Improving practice : child protection as a systems problem

This paper argues for treating the task of improving the child protection services as a systems problem, and for adopting the system-focused approach to investigating errors that has been developed in areas of medicine and engineering where safety is a high priority. It outlines how this approach differs from the traditional way of examining errors and how it leads to different types of solutions. Traditional inquiries tend to stop once human error has been found whereas a systems approach treats human error as the starting point and examines the whole context in which the operator was working to see how this impacted on their ability to perform well. The article outlines some factors that seem particularly problematic and worthy of closer analysis in current child protection services. A better understanding of the factors that are adversely effecting practitioners’ level of performance offers the potential for identifying more effective solutions. These typically take the form of modifying the tasks so that they make more realistic and feasible demands on human cognitive and emotional abilities

Empowering looked after children

Children’s rights include the right to participation in decisions made about them. For looked after children, this right is enshrined in the Children Act, 1989. This article reports the results of a study of children’s views about their experience of being looked after and the degree of power they felt they had to influence decision making. Their main areas of criticism were frequent changes of social worker, lack of an effective voice at reviews, lack of confidentiality and, linked to this, lack of a confidante. The findings are discussed in relation to recent policy changes. Specifically, the Looked After Children documentation and the Quality Protects Initiative by setting out uniform objectives and performance criteria seem to restrict the freedom of local authority management and of social workers to respond to individual children’s preferences or to give weight to what the children themselves consider to be in their best interest

The role of risk assessment in reducing homicides by people with mental illness

Background: Improved risk assessment has been stressed as the way to reduce homicides by people with mental illness. The feasibility of predicting rare events needs examining. Aims: To examine the findings of public inquiries into homicides by people with mental illness to see if they support the claim that better risk assessment would have averted the tragedy. Method: Analysis was made of the findings of the public inquiries between 1988 and 1997 in relation to the predictability and preventability of the homicides. Results: Of the homicides considered by the inquiry panels, 27.5% were judged to have been predictable, 65% preventable and 60% of the patients had a long-term history containing violence or substantial risk factors for violence. Conclusions: Improved risk assessment has only a limited role in reducing homicides. More deaths could be prevented by improved mental health care irrespective of the risk of violence. If services become biased towards those assessed as high risk, then ethical concerns arise about the care of both violent and non-violent patients

Review of \u3cem\u3eChildren, Family and the State: Decision-making and Child Participation.\u3c/em\u3e Nigel Thomas. Reviewed by Eileen Munro.

Book review of Nigel Thomas, Children, Family and the State: Decision-making and Child Participation. New York: St. Martin\u27s Press, 2001. $65 hardcover

Decision making under uncertainty in child protection: creating a just and learning culture

The argument is made for having a positive error culture in child protection to improve decision making and risk management. This requires organizations to accept that mistakes are likely and to treat them as opportunities for learning and improving. In contrast, in many organizations, a punitive reaction to errors leads to workers hiding them and developing a defensive approach to their practice with children and families. The safety management literature has shown how human error is generally not simply due to a ‘bad apple’ but made more or less likely by the work context that helps or hinders good performance. Improving safety requires learning about the weaknesses in the organization that contribute to poor performance. To create a learning culture, people need to feel that when they talk about mistakes or weak practice there will be a constructive from their organization. One aspect of reducing the blame culture is to develop a shared understanding of how practice will be judged and how those appraising practice will avoid the hindsight bias. To facilitate a positive error culture, a set of risk principles are presented that offer a set of criteria by which practice should be appraised

Blending systems thinking approaches for organisational analysis: reviewing child protection in England

This paper concerns the innovative use of a blend of systems thinking ideas in the ‘Munro Review of Child Protection’, a high-profile examination of child protection activities in England, conducted for the Department for Education. We go ‘behind the scenes’ to describe the OR methodologies and processes employed. The circumstances that led to the Review are outlined. Three specific contributions that systems thinking made to the Review are then described. First, the systems-based analysis and visualisation of how a ‘compliance culture’ had grown up. Second the creation of a large, complex systems map of current operations and the effects of past policies on them. Third, how the map gave shape to the range of issues the Review addressed and acted as an organising framework for the systemically coherent set of recommendations made. The paper closes with an outline of the main implementation steps taken so far to create a child protection system with the critically reflective properties of a learning organisation, and methodological reflections on the benefits of systems thinking to support organisational analysis