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Modern medical care for critically ill children meets the definition of a Volatile, Uncertain, Complex, and Ambiguous (VUCA) situation with an additional “R” factor of high risk (suffering and potential death of a child). The circumstances of care for a critically ill child create a unique psychological, social, and technical crucible for all involved, one primed for conflict. This article will trace the evolution of our study of inter-group conflict between physicians in the care of critically ill children from initial observations to broad, systematic surveys and qualitative analysis of practitioner focus groups. Our findings indicated that unconscious inter-group dynamics, shaped by setting variables, can significantly impair collective work towards the best interests of patients in these fraught circumstances, making “integrative deci-sion-making” difficult to achieve. Patterns in inter-group relations clearly suggested the use of splitting as a social defence. The findings and related hypotheses pro-vided clues for strategies to mitigate the impact of these dynamics. This article con-cludes with a description of the design and pilot testing of a structured method of case review designed to provide containing structures tuned to the specific context with the ultimate aim of facilitating integrative decision-making and optimising co-ordination of care for complex cases.