The Royal Commission has released a research report on understanding failure to identify and report child sexual abuse.

The report makes reference to James Reason’s ‘Swiss cheese’ model, often used to analyse medical errors and patient safety incidents (page 17).

Key findings:

  • Detecting child sexual abuse is a task that many people may do rarely – if ever – at work. Grooming behaviour in particular is often ambiguous, making it difficult for colleagues, who may not be experienced in detecting grooming, to make sense of the behaviour and recognise it as child sexual abuse.
  • Organisations that implement systems and processes that provide ways for staff to talk through their judgements and decision making process, and encourage a culture of critical reflection, can help minimise errors of reasoning and cognitive bias.

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