Six themes from the Mullighan Report


Pam Simmons Guardian

Capturing public attention in the past two months has been the release of the report from the Children in State Care Commission of Inquiry (the Mullighan Inquiry). It has drawn renewed focus on past abuses of South Australian children. Such inquiries or investigations have been sadly necessary and repeated across the country and there is great sorrow and abhorrence at the stories of abuse that have emerged.

Commissioner Mullighan took evidence from 792 people who said they were victims of child sexual abuse and 242 had been children in state care at the time of their alleged abuse. Many of the alleged incidents were in the 1960s and 70s.

The Commissioner has acknowledged that most state care provided is good care and, in the glare of the inquiry’s spotlight, it is important to remind ourselves of this while paying close attention to what still needs to be done.

Here in the Office of the Guardian we are in a privileged position to see how the child protection system works for children and every day we see evidence of great achievements by children and young people, excellent care and superior professional practice.

We are also acutely aware of the challenges in delivering the best child protection service. Not the least of these is a huge change of emphasis from a notification and investigation-driven model of child protection to a child and family-centred system of early response to problems. This is very difficult to achieve in the over-heated political environment that accompanies the stories of children who have been let down by family and state.

There is opportunity, though, to learn from examining what happens when things go horribly wrong. Here are six themes that emerged for me in reading the Mullighan Report.

  • Prevent abuse happening through, among other things, empowering children to voice their experience and views in an environment of trust and respect. Much of the response to abuse in care has rightly focussed on regulation, monitoring and scrutiny. Less attention had been paid to the organisational culture and power imbalances between children and adults and between staff and management that prevent the alarm being raised when things go wrong.
  • Clear and decisive action is required when children disclose abuse and the response must be constantly supportive of children. The stories of children telling someone but nothing happening are chilling. Alarming too is the response that effectively punishes the child by separation, scepticism, and frightening interactions with too many strangers.
  • Clear messages should be sent to all about what constitutes abuse, that it is wrong and that there are serious consequences for perpetrators. This includes timely and resolute pursuit of abusers in dismissal from employment, charges and prosecutions.
  • We must also consider how best to follow up with children and young people and adults on the impact of child abuse. This will include assisting them to overcome the trauma, to believe in themselves and to trust others again.
  • We must learn from mistakes, oversights and false assumptions by reviewing where things went wrong and then acting on what was found to be deficient.
  • Important, but perhaps less obvious, is the reminder to re-examine our routine practices for potential disrespect or disregard that can creep into family meetings, conversations with children, case conferences, case records, decision-making and responses to requests for help.

Other readers will have read other themes in the report but there is no doubt that each will be as determined as we are that such abuse will not occur while we have voice to speak and courage to act.

Review of programs in youth training centres

In July 2007 the South Australian Guardian for Children and Young People commissioned the Centre for Applied Psychological Research, University of South Australia to conduct a review of programs available to young people in secure custody. The report was completed in January 2008. There had been no independent review of programs in secure custody, although the need to develop youth justice programs was identified by the Families SA Youth Justice Directorate in their 2007 Training Centre Action Plan, the SA Social Inclusion Commissioner, and the SA Parliamentary Select Committee on the Youth Justice System which reported in 2005.

The report is in two sections. Part 1 is a review of the scientific literature on theories and practice in youth justice. Part 2 reports the findings from interviews with a range of stakeholders and focus groups with young residents. Part 2 also contains the recommendations.

Download the literature review

Download the report

link to GCYP twitter

Improving educational outcomes for children and young people under guardianship in South Australia

It is widely acknowledged that children and young people under guardianship are highly disadvantaged in achieving a good education. This does not mean they are not capable, nor that individual educators and carers do not support them. It does mean that we can do more to overcome the significant obstacles the students face with recovering from trauma, changing schools, and early neglect.

In February 2007 we commenced an investigation into improving educational outcomes for students in care. The Office engaged Ms Julie White and Ms Helen Lindstrom to investigate what was available now for children in care and prepare an ‘ideas’ report on additional action required to improve children’s experience of school and learning. In the subsequent months they conducted a review of the literature in Australia and overseas, summarised the strategies currently in place in this state, interviewed children and young people under guardianship or formerly under guardianship and interviewed a range of stakeholders.

Improving educational outcomes for children and young people under guardianship in South Australia and a summary of Improving educational outcomes for children and young people under guardianship in South Australia can be downloaded as  PDF files.

Download the Summary Report here.

Download the Full Report here.

Response to Discussion Paper, Attorney- General’s Department – Review of Domestic Violence Laws

Among other statutory functions the Guardian for Children and Young People acts as an advocate for the interests of children under the guardianship, or in the custody, of the Minister for Families and Communities.  We have a major interest in preventing children from requiring statutory protection and protecting children from harm.

This response is prepared on the basis of the Office’s experience in investigating individual matters and talking with experts in the area of children and domestic violence.

You can download a PDF file of the Response to the domestic violence law review.

Good systems learn from mistakes

Pam Simmons Guardian

Jodi was nine and one of five children. In total there had been over 40 child abuse notifications made about Jodi and her siblings. On their own the notifications were relatively minor. It was the pattern that told the story. When Jodi was admitted to hospital with a serious injury, people were angry that nobody had intervened before now. Everyone was looking to blame somebody.

To state the obvious, child protection is a seriousb usiness with weighty responsibilities. It is highly contested and there are few absolutes. It is a ‘high hazard’ environment where mistakes or oversights have a big impact for someone.

There are other high hazard environments, such as public transport, hospitals, mining, aviation, armed conflict and family law, to name a few. Some systems do better than

others at minimising the incidence and impact of mistakes.

Two international experts on human error and safe systems are Marilyn Rosenthal at the University of Michigan and Jim Reason at the University of Manchester. They make comparisons between aviation and health systems pointing to the success of the former in accepting that human error will occur and constructing a mostly sound system

of checks against error. Health systems do this too, to a greater or lesser degree, but it is a more ‘personal business’ with the health consumer playing a key role in safety. In health systems there is also a greater, and largely unhelpful, tendency when errors occur to blame the individual.

The same comments could be made about the child protection system. It is a highly personal business and we do tend to look to blame somebody. Bad parents, bad child, bad social worker or bad carer. Wrong court judgement, wrong assessment, wrong school or wrong choice. This is not always misplaced but it rarely provides a complete picture of what led to an incident or error in judgement.

So, what makes a good system with low incident rates and successful correction for mistakes?

Clearly, employing good workers and providing them with ongoing skills development and reward for good work is a start. Maintaining a healthy workplace and work hours is another. But good workers make mistakes too. Every good worker has. In most circumstances we don’t want to lose good workers because of a mistake, but we do want the wrong done to a person and its impact to be well acknowledged.

A good response to a mistake is to report it, admit it and apologise. But few people will do that if they expect to be hung out to dry.

What happens when we look to lay blame? Everyone keeps their head low, hopes someone else made a bigger mistake, searches for justification to support their judgement, and bunkers down until the storm passes. Most also continue to feel bad.

A good system is analytical and responsive. It will encourage the reporting of mistakes, help put things right, avoid blame, examine the mistake or incident closely and look at how the system should change to minimise the chance of it happening again. It should provide the checks and balances against escalation or repetition. It must also of course deal fairly and decisively with ongoing poor performance.

Any number of things could have gone wrong in Jodi’s case. The data system was inadequate and the notifications weren’t linked, there was high turnover of staff so no one made the connections, the notifiers expected that someone else would take responsibility, staff were intimidated by threats from the family or there were too many more urgent matters ahead of this one. Jodi should have been better protected. She wasn’t. We owe her an apology and assistance to recover. We ask why and we talk to everyone involved, without blame but looking for answers.

Dismissing a mistake or oversight as ‘just the system’ is also not useful. As said, child protection is a personal business and relies heavily on human interaction and

communication. A bad day can be a gravely bad day. Good workers will recognise when they are in a high risk situation. It may be the seriousness of the matter, the

difference of opinion, their personal feelings about one of the people, their tiredness and state of mind. They may start to look at something through a single lens and

recognise only the evidence that supports their view or recommendation. Good workers will seek help and good systems will have it.

There must be a way of attending to problems that accepts fallibility and is not shaming to people who talk about their mistakes. This will also support a professional culture that is consumer centred and will acknowledge the hurt done.

There are more external checks in the child protection system in South Australia now – Child Death and Serious Injury Review Committee, Health and Community Services

Complaints Commissioner, the Guardian for Children and Young People. There are also internal checks, the Adverse Events Committee, the Special Investigation Unit, and the Customer Relations Office. The more significant response though will come from deeper in the system – at the agency level where the services are provided. And the answer does not lie in increased regulation or scrutiny but in safety to report, admit, examine, review and change. It also of course lies with compassion and empathy.

Human error and health systems are discussed in the work of James Reason, Emeritus Professor of Psychology, University of Manchester in the U.K. who has written books

on absent-mindedness, human error, aviation human factors and on managing the risks of organizational accidents. Read more of his ideas in an interview at Marilyn Rosenthal, Professor of Sociology at the University of Michigan, has researched extensively on why doctors make mistakes.  Two of her books are Dealing with Medical Malpractice: The British and Swedish Experience and The Incompetent Doctor: Behind Closed Doors.

Office of the Guardian’s Monitoring Framework

The Office of the Guardian’s Monitoring Framework is the basis of our monitoring and intervention.  It is derived from the Charter of Rights and contains 12 statements which encompass our aspirations for children and young people in care.

  1. This child lives in a kind and nurturing environment.
  2. This child is safe and feels safe.
  3. This child is loved.
  4. This child is receiving appropriate shelter, clothing and nourishment.
  5. This child is cared for in a placement that is stable and secure.
  6. This child has a secure personal space to which she/he can withdraw and where personal things are kept safe.
  7. This child has contact with family, friends, and cultural community that provide emotional support and identity.
  8. This child has access to health and disability services that meets his/her needs.
  9. This child is getting an education suited to her/his needs and the opportunity for artistic, cultural and sporting development.
  10. This child understands to the full extent of his/her capacity why he/she is in his/her current circumstances.
  11. This child has knowledge of and participates in decisions that affect him/her.
  12. This child has regular contact with the same case worker who is skilled, knowledgeable, respectful and advocates energetically in the child’s best interests.