Being in care not the same as being safe - DANNY’S DEATH
Danny Talbot who died of a drug overdose within two weeks of leaving prison showed the “folly” of assuming children are safe because they are in the care system.
He is called Luke in the report on the tragic teenager, described as a young person full of contradictions by those who knew him.
Danny could be very charming and had a good sense of humour, but he had emotional difficulties that were very evident in his mood swings, his low self-image and his sometimes aggressive behaviour.
His mother had intellectual and learning disabilities which meant she was unable to care for her children.
Danny lived with his father and a severely disabled sibling until his father’s death when he was nearly 10 years old.
Danny was seven when his primary school raised concerns with the HSE’s social work department about possible sexual abuse.
However, the review team were unable to establish how the sexual abuse concern was followed up
because of poor records.
He was placed in foster care with friends of his extended family when his father died but there is no
evidence that the arrangement was formally assessed and approved by the health board at the time.
Danny’s foster care arrangement broke down when he was 15. years old. It followed a year during which he had been suspended from school and had disclosed earlier sexual abuse by his father.
His life became chaotic in the years that followed. He went from a residential unit to an emergency hostel for homeless young people in the inner city and spent another spell with his former foster carers.
Each of the placements broke down because of his behaviour and inability of those caring for him to manage it.
Danny was becoming increasingly involved in substance abuse and criminal activity and sometimes slept rough on the streets of Dublin.
At one stage, his extended family went to court because they were very concerned about him.
Danny spent three, separate periods in prison after his 18th birthday and stayed in crisis accommodation in between sentences.
He had intended undergoing drug treatment after his last prison release. He appeared to manage well initially, showing no sign of substance abuse at first. However, within two weeks of leaving prison he died from a drug overdose in August 2009.
The review team found there was an “inadequate response” to evidence that Danny was experiencing child abuse and neglect as a young child, which compounded his later problems. Also, Danny’s needs were not comprehensively assessed at any time,throughout the short history of his life, despite the many crises he experienced.
There appeared to be a chronic lack of placement options available to a child with Danny’s needs.
Too much responsibility for his care was left with his family and foster parents and there were serious weaknesses in management and accountability within the HSE.
'Crisis child needs prompt response’ - Nicholas's DeathNicholas was just five years old when he was first referred to the HSE’s social work department — 12 years later he died after consuming a toxic combination of drugs.
The original reason for contact between Nicholas* and the child protection services was neglect, due to parental conflict, maternal alcohol misuse and family homelessness.
The report was particularly critical of the health authority for allowing him to remain too long in an environment where drug misuse was the norm.
Family issues were addressed through the separation of his parents and the provision of supported accommodation for his father, himself and his siblings.
There were concerns, however, about Nicholas being neglected and abused — both emotionally and physically — and the obvious inability of his father to care for himself, let alone his children, because of his chronic drug problem and poor health.
Despite the concerns, the emphasis on social work intervention was on maintaining the family and attempting to build the father’s parenting capacity.
The review team thought it was “ambitious” to think that Nicholas’ father could provide adequate care.
“Too much energy was spent supporting Philip (the father) to exert control, which he was clearly incapable of exerting, rather than supporting Nicholas to remain in school, avoid exposure to drugs and crime and develop into a responsible adult.”
Because the boy’s father was passive, well liked and relatively amenable, the issue did not become as pressing as it should have and, despite the obvious inadequacy of the domestic environment, matters were allowed to drift.
“The extent to which Philip’s drug use went unchallenged by the staff involved in the case was striking,” the review team stated.
Nicholas became a father in his mid teens and shortly afterwards ended up in a high-support unit after becoming involved in anti-social behaviour and drug misuse.
He was known to smoke cannabis regularly, sometimes in the presence of his father and, on several occasions, had become dangerously affected by the products of so-called head shops.
When Nicholas was perceived to be presenting an excessively high risk, a child protection case conference was arranged but it was postponed for more than five months.
When it eventually met and a decision was made to seek a high-support place, another four months elapsed before the place was made available.
The review team said this was an inordinately long time for all of the parties directly involved to have to wait for action: “For a child in a crisis, a measured and prompt response is essential.”
They concluded that the services made available to Nicholas could not compensate for the neglect he experienced from parents who did not have the capacity to provide adequate care and his childhood exposure to domestic violence and substance abuse.
Parents’ reluctance limited positive impact - Susan's Death
A little girl died in an accident in her home just six months after being returned from foster care to her family.
Known as Susan*, she was the only child of her mother, Kate, and had often been left in the care of other people, some of whom did not know her. After three-and-a-half months in care, Susan was returned to her family and remained with them until her death. She was 15 months old.
However, a review of her case found there was no link between the services offered to the family and the child’s tragic death.
The report points out that those who knew Susan described her as a beautiful, happy, bubbly child who was “easy to give cuddles to”.
Her mother, Kate, and her husband, Paul, were married, and while Susan was not Paul’s biological child, he was very involved in her care.
Neither Kate nor Paul came from Ireland; they had no family in the country or wider community support.
Susan was referred to the HSE when she was six months old.
A woman who had agreed to mind Susan brought her to a Garda station after being unable to contact her mother.
The child was taken into care on the basis that she would be eventually returned to her family.
A family support worker was allocated to Kate and her partner and a place arranged for Susan in a community nursery.
After Susan was returned to her family, the main risk identified was the tendency of her mother to disengage from supports. The child was making progress at home and developed a good bond with her mother.
Kate withdrew Susan from the nursery and the family support service was terminated due to her lack of commitment and a difficulty in identifying a role for the service.
No concerns were noted about the child’s safety and welfare. The public health nurse continued to visit the child’s home.
However, the team found there was no written plan or contract on file in respect of the child’s return home.
They did find that appropriate services were put in place when the child returned to her family, but the reluctance of Susan’s parents limited their positive impact.
The review team also felt that there was probably a level of over optimism in the assessment of the child’s parents’ capacity to mind her, largely because of the lack of available information and the family’s avoidance of contact.
Family withheld consent for boy’s continuing medical treatment - Johns Death
Social workers acted promptly in dealing with a boy who later died from a serious illness, a report has found.
His family withheld consent for continuing medical treatment, opting for alternative and complementary medicine.
The review team found that neither the HSE nor the hospital could have done anything more to prolong the life of the boy, known as John*.
However, it found there was a lack of clarity about whether the hospital or the HSE should take legal action, and that delayed intervention for months.
After the case was referred to the HSE, it applied to the High Court for an order to dispense with parental consent for treatment.
When the case was adjourned and a third medical opinion upheld two made previously, the boy’s parents agreed to resume treatment.
Shortly afterwards, one of the parents removed John from the jurisdiction.
The High Court declined to make an order in case it would deter the parent from returning with John.
The parent brought John back to Ireland and he died some time later in hospital.
However, while the coroner was informed of the circumstances of the boy’s death, no inquest was held. The review team believes an inquest would have been a useful exercise.
It also believes the Office of the Attorney General should be made aware of the case’s circumstances.
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