Mr. Fred McBride:

We have addressed some of them. The signs of safety approach is not just about a practice model; it is about culture change as well. We are trying hard to give people the confidence and the practice tools. We are trying to encourage openness and transparency in how they practise. Part of the approach is about opening up their practice to other practitioners and agencies, outlining what we think is the right decision in a case and asking them what they think. It is about how we can share ideas, knowledge and experience about the right decision. Some of these decisions are very challenging and they are very much based on a balance of judgment. We try to gather as much as evidence and information as we can to make these decisions. Sometimes the information is partial, ambiguous, conflicting, or old. There is a challenge in trying to get the balance of judgment correct. On most occasions we get it right, but there will be times when we do not. Part of the culture we are trying to create is to make staff aware that they will be judged by reasonable standards, and not by the distorting effect of hindsight, which can make them feel extremely exposed and frightened of public criticism. We are trying to create a management system and culture that supports people. Of course, people will have to be held accountable if something goes wrong. Ultimately, I will be held accountable and I am happy for that to happen provided we are judged by reasonable standards. That is part of the culture we are trying to create.