Social Work now, Issue 31, pages 8-11.
In a number of high-profile cases involving the death of a child, it has been revealed that social workers handling the case made decisions that appeared to violate the organisation’s established procedures or commonly-held ideas of good practice. When an accident is attributed to failure to follow the rules, the common reaction is “how can they have been so stupid, neglectful or disobedient?” The usual response from the authorities is to conduct an investigation, apologise for the error, possibly discipline the offending social workers and introduce more rules.
The problem of apparently inexplicable disastrous operator decisions is not confined to social work. Experienced surgeons remove the wrong limb from a patient. Pilots deliberately fly well below safe altitudes and into mountains in clear, still air. At Chernobyl, engineers disabled safety interlocks, leading to a catastrophic explosion in the reactor. In the last two decades, accident investigations into these highrisk activities have begun to take a systemic approach. Questions to ask include:
- What was it about not only the decision makers but about the situation they were in that might have contributed to the error?
- Why did the usual safeguards against error fail in this case?