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.