1. Learning from experience Reflections on piloting a new approach to Management and Serious Case Reviews in Hillingdon James Blewett 3 rd November 2011

2. 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

3. 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

4. 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

5. The children ⅔ were under 5 ½ were under 1 Minority aged 6-10 ¼ over 11 11% over 16

6. 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

7. continued Issues of neglect were often present in those children who died. Sexual abuse was the prime concern in 1 in 12 cases.

8. 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

9. continued Neglect was the most common pre- existing 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..

10. 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.

11. 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

12. 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.

13. 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.

14. 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”

15. 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

16. 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

17. 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

18. A concern with doing things right versus a concern for doing the right thing

19. 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

20. The importance of staying child focused Highlights the impact of delay Recognising uncertainty in child protection work Risk aversion and professional practice

21. “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”

23. 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)

24. 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)

25. Safe Certainty Safe uncertainty Unsafe certainty Unsafe uncertainty

26. 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”

27. 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. The principles behind systems thinking...

28. 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.

29. Why did this action/inaction/decision seem the sensible thing to do at the time? Target recommendations at: - making it harder to safeguarding poorly and easier to do well

32. 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

33. 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

35. 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.

36. Blunt end Sharp end

37. 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!

38. 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’

39. Key features A review group (multi agency) A case group (conversations) Key practice episodes Underlying patterns and issues for the LSCB to consider

40. 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

41. 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

42. However Time and resources How new are the lessons The challenge of applying systems theory to practice in a sophisticated and robust way

43. 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