Baby ‘Jack’ died while co-sleeping with his mother who allegedly used drugs

Tusla social workers “missed” an opportunity to intervene in the case of an infant whose mother was allegedly using illegal drugs and who subsequently died, a review of the case finds.

The baby, known as "Jack", died while co-sleeping with his mother. His case is among six reports into the deaths of children in care, or who were known to Tusla, which were published by the independent National Review Panel (NRP) on Thursday. Names are changed in the reviews.

Jack’s mother “Kim”, who lived with Jack’s father, had used drugs during the pregnancy and the family was visited regularly by two public health nurses (PHN).

A PHN referred the family to Tusla social workers while Kim was expecting due to concerns over Kim’s drug use. “There is no record of this referral in the social work records.”

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When Jack was born the case was referred to social workers by the maternity hospital, and a social worker visited Kim. Her drug use was discussed. Although a PHN said in an earlier report that Kim’s partner also used drugs, this was not brought up and was “possibly not known to the social worker”.

“The case was classified as child welfare, ie under the threshold for child protection intervention, and closed.”

A few weeks later, Jack was still being monitored by PHNs and was “apparently doing well”.

“Gardaí notified the SWD [Social Work Department] that a few hours before [Jack’s] death they had been called to the family home and found both parents under the influence of drugs. Jack was sent to a relative for the night and Kim later joined him. It appears that during the night, while he was in bed with Kim, Jack died. The postmortem indicated he had died as a result of sudden infant death syndrome [SIDS].”

The review finds the first referral note, from the PHN to social workers, “was not noted in the SWD files and was “not known to the social worker that later followed up the second referral.

“As this report contained important information about Kim’s alleged drug use...an opportunity to intervene at that stage was missed.”

Very limited communication took place between the SWD and the PHN service which meant opportunities for getting the full picture about the family were missed.

Risk-taking behaviour

In another case, a Traveller boy, “Alan”, died at age 16 in an incident “associated with what appears to have been risk-taking behaviour”.

Reports had been made to Tusla from when he was aged seven, about him and his siblings, “detailing neglect... parental alcohol misuse, mental health problems and domestic violence... He and his siblings lived in different accommodations...and experienced periodic homelessness.

“Overall, a low standard was applied to evaluating their situation following the first referrals about the family...It is notable the children’s needs were never assessed individually,” says the review.

“Assessing the needs of children from the Traveller community requires consideration of needs that may be additional to those of children from the settled community.

“The review found the response to Alan and his family following initial reports was inadequate.”

Failures by social workers to fully appreciate the degree to which children were at risk feature in a further three reports.

In a sixth, social workers and relative foster carers were praised for providing a “consistent, child-centred service” to “Oisín”, who died aged 13 of a sudden viral illness.