The death of Baby P has highlighted failings in assessing risk. Staff must be supported in making tough decisions if the chances of such tragedies happening are to be minimised

The first reactions to the coverage of the killing of a 17-month-old child in Haringey, London, are of horror and revulsion. Details revealed during the harrowing court case mean we all share that progression of emotion running through disbelief to disgust and anger.

But there is also, in the mix, the sickening realisation that we have been here before.

We have responded to previous findings and inquiries, notably the Victoria Climbie case. We have improved our systems but seemingly remain helpless to stop this happening again. It is impossible for anyone who has provided care, or led teams that do, to read the accounts of the case of Baby P without thinking hard about cases they have dealt with either directly or as a manager and about how they would have handled this one. How would they have supported practitioners working with a deceptive mother who tried at every turn to conceal what was being done to her child? How would they have dealt with the maze of information, opinions and professional viewpoints? How would they maintain the balance between the long-term benefits of keeping a child with its family or protecting a child in the short term by placing him or her in care? At what stage would they have said enough is enough?

If we take one lesson from this case it must be that even with the considerable improvements in reporting and cross agency co-operation introduced following the inquiry into the death of Victoria Climbie, it is still possible for the human element of the process to fail. One of the most worrying allegations made among the many whirling around the death of Baby P is that there is still a tendency for health and social care professionals to be either reluctant or unable to change their minds about a complex case.

It seems clear that once a course had been set and the decision made that the child's care at home was neglectful, rather than abusive, then it was difficult to get that perception changed.

Hard questions

This is why at times like these leaders and frontline staff need to think creatively and honestly about the cultures in their organisations.

Do we support people in making hard decisions and in using their own judgement in difficult cases like this? Do we make it easy enough for people to raise misgivings and challenge preconceptions, sometimes even about a colleague's judgements? Are we willing to relinquish some of our own professional comfort zone, in order to provide more certainty that we really have done everything we can to safeguard an at risk child or a vulnerable adult? Can we justify our systems, processes and actions when things go wrong?

These are hard questions to answer truthfully but we need to do so. At times like these leaders in the health service, as well as in social services and the police, have to step up and provide their people with the reassurance and support they need to do their jobs properly. The systems set up following the Laming inquiry have been in place for some time. But what will ultimately make these processes work are the people who make the relationships at strategic and managerial levels. We must resist the temptation to believe that structural changes will change the capacity of the system to respond to difficult and very human challenges.

Thoughtful leadership

Ultimately we all know evil things will still happen but that does not get us off the hook in cases like this where there were so many home visits made, so much evidence, so much contact and expertise brought to bear. What can really make a difference is thoughtful and responsible leadership; encouraging a culture that supports frontline staff in asking the extra question; being a bit more persistent with their efforts to get to the bottom of what is really going on and getting the difficult calls right.

There is little doubt the state makes a pretty poor parent and we all know that by taking a child into care you create another set of problems. But the prevention of further harm, the extension of a protective arm to the vulnerable, is our human responsibility and all we do professionally should work to support that final safeguard, that covenant of trust we pledge to our children. It may well be true that hard cases make bad law and the killing of Baby P is as hard a case as you could come across. But its grim details contain lessons which even the best care providers can learn. It is right that we should all think hard about how we make the best use of what it teaches us about the way we work, the way we support each other and the way we all make decisions.