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Serious Case Reviews and Airplane Crashes

November 4, 2009

I previously did a brief post about Social Work TV (or Social Care TV as they prefer).  One of the videos at SCTV (Google that at your peril) is called A New Approach to Case Reviews – mostly meaning serious case reviews (SCRs). The video suggests that SCRs should be conducted more like Air Accident investigations. These ideas are repeated in an article entitled Beyond the Blame Culture by (Professor) Eileen Monro in todays Comment is Free column in the Guardian. Two statements by Monro come in for particularly stringent criticism in the comments following her article.

A plane unaccountably crashes into a mountain and everyone, including the pilot, is killed. There will, quite properly, be an investigation, but one possibility it is most unlikely to consider is that the pilot may have caused the crash through laziness or stupidity. This is for the simple reason that unless he or she wanted to die, the pilot would have done everything possible to avoid it.


Both public opinion and formal investigations conclude that children are harmed or killed because people working in child protection are stupid, malicious, lazy or incompetent. … Why is this assumed? Surely it is reasonable to believe that people who choose to work in this demanding field want to help children, rather than allow them to be hurt?

Commenters trenchantly challenge both these ideas. Pilots, they say, frequently are blamed for crashes and piloting a plane does not guarantee the pilot will not behave stupidly or be lazy and similarly, being a Social Worker does not guarantee that either. I tend to agree. Those who are not culpable should not be blamed, not by their employer, not by Ministers and not by the public. But, those who are culpable – well, why should they not be blamed? However the analogy comparing social workers to pilots is itself stupid. The negligent pilot directly causes the crash which kills himself and his passengers. The negligent social worker fails to take the action which might possibly prevent another person, at a later time and in a different place,  attacking a child which attack might result in death. That’s a much more indirect and uncertain chain of events and possibilities than the virtually certain result of the lone pilot falling asleep in the cockpit.

The great fear of every child protection social worker is that if a death occurs in one of their cases the subsequent inquiry will focus on what was done and not done on that case with the sole aim of identifying some recording or procedural failure, which will permit the management to blame and sack the social worker and avoid any wider scrutiny. I cannot think of a single child death inquiry which failed to blame the allocated social worker, sometimes alongside others, but always the social worker.

The fact is that for the child protection social worker with a caseload of up to of 40 children at risk in say 20 potentially abusive families however competent and efficient that worker is if a child on his/her caseload is killed then that social worker’s career is ended.  Ended full-stop. Rather like an plane-crash but with added media abuse and financial ruin. The truth is when a child is killed in these circumstances the killer not only kills the child but also kills the career of the social worker who was trying to protect the child. Many a social worker will be wondering whether it is worth taking that risk to self, to career and to family.

We have far too little reliable knowledge about the causation of child abuse generally and especially about how to investigate and predict serious abuse early and certainly enough to provide the evidence necessary to intervene forcefully before it occurs. The paramount objective of inquiries and SCRs obviously should be about how to prevent such a tragedy happening again. The fact that these tragedies do keep on happening demonstrates not the failure of a succession of individual social workers and their managers, but the failure of the whole panoply of inquiries and SCRs over the years to meet their primary objective and equip social workers with the knowledge to better protect the children (and themselves) in future.

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