Daniel Pelka - mandatory reporting?

As a result of the Daniel Pelka tragedy, a campaign for a “good Samaritan” law is being run by members of the public. They want legislation that would make it illegal for teachers or other professionals not to report that they suspect a child is being mistreated. 

http://www.coventrytelegraph.net/news/coventry-news/daniel-pelka-campaign-new-law-5673254 

Mandatory reporting is not without its problems and I believe it is very unwise to press for major policy changes before the Serious Case Review into Daniel’s death has reported.

We have seen in the past how ‘knee-jerk’ responses to child protection disasters have resulted in policies and procedures which often have unforeseen dysfunctional consequences. 

I would like to appeal to all those concerned in developing child protection policy to try to avoid quick fixes and to reflect very carefully on the lessons to be learned from Daniel’s death.

Little Stars - Ofsted have some questions to answer

The Serious Case Review (SCR) report by the Birmingham Safeguarding Children Board and the Ofsted report of the inspection conducted on 29^th Novemeber 2010, describe the standard of provision in 2010 at the Little Star's Day Nursery, (Nechells, Birmingham) a little differently.

The Ofsted report says that the quality of the provision is good:

"Children are cared for in a safe and secure environment where they are able to make good progress towards the early learning goals through a range of varied activities that challenge and stimulate their interest" (Little Star's Day Nursery Inspection report for early years provision (Nechells Regeneration Project, Nechells Park Road, Nechells, Birmingham), Unique reference number EY315338, Inspection date 29/11/2010, http://www.ofsted.gov.uk/inspection-reports/find-inspection-report/provider/CARE/EY315338 page 4, my emphasis) 

The Serious Case Review says that there was poor management at the nursery and that, in particular: 

“… the necessary safety mechanisms including robust staff recruitment processes, strong performance management, whistle blowing processes and a culture where no one person could assume inappropriate power within the staff group were not in place" (http://www.lscbbirmingham.org.uk/index.php/home page, 46 my emphasis)

To be sure the SCR report did have the benefit of the hindsight that a worker at the nursery had raped a small child there (see - http://www.theguardian.com/society/2013/aug/27/ofsted-council-rape-toddler-nursery). 
  
But the discrepancy in findings between the two reports is something that must give cause for alarm at Ofsted.

I wonder whether or not Ofsted inspections have any other way of looking at safety than through some sort of tick box approach. 

I see no evidence that they actively seek to test organisational defences in order to find out where the ‘holes’ in the Swiss cheese are. 

That is the way Professor James Reason suggests is best to make organisations safer. For more on his Swiss cheese model see http://patientsafetyed.duhs.duke.edu/module_e/swiss_cheese.html  

Do we need to focus on ‘a hard core’?

In New South Wales, and elsewhere in Australia, there is a shortage of child protection social workers. Some agencies are experiencing severe problems.

http://www.theherald.com.au/story/1719472/child-protection-hit-by-staff-shortages-red-tape/

http://www.abc.net.au/news/2013-05-15/alice-faces-child-protection-workers-shortage/4691418

http://www.theaustralian.com.au/news/breaking-news/risk-of-harm-report-for-kids-not-followed/story-fn3dxiwe-1226705930708

An interesting argument on this topic is developed by Jeremy Sammut who argues that “…(t)he real and systemic problem with child protection in Australia concerns the large number of children who are re-reported because of unresolved safety concerns”.

Sammut tells us that approximately half of all child protection reports in New South Wales concern what he calls “…a hard core of around seven or eight-thousand frequently-reported, highly dysfunctional families”. He says that “… many of these children have a long history of risk of harm reports stretching over many years, and end up being damaged by prolonged exposure to parental abuse and neglect”.

He concludes that too little is being done for these children who, he says, “… would be better off if they were removed earlier and permanently, preferably by means of adoption”.

Sammut concludes by saying that a welcome consequence of so doing would be a reduction in the numbers of child protection referrals, resulting in less stressed and therefore more effective services.

http://www.onlineopinion.com.au/view.asp?article=15399

There is more than a superficial plausibility to this argument. Many years ago quality gurus, such as Deming and Crosby, told us that doing it right first time is usually cheaper than doing it wrong and then putting it right. ‘Rework’, as it is known in operations management, is usually very costly and there is no reason to suppose that it is any less of a problem in child protection than in a commercial manufacturing context. Indeed, if a consequence of not getting it right first time is that children continue to suffer abuse or neglect, ‘rework’ in child protection is not only a financial but also a moral evil.

Where I part company from Sammut’s argument is that he appears to ascribe the cause of the problems to an underlying assumption that the authorities “… believe in 'family preservation' at nearly all costs”. Personally I do not know many social workers or child protection managers, or even policy makers, who believe that ‘family preservation’ is worth a child suffering abuse and neglect; indeed I do not know any.

My own view is that we lack the relevant knowledge and resources to deal with this kind of problem. In the first place we do not have anything like the right kind of research or routine statistics to understand what is happening; about what kind of ‘hard core’ exists and how to find it. How many children who receive a child protection service each year are re-referred suffering re-abuse or re-neglect? What are their characteristics: how old are they; what are their family circumstances; what systemic and organisational factors result in their being returned home after an abusive or neglectful incident?

Secondly we are not developing the right kinds of assessment tools to use particularly with very young children. If we were to make an impact on the numbers of children who are re-referred we would need some way of having much more accurate assessments at the first signs of abuse or neglect and particularly during the child’s earliest years. Just having different versions of some standard form – along the lines of the Assessment of Children in Need approach – is completely the wrong idea. What we need are ways in which different professionals from different professions and agencies can work together to create a much fuller and more accurate assessments of, particularly, very young children referred for the first time. Possibly some multi-agency expert assessment units are required, or at the very least the incorporation of psychological and paediatric expertise into front-line teams.

Finally we need much better community child health services focused on the early years. For too long in Britain there was a catastrophic decline in health visiting and, although there are plans in hand to reverse this trend, the outcomes are still not certain.  

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213759/dh_124208.pdf

http://www.unitetheunion.org/news/trainingworriesforthenextgenerationofhealthvisitors/

Having more well trained health professionals regularly visiting families at home more often, and monitoring child care and development especially during the first one or two years of life, seems to me to be something most people would welcome. It would facilitate much quicker and more decisive action if concerns of abuse and neglect come to light during the early years. 

Birmingham nursery rapist – confirmation bias?

Nursery worker Paul Wilson was jailed for life this week for among other things raping a small child at the Birmingham nursery where he worked.

Jane Held of the Birmingham Safeguarding Children Board provides a clear account of what went wrong in a BBC TV interview. 

http://www.bbc.co.uk/news/uk-england-23857935 

She explains that staff at the nursery had expressed concerns about Wilson’s forming an inappropriately close relationship with the child, but that the local authority's designated officers made a judgement on the basis of what they were told that this was “… a matter of professional conduct not a matter of child abuse”.

Subsequent investigations by Ofsted and the local authority lacked rigour and depth, she said.

Crucially we are told that nobody talked to the child.

It seems to me that this case demonstrates what human factors experts call confirmation bias. This is a type of loss of situation awareness in which facts are selected or distorted to support or confirm a wrong mental model of the situation. ‘Bending the facts to fit the theory’ is another way of saying it.

So once a decision was taken – an issue of professional conduct, not a matter of child abuse – those investigating simply clung to this 'fact' and whatever evidence they found seemed to support it.

Confirmation bias is something that happens to all of us. Those who work in safety critical industries and those who have special safety responsibilities – such as Ofsted inspectors and local authority designated officers – should always be aware of the possibility that evidence can be tailored to support the status quo. They need to make sure that they double-check any theory or belief from an alternative standpoint.

Speaking to, and listening to, the child in this case would probably have made people think twice. Being aware of the risks of confirmation bias would have disposed those conducting investigations to review their findings more critically.

Family Courts and the Press

Yesterday in one of Britain’s national newspapers, there was a horrifying article which names children following a custody battle in the civil courts and provides pictures of them and discusses all kinds of family details in a lurid tabloid sort of way.

I’m not going to provide a link to it, or name the paper in question, because that would be like re-publishing it.

I think it is shocking that this sort of article can appear in any newspaper, let alone a mass circulation one. I opposed easing reporting restrictions in the Family Courts. But I have had to accept that I was on the loosing side of that debate, in which those in favour pointed to all kinds of safeguards that they said would prevent individual families and children being identified and children’s rights to privacy being flouted.

I think those who so cheerily sought to ‘open up’ the family courts should now take stock and revisit the issue because this type of article has the potential to ruin children’s lives.

Have you ever read an Ofsted report?

Have you ever read an Ofsted report of inspection of local authority arrangements for the protection of children? No? You are lucky. I have just been reading the report of the inspection at Somerset County Council (http://www.ofsted.gov.uk/local-authorities/somerset). It is hard work.

The first thing you notice about these reports is that there is a lot of repetition in them. There is a section on ‘overall effectiveness’ and then a section about ‘the effectiveness of help and protection to children, young people, families and carers’ which seems to repeat some of the points made in the ‘overall effectiveness’ section. Then there is a section on the ‘quality of practice’ where some points are recycled again. That is followed by a section on ‘leadership and governance’ which seems to focus on the same issues from the leadership and governance perspective.

And it goes on and on and on .... In the Somerset report these sections occupy ten pages. They are written, as is typical in these reports, in a strange rambling style where points fall thick and fast, but evidence is hard to find. Take, for example, paragraph 12 of the Somerset report which concerns ‘overall effectiveness’:

"12. The overall effectiveness of arrangements to protect children in Somerset is inadequate. Most children who are at risk of harm are identified and receive help to protect them. However inspectors also found a number of cases where not enough was done to protect children, and where the risk of harm remained present for too long. New referrals to children’s social care services normally receive a prompt and proportionate response, but there is a lack of clarity among the different agencies about thresholds for children’s social care involvement. Somerset Direct staff are not always assertive enough in pushing cases back to referrers where a social care response is not needed. As a result, some children and families receive help that is disproportionate to their needs. "

What does “… a number of cases where not enough was done to protect children, and where the risk of harm remained present for too long” mean? Does it mean 25% or 10% or 1% of cases and for how long – a day, a week, a month or a year? We are not told.

And what is meant by the assertion that there is “…a lack of clarity among the different agencies about thresholds for children’s social care involvement”? Does that mean that a couple of people seemed a bit confused or that hundreds have signed a petition to say that the thresholds are not clear? Again the report does not enlighten us.

Finally what do we make of the statement that “Somerset Direct staff are not always assertive enough in pushing cases back to referrers where a social care response is not needed”? “Not always assertive enough” is an oddly equivocal phrase that is not very informative. I would like to know how often, compared with elsewhere, these people are not ‘assertive enough’ and I would like some standard by which to judge what is ‘assertive enough’ and what is ‘not assertive enough’. The report does not give us any of that: we are just being asked to trust the inspector’s judgement without being given any details.

Paragraph 12 is a good example of what I call Ofsted-speak. The whole report is full of phrases that are uninformative or puzzling. ‘Robust’ is a favourite word, with, for example, management of cases and quality assurance procedures not being ‘robust’. I also spotted at least three uses of the word ‘embedded’, with “routine senior-level case file auditing” being one thing, among others, that was not embedded. Oh dear …

My main objection to the report, however, is that it tends to focus on process rather than outcome. It centres on poor quality assessments, plans and what it says is under-use of the Common Assessment Framework (CAF). These are process issues if ever I saw them.

And nowhere in the report can I find a clear, well-evidenced statement to the effect that the arrangements in Somerset serve children worse than elsewhere. We are told referrals to CAMHS are slow, but there is no explanation of how much slower they are in Somerset, or why.

Another sad thing is that in the case of Somerset – which Ofsted found to be ‘inadequate’ on all counts – the report makes often puzzling recommendations for improvement, such as the following:

“Ensure that early help provision is coordinated, operates to clearly defined thresholds and aligns with social care services to enable children and their families to get help at the right level, and to move between the different levels of help as their circumstances change.”  (page 3)

I pity anyone who has to demonstrate that that has been implemented. I’ve read it several times and still don’t really know what it means.

I’m currently awaiting some developments on the Ofsted front, but hope before long to bring you a raft of suggestions about how the inspection regime could be improved. Watch this space …

Police Training

I see that the Home Secretary is reported by the Daily Mail as having “… ordered special child protection training be given to 4,000-plus officers in the National Crime Agency”. http://www.dailymail.co.uk/news/article-2396639/Teresa-May-Thousands-police-officers-special-training-child-protection.html?ITO=1490&ns_mchannel=rss&ns_campaign=1490 

That seems a bit odd to me, as one of the Home Secretary’s favourite refrains is ‘I don’t interfere in operational police matters’. But if they say it in the Daily Mail then it must be true … surely!!

What I’m not at all clear about is that the new NationalCrime Agency (NCA), which will include the Child Exploitation and OnlineProtection Centre (CEOP), is to be a national body that will have a few staff based in central locations. However, most child protection work in Britain is undertaken by local authorities supported by local police forces.

I would certainly support more training in child protection for local police officers, but I am not clear what the cost effectiveness is of training NCA staff, some of whom will presumably be involved in dealing crimes like with complex frauds. 

It seems to me that what we want is some sort of national training strategy for all staff engaged in child protection, with priorities clearly identified. My gut feeling is that recognition and initial response to abuse would be the area in which money spent on training would deliver the greatest improvement in performance, but I accept that that is an empirical matter which needs some research before priorities become set in stone.