Hear no evil, see no evil: Understanding failure to identify and report child sexual abuse in institutional contexts

Professor Eileen Munro and Dr Sheila Fish

September 2015

ISBN 978-1-925289-30-5

Executive summary

The failure to protect children from sexual abuse not only arouses shock and anger but also puzzlement: how could people who are employed to care for children fail to protect them when, with hindsight, the evidence of harm or danger seems all too obvious.

In the aviation and healthcare sectors, attributing failure simply to individual error is no longer seen as sufficient for encouraging safe practices in the future. Instead, attention has turned to seeking a deeper understanding of why errors occur. Failures are seen as consequences, not just causes. Solutions to failures are built on gaining a greater understanding of the factors that contributed to human error. Those factors lie in the nature of the activity being managed, the type of reasoning errors that people are prone to and the wider system in which workers operate.

Applying this approach to the two case studies available from the Royal Commission into Institutional Responses to Child Sexual Abuse when we began this study, it is possible to offer some speculative findings on individual and organisational factors that contributed to the failure to protect children in a timely and effective way.

The nature of the problem

The challenges posed by the problem of child sexual abuse are (1) that perpetrators seek to conceal their activities; (2) children and young people who are abused can be unable or slow to ask for help; and (3) many of the behavioural indicators of abuse and ‘grooming’ are ambiguous, requiring judgement or interpretation to decide if they are cause for concern. ‘Grooming’ involves actions by the perpetrator to increase their chances of abusing a child undetected.

Errors of human reasoning

Workers’ judgements are vulnerable to cognitive biases. The current understanding of human reasoning is such that when we seek to understand the actions or inaction of those involved in the organisations where an abuser was operating, we should not imagine these people as cold, logical processors of data. A more apt image is of living, feeling human beings whose understanding and actions arise from the interplay of their reasoning capacities, both logical and intuitive, and their emotions as they respond to the world around them.

Research has found that it is hard to eradicate biases, and especially hard for a person to eradicate their own biases. The strategies that have had some success involve a person trying to consider alternative perspectives or explanations, and this is best achieved with the help of others. Organisations have a major part to play in creating the conditions in which errors of reasoning can be quickly picked up and corrected. They can do this by providing mechanisms for staff members to talk through their judgements and encouraging a culture of critical reflection.

Organisational factors

The case studies examined in this report explore many of the organisational factors that influence how well children are protected: the recruitment process, training in recognising and responding to indications of abuse, and formal policies about what people should do both to prevent and react to abuse. Our study highlighted less tangible but equally influential aspects of organisations that were also evident in the case studies, including:

Local rationality: People do what they think is right or sensible at a given time, and inquiries such as this need to find out what local rationalities may have influenced their actions.

Organisational culture: This is partly created by the explicit strategies and messages of senior managers but is also strongly influenced by covert messages that are transmitted throughout organisations, influencing individual behaviour. These can significantly affect the rigour with which policies and procedures are implemented.

Balancing risks: Policies and actions that protect children can also create dangers. Workers who are fearful of being wrongly suspected of abuse may keep their distance from children and not provide the nurturing, healthy relationships that children need to have with adults. Organisations have to reach some conclusion as to what level of concern should be reported. Making it compulsory to report even a low level of concern will identify more cases of abuse but at the cost of including numerous non‐abusive cases. Efforts therefore need to be made to create a culture that understands the ambiguity of the behaviour so that innocent people’s reputations are not tainted by false reports.

Drift into failure: Organisations face the problem of maintaining vigilance and avoiding a drift into failure. For any one worker, the chances of working with an abuser are low and so they may not be as vigilant as they would be if they had recurrent experiences of detecting abuse. Indeed, if they are asked to report low‐ level concerns, they may experience so many false alarms that they become cynical about them. There is no quick fix to this problem. It requires that managers continually monitor and endorse protection policies to stress the importance of vigilance.

Organisations that achieve a very good safety level – known as High Reliability Organisations (Weick, 1987) – provide useful examples of what organisations can do to make themselves safer places for children. They share a fundamental belief that mistakes will happen and their goal is to spot them quickly. They encourage an open culture where people can discuss difficult judgements and report mistakes so that the organisation can learn. Organisations seeking to be safe places for children must encourage frequent, open and supportive supervision of staff to help counteract the difficulties people face in making sense of ambiguous information about colleagues. A shared acknowledgement of how difficult it can be to detect and respond effectively to abuse contributes to a culture that keeps the issue high on the agenda.