系統除錯？個人咎責？──台灣重大兒虐事件檢討機制之探究

System debugging? Individual blame? Serious Case Reviews of Child Maltreatment Fatalities in Taiwan

兒童嚴重受虐是人權保障不可承受之重，而重大兒虐事件檢討會議則是兒保體系為從中找出風險因子、促成制度除錯與改善、預防兒少再次受虐所發展出來的一項風險管控機制。本文從結構、過程、結果等三個構面統整國內外探討重大兒虐風險管控機制之相關文獻，並以兒保網絡工作者焦點團體之實證資料為基礎，描繪與分析台灣重大兒虐事件檢討機制之內外部動力、操作模式與實務工作者的感受，以及可能造成的結果，並提出政策與實務建議。本文指出地方與中央層級的重大兒虐事件檢討會議都有在知情不足情況下討論與做出決議的基本問題，儘管已淡化咎責與懲處的氛圍，但會中的討論與決議仍偏向個別社工實務操作層次，未處理長年無解的資源不足及網絡合作等系統議題。本文建議政府在政策面宜採生態系統理論觀點，找出造成不良結果的制度與系統根因並提出知情建議以對症下藥。在操作面則建議每年選定若干具指標性重大案件進行系統模式分析，並即時傳遞得自重大兒虐事件檢討會議的知識給一線工作者。

"Serious child abuse presents an unbearable weight for human rights protection. Serious Case Reviews (SCRs) in child abuse are risk management mechanisms to identify risk factors, facilitate system improvements and correction, and prevent recurrences. This paper reviews domestic and international literature on risk management mechanisms of serious child abuse cases from three dimensions: structure, processes, and outcome. The empirical data, generated by two waves of child protection social workers focus group and interviews, describe, and compare the longitudinal internal and external dynamics of SCRs, patterns of practice, and practitioners’attitude, as well as the potential consequences in Taiwan. Specific recommendations for policies and procedures have been made. The SCRs, at both the local and central government levels, have realized that discussions and decisions were made without sufficient information. Although the perceived finger-pointing and fault-finding culture has decreased, the discussions and resolutions are still focusing on scrutinizing individual social worker’s practice, while the system improvement opportunities, such as resources allocation and interagency collaboration, are lost. At the policy level, this paper recommends that the government adopt a holistic approach to examine institutional and systemwide root causes for undesirable outcomes, and develop a plan of action accordingly. At the professional practice level, this paper recommends that cases with specific characteristics be identified and selected each year for a systematic in-depth analysis whose objective is to share the knowledge gained and lessons learned from SCRs with frontline child protection workers."