Murder - by the cultural acceptance of systematic logical departmentalisation

Over the last Decade, Victoria Climbie, Baby P (Peter Connolly) & now Daniel Pelka, have all been physically and psychologically abused and tortured to death by their parents and guardians. It makes for horrific reading and anyone who hears the account on the news would be hard pressed not to have a tear or two in sympathy for a young life ended in such heinous conditions, God knows what fear they must have experienced on a daily basis.

We hear of Daniel's abuse and look at the health professionals, social workers, teachers and police involved, wondering how a 4 year old boy can be starved and beaten to death without anyone realising what was happening and stepping in to stop his living hell. I'm sure the people involved are all asking themselves the same questions, as the old saying goes, few people go to work each day to do a bad job ... so what went wrong?

After Victoria and baby P, the resounding message back was, "Each department had their concerns, but there was no-one there to join the dots." The promises to 'improve process' came and went. Change may have occurred in policy and procedure after Victoria died in 2000, but Baby P still died in the Haringey council area in 2007.

Now Daniel has been failed by a similar system and the one strong message we hear so far is "Each department had their concerns but there was no-one there to join the dots."

The real issue behind these terrible outcomes is departmentalisation, specialisation and certification. I'm sure the investigations surrounding these tragic events found those who needed training had received it, that all the procedure and process had been followed, that the right specialists were employed by the right departments in the right organisation ... but he is still dead.

The capacity to communicate, to make sense of data, to 'join the dots', to infer and interpret meaning from statistics and outputs, to consider the findings of visits, meetings & investigations is a very human thing. I could bang on about HTM (Hierarchical Temporal Memory) and the algorithms in the brain identified by Dileep George at Numenta, but I think in this instance we can work with the summary - 'PEOPLE' make sense of the world they experience in ways that departmentalised, specialist, regulated, logical process and procedure cannot and does not!

In industry, this lack of 'common sense', i.e. the problem of poor communications across departments full of specialists and experts in their field has been addressed in some cases with 'Value Stream managers', or 'Chief Engineers', fully responsible for the P&L for the entire process for a particular product. This allows one person, who has worked their way up through the organisation, with the tacit and intuitive knowledge and understanding that only comes from 'Doing the job', to assess 'what is right and wrong', 'what works and doesn't work'. These are the people who understand all of the interconnectivity of an ERP system, who can sanity check the actions of  those pushing buttons in isolated silo's, who can't see the big picture due to their work design, who fail to join the dots, while forced to follow strict policy and procedure to meet regulation and quality control criteria.

We are obsessed with the narrow and deep capability of the specialist, our education system rewards people for specialising, for focusing on one subject. We've forgotten the value of a holistic view that only comes from broad experience of many subjects. We've become certified through a classroom, rather than educated through experience (thinking of apprenticeships).

It occurs to me, that unless a similar role is created, which provides a qualified person (through experience as much as certification) the capacity to 'understand' the findings of the health service, the social services, the education environment and the police involvement in such cases will not improve & we will unfortunately see this kind of child abuse repeated. I suspect the role of 'child protection' in society requires some significant restructuring with recognition for the value that comes from an holistic capacity to 'join the dots'.

Without wishing to deegrate the level of seriousness or suggest the control of a P&L account or a balance sheet is anything like the protection of a life, I will suggest, at a process and 'human interaction' level, that if we can establish the equivalent of a Value Stream Managers role, who intuitively knows how to work across organisations, who can 'See the signs', we might not only pick up the worst of these crimes before it's too late, but we might also start to connect the dots and stop the abuse of those children who are abused throughout their childhoods into adulthood, ..... those who do not end up another reported death.

A final point to note - many years ago, when I was still a boy, I unfortunately and unconsciously saw this kind of hidden abuse 1st hand. I didn't realise what was going on behind closed doors and nor did anyone else exposed to the family, until the social workers highlighted some of the incidents of course, then all the strange behaviours made sense .... we all have 20/20 hindsight.

In that case the system worked, the two children concerned were removed from the abusing adult and the family home where other children were treated normally by the same parent. The one thing that rings out loud for me when thinking back on this experience, is that the behaviours of the child who suffered the worst abuse included stealing, sneaking and gorging food at every opportunity, not too dissimilar to the actions witnessed by poor Daniel Pelka. In the case i'm aware of, before the child was removed, every adult around me discussed the 'bad behaviour' of the child, "he's so greedy" they would say ...... they, at the cost of the child, never imagined what was really happening.

Accepting there may be other medical or psychological reasons children steal and gorge food, we can't afford to assume abuse is always behind such behaviours. Equally, we can't assume it's not. This has to be highlighted as a strong warning sign to anyone and everyone involved with the protection of vulnerable children.... perhaps the equivalent of a VSM would have this kind of knowledge and connect the dots ... with a holistic role created, maybe the next poor child in these circumstances can be saved.

If we continue to rely so heavily on process and procedure within organisational and departmental silo's which fail to communicate and generate meaning from their actions, the reality is, Daniel Pelka will not be the last child who's death we hear about in the news.

Then of course we have to question the mentality of the Mother / abuser .... and get to root cause of that, which is a much bigger issue.