With the benefit of the hindsight there can be little doubt that the ruling by a highly experienced judge in the case of six-year-old Ellie Butler that she should live with her father, Ben Butler, was a catastrophic error. As we now know Ellie’s father subsequently beat her to death.
The phrase “with the benefit of hindsight” is one that we often hear in these circumstances. It belies the fact that we never take decisions with the luxury of knowing for sure what the outcome will be. Indeed, we only experience the ‘benefits’ of hindsight when it is already too late. Parading the view from hindsight as a counsel of perfection is seldom, if ever, helpful. “So-and-so ought to have done X” is often just a statement of the blindingly obvious. It does not help us to understand how to make practice and systems safer in the future.
For all our attempts to learn from forensic and microscopic examination of child protection tragedies, by means of public enquiries and Serious Case Reviews, we have not learnt enough to prevent similar tragedies occurring with sickening regularity. We probably haven’t even learnt enough to make their occurrence less likely. We continue to be shocked by some new and hitherto unthinkable way in which the best laid plans, and the most developed systems, seem to be riddled with holes through which the trajectory of errors pass untroubled. For all our best endeavours things keep going wrong in surprising ways.
More often than not when a child dies, because an opportunity to protect is missed, it is a decision taken by a social worker or a doctor or a health visitor which comes under intense scrutiny and which is at the centre of the media storm. In this case it was a decision which was taken by a judge.
The Guardian’s editorial tells us that judges are different from professionals like doctors and social workers and health visitors. The editorial argues that there are “sound constitutional reasons” that prevent judges appearing before external enquiries and that the only appropriate place to challenge a judicial decision is in a higher court.
I am no expert on the constitution, but I agree that a public inquiry, such as the one demanded by Ellie’s grandfather at which the judge and others involved would have to testify, would be unlikely to explain why things went wrong. I expect that the outcome would be to provide more factual detail with no increased understanding of the causes or how to prevent a reoccurrence in future. The vast amount of money spent on the Victoria Climbié inquiry produced lots of detail, but little understanding. An inquiry into Ellie’s death would be likely to be similarly unproductive.
I believe that what is required are not more post mortems but more pre mortems. Instead of trying to unearth the ephemeral historical ‘truth’ of tragedies like Ellie’ s, we need to try to understand how and why we make mistakes and how why our organisations fail to prevent some errors. We need to understand why sometimes we lose situation awareness and why sometimes we make flawed decisions and why sometimes our communications are misunderstood or not heard. Reflecting on tragedy will not help us, but reflecting on day-to-day practice will.
We need to learn from professionals in other kinds of safety critical industries about how human factors contribute to safety – or to the absence of it – and about ways in which we can build safer and more resilient organisations which have better defences and less error traps.
Surprisingly beginning a journey like that is not hard to do. We need to acquire a language which allows us to talk about our errors and to put them into their scientific context. We need to be able to look at the defences against error in our organisations and to analyse them to find their weaknesses. And we need to build a culture in which talking about error is the norm. We need to ensure that those who want to talk about errors and to learn from them are congratulated for doing so, not punished.
If we want to stop further tragedies like Ellie’s we must start to do that. Either in our workplaces with our colleagues, or, if we are judges, in our chambers with other judges. We all make mistakes, most of the time. The greatest crime is not to discuss them openly, to analyse them and to learn from them.