Briefing Paper
Developing a Responsive Safety Culture in Child Protection Services
October 2015

The Problem

Child protection is a safety critical activity. When things go wrong they can go very wrong. Ever since the enquiry into the death of Maria Colwell in 1974 policy makers in Britain have wrestled with the issue of how to make child protection services safer. Various approaches have been tried - more procedures, more training, more inter-agency working, more information sharing, new approaches to assessment, new checklists and forms, serious case reviews, organisational redesign. But serious service failures have persisted.

The core of the problem is that we are not learning appropriately from error. There is a culture of anxiety and fear within services. Professionals and organisations practice defensively. There is a general unwillingness to admit to mistakes and to examine objectively how errors occur. Practitioners who have genuine safety concerns are often silenced by coercive organisational cultures. There are people who can see what is going wrong and who could speak out. But they don’t.

Formal means of learning from error, such as Serious Case Reviews, are time-consuming, expensive and have become formulaic. Following inquiries, leaders often declare that ‘lessons will be learned’, but there is resignation and cynicism. Many people try to keep their heads down and hope that the next time a tragedy occurs, it will not be on their watch.

What needs to happen?

We believe that there are five things that can be put in hand immediately that would begin the process of building a Responsive Safety Culture in child protection; of making safeguarding appreciably safer. This is not just a ‘shopping list’ of proposals that are merely desirable. Doing these things is essential if we are to put an end to repeating the cycle of unnecessary tragedy, stunned disbelief and public outrage.

  1. Learn from other safety critical industries.

    The kinds of mistakes that happen in child protection are very similar to those that occur in other safety critical fields. In civil aviation it has long been understood that human error is the major single cause of disasters. Since the 1980s civil aviation professionals have developed an impressive portfolio of training and development approaches to help professionals deal constructively with loss of situation awareness and other types of human error. Child protection professionals should seek to understand and adopt these approaches.

  2. Develop a just reporting culture.

    Practitioners must be given permission and encouraged to talk about errors. Organisations that inhibit discussion of errors are inherently unsafe. A reporting culture is one in which committing, discovering or witnessing an error is seen as a learning opportunity: a chance to make the organisation safer. Blame inhibits reporting but we do not advocate a blame free culture. What is required is a just culture. That is one in which it is acknowledged that those who make errors while acting in good faith should not be blamed simply because a bad outcome has ensued.

  3. Support and respect those who raise safety concerns.

    Professionals are often well placed to see the risks, but too often they are silenced. People who raise safety concerns, either about their own work or about organisational failings, must be rewarded for doing so. Whistleblowers should be supported and shown respect. Sadly all too often whistleblowers in health and social care have been overtly bullied or subjected to subtle forms of maltreatment. This must stop.

  4. Equip practitioners to talk about workplace errors and to analyse and understand how mistakes happen.

    Human Factors training (HF) is a form of non-technical training that emerged in civil aviation during the late 1970s and 1980s. It has now become mandatory for 3 all US and European airlines. In recent years HF thinking has been found to be transferable to medical contexts such as surgery and anaesthesia. We have found that it can also be used very successfully with child protection professionals. A short basic course of one or two days duration equips someone with sufficient knowledge to begin to practice and share HF thinking at work, using it to help reduce and mitigate workplace error.

  5. Gain a broad and accurate picture of the types and frequencies of mistakes and service failings.

    We need better systems to create better quality data about the kinds of errors that occur daily in child protection practice. Confidential Near Miss Reporting (sometimes called Critical Incident Reporting) is a simple, cost effective technique for gathering information about the kind of errors that occur daily, not just fatal, or near fatal, incidents. It is widely practiced in transport industries and also in some branches of medicine. We believe that it should be practiced in child protection too. That would allow managers, practitioners and academics the opportunity to study the nature and circumstances of errors that routinely occur; and to analyse them and suggest ways in which they can be reduced or mitigated.

Why now?

The experience in aviation and other safety critical industries shows that while technological changes can result in steady safety improvements, there are always residual human error issues that will continue to compromise safety, unless specifically addressed. For example, the computerised flight deck in aviation has a number of advantages, but it has also brought with it new varieties of human error, associated with misunderstandings, often complex, about what the computers are telling the pilots.

In child protection new ways of working – innovations – will hopefully lead to higher quality and safer services. But innovations also have their risks. While new structures, new service offerings and new accountability arrangements may offer some clear advantages, they also embody dangers associated with novelty and change.

We believe that to take forward significant changes, specific steps need to be taken to create appropriate systems and a suitable environment in which learning from error can easily and effectively take place. In addition all key personnel need to be equipped with critical skills in understanding the effects of human error in their working environments and in devising ways of avoiding, reducing and mitigating error in their day-to-day work.

The Safer Safeguarding Group - who we are what we have to offer

The Safer Safeguarding Group was formed in 2014. It comprises professionals from a variety of backgrounds: social work, social care management, medicine and civil aviation. Those contributing to this briefing include two former airline pilots who are human factors specialists, three people with extensive experience of child protection social work and child protection management and a consultant paediatrician who has been instrumental in raising concerns about unsafe system issues in child protection services.

As a group we can offer advice and consultancy to local authorities and other organisations that want to begin the journey towards becoming responsive safety cultures. We would be happy to work with LSCBs or other co-ordinating groups to identify ways forward.

We are keen to work with organisations that would like to develop Near Miss Reporting systems, which we believe to be a low cost way of generating vital information about when, how and why errors and failings occur.