Scie calls for lessons to be learned from near misses

Child protection systems must investigate near misses as well as incidents of serious harm if children are to be better protected, the Social Care Institute for Excellence has recommended.

Its new report on managing risk and minimising mistakes in children and families services says that looking into cases where children have narrowly avoided being harmed would mean that the complex assessment, decision-making and review systems involved could be put under the microscope and valuable lessons learned.

The organisation is calling for the creation of a national body to identify such cases and for systems to monitor and correct them to be put in place. The report points out that National Patient Safety Agency was set up in 2001 to operate a similar system for the health service to allow it to learn from mistakes and problems that affect patient safety.

Scie said work on near misses needed to be done in an open and blame-free culture, and recommended the setting up of a professional network for referral and assessment workers to promote good practice. A critical incident reporting system within children’s services should also be piloted.