These case histories are drawn from reports published online by the National Review Panel, an independent group of professionals which report to the Tusla, the Child and Family Agency. Names of the children and their families have been changed to protect their identities.
Harry (7 months)
Cause of death: sudden infant death
Harry’s mother was allegedly a victim of domestic violence from her partner. This included an assault on the day prior to the boy’s birth.
Following an investigation by social workers, his case was designated as “welfare” and not a high risk.
Harry’s family was referred to a community agency for assessment. However, it was unable to undertake an assessment without the consent of the boy’s father. His mother said she was unwilling to share his contact details for fear of reprisals.
Shortly after, the public health nurse had difficulty contacting his mother and became aware that she had suffered an injury and had been evicted.
She was later found to be staying with family members at the time of Harry’s death.
The review found the response to concerns about Harry and his family was slow and highlighted poor communication between social workers and the public health nurses.
While it did not find any connection between his death and any inaction on the part of Tusla, it found that the designation of “welfare” in this case had implications for the way that the case was managed.
The review panel’s report recommends a better response to domestic violence issues and the need to improve communication between different agencies,
Avril (17)
Cause of death: accident/misadventure
Her family background was characterised by domestic violence, criminality and changes of accommodation. Avril’s mother was a victim of domestic violence and found it difficult to manage her children.
An assessment at the age of 11 found Avril to be unhappy, out of touch with her emotions and lacking confidence.
While staff at a youth service project believed “increased statutory involvement” was required for the family, in fact her case was closed the following year. She also ceased attending the youth service around this time.
The review notes that Avril displayed a lot of resistance to social work involvement and could be aggressive with social work staff.
There was intermittent contact between her and social services until her death at 17 year of age.
While it was suspected that she took her own life, a coroner delivered a verdict of death by misadventure.
The review did not find evidence that inaction of social work services was linked in any way to Avril’s death.
However, the review also found that opportunities to intervene when Avril was younger were missed. It also found the rationale for closing the case overlooked Avril’s significant vulnerabilities
Tim (15)
Cause of death: suicide
Tim, described as a talented young man who was easygoing, upbeat and a bit stubborn at times, spent most of his childhood in his father’s care.
His mother had a drug problem which was ongoing for a number of years. Although Tim had been a placid child, his behaviour became very challenging in his early teens and wanted to live with his mother.
His father was uneasy about this plan but felt he had little choice, so Tim moved to stay with his mother and half-sibling in another area.
Social workers intervened in response to reports that Tim and his half sibling, who also had some special needs, were being neglected and drawn into their mother’s addictive behaviour.
He later went to live with an older half-sibling, Tara, who was required to ensure the boys were never left unsupervised with their mother.
In reality, Tara was reliant on her mother for practical tasks such as school runs.
His death by suicide when he was 15 came as a terrible shock to his family, though Tara said she later became aware of allegations that he was being bullied at school.
The review found social workers acted correctly and quickly to reports about the children but they failed to properly assess the children’s needs or their sibling’s capacity to care for them.
Joe (15)
Cause of death: suicide
Joe lived predominantly with his father, at times with both parents and for short periods with his mother. There was a history of domestic violence in the family home along with alleged alcohol abuse. The children experienced a level of instability as a result of all these factors.
As Joe grew older his relationship with school became “problematic” and attended mental health services for behavioural issues.
Joe’s father struggled to manage the children’s behaviour and sought support from services. The case was wait-listed as a high priority for more than a year prior to Joe’s death. However, it could not be allocated because of staff shortages.
Joe ended up taking his own life at the age of 15.
A review found no evidence that action or inaction by the HSE services involved with Joe directly contributed to his death.
However, it said the case should have received consistent intervention from an early stage and a lack of assessment meant the family’s needs were neither identified nor met.
The inability of the social work team to manage the high number of referrals that was received in the area meant there were delays in responding to concerns over Joe’s wellbeing.
Dylan (16)
Cause of death: overdose
Dylan was in State care in a residential unit when he died just before his 17th birthday.
He had been in care for only a few months and had lived mainly with his mother who had a drug problem.
From the time he was quite young, social services had been alerted to concerns over Dylan including neglect, poor school attendance and age-inappropriate responsibilities he was carrying.
Following a crisis in the family home, he was placed in emergency care for a short period and moved to live with his stepfather.
While his stepfather’s extended family also offered him support and he appeared to settle down well, Dylan moved back to stay with his mother a few months later.
A child protection conference was held at that point and a child protection plan was developed but not actually implanted.
Approximately a year later, Dylan re- entered the care system with his mother’s consent following a row he had with her.
He was found dead in the unit a few weeks later. The coroner reported that high levels of toxicity were found in his system.
