Failures of Child and Family Agency leaving some children at risk of abuse

The Child and Family Agency (Tusla) must take urgent action to address serious shortcomings in how it manages allegations of child sexual abuse, according to the findings of an investigation published today by the Health Information and Quality Authority (Hiqa).

The investigation was requested by the Minister for Children and Youth Affairs Katherine Zappone TD following Tusla’s handling of a false allegation about garda whistleblower Maurice McCabe.

"The Investigation found that while Tusla focused on examining current risks to children, this often resulted in a lack of urgency in responding to allegations of abuse involving adults who alleged they had been abused as children," said Mary Dunnion, Hiqa’s director of regulation.

This meant that children who are potentially at risk — from adults who are alleged to have abused children in the past, and or who were convicted of child sexual abuse in the past, and who now have access to other children — may be missed.

"The deficiencies identified in this investigation demonstrate that some children and adults who come in contact with Tusla in connection with child sexual abuse and retrospective abuse allegations have a varied experience of Tusla services.

"While for some this was a positive one, others experienced lengthy delays or no response to their cases.

Mary Dunnion, Hiqa’s director of regulation.

“Those with responsibility at executive and board level in Tusla must recognise that managing all allegations of child sexual abuse follows the same referral pathway as child protection and welfare referrals.

"As such, there is a significant risk that the deficiencies identified during this investigation in the pathway for allegations of child sexual abuse in a sample of the services provided by Tusla may be replicated across the wider child protection and welfare services.

"Therefore, the Investigation Team recommends, for the elimination of doubt in relation to actual or potential risk to children, that Tusla, as a matter of urgency, implements a time-bound action plan to effectively address these findings, to include ongoing evaluation and assurance."

Commenting on the publication Fred McBride, Chief Executive of Tusla said: "I fully accept that inconsistencies in practice remain where children are not at an immediate risk, and this is something that is being addressed through our comprehensive programme of reform which is showing real improvements – for example on the July 9 for the first time in the history of the State all 17 areas around the country will be able to access an integrated system through the National Childcare Information System.”

He continued: “It is also important to note that the area of child abuse and neglect is extremely challenging and complex.

"Children are abused or at risk of abuse every day in Ireland.

"Our staff are professionally trained to deal with complex human relations and often with unpredictable, irrational and sometimes violent human behaviour and whilst policies and procedures are of the utmost importance each situation requires and individual response and what is in the best interests of the child in one situation may not be appropriate in another."

The report makes four main recommendations for the Department of Children and Youth Affairs and for Tusla, in addition to other actions which Tusla must urgently take.

These include the Department establishing an oversight group to support and advise on the implementation of these recommendations and the Department and Tusla creating formal career-paths for students and graduates to reinforce child protection and welfare services.

“It is vital that Tusla’s governance structures to support the implementation of the findings and recommendations of this investigation report are clear, and include a named accountable person within Tusla who has the overall delegated responsibility for implementing these recommendations," said Ms Dunnion.

"The associated implementation plan should include clear timelines against each action and identified individuals in Tusla who are responsible for implementing those actions.

"We acknowledge there is now a clear strategic direction and a long-term vision of what Tusla wants to achieve, and there are structures and systems in place to govern Tusla child protection and welfare services.

"However, these are not comprehensively and consistently understood, embedded or implemented in front-line practice in the services areas visited by the Investigation Team.

A shortage of qualified social work staff is undoubtedly contributing to delays in the appropriate management of referrals and the early assessment of children at risk.

"However, Tusla, in conjunction with the Department of Children and Youth Affairs, has to manage the same workforce challenges faced by other jurisdictions and avoid an organisational mind-set that sees such problems as insurmountable due to factors outside its control."

While appropriate action had been taken by social workers when children were assessed as being at immediate and serious risk, the investigation found some children are being left at potential risk due to a number of failures at operational level.

These include failures to:

  • consistently implement Tusla’s national policies and business processes;
  • accurately record important decisions made and actions taken;
  • monitor the effectiveness of the steps taken to protect children;
  • support staff members’ personal development;
  • manage under-performance.
  • These failings stem from a gap between national Tusla policy and what is actually happening on the ground.

    The Investigation found shortfalls in:

  • how child abuse allegations were screened;
  • how safety plans for children were developed and managed;
  • how people who were the subject of an allegation of abuse were communicated with.
  • It identified systems risk as a result of three main defective points in Tusla’s response to managing allegations of child sexual abuse, including allegations made by adults about being abused when they were children, and which in some cases, left children at potential risk.

    Tusla must now address as a matter of urgency:

  • Screening and preliminary enquiry: The investigation found inconsistencies in practice around the screening of allegations of child sexual abuse and making preliminary enquiries into these allegations, which meant that not all children at potential risk were being assessed and where necessary, protected by Tusla, in a timely and effective manner.
  • Safety planning: Inconsistencies in safety-planning practice by Tusla for children meant that while some children were adequately safeguarded, others at potential risk were not. Even for children who had a safety plan, these plans were not always reviewed to ensure the continued safety and wellbeing of the child.
  • Management of retrospective cases: While there was a policy on managing allegations made by adults of abuse during their childhood, it did not include a standardised approach to direct and guide staff in case management, leading to variation in practice and delays. Some people were not told that an allegation of abuse had been made against them and others were given only limited information.
  • In other findings, while there was a system in place for the notification of suspected child sexual abuse between An Garda Síochána and Tusla, there was no electronic data transfer system in place between these two agencies.

    Instead, these notifications have to be sent by fax or posted.

    The Investigation found poor quality record-keeping in the services reviewed, which could not assure HIQA about the quality and effectiveness of Tusla’s child protection and welfare service.

    The Investigation Team reviewed 164 cases reported as closed in six Tusla service areas and could not establish if some of the cases reviewed were actually closed.

    Furthermore, the Investigation Team found cases which were inappropriately closed as there were outstanding child protection concerns.

    The Investigation Team also expressed concern about Tusla plans to continue to use paper records for cases involving allegations made by adults that they were abused as children.

    "Tusla must now ensure that it now urgently addresses the systemic deficiencies identified by HIQA in its governance and support arrangements," said Ms Dunnion.

    This is necessary to ensure the effective and sustainable management of child sexual abuse referrals involving adults of concern, including where adults alleged they were abused as children.

    Read the report in full here:

    Read Tusla's full response to the report below.

    Child and Family Agency notes the publication of, and accepts the findings and recommendations in HIQA’s ‘Investigation into the management of allegations of child sexual abuse (CSA) against adults of concern by the Child and Family Agency (Tusla), upon the direction of the Minister for Children and Youth Affairs (the investigation)’.Tusla’s core mission is the wellbeing of children and families and we welcome any scrutiny and evaluation that drives improvement to ultimately enhance services for children and families. This HIQA investigation highlights issues faced by the Agency, which we take exceptionally seriously, which we have been actively working to address over the past four years through a comprehensive organisational and cultural reform programme. We welcome HIQAs’ recommendations and look forward to working with the oversight group being established by the Minister to support the implementation of the recommendations made by HIQA. As an agency, we have previous experience of working with oversight groups and as an agency we work very successfully with these groups. Commenting on the publication Fred McBride, Chief Executive, Tusla said: “I welcome HIQA’s recognition that there is now clear strategic direction and a long term vision of what Tusla wants to achieve. Our core mission is the wellbeing of children and families and I want to reassure the public that where a child is referred to Tusla and there is an immediate risk they receive an immediate protective response to keep them safe from harm. Tusla welcomes HIQA’s confirmation in this investigation and all other HIQA inspection reports that practice in this area is consistent around the country.I fully accept that inconsistencies in practice remain where children are not at an immediate risk, and this is something that is being addressed through our comprehensive programme of reform which is showing real improvements – for example on the 9th of July for the first time in the history of the State all 17 areas around the country will be able to access an integrated system through the National Childcare Information System.”He continued: “It is also important to note that the area of child abuse and neglect is extremely challenging and complex. Children are abused or at risk of abuse every day in Ireland. Our staff are professionally trained to deal with complex human relations and often with unpredictable, irrational and sometimes violent human behaviour and whilst policies and procedures are of the utmost importance each situation requires and individual response and what is in the best interests of the child in one situation may not be appropriate in another.In 2018 Tusla was allocated and additional €40.6m which brought the operational budget to over €750m* and this significant investment is allowing us to progress across key areas. It is important that we continue to improve consistency throughout the country so that children and families receive a timely and proportionate response and I welcome the announcement that the Minister is establishing an oversight group to support the implementation of the recommendations made by HIQA. We have previous experience of working with oversight groups and as an agency we work very successfully with these groups.”As HIQA notes, some inconsistencies and delays remain in the system in relation to cases where children are not at an immediate risk and it is crucial that consistency is achieved to provide timely, appropriate and proportionate services to children and families. This is why in 2015 Tusla developed a clear understanding of the problems in child protection and welfare and developed a comprehensive programme with strong governance and monitoring arrangements where all cases are screened and prioritised as part of our work, which in turn brings consistency to practice and assists the agency in ensuring the high risk cases are responded to first. This is also supported by a new approach to practice – Signs of Safety.Tusla was established in 2014 following 29 inquiries and 551 recommendations to improve child protection in Ireland the agency welcomes HIQA’s view that the development of Tusla in 2014 for the protection of children and families at risk is a positive development.When the agency was established it inherited many outdated systems and significant challenges which are actively being worked through as part of the programme of reform.Key developments over the past four years include:

  • The national roll out of a national computerised information system across the country which means that for the first time in the history of the state, all 17 areas on one integrated system.
  • Responding to over 53,000 referrals a year – one referral every 10 minutes.
  • The development of inter-agency protocols to assist working with key partners and the monitoring of these arrangements at local level.
  • The development of a new Child Protection and Welfare Strategy which includes a new approach to practice - Signs of Safety, which focuses on working alongside children and families to find solutions.
  • The development and expansion of early intervention work through the Prevention, Partnership and Family Support programme which supports families in their local communities with initiatives such as parenting 24/7 and Meitheal.
  • The reduction of high priority unallocated cases by 75% since establishment.
  • The reduction of unallocated cases by 51% since establishment.
  • Tusla welcomes all of the recommendations made by HIQA and will promptly:
  • Review all of the findings of this investigation.
  • Review these findings as they relate to all other child protection and welfare referrals.
  • Review all of the recommendations made by the investigation team.
  • Publish an action plan on www.tusla.ie outlining the measures to be taken and clear timelines for this.
  • Continually review and update this action plan.
  • Work with the Department of Children and Youth Affairs to seek the assistance of the higher education and training establishments to create formal career-path mechanisms for students and graduates to support current and future workforce needs in Tusla.
  • Work with the Department of Children and Youth Affairs to review the current operational arrangements in Tusla to identify efficiencies and improvements in workflow, including the review of the existing social worker, social care worker and support staff skill-mix, and the development of a workforce strategy.

    Digital Desk


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