The David Foley Report (Summary)

8/9/2019 The David Foley Report (Summary)

1/15

CCCHHHIIILLLDDD IIINNN CCCAAARRREEE DDDEEEAAATTTHHH

RRREEEPPPOOORRRTTT

CCCHHHIIILLLDDD::: YYYOOOUUUNNNGGG PPPEEERRRSSSOOONNN AAA

AAAPPPRRRIIILLL 222000111000


2/15

2

1. INTRODUCTION

1.1.Purpose and Forma t o f this Rep ortThe purpo se of this report is to :

Esta b lish the lessons to be learned by the Hea lth Services Exec utive(HSE) in the p rac tice o f protec ting and prom oting the w elfare of

children.

Learn from these lessons, to ensure ongoing improvement in thedelivery of servic es to p rote c t and p rom ote the welfare of child ren.

The forma t o f this report is to :

Prote c t the d ignity of this dec ea sed young pe rson. Prevent the details relating to their particular difficulties and the

spec ific services, ava iled of b y this young p erson from being d isc losed .

Make every effort to protect the identity of this young person frombe ing disc losed .

Prevent interference w ith the p rivac y of a c hild in its c are o r who wa s inits c are.

Ensure that the report contains nothing that might infringe upon thischild s honour and rep utation.

1.2.Death of a ChildThe unexpe c ted dea th of a ny child , unde r any circumsta nc es is a

trag ed y. The d ea th of a c hild in care in pa rticular is a serious issue a nd is

required to be investigated thoroughly, sensitively and fairly.

1.3.The In Loco ParentisRole of the HSEThe HSE, a c ting in loco parentishas the responsibility of seeking the best

possible outc om es for child ren in its c are. Suc h a role enc om passes three

key elements:

The sta tuto ry duty of t he HSE to p rom ote the we lfare o f c hild ren a ndyoung p eop le w ho a re in its c are.


3/15

3

Co-ordinating the activities of many different professionals, carers andpa rtner ag enc ies who are involved in a c hild or young p erson s life a nd

taking a strategic , c hild -centred app roa c h to service delivery.

Shifting the emphasis from institutiona l to parenting , de fined as theperformance of all actions necessary to promote and support the

physical, emotional, social and cognitive development of a child or

young person.

1.4.Key Objectives when Conducting Investigations and Inquiries into theDeath of a Child

The HSE ac knowledge s tha t c hild ren c an c om e into c are w ith very

complex needs, backgrounds and levels of difficulties and that their care

c an p resent c ha lleng es to the organisa tion, ca rers and sta ff.

There a re a numb er of key ob jec tives for the HSE in conduc ting

investiga tions and inquiries into the dea th o f a child , inc luding:

Seeking to understa nd the reasons for the de ath of a c hild a nd c ausa lfactors.

Reviewing of all information and making effective recommendationsand directions, insofar as possible, to prevent other deaths and keep

children healthy, safe and protec ted .

Improving communication and linkages with other agencies. Imp roving delivery of services to c hild ren a nd families. Ident ifying signific ant risk fac to rs and trends in child d ea ths. Identifying req uired c hange s in polic ies, prac tices and proc ed ures.

In essenc e the HSE seeks to understa nd the rea sons for the dea th of a

c hild and to a ddress the possib le need s of o ther child ren in care a s we ll as

the need s of all fa mily members. The HSE a lso see ks to c onside r any

lessons to be learned about how best to safeguard and promote

c hild ren s we lfare in the future.


4/15

4

1.5.Balancing the Needs of Investigative Requirements and the Needs ofthe Family

There is a need to keep an a pp rop riate ba lanc e b etwe en statutory and

investiga tive requirem ents and a fa mily s nee d for support. There a re

c om plex interests to b a lanc e, inc luding:

The ne ed to ma inta in c onfident ia lity in respe c t o f persona l informat ionconta ined within rep orts on the child , family memb ers and othe rs.

The acc ounta b ility of pub lic servic es and the imp ortanc e ofma inta ining p ub lic confidenc e in the p roc ess of review.

The nee d to sec ure full and op en p artic ipa tion from different a ge nciesand profe ssiona ls invo lved .

The responsibility to p rovide releva nt informa tion to tho se w ith alegitimate interest.

The c onstraints on p ub lic informa tion sharing if c riminal proc eed ingsare outstanding, in that providing access to information may not be

within the c ontrol of the Review Panel.

1.6.Guida nc e to Conduc t Reviews and Pub lish Rep ortsReviews of significant incidents in regard to children have been

undertaken by statutory child care authorities in Ireland on a number of

occasions. However, available guidance as to when and how these

reviews are conducted and subsequent reports generally deal with an

individua l ch ild c are c ase. Therefo re, it is not possible to pub lish in full suc h

a rep ort where pe rsona l informa tion m ay lead to the identific ation of any

person and in p articular vulnerab le c hild ren/ persons.

Recommendation 36 of the Ryan Implementation Plan 2009 states that

the Health, Information and Quality Authority will develop guidance for

the HSE on the review of serious incidents, inc luding the d ea th o f child ren

in c are and dete ntion. The Guidanc e fo r the Hea lth Service Exec utive for

the Rev iew o f Serious Inc ide nts, inc luding Dea ths of Child ren in Ca re was

published in March 2010 and sets out a standard, unified, independent

and transparent system for the review of serious incidents and deaths of


5/15

5

c hild ren in ca re. It rec ommends tha t a na tional review p roc ess be set up ,

with the estab lishment o f a Nationa l Review Tea m, including a n

indepe ndent c hair and de puty c hair. The Guida nce also rec ommend s

tha t a ll dea ths of c hildren in care or child ren known to the c hild p rotec tion

system should b e notified to the Hea lth, Informa tion and Qua lity Autho rity,

Soc ial Servic es Inspec to ra te within 48 hours of the d ea th oc c urring.

2. REVIEW DETAILS

2.1.MethodologyTerms of Refe renc e

a) To review the c are p rovided to Young Person A from the time thisyoung person c ame into c onta c t w ith the HSE and its p red ec essor.

b ) To review ho w the case w as hand led by d ifferent services/ a rea s of thehea lth system.

c ) To m ake any rec om mendations from the findings.d ) To submit a rep ort to the Loc a l Hea lth Ma nage r of the review, find ings

and rec omm enda tions.

Description of the Proced ures Followed

All rec ords pe rta ining to this c hild s c ase we re examined.

2.2.Governing Legislation/Policy and Reports Considered by the ReviewTeam

a) Child Ca re Ac t, 1991b) Child Care (Placement of Children in Residential Care) Regulations,

1995

c ) Children First, National Guidelines for the Protection and Welfare ofChild ren, 1999


6/15

6

d) Rep ort of the Working Group on the Trea tment of Under 18 year oldsPresenting to Trea tm ent Services with Serious Drug Prob lems,

Department of Hea lth a nd Child ren a nd HSE, 2005

e) Establishing and Conducting Committee of Inquiry A PracticeMa nua l, The Hea lth Boards Exec utive , 2004

2.3.Involveme nt o f Agenc ies/ ServicesFrom the initial referral of Young Person A to the Health Board, 32

agenc ies/ services we re involved with Young Person A. This young person

d id no t a va il of a ll of these services. These inc luded :

Soc ial wo rk services - Young Person A ha d ac c ess to soc ial wo rkers fora number of years. In addition this young person had access to child

care workers and support services. Soc ial work services a lso

contracted other services to provide support. Furthermore, Young

Person A had access to out of hours services which provided support

and ac commoda tion.

Health services - these provided a broad range of services, bothgeneral and spec ific .

Educational services - this comprised of school and additionaleducational supports provided by external agencies.

Psychiatric, psychological and assessment services. Housing services - Young Person A availed of accommodation

provide d by the Health Boa rd/ HSE and ac c ommod ation a lso

contrac ted from external services.

Youth justice system. Young Person A a lso a va iled of a numb er of other services tha t c anno t

be identified in this report in order to protect the honour and

rep uta tion of this young person.

3. KEY FINDINGS

a) Young Person A was born in October 1987 and came into contactwith the Hea lth Boa rd in 2000. Young Person A t rag ica lly pa ssed

awa y in Sep tem ber 2005, p rior to reac hing the a ge o f ma jority. An


7/15

7

Inquest into Young Person A s dea th was held in 2006. The ve rd ict

wa s de ath by m isad venture.

b ) A w ide rang e o f servic es has been p rovided to Young Person A fromthe time this young person came into contact initially with the

predecessor(s) to the HSE and sub seq uently w ith the HSE.

c ) From 23rd Sep temb er 2002 to 13th July 2004, residential services forYoung Person A w ithin the Crisis Intervention Services were p rovided

unde r Sec tion 5 of the Child Ca re Ac t, 1991.

d) While acknowledging the commitment of staff and the high level ofac tivity in this c ase, the Review Tea m fo und an absenc e o f forma l

integrated case and care planning both from a child welfare and

protection perspective under Children First, National Guidelines for

the Protection and Welfare of Children, 1999 and from a care

p lanning p erspe c tive unde r the Child C are (Plac ement o f Child ren in

Residential Care) Regulations 1995 from 14th July 2004 when Young

Person A w as rec eived into voluntary care.

4. OBSERVATIONS

a) Young Person A was accessing out of hours services 22 monthsbefore this young person w as rec eived into voluntary ca re.

b ) This c ase exposes trag ic systemic fa ilures. Two d ifferent strea ms ofservices we re involved in the c are of Young Person A. These servic es

were soc ial work services and out of hours services. This resulted in a

lack of singular assigned responsibility and a confusion of roles. An

assumption prevailed that there was a lack of authority to take

action, which lead to limitations in involvement. Consequently there

was a lack of initiative and a fear of taking charge of the situation

perta ining to this very vulnerab le young person. There w ere

inexcusable delays in providing essential services, a lack of case


8/15

8

management, a fragmented approach to this young persons care,

and a lack of cooperative structure within the Health Board areas.

There were ineffec tive meetings resulting in unc ertainty as to whe ther

c onc erns ra ised we re d ea lt with. There was a fa ilure to ide ntify a

solution to the care needs of this young person and, consequently a

failure to p rovide tha t solution.

c ) This c ase further highlights the errone ous approa c h of req uiring theneeds of the individual to fit within the services that are available,

rather than the essential approach that must be adopted of ensuring

tha t the servic e meets the ne ed s of the ind ividua l. The a pp lica tion of

c ertain c riteria in d ete rmining the entitlement of this young person to

access services led to Young Person A being denied access to

services which were d esperate ly need ed .

d) Young Person A was very vulnerable and had been for a substantialportion of their life. The m anner in which servic es we re p rovided left

this young person deprived of a sense of security and in a chaotic

environment.

e) This c haot ic environme nt left Young Person A exposed to a sub-culture, which exists among certain young homeless people and

which educates impressionable and vulnerable children on how to

avoid certain services and exploit other services to their own

detriment. An example of this was the practice adopted of utilising

the out of hours services which provided financial incentives if the

c hild c hose no t to a ttend schoo l or training c ourses.

f) Sec tion 4 of the Child Ca re Ac t, 1991 imposes a duty on the HSE totake a c hild into its c are where it app ea rs tha t the c hild req uires c are

or protection and that the child is unlikely to receive that care or

p rotec tion unless the c hild is ta ken into its c are. The HSE has a duty

under this section to maintain the child in its care so long as it

app ea rs tha t the we lfare of the c hild req uires it. Sec tion 5 of the Ac t

ma ndates the HSE to take suc h steps as a re reasonab le to m ake

available suitable accommodation for homeless children.


9/15

9

g) In this c ase the HSE fa iled to adeq ua te ly address the c are,protection, and accommodation needs that this vulnerable young

pe rson de spe rately neede d.

5. RECOMMENDATIONS

1) Tha t the d ra ft HSE Nat iona l Guide lines for Ca re Planning andSta tutory Child in Care Reviews be signe d off a nd c irculated for

ad op tion with a review d ate.

2) With reg ard to the p rovision o f Crisis Inte rvent ion Services, tha tc onsideration be g iven to the imp lic a tions of the fo llow ing:

a ) Having a ll emergency plac eme nts in a c ity c entre;b ) Having only residential emergency placements as opposed

to a mix of foster care, supported lodgings and residential

placements;

c ) The p rac tice of providing servic es und er Sec tion 5 of theChild Care Act, 1991 in particular for children under 16 years

and especially for those who remain beyond short term in

Crisis Intervention Services.

6. RESPONSE

6.1.Gaps in ServiceSom e a spec ts of w ork carried out by HSE sta ff in high p rofile ind ividua l

c ases relating to c hild protec tion have unde rmined the c onfide nce whic h

both the public and o ur own sta ff have in the services we p rovide . While

fa ilures ma y a rise in any system, the HSE believe s tha t the wo rk done in our

child protection services is delivered by deeply committed and

hardworking professionals.

These findings, while g enera lly ac knowledging c om mitment o f sta ff and

the efforts made to address the complex needs of the young person

involved, nevertheless, point to gaps in service provision, lack of


10/15

10

communication between service providers, lack of clarity around care

p lanning a nd fo rma l p roto c ols for same .

6.2.Child ren and Family Servic esChild ren and Families Servic es a re foc used on p rom oting the we lfare o f

c hild ren unde r child c are leg islat ion ma inly the Child Ca re Ac t, 1991 and

the Child ren Ac t, 2001. The overarching policy direc tion co mes from the

UN Convention on the Rights of the Child w hich Ireland ratified in 1992. A

wide rang e of services are p rovided including c hild hea lth, ad op tion a nd

fostering, fam ily supp ort, residential ca re a nd c hild we lfare and protec tion

servic es. The overall foc us of Child ren and Families services reflec t the

message of the Office of the Minister for Children and Youth Affairs

Ag end a fo r Child ren s Services 2007. This high lights tha t family support as

the basis for enha nc ing c hild ren s hea lth and we lfare. Ove r time , the

focus of our services to protect children will be to further enhance family

support servic es. This is known to b e a muc h mo re e ffec tive mea ns of t ruly

prote c ting child ren from ha rm. Child p rote c tion servic es will a lwa ys be

req uired , however, and so the HSE is mo ving immed iate ly to streng then

those services across all our Local Health Offices.

6.3.Reg ulations, Nat iona l Sta ndards and Inspec tionsIn some areas of our services for children and families, well regulated

systems exist, with clear national standards and lines of reporting and

governance.

Servic es for child ren in residential and foste r c are a re sub jec t to

Reg ulations and Nat iona l Sta ndards. These servic es a re m onito red and

inspe c ted by the HSE and the Hea lth, Information and Qua lity Authority,

Soc ial Services Inspec to ra te and inspec tion rep orts a re pub lished . The

quality of these services is therefore transparent and open to scrutiny by

the releva nt authorities and the public .

In child protection, for historic reasons, we do not have a national set of

standards against which we can measure and demonstrate the strength

of those services, or properly identify and address the gaps that may exist.


11/15

11

However, this will be addressed with the development of standards and

the commencement of inspections of Child Protection and Welfare

Servic es by the Soc ial Services Inspec to ra te of the Hea lth, Informa tion a nd

Qua lity Autho rity by 2011. In the interim the HSE will build o n the significant

wo rk done b y the Task Force on Child ren a nd Families to sta ndard ise a nd

enha nce o ur servic es for child ren. Child p rote c tion services are p rovided

on the basis of legislation but have not been subject to regulations or

national standards. Where the intervention of the Court is required in

serious child protection cases, all aspects of the case are subject to the

sc rutiny of the Judg e.

In the past there has been a lack of consistency in how our services

op erate ac ross the 32 sep arate Loc a l Hea lth Offices. While the lac k of

consistency in services does not imply that they are weak or

inappropriate, it does make them difficult to compare, and that has

ma de it diffic ult for us to e va luate the sta te o f our services. It has a lso

mitigated our ab ility to p rovide the required rea ssuranc e to the public and

to government that our services provide effec tive p rotec tion to c hildren a t

risk.

The HSE is awa re of the urgent need to ensure a high leve l of

standardisation and consistency of child protection services across the

country so that there is a high level of public confidence in them and in

2009, esta b lished the Task Forc e on Child ren a nd Family Servic es to

address this issue.

6.4.Children and Families Task Force 2009The 2009 Task Forc e on Child ren a nd Family Services was set up to address

this inco nsistenc y in services, and to imp lement, for the first t ime, a unified

sta ndardised a pproa c h to all child p rote c tion services in Ireland . It has

identified and developed :

A single standardised approach to a duty social work and intakesystem, mea ning tha t a ll 32 a rea s will dea l with a ll refe rra ls to the soc ial

work departments using the same methodology.


12/15

12

An Assessment Framework which will lay out a step by step approachto dealing with each referral to or contact with all social work

departments.

Standard isat ion in how c are p lans and care p lanning is c arried out, atwha t intervals, and to wha t d eta il.

Protocols to ensure uniformity of approach and to demonstrateaccountability.

Sta ndardisa tion of a ll business p roc esses in child and family services. Once off identification of outstanding or unresolved child protection

issues.

Sta ndard isa tion a nd d issem ination o f a ll existing p olic ies and theide ntific ation and de velop ment of new ones as req uired .

Clarificat ion of g overnance arrang eme nts in c hild c are and p rotec tionsystems.

Tra ining a nd Supervision Polic ies agree d a nd imp lemented . A d eta iled ba seline survey o f servic es which desc ribed p rac tice ac ross

a range of key areas and clearly evidenced the lack of

standardisation, the variation in definitions used and the urgent need

for standards in all a rea s of p rac tice .

Many of the parts of this overall project were either already in train under

the fo rme r Nationa l Stee ring C ommittee , or planned a nd set o ut in the

HSEs 2009 Servic e Plan.

The Task Force examined a ll c hild p rotec tion and w elfare p roc esses

nationally, and carried out extensive consultation with hundreds of

professional and managerial staff in our child protection services.

This g ives us a c lear and very com prehe nsive set of p roc ed ures and

protocols that our staff will follow, from initial referral through to closing a

c ase. Eac h element a nd e ac h step in the c hild protec tion p roc ess has

been strengthened and standardised, taking the best practice in place

and ap plying it na tiona lly.


13/15

13

Clarity ha s a lso b een b roug ht b y the Task Force o n governanc e issues,

p rod uc ing a written set of roles and responsib ilities for eac h sta ff me mb er

involved in the child protection journey supported by measurement and

rep orting on how servic es a re pe rforming. It supports the req uirem ent for

a Nat iona l Child Ca re Information System. This is a p rop osed na tiona l IT

system to support the Child Protec tion and Welfare Service , which w ill

provide accurate and timely child care information and allow that

information to be easily shared.

There a re high a nd often una voida ble risks inherent in ma nag ing c hild ren

and family services, and the HSE must ensure tha t we c an respond

effe c tively to the need s of vulnerab le c hild ren. The Task Force s

prog ramme of wo rk will make sure tha t a ll of the HSEs 32 Loc a l Hea lth

Offic es a re operat ing the ir Child and Family Services in the same wa y, to

the same standards and in a safe and well regulated environment.

Bringing consistency to our services will bring higher standards, better

information, and mo re effec tive servic es for child ren and fam ilies.

7. IMPLEMENTATION AND MONITORING

The append ed tab le sets out the rec om mendations from this rep ort and a

summa ry of the p rogress in rela tion to the Hea lth Service Executive s

respo nse to ea c h one.

No Rec omm end ation Sta tus

1 Tha t the Draft HSE

National Guidelines for

Care Planning and

Sta tuto ry Child in Ca re

Reviews be signed off

and circulated for

adoption with a review

The HSE Task Force, Child ren & Families

Services wa s esta b lished in Feb ruary, 2009 to

accelerate the development of a national

unified and standardised approach for

children. As part of this process a

standardised care plan and review process is

be ing imp lemente d as outlined in the HSE


14/15

14


date . Nat iona l Service Plan 2009 and is ongoing in

2010.

2 With reg ard to the

provisions of Crisis

Inte rvention Services,

that consideration be

given to the

implications of the

following:

a ) Having a llemergency

plac ements in a

c ity loc at ion

b) Having onlyresidential

emergency

place ments as

opp osed to a mix

of foster care,

supported

lod gings and

residential

placements.

In line w ith Youth Hom elessness Strategy

(2001) which recommends that crisis services

for young people should not be centralised in

the city c ent re. Since Janua ry, 2009 ten

emergency placements have been

reloca ted from the c ity centre to a loc ation in

North County Dublin. In add ition, the HSE is

hoping to provide a broad range of options

for Local Health Office Areas including the

provision of emergency foster carers,

particularly to cater for 12 to 15 year olds,

which should obviate the need for

eme rgency bed s in the c ity centre.

It is HSE polic y to have a mixture o f p lac em ent

options available including foster care,

supported lodgings and residential

placements to meet the needs of young

people who are out of home. It is the

experience of service practitioners that, due

to the sometimes challenging behaviour

displayed by service users, foster carers are

not disposed to providing support to this

group of young peo p le. How ever, the HSE is


15/15

15


c ) The p rac tice o fproviding services

under Sec tion 5 of

the Child C are

Ac t, 1991 in

particular for

child ren under 16

yea rs and

espec ia lly fo r

those who rema in

beyond short term

in Crisis

Intervention

Services.

develop ing Multi-Trea tment Foster Ca re,

Differential Response Model and Emergency

Plac e o f Sa fety Servic e to me et the individual

needs of c hild ren.

Sec tion 5 of the C hild Ca re Ac t, 1991 a llow s

the HSE to p rovide a cc ommoda tion for

young peop le who are out of home. The

Crisis Inte rvention Service e ndea vours to

return these young people to their own

home/extended family or arrange for an

alternative care placement as near as

po ssib le to the young person s hom e.

The David Foley Report (Summary)

Documents

Transcript of The David Foley Report (Summary)