"The failure to protect children from sexual abuse not only arouses shock and anger but also puzzlement: how could people who are employed to care for children fail to protect them when, with hindsight, the evidence of harm or danger seems all too obvious.

In the aviation and healthcare sectors, attributing failure simply to individual error is no longer seen as sufficient for encouraging safe practices in the future. Instead, attention has turned to seeking a deeper understanding of why errors occur. Failures are seen as consequences, not just causes. Solutions to failures are built on gaining a greater understanding of the factors that contributed to human error. Those factors lie in the nature of the activity being managed, the type of reasoning errors that people are prone to and the wider system in which workers operate.

Applying this approach to the two case studies available from the Royal Commission into Institutional Responses to Child Sexual Abuse when we began this study, it is possible to offer some speculative findings on individual and organisational factors that contributed to the failure to protect children in a timely and effective way." (From the website). This is one of a number of research reports published as part of the work of the Royal Commission into Institutional Responses to Child Sexual Abuse, conducted in Australia. Reports have been published on the themes of Causes, Identification, Prevention, Institutional responses, Government responses, Treatment and support needs, Institutions of interest and Ensuring a positive impact. Follow the link to find other material on the website. Record #5100