Working with other professionals

Child protection work takes place in inter professional contexts and it has increasingly been shown that failures of communication and cooperation between professionals lie at the heart of many tragedies (Manthorpe & Stanley, 2004; Corby et al., 2012) . Indeed, hardly a review or inquiry into a child death concludes without pinpointing failures in professional communication. There is something of a “solid” and “liquid” (Ferguson, 2004) dichotomy here too: on the one hand the official view is that inter professional communication is an unalloyed good thing and usually works well and a much more mixed perspective from researchers and practitioners. An overview of this research has been presented in chapter 3.

Government policy - as in the Working Together to Safeguard Children guidelines (Dept for Education, 2013) - and legislation (the 2004 Children Act) define child protection as an inter professional project and these participants worked alongside other professionals as a matter of course. While I did not ask any questions specifically about this topic it emerged as a theme in 75% of the interviews.

In my observations of duty sessions I observed workers almost as a matter of course referring cases involving teenage children to their schools for advice and intervention. On some occasions workers argued that as schools were universal services their input would be less stigmatising than that of social workers. The social workers’ awareness of the unpopular nature of their work and the frequent lack of an optimal solution to problems seemed to lie behind this but I also observed quite complex cases being referred to schools which made me wonder how appropriate these referrals were. In other situations health visitors and midwives were asked to monitor situations. So the social workers seemed to use referrals to other professionals as part of gatekeeping. How satisfied they were with these professionals

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seemed to some degree to depend on their willingness to take on these cases. Some schools for example were seen as willing to take cases on and not to panic about them others were less willing and quick to refer cases back.

The child protection referral I observed being dealt with began with a referral from a Health Visitor who had visited a parent who pointed out a bruise on her child who had just returned from contact with his father. While the incident was being treated seriously the workers spoke of the Health Visitor with respect as an experienced colleague but an inconclusive medical and the discovery that the allegation from the mother seemed to be part of a custody dispute changed this. When the social worker returned from visiting the family I noted this conversation:

Social Worker: I couldn’t see much of a bruise. I had to take him into the light to see it. Manager: Sometimes it’s (the Health Visitor’s) vivid imagination. She gets carried away (observation field note).

The Health Visitor’s expertise was now openly questioned. Throughout my study participants were careful not to blame colleagues in the team for mistakes or suggest they lacked competence although it was clear that errors and mistakes did get made: Pithouse’s (1998) theory of an “assumption of collegial competence” (p.55) has been discussed earlier. Other professionals, outsiders to the team, do not have this assumption extended to them.

In this same case it was necessary to have the (alleged) bruise seen by medical experts who could determine whether or not the injury was non-accidental. The workers expected this would be inconclusive, that doctors would be reluctant to state the nature and time of the bruising and in this they were correct. The child protection medical is an essential part of many investigations yet when medicals were discussed by participants it was usually to say how inconclusive they were even in cases of serious injury. In one case a child was hospitalised with retinal haemorrhages and sub-dural haematomae – life threatening injuries strongly suggestive of non-accidental injury by violent shaking but in this case the child had been born with severe disabilities.

So, the difficulty was that medical professionals were saying ‘we don’t know how these are being caused, one potential explanation is non-accidental injury’ and then as time went on they started putting forward these hypothetical situations that could have caused them but at the same time they’d never seen them before (SW1).

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In the end no conclusions were drawn and it was never certain how the injuries had occurred. A similar case involved a child taken to hospital with a skull fracture. The family said they thought the child’s sibling had thrown a toy at him and the police decided there was no action for them to take. Again a medical did not provide a conclusive answer:

and the radiologist....felt that he couldn’t rule out that the toy may have caused this injury - it’s extremely unlikely, he’d not experienced it in his professional background but couldn’t entirely rule it out.(TM2)

Again there is a sense here that medical examinations are often not conclusive but part of a complex unfolding story and just as ambiguous as other elements of that story might be. The doctors were often very reluctant to commit themselves and for the social workers there was a sense of a group of professionals who were clearly highly respected in the courts and whose opinions were vital for decision making on cases – the social workers depended on them heavily – but who often turned out to be less than reliable colleagues.

In another case a small child was medically examined to see if he had been sexually abused by a relative with whom he had spent a weekend. The social worker, with some misgivings, as she knew how distressing the experience would be, persuaded the family to give permission for the examination:

and it’s very distressing listening to a little child really screaming and sobbing and you know really, really distressing...and I don’t know how much of that is the examination itself or just the fact that he’s in a strange place with strange people and his mum and his grandma were there but I’m sure it’s still very disturbing for a small child to be in that environment....So we did that, and obviously grandmother and mother were very distressed as well...and I think C (the other social worker) and myself were quite distressed as well...um, so, once that had concluded they...the doctors sat down, sat them down, and said actually I can’t see anything to suggest he’s been abused. Everything looks pretty normal. (SSW2)

Here at least the medical exam has had a positive outcome in putting the family’s minds at rest but it was an unpleasant experience.

In this case suspicions had been aroused because the relative was acquainted with a known local paedophile who was the subject of a major police investigation. The police had given the social worker some information which she was told not to pass on to the family and she clearly felt constrained by the police and had some anxiety that she might say the wrong thing and compromise their investigation. While the social worker felt that getting the child

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examined was worthwhile she was influenced by the police need for possible forensic evidence.

So, we were really debating whether or not we needed to have D medicalled to see whether he had been sexually abused and obviously that’s quite a difficult decision because it’s an invasive procedure in itself and very distressing for the child also....he was so little anyway that he wasn’t going to be able to substantiate anything verbally, he’s only got a few words and...so we ummed and aahed and I said well I’ll discuss it further in the morning when we’ll see where we go, so then I had discussions with the consultant paediatrician, Dr P, and obviously gave him the scenario, the background, the information we’d got (SSW2)

The decision was only reached after consulting the police and medical staff but the possibility that some forensic evidence might be found was clearly a factor in the decision.

In another case a child suffered serious injuries and the police begin an investigation. The social worker felt that this investigation powerfully shaped her work – she said she felt led by the police, constrained by what information she could and could not give to the family and constrained as to what decisions she could make.

....I really felt that we were being restrained by what the police were doing and it drifted because of that (SW3)

The child died and the police were now investigating a possible murder. Because of the high profile of the case senior management became involved and took over some of the decision making about the future of the dead child’s sibling. She did not agree with all of the decisions made because she felt that focused on the short term rather than the longer term needs of the child.

Everything I believe we did properly but we could have done things better. (SW3)

The social worker felt that the serious nature of the police investigation and the involvement of senior managers profoundly affected decision making. While the decisions made were “proper” they could have been better geared to the long term needs of the dead baby’s brother.

In another case where a child had died and senior managers became involved the social worker assessing the family made a decision about the parents’ contact with their children which was countermanded by senior management and she drew a distinction between a “safe” and an optimal decision:

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I made the right decision. Service level made the safest decision, I think...is the best way of putting it...but mine was right (laughs)...(SSW2)

Police actions in another case of an injured child were quite different. In this instance parents took their child to hospital having noticed some swelling in his head and a fracture was diagnosed. The family seemed respectable and the police quickly decided to take no action. The worker felt there was

....some collusion between the police and the family ....the police officer had done some informal interviews, literally 10 minute chats, with people and decided that, you know...shrugged his shoulders basically. We don’t know what’s happened to this baby but, you know, these people seem to be alright kind of thing.(TM2)

The family were then extremely aggrieved that the social workers continued to assess the situation. The social workers involved found themselves trying to steer a middle course between police inaction and a team of colleagues who wanted to immediately remove the child under a Care Order:

. we’d got three different perspectives: the police were quite clearly saying, which shocked me rigid really, but this didn’t meet their threshold to investigate so therefore we’re not going to interview the parents or anybody. The (longer term child care) team were saying this is a really serious injury to a very small child and we need to start Care proceedings and maybe ask a Court to make a Finding of Fact and there was (SSW1) and myself saying we need to do an assessment....(TM2)

The “Working Together” procedures (Dept for Education, 2013) require a range of interprofessional meetings and case conferences to take place at which important decisions are made about safeguarding children. Such meetings can be productive but can also cause major disagreements in which professional differences come to the fore . One worker faced strong disagreement at a Case Conference from other professionals regarding a plan she was suggesting to protect a child. To some degree her past experience had led her to half expect this:

Quite often what happens at conferences is that it’s like us against everyone else including the professionals (SW7)

In this case she was annoyed because she felt some professional colleagues had agreed with her prior to the Conference but were now disputing her plan and this continued into subsequent meetings:

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and so at the core group the family and also the midwife and the Children’s Centre worker they all kind of ganged up on me...(SW7)

However despite such disagreements it was necessary to try to maintain harmonious relationships albeit with some difficulty

because you’ve got to sustain some sort of, maintain a relationship with them because of course the following week you could be working with them on a different case, so yeah that was particularly difficult...(SW7)

There is evidence that such meetings can be prone to a range of group dynamics such as groupthink which can compound some of the errors and biases to which decision making is prone (Munro 2008).

It seems clear that decision making by social workers must be seen in the context of inter professional collaborations which can be prone to problems of poor communication and information sharing in which “atrocity stories” (Dingwall 1977; White & Featherstone, 2005) about other professionals (such as some of the accounts cited above) can thrive. The social workers in my study worked closely alongside health visitors, nurses, doctors, schools, the police and other professions and at times their work and the decisions they made were enmeshed in those inter professional relationships.

7.4.1 Summary

Inter professional working is an inescapable aspect of child protection work. Official guidance demands it take place according to certain procedures and it is a common feature of daily practice. Social workers routinely worked alongside doctors and other health professionals, health visitors, schools and the police and these collaborations significantly shaped the way they practised. While the social workers depended on the expertise of these professionals inter professional relationships were not always experienced as helpful or useful. One example of this was the carrying out of medicals where children had been abused. These medicals are a crucial element of many child protection investigations yet they are often inconclusive and fail to provide definitive answers. Another was the way social work decisions were affected by the need to cooperate with police inquiries.

In a number of serious cases senior managers who would not normally become involved in such work intervened and made key decisions that the social workers felt were not necessarily in the best interests of the children and families.

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Decisions in the cases discussed in this chapter were rarely taken by social workers acting alone. But in both daily practice and in the more official meetings where child protection cases were processed decision making could become a contested matter with inter professional differences coming to the fore.

7.5 Conclusion

In this chapter three themes have been identified as characterising the social workers’ daily work with families: home visiting, undertaking assessments and working with other professionals. All three suggest a practice world of considerable complexity, very different from more straightforward technical and legalistic accounts. Information and knowledge required for decision making is almost invariably contested, complex, emotionally and cognitively demanding and is usually contingent upon and constructed within the contexts of daily practice rather than appearing as “fact”.

But social workers have to make vital decisions, sometimes very quickly, about protecting children and these accounts of practice often try to strike a balance between “traditional” social work values and more forensic, investigatory approaches. There is a tension between what Platt (2006a; 2006b) describes as an “events-focused....incident driven culture” (2006a, p. 275) which has quite a narrow focus on risk factors and a more wide ranging engagement with and assessment of families’ practices and interpersonal dynamics. Holland (1999; 2004) suggests that there are two discourses of decision making in social work assessment – a “scientific” approach that emphasises gathering facts and listing risk factors and a more “reflective” model that emphasises an in-depth assessment. The suggestion is that workers follow one or the other model but the participants here seemed often to be trying to follow both, reflecting the complexity of their relationships with family members: a complexity that involves elements of caring and controlling and where many family members are, at different times, seen in different ways: as parent, teenager, victim, perpetrator or abuser and as self- actualising adult.

The encounters, visits and other activities that make up the participant accounts in this chapter exemplify Ferguson’s (2004) concept of the liquid and Pithouse’s (1998) of invisibility: much information gathering and decision making took place in fleeting, transient moments, in private, intimate places, rendering crucial elements of practice difficult to see and to analyse. This practice world was characterised by complex, uncertain and dynamic situations that required complex sense-making. The cases discussed here had a number of key features that

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made gathering undisputed information about them difficult because of complex family relationships, problematic and contested situations where levels of risk could be hard to ascertain, disagreements between professionals and a lack of clearly articulated professional knowledge about the diversity of family practices in a post-modern society.

Such a world may be best suited to intuitive reasoning based on experience and practice wisdom (Hammond, 1996; Hackett & Taylor, forthcoming). Some social workers talked about assessments as “building a picture” or creating a kaleidoscope and this may suggest they were creating mental representations as suggested by naturalistic models of decision making such as Klein’s Recognition Primed model (Klein, 1993) and Brunswik’s judgement analysis (Hammond, 1993; Thompson & Dowding, 2009) where experience and professional cultures create a “lens” through which situations are judged. In such models creating a coherent picture or narrative is important in making sense of complexity. As has been argued, intuitive and naturalistic models have considerable strengths and may be best suited to the realities of daily practice but they are not infallible and are open to a variety of errors .Models of analytical decision making which consider factors sequentially may be important in uncovering and correcting these biases. However there was little evidence that in daily practice the social workers were incorporating the tools of analytical decision making such as risk assessment or Structured Decision Making schedules in their assessments or making explicit use of research- and theory-based evidence.

Formal management practices such as supervision are, it is often suggested, the best place to employ more analytical reasoning. These are also the practices within which social workers account for – or as Pihouse (1998) puts it – render visible – their actions. This area of practice is the subject of the next chapter.

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