Responding to the deaths of children known to child protection agencies.

• Author: Connolly, Marie

Abstract

Reviews of maltreatment deaths of children known to child protection authorities spring from a desire to improve practice and enhance safety for children. As such, they may be failing their core purpose. This article explores the use made of such reviews and how limiting our learning to these tragic events may have unintended consequences in terms of building strong systems of support for children. It is argued that the risk-averse systems that can result from political and organisational responses to child death reviews have the potential to impact negatively on services for at-risk children. A systems framework is proposed as a more productive way of exploring the complex and multi-faceted aspects of case work invariably associated with these tragic events. A systems analysis provides a change of focus from the conduct of an individual social worker, by extending examination across a set of related dimensions--the family system, the worker system, the organisational system and the wider system. The authors conclude that child death reviews that place practice in a wider context are more likely to contribute positively to the strengthening of services for children overall.

INTRODUCTION

Although death by assault is relatively rare for children, the impact of a child dying in this way is felt far beyond the child's own family context. These deaths touch a deep vein of public emotion as people wonder why anyone would harm a child in such a way. They stimulate media frenzy, followed by public outcry, calls for accountability, and expectations of statutory reform. The first significant child homicide death review was undertaken in the United Kingdom in 1973. The tragic death of Maria Colwell brought child homicide to the forefront of public attention, and since that time reviewing high-profile deaths has become a common response in English-speaking countries. Despite their rarity, child death reviews have become influential to the understanding of professional systems of response as well as child abuse more broadly. Within the current climate it is possible for the death of a single child to result in calls for widespread child welfare reform (Ferguson 2004). Although it is clearly important that we understand the circumstances surrounding child deaths, it is wrong to assume that one tragic situation necessarily characterises practice with children and family across an entire system. Indeed, such situations may just as likely reflect a set of idiosyncratic circumstances located in a particular time and place.

This article explores the use made of New Zealand child maltreatment death reviews--carried out either by Child, Youth and Family Services (CYF) or the Office of the Children's Commissioner (OCC)--and how limiting our learning to these tragic events may have unintended consequences in terms of building strong systems of support for children. It is argued that the risk-averse systems they unintentionally foster may ultimately be harming some of the vulnerable children they seek to protect.

CHILD PROTECTION, RISK AND CHILD HOMICIDE

In his thoughtful analysis of protecting children in time, Ferguson (2004) ponders a paradox: why are we consumed by child homicide risk anxiety when throughout history it has never been less risky for children? Contemporary systems of child welfare are more sophisticated than ever before in identifying and responding to risk, and children probably face less danger than they ever have in history:

The upshot of [this] is a greatly increased sense of risk and danger in child protection, although the actual numbers or proportion of cases involving life-threatening situations for children is small. (Ferguson 2004:116) Risk consciousness, according to Ferguson, has turned into risk anxiety and social workers carry the burden of it.

To understand this phenomenon it is useful to consider what has happened as child homicide has gained greater public exposure. Children have always died at the hands of adults, and the number of child deaths has remained relatively stable over recent times. But the degree of public awareness of situations of child homicide has varied. In the United Kingdom, child maltreatment deaths known to the National Society for the Prevention of Cruelty to Children (NSPCC) were recorded from 1915 until 1936 (Ferguson 2004). Subsequently, deaths of children known to agencies disappeared from view, partly because of changes in the management of information and partly because the numbers had dropped to the point of being of limited significance to practice. Over time, according to Ferguson, "death went out of sight in order to promote public trust and feelings of security in child protection and to repress people's worst social fears about families and violence" (p. 90). Social workers became the "containers" for community anxiety or, as Munro (2005:378) puts it, people who can "bear the guilt for the disaster and ... be the target of feelings of rage and frustration".

By the mid-1970s, however, child protection had become more visible. Knowledge about child abuse was developing, and increased awareness of the sexual abuse of children thrust child protection work into the limelight. The public was no longer protected from the horrors of child abuse, and the media relentlessly pursued every opportunity to bring tragic stories to public attention. Enquiries into these deaths began to open systems of child welfare to public scrutiny:

With the invariably aggressive attentions of the media, public disclosures of child deaths and inquiries into system "failures" have played a crucial symbolic role in opening out child abuse and protection services, as well as professional anxiety, to public view ... They were also shocking in the sense that they appeared to be completely new and to reflect a real decline in professional standards. (Ferguson 2004:110) They were...