you're reading...

It should never happen again – but it will!

Guest blog from Dr Mike Lauder, Visiting Fellow at Cranfield’s Centre for Business Performance:

Today I sat in a field in Cumbria waiting for the rain to pass. To pass the time I spent the day reading news reports about yet another inquiry that seemed to suggest the last one made little difference.  A little bit of deja vue (squared); another day of rain when I had hoped to go for a cycle and another inquiry that just seems to repeat what we have heard before.

The press set to work expressing public outrage, as they usually do. The usual set of responsible bureaucrats all said how sorry they were, they recognised what might have been done and came up with a few “if onlys” which they thought might have prevented the problem, but they all agreed, as usual, that “it should never happen again”. But it will.

While each case that involves the death of a child is a tragedy, one has to question whether is it possible for society to arrange itself in such a way that it can ensure that such tragedies cannot happen. One of the regrettable aspects of these events is the poor level of debate that results.

I have however seen a few shafts of light. I would like to comment on two. The first concerns the media and the second academia.

The BBC home editor Mark Easton cautions “that (such tragedies) will happen again”,  and warns that the calls for more regulations and mandatory procedures may have equally undesirable unintended consequences. While such legislation might seem “an attractive idea at first sight, ensuring that warning signs don’t get ignored”, he cautions that “introducing mandatory reporting may produce many unfounded warnings that could blind professionals to the most serious abuses.” Mark Easton asks us to think about the unintended consequences generated by report recommendations, as this matter is frequently overlooked by those penning the recommendation.

The second ray of light was offered by Professor Eileen Munro of the LSE on Radio 4’s Today  programme. She questioned the way the review was conducted as it, along with many others, relied heavy on hindsight when formulating its findings and recommendations. The underlying question is the credibility of the report and the weight that should be given to its recommendations. The use of hindsight in this way is a fundamental flaw in the process; those who question this assertion have to ask themselves why they are not millionaires. Every national lottery ticket contains all the information required to win. All the person has to do is to select the right information: this is easy in hindsight. It is the selection of the appropriate data on which to make decisions that is often the critical failure in these circumstances and here we will continue to make mistakes.

The serious case review into the case of Daniel Pelka offered the advice that practitioners need to “think the unthinkable” and to avoid being overly optimistic. If this was a natural thing to do we would manage organisations using risk management rather than performance management. Humans are naturally optimistic creatures, the world is such a complex and hazardous place, we would all become overwrought if we were not. As someone who has been trying to align risk management and performance management for the last 5 years, I am only too aware of the issues this proposal raises.

With my book “it should never happen again” I have tried to raise the level of debate on the conduct of inquiries and their value to society.

While, as a society we spend millions on their conduct and millions more on implementing flawed recommendations, we spend very little time and effort trying to improve the quality of the process. While many branches of academia make inquires into failures in their own practical field (in the case of child protection I know of work being done by Professor Munro, academics at Warwick University and members of ofsted staff), I can find no attempt to improve the underlying practice itself. If something should be done, surely this would be the first place to start?

Finally, and again quoting Mark Easton, “The real tragedy of Daniel Pelka is that we may simply not be able to prevent more children suffering and ultimately dying, hidden in public view”. This will continue while such inquiry process continues to be run in such an unprofessional manner[1].

Dr Mike Lauder

[1] Ofsted’s evaluation of serious case reviews from 1 April 2009 to 31 March 2010: 16% were judged to be inadequate. 42% were judged to be inadequate. 42% were judged to be good. There were no outstanding reviews. There 58% are judge to be in the lower 2 categories.


2 thoughts on “It should never happen again – but it will!

  1. It is good to see that the unintended consequences of performance and risk management are being identified.
    Mandatory reporting simply means that more cases will be reported. This will mean that scarce resources are spread across more cases rather than being focused on the few.

    Each child abuse case, such as Daniel Pelka, is a tragedy.

    But can such tragedies be prevented in the future?

    What is it that we are missing here?

    Posted by Prof Mike Bourne | September 18, 2013, 1:59 pm


  1. Pingback: It should never happen again – but it will! | SoMResearchInsights - September 20, 2013

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

%d bloggers like this: