Sequeli Summary of Seminars for MRC Newsletter
Sequeli Summary of Seminars for MRC Newsletter
LEARNING LESSONS: A JOINT ENDEAVOUR
Making Research Count at King’s College London has supported an innovative approach to reviews and investigations, which aims to improve the learning of lessons in children’s, vulnerable adults’, domestic violence and mental health services.
Reviews in a New Service Landscape was a programme of three seminars which ran in June and July 2011. Run by Sequeli, a new not-for-profit company, in association with King’s College London and 1 Garden Court Family Law Chambers,it attracted participants from the largely separate worlds of serious case reviews (children and vulnerable adults), domestic homicide reviews and mental health investigations. Police officers sat alongside independent social workers, chairs, report writers, health service managers, andindividuals from children’s services and local authorities – fifty participants in all.
Sequelirealised that all reviews and investigations have at their heart the same purpose, problems and potentially, solutions. These seminars, the first of their kind, were based on Sequeli’s training curriculum Core Competencies.
From the opening of the programme by Professor Sir Ian Kennedy, an array of distinguished speakers and experienced participants reached out across boundaries.
Sir Ian spoke of the difficult and isolating task facing all chairs, welcoming the seminars as the start of a new journey, with Sequeli’s development of a network of support for those who undertake these tasks. Energising those who heard him, Sir Ian described the need for chairs to have confidence in bearing their responsibility, especially during this time of challenge for services. Leadership, clarity in one’s own mind as to purpose, sharing this with others, being thorough as to gathering facts, including follow-up in Terms of Reference; these he emphasised apply to all reviews, investigations and inquiries whether large or small. Cutting to the heart of reviews, Sir Ian urged the importance of being guided by humanity during this task where catharsis must be recognized as one of its proper functions.
Unravelling review principles
The first seminar Unravelling Reviews unpicked the context of reviews and investigations, where principles, values, the politics of reviews, victims’ experiences and the law, apply to all.
Beginning with the victim’s voice, Frank Mullane, brother of Julia Pemberton who was killed in a domestic homicide along with her son, spoke of his input into the new statutory domestic homicide review Multi-Agency Guidance. More than this, he has helped to write innovative leaflets produced by the Home Office to advise families. Most memorable was his description of the need for a ‘wide-angle lens’ in reviews, including victims’ and perpetrators’ families, friends and colleagues. Emotion, he said, should not be shied away from as it helped to embed learning. Families can helpfully keep an eye on progress with recommendations when they might otherwise be forgotten.
Amerdeep Somal, Independent Police Complaints Commissioner for the East Midlands, joined with Frank Mullane insupporting the case for involvement of victims’ families, but pointed out that the definition of victim is often very narrow, frequently being limited to close relatives. In reality those involved with the victim might include wider family, friends, colleagues and neighbours, any or all of whom could be victims themselves in the sense that they have experienced bereavement. Professionals and their families could also be traumatized by the events. The range of possible victims should be acknowledged and reviews and investigations should be open to hearing from many individuals who could shed light on the victim’s needs and circumstances.
Addressing the politics, Professor Jill Manthorpe of King’s College London looked back at the case of Maria Colwell and others which made headlines, reflecting on new insights taken from the 2011 book by Ian Butler and Mark Drakeford, Socal work on trial: the Colwell Inquiry and the State of Welfare(Policy Press). She, and later, Professor Roger Bullock of the Social Research Unit at Dartington, pointed out that the many ‘hidden inquiries’ require just as much rigour as those which are high profile. Similarly, the need to set out principles for reviews applies even where there are differing procedures, for example in Scotland, England and Wales. A tendency to seek evidence only from powerful professionals and experts in reviews should be resisted. As Professor Manthorpe put it ‘the more powerful the voice, the more likely they are to be asked to turn up whereas those with the most crucial information could be the cleaners’.
Making sure the legal context of reviews and investigations was covered, Aswini Weereratne, Barrister from Doughty Street Chambers, outlined the place of Article 2 of the European Convention of Human Rights which, when engaged because the State’s duty of care may have been breached, requires an effective investigation by the State. Depending on the circumstances, this is potentially applicable to any review.
Bringing together children’s serious case reviews and mental health investigations, Donna Forsyth from the National Patient Safety Agency and Dr Sheila Fish fromthe Social Care Institute for Excellence together presented a fascinating session on systems methodologies, showing the similarity between these approaches in mental health and children’s services. With an emphasis on understanding the context of professional decision-making rather than apportioning blame, all systems methodologies urge ‘don’t judge too quickly’. Their preventative style requires that ‘things be put into place to check the likelihood of recurrence’, ensuring that systems methodology can fit well with the need for written recommendations, whatever the type of review.
As a contrast to the systems approach, Barbara Stow, chair of statutory inquiries held under the Inquiries Act 2005 into deaths in custody, spoke of the value of statutory inquiries and Article 2 of the European Convention of Human Rights’ approaches to investigations. With their focus on fairness procedures, their flexibility and inclusion of evidence from a range of staff this was a common sense approach, not a rigid one, with much that could be drawn upon by other forms of review.
The good practice inquiry journey
Crammed with content, the second seminar, The Inquiry Journeyexamined the process of reviews and investigations from beginning to end.Good review practice was the theme.
Professor Jill Manthorpe spoke on vulnerable adults’ serious case reviews, Wendy Rose (currently working with the Welsh Assembly Government) on children’s serious case reviews, Detective Inspector Paul Gardner (Head of the Domestic Homicide Review Service in the Metropolitan Police) on domestic homicide reviews and Dr Androulla Johnstone (Chief Executive of the Health and Social Care Advisory Service)on mental health investigations.
Features in common were discussed throughout the day. In particular, how it was wondered, could reviews properly be conducted in the current economic climate and with limitations on public expenditure, when this was exactly the point at which services need to be reviewed following an untoward incident? Examples were given of single reviews conducted under parallel guidance, for example, under domestic homicide review and mental health investigation guidance. Can they be successfully combined to prevent unnecessary duplication? There was a lack of clarity over the management of reviews in this situation, yet there seemed to be many advantages to a combined approach. Given difficulties over funding and the frequent overlap between mental health, domestic violence, vulnerable adults and children (DI Paul Gardner cited a rough figure of 80% in domestic homicide cases), the view was frequently expressed that there would be increasing numbers of jointly managed or commissioned reviews.
Challenging questions were asked by Alison Ball QC of 1 Garden Court Family Law Chambers London. For example, how, when you prefer one set of evidence to another, say the explanation given by Dr A over that of Nurse B, do you make that decision? In legal terms, what is your ‘standard of proof? Do you reach your decision based on the balance of probabilities, that is, that one is more likely than the other? There is, of course, no legal basis for this in reviews and investigations, but it caused many to comment that they would think more analytically about the way they examine evidence. Where disputes over evidence exist it may sometimes be right not to reach a conclusion, but to set the evidence out for the reader of the report.
‘Splendidly provocative’ was one of the remarks following Dr Mark Salter’s presentation. As a community psychiatrist (and journalist and writer) in East London, he had been on the sharp end of an incisive mental health homicide investigation. Speaking about risk, predictability, probability and hindsight, using thought-provoking examples, participants were asked to think carefully about how they reached conclusions in this minefield and to treat professionals fairly when the consequences for them could be far-reaching.
James Blewett from King’s College London prompted debate on publication, with an extract from the first published children’s serious case review in Birmingham last year. Openness could be well-managed it was thought, if there were means to protect the interests of children devised on a case-by-case basis. However, the extract chosen by James Blewett quoted the Terms of Reference, a bland and formulaic recitation from ‘Working Together’. This it was felt should be much more detailed and specific if it was going to set out the purpose of individual reviews in a way which would lead to a readable and publicly accountable published report.
Returning to the theme of fairness to professionals and staff, but also including families and the perpetrator, Richard Lingham, former Director of Social Services and Chair of a Health Authority, spoke with authority from his long experience as chair and panel member of many mental health investigations. On the subject of being accompanied at a hearing, there was loud agreement to his question ‘If I was asked to appear before an investigation panel, I would not dream of going alone. Would you?’
What lies beyond publication? Gillian Downham, barrister, mental health tribunal judge and chair of mental health homicide investigations, touched on the subject of writing recommendations and their implementation, having published an article Learning Lessons: Using Inquiries for Change (Journal of Mental Health Law, Spring 2009) with Richard Lingham on the topic. Inspiration to create a methodology for implementation came after they had heard the following words from the son of a victim of homicide, two years after publication of the investigation report ‘How long does it usually take to implement a recommendation?’ Bringing together some of the good practice features from the day, she underlined the need to base every recommendation on facts and conclusions drawn fairly from the evidence. They should be honed to a state in which they are workable, enlisting the advice of the organisations concerned. Implementation should be evidence-based, with independent follow-up, ideally by the review chair or panel, with reports back to commissioners, public and victims’ families.
Specialist Modules
Having been introduced to the core knowledge and skills required for all reviews and investigations, the third seminar focused on some specialist topics.
Professor Jill Manthorpe and Paul Bedwell from Essex Safeguarding Adults Service gave absorbing presentations on vulnerable adults as the Cinderella area for reviews. In the wake of abuse recently revealed at the hospital unit Winterbourne View, it may be that this area will now emerge from the darkness in the way that child abuse did 20 years ago. Professor Manthorpe described the questions of capacity which sometimes governed the very decision whether to hold a serious case review at all. For example, should there be a review where an elderly person has died apparently from self-neglect? Might this not be an act of self will? The Mental Capacity Act 2005 has helped structure the approach to this situation.
DI Paul Gardner led a domestic homicide review discussion which dwelt on the need to differentiate between a high likelihood of moderate harm and a low likelihood of serious harm. The value of a lengthy chronology was debated. Whilst the recent emphasis is upon curtailing the scope in time of reviews, nothing predicts the future like the past. For this reason past history is cannot be ignored. Where ‘normalisation’ may be an issue, with case histories lost or forgotten and dangerousness under-assessed, there needs to be careful examination of risk assessments, past and present. Decisions as to the scope of reviews need to be carefully made case by case. Hannana Siddiqui, Joint Co-coordinator of Southall Black Sisters, challenged the view that failing to access services means there is no problem to be investigated. Women subject to honour-based violence typically do not report to services for fear of recrimination. Under these circumstances the question needs to be asked ‘how can services be improved to encourage reporting?’
Children’s serious case reviews, in the midst of change, were discussed by Peter Maddocks an independent consultant and Sean Haresnape of the Family Rights Group. In a thoughtful debate, the question was raised whether the language of serious case reviews is different to that of mental health investigations. Peter Maddocks spoke of ‘increasing the depth of learning’ from reviews, this being geared towards action learning for organisations and professionals on the receiving end of reviews. It contrasted with the evidence-based focus of mental health investigations where independent chairs seek objective accounts of events, aiming to construct from them sound recommendations leading to measurable implementation, with accountability to commissioners, public and victims being key. However, these descriptions were not incompatible. It was a question of whether you viewed a review from the inside or the outside. Sean Haresnape, from the Family Rights Group, provided from his own study a sad glimpse into the way that absent birth fathers are sidelined in many social work assessments even when they have regular contact with their children, the indications being that this also applies to serious case reviews, with such fathers rarely being invited to comment.
How fortunate participants were to hear from Dr Ben Thomas, who is the Director of Mental Health and Learning Disability Services at the Department of Health and the only remaining author there of the 2005 Guidance on independent mental health investigations. He was able to explain the way that the Guidance developed, and spoke of one unintended consequence. The requirement for an internal review was never intended to be the sole requirement for homicide investigations; there must always be an independent investigation where there has been six months’ contact with mental health services. However, increasingly there has been the hope expressed by some Strategic Health Authorities that, having put a great deal of work into the internal review and used an independent chair, that might be sufficient. This is not sufficient as it fails to take into account the need to hear from additional organisations. Moreover, families are rarely included at the internal review stage. Unnecessary expenditure and duplication of effort can be the result. Julian Hendy, maker of the film “Why Did you Kill My Dad?” showed extracts from his film, which has been shown on BBC2, discussing his experiences and urging sensitivity towards those who are likely still to be grieving following a homicide.
It was apposite that at the end of the seminars there was a return to the themes with which the programme began; the need for humanity, a wide-angle lens, fairness and meticulousness from preparation right up until the drafting and implementation of recommendations.
Feedback from the seminars included "Excellent depth and breadth of speakers - inspirational!" and “I would like to congratulate you on an excellent series of seminars. I found them very useful and they helped me to clarify my own thinking about future work possibilities". For more views from participants and information about the seminars, including the programme visit .
As a result of the positive comments and wish for more, including in-depth sessions and an interactive forum for online discussion, Sequeli has launched SequeliNetwork which will provide an online facility for discussion and access to training materials, including the presentations from these seminars; visit Sequeli will repeat this seminar programme, updated, in the Summer of 2012. It is also working with the University of Lancaster in order to run seminars in the North of England and with King’s College London to produce a series of Workshops for in-depth study of the many topics these seminars were, tantalisingly, only able to touch upon.
Gillian Downham, Wendy Rose, Professor Roger Bullock and Professor Jill Manthorpe
25 July 2011
1