Liam Fee, a two-year-old from Glenrothes, Fife, died at the hands of his carers in 2014.
Reading the learning summary from the significant case review (published last month) does not provide any stunning new insights. It is full of the same old ‘lessons’ which have been rehearsed and rehearsed in hundreds of similar documents.
Disguised compliance is an important theme of the report. Liam’s carers were skilful deceivers. They lied and manipulated and hoodwinked, carefully playing one agency against another, one professional against another, pretending to co-operate while preventing anybody recognising the child’s true situation and so preventing agencies responding appropriately.
It all goes to show just how easy it is to lose situation awareness in child protection. Professionals are not only dealing with human behaviour, which at the best of times is difficult to perceive, understand and predict correctly, but they are faced with people who are sometimes hell-bent on deliberately misleading them about what behaviour is actually occurring and why.
Child protection, like other safety critical activities, needs to adopt specific measures to guard against loss of situation awareness. These should focus on improving workers’ non-technical skills. In their excellent guide to non-technical skills Flin et al  provide a useful list of ways of maintaining situation awareness during the performance of safety critical tasks. These include:
- having a good briefing
- minimising distraction and interruption
- frequent opportunities to test and compare the mental model of the situation with the available evidence
- encouraging everybody to speak up and voice reservations and uncertainties
- avoidance of unnecessarily tight timescales
In child protection in Britain there has not been much focus on any of these. Although serious case reviews often draw attention to ‘information sharing’ problems, I don’t know of any research that has looked at how child protection professionals are briefed by others or of any discussions about how briefings can be improved. The Liam Fee report speaks of insufficient attention being given to existing information, saying that it was neither reviewed nor considered before decisions were taken. It also says that professionals had an inadequate understanding of the roles and responsibilities of other agencies and that they were often unclear about who was in charge of the case. A good briefing would have addressed these issues.
There is very little discussion in the child protection literature about the impact on professionals of distraction and interruption. I could see no obvious discussion of it in the Liam Fee report. Although taking eyes off the ball is a common theme of child protection tragedies, the causes are seldom examined. The extent to which workers are distracted by bureaucratic issues, organisational dynamics and events occurring in other cases is not routinely assessed. Rather than trying to minimise interruption and distraction, local authorities in Britain seem to have compounded these problems by creating noisy shared offices and sometimes even opting for hot-desking. Unnecessary procedures, meeting performance targets, poorly designed IT systems and form-filling all serve to distract workers from doing what they should be doing – focusing on the child. Completing complicated assessments can be time consuming, often with no guarantee that the result will be particularly informative. Sometimes even meetings and conferences are distracting and counterproductive, using up a lot of time without clear purpose.
Checking out the mental model of a situation is vital, but research suggests that this happens less often in child protection than it should. There is often pressure not to challenge or dissent from a dominant view of a child’s situation and the accompanying risk of confirmation bias (the tendency for all new evidence to be seen as confirming the original hypothesis). As Eileen Munro once remarked: “… the most striking lesson to be learned from inquiry reports … is how resistant people are to altering their beliefs. Inquiry reports repeatedly comment on the workers' reluctance to alter their views….”  Performance targets and high workloads also reduce opportunities to test and compare the mental model of the situation with the available evidence. And, as Broadhurst et al  discovered: “Meeting performance targets, especially when the volume of incoming work threatens to exceed capacity, workers must make quick categorizations based on limited information; this will inevitably mean that some cases are filtered out that may require intervention.” Perhaps this is what the author of the Liam Fee review means by talking of a "lack of professional curiosity"?
There is, in Britain, often a lamentable failure to encourage everybody to speak up and voice reservations and uncertainties about a case, especially when something may have gone wrong. The pervasive culture in British local authorities, the police and health services is still one of blame. Workers continue to feel the need to ‘cover their backs’. We are still very far from what Dekker  calls ‘a just culture’ and much management practice is still rooted in what Reason calls ‘the person approach’ to organisational safety, focusing on “…the errors and failings of individuals” and blaming them for “forgetfulness, inattention, or moral weakness”.  The Liam Fee review speaks of a reluctance of workers to challenge the explanations given by his mother and her partner. That suggests that there was more generally a reluctance to challenge the status quo. Organisations have to work very hard to encourage people to speak-out. They have to build-up the confidence of workers and managers to challenge and be challenged and to reappraise and backtrack if doubts arise about the dominant view of a case.
Flin et al’s final recommendation for maintaining situation awareness is to avoid unnecessarily tight timescales. Sadly, in Britain, the completion of formal assessments in child protection cases is often accompanied by unforgiving timetables imposed by managers and civil servants which result in ‘hurry-up syndrome’. This is often exacerbated by rising demand for services, shortfalls in staffing and other resources and the consequent need to rush work in order to cope with unmanageable workloads.
It is not surprising that professionals dealing with Liam Fee lost situation awareness, believing as they did that they were dealing with a needy family rather than a dangerous case of abuse and neglect. Because it is all too easy to lose situation awareness in child protection, organisations need to take clear and deliberate steps to create systems which help to maintain it. It is no good just deploring the practice of individual workers who have held on to the wrong mental model of a case. Rather we all need to ask ourselves why and how loss of situation occurs and work together to create ways of reducing the likelihood of it happening in future.
 Flin, R. O'Connor, P. and Crichton, M. Safety at the Sharp End (Ashgate 2008)
 Munro, E. (1996) “Avoidable and unavoidable mistakes in child protection work”
British Journal of Social Work 26 (6) http://eprints.lse.ac.uk/archive/00000348/
 K. Broadhurst D. Wastell S. White C. Hall S. Peckover K. Thompson A. Pithouse D. Davey “Performing ‘Initial Assessment’: Identifying the Latent Conditions for Error at the Front-Door of Local Authority Children's Services” Br J Soc Work (2010) 40 (2): 352-370.
 Dekker, S. Just Culture: Balancing Safety and Accountability (Ashgate 2007)
 Reason J. “Human error: models and management” British Medical Journal 2000; 320:768–70