Fatal failures to change? The case of Haringey social care

Victoria Climbié (1991–2000) and Peter Connelly (2006–2007) were both well known to the medical, legal and social care agencies in London’s Borough of Haringey. Despite this, in each case these agencies ignored evidence and failed to intervene to stop the sustained physical abuse the carers of these young children had inflicted upon them. After Victoria's death, a public inquiry chaired by Lord Laming led to the establishment of a new framework for the protection of children which was incorporated into the Children Act, 2004. Despite this statute and policy change, the circumstances of Peter’s death in 2007 revealed a similar pattern of multi-agency confusion and inaction to that which had hindered the protection of Victoria (HLSCB, 2009). Laming noted that child protection agencies had failed to implement the recommendations that he considered little more than good practice (Laming, 2008). While change was evident in structures and policies adopted, practical effects were inadequate. Practices, such as strategic leadership, critical reflection on evidence, coherent professional interactions and the integration of systems, remained problematic. This case highlights the real problems of translating policy learning into practical outcomes. Difficulties in enacting change were exacerbated by institutional boundaries within a multi-agency environment. Responsibility, without the authority to compel other agencies to engage with the change process, left those charged with accountability exposed to censure should the system fail again. The search for 'culprits', within this case, obscured the systemic issues that made inter-organizational learning and change extremely challenging. Policy learning has to address the practical challenge of implementing recommendations within a complex context.