Messages from Serious Case Reviews

1. Messages from Serious Case Reviews Patrick Ayre Department of Applied Social Studies University of Bedfordshire Park Square, Luton email: pga@patrickayre.co.uk web: http://patrickayre.co.uk

2. Learning from enquiries Those who cannot learn from history are doomed to repeat it (George Santayana)

3. Serious Case Reviews: A systemic approach Principles (with thanks to SCIE): • Any worker’s performance is a result of both their own skill and knowledge and the organisational setting in which they are working. • Improving safety therefore means clarifying which aspects of the work context make errors more likely to happen, and which support workers to accomplish their tasks successfully.

4. Serious Case Reviews: A systemic approach • Instances of problematic practice may look different in different cases, but underneath may have much in common • It is these similarities or common patterns that need to be identified in case reviews. • ‘Heroic workers can achieve good practice in a poorly designed system, but efforts to improve practice will be more effective if the system is redesigned so that it is easier for average workers to do so’.

5. Serious Case Reviews: Preparation • Identifying a case for review • Selecting the review team • Identifying who should be involved • Preparing participants • The importance of all workers’ views

6. Serious Case Reviews: Collecting and organising data • Selecting documentation • One-to-one conversations • Producing a narrative of multi-agency perpectives • Identifying and recording key practice episodes and their contributory factors

7. Serious Case Reviews: Analysing data • Reviewing the data and analysis  • Identifying and prioritising generic patterns • Making recommendations

8. The background • Widespread and persistent concern over standards • Many enquiries and Serious Case Reviews • Far reaching reforms • Little evidence of improvement, in England at least

9. Why haven’t we learned? (Addictive behaviours) If it doesn’t work, do more of it Procedures and micromanagement Training Performance indicators

10. Failure to learn from experience • The proceduralisation, technicalisation and deprofessionalisation of the professional task • Process and procedures prioritised over outcomes and objectives • Targets and indicators prioritised over values and professional standards • Compliance and completion prioritised over analysis and reflection

11. Deprofessionalisation • Part of a wider trend • Managerialism, McDonaldisation and the audit culture • Management by external objectives • Professionals not to be trusted

12. The ‘scandal’ model of case review • Public pillorying • Public enquiry with many recommendations • Law and guidance from the government

13. Climatic conditions for safeguarding • Climate of fear • Climate of mistrust • Climate of blame

14. Responsible journalism at its best “Today The Sun has demanded justice for Baby P — and vows not to rest until those disgracefully ducking blame for failing the tot are SACKED” “The fact that Baby P was allowed to die despite 60 visits from Haringey Social Services is a national disgrace. I believe that ALL the social workers involved in the case of Baby P should be sacked - and never allowed to work with vulnerable children again. I call on Beverley Hughes, the Children's Minister, and Ed Balls, the Education Secretary, to ensure that those responsible are removed from their positions immediately”. (The Sun, 13 November 2008)

15. Climatic conditions • Climate of fear • Climate of mistrust • Climate of blame

16. Climate of mistrust ‘Child stealers’ who ‘seize sleeping children in the middle of the night’; ‘abusers of authority, hysterical and malignant’, ‘motivated by zealotry rather than facts’ or ‘like the SAS in cardigans and Hush Puppies’. On the other hand, they are ‘naïve, bungling, easily fobbed off’, ‘incompetent, indecisive and reluctant to intervene’ and ‘too trusting with too liberal a professional outlook’.

17. Climate of mistrust The safeguarding worker who took a child away from its parents The safeguarding worker who failed to take a child away from its parents

18. Climatic conditions • Climate of fear • Climate of mistrust • Climate of blame

19. Maximising learning Serious Case Reviews must: • Explore WHY things were done (or not done) and not just WHAT was done (or not done) • Distinguish individual ignorance and error from strategic and systemic issues • Interpreting what happened locally in the wider context of practice knowledge

20. Exploring the WHYs (Level 1) A Serious Case Review along these lines is pretty much a waste of time : Fact: This child was injured because we did not do X Recommendation: Do X in the future We need to know WHY X was not done

21. Why was X not done? • Was it individual ignorance or error? (Outcome: training, competency issues) • Was the requirement not expressed clearly in procedures when it should have been (Outcome: Procedural change) • Was this requirement not understood? (Staff development; strategic or systemic considerations)

22. Why was X not done? • Were resources/commitment absent? (Strategic or systemic considerations) And finally and most crucially: • Was the service environment conducive to and supportive of good practice? (Strategic or systemic considerations)

23. Exploring the WHYs (Level 2) Fact: This child was injured because we did not do X Recommendation: Train staff to know they have to do X and/or write some new procedures (or both) (In fact, we know that people often don’t do X even though they know, in theory, that they should and there are procedures which tell them that they must. The key question is often, why did they still not do it?)

24. Exploring the WHYs (Level 2) BBC Regional News, 17 November 2011: “The latest Ofsted inspection has found Children’s Services in Peterborough to be inadequate in seven out of nine categories. The Director of Children’s Services announced that the council had embarked on a programme of updating procedures and improving staff training”

25. Blaming, training and writing procedures • Procedural proliferation • Blaming and training • The myth of predictability

26. Procedures as a net to catch problems

27. Procedures as a net to catch problems

28. Procedures as a net to catch problems

29. Procedures as a net to catch problems

30. Blaming and training Causes of accidents can be traced to ‘latent failures and organizational errors arising in the upper echelons of the system in question Accident sequences begin with problems arising in management processes such as planning, specifying, communicating, regulating and developing. Latent failures created by these organisational errors are ‘transmitted along various organizational and departmental pathways to the workplace where they create the local conditions that promote the commission of errors and violations (e.g. high workload, deficient tools and equipment, time pressure, fatigue, low morale, conflicts between organizational and group norms and the like’ (Reason, 1995 p.1710). In this analysis, ‘people at the sharp end are seen as the inheritors rather than the instigators of an accident sequence’ (Reason, 1995 p.1711).

31. Exploring the WHYs (Level 3) Fact: This child was injured because we did not do X Recommendation: • Review on an interagency basis the adequacy of the child safeguarding services available to, say, young people abused through prostitution; or • Review quality assurance processes and managerial processes to ensure that they focus more on quality than quantity.

32. Exploring the WHYs (Level 3) Fact: This child was injured because we did not do X Recommendation: • Review whether the service environment was conducive to and supportive of good practice?

33. Micromanaging recording and reporting Format: Endless predetermined tick boxes and text boxes Content: Repetitive and disaggregated Concept: Routinised and mechanistic Purpose: Well, what is the purpose?

34. Micromanaging assessment and reporting Format: Endless predetermined tick boxes and text boxes Content: Repetitive and disaggregated Concept: Routinised and mechanistic Purpose: Well, what is the purpose? Understanding what it is like to be that child, and what it will be like if nothing changes

35. Micromanaging assessment and reporting Format: Endless predetermined tick boxes and text boxes Content: Repetitive and disaggregated Concept: Routinised and mechanistic Purpose: Well, what is the purpose? Understanding what it is like to be that child, and what it will be like if nothing changes Getting the assessment done 

36. Micromanaging assessment and reporting What we want: Coherent, confident and compelling What we get: Disassembled, disarticulated and decontextualised

37. KPIs: Ministers and managers Outcomes hard to measure, process easy Easy to obtain, easy to digest (but what do they tell us?) Quality = KPI scores False sense of security Distort resource allocation ?A third of the mix

38. On the front line Learn by doing more than by training What is important in what I do? What is good practice? Supervision: qualitative or quantitative?

39. Escaping the spiral of decline requires Research-informed, reflective, confident and critically-challenging practitioners Management systems which promote rather than undermine their effectiveness.   Ministers and senior managers committed to a significant change of direction, both practical and conceptual

40. Checkpoint 1 Was any of this ‘true for us’? Three things we have done/are doing/could do to put things right

41. Learning from Past Experience Major themes from SCR reviews of the 90s: Collecting and interpreting information Importance of comprehensive family assessments, especially male figures Failure to give sufficient weight to relevant case history Understanding thresholds, especially the importance of neglect and emotional deprivation and the need to accumulate evidence

42. Learning from Past Experience Major themes from SCR reviews of the 90s: Collecting and interpreting information Importance of comprehensive family assessments, especially male figures Failure to give sufficient weight to relevant case history Understanding thresholds, especially the importance of neglect and emotional deprivation and the need to accumulate evidence

43. Learning from Past Experience Major themes from SCR reviews of the 90s: Collecting and interpreting information Importance of comprehensive family assessments, especially male figures Failure to give sufficient weight to relevant case history Understanding thresholds, especially the importance of neglect and emotional deprivation and the need to accumulate evidence

44. Capturing chronic abuse • Judging the impact of long-term abuse is an essential component of any assessment but how well do we do it? • Judgements subjective and prone to bias • Intangible: Difficult to capture and compare • High threshold for recognition • Neglect is a pattern not an event

45. Capturing chronic abuse • Judging the quality of care is an essential component of any assessment but how well do we do it? • Judgements subjective and prone to bias • Intangible: Difficult to capture and compare • High threshold for recognition • Neglect is a pattern not an event

46. Our image of assessment

47. The reality of assessment?

48. Capturing chronic abuse • Judging the quality of care is an essential component of any assessment but how well do we do it? • Judgements subjective and prone to bias • Intangible: Difficult to capture and compare • High threshold for recognition • Neglect is a pattern not an event

49. The pattern of neglect: atypical

50. The pattern of neglect: typical