Saturday, 30 June 2012

Causing or Allowing

It is sensible to amend the law to ensure that the offence of “causing or allowing” applies in cases where a child is injured, as well as those in which a child dies. So we must welcome the new offence, under the Domestic Violence, Crime and Victims (Amendment) Act 2012. From next week child abusers in England and Wales could be found guilty of the new offence of deliberately causing or allowing serious physical harm to a child or vulnerable adult and face up to 10 years in prison.

I thought some of the coverage of these developments was a bit sloppy. The whole point of the new law is that it is designed to deal with just those situations where two or more carers, having the care of a child who has suffered non-accidental injury, opt to stay silent or to make mutual allegations. And a jury still has to be satisfied beyond a reasonable doubt that a defendant either caused the injury or was, or ought to have been, aware of the risk to the child, failed to take reasonable steps to protect the child and that in circumstances the defendant foresaw or ought to have foreseen the injury.

One BBC report ( ) proclaimed:

“From Monday anyone who deliberately causes or allows serious physical harm to a child or vulnerable adult faces up to 10 years in prison.”

That sounds as if hitherto it has not proved possible to prosecute anyone who caused non-accidental injuries to a child, which is, of course, manifestly false! A similar misleading impression is given in the video clip (

I hope and expect that the new law will be used sparingly, with most child abusers being prosecuted for assault in the traditional way.

Thursday, 21 June 2012

The first shoots of the Munro spring?

According to Community Care there are early indications that abolishing the deadlines for conducting child-in-need assessments, as recommended by Professor Eileen Munro, is having a positive effect.

A representative of Islington Children’s Services, in London, is quoted as saying that before, when a 10 day deadline was in force, there was undue pressure to prioritise documentation and recording, at the expense of family contact.

Under the new approach there is more time to build a relationship with a family, resulting in better assessments.

Grim Reading from Ireland

The Republic of Ireland’s Children’s Minister, Francis Fitzgerald, has said that a report into the deaths of children known to the Health Services Executive, shows that they had been failed. She says that it is a disgrace that missed interventions have resulted in lost childhoods and child deaths.

The report, by Dr Geoffrey Shannon and Norah Gibbons runs to nearly 500 pages and can be downloaded at:

Wednesday, 20 June 2012

Why Do Errors Happen? How Can We Prevent Them?

While looking for Sidney Dekker's video (see last post) I also found this one by Professor Lucian Leape of Harvard Medical School.

Take a look. It concerns medicine, but can obviously be applied to child protection.

The point is that blame does not promote safety - it inhibits it.

Shoesmith, Safety and the Sun

There is a very interesting entry on the Community Care Children’s Services Blog written by former Haringey Children’s Services Director, Sharon Shoesmith. 

Much of this post is concerned with supporting the cases of social worker Maria Ward and team manager Gillie Christou who recently lost their appeals against dismissal in the Employment Appeals Tribunal. Maria was Peter Connelly’s social worker and Gillie was her manager.

I strongly endorse support of this nature. A most unpleasant stink hangs over the whole business by which individual Haringey staff were named and shamed for what was clearly a corporate failing. 

As I keep reminding people, Professor Sidney Dekker argues forcefully and convincingly that a JUST organisational culture is a precondition of a safe working environment.
As long as there are stark examples of workers who appear to have been treated unfairly there will never be the trust required for employees to draw attention to the error traps in the organisation. As Professor James Reason puts it: ‘Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we have no way of uncovering recurrent error traps or of knowing where the “edge” is until we fall over it.’ (BMJ VOLUME 320 18 MARCH 2000

Those who stoke up the blame culture do nothing to make abused and neglected children safer. Indeed the effects of their actions are invariably negative, resulting in fearful staff, defensive cultures and ultimately organisations in which learning is made more or less impossible. The opposite of what is intended is achieved. Employees are afraid to draw attention to unsafe working practices, so more and more children are put at risk.

Which brings me to Sharon Shoesmith’s interesting remarks concerning the Sun newspaper’s campaign against Haringey employees at the time of the Baby Peter tragedy. Shoesmith refers to the communication between Ed Balls, then Secretary of State for Children, Schools and Families, and the former editor of the Sun, Rebekah Brooks, which Brooks revealed to the Leveson enquiry on 11th May 2012.

Now if there was ever a clear example of the blame culture, the Sun’s disgraceful campaign for ‘justice for Baby P’ is clearly a paradigm example. And the thought of Rebecca Brooks, the architect of that campaign, having privileged access to the relevant minister, is indeed a chilling one.

Sadly one is left to conclude that rather than base our child protection system on sound safety principles, developed by the likes of Reason and Dekker, we have allowed the likes of Rebecca Brooks, a strident tabloid editor who probably knows nothing about safety (or children's services for that matter), to be paramount. 

We must ensure that this never happens again. Management of child protection is too important to be left to tabloid newspaper editors.

Working Together

My trip to Italy and Austria coincided with the publication of the new Working Together guidance and I have only just had the opportunity to look at it in detail. 

What I liked:

  • The guidance is commendably short
  • There are two documents separating guidance on assessment from the general arrangements for ‘working together’
  • Vast swathes of ill-thought-out detailed guidance have been deleted, marking an end to governments’ attempts to micro-manage practice
  • There is no attempt (as there was in previous guidance) to impose a single monolithic view of how things should operate – rather the guidance seeks to set out the basics
  • Silly targets and time-scales have been eliminated

What I didn’t like:

  • Largely this new guidance is an edit – albeit substantial – of the previous Working Together
  • There has been little attempt to be original or innovative
  • The guidance still has the tone of civil servants and ministers ‘telling’ rather than creating documents which will be useful in practice
  • The ‘user-perspective’ seems to have been ignored – how easy will these documents be to use / understand / remember?
  • The truly awful flow charts – which do not conform to the usual flow chart conventions – have been retained
  • The definitions of physical abuse, neglect, sexual abuse and emotional abuse are relegated to a glossary – almost as if the authors didn’t want to be too obviously identified with documents about child maltreatment!

Critics are right to stress that this new guidance will not be a panacea. But then who expected it would be? It is a beginning not an end. 

I would also like to warn of a possible danger, namely that local officials will reinvent lots of the detailed guidance and incorporate it in local procedures. We need to devise ways of insuring that that does not happen. We want services that are driven by children’s needs, not by procedural manuals!

I will be taking a very careful look at the new guidance and responding to the public consultation. Can I suggest that you should consider doing the same, especially if you are directly involved in providing child protection services?

Sunday, 10 June 2012

Increased Neglect

The NSPCC's Helpline reports a 30% rise in cases of child neglect during the last year. Some of this is likely to be as a result of greater awareness, rather than increased incidence, but the impact is no less palpable. Increased numbers of neglect referrals will feed in to increases in casework, as children's services continue to face unremitting rises in demand. Ministers should not fiddle while Rome burns!

Saturday, 9 June 2012

Is Ofsted doing a good job?

As I sat in a not very good restaurant next to the Ponte Vecchio in Florence, my mind turned from the indifferent risotto mare to the indifferent Ofsted report I had been reading that afternoon.  I should explain - I am not in Italy to read Ofsted reports. Far from it with the Uffizi a mere stone's throw away, I have better things to do.  But a very unpleasant chest infection acquired en route to Italy had left me confined to the hotel room for most of the day.  What better to do when you have a bad chest and a temperature than read a report on safeguarding in the London Borough of Sutton? On the surface of it this Ofsted report is no different to the many that brand safeguarding in local authorities 'inadequate'. It is liberally peppered with all the usual platitudes. Apparently management failed to challenge sufficiently, leading to poor practice and outcomes (a familiar refrane) and (surprise, surprise) the quality of assessments and plans was generally poor. Nor is the report different in its mealy mouthed recommendations. The one I 'liked' the most was: "ensure that all child protection plans clearly identify what needs to change, by when and what contingencies are in place if change is not forthcoming" The inspector might as well have said: "ensure all staff have perfect knowledge of the future"! To be fair this report was based on an 'old style' inspection conducted in April, but I am really quite concerned that the gap between Ofsted thinking and what is required of any 'new style' inspection regime is too big to overcome. The Munro Review, conceives child protection practice as requiring the ability to think outside the box. Assessments and decisions are made on the basis that information is soft and uncertain. Professionals need to be flexible and willing to revise their opinions in the light of new evidence. Osted seems to think that they need to complete the 'what needs to change' box 100% of the time. It only took a little bit of ferreting away on Google to find Ofsted's John Goldup's statement about the new inspection regime for child protection which began in May.  While he concedes the need for a more child focused approach, he does not mention a systems approach. If the central core of Munros's thinking is that we only learn to avoid errors (e.g. through a serious case review) by discovering the features of organisations, working practices and systems, which predispose to error, then it seems very odd to me that the the inspectorate's approach to quality (the opposite of error)fails to take that into account. But it seems that Ofsted may be stuck in the past, still conceiving errors as causes not consequences and still conceiving the approach to safer practice as being person-centred - i.e. focused on individual failures and management's inability to achieve compliance with rules and procedures. Perhaps that's why Ofsted reports continue to hunt out poor assessments and incomplete plans.

Sunday, 3 June 2012

Away in June - but not completely away

The iPad is a wonderful thing. I brought mine along with me to Italy just in case I got bored looking at Michael Angelos or da Vincis. A virus knocked me flat and I have had little else to do except play with the iPad. So even though I had already signed off for June I'm afraid there may be just a few posts on this blog as well.