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.
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.
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.
