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When it comes to understanding why some institutions fail to identify and report child sexual abuse, research released by the Royal Commission suggests that a new approach that seeks a deeper understanding of why errors occur would be more effective in encouraging safe practices in the future.

The research, ‘Hear no evil, see no evil: understanding failure to identify and report child abuse in institutional contexts’ was conducted by Professor Eileen Munro (London School of Economics and Political Sciences) and Dr Sheila Fish (Social Care Institute for Excellence).

Royal Commission CEO Philip Reed said the research draws on two Royal Commission case studies and offers speculative findings on individual and organisational factors that have contributed to the failure to protect children in a timely and effective way.

The study identifies a number of challenges to creating and maintaining a safe organisation where staff members; are quick to recognise grooming or abuse behavior and trigger a process that investigates concerns and can take appropriate action so that children are protected from harm.

According to the researchers, one such challenge is the nature of child sexual abuse itself.

Perpetrators seek to conceal their activities, children and young people who are abused can be unable or slow to ask for help, and many behavioural indicators of abuse and grooming are ambiguous.

Mr Reed said the report contains useful examples of what organisations can do to make themselves safer places for children.

“According to the research, organisations that achieve a very good safety level share a fundamental belief that mistakes will happen and their goal is to spot them quickly,” he said.

“They encourage an open culture where people can discuss difficult judgements and report mistakes so that the organisation can learn.”

“The research will help the Royal Commission understand how child sexual abuse can be better identified and prevented in the future.”

Key findings:

  • Detecting child sexual abuse is a task that many people may do rarely – if ever – at work. Grooming behaviour in particular is often ambiguous, making it difficult for colleagues, who may not be experienced in detecting grooming, to make sense of the behaviour and recognise it as child sexual abuse.
  • Organisations that implement systems and processes that provide ways for staff to talk through their judgements and decision making process, and encourage a culture of critical reflection, can help minimise errors of reasoning and cognitive bias.

Read the full report here.

About the researchers:

Professor Eileen Munro CBE, Professor of Social Policy, Department of Social Policy, London School of Economics and Political Sciences. Professor Munro led the independent review of child protection in England.

Dr Sheila Fish, Head of Learning Together / Senior Research Analyst, Social Care Institute for Excellence (SCIE). Dr Fish leads SCIE’s work on a systems approach to safeguarding reviews.

If the documents provided by the Royal Commission are not accessible please contact the Royal Commission by emailing This email address is being protected from spambots. You need JavaScript enabled to view it. or calling 1800 099 340.