There may be anomalies between the trends identified in Pritchard’s and Williams’ study, mentioned in the last post, and a recent report in the Times (“Child abuse deaths still rising despite action after Baby P” 1/2/10). According to the Times article almost four children per week died or suffered serious injury through abuse or neglect in 2009, said to be a 23% rise on 2008 (186 cases of death or serious injury in England in 2009 compared with 144 in 2008).
It is not clear on what basis these figures, apparently from Ofsted, are compiled or what the long-term trends in this data are. It is, however, said that they were obtained under a Freedom of Information Act request, suggesting that they are not routinely published.
Regularly published, reliable statistics on child abuse related deaths and injuries are essential information for anyone concerned in providing or monitoring child protection services. If Ofsted is in possession of this type of data it should be made publicly available on a regular basis.
Monday, 8 February 2010
Sunday, 7 February 2010
Child deaths - trends
We must be cautious in drawing strong conclusions from the analysis of WHO data on child abuse related deaths (CARD) undertaken by Colin Pritchard and Richard Williams (British Journal of Social Work - forthcoming - reported by the BBC on 4th February 2010). The analysis shows not only a welcome reduction in the rate of CARD over the period 1974-2006, but an improvement in the ranking of England and Wales in this respect relative to other developed countries.
There are many issues with international comparisons of this sort, not least different diagnostic and coronial practices in different jurisdictions. While Pritchard and Williams are right to point out that their findings may be a reason for "cautious satisfaction about the progress being made" it seems to me a step too far to conclude that this is reliable evidence of improvements in the child protection systems in England and Wales. There are too many compounding variables to be sure what the causes of such trends are.
It would be very sad if this careful academic study was used by careless commentators to foster any sense of complacency about how effective our child protection services are. The popular press are only too ready to draw unjustified conclusions from the thankfully rare cases where the child protection system fails disastrously. Those of us who deplore such scaremongering must be careful not to make the same mistake in the opposite direction.
There are many issues with international comparisons of this sort, not least different diagnostic and coronial practices in different jurisdictions. While Pritchard and Williams are right to point out that their findings may be a reason for "cautious satisfaction about the progress being made" it seems to me a step too far to conclude that this is reliable evidence of improvements in the child protection systems in England and Wales. There are too many compounding variables to be sure what the causes of such trends are.
It would be very sad if this careful academic study was used by careless commentators to foster any sense of complacency about how effective our child protection services are. The popular press are only too ready to draw unjustified conclusions from the thankfully rare cases where the child protection system fails disastrously. Those of us who deplore such scaremongering must be careful not to make the same mistake in the opposite direction.
Wednesday, 3 February 2010
Clear messages about the Family Courts
Two recent research studies give a clear picture of children and young people's views of the family courts.
Reporting the interim findings of a study undertaken by Dr Julia Brophy of Oxford University and funded by the Children's Commissioner for England, a press release by 11 Million states that almost all the children interviewed so far are opposed to the media being present in the family courts and to reporting their findings. The children interviewed were also very opposed to journalists having access to medical and other expert reports, saying that they would unwilling to share information with doctors and other professionals if they thought the press would have access to it.
In similar vein another recent study of children's views of family court cases, this time conducted by Cafcass (Private Law Consultation: "How It Looks To Me"), reports that many children and young people not only wanted more opportunities to tell the court their views, but also were concerned about the confidentiality of the information put before the court.
The overwhelming weight of all the available research evidence points in the same direction. Children and young people subject to family court proceedings are intensely concerned about their privacy. They fear having initmate details of family life aired in public and, if they think that is likely to happen, they will keep quiet. Research conducted as part of a consultation in 2007 was taken very seriously by the then Justice Secretary, Lord Falconer. The Government's response to this consultation concludes: "In line with the overwhelming evidence from children and young people and the groups which support, protect and represent them, we now believe that the right course of action is not to proceed with this proposal (to allow the media access)."
Sadly Jack Straw has taken a different view and legislation currently before Parliament will, if passed, permit the media wide access to the family courts. The effect on both private and public cases will be substantial. In particular there is a very real danger that abused and neglected children will not co-operate fully with the court process, making it much harder to protect them and to ensure that the court decides in their best interests.
Reporting the interim findings of a study undertaken by Dr Julia Brophy of Oxford University and funded by the Children's Commissioner for England, a press release by 11 Million states that almost all the children interviewed so far are opposed to the media being present in the family courts and to reporting their findings. The children interviewed were also very opposed to journalists having access to medical and other expert reports, saying that they would unwilling to share information with doctors and other professionals if they thought the press would have access to it.
In similar vein another recent study of children's views of family court cases, this time conducted by Cafcass (Private Law Consultation: "How It Looks To Me"), reports that many children and young people not only wanted more opportunities to tell the court their views, but also were concerned about the confidentiality of the information put before the court.
The overwhelming weight of all the available research evidence points in the same direction. Children and young people subject to family court proceedings are intensely concerned about their privacy. They fear having initmate details of family life aired in public and, if they think that is likely to happen, they will keep quiet. Research conducted as part of a consultation in 2007 was taken very seriously by the then Justice Secretary, Lord Falconer. The Government's response to this consultation concludes: "In line with the overwhelming evidence from children and young people and the groups which support, protect and represent them, we now believe that the right course of action is not to proceed with this proposal (to allow the media access)."
Sadly Jack Straw has taken a different view and legislation currently before Parliament will, if passed, permit the media wide access to the family courts. The effect on both private and public cases will be substantial. In particular there is a very real danger that abused and neglected children will not co-operate fully with the court process, making it much harder to protect them and to ensure that the court decides in their best interests.
Sunday, 24 January 2010
Edlington - the Serious Case Review
I've always been a bit hesitant when I hear calls for the full serious case review report to be made public. Clearly the privacy of children and members of the public needs to be protected and I can see sense in the argument that some measure of confidentiality is necessary in order to persuade professionals and practitioners to be open and frank.
But having read the Executive Summary of the serious case review report in the Edlington case I feel some sympathy for those who advocate making the full report public. This Executive Summary is much more "summary" than it is "executive". It contains hardly any descriptive detail of the case and devotes most of its eleven pages to eighteen recommendations to the Doncaster Local Safeguarding Children Board and Doncaster Children's Services. I doubt whether members of the public are likely to make much sense of these. They are largely concerned with the detail of management and bureaucratic process and expressed in what I call "local government speak".
The guts of the report are in Section 8: five short paragraphs amounting to about a page or 500 words in all. These fail to provide:
An executive summary of this sort is of little value; it must have been possible to have produced a more detailed document without breaching confidences. Rather than blandly resisting calls for the full report to be published, Ed Balls should order that the executive summary be re-written as an informative document.
But having read the Executive Summary of the serious case review report in the Edlington case I feel some sympathy for those who advocate making the full report public. This Executive Summary is much more "summary" than it is "executive". It contains hardly any descriptive detail of the case and devotes most of its eleven pages to eighteen recommendations to the Doncaster Local Safeguarding Children Board and Doncaster Children's Services. I doubt whether members of the public are likely to make much sense of these. They are largely concerned with the detail of management and bureaucratic process and expressed in what I call "local government speak".
The guts of the report are in Section 8: five short paragraphs amounting to about a page or 500 words in all. These fail to provide:
- any sort of chronology
- any account of the nature of the involvement of various agencies (a list is all that is provided)
- any details of mistakes, departures from procedure or service failings
- an explanation of why the boys were with foster parents
- an analysis of why there was apparently no assessment of their needs, given that they were in the care of the local authority
- why what appear to have been a number of incidents of physical and emotional abuse were not responded to
- any details of section 47 inquiries, planning meetings, child protection conferences, opportunities for legal action - if there were any
- what decisions were taken and why
An executive summary of this sort is of little value; it must have been possible to have produced a more detailed document without breaching confidences. Rather than blandly resisting calls for the full report to be published, Ed Balls should order that the executive summary be re-written as an informative document.
Tuesday, 19 January 2010
The Lessons of Edlington
Accounts of the serious case review appear to suggest that, as in many child protection disasters, professionals in this case had lost situational awareness in their dealings with the family of the two boys. In particular the BBC Newsnight report (18th Jan 2010) mentioned focusing on the needs of the mother, not the boys, and failing to take sufficiently seriously reports of their previous violence.
The crucial question, however, is why professionals lost situational awareness. As usual there is much less information on this. We do know that there were organisational problems and over-dependence on temporary staff, but what has been reported so far gives no real clue to the reasons why those dealing with the boys failed to respond appropriately.
There is little point in simply saying "they should have focused on the children". That is both obvious and unhelpful. What is required is an analysis of why they failed to do so, and at present there is little indication that such an analysis exists in the SCR.
From the study of disasters in aviation and medicine we know that when decision makers are under stress and high workload they are prone to missing incoming information, resulting in the loss of situational awareness involving confirmation bias (all the evidence appears to support the current hypothesis) and naturalistic decision making (pattern matching). People have a tendency to reason uncritically from past experience to an obvious (but sometimes mistaken) conclusion. "This case is like a case I dealt with last year - I'll do what I did then."
There are techniques for minimising these tendencies and people can be trained to recognise when they are losing situational awareness and to act accordingly. But at present the Human Factors approach (HF) has been little studied in the context of child protection and is not widely applied. The Edlington case, as so many others, is one more reason why we need to get together with HF experts from aviation and other fields and to learn from their experience.
The crucial question, however, is why professionals lost situational awareness. As usual there is much less information on this. We do know that there were organisational problems and over-dependence on temporary staff, but what has been reported so far gives no real clue to the reasons why those dealing with the boys failed to respond appropriately.
There is little point in simply saying "they should have focused on the children". That is both obvious and unhelpful. What is required is an analysis of why they failed to do so, and at present there is little indication that such an analysis exists in the SCR.
From the study of disasters in aviation and medicine we know that when decision makers are under stress and high workload they are prone to missing incoming information, resulting in the loss of situational awareness involving confirmation bias (all the evidence appears to support the current hypothesis) and naturalistic decision making (pattern matching). People have a tendency to reason uncritically from past experience to an obvious (but sometimes mistaken) conclusion. "This case is like a case I dealt with last year - I'll do what I did then."
There are techniques for minimising these tendencies and people can be trained to recognise when they are losing situational awareness and to act accordingly. But at present the Human Factors approach (HF) has been little studied in the context of child protection and is not widely applied. The Edlington case, as so many others, is one more reason why we need to get together with HF experts from aviation and other fields and to learn from their experience.
Tuesday, 8 December 2009
Serious Case Reviews - a poor tool for learning?
Drawing on a report prepared in October 2009, the Care and Social Services Inspectorate Wales Annual Report 2008-2009 makes some interesting remarks on the value of Serious Case Reviews (SCRs).
The inspectorate (CSSIW) says that "...there is a high level of agreement across Wales about the fact that the current arrangements are not working". It complains of the "...huge amounts of time and resources ... spent in conducting these reviews ... with little clear evidence to show how they are leading to improvements in systems and practice ...." The report concludes: "Time and again serious case reviews identify the same issues as contributing to not protecting children, yet still the problems keep recurring."
What a contrast in thinking here with the approach of Ofsted in the October 2009 report Learning lessons from serious case reviews: year 2. Ofsted has somehow contrived to turn what might have been valuable research into the effectiveness (or non-effectiveness) of SCRs into a tick-box, process-focused exercise comparable to marking GCSE coursework. CSSIW, on the other hand has recognised that the whole point is whether or not SCRs promote learning which improves services which make children safer.
The Ofsted report lectures us on how to write a good SCR while forgetting what the purpose of an SCR is. Its pedantry is unmistakable in the examples of comments it gives on SCRs judged to be "outstanding" (paragraph 101), which concentrate on whether reports addressed issues thematically, whether sub-headings were used, whether summaries are clear and whether the reports were well written.
Maybe the inspector was a former teacher? I'd give Ofsted 3 out of 10 and say "Must try harder".
The inspectorate (CSSIW) says that "...there is a high level of agreement across Wales about the fact that the current arrangements are not working". It complains of the "...huge amounts of time and resources ... spent in conducting these reviews ... with little clear evidence to show how they are leading to improvements in systems and practice ...." The report concludes: "Time and again serious case reviews identify the same issues as contributing to not protecting children, yet still the problems keep recurring."
What a contrast in thinking here with the approach of Ofsted in the October 2009 report Learning lessons from serious case reviews: year 2. Ofsted has somehow contrived to turn what might have been valuable research into the effectiveness (or non-effectiveness) of SCRs into a tick-box, process-focused exercise comparable to marking GCSE coursework. CSSIW, on the other hand has recognised that the whole point is whether or not SCRs promote learning which improves services which make children safer.
The Ofsted report lectures us on how to write a good SCR while forgetting what the purpose of an SCR is. Its pedantry is unmistakable in the examples of comments it gives on SCRs judged to be "outstanding" (paragraph 101), which concentrate on whether reports addressed issues thematically, whether sub-headings were used, whether summaries are clear and whether the reports were well written.
Maybe the inspector was a former teacher? I'd give Ofsted 3 out of 10 and say "Must try harder".
Thursday, 3 December 2009
Social Work Task Force
It is hard not to be pleased by many of the recommendations of the Social Work Task force. The idea of a national college - it should be a Royal College - is a good one and reform of pay and conditions to help retain experienced staff at the front line has to be warmly welcomed.
I was also pleased to read Deidre Sanders piece on the Task Force's recommendations in the Sun. I have to admit that I had more than a few reservations when Ed Balls announced that she would be a member, but her ringing endorsement of the Task Force's conclusions is to be welcomed. And she makes some sensible comments, especially recognising that child protection social workers are "hard-working" and do "a tough and often dangerous job".
The Guardian speaks of increasing "...the self-esteem of a profession knocked by widespread public criticism". We need to be careful, however, to remember that the current demoralised state of child protection social work is not a self-inflicted wound. Successive governments have failed the profession by under-resourcing one of the most difficult and challenging tasks that society has to offer, while at the same time bureaucratising the work with poorly designed frameworks and complex regulations. Which brings me to the Integrated Children's System (ICS) ....
The Task Force has recognised some of the problems with ICS and associated computer software. But it is not simply a matter of spending a little more on software development to achieve a bit more user-friendliness. ICS is not just badly engineered, it is misconceived. At the heart of this misconception is the naive assumption that child protection social work involves simply collecting discrete items of information which accumulate into an assessment of risk and need. On the contrary child protection social workers deal with complex, uncertain and largely unstructured information which has to be carefully assessed and weighed in taking what are often momentous decisions. The design of any computer software to support the child protection process has to begin by recognising this.
Then there is the issue of caseload. The Task Force's report says some sensible and interesting things about caseload and workload. Nearly half of the children's social workers responding to one of the Task Force's surveys had caseloads in the high teens, twenties or thirties. And shockingly 49% worked more than their contracted hours with 9% actually working an extra working day in order to cope. But the Task Force's report shies away from recommending smaller caseloads, preferring instead to talk in terms of improved "caseload management".
There is no point in introducing improvements in terms and conditions, training and public recognition if child protection social workers continue to be chronically over-worked. And abused and neglected children have a right to a social worker who has the time and space to give them the attention they need and deserve. I think the Task Force should have been much more forceful on this issue. There is clear evidence of a culture of over-work in which people are holding too many cases to manage safely. This needs to be tackled as a priority.
I was also pleased to read Deidre Sanders piece on the Task Force's recommendations in the Sun. I have to admit that I had more than a few reservations when Ed Balls announced that she would be a member, but her ringing endorsement of the Task Force's conclusions is to be welcomed. And she makes some sensible comments, especially recognising that child protection social workers are "hard-working" and do "a tough and often dangerous job".
The Guardian speaks of increasing "...the self-esteem of a profession knocked by widespread public criticism". We need to be careful, however, to remember that the current demoralised state of child protection social work is not a self-inflicted wound. Successive governments have failed the profession by under-resourcing one of the most difficult and challenging tasks that society has to offer, while at the same time bureaucratising the work with poorly designed frameworks and complex regulations. Which brings me to the Integrated Children's System (ICS) ....
The Task Force has recognised some of the problems with ICS and associated computer software. But it is not simply a matter of spending a little more on software development to achieve a bit more user-friendliness. ICS is not just badly engineered, it is misconceived. At the heart of this misconception is the naive assumption that child protection social work involves simply collecting discrete items of information which accumulate into an assessment of risk and need. On the contrary child protection social workers deal with complex, uncertain and largely unstructured information which has to be carefully assessed and weighed in taking what are often momentous decisions. The design of any computer software to support the child protection process has to begin by recognising this.
Then there is the issue of caseload. The Task Force's report says some sensible and interesting things about caseload and workload. Nearly half of the children's social workers responding to one of the Task Force's surveys had caseloads in the high teens, twenties or thirties. And shockingly 49% worked more than their contracted hours with 9% actually working an extra working day in order to cope. But the Task Force's report shies away from recommending smaller caseloads, preferring instead to talk in terms of improved "caseload management".
There is no point in introducing improvements in terms and conditions, training and public recognition if child protection social workers continue to be chronically over-worked. And abused and neglected children have a right to a social worker who has the time and space to give them the attention they need and deserve. I think the Task Force should have been much more forceful on this issue. There is clear evidence of a culture of over-work in which people are holding too many cases to manage safely. This needs to be tackled as a priority.
Subscribe to:
Posts (Atom)