Learning from mistakes

The tragic case of Ayeeshia Jane Smith has received wide coverage in the British press following the convictions of her mother and stepfather in connection with her death.

http://www.bbc.co.uk/news/uk-england-stoke-staffordshire-35938209

Only limited information about the involvement of statutory services is available at this stage, but the case appears to have all the hallmarks of one in which there had been substantial involvement prior to the child’s death. The child had been in care and then returned home; and she was subject to a child protection plan. Inevitably the papers are asking the question ‘why?’ and some are comparing the case to the Baby Peter tragedy.

http://www.dailymail.co.uk/news/article-3530859/Why-did-hand-baby-Social-workers-took-Ayeeshia-violent-drug-addled-mother-returned-despite-string-warnings-months-brutally-killed.html

An MP is calling for a public inquiry to be set up.

http://www.bbc.co.uk/news/uk-england-stoke-staffordshire-36006198

Until the Serious Case Review (SCR) report is published we can only speculate about the extent and nature of statutory services’ involvement. However, I believe that we are unlikely to learn much new about how to make services safer from either the SCR or from any form of inquiry. Almost certainly the kind of mistakes that have happened in this case are comparable to those that have happened in all the similar cases dating back to Maria Colwell in the early 1970s and beyond. Professionals have lost situation awareness, made poor decisions and become embroiled in communication foul-ups. Simply recounting it all again will not make it less likely that they will reoccur.

Instead of putting our faith in formal administrative reviews or legalistic inquiries, it would be much better if we applied what we know about the psychology of human error and addressed the questions of how people working in child protection organisations make mistakes and how they can work more safely. We need to address the question “why?” Why are ‘obvious’ signs of abuse and neglect missed? Why do individual practitioners and groups of professionals sometimes become strongly attached to misperceptions and misjudgements which seem to them at the time very sensible but which are hard to justify with the benefit of hindsight? Why do communications become confused or obscured?

I am delighted to see that the British Department for Health is now strongly embracing a human factors approach to safety and I was impressed by a speech made by the Secretary of Sate for Health, Jeremy Hunt, in which he argues is that patient safety is compromised because there is more interest in blaming than in learning.

http://www.ukpol.co.uk/2016/03/10/jeremy-hunt-2016-speech-on-a-blame-culture-in-the-nhs/

Quoting Matthew Syed’s book Black Box Thinking Hunt draws heavily on the experience of the airline industry saying: “… the airline industry realised that if it was going to reduce airline fatalities, it needed to change its culture. They realised that ‘human factors’, rather than technical or equipment failure had been at the heart of the problem.”

He goes on to argue that in order to improve safety in the NHS there needs to be a cultural change involving two elements: (i) openness and transparency about where problems exist and (ii) a true learning culture to put them right. He explicitly draws on the experience of civil aviation in developing human factors approaches to safety, and announces a proposal to create an organisation modelled on the Air Accident Investigation Branch to investigate accidents and safety concerns in health care (something that I suggested for child protection in 2010 - http://chrismillsblog.blogspot.co.uk/2010/04/my-election-manifesto.html). He stresses that: “Other industries – in particular the airline and nuclear industries – have learned the importance of developing a learning culture and not a blame culture if safety is to be improved.”

Hunt has told the House of Commons that the Government proposes developing this type of safety culture in the British National Health Service (NHS). That is a development greatly to be welcomed.

What is less welcome, however, is that there appears to be little by way of parallel developments from the Department for Education, which in England is responsible for children’s social care and child protection. Indeed a significant disconnect appears to be emerging between the safety approaches being developed in the NHS and attempts to improve safety in child protection and children’s social care, which are still deeply rooted in old-fashioned administrative approaches to human error and a thinly disguised blame culture.

Children’s sector leaders are by and large dismissive or disinterested in human factors thinking. There is no knowledge or interest within Ofsted about this type of approach. Civil servants have told me and other campaigners that they believe human factors training is of marginal value to child protection and that learning from error is adequately taken care of by serious case reviews! Now, while closely linked services within the purview of the Department of Health are to be taken down the fruitful path that has been well trodden by the airline and nuclear industries and which is a proven route to greater safety, it appears that children’s services are to be allowed to languish in a safety time warp.

In my view officials from the Department for Education should be meeting urgently with their counterparts in the Department for Health and trying to go up the steep learning curve they need to climb to begin to embrace the ideas that Jeremy Hunt has so clearly articulated.

Sickening caseloads

I am probably not alone in being saddened, but not surprised, by the account in the Guardian of a child protection social worker being overwhelmed by the size and demands of her caseload.

http://www.theguardian.com/social-care-network/social-life-blog/2016/mar/23/overwhelmed-new-social-worker-child-protection-workload

Even sadder is that there will be some to whom the account will be water off a duck's back. For years and years it has generally been accepted that far too many children's social workers are chronically overworked; and over-burdened by time-consuming and unwieldy administration systems which put meeting bureaucratic requirements above doing the job well. But still it goes on in far too many places, with key people at the top simply shrugging their shoulders and doing nothing.

It ain't right.   

Confirmation Bias

A serious case review which is reported in Community Care (http://www.communitycare.co.uk/2016/03/21/lack-reflective-supervision-hindered-action-baby-death-case/?cmpid=NLC%7CSCSC%7CSCNEW-2016-0323) draws two important conclusions which appear to be based on a human factors approach to safety in child protection. The review concludes:

“One of the most persistent and problematic tendencies in human cognition is a reluctance to revise an initial assessment of a situation."

“Reflective supervision is crucial when addressing cognitive issues. These types of erroneous thinking and decision making are unlikely to be recognised by the individuals themselves.”

Confirmation Bias is the tendency we all have to resist revising our assessments of situations.  It is a form of Loss of Situation Awareness in which new information which disconfirms an initial hypothesis is ignored or degraded to preserve the status quo.  The author of the SCR is also correct to note that Confirmation Bias can be difficult to detect, especially by individuals working alone.  Good supervision is one factor in helping people recover from loss of situation awareness. By so is good team work in which colleagues feel free to challenge peers and especially superiors.

A major factor in the world's worst aviation disaster (at Tenerife North Airport) in 1977, was a mistaken decision to take off by a pilot who thought he had permission to do so, when he didn't. He was the airline's most senior captain, which may have been a factor which inhibited his two flight deck colleagues from confidently challenging what must have seemed to them to be an unaccountable and fatal decision.   

When child protection agencies are under too much pressure

The British (Conservative) government is making swingeing financial cuts to local authorities (which are responsible for child protection) and often talks as if cutting funding is a spur to innovation – take money away and it concentrates the mind! Only recently Children’s Minister, Edward Timpson, opined that that there is no “correlation between spend and quality” in children’s social care. 

The case of the Louisiana Department of Children and Family Services seems to provide evidence (if any were required) that once spending falls below a certain level, there is an inevitable knock-on effect on quality.

An article in the Advocate describes a situation in which Louisiana’s funding for child protection has fallen steadily since 2007-8, when the budget was nearly $300 million, to approximately $240 million in 2014-5. As a consequence the number of child protection workers has fallen from nearly 1,350 in 2007 to 1,125 in 2015. At the same time caseloads have been rising, reportedly by 18% according to a report prepared for Louisana’s Governor.

The results is a looming under-funding crisis for the department, with a staff turnover rate of nearly 25% and, according to another report, front-line workers finding themselves pressurised into completing tasks in unrealistically short periods, with consequent implications for the quality and safety of service that children and young people receive.

There are three different approaches to public spending. The first is to ‘spend, spend, spend’; to let rip and fund the system generously (some may say too generously). The second is to ‘cut, cut, cut’ and precipitate a funding crisis. The third, which is my preference is the ‘Lean, Lean, Lean’ approach to public spending. Activities that add value (to the benefit of the service user or the public good) should be funded without stinting, but unnecessary spending (on overhead, waste, the costs of poor quality etc.) should be rigorously reduced at every opportunity.

Perhaps in both Louisiana and Great Britain people in children’s services will eventually realise that Lean is the way forward.  

At Long Last

I was very happy to read on the BBC’s website this morning about the NSPCC’s child abuse whistle-blowing helpline.

The helpline, operated by the NSPCC and funded by the Home Office, will take confidential calls or emails from members of staff from any agency who have concerns about how their organisations are dealing with cases of child abuse and neglect and who feel afraid or unable to raise these concerns with their employers.

At long last: that’s what I say. This is a big step forward, a means of capturing vital information about shortfalls in services and circumstances in which things have gone wrong; and a way of taking these concerns forward for the benefit of children.

Of course a lot will depend on the detail of how the scheme will operate – not least how the confidentiality of informants will be protected – but this scheme really does have great promise. It may not be a critical incident or near miss reporting scheme (which I have been advocating since 1990) but it is a big step in the right direction.

One small concern or question: I wonder why the Department for Education (which is the government department with responsibility for local authority children’s services) is not mentioned as being involved in the scheme? And the Department of Health should also give its endorsement to the scheme, to make it clear that it should be used by healthcare professionals and practitioners.

And one ‘small’ suggestion: the NSPCC must find a way of publishing (perhaps annually), in a suitably anonymised format, an aggregate summary of reports to the helpline so that the general lessons can be learned.

Comparative Costs?

Last week Children’s Minister Edward Timpson was reported in Community Care as telling MPs that there is no “correlation between spend and quality” in children’s social care. According to the minister, some of the councils where the government has been forced to intervene are ‘high spending’.

  

Such a finding must be enormously comforting to a government hell bent on cutting every cost in sight! But I wonder on what data the minister is basing his claims. Working out comparative costs between different local authorities is not easy, because, as management accountants* tell us, it is very difficult to derive accurate costing information where a large part of an organisation’s costs are represented by overhead and where more than one type of product or service is produced.

So far as I know, the Government doesn’t publish any comparative cost information about local authority children’s services. That makes it very hard for us ordinary citizens to assess the minister’s claims. To put our minds at rest perhaps the DfE would like to publish this information, if it has it, and explain how it is calculated, so that we all have a clearer idea about exactly what Mr. Timpson is saying.

* See for example Kaplan, R.S. and Cooper, R., “Make Cost Right: Make the Right Decisions”, Harvard Business Review, September–October 1988

Self-fulfilling prophesies?

Eleanor Schooling, Ofsted’s Director of Social Care, has been explaining why the controversial single inspection framework of local authorities children’s services in England is running behind schedule.

I can’t say that hearing that these inspections are taking longer than expected upsets me very much. As far as I am concerned the whole programme could be indefinitely delayed with no ill effects. But I was interested to read in Children and Young People Now Eleanor Schooling’s remarks on why she thinks such a large proportion of local authorities have received low judgements from her inspectors – about 75% of councils inspected so far are rated either "inadequate" or "requires improvement".

She is reported as saying that Ofsted has prioritised areas where “there was the most anxiety”, resulting in a skewed picture. I had to read that a couple of times to let in sink in. How does anybody know prior to an inspection taking place what the inspection will show? And what powers of second sight do Ofsted inspectors have to be able to pre-judge their own results? And what is the point of carrying out an expensive inspection if there is another quicker way of making the judgement?