“…Mirroring this trend, solutions to the problem of communication failures between processionals contributing to the deaths of children in care have tended to focus on the technical transfer of information, instituting tools to support this purpose (Department for Health and Social Security, 1982;Department of Health, 1991 ;Laming, 2003;Reder & Duncan, 2013). Tools may include, for example, procedure manuals, assessment frameworks and decision making tools (Hall & Slembrouck, 2007;Houston, 2015;Munro, 2011;Reder & Duncan, 2003). Research in child protection systems (Munro, 2011) as well as other high-risk industries (Sidney Dekker, Hollnagel, Woods, & Cook, 2008) has demonstrated that an overreliance on a technocratic approach may not only be ineffective in securing a safer system, but may also produce unwanted consequences.…”