SCIE Report 6: Managing risks and minimising mistakes in services to children and families
By Dr Lisa Bostock, Sue Bairstow, Sheila Fish and Fiona Macleod
Published September 2005
Social workers must sometimes make very difficult judgements. Unfortunately, these judgements can sometimes lead to harmful consequences. Strangely though for such a vital industry, the social care sector only seeks to learn from these mistakes in the most tragic of circumstances - when a person is hurt, or worse, killed.
This report is about how organisations can learn from mistakes.
This report focuses specifically on reducing risk in services to children and families by identifying and learning from near misses in children's services. It aims to start a debate about the management of risk at an organisational level and to support the introduction of the Children Act 2004 in England and Wales and the development of Local Safeguarding Children Boards (LSCBs).
The report is aimed at a wide group of people and organisations who seek to better understand why things go wrong, with a view to improving systems for managing risk. This includes social care workers and managers, policy makers, national regulatory organisations, educators and more.
Messages from the report
- Near misses do occur, and they occur often. Fortunately, most near miss cases are when something could have gone wrong but was prevented rather than cases where something had gone wrong and no harm was caused.
- Many near misses involve cases where actual or potential significant harm to children has been overlooked.
- Many near misses during the referral and assessment stage arise due to:
- the prioritisation of cases
- professionals not having an accurate or full picture of what is happening
- decisions made by other teams and agencies.
- The current culture of blame that presides in children's services acts as a strong disincentive to organisational learning. The sector must shrug off its blame culture and to start being constructive about learning from its mistakes.
- There are few opportunities for organisations to learn from near misses. Where learning occurs, it is located at the front line, in supervision between social workers and their managers.
- 'Learning' is based around blame and condemnation of individuals, rather than identifying the key factors that contributed to the mistake and preventing them from reoccurring.
- Learning from safeguarding incidents is dependent on five fundamental features of a learning organisation: structure; organisational culture; information systems; human resources practices; and leadership. This means that work to promote learning from near misses can take place throughout an organisation.
- Harnessing the knowledge and expertise of service users and carers is a key way of learning about safeguarding incidents and improving systems to protect and promote the welfare of children. This serves to restore their trust in social services and help families begin to recover from what are often painful experiences.
- The sector should explore options for a social care safety agency to promote an open and fair culture, encouraging staff and other stakeholders such as policy-makers to understand their roles in decision-making and preventing error.
- Consider whether the development and implementation of LSCBs alongside other systems could include a focus on the range of safeguarding incidents rather than one that is solely directed on unexpected child deaths or the serious injury of children.
- Increase capacity within local authorities to adopt a system for understanding why things do, or almost, go wrong.
- Survey the development of a culture of learning within service provider organisations.
- Explore latent failures embedded within organisations as well as active failures made by front-line staff.
- Pilot critical incident reporting within children's services, exploring how best to promote an open and blame-free approach.
- Develop a professional network for referral and assessment workers to promote good practice in complex decision-making.