Children’s services must learn from their mistakes

Children’s services must move away from a “culture
of blame” and start learning from their mistakes, according
to a report launched today by the Social Care Institute for
Excellence, writes Maria Ahmed.

The report raises concerns that learning in social care tends to
take place only when things have gone seriously wrong for children,
such as in the case of Victoria Climbie, rather than before harm

Victoria died aged eight-years-old in February 2000 after
enduring months of abuse at the hands of her great aunt
Marie-Therese Kouao and her boyfriend Carl Manning. Lord Laming
chaired an inquiry into the child’s death which resulted in a
number of recommendations, and the government’s response
formed the Every Child Matters agenda.

But the Scie report argues that social care has to move away
from “solely identifying faults with individual
practice,” to understanding why things go wrong.

It suggests introducing models of risk management similar to
those already established in aviation and healthcare.

It finds that information on “near misses” –
incidents where something could have gone wrong but has been
prevented – are not collected across the country, and
suggests that these should be routinely examined as well as
incidents of serious harm.

The report is based on interviews with 60 social workers, their
managers and 40 young people and parents which found around 60
‘near miss’ incidents.

The report says: “Currently, there are few opportunities
for organisations to learn from near misses. Where learning occurs,
it is located at the frontline, in supervision between social
workers and their managers.”

It finds that many professionals are concerned that learning
from serious case reviews is “still limited”.

Dr Lisa Bostock, the report’s author and senior research
analyst at SCIE, said: “We’re trying to start a debate
about how children’s services might do things differently
when it comes to learning from mistakes.

“SCIE is calling for the introduction of a critical
reporting system within children’s services – we must
get away from the culture of blame that has plagued services for
too long.”

‘Managing risks and minimising mistakes in services to
children and families’ from

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