Learning from Preston Davey's death

In this week's episode I am reflecting on the tragic death of 13-month-old Preston Davey and asking the difficult question that follows so many safeguarding tragedies: how can warning signs exist, yet a child still isn't protected? Rather than focusing on blame, this episode explores what statutory reviews repeatedly tell us about how systems fail, why information doesn't always become understanding, and what we can all learn as about the system. In this episode I discuss: Why safeguarding failures are rarely the result of one individual mistake, but an accumulation of small decisions and missed opportunities. How agencies can each hold pieces of information without anyone seeing the complete picture. The proposed mechanism for learning The Children's Commissioner's call for greater accountability and the proposed Child Protection Authority. Are you interested in joining a supportive community for independent reviewers and review professionals? My Momentum membership provides a space for community, reflection and experiential learning. The doors are open for a limited period. Whats app me here the word COMMUNITY and I can send you the details.    About Donna: Donna has 16 years public sector experience, including her last role as Head of Law for a leading metropolitan authority. Now a safeguarding adviser & trainer, Donna is involved in all 3 types of safeguarding reviews in both children's and adults' safeguarding and domestic homicide and is a SILP Reviewer and Mentor. Donna offers 'SILP School' her university accredited training course, Momentum her space for reviewers & a free online network for leaders in review practice.   Linkedin: https://www.linkedin.com/in/donna-ohdedar-review-consulting-ltd/ Join my free Facebook group Blue Light Professionals here   Engagement + proportionality + strengths = SILP].