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.