Everybody who works in, or who has responsibility for, child protection should listen to Matthew Syed’s three-part series on BBC Radio 4, ‘Learning from life and death’.
He promises to explore how and why individuals and organisations learn from their mistakes or, alternatively, how they fail to do so. The programmes, we are told, will identify common obstacles to learning from experience and ways in which they can be overcome.
Not surprisingly the aviation industry is cited by Matthew as a repository of good practice. Learning, he argues, is at the heart of aviation’s safety culture. The emphasis is on learning lessons, not apportioning blame. Avoiding unnecessary blame and treating people fairly when they make mistakes results in a high level of reporting, which provides aviation professionals with a wealth of data which can be analysed. As a result, the causes of errors can be understood and systematic improvements made.
Regular readers of this blog will not be surprised to hear me endorsing these arguments. For years now I (and others, such as members of the Safer Safeguarding Group) have been banging our heads against glass walls and ceilings (and even floors) trying to get policy makers to recognise that child protection will only become safer if it adopts an approach which is similar to that adopted by the airlines. Routine errors and mistakes should be seen, not as excuses to blame and censure, but as opportunities for learning and understanding. There is a overbearing need for transparency; for a just culture that thrives on openness.
Five routes to safer organisations emerge from the first of the three programmes:
- Understand that error does not equal disaster, it equals opportunity
- Put learning at the centre of the organisation’s culture
- Learn lessons, not apportion blame
- Treat people fairly
- Achieve a high level of reporting of mistakes and service failings
I believe each of these should be put into effect in child protection. Unless we begin to adopt approaches the wisdom of which is now widely acknowledged, we will be open to accusations of negligence, of letting children and young people down by not doing all we can to keep them safe.
The names of three people mentioned in the programme will stay with me. The first is that of the philosopher of science, Sir Karl Popper, who believed that the route to better science and a more open society lies in trying to falsify hypotheses, not confirm them. What counts is not having a theory that fits with all the facts but rather having a theory which is capable of being tested.
The second name is that of the statistician George Box.
Box is credited with arguing that all models are wrong but some are useful. He wrote: "The most that can be expected from any model is that it can supply a useful approximation to reality: All models are wrong; some models are useful".
Like Popper's, this philosophy is a form of fallibilism, the view that people cannot attain absolute certainty concerning questions of fact. We should always be ready to be proved wrong and when we are we should learn from our mistakes.
The third name is that of the comedian John Cleese. Speaking about how he tries to learn to be funnier, he told Matthew Syed that it was vital to create a gap between yourself and your ego. He always tried to stand back and view things objectively, not emotionally. The key barriers to learning were blame and ego.
There is a great deal to think about in this series and a great deal that is very relevant to building safer child protection services. I am looking forward greatly to next week’s episode.