Avoidable Tragedy?

Today's Inland Valley Daily Bulletin carried an Associated Press story, reported originally on the front page of yesterday's Los Angeles Times, of an 11-year-old boy who killed himself one afternoon in June despite having alerted school officials earlier in the day that he felt suicidal.

Did it have to happen?

My experience as an executive tells me that disastrous incidents occur for any one of a number of reasons. There may be systemic problems: policies and procedures may be inadequate or even non-existent; required equipment may be lacking or in a state of disrepair. Personnel may be inadequately trained. Personnel may be placed in jobs they could not perform regardless of training because they simply do not meet basic qualifications. Or the system itself maybe overwhelmed due to understaffing.

At first glance, the incident at hand appears to fall primarily into category number one. The school counselor with whom the boy spent the morning crying, reporting that he didn't want to live anymore because of people hitting him all the time, did the right thing by promptly calling appropriate Los Angeles County authorities. Shortly after the boy returned home from school, he was visited by a social worker, accompanied by the police. The social worker, based on information available (which turned out to be incomplete), decided not to remove the child from the home. Shortly thereafter the little boy used a jump rope to hang himself.

Both newspaper reports indicate that a lack of information hampered the social worker from performing his/her job thoroughly. The stepfather who answered the door had been legally barred from living there -- but due to the inability to search computer records from the field, the social worker didn't know that. The social worker apparently also did not know that the child had a history of living in foster homes and homes characterized by violence and drug use. The social worker used a cell phone to make inquiries of relevant Los Angeles County departments that might have provided useful information, but those calls went unanswered and unreturned.

So -- based on facts available at the moment -- this is not a story about incompetence at the operational level. It may be a story about the failure of top management -- given that the County had purchased computers that might have been helpful but not issued most of them to field workers because management failed to purchase the wireless devices required to make the computers useful in the field.

I propose two additional reasons for what might have been a preventable tragedy. First, our society has become so large and complex that specialization governs the manner in which we respond to practically everything. Just suppose that the school counselor with first-hand information on the boy's complaints, not a separate social worker, had been the person to go to the boy's home. Would it have made a difference? We'll never know. But that wasn't the counselor's job. Had the counselor been at the home and made the determination that the boy was not safe, he most likely would not have had the authority to take the appropriate action. Suppose that an inter-departmental case manager had been assigned to the boy from the time he was an infant -- someone who would have known the relevant history and been in a better position to make a judgment. But no such person existed. And in our mobile society, it is unlikely that any such person could have existed over an 11-year period of time. We are stuck, instead, with a fragmented written record -- that was mostly inaccessible.

There is one more reason for tragedies that I deliberately left out of paragraph three above: the people in charge -- the leaders -- have not established the proper guiding organizational philosophy and mission, a creed that governs the actions of every employee every minute of every day. Apparently "NO MORE TRAGEDIES" is not something the leaders have communicated in strong enough terms. Los Angeles County Supervisors have been aware for years that several of their largest departments -- Juvenile Probation and Children and Family Services among them -- are dysfunctional. They claim to care -- but the problems persist. There is one thing a leader does in urgent times -- take urgent action!

I am not naive enough to believe in a perfect world. Sh*t happens. But it could happen a lot less often. We are still waiting for Los Angeles County Supervisors to take urgent action. And while we wait, we weep.

A Grand Fourth

We've just celebrated our 234th anniversary of the Declaration of Independence. There's nothing wrong with a good holiday, a little beer, one hot dog too many, and some fireworks to help it all settle in. Yes, freedom is a good thing.

FDR spoke about "four essential freedoms" on January 6, 1941, naming 1) freedom of speech and expression; 2) freedom of every person to worship in his own way; 3) freedom from want; and 4) freedom from fear -- which he explained was related to a reduction of armaments and the lack of physical aggression against any other country in the world.

We're actually doing pretty well with #1. Thanks to the Supreme Court, corporations are doing pretty well, too. Expect lots of "free speech" this coming fall, just prior to the general election. Only it won't really be "free" -- all of us will pay for it in higher prices for everything we buy.

Americans are doing pretty well with #2 as well -- far better than people in most countries. I wish we were doing half as well in recognizing the freedom of people not to worship. (Well, it's true, nobody can make us pray. But if we need to interact with certain elements of society, we can be made to feel uncomfortable if we choose that option. Try belonging to a Rotary Club! Try attending a City Council meeting!)

In regard to #3 -- not so much. What FDR was referring to was "economic understanding which (sic) will secure to every nation a healthy peacetime life for its inhabitants." Right now economists worldwide are debating the merits of stimulus vs. deficit reduction -- without giving much thought to methods of reducing the deficit that are politically unpopular. As a result, people will go hungry, which usually is not consistent with "healthy."

Freedom from fear -- unfortunately not. Physical aggression -- between nations, between people -- continues unabated, even when it's unnecessary, unproductive, and unpopular. Tell the Marines getting their limbs blown off in Afghanistan that they possess "freedom from fear."

My birthday is coming up soon. If you're thinking of getting me a present, consider the following: 1) freedom from deregulation where the potential (no, the LIKELY) result is higher profit at the expense of unnecessary loss of life (e.g. mining and oil extraction operations); 2) freedom from people who use "no taxation without representation" as an excuse to promote their actual philosophy, which is "no taxation at all"; 3) freedom from any more deaths resulting from stupid wars and government agencies that don't do their jobs (e.g. child protective services, juvenile probation departments, etc.); and 4) freedom from rigged elections, anywhere in the world, but especially here in the good ol' US of A.