Hillsborough

The revelations of a toxic culture of cover up and denial and blame in the South Yorkshire police force, which are now revealed following the Hillsborough inquests, contribute greatly to our understanding of what went wrong in Rotherham, a town served by that same police force, where young people were ruthlessly sexually exploited without effective action by the police and other agencies to protect them.

Clearly on that fateful day in 1989 terrible mistakes – errors of judgement - were made in the policing of the football match. If only the reaction of the police had been to be immediately open and frank about the disaster, to be honest about what may have gone wrong and to look for safety lessons, not scapegoats, it could all have been so different. A great deal of needless unbearable pain and suffering could have been avoided.

Whether it be football crowd control or responding to child abuse and neglect, the message from recent events is clear. There are no greater enemies of public safety than secrecy, fear, blame, denial, conspiracy and self-protection.

Human factors thinking in child protection - cheaper and quicker than blue skies research

NSPCC Scotland’s Matt Forde, writing in The Herald, makes the astute observation that if inquiries into child protection failures worked, the problem of preventing child abuse and neglect would have been solved by now. He says: “Dozens of cases, over more than four decades, cite familiar problems – professionals not talking to each other, not putting the picture together and missing opportunities to act.”

Matt goes on to recommended increased spending on research into the causes and consequences of abuse and neglect – undoubtedly a very worthy cause – but my conclusion from his premise is somewhat different. 

If inquiries into the causes of disasters have not worked, we need to think of better ways of gaining an understanding of why things go wrong. That’s exactly what they realised in civil aviation in the 1980s and since then they have practiced human factors thinking [*] which helps all kinds of employees – not just pilots – to recognise how and why mistakes happen in the workplace and what can be done to put them right.

Human factors thinking is not about blue skies research. It is based on a number of simple skills, stemming from the insights of the psychology of human error, which are practiced daily by everybody involved in a safety critical activity, like child protection. 

It ain’t rocket science and it’s a lot cheaper and quicker than conducting huge studies into the causes and effects of abuse. And we could all be doing it, as they do in other industries, if only the leaders of the children’s sector and their political rulers would open their minds and see the sense of it.

* See Flin et al Safety at the Sharp End: a guide to non-technical skills Farnham, Ashgate, 2008 - for a very readable introduction.

Child Refugees

James Brokenshire MP, a Home Office minister, is reported in the Guardian as saying in the recent House of Commons debate that for Britain to accept refugee children already in Europe would “…. inadvertently create a situation in which families see an advantage in sending children alone, ahead and in the hands of traffickers, putting their lives at risk by attempting treacherous sea crossings to Europe which would be the worst of all outcomes”.

http://www.theguardian.com/world/2016/apr/25/tories-vote-against-accepting-3000-child-refugees

That’s a bit like saying that we shouldn’t provide medical care to the victims of motor accidents because to do so might encourage people to drive less safely!

The Shadow Immigration Minister, Keir Starmer MP has my support. He is reported as saying that Brokenshire is arguing that we must abandon these children to their fate. I’m glad that Starmer and many other Parliamentarians, such as Alf Dubbs and Yvette Cooper,  are standing up to this indefensible and cruel policy adopted by the British government.

Education Committee - written evidence from the Safer Safeguarding Group

The Safer Safeguarding Group’s written evidence to the House of Commons Education Committee enquiry into the reform of children’s social work can be found on the Committee’s website.

http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/education-committee/social-work-reform/written/29966.html

The group concludes that the Government lacks a clear focus on safety in children’s services and fails to take account of a human factors approach to making children’s social work safer. On a number of important issues – training, recruitment and retention, learning – the Government fails to provide a clear analysis of the problems and any clear vision of how safer and higher quality children’s social work can be brought about.

The Safer Safeguarding Group’s evidence stresses the need for cultural change and the importance of helping children’s social workers talk more freely and openly about the errors they make so that they can learn more readily from then and discover the error traps that lurk within their organisations.

The group commends to the Committee inexpensive and evidence-based approaches to learning that have found favour in other safety critical industries – human factors training (mandatory in civil aviation) and Near Miss Reporting, which has played a significant role in exposing error traps in fields such as civil aviation and anaesthesia. 

Because the protection and safeguarding of children is a multi-agency activity, involving the practice of many different types of professionals and agencies, the group believes that a learning culture based on an understanding of human factors and near-miss reporting should be incorporated into multi-agency training and management of cross-agency work, not just social work training.

Retention, not recruitment: that's the problem

Moira Gibb, who chaired the Social Work Task Force a few years ago, has hit the nail on the head in giving evidence to the House of Commons Education Committee regarding the Government’s plans for the accreditation of children’s social workers. She is quoted in Community Care as telling the Committee that the problem is that there are plenty of people who join the profession but they don’t stay; and that what is needed is people who have long experience, not people who practice for a couple of years and then move on.

  

She is absolutely right to recognize that it is difficulties retaining experienced children’s social workers that is the problem. And I believe that retaining people requires careful thought about how jobs are designed and about how staff are developed and supported; not just quick apparent fixes with silly natty titles.

I've been banging on about the importance of retention since 2009, without much success. I hope Moira Gibb, will have better luck in getting people to listen to her. Who knows?

Learning from mistakes

The tragic case of Ayeeshia Jane Smith has received wide coverage in the British press following the convictions of her mother and stepfather in connection with her death.

http://www.bbc.co.uk/news/uk-england-stoke-staffordshire-35938209

Only limited information about the involvement of statutory services is available at this stage, but the case appears to have all the hallmarks of one in which there had been substantial involvement prior to the child’s death. The child had been in care and then returned home; and she was subject to a child protection plan. Inevitably the papers are asking the question ‘why?’ and some are comparing the case to the Baby Peter tragedy.

http://www.dailymail.co.uk/news/article-3530859/Why-did-hand-baby-Social-workers-took-Ayeeshia-violent-drug-addled-mother-returned-despite-string-warnings-months-brutally-killed.html

An MP is calling for a public inquiry to be set up.

http://www.bbc.co.uk/news/uk-england-stoke-staffordshire-36006198

Until the Serious Case Review (SCR) report is published we can only speculate about the extent and nature of statutory services’ involvement. However, I believe that we are unlikely to learn much new about how to make services safer from either the SCR or from any form of inquiry. Almost certainly the kind of mistakes that have happened in this case are comparable to those that have happened in all the similar cases dating back to Maria Colwell in the early 1970s and beyond. Professionals have lost situation awareness, made poor decisions and become embroiled in communication foul-ups. Simply recounting it all again will not make it less likely that they will reoccur.

Instead of putting our faith in formal administrative reviews or legalistic inquiries, it would be much better if we applied what we know about the psychology of human error and addressed the questions of how people working in child protection organisations make mistakes and how they can work more safely. We need to address the question “why?” Why are ‘obvious’ signs of abuse and neglect missed? Why do individual practitioners and groups of professionals sometimes become strongly attached to misperceptions and misjudgements which seem to them at the time very sensible but which are hard to justify with the benefit of hindsight? Why do communications become confused or obscured?

I am delighted to see that the British Department for Health is now strongly embracing a human factors approach to safety and I was impressed by a speech made by the Secretary of Sate for Health, Jeremy Hunt, in which he argues is that patient safety is compromised because there is more interest in blaming than in learning.

http://www.ukpol.co.uk/2016/03/10/jeremy-hunt-2016-speech-on-a-blame-culture-in-the-nhs/

Quoting Matthew Syed’s book Black Box Thinking Hunt draws heavily on the experience of the airline industry saying: “… the airline industry realised that if it was going to reduce airline fatalities, it needed to change its culture. They realised that ‘human factors’, rather than technical or equipment failure had been at the heart of the problem.”

He goes on to argue that in order to improve safety in the NHS there needs to be a cultural change involving two elements: (i) openness and transparency about where problems exist and (ii) a true learning culture to put them right. He explicitly draws on the experience of civil aviation in developing human factors approaches to safety, and announces a proposal to create an organisation modelled on the Air Accident Investigation Branch to investigate accidents and safety concerns in health care (something that I suggested for child protection in 2010 - http://chrismillsblog.blogspot.co.uk/2010/04/my-election-manifesto.html). He stresses that: “Other industries – in particular the airline and nuclear industries – have learned the importance of developing a learning culture and not a blame culture if safety is to be improved.”

Hunt has told the House of Commons that the Government proposes developing this type of safety culture in the British National Health Service (NHS). That is a development greatly to be welcomed.

What is less welcome, however, is that there appears to be little by way of parallel developments from the Department for Education, which in England is responsible for children’s social care and child protection. Indeed a significant disconnect appears to be emerging between the safety approaches being developed in the NHS and attempts to improve safety in child protection and children’s social care, which are still deeply rooted in old-fashioned administrative approaches to human error and a thinly disguised blame culture.

Children’s sector leaders are by and large dismissive or disinterested in human factors thinking. There is no knowledge or interest within Ofsted about this type of approach. Civil servants have told me and other campaigners that they believe human factors training is of marginal value to child protection and that learning from error is adequately taken care of by serious case reviews! Now, while closely linked services within the purview of the Department of Health are to be taken down the fruitful path that has been well trodden by the airline and nuclear industries and which is a proven route to greater safety, it appears that children’s services are to be allowed to languish in a safety time warp.

In my view officials from the Department for Education should be meeting urgently with their counterparts in the Department for Health and trying to go up the steep learning curve they need to climb to begin to embrace the ideas that Jeremy Hunt has so clearly articulated.