Baby P: Quality reflective practice and supervision needed

The missing link in the Victoria Climbié Inquiry returns to haunt us in the Baby P case, says safeguarding expert Rhian Stone (pictured)

The death of Baby P, with chilling echoes of Victoria Climbié’s experience, has inevitably led to questions over the effectiveness of the reforms that arose from the inquiry into her death. The government responded positively to Lord Laming’s recommendations by introducing a framework for effective multi-agency partnerships, clearer statutory responsibilities and strong lines of accountability – all essential features of a modern safeguarding system.

Whether the Children Act 2004 and the Every Child Matters framework have been properly implemented will now be the focus of a review, again conducted by Laming.

Certainly, initial responses from Haringey Council and the whistleblowing concerns would suggest complacency and lack of accountability still exist in the system, and require looking at again.

Support systems

But for me a key aspect of our safeguarding system that was given insufficient focus at the time of the Victoria Climbié Inquiry was a debate on what system is required to support professionals so that they can safeguard children effectively.

To address this means thinking about the system as a set of relationships rather than solely about structures and managerial processes. It requires a focus on the people within it – on the interactions between the family, child and professionals and the emotional impact of this work on decision-making.

Narrowing the new review to an audit of whether the current reforms are being successfully implemented will not answer the question that the deaths of Victoria and Baby P raise and which a focus on professional practice would help us answer. The public looking in on our child protection system must be asking why professionals repeatedly fail to respond to, and make sense of, the evidence in front of them. The answers are complex but they are not unobtainable. It requires some sophisticated and lateral thinking and a thorough understanding of the nature of child abuse.

Serious case review

The Haringey serious case review into Baby P’s death concluded: “Many factors contributed to the inability of the agencies to understand what was happening [to the child]. With the possible exception of the paediatric assessment, none on their own were likely to have enabled further responses that might have prevented the tragic outcome.”

These factors – patterns of injury and bruising, blaming the child, inadequate explanations from parents and repeated professional concern – as a whole were precisely those that should have given insights into what was happening for this child. A responsive system with competent professionals who understand known risk factors should be able to respond to the most sadistic and mentally disturbed carers who have the capacity to harm children in a systematically cruel way.

First, we have to acknowledge and understand, helped by case history, that cruelty on this incomprehensible scale exists. Second, that carers’ behaviour and actions have an emotional impact on the professionals involved sometimes the response is one of fear but it can also be a desire to “rescue” and over-support. Parents who harm children will try, often successfully, to deflect attention away from their actions.

Risk factors

These are long-standing known risk factors which have to be worked with, not used to explain away mistakes. The work is complex and emotionally intense. The impact on you is not always evident in a clear and conscious way. It can be difficult – almost impossible to see and understand what is going on – even for the most experienced practitioner. But you can if you have experienced people around you who can help you make sense of it. You need space and time to reflect on what’s going on with an experienced manager and to challenge things. This didn’t happen in Victoria’s case and neither did it happen with Baby P.

I worked in frontline practice on a stretched child protection team. It was tough work. Sometimes you don’t want to acknowledge to yourself what is going on in a family the consequences and implications are huge – possible removal of a child, tackling the parents, working until midnight on a Friday and going to court.

What I had around me was experienced trusted colleagues and a manager who asked about my work, raised constructive questions about my approach and who saw our supervision as a time for reflection, challenging my observations of the child, the interactions and the patterns of behaviour. This helped me to build a picture, challenge my own assumptions and provide that challenge to the family.

I also had good professional social work training, but nothing can prepare you fully for what’s to come – you have to learn on the job and that’s where the system to support you is vital.

Importance of reflection

During the Victoria Climbié Inquiry I attended one of the professional seminars. The point was raised about the importance of reflection and space for thought to support the emotional and intellectual demands of working in child protection. The issue didn’t get the attention it deserved it was somehow lost in the huge number of other considerations. But it is fundamentally important and, until we address it, we won’t have an effective child protection system and the same questions will arise when the next high-profile death occurs.

Our system needs a requirement for quality supervision and reflection built into decision-making. Not as an add-on if there’s time, but as a core part of the job. We have to make time for what’s important. Visiting families isn’t an end in itself, neither is paperwork. They are effective only if competent skilled people are interpreting what is witnessed from a strong professional practice knowledge and offering effective interventions to families where change is possible. Where it is not, difficult but clear decisions must be made about alternative care. This may not be within the gift of the newly qualified or inexperienced professional – but it should at the very least be within our managers and senior practitioners.

Professional judgement

We need a system that supports professional judgement and effective decision-making through reflection and quality supervision and which focuses on the relationships between the people within it.

We must embed a culture of quality reflective practice every day in our safeguarding system. Local safeguarding children’s boards have a leading role to play, energising the workforce and encouraging a change in behaviour. They could organise practice seminars on reflective and professional practice and decision-making, undertake file audits, and talk to staff about findings and concerns. We need to open up our system to work with the emotional content of the work rather than suppress it in management process.

This is the time to think differently. The failures are the same so clearly we haven’t found the answers. We have to make sure we’re asking the right questions, so that we find a way to stop coming back to this point and letting children down in this way.

Rhian Stone is an independent consultant and interim manager. She was child protection adviser at the NSPCC during the Victoria Climbié Inquiry

Links and resources

This article is published in the 20 November 2008 edition of Community Care under the headline “The failures are the same”

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