So, another serious case review is convened to investigate the tragic circumstances of the death of a child at the hands of his parents.

This from The Guardian back in August. It makes for gut wrenching reading;

The mother and stepfather of Daniel Pelka will each spend at least 30 years in prison after a judge told them they had waged an “unprecedented” campaign of cruelty on the four-year-old boy.

Mrs Justice Cox said Daniel looked like a concentration camp victim at the time of his death and on the evening he suffered the fatal blow to his head had been force-fed salt and subjected to a form of water torture, which would have left him “terrified”.

The judge said it was possible the little boy, who was left to die in his filthy box room at the couple’s home in Coventry, may have been “lucid” after the final brutal beating and would have suffered “fear, anguish and physical pain” before losing consciousness.

She told his mother, Magdelena Luczak, 27, and her partner, Mariusz Krezolek, 34, that one of the most aggravating factors was the “chronic and systematic starvation” Daniel endured in the last months of his life.

“Both of you deliberately deprived him of food. He was literally wasting away,” she said. “His starvation was so chronic that his bones ceased to grow.” The judge reminded them that experts said during the trial that they had never seen such emaciation in the UK. “They likened his appearance to those who failed to survive concentration camps.”

Faced with stories like this, we first ask how on earth parents could do this to a tiny child. What kind of depravity could bring someone to such evil? Are they mad, or just bad?

Next we ask another question- why was nothing done about it? How come in this modern age, with billions spent on societal supports like social work, health, education and police, still we could not save this boy?

The most high profile case of the blame game that then follows on from these dreadful incidents was that known as ‘Baby P’. I have written extensively about this case- here for example. In this case, the media and the then Labour goverment (particularly Ed Balls) competed with each other to heap burning coals on the heads of people involved- particularly social workers. The arguments over how this tragedy became politicised and spun by a government on its last legs rages still.

Early signs are that we currently live in different times. David Cameron actually praised social workers in his speech at the recent Conservative Party Conference- which ironically contained many other policy statements that will fill social workers with rage and despair. The mood at present seems to be to accept that the nature of the social work task is incredibly difficult and that perhaps we can never save all children. There was another brilliant piece in The Guardian that tries to dig into the psychology of what happens when a social worker is faced with the messy reality of a family in difficulty (sorry, I know most of my references come from here, but it is my daily read!)

These were not bad or psychologically flawed practitioners; they were outmanoeuvred by aggressive parents, and overcome by the suffering and sadness in the atmosphere of such homes and in children’s lives. The case review on Daniel refers to how his home “was clearly one with a tense and sometimes violent atmosphere”. Caught up in such atmospheres, social workers become overwhelmed by anxiety and lose their purpose and focus.

Teachers, who tend not to visit the home, can be immobilised by how parents project into them their rage, lies and irrational beliefs – such as Daniel’s supposed eating “obsession”.

The case review concludes that Daniel “must have felt utterly alone and worthless … At times he was treated as inhuman, and the level of helplessness he must have felt in such a terrifying environment would have been overwhelming.” Perhaps the most painful truth that must be confronted is that, faced with the helplessness of children, social workers themselves can become helpless because they find the children’s suffering unbearable.

Every time we take a postmortem examination of the what when an why of one of these tragic incidents, there is a depressing familiarity about some of the conclusions. We always see ‘missed opportunities’ when professionals might have acted differently.

The other conclusion that might be inked in before the serious case review begins is this one- agencies will not have been seen to work together closely enough. They will not have ‘communicated’ or ‘co-operated’ effectively.

Why? It sounds so petty does it not? I have been reflecting on my almost 25 year social work career and trying to understand what this is all about. Here are my thoughts;

1. Co-operation is about relationship. If you allow relationships between key people in different organisations to sour, it becomes almost impossible to work together. Everything stops. I can think of times when I have nurtured by dislike of opposite numbers, to the detriment of our respective services. I can think of other times when I have gritted my teeth and refused to allow myself to take offence, and I am much prouder of the latter. I have been part of a work culture however that operated in almost constant conflict and suspicion at high levels. This is a toxic mix that is almost psychopathic and is certainly highly dangerous.
2. Under pressure, it is very easy to play the responsibility game. It is a very human thing- none of us can do everything, and when we perceive something to be the primary responsibility of someone else, we defer to them mentally as well as physically. This means that we tick boxes and pass them in them over, or we perhaps assume that they are attending to aspects of the whole that excuse us- after all there are usually a thousand other things clamouring for our attention.
3. Different organisations have their own jargon, their own sub cultures. These greatly affect not only how they understand a particular set of information, but also how they respond to it. Some organisations revert to ‘doing it by numbers’, in an attempt to make sure that they are covered. This only succeeds in managing responsibility, it does not really save lives. Real people are messier than a checklist or two.
4. Organisational cultures and value bases lead to in/out group mentalities. We are skewed towards suspicion of the other. Which makes point 1 all the more important. I have worked in situations in which the police actively denigrate social work and where social workers regard nursing colleagues with contempt.
5. Sometimes people simply fear over reaction, or lack trust in partners to act in a way that they feel would be competent. There has long been a suggestion that if you tell a social worker about a child in need they will whip kids into care far too fast. The irony is that we now remove a far greater number of kids because of criticisms about the death of children when we have NOT done so. This culture has shifted but is remarkably persistent.

Are these things to blame for the death of children?

No, the cycles of damage done and received by individuals are cause the death of children. Drug use, alcohol use, broken people who break others. The blame game often answers few questions about why.

However, there is no doubt that some things will make it harder for us to co ordinate our efforts to save kids.