Lisa* was 14 and in the care of Tusla when she died by suicide. She “gained very little from” her referrals to the Child and Adolescent Mental Health Service (Camhs), a review of her death has found. She faced “unacceptable” delays accessing Camhs and the service was “fragmented”.
The review is one of four into deaths of children published on Thursday by the independent National Review Panel (NRP). It examines deaths of children or young people in State care, or known to Tusla. The reports were published alongside the NRP 2023 report, which finds 29 young people in care or aftercare, or known to Tusla, died last year, an increase of six compared with 2022.
“Lisa lived mainly with her mother, her parents having separated when she was a small child,” says the report. “She was ... described as smart and creative with a great sense of humour ... Lisa was well liked, yet professionals were left with a feeling of being unable to reach her.”
She was first referred to Camhs aged 11 “after a serious self-harm attempt”. She was not diagnosed with a mental illness but “Camhs observed attachment difficulties between her and her family”. Though offered appointments she was unwilling to engage.
She was referred to Tusla after an incident where gardaí placed her in emergency care. Her mother was unable to keep her safe. Lisa had four foster placements in four weeks. Her foster carers were unable to deal with her behaviour. Residential care was deemed more suitable.
Lisa initially settled into residential care but her behaviour became challenging. Due to her “high-risk behaviour” Tusla decided to pursue a special care placement. “She had no allocated social worker due to staff shortages ... The principal social worker kept oversight of her case ... A new social worker was allocated six months after she entered the special care unit. She settled reasonably well ... and was reluctant to move on,” but her placement was for three months only.
She found the move to a private residential unit difficult and sometimes assaulted staff but this reduced as she settled. Her death occurred after she seriously assaulted a staff member and gardaí were called. That night: “Lisa appeared to settle in her room. The staff member that was due to call Lisa in the morning found that she had taken her life.”
During her first residential placement Tusla tried to transfer Lisa’s mental healthcare to the local Camhs but a six-month delay ensued. Her mental healthcare “was disjointed due to her different placements”.
The report recommends: “Tusla, in conjunction with the HSE and other relevant parties, should develop a national policy and strategy to address the mental health needs of children and young people in care.”
*This is not her real name
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