Learning together to safeguard children: developing a multi-agency systems approach for case reviews

Appendix 1: Introductory letter for participants

Dear colleague,

Someone from your team or organisation may have spoken to you about the plan to conduct a case review of [fill in relevant details]. With this letter, we would like to take the opportunity to give you a brief summary of the approach that is going to be taken and the role that we would like you to play.

The approach

In this case review we are going to use a new method called ‘systems analysis’.

This sort of review process will be familiar to Health colleagues but applying a systems approach to safeguarding work is still a relatively new endeavour. Up till now, any review of cases had tended to take the ‘bad apple’ approach, which focuses on blaming the ‘bad apple’ individual for mistakes and failures.

A systems approach concentrates not on judging people’s work. Instead, by taking account of the situation they were in, the tasks they were performing, and the tools they were using etc, it focuses on understanding why someone acted in a certain way. It highlights what factors in the system contributed to their actions making sense to them at the time. Importantly, it also highlights what is working well and patterns of good practice.

Traditional ‘bad apple’ approach Systems approach
Human error is the cause of accidents Human error is a symptom of trouble deeper inside the system
To explain failure, you must seek failure To explain failure, do not try to find where people went wrong
You must find people’s inaccurate assessments, wrong decision, bad judgements Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them

Your role

The experiences and perspectives of people like yourself, who were directly involved in this case, are central to a systems review. The review is, therefore, very much a joint venture which we hope you will take an active part in.

We would, therefore, like to invite you to talk with us about the case on a number of different occasions. Details of the most immediate meetings are given below.

Introduction to systems analysis

On [fill in relevant details: date; place], [fill in relevant details: name] will be giving an introduction to systems analysis. We then hope to discuss plans for using this method in relation to the case we are reviewing. This will include one-to-one conversations with everyone involved in the case, as detailed below.

One-to-one conversations

The purpose of this conversation is to ascertain how you understood the situation at the time, how you understood your role or the part you were playing in the case and your perspective on what aspects of the whole system influenced you as a worker. We hope to be able to arrange a time to have this one-to-one talk some time in [fill in relevant details: month], during the initial meeting. Conversations will take up to one hour and a half.

Feedback meetings

A joint meeting of the review team and all the people involved in the case after individual conversations have taken place will be arranged at a later date.

Organisational backing

The use of the systems approach has the full backing of the local safeguarding children board and the agencies to which they are accountable. The LSCB has agreed that this process is NOT about blame and disciplinary action, but about an open and transparent learning from practice, in order to improve inter-agency working. The board has actively promoted the ‘no blame’ premise of this work. Chief officers of all agencies have been informed and are in agreement.

Staff can, therefore, be confident they will not be penalised for taking part in this project. In formal terms, the thresholds for disciplinary action have been raised for the sake of learning. If serious malpractice were to emerge in the course of the review, then disciplinary procedures would, of course, come into play.

We very much look forward to working with you in this exciting project. If you have any queries then please do not hesitate to contact one of us.

All the best,

[fill in relevant details: names of review team]