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 [1]
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….” [2] 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 [3] 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 [4] 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”. [5] 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.
Notes
[1] Flin, R. O'Connor, P. and Crichton, M. Safety
at the Sharp End (Ashgate 2008)
[2] 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/
[3] 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.
https://academic.oup.com/bjsw/article/40/2/352/1645645/Performing-Initial-Assessment-Identifying-the
[4] Dekker, S. Just Culture: Balancing
Safety and Accountability (Ashgate 2007)
[5] Reason J. “Human error: models and
management” British Medical Journal
2000; 320:768–70
