Death review group struggles to cope with caseload

A GROUP set up to review deaths and serious incidents involving children in state care or known to the child protection services is struggling to cope with its workload.

The National Review Panel (NRP), established a year ago under the auspices of the HSE, is now questioning whether every case should be reviewed.

In its first annual report, it points out that original estimates suggested it would have to deal with two deaths and up to five serious incidents every year.

It emerged yesterday that the panel has been asked to review 51 cases, among them 35 deaths, since it was set up in March of last year.

Three of the deaths involved children in care, 20 related to children known to the protection services and 12 to young adults.

Just 11 of the 51 reviews have been completed with 22 described as being “under review”.

With such a large and unanticipated volume of cases, the report questions whether it was necessary or even beneficial for every case to be reviewed.

It described timelines enforced on it to complete reviews as “unworkable” and raised the possibility of only assessing certain cases.

“It would and perhaps should be possible for the independent chair of the NRP to select representative cases from which maximum learning can be extracted without running the risk, as has happened in other jurisdictions, of services being drowned in a flood of similar conclusions and recommendations,” it states.

Chair of the review, Professor Helen Buckley, said they believed that priority should be given to more serious cases.

The NRP was set up after concern over the HSE’s child protection service and lack of transparency regarding child deaths.

Last year, the Health Information and Quality Authority told the health authority to review all serious incidents, including deaths in care and detention. A national review team was established and since then the HSE must notify HIQA of all deaths and serious incidents within 48 hours.

Of the 30 cases brought before the panel between March and December last year, 12 remained under review by the end of the year.

The NRP also examined the deaths of young adults up to 21 years of age, who were in the care of the HSE immediately before turning 18 or had been receiving after care services.

Prof Buckley said they did not find that any of the deaths or serious incidents were directly attributable to HSE action or inaction.

However, they found examples of less than adequate responses or a failure by the HSE to implement its own policies and, in some cases, a failure to develop a policy known to be required.

And, she said, a very clear finding in almost all of the reports was the HSE lacked a standard method for assessing the needs of children and young people who come to their attention.

“This is a deficit that has been known to the HSE and pointed out to the HSE over a number of years.”

Prof Buckley said there should also be a standardised form of record keeping.

“We found that the records presented to us in some cases were quite difficult to navigate.”

They also found evidence of poor inter-agency collaboration. In cases where the most weaknesses were spotted, communication levels were poor.