When Blame Isn’t Enough
By OLIVIA A. GOLDEN
NYT
Washington
THE death of Marchella Pierce, a 4-year-old girl in Brooklyn who was beaten, malnourished and tied to a bed, has again aroused anger over child welfare in New York City. Her mother stands accused of murder, and a caseworker and a supervisor were charged last month with criminally negligent homicide.
Reading about Marchella’s death in September brought back painful memories. When I was the director of child welfare in the District of Columbia I often woke up at 3 a.m., fearing all that could go wrong. During my tenure, there were increases in adoptions and speedier investigations, and more children went to live with foster families rather than in institutions. But substandard care and terrible cases also continued.
Because there is so much to fix, improvements and calamities can happen simultaneously in long-troubled child welfare systems. In Washington, where I took over from a court-appointed receiver, the work ranged from reducing caseloads to overhauling information technology, contracting, licensing and personnel systems. On good days, we reminded ourselves that it was all worth it. But when a child was hurt or killed, we often reacted defensively, fearing that a misdirected public outcry could undercut our plans for reform.
After I left that job, I kept looking for solutions. For ideas, I examined institutions like airlines and some hospitals that have reduced deaths and injuries. Through rigorous data analysis, they have developed systemic approaches to safety, focusing on clear communication, minimum-staffing requirements and “fail-safe” strategies to reduce the consequences of inevitable human error. Such strategies — including checklists and passing on information at crucial moments like shift changes — can be applied to protecting children.
(More here.)
NYT
Washington
THE death of Marchella Pierce, a 4-year-old girl in Brooklyn who was beaten, malnourished and tied to a bed, has again aroused anger over child welfare in New York City. Her mother stands accused of murder, and a caseworker and a supervisor were charged last month with criminally negligent homicide.
Reading about Marchella’s death in September brought back painful memories. When I was the director of child welfare in the District of Columbia I often woke up at 3 a.m., fearing all that could go wrong. During my tenure, there were increases in adoptions and speedier investigations, and more children went to live with foster families rather than in institutions. But substandard care and terrible cases also continued.
Because there is so much to fix, improvements and calamities can happen simultaneously in long-troubled child welfare systems. In Washington, where I took over from a court-appointed receiver, the work ranged from reducing caseloads to overhauling information technology, contracting, licensing and personnel systems. On good days, we reminded ourselves that it was all worth it. But when a child was hurt or killed, we often reacted defensively, fearing that a misdirected public outcry could undercut our plans for reform.
After I left that job, I kept looking for solutions. For ideas, I examined institutions like airlines and some hospitals that have reduced deaths and injuries. Through rigorous data analysis, they have developed systemic approaches to safety, focusing on clear communication, minimum-staffing requirements and “fail-safe” strategies to reduce the consequences of inevitable human error. Such strategies — including checklists and passing on information at crucial moments like shift changes — can be applied to protecting children.
(More here.)
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