10 October 2015


'Hear no evil, see no evil: Understanding failure to identify and report child sexual abuse in institutional contexts', a report [PDF] by Eileen Munro and Dr Sheila Fish for the Royal Commission into Institutional Responses to Child Sexual Abuse, comments
The failure to protect children from sexual abuse not only arouses shock and anger but also puzzlement: how could people who are employed to care for children fail to protect them when, with hindsight, the evidence of harm or danger seems all too obvious.
In the aviation and healthcare sectors, attributing failure simply to individual error is no longer seen as sufficient for encouraging safe practices in the future. Instead, attention has turned to seeking a deeper understanding of why errors occur. Failures are seen as consequences, not just causes. Solutions to failures are built on gaining a greater understanding of the factors that contributed to human error. Those factors lie in the nature of the activity being managed, the type of reasoning errors that people are prone to and the wider system in which workers operate.
Applying this approach to the two case studies available from the Royal Commission into Institutional Responses to Child Sexual Abuse when we began this study, it is possible to offer some speculative findings on individual and organisational factors that contributed to the failure to protect children in a timely and effective way.
The nature of the problem
The challenges posed by the problem of child sexual abuse are (1) that perpetrators seek to conceal their activities; (2) children and young people who are abused can be unable or slow to ask for help; and (3) many of the behavioural indicators of abuse and ‘grooming’ are ambiguous, requiring judgement or interpretation to decide if they are cause for concern. ‘Grooming’ involves actions by the perpetrator to increase their chances of abusing a child undetected.
Errors of human reasoning
Workers’ judgements are vulnerable to cognitive biases. The current understanding of human reasoning is such that when we seek to understand the actions or inaction of those involved in the organisations where an abuser was operating, we should not imagine these people as cold, logical processors of data. A more apt image is of living, feeling human beings whose understanding and actions arise from the 6 interplay of their reasoning capacities, both logical and intuitive, and their emotions as they respond to the world around them.
Research has found that it is hard to eradicate biases, and especially hard for a person to eradicate their own biases. The strategies that have had some success involve a person trying to consider alternative perspectives or explanations, and this is best achieved with the help of others. Organisations have a major part to play in creating the conditions in which errors of reasoning can be quickly picked up and corrected. They can do this by providing mechanisms for staff members to talk through their judgements and encouraging a culture of critical reflection.
Organisational factors
The case studies examined in this report explore many of the organisational factors that influence how well children are protected: the recruitment process, training in recognising and responding to indications of abuse, and formal policies about what people should do both to prevent and react to abuse. Our study highlighted less tangible but equally influential aspects of organisations that were also evident in the case studies, including:
Local rationality: People do what they think is right or sensible at a given time, and inquiries such as this need to find out what local rationalities may have influenced their actions.
Organisational culture: This is partly created by the explicit strategies and messages of senior managers but is also strongly influenced by covert messages that are transmitted throughout organisations, influencing individual behaviour. These can significantly affect the rigour with which policies and procedures are implemented.
Balancing risks: Policies and actions that protect children can also create dangers. Workers who are fearful of being wrongly suspected of abuse may keep their distance from children and not provide the nurturing, healthy relationships that children need to have with adults. Organisations have to reach some conclusion as to what level of concern should be reported. Making it compulsory to report even a low level of concern will identify more cases of abuse but at the cost of including numerous non ‐ abusive cases. Efforts therefore need to be made to create a culture that understands the ambiguity of the behaviour so that innocent people’s reputations are not tainted by false reports.
Drift into failure: Organisations face the problem of maintaining vigilance and avoiding a drift into failure. For any one worker, the chances of working with an abuser are low and so they may not be as vigilant as they would be if they had recurrent experiences of detecting abuse. Indeed, if they are asked to report low ‐ level concerns, they may experience so many false alarms that they become cynical about them. There is no quick fix to this problem. It requires that managers continually monitor and endorse protection policies to stress the importance of vigilance.
Organisations that achieve a very good safety level – known as High Reliability Organisations (Weick, 1987) – provide useful examples of what organisations can do to make themselves safer places for children. They share a fundamental belief that mistakes will happen and their goal is to spot them quickly. They encourage an open culture where people can discuss difficult judgements and report mistakes so that the organisation can learn. Organisations seeking to be safe places for children must encourage frequent, open and supportive supervision of staff to help counteract the difficulties people face in making sense of ambiguous information about colleagues. A shared acknowledgement of how difficult it can be to detect and respond effectively to abuse contributes to a culture that keeps the issue high on the agenda.
The authors state -
When people hear about cases of institutional child sexual abuse that were not exposed at the time they occurred, it’s difficult for them to fathom how others within the institution could have missed the signs or turned a blind eye to indications that a child was suffering harm. In his report on Case Study Two of the Royal Commission Professor Stephen Smallbone comments: ‘It seems surprising that Ms Barnat remained unaware of the long list of ambiguous and clearly concerning incidents’ (Smallbone, 2014b para.85). Following these types of cases, efforts to improve practice tend to assume that the major problem lies in human error. Typically, solutions then take the form of providing additional training, emphasising the importance of being vigilant and creating more detailed policies on what people should or should not do. These are, of course, part of the solution but the case studies prepared by the Royal Commission show that these policies have not, to date, been sufficient to protect children. One option may be to do more of the same – increase the training, procedures and monitoring. However, this report argues that we should learn from the impressive progress made in other sectors where safety is a key concern. Industries such as nuclear power and aviation may seem remote from child protection but they have in common that they involve human beings and they seek to prevent adverse outcomes that are of low probability but can have a high impact when they do happen, such as plane crashes and child abuse. Progress in those fields has been achieved by looking beyond human error to study how their organisational factors help or hinder them in producing high ‐ quality work.
Going beyond human error means analysing the skills needed for the tasks we want workers to do, considering the strengths and limitations of human beings in demonstrating those skills, and examining how organisational factors influence the level of skill achieved. Sometimes error is due to deliberate malpractice, but more often a series of weaknesses in the system produces the failure.
Our methodology involved analysing the two published case studies available when our work began – Case Study One and Case Study Two – and drawing on research into human errors of reasoning and on how organisational factors can contribute to human error. We are not duplicating the work of the hearings of the Royal Commission but using their findings to inform our analysis of the data from another theoretical approach to see whether drawing on lessons from other sectors can further illuminate systemic factors that contribute to failure in the care of children.
Nothing in this report should be read as disagreement with any of the findings of the Royal Commission but as offering additional understanding of why people acted as they did. The aim is not to exonerate workers from responsibility for their actions, or lack of action, but to seek a deeper understanding of how inaction or ineffective action occurs, with a view to formulating strategies to improve practices in sectors contributing to the care of children.
This report starts by detailing the methods we used, then discusses the challenges of suspecting, identifying and responding to grooming and abusive behaviour. Next, we summarise how and why other sectors instigated change in analysing human errors, and give a brief introduction to a system’s approach to understanding behaviour. This provides the theoretical framing of the subsequent sections. We begin by presenting a selective review of research into the strengths and limitations of human reasoning, relevant to detecting and preventing child sexual abuse in institutions and with illustrations of weaknesses that can be detected in the case studies. This leads to consideration of selective research into how organisations can create an environment suitable for preventing and detecting child sexual abuse, allowing for known human cognitive tendencies. Again, illustrations are provided from the case studies.
The concluding chapter summarises the key messages.
In that chapter they state
... We all share the ambition of creating ‘safe organisations’, where children are protected from harm while being able to enjoy the service provided. The case studies are examples of failure but the analyses of how the abuse was not prevented or identified reveals the challenges inherent in these tasks.
This study has identified a number of challenges to creating and maintaining a safe organisation in which staff members are quick to suspect grooming or abusive behaviour and can trigger a process that investigates the concerns and takes appropriate action so that children are protected from harm.
The first difficulty lies in the nature of the problem itself – especially with regard to the ambiguity of much abusive and grooming behaviour – where behaviours that should trigger concern cannot simply be listed. Policies can certainly help to explain the type of behaviour to look out for but the use of words like ‘appropriate’ and ‘inappropriate’ indicate the need to make judgements about the meaning of what is being observed.
Such judgements are fallible. The section of this report on errors of reasoning detailed how people’s reasoning processes can lead to errors so that they fail to interpret what they see as suspicious behaviour. Research shows that it is hard to police one’s own intuitive reasoning and most strategies to reduce bias involve other people helping you to critically review your explanation and consider alternative explanations.
The need for help in reaching more accurate judgements and detecting abusive or grooming behaviour more quickly brings in the central role that organisational systems play in creating a safe place for children. Opportunities to reflect on one’s reasoning are valuable if conducted in a supportive, non ‐ blaming atmosphere. For this reason, all staff, including the senior people to whom others report their concerns, would benefit from supervision to ward against common errors of human reasoning. ...
Our analysis of how organisational factors have influenced individuals’ behaviour showed that these should, in part, be explained by features of the work environment, some aspects of which may help to produce the right behaviour and other aspects of which may encourage the wrong behaviour. While individuals must hold some responsibility for their actions, the case studies show how many organisational factors contributed to what, in hindsight, was poor practice in protecting children. Good training and policies are necessary elements but their contribution to safety requires that they be implemented accurately. They need to be seen as important in the organisational culture, with senior managers demonstrating this by monitoring whetherthat people understand and use them. Failure to do this is evident in Case Study Two.
Organisations also influence the level of concern that will cause a worker to report suspicions. In this, they are not faced with a simple choice between ‘safe’ and ‘dangerous’, but a requirement to balance risks. Efforts to ensure the safety of children can have negative as well as positive effects. For example, a threshold that is low for reporting concerns may lead to many false alarms, potentially harming the reputations of innocent people and deterring people from working with children. A high threshold for reporting will mean that workers miss or will be slow to detect some instances of abuse.
The wider society also influences organisational and individual behaviour. The Royal Commission will itself have a strong influence on future behaviour, demonstrating how society considers child sexual abuse as a very serious matter. The Royal Commission’s existence will alter the equation in terms of calculating reputational risk. In Case Study One, the desire to protect the organisation’s reputation was deemed to lead to a failure to act effectively in stopping abuse. The reputational risk in being found to have concealed instances of abuse is now much higher and should make cover ‐ ups less appealing.
The current social concern about institutional sexual abuse is beneficial in many respects but it does carry the danger of creating an atmosphere of public vilification for past mistakes that leads to defensive practices in organisations. For instance, organisations may retreat to the safety of fixed rules governing behaviour, such as banning all physical contact between an adult and a child, thereby removing any need for individual judgement. This protects adults from false accusations of grooming or abuse but at the cost of depriving children of appropriate and nurturing human contact. Even if the policies themselves avoid na├»ve rules, workers may interpret principles as rules because they are scared of getting into trouble if their judgements turn out to be wrong. To counter this, a ‘fair’ culture is needed where workers are confident that they will receive a just hearing and only be punished if they acted carelessly or with malice.
Organisations that achieve a very good safety level – known as High Reliability Organisations (Weick, 1987) – provide useful examples of what organisations can do to make themselves safer places for children. They share a fundamental belief that mistakes will happen and their goal is to spot them quickly. They encourage an open culture where people can discuss difficult judgements and report mistakes so that the organisation can learn from them.
Safety can also be improved by organisations recognising the central importance of the frequent, open and supportive supervision of staff members, to help them maintain vigilance and to counteract the difficulties people face in making sense of ambiguous information about colleagues. A shared acknowledgement of how difficult it can be to detect and respond effectively to abuse contributes to a culture that keeps the issue high on the agenda.
The Royal Commission case studies analysed in this report identify the failure of people to see or act effectively upon suspicions of grooming and abuse in institutional  settings and, with hindsight, these failures seem incredible. In this study, we set out to find out whether applying a different lens could help to better explain such failures. We have illustrated how applying current understanding of human reasoning and a systems approach to error investigation can help make people’s decisions and actions more understandable. There are common ways in which people fail to accurately interpret the world around them and common organisational factors that contribute to the failure of people to see or act upon suspicions of grooming and abuse. These provide additional insights into failures to protect children from sexual abuse in institutions. Providing better explanations of why people acted as they did in error, holds promise for providing the kind of support that will help people to better protect children in the future. Crucially, a safe organisation requires the combination of several factors that will jointly contribute to facilitating and encouraging the protective behaviour that is needed.