Thursday, 6 June 2019


The county of Northamptonshire has featured on the pages of this blog on a number of occasions. 

The council has, to put it bluntly, run out of money. In 2018 it announced that the only way to balance its books was to make drastic cuts to its services, including children’s services, to achieve a position in which only the minimum legally required services were provided. Subsequently it appears that a major reorganisation of local government in Northamptonshire is planned, with the existing council being abolished and replaced with new arrangements.  

It is against this background that two children, with whom Northamptonshire’s children’s services had contact during 2017 and 2018, died at the hands of their carers. 

Yesterday, two serious case review reports were published. The first examined the circumstances of the death of Dylan Tiffin-Brown, aged 2, who died of cardiac arrest following an assault by his father in December 2017. The second looked into the death of  Evelyn-Rose Muggleton, aged one year, who died in April 2018 after being battered by her mother’s partner.

A good overview of the reports and other comments is provided in a Guardian article by Patrick Butler.

The reports list similar failings in both cases: poor decision-making, poor information sharing, being too focused on the adults, not seeing things from the child’s perspective. Mostly, however, they do not try to explain why these failings occurred. A possible exception, however, is found in the report on Dylan Tiffin-Brown (Child Ak) although the relevant paragraph (3.20) is brief and sketchy. The paragraph lists ‘local strategic level factors’ as potentially impacting on the effectiveness of services. These are:
  • high turnover of staff
  •  large numbers of agency staff
  •  significant levels of management sick leave
  •  ineffective case management and priority monitoring systems compounding problems and resulting in a lack of accuracy in identifying high risks or the need for urgency
  • high caseloads
  •  a focus on ‘imminent danger’
  • lack of appropriate escalation 

Sadly that is it! Just a list is given with no discussion or analysis. And then the report reverts to considering what might be described as individual practice and management failings.

Interestingly, the list accords with Ofsted’s findings in Northamptonshire, which were set out in a letter to the council following a “focused visit” in October 2018. An important paragraph in this letter states:
Against a backdrop of recent significant financial uncertainty and changes in
leadership at corporate and managerial levels, services considered during this visithave significantly declined in the past two years since the single inspection in 2016. This uncertainty has contributed to significant shortfalls in social work capacity across the service, resulting in unmanageable caseloads and high volumes of unallocated and unassessed work. Senior leaders are aware of these serious weaknesses and have taken remedial action to respond. However, this has not been effective or with sufficient urgency or rigour. Consequently, at the time of this focused visit there was insufficient capacity in the MASH and the first response teams to meet the needs of children and families.”

Another paragraph in the Ofsted letter gives more detail of the findings:
Social work caseloads in the first response teams are too high, with many social workers responsible for between 30 and 50 children. Social workers reported to inspectors that they were ‘overwhelmed’ and ‘drowning’. As a result, visits to children are not sufficient, and rushed home visits lead to superficial, weak assessments, which results in delays in providing support.”
Clearly these are not just ‘contextual factors’, but deep seated substantial organisational problems which cannot fail to impact the quality of practice. So it is deeply surprising to find, as reported in Patrick Butler’s Guardian article, the newly appointed Director of Children’s Services in Northamptonshire responding to the publication of the two reports by saying that "financial considerations" had played no part in the tragedies. She is also quoted in the Daily Mail as saying that there had been a number of “disciplinary outcomes” and that  people had left the authority in relation to these cases.

It appears that those at the top of Northamptonshire’s management pyramid are in denial about why these children received substandard services. In my view, the Director of Children’s Services should not have apologised for poor decision-making and poor information sharing, with the implication that practitioners and first line managers were at fault. She should have pointed to high caseloads, high turnover of staff, high use of agency workers, and to inefficient systems and working practices which result in staff burnout and high levels of sickness absence. Some acceptance that these deep seated issues - and their origins in the collapsing finances of the council - played a significant causal role in what went wrong would have been the beginning of understanding. It would have been the first step to getting things right.

Professor James Reason, a world leading expert in organisational safety tells us that there are two approaches to creating safe services: the person approach and the system approach*. He argues that the person approach, which focuses on identifying the errors of individuals and blaming them for “forgetfulness, inattention, or moral weakness” is not effective. Active failures, he says are like mosquitoes. “They can be swatted one
by one, but they still keep coming.” On the other hand the system approach “… concentrates on the conditions under which individuals work and tries to build defences to avert errors or mitigate their effects”. He concludes that the best remedies for safety failings are to create more effective defences. As he says: “… to drain the swamps in which (the mosquitoes) breed.” Those swamps are what he calls “latent conditions”; by which he means things like high caseloads, high turnover of staff, high use of agency workers, inefficient systems and working practices, staff burnout and high levels of sickness absence.

They need to read some of Reason’s articles in Northamptonshire!

*British Medical Journal 2000;320:768-770 (18 March)