Friday, 30 August 2013

Daniel Pelka - mandatory reporting?

As a result of the Daniel Pelka tragedy, a campaign for a “good Samaritan” law is being run by members of the public. They want legislation that would make it illegal for teachers or other professionals not to report that they suspect a child is being mistreated. 

Mandatory reporting is not without its problems and I believe it is very unwise to press for major policy changes before the Serious Case Review into Daniel’s death has reported.

We have seen in the past how ‘knee-jerk’ responses to child protection disasters have resulted in policies and procedures which often have unforeseen dysfunctional consequences. 

I would like to appeal to all those concerned in developing child protection policy to try to avoid quick fixes and to reflect very carefully on the lessons to be learned from Daniel’s death.

Thursday, 29 August 2013

Little Stars - Ofsted have some questions to answer

The Serious Case Review (SCR) report by the Birmingham Safeguarding Children Board and the Ofsted report of the inspection conducted on 29th Novemeber 2010, describe the standard of provision in 2010 at the Little Star's Day Nursery, (Nechells, Birmingham) a little differently.

The Ofsted report says that the quality of the provision is good:
"Children are cared for in a safe and secure environment where they are able to make good progress towards the early learning goals through a range of varied activities that challenge and stimulate their interest" (Little Star's Day Nursery Inspection report for early years provision (Nechells Regeneration Project, Nechells Park Road, Nechells, Birmingham), Unique reference number EY315338, Inspection date 29/11/2010, page 4, my emphasis) 
The Serious Case Review says that there was poor management at the nursery and that, in particular: 
“… the necessary safety mechanisms including robust staff recruitment processes, strong performance management, whistle blowing processes and a culture where no one person could assume inappropriate power within the staff group were not in place" ( page, 46 my emphasis)
To be sure the SCR report did have the benefit of the hindsight that a worker at the nursery had raped a small child there (see - 
But the discrepancy in findings between the two reports is something that must give cause for alarm at Ofsted.

I wonder whether or not Ofsted inspections have any other way of looking at safety than through some sort of tick box approach. 

I see no evidence that they actively seek to test organisational defences in order to find out where the ‘holes’ in the Swiss cheese are. 

That is the way Professor James Reason suggests is best to make organisations safer. For more on his Swiss cheese model see  

Do we need to focus on ‘a hard core’?

In New South Wales, and elsewhere in Australia, there is a shortage of child protection social workers. Some agencies are experiencing severe problems.

An interesting argument on this topic is developed by Jeremy Sammut who argues that “…(t)he real and systemic problem with child protection in Australia concerns the large number of children who are re-reported because of unresolved safety concerns”.

Sammut tells us that approximately half of all child protection reports in New South Wales concern what he calls “…a hard core of around seven or eight-thousand frequently-reported, highly dysfunctional families”. He says that “… many of these children have a long history of risk of harm reports stretching over many years, and end up being damaged by prolonged exposure to parental abuse and neglect”.

He concludes that too little is being done for these children who, he says, “… would be better off if they were removed earlier and permanently, preferably by means of adoption”.

Sammut concludes by saying that a welcome consequence of so doing would be a reduction in the numbers of child protection referrals, resulting in less stressed and therefore more effective services.

There is more than a superficial plausibility to this argument. Many years ago quality gurus, such as Deming and Crosby, told us that doing it right first time is usually cheaper than doing it wrong and then putting it right. ‘Rework’, as it is known in operations management, is usually very costly and there is no reason to suppose that it is any less of a problem in child protection than in a commercial manufacturing context. Indeed, if a consequence of not getting it right first time is that children continue to suffer abuse or neglect, ‘rework’ in child protection is not only a financial but also a moral evil.

Where I part company from Sammut’s argument is that he appears to ascribe the cause of the problems to an underlying assumption that the authorities “… believe in 'family preservation' at nearly all costs”. Personally I do not know many social workers or child protection managers, or even policy makers, who believe that ‘family preservation’ is worth a child suffering abuse and neglect; indeed I do not know any.

My own view is that we lack the relevant knowledge and resources to deal with this kind of problem. In the first place we do not have anything like the right kind of research or routine statistics to understand what is happening; about what kind of ‘hard core’ exists and how to find it. How many children who receive a child protection service each year are re-referred suffering re-abuse or re-neglect? What are their characteristics: how old are they; what are their family circumstances; what systemic and organisational factors result in their being returned home after an abusive or neglectful incident?

Secondly we are not developing the right kinds of assessment tools to use particularly with very young children. If we were to make an impact on the numbers of children who are re-referred we would need some way of having much more accurate assessments at the first signs of abuse or neglect and particularly during the child’s earliest years. Just having different versions of some standard form – along the lines of the Assessment of Children in Need approach – is completely the wrong idea. What we need are ways in which different professionals from different professions and agencies can work together to create a much fuller and more accurate assessments of, particularly, very young children referred for the first time. Possibly some multi-agency expert assessment units are required, or at the very least the incorporation of psychological and paediatric expertise into front-line teams.

Finally we need much better community child health services focused on the early years. For too long in Britain there was a catastrophic decline in health visiting and, although there are plans in hand to reverse this trend, the outcomes are still not certain.  

Having more well trained health professionals regularly visiting families at home more often, and monitoring child care and development especially during the first one or two years of life, seems to me to be something most people would welcome. It would facilitate much quicker and more decisive action if concerns of abuse and neglect come to light during the early years. 

Wednesday, 28 August 2013

Birmingham nursery rapist – confirmation bias?

Nursery worker Paul Wilson was jailed for life this week for among other things raping a small child at the Birmingham nursery where he worked.

Jane Held of the Birmingham Safeguarding Children Board provides a clear account of what went wrong in a BBC TV interview. 

She explains that staff at the nursery had expressed concerns about Wilson’s forming an inappropriately close relationship with the child, but that the local authority's designated officers made a judgement on the basis of what they were told that this was “… a matter of professional conduct not a matter of child abuse”.

Subsequent investigations by Ofsted and the local authority lacked rigour and depth, she said.

Crucially we are told that nobody talked to the child.

It seems to me that this case demonstrates what human factors experts call confirmation bias. This is a type of loss of situation awareness in which facts are selected or distorted to support or confirm a wrong mental model of the situation. ‘Bending the facts to fit the theory’ is another way of saying it.

So once a decision was taken – an issue of professional conduct, not a matter of child abuse – those investigating simply clung to this 'fact' and whatever evidence they found seemed to support it.

Confirmation bias is something that happens to all of us. Those who work in safety critical industries and those who have special safety responsibilities – such as Ofsted inspectors and local authority designated officers – should always be aware of the possibility that evidence can be tailored to support the status quo. They need to make sure that they double-check any theory or belief from an alternative standpoint.

Speaking to, and listening to, the child in this case would probably have made people think twice. Being aware of the risks of confirmation bias would have disposed those conducting investigations to review their findings more critically.

Saturday, 24 August 2013

Family Courts and the Press

Yesterday in one of Britain’s national newspapers, there was a horrifying article which names children following a custody battle in the civil courts and provides pictures of them and discusses all kinds of family details in a lurid tabloid sort of way.

I’m not going to provide a link to it, or name the paper in question, because that would be like re-publishing it.

I think it is shocking that this sort of article can appear in any newspaper, let alone a mass circulation one. I opposed easing reporting restrictions in the Family Courts. But I have had to accept that I was on the loosing side of that debate, in which those in favour pointed to all kinds of safeguards that they said would prevent individual families and children being identified and children’s rights to privacy being flouted.

I think those who so cheerily sought to ‘open up’ the family courts should now take stock and revisit the issue because this type of article has the potential to ruin children’s lives.

Friday, 23 August 2013

Have you ever read an Ofsted report?

Have you ever read an Ofsted report of inspection of local authority arrangements for the protection of children? No? You are lucky. I have just been reading the report of the inspection at Somerset County Council ( It is hard work.

The first thing you notice about these reports is that there is a lot of repetition in them. There is a section on ‘overall effectiveness’ and then a section about ‘the effectiveness of help and protection to children, young people, families and carers’ which seems to repeat some of the points made in the ‘overall effectiveness’ section. Then there is a section on the ‘quality of practice’ where some points are recycled again. That is followed by a section on ‘leadership and governance’ which seems to focus on the same issues from the leadership and governance perspective.

And it goes on and on and on .... In the Somerset report these sections occupy ten pages. They are written, as is typical in these reports, in a strange rambling style where points fall thick and fast, but evidence is hard to find. Take, for example, paragraph 12 of the Somerset report which concerns ‘overall effectiveness’:

"12. The overall effectiveness of arrangements to protect children in Somerset is inadequate. Most children who are at risk of harm are identified and receive help to protect them. However inspectors also found a number of cases where not enough was done to protect children, and where the risk of harm remained present for too long. New referrals to children’s social care services normally receive a prompt and proportionate response, but there is a lack of clarity among the different agencies about thresholds for children’s social care involvement. Somerset Direct staff are not always assertive enough in pushing cases back to referrers where a social care response is not needed. As a result, some children and families receive help that is disproportionate to their needs. "

What does “… a number of cases where not enough was done to protect children, and where the risk of harm remained present for too long” mean? Does it mean 25% or 10% or 1% of cases and for how long – a day, a week, a month or a year? We are not told.

And what is meant by the assertion that there is “…a lack of clarity among the different agencies about thresholds for children’s social care involvement”? Does that mean that a couple of people seemed a bit confused or that hundreds have signed a petition to say that the thresholds are not clear? Again the report does not enlighten us.

Finally what do we make of the statement that “Somerset Direct staff are not always assertive enough in pushing cases back to referrers where a social care response is not needed”? “Not always assertive enough” is an oddly equivocal phrase that is not very informative. I would like to know how often, compared with elsewhere, these people are not ‘assertive enough’ and I would like some standard by which to judge what is ‘assertive enough’ and what is ‘not assertive enough’. The report does not give us any of that: we are just being asked to trust the inspector’s judgement without being given any details.

Paragraph 12 is a good example of what I call Ofsted-speak. The whole report is full of phrases that are uninformative or puzzling. ‘Robust’ is a favourite word, with, for example, management of cases and quality assurance procedures not being ‘robust’. I also spotted at least three uses of the word ‘embedded’, with “routine senior-level case file auditing” being one thing, among others, that was not embedded. Oh dear …

My main objection to the report, however, is that it tends to focus on process rather than outcome. It centres on poor quality assessments, plans and what it says is under-use of the Common Assessment Framework (CAF). These are process issues if ever I saw them.

And nowhere in the report can I find a clear, well-evidenced statement to the effect that the arrangements in Somerset serve children worse than elsewhere. We are told referrals to CAMHS are slow, but there is no explanation of how much slower they are in Somerset, or why.

Another sad thing is that in the case of Somerset – which Ofsted found to be ‘inadequate’ on all counts – the report makes often puzzling recommendations for improvement, such as the following:

“Ensure that early help provision is coordinated, operates to clearly defined thresholds and aligns with social care services to enable children and their families to get help at the right level, and to move between the different levels of help as their circumstances change.”  (page 3)

I pity anyone who has to demonstrate that that has been implemented. I’ve read it several times and still don’t really know what it means.

I’m currently awaiting some developments on the Ofsted front, but hope before long to bring you a raft of suggestions about how the inspection regime could be improved. Watch this space …

Police Training

I see that the Home Secretary is reported by the Daily Mail as having “… ordered special child protection training be given to 4,000-plus officers in the National Crime Agency”. 

That seems a bit odd to me, as one of the Home Secretary’s favourite refrains is ‘I don’t interfere in operational police matters’. But if they say it in the Daily Mail then it must be true … surely!!

What I’m not at all clear about is that the new NationalCrime Agency (NCA), which will include the Child Exploitation and OnlineProtection Centre (CEOP), is to be a national body that will have a few staff based in central locations. However, most child protection work in Britain is undertaken by local authorities supported by local police forces.

I would certainly support more training in child protection for local police officers, but I am not clear what the cost effectiveness is of training NCA staff, some of whom will presumably be involved in dealing crimes like with complex frauds. 

It seems to me that what we want is some sort of national training strategy for all staff engaged in child protection, with priorities clearly identified. My gut feeling is that recognition and initial response to abuse would be the area in which money spent on training would deliver the greatest improvement in performance, but I accept that that is an empirical matter which needs some research before priorities become set in stone.

Friday, 16 August 2013

The future of the Munro Reforms and attitudes to IT

There is an interesting article in June’s issue of Practice: Social Work in Action reporting research looking at the views of experienced social work practitioners on the Munro Review. [1]

The respondents strongly agreed with Munro’s analysis and warmly welcomed her recommendations. However, they doubted whether the review would result in lasting and sustained change. Members of the group questioned the political will to implement the recommendations in a climate where cost cutting had become endemic.

Interestingly it is reported that members of the group had a lot to say about IT. Participants were reported to believe that “… key tasks were too regimented” and were “… dictated to by the demands of computer systems”.

Munro does not say a great deal about IT in her report. One way of looking at badly designed IT systems, however, is to see them as ways of unnecessarily bureaucratising activity. The IT system forces the practice by requiring that particular fields (mandatory fields) are completed in particular ways, even though practitioners perceive no value or purpose in so doing. The exemplars of the ICS system are a particularly good example. There are lots of boxes to check, but whether of not checking them helps any child, or records anything that is true and useful, or saves any time or cost is not apparently an issue.

A useful adjunct to trying to successfully implement Munro’s reforms would be to revisit the issue of IT and to devise an approach that was useful to, and supportive of, practitioners. Give people something that will make their working days easier by reducing, not increasing, unnecessary bureaucracy. Give them something that does not impose arbitrary constraints, which have no justification, and give them something that actually helps them do a demanding professional job more easily.

Surprisingly it is NOT rocket science. It just takes a little bit of sensible thought. We could do far worse than asking practitioners what they think they need - although to do so may be anathema to those who led on failed projects like ICS.

[1] David Edmondson, Ann Potter and Hugh McLaughlin, “Reflections of a Higher Specialist PQ Student Group on the Munro Recommendations for Children’s Social Workers”, Practice: Social Work in Action Volume 25 Number 3 (June 2013), 191–207

Wednesday, 14 August 2013

‘Systems’ approach to the Daniel Pelka Serious Case Review

I was pleased to read in Children  and Young People Now that those undertaking the Serious Case Review into Daniel’s death are using the ‘systems’ approach recommended by Eileen Munro and the Social Care Institute of Excellence. 

See my previous post for more details of this approach.

Tuesday, 13 August 2013

The Silly Season - Charging Plan Madness

Worcestershire County Council’s proposed scheme under which some children could be forced to help meet the costs of being taken into care, is not just silly or stupid, it’s nasty.

The Guardian quotes Tom Rahilly, head of strategy and development for looked-after children at the NSPCC, as saying: "(The scheme) has the potential to prevent parents seeking help at the earliest opportunity which will be bad for those children and means their problems will get worse."

He’s absolutely right and Worcestershire County Council is absolutely wrong on this issue. Time to think again.

A new guide to implementing Munro

Just as I was beginning – in my previous post - a lament for the Munro Review, a notification of a publication was arriving in my email in-box that seems to indicate that rumours of the demise of the review’s influence may be premature. Even if the government has gone cold on Munro there are some who still appear to be keeping a torch burning.

The document in question is Social Work Associate Practice Programme A Children’sImprovement Board Reference Document, published by the LGA, SOLACE and ADCS.

The introduction explains that following a decision by the DfE to withdraw funding from the Children’s Improvement Board it has been decided that the guide would be published by the three organisations mentioned in the preceding paragraph.

The document is 166 pages long, so I won’t be commenting in detail at this stage, but it is worth noting that the introduction identifies two main aims: 
  • To help frontline managers understand the tasks they are being asked to undertake and to help them understand how they will go about 
  • To help organisations create the conditions to support frontline managers in this role.
The starting point appears to be Munro’s aspiration in her final report: 

“This is an opportunity not to set the ‘right’ system in stone, but to build an adaptive, learning system which can evolve as needs and conditions change. It is only by seeking well balanced flexibility that the system can hope to retain its focus on helping children and families, rather than simply coming to serve its own bureaucratic ends.” Munro (2011) 

That seems all well and good, but my heart began to sink a little as I began to skim the 166 pages of the Social Work Associate Practice Programme document. It seemed to be introducing large numbers of new ideas and jargon at an alarming rate. It calls itself  ‘a reference document’ so I guess that may be OK, but I’ll let you know when I’ve got to the end, which may be some time!

Saturday, 10 August 2013

Is the Munro Review being forgotten?

In the wake of the Daniel Pelka tragedy Bridget Robb, the Chief Executive of the British Association of Social Workers (BASW), is quoted by Hayley Meachin as saying that child protection social workers are still not spending enough of their working days seeing children, rather than dealing with paperwork. She adds:

"If all your time is spent preparing for inspections, how can you possibly be expected to improve your practice?"

"… the needs of children are being lost in a target-driven culture; this makes us wonder if the good work proposed by Munro is simply being swept aside."

I agree. It seems to me that there is precious little evidence of much substantial progress on the Munro reforms. If the Government believes that it is enough simply to abridge the Working Together guidance, then I fear that they did not really understand what Munro was saying.

There are no signs of major changes in working practices designed to simplify processes and to abandon local procedural manuals.  Indeed the new Working Together opened the floodgates to creating local procedures at the same time as the national guidance was foreshortened, with what I regard as foolish, and possibly dangerous, talk of ‘local assessment frameworks’.

The Government needs to take stock of where it is on Munro. If her good work is, as Bridget Robb suggests, being swept aside, at least we should be told.

Ministers should be aware that talking the talk while not walking the walk is a role fit only for hypocrites.

Friday, 9 August 2013

Another one bites the dust ....

Now it is the turn of Somerset to get the 'inadequate' rating from Ofsted.

It is difficult to know where will be 'inadequated' next. Surely there must be some emerging themes from this growing catalogue of failure? 

It's about time Ofsted addressed that question. Just waiving the big stick of a bad inspection outcome is not enough. Learning, not finger pointing, is required.

Monday, 5 August 2013

The Child's Perspective

Carolyne Willow very rightly remarks that: “… a more striking finding of these (serious case) reviews is that all kinds of adults who are paid to protect and care for children consistently ignore the child's perspective”.

Had somebody sat down with Daniel Pelka and given him enough time and space he might have said something which would have precipitated more robust action sooner. So might Victoria Climbié or Khyra Ishaq.

But the crucial question is why it is often the case that the child's wishes and feelings are ignored or not even sought. Could it be that the knee-jerk response which has so dominated child protection in the UK – to introduce more structures and frameworks and procedures – sits uneasily with interpreting, giving meaning to and valuing what children say? So often we are forced to wallow in the pseudo-science of ‘assessment’ and ‘risk management’ and, God help us, such things as ‘inter-agency information sharing protocols’ when what we ought to be doing is playing with and talking to and listening to a child.

Politicians and civil servants and ‘experts’ have made child protection crowded with impedimenta that often have their origins in naïve policies, managerialism or theoretical quackery. Children, especially distressed children, cannot be made to ‘disclose’ conveniently in order to comply with organisational timescales and targets. Nor will they obligingly always say things which can be fitted into a box on a form. Not uncommonly things may have to be said obliquely and indirectly. It is hard to talk about pain and fear.  

Children need time and space to go at their own speed. And they need people they can trust to listen to them and to protect them – not people driven by bureaucratic imperatives which make little sense to anyone.  

Daniel Pelka and Keanu Williams - a systems approach to discovering what went wrong?

It is puzzling why so much less has been written about the tragic death of Keanu Williams, than about the murder of Daniel Pelka.

Both cases are, of course, horrific. Both appear to have involved similar failings. As we wait for the report of the Serious Case Review concerning Daniel, we must also expect the equivalent report concerning Keanu.

We certainly need to understand what has happened in both these cases. I hope the reports will result in some important learning, although I am becoming increasingly pessimistic about the ability of Serious Case Reviews to generate useful information. Just pointing out what went wrong is not enough. The reports need to be analytic. They need to go beyond simple descriptions of what went wrong and to try to answer the question of why things went wrong.

I hope the authors of the reports are adopting the systems approach to conducting a serious case review, advocated by Eileen Munro and SCIE ( The ‘systems’ model focuses on those factors in the working environment that support good practice, and those which result in unsafe working practices and systems. The idea is to produce organisational learning that provides an explanation that moves beyond the basic facts of a case and to identify underlying causes of what has gone wrong.

Saturday, 3 August 2013

Early Intervention … careless talk?

In the wake of the dreadful revelations about the death of Daniel Pelka, it’s not surprising that people should be casting around for quick fixes. The phrase ‘early intervention’ trips off the tongues of many people and certainly no-one can deny that prevention is better than cure. But the concept of ‘early intervention’ is a tricky one and the issues are complex.

Maggie Atkinson, England’s Children’s Commissioner said in a BBC radio interview (which readers in the UK can hear at

“…. maybe it’s time for us to have the conversation about whether it should be a statutory requirement that you intervene early  (my emphasis).

Helen Donohoe, Director of Public Policy, Action for Children is quoted in a press release as saying: 

“…we need to ensure that professionals have all the resources they need-in particular having the ability to intervene as early as possible (again my emphasis). 

I do not know what these speakers intended by their remarks, but there is a danger that they could be interpreted as a call for professionals to have powers to intervene earlier in family lives.  Indeed Maggie Atkinson’s remarks were taken up by Isabel Hardman (a panellist in BBC Radio 4’s ‘Any Questions’ last night - for those in the UK) who said: “… that perhaps there needs to be a statutory obligation to intervene early in these cases, even if it’s removing the child into temporary care so they (professionals) can find out what is going on.”

I have often heard people say that Eileen Munro recommended a statutory duty of early intervention. But Munro is very precise and measured in what she recommends which is:

“The Government should place a duty on local authorities and statutory partners to secure the sufficient provision of local early help services for children, young people and families.” (The Munro Review of Child Protection: Final Report – A child-centred system paragraph 5.27 - - my emphasis)

There is a world of difference between a general duty to provide early help services and taking children into care on a precautionary basis!

I recommend that anybody who wants to come to a better understanding of the issues surrounding what Munro calls ‘early help’ reads Chapter 5 of her final report very carefully. However, there is one important matter which she does not discuss in detail and which I will briefly outline here.

It is the problem of false positives. Statisticians tell us that even if we have quite sophisticated tools for assessing whether or not a member of a population has a certain characteristic (e.g. being at risk of abuse and neglect) where the actual incidence of that problem in the population is quite small, the assessment tool will predict a substantial number of false positives, i.e. instances where the assessment detects the presence of the characteristic in cases in which the problem is not in fact present. Indeed, if the tool is good enough not to miss any true cases, we would expect the number of false positives to exceed the number of true positives. For example screening tests for cancer will generally result in a number of false positives who are then referred for further examination before being given the ‘all-clear’. 

I do not believe that providing ‘early help’ to families that are ‘false positives’ is a problem if the service provided is optional, welcomed by the families and provides genuine assistance to them. For example, being able to attend a Sure Start Centre is something that many families will welcome, regardless of whether or not their children are at risk, because the centre provides services that many families value.

However, other kinds of ‘early intervention’ are quite different – such as Isabel Hardman’s suggestion that some children be removed into temporary care in order to find out what is happening in their families. Not only is such an intervention not likely to be welcomed, it is likely to be extremely harmful in cases of false positives, where some children will be unnecessarily and traumatically removed from people who are, in fact, genuine caring parents.

Indeed it is very difficult to square some types of early intervention with the obligations that we have in international law such as the UN Convention of the Rights of the Child and the European Convention on Human Rights. And I have yet to encounter a good argument against the balance which is struck admirably in the Children Act 1989 where the threshold for statutory action is defined in terms of the ‘likelihood of significant harm’.

So I think we must be very careful when it comes to discussions of ‘early help’ – which I believe must be voluntary and attractive to those to whom it is targeted. We must avoid confusing it with authoritarian forms of ‘early intervention’ that seek to reduce the threshold for statutory intervention.  And we must be absolutely clear that sound arguments for early help do not transform into calls for the state to interfere more widely in family life and to diminish the rights of children and their families.

Friday, 2 August 2013

Is Improvement Possible?

According to the Daily Telegraph, remarks made by Andrew Webb, president of the Association of Directors of Children’s Services, during a BBC radio interview on the Daniel Pelka tragedy, have drawn criticism from Peter Saunders, head of the National Association for People Abused in Childhood.

Webb is reported as saying that the number of child abuse deaths was “… remarkably consistent, which tends to suggest that there’s a problem here we will never, ever manage to crack.” In reply Saunders accused Webb of defeatism saying: “We are very interested in people who are supposed to be leading the way but who are almost throwing their hands up and admitting defeat.”

Most sensible people will be inclined to side in this debate with Peter Saunders. It is foolish to believe that nothing more can be done.

But this does not imply, in the wider debate, that something can be done quickly and dramatically. The great fallacy of the Every Child Matters agenda was precisely that – ‘a significant step’ I think Tony Blair called it, when it was nothing of the kind. Throwing policies at child abuse and neglect, and introducing untried and poorly designed systems that are supposed to mark the beginning of a new era, is the territory of the fantasist.

In contrast, what is required is small, incremental, continuous improvement. That means daily learning with the aim of having services that are just a little bit better today than they were yesterday. Modest, achievable and sustainable changes should be initiated by those who actually do the job or be based on an evolving understanding of the needs and wants of children and young people who receive the services.

This kind of continuous improvement can have impressive cumulative results. Services which are made just a little bit better every day will often be substantially better at the end of the year and significantly improved at the end of the decade. But what we do not want are grand policies devised by political and managerial elites, which take years to implement only to be shown to be hollow vessels.  

Thursday, 1 August 2013

Daniel Pelka - more reaction

Deputy Prime Minister, Nick Clegg, is quoted in The Guardian as saying:

“… I think what people worry about is that maybe one bit of the system doesn't talk to another bit of the system and information can fall between stools. That's what the serious case review is all about."

The early indications are that people were talking to each other, but the wrong decisions were being made. There is a need for great caution here, remembering some of the wrong-headed and wasteful ideas that sprung-up in the wake of the Victoria Climbié tragedy.

Please Mr. Clegg, don’t go down the information-sharing-will-sort-it all-out road. It is more complex - much more complex – than that.

The death of Daniel Pelka - early reactions

Ray Jones makes some telling points against knee-jerk reactions to the tragic death of Daniel Pelka. In particular he is right to draw attention to the increased workload that has afflicted child protection services in Britain since the death of baby Peter Connelly.|SCCC|SC019-2013-0108#.UfpWTFPUCUc 

Ray is also right to caution against the blame culture. However, he does not, to my mind, make strongly enough the important point that blame inhibits learning and that it is only through sustained and serious learning that we can hope to avoid similar tragedies. [1]

Having a model of how serious mistakes come about is absolutely essential. Most people go to work anxious to do a good job. The last thing they want to see is a tragic outcome. But individual and organisational defences against error are always imperfect. We, and the organisations we work in, are error prone, and it is only by having multiple layers of defences that most of the time things do not result in bad outcomes. [2] 

Safety is only improved by constant improvements in organisational defences and by gaining ever greater insight and understanding of our own propensities to make mistakes. We need to understand how we lose situational awareness or make bad decisions or fail to communicate effectively or respond in appropriately to authority or challenge or provide poor leadership and contribute to poor teamwork.

A Human Factors perspective [] is not just a novel or interesting approach to error in child protection. It is an essential precondition of learning how to make children safer.

[1] See Dekker, S. Just Culture: Balancing Safety and Accountability, Ashgate, 2000

[2] See Reason, J. “Human error: models and management.”  British Medical Journal 2000; 320:768-770 (18 March)