Scrambled messages

    According to many professionals, new
    technology and the beefing up of area child protection committees
    would help ensure that the kind of communication errors which
    contributed to Victoria Climbie’s death do not reoccur. Mark Hunter
    reports.

    If the various agencies involved in child
    protection found sharing information as easy as passing the buck
    then Victoria Climbie might never have died. As witness after
    witness at the recent inquiry gave their accounts of the disjointed
    sequence of interventions in Victoria’s case, a sorry story emerged
    of individuals working on different pieces of the jigsaw with no
    one able to see the whole terrifying picture.

    The
    breakdowns in communication were astonishing to outsiders. Victoria
    was seen by more than 70 different professionals during her
    10-month stay in the UK. At least 12 different opportunities to
    intervene were missed. But while housing officials dealt with her
    housing issues and doctors treated her wounds, health visitors
    didn’t visit, social workers remained unaware of the risk and
    police officers failed to investigate.

    Concerns about Victoria’s safety
    were raised at almost every juncture, but were lost in the cracks
    between professions or within the black hole that appears whenever
    someone moves between boroughs in London. Important information was
    left scribbled on scraps of paper, messages were not passed on,
    computer systems were incompatible, and searches for the records of
    at-risk children failed because of a simple misspelling of their
    name.

    The
    situation was summed up at the inquiry when lead counsel Neil
    Garnham QC questioned Ealing’s senior commissioning manager Judith
    Finlay on the mess within the council’s case-tracking system. “Was
    it not the obvious way to deal with this problem, as the number of
    cases grew, not to depend on scribbling notes on sheets of paper,
    but to computerise it? This is not 1970, this is
    1998-9.”

    “You
    obviously have not experienced local authority infrastructures,”
    was Finlay’s reply.

    Some
    of the lack of communication came about because of a disturbing
    ignorance among different professions over each other’s roles and
    responsibilities. Doctors, police officers and housing officials
    clearly felt that child protection was the role of social services.
    Yet social workers would often defer to the judgement of other
    professions. For instance, when consultant paediatrician Ruby
    Schwartz diagnosed Victoria’s skin condition as scabies, social
    services stopped investigating the case. Yet Schwartz described
    herself as “stunned and puzzled” when she heard that Victoria had
    been taken off the at-risk register.

    In the
    series of seminars that have formed the second stage of the
    inquiry, a number of solutions have been suggested to ensure the
    breakdown in communication does not happen again. One suggestion
    from the inquiry chairperson Lord Laming is that “virtual teams”
    could be set up using computer systems to link different
    professionals so that each would be aware of what the other was
    doing.

    Such a
    scheme has already been developed in Bradford and is due to be
    launched as a pilot project within the next two months.

    Constructed in co-operation
    between Bradford Council, the Bradford area child protection
    committee and software company Liquidlogic, the system aims to
    provide an interactive link between medical staff in the local
    primary care groups, paediatricians at the region’s two teaching
    hospitals, the police child protection unit and the social services
    child protection unit.

    Rather
    than trying to achieve compatibility between the various agencies’
    disparate computer networks, the system uses software that is able
    to dip into the relevant databases and retrieve the necessary
    information. Computerised protocols aim to ensure that access is
    limited to authorised personnel and that only the relevant data can
    be retrieved. Although Richard Bates, Bradford’s manager of policy
    performance and commissioning (children) baulks at the term
    “virtual agency”, he claims the system will “enable professions to
    look at what others are doing and see what stage they are at in a
    particular case.”

    Importantly it will offer “a
    real-time view” of exactly what contact has taken place with whom,
    what information has been gathered and what actions taken by the
    individual parties. “It means you won’t have to wait three days for
    a letter to arrive before you know something has happened,” says
    Bates.

    The
    system will also be able to bring together snippets of information
    that on their own do not appear significant but which viewed
    together may indicate that a child is at risk. “For instance, if
    there have been two separate queries about a particular child, the
    system can flag that up and alert social services so that they can
    have a closer look,” says Bates.

    Bates
    claims that had such a system been available to agencies involved
    with Victoria Climbie, an electronic multi-agency case file would
    have been created at her first presentation to a care provider.
    This would have been augmented by each subsequent contact and been
    available to clinicians when she presented at hospital. “Her
    injuries could then have been assessed in the knowledge of her
    referral to social services made a month earlier.”

    The
    idea of virtual child protection teams has also met with cautious
    approval from the Association of Directors of Social
    Services.

    In his
    submission to the Victoria Climbie inquiry ADSS president Michael
    Leadbetter expresses interest in exploring “the model of virtual
    child protection teams operating to specific national standards and
    outcomes”.

    Leadbetter is quick to stress,
    however, that inter-agency interaction should involve more than a
    few clicks on a computer mouse. “The ADSS has long argued that a
    close working relationship between the relevant professionals is a
    key component in protecting children.”

    And in
    one recent and perhaps encouraging example of inter-agency
    co-operation, the ADSS has joined forces with a number of
    children’s charities, the Local Government Association, the NHS
    Confederation, the Royal College of Paediatrics and Child Health,
    the Society of Education Officers and the Metropolitan Police to
    urge the government to strengthen the role of area child protection
    committees. In a joint statement they are calling for ACPCs to be
    placed on a statutory footing and jointly funded to oversee
    national policies for protecting children.

    Social
    services director of Kensington and Chelsea, Moira Gibb believes
    ACPCs may also be able to help combat the loss of information
    between local authority boundaries and to encourage professions
    other than social workers to take more of an interest in child
    protection. In her submission to the Victoria Climbie inquiry Gibb
    calls for ACPCs to tackle the disincentives experienced by some
    professions to following up concerns about children.

    “Housing departments and other
    agencies which deal with the public should be enabled to understand
    the system through some form of participation in ACPCs,” she says.
    “For complex areas such as London where children frequently cross
    authority boundaries there should be a regional ACPC or strategic
    and problem-solving body to ensure collaboration across
    organisational boundaries.”

    Of
    course the moves to strengthen ACPCs may also be designed to head
    off calls for the creation of a separate agency whose sole role is
    child protection. This suggestion has been vehemently opposed by
    the ADSS, which believes that a separate agency would simply
    strengthen false perceptions that at-risk children form a discrete
    group.

    In
    fact there appears to be little support within any of the
    professions involved in child protection for a widespread
    organisational change. According to John Ransford, the Local
    Government Association’s director of education and social policy,
    it is not so much the system that needs to be changed as the whole
    concept of multi-agency working. The current rigid demarcation of
    roles within a team can create a reluctance to challenge across
    professional and agency boundaries, he says.

    “The
    LGA would like to see the establishment of individual personal
    authority, enshrined in procedures as part of multi-agency team
    working.”

    Perhaps if this concept of
    personal authority can be combined with that of personal
    accountability we will be spared the experience of another inquiry
    in which each professional witness tries to blame the next for the
    lack of communications that contributed to a child’s
    death.

     

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