Tuesday, 19 January 2016

Getting it wrong about making mistakes: flaws in the government’s vision for children’s social work

I have been reading the British Government’s latest document about children’s social work in England - Children’s social care reform: a vision for change 
I should say that there is quite a lot I don’t like in this document, so my spirits picked up when I noticed what promised to be an encouraging paragraph on page 7. Talking of practice and systems it says:

“Learn when things go wrong. The system is still too often characterised by repeating the same mistakes. We need a deeper and more sophisticated understanding of why mistakes occur and how the system can learn to avoid them. This requires overhauling the serious case review process.”

There is so much to agree with in this paragraph other than its conclusion! We must learn from things going wrong, the same mistakes do keep happening and we need a better understanding of how they happen and how to avoid and mitigate them. But we don’t want to spend a lot of time reforming the serious case review process. There are better ways.

I have held forth before about serious case reviews and I have now come to the view that they cannot be made to work. They are costly, time consuming and disruptive. They are often very slow to report. They are nearly always descriptive rather than being analytical. They are unrepresentative, because they concern mostly fatal or near fatal incidents. And they don’t get at the truth, often because the people involved in the incident have something to gain by not being open with those conducting the review. In short there is so much wrong with serious case reviews that the prospect of an overhaul is not just daunting, it is overwhelmingly dispiriting.

Instead what we should be doing is building a just and responsive reporting culture, in which everybody, but perhaps most importantly those that work on the front line, feel confident about reporting, discussing and analysing what goes wrong in everyday practice and how to put it right. Such a reporting culture would be based on a widespread understanding of human factors in the workplace, supported by systems which encourage openness and reporting, such as confidential near miss reporting, and underpinned by an ethic which values, respects and protects those who raise safety concerns.