How can we help minimise errors in Child Protection?
What does safeguarding have in common with flying Boeing 747s? Well in terms of why things go wrong, perhaps more than most people realise.
No matter what walk of life you work within, human fallibility interferes. A brief examination of many serious case reviews shows comments about missed signs of abuse, missed opportunities to intervene. The recent SCR into Levi-Blu Cassin refers to serious failings and 'professional optimism' http://www.bbc.co.uk/news/uk-england-birmingham-34416644 . Professor Eileen Munro in her report subtitled 'A child-centred system' published in May 2011 wrote "errors and mistakes should be accepted as to some degree inevitable and to be expected, given the complexity of the task and work environment."
Of course it is never quite so easy to spot things when perpetrators are concealing the harm. Consider Baby P where his Mother concealed his facial bruising under chocolate. Furthermore the paediatrician who examined him before his death had not been told he was on a child protection plan. This was an apparently simple communication error that had immense consequences because she was not aware of the background.
Very few of us work with colleagues who intend harm, but error is rife. Much of it is due to our being asked to work in ways which we are simply not designed for, such as extreme workload, interruptions and distractions. Also this case as I write http://www.bbc.co.uk/news/uk-england-somerset-34547660 demonstrates the importance of shared information to build Situation Awareness. The police failed to pass on vital information that the father had a relevant record of domestic abuse. Situation Awareness is a crucial concept referring to the 'mental model' we all have of what we are expecting now and what happens next. When this conflicts with what we see and experience there is clearly a problem.
There is a potential danger sign anytime you hear yourself or others say "Oh, I thought this or that was what we are doing" or perhaps "I am seeing this and you are not". There are classic signs that Situation Awareness is being lost, such as conflict between 2 sources of information. However to simply blame 'being human' is not good enough for the professional. To us it is incumbent to recognise how and why we all make mistakes and adopt methods that help keep us, our colleagues and our clients safe.
These non-technical skills are well understood and can be trained and coached. They encompass social skills such as Leadership, Followership, Cooperation and Management of others and cognitive skills of Situation Awareness and Decision making.
The culture is also riddled with blame, but what does it achieve? High reliability organisations recognize blame is mostly inappropriate and counter-productive. If it drives near-miss and error reporting underground it is useless.
The frontline teams know where the barriers to safety are, which procedures are not fit for purpose and where communication blocks occur. Their reports should be welcomed, responded to and acted upon. This is how commercial aviation has become safer and it can be adapted to safeguarding. Atrainability offers training solutions to address these issues.
Trevor Dale, Atrainability
I am Levi-blus Nan and I have just read your blog. Firstly the police never failed to pass on information it was never requested, the social worker wrongly sent for crb check instead. I know that things are not put chronologically but when family are reporting just neglect monthly and go to the lengths of taking him without consent and reporting it to police then you know there are big issues. The authorities also thought that there was major risks to levi that's why they took him off his parents and gave him to me. The big mistake was making me give him back. His life was priceless never ever forget.