The too short life of Chloe Valentine and the tragic end has touched all who have heard about her. The Coroner’s inquest has shone light on everything that was known, and what was not known. Everyone had only part of the picture, and now we have it all.
Child protection is all about children and their reliance on us to do our best by them. In this case, we failed. The consequences of actions taken or not taken in statutory child protection work are momentous. The decisions are highly contested and there are few absolutes.
When a child dies everyone is shocked, sad and angry, particularly those closest to the child. We tend to look to blame somebody – bad parents, bad child, bad social worker or bad carer, wrong court judgement, wrong assessment, wrong choice. This criticism is not always misplaced but it rarely provides a complete picture of what led to an incident or errors in judgement.
Media coverage of the inquest narrowed the public gaze to individual judgements, evidence and action. The Coroner’s report though, in its entirety, points to systemic problems such as organisation-wide confusion about procedures and powers, philosophy reduced to slogans, incomplete knowledge of legislation that governs operations, lack of training in case record-taking, and discontinuity in worker and client relationship.
Commentary on the Coroner’s findings has ranged from condemning to defending. Neither of the extreme positions is constructive. The Department, and all who have influence on its work, must analyse the findings and respond. A good response will help put things right. It will avoid blame, encourage the reporting of mistakes, examine future mistakes or incidents closely and look at how the system should change to minimise the chance of it happening again. It will provide the checks and balances against escalation or repetition. It will also deal fairly and decisively with ongoing poor performance.
However, the systemic issues are not just about errors but also about the proactive task of creating a professional, high-performing organisation that delivers sound human services to children at risk. This requires more than following the Coroner’s recommendations. It obliges leadership, from Cabinet down, to wrestle with the future plan for child protection including and well beyond Families SA. They need to address the resources required to deliver on what it promises, the type of workforce needed and investment in its development, the defeated air throughout Families SA and the anxiety among its workers because they cannot attend to every high-risk situation.
Those with long memories, like me, will remember the optimism and energy that followed the review of the child protection system by Hon Robyn Layton in 2003 and the subsequent child protection plan. Also in 2003 there was a workload analysis done by an independent consulting firm. I went back to that report recently and it read like it could have been written today. The consultants reported issues with systems and processes to manage the quantity and quality of the organisation’s work and inadequate data to know the basics of how the organisation operates. In the absence of measures of efficiency and effectiveness, the consultants resorted to measuring unmet demand. This was substantial wherever they looked.
To an extent the unmet demand issues are ever present, but the degree of risk can be shallow or deep. Right now it is deep. I expect that the passion that Chloe Valentine’s death has stirred will translate to compassion, empathy and, most of all, action from deep within government.
