Friday, 17 August 2012

Consultation (3): About the Learning and Improvement Guidance

Here is what I have to say about the Learning and Improvement Guidance

General Comments about Learning and Improvement
This document seems to say some of the right kind of things about improvement, such as referring to "a culture of continuous improvement" and to a "systems approach".

Sadly I don't think the authors have recognised that these approaches require big changes in organisational and professional culture and attitudes. They are approaches that are not compatible with self-protecting, top-down bureaucracies. They involve redistributing power within organisations. They involve leaving the blame culture behind and embracing a "just culture" (see Sidney Dekker's book of that name; Just Culture, Ashgate, 2007).

I was impressed by the thoughts expressed in a letter written by the Right Hon. Michael Gove MP, the Secretary of Sate for Education on the subject of the Edlington tragedy. Concerning Serious Case Reviews he wrote:

I do not want these reports to be used to assign blame where terrible incidents have taken place. People working in these circumstances need to have confidence that they will be backed by their managers when they take difficult decisions with good intent and sound judgement, whatever the outcome. Publishing factual information about serious incidents helps ensure that all the lessons are learned, nationally and locally, to reduce the risk of repeating mistakes. This will not only help people working at the front line; it will also give the public greater confidence. We want an open, confident, self-regulating system where professionals are continually asking how they can improve rather than a system clouded by secrecy and fear.”

I am surprised and saddened that the guidance does not contain a similarly strong statement about the kind of culture and ethos that should be developed both nationally and locally. And, of course, the guidance needs to go beyond statements of intent and offer suggestions about how such a culture could be created. I see nothing in the guidance that addresses that question.

Another deficit of the document is that Serious Case Reviews (SCRs) and Child Death Reviews (CDRs) are only a part of learning and improvement in child protection. Other approaches to learning and improvement get scant mention, if any. I have identified seventeen possible approaches (‘Kaizen’ appears in the list twice) to learning and development and there may be more. Those I have identified are:

1.             Post Failure Analysis
a.    Fatal (or serious) incident enquiries / accident enquiries – SCRs
b.    Complaints
c.     Fault tree analysis. Start with a failure and work backwards to identify all possible causes
d.    Root cause analysis. Similar to fault tree analysis. Traces causes of disaster by repeatedly asking ‘why?”

2.             Pre-Failure Analysis
a.    Critical incident reporting. Reporting of non-fatal/serious critical incidents, or near misses, that would have otherwise been unremarked. Best achieved through anonymous/independent reporting system
b.    Feedback from service users
c.     Individual and Team de-briefings
d.    Safety audits
e.    Feedback from inspection / management
f.      Failure-Mode-Effect Analysis. What is the likelihood that failure will occur? What would the consequences of the failure be? How likely is the failure to be detected before it impacts the service user?
g.    Kaizen – continuous improvement

3.             Designing safer services
a.    Service modelling / design – involving employees and users
b.    Prototyping – trying out service modifications before full implementation
c.     House of quality – ever closer matching of design features of the service with user-requirements. Also known as Quality Function Deployment
d.    Delphi technique
e.    Poka Yoke / Failsafing
f.      Employee suggestion schemes
g.    Kaizen – continuous improvement

I believe that the guidance would be improved if some attention was also given to some, if not all, of these approaches to learning and improvement. Consideration needs to be given to the view that neither SCRs nor CDRs are the most effective ways of learning and that other methods might produce better learning more easily and at lower cost.

What needs to happen to ensure that there are enough people who are trained and qualified to conduct high quality Serious Case Reviews (SCRs)?

There needs to be a recognition that a wide range of skills – practice, professional, management, safety – are required. At the very least I would argue that someone conducting an SCR should have considerable experience of child protection coupled with specific training in human factors approaches to safety. Much of the training available in the area of human factors derives from aviation and medicine and it will be necessary to involve trainers from these fields, especially in the early days.

There needs to be funds, possibly made available through LSCBs, to provide training in human factors approaches to safety.

It is important that the widest pool of talent be drawn on in recruiting people to conduct SCRs. It is not acceptable for a small group of ‘insiders’ to receive the appropriate training and to divide the work up between them. LSCBs should recruit people to conduct SCRs through public advertisement and an open competition.

What arrangements should be put in place to ensure the quality of Serious Case Reviews?

The quality of a Serious Case Review should be located in the benefits it delivers – not in the mode or style of its presentation in a report. Ofsted is no longer involved in assessing the quality of SCRs, but when it was, it contrived to turn what might have been valuable research into the effectiveness (or non-effectiveness) of SCRs into a tick-box, process-focused exercise. Ofsted’s evaluations concentrated on whether reports addressed issues thematically, whether sub-headings were used, whether summaries were clear and whether the reports were well written. The Ofsted studies focused on how to write a good SCR report while forgetting what the purpose of an SCR is – learning and improvement to reduce the risk of a future tragedy.

Anyone trying to assess the quality of a SCR needs to explore the impact that the review has had on practice - on practitioners, professionals and managers. What lessons have been learned and what changes have been implemented as a result? Inevitably some empirical work is required.

Academic research might profitably focus on these issues, but I would suggest that routine business research may be a more valuable tool. In the wake of a Serious Case Review the LSCB should routinely survey local practitioners, professionals and managers to determine their assessment of learning from the SCR and whether recommendations are being put into practice and with what success. 

What arrangements should be put in place to share learning at a regional and national level?

There needs to be an easy to digest summary of the aggregate findings of SCRs. The current system needs to be improved – better circulation of findings should be a high priority.

Peter Sidebotham has argued:

“… with over 100 SCRs conducted each year, it is neither possible nor effective for individual practitioners to read and learn from each one. Rather, the system for national analyses needs to be continued and strengthened, and fresh ways of disseminating knowledge from these analyses need to be developed.”
(“What do serious case reviews achieve?” Arch Dis Child 2011. doi: 10.1136/archdischild-2011- 300401)

I would like to suggest that some brief reporting format be devised to facilitate a simple, but widely distributed, electronic publication summarising all the SCRs conducted in (say) the last six or twelve months. This would not be an academic publication but rather an industry/technical publication, aimed at being available as soon as possible after the SCR reports are published.


Thursday, 16 August 2012

Consultation (2): About the document entitled: Managing Individual Cases: the Framework for the Assessment of Children in Need and their Families

Sadly I have written a lot about the document entitled Managing Individual Cases: the Framework for the Assessment of Children in Need and their Families

I didn't like this document at all. 

I wrote:

(About local frameworks for assessment)

I have severe reservations about the idea of local frameworks for assessment. It seems to me that the document is in danger of inviting local managers to compose at local level the very type of convoluted guidance that the Government has been at pains to expunge at national level.

Furthermore I really cannot see why detailed guidance is required on assessment in the first place. Few, if any, would argue that central or local Government – or other bodies - should issue detailed guidance to (say) doctors on diagnosis or to (say) barristers on how to represent their clients in legal proceedings.

But the Framework for the Assessment of Children in Need (DoH, 2000) has, over the past 12 years, become a holy book of ‘children’s social care’, despite its many defects and shortcomings, establishing an unwelcome tradition of proceduralising assessment.

With the benefit of hindsight we can now question why anyone ever thought that an attempt to specify in detail what questions a social worker should ask in carrying out an assessment was anything other than a crude attempt to micromanage practice. And, with the benefit of the insights of the Munro review, we should now be ready to cut free from a tradition based on a ‘framework’ that, through the Integrated Children’s System and previous Government guidance, has become a central element in the bureaucratic proceduralisation of professional practice.

Whether local or national, frameworks drafted by managers and officials and imposed on professional social workers are a bad idea. One only needs to read accounts of the excellent research of Broadhurst and colleagues (“Performing ‘Initial Assessment’: Identifying the Latent Conditions for Error at the Front-Door of Local Authority Children’s Services” British Journal of Social Work (2009) 1–19) to understand the dysfunctional consequences when a framework for assessment becomes a formally endorsed checklist and evolves into step-by-step procedures built in to a computerised system.

This has happened with the Framework for the Assessment of Children in Need spawning the ‘exemplars’ of the Integrated Children’s System. There is a great danger that practice is driven, not by commonsense and professional judgement, but by arbitrary compliance with ‘the rules’. The Munro Review has persuasively drawn attention to the dangers of such a situation and the Government has accepted Munro’s arguments as a foundation for policy change. But this guidance, locating as it does ‘assessment frameworks’ at the apex of policy, is at variance with the new paradigm.

I do not rule out the use of assessment frameworks entirely, but they should not have the force of procedure or regulation; and they should be developed through professional networks and research, not through bureaucratic diktat, whether local or national. Only when the evolution of frameworks is led by practitioners can practice develop and improve, as different ‘frameworks’ are tested, amended or replaced. Professionally evolved frameworks, of this sort, would be more like tools than sets of instructions. Practitioners would choose a framework best suited to the task and their particular needs at the time, and use it flexibly and creatively.

Otherwise, in the top-down world of imposed frameworks, the wheels of government bureaucracy, either central or local, grind too slowly and inflexibly resulting in what might be useful tools of professional practice effectively being set in stone.

(About internal review points)
Specifying ‘internal review points’ or timescales or deadlines is not an effective way to make processes run more quickly while maintaining acceptable levels of quality. Trying to impose these types of requirement is likely to unbalance the process, leading to backlogs of work at some points and idle workers at others. Quality is likely to suffer.

The correct way to speed-up a process is to begin by trying to understand it. Where do bottlenecks occur? Why? How can resources be re-distributed within the process to increase speed? The process will run at the speed of the slowest bottleneck, so there is no point in speeding up some parts of the process if the bottleneck is not addressed. That just wastes resources.

Usually, the speed of the process is not a matter of ‘control’ – it is a matter of design. You can try to control a badly designed process until you are exhausted but you won’t make it operate effectively. Resources are consumed by controls that do not work. Workers are alienated by controls that they perceive as unreasonable. The operation is made more complex than it needs to be while the human beings that run it become confused and dispirited. The quality of the service goes down.

Re-designing a process should always be undertaken interactively with the people currently undertaking the work. They usually have a better understanding of the process than outsiders.

I am saddened that apparently, once again, the guidance appears to be reintroducing practices through the ‘back door’ at local level that the Munro Review has challenged as counter-productive at national level. For local managers to specify normatively timescales, without investigating the process and understanding why it operates as it does, is no better than allowing civil servants or politicians to set deadlines nationally. The whole force of paragraph 2.5 seems to be to urge local authorities to recreate at a local level exactly the kind of timescales and deadlines, that Munro warns against at national level. This must be undesirable. Local bureaucracy is as crippling as national bureaucracy, possible more so.

(About the whole document)
The best thing about the document entitled “Managing individual cases: the Framework for the Assessment of Children in Need and their Families” is that it is short; other than that it is confused, difficult to read and not very helpful.

The problem starts with its title. It is a fundamental mistake to try to weave together guidance about assessing children in need with guidance about how to respond to child abuse and neglect. While the two processes are closely related, and may be carried out by the same people, they should not be portrayed as a single process involving different pathways. The parents of a disabled child, asking for a child in need assessment under Section 17 of the Children Act 1989, would rightly be outraged to find that the service they receive is subsumed under a child protection rubric.

The 2010 version of Working Together makes it clear that Chapter 5 (“Managing individual cases where there are concerns about a child’s safety and welfare”) concerns those cases where there is a concern that a child may be suffering abuse or neglect. This is made abundantly clear in paragraph 5.1 which states that “This chapter provides guidance on what should happen if somebody has concerns about the safety and welfare of a child (including those living away from home) and, in particular, that a child may be suffering, or is likely to suffer, significant harm”.

This new guidance should start with a similar unambiguous statement making it quite clear that the individual cases being managed are those in which abuse and neglect are suspected. It should then concentrate on providing guidance on child protection, and only on the assessment of need in so far as this contributes to managing a child protection episode.

To confuse child protection with cases where there are no concerns at all about abuse and neglect, but where a child has unmet needs, is unhelpful for a number of reasons. First, as indicated above, parents of children who are in need, but not in need of protection, should not be stigmatised. Secondly, a different speed and urgency of response is invariably required where children may be in danger, possibly of their lives. Thirdly, there is no reason why guidance that is applicable to children in need of protection should be applied more widely to children in other types of need. The guidance should fit the service, not vice versa.

The legitimate complaints raised by the Every Child in Need Campaign are a direct consequence of seeking to amalgamate guidance on child protection with guidance on assessment. The core of the campaign’s concern seems to be that the Government’s proposals remove national minimum standards for child-in-need assessments. The campaign’s website points out that while the proposals are focused on ‘children at risk,’ the changes will apply to all children in need. It is argued that removing the requirement that a child in need (for example a disabled child) must be assessed within 35 working days, will allow local authorities to get away with leaving such children “… to languish, without the assessments and services they desperately need – and are statutorily entitled to”.

The problem with the imposed deadline for assessment in child protection work is that it ties the hands of social workers, possibly distracting them from work necessary to complete the Section 47 enquiry and from work necessary to take protective action. Rather than doing what is best for the child, the aim becomes one of completing the paperwork in time. So I am very much in favour of a more flexible approach where a child is at risk of significant harm.

On the other hand I can see the campaigners’ point, that families who ask for a child’s needs to be assessed do have a right to have an assessment in reasonable time. This suggests that the guidance on requested ‘in-need’ assessments might require a deadline, whereas that on child protection does not. What a reasonable deadline would be depends on an analysis of the process of producing such an assessment and the level of resource given to the task.

Generally I am perplexed about why anyone thought it a good idea to try to subsume guidance concerning the Framework of Assessment of Children in Need into guidance on child protection. I see nothing in the Munro report to suggest that such a mishmash of guidance would result in better services.

(About other ways in which the the guidance is defective)

The document does not follow a simple logical order that corresponds to the natural stages of the child protection process. This order is as follows:

·       Recognising the signs of significant harm or otherwise forming a concern that a child may be at risk of significant harm

·       Making a referral to children’s social care

·       Accepting a referral by children’s social care

·       Deciding on action, including involving the police in cases where a crime is suspected

·       Taking emergency action if required

·       Carrying out a Section 47 enquiry

·       Undertaking an assessment of a child’s needs

·       Deciding whether a child protection conference is required

·       Holding a child protection conference

·       Making a child subject to a child protection plan and subsequent involvement

·       Deciding whether further legal proceedings are required

While some of the later stages are dealt with in a sequenced fashion, the guidance begins with assessment and with a lengthy discussion of the “local framework for assessment”. This suggests that the process to which the guidance applies is ‘assessment’, when in reality ‘assessment’ is only a part of the process of protecting and safeguarding a child.

The emphasis on assessment in the early paragraphs of the guidance has another unwelcome consequence; the issue of abuse and neglect is obscured, if not completely avoided. Indeed the definitions of the various types of abuse and neglect are relegated to a glossary. This is very unfortunate. It is only too easy for members of the public, professionals and practitioners, to shy away from the recognition of child abuse; none of us wants to think that a child is being abused. But it is wholly unacceptable for a Government document to fight shy of using robust and accurate language to describe child maltreatment. Apart from references to “low-level abuse and neglect” and “the early signs of abuse and neglect”, both in paragraph 1.3, the word ‘abuse’ does not occur again until page 20 and the word ‘maltreatment’ only appears at page 26, in the glossary. Incidentally there is no such thing as ‘low-level abuse’; that is if you happen to be a child on the receiving end of it!

Section 2 of the guidance continues to integrate the process of receiving a referral requesting an assessment of need with the process of responding to a concern about child abuse and neglect. While it is appreciated that some cases referred for a needs assessment will turn out to involve abuse and neglect, and some cases referred for protection will ultimately not involve child maltreatment, it is difficult to imagine why paragraph 2.4 should apply, for example in the case of a disabled child referred for a needs assessment.

Indeed paragraph 2.4 seems to set a wholly unrealistic timescale. Within one working day it would be reasonable to expect a social worker, handling a child protection referral, to have decided if the referral involved a concern that a child was at risk of significant harm; and such a child should ordinarily be seen immediately and the situation assessed to determine if the child is in need of emergency protective action. However, the social worker will only at this stage have a partial view about “the course of action to be taken” and “what type and level of help and support is needed”. Neither is it realistic, nor indeed safe, to expect that feedback to the referrer should be provided at this stage.

Resource problems for ‘children’s social care’ would be generated if there is an expectation that response to cases where there is no suggestion of child abuse or neglect will also be responded to within “one working day”. Such an expectation is both unnecessary and unworkable.

The heading above paragraph 2.2 “Referral into children’s social care” is at best unusual English. We don’t speak of ‘referral into the X-ray Department’ or ‘referral into a specialist’. Surely the correct English is ‘referral to children’s social care’?

Incidentally, the expression ‘children’s social care’ to describe teams of social workers who undertake child protection work is, in my view, unhelpful. The expression emerged a few years ago when there seemed to be a concerted effort to airbrush the phrase ‘social work’ from Government documents. But ‘social work’ is the correct description of what these teams of social workers do. In the era of ‘reclaiming social work’ we should now not be afraid of speaking confidently about ‘children’s social work’ (see Social Work Reclaimed, by Steve Goodman and Isabelle Trowler, Jessica Kingsley).

(About Flow Charts)
The first of several flow charts appears at page 10 of the guidance document. All the flow charts are amateurish, difficult to understand and do not follow the conventions for drawing flow-charts that are widely used and accepted in the business literature (see Slack et al, Operations and Process Management, 2nd edition, Pearson, 2009 pp 143-146). If flow charts are thought to be essential then they should be drawn by someone who knows how to draw them, based on a sound empirical understanding of the relevant processes, not on speculative or normative presuppositions.

Flow-chart 2 (page 13) refers puzzlingly to a ‘relevant agency’ (a term which is unexplained) and the chart does not make clear how a decision is arrived at to pursue emergency action or not. Whoever constructed the flow-chart seems to have neglected the possibility that the emergency action can occur at any time during contact with a child and family, and may not be considered necessary until after a Section 47 enquiry is complete or almost complete. The flow-chart, however, portrays a Section 47 enquiry as dependent on an upstream decision concerning emergency action.

Flow-chart 3 (page 14) suggests that some assessment of whether a child is at risk of significant harm needs to take place in all cases referred, presumably even if there has been no suggestion at all that abuse or neglect is suspected. This is undesirable for reasons already discussed in answer to Question 5 above.

This flow chart also subsumes Section 47 enquiries under the heading of ‘assessment’ – when ‘enquiries’ is obviously the correct word. And, it is best to keep these two activities distinct so that the questions ‘Has this child been abused and neglected?’ and ‘Is this child in need?’ are addressed separately. This avoids the development of the undesirable mental model in which children are assumed not to be in need just because the allegation of abuse is not substantiated.

Flow Chart 4 (page 16) has at least one important box that has no successor activity, despite the fact that a successor activity is necessary (the sequence ends in a box simply marked “Yes”). Following on from the activity “Social worker leads assessment under section 47 of Children Act 1989 and other professionals contribute” there are three possible outcomes, when there should be at least four – i.e. there is no mention of a situation where the    concerns are not substantiated and the child is not in need.

In Flow Chart 5 (page 24) it is difficult to see if the activities immediately following the commencement of the process are alternatives, resulting from a decision, or parts of the process that occur in parallel. Although it may be obvious to most readers that “No further concerns about significant harm” means that there is no concern that the child is at continued risk of significant harm, the words need to be adjusted to avoid the (erroneous) interpretation that the Child Protection Plan can be discontinued if no additional concerns come to light!!

The text box entitled ‘Response to a Referral’ (page 8) begins with the sentence “When a person contacts local authority children’s social care with concerns about a child’s welfare, it is the local authority’s responsibility to determine the most appropriate response.” While this is literally true, the text box makes no mention of abuse and neglect and the very special responsibilities that any professional or other practitioner has if s/he suspects maltreatment. As it stands the guidance contained in this text box may encourage referrers to refer cases involving less urgent concerns as if they were child protection matters, a situation which could create a bottleneck at the point of initial referral. That would slow the whole process and consume additional resources. And it would have the effect of diminishing the speed and quality of response of the whole service.

What am I saying in my response to the Government’s consultation on the Revised Safeguarding Statutory Guidance? (1) About the document titled "Working Together to Safeguard Children"

This is the first of three posts on what am I saying in my response to the Government’s consultation on the Revised Safeguarding Statutory Guidance. This post is about the document entitled Working Together to Safeguard Children -

I say:

  • This guidance appears to cover most of the main legislation, but not always in a logical and accessible way.
  • Like the other two documents, this document is written in a dense style – ‘official-ese’ - which makes few concessions to the reader.
  • I believe that it would be preferable for documents like this to be written with a view to being helpful to those who have to read them. For example this might be achieved by organising the information about the duties and responsibilities of each agency under logical headings. Listing agencies in alphabetical order might also improve accessibility.
  • The Guidance provides an outline of what Local Safeguarding Children's Boards should do and provides some pointers to good practice. How these bodies become ‘effective’ (or ‘more effective’) is beyond the scope of guidance of this type – a textbook on that subject would be required.
  • There should be more learning from best practice and sharing ideas between LSCBs. The Guidance might be improved to suggest ways in which this could be done.
  • Thematic inspection or research into the effectiveness of LSCBs would be helpful, but this must go beyond superficial enquiries and simplistic research questions, typical of many Ofsted inspections. Substantive issues should be addressed such as what are the outputs of LSCBs, what impact do they have, how are they planned and controlled, how could they be improved?

Wednesday, 15 August 2012

Child abuse and witchcraft

Tim Loughton, the Children’s Minister, is 100% correct to prioritise stopping ritual child abuse conducted because the perpetrators believe that the child is a witch.

Tim is right to want to raise awareness of police, social workers, health and other professionals.

Although I am generally sceptical about the impact of the criminal law in reducing child abuse and neglect, some years ago I suggested that a criminal offence of inciting significant harm to a child might be considered.

My idea was that this should be akin to the offence of inciting racial hatred (Race Relations Act 1976, Public Order Act 1986, Criminal Justice and Public Order Act 1994). No specific person would have to exist as the object of the incitement. It would be sufficient that a person urged others to commit an assault on any child.

That, I thought, would be one way to prosecute ‘rogue pastors’ and others who advocate brutal treatment of children who are believed to be witches, but who are careful not to be seen to conspire with others to commit a particular criminal offence against a particular child.

Would that be helpful? Let me know by emailing:

Tuesday, 7 August 2012

Learning from the Olympics

Ian Dean, the Manager of the London Safeguarding Children Board, provides an interesting account in today’s Guardian of how London Boroughs have co-operated to provide a child protection service covering the "Olympic co-ordination zone", which spans four local authority areas.

The interesting issue which Ian does not go on to discuss is, if this type of co-operation between local authorities is possible during the Olympics, why is it not occurring more commonly on a-day-to-day basis? In an age of central government cuts and restricted local government budgets, it makes enormous sense to consider what parts of child protection services can be provided more efficiently across a larger area. Why duplicate services and resources across the thirty-two local authorities (boroughs) which form London?

Greater co-operation would result not only in services which are more efficient, and therefore cheaper, but in higher quality services. A central point of referral would act as a central store of information. A larger group of social workers could be deployed more flexibly and more quickly. Pooling intelligence and human resources would result in a much larger pool of corporate and professional knowledge. Common systems for recording would speed the service response and ensure that information was appropriately shared. Out of hours services would benefit particularly.

I find it surprising that London Boroughs and other local authorities, especially in metropolitan areas, have not been more inventive and aggressive in trying to co-operate and share child protection services. As I understand it, legislation (Local Government Act 1972 and Local Government Act 2000) allows officers of one authority to act as officers of another and for one authority to delegate a function to another authority and for two or more authorities to jointly exercise their functions. So the legal basis seems clear, as it must be in order for this to have happened during the Olympics.

Perhaps the London Safeguarding Children Board will now take the model forward with a view to widespread co-operation in child protection across the capital?

Monday, 6 August 2012

Puzzling Statistics

What strange statistics the mandarins of Whitehall produce. I came across these on Child Death Reviews the other day.

I found them to be virtually impenetrable and surprisingly uninformative.

The only purpose I can think of in having child death reviews is to discover how children die and how they can be made safer. But these statistics seem to concentrate on the child death review process, rather than on issues of improved safety.

I defy anyone to read them and be any the wiser about how to save children’s lives as a result.

Sunday, 5 August 2012

Systems, not individuals, failed Shafilea Ahmed

I am sure that Barbara Ellen, in today’s Observer is right in saying that it is wrong to say that the death of Shafilea Ahmed can be blamed on “… a culture of political correctness, liberalism, leftie cultural squeamishness, call it what you will”.

And I am sure that she is right in suggesting that health, police and social care systems failed Shafilea badly.

But I do wish that she had been more careful not to invoke the blame culture  - what Sidney Dekker (The Field Guide to Understanding Human Error, Ashgate, 2006) calls the ‘Bad Apple Theory’ - as she does when she writes:
“This failure wasn't about some misguided PC wish not to offend Islam, or anything else, it was about incompetence, pure and simple: the collapse of a system of care, leading to a young girl falling through the cracks.” (my emphasis)

Yes, a young girl fell “through the cracks”, but we have no reason to believe that it was due to the incompetence of anybody. It is much more likely that individuals, trying their best to deliver services through imperfect and error prone systems, were unable to see what was happening to Shafilea. We should begin by assuming that it was the systems that failed, not the individuals. As Sidney Dekker says “You have to assume that nobody comes to work to do a bad job.”

Everything we know about investigating accidents and disasters points in the direction of what Dekker calls "the new view of human error". Mistakes by individuals are not a cause of things going wrong, but rather they are an effect of failings in the design of systems and organisations. Inquiries should not end with the conclusion 'human error'; they should begin by looking for the deeper causes of human error. 

That, of course, is also the perspective of Munro’s ‘systems approach’ to Serious Case Reviews (SCRs). Although I’m not a great fan of SCRs generally, I believe that one is required in this case – and I hope that when, or if, it is prepared, it will be informed by a system’s perspective. 

Saturday, 4 August 2012

Research shows what we all know - babies continue to be killed

The Daily Mirror reports on research by the NSPCC which looked at the Serious Case Reviews completed since Baby Peter’s death.

The research found that a hundred deaths of babies and toddlers had resulted in a Serious Case Review (SCR) since the death of Baby Peter. Andrew Flanagan, chief executive of the NSPCC, is quoted as saying: “Despite calls for this never to happen again here we are five years on with babies being killed in brutal ways.”

Reports into twenty-eight child deaths were examined in detail. This showed that in several cases drug and alcohol abuse, domestic violence and mental illness were significant factors. Twelve of the reviews concerned cases where the focus of the work was said to be on the adults and not the child. An ‘unknown’ male joining the family was said to be a factor in seven cases.

Unfortunately these kinds of statistics are not particularly helpful. Many of the factors identified are also found not infrequently in families where abuse and neglect of children do not take place. Obviously professionals cannot react to these cases as if they required child protection. Not only do they not have legal powers to intervene, but services would be overwhelmed.

I wish the NSPCC would fund some research into how to reduce error in child protection practice. Sadly whatever changes in law, practice and procedure occur, there seems to be a core of cases in which, despite the efforts of professionals, neglect and abuse continue and result in tragedy. The wrong decisions are taken and a child dies.

Many years ago I suggested that trying to understand more about non-fatal, routine errors might help - . My favourite quote from Professor Jim Reason applies:

‘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 - )  

Responding to child abuse and neglect will always be difficult. Failures in practice will only reduce if we have sound understanding of the interactions between practitioners, their organisations, systems and procedures, the wider environment and families who are being helped.

Critical incident reporting would result in a better understanding of when and how mistakes occur and how systems fail. An organisation like NSPCC would be ideally placed to co-ordinate a critical incident reporting system.  

Shafilea Ahmed

The Independent and the Daily Mail  report on the shocking case of Shafilea Ahmed, whose parents have just been convicted of her murder in 2003. The parents’ motive is reported to have been that they were ashamed that their daughter was becoming ‘westernised’.

Shafilea was 17 years-old at the time of her death. It appears that health professionals, police and social workers were involved with her in the year prior to her death, when she ran away from home and complained to teachers that she was being abused at home. She also attempted suicide by drinking bleach.

The papers provide only scanty details of health and social care involvement with Shafilea. There is no information about a Serious Case Review and no SCR report is mentioned on the Warrington Safeguarding ChildrenBoard website. However Edwina Harrison, the independent chair of the Warrington Safeguarding Children Board, is quoted in the papers as saying that procedures have been changed since Shafilea's murder. She said that now a homeless 16-year-old would receive a better service and would be fully assessed by a social worker. To my mind the question should be about why no child protection (Section 47) enquiries were put in hand.

Given that the Serious Case Review is seen by government as the main vehicle for learning and improvement in child protection, I hope Warrington Safeguarding Children Board are preparing one in this case. On the face of it this sounds to be a case where a young person was seriously failed by the system. Without a better understanding of what went wrong, Edwina Harrison’s reassurances that the same thing cannot happen again have a hollow ring.