Thursday, 27 March 2014

A Tale of Two Cities?

Two neighbouring English cities, Birmingham and Coventry, have child protection services that are deemed to be ‘inadequate’. Both are in the news today airing their improvement plans.

Coventry is calling a special meeting of councillors to discuss the situation.

Birmingham has had a ‘commissioner’ imposed on it by the government.

I wonder if these cities are really the ‘bad apples’ that many people assume they are, or whether they are just symptoms of a wider malaise. How many other children’s services departments in other British cities are operating at full stretch? How many social workers struggle daily with inadequate resources? How prevalent is the toxic blame and shame culture? How many opportunities for learning are being lost because people are afraid to talk openly about where and how mistakes happen? How many children are at risk of re-abuse because services are not meeting their needs?

Brum and the New Commissioner

I’m at a bit of a loss to know exactly what Labour peer and former minister, Lord Norman Warner, is going to do in his new role as ‘commissioner’ of Birmingham Children’s Services. 

I’m sure that somebody somewhere thinks this is a good idea, but I frankly can’t see how adding more tiers of management and oversight is likely to result in the much needed improvements.

What Birmingham needs is a change of culture, not a change of top personnel. And it desperately needs more resources at the front line, not another overlord.

Tuesday, 25 March 2014

Moving beyond blame in Tennessee

There is a very interesting article in the Tennessean recounting the Tennessee Department of Children's Services’ sponsoring of what is thought to be the first survey of child protection workers in the USA.

It is reported that the survey was designed by Vanderbilt University’s assistant professor of health systems management, Michael Cull. It is said to reveal that caseworkers involved in investigating child maltreatment, and rescuing children from it, consistently work overtime, tend not to recognize how stress and fatigue impacted their decisions, and recognise that the ways in which they work with supervisors to detect and correct problems can be improved.

The survey attempted to assess three things: the relationship between caseworkers and their supervisors, their willingness to speak about their problems, and factors that result in burnout.

Of particular interest to me was that the caseworkers were asked how often mistakes were "held against them”. This seems to reflect a very encouraging approach in Tennessee’s Department of Children’s Services, where it seems managers are trying to encourage staff to speak openly about their mistakes in order to learn from them. Tennessee’s deputy commissioner of child health, Tom Cheetham, is quoted as saying: "We've moved beyond a blame culture, where we won't ever really know what's going on. Our staff — everyone — needs to believe, not by our words, but our actions, that we're not looking to blame."

This is exactly the approach that we need in Britain – and everywhere else too. I would dearly love to hear some senior leaders of children’s services in Britain echo Tom Cheetham’s words. Without encouraging people to speak openly about their mistakes little progress will be made to make child protection work safer.

Saturday, 22 March 2014

Welcome IT from the National Health Service in England

Having been a fervent opponent of ContactPoint and a strident critic of both eCAF and ICS, some readers may assume that my response to IT systems in child protection is invariably negative. 

That would be a mistake. The NHS CP-IS (Child Protection Information Sharing Project) is in my view exactly what is required and it is a great pity that it wasn’t developed and implemented many years ago, rather than having to wait while policy makers played fast and loose with poorly conceived IT systems of no proven worth, such as ContactPoint.

Unlike those other systems CP-IS has a clear and comparatively simple objective. It aims to inform NHS medical staff treating a child (1) whether that child is either subject to a child protection plan or looked after by the local authority and (2) to tell local authority children’s social care staff if a child who is subject to a child protection plan or who is looked after receives NHS care.

That means that if a child who is, for example, subject to a child protection plan is taken to the Accident and Emergency Department of either a local hospital, or one in another town or city, staff at that hospital will know that s/he is subject to a child protection plan and subsequently her/his social worker will be informed that the hospital visit has taken place.

You can discover more about CP-IS at:

I think the architects of CP-IS are to be congratulated for designing a system which only exchanges small amounts of data about a small number of children in circumstances which are entirely justifiable. My only reservation about the system is that it seems it will only be implemented in England. I think there should be a single joined up system for the whole of the UK.

Friday, 21 March 2014

Coventry’s latest Ofsted Report – a verdict of ‘inadequate’

It comes as no surprise that Ofsted’s inspection of child protection arrangement in Coventry has come to a verdict of ‘inadequate’. Managers and elected members there have been quite open about the problems the organisation has experienced in the wake of the death of Daniel Pelka.

A copy of the report can be downloaded from the Ofsted website. The story is also covered by the Coventry Telegraph and the BBC.  

The report of the inspection says that staff in Coventry’s referral and assessment teams cannot do their jobs properly because of very high caseloads. As a result, the authority is said to be too slow in responding and children who need protection are not being seen or assessed sufficiently quickly.

Leadership and management of children's services are also criticised as being below standard. And - surprise, surprise - information sharing between agencies is also said to be inadequate. The Coventry Safeguarding Children Board is also criticised.

Brian Walsh, the council’s recently appointed director of children’s services, said that he was expecting a poor Ofsted report, following the impact of the Daniel Pelka tragedy. He drew attention to the significant rise in the number of referrals to the authority Children’s services. Caseloads were said to have risen from just over 3,000 children in 2013 to just over 4,500 a year later.

I am firmly convinced that there is often a downward spiral following a child protection tragedy. More referrals result in increased pressure on staff and resources. In turn that results in increased vacancy rates because not many people want to work under great pressure for an ‘inadequate’ employer.

I am pleased to see that  Coventry City Council is making extra resources available to try to address the issues, but sadly I think the Ofsted inspection system points to, and indeed exacerbates, the problems while not identifying the solutions. The inspector provides a long list of recommendations of the this-is-wrong-put-it-right variety (see page 6 of the report), but I don’t see how any of these tackles the fundamental problem of too few people doing too much work.

Thursday, 13 March 2014

A case for learning, not blaming

The provides an account of a situation in which colleagues’ concerns about a nursery worker appear to have been dismissed, when in fact he was abusing two young boys.

Reports of fellow workers’ ‘discomfort’ with the man are said to have been confused with the mistaken belief that there was discrimination against a male worker.

This is a good example of not being able to see what is happening despite there being some clear evidence that things are amiss. It is only too easy in an institutional context for a ‘corporate view’ to emerge which seems reasonable at the time, but is hard to justify with the benefit of hindsight.

Confirmation bias – our natural tendency to find evidence that supports our beliefs, rather than information which refutes them – and fixation/distraction error – in which an individual or group focuses on the wrong issue excluding other possibilities - were probably factors in the apparent short-sightedness of managers in this case.

The authors of the Serious Case Review report also note how difficult it is to whistle blow, arguing that whistle blowers often fear receiving a 'shoot the messenger' response.

There is no point blaming individual managers in this sort of case. We need to consider how we can create organisational cultures in which decisions are properly explored, challenged and reviewed and in which people are able to feel safe in raising concerns.

Wednesday, 12 March 2014

Mandatory reporting is NOT necessary: striking the right balance in Queensland

I was pleased to read that the Queensland State Government in Australia has decided against introducing mandatory reporting, despite a petition calling for new laws making it an offence for childcare workers not to report suspected cases of abuse. Instead it has been decided to put in place reforms recommended under the Queensland Child Protection Commission of Inquiry. These include improving prevention and support services and the statutory response to children at risk of significant harm. Stronger reporting guidelines will be drawn up making it clearer when childcare workers should report abuse.

This is clearly the right way to go. I hope those in England campaigning for mandatory reporting in response to the tragic death of Daniel Pelka will take note of what is happening in Queensland.

Mandatory reporting will not bring about safer services – and may even make children less safe, because it will make practitioners defensive. Helping professionals to be better at recognising child abuse and neglect and being better informed about how to respond seems to be a much more constructive way forward.

Monday, 10 March 2014

More news from Coventry

The BBC has another report from Coventry, this time on the effects on demand for child protection services following the Daniel Pelka tragedy.

The report says that the number of referrals involving suspected child abuse in Coventry has increased by 40% since 2011. The number of calls per day reporting suspected abuse is said to have risen from an average of 42 calls per day in 2011 to an average of 60 per day in 2013.

Council officials are reported as saying that it is difficult to recruit and retain sufficient numbers of permanent trained social workers to meet the increased demand and that there is heavy reliance on agency workers staff.

The leader of the council is reported as saying that Coventry’s social workers have a high rate of burn-out. Apparently there has been a large increase since 2010 in the numbers off work because of stress.

The leader of the council is quoted as describing the council’s social workers as ‘heroes’ saying that she does not know why they do the job.

There often seems to be a downward spiral following a child protection tragedy. Members of the public and professionals have heightened awareness of the risks of child abuse and neglect. They make more referrals, which increases pressure on the local authority. Members of staff come under increased pressure, resulting in sickness absence and increased vacancy rates. That results in poorer quality services and increases the chances that something will go seriously wrong. Children are put at greater risk.

Tuesday, 4 March 2014

The legacy of the tragedy of Daniel Pelka?

The BBC has a report [1] from Coventry about the continuing impact on the city’s children’s services of the death of Daniel Pelka. A social worker tells the BBC that he and his colleagues:  

·       Take the tragedy “really personally”

·       Feel responsible

·       Acknowledge that they have “collectively failed"

·       Understand that the social workers involved in the case lacked both “support from partner agencies” and relevant information

The social worker concludes by saying that they have all read the serious case review report and that they all know Daniel’s case “inside and out”.
Some might be tempted to think that the serious case review process has had a significant impact. But I am sceptical. Over the years I have become less and less enamoured with serious case reviews. Time and time again these reviews seem to identify the same sort of factors  - especially inter-agency co-operation and information sharing – and time and time again, despite everybody claiming to have learned the lessons, another child dies somewhere else in very similar circumstances, occasioning yet another serious case review.

And I wonder to what extent the kind of self-flagellation that they seem to be going through in Coventry contributes to greater safety. Perhaps it just distracts from the crucial issues?

In a very interesting and important paper published last year [2], Andrew Turnell, Eileen Munro and Terry Murphy argue that child death inquiries “ … repeatedly manufacture the notion that the cause of the fatality can be isolated, those culpable identified, and then new procedures can be put in place to make sure the tragedy will never happen again”. They suggest that what they call this “linear approach” has resulted in little improvement.

I heartily agree. Serious case reviews focus on cases which are unrepresentative of normal practice – usually cases in which a child has died – and generally they describe what has happened but fail to explain why. They take a simple, mechanical view of causation – information wasn’t shared or agencies didn’t co-operate, therefore lack of information sharing or inter-agency co-operation was the cause of the tragedy – and they seldom if ever reveal the kind of ‘error traps’ [3] that we know lurk beneath the surface of all business and professional processes. They continue to assume that human error is a rare aberration rather than a normal part of everyday practice. Often their authors seem to believe that error can be eliminated by the adoption of simple bureaucratic rules and procedures.

If that wasn’t bad enough serious case review reports take a long time to prepare and circulate. They are often long and difficult to read. They make numerous and often puzzling recommendations and they contribute to a continuing culture of blame by suggesting that the actions of individuals or groups specifically ‘caused’ the tragedy. They operate with lashings of hindsight bias and more than just a smidgen of holier-than-thou.

I don’t think the answer to these problems lies in reforming the serious case review process, although I do not think that fatal incident inquiries should be abolished altogether. The priority, I believe, is to recognise that the primary approaches to learning are to be found in other places.

I know of two methods that offer a fresh and different approach to learning about how to provide safer child protection services. They are similar to each other. 

The first is Confidential Critical Incident Reporting [4] (sometimes called Confidential Near Miss Reporting) which offers practitioners a safe and supportive means of reporting their mistakes in such a way that others can learn from them – before a tragedy occurs. Confidential Critical Incident Reporting has been widely adopted in transport industries [5] [6] and some branches of medicine [7] [8] [9]. It has even been used to understand failures in marketing [10]. It provides a means of achieving what James Reason tells us is a precondition of safer organisations: a reporting culture. He writes:

‘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.’ [11]

The second method has its origins in manufacturing. Kaizen [12] (the Japanese word for ‘improvement’) is the idea that all employees should be involved on a daily basis in a constant and continuous quest for information about the causes of quality defects and about ways in which small but significant improvements can be made to improve business processes. Lots of small changes add up to something significant, even momentous - as they found out at Toyota in the 1950s-1960s when they introduced Kaizen. They collected thousands and thousands of suggestions from their workers on a daily basis, all for making small changes to improve quality, to make processes run more smoothly or to eliminate waste and delay. Within ten years they moved from being a very inefficient producer, with low quality products, to being one of the most efficient with very high quality – a world-beater in fact.

Unlike serious case reviews, which tend to be bureaucratic exercises, neither Critical Incident Reporting nor Kaizen are just methods. They are philosophies or cultures of practice. They are about management realising that business and professional processes are best understood by those who deliver them (not by supervisors or 'experts' or consultants) and that the role of management is not to implement change top-down, but rather to facilitate improvements suggested from the 'front-line'. In this way all the little things that many managers do not even know about that result in poor quality or unsafe practices are revealed and addressed.

That’s the way to make child protection services safer and to offer children and young people higher quality services. It would be good if it were to become the legacy of the tragic death of Daniel Pelka, rather than a long, puzzling and, I believe, not very informative report! 



[2] Andrew Turnell, Eileen Munro and Terry Murphy: “Soft is Hardest: Leading for Learning in Child Protection Services Following a Child Fatality” Child Welfare, Vol. 92, No. 2, 2013. There is a brief journalistic summary of this article at: 

[3] See Reason, J. “Human error: models and management.” British Medical Journal 2000; 320:768

[4] Flanagan, J.C. (1954) ‘The Critical Incident Technique', Psychology Bulletin, 51, pp.327-58


[6] Edvardsson, B (1992) “Service Breakdowns: A Study of Critical Incidents in an Airline,” International Journal of Service Industry Management, 3 (4), 17-29

[7] Williamson, J. (1988) 'Critical Incident Reporting in Anaesthesia - Monitoring and Patient Safety', Anaesthesia and Intensive Care, 16, pp. 101-03.

[8] Mahajan, R. P. “Critical incident reporting and learning” Br. J. Anaesthesia (2010) 105 (1): 69-75

[9] S. Reed, D. Arnal, O. Frank, J. I. Gomez-Arnau, J. Hansen, O. Lester, K. L. Mikkelsen, T. Rhaiem, P. H. Rosenberg, M. St. Pierre, A. Schleppers, S. Staender and A. F. Smith, “National critical incident reporting systems relevant to anaesthesia: a European survey.”

British Journal of Anaesthesia 112 (3): 546–55 (2014)

[10] Gremler, D.D. The Critical Incident Technique in Service Research, Journal of Service Research, Volume 7, No. 1, August 2004 65-89 

[11] Reason, J op. cit 

[12] Imai, M. (1986). Kaizen: The Key to Japan's Competitive Success. New York: Random House