The findings of the National Review Panel (NRP) looked at six cases, including that of a baby, ‘Jack’, who died in bed with his mother, who had been using drugs earlier that day.
In that case, it found “very limited communication” between the social work department (SWD) and public health nurses, including regarding information about the parents’ drug use. Just hours before the baby’s death Gardai had notified the SWD after they found Jack’s parents under the influence of substances. He was sent to a relative’s but was later joined there by his mother and died of Sudden Infant Death Syndrome with her.
In another case, that of ‘Hugh’, a 16-year-old who died from a suspected accidental drugs overdose, the NRP said a Child and Adolescent Mental Health Services (CAMHS) policy had impacted access to treatment for young people using drugs.
Hugh was left without treatment for his ADHD and conduct disorders because of his drug use, due to a CAMHS policy whereby young people who are using drugs are not eligible for a service,” it read.
“The NRP understands that policies made by CAMHS are outside the remit of Tusla. However, it recommends that Tusla use any possible opportunity to highlight situations where policies operated by CAMHS may ultimately result in young people who have clinical diagnoses being left vulnerable and without services.”
In the same case the review found that “matters were allowed to drift for around 18 months” before action was taken, adding that it fit a pattern of previous reviews where the child presents with a range of different problems in a relatively short space of time, meaning the initial child protection referrals have received incomplete screening and assessment.
In two cases the NRP found the care provided was mostly appropriate, but the NRP also referred to how some cases were classified as ‘welfare’ cases, when an earlier escalation to a ‘child protection’ classification might have resulted in more impactful early intervention.
In the case of ‘Frank’, who died by suicide with a toxic blood-alcohol level, the NRP questioned the designation of ‘welfare’ status as it “raises the question of how serious a child’s situation must be before it is classified as ‘child protection’.”
Tusla offered its sympathies on the “unspeakable tragedy” of the death of the children and said a “consistent theme” of reviews was how agencies could work better together.
It said this was a key area, resulting in joint working protocols with both the HSE and An Garda Síochána last year, as well as a new five-year Child Protection and Welfare Strategy including a new national approach to practice, Signs of Safety.
A spokesperson said: “Tusla is currently developing a revised Alternative Care Strategy to enhance services for children in care” with the aim of strengthening preventative strategies.
Responding to the publication of the reports, June Tinsley, Barnardos head of advocacy, said the report highlighted again the importance of thorough screening and assessment of a case by social workers and the ongoing challenges of inter-agency working.
“We can never be complacent in building child-responsive systems.”
died last December aged 13 of an "unexpected" viral illness.
He had been in long-term foster care with relatives. A pleasant and resilient young person, Oisin was in voluntary care on three separate occasions with two separate sets of relative carers. From 11 he remained in long-term foster care.
Oisin was predominantly in contact with two social workers but he did not have an allocated social worker for the final 10 months of his life - "regrettable", according to the NRP.
A member of the Traveller community,was 16 when he died in an accident last August, possibly from "risk-taking behaviour".
He was described as "a pleasant young man who was easily led by others".
He had experienced periodic homelessness. The SWD was involved from when he was aged seven. However, the NRP said despite sporadic visits there is no evidence of action being taken until he was 14. By then he was missing school and potentially serious offending. A social worker and family support worker became involved.
According to the NRP: "Neither his needs, nor those of his siblings, were assessed adequately and the family did not receive the degree of intervention they needed when the children were young."
died by suicide last July aged 17 and had toxic levels of alcohol in his blood.
Both his parents had histories of substance abuse and Frank was first referred to the SWD at 16, and again months later. "He drank beer and spirits to excess". He also used cannabis. Missing school, he occasionally expressed suicidal ideation.
Respite care was discussed, "however, due to unavailability, the placement did not go ahead". He stayed with a relative but took his life some months later. A project worker had not been able to meet him prior to his move.
The NRP questioned the designation of ‘welfare’ in the case, stating it could have been escalated to ’child protection’.
was 16 when he died last January from a suspected accidental drug overdose.
He was known to Tusla from the age of 12. He was the subject of eight social work referrals, had mental health difficulties and was diagnosed with ADHD.
As he got older concerns persisted, yet when his behaviour seemed to improve, the SWD decided to close the case. He died shortly afterwards.
The NRP said there could have been"earlier intervention" and the case was "allowed to drift for around 18 months" and also queried a CAMHS policy which meant Hugh could not access services until he was free from drugs.
was born prematurely and died last December while co-sleeping with his mother, who had used drugs during her pregnancy. Jack was diagnosed with failure to thrive when he was a few weeks old and was regularly visited by two Public Health Nurses (PHN).
A PHN had referred the family to the SWD while his mother was pregnant.
Gardaí had notified the SWD that a few hours prior to Jack’s death, they found both parents under the influence of substances. Jack was sent to a relative for the night and his mother later joined him. The post-mortem indicated Sudden Infant Death Syndrome.
, who liked farming as a young boy, took his own life at 15 last August. His behaviour had become challenging and he had been diagnosed with a learning difficulty and developmental disorder.
His parents, who had separated, struggled to control his behaviour. Karl drank and missed a lot of school.
Karl received services from the SWD, CAMHS, and others and three social workers were involved with him, but Karl showed limited interest.
The NRP said there were "missed opportunities to regularly review the outcome of decisions made" and recommended that Tusla develop a protocol for cases where children are at ongoing risk of significant harm from their own behaviour.