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

Key concepts and fundamental assumptions - Contributory factors

  • Contributory factors include all the possible variables that make up the workplace and influence practice.
  • They are not just policies, procedures and protocols, but include ‘softer’ factors such as team and organisational cultures.

The review team needs a sufficiently detailed picture of the circumstances of the key practice episodes to help with the task of identifying ‘contributory factors’. These include all possible variables that make up the workplace and influence performance (not just ‘Are the right systems in place?’). They include the more tangible systems factors such as policies, procedures and protocols and tools and aids, working conditions, resources and so on, and also more nebulous issues, such as team and organisational ‘cultures’ and the covert messages that are communicated and acted upon.

Drawing again on the work of Vincent et al. (Taylor-Adams and Vincent, 2004), we have developed a single framework of contributory factors relevant to child welfare work. These are divided into three different levels reflecting where in the child welfare system they originate: frontline, local or national.

Summary of framework for contributory factors

Frontline factors

Local strategic level factors

National/government level factors

Further details for each category are provided in Appendix 5.

Is there no accountability? What about the ‘bad apples’?

The systems approach is sometimes called a ‘no blame’ approach but a better description of the objective is the development of ‘an open and fair culture’  (Vincent, 2006: 158) in which decisions about culpability are more nuanced. This does not forgo recognition of personal responsibility or accountability.

What the approach highlights is that holding a particular individual or individuals fully responsible and accountable is often highly questionable because, typically, incidents arise from a chain of events and the interaction of a number of factors, many of which are beyond the control of the individual concerned. The difficulty lies in deciding where the boundary lies or what degree of culpability an individual carries within a faulty system. The UK National Patient Safety Agency has done some work on this problem.

There is, however, nothing inherent in the model to prevent the recognition and identification of, for example, cavalier or malicious practice where there was either a blasé attitude to whether harm resulted or the causing of harm was intended.

Next section: Putting it into practice.