Latent Error Analysis and Child-Care Chronicling Systems

Ince, Darrel (2010). Latent Error Analysis and Child-Care Chronicling Systems. Technical Report 2010/12; Department of Computing, The Open University.

DOI: https://doi.org/10.21954/ou.ro.000160a1

Abstract

Munro (Munro, 2005) and others have made the point that approaches to investigating child abuse deaths have concentrated on surfae issues where human error is regarded as the terminating point in an investigation. This article describes the use of an approach to accounts of serious abuse that is systemic. The approach is based on one that is used by Boeing, the aircraft manufacturer, to trace back problems to latent errors. The context here is in the development of a set of properties for a computer system that is used for chronicling the interactioni between a child and their family, relevant professionals and agencies. Boeing would normally use an aircraft incident report, accident report or an informal description of a set of incidents as their starting point. The research detailed here uses the report of the Victoria Climbie inquiry. The properties developed from this exercise are then compared with the specificaiton of the Integrated Children's System (ICS), a British chronicling system that has had major problems assocaited with it. It is posited that a systemic approach would have eliminated many of the problems with the ICS requirements specification. Although this article describes one system that is extant in two countries it is general in nature in that the principles hold for any chronicling system, for example those used in other branches of social work areas, and is not specific to England and Wales, the countries whose social workers employ computer systems associated with ICS.