Monday, 11 September 2017

Reflections on the Ayeeshia-Jayne Smith Serious Case Review

In the wake of the serious case review into the death of Ayeeshia-Jayne Smith, Joanna Nicholas (in the Guardian) wrestles with the problem of agencies appearing just to pay ‘lip service’ to the importance of learning from child protection tragedies. She concludes that we “… make all the right noises but then seem to carry on doing what we were doing before”.

Joanna points to two apparently obvious failings highlighted in the review: failure to follow-up a missed medical appointment of a child subject to a child protection plan and failure of medical staff to think about the possibility of abuse and neglect in framing their differential diagnosis. She despairs that what she calls these ‘simple aspects of practice’ were not followed in Ayeeshia’s case.

Sadly, except for a couple of concluding comments that there needs to be more research and clearer management direction, Joanna doesn’t provide us with a solution to the problem she outlines.

In contrast, I think that there is a solution. I think that what is needed is to create a responsive safety culture in child protection, just as they have done in other safety critical industries. We need to stop wagging the finger of blame and hoping to solve problems by top-down management fiat. Instead, we need to give people permission to learn and to put things right.

Unsafe practice persists not because child protection professionals are weak, ignorant, lazy or ill-informed, which, of course, by and large they are not. It persists because they are too often prevented from speaking openly and critically about what goes wrong routinely and analysing why it goes wrong.

Human error and organisational failings, just like Benjamin Franklin’s death and taxes, will always be with us. Rather than pretending that they can somehow be switched off at the click of a button, if only we could find it, we need to realise that the only solution is to improve continuously in small incremental steps. Building safer organisations and fostering safer practice is something that everybody involved in child protection needs to be involved in every day. They need to be permitted, encouraged and rewarded for learning from all the small and seemingly insignificant errors that are part of routine practice, but which one day may cumulate to cause a tragic death.

Professionals need to concentrate not so much on relatively rare tragedies. Rather, they need to focus on the mundane daily errors which we all make and look at ways in which better defences to them can be built and sustained.

Joanna Nicholas begins her article by asking: “when will we child protection professionals learn from child deaths?”

I would prefer to rephrase that question as follows: “when will we all (professionals, managers, policy makers, politicians, members of the public, journalists) realise that daily continuous learning is central to a safety critical activity like child protection? And when will we begin to put in place the conditions that are necessary to make that kind of learning flourish?”