Preventing child deaths: lessons from highrisk industry

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Quality and performance in Social Services in
Europe17th European Social Services Conference.
Prague, 2224th June 2009

• Preventing child deaths lessons from high-risk
  industry
• Dr Sheila Fish Sarah Carr
• Tues 23 June 11.30-13.00

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Overview of the session

• Introduction to the theory and practice of the
  systems model
• Discussion
• Does your region/country tend to blame or explain
  child death tragedies?
• Does the systems approach seem relevant to your
  region/country? What might help or hinder people
  from using it?

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The problem of unresolved puzzlement

• as a social worker people keep asking me about
  Baby P how could this possibly have happened?
  And all I can say is there must have been
  reasons its complicated

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Without adequate explanations

• incredulity quickly turns to anger and
  condemnation of those involved - hard to believe
  that a motivated, well-meaning, competent worker
  could act this way
• so conclude must be the result of stupidity,
  malice, laziness or incompetence
• YET reasonable to assume that most people come to
  work each day wanting to help children, not to
  allow them to be harmed
• practitioners rarely intend to make mistakes
• so better explanations are required
• the systems approach is explicitly designed to
  address these why questions

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Getting to the bottom of things

• Developed in aviation
• implausible to put the error down to laziness or
  stupidity
• An organisation with a memory (DH, 2000)
• Relevance to child welfare in theory
• Munro (2005) A systems approach to investigating
  child abuse deaths British Journal of Social
  Work, 35, 531- 546
• not off the shelf detailed developmental work
  required to adapt it

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Available at www.scie.org.uk Authors Sheila
Fish, Eileen Munro Sue Bairstow
Learning together to safeguard children
developing a multi-agency systems approach for
case reviews
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Lessons from aviation contrasting ways of
understanding the human role

• Vs.
• person-centred
• vs.
• system-centred

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Implications for work on safety

• Person-centred
• Erratic people degrade a safe system so that work
  on safety requires protecting the system from
  unreliable people.
• Alternative system-centred
• Individuals are part of the system and their
  behaviour is shaped by systemic influences
• So, dont stop when you find human error but ask
  why did this seem the sensible thing to do at
  the time?
• Aim making it harder for practitioners to
  safeguard poorly and easier for them to do it
  well

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Underlying theories of causality
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Theory into practice

• key features of the systems case review process
  for child welfare

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How the systems model can be used

• The SCIE model is intended to be used in any
  circumstance where practice needs to be reviewed,
  not just in the cases of serious harm or death
• Community Care blueprint for serious case
  reviews 16 February 2009
• Good reasons to focus on
• routine practice,
• practice that practitioners and/or families are
  happy with and
• innovations that seem to be working well

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Where you want to get to

• Final part of analysis involves moving beyond the
  particular case
• This is necessary in order to make one case act
  as a window on the system (Charles Vincent
  2004)
• Good or problematic practice may look the
  different in different cases but the sets of
  underlying influences may be the same
• Developed a 6-part typology of such patterns for
  child welfare

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Typology of underlying patterns

• human-tool operation
• e.g. Are there aspects of the ICT system that
  militate against good recording and analysis?
• family-professional interactions
• e.g. Patterns of not engaging with fathers?
• human judgement/reasoning
• e.g. failure to review judgements and plans
• human-management system operation
• e.g. What organisational messages are workers
  getting about priorities? through put over
  quality
• communication and collaboration in multi-agency
  working in response to incidents/crises
• e.g. Is there spare capacity to respond to
  unexpected developments?
• communication and collaboration in multi-agency
  working in assessment and longer-term work
• e.g. Who is responsible for thinking?

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Benefits of such a typology

• provides a conceptual framework for organising
  all the layers of interaction influencing the
  work done with a family
• comparisons across cases can be easily conducted,
  
• providing greater opportunity for cumulative
  learning from the series of SCRs

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How you get there key features of the process

• Instead of starting with assessing individual
  agencies (as per IMRs), the systems approach is
  multi-agency from the start.
• Draws on 2 data sources includes in-depth 1-1
  conversations, as well as documentation
• without family members key perspectives will be
  missed but user involvement is under-developed in
  the model
• Involves high degree of collaboration
• Introductory meeting to explain the approach
• Sharing of draft reports
• Feedback meetings for dialogue about analysis and
  broader relevance

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Key aspects of organising and analysing the data

• Expanding the chronology - assemble narrative
  of multi-agency perspectives
• Identifying key practice episodes (significant
  to the way the case developed or was handled),
• adequacy of practice
• contributory factors
• Continually checking back with participants
  exploring further
• check on basic accuracy
• validate the analysis
• prioritisation of issues

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Feedback from pilot participants

• This way of carrying out reviews does feel much
  more empathetic both to professionals and family,
  also more wide ranging and about normal human
  behaviour rather than endless policies and
  procedures were they present, and who didnt
  follow them?
• The recommendations feel much more constructive
  and practical the aim to address real
  difficulties of shopfloor workers not to make a
  whole lot more work developing new processes
  almost for the sake of being seen to do
  something.

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Discussion Part 1

• Where on the spectrum between blaming and
  explaining would you place reactions to child
  death tragedies in your own region or country?
• Think of a recent high profile case.
• How did different parties react media,
  politicians, unions, professionals, academics,
  families?

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Example of findings from the inquiry into a
recent train crash

• There was a "them and us" mentality between track
  patrols and area supervisors and a "culture of
  learned helplessness", it said.
• The report said there was "discord" between local
  managers and area supervisors, adding "This
  created a disrespectful environment and
  reinforced the 'them and us' mentality."
• A "culture of learned helplessness" resulted in
  "a management style where breaches were left
  unchecked and observance was unrewarded", the
  report said.
• Bad habits and poor discipline were "reinforced"
  by supervisors who "failed to adhere to rules and
  standards".
• Patrolling without lookouts was a "routine
  violation".
• A change to a new Sunday morning inspection
  regime had been "poorly planned and poorly
  managed". As a result, inspections of the track
  in Cumbria and Lancashire became reliant on
  weekend overtime, leading to a lack of continuity
  between inspections.
• Some track inspectors with lapsed accreditation
  were not even properly certified to carry out
  such work.

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Discussion Part 2

• Does SCIEs systems model seem relevant to your
  region/country?
• What would encourage people to use it?
• What might be seen as obstacles to its take up?

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• Fish, S Munro, E Bairtsow, S. 2008. Learning
  together to safeguard childrendeveloping a
  multi-agency systems approach for case reviews.
  London SCIE
• Contact sheila.fish_at_scie.org.uk

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