| Abstract: | A new systemic approach to investigating child abuse deathsis proposed, drawing on the lessons learned in engineering.Investigations have traditionally taken the approach of concludingonce faults in professional practice are identified. Solutionstake the form of trying to control erratic practitioners: psychologicalpressure to achieve higher standards, increasing formalizationand guidelines to reduce the scope for individual fallibility,and stricter management surveillance. The inquiry into the deathof Victoria Climbie fits this model. However, thirty years ofsuch inquiries have not led to the expected improvement in professionalpractice. Indeed, the Climbie report describes several agenciesoperating at a very low level, and failing to implement themost basic elements of good practice. A similar history of failurein engineering has led to the development of a systems approach.Human error is taken as the starting point, not the conclusion,and the investigation tries to understand why the mistake wasmade, by studying interacting factors in the practitioners,the resources available and the organizational context. Theway this approach could be adopted in child protection workis outlined. |
