I was very pleased to see that Donald Henderson, the Scottish Government’s Deputy Director for Care and Protection, speaking at a recent event, is quoted as saying:
“How did the best systems learn? The best systems learn from the mistakes they make, the mistakes that were almost made, or ‘near misses’, and also from the successes. There needs to be an honesty about it.”
I only wish English civil servants and their political bosses would be as quick to acknowledge this very simple and straightforward truth. We learn from being honest about what can go wrong. And in order to allow people to speak freely about mistakes and service failures, we need to make it safe for them to do so.
In order to make child protection safer we need to develop a just reporting culture, in which practitioners are given permission and encouraged to talk about errors. We need to support and respect those who raise safety concerns and stop intimidating whistle blowers. We need to equip practitioners to talk about workplace errors and to analyse and understand how mistakes happen by providing Human Factors training like the training that pilots and other airline employees currently receive. And we need to gain a broad and accurate picture of the types and frequencies of mistakes and service failings by developing better systems – such as Confidential Near Miss Reporting - to create better quality data about the kinds of errors that occur daily in child protection practice.
The Safer Safeguarding Group campaigns on these issues. Join us in our quest for more openness and honesty about mistakes.