Lost lives. A broken system


This week’s devastating report by the Independent Child Death Review Group spelled out the cases of 196 children who died while in contact with State services. What went wrong with the system that allowed this to happen, and how likely are we to ensure that history doesn’t repeat itself – again?

THE CHILD AND FAMILY SERVICE headquarters of Area 3 in Dublin’s south inner city sounds likes a neutral, bureaucratic office, but raw and disturbing human episodes unfold here every day. Every call to the social workers on the child-protection team here reveals details of another human catastrophe: family breakdown, drug addiction, mental illness or child abuse. It’s normally a hidden world of families living on the edge of society, on the edge of the health system and, in extreme circumstances, on the edge of life. This week, however, a shocking Government report shone a light on this tragic and often unexamined corner of Irish life.

The report, described by its authors as a devastating indictment of social services, found that 196 children who were in contact with State services died between 2000 and 2010. Of these, 112 died of overdoses, by suicide, in unlawful killings and of other non-natural causes.

It said that most of these children received an inadequate child-protection service, that files in some cases were in “complete disarray” and that it had found evidence that social services had closed files on some cases even though children were still at risk. But more shocking still were the individual stories of ruined childhoods and preventable deaths.

There was a little boy who suffered severe neglect as a toddler and was discovered with his mother’s body after she had died of an overdose; at one stage he was found eating frozen fish fingers from the freezer. That boy died of a suspected drugs overdose at the age of 16.

There was a girl who was placed in care at the age of nine, after serious abuse at home. Instead of structure and stability, she moved between respite foster placement on 32 occasions. She took her own life when she was 12.

There was a 14-year-old boy who asked to be placed in care after trouble at home. As two community-care areas bickered over who was responsible, he was placed in an out-of-hours emergency hostel in the inner city instead of in foster care. He died of a drugs overdose just over two years later.

There was evidence, too, of good practice by social workers in what were often highly complex cases: building up good relationships with vulnerable children, linking them in with a range of services, even using their own money to help young people when resources were denied by management. But too often, the report found, this kind of response was “sporadic and inconsistent”.

Overall, the picture of poor communication between State agencies, the lack of an early response to meet the needs of children and a failure to introduce a standardised approach to dealing with child-protection concerns were among the main faults exposed in the system.

“What we have found, in one word, is a disgrace,” Minister for Children Frances Fitzgerald said after the report was published. “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.”

MANY OF THE social workers in the child and family services section of Area 3, which stretches from the south inner city towards the more middle-class suburbs of Terenure and Rathfarnham, had been waiting grimly for the report for months. The social workers here, who are, for the most part, young, college-educated women, are on the front lines of society’s failings, trying to help restore stability to chaotic families, linking them in with health or social supports, or meeting the needs of vulnerable children whose lives may be at serious risk.

The findings are not a surprise to most: they know all too well about the poor interagency communications and the pressure to deal with emergency cases rather than intervening earlier in children’s lives. But it is ultimately their responsibility to respond. The Health Service Executive has a primary responsibility under the Child Care Act of 1991 to “identify children who are not receiving adequate care and protection” and to provide them with suitable protection.

Whenever a teacher, garda or member of the public raises a concern about a child’s welfare, the phone rings in this office and the duty social-work team responds, A whiteboard in the corner of the duty room is filled with names of dozens of children at risk of abuse or neglect, written neatly in blue marker. They have come to the attention of social services over the past week or so.

The names in the first column are Priority 1 cases. These tend to be emergency concerns that require an immediate response. The names in the next column tend to be welfare issues, such as neglect, while the third tend to be children caught in custody or access disputes.

“Once we get a call about one of these children, the detective work begins,” says Rita Byrne, the duty manager. “It’s like putting a jigsaw puzzle together, getting all the pieces of information to build a picture of what’s going on.” If investigations reveal that a child is at serious risk, an emergency care order is taken out and the child is placed in foster care. This happens quite regularly.

Last week a teacher in the area phoned to say two girls, aged eight and 10, from an immigrant family had shown signs of distress in school. “It turned out their mother was forcing chopped- up pieces of chilli peppers into their vaginas for long periods and then making them cross their legs,” says one social worker, shaking her head in disbelief. “We had heard of this happening in African communities in London, but had never come across that here before.”

Other cases require ongoing support and linking children in with mental-health, psychological and therapeutic interventions.

More often than not, the parents require help. They may be using drugs or alcohol or be unable to cope. There are a range of options, such as parental support or detox programmes. Taking a child away from parents and into care is generally the last step in a series of actions, depending on the severity of the case.

AFTER THE PUBLICATION of the report of the Independent Child Death Review Group this week, many people expressed incomprehension at the scale of tragedies and missed opportunities. How could such gross failings occur in a system that is designed to protect the welfare of vulnerable children? The social workers here try to explain how these failures occurred.

“It is very unfortunate that young people have died,” says one social worker. “But you’re working within a bigger system, trying to get access to mental-health or social supports . . . There often is no recognition of the good work done, the good practice, the attempts to engage and support families.”

Another says: “We hurt as well if a child dies. You might have a relationship with them. And then suddenly you’re surrounded by dictaphones, being asked what you did and didn’t do. And yet you’re the one who spent time with them, bought them a pizza, helped them find a hostel or read their text messages for them because they couldn’t read properly.”

“I tend not to tell people what I do,” another says. “To middle-class people we’re the ones who fail children. In working-class areas we’re worse than the police: we’re the ones taking people’s children away.”

Linda Creamer, the area manager for child-protection services, says many of the problems are down to poor management. The old HSE management saw social services as a “thorn in its side”, she says. “It was something they didn’t want, something they couldn’t get a handle on and a risk they didn’t want to manage.”

That neglect resulted in weak links between the child-protection and mental-health services, difficulties retaining social workers and a lack of standardised approaches to providing care and protection.

Creamer says her department has been introducing new business processes over the past year to create a seamless service. The introduction of a new head of child and family services has injected new energy into the reform process. “Everyone here knows what their role is and what they have to do, and they are accountable,” she says. “Goals are set with families, the voice of the child is heard, we’re engaging with families.”

There are signs that these reforms are working: social workers in the area say there is no waiting list for child protection here. Every case brought to their attention is allocated a social worker and receives a response. And there are many good-news stories that will never make headlines but are profoundly benefting many young people and families.

BUT THE REALITY is that in many parts of the country the system is operating against a backdrop of scarce resources, staff shortages and dangerously heavy caseloads, and children continue to fall through the cracks.

And so, in many respects, Dublin’s Area 3 might be the exception rather than the rule. Social workers in other areas, including some within Dublin, say there are alarming gaps in services and that there is a failure to respond to urgent reports of abuse or neglect. Hundreds of serious child-protection reports are not being properly assessed or followed up. The result is that vulnerable young people remain at serious risk of abuse or mistreatment.

Social-work files from some of these areas demonstrate that a system designed to protect the most vulnerable children is not responding in many cases to the needs of those at serious risk of abuse or neglect until it is too late.

They also demonstrate the scale of the challenge facing policymakers and managers responsible for the necessary reforms.

Frances Fitzgerald said this week that the Government is committed to transparency and honesty about the challenges in getting children’s services right. She pledged to make a series of reforms, including strengthening the entitlement of children in care to aftercare services once they reach 18; establishing a new child and family agency that will take responsibility for child protection away from the HSE; and a nationwide consistency of approach in practice and implementation of guidelines on the handling of child-welfare and child-protection cases.

But new laws and new nameplates will not be enough. What is more urgent is the requirement to change the culture of health and social services and to ensure gaps of the kind that have existed until now are no longer tolerated. Politicians and policymakers will now be judged on whether these recommendations are implemented or whether they go will the way of similar proposals made in many previous reports.

If the results of this week’s report show anything, it’s that most vulnerable children cannot afford to wait any longer.

‘The State put more time and effort into tracing farm animals than it did into tracing lost children’


IN JANUARY 1919 the first Dáil met in Dublin and declared a republic. But how would people know the republic existed? The Dáil set out a very basic test: “It shall be the first duty of the Government of the Republic to make provision for the physical, mental and spiritual well-being of the children.” Child welfare was to be the primary benchmark by which the new Republic would measure its success. It was a good standard to adopt and one by which, yet again, the report by the Independent Child Death Review Group this week showed the Republic to have failed.

The report is as harrowing as the advance publicity suggested. It is a catalogue of appalling suffering through neglect, abuse, indifference and incompetence, a desolate record of the careless waste of precious young lives. It evokes tears and rage in equal measure. But neither response is much use to children at risk of the same fate. The real challenge is to face up to what the stories in the report tell us about the State. Ultimately, these children are victims of systematic misgovernment. Their deaths shine a harsh light on three basic aspects of a functioning democracy: values, accountability and priorities.

It is often said that societies count what they value and come to value what they count. In this sense it is striking that these dead children were not counted and therefore literally didn’t count. The numbers tell their own story about what our political and administrative systems value.

In early June 2010, after the publication of the report on the death of Tracey Fay, the then minister for health, Mary Harney, said she was confident that the number of such deaths in the care of the HSE was 23. The very next day the HSE itself said the number was 37. Later the same month, when all children in contact with the State services were included, the figure was said to be 188. In the end, it turned out to be 196.

The State could tell anyone who asked, for example, the exact number of pigs on Irish farms and keep track of their breeds and weights. It could tell a customer in France precisely which farm a piece of steak came from. But it couldn’t keep track of children who died in its care. The State put more time, effort, money and expertise into tracing farm animals than it did into tracing lost children.

Jonathan Swift suggested in a savage satire that unwanted children should be killed and eaten. The truth of 21st-century Ireland is that, if they had been, the State would have applied high technology and administrative efficiency to ensuring their traceability from farm to fork. Instead “many records were handwritten and barely legible, files themselves were often incomplete and important notes were scribbled on pieces of paper and data such as birth dates were entered differently on different forms.” Astonishingly, in most cases, the death of the child did not even result in the compilation of a “critical incident” report.

This slovenliness is a result of very bad management within the childcare system. But it is also an expression of communal values. No minister and no senior civil servant cared enough to make sure the system functioned.

And this carelessness is consistent with the broader political culture.

Would any politician suffer electorally for this kind of failure? Conversely, would any TD who decided to become a voice for vulnerable children rather than a messenger for constituents be re-elected, even now?

Which raises the question of accountability. Accountability is not a crude demand that heads must roll. It is a system and a culture in which someone is in charge and in which that someone takes personal responsibility. In this case the utter absence of accountability was embodied right at the top of the system. In June 2010 the Irish Examiner asked Harney about accountability for the deaths of children in HSE care. She replied that “to be fair to the HSE, an awful lot of these issues are legacy issues”, implying that the problems were mainly in the dark past before she created the HSE. (In fact, as the report shows, there was a substantial increase in relevant deaths after the HSE was established, in 2005.) She added that “if the data stands up that we’ve heard about, then serious questions have to arise of course for people who have responsibility, very serious questions.” It is clear from her answer that she did not include herself among the “people who have responsibility” and that she did not expect any action to be taken against any senior figures in the HSE.

This lack of accountability continues. One of the more breathtaking episodes in this whole process is the initial refusal, and then extreme reluctance, of the HSE to hand over files to the review group. Even after it stopped hiding behind the in-camera rule, the HSE’s cooperation with the review was partial and grudging: “The piecemeal manner in which the HSE provided the information endured throughout the review and significantly hampered the review team in producing this report.” But who in the HSE decided to obstruct the inquiry, and will anyone be punished for hampering such a vital investigation? Even now the absence of accountability is glaring.

Intertwined with skewed values and a systematic refusal of accountability is the question of public priorities. Money is by no means the only issue involved in the failure of the child-protection system, but it is a good measure of priorities. Fergus Finlay of Barnardos estimated that it would take between €20 million and €30 million to make the system at least adequate. To put that in context, €20 million is what political parties and Independent TDs received in expenses last year. The money lost by a single public body, the Dublin Docklands Development Authority, on a single property deal, the Irish Glass Bottle site, was €52 million.

Ireland can afford a reasonable system of care for vulnerable children. It chooses not to do so for a simple reason: the lives of troubled children, usually from chaotic families in poor communities, are not a priority in any area of public policy. Even within the HSE child welfare is a poor relation: Finlay noted in 2010 that the subject of children at risk was discussed once by the HSE board that year.

Will this change or will the shock wear off, as it has done before? Almost 20 years ago, in 1993, the Kilkenny Incest Investigation, headed by Catherine McGuinness, identified precisely the same problems as this week’s review: poor communication between agencies and social workers, bad record-keeping, the Constitution’s failure to afford specific rights to children. The then minister for health, Brendan Howlin, declared that “the entire nation was shocked and horrified”. The Dáil debate on the report is full of statements such as “a dreadful reflection on our society”, “an indictment of a value system which has informed decisions and policy in this country”, “a scandalous level of incompetence bordering on negligence in the public services” and “governmental neglect, ministerial incompetence and self-delusion, health board management failures and political posing”. Such phrases could be cut and pasted again into the Dáil record to save TDs the bother of working themselves into another fit of outrage. Until the preventable death of a child is a scandal that will destroy the career of a politician or a senior manager, they can be recycled for many years to come.

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