The Negative Consequences of Disciplinary Action

There are important negative consequences of local authorities in England taking cases, like the recent one of a social worker in London, to the Health and Care Professions Council. 

(http://www.hpc-uk.org/complaints/hearings/index.asp?id=3467)

Apparently the person in question had recently come to the UK from East Africa. It is not hard to see from a quick reading of the evidence that the she was:

·       Inexperienced

·       Unfamiliar with child protection work in Britain

·       Felt herself to be under pressure and overworked

·       Felt intimidated by her managers

·       Felt unwell

Clearly her work fell short of accepted good practice, but there seems to be no suggestion that she acted maliciously or willfully. It appears that she just didn’t do her job very well.   

Is discipline the right response to this sort of case? My argument is that discipline in the workplace is required only where people act dishonestly, corruptly or deliberately dangerously.

When people screw up or just fail to live up to expectations they should be re-trained and supported in their improvement. That is the humane and constructive response so far as the individual is concerned.

More importantly a rush to disciplinary procedures nurtures a blame culture and that contributes to undermining safety in the organisation. Resorting to discipline in the case of an individual has important consequences for how other employees will behave.

We know that when people fear admitting their mistakes that they will cover them up. The consequence is that management remains in ignorance of day-to-day failings at the front line and, as a result, the organisation becomes even more unsafe.

Let's have som e simple statistics on SCRs

Having a national research database of all child deaths seems to be such a good idea that it is difficult to know why it has not been done already, especially when the data is collected by local Child Death Overview Panels which were set up to investigate the circumstances surrounding child deaths in each local authority area. http://www.cypnow.co.uk/cyp/news/1119106/national-child-death-database-mooted

It also seems bizarre, given the importance attached by the authorities to Serious Case Reviews (SCRs), that there is no routine national collection of statistical information about them. There have been research exercises and some lengthy research reports from academics, and, of course, Ofsted produced some work which sadly failed to inform a great deal. (http://chrismillsblog.blogspot.co.uk/2011/10/is-ofsted-learning-from-serious-case.html)

But what I am talking about are some simple statistics every six months. How many serious case reviews have been completed in the period, how long did they take to prepare, how many are currently being completed, which local authorities are involved, what are their cumulative totals of reports since the monitoring started, what are the ages of the children involved, what type of maltreatment was involved, did the child die etc etc.?

Asking the author of the overview report to fill out a short questionnaire on completion of the report could also provide more information. What factors were involved in the case, what was the family status, in what systems (health, social care, law enforcement etc.) where failings identified?

These are just some examples of what data could be collected. Simple stuff but it would be informative.

The wrong approach?

In the wake of the Daniel Pelka tragedy Coventry Council has announced that it is to appoint a retired high court judge to advise it on child protection. http://www.bbc.co.uk/news/uk-england-coventry-warwickshire-24487953

I do not know the judge in question, but clearly what went wrong in Daniel’s case was not of a legal nature. It was much more about how to spot children who are in difficulty as a result of abuse and neglect at the earliest possible opportunity. That seems to me to imply that the kind of help most required is either of a technical working-with-and-listening-to-children type or of a more general organisational safety type.

So I am not sure how the judge is going to help.

It is also reported that Coventry councillors have decided to ask a House of Commons select committee to look at safeguarding children issues. I don’t think that that is the right approach. It is not so long since the Education Select Committee looked at child protection and seemed to wander all over the place, including a lengthy un-productive discussion about the definition of neglect. http://chrismillsblog.blogspot.co.uk/2012/01/definition-of-neglect.html

I don’t think that child protection will ever improve if it is left to councillors and judges and MPs to come up with ‘bright ideas’ about how to reform systems.

Responsibility for improvement has to be located at the ‘coalface’ with those who do the work and who understand how business and professional processes operate. Such people also need to understand how active errors occur during the course of practice and how latent conditions contribute to failures in systems. So there is scope for input from people who understand organisational safety in other industries to become involved.

We need to create the conditions for improvement, not create the opportunity for yet another poorly focused public debate. The role of Government, both central and local, is not to get involved in the detail of service provision. It is to set the broad objectives, to resource services adequately and to hold those delivering services to account – not for being right all the time, but for ensuring continuous improvement in quality and safety.  

Assessments in a jiffy

Professor Harry Fergusson makes some important points in his article in the Guardian last week.

http://www.theguardian.com/society/2013/sep/24/why-social-workers-become-helpless 

There is no substitute for reading the whole of this excellent article, but I was particularly struck by one of Harry’s observations from his own research. 

He found that heavy social worker workloads and high levels of bureaucracy resulted in reduced time devoted to effective child protection interventions and that “… working conditions led to assessments being made after a matter of minutes spent alone with children”.

Harry is absolutely right to conclude that the resources must be made available for those safeguarding and protecting children to have sufficient time to conduct assessments properly.

The Judgements of Ofsted

I do not find it surprising that the school attended by Daniel Pelka - at which teachers and other staff did not suspect neglect as Daniel starved to death - had been described in a recent Ofsted inspection as having ‘robust’ arrangements for child safeguarding and protection. http://www.coventrytelegraph.net/news/coventry-news/ofsted-criticised-describing-safeguarding-daniel-6160992 

The problem is not with the school so much as with Ofsted. The spot-check inspection approach favoured by Ofsted is unlikely to be reliable (or ‘robust’ for that matter). A few questions will have been asked and a few boxes will have been ticked and, hey presto, we don’t have to worry too much until the next formulaic inspection. What a relief!

The inspection judgement sends the wrong message, to staff and to parents, and it lets down children because a safe school is not one in which a few neatly typed documents are available to the inspectors. It’s one where members of staff have the right state of mind; where they understand human error and how it can and does occur; and where they remain creatively anxious about the possibility of failure. It's a school where everybody takes a part in improving services and systems to make them safer.

I wonder how much the inspector who wrote that clean bill of health knew about organisational safety?

Keanu Williams - some reflections on the Serious Case Review

Coverage of the Keanu Williams Serious Case Review report has focused on the problems being experienced by the Birmingham Children’s Services Department. The BBC highlights the rapid changes in senior managers in the department, with the interesting, if possibly irrelevant, detail that one was paid £1,000 per day! http://www.bbc.co.uk/news/uk-england-birmingham-24332978

There seems to be a sense of despair. Birmingham, Europe’s largest local authority, seems to be lumbering towards yet more child protection disasters.

http://www.bbc.co.uk/news/uk-england-birmingham-24305689

There are high sickness absence rates among staff (http://www.bbc.co.uk/news/uk-england-birmingham-21352709) and a staggeringly large number of serious case reviews have been necessary in Birmingham in recent years, estimated to be as high as 23 since 2006. (http://www.bbc.co.uk/news/uk-24384977).

It almost goes without saying that there is a chronic tendency to fail Ofsted inspections. http://www.ofsted.gov.uk/local-authorities/birmingham

None of this comes as news to anyone who has been watching Birmingham even casually for the last few years. As long ago as 2009 I reported in this blog that an audit of case files in Birmingham found that child care planning and practice was "unacceptably poor" in 53% of cases, "acceptable" in 39% and "good" in only 7%. Services for children in need were said to be “sparse”. http://chrismillsblog.blogspot.co.uk/2009/10/more-detail-on-birmingham-scrutiny.html

These considerations make it all the more surprising that Jane Held of the Birmingham Safeguarding Children Board – and I suspect many other senior people connected with child protection in Birmingham – chose to respond to the serious case review with such an old-fashioned rotten-apples-have-been-rooted-out approach. Not for her any consideration of the fact that Birmingham Children’s Services is a failing, and probably toxic, organisation. Rather her press release states:

“Keanu died because people missed opportunity after opportunity to intervene, and do something decisive to ensure he was safe and properly cared for. Some staff did their best for Keanu but some staff did not comply with required practice, processes and procedures. Those staff have already been held to account for this by individual agencies.”

So mostly it is individuals who are to blame and had people followed ‘required practice, processes and procedures’ the tragedy may never have happened: I don’t think so!

Another paragraph in this press release also annoyed me. Jane said:

“It is absolutely clear that if everyone had known what others knew there may have been a very different outcome. Children are best protected when there are local networks of competent confident professionals working together to share information. This enables them to build relationships, share responsibility for the situation, critically challenge, assess the information they have and to plan action collectively to support children, young people and their families. When there is a risk of significant harm, they would then be able to act decisively.”

I wonder if Jane has ever heard of hindsight bias (http://en.wikipedia.org/wiki/Hindsight_bias) and I wonder if she understands the nature and extent of those problems in the Children’s Department that her Board is supposed to hold to account? I found myself agreeing with the frustration of Jackie Long who – writing about the Hamzah Khan tragedy in her Channel 4 News Blog - said:

'By now we can all close our eyes and take a guess at what serious case reviews will say. There needs to be “more communication”, a “multi agency approach” and – I almost scream as I write – “better sharing of information.”'

http://blogs.channel4.com/jackie-long-on-social-affairs/amanda-hutton-guilty-starving-child/916

I found the Keanu Williams Serious Case Review report itself (http://www.lscbbirmingham.org.uk/) very frustrating. It was full of information but I struggled to be informed. There seem to be two big unexplained ‘whys’. Why did a child protection conference not put Keanu on a Child Protection Plan when there was ample evidence that he was at risk of significant harm? There is no explanation in the SCR report although some of the events surrounding the decision are described.

The second ‘why’ is why didn't the nursery staff refer Keanu to Children's Social Care when they observed suspicious bruising? We are just told they accepted mother's explanations. Maybe there was a history of problems in making referrals to Children's Social Care, or maybe there were conflicts between different people in the nursery, or maybe training had been poor. Perhaps there was a management system that made referral difficult and stressful. Who knows, because the Serious Case Review does not tell us?

Like the Daniel Pelka report, this report – although containing sections headed ‘analysis’ and ‘lessons learned’ – does not aspire to the systems model proposed by Eileen Munro and SCIE (http://www.scie.org.uk/publications/ataglance/ataglance01.asp) . It never seems to get behind mounds of detail to identify causal factors or even to explore possibilities.

It all seems very frustrating. Two more children – Daniel and Keanu - seem to have died needlessly and we seem to have advanced our state of knowledge of how to avoid a repeat performance by not one jot. It is difficult not to despair.

For me hope comes from trying to think laterally. We need to reverse the assumption that we need to wait for disaster before we start learning. We need to create the conditions so that we learn much more - and much more quickly - earlier. And we need to realise that the people who need to learn are the people who do the work.

In other words the best way forward from this juncture is to change the culture, not the procedures or the personnel or the computer systems or the law. For an authority like Birmingham, I think this does presuppose some immediate triage work to remedy the staff shortages and high turnovers and to stabilise the lurching services and haemorrhaging resources. But thereafter I see the solution as being one of opening minds, including those at the top, to new ways of thinking. Improvement will come not from kicking people out or revising the rulebook. It will come from an increasing awareness of how human factors interact with organisational safety.

The day that people working in Birmingham, and elsewhere, begin not to think about watching their backs, and begin to think about what improvements they can make today and tomorrow to make the service they offer safer and more effective, will be the day things turn around.

Keanu Williams - First Reactions

I noted two important comments on the Serious Case Review this morning. 

The first was from Bridget Robb, the Chief Executive of the British Association of Social Workers, who was quoted in the Daily Mail as saying that Birmingham Council has an old fashioned, hierarchical culture and that members of staff there are afraid to discuss their mistakes.

Then, in confirmation, I read in a BBC report that Jane Held, of the Birmingham Local Safeguarding Board, had said that there had been 'double-figure' sackings in Birmingham since Keanu's death.

Sadly many newspapers, and many members of the public, will think that a blame culture is justified in the wake of the failings that resulted in the tragedy. The truth is the exact opposite. Make people afraid and the first casualty is safety. Bridget Robb is absolutely right when she calls for Birmingham to support front line staff in making improvements, rather than conducting a 'witch-hunt' when things go wrong.

(Apologies for lack of links - written on my iPad on a Portuguese beach)