Child death review report: case studies

How three young people slipped through the cracks of child protection and welfare services


He first came to the attention of social services when he was five following an allegation he had been sexually abused by a person known to his mother. By the age of seven, there was another allegation of neglect and physical abuse. He was eventually admitted to the voluntary care of the HSE at the age of 11, after disclosing serious neglect, abuse and witnessing severe domestic violence.

Robert was placed in the care of separate family members over the following years, but his behaviour became very challenging during this time including drug and alcohol use. In his late teens, he was offered treatment for drugs, but declined it. He made contact with counselling services at about this time. One morning he rang a number of family members, telling one that it was “time to go to sleep for good”. He took his own life later that day.

The review found significant deficits in services offered to him in his early years. No serious effort was made to assess his safety and welfare on the rare occasions when social workers met him. In addition, he was “virtually ignored” during the first four years of his placement in care. Overall, it found he received a very poor – and in some cases non-existent – service from HSE child protection over many years. In addition, many health and education staff did not appear to take the neglect of the boy seriously.

Much of Tom’s childhood involved witnessing the chaotic lifestyle of his parents. His mother drank to excess, took drug overdoses and was a victim of domestic violence. An opportunity for stability in his life came when he was placed in foster care with relatives. But there is evidence he was excessively beaten by his guardians. The death of his mother, and a sense of entitlement by his father, added to his sense of loss and rejection. A breakdown in relations with his foster parents appeared to lead to a downward spiral: he began taking drugs and ricocheting between different residential units in the care system, occasionally sleeping rough. In all, he went through 17 different care settings.

After turning 18 he moved into HSE aftercare and social workers expressed mounting concern over his drug use. Not long after, he was found dead. An inquest found he died as a result of “misadventure”.

The review report found that alternative foster carers – with training and expertise – should have been available to him. A failure to hold care reviews – that could have included input from his school and other agencies – was a major failing; his movement between different residential units also played a role in his deteriorating behaviour. It found, however, that the social work department achieved most of the tasks that could have been expected of it in Tom’s later years.

Her family was referred to social services on a number of occasions in the years before her death. There were a range of reports regarding her mother’s mental health, heavy drinking and allegations of domestic violence. During the three years prior to her death, her poor attendance at school, vulnerability due to mixing with older people and self-harm flagged her increasing vulnerability.

The report does not state how the girl died, in order to protect her identity. Overall, the review team found that her needs were never formally assessed by social or family support services. It was impressed at the support provided by school staff . But social work services were under major pressure and this contributed to delays in responding to concerns about the girl’s welfare. Management weaknesses were evident at local level. For example, there was no record in the childcare manager’s office of any follow-up to two child protection notifications from the Garda. In addition, relationships between social services and family support appeared to be strained. The review said a key learning point for services is the importance of meeting the needs of children at the earliest possible stage using effective assessment methods.