The findings of a report into the deaths of 196 children in care or known to the Health Service Executive have 
been branded “a disgrace” by Minister for Children, Frances Fitzgerald.
The report [1], carried out by child law expert Geoffrey Shannon and Norah Gibbons of children’s charity Barnardos deals with the period 2000 to 2010.
It found that 115 of these children died from unnatural causes ranging from suicide to drug abuse, accidents and killings and that many of these deaths were preventable.
It concludes that “the majority of the children the subject of this review did not receive an adequate child protection service”.
Ms Fitzgerald said the findings were “deeply disturbing” and pledged to implement all of the report’s recommendations, which include a root-and-branch review of the care system..
“What we have found, in one word, is a disgrace,” Ms Fitzgerald said. “If ever evidence was required of the scale of the challenge which this Government and I have had to face into, then this report is it.”
In total the report examines the files of 36 children and young persons who were known to the HSE at the time of their death. Seventeen of these were due to non natural causes.
The report notes that while good practice was adhered to in some cases, “the fact remains that its application was sporadic and inconsistent”.
It says: “In many cases these children engaged in ever more risk taking during adolescence with tragic outcomes.
“The earlier and more consistent presence of good practice would have increased the chances that these children might have overcome their vulnerabilities, although it is not possible to conclude that the death of the child or young person would have been ultimately prevented.”
It says that “a uniform and structured approach” to child care provision would have provided “the best opportunity to manage and mitigate risk in the lives of such vulnerable children and young people”.
It identified 12 indicators of good practice, such as risk identification and planning and the following of childcare regulations, but said that these indicators were not present in the majority of cases.
Amongst the concerns identified by the report were:
• Evidence of delay in taking the child into care.
• The lack of a care plan for 15 of the children or young people examined by the report.
• Evidence of failure on the part of child care workers to follow appropriate procedures such as ensuring children underwent a medical examination
• Evidence of difficulties in relation to the consistency and appointment of social workers to a child
• In 10 of the files examined there were evident difficulties in locating suitable placements for a child.
The report also noted the importance of a clear reporting structure being put in place so that any social worker who may be subsequently assigned to a child can read the file and be in a position to meet the needs of the child.
However it said: “In 15 of the 36 files examined there was evidence of a poor standard of record keeping and incomplete records. Critical incident reports are to be completed in the event of a serious incident occurring whilst the child is in care. The death of a child would be such a serious incident. There was no such report in 26 of the 36 files examined.”
The term “in care” relates to the voluntary placement of a child in the care of the HSE or the placement under an Emergency Care Order, Interim Care Order, Care Order or Special Care Order issued by the courts.
There are over 6,000 children in the care of the HSE at any one time. Over 90 per cent are placed with foster carers with the remainder in residential care.