A 16-year-old girl who died by suicide did not get suitable care due to a “lack of appropriate placements”, while another who died “tragically” was not offered therapeutic supports after disclosing sexual abuse.
Lack of appropriate residential placements, ineffective communication between professionals, overburdened caseloads and systemic failing were factors in the deaths of four children between 2016 and 2018, examined in reports from the independent National Review Panel (NRP) published on Wednesday.
The NRP is tasked by Tusla to review deaths of children in its care or known to it.
The 16-year-old named in the report as “Mary” agreed to enter residential care and then foster care, and was then placed in a unit “in another county which was the only available option”.
She “made a number of serious suicide attempts that were escalating in frequency and potential lethality”.
Following psychiatric hospital treatment she was moved to a unit nearer home which had no night staff cover.
“This plan was made in a context of limited options as the type of placement – a therapeutic community that was proposed by her mental health team . . . was not available in this jurisdiction”. Two months later she took her own life.
Poor communication
Aged 13, “Ava” disclosed sexual abuse by a relative. She was living in a social work area, called B in the report, and the alleged abuser in another area, called A.
Social workers and gardaí in area A interviewed her to assess any ongoing risk, but social workers in B did not meet her. Following attempted suicide, the child and adolescent mental health services said she had no treatable mental health illness.
“Seven months after this, Ava was reported missing and her body was found a few days later.”
Poor communication between social workers meant “certain assumptions were made about the extent to which Ava’s needs were being met”.
In a complex case, “Declan” died in his mid-teens of a suspected overdose. He was “extremely vulnerable” with intellectual and physical challenges which “were neither fully understood nor met in a co-ordinated way by the services he was engaged with”.
The case of “David” (16), who died following as assault, was closed after a relative said the family no longer needed supports. Tusla staff told the panel the “volume of referrals was high at the time”.
NRP chair, Dr Helen Buckley, said despite evidence of good practice, limited multiagency working arrangements and protocols contributed to difficulties in these cases.
