Tuesday, 28 February 2012

Problems of Authority

The Executive Summary of the Serious Case Review Report into injuries sustained by ‘Child F’ in the East Riding of Yorkshire provides some interesting insights.

The case concerns a man who has now been jailed for injuring two babies. In the first instance, however, a decision was taken that there was insufficient evidence to prosecute. Subsequently the man moved into another household with children and a social worker assessment was undertaken. That concluded in a decision to take no further action. Later the man injured a baby in the second household causing permanent brain damage. http://www.bbc.co.uk/news/uk-england-humber-17183309

We are told that, among other failings, poor judgements were made by managers when approving the closure of the case (para. 6.7, page 5). The author of the report notes: “The social worker clearly required direction and support which managers failed to make available. It is also noteworthy that the social worker felt ‘too junior’ to challenge the direction offered by managers” (para. 6.8, page 5 – my emphasis).

The issue of ‘challenging authority’ has for many years been of concern to safety experts in aviation and, more latterly, medicine. As long ago as 1977 it was recognised that a probable causal factor in the Tenerife North disaster was the fact that the captain of one of the two jumbo jets involved was the airline’s (KLM’s) most senior training pilot. When he made the fatal decision to take off in dense fog without the permission of the tower, his two colleagues on the flight deck appear to have dissented from the decision, but were apparently unable to challenge it. The flight engineer’s last words were “That Pan Am, is he not clear?” – a remark that the captain curtly dismissed. As a result the 747 hit the other heavily loaded aircraft half-way down the runway resulting in over 500 people losing their lives.

In another famous example some of the cabin crew and passengers of a British Midland 737 aircraft that crashed at Kegworth in 1989 failed to challenge the pilot’s announcement that the right engine of the airplane had failed, despite the fact that they could see smoke and flames coming from the left engine.

Lessons from such tragedies have resulted in the development within the airline industry of Crew Resource Management (CRM) or, as it is often called, Human Factors Training. (see Helmreich, R. L. “On error management: lessons from aviation” British Medical Journal Volume 320 18 March 2000, for an overview). Now mandatory with all major airlines employees are taught a variety of techniques to help them work together with colleagues in order to reduce errors and to mitigate their consequences. An important part of any such course will be looking at issues of how to challenge and how to be challenged.

It is some measure of the success of HF / CRM training that an embedded authoritarian culture in aviation has, over the years, given way to the expectation that junior crew members will challenge a more senior colleague when necessary and that senior staff understand how to accept challenge without feeling threatened or undermined.

The East Yorkshire case certainly suggests that similar approaches are required in child protection. And it only takes a moment or two to reflect that problems of authority pervade accounts of child protection disasters. Consider for example how Victoria Climbié’s social worker seemed unable to question a puzzling report by a senior paediatrician, or how the local authority accepted a decision by the police not to prosecute Baby Peter’s mother as a bar to continuing with care proceedings, or how teachers in the Khyra Ishaq case felt they just had to accept a decision by Children’s Social Care that Khyra was not in need of protection.

These and many other similar examples are ample evidence of the need to look urgently at the culture of many of the agencies involved in child protection; and to design ways of helping staff, many of whom are conditioned to working in hierarchical and bureaucratic environments, to think critically and constructively about how professional and agency disagreements can be handled so as to minimise the possibility of them resulting in errors and tragedies.