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Learning from Serious Case Reviews?
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  1. Learning from Serious Case Reviews? Patrick Ayre Department of Applied Social Studies University of Bedfordshire Park Square, Luton email: pga@patrickayre.co.uk web: http://patrickayre.co.uk

  2. Learning from enquiries Those who cannot learn from history are doomed to repeat it (George Santayana)

  3. The background • Widespread and persistent concern over standards • Many enquiries and Serious Case Reviews • Far reaching reforms • Little evidence of improvement, in England at least

  4. Why? (Addictive behaviours) If it doesn’t work, do more of it Procedures and micromanagement Training Performance indicators

  5. Failure to learn from experience • The proceduralisation, technicalisation and deprofessionalisation of the professional task • Process and procedures prioritised over outcomes and objectives • Targets and indicators prioritised over values and professional standards • Compliance and completion prioritised over analysis and reflection

  6. Deprofessionalisation • Part of a wider trend • Managerialism, McDonaldisation and the audit culture • Management by external objectives • Professionals not to be trusted

  7. The ‘scandal’ model of case review • Public pillorying • Public enquiry with many recommendations • Law and guidance from the government

  8. Climatic conditions for safeguarding • Climate of fear • Climate of mistrust • Climate of blame

  9. Responsible journalism at its best “Today The Sun has demanded justice for Baby P — and vows not to rest until those disgracefully ducking blame for failing the tot are SACKED” “The fact that Baby P was allowed to die despite 60 visits from Haringey Social Services is a national disgrace. I believe that ALL the social workers involved in the case of Baby P should be sacked - and never allowed to work with vulnerable children again. I call on Beverley Hughes, the Children's Minister, and Ed Balls, the Education Secretary, to ensure that those responsible are removed from their positions immediately”. (The Sun, 13 November 2008)

  10. Climatic conditions • Climate of fear • Climate of mistrust • Climate of blame

  11. Climate of mistrust ‘Child stealers’ who ‘seize sleeping children in the middle of the night’; ‘abusers of authority, hysterical and malignant’, ‘motivated by zealotry rather than facts’ or ‘like the SAS in cardigans and Hush Puppies’. On the other hand, they are ‘naïve, bungling, easily fobbed off’, ‘incompetent, indecisive and reluctant to intervene’ and ‘too trusting with too liberal a professional outlook’.

  12. Climate of mistrust The safeguarding worker who took a child away from its parents The safeguarding worker who failed to take a child away from its parents

  13. Climatic conditions • Climate of fear • Climate of mistrust • Climate of blame

  14. Maximising learning Serious Case Reviews must: • Explore WHY things were done (or not done) and not just WHAT was done (or not done) • Distinguish individual ignorance and error from strategic and systemic issues • Interpreting what happened locally in the wider context of practice knowledge

  15. Exploring the WHYs (Level 1) A Serious Case Review along these lines is pretty much a waste of time : Fact: This child was injured because we did not do X Recommendation: Do X in the future We need to know WHY X was not done

  16. Why was X not done? • Was it individual ignorance or error? (Outcome: training, competency issues) • Was the requirement not expressed clearly in procedures when it should have been (Outcome: Procedural change) • Was this requirement not understood? (Staff development; strategic or systemic considerations)

  17. Why was X not done? • Were resources/commitment absent? (Strategic or systemic considerations) And finally and most crucially: • Was the service environment conducive to and supportive of good practice? (Strategic or systemic considerations)

  18. Exploring the WHYs (Level 2) Fact: This child was injured because we did not do X Recommendation: Train staff to know they have to do X and/or write some new procedures (or both) (In fact, we know that people often don’t do X even though they know, in theory, that they should and there are procedures which tell them that they must. The key question is often, why did they still not do it?)

  19. Exploring the WHYs (Level 2) BBC Regional News, 17 November 2011: “The latest Ofsted inspection has found Children’s Services in Peterborough to be inadequate in seven out of nine categories. The Director of Children’s Services announced that the council had embarked on a programme of updating procedures and improving staff training”

  20. Exploring the WHYs (Level 3) Fact: This child was injured because we did not do X Recommendation: • Review whether the service environment was conducive to and supportive of good practice?

  21. Procedures as a net to catch problems

  22. Procedures as a net to catch problems

  23. Procedures as a net to catch problems

  24. Procedures as a net to catch problems

  25. Micromanaging recording and reporting Format: Endless predetermined tick boxes and text boxes Content: Repetitive and disaggregated Concept: Routinised and mechanistic Purpose: Well, what is the purpose?

  26. Micromanaging assessment and reporting Format: Endless predetermined tick boxes and text boxes Content: Repetitive and disaggregated Concept: Routinised and mechanistic Purpose: Well, what is the purpose? Understanding what it is like to be that child, and what it will be like if nothing changes

  27. Micromanaging assessment and reporting Format: Endless predetermined tick boxes and text boxes Content: Repetitive and disaggregated Concept: Routinised and mechanistic Purpose: Well, what is the purpose? Understanding what it is like to be that child, and what it will be like if nothing changes Getting the assessment done 

  28. Micromanaging assessment and reporting What we want: Coherent, confident and compelling What we get: Disassembled, disarticulated and decontextualised

  29. KPIs: Ministers and managers Outcomes hard to measure, process easy Easy to obtain, easy to digest (but what do they tell us?) Quality = KPI scores False sense of security Distort resource allocation ?A third of the mix

  30. On the front line Learn by doing more than by training What is important in what I do? What is good practice? Supervision: qualitative or quantitative?

  31. Escaping the spiral of decline requires Research-informed, reflective, confident and critically-challenging practitioners Management systems which promote rather than undermine their effectiveness.   Ministers and senior managers committed to a significant change of direction, both practical and conceptual