Learning together to safeguard children: developing a multi-agency systems approach for case reviews
Appendix 6: Typology of underlying patterns
Patterns of systemic factors that contribute to good practice or make problematic practice more likely
1. Patterns in human–tool operation
- The influence of assessment forms
- No detail on the quality or depth of assessments, or difficulties faced in completing them
- Discourages documentation of the rationale or complexity behind conclusions drawn
- Encourages factual statements and assertions and discourages the recording of a healthy unease or gaps in understanding
- The influence of the assessment framework
- Focus on the assessment of need discourages articulation of risk factors
- The influence of case management framework e.g. assessment, planning, implementation and review (APIR)
- Revision becomes an interruption in the flow of practice
2. Patterns in human–management system operation
- Resource-demand mismatch
- Difficulties accessing expert assessments
- Gaps in service provision
- Funding disputes and practitioners creating safety
- Performance indicators and borrowing from safety
- Trade-offs between competing priorities; overt and covert messages
- Conceptual blurring
3. Patterns in communication and collaboration in multi-agency working in response to incidents/crises
- Organisational culture around priority setting
- Understanding the nature of the task; overlooking the wider needs of the children in child protection response
- Reserve capacity
- The importance of knowing each other
- Referral procedures and cultures of feedback
4. Patterns in communication and collaboration in multi-agency working in assessment and longer-term work
- Understanding the nature of the task; assessment and planning as one off event or on-going process?
- Clarity of roles and responsibilities
- How much shared responsibility is there?
- Who is responsible for thinking?
- What and how much should be shared?
- What barriers and facilities exist contribute to good team work in longer-term case work?
- Are conflicts of opinion repressed or is there a shared culture in which it is acceptable and even desirable to query each other’s assessments?
- Group think
- Ascribed and perceived occupational status
- Overestimating the remit of service provision of different agencies
5. Patterns in family–professional interactions
- Salience of the mother in social services involvement
- Classic gendered presentation of problems by family members
6. Patterns in human judgement (thinking, reasoning)
- Failure to review judgements and plans
- Drift into failure
- Attribution error
- Tunnel vision