Thursday, 14 April 2016

Learning from mistakes

The tragic case of Ayeeshia Jane Smith has received wide coverage in the British press following the convictions of her mother and stepfather in connection with her death.

Only limited information about the involvement of statutory services is available at this stage, but the case appears to have all the hallmarks of one in which there had been substantial involvement prior to the child’s death. The child had been in care and then returned home; and she was subject to a child protection plan. Inevitably the papers are asking the question ‘why?’ and some are comparing the case to the Baby Peter tragedy.

An MP is calling for a public inquiry to be set up.

Until the Serious Case Review (SCR) report is published we can only speculate about the extent and nature of statutory services’ involvement. However, I believe that we are unlikely to learn much new about how to make services safer from either the SCR or from any form of inquiry. Almost certainly the kind of mistakes that have happened in this case are comparable to those that have happened in all the similar cases dating back to Maria Colwell in the early 1970s and beyond. Professionals have lost situation awareness, made poor decisions and become embroiled in communication foul-ups. Simply recounting it all again will not make it less likely that they will reoccur.

Instead of putting our faith in formal administrative reviews or legalistic inquiries, it would be much better if we applied what we know about the psychology of human error and addressed the questions of how people working in child protection organisations make mistakes and how they can work more safely. We need to address the question “why?” Why are ‘obvious’ signs of abuse and neglect missed? Why do individual practitioners and groups of professionals sometimes become strongly attached to misperceptions and misjudgements which seem to them at the time very sensible but which are hard to justify with the benefit of hindsight? Why do communications become confused or obscured?

I am delighted to see that the British Department for Health is now strongly embracing a human factors approach to safety and I was impressed by a speech made by the Secretary of Sate for Health, Jeremy Hunt, in which he argues is that patient safety is compromised because there is more interest in blaming than in learning.

Quoting Matthew Syed’s book Black Box Thinking Hunt draws heavily on the experience of the airline industry saying: “… the airline industry realised that if it was going to reduce airline fatalities, it needed to change its culture. They realised that ‘human factors’, rather than technical or equipment failure had been at the heart of the problem.”

He goes on to argue that in order to improve safety in the NHS there needs to be a cultural change involving two elements: (i) openness and transparency about where problems exist and (ii) a true learning culture to put them right. He explicitly draws on the experience of civil aviation in developing human factors approaches to safety, and announces a proposal to create an organisation modelled on the Air Accident Investigation Branch to investigate accidents and safety concerns in health care (something that I suggested for child protection in 2010 - He stresses that: “Other industries – in particular the airline and nuclear industries – have learned the importance of developing a learning culture and not a blame culture if safety is to be improved.”

Hunt has told the House of Commons that the Government proposes developing this type of safety culture in the British National Health Service (NHS). That is a development greatly to be welcomed.

What is less welcome, however, is that there appears to be little by way of parallel developments from the Department for Education, which in England is responsible for children’s social care and child protection. Indeed a significant disconnect appears to be emerging between the safety approaches being developed in the NHS and attempts to improve safety in child protection and children’s social care, which are still deeply rooted in old-fashioned administrative approaches to human error and a thinly disguised blame culture.

Children’s sector leaders are by and large dismissive or disinterested in human factors thinking. There is no knowledge or interest within Ofsted about this type of approach. Civil servants have told me and other campaigners that they believe human factors training is of marginal value to child protection and that learning from error is adequately taken care of by serious case reviews! Now, while closely linked services within the purview of the Department of Health are to be taken down the fruitful path that has been well trodden by the airline and nuclear industries and which is a proven route to greater safety, it appears that children’s services are to be allowed to languish in a safety time warp.

In my view officials from the Department for Education should be meeting urgently with their counterparts in the Department for Health and trying to go up the steep learning curve they need to climb to begin to embrace the ideas that Jeremy Hunt has so clearly articulated.