Learning from the deaths of children

Children die when involved with child protection systems. It is inevitable that some children will die as it is impossible to predict which parent is going to kill a child. However, there are several behaviours by social workers that can reduce the risks. This poster represents some of the most important themes that we have found in our research of Canadian published case reviews.

There are a few I would like to highlight:

1. Supervision really matters - when a front line worker gets good supervision we have another set of informed eyes talking about the case. The supervisor gets to ask questions about missing data, why case plans are structured the way they are and to offer ideas and suggestions about what might be done. Remember that a large number of front line workers have less than 5 years experience. Supervision matters.
2. The child is the reason the case exists - it is not hard to get distracted by the needs of the parent. This can be particularly true in cases where there is a conflict through the court system. Indeed, in a recent case I was involved in, I experienced counsel for the parents as being strongly focused on what was best for the parent but disguised in questions that made it seem about the child. Our task is to bring the case back to what serves the child.
3. Being open to the unimaginable - case workers do not like to think that the parent or caregiver that they are working with would kill the child - but if we are open to that as a possibility then we ask better questions and consider the data more thoroughly.
4. Front line social workers are generalists - they often lack specialist training in the complex issues that child protection work brings. This can range from mental health to addictions to inter personal violence to FASD and so on. BUT, the front line worker does need to know how to get at experts who can aid them in understanding the case. These experts also need to learn how to talk to front line workers in ways that make the issue clear.
5. One assessment at the beginning is not the end of assessment - assessment is an ongoing process. Things change in cases and so should the social workers understanding of the case.
6. If the child is at the centre of the case - see the child - see the child frequently.
7. History does matter - it tells us a lot - what have been the problems in the past and how successful were interventions; how are things different now that may yield strengths or ongoing deficits; is there a pattern that needs to be considered and so on.
8. The new partner is a risk - they need to be met and assessed. 

One of the big lessons for us is how important it is to talk to students about these issues - but talk with students inter professionally. Child protection requires an ability to work across professions - medical, psychology, social work, criminal justice, law - and be able to do so with a grounding in what protecting a child is all about. Inter professional communication has been a problem at the heart of many cases.

There are also cultural implications to our research which I will review in the next posting.

I do want to leave with this message as well - case reviews where things have gone wrong need to be done at the front line - but not in a way that is hanging people out to dry but rather in using the case to enhance learning and improve practice. That helps to reduce the risks of the death for children involved with child protection.

Phoenix Sinclair Report recommendations go over all too familiar ground

The inquiry headed by Justice Ted Hughes into the death of Phoenix Sinclair has now issues its report. It turned out to be the most expensive inquiry in Manitoba's history but it covers territory that is all too familiar. Mistakes by social workers that should never have been made in a system that ought to have prevented the death. This is part of a long line of inquiries that reach very similar conclusions.

The full report can be read here.

Phoenix Sinclair

The report does make some very valuable suggestions such as all child protection workers should be trained social workers who are registered with the Manitoba social work association; case loads be kept manageable; records be well maintained; better communication with others involved including when transferring a case; the system be more transparent and that more effort be put into prevention.

The big idea that Hughes came up with is that child protection requires a national conversation. He suggests that the issue belongs on the agenda of the next Premier's conference which the Manitoba premier has asked be done. The notion of a cross country conversation makes a great deal of sense. I recently attended a roundtable on child protection here in Alberta which was organized by Human Services Minister Manmeet Bhullar. In his opening comments, the Minister noted that there have been over 50 reports on child protection problems across Canada. I have read them. They have a numbing familiarity raising problems about caseloads, funding, the decision making environment, poor communication between agencies, poor record keeping, the need for better training, missing cues and so on.

What so many reports do not address is the very human nature of child protection work. Social workers are rarely invited into families. Most often, they arrive because there has been an allegation of abuse or neglect which requires investigation. Families are very understandably defensive and sometimes downright resistant. This is so much an issue that last year Siobhan Laird wrote a text on managing conflict, hostility and aggression in child protection. It is in that environment that a worker must try to determine the safety and risks for a child.

The information is always (and I use that word very consciously) incomplete. No social worker ever knows everything that is relevant. Thus, the decision making is done with an information set that is changing constantly. Decisions often need to be revisited. There is no way (again I use that phrase consciously) that a worker can predict with absolute certainty the risks. There is probability. We are still faced with the fact that the best predictor of future behaviour is past behaviour in the absence of a compelling story of change.

Part of the challenge with child protection is that there is an expectation of perfection. There is a zero tolerance in the public's mind regarding a death of a children. But there is a reality that no system anywhere can guarantee that. We do have an obligation to provide the best system we can and to really understand how we can reduce risks.

There is also an obligation by society at large to fund prevention which is best done by poverty reduction. The majority of children brought to child protection attention are related to neglect - which is very strongly rooted in poverty. Reducing poverty reduces children in care which increases the attention that can be paid to the higher risk cases.

Seth Ireland Death Sees an Important Jury Decision

Seth Ireland, seen in the photo below, died at the hands of his mother's boyfriend LeBaron Vaughn. Child protective services in Fresno California had received numerous calls about this child. They investigated but they could not find anything wrong according to news reports.

However, the father of Seth, Joseph Hudson, brought a civil liability action against CPS. Yesterday, the  jury awarded him $5 million dollars and Seth's step brother $3.5 million (US dollars). The jury appears to have found that CPS did not follow more than a dozen protocols and had also failed to investigate in a timely fashion.

There are many implications for child protection arising from a decision like this. Front line workers need to be aware that the quality of their work can be subject to intense external scrutiny with liability implications. Many have thought that CPS was immune to lawsuits for their work, but this may be changing.

That workers could be subject to intense public scrutiny is not news - consider the Phoenix Sinclair inquiry presently underway in Manitoba; the recent review of St. Andrew's Hostel Katanning in Australia as well as the Baby Peter case in England.

But front line social workers are the ones who may bear the brunt of public scrutiny, it is the funders of child protection services who should have the heaviest magnification on their decisions. They want increased effectiveness for decreasing dollars. You cannot expect that front line workers can be consistently meeting paperwork, face to face time with clients, investigation time lines and good case management if resources and funding are limited. As budgets continue to tighten in jurisdictions around the world, it will be harder and harder for front line to meet expectations.

This discussion cannot be complete without thinking about the highly complex reality of child protection investigations. People are able to successfully hide what they are doing for many reasons, such as:

• they can effectively lie;
• children can be too afraid to tell the truth;
• parents move making it hard to follow them;
• these families can be isolated making it hard for eyes in the community to see what is happening;
• families counter suspicion with plausible explanations;

Workers, often faced with huh caseloads will make miss cases for these and other reasons. No child protection system can eliminate child deaths. However, what the Seth Ireland case does do, is say that accountability will still exist and doing it right may matter when public scrutiny is brought to bear. Each time a child dies when CPS is involved, public scrutiny can be increasingly expected.

Child Maltreatment Fatalities - Questioning Assumptions

New research just published by Emily Douglas in the United States questions some long held beliefs about the workers involved in child maltreatment fatality cases within child protection systems. As she points out at the beginning of her article:

Some argue that the child welfare profession is out of control: workers who

experience fatalities are young, inexperienced, and lack professional training, and they miss warning signs leading up to the deaths

Indeed, there has been much criticism of the failings of the child protection systems when a child dies. One needs only recall the ,media frenzy in the UK around the cases of Victoria Climbie and Peter Connelly.

About 30 - 40 % of children who die from maltreatment will be known to child protection, she advises. Douglas' research however, tells us that workers did know their families and that, unlike previous suggestions, workers tended to not be new and inexperienced. The workers in her sample were not overly burdened with high case loads, although she may not have fully explored whether these more experienced workers were handling much more complex cases. The workers felt that they had the skills needed to manage the cases and also that they were appropriately supported. She notes that 27% saw that the fatality was likely unavoidable.

Douglas' sample was small and retrospective - limitations that she notes. However, her research does open up new understandings of these cases and the workers managing them. This is an important addition to the conversation. Hopefully, it leads to further work.

References:

Douglas, E.M. (2013). Child welfare workers who experience the death of a child client. Administration in Social Work, 37 (1), 59-72. http://dx.doi.org/10.1080/03643107.2012.654903 

Dennis and Terence O'Neill

During World War II Dennis O'Neill was murdered by Mr. and Mrs. Gough. The death occurred in rural England. It occurred while these two boys were placed with them as foster children. During their stay with the Goughs, two other foster children were removed from their care as the home was deemed as quite unfit. Dennis died but his brother Terence barely survived. On the very, very few occasions that child protection systems interviewed the boys, they were either under the watch of the Goughs or were too afraid to speak up. The abuse grew over time until the brutal night that Dennis would be killed.

What is fascinating about this case is the amazing similarity to present day cases - children who were moved about within the foster care system; rarely seen by child protection workers; failure of information to properly flow between those who could have saved Dennis; failure to properly inspect the Gough house; failure to have the children properly assessed by a physician.

It is sad to see, some 60+ years later, the same mistakes being made by child protection systems.

Terence O'Neill has written an autobiography of his story in the book, Someone to Love Us. In it he tells of the unstable journey through the child protection system of the day. What is even more fascinating, is the story of his life afterwards. He wrote the book only a few years ago - in his seventies.  In the book, you get to experience the trauma and its legacies throughout the lifespan. How the damages of childhood becomes the hungry ghost of adulthood.

This is a book that anyone interested in child protection should read.

The effect of a high profile death

The case of Baby P in England continues to have a long term effect. While there is no question that Baby P's death was a horrible and no child should die in such circumstances, it is his legacy that is of note. Since his death, there has been a growing number of cases reported to child protection cases in the UK.

The latest numbers come out of Wales. "There were 2,700 children on the child protection register in March 2010, an increase of 31% from 31 March 2009, the Welsh Assembly Government figures found. The figures show an even more marked rise on statistics for March 2008, eight months before the Peter Connolly case hit the headlines, when 2,320 children were on the register." (Source: BASW news, December 1, 2010).

What is perhaps most interesting is how again we see the link between child protection concerns, particularly neglect, and poverty. A report reviewing child protection in Wales, From Vision to Action, notes that while social workers are often overwhelmed with caseloads, and budgets from governments often more limiting, there are powerful societal trends at work. "...the From Vision to Action report by the Independent Commission on Social Services in Wales which points to a calculation that 51% of looked after children in Wales live in the 17% of neighbourhoods identified as the most deprived (BASW).

The Welsh report wisely notes that budget cuts in services to vulnerable populations will lead to some long term costs. "Retreating into core services and away from prevention and collaborative improvement would undo gains made in recent years and would quickly become unsustainable" (p.6).

One of the more delightful insights from the Welsh report is how the bureaucratization of child welfare (often a response to high profile deaths) is counter productive. "Current assessment systems for adults and children are overly-bureaucratic, too concerned with process, poorly served by IT and do not assist professional judgment about risk" (p.7).

I am very struck by a quote in the Welsh report that puts into context the world in which services and programs for children and families operate: “ People want a life not a service” (p.27). If we are busy serving the bureaucracy and protecting it,how well do we really serve clients?

Welsh report:
Pearson,G., Jones, J.,Williams, R.H. & Robson, P. (2010). From vision to action: The report of the independent commission on social services in Wales. Downloaded December 2, 2010 from http://dl.dropbox.com/u/3522570/ebulletin/wales-visiontoactionenglish.pdf