Files reveal a litany of failures

A summary of the report into the HSI failings by Independent Child Death Review Group.

DEATH OF CHILDREN IN CARE

* Failure to review death: In relation to 26 of the deaths of children in care, there was no evidence of a review of the death, or of the care that child received prior to his or her death.

* Delays in placing child in care or full care: In 12 of the files reviewed by ICDRG there was a delay on the part of the HSE in taking the child into care or in seeking to place the child on a statutory care order from voluntary care.

* Failure to create care plan: In 15 cases, no care plan was created, which would have shown there was forward-planning for the child.

* Consistency of social workers: In 11 files, there was “a difficulty with the consistency and appointment of social workers to the child’s case”, with some having a high social worker turnover during care and some having none.

* Difficulty with placements: In 10 files, there were “poor placement choice”, frequent moves and multiple placements.

* Lack of critical incident reports: In 26 files where there was a “serious incident” involving the child, there was no “critical incident report” produced to the ICDRG.

* Failure to refer to appropriate services: In five files, there was failure to follow up serious issues and/or refer the child to the appropriate services.

* Poor record-keeping: In 15 files, there was poor record-keeping — incomplete records, failure to record the death of the child, and a failure to provide a closing summary. In two files, there was no individual file for the child. In seven, there was no birth cert available.

* Poor procedural practice: In nine files, there was no evidence a medical exam was carried out on the child. In seven cases, there was no evidence the court was told of the death.

* Lack of professional support and/or supervision: In 12 cases, there was no evidence of supervision and/or support of social workers.

DEATHS OF YOUNG PEOPLE IN AFTERCARE

* Failure to provide any or any appropriate aftercare: In one file a young person was not provided any aftercare despite being in a vulnerable position. Other files show a failure to provide aftercare at all. Another was discharged from care because he was not co-operating and was then left unmonitored despite vulnerability.

* Poor record-keeping: Eight files were in “disarray”. In a further three, it was impossible to assess the work of those involved due to the poor standard of record-keeping.

* Consistency and engagement of social workers: In three files, there was evidence the young person had no social worker at times. Files showed a high turnover of social workers.

* Failure to refer to appropriate services: Although young people had self-harmed, been sexually or physically abused, had educational difficulties, suffered grief, or experienced confusion over their sexual orientation, they were not referred to specialist services and supports.

* Inappropriate placements: There was an over-reliance on the out-of-hours service and use of temporary placements.

* Lack of proper procedures: There was no evidence of supervision of staff on most of the aftercare files. In two, there is a requirement for an indepth review. On other files, there was no evidence of processes/procedures carried out following the death of the young person.

* Review of death: There was no HSE review of a death or its circumstances in 29 cases.

DEATHS OF CHILDREN AND YOUNG PEOPLE KNOWN TO THE HSE

* Family issues/risk indicators: There were indications of “significant problems” with drug and alcohol abuse, gambling addiction, and domestic violence in the families of several children who died who were known to the HSE. In a number of cases, the HSE closed the child or family’s file while the issues were ongoing.

* Resource requirements: In several cases, there was a lack of resources such as out-of-hours social work service. In one case, after children were removed from the home under a safety order and placed in a hospital, they were forcibly removed from there the next day.

* No emergency accommodation: In one case, a family had to sleep in the car during the winter months because of housing arrangements in a “different jurisdiction”.

* Delays: In one case, there was a delay of a year before the HSE Child Protection Services were made aware of the death of a child.