Somerset Survivors

What is a safety critical system

A life-critical system or more commonly a safety-critical system is a system whose failure or malfunction may result in one (or more) of the following outcomes: death or serious injury to people. loss or severe damage to equipment/property.

But a more intuitive explanation may be

with the consequences of failure .If the failure of a system could lead to consequences that are determined to be unacceptable, then the system is safety-critical. In essence, a system is safety-critical when we depend on it for our well being. [1]

So does an investigation by the police constitute a safety critical system?

Despite it being rather counter intuitive, how can an investigation into a report of a crime that may have happened 10, 20 or more years ago, be safety critical and does it fit the into a reasonable definition of a system anyhow.
I would argue that yes it does meet both of these requirements.

Firstly, can the investigation of historic abuse constitute a system in its own right.

Well a good working definition of a system is in this case:
an organized or established procedure [2]

Well many, if not all police forces have a team dedicated to either just historic abuse or abuse more generally. This team will have specific training and resources and concentrate on those particular cases. The investigatory process should be consistent and be established by the higher management structures to ensure that investigations are conducted correctly.

For example Hampshire Police were asked for their “procedures are regarding investigating reports of non-recent sexual abuse”

The response indicated a well-developed system:
“A specialist team is likely to be allocated to speak to the victim if they are now an adult. Non-recent abuse on a victim who is still a child is assessed in a multi-agency setting (MASH) which is standard procedure. “ [3]

This I feel shows that the process and procedures used in these investigations fit well with the definition, and indeed the ‘common sense’ understanding of what constitutes a system and that it is fair to consider these processes in the light.

The next question is, while the investigation can be considered a system can it be considered ‘safety critical’?

Again I feel that it can be considered ‘safety critical’.  The working definition being “a system whose failure or malfunction may result in one (or more) of the following outcomes: death or serious injury to people.”

Research tells us that Childhood abuse is linked to increased risk of non-accidental injury “Self Harm” in later life. For example

Path analysis confirmed the contributory role of childhood
sexual abuse to deliberate self-harm [4]

and

There was a clear statistical association between sexual abuse in childhood and self harm [5]

The same applies to suicide ideation with an increased risk of such ideation, and obviously, a similar increased risk of the victim actually taking their own life,
The prevalence of suicidal ideation was about five times higher in abused men and women compared with their non abused counterparts. [6]

This increased risk of harm to the victim of historic / non-recent abuse clearly represents a risk of “Death or serious injury” and as such clearly brings the investigation of such clearly into the remit of a safety critical system.

In addition to this there is the wider impact on society, it is often the case that the investigation allows other victims to disclose non-recent abuse and there for get help to address the above identified risk factors that wouldn’t have been possible if the investigation hadn’t taken place. We also see a number of cases where non-recent abuse allows the authorities to identify both ongoing abuse and risk of future abuse thereby allowing for safeguarding process to be implemented.

Both of these wider impacts clearly show the safety critical nature of any investigatory system used by the police in that such a system is closely linked to the prevention, and minimisation, of risk of serious harm or death to others.

Clearly then the investigation of Non Recent abuse can, and should, be considered a safety critical system and implemented as such. The question is “is this the case?”

Is the Current Police organisational structure compatible with a Safety Critical System of Investigation

I would argue that the organisation of the Police forces in the UK act against the ability of them to implement and operate a safety critical process(s) in regard to non-recent abuse. The key element being that the regional nature of the police, with separate constabularies operating in, and responsible for, different geographical regions, acts to undermine any attempt to operate such investigations as a ‘Safety Critical System’ because of the vastly increased number of organisation interfaces that such an organisational structure brings with it.

As an example, we can posit a person who have moved away from the family home and now lives in a different part of the country, from the FoI request [3] we see

“If the incident occurred in our force area but the victim is in another we will contact the other force as part of an investigation or discussion in how such an investigation can be progressed”

Instantly we see both an undefined interface and indeed interface to another process / system of investigation that may well not be compatible and certainly won’t be seamless.

If we add in additional interfaces, such as the NHS and Social Services, we can see one force contacting another force to investigate the offence and then either relying on that second force to interface with the local NHS and Social Services or attempting to engage with the remote NHS and Social Services themselves.

One of the key dangers in any safety critical system is the organisation interfaces. A good example of the problems that can occur when different organisation have to establish interfaces, and the issues that can occur when these interfaces fail is that of the Mars Climate Orbiter which crashed. The subsequent investigation showed that the root cause of the crash was that software developed by two different organisations used different unit of measure.

The interface between the two organisations failed, information could not be passed between the two systems and the result was a nasty mess on the surface of Mars and a lot of red faces. [1]
Similar issues of failing interfaces between organisations have however led to significant injury and deaths.

The potters bar rail crash show exactly what can happen when two organisations have safety critical systems that do not interface correctly. In large part the deaths of 7 people could have been avoided if there were no interfaces between the track maintenance and management organisations. In the aftermath of the crash, and to ensure that such interface issues didn’t happen again network rail brought track maintenance in-house. [7]

It is my belief that the numerous interfaces required to investigate non-recent abuse cases can, and do, cause what should be a Safety Critical System to fail. Investigations not carried out fully, Care and concern for victims not implements fully and risk factors not identified.

Is there a solution?

The solution it would seem would be for the investigation of non-recent abuse to be run and managed by a national team, thus minimising the number of interfaces and where interfaces are required they could be designed nationally and implemented nationally ensuring both consistency and effectively.

 

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[1] Safety Critical Systems: Challenges and Directions: http://users.encs.concordia.ca/~ymzhang/courses/reliability/ICSE02Knight.pdf
[2] https://www.merriam-webster.com/dictionary/system
[3] https://www.whatdotheyknow.com/request/procedure_regarding_reports_of_n#incoming-882289
[4] Am J Psychiatry 161:8, August 2004
Implications of Childhood Trauma for Depressed Women:
An Analysis of Pathways From Childhood Sexual Abuse to Deliberate Self-Harm and Revictimization

[5] sexual Abuse in Childhood and Deliberate Self harm
http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.468.7957&rep=rep1&type=pdf

[6] Evidence Supporting an Independent Association between Childhood Physical Abuse and Lifetime Suicidal Ideation
http://onlinelibrary.wiley.com/doi/10.1111/j.1943-278X.2012.00089.x/abstract