Sharon Shoesmith and Baby P – the real lessons

http://www.ofsted.gov.uk/oxcare_providers/la_download/(id)/4657/(as)/jar_2008_309_fr.pdf

The main report into the farce that killed Baby Peter |Connelly and left him in the hands of grim psychopaths can be found above.  The report is essentially useless blather.

All of us could have worked out child protection in this country had problems simply by paying respects to the sad corpse of Baby P, and then taking a step back to think about cases in which good mothers have been found guilty of murdering their kids in cot death incidents.  Our authorities get a great deal wrong, and are also working in situations of great adversity.

This area is typical of much public sector activity in that we have little first hand experience to work with in deciding whether the reasonable job we expect is being done.  This first hand experience is intentionally blocked from serious public scrutiny.  The sweeping excuse is ‘confidentiality’, though this quickly fades as the real reason emerges – secrecy, not at all the same issue.

The report’s summary finding is:

This inspection has identified a number of serious concerns in relation to
safeguarding of children and young people in Haringey. The contribution of
local services to improving outcomes for children and young people at risk or
requiring safeguarding is inadequate and needs urgent and sustained attention.

Baby P’s body told us all that.  The main findings and recommendations follow the same kind of line.  The real conclusion is that child protection in the area was such a mess that no basic management was taking place, and that someone equipped with a generic checklist would do a better job than the bunglers involved.  It quickly becomes clear that ‘poor communication’ is going to cop much of the blame.

I won’t inflict any more of the report on the reader.  It beggars belief that cases like Baby P could somehow slip through the net of any working system.  The hidden cameras of Dispatches and Panorama do a better job.  The real lessons are that we can’t trust any of our review bodies to get the real evidence out in front of us.  Years after Hutton, we discover someone inside our security services saying ‘the dossier was skewed to make the case for war’ – and we barely know, as a public, how many Iraqis were killed and maimed.  Years after and after various high court stuff, we discover Shoesmith didn’t get due process.  It takes an inquest to get our DPP round to what was at least obvious enough for most of us to think a trial appropriate on Harwood.

The kind of evidence we needed on Baby P did include whether Sharon Shoesmith was any better of worse than most people doing her kind of job.  I suspect she may not have been as bad as most remain.  We need to know the nature and extent of the work we expect to be done to prevent child abuse – but the raw material here is not available from case files, but amongst us generally.  It would be accessible to the right kind of research.

The easiest way to give an idea of this is to think of cases like the Pilkingtons and Mr. Askew.  Deaths occurred here after very long periods of harassment, about which not much effective was done.  How many crimes were really committed against these people?  We don’t know, because most were not recorded or even attended on occasion.  Yet we can find similar, ongoing instances and could produce a generalisable statistical analysis for use.  We could and should be doing this across our public sector, on material not already influenced by the fatal nexus of interest groups involved.

My own preference is to get back to ad hoc working and integrity.  This is a system like any other, and consequently we can’t just hope it will work – we have to give workers back responsibility they can’t be stopped from using.  My guess is this means we all have to be less scared of losing our jobs in order to do them better.  We have to unravel Max Weber’s ‘iron cage’ and recognise there are no special individuals who can make us all do a good job – indeed this notion of ‘leadership’ may well be the problem.

My gut feeling, from personal experience, is that the main issue for any victim of bullies is representation and not having any.  Things are so bad, that the very authorities one might expect to help, start bullying themselves to try to get the victim to give up or the work go away.  If we can describe the system Baby P and others are in broadly, then it’s a rationing system.  Baby P just didn’t have his card and surrounding such victims with people trying to mark off their own in some checkpoint management routine is no answer.

When a social worker or cop turns up to deal with a call, it is possible to cost the incident.  I used to do a lot of work like this in project budgets.  The spreadsheet will quickly make anyone blench at the cost.  The ‘answer’ in  terms of child or victim protection is often prohibitive.  The worker bringing the costs of doing the right thing by child or victim will not last long.  The system has long expected them to ration, both in terms of money and their own availability for the next ‘response’ or an extended chinwagg with mates.  I suspect this is what is really managed and what needs to change.  And to get there, we need to expose what is really going on.  I’m sure the trail of a case would make British Leyland look like a modern 21st century manufacturing model in comparison with the goings-on.

According to the report, Shoesmith was leading a department devoid of the simple management measures we teach undergraduates.  Worse, these are the very solutions put forward to make things better.  Meanwhile, Leicstershire have retrained 2,500 people in light of Pilkington – and one can bet other forces haven’t.  The Cochranes were killed here in GMP and I haven’t met a single officer who has heard of this ‘lessons leartned’ case.

Broadly, the idea of good management is that you don’t have to do much of it.  Your people do chat, exchange information, teach each other and so on.  When you have to get round to enforcing these matters, you’ve missed the point and probably start planning a trip to Japan to read out a desiloisation paper written by a nurse.

Note that Sharon Shoesmith got representation and looks like getting a payout most of us think she should have to do without.  Baby P got no representation until he was dead.

Speaking on Radio 4’s Today programme, Mrs Shoesmith said: “As a director of children’s services I cannot control what the police do, I cannot control what health does. I cannot control the fact that when a social worker rings to get an appointment at a hospital she cannot get it for four months… I cannot control the fact when a social worker is referring a child for abuse that she rings up and finds that a case has not been allocated to a police officer for four months. I can’t control those matters, this is much more complex than saying you are responsible, let’s sack you and the whole nation will be at peace.”

Of course it is Dearie.  We wouldn’t just find you saying, somewhere else, that you had ‘established excellent partnership working’, now would we?  Like all the other bureaucrats have learned to say?  Did you point out all these, and no doubt more failings in your own performance review?  The report rather suggests not –

Performance management arrangements across agencies are insufficiently
robust. The reliance on national and local performance indicators is too great
and does not enable understanding of the quality and effectiveness of service
provision on the ground. Insufficient attention has been given to evaluating the
quality of front line practice and quantifying the impact of services upon
children. There has been a failure to use the outcomes from qualitative audit
activity to critically self evaluate and to report on the actual outcomes for
children and young people. The partnership does not use performance
indicators to question and challenge underlying issues about the quality of front
line practice.

What did you do when matters you now use in denial came to your attention?  The real question may well be what do other managers do across the UK.  One police inspector, telling me he was going back on shift to get away from our local town hall, said ‘It’s like platting snot, mate’.  GMP still claims ‘excellent partnership working’ as it did then.  The time to tell the truth is while in post.  As Gadget and many other blogs point out, this is mortgage suicide.

Didn’t you sack a social worker trying to tell the truth Sharon, or do nothing?  I’m thinking about Mrs. Kemal.  Her case had also been scrutinised through the Joint Area Review involving other agencies and through court proceedings, the CSCI said, but it added that its inspectors ended their inquiries at that point, and did not explore Ms Kemal’s wider concern, expressed in a letter from her lawyer, that child protection procedures were being flouted. That admission will raise concerns about the broader oversight system.

The CSCI statement came after Opposition accusations of “bureaucratic buck-passing” in Whitehall departments remarkably similar to what you now say.  What prevented you supporting Mrs. Kemal then?

“The public are tired of hearing that correct procedures have been followed when a child died in agony. Ministers were told six months before Baby P’s death that there were profound problems in Haringey’s Children’s Services Department.”

“Yet all that appears to have happened is the sacking and gagging of the whistleblower and bureaucratic buck-passing in Whitehall. We need a proper explanation of what steps were taken at the highest level to investigate the concerns raised.”

Ms Kemal’s warning came just six months before the death of Baby P, who died in August 2007 from multiple injuries including a broken back.

Ms Kemal told Haringey Council in 2004 that a case involving alleged sex abuse bore similarities to the circumstances surrounding the death four years earlier of Victoria Climbié, the eight-year-old murdered by her guardians.

Ms Kemal was suspended soon afterwards on what she alleged were false charges of misconduct, and went on to sue the council for race discrimination and harm she suffered under the Public Interest Disclosure Act. The claim is understood to have been settled.

In February 2007, Ms Kemal’s solicitor, Lawrence Davies, wrote to the Health Secretary of the time, Patricia Hewitt, and to MPs, alerting her to the problems and calling for a public inquiry. “Statutory child protection procedures are not being followed. Child sex abusers are not being tackled,” he wrote.

The Department for Health said that it passed the letter on to the Department for Education and Skills – now the Department for Children, Schools and Families (DCSF) – because it had no jurisdiction after responsibilities in the department were changed

A spokeswoman for the DCSF said that officials replied the following month and suggested that the complaint be passed on to the CSCI. “The Permanent Secretary of the DCSF has looked at the reply and is confident that the proper procedures were followed,” she said.

But Mr Davies said that his pleas had been ignored. “I did not get a reply from anyone, I copied several MPs into the letter. If someone had acted then maybe Baby P would not have died,” he said.

Ms Kemal herself is not allowed to talk about the case because of an injunction obtained by Haringey Council.  What message will any court who does reward Sharon Shoesmith’s silence?  Business as usual?  Don’t blow your whistle to save a child, only to protect your own comforts?  This is the reasoning of people we want looking after children in misfortune?

What’s going on is ‘area search no trace’, which is essentially what bankers do.  The real data end up ‘offshore’.  The real questions concern how we could get twice as much outcome from the current systems at the same cost or less.  This can’t be about backoffice savings and waste management in the crude politicians’ sense – this flies in the face of research findings.

The first thing wed’d need to know about is the ‘demand’.  My understanding from reading the field and friends in the business is this is as huge as when I stopped teaching in the area in 1988.  This could not be done in a manner that assumed we could just fund the demand.

The next obvious business move would be to look how costs arise in meeting the real demand and what could be done in really making that system truly efficient through delayering and cost savings.  This can be done, but obviously is more a question of problem identification than a solution.

The next question is whether we can move to a new business model, with innovative case investigation and presentation methods, safe methods, homes and education for the kids, getting parents up to the mark if possible …

In any of this, we’d have to question why the issue comes about as such a massive cost, dwarfing the actual cost of raising a child in a rich family going to Public School.

Other obvious matters arise, to do with the psychopathic swooning of officials, difficulties with evidence (where were the neighbours in Baby P?) and training that doesn’t take people off-the-job.  Whatever rationing goes on, this should not be on the basis of likely court costs and others that lead to management being about the devolved budget.

It’s often my job to write business development plans, so I’ll leave this one at its start.  We also clearly need to do something about job satisfaction and the HRM piffle that gets in the way of that.  My own view is this involves getting rid of the ‘boss cadre’ entirely, whilst bringing about more supervision from experience and area management.

This needs to be done by people who know the job, able to speak freely.  Procedures ain’t it – you just get procedural behaviour.  The behaviour we do need is complex, but we do know quite a bit about getting informal systems that work working.  We can talk matrix management and a wad of similar, but really its about getting rid of mean actions and the attitude of not being able to cooperate and only move when your boss says so.

Instead of an expanded version of this, the report on Baby P is effectively directing ‘have better excuses next time’.

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