Spirit of inquiry

Nicky Stanley is professor of social work at the
University Central Lancashire.  Her research interests are in the
areas of mental health, child protection and young people. Her
recent studies have examined the mental health needs of looked
after children, mothers’ mental health, teenage pregnancy and
student suicide.

Jill Manthorpe is professor of social work at King’s
College London and co-director of the Social Care Workforce
Research Unit. She has particular interest in older people’s
services and in the overlap between health and social care. Current
research topics include the new social work degree, advocacy and
adult protection.

One of the key achievements of inquiries has been to bring to
public notice the experiences of those who are socially excluded;
whether they are reliant on community mental health services,
living in children’s homes or residential care for older people, or
have long-term involvement with child care services.

Inquiry reports are also one of the few ways the public gets to
glimpse the day-to-day activities of social workers. Lord Laming’s
Victoria Climbie Inquiry (1) painted a vivid picture of life in
social work offices, with their bureaucracy, mismanagement and
staffing problems. This world with its limited resources, high
levels of stress, human and technological failings and complex
decisions made in the context of insufficient information needs to
be exposed to wider scrutiny.

Inquiry conclusions are said to be repetitive. Numerous inquiries
report problems with interprofessional communication, with
inadequate risk assessments and failures to predict deaths or
violence. But, many recent inquiries have provided important
lessons for practitioners and policy makers. The Victoria Climbie
Inquiry, for example, raised critical issues about responses to
migrant families and about problems in social work management and
supervision, and information-sharing. The David Bennett inquiry (2)
exposed the issue of racism within NHS services. Meanwhile the
report into the abuse of a woman with learning difficulties in the
Borders Region (3) stressed the importance of adult protection
issues and procedures to the delivery of services for people with
learning difficulties, and highlighted the extent to which health
and social care services had neglected the needs of a highly
vulnerable individual. The report was one of the reasons that the
Scottish executive recently launched an inquiry into social

Inquiries can be important learning tools. But, other than their
well-known capacity to provoke fear and defensive, risk-averse
practice, it is difficult to point to positive messages about what
works. Yet examples of good practice are evident in many reports.
Learning from real life cases that are reported in detail provides
any student, before or after qualification, with an authentic
picture of agency working and local systems as well as a range of
professional perspectives.

Any such learning has to recognise the “wisdom of hindsight” that
informs inquiry reports. Associations between events and actions
emerge that may not have been apparent to those involved at the
time. This means inquiries have to be placed in context and
critical incidents assessed. Most inquiries argue that a history of
a service user’s contact with services is very helpful to
understanding the past and an individual’s needs and behaviour, and
to evaluating service performance. Many inquiry reports offer
useful models of such chronologies.

The Borders Region report uses a brief summary format combining the
findings of inquiries by the Mental Welfare Commission and the
Social Work Services Inspectorate. Yet it lacks the detailed
account of services users’ lives and interactions with health and
social work professionals that characterises other inquiry

Current inquiries reveal how the “blame culture”, to which the
reports themselves have contributed, permeates social work teams.
This has resulted in a preoccupation with procedure and guidance,
with “watching your back” and “passing the case on” to the
detriment of engaging with service users and their needs.

In future, inquiries need to focus less on their role in allocating
blame and more on their capacity for promoting learning and

Their format also requires revision. Paul and Audrey Edwards’ (4)
account of the inquiry into the death of their son in Chelmsford
Prison emphasises families’ lack of power in the inquiry process.
Inquiries are still wedded to the legal model of the tribunal. A
more participatory model for inquiries would allow family members,
professionals and other service users to contribute, rather than
just being interrogated by inquiry officials.

A national structure and organisation for inquiries could be
developed. Inquiries into both mental health and children’s
services are currently under review. Mental health inquiries could
adopt the local interagency review model used for serious case
reviews into child deaths. This might limit the cost of such
inquiries and increase the likelihood of the recommendations being
implemented at local level. Currently, inquiries rarely return to
check whether recommendations have been translated into local
practice and policy.

Similarly, the Confidential Inquiry into Homicides and Suicides by
People with Mental Illness (5) has proved a useful model for
bringing together and analysing common themes from individual cases
that could be applied to child deaths. Just as the confidential
inquiry lists homicides committed by mental health service users
alongside those for homicides in the general population, so child
deaths that occur as a result of abuse or neglect might be
presented in the context of all sudden deaths among children,
including accidents. Such an approach might have the effect of
reframing the protection of children as a broad social
responsibility, not just a task for professionals.

Our work on inquiries suggests that they play a valuable role in
opening the world of health and social care services up to public
scrutiny. We believe that their role should be retained while
encouraging the development of new and more participatory formats
for the inquiry. Such models should exploit the learning
opportunities offered by inquiries while minimising the potential
for allocating blame.

ABSTRACT:  This article looks at the potential and
pitfalls of inquiries and argues that they have much to contribute
to learning, but that this is not always realised. Reform of
inquiries should build on this and also make the most of the
capacity of inquiries to learn from each other.

REFERENCES: (1) H Laming, The Victoria
Climbie‚ Inquiry: Report of an Inquiry by Lord Laming, The
Stationery Office, 2003  (2) J Blofeld, Independent Inquiry into
the Death of David Bennett, Cambridge, Norfolk, Suffolk and
Cambridgeshire Strategic Health Authority, 2004  (3) Investigations
into Scottish Borders Council and NHS Borders Services for People
with Learning Disabilities: Joint Statement from the Mental Welfare
Commission and the Social Work Services Inspectorate, Scottish
executive, 2004  (4) P Edwards, A Edwards, “The family’s
perspective”, in N Stanley and J Manthorpe, (eds) The Age of the
Inquiry, Routledge, 2004  (5) L  Appleby, J Shaw, J Sherratt, T
Amos, J Robinson, and R McDonald, Safety First: Five Year Report of
the Confidential Inquiry into Suicide and Homicide by People with
Mental Illness, Department of Health, 2001.

Manthorpe, (eds) The Age of the Inquiry: Learning and Blaming in
Health and Social Care, Routledge, 2004.

CONTACT THE AUTHORS:   E-mail: NStanley@uclan.ac.uk  or
write to Nicky Stanley at: Social Work Department, University of
Central Lancashire, Preston PR1 2HE.  E-mail: jill.manthorpe@kcl.ac.uk 
or write to Jill Manthorpe at: SCWRU, King’s College London, 150
Stamford Street,   London SE1 9NN.

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