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The lessons we should learn from Baby P

Picture_2_3 Martin Sewell is a Kent-based family lawyer specialising in child protection.

The discussions and recriminations over the death of Baby P will long continue, and no doubt the lessons and recommendations will join those from a plethora of previous Public Enquiries from the time of Maria Colwell to Victoria Climbie. The whole process is depressingly familiar.

There are, however, a few common features which we should usefully bring into account at this stage, whether we are offering commentary today or making plans for carrying these responsibilities in the longer term.

Before drawing out those themes however, we ought to pay heed to some of our own core values and those who enunciate them. David Cameron speaks of "the Broken Society" and Iain Duncan Smith writes elsewhere of the need to promote marriage.

We ought not to be shy of prefacing our analysis with the plainest of statements that, however hard it is to re-achieve it, children are safest in the homes of parents who are married to each other, in work, and who do not abuse drink or drugs. When the parents additionally understand that the care of children involves at least as much self sacrifice as self fulfilment, then the incidence of such tragedies becomes virtually negligible.

If we are serious about promoting the welfare of children then nothing that undermines those principles should be allowed to pass unexamined. For as long as we treat as unimportant the drift from the traditional family model, with all its imperfections, we shall miss the very simple point. Chaos theory tells us that things move from order to disorganisation and family life is no exception to this.

Failed families cost on a variety of levels.Those who experience dysfunctional family life have greater difficulty in sustaining the stabilities and routines within which children thrive, and in a dreadful Malthusian way, we have seen an exponential rise in family break-up and the need for state interventions whether through the provision of Courts, Social Services, or the NHS itself, which picks up the pieces in a variety of ways from drugs clinics, through A&E admissions to a variety of mental health services.

Year on year, everyone in those services wants more money. However tempting it may be to rail against the periodic failures of those services to offer water tight security to children, the simple truth is that the rate of growth in the problems is fast outstripping the rate at which we are willing and able to provide the resources to address them.

That said, changing the Societal deficiencies is a daunting longer term task, and it cannot absolve us from trying to make improvements in the short term. I address the rest of this piece to any aspiring politician, but caution him/her from trying to suggest that such things will not happen on their watch because experience shows that it almost certainly will.

First, one must have a realistic recognition of the common features of such tragedies. Generally these cases do not occur in the county shires, they tend to be inner city occurrences. Ed Balls declaration that he wishes to ensure a uniform protection throughout the country may be doctrinally sound but if we pretend that there is no difference between areas children will continue to suffer.

This is because of the concentration of dysfunctionality which can more easily overwhelm a large metropolitan/urban Social Services Department when it is attempting to serve massively diverse and sometimes impenetrable "communities". That which attracts attention in Ambridge passes as unremarkable in the inner city estate where the word "community" is a misnomer. If you do not share the same language as your neighbours you are less likely to be either part of a support network or a potential informant when things go wrong.

Whilst ethnicity does not seem to be a factor on this occasion, it has to be noted that in many of the previous cases of child deaths, minority/mixed race children(particularly girls) do seem to be disproportionately represented. This is not said to disparage but rather to highlight that ethnic isolation in some form can be a common issue. This may be by reason of resistence by the parent, or official inability/reluctance to intrude. Whatever the cause, remedies concentrated in such areas will provide the maximum prospect of effectiveness.

Cultural sensitivity, and simple translation problems exist now which simply were not present 25 years ago and when a Department has to cope with added complexities, its burdens increase. This is not to blame diversity but to ignore its impact or relevance would not be honest.

We should not overlook the problem of discernment. Any front line Social Worker will have many families within their case load which fit the same profile. Most do not go on to injure their children. The institution of proceedings is a serious, expensive, and resource intensive step to take, and if misjudged, it can undermine future efforts to protect, not least as family members who might have co-operated with a low level intervention, close ranks to exclude officialdom.

Successful discernment comes from experience and personal contact, not systems. Unfortunately have seen the growth of a managerial culture that prioritises systems over children, and weighs down the practitioner with distractions that rarely help to protect children. I.T. takes time and can be a substitute for analysis and evaluation.

After the event we have Judges to evaluate what went wrong, not computers. The same should apply when the risk is being assessed. We should remember this when we hear that managers over rule the risk assessments of practitioners, recalling that their’s is the discipline that runs the systems and manage the budgets.

Both in the individual cases and in the general discussions of these matters we find that front line workers have warned, but not been listened to. Too often when they speak, particularly of they refer to more resources or overwork, their concerns have been glibly dismissed as the special pleading of special interest groups by politicians, consultants and bureaucrats. Few planning or proposing changes have ever engaged in "front line" child protection and fewer still are current practitioners as new "improvements" are dreamt up without reference to those who know.

A politician who pledged to adjust reform in line with front line practitioner advice would enjoy a tidal wave of acclamation from those who do the work. Functional reform that was fit for purpose would be more likely to follow if we did.

We should not underestimate the corrosive effect of the human rights culture in this regard, not because the Child Protection legislation is other than intelligent and balanced in its drafting, but because lawyers would be rightly criticised if they did not use every weapon in their armoury, and in this jurisdiction the analysis of those rights comes with a very expensive price tag.

In the time leading up to baby P’s death, we know that the Social Services Department was 25% understaffed: inner city Public Services always struggle in the recruiting stakes. However, the basic problem may have been exacerbated. What was an institutional weakness cannot have been assisted by the decision to run a pilot scheme in London for a new Protocol for dealing with children’s legal cases. Whereas once proceedings would have been instituted and the assessments of the parents followed, a whole new approach was being developed and trialed so that the Local Authorities had to plan and undertake assessments in advance. Plainly an emergency would over-ride such requirements but with such procedural and cultural changes in prospect, there would have been training and planning requirements added to the everyday work at many levels.

Innovation added to chronic workload stress cannot fail to weaken effectiveness at every level. The target culture contributed. Those with learning disability are the low hanging fruit of child protection. When they are failing, they tend towards physical and emotional neglect rather than physical harm. They are often more compliant, and less confrontational. They present easier boxes to tick than the evasive, the persuasive and the aggressive. I suspect that the risk to children has not reduced since the death of baby P.

Last September for no obviously good reason the costs of assessment of parents was shifted from being the responsibility of the Legal Services Commission and onto the cash strapped Local Authorities. There is a current economic imperative to issue fewer protective legal cases and to struggle on with administrative efforts to resolve problems. Whilst nobody likes to encourage legal involvement, few child deaths occur once the case has reached the legal arena for three obvious reasons.

First, the case management moves from the Social Services and Case Conferences, (where all too often invitees cannot/do not attend) to becoming the responsibility of experienced and questioning Judges who insist on reports and attendances on time.

Second, an independent Children’s Guardian is appointed with his/her own lawyer, access to all case papers, and an active role to engage with the family.

Third, the parent has their own lawyer who frequently has a beneficial advisory effect.

Unfortunately since the new procedures were introduced, there has been a widespread reduction in the number of cases issued - 50 % in my own area of Kent which is a good Local Authority. Few experienced practitioners believe this is an optimistic indicator of improved safety for children and many predict more tragedies.

In the immediate past there has been a positive Government drive to reduce the number of cases issued. If that were to mean a shifting emphasis from the purely speculative or the slightly worrying, towards a concentration upon the truly dangerous, then provided Society was comfortable to see a raising of the bar of interventions and a greater tolerance of imperfect parenting then so be it.

The continuing worry of professionals is however that what we are seeing is a thinning of the protections for very young vulnerable children. Albert Einstein said that the definition of a madman is one who repeats the same actions and expects a different outcome. After all the previous reports we need to think differently and this ought to begin by prioritising the contributions of the front line workers. If the response to this and similar deaths should be more systems and more managerialism then we can only expect more of the same.


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