Thursday, 28 April 2016


The revelations of a toxic culture of cover up and denial and blame in the South Yorkshire police force, which are now revealed following the Hillsborough inquests, contribute greatly to our understanding of what went wrong in Rotherham, a town served by that same police force, where young people were ruthlessly sexually exploited without effective action by the police and other agencies to protect them.

Clearly on that fateful day in 1989 terrible mistakes – errors of judgement - were made in the policing of the football match. If only the reaction of the police had been to be immediately open and frank about the disaster, to be honest about what may have gone wrong and to look for safety lessons, not scapegoats, it could all have been so different. A great deal of needless unbearable pain and suffering could have been avoided.

Whether it be football crowd control or responding to child abuse and neglect, the message from recent events is clear. There are no greater enemies of public safety than secrecy, fear, blame, denial, conspiracy and self-protection.

Wednesday, 27 April 2016

Human factors thinking in child protection - cheaper and quicker than blue skies research

NSPCC Scotland’s Matt Forde, writing in The Herald, makes the astute observation that if inquiries into child protection failures worked, the problem of preventing child abuse and neglect would have been solved by now. He says: “Dozens of cases, over more than four decades, cite familiar problems – professionals not talking to each other, not putting the picture together and missing opportunities to act.”

Matt goes on to recommended increased spending on research into the causes and consequences of abuse and neglect – undoubtedly a very worthy cause – but my conclusion from his premise is somewhat different. 

If inquiries into the causes of disasters have not worked, we need to think of better ways of gaining an understanding of why things go wrong. That’s exactly what they realised in civil aviation in the 1980s and since then they have practiced human factors thinking [*] which helps all kinds of employees – not just pilots – to recognise how and why mistakes happen in the workplace and what can be done to put them right.

Human factors thinking is not about blue skies research. It is based on a number of simple skills, stemming from the insights of the psychology of human error, which are practiced daily by everybody involved in a safety critical activity, like child protection. 

It ain’t rocket science and it’s a lot cheaper and quicker than conducting huge studies into the causes and effects of abuse. And we could all be doing it, as they do in other industries, if only the leaders of the children’s sector and their political rulers would open their minds and see the sense of it.

* See Flin et al Safety at the Sharp End: a guide to non-technical skills Farnham, Ashgate, 2008 - for a very readable introduction.

Tuesday, 26 April 2016

Child Refugees

James Brokenshire MP, a Home Office minister, is reported in the Guardian as saying in the recent House of Commons debate that for Britain to accept refugee children already in Europe would “…. inadvertently create a situation in which families see an advantage in sending children alone, ahead and in the hands of traffickers, putting their lives at risk by attempting treacherous sea crossings to Europe which would be the worst of all outcomes”.

That’s a bit like saying that we shouldn’t provide medical care to the victims of motor accidents because to do so might encourage people to drive less safely!

The Shadow Immigration Minister, Keir Starmer MP has my support. He is reported as saying that Brokenshire is arguing that we must abandon these children to their fate. I’m glad that Starmer and many other Parliamentarians, such as Alf Dubbs and Yvette Cooper,  are standing up to this indefensible and cruel policy adopted by the British government.

Sunday, 24 April 2016

Education Committee - written evidence from the Safer Safeguarding Group

The Safer Safeguarding Group’s written evidence to the House of Commons Education Committee enquiry into the reform of children’s social work can be found on the Committee’s website.

The group concludes that the Government lacks a clear focus on safety in children’s services and fails to take account of a human factors approach to making children’s social work safer. On a number of important issues – training, recruitment and retention, learning – the Government fails to provide a clear analysis of the problems and any clear vision of how safer and higher quality children’s social work can be brought about.

The Safer Safeguarding Group’s evidence stresses the need for cultural change and the importance of helping children’s social workers talk more freely and openly about the errors they make so that they can learn more readily from then and discover the error traps that lurk within their organisations.

The group commends to the Committee inexpensive and evidence-based approaches to learning that have found favour in other safety critical industries – human factors training (mandatory in civil aviation) and Near Miss Reporting, which has played a significant role in exposing error traps in fields such as civil aviation and anaesthesia. 

Because the protection and safeguarding of children is a multi-agency activity, involving the practice of many different types of professionals and agencies, the group believes that a learning culture based on an understanding of human factors and near-miss reporting should be incorporated into multi-agency training and management of cross-agency work, not just social work training.

Thursday, 21 April 2016

Retention, not recruitment: that's the problem

Moira Gibb, who chaired the Social Work Task Force a few years ago, has hit the nail on the head in giving evidence to the House of Commons Education Committee regarding the Government’s plans for the accreditation of children’s social workers. She is quoted in Community Care as telling the Committee that the problem is that there are plenty of people who join the profession but they don’t stay; and that what is needed is people who have long experience, not people who practice for a couple of years and then move on.
She is absolutely right to recognize that it is difficulties retaining experienced children’s social workers that is the problem. And I believe that retaining people requires careful thought about how jobs are designed and about how staff are developed and supported; not just quick apparent fixes with silly natty titles.

I've been banging on about the importance of retention since 2009, without much success. I hope Moira Gibb, will have better luck in getting people to listen to her. Who knows?