Woeful situations made worse by inaction and bad decisions
“He suffered from severe neglect as a toddler. He was found at one stage trying to eat fish fingers from the freezer. When his mother died [of a drugs overdose], he was discovered with her body. At that time, his father was serving a long- term prison sentence overseas.”
Young Person in Care 8 died in 2009 aged just 16 and his story highlights many of the dreadful aspects of lives blighted by neglect, family breakdown, crime and drug and alcohol misuse.
The story highlights some of the failings of the care service but also, crucially, the good practice in some of the cases which feature in the grim findings of the Independent Child Death Review Group.
In the case of Young Person 8, it is obvious he did not enjoy a good start to life. Once his mother died, his aunt and uncle cared for him, but this placement broke down when his father was released from jail. In just three pages, his life is summed up as a succession of care placements and interaction with state services aligned with his escalating poor behaviour.
He was admitted to special care and spent 20 months in a unit there; remarkably, in his case, the report details how “he was also involved in a gambling incident with a staff member in the secure unit whereby he won a significant amount of money”.
That is not in the guidebook, but the rest of the story is all-too-typical in the context of the report: the out of hours service, homeless shelters, crime and regularly absconding. He had been in the care of the HSE for three years at the time of his death and the report notes how “the work of the social worker was excellent”, there was clear evidence of good casework and good supervision and planning, as well as excellent cooperation between the gardaí and HSE.
In launching yesterday’s report, both co-author Geoffrey Shannon and the HSE’s national director of children and family services, Gordon Jeyes, stressed that these cases, stretching from 2000 to 2010, must be placed in the context of the 6,200 children currently in the care system — 90% of whom are in foster care and succeeding in making better lives for themselves.
However, it is sometimes difficult to keep that in mind when you leaf through the report which paints a bleak picture of a Kafkaesque HSE service which “abdicated responsibility” and repeatedly messed up the care and aftercare required by children and young people who are no longer around to tell their own story.
It is understood that the process of compiling the report was torturous. Yesterday, Mr Shannon said he had expected greater cooperation from the HSE; instead files were handed over in a “piecemeal manner” and it is also understood that right up until recent weeks, there were internal wranglings over whether or not elements of the report should be redacted. In the end it was published in full, devastating detail.
It illustrates the mess that the child welfare system had become during the years when we were apparently swimming in cash. It seems that in some offices they could not afford binders — how else to explain the “poorly kept and presented file records”, some featuring “handwritten notes and barely legible”. Files were often “incomplete”, with inaccurate data. In some cases there was no birth certificate. The records were often bad, the decisions — or lack of decision making — often worse.
Take the case of Child in Care 3, who died in 2008 aged 12. Obviously mentally unwell, the file records a decision not to request the child’s GP to have her referred to mental health services “as this might encourage more worrying behaviour giving it attention”.
Young Person in Care 6 was not alone in having a period of time where she had no social worker, in addition to a high turnover of social workers. She had a high number of placements, there was a failure to follow up allegations of abuse made by her, and inappropriate care plans were put in place. Her body was discovered two weeks after the last telephone contact from her.
Young Person in Care 11 witnessed alcoholism in the home and some positive placements but was at one point placed in a detention centre for males aged 16 to 21. A placement was found for him which unfortunately placed him close to a peer group who were drinking and taking drugs.
Young Person in Care 13 arrived in Ireland from the Middle East, was placed in a hostel and made numerous suicide attempts. At the end, his foster carer left a message for the social worker to call them as soon as possible. The social worker texted back that he would call back the next day when he was on duty. When he turned his phone on the next day, there was a message that the young man was dead.
From babies to young adults, male and female, many of the cases covered by the report are astonishingly complex and it cannot be said that if different decisions had been made, these people might have survived. However, the outcomes could have been different and the shortcomings are stark.
The application of good practice, says the report, was “sporadic and inconsistent”. In some cases no aftercare was provided, something the authors describe as “an abdication of duty” by the HSE and “unacceptable”.
Some of the files were in such “complete disarray” that no record was kept of interaction with aftercare services and damningly, the report states that “surprisingly, out of the 32 files examined [of those who died in aftercare] no review of the death of the person is recorded or planned”.
Frances Fitzgerald, the minister for children, spoke in sombre tones of the shoddy legacy bequeathed to the Government at a time of diminished resources: she and her government colleagues have made a start of cleaning up the mess.
Themes emerge of drug and alcohol dependence by parents who seem utterly incapable of raising their children, of undiagnosed learning difficulties, or extreme behavioural problems.
The questions posed by the dreadful deaths of these children and young people are myriad. In some cases the family was the problem, not the solution. This woeful situation was aggravated by inaction, such as the report’s finding that in some cases, the HSE was aware of continuing drug and drink problems in the home but still closed the file. In other cases, it was a missed connection, a failure to get a placement, a meeting that did not happen — it is hard to say whether the outcomes would have been different, but they might have been.
Yesterday, Mr Jeyes was unable to say if any of those responsible for serious failings had lost their jobs, although disciplinary actions are under way in other cases. Social workers will tell you that often they are weighed down with caseloads, while the report outlines how highly qualified psychologists were often dealing with less severe cases while social workers were landed with the difficult ones. Some of the people in this report, who effectively never had a childhood themselves, had children of their own.
Meanwhile, in the High Court, huge sums of money are being spent on discharging litigation over special care orders and the like when, as Mr Shannon argues, the cash could instead be spent on the services these children require — children who are increasingly being placed in facilities overseas.
Ms Fitzgerald outlined the steps that have been taken to address some of the problems and promised more action in future, but it is not unfair to question whether those actions are going to be hampered by cuts elsewhere.
Mr Shannon pointed to the school drop-out rate among the children in the report, yet the body charged with monitoring attendance, the National Education Welfare Board, has fewer staff than ever. A swathe of public health nurses took the retirement option in February, experienced professionals who are often among the first to spot trouble in the home.
There are issues over mental health, and to take the case of Child Known to the HSE 14 — known to the HSE for just over a month prior to her death — we know that nothing has changed in one instance. It is understood the case is that of Sharon Grace in Wexford, and the child is one of her two daughters who died with her at Kaat’s Strand in Wexford in 2005. “There was no inquiry by the HSE as to the circumstances that pertained when this young mother could not access support and the Independent Child Death Review Group has not been informed of any changes in practice that would ensure that in these circumstances the same response [ie, no service out-of-hours] would not prevail today.”
The list of actions needed is nearly as long as the list of things that went wrong.
Much more needs to be done to limit future tragedies.
CONNECT WITH US TODAY
Be the first to know the latest news and updates
