Tusla criticised over death of baby boy who died while sleeping with his mother
Tusla social workers did not adequately consider a family's vulnerabilities in a case where a baby boy had died, a review has found.
The infant, known as "Jack", died while sleeping with his mother, who is described as a user of illegal drugs.
His case is among six reports into the deaths of children in care, published by the National Review Panel yesterday.
The reports were only reported on the Tusla website without notifying the media.
Asked why media was not notified a Tusla spokeswoman said today it is “in the interests of children and families for whom publication of these reports can be very traumatic.”
Jack's mother "Kim" had used drugs during her pregnancy and was visited frequently by two public health nurses.
Kim and her partner were referred to Tusla while she was expecting due to concerns over her drug use.
When Jack was born, hospital nursing staff sent a referral to the SWD and a social worker visited and discussed Kim’s reported drug use and its impact on the children with her.
Although a PHN had mentioned in an earlier report that Kim’s partner also used drugs, this matter was not brought up by and "possibly not known to the social worker".
The case was classified as ‘child welfare’, i.e. under the threshold for child protection intervention, and closed, but the basis for the decision is not recorded.
A few weeks later, baby Jack was admitted to hospital because of weight loss and was apparently doing well.
Gardaí notified the SWD that a few hours prior to Jack's death, they had been called to the family home and found both parents under the influence of substances.
Jack was sent to a relative for the night and Kim later joined him there. It appears that during the night, whilst he was in bed with Kim, Jack died.
The post-mortem indicated that he died as a result of Sudden Infant Death Syndrome (SIDS).
The National Review Panel found that the first referral note, from the PHN to social workers, “was not noted in the SWD files and was “not known to the social worker that later followed up the second referral.
"As this report contained important information about Kim’s alleged drug use during pregnancy, an opportunity to intervene at that stage was missed by the SWD.
"The review has found that very limited communication took place between the SWD and the PHN service as well as between the SWD and other professionals.
"No interagency meetings were held on the case, which meant that opportunities for sharing information about the full range of vulnerabilities being experienced by the family was not given due attention.
In a separate case, the independent panel found that responses made to a 16-year-old boy before his tragic death were inadequate.
The teen, known as Alan, was killed in an accident "associated with what appears to have been risk taking behaviour".
Reports were made about Alan and his siblings to the social work department (SWD) from the time he was seven years old, detailing neglect of the children, parental alcohol misuse, mental health problems and domestic violence.
Following his death, the review found that the responses made to Alan and his family following initial reports was inadequate and there were a number of shortcomings in management and practice up to the time he was in his early teens.
"Neither his needs, nor those of his siblings, were assessed adequately and the family did not receive the degree of intervention they needed when the children were young. Overall, a low standard was applied to evaluating their situation following the first referrals made about the family."
In another case, involving the death of a 16-year-old who died from a suspected accidental drug overdose, the panel found that the SWD along with the other services involved, did their best to support and guide him during the last three years of his life.
Responding, a spokesperson from Tusla said it extends "sincere sympathies" to all those affected by the deaths of the children and young people reviewed by the National Review Panel.
"A consistent theme emerging from case reviews, inquiries and policy developments within Child and Family Services in recent years is that services for children and young people could be improved if statutory agencies worked more effectively together. This is a key area of focus for Tusla."