What am I saying in my response to the Government’s consultation on the Revised Safeguarding Statutory Guidance? (1) About the document titled "Working Together to Safeguard Children"

This is the first of three posts on what am I saying in my response to the Government’s consultation on the Revised Safeguarding Statutory Guidance. This post is about the document entitled Working Together to Safeguard Children - http://www.education.gov.uk/a00211065/revised-safeguarding-guidance

I say:

• This guidance appears to cover most of the main legislation, but not always in a logical and accessible way.
• Like the other two documents, this document is written in a dense style – ‘official-ese’ - which makes few concessions to the reader.
• I believe that it would be preferable for documents like this to be written with a view to being helpful to those who have to read them. For example this might be achieved by organising the information about the duties and responsibilities of each agency under logical headings. Listing agencies in alphabetical order might also improve accessibility.
• The Guidance provides an outline of what Local Safeguarding Children's Boards should do and provides some pointers to good practice. How these bodies become ‘effective’ (or ‘more effective’) is beyond the scope of guidance of this type – a textbook on that subject would be required.
• There should be more learning from best practice and sharing ideas between LSCBs. The Guidance might be improved to suggest ways in which this could be done.
• Thematic inspection or research into the effectiveness of LSCBs would be helpful, but this must go beyond superficial enquiries and simplistic research questions, typical of many Ofsted inspections. Substantive issues should be addressed such as what are the outputs of LSCBs, what impact do they have, how are they planned and controlled, how could they be improved?

Child abuse and witchcraft

Tim Loughton, the Children’s Minister, is 100% correct to prioritise stopping ritual child abuse conducted because the perpetrators believe that the child is a witch. http://www.telegraph.co.uk/news/religion/9475115/Witchcraft-child-abuse-social-services-and-police-cowed-by-political-correctness-claims-minister.html

Tim is right to want to raise awareness of police, social workers, health and other professionals.

Although I am generally sceptical about the impact of the criminal law in reducing child abuse and neglect, some years ago I suggested that a criminal offence of inciting significant harm to a child might be considered.

My idea was that this should be akin to the offence of inciting racial hatred (Race Relations Act 1976, Public Order Act 1986, Criminal Justice and Public Order Act 1994). No specific person would have to exist as the object of the incitement. It would be sufficient that a person urged others to commit an assault on any child.

That, I thought, would be one way to prosecute ‘rogue pastors’ and others who advocate brutal treatment of children who are believed to be witches, but who are careful not to be seen to conspire with others to commit a particular criminal offence against a particular child.

Would that be helpful? Let me know by emailing: chris-mills-child-protection-blog@gmx.co.uk

Learning from the Olympics

Ian Dean, the Manager of the London Safeguarding Children Board, provides an interesting account in today’s Guardian of how London Boroughs have co-operated to provide a child protection service covering the "Olympic co-ordination zone", which spans four local authority areas. http://www.guardian.co.uk/social-care-network/2012/aug/07/safeguarding-children-olympics?newsfeed=true

The interesting issue which Ian does not go on to discuss is, if this type of co-operation between local authorities is possible during the Olympics, why is it not occurring more commonly on a-day-to-day basis? In an age of central government cuts and restricted local government budgets, it makes enormous sense to consider what parts of child protection services can be provided more efficiently across a larger area. Why duplicate services and resources across the thirty-two local authorities (boroughs) which form London?

Greater co-operation would result not only in services which are more efficient, and therefore cheaper, but in higher quality services. A central point of referral would act as a central store of information. A larger group of social workers could be deployed more flexibly and more quickly. Pooling intelligence and human resources would result in a much larger pool of corporate and professional knowledge. Common systems for recording would speed the service response and ensure that information was appropriately shared. Out of hours services would benefit particularly.

I find it surprising that London Boroughs and other local authorities, especially in metropolitan areas, have not been more inventive and aggressive in trying to co-operate and share child protection services. As I understand it, legislation (Local Government Act 1972 and Local Government Act 2000) allows officers of one authority to act as officers of another and for one authority to delegate a function to another authority and for two or more authorities to jointly exercise their functions. So the legal basis seems clear, as it must be in order for this to have happened during the Olympics.

Perhaps the London Safeguarding Children Board will now take the model forward with a view to widespread co-operation in child protection across the capital?

Puzzling Statistics

What strange statistics the mandarins of Whitehall produce. I came across these on Child Death Reviews the other day.

http://www.education.gov.uk/childrenandyoungpeople/safeguarding/safeguardingchildren/a00211333/child-death-reviews-completed-in-england-31-march-2012

I found them to be virtually impenetrable and surprisingly uninformative.

The only purpose I can think of in having child death reviews is to discover how children die and how they can be made safer. But these statistics seem to concentrate on the child death review process, rather than on issues of improved safety.

I defy anyone to read them and be any the wiser about how to save children’s lives as a result.

Systems, not individuals, failed Shafilea Ahmed

I am sure that Barbara Ellen, in today’s Observer,  is right in saying that it is wrong to say that the death of Shafilea Ahmed can be blamed on “… a culture of political correctness, liberalism, leftie cultural squeamishness, call it what you will”.

And I am sure that she is right in suggesting that health, police and social care systems failed Shafilea badly.

But I do wish that she had been more careful not to invoke the blame culture  - what Sidney Dekker (The Field Guide to Understanding Human Error, Ashgate, 2006) calls the ‘Bad Apple Theory’ - as she does when she writes:

  

“This failure wasn't about some misguided PC wish not to offend Islam, or anything else, it was about incompetence, pure and simple: the collapse of a system of care, leading to a young girl falling through the cracks.” (my emphasis)

Yes, a young girl fell “through the cracks”, but we have no reason to believe that it was due to the incompetence of anybody. It is much more likely that individuals, trying their best to deliver services through imperfect and error prone systems, were unable to see what was happening to Shafilea. We should begin by assuming that it was the systems that failed, not the individuals. As Sidney Dekker says “You have to assume that nobody comes to work to do a bad job.”

Everything we know about investigating accidents and disasters points in the direction of what Dekker calls "the new view of human error". Mistakes by individuals are not a cause of things going wrong, but rather they are an effect of failings in the design of systems and organisations. Inquiries should not end with the conclusion 'human error'; they should begin by looking for the deeper causes of human error. 

That, of course, is also the perspective of Munro’s ‘systems approach’ to Serious Case Reviews (SCRs). Although I’m not a great fan of SCRs generally, I believe that one is required in this case – and I hope that when, or if, it is prepared, it will be informed by a system’s perspective. 

Research shows what we all know - babies continue to be killed

The Daily Mirror reports on research by the NSPCC which looked at the Serious Case Reviews completed since Baby Peter’s death.

The research found that a hundred deaths of babies and toddlers had resulted in a Serious Case Review (SCR) since the death of Baby Peter. Andrew Flanagan, chief executive of the NSPCC, is quoted as saying: “Despite calls for this never to happen again here we are five years on with babies being killed in brutal ways.”

Reports into twenty-eight child deaths were examined in detail. This showed that in several cases drug and alcohol abuse, domestic violence and mental illness were significant factors. Twelve of the reviews concerned cases where the focus of the work was said to be on the adults and not the child. An ‘unknown’ male joining the family was said to be a factor in seven cases.

Unfortunately these kinds of statistics are not particularly helpful. Many of the factors identified are also found not infrequently in families where abuse and neglect of children do not take place. Obviously professionals cannot react to these cases as if they required child protection. Not only do they not have legal powers to intervene, but services would be overwhelmed.

I wish the NSPCC would fund some research into how to reduce error in child protection practice. Sadly whatever changes in law, practice and procedure occur, there seems to be a core of cases in which, despite the efforts of professionals, neglect and abuse continue and result in tragedy. The wrong decisions are taken and a child dies.

Many years ago I suggested that trying to understand more about non-fatal, routine errors might help - http://bjsw.oxfordjournals.org/content/20/3/215.abstract . My favourite quote from Professor Jim Reason applies:

‘Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we have no way of uncovering recurrent error traps or of knowing where the “edge” is until we fall over it.’ (BMJ Volume 320 18 March 2000 - http://www.bmj.com/content/320/7237/768 )  

Responding to child abuse and neglect will always be difficult. Failures in practice will only reduce if we have sound understanding of the interactions between practitioners, their organisations, systems and procedures, the wider environment and families who are being helped.

Critical incident reporting would result in a better understanding of when and how mistakes occur and how systems fail. An organisation like NSPCC would be ideally placed to co-ordinate a critical incident reporting system.  

Shafilea Ahmed

The Independent and the Daily Mail  report on the shocking case of Shafilea Ahmed, whose parents have just been convicted of her murder in 2003. The parents’ motive is reported to have been that they were ashamed that their daughter was becoming ‘westernised’.

Shafilea was 17 years-old at the time of her death. It appears that health professionals, police and social workers were involved with her in the year prior to her death, when she ran away from home and complained to teachers that she was being abused at home. She also attempted suicide by drinking bleach.

The papers provide only scanty details of health and social care involvement with Shafilea. There is no information about a Serious Case Review and no SCR report is mentioned on the Warrington Safeguarding ChildrenBoard website. However Edwina Harrison, the independent chair of the Warrington Safeguarding Children Board, is quoted in the papers as saying that procedures have been changed since Shafilea's murder. She said that now a homeless 16-year-old would receive a better service and would be fully assessed by a social worker. To my mind the question should be about why no child protection (Section 47) enquiries were put in hand.

Given that the Serious Case Review is seen by government as the main vehicle for learning and improvement in child protection, I hope Warrington Safeguarding Children Board are preparing one in this case. On the face of it this sounds to be a case where a young person was seriously failed by the system. Without a better understanding of what went wrong, Edwina Harrison’s reassurances that the same thing cannot happen again have a hollow ring.