An Analysis of the Reports of the National Review Panel for Serious Incidents and Child Deaths

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A fortnight ago the HSE published the first round of reports from the National Review Panel for Serious Incidents and Child Deaths relating to children known social services within the HSE.

As one has, regrettably, come to expect the report received fleeting coverage in the print and broadcast media. The coverage it did receive was littered with cliché ridden, factually incorrect  hand-wringing while lacking robust scrutiny and investigation.

First allow me to give some background to the publication of this report. The National Review Panel was set up in 2009 to review deaths and serious incidents experienced by children either known to the HSE Children and Family Services or were in the care of the state. The origins of the review panel lay in the Report of the Commission to Inquire into Child Abuse (Frequently called the Ryan Report, 2009) who recommended that:

the HIQA will develop guidance (by November 2009) for the HSE on the review of serious incidents, including deaths of children in care and detention. These will be reported to the HIQA and the Department of Health and Children/IYJS. The HSE and IYJS will develop a panel (internal and external) of appropriately skilled professionals to undertake investigations.'(2009: 49)

In January 2010, HIQA published Guidance for the Review of Serious Incidents including Deaths of Children in Care. This guidance required the establishment of a panel of professionals to review cases under the guidelines set down by HIQA (Health Service Executive, 2011:3).  This report has emerged from the work that panel has being carrying out.

One of the initial startling aspects of this report is the broad, almost unwieldy criteria for review which was set down by HIQA. The report comments that while much public and political attention has been on deaths of those children who died within the care system, HIQA’s criteria stretched to children who have never been in the formal care system (2011:4).  HIQA’s criteria directed the panel to review;

  • All deaths of children in care, including those who died by natural causes,
  • All deaths of children known to HSE child protection service,
  • Deaths of young adults (up to twenty-one years of age) who were in the care of the HSE immediately prior to their eighteenth birthday or were in receipt of aftercare services under Section 45 of the Child Care Act 1991
  • Where a case of suspected or confirmed abuse involves death of, or a serious incident to, a child known to the HSE or a HSE funded services,
  • Serious incidents involving children known to the HSE Child Protection Services.

The report noted that these criteria were for broader than has been the norm in  other reviews of this type (see Northern Ireland’s Co-operating to Safegaurd Children). It would be my interpretation of HIQA’s criteria that they wanted to create a transparent system which would provide answers to the deaths of all children known to the HSE. This  may have been partly motivated by the desire to eliminate any future queries about why certain cases were excluded from consideration. In the context of historically hidden child mistreatment by agents of the State and Church this motivation is somewhat understandable. It is unfortunate however that this broad criteria appeared to stymie the valuable work being carried out by the panel.

Unsurprisingly the broad review criteria created a scenario where a large volume of cases needed to be reviewed. The report states that during the nine months where the criteria applied in 2010, twenty-two deaths and eight serious incidents were notified to it.

A further error from HIQA was evident in the brief timelines in which reviews were expected to be completed. HIQA advised that serious incidents reviews should be commenced within four months and reviews of deaths within one month. Given the various sources of information that needed to be collated in these reviews these timelines proved “un-workable” (National Review Annual Report, 2011:5).

Further still, the report format required under the HIQA guidance appears to have been imprudent and troubling to the  review panel. As the report notes the guidance required information of such detail that it had potential to jeopardise the confidentiality of cases and reveal family identities. It also required that separate chronologies be provided for both the child and family which proved to be a time-consuming, fruitless exercise.

In October 2010 the HSE undertook an analysis of deaths of children and young people known to the Children and Family Services over the past ten years. During that period in excess of 200,000 referrals were made to Children and Family Services. In excess of 20,000 of these related to child protection concerns. Of these 199 children were identified  within HIQA’s criteria in which thirty-five died in care. It is of note that the majority of these children (n=133) were known to the HSE but were not ‘in care’ of the HSE. This is an important, statutory distinction.

In the period between March and December 2010, thirty cases were referred to HIQA and  twelve cases were under review. The report notes that some of these cases are historical in nature but that the children/young people were in the care of the HSE at the time of the incident.  The report does offer a comprehensive breakdown of data in terms of gender, cause of death, geographical area and age of child (p.11-13) which for the sake of brevity I will not discuss in great detail here.

So what can be learnt from the report? On a practical level it is apparent that the guidelines HIQA for the panel appear to be arbitrary, not in line with best international practice and having potential to be unhelpful to the work of the panel. It is apparent that the panel themselves were critical of, and highlighted, these issues to HIQA which may see a future re-drafting of the guidelines.

In relation the state of the HSE Children and Family services the report rings a familiar tone. While acknowledging that staff are committed to protecting children, familiar issues of high caseload, poor interagency communication and the lack of a standardised assessment tool continue to be issues. It is important to call these issues what they are -that being, systemic/structural problems rather than individual failings. It is heartening that not one of the cases where a child died in care was due to professional negligence.

As previously noted the commentary on these reports was brief which should again have us querying how important we take consideration of children’s issues. The discourse that did take place on the reports tended to focus on the individual cases where case studies were provided within the context of the reports. It is all too easy for media outlets to focus on individual cases, especially when said cases are laid out ‘chapter and verse’ in case studies. However, this type of regurgitated journalism does little to assist with the understanding of a complex problem such as children at risk.

RTE’s Drivetime discussed one case, Baby G, in detail with little discussion on broader systemic/structural themes. It appeared to try to redress the balance by speaking to solicitor, Catherine Ghent. Ms Ghent herself acknowledged that she had had only a cursory glance at the report which limited the contribution she could make. Print media reported that thirty-five children had died in care in 2010 (35 children in contact with HSE died over last 18 months – The Irish Times, the 19th of October 2011) which is a misinterpretation of the report. The report noted that death rate for children in care does not exceed the national average for child deaths (2011:4).

It is also concerning that the role HIQA’s guidelines played in the work of the panel were not discussed at all in media reporting. The fact that their review criteria was not discussed is a serious omission given the impact it had on the number of cases coming before the panel and also the impact on the important work of the panel. Further, it leaves questions around HIQA’s broader role within public services which were not addressed.

While this review was a necessary and important step in the improvement of  children and family services it is unfortunate that oppressive bureaucracy appears to have slowed down its work.  It is also hugely disappointing that media discussions of the mechanisms report and its findings were not given more serious, considered attention.  More reports will emerge from this panel and one would be hopeful that ‘panel-driven’ changes to the review process will benefit their work.

Darren Broomfield is a practising social worker and academic whose research interests include social justice, social policy and criminal justice.