Transcript Slide 1

Learning from experience
Reflections on piloting a new approach to
Management and Serious Case Reviews in
Hillingdon
James Blewett
3rd November 2011
Aims
•To explore the context of piloting the SCIE
model
•To consider the existing messages from
research into serious case reviews?
•To look at the key features of the new
approach
•To reflect on the experience applying it to a
management review in Hillingdon
Serious Case Review Background
• ‘Serious Case Reviews’ are undertaken when a
child dies or is seriously injured and abuse or
neglect are suspected to be a factor and there
are lessons to be learnt about inter-agency
working to protect children. Regular reports to
Ministers from Ofsted.
• In addition, DfE commissions an analysis of
these Reviews every 2 years – the fourth
national study analysis 2007-9 was published a
year ago
Context
• A difficult population to study and learn
from - ‘hard cases make bad laws’
• Public scrutiny - high profile cases, media
interest, court involvement, uncertainty,
confidentiality, data protection etc
• Professional anxiety about scrutiny – can
reduce morale
• Findings can be misinterpreted
The children
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⅔ were under 5
½ were under 1
Minority aged 6-10
¼ over 11
11% over 16
What happened to the children
(2009)
• ⅔ of 189 children died
• ⅓ seriously injured or harmed
• The highest risk of maltreatment related
deaths and serious injury are in the first
five years of life
• Physical assault was the major cause of
death
• Most of the older adolescents died through
suicide
continued
• Issues of neglect were often present in
those children who died.
• Sexual abuse was the prime concern in 1
in 12 cases.
Were there known child protection
risks?
• 17% of the children were the subject of a
child protection plan (mostly neglect)
• In a third of the 189 families there were
known child protection risks as either the
index child or a sibling were at some time
the subject of a child protection plan
• Just over half of the children were known
to children’s social care at the time of the
incident
continued
• Neglect was the most common preexisting factor in those children or siblings
who had. been previously known to
children’s social care
• The needs and distress of the older young
people were often missed or too
challenging or expensive for services to
meet.
• The families of very young children who were
physically assaulted (including those with head
injuries) tended to be in contact with universal
services or adult services rather than children’s
social care.
• In families where children suffered long term
neglect, children’s social care often failed to take
account of past history and adopted the ‘start
again syndrome’.
• In the cases where the information was available,
well over half of the children had been living with
domestic violence, or parental mental ill health, or
parental substance misuse. These three
problems often co-existed.
Other themes
• The importance of understanding the
impact of psycho social history on
parenting
• Working with hard to help adolescents
• Working with men
• Substance misuse
• Working together to manage risk
• Assessment, care planning and review
• The importance of high quality supervision
Some key messages from SCRs
(Brandon et al, 2010)
• The chaotic behaviour in families was
often mirrored in professionals’ thinking
and actions.
• Many families and professionals were
overwhelmed by having too many
problems to face and too much to achieve.
These circumstances contributed to the
child being lost or unseen.
Themes and learning points
• The capacity to understand the ways in
which children are at risk of harm is
complex and requires clear thinking.
• Practitioners who are overwhelmed, not
just by the volume of work but also by its
nature, may not be able to do even the
simple things well.
• Good support, supervision and a fully
staffed workforce is crucial.
Themes (contd)
• Reluctant parental co-operation and
multiple moves meant that many children
went off the radar of professionals.
• However, good parental engagement
sometimes masked risks of harm to the
child.
• “Start again syndrome”
The problem
• Serious case reviews have become a key
forum for reviewing practice both nationally
and locally
• The messages from serious case reviews
often resonate with practitioners and
managers
• However they also highlight difficulties that
remain obstinately difficult to change
• There is a national debate over the efficacy
of SCRs
Munro: A challenge to the sector
• An ambitious attempt to promote a
fundamental culture change in social work
(social care)—provides the impetus for the
SWRB
• The aim is to produce more self confident,
authoritative practitioners able to exercise
professional judgment, thinking clearly and
critically at both the individual and systems
level
Munro Review: Conceptual
frameworks
• Systems approach
• ‘The aim is to make it harder for people to
do something wrong and easier for them
to do it right.’
• Understanding the relationship between
doing, thinking and learning
A concern with
doing things right
versus a concern for
doing the right thing
• Promotes a socio–technical perspective
• Identifies the impact of managerialism, risk
aversion and a technocratic approach to
performance management
• ‘In design, we either hobble or support
people’s natural ability to express forms of
expertise
• The importance of staying child focused
• Highlights the impact of delay
• Recognising uncertainty in child protection
work
• Risk aversion and professional practice
“Professionals can make two types of
error: they can over-estimate or
underestimate the dangers facing a child
or young person. Error cannot be
eradicated and this review is conscious of
how trying to reduce one type of error
increases the other”
A balancing act
Collusive practice
punitive practice
Possible barriers to learning
• Workload (nature as well as quantity)
• The profile of workforce in frontline teams
• Defensive workplace cultures: Ambiguity,
mistakes and blame
• Nature of systems for measuring practice
• Lack of effective supervision (at all levels)
Understanding families
• Ambiguity and uncertainty (a reality!)
• The relationship between parental difficulties
and outcomes for children (Blewett et al,
2011)
• Enmeshment with emotive families
• Meaning of “truth and lies” (Harvey, 2010)
• The role of the home visit (Ferguson, 2010)
Safe Certainty
Unsafe certainty
Safe uncertainty
Unsafe uncertainty
A new approach
• Being piloted by SCIE (Fish, Munro and
Bairstow)
• The largest pilot currently being completed
in London
• Attempts to ask different questions,
answer them in different ways and
therefore come up with different types of
“answers”
The principles behind systems
thinking...
• We analyse the causal sequence until we
get to a satisfactory explanation - then we
stop.
• Human error is a satisfactory explanation: If only the social worker had (not) done... then the
tragedy would not have happened.
• Conclusion: erratic people degrade an
otherwise safe system. Work on safety
requires protecting the system from
unreliable people.
• Put psychological pressure on and retrain
workers to perform better.
• Reduce human factor as much as
possible:
formalize/mechanize/proceduralize.
• Increase surveillance to ensure
compliance with instructions etc.
• Active failures are like mosquitoes, they
can be swatted one by one but they still
keep coming.
• The best remedies are to create more
effective defences and to drain the
swamps in which they breed.
• The swamps, in this case, are the ever
present latent conditions.
—James Reason
• Hindsight bias leads us to grossly
overestimate how reasonable an action
would have looked at the time and how
easy it would have been for the worker
to do it.
• It is only with hindsight that the world
looks linear because we know which
causal chain actually operated—domino
theory of causation
• Individuals are not totally free to choose
between good and problematic practice
• We are all part of the multi-agency
systems and our behaviour is shaped by
systemic influences
• The standard of performance is
connected to features of
• tasks,
• tools and
• operating environment.
Blunt end
Sharp end
• The theory / principles of the model
dictates:
• How and what gets investigated
• How and what is reported
• How we formulate findings
(challenges)
– The result may be unfamiliar!
• A case review needs to provide a
‘window on the system’ identifying
i) which factors are supporting good practice
and
ii) which factors are, inadvertently making
poor practice more likely.
• For both good and poor practice, need
to understand the ‘local rationality’
Key features
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A review group (multi agency)
A case group (conversations)
Key practice episodes
Underlying patterns and issues for the
LSCB to consider
Early reflections on the Hillingdon
management review
• Vulnerable adolescent who stretched the
system
• How we understand safeguarding and
adolescence
• The meaning of joined up working with
complex cases
Reflections on the process
• Does provide insight into complex
systemic processes
• Is more multi agency
• Avoids slipping into simplistic solutions to
long term issues
• Does recognise the impact of local,
regional and national issues
However
• Time and resources
• How new are the lessons
• The challenge of applying systems
theory to practice in a sophisticated and
robust way
Conclusions
• Overall the pilot has stimulated new
thinking and debate
• Challenge to the sector on how we
manage risk, complexity and uncertainty
• The importance of promoting professional
expertise
• Meeting the needs of vulnerable children
in challenging times