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.