Investigation details health service's failure to protect six abused children
A LITANY of failures by social workers and health service management led to six Roscommon children enduring years of unnecessary abuse, according to the findings of an inquiry published yesterday.
The inquiry, commissioned by the Health Service Executive after the jailing of the children’s mother for seven years in January 2009, found faulty decisizon making; ineffective interdisciplinary working; ineffective assessment processes; weak management systems, a failure to learn from previous case reviews and poor knowledge of childcare legislation all contributed to the children being let down.
There was also an over-reliance on using family support services in situations where child protection should have been an overriding concern.
There had been many reports of neglect and emotional abuse in relation to the children to the former Western Health Board over a protracted period until the children’s admission to care in 2004, the report said.
These included reports from a concerned neighbour, serious concerns expressed by relatives, and also by members of the public and a school, as well as a garda.
“In most cases, these concerns were addressed in an episodic manner. In this way the insidious, incremental and long-term effects of chronic neglect went largely unnoticed and, therefore, largely unaddressed”.
At a particular point the older children were cared for by relatives at weekends who saw persistent head lice, dirty clothes, an absence of underwear, hunger and the children spending pocket money not on treats but on things like cans of tuna.
But social workers did not know this as they were not in touch with the relatives. No social worker sat down with the family’s relatives until August 2000.
The inquiry found that staff knowledge about the family was not shared among professionals, staff worked in “silos”, and with one or two exceptions, staff were constantly “diverted and deceived by the parents and were unduly optimistic about the parents’ ability and willingness to care adequately for their children”.
One social worker in particular is singled out for criticism. He “was not accredited and was not functioning to an acceptable level of professional work standard”.
He was presenting information at case conferences “as if it was current when it was, in fact, repeated verbatim from earlier reports without any fresh assessment or review being undertaken. The absence of case notes from this worker makes it impossible to judge from where the justification of his optimistic reports to case conferences came”.
The purpose of many of the case conferences held in relation to the family was unclear. They were convened as a matter of routine rather than to achieve positive outcomes and in that format “were a waste of time and money”.
There was a failure to identify the extent and severity of the neglect and abuse suffered by each of the children from the time of their birth until their admission to care in 2004, the report said.
“A significant contributory factor to this failure was the absence of meaningful engagement with the children . . . prior to their admission to care, the voice of the child is virtually silent”.
Workers were not sufficiently alert to indications of ongoing neglect. Such indications included the squalor in which the children almost constantly lived.
The inquiry noted the birth of one of the children in 1990 occurred at home following a night of binge-drinking, after which the mother did not realise she was in labour.
A public health nurse attended the mother later, but “did not subsequently raise this situation as a child protection concern with colleagues”.
Records in this family’s case were usually handwritten, often unsigned and in some instances key records were missing, according to the report.
While the family was in receipt of health board services from 1989, following the birth of their first child, a social worker’s file covering the period prior to 1996 was missing.
In 2000, when a new social worker undertook an assessment of the case, a plan for a shared parenting arrangement between relatives and the parents was drawn up. However, following a legal action by the parents, this was scuppered and the health board decided to try and secure a full care order on the children. “This application was not made to the District Court. The next documented formal assessment happened when the children were taken into care in 2004”.
In addition, there was no case conference between October 2000 and February 2002, despite the fact that during that period there was a complete change from a plan to apply for care orders in respect of all six children to a decision not to apply for a protective order. There was little evidence to suggest a learning culture prevailed in HSE West.
In particular, the learning from the Kelly Fitzgerald case (1986) in Mayo was not incorporated in any organised way into the professional development of staff.
The same was true for the west of Ireland farmer case (1995), which occurred in the adjoining county of Sligo. These highlighted areas for improvement in dealing with neglect and child abuse cases “which, had they been acted upon, may have prevented more unnecessary suffering by children in Roscommon”.