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:

• 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
  

In the absence of this sort of information it is impossible even for some-one who understands the system to gain a rudimentary idea of what happened.

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.

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.

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".

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.

The Ofsted issue - inspection and quality in child protection

The heated row between Ofsted and ADCS continues. ADCS president, Kim Bromley-Derry, has forcefully criticised Ofsted's Comprehensive Area Assessment (CAA) methodology as flawed and condemned some draft reports as not making sense. ADCS has published a position paper on inspection which makes some good points. It criticises Ofsted's inspection frameworks for being "process-driven" and for using conformity to process as a proxy measure for quality. It is argued that this leads to inspectors falsely concluding that a process failing (e.g. late recording of an assessment) equates to an outcome failing (e.g. putting a child at risk).

In reply John Goldup, Ofsted’s director of social care, has defended the inspectorate's work as a key element in improving child protection services. His boss, Christine Gilbert, has been more forceful saying in a BBC radio interview that there can be no hiding place for poor practice.

There is a pervasive assumption that inspection is central to quality improvement in public services, but there are several reasons why we should be cautious in accepting that this is so. In the first place there is no reason to believe that an inspectorate like Ofsted is a repository of wisdom about how a complex professional task, like child protection, should be achieved. Even accepting John Goldup's protestations that some of his inspectors were inherited from CSCI, and so have many years dealing with children's services (as opposed to schools), there is little evidence that Ofsted knows best. They do not seem to draw on academic expertise in the field, nor do they conduct thematic research to explore issues like quality and service development. Instead they appear to derive their assumptions about what is and what is not good practice from statutory guidance and associated performance indicators, such as the timescales laid down for completion of assessments, holding of child protection conferences etc.

Secondly we need to question seriously whether inspection is an activity which "drives" quality at all. One of the 20th century's most important quality "gurus" was the American engineer W. E. Deming, who is often credited with inspiring Japan's quality revolution in the 1950s and after whom the prize awarded by the Japanese Union of Scientists and Engineers is named. Deming did not like inspection. He lays down as one of his key principles for achieving quality that the need for inspection must be eliminated by building quality into the product in the first place. Inspection, he says comes too late. It is ineffective and costly and it does not result in quality improvements which come only from direct efforts (such continuous improvement methodologies) to improve the production process.

Putting resources into inspection, rather than into service delivery, has a number of perverse consequences. Staff find the inspection process stressful. Negative feedback is always demotivating. Being told that work is inadequate is not the same as being helped to improve. And, of course, inspections disrupt normal services, are distracting and use up scarce staff time and other resources while adding no value.

Often inspections result in pointless recommendations such as the one I quoted in my post on the Cornwall inspection a few weeks ago:  "Ensure children’s social care team managers have the appropriate skills and expertise and consistently follow guidance, procedures and protocols". This tells the inspected authority nothing of value about how to improve its services. It just waives the critical stick in a high-handed and self-serving manner. It is both pejorative and self-righteous. It makes nothing better.

The ADCS position paper very rightly stresses the importance of supporting continuous improvement and calls on Ofsted to help in this. But continuous improvement can only take place where those who are delivering the services themselves investigate and understand where improvement needs to happen. Being dictated to by detached outsiders will frustrate and dispirit those best placed to improve quality.

Ofsted's John Goldup is quoted in Children and Young People Now as saying “If inspection isn't helping to drive improvement, it is a huge waste of money." He is right but I would be more inclined to put it slightly differently: "Inspection isn't helping to drive improvement and that is a huge waste of money".

Recruiting and retaining social workers and the blame culture

Today the BBC reports that research by the Local Government Association finds sixty percent of English local authorities are reporting problems of retaining child protection staff. This represents an increase of 50% compared to last year. Public and press anger at social workers following the Baby Peter tragedy are said to be an important factor.

No surprise there. The effects of stoking up the blame culture are entirely predictable. A year ago ministers, the leader of the opposition and, of course, some newspapers were remiss in not exercising greater restraint in this regard. The effects will be long-lasting and profound.

The role of the Independent Safeguarding Authority

When I started this blog I promised myself that I would not become sucked into wider safeguarding issues. But the mess that seems to be emerging around the Independent Safeguarding Authority (ISA) is more than adequate justification for a short diversion.

This week the ISA's chair, Sir Roger Singleton, has been widely reported as having predicted that registration with the ISA will become usual not only for those who work with children and vulnerable adults, but also for those who don't. The argument seems to be that plumbers, electricians, hoteliers and even undertakers will see that being able to declare their organisations free from undesirable employees confers a commercial advantage. ISA checks may become a bit like ISO 9000, the Kite Mark or Investors in People.

This is so far from what was originally envisaged by Bichard that it is breathtaking. And the argument can be pushed even further. If hotels gain competitive advantage from employing only ISA-checked employees, then why not have hotels which only allow ISA-checked guests? They would be really safe for families with children, or would they?

The truth of the matter is that criminal records and related checks are fairly crude defences against child abuse. The nursery worker recently sentenced for abusing and taking obscene photographs of children had a previously clean record. And sophisticated child abusers can always find ways to deceive complex bureaucracies.

So widespread checking can only encourage a false sense of security. It will not make children any safer and it is likely to consume time and resources that are best devoted to other things. And it will upset and alienate the general public from the cause of safeguarding children. Philip Johnston in the Daily Telegraph writes this week that the ISA is turning the entire adult population into a collection of suspects. Sadly he may be right. The best way to safeguard and protect children is by educating, engaging and motivating people; not by alienating them.