Minister's job to find out who let a child die

MICHAEL Noonan said at the weekend he was "not in the business of finding scapegoats" for the official negligence that contributed to the death of Kelly Fitzgerald. If the Minister for Health is "not in the business of finding scapegoats" for the circumstances that led to the death of Kelly Fitzgerald, how can accountability for the failure to adhere to established procedures be enforced?

Kelly Fitzgerald was born in London on May 4th 1977. Less than six months later Kelly was brought to a hospital casualty department and was found to be severely emaciated and dehydrated. X rays revealed two healed fractures. Because her older sister appeared to be healthy the social workers involved at the time did not register Kelly as "at risk".

There was no further social services involvement in her case until 1988, when she was 11. She was then referred to child guidance because of reported behavioural problems. In May 1989 she was placed on the Social Services Child Protection At Risk Register and stated to be at risk "of emotional deprivation and abuse and, at times, [suffering] extreme mental cruelty from parents". Shortly afterwards she went to live with her maternal grandparents.

A year later one of Kelly's sisters was also placed on the "at risk" register, under the heading "grave concern" and around this time the family moved from London to a small house in east Mayo. In December 1990 the West Lambeth Health Authority sent its child care files concerning Kelly's sister to the Western Health Board, noting also the concerns that had arisen concerning Kelly.

Almost two years later, in December 1992, Kelly went to live with her family in Co Mayo. She died five months later.

Almost two years before Kelly returned to live with her family, sometime in early 1991, a senior official of the health board received two phone calls from a family relative in London stating that if Kelly ever returned to live with her family she would be at serious risk. No log was made of this call. Neither does there appear to have been any attempt to follow through on the information sent by the Lambeth Health Authority.

In February 1991, in response to a referral from the public health nurse, the senior social worker requested that a social worker review the file before making a home visit to the Fitzgerald family. No home visit was made.

In June and July 1991 there was a succession of reports to the health board from neighbours expressing concern for Kelly's sister. These reports stated that she had been left in the care of an older sister when her parents went to Britain; that she was stealing lunches and falling asleep in school; and that she was leaving home at night to steal food from neighbours, on one occasion clad only in a blanket. No investigation was conducted into these reports, in contravention of the requirements of the 1987 Department of Health guidelines on child abuse.

On July 1st 1991, the acting senior area medical officer visited the Fitzgerald home. This officer found Kelly's sister to be withdrawn, frail and unhappy. The report states that "she stood with her arms folded over her chest, her shoulders hunched in a semi foetal position". A case conference was held two days later but nothing was done.

OVER the Christmas/New Year period of 1991/92 Kelly's sister was admitted to Castlebar General Hospital with 20 lesions which were suspected of having been caused by cigarette burns. She was also grossly underweight. During her three week stay in hospital in Castlebar and later at St Anne's Children's Centre in Galway she gained a stone in weight. There was no conclusive assessment of her physical, psychological or emotional condition, even in spite of the previously known concerns and allegations concerning her.

In February 1992 a case conference agreed there should be therapeutic intervention with both the girl and the parents. The parents agreed to this but discontinued after three sessions. There was no follow through.

Several case conferences on the FitzGerald family took place at this time but at the final conference (in April 1992) of this sequence of conferences it was decided there was not sufficient evidence available to support an application to the district court for a Fit Person Order. It was to be a further 7 1/2 months before a subsequent case conference was held.

It was into this environment that Kelly came to live with her family in September 1992.

It was at her own instigation that she did so but within a few weeks she wanted to return to her maternal grandparents in London. The report states that from a relatively early stage after her return, her parents began to deprive her of food and made excessive demands on her to do chores around the home and farm. Her father beat her on average twice a day with a belt without stated reason. During the five months that she lived with her parents before her death she lost 33 lb. While she was clearly urgently in need of medical attention in January 1993 and was denied this by her parents, a vet was called to the farm to tender to a sick cow.

The parents became anxious about Kelly's condition and on January 30th 1993; her father telephoned his brother in London and arranged that Kelly would fly to Stansted airport on Monday, February 1st, accompanied by her older sister. Her condition was rapidly deteriorating and the parents admitted that on their way to Knock airport they considered taking her to Castlebar General Hospital but believed she could be admitted to hospital in London almost as soon. On arrival in London she was taken to St Thomas's Hospital. She was diagnosed there on Tuesday as having meningoccocal septicaemia. She died in the early hours of Thursday, February 4th 1993, aged 16 years and nine months.

On May 17th 1994 her parents pleaded guilty to a charge of wilful neglect and on November 1st they were both sentenced to 18 months' imprisonment.

The Western Health Bord Committee of Inquiry report makes several recommendations for improved procedures and more resources to deal with cases such as this but it goes on to note: "It is clear . . . that the procedures which provide for the identification, notification and investigation of suspected child abuse or neglect were not followed in this case in a number of significant respects". This echoed a comment made in the Kilkenny incest investigation report that "procedures in themselves, whether statutory or otherwise, are not a substitute for good practice".

Thus the announcement that the Minister is "not in the business of searching for scapegoats" is an indication that one of the central problems in the handling of such cases - officials ignoring their obligations under established guidelines - is to be ignored. The addition of additional procedures is therefore largely an irrelevance.