This article explores the recurring theme of systemic failures in protecting individuals from violence, highlighting recent tragedies in the UK. It examines the roles of mental health services, law enforcement, and child protection agencies, arguing that a culture of process over people has eroded individual responsibility and allowed dangerous individuals to slip through the cracks.
A mother hugs her child as they look at floral tributes for the victims of a deadly knife attack in Southport. How many times can a car break down before we conclude it is broken? How many times can the system charged with protecting us fail, before we conclude that too is broken? Investigations into recent tragedies revealed that if the system supposed to protect us had worked properly, these deadly acts might never have occurred.
Weeks earlier, we learned how tortured and killed Grace O’Malley Kumar, Barnaby Webber, and caretaker Ian Coates in June 2023. Axel Rudakubana chose to kill Elsie Dot Stancombe, seven, Bebe King, six, and nine-year-old. This conversation about failings in the system must never take responsibility away from those who actually carried out such evil acts. And yet, once again, we learn the system failed to prevent them in their intent. The mental health system at Nottinghamshire Healthcare NHS Trust failed Grace, Barnaby, and Ian when medics let Calocane refuse antipsychotic medication because he “did not like needles” and refused to engage with them – so was discharged to his GP. The report also revealed other patients being treated by the Trust went on to commit stabbings and other acts of violence between 2019 and 2023. The police failed them too with a software system so outdated it was unable to process images from the killer’s extreme social media postings. The Child Protection and Education systems failed Sara with no intervention in place despite evidence of violence at home since her birth. And they allowed her to be home-schooled, isolating her from anyone who could have intervened before it was all too late. These three cases made headlines and shocked Britain. But we fool ourselves that it is the infrequency of such failings which made them newsworthy. The failings are so frequent they go largely unnoticed; it is only the scale of these horrors which caught our attention. Some of those in recent years who paid the ultimate price for state system failings and opportunities missed may remain with you, like murdered children Star Hobson and Arthur Labinjo-Hughes. Too many others have slipped from collective memory, buried beneath a mountain of inquiries and reports and recommendations and forlorn hopes of “Never Again”. Of course, each day there are multiple times we are protected by the stuttering systems in place. But what a cliché “Never Again” is. The reality is that right now failings are happening in the systems designed to protect us; whether those will have fatal consequences, only time can tell. The term “going sour” was first coined to refer to failings which came about where there has been a slow degradation of system performance over time. And sour is where we are right now. Staff at the cutting edge of services which keep the rest of us safe are demoralised and devalued after 14 years of austerity and a general undermining of public service. The Police, civil servants and social workers are all struggling to recruit and retain staff due to poor morale and insufficient numbers of people wanting to do what is often hard, difficult and stressful work for the same money as you can get working in Aldi. We need to notice these people at times other than a crisis. And yet we also have to acknowledge that whether it’s poor morale, poor pay or just poor work ethic, some people in these roles have simply not been good enough. Hard grafters at the cutting edge of these services are the first to tell you of colleagues who have been allowed to drift in a pond of mediocrity. A pond that comes all too often in organisations that are process fixated rather than output focused. Sometimes it seems that form filling and box ticking has become a national obsession, rather than simply getting the job done. Certainly it is cheaper than employing enough people to cope with the surging demand for services. There have been layers of compliance, risk assessment, regulation and bureaucracy introduced with the intention of making things safer. But the unintended consequence has been that the weight of the system has crushed individual sense of responsibility. And with the growth of “the system” there are more places for individuals to hide. After all, why put your neck on the line with a big call if there is a shared Google doc to shelter behind instead? With Calocane, the paperwork was completed to note he didn’t like needles. But no one individual took action to stop him attacking. With Rudakubana, a form was filled to say he was carrying a knife. Another was filled to say he had created a hit list. There were probably a dozen more too. But no one person spotted his murderous intent and stepped in to stop him. After these terrible cases there will be a new raft of recommendations
Systemic Failures Violence Mental Health Child Protection Law Enforcement Social Services UK News
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