No guarantee it won't happen again

2010 Roscommon report:As far back as 1993, report after report shows the same system failures within the health services are putting children at risk of abuse. Even after this week's shocking Roscommon report, the HSE can shed little light on a solution, writes EITHNE DONNELLAN, Health Correspondent

IN NOVEMBER 1996 when the first of 11 case conferences was held by Western Health Board staff to discuss concerns that children in a Roscommon household were being neglected by their alcoholic parents, the findings of how the same health board failed a Mayo teenager were just sinking in.

A report into the death of 15-year-old Kelly Fitzgerald had been published in April that year and was highly critical of the Western Health Board. It found information about the family gathered by health-board officials was neither adequately collated nor assessed. It also criticised the case conferences it held in relation to this family.

Kelly died from blood poisoning in a London hospital in 1993 after travelling there from the family home in Mayo. She was underweight and emaciated.

Among the recommendations of the report in her case was that the health board should substantially overhaul arrangements for holding case conferences.

The report into the Roscommon childcare case, published earlier this week, found the manner in which case conferences were held was still an issue. 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”.

It also found a lot of information gathered wasn’t collated to recognise the full extent of the children’s suffering.

Crucially, the Roscommon report observes that had the recommendations of the Kelly Fitzgerald report been acted on – as well as the findings of a report in 1995 into the abuse of the McColgan children in Sligo by their father – it “may have prevented more unnecessary suffering by children, this time in county Roscommon”. It adds: “There was no evidence of any systematic attempt by management at the highest level in the WHB/HSE West to implement the salient recommendations of these reports or to involve staff working in the area in an examination of the issues that arose in those cases.”

Following the McColgan case review, published in 1998, the North Western Health Board admitted it failed that family, who suffered years of abuse at the hands of their father, Joe McColgan, and it apologised. The review found the McColgan children could have been spared much of the suffering they experienced at the hands of their father had the health board collated all the information in its possession from 1979 on and used it as the basis for legal action to take the children into care. Again, many similarities with the Roscommon case.

There was a failure to hold case conferences at key times, the McColgan review found, and there was an operational practice within the social-work department focused on a “non-legal interventionist approach towards child protection”, something echoed in the Roscommon case.

Another report – the Kilkenny incest case in 1993 – found the victim had more than 100 contacts with the health services in the southeast between 1982 and 1992 before her father was arrested. It recommended the attendance of all relevant persons at case conferences – this did not happen in the Roscommon case with schools, GPs and social-work managers regularly absent.

The inquiry into the plight of the six children in the Roscommon case – whose parents are now in jail – found umpteen concerns about their neglect had been conveyed to social services between 1989 and 2004 when they finally “rescued themselves” and were taken into care.

The parents in the case were first brought to the health board’s attention after their first child was born in 1989. It was alleged the parents were drunk and giving alcohol to the baby. The following year the health board was aware the mother, after 11 vodkas, gave birth to her second child and was so drunk she didn’t even know she was in labour.

Exactly what happened in terms of health-board action between 1989 and 1996 is unclear because the file is missing. But from then on a plethora of social workers and other health-service staff were aware of their plight. A social worker who visited in 2000 observed: “Going around the place it was just like squalor . . . there was just filth everywhere . . . the smell was overpowering.”

By then the family was known to social services for 11 years but this was the first social worker to inspect the whole house and sit down and speak to relatives. Their concerns and that of others – that the children were left unsupervised while their parents were in the pub and left to go hungry; a baby being fed watered down cow’s milk and not being stimulated; another having nightmares – had been brought to the attention of social services for years.

It wasn’t until late 2000 that plans were put in place for a shared parenting arrangement between the parents and the relatives of the children. This plan was scuppered by a High Court injunction secured by the mother restraining the health board from removing any of the children from her custody.

It was the first court intervention, albeit unsuccessful, in a case that had been crying out for such attention for years.

One social worker on the case in early 2001 – the one who sat down with the relatives for the first time – is recorded as having become frustrated the case was being allowed to drift, despite reports and evidence of child neglect. Up to now all the emphasis had been on supporting the parents in this case to do a better job but this social worker said there was a “management vacuum” around the case. “The senior people I just felt that they just didn’t seem to get the urgency of this . . . they wanted to believe all the time that this family were capable of turning it around . . . I just didn’t believe a word of it.”

The senior staff, in meetings with the inquiry, were adamant there was no management vacuum. One said: “We would have loved to have gone in there in the morning and taken those children into care but you can’t do that,” pointing out that all the evidence had to be put together first. Another senior social worker said: “There are very few neglect cases that win court orders.”

Eventually, seven months after the High Court injunction, an application was made by the health board to the High Court to vacate its earlier order, something the inquiry found should have been done much earlier. The judge varied the order, this time restraining the health board from removing the children unless in accordance with an order of the district court. It appears health-board staff misunderstood this to mean a care order should not be granted on the basis of the information before the court and that an application to the district court for a care order would be unlikely to succeed.

In all, between 1996 and 2004 the family had five primary social workers, leading to a lack of continuity in dealing with the case. The overall conclusions of the inquiry team, led by Norah Gibbons of Barnardos, was that faulty decision making, a lack of interdisciplinary working, ineffective assessment processes and weak management systems, and a failure to learn from previous inquiries, combined with a poor knowledge of childcare legislation, all contributed to the children being let down.

Social services were well aware the children were at risk but did not exercise their statutory authority to protect the children at the earliest possible point.

There are calls now for those who failed the children to be held accountable even though the report says staff were well-intentioned and acknowledges child-protection work is difficult. Geoffrey Shannon, child-law expert, says a fundamental question arising is whether or not social workers understand the provisions of the 1991 Child Care Act. There had been a failure in this case to use it in an effective and timely fashion.

Prof Pat Dolan of NUIG stresses social work needs to go back to its roots in doing direct work with parents and children, not just case management, to ensure children’s voices are heard. He also says the training of social workers needs to change. They need to gain better skills in assessment and there needs to be more research on the best ways children could be helped by social workers.

The report stressed resources, per se, were not an issue in this case but Ineke Durville, president of the Irish Association of Social Workers, doesn’t understand how it comes to this conclusion. She says two social workers at least had heavy caseloads and there were difficulties recruiting staff, something confirmed in the report.

The HSE apologised to the six children for its failures and now faces a claim for damages. Bernard Gloster, a local-health-office manager with HSE West, can’t shed light on why the recommendations of previous reports were not implemented. He says every effort is made to implement the findings of reports in cases like this but “getting blanket implementation” across the system can be challenging.

“The absolute reality is you can never give absolute guarantees in relation to child-protection work” that similar mistakes will never happen again, he says.

1998 McColgan case

• Sligo farmer Joe McColgan sexually and physically abused a number of his children for years
• Review found children could have been spared suffering had the health board collated all information in its possession
• Failure to hold case conferences at key times

1996 Kelly Fitzgerald report

• Mayo teenager died from blood poisoning in 1993, underweight and emaciated
• Review found information about family not adequately collated or assessed
• Recommended internal consultative process to identify children at risk and overhaul how case conferences held

1993 Kilkenny incest case

• Victim had more than 100 contacts with health services between 1982 and 1992, before her father was arrested
• Report recommended attendance of all relevant persons at case conferences, mandatory reporting of all forms of child abuse and an amendment to the constitution to strengthen the rights of children