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.