Care oversights in children’s deaths

Five reports into the deaths of children known to the care services have found shortcomings in how the cases were dealt with.

Two teenagers died by suicide, another died while in residential care, and a seven-month-old baby died from sudden unexpected death in infancy (SUDI). The cause of death was not revealed in one case. The reports were published by the National Review Panel (NRP).

In all cases, the reviews state that “it has found no evidence that action or inaction by the HSE services involved with [the child] directly contributed to [his or her] death”, but numerous shortcomings are highlighted, as well as the children’s backgrounds, which often involved domestic violence, family instability, and alcohol or drug abuse in the home.

In one case, involving a 15-year-old referred to as Tim, the report noted that while the “SWD acted correctly and quickly to reports” involving him and his siblings, initially, “apart from one brief, initial assessment, no further assessment of their needs, and no social history, was compiled or recorded”.

It said the Social Work Department (SWD) was unaware of many details of Tim’s past and made no contact with his father, even though Tim had lived with him for most of his life. There was only “intermittent” contact between the allocated social worker and the family, and “the staffing situation in the area is likely to have contributed to weak practice”.

In the case of Joe, another 15-year-old who died by suicide, staffing was also an issue. “The case was wait-listed as a high priority for over a year prior to Joe’s death, but, according to the evidence provided to the review, it could not be allocated, because of staff shortages,” the report said. All the children in the family had experienced neglect over many years and “should have received consistent intervention from an early stage”, instead of an incident-based response. “The SWD did not make an appropriate response to the reports of concern about Joe at different points, and particularly during the months before his death,” it said.

In the case of Baby Harry, the response to concerns about him was slow, with “none of the services communicating interactively”. No full assessment was conducted and a key point was when Harry’s mother, a victim of domestic abuse, “became reluctant to engage in an assessment, when it was made clear to her that Harry’s father would have to give his consent”. The report said it was not unreasonable that she was “fearful of repercussions” and so “put off by the requirement for both parents to consent to an assessment”.

As for ‘Dylan’, found dead in a residential unit with high levels of toxicity in his system, there were “practice weaknesses” in the case, which was allowed to drift, alongside “some missed opportunities”. It said: “There were gaps in management and supervision, as well as adherence to policies at this time, attributed by staff to a high turnover of social workers and pressure of work, which led to ‘firefighting’.”

‘Avril’ had been out of contact with the SWD for nearly two years, when she died aged 17. The case had been opened on more than one occasion previously. The review found the rationale for closing the case “overlooked Avril’s significant vulnerabilities and that the SWD did not satisfy itself that her needs were being met by alternative services”.

Director of EPIC (Empowering People In Care), Terry Dignan, said: “A lot of these reports refer to the same things — there are recurring themes.”

He said these included inconsistent approaches to cases and responses to crises, rather than continued monitoring and due diligence. He also recommended giving more responsibility to fewer agencies. “We need to follow [the cases] through, until we get an outcome.”

Tusla said it would launch a new Child Protection and Welfare Strategy, later this month, and is developing a revised Alternative Care Strategy to enhance services for children in care.

Jim Gibson, Tusla chief operations officer, said: “The key learning from these reports is that good individual supports are not enough, without a coordinated, multi-agency approach.”

Avril, aged 17

Avril died at 17. Her older siblings were in care when they were young and the family background featured domestic violence, criminality and changes of accommodation. Her mother was a victim of domestic violence and found it difficult to manage her children. Social workers closed her case when Avril was 12 and later reopened and then closed again, but in her early teens she was often out of her mother’s supervision and also out of school for long periods. Her mother was resistant to social work intervention. Avril had been out of contact with the social work department for nearly two years when she died.

Dylan, aged 17

Dylan had only been in Tusla residential care for a few months when he died aged 17. His mother had a drug problem and he and his siblings had been reported to the social work department because of concerns about neglect, poor school attendance, and the age inappropriate responsibilities Dylan was carrying. He switched between living with his stepfather to staying with his mother, who was resistant to social work intervention, before re-entering care following a row with his mother. He was placed in a residential unit as per his wishes but was found dead in the unit a few weeks later.

Baby Harry

The young life of Baby Harry, who died from Sudden Unexpected Death in Infancy at seven months, was marked by the domestic violence suffered by his mother, including an assault the day prior to his birth. The family was referred to a community agency for assessment, but this needed the consent of Harry’s father. Harry’s mother was unwilling to share his contact details for fear of reprisals and stepped back from the process. The public health nurse and the SWD had difficulty keeping in contact with Harry’s mother, who was evicted, and only managed to make brief contact before Harry died.

Joe, aged 15

Joe, who died by suicide at 15, mainly lived with his father, for short periods with his mother, and sometimes with both. There was a history of domestic violence in the family home, along with alleged alcohol abuse. His case was opened and closed at different periods and for most of the time it was allocated, the focus was on Joe’s younger siblings. His education suffered amid mental health and behavioural issues. His father was struggling with his behaviour and sought help but while the case was listed as a high priority for over a year prior to Joe’s death, it could not be allocated because of staff shortages.

Tim, aged 15

Tim’s parents separated when he was young. He stayed mainly with his father. His mother had a drug problem. Tim’s behaviour became very challenging in his early teens. He went to live with his mother and reports emerged that he and his half-sibling were being neglected and drawn into their mother’s addictive behaviour. Tim, who had ADHD, then went to live with an older half-sister, who “was offered no financial assistance by the HSE and had to rely on her mother to provide money”. Following his death, Tim’s half-sister said she later became aware of allegations that he was being bullied at school.


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