Tragic end to a case that was ‘poorly managed at every level’

Robert was described as “a little charmer” — likeable, funny, and popular. He died by suicide as a young adult with the coroner linking his death to “the recent use of multiple drugs”. It was a sad end to a difficult and damaged life.

The comprehensive review into his death, led by HSE National Review Panel chairwoman Dr Helen Buckley, found shortcomings in how his case was dealt with; with gaps in records and numerous missed opportunities.

Robert had been in the care of the HSE and living with relatives for the seven-and-a-half years prior to his death. His mother’s eldest child, Robert’s father died before he was born. Aged five, there was an allegation he had been sexually abused by someone known to his mother — who herself claimed she had been abused by her father — but the allegation was not confirmed. Aged seven, there was an allegation of neglect and physical abuse. Aged 11, he and his siblings were admitted to voluntary care. He stayed with one family member for five years and another family member for two.

Aged 16, he began to drink and take drugs. Robert declined drug treatment and turned down aftercare when he turned 18. He contacted a counselling service prior to his death, which was premeditated. He rang family members the day he died, telling one it was “time to go to sleep for good”; he asked another to look after his grave.

That is just part of the story. His mother’s partner had physically and verbally abused him, with his mother admitting to being beaten and to injecting drugs. It was feared at one point that they were spending “all their money” on drugs as the children went hungry.

Robert’s schooling suffered and aged nine he appeared malnourished and sometimes slept rough. By 10 he was drinking and smoking cannabis. The review found the only formal attempt to identify his needs when he was younger was recorded in his only care plan when he was aged 11.

The review shows that there were no records to show which social worker, if any, was allocated to Robert in the five-year period after his first social worker left and when he turned 16.

His second social worker was with him for a year “but there are very few records of her work on file”. The third social worker then worked with him for a year, and after that two other social workers were allocated to Robert, but neither met him.

“There are no records whatsoever about Robert’s first foster placement which lasted five years,” according to the review. Alarmingly, the third social worker who dealt with Robert’s case told the review panel that she believed case notes she had written were omitted from the files. The issue was raised with the social work department and according to the report: “We were informed by some of the staff we interviewed that many files in the area were missing.”

His first social worker tried to transfer his case to another area, but one was sent to the wrong area, and both were refused.

“It later transpired that the foster care team leader was unaware that the transfer had not occurred and consequently no fostering link worker was allocated to either Robert’s foster carers or to his siblings’ foster carers, and no assessment of either placement was conducted. This situation persisted for five years.”

The “clumsy” non-transfer did result in communication from one area to another about the sex abuse allegation regarding “a person with whom [Robert] was now likely to have contact. No response appears to have been made to this information.”

Overall, the review finds that in some cases no action was taken when it was required, at other times intervention was insufficient or came too late. “This was a poorly managed case at every level,” it concluded.


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