UNDERSTANDABLY, A great deal of the commentary on the Monageer tragedy has centred on two themes, firstly the way in which the report was presented with key parts blacked out, and secondly the failure to provide an out-of-hours emergency social work service. The way in which the report is presented is truly bizarre. Not only are page after page of conclusions and recommendations blacked out, but in a new high of censorship, an abbreviation and its explanation has also been obscured.
Given that Ireland is virtually unique among developed countries in not having an out-of-hours service, it is long past time that such a service existed. But if it had existed, could it have saved the lives of the Dunne family? At best, that is debatable. Perhaps if professionals trained in risk assessment had met the family, they might have spotted danger signs. However, as Dr Helen Buckley, senior research fellow in Trinity’s Children’s Research Centre, commented this week, you cannot take children into care on the basis of a bad feeling. She went on to say that the problem is far deeper than the provision of out-of-hours service, welcome and important though that provision would be. The Dunne family was failed long before that weekend in April 2007.
As Kieran McGrath, a well respected figure in the area of child welfare, said wearily on RTÉ radio during the week, the report from this inquiry could have been written before the inquiry even started. The concerns raised are all too familiar.
For example, one of the recommendations of the 1993 groundbreaking Kilkenny incest case report was a standardised system of communication between agencies. Yet the Monageer report highlights once again, that although many, many different services were in contact with the Dunne family, essential people did not have the full picture. For example, the public health nurse told the inquiry she did not know about repeated missed hospital appointments for the children.
Peter Reder’s classic text on child protection, Beyond Blame – Child Abuse Tragedies Revisited, was published 15 years ago. The title highlights that a search for scapegoats may satisfy our desire for vengeance, but it is counterproductive. It is far more important to learn what caused the tragedy and to begin to implement change. The book analyses 35 inquiries into child deaths in the UK and summarises key recurring themes.
One of the red flags highlighted in Beyond Blame is the failure to keep appointments. Never mind a family trip to order white coffins, Adrian Dunne’s repeated, documented failure to keep the children’s hospital appointments should have been enough to trigger concern. Combined with the six moves the family made in four years, and that these were vulnerable people with significant learning difficulties, attention should have been paid far earlier. It is very difficult to stop someone who has made up their mind that suicide is the only answer. Intervention and support at a much earlier stage would have had a far higher chance of averting tragedy.
There is something deeply cynical about setting up inquiry after inquiry that reach the same conclusions and make the same recommendations, and ignoring those recommendations until there is yet another tragedy. Then the cycle begins again.
It is long past time that we analysed the recommendations of all the inquiries we have had into child abuse and began, painstakingly, to put them into practice. Standardised training, robust procedures and centralised information systems would be a good place to begin. When the Government introduced the child protection guidelines, Children First, there was a spate of training.
However, a report commissioned by the Department of Health and Children last year highlighted the fact that the implementation of Children First varies wildly from one HSE area to another. As Irish Times social affairs correspondent Carl O’Brien pointed out this week, so does the caseload of social workers, and Wexford has one of the highest in the country.
The backlog of cases that has not been properly processed is bad enough, but even where children have been identified and taken into care, best practice is not followed. The majority of children in care in this country do not have an allocated social worker. If concerns arise, a social worker on duty will deal with it. In theory, a child in foster care could have a different social worker every time a concern arises. It is a recipe for disaster if no one has overall responsibility.
To implement change would require real leadership, and sadly, it is in short supply. The fact that the HSE has become such a monstrosity is part of the problem. Speaking to social workers with decades of experience, it is clear that they believe that services in some ways have deteriorated, rather than improved. One source spoke of being “up the side of a mountain, at 11 o’clock at night in the winter”, responding, quite properly, to a client’s needs, and he was certain it would not happen today.
He described a system rendered defensive not only because of an increasingly litigious culture, but also where everyone is watching his or her back and afraid to take the initiative in case they become a scapegoat if something goes wrong.
Communication between different agencies is essential. Is it not extraordinary that we cannot create a system of sharing information in a sensitive and confidential manner, even between people who all work for the HSE? It is true that we can never prevent all tragedies. That is no excuse for failure to intervene early enough to support vulnerable families.