The Daily Mirror reports on research by the NSPCC which looked at the Serious Case Reviews completed
since Baby Peter’s death.
The research found that a hundred deaths of babies and
toddlers had resulted in a Serious Case Review (SCR) since the death of Baby
Peter. Andrew Flanagan, chief executive of the NSPCC, is quoted as saying:
“Despite calls for this never to happen again here we are five years on with
babies being killed in brutal ways.”
Reports into twenty-eight child deaths were examined in
detail. This showed that in several cases drug and alcohol abuse, domestic
violence and mental illness were significant factors. Twelve of the reviews
concerned cases where the focus of the work was said to be on the adults and
not the child. An ‘unknown’ male joining the family was said to be a factor in
seven cases.
Unfortunately these kinds of statistics are not particularly
helpful. Many of the factors identified are also found not infrequently in
families where abuse and neglect of children do not take place. Obviously
professionals cannot react to these cases as if they required child protection.
Not only do they not have legal powers to intervene, but services would be
overwhelmed.
I wish the NSPCC would fund some research into how to reduce
error in child protection practice. Sadly whatever changes in law, practice and
procedure occur, there seems to be a core of cases in which, despite the
efforts of professionals, neglect and abuse continue and result in tragedy. The
wrong decisions are taken and a child dies.
Many years ago I suggested that trying to understand more
about non-fatal, routine errors might help - http://bjsw.oxfordjournals.org/content/20/3/215.abstract
. My favourite quote from Professor Jim Reason applies:
‘Without a detailed analysis of mishaps, incidents, near misses, and “free lessons,” we have no way of uncovering recurrent error traps or of knowing where the “edge” is until we fall over it.’ (BMJ Volume 320 18 March 2000 - http://www.bmj.com/content/320/7237/768 )
Responding to child abuse and neglect will always be
difficult. Failures in practice will only reduce if we have sound understanding
of the interactions between practitioners, their organisations, systems and procedures, the wider
environment and families who are being helped.
Critical incident reporting would result in a better understanding of when and how mistakes occur and how systems fail. An organisation like NSPCC would be ideally placed to co-ordinate a critical incident reporting system.
Critical incident reporting would result in a better understanding of when and how mistakes occur and how systems fail. An organisation like NSPCC would be ideally placed to co-ordinate a critical incident reporting system.
