
A couple of years ago I wrote a post that was critical of the way in which the Representative for Children in Youth in British Columbia drove practice changes among social workers. In short the reason had to do with apply too much order (rules and checklists) in a complex space (social work practice). At a certain point, when you are trying to prevent deaths that have occurred in the past, you end up outlawing all but the deaths that will surprise you in the future. We look at reviews of child deaths as if they were expected and predictable …