Training | 2009.11.10
Beyond the blame culture | Eileen Munro
When child protection fails, we need a system of accountability that asks not who, but why
A plane unaccountably crashes into a mountain and everyone, including the pilot, is killed. There will, quite properly, be an investigation, but one possibility it is most unlikely to consider is that the pilot may have caused the crash through laziness or stupidity. This is for the simple reason that unless he or she wanted to die, the pilot would have done everything possible to avoid it – from training to fly in the first place to arriving for work with the presumption that mountains should be steered round.
Contrast this with investigations triggered when a child is killed or seriously injured in a domestic setting. These investigations (known as serious case reviews ) make no such assumptions about the professionals involved – doctors, police officers and social workers. Indeed, the public response to these awful cases is one of bafflement that so many professionals could fail to follow procedures – a response usually echoed by the official inquiries that follow.
Both public opinion and formal investigations conclude that children are harmed or killed because people working in child protection are stupid, malicious, lazy or incompetent. (There is, as Sharon Shoesmith knows, deep and lasting anger.) Why is this assumed? Surely it is reasonable to believe that people who choose to work in this demanding field want to help children, rather than allow them to be hurt?
If we make this small leap of faith, we might consider if there is any point in repeatedly asking why staff do not follow procedures, and ask instead what hampers them from doing so. We need a way of conducting serious case reviews that treats people and procedures as integral parts of the same system.
This is what the air crash investigators will do from the moment they arrive at the scene. They will ask not only why the pilot didn\'t see the mountain or take evasive action; they will consider which aspects of the workplace made the error more likely to happen. For example, did the cockpit design make it easy for the pilot to confuse key instruments and so misjudge height and position.
This is the systems approach – a recognition that performance is a blend of a worker\'s skill, experience and dedication with the design and organisation of their workplace. When we ask "Are the right systems in place?", we tend to mean "Are there rules and procedures to follow?" and are glimpsing only a part of the mechanism. In a true systems approach, the term is used to mean the full range of people, procedures, skills, tools, organisation and culture.
This is an approach that could work for serious case reviews – and already is. I and colleagues at the Social Care Institute for Excellence have devised a model that draws on practice in aviation, health and other high-risk areas. It allows that decisions may have seemed sensible at the time and goes beyond asking what failed to asking how the system can be re-calibrated.
This is not just theory – our method is already being run on a pilot basis in the north-west. The early signs are that it gives us a way of adjusting the system so that it is easier for people to do the right thing and harder to make mistakes.
Critics will object that this is a "no blame" culture. It is not. It is a call for us to abandon a poor system of accountability that allows us to blame individuals but offers nothing that will help us to build a more functional system with an open and fair culture of accountability.
We know well that protection broke down in the cases of Baby Peter , Victoria Climbié and others whose names are still veiled. But we have failed to ask the right questions in response – not "How could they get it so wrong?", but rather: "How can we build a system that is more likely to get it right?"
For more information, please visit
http://www.guardian.co.uk/commentisfree/[...]s-case-review-child-protection
