The Baton Passed On — Statecraft

From Zoetermeer 2015 to Stadskanaal 2026: why the Dutch youth-care chain does not learn

Jacob Huibers — Statecraft, 21 May 2026

§ 01 · The mainstreamed diagnosis

On news site NU.nl on 21 May 2026 there is a quote that would not, until recently, have come from the mouth of the Netherlands Youth Institute, the national knowledge institute that sets the practice standard for Dutch youth care. Asked to explain why youth care had failed again after Stadskanaal, Agnes Derksen described the Dutch system thus: “The care system in the Netherlands works as a relay model. All the organisations involved have tasks and powers laid down in law. When one organ’s task is done, they pass the baton to the next party.” A few paragraphs on, she added: *“Professionals act after each other, not alongside each other.”*¹

Mariëlle Bruning, professor of youth law at Leiden, sets the operational symptom alongside it. Each organisation carries part of the responsibility, no one holds overall direction, the greatest risk is that no one takes that direction. A chain of waiting lists, in each link a new waiting list, with information aging in each waiting period. The diagnosis is that the system behaves exactly as designed. Until recently these were observations from the margin. They now stand, editorially polished, in the largest Dutch news source, in the words of the knowledge institute that sets the executive standard.

The occasion is Stadskanaal. A six-year-old girl and her seven-year-old brother, abused and starved for months by their mothers. The girl had to eat her own vomit, was tied up in a cellar, and was placed in a medically induced coma in February. Veilig Thuis, the Dutch reporting centre for domestic violence and child abuse, had received multiple notifications, including a statement from the primary school about a cut to the head inflicted by the mother with a broomstick. The Health and Youth Care Inspectorate was informed only on 13 May 2026, more than three months after the coma.² What the system accepts as self-diagnosis, it could not prevent in this family.

§ 02 · Christiaan, and what has not changed in eleven years

On 21 April 2015 the police in a rented house in Zoetermeer found a 22-year-old man dead. His name was Christiaan, he was the only one of five children without intellectual disability, he weighed one hundred and ninety kilos, and he lay on a bed in a house that smelt of urine and where the larder was filled with decomposing dead rabbits. His four younger brothers and sister, all four intellectually disabled, lived in the same house. Both parents likewise had an intellectual disability. The family had been known to social services since 2007, eight years before Christiaan’s death. According to the reconstruction by Andreas Kouwenhoven and Ingmar Vriesema in NRC Handelsblad, the help offered proceeded from the own strength of the parents.³ State Secretary Martin van Rijn spoke in September 2015 of something that had “gone terribly wrong” and wanted “the bottom stone to come up”. Christiaan died nearly four months after the Dutch Youth Act, the Jeugdwet, came into force, in the first year of a decentralisation that was to bring care closer to the client.

Between Christiaan and the six-year-old girl in Stadskanaal sits eleven years. In those eleven years the system has inventoried itself repeatedly and redesigned itself on parts. The Samson Committee reported on sexual abuse in residential care. The De Winter Committee on violence in youth care. The Youth Care Reform Agenda was signed in July 2023 between central government, the Association of Netherlands Municipalities and providers. The Van Ark Committee found in January 2025 that the agenda’s billion-euro savings target was not feasible. In the Vlaardingen foster home in November 2025 foster parents were sentenced to eight years in prison for the abuse of a girl who had been kept, among other things, locked in a cage. In Harreveld and Zetten in 2024 the closed-setting youth-care units known as ZIKOS were shut after an inquiry by lived-experience advocate Jason Bhugwandass into twenty hours of daily isolation of juveniles. Every time the same sequence. A report, a pledge, a draft bill, a recalibration, a next case.

What went wrong in Stadskanaal in 2026 was not what went wrong in Zoetermeer in 2015. The cases differ in facts, in organisations involved, in legal qualification. What does not differ is the architecture that makes them possible. Eight years of involvement before Christiaan’s death. Months of involvement before the girl’s coma. Between the two cases a Reform Agenda whose savings target had been withdrawn before it came into force, a rise in the number of youth-care providers from roughly twelve hundred to around seven thousand, and an average waiting time for a child in need that during this period has climbed to forty-four weeks.⁴ The system now diagnoses itself accurately. It does not change itself.

§ 03 · The law that arrives narrower, and the law that was taken away

On 5 May 2020 the draft Wet aanpak meervoudige problematiek sociaal domein, the Multiple Problems Social Domain Act (Wams), entered public consultation. The aim was to lay the legal basis for cross-domain data sharing in families with multiple problems — the kind of families for which the slogan “one family, one plan, one regisseur” (one director-coordinator) had been devised since the 2015 decentralisation without the legal basis for data exchange ever being delivered. Consultation closed on 1 June 2020. The consultation report appeared on 28 September 2021. Intended entry into force was end-2022, then 1 July 2024, then indefinite. In April 2016 the Dutch Data Protection Authority (AP) had already signalled that a sound legal basis for data sharing was missing and that this led to operational paralysis.⁵

In September 2023 the Rutte IV cabinet fell. The Wams was at parliament’s request declared controversieel, the Dutch term for legislation parked pending a new cabinet. Only under the coalition agreement Aan de slag (“To Work”) of D66, VVD and CDA, signed on 30 January 2026, was the bill taken up again. On 19 February 2026 State Secretary Pouw-Verweij published an amendment that substantially narrowed the original ambition. The proposed possibility to breach medical confidentiality under a Wams legal basis was struck out. Only the explicit consent of the data subject, or an existing statutory exception, remains available as a processing basis for substantive sharing. Use of Wams data for enforcement or fraud-fighting was expressly forbidden and criminalised.⁶

A clarification belongs here that is rarely made explicit in the public debate. The professional confidentiality at issue in the Wams is principally the medical confidentiality of article 7:457 of the Civil Code and article 88 of the Wet BIG, the Act regulating health-care professions, which binds those registered under it. Social professionals in the youth-care chain, such as youth-protection officers, family guardians and Veilig Thuis staff, do not fall under it. For the chain itself, grounds for substantive sharing already exist under articles 7.3.11 and 7.3.12 of the Youth Act, and the reporting right of article 5.2.6 of the Social Support Act 2015. What the amendment strikes is the possibility of legally covering that substantive sharing on the medical flank of the chain, where general practitioners, youth doctors and mental-health professionals hold signals that in multi-problem families are often the sharpest.

A second hollow joins it. As of 1 January 2024 the Verwijsindex Risicojongeren, the Referral Index for At-Risk Youth (VIR), was abolished by amendment to the Youth Act without a successor being delivered.⁷ The Referral Index recorded not the content of care but the fact that a professional was involved with a minor, with a match mechanism that brought the involved professionals to one another. The legal distinction between that-information (the fact of involvement) and what-information (the content) was anchored as design principle in its architecture. For the Stadskanaal typology, in which the problem is not always that the family doctor may share his file but that the compulsory-education officer or Veilig Thuis staff member simply does not know that a doctor is in the picture, that is a considerable loss of basic infrastructure.

The system therefore lacks two things at once. For what-sharing across the medical-social boundary, the amendment leaves no workable legal basis. For that-sharing, the base layer that makes who-is-involved-with-whom visible, no working provision has existed since January 2024. The municipalities meanwhile — as the AP enforcement of February 2026 underscores with a combined fine of two hundred and fifty thousand euros for ten municipalities for processing without a sound legal basis — continue to carry the full burden of proof for processing on a sound legal basis.⁸ The law that was meant to legally carry the cooperation does not provide that backing, and the provision that was to anchor elementary findability of professionals within a single family has not existed for over a year and a half.

§ 04 · The architecture beneath the chain

Arjan Widlak and Rik Peeters, lead researchers of the Kafkabrigade Foundation, have in their work on the digital state introduced a distinction that is diagnostic in this dossier. Alongside the street-level bureaucracy of Lipsky they distinguish what they call infrastructure-level bureaucracy: the layer at which registers, data linkages, identification systems and exchange protocols determine which outcomes are possible at all before any professional or administrator takes a decision.⁹ In the car-theft case of a woman from Amersfoort that they have made publicly known, the vehicle registration authority, the central fines collection agency and the tax administration pursued her for ten years for a vehicle she no longer owned. No civil servant worked carelessly. The architecture produced the outcome.

Applied to the youth-care chain that lens gives a different picture from the one the cooperation discussion presupposes. The chain Veilig Thuis, municipality, Child Protection Board, juvenile court judge, youth-protection agency has no shared dossier, no integrated sight of who is involved with which child, no audit trail of earlier signals, no cross-organisational that-provision to replace the abolished Referral Index. The procurement infrastructure differs per municipality, often in an Open House arrangement under which the number of providers has multiplied sevenfold in ten years. The legal infrastructure for substantive data sharing across the medical-social boundary is, even after the Wams has been resumed in February 2026, narrower than the chain would ask of it. The funding infrastructure runs partly through the municipal fund, partly through specific grants, partly through supplementary central contributions, in a distribution model patched together through litigation and arbitration.

Anyone who does not touch the architecture can cooperate without limit at the organisation level. The family guardian will still consult by phone with the compulsory-education officer, the family doctor, the local team, the debt counsellor, the youth doctor and the youth-protection officer. Every handover will remain informal, person-dependent, legally fragile and architecturally unanchored. The next Stadskanaal case will not fail because the professionals did not want to cooperate. It will fail because the infrastructure beneath them makes cooperation impossible at the scale the problem would ask of it.

The constructive route is therefore not to wait for a broader Wams. It is to build the that-layer that was taken away in January 2024 with the abolition of the Referral Index, with better governance than the Referral Index ever had. That is what has been developed in recent years under the House of Viridian flag with iRecord: a platform that registers the involvement of professionals with a client, with legal basis, purpose, timestamp and parties involved in an immutable audit trail.¹⁰ It is deliberately a that-platform and not a what-platform. What the family doctor or youth doctor then shares in further professional contact remains a conversation between professionals under the exception grounds of article 7.3.12 of the Youth Act or emergency. iRecord makes it possible for them to find one another at all; it does not breach their professional confidentiality.

The legal space for this type of platform is therefore not dependent on what parliament does with the Wams. The grounds for that-sharing exist, in articles 7.3.11 and 7.3.12 of the Youth Act, in article 5.2.6 of the Social Support Act 2015 and in the broader GDPR grounds. What is missing is the infrastructure, and until January 2024 that was the Referral Index. The position is more modest than the Wams in its original form had promised. It is more practical than waiting for the next parliamentary majority, and it has the advantage of being legally uncontroversial.

§ 05 · Why the chain does not learn

Chris Argyris and Donald Schön distinguished in Organizational Learning (1978) two levels of learning. Single-loop is the correction of actions within existing assumptions about how work is supposed to be done. Double-loop is the questioning of the assumptions themselves. Argyris worked on into the 1990s on the observation that organisations confronted with dysfunction systematically remain in single-loop, and that they do so through defensive routines, predictable patterns by which individuals and groups protect themselves and the organisation against the painful information that the assumptions themselves are wobbling.¹¹ The application of this frame to the Dutch repair operations was worked out earlier in this corpus in De opgenomen schuld zonder integratie (“The Debt Absorbed Without Integration”). Here the pattern unfolds in real time.

The reaction to Stadskanaal now taking shape is single-loop in every part. A better cooperation agreement between Veilig Thuis and the Child Protection Board, single-loop. A coordinator for the approach to multiple problems, single-loop. A revision of notification prioritisation within Veilig Thuis, single-loop. A new framework for executive authority in family guardianship, single-loop. A pilot in a handful of municipalities, single-loop. A working conference, a report to parliament, a recalibration of the Strong Local Teams Covenant, all single-loop. The apparatus is patched. The frame within which the apparatus operates remains intact.

Double-loop would ask whether the chain itself is the right form. Whether the separation between Veilig Thuis, Child Protection Board and youth-protection agency, born of historical and administrative grounds that only partly correspond to today’s task, can be maintained in its current form. Whether the Open House procurement model under which the number of providers has exploded should be replaced by tendering that makes capacity and quality actually steerable. Whether the municipal responsibility for execution and the central-government system responsibility should be unified into a single institutional carrier. Whether the choice in the Wams amendment to strike the breach of medical confidentiality, and the choice to abolish the Referral Index without successor, together permanently block the workability of one family, one plan, one director-coordinator for the families for which it was intended. Whether the Child Protection Board should retain its institutional independence in a context that demands direction.

None of these questions will be put in the State Secretary’s pre-summer announcement. Not because they are suppressed, but because the institutional set-up of the system has no actor able to put them. The Child Protection Board has expressly indicated that it wishes to remain independent. That is rational self-protection within a chain where responsibility is fragmented. The same applies to youth protection, to the certified institutions, to the municipalities, to the ministry. Every player is incentive-aligned to defend its own position within the existing architecture. The sum of those rationalities is a chain that diagnoses itself accurately and cannot convert that diagnosis into redesign.

That is what Argyris meant by defensive routines at system level. The competence of each individual actor in protecting its own mandate is what smothers the collective learning impulse. Whoever within the chain proposed that their own organisation be abolished or absorbed into another institutional carrier would endanger their next assignment. The double-loop has no carrier in this architecture. It would have to come from outside, from an actor with a mandate that transcends the existing organisations and that is independent of their continued existence. No such actor exists.

§ 06 · Conclusion

What the Stadskanaal case yields for the corpus is not a new diagnosis. It is a triple confirmation. The knowledge institute of youth care now articulates in its own words what this corpus has earlier characterised as a dissociated system. The law that should have legally carried the substantive cooperation across the medical-social boundary has, after six years of parliamentary silence and a change of coalition, arrived narrower than the diagnosis asks. And the base layer that anchored visibility of involvement, the Referral Index for At-Risk Youth, was taken away well over a year earlier without a successor. Between Zoetermeer 2015 and Stadskanaal 2026 sits eleven years of diagnosis without redesign, and on top of that a year and a half without a that-layer.

Christiaan in Zoetermeer and the girl in Stadskanaal did not wait for a working conference, a recalibration, a pilot. They waited for the link that would sum up the signals present in the system into one picture and act on it. That link was not there for Christiaan. It was not there for the six-year-old girl. The relay was run in both cases. The baton was passed in both cases. The finish remains out of sight.

A chain does not learn without a carrier that can hold double-loop institutionally. As long as the lower house of parliament does not adopt its bill in a form that truly covers the diagnosis, the Child Protection Board does not relativise its independence, central government does not unify its system responsibility with executive responsibility, and the municipalities do not rebuild their procurement and information infrastructure, Stadskanaal remains a way station. The next case will come in a form not yet predictable, in a place we do not know, with names we have not yet heard. The architecture that makes it possible is the same.

Colofon

“The Baton Passed On” is a Statecraft essay placing the Stadskanaal case alongside the Zoetermeer case of 2015 and laying bare the architecture beneath the Dutch youth-care chain.

Statement of interest. The author is the founder of House of Viridian OÜ, under which iRecord is developed. The analysis in this publication has come about on the author’s own initiative and reflects the substantive position of Statecraft.

Responses and counter-arguments via Statecraft.nl.

Jacob Huibers is an interim manager with more than twenty years of experience in the Dutch public sector. He has worked as cluster manager, cluster director and quartermaster at municipalities ranging from fifty thousand to over two hundred thousand inhabitants, and at inter-municipal collaborative bodies across the social and physical domains. Statecraft is his platform for strategic reflection on public-sector execution, pillar IV of House of Viridian.

Footnotes

¹ Fenna van Loenhout, “Iedereen wil weten waarom jeugdzorg wéér kon falen: ‘Stokje wordt doorgegeven’” (“Everyone wants to know why youth care could fail again: ‘The baton is being passed’”), NU.nl, 21 May 2026.

² NOS, “Kindermishandeling door moeders Stadskanaal was planmatig, stellen experts” (“Child abuse by Stadskanaal mothers was planned, experts say”), 16 May 2026; Nationale Zorggids, “Directe uithuisplaatsing kinderen Stadskanaal bleef uit ondanks meerdere signalen” (“Immediate removal of Stadskanaal children failed despite multiple signals”), 19 May 2026; Hart van Nederland, “Dit weten we nu over de gruwelijke mishandeling van 2 kinderen in Stadskanaal” (“What we now know about the horrific abuse of 2 children in Stadskanaal”), 16 May 2026; press conference of Mayor Klaas Sloots and the Health and Youth Care Inspectorate, 16 May 2026.

³ Andreas Kouwenhoven and Ingmar Vriesema, “Probeert u het eerst nog even zelf” (“Could you please try it yourself first”), NRC Handelsblad, 26 September 2015. The article won De Tegel for investigative journalism in 2016. See also Omroep West, “Instanties trekken aan de bel na dood man uit probleemgezin Zoetermeer” (“Agencies sound the alarm after death of man from troubled Zoetermeer family”), 28 September 2015.

⁴ Jacob Huibers, Dissociated Organisations (Statecraft, 2026), § 05 “Second case: the youth-care chain”; Improven, Final Report Expenditure Survey Youth Care 2023 and 2024, commissioned by the Ministry of Health, Welfare and Sport, November 2024; Van Ark Expert Committee, Groeipijn (“Growing Pains”), interim advice on the Youth Care Reform Agenda, 30 January 2025; for the growth in providers see Chamber of Commerce registrations, as set out in the youth-care section of Dissociated Organisations.

⁵ Dutch Data Protection Authority, Verwerking van persoonsgegevens in het sociaal domein: De rol van toestemming (“Processing of personal data in the social domain: the role of consent”), April 2016; later DPA, Advice on the draft Wams, on the bill as offered for consultation in spring 2020.

⁶ Amendment to the Wet aanpak meervoudige problematiek sociaal domein, State Secretary Pouw-Verweij, 19 February 2026; coalition agreement Aan de slag, D66 / VVD / CDA, 30 January 2026; Legislative Calendar, Wet aanpak meervoudige problematiek sociaal domein (Wams), WGK010837; Association of Netherlands Municipalities, Wetsvoorstel aanpak meervoudige problematiek in het sociaal domein (Wams), updated after the amendment of February 2026.

⁷ The Referral Index for At-Risk Youth (VIR) was regulated in article 7.1.4.1 and following of the Youth Act, originally based on the Youth Care Act and incorporated into the Youth Act in 2015. The abolition as of 1 January 2024 took place through an amendment to the Youth Act, after evaluations pointing to limited use and operational problems, without a successor being provided for. For the design principle of separation between the fact of involvement (that) and the content of care (what), see the original explanatory memorandum, Parliamentary Papers II 2007/08, 31 855, and the subsequent evaluations.

⁸ Dutch Data Protection Authority, fine decisions ten municipalities, February 2026, total sum € 250,000 for processing without a sound legal basis in the social domain. For the interpretation of this simultaneity see also House of Viridian, WAMS, toestemming en de infrastructuur die ontbreekt (“WAMS, consent and the missing infrastructure”), position paper, 20 February 2026.

⁹ Arjan Widlak and Rik Peeters, De Digitale Kooi (“The Digital Cage”), Boom Bestuurskunde, 2018; Widlak, Volwassen Digitale Overheid (“A Mature Digital Government”), Boom Bestuurskunde, 2022; Widlak and Peeters, “A theory of the infrastructure-level bureaucracy”, Government Information Quarterly 42(2), 2025; Denktank Achterkant van de Overheid, Nieuwland: een ontwerp voor de digitale rechtsstaat (“Nieuwland: a design for the digital rule of law”), 2026.

¹⁰ iRecord is developed by Viridian B.V. under House of Viridian. For its positioning around consent, legal-basis and purpose-binding management in the social domain, see irecord.houseofviridian.org and the position paper WAMS, toestemming en de infrastructuur die ontbreekt, House of Viridian, 20 February 2026. For the earlier conceptual embedding see Jacob Huibers, Gedissocieerde Organisaties (“Dissociated Organisations”) (Statecraft, 2026), § 05.

¹¹ Chris Argyris and Donald Schön, Organizational Learning: A Theory of Action Perspective, Addison-Wesley, 1978; Argyris, Overcoming Organizational Defenses, Allyn & Bacon, 1990; for the earlier application of this frame to the Dutch repair operations see Jacob Huibers, “De opgenomen schuld zonder integratie”, symptom paper III in the series Gedissocieerde Organisaties, Statecraft, May 2026.