Deaths in State care show systemic cracks remain despite reforms

Problems in care system remain nearly 10 years on from scathing report

A landmark report into deaths of children in State care, published in 2012, found “systematic failures” were resulting in the most vulnerable young people falling fatally through the cracks in child-protection services.

The report, authored by Dr Geoffrey Shannon and Norah Gibbons, was scathing of how young people were let down by the State, and called for "root and branch reform", which later led to Tusla being set up as a standalone child-protection agency.

A little less than 10 years on, new figures on the number of deaths in the care system show despite significant reforms, cracks remain.

Forty-two children died in State care between 2010 and 2019, with 18 dying by suicide or from a drug overdose. They include those who died while receiving aftercare support services in the years after turning 18.


While progress has been made, the same failings highlighted in 2012 still occur today. These include a lack of co-operation between agencies, inadequate access to mental-health services and gaps in supports when people leave care.

The National Review Panel (NRP) produces regular reports into deaths of young people in care, and those known to child-protection services.

Dr Helen Buckley, who chairs the panel, said the system was suffering "enduring" issues.

Often deaths would occur during the transition out of the care system, which was a period of increased “vulnerability” in the young person’s life, she said.

‘Endearing young child’

This was the case for a man named in an NRP report as Jim, who was taken into care when he was three years old due to substance abuse and domestic violence in his family home.

Described as an “endearing young child”, by the time he was 19 he was dead from a drug overdose. He had been moved between foster placements and residential units for young people.

He fell into antisocial behaviour and criminality, and by his mid-teens was involved in regular substance abuse, which his psychiatrist felt stemmed from his experience of loss and anxiety about shifting homes.

After turning 18, he received aftercare support, living between his own flat, his mother’s home and prison. He died the following year.

A report into Jim’s death, published in 2018, found the management of his case had been “inadequate” and noted shortcomings in the provision of psychotherapeutic and education services.


The review panel, effectively the watchdog for deaths in the care system, has privately raised concerns about its resources, and that it has not been placed on a statutory footing.

In May 2020, Dr Buckley wrote to Pat Rabbitte, chair of Tusla, warning a lack of staff could delay reviews by up to two years.

Such delays would “greatly diminish the value of reviews” and would be “disrespectful” to the families of the deceased young people, Dr Buckley said in the letter, obtained under the Freedom of Information Act.

A Department of Children spokeswoman said a “range of options” around the future of the review panel were being considered, including whether it should be put on a statutory footing.

The department “continues to support the National Review Panel in the performance of its important functions,” she said.