Forty-six children known to care services have died since the start of 2010 including 13 in the first four months of this year, with the HSE admitting that its frontline services are under pressure.
The figures were revealed as the independent National Review Panel (NRP), charged with investigating the circumstances of deaths in care, published six detailed files relating to five deaths and one serious incident.
Three deaths followed an accident, one was a suicide and one was natural causes. It found examples of both good and bad practice in the cases, with concerns over a growing number of neglect cases and shortcomings in how they are dealt with.
The figures show that of the 11 deaths in 2011 and the 13 deaths so far this year, five were suicides.
Yesterday Dr Helen Buckley, chair of the NRP, said there was a need for greater integration of services to help young people passing through the care system, particularly regarding issues such as mental health and substance abuse.
Sending their condolences to the families of those who had died, both Dr Buckley and Paul Harrison, HSE national childcare specialist, said improvements were needed to the service.
“From a national perspective there is a lack of policy or a lack of implementation of that policy regarding assessments, supervision and recording,” Dr Buckley said, adding that this was particularly so in cases involving suicide prevention.
Dr Buckley said there had been pressure on services, people placed on waiting lists, delays in referrals and delays in contacting family members, as well as some shortcomings in management and frontline services.
Case conferences had been under-utilised, she said, while inadequate assessments had also featured.
Crucially, she said there had been a failure, “reminiscent of the Roscommon Report”, to take child neglect seriously.
Mr Harrison said there had been improvements in the system since 2010 and work was continuing on achieving better integration of services needed by young people in the care system.
The case files highlighted certain issues, such as the shortage of localised drug treatment places for adolescents and the “labelling” of cases dictating the seriousness with which they were treated, with the panel claiming that neglect is sometimes deprioritised when it can be the most harmful type of child abuse. Mr Harrison said: “Neglect is not an event, it is a process.”
In one case involving a 16-year-old boy who died in an accident, the report shows how he and his siblings suffered neglect in the home and drug use and criminality became commonplace, yet the children remained living with parents who were unable to exert any control in a squalid domestic setting.
The report shows how staff looking at the case took a “family support approach” which in hindsight was unsuccessful.
In the case of ‘Adam’ a young person who died by suicide, the social worker in the case claims they had been consistently told to keep down their mileage.
More reports from the NRP will be forthcoming, including its 2011 annual review in the coming months.
Barnardos chief Fergus Finlay said the report “highlights, yet again, the urgency of reforming the system”.
Care death toll
* 13 deaths so far in 2012 — 7 from natural causes, 3 suicides, 1 RTA and 2 accidents.
* 11 deaths in 2011 — 5 natural causes, 2 suicides, 2 RTA, 1 accident, 1 drug overdose.
* 5 children died in care since the start of 2010.
* 29 people died who were known to childprotection services 2010-2012.
* 12 young adults died 2010-2012.
Inadequacies, failures, and lack of focus on needs
* ADAM: Adam died by suicide in his early teens in 2010. He had been referred to the HSE children and family services in 2009 when he was assaulted while under the influence of alcohol. His case was open at his time of death.
Following the assault he began self-harming then attempted suicide. A family member had died by suicide, his parents were separated and he had been using alcohol and drugs.
The report claims Adam was seen as “relatively low priority” in terms of a child protection risk and that he could have been seen earlier by a social worker.
The report found deficits included limited management oversight, a failure to conduct an assessment of the case beyond the initial screening, and a complete lack of engagement with Adam’s father.
* CHILD N: He had been known to the HSE children and family services for two years prior to his death in 2010.
In the three years before his death he had engaged in risky behaviour, including drug and alcohol misuse, and started borrowing money for drugs. He was threatened and harmed as a result and there were concerns he was contemplating suicide. He made an attempt. Youthreach became involved. His parents sought to admit him into a residential centre for drug treatment, but he turned down one place and was then suspended from Youthreach.
No formal contact was made with N’s school or gardaí, despite his absences from school and home. Concerns about his reasons for drinking and over the suicide of one of his friends was not explored, there is no evidence of any risk assessment in respect of his suicide attempt and the review team was concerned that no case conference or formal strategy was implemented. Children First guidelines were not followed. Reach Out policy guidelines were not applied.
He died in an accident.
* CHILD O: He died in 2010 when he was involved in an accident aged 15. He was the middle child in a large family known to care services since 1991. He lived with his parents but was the subject of a supervision order in the weeks prior to his death.
At that time he had been mixing with peers engaged in drug and alcohol misuse and was missing school. He was involved in criminal behaviour and older boys may have been using him to deal drugs. His parents seemed unable to exercise control. Concerns were raised in 2004.
In 2010 O was seen “out of his head” in a town and had been in head shops. Later that year he was arrested twice and his father said he was on drugs, while conditions at the house were described by a garda as “disgusting”.
The report shows the children and family service adopted a “family support approach”, meaning it was deemed a “welfare” rather than “child protection” issue. The report finds this approach was wrong.
No assessment of the needs of the family was undertaken.
The report accepts that staff were affected by O’s death and the report says in the year prior to it there was little focus on him.
* CHILD R: She was known to the child protection services prior to her death in 2010. She had lived at different periods with her mother and separately with her father.
Early that summer R was removed from a house by gardaí who referred her to the HSE. The case was given the second most urgent rating but by the time she died two months later no contact had been made with R or her family.
The report found that no profile of R’s needs was recorded in any files, R’s extended absences from school were never the subject of recorded discussions, and despite the rapid response of a social worker to the initial garda referral there was not full adherence to Children First guidelines.
However, the NRP believes there is no basis for believing that the placement of R on a waiting list for social work services contributed to her death and accepts there were “undoubted significant staffing and other resource issues”.
* SEAN: He was 14 months old when he died. HSE child and family services worked with his mother, Susan, for months prior to his death and he had been in foster care.
Sean’s mother had been attending counselling for drug use and had problems with depression and alcohol use as well as a history of violent relationships.
When Sean was a baby a domestic violence incident took place in his presence and following a further incident he was deemed at risk and later “confirmed neglect”. He was the subject of a supervision order.
Supports were provided to Sean from the time of his birth to his entry into foster care. The report praises the level of care provided. There was “full compliance” with regulations and the review finds that nothing the HSE children and family service did contributed to his death, which was from natural causes.
* CHILD V: He survived a serious accident in 2010 that affected his wellbeing.
In gardaí notified the HSE after a contact from a relative that V had had an argument with his mother. Gardaí said the referral was “child/parent relationship” rather than “child abuse”.
A student social worker was allocated to V’s case and when their placement ended the case was referred to another social worker with knowledge of the case, which was signed off in summer 2009 with the words: “Things are OK.”
The NRP report found the first meeting between the student social worker and V did not take place until six weeks after the referral — “a long delay” — and that insufficient material was gathered regarding V’s needs, his mental and emotional state, and Garda reports of his underage drinking. His mother voiced concerns he might harm himself but his GP and mental health services were not notified while his father was not engaged in the assessment of V.
That assessment determined there was no need for urgent intervention, but the report states this was “inadequate and unfocussed”, leading to the case “fizzling out”.
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