Now it is the turn of Somerset to get the 'inadequate' rating from Ofsted.
http://www.thisissomerset.co.uk/Ofsted-slams-child-protection-service/story-19633668-detail/story.html#axzz2bSg61env
It is difficult to know where will be 'inadequated' next. Surely there must be some emerging themes from this growing catalogue of failure?
It's about time Ofsted addressed that question. Just waiving the big stick of a bad inspection outcome is not enough. Learning, not finger pointing, is required.
Friday, 9 August 2013
Monday, 5 August 2013
The Child's Perspective
Carolyne Willow very rightly remarks that: “… a more
striking finding of these (serious case) reviews is that all kinds of adults
who are paid to protect and care for children consistently ignore the child's
perspective”.
Had somebody sat down with Daniel Pelka and given him enough
time and space he might have said something which would have precipitated more
robust action sooner. So might Victoria Climbié
or Khyra Ishaq.
But the crucial question is why it is often the case that the
child's wishes and feelings are ignored or not even sought. Could it be that
the knee-jerk response which has so dominated child protection in the UK – to
introduce more structures and frameworks and procedures – sits uneasily with
interpreting, giving meaning to and valuing what children say? So often we are
forced to wallow in the pseudo-science of ‘assessment’ and ‘risk management’
and, God help us, such things as ‘inter-agency information sharing protocols’
when what we ought to be doing is playing with and talking to and listening to a
child.
Politicians and civil servants and ‘experts’ have made child
protection crowded with impedimenta
that often have their origins in naïve policies, managerialism or theoretical quackery.
Children, especially distressed children, cannot be made to ‘disclose’ conveniently in order
to comply with organisational timescales and targets. Nor will they obligingly always say things which can be fitted into a box on a form. Not uncommonly things may have to be said obliquely and indirectly. It is hard to talk about pain and fear.
Children need time and space
to go at their own speed. And they need people they can trust to listen to them and to protect them –
not people driven by bureaucratic imperatives which make little sense to
anyone.
Daniel Pelka and Keanu Williams - a systems approach to discovering what went wrong?
It is puzzling why so much less has been written about the
tragic death of Keanu Williams, than about the murder of Daniel Pelka.
Both cases are, of course, horrific. Both appear to have
involved similar failings. As we wait for the report of the Serious Case Review
concerning Daniel, we must also expect the equivalent report concerning Keanu.
We certainly need to understand what has happened in both these
cases. I hope the reports will result in some important learning, although I am
becoming increasingly pessimistic about the ability of Serious Case Reviews to
generate useful information. Just pointing out what went wrong is not enough.
The reports need to be analytic. They need to go beyond simple descriptions of
what went wrong and to try to answer the question of why things went wrong.
I hope the authors of the reports are adopting the systems approach to conducting a serious
case review, advocated by Eileen Munro and SCIE (http://www.scie.org.uk/publications/reports/report19.asp).
The ‘systems’ model focuses on those factors in the working environment that support
good practice, and those which result in unsafe working practices and systems. The
idea is to produce organisational learning that provides an explanation that moves
beyond the basic facts of a case and to identify underlying causes of what has
gone wrong.
Saturday, 3 August 2013
Early Intervention … careless talk?
Maggie Atkinson, England’s Children’s Commissioner said in a BBC radio interview (which readers in the UK can hear at http://www.bbc.co.uk/programmes/p01dmrnw):
“…. maybe it’s time for us to have the conversation about whether it should be a statutory requirement that you intervene early” (my emphasis).
Helen Donohoe, Director of Public Policy, Action for Children is quoted in a press release as saying:
“…we need to ensure that professionals have all the resources they need-in particular having the ability to intervene as early as possible” (again my emphasis).
http://www.actionforchildren.org.uk/news/archive/2013/august/statement-following-daniel-pelka-sentencing
I do not know what these speakers intended by their remarks, but there is a danger that they could be interpreted as a call for professionals to have powers to intervene earlier in family lives. Indeed Maggie Atkinson’s remarks were taken up by Isabel Hardman (a panellist in BBC Radio 4’s ‘Any Questions’ last night - http://www.bbc.co.uk/programmes/b037jnl5 for those in the UK) who said: “… that perhaps there needs to be a statutory obligation to intervene early in these cases, even if it’s removing the child into temporary care so they (professionals) can find out what is going on.”
I have often heard people say that Eileen Munro recommended a statutory duty of early intervention. But Munro is very precise and measured in what she recommends which is:
“The Government should place a duty on local authorities and statutory partners to secure the sufficient provision of local early help services for children, young people and families.” (The Munro Review of Child Protection: Final Report – A child-centred system paragraph 5.27 - https://www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system - my emphasis)
There is a world of difference between a general duty to provide early help services and taking children into care on a precautionary basis!
I recommend that anybody who wants to come to a better understanding of the issues surrounding what Munro calls ‘early help’ reads Chapter 5 of her final report very carefully. However, there is one important matter which she does not discuss in detail and which I will briefly outline here.
It is the problem of false positives. Statisticians tell us that even if we have quite sophisticated tools for assessing whether or not a member of a population has a certain characteristic (e.g. being at risk of abuse and neglect) where the actual incidence of that problem in the population is quite small, the assessment tool will predict a substantial number of false positives, i.e. instances where the assessment detects the presence of the characteristic in cases in which the problem is not in fact present. Indeed, if the tool is good enough not to miss any true cases, we would expect the number of false positives to exceed the number of true positives. For example screening tests for cancer will generally result in a number of false positives who are then referred for further examination before being given the ‘all-clear’.
http://en.wikipedia.org/wiki/False_positive_paradox
I do not believe that providing ‘early help’ to families that are ‘false positives’ is a problem if the service provided is optional, welcomed by the families and provides genuine assistance to them. For example, being able to attend a Sure Start Centre is something that many families will welcome, regardless of whether or not their children are at risk, because the centre provides services that many families value.
However, other kinds of ‘early intervention’ are quite different – such as Isabel Hardman’s suggestion that some children be removed into temporary care in order to find out what is happening in their families. Not only is such an intervention not likely to be welcomed, it is likely to be extremely harmful in cases of false positives, where some children will be unnecessarily and traumatically removed from people who are, in fact, genuine caring parents.
Indeed it is very difficult to square some types of early intervention with the obligations that we have in international law such as the UN Convention of the Rights of the Child and the European Convention on Human Rights. And I have yet to encounter a good argument against the balance which is struck admirably in the Children Act 1989 where the threshold for statutory action is defined in terms of the ‘likelihood of significant harm’.
So I think we must be very careful when it comes to discussions of ‘early help’ – which I believe must be voluntary and attractive to those to whom it is targeted. We must avoid confusing it with authoritarian forms of ‘early intervention’ that seek to reduce the threshold for statutory intervention. And we must be absolutely clear that sound arguments for early help do not transform into calls for the state to interfere more widely in family life and to diminish the rights of children and their families.
I do not know what these speakers intended by their remarks, but there is a danger that they could be interpreted as a call for professionals to have powers to intervene earlier in family lives. Indeed Maggie Atkinson’s remarks were taken up by Isabel Hardman (a panellist in BBC Radio 4’s ‘Any Questions’ last night - http://www.bbc.co.uk/programmes/b037jnl5 for those in the UK) who said: “… that perhaps there needs to be a statutory obligation to intervene early in these cases, even if it’s removing the child into temporary care so they (professionals) can find out what is going on.”
I have often heard people say that Eileen Munro recommended a statutory duty of early intervention. But Munro is very precise and measured in what she recommends which is:
“The Government should place a duty on local authorities and statutory partners to secure the sufficient provision of local early help services for children, young people and families.” (The Munro Review of Child Protection: Final Report – A child-centred system paragraph 5.27 - https://www.gov.uk/government/publications/munro-review-of-child-protection-final-report-a-child-centred-system - my emphasis)
There is a world of difference between a general duty to provide early help services and taking children into care on a precautionary basis!
I recommend that anybody who wants to come to a better understanding of the issues surrounding what Munro calls ‘early help’ reads Chapter 5 of her final report very carefully. However, there is one important matter which she does not discuss in detail and which I will briefly outline here.
It is the problem of false positives. Statisticians tell us that even if we have quite sophisticated tools for assessing whether or not a member of a population has a certain characteristic (e.g. being at risk of abuse and neglect) where the actual incidence of that problem in the population is quite small, the assessment tool will predict a substantial number of false positives, i.e. instances where the assessment detects the presence of the characteristic in cases in which the problem is not in fact present. Indeed, if the tool is good enough not to miss any true cases, we would expect the number of false positives to exceed the number of true positives. For example screening tests for cancer will generally result in a number of false positives who are then referred for further examination before being given the ‘all-clear’.
http://en.wikipedia.org/wiki/False_positive_paradox
I do not believe that providing ‘early help’ to families that are ‘false positives’ is a problem if the service provided is optional, welcomed by the families and provides genuine assistance to them. For example, being able to attend a Sure Start Centre is something that many families will welcome, regardless of whether or not their children are at risk, because the centre provides services that many families value.
However, other kinds of ‘early intervention’ are quite different – such as Isabel Hardman’s suggestion that some children be removed into temporary care in order to find out what is happening in their families. Not only is such an intervention not likely to be welcomed, it is likely to be extremely harmful in cases of false positives, where some children will be unnecessarily and traumatically removed from people who are, in fact, genuine caring parents.
Indeed it is very difficult to square some types of early intervention with the obligations that we have in international law such as the UN Convention of the Rights of the Child and the European Convention on Human Rights. And I have yet to encounter a good argument against the balance which is struck admirably in the Children Act 1989 where the threshold for statutory action is defined in terms of the ‘likelihood of significant harm’.
So I think we must be very careful when it comes to discussions of ‘early help’ – which I believe must be voluntary and attractive to those to whom it is targeted. We must avoid confusing it with authoritarian forms of ‘early intervention’ that seek to reduce the threshold for statutory intervention. And we must be absolutely clear that sound arguments for early help do not transform into calls for the state to interfere more widely in family life and to diminish the rights of children and their families.
Friday, 2 August 2013
Is Improvement Possible?
According to the Daily Telegraph, remarks made by Andrew
Webb, president of the Association of Directors of Children’s Services, during
a BBC radio interview on the Daniel Pelka tragedy, have drawn criticism from Peter
Saunders, head of the National Association for People Abused in Childhood.
http://www.telegraph.co.uk/news/uknews/crime/10216127/Head-of-childrens-services-chiefs-accused-of-defeatism-after-he-says-we-will-never-prevent-all-child-deaths.html
Webb is reported as saying that the number of child abuse deaths was “… remarkably consistent, which tends to suggest that there’s a problem here we will never, ever manage to crack.” In reply Saunders accused Webb of defeatism saying: “We are very interested in people who are supposed to be leading the way but who are almost throwing their hands up and admitting defeat.”
Most sensible people will be inclined to side in this debate with Peter Saunders. It is foolish to believe that nothing more can be done.
But this does not imply, in the wider debate, that something can be done quickly and dramatically. The great fallacy of the Every Child Matters agenda was precisely that – ‘a significant step’ I think Tony Blair called it, when it was nothing of the kind. Throwing policies at child abuse and neglect, and introducing untried and poorly designed systems that are supposed to mark the beginning of a new era, is the territory of the fantasist.
In contrast, what is required is small, incremental, continuous improvement. That means daily learning with the aim of having services that are just a little bit better today than they were yesterday. Modest, achievable and sustainable changes should be initiated by those who actually do the job or be based on an evolving understanding of the needs and wants of children and young people who receive the services.
This kind of continuous improvement can have impressive cumulative results. Services which are made just a little bit better every day will often be substantially better at the end of the year and significantly improved at the end of the decade. But what we do not want are grand policies devised by political and managerial elites, which take years to implement only to be shown to be hollow vessels.
http://www.telegraph.co.uk/news/uknews/crime/10216127/Head-of-childrens-services-chiefs-accused-of-defeatism-after-he-says-we-will-never-prevent-all-child-deaths.html
Webb is reported as saying that the number of child abuse deaths was “… remarkably consistent, which tends to suggest that there’s a problem here we will never, ever manage to crack.” In reply Saunders accused Webb of defeatism saying: “We are very interested in people who are supposed to be leading the way but who are almost throwing their hands up and admitting defeat.”
Most sensible people will be inclined to side in this debate with Peter Saunders. It is foolish to believe that nothing more can be done.
But this does not imply, in the wider debate, that something can be done quickly and dramatically. The great fallacy of the Every Child Matters agenda was precisely that – ‘a significant step’ I think Tony Blair called it, when it was nothing of the kind. Throwing policies at child abuse and neglect, and introducing untried and poorly designed systems that are supposed to mark the beginning of a new era, is the territory of the fantasist.
In contrast, what is required is small, incremental, continuous improvement. That means daily learning with the aim of having services that are just a little bit better today than they were yesterday. Modest, achievable and sustainable changes should be initiated by those who actually do the job or be based on an evolving understanding of the needs and wants of children and young people who receive the services.
This kind of continuous improvement can have impressive cumulative results. Services which are made just a little bit better every day will often be substantially better at the end of the year and significantly improved at the end of the decade. But what we do not want are grand policies devised by political and managerial elites, which take years to implement only to be shown to be hollow vessels.
Thursday, 1 August 2013
Daniel Pelka - more reaction
Deputy Prime Minister, Nick Clegg, is quoted in The Guardian
as saying:
“… I think what people worry about is that maybe one bit of
the system doesn't talk to another bit of the system and information can fall
between stools. That's what the serious case review is all about."
The early indications are that people were talking to each
other, but the wrong decisions were being made. There is a need for great
caution here, remembering some of the wrong-headed and wasteful ideas that
sprung-up in the wake of the Victoria Climbié tragedy.
Please Mr. Clegg, don’t go down the information-sharing-will-sort-it
all-out road. It is more complex - much more complex – than that.
The death of Daniel Pelka - early reactions
Ray Jones makes some telling points against knee-jerk
reactions to the tragic death of Daniel Pelka. In particular he is right to
draw attention to the increased workload that has afflicted child protection
services in Britain since the death of baby Peter Connelly.
http://www.communitycare.co.uk/blogs/childrens-services-blog/2013/08/daniel-pelkas-shocking-death-must-be-understood-in-its-national-and-local-context/?cmpid=NLC|SCCC|SC019-2013-0108#.UfpWTFPUCUc
Ray is also right to caution against the blame culture. However, he does not, to my mind, make strongly enough the important point that blame inhibits learning and that it is only through sustained and serious learning that we can hope to avoid similar tragedies. [1]
Having a model of how serious mistakes come about is absolutely essential. Most people go to work anxious to do a good job. The last thing they want to see is a tragic outcome. But individual and organisational defences against error are always imperfect. We, and the organisations we work in, are error prone, and it is only by having multiple layers of defences that most of the time things do not result in bad outcomes. [2]
Safety is only improved by constant improvements in organisational defences and by gaining ever greater insight and understanding of our own propensities to make mistakes. We need to understand how we lose situational awareness or make bad decisions or fail to communicate effectively or respond in appropriately to authority or challenge or provide poor leadership and contribute to poor teamwork.
A Human Factors perspective [http://chrismillsblog.blogspot.co.uk/2013/01/human-factors-key-to-safer-practice.html] is not just a novel or interesting approach to error in child protection. It is an essential precondition of learning how to make children safer.
[1] See Dekker, S. Just Culture: Balancing Safety and Accountability, Ashgate, 2000
Ray is also right to caution against the blame culture. However, he does not, to my mind, make strongly enough the important point that blame inhibits learning and that it is only through sustained and serious learning that we can hope to avoid similar tragedies. [1]
Having a model of how serious mistakes come about is absolutely essential. Most people go to work anxious to do a good job. The last thing they want to see is a tragic outcome. But individual and organisational defences against error are always imperfect. We, and the organisations we work in, are error prone, and it is only by having multiple layers of defences that most of the time things do not result in bad outcomes. [2]
Safety is only improved by constant improvements in organisational defences and by gaining ever greater insight and understanding of our own propensities to make mistakes. We need to understand how we lose situational awareness or make bad decisions or fail to communicate effectively or respond in appropriately to authority or challenge or provide poor leadership and contribute to poor teamwork.
A Human Factors perspective [http://chrismillsblog.blogspot.co.uk/2013/01/human-factors-key-to-safer-practice.html] is not just a novel or interesting approach to error in child protection. It is an essential precondition of learning how to make children safer.
[1] See Dekker, S. Just Culture: Balancing Safety and Accountability, Ashgate, 2000
[2] See Reason, J. “Human error: models and
management.” British Medical
Journal 2000; 320:768-770 (18 March)
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