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.
