According to the United Nations Children’s Fund, the lot of Britain’s children has improved. Ranked 16th out of 29 developed countries surveyed, action on child obesity, smoking and alcohol abuse has been successful. However, as shown by the case of four-year-old Hamzah Khan who was starved to death by his substance-abusing mother, there is a dark underbelly to British society. Such episodes are not new.
On 7 January, 1973, seven-year-old under-nourished Maria Colwell was taken to hospital in a pram where she was pronounced dead from injuries inflicted by her parents. The murder caused an outcry. Child-care was overhauled. Politicians said it must never happen again. It did. In 1984 toddler Tyra Henry was murdered by her father, Andrew. Prior to her birth, Andrew had assaulted Tyra’s six-month-old brother leaving him brain-damaged. In 1992, three-year-old Toni Dales died from blows to the head. Then came the deaths of Victoria Climbié (2000), Peter Connelly (2007) and Daniel Pelka (2013), to name but a few. In most cases warning signs were either missed, not acted upon or not acted upon effectively. Climbié was tied up, burnt with cigarettes and hit with hammers and bike chains. Local authorities, the Metropolitan Police, the NSPCC and the NHS had noted signs of abuse. No effective action was taken. A judge accused agencies of ‘blinding incompetence’.
Every ten days in England and Wales a child is killed at the hands of their parent. Why can’t society stop the carnage? The answer lies in what risk specialists call Normal Accident Theory (NAT). NAT says that large systems are destined to fail by virtue of their complexity. The more complex a system, the more difficult it is to manage. System failure is not always about the personnel. Sometimes it reflects the system’s topography (structure). NAT teaches that failure is programmed into large, complex systems because they inhibit communication and are difficult to co-ordinate. Seen through the lens of NAT our childcare system is complex, poorly co-ordinated and vulnerable. Improvements take an age. The 1974 report into the death of Maria Colwell observed:
“What has clearly emerged, at least to us, is a failure of the system compounded of several factors of which the greatest and most obvious must be that of the lack of, or ineffectiveness of, communication and liaison. A system should so far as possible be able to absorb individual errors and yet function adequately.” (Report of the Committee of Inquiry into the Care and Supervision provided by local authorities and other agencies in Relation to Maria Colwell and the co-ordination between them, para. 240).
In his 2003 report into the death of Victoria Climbié, Lord Laming commented:
“[T]he suffering and death of Victoria was a gross failure of the system and was inexcusable …. Having considered the response to Victoria from each of the agencies, I am forced to conclude that the principal failure to protect her was the result of widespread organisational malaise …. [T]he greatest failure rests with the managers and senior members of the authorities …. It is significant that while a number of junior staff in Haringey Social Services were suspended and faced disciplinary action after Victoria’s death, some of their most senior officers were being appointed to other, presumably better paid, jobs. This is not an example of managerial accountability that impresses me much.” (The Victoria Climbié Inquiry, paras. 1.18-1.23).
Are more children going to be murdered? Unfortunately, yes. We can, however, reduce the number by taking a lesson from the military.
Carrier operations achieve high levels of safety. How? Because of the intense focus on communication, co-ordination, provision of timely, high-quality management information, training, exercising, failure-analysis and empowerment of those in the best position to evaluate a situation and make decisions (often the people at the ‘sharp-end’). As an officer on board the USS Nimitz explains: “Co-ordination between ship’s company and the air wing occurs across every rank and in every space aboard the ship”. It is ironic that a system designed to deliver death and destruction – the aircraft carrier – can teach us how to save lives. Safety science has learned much from military protocol. High Reliability Theory (HRT) condenses the lessons. Safety guru Professor Jim Reason defines high-reliability in his latest book:
[A high-reliability organisation] respects, anticipates and responds to risks. [It has] a just, learning, flexible, adaptive, prepared and informed culture (A Life In Error, 2013: 93).
A final point, and a personal one: The author has spent the majority of his working life trying to make our bustling and ever-more complex world a safer place. To this end he has engaged with as many practitioners as possible, usually by working as a consultant to businesses and governments. It seems to the author that, at least in the matter of engagement, universities have some way to go. Which is a problem, because universities’ legitimacy and credibility depend to some degree on how much they improve the immediate quality of life. The quality of this country’s child-protection regime could be improved if academics engaged with it not just when it malfunctions, but on a day-to-day basis. This would apply to other areas, too, like a police service that seems unable or unwilling to control some of its officers. Witness the Orgreave and Hillsborough cover-ups, officers taking money from journalists and the simmering ‘Plebgate’ affair. It does not have to be like this.
By Dr Simon Bennett, Director, Civil Safety and Security Unit, University of Leicester.