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.