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In accordance with this Committee’s terms of reference, this Committee adopts the report of the Committee of Inquiry into the death of the child Kelly Fitzgerald by way of a preliminary report for submission to both Houses of the Oireachtas asking that members of each House submit to this Committee within 6 weeks of this date, their observations on the recommendations contained in it to facilitate this Committee in its preparation of a final report.
This case has attracted immense public interest arising from which Kelly and her family have become almost household names. We are concerned at the long term impact of this on the other innocent victims, Kelly’s brothers and sisters. For this reason we have decided not to use their names or the family name in the course of this report. We hope that this approach will be respected and maintained in any further public comment on the case. -ACKNOWLEDGEMENTS-I wish to express my gratitude to the following people who assisted the inquiry. I would like to thank everyone who gave evidence to the inquiry which included health board staff, personnel from other organisations and individuals. I wish to record an appreciation of the co-operation and assistance we received from management and staff of a number of authorities in the United Kingdom including Lambeth Social Services Department. West Lambeth Community Care Trust, and the Metropolitan Police Child Protection Team. Although we did not actively seek submissions the inquiry was pleased to receive a small number which we carefully considered and found most helpful. It is important that I record with grateful thanks the co-operation and assistance we received from the outset from the management and staff of the Western Health Board. This, I believe, reflected the board’s investment in, and commitment to, the inquiry. I wish to particularly thank members of the board’s community care staff in both Galway and Mayo who responded to our many requests for files and information with speed and efficiency. We also greatly appreciated the assistance of management and staff of Aras Attracta in Swinford and the Child Care Unit in Merlin Park, Galway in facilitating us with accommodation on many occasions. The assistance given the inquiry by Angela Canavan of Barnardo’s National Children’s Resource Centre and Sandra Keating, librarian with the Midland Health Board was especially valuable both with literature searches and loan of publications. I am grateful to Marion Donoghue who typed the entire report, both preliminary drafts and the final version, for her positive, professional and efficient approach. On behalf of the team I wish to acknowledge the particular contribution of Laurence Gaughan who was appointed secretary to the inquiry. His astuteness, determination and quiet efficiency proved to be an invaluable resource to the inquiry at all times. Finally I wish to pay a special tribute to my colleagues Mary Finucane and Siobhan Keogh for their knowledge, insights, expertise and commitment whilst also managing many other professional and personal demands. The members of the inquiry team share the hope that their contribution in producing this report will add to our knowledge and capacity to protect children at risk of abuse and neglect. We are unanimous in our findings and recommendations as contained in this report. OWEN KEENAN 3rd November, 1995 - RECOMMENDATIONS -We recommend most strongly that the Government make a commitment to the continuing development of services for children over a seven to ten year period. We recommend the creation of a senior professional post with responsibility for child welfare within the headquarters management staff of each health board. We recommend that a dedicated child welfare management post be created in each community care area to provide the leadership and direction necessary for the effective discharge of the board’s statutory child welfare functions, including child protection. We recommend that these posts be filled by professional staff with a relevant qualification, frontline child welfare experience, post-qualifying training and a clear interest in managing this function. We further recommend that these child care management posts include a developmental function and responsibility for children in care, fostering and adoption and family support services. We recommend that the Western Health Board establish an internal consultative process with relevant staff and services with the objective of maximising its organisational capacity to accurately identify children at risk in the region and to intervene effectively to eradicate or to reduce the degree of risk to which children are exposed. We recommend that the Western Health Board review its own current deployment of community care staff. We recommend that the Western Health Board give consideration to the development of multi-disciplinary child protection teams covering a geographical area. We recommend that the Department of Health examine, in consultation with the relevant interested parties, the most effective means of delivering child welfare services nationally. We recommend that the Department of Health take appropriate measures to protect resources for preventive, support and treatment services thus avoiding their being directed exclusively towards investigation of instances of abuse and neglect. We recommend that the Department of Health adopt a proactive approach in monitoring health boards child care developments in order to ensure consistency on a national scale both in provision and of procedures and practice. We recommend the establishment at national level of a system for the setting and monitoring of child protection standards, to promote examples of good practice and to inquire into serious failures of practice. In view of its ratification by Ireland in 1992 we recommend that all Government actions in respect of children and, in particular, in respect of children who are vulnerable due to abuse or neglect, be founded on the principles and articles of the U.N. Convention on the Rights of the Child. The inquiry supports and echoes the recommendation of the Kilkenny Incest Investigation that consideration be given by the Government to the amendment of Articles 41 and 42 of the Constitution so as to include a statement of the constitutional rights of children. We further recommend that the body currently reviewing the Constitution give consideration to ensuring consistency between Ireland’s ratification of the United Nations Convention of the Rights of the Child and the constitutional provision in this regard. We recommend the development of national standards in the provision of an advocacy or guardian ad litem service to children who are the subjects of legal proceedings. We recommend that judges and officers of the Courts be informed of the indicators of emotional abuse and neglect and of their particular risks to individual children. We recommend that the reporting of actual or suspected child abuse or neglect become a legal requirement for relevant designated staff, including health board personnel, general practitioners, the Gardai, teachers and staff of voluntary and private child care services. We also recommend that the mandatory reporting requirement be accompanied by guidelines to these staff who should have immunity in any legal proceedings. We recommend that the Irish Government take the initiative in establishing European Union protocols for liaison and sharing of information between Member States in the interests of protecting children. We recommend that the Department of Health establish bilateral arrangements with other jurisdictions for the sharing of information between relevant authorities where children are, or are suspected of being, at risk. We recommend that any authority where it knows that a family whose children are, or are suspected of being, at risk has moved to another area, take all steps to ascertain the family’s new address and to provide the equivalent authority in the new area with all relevant information. This should include the extent to which the family was known to the services in the former area and their motivation for moving, where known. We recommend that the receiving authority adopt a proactive approach in seeking information on any family which has recently moved into its area in relation to whom an allegation or referral is made. We recommend that a national agreed standard and format be established by the eight regional health boards for the transfer of information from one board to another. We recommend that health boards support in principle and facilitate where necessary, relevant staff from two or more authorities meeting, even where this involves travel to another jurisdiction. We recommend the adoption of a standardised case summary sheet similar to the format used in the chronology included in this report. This should be located at the front of all files, should include details of family history and be continuously updated with factual summaries of new information and events. We recommend that all allegations be recorded on a special colour-coded form to be used for this purpose by all disciplines in all health boards. We recommend that where a completed investigation indicates that a child is indeed at risk, his/her name should be entered on an ‘At Risk’ Register. The operational aspects of this Register, including protocols for the registration, maintenance and removal of a name should be enunciated by the Department of Health following consultation with the health boards, voluntary organisations and other interested parties. We recommend that the Western Health Board assess the current level of knowledge and compliance of its staff with the Department of Health Guidelines and establish and address any reasons for non-compliance. We recommend that the Western Health Board ensure that all of its child protection staff are aware of the importance of assessment and that all relevant staff receive training in the identification of abuse including indices of abuse, and in risk assessment. We recommend that in each case the Western Health Board develop a plan of intervention based on its assessment of the risk involved to the child. We recommend that the Western Health Board take all necessary steps to ensure that the arrangements for the holding of case conferences be substantially overhauled and that appropriate training be provided to relevant staff to ensure that the case conference becomes a significantly more effective element of the Board’s child protection strategies. We recommend that the Western Health Board clarify the status of legal advice given at case conferences and whether any such advice which indicates that a Court application will not be successful, should be followed in every case irrespective of the views of relevant staff. We recommend that a key worker be appointed in each case and that all those with an involvement in the case are aware of the key worker’s identify and share information with him/her. We recommend that the Western Health Board, in the interests of strengthening collaboration between agencies in support of the child protection function, give serious consideration to reversing its policy of requesting representatives of other agencies to leave case conferences once they have given their report. We recommend that a comprehensive training programme be developed in consultation with staff to include, inter alia, -assessment -dynamics of abusing families -case conference management, roles, etc. -corporate responsibilities under Child Care Act 1991 -team development -the psychology of inter-disciplinary and inter-agency collaboration -communication - its dynamics and processes -investigative techniques We recommend that the Department of Health explore the development of a modular approach to the expansion of child protection training. We recommend that the Western Health Board take the steps necessary to ensure an adequate level of administrative support to child protection staff. We recommend that the Western Health Board ensures that all professional staff remain accountable for appropriate administrative tasks such as the writing, signing and dating of case notes. We recommend that the development of child protection services be matched by the provision of appropriate accommodation and facilities. We recommend that responsibility for communicating health board child protection policy and provision to schools should be one of the responsibilities of the new post of child care manager in each community care area. We recommend that each school nominate a teacher to develop special expertise in the identification of child abuse and neglect and function as its liaison officer with local health board staff. Special joint in-service training programmes should be provided and this will assist in developing collaborative relationships locally. We recommend that the development by the Department of Education of a new sex education and lifeskills curriculum for primary and postprimary school students should address issues of child abuse and neglect. In-service training for teachers of this curriculum should include the development of skills in identifying and facilitating pupils who wish to make a disclosure. We recommend that the Western Health Board initiate a process to consider all aspects of inter-disciplinary and inter-agency communication and collaboration involving staff from each discipline and agency. We recommend that the Western Health Board investigate measures used in other employments to provide support to workers who may experience trauma in the conduct of their professional duties. CHAPTER 1- INTRODUCTION -Kelly was admitted to St. Thomas’ Hospital, London, on 1st February 1993 and died there on 4th February 1993. The inquest into her death opened on 8th February 1993 and was adjourned to 21st April 1993. Preliminary evidence suggested that she had been neglected prior to her death. The Inquest was reconvened on 21st February 1995 where a verdict of death due to gram negative septicaemia and natural causes was recorded. In December 1993 Kelly’s parents were both charged with wilful neglect and occasioning actual bodily harm to Kelly. In May 1994 they pleaded guilty to the charges of wilful neglect and the charges of occasioning actual bodily harm were dropped. In November 1994, they were each sentenced to 18 months imprisonment. At the Western Health Board meeting of 7th November 1994, the Chief Executive Officer issued a statement in which he announced the setting up of a committee to examine the Board’s involvement in the case. The Western Health Board at its meeting of 2nd May 1995, was informed by the Chief Executive Officer of the appointment of an inquiry team. Its members were: Mr. Owen Keenan. Director of Barnardos (Chairperson) Ms. Mary Finucane, Retired Superintendent Public Health Nurse, Mid-Western Health Board Ms. Siobhan Keogh, Child Care Development Officer, Midland Health Board Its terms of reference were: (a)To inquire into the circumstances of the late Kelly( ) and her family and, having regard thereto, to examine the Western Health Board’s child protection practices and procedures and to make such recommendations as are deemed necessary; (b)To make such other recommendations as are considered relevant; and (c)To report to the Chief Executive Officer of the Board in the matter as soon as possible for presentation by him to the Board. Mr. Laurence Gaughan, Western Health Board was appointed Secretary to the inquiry. The members of the inquiry team met for the first time on the 8th May 1995. In considering the terms of reference it was decided that it would be necessary to inquire into the Board’s contact with the family from the time of their move to Ireland in 1990. This was in spite of the fact that Kelly had lived with her family in Ireland from September 1992 until February 1993 only, a period of five months. Prior to this period the Western Health Board had been involved with the family due to concerns about one of Kelly’s younger sisters. All the health board files on the family were received by the inquiry team for review. This included a number of hospital records in addition to files held by the various Community Care disciplines relating to the family. It was decided to hold initial group meetings in Castlebar and Galway with members of staff who had an involvement with the family. This also included hospital based staff. The purpose of these meetings was to introduce the members of the inquiry team, explain the process which the inquiry would take and to answer questions from staff. The inquiry team did not have power to compel witnesses to attend and the letters issued by the inquiry team invited persons to assist in the inquiry process. All persons attending for interview were also informed that they could be accompanied if they wished and a number availed of this opportunity. The thrust of the interviews was inquisitorial rather than accusatory. For the purposes of accurate recording of interviews the services of a stenographer were engaged. While we do not consider our terms of reference extend to evaluating practice in the case during the time the family was resident in the United Kingdom it was decided at an early stage that it would be necessary to visit London to consult with relevant health and social services personnel. Whilst in London we also met with a head teacher from the school attended by some members of the family and a Detective Constable from the London Metropolitan police. We also invited some members of the extended family in London to meet with the inquiry team, but they declined our invitation. During the course of the inquiry the possibility of meeting with other children in the family was considered. In the event we did not seek to meet the children due to the need for sensitivity with regard to the current nature of health board staffs involvement with them. However, we do wish to state our view that children’s opinions should generally be sought. We did invite Kelly’s older sister to meet with us but she declined. At various stages in the process we had the benefit of legal advice from Mr. J. Rogers, S.C. and Mr. W.B. Glynn, Solicitor. Consultations were also held with Dr. Harry Ferguson, senior lecturer, Department of Applied Social Studies, University College Cork and Mr. John Fitzgerald, Director of the Bridge Child Care Consultancy Services, London. Dr. Owen Hensey, Consultant Paediatrician acted as medical adviser to the inquiry. Superintendent T. Tully of the Garda Siochana also met with members of the inquiry team. At the time of Kelly’s death Superintendent Tully was based in Swinford, Co. Mayo and had direct responsibility for the garda investigation. In total, 52 individuals were interviewed in the course of the inquiry. These included, in addition to Health Board staff and individuals referred to above, members of the teaching profession and neighbours of the family. CHAPTER 2- THE FAMILY HISTORY -Kelly’s parents were both born in England of Irish parents. Kelly’s mother is one of a family of five. two girls and three boys. Kelly’s father is the eldest in a family of two boys. His brother married his wife’s sister. His mother suffered poor health and he spent the first five years of his life with his paternal grandmother in Ireland. Kelly’s parents met when her mother was fourteen years old and her father was nineteen years old. When Kelly’s mother was seventeen years old she became pregnant by Kelly’s father and they married due to family pressures. At the time of their first child’s birth (a daughter) the parents were living in a caravan with the travelling community a short distance outside London. This has been reported to have been a stable period but ended when the local authority evicted the travellers from the site. Kelly’s parents returned to London and stayed with her mother’s family. Her father did not enjoy a happy relationship with his mother-in-law and the marriage was strained during this period, with Kelly’s father moving out of the home. These were the family circumstances at the time of Kelly’s birth on 04.06.77. She was a premature baby weighing just over 5lbs. 7ozs. Shortly after Kelly’s birth the family was housed. On 29th September 1977 when Kelly was not quite four months old she was seen by the family’s General Practitioner because of her failure to gain weight. Reports suggested that Kelly’s mother was diluting her feeds excessively. Advice was given and she was asked to return in 4 days time to monitor Kelly’s progress. This appointment was not kept. On 23rd October 1977 Kelly was taken to St. Thomas’ Hospital casualty department by both parents. She had lost a considerable amount of weight and was severely emaciated and dehydrated. The doctors were seriously concerned about her prospects for survival. X rays further revealed evidence of two healed fractures. A place of Safety Order was successfully applied for due to Kelly’s medical presentation. At the following case conference considerable doubt existed as to whether Kelly’s severe neglect was deliberate or a case of ignorance on the part of the mother with regard to child rearing. At this time Kelly’s older sister was a healthy 18 month old about whom there were no concerns regarding neglect or inadequate parenting. A case conference decided not to place Kelly’s name on the ‘at risk’ register but the provision of on going support from the social services was seen as an “urgent requirement”. We are not aware of social services involvement in this case again until 1988 when Kelly was referred to child guidance because of reported behavioural problems. By now there were six children in the family, four girls and two boys. In April 1989 concerns were expressed about the relationship between Kelly and her parents, who were requesting that she be taken into care to be punished. They complained that they were unable to cope with her behaviour. On 31st May 1989 Kelly was placed on the Social Services Child Protection. At Risk Register because she was considered to be at risk “of emotional deprivation and abuse and, at times, suffers extreme mental cruelty from her parents”. About this time she went to live with her maternal grandparents. This placement was initiated by the Social Services Department and Kelly’s parents are reported to have only reluctantly agreed to this arrangement. They would have preferred her to have been punished by being placed in a children’s home. At a case conference six months later, on 22 November 1989, a marked improvement was noted in Kelly who was reported ‘to have put on weight’, was now “chatty” and had blossomed. Kelly’s parents had, since her move to her grandparents, isolated and excluded her from their family, not allowing her to meet her siblings or to attend family occasions, such as birthdays. Concerns however were now being expressed about Kelly’s younger sister, Girl 3. She was failing to thrive despite eating abnormally large amounts of food at lunch time in school, and her weight had fallen from the 10th to 3rd percentile *. Girl 3 was being closely monitored by the Social Services Department and the Paediatrics Outpatient Department of St. Thomas’s Hospital. In July 1990, Girl 3 was placed on the ‘At Risk’ register under the heading ‘Grave Concern’. This situation was still being investigated when the family moved from London to a house and small farm in a rural part of east Co. Mayo in the west of Ireland. Kelly remained with her grandparents in London. Neither of Kelly’s parents had any connection with Co. Mayo and neither had had any experience of farming. They financed the purchase of the farm with compensation received following a road traffic accident in 1986 in which Kelly’s father lost his left leg. In December 1990, as soon as it became aware of the family’s move to Ireland. West Lambeth Health Authority (now West Lambeth Community Care National Health Service Trust) sent its child health files to the Western Health Board which was the relevant child care authority for counties Mayo, Galway and Roscommon. Concerns regarding Girl 3 were noted in file reports. Subsequently, in January 1991, the Lambeth Social Services Department notified the Western Health Board in writing of its involvement with the family and of concerns regarding Girl 3. They also referred to prior concerns which resulted in Kelly now residing with her maternal grandmother. Immediate monitoring of Girl 3’s weight began as it continued to be a cause for concern. The Western Health Board’s involvement is described in detail in the chronology (Chapter 3) In July 1991 Kelly came to Co. Mayo on holidays for two weeks with relatives from England. In August 1992 she returned again for holidays. This time, on her return to London, Kelly contacted her parents by phone and asked if she could come back and live with the family in Co. Mayo. Within days, at the start of September 1992, Kelly returned to live with her family. She had not lived with them for more than 3 years. Kelly died in suspicious circumstances 5 months later. Her parents were charged and pleaded guilty to a charge of wilful neglect. They are currently in prison and all their children except their eldest daughter, now aged nineteen years, are in care. A detailed breakdown of the Western Health Board’s involvement with this family from 1991 to the time of Kelly’s death in February 1993 follows in Chapter 3.
CHAPTER 3- CHRONOLOGY OF WESTERN HEALTH BOARD INVOLVEMENT -
- SIGNIFICANT EVENTS SINCE KELLY’S DEATH -
CHAPTER 4- EVALUATION OF WESTERN HEALTH BOARD INVOLVEMENT -INTRODUCTION:Unlike the approach adopted by the Kilkenny Incest Investigation team which, justifiably in our view, evaluated health board practice in that case in the context of prevailing contemporaneous standards over a sixteen year period, we have found it impossible to distinguish with any clarity or accuracy practice standards of 1991/93 from current standards in 1995. We acknowledge that there have been significant changes in the intervening period brought about largely as a result of the Report of the Kilkenny Incest Investigation itself and the subsequent development of child care services it heralded. Some of these improvements are evident already in the child care resources, provision and practices of the Western Health Board. However it would be invidious to identify aspects of health board practice and suggest that while they might have been acceptable in 1992 that would no longer be the case today. In any event that might also imply that current standards reflect best child protection practice. Given that health board resources, facilities and services are currently in a process of development such a claim would be difficult to sustain. We have, accordingly, chosen to evaluate health board practice in this case in the context of the minimum standards necessary if we are to reasonably expect children at risk in this country to be protected. We are conscious that it might be considered unfair to measure health board practice in the period 1990 to 1993 against a set of standards which, typically, have not yet been achieved in 1995. However we are motivated by a concern to move as quickly as possible to a point where we can expect children at risk to be identified and protected by the statutory authorities to an acceptable level of effectiveness. In this regard we have been impressed and reassured in general by the openness, commitment and frankness of the people we have interviewed in the course of this inquiry. Many have expressed the hope that finally, some good will emerge from the tragedy of Kelly’s life and death. We hope that, where we are critical of aspects of the health board’s involvement with her family, this criticism will be interpreted as a necessary contribution to the identification of lessons to be learned and, ultimately, to the improvement of child protection practice generally. It will be evident from the chronology that the Western Health Board had substantial involvement with Kelly’s family for twenty months prior to her return from London to live with them. This involvement by the Health Board commenced shortly after the family’s arrival in Ireland and focused primarily on the welfare of Kelly’s younger sister, Girl 3, within the family. While the inquiry was established specifically as a result of Kelly’s death, in view of the brevity of the period during which she lived with her family in Ireland, the inquiry team decided at an early stage that it could not adequately evaluate the health board’s involvement in relation to Kelly without reference to its intervention with the family as a whole from the time of first referral in January 1991. In adopting this approach we have been repeatedly struck by many parallels between Kelly and Girl 3 in terms of their development, their relationships with their parents and, indeed, of their contact with the child welfare authorities in both the United Kingdom and Ireland. We have also noted the confusion in some of the media coverage of the case, in the reporting of the health board’s involvement in respect of Girl 3 which may have led to its involvement with Kelly being misconstrued. In spite of the similarities between Kelly and Girl 3, particularly in relation to suspected abuse, we wish to emphasise that in child protection it is essential to view each child as an individual and avoid assumptions that the experience of one child will exactly mirror that of another. Kelly’s death, any child’s death where abuse and neglect are at least contributory factors, is a tragedy of the most frightening and distressing dimensions. The understandable shock and anger of the public response creates a need to understand what happened identify who was responsible and how a similar tragedy might be avoided in the future. It is necessary to place such concerns in the context of our capacity as a society to protect children at risk of abuse or neglect generally. How do we provide the legislation, the structures, the finance and the personnel and then ensure that they combine effectively to protect children? And can the protection of children be guaranteed by a sufficiency of resources? It would seem both necessary and appropriate that there should be accountability in our child protection system and that the quality of practice be continually reviewed. Instances where the system has failed to adequately protect a child should be studied to identify deficiencies and to inform future practice. Within the context of the current significant development of child welfare services and the impending full implementation of the Child Care Act 1991 the inquiry team has put a particular emphasis on establishing and understanding where practice in this case was less than satisfactory. Allied to this is the important task of identifying lessons, many of which have national significance, which need to be learned in the interests of improving our capacity to intervene effectively in order to protect children in abusive or neglectful situations. REVIEW AND EVALUATION:In reviewing and evaluating the Western Health Board’s involvement with Kelly’s family from the time of the first contact we have been concerned to establish whether any different approach might have resulted in a more comprehensive understanding by the health board, at the time of her return to live with her family in September 1992, of the nature and degree of risk to which she was exposed. In other words, could anything have been different and, if so, would that difference have resulted in Kelly’s death being prevented? We have, in fact, identified at least ten occasions from December 1990 to January 1993 when, with hindsight, a different action or decision might have been expected. However in highlighting these it is important to caution against an immediate or simplistic link being made with the fact of Kelly’s death. It has to be recognised that any different approach or action by the health board would almost certainly have been met by a correspondingly different defensive reaction on the part of the family. This has, in fact, been confirmed to us by both parents. We shall return to this point in Chapter Six.
-Adherence to established procedures -Assessment -Case Conferences -Inter-disciplinary communication and co-operation -Supervision -Management ADHERENCE TO ESTABLISHED PROCEDURESThe procedures in force at the time Kelly’s family first came to the notice of the Western Health Board were the 1987 Department of Health Revised Guidelines on Procedures for the Identification, Investigation and Management of Child Abuse. The Western Health Board supplemented these guidelines with two appendices and the combined documents comprised the overall policy of the Board for the management of child abuse cases in its area from August 1989 to the present. We shall deal in due course with aspects of the guidelines relating to assessment, case conferences, inter-disciplinary co-operation and case management. However it is clear to the inquiry team that the procedures which provide for the identification, notification and investigation of suspected child abuse or neglect were not followed in this case in a number of significant respects: -while the procedures provide for the delegation by the Director of Community Care/Medical Officer of Health of responsibility for the monitoring and co-ordination of cases of child abuse and neglect, delegation in this case was informal and led to inconsistent practice by community care staff; -the requirement to notify the D.C.C./M.O.H. of allegations of child abuse were not being followed; -the social work investigation begun in February 1991 following the referral from the public health nurse was not completed and it was almost a further year before social work intervention commenced; -on several occasions during 1991 and 1992 allegations from neighbours and others in the community were not treated with urgency and in several instances do not appear to have been investigated at all; a number of these allegations do not appear to have been notified to the D.C.C./M.O.H. as prescribed by the procedures. -there was a bias in the health board area towards the investigation of reported child sexual abuse which overshadowed concerns about emotional abuse and neglect, statistics of which were not recorded in the Board’s Annual Report for 1992. Deviation from the Department of Health guidelines is not peculiar to this case. The Kilkenny Incest Investigation Report (1993) acknowledges that “current guidelines are not implemented uniformly within the eight health board regions”1. It goes on to make the important point that “Procedures in themselves, whether statutory or otherwise, are not a substitute for good practice and services must be responsive to local circumstances and resources must be available to ensure that intervention is effective”2. Ferguson3 comments, in similar vein. “while child abuse guidelines have been developed with some success, they have also too often been inadequately understood and even ignored ........... Thus, it is one thing to prescribe policies through the law and procedures and quite another as to how, or indeed whether, they are turned into actual practices”. By the same token we are concerned that practice which is governed by procedures that are adhered to only intermittently or which lead to disparities of understanding between management and practitioners is potentially dangerous to the children they purport to protect. We note that there have been improvements in the interim within the Western Health Board to regularise and standardise the notification of child abuse. We welcome new guidelines on arrangements for notification of suspected cases of child abuse between health boards and gardai. We also recognise that a number of health boards have further amended the 1987 guidelines in order to address their shortcomings. We wish to sound a note of caution in this respect. There is a danger that this will result in a series of individual sets of guidelines produced by individual health boards which may not be entirely uniform or even consistent. This again is potentially dangerous. It is surely not beyond the relevant personnel to adopt protocols which can be applied consistently throughout the State. The challenge then would be to harmonise these with their equivalents in Northern Ireland, the United Kingdom and the rest of the European Union, at least. ASSESSMENT“The key to working effectively with children at risk is the detailed and accurate assessment of their needs from the time that the case is opened. The basis of good quality assessment work has to be accurate collation of detailed information about the family; the child’s own history and that of brothers and sisters; the observation of their behaviour patterns over time; inter-disciplinary co-operation between the professionals involved and the effective use of inter-disciplinary case conferences”4. Accurate and detailed collation of information is an essential first step in the assessment process, yet one that all too often is incomplete. In understanding the reasons for this it is important to recognise that the gathering, sifting and analysis of relevant information is painstaking and time-consuming and the realities of health board child protection demands suggest that it is rarely completed with the thoroughness required. It has taken the inquiry team a significant period of time, with assistance, to piece together the substantial amount of information available on this family. A great deal of time had already been expended by health board personnel in collating information and reports in advance of the inquiry. This is but one case where children were deemed to be at risk. When one considers that individual health board staff may be carrying twenty or more such cases at any one time one can begin to appreciate the size of the task involved. This raises issues not only with regard to the skills, resources and workload of child protection practitioners but also the extent of administrative resources available, systems for filing and retrieval of information and policies with regard to access and sharing of information and reports etc. Such issues have broad significance in child protection which we shall address in chapter 6, “Findings and Recommendations”. These issues and realities apart, however, we have to say that we have found no evidence of a concerted attempt by the health board personnel involved in the two years prior to Kelly’s death to form a comprehensive assessment of the family or of the degree of risk it represented for some or all of the children. Certainly individual workers had their views and formed their own assessments, but we are not convinced that at any time during this period there was a coherent ‘health board’ assessment of the family which could be substantiated by verifiable information. There is evidence that some personnel were conscious of this deficit but felt it could not be remedied until more information had become available. This suggests a view that assessment is not possible until it can be definitive. We disagree. We believe that an assessment should be as comprehensive as possible but an initial assessment must at least be made with the recognition that it will need to be reviewed and possibly amended in the light of new information, knowledge or experience. It also is the case that the health board had more information in its possession than was availed of. We have already referred to the review of the UK Health Authority file by a social worker in February 1991 which was unrecorded. However that file contained significant information on the family from 1976 including case conference minutes from the time of Kelly’s hospital admission in 1977, aged four months. It also indicated UK social services involvement which might have been pursued for additional material. A summary of this file was prepared at the request of the Director of Community Care in approximately March 1992 when the advice of the health board’s solicitor was being sought. However this summary does not appear to have led to the formulation of a coherent assessment of the risk presented. Furthermore it would appear that while the concerns expressed by neighbours were noted, they were given only limited weight. Certainly the neighbours do not appear to have been encouraged to expand on their concerns, for example by meeting with health board staff, although the Director of Community Care did meet with a neighbour following Kelly’s death. There has been considerable ambivalence by health board staff generally in accepting anonymous referrals, firstly out of fear that they may be malicious or vexatious and, secondly, because they are of limited value in the event of legal action being required if the referrer is unwilling to give evidence in court proceedings. That may have been a difficulty in this case prior to Kelly’s death but having met with some of these neighbours in the course of this inquiry we are satisfied that they could have shared information in confidence which would have facilitated an accurate assessment of the family being made. Furthermore the 1987 Department of Health Guidelines require that “all reports of child abuse (including anonymous calls) should be investigated”5. It is our understanding that this is now standard practice in the Western Health Board. It is rare in cases of suspected child abuse and neglect for all of the relevant information to be immediately apparent and available to the worker(s) mainly involved. Assessment and intervention in the interests of protecting children typically involves the identification and sharing of relevant information, often from many diverse sources. This is particularly so in cases of emotional abuse and neglect where the evidence may not be very specific or clearcut. “More than any other single form of abuse, the detection and diagnosis of neglect is dependent on establishing the importance and collation of sometimes small, apparently undramatic single pieces of factual information which, when seen together, are of considerable significance. Information relating to these signs is likely to be spread throughout the community of child care professionals, and the implications for multi-disciplinary working are immense. Some of that information may be hard fact, whilst some of it may be more in the nature of expressing a concern”6. We are satisfied that the importance of the school in contributing information, specifically with regard to Girl 3, was recognised and the health board made regular contact with teachers who were occasionally invited to attend case conferences. Also, it was the health board social worker who took the initiative in visiting Kelly’s school shortly after she was enrolled to ascertain how she had settled and to request that she be contacted should the school have any subsequent concerns. However the school principal has a different recollection of this visit. It is important to understand and address the issues which lead to such differences of perception and the respective expectations of both schools and health boards if they are to combine effectively in the interests of protecting children at risk. We shall return to this point later. From our review of the health board’s involvement in this case it appears that the actual experience and observations of professional staff in their contacts with Kelly’s family and individual children were neither adequately collated nor assessed in terms of the degree of risk they represented for one or more children. The following are just some examples: -Girl 3 was described in July 1991 as “withdrawn, standing to one side, thin, frail and very unhappy”; she stood with her arms “folded over her chest, her shoulders hunched almost in a semi-foetal position”; -on the same occasion both her parents were described as being very negative when talking about Girl 3 - they said there was no hope for her, she disrupted the family, etc., and they did not know why she was “this way”; -Girl 3 was described to another worker by her father as a troublemaker who needed a ‘shock’ and to know she could be sent away; she was different from other children as no matter what one did for her she would not do what one wanted; he had tried everything that his parents had done to him, i.e., “slaps and deprived of things”; -father was described as a very strict disciplinarian; -Girl 3’s marked difference from her siblings in appearance and demeanour never changed; -when asked in school why she appeared to be tired Girl 3 replied that she got up early in the morning to “walk the dogs”; -the house was described as very untidy/dirty with paint peeling off the walls. On occasions there were up to four dogs in the house and they had to be locked in a room when visitors, including health board staff, called; -Kelly’s progress was reported to have been very dramatic since being removed from her family; -it was noted at the case conference on 28th February 1992 that meals and food had been used as a form of punishment by the family; reports had been received from both neighbours and school about Girl 3 stealing food; her weight had been a continuing cause for concern yet increased by approximately 23% during the five weeks in which she was away from home in Castlebar General Hospital and St. Anne’s Children’s Centre. Similarly information about the parents’ attitudes and motivation regarding their children’s welfare was not sufficiently weighted. For example: -their reluctance to sign consent forms (for school medical examination and for psychological intervention); -their habitual failure to keep paediatric and other out-patient appointments; -their failure to demonstrate concern about objective facts, for example, Girl 3’s seriously delayed physical development; -their withdrawal from the joint social work/psychology therapeutic programme (February 1992); Clearly all of these factors were noted by individual workers and by the relevant case conferences. What was missing in our opinion, however, was the formulation of a comprehensive and accurate assessment of the actual degree of risk to which Girl 3 at least was exposed. It would seem that the case conference of 6th April 1992 seriously considered making an application to the District Court for a Fit Person Order in respect of this child but reluctantly concluded that there might not have been sufficient evidence to have confidence that an order would be granted. There was concern that an application which failed might actually increase the level of risk to this child. This was a reasonable concern but we are not satisfied that there was sufficient understanding of the level of risk to the child if an application was not made. We also believe that a fuller accumulation and analysis of available data would have significantly strengthened the health board’s case, particularly if allied to a well established and respected framework for assessment such as that outlined in Figure 1. Ferguson 7 argues that the assessment process should also include an assessment of existing knowledge gaps: “On a case by case level, it requires that “risk profiles” …. should routinely include an assessment of the extent of knowledge gaps. Risk assessments need to incorporate an understanding of the limits of social intervention. It is striking how difficult professionals find it to face up to this and to spell out knowledge gaps. However, attention should be given in case conferences/reviews and informal decision-making contexts (such as staff supervision) to what it appears cannot be done (our emphasis) to guarantee the protection of children”. “The aim of assessment is to guide action”8
Without a proper assessment there can be no effective plan and without a plan there can be no coherent direction in the management of a case. As a consequence the purpose and objectives of intervention will be unclear and there will be no frame of reference by which progress, or the lack of it, can be judged. This is likely to lead to “drift” which increases pressure on frontline staff who find they are carrying responsibility without clarity of expectations of them, of their boundaries or of the support and guidance available to them. Typically it is at this stage that workers describe their role as a “monitoring” one. The situations where monitoring is appropriate are limited and must be within the context of planned intervention. Where there is no plan monitoring is of little value and may actually be dangerous for it gives the impression of intervention when the reality is that there is none. The absence of assessment may also leave an effective vacuum which allows unverified or unexplored stories. myths and theories to take hold. One such in this case was the oft-quoted statement (at least in the family’s first year in Ireland) that they were very opposed to social work intervention due to their experience of social services in England. There does not appear to have been any substantial questioning of whether the parents had an ulterior motive in stating that they did not wish to have social work intervention. It seems, in fact, that the family were resistant to any professional who pursued their concerns about the children. In fact there was no exceptional resistance to the social worker who commenced involvement in January 1992. Yet this statement achieved a currency of its own and was a significant factor in the non-involvement of the health board’s social work department throughout 1991 which was unusual for a case in which there were such concerns about the welfare of children. A further risk of an ineffective assessment process is that it allows workers to develop a fixed view about a case which fails to acknowledge objective facts or new information. Such fixed views can become pervasive within a network of professional colleagues. Reder et al suggest that this may arise where “workers may be so conscientious that they are unable to take a step back and instead they resolutely continue with the same focus. Furthermore, the stress of child protection work can drive staff to seek allies to share their anxieties or confirm their beliefs” 9. In this case, it appears to the inquiry team, a view was formed which became both pervasive and resilient, that successive children became/would become the target for abuse as they approached adolescence. Thus Girl 3’s situation began to be understood as a symptom of the parents’ difficulty in managing the transition of their child into adolescence as, it was assumed, had also been the case with Kelly. This view, with which we disagree, appears to have continued for a considerable period even after Kelly’s death. It ignores the fact that Kelly was admitted to hospital in an emaciated state at the age of only four months when her sister was already a healthy eighteen month old. It also fails to explain how this eldest sister appears to have survived adolescence without the traumas suffered by Kelly and Girl 3. It is our view that such abuse was a factor of the parents’ perceptions of and relationship with these daughters rather than an inevitable temporary phase to be visited on each child in turn as they passed through adolescence. In the context of assessment of risk in child protection this becomes critical. Problems associated with child management indicate a deficit in parenting skills which can be addressed effectively with support, guidance or training. On the other hand problems relating to the way a particular child is perceived within his/her family relative to their siblings are indicative of a much more serious and potentially dangerous dynamic. Finally, we have already indicated our belief that it is important in preparing cases for court, and especially where the concerns are less tangible - as is typical in cases of emotional abuse and/or neglect - to relate the facts of the case to well-proven indices of abuse. Having said that, we must acknowledge that on the evidence presented to this inquiry it would appear that the health board experienced difficulty in obtaining Fit Person Orders from the District Court on the surviving children after Kelly’s death. This would suggest that the pessimism with which a possible application was viewed in April 1992 was possibly well-founded, even had the case been more effectively constructed. In this regard we find it necessary to draw attention to the fact that following Kelly’s death. -it took 8 District Court hearings before the Western Health Board succeeded in its application for Fit Person Orders in respect of her surviving siblings; -the District Court refused to hear evidence relating to Kelly and Girl 3’s emotional abuse and scapegoating; -the District Court ordered that all the surviving children should be returned to their parents for two weeks at Christmas 1993 - this was reduced to three days only on appeal to the Circuit Court by the Western Health Board against this decision; -decisions of the District Court clearly influenced health board staff in pursuing a plan of action with regard to the children which they did not consider to be necessarily in the children’s best interests but which they felt compelled to follow. We consider this to have serious implications both for the extent to which the court system functions to protect children who are vulnerable to all forms of abuse and for the way in which health boards interpret their responsibilities under court directions. In such situations we believe that health boards are obliged to make an unambiguous statement to the Court on the extent to which they believe they can offer protection to the vulnerable children concerned. CASE CONFERENCES“Case conferences are an essential feature of inter-agency co-operation. They provide a forum for the exchange of information between different professionals involved with the child and family. The outcome of such discussions is recommendations to individual agencies for action” 10. “A case conference is the forum through which major issues concerning the protection of a particular child are dealt with. Of all the procedures and processes involved in child protection work it is within the case conference that the most critical recommendations are made” 11. The Western Health Board held a total of seven case conferences on Kelly’s family prior to her death, the first on 3rd July 1991 and the last on 26th January 1993. Four conferences were held in the period from 19th December 1991 to 6th April 1992 (inclusive), a total of almost sixteen weeks. In all, a minimum of eighteen staff attended the seven conferences of whom only one, at most, may have attended every one. In general we have to report that these case conferences were amongst the least satisfactory aspects of the health board’s response in this case for the following reasons: •the absence of an effective assessment and consequently of planned intervention resulted in the case conferences’ purpose being unclear; •the notification given for at least two of the case conferences was inadequate; •the list of those invited to attend was inconsistent; •on one occasion the frontline worker with most direct contact with the family, the public health nurse, was advised it was not necessary for her to attend; •the administrative recording of case conferences was inconsistent: there are typed minutes of only three out of the seven conferences. There are handwritten notes made by individuals attending the other four conferences. These have not been circulated or agreed; •no administrative staff attended any of these conferences for the purpose of taking notes or recording decisions; •the record of those attending or sending apologies is incomplete; •the record of discussion and decisions at most of the case conferences is inadequate. There is no record of dissent or that there was no dissent; •where decisions are recorded they typically exclude a plan of action and identification of responsibility for implementation; •on only one occasion is there a reference to the appointment of a key worker: this is in the personal notes of two participants at the 28th January 1992 case conference. However this ‘key worker’ did not attend the following case conference on 28th February 1992 and left the community care team to take up another post shortly afterwards. This person reported in evidence to the inquiry team that she was unaware of her appointment as keyworker; •written reports were provided by some workers to some case conferences. However it would appear that the majority attending most conferences had not prepared a report in advance; •there does not appear to have been any consistent practice with regard to informing Kelly’s parents that a case conference was taking place or of its outcome; •there were some case conference decisions which were not implemented without a clear reason being advanced and also decisions that were changed subsequently. There is no evidence available to the inquiry which indicates that the decisions of previous conferences were reviewed and any changes accounted for. These specific criticisms suggest a serious lack of clarity about the purpose and objectives, and the chairing, recording, contributing, deciding and implementing functions of case conferences. In the context of this specific case they represent a significant potential resource which was not effective either in terms of outcome or resources. More generally, evidence given to the inquiry team in interviews would suggest that the discussion between participants at case conferences was also unsatisfactory. Examples include: •there was a perception that greater weight was put on the contributions of participants with higher status but who might not have had direct contact with any member of the family, or whose contact was minimal; •impressions were contributed without substantiation - they frequently then took on the currency of facts; for example, the case conference of 17th November accepted an opinion that Girl 3’s low weight and height were attributable to the small stature of her family generally, which was inaccurate and misleading - careful charting of her own and her siblings’ developmental growth would have demonstrated this; •statements were made which increased the anxiety of frontline staff without the support necessary to deal with it being offered; •professional views were changed, particularly in the context of requests to give evidence to support Fit Person applications to the Court: these inconsistencies were not challenged; •there appears to have been a failure to appreciate the distinction between legal advice, the purpose of which was to ensure that the health board properly discharged its statutory functions and in that respect to protect the board, and legal advice the primary objective of which was to protect the interests of the child; •the case conferences were too reactive to recent events and reports rather than setting them in the context of the family history. When the ineffectiveness of case conferences is combined with the inadequacy of assessment one can begin to understand how the interpretation and assessment of concerns in relation to Girl 3 fluctuated and was of little assistance to frontline staff. For example, the lesions with which she was admitted to Castlebar General Hospital in December 1991 were variously described over the following year as having been caused by cigarette burns, self-mutilation, fleas, a rash. Concern about Girl 3’s exceptionally low weight was described variously as being due to failure to thrive, food deprivation, food refusal, and as consistent with the alleged small stature of the family generally. It is easy to understand, therefore, the frustration of frontline staff who were concerned that the more serious possible diagnoses of neglect or abuse might be accurate but did not have confidence in the sustainability of any case to be put before the Court in the light of such inconsistency. Ideally the case conference should function as a support to frontline workers, contributing additional relevant information to their reports of their interventions, reviewing previous history and case conference decisions, forming a collective view on the current situation, advising with regard to future action and assigning responsibility for carrying it out. INTER-DISCIPLINARY AND INTER-AGENCY COMMUNICATION AND CO-OPERATION Communications between professional staff in child protection is a most complex issue which has featured repeatedly in child abuse inquiries. Reder et al, who studied thirty five fatal child abuse inquiry reports on children who died in the United Kingdom between 1972 and 1987 state “Report after report highlights how crucially relevant information was not passed on to new workers or agencies and that information was not shared amongst concurrently involved professionals” 12. Subsequent inquiry reports have continued to address this issue. Fitzgerald et al in their report on a child who died in the U.K. one month after Kelly state “there is no doubt in our minds that, due to the perception of the children as being in need but not at risk, the quality of inter-agency communication and co-operation fell short of what would now be regarded as essential” 13. The Kilkenny Investigation Report similarly found that “each aspect of the health services dealt with the individual manifestations of Mary’s abuse and her various illnesses entirely separately and without interdisciplinary communication and co-operation” 14. In general we have found that the sharing of information between individual professional staff in this case was quite good but that paradoxically the quality of communication between them left a lot to be desired. Information was shared openly between the various staff involved, both health board and non-health board, and we have no evidence of potentially vital information being deliberately withheld. However effective communication is more than the sharing of information and is influenced to a significant extent by the relationships between professionals and between agencies. The quality of professional relationships is clearly influenced by the organisational structures and practical issues such as the location of staff. The arrangement of a relatively high number of case conferences may have been an attempt to transcend logistical constraints and certainly with regard to this case it would appear that the case conference became the forum at which most information was exchanged. Intra Health Board Communication (a)Community Care Disciplines We are concerned, however, at the relative lack of contact between the social worker and public health nurse. as the two frontline workers in the case, other than at case conferences. As we have already noted we do not believe that this led to any serious information gaps but more frequent meetings and effective communication would have enabled them to jointly plan their interventions, to compare notes and to support each other. It would also have demonstrated to the family that the two main health board workers were working in concert. To understand this lack of contact it is important to note that these workers were based approximately twenty miles apart, the social worker based in Castlebar with the majority of the social work team for County Mayo, the public health nurse alone in a small health centre in a rural area close to where the family lived. Neither was there a context for a relationship as the social worker had joined the Western Health Board only a short time prior to assuming responsibility for this case and this was the only case they both had in common. Furthermore communications tended to be rather formal with the public health nurse reporting matters of significance in writing to her Superintendent Public Health Nurse who passed them, where relevant, to the Senior Social Worker who would then, in turn, inform the social worker. Communications between other members of the community care team were facilitated by the fact that they were based in the same location. They were, however, influenced by the inevitable issues of status and the relationships between the various disciplinary groups. We shall be making a number of recommendations aimed at promoting positive and collaborative relationships amongst community care staff with particular reference to child protection matters. In addition to the Mayo Community Care staff two specialised facilities of the Western Health Board had a significant involvement in this case, viz. Castlebar General Hospital and St. Anne’s Children’s Centre, Taylor’s Hill, Galway. (b)Castlebar General Hospital The involvement of Castlebar General Hospital included the provision of outpatient appointments for several children of the family, the admission of Girl 3 for three weeks from 13th December 1991 to 2nd January 1992 and it was also to this hospital that the surviving children were initially admitted on Place of Safety Orders on 4th February 1993. In general it would appear that the consultant, nursing and paramedical staff of the hospital supported their community care colleagues in a facilitative and co-operative way. For example, outpatient appointments were arranged at the behest of community care personnel and, indeed, brought forward where there was a need for greater urgency. Medical and paramedical staff generally provided reports as required and attended several case conferences. Community care staff did however experience frustration that no definitive diagnosis was made of Girl 3’s injuries and failure to thrive following her hospitalisation. This would have been important in supporting the preparation of a successful application for a Fit Person Order. (c)St. Anne’s Children’s Centre St. Anne’s Children’s Centre is the child psychiatric service of the Western Health Board. Based in Galway it provides out patient clinics generally once a month in various parts of the Board’s area including Ballina, Castlebar, Roscommon, Ballinasloe and Tuam. Whilst it is predominantly an outpatient service it does include a residential centre at St. Anne’s for assessment of emotionally disturbed children. It was to St. Anne’s that Girl 3 was transferred following her three week admission to Castlebar General Hospital in December 1990. She was admitted to St. Anne’s on 2nd January 1992 and discharged on 16th January. There would appear to have been a difference of understanding between community care staff and St. Anne’s as to the purpose of this admission and of expectation with regard to outcome. St. Anne’s saw it as a relatively routine admission to assess whether Girl 3 was suffering from any psychiatric disturbance which would have warranted the continued involvement of the child psychiatric service following her discharge from the residential centre. In the event St. Anne’s found no evidence of psychiatric disturbance and did not envisage any continuing therapeutic role for the child psychiatric services with Girl 3 or her family. They did recognise that there were family relationship issues which, they understood, community care staff had been addressing and would continue to do so. From the community care perspective it was hoped that Girl 3’s admission would result in an assessment of her emotional and psychological state and provide an insight into her relationships with her parents and siblings. It was expected that the process adopted would be intensive and focused on eliciting a disclosure from her which would shed light on the actual cause of her injuries and failure to thrive and on her treatment by her parents. Community care personnel were disappointed that this approach did not appear to have been adopted and that St. Anne’s did not envisage continuing involvement due to Girl 3 being adjudged as not having a psychiatric disturbance. We understand that their dissatisfaction was compounded by what they saw as Girl 3’s unexpected discharge on 16th January 1992 without prior consultation and by the delay in receiving a report on her admission which was not received until 2nd April 1992. It is difficult to pass judgement at this remove on the relative merits of either perspective. What seems clear, however, is that communications in this instance between St. Anne’s and community care personnel were overlain with professional and relational differences which hampered the development of a unified and coherent health board response to the needs of children at risk. Inter-Agency Communication and Co-Operation The primary agencies external to the Western Health Board in this case were the family General Practitioner and the two schools (National School and Secondary School). The health board staff who had most contact with the family’s General Practitioner were the public health nurse and the Director of Community Care. The General Practitioner was aware of the health board’s concerns and attended two case conferences. Within the normal limits of his role it would seem that communications between him and the health board were satisfactory. Over the period of two years to the time the children were placed in care in February 1993 there was significant contact between health board staff and the National School, commencing with a school medical examination on 8th February 1991, only two months following the family’s arrival in Ireland. The school was well aware of, and shared, the health board’s concerns about Girl 3, submitted reports to case conferences and was represented at one case conference, at least. However in spite of this level of contact school personnel have expressed frustration and annoyance with regard to their experience of involvement with health board staff. One explanation is that there is a divergence of interest and responsibility between school and health board staff combined with a misperception of each other’s role and professional constraints. There is also a sense, though, on the part of the school that the relationship was one-sided; teachers were asked for reports and information but received little in return. This was confirmed for one of the teachers involved when, having attended a case conference at the health board’s invitation, he was asked to leave once he had given his report. This was consistent with the Western Health Board’s procedures with regard to the participation of external personnel in case conferences. The inquiry team finds it difficult to understand how this practice is expected to contribute to the development of collaborative relationships with personnel from other agencies in the interests of protecting children. If it does have a justifiable rationale, it does not appear to have been explained on this occasion. It is accepted that there are occasions when it is not appropriate to share information. One such was when, on the 3rd February 1993, the day before Kelly died, the health board was preparing a Place of Safety application and it was vital that this should proceed speedily and confidentially. To assist the preparation of the application information was sought from both schools by health board staff who, perhaps justifiably, did not feel they could be open as to their intentions due to the sensitivity of the situation. However this was a further cause of annoyance for school staff as teachers experienced it as a further example of health board reticence and failure to reciprocate the sharing of information. Perhaps it might have been possible for the health board staff to acknowledge the difficulty and to assure the school that their reticence was justifiable and would be explained later. Communication with the secondary school was necessarily limited but no less problematical. We have already referred to the social worker’s visit to the school on 16th October 1992 and her perception of it which differed widely from that of the school principal whom she met. The social worker states that the purpose of the visit was to inform the principal of her involvement with Kelly’s family; to find out how she was settling in and the school’s impressions of her; what her attendance record was like; and to request that any change in Kelly’s performance, attendance, mood, appearance, be notified to her. She did not disclose Kelly’s history other than to refer to the fact that she had returned to the family having lived apart for some time. The school principal, on the other hand, recollects that not one, but two, social workers visited to enquire how Kelly was attending and settling into school. They did not divulge any information or ask that the school pass on any information to the health board should it have any subsequent concerns. We find it impossible to state which version is the more accurate but the discrepancy is disturbing and could have been very significant in the context of Kelly’s failure to return to school after Christmas. However it does seem clear that only one social worker visited the school in October - the family social worker was accompanied by a colleague on a subsequent occasion at the time of Kelly’s fatal illness. We have also established that on no occasion prior to Kelly’s death did the health board consider involving the Gardaí. This was not unusual for the time, given the nature of the case. However in view of more recent developments in child protection one would now expect the Gardaí be involved, at least at the level of consultation, at an early stage. Generally, we have found that all relevant agencies were positively disposed to sharing information and to co-operating in the interests of children. This stance however was tempered in practice by the relational context between them which contributed to communication difficulties arising in some instances. SUPERVISION:Individual disciplines differ in their supervision norms. Some have very specific arrangements, others tend to operate less formally, while still others do not make provision for supervision once practitioners have reached a certain level of qualification and experience. Having regard to the current, relatively underdeveloped stage of our child protection services the inquiry team is of the view that a premium must be placed on good quality professional supervision for all child protection staff, irrespective of discipline. If it is to be effective supervision requires a reasonably facilitative context in terms, for example, of organisational stability, manageable workloads, physical arrangements and, not least, competent supervisors. The task of child protection is so serious, responsible and demanding that in our view health boards carry a heavy onus to assure the quality of their staffs’ work and also to provide essential supports to those staff. We note that in Co. Mayo during the course of the health board’s involvement in this case between 1991 and 1993 senior staff in the various disciplines attempted to be available to support their frontline staff as required. A number of supervisors and frontline workers have referred to ‘open door’ policies, for example, being available to their staff, debriefing after particularly difficult visits, etc. This is highly laudable and demonstrates recognition of the demands being made of their staff and a genuine desire on the part of those supervisors to be supportive. Nevertheless we feel compelled to caution against this type of informal support being seen as a substitute for formal supervision. Informal debriefing sessions focus mainly on the here and now, and do not lend themselves to dispassionate analysis of developments over a period of time. Neither is there time for adequate preparation. We found there was a generally consistent level of dissatisfaction with the availability and quality of their supervision amongst frontline workers and a realistic and frank assessment by supervisors themselves. There appears to be over-reliance on workers to demand supervision when they need it but this does not address the problem of it being those who perhaps need it most who never demand it. Supervision “on demand” is neither appropriate nor effective. There is a sense in which it may be said that a majority of staff involved in this case were either inexperienced professionals or experienced professionals who were relatively inexperienced in child protection work. This was compounded by the fact that, where supervision was provided, it was typically offered by an inexperienced supervisor or one who was experienced in supervising but not in relation to child protection. This is a generalisation, it is not intended as a criticism, but it reflects to a great extent the situation then existing in many health boards. Nonetheless it is important that recent improvements be acknowledged. For example, in Mayo in 1992 social work supervision was offered by one acting senior social worker. Shortly there will be one senior social worker and three team leaders. They have and will continue to make a difference, but there is a need for further improvement. It is essential that those charged with the task of supervising frontline child protection professionals should themselves have the requisite knowledge, understanding, skills and experience to be effective. This must be a key priority of the further development of our capacity to protect children. We have been considering supervision in terms of providing support and guidance to frontline workers in their child protection practice. It is essential that supervision be seen also a function of management. In this respect health boards now hold the statutory responsibility for child protection which is carried out by its officers who are professional staff in various disciplines. The boards, corporately, must be seen to be accountable for the quality of its officers’ practice. They must, therefore, demonstrate that their staff are accountable to them as their employer and that they have taken all reasonable steps to assure the quality of that practice through the provision of appropriate and effective supervision. MANAGEMENTIn considering the management aspects relevant to the Board’s involvement with Kelly’s family we will comment separately on the local community care management issues and those relating to central health board management. Community Care Management; In addressing the management issues at community care level it is important to explain the context of the management of child abuse cases, and particularly neglect, at the time. “Responsibility for monitoring and co-ordinating the management of such cases rests with the health boards as part of the child care services provided within the community care programme. The Director of Community Care and Medical Officer of Health (DCC/MOH) or person delegated by him has overall responsibility for the monitoring and co-ordination of cases of child abuse occurring in his area”15. In practice the DCC/MOH is assisted in his/her task by senior staff of the relevant disciplines, primarily public health medicine, social work, public health nursing and psychology. Mayo community care area established a ‘Core Group’ of senior staff in 1988 which met weekly to consider and co-ordinate the appropriate health board response in cases of allegations of sexual abuse. This focus on sexual abuse reflected the response of health boards’ to the growing recognition of sexual abuse as a significant problem. The 1987 revision of the Department of Health Guidelines had included reference to sexual abuse for the first time. As a result the health board developed a reasonably satisfactory approach to the investigation and management of alleged cases of child sexual abuse. Paradoxically it would seem that cases of suspected physical or emotional abuse or of neglect came to be seen as lower priorities and in that order. Neglect, in particular, was seen differently from other forms of abuse perhaps partly because individual cases are more difficult to diagnose as deliberate neglect as opposed to inadequate parenting due to other factors. It should be recognised, however, that such cases form a substantial part of social workers caseloads. At any given time as many children are in the care of health boards for reasons of neglect/inadequate parenting as for all other reasons put together. Such cases however appear not to have been notified routinely to the D.C.C./M.O.H. The inquiry team is unable to say whether this deviation from the Department of Health Guidelines happened as a result of a directive although it seems more likely that it simply evolved. It does however suggest that a relatively sudden recognition of the reality of sexual abuse led to an imbalance in the system and a lowering of the concern and priority accorded to cases of suspected neglect. We do not in fact believe that this was peculiar only to Mayo Community Care Area but that it pervaded the Western Health Board as a whole and possibly other health boards as well. The Western Health Board Annual Report for 1992 for example includes statistics for child sexual abuse only and makes virtually no reference to the Board’s involvement with other forms of child abuse. It should be noted at this point that the Core Group’s remit has since been broadened to include all types of child abuse including neglect. It will be clear from our evaluation so far of the health board’s involvement with Kelly’s family that there is a management dimension to the shortcomings identified. These include: -the formally established procedures for the recording, notification and investigation of such cases were not followed; -there was no effective assessment of the risk this family represented, prior to Kelly’s death; -as a result, there was no effective case management plan; -the organisation and operation of case conferences was unsatisfactory in many respects. We therefore have to conclude that there was a lack of leadership and direction which led both to inconsistencies in the health board’s intervention with the family and in the implementation of case conference decisions. This was further exacerbated by a significant turnover of senior staff at the time in question. For example, between February 1991 and February 1993: -the Senior Area Medical Officer who specialised in child abuse and represented the DCC/MOH on the Core Group resigned with effect from 30th April 1991 and was not immediately replaced; -there were three Acting Senior Area Medical Officers between May 1991 and February 1993; -the DCC/MOH took leave from 1st September 1991 to 16th January 1992. The Acting Senior Area Medical Officer who had been instrumental in calling the case conference on 3rd July 1991 resigned with effect from 31st August 1991. As a consequence, from the beginning of September there was a complete change in the medical team at DCC/MOH and A/SAMO levels; -there was a further change of medical personnel when the DCC/MOH returned from leave in January 1992; -the Senior Social Worker in early 1991 was undertaking a postgraduate diploma course which required him to be absent from his office for an average of one week in four. He was not replaced for these weeks and as a result his staff were unsupervised; -the Senior Social Worker resigned from his post with effect from 1st November 1991. He was replaced, in an acting capacity by one of his staff from December 1991 to July 1993 when a permanent appointment was made. We believe that this turnover at senior levels in Mayo Community Care Area detracted from the capacity of the health board to sustain a planned, coherent and cohesive intervention driven by clarity of objectives and desired outcomes. However it is important that we are clear in relation to such changes: we are not being critical of those individuals who resigned or took leave. That was their right. What is important from a management perspective are the effects of such turnover and the systems that might be put in place to minimise its impact. In this case the combination of a lack of a sufficiently coherent intervention strategy coupled with substantial turnover in key positions contributed to a deficit of direction. We consider it to be the responsibility of management to ensure that in each area there is sufficient continuity of health board personnel who have the capacity to discharge the board’s child protection responsibilities effectively. The inquiry team does have serious concerns about the capacity of the present community care structures and arrangements to provide an effective response to the needs of children at risk of abuse or neglect. In this regard it is important to note that for a number of health board professional disciplines engaged in this work the assessment, treatment and management of cases of child abuse is not their sole, or perhaps primary, function. Furthermore the Director of Community Care/Medical Officer of Health also has responsibility for an enormous spread-of function from public health issues such as control of infectious diseases to food hygiene to services for the elderly. In addition she/he has responsibility for the management of the health board’s staff and services in the community care area. In the view of the inquiry team it is neither possible nor reasonable to expect one individual to effectively manage and lead the board’s statutory response to cases of child abuse whilst also carrying responsibility for so many other functional areas. We shall be returning to this issue in our recommendations. Health Board Management; In the normal course of events health board management would not become involved in issues concerning individual cases - that would usually and more appropriately reside with the DCC/MOH and heads of disciplines. As far as we are aware, senior health board management had no involvement in this case prior to Kelly’s death. However it is the responsibility of senior management to provide the staff, resources, facilities and conditions necessary to enable the board’s functions to be carried out in each community care area. In so providing they are constrained by budgetary parameters and the policy priorities as laid down by the Department of Health and the Health Board. They also have ultimate responsibility for the quality of management and of service provided within these constraints. We are conscious that the relative priority accorded to child protection nationally has significantly changed since the period under review. Additional resources have been provided which have enabled extra staff to be employed, an improved social work structure to be created and new services to be developed. Nevertheless substantial additional development will in our view be required if children exposed to abuse or neglect are to be adequately protected by the statutory services. In considering management aspects relevant to the case in question we will make both specific and general comments:- -We have already referred to the level of turnover amongst staff with supervisory experience in Mayo Community Care area in the period 1991 - 1993. We cannot say if this was exceptional but we are concerned at the number of ‘acting-up’ arrangements that were in place and delays in replacing staff who had resigned. -We further believe that management has a responsibility to ensure that the board’s policies with regard, for example, to recording, notification and investigation of allegations are being followed and assuring the accountability of its staff. -We consider that during the period under review there was an over-emphasis on sexual abuse relative to physical and emotional abuse and neglect. While we cannot comment on the origins of this the fact that the Western Health Board’s Annual Report for 1992 contains statistics relating only to sexual abuse suggests that this emphasis was at least reinforced by management. -It appears to the inquiry team that there have been insufficient opportunities for professional staff to benefit from management training and to engage in collaborative initiatives with health board senior management which would serve to improve relationships and generate greater understanding of their respective perspectives. -Accommodation for community care staff in Mayo Community Care Area has been inadequate for many years. Most staff are based in pre-fabricated buildings at the County Clinic in Castlebar close to the General Hospital. While the facilities for staff leave a lot to be desired the waiting accommodation for members of the public is particularly unacceptable. The inquiry team acknowledges that this will improve in the near future when a newly acquired premises nearby will become available. However we question the advisability of staff being accommodated solely on the basis of their disciplinary group and its implications for inter-disciplinary relationships and co-operation. We shall return to this issue in our recommendations. At a general level we do believe that it is primarily the responsibility of management to provide the climate and conditions that facilitate the delivery of effective child protection services and against which staff can be held accountable. The importance of a supportive agency context including stability of both organisation and staffing features prominently in the child protection literature. We have concerns that tensions between some frontline staff and health board management may adversely affect the quality of child protection service delivery. This is neither new nor unique to the Western Health Board but we believe we cannot positively contribute to the development of our child protection capacity without addressing this issue. It is fundamental and cannot be ignored. In our experience there is a clear lack of understanding and sympathy between health board managements and child protection staffs which potentially will limit the effectiveness of interventions on behalf of children unless it is resolved. While complex its source, in our opinion, lies in differences of objectives and expectations between management and frontline staff. To generalise, it may be manifested in management questioning the realism and loyalty of its professional staff who may, in turn, doubt the sincerity and support of management. It is our view that a coherent and cohesive organisational approach is essential if the capacity of agencies to intervene successfully on behalf of children at risk is to be assured. In the midst of legislative and resource development we consider that this issue has not received sufficient attention. We firmly believe that it must be acknowledged and addressed if we are realistically to develop the type of organisational culture and climate that will positively embrace the task of protecting children from harm and will achieve the highest standards of effectiveness and professionalism. CONCLUSIONWe have identified a number of key points in the health board’s involvement with Kelly’s family when different actions or decisions might have been expected. We are particularly critical of; -the lack of a comprehensive health board assessment of the family and the degree of risk it represented for some of the children, at least; -the ineffectiveness of the case conferences held on the family; -the arrangements in place to support and supervise frontline staff. Consequently we must conclude that the system employed to protect Girl 3 failed to achieve this objective. By the time Kelly returned to live with her family, health board personnel, in spite of having had involvement for twenty months, had no real appreciation of the risk to which she was exposed. As a result we find that the intervention of the health board, in spite of the best efforts of individual staff, was native and ineffective when pitted against parents who represented a significant danger to at least two of their children. It appears to us that this case illustrates many features of the deficits in health board child protection practice which existed prior to the programme of development which was commenced in 1993 following the publication of the Kilkenny Incest Investigation Report, three months after Kelly’s death. While it is important to acknowledge the progress made in the interim, for example, in terms of staff awareness and training and of the provision of resources, it is essential that we should not become complacent. The task of child protection is complex and requires a degree of sophistication in terms of skills, resources and practices which, generally, we have not yet achieved in Ireland. The remainder of this report is largely devoted to the task of improving our capacity to intervene effectively to protect children. CHAPTER 5- SIGNIFICANT FEATURES OF CHILD ABUSE AND NEGLECT -Through our developing understanding of what actually was happening in this case we have identified a number of critical issues which are typical of abuse and abusing families and which feature prominently in the child protection literature. We include in this chapter brief outlines of the more salient issues of relevance to this case as a contribution to extending child protection knowledge in Ireland generally. However, we cannot recommend too strongly that professionals who carry responsibility for any aspect of child protection familiarise themselves thoroughly with such issues and their characteristics through reading, training and extending their practice experience. It is equally essential that agencies fully and actively support their staff in these endeavours. The issues addressed here are not intended to be all inclusive. They appear to us to have particular relevance to the case which is the subject of this inquiry. The summary on emotional abuse and neglect has been contributed by Dr. Owen Hensey, F.R.C.P.I., D.C.H., Consultant Paediatrician. EMOTIONAL ABUSE AND NEGLECTINTRODUCTION:Emotional abuse and neglect of children may take many forms from lack of care for their physical needs, to a failure to provide consistent love and care, to overt hostility and rejection. The harmful effects upon developing children are correspondingly diverse and tend to vary with age. In infancy neglect of physical care is likely to produce the most obvious consequences and developmental delay is also found. Pre-school children may additionally present with disorders of social and emotional adjustment. Older children are likely to show behavioural problems at school, which are often accompanied by significant learning difficulties. DEFINITION:Emotional abuse can be defined as the adverse effect on the behaviour and emotional development of a child caused by persistent or severe emotional ill treatment or rejection. or exposure to ongoing domestic violence. There is characteristically an absence of normal parental care with failure to show the expected concern and love for the child. It occurs in all social backgrounds and is extremely difficult to detect. It may be passive, involving such practices as leaving a child unattended for long periods, not showing affection or failing to stimulate and encourage the child when appropriate. Active abuse includes threatening the child repeatedly, limiting peer contact and play experiences by confining a child to a limited space such as a cupboard or cellar, and the undermining of self esteem by constant criticism. Neglect can be defined as the persistent or severe neglect of a child, whether wilful or unintentional, which results in serious impairment of the child’s health, development or welfare. There is considerable overlap between neglect and emotional abuse. Neglected children may be left unattended for long periods, putting them at risk of injury or death as a result of home accidents. They may not be provided with adequate nutrition, shelter, protection from injury or medical care. PRESENTATION:Although concerns regarding standards of parenting may raise suspicions about the presence of emotional abuse or neglect, it is most commonly detected as a result of its consequences in the child, the effects depending on the age of the child. Infants: Failure to thrive is a major feature resulting from poor nutritional intake, the child’s weight and length diverging from the normal expected growth curve. In addition, there may be signs of a severe nappy rash. Where there has been serious neglect, there may be general developmental delay, motor skills failing to develop because a child has not been given the opportunity to explore and social skills affected because of understimulation. Pre-School children: The consequences in pre-school children of persistent abuse and neglect include a poor growth pattern. Characteristically, when placed in a caring environment, the growth pattern of the child will improve. As emotional abuse and neglect is only part of the spectrum of abuse, signs of physical abuse may be present, especially bruising. Language delay may be a key feature. The child may also present with behavioural problems showing signs of anxiety, poor attention and aggression. Playskills may not be developed because the children will not have had the opportunity to mix with their peers. School Children: School children in addition to physical features, characterised by poor hygiene, unkempt appearance and possibly short stature, may have significant learning difficulties present, particularly poor concentration abilities. Persisting abuse will inevitably cause a lowering of self esteem. As a result it is difficult for these children to form and keep friendships in school, the social skills needed to negotiate such relationships never having been learnt. In extreme cases, self stimulation or self injurious behaviour may be present. THE ABUSIVE PROFILE:In general there are a number of characteristic features present in families where parents are abusing their child. Three major factors relate to the parents themselves, the child that is abused and precipitating circumstances. The parents will characteristically have the potential to abuse which has been acquired over a lifetime. They may have been abused themselves as a child and never learnt a proper parenting pattern. They may have become isolated individuals who cannot trust or use others and thus ask for help. One or other parent may be a passive partner, being unable to support the abusing partner. The parents may also have unrealistic expectations of their child, or children. The child may be perceived by his parents as different. Within a family, one child only may be scapegoated, either because he is seen differently by his parents, he fails to respond in the expected manner or, possibly, the child really is different, having a birth defect, learning disability or indeed possessing greater intellectual development and physical ability than his parents actually have. Often the perfectly normal child is seen as bad, wilful, stubborn, demanding, spoiled or slow. Finally, there is usually some form of precipitating crisis that sets the abusive act into motion. This can be a relatively minor crisis or indeed a major crisis. The crisis is never the cause of the abuse but the precipitating factor. The crisis takes place against a background of other factors such as poverty, unemployment, marital problems and alcohol/drug abuse. Families where abuse is suspected or has actually taken place are often known to the local services. However such families may not have been engaged, either because the families have been unwilling to link into local services or the potential for abuse to occur within the family has been underestimated by the local services. If the potential for abuse is high, it is likely that every child in the family is at risk of abuse while, if considered low, usually one child only is scapegoated. The scapegoated child may be the child within the family upon whom all the family’s problems and difficulties are projected and that person is usually maintained within the family. SPECTRUM OF ABUSE IN KELLY’S FAMILY:The family fit into the profile outlined above with, in particular, emotional abuse and neglect being major components of ongoing abuse. Physical abuse was also identified at various times. Within the family Kelly and Girl 3 were at particular risk, with evidence that once Kelly was not at home, Girl 3 bore the brunt of the abuse. The social work report prepared for Court in March, 1993 by the Social Worker, reveals significant factors relating to the parents’ profile. While there had been concern before the family returned from London, in Co. Mayo the parents attitude and behaviour raised further concerns. They blamed Girl 3’s failure to thrive on her abnormal eating pattern and behaviour, describing her as disobedient at home and difficult to relate to. Her cigarette burns were ascribed to self-mutilation behaviour. Once engaged by the social worker they were extremely resistant to implementation of a parenting plan. They apportioned all the blame and responsibility on Girl 3 for the problems within the family. The father went so far as to state that if Girl 3’s behaviour got to such a point that she was out of control, she would have “to go into care”. The parents had a similar approach to Kelly, describing her as bad, spoilt and difficult at varying times. In England they wanted Kelly to be taken into care and put in a children’s home as a punishment. They were angered that the social services had placed Kelly with her Grandmother. Up to Kelly’s last journey to England they continually commented on Kelly’s behaviour, including her refusal to walk and take food in her last few days. They were extremely secretive in Kelly’s last two months by failing to engage with any workers until after she had died. Kelly, when present in the family, was scapegoated by other family members. The longterm effects of chronic abuse on Girl 3 and Kelly is evident if one studies the growth pattern, as charted on the percentile charts. These charts show the expected weight and height for 94% of the population at any age. Girl 3’s gain in weight during the period of her hospitalisation in Castlebar in December, 1991 is significant, as was Kelly’s weight pattern while staying with her Grandmother. In the five months Kelly spent in Ireland she lost 33 lbs. having been just below the 50th centile before leaving for Ireland. Kelly’s height at death was on the 3rd centile. Girl 3’s weight was on the 3rd centile on reception into Care but has increased as has her height towards the 50th centile over the past two years since being placed in Care. Boy 1, Girl 4 and Boy 2, although exposed to their parents’ rearing pattern with strict and unacceptable practices, did not bear most of the abuse. This is evident by their own statements and also by their weights on reception into care, all being approximately on the 50th centile. However, in the absence of a normal caring family environment, they have obviously suffered emotional damage. SUMMARY:Emotional abuse and neglect can be difficult to identify and have profound effects on social, emotional and cognitive development. It is the psychological aspects of the maltreatment that are of the greatest significance for future adjustment. Within the family, intensive intervention will be required to help the surviving members to come to terms, not only with Kelly’s death, but their father’s and mother’s unacceptable parenting practices. Only by such intervention can the cycle of abuse, and its perpetuation, be avoided in the next generation.
THE MEANING ASCRIBED TO A CHILD;The historical context of a family is an essential, if sometimes undervalued ingredient for accurate assessment of the risk presented to a particular child. Assembling and understanding a family history may be difficult either because there is scant information or because in practice the relevant professional may not have the time resources to forage out the information from files that were not compiled in a way that facilitates easy retrieval. This is an issue to which we shall return in our recommendations. A further problem can be that one may be reliant on information provided by the parent(s) which may be one-dimensional and/or misleading. In addition, it is essential that the information available from all sources is collated both accurately and in detailed fashion. In any event the analysis of the information available requires an understanding that the specific roles ascribed to each family member may have significance for the level of risk to which they are exposed. More specifically, it is the meaning ascribed to each child within the family that may determine whether or not that child is at risk. Whereas in most families it is expected that parents will make the satisfaction of at least some of their own needs secondary to the satisfaction of their children’s needs it seems that this normal pattern becomes subverted in abusing families. In these cases the parents’ own needs or the factors which have contributed to how the child is seen by the parents can result in the child assuming a particular role within the family that may eventually take over and replace the natural development of his/her personality. This effectively results in the child being weighed down by expectations that he/she will compensate for past deficiencies in family functioning and “… This task is not only impossible for the child but is the reverse of the support and dependability needed from the parent. The child is both allotted a specific meaning within the family and is doomed to fail in that role”16. We wish to draw attention to, and emphasise, the importance to the assessment process of understanding the meaning ascribed to a particular child(ren) within a family. In doing so we recognise that this may be difficult and frequently speculative, yet we consider it to be an important contribution to understanding why it is that some children appear to be singled out within their families for specific abuse or neglect and that the apparently positive parenting of some children is withheld from their sibling(s). Studies (Reder et al, Fitzgerald et al 1991 and 1995) of children who have died as a result of abuse or neglect by their parents or carers suggest that some children may be ascribed meaning within their families arising from their parents’ unresolved or unmet dependency needs. Reder et al suggest that children “born to mutually interdependent parents are experienced by them as competitors for limited caring resources. The normal and essential parental balance of care and control is subverted by their experience of the child which threatens their sense of security”. It may be speculated that in Kelly’s case her return from the U.K. further upset a precarious family situation based on excessive control. Indeed, having lived and progressed independently of her family for three years it is likely that her assertion of her own needs led to her parents perceiving her as a threat and escalating their use of control measures. In assessing families’ capacity to provide a safe and nurturing environment for their children it is important to consider factors beyond the apparent skill levels of the parents. It may not be a case of parental inability to adequately clothe, feed, nurture one particular child but rather a withholding, whether conscious or unconscious, of the level of care and attention provided to the child’s siblings. Indeed the existence of proven parenting skills which are clearly not applied in the case of a particular child may be of significance in the identification and assessment of the degree of risk to this child. THE CONCEPT OF DANGEROUSNESS;Accurate, detailed assessment is a fundamental and essential element in child protection work. This assessment must include parental motivation, capacity and relationships; assessment of children’s appearance, demeanour, school attendance, behaviour, development, health etc; assessment of potential stress factors, eg. family income, housing conditions, contact with neighbours, local services and general environment, etc. Essentially it is about assessing the degree of risk to which the child or children are exposed. In this respect we believe that there is an immediate need to raise the awareness of all statutory and non-statutory staff providing services to children about the reality and characteristics of what has been called ‘the concept of dangerousness’. It is a term that is well understood in determining, for example, staffing ratios for violent inmates of psychiatric or penal institutions. It has been defined as “the potential to cause serious physical and psychological harm to others”17 but it has only been within the last ten years that it has appeared, to a limited extent, within the child protection literature internationally and, in very recent times, in training and literature in Ireland. In raising awareness of relevant staff it must be recognised that this will involve considerable shift in prevailing values and perceptions. “Those employed in social services, health or education services are usually caring people whose own experience and training is far removed from the deliberate control or infliction of violence. They tend to look for stress factors leading to loss of control as a cause of child abuse rather than for the manipulation of violence to impose an individual’s will within the family. Their lives and careers are directed to seeing positive attributes in individuals, therefore to think in terms (of dangerousness) will require a major change in perceptions and attitudes”18 Without an awareness of dangerousness and an understanding of its nature, professionals are likely to become drawn into the identification of stress factors (e.g. relationship difficulties, poverty, unemployment, housing etc.) as the cause of abuse in dangerous families and to their remedy as the objective of their involvement. While this may be relevant and beneficial in many instances, where the abuse is a feature of a family that is dangerous it will serve only to disguise the real risk, to prolong the exposure of the child to that risk and may in fact exacerbate the situation. Typically parents who are dangerous will adapt their presentation of themselves to meet the needs of particular circumstances. The father in this case was described variously by witnesses as talkative, non-communicative, straight, aggressive, hostile, charming and intimidating; the mother was described as gentle, quiet, scheming, lying, pleasant, non-committal, calculating. These are remarkably varied and contradictory sets of descriptions. Such parents will use, manipulate and exploit any weakness in an individual worker or in the professional worker network to retain control. This is facilitated by failure on the part of workers to effectively communicate their experience of the parent(s) and to share information appropriately. It is difficult to adequately convey the degree of manipulative power that such parents can exert. They can exude persuasiveness and plausibility in the face of the most incontrovertible evidence to the contrary. If the professionals are in any way uncertain of the true facts they are most likely to be taken in by the parents’ statements. It is essential therefore for the professionals involved to share detailed, accurate information and ensure that they retain a focus, at all times, on facts not perceptions. Such parents can give plausible explanations to minimise their culpability for the death of their child, where this has occurred. How much more difficult is it to accurately predict a tragedy where one has not yet occurred? Dale et al refer to the fact that research demonstrates that predictors of dangerousness are poor and unrefined. They regret the lack of a systematic way of indicating the families which pose an immediate and serious threat to the life and safety of a child and suggest that significant information in this respect can be gained from a viewpoint of how the entire family operates as a system. They also make the observation that the most likely cause of a 50% reduction in official figures in the United Kingdom for cases of fatal child abuse between the late 1970’s and late 1980’s is “the vastly improved efficiency and effectiveness of inter-agency child abuse management systems, together with increased awareness and skill on the part of all relevant professionals to identify cases at an early stage and to take effective protective action to prevent the classic spiral of repeated minor injuries becoming serious and ultimately fatal” 19. The same authors, however, also draw attention to the dangerousness of dysfunctional professionals and inter-agency systems. The former may occur, they postulate, where boundaries between personal needs and professional roles become confused, possibly leading to the worker becoming over-involved and over-identified with the family. This may lead, ultimately, to their being unable to see the direction of family processes or the significance of certain events. With regard to inter-agency dangerousness they cite the case conference as a prime example and stress the importance of “the recognition that the processes operating in the conference may be more powerful than the issues being discussed. In caricature, the activity ‘on top’ of the table - the discussion about the family - may be seriously affected by the simultaneous activity ‘below the table’. The covert activity ‘below the table’ may include a wide range of power struggles, status and experience differences, and undisclosed personal agendas” 20. Fundamentally Dale and his colleagues make the case for all agencies to become proactive in reducing their own potential for dangerousness through providing sufficient training and measures for the emotional support of professionals involved in the management and treatment of child-abusing families. They also stress the responsibility of the individual professional in recognising and expressing their needs in these areas. CONTROL CONFLICTS;This case illustrates several examples of characteristics which Reder et al in their study of thirty five child abuse deaths have termed collectively, care and control conflicts 21. Those which have most relevance in this case are the control conflicts of; (a)Closure (b)Disguised compliance (c)Flight (a)Closure is described as a family’s attempts to tighten the boundary around themselves so that they reduce their contact with the outside world and few people are able to meet or speak with them. Closure occurred in more than half the cases studied and was exemplified by parents failing to keep appointments with professionals, children not being taken to scheduled visits to health clinics and social workers and health visitors failing to gain entry to the family home. In the majority of cases closure was intermittent with each recurrence coinciding with periods of increased stress whether from within or outside the family, together with escalating abuse of the children. In approximately one third of cases the child’s death was preceded by a period of closure or ‘terminal abuse’. Reder and his colleagues postulate that closure is primarily an issue about control, with parents feeling that they were in precarious control of their lives and outsiders were unwelcome intruders who would further undermine them. The very fact that allegations of abuse resulted in professionals adopting an investigative or monitoring role led, in effect, to the exaggeration of the parents’ conflicts about being controlled and they responded by shutting out the professionals in an attempt to regain control. We believe that Kelly’s family engaged in intermittent closure throughout the period of the Western Health Board’s involvement. For example, they failed to keep many outpatient appointments, they did not respond to the written request-in April 1992 to meet with the Director of Community Care and the Acting Senior Social Worker and they withdrew from the joint intervention programme initiated by the psychologist and social worker. Most significantly there was a terminal closure from late 1992 which continued to Kelly’s death in February 1993. During this time Kelly did not attend school, her parents did not seek either therapeutic or medical assistance in spite of a rapidly deteriorating situation and, while they allowed the public health nurse and social worker access to their home, they neither disclosed what was happening nor responded to the workers’ concerns or proposals. In fact on her last visit prior to Kelly’s death the parents told the public health nurse that they would not be attending the paediatric outpatient appointment she had arranged. The last known sighting of Kelly by anyone outside the family prior to her flight to Stansted on 1st February was by the neighbours’ daughter-in-law who intervened on Christmas Eve because of a chimney fire. The family’s closure was neither complete nor consistent and is more apparent with hindsight. More frequently, it appears to us, they engaged in a variation of closure, described by Reder et al as ‘disguised compliance’. (b)Disguised compliance, typically, is apparent co-operation by the family which has the effect of neutralising the professional’s attempts to take a more interventionist or controlling stance and returns the relationship to closure and the previous status quo. Examples of such compliance would include agreement to the proposal that Girl 3 be transferred to St. Anne’s Children’s Centre and subsequent agreement to the joint social work/psychology intervention; the parents’ continuing co-operation with the monitoring of Girl 3’s weight; and their agreement to allow the social worker to meet and speak with Kelly in November 1992. In each instance the health board was asserting its authority in matters of child welfare and whilst the parents apparently complied, there was no continuing benefit to the child in question: Girl 3’s weight subsequently reverted to its former pattern; parents withdrew from the therapeutic programme established; the regular monitoring of the public health nurse appeared to become an end in itself; and the parents were present throughout the social worker’s meeting with Kelly and she was never subsequently allowed to meet the social worker. (c)Flight is described as a form of closure in which families close their boundaries and retreat from contact with the external world by moving elsewhere. Some of the cases in the study by Reder and his colleagues graphically manifested this characteristic with numerous changes of address. In the case of Kelly’s family the only possible case of flight in recent years was their move to Ireland in late 1990. It is difficult to be sure whether this was a case of flight or otherwise. Certainly their new address in Ireland was given to the children’s primary school and, possibly, to other agencies in London; on the other hand Kelly’s father told the inquiry in his evidence that their trouble with Kelly was partly the reason for their move, together with the opportunity presented by his accident compensation. It is important that every effort is made to establish previous family history and, where relevant, to make contact with the authorities in the previous jurisdiction. We shall be returning to this matter in our recommendations where we shall also be addressing the need for protocols for the sharing of information on an inter-country basis and, particularly, within the European Union. Reder et al identify with great clarity the dilemmas facing workers in situations of control conflicts. They found a striking association between escalating abuse of a child and parental withdrawal from contact with professionals and others in the outside world which, we suggest, is also evidenced in this case. Withdrawal could take the form of closure, disguised compliance or flight. They conclude that workers should be particularly concerned that the risk to a child is increased when a family in which abuse has previously occurred shows any form of closure. In several instances a child was killed during an episode of closure but this study identified no reliable clues which could help a worker anticipate the likelihood of closure being terminal. A particular dilemma for workers is that the difficulty in predicting which episode of closure might end in the child’s death is compounded by the fact that it is not possible to anticipate how the family might react to mounting control from outside. “It is impossible to predict, on present knowledge, what the parents’ responses might be to a more confronting stance and whether it will increase the likelihood of the child being killed” 22. The authors identify two significant implications for practice; (1)that all episodes of closure should be seen as potentially fatal; (2)that professional’s response in such circumstances must not be half-hearted requests to see the child - taking a little control may be more dangerous than taking none at all. “The intervention needs to be authorative and decisive so that the situation is assessed and the child protected before any vicious circle can spiral out of control. In other words, if professionals decide to take control they should take a lot of it” 23. The inquiry team is strongly of the view that the necessary development of child protection in Ireland must be founded on a solid knowledge base. There is now a substantial and expanding international body of literature on child abuse and neglect and we consider it the professional responsibility of the relevant staff and their employers to access it effectively. We also consider that the development of Irish-based research and of literature is essential and must be supported and encouraged by the Department of Health. CHAPTER 6- FINDINGS AND RECOMMENDATIONS -In this chapter we address the following questions: What happened to cause Kelly’s death? Was Kelly’s death preventable? What can we learn from this case for child protection, practice and provision? We subsequently make our recommendations for changes at the levels of policy, provision, management and practice. WHAT HAPPENED TO CAUSE KELLY’S DEATH? When her family moved to Ireland in December 1990 Kelly remained with her maternal grandparents with whom she had been living since May 1989. This had come about following a breakdown in her relationship with her parents. The family was known to Lambeth Social Services Department and Kelly was on its ‘At Risk Register’ due to emotional and possible physical abuse. There was also concern about her low weight and height. Her parents wanted her to be taken into care as a punishment and only agreed reluctantly with her being placed with her grandparents. Kelly’s name was removed from the register by decision of a case conference in Lambeth in February 1991 as she had made considerable progress. Kelly visited her family in County Mayo for two weeks in the summer of 1991 in the company of her uncle, aunt and cousins. She was introduced locally as a friend of her sister, Girl 1, from London and given a fictitious surname. After she had returned to London it would appear that her parents had little further contact with her until she returned on holiday in the summer of 1992. Her father reports that he had no contact with Kelly during the intervening year while her mother states that she had intermittent contact by phone in the course of telephone calls to her mother (Kelly’s grandmother). According to neighbours Kelly was introduced in 1992 as a cousin. Kelly’s mother, however, denies this and has stated in evidence that in 1992 Kelly was introduced as their daughter. Immediately on her return to London Kelly insisted that she wanted to return to Ireland to live with her family. There were several phone calls between Kelly, her parents and their extended family in London. Her parents report that they were apprehensive but did not actually refuse to allow her to return. Her mother stated that her apprehension around Kelly’s return was partially related to their past relationship with her and her own concern that the relationship would again go “from bad to worse”. In the event Kelly did return within a matter of days and was enrolled in the local convent secondary school. She was placed in the same class as Girl 1. It would appear that problems emerged before long and within weeks Kelly expressed a wish to return to London. This was opposed by her father on the basis that only he could determine when, if ever, she could return. It also appears that her parents resented the additional cost that Kelly’s return represented, in particular, the cost of the food she ate. (Curiously, however, they did not apply to have her included as a dependent on her father’s Disabled Person’s Maintenance Allowance nor for Child Benefit. We estimate that for the five months Kelly lived with them up to the time of her death this additional payment would have been of the order of £365.00 in total). It would appear that from a relatively early stage her parents began to deprive Kelly of food and also made excessive demands of her to do chores around the house and farm. Neighbours report that the heavier tasks were assigned to Kelly and Girl 3. These included bringing in turf and cleaning out the cowshed. Both girls also had to save turf and were left to work in the bog even when the infestation of midges was so extreme that everyone else had to leave. No matter how well Kelly had performed a task her father would always find some reason for dissatisfaction and to punish her. We understand that from a relatively early stage her father would beat Kelly regularly, systematically and persistently, with or without a stated reason. These beatings were premeditated and a belt, or other such device, would commonly be used. Although members of her extended family from London visited the family in October and again in November the seriousness of the situation was concealed. On the November visit Kelly did not speak to her relatives and it may be speculated that she had been silenced. Statements made by the parents to this inquiry paint a somewhat different picture. They suggest that Kelly viewed her return as an extension of her holiday and, in the interests of enabling her to settle, they made few demands of her for the first four to six weeks. The main responsibility she was subsequently given was for washing-up but, according to them, she resented having to assist in any way. Once her parents insisted, Kelly decided that she should return to London. However her parents considered that, having decided to rejoin her family, she should be forced to see it through. They describe Kelly becoming progressively obstinate, difficult and that she began to hit out at her mother who had just discovered that she (the mother) was pregnant. In their efforts to best her, what began as minor abuse spiralled out of control leading, almost inevitably, to her eventual death. Having considered all the facts of the case at the time the inquiry team is highly sceptical about this version of what occurred. During her five months living with her parents Kelly lost approximately 33 lbs. We are advised that it would take several months for a girl of her age to lose this amount of weight. It is our view that Kelly was systematically beaten and deprived of food for much of the time she lived in Mayo. There is evidence that food and its deprivation represented a major element of the parents’ methods of disciplining some of the children in the family. We have seen how there were concerns about Girl 3’s weight in the United Kingdom and latterly following the family’s move to Ireland. Yet her weight increased by approximately 23% during the course of a five week absence from the family home whilst in hospital and, later, in St. Anne’s Children’s Centre in Galway. One of the reasons the parents gave for their withdrawal from the therapeutic programme initiated by the social worker and psychologist in February 1992 in relation to Girl 3 was that it “had taken their power away and now they had no way to control her behaviour through eating”. Similarly there had been concerns about Kelly’s weight prior to her placement with her maternal grandmother in London. Within six months she had “settled in, put on weight and become very chatty. She blossomed”. Kelly’s parents have stated that in January 1993 she was almost compulsively eating sugar “by the cupful”. This had become a source of conflict with her father measuring the sugar and beating her when he found she had taken more. However it is our belief that not only was Kelly deprived of food, but that bread, jam and sugar were kept in the room in which she slept. Bread slices were counted and the jam and sugar levelled off and measured. If her father considered that Kelly had eaten any of this food she would be further beaten. In short, we are satisfied that Kelly was required to do heavy physical work from an early stage following her return and that she was regularly and systematically deprived of food and beaten. Furthermore she was subjected, we believe, to extreme physical and emotional control to prevent her divulging what was happening to her to extended family,” to teachers, to neighbours or to the health board social worker. Both parents recall the health board social worker insisting on seeing Kelly, which actually occurred on 12th November 1992. They confirm that they stated that Kelly did not wish to talk to a social worker because she had had bad experiences of social workers in the U.K. While they say it is true that Kelly did not want to meet social workers they admit that it was primarily they themselves who were unhappy about it. Kelly’s mother referred to their telling the social worker on another occasion about Kelly missing England and her grandmother. The social worker suggested that she might talk with Kelly but they had not agreed to this. We do believe that the abuse became progressively worse over the Christmas period and into January 1993. Her parents have admitted that she was beaten on average twice a day, usually with a belt. Their next door neighbours’ daughter-in-law visited unexpectedly, on Christmas Eve, due to the family’s chimney going on fire while the parents were out. This was the first time she had seen Kelly since the summer and she noticed a marked deterioration in Kelly’s appearance. As far as we are aware this was the last sighting of Kelly by anyone outside the family prior to her flight to Stansted on 1st February 1993, less than three days before her death. At no stage did the parents give any external indication of what was occurring, other than that Kelly had expressed a wish to return to England. Nor did they seek any assistance, in spite of having had ample opportunity. When the public health nurse visited on 19th January she was told by the father that Girl 3 would not be attending any further paediatric appointments. The social worker visited on the following day and was told by the mother that Kelly and Boy 1 were at home from school with “tummy bugs”. The social worker did not see Kelly, however, although she appears to have given her mother opportunities to disclose if they were having problems. Kelly’s mother has stated in her evidence to the inquiry that when the social worker left that day “there was a gut feeling in my stomach that I should have said something to her”. She says she thought of phoning the social worker subsequently but did not do so. According to her they had stopped beating Kelly prior to the social worker’s visit and before they realised that she was ill. Immediately following this visit the social worker visited the national school where she spoke with Girl 3 who complained of a pain. The social worker was concerned about this pain and phoned the parents that evening without success and again on the following morning. She spoke with the father and suggested that they take Girl 3 to the family doctor. However the father said that Girl 3 was fine that morning, had gone to school and had not complained to them of a pain. Some days later, on 26th January, both parents attended Castlebar General Hospital for the mother’s antenatal appointment. Kelly’s father states that his wife said on this occasion that if they bumped into the social worker, who was based at the adjacent County Clinic, she would tell her they were having problems with Kelly. However they did not meet the social worker nor did they seek her out. This was in fact, quite typical as there was no history of the family independently initiating contact with any service, including the general practitioner, on behalf of the children. This is in contrast with neighbours’ reports of their concern about any animal that might be in pain. In fact we understand that in the midst of the crisis with Kelly, they had arranged for a vet to come to a sick cow, in or around the 11th January. According to the parents’ version, throughout most of January they considered that Kelly was being obstinate, defiant and manipulative in order to force them to allow her to return to London. They were not necessarily opposed to her returning but they were determined not to give in to her. They stated that it was sometime before they considered that she might be ill - according to her father, even by the end of January he believed it was a question of her not co-operating rather than being ill. Her mother however says that she gradually realised over the week to ten days prior to Kelly going to England that she was ill. She states that Kelly at this time was in bed or, if they got her up, at the table. She would walk but she was weak. She last spoke to them on Thursday 28th January. They tried unsuccessfully to spoonfeed her on the following Saturday, 30th January. The inquiry team wishes to state that it does not find this version of events credible. We have already noted Kelly’s weight loss of 33 lbs during the time she lived with her parents, which suggests deprivation of food over a period of months, and that she was systematically beaten. It is difficult not to conclude that her resultant condition had a direct influence on her vulnerability to the infection which ultimately caused her death. One of her injuries detected on her admission to St. Thomas’ Hospital would, had she survived, have required an amputation of toe. On admission she was described as “comatose but responsive and there were multiple jittery movements of her hands, feet and jaw. She was significantly wasted. A Paediatric clinic weight, taken early in 1992 at St Thomas’ Hospital, had been some 13kg (29lbs, approx.) heavier and there was obvious buttock wasting”. Photographs taken at the time of her admission confirm this. We consider that, contrary to Kelly presenting as defiant and obstinate, it was evident for a considerable time prior to her eventual flight to England that her condition was that of a seriously ill girl caused, at least in part, by her parents treatment of her and who was urgently in need of medical attention which was denied her. On Saturday 30th January, having realised the implications of Kelly’s condition, her father telephoned his brother in England and arranged that Kelly would fly to Stansted Airport on Monday, 1st February accompanied by Girl 1. He arranged the flight with a travel agent in Charlestown and ordered a wheelchair for Kelly. It would appear that at this stage Kelly’s parents realised that they had passed the point of no return. In spite of Kelly’s rapidly deteriorating condition they drove past their General Practitioner’s surgery on the way to Knock Airport. At Knock Airport both parents were anxious that somebody might remark on Kelly’s condition and her father has stated that, if challenged, they would probably have said that she was suffering from multiple sclerosis. While he waited in the car her father says he considered whether they should take her to hospital in Castlebar but decided she could be in hospital in London almost as soon. He also commented in his evidence that had a social worker made contact with them at this stage “we would probably have covered up”. In the event nobody at the airport commented on Kelly’s condition. Clearly the fact that people in wheelchairs would be a common sight at Knock Airport made it less likely that they would be challenged. On their arrival at Stansted Airport their uncle brought Kelly and Girl 1 home and, on realising how seriously ill Kelly was, he brought her to St. Thomas’ Hospital. Kelly was diagnosed with meningococcal septicaemia on Tuesday 2nd February. She died in the early hours of Thursday 4th February 1993. The inquest into her death opened on 8th February and was adjourned to 21st April 1993. It was further adjourned pending criminal investigations and re-opened on 21st February 1995. Having heard evidence from a number of witnesses the Coroner returned a verdict: (1) that Kelly died of Gram-Negative Septicaemia and (2) that she died as a result of natural causes. Kelly’s parents were charged with wilful neglect and occasioning actual bodily harm on 15th December 1993. They appeared in the Circuit Court in Castlebar on 17th May 1994 where they pleaded guilty to the charge of wilful neglect. On 1st November 1994 they were both sentenced to a period of 18 months imprisonment. WAS KELLY’S DEATH PREVENTABLE? In Chapter 4 we concluded that the Western Health Board’s intervention was naive and ineffective in its attempts to protect Girl 3 and Kelly from the danger which their parents posed to them. Fundamentally the health board failed to form an effective assessment of the family and consequently did not devise a relevant and successful intervention strategy to protect the children. Indeed, by the time Kelly came to live with her family in Mayo, the health board as a whole still did not have a sufficient appreciation of the nature of the family in spite of involvement over twenty months and, by extension, of the degree of risk to which she was exposed. Had the health board’s intervention been more effective it is likely that by September 1992 when Kelly returned, Girl 3 would have been in care or, alternatively, at home, an application for a Fit Person Order having failed. We can only speculate on the effect such a failure might have had both on the degree of risk to which she might then have been exposed and on the relationship between the health board and the family. However an accurate assessment of the family would, we believe, have resulted in Kelly’s return to her family being met with considerable alarm on the part of the health board. In particular, if Girl 3 were now in care Kelly may have been considered to have returned to take her (Girl 3’s) place. However could anything have been done to prevent her return? We think not, in practice. If legal action had been taken in the U.K., it would presumably have had to be taken by Lambeth Social Services Department, or the extended family or both, jointly. Lambeth, however, did not have any concerns about Kelly at that time and she was in the care of her grandparents on a voluntary basis only; and while some of Kelly’s relatives may have had reservations about her return they do not appear to have been so serious as to warrant resort to the Courts. Even if court action had been initiated, by any party, it is highly unlikely that it would have resulted in a ruling against the wishes of a fifteen year-old who sought to make a fresh start with her family in Ireland. By the same token we do not find credible any suggestion that an Irish court at that time could or would have intervened to prevent this reunion, even if the health board had sought such an order. It is also important to note that the health board social worker was advised by her colleague in Lambeth that Kelly’s arrival in Ireland was entirely a matter for her family. Kelly then, having returned home, would have been enrolled in secondary school and one would have expected the social worker to have made contact with the school to establish how she was settling and to request that the school monitor her progress and keep the health board informed of any change in her attendance, behaviour, appearance or demeanour. This we understand to have been the purpose of the social worker’s visit to the school on 12th November 1992 although, as we have noted earlier, communication between the social worker and school principal on the occasion of this visit appears to have been unsatisfactory. One would also have expected the social worker to have ensured that she actually saw and spoke with Kelly and again it is important to note that the social worker achieved this although it required significant determination and resilience in the face of the parents’ resistance. The family’s social worker was aware that some of Kelly’s relatives visited the family in Ireland in both October and November. By now she (the social worker) had a copy of a letter written by a relative of Kelly’s in 1988 to Lambeth Social Services Department detailing concerns about Kelly’s relationship with her parents and their treatment of her. She took comfort from the fact that no such indication of concern was communicated to her or to any health board colleague following these visits. Had an accurate assessment of the family been made and certainly if Girl 3 had, by now, been in care it is highly unlikely that the case conference of 17th November 1992 would have decided as it did, to reduce the frequency of visits by the social worker and the public health nurse. This case conference decision in fact was based on a number of more positive reports of the family, not least on an opinion that Girl 3’s low weight and stature was attributable to the small stature of her family members generally. This was inaccurate and misleading which would have been illustrated by careful charting of her weight and height and that of her siblings over the previous two years. It is difficult to suggest that the decision to reduce the frequency of visits made a difference prior to Christmas as Kelly continued to attend school and no reports of concern were made by school staff. The social worker visited the family on 9th December. There was a significant break of contact up to mid-January which was compounded by the closure of the school for some days due to a heavy snowfall. The social worker was on leave from 24th December until 11th January. She telephoned Kelly’s mother on her return but again because of the snow did not visit until the following week, on 20th January. The public health nurse had visited on 19th January. There was nothing particularly untoward noted on either of these visits to indicate how seriously the situation had deteriorated and the condition Kelly must have been in at that time. With hindsight it is of course to be regretted that neither worker insisted on seeing Kelly or, had they been refused, subsequently sought a place of safety order or Garda assistance. But could that have reasonably been expected? We think not. In the five months since Kelly’s arrival there had not been a single report of concern about her condition whether from neighbours, extended family, school, Gardai or other health board personnel. The unsatisfactory contact between health board social worker and school principal of the previous October now assumes additional importance since, had either been in contact with the other during January Kelly’s absence from school after Christmas might well have been considered significant. However, it must also be recognised that parents who abuse or neglect their children are particularly skilled at deflecting concern. For example, on the social worker’s visit of 20th January it was Kelly’s mother who volunteered that Kelly was ill - with a tummy bug - perhaps for fear that the social worker was aware that Kelly was not at school. Nevertheless the social worker left the house that day with a niggling concern that the parents’ relationship with Kelly might be deteriorating. She gave Kelly’s mother ample opportunity to disclose any difficulty but left, determined to see Kelly on her next visit. Kelly’s mother has confirmed this, stating that when the social worker left that day she had a “gut feeling” that she should have said something to her. Unfortunately there was to be no further visit before Kelly was sent to London in a critical state. The case conference held on 26th January reflects the fact that health board personnel continued to have concerns about the wellbeing of Kelly and Girl 3 yet had neither an accurate assessment of the situation nor effective intervention strategy. Indeed, while Kelly was still alive at this point it would seem that in terms of the health board’s capacity to intervene, it was already too late. Kelly’s father has stated in his evidence to this inquiry concerning the health board’s involvement: “They didn’t have any reason to worry about Kelly at the time. I mean I can look back and say, yes that is what they should have done but it is easy to look back and say that’s what should have happened. I can’t say at that time they should have done this or should have done that. We weren’t co-operating with them at all so they could only react in the way they thought fit at the time.” We believe that Kelly’s parents belong to a minority of abusive parents in that the abuse is a result of a pathological need to impose their will rather than a lack of capacity or an inability to cope with a number of stress factors. Consequently intervention strategies in such circumstances need to recognise that the relief of stress will not, of itself, eradicate the risk of abuse. In our view an accurate assessment of the family, followed by an effective intervention strategy would have resulted in a greater appreciation of the nature of the risk to which Kelly and Girl 3 were exposed. Nevertheless we find it impossible to state with any certainty that such an assessment would necessarily have prevented Kelly’s death. In the first place it is important to note that we do not believe that her parents ever intended that Kelly should die; secondly, from what we know of her parents’ behaviour and their statements it is likely that any different approach by the health board would have been met by them in an even more defensive and closed manner; and thirdly, as we have seen in Chapter 5, it is not possible to anticipate either those instances of closure which are potentially terminal nor how a family might react to attempts by the relevant authorities to exert additional external control. In fact Kelly’s parents have confirmed to the inquiry that they would have reacted against any attempt by the health board to become more intrusive. They have further stated that as the situation deteriorated and their abuse of Kelly escalated, it took on a certain inevitability that, in their opinion, no intervention from the health board would have countered. While we do not necessarily share her parents’ description of events, based on all relevant factors and the available evidence it is the view of the inquiry team that, in spite of our criticism of many aspects of the Western Health Board’s involvement with this family, it is not possible to conclude that a more effective response would necessarily have prevented Kelly’s death. WHAT CAN WE LEARN FROM THIS CASE FOR CHILD PROTECTION PRACTICE AND PROVISION? We consider that there are significant lessons to be learned from this case to inform child protection practice nationally. We have identified substantial shortcomings in the Western Health Board’s practices and procedures, relating most notably, to failures in child protection procedures, the absence of an effective assessment and several deficits in overall case management, including the use of case conferences. We have been particularly compelled to draw attention to these shortcomings both because we do not consider them to be unique to the Western Health Board and we believe they could have even greater significance for the eventual outcome in other cases. PRACTICEWe consider it important to recognise that no matter how effectively authorities intervene they cannot guarantee that children will not be abused or killed by their parents or carers. To suggest otherwise is tantamount to expecting that there would be no crime because of the existence of the Garda Siochana. This is an uncomfortable and tragic fact but its acknowledgement is vital to the context, management and practice of child protection. In terms of practice it should not be met with a fatalistic hopelessness but rather with an appreciation on the part of professionals that, for whatever reasons, some parents/carers do cause serious injury and death to their children, whether directly or indirectly. This clearly demonstrates the importance of accurately identifying and effectively assessing those families which represent a serious risk to one or more children and planning intervention accordingly. Emotional Abuse and NeglectThe physical abuse which Kelly suffered had its genesis in emotional abuse and neglect. There is a need therefore to recognise the significance of emotional abuse and neglect as a form of abuse that can be as dangerous as other, more obvious, forms. We have noted the relative bias of the Western Health Board towards sexual abuse and the more recent inclusion of all forms of abuse in its child protection strategies. The importance of recognising indicators of emotional abuse or neglect cannot be over-emphasised while it is equally important that legal provision and practice should facilitate the protection of children at risk of these particular forms of abuse. It is particularly vital that courts be receptive to hearing evidence of emotional abuse and neglect. Significance of AgeTypically it is pre-school children who have been considered to be most vulnerable to abuse, both because of the fact that they have not yet acquired the intellectual, language, emotional, physical or social skills to alert others and because of the limited opportunities of the authorities to gain access to them, since they have not yet begun to attend school. Most of the children who have been killed as a result of abuse or neglect have, indeed, been preschool children. A study by Reder et al of thirty five children who died in the United Kingdom while in the care of their parents or carers found that their mean age was 3 years, 1 month. These authors refer to a Canadian study24 of 100 children who died in Ontario between 1973 and 1982 which found that 57% of the victims were aged below 1 year and 95% were younger than 6 years. Kelly’s age at the time of her death, therefore, is of particular note. Indeed the relative lack of concern at her return to her family aged 15 years 3 months may have been attributable, at least in part, to a perception that she was now old enough to look after herself and, if subjected to abuse, she would be able to attract attention and assistance. That she did not do so, in the event, is itself of significance. Whether it was because she could not, or chose not to, we may never know. Vulnerability of the VictimsThe Kilkenny Incest Investigation drew attention to the fact that victims, by virtue of their status as victims, are frequently unable to make rational choices and reasonable responses. It also drew attention to the dynamics of domestic violence and contributed to advancing both public and professional understanding of, and responses to, both victims and perpetrators. It is clearly important, therefore, that there equally be an understanding of the vulnerability of the child victim, even where s/he is a teenager. This recognition demands that we suspend our normal perceptions of teenagers and recognise the particular profile of teenagers suffering abuse or neglect. Supervision OrdersWith the implementation of the Child Care Act 1991 health boards will, for the first time, have the power to apply to the Courts for supervision orders on children about whose welfare they are concerned. It is impossible to say with certainty whether a supervision order would have made a difference in this case but it is likely that the health board staff concerned might have felt more confident about applying for a Supervision Order than they did about a Fit Person Order in early 1992. One benefit of a supervision order would be to give a health board access to a child. That alone, however will not be sufficient and indeed, it has always been possible even prior to the introduction of supervision orders to insist on access, with the assistance of the Gardai, if the concerns were of sufficient seriousness. However, as we have seen, access on its own is of limited value. We believe that supervision orders will have to be used flexibly and imaginatively if they are to be really effective. There will be a need to develop a range of other services to which children and their parents can be referred under supervision orders; there will need to be variety with regard to how professionals work with children, for example through drama, art therapy, sport, etc; and professionals will need to have access to further training in working with children and, indeed, in accurately recognising and interpreting the significance of what they say. Accessing the views of childrenA positive feature to be noted, in spite of the fact that it was not entirely successful, was the recognition by both the social worker and psychologist of the importance of accessing the views of the children, in this case Girl 3 and, to a limited extent, of Kelly herself. It is most important, although frequently difficult, to create opportunities to hear the views of children, particularly where they are suspected of being abused or neglected. The social worker and psychologist jointly met with Girl 3 for four sessions in February 1992. They were also meeting with her parents at this stage but when the parents withdrew their co-operation the workers concluded that there would be little benefit in continuing to see Girl 3 on her own, other than as a support to her. It appears that this was not followed further but had the parents consented we believe that it might have been helpful if it had. Later the social worker was clearly anxious to create opportunities to talk with Kelly on her own but her parents would not agree. She also talked with Girl 3 in school and recognised that she was clearly upset by events at home but did not disclose any specific cause for concern. Working with childrenThis highlights a further feature of working with children who have been abused or neglected. Such cases are complex in the extreme and the children concerned typically have a very mixed relationship with their parents of which extreme loyalty and collusion are features. They do not tend to easily volunteer what is or has been happening but they may give obscure clues even unknown to themselves. It is vital that workers recognise and accurately interpret such clues. However it must be recognised that some children never give clues or make a disclosure. Issues of communication and co-operationWe have highlighted a number of communication deficits in this case and this has featured as an issue in virtually every inquiry into a child death in other countries. We have noted that in general there was a willingness to share information but have drawn attention to the difference between informing and communicating. Of particular importance is the context within which information is imparted and this is clearly influenced by the status and relationship of the workers concerned and of their respective organisations and/or departments. It seems to us that this will always be a complex and difficult area. It will only be ameliorated, in our view, by increasing awareness and understanding of professional staff through specific training initiatives which address the ‘psychology’ of, as well as the formal procedures for, interdisciplinary and inter-agency communication and co-operation. It will be facilitated, however, by the promotion of a positive organisational context which demonstrates a commitment to collaborative arrangements in the interests of the welfare of children. ORGANISATIONAL CONTEXTFundamental to the development of child protection provision is that health boards, as the relevant statutory authorities, should perceive themselves, and be perceived, as child protection agencies. Clearly they are much more besides but we are not satisfied that this basic requirement is adequately met at present. Certainly social work departments, and other disciplines and services to a lesser extent, are perceived to have a child protection function but we have to question the extent to which this is seen as a corporate function as we believe it must. The implications of health boards assuming corporate responsibility for child protection include ensuring that all of their relevant resources and facilities are directed, where appropriate, towards the exercise of this function; that the organisational culture accommodates and reflects the demands of child protection; and that health board managements accept responsibility for assuring the quality of services and interventions which includes arrangements for staff support, supervision and training. We believe that changes in both structures and the deployment of staff are required to achieve this. Acknowledgement of continuing riskWe have concluded that, tragically, children will continue to be abused by their parents and/or carers. It is important that health boards, in developing as child protection agencies, accept this fact. This will allow them to focus on the objectives of identifying children at risk and intervening effectively to remove or reduce the risk involved to the child. In effect this will put the child at the centre of the health board’s focus. Paradoxically the objective of preventing all abuse focuses on the protection of the health board, is neither realistic nor credible and too often results in defensive or ineffective practice by frontline staff. We are anxious to ensure that this is not perceived as a rationalisation for ineffective action by health boards. On the contrary we believe that a realistic appraisal of that which can, and cannot, be achieved will lead to higher standards of practice, greater accountability and effectiveness. We do recognise, however, that there is a fundamental issue as to the extent to which health boards, politicians, the media and the public are prepared to accept that the protection of children from child abuse cannot be guaranteed in every instance. Relations between management and frontline staffWe are concerned that there appears to be tension between frontline staff and management which is not unique in this instance and which continues to exist. We believe that, organisationally, this is primarily a matter for management to address but that changing the context as outlined above will be significant. By the same token it is our view that, professionally, there is an onus on child protection staff to adopt a constructive and collaborative position vis a vis management which acknowledges progress and contributes to future policy and provision. Authority in child protectionWe also consider that social workers, in particular, and their supervisors need to reconcile more effectively the dual roles of support and authority. We believe that the appropriate use of authority in child protection is essential and we welcome recent developments in co-operation between health boards and gardai. A framework to protect childrenIt is evident from this case that there is a need to provide an effective framework for the protection of children at risk, ranging from legislation. to resources, to agency structure and orientation, to professional expertise, to effective inter-disciplinary and inter-agency communication and collaboration to a continuum of services. This continuum must itself encompass a full range of child welfare, as opposed to specifically child protection, services. It must include services that are essentially preventive and supportive, services directed towards children as well as those provided for parents and they must be integrated with other relevant resources provided by schools, voluntary organisations, etc. This is particularly relevant because in addition to the interventions such services provide, they also offer additional opportunities to develop relationships with children and families. In this way they can be supportive of statutory child protection interventions, for example, supervision orders, and they may ameliorate the difficulty of families being resistant to developing a relationship with social workers due to their child protection function. Finally, it is important to acknowledge and address the difficulty of providing a full range of effective services in a predominantly rural area with a dispersed population. In this regard it is important to adjust staffing ratios to take account of the particular distances and travelling times encountered in a county like Mayo. It is also important to recognise that amongst health board disciplines it is social workers, i.e. the professionals with the most specific focus on child abuse and neglect, who typically travel the most. While this has implications for actual numbers of staff it also suggests a need both to review how staff are deployed and to explore options for the development of appropriate and effective support services within rural communities. - RECOMMENDATIONS -The past two years have seen a substantial development of services to protect children at risk which followed the publication of the Report of the Kilkenny Incest Investigation. As a result, it is probable that our capacity to intervene to protect such children is now greater than ever before. We are compelled, however, to note that the shortcomings caused by many years of relative neglect of provision for children in need cannot be reversed within a three year programme of development, however effective it may be. Kelly died in February 1993, one week after the Government Budget had made no additional provision for the implementation of the Child Care Act 1991 and one month before the Kilkenny case came to public attention. The present Government’s commitment to implement the legislation by 1996 is welcome but it is equally important that we ensure that our capacity to ensure its effectiveness is fully developed. We find it inconceivable, therefore, that the development of child care services should be considered to be coming to an end. It has barely begun. In spite of the progress of the past two years current provision falls far short of a level that could be judged to be adequate. Child protection also must be seen in the context of child welfare generally with the development of preventive and support measures so that problems can be addressed as early and as effectively as possible. We recommend most strongly that the Government make a commitment to the continuing development of services for children over a seven to ten year period. This should include the development of a comprehensive and integrated plan and the provision of the resources necessary to implement it. The implementation of the Child Care Act 1991 in full will increase the statutory powers and responsibilities of the eight health boards for the protection and welfare of children. Essential to the exercise of these powers is, we believe, the development within each health board of a perspective which gives corporate recognition to its functions as a child protection and welfare agency. This will require the commitment and leadership of senior health board managements, supported by the Department of Health and the harnessing of relevant facilities and services in support of this statutory function. It will also require the development of a co-ordinated and integrated approach in the planning and delivery of services and consistency in practices and procedures both within and between each health board. In order to ensure that these requirements can be met we recommend the creation of a senior professional post with responsibility for child welfare within the headquarters management staff of each health board. The post of Director of Community/Medical Officer for Health carries responsibility for the monitoring and co-ordination of cases of child abuse occurring in each community care area. However since this responsibility was first assigned the particular demands and complexities of health boards’ child protection mandate have become more apparent and have grown significantly. The impending implementation of the child care legislation will impose additional responsibilities on health boards and, by implication, on the relevant management personnel in each community care area. The D.C.C./M.O.H.’s responsibilities however extend across a very broad range of functions, for example, water quality, nursing homes regulations and control of infectious diseases, to name but three. Responsibilities in many of these areas have also increased over the past ten to fifteen years whilst others have been added. Having reviewed the disparate nature of the current functions of the post the inquiry team has formed the view that it is no longer reasonable or realistic to expect the D.C.C./M.O.H. to provide the leadership and support necessary to enable the health boards to discharge their statutory child protection function effectively whilst also carrying out their other responsibilities as required. We are conscious that health board structures are currently being reviewed, particularly in the light of the creation of the new Departments of Public Health and their implications for the posts of D.C.C./M.O.H. While it has not been appropriate for this inquiry to involve itself in the wider structural issues under review we do consider it essential that any future arrangements would provide for the creation of a specific post of responsibility for child welfare, including child protection within each community care area. We recommend that a dedicated child welfare management post be created in each community care area to provide the leadership and direction necessary for the effective discharge of the board’s statutory child welfare functions, including child protection. We recommend that these posts be filled by professional staff with a relevant qualification, frontline child welfare experience, post-qualifying training and a clear interest in managing this function. We further recommend that these child care management posts include a developmental function and responsibility for children in care, fostering and adoption and family support services. We consider that the Western Health Board has adopted a positive and considered approach to the increased child care resources of the past two years with the establishment of its Child Care Unit at its Galway headquarters, the commissioning of evaluation reports on its services and the prioritising of training as a critical prerequisite of development. Further, the establishment of arrangements for improved communication and co-operation between the Gardaí and officers of the Board is most welcome and the benefits are already evident. With specific reference to Mayo Community Care Area, developments have included additional professional and administrative staff, appointment of social work team leaders, establishment of a new family support service in Ballina and development of foster care and residential child care provision in the county. These developments are to be welcomed but the challenge now is to ensure that they can be translated into the provision of effective services “on the ground” to advance the welfare of children in the Board’s area. Of fundamental importance, in our view, is that the Board consider how its various functions and initiatives on behalf of the welfare of children can best be integrated into a cohesive strategy to enable it to assume its increased responsibilities with the implementation of the child care legislation. The acknowledgement of its increased corporate responsibility for child welfare including its responsibility to assure the quality of its services for children at risk will make new demands of the Board, of management and of frontline staff. To ensure that it can assume these additional responsibilities with confidence we recommend that the Western Health Board establish an internal, consultative process with relevant staff and services with the objective of maximising its organisational capacity to accurately identify children at risk in the region and to intervene effectively to eradicate or to reduce the degree of risk to which children are exposed. This process should result in the articulation of an agreed, achievable objective to be endorsed both by management and frontline staff; with a commitment from management to adopt a positive, supportive approach which recognises the complexities of child protection and the stresses it holds for relevant staff, both individually and collectively; and with the adoption of a positive and constructive approach by frontline staff which acknowledges progress while seeking solutions to continuing or emergent problems. This recommendation is founded on our conviction, which is supported by the relevant literature, that a stable and progressive organisational climate is a vital if frequently overlooked component of effective child protection. We recommend that the Western Health Board review its current deployment of community care staff. In our view the public health nurse in this case was too isolated whilst other staff were too centrally located in Castlebar. We believe it is important in terms of the morale, professional development, psychological support and physical protection of staff that they should not work on their own, particularly where that work entails at least aspects of child protection. Effective deployment of staff, particularly on an inter-disciplinary basis, offers opportunities for the development of relationships of trust and confidence in colleagues, across disciplines, for sharing of information, co-working and may facilitate more efficient and economical use of resources. Allied to this we recommend that the Western Health Board give consideration be to the development of multi-disciplinary child protection teams covering a geographical area. We believe that the benefits of having an integrated system of health and social services within health boards generally is not being fully exploited in the present deployment of staff. We recognise that this recommendation will have substantial professional and logistical implications but we would like to see them tested at least on a pilot basis. The implementation of these recommendations will have implications both for community care structures in general and, specifically, for the management of, and interface between the various relevant disciplines with a responsibility for child welfare. For this reason, and also because we believe that the way child welfare staff are currently deployed and managed should be the subject of a national review, we recommend that the Department of Health examine, in consultation with the relevant interested parties, the most effective means of delivering child welfare services nationally. While the provision of adequate resources for effective investigation and assessment is essential, there is a danger that this aspect of child protection can absorb an unequal share of available resources to the detriment of treatment facilities both for victims and perpetrators of abuse and neglect or of preventive and support services. We recommend, therefore, that the Department of Health take appropriate measures to protect resources for preventive, support and treatment services thus avoiding their being directed exclusively towards investigation of instances of abuse and neglect. We recommend that the Department of Health adopt a proactive approach in monitoring health boards’ child care developments in order to ensure consistency on a national scale both in provision and of procedures and practice. We also consider that there is a need at national level to set and monitor standards of practice in child protection, to establish good practice guidelines, to promote examples of good practice and to inquire into failures of practice. It has not been possible for this inquiry to explore in sufficient depth the arguments for or against the location of this function within the Department of Health or, alternatively, the establishment of an independent and authoritative Commissioner/Ombudsman for Children whose other functions might include the promotion of children’s rights. We do, however, recommend the establishment at national level of a system for the setting and monitoring of child protection standards, to promote examples of good practice and to inquire into serious failures of practice. In view of its ratification by Ireland in 1992 we recommend that all Government actions in respect of children and, in particular, in respect of children who are vulnerable due to abuse or neglect, be founded on the principles and articles of the U.N. Convention on the Rights of the Child. We are concerned about the apparent difficulty in making successful court applications on behalf of children at risk as evidenced in this case. Concerns that an application on behalf of Girl 3 in April 1992 might not have been successful were subsequently borne out by the apparent difficulty experienced by the health board in seeking Fit Person Orders on the surviving children after Kelly’s death. These were granted eventually when the parents withdrew their opposition. There is evidence to support the view of the Kilkenny Incest Investigation that the emphasis on the rights of the family in the Constitution may be interpreted as giving a higher value to the rights of parents than to the rights of children. There is need to acknowledge that the rights and interests of children may indeed be in conflict with those of their parents, in certain circumstances. This inquiry supports and echoes the recommendation of the Kilkenny Incest Investigation Report that consideration be given by the Government to the amendment of Articles 41 and 42 of the Constitution so as to include a statement of the constitutional rights of children. We further recommend that the body currently reviewing the Constitution give consideration to ensuring consistency between Ireland’s ratification of the United Nations Convention of the Rights of the Child and the constitutional provision in this regard. In view of the potential conflict between the interests of health boards and the interests of children we recommend the development of national standards in the provision of an advocacy or guardian ad litem service to children who are the subjects of legal proceedings. We recommend that judges and officers of the Courts be informed of the indicators of emotional abuse and neglect and of their particular risks to individual children. We recognise that there are conflicting views on the desirability or otherwise of the introduction of mandatory reporting of all forms of child abuse and neglect by professional staff. However the concern to provide maximum protection for children at risk must, in our view, take precedence over all other concerns. We recommend that the reporting of actual or suspected child abuse or neglect become a legal requirement for relevant designated staff, including health board personnel, general practitioners, the Gardaí, teachers and staff of voluntary and private child care services. We also recommend that this mandatory reporting requirement accompanied by guidelines to these staff who should have immunity in any legal proceedings. The case in question also highlights the importance of acting when accurate, relevant and appropriate information is received about families who move to Ireland from other jurisdictions and whose children are considered to be at risk. It is known that such families can be highly mobile, often motivated by a concern to escape the attention of the relevant authorities. It is essential that they do not succeed. Nevertheless their mobility is facilitated by the increased freedom to travel within the European Union. In view of the increasing numbers of families from other jurisdictions settling in Ireland, particularly in rural areas, we recommend that the Irish Government take the initiative in establishing European Union protocols for liaison and sharing of information between Member States in the interests of protecting children. In the meantime we recommend that the Department of Health establish bilateral arrangements with other jurisdictions for the sharing of information between relevant authorities where children are, or are suspected of being, at risk. The establishment of international protocols governing the information to be transferred where families whose children are considered to be at risk move between jurisdictions, also has relevance in any situation where such a family moves between areas, even within the same health board region. We recommend that any authority where it knows that a family whose children are, or are suspected of being, at risk has moved to another area, take all steps to ascertain the family’s new address and to provide the equivalent authority in the new area with all relevant information. This should include the extent to which the family was known to the services in the former area and their motivation for moving, where known. We equally recommend that the receiving authority adopt a proactive approach in seeking information on any family which has recently moved into its area in relation to whom an allegation or referral is made. We recommend that a national agreed standard and format be established by the eight regional health boards for the transfer of information from one board to another. This could then form the basis of agreements with other jurisdictions, particularly Northern Ireland, the United Kingdom and the other member states of the European Union. Where a family, some or all of whose children are considered to be at risk, has moved from one area to another, we recommend that health boards support in principle and facilitate where necessary, relevant staff from two or more authorities meeting, even where this involves travel to another jurisdiction. We are firmly convinced that assessment of concerns can be much more accurate where the relevant staff have an opportunity to meet and discuss the case rather than be totally reliant on sterile documentation. We do not state categorically that meetings should occur in every instance. We believe however that this should be an option at the discretion of the staff concerned in consultation with their line manager and that the organisational climate should be conducive to it. We also believe that it should be possible to establish national standards with regard to the structure of child protection files. In particular we recommend the adoption of a standardised case summary sheet similar to the format used in the chronology included in this report. This should be located at the front of all files, should include details of family history and be continuously updated with factual summaries of new information and events. This summary should be considered as a key, dynamic device in child protection case management rather than as a routine administrative task. We cannot emphasise too strongly the importance of child protection staff being receptive to and actively seeking out, information relating to families and children about whom concerns have been expressed. The stresses and complexities of child protection and, heretofore, the poor morale and inadequate resourcing which appears endemic in the area have led, we suspect, to a subconscious “deafness” to reports and subtle diversion of concerns and allegations about children. Professionals may feel already overwhelmed with cases and become psychologically resistant to new referrals or, indeed, place obstacles in the way of members of the public who wish to report their concerns, for example, by insisting that they give their names or come to the health board office. The Department of Health Guidelines unambiguously state that all reports of child abuse, including anonymous calls, should be investigated. The terms ‘referral’ and ‘allegation’ have been used almost interchangeably by health board staff. We consider it important to distinguish between the two, not least because while in practice they tend to amount to the same for social work departments, cases where there are allegations represent perhaps only a small percentage of referrals to some other disciplines. We wish to emphasise the importance of the Department of Health Guidelines, including the requirement to notify the D.C.C./M.O.H. or other designated professional immediately and that all allegations be investigated urgently. We recommend that all allegations be recorded on a special colour-coded form to be used for this purpose by all disciplines in all health boards. This will make it immediately apparent that allegations have been made about a child in a family. Where, following investigation of an allegation, it is decided not to take any further action it is essential that this decision be recorded and explained. By the same token, where action is considered necessary following investigation of an allegation a written report with a substantiated recommendation is essential. The D.C.C./M.O.H. or other designated professional must retain a separate log of all allegations and satisfy him/herself that appropriate action is being taken. We recommend that where a completed investigation indicates that a child is indeed at risk, his/her name should be entered on an ‘At Risk’ Register. The operational aspects of this Register, including protocols for the registration, maintenance and removal of a name should be enunciated by the Department of Health following consultation with the health boards, voluntary organisations and other interested parties. We have reason to be concerned at the level of awareness and understanding of the 1987 Department of Health Guidelines amongst health board and voluntary organisation child care staff, teachers and Gardaí. We also have concerns about the current level of compliance even where the content of the guidelines is known. We consider that where relevant, every organisation is obliged to ensure that each member of its staff is fully au fait with the guidelines and is abiding by them. In particular, we recommend that the Western Health Board assess the current level of knowledge and compliance of its staff with the Department of Health Guidelines and establish and address any reasons for non-compliance. The purpose of gathering, collating and analysing information is to facilitate the accurate assessment of the situation, in particular of the extent of any risk to a child. The purpose of the assessment is to underpin and guide appropriate action. The formulation of an assessment must be a priority, whether based on the outcome of the initial investigation, following a case conference or on the recommendation of a worker specifically assigned to gather all available information for a subsequent case conference. We wish to emphasise the importance to assessment of gathering information on the family history. Assessments, particularly initial assessment, should always be reviewed in the light of new information but it is important in the interests of a coherent intervention to protect children that they remain rooted in factual information and any revision be justifiable on the basis of fact. We recommend that the Western Health Board ensure that all of its child protection staff are aware of the importance of assessment and that all relevant staff receive training in the identification of abuse including indices of abuse, and in risk assessment. We recommend that in each case the Western Health Board develop a plan of intervention based on its assessment of the risk involved to the child. The plan must have clear objectives to be achieved within a defined timeframe with an established process for review. This plan may be the product of an initial case conference but this will not necessarily be so in every case. Case conferences should be arranged to facilitate the implementation of planned intervention or to review its continuing appropriateness or effectiveness. In each instance the purpose of the case conference should be clear. Only personnel with a relevant practice or supervisory involvement should be present. The practice of sending deputies should be avoided if at all possible and should only be considered where they are comprehensively briefed. There must be clarity with regard to responsibility for chairing and recording the case conference proceedings. We consider it essential that case conference proceedings be recorded by an administrative person with appropriate training. The record should note those invited, those present, those who have sent apologies; there should be a record of the discussion, recommendations and of any dissenting views. It should be recognised that the chairing of case conferences is a particularly important task in the process of child protection. It is the responsibility of the chair to ensure that the conferences - -are professional and effective; -that relevant reports are provided in advance; -that those attending are clear about its purpose and of expectations of their participation; -that the case conference retains a focus on facts, not impressions; -that opinions expressed are substantiated; -those attending be prepared to contribute to future action, if necessary through the courts; -that all potential contributions are made and that due consideration is afforded to all contributions. It is also most important that there is a common understanding of the confidentiality of the case conference and that it has the power only to make recommendations since the health board as the lead agency with statutory responsibility is accountable for subsequent action. Where formal assessments have been made by specialised facilities it is important that these reports be made available to the case conference. There may from time to time be concerns expressed about aspects of confidentiality and professional boundaries in this regard but we consider these concerns to be superseded by the interests of protecting children. We recommend that the Western Health Board take all necessary steps to ensure that the arrangements for the holding of case conferences be substantially overhauled and that appropriate training be provided to relevant staff to ensure that the case conference becomes a significantly more effective element of the Board’s child protection strategies. We recommend that the Western Health Board clarify the status of legal advice given at case conferences and whether any such advice which indicates that a Court application will not be successful should be followed in every case irrespective of the views of relevant staff. We recommend that a key worker be appointed in each case and that all those with an involvement in the case are aware of the key worker’s identity and share information with him/her. The key worker is accountable to the D.C.C./M.O.H. or other designated professional for progress in the case and for ensuring that the health board’s policies are implemented. We recommend that the Western Health Board, in the interests of strengthening collaboration between agencies in support of the child protection function, give serious consideration to reversing its policy of requesting representatives of other agencies to leave case conferences once they have given their report. In spite of its existing progressive approach to the provision of training we believe that there is a continuing need for the Board to invest significantly in staff training and development. We recommend that a comprehensive training programme be developed in consultation with staff to include, inter alia, -assessment -dynamics of abusing families -case conference management, roles, etc -corporate responsibilities under Child Care Act 1991 -team development -the psychology of inter-disciplinary and inter-agency collaboration -communication - its dynamics and processes -investigative techniques In view of the practical difficulty of reconciling the need for a substantial investment in training in various aspects of child protection with heavy workload demands and staff shortages, we recommend that the Department of Health explore the development of a modular approach to the expansion of child protection training. In this event credits could be awarded for the successful completion of relatively short training modules, leading to the award of an appropriate qualification on reaching a prescribed number of credits. This would allow for a targeted approach of training to needs while accommodating and indeed being complemented by, continuing practice demands. It is essential that any such development of training would have the acquisition and extension of child protection skills as its focus. The provision of administrative supports to multi-disciplinary health board staff has not been a high priority in the past. However the effective operation of the child protection function demands a degree of administrative coherence and support that is neither feasible nor appropriately provided by professional staff. We recommend therefore that the Western Health Board take the steps necessary to ensure an adequate level of administrative support to child protection staff. We also recommend that the Western Health Board ensures that all professional staff remain accountable for appropriate administrative tasks such as the writing, signing and dating of case notes. Notes do not have to be typed but the writer has a responsibility to ensure that they are legible; reports should be signed rather than initialled and care must be taken to ensure accuracy, for example, with regard to addresses and dates - otherwise they may be mis-filed with potentially very serious consequences; times of visits, phone calls etc., should be noted and all incoming post must be date stamped. We believe there to be a relationship between the perceived priority accorded to a service and the quality of accommodation provided for its execution. We recommend that the development of child protection services be matched by the provision of appropriate accommodation and facilities. We have seen that in this case there were specific problems of communication between health board and school staff. This can present particular difficulties in attempting to protect children at risk. We recommend that responsibility for communicating health board child protection policy and provision to schools should be one of the responsibilities of the new post of child care manager in each community care area. We also recommend that each school nominate a teacher to develop special expertise in the identification of child abuse and neglect and function as its liaison officer with local health board staff. Special joint in-service training programmes should be provided and this will assist in developing collaborative relationships locally. We recommend that the development by the Department of Education of a new sex education and lifeskills curriculum for primary and postprimary school students should address issues of child abuse and neglect. In-service training for teachers of this curriculum should include the development of skills in identifying and facilitating pupils who wish to make a disclosure. We have already drawn attention to the need to take specific measures to improve inter-disciplinary and inter-agency communication and co-operation and to the fact that experience does not appear to match commitment. It is essential to understand the dynamics and psychology of the constraints on collaboration. We recommend that the Western Health Board initiate a process to consider all aspects of inter-disciplinary and inter-agency communication and collaboration involving staff from each discipline and agency. We have also been concerned during the course of this inquiry by the human impact of this type of work on the workers concerned. This ranges from the apprehension with which some staff may embark on a home visit, to the relative danger to some staff of adopting a confrontative stance with abusing parents in an isolated home. At the other end of the spectrum there is the trauma experienced by workers in cases where a tragedy occurs, for whatever reason, and they themselves become subjected to abuse, vilification or innuendo. This is itself a difficult and complex area and we recommend that the Western Health Board investigate measures used in other employments to provide support to workers who may experience trauma in the conduct of their professional duties. We believe that a progressive and proactive approach by the health board in this regard will be repaid in the increased confidence and morale of its staff in the exercise of their professional functions. CHAPTER 7- CONCLUSION -A CHILD IS DEADThis tragic reality can so easily be obscured by the hysteria caused by media reports, politicians’ questions, legal proceedings, professionals’ vulnerability, establishment of inquiries, recommendations for change in legislation, policy, service provision and practice. While this may be inevitable we believe it can only be justified in terms of a commitment to improve the effectiveness of the protection we provide, as a society, to children at risk of abuse or neglect. In conducting this inquiry we have endeavoured from the beginning to acknowledge Kelly’s tragic life and death through retaining a focus on how her distressing experience might itself contribute to making children safer in Ireland. We have tried to take an approach which was characterised by thoroughness and fairness. Our findings may be summarised as follows: 1.We have identified substantial shortcomings in the health board’s involvement with Kelly’s family over a two year period which suggests that child protection practice in the Western Health Board and, we believe, in health boards generally, falls far short of the standards necessary to afford adequate protection of children; 2.The intervention of the Western Health Board with Kelly’s family, in spite of the best efforts of individual staff, was naive and ineffective when pitted against parents who represented a significant danger to at least two of their children; 3.It cannot be concluded with any certainty, however, that a more effective intervention would necessarily have prevented Kelly’s death from a meningococcal infection, which was neither intended nor foreseeable, and given the nature of her parents and the unpredictability of how they might have reacted against any alternative health board intervention; 4.We do not believe it is possible to guarantee that children will not be abused but we believe that health boards, as child protection agencies, must aim to ensure that all children at risk are accurately identified and that intervention is effective in reducing the level of risk to a child or removing it altogether; 5.We consider that substantial further development of services for the welfare of children is required nationally and that this development must include improvements in legislation, policy, service provision and practice. Fundamentally we believe that all practice in relation to children should have his or her best interests at its core. It should actively seek out and value the child’s views. This will require an attitude change in order that children be regarded as active, participating, developing citizens rather than as passive recipients of services. We have been acutely conscious that this has been only the second such inquiry to be published, the other being the Report of the Kilkenny Incest Investigation (1993). We are aware of other recent or current inquiries into alleged abuse in residential care centres and of sexual abuse perpetrated by a parent. Such inquiries, of themselves, can create a context for child protection practice which has the potential to be either beneficial or damaging. We strongly urge that every effort is taken to ensure that they make a positive and constructive contribution to the more effective protection of children. For this reason, given the relative rarity of published reports into causes of child abuse or neglect and the fact that this is the first such inquiry in Ireland into the death of a child, we have felt compelled to include in this report substantial details of the health board’s involvement with Kelly’s family. This is reinforced by several significant factors in this case to which we wish to draw attention, viz. the potential threat of emotional abuse and neglect to the physical integrity of a child, and the fact that, in certain circumstances, a teenager can become as vulnerable to abuse as a preschool child. In including substantial details of the health board’s involvement with Kelly’s family in this report we are sensitive to the difficulty this may present to those professionals involved who have themselves been traumatised both by Kelly’s death and by events which followed it. We wish to place on record our appreciation of their forthcoming and constructive approach to this inquiry which, we believe, reflects their own distress at Kelly’s death and their commitment to learning lessons from the experience. There will be those who will argue that individual practitioners should be identified and held accountable. Our concern is to ensure that the context within which child protection staff are engaged is conducive to high standards of practice against which they can then be evaluated. Blaming individuals who are otherwise competent will be a distraction to satisfy some but limit necessary action. In the event, we can state with confidence that no one professional was responsible for the outcome. Responsibility for inadequate or ineffective intervention must be seen to be corporate rather than individual. While we have inevitably had to focus on the health board’s shortcomings we wish to record that we have found many examples of professionalism and integrity on the part of health board staff in the course of this inquiry. We would be concerned therefore at any attempt to apportion blame or to identify and take action against any of the individuals involved. This would serve only to satisfy sectional interests and would, in fact, ignore the realities and complexities of the case. It is essential, however, that the case be considered and understood as a contribution to the current development of services for children at risk, a process in which the Western Health Board is already vigorously engaged. We also wish to place on record our acknowledgement and appreciation of the impact Kelly’s death has had on the community in which she lived for only five months. Many statements have been made in the media which suggest that neighbours were less than caring or supportive. To our knowledge, nothing could be further from the truth. From the day that Kelly’s family arrived in the area they were met with and received the type of welcome, support, generosity and assistance one would expect in such a rural community. This community has been traumatised by the tragedy that occurred in its midst and by the media attention which ensued, the impact of which will continue for a considerable period. Of particular importance is that sensitivity be shown to the circumstances of Kelly’s surviving siblings. In this regard we wish to express our concern at some of the media reporting of this case which has identified Kelly’s siblings both in photographs and reports and has included specific personal information relating to some of them. We consider Kelly’s siblings to also be innocent victims of this tragedy and we would expect a greater level of sensitivity towards them than has been in evidence from some quarters. The inquiry team considered meeting with the children but took the view that this might be intrusive at this time and interfere with current health board intervention with them. However we would not want the fact that we did not meet them to be construed as a failure to acknowledge the importance of accessing and valuing their perspective on their situation. We did seek, through an intermediary, to meet with Girl 1, now aged 19 years, but she declined our invitation. It is now two and a half years since Kelly’s death, yet the trauma continues for her family, her relatives, the community and the various professional staff. It is important that all should now have an opportunity to put the past behind them and begin to focus on the future. While this will be difficult, it is essential. For those of us who have a professional involvement the best contribution we can now make to valuing Kelly is to commit ourselves to ensuring that the quality of our interventions to protect children at risk is significantly enhanced as a direct outcome of our knowledge and understanding of what happened to her.
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