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.