Thursday, June 21, 2012
A record of Death and Shame
The publication of the report by the Independent Child Death Review Group is a chilling indictment of the child protection systems in the Irish state that repeatedly failed to save children from abuse and in some cases death.
The last few years have seen a succession of reports and revelations around abuse. The Commission to Inquire into Child Abuse, generally known as the Ryan Commission, was published in May 2009. It ran to five volumes and looked at the extent of abuse against children in Irish institutions from 1936.
Most of these related to the system of residential and industrial schools that were run by the Catholic Church under the supervision of the Department of Education and which saw children treated like slaves and prisoners. They were subject to the most horrendous conditions and abuse.
Other reports, including the Ferns Inquiry, the Cloyne Report, the Murphy Report and the scandal of the Magdalene Laundries focused on abuse by Catholic clergy and religious orders.
The ICDRG report provides a disturbing and harrowing insight into the systemic failure of the Irish state’s child protection systems between 2000 and 2010. It is also a damning reflection on previous governments which failed to use the wealth of the boom years of the Celtic Tiger to invest in child protection services and strategies.
The system was so bad and the state of organisation so poor that when the Independent Child Death Review Group was established in 2010 the Health Service Executive (HSE) could not provide the ICDRG with accurate data on the scale of the problem.
The ICDRG report records how bad this was. It reveals that ‘there was considerable confusion in relation to the numbers of children who had died while in care of or known to the HSE. Initial figures reported by the HSE fell far short of the actual number of cases subsequently uncovered by the HSE. Once cases had been identified there was significant delay in the handover of the files to the ICDRG...However many files were incomplete and the ICDRG requested missing components from the HSE on an ongoing basis, specifically death certificates and reports from coroners which continued to arrive throughout the period of the review. The piecemeal manner in which the HSE provided the information endured throughout the review and significantly hampered the review team in producing this report.’
In addition successive governments had failed to provide for a national framework for service delivery or a standard approach to assessing risk and referring cases, and there was no co-ordination between agencies dealing with children and young people.
This emerges most clearly in the individual case histories that are recorded in the report. They make distressing reading. Although the names have been withheld nonetheless the tragedy of children and young people in desperate circumstances comes through.
For example, the report tells the story of ‘Young person in Care 6’ who died in 2000 at the age of 15. ‘She was known to the HSE for three years prior to her death and she was in care for most of this time...This young person had six different placement during her time in care. She was also missing for some periods and believed to have been living on the streets. She travelled abroad at one point...She had four different social workers and there appears to have been one period of 7 months when no Social Worker was allocated to this case despite the high risk to her well bring noted on her files...This young person was identified as being at severe risk of harming herself or others ...’
At the conclusion of each account the ICDRG identifies concerns arising from each person’s experience. There is a stark similarity in conclusions across most of those who died from unnatural causes.
In this young girls case there was:
• No information on the file regarding the circumstances of her death.
• The file recording is very poor, confusing and difficult to follow.
• There are multiple copies of reports, many not dated so it is difficult to ascertain the sequence of the documents and the events involved in this young person’s care.
• Four different social workers in the three years this young person was in care.
• Some periods where no Social Worker was assigned to this young person.
• High number of placements for this young person.
• It appears that there may have been a failure to follow up allegations of abuse made by this young person and a failure to follow up a disclosure of her involvement in prostitution
• Inappropriate care plans were put in place
• Interagency working was less than optimal.
• There is no record of notification to the High Court of this young person’s death.
It’s almost as if with this latter omission the system was erasing her life – treating it and her as of no consequence, as if she never existed.
Page after page of the report records the lives and deaths of one young person after another and with each conclusion it is clear that the child protection system failed time after time.
The state abdicated its duty in respect of these young people and failed to provide the adequate child protection support that should be expected of a modern state in the 21st century.
The key to successfully protecting children is early intervention. The ICDRG found that too often there was a sporadic approach to dealing with young people at risk and that earlier and more consistent intervention could have helped these young people to overcome their vulnerabilities. This didn’t happen.
In other words lives could have been saved but these young people and their families were failed by the state. This is a long way from cherishing the children of the nation equally.
While I have welcomed the appointment of a full cabinet Minister for Children and Youth Affairs and the publication of the Children’s First Bill, it clear from this report that much more needs to be done.
There is an onus on the government to ensure that the inadequacies identified by the ICDRG, in relation to the systems of care for vulnerable children and young people, are rectified.
It also has a duty of care to our young people to implement the recommendations emerging from the ICDRG report, particularly in respect of transparency and accountability. That especially means it has to provide the necessary resources in terms of personnel, social workers or other resources to guarantee that there is no reoccurrence of this appalling litany of death and shame.