Looking at two recent tragedies - the Grenfell Tower disaster and the deaths of 39 migrants trapped in a refrigerated container – he argues that there is… "a deeper cultural tendency to focus on the proximate causes of social tragedies and to ignore, or downplay, more distant but often more significant issues”.
In the case of Grenfell Tower this tendency, he argues, is evidenced by the way in which the inquiry has first focused on the actions (or inactions) of individual and groups of firefighters, while shelving issues relating to the building’s cladding, the deregulation of fire safety and failures of policy and ministerial oversight for the inquiry’s second stage.
In the case of the migrants’ deaths he argues that the tendency is evidenced by focus on the ‘evil’ smugglers, rather than on factors which predispose to creating a demand for smuggling people into countries like Britain.
It doesn’t take a lot of thought to see how this analysis can be extended to child protection tragedies. So often the focus is on individual workers’ failings and shortcomings, while there is frequently a tendency to ignore the deeper causes – factors such as pressurised working environments, excessive caseloads, lack of resources and political malaise.
Understanding the deeper causes of any tragedy requires an open responsive safety culture in which there is a willingness to go far beyond laying the blame on the usual suspects. We need to focus on uncovering and analysing information which can really help to make systems safer. And to do that we have to have an open, just reporting culture in which people feel free to talk about what went wrong without the fear that they will be singled out and blamed if they do.
We need to ask the question why? again and again and again. Why did a particular worker fail to see something which with the benefit of hindsight seems obvious? Why was a communication ignored or misunderstood? Why did a particular decision seem reasonable at the time?
The answers to these ‘why’ questions are likely to be found in the design of systems, the availability of resources and the cultures of organisations – not in superficial accounts of individual failings.