Review of 18 child deaths finds key flaws

Thu, Jan 24, 2013, 00:00

A report published today examines 24 cases of abuse and neglect that resulted in children dying or being seriously injured in Northern Ireland.

Poor communication between professionals, children not being listened to, a failure to act on signs of neglect, and procedures not being followed are some of the concerns raised about the handling of the cases before the key crisis event in each case.

The report, Translating Learning into Action, was commissioned by the Department of Health, Social Services and Public Safety and has been seen by The Detail, an investigative news website based in Belfast.

There were 18 child deaths from 2003 to 2008, it says: four died as a result of a physical or sexual assault; six infants died unexpectedly, for which there was no cause established (Sudden Unexpected Death in Infancy); and eight died by suicide.

Each case was subject to a case management review – a formal process that takes place when a child has been seriously injured or dies as a consequence of abuse or neglect.

For the report, academics from Queen’s University in Belfast joined children’s charity the NSPCC to examine all of the case management review reports completed in the five-year period.

Mental health

The researchers found that the majority of the 45 children involved in the 24 reviews were living in families where parents were experiencing difficulties with their mental health, alongside misuse of alcohol or drugs, and domestic violence.

Non-accidental child deaths are rare in Northern Ireland but the number of homicides of children averages about two or three a year. At the end of March 2012, 2,127 children were listed on child protection registers.

The Safeguarding Board for Northern Ireland took over the case management review process in September 2012.

As a result of referrals to the board, two further child protection cases will be subject to review. Neither of the children died but the fact the safeguarding board is progressing with a review means it has concerns about agency care provided to these children.

Between 2003 and 2008, 24 case reviews were undertaken in which 45 children were involved, 27 male and 18 female.

Eighteen children died and others were seriously injured. The other children subject to review were siblings of those who died or had been seriously hurt, or other children connected to the cases.

None of the children subject to review are named in the report.

The reviews aim to establish the facts of each case and assess whether there are lessons to be learned about the way in which professionals and agencies worked together.

They are not intended to be inquiries into how a child died or who was culpable. These issues are dealt with by the coroner and criminal courts.

Protection register

Most of the children were known to social services at the time of the event leading to the review, although only four were on the child protection register.

The reviews concluded it was unlikely the children who died or were seriously injured could have been identified as being at heightened risk.

Report author Dr John Devaney, senior lecturer in social work in the school of sociology, social policy and social work at Queen’s, said: “Quite often these children and their families were very similar to hundreds of families who are known to social services at any moment in time.”

Case review: 18 deaths


Children died as a result of a physical or sexual assault.


Infants died unexpectedly. No cause established


Eight young people died by suicide