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Learning together to safeguard children. London Safeguarding Board annual conference December 5 th 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

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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

Or assume ‘to err is human’ and that people are also the source of safety

Emphasis on flexibility and adaptability, recovery from error; spotting error inducing conditions

Focus on redesigning systems to play to our strengths as human beings and support our predictable weaknesses

  • Do we treat people as the source of errors?

  • Emphasis on fallibility and irrationality

  • Requirement for procedural interventions and standardization

  • Increase use of technical solutions


  • 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


spaces in between





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

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

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’.


  • LSCB and member agencies

  • Lead reviewers

  • Review team

  • Case Group

  • 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

    • Knowing best

      • ultimately the most total barrier to learning

    • Fear of loss of control

      • assumption that control is their job

    • Not knowing how to change thinking

      • lack of personal awareness and pressure of work

        Jake 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


    • Contact:

    • [email protected]

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