Guest Author: Jon Trew
When a child dies of abuse or neglect, it is the duty of all of us to learn from that tragedy and ensure that any failings or errors are remedied. We must look at these events as a chance to honestly examine our safeguarding practice.
The importance of serious case reviews
When an event like this occurs a review of the case is conducted. These investigations have different titles and follow slightly different procedures and formats depending on in which parts of the country they are conducted. Originally, they were called Serious Case Reviews (SCR’s) and were introduced in the first edition of Working Together to Safeguard Children, published on the same day as the Cleveland inquiry report in July 1988.
In England in 2018-19 they were replaced by a new system of local child safeguarding practice reviews (LCSPRs). While the format has changed over the years, the aim is the same, to identify areas of learning from the event and to see if existing policy and practice were suitable and appropriate or needs to be amended or improved and to recommend any appropriate action.
The serious case review was inspired by the world of medicine. When a patient dies unexpectedly a medical examiner looks at records of the treatment, the types of medication, the care plan and anaesthetic used and asks the question “if things had been done differently might the patient have lived. If another surgical procedure was used or undertaken earlier might there have been a different outcome?” This practice has been adapted by the world of social work and has evolved into the practice reviews.
How safeguarding practitioners can learn from serious case reviews
There is a comprehensive collection of case reviews hosted by the NSPCC from across the UK. It contains over 2,000 case reviews dating back to 1945.
While the events they record are often tragic and upsetting, they also reveal many important lessons and learning opportunities. It is often apparent within the reviews that serious incidents are rarely a result of a single failure or lone error. In many of the reviews we see multiple errors made by various individuals and agencies, that when combined mean that important opportunities to protect children were missed.
Understanding Systemic Safeguarding Failures
The ‘Swiss Cheese model’ devised by Professor James Reason is often applied in healthcare and engineering concepts, but it is also a useful way of understanding how these multiple minor errors act together to cause a much more serious failure in safeguarding. Reason’s theory proposes a visual model of how serious failures occur and imagined that it was made from several slices of Swiss cheese, each full of holes.
The “slice” of cheese represents a layer of defence (like procedures, training or safety checks), while the holes symbolise weaknesses or failures in those layers. Normally, the holes don’t line up, so risks are contained. However, when multiple weaknesses align, a hazard can pass through all layers, leading to an incident.
The model highlights that failures are often systemic rather than caused by a single error, emphasising the importance of strengthening multiple layers of protection rather than blaming individuals.
Professor Reason recognised that humans are fallible and in any system errors will inevitably occur:
- An individual may be preoccupied, tired or have a family issue that is distracting them from the task at hand.
- They may need training or lack knowledge of safeguarding policy and procedures.
- A poor recruitment process may have resulted in the wrong person being appointed who does not have the particular skills and knowledge required for the task.
- A lack of supervision or weak management may fail to identify any of these problems.
Reason described these kinds of failings as ‘Latent Failures’.
We are frequently distracted by Active failures – unsafe or abusive actions committed by people in contact with children. However, practitioners must also be on the lookout for underlying problems embedded within the system that can lead to error-inducing conditions and risks. A system that is not working well makes it easier for mistakes or failures to occur and makes it more difficult to identify and respond to potential abuse.
How safeguarding software can close gaps and reduce risks
An electronic safeguarding system like CPOMS StudentSafe enables practitioners to identify many of these latent failures by allowing all staff members the ability to report safeguarding concerns.
This can also provide clear evidence to both governors and to school inspectors that ‘effective safeguarding’ is taking place in the school. The report can be easily anonymised and can demonstrate to governors and inspectors that staff are fulfilling their duty to keep children safe in education.
To see CPOMS StudentSafe in action and learn how it can help your setting to close safeguarding gaps, arrange a free demonstration today.
