Poor link between services
In the five years between the birth of their first child, Lean, and the family’s deaths, they were in contact with paediatricians, eye specialists, hearing specialists, child development clinics, GPs, public health nurses, social workers, community welfare officers and other personnel.
Details of this interaction is sketchy during some periods as parts of the report have been blacked out. Similarly, 15 out of 31 conclusions. mainly dealing with the HSE, are also blacked out as are seven of the 26 recommendations.