Home > Report of the Independent Child Death Review Group 2000-2010.

Shannon, Geoffrey and Gibbons, Norah (2012) Report of the Independent Child Death Review Group 2000-2010. Dublin: Government Publications.

PDF (Report of the Independent Child Death Review Group 2000-2010 ) - Published Version
PDF (Report of the Independent Child Death Review Group 2000-2010 - Summary) - Supplemental Material
PDF (Department of Children briefing note for ICDRG) - Supplemental Material

The report, authored by Dr. Geoffrey Shannon and Norah Gibbons, gives details of the 196 children who died over the period 2000-10, both of natural and unnatural causes. The children in the report include children who were in the care of the state at the time of their death, young adults who were in aftercare and other children who were not in care but were known to the HSE.

Speaking at the publication of the report, Minister Fitzgerald said; “Before this Government took office; there was conflicting data about the numbers of children who died in state care. The lack of transparency and the lack of accountability, shocked. It was utterly unacceptable that the state could not even tell how many children had died in state care.

The Minister stated that this report now gives clarity on this vital issue. There were 112 children who died of unnatural causes; 17 of whom were in care, 27 of whom were in receipt of aftercare and 68 of whom were not in care, but were in some way known to the HSE child and family services. The children and young adults in this report died from a range of causes. Some died from a range of illnesses, 4 died of accidental drowning; 5 died in house fires; 17 died from road traffic accidents; 16 were unlawfully killed; and at least 28 died by suicide.

The Minister stated: “I wish to extend my deepest sympathy, and that of the state, to all those touched by a loss in this report. No parent should expect to lose a child. I do not expect today’s report to bring closure. Indeed, I am sure it will, for many, bring fresh pain. But this work shines a light on a dark, often unexamined and tragic corner of Irish life. The authors have done a professional and painstaking job in making real and understandable the lives and deaths of children who are no longer with us.”

Responding to the report the Minister stated: “The findings of this report are deeply disturbing. We read of children and young people and families, often vulnerable, often in crisis, who needed support. We read of services often willing, but fragmented and not comprehensive in their response. The question must arise how, after a period of such unprecedented economic prosperity, we were left with a child protection service in need of such reform.

“If ever evidence was required of the scale of the challenge which this Government and I have had to face into, then this report is it. If ever evidence was required of why we need an utterly reformed system of state care and intervention, then this report is it. And if ever evidence was required of the need to take child protection away from the HSE, wherein up until recently, it was lost, and to set up a new agency; the Child and Family Support Agency, then this report is it.

The report highlighted system failings in the Irish child protections services including
• Poor risk assessment
• Poor co-ordination between services
• Poor flows of information
• Limited access to specialist assessment and therapeutic services
• Limited interagency work for children and families with complex needs.
• A lack of early intervention and family support services responding proportionately to the needs of children at risk and families in crisis.

Commenting on these failings Minister Fitzgerald stated: “if the system had done a better job, outcomes for some of these children might well have been very different. The key to a successful child protection service is early intervention. This concept must become part of our national psyche. Parachuting in a service at a late stage is not the most efficient or effective way to help the child, or to help the family.

Responding to the report Minister Fitzgerald stated that “the current government reform programme is an essential response to this report, in particular the establishment of the Child and Family Support Agency led by CEO Designate Gordon Jeyes. Already, under Gordon’s leadership we are seeing implementation of a ‘change agenda’ in children and families services which will continue and be accelerated under the new agency; and will be further informed by the recommendations of this report.

Key element of the ‘change agenda’ in children and families services include:
• A service delivery model that will address a multi-agency, albeit differentiated, approach to managing the child welfare and protection system;
• A nationwide consistency of approach in practice and implementation of Children First and child welfare and protection services generally;
• Use of standardised definitions, criteria and thresholds for reporting and referrals including prioritisation of cases;
• Greater reliance on real-time data on social work referrals and alternative care collated through HSE performance management indicators and the ongoing development of the National Child Care Information System;
• Improved resource allocation responsive to changing needs;
• Clearer management and budgetary accountability;
• Better workforce planning, training and induction of new staff.”

The Minister added: “The Task Force which I established in September 2011 to advise on the new Agency, will present its final report by the end of this month and I look forward to addressing its recommendations relating to vision, governance and scope-of-services, such that the Agency is established and up-and-running next January 2013.”

In the report the authors remark that “a key issue to be emphasised is the vulnerability of these children”.

The Minister responded stating: “Many of these individuals had extremely complex needs. There is no doubt that children in these circumstances sometimes have little to draw on, in terms of their own resilience, and limited positive experiences to allow them to cope with even the ordinary challenges they subsequently had to deal with.

“The role of alcohol and drugs in Irish society plays heavily in the lives and deaths of many of the children and young people in this report, highlighting in the most serious way, our national problems with alcohol and drug abuse. I am committed to working with Minister Roisin Shortall and the relevant agencies on progressing a fresh new approach to identifying and addressing the hidden harm posed by substance misuse.

Responding to the report Minister Fitzgerald also announced a number of other measures.

The Minister accepted the essential criteria set out in the Report on developing an independent child death review structure and confirmed that she will be making an announcement on this in September.

The Minister announced that HIQA will next month publish new National Standards for the Protection and Welfare of Children which will lay-out a new standards-led approach to enforcing a new culture of quality, effectiveness and accountability in Ireland’s child protection services.
The Minister also commented on the concerns raised on aftercare in this report: “Young people with a need for aftercare should; and must, receive the support they require when they leave care. I believe the law needs to be strengthened in this regard, and with advice from the Attorney General, I will be proposing legislative change later this year, in the bill to establish the Child and Family Support Agency.”

The Minister confirmed that along with Gordon Jeyes she is working to extend access to 24 hour social work assistance: “Child protection crises arise 24-7. So why should child protections services operate any differently?”

The Minister concluded saying: “today is an especially difficult day for the families of the children in this report. We cannot change things for their children. However, I hope it is clear that already a great many changes have been put in train for other children because of what happened. I hope it is clear that this Government is committed to transparency and honesty about the challenges in getting children’s services right. Child protection remains a high priority on our agenda and changes at every level – policy, law, structures and individual practitioner - have happened and will continue to happen; and will make a difference for the future.”

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