A National Traffic Lights System To Report NHS And Other Concerns Would Ensure Accountability
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UK news a few days ago of the paediatric nurse Lucy Letby ‘Guilty’ verdicts – confirming that she did indeed murder several tiny babies (and tried to kill even more) – has left most of us numb, almost unable to comprehend what happened. But behind these verdicts lie questions about why it took so long to stop the horror; and what can be done to prevent such awful crimes in the future? One possible way forward would be a national ‘traffic lights’ system to record all child or vulnerable adult abuse concerns and the official responses to them.
Wider contexts: the ‘whistleblower’ moral panic
The twenty-tens in the UK saw much confusion and media-led moral panic about the reporting of suspected child abuse. To quote one sociological source ‘…reporting on threats that become moral panics increases viewership and makes money for news organizations….’. It was inevitable that these dire ‘cases’ would become big news.
Examples of media amplified concerns around child abuse in the early second decade of the new millennium, include variously Rolf Harris, Jimmy Savile (both found guilty of child abuse) or, conversely, Carl Beech (guilty, it transpired, of false abuse allegations against leading politicians). In the first two examples, what should have been seen as serious abuse of children was eclipsed by the media-created persona of the offenders; in the third example, the then-MP, now Lord, Tom Watson was criticized forcefully (he later apologised) for insisting that Beech’s claims should be extensively investigated, when in fact the offensive behaviour was Beech’s dishonest allegations about senior public figures.
But regardless of how he did so, Watson is correct that ‘The choice facing anyone who is presented with testimony of this kind is whether to pass it on to the authorities and urge them to investigate or to ignore it… I chose the first option. I felt it was my duty to do so.’ He added that initially he contacted the Director of Public Prosecutions in 2014 because he believed that the allegations made against Leon Brittan and others (whom Carl Beech had accused of abuse) ‘should be fully investigated.’
2023
In my time I have been an NHS Board NED (non-executive director), a partner in the then-HPC (Health Professions Council), a teacher, a social worker and a decades-long campaigner to eradicate FGM and other violence against women and children. I have some idea about how difficult these matters can be.
Nonetheless, possible lack at the time of communication or responsibility in the Lucy Letby case remains a very serious error; but the dramatic nationally reported media setting, almost a decade ago when questions about her behaviour first arose, might explain why some of the hospital management were reluctant to follow through on the concerns about Letby which several whistleblowing doctors had shared?
The vital message, ‘always give some credence to concerns about child (or adult) abuse or harm’ was perhaps lost in the media storms about these and other cases which made national headlines.
This was potential media attention few organisations would have welcomed and some, probably including the Countess of Chester Hospital, fearing for their ‘reputation’, sought actively to avoid.
A national ‘traffic lights’ system
None of this excuses any failure to report very serious matters immediately to the Police, but if a mandatory national ‘traffic lights’ system – indicating the gravity or otherwise of any reports – had been in place, clinicians concerned in the awful Letby case would also have been required to record their concerns via this system, and the breadth and massive significance of these concerns might have been registered much earlier. There could be no recriminations, because there was a legal duty to report.
I first proposed such a system in regard to suspected female genital mutilation (FGM) some years ago, but since then it has become apparent that there are also many other situations in which a child or vulnerable adult may be thought to be in need of protection. There must be one single reporting route, shared by all the services which require it.
And that route must be on at least a regional, if not – ideally – a national, level. Vulnerable children and adults do not stay tidily in one place, attended by only a single set of clinicians or other professionals.
The evidence for such a system is clear. The ‘cases’ (tragedies) of children such as Baby Peter, Victoria Climbié, Kristy Bamu, some students at Caldicott and Chetham’s Schools and Mirfield Junior Seminary, other reports of church-related child abuse, the grooming and sexual abuses in Oldham, Oxford and elsewhere, the so-called ‘honour’ killing of Shafilea Ahmed and other instances of abuse of minors all demonstrate that procedures for preventing intentional child harm of any kind must be considered together and fundamentally improved in the UK. (I list all these children here because we must never forget how many have been harmed by failures of safeguarding.)
There are currently huge discrepancies between different UK agencies and locations in how quickly and easily concerns around suspected child abuse or harm can be registered. There is now better (but certainly not perfect) legislation around reporting FGM, but many uncertainties remain about who, if anyone, must report concerns to whom about various other suspected abuses.
A national system (securely IT based and mandatory for all professionals in any discipline who suspect harm) would remove reluctance to report possible abuse, and would protect those reporting from accusations of wilfully rocking the boat. It would be their legal duty to report. Yes, there are significant legal, cost, time and training implications in this proposal, but then so there are – even pain and distress apart – in leaving a situation whereby children and vulnerable adults are at avoidable risk.
Who are the ‘at risk’ children and vulnerable adults?
We know that children such as those mentioned above are at significant risk – they are the ones missed by schools, clinics and social services often because they are at the margins. This vulnerable segment of our communities is probably larger now than before Covid led to school closures and mass isolation, but little of significant impact seems to be in place to address the particular risks these children now encounter.
Similar concerns may apply to the vulnerabilities of some adults of any age. Children do not all become rounded adults on their eighteenth birthday; for some their vulnerability may increase in those early ‘adult’ years. And some adults need care throughout their lives. We know for certain too, that older adults may be extremely vulnerable as inevitably their capabilities diminish.
Importantly, it’s also necessary to acknowledge that the risks and vulnerabilities facing some people at any stage of life are not simply those reported in the media, critical as these may be. News stories of neglect and cruelty are tragically commonplace, but there are other forms of risk and harm which are less often reported.
How does one report a concern about a medical or care procedure? There is a voluntary ‘Yellow Card‘ system for suspected negative impacts of pharmaceutical and some other products, but even that, whilst uptake has increased, is not well-known. And the mode of reporting for errors or harm in clinical or care practice is at best for most of us vague. How does one share concerns around poor treatment or, even worse, suspected negligence or intended harm?
What if a clinician, teacher or other person in a regulated profession, or an organisation manager, fails to report concerns, or it is actually thought somebody may be causing intentional harm?
Who must report concerns?
Even in 2023 a government consultation continues in England about who should be obliged to report, for instance, child abuse.
People in positions of responsibility may be reluctant to share concerns because they fear they could be mistaken, or they think it will be damaging for their organisation or themselves, or they have loyalties of some sort with the person they think may be causing harm (whether that harm is intentional or not). Other obstacles to reporting might be that the potential reporter doesn’t want to upset anyone associated or attached to the possible victim, or another worker has told them not to.
None of these is actually a ‘good’ excuse, but while confusion remains in some instances about when reporting is mandatory (legally required) or not, it is unsurprising that valid concerns are sometimes not shared.
And added to that, there may be a fear of the sort of national media moral panic referred to above which clouded judgements in so many ways during the last decade.
Putting concerns on the record
A national system for reporting concerns, whether about neglect or vulnerability or harm of any sort, would encompass all regulated professional activity, and should also be available for other members of the public if they have concerns. Perhaps neighbours have seen a child or elderly person whom they suspect has been maltreated?
Perhaps a family member (even parent) wants to question the professional treatment of a vulnerable child or adult – an issue around ‘Gillick competence / consent’ now coming to the fore in regard, eg, to the treatment of children and young people who don’t want their parents to know they are seeking ‘transition’ to the opposite gender (biological sex itself is determined at conception and cannot be changed; but physical appearance and gender can be more fluid). Some of these children may also have other psycho-social vulnerabilities which some parents, and doctors, believe attending clinicians must accommodate, but perhaps are not, in any treatment.
There has to be a way that worries about what’s happening to family members and others about whom people have legitimate concerns can be put on securely on the record.
In some instances a single concern might be seen as fairly insignificant or unimportant, a mildly ‘amber’ alert, or still ‘green’. In other examples multiple reports of whatever severity (either about a particular child, or about the conduct of a particular professional) , or indeed single reports of severe risk or harm, will at some point be understood to be a vital matter – ‘red’.
In all cases the initial report would be followed by a record of the response by those who take the safeguarding decisions, based on the evidence to hand at the time. Sometimes that would be ‘wait and see’, sometimes it would be more investigation, and sometimes it would be urgent action.
Placing responsibility where it lies
The traffic lights system would also record all official responses to reports of suspected harm. There would be nowhere for reluctant managements to hide; it would all be on the record. With this system deep concerns such as those around Letby might have been addressed when the alarm was first raised. (Indeed, concerns might also have been recorded in her previous employment – now under serious scrutiny – if there had been a ‘safe place’ to lodge them?)
This is absolutely not about conducting a ‘witch hunt’. Bringing concerns across the board together cogently, and recording responses to them, enables management and other senior staff (in whatever institution/s, collaborately or alone) to demonstrate that they have made decisions appropriate to the level of harm which seems to be indicated.
Investment in a national mandatory reporting system is urgently required so that serious concerns around harm (of any sort) to children and vulnerable adults can be raised without recriminations, and timely responses secured and recorded responsibly. This would result in better, more coherent, care; fewer children might slip between the cracks. (It might even save money in the longer term?)
Recent events show yet again that current protocols are nowhere near good enough to protect either the most vulnerable (of any age) or, indeed, their clinicians and others who have a duty of care for them.
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Read more about Traffic light / Mandatory Reporting.
Your Comments on this topic are welcome.
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Books by Hilary Burrage on female genital mutilation
https://orcid.org/0000-0002-6684-2740
Hilary has published widely and has contributed two chapters to Routledge International Handbooks:
Female Genital Mutilation and Genital Surgeries: Chapter 33,
in Routledge International Handbook of Women’s Sexual and Reproductive Health (2019),
eds Jane M. Ussher, Joan C. Chrisler, Janette Perz
and
FGM Studies: Economics, Public Health, and Societal Well-Being: Chapter 12,
in The Routledge International Handbook on Harmful Cultural Practices (2023),
eds Maria Jaschok, U. H. Ruhina Jesmin, Tobe Levin von Gleichen, Comfort Momoh
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PLEASE NOTE:
The Inter-African Committee on Traditional Practices Affecting the Health of Women and Children, which has a primary focus on FGM, is clear that in formal discourse any term other than ‘mutilation’ concedes damagingly to the cultural relativists. ‘FGM’ is therefore the term I use here – though the terms employed may of necessity vary in informal discussion with those who by tradition use alternative vocabulary. See the Feminist Statement on the Naming and Abolition of Female Genital Mutilation, The Bamako Declaration: Female Genital Mutilation Terminology and the debate about Anthr/Apologists on this website.
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This article concerns approaches to the eradication specifically of FGM. I am also categorically opposed to MGM, but that is not the focus of this particular piece, except if in any specifics as discussed above.
Anyone wishing to offer additional comment on more general considerations around male infant and juvenile genital mutilation is asked please to do so via these relevant dedicated threads.
Discussion of the general issues re M/FGM will not be published unless they are posted on these dedicated pages. Thanks.
Hilary Burrage 