Focus on what went wrong isn’t making child protection safer

When child protection services fail, people understandably want to know who, or what, was responsible. 

In England, there is a long history of public inquiries, local reviews, and a vast (and ever-growing) library of reports. 

The Children and Social Work Act 2017 established the Child Safeguarding Practice Review Panel to coordinate and analyse locally produced reviews of serious incidents, including fatal cases, through what the panel’s former chair, Annie Hudson, called “the very specific lens” of where things have gone seriously wrong for children. 

The government has recently proposed transferring the panel’s work to a new body, the Child Protection Authority, which would continue and expand that role.

There is no evidence that all this activity has improved child protection or made any child safer. Every so often, there is another disaster and another public outcry. Inquiries produce reports and make numerous recommendations, but there is seldom any reflection on whether we are learning effectively. 

Perhaps we need a better understanding of how we learn to make services safer, and how we can improve learning from practice.

Wrong approach

There are several things wrong with the current approach. The first is that fatal incident inquiries are generally produced and reviewed by people who are removed from practice, such as managers or experts, sometimes lawyers or academics. They often operate with an unrealistic view of practice, based on what they believe should be done, rather than what is routinely achieved at the sharp end every day. 

This can result in counterfactual reasoning and hindsight bias. Lord Laming provided a clear example of that when he remarked in his report concerning Victoria Climbié: “…the social workers involved would have needed only to do the simple things properly in order to have greatly increased the chances of Victoria being properly protected”. 

That ‘explanation’ gives no real insight into why things went wrong. We are just invited to be satisfied with a virtual tautology: the social workers got it wrong because they didn’t do what they should have done!

Social work is not mechanical

Another difficulty is the tendency of many investigations into child protection tragedies to apply mechanical, linear explanations that are not appropriate. When a mechanical system, like a car engine, fails, it is often possible to trace the problem to a particular component – for example, a failed fuel pump or a faulty battery. There is usually a straightforward chain of events, each causing the next. 

However, systems that depend mainly on human action are harder to understand, and it is difficult to identify simple connections. Safety scientists describe these human systems as complex: they comprise interactions between individuals and groups, producing sequences of events that are unplanned and unexpected. 

Trying to apply mechanical, linear analysis to complex systems is a serious mistake. Doing so often results in attributing negative outcomes to factors such as “human error”, “poor decision-making”, or “inadequate information sharing”. 

But such labels do not explain why the situation unfolded as it did, nor do they show how to prevent recurrence. They just offer another description of what went wrong.

To understand a serious service failure in a complex system, we need to ask not only what happened, but why a particular course of action made sense to those involved at the time. As psychologist Sidney Dekker argues, this means seeing events from practitioners’ perspectives, rather than from the vantage point of detached observers. 

Yet this is often difficult. Those involved may be unable to give a full account, especially where a culture of blame discourages openness about perceived weaknesses or failings.

Warped focus on serious incidents 

A further problem concerns whether focusing primarily on cases where things have gone seriously wrong for children is a sensible approach. Serious untoward incidents are only a small fraction of service failures, and an even smaller fraction of day-to-day practice – most of which achieves some degree of success. 

It follows that serious failures are not representative of normal work. So however detailed the review, analysing them is unlikely to generate much useful knowledge that leads to significant safety improvements. 

Instead, we need a broader understanding of how safety is created in practice – and how practitioners can be supported to overcome obstacles to delivering safer care.

Problem with top-down recommendations

A final difficulty concerns the implementation of recommendations from reviews and inquiry reports. Not only are these recommendations numerous, and often very detailed, but they are the product of the ‘expert’ deliberation of a few clever people rather than being grounded in the practice experience of many. 

They are passed top-down from those who inquire and reflect to those who do the job. When recommendations sit uneasily with practitioners, as they often do, the result is disorientation, resentment, resistance, and sometimes token compliance. It is seldom improvement.

Understanding normal practice

It is hard not to conclude that improving the safety of services will never come from endlessly documenting extreme failures or trying to understand them by elaborating their immediate causes and contexts. To make services safer, we need instead to design resilient organisations, so that the likelihood of failure declines over time as practitioners learn and adapt.

Effort and resources must be directed towards researching normal practice and understanding how practitioners create and manage safety each day in the organisations in which they work. 

Academic research can help, but the most important research and learning must take place at the sharp end where the work is done, by the people who do it. 

An important requirement is a culture in which people can talk openly about their work and its context without fear of blame or discipline. They must be given time, space and permission to reflect and learn. 

Space for structured reflection

At the core of learning to practice more safely is structured reflection. Donald Schön’s seminal book, The Reflective Practitioner, outlines the limitations of “technical rationality” in professions like social work and argues that professional knowledge depends heavily on “reflection-in-action”.

Yet, more than 40 years after its publication, reflective practice is still only paid lip service in many social work settings. This must change. Workers need time and space to study and understand their own work, and the tools and resources to do so.

Simple organisational research techniques are valuable, but less formal approaches can also help. For example, debriefing allows everyone involved in a discrete piece of work to share feedback on what went well and what did not; lessons can then be disseminated and escalated to management for possible action. 

Consult children and young people

Capturing and formalising feedback from service users is also an important source of knowledge about the impact of services. Consultation with children and young people is not an optional extra; it is core to understanding how services work, or fail to work, and how they can be sustained and improved. Listening to feedback should be a key part of every practitioner’s work.

In contrast, the government’s proposal to establish a Child Protection Authority in England, with powers to replicate and expand the work of the Child Safeguarding Practice Review Panel, is an uncritical acceptance of a status quo that is not working to make services safer. 

The proposal should be revisited before money is wasted on bringing it about.

Chris Mills is a retired child protection social worker, academic and researcher. He has worked as policy adviser on child protection for a children’s charity and has provided training in promoting human factor approaches to safety in child protection