising ways.

More often than not when a child dies, because an opportunity to protect is missed, it is a decision taken by a social worker or a doctor or a health visitor which comes under intense scrutiny and which is at the centre of the media storm. In this case it was a decision which was taken by a judge.

The Guardian’s editorial tells us that judges are different from professionals like doctors and social workers and health visitors. The editorial argues that there are “sound constitutional reasons” that prevent judges appearing before external enquiries and that the only appropriate place to challenge a judicial decision is in a higher court.

https://www.theguardian.com/commentisfree/2016/jun/22/the-guardian-view-on-ellie-butlers-murder-human-fallibility

I am no expert on the constitution, but I agree that a public inquiry, such as the one demanded by Ellie’s grandfather at which the judge and others involved would have to testify, would be unlikely to explain why things went wrong. I expect that the outcome would be to provide more factual detail with no increased understanding of the causes or how to prevent a reoccurrence in future. The vast amount of money spent on the Victoria Climbié inquiry produced lots of detail, but little understanding. An inquiry into Ellie’s death would be likely to be similarly unproductive.

I believe that what is required are not more post mortems but more pre mortems. Instead of trying to unearth the ephemeral historical ‘truth’ of tragedies like Ellie’ s, we need to try to understand how and why we make mistakes and how why our organisations fail to prevent some errors. We need to understand why sometimes we lose situation awareness and why sometimes we make flawed decisions and why sometimes our communications are misunderstood or not heard. Reflecting on tragedy will not help us, but reflecting on day-to-day practice will.

We need to learn from professionals in other kinds of safety critical industries about how human factors contribute to safety – or to the absence of it – and about ways in which we can build safer and more resilient organisations which have better defences and less error traps.

Surprisingly beginning a journey like that is not hard to do. We need to acquire a language which allows us to talk about our errors and to put them into their scientific context. We need to be able to look at the defences against error in our organisations and to analyse them to find their weaknesses. And we need to build a culture in which talking about error is the norm. We need to ensure that those who want to talk about errors and to learn from them are congratulated for doing so, not punished.

If we want to stop further tragedies like Ellie’s we must start to do that. Either in our workplaces with our colleagues, or, if we are judges, in our chambers with other judges. We all make mistakes, most of the time. The greatest crime is not to discuss them openly, to analyse them and to learn from them.

Simply a good idea – and a LEAN one

Ann Longfield, England’s Children’s Commissioner, is to be warmly congratulated for suggesting the use of a ‘Children’s House’ to interview children in abuse cases.

http://www.bbc.co.uk/news/uk-36524422

The idea, which comes from Iceland’s ‘"Barnahus", is simple, effective and humane. It allows a child to be interviewed in a safe and comforting location, by a specially trained interviewer, only once and for the interview to be recorded for future use in trials and court hearings. The child is spared further interviews, attending court and, importantly, cross examination. And the child can be offered counselling and other therapeutic help following on from this single interview.

It is not only a simple, effective and humane idea, but it is a Lean one too. Re-work and unnecessary process steps are anathema to Lean. Keeping it simple, doing it only once and avoiding any unnecessary repeated work helps to promote high quality and to reduce unnecessary costs, so allowing more resources to be directed to adding value in an improved service to the child.

http://www.lean.org/WhatsLean/

Round and round and round we go ….reflections on the tragedy of Liam Fee

There is a dizzying air of déjà vu hanging over all the column inches devoted to the dreadful murder of toddler Liam Fee. Cruel, manipulative and devious carers neglected, abused and killed the little boy, while he ‘dropped off the radar’ of statutory services.

http://www.bbc.co.uk/news/uk-scotland-36397785

Matt Forde, head of service for NSPCC Scotland, calls for more early intervention and a service model which is less ‘incident lead’ with a greater focus on children’s early years.

http://thirdforcenews.org.uk/blogs/child-preotection#jxukocwOplqs35o5.99

Social Work Tutor, in the Guardian, pleads for social workers to have more time for direct work with children and their families and less distraction from paperwork and administration.

http://www.theguardian.com/social-care-network/2016/jun/03/liam-fee-social-workers-child-protection?CMP=ema-1696&CMP=

The truth of the matter is that knowledgeable, concerned, thoughtful and influential people can come up with all sorts of plausible, innovative and interesting suggestions for change in the wake of a tragedy. But proposals, however sensible, in these circumstances have a habit of fading, like Shakespeare’s insubstantial pageant, and leave not a rack behind. In the wake of every tragedy, from Maria Colwell in the early 1970s onwards, bright and sensible ideas have been propounded and discussed and promulgated, only to be eventually shelved and forgotten.

My view is that if you want lessons to be learned you need to create an environment in which the people who do the work can learn. Hierarchical organisations which operate through rigid command and control structures, in which frontline workers are compelled to deliver ‘reforms’ that they do not support or understand and in which they fear to raise dissenting voices or admit to errors and failings, frustrate learning and so compromise safety and quality of service. A culture of blame and a climate of fear are the worst enemies of innovation and improvement and safety.

And it is utterly pointless for the government to bang on about innovation without taking positive steps to create and sustain the conditions in which learning and innovation can take place.

http://chrismillsblog.blogspot.co.uk/2016/01/risk-and-innovation-sloppy-drafting.html

So the most important lessons we should be learning from Liam’s tragic death, and those of so many other children in similar circumstances, are not specific lessons such as ‘more early intervention’ or ‘less administration’. Rather we should begin by taking steps to build organisations and cultures which actively promote learning, rather than inhibiting it, and start ensuring that everyone involved in child protection work, at every level, is able to embrace continuous learning and improvement as a central part of their work.