Learning together to safeguard children

London Safeguarding Board annual conference December 5th 2011

Dr Sheila Fish,

Senior Research Analyst

Current context

Munro Rec. 9: Govt. require LSCBs to use systems methodology.

July 2012 Govt. agreed and plan transition

First test SCR announced by Tim Loughton 8th November

Brief history

Early development work Pilot programme completed – NW & W Mids Training & accreditation programme

& network of accredited reviewers

Developing a tiered offer: Collaborative Condensed Focused

Nb. ‘deep and narrow’ not ‘quick and dirty’

Supporting test SCRs

The methodological heart

remains the same based on a

theoretically-informed understanding of human performance

adapted from aviation and NHS

Methodology hinges on how do we understand the human role in good or poor practice

Do we treat people as the source of errors?Emphasis on fallibility and irrationality Requirement for procedural interventions and standardizationIncrease use of technical solutions

Or assume ‘to err is human’ and that people are also the source of safetyEmphasis on flexibility and adaptability, recovery from error; spotting error inducing conditionsFocus on redesigning systems to play to our strengths as human beings and support our predictable weaknesses

Fundamentals:

Goal is to provide a ‘window on the system’ An explicit last step moves beyond

case-specific learning to identify & prioritise the generalisable

An open enquiry is required with the focus of analysis led by the data The focus/findings not pre-set at the beginning

Must be multi-agency from the outset Need to understand the interactions between agencies; Individual Management Reviews are not part of the process;

And collaborative with people at all levels Necessary in order to explore what

lay behind actions/decisions And to indicate whether or not issues are usual/common

So back to that heart

involves three key aspects

1. Reconstructing how different professionals saw the case as it unfolded

“Remember at all times, what you are trying to do. In order to understand other people’s assessments and actions, you must try to attain the perspective of the people who were there at the time. Their decisions were based on what they saw on the inside of the tunnel – not on what you happen to know today (Dekker 2002: 79)

2a. Identifying Key Practice Episodes (KPEs) for detailed analysis

Timeline

spaces in between

KPE 2KPE 211 KPE 3KPE 3 KPE4KPE4

2b. Analysing KPEs: appraising practice & identifying the contributory factors

Description of episode & time span covered

Explanation of its significance to how the case developed and/or was handled

Appraisal/Judgement of practice

Contributory factors

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Aspects of the family: Fawefijow faio iooif0 dsndk e e9j we9u dp

Multi-agency factors: aselfiu feuseoi

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Personal aspects: Asfaweu oif oawi raweior iu siiesa

3. Questioning what light the case has shed on current strengths and problematic areas?

Identification and prioritisation of generic, underlying patterns (using consistent typology)

Formulated as ‘challenges’ or ‘considerations’ for the Board and member agencies, leaving the Board to decide on appropriate

action

The findings tend to be “insights” into how the multi-agency

system is functioning More nuanced explanations of what lies behind

problematic areas

often issues themselves are not new, but the systems framework allows us to formulate what they are about in different ways

helps Boards and member agencies think differently issues need consideration; to be grappled with

with implications for ‘action plans’ resonates with Marion Brandon’s latest

research on SCR recommendations

Difference between the three tiers

Who conducts the data collection & analysis Multi-agency review team vs. pair of reviewers Former more resource intensive but generates

strong ownership of the findings

How to collaborate with people at all levels Includes both data collection and opportunities for

staff to correct, challenge and amplify the analysis Individual conversations and/or workshop or

workshops Impacts on extent of the

‘training effect’ of the process

Collaborative Condensed Focused

Time span 4-6 months 3-4 months 1-2 weeks

Focus Picture window Portal Letter box

Lead reviewers

20 days 10-15 days 5-10 days

Senior managers

5-10 2-4 days 1-2 days

Case workers 2-3 days 2 days 1 day

But what about the impact?

‘There are no studies in peer-reviewed literature on the effectiveness of RCA in reducing risk or improving safety, and there are no evaluations of the cost or cost-effectiveness of the procedures compared with other tools to mitigate hazards’ (Wu, et al. 2008: 686).

If we focus on quality and consistency of application & requirement to monitor longer term outcomes, we may be in a better position in a decades time

So what of the process?

A SCIE Learning Together case review can help in the following scenarios:

a particular practice theme or issue has been identified as of concern

particular ways of working seem to be going well and need to be better understood

a case that has been considered for an SCR but didn’t meet the criteria where there is nonetheless learning to be pursued

an serious untoward incident / SCR

Key players organised like this

Process is structured around key meetings

The review team meet with the case group for an introductory meeting, individual conversations and two group ‘follow on’ meetings

The review team meet alone for initial planning meetings to review relevant documentation and for ‘analysis meetings’.

Exercise

1. LSCB and member agencies

2. Lead reviewers

3. Review team

4. Case Group

5. Family members In light of what you have heard so far, what might the

perspectives be of people in your group’s position? What might the biggest fears be for them about this

process? What would they see as the biggest

challenges and what most exciting?

Three known key barriers to take up of this approach have been identified

1. Knowing best ultimately the most total barrier to learning

2. Fear of loss of control assumption that control is their job

3. Not knowing how to change thinking lack of personal awareness and pressure of

workJake Chapman 2004 System failure: why governments must

learn to think differently. 2nd edition. London: Demos.

For further info

Learning together publications

& social care tv films

available on

www.scie.org.uk

Contact: sheila.fish@scie.org.uk